Diet is an important factor in both the pathogenesis and in the clinical course of Crohn's disease (CD). However, data on dietary patterns of CD patients are rather limited in the literature. This cross-sectional study included 60 patients with CD, aged 18–60 years. Dietary intake was assessed using a validated food frequency questionnaire to measure food consumption patterns by principal component analysis (PCA). Multiple regression analysis was performed to investigate the association between dietary patterns and clinical and demographic variables. Three dietary patterns were identified: "Traditional + FODMAP" was associated with symptoms, gender, previous surgeries, and duration of the disease. "Fitness style" was positively associated with physical activity and negatively associated with body mass index and smoking. "Snacks and processed foods" was positively associated with duration of the disease and negatively associated with age. According to the weekly food consumption analysis, patients with active disease consumed less coffee and tea. We found significant associations between the three dietary patterns and the variables, but not with the stage of the disease. Prospective studies are necessary to determine the effects of food consumption patterns on the clinical course of CD.
These authors contributed equally: Marina Moreira de Castro and Ligiana Pires Corona.
Crohn's disease (CD) causes chronic inflammation in the gastrointestinal tract[
The role of diet has also been discussed in the clinical course of CD[
Diet patterns may also aggravate symptoms in patients with IBD. A Mexican study reported that foods such as beans, whole milk, plum, lima beans and spicy sauce increased the frequency of symptoms in patients with Ulcerative Colitis (UC), another condition of IBD[
Therefore, the evaluation of the diet as a whole and the different dietary patterns defined by food groups should be taken into account. Data reported in the literature about the dietary patterns of patients with CD are scarce. Therefore, this study aimed to identify dietary patterns of patients with CD and to investigate the associated factors.
This cross-sectional study was performed on CD patients of the IBD outpatient clinic of the Coloproctology Unit at the Gastrocenter of the University of Campinas (UNICAMP) from May 2017 through July 2018. Patients were considered eligible for this study if they had a confirmed diagnosis of CD and had completed endoscopic or imaging tests within two months of recruitment. Only then were they invited to participate. The diagnosis of CD was based on endoscopic, radiological, and histological criteria. Inclusion criteria were: age between 18 and 60 years, with the disease located in the ileum and/or colon. Exclusion criteria were: pregnant and breastfeeding women, patients with edema and patients who lacked endoscopic or imaging tests.
This study protocol was approved by the Ethics Committee of the University of Campinas (CAAE n° 62802016.0.0000.5404) and a written informed consent form was obtained from all patients before the interview and data collection. Additionally, all methods were performed in accordance with the relevant guidelines and regulations.
Dietary intake data were collected using a validated food frequency questionnaire (FFQ), which consisted of 76 food items in total with standard portion sizes, including foods rich in Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAP), such as apple, pear, watermelon, cauliflower, garlic, onion, milk, yogurt, etc. The frequency was evaluated in these categories: never or almost never; once a month; twice a month; once a week; twice or three times a week; four to five times a week; every day. Data were converted into an estimate of weekly consumption and the 76 food items were aggregated into 22 food groups, which were based according to the nutritional characteristics and the preliminary factor analysis.
Principal component analysis (PCA) was used to identify food consumption patterns, a multivariate analysis using reported information to identify common underlying dimensions (factors or patterns) of food consumption, as it enables the items to be grouped based on the degree of correlation among them. The variables grouped in each factor are more strongly correlated with each other than with the variables belonging to the other factors. Therefore, this procedure enables the food items contained in the food consumption assessment instrument to be grouped on the basis of the degree of correlation among them. The interpretation and denomination of the factors, in the case of dietary patterns, depends on the meaning of each combination of the variables (food items) observed in the factor and, especially, those items with the highest factorial load[
An eigenvalue cut-off>1 (which represents the total variance explained by each factor or diet component)[
Factors related to each pattern had their scores estimated and were described according to means and standard error, and the differences between groups was tested using the Student t test. Subsequently, univariate and multiple regression analysis using generalized linear models were made to investigate the association of each pattern with clinical and demographic variables. The significant variables or the ones that adjusted other variables <0.20 were maintained in multiple models. Data were analyzed using Stata® 14, with critical value of 5%.
This survey was approved by the Ethics Committee of the University of Campinas (62802016.0.0000.5404).
All participants provided written informed consent to participate in this study.
A total of 60 patients with CD were interviewed. Of these, 31 patients were in remission and 29 in activity assessed by Crohn's Disease Endoscopic Index of Severity (CDEIS). Most of the patients were male (51.7%), aged between 30 to 60 years (76.7%). We investigated if there were associations between these previously findings with dietary pattern. First, we analyzed the frequency of consumption and obtained three dietary patterns described in Table 1 as well as the percentage of variance explained for each factor. Pattern 1, named "traditional + FODMAP", was mainly characterized by higher consumption of rice, pasta, red and poultry meat, legumes, industrialized juice, soft drink, and FODMAP. Pattern 2, named "fitness style" with high loadings for tapioca, eggs, pepper, olive, canned, and fruits. Pattern 3, called "Snacks and processed foods", was mainly characterized by higher consumption of pizza, pie, snacks, cheese, red and poultry meat, and sausages. The three derived dietary patterns explained 38.4% of the variance in food intake.
Distribution of factor loading of food/food groups in three food consumption patterns in CD patients.
Food/food groups Patterns Traditional + FODMAP Fitness style Snacks and processed foods Rice, pasta −0.062 −0.046 Breads, cookies 0.105 −0.001 0.090 Pizza, pie −0.069 −0.028 Snacks -0.102 −0.071 Tapioca −0.039 −0.097 Sweets 0.095 −0.048 0.239 Lactose free milk, yogurt −0.123 0.136 −0.154 Cheese −0.040 0.010 Coffee, tea 0.112 −0.062 −0.018 Butter, margarine 0.205 −0.180 −0.143 Fish 0.149 −0.004 −0.169 Eggs 0.089 −0.056 Red, poultry meat −0.016 Sausages 0.081 −0.018 Pepper −0.003 −0.049 Olive, canned −0.100 0.200 Vegetables 0.202 0.151 0.183 Fruits −0.008 0.023 Legumes −0.123 −0.070 Industrialized juice, soft drink 0.189 0.017 Seasoning 0.217 −0.127 −0.120 FODMAP* 0.230 0.052 Explained Variance by factor (%) 15.1 12.3 10.9 Accumulated variance (%) 15.1 27.5 38.4
*FODMAP: Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols.
Table 2 displays the mean scores of food patterns according to independent variables. The scores of the pattern "traditional + FODMAP" were significantly higher in males and patients with ≥5 symptoms. The scores of the pattern "snacks and processed foods" were significantly higher in males and patients aged from 18 to 29 years. We did not observe significantly higher scores in the pattern "fitness style".
Mean scores (standard error) of food consumption patterns according to clinical and demographic characteristics of CD patients.
Variables Patterns Traditional + FODMAP Fitness style Snacks and processed foods Gender p = 0.799 Male 31, 51.7 0.508 (0.388) 0.052 (0.368) 0.410 (0.321) Female 29, 48.3 −0.543 (0.220) −0.056 (0.205) −0.438 (0.207) Age group (years) 14, 23.3 p = 0.592 p = 0.472 18 to 29 46, 76.7 0.231 (0.684) −0.280 (0.310) 0.774 (0.572) 30 to 60 31, 51.7 −0.070 (0.230) 0.085 (0.261) −0.235 (0.185) CD stage 29, 48.3 p = 0.654 p = 0.535 p = 0.894 Remission −0.103 (0.280) −0.128 (0.204) 0.026 (0.253) Activity 0.110 (0.388) 0.137 (0.385) −0.027 (0.317) Smoking p = 0.266 p = 0.263 p = 0.888 Yes 1, 1.7 −2.007 (−) −1.826 (−) −0.218 (−) No 59, 98.3 0.034 (0.237) 0.030 (0.214) 0.003 (0.203) Alcohol drinker p = 0.380 p = 0.980 p = 0.847 Yes 22, 36.7 0.274 (0.468) 0.007 (0.231) 0.051 (0.250) No 38, 63.3 −0.158 (0.256) −0.004 (0.310) −0.029 (0.282) Duration of the disease (years) p = 0.161 p = 0.753 p = 0.176 <1 5, 8.3 −0.998 (0.397) 0.216 (0.620) −0.913 (0.415) 1 to 5 15, 25 0.333 (0.670) −0.054 (0.285) −0.049 (0.341) 5 to 10 12, 20 −0.106 (0.389) −0.484 (0.266) 0.180 (0.400) ≥10 28, 46.7 0.045 (0.308) 0.198 (0.401) 0.112 (0.340) Number of frequent symptoms p = 0.623 p = 0.125 None 20, 33.3 0.039 (0.281) −0.075 (0.229) 0.509 (0.467) 1 to 2 28, 46.7 −0.085 (0.308) −0.006 (0.405) −0.182 (0.222) 3 to 4 10, 16.7 −0.471 (0.533) 0.062 (0.353) −0.366 (0.333) ≥5 2, 3.3 3.159 (4.807) 0.538 (1.422) −0.705 (1.147) Previous surgeries p = 0.061 p = 0.878 p = 0.410 Yes 44, 73.3 0.265 (0.292) 0.019 (0.275) −0.100 (0.239) No 16, 26.7 −0.729 (0.306) −0.054 (0.262) 0.275 (0.362) BMI (kg/m2) p = 0.774 p = 0.112 p = 0.992 Low weight/Eutrophic 35, 58.3 0.057 (0.332) 0.286 (0.333) 0.001 (0.209) Overweight/Obesity 25, 41.7 −0.081 (0.328) −0.400 (0.189) −0.002 (0.386) Physical Activity p = 0.616 p = 0.078 p = 0.460 Yes 15, 25 0.206 (0.427) 0.648 (0.690) 0.258 (0.513) No 45, 75 −0.068 (0.281) −0.216 (0.161) −0.086 (0.207)
FODMAP: Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols.
No difference was observed in dietary patterns between remission and active disease group, so we chose to present a qualitative analysis of mean weekly consumption of each food group according to disease phase (Fig. 1). The reason for this is that when we observe the spatial representation of consumption of food portions distribution by patients in active disease or in remission, the pattern formed is similar (Fig. 1A). However, the consumption of coffee and tea was lower in the activity group than in the remission group (p = 0.015). When we observed in more detail the consumption in portions, in relation to patient's symptoms, the pattern formed is also similar between the groups, with the exception for some food group distribution in relation to patients with ≥5 symptoms, such as rice, pasta, breads, cookies, butter, margarine, eggs, red and poultry meat, industrialized juice, soft drink, and FODMAP (Fig. 1B).
Graph: Figure 1 Detailed description of the 22 foods groups used in the PCA. Food groups distribution according to remission and activity CD (A). Food groups distribution according to patients' symptoms in both remission and activity CD (B). PCA: principal component analysis. FODMAP: Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols.
Concerning the three identified dietary patterns, we analyzed the associations with the studied variables. As observed in Table 3, the factors associated with the pattern "traditional + FODMAP" were symptoms, gender, previous surgeries, and duration of the disease. The pattern "fitness style" was positively associated with physical activity, but negatively associated with BMI and smoking. The pattern "snacks and processed foods" showed negative association with age and positive association with duration of the disease (>10 years).
Analysis of multiple linear regression of clinical and demographic factors associated with food consumption patterns in CD patients.
Variables β 95% CI Pattern "Traditional + FODMAP" Number of frequent symptoms ≥5 3.456 (0.924, 5.988) 0.007 Gender Male −1.192 (−2.100, −0.283) 0.010 Previous surgeries 1.092 (0.073, 2.111) 0.036 Duration of the disease 1 to 5 1.758 (0.068, 3.448) 0.041 Pattern "Fitness style" Physical Activity 1.632 (0.654, 2.611) 0.001 BMI (kg/m2) Overweight/Obesity −1.454 (−2.318, −0.590) 0.001 Smoking −3.795 (−6.881, −0.708) 0.016 Pattern "Snacks and processed foods" Age 30 to 60 −1.354 (−2.317 −0.390) 0.006 Duration of the disease >10 1.470 (0.029, 2.912) 0.045
FODMAP: Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols.
As it is difficult to assess the effect of isolated foods group in the clinical course of patients with IBD, we evaluated the association between the dietary patterns and its related factors in both remission and activity CD outpatients. A dietary pattern is a comprehensive food evaluation in which multiple foods and nutrients are studied collectively. This approach is a simplification designed to make it easier to understand complex diet-disease relations[
Our results reveal important associations between the three identified dietary patterns and their associated factors, as well as complex combinations of food intake. Pattern 1 (traditional + FODMAP) which, as expected, explained the greater variance among the factors (15.1%), reflects traditional Brazilian eating habits and is characterized mainly by the consumption of rice and legumes, especially beans. This pattern was associated with ≥5 symptoms, previous surgeries, and 1 to 5 years of the disease and negatively associated with being male. It is possible that differences between men and women occur in relation to diet in CD, and investigations are necessary to verify a possible role of sex in diet-related course of CD. Flood et al. found that differences were observed between sex and dietary pattern in patients with colorectal cancer, and the authors suggest a possible role of sex in disease etiology[
The positive association of Pattern 1 (traditional + FODMAP) with previous surgeries in our study may be explained by the improvements in the BMI parameter, and in food intake in the postoperative period. The state of well-being after recovery from surgery may lead to the less selective food intake, including FODMAPs, which could in turn lead to the appearance of abdominal symptoms, even in the absence of active endoscopic disease. The recovering of the nutritional status after surgery depends on the total length of the resected bowel and the adopted technique (resection and/or stricturoplasty). Patients who have undergone only intestinal stricturoplasty, a conservative surgical technique often used in CD treatment, frequently cease to have obstructive symptoms and also gain weight secondary to oral intake improvement[
Pattern 2 was named "fitness" because the food items that compose it are usually part of diets adopted by more health-conscious people, and are also more susceptible to "fashion" diets. Tapioca is a starch extracted from the storage roots of the cassava plant, highly consumed in the north region and central-west region of Brazil[
Reinforcing this hypothesis, "fitness style" pattern was positively associated with physical activity, in which a meta-analysis showed that it has a protective effect in CD[
Pattern 3 (snacks and processed foods) was associated with>10 years of the disease and negatively associated with older age group, between 30 and 60 years. This result is often reported, as younger patients tend to have higher intakes of snacks and processed foods. According to the latest Brazilian household food budget survey, sweets, milk-based flavored drinks and cookies, for example, appeared among the most commonly consumed foods only for adolescents and young adults[
We did not find any associations between eating patterns and the stage of the disease (remission and activity). This result is consistent with some previous studies, as we describe below, even if comparison between the studies is difficult because of the differences in dietary pattern composition identified as well as the high variability in the population.
The study by Taylor et al. explored and compared the dietary pattern of CD patients in remission with the Mediterranean diet according to the Mediterranean diet scores (P-MDS) recommendations in a Canadian ambulatory clinic. They identified low intakes of olive oil, legumes, nuts, fruits and vegetables. Only a few patients met the P-MDS criteria for intake of vegetables or legumes, the median intakes of fruit were 50% below the recommendations, 30% of men exceeded red or processed meats recommendations, and over 80% of patients reported inadequate intake of fish and nuts[
In the recent literature, restricted diets, such as the Specific Carbohydrate Diet (SCD)[
The predictors of relapse, which may include the environmental factors, could represent an important advance in clinical management and in the future therapeutic strategies[
This study has some limitations that should be addressed. First, it is an observational design study and we cannot determine causality. Thus, interventional studies are necessary to evaluate the influence of diet on the course of CD and the effects of food consumption patterns on disease severity in order to make recommendations on diet modifications. However, dietary intervention studies are considered complex, taking into account their challenges, including the recruitment and retention of patients and the economic costs[
Furthermore, our sample size is somewhat restricted to the use of pattern analysis, and therefore the food groups had to be aggregated for analysis to be feasible. Nevertheless, the patterns extracted from the factor analysis accounted for 38.4% of the total variance in food intakes. Considering previous studies with the same analysis, this percentage is relatively high. Myklebust-Hansen et al. explained 10.98% of the variance in 3 factors in the study of IBD women[
The combination of nutritional education and dietary modification improves nutritional awareness, making it an effective approach for potentially promoting health[
In summary, we identified three different dietary patterns among CD patients as well as their association with important clinical and demographic variables. Pattern 1 "traditional + FODMAP" was associated with ≥5 symptoms, previous surgeries, and 1 to 5 years of the disease and negatively associated with male; pattern 2 "fitness style" was positively associated with physical activity and negatively associated with BMI and smoking and pattern 3 "snacks and processed foods" was associated with>10 years of the disease and negatively associated with older age group, between 30 and 60 years. Although this study has not demonstrated associations between eating patterns and the stage of the disease, we noted a lower intake of coffee and tea during the active phase of CD. Moreover, more research should be performed in the near future to explore the benefits of nutritional treatment so as to improve the quality of food consumption and its effects on clinical outcomes, which could lead to a great public health impact in this specific population.
We thank Dr. Tristan Torriani for revising the English version of our manuscript. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
M.M.C. was responsible for the patient recruitment and for the data collection, contributed to intellectual planning, literature review, analysis and interpretation of data, writing and to a critical review of the manuscript, read and approved the final manuscript. R.F.L. was responsible for the patient recruitment, contributed to writing and to a critical review of the manuscript, read and approved the final manuscript. L.P.C. and M.M. contributed to intellectual planning, literature review, analysis and interpretation of data, contributed to writing and to a critical review of the manuscript, read and approved the final manuscript. L.B.P., J.E.M., L.M.I.S., M.L.S.A., M.A.T. and A.S.T. contributed to writing and to a critical review of the manuscript, read and approved the final manuscript.
Please contact the corresponding author for data requests.
The authors declare no competing interests.
Graph: Table S1.
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By Marina Moreira de Castro; Ligiana Pires Corona; Lívia Bitencourt Pascoal; Josiane Érica Miyamoto; Leticia Martins Ignacio-Souza; Maria de Lourdes Setsuko Ayrizono; Marcio Alberto Torsoni; Adriana Souza Torsoni; Raquel Franco Leal and Marciane Milanski
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