Crohn’s & Colitis Congress 2024: Updates on IBD Diet & Nutrition Research

By Andreu Prados, PhD, BPharm, RDN, and Stacey Collins, MA, RDN/LD

Sessions at the 2024 Crohn’s & Colitis Congress® covered basic and translational research in inflammatory bowel disease (IBD), including evidence-based dietary interventions for reducing inflammation and maintaining remission.

Malnutrition in Patients with IBD Undergoing Surgery

Malnutrition and micronutrient deficiencies are common in patients with IBD and are associated with poor disease activity, greater hospital length of stay, and increased risk of postoperative complications. Poster findings from Zoe Memel, Kendall R Beck and colleagues at the University of California San Francisco showed that the incidence of at least one micronutrient deficiency, especially vitamin D, iron, and vitamin B₁₂, was high among older adults with ulcerative colitis who have undergone bowel surgery and should be monitored and screened annually.

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Oral supplementation with specific nutrients before surgery is also relevant for improving surgical outcomes. Poster findings from Kelly Issokson and colleagues at Cedars Sinai Medical Center showed preoperative carbohydrate loading and perioperative immunonutrition oral nutrition supplements may reduce the number of patients with IBD undergoing abdominal surgery who stay in the hospital for more than four days. They also found that regardless of nutrition status, the patients who completed their recommended nutrition protocol with greater adherence were associated with a shorter hospital length of stay after their IBD-related surgeries^.1

All Patients with IBD Should Undergo Individual Counseling by a Dietitian

While sometimes people think dietitians are only for patients with IBD who are malnourished, the reality is that there are many ways to integrate a dietitian into the IBD care team. Dietitians who specialize in IBD can be involved in nutritional assessment, dietary counseling, peri-operative dietary education, cross-disciplinary collaboration, and research, according to Kelly Issokson, registered dietitian and clinical nutrition coordinator at Cedar-Sinai IBD Institute.

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Different diets may offer some symptom relief in patients with IBD, thus increasing quality of life. Rebekah Preston and colleagues at the University of Alabama reviewed dietary interventions with variable efficacy that can positively impact the quality of life in adults with IBD, including the low FODMAP diet, the IgG₄ diet, the Dietary Modified Program, the Dietary Modified Framework, the Autoimmune Protocol Diet, the Specific Carbohydrate Diet, the Mediterranean diet, and a low-fat high-fiber diet. Many of these dietary approaches may be challenging to follow or maintain long-term and sometimes are not intuitive for the patient, so a registered dietitian with experience in IBD is needed to individualize the proper diet so it meets nutrient needs and accommodates daily life.²

Stacey Collins, an IBD-focused registered dietitian, highlighted that almost 70% of patients report that they have never actually received any advice about their diet and explained how to choose an IBD dietitian. There is compelling evidence that diet in IBD makes a difference when it comes to improving patients’ quality of life, disease outcomes, and response to medications. For patients with IBD to benefit from nutritional therapy, they must ensure to visit IBD-trained registered dietitians with experience as part of an IBD care team instead of generalist registered dietitians. Nowadays, academic centers such as Cedars Sinai provide comprehensive IBD-focused nutrition education to physicians, advanced practice providers, and registered dietitians.

Fiber and Hydration Intake for Patients with J-Pouch or Ileostomy

Many patients with IBD require surgery during their disease course. The creation of a surgical reservoir made with a part of the small intestine (J-pouch) or an ileostomy are common types of surgery in ulcerative colitis that are associated with a high hospital readmission rate.

Collins explained how to help patients with J-pouch or ileostomy as it relates to dietary fiber and fluid intake. Most patients with IBD referred to surgery are at high nutritional risk like oncologic patients and show an inadequate intake of fiber probably due to their belief that fiber can worsen bowel obstructions.³ However, the reality is that fiber can help promote surgical wound healing and improve nutritional adequacy with a low risk of anastomotic leaks.⁴ 

For instance, dietary fibers with small particle sizes (e.g., blended smoothies, purees, and fork-tender vegetables) are easily digestible, allow to diversify diet and promote a healthy gut microbiome. As the majority of patients with IBD make self-directed, nutritionally inadequate dietary modifications, there is a need of IBD-trained, experienced dietitian that help improving their quality of life and help them to temper expectations on nutritional therapy. 

‍Patients might benefit from using Oral Rehydration Solutions, which can be bought in pharmacies or prepared at home, are easily absorbed, and help maintain good hydration. In contrast, the general advice of “drink more fluids” does not work as some drinks such as soda, sugar-sweetened teas and juices, sports drinks, plain tea, and coffee can boost bowel movements and worsen dehydration. General hydration tips shared by Collins included drinking about 67 to 100 fluid ounces, including 16 to 32 fluid ounces (1 quart) of oral rehydration solutions slowly throughout the day.^5,6

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Filling up on Fermentable Fibers for a Healthy Gut in IBD

Most gut microbiome studies in IBD are based on the colonic microbiota (i.e., obtained from fecal samples). Poster findings from Jacques Izard and colleagues at the University of Nebraska Medical Center showed by studying fecal affluents that the lack of the whole colon in patients undergoing ileostomy led to decreased levels of eight short-chain fatty acids but not lactic acid and a higher abundance of lactate-producing bacteria compared to patients with partial resection of the colon. While reduced levels of SCFAs could have negative consequences due to the loss of their anti-inflammatory properties, the implications of these findings for patients with IBD’s gut physiology and disease course remain to be seen"

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Although recent research recognizes the role of the gut microbiome in IBD, the potential benefits of prebiotics have scarcely been studied. Jessica Breton, pediatric gastroenterologist at Children’s Hospital of Philadelphia, presented the first clinical trial suggesting that 2-month oligofructose-enriched inulin supplementation in children with subclinical active IBD activity may favor an increase of Bifidobacterium and butyrate producer Anaerostipes at four weeks of treatment. While fecal metabolites were not altered during the 8-week intervention, an increase in butyrate, a fermentation product of dietary fiber that is reduced in the IBD gut microbiome, was seen two months after discontinuing inulin supplementation. High levels of Bifidobacterium and Anaerostipes were also associated with low levels of gut inflammation assessed by fecal calprotectin. Altogether, these findings suggest that dietary β-fructans could help prevent relapse in children with subclinical IBD activity.⁷

Findings in mice presented by Andrew Gewirtz, a researcher at Georgia State University Institute for Biomedical Sciences in Atlanta, showed that a Western-style diet (rich in saturated fats and simple sugars, but low in dietary fiber) induced infiltration of bacteria into the normally almost-sterile inner mucus layer and intestinal atrophy. However, these detrimental effects were reversed by consuming a fermentable fiber (inulin) in a gut microbiota-dependent manner.⁸ 

Pros and Cons of Exclusive Enteral Nutrition in IBD

Nutritional therapy can be a powerful tool as monotherapy in select patients and when used alongside medical therapy. Lindsey Albenberg, assistant professor of pediatrics at Children’s Hospital of Philadelphia, highlighted that “practitioners should be using all of the tools in their toolbox”. Exclusive enteral nutrition (EEN), also known as “defined formula diet”, has shown robust evidence in inducing remission for Crohn’s disease and favoring mucosal healing when used in monotherapy. There is also some evidence supporting the efficacy of enteral nutrition combined with biologics.^9,10 

In particular, children and adults placed on EEN could improve postoperative outcomes, food tolerance, weight gain, and symptoms such as crampy abdominal pain. The rationale behind its use involves a reduction in intestinal inflammation while allowing weaning of steroids without flares.¹¹ 

Despite EEN efficacy, it is an underused therapy for the induction of remission in Crohn’s disease, especially among North American pediatric gastrointestinal physicians compared to European counterparts.¹² EEN implementation is challenging, shows tolerance issues, has a high cost, and lacks insurance support. The lack of clinicians' training on EEN is also a barrier when using it in their clinical practice and uncertainties remain about the best exit strategy. Common used exit strategies for EEN include using it as a bridge to whole food-based therapeutic diets (e.g., Crohn Disease Exclusion Diet) and to biologics/small molecules. 

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References:

<sup>1. Collins S, Cedillo Castelan V, Wernick R, et al. Effects of nutrition status and perioperative nutrition supplement completion on postoperative outcomes in patients with inflammatory bowel disease undergoing surgery. Gastroenterology. 2024; 166(3):S22-23. doi: 10.1053/j.gastro.2023.11.081.
2. Preston R, Knol L, Douglas J. The relationship of diet interventions to quality of life in adults with inflammatory bowel disease: a narrative review. Gastroenterology. 2024; 166(3):S25. doi: 10.1053/j.gastro.2023.11.085.
3. Fiorindi C, Dragoni G, Alpigiano G, et al. Nutritional adequacy in surgical IBD patients. Clin Nutr ESPEN. 2021; 41:198-207. doi: 10.1016/j.clnesp.2020.12.021.
4. Kok DE, Arron MNN, Huibregtse T, et al. Association of Habitual Perioperative Dietary Fiber Intake With Complications After Colorectal Cancer Surgery. JAMA Surg. 2021; 156(9):1-10. doi: 10.1001/jamasurg.2021.2311.
5. Rees Parrish C. A Patient’s Guide to Managing a Short Bowel, 4th Edition. Intouch Solutions, Overland Park, KS; June 2016.
6. Rees Parrish C, Wall E. The Clinician’s Toolkit for the Adult Short Bowel Patient Part I: Nutrition and Hydration Therapy. Nutrition Issues in Gastroenterology, Series #222. Pract Gastroenterol. 2022; 46(6):32-53.
7. Breton J, Tanes C, Kyle B, et al. The modulatory effect of prebiotic inulin-type fructans on the microbiome profile of children with inflammatory bowel disease: a double-blind randomized controlled trial. Inflammatory Bowel Diseases. 2024; 30(Issue Supplement_1): S10. doi: 10.1093/ibd/izae020.023.
8. Zou J, Chassaing B, Singh V, et al. Fiber-mediated nourishment of gut microbiota protects against diet-induced obesity by restoring IL-22-mediated colonic health. Cell Host Microbe. 2018; 23(1):41-53.e4. doi: 10.1016/j.chom.2017.11.003.
9. Swaminath A, Feathers A, Ananthakrishnan AN, 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(7):645-656. doi: 10.1111/apt.14253.
10. Wands DIF, Gianolio L, Wilson DC, et al. Nationwide real-world exclusive enteral nutrition practice over time: persistence of use as induction for pediatric Crohn’s disease and emerging combination strategy with biologics. Inflamm Bowel Dis. 2023; izad167. doi: 10.1093/ibd/izad167.
11. Albenberg L. The role of diet in pediatric inflammatory bowel disease. Gastroenterol Clin North Am. 2023; 52(3):565-577. doi: 10.1016/j.gtc.2023.05.011.
12. Critch J, Day AS, Otley A, et al. Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease. J Pediatr Gastroenterol Nutr. 2012; 54(2):298-305. doi: 10.1097/MPG.0b013e318235b397.</sup>

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^‍‍About the writers:

‍Dr. Andreu Prados is a science and medical writer specializing in making reliable evidence of non-prescription therapeutics for gastrointestinal conditions understandable, engaging and ready for use for healthcare professionals and patients. He holds bachelor’s degrees in Pharmacy and Human Nutrition and Dietetics and a PhD in nutrition communication.

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‍Stacey Collins, MA, RDN/LD is an IBD-focused registered dietitian who owns her own virtual nutrition private practice where she gets to help people with Inflammatory Bowel Diseases (IBD) approach food with more curiosity and celebration while finding safer, more individualized ways to nourish their bodies. She has a special interest in helping colorectal surgical patients feel more confident and supported through their surgical journeys. She was the inaugural IBD Dietitian Apprentice at Cedars-Sinai and completed her graduate nutrition training at The University of Oklahoma Health Sciences Center, where she is currently exploring patient interest in expanding IBD RD accessibility through a second master's program.  In her spare time she enjoys exploring outside with her husband and carrying her deaf dog along whatever adventure awaits.

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