Nutrition, IBD and the IBD Standards

Katie Keetarut is a highly specialist Dietitian in IBD at University College London Hospitals NHS Trust (UCLH) since 2010. Katie is the British Dietetic Association (BDA) representative on IBD UK and was the BDA representative for the UK IBD Audit and a sub-group member for the Inpatient Experience, Inpatient Care and Organisational Audits.

The 2019 IBD Standards include a number of key points to improve the nutritional management of IBD patients by ensuring that patients have access to a dietitian along the whole patient journey, from diagnosis through flare management and around the perioperative period.

It was recommended in the IBD audit that “all patients with IBD have access to a dietitian”. However, despite this, the number of patients seen by a Dietitian during hospital admission has not increased across all audits and remains under 40%.

Statement 3.2: All newly diagnosed IBD patients should be seen by an IBD specialist and enabled to see an adult/paediatric gastroenterologist, IBD nurse specialist, specialist gastroenterology dietitian, surgeon, psychologist and expert pharmacist in IBD as necessary.

The new 2019 IBD Standards emphasise the importance of a specialist gastroenterology dietitian as a core member of the IBD team and that all newly diagnosed patients are “enabled to see” a dietitian ideally in a “one stop” clinic. Having contact from all core members of the team at diagnosis will help ensure the correct support and MDT management is provided right from the beginning of the patient's journey. To support these recommendations the dietetic provision has increased from 0.5 WTE to 1.0 WTE dietitian allocated to gastroenterology per 250,000 population in line with current identified needs. However, a full UK-wide caseload modelling project is urgently required to strengthen the recommendation.

Statement 1.15: All forms of nutritional therapy should be available to IBD patients, where appropriate, including exclusive enteral therapy for Crohn’s Disease and referral to services specialising in parenteral nutrition.

IBD is a complex and unpredictable condition where dietetic intervention can be a crucial part of the patient's management both during a disease flare-up and during remission.

The symptoms experienced by IBD patients and their clinical journey is highly individual. For example, some patients may benefit from tailored dietary advice to meet micronutrient requirements, while supplementation may be more appropriate for others. Nutritional support using enteral nutrition or parental nutrition may be required e.g., during stricturing disease or in the perioperative period.

"It is recommended that primary nutritional therapy in the form of exclusive enteral nutrition (EEN) is considered in all patients with acute active CD and that this is a first choice in patients at high risk from alternative therapy such as steroids” (Forbes et al, 2017).1

It is well documented that EEN is as effective as steroids at inducing remission in paediatric Crohn's. EEN has the additional advantage of reduction in steroid induced side effects including deleterious effect on growth. EEN should be offered as a treatment choice for adults where patients wish to avoid the potential side effects of steroids. This highlights the importance of providing personalised care and involving patients in the decision-making process.

There has been some evidence of benefit of EEN in stricturing Crohn’s where it has been shown to reduce inflammatory strictures and induce remission (Hu et al, 2014).2

During disease remission, functional gastrointestinal symptoms are very common (Simren 2002)3 and specific dietary exclusions including the low FODMAP diet have been shown to improve symptoms.

In the new IBD standards there is a greater emphasis on the importance of dietetic input, nutrition support and advice in the perioperative period with initiation of appropriate nutrition support where required.

Malnutrition is common in IBD and is an independent risk factor for postoperative complications (Stoner et al, 2018).5

Appropriate identification and nutritional management of patients at nutritional risk in the perioperative period could help improve post-operative recovery and surgical outcomes and is recommended in other guidelines (ESPEN guideline: Clinical nutrition in surgery, ESPEN Guideline: Clinical Nutrition in inflammatory bowel disease).6,7


1 ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Alastair Forbes, Johanna Escherb, Xavier Hebuternec, Stanisław Kłekd, Zeljko Krznarice, Stephane Schneiderc, Raanan Shamirf, Kalina Stardelovag, Nicolette Wierdsmah, Anthony E. Wiskini, Stephan C. Bischoff. Clinical Nutrition 36 (2017).

2 Hu D, Ren J, Wang G, Li G, Liu S, Yan D, et al. Exclusive enteral nutritional therapy can relieve inflammatory bowel stricture in Crohn's disease. J ClinGastroenterol 2014 Oct; 48:790

3 Simren, M, Axelsson, J, Gillberg, R et al. Quality of life in inflammatory bowel disease in remission: the impact of IBS‐like symptoms and associated psychological factors. Am. J. Gastroenterol. 2002; 97: 389– 396.

5 Patrick L. Stoner, 1 Amir Kamel, 2 Fares Ayoub, 1 Sanda Tan, 3 Atif Iqbal, 3 Sarah C. Glover, 1 and Ellen M. Zimmermann 1 Gastroenterol Res Pract. Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support, 2018.

6 ESPEN guideline: Clinical nutrition in surgery. Arved Weimanna, Marco Bragab, Franco Carlic, Takashi Higashiguchid, Martin Hübnere, Stanislaw Klekf, Alessandro Lavianog, Olle Ljungqvisth, Dileep N. Loboi, Robert Martindalej, Dan L. Waitzbergk, Stephan C. Bischoffl, Pierre Singerm Clinical Nutrition 36 (2017) 623e650.

7 ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Alastair Forbes, Johanna Escherb, Xavier Hebuternec, Stanisław Kłekd, Zeljko Krznarice, Stephane Schneiderc, Raanan Shamirf, Kalina Stardelovag, Nicolette Wierdsmah, Anthony E. Wiskini, Stephan C. Bischoff. Clinical Nutrition 36 (2017).