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CD-TREAT diet as an alternative to enteral nutrition (EEN)

Drs. Gerasimidis and Svolos discussing the diet:


The CD-TREAT is a prescriptive and personalized diet. It recreates EEN by the exclusion of certain dietary components (eg, gluten, lactose, and alcohol) and matching of others (macronutrients, vitamins, minerals, and fiber) as closely as possible using ordinary food. We based the composition of CD-TREAT on Modulen IBD (Nestle, Vevey, Switzerland), the most popular formula used in Europe, and on which we have based our mechanistic studies.6, 7 Maltodextrin, an artificial glucose polymer and the commonest form of carbohydrate in EEN feeds, but not present in natural foods, was substituted by food high in starch and low in fiber.
Link to the full text (long read) - Treatment of Active Crohn’s Disease With an Ordinary Food-based Diet That Replicates Exclusive Enteral Nutrition:
https://www.gastrojournal.org/article/S0016-5085(18)35398-8/fulltext

A day’s menu of CD-TREAT diet for a boy with CD, 15 y, 48 kg and 170cm.
Breakfast:
1 multivitamin tablet
Full fat milk (360ml)
Rice breakfast cereals (45g)
Apple juice (360ml)
Morning snack:
Pineapple juice (360ml)
1 peeled apple
Lunch:
1 sandwich with white bread (2 slices), cheddar (45g) and cream cheese (45g), lettuce (20g) and peeled cucumber (20g)
1 bowl chicken and rice soup
Afternoon snack:
1 rice pudding
Dinner:
1 portion grilled salmon (180g) with mashed potatoes (260g) and cheese sauce
 
Maltodextrin, an artificial glucose polymer and the commonest form of carbohydrate in EEN feeds, but not present in natural foods, was substituted by food high in starch and low in fiber.
Maltodextrin comes in many forms, but maltodextrin is not a starch, you aren't mimmicking EN if you simply replace it with a starch.

I have no idea why you would use starches to replace maltodextrin.

Maltodextrin is made through hydrolysis of starches, but it's no longer a starch at that point. Starches have a DE of 0, and depending on how many minutes the starches are hydrolised you can end up with a maltodextrin with a DE from 3 to 20 or more.

Those EN formulations likely have maltodextrins with a high DE. They mentioned Modulen, Modulen's maltodextrin is allowed to be called 'glucose syrup' in Europe, they would not be allowed to be called glucose syrups if they had a low DE.
 
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Breakfast:
Full fat milk (360ml)
Lunch:
1 sandwich with white bread
''The CD-TREAT is a prescriptive and personalized diet. It recreates EEN by the exclusion of certain dietary components (eg, gluten, lactose, and alcohol) ''
What?

Why do they use cow milk in the diet if they say their diet is excluding lactose?

Secondly, why do they use sandwiches and bread in the diet if they say their diet is excluding gluten?


The study seems to contradict itself when it comes to fiber content too. EN doesn't use fibers, yet their diet does.

Full fat milk is also not a replacement for the fat used in EN. The fats from EN are MCTs, which is something completely different from the fats found in cow milk. They could have used baby milk formulas enhanced with MCT or goat milk instead, cow milk has almost no MCT.
 
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The whole study makes no sense to me, I frankly don't understand how this got through peer review.

The goal of their study and diet was to recreate EN with a regular meal.

Going over their list again, their diet contains gluten, lactose, fructose, starches and fiber. All things that EN doesn't contain.

And their diet doesn't contain anything that is actually found in EN. Nothing in their diet contains anything that EN contain. It doesn't contain maltodextrin and doesn't contain MCT or TGFB2 in relevant quantities.

Their diet is based on milk, fruit juices, bread, cereals, cheese, rice, chicken, and fish. A non-diet that doesn't strike me as any different from what people simply eat on a regular basis. You can basically eat anything on this diet.

They argue their diet doesn't contain alcohol and neither does EN. Ok, not sure we needed a study for that, I don't think most people give kids alcohol.

I really do not understand the point of this study.
 
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pwadm

Administrator
Staff member
Secondly, why do they use sandwiches and bread in the diet if they say their diet is excluding gluten?
If you look through the details of the study:

All dairy products were lactose free; all cereal-based products were gluten free

In the discussion section they also say:
The specific dietary components and how these interact with the gut microbiome are not yet fully elucidated. In the absence of detailed knowledge, we developed CD-TREAT, a personalized and tolerable diet with comparable composition to EEN.
Basically there are lots of unknowns and they experimented with changing some ingredients comparing to the composition of EEN.
As longs as the diet proves to provide the same benefits as EEN the difference in the composition is not that important.
 
Thanks for clarifying I was also confused to see milk and bread on the dairy free gluten free diet.

The maltodextrin/ starch debate is above my pay grade.

Karob May I ask if you have kept up the diet and if so stayed in remission? There is so much conflicting info about diet and Crohn’s it’s always nice to hear what has helped people.
 
Kiny, clearly you did not thoroughly read the article and missed the points which “pwadm” pointed out to you.
I read it just fine.

Nowhere in the linked study was there mention of gluten free cereal products or lactose free milk. It was hidden in a secondary PDF in tiny letters. It was easy to miss, it should have been in their main study results.

They claimed there was no lactose and gluten in their diet, yet suggested milk and bread.

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Not every ingredient is listed on what is in the foods prepared/given to the patient.
Why not.


I don't believe the researchers wish to divulge every detail in research
Why not.


There are other ingredients and scientific breakdowns used in this dietary treatment where MCT comes from.
What are they and why are they left out of the study?

And it doesn’t state that the MCT is coming from the milk.
Right. There are no significant quantities of MCT in cow milk, yet they claim to want to mimmick EN which is based around the use of MCT.
 
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I'm happy for you. My critique is mainly that the study is rather weak.

They reference studies and EN that are based on maltodextrin. Yet they use a starch, maltodextrin is not a starch. Starches have a DE of 0, the maltodextrins used in EN have DE of around 20, which is why they are allowed to call it glucosy syrup in Europe.

They reference studies that used a diet based around milk that was not lactose free (reference 18), yet they themselves use lactose free milk (which they didn't put in their main study and hid in the PDF in tiny letters).

I missed those tiny letters in the accompanying PDF, as most people likely would. One assumes they do not use lactose free milk in their study if they reference to studies that do not use lactose milk to begin with.

bnmbmbmbm.JPG


The fact they use very different products than what they use as references for their argument, makes their study fall apart.

They reference Modulen and casein milk, but the tgfb2 from Modulen is not coming from the casein in modulen, Nestlé artificially adds tgfb2 with a patented procedure.

Nestlé extracts tgfb2 from caseins, but it is not from the casein put into the modulen, which doesn't contain enough tgfb2 to have a meaningful effect. Nestlé uses a patented procedure to greatly increase the tgfb2 (1). Yet the study fails to point it out, you can't just mimmick the tgfb2 content of modulen by giving people some lactose free milk.

(1) Nestlé ''Modulen® IBD est aliment complet buvable ou par sonde, en poudre, à base de caséine traitée spécialement ce qui explique la richesse en TGF-ß2 ''
 

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If you could mimmick EN by just drinking some lactose free milk and some gluten free cereal products, I would be all for it. But that's likely not how EN works.

EN are based on maltodextrins (MDX) that have a high DE value, you can not find these MDX in regular products. MDX used as sugar replacements or bulking agents in food stores are MDX with a much lower DE value. You can also not just replace a MDX with a starch, MDX are not starches. Just because one isolated MDX from a starch, doesn't make it a starch, these two substances couldn't be any more different from each other.

EN are based on MCT, but they are MCT treated with agents (like MDX) to change them into a powder and they are mixed with around 20% LCT.

Some EN contain growth factors (like Nutricia 028 and Modulen). Concentrated growth factors. They are isolated from casein, but you can not simply give people some lactose free milk and hope to recreate the amount of growth factors found in those EN. Lactose free milk contains meaningless amounts of growth factors compared to the amount found in EN.

If Nutricia could recreate the effectiveness of their 028 product, that costs a lot to manufacture and is very expensive, by adding some lactose free milk and starches instead of isolating growth factors, they would do it, it would save them millions of $. But that's not how it works.
 
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A day’s menu of CD-TREAT diet for a boy with CD
Apple juice (360ml)
Pineapple juice (360ml)
1 peeled apple
I also question the wisdom of this study to suggest crohn's disease patients start drinking lots fruit juices and fruit products that are very high in fructose (apples, apple juices, pineapple juices, etc).

They suggest people with crohn's disease drink 720ml of daily fruit juices instead of water. That's 3 to 4 whole glasses of fruit juice a day, on top of the fruit the diets suggests you eat.

This goes against all recent data. People with crohn's disease are increasingly shown to be malabsorbing fructose (see low-FODMAP), yet this diet suggests ample intake of fructose and even suggest it as a daily ''snack''.

And again, EN does not contain fructose. Nothing in this diet is relevant to EN.

https://www.ncbi.nlm.nih.gov/pubmed/19392860

''Fructose malabsorption was more frequent in Crohn's disease (61%) than other groups (33-44%, P < 0.05). In Crohn's disease, concurrent Fructose malabsorption and lactose malabsorption was most common (29%), and the association of fructose malabsorption with ERBHAL seen overall (62%) was not observed (36%, P < 0.0001).''
 
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Right. I am not an researcher, I studied biology but never have I claimed or ever suggested I was a researcher. I wanted to make that clear in a post I wrote since I was asked that question.
 
However, I think my critiques of this study are valid.

1) Maltodextrin is not a starch. Yet, the study incorrectly claims that one can simply replace the maltodextrin found in EN with starches. Maltodextrin have a much higher DE value and have little to nothing to do with starches after hydrolysis. DE value of MDX is very high, unlike MDX used as bulking agents in the food industry, hydrolisis time of MDX found in EN is much higher (the EU does not allow one to reference MDX as glucose syrup if the resulting substance does not have a DE of 20, modulen references their MDX as glucose syrup in Europe, suggesting it has a very high DE).

2) If one makes references to studies with diets using regular milk (a), but then use lactose free milk, then this should be clearly stated in the study, it was not. It was hidden in tiny letters in an acompanying PDF.

3) They make reference of a study diet containing growth factors and suggest adding milk to their diet would mimmick the growth factors in Modulen (which they reference). But Modulen does not attain its ample growth factors through the addition of casein based proteins. They isolate tgf proteins through a patented technology.

4) EN are based around the use of MCT, and the observed bioavailability of EN is likely in part due to the use of MCT which are readily absorbed and have very different metabolic pathways that the use of the their ''fat milk'' based on cow's milk, which is low in MCT and much less bioavailable than those found in EN.

5) They suggest patients drink 720ml (around 3 glasses) of fruit juice daily (Apple juice high in fructose) instead of plain water, and suggest people eat fruits, referenced as 'snacks' on top of that. Even though we have increasing evidence of fructose malabsorption in crohn's disease.

(a) Milk casein-based diet containing TGF-beta controls the inflammatory reaction in the HLA-B27 transgenic rat model https://www.ncbi.nlm.nih.gov/pubmed/15980276?dopt=Abstract
 
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Drs. Gerasimidis and Svolos discussing the diet:




Link to the full text (long read) - Treatment of Active Crohn’s Disease With an Ordinary Food-based Diet That Replicates Exclusive Enteral Nutrition:
https://www.gastrojournal.org/article/S0016-5085(18)35398-8/fulltext

A day’s menu of CD-TREAT diet for a boy with CD, 15 y, 48 kg and 170cm.
Breakfast:
1 multivitamin tablet
Full fat milk (360ml)
Rice breakfast cereals (45g)
Apple juice (360ml)
Morning snack:
Pineapple juice (360ml)
1 peeled apple
Lunch:
1 sandwich with white bread (2 slices), cheddar (45g) and cream cheese (45g), lettuce (20g) and peeled cucumber (20g)
1 bowl chicken and rice soup
Afternoon snack:
1 rice pudding
Dinner:
1 portion grilled salmon (180g) with mashed potatoes (260g) and cheese sauce
It's an interesting one. I certainly think there's a fascinating piece around the tolerance of different starches and plant fibres.

Personally, I have Crohn's – limited to the colon – and, whilst things like stress are massive for my disease and certain supplements have been beneficial, specifically on the diet front, one of the things most clear to me is:

-> Fibre has bar far one of the biggest effects on my disease of anything I've ever tested over the years.

I didn't believe this at first because of the science I'd read so I kept on trying variations of a whole foods plant based diet. Each time I would quickly run into GI problems and I would get generalised itching and eczema. Each time, without failure, these symptoms would completely go when I removed all the fibres and flipped to a very low-residue diet.

Likewise, at a much accelerated rate, the same would happen with fibre supplements, from the likes of apple pectin to resistant starch. All awful experiences.

Over time, by noting any symptoms, keeping a food diary and getting frequent calprotectin measurements, I've found, for some reason, my body tolerates one morning serving of oats very well, but other wholegrains and legumes or more serving of oats in a day cause issues over time. Why? I'm not completely clear. Similarly, fruit consumption seems to become problematic for me. As does most veg consumption, especially raw and cruciferous. Extremely well-boiled and peeled potatoes and carrots are my safest veg options.

Strangely though, again on the basis of my lack of reaction and low calprotectin levels, the white bread I make seems extremely well tolerated, as does milk, which is a mix of lacto-free and a bit of the normal stuff these days. Guess the lack of small intestinal disease might be a factor in this.

It would be good to see further studies in this area that play around with different amounts of specific sources of fibres and/or starches. Might help tease out some of the indiviudal differences that I suspect exist.
 
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