Enteral and Parenteral nutrition with Neha Shah, RD!

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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! ;)

Links: 

• South Asian IBD Alliance- Neha is on the board and super active with SAIA! 
• Nutrition and IBD info- UCSF health 
• Info on Exclusive Enteral Nutrition- Nutritional Therapy for IBD
• Info on Partial Enteral Nutrition- Nutritional Therapy for IBD
• Great overview of therapeutic diets for IBD! - Nutritional Therapy for IBD
• Diet and Nutrition Info- Crohn's & Colitis Foundation 
• Diet and Nutriti

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Bowel Moments, the podcastsharing real talk about the
realities of IBD Serve on therocks.
This week we were joined byregistered dietitian Neha Shah.
This is actually Neha's secondspot on the Bowel Moments
podcast, so go back to episode42, where you can hear her talk

(00:21):
to friend of the show andregistered dietitian Stacey
Collins.
Neha is a registered dietitianwho's in private practice but
who's also embedded in the IBDCenter at University of
California, San Francisco.
We talked to her all aboutenteral nutrition and parenteral
nutrition and why someone maychoose this as part of their
treatment journey and what theyshould expect.
We really enjoyed ourconversation with Neha and

(00:42):
learned so much about enteralnutrition and parenteral
nutrition, and we know you willtoo.
Cheers.

Robin (00:51):
Hi everybody, this is Robin.

Alicia (00:54):
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 toyou.
Just for note for everybodyelse, Neha has spent another
episode with us before, and sothat's episode 42.
So we're going to invite you togo back and listen to that one,
because we dig in a little bitmore about her background and

(01:14):
lots and lots and lots of reallygood stuff.
But we brought you backspecifically because we ran into
you at a conference and gotchatting with you I think, Robin
, specifically and wanted tofocus on a couple of things.
But our first veryunprofessional question for you
is what are you drinking?

Neha (01:29):
So I'm drinking port.
I just got back from Portugaland I never ran into so many
varieties of port and I had tobring some back, so I am
enjoying my little glass of portright now.
I love that.
I love a port.

Alicia (01:42):
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 shouldhave this, and then you forget
about it again.
I actually have a bottle ofport down in my cellar, I
guarantee and I now that yousaid that I'm like, oh yeah, I
bought that.
That's how often I think aboutis because Robin got chatting

(02:05):
with you at gosh in January wasit?

Robin (02:07):
Excuse me.
Excuse me, Alicia Barron.
What are you drinking?

Alicia (02:11):
Oh my gosh, Robin.
What was I thinking?
Okay, robin, what are youdrinking?

Robin (02:16):
Our whole shtick, alicia, this was unintentional.
I love it.
We'll find out.
I'm actually drinking KateFarms, which is Entral Nutrition
.
I have been under the weatherfor like two weeks now, and so
I've been trying to get my whatI lovingly refer to them as
electric lights and also someextra protein and something
that's a little bit easy on myGI tract.

(02:36):
So I have been drinking.
I'm drinking chocolate tonight.
Kate Farms chocolate, entralNutrition.
Let us have it, alicia.
Let us have it, alicia.
Let us have it.
Full disclosure everyone.

Alicia (02:46):
What are you drinking?
I mentioned to them I'm colonprepping at the moment, so I'm
very sad and hungry and have aheadache right now, but I'm
drinking a raspberry, nectarinewater, lose, which is quite good
, and also a little bit oflemonades, because I just need
to drink, apparently, tons andtons of liquids.
I'm about to float away and I'mready for this to be done, so I

(03:10):
have a lot of sympathy, empathy, for all of our IBD friends
that have to do this way morefrequently than I do, but I'm
going to feel sad for myself forthe moment.
So I'm going to feel a bit sorry, but you know what?
The Waterloo is delicious, so Iwill stop being sad about that,
because that one is actuallyquite good.
Now, neha, the reason webrought you back is because
Robin was chatting with you wayback in January at the Crohn's
and Colitis Congress and we gottalking about, like, how kind of
misunderstood it is for enteralnutrition and parental

(03:34):
nutrition.
So we wanted to bring you backso you could give us the rundown
of this.
So start us out by kind ofexplaining what is enteral
nutrition, what is parenteralnutrition, parenteral nutrition
boy, that's hard to saydifferences, similarities and
then we'll go from there.

Neha (03:54):
Absolutely.
You know.
This topic is actually also verytimely as it is Malnutrition
Awareness Week this week,september 16th to 20th and the
use of enteral nutrition I'mgoing to abbreviate it as EN and
the use of parental nutritionI'm going to abbreviate it as PN
are both used not just a partof a treatment for IBD, but it's
also used to help correctmalnutrition that arises as a
consequence from IBD.
So let's start with EN.

(04:14):
So EN consists of either whatwe call oral nutrition
supplements I like to use theword oral caloric protein shakes
as well they're either taken bymouth or can also be
administered as formulas througha feeding tube.
And, in contrast, pn bypassesthe gastrointestinal tract

(04:35):
altogether and it's really aspecialized formula of
carbohydrates, proteins, fats,vitamins and minerals in water,
of carbohydrates, proteins, fats, vitamins and minerals and
water.
And that is all formulatedespecially to be delivered
through an IV, to delivernutrients that one cannot take
by mouth or through a feedingtube.
And, of course, en is alsocomposed of carbohydrates,

(04:57):
proteins and fats, and vitaminsand minerals that our
gastrointestinal tract candigest and absorb as well.

Alicia (05:03):
Got it Okay.
And I think we did have a gueston who had short gut syndrome
and so she used parenteralnutrition, but she also able to.
She had started to be able toeat as well and it sort of had
gained some of the sort offunctionality back and was able
to take in more calories thatway.
So that was very exciting forher.
But she is a long time itsounds like parenteral nutrition

(05:24):
user.
So got it Okay.
That's super helpful.
I'm going to ask you somequestions, but let's focus
specifically on EN right now.
Enteral nutrition, so that isby mouth enteral nutrition, or
through feeding too, but stillinto your gut.
So basically by gut.
Maybe is the nice way to saythat.

Neha (05:40):
Sure, let's do it.

Alicia (05:41):
It's a question mark on that one.
Okay, good, okay, so youmentioned malnutrition, which
unfortunately is common for ourcommunity and not terribly
recognized, I think, and that'sa whole conversation for a
different day.
But why would one berecommended to use this?
If you're a person living withIBD, you go to your doctor's
office or you meet with yourdietician.
What happens now?

Neha (06:02):
Yes.
So several reasons why EN canbe brought in.
One aspect is that EN asexclusive enteral nutrition, een
okay, another abbreviation.
In IBD it involves the use ofagain, the oral nutrition
supplement by mouth or it can bedelivered through a feeding
tube to meet close to 100% ofnutritional needs.

(06:25):
And a lot of the aspects of EENare gluten-free, lactose-free,
many of them are low in fiber.
They have different nutrientcompositions.
How EEN is used in IBD is thatin pediatrics it's used most
often as the first lineinduction therapy when I say the
word induction therapy, meaningto induce remission of the IBD.

(06:46):
And what they have found inpediatrics is that there's no
difference in efficacy formucosal healing between EEN and
the use of corticosteroids.
Now, in adults the benefit hasalso been seen there.
However, it's not often used asa therapy due to perceived less
compliance, less adherence tothe therapy.
Now, the use of EEN withmucosal healing has been

(07:10):
reported in 79% of children andadult patients after being on
EEN for an average of 123 days.
This is about 12 weeks of EENand 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 wasfound between the different

(07:33):
types of formulas that areavailable out there.
I certainly have additionalinformation on what are the
proposed mechanisms and also whyEEN can be brought in, but I'd
love to hear any thoughts orquestions.

Alicia (07:41):
Okay, so that is interesting and I think it's
really interesting that it isshowing remission at that high
of a rate.
That's really great.
But I know it's reallyinteresting that it is showing
remission at that high of a rate.
That's really great.
But I know one of thecomplications, one of the sort
of issues of this is a lot oflike you said.
So there's this sort ofunderstanding or idea that
people can't take it, they can'thang for that long and so and
it would be tough, especially ifyou're a kid, you know to just

(08:02):
get your nutrition through oralsupplements.
If you're an adult, forinstance, at your doctor's
office, when would this besomething that your doctor would
recommend to you?
Is it like that you've used alot of steroids and maybe it's
kind of like gosh, you've hadprobably enough steroids, let's
try something different?
Is there kind of a rationalefor when either you would
consult with somebody and say Ithink you should try this, or
your doctor would say let's dothis instead of steroids?

Neha (08:24):
Absolutely so.
The use of EEN and I will labelas the first option there it's
induction therapy is usuallybrought in.
The most data is robust ininducing remission in Crohn's
disease.
So if one has Crohn's disease,one is in an active disease from
that reoccurrent flares, fromthe Crohn's disease.

(08:44):
Those are some of theindications that EEN can be
potentially brought in.
I would have to say, from myconversations with my adult
patients, some of them havenever heard of the therapy and
then some of them have heard ofit and naturally so, completely
valid.
Like you want me to give upfood and most fluids for four
weeks.
I don't think I can do that andthat's a complete, valid

(09:06):
response.
My role as the dietician I wantto be transparent with all the
treatment options out there forCrohn's and ulcerative colitis.
So I will bring it forward as apossible option.
But and it's really importantto have that discussion on what
it is what does the evidenceshow?
What are the pros and cons?
How would this be implemented?
How would this be monitored?
How do we, you know, initiatethat process to bring back foods

(09:30):
?
How do we completely stop EENbefore anyone decides whether
this is a process for them?
And I would have to say some ofthe adult patients that have
come my way, they were so gladthat I brought it their way.
They're like this has neverbeen brought to my attention.
And then some of them were likeI already heard of this before,
like I mentioned earlier, andno, we're not interested, and
that's again completelyunderstandable.

(09:50):
But again, it's important to bevery transparent of all the
treatment options out there.

Robin (09:54):
So my question is, now that they've heard of this and
they're like, okay, I'm going togive it a shot.
There are so many options, likehow do you pick which one's the
right one?
I mean, I picked because I hada registered dietician walk me
through the process, but, like,not everybody's going to have
access to that.

Neha (10:13):
So 100%.
So this is where, initially, itreally is important that these
patients any patient beingconsidered for EEN or has
questions about EEN getsreferred to meet with a
dietician, who will you know,and dietitian, will help provide
a full nutrition assessment aswell as to go over, you know,
the general compositions of EEN,the types of formulas out there

(10:34):
.
How can we come up with aregimen 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, inthe evenings I'm so busy with my
kids I don't have time to keepon going back and forth and
drinking shakes.
So how do we calculate aregimen that would be workable?
Definitely going through thelist of ingredients in each
formula, because some peoplewill say well, I can't have

(10:57):
lactose, which all formulas arenaturally pretty much
lactose-free.
I can't have gluten Okay, allformulas are naturally
gluten-free.
You know I'm a diabetic.
Okay, all formulas arenaturally gluten-free.
You know I'm a diabetic.
Are there formulas out therethat have less carbohydrates
than others?
So it's really important towork with a dietician that can
help match the right type of ENthat can help meet some of those
needs as much as we can If apatient has high calorie needs.

(11:21):
And then some of these formulas.
There are different caloricdensities.
A lot of these EN formulas arelabeled 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 2000calories, the last thing I want
them to do is to drink 10bottles of one particular type

(11:41):
of EN just to get to that number.
Maybe it's better for me toconcentrate the formula so
there's more calories per bottleto help meet that.
So that is another option there.
And then certainly to reallyanswer other questions, you know
how do I be on this regimenwhen others are eating around me
?
How do I travel with thisregimen?
I want to go on the airplane.

(12:04):
Do I need a letter to bring allof this on the plane?
So all that is factored in intothe evaluation to help really
determine their appropriate EENregimen and whether it's
appropriate altogether.
You know this is made as ashared decision-making process
with the patient.
It is so important to hear theinput of my patients on whether
this is possible or not.
And then if the patient wantsto proceed with EEN, then I

(12:27):
usually like to recommend astart date, like it's important
that we set up the kitchen.
We find the formulas you knowthat taste well, we find the
regimen that works, all that isin place, and then we start.
So that way, a lot of time hasbeen put into the planning
process in order to make thissuccessful.

Robin (12:44):
I'm glad you mentioned taste, because they all taste
completely different.
I would recommend doing a tastetest.
You should definitely do ataste test before you decide to
purchase a whole bunch of these.

Neha (12:56):
Yeah, absolutely Absolutely.
Taste testing is important.
Different ways to hold hotfrozen, there's different
flavors.
Absolutely, that's an importantpiece.
So, again, no decision is madeat the time of the assessment.
A lot of it is just reallygoing into what it may entail

(13:17):
and then, like I said, some ofthem have been really content
with moving forward with itbecause they're like well, we
tried everything else with ourmedical treatment.
This has not been brought to myattention.
I like to give it a go, andunder supervision at all means.
I want to make sure my patientsare staying nourished and not
losing weight, tolerating theregimens well, and I want to be
able to troubleshoot the issuesalong the way as well.

Alicia (13:39):
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 averageof how much people would be
drinking?
And then what is that cadence?
Because obviously you're notsaying about breakfast, you sit
down and chug three of thesethings because that would kind
of make you feel gross.
And so how do you calculatethat out for people?

Neha (13:56):
It's so individualized.
I like to learn a little bitmore about the lifestyle.
If I hear my patient tell methat, you know, I'm always
running late in the morning andI don't feel good when I wake up
.
I feel like it takes me a while.
The last thing I'm going tohave them do is drink two
bottles.
You know, at a time I've maybehad them drink half a bottle or
a bottle.

(14:16):
At that point I like to learn alittle bit more about their day
.
If they have a role at work thatinvolves them to be quite
active, climbing roofs and, youknow, not on their feet all the
day, then again, how do weschedule in these shakes that
would work for them and theirbreaks?
What part of the day do theyfeel best at?
You know, can we drink a littlebit more in that part of the

(14:38):
day versus the other parts ofthe day to get that in?
Oh, it's really difficult foryou to finish all six bottles.
Maybe I need to concentrate itagain and bring it down to four
bottles.
So I would have to say it's soindividualized that I think
learning a little bit more aboutthe lifestyle will help me
understand how we can plan out aregimen, or sometimes we need a
weekday regimen and we need aweekend regimen when one is home

(15:01):
more often.
I have written letters for someof my patients if they can be
allowed to work remotely fromhome while they do EEN, so that
way they can focus theirattention on these shakes
without being in front of othersLike meetings may involve lunch
.
Food is so central to a lot ofmeetings and social settings and

(15:22):
all that.
So it was their way to not bein those situations when they're
doing this therapy.
So what do you need for me tosupport you during this time?
So that's how it helps me alsodetermine the regimen as well.

Alicia (15:39):
That's really helpful, I mean.
I think that makes sense too.
It's the way we want ourmedical care to go right, so
like be optimized to that person.
So let's talk a little bitabout troubleshooting, and one
of the questions I had for youis kind of like you know, when
somebody is doing especiallyexclusive enteral nutrition, are
there complications that canpop up Also?
Is there, I mean, and this isthe big, big question.
So maybe we start withcomplications and then the
second part of that question isreally also like what about
coverage, insurance coverage forthis?

Neha (16:00):
Yeah, absolutely so.
Complications certainly, asmentioned earlier, en can be.
We can drink it by mouth or itcan be delivered through a
feeding tube.
So obviously, if it's deliveredthrough a feeding tube and I
have worked with patients withthat that's a whole set of
complications.
But the common complicationsthat I would address, either

(16:22):
when one is drinking EN by mouthor having it through a feeding
tube, is certainly weightchanges, weight loss or weight
gain.
So if one is losing a lot ofweight on the formula, I like to
learn a little bit more aboutokay, this is how many bottles
that we have agreed toadminister.
Is this what's happening athome?
If you're not able to bring inthat many bottles in, then what

(16:42):
are the barriers?
What is getting in the way?
We need to be able totroubleshoot what that is.
Are there GI symptoms that areleading to that weight loss?
Nausea, vomiting, gas, bloating, changes in bowel movements?
That's already in place on somelevel with IBD and during
active disease.
So if there are GI symptomswith the regimen, then learning
a little bit more about how muchthey can tolerate at a time,

(17:04):
maybe I need to concentrate it.
Maybe someone you know, maybethe formula has fiber in there
which you know, that's a wholenew topic itself fiber and IBD.
But sometimes when one isbarely eating anything or have a
very restrictive diet, theirdiet automatically becomes low
in fiber.
Then all of a sudden they'redrinking these shakes that have
a lot of different types offiber in there all at once and

(17:26):
then, yeah, you're going to.
One can get a lot of gas andbloating because of just
bringing in that fiber.
Maybe it would help to take outsome of the fiber initially or
reduce, you know, some of theshakes to half fiber, half not,
to help with some of thosesymptoms.
Maybe the weight loss isrelated to I just can't do this
all day when I'm so busy withthis X project that I have to

(17:47):
get done so maybe it'sincompatible with lifestyle and
travel and all that.
So how do we again learn alittle bit more about what's
going on in my patient'senvironment to help address the
weight loss?
And then some of the strategiesthere is that you know.
Maybe we need to up the volume.
Maybe we need to curb feedingand lessen the feedings by

(18:07):
concentrating it.
Maybe we need to change it toformula.
You know, low fiber to lessfiber.
I have definitely you mentionedinsurance issues.
That has definitely also led tosome nutritional complications,
because patients will call meand 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'stake a look, let's call the home

(18:32):
EN delivery companies that aredelivering your formula.
Let's learn a little bit moreabout why is that being holed up
, if insurance is covering thatand they're getting delivery?
Or perhaps maybe the store'sout of stock if one's paying out
of pocket.
So how do we get into otherresources to improve access to
that?
So there's a lot of differentreasons and that way it's

(18:52):
important for me as a dietitianto assess all the reasons that
could be there and then we gofrom there to troubleshoot.

Alicia (18:59):
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 somelimited flavors of these things.
So like how do you help peoplecope with just kind of the
boredom that may come with this?

Neha (19:11):
The repetition right.
So definitely having maximizingthe variety of flavors
available for that particularproduct, or different products
can be brought in, doesn't haveto be the same product six times
a day.
It could be different productsfrom different brands.
Frozen hot, cold is also youknow, other options to have it

(19:32):
in different textures.
I've seen individuals do likeas is in the morning because
it's something that's quick andeasy to do.
They'll have some in thefreezer as popsicles and they'll
have it as a snack, or perhapsthey'll heat up the chocolate
flavor of the particular productand have it as like.
I guess I don't want to call ithot chocolate, it's not hot
chocolate, but or maybe you cancall it hot chocolate.

(19:55):
So, different temperatures,different ways.
That's one way to add varietyas much as we can.
As a part of this, I would haveto say, from just learning from
the experiences from mypatients, the first week or two
has been the hardest as theylearn to transition from eating
to this and then eventuallythey've been able to ease into a

(20:16):
routine that has become more, Iguess, as they report, a little
bit more routine for them andnormal for them, but it's that
transition period that has beendifficult for most.

Alicia (20:26):
Got it.
That's helpful and I thinkcertainly kind of the idea of
blending one of these with someice and making it into kind of
almost like a milkshake soundskind 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 aKate Farms, just because she
doesn't feel very well, likewhat about sort of the
supplementation enteralnutrition as supplementation?

Neha (20:48):
Absolutely so.
There is a term, what we callpartial enteral nutrition, or
just simply bringing an EEN tosupplement the diet when you
don't feel well.
So EEN we already talked aboutinduction therapy.
Een and it's tied into PEN isalso used as a bridge to
elective surgery for adults inCrohn's disease who have
strictures and fistulas, and EENis also used as prehabilitation

(21:11):
nutrition to reducemalnutrition prior to surgery,
and we can circle back to that alittle bit on a later time.
But how that's tied in is thatpartial enteral nutrition can
also be used for many of thoseaspects to prevent malnutrition
occurring.
I've seen others say they're notfeeling well and they're like,
okay, I'm just not going to eatwhere.

(21:31):
I think bringing in a shake likethat, or even a homemade
version of it of some sort, is away to bring in liquid calories
and protein to offset and giveyou the nutrients that you need
for energy, reduce the risk ofany type of macro deficiencies
or micro deficiencies as well,and that can be easily brought
in with partial internalnutrition.

(21:52):
What that would entail insteadof EEN being used as pretty much
all of your nutritional needs100%, 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 likea midway between meals, or some
people have used it as a mealreplacement if they just don't
feel well enough to eat, andthat's a common strategy that I

(22:13):
will use.
I'm like, okay, you don't feelwell enough to eat, but skipping
a meal may not be the solution,because all that can do,
potentially, is lead to weightloss, low energy, possible
dehydration, loss of muscle mass.
So how do we even bring in somecalories and protein that's
easy for you to consume?
So that way we can still helpyou get the nourishment that you

(22:37):
need.

Robin (22:38):
I started drinking shakes after my J-pouch surgery
because in between and thenafter my J-pouch surgery,
because I was recovery, has beena long road for me.
And I've continued to drinkshakes because I know I need
more protein and this is an easyway for me to get it.
So I kind of do partialinternal nutrition, because I

(22:59):
will have at least one or twoshakes today in place of meals,
but what I do is I use them asthe liquid for my smoothie.
So I will throw in a vanillainternal nutrition shake 1.0 and
I will add some nonfat Greekyogurt and then I will add a
nonfat Greek yogurt and then Iwill add a whole bunch of fruit
and maybe some frozen broccolior some frozen spinach or some
frozen avocado.
I know that broccoli andavocado and spinach and avocado

(23:21):
are not the same thing.
So I try to like pack as muchstuff into an actual smoothie,
using my internal nutritionshake as my liquid base, because
I need more protein.
I know I'm not able to eatenough protein and having the J
pouch going to the bathroom, youknow, I mean, let's be honest,
on a eight times a day six toeight times a day, sometimes
more you know that your body'snot absorbing everything that

(23:44):
you're putting in there.
So, yeah, I do like at leastone shake a day, sometimes two
and a smoothie.

Neha (23:50):
I think that's an excellent way to use the shakes
is that one can blend it withother flavors fruit, vegetables,
yogurt I've seen people putpeanut butter, cauliflower, rice
, pumpkin I know pumpkinseason's coming up the yams,
sweet potatoes, anything toblend the shake as a homemade
liquid shake that can bring inextra calories and protein.

(24:11):
So EEN and PEN, a lot of thestudies have just used the
shakes, as is right.
You open the bottle, you drinkit and that's how a lot of the
studies have been coming up andabout.
But what I hope as futurestudies and future directions
includes whole food shakes andwhat's that impact on the gut as
well.
I know there's some studies outthere very interested in

(24:32):
exploring that, but that couldbe.
The next step is, instead ofthese ready-to-go shakes, that
people have different sentimentsabout their taste.
But how do we bring in theseshakes and add different flavors
and then also study the impacton that on our gut to induce
remission or use it as a bridgeto surgery or even complications
that can arise from justdrinking EEN or PEN alone

(24:55):
diarrhea, constipation, othergas, bloating, other nutritional
consequences that can occur ifwe can add, like maybe a banana
into the shake for soluble fiberto help reduce the risk of
diarrhea versus me just tryingto adjust the volume of this EEN
.
So a lot more to come.
The volume of this EEN, so alot more to come.
A lot of areas to look into.

Alicia (25:21):
I'm curious how you help people transition.
So it's time for people to goback to trying to eat food, but
we all know this is a veryfraught time.
A lot of folks with IBD, foodhas hurt them and so this is a
bit challenging.
Now they haven't been eating.
How do you help peopletransition off of that?
When do you make thatdetermination?

Neha (25:35):
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 atleast four weeks of being on EEN
, or even two weeks.
Some, some of the studies havesupported two weeks learning a
little bit more about wherethey're at with their

(25:55):
inflammatory biomarkers.
Are we using this in inductiontherapy?
So where does the IBD standafter this treatment and
learning a little bit more?
Do we need to continue or canwe start adding back foods if
we're starting to see areduction in their inflammation?
So if it's EEN, then one aspectis that when we start to add
back foods, some aspects of EENwill continue, and I usually

(26:16):
like to bring back one meal as astart and we work out options
for that one meal that's notgoing to necessarily cause a lot
of gas or bloating.
So I'm not going to recommendthat big bowl of chili, to be
honest, as their first meal.
Or perhaps what are someprotein options that we can
consider that are tolerable?
What are some fruit and veggieoptions that we can consider

(26:39):
that can help reduce the risk ofany loose stools or gas or
bloating and GI discomfort?
This gut hasn't had food forabout four weeks or even more.
So I like to gradually go slowwith 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 ohmy God, I don't feel good, I'm

(27:01):
flaring, I cannot do this.
And then now there's some fearassociated with reintroducing
food.
So I tend to continue with EEM,but maybe reduce it by a bottle
or two and then bring in onemeal, and with EEN, but maybe
reduce it by a bottle or two andthen bring in one meal, and
that goes on for another week,and then bring back a second
meal and continue to go down onthe bottles, and then we work
out, you know, food options.
Now there's always the questionof what diet to transition to

(27:25):
after EEN.
I generally like to work witheither what like Mediterranean
diet, way of eating, plant-based.
There's different types offibers in the diet and different
types of fibers have adifferent impact on the gut.
So again, I'm going to probablychoose a class of fibers that,
again, they're not super gassyor may cause a lot of bloating

(27:46):
or may reduce the risk ofurgency or anything like that.
That would be my preference.
There's also some studies toshow that some people have done
EEN and then they have gonestraight to what we call partial
again, partial enteralnutrition, pen, but they have
combined it with the Crohn'sdisease exclusion diet.
There's some studies to showthat one can do EEN and then

(28:08):
they go straight into the CDED,but PEN as another way for as an
induction therapy.
The studies are limited butthere are some studies there.
And then they continue on theCrohn's disease exclusion diet,
the three-phase whole food diet.
Following each phase of whatfoods are recommended to eat
more, of which foods arerecommended to eat less of the
mandatory foods as a part of theCrohn's disease exclusion diet.

(28:30):
Two potatoes a day, boiled,cooled, reheated.
Two bananas a day, one apple aday.
So again, it really all dependson how we transition the
patient.
For the most part I tend totransition my patients over to
the Mediterranean diet way ofeating to optimize variety into
the diet.
But then there are someinstances where I have used the
CDED as a bridge to theMediterranean way of eating, if

(28:53):
we're aiming to explore that aswell.

Alicia (28:55):
Why do you have to cool the potatoes down and then
reheat them?

Neha (28:58):
Oh, great question.
I love food science and sothere are different types of
resistant starches in the diet.
So when we boil and cool down astarch this could be a potato,
sweet potato, yam, butternutsquash, rice, quinoa, oatmeal
that cooling process form.