Partial Enteral Nutrition (PEN) - Dietary Options in IBD

Partial Enteral Nutrition

Partial Enteral Nutrition uses a combination of liquid nutrition and solid foods.

Principles of Partial Enteral Nutrition

Partial Enteral Nutrition (PEN) involves consuming 35-50% of daily calories from over-the-counter meal replacement formula while allowing unrestricted food for the remaining intake.¹ Many healthcare providers encourage closer to 50% of daily requirements from liquid nutrition with the remaining 50% of intake from healthy whole foods.

PEN in combination with medications is a promising nutritional option to help maintain remission in Crohn’s disease (CD), improve response to biologics, or optimize nutrition before and after surgery.

PEN is well-tolerated and has a few mild adverse events.²^,³^,⁴^,⁵^,⁶^,⁷

PEN Combined with Biologics to Induce Remission of Crohn's Disease

PEN combined with biologics can enhance efficacy and achieve improved disease induction outcomes for active CD in:
‍

Patients with complicated (fistulizing) disease ⁸‍
Patients who are intolerant to biologics⁹‍
Patients who do not gain adequate control with increasing doses of biologics¹⁰^,¹¹^‍‍^‍

About 30%-75% of patients do not respond to biologic therapy alone, while others lose response over time.¹²^,¹³^,¹⁴

In adult patients who underwent surgery and did not respond to multiple biologics, PEN in combination with biologics administered at gradually increasing doses (dose escalation), as compared to biologics alone, can lead to:¹⁰

Clinical remission
Evidence of healing of all layers of the bowel

The authors highlight that PEN could contribute to delaying the need for surgery

There is also evidence that combining biologics with PEN could be as effective as combining them with Exclusive Enteral Nutrition (EEN) for inducing remission of CD. As compared to combining adalimumab with EEN, adult patients with CD that combined PEN with adalimumab showed a similar decrease in:¹⁵

Fecal calprotectin
C-reactive protein after 12 weeks of treatment

However, there was no change in fecal calprotectin in patients receiving adalimumab alone.¹⁵

In patients with moderate to severe CD undergoing biologic therapy, combined enteral nutrition therapy of ≥600 kcal/day increased the remission maintenance rate.¹⁶

After 1 year:¹⁶

Specialized enteral nutrition therapy with infliximab resulted in 79 of 106 (74.5%) patients remaining in clinical remission
Compared with 62 of 126 (49.2%) patients receiving infliximab monotherapy

A new clinical trial, BIOPIC (Biologics and Partial enteral nutrition in Crohn’s Disease Study), in adults with active ileocolonic Crohn’s disease is evaluating the use of PEN given as 50% of calories combined with biologics.

PEN to Maintain Remission

Cumulative studies and the latest treatment guidelines recommend PEN as a strategy to prolong CD remission in patients who are willing and able to tolerate the formula with routine monitoring by a registered dietitian.¹⁷^,¹⁸

^‍‍^‍

Children and adults with Crohn’s disease receiving medications and PEN with 35-50% of daily calories have shown:²^,³^,⁴^,⁵^,⁶^,⁷

A significantly higher rate of maintaining clinical remission
Fewer relapses than those not receiving nutritional therapy

Clinical remission rates vary between 14% (if based on fecal calprotectin) and 64% (if based on CD activity indices).¹⁹^,²⁰

The percentage of caloric requirements provided by PEN seems relevant for remission rates. One study showed that PEN providing at least 50% of daily calories is comparable to a liquid-only diet (EEN) in terms of changes in fecal metabolites and pH.²¹

PEN to Improve Nutrition Status

PEN improvement in GI symptoms and quality of life of patients with IBD is often accompanied with:

Increasing weight, similar to that observed with EEN²²
Improving body fat percentage, muscle, and body water.¹⁰^,¹¹
Improving serum proteins such as insulin-like growth factor 1 and albumin²²
Enhancing growth rate for children, which is particularly helpful in children experiencing pubertal delay.²³^,²⁴^,²⁵

PEN to Improve Surgical Outcomes

Personalized nutrition support before and after surgery in patients with IBD is associated with:²⁶

Improved disease activity
Decreased hospital length of stay
Lower 30-day readmission rates
Decreased risk of postoperative complications

Find out more about the dos and don’ts of PEN before and after surgery

References

Deas J, Shah ND, Konijeti GG, et al. Dietary therapies for adult and pediatric inflammatory bowel disease. Nutr Clin Pract. 2024;39(3):530-545. doi: 10.1002/ncp.11146.
Verma S, Kirkwood B, Brown S, Giaffer MH. Oral nutritional supplementation is effective in the maintenance of remission in Crohn's disease. Dig Liver Dis. 2000;32(9):769-774. doi:10.1016/s1590-8658(00)80353-9‍‍
Takagi S, Utsunomiya K, Kuriyama S, et al. Effectiveness of an 'half elemental diet' as maintenance therapy for Crohn's disease: A randomized-controlled trial. Aliment Pharmacol Ther. 2006;24(9):1333-1340. doi:10.1111/j.1365-2036.2006.03120.x
Wall CL, Gearry RB, Day AS. Treatment of Active Crohn's Disease with Exclusive and Partial Enteral Nutrition: A Pilot Study in Adults [published correction appears in Inflamm Intest Dis. 2018 Jul;2(4):236]. Inflamm Intest Dis. 2018;2(4):219-227. doi:10.1159/000489630
Yang H, Feng R, Li T, et al. Systematic review with meta-analysis of partial enteral nutrition for the maintenance of remission in Crohn's disease. Nutr Res. 2020;81:7-18. doi:10.1016/j.nutres.2020.06.006 ‍
Gkikas K, Gerasimidis K, Milling S, Ijaz UZ, Hansen R, Russell RK. Dietary Strategies for Maintenance of Clinical Remission in Inflammatory Bowel Diseases: Are We There Yet?. Nutrients. 2020;12(7):2018. doi:10.3390/nu12072018.
Critch J, Day AS, Otley A, et al. Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease [published correction appears in J Pediatr Gastroenterol Nutr. 2012 Apr;54(4):573]. J Pediatr Gastroenterol Nutr. 2012;54(2):298-305. doi:10.1097/MPG.0b013e318235b397.
Tanaka T, Takahama K, Kimura T, et al. Effect of concurrent elemental diet on infliximab treatment for Crohn’s disease. J Gastroenterol Hepatol. 2006; 21(7):1143-1149. doi: 10.1111/j.1440-1746.2006.04317.x.
Hirai F, Takeda T, Takada Y, et al. Efficacy of enteral nutrition in patients with Crohn’s disease on maintenance anti-TNF-alpha antibody therapy: a meta-analysis. J Gastroenterol. 2020; 55(2):133-141. doi: 10.1007/s00535-019-01634-1.
Nardone OM, Calabrese G, La Mantia A, et al. Effectiveness of partial enteral nutrition as add-on to biologics in patients with refractory and difficult-to-treat Crohn’s disease: a pilot study. Crohns Colitis 360. 2024; 6(1):otae011. doi: 10.1093/crocol/otae011.
Hisamatsu T, Kunisaki R, Nakamura S, et al. Effect of elemental diet combined with Infliximab dose escalation in patients with Crohn’s disease with loss of response to Infliximab: CERISIER trial. Intest Res. 2018; 16(3):494-498. doi: 10.5217/ir.2018.16.3.494.
Beagan BG, Rutgeerts P, Sands BE, et al. Vedolizumab as induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2013; 369(8):699-710. doi: 10.1056/NEJMoa1215734.
Patel PV, Zhang A, Bhasuran B, et al. Real-world effectiveness of Ustekinumab and vedolizumab in TNF-exposed pediatric patients with ulcerative colitis. J Pediatr Gastroenterol Nutr. 2024; 78(5):1126-1134. doi: 10.1002/jpn3.12169.
Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005; 353(23):2462-2476. doi: 10.1056/NEJMoa050516.
Zhou S, Huang Z, Hou W, et al. Prospective study of an adalimumab combined with partial enteral nutrition in the induction period of Crohn’s disease. Inflamm Res. 2024; 73(2):199-209. doi: 10.1007/s00011-023-01828-7.
Nguyen DL, Palmer LB, Nguyen ET, et al. Specialized enteral nutrition therapy in Crohn’s disease patients on maintenance infliximab therapy: a meta-analysis. Therap Adv Gastroenterol. 2015;8(4):168-175. doi: 10.1177/1756283X15578607.
van Rheenen PF, Aloi M, Assa A, et al. The medical management of paediatric Crohn’s disease: an ECCO-ESPGHAN guideline update. J Crohns Colitis. 2020;15:171-194. doi: 10.1093/ecco-jcc/jjaa161.
Gordon H, Minozzi S, Kopylov U, et al. ECCO guidelines on therapeutics in Crohn’s disease: medical treatment. J Crohns Colitis. 2024;jjae091. doi: 10.1093/ecco-jcc/jjae091.
Johnson T, Macdonald S, Hill SM, Thomas A, Murphy MS. Treatment of active Crohn’s disease in children using partial enteral nutrition with liquid formula: a randomised controlled trial. Gut. (2006) 55:356–61. 10.1136/gut.2004.062554.
Lee D, Baldassano RN, Otley AR, et al. Comparative Effectiveness of Nutritional and Biological Therapy in North American Children with Active Crohn's Disease. Inflamm Bowel Dis. 2015;21(8):1786-1793. doi:10.1097/MIB.0000000000000426.
Jatkowska A, Gkikas K, Nichols B, et al. Dose-dependent effects of enteral nutrition on the faecal microbiota and short chain fatty acids. Clin Nutr. 2024;43(5):1200-1207. doi: 10.1016/j.clnu.2024.04.010.
The role of partial enteral nutrition for induction of remission in Crohn’s disease: a systematic review of controlled trials. Nutrients. 2022;14(24):5263. doi: 10.3390/nu14245263.
Critch, Jeff*; Day, Andrew S.†; Otley, Anthony‡; King-Moore, Cynthia§; Teitelbaum, Jonathan E.||; Shashidhar, Harohalli# on Behalf of the NASPGHAN IBD Committee. Use of Enteral Nutrition for the Control of Intestinal Inflammation in Pediatric Crohn Disease. Journal of Pediatric Gastroenterology and Nutrition 54(2):p 298-305, February 2012. | DOI: 10.1097/MPG.0b013e318235b397‍
Wilschanski M., Sherman P., Pencharz P., Davis L., Corey M., Griffiths A. Supplementary enteral nutrition maintains remission in paediatric Crohn’s disease. Gut. 1996;38:543–548. doi: 10.1136/gut.38.4.543‍
Schulman J.M., Pritzker L., Shaoul R. Maintenance of Remission with Partial Enteral Nutrition Therapy in Pediatric Crohn’s Disease: A Retrospective Study. Can. J. Gastroenterol. Hepatol. 2017;2017:5873158. doi:10.1155/2017/5873158.
Vanderstappen J, Hoekx S, Bislenghi G, et al. Preoperative optimization: Review on nutritional assessment and strategies in IBD. Curr Opin Pharmacol. 2024; 77:102475. doi: doi: 10.1016/j.coph.2024.102475.