IBD: Diet Improves Symptoms in Small Study

Marcia Frellick

January 04, 2017

Diet alone can lead children with mild to moderate ulcerative colitis and Crohn's disease into clinical remission, suggests a small study published online December 27, 2016, in the Journal of Clinical Gastroenterology.

"This changes the paradigm for how we may choose to treat children with inflammatory bowel disease [IBD]," lead author David L. Suskind, MD, from Seattle Children's Hospital in Washington, said in a hospital news release.

Most centers typically treat with steroids or other medications, which come with potential adverse effects, the authors note.

Specific Carbohydrate Diet

The diet tested over the course of 12 weeks is called the specific carbohydrate diet (SCD), and it removes processed foods and sugars (except honey), dairy, and grains. It includes only vegetables, fruits, meats, and nuts — natural foods rich in nutrients.

At the end of the 3-month study, eight of the 10 patients, aged 10 to 17 years, who finished the study achieved remission from the diet alone, the authors report.

Twelve patients (nine in Seattle, and three in Atlanta, Georgia) started SCD with evaluations at 2, 4, 8, and 12 weeks.

By the end of the study, mean pediatric Crohn's disease activity index decreased from 28.1 ± 8.8 to 4.6 ± 10.3. Mean pediatric ulcerative colitis activity index dropped from 28.3 ± 23.1 to 6.7 ± 11.6.

The diet was not effective for two patients, and two were unable to maintain the diet. Mean C-reactive protein level dropped from 24.1 ± 22.3 to 7.1 ± 0.4 mg/L at 12 weeks in Seattle patients (normal, <8.0 mg/L) and decreased from 20.7 ± 10.9 to 4.8 ± 4.5 mg/L among the Atlanta patients (normal, <4.9 mg/L).

The patients in the prospective trial had mild to moderate IBD, determined either by a pediatric Crohn's disease activity index of between 10 and 45 or a pediatric ulcerative colitis activity index of between 10 and 65.

To be eligible, patients could not have started a new IBD medication for at least 1 month before the study for immunosuppressives and 2 months for biologics.

Unanswered Questions

Steven Brant, MD, professor of medicine and director of the Meyerhoff Inflammatory Bowel Disease Center at Johns Hopkins University in Baltimore, Maryland, said the initial results are interesting, but inconclusive.

He noted that the study was designed to be preliminary and to test safety and potential efficacy, and results should be interpreted as such. There was no control group, it was open label, and the patient size was very small.

In addition, two patients dropped out because they could not maintain the diet, he points out.

"In a strictly clinical science way, you have to look at those as failures...you have to assume those people would have done poorly," Dr Brant said. Also, he said, it is important to consider that three of the patients who remained in the study lost weight, a particular concern in children.

Still, eight of the original 12 children were in remission, and that is impressive compared with many other therapies for IBD, he said.

He added that it may be unclear how much effect any new medications, rather than the diet, might have on the outcomes. Although participants could not change medications for a month before the study (2 months for stronger medications), some drugs take longer than that to show effectiveness, Dr Brant said.

Among those is azathioprine, Dr Brant said, which would fall under the 1-month restriction in the study, but can take 2 to 4 months to show effectiveness. According to the study, two patients were taking that drug.

The patients may have also become more adherent to their medications because they were part of a study and would regularly be checked by a physician, he added.

"The exciting thing really was that there was a significant decrease in the C-reactive protein," he said.

These are the kinds of studies that move us forward and show that it may be worthwhile to take the next step in a large study, he said.

First, it is important to find out with larger studies whether this diet really does work compared with a control group, and if so, what part makes the difference, he said.

In addition, the authors report that the diet helped patients move toward a more normal microbial pattern, which raises a chicken-and-egg question, Dr Brant said: "Is it that you got improvement in the inflammation and then the bacteria changed, or did a change in the bacteria improve the inflammation?"

Dr Brant told Medscape Medical News that he has had mixed results among his own patients who have tried SCD. Whereas some patients on the diet have been able to move off immunosuppressive therapies, most have not. "Some have been able to come off but then have had to come on again," he said.

"I think there's great interest in [SCD]. I think it's a very big challenge to follow the diet," he said.

He more commonly recommends a Mediterranean-style diet with few processed foods and simple sugars and more fish than animal protein.

The authors acknowledge the limitations of the study, and Dr Suskind said in the news release that priorities for treatments will vary by the individual.

"SCD is another tool in our tool belt to help treat these patients. It may not be the best treatment option for everyone, but it is an effective treatment for those who wish to try a dietary therapy," he said.

The authors and Dr Brant have disclosed no relevant financial relationships.

J Clin Gastroenterol. Published online December 27, 2016. Abstract

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