Nutrition In Crohn's And Colitis: Old And New Ideas

Providing appropriate and adequate nutrition has long been an important part of taking care of patients with Crohn's disease and ulcerative colitis (two of the most common Inflammatory Bowel Dieases, or IBD). This has been particularly true for children with IBD. They often have decreased growth (and delay in starting puberty). So the idea has always been to give them more (and better) nutrition--more calories with higher protein levels to improve growth and the kids' general health, and to replace or supplement what they may not be able to absorb completely through inflamed intestines.

And though the research hasn't been performed, patients having a flare up of the their symptoms have often been instructed to lessen their fiber and roughage, because we don't want all of that scraping against their inflammed intestines to cause more bleeding. We've often instructed patients with Crohn's not to have nuts and popcorn in quantity, because the swelling in the small intestine can lead to narrowed sections where these dense, fibery foods could get stuck and cause more inflammation. I've also told the children (especially the 8 year olds), not to have beer, because then they'll want to eat nuts and popcorn.

A New Approach

Yes, that's needed but now the role of nutrition has expanded. Research and thus treatment has still been on medication to reduce the overactive immune system that seems to cause injury to the intestine. But our new understanding of the intestinal flora, the bacteria and other microorganisms that make up what has been called the microbiome (see my blogposts on the cause of Crohn's and on intestinal bacteria and why you need to be nice to them) has changed thinking about the importance of nutrition in IBD.

The Europeans, Canadians and Japanese have been using aggressive nutritional therapy to treat Crohn's disease when a patient is diagnosed. They would calculate the child's or teen's nutritional needs and provide them as liquid nutrition for a number of weeks. This would often require a tube that goes through the nose to deliver the formula into the stomach--because the child or teen was often unable to drink the large amount of fluid required. And so, it often called enteral therapy, which basically means tube-fed nutrition.

Enteral therapy seems especially traumatic to a child and the entire family who has just received the diagnosis of IBD, a sometimes difficult, lifelong condition. And so, many doctors and patients resisted. But the amazing and important thing is that it worked. In fact, it worked just as well as steroids in bringing patients with Crohn's disease into remission with none of the steroid side effects and comparable improvement in the intestine.

Why Does Enteral Nutrition Work?
  • It might because the child is getting in all that extra nutrition (the nutrients and calories) that they might not otherwise be able to eat when they're not feeling well
  • It might be because all the nutrients are being absorbed high up in the intestine, with little going down further, giving the lower intestine time to heal
  • It might be what's in the formulas. As we now know nutrients can change the balance of the intestinal microbiome to a healthier flora, giving the immune system less to overreact to.
The Immediate Future

So a number of centers are piloting some preliminary trials of partial enteral nutrition (allowing the patients to eat some foods) or other limited diets to see if we can accomplish the same goals achieved with the enteral therapy (and perhaps even some higher goals).

But there's still a lot we don't know--yet:

  • Are any specific elements of these diets more effective? If so, they might not have to be so restrictive.
  • Are these diets effective long term or just in the beginning? So far, the only thing that's been shown is that they are only temporarily effective in children with newly diagnosed Crohn's disease.
  • Can they be used for adults with long standing disease or in ulcerative colitis? Can they be used for any other conditions? The research has started
  • Can they replace medication as the primary treatment? Wouldn't that be wonderful
  • Can the diets be modified? Because they are difficult to follow
  • Can we find out how the nutrition helps? If so, we might be able "to bottle it."
  • Is there any diet that works best? Read my blogpost on specific diets for Crohn's disease

What cautions need to be exercised? Several. Children can lose weight initially getting used to the diets and they can have trouble following them at school or when they are away from home. The diets can seem worse than the disease emotionally for some of the children, especially if they feel they are being pushed into them. They may not work for everybody (because as you will note from my blogpost on the cause of Crohn's, there are lots of variations). And as you can see, what we know doesn't compare to what we don't know. So if you are going to try one of the diets, do so with help and supervision from your doctor and a registered dietitian.

Dr. Stan Cohen 16 July 2014

Dr. Stan Cohen is one of our founders and our CEO as well as the Chairman of our Medical Advisory Board. Dr. Stan is an internationally recognized expert in pediatric gastroenterology and nutrition. He is a Read More

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