What Pharmacists Need to Know About Inflammatory Bowel Disease Dietary Recommendations
It seems like a no-brainer to say that inflammatory bowel disease and diet are closely related, yet in spite of the obvious connection, information gaps abound and few guidelines exist to help patients find optimal relief. As these patients follow step-wise therapy that includes prescription medications, pharmacists land in the middle of any miscommunication or differing perspectives that exist between patients and their physicians. To effectively counsel patients and answer questions, you need to know about dietary concerns and recommendations for inflammatory bowel disease.
Miscommunication Between Patients and Doctors
Two studies have been published recently that offer some insight into the different perspectives of patients and doctors when it comes to diet and inflammatory bowel disease (IBD), which includes ulcerative colitis and Crohn’s disease. The first one, from the Journal of Human Nutrition and Dietetics in July 2016, reported on a survey completed by 928 patients with IBD, two-thirds of whom had Crohn’s disease.1 Responses included:
- Does diet affect IBD? 71 percent of patients believe it does—only 44 percent of gastroenterologists say diet is a factor.
- Do physicians offer dietary advice? 26 percent of patients say they received dietary advice and 61 percent felt their IBD specialist disregarded diet.
In fairness, it should be said that clinicians do not routinely endorse diets for IBD because scientific evidence is sparse. It’s also interesting to note that only 17 percent of dietitians said they felt that diet is a factor in IBD. However, diverse perspectives may arise from confounding medical advice that says no known dietary changes prevent IBD and no known dietary substances have been consistently shown to activate IBD, yet dietary factors may influence symptoms.
The second study, published in the October 2016 issue of Inflammatory Bowel Diseases explored the issue of malnutrition in IBD patients and whether clinicians were prepared to deal with dietary concerns.2 Out of 223 providers surveyed (65.5 percent gastroenterologists, 15.2 percent nurses and 6.7 percent dietitians), most of the dietitians said their expertise about nutrition in IBD was “very good,” but only 41 percent of gastroenterologists and 16 percent of nurses rated their knowledge as “very good.”
Here’re the most important takeaway points for pharmacists:
- 33 percent of gastroenterologists do not routinely screen IBD patients for malnutrition, even though patients with active IBD are at a high risk for protein-energy malnutrition.
- Chances are your patients receive inadequate, heterogeneous advice from their health care team.
Dietary Recommendations for Patients with IBD
Research into diet and IBD is an evolving field that doesn’t have many solid answers. One question being explored is whether diets that are high in fat and sugar trigger changes in the intestinal microbiome or gastrointestinal barrier that cause IBD or trigger flare-ups. Of course, that doesn’t help patients trying to relieve their current symptoms. Scientific proof to support dietary intervention is generally lacking. According to a study in Nutrition and Metabolism published in June 2016, here’s what we know:3
- Common food ingredients can alter the intestinal barrier and cause inflammation.
- Complex carbohydrates are known to have a detrimental effect on the intestine.
- Exclusive enteral nutrition has been proven to induce intestinal healing and remission in patients with Crohn’s disease—in some parts of the world, it’s first-line treatment.
Anecdotal reports from patients with IBD and some small studies tell about certain diets that result in symptom relief. The diets commonly used to help these patients include:
- FODMAP diet: FODMAP is an acronym that represents fermentable foods, oligosaccharides (fructans and galactans), disaccharides (lactose), monosaccharides (excess fructose), and polyols (sugar alcohols). All of these foods are poorly absorbed and result in intestinal bacterial overgrowth, which can lead to inflammation, abdominal pain, gas, and diarrhea or constipation. When high-FODMAP foods are removed from the diet of patients with IBD, 75 percent see a reduction in, or resolution of, their gastrointestinal symptoms.4 However, patients with inflammatory bowel disease should only implement the diet when they’re not having a disease flare.
- Specific carbohydrate diet: This diet follows the same theory as the FODMAP diet, but is less restrictive because it focuses on eliminating disaccharides and polysaccharides. More specifically, patients restrict or eliminate glucose, fructose, and galactose. One retrospective study suggests that children kept IBD in remission when they followed a specific carbohydrate diet, but they also stayed on maintenance drug therapy.
- Crohn’s disease exclusion diet: Removes and reintroduces foods in stages, focusing on diets that contain lean chicken, fish, eggs, vegetables, and rice. When the diet was used together with 12 weeks of partial enteral nutrition, patients experienced a drop in C-reactive protein, some mucosal healing, and occasional remission. 5
- Other diets: The anti-inflammatory, allergen-elimination, and gluten-free diets have also been used. They’ve all helped relieve symptoms and put IBD into remission in some patients.6
- Nutritional supplements: The November 2016 issue of the European Journal of Gastroenterology and Hepatology included a comprehensive review of complementary and alternative medicine for inflammatory bowel disease.7 The review suggested that curcumin, green tea, and vitamin D may reduce IBD-related inflammation, while probiotics help in mild to moderate ulcerative colitis. Patients with IBD may also be at risk for deficiencies in folate, zinc and vitamin D, which increases the risk for osteoporosis. If your patients take supplemental iron, be aware that excessive iron may exacerbate intestinal inflammation. Fiber intake isn’t associated with any beneficial clinical endpoints.
Roles for Pharmacists When Counseling IBD Patients
The American Gastroenterological Association notes that “What should I eat?” is one of the most commonly asked questions and also one of the most difficult to answer.8 Even if you don’t feel like you’re a nutrition expert, you can answer patients’ questions when you’re prepared with the most up-to-date info, and then recommend they consult a registered dietitian who can work with them to determine the choices that are best for them. Simply knowing they can “ask the pharmacist” helps people with inflammatory bowel disease to feel like they have support and are on the road to relief.
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- “Patients with Inflammatory Bowel Disease and Their Treating Clinicians Have Different Views Regarding Diet,” July 2016, https://www.ncbi.nlm.nih.gov/pubmed/27412965 ↩
- “Knowledge, Attitudes, and Beliefs Regarding the Role of Nutrition in IBD Among Patients and Providers,” October 2016, http://journals.lww.com/ibdjournal/pages/articleviewer.aspx?year=2016&issue=10000&article=00018&type=abstract ↩
- “Role of Diet in Inflammatory Bowel Disease,” June 2016, http://www.karger.com/Article/FullText/445392 ↩
- “Low FODMAP Diet Introduction,” November 2015, http://www.med.umich.edu/1libr/Gastro/LowFODMAPDietIntroduction.pdf ↩
- “Nutritional Therapy in Inflammatory Bowel Disease,” 2015, http://www.medscape.com/viewarticle/847345_4 ↩
- “Diet in the Pathogenesis and Treatment of Inflammatory Bowel Diseases,” January 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4409494/ ↩
- “Use of Complementary and Alternative Medicine in Swedish Patients with Inflammatory Bowel disease: A Controlled Study,” November 2016, http://journals.lww.com/eurojgh/Fulltext/2016/11000/Use_of_complementary_and_alternative_medicine_in.15.aspx ↩
- “Does Diet Influence the Disease Course in Patients with IBD?” November 2015, http://www.gastro.org/news_items/does-diet-influence-the-disease-course-in-patients-with-ibd ↩