9/5/2023

Application Deadline: September 15, 2023

Apply Online: gi.org/advanced-leadership

1
American College of Gastroenterology
 9/5/2023

2
American College of Gastroenterology
 9/5/2023

Participating in the Webinar

All attendees will be muted and
will remain in “Listen Only Mode”

Type your questions here so that the moderator

can see them.
Not all questions will be answered but we will get
to as many as possible.

A handout with the slides and room to take notes can

be downloaded from your control panel.
Moderator:
Colleen Webb, MS, RD

ACG Virtual Grand Rounds

Join us for upcoming Virtual Grand Rounds!

Week 37 – Thursday, September, 14, 2023

The Aging Gastroenterologist: Retire or Slow down?
Faculty: Steven L. Carpenter, MD, FACG
Moderator: Sumanth R. Daram, MD
At Noon and 8pm Eastern

Week 38 – Thursday, September, 21, 2023

AGA-ACG Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic
Constipation
Faculty: Lin Chang, MD, FACG
Moderator: William D. Chey, MD, FACG
At Noon and 8pm Eastern

Visit gi.org/ACGVGR to Register

3
American College of Gastroenterology
 9/5/2023

ACG has created presentation-ready,

semi-customizable MS PowerPoint clinical slide decks
for your unique teaching and learning needs.

Visit gi.org/ACGSlideDecks to learn more and

request access to the standard slide decks!

4
American College of Gastroenterology
 9/5/2023

Disclosures

Jason K. Hou, MD, MS, FACG

AbbVie: Grant/Research Support
American Regent: Speakers Bureau
Bristol Myers Squibb: Grant/Research Support
Eli-Lilly: Grant/Research Support
Janssen: Grant/Research Support
Pfizer: Grant/Research Support

Colleen Webb, MS, RD

Advisory Board: Orgain

*All of the relevant financial relationships listed for these individuals have been mitigated

Diet, Nutrition, and Inflammatory Bowel

Disease: Digesting the Facts
Jason K. Hou, MD, MS, AGAF, FACG
Director, BCM IBD Program
Associate Professor, Baylor College of Medicine

10

5
American College of Gastroenterology
 9/5/2023

Objectives
• Review basis for diet and IBD connection
• Understand challenges for diet and IBD research
• Review clinical data on food as medicine for IBD
• Describe practical means of integrating diet and nutrition in IBD clinical
practice

11

Basis for Diet and IBD connection

 “You are what you eat”

12

6
American College of Gastroenterology
 9/5/2023

Basis for Diet and IBD connection

Removing Inflammatory
? Adding Anti-inflammatory
Trigger Nutrients

13

Basis for Diet and IBD connection

Removing Inflammatory
? Adding Anti-inflammatory
Trigger Nutrients

Treating functional GI symptoms

related to diet

14

7
American College of Gastroenterology
 9/5/2023

Basis for Diet and IBD connection

 Other Dietary
Components
 Emulsifiers
 Impact
microbiome
 Increase
intestinal
permeability
 Microparticles
 Titanium dioxide
 Aluminum
silicate
Bancil et al. JCC, 2021; 1068

15

Basis for Diet and IBD connection

Diet and Risk of IBD- Systematic Review
•19 studies- Evaluated diet patterns before IBD diagnosis
•2,609 IBD patients

Increased IBD risk: Decreased IBD risk:

Total fat 2-3X Fiber < 1/2 X
Polyunsaturated fats 2-6X Fruits < 1/2 X
Omega 6 2-3X
Meats 3-4X

Hou et al. Am J Gastroenterol. 2011;106(4)

16

8
American College of Gastroenterology
 9/5/2023

Challenges for Diet and IBD Research

 Dependent on how well people remember what they ate - “recall bias”
 Diet adherence is low
 Variation in baseline diet
 How to control?
 How to blind?

Limketkai et al. Cochrane Database 2019(2). Art. No.: CD012839

17

Challenges for Diet and IBD Research

Food type ≠ nutritional content

Aakre et al. Foods. 2020;9, 1516

18

9
American College of Gastroenterology
 9/5/2023

Challenges for Diet and IBD Research

Food type ≠ nutritional content

Several Fold difference in

fatty acid content

Aakre et al. Foods. 2020;9, 1516

19

Challenges for Diet and IBD Research

Food type ≠ nutritional content

Aakre et al. Foods. 2020;9, 1516

20

10
American College of Gastroenterology
 9/5/2023

Challenges for Diet and IBD Research

Food type ≠ nutritional content

Several Fold difference in

Vitamin content

Aakre et al. Foods. 2020;9, 1516

21

Challenges for Diet and IBD Research

Not just amount, but ratio of food to other foods

Omega 6-PUFA- increase inflammation Omega 3-PUFA- decrease inflammation

Leukotriene B4 Leukotriene B5
- chemotaxis

Arachadonic Lipoxygenase α-linolenic acid

DHA - rapeseed (canola oil)
Linoleic acid acid
EPA - soybeans
- sunflower oil - meat
- fish oil - walnuts
- safflower oil - eggs
Cyclooxygenase - flaxseed (linseed oil)
- dairy
- green leafy vegetables

Prostaglandin E2
- vasodilation Prostaglandin E3
- potentiate edema

Hou et al. Therapy. 2010, 7(2)

22

11
American College of Gastroenterology
 9/5/2023

Objectives
• Basis for Diet and IBD connection
• Challenges for Diet and IBD research
• Review clinical data on food as medicine for IBD
• Describe practical means of integrating diet and nutrition in IBD clinical
practice

23

Objectives
• Basis for Diet and IBD connection
• Challenges for Diet and IBD research
• Review clinical data on food as medicine for IBD
• Describe practical means of integrating diet and nutrition in IBD clinical
practice Exclusive Enteral Nutrition (EEN)
Specific Carbohydrate Diet (SCD)
Crohn’s Disease Exclusion Diet (CDED)
Low FODMAPS

24

12
American College of Gastroenterology
 9/5/2023

Exclusive Enteral Nutrition (EEN)

• All nutrition from formula- NO solid food
• Mostly used in pediatrics, Crohn’s
• Nearly as effective as prednisone
• VERY difficult to maintain
• Not clear if it works for adults

Rheenen et al. JCC. 2021, 171

25

Exclusive Enteral Nutrition (EEN)

Narula et al, Cochrane Database of Systematic Reviews 2018, Issue 4. Art. No.: CD000542

26

13
American College of Gastroenterology
 9/5/2023

Exclusive Enteral Nutrition (EEN)

Akobeng et al, Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD005984

27

Exclusive Enteral Nutrition (EEN)

• Partial Enteral Nutrition (PEN)
• Pragmatic approach to enteral nutrition
• Not as effective as EEN
• Potential role in combination with other
dietary approaches (CDED)

Lee D, et al. Inflamm Bowel Dis. 2015;21(8)

28

14
American College of Gastroenterology
 9/5/2023

Specific Carbohydrate Diet (SCD)

• Initially proposed by Dr. Sidney Haas as treatment for celiac
disease in 1924
• Theory:
•  Some carbohydrates are poorly absorbed
•  Bacterial/yeast overgrowth
•  Small intestine injury
• Some studies to suggest may reduce GI symptoms in IBD
• No placebo controlled studies
• Difficult to maintain
• At risk for nutritional deficiency

29

DINE-CD: RCT of SCD vs. Mediterranean Diet

• 194 Adult CD patient randomized 1:1 to Simple
Carbohydrate Diet vs. Mediterranean Diet
• Mild-mod Crohn’s disease
• Evidence of active inflammation within 3 mo before
screening (CRP, Calpro, Endoscopy)
• Allowed continuation of treatment (including biologics)
• 6 weeks of prepared food, then 6 weeks following diet
independently
• Primary Outcome: Symptomatic remission @ week 6

Lewis et al. Gastroenterology 2021:161

30

15
American College of Gastroenterology
 9/5/2023

DINE-CD: RCT of SCD vs. Mediterranean Diet

Lewis et al. Gastroenterology 2021:161

31

Crohn’s Disease Exclusion Diet (CDED)

• “Whole food” diet
• Reduce dietary components hypothesized to
induce dysbiosis and increase intestinal
permeability

• 3 Phases- combined with partial enteral

nutrition (PEN)
• Phase 1- Exclusion
• Phase 2- Add back
• Phase 3- Maintenance

Levine, A et al. Gastroenterology 2019:157(2)

32

16
American College of Gastroenterology
 9/5/2023

Crohn’s Disease Exclusion Diet (CDED)

• More tolerable than EEN
• “Similar” response to EEN
• Small studies
• No placebo control

Levine, A et al. Gastroenterology 2019:157(2)

33

Low FODMAPs
 Fermentable Oligo-, Di- and Mono-saccharides and Polyols
 Primarily studied for Irritable bowel syndrome
 May produce improvement of functional GI symptoms

“However, through careful critical appraisal of the evidence, the present

systematic review failed to provide adequate evidence in terms of quality and
quantity to support recommendations for an LFD for IBD patients with FGD.”

Grammatikopoulou, et al. Nutrients 2020;12(12)

34

17
American College of Gastroenterology
 9/5/2023

Objectives
• Basis for diet and IBD connection
• Challenges for diet and IBD research
• Review clinical data on food as medicine for IBD
• Describe practical means of integrating diet and nutrition in IBD clinical
practice

35

Integrating diet and nutrition in IBD clinical

practice

36

18
American College of Gastroenterology
 9/5/2023

Integrating diet and nutrition in IBD clinical

practice:
 Tip 1) Recognize food avoidance is very common among IBD patients
 75% of patients modified diet at diagnosis
 82% of patients restrict food to prevent flares

Yes (%)
Do you believe that diet can be a trigger for IBD flare? 85.4
Do you believe that your diet may cause nutritional deficiencies? 65.9
Do you think that you should avoid some products to prevent disease relapse? 81.7
Are you on a special diet (vegetarian, lactose free, gluten free, low FODMAPS) 53.7

Godala et al. J Clin Med. 2023 (12), 3455

37

Integrating diet and nutrition in IBD clinical

practice:
 Tip 1) Recognize food avoidance is very common among IBD patients
 Tip 2) Proactively engage with patients about food
 “What did you eat yesterday?”
 “Do you eat anything on days you are out of the house?”

38

19
American College of Gastroenterology
 9/5/2023

Integrating diet and nutrition in IBD clinical

practice:
 Tip 1) Recognize food avoidance is very common among IBD patients
 Tip 2) Proactively engage with patients about food
 “What did you eat yesterday?”
 “Do you eat anything on days you are out of the house?”
 Tip 3) Become familiar with patient directed diets (defined diets)

39

Integrating diet and nutrition in IBD clinical

practice: Exclusive Enteral Nutrition (EEN)
 Tip 1) Recognize food avoidance is very common amongSpecificIBD
Carbohydrate
patients Diet (SCD)
 Tip 2) Proactively engage with patients about foodCrohn’s Disease Exclusion Diet (CDED)
Low FODMAPS
 “What did you eat yesterday?”
 “Do you eat anything on days you are out of the house?”
 Tip 3) Become familiar with patient directed diets

Anti-inflammatory diet (IBD-AID)

Autoimmune protocol diet (AIP)
CD- TREAT

40

20
American College of Gastroenterology
 9/5/2023

Integrating diet and nutrition in IBD clinical

practice:
 Tip 1) Recognize food avoidance is very common among IBD patients
 Tip 2) Proactively engage with patients about food
 “What did you eat yesterday?”
 “Do you eat anything on days you are out of the house?”
 Tip 3) Become familiar with patient directed diets
 Tip 4) Find an GI dietician familiar with IBD

41

Integrating diet and nutrition in IBD clinical

practice:
 Tip 1) Recognize food avoidance is very common among IBD patients
 Tip 2) Proactively engage with patients about food
 “What did you eat yesterday?”
 “Do you eat anything on days you are out of the house?”
 Tip 3) Become familiar with patient directed diets (defined diets)
 Tip 4) Find an GI dietician familiar with IBD

42

21
American College of Gastroenterology
 9/5/2023

IBD- Nutrition Care Pathway

IBD-NCP pilot testing in IBD Qorus

- 2,388 patients screened
- 72% Low risk (mMUST 0)
- 10% Medium risk (mMUST 1)
- 18% High risk (mMUST ≥ 2)

Hwang et al. Clin Gastroenterol Hepatol. 2020Nov:118(12)

43

Hwang et al. Clin Gastroenterol Hepatol. 2020Nov:118(12)

44

22
American College of Gastroenterology
 9/5/2023

Hwang et al. Clin Gastroenterol Hepatol. 2020Nov:118(12)

45

Hwang et al. Clin Gastroenterol Hepatol. 2020Nov:118(12)

46

23
American College of Gastroenterology
 9/5/2023

Hwang et al. Clin Gastroenterol Hepatol. 2020Nov:118(12)

47

Hwang et al. Clin Gastroenterol Hepatol. 2020Nov:118(12)

48

24
American College of Gastroenterology
 9/5/2023

Hwang et al. Clin Gastroenterol Hepatol. 2020Nov:118(12)

49

Take Home Points

 Plethora of data linking association of diet and IBD
 Be aware of potential food as medicine approaches for IBD
 Scientific basis for diet-based inflammation control (EEN)
 Limited data of diet efficacy for IBD disease management
 Incorporate diet into your IBD practice

50

25
American College of Gastroenterology
 9/5/2023

Take Home Points

 Incorporate diet into your IBD practice
 Tip 1) Recognize food avoidance is very common among IBD patients
 Tip 2) Proactively engage with patients about food
 Tip 3) Become familiar with patient directed diets
 Tip 4) Find an GI dietician familiar with IBD
 Tip 5) Be familiar with the IBD-Nutrition Care Pathway

51

Thanks for Listening! Questions?

jkhou@bcm.edu

52

26
American College of Gastroenterology
 9/5/2023

Questions?

Jason K. Hou, MD, MS, FACG

Colleen Webb, MS, RD

*All of the relevant financial relationships listed for these individuals have been mitigated

53

54

27
American College of Gastroenterology