Crohn's disease: nutrition and nutritional therapy

Treatment of Crohn's Disease with an IgG4-Guided Exclusion Diet: A Randomized Controlled Trial

BACKGROUND AND AIM

We previously reported an improvement in symptoms in Crohn's disease following an IgG4-guided exclusion diet in an open-label study. We aimed to evaluate, in a double-blinded randomized sham-controlled setting, the efficacy of IgG4-guided diet in improving quality of life in patients with Crohn's disease.

METHODS

Consecutive patients with Crohn's disease and a Crohn's disease activity index (CDAI) of 80-400 attending tertiary and secondary care centers were screened. All patients had IgG4 titers tested against 16 common food types using ELISA. The true diet group excluded four food types with the highest antibody titers for 4 weeks, and the sham group excluded four foods with the lowest antibody titers. Quality of life was assessed using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) at beginning and end of the trial. Secondary outcome measures were CDAI, Harvey Bradshaw index, serum C-reactive protein, and fecal calprotectin.

RESULTS

One hundred and forty-five subjects were screened and 96 subjects had initial food antibody testing performed with 76 patients completing the study. Milk, beef, pork and egg were the most commonly excluded food types in the true diet group. There was a 3.05 (0.01-6.11) p < 0.05 improvement in SIBDQ and 41 (10.4-71.5) in CDAI p = 0.009.

CONCLUSION

IgG4-guided exclusion diet, as an adjunct, can improve quality of life and symptoms in patients with CD.

The efficacy of exclusive nutritional therapy in paediatric Crohn's disease, comparing fractionated oral vs. continuous enteral feeding

BACKGROUND

Nutritional therapy has an established role as induction therapy in paediatric Crohn's disease. However, compliance is the main difficulty and may be greatly influenced by the administration route.

AIM

To analyse the efficiency of exclusive nutrition to induce remission in children with Crohn's disease comparing fractionated oral vs. continuous enteral feeding.

METHODS

The medical records of 106 patients treated by exclusive nutritional therapy [Modulen IBD (R)] by either oral or continuous enteral route were reviewed retrospectively. Comparative analyses of remission rates, changes in anthropometry, Paediatric Crohn's disease Activity Index (PCDAI), laboratory indices and compliance rates were performed.

RESULTS

On exclusive enteral nutrition, at 8 weeks, 34/45 patients achieved remission in the oral group (75% on intention-to-treat analysis) and 52/61 (85%) in the enteral nutrition group (P = 0.157). All patients showed a significant decrease in disease severity assessed by PCDAI (P < 0.0001) and significant improvements in anthropometric measures and inflammatory indices. No difference was observed whether Modulen IBD was administered orally or by continuous enteral feeding, apart from weight gain, which was greater in the enteral group (P = 0.041). In a subgroup of patients, mucosal healing was evidenced on follow-up endoscopies showing a clear correlation to remission. Compliance rates (87% and 90%) were similar. Nevertheless, noncompliant patients had lower mucosal healing and remission rates.

CONCLUSIONS

These retrospective data suggest that the use of fractionated oral nutritional therapy might be as efficacious as continuous enteral administration to induce remission and mucosal healing in children with Crohn's disease. However, appropriate prospective clinical trials are needed to confirm these findings.

The aetiology and impact of malnutrition in paediatric inflammatory bowel disease

Disease-associated undernutrition of all types is very common in paediatric inflammatory bowel disease (IBD). Recent weight loss remains one of the triad of clinical manifestations and a cornerstone for the diagnosis of Crohn's disease (CD), although significantly fewer patients now present as being underweight. Recent evidence suggests that the introduction of medical treatment will quickly restore body weight, although this does not reflect concomitant changes in body composition. CD children present with features of nutritional cachexia with normal fat stores but depleted lean mass. Poor bone health, delayed puberty and growth failure are additional features that further complicate clinical management. Suboptimal nutritional intake is a main determinant of undernutrition, although activation of the immune system and secretion of pro-inflammatory cytokines exert additional independent effects. Biochemically low concentrations of plasma micronutrients are commonly reported in IBD patients, although their interpretation is difficult in the presence of an acute phase response and other indices of body stores adequacy are needed. Anaemia is a common extraintestinal manifestation of the IBD child. Iron-deficient anaemia is the predominant type, with anaemia of chronic disease second. Decreased dietary intake, as a result of decreased appetite and food aversion, is the major cause of undernutrition in paediatric IBD. Altered energy and nutrient requirements, malabsorption and increased gastrointestinal losses are additional factors, although their contribution to undernutrition in paediatric CD needs to be studied further.

Role of diet in the management of inflammatory bowel disease

Many studies have looked at connections between diet, etiology, signs and symptoms associated with inflammatory bowel disease (IBD). Although these connections are apparent to clinicians, they are difficult to prove qualitatively or quantitatively. Enteral feeding and polymeric diets are equally effective at bringing about remission in Crohn’s disease (CD). Parenteral feeding is also effective, although none of these methods is as effective as corticosteroid therapy. However, enteral feeding is preferred in the pediatric population because linear growth is more adequately maintained via this route. Exclusion diets in patients brought into remission using an elemental diet have been shown to maintain remission for longer periods. Studies that aim to isolate culpable food groups have shown that individuals react differently on exposure to or exclusion of various foods. The commonly identified food sensitivities are cereals, milk, eggs, vegetables and citrus fruits. Studies that have looked at gut mucosal antigen behavior have shown higher rectal blood flow, in response to specific food antigens, in those with CD over healthy subjects. Exclusion of sugar shows little evidence of amelioration in CD. Omega 3 fatty acids show promise in the treatment of IBD but await larger randomized controlled trials. Patients frequently notice that specific foods cause aggravation of their symptoms. Whilst it has been difficult to pinpoint specific foods, with advances in the laboratory tests and food supplements available, the aim is to prolong remission in these patients using dietary measures, and reduce the need for pharmacotherapy and surgical intervention.

Comparison between handgrip strength, subjective global assessment, anthropometry, and biochemical markers in assessing nutritional status of patients with Crohn's disease in clinical remission

INTRODUCTION

Crohn's disease (CD) may lead to protein and calorie malnutrition (PCM) secondary to impaired digestive and absorptive functions of the small intestine and sometimes to the influence of diet taboos. The earlier the PCM is diagnosed, the higher are the odds of reversal. The objective of this study was to compare different methods of nutritional assessment in patients with CD and correlate them with the disease characteristics.

SAMPLE

The sample comprised 75 patients with CD from the Gastroenterology Service at the Hospital de Clínicas de Porto Alegre; 37 were male, with a mean age of 38.2 years old (SD = 13.3). All patients had been in clinical remission (CDAI <150) for over 3 months. They were not receiving enteral or parenteral nutrition. The nutritional assessment was considered: body mass index (BMI), triceps skin fold (TSF), arm circumference (MAC), arm muscle circumference (MAMC), subjective global assessment (SGA), non-dominating handgrip strength (HGS) and food intake inquiries.

RESULTS

When comparing the different nutritional assessment methods, 26.7% of the patients were malnourished according to the MAC, 29.3% according to the MAMC, 18.7% according to the SGA, 6.7% according to the BMI, 37.3% according to the TSF and 73.3% according to the HGS. No statistically significant associations were found for disease location, its behavior, drugs utilized, ESR, CRP, age of patients and disease time with the nutritional state verified by HGS, TSF, MAMC and SGA.

CONCLUSION

The prevalence of malnutrition is significant in patients with CD, even in clinical remission. The BMI should not be used as reference in this population. The HGS detected a high prevalence of nutritional risk in patients with CD in remission. Studies are required that correlate it with more sensitive methods, for the patients' effective nutritional state assessment.

Post-weaning effects of milk and milk components on the intestinal mucosa in inflammation

Many milk-derived components have immunomodulatory and anti-inflammatory properties, and some of these reduce intestinal inflammation when orally administered to animal models of colitis. However, the potential for ruminant milk or milk components to benefit people with intestinal inflammatory disorders (such as Inflammatory Bowel Disease) has not been well-researched. This review describes published research into mechanisms by which ruminant milk and its components may have beneficial effects when consumed by people who have intestinal inflammation.

Comparison of cytokine modulation by natural peroxisome proliferator-activated receptor gamma ligands with synthetic ligands in intestinal-like Caco-2 cells and human dendritic cells--potential for dietary modulation of peroxisome proliferator-activated receptor gamma in intestinal inflammation

BACKGROUND

Peroxisome proliferator-activated receptor gamma (PPARgamma) plays a role in the regulation of intestinal inflammation and is activated by both natural (polyunsaturated fatty acid; PUFAs) and synthetic (troglitazone) ligands. The fatty acid content of defined formula diets may play a role in mediating the antiinflammatory effect, but the mechanism is unclear.

OBJECTIVE

We evaluated to what extent the effect of PUFAs on intestinal inflammation is mediated via PPARgamma.

DESIGN

The human enterocyte-like cell line Caco-2 and human dendritic cells were stimulated by interleukin (IL) 1beta and lipoprotein polysaccharide, respectively, in the presence of PPARgamma agonists (troglitazone or PUFAs) or antagonist (GW9662). Five PUFAs were tested: alpha-linolenic acid (ALA), conjugated linoleic acid (CLA), docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and gamma-linolenic acid (GLA). Cytokine production was measured by enzyme-linked immunosorbent assay and PPARgamma, I-kappaB, and inducible nitric oxide synthase (iNOS) expression by Western blot.

RESULTS

In Caco-2 cells, IL-6 secretion was significantly decreased by troglitazone, DHA, EPA, and GLA. IL-8 production was significantly decreased by troglitazone, ALA, DHA, EPA, and GLA. PPARgamma expression was significantly increased by troglitazone, DHA, and EPA. iNOS expression was significantly decreased by troglitazone, DHA, and EPA. Troglitazone and PUFAs at 0.1 mumol/L tended to increase the expression of I-kappaB. Addition of GW9662 reversed the effect of troglitazone and PUFAs at 0.1 mumol/L on IL-8 production and decreased the expression of PPARgamma. EPA and DHA also modulated the dendritic cell response to lipoprotein polysaccharide.

CONCLUSIONS

The tested PUFAs exerted an antiinflammatory effect in vitro in both models. This effect of PUFAs in Caco-2 cells is similar to that of troglitazone on intestinal inflammation mediated by PPARgamma, and the potency of the antiinflammatory effect is linked to the number of double bonds.

Polymeric formula has direct anti-inflammatory effects on enterocytes in an in vitro model of intestinal inflammation

Exclusive enteral nutrition using polymeric formula (PF) is a well-established therapeutic option for active Crohn's disease; however, its mechanisms of action are unknown. We investigated the anti-inflammatory effects of PF in an in vitro model of epithelial cell inflammation. PF did not affect cell viability over a range of dilutions, but when PF was added to the culture medium the interleukin (IL)-8 response to proinflammatory stimuli was significantly reduced. This effect was due to PF acting directly on the cells as the IL-8 response was still reduced when PF was separated from the proinflammatory stimuli in a 2-compartment system. In the presence of PF, nuclear factor (NF)-kappaB nuclear migration was not inhibited; however, IkappaBalpha degradation was delayed. PF has direct anti-inflammatory effects upon immortalized colonic enterocytes. Therefore PF may, in part, modulate gut inflammation by directly reducing the inflammatory response of the intestinal epithelium.

Control of systemic and local inflammation with transforming growth factor beta containing formulas

Enteral nutrition therapy with liquid diet has been shown to be effective in achieving clinical remission in intestinal Crohn's disease. The mechanism of action of this therapy, however, is still poorly understood. As part of our assessment of the action of 3 related polymeric enteral therapies, we have used a variety of techniques to document the histological and cytokine responses, in the mucosa and, systemically, to these treatments. The feeds studied (AL110, Modulen IBD and ACD004 [Nestle, Vevey, Switzerland]) all have casein as the protein source, are lactose free and are rich in transforming growth factor beta (TGF-beta). They have all been shown to induce clinical remission associated with mucosal healing. In the case of Modulen IBD, as well as mucosal macroscopic and histological healing there was a fall in mucosal proinflammatory cytokines: interleukin-1 mRNA in colonic and ileal, interleukin-8 mRNA in the colon and interferon gamma mRNA in the ileum, but a rise in the regulatory cytokine TGF-beta mRNA in the ileum. These results indicate that these formulas are influencing the disease process itself, and thus suggest that the clinical remission achieved is a result of a reduction in inflammation, rather than a consequence of some other nutrition effect.

Impact of elemental diet on mucosal inflammation in patients with active Crohn's disease: cytokine production and endoscopic and histological findings

BACKGROUND

The aim of this study was to examine the impact of elemental diet on mucosal inflammation in Crohn's disease (CD), mainly by cytokine measurements.

METHODS

Twenty-eight consecutive patients with active CD were treated with an elemental diet (Elental) for 4 weeks. The mucosal biopsies were obtained from the terminal ileum and large bowel before and after treatment. As a control group, mucosal biopsies were obtained from 20 patients without inflammation. Mucosal cytokine concentrations were measured by enzyme-linked immunosorbent assay.

RESULTS

After treatment, clinical remission was achieved in 20 patients (71%). Endoscopic healing and improvement rates were 44% and 76% in the terminal ileum and 39% and 78% in the large bowel, respectively. Histologic healing and improvement rates were 19% and 54% in the terminal ileum and 20% and 55% in the large bowel, respectively. Before treatment, the mucosal concentrations of interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1ra), IL-6, IL-8, and tumor necrosis factor-alpha in the ileum and large bowel were significantly higher than in controls. These cytokine concentrations decreased to the levels of control after treatment. IL-1ra/IL-1beta ratio in the ileum and large bowel was significantly lower than in controls before treatment. The ratio increased to the level of controls after treatment. The endoscopic and histologic healing of the mucosal inflammation was associated with a decline of the mucosal cytokines and an increase of the IL-1ra/IL-1beta ratio.

CONCLUSIONS

The elemental diet (Elental) reduced mucosal cytokine production and corrected an imbalance between proinflammatory and anti-inflammatory cytokines in CD.

Inflammatory bowel disease in early childhood and adolescence: special considerations

Several aspects of IBD overlap between pediatric and adult population. Those include nutritional issues, bone density, and medical and surgical therapies. Some aspects like natural course of the disease, and epidemiology and genetics are more easily examined and researched in the pediatric population. Others like pubertal and growth delay, and transition of health care are unique to pediatric patients. This article examines some of the similarities, as well as differences of IBD in these two populations.

Body composition in patients with inflammatory bowel disease: a population-based study

OBJECTIVE

Weight loss and nutritional depletion are common features of inflammatory bowel disease. Our aim was to assess body composition in patients with Crohn's disease (CD) and ulcerative colitis (UC) and to evaluate possible differences between the patient groups and healthy subjects.

METHODS

A total of 60 patients with CD, 60 patients with UC, and 60 healthy subjects were investigated. Each group consisted of 24 men and 36 women. Body composition was measured by dual x-ray absorptiometry and Z scores were obtained by comparison to age- and sex-matched normal values.

RESULTS

Bone mineral content and lean body mass were significantly lower in patients with CD compared with patients with UC and healthy subjects. The body composition of CD men was more strongly affected than that of women. UC patients had significantly higher fat mass and body mass index than patients with CD and healthy subjects. There was no difference in the percentage of fat mass between the two patient groups. Corticosteroid treatment and smoking had a negative impact on bone mineral content and lean body mass in CD patients independently of each other.

CONCLUSIONS

CD was associated with disturbances in body composition: both bone mineral content and lean body mass were significantly reduced, especially in men with CD. Corticosteroid therapy and smoking had a significant influence on body composition in patients with CD. When studying the effects of inflammatory bowel disease on body composition and nutritional status, patients with CD and UC should be evaluated separately.

Effect of steroids on energy expenditure and substrate oxidation in women with Crohn's disease

OBJECTIVE

Patients with Crohn's disease (CD) have increased energy expenditure and fat oxidation. Steroids, commonly used to treat flare-up of CD, induce weight gain. This study was designed to evaluate the effects of prednisone and budesonide on energy expenditure and substrate oxidation in patients with CD.

METHODS

Twenty-nine women with CD and 10 healthy controls were studied. Ten patients received prednisone (0.75-1.0 mg/kg/day), nine received budesonide (9 mg/ day), and 10 did not receive steroids. Resting energy expenditure and substrate oxidation were measured by indirect calorimetry in a fasting state and after a standard diet.

RESULTS

In the fasting state, resting energy expenditure was higher in patients without steroids than in the controls. Lipid oxidation was lower (p < 0.01) in patients with prednisone (0.46 +/- 0.39 mg/kg/min) than in patients with budesonide (0.97 +/- 0.28 mg/kg/min) and without steroids (1.06 +/- 0.32 mg/kg/min), but was similar with control subjects (0.47 +/- 0.20 mg/kg/min). Postprandially, lipid oxidation was lower (p < 0.01) in patients with prednisone (0.32 +/- 0.23 mg/kg/min) than in patients with budesonide (0.75 +/- 0.20 mg/kg/min), without steroids (0.82 +/- 0.23 mg/kg/min), and controls (0.58 +/- 0.15 mg/kg/min). Protein oxidation was significantly higher in patients with prednisone than in the other subjects.

CONCLUSIONS

In women with CD, prednisone decreases lipid oxidation and increases protein oxidation. These effects are not observed with budesonide and may contribute to the weight gain and side effects commonly observed with prednisone. A low-fat/high-protein diet could be proposed during a course of prednisone.

Anti-inflammatory effects of enteral diet components on Crohn's disease-affected tissues in vitro

BACKGROUND

The mechanism of action of elemental diet in Crohn's disease treatment, is unknown. Alteration of bacterial flora, low antigenicity, low fat content and improvement of nutritional status are postulated to play a role in the anti-inflammatory effect of elemental diet.

AIM

To determine whether elemental diet or its modifications has a direct anti-inflammatory effect on colonic tissue biopsies in vitro.

PATIENTS AND METHODS

Colonic or ileal biopsies from 39 patients with inflammatory bowel disease and control patients were incubated for 24 hours with enteral diets in which nitrogen sources were amino acids as in elemental diet, casein or whey. Tissues were incubated with elemental diet, casein or whey, at dilutions of 1:5, 1:10 or 1:20 in Waymouth's complete medium; a medium control was also included. Tissue viability was assessed by bromodeoxyuridine uptake. Interleukin-1beta, interleukin-1 receptor antagonist and interleukin-10 concentrations in supernatants were measured by immunoassay (enzyme-linked immunosorbent assay).

RESULTS

Incubation of tissues from Crohn's disease with elemental diet resulted in an increase in the ratio of interleukin-1 receptor antagonist/interleukin-1beta vs control statistically significant at 1:10 (89.6+/-17 vs 45.7+/-9. 1, p<0.05). Incubation of Crohn's tissue with casein resulted in a significant increase of interleukin-1 receptor antagonist/interleukin-1beta ratio at dilutions 1:20, 1:10 and 1:5 (101.8+/-22.0, p=0.05, 142.8+/-24.6, p<0.05; 109.7+/-25.0, p=0.05). In ulcerative colitis tissue and non-inflamed non-inflammatory bowel disease control tissue, no significant increase in interleukin 1 receptor antagonist/interleukin-1beta ratio was seen after incubation with elemental diet, casein and whey.

CONCLUSION

Elemental diet incubation increases anti-inflammatory:proinflammatory cytokine ratio in Crohn's disease and this anti-inflammatory effect is not specifically due to amino acid composition, as diets containing casein have similar anti-inflammatory effects.

Medical treatment of Crohn's disease

Crohn's disease is not medically (and is rarely surgically) curable. Patients do, however, live a normal life span. The goal of therapy is to optimize the quality of life, minimize disease activity and disease-related complications, and avoid therapeutic toxicity.

Modification of enteral diets in inflammatory bowel disease

The provision of food is thought to promote the maintenance of gut integrity. Nutrients are able to elicit and affect both systemic and mucosal immune responses. Enteral diet therapy has long been known to be efficacious in inflammatory bowel disease (IBD), particularly in childhood Crohn's disease. However, the mechanisms of action of these diets are not clear. Nutritional repletion, direct effects on the gut mucosa or decreased intestinal permeability have all been postulated as being important in nutritional therapy. There is some evidence that the enteral diet has a direct effect on the gut mucosa by reducing cytokine production and the accompanying inflammation, thus leading to decreased intestinal permeability. Modifications of enteral diet composition have been evaluated in many studies. Such modifications include fat and/or protein content and the addition of bioactive peptides. The fatty acid composition of the enteral diet seems to have a much greater impact on its efficacy than modification of the N source. As specific fatty acids are precursors of inflammatory mediators derived from arachidonic acid, the reduction in these components may be beneficial in nutritional therapy for IBD. Addition of bioactive peptides to enteral diet formulas may also have a role; such peptides may have specific growth factor or anti-inflammatory actions. There is still much work to be done to define disease-specific enteral diet formulas that are effective as therapies for both Crohn's disease and ulcerative colitis.

Review article: the management of severe Crohn's disease

The treatment of severe and active Crohn's disease is currently based on immunosuppression, but also involves the management of nutrition, appropriate selection of patients for surgery, and maintenance of remission in the long term. Corticosteroids remain the drug of the first choice, particularly in the acute setting. However, there is evolving understanding of the role of other immunosuppressants and immune modifiers, as major concerns regarding side-effects and efficacy of steroids in the medium to long-term drive the search for alternatives.

Dietary recommendations to prevent and manage chronic pediatric health conditions: adherence, intervention, and future directions

This review provides a summary of the dietary aspects of pediatric health conditions. Within each condition, dietary recommendations are reviewed, and adherence rates, factors affecting adherence, and known interventions are reported. Findings indicate that knowledge is necessary but not sufficient for dietary change. Interventions specifically targeting diet appear more promising than interventions aimed at global treatment adherence. Behavioral interventions and group treatment modalities also appear promising. Recommendations for future research include a systematic assessment of barriers to dietary adherence across populations, integration of the research on normative development of eating behavior in childhood, and the application of this information to the design and implementation of future treatment.

Nutritional support for Crohn's disease

This article reviews nutritional considerations that arise in the care of patients with Crohn's disease. The causes and presentation of malnutrition in these patients are discussed, and a rational method is presented for comprehensive nutritional assessment. The indications for nutritional intervention, either as supportive or primary therapy for Crohn's disease, are reviewed.

Mucosal healing and a fall in mucosal pro-inflammatory cytokine mRNA induced by a specific oral polymeric diet in paediatric Crohn's disease

BACKGROUND

Although enteral nutrition is a recognized form of treatment for intestinal Crohn's disease, there are persisting problems with feed palatability and only limited data as to its mode of action.

AIM

To assess the effects of a specific oral polymeric diet (CT3211; Nestle, Vevey, Switzerland), which is rich in transforming growth factor beta2, on the mucosal inflammatory process.

METHODS

Twenty-nine consecutive children with active intestinal Crohn's disease were treated with CT3211 as the sole source of nutrition for 8 weeks. Patients were assessed clinically, and endoscopically, whilst cytokine mRNA was measured in mucosal biopsies before and after treatment by quantitative reverse transcriptase polymerase chain reaction.

RESULTS

After 8 weeks 79% of children were in complete clinical remission. Macroscopic and histological healing in the terminal ileum and colon was associated with a decline in ileal and colonic interleukin-1beta mRNA (pre-treatment to post-treatment ratio 0.008 and 0.06: P < 0.001, P = 0.006). In the ileum there was also a fall in interferon gamma mRNA (ratio 0.15, P < 0.001) with a rise in transforming growth factor beta1 mRNA (ratio 10, P = 0.04), whilst in the colon interleukin-8 mRNA fell with treatment (ratio 0.06, P < 0.05).

CONCLUSIONS

The clinical response to oral polymeric diet CT3211 is associated with mucosal healing and a down regulation of mucosal pro-inflammatory cytokine mRNA in both the terminal ileum and colon. In the ileum there was also an increase in transforming growth factor beta1 mRNA.

Nutrition in inflammatory bowel disease

The nutritional impact of inflammatory bowel disease is notable, both in Crohn's disease and ulcerative colitis. The causes of malnutrition include decreased intake, maldigestion, malabsorption, accelerated nutrient losses, increased requirements, and drug-nutrient interactions. Inflammatory bowel disease causes alterations in body composition and, because of these changes, affects energy expenditure. Various approaches have been most effective in correcting malnutrition, supporting growth, and managing short-bowel syndrome, but the success of primary therapy has been limited.