An Overview of Nutritional Interventions in Inflammatory Bowel Diseases

[kiny]

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[kiny]

"One of the key observations in recent years has related to the significant changes in the patterns of the intestinal microbiome during a course of EEN.... a reduction in microbial diversity with EEN..Clearly, this is somewhat paradoxical given the general dysbiosis noted in individuals with CD.

It's only paradoxical if you assume the microbiome has some protective role to play in crohn's disease, and went along with the notion that dysbiosis is responsible for crohn's disease, which I always objected to. It happens in every disease with chronic intestinal inflammation. Intestinal TB features dysbiosis, we don't blame intestinal TB on dysbiosis.

EN worsens "dysbios", decreases diversity, and yet is highly effective in inducing remission. This whole notion that the microbiome has a protective role to play in any disease seems questionable when you look at all the mechanics the immune system has to employ to avoid the microbiome coming anywhere near tissue. There's no crohn's disease in a sterile environment.

All these other "healthy "diets recommended by your average dietician, are unable to induce remission. But EN, a modern dietician's worst nightmare, is spectacularly successful.

The suggestion that EN contains specific components that induce remission or are anti-inflammatory makes no sense. There's no magic component in EN, most EN work, they're not very complex nor challenging to make yourself.

What EN does do is relieve all the stress the ileum is under, avoiding all the workload of absorbing these other whole food diets. EN doesn't work for UC, EN doesn't work nearly as well for crohn's colitis. It works spectacularly well for ileal crohn's disease. High digestibility and proximal absorption of EN in the duodenum and jejunum allows the ileum to heal. It avoids large dietary particles, starch or gluten ending up in the ileum. It avoids difficult to digest fats that would otherwise result in the ileum having to work to recycle bile salts, it avoids lymphatic transport of dietary fats. The creeping fat seen in crohn's disease is a response to fecal content in the ileum, filtering the fecal content with an ultrafiltrate causes resolution of inflammation. It's not because there is something special in EN, there's not, it's a 21th century implementation of a "low residue diet" that stood the test of time.

 

[Soryan]

@kiny, thank you for posting as always. You may not know but the insight you bring here is the silver lining to many of us. I have tried EEN myself and it’s definitely legit - more than one time saved me from surgery and complications. When it comes to the management of ileal CD, EN has efficacy that is superior to all other existing treatments, even combined immunosuppressants/biologics. The evidence is overwhelming.

But sadly, it still isn't the best option. It's just the sharpest knife in the rust. Inflammation would come back after food reintroduction. Straight adherence is not easy.

That being said, more seem to be under the hood for EN.


There have been studies and echo to what you've posted the other day that a prolonged course of EEN (16+ weeks) may result in better healing:

Real-world evidence of combined treatment of biologics and exclusive enteral nutrition in patients with ileum-dominant Crohn's disease: A multicenter study​

https://pubmed.ncbi.nlm.nih.gov/38663050/​

Oral exclusive enteral nutrition induces mucosal and transmural healing in patients with Crohn's disease​

https://pubmed.ncbi.nlm.nih.gov/31217981/​

Also, cyclically go through exclusive periods of EN vs normal food intake is a better maintenance strategy than mixed, partial EN:

Real-world evidence of combined treatment of biologics and exclusive enteral nutrition in patients with ileum-dominant Crohn's disease: A multicenter study​

https://academic.oup.com/ecco-jcc/article/15/Supplement_1/S015/6286121​

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This "exclusiveness" is important as it keeps the bowel away from further damages and gives time for the intestine to replenish itself.


Jean-Frédéric Colombel in a recent interview also pointed out that a subset of the patients have achieved sustained remission after surgery. This aligns with what we hear from the CD veterans, some now in their 50-60s already enjoyed years of symptom free remission post-surgery:

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These all make me wonder if there exist a "tipping point" if we want to achieve deep remission and eventually change the disease's progression? If the disease isn't controlled up until such point, inflammation would easily come back when antigens are present - and you can't do EN a lifetime.

If so, do weapons in our current medical arsenal (TNF-a / IL-23 antagonists etc.), combined with EN, sufficient to bring us across that chasm? In other words, is deep, histological and biomolecular remission an achievable goal now?

 

[kiny]

Also, cyclically go through exclusive periods of EN vs normal food intake is a better maintenance strategy than mixed, partial EN:

Real-world evidence of combined treatment of biologics and exclusive enteral nutrition in patients with ileum-dominant Crohn's disease: A multicenter study​

https://academic.oup.com/ecco-jcc/article/15/Supplement_1/S015/6286121​

​

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Right. High quality studies have shown partial EN is not effective, they have consistently been ignored in the media favor of "CDED+PEN" studies that are of much lower quality. Pediatrics in general seem somewhat biased towards low quality studies that show adherence isn't necesarry, and ignore studies that show quite strict adherence is necessary (Anthony Segal only allowed patients to drink some tea).

It is likely the exclusive nature of EEN, rather than the addition of EN, that explains its method of action. The only noteworthy similarity between all these different types of EN, that all seem to induce remission, is that it's a liquid and that it's proximally absorbed, there's otherwise nothing really noteworthy about EN.

These all make me wonder if there exist a "tipping point" if we want to achieve deep remission and eventually change the disease's progression? If the disease isn't controlled up until such point, inflammation would easily come back when antigens are present - and you can't do EN a lifetime.

In some people crohn's disease disappears, but it's quire rare, and yes it happens after long term induced remission like Colombel said. EN studies are generally somewhere between 4 and 8 weeks, until calprotectin is in the normal range and a colonoscopy shows mucosal healing. But inflammation just comes back in these patients rather quickly after reintroduction of a regular diet. But it is not uncommon to use EN exclusively for much longer. There are several EN studies that used EEN as a form of nurtitional support from the 80s and 90s that used EN for much longer, Anthony Goody used EEN in crohn's disease patients for 360 days in 1976.

I got introduced to EN because I was extremely underweight, extremely anorexic, I simply stopped eating when I had crohn's disease, until my parents and school forced me to see a nutritionist. So I was put on IV feeding for a week, and then EN, I have been on EN for years. Eventually you get used to it, the desire to eat whole foods disappears, it gets much easier after a few months. I don't know what would happen if I reintroduced whole foods, I assume inflammatoin would come back, but I remain on EN because I don't want to go through all this again and I know reintroduction of whole foods would make it harder to adhere to EN (studies with partial EN actually seem to have lower rates of compliance than those using EEN, which shouldn't be surprising, these studies keep reintroducing whole foods so the desire for a regular diet doesn't go away).

 

[Opieshuffle13]

@kiny just to be clear you are 100% on EEN? Meaning you eat NO "solid" foods ever?