The Red Section

Am J Gastroenterol 2017; 112:1491–1492 doi:10.1038/ajg.2017.269; published online 5 September 2017

Living on Liquids: Surviving and Thriving on Exclusive Enteral Nutrition

Kelly Issokson MS, RD, CNSC1

1Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, USA

Correspondence: Kelly Issokson, MS, RD, CNSC, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, LL A601, Los Angeles, California 90048-0750, USA. E-mail: issoksonk@cshs.org

I love food — from street food, to fine dining, and everything in between. I love it so much that I studied Culinary Arts in college before specializing in nutrition. For most of us, eating is more than just a means of survival. It’s a crucial part of our social and emotional well-being. Food has power well beyond its flavor or nutritional content — it can conjure up strong memories of a special person or place, provide comfort to someone who is grieving, or even welcome someone after a long journey. So I never imagined that I would encourage my patients to give up solid food as a way to help them heal, and I certainly never thought that I would give up solid food in order to understand what they might be going through on such a diet.

Nutrition can serve a strong therapeutic purpose. As a clinical dietitian specializing in inflammatory bowel disease (IBD), the number one question I hear from my patients is “how can I use diet to help my IBD?” IBD pathogenesis is thought to involve an interplay between the environment, microbiome, and an overactive immune system in a genetically susceptible individual (1), and patients often seek natural ways to alter the environmental and microbial components that may be driving inflammation.

One form of nutrition therapy for Crohn’s disease (CD) is exclusive enteral nutrition (EEN). EEN involves drinking a formula (polymeric, semi-elemental, or elemental) that provides 100% of nutrient needs for 4–12 weeks. EEN has been shown to induce remission in pediatric CD, and to a lesser extent in adult CD (2) (mainly due to a lower compliance rate). Patients using EEN during active inflammation had remission rates equivalent to steroid therapy, but EEN has the added benefit of mucosal healing, sparing bone health, and providing nourishment (3). One study found improved quality of life, emotional, and social scores after remission induction with EEN (4). EEN is used as a primary therapy in pediatric CD in Japan and Europe, and is recommended in adults with CD when corticosteroids are not feasible (5, 6, 7, 8, 9). Despite this, EEN is rarely prescribed by physicians in the US due to lack of familiarity, perceived poor acceptability, and/or lack of clear protocols (10).

To increase awareness, I underwent an EEN trial for 30 days. For the record, I do not have IBD. But I often recommend EEN to my patients and I wanted to gain insight into some of the challenges my patients face so that I could better support them through their EEN journeys.

It wasn’t until I publicly announced a start date to my EEN challenge that it began to feel real. And on day one, I went from my regular breakfast of coffee with a poached egg and toast, to formula. “Why didn’t I think to wean myself off caffeine before starting?” I thought. And from chicken salad with fresh fruit and water, to formula. And from roasted salmon and veggies with a glass of red wine for dinner, to formula. As expected, week 1 was difficult, producing symptoms including borborygmi, bloating, headaches, fatigue, and dry mouth. But it also presented a major perk: extra time. I had nearly two extra hours in my day, time I would have spent grocery shopping, washing dishes, or preparing meals.

By week 2 I was comfortable with my new routine (two shakes for breakfast, two shakes for lunch, two shakes for dinner) and my GI symptoms had subsided. Cravings were mainly for textured foods, which I successfully satisfied by the freezing formula in popsicle molds. I had to learn to remove the emotional aspect from eating, relying on food as pure nourishment.

Week 3 was much easier than the previous two. I was more comfortable with my free time, focusing on non-food-centric activities, and was able to maintain my social life. I didn’t exclude myself from parties—I still attended, but with formula in hand (or hidden in a coffee cup).

By week 4, I was an EEN pro. But realizing my trial was soon ending reinvigorated food cravings — particularly for salty foods. I really missed the basic neural response associated with eating: salivation. I spent most of week 4 planning my first meal post EEN and settled on simple chicken broth. At the end of my trial, my weight was stable and I was feeling good. I slowly reintroduced foods and am now back to my regular diet. For those considering EEN, here are my five tips for success:

  1. Establish clear expectations: Discuss the duration of therapy, time frames for remission, expected symptoms, and what to do in case of weight loss or lack of response to EEN—these are all key to shared decision making.
  2. Provide support: A drastic diet change is scary and support can make the difference between EEN success and failure. Dietitians help support patients through their EEN and ensure they are getting enough nutrition for healing and weight maintenance.
  3. Be enthusiastic: Using EEN to induce remission is a low-risk and safe therapy that allows patients more control over their disease. This is cool!
  4. Celebrate achievements: Every day on EEN is an accomplishment. At the end of the EEN trial, splurge on something fun with all the money saved from not buying food.
  5. Reintroduce food slowly: Remind your patients that solids require more digestive effort than liquids and the body needs time to acclimate. Lower-fiber and lower-fat foods may be tolerated best initially.

My EEN trial helped me gain a better understanding of the challenges one faces when undergoing EEN. It wasn’t easy, but it certainly was not impossible and there are many aspects of EEN that are positive, aside from inducing IBD remission. Yes, EEN can induce IBD remission. Although it may not be appropriate for everyone with IBD, EEN is worth consideration. And I feel it is critical that, when appropriate, we inform and encourage patients to undertake this efficacious complimentary IBD therapy.

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Conflict of interest

Guarantor of the article: Kelly Issokson, MS, RD, CNSC.

Specific author contributions: Kelly Issokson was the sole contributor of this manuscript and she has approved the final draft submitted.

Financial support: There were no funding sources for this publication. Although independent of this work, formula for the author’s EEN trial was generously donated by Orgain, Inc.

Potential competing interests: None.

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References

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