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Let thy food be thy medicine

‘Let thy food be thy medicine and medicine be thy food’, is a dictum often attributed to Hippocrates. Adult patients with inflammatory bowel disease (IBD) interested in this therapeutic approach often wonder why clinicians do not advocate for specific dietary interventions in induction of remission. For physician decisions, the paucity of controlled trials demonstrating the efficacy of specific nutritionbased strategies is in stark contrast to multiple randomised controlled trials of pharmacological agents. So, when a patient asks, ‘how can I manage my Crohn’s disease based on dietary measures only’, the knowledgebase and resources to guide patients usually lags those of prescription drugs. In FG, Melton et al share their experience with the use of exclusive enteral nutrition (EEN) as therapy in adult patients with active Crohn’s disease. They report outcomes in 60 patients with active Crohn’s disease treated in both outpatient and inpatient settings. Similar to prior literature, they noted both a high rate of induction of clinical remission (24/28), but also a high dropout (21 patients), mainly due to intolerance. It is important to mention that, more than half the patients in this study were on some medical treatment prior to initiation of EEN. Further clinical trials are needed to compare efficacy of a multipronged approach including diet and medications. The study also highlights the technical and social challenges to EEN use in the clinic, and need for health system support, social support and availability of formula. The authors concluded that most patients discontinued therapy due to inconvenience and avoidance of regular food for a prolonged period. To overcome this challenge, various more palatable diets have been studied. A 12week randomised study of 194 patients assigned to either specific carbohydrate diet or Mediterranean diet did not show superiority of one diet over the other in achieving improvement of symptoms or biomarkers (Creactive protein)/faecal calprotectin). A control arm of standard diet was not included, so we cannot determine an effect relative to no dietary intervention. A recent openlabel randomised study of 44 patients by Yanai et al demonstrated similar efficacy of the Crohn’s disease exclusion diet (CDED) alone, or in conjunction with partial enteral nutrition in adult patients with mild to moderate Crohn’s disease. Patients in both groups (68% in combined group and 57% in CDED group) achieved clinical remission at 6 weeks. At 24 weeks, 80% of the above patients continued to remain in clinical remission. For clinicians, we have an evolving body of evidence to support specific dietary interventions for active Crohn’s disease. An ideal next step would be to compare these to induction therapy with standard pharmacological agents (eg, antitumour necrosis factor), or compare combination dietary and pharmacological induction to drug treatments alone. While we expect EEN should be safer, whether it is sustainable with current formulations is uncertain. For dietary treatment to succeed, we need wellinformed patients and clinicians, with IBDspecific nutrition support locally, and funded research to transform the field. We also need payers to provide equivalent support to nutritional interventions as they do for highcost drug treatments. Since the ‘exposome’ is now considered a critical component of the pathogenesis of IBD, both at the microbial and epithelial barrier level, ‘you are what you eat’ should be considered more important than ever in IBD management.