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Landorf E, Hammond P, Abu-Assi R, Ellison S, Boyle T, Comerford A, Couper R. Formula modifications to the Crohn's disease exclusion diet do not impact therapy success in paediatric Crohn's disease. J Pediatr Gastroenterol Nutr 2024; 78:1279-1286. [PMID: 38623960 DOI: 10.1002/jpn3.12215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/14/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES The Crohn's disease exclusion diet (CDED) + partial enteral nutrition (PEN) is an emerging diet used to induce clinical remission in children with active Crohn's disease (CD). This study aims to determine the effectiveness of using the CDED+PEN to induce clinical remission in an Australian group of children with active CD using different PEN formulas and incorporating patient dietary requirements. METHODS We retrospectively collected data from children (both newly diagnosed and with existing CD while on therapy) with active CD (Paediatric Crohn's Disease Activity Index [PCDAI] ≥10) and biochemical evidence of active disease (elevated C-reactive protein [CRP], erythrocyte sedimentation rate [ESR] or faecal calprotectin [FC]) who completed at least phase 1 (6 weeks) of the CDED+PEN to induce clinical remission. Data were collected at baseline, Week 6 and Week 12. The primary endpoint was clinical remission at Week 6 defined as PCDAI < 10. RESULTS Twenty-four children were included in phase 1 analysis (mean age 13.8 ± 3.2 years). Clinical remission at Week 6 was achieved in 17/24 (70.8%) patients. Mean PCDAI, CRP, ESR and FC decreased significantly after 6 weeks (p < 0.05). Formula type (cow's milk based, rice based, soy based) did not affect treatment efficacy. A greater than 50% decrease in FC was achieved in 14/21 (66.7%) patients who completed phase 1 and 12/14 (85.7%) patients who completed phase 2 of the CDED+PEN. CONCLUSIONS Formula modifications to the CDED+PEN do not impact the expected treatment efficacy in Australian children with active luminal CD.
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Affiliation(s)
- Emma Landorf
- Department of Nutrition, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Paul Hammond
- Department of Gastroenterology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Rammy Abu-Assi
- Department of Gastroenterology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Samuel Ellison
- Department of Gastroenterology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Terry Boyle
- Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Annabel Comerford
- Department of Nutrition, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Richard Couper
- Department of Gastroenterology, Women's and Children's Hospital, Adelaide, South Australia, Australia
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2
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Deas J, Shah ND, Konijeti GG, Lundin A, Lanser O, Magavi P, Ali S. Dietary therapies for adult and pediatric inflammatory bowel disease. Nutr Clin Pract 2024; 39:530-545. [PMID: 38505875 DOI: 10.1002/ncp.11146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Diet is an environmental exposure implicated in the development of inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC). Dietary therapy is also a tool for management of these conditions. Nutrition therapy for IBD has been shown to reduce intestinal inflammation, promote healing, and alleviate symptoms, as well as improve patients' nutrition status. Although the mechanisms of action of most nutrition therapies for IBD are not well understood, the diets are theorized to eliminate triggers for gut dysbiosis and mucosal immune dysfunction associated with the typical Western diet. Exclusive enteral nutrition and the Crohn's disease exclusion diet are increasingly being used as the primary treatment modality for the induction of remission and/or maintenance therapy in children, and in some adults, with CD. Several other diets, such as the Mediterranean diet, anti-inflammatory diet for IBD, and diets excluding gluten, FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), lactose, or other compounds, may be helpful in symptom management in both CD and UC, though evidence for biochemical efficacy is limited. In this review, we discuss the role of diet components in IBD pathogenesis and examine diets currently used in the management of children and adults with IBD. We also address practical, psychosocial, and cultural considerations for dietary therapy across diverse populations.
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Affiliation(s)
- Jessica Deas
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California San Francisco, San Francisco, California, USA
| | - Gauree G Konijeti
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Abigail Lundin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Benioff Children Hospitals, University of California San Francisco, San Francisco, California, USA
| | - Olivia Lanser
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Pooja Magavi
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Sabina Ali
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Benioff Children Hospitals, University of California San Francisco, San Francisco, California, USA
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Lee D, Braly K, Nuding M, Braly I, Hopp C, Twible H, Pope C, Hayden HS, Hoffman L, Zheng H, Wahbeh G, Suskind DL. Reverse-engineered exclusive enteral nutrition in pediatric Crohn's disease: A pilot trial. J Pediatr Gastroenterol Nutr 2024; 78:1135-1142. [PMID: 38558411 DOI: 10.1002/jpn3.12196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/18/2024] [Accepted: 03/02/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND In pediatric Crohn's disease (CD), commercial formulas used as exclusive enteral nutrition (EEN) are effective at inducing remission. This study aims to assess the impact of a whole-food blended smoothie as EEN on CD activity and the intestinal microbiome. METHODS A 4-week prospective trial assessed the impact of EEN with a whole-food smoothie on newly diagnosed mild-to-moderate active pediatric CD. The smoothie with a multivitamin were developed to meet age-appropriate nutritional requirements. Assessment over 4 weeks included Pediatric Crohn's Disease Activity Index (PCDAI), serum laboratories, fecal calprotectin (FCP), and stool collection for metagenomic shotgun sequencing and microbiota composition analysis. Clinical remission was defined as PCDAI ≤ 10 at week 4. RESULTS Ten participants were enrolled with median age 14.5 years, and 8 completed the trial. Baseline mean PCDAI was 26.3 ± 9.1 and mean FCP 1149 ± 718 µg/g. At week 4, 80% of participants achieved clinical remission. FCP decreased by over half in 60% of participants, with FCP below 250 µg/g in 60% and below 100 µg/g in 40%. Microbiome analysis showed a significant increase in species richness over 4 weeks (p = 0.01). Compared to baseline, the relative abundance at week 2 and at week 4 was significantly increased for Bifidobacterium and Streptococcus and decreased for Blautia (p < 0.05 for all). CONCLUSION A whole-food blended smoothie was effective for inducing clinical remission and decreasing FCP in pediatric CD similar to commercial EEN formulas. Further research may give insight into data-driven whole-food dietary approaches for CD management. CLINICALTRIALS gov NCT03508193.
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Affiliation(s)
- Dale Lee
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kim Braly
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mason Nuding
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ian Braly
- Department of Chemical Engineering, University of Washington, Seattle, Washington, USA
| | - Courtney Hopp
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Heather Twible
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Christopher Pope
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Hillary S Hayden
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Luke Hoffman
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Department of Microbiology, University of Washington, Seattle, Washington
| | - Hengqi Zheng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ghassan Wahbeh
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - David L Suskind
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
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Stummer N, Feichtinger RG, Weghuber D, Kofler B, Schneider AM. Role of Hydrogen Sulfide in Inflammatory Bowel Disease. Antioxidants (Basel) 2023; 12:1570. [PMID: 37627565 PMCID: PMC10452036 DOI: 10.3390/antiox12081570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Hydrogen sulfide (H2S), originally known as toxic gas, has now attracted attention as one of the gasotransmitters involved in many reactions in the human body. H2S has been assumed to play a role in the pathogenesis of many chronic diseases, of which the exact pathogenesis remains unknown. One of them is inflammatory bowel disease (IBD), a chronic intestinal disease subclassified as Crohn's disease (CD) and ulcerative colitis (UC). Any change in the amount of H2S seems to be linked to inflammation in this illness. These changes can be brought about by alterations in the microbiota, in the endogenous metabolism of H2S and in the diet. As both too little and too much H2S drive inflammation, a balanced level is needed for intestinal health. The aim of this review is to summarize the available literature published until June 2023 in order to provide an overview of the current knowledge of the connection between H2S and IBD.
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Affiliation(s)
- Nathalie Stummer
- Department of Pediatrics, University Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.S.); (R.G.F.); (D.W.); (B.K.)
| | - René G. Feichtinger
- Department of Pediatrics, University Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.S.); (R.G.F.); (D.W.); (B.K.)
| | - Daniel Weghuber
- Department of Pediatrics, University Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.S.); (R.G.F.); (D.W.); (B.K.)
| | - Barbara Kofler
- Department of Pediatrics, University Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.S.); (R.G.F.); (D.W.); (B.K.)
- Research Program for Receptor Biochemistry and Tumor Metabolism, Paracelsus Medical University (PMU), 5020 Salzburg, Austria
| | - Anna M. Schneider
- Department of Pediatrics, University Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.S.); (R.G.F.); (D.W.); (B.K.)
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5
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Hoelz H, Heetmeyer J, Tsakmaklis A, Hiergeist A, Siebert K, De Zen F, Häcker D, Metwaly A, Neuhaus K, Gessner A, Vehreschild MJGT, Haller D, Schwerd T. Is Autologous Fecal Microbiota Transfer after Exclusive Enteral Nutrition in Pediatric Crohn’s Disease Patients Rational and Feasible? Data from a Feasibility Test. Nutrients 2023; 15:nu15071742. [PMID: 37049583 PMCID: PMC10096730 DOI: 10.3390/nu15071742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Background: Exclusive enteral nutrition (EEN) is a highly effective therapy for remission induction in pediatric Crohn’s disease (CD), but relapse rates after return to a regular diet are high. Autologous fecal microbiota transfer (FMT) using stool collected during EEN-induced clinical remission might represent a novel approach to maintaining the benefits of EEN. Methods: Pediatric CD patients provided fecal material at home, which was shipped at 4 °C to an FMT laboratory for FMT capsule generation and extensive pathogen safety screening. The microbial community composition of samples taken before and after shipment and after encapsulation was characterized using 16S rRNA amplicon sequencing. Results: Seven pediatric patients provided fecal material for nine test runs after at least three weeks of nutritional therapy. FMT capsules were successfully generated in 6/8 deliveries, but stool weight and consistency varied widely. Transport and processing of fecal material into FMT capsules did not fundamentally change microbial composition, but microbial richness was <30 genera in 3/9 samples. Stool safety screening was positive for potential pathogens or drug resistance genes in 8/9 test runs. Conclusions: A high pathogen burden, low-diversity microbiota, and practical deficiencies of EEN-conditioned fecal material might render autologous capsule-FMT an unsuitable approach as maintenance therapy for pediatric CD patients.
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Affiliation(s)
- Hannes Hoelz
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
| | - Jeannine Heetmeyer
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
| | - Anastasia Tsakmaklis
- Clinical Microbiome Research Group, Department of Internal Medicine I, University Hospital of Cologne, 50931 Cologne, Germany
| | - Andreas Hiergeist
- Institute for Microbiology and Hygiene, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Kolja Siebert
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
| | - Federica De Zen
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
| | - Deborah Häcker
- Chair of Nutrition and Immunology, Technical University Munich, 85354 Freising-Weihenstephan, Germany
| | - Amira Metwaly
- Chair of Nutrition and Immunology, Technical University Munich, 85354 Freising-Weihenstephan, Germany
| | - Klaus Neuhaus
- ZIEL-Institute for Food and Health, Technical University Munich, 85354 Freising-Weihenstephan, Germany
| | - André Gessner
- Institute for Microbiology and Hygiene, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Maria J. G. T. Vehreschild
- Clinical Microbiome Research Group, Department of Internal Medicine I, University Hospital of Cologne, 50931 Cologne, Germany
- Section of Infectious Diseases, Department of Internal Medicine II, University Hospital Frankfurt, Goethe University Frankfurt, 60596 Frankfurt am Main, Germany
| | - Dirk Haller
- Chair of Nutrition and Immunology, Technical University Munich, 85354 Freising-Weihenstephan, Germany
- ZIEL-Institute for Food and Health, Technical University Munich, 85354 Freising-Weihenstephan, Germany
| | - Tobias Schwerd
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
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Panufnik P, Więcek M, Kaniewska M, Lewandowski K, Szwarc P, Rydzewska G. Selected Aspects of Nutrition in the Prevention and Treatment of Inflammatory Bowel Disease. Nutrients 2022; 14:nu14234965. [PMID: 36500995 PMCID: PMC9737796 DOI: 10.3390/nu14234965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Inflammatory bowel disease has become a global health problem at the turn of the 21st century. The pathogenesis of this disorder has not been fully explained. In addition to non-modifiable genetic factors, a number of modifiable factors such as diet or gut microbiota have been identified. In this paper, the authors focus on the role of nutrition in the prevention of inflammatory bowel disease as well as on the available options to induce disease remission by means of dietary interventions such as exclusive and partial enteral nutrition in Crohn's disease, the efficacy of which is reported to be comparable to that of steroid therapy. Diet is also important in patients with inflammatory bowel disease in the remission stage, during which some patients report irritable bowel disease-like symptoms. In these patients, the effectiveness of diets restricting the intake of oligo-, di-, monosaccharides, and polyols is reported.
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Affiliation(s)
- Paulina Panufnik
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Subunit, Central Clinical Hospital of Ministry of the Interior and Administration in Warsaw, 02-507 Warszawa, Poland
- Correspondence: (P.P.); (G.R.)
| | - Martyna Więcek
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Subunit, Central Clinical Hospital of Ministry of the Interior and Administration in Warsaw, 02-507 Warszawa, Poland
| | - Magdalena Kaniewska
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Subunit, Central Clinical Hospital of Ministry of the Interior and Administration in Warsaw, 02-507 Warszawa, Poland
| | - Konrad Lewandowski
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Subunit, Central Clinical Hospital of Ministry of the Interior and Administration in Warsaw, 02-507 Warszawa, Poland
| | - Paulina Szwarc
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Subunit, Central Clinical Hospital of Ministry of the Interior and Administration in Warsaw, 02-507 Warszawa, Poland
| | - Grażyna Rydzewska
- Clinical Department of Internal Medicine and Gastroenterology with Inflammatory Bowel Disease Subunit, Central Clinical Hospital of Ministry of the Interior and Administration in Warsaw, 02-507 Warszawa, Poland
- Collegium Medicum, Jan Kochanowski University, 25-317 Kielce, Poland
- Correspondence: (P.P.); (G.R.)
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7
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Dietary Therapy to Improve Nutrition and Gut Health in Paediatric Crohn’s Disease; A Feasibility Study. Nutrients 2022; 14:nu14214598. [DOI: 10.3390/nu14214598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Bovine colostrum (BC) has anti-inflammatory, anti-infective, growth and intestinal repair factors that may be beneficial in Crohn’s disease (CD). We assessed whether daily BC for up to 3 months was acceptable to children and young people (CYP) with CD in remission or of mild/moderate severity. CYP were randomised to receive either BC or matching placebo milk daily for 6 weeks (blinded phase); all received BC for the following 6 weeks (open phase). In 23 CYP, median (inter-quartile range) age was 15.2 (13.9–16.1) years and 9 (39.1%) were girls. A similar proportion of CYP in the BC and placebo arms completed the blinded phase (8/12, 75.0% and 9/11, 81.8% respectively). Twelve (70.6%) CYP completed the open phase with 7 (58.3%) tolerating BC for 3 months. Diaries in weeks 2, 6 and 12 revealed that most CYP took BC every day (5/7, 71.4%; 5/8, 62,5% and 6/11, 54.5% respectively). In interviews, opinions were divided as to preference of BC over the placebo milk and some preferred BC over other nutritional supplements. Symptoms, clinical and laboratory variables and quality of life were similar in the two arms. BC may be an acceptable nutritional supplement for daily, longer-term use in CYP with CD.
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Burgess D, McGrath KH, Watson C, Collins T, Brown S, Marks K, Dehlsen K, Herbison K, Landorf E, Benn L, Fox J, Liew M. Exclusive enteral nutrition: An optimal care pathway for use in children with active luminal Crohn's disease. J Paediatr Child Health 2022; 58:572-578. [PMID: 35181966 DOI: 10.1111/jpc.15911] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 12/30/2022]
Abstract
AIM Exclusive enteral nutrition (EEN) is recommended as a first-line therapy for active luminal paediatric Crohn's disease, by many contemporary consensus guidelines. However, EEN protocols vary internationally. A key enabler for the use of EEN therapy has been identified as the standardisation of protocols. The aim of this study was to develop an optimal care pathway for use of EEN in children with active luminal Crohn's disease. METHODS A working group of 11 paediatric gastroenterology dietitians and one paediatric gastroenterologist from Australia and New Zealand was convened to develop a standard optimal care pathway. Seven key areas were identified; clinical indications, workup assessments, EEN prescription, monitoring, food reintroduction, partial enteral nutrition and maintenance enteral nutrition. Recent literature was reviewed, assessed according to the National Health and Medical Research Council guidelines, and consensus statements were developed and voted on. Consensus opinion was used where literature gaps existed. RESULTS A total of nineteen consensus statements from the seven key areas were agreed upon. The consensus statements informed the optimal care pathway for children with active luminal undertaking EEN in Australia and New Zealand. CONCLUSION This study developed an EEN optimal care pathway to facilitate standardisation of clinical care for children with active luminal Crohn's disease, and hopefully improve clinical outcomes and identify areas for future research.
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Affiliation(s)
- Deirdre Burgess
- Department of Paediatric Gastroenterology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Caitlin Watson
- Department of Paediatric Dietetics, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Tanya Collins
- Department of Paediatric Dietetics, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Stephanie Brown
- Department of Paediatrics, Christchurch Public Hospital, Christchurch, New Zealand
| | - Katie Marks
- Children's Hospital Westmead, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
| | - Kate Dehlsen
- Sydney Children's Hospital, Sydney Children's Hospital Network, Sydney, New South Wales, Australia
| | - Kim Herbison
- Department of Paediatric Dietetics, Starship Children's Hospital, Auckland, New Zealand
| | - Emma Landorf
- Department of Paediatric Dietetics, Womens and Children's Hospital, Adelaide, South Australia, Australia
| | - Laura Benn
- Department of Paediatric Dietetics, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Julia Fox
- Department of Paediatric Dietetics, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ming Liew
- Department of Paediatric Dietetics, Queensland Children's Hospital, Brisbane, Queensland, Australia
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9
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Oral exclusive enteral nutrition for induction of clinical remission, mucosal healing, and improvement of nutritional status and growth velocity in children with active Crohn's disease - a prospective multicentre trial. GASTROENTEROLOGY REVIEW 2022; 16:346-351. [PMID: 34976243 PMCID: PMC8690944 DOI: 10.5114/pg.2021.111483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/10/2021] [Indexed: 11/17/2022]
Abstract
Introduction Undernutrition and growth failure are common problems in paediatric patients with active Crohn's disease (CD). Aim The aim of exclusive enteral nutrition (EEN) commencement is not only to induce clinical remission and promote mucosal healing but also to initiate weight and growth gain, especially in patients with poor nutritional status. We assessed the effectiveness of treatment with EEN and its impact on nutritional status in children with active CD. Material and methods Twenty children (male/female: 14/6) in median age of 14 years with active CD had EEN with polymeric industrial diet (Modulen IBD) applied for 6 weeks. The daily caloric intake was established according to the age and nutritional status. In patients with undernutrition, it was increased to 120-150% relative to recommendations for the healthy peers. The Paediatric CD activity index (PCDAI) - a marker of clinical remission, faecal calprotectin (FCP) - a marker of mucosal healing (MH), and nutritional status were assessed at baseline and 4 weeks following the end of the therapy (week 10). Results In the studied group the mean decrease in PCDAI score was statistically significant (from 25.6 ±12 to 5.4 ±10, p < 0.05). Full remission (defined as PCDAI < 10) was achieved in 65% of patients, and clinical response in another 30% of them. Only 5% of children did not respond to the treatment. Mean decline in FCP level was statistically significant as well (from 3380 ±7746 to 1046.6 ±1219, p < 0.05). All patients, apart from one who was fed with a nasogastric tube, accepted oral intake of industrial formula. EEN was generally well tolerated. Initially, in 20% of patients the symptoms of intolerance to the industrial diet were observed, but they receded within the first days of the therapy. The recommended daily intake of the formula was achieved in 95% of children. Only one child was unable to intake the prescribed amount of the diet due to intolerance. At baseline, undernutrition was observed in 30% of patients, which was established by a body mass index (BMI) score below the third percentile according to the recommended charts for the Polish paediatric population. In all patients, improvement in BMI status was reported at the end of the treatment. The mean increase in BMI score was 0.91, and it was greater in the malnourished group compared to patients with normal nutritional status (1.19 vs. 0.62). After the treatment two-thirds of children with malnutrition achieved a BMI score within the normal range. In 25% of patients, growth deficit was observed (defined as growth below the third percentile according to the Polish charts) before the EEN introduction. An increase in body height was obtained generally in 55% of children and in 80% of those with initial growth failure. The mean increase in growth was 1 cm, and it was greater in the group with initial growth deficit relative to patients with baseline normal height (1.5 cm vs. 0.8 cm, respectively). Conclusions A 6-week course of oral EEN was an effective and well-tolerated method of treatment in children with active CD. Nutritional therapy not only induced full clinical remission and led to decline in FCP level (as a marker of MH) in the majority of patients, but also contributed to the improvement in their nutritional status and growth velocity. These are very important observations because proper development is crucial for paediatric CD patients.
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10
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Borsani B, De Santis R, Perico V, Penagini F, Pendezza E, Dilillo D, Bosetti A, Zuccotti GV, D’Auria E. The Role of Carrageenan in Inflammatory Bowel Diseases and Allergic Reactions: Where Do We Stand? Nutrients 2021; 13:3402. [PMID: 34684400 PMCID: PMC8539934 DOI: 10.3390/nu13103402] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 12/17/2022] Open
Abstract
Carrageenan (CGN) is a high molecular weight polysaccharide extracted from red seaweeds, composed of D-galactose residues linked in β-1,4 and α-1,3 galactose-galactose bond, widely used as a food additive in processed foods for its properties as a thickener, gelling agent, emulsifier, and stabilizer. In recent years, with the spread of the Western diet (WD), its consumption has increased. Nonetheless, there is a debate on its safety. CGN is extensively used as an inflammatory and adjuvant agent in vitro and in animal experimental models for the investigation of immune processes or to assess the activity of anti-inflammatory drugs. CGN can activate the innate immune pathways of inflammation, alter the gut microbiota composition and the thickness of the mucus barrier. Clinical evidence suggests that CGN is involved in the pathogenesis and clinical management of inflammatory bowel diseases (IBD), indeed food-exclusion diets can be an effective therapy for disease remission. Moreover, specific IgE to the oligosaccharide α-Gal has been associated with allergic reactions commonly referred to as the "α-Gal syndrome". This review aims to discuss the role of carrageenan in inflammatory bowel diseases and allergic reactions following the current evidence. Furthermore, as no definitive data are available on the safety and the effects of CGN, we suggest gaps to be filled and advise to limit the human exposure to CGN by reducing the consumption of ultra-processed foods.
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Affiliation(s)
- Barbara Borsani
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20122 Milan, Italy; (R.D.S.); (V.P.); (F.P.); (E.P.); (D.D.); (A.B.); (G.V.Z.); (E.D.)
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11
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Diet and Nutrition in Pediatric Inflammatory Bowel Diseases. Nutrients 2021; 13:nu13020655. [PMID: 33671453 PMCID: PMC7922138 DOI: 10.3390/nu13020655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 12/17/2022] Open
Abstract
Both genetic and environmental factors are involved in the onset of inflammatory bowel disease (IBD). In particular, diet composition is suspected to significantly contribute to IBD risk. In recent years, major interest has raised about the role of nutrition in disease pathogenesis and course, and many studies have shown a clear link between diet composition and intestinal permeability impairment. Moreover, many IBD-related factors, such as poor dietary intake, nutrients loss and drugs interact with nutritional status, thus paving the way for the development of many therapeutic strategies in which nutrition represents the cornerstone, either as first-line therapy or as reversing nutritional deficiencies and malnutrition in IBD patients. Exclusive enteral nutrition (EEN) is the most rigorously supported dietary intervention for the treatment of Crohn's Disease (CD), but is burdened by a low tolerability, especially in pediatric patients. Promising alternative regimens are represented by Crohn's Disease Exclusion Diet (CDED), and other elimination diets, whose use is gradually spreading. The aim of the current paper is to provide a comprehensive and updated overview on the latest evidence about the role of nutrition and diet in pediatric IBD, focusing on the different nutritional interventions available for the management of the disease.
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12
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Disease-Related Knowledge in New Zealand Children with Inflammatory Bowel Disease (IBD) and Their Parents. GASTROINTESTINAL DISORDERS 2021. [DOI: 10.3390/gidisord3010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Insufficient disease-related knowledge can be a barrier to the effective management of the unpredictable and lifelong course of inflammatory bowel disease (IBD). Patients with chronic illnesses have high non-adherence rates, with direct clinical consequences. While no single intervention strategy can improve the adherence of all patients, the success of attempts to improve patient adherence depends upon the realistic assessment of patients’ knowledge and their understanding of the regimen. The aim of this study was to assess the disease-specific knowledge of the parents and patients with IBD in the South Island of New Zealand, and identify areas of poor knowledge. Families of children diagnosed with IBD were asked to complete the IBD Knowledge Inventory Device (IBD-KID). Patients 10 years and older were asked to participate along with their parents. Of 110 families, 91 responded, with completed questionnaires received from 153 parents and 66 patients. Overall, parents scored significantly higher (13.64 ± 3.88) than their children (10.03 ± 4.07; p < 0.001). Areas of poor knowledge included aspects of treatment (both conventional and alternative), along with long-term disease outcomes. This study has shown clear areas of concern in this population’s disease-specific knowledge of their disease. This should be addressed through targeted education for both the patient and the parents to improve not only their knowledge, but also their adherence and disease self-management.
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13
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McVeigh L, Payne A. Inducing remission in paediatric Crohn's disease using nutritional therapies - A systematic review. J Hum Nutr Diet 2019; 33:170-186. [PMID: 31797471 DOI: 10.1111/jhn.12714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is known to be a safe and effective treatment option for managing active Crohn's disease (CD) in children, although no uniform protocol exists. The aim of this systematic review was to evaluate and compare the clinical effectiveness of aspects of EEN protocols to ascertain whether an optimum regimen can be identified. METHODS A systematic search of the Cochrane Library, PubMed, MEDLINE, EMBASE, CINAHL and AMED was conducted for studies published between 1998 and 2018 that examined paediatric patients being treated with an enteral nutrition protocol to induce remission. Studies that included patients receiving concurrent medication for active disease were excluded. Quality assessment was performed using separate tools for randomised controlled trials, cohort studies and for studies without a control group. RESULTS Sixteen studies met the inclusion criteria. Of these, six found insufficient evidence to support use of a specific formula. One study examined the route of EEN, finding no difference between oral or nasogastric tube administration with respect to inducing remission. Three examined the use of partial enteral nutrition to induce remission, although conflicting results were seen. No studies explored the effect of length of treatment or energy prescription on remission rates CONCLUSIONS: An optimum enteral nutrition protocol for inducing remission cannot be identified. Further focused research is required by well designed, adequately powered prospective clinical trials to examine aspects of enteral feeding protocols that remain uncertain, including the use of partial enteral nutrition as a potential alternative to EEN.
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Affiliation(s)
- L McVeigh
- Nutrition and Dietetics Department, Bristol Royal Hospital for Children, Bristol, UK
| | - A Payne
- Faculty of Health & Human Sciences, School of Health Professions, The University of Plymouth, Plymouth, UK
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14
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Agin M, Yucel A, Gumus M, Yuksekkaya HA, Tumgor G. The Effect of Enteral Nutrition Support Rich in TGF-β in the Treatment of Inflammatory Bowel Disease in Childhood. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E620. [PMID: 31546703 PMCID: PMC6843769 DOI: 10.3390/medicina55100620] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 01/07/2023]
Abstract
Background and Objective: Malnutrition is a major complication of inflammatory bowel disease (IBD). Our aim of the study was to examine the effects of Modulen IBD supplementation, which was administered to IBD patients without limiting their daily diet in addition to medical treatment, on the clinical, laboratory, anthropometric values, and disease activities of these patients. Materials and Methods: Seventy three children with IBD were evaluated retrospectively. The cases were classified as those who had Crohn disease receiving (CD-M; n = 16) or not receiving Modulen IBD (CD; n = 19) and those who had ulcerative colitis receiving (UC-M; n = 13) or not receiving Modulen IBD (UC; n = 25). Disease activities, laboratory values, remission rates, and anthropometric measurements of the groups were compared. In addition to IBD treatment, Modulen IBD in which half of the daily calorie requirement was provided was given for eight weeks. Results: In the third month of treatment, 14 (88%) patients were in remission in CD-M group and eight (42%) patients were in remission in CD group. The height and weight z scores, which were low at the time of diagnosis, improved in the first week in CD-M group. Inflammatory parameters (UC) were significantly lower in the UC-M group compared to the UC group in first and third months. In the third month, eight (62%) patients in the UC-M group and four (16%) in the UC group were remitted clinically and in terms of laboratory values. Conclusions: TGF-β-rich enteral nutrition support in children with IBD is an easy, effective, and reliable approach. It was shown that TGF-β-rich enteral nutritional supplementation enabled the disease to enter the remission earlier, and contributed to the early recovery of weight and height scores.
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Affiliation(s)
- Mehmet Agin
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cukurova University Medical Faculty, Saricam, 01380 Adana, Turkey.
| | - Aylin Yucel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necmettin Erbakan University Medical Faculty, Meram, 42080 Konya, Turkey.
| | - Meltem Gumus
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necmettin Erbakan University Medical Faculty, Meram, 42080 Konya, Turkey.
| | - Hasan Ali Yuksekkaya
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necmettin Erbakan University Medical Faculty, Meram, 42080 Konya, Turkey.
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cukurova University Medical Faculty, Saricam, 01380 Adana, Turkey.
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15
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Kaenkumchorn T, Kesavan A. Dietary Management of Pediatric Inflammatory Bowel Disease. J Med Food 2019; 22:1092-1099. [PMID: 31329006 DOI: 10.1089/jmf.2019.0063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a life-long relapsing and remitting condition characterized by inflammation of the intestine. While the exact pathogenesis of IBD is unclear, the current belief is that both genetic and environmental factors play a role in development of disease. Management options include nutritional, pharmacological, and surgical therapies. In particular, nutritional therapies for IBD have garnered significant interest due to their limited side effect profile, bowel-sparing nature, and naturalistic approach. This review will examine the role of diet in the pathogenesis and malnutrition in IBD, and will discuss dietary approaches to management of IBD, including exclusive enteral nutrition, specific carbohydrate diet, anti-inflammatory diet, and food supplements (specifically curcumin and long-chain n-3 polyunsaturated fatty acids). Past and recent literature on these subjects were reviewed in Medhub and Scopus databases for this review article with a focus on pediatric and high-quality publications. At this time, these approaches seem to be safe and show promise of an efficacious sole or supplemental role in the treatment of IBD, but randomized, prospective studies are lacking. Additional studies investigating these diets and food supplements are needed to provide more information on their efficacy, mechanism, applicability, and safety.
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Affiliation(s)
- Tanyaporn Kaenkumchorn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Anil Kesavan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Rush University Children's Hospital, Chicago, Illinois, USA
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16
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Czuber-Dochan W, Morgan M, Hughes LD, Lomer MCE, Lindsay JO, Whelan K. Perceptions and psychosocial impact of food, nutrition, eating and drinking in people with inflammatory bowel disease: a qualitative investigation of food-related quality of life. J Hum Nutr Diet 2019; 33:115-127. [PMID: 31131484 DOI: 10.1111/jhn.12668] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Extensive research has provided an important understanding of the impact of inflammatory bowel disease (IBD) on nutrient intake, requirements and metabolism. By contrast, there has been limited research examining the psychosocial aspects of food, eating and drinking in IBD. The present study aimed to address this unmet need. METHODS Qualitative semi-structured interviews regarding the perceptions and psychosocial impact of food, eating and drinking were undertaken with 28 purposively selected people with IBD. Interviews were audio-recorded and transcribed verbatim. Colaizzi's framework was used to structure the data analysis. RESULTS Five major themes were identified. IBD symptoms and both surgical and medical treatments were described as having a direct impact on eating and drinking, with participants also using different food-related strategies to control IBD symptoms. These included a process of experimentation to identify trigger foods, following a severely restricted and limited diet, eating small portions, and eating more frequently. However, their limited knowledge about if, and how, food affected their symptoms, often resulted in negative coping strategies that impacted on psychosocial functioning, including a lack of enjoyment of eating, being afraid to eat and finding social occasions stressful. Managing food and drinking also made food shopping and preparation more burdensome, creating problems with families, at work and for social life, as well as the need for careful preparation and advanced planning of activities. CONCLUSIONS Inflammatory bowel disease has a profound impact on psychosocial aspects of food and nutrition, which impacts on 'food-related quality of life' (FRQoL). Further research is required to identify interventions that will improve FRQoL in patients with IBD.
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Affiliation(s)
- W Czuber-Dochan
- Department of Nutritional Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - M Morgan
- Institute of Pharmacological Sciences, King's College London, London, UK
| | - L D Hughes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M C E Lomer
- Department of Nutritional Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - J O Lindsay
- Barts Health NHS Trust, The Royal London Hospital, London, UK.,Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - K Whelan
- Department of Nutritional Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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17
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A Review of Dietary Therapy for IBD and a Vision for the Future. Nutrients 2019; 11:nu11050947. [PMID: 31035465 PMCID: PMC6566428 DOI: 10.3390/nu11050947] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 12/18/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory condition affecting the gastrointestinal tract. The rising incidence of IBD has been associated with urbanization and shifts toward a Westernized diet. The intestinal microbiome has been a focus of disease pathogenesis and also therapeutic intervention. Dietary therapy for IBD has been well-studied with exclusive enteral nutrition, a formula-based diet with the exclusion of foods. In addition, interest in food-based exclusion diets has been increasing, with patients and families leading the charge. Challenges with dietary therapy for IBD include the lack of understanding of a detailed mechanistic pathway to explain the impact of diet on IBD pathogenesis and the difficult nature of designing and implementing dietary clinical trials. Epidemiological studies have demonstrated associations and intervention studies have demonstrated efficacy, but specific dietary targets remain as hypotheses at present. Current IBD therapy focuses on suppression of the immune system, yet the incomplete efficacy of present drugs suggests that other therapies must be developed and employed. Dietary interventions, with known ability to modulate the intestinal microbiome, are a unique opportunity to improve outcomes in IBD. Dietary intervention trials are challenging, and capturing both broad dietary patterns as well as exposure to individual food compounds is important. With increasing patient interest and preliminary research in dietary therapy indicating efficacy, it is imperative to further advance the science of utilizing diet in IBD, as well as to support patients by proactively addressing diet within their care plan.
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18
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Kang Y, Park S, Kim S, Kim SY, Koh H. Therapeutic Efficacy of Exclusive Enteral Nutrition with Specific Polymeric Diet in Pediatric Crohn's Disease. Pediatr Gastroenterol Hepatol Nutr 2019; 22:72-79. [PMID: 30671376 PMCID: PMC6333584 DOI: 10.5223/pghn.2019.22.1.72] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The efficacy of exclusive enteral nutrition (EEN) with a polymeric diet has not been confirmed in Korean pediatric patients with Crohn's disease (CD). This study aimed to compare the effectiveness of EEN with a specific polymeric diet (Encover®) and corticosteroids (CSs) for the induction of remission in Korean pediatric CD patients. METHODS We retrospectively compared data from 51 pediatric CD patients who underwent induction therapy with EEN (n=19) or CSs (n=32) at Severance Children's Hospital or Incheon St. Mary's Hospital in Korea. The primary endpoint of this study was the rate of clinical remission, defined as a Pediatric Crohn's Disease Activity Index (PCDAI) score <10, after 8 weeks of induction treatment. Clinical, laboratory, and growth data at post-induction as well as their changes from baseline were also compared between groups. RESULTS After 8 weeks of induction therapy, clinical remission rates were 78.9% (15/19) and 65.6% (21/32) in the EEN and CS groups, respectively (p=0.313). No significant differences in PCDAI scores, laboratory variables, and growth parameters were noted between the two groups at post-induction. However, significant changes in albumin levels at post-induction were observed in the EEN group compared to the CS group (p=0.038). CONCLUSION Our results suggest that the effectiveness of EEN with a polymeric diet and CSs for induction therapy did not differ in Korean pediatric CD patients. EEN with a polymeric diet is a good first-line treatment option for the induction of remission in these patients.
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Affiliation(s)
- Yunkoo Kang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sowon Park
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Yong Kim
- Department of Pediatrics, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Hong Koh
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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19
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Gavin J, Marino LV, Ashton JJ, Beattie RM. Patient, parent and professional perception of the use of maintenance enteral nutrition in Paediatric Crohn's Disease. Acta Paediatr 2018; 107:2199-2206. [PMID: 30192409 DOI: 10.1111/apa.14571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/29/2018] [Accepted: 09/05/2018] [Indexed: 12/30/2022]
Abstract
AIM Maintenance enteral nutrition (MEN) is routinely used in Paediatric Crohn's Disease (CD) to prolong remission although there is limited evidence for efficacy and a lack of formal guidelines. This study surveyed patients', parents' and professional experience with MEN. METHODS Two questionnaires were developed to survey the experience of MEN; (i) Patients/Parents (children >10 years of age aimed to complete independently) and (ii) Dietitians. Questionnaires were sent to families prescribed MEN after exclusive enteral nutrition (EEN) between 2015-17 (n = 77) and dietitians working in paediatric regional centres in UK (n = 23). RESULTS Response rate to the questionnaires was 53% patients, 62% parents and 83% dietitians. Patients/parents reported medical/dietetic advice to be the primary factor affecting compliance, 30% patients reported side effects. Fifty-six per cent of patients/58% parents stated a preference for dietary advice rather than MEN. Dietetic responses indicated 79% used MEN after EEN as standard procedure and 79% did not have exit criteria for MEN. Sixty-eight per cent perceived the taste was the primary factor affecting patient compliance. CONCLUSION Patients' perception of the usefulness of MEN differs to professionals. This study highlights the extensive practice of MEN after EEN in clinical remission, which may not be nutritionally indicated. Patient preference is for dietary advice rather than MEN.
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Affiliation(s)
- J Gavin
- Department of Dietetics/SLT; University Hospital Southampton Foundation NHS Trust; Southampton UK
| | - L V Marino
- Department of Dietetics/SLT; University Hospital Southampton Foundation NHS Trust; Southampton UK
- Department of Human Genetics and Genomic Medicine; University of Southampton; Southampton UK
| | - J J Ashton
- Department of Human Genetics and Genomic Medicine; University of Southampton; Southampton UK
- Department of Paediatric Gastroenterology; Southampton Children's Hospital University Hospitals Southampton; Southampton UK
| | - R M Beattie
- Department of Paediatric Gastroenterology; Southampton Children's Hospital University Hospitals Southampton; Southampton UK
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20
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Copova I, Hradsky O, Zarubova K, Gonsorcikova L, Potuznikova K, Lerchova T, Nevoral J, Bronsky J. Fecal calprotectin is not a clinically useful marker for the prediction of the early nonresponse to exclusive enteral nutrition in pediatric patients with Crohn disease. Eur J Pediatr 2018; 177:1685-1693. [PMID: 30128744 DOI: 10.1007/s00431-018-3228-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 12/22/2022]
Abstract
Exclusive enteral nutrition (EEN) has been recommended as the first-line therapy in children with active Crohn disease (CD). The primary aim of our study was to determine whether it is possible to use the difference between basal fecal calprotectin (F-CPT) and the value at week 2 of EEN to predict clinical response at week 6. We prospectively collected stool samples for F-CPT analysis and clinical and laboratory parameters during EEN from 38 pediatric patients (28 boys, median age 12.8 years) with newly diagnosed active luminal CD. The difference between F-CPT concentrations before EEN and at week 2 did not predict clinical non-response at week 6 (OR 0.9996 95% CI 0.9989-1.0002, p = 0.18); however, it predicted patients who did not achieve clinical remission at week 6 (OR 0.9993, 95% CI 00.9985-0.9998, p = 0.006) with sensitivity of 58%, and specificity of 92% for cut-off of F-CPT increase by 486 μg/g.Conclusions: An early decrease in F-CPT levels in children with newly diagnosed active luminal CD did not predict clinical response at week 6 of EEN induction therapy, and clinical remission was predicted with low accuracy. Therefore, F-CPT cannot be used as a predictor to select the patients in whom EEN should be terminated. What is Known: • The fecal calprotectin (F-CPT) is an important marker of intestinal inflammation. • Approximately 25% of pediatric patients with Crohn disease (CD) do not achieve clinical remission, and there is still no sufficient predictor of response to exclusive enteral nutrition (EEN) treatment. What is New: • The difference between the F-CPT concentrations before EEN treatment and at week 2 did not predict clinical response to treatment at week 6, even if it predicted clinical remission, however, with low accuracy. F-CPT is not a suitable predictor to select the patients for discontinuing of EEN induction therapy.
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Affiliation(s)
- Ivana Copova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic.
| | - Ondrej Hradsky
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Kristyna Zarubova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Lucie Gonsorcikova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Kristyna Potuznikova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Tereza Lerchova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Jiri Nevoral
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
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Lee D, Swan CK, Suskind D, Wahbeh G, Vanamala J, Baldassano RN, Leonard MB, Lampe JW. Children with Crohn's Disease Frequently Consume Select Food Additives. Dig Dis Sci 2018; 63:2722-2728. [PMID: 29862484 PMCID: PMC6290903 DOI: 10.1007/s10620-018-5145-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/28/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Certain food additives may promote the pathogenesis of Crohn's disease (CD), but thus far the evaluation of food additive exposures in humans has been limited. The objective of this study was to quantify food additive exposures in children with CD. METHODS In a trial for bone health in CD, children were followed over 24 months with evaluation of disease characteristics, dietary intake, and body composition. At baseline, participants completed three 24-h dietary recalls. Foods were categorized, and the ingredient list for each item was evaluated for the presence of select food additives: polysorbate-80, carboxymethylcellulose, xanthan gum, soy lecithin, titanium dioxide, carrageenan, maltodextrin, and aluminosilicates. The frequency of exposures to these food additives was described for study participants and for food categories. RESULTS At study baseline, 138 participants, mean age 14.2 ± 2.8 years, 95% having inactive or mild disease, were enrolled and dietary recalls were collected. A total of 1325 unique foods were recorded. Mean exposures per day for xanthan gum was 0.96 ± 0.72, carrageenan 0.58 ± 0.63, maltodextrin 0.95 ± 0.77, and soy lecithin 0.90 ± 0.74. The other additives had less than 0.1 exposures per day. For the 8 examined food additives, participants were exposed to a mean (SD) of 3.6 ± 2.1 total additives per recall day and a mean (SD) of 2.4 ± 1.0 different additives per day. CONCLUSION Children with CD frequently consume food additives, and the impact on disease course needs further study.
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Affiliation(s)
- Dale Lee
- Seattle Children’s Hospital, 4800 Sand Point Way, Seattle WA 98105., Tel: (206) 987-7339. Fax: (206) 987-2721.,
| | - C. Kaiulani Swan
- Nutrition Sciences, University of Washington, Seattle, Washington, 4800 Sand Point Way, Seattle WA 98105., Tel: n/a Fax: n/a,
| | - David Suskind
- Seattle Children’s Hospital, 4800 Sand Point Way, Seattle WA 98105., Tel: (206) 987-2521. Fax: (206) 987-2721.,
| | - Ghassan Wahbeh
- Seattle Children’s Hospital, 4800 Sand Point Way, Seattle WA 98105., Tel: (206) 987-2521. Fax: (206) 987-2721.,
| | - Jairam Vanamala
- Penn State University, 326 Rodney A. Erickson Food Science Building, University Park, PA 16802, Tel: 814-865-6842,
| | - Robert N. Baldassano
- The Children’s Hospital of Philadelphia, 324 S. 34th Street, Philadelphia, PA 19194, Tel: (267) 426-5123. Fax: (215) 590-3606,
| | - Mary B. Leonard
- Chairman of Pediatrics Stanford University, 770 Welch Rd Ste 300, Palo Alto, CA 94304, Tel: (650) 723-5104. Fax: (650) 49806714,
| | - Johanna W. Lampe
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109., Tel: (206) 667-6580. Fax: (206) 667-7850,
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22
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Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:687-708. [PMID: 29570147 DOI: 10.1097/mpg.0000000000001896] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients. METHODS A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature. RESULTS A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD. CONCLUSIONS This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.
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23
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Alhagamhmad MH. Enteral Nutrition in the Management of Crohn's Disease: Reviewing Mechanisms of Actions and Highlighting Potential Venues for Enhancing the Efficacy. Nutr Clin Pract 2018; 33:483-492. [PMID: 29323428 DOI: 10.1002/ncp.10004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/12/2017] [Accepted: 10/10/2017] [Indexed: 12/16/2022] Open
Abstract
Crohn's disease (CD) is a chronic condition that affects the gut and has adverse effects on growth and development. There is a global increase in the incidence and prevalence rates, and several factors are believed to contribute to this rise, including dietary habits. In contrast, the use of enteral nutrition (EN) as an exclusive source of nutrition is increasingly becoming the preferred induction treatment of pediatric CD patients in part to address the nutrition complications. However, EN therapy is considered less effective in adults with CD. A better understanding of the molecular mechanisms of enteral therapy will help improve the clinical management of CD. It is increasingly becoming evident that the therapeutic utility of EN is in part due to the reversal of the microbial changes and the direct immunomodulatory effects. Moreover, there is a potential tendency for enhancing the efficacy of EN therapy by improving the palatability of the given formulas and, more important, by magnifying the anti-inflammatory properties. Recent observations have shown that the immunomodulatory effects of EN are mediated at least in part by blocking nuclear factor-κB. Furthermore, it is likely that several ingredients of EN contribute to this activity, in particular glutamine and arginine amino acids. In addition, manipulating the composition of EN therapy by altering concentrations of the key ingredients is found to have the potential for more efficient therapy. In this review, the underlying mechanisms of EN actions will be discussed further with a focus on the potential methods for enhancing the efficacy.
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Affiliation(s)
- Moftah H Alhagamhmad
- Faculty of Medicine, University of Benghazi (Al-Arab Medical University), Benghazi, Libya
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McIlroy J, Ianiro G, Mukhopadhya I, Hansen R, Hold GL. Review article: the gut microbiome in inflammatory bowel disease-avenues for microbial management. Aliment Pharmacol Ther 2018; 47:26-42. [PMID: 29034981 DOI: 10.1111/apt.14384] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 05/29/2017] [Accepted: 09/25/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The concept of an altered collective gut microbiota rather than identification of a single culprit is possibly the most significant development in inflammatory bowel disease research. We have entered the "omics" era, which now allows us to undertake large-scale/high-throughput microbiota analysis which may well define how we approach diagnosis and treatment of inflammatory bowel disease (IBD) in the future, with a strong steer towards personalised therapeutics. AIM To assess current epidemiological, experimental and clinical evidence of the current status of knowledge relating to the gut microbiome, and its role in IBD, with emphasis on reviewing the evidence relating to microbial therapeutics and future microbiome modulating therapeutics. METHODS A Medline search including items 'intestinal microbiota/microbiome', 'inflammatory bowel disease', 'ulcerative colitis', 'Crohn's disease', 'faecal microbial transplantation', 'dietary manipulation' was performed. RESULTS Disease remission and relapse are associated with microbial changes in both mucosal and luminal samples. In particular, a loss of species richness in Crohn's disease has been widely observed. Existing therapeutic approaches broadly fall into 3 categories, namely: accession, reduction or indirect modulation of the microbiome. In terms of microbial therapeutics, faecal microbial transplantation appears to hold the most promise; however, differences in study design/methodology mean it is currently challenging to elegantly translate results into clinical practice. CONCLUSIONS Existing approaches to modulate the gut microbiome are relatively unrefined. Looking forward, the future of microbiome-modulating therapeutics looks bright with several novel strategies/technologies on the horizon. Taken collectively, it is clear that ignoring the microbiome in IBD is not an option.
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Affiliation(s)
- J McIlroy
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - G Ianiro
- Internal Medicine, Gastroenterology and Liver Unit, Gastroenterology Area, Fondazione Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - I Mukhopadhya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - R Hansen
- Royal Hospital for Children, Glasgow, UK
| | - G L Hold
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Gavin J, Ashton JJ, Heather N, Marino LV, Beattie RM. Nutritional support in paediatric Crohn's disease: outcome at 12 months. Acta Paediatr 2018; 107:156-162. [PMID: 28901585 DOI: 10.1111/apa.14075] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/10/2017] [Accepted: 09/08/2017] [Indexed: 12/22/2022]
Abstract
AIM Paediatric Crohn's disease (CD) is associated with growth delay and poor nutritional status. Maintenance enteral nutrition (MEN) supplementation is a potential adjunct to improve growth/prolong remission. METHODS Newly diagnosed CD patients were identified. Anthropometry, treatments and outcomes were collected for 12 months following diagnosis. Data are presented as medians. RESULTS A total of 102 patients were identified (age = 13 years, 76% male), 58 (57%) completed exclusive enteral nutrition (EEN) as induction therapy, and 77 (75%) entered clinical remission. Following induction, 58 (57%) of all patients continued MEN and 44 (43%) consumed normal diet (ND). BMI Z-score increased (diagnosis-12 months) for EEN (-1.41 to -0.21 (p = <0.0001)) and steroid groups (-0.97 to -0.11 (p = 0.001)). BMI Z-score increased (post induction - 12 months) for MEN (-0.62 to -0.44 (p = 0.04)) but not ND (-0.33 to -0.4 (p = 0.79)). Height Z-score did not increase for any treatment group over 12 months. MEN and ND group relapse rates were similar at six months, MEN = 21/58 (36%); ND = 21/44 (48%) (p = 0.24) and 12 months, MEN = 24/58 (41%); ND = 13/44 (30%) (p = 0.22). Fewer patients treated with EEN then MEN relapsed less than six months, 14 of 43 (33%), compared to patients treated with steroids then ND 16/29 (55%) (p = 0.09). CONCLUSION BMI Z-score increased but height Z-score remained unchanged over 12 months for the MEN group. Use of MEN was not associated with prolonged time to relapse. Prospective studies are required to examine the utility of MEN.
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Affiliation(s)
- J Gavin
- Department of Dietetics; University Hospital Southampton Foundation NHS Trust; Southampton UK
| | - JJ Ashton
- Department of Paediatric Gastroenterology; Southampton Children's Hospital; University Hospitals Southampton; Southampton UK
- Department of Human Genetics and Genomic Medicine; University of Southampton; Southampton UK
| | - N Heather
- Department of Dietetics; University Hospital Southampton Foundation NHS Trust; Southampton UK
| | - LV Marino
- Department of Dietetics; University Hospital Southampton Foundation NHS Trust; Southampton UK
| | - RM Beattie
- Department of Paediatric Gastroenterology; Southampton Children's Hospital; University Hospitals Southampton; Southampton UK
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Sigall-Boneh R, Levine A, Lomer M, Wierdsma N, Allan P, Fiorino G, Gatti S, Jonkers D, Kierkus J, Katsanos KH, Melgar S, Yuksel ES, Whelan K, Wine E, Gerasimidis K. Research Gaps in Diet and Nutrition in Inflammatory Bowel Disease. A Topical Review by D-ECCO Working Group [Dietitians of ECCO]. J Crohns Colitis 2017; 11:1407-1419. [PMID: 28961811 DOI: 10.1093/ecco-jcc/jjx109] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
Although the current doctrine of IBD pathogenesis proposes an interaction between environmental factors and gut microbiota in genetically susceptible individuals, dietary exposures have attracted recent interest and are, at least in part, likely to explain the rapid rise in disease incidence and prevalence. The D-ECCO working group along with other ECCO experts with expertise in nutrition, microbiology, physiology, and medicine reviewed the evidence investigating the role of diet and nutritional therapy in the onset, perpetuation, and management of IBD. A narrative topical review is presented where evidence pertinent to the topic is summarised collectively under three main thematic domains: i] the role of diet as an environmental factor in IBD aetiology; ii] the role of diet as induction and maintenance therapy in IBD; and iii] assessment of nutritional status and supportive nutritional therapy in IBD. A summary of research gaps for each of these thematic domains is proposed, which is anticipated to be agenda-setting for future research in the area of diet and nutrition in IBD.
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Affiliation(s)
- Rotem Sigall-Boneh
- PIBD Research Center, Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Israel
| | - Arie Levine
- Paediatric Gastroenterology & Nutrition Unit, Wolfson Medical Center, Tel Aviv University, Israel
| | - Miranda Lomer
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust and King's College London, UK
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, VU University Medical Centre, The Netherlands
| | - Philip Allan
- Department of Translational Gastroenterology, John Radcliffe Hospital, UK
| | - Gionata Fiorino
- Department of Gastroenterology, IBD Center, Humanitas Research Hospital, Italy
| | - Simona Gatti
- Department of Paediatrics, Polytechnic University of Marche, Italy
| | - Daisy Jonkers
- Division Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, The Netherlands
| | - Jaroslaw Kierkus
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, Children's Memorial Health Institute, Poland
| | - Konstantinos H Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Greece
| | - Silvia Melgar
- APC Microbiome Institute, University College Cork, Ireland
| | - Elif Saritas Yuksel
- Department of Gastroenterology, Izmir Katip Celebi University Ataturk Teaching and Research Hospital, Turkey
| | - Kevin Whelan
- King's College London, Division of Diabetes and Nutritional Sciences, UK
| | - Eytan Wine
- Division of Paediatric Gastroenterology and Nutrition, Departments of Paediatrics and Physiology, University of Alberta, Canada
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Swaminath A, Feathers A, Ananthakrishnan A, Falzon L, Ferry SL. Systematic review with meta-analysis: enteral nutrition therapy for the induction of remission in paediatric Crohn's disease. Aliment Pharmacol Ther 2017; 46:645-656. [PMID: 28815649 PMCID: PMC5798240 DOI: 10.1111/apt.14253] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 03/30/2017] [Accepted: 07/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite potential adverse-events in a paediatric population, corticosteroids are used to induce remission in paediatric Crohn's disease. Exclusive enteral nutrition also induces remission, but is infrequently used in the USA because corticosteroids are considered the superior therapy. New data have become available since the publication of the most recent meta-analysis in 2007. AIM To see if current literature supports the use of EEN versus CS in paediatric populations. METHODS All studies with comparator arms of exclusive enteral nutrition and an exclusive corticosteroids, with remission clearly defined were identified by searching eight online databases. RESULTS Of 2795 identified sources, nine studies met our inclusion criteria. Eight of these (n = 451), had data that could be abstracted into our meta-analysis. Exclusive enteral nutrition was as effective as corticosteroids in inducing remission (OR = 1.26 [95% CI 0.77, 2.05]) in paediatric Crohn's disease. There was no difference between Exclusive enteral nutrition and corticosteroids efficacy when comparing newly diagnosed Crohn's (OR = 1.61 [95% CI .87, 2.98]) or relapsed (OR = 0.76 [95% CI .29-1.98]). Intestinal healing was significantly more likely among patients receiving Exclusive enteral nutrition compared to corticosteroids (OR = 4.5 [95% CI 1.64, 12.32]). There was no difference in the frequency of biomarker normalisation including CRP (OR = 0.85 [95% CI .44, 1.67]) and faecal calprotectin (OR 2.79 [95% CI .79-10.90]). CONCLUSIONS There is no difference in efficacy between exclusive enteral nutrition and corticosteroids in induction of remission in Crohn's disease in a paediatric population. Exploratory analyses suggest that a greater proportion of patients treated with exclusive enteral nutrition achieved mucosal healing.
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Affiliation(s)
- Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, New York, NY,
USA
| | | | | | - Louise Falzon
- Columbia University Medical Center, New York, NY, USA
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Connors J, Basseri S, Grant A, Giffin N, Mahdi G, Noble A, Rashid M, Otley A, Van Limbergen J. Exclusive Enteral Nutrition Therapy in Paediatric Crohn's Disease Results in Long-term Avoidance of Corticosteroids: Results of a Propensity-score Matched Cohort Analysis. J Crohns Colitis 2017; 11:1063-1070. [PMID: 28575325 PMCID: PMC5881686 DOI: 10.1093/ecco-jcc/jjx060] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/25/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Exclusive enteral nutrition [EEN] is recommended as a first-line induction therapy for paediatric Crohn's disease [CD] although corticosteroids [CS] are still used commonly. Our aim was to compare short- and long-term disease outcomes of paediatric CD patients initially managed with either EEN or CS. METHODS Medical records of newly diagnosed paediatric CD patients treated with EEN or CS as induction therapy were retrospectively reviewed. To minimise selection bias inherent in observational cohort studies, propensity analysis was carried out. Data on anthropometrics, medical history, and presenting phenotype were collected at time of diagnosis [baseline]; outcomes of interest, including medication use, hospitalisation, surgical procedures, and disease progression were assessed up to 6 years following diagnosis. RESULTS Of 127 patients reviewed, a total of 111 propensity-score matched CD patients receiving EEN [n = 76] or CS [n = 35] were analysed. By 4-12 weeks of induction therapy, 86.6% of EEN-treated patients achieved remission (Paediatric Crohn's Disease Activity Index [PCDAI] ≤ 7.5) compared with 58.1% of patients in the CS-treated group [p < 0.01]. Choice of EEN over CS for induction was associated with avoidance of corticosteroids over a 6-year follow-up period. Analysis of long-term linear growth, hospitalisation, need for biologic therapy, or surgical intervention did not reveal any significant differences. CONCLUSIONS These findings suggest that EEN induction therapy is more effective in achieving early remission and is associated with long-term steroid avoidance without increased use of biologics or need for surgery.
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Affiliation(s)
- Jessica Connors
- Division of Gastroenterology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Sana Basseri
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amy Grant
- Division of Gastroenterology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Nick Giffin
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gamal Mahdi
- Division of Gastroenterology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Angela Noble
- Division of Gastroenterology, IWK Health Centre, Halifax, Nova Scotia, Canada,Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mohsin Rashid
- Division of Gastroenterology, IWK Health Centre, Halifax, Nova Scotia, Canada,Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anthony Otley
- Division of Gastroenterology, IWK Health Centre, Halifax, Nova Scotia, Canada,Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Johan Van Limbergen
- Division of Gastroenterology, IWK Health Centre, Halifax, Nova Scotia, Canada,Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada,Corresponding author: Johan Van Limbergen, MD, PhD, Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, IWK Health Centre, Dalhousie University, 5850/5980 University Avenue, Halifax, Nova Scotia B3K 6R8, Canada. Tel.: [902] 470–8746/8225; fax: [902] 470–7249;
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Ishige T, Tomomasa T, Tajiri H, Yoden A. Japanese physicians' attitudes towards enteral nutrition treatment for pediatric patients with Crohn's disease: a questionnaire survey. Intest Res 2017; 15:345-351. [PMID: 28670231 PMCID: PMC5478759 DOI: 10.5217/ir.2017.15.3.345] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 11/22/2016] [Accepted: 12/01/2016] [Indexed: 01/04/2023] Open
Abstract
Background/Aims Enteral nutrition (EN) is recommended for the treatment of pediatric Crohn's disease (CD) in Japan. However, the indications and treatment protocols for EN vary among hospitals. In the present study, we aimed to determine how EN was administered to pediatric patients and whether physicians followed treatment guidelines in their practices. Methods Two types of questionnaires were administered to 32 physicians who were involved in the treatment of pediatric CD. The consensus questionnaire evaluated the physicians' attitudes towards EN, whereas the efficacy questionnaire collected data on patients with CD, aged <17 years, who had undergone induction therapy between 2006 and 2011. Results A total of 23 physicians responded to the questionnaires. The results of the consensus questionnaire indicated that 82% and 59% of study participants recommended EN treatment for all newly diagnosed pediatric patients with CD and all relapsed patients, respectively. Exclusive EN (EEN) and elemental formula were recommended by 84% and 85% of physicians, respectively. The efficacy questionnaire revealed that 57 of the 58 patients received EN. Elemental formula was used in 39 of 40 patients who were treated with EEN. Of these 40 patients, 27 were treated with EEN alone; of these, 22 (81%) achieved remission without any other treatment. The mean duration of EEN was 15.9 days. Conclusions EN is widely recommended by physicians treating pediatric CD in Japan. In contrast to Western countries, clinicians used elemental formula more often and with a shorter EEN treatment duration.
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Affiliation(s)
- Takashi Ishige
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Hitoshi Tajiri
- Department of Pediatrics, Osaka General Medical Center, Osaka, Japan
| | - Atsushi Yoden
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
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Däbritz J, Gerner P, Enninger A, Claßen M, Radke M. Inflammatory Bowel Disease in Childhood and Adolescence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:331-338. [PMID: 28597827 PMCID: PMC5470346 DOI: 10.3238/arztebl.2017.0331] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 11/17/2016] [Accepted: 03/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The incidence of inflammatory bowel disease (IBD) in childhood and adolescence is 5-11 cases per 100 000 persons per year, corresponding to a new diagnosis of IBD in 800-1470 patients in Germany each year. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed, including guidelines from Germany and abroad. RESULTS Children and adolescents with IBD often have extensive involvement and an aggressive course of disease. Nonetheless, infliximab and adalimumab are the only biological agents that have been approved for this group of patients. In Crohn's disease, exclusive enteral nutrition is the treatment of first choice for inducing a remission. Patients with (peri-)anal fistulae are treated primarily with infliximab. Corticosteroids and aminosalicylates should be used with caution. In contrast, children and adolescents with ulcerative colitis are treated with either aminosalicylates or prednisolone to induce a remission. As a rule, maintenance pharmacotherapy with thiopurines in Crohn's disease and severe ulcerative colitis, or with aminosalicylates in mild to moderate ulcerative colitis, is indicated for several years, at least until the end of puberty. Patients with refractory disease courses are treated with methylprednisolone, anti-TNF-α-antibodies, and/or calcineurin inhibitors. The spectrum of surgical interventions is the same as for adults. Specific aspects of the treatment of children and adolescents with IBD include adverse drug effects, the areas of nutrition, growth, and development, and the structured transition to adult medicine. CONCLUSION Children and adolescents with IBD or suspected IBD should be cared for by pediatric gastroenterologists in a center where such care is provided. Individualized treatment with multidisciplinary, family-oriented longterm care is particularly important. Drug trials in children and adolescents are needed so that the off-label use of drugs to patients in this age group can be reduced.
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Affiliation(s)
- Jan Däbritz
- Department of Pediatrics, University Hospital Rostock
- Centre for Immunobiology, Blizard Institute, Barts Cancer Institute the Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Großbritannien
| | | | | | - Martin Claßen
- Department of Pediatrics, Klinikum links der Weser, Bremen
| | - Michael Radke
- Department of Pediatrics, University Hospital Rostock
- Department of Pediatrics, Klinikum Westbrandenburg, Potsdam
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MacLellan A, Moore-Connors J, Grant S, Cahill L, Langille MGI, Van Limbergen J. The Impact of Exclusive Enteral Nutrition (EEN) on the Gut Microbiome in Crohn's Disease: A Review. Nutrients 2017; 9:nu9050447. [PMID: 28468301 PMCID: PMC5452177 DOI: 10.3390/nu9050447] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/18/2017] [Accepted: 04/26/2017] [Indexed: 12/17/2022] Open
Abstract
Crohn’s disease (CD), a form of inflammatory bowel disease (IBD), is thought to arise from a complex interaction of genetics, the gut microbiome, and environmental factors, such as diet. There is clear evidence that dietary intervention is successful in the treatment of CD—exclusive enteral nutrition (EEN) is able to induce remission in up to 80% of CD patients. While the mechanism of action of EEN is not clear, EEN is known to cause profound changes in the gut microbiome. Understanding how EEN modifies the gut microbiome to induce remission could provide insight into CD etiopathogenesis and aid the development of microbiome-targeted interventions to guide ongoing dietary therapy to sustain remission. This review includes current literature on changes in composition and function of the gut microbiome associated with EEN treatment in CD patients.
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Affiliation(s)
- Amber MacLellan
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
| | - Jessica Moore-Connors
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Shannan Grant
- Department of Applied Human Nutrition, Mount Saint Vincent University, Halifax, Nova Scotia, Canada.
| | - Leah Cahill
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
| | - Morgan G I Langille
- Department of Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Johan Van Limbergen
- Division of Pediatric Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia B3K 6R8, Canada.
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
- Department of Immunology & Microbiology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Yamamoto-Furusho J, Bosques-Padilla F, Daffra P, De Paula J, Etchevers J, Galiano M, Ibañez P, Juliao F, Kotze P, Marroquín de la Garza J, Monreal Robles R, Rocha J, Steinwurz F, Vázquez-Frías R, Veitia G, Zaltman C. Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part). REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Yamamoto-Furusho JK, Bosques-Padilla F, Daffra P, De Paula JA, Etchevers J, Galiano MT, Ibañez P, Juliao F, Kotze PG, Marroquín de la Garza JM, Monreal Robles R, Rocha JL, Steinwurz F, Vázquez-Frías R, Veitia G, Zaltman C. Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part). REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 82:134-155. [PMID: 28318706 DOI: 10.1016/j.rgmx.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 12/15/2022]
Abstract
This is the first Latin American Consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) regarding special situations in patients with inflammatory bowel disease (IBD). The aim of this consensus is to raise awareness in the medical community in all Latin American countries with respect to pregnancy, vaccinations, infections, neoplasms, including colorectal cancer, and pediatric issues in patients with IBD.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - F Bosques-Padilla
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - P Daffra
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - J A De Paula
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - J Etchevers
- Servicio de Gastroenterología, Hospital Italiano, Buenos Aires, Argentina
| | - M T Galiano
- Clínica de Enfermedad Inflamatoria Intestinal, Clínica Marly, Bogotá, Colombia
| | - P Ibañez
- Programa de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Clínica Las Condes, Santiago, Chile
| | - F Juliao
- Clínica de Enfermedad Inflamatoria Intestinal, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P G Kotze
- Hospital Universitario Cajuru, Universidad Católica del Paraná (PUCPR), Curitiba, Brasil
| | - J M Marroquín de la Garza
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - R Monreal Robles
- Servicio de Gastroenterología, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, México; Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, México
| | - J L Rocha
- Grupo Académico y de Investigación en Crohn y Colitis Ulcerosa Crónica Idiopática de México, Ciudad de México, México
| | - F Steinwurz
- Hospital Israelita Albert Einstein, São Paulo, Brasil
| | - R Vázquez-Frías
- Departamento de Gastroenterología Pediátrica, Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - G Veitia
- Servicio de Gastroenterología, Hospital Vargas, Caracas, Venezuela
| | - C Zaltman
- Servicio de Gastroenterología, Hospital Clementino Fraga Filho, Departamento de Medicina Interna, Universidad Federal do Rio de Janeiro (UFRJ), Río de Janeiro, Brasil
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Haskey N, Gibson DL. An Examination of Diet for the Maintenance of Remission in Inflammatory Bowel Disease. Nutrients 2017; 9:nu9030259. [PMID: 28287412 PMCID: PMC5372922 DOI: 10.3390/nu9030259] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/08/2017] [Accepted: 03/08/2017] [Indexed: 12/11/2022] Open
Abstract
Diet has been speculated to be a factor in the pathogenesis of inflammatory bowel disease and may be an important factor in managing disease symptoms. Patients manipulate their diet in attempt to control symptoms, often leading to the adoption of inappropriately restrictive diets, which places them at risk for nutritional complications. Health professionals struggle to provide evidence-based nutrition guidance to patients due to an overall lack of uniformity or clarity amongst research studies. Well-designed diet studies are urgently needed to create an enhanced understanding of the role diet plays in the management of inflammatory bowel disease. The aim of this review is to summarize the current data available on dietary management of inflammatory bowel disease and to demonstrate that dietary modulation may be an important consideration in managing disease. By addressing the relevance of diet in inflammatory bowel disease, health professionals are able to better support patients and collaborate with dietitians to improve nutrition therapy.
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Affiliation(s)
- Natasha Haskey
- Department of Biology, The Irving K. Barber School of Arts and Sciences, University of British Columbia, Room, ASC 368, 3187 University Way, Okanagan campus, Kelowna, BC V1V 1V7, Canada.
| | - Deanna L Gibson
- Department of Biology, The Irving K. Barber School of Arts and Sciences, University of British Columbia, Room, ASC 368, 3187 University Way, Okanagan campus, Kelowna, BC V1V 1V7, Canada.
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Alhagamhmad MH, Day AS, Lemberg DA, Leach ST. Exploring and Enhancing the Anti-Inflammatory Properties of Polymeric Formula. JPEN J Parenter Enteral Nutr 2017; 41:436-445. [PMID: 26826259 DOI: 10.1177/0148607115625627] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) therapy using a polymeric formula (PF) can substantially attenuate intestinal inflammation in Crohn's disease (CD) patients. However, the mechanism(s) by which EEN suppresses inflammation are not yet fully understood. The aims were to examine cellular mechanism(s) through which EEN may suppress inflammation and investigate potential pathways to enhance anti-inflammatory properties of EEN. METHODS Glutamine, arginine, vitamin D3, and α linolenic acid (ALA), present in PF, along with curcumin, were identified as immunoactive nutrient therapies. Tumor necrosis factor (TNF)-α-exposed HT-29 colonic epithelial cells were used to investigate the immunosuppressive activity of the nutrients by assessing their effect on cell viability, cell activity, chemokine response (interleukin-8 [IL-8]), nuclear factor (NF)-κB, P38 mitogen-activated protein kinase, IκB kinase (Iκκ), and nitric oxide (NO). RESULTS Cellular viability and activity were maintained with all nutrient treatments. Glutamine, arginine, and vitamin D3, but not ALA, significantly attenuated IL-8 production. Glutamine and arginine led to phosphorylation blockade of the signaling components in NF-κB and P38 pathways, reduction in kinase activity, and enhancement in NO production. Combining glutamine, arginine, and curcumin at optimal concentrations completely abolished the IL-8 response. CONCLUSIONS These data indicate that glutamine, arginine, and vitamin D3 can suppress inflammation at concentrations equivalent to those used in PF. The mechanisms of this action were mediated through influencing the NF-κB and P38 cascades. Glutamine and arginine-fortified PF with curcumin might be a promising option to enhance the effectiveness and expand the scope of EEN therapy in CD treatment.
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Affiliation(s)
- Moftah H Alhagamhmad
- 1 School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew S Day
- 1 School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- 2 Paediatrics, University of Otago, Christchurch, New Zealand
| | - Daniel A Lemberg
- 1 School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- 3 Department of Gastroenterology, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia
| | - Steven T Leach
- 1 School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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Outcomes of exclusive enteral nutrition in paediatric Crohn’s disease. Eur J Clin Nutr 2016; 71:185-191. [DOI: 10.1038/ejcn.2016.210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 09/04/2016] [Accepted: 09/26/2016] [Indexed: 12/21/2022]
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Kim HJ, Kim Y, Cho JM, Oh SH, Kim KM. Therapeutic Efficacy of Oral Enteral Nutrition in Pediatric Crohn's Disease: A Single Center Non-Comparative Retrospective Study. Yonsei Med J 2016; 57:1185-91. [PMID: 27401650 PMCID: PMC4960385 DOI: 10.3349/ymj.2016.57.5.1185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/04/2015] [Accepted: 03/11/2016] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Exclusive enteral nutrition (EEN) therapy effectively induces clinical remission in Crohn's disease (CD). It remains unclear, however, whether partial enteral nutrition (PEN) can maintain remission. This study was performed to determine the abilities of oral EEN and oral PEN to induce and maintain clinical remission in pediatric patients with CD, respectively. MATERIALS AND METHODS Pediatric patients with CD who received oral EEN at a single center in 2000-2014 were identified retrospectively. Remission rates of the EEN and PEN during the 2 years study period were determined. Risk factors for EEN and PEN failure were identified. RESULTS Of the 66 patients who started EEN, 61 (92%) completed the course. Clinical remission was achieved in 88% (58/66) of the patients. All 58 patients with remission continued with PEN: 43 (74%) were treatment adherent. The cumulative remission rates at 1 and 2 years were 67% and 52%, respectively. Differing from EEN, limited therapeutic efficacy of PEN was shown in severe CD patients. Female gender associated significantly with non-adherence. CONCLUSION Oral EEN and PEN effectively induced and maintained remission in a pediatric population. Non-adherence was a limiting factor in the success of therapy.
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Affiliation(s)
- Hyun Jin Kim
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Young Kim
- Department of Pediatrics, Kwangju Christian Hospital, Gwangju, Korea
| | - Jin Min Cho
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea.
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De Voogd FA, Gearry RB, Mulder CJ, Day AS. Osteoprotegerin: A novel biomarker for inflammatory bowel disease and gastrointestinal carcinoma. J Gastroenterol Hepatol 2016; 31:1386-92. [PMID: 26896745 DOI: 10.1111/jgh.13324] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 02/08/2016] [Accepted: 02/13/2016] [Indexed: 12/22/2022]
Abstract
Osteoprotegerin (OPG) is a member of the tumor necrosis factor receptor superfamily of proteins. Although initial data illustrated the key role that OPG plays in bone turnover, numerous recent reports indicate that OPG is also an important factor in inflammatory pathways and tumor cell survival. OPG contributes directly to inflammatory processes and has been evaluated as a novel non-invasive biomarker of gut inflammation. Furthermore, OPG affects cell turn-over, differentiation, death, and survival via extracellular pathways, correlating with worse prognosis in inflammatory bowel diseases and several gastrointestinal carcinomas. It is now clear that OPG has multiple functions and characteristics. This review gives an overview of OPG, highlights its roles in different extracellular pathways, and outlines how OPG could be used as a novel non-invasive biological marker in inflammatory bowel diseases and gastrointestinal carcinomas.
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Affiliation(s)
- Floris Ae De Voogd
- Departments of Paediatrics, University of Otago-Christchurch, Christchurch, New Zealand.,Department of Medicine, University of Otago-Christchurch, Christchurch, New Zealand
| | - Richard B Gearry
- Department of Medicine, University of Otago-Christchurch, Christchurch, New Zealand.,Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
| | - Christopher J Mulder
- Department of Gastroenterology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Andrew S Day
- Departments of Paediatrics, University of Otago-Christchurch, Christchurch, New Zealand.,Department of Paediatrics, Christchurch Hospital, Christchurch, New Zealand
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Response to Kaakoush et al. Am J Gastroenterol 2016; 111:1033-4. [PMID: 27356826 DOI: 10.1038/ajg.2016.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hradsky O, Copova I, Zarubova K, Nevoral J, Bronsky J. Time to Relapse in Children with Crohn's Disease Treated with Azathioprine and Nutritional Therapy or Corticosteroids. Dig Dis Sci 2016; 61:2041-50. [PMID: 26971092 DOI: 10.1007/s10620-016-4103-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 02/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The duration of remission has been shown to be longer in patients initially treated with exclusive enteral nutrition (EEN) compared to corticosteroids (CS). However, no published studies required concurrent immunomodulator [6-mercaptopurine or azathioprine (AZA)] use at the time of diagnosis. AIMS The aims of this retrospective study were to compare the duration of remission between patients initially treated with AZA in combination with CS or EEN and identify predictors of early relapse in these patients. METHODS Data from 65 newly diagnosed children with CD in clinical remission on either EEN or CS and commencing AZA at diagnosis were included. We compared duration of remission using physician global assessment and carried out Cox regression analysis to identify predictors of early relapse. Patients were followed up to the time of first relapse or for at least 12 months. RESULTS There were no differences in the duration of remission between patients initially treated with EEN or CS (p = 0.978). We identified younger age at diagnosis [hazard ratio (HR) 0.87, 95 CI 0.78-0.98, p = 0.016], lower height Z score at diagnosis (HR 0.61, 95 CI 0.44-0.85, p = 0.003), involvement of the upper gastrointestinal tract (HR 2.69, 95 CI 1.27-5.66, p = 0.009), and elevated platelet count at remission (HR 1.004, 95 CI 1.001-1.008, p = 0.021) as independent predictors of early relapse. CONCLUSIONS Neither induction regime demonstrated longer duration of remission of CD in patients treated with immunomodulators since the time of diagnosis.
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Affiliation(s)
- Ondrej Hradsky
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic.
| | - Ivana Copova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Kristyna Zarubova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Jiri Nevoral
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
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Begun J. Inflammatory bowel disease in the clinic: Escalation and de-escalation of therapy: A longitudinal case-based discussion. J Gastroenterol Hepatol 2016; 31 Suppl 1:12-3. [PMID: 26990807 DOI: 10.1111/jgh.13348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Jakob Begun
- Mater Hospital, Brisbane, Queensland, Australia. .,Mater Research Institute, Brisbane, Queensland, Australia. .,University of Queensland School of Medicine, Brisbane, Queensland, Australia.
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Matijašić M, Meštrović T, Perić M, Čipčić Paljetak H, Panek M, Vranešić Bender D, Ljubas Kelečić D, Krznarić Ž, Verbanac D. Modulating Composition and Metabolic Activity of the Gut Microbiota in IBD Patients. Int J Mol Sci 2016; 17:ijms17040578. [PMID: 27104515 PMCID: PMC4849034 DOI: 10.3390/ijms17040578] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 02/06/2023] Open
Abstract
The healthy intestine represents a remarkable interface where sterile host tissues come in contact with gut microbiota, in a balanced state of homeostasis. The imbalance of gut homeostasis is associated with the onset of many severe pathological conditions, such as inflammatory bowel disease (IBD), a chronic gastrointestinal disorder increasing in incidence and severely influencing affected individuals. Despite the recent development of next generation sequencing and bioinformatics, the current scientific knowledge of specific triggers and diagnostic markers to improve interventional approaches in IBD is still scarce. In this review we present and discuss currently available and emerging therapeutic options in modulating composition and metabolic activity of gut microbiota in patients affected by IBD. Therapeutic approaches at the microbiota level, such as dietary interventions alone or with probiotics, prebiotics and synbiotics, administration of antibiotics, performing fecal microbiota transplantation (FMT) and the use of nematodes, all represent a promising opportunities towards establishing and maintaining of well-being as well as improving underlying IBD symptoms.
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Affiliation(s)
- Mario Matijašić
- Center for Translational and Clinical Research, University of Zagreb School of Medicine, 10000 Zagreb, Croatia.
| | - Tomislav Meštrović
- Clinical Microbiology and Parasitology Unit, Polyclinic "Dr. Zora Profozić", Bosutska 19, 10000 Zagreb, Croatia.
| | - Mihaela Perić
- Center for Translational and Clinical Research, University of Zagreb School of Medicine, 10000 Zagreb, Croatia.
| | - Hana Čipčić Paljetak
- Center for Translational and Clinical Research, University of Zagreb School of Medicine, 10000 Zagreb, Croatia.
| | - Marina Panek
- Center for Translational and Clinical Research, University of Zagreb School of Medicine, 10000 Zagreb, Croatia.
| | - Darija Vranešić Bender
- Department of Internal Medicine, Division of Clinical Nutrition, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia.
| | - Dina Ljubas Kelečić
- Department of Internal Medicine, Division of Clinical Nutrition, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia.
| | - Željko Krznarić
- Department of Internal Medicine, Division of Clinical Nutrition, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia.
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Clinical Hospital Centre Zagreb, 10000 Zagreb, Croatia.
- Department of Internal Medicine, University of Zagreb School of Medicine, 10000 Zagreb, Croatia.
| | - Donatella Verbanac
- Center for Translational and Clinical Research, University of Zagreb School of Medicine, 10000 Zagreb, Croatia.
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Durchschein F, Petritsch W, Hammer HF. Diet therapy for inflammatory bowel diseases: The established and the new. World J Gastroenterol 2016; 22:2179-2194. [PMID: 26900283 PMCID: PMC4734995 DOI: 10.3748/wjg.v22.i7.2179] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/10/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Although patients with inflammatory bowel diseases (IBD) have a strong interest in dietary modifications as part of their therapeutic management, dietary advice plays only a minor part in published guidelines. The scientific literature shows that dietary factors might influence the risk of developing IBD, that dysbiosis induced by nutrition contributes to the pathogenesis of IBD, and that diet may serve as a symptomatic treatment for irritable bowel syndrome-like symptoms in IBD. The role of nutrition in IBD is underscored by the effect of various dietary therapies. In paediatric patients with Crohn’s disease (CD) enteral nutrition (EN) reaches remission rates similar to steroids. In adult patients, however, EN is inferior to corticosteroids. EN is not effective in ulcerative colitis (UC). Total parenteral nutrition in IBD is not superior to steroids or EN. The use of specific probiotics in patients with IBD can be recommended only in special clinical situations. There is no evidence for efficacy of probiotics in CD. By contrast, studies in UC have shown a beneficial effect in selected patients. For patients with pouchitis, antibiotic treatment followed by probiotics, like VSL#3 or Lactobacillus GG, is effective. When probiotics are used, the risk of bacterial translocation and subsequent bacteremia has to be considered. More understanding of the normal intestinal microflora, and better characterization of probiotic strains at the phenotypic and genomic levels is needed as well as clarification of the mechanisms of action in different clinical settings. A FODMAP reduced diet may improve symptoms in IBD.
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Comparative Effectiveness of Nutritional and Biological Therapy in North American Children with Active Crohn's Disease. Inflamm Bowel Dis 2015; 21:1786-93. [PMID: 25970545 DOI: 10.1097/mib.0000000000000426] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Therapeutic targets in pediatric Crohn's disease include symptoms, quality of life (QOL), and mucosal healing. Although partial enteral nutrition (PEN), exclusive enteral nutritional (EEN), and anti-tumor necrosis factor alpha (anti-TNF) therapy all improve symptoms, the comparative effectiveness of these approaches to improve QOL and achieve mucosal healing has not been assessed prospectively. METHODS In a prospective study of children initiating PEN, EEN, or anti-TNF therapy for Crohn's disease, we compared clinical outcomes using the Pediatric Crohn's Disease Activity Index (PCDAI), QOL (IMPACT score), and mucosal healing as estimated by fecal calprotectin (FCP). PCDAI, IMPACT, FCP, and diet (prompted 24-h recall) were measured at baseline and after 8 weeks of therapy. RESULTS We enrolled 90 children with active Crohn's disease (PCDAI, 33.7 ± 13.7; and FCP, 976 ± 754), of whom 52 were treated with anti-TNF, 22 with EEN, and 16 with PEN plus ad lib diet. Clinical response (PCDAI reduction ≥15 or final PCDAI ≤10) was achieved by 64% on PEN, 88% EEN, and 84% anti-TNF (test for trend P = 0.08). FCP ≤250 μg/g was achieved with PEN in 14%, EEN 45%, and anti-TNF 62% (test for trend P = 0.001). Improvement in overall QOL was not statistically significantly different between the 3 groups (P = 0.86). However, QOL improvement was the greatest with EEN in the body image (P = 0.03) domain and with anti-TNF in the emotional domain (P = 0.04). CONCLUSIONS Although PEN improved clinical symptoms, EEN and anti-TNF were more effective for decreasing mucosal inflammation and improving specific aspects of QOL.
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The major pathway by which polymeric formula reduces inflammation in intestinal epithelial cells: a microarray-based analysis. GENES AND NUTRITION 2015; 10:479. [PMID: 26183161 DOI: 10.1007/s12263-015-0479-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 07/02/2015] [Indexed: 12/12/2022]
Abstract
Nutritional therapy is well established as a means to induce remission in active Crohn's disease (CD). Evidence indicates that exclusive enteral nutrition (EEN) therapy for CD both alters the intestinal microbiota and directly suppresses the inflammatory response in the intestinal mucosa. However, the pathway(s) through which EEN suppresses inflammation is still unknown. Therefore, the aim of the current study was to use microarray technology to investigate the major pathway by which polymeric formula (PF) alters inflammatory processes in epithelial cells in vitro. HT-29 cells were grown to confluence and then co-cultured with tumour necrosis factor (TNF)-α (100 ng/ml) for 5 h in the presence or absence of PF, as used for EEN. Following incubation, RNA was extracted and subjected to polymerase chain reaction (PCR) and microarray analysis. Enzyme-linked immunosorbent assays were employed to evaluate cytokine protein levels. Neither TNF-α nor PF had a toxic effect on cells over the experimental period. Microarray analysis showed that PF modulated the expression of genes specifically linked to nuclear factor (NF)-κB, resulting in downregulation of a number of genes in this pathway. These findings were further confirmed by real-time PCR of selected dysregulated genes as well as reduced expression of IL-6 and IL-8 proteins following PF treatment. The results arising from this study provide evidence that PF alters the inflammatory responses in intestinal epithelial cells through modulation of the NF-κB pathway.
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Hamedi A, Rezaei H, Azarpira N, Jafarpour M, Ahmadi F. Effects of Malva sylvestris and Its Isolated Polysaccharide on Experimental Ulcerative Colitis in Rats. J Evid Based Complementary Altern Med 2015; 21:14-22. [PMID: 26045553 DOI: 10.1177/2156587215589184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/25/2015] [Indexed: 01/25/2023] Open
Abstract
Malva sylvestris is an edible plant that is consumed as a herbal supplement for its antiulcer and colon cleansing properties in traditional Persian medicine. This study was designed to evaluate its effects on ulcerative colitis, which is a chronic gastrointestinal inflammation. Colitis was induced by rectal instillation of acetic acid solution. Rats in different groups received aqueous, n-hexane, or ethanolic fractions of the plant before induction of colitis. Isolated polysaccharide of plant was also tested in 2 groups before and after induction of colitis. Macroscopic and microscopic evaluation of colitis showed that the aqueous fraction was very effective in preventing the inflammation and efficacy was lower for ethanolic and n-hexane fractions. Polysaccharide was effective in reducing signs of inflammation, especially as pretreatment. These beneficial effects provide evidences that this plant can be suggested for patients with this disease to improve their health condition or to reduce adverse effects of their medication.
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47
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Lahad A, Weiss B. Current therapy of pediatric Crohn’s disease. World J Gastrointest Pathophysiol 2015; 6:33-42. [PMID: 25977836 PMCID: PMC4419092 DOI: 10.4291/wjgp.v6.i2.33] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 04/02/2015] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD), including Crohn’s disease (CD) and ulcerative colitis, are chronic relapsing and remitting diseases of the bowel, with an unknown etiology and appear to involve interaction between genetic susceptibility, environmental factors and the immune system. Although our knowledge and understanding of the pathogenesis and causes of IBD have improved significantly, the incidence in the pediatric population is still rising. In the last decade more drugs and treatment option have become available including 5-aminosalicylate, antibiotics, corticosteroids, immunomodulators and biological agents. Before the use of anti-tumor necrosis factor (TNF)-α became available to patients with IBD, the risk for surgery within five years of diagnosis was very high, however, with anti-TNF-α treatment the risk of surgery has decreased significantly. In the pediatric population a remission in disease can be achieved by exclusive enteral nutrition. Exclusive enteral nutrition also has an important role in the improvement of nutritional status and maintained growth. In this review we summarize the current therapeutic treatments in CD. The progress in the treatment options and the development of new drugs has led to optimized tactics for achieving the primary clinical goals of therapy - induction and maintenance of remission while improving the patient’s growth and overall well-being.
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Lee D, Albenberg L, Compher C, Baldassano R, Piccoli D, Lewis JD, Wu GD. Diet in the pathogenesis and treatment of inflammatory bowel diseases. Gastroenterology 2015; 148:1087-106. [PMID: 25597840 PMCID: PMC4409494 DOI: 10.1053/j.gastro.2015.01.007] [Citation(s) in RCA: 265] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 12/14/2022]
Abstract
Some of the most common symptoms of the inflammatory bowel diseases (IBD, which include ulcerative colitis and Crohn's disease) are abdominal pain, diarrhea, and weight loss. It is therefore not surprising that clinicians and patients have wondered whether dietary patterns influence the onset or course of IBD. The question of what to eat is among the most commonly asked by patients, and among the most difficult to answer for clinicians. There are substantial variations in dietary behaviors of patients and recommendations for them, although clinicians do not routinely endorse specific diets for patients with IBD. Dietary clinical trials have been limited by their inability to include a placebo control, contamination of study groups, and inclusion of patients receiving medical therapies. Additional challenges include accuracy of information on dietary intake, complex interactions between foods consumed, and differences in food metabolism among individuals. We review the roles of diet in the etiology and management of IBD based on plausible mechanisms and clinical evidence. Researchers have learned much about the effects of diet on the mucosal immune system, epithelial function, and the intestinal microbiome; these findings could have significant practical implications. Controlled studies of patients receiving enteral nutrition and observations made from patients on exclusion diets have shown that components of whole foods can have deleterious effects for patients with IBD. Additionally, studies in animal models suggested that certain nutrients can reduce intestinal inflammation. In the future, engineered diets that restrict deleterious components but supplement beneficial nutrients could be used to modify the luminal intestinal environment of patients with IBD; these might be used alone or in combination with immunosuppressive agents, or as salvage therapy for patients who do not respond or lose responsiveness to medical therapies. Stricter diets might be required to induce remission, and more sustainable exclusion diets could be used to maintain long-term remission.
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Affiliation(s)
| | | | | | | | | | - James D. Lewis
- Co-Corresponding authors: James D. Lewis, Professor of Medicine and Epidemiology, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, 720 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, Office: (215) 573-5137, Fax: (215) 573-0813, ; Gary D. Wu, Professor of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Suite 915, Biomedical Research Building, 421 Curie Boulevard, Philadelphia, PA 19104, Office: (215) 898-0158, Fax: (215) 573-2024,
| | - Gary D. Wu
- Co-Corresponding authors: James D. Lewis, Professor of Medicine and Epidemiology, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, 720 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, Office: (215) 573-5137, Fax: (215) 573-0813, ; Gary D. Wu, Professor of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Suite 915, Biomedical Research Building, 421 Curie Boulevard, Philadelphia, PA 19104, Office: (215) 898-0158, Fax: (215) 573-2024,
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Ruemmele FM, Veres G, Kolho KL, Griffiths A, Levine A, Escher JC, Amil Dias J, Barabino A, Braegger CP, Bronsky J, Buderus S, Martín-de-Carpi J, De Ridder L, Fagerberg UL, Hugot JP, Kierkus J, Kolacek S, Koletzko S, Lionetti P, Miele E, Navas López VM, Paerregaard A, Russell RK, Serban DE, Shaoul R, Van Rheenen P, Veereman G, Weiss B, Wilson D, Dignass A, Eliakim A, Winter H, Turner D. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease. J Crohns Colitis 2014; 8:1179-207. [PMID: 24909831 DOI: 10.1016/j.crohns.2014.04.005] [Citation(s) in RCA: 741] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/14/2014] [Accepted: 04/14/2014] [Indexed: 02/07/2023]
Abstract
Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.
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Affiliation(s)
- F M Ruemmele
- Department of Paediatric Gastroenterology, APHP Hôpital Necker Enfants Malades, 149 Rue de Sèvres 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 2 Rue de l'École de Médecine, 75006 Paris, France; INSERM U989, Institut IMAGINE, 24 Bd Montparnasse, 75015 Paris, France.
| | - G Veres
- Department of Paediatrics I, Semmelweis University, Bókay János str. 53, 1083 Budapest, Hungary
| | - K L Kolho
- Department of Gastroenterology, Helsinki University Hospital for Children and Adolescents, Stenbäckinkatu 11, P.O. Box 281, 00290 Helsinki, Finland
| | - A Griffiths
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8 Toronto, ON, Canada
| | - A Levine
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, 62 HaLohamim Street, 58100 Holon, Israel
| | - J C Escher
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - J Amil Dias
- Unit of Paediatric Gastroenterology, Hospital S. João, A Hernani Monteiro, 4202-451, Porto, Portugal
| | - A Barabino
- Gastroenterology and Endoscopy Unit, Istituto G. Gaslini, Via G. Gaslini 5, 16148 Genoa, Italy
| | - C P Braegger
- Division of Gastroenterology and Nutrition, and Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - J Bronsky
- Department of Pediatrics, University Hospital Motol, Uvalu 84, 150 06 Prague, Czech Republic
| | - S Buderus
- Department of Paediatrics, St. Marien Hospital, Robert-Koch-Str.1, 53115 Bonn, Germany
| | - J Martín-de-Carpi
- Department of Paediatric Gastroenterolgoy, Hepatology and Nutrition, Hospital Sant Joan de Déu, Paseo Sant Joan de Déu 2, 08950 Barcelona, Spain
| | - L De Ridder
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - U L Fagerberg
- Department of Pediatrics, Centre for Clinical Research, Entrance 29, Västmanland Hospital, 72189 Västerås/Karolinska Institutet, Stockholm, Sweden
| | - J P Hugot
- Department of Gastroenterology and Nutrition, Hopital Robert Debré, 48 Bd Sérurier, APHP, 75019 Paris, France; Université Paris-Diderot Sorbonne Paris-Cité, 75018 Paris France
| | - J Kierkus
- Department of Gastroenterology, Hepatology and Feeding Disorders, Instytut Pomnik Centrum Zdrowia Dziecka, Ul. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - S Kolacek
- Department of Paediatric Gastroenterology, Children's Hospital, University of Zagreb Medical School, Klaićeva 16, 10000 Zagreb, Croatia
| | - S Koletzko
- Department of Paediatric Gastroenterology, Dr. von Hauner Children's Hospital, Lindwurmstr. 4, 80337 Munich, Germany
| | - P Lionetti
- Department of Gastroenterology and Nutrition, Meyer Children's Hospital, Viale Gaetano Pieraccini 24, 50139 Florence, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Via S. Pansini, 5, 80131 Naples, Italy
| | - V M Navas López
- Paediatric Gastroenterology and Nutrition Unit, Hospital Materno Infantil, Avda. Arroyo de los Ángeles s/n, 29009 Málaga, Spain
| | - A Paerregaard
- Department of Paediatrics 460, Hvidovre University Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - R K Russell
- Department of Paediatric Gastroenterology, Yorkhill Hospital, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - D E Serban
- 2nd Department of Paediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Children's Hospital, Crisan nr. 5, 400177 Cluj-Napoca, Romania
| | - R Shaoul
- Department of Pediatric Gastroenterology and Nutrition, Rambam Health Care Campus Rappaport Faculty Of Medicine, 6 Ha'alya Street, P.O. Box 9602, 31096 Haifa, Israel
| | - P Van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, Netherlands
| | - G Veereman
- Department of Paediatric Gastroenterology and Nutrition, Children's University Hospital, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - B Weiss
- Paediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52625 Tel Hashomer, Israel
| | - D Wilson
- Child Life and Health, Paediatric Gastroenterology, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh EH9 1LF, United Kingdom
| | - A Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Wilhelm-Epstein-Str. 4, 60431 Frankfurt/Main, Gemany
| | - A Eliakim
- 33-Gastroenterology, Sheba Medical Center, 52621 Tel Hashomer, Israel
| | - H Winter
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mass General Hospital for Children, 175 Cambridge Street, 02114 Boston, United States
| | - D Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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Duncan H, Buchanan E, Cardigan T, Garrick V, Curtis L, McGrogan P, Barclay A, Russell RK. A retrospective study showing maintenance treatment options for paediatric CD in the first year following diagnosis after induction of remission with EEN: supplemental enteral nutrition is better than nothing! BMC Gastroenterol 2014; 14:50. [PMID: 24645851 PMCID: PMC4234202 DOI: 10.1186/1471-230x-14-50] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 03/14/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A limited body of research suggests that ongoing maintenance enteral nutrition (MEN) can be beneficial in maintaining disease remission in Crohn's Disease (CD). We aimed to assess how achievable MEN is and whether it helps to prolong remission. METHODS Patients newly diagnosed with CD in 2010 and 2011 who commenced exclusive enteral nutrition (EEN) for 8 weeks were followed up for a year post diagnosis. All patients who took EEN were encouraged to continue MEN post EEN. Data on azathioprine use was also collected. Categorical variables were compared using chi-square/Fischer's exact test. Medians were expressed along with complete data ranges. RESULTS 59 patients (34 male, median age 11.07 years, range 2.5-16.33 years) were identified. 11/59 (18%) had a poor response to EEN and were switched to steroids. 48/59 patients completed 8 weeks EEN and achieved clinical remission/response. 46/48 patients received Modulen IBD®, 29/48 (60%) consumed EEN orally and 19/48 (40%) via NGT. 15/48 (31%) patients were able to continue MEN post EEN completion. MEN was consumed for a mean of 10.8 months (range 4-14 months). 14/15 patients drank MEN and 1/15 had MEN via NGT. Remission rates at 1 year in patients continuing MEN were 60% (9/15) compared to 15% (2/13) in patients taking no treatment (p = 0.001) and 65% (13/20) in patients taking azathioprine (p = 0.14). CONCLUSION A sub group of patients can continue MEN as a maintenance treatment and this seems a useful strategy, especially in those who are not commencing azathioprine.
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Affiliation(s)
- Hazel Duncan
- Department of Nutrition & Dietetics, Yorkhill Hospital Glasgow, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - Elaine Buchanan
- Department of Nutrition & Dietetics, Yorkhill Hospital Glasgow, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - Tracey Cardigan
- Department of Nutrition & Dietetics, Yorkhill Hospital Glasgow, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - Vikki Garrick
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Lee Curtis
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Paraic McGrogan
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Andrew Barclay
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Richard K Russell
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
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