Malnutrition is rather frequent in Crohn's disease, particularly in children and in adults with unremitting and/or complicated disease. Several factors can contribute to malnutrition and some of them can be shared by the same patient. Early and/or subtle nutritional changes should be considered in the comprehensive evaluation of patients affected by IBD. Bone changes and increased fracture risk have been described in both Crohn's disease and ulcerative colitis. Though chronic use of steroids has been considered a determinant in BMD impairment, the relationship between steroid administration and fracture risk has recently been questioned. Increasing attention has been focused on the role of the underlying chronic inflammatory process as a major factor of bone disease. In any case, the use of vitamin D and calcium supplementation is highly recommended, especially in those that have been steroid treated and elderly patients. Bisphosphonate can be useful in preventing and treating bone changes, but indications and selection of patients still remains unclear. Further studies on genetic determinants of bone changes in IBD could probably improve our ability in selecting patients for appropriate treatment. On the other hand, it has been shown that maintenance therapy with infliximab can improve BMD, which underscores the role of inflammation in IBD-related bone disease.

A nutritional approach in IBD, namely in Crohn's disease, is not just calorie supplementation [119]. It is mainly recommended in children with active Crohn's disease, where it constitutes a major therapeutic tool, not only in improving nutritional status, but also in favouring clinical remission, in sparing or avoiding steroids, in allowing and accelerating growth, in hastening the onset of puberty (especially if the treatment is started early and in the prepuber-tal period) and in improving school performance and social activities. In Crohn's disease, EN should be preferred to parenteral treatment due to its lower cost and side effects. Moreover, EN may have the role of primary care in this disorder. Improvement in intestinal permeability and modulation of the inflammatory response are candidates for mechanisms that have a positive effect in active Crohn's disease. An imbalance between Th1 and Th2 (and related cytokines) is considered to be associated with pathological response, and recognition of commensal bacteria contributes to the Th1-Th2 cytokine balance, underscoring that gut bacteria are necessary for maintaining the immune homeostasis. This balance is altered in Crohn's disease, leading to chronic inflammation. However, no information is currently available on the effect of defined EN formulas in modifying or modulating microflora and related action on gut mucosa and inflammatory response.

Comparable clinical results have been shared by different EN formulas, and special formulas have not shown any superiority over "regular" ones. Since the basic composition of polymeric EN does not substantially differ from foods and, although there is evidence of actions on some inflammation-related mechanisms, one might speculate whether the effect is related to specific components, to some balance or imbalance between them or whether it is aspecific and related to the presence of nutrients in an inflamed intestine.

In adult EN, although it offers some alternative to drug therapy for inducing remission, in clinical practice it is actually restricted to patients suffering from severe and persisting anorexia and from malnutrition due to unremitting disease and/or complications. It has not proven to be effective in poor or non-responders to first-line drug therapy, and few data support its use in patients with suspected or effective food intolerance, not amenable by means of food exclusion diets.

Therapeutic improvement via infliximab in inducing remission and in long-term management of Crohn's disease, in treating fistulas, and its role in promoting better quality of life scores could restrict indications for the nutritional approach as primary care in Crohn's disease. Nutritional care will probably maintain its role in children in complicated cases in which drug therapy (namely steroids) can be associated with a higher rate of long-term side effects on growth, bone and endocrine system. Mechanisms whereby EN formulas have a real therapeutic effect on the immune and inflammatory response represent an intriguing research field for improving our understanding of the pathophysiolo-gy of IBD. In a practical setting, oral nutrition should always be preferred and promoted via nutrient and energy dense foods with good calcium content, according to local nutritional habits and individual preferences.

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