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Diet, Nutrition and Inflammatory Bowel Disease

Diet, Nutrition and Inflammatory Bowel Disease. Jason K. Hou , MD Baylor College of Medicine Houston, TX. Disclosures. None. Objectives. At the conclusion of the conference, participant should be able to: 1) Describe the possible role of diet in the development of IBD

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Diet, Nutrition and Inflammatory Bowel Disease

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  1. Diet, Nutrition and Inflammatory Bowel Disease Jason K. Hou, MD Baylor College of Medicine Houston, TX

  2. Disclosures None

  3. Objectives • At the conclusion of the conference, participant should be able to: • 1) Describe the possible role of diet in the development of IBD • 2) Identify the importance of nutritional deficiencies in IBD • 3) Describe the potential use of diet as therapy for IBD

  4. So doc, what can I eat? • “Intellectual divide” • Physicians focus on nutritional deficiencies • Patients interested in diet as cause or cure of symptoms

  5. Malnutrition- then and now • 20-85% of IBD patients with protein-energy malnutrition • Hospital based studies (1970s) • Most prevalent nutritional abnormality = excess body weight (2007) Sousa Guerreiro et al. Am J Gastroenterol. 2007 Nov;102(11):2551-6

  6. Got milk? • Food avoidance • 65% of IBD patients report food avoidance • 28% of IBD patients on dairy-free diet • Lactose intolerance no more common or even less common in UC than non-IBD controls. Gerasimidis et al. Aliment Pharmacol Ther. 2008 Jan 15;27(2):155-65 Bernstein et al. Am J Gastroenterol. 1994 Jun;89(6):872-7

  7. Diet as Etiology

  8. Incidence of IBD is increasing Hou et al. Am J Gastroenterol. 2009 Aug;104(8):2100-9

  9. Dietary fats • Omega 3-fatty acids • Docosahexonenoic acid (DHA) • Eicosapentaenoic acid (EPA) • Docosepentaenoic acid (DPA) • Omega 6-fatty acids • Linoleic acid

  10. Dietary fats Hou et al. Therapy, Mar 2010, 7(2), 179-189

  11. Dietary fats • Food frequency questionnaire in newly diagnosed pediatric CD patients (130 patients) • Dose dependent protective effect of omega-3 FA (EPA, DPA, DHA) for CD • OR 0.44 (95% CI 0.19-1.00) • Ratio of omega-3 PUFA/ omega-6 PUFA • OR 0.32 (95% CI 0.14-0.71) Amre et al. Am J Gastroenterol. 2007 Sep;102(9):2016-25

  12. Dietary fats • Vegetable, fruit, nut, fish, dietary fiber intake protective in dose dependent manner • “Western diet” • meat, fried food, fast food, snacks, dessert • positive associated in development of CD in girls [OR 4.7 (95% CI 1.6-14.2)] D'Souza et al. Inflamm Bowel Dis. 2008 Mar;14(3):367-73

  13. EPIC • Prospective cohort study 203,193 persons • Case control of 126 incident cases of UC • Linoleic acid positively associated with development of UC in a dose dependent manner • OR 2.49 (95% CI 1.23-5.07 in highest quartile) • Dose dependent protective effect of DHA for UC • OR 0.23 (95% CI 0.06-0.97) Hart et al. Gut. 2009 Jul 23

  14. EPIC-UK De Silva et al. Abstract DDW 2010 • UK subset of EPIC • 25, 639 persons • Ages 40-74 • 22 incident UC (median f/u 3.9 years) • The highest tertile of dietary oleic acid protective for UC (OR 0.11 (95% CI=0.01-0.87)

  15. Carbohydrates • FODMAPs • Fermentable • Oligo- • Di- • Mono-saccharides • And • Polyols

  16. FODMAPs • May increase bacterial overgrowth in distal small bowel • Increase intestinal permeability • Trigger CD in susceptible host No data • Gibson et al. Aliment Pharmacol Ther. 2005 Jun 15;21(12):1399-409

  17. Nutritional Deficiencies

  18. Nutritional deficiencies • CD • 32% overweight • 8% obese • 2.6% underweight • 5.3 % considered malnourished by SGA Sousa Guerreiro et al. Am J Gastroenterol. 2007 Nov;102(11):2551-6

  19. Nutritional deficiencies • Food avoidance • 29% excluded grains • 28% excluded milk • 18% excluded vegetables • 11% excluded fruits Sousa Guerreiro et al. Am J Gastroenterol. 2007 Nov;102(11):2551-6

  20. Nutritional deficiencies • Percentage of patients who reached daily recommended intake Sousa Guerreiro et al. Am J Gastroenterol. 2007 Nov;102(11):2551-6

  21. Calcium and Vitamin D • 21-40% increased risk of fractures • Increased risk even after adjusting for steroid use • Management • Bisphosphonate Bernstein et al. Gastroenterology. 2003 Mar;124(3):795-841 Siffledeen et al. ClinGastroenterolHepatol. 2005 Feb;3(2):122-32 von Tirpitz et al. Eur J GastroenterolHepatol. 2000 Jan;12(1):19-24

  22. Who to Screen > 3 months steroids Low trauma fracture Postmenopausal female Male > 50 Hypogonadism Management DEXA T score < -2.5 OR history of compression fracture Bisphosphonate -2.5 <T score < -1 Bisphosphonate if need to continue steroids AGA guidelines (2003) Bernstein et al. Gastroenterology. 2003 Mar;124(3):795-841

  23. Folate/B12 • Decreased intestinal transport- sulfasalazine • Deficiency may result in hyperhomocystinemia • Hypercoagulable state • Folate supplementation- possible protective against colorectal cancer/dysplasia Lashner et al. Gastroenterology. 1989 Aug;97(2):255-9 Lashner et al. Gastroenterology. 1997 Jan;112(1):29-32

  24. Micronutrients • Zinc • wound healing • Selenium • possible anti-inflammatory and anti-neoplastic properties • Antioxident vitamins

  25. Diet as Therapy

  26. Possible pathways • Remove toxin/antigenic stimulus (elemental diet) • Alter bacteria flora (prebiotic) • Alter intestinal fluid transport/gas production

  27. Enteral therapy • Elemental and non-elemental diet • No differences in efficacy • Limitations • Palatability • May require nasogastric feeding

  28. Enteral Therapy- Cochrane review (2007) • Induction of remission: 20-84% • Beneficial but inferior to corticosteroids • Open label RCT • 37 pediatric new diagnosed CD • Remission (10 wk) • ET: 79%; 95% confidence interval (CI), 56%-92% • Steroid 67%; 95% CI, 44%-84% P = .4 • Endoscopic healing seen only in ET group Zachos et al. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD000542 Borrelli et al. ClinGastroenterolHepatol. 2006 Jun;4(6):744-53

  29. Nutritional supplements • Omega-3- PUFA (Fish oil) and CD • EPIC-1 (quiescent disease) • EPIC-2 (flare, remission induction by steroids) • 4 grams daily • Control- MCT Feagan et al. JAMA. 2008 Apr 9;299(14):1690-7

  30. Nutritional supplements • Omega-3- PUFA • EPIC-1 • At 1 year 31.6 % vs. 35.7% relapse • HR 0.82, 95% CI 0.57- 1.19 • EPIC-2 • At 1 year 47.8% vs. 48.8% relapse • HR 0.90, 95% CI 0.67- 1.21 Feagan et al. JAMA. 2008 Apr 9;299(14):1690-7

  31. Nutritional supplements • Omega-3- PUFA • Cochrane review (2009) • Small pooled benefit • RR 0.77, 95% CI 0.61-0.98 • Authors conclude likely no benefit based on EPIC Turner et al. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006320

  32. Nutritional supplements • Fiber and UC • Converted to short chain fatty acids (SCFA) • Energy source for colonocytes • Modulate local immune response • (attenuate IL-6, IL-8, TNF-α, leukocyte adhesion) • Modify microbiota (prebiotic) Menzel et al. Inflamm Bowel Dis. 2004 Mar;10(2):122-8 Galvez et al. Mol Nutr Food Res. 2005 Jun;49(6):601-8

  33. Nutritional supplements • Butyrate (SCFA) • Increase in dietary fiber can increase fecal butyrate • Germinated barley foodstuff (GBF) • Alter colonic bacterial concentrations • Increase in Bifidobacterium sp. and Eubacteriumlimosum Hallert et al. Inflamm Bowel Dis. 2003 Mar;9(2):116-21 Kanauchi et al. J Gastroenterol. 2002 Nov;37 Suppl 14:67-72

  34. Nutritional supplements • Butyrate (SCFA) • Butyrate enemas • Benefit in UC (pilot study) • Did not reach statistical significance in RCT • Plantagoovata seeds • Open label randomized trial (105 pts) • Mesalamine 500 TID vs. fiber 10 gm BID • Increased fecal butyrate in fiber group • No difference @ 1 year • Relapse 40% in fiber • Relapse 35% in mesalamine Scheppach et al. Gastroenterology. 1992 Jul;103(1):51-6 Fernández-Bañares et al. Am J Gastroenterol. 1999 Feb;94(2):427-33

  35. Nutritional supplements • Defined diets- No data • Specific Carbohydrate Diet • “Breaking the Viscious Cycle” • Maker’s diet • “juicing” diets

  36. Nutritional supplements- CAM Hou et al. Therapy, Mar 2010, 7(2), 179-189

  37. Ongoing research BCM

  38. BCM Food aversion study • Hypothesis: • Food aversion in IBD is common. • Food aversion in IBD may be related to several factors • Physician • Patient directed education • Patient symptom correlation

  39. BCM Food aversion study • Primary aim: To define the frequency and character of dietary alterations that occur in patients with IBD • Secondary aims: • Identify the reason IBD patients initiate dietary modifications • Identify if IBD patients feel dietary modifications are effective

  40. Methods • Prospective, controlled data acquisition • 100 IBD patients • 50 CD • 50 UC • 100 healthy controls • Non-IBS • Matched for age, sex

  41. BCM Food aversion study • Goals • Establish food aversion patterns in IBD • Identify etiology of food aversion patterns in IBD • Create pilot data for further studies regarding dietary habits and IBD • Establish if unnecessary food aversion result in nutritional deficiency • Apply educational tools to correct nutritional deficiencies

  42. Conclusions • Diet as Etiology • Fatty acids composition may play a role in pathogenesis • Nutritional deficiencies • Protein-calorie malnutrition becoming less common, but Micronutrient deficiencies common • Diet as Therapy • Fiber, enteral therapy, CAM

  43. Thank you for listening Special thanks to Drs. Hashem El-Serag, Joseph Sellin, and SelviThirumuthi

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