Applied nutritional investigationSpecific carbohydrate diet for pediatric inflammatory bowel disease in clinical practice within an academic IBD center
Introduction
Inflammatory bowel disease (IBD) is characterized by acute and chronic intestinal inflammation in the absence of a recognized etiology [1]. Although no specific causes have has been found, evidence from human and animal studies supports the hypothesis that patients with IBD have a dysfunction of the adaptive and innate immune system in response to the fecal microbiome [1]. Despite dietary exposures having been associated with the development of IBD and disease course [2], [3], the primary therapies for IBD are medications that suppress the immune system or possess direct anti-inflammatory effects.
Nutritional therapy, outside of the use of exclusive enteral nutrition (EEN) for Crohn's disease (CD), has not had an established role within pediatric IBD [4], [5], [6]. To date, nutritional therapy aimed at modifying disease activity has primarily referred to formula-based enteral nutrition. EEN has been shown to alleviate clinical symptoms, improve an individual's nutritional status, and improve abnormal laboratory parameters associated with active inflammation. In children with CD, EEN has been effective at inducing clinical remission, and superior at achieving mucosal healing when compared with steroids [7], [8].
Our group, as well as others, has demonstrated that dietary intervention including the specific carbohydrate diet (SCD) has efficacy in CD [9], [10]. The SCD that was used initially to treat celiac disease in the mid 20th century, and was popularized in the 1990s, removes grains including wheat, barley, corn, and rice; and uses nut flours such as almond and coconut flours to make breads and other baked goods. Additionally, added sugar is limited to honey. The diet also restricts most milk products except for fully fermented yogurt. Although the mechanism of action for the SCD is not known, it is hypothesized that the diet decreases intestinal inflammation by changing the fecal microbiome from a proinflammatory state to noninflammatory state [11]. Since our initial report of efficacy of the SCD, further studies showing efficacy of dietary intervention have been reported [10], [12]. Based on emerging data, Seattle Children's Hospital IBD Center developed an integrated dietary program incorporating the SCD into its treatment paradigm. This treatment paradigm uses the SCD as primary therapy for IBD as well as adjunctive therapy when partial response to medication occurs. This retrospective study reviews the medical records of patients with IBD on the SCD since the initiation of the SCD protocol. The aim of this study was to evaluate the potential effects of the SCD on clinical outcomes and laboratory studies of pediatric patients with CD and ulcerative colitis (UC).
Section snippets
Materials and methods
We initiated a retrospective chart review of children with CD and UC seen at Seattle Children's Hospital from December 2012 to December 2014 who had been on SCD therapy. The protocol was approved by the Seattle Children's Hospital Institutional Review Board (IRB study #15309). Criteria for inclusion in the analysis were patients who had trialed the specific carbohydrate diet as part of their treatment for IBD. All data was extracted from electronic medical records. The diagnosis of CD or UC was
Results
Fifty pediatric patients with IBD were identified for this review. Patients previously reported in the medical literature were excluded from the analysis (n = 7) as well as those patients enrolled in our current prospective study (n = 7; Clinical trial.gov number 14956). In all, 36 patients met inclusion criteria. Of these, 26 were able to remain on the SCD >2 wk. Ten individuals were not able to maintain on the SCD and began standard medical therapy. These patients acted as controls for this
Discussion
Nutritional therapy in the form of EEN is a fundamental component of patient care in pediatric IBD. Recent studies using formula-based therapies have amended standard EEN with the addition of dietary foods [12]. It has been shown that diet itself may be able to modify both inflammatory processes and symptoms in CD [9], [10]. Dietary therapy in the form of SCD has been integrated into our clinical practice for those patients and patient families invested in trying a monitored nutrition-based
References (24)
- et al.
Diet in the pathogenesis and treatment of inflammatory bowel diseases
Gastroenterology
(2015) - et al.
Polymeric diet alone versus corticosteroids in the treatment of active pediatric Crohn's disease: a randomized controlled open-label trial
Clin Gastroenterol Hepatol
(2006) - et al.
Development, validation, and evaluation of a pediatric ulcerative colitis activity index: a prospective multicenter study
Gastroenterology
(2007) - et al.
Diet and inflammatory bowel disease: review of patient-targeted recommendations
Clin Gastroenterol Hepatol
(2014) - et al.
Unravelling the pathogenesis of inflammatory bowel disease
Nature
(2007) - et al.
Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature
Am J Gastroenterol
(2011) - et al.
Meta-analysis: enteral nutrition in active Crohn's disease in children
Aliment Pharmacol Ther
(2007) - et al.
Enteral nutrition and corticosteroids in the treatment of acute Crohn's disease in children
J Pediatr Gastroenterol Nutr
(2000) - et al.
Nutrition in pediatric inflammatory bowel disease
Nutr Clin Pract
(2010) - et al.
Exclusive enteral feeding as primary therapy for Crohn's disease in Australian children and adolescents: a feasible and effective approach
J Gastroenterol Hepatol
(2006)