Peter D.R. Higgins, MD, PhD, MSc
Director, IBD Program
University of Michigan
@ibddoctor


The Credibility Gap on Diet in IBD

The Challenges of Diet Research in IBD

Engaging patients on Diet

Flare diet – but return to full diet

Evidence-Based Approaches

Nutritional deficiencies

Symptom Interventions


Patients are INTERESTED in Diet Relationship to IBD

#1 reason for calling CCFA Help Telephone line

Top Concern on Facebook Chats

Often looking for dietary advice

Patients correlate changes in diet with food-related changes in symptoms

Often without changes in disease activity


Food-related Symptoms result in Patients Using
Extreme Diets

SCD, Paleo Diet, macaroon diet, macrobiotic

Many restrict important nutrients

Many spend lots of $$ on supplements

We need to prevent self-harm


Reduce antigens, toxins, or aggravating things

Elemental diet

Defined diets

Alter bacterial composition in the intestines

Food = original Prebiotic

Alter gas production/fluid retention


One Simple Trick web Ads

They Don’t Want You to Know Ads

Denigrating Western Medicine

Go to Peru, drink frog venom and be Cured!

Promising a cure

Selling Snake Oil is VERY Profitable

Drink liquids containing defined sugars
Image patients’ small bowel water content
Clear effects of sugars and fructans occur
AJG 2014; 109:110–119

I am so bloated and uncomfortable. This doctor is clearly an idiot who knows nothing about IBD. I’m going to get that diet book.
Diet does not affect inflammation in IBD


Macaroon diet

Specific Carbohydrate Diet
 Initially proposed by Dr. Sidney Haas as Rx for celiac disease in 1924

Subsequently debunked – gluten is cause
 But it will not die
 Breaking the Vicious Cycle, Elaine Gottschall

Paleo Diet

Fruitatarian diet

Juicing
Kill. Eat.
Form LLC.
Curing Pancreatic Cancer
With Diet


Patients seek alternative therapies, diet cures

Patients severely restrict diets and nutrition

Patients STOP effective anti-inflammatory therapies

Spend their money on alternatives

Can’t afford copays for effective medications
>

Fruits
Vegetables
Red Meat
Whole grains
Refined grains
Dairy
Nuts
Include (%) Avoid (%)
40
17
4
24
57
20
26
44
22
80
56
60
69
79
Internally
Conflicting
32
21
-
18
-
-
17
Hou et al. CGH 2014:12(10)

•19 studies- Evaluated diet patterns prior to
IBD diagnosis
•2,609 IBD patients

Increased IBD risk:
 Total fat 2-3X
 PUFA
 Omega 6
 Meats
2-6X
2-3X
3-4X

Decreased IBD risk:
 Fiber < 1/2 X
 Fruits < 1/2 X
Hou et. al. AJG 2011;106

More Inflammation Less Inflammation
Hou et al. Therapy. 2010, 7(2)

 High rate of food avoidance among IBD patients

89% of Crohn’s disease

84% of ulcerative colitis

40% at Cedars-Sinai with at least 3 food restrictions
 Common to avoid dairy, gluten, vegetables, and red meat, and poultry.
 Both CD and UC patients avoided nuts
 Exacerbation of symptoms is the most commonly cited reason for food avoidance among IBD patients
Issokson, K., et al. AIBD, Poster 89


Percentage of Crohn’s disease Patients who reached recommended daily dietary intake by nutrient
Nutrient
Fiber
Calcium
Selenium
Vitamin A
Vitamin C
Vitamin D
Vitamin E
Vitamin K
CD Patients
15
25
6
21
47
10
5
0
Controls
38
61
80
40
73
26
24
0
Sousa Guerreiro et al. Am J Gastroenterol. 2007 (11)


7% of hospitalized IBD patients meet criteria for severe protein-calorie malnutrition

Associated with 3.5 fold increased mortality

Associated with doubled LOS, >2x hospital charges
 IBD patients in clinical remission vs. controls

Decreased body cell mass vs. controls

Decreased handgrip strength vs. controls
 Effects larger in patients with elevated CRP
Nguyen IBD 2008; 14:1027.
Valentini Nutrition 2008; 24:694–702

Diet and IBD


Medline search – nutrition, RCT, UC, CD

99 publications - only 11 are actually Randomized trials

ZERO positive studies.

ZERO


Elemental (Peptamen) vs. steroids in CD, N=22

2 weeks of Rx, no placebo control

Possibly some benefit ESR 21 ’ 16.
 Not clinically meaningful….

Fructo-oligo-saccharides (prebiotic)

N=103, placebo controlled. No benefit

26% dropout rate in FOS arm vs. 8% placebo arm
 Due to increased BLOATING
APT 1997, 11: 735-40.
Gut 2011, 60: 923-9.


Cochrane meta-analysis
 15 trials, totaling 334 patients
 Enteral nutrition therapy for Crohn’s disease was
3 times LESS effective than steroids
 Forms of enteral therapy

Elemental = non-elemental = polymeric

Low fat = high fat

Type of fat did not matter

ENT not very effective in inducing remission

Very rare to have objective endoscopic evidence

Very poor adherence
Zachos, M., et al, Cochrane Database Syst Rev. 2007


Zero prospective RCTs with mucosal healing endpoints for EEN.

In contrast, anti-TNFs proven in adults and children with multiple large RCTs with clear evidence of mucosal healing.

Evidence base for
>>>
EEN
Levine, et al, IBD 2014; 20:278
Grover, et al., J Gast 2014; 49:638


But…GROWTH-CD – not randomized, not blinded.

But, but….some healing in 34 - not randomized, not blinded.
 But, but, but….it probably improves microbiota!

Actually less diverse.
 A proper CD RCT with objective endpoints is needed

Anti-TNF is the standard of care

Can EEN beat this OR add to this? – to be determined.
Levine, et al, IBD 2014; 20:278.
Grover, et al., J Gast 2014; 49:638.
Gerasimidis, et al., IBD 2014; 20:861.


Need RCTs with adequately large sample size

Requires blinding

Need a convincing placebo/sham diet

Needs to be identical to intervention diet in every way
(except intervention), including texture and taste .

This is difficult and expensive


For full diet, you have to replace ALL food all patients would eat, including snacks, for the length of the study

Very expensive

Patients can not cheat, sample “outside of study” food

Have to provide interesting, tasty variety of food

Expensive


For supplements, you have to assume:

Supplement will be so powerful that it will overwhelm the effects (noise) of all the other food patients eat

People eat very diverse diets
 Potentially a lot of noise in study – larger sample size needed

Sham supplement must be matched, convincing


No intellectual property. Hard to patent food.

Exception – trademarked cakes in Austria
 No one makes a profit if you can’t protect your ideas.

No incentive to develop true evidence-based,
FDA-approved nutritional therapy


Congress has undermined the Intent of the Pure Food and
Drug Act

Unfounded medical claims about “nutriceuticals” or
“supplements” or “medical foods”
 Promoted by paid celebrities like Oz
 No evidence base or rigorous research needed
 Certainly not peer review
 Definitely not FDA Approval

Incentives align to get an appealing product on the
Dr. Oz show and rake in profits without any evidence


Engage patients on diet

Differentiate between symptoms and control of inflammation

Encourage them to control symptoms with diet

But also control inflammation


Fish Oil – EPIC 1 and EPIC 2, N=738

2 Rigorous RCTs of omega 3 fatty acids in Crohn’s
30
20
10
0
60
50
40
31.6
35.7
47.8
48.8
Omega3
Placebo
EPIC-1 EPIC-2
Feagan et al. JAMA. 2008;299(14)


Treating Nutritional Deficiencies

Iron

Vitamin D

Vitamin B12

Engage patients on these

Test regularly

Reassure if normal

Supplement when deficient

 Folate

In patients on methotrexate or sulfasalazine

Reduces spina bifida in future children
 Calories

Make sure meeting protein and caloric needs

If that is hard with regular food
 Consider liquid supplements
 Keep cost low
 Anything else?

No evidence

 Gearry study of Low FODMAP diet on IBD Symptoms
 52 CD patients, 20 UC patients enrolled

No controls

No randomization

Retrospective recall assessment of symptoms

Roughly 50% responded

Improvement seen in overall abdominal symptoms, abdominal pain, bloating, passing gas, and diarrhea

No evidence of change in inflammation
Gearry, et al. Journal of Crohn’s and Colitis, 2009, 3: 8-14

 A bad study

No controls

No comparison diet

Not prospective

Not a validated measure

Basically a case series
 No evidence of harm
 Why do it?

Allows you to regain credibility

Recapture patient from Rasputin.

No NG tube, Low cost
 By treating symptoms, you help the patient engage on inflammation.


History of

Bloating

Distension

Lots of Gas

Strictures

Adhesions

Slow motility

Lacking IC valve

History of SIBO responsive to antibiotics

And Afterward


Most patients report that they benefit from restricting diet during flares
 Less input –> Less output, fewer symptoms
 Bland food – fewer symptoms

Have bad reactions to foods they have tolerated in the past
 Liquid diet often better tolerated
 Limit caffeine (increased motility)
 Limit caffeine and alcohol (decreased hydration)

Problems
 Increased risk of dehydration
 Rapid and significant malnutrition

During a flare they need more calories
 May continue to restrict after a flare


Listen to your body

Limit what gives you trouble

Often spicy foods, fats

Liquids often >> solids
 Avoid dehydration

Not just water
 Salt, sugar, rice in ORS


Get calories and protein into patient

Inexpensive supplements

High caloric density

Options
 Address lactose intolerance

Gradually return to full diet after flare

Start slowly, small portions

Get over fear of particular food/PTSD


Most patients learn these rapidly
 Vomiting provides powerful negative feedback

Low residue diet: avoid

Raw Vegetables

Fruits with skins
 Insoluble Fiber

Beans

Tough Red Meat
 OK

Lean protein (fish, chicken, eggs)
 Pulp and skin free fruit
 If you want to eat fiber

Cut it across the grain into < 1 cm lengths

Cook it until soft


Important to achieve adequate protein and calorie intake

Often this will require temporary liquid diet
 Teach about calorie and protein goals
 Help patients find tolerable protein/calorie supplements

Identify low cost versions

 Instruct and have downloadable handouts

Flare Diet

Obstructive low residue diet
 Have dietician involvement

Low FODMAP Diet

Low oxalate diet for renal stones

Complicated and hard to accomplish by patient
 Foods are NOT labeled by FODMAP content
 Requires diet diaries and analysis.
 Determine which FODMAPs patient can tolerate

Determine threshold for symptoms for each

Why Recommend Restricting
FODMAPs?

30% of IBD patients meet Rome criteria for IBS

Could be post-inflammatory enteric neuritis
→ hypersensitivity

Many, many patients try expensive or fad diets

SCD, Paleo Diet, macaroon diet, macrobiotic
 Many restrict important nutrients

Many spend lots of $$ on supplements

We have to prevent self-harm

And around 50% do benefit
 Especially if gas, bloating, distension are active symptoms
 Especially if abnormal anatomy

Crohn’s surgeries, strictures, fistulas, etc.


Patient volume/interest

RDs, preferably embedded in clinic

Payor mix – mostly BCBS coverage and some self-pay
Lauren van Dam Emily Haller
• Typically see 3-4 NPs, 4 RVs per day
• 50% BCBS
• Some self-pay
• Limit four billable visits per year for BCBS

FODMAP teaching, start restriction
Food diary
Review and
Symptom response
Targeted small dose reintroduction of selected
FODMAPs
Established tolerance by
FODMAP and dose with least restrictive diet


Engage patients on diet

Largely to prevent self harm
 Teach maintenance of protein and caloric needs

Teach maintenance of hydration

Bland flare diets – but return to full diet

Low FODMAP for selected patients
 Low residue for patients with obstruction
@ibddoctor