Nutritional Therapy in Inflammatory Bowel Disease

Bioactives in Oral Nutritional Supplementation: A Pediatric Point of View

BACKGROUND

Oral nutritional supplements (ONSs) are crucial for supporting the nutritional needs of pediatric populations, particularly those with medical conditions or dietary deficiencies. Bioactive compounds within ONSs play a pivotal role in enhancing health outcomes by exerting various physiological effects beyond basic nutrition. However, the comprehensive understanding of these bioactives in pediatric ONSs remains elusive.

OBJECTIVE

This systematic narrative review aims to critically evaluate the existing literature concerning bioactive compounds present in oral nutritional supplements from a pediatric standpoint, focusing on their types, sources, bioavailability, physiological effects, and clinical implications.

METHODS

A systematic search was conducted across the major academic databases, including PubMed, Scopus, and Web of Science, employing predefined search terms related to oral nutritional supplements, bioactives, and pediatrics. Studies published between 2013 and 2024 were considered eligible for inclusion. Data extraction and synthesis were performed according to the PRISMA guidelines.

RESULTS

The initial search yielded 558 of articles, of which 72 met the inclusion criteria. The included studies encompassed a diverse range of bioactive compounds present in pediatric ONS formulations, including, but not limited to, vitamins, minerals, amino acids, prebiotics, probiotics, and phytonutrients. These bioactives were sourced from various natural and synthetic origins and were found to exert beneficial effects on growth, development, immune function, gastrointestinal health, cognitive function, and overall well-being in pediatric populations. However, variations in bioavailability, dosing, and clinical efficacy were noted across different compounds and formulations.

CONCLUSIONS

Bioactive compounds in oral nutritional supplements offer promising avenues for addressing the unique nutritional requirements and health challenges faced by pediatric populations. However, further research is warranted to elucidate the optimal composition, dosage, and clinical applications of these bioactives in pediatric ONS formulations. A deeper understanding of these bioactive compounds and their interplay with pediatric health may pave the way for personalized and effective nutritional interventions in pediatric clinical practice.

Immunosuppressant-Responsive Enteropathy and Non-Responsive Enteropathy in Dogs: Prognostic Factors, Short- and Long-Term Follow Up

Simple Summary

Chronic intestinal inflammation in dogs is a challenging disease to manage. Most studies about prognostic factors and follow-up data are only available for small populations or with short-term follow-up. The aim of this study of 165 dogs with chronic intestinal inflammation was to identify clinical and haematological factors associated with mortality, clinical response and relapse, with long-term follow-up. Nine per cent of dogs did not respond to therapy at 1 month follow-up. Most dogs with chronic intestinal inflammation had a good clinical course in most cases, and the non-response or relapse rate was 9–11%. A reduction of body condition (loss of weight), lower serum albumin concentration and presence of lacteal dilatation on intestinal histology at diagnosis were identified as factors associated with a decreased response rate, higher mortality and lower chance of achieving long-term remission.

Abstract

A multicentre prospective study was performed to assess whether clinical, hematobiochemical, endoscopic and histopathological parameters were associated with mortality, clinical response and relapse of disease in short- and long-term follow-up of a total of 165 dogs with chronic inflammatory enteropathy, of which 150 had immunosuppressant responsive enteropathy (IRE), and 15 had non-responsive enteropathy (NRE) dogs. Clinical severity (CCECAI) was evaluated from presentation (T0) to 18 months (T18) from diagnosis. T0 body condition score (BCS), selected haematological parameters and endoscopic and histopathological scores were evaluated. Presence/absence of histopathological duodenal lesions was recorded. Responders were evaluated using CCECAI at T1. Relapse was evaluated from T3 to T18. Long-term responders included dogs who responded at T1 and showed no relapse. Dogs were divided into responders/non-responders, survivors/non-survivors and relapsed/non-relapsed. At T1, 15/165 dogs (9%) were considered NRE. Sixteen dogs (11%) were considered relapsed at T3, 8% at T6 and 10% at T12, and none of 96 dogs relapsed at T18. NREs showed significantly lower BCS than IREs. Non-survivors showed a significantly lower serum albumin concentration and BCS than survivors. Non-responders, relapsed or non-survivors had higher presence of lacteal dilatation compared to long-term responders. Dogs with IRE showed a good clinical course with a low relapse rate, with only a few dogs in the NRE group. Reduction of BCS, albumin and lacteal dilatation at diagnosis may be considered negative prognostic factors for response, mortality and long-term disease remission.

Influence of skin wounds on the intestinal inflammatory response and barrier function: Protective role of dietary Shewanella putrefaciens SpPdp11 administration to gilthead seabream (Sparus aurata L.)

The effects of skin wounds on the intestinal barrier function and the beneficial effects of the dietary administration of Shewanella putrefaciens (known as SpPdp11) in gilthead seabream (Sparus aurata L.) were studied. Two replicates of fish were fed a commercial diet (control, CON) or CON diet enriched with 10⁹ cfu g^-1 SpPdp11 (SP diet) for 30 days. After this time, half of the fish were sampled, while the others were injured below the lateral line (wounded fish, W) and fed the same diets for an extra week before sampling (CON + W and SP + W groups). The intestinal histology and gene expression of different genes relevant for the intestinal barrier function were studied. The results showed that injured fish had a disordered enterocyte nucleus disposition, a more intense infiltration of mixed leucocytes and a thicker lamina propria in the intestine compared to the control fish. However, the fish in the SP + W group did not present these pathological symptoms in the intestine. No significant variations in the number of goblet cells were detected among the different experimental groups. Pro-inflammatory cytokines (colony-stimulating factor receptor 1, CSF1R, myeloperoxidase, MPO and interleukin-1β, IL-1β), mucins (intestinal mucin, IMUC and mucin 2, MUC2), and immunoglobulin T heavy chain (IGHT) were up-regulated, while tight junction protein occludin was down-regulated in the intestine from fish of the CON + W group. Similarly, the dietary administration of SpPdp11 markedly depressed the gene expression of pro-inflammatory cytokines, MUC2 and IGHT, but increased the gene expression of anti-inflammatory cytokine transforming growth factor-β1 (TGF-β1) and the tight junction proteins tricellulin and occluding after wounding. In brief, the skin wounds provoked an intestinal inflammatory response that included changes in the mucus layer and tight junction disruptions. Besides this, preventive administration of SpPdp11 alleviated the intestinal dysfunctions caused by skin wounds in gilthead seabream.

The Effect of Enteral Nutrition Support Rich in TGF-β in the Treatment of Inflammatory Bowel Disease in Childhood

Background and Objective: Malnutrition is a major complication of inflammatory bowel disease (IBD). Our aim of the study was to examine the effects of Modulen IBD supplementation, which was administered to IBD patients without limiting their daily diet in addition to medical treatment, on the clinical, laboratory, anthropometric values, and disease activities of these patients. Materials and Methods: Seventy three children with IBD were evaluated retrospectively. The cases were classified as those who had Crohn disease receiving (CD-M; n = 16) or not receiving Modulen IBD (CD; n = 19) and those who had ulcerative colitis receiving (UC-M; n = 13) or not receiving Modulen IBD (UC; n = 25). Disease activities, laboratory values, remission rates, and anthropometric measurements of the groups were compared. In addition to IBD treatment, Modulen IBD in which half of the daily calorie requirement was provided was given for eight weeks. Results: In the third month of treatment, 14 (88%) patients were in remission in CD-M group and eight (42%) patients were in remission in CD group. The height and weight z scores, which were low at the time of diagnosis, improved in the first week in CD-M group. Inflammatory parameters (UC) were significantly lower in the UC-M group compared to the UC group in first and third months. In the third month, eight (62%) patients in the UC-M group and four (16%) in the UC group were remitted clinically and in terms of laboratory values. Conclusions: TGF-β-rich enteral nutrition support in children with IBD is an easy, effective, and reliable approach. It was shown that TGF-β-rich enteral nutritional supplementation enabled the disease to enter the remission earlier, and contributed to the early recovery of weight and height scores.

Oligomeric Enteral Nutrition in Undernutrition, due to Oncology Treatment-Related Diarrhea. Systematic Review and Proposal of An Algorithm of Action

Oncology treatment-related diarrhea and malnutrition appear together in oncological patients because of the disease itself, or the treatments that are administered for it. Therefore it is essential to carry out a nutritional treatment. Enteral nutrition formulas, containing peptides and medium chain triglycerides, can facilitate absorption in cases of malabsorption. There are few references to the use of enteral nutrition in the clinical society guidelines of patient management with oncology treatment-related diarrhea (OTRD). A bibliographic review of the studies with oligomeric enteral nutrition in OTRD found only nine studies with chemotherapy (all with the same oligomeric formula in which oral mucositis improves, while the rest of the outcomes show different results), and eight studies with radiotherapy (with different products and very heterogeneous results). We hereby present our action algorithm to supplement the diet of OTRD patients with an oligomeric enteral nutrition formula. The first step is the nutritional assessment, followed by the assessment of the functional capacity of the patient’s intestine. With these two aspects evaluated, the therapeutic possibilities available vary in degrees of complexity: These will range from the usual dietary recommendations, to supplementation with oral oligomeric enteral nutrition, along with complete enteral nutrition with oligomeric formula, and up to potentially total parenteral nutrition.

Association of chronic enteropathy activity index, blood urea concentration, and risk of death in dogs with protein-losing enteropathy

Background

Malnutrition is associated with increased risk of premature death in humans with inflammatory bowel disease.

Hypothesis/Objective

To determine if historical, clinical, and laboratory markers of malnutrition in dogs at the time of histologic diagnosis of protein‐losing enteropathy (PLE) caused by chronic enteropathy (CE) or lymphangiectasia are associated with increased risk of death.

Animals

Seventy‐one client‐owned dogs diagnosed with PLE.

Methods

The medical records were retrospectively searched for cases of PLE, diagnosed with CE or lymphangiectasia on the basis of histopathology of intestinal biopsies at a referral hospital. For each case, various variables at the time of diagnostic investigation were recorded and follow‐up obtained by telephone contact with the referring veterinarian.

Results

A multivariable cox model indicated that canine chronic enteropathy activity index (CCEAI) and blood urea concentration were significantly associated with death (P values <.01). For each unit increase in CCEAI, the hazard of death increased by 22.9% (confidence interval [CI]: 6.9%‐41.2%). Dogs with a CCEAI of ≤8 and dogs with urea ≤7 mmol/L survived 256 days longer (P = .001, CI: 106.7‐405.4 days) and 279 days longer (P = .009, CI: 70.0‐488.7 days) than those with a CCEAI of >8 and urea >7 mmol/L on average, respectively, when followed up for 647 days.

Conclusions and Clinical Importance

Increased CCEAI and blood urea concentration at the time of diagnosis might be predictive of death in dogs with PLE caused by CE or lymphangiectasia.

Dietary intervention with serum-derived bovine immunoglobulins protects barrier function in a mouse model of colitis

Dietary supplementation with immunoglobulins from animal plasma has anti-inflammatory effects on intestinal and lung models of acute inflammation. Here, we aimed to establish whether dietary intervention with serum-derived bovine immunoglobulin (SBI) can prevent alterations in intestinal barrier function in a mouse model with a genetic predisposition to inflammatory bowel disease (IBD). Wild-type (WT) mice and mice lacking the mdr1a gene (KO) were fed diets supplemented with either SBI (2% wt/wt) or milk proteins (control diet), from day 21 (weaning) until day 56. The epithelial permeability of distal colon crypts was measured by confocal microscopy using a fluorescent marker. The expression of junctional epithelial E-cadherin and β-catenin proteins were determined by Western blot and zonula occludens-1 (ZO-1) by immunofluorescence. Mucins (MUC1, MUC2, MUC4), TFF3, cytokines (TNF-α, IFN-γ), and inducible nitric oxide synthase RNA expression were quantified by real-time PCR. SBI blocked the increase in colon crypt permeability and partially prevented the reduction in E-cadherin and ZO-1 expression that characterize the KO mouse model (both P < 0.05). SBI inclusion also reduced the mucosal expression of the inflammatory markers TNF-α, IFN-γ, and inducible nitric oxide synthase (all P < 0.005). The number of goblet cells in the colon of KO mice was low and correlated well with MUC2 and TFF3 expression (P < 0.001), whereas dietary supplementation with SBI attenuated these effects (all P < 0.05). In short, dietary SBI ameliorated colonic barrier alterations and reduced the expression of mucosal inflammatory markers in a genetic model of IBD.

National Trends and In-Hospital Outcomes of Adult Patients With Inflammatory Bowel Disease Receiving Parenteral Nutrition Support

BACKGROUND

Patients with inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are susceptible to protein-calorie malnutrition secondary to decreased oral intake, malabsorption, and increased metabolic expenditure. In this study, we seek to assess the national frequencies of parenteral nutrition (PN) use among hospitalized patients with IBD and to determine their in-hospital outcomes.

METHODS

We analyzed the Nationwide Inpatient Sample from 1988-2006 to determine the frequency of PN usage among patients with UC or CD and to determine their in-hospital outcomes. A multivariate analysis was performed to identify factors predictive of increased inpatient mortality in this population.

RESULTS

From 1988-2006, the annual incidence of PN use among hospitalized patients with CD was 4.29 per 100,000 and among those with UC was 3.80 per 100,000, with trends being relatively stable through the indexed period. The mean length of hospitalization among patients with UC receiving PN was longer compared with patients with CD. Factors predictive of an increased risk for mortality include the following: age >50 years, acute kidney injury, hospital-acquired pneumonia, Clostridium difficile colitis, prolonged postoperative ileus requiring PN use, pulmonary embolism, malnutrition, and patients with UC relative to CD.

CONCLUSION

Traditionally, patients with CD are at a higher risk for developing malnutrition than patients with UC; however, there is a 2-fold higher risk for inpatient mortality and a longer length of hospitalization among patients with UC compared with those with CD. This pattern suggests that the use of PN, particularly among patients with UC, serves as a surrogate marker of higher disease acuity and severity.

Racial and geographic disparities in the use of parenteral nutrition among inflammatory bowel disease inpatients diagnosed with malnutrition in the United States

BACKGROUND

Racial disparities have been described in the use of a diverse spectrum of surgical procedures. The objectives of this study are to determine whether disparities also exist for the use of parenteral nutrition (PN) in inflammatory bowel disease (IBD).

METHODS

The U.S. Nationwide Inpatient Sample between 1998 and 2003 is analyzed to determine PN use among IBD inpatients diagnosed with protein-calorie malnutrition and assess whether use patterns differ by race and geographical region.

RESULTS

The proportion of African American IBD admissions with protein-calorie malnutrition who receive PN is significantly lower than that in whites (19.9% vs 28.1%, P = .001), whereas there is no difference between Hispanics and non-Hispanic whites. After adjustment for gender, comorbidity, health insurance status, geographic region, and median neighborhood income, African Americans remain less likely than whites to receive PN (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.50-0.89), whereas the difference between Hispanics and non-Hispanic whites is marginally significant (OR 0.65; 95% CI, 0.41-1.04). PN use varies geographically, with highest rates in the Northeast (44.3%) and lowest in the Midwest (17.3%). Uninsured patients are less than half as likely to receive PN as those with insurance (OR 0.46; 95% CI, 0.31-0.69). Compared with whites, Hispanics experience a longer time interval between admission and initiation of PN (3.5 vs 4.8 days, P = .02) and have higher rates of catheter-related complications (5.1% vs 12.2%, P = .04).

CONCLUSIONS

Among IBD inpatients with clinically diagnosable malnutrition, PN use is lower among African Americans compared with whites. The underlying mechanisms of these racial variations merit further investigation.

Symposium on 'The challenge of translating nutrition research into public health nutrition'. Session 3: Joint Nutrition Society and Irish Nutrition and Dietetic Institute Symposium on 'Nutrition and autoimmune disease'. Nutrition in Crohn's disease

The exact aetiology of Crohn's disease remains unknown. The consensus is that the disease results from a complex interaction between genes, immunity and environmental factors. Diet is attractive, in theory, as an environmental risk factor in the aetiology of the disease. The epidemiological data, often impeded by methodological issues, have failed to confirm a direct link between pre-diet illness and the development of Crohn's disease. Once diagnosed, however, nutrition has an important role in disease management. Among the nutritional issues are malnutrition, weight loss and suboptimal nutritional status; these outcomes may be present at any stage of the disease but are likely to be overt during acute illness and hospitalisation. Malnutrition has been identified in approximately 40% of hospital admissions with Crohn's disease and is associated with higher mortality, longer hospital stays and higher healthcare costs. Patients in remission may indeed be overweight and appear to be influenced by the general population trends toward overweight and obesity. Irrespective of BMI, patients are at risk of micronutrient deficiencies. Vitamin D deficiency, for example, is common in Crohn's disease and has important implications for bone health. Moreover, newer evidence suggests that vitamin D has potential anti-inflammatory effects. Dietary approaches, in the form of enteral nutrition, have previously been shown to reduce inflammation and treat the active disease. Current guidelines now recommend that corticosteroids are more effective than enteral nutrition for treating adults. Enteral nutrition has important growth and developmental benefits and continues to be a recommended therapy for children with Crohn's disease.

Nationwide prevalence and prognostic significance of clinically diagnosable protein-calorie malnutrition in hospitalized inflammatory bowel disease patients

BACKGROUND

Inflammatory bowel disease (IBD) patients are at increased risk of protein-calorie malnutrition. We sought to determine the prevalence of clinically diagnosable malnutrition among those hospitalized for IBD throughout the United States and whether this malnutrition influenced health outcomes.

METHODS

We queried the Nationwide Inpatient Sample between 1998 and 2004 to identify admissions for Crohn's disease (CD) or ulcerative colitis (UC) and a representative sample of non-IBD discharges. We assessed the prevalence and predictors of malnutrition and its association with in-hospital mortality and resource utilization.

RESULTS

The prevalence of malnutrition was greater in CD and UC patients than in non-IBD patients (6.1% and 7.2% versus 1.8%, P < 0.0001). The adjusted odds ratio for malnutrition among IBD admissions compared with non-IBD admissions was 5.57 [95% confidence interval (CI): 5.29-5.86]. More IBD discharges than non-IBD discharges with malnutrition received parenteral nutrition (26% versus 6%, P < 0.0001). There was increased likelihood of malnutrition among those with fistulizing CD (OR 1.65; 95% CI: 1.50-1.82) and among those who had undergone bowel resection (OR 1.37; 95% CI: 1.27-1.48). Malnutrition was associated with increased in-hospital mortality 3.49 (95% CI: 2.89-4.23), length of stay (11.9 days versus 5.8 days, P < 0.00001), and total charges ($45,188 versus $20,295, P < 0.0001).

CONCLUSIONS

Clinically apparent malnutrition is more frequent among IBD admissions than among non-IBD admissions. Its association with greater mortality and resource utilization may reflect more severe underlying disease that can lead to both malnutrition and worse outcomes. Nonetheless, diagnosable malnutrition may serve as a clinical marker of poor IBD prognosis in hospitalized patients.

Clinical trial: normal diet vs. partial replacement with oral E028 formula for the prevention of gastrointestinal toxicity in cancer patients undergoing pelvic radiotherapy

BACKGROUND

Acute gastrointestinal symptoms affect 90% of patients during pelvic radiotherapy. Elemental diet is protective in animal models. A nonrandomized study suggested benefit from a partial elemental diet. A pilot study suggested that radiotherapy patients only tolerate oral elemental diet comprising one-third of total calories for 3 weeks.

AIM

To assess the feasibility and efficacy of replacing one-third of normal diet with elemental diet during the first 3 weeks of pelvic radiotherapy in reducing acute gastrointestinal toxicity.

METHODS

Patients were randomized to elemental diet or no intervention. Toxicity was assessed using the Inflammatory Bowel Disease Questionnaire, Vaizey Incontinence scale and Radiation Therapy Oncology Group tool. Faecal calprotectin measured intestinal mucosal inflammation.

RESULTS

Twenty-nine women and 21 men, median age 61.5 years were randomized. Patients taking elemental diet did not have lower gastrointestinal toxicity ratings or inflammatory markers (P > 0.2). The mean dose taken was 21% (2-36%) of total caloric requirements.

CONCLUSIONS

Patients cannot tolerate large volumes of oral elemental diet. The quantities consumed in this study produced no therapeutic benefit. Future studies should aim to replace a higher proportion of nutritional intake for a longer duration of radiotherapy treatment.

Attenuation by dietary taurine of dextran sulfate sodium-induced colitis in mice and of THP-1-induced damage to intestinal Caco-2 cell monolayers

The effects of dietary taurine on the experimental colitis induced by dextran sulfate sodium (DSS) in mice were evaluated. C57BL/6 female mice were given 3% DSS in drinking water for 5 d to induce acute colitis. Taurine at 2% was added to the drinking water 5 d before and during the DSS-treatment to investigate its preventive effect. Taurine supplementation significantly attenuated the weight decrease, diarrhea severity, colon shortening, and the increase in the colonic tissue myeloperoxidase activity induced by DSS. Taurine also significantly inhibited the increase in the expression of a pro-inflammatory chemokine, macrophage inflammatory protein 2 (MIP-2), but not of interleukin (IL)-1beta or tumor necrosis factor (TNF)-alpha mRNA. Furthermore, taurine significantly protected the intestinal Caco-2 cell monolayers from the damage by macrophage-like THP-1 cells in an in vitro coculture system. These results suggest that taurine prevented DSS-induced colitis partly in association with (1) its inhibitory effects on the secretion of MIP-2 from the intestinal epithelial cells and on the infiltration of such inflammatory cells as neutrophils and (2) its cytoprotective functions on the epithelial barrier from the direct toxicity of DSS and from the inflammatory cell-induced injury.

Short- and long-term therapeutic efficacy of nutritional therapy and corticosteroids in paediatric Crohn's disease

BACKGROUND

Comparative data on the therapeutic efficacy of different enteral nutrition formulas and corticosteroids to obtain clinical remission and to induce mucosal healing influencing long-term disease course in paediatric Crohn's disease are still scarce.

AIMS

To investigate the efficacy of nutritional therapy using three different formulas versus corticosteroids to achieve clinical remission as well as to induce intestinal mucosal healing in active Crohn's disease children. Duration of remission and effect on growth recovery were also assessed.

PATIENTS AND METHODS

Clinical, laboratory, endoscopic and histological data of all new diagnosed active Crohn's disease paediatric cases were retrospectively recorded and reviewed. Thirty-seven children (median age 12.1 years) received nutritional therapy (12 polymeric; 13 semi-elemental; 12 elemental diet) and 10 subjects (median age 12.4 years) received corticosteroids.

RESULTS

Similar clinical remission rate were observed after 8 weeks of treatment: 86.5% children receiving nutritional therapy versus 90% treated with corticosteroids. Improvement in mucosal inflammation occurred in 26 out of 37 (64.8%) patients on nutritional therapy and in 4 out of 10 (40%) children on steroids (p < 0.05). Finally, seven subjects on nutritional therapy and none on corticosteroids achieved complete mucosal healing (p < 0.005) at the end of the treatment. Nutritional therapy was more effective than corticosteroids in improving nutritional status and linear growth recovery. Compared to corticosteroids, the duration of clinical remission was longer in the nutritional therapy groups without differences among the three different formulas.

CONCLUSIONS

In children with active Crohn's disease, nutritional therapy is more effective than corticosteroids to improve intestinal inflammation and to maintain a more sustained clinical remission.

Nutrition in inflammatory bowel disease

Nutrition has an important role in the management of inflammatory bowel disease. This role includes the prevention and correction of malnutrition, the prevention of osteoporosis and in children the promotion of optimal growth and development. In active Crohn's disease nutritional therapy (in the form of enteral feeding) is an effective primary therapy for many patients. Corticosteroids, however, are more effective than enteral diet therapy in adults. Enteral diets should be considered as primary therapy in pediatric Crohn's disease, especially in children with poor nutritional status or growth impairment. Enteral nutrition does not have a proven primary therapeutic role in ulcerative colitis. There are many theories that suggest that diet may be implicated in the aetiology of inflammatory bowel disease, however, there are, as yet, no dietary approaches proven to reduce the risk of developing IBD.