In children, a treatment known as exclusive enteral nutrition, or EEN, is considered the first line therapy to treat Crohn’s. It is a short-term treatment program involving a fully liquid diet meant to induce remission. EEN is not typically used to treat adults with Crohn’s, and more research is needed to determine its effectiveness in this population, says Arielle Leben, a registered dietitian at NYU Langone Health’s Inflammatory Bowel Disease Center in New York City. “One potential explanation for this lack of research is poor compliance,” she says. “Many adults find the EEN formulas unpalatable and decline the alternative of receiving the formula through a temporary nasogastric tube.” However, some adults with Crohn’s may benefit from EEN in certain cases, though this should always be discussed with your gastroenterologist. “Starting EEN should be an informed, shared decision between a patient and doctor,” Leben says. “It is not recommended to try EEN without the support of a clinical care team, including a registered dietitian who can ensure that a patient’s nutritional needs are met.” “A registered dietitian would calculate the number of cartons of formula you would need to take in each day based on your protein and caloric needs,” Cavagnaro says. The formula can be taken orally or through a feeding tube. After the course of EEN is finished, a patient is weaned to PEN or “partial enteral nutrition,” where 25 to 50 percent of their caloric needs come from formula, with the rest coming from food, Cavagnaro says. “Ultimately patients are weaned to what we consider our ‘Crohn’s maintenance diet’ or a Mediterranean diet in the long-term to promote overall health,” she explains.
Who May Benefit From EEN?
While there is currently no standard protocol in place for when to initiate EEN in adults with Crohn’s, there are small studies and case reports promoting its efficacy in certain complicated cases, Leber notes. For example, a case series published in 2019 in Crohn’s & Colitis 360, a journal of the Crohn’s and Colitis Foundation, looks at the use of EEN in 13 adult patients with complex Crohn’s disease. The participants were offered EEN based on either meeting malnutrition criteria, inability to receive immunosuppressive therapy, or Crohn’s disease that was resistant to multiple therapies. Many also had complications such as abscesses or fistulas. Participants received EEN for two or more weeks with outcome data recorded at two and six weeks. The report found that 9 of the 13 patients “experienced subjective improvement in well-being,” and the authors concluded that EEN can help lead to healthy weight gain and reduce the need for surgery in people with Crohn’s. Cavagnaro notes that patients with small bowel Crohn’s disease who are currently in a flare may also benefit from EEN “as a bridge to getting on medication to help the flare.” “Starting EEN may help with symptoms and get the patient on the road to remission more quickly while waiting for a biologic medication to start to work, which can take time,” she says. EEN is also recommended in adult patients in a flare in which steroids are not feasible, such as someone with uncontrolled diabetes or severe bone loss who would like to stay off of steroids, Cavagnaro says.
What to Consider Before Trying EEN
When performed under the supervision of a doctor and registered dietitian, EEN is generally low risk. “Throughout the course of the therapy, tolerance of the formula, weight status, and disease activity markers should be monitored,” Leber says. “Any food allergies should be discussed prior to the initiation of therapy so that the formula ingredients can be reviewed.” Another thing to consider is palatability and taste fatigue. “Drinking the same formula for weeks on end can grow tiresome,” Cavagnaro says. “It is incredibly important to choose a formula that you do not mind drinking from the beginning.” She also suggests mixing up flavors within the same formula for some variety. Finally, experts say the potential effects on one’s social life should be considered before trying EEN. “It can be difficult to sit at the dinner table watching your friends and family eat while you sip on your shake,” Cavagnaro says. “You may stop wanting to go out to eat or sit with friends and family as they eat together, which can in turn hurt one’s mental health.” Cavagnaro recommends having frank conversations with friends and family about why you’re on a liquid diet. And remember, it is only temporary. Additional reporting by Ashley Welch.
