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Update for IBD

Nneka Ricketts-Cameron, RD and Tamara Sims-Dorway, RD

Arnold Palmer Medical Center is nationally ranked by U.S. News & World Report as one of the 2014-2015 “Best Children’s Hospitals” in Gastroenterology & GI Surgery Objectives

• Identify possible nutrient deficiencies for patients with IBD

• Review of interventions Nutrient Deficiencies

• Protein – increased needs due to losses from inflammation • Calories – poor intake during flares • D – prednisone known to induce state of resistance • Iron – blood losses (more prevalent with UC) • Folate – medications such as methrotrexate and sulphasalazine • Vitamin B12 - surgical resection of stomach or terminal ileum • Calcium – avoidance of , corticosteroids, malabsorption, poor bone density • Magnesium – increased intestinal losses • – excessive stool losses or high output fistulas Alternative Diets

Specific Diet

• Created in mid-20th century by gastroenterologist to treat celiac disease • Became popular in the 1990’s for IBD • Limits all grains and sugar except for in the form of honey • Restricts most milk products except for fully fermented yogurt (home made) • Restricts canned vegetables and fruit juices • Includes unprocessed meat, fish, eggs, vegetables, nuts, most fruits (fresh, frozen or dried) without additives Alternative Diets

Specific Carbohydrate Diet

Pros Cons • Eliminates processed foods and • Rigid and difficult to maintain additives • Psychologically stressful for • Appeals to individuals with children digestive and immune disorders • Socially restrictive who have failed other dietary • More studies required approaches • Results are variable • Contains a good variety of highly nutritious, unprocessed foods Alternative Diets

Specific Carbohydrate Diet - Research

• Survey of 50 patients within continental US on the SCD (9 UC, 36 CD, 5 ID) • 21 patients (42%) were on no medication • SIBDQ average: 60.9 (35-70) • Average length of time on diet: 35.4 months • Mean adherence rating: 95.2% (71-100%) • 32% reported occasional ability to eat forbidden foods • 82% report reason for starting diet was fear of long-term complications of medications • 66% noted complete symptom resolution after avg of 9.9months on diet • Effectiveness in controlling acute flare: 91.3% (30-100%) • Effectiveness in maintaining remission: 92.1% (53-100%) Alternative Diets

Low FODMAP

• Created by Monash University • Often used in treatment in IBS • Limits which are known to be osmotic and highly fermentable when eaten in excess: fructose, lactose, , galactans and • Avoids high fructose corn syrup • Includes free grains, meats, eggs, lactose free dairy, non-cruciferous vegetables and table sugar • Diet is followed for 6 weeks and then one carbohydrate from a particular group is introduced one at a time, weekly

Alternative Diets

Low FODMAP diet

Pros Cons • Eliminates foods known to cause • Difficult for parents to plan • Limited resources for guidelines • Reduces processed foods in diet • Very limiting for vegetarians • Helps to identify food • Hard to remain on diet intolerances making diet more • Variable results individualized Alternative Diets

Fodmap - Research

• UK survey of 35 patients with IBD (17 UC, 17 Crohn’s, 1 unclassified) using GSQ pre and post (6 weeks) low fodmap dietary advice • 63% female and mean age 39 years • 70% reported adherence • Fewer patients reported symptoms post dietary advice • Abdominal pain: pre (37%) post (17%) • Abdominal bloating: pre (71%) post (26%) • Borborygmi: pre (49%) post (17%) • Fecal urgency: pre (63%) post (17%) • Lethargy: pre (77%) post (40%) • Stool frequency > 3x/d: pre (49%) post (23%) • Limitations. No RDBC studies.

Alternative Diets

Semi-Vegetarian Diet

• Developed by Mitsuro Chiba, Japanese gastroenterologist • Diet created to mimic diet of non-westernized nations • Includes foods that help increase beneficial bacteria • Includes egg, vegetables, fruits, , potatoes, fermented foods, green tea, brown rice and plain yogurt daily; fish once per week and meat once every 2 weeks • Avoids sweets, bread, cheese, margarine, fast food, carbonated beverages and juices.

Alternative Diets

Semi-Vegetarian Diet

Pros Cons • Reduces processed foods in • Compliance difficult for meat diet lovers • Increased intake of foods • More studies required with anti-inflammatory properties • Rich in • No side effects Alternative Diets

Semi-Vegetarian Diet - Research

• Prospective, single center, 2-year clinical trial • Study came out of Japan after introduction in 2003 at Nakadori General Hospital to all patients with CD. • 22 adult patients with CD who achieved clinical remission • 16 patients completed study with remission maintained in 15 out of 16 patients • Remission rate 100% at 1 year and 92% at 2 years • Limitation: lack of pediatric studies

Alternative Diets

Paleo Diet

• Introduced by Dr. Walter L. Boegtlin, a gastroenterologist. • Based on diet of Paleolithic man • High protein diet (19-35% protein, 22-40% CHO, 28-47% fat) • Includes lean meats, eggs, fruits, vegetables, seafood, nuts and seeds, and healthy fats • Avoids grains, legumes, dairy products, processed foods and sugars, potatoes, refined vegetable oils, starches, alcohol and salt Alternative Diets

Paleo

Pros Cons • reduces pro-inflammatory • Has not been shown to be foods effective • Reduces inflammatory • Expensive stressors • Poor long term compliance

Alternative Diets

Paleo - Research

• No recent studies Enteral Nutrition

• Proven effective modality for inducing and maintaining remission in patients with Crohn’s disease • Enteral formula is primary therapy used in Europe • May be consumed orally or via NG tube • Therapy should continue for 8-12 weeks

Enteral Nutrition

Pros Cons • Evidenced based research • Difficult to drink large • Induces and maintains volumes of formula remission • Not always covered by • Promotes growth insurance/Costly • Low risk of nutrient • Psychologically and deficiencies emotionally difficult for • Alternative to steroid use children (NG tube) • Limited oral intake of “regular” food Alternative Diets

Enteral- Research

• Retrospective chart review at CHOP of 43 children after exclusions • PCDAI was calculated for 23 participants before EN initiation and at follow up • Participants received 80-90% of calories from EN overnight • Remainder of calories were small or snacks during the day; unrestricted diet • Patients with active Crohn’s Disease treated with CHOP protocol demonstrated 65% remission rate and 85% response rate Alternative Diets

What they hear vs What we say

Avoid Eat a Clean Diet!! • Raw veggies and cruciferous Avoid vegetables • Animal fat • Citrus fruits • High sugar intake • Red meat • High fructose corn syrup • Carbonated beverages • Additives and preservatives • Coffee and Tea • Gliadins, emulsifiers, • Alcohol maltodextrins • Fatty and Fried Foods

• Spicy Foods

• Sugar

• Seeds and Popcorn

Questions References

Gupta, Kernika, et al. “A Novel Enteral Nutrition Protocol for the Treatment of Pediatric Crohn’s Disease.” Inflammatory Bowel Diseases 19.7 (2013): 1374-3 78. Print. Chiba, Mitsuro. “Lifestyle-related Disease in Crohn’s Disease: Relapse Prevention by Semi-vegetarian Diet.” World Journal of Gastroenterology WJG 16.20 (2010): 2484. Print. Joyce, T., H. Staudacher, K. Whelan, P. Irving, and M. Lomer. “PWE-092 Symptom Response Following Advice On A Diet Low in Short-Chain Fermentable Carbohydrates (fodmaps) For Functional Bowel Symptoms in Patients With IBD.” Gut 63.Suppl 1 (2014): A164. Web. Kakodkar, Samir, et al. “The Specific Carbohydrate Diet for Inflammatory Bowel Disease: A Case Series.” Journal of the Academy of Nutrition and Dietetics 115.8 (2015): 1226-232. Print. Cordain, Loren. The Paleo Diet: Lose Weight and Get Healthy by Eating the Foods You Were Designed to Eat. Hoboken, NJ: Wiley, 2011. Print.