Introduction

Dietary fatty acids impact the fatty acid profile of cell membranes and act as a source of fatty acids for many key physiological pathways. Overconsumption of n-6 polyunsaturated fatty acids (PUFAs) with low intake of n-3 PUFAs is associated with the pathogenesis of inflammatory-driven diet-related chronic diseases, including CD. Derivatives of n-6 PUFAs, such as arachidonic acid (AA) are involved in the proinflammatory cascade, whereas the n-3 PUFAs (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)) maintain anti-inflammatory homeostasis. Considering that fatty acids in the cell membrane may be relevant to inflammation, we examined how changing the fatty acid composition of the diet would alter the erythrocyte cell membrane's (EM) fatty acid profile in adult patients with mild-moderate luminal CD following the CD Therapeutic Dietary Intervention (CD-TDI).

Aims & Methods

This is a sub-study (n=24, 46% female, median age 43(31-54)) of an ongoing RCT designed to determine the effectiveness of the CD-TDI to induce clinical and biomarker remission in patients with CD. We examined how the fatty acid profile of the EM changes in adults with mild-moderate luminal CD (n=13) that follow the CD-TDI or their habitual diet (HD) (n=11) for 13 weeks. The CD-TDI is a whole-food diet which incorporates principles of the Mediterranean diet, with one strategy being to shift the fatty acid profile by limiting dietary sources of n-6 PUFA, increasing dietary sources of n-3 PUFA and monounsaturated fatty acids (MUFA). The HD did not change their dietary intake. Blood samples were collected at Week 0 (W0) and Week 13 (W13) and analyzed for EM fatty acid composition. Fatty acids were extracted using a combined extraction and methylation protocol with direct-injection gas chromatography to quantify long-chain fatty acids from the EM. Dietary intake was evaluated using the ASA 24-hour Dietary Assessment Tool^®.

Results

Diet analysis comparing intakes from W0 to W13 revealed a significant reduction in AA intake (p=0.05) with a trend for increased intake of n-3 PUFA from DHA (p=0.07). The HD group had a significantly higher intake of AA (p=0.03), with no other dietary changes in fatty acid intakes observed within or between groups. In the EM of the CD-TDI group, within-group differences at W13 showed a lower percentage of arachidonic acid (n-6 PUFA) (0.3±0.3% vs. 0.1±0.1%, p=0.03), a significant increase in oleic acid (MUFA) (12±2.3% vs 13±2.2% p=0.02) and a trend for higher DHA (n-3 PUFA) (2.9±0.9% vs. 3.4±0.9%; p=0.08). No significant differences within groups were observed in the HD at W0 and W13. Between-group differences at W13 demonstrated that the CD-TDI group had a significantly higher mean percentage of total EM n-3 PUFAs than the HD (4.4% vs. 3.2%; p=0.005). At week 13 a higher EM PUFA balance (EPA+DHA/n-6 PUFA) was observed between groups (CDI:15±3.1% vs HD:11±2.1%; p=0.002). PUFA balance was inversely correlated to the change in the intestinal biomarker fecal calprotectin at W13 in the CDI-group (r2=0.634; p=0.03).

Conclusion

The CD-TDI altered the fatty acid profile of the EM in patients with mild-moderately active CD. Within the EM, the CD-TDI group demonstrated significant reductions in the proinflammatory mediatory AA while increasing oleic acid, total n-3 PUFA, leading to a higher PUFA balance which correlated with intestinal biomarkers of mucosal inflammation. More research is needed to fully understand the relationship between EM and gut inflammation to determine the underlying mechanisms involved.

Introduction

Exclusive enteral nutrition (EEN) is effective and commonly used to induce remission in pediatric Crohn’s disease (CD). Nevertheless, the reasons for its low usage in adult patients are not fully understood. We aimed to identify the barriers to EEN use, evaluate the approaches of patients and physicians, and compare them.

Aims & Methods

An online questionnaire was sent to adult CD patients and gastroenterologists. The questionnaires included demographics, disease characteristics, education, previous EEN exposure, approach to EEN and approach to potential barriers (Likert scale of 1-5). Descriptive analysis was followed by comparative analysis of patients/physicians reluctant to use/provide EEN and those who were not reluctant. Logistic regression was applied to search for variables and potential barriers associated with EEN-reluctance. An association network was generated to visualize how different barriers contribute to reluctance to trying EEN.

Results

Three-hundred and fifteen CD patients and 42 physicians completed the questionnaire. The mean age was 36.7 (SD±16) with a median disease duration of 10 (range 0-60) years. Previous EEN use was reported by 40% (n=101), while EEN-reluctance was reported by 20.3% (n=64). No significant baseline variables were found to be associated with EEN reluctance in univariate and multivariate analyses, except for current advanced treatment (biologic/small molecules) use (OR 2.06 [95%CI 1.05-4.35]). Among physicians, 71% had previously prescribed EEN to a patient, while 81% were willing to prescribe EEN. Knowledge of remission rates in adult patients using EEN varied widely. The indication for EEN use varied from mild-moderate disease (41% of respondents) to complicated disease (38% for penetrating disease, 55.9% for severe disease, 52.9% for structuring and 55.9% for malnourished patients). Previous EEN prescription was associated with willingness for future EEN recommendation (OR 4.66 [95%CI 1.11-19.54]). Top-ranked barriers perceived by patients were lack of food variety (65% with scored 4-5), lack of meal-associated social interaction (59% with scored 4-5) and treatment duration (49% scored 4-5). The respondents were less concerned about potential complications (14.6% scored 4-5), treatment-related diarrhea/pain (25.1% scored 4-5) and the notion that the formula is dairy-sourced (29.2% scored 4-5). For physicians, lack of food-associated social interaction (67.3% scored 4-5) and concern about taste (54.7% scored 4-5) were ranked highest among the perceived patient barriers.
Overall, the physicians’ perspectives largely aligned with those of the patients. However, we found that ‘lack of food variety’ and ‘hunger concerns’ were barriers scored significantly higher by patients than physicians (p<0.05 for both). Network analysis revealed the top three patient barriers associated with EEN reluctance were ‘food variety’, ‘treatment duration’ and ‘fear of liquid only diet’, which were correlated with each other. Supportive factors that could facilitate EEN use were: direct communication with a staff member (68.6% scored 4-5) full funding of the formula (65% scored 4-5), family support (59.7% scored 4-5) and talking with other patients that are EEN experienced (52% scored 4-5). Overall, 47% of the respondents expressed a desire to hear more about EEN, and 87.6% preferred to receive information about EEN from their physician.

Conclusion

Most patients with CD are open to discussing EEN and wish to discuss it with their physicians. Potential barriers to address are the tactile and social eating experience as well as the length of therapy.

Introduction

Ultra-processed foods (UPFs) have been linked to inflammatory bowel disease (IBD) incidence and progression(1)

Aims & Methods

We compared UPF and emulsifier intake in patients with IBD and healthy controls (HC) and examined their association with IBD-relevant outcomes.
Dietary intake was calculated from Food Frequency Questionnaires (FFQs) and food logs. Two 24-hour dietary recalls in patients with IBD were compared to two prospective logs from HC from an interventional study. Patients were recruited at the infusion unit and followed up for one year. For cross-sectional analysis, Kruskal Wallis with post-hoc Dunn test and Fisher exact test were used, as appropriate, to compare UPF and emulsifier intake, adjusted for multiple testing using Bonferroni. Kaplan–Meier survival analysis and log-rank tests were used to assess the association between tertiles of UPF and emulsifier intake and the incidence of IBD-related outcomes.

Results

We included 186 subjects (65 HC, 59 Crohn’s disease (CD) and 62 ulcerative colitis (UC)). Median (IQR) age was 26 (23 - 33) years for HCs, and 41 (32 - 51) and 46 (35 - 55) years for CD and UC resp. We included 52 healthy females, and 25 and 24 females in the CD and UC cohort resp.
Assessing food logs, UPF intake was similar in all groups, but emulsifier intakes were higher in IBD compared to HC (Table 1). In both UC and CD, higher intakes of potassium alginate, oat gum, mono- and di-glycerides of fatty acids, as well as carrageenan and xanthan gum were seen, compared to HC. Intake of polyglycerol polyricinoleate was higher in CD compared to HC, while intake of guar gum was higher in UC compared to HC. The proportion of non-consumers of potassium alginate was higher in HC compared to IBD.
Compared to HC, soft drinks, meat, and butter intake was higher in patients with IBD. However, intake of breakfast cereals, legumes, meat substitutes, whole grain pasta and rice, and fiber was lower in UC and CD. Coffee, potato, deli meat, and sodium intake was higher in CD patients than HC, while nut and seed intake was lower. There was no correlation between serum CRP and intake of UPFs, emulsifiers, macronutrients or total energy.
Longitudinal analysis showed a trend towards increased UPF intake and more frequent emergency department (ED) visits (p=0.059) and surgery (p=0.064), but not for IBD-related hospitalization (p>0.1). For increased emulsifier intake, we report a trend towards an increase in IBD-related hospitalisation (p=0.056), but not for ED visits or surgery (p>0.1).

Conclusion

We show higher intakes of emulsifiers in patients with IBD compared to HC, with similar UPF intake. Longitudinal analysis trends towards a link between UPF and emulsifier intake and poorer IBD-related outcomes, emphasizing the need for larger cohorts. The increased intake of specific emulsifiers such as carrageenan and guar gum warrant further investigation into their role in the propagation and maintenance of gut inflammation, as well as their impact on IBD-relevant patient outcomes.

References

(1) Chen J & Wellens J, Kalla R, et al. Intake of Ultra-processed Foods Is Associated with an Increased Risk of Crohn's Disease: A Cross-sectional and Prospective Analysis of 187 154 Participants in the UK Biobank. J Crohns Colitis. 2023 Apr 19;17(4):535-552.

Disclosure

JW reports no conflicts of interest.
MD reports no conflicts of interest.
SH received consultancy fees from Ferring, Takeda.
ML reports no conflicts of interest.
JV received speaker’s fees from Janssen; consultancy fees from Ferring.
EDM reports no conflicts of interest.
EV reports no conflicts of interest.
MF received research grants from AbbVie, EG Pharma, Janssen, Pfizer, Takeda and Viatris; con-sultancy fees from AbbVie, AgomAb Therapeutics, Boehringer Ingelheim, Celgene, Celltrion, Eli Lilly, Janssen-Cilag, Merck Sharp and Dohme, MRM Health, Pfizer, Takeda and ThermoFisher; and speakers’ fees from AbbVie, Biogen, Boehringer Ingelheim, Dr Falk Pharma, Ferring, Janssen-Cilag, Merck Sharp and Dohme, Pfizer, Takeda, Truvion Healthcare and Viatris.
BV reports research support from Sossei Heptares/Nxera and Takeda. In addition, BV reports speaker’s fees from Abbvie, Agomab, Alfasigma, Biogen, Bristol Myers Squibb, Celltrion, Eli Lily, Falk, Ferring, Galapagos, Johnson and Johnson, Pfizer, Sandoz, Takeda, Tillots Pharma, Truvion and Viatris, consultancy fees from Abbvie, Alfasigma, Alimentiv, Anaptys Bio, Applied Strategic, Astrazeneca, Atheneum, BenevolentAI, Biora Therapeutics, Boxer Capital, Bristol Myers Squibb, Domain Therapeutics, Eli Lily, Galapagos, Guidepont, Landos, Merck, Mirador Therapeutics, Mylan, Nxera, Inotrem, Ipsos, Johnson and Johnson, Pfizer, Sandoz, Sanofi, Santa Ana Bio, Sapphire Therapeutics, Sosei Heptares, Takeda, Tillots Pharma and Viatris, and stock options from Vagustim.
SV received financial support for research from AbbVie, J&J, Pfizer, Takeda and Galapagos; receives speakers’ and consultancy fees from AbbVie, Abivax, AbolerlsPharma, AgomAb, Alimentiv, Arena Pharmaceuticals, Astrazeneca, BioraTherapeutics, BMS, Boehringer Ingelheim, Celgene, Cytoki Pharma, Ferring, Galapagos, Genentech Roche, Gilead, GSK, lmidomics, Janssen, J&J, Lilly, Materia Prima, Mestag Therapeutics, Microbiotica, MiroBio, Morphic, MrMHealth, Pfizer, Progenity, Prometheus, Surrozen, Takeda, Theravance, Tillots Pharma AG, VectivBio, Ventyx, Zealand Pharma.
JS received financial support for research from Galapagos and Viatris; receives speakers’ fees from Pfizer, Abbvie, Ferring, Falk, Takeda, Janssen, Fresenius, and Galapagos; and receives consultancy fees from Pfizer, Janssen, Ferring, Fresenius, Abbvie, Galapagos, Celltrion, Pharmacosmos, and Pharmanovia.

Introduction

Exclusive enteral nutrition (EEN) is a well-established first-line treatment for inducing remission in paediatric Crohn's disease, however, its use in adult Crohn’s disease treatment remains limited. In adults, 22% of patients require surgery within the first five years after diagnosis¹, with postoperative complication rates reaching around 25%². This study investigates whether preoperative EEN can reduce postoperative complications in adults with Crohn’s disease undergoing elective surgery.

Aims & Methods

A systematic search was conducted on October 26, 2024, across three databases: PubMed, EMBASE, and the Cochrane Library. Studies were included if they involved at least two weeks of preoperative EEN and reported postoperative outcomes. The primary outcomes were anastomotic leakage, stoma formation, and abscess formation, while the secondary outcome was the length of hospital stay. The odds ratio (OR) and mean differences (MD) with their 95% confidence interval (CI) were calculated using a random-effect model.

Results

A total of 11 studies, including 2112 patients, were included in the analysis. EEN significantly reduced the odds of anastomotic leakage (OR=0.29, CI: 0.19-0.47), stoma formation (OR=0.39, CI: 0.09-1.73), and abscess formation (OR=0.41, CI: 0.23-0.72). However, there was no significant reduction in the length of hospital stay (MD: 0.88 days, CI: -1.85-0.09).

Conclusion

Preoperative EEN significantly reduces the risk of anastomotic leakage, stoma formation, and abscess formation, leading to improved postoperative outcomes. These findings support adding EEN into preoperative management for adult Crohn’s disease patients undergoing elective surgery to enhance recovery and minimize complications.

References

1. Burisch, J., et al.,(2019). Natural disease course of Crohn's disease during the first 5 years after diagnosis in a European population-based inception cohort: an Epi-IBD study. Gut, 68(3), 423–433. https://doi.org/10.1136/gutjnl-2017-315568
2. Luglio, G., et al.,(2022). Post-operative morbidity in Crohn's disease: what is the impact of patient-, disease- and surgery-related factors?. International journal of colorectal disease, 37(2), 411–419. https://doi.org/10.1007/s00384-021-04076-5