EXPERT ANALYSIS FROM 2015 ADVANCES IN IBD
ORLANDO (FRONTLINE MEDICAL NEWS) – You think in terms of inflammation, but your inflammatory bowel disease patients tend to think in terms of clinical symptoms, often unilaterally changing their diets according to how they “feel,” rather than in relation to their disease activity, despite your reassurances that diet is not causal to their disease state.
“The data on IBD and diet are awfully thin,” Dr. Peter D.R. Higgins, who directs the IBD program at the University of Michigan, Ann Arbor, said at a conference on inflammatory bowel diseases. The result of this data dearth is that clinicians “have a credibility gap when it comes to diet and IBD,” he said.
Although diet can be manipulated to reduce antigens, toxins, and other aggravating elements, as well as to alter gut bacteria composition, gas, and fluid retention – all possible, even “sensible” mechanisms for some symptoms, according to Dr. Higgins – there still is not enough evidence to link them to disease activity.
Any studies that show a modicum of relationship between diet and IBD currently are still bench science. Of the 11 clinical, randomized, controlled trials Dr. Higgins said he reviewed, none were positive studies. “Zero.”
That goes for exclusive enteral nutrition, too. “There are zero prospective randomized, controlled trials for mucosal healing endpoints for EEN. None,” said Dr. Higgins.
To accrue such data is difficult for many reasons, Dr. Higgins said, especially because extremely large sample sizes are needed, a Herculean feat since so many IBD patients have very decided opinions about diet and would balk at being randomly assigned to certain test groups, and because to blind them as to what they were eating would be difficult. “You need a convincing sham diet that is identical to the intervention diet in every way.” He said there are similar concerns for testing nutriceuticals.
Meanwhile, patients desperate to assuage symptoms such as bloating and abdominal pressure thus go rogue, severely restricting their diets, spending money on alternative therapies, and even discontinuing their prescribed anti-inflammatories per the counsel of so-called Internet gurus whose primary directive is, according to Dr. Higgins, “to denigrate Western medicine.
Very often, IBD patients will develop food avoidances, usually dairy, gluten, fiber, nuts, and some meats, Dr. Higgins said, citing a poster presented at the meeting. Patients with Crohn’s disease or ulcerative colitis reported that they believed certain foods exacerbated their symptoms, so they cut them from their diets. Over time, this leads to malnutrition, including a depletion of micronutrients, he noted.
One study showed that 7% of inpatients with IBD met criteria for severe protein and calorie malnutrition, which was associated with more than triple mortality rates for this cohort, as well as double the length of stays and at twice the cost.
“Patients who choose to do this make their outcomes a lot worse,” Dr. Higgins said. “We really need to prevent [patients from inflicting] self-harm.”
The way forward is to engage patients on diet, and keep them talking.
“Reassure them that you are paying attention to their nutrition, and test them regularly for low iron, low vitamin D, and vitamin B12. Reassure them when [the levels] are normal, and supplement them when deficient,” Dr. Higgins said.
There’s just not enough evidence for offering more treatment than that, aside from patients making sure to meet their protein and caloric needs, according to Dr. Higgins. For patients on methotrexate or sulfasalazine, “you could also recommend folate,” he said.
To facilitate conversations about diet and IBD with patients, Dr. Higgins said he does rely on one “ terrible study ” that had no controls, no randomization, and only retrospective patient assessment of symptoms, but which correlated a low FODMAP (fermentable oligo-, di-, monosaccharides and polyols) diet with lower rates of abdominal pain, bloating, gas, and diarrhea in half of the 52 Crohn’s and 20 ulcerative colitis patients who participated. There was no change in levels of inflammation, however.
“It’s basically a case series, but at least there is no evidence of harm, and it allows me to regain credibility and recapture the patient from the [online] Rasputins,” Dr. Higgins said.
He offered this strategy: Engage patients by talking about and treating their IBD symptoms, so you can get them to work with you when you have concerns around any disease activity. If you think a patient would benefit from a low FODMAP diet, try it. Typical candidates for this approach, he said, are those who have a small intestine bacterial overgrowth response to antibiotics, and those with a history of abdominal pain, distension, extreme amounts of gas, strictures, adhesions, slow motility, and those lacking an ileocecal valve.
If a patient experiences a flare, restricting the diet does make sense in terms of reducing discomfort, Dr. Higgins said, but these patients run the risk of “dehydration, and rapid and significant malnutrition” if they continue to restrict their diets once the flare has quieted.
To lessen symptoms during a flare, patients can be counseled to eat smaller quantities of food, to eat bland food, and to steer clear of caffeine and alcohol, the former making motility worse, and the latter increasing dehydration.
Patients seeking to alleviate symptoms can benefit from “low residue” diets that are low in fiber. Overall, stress the importance of protein and caloric intake, even recommending that patients take liquid calorie supplements if necessary, particularly when sick.
To deepen and continue this kind of patient interaction in your clinic, Dr. Higgins said it is increasingly possible to find a balance between patient volume and interest in this model, registered dietitians – preferably those who can see patients on site, and third-party payers who will cover these services.
The meeting was sponsored by the Crohn’s & Colitis Foundation of America. Dr. Higgins has numerous financial relationships with pharmaceutical companies, including Abbott, Buhlman, Centocor, Millenium, and Pfizer.
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