AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review

DescriptionDiet plays a critical role in human health, but especially for patients with inflammatory bowel disease (IBD). Guidance about diet for patients with IBD are often controversial and a source of uncertainty for many physicians and patients. The role of diet has been investigated as a risk factor for IBD etiopathogenesis and as a therapy for active disease. Dietary restrictions, along with the clinical complications of IBD, can result in malnutrition, an underrecognized condition among this patient population. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the topics of diet and nutritional therapies in the management of IBD, while emphasizing identification and treatment of malnutrition in these patients. We provide guidance for tailored dietary approaches during IBD remission, active disease, and intestinal failure. A healthy Mediterranean diet will benefit patients with IBD, but may require accommodations for food texture in the setting of intestinal strictures or obstructions. New data in Crohn’s disease supports the use of enteral liquid nutrition to help induce remission and correct malnutrition in patients heading for surgery. Parenteral nutrition plays a critical role in patients with IBD facing acute and/or chronic intestinal failure. Registered dietitians are an essential part of the interdisciplinary team approach for optimal nutrition assessment and management in the patient population with IBD.MethodsThis expert review was commissioned and approved by the AGA Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet and nutritional therapies in patients with IBD. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed.Best Practice Advice StatementsBest Practice Advice 1Unless there is a contraindication, all patients with IBD should be advised to follow a Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt for their overall health and general well-being. No diet has consistently been found to decrease the rate of flares in adults with IBD. A diet low in red and processed meat may reduce ulcerative colitis flares, but has not been found to reduce relapse in Crohn’s disease.Best Practice Advice 2Patients with IBD who have symptomatic intestinal strictures may not tolerate fibrous, plant-based foods (ie, raw fruits and vegetables) due to their texture. An emphasis on careful chewing and cooking and processing of fruits and vegetables to a soft, less fibrinous consistency may help patients with IBD who have concomitant intestinal strictures incorporate a wider variety of plant-based foods and fiber in their diets.Best Practice Advice 3Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn’s disease, with stronger evidence in children than adults. Exclusive enteral nutrition may be considered as a steroid-sparing bridge therapy for patients with Crohn’s disease.Best Practice Advice 4Crohn’s disease exclusion diet, a type of partial enteral nutrition therapy, may be an effective therapy for induction of clinical remission and endoscopic response in mild to moderate Crohn’s disease of relatively short duration.Best Practice Advice 5Exclusive enteral nutrition may be an effective therapy in malnourished patients before undergoing elective surgery for Crohn’s disease to optimize nutritional status and reduce postoperative complications.Best Practice Advice 6In patients with IBD who have an intra-abdominal abscess and/or phlegmonous inflammation that limits ability to achieve optimal nutrition via the digestive tract, short-term parenteral nutrition may be used to provide bowel rest in the preoperative phase to decrease infection and inflammation as a bridge to definitive surgical management and to optimize surgical outcomes.Best Practice Advice 7We suggest the use of parenteral nutrition for high-output gastrointestinal fistula, prolonged ileus, short bowel syndrome, and for patients with IBD with severe malnutrition when oral and enteral nutrition has been trialed and failed or when enteral access is not feasible or contraindicated.Best Practice Advice 8In patients with IBD and short bowel syndrome, long-term parenteral nutrition should be transitioned to customized hydration management (ie, intravenous electrolyte support and/or oral rehydration solutions) and oral intake whenever possible to decrease the risk of developing long-term complications. Treatment with glucagon-like peptide-2 agonists can facilitate this transition.Best Practice Advice 9All patients with IBD warrant regular screening for malnutrition by their provider by means of assessing signs and symptoms, including unintended weight loss, edema and fluid retention, and fat and muscle mass loss. When observed, more complete evaluation for malnutrition by a registered dietitian is indicated. Serum proteins are no longer recommended for the identification and diagnosis of malnutrition due to their lack of specificity for nutritional status and high sensitivity to inflammation.Best Practice Advice 10All patients with IBD should be monitored for vitamin D and iron deficiency. Patients with extensive ileal disease or prior ileal surgery (resection or ileal pouch) should be monitored for vitamin B12 deficiency.Best Practice Advice 11All outpatients and inpatients with complicated IBD warrant co-management with a registered dietitian, especially those who have malnutrition, short bowel syndrome, enterocutaneous fistula, and/or are requiring more complex nutrition therapies (eg, parenteral nutrition, enteral nutrition, or exclusive enteral nutrition), or those on a Crohn’s disease exclusion diet. We suggest that all newly diagnosed patients with IBD have access to a registered dietitian.Best Practice Advice 12Breastfeeding is associated with a lower risk for diagnosis of IBD during childhood. A healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultraprocessed foods have been associated with a lower risk of developing IBD. Diet plays a critical role in human health, but especially for patients with inflammatory bowel disease (IBD). Guidance about diet for patients with IBD are often controversial and a source of uncertainty for many physicians and patients. The role of diet has been investigated as a risk factor for IBD etiopathogenesis and as a therapy for active disease. Dietary restrictions, along with the clinical complications of IBD, can result in malnutrition, an underrecognized condition among this patient population. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the topics of diet and nutritional therapies in the management of IBD, while emphasizing identification and treatment of malnutrition in these patients. We provide guidance for tailored dietary approaches during IBD remission, active disease, and intestinal failure. A healthy Mediterranean diet will benefit patients with IBD, but may require accommodations for food texture in the setting of intestinal strictures or obstructions. New data in Crohn’s disease supports the use of enteral liquid nutrition to help induce remission and correct malnutrition in patients heading for surgery. Parenteral nutrition plays a critical role in patients with IBD facing acute and/or chronic intestinal failure. Registered dietitians are an essential part of the interdisciplinary team approach for optimal nutrition assessment and management in the patient population with IBD. This expert review was commissioned and approved by the AGA Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet and nutritional therapies in patients with IBD. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements Unless there is a contraindication, all patients with IBD should be advised to follow a Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt for their overall health and general well-being. No diet has consistently been found to decrease the rate of flares in adults with IBD. A diet low in red and processed meat may reduce ulcerative colitis flares, but has not been found to reduce relapse in Crohn’s disease. Patients with IBD who have symptomatic intestinal strictures may not tolerate fibrous, plant-based foods (ie, raw fruits and vegetables) due to their texture. An emphasis on careful chewing and cooking and processing of fruits and vegetables to a soft, less fibrinous consistency may help patients with IBD who have concomitant intestinal strictures incorporate a wider variety of plant-based foods and fiber in their diets. Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn’s disease, with stronger evidence in children than adults. Exclusive enteral nutrition may be considered as a steroid-sparing bridge therapy for patients with Crohn’s disease. Crohn’s disease exclusion diet, a type of partial enteral nutrition therapy, may be an effective therapy for induction of clinical remission and endoscopic response in mild to moderate Crohn’s disease of relatively short duration. Exclusive enteral nutrition may be an effective therapy in malnourished patients before undergoing elective surgery for Crohn’s disease to optimize nutritional status and reduce postoperative complications. In patients with IBD who have an intra-abdominal abscess and/or phlegmonous inflammation that limits ability to achieve optimal nutrition via the digestive tract, short-term parenteral nutrition may be used to provide bowel rest in the preoperative phase to decrease infection and inflammation as a bridge to definitive surgical management and to optimize surgical outcomes. We suggest the use of parenteral nutrition for high-output gastrointestinal fistula, prolonged ileus, short bowel syndrome, and for patients with IBD with severe malnutrition when oral and enteral nutrition has been trialed and failed or when enteral access is not feasible or contraindicated. In patients with IBD and short bowel syndrome, long-term parenteral nutrition should be transitioned to customized hydration management (ie, intravenous electrolyte support and/or oral rehydration solutions) and oral intake whenever possible to decrease the risk of developing long-term complications. Treatment with glucagon-like peptide-2 agonists can facilitate this transition. All patients with IBD warrant regular screening for malnutrition by their provider by means of assessing signs and symptoms, including unintended weight loss, edema and fluid retention, and fat and muscle mass loss. When observed, more complete evaluation for malnutrition by a registered dietitian is indicated. Serum proteins are no longer recommended for the identification and diagnosis of malnutrition due to their lack of specificity for nutritional status and high sensitivity to inflammation. All patients with IBD should be monitored for vitamin D and iron deficiency. Patients with extensive ileal disease or prior ileal surgery (resection or ileal pouch) should be monitored for vitamin B12 deficiency. All outpatients and inpatients with complicated IBD warrant co-management with a registered dietitian, especially those who have malnutrition, short bowel syndrome, enterocutaneous fistula, and/or are requiring more complex nutrition therapies (eg, parenteral nutrition, enteral nutrition, or exclusive enteral nutrition), or those on a Crohn’s disease exclusion diet. We suggest that all newly diagnosed patients with IBD have access to a registered dietitian. Breastfeeding is associated with a lower risk for diagnosis of IBD during childhood. A healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultraprocessed foods have been associated with a lower risk of developing IBD. The central purpose of the gastrointestinal tract is nutrition, and this essential function is often compromised in patients with inflammatory bowel disease (IBD). There is growing recognition of the role of diet in the care of patients with IBD, as both an etiopathogenic risk factor and, more recently, as a disease-modifying modality. Historically, there was limited guidance regarding diet for patients with IBD. Other than to counsel on avoiding foods that worsen symptoms and to avoid foods that may predispose to obstruction in those with strictures, health care providers had limited diet-related input to give their patients. Although such dietary advice may help improve symptoms in the acute setting, these approaches frequently led patients with IBD to avoid what are traditionally considered healthy foods, even after achieving clinical remission. New insights have resulted from the investigation of diet and nutrition in the overall care of patients with Crohn’s disease (CD) and ulcerative colitis (UC). The aim of this American Gastroenterological Association Clinical Practice Update is to provide best practice advice statements on the role of diet and nutritional therapies in the treatment of patients with IBD, with a focus on common clinical scenarios encountered during IBD care. Unless there is a contraindication, all patients with IBD should be advised to follow a Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt for their overall health and general well-being. No diet has consistently been found to decrease the rate of flares in adults with IBD. A diet low in red and processed meat may reduce ulcerative colitis flares, but has not been found to reduce relapse in Crohn’s disease. The guidance for consumption of healthy eating patterns, such as the Mediterranean diet rich in fruits and vegetables, for IBD management is a substantial revision from past instructions (Figure 1, Table 1). Prior emphasis on a low-residue, low-fiber diet is reasonable for patients with IBD who are experiencing symptomatic disease flares and worsening abdominal symptoms, but whenever possible, long-term IBD management should attempt to reintroduce fresh fruits, vegetables, and fiber (preferably soluble fiber). Recent prospective, randomized, short-term (6–12 weeks) studies have suggested that a Mediterranean diet and a more structured specific carbohydrate diet were equally effective in achieving symptomatic remission and calprotectin response (Table 1).1Lewis J.D. Sandler R.S. Brotherton C. et al.A randomized trial comparing the specific carbohydrate diet to a Mediterranean diet in adults with Crohn's disease.Gastroenterology. 2021; 161: 837-852.e9Google Scholar Importantly, the use of a Mediterranean diet may mechanistically improve the diversity of the gut microbiome and metabolome and hold additional long-term health benefits, such as reduction of cardiovascular disease, metabolic syndrome, and cancer. An independent validation of the efficacy of the Mediterranean diet for patients with IBD was performed by Chicco et al.2Chicco F. Magri S. Cingolani A. et al.Multidimensional impact of Mediterranean diet on IBD patients.Inflamm Bowel Dis. 2021; 27: 1-9Google Scholar Nutritional counseling was provided to 142 patients with IBD. After 6 months, both patients with UC and patients with CD adhering to the Mediterranean diet had lower rates of active disease, inflammatory biomarker elevation, and improved quality of life.Table 1Diets That Have Been Studied in Patients With Inflammatory Bowel DiseaseDietDescription/RationaleCommentsThe Mediterranean dietPlant-focused diet emphasizing variety of whole grains, fruits, and vegetables.Main fat source is from fish, olive oil, nuts, and seeds.Lean protein sources are from low-fat dairy, poultry, fish, shellfish, beans, and/or legumes.Higher saturated fat containing meats (ie, red meat) are consumed at much lower frequency and quantity.A recent study (2021)1Lewis J.D. Sandler R.S. Brotherton C. et al.A randomized trial comparing the specific carbohydrate diet to a Mediterranean diet in adults with Crohn's disease.Gastroenterology. 2021; 161: 837-852.e9Google Scholar suggested that for adults with mild to moderate CD, the Mediterranean diet has similar efficacy to a specific carbohydrate diet.The Mediterranean diet aligns with a moderate- to high-fiber diet for those in remission.The Mediterranean diet has demonstrated health benefits separate from IBD, such as reduced cardiovascular disease incidence.Specific carbohydrate dietNutritionally complete grain-free diet, low in sugar and lactose. Restricts all hard-to-digest carbohydrates, only eating those that are easy to break down.Examples of included foods:Additive free meat and oils (white vinegar, cider, and mustard)Sugar-free coffee, tea, nut butters, and juiceLow-lactose dairyNonstarchy vegetablesExamples of foods not allowed:Grains and grain productsCandy or foods made with high-fructose corn syrupHigh-lactose dairyStarchy vegetablesSugars, excluding honeyHypothesis is that these foods fuel “bad” bacteria in the gut, and thus avoiding them aids “good” bacterial survival.Challenging to follow.There have been limited large-scale studies showing evidence of benefit. Relatively similar efficacy to Mediterranean diet in DINE-CD (Diet to Induce Remission in Crohn's Disease) trial.Low-FODMAP dietElimination rechallenge diet that limits fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which are short-chain carbohydrates (sugars) that the small intestine absorbs poorly. These are omitted from the diet for up to 8 wk, then reintroduced 1 at a time.May be worth trying in patients with IBD who have concomitant IBS-like symptoms.CDEDaPlease refer to Figure 2.Whole foods diet designed to limit foods that may adversely affect the microbiome or alter intestinal barrier function. Diet is initiated in 3 phases and each phase is 6 wk long and includes partial EN (liquid formula either by mouth or enterically infused).Phase 1:Mandatory intake of fish, chicken breast, and eggsAllows rice, cooled potatoes, tomatoes, onion, garlic, ginger, olive oil, and canola oilLimited quantities of cucumber, carrots, spinach, lettuce, bananas, apples, avocados, strawberries, melon, and citrus juicesPhase 2:Phase 1 foods + tuna, whole-grain bread, oats, yams, and red peppersCertain vegetables, beans, peas, turnips, and parsnips are reintroduced after wk 10Phase 3:“Maintenance phase”Phase 1 and 2 foods + more seafood, eggs, cocoa, coffee, grains, some dairy, and alcohol if toleratedMay be worth attempting in patients with mild to moderate CD with short duration of flares.Allows for some solid foods compared with the 100% liquid nature of EEN; may improve compliance and be easier to follow.a Please refer to Figure 2. Open table in a new tab To date, there is no consistent evidence supporting the avoidance of gluten in patients with IBD in the absence of a celiac disease diagnosis or suspected gluten sensitivity. Although the use of a low fermentable oligo-, di-, and monosaccharide and polyols (FODMAP) diet was found to improve symptoms in patients with IBD in a prospective, randomized trial, this may be accompanied by potential negative long-term consequences.3Cox S.R. Linday J.O. Fromentin S. et al.Effects of low FODMAP diet on symptoms, fecal microbiome, and markers of inflammation in patients with quiescent inflammatory bowel disease in a randomized trial.Gastroenterology. 2020; 158: 176-188.e7Google Scholar The low-FODMAP diet results in the reduction of certain fecal microbiome organisms and reduced generation of the short-chain fatty acid butyrate, a key nutrient for gut epithelial health. Research has found that the organisms that are diminished in patients on a low-FODMAP diet tend to be associated with endoscopic and clinical remission when found in abundance, raising concern about the long-term effects of low-FODMAP diets.4Ng S.C. Benjamin J.L. McCarthy N.E. et al.Relationship between human intestinal dendritic cells, gut microbiota, and disease activity in Crohn's disease.Inflamm Bowel Dis. 2011; 17: 2027-2037Google Scholar, 5Sokol H. Pigneur B. Watterlot L. et al.Faecalibacterium prausnitzii is an anti-inflammatory commensal bacterium identified by gut microbiota analysis of Crohn disease patients.Proc Natl Acad Sci U S A. 2008; 105: 16731-16736Google Scholar, 6Varela E. Manichanh C. Gallart M. et al.Colonisation by Faecalibacterium prausnitzii and maintenance of clinical remission in patients with ulcerative colitis.Aliment Pharmacol Ther. 2013; 38: 151-161Google Scholar Thus, short-term use of a reduced-fiber, low-FODMAP dietary approach during a symptomatic IBD flare may be helpful, but as patients achieve symptom resolution, we propose that a return to a healthy Mediterranean-style diet is in the best long-term interest of patients with IBD. Adherence to a healthy, balanced Mediterranean diet will confer the additional benefit of effectively reducing intake of ultraprocessed foods, which often contain added sugar, excess salt, and other food additives. High consumption of ultraprocessed foods has been implicated in the emergence of health problems throughout the world, including chronic inflammation, and IBD with CD has the strongest association,7Chen J. Wellens J. Kalla R. et al.Intake of ultra-processed foods is associated with an increased risk of Crohn's disease: a cross-sectional and prospective analysis of 187 154 participants in the UK Biobank.J Crohns Colitis. 2023; 17: 535-552Google Scholar,8Lo C.H. Khandpur N. Rossato S.L. et al.Ultra-processed foods and risk of Crohn's disease and ulcerative colitis: a prospective cohort study.Clin Gastroenterol Hepatol. 2022; 20: e1323-e1337Google Scholar At present, it is not known which dietary components of the Mediterranean diet that are emphasized vs those that are minimized underlie its overall efficacy in improving the health of patients with IBD. Specific dietary components that patients with IBD should be cautioned to avoid are sugar-sweetened beverages, which have been linked to etiopathogenic risk and a more severe multiyear clinical course of IBD in a recent prospective cohort study.9Fu T. Chen H. Chen X. et al.Sugar-sweetened beverages, artificially sweetened beverages and natural juices and risk of inflammatory bowel disease: a cohort study of 121,490 participants.Aliment Pharmacol Ther. 2022; 56: 1018-1029Google Scholar,10Ahsan M. Koutroumpakis F. Ramos Rivers C. et al.High sugar-sweetened beverage consumption is associated with increased health care utilization in patients with inflammatory bowel disease: a multiyear, prospective analysis.J Acad Nutr Diet. 2022; 122: 1488-1498.e1Google Scholar IBD-specific diet and nutrition guidance for patients and caregivers are available from Crohn’s and Colitis Canada and Crohn’s and Colitis Foundation.11Crohn's and Colitis CanadaDiet and nutrition.https://crohnsandcolitis.ca/About-Crohn-s-Colitis/IBD-Journey/Diet-and-Nutrition-in-IBDDate accessed: September 2, 2023Google Scholar,12Crohn's and Colitis FoundationDiet and nutrition.https://www.crohnscolitisfoundation.org/diet-and-nutritionDate accessed: September 2, 2023Google Scholar Patients with IBD who have symptomatic intestinal strictures may not tolerate fibrous, plant-based foods (ie, raw fruits and vegetables) due to their texture. An emphasis on careful chewing and cooking and processing of fruits and vegetables to a soft, less fibrinous consistency may help patients with IBD who have concomitant intestinal strictures incorporate a wider variety of plant-based foods and fiber in their diets. Inflammatory injury of the gastrointestinal tract can lead to intestinal remodeling with scarring and strictures, making fibrous, plant-based foods a trigger for obstructive symptoms (Figure 1). Although previous IBD dietary guidance has suggested avoiding these foods, successful reintroduction of fruits and vegetables can be achieved with careful chewing, as well as cooking and processing of these foods to achieve favorable, soft textures that may allow safe ingestion of dietary fiber.13Serrano Fernandez V. Palomino M.S. Laredo-Aguilera J.A. et al.High-fiber diet and Crohn's disease: systematic review and meta-analysis.Nutrients. 2023; 15: 3114Google Scholar,14Heaton K.W. Thornton J.R. Emmett P.M. Treatment of Crohn's disease with an unrefined-carbohydrate, fibre-rich diet.Br Med J. 1979; 2: 764-766Google Scholar Patients readily understand the difference in texture between a fibrous, unpeeled apple (a culprit for obstruction) and the thick, liquid texture of applesauce (easily tolerated) to illustrate this dietary accommodation. Patients with IBD in remission who do not have intestinal strictures do not need to limit their fiber intake. Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn’s disease, with stronger evidence in children than adults. Exclusive enteral nutrition may be considered as a steroid-sparing bridge therapy for patients with Crohn’s disease. Crohn's disease exclusion diet, a type of partial enteral nutrition therapy, may be an effective therapy for induction of clinical remission and endoscopic response in mild to moderate Crohn’s disease of relatively short duration. Exclusive enteral nutrition (EEN) is a form of intense dietary therapy that demands that the entirety of a person's caloric intake come from commercially available oral liquid meal replacements, excluding all other foods, typically for a 6- to 8-week period.15Lamb C.A. Kennedy N.A. Raine T. et al.British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults.Gut. 2019; 68: s1-s106Google Scholar, 16Forbes A. Escher J. Hébuterne X. et al.ESPEN guideline: clinical nutrition in inflammatory bowel disease.Clin Nutr. 2017; 36: 321-347Google Scholar, 17Whitten K.E. Rogers P. Ooi C.K.Y. et al.International survey of enteral nutrition protocols used in children with Crohn's disease.J Dig Dis. 2012; 13: 107-112Google Scholar EEN is usually consumed by mouth. EEN is most often initiated in pediatric patients with CD and is routinely offered as a first-line, steroid-sparing therapy, achieving clinical remission rates similar to corticosteroids (between 60% and 80%).18Heuschkel R.B. Enteral nutrition in children with Crohn's disease.J Pediatr Gastroenterol Nutr. 2000; 31: 575Google Scholar Although EEN is not as widely prescribed for adult patients with CD, several studies reported that when tolerated, EEN may be effective for inducing clinical and biochemical remission.19Melton S.L. Fitzpatrick J.A. Taylor K.M. et al.Lessons from an audit of exclusive enteral nutrition in adult inpatients and outpatients with active Crohn's disease: a single-centre experience.Frontline Gastroenterol. 2023; 14: 6-12Google Scholar, 20Rigaud D. Cosnes J. Le Quintrec Y. et al.Controlled trial comparing two types of enteral nutrition in treatment of active Crohn's disease: elemental versus polymeric diet.Gut. 1991; 32: 1492-1497Google Scholar, 21Kakkadasam Ramaswamy P. Exclusive enteral nutrition with oral polymeric diet helps in inducing clinical and biochemical remission in adults with active Crohn's disease.JPEN J Parenter Enteral Nutr. 2022; 46: 423-432Google Scholar, 22Wall C.L. Gearry R.B. Day A.S. Treatment of active Crohn's disease with exclusive and partial enteral nutrition: a pilot study in adults.Inflamm Intest Dis. 2018; 2: 219-227Google Scholar, 23Royall D. Jeejeebhoy K.N. Baker J.P. et al.Comparison of amino acid v peptide based enteral diets in active Crohn's disease: clinical and nutritional outcome.Gut. 1994; 35: 783-787Google Scholar It is important to acknowledge that the lack of definitive adult data is likely related to difficulties in trial recruitment, as well as poor adherence to the EEN regimen itself. The risk of product fatigue is high with EEN, and adults may find this more challenging to ingest day to day, particularly in group settings where food is being consumed. There is no evidence to support the use of any one particular EEN product, and standard polymeric formulations are generally well tolerated. Prudent selection of products containing nutritional balance and that are calorically individualized to the patient is key for patient safety. Common products used may be va