Bowel Moments

Enteral and Parenteral nutrition with Neha Shah, RD!

• Alicia Barron and Robin Kingham • Season 1 • Episode 122

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This week we welcomed back Registered Dietitian, Neha Shah! Neha joined us back in episode 42 where she was interviewed by friend of the show and IBD RD Stacey Collins. Neha specializes in IBD and other GI disorders and has both a private practice and is also part of the Colitis & Crohn's Disease Center at UCSF.  We spent this episode shedding light on the distinctive roles of enteral and parenteral nutrition in combating IBD-related malnutrition. This episode is your gateway to understanding how enteral nutrition (EN) and parenteral nutrition (PN) can transform treatment strategies.

We discuss everything there is to know about enteral nutrition, especially exclusive enteral nutrition (EEN), a potential game-changer for Crohn's disease management. Discover how EEN can stand alongside or even replace corticosteroids, offering an alternative path to remission and mucosal healing. While this approach has shown promise in pediatric cases, we delve into the more complex dynamics of adult treatment where compliance and lifestyle factors bring their own set of challenges. Neha emphasizes the pivotal role of dietitians in crafting personalized nutritional plans, ensuring that patients receive the tailored guidance they need.

From navigating the hurdles of enteral nutrition to transitioning to varied diets, this episode is packed with practical strategies and expert advice. Neha addresses common obstacles like weight fluctuations and gastrointestinal discomfort, offering solutions such as formula adjustments and the integration of partial enteral nutrition (PEN). As patients move from EEN to lifestyle-friendly diets like the Mediterranean or plant-based options, we explore how specific fibers and the Crohn's Disease Exclusion Diet (CDED) can optimize gut health. Whether you're a patient or a caregiver, this episode offers a comprehensive guide to navigating the nutritional complexities of IBD.

Please keep in mind that the views and opinions expressed in this program are those of the speakers and should not be considered medical or legal advice. Please consult with your healthcare team on any changes to your disease, diet, or treatment. We want you to stay safe and healthy! ;)

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Alicia:

Hi, I'm Alicia and I'm Robin and you're listening to Bowel Moments, the podcast sharing real talk about the realities of IBD Serve on the rocks. This week we were joined by registered dietitian Neha Shah. This is actually Neha's second spot on the Bowel Moments podcast, so go back to episode 42, where you can hear her talk to friend of the show and registered dietitian Stacey Collins. Neha is a registered dietitian who's in private practice but who's also embedded in the IBD Center at University of California, San Francisco. We talked to her all about enteral nutrition and parenteral nutrition and why someone may choose this as part of their treatment journey and what they should expect. We really enjoyed our conversation with Neha and learned so much about enteral nutrition and parenteral nutrition, and we know you will too. Cheers.

Robin:

Hi everybody, this is Robin.

Alicia:

Hey guys, this is Alicia and we are so, so excited to be joined again by Neha Shah. Neha, welcome back to the show. Thank you for bringing me back. We are so excited to talk to you. Just for note for everybody else, Neha has spent another episode with us before, and so that's episode 42. So we're going to invite you to go back and listen to that one, because we dig in a little bit more about her background and lots and lots and lots of really good stuff. But we brought you back specifically because we ran into you at a conference and got chatting with you I think, Robin, specifically and wanted to focus on a couple of things. But our first very unprofessional question for you is what are you drinking?

Neha:

So I'm drinking port. I just got back from Portugal and I never ran into so many varieties of port and I had to bring some back, so I am enjoying my little glass of port right now. I love that. I love a port.

Alicia:

I don't drink port very much, but yeah it's everyone's fault when. I do try it. I'm like, oh, maybe I should have this, and then you forget about it again. I actually have a bottle of port down in my cellar, I guarantee and I now that you said that I'm like, oh yeah, I bought that. That's how often I think about is because Robin got chatting with you at gosh in January was it?

Robin:

Excuse me. Excuse me, Alicia Barron. What are you drinking?

Alicia:

Oh my gosh, Robin. What was I thinking? Okay, robin, what are you drinking?

Robin:

Our whole shtick, alicia, this was unintentional. I love it. We'll find out. I'm actually drinking Kate Farms, which is Entral Nutrition. I have been under the weather for like two weeks now, and so I've been trying to get my what I lovingly refer to them as electric lights and also some extra protein and something that's a little bit easy on my GI tract. So I have been drinking. I'm drinking chocolate tonight. Kate Farms chocolate, entral Nutrition. Let us have it, alicia. Let us have it, alicia. Let us have it. Full disclosure everyone.

Alicia:

What are you drinking? I mentioned to them I'm colon prepping at the moment, so I'm very sad and hungry and have a headache right now, but I'm drinking a raspberry, nectarine water, lose, which is quite good, and also a little bit of lemonades, because I just need to drink, apparently, tons and tons of liquids. I'm about to float away and I'm ready for this to be done, so I have a lot of sympathy, empathy, for all of our IBD friends that have to do this way more frequently than I do, but I'm going to feel sad for myself for the moment.

Alicia:

So I'm going to feel a bit sorry, but you know what? The Waterloo is delicious, so I will stop being sad about that, because that one is actually quite good. Now, neha, the reason we brought you back is because Robin was chatting with you way back in January at the Crohn's and Colitis Congress and we got talking about, like, how kind of misunderstood it is for enteral nutrition and parental nutrition. So we wanted to bring you back so you could give us the rundown of this. So start us out by kind of explaining what is enteral nutrition, what is parenteral nutrition, parenteral nutrition boy, that's hard to say differences, similarities and then we'll go from there.

Neha:

Absolutely.

Neha:

You know.

Neha:

This topic is actually also very timely as it is Malnutrition Awareness Week this week, september 16th to 20th and the use of enteral nutrition I'm going to abbreviate it as EN and the use of parental nutrition I'm going to abbreviate it as PN are both used not just a part of a treatment for IBD, but it's also used to help correct malnutrition that arises as a consequence from IBD.

Neha:

So let's start with EN. So EN consists of either what we call oral nutrition supplements I like to use the word oral caloric protein shakes as well they're either taken by mouth or can also be administered as formulas through a feeding tube. And, in contrast, pn bypasses the gastrointestinal tract altogether and it's really a specialized formula of carbohydrates, proteins, fats, vitamins and minerals in water, of carbohydrates, proteins, fats, vitamins and minerals and water. And that is all formulated especially to be delivered through an IV, to deliver nutrients that one cannot take by mouth or through a feeding tube. And, of course, en is also composed of carbohydrates, proteins and fats, and vitamins and minerals that our gastrointestinal tract can digest and absorb as well.

Alicia:

Got it Okay. And I think we did have a guest on who had short gut syndrome and so she used parenteral nutrition, but she also able to. She had started to be able to eat as well and it sort of had gained some of the sort of functionality back and was able to take in more calories that way. So that was very exciting for her. But she is a long time it sounds like parenteral nutrition user. So got it Okay. That's super helpful. I'm going to ask you some questions, but let's focus specifically on EN right now. Enteral nutrition, so that is by mouth enteral nutrition, or through feeding too, but still into your gut. So basically by gut. Maybe is the nice way to say that.

Neha:

Sure, let's do it.

Alicia:

It's a question mark on that one. Okay, good, okay, so you mentioned malnutrition, which unfortunately is common for our community and not terribly recognized, I think, and that's a whole conversation for a different day. But why would one be recommended to use this? If you're a person living with IBD, you go to your doctor's office or you meet with your dietician. What happens now?

Neha:

Yes. So several reasons why EN can be brought in. One aspect is that EN as exclusive enteral nutrition, een okay, another abbreviation. In IBD it involves the use of again, the oral nutrition supplement by mouth or it can be delivered through a feeding tube to meet close to 100% of nutritional needs. And a lot of the aspects of EEN are gluten-free, lactose-free, many of them are low in fiber. They have different nutrient compositions.

Neha:

How EEN is used in IBD is that in pediatrics it's used most often as the first line induction therapy when I say the word induction therapy, meaning to induce remission of the IBD. And what they have found in pediatrics is that there's no difference in efficacy for mucosal healing between EEN and the use of corticosteroids. Now, in adults the benefit has also been seen there. However, it's not often used as a therapy due to perceived less compliance, less adherence to the therapy. Now, the use of EEN with mucosal healing has been reported in 79% of children and adult patients after being on EEN for an average of 123 days. This is about 12 weeks of EEN and used for 12 weeks in some of those studies, but as a minimum, four weeks is needed as the sole source of nutrition. And, again with EEN. No difference in efficacy was found between the different types of formulas that are available out there. I certainly have additional information on what are the proposed mechanisms and also why EEN can be brought in, but I'd love to hear any thoughts or questions.

Alicia:

Okay, so that is interesting and I think it's really interesting that it is showing remission at that high of a rate. That's really great. But I know it's really interesting that it is showing remission at that high of a rate. That's really great. But I know one of the complications, one of the sort of issues of this is a lot of like you said. So there's this sort of understanding or idea that people can't take it, they can't hang for that long and so and it would be tough, especially if you're a kid, you know to just get your nutrition through oral supplements. If you're an adult, for instance, at your doctor's office, when would this be something that your doctor would recommend to you? Is it like that you've used a lot of steroids and maybe it's kind of like gosh, you've had probably enough steroids, let's try something different? Is there kind of a rationale for when either you would consult with somebody and say I think you should try this, or your doctor would say let's do this instead of steroids?

Neha:

Absolutely so. The use of EEN and I will label as the first option there it's induction therapy is usually brought in. The most data is robust in inducing remission in Crohn's disease. So if one has Crohn's disease, one is in an active disease from that reoccurrent flares, from the Crohn's disease. Those are some of the indications that EEN can be potentially brought in. I would have to say, from my conversations with my adult patients, some of them have never heard of the therapy and then some of them have heard of it and naturally so, completely valid. Like you want me to give up food and most fluids for four weeks. I don't think I can do that and that's a complete, valid response.

Neha:

My role as the dietician I want to be transparent with all the treatment options out there for Crohn's and ulcerative colitis. So I will bring it forward as a possible option. But and it's really important to have that discussion on what it is what does the evidence show? What are the pros and cons? How would this be implemented? How would this be monitored? How do we, you know, initiate that process to bring back foods? How do we completely stop EEN before anyone decides whether this is a process for them? And I would have to say some of the adult patients that have come my way, they were so glad that I brought it their way. They're like this has never been brought to my attention. And then some of them were like I already heard of this before, like I mentioned earlier, and no, we're not interested, and that's again completely understandable. But again, it's important to be very transparent of all the treatment options out there.

Robin:

So my question is, now that they've heard of this and they're like, okay, I'm going to give it a shot. There are so many options, like how do you pick which one's the right one? I mean, I picked because I had a registered dietician walk me through the process, but, like, not everybody's going to have access to that.

Neha:

So 100%. So this is where, initially, it really is important that these patients any patient being considered for EEN or has questions about EEN gets referred to meet with a dietician, who will you know, and dietitian, will help provide a full nutrition assessment as well as to go over, you know, the general compositions of EEN, the types of formulas out there. How can we come up with a regimen that would be workable for your lifestyle? Like some patients will tell me, well, I don't want to be on this at work or, you know, in the evenings I'm so busy with my kids I don't have time to keep on going back and forth and drinking shakes. So how do we calculate a regimen that would be workable? Definitely going through the list of ingredients in each formula, because some people will say well, I can't have lactose, which all formulas are naturally pretty much lactose-free. I can't have gluten Okay, all formulas are naturally gluten-free. You know I'm a diabetic. Okay, all formulas are naturally gluten-free. You know I'm a diabetic. Are there formulas out there that have less carbohydrates than others? So it's really important to work with a dietician that can help match the right type of EN that can help meet some of those needs as much as we can If a patient has high calorie needs.

Neha:

And then some of these formulas. There are different caloric densities. A lot of these EN formulas are labeled as 1.0, meaning one calorie per ml. And you're nodding your head, yes, like you're aware of that. 1.2 calorie per ml and so forth. So if someone needs about 2000 calories, the last thing I want them to do is to drink 10 bottles of one particular type of EN just to get to that number. Maybe it's better for me to concentrate the formula so there's more calories per bottle to help meet that. So that is another option there.

Neha:

And then certainly to really answer other questions, you know how do I be on this regimen when others are eating around me? How do I travel with this regimen? I want to go on the airplane. Do I need a letter to bring all of this on the plane? So all that is factored in into the evaluation to help really determine their appropriate EEN regimen and whether it's appropriate altogether. You know this is made as a shared decision-making process with the patient. It is so important to hear the input of my patients on whether this is possible or not. And then if the patient wants to proceed with EEN, then I usually like to recommend a start date, like it's important that we set up the kitchen. We find the formulas you know that taste well, we find the regimen that works, all that is in place, and then we start. So that way, a lot of time has been put into the planning process in order to make this successful.

Robin:

I'm glad you mentioned taste, because they all taste completely different. I would recommend doing a taste test. You should definitely do a taste test before you decide to purchase a whole bunch of these.

Neha:

Yeah, absolutely Absolutely. Taste testing is important. Different ways to hold hot frozen, there's different flavors. Absolutely, that's an important piece. So, again, no decision is made at the time of the assessment. A lot of it is just really going into what it may entail and then, like I said, some of them have been really content with moving forward with it because they're like well, we tried everything else with our medical treatment. This has not been brought to my attention. I like to give it a go, and under supervision at all means. I want to make sure my patients are staying nourished and not losing weight, tolerating the regimens well, and I want to be able to troubleshoot the issues along the way as well.

Alicia:

So what's an average? I mean, I realize you calculate, depending on the person, what they're trying to do, blah, blah, blah. But is there kind of an average of how much people would be drinking? And then what is that cadence? Because obviously you're not saying about breakfast, you sit down and chug three of these things because that would kind of make you feel gross. And so how do you calculate that out for people?

Neha:

It's so individualized. I like to learn a little bit more about the lifestyle. If I hear my patient tell me that, you know, I'm always running late in the morning and I don't feel good when I wake up. I feel like it takes me a while. The last thing I'm going to have them do is drink two bottles. You know, at a time I've maybe had them drink half a bottle or a bottle. At that point I like to learn a little bit more about their day.

Neha:

If they have a role at work that involves them to be quite active, climbing roofs and, you know, not on their feet all the day, then again, how do we schedule in these shakes that would work for them and their breaks? What part of the day do they feel best at? You know, can we drink a little bit more in that part of the day versus the other parts of the day to get that in? Oh, it's really difficult for you to finish all six bottles. Maybe I need to concentrate it again and bring it down to four bottles. So I would have to say it's so individualized that I think learning a little bit more about the lifestyle will help me understand how we can plan out a regimen, or sometimes we need a weekday regimen and we need a weekend regimen when one is home more often.

Neha:

I have written letters for some of my patients if they can be allowed to work remotely from home while they do EEN, so that way they can focus their attention on these shakes without being in front of others Like meetings may involve lunch. Food is so central to a lot of meetings and social settings and all that. So it was their way to not be in those situations when they're doing this therapy. So what do you need for me to support you during this time? So that's how it helps me also determine the regimen as well.

Alicia:

That's really helpful, I mean. I think that makes sense too. It's the way we want our medical care to go right, so like be optimized to that person. So let's talk a little bit about troubleshooting, and one of the questions I had for you is kind of like you know, when somebody is doing especially exclusive enteral nutrition, are there complications that can pop up Also? Is there, I mean, and this is the big, big question. So maybe we start with complications and then the second part of that question is really also like what about coverage, insurance coverage for this?

Neha:

Yeah, absolutely so. Complications certainly, as mentioned earlier, en can be. We can drink it by mouth or it can be delivered through a feeding tube. So obviously, if it's delivered through a feeding tube and I have worked with patients with that that's a whole set of complications. But the common complications that I would address, either when one is drinking EN by mouth or having it through a feeding tube, is certainly weight changes, weight loss or weight gain.

Neha:

So if one is losing a lot of weight on the formula, I like to learn a little bit more about okay, this is how many bottles that we have agreed to administer. Is this what's happening at home? If you're not able to bring in that many bottles in, then what are the barriers? What is getting in the way? We need to be able to troubleshoot what that is. Are there GI symptoms that are leading to that weight loss? Nausea, vomiting, gas, bloating, changes in bowel movements? That's already in place on some level with IBD and during active disease. So if there are GI symptoms with the regimen, then learning a little bit more about how much they can tolerate at a time, maybe I need to concentrate it. Maybe someone you know, maybe the formula has fiber in there which you know, that's a whole new topic itself fiber and IBD. But sometimes when one is barely eating anything or have a very restrictive diet, their diet automatically becomes low in fiber. Then all of a sudden they're drinking these shakes that have a lot of different types of fiber in there all at once and then, yeah, you're going to. One can get a lot of gas and bloating because of just bringing in that fiber. Maybe it would help to take out some of the fiber initially or reduce, you know, some of the shakes to half fiber, half not, to help with some of those symptoms. Maybe the weight loss is related to I just can't do this all day when I'm so busy with this X project that I have to get done so maybe it's incompatible with lifestyle and travel and all that. So how do we again learn a little bit more about what's going on in my patient's environment to help address the weight loss?

Neha:

And then some of the strategies there is that you know. Maybe we need to up the volume. Maybe we need to curb feeding and lessen the feedings by concentrating it. Maybe we need to change it to formula. You know, low fiber to less fiber. I have definitely you mentioned insurance issues. That has definitely also led to some nutritional complications, because patients will call me and say I haven't gotten my delivery. What's going on? I'm down to like five bottles. I'm like, oh okay, so let's take a look, let's call the home EN delivery companies that are delivering your formula. Let's learn a little bit more about why is that being holed up, if insurance is covering that and they're getting delivery? Or perhaps maybe the store's out of stock if one's paying out of pocket. So how do we get into other resources to improve access to that? So there's a lot of different reasons and that way it's important for me as a dietitian to assess all the reasons that could be there and then we go from there to troubleshoot.

Alicia:

I guess I'm wondering too about, like you know, because just drinking something, the same thing for 12 weeks, I mean, and also there's some limited flavors of these things. So like how do you help people cope with just kind of the boredom that may come with this?

Neha:

The repetition right. So definitely having maximizing the variety of flavors available for that particular product, or different products can be brought in, doesn't have to be the same product six times a day. It could be different products from different brands. Frozen hot, cold is also you know, other options to have it in different textures. I've seen individuals do like as is in the morning because it's something that's quick and easy to do. They'll have some in the freezer as popsicles and they'll have it as a snack, or perhaps they'll heat up the chocolate flavor of the particular product and have it as like.

Neha:

I guess I don't want to call it hot chocolate, it's not hot chocolate, but or maybe you can call it hot chocolate. So, different temperatures, different ways. That's one way to add variety as much as we can. As a part of this, I would have to say, from just learning from the experiences from my patients, the first week or two has been the hardest as they learn to transition from eating to this and then eventually they've been able to ease into a routine that has become more, I guess, as they report, a little bit more routine for them and normal for them, but it's that transition period that has been difficult for most.

Alicia:

Got it. That's helpful and I think certainly kind of the idea of blending one of these with some ice and making it into kind of almost like a milkshake sounds kind of yummy. But I am curious. We've talked a lot about EEN, which is exclusive enteral nutrition. What about? You know? Robin mentioned she's having a Kate Farms, just because she doesn't feel very well, like what about sort of the supplementation enteral nutrition as supplementation?

Neha:

Absolutely so. There is a term, what we call partial enteral nutrition, or just simply bringing an EEN to supplement the diet when you don't feel well. So EEN we already talked about induction therapy. Een and it's tied into PEN is also used as a bridge to elective surgery for adults in Crohn's disease who have strictures and fistulas, and EEN is also used as prehabilitation nutrition to reduce malnutrition prior to surgery, and we can circle back to that a little bit on a later time. But how that's tied in is that partial enteral nutrition can also be used for many of those aspects to prevent malnutrition occurring.

Neha:

I've seen others say they're not feeling well and they're like, okay, I'm just not going to eat where.

Neha:

I think bringing in a shake like that, or even a homemade version of it of some sort, is a way to bring in liquid calories and protein to offset and give you the nutrients that you need for energy, reduce the risk of any type of macro deficiencies or micro deficiencies as well, and that can be easily brought in with partial internal nutrition.

Neha:

What that would entail instead of EEN being used as pretty much all of your nutritional needs 100%, it could be around 50% of your needs or 25% of your needs, which is about a bottle or two a day, which can be used as like a midway between meals, or some people have used it as a meal replacement if they just don't feel well enough to eat, and that's a common strategy that I will use. I'm like, okay, you don't feel well enough to eat, but skipping a meal may not be the solution, because all that can do, potentially, is lead to weight loss, low energy, possible dehydration, loss of muscle mass. So how do we even bring in some calories and protein that's easy for you to consume? So that way we can still help you get the nourishment that you need.

Robin:

I started drinking shakes after my J-pouch surgery because in between and then after my J-pouch surgery, because I was recovery, has been a long road for me. And I've continued to drink shakes because I know I need more protein and this is an easy way for me to get it. So I kind of do partial internal nutrition, because I will have at least one or two shakes today in place of meals, but what I do is I use them as the liquid for my smoothie.

Robin:

So I will throw in a vanilla internal nutrition shake 1.0 and I will add some nonfat Greek yogurt and then I will add a nonfat Greek yogurt and then I will add a whole bunch of fruit and maybe some frozen broccoli or some frozen spinach or some frozen avocado. I know that broccoli and avocado and spinach and avocado are not the same thing. So I try to like pack as much stuff into an actual smoothie, using my internal nutrition shake as my liquid base, because I need more protein. I know I'm not able to eat enough protein and having the J pouch going to the bathroom, you know, I mean, let's be honest, on a eight times a day six to eight times a day, sometimes more you know that your body's not absorbing everything that you're putting in there. So, yeah, I do like at least one shake a day, sometimes two and a smoothie.

Neha:

I think that's an excellent way to use the shakes is that one can blend it with other flavors fruit, vegetables, yogurt I've seen people put peanut butter, cauliflower, rice, pumpkin I know pumpkin season's coming up the yams, sweet potatoes, anything to blend the shake as a homemade liquid shake that can bring in extra calories and protein. So EEN and PEN, a lot of the studies have just used the shakes, as is right. You open the bottle, you drink it and that's how a lot of the studies have been coming up and about. But what I hope as future studies and future directions includes whole food shakes and what's that impact on the gut as well. I know there's some studies out there very interested in exploring that, but that could be.

Neha:

The next step is, instead of these ready-to-go shakes, that people have different sentiments about their taste. But how do we bring in these shakes and add different flavors and then also study the impact on that on our gut to induce remission or use it as a bridge to surgery or even complications that can arise from just drinking EEN or PEN alone diarrhea, constipation, other gas, bloating, other nutritional consequences that can occur if we can add, like maybe a banana into the shake for soluble fiber to help reduce the risk of diarrhea versus me just trying to adjust the volume of this EEN. So a lot more to come. The volume of this EEN, so a lot more to come. A lot of areas to look into.

Alicia:

I'm curious how you help people transition. So it's time for people to go back to trying to eat food, but we all know this is a very fraught time. A lot of folks with IBD, food has hurt them and so this is a bit challenging. Now they haven't been eating. How do you help people transition off of that? When do you make that determination?

Neha:

So one aspect is it depends on the type of therapy that they're on. So one aspect is that, again, if they're on EEN and say they're, they've completed at least four weeks of being on EEN, or even two weeks. Some, some of the studies have supported two weeks learning a little bit more about where they're at with their inflammatory biomarkers. Are we using this in induction therapy? So where does the IBD stand after this treatment and learning a little bit more? Do we need to continue or can we start adding back foods if we're starting to see a reduction in their inflammation? So if it's EEN, then one aspect is that when we start to add back foods, some aspects of EEN will continue, and I usually like to bring back one meal as a start and we work out options for that one meal that's not going to necessarily cause a lot of gas or bloating. So I'm not going to recommend that big bowl of chili, to be honest, as their first meal. Or perhaps what are some protein options that we can consider that are tolerable? What are some fruit and veggie options that we can consider that can help reduce the risk of any loose stools or gas or bloating and GI discomfort? This gut hasn't had food for about four weeks or even more. So I like to gradually go slow with that only because the last thing I want happening is that, sure, let's just stop everything altogether. Let's add the three meals back, a snack back, and then all of a sudden my patients are like oh my God, I don't feel good, I'm flaring, I cannot do this. And then now there's some fear associated with reintroducing food. So I tend to continue with EEM, but maybe reduce it by a bottle or two and then bring in one meal, and with EEN, but maybe reduce it by a bottle or two and then bring in one meal, and that goes on for another week, and then bring back a second meal and continue to go down on the bottles, and then we work out, you know, food options.

Neha:

Now there's always the question of what diet to transition to after EEN. I generally like to work with either what like Mediterranean diet, way of eating, plant-based. There's different types of fibers in the diet and different types of fibers have a different impact on the gut. So again, I'm going to probably choose a class of fibers that, again, they're not super gassy or may cause a lot of bloating or may reduce the risk of urgency or anything like that. That would be my preference.

Neha:

There's also some studies to show that some people have done EEN and then they have gone straight to what we call partial again, partial enteral nutrition, pen, but they have combined it with the Crohn's disease exclusion diet. There's some studies to show that one can do EEN and then they go straight into the CDED, but PEN as another way for as an induction therapy. The studies are limited but there are some studies there. And then they continue on the Crohn's disease exclusion diet, the three-phase whole food diet. Following each phase of what foods are recommended to eat more, of which foods are recommended to eat less of the mandatory foods as a part of the Crohn's disease exclusion diet.

Neha:

Two potatoes a day, boiled, cooled, reheated. Two bananas a day, one apple a day. So again, it really all depends on how we transition the patient. For the most part I tend to transition my patients over to the Mediterranean diet way of eating to optimize variety into the diet. But then there are some instances where I have used the CDED as a bridge to the Mediterranean way of eating, if we're aiming to explore that as well.

Alicia:

Why do you have to cool the potatoes down and then reheat them?

Neha:

Oh, great question. I love food science and so there are different types of resistant starches in the diet. So when we boil and cool down a starch this could be a potato, sweet potato, yam, butternut squash, rice, quinoa, oatmeal that cooling process form.