Mistakes in nutrition in IBD and how to avoid them

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Mistakes in nutrition in IBD and how to avoid them

Richard K Russell, Konstantinos Gerasimidis

Summary

AI Generated

This article discusses common mistakes in nutritional management of inflammatory bowel disease, drawing on evidence-based strategies and decades of clinical experience.

Evidence-based nutritional strategies are being utilised as a key part of the therapeutic armamentarium in Crohn's disease for both induction and maintenance, as primary and adjuvant treatment methods.
Exclusive enteral nutrition is well established in the treatment of paediatric IBD and adult centres are increasingly incorporating it into treatment models as an effective, drug-free alternative.
The roles for partial enteral nutrition and Crohn's disease specific diets are being more clearly elucidated.
When used appropriately and through engagement with dietetic support services, nutritional therapies can achieve IBD treatment targets and optimise growth, bone health, body composition and overall patient well-being.
This evidence-based discussion with key references would be relevant for clinicians managing IBD who wish to avoid common mistakes in nutritional management.

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Ruemmele F, et al. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease. J Crohns Colitis 2014; 8: 1179–1207. [Link]

Swaminath A, et al. 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. [Link]

Matstui T, Sakurai T and Yao T. Nutritional therapy for Crohn’s disease in Japan. J Gastroenterol 2005; 4016: 25–31. [Link]

Narula N, et al. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Revs 2018; 4: CD000542. [Link]

Pigneur B, et al. Mucosal healing and bacterial composition in response to enteral nutrition vs steroid-based induction therapy—A randomised prospective clinical trial in children with Crohn’s disease. J Crohns Colitis 2019; 13: 846–855. [Link]

Borrelli O, et al. Polymeric diet alone versus corticosteroids in the treatment of active pediatric Crohn’s disease: a randomized controlled open-label trial. Clin Gastroenterol Hepatol 2006; 4: 744–753. [Link]

Grover Z, Muir R and Lewindon P. Exclusive enteral nutrition induces early clinical, mucosal and transmural remission in paediatric Crohn’s disease. J Gastroenterol 2014; 49: 638–645. [Link]

Shukla D, et al. DOP01 Exclusive enteral nutrition for the treatment of adult Crohn’s disease. J Crohns Colitis 2020; 14 (Suppl 1): S672–S709. [Link]

Day A, et al. Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease. JGH Open 2020; 4: 260–266. [Link]

10.

Lee D, et al. Comparative effectiveness of nutritional and biological therapy in North American children with active Crohn's disease. Inflamm Bowel Dis 2015; 21: 1786–1793. [Link]

11.

Johnson T, et al. Treatment of active Crohn’s disease in children using partial enteral nutrition with liquid formula: a randomised controlled trial. Gut 2006; 55: 356–361. [Link]

12.

Levine A, et al. Crohn’s disease exclusion diet plus partial enteral nutrition induces sustained remission in a randomized controlled trial. Gastroenterology 2019; 157: 440–450. [Link]

13.

Lewis JD, et al. Inflammation, antibiotics, and diet as environmental stressors of the gut microbiome in pediatric Crohn’s disease. Cell Host Microbe 2015; 18: 489–500. [Link]

14.

Svolos V, et al. Treatment of active Crohn’s disease with an ordinary food-based diet that replicates exclusive enteral nutrition. Gastroenterology 2019; 156: 1354–1367. [Link]

15.

Yang Q, et al. Efficacy of exclusive enteral nutrition in complicated Crohn’s disease. Scandinavian J Gastroenterol 2017; 52: 995–1001. [Link]

16.

Cameron FL, et al. Clinical progress in the two years following a course of exclusive enteral nutrition in 109 paediatric patients with Crohn's disease. Aliment Pharmacol Ther 2013; 37: 622–629. [Link]

17.

Frivolt K, et al. Repeated exclusive enteral nutrition in the treatment of paediatric Crohn's disease: predictors of efficacy and outcome. Aliment Pharmacol Ther 2014; 39: 1398–1407. [Link]

18.

Grass F, et al. Preoperative nutritional conditioning of Crohn’s patients—systematic review of current evidence and practice. Nutrients 2017; 9: 562. [Link]

19.

Rocha A, et al. Preoperative enteral nutrition and surgical outcomes in adults with Crohn’s disease: a systematic review. GE Port J Gastroenterol 2019; 26: 184–195. [Link]

20.

Heerasing N, et al. Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease. Aliment Pharmacol Ther 2017; 45: 660–669. [Link]

21.

Li Y, et al. Role of exclusive enteral nutrition in the preoperative optimization of patients with Crohn's disease following immunosuppressive therapy. Medicine 2015; 94. [Link]

22.

Logan M, et al. The reduction of faecal calprotectin during exclusive enteral nutrition is lost rapidly after food re‐introduction. Aliment Pharmacol Ther 2019; 50: 664–674. [Link]

23.

Quince C, et al. Extensive modulation of the fecal metagenome in children with Crohn's disease during exclusive enteral nutrition. Am J Gastroenterol 2015; 110: 1718. [Link]

24.

Yamamoto T, et al. Impacts of long-term enteral nutrition on clinical and endoscopic disease activities and mucosal cytokines during remission in patients with Crohn's disease: a prospective study. Inflamm Bowel Dis 2007; 13: 1493–1501. [Link]

25.

MacLellan A, et al. The impact of exclusive enteral nutrition (EEN) on the gut microbiome in Crohn's disease: a review. Nutrients 2017; 9: 447. [Link]

26.

Laudisi F, Stolfi C and Monteleone G. Impact of food additives on gut homeostasis. Nutrients 2019; 11: 2334. [Link]

27.

Gerasimidis K, et al. The impact of food additives, artificial sweeteners and domestic hygiene products on the human gut microbiome and its fibre fermentation capacity. Eur J Nutr 2020; 59: 3213–3230. [Link]

28.

Shang Q, et al. Carrageenan-induced colitis is associated with decreased population of anti-inflammatory bacterium, Akkermansia muciniphila, in the gut microbiota of C57BL/6J mice. Toxicol Lett 2017; 279: 87–95. [Link]

29.

Fahoum L, et al. Digestive fate of dietary carrageenan: Evidence of interference with digestive proteolysis and disruption of gut epithelial function. Mol Nutr Food Res 2017; 61: 1600545. [Link]

30.

Chassaing B, et al. Dietary emulsifiers impact the mouse gut microbiota promoting colitis and metabolic syndrome. Nature 2015; 519: 92–96. [Link]

31.

Logan M, et al. Analysis of 61 exclusive enteral nutrition formulas used in the management of active Crohn’s disease—new insights into dietary disease triggers. Aliment Pharmacol Ther 2020; 51: 935–947. [Link]

32.

Lim H-S, Kim S-K and Hong S-J. Food elimination diet and nutritional deficiency in patients with inflammatory bowel disease. Clin Nutr Res 2018; 7: 48–55. [Link]

33.

Casanova MJ, et al. Prevalence of malnutrition and nutritional characteristics of patients with inflammatory bowel disease. J Crohns Colitis 2017; 11: 1430–1439. [Link]

34.

Limketkai BN, et al. Dietary interventions for induction and maintenance of remission in inflammatory bowel disease. Cochrane Database Syst Revs 2019; 2: CD012839. [Link]

35.

Wedlake L, et al. Fiber in the treatment and maintenance of inflammatory bowel disease: a systematic review of randomized controlled trials. Inflamm Bowel Dis 2014; 20: 576–586. [Link]

36.

Tsujikawa T, Satoh J and Uda K. Is fish oil (n-3 fatty acids) effective for the maintenance of remission in Crohn's disease? J Gastroenterol 2000; 35: 173–175. [Link]

37.

Lev‐Tzion R, et al. Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease. Cochrane Database Syst Revs 2014; 2; CD006320. [Link]

38.

Turner D, Steinhart AH and Griffiths AM. Omega 3 fatty acids (fish oil) for maintenance of remission in ulcerative colitis. Cochrane Database Syst Revs 2007; 3: CD006443. [Link]

39.

Hou JK, Abraham B and El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. Am J Gastroenterol 2011; 106: 563–573. [Link]

40.

Chiba M, et al. Lifestyle-related disease in Crohn's disease: relapse prevention by a semi-vegetarian diet. World J Gastroenterol 2010; 16: 2484–2495. [Link]

41.

Albenberg L, et al. A diet low in red and processed meat does not reduce rate of Crohn's disease flares. Gastroenterology 2019; 157: 128–136.e125. [Link]

42.

Gerasimidis K, McGrogan P and Edwards CA. The aetiology and impact of malnutrition in paediatric inflammatory bowel disease. J Hum Nutr Diet 2011; 24: 313–326. [Link]

43.

Valentini L, et al. Malnutrition and impaired muscle strength in patients with Crohn's disease and ulcerative colitis in remission. Nutrition 2008; 24: 694–702. [Link]

44.

Bischoff SC, et al. ESPEN practical guideline: clinical nutrition in inflammatory bowel disease. Clin Nutr 2020; 39: 632–653. [Link]

45.

Ishige T. Growth failure in pediatric onset inflammatory bowel disease: mechanisms, epidemiology, and management. Transl Pediatr 2019; 8: 16–22. [Link]

46.

Lomer MCE, et al. A multicentre study of nutrition risk assessment in adult patients with inflammatory bowel disease attending outpatient clinics. Ann Nutr Metab 2019; 74: 18–23. [Link]

47.

Kim S-E. Clinical Implication of sarcopenia in patients with inflammatory bowel disease. Korean J Gastroenterol 2018; 71: 308–314. [Link]

48.

Singh S, et al. Epidemiology, risk factors and management of cardiovascular diseases in IBD. Nat Rev Gastroenterol Hepatol 2015; 12: 26–35.

49.

Barroso T, et al. Patients with inflammatory bowel disease have higher abdominal adiposity and less skeletal mass than healthy controls. Ann Gastroenterol 2018; 31: 566–571. [Link]

50.

Gerasimidis K, et al. Assessment and Interpretation of vitamin and trace element status in sick children: a position paper from the European Society for Paediatric Gastroenterology Hepatology, and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2020; 70: 873–881. [Link]

51.

McMillan DC, Maguire D and Talwar D. Relationship between nutritional status and the systemic inflammatory response: micronutrients. Proc Nutr Soc 2019; 78: 56–67. [Link]

52.

Kulnigg S and Gasche C. Systematic review: managing anaemia in Crohn's disease. Aliment Pharmacol Ther 2006; 24: 1507–1523. [Link]

53.

Dignass AU, et al. European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel disease. J Crohns Colitis 2015; 9: 211–222. [Link]

54.

Leitgeb C, et al. Quality of life in chronic anemia of cancer during treatment with recombinant human erythropoietin. Cancer 1994; 73: 2535–2542. [Link]

55.

Pels LPM, et al. Slow hematological recovery in children with IBD-associated anemia in cases of 'expectant management'. J Pediatr Gastroenterol Nutr 2010; 51: 708–713. [Link]

56.

Bonovas S, et al. Intravenous versus oral iron for the treatment of anemia in inflammatory bowel disease: a systematic review and meta-analysis of randomized controlled trials. Medicine 2016; 95: e2308–e2308. [Link]

57.

Cormie P, et al. Clinical Oncology Society of Australia position statement on exercise in cancer care. Med J Aust 2018; 209: 184–187. [Link]

58.

Blanchard CM, Courneya KS and Stein K. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society's SCS-II. J Clin Oncol 2008; 26: 2198–2204. [Link]

59.

Fong DY, et al. Physical activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ 2012; 344: e70. [Link]

60.

Cormie P, et al. The impact of exercise on cancer mortality, recurrence, and treatment-related adverse effects. Epidemiol Rev 2017; 39: 71–92. [Link]

61.

Mishra SI, et al. Exercise interventions on health‐related quality of life for cancer survivors. Cochrane Database Syst Revs 2012; 8: CD008465. [Link]

62.

Robinson RJ, et al. Effect of a low-impact exercise program on bone mineral density in Crohn's disease: a randomized controlled trial. Gastroenterology 1998; 115: 36–41. [Link]

63.

Klare P, et al. The impact of a ten-week physical exercise program on health-related quality of life in patients with inflammatory bowel disease: a prospective randomized controlled trial. Digestion 2015; 91: 239–247. [Link]

64.

Farrell D, et al. Interventions for fatigue in inflammatory bowel disease. Cochrane Database Syst Revs 2020; 4: CD012005. [Link]

65.

Jones PD, et al. Exercise decreases risk of future active disease in patients with inflammatory bowel disease in remission. Inflamm Bowel Dis 2015; 21: 1063–1071. [Link]

66.

Packer N, Hoffman-Goetz L and Ward G. Does physical activity affect quality of life, disease symptoms and immune measures in patients with inflammatory bowel disease? A systematic review. J Sports Med Phys Fitness 2010; 50: 1. [Link]

67.

Cederholm T, et al. GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community. Clin Nutr 2018; 38: 1–9. [Link]

68.

European Society for Clinical Nutrition and Metabolism. ‘GLIM! Global Consensus for Diagnosing Malnutrition’, https://www.espen.org/component/content/article/30-news/263-glim-global-consensus-for-diagnosing-mal (2018, accessed November 2020). [Link]

Abstract

The relationship between nutrition and inflammatory bowel disease (IBD) has been an area of substantial interest and research for many decades now. Evidence-based nutritional strategies are being utilised as a key part of the therapeutic armamentarium in Crohn’s disease for both induction and maintenance, as primary and adjuvant treatment methods. Exclusive enteral nutrition, for instance, is well established in the treatment of paediatric IBD and adult centres are increasingly incorporating it into treatment models as an effective, drug-free alternative. The role for partial enteral nutrition and Crohn’s disease specific diets are also being more clearly elucidated. Used appropriately, and through engagement with dietetic support services, nutritional therapies can not only achieve the IBD treatment ‘targets’ but serve to optimise other vital aspects of care, such as growth, bone health, body composition and overall patient well-being. Here we discuss some of the mistakes that are frequently made in the area of nutritional management of IBD. The discussion is evidence based, with key references incorporated for further analysis beyond the scope of this article, and combines several decades of leading clinical and research experience in the area of nutrition and IBD from the authors.

Topics

Small Intestine & Nutrition

Citation

Meredith J, Russell RK and Gerasimidis K. Mistakes in nutrition in IBD and how to avoid them. UEG Education 2020; 20: 25–30.

Published

2020

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ABSTRACT

Introduction

Abdominal distension is an objective visible sign of increased abdominal girth. Bloating is a feeling of abdominal fullness and discomfort. Bloating may be associated or not with abdominal distension. Bloating and abdominal distension are among the most commonly reported gastrointestinal symptoms and may be associated with both organic and functional disorders. Nevertheless, specific consensus and recommendations on diagnosis, underlying mechanisms, assessment and management of functional bloating and abdominal distension are still lacking. The aim of this European consensus, then, is to provide expert opinions and recommendations on the epidemiology, diagnosis, pathophysiology and treatment of functional bloating and abdominal distension.

Methods

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Results

Functional bloating and abdominal distension are common and frequently overlap with other disorders of gut-brain interaction. Diagnosis is made according to the Rome IV criteria after the exclusion of organic disease, based on the physical examination and assessment of the patient's medical history and alarming signs. In the absence of alarming signs or any relevant finding, clinical laboratory, imaging or endoscopic tests are unnecessary. The pathophysiology of functional bloating and abdominal distension is multifactorial and involves visceral hypersensitivity, abdomino-phrenic dyssynergia, intestinal dysmotility and dysbiosis. Treatment may include dietary modifications (e.g. lactose-limiting diet and low FODMAP diet), probiotics, antispasmodics (e.g., otilonium bromide, peppermint oil), rifaximin, secretagogues (e.g., linaclotide), neuromodulators (e.g., serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, buspirone), and plethysmography-based biofeedback. Moreover, cognitive behaviour therapy and hypnotherapy can be used in case of functional bloating associated with irritable bowel syndrome.

Conclusion

This consensus provides an evidence-based framework for the evaluation and treatment of patients with functional bloating and abdominal distension.

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Ruemmele F, et al. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease. J Crohns Colitis 2014; 8: 1179–1207. [Link]

Swaminath A, et al. 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. [Link]

Matstui T, Sakurai T and Yao T. Nutritional therapy for Crohn’s disease in Japan. J Gastroenterol 2005; 4016: 25–31. [Link]

Narula N, et al. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Revs 2018; 4: CD000542. [Link]

Grover Z, Muir R and Lewindon P. Exclusive enteral nutrition induces early clinical, mucosal and transmural remission in paediatric Crohn’s disease. J Gastroenterol 2014; 49: 638–645. [Link]

Shukla D, et al. DOP01 Exclusive enteral nutrition for the treatment of adult Crohn’s disease. J Crohns Colitis 2020; 14 (Suppl 1): S672–S709. [Link]

Day A, et al. Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease. JGH Open 2020; 4: 260–266. [Link]

10.

Lee D, et al. Comparative effectiveness of nutritional and biological therapy in North American children with active Crohn's disease. Inflamm Bowel Dis 2015; 21: 1786–1793. [Link]

11.

Johnson T, et al. Treatment of active Crohn’s disease in children using partial enteral nutrition with liquid formula: a randomised controlled trial. Gut 2006; 55: 356–361. [Link]

12.

Levine A, et al. Crohn’s disease exclusion diet plus partial enteral nutrition induces sustained remission in a randomized controlled trial. Gastroenterology 2019; 157: 440–450. [Link]

13.

Lewis JD, et al. Inflammation, antibiotics, and diet as environmental stressors of the gut microbiome in pediatric Crohn’s disease. Cell Host Microbe 2015; 18: 489–500. [Link]

14.

Svolos V, et al. Treatment of active Crohn’s disease with an ordinary food-based diet that replicates exclusive enteral nutrition. Gastroenterology 2019; 156: 1354–1367. [Link]

15.

Yang Q, et al. Efficacy of exclusive enteral nutrition in complicated Crohn’s disease. Scandinavian J Gastroenterol 2017; 52: 995–1001. [Link]

16.

17.

Frivolt K, et al. Repeated exclusive enteral nutrition in the treatment of paediatric Crohn's disease: predictors of efficacy and outcome. Aliment Pharmacol Ther 2014; 39: 1398–1407. [Link]

18.

Grass F, et al. Preoperative nutritional conditioning of Crohn’s patients—systematic review of current evidence and practice. Nutrients 2017; 9: 562. [Link]

19.

Rocha A, et al. Preoperative enteral nutrition and surgical outcomes in adults with Crohn’s disease: a systematic review. GE Port J Gastroenterol 2019; 26: 184–195. [Link]

20.

Heerasing N, et al. Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease. Aliment Pharmacol Ther 2017; 45: 660–669. [Link]

21.

Li Y, et al. Role of exclusive enteral nutrition in the preoperative optimization of patients with Crohn's disease following immunosuppressive therapy. Medicine 2015; 94. [Link]

22.

Logan M, et al. The reduction of faecal calprotectin during exclusive enteral nutrition is lost rapidly after food re‐introduction. Aliment Pharmacol Ther 2019; 50: 664–674. [Link]

23.

Quince C, et al. Extensive modulation of the fecal metagenome in children with Crohn's disease during exclusive enteral nutrition. Am J Gastroenterol 2015; 110: 1718. [Link]

24.

25.

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Abstract

Familial Mediterranean fever (FMF), also called periodic disease, Armenian disease, etc., is a prototypical autoinflammatory disorder where the underlying mechanism is the dysfunction of innate immunity, resulting in unprovoked episodes of inflammation.¹ Although considered rare worldwide, it is prevalent in people of Mediterranean origin; however, one can expect to encounter patients in all parts of the modern world. FMF is a monogenic disease with autosomal recessive inheritance.² Unlike other monogenic disorders, the diagnosis remains largely clinical, and it is important to understand the limitations of genetic testing. Another distinguishing feature is the well-established effectiveness of lifelong monotherapy with colchicine in preventing attacks and complications.³

Topics

Primary Care

Published

2025

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