Chapters Transcript Video IBD Breakout: Dietary Modifications in the Treatment of IBD IBD Breakout Session: Dietary Modifications in the Treatment of IBD *Not Eligible for CME Credit Hi, and good morning. Good afternoon or good evening. Depending on where you're joining us, uh, from, uh, uh, uh, uh, the today's session is, uh, entitled, uh, E E N and P and I B DS Underutilized Therapeutic, uh, gems. Um, uh, and we're gonna be focusing on, uh, enter nutrition's potential roles in, in, in, in I B D for those of you who don't know me. Uh, I'm Doctor Eric Vasas. I've been at Cedars for roughly 30 years, um, focused in on, uh I B D and I'm currently the, uh, director of our, uh, nutrition and integrative multidisciplinary specialty program. And I have the pleasure of, of presenting today with my co-host Aaron. Hi, I'm Aaron Feldman. I have been at Cedars, uh, for 24 years and with the pediatric Diabetes Center since its inception in 2001. I'm the, um, pediatric dietician. And, uh, today we're gonna, uh, during this session, we're gonna be exploring, uh, sort of a, a fast-paced focused dive into the, uh, uh, you know, what you see here, the potential roles of an, in the formulas, uh, therapies, uh, the data supporting antril attrition and I B D when to consider them. And then uh wrap it up with how to infect uh effectively incorporate uh an nutrition uh into practice, including challenges that, that uh uh we might face. Uh and uh importantly, interventional strategies for uh success. Um um All right, I'm gonna take it from here. Um So, exclusive intral nutrition means that 100% of a patient's nutrient needs are provided by a formula. There's three different classifications of formulas. There's elemental, which is free amino acid um based. And examples of that would be viven or to um a lot of times the pala palatability and oral tolerance may be poor. Um But this is a good option for patients who have severe G I dysfunction or multiple food allergies or if you're treating Sebo and then there's some semi elemental forms that are extensively hydrolyzed proteins, um such as peptid and vital and then there's polymeric like intact protein, uh formulas such as boost insure or gain Kate farms. And then there's pediatric versions of all of these as well. Um Research shows there's no significant difference between formula types and inducing remission. So, um we'll talk about uh you know, choosing a formula later on in the talk, but um there's gluten free, low residue lactose, free Kosher and vegan options. So, there's a lot of formulas out there. Uh And then partial intro nutrition is when uh the liquid nutrition or formula provides 30 to 50% of the patient's nutrient needs. And then the remainder of the nutrition comes from a healthy diet. There are some fairly new I O I B D guidelines that recommend increasing intake of fruits and vegetables, decreasing intake of red and processed meats in uh decreasing saturated fat such as palm and coconut oil, um avoiding unpasteurized dairy trans fats, maltodextrin, carbo, carboxymethyl cellulose, uh polysorbate, 80 artificial sweeteners, carin titanium dioxide sulfides, all the additives. Um And also, you know, a healthy diet includes a Mediterranean style diet um or a semi vegetarian diet which um you know, both of them avoid processed foods, added sugars and have an emphasis on plant based proteins. All right. So, uh with all the advancements in I B D therapies, uh why should we consider uh nutrition? Uh And that's because really, uh as we heard this morning, long term fail, uh therapies uh are, are really, are falling short. These are just three examples of, of various uh uh clinical trials in I B D. Um uh you know, in terms of patients, you know, they think of responses getting is going from bad to better. And we can see that about two thirds of patients typically uh respond at least acutely to uh uh to any sort of uh given uh therapy that we have. Uh and that remission, which in a patient's mind is feeling well. Um We obviously have other definitions too. Um uh about a third or So uh achieve uh a a mission. Uh And if you look at clinical trials overall again, about two thirds uh uh have a short term response, uh about a third uh longer term response but sustained response off uh steroids. Uh there's clearly a lot of room for improvement. And in real life, you know, we can do dose adjusting, uh we can blend therapies um to get better results hopefully. Uh but there's still a cost and side effect, you know, concern. So, um you know, how can we do more? Doctor David this morning? Kind of alluded to nutrition being important. Um And so, uh that's what we're gonna take a dive into uh today. So this case will hopefully uh help us better understand how Innu can be incorporated into the I B D therapeutic toolbox. This is a, a 21 year old female with a history of stricturing, stricturing iliac Crohn's disease who had a resection uh inflammation recurred uh side effects. She had side effects for incomplete response uh to, you know, all the various therapies you see on, on, on, on here. Uh So she was started on Vidaza uh with initial improvement, but then seven months later, uh developed increased symptoms, increased inflammatory mark workers. And despite uh bide, uh and so now, um this is a couple of years back. Uh but you know, what were the options? The options might include? Um you know, switching to is Staab uh but honestly, she is skeptical and hesitant to try another biologic uh though, uh just given how she's done with the other ones, uh and other therapies and, but she is willing to consider if she absolutely needs to, um I V steroids are certainly reasonable to try to kind of quiet down the inflammation. Uh However, she doesn't want systemic steroids due to prior side effects and she's already feeling b decline um, surgery starting with a clean slate for distal ali recurrence uh would be an option but you still need a post op strategy. Um And what about E E N uh in place the steroid to induce remission or, and then uh or uh partial in nutrition as a potentially sort of a, a boost to uh uh uh boost the effectiveness of her biologics. Um So, uh uh this um meta analysis uh uh shows that um uh uh that's that uh although uh uh E E N. Um sorry. Yeah. Yeah. Although uh uh E N uh in uh in, in a meta analysis, uh slightly favors steroids in terms of efficacy, unlike sort of the earlier studies. Um uh there I I it, it has uh uh it, it doesn't have the same, same side effect that uh you know, that, that have and it comes pretty close in terms of overall efficacy. Uh But E N also offers the advantages of again, fewer side effects, the potential for mucosa healing. Uh It can be uh uh uh conti continuous P N, you know, as part of manus therapy. And it can also lead to uh uh you know, weight gain and, and uh and, and uh uh improved nutrition. Um And in this study, uh uh exclusive nutrition uh uh uh in patients in, in pediatric patients with uh with, with Crohn's disease, uh shows how E N can lead to rapid induction of clinical remission. Uh If you look over at the graph on the uh right hand side, uh you see that there was a very rapid uh uh response. Um And that roughly 80% of patients uh whether uh it was given earlier or, or via N G uh had a clinical uh uh response uh uh to that. Um uh Nearly 80% of the adolescents with Crohn's in this uh E E N study uh with a polymeric uh E N uh uh formula, achieved clinical remission uh uh without steroids uh by eight weeks and some even achieve newco healing um in, in this uh pediatric study. Uh E N was found to be actually just as effective as anti F therapy by week eight. Uh particularly if you focus in on the uh higher disease activity group. Those are the P D A I S uh P CD I over 30. Uh you can see that they uh that they have pretty similar overall uh response rates uh uh uh there. Um And uh if you know what about adults? Uh So this, this, this study looked at patients with obviously very severe disease because they were getting, uh, being considered for surgery, uh, for either stricturing or penetrating disease. And if we look at the, the data, uh, it turns out that, uh, uh, they got, uh E N for a mean of 6.3 weeks, 94% of these adults tolerated at least four weeks of E E N. And interestingly, um 25% improved to the point where they no longer require surgery. So that's uh uh it seems like some pretty powerful nutritional medicine uh uh there. Um and the conclusions of the study uh were that uh that E N could downstage the need for urgent surgery, could bridge to semi elective or safer surgery. And those with more complicated Crohn's disease and importantly, also resulted in fewer complications. And so, what have we learned about E N and I B D? Well, well, when E N is adhered to strictly for several months, it can provide symptom relief. Um It can improve inflammatory markers, it can induce clinical remission in many muco healing in some and can alter the microbiome which we also know plays a role in, in, in, in, in things. Um But if E N is usually, is discon, so the, the the concern though is that E N is usually discontinued before you actually get that deep mucosal healing, you know, where you look inside and there's no more endoscopic or histologic uh uh uh healing. And so what typically happens when you stop E N and go back to eating a regular diet, I'll point out regular diet, the symptoms and disease tend to recur kind of like if you start steroids and you stop them a little bit too soon, the disease can recur um And what about going longer than 3 to 4 months with E E N, I mean, it, it can be done, but it's very challenging to sustain a longer term. So you really need some sort of exit strategy. Uh You know, that could be either transitioning to uh a maintenance medication, uh such as a biologic immunomodulator, five BS A transitioning over to partial nutrition and a healthy diet or possibly the, the Crohn's Disease glu diet. Um Another therapeutic diet such as the uh specific carbohydrate diet or the A I I B D A A ID, um uh et cetera. Now, uh you know, when we think about combination therapy, um we usually think about uh adding in an immunomodulator uh such as six MP or methotrexate to boost outcomes uh of a of, of a biologic. Um But uh what about uh combining a biologic plus partial nutrition, sort of nutritional combo therapy? Um This me analysis uh shows that uh combining uh uh partial antri with Infliximab uh uh was better than Infliximab monotherapy. And in fact, there was a twofold increase in the odds of achieving clinical remission using this strategy. Uh And the probably the maintaining uh clinical remission with this combination extended beyond uh beyond one year. So it's pretty, again, pretty powerful uh nutritional medication, uh medicine. Uh So this uh uh young lady started uh exclusive Antri in form of for, she took it for four months. Uh and colonos five months later showed actually deep remission. You can see the healing here. She, this is off of the B has a normal set rate, um uh minimally uh border, borderline C R P. But endoscopically is she is quite with a normal uh the, the uh uh neo I and the pathology came back uh throughout showing uh no evenness of any uh uh uh inflammation. So now what uh uh do we continue long term E P N without uh E N without medication? Again, that's difficult to do and without medication. Uh If E N is discontinued, the disease tends to quickly recur uh do we see if she can be now sustained on viala alone? Uh just like sometimes we use steroids to sort of quiet down the inflammation and then have the background inflamma uh uh medication sort of continue uh uh uh uh uh and, and see if that that works. Uh Does she continue Vidaza along with longer term uh partial in nutrition uh perhaps in the form of a CD E D or uh continue viala along with a semi vegetarian diet. Um Well, uh uh this study uh uh out of Japan illustrates very nicely the roles of e uh uh in, in Crohn's disease. In the first part of the study, uh they induce clinical remission with one of uh four strategies uh either in flux, Predisone T PM or total nutrition. Um And uh uh uh once these individuals achieved their mission, they were then randomized to either receive a partial nutrition for the next two years or just follow their sort of free range regular diet and uh uh what they found and what you see in the graph over there in terms of relapse rates is that predictably about two thirds of patients um on essentially no therapy in a regular diet clinically flared. Uh compared to a much lower rate of only 30% of those who incorporated uh partial and nutrition into their uh treatment paradigm. Again, a very simple strategy um with basically uh no side effects. Uh We also know that um uh in the post office setting, uh uh uh endoscopic recurrence pres sees symptomatic recurrence and that without therapy by three years, uh about 70% will be symptomatic. Um and nearly 100% if you look inside uh will have endoscopic recurrence. Um And that's with uh again, medication and on a regular diet prone comes back. Um OK. Uh And so, uh just real quickly. Um uh so this study, partial end attrition, uh reduced post recurrence uh with a much lower uh relapse rate of only 30% after a year compared to 70% on a regular diet. And the basic of this semi vegetarian diet. Um uh in a similar situation, uh let's uh uh on AAA 92% remission rate versus a 25% remission rate in those eating our full regular diet. OK. So we're gonna talk about how to effectively incorporate E E N and some of the challenges and intervention strategies to overcome those um challenges. So, one of the things that uh we see a lot of is is the adherence or, or patients not wanting to adhere to E E N maybe because of the lack of variety or pala palatability of the formula, it could be monotonous. Um They might miss social aspects of food, uh lack of motivation and and possible side effects. So it's really important to discuss the positive aspects of E N um to increase the motivation, their adequate hydration, weight gain, more energy healing. Um That's number one that, you know, the provider should, should talk about all the great things that come with E E N. Um you could individualize the formula per patient taste preference. Um All the formula companies have reps that will send out samples so patients can try it and um just help alter the mindset of the patient, you know, talking about encouraging um alternative social activities that don't, don't, um, aren't surrounded by meals. So maybe hiking or game night or something like that. Um Then the next concern might be cost, uh, a lot of times insurance doesn't pay for oral nutrition. Um, they might pay for if it goes through a tube but not by mouth. So, um, that's one of the potential challenges, but when you look at the overall cost of the formula, um, for example, excuse me, six bottles of insurance plus cost less than $13 a day. A lot of times. Um people are eating out at a restaurant once a day and you know, in the whole grand scheme of things, uh the formula could be less than just one meal out at a restaurant and that could provide their entire nutrition for the day. Um Patients can also look into like flexible spending accounts and health savings accounts to possibly cover some of those costs. Uh and then, you know, making sure that there is an inter interdisciplinary team uh in place, you know, having a dietician access to a nurse for some education, psychological support is really important. Um And all of these things can improve patient outcomes. Uh health care, the whole health care process and the level of satisfaction, really good outpatient care can prevent or reduce need for hospitalization and um and really help the patient avoid potential surgery. So if you don't have a dietician, you can always refer to to one. Um you know, outside psychological support, but it's really important to have a good team in place and then just quickly transitioning from exclusive intral nutrition to partial inter inter nutrition. You can transition over 3 to 5 days. Um, you can start with soft, low fat, um, small portions and really replace 11 introduce one meal in place of a portion of the l nutrition. You know, until eventually you, um your, the patient is eating a healthy diet or you can, you know, incorporate uh a healthy diet and continue the partial internal nutrition. Um depending on what the, what the course is for that patient. And um just to kind of recap the potential roles for exclusive ventral nutrition is to induce symptomatic remission, possibly uh heal the mucosa to avoid steroids for those. Um with, with uh with in inflammatory structures could be used as a bridge for um until whatever therapy you're, you're using kicks in. Uh it could be a bridge to semi elective and safe for surgery. And also it's used um to treat small intestinal bacterial overgrowth. Um and also, you know, using partial internal nutrition, it can just boost caloric and nutritional intake. You know, for patients who are really sick or if they're not able to absorb all of their um food from a regular diet and maybe they have poor intake um due to nausea, strictures, adhesions, it really can help for long periods of remission. Um can reduce the likelihood of uh postoperative crowns recurrence and it may boost the efficacy of biological therapy. So there's lots of formula options. Um It is fairly simple. You just have to really have the buy-in of the patient and that really stems from good communication and kind of talking it up and, and talking about the great benefits of it. Yeah, and we have more and more patients uh opting for this as we offer it up. Uh uh It's actually quite uh amazing how uh receptive people are uh to trying these things, especially when you present them with the uh you know, with the, with the data and the benefits and the options. And uh I, I just, you know, if people who are uh you know, say outside of cedars in private practice, if you can identify a dietician to work with, who can become very familiar with these, it's just, it's just so invaluable to have a knowledgeable, uh you know, G I or I B D focus dietician if possible. Uh It's just super beneficial. It's a great way to avoid steroids, which I think, you know, patients, that's a main priority for a lot of patients is to not go on steroids. Ok. Oh, great. Well, thank you very much. Created by
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