IBD Drive Time: Dr Jana Al Hashash on Diet and Nutrition in IBD Care

Dr Jana Al Hashash offers guidance on how diet can affect IBD and the best approaches to maintaining adequate nutrition, along with hosts Millie Long, MD, and Raymond Cross, MD.

Jana Al Hashash, MD, is associate professor of medicine and IBD specialist at Mayo Clinic—Jacksonville, Florida.  Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland. Millie Long, MD, is a professor of medicine, vice chief of education, and director of the fellowship program in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill.

TRANSCRIPT:

Hello, this is Millie Long from University of North Carolina. I'm here with my cohost, Ray Cross, who is now at Mercy in Maryland. And we have an outstanding guest today.

We have Dr. Jana Al Hashash. She is associate professor of medicine at Mayo Clinic in Jacksonville in their IBD Center there. And she's here to teach us a lot about diet and IBD. So welcome, Jana, to the program.

Dr Al Hashash: Yeah, thanks so much for having me today. Appreciate it.

Dr Long: Well, we're thrilled. And we're just going to jump right in for the learning. So we have a series of questions we want to kind of pick your brain about in regard to diet and how best to communicate with patients surrounding this. The first question, which is a common question that my patients ask me, is which diet should a patient with IBD follow? And specifically I get asked, is there a diet that prevents the risk of relapse? How do you answer that and what's the evidence?

Dr Al Hashash: Thank you very much for this question. And I agree, it's a very common question that we get asked almost every day by our patients. So in general I would recommend a balanced Mediterranean diet for all patients with inflammatory bowel disease unless there's a contraindication to ingesting fibrous foods such as fruits and vegetables, and this really would be in patients who have intestinal strictures or narrowings, as you know. The Mediterranean diet, what's nice about it is that it's low in processed foods, low in red meat, low in salt, low in sugar, and therefore it's healthy for a person's general well-being. It's also been studied and shows low rates of active disease, inflammatory biomarkers, and tends to improve the quality of life of patients with IBD.

Actually, the CD-DINE study, which was conducted by one of my coauthors, Dr. Jim Lewis, where he took patients who were prospectively randomized to either Mediterranean diet or Specific Carbohydrate Diet, showed that both diets were very similar, very effective in achieving symptomatic remission and calprotectin response. So patients did well on both diets.

Dr Long: That's important, right? Because the specific carbohydrate diet is much more of a limited diet. I think it may be a little bit harder for our patients to follow. So, the fact that we can still have good symptomatic, you know, kind of outcomes in terms for our patients, when used in a complimentary fashion, because these patients were still on other medications, it can improve symptoms.

Is that kind of how you come about recommending the Mediterranean diet? It's just less restrictive.

Dr Al Hashash: Yeah, less restrictive, easier to follow, the whole family can follow it really because it's good for everything. It's good for the heart, it's good for really metabolic syndrome, etc. So it's a healthy diet, which, I think improves everybody's quality of life.

Dr Long: Absolutely. Now, specifically, sometimes people ask, you know, are there like specific foods that decrease flares? Or, you know, do you have any guidance along those lines?

Dr Al Hashash: Yeah, so, as you know, the studies have not been very consistent in avoiding this kind of food and then you're okay, no flares. The strongest data is really for patients with ulcerative colitis as a diet low in red and processed meat has been shown to possibly reduce ulcerative colitis flares and interestingly this has not been found to hold true in patients with Crohn's disease.

Dr Long: Yeah absolutely You know, I was actually a part of a study that was one of the first internet-based studies, which was the one Jim Lewis did looking at red meat in Crohn's disease. And we randomized patients, told them, you need to eat this versus high meat, low meat. And we really didn't see much of a difference, which I think is helpful to say it's not one food, right? And it's probably more, as you mentioned, kind of the global healthy diet, the Mediterranean diet that can be helpful without necessarily saying you need to restrict A, B, or C.

So I think that that's an instance where a negative study can actually be helpful. So next question for you, so when you are trying to induce remission in Crohn's disease, if you choose dietary therapy and some of our patients do, they may be perhaps they're hesitant to do medications first and they want to try diet and if a patient is really certain they want to do this I will let them do it under guardrails and kind of say okay but if you don't respond we need to do you know kind of next steps but how do you if you have a patient who is trying primarily dietary therapy, what kind of paradigm do you put them in, how do you monitor, and at what point do you say okay dietary therapy has not been or has been effective. Now

Dr Al Hashash: Excellent question. And as you know, it's extremely difficult for someone to start and stay on dietary therapy. And the strongest data comes from exclusive enteral nutrition, which is EEN. And EEN can be given either by mouth—it's just like a form of intense dietary therapy where a patient has to just drink all their caloric intake and it doesn't taste very good, it's very hard for adults to adhere to it, and it causes social isolation because you can't go out to lunch or dinner with your friends, and there's been data to show that it's been associated with product fatigue, but regardless and that's why the data is really strongest in pediatric patients because you can control what you're giving your child and perhaps the parents are more concerned about accepting biologic therapy for their patients and they just want to try a diet. So you try the EEN and data is actually very, very promising, but it's very hard to continue on that for a long term.

Again, just to mention that a lot of times you can have EEN by mouth, but some people opt to just insert a feeding tube like an enteral tube and start getting the feedings through that. Now, interestingly, there's been data to show a partial enteral nutrition is also equally effective, where you would start to rely on EEN, but also start to introduce certain foods, certain components of foods in 3 different phases. So it's extremely important to work very closely with a dietitian and nutrition team who can help encourage patients and health guide with therapy.

Now in terms to how long to try diet therapy before transitioning, it really depends on when we're using this. Is it just trying to control moderately severe, mild to moderate severe Crohn's disease or is it someone who we're trying to bridge to surgery? So it really depends on the situation.

Dr Long:  No, I was going to say, I'll let you know the way I do. For me, this is a great therapy for the mild Crohn’s patient, where we monitor for a biologic response as well as a symptomatic response. Just because, you know, from a mild Crohn’s disease perspective, we don't necessarily know that the biologics are necessary and this may be a way that we can maintain that patient.

I would say for the more severe patient, I like to use diet more complimentary rather than as a primary therapy. But in any of those scenarios, I just think it's important to have not only symptoms, but some sort of biologic evaluation, typically in a 3-ish month time span. So you can kind of say, is this effective in and of itself, or do we need to move on?

I don't know, Ray, diet in your practice,

Dr Cross: No, no, I was going to I was going to say the same thing and I was going to hold off on the complicated Crohn's and how you manage that with diet, but Jana, if you decide that you're going to implement diet as a treatment strategy or even as an add-on, is your monitoring approach any different than if you were starting a conventional medication?

Dr Al Hashash: No, I would monitor them the same way, but perhaps more intensely initially, meaning if I start someone on medication, I may check noninvasive biomarkers in 3 months. For dietary therapy, especially if a patient, if I feel that this patient needs medicine, someone who's moderate to severe, then I would want to perhaps check every 4 to 6 weeks just to make sure that things aren't progressing and that the patient isn't developing a complication or super worsening of his or her disease.

Dr Cross: And so it's a treat to target, just like you would with anything else. You're doing a symptomatic assessment by a marker and endoscopy or IUS, whatever monitoring tool you're using.

Dr Al Hashash: Yes, agree.

Dr Long: I think that's a key take home point because in reality, kind of in some instances, which are one of our goals. Patients can feel better with dietary modifications but we want to make sure it's also treating the underlying inflammation.

Dr Al Hashash: Absolutely.

Dr Long: All right, one more question for me and I'm going to turn it over to Ray. So we talked a little bit about the more mild end and how diet can be used as an alone primary therapy but what about the patient with more complicated Crohn's disease or potentially where you know you may have a planned surgery and we have options. We have enteral options like EEN, we also have TPN. How are you thinking about nutrition in that scenario?

Dr Al Hashash: Yeah, so diet is so important. Nutrition is so important in the preop setting. We really don't want patients who have malnutrition to undergo especially elective surgery because it's been linked to worse postoperative outcomes. It's also been shown to increase perioperative morbidity, mortality, and malnutrition actually has shown to help reduce this risk. So whenever the gut is intact, meaning available to use, we'd like to use it. So we always like to go with enteral nutrition over parenteral nutrition whenever possible. Of course, sometimes patients have a very severe stricture, high ostomy output, ileus, short bowel syndrome, and they need to have surgery for, you know, for a reason, and they're not able to use their GI tract. So that's when we, you know, proceed with parental nutrition.

Dr Cross: What about the intra-abdominal abscess patient who as a fistula? So I always felt like those patients, you kept feeding them and it kept feeding the collection and that was going to increase their chance that they would need an ostomy at the time of the resection. So are you a little more leaning towards TPN in those patients?

Dr Al Hashash: Yeah, it's an excellent point, which is very controversial also. Most of these patients have a stricture and they're basically fistulized above it or more proximal to it. So yes, I'm of the people who actually would bowel-rest patients, give them parental nutrition for at least a couple of weeks, 2 to 4 weeks. If they're on steroids, hopefully they're not, we try to get them off so that we can then operate on them when they're off of steroids maximized nutritional status while bowel resting them.

Dr Cross: Yeah, I agree. And I was at the recent ECCO meeting, which I keep plugging because it's such a wonderful meeting. And I think correct me if I'm wrong, but there was a study that looked at using enteral supplements before surgery and 2 enteral supplements a day before an elective resection decreased perioperative morbidity. Does that sound right, Jana? Am I making that up?

Dr Al Hashash: Yeah, there's been several studies where patients with Crohn's disease and malnutrition were basically given preoperative EEN, and this has shown to really improve disease activity, CRP, nutritional status, and postoperative infectious and noninfectious complications such as anastomotic leaks, abscesses, surgical site infections, reoperation.

Dr Cross: Jana, you mentioned malnutrition, and we know that that's common in our patients with IBD. For practices that do not have a dietitian to assess this, how can providers in their busy practices screen for this? What are a couple of questions they could ask or a couple of objective things they could look at.

Dr Al Hashash: Yeah, I think this is an extremely important question because malnutrition is really underdiagnosed in our patients with inflammatory bowel disease. And a lot of us, I think, rely on looking at the albumin which is really not something that we should be doing to assess nutritional status because it's not specific and it's highly sensitive to inflammation. So you can have false positives by just looking at albumin. Really instead, we should look at our patient. We should look to see if anyone has had unintentional weight loss, whether they have any edema fluid retention, fat, muscle mass loss. And there's a lot of really great Sorry. So, yeah. There are several criteria that can be used. Some are from the ASPEN, the American Society for Parenteral and Enteral Nutrition, and there's GLIM criteria, which is Global Leadership Initiative on Malnutrition criteria, where they look at clinically significant weight loss, which is very, very easy to do in clinic because we measure the weight of our patients and the patients tell us also. You look at BMI, muscle mass, and also you look and ask patients for reduced food consumption, look at their inflammatory status and accordingly decide if they're malnourished or not.

But really the key thing is weight loss.If someone lost a tremendous amount of weight, their albumin is still normal, it doesn't mean that they're in good shape. They are malnourished automatically.

Dr Cross: There's 2 nutritional screening questions that we added to our quality of life questionnaire at the end, and we asked them subjectively if they've lost weight without trying, and we asked them if they have an altered appetite. I think that plus looking at the body weight, like almost any practice can incorporate those simple weight and 2 quick questions. And then you could, of course, as you mentioned, it's the eyeball test. You look at a patient today, look frail, you're looking at their muscle mass and getting a— it's not a perfect assessment, but you certainly get a sense of someone who's in trouble.

Dr Al Hashash: You know something else that’s included in some of the criteria is grip-strength testing. If their grip strength is weak, you know they’re malnourished, they’ve lost muscle mass.

Dr Cross: So you can’t bump knuckles or elbows with them, you have to make them shake your hand. That’s important.

How about monitoring? So obviously we're going monitor their weight and their appetite and so forth, but which vitamin and mineral should we be monitoring to identify deficiency and how often do you do this in your clinical practice? Let's say for a routine patient with Crohn's or ulcerative colitis.

Dr Al Hashash: Yeah, I think that's a great question. I think all patients with inflammatory bowel disease should be monitored for vitamin D deficiency and iron deficiency. And for certain patients who have extensive ileal disease or an ileal resection or even a J pouch or a pouch, we should monitor them for vitamin B12 deficiency because that's where the vitamin B12 gets absorbed.

Of course, other vitamin and mineral deficiencies are important to consider. And depending on other risk factors, we should be checking them such as zinc, copper, fat-soluble vitamin deficiencies, folic acid, particularly the folic acid for patients on methotrexate and sulfasalazine.

And of course, you know that whenever someone has a lot of inflammation or they’re in remission, the vitamin levels can fluctuate because a lot of them are acute phase reactants. So it's extremely important to really measure them when patients are in remission, but the reality is a lot of times when we see our patients, we see them when they're flaring up. And although it's preferable to check them when they're in remission, I still check them when they're seeing me in clinic.

If someone's in remission, it's okay to check them every 6 to 12 months, but if they're really having active disease and I check them I just make sure they're still okay in 3 months.

Dr Cross: And you know Dr. Binion has taught me that B12 assessment can be highly inaccurate. So do you just try to, do you have a mental adjuster for B12 or do you routinely get a methylmalonic acid when you order a B12? How do you approach that problem?

Dr Al Hashash: So really I check patients for fatigue. If someone's fatigued, even if their vitamin B12 is like 300, which is technically normal, I still give them vitamin B12 and I ask them at the follow-up, did you feel better? And most of the time patients really feel so much more energy, so much better after vitamin B12 supplementation.

Of course, you know, keeping in mind risk factors, right? If someone has ileal involvement, it's different than someone has ulcerative colitis with no ileal involvement, with no inflammation at all in a small bowel.

Dr Cross: So you interpret, if I'm summarizing this, you interpret the B12 in the context of their ongoing symptoms. So if they felt completely awesome and their B12 was 320, you would be fine with that. But if, like you and if they were having some other symptoms, you would just treat them and see how they do.

Dr Al Hashash: If they have UCS, if their level is 300, they have Crohn's, TI is inflamed, then I may actually recommend giving them vitamin B12 and use a higher cutoff, which is 500.

Dr Cross: Okay, and we get this quick and sometimes particularly we're all aging with our patients so we are starting to see their children. And if a parent says what can I do to decrease my child's risk of IBD from a nutrition perspective? Is there anything that you can offer them or anything you can recommend?

Dr Al Hashash: Really depends on how old the child is. If they're still within breastfeeding age, I think breastfeeding has shown to be associated with lower risk for diagnosing IBD during childhood. So that's where the, I think, strongest data is. So I would recommend breastfeeding for at least 12 months.

Again, I would just recommend a Mediterranean diet rich in fruits and vegetables and low in ultraprocessed foods to everybody, even the children.

Dr Cross: So Jim Lewis had a good rule of thumb for me. I don't know if you heard this, Jana, but he said that, you know, tell family, tell patients and families that they should really shop in the periphery of the grocery store and stay away from the aisles where the food is more processed. And that's a really pretty simple rule of thumb and something that's very pragmatic. Of course, Jim would come up with something super pragmatic like that.

So all right, this is the fun question unless Millie has any other questions. So tell us something, maybe even something that I don't know about yourself.

Dr Al Hashash: So what do you know about me?

Dr Cross: I know that, I'm going to take one away from you. I know that you are an avid Pittsburgh Steelers fan. That I know, you probably have a terrible towel somewhere in your office, I imagine.

Dr Long: Well, so I'm here with two avid Pittsburgh Steelers fans and I will say that Ray gave me my first ever terrible towel and so I have been to a Pittsburgh Steelers game as well.

Dr Cross: And you have a towel so there you go. Yes.  Sorry other than that what can we learn about Jana?

Dr Al Hashash: So I actually played the piano growing up and my parents whenever we traveled for summer vacation—it was vacation, right? Whether it was like somewhere we had family, like Germany or the UK, they would always make sure that there was a piano available for us to practice every single day. And so I grew up learning the piano and then the clarinet. And I was part of a band where I played the clarinet.

Dr Long: That's great. We really should have an IBD Drive Time band. We've had so many musical guests. This is amazing.

Dr Cross: Yeah, that's definitely not far in the way the most common response is something musical from our guests. So very interesting. Jana, this has been wonderful. Thanks for doing this. It's timely with the new AGA guidelines and hopefully we'll have you back soon.

Dr Al Hashash: Thank you very much. It was nice seeing you both.