Effect of Ensure, a defined formula diet, in patients with Crohn's disease

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

The Impact of Dietary Interventions on the Symptoms of Inflammatory Bowel Disease: A Systematic Review

Diet may be a successful part of the treatment plan for improving outcome in patients with inflammatory bowel disease (IBD). This study aimed to systematically review all published clinical trials evaluating the effects of a regular diet on symptoms of IBD. Three medical databases were searched for clinical trials evaluating an intervention that involved dietary manipulation using a regular diet on adults with IBD whose symptoms were objectively measured before and after the intervention. The most common types of regular diet interventions that we observed in the literature fell into the following three categories: low residue/low fiber diets, exclusion diets, or other specific diets. Of all included studies, the few that were of higher quality and that observed a statistically significant improvement in symptoms in the diet group compared to the control group fell under the exclusion diet group or the other specific diet group. We were able to identify several high quality clinical trials evaluating dietary manipulations on symptoms of IBD. Exclusion diets and the low FODMAP diet are two areas identified in this review that show promise for having therapeutic benefits for patients with IBD.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested as the initial approach for managing disease-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice in adults with disease-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements combined with dietary advice and to compare the effects of dietary advice with oral nutritional supplements.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearching.Last search: 14 February 2010.

SELECTION CRITERIA

Randomised controlled trials of dietary advice with or without oral nutritional supplements in people with disease-related malnutrition in any health-care setting compared with no advice, oral nutritional supplements or dietary advice given alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, risk of bias and extracted data.

MAIN RESULTS

Forty-five studies (3186 participants) met the inclusion criteria; (dietary advice compared with: no advice (1053 participants); with oral nutritional supplements (332 participants); with dietary advice and oral nutritional supplements (731 participants); and dietary advice plus oral nutritional supplements compared with no additional intervention (1070 participants). Follow-up ranged from 18 days to 24 months. No comparison showed a significant difference between groups for mortality or morbidity. There was a significant change in weight found between groups when comparing dietary advice to no advice for interventions lasting greater than 12 months, mean difference 3.75 kg (95% confidence interval 0.97 to 6.53), and when all studies were combined, mean difference 1.47 kg (95% confidence interval 0.32 to 2.61) although there was significant heterogeneity in the combined analysis (I(2) = 90%). Similar improvements in weight were found for the comparison of dietary advice with nutritional supplements if required versus no advice, mean difference 2.20 kg (95% confidence interval 1.16 to 3.25). Dietary advice compared with no advice was also associated with significantly improved mid-arm muscle circumference when all studies were combined, but with moderate heterogeneity, mean difference 0.81 mm (95% confidence interval 0.31 to 1.31). Dietary advice given with nutritional supplements compared with dietary advice alone resulted in improvements in: mid-arm muscle circumference, mean difference -0.89 mm (95% confidence interval -1.35 to -0.43); triceps skinfold thickness, mean difference -1.22 mm (95% confidence interval -2.34 to -0.09); and grip strength, mean difference -1.67 kg (95% confidence interval -2.96 to -0.37), although the effects on triceps skinfold thickness and grip strength were heterogeneous. Dietary advice with supplements if required resulted in a significant increase in triceps skinfold thickness compared with no advice, mean difference 0.40 mm (95% confidence interval 0.10 to 0.70), although these results are from a single trial with only 29 participants.

AUTHORS' CONCLUSIONS

Evidence of variable quality suggests that dietary advice with or without oral nutritional supplements may improve weight, body composition and grip strength. We found no evidence of benefit of dietary advice or oral nutritional supplements given alone or in combination on survival. Studies addressing the impact of nutritional interventions on nutritional, functional and patient-centred outcomes are needed.

Dietary advice for illness-related malnutrition in adults

BACKGROUND

Illness-related malnutrition has been reported in 10% to 55% of ill people in hospital and the community in areas of food sufficiency. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested for managing illness-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice to improve nutritional intake in adults with illness-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements given in combination with dietary advice.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional studies were sought by contacting dietitians, clinicians and the manufacturers of nutritional supplements. Last search: September 2007

SELECTION CRITERIA

Randomised controlled trials of dietary advice in people with illness-related malnutrition compared with:(1) no advice;(2) oral nutritional supplements; and(3) dietary advice plus oral nutritional supplements.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality and extracted data.

MAIN RESULTS

Thirty-six studies (37 comparisons) met the inclusion criteria with 2714 randomised participants. Twelve trials (comparing dietary advice plus supplements if required with no advice) identified during searching are included as a separate comparison. Follow up ranged from 18 days to 24 months. No comparison showed a significant difference in mortality. There are several significant results for change in weight and other nutritional indices favouring nutritional intervention, but the precise contributions of the different strategies have yet to be determined. It is uncertain whether nutritional supplements and dietary advice produce the same effects. There was insufficient evidence to draw conclusions about clinical outcomes and cost. Few data were available for other outcomes.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence for the provision of dietary advice in managing illness-related malnutrition. Dietary advice plus nutritional supplements may be more effective than dietary advice alone or no advice in enhancing short-term weight gain, but whether this is sustainable, or whether survival and morbidity are improved remains uncertain. A large adequately-powered randomised controlled trial is needed comparing the efficacy of different therapies to increase dietary intake in people with illness-related malnutrition and examining the impact of this on clinical function and survival.

Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials

BACKGROUND

Both parenteral nutrition (PN) and enteral nutrition (EN) are widely advocated as adjunctive care in patients with various diseases. A systematic review of 82 randomized controlled trials (RCTs) of PN published in 2001 found little, if any, effect on mortality, morbidity, or duration of hospital stay; in some situations, PN increased infectious complication rates.

OBJECTIVE

The objective was to assess the effect of EN or volitional nutrition support (VNS) in individual disease states from available RCTs.

DESIGN

We conducted a systematic review. RCTs comparing EN or VNS with untreated controls, or comparing EN with PN, were identified and separated according to the underlying disease state. Meta-analysis was performed when at least three RCTs provided data. The evidence from the RCTs was summarized into one of five grades. A or B, respectively, indicated the presence of strong or weak (low-quality RCTs) evidence supporting the use of the intervention. C indicated a lack of adequate evidence to make any decision about efficacy. D indicated that limited data could not support the intervention. E indicated either that strong data found no effect, or that either strong or weak data suggested that the intervention caused harm.

PATIENTS AND SETTINGS

RCTs could include either hospitalized or nonhospitalized patients. The EN or VNS had to be provided as part of a treatment plan for an underlying disease process.

INTERVENTIONS

The RCT had to compare recipients of either EN or VNS with controls not receiving any type of artificial nutrition or had to compare recipients of EN with recipients of PN.

OUTCOME MEASURES

These were mortality, morbidity (disease specific), duration of hospitalization, cost, or interventional complications. SUMMARY OF GRADING: A: No indication was identified. B: EN or VNS in the perioperative patient or in patients with chronic liver disease; EN in critically ill patients or low birth weight infants (trophic feeding); VNS in malnourished geriatric patients. (The low-quality trials found a significant difference in survival favoring the VNS recipients in the malnourished geriatric patient trials; two high-quality trials found nonsignificant differences that favored VNS as well.) C: EN or VNS in liver transplantation, cystic fibrosis, renal failure, pediatric conditions other than low birth weight infants, well-nourished geriatric patients, nonstroke neurologic conditions, AIDS; EN in acute pancreatitis, chronic obstructive pulmonary disease, nonmalnourished geriatric patients; VNS in inflammatory bowel disease, arthritis, cardiac disease, pregnancy, allergic patients, preoperative bowel preparation. D: EN or VNS in patients receiving nonsurgical cancer treatment or in patients with hip fractures; EN in patients with inflammatory bowel disease; VNS in patients with chronic obstructive pulmonary disease. E: EN in the first week in dysphagic, or VNS at any time in nondysphagic, stroke patients who are not malnourished; dysphagia persisting for weeks will presumably ultimately require EN.

CONCLUSIONS

There is strong evidence for not using EN in the first week in dysphagic, and not using VNS at all in nondysphagic, stroke patients who are not malnourished. There is reasonable evidence for using VNS in malnourished geriatric patients. The recommendations to consider EN/VNS in perioperative/liver/critically ill/low birth weight patients are limited by the low quality of the RCTs. No evidence could be identified to justify the use of EN/VNS in other disease states.

Dietary advice for illness-related malnutrition in adults

BACKGROUND

Illness-related malnutrition has been reported in 10% to 55% of ill people in hospital and the community in areas of food sufficiency. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested for managing illness-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice to improve nutritional intake in adults with illness-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements given in combination with dietary advice.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional studies were sought by contacting dietitians, clinicians and the manufacturers of nutritional supplements. Last search: October 2006

SELECTION CRITERIA

Randomised controlled trials of dietary advice in people with illness-related malnutrition compared with:(1) no advice;(2) oral nutritional supplements; and(3) dietary advice plus oral nutritional supplements.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality and extracted data.

MAIN RESULTS

Thirty-five studies (37 comparisons) met the inclusion criteria with 2648 randomised participants. Twelve trials (comparing dietary advice plus supplements if required with no advice) identified during searching are included as a separate comparison. Follow up ranged from 18 days to 24 months. No comparison showed a significant difference in mortality. Significant improvements in weight at three months were found for groups receiving dietary advice plus nutritional supplements compared with dietary advice alone, WMD 1.68 kg (95% CI 0.14 to 3.21) or no additional advice, WMD 1.97 (95% CI 0.07 to 3.86). There were significant improvements in grip strength and mid-arm muscle circumference in the advice plus supplement groups compared with dietary advice alone. It is uncertain whether nutritional supplements and dietary advice produce the same effects. No significant differences were found between groups for clinical outcomes. Few data were available for other outcomes.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence for the provision of dietary advice in managing illness-related malnutrition. Dietary advice plus nutritional supplements may be more effective than dietary advice alone or no advice in enhancing short-term weight gain, but whether this is sustainable, or whether survival and morbidity are improved remains uncertain. A large adequately-powered randomised controlled trial is needed comparing the efficacy of different therapies to increase dietary intake in people with illness-related malnutrition and examining the impact of this on clinical function and survival.

Remission following an elemental diet or prednisolone in Crohn's disease

The short- and long-term effects of an elemental diet in children with acute Crohn's disease were compared with those of prednisolone in historical controls. Clinical remission was induced in 25 of 30 and in 18 of 28 episodes treated for six weeks with an elemental diet and prednisolone. Patients with proximal disease had longer remission after treatment with an elemental diet (p < 0.05) than did patients with colonic disease after treatment with prednisolone (p < 0.01). Disease activity index score improved in both groups compared with the pretreatment scores (p < 0.05). However, the improvement in the elemental diet group was significantly better than in the prednisolone group (p < 0.001). Changes in linear growth were better after treatment with an elemental diet compared with steroids (p < 0.001). Serum albumin and haematocrit concentrations all improved significantly in the children treated with an elemental diet (p < 0.001) but not in those treated with steroids. Thus an elemental diet was better than prednisolone in proximal disease and confirmed improved growth and nutritional status.

Enteral feeding as sole treatment for Crohn's disease: controlled trial of whole protein v amino acid based feed and a case study of dietary challenge

A controlled trial was performed to compare enteral feeding with either an amino acid based feed or a whole protein feed as sole treatment for active Crohn's disease. Twenty four patients were studied (nine with ileal, 11 with ileocolonic, and four with colonic disease). Both feeds proved effective; nine of 13 patients randomised to receive the amino acid based feed were in clinical remission within three weeks as defined by a simple activity index compared with eight of 11 treated with the whole protein feed. Patients in clinical remission were then crossed over onto the other feed. None of the six patients who were changed to the whole protein feed relapsed over the subsequent three week period compared with three of seven patients who were changed to the amino acid based feed. In responders the median serum C reactive protein concentration fell from 21 mg/l (range 9-82) on entry to 6 mg/l (range 3-19) at six weeks. Seven patients relapsed within eight months of starting solid food (mean 3.7 months), while nine were still in remission (follow up period 3-9 months, median six months). Detailed studies of staged reintroduction of food and permitted food additives were carried out over a four year period in a patient with extensive stricturing small bowel Crohn's disease who had been brought into remission by open treatment with enteral feeding. Carrageenan, other permitted emulsifiers, bread, meat, potatoes, oranges, refined sugar, dairy produce, flour, and rice were all reintroduced without any objective ill effect, but green vegetables provoked a clinical and biochemical relapse within one week of introduction. Remission was rapidly achieved by switching back to the enteral feed but reintroduction of the low residue diet that had been previously tolerated produced a brisk relapse. Clinical and biochemical remission was again achieved by a return to the enteral feed but relapse again occurred with reintroduction of the low residue diet. These studies confirm the therapeutic effect of enteral feeding in Crohn's disease. This effect does not seem to be due to avoidance of whole protein, but the very low residue of chemically defined enteral feeds may be important, particularly in patients with intestinal strictures.

Ten years' experience with an elemental diet in the management of Crohn's disease

The immediate and longterm outcome of treating patients with acute Crohn's disease with an elemental diet was studied retrospectively. Successful diet induced remission was achieved in 96 of 113 patients (85%) regardless of age, sex, site or severity of disease, or associated complications of strictures, fistula, or perianal disease. Treatment was unsuccessful in 17 patients (15%), but there were no features at the outset of treatment that distinguished these patients from those who had successful remission. The longterm outcome of treatment was assessed over a five year period by analysis of life tables and survival curves. Twenty two per cent of the patients relapsed within six months of treatment and thereafter the annual relapse rate was 8-10%. Patients with disease complicated by fistula or perianal involvement had early relapse, approaching 100% for the latter. A further retrospective comparison of longterm outcome of diet v steroid induced remissions showed no significant difference in the relapse rates between the two groups at one, three, and five years.

Nutritional consequences of inflammatory bowel disease on growth

This review summarizes much of the current information concerning the problem of growth failure in children and adolescents with inflammatory bowel disease. Growth impairment is discussed as a dynamic process and ways of recognizing and monitoring subtle changes in growth velocity are presented. Factors which contribute to growth delay are described, with special attention to prolonged insufficient nutrient intake. Studies using different methods of nutritional intervention to reverse growth failure are presented as a guide to the management of this challenging group of patients.