European Crohn’s and Colitis Organisation consensus on dietary management of inflammatory bowel disease

Statement 1: In the absence of a specific dietary intervention that is recommended by an IBD 56 healthcare professional, healthy eating guidelines should be followed by people with IBD, as 57 recommended for the general population.[EL5] [Consensus: 100%] 58 Statement 2: All people with IBD should have access to a dietitian with experience in IBD.[EL5] 59 [Consensus: 96%] 60 To drive engagement with diet as a routine part of IBD care, to enable diet as both a primary and 61 adjunctive therapy, and to facilitate high-quality dietary research, it is essential to include specialist 62 dietetic input in clinical care and research.Statement 2 is arguably the most important statement 63 within this consensus.Recommendations for nutritional assessment and execution of dietary 64 interventions are outlined through the statements of this consensus, based on evidence for its efficacy 65 and safety.Where evidence is lacking, as indicated by EL5, mechanism-based reasoning should ensue 66 without compromise to safety.Ideally, nutritional assessment should be performed by a dietitian, who 67 can assess and correct abnormalities in nutrition and eating behaviour.Where no such dietetic 68 expertise is available, a healthcare professional with training in nutrition assessment and optimisation 69 should be consulted.A dietitian well-versed in IBD should execute and monitor IBD-specific dietary 70 interventions, particularly diets of restrictive nature, as such diets carry nutritional and psychosocial 71 risks and require skilled dietetic supervision.6 119 also support the use of EEN in abdominal abscesses, intestinal fistulae, and inflammatory intestinal 120 strictures 24-27 .There are additionally emerging retrospective data suggesting that EEN may augment 121 response to advanced therapies, with a multicentre study of patients with ileal CD commencing 122 advanced therapy demonstrating mucosal healing in 85.7% of those also receiving EEN for 16 weeks, 123 compared with 23.7% receiving advanced therapy alone 28 .124 In paediatrics, PEN is likely less effective than EEN, although the proportion of enteral nutrition has 125 varied between studies.The first trial comparing PEN and EEN in CD found lower clinical remission for 126 PEN [15%] versus EEN [42%] after 6 weeks, although both reduced disease activity, with stronger 127 benefits in EEN 29 .However, in a separate study when PEN accounted for 47% of caloric intake, 128 remission was achieved by 50%, 76%, and 73% in PEN, EEN, and biologic groups, respectively, based 129 on faecal calprotectin 16 .When PEN provided 80-90% of caloric intake, 87% clinical response, 65% 130 remission, and improvements in biochemical outcomes were observed irrespective of disease 131 location 30 .However, for a similar protocol only 42% completed the prescribed course due to lack of 132 response [25%] and intolerance [23%] 31 .133 In adults, PEN that provides at least 50% of caloric intake alongside adalimumab led to remission rates 134 and inflammatory marker improvements similar to EEN, outperforming regular diet 32 .135 Data on the use of EEN and PEN for the treatment of active ulcerative colitis [UC] are limited.A single 136 small open label RCT suggests that EEN may reduce hospital stay and corticosteroid failure in patients 137 with acute severe UC, but these findings require replication 33 .138 Statement 4.1: Partial enteral nutrition [PEN] could be considered for the maintenance of remission 139 in Crohn's disease [EL2], including as an adjunct to medical therapy [EL3], with the most convincing 140 evidence of efficacy for PEN comprising >35% daily energy requirements [EL2].However, details of 141 optimal duration and psychological impact of long-term PEN are unknown.[Consensus 96%] 142 Statement 4.2 There is insufficient evidence to recommend PEN for the maintenance of remission of 143 ulcerative colitis.[EL5] [Consensus 88%] 144 PEN as maintenance therapy for CD has been evaluated by prospective trials, retrospective trials, and 145RCTs as reported in several meta-analyses and systematic reviews [34][35][36][37] .

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