Elsevier

Nutrition

Volume 32, Issue 4, April 2016, Pages 418-425
Nutrition

Applied nutritional investigation
Specific carbohydrate diet for pediatric inflammatory bowel disease in clinical practice within an academic IBD center

https://doi.org/10.1016/j.nut.2015.08.025Get rights and content

Abstract

Objective

Despite dietary factors being implicated in the pathogenesis of inflammatory bowel disease (IBD), nutritional therapy, outside of exclusive enteral nutrition (EEN), has not had a defined role within the treatment paradigm of pediatric IBD within IBD centers. Based on emerging data, Seattle Children's Hospital IBD Center has developed an integrated dietary program incorporating the specific carbohydrate diet (SCD) into its treatment paradigm. This treatment paradigm uses the SCD as primary therapy as well as adjunctive therapy for the treatment of IBD. The aim of this study was to evaluate the potential effects of the SCD on clinical outcomes and laboratory studies of pediatric patients with Crohn's disease (CD) and ulcerative colitis (UC).

Methods

In this retrospective study, we reviewed the medical records of patients with IBD on SCD.

Results

We analyzed 26 children on the SCD: 20 with CD and 6 with UC. Duration of the dietary therapy ranged from 3 to 48 mo. In patients with active CD (Pediatric Crohn's Disease activity index [PCDAI] >10), PCDAI dropped from 32.8 ± 13.2 at baseline to 20.8 ± 16.6 by 4 ± 2 wk, and to 8.8 ± 8.5 by 6 mo. The mean Pediatric Ulcerative Colitis Activity Index for patients with active UC decreased from a baseline of 28.3 ± 10.3 to 20.0 ± 17.3 at 4 ± 2 wk, to 18.3 ± 31.7 at 6 mo.

Conclusion

This retrospective review provides evidence that the SCD can be integrated into a tertiary care center and may improve clinical and laboratory parameters for pediatric patients with nonstructuring, nonpenetrating CD as well as UC. Further prospective studies are needed to fully assess the safety and efficacy of the SCD in pediatric patients with IBD.

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

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