Analysis of 61 exclusive enteral nutrition formulas used in the management of active Crohn's disease-new insights into dietary disease triggers

Abstract

Background: Exclusive enteral nutrition (EEN) is an effective treatment for Crohn's disease.

Aims: To investigate the hypothesis that ingredients of EEN formulas are unlikely to initiate a disease flare and that their dietary elimination is not essential for disease amelioration.

Methods: We performed compositional analysis of EEN formulas with evidence of efficacy in management of active Crohn's disease. Macronutrient content was compared against the dietary reference values (DRV), the UK National Diet and Nutrition Survey (NDNS) and intake of Crohn's disease children. Food additives were cross-referenced against the FAO/WHO database.

Results: Sixty-one formulas were identified with variable composition (carbohydrates [22.8%-89.3%], protein [7.8%-30.1%], fat [0%-52.5%]). Maltodextrin, milk protein and vegetable/plant oils were the commonest macronutrient sources. Their n-6:n-3 fatty acid ratio varied from 0.25 to 46.5. 56 food additives were identified (median per formula: 11). All formulas were lactose-free, gluten-free, and 82% lacked fibre. The commonest food additives were emulsifiers, stabilisers, antioxidants, acidity regulators and thickeners. Food additives, implicated in Crohn's disease aetiology, were present in formulas (modified starches [100%], carrageenan [22%], carboxymethyl cellulose [13%] and polysorbate 80 [5%]). Remission rates did not differ between EEN formulas with and without those food additives. Analysis including only formulas from randomised controlled trials (RCTs) retained in the latest Cochrane meta-analysis produced similar findings. EEN formulas contained less energy from saturated fat than NDNS intake.

Conclusion: We have identified food ingredients which are present in EEN formulas that are effective in Crohn's disease and challenge perceptions that these ingredients might be harmful.

Figure 1

Flowchart of search strategy to identify EEN formulas with published evidence of efficacy in the induction of remission in active Crohn's disease

Figure 2

Sources of carbohydrates, fat, protein and fibre in EEN formulas used for induction of clinical remission in patients with active Crohn's disease, as this is reported on the nutritional information label of the EEN formula. Blue: All EEN formulas identified; Green: EEN formulas of RCTs retained in Cochrane meta‐analysis

Figure 3

Heatmap of food additives and their associated General Standard for Food Additives functional classes contained in EEN formulas used in the literature for induction of clinical remission in patients with active Crohn's disease. i, All EEN formulas identified; ii, EEN formulas of RCTs retained in the Cochrane meta‐analysis; A, Food additives with no nutritional value, B, Food additives with nutritional value

Figure 4

Comparison of remission rates induced by EEN formulas containing food additives implicated in inflammatory bowel disease with remission rates induced by EEN formulas not containing these food additives. A, All EEN formulas identified, B, EEN formulas of RCTs retained in Cochrane meta‐analysis

Figure 5

Macronutrient content of EEN formulas used for induction of clinical remission in patients with active Crohn's disease, intakes of children with Crohn's disease and from the general population (4‐18 years) of the National Diet and Nutrition Survey, along with the UK dietary reference values. Footnote: p‐value in blue indicates comparison of “All EEN formulas” with dietary reference values (DRV) and in red indicates comparison with the National Diet and Nutrition Survey (NDNS)