Final Paper 1

IBD and the Knowledge of MI RDNs: An Exploratory Research Study

Clarissa Sumanting

Professor Ford

December 11, 2020

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Abstract

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory disease that affects

one’s intestines, exhibiting mild to severe periods of intestinal inflammation with periods of

remission. The two common types of IBD are Crohn’s disease (CD) and ulcerative colitis (UC),

characterized according to the site of inflammation. Due to the increase of IBD cases, more

research and large-scaled randomized controlled trials (RCTs) are needed to update evidence-

based guidelines that will assist dietitians and healthcare practitioners in providing the most up-

to-date information to patients with IBD.

Objective: The objective of this exploratory research study is to acquire information about

dietitians’ current knowledge of IBD and its interventions.

Methods: A 10-minute survey was created through Qualtrics and disseminated to the members

of Dietitians of West Michigan (DWM) through an email distribution list. The data was collected

and reviewed using Statistical Product and Service Solutions (SPSS) version 25, using descriptive

statistics to formulate the results into data tables.

Results: While the participating dietitians (n=8) were familiar with IBD and the more well-

known interventions, such as the low fermentable oligo-, di-, monosaccharides and polyols

(FODMAP) diet (75%, 6 of 8 dietitians) and Specific Carbohydrate Diet (SCD) (37.5%, 3 of 8

dietitians), the type of dietary interventions recommended to patients or clients significantly

varied.

Conclusion: The results demonstrated that RDNs perform their own research outside of what

they have learned from their graduate courses, didactic program and internship to create
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individualized plans for patients. Additionally, it revealed a disconnection between the IBD

interventions that RDNs are familiar with versus the interventions the normally prescribe or

recommend to patients. This study suggests that additional research, specifically large-scaled

RCTs, are needed to assess what interventions RDNs may recommend to relieve patients’

symptoms sooner and/or induce remission. Future research may also include the perspective of

RDNs in regards to the need of improved evidence-based guidelines that may be incorporated

to the curriculum of graduate courses and didactic programs.

Background & Literature Review

Inflammatory bowel disease (IBD) is a chronic inflammatory disease that affects one’s

intestines, exhibiting mild to severe periods of intestinal inflammation with periods of

remission.1 The symptoms inflicting individuals diagnosed with IBD can vary but include the

following in no particular order: fatigue, bloating, abdominal cramps, weight loss, diarrhea,

steatorrhea, malnutrition and anemia, ultimately affecting one’s quality of life due to repeated

days of missing work and feelings of social isolation.1,2,3 The two common types of IBD are

Crohn’s disease (CD) and ulcerative colitis (UC), characterized according to the site of

inflammation.1 Despite the commonalities between the two such as an increased risk for colon

cancer, the significant distinguishing difference between CD and UC is the presentation of

inflammation throughout the GI tract in addition to the mucosa. 1 For an individual with UC,

inflammation is generally evident in the submucosa or mucosa of the rectum or colonic area,

whereas CD exhibits transmural inflammation of the individual’s colon or ileum. 4 Although the

etiology of IBD remains unknown, an increased occurrence and rise in cases seen in

industrialized and Westernized areas have linked the possibility of environmental factors, in
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addition to the influence of the immune system and genetics, to play a significant role in the

pathogenesis of IBD.3 As more populations begin to follow a Westernized lifestyle, with North

America and Northern Europe as the countries most prevalent in IBD incidences, an association

between the Western diet and IBD has been formed due to the adverse effects the foods of this

diet has shown upon the gut and microbes.5,6 Examples of these foods include the following:

alcohol, non-caloric artificial sweeteners, preservatives, refined carbohydrates and processed

meats and other animal products.6

As previously stated, the immune system and genetics of an individual also have an

important part in the pathophysiology of IBD. Specifically, IBD may develop when a genetically

susceptible individual is exposed to an environmental factor such as diet, creating a dysbiotic

gut microbiome which activates the immune response, resulting in chronic inflammation. 5,6

Therefore, diet is believed to act as a form of therapeutic treatment due to its ability to interact

with the microbiome and the mucosal immune system.7

Britto and Kellermayer concentrated on the monotony of carbohydrates within the diet

as a form of treatment and prevention from IBD.8 The authors hypothesize that a diet varying in

carbohydrates will induce dysbiosis, create defects within the mucosa and cause immune

dysfunction, thereby increasing the susceptibility of an IBD diagnosis. 8 With this hypothesis,

Britto and Kellermayer believe that carbohydrate monotony may have the ability to undo the

pathology of IBD.8 Current dietary interventions for IBD, such as exclusive enteral nutrition

(EEN), the specific carbohydrate diet (SCD), the gluten-free diet (GFD) and the low fermentable,

oligo-, di-, monosaccharides, and polyols (FODMAP) diet, were reviewed to emphasize the

importance of this viewpoint and its possibility to assist in the treatment of IBD. 8 First, EEN is
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considered as one of the most widely used forms of therapeutic treatment for inflammatory

bowel disease as a result of its effectiveness.8 As a dietary intervention, EEN is the consumption

of enteral formulas, consisting of either polymeric or elemental protein. 8 In comparison to

steroid use in patients with IBD, EEN has illustrated that its use can also result in the

improvement of one’s clinical labs similar to that seen of steroid use. 8 Additionally, EEN has

demonstrated benefits for patients such as the following: an increase in one’s quality of life and

growth, the initiation of healing in the mucosa lining, and the improvement in bone

metabolism.8 If patients are consistent and compliant with this diet intervention, EEN could

induce clinical remission and patients may maintain this status as well observe a decrease in

fecal calprotectin.8 It is important to note that the type of enteral formula consumed is

unimportant, varying from choices of Osmolite, Boost and Pediasure, but rather that the

method of delivery and preparation is consistent. 8 Therefore, it is this specific detail in which

the belief of carbohydrate monotony may be the answer to a successful intervention and

treatment of IBD because of the same unchanged enteral formula consumed daily. 8 The second

nutritional therapy reviewed is the specific carbohydrate diet. SCD is a restrictive diet in which

only monosaccharides, specifically glucose, galactose and fructose, are consumed due to the

belief that other carbohydrates, such as disaccharides and polysaccharides, remain undigested

within the colon, allowing an overgrowth of bacteria and fungus to occur, leading to harmful

and unfavorable results within the body.8 Although its mechanism is unknown, it is proposed

that following SCD may reduce inflammation of the intestines and therefore alter the pro-

inflammatory condition of the fecal microbiome to a non-inflammatory environment. 8 While

the outcome of SCD illustrates an increase in microbial diversity, this differs from EEN which
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significantly reduces the diversity within the gut microbiome, indicating that each of these diets

can be beneficial to individuals despite these different effects to the microbiome. 8 The mutual

aspect of both of these diets is the monotonous carbohydrate sustenance consumed by the

patient, further supporting the viewpoint and hypothesis of Britto and Kellermayer. 8 The next

diet interventions, the gluten-free diet and low-FODMAP diet, have been shown to decrease

the gastrointestinal (GI) symptoms associated with IBD.8 According to a 2014 published cross-

sectional study of individuals diagnosed with IBD and following GFD, about 66% of patients

noted an improvement in GI symptoms and roughly 30% mentioned a reduced amount or

decreased severity in IBD-related flares.8 Though studies have determined that gluten does not

cause inflammation in the intestines of people not diagnosed with celiac disease, Biesiekieski et

al proposed that the decreased GI symptoms may be due to the limited consumption of low

FODMAPs rather than the absence of gluten from the individual’s diet. 8 An excess consumption

of FODMAPs within the diet is believed to further escalate permeability within the intestines, a

recognized characteristic of CD development in an individual that is genetically susceptible. 8 A

low FODMAP diet is highly restrictive, avoiding lactose, fructose, sorbitol, galactans and fruco-

oligosaccharides, resulting in the alleviation of irritable bowel syndrome (IBS)- related

symptoms, often present in IBD patients.8 The adherence to both GFD and the low FODMAP

diet once again illustrates the carbohydrate monotony existing in these diet therapies that

promotes the theory that the monotonous consumption of carbohydrates specifically may be

the commonality between each of these dietary interventions in the successful treatment for

IBD.8
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As previously mentioned, EEN is a commonly used form of diet intervention in both

children and adults diagnosed with IBD and has demonstrated successful outcomes over the

past few decades, effectively becoming the primary choice of therapy for children and

adolescents experiencing active Crohn’s disease.9 According to protocol in New Zealand, EEN is

adhered to for 8 weeks, only allowing a liquid diet of enteral nutrition, preferable with a

polymeric formula because of its improved taste and tolerance according to patients. 10 EEN has

been successful in inducing remission, both clinical and biochemical, in 85% of children

experiencing active CD, demonstrating a similar response to the use of corticosteroids. 9 Though

the percentage of children entering remission is high, the location of the disease may impact

the outcome of using EEN as treatment, although more data is needed to confirm this

information.9 Regardless of the positive outcome EEN produces for children with CD, data is still

needed to understand the role of EEN in lowering intestinal inflammation. 9 Recent information

proposes that the use of EEN reduces inflammation by altering the bacteria of the gut lumen. 9

Additionally, the formula consists of active ingredients that possess anti-inflammatory effects

on the epithelial cells of the intestines to prevent the actions of pro-inflammatory cytokines on

the mucosal lining.9 Lastly, the enteral formula assists in up-regulating epithelial proteins to

produce tighter junctions.9 In regards to the effect of EEN on the microbiome, Gatti et al

published a systematic review on the effects of this intervention on the microbiota profile of

patients diagnosed with CD.11 This systematic review included several different types of studies,

such as cross-sectional, case-controls and cohorts, to evaluate how EEN and partial enteral

nutrition (PEN) affected the composition of one’s microbiome or the metabolomics profile in

individuals.11 Participants that used antibiotics a week to 3 months prior to the study or used
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probiotics two weeks beforehand were excluded from this study. 11 A total of fourteen studies,

twelve studies on children and two with adults, were included in this review, resulting in a total

of 462 participants with 314 diagnosed with CD.11 One of the main outcomes from these studies

was the significant decrease in microbiome diversity during the course of EEN treatment. 11

Despite this reduction, this outcome correlated positively with the induction of clinical

remission and also exhibited a reversal of remission once patients began a normal diet. 11

Ultimately, the effect of this diet intervention on specific species of bacteria differed greatly

according to these studies’ results.11 A high rate of remissions, roughly 90%, was apparent in CD

patients due to the adherence to this diet and a decrease in the bacteria F. prausnitzii and

Bacteroides-Prevotella were also associated with attaining remission.11 The authors of this

review revealed that the is a limited number of studies and trials with a large sample size

following a specific methodology and enforcing criteria for inclusion and exclusion. 11 Though the

decreased amount of bacteria may be due to EEN, it is noted that this may already be due to a

depletion in an individual’s microbiome before the intervention. 11 Consequently, Gatti et al

suggest that the inability to reveal common differences in these studies may imply that future

studies should focus on applicable inconsistencies, such as at the functional or metabolic level. 11

Although there are several positive outcomes from adhering to EEN as a form of treatment for

IBD, a randomized controlled trial of children with mild or moderate CD was performed to

record whether EEN, CD exclusion diet (CDED) with 50% partial EN (PEN), or CDED with 25%

PEN was favorable.12 Ultimately, while CDED with PEN and EEN resulted in remission, the

former dietary intervention proved to be more effective in remission induction and illustrated

alterations in the individuals’ fecal microbiome. 12

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Due to the several positive outcomes from the use of EEN for CD and the lack of a

standardized approach to using this method as treatment, Day et al created a study to develop

a standard of care for practicing physicians to follow and to offer a pathway for more

research.12 The methods of this study included a working group consisting of twelve IBD

specialists from Australia and New Zealand to create a care pathway for the use of EEN in adults

diagnosed with IBD.12 The resulting care pathway formulated by these specialists included the

six following consensus statements: clinical indications for use of this diet therapy, nutrition

assessment, the EEN prescription and duration of intervention, criteria for monitoring,

reintroduction to foods and the function of partial EEN.12 The purpose of this care pathway was

to create a standardized approach to EEN in adult individuals with IBD. 12 Additionally, these

statements were formed using the opinions of experts and recent evidence, but a personalized

and individualized approach should be created by a Registered Dietitian Nutritionists

specializing in IBD in combination with the multidisciplinary team. 12

The next most commonly used nutrition therapy for IBD is the low FODMAP diet. This

dietary intervention is mostly known for its reduction in GI or IBS-related symptoms. Zhan et al

performed a meta-analysis and systematic review which resulted in a total number of 319

patients with IBD in four before-after studies and two randomized controlled trials (RCTs). 13 The

primary symptom and outcome the authors focused on when reviewing these studies was the

response on diarrhea.13 The secondary outcomes to be reviewed included the following:

abdominal bloating, abdominal pain, fatigue, nausea and constipation. 13 Of the six studies,

almost all symptoms demonstrated a significant improvement when comparing the results to

individuals of the low FODMAP diet group (LFD) or those following a normal diet (ND). 13
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Specifically, diarrhea, abdominal bloating, abdominal pain, fatigue and nausea all resulted in

significant improvement from IBD in the LFD group but constipation showed no significant

difference between both groups.13 A low FODMAP diet has been demonstrated to be effective

in reducing IBS-like symptoms that appear in roughly 40% of IBD patients.14 FODMAPS are

restricted from one’s diet due to the poor absorption of these sugars in the small intestine,

leading to bacterial fermentation within the colon that can create common GI symptoms such

as diarrhea, constipation, bloating and abdominal pain and gas.14 Prince et al illustrated the

effectiveness of this diet by documenting the improvement of an individual’s frequency in

bowel movements, the consistency in stool and the reduction of symptoms.15 In addition to the

uncomfortable experience with these symptoms, these indications can also affect the

individual’s quality of life, warranting the use of the low FODMAP diet as an intervention. 14,16

Another study, a re-challenge trial by Cox et al, performed a fermentable carbohydrate

challenge for three days consisting of a total of 32 patients. 17 The following types of

fermentable carbohydrates were used in this study: fructan, sorbitol, galacto-oligosaccharides

(GOS) and a placebo of glucose.17 This study revealed that fructans, at high amounts, can

worsen functional gastrointestinal symptoms (FGS) in those undergoing quiescent inflammatory

bowel disease.17

Originally used as a treatment for celiac disease by Dr. Sidney Haas, the specific

carbohydrate diet (SCD) only allows the consumption of monosaccharides, excluding most

polysaccharides and disaccharides.15,18 Despite its name, SCD is not simply a low-carbohydrate

diet but a diet consisting of monosaccharides, fats, solid proteins, fruits, nuts, homemade

fermented yogurt and vegetables with a high amylose to amylopectin ratio. 15 It is hypothesized
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by Gottschall that individuals with IBD can only absorb monosaccharides well because of a

dysfunction of the enzyme disaccharidases which is specifically used to digest and absorb high

amylopectin foods and disaccharides.15 This dysfunction may arise due to the excess production

of mucus inhibiting the intestinal enzymes along the brush border from contacting the

disaccharidases and amylopectin, resulting in maldigestion. 15 Therefore, following SCD can

prevent the consumption of disaccharides and reduce the IBD-related symptoms in addition to

reversing the impaired microbiome.15 Few studies evaluating the effectiveness of SCD among

individuals diagnosed with IBD have indicated various outcomes.17 A large retrospective study

involving a total of 417 patients, 43% with UC and 47% with CD, reported reaching clinical

remission between 6 – 12 months for 42% of the participants. 17 Another uncontrolled

prospective study of 12 patients illustrated reaching clinical remission at 12 weeks. 17

Additionally, in a pediatric study of 12 patients with no control group, Suskind et al reported an

improvement in both clinical and objective labs in 11 individuals at 8 weeks and a majority also

received remission with inflammatory markers that were normalized at 12 weeks. 19 Lastly,

Chutkan et al recorded the results of a five-year longitudinal study of 8 patients who adhered to

SCD.20 Individuals experienced improvement after 30 days of compliance and 75% of individuals

adhered to the diet 80-100% during this time where as 25% were 60-80% compliant. 20 As a

result, 3 participants showed full mucosal healing and 4 patients had the ability to terminate

immunosuppressive therapy and biologics, indicating that SCD may prove to be a useful long-

term intervention for IBD.20

The last dietary intervention to be reviewed is the IBD anti-inflammatory diet (IBD-AID).

IBD-AID focuses on reducing the severity and frequency of flares in order to achieve and
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maintain remission.19 Additionally, IBD-AID is considered to be an individualized form of

treatment consisting of several steps that is hypothesized to prevent the growth of a dysbiotic

microbiome by limiting the production of pro-inflammatory microbes within the GI tract. 20

It consists of the following five components: (1) modifying carbohydrate, such as refined sugars

and lactose, (2) emphasizing prebiotic and probiotic ingestion, (3) differentiating between

saturated, mono-, poly-, unsaturated fats and trans-fats, (4) reviewing the complete dietary

pattern, and (5) altering food textures if needed.19 The results of the study revealed 24 patients

who complied with the diet and experienced a good to very good reaction to the intervention

whereas 3 patients reported mixed results.19 Ultimately, all patients were able to cease taking at

least one of their IBD medications after adhering to IBD-AID. 19 In contrast with these favorable

results, in a cross-sectional study of 143 patients with IBD, specifically 111 diagnosed with UC

and 32 with CD, respectively, Mirmiran et al tried to determine if an inflammatory diet

influenced the disease activity of IBD.20 Ultimately, a significant association was not found

between the two.20 For example, although n-3 fatty acids and fish are considered anti-

inflammatory food items, beneficial results were not observed in the disease activity of IBD. 20

In addition to these restrictive diets, other diets have been considered for IBD

treatment, such as a vegetarian or gluten-free diet, a plant-based diet, or a fasting-mimicking

diet although few studies have been performed. According to Schreiner et al, 52 patients

following a vegetarian diet and 54 patients following a gluten-free diet illustrated no beneficial

results in disease activity or fistulas although these individuals did present with a lower

psychological state.21
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Regardless of these various diets that one may follow as a nutrition therapy for IBD, and

with any type of diet to be followed, it is important to note that those diagnosed with IBD will

need a personalized diet. As seen with the differing results from these studies, each person may

react to the diet positively, negatively, or experience no changes in the symptoms or frequency

of flare-ups related to IBD. Therefore, Laing et al concentrates on nutrigenomic research. 22

Nutrigenomics is the study of interactions between genes and nutrients, indicating and

supporting the different reactions individuals experience when adhering to a specific dietary

intervention for IBD.22 For that reason, nutrigenomic research may assist in providing an

individualized plan of treatment by including specific foods that will not result in malnutrition,

worsening IBD-related symptoms or a decreased quality of life.22 Guadagnoli et al emphasizes

the importance of food-related quality of life (FRQoL) in regards to IBD or IBS. FRQoL judges

how one’s diet, food-related anxiety or eating behaviors may have an impact on a person’s

quality of life.23

In a topical review by Sigall-Boneh et al, a working group of dietitians of the European

Crohn’s and Colitis Organization, D-ECCO, addressed several gaps in research regarding IBD and

diet in three significant themes: (1) the position of diet in the etiology of IBD as an

environmental factor, (2) the possible role diet plays in inducing and maintaining remission in

IBD, and (3) assessing one’s nutritional status to provide nutrition support for those diagnosed

with IBD.24 In research that focuses on inducing or managing IBD, EEN, partial EN and

elimination diets, such as SCD, IBD-AID and CDED, were reviewed.24 Despite the few trials and

studies performed, several research gaps arise, such as trials needed to study the diet’s efficacy
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in IBD, the regimen one must follow to encourage remission, and the mechanism of action of

the specific diet.24

The systematic review of Limketkai et al focused on the compilation of dietary

interventions used in RCTs to study and document which diet may prove to be successful in

inducing and maintaining remission in IBD, specifically in active and inactive CD and UC. 25 A

total of 18 RCTs that consisted of 1878 participants were gathered from the following

databases: Medline, Central, Cocharine IBD Group Specialized Register, Embase,

Clinicaltrials.gov, Web of Science and WHO ICTRP.25 Despite the inclusion of a control group, the

uncertain results of these studies demonstrate the need for more RCTs that consist of a large

group of participants in order to document dietary interventions that individuals diagnosed

with IBD will find helpful and resourceful.25 In addition to serving as a source of information for

patients and/or clients, these results will also assist health care professionals, such as

Registered Dietitian Nutritionists (RDNs), in furthering their understanding in the most up-to-

date and evidence-based dietary interventions that may be provided to individuals diagnosed

with IBD who are in need of information that will assist in reducing specific symptoms and

inducing remission of this chronic disease.

Furthermore, a second systematic review by Akobeng et al, focused on the use of

enteral nutrition (EN) as a method of maintaining remission in CD, specifically. 26 A search of the

following databases were performed to gather information on the effectiveness of EN in

Crohn’s disease and the influence that different compositions of EN may have overall: Central,

Cochrane IBD Group Specialized Register, Embase, Medline and clinicaltrials.gov. 26 A total of

four RCTs with 262 participants were collected.26 These four trials compared the following: (1)
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elemental diet vs polymeric diet, (2) half-elemental diet vs regular free diet, (3) elemental diet

vs a control group with no treatment, and (4) a polymeric diet vs mesalamine. 26 Ultimately,

similar to the previous systematic review, each of these RCTs culminated uncertain results with

no definite verdict on whether the use of EN for CD was a safe and effective method for

supporting remission.26 This review further emphasizes the importance of more research and

desire for large-scaled RCTs to advance the knowledge needed to increase one’s understanding

on the use of diet as an alternative therapy to IBD.

All three of these studies demonstrate the significant research gaps found in the

majority of these trials focusing on potential dietary interventions and nutrition therapy

treatment for IBD. Although there are several ongoing trials that will fulfill some of these gaps,

health care professionals today are still in need of evidence-based information to not only

increase their understanding of IBD but to be able provide successful interventions to those

diagnosed with IBD to reduce symptoms and induce or maintain remission. Despite the many

organizations that focus on CD and UC and the several open-access journals currently available

today, RDNs may feel unprepared to assist this specific population due to changing results and

growing information on IBD. Therefore, the objective of this exploratory research study is to

acquire information about dietitians’ current knowledge of IBD and its interventions. The survey

will be encourage RDNs to express which dietary interventions they commonly prescribe to

patients and their opinions on how well he or she was educated about IBD before entering the

professional field. Ultimately, this will assist in future recommendations that could be added to

graduate courses, didactic programs or internships to better prepare the future RDNs in the

growing field of Crohn’s disease and ulcerative colitis.

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Materials and Methods

This exploratory research study began with the creation of a 10-minute survey through

Qualtrics, an online survey platform licensed by Grand State Valley University (GVSU). The

survey consisted of twelve questions written in a variety of formats, such as multiple choice,

open-ended and Likert-scale questions, to elicit both short-answer responses and the option to

include additional information to answer the question more thoroughly.

Once approved by GVSU’s Institutional Review Board for Human Subjects (IRB), the

survey was disseminated to the members of Dietitians of West Michigan (DWM) through an

email distribution list. Consent of the participants was embedded as the primary question in the

Qualtrics survey and obtained electronically before accessing the remainder of the questions.

Participating RDNs had two weeks to complete the survey before the results and data were

collected and stored in a secure room.

A final report of the data was collected and reviewed by GVSU Statistical Consulting

Center in which the data were analyzed with SPSS version 25, using descriptive statistics to

formulate the results into data tables.

Results

A total of 12 individuals consented to participate in this study but only 8 individuals

completed the online survey. Two descriptive questions from the survey inquired the number

of years working in the dietetics profession and the areas in which one has been employed in.

Of these 8 participants, seven reported the number of years practicing as an RDN, resulting in a

mean of 19.6 years. Six individuals responded with various settings in which one has worked,
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fulfilling each of the general areas in which RDNs have career opportunities in, such as clinical,

community, private consultation, education and administration.

Familiarity with IBD and its dietary interventions

Each participant rated their familiarity with IBD on a Likert scale of 1-10, with 10 being

the highest. The mean value was 7, indicating an above average familiarity with this chronic

inflammatory disease. Additionally, each participating dietitian chose from a list of dietary

interventions he or she was familiar with as recommendations for IBD. The interventions listed

were the following: Low fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet,

Specific Carbohydrate Diet (SCD), Exclusive Enteral Nutrition (EEN), IBD Anti-Inflammatory diet

(IBD-AID), Crohn’s Disease Exclusion Diet (CDED), Semi-vegetarian diet, Probiotics, and the

Mediterranean diet.

The survey yielded the following percentages of one’s awareness in these interventions:

75% (6 out of 8) were familiar with the Low FODMAP diet, 37.5% with SCD, 12.5% in EEN, 0%

with IBD-AID, 37.5% with CDED, 12.5% with Semi-Vegetarian, 25% with probiotics and 25% with

the Mediterranean diet.

Education in IBD

When asked at what time one had learned about IBD, participants had the ability to

select more than one choice of his or her location of learning and acquired education. Twenty-

five percent of the 8 dietitians reported learning extensively about IBD in their Didactic Program

in Dietetics (DPD), 37.5% in graduate classes, 37.5% in their internship and 50% replied learning

about IBD elsewhere.

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A mean average of 4.7 out of a 1-10 Likert scale was calculated from 7 of the 8 dietitians

regarding how adequately he or she felt educated and prepared to treat patients with IBD.

Three of these dietitians included comments on the need for additional research to keep up-to-

date and to create individualized interventions as general recommendations would not suffice

everyone.

The remaining dietitian out of the total participants did not answer the question using

the Likert scale but rather reported feeling both adequately educated and prepared to treat

individuals although he or she did not see patients with IBD often.

IBD in the Workplace

Participants were asked if he or she treated patients with IBD and how often. Seventy-

five percent of the dietitians have worked with these patients or clients undergoing this chronic

disease and the remaining 25% have not. In regards to how often, 25% reported working with

these individuals yearly, 25% monthly, 25% weekly (2-3 times per week), and 25% stated they

have never treated patients with IBD.

The dietary interventions recommended or prescribed to patients varied with the

following results: 37.5% (3 out of 8) dietitians recommended a Low FODMAP diet, 37.5%

recommended a type of exclusion diet or avoidance to trigger foods, 12.5% prescribed

peppermint oil, 12.5% with Heather’s tummy control suggestions, 12.5% prescribed a low

residue diet, 12.5% with a low/high fiber diet, 12.5% recommended the Mediterranean diet,

12.5% with probiotics, 12.5% recommended IBD-AID and 25% replied with N/A or no answer.
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Lastly, once these interventions were suggested, 75% of the dietitians reported that the

patients did not ask for a different dietary intervention at follow-up, 12.5% disclosed having a

patient that requested a different recommendation and 12.5% chose not to answer.

Discussion

The objective of this exploratory study was to acquire information about dietitians’

knowledge of inflammatory bowel disease (IBD) and its interventions. Based upon the results of

the survey, while dietitians are familiar with IBD, the knowledge of its interventions widely

varies. Although several participants stated they were aware of the low FODMAP diet, only a

few were familiar with other dietary interventions that have been studied for this chronic

disease, such as the specific carbohydrate diet (SCD) and exclusive enteral nutrition (EEN).

The majority of this study’s participants have worked with patients with IBD and the

frequency of these visits equally varied between weekly, monthly or yearly sessions,

demonstrating the significant role dietitians have in the relationship between diet and

individuals with this chronic inflammatory disease. Further investigation revealed that despite

the majority of dietitians’ knowledge about the low FODMAP diet as a possible intervention for

IBS-related symptoms for those with IBD, only 3 out of 8 dietitians recommended this diet. The

next well-known interventions that dietitians were aware of are the SCD and CDED, although

results showed these diets were not suggested to patients at all. The dietitians recommended

interventions that primarily focused on food items being excluded from the diet, such as the

avoidance of trigger foods, a low residue diet, IBD-AID and a low fiber diet. There may be

several reasons as to what these results may suggest, such as the following: (1) these specific
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diets (i.e. low FODMAP, SCD, CDED, etc.) may not have resulted in positive outcomes in the

past, (2) these diets may have been too restrictive for patients to adhere to, (3) additional

research is needed to study the effects of these interventions and the results need to be

disseminated, and/or (4) RDNs are choosing interventions from experience that have yielded

beneficial results.

Lastly, half of the participating dietitians reported having learned about IBD

comprehensively elsewhere while 3 out of 8 dietitians stated learning during one’s internship

and graduate classes and 2 out of 8 in his or her DPD. Furthermore, the survey demonstrated

varying opinions as to whether he or she felt sufficiently equipped with the knowledge and

education before counseling patients with IBD. Additionally, three dietitians reported having to

research information further in order to construct individualized plans for patients. This

information, in combination with the contrasting actions of the familiarity with IBD

interventions but prescribing others as previously stated, emphasizes the need for additional

evidence-based research that could then be included into curriculums to better prepare and

equip current and future dietitians.

Strengths and Limitations

While the strength of this exploratory study involved a simple, anonymous

questionnaire, the limitations include a small sample size (n= 8) to represent the opinions and

attitudes towards dietary interventions for IBD and the reasons for using his or her own

recommendations. Moreover, this survey was only disseminated to one Michigan organization,
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Dietitians of West Michigan, and these members had a short, limited amount of time to

complete this survey, two weeks.

Conclusion

The Nutrition Care Manual (NCM) evidence-based guidelines focus primarily on treating

symptoms during acute exacerbation that may inhibit adequate oral intake, such as nausea,

vomiting, diarrhea, pain, altered taste or anorexia, by adhering to a diet that is low-fiber, low-

fat, high-calorie, high-protein and consuming small, frequent meals as one is able to tolerate. 27

Additional interventions include correcting the individual’s nutritional deficiencies as

malabsorption results from a decline in bowel function due to inflammation, strictures,

bacterial overgrowth and/or surgical resection.27

Once in remission, recommendations to patients with IBD include consuming a nutrient-

dense diet high in energy and protein to assist in maintaining weight and replenishing one’s

nutrients stores that may have decreased during a flare-up.27,28 Dietary fiber should also be

gradually increased to the recommended level, in addition to increasing high antioxidant foods

into the diet.28 Lastly, supplementation for glutamine, omega-3 fatty acids and probiotics and

prebiotics may be considered.27

Essentially, during an acute exacerbation that may last days or weeks, individuals with

IBD undergo a period of inadequate oral intake that must be corrected during remission. While

individualized meal plans are needed for this chronic disease due to the varying GI symptoms

and food intolerances one may be experiencing, additional future research including

randomized-controlled trials with diets (i.e. low FODMAP, SCD, etc.) to assist in reducing
Final Paper 22

specific symptoms may help dietitians and other health care practitioners to relieve patients’

pain sooner.

Furthermore, a complete comprehensive research regarding dietitians’ attitude towards

the need for new information about IBD interventions and the reasons for recommending

different interventions as the survey demonstrated compared to that of other diets can aid in

steering the direction of future studies. Once an increased number of randomized-controlled

trials with larger sample sizes is completed and results in improved evidence-based guidelines,

this information can be included into the curriculum of graduate courses and didactic programs.
Final Paper 23

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Final Paper 24

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Final Paper 25

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