Nutritional and Dietary Aspects of IBD

[00:30]

Hello, I’m Kelly Issokson and welcome to IBDIQ, part of The IBD Project by Takeda, where we’re coming together to help enhance expertise in IBD care—right from the start.

Today, we will take a closer look at nutritional deficiencies that may be observed in patients with IBD. We'll talk about some of the causes of these deficiencies and the potential impact on patients. We'll also examine the role of proactive monitoring and dietary intervention in optimizing patient outcomes.

[1:00]

To begin, diet plays an important role in the health of patients with IBD.¹

Nutritional deficiencies can occur in patients with either Crohn's disease (or CD) or ulcerative colitis (or UC).²

However, nutritional deficiencies can be more significant in patients with Crohn's because Crohn's disease can impact any part of the digestive tract.²

In contrast, ulcerative colitis is restricted to the colon and patients with UC experience fewer nutrient absorption defects than those with Crohn’s.^3,4

A study published in 2008 examined the hospital discharge data of more than 75,000 US patients—all ages 5 and older—between the years of 1998 and 2004. This study found that patients who were hospitalized and had a primary diagnosis of IBD were approximately 5.5 times more likely to be at risk of malnutrition than hospitalized patients who did not have an IBD diagnosis.⁵

[01:57]

Patients with Crohn's disease are always at risk of nutritional deficiencies, even when their disease activity appears to be low or quiet.⁴

In contrast, patients with ulcerative colitis are more likely to experience nutritional deficiencies when the disease is active.⁴

Although the risks of nutritional deficiencies may vary based on disease activity in Crohn’s and UC, the potential causes of nutritional deficiencies are similar between the two diseases.⁴

Potential causes of nutritional deficiencies include reduced oral food intake, increased nutrient or energy requirements, loss of nutrients from the gastrointestinal (or GI) tract, and drug-nutrient interactions.^1,4,6

Nutritional deficiencies can also be caused by certain medications, malabsorption, and short bowel syndrome (or SBS).¹

Possible nutritional deficiencies in patients with IBD may include an array of vitamins, including vitamin D, vitamin B12, vitamin B7, vitamin B1, fat-soluble vitamins, and folate.^1,4,7,8

Nutritional deficiencies can also include an array of minerals such as zinc, iron, copper, selenium, magnesium, and calcium.^1,2 

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Potential consequences of these nutritional deficiencies may include, but are not limited to, anemia, fatigue, neuropathy, and osteoporosis.^1,4,9

It is also worth noting that iron-deficiency anemia is a common extraintestinal manifestation of IBD.^4,10

So, what does the impact of malnutrition look like? 

Malnutrition in patients with IBD can have a range of implications that can impact the long-term prognosis of the patient.

These may include increased likelihood of experiencing IBD flares or surgical complications, hospital admission, increased likelihood of contracting a severe infection, emergency department visits, and reduced quality of life.^1,4,11 

In patients hospitalized for IBD, malnutrition has been shown to be an independent risk factor for venous thromboembolism; nonelective surgery; longer duration hospital stays—both in general and after surgery; numerous postsurgical complications that may be severe; as well as increased mortality.⁴

[04:13]

Children with IBD can also experience malnutrition, which can lead to numerous complications, including impaired growth and impacts on puberty. It may also increase the risk of IBD flares and postoperative complications, as well as increase the duration of hospital stays.⁴

Proactive monitoring of patients’ nutritional levels can help us help patients avoid such outcomes.

The American Gastroenterological Association (or AGA) Clinical Practice Update on Diet and Nutritional Therapies in Patients with Inflammatory Bowel Disease (which we’ll refer to in this talk as the AGA Nutritional Guidelines) and the European Society on Clinical Nutrition and Metabolism (which we’ll call the European Nutritional guidelines) highlight the importance of regular screening for malnutrition, which can help clinicians better understand those patients who may benefit from a comprehensive nutrition assessment by an IBD-focused registered dietitian.^1,4

[05:10]

Both of these guidelines recommend that patients with IBD be evaluated for nutritional deficiencies at the time of diagnosis and continue to be regularly monitored as needed.^1,4

The AGA Nutritional guidelines specifically recommend that healthcare providers regularly assess patients for clinical signs and symptoms of malnutrition, such as unintended weight loss, edema and fluid retention, and fat and muscle mass loss.¹

There are tools that can be used to support screening patients who are at risk of malnutrition. One validated tool is the Malnutrition Universal Screening Tool (or MUST) for inpatients. There is also the modified MUST (or mMUST), which is for outpatients and self-use.^4,6,12

The MUST consists of 3 steps and survey questions about body mass index (or BMI), percentage of weight lost during a time period, and acute effect of disease on oral intake.¹² 

The MUST is a way to stratify patients into 3 categories: low, medium, or high risk of malnutrition.¹²

[06:13]

The AGA Nutritional Guidelines also recommend general laboratory testing for C-reactive protein, as well as screening for common micronutrient deficiencies such as vitamin B12, iron, and vitamin D.¹

Laboratory test results should be interpreted with caution in the setting of active inflammation, as serum levels of some micronutrients—such as ferritin, copper, folate, and zinc—may increase or decrease in the setting of inflammation. In these cases, testing should be repeated when the disease is not active.^1,13

When nutritional deficiencies are confirmed, patients should be referred to a registered dietitian for a thorough evaluation to identify nutritional deficiencies and possible dietary interventions that may be required.¹

[07:01]

Registered dietitians should be a core component of a multidisciplinary IBD care team.^1,14 They are experienced in both the diagnosis and management of nutritional deficiencies through the various stages of disease.¹

In addition, registered dietitians can help prevent extraintestinal IBD complications through dietary modification with the appropriate patients.¹

When patients are referred to registered dietitians such as myself, a comprehensive nutritional assessment will likely be done. That evaluation will explore many health domains, including the patient's goals for their nutrition and diet, medical and surgical history, current or past diets, relationship with food, medications and supplements, and anthropometry, including current weight and weight trends.^13,15-18 

Registered dietitians will also evaluate biochemical markers of nutrition status, review endoscopies and imaging studies, and perform a nutrition-focused physical exam.^13,19

[08:02]

Information from the dietary assessment is used to identify dietary habits and behaviors and develop a personalized plan.¹⁷

Dietitians further develop their understanding of a patient’s nutritional issues using problem-etiology-signs and symptoms (or PES) statements that outline the root cause of the problem. 

PES statements also use supportive data to reassess the problem and whether further dietary intervention may be needed.²⁰

Using the information gathered via the comprehensive nutritional assessment, the PES statement, and other clinical assessment methods, the dietitian will start to consider the best approach to nutritional support.^13,16,18

There is growing interest in the use of diet as an aspect of treatment for both CD and UC.¹ 

Before we explore this further, it’s important to recognize that there is no consensus for a singular “IBD diet.”⁴ Diet recommendations should be personalized and consider many factors, such as a patient’s nutritional status, IBD type, disease activity, surgical plans, and cultural and social beliefs.^4,21

[09:10]

An evidence-based diet therapy for Crohn’s disease and ulcerative colitis is the Mediterranean diet pattern.¹

The Mediterranean diet is rich in fruits, vegetables, complex carbohydrates, and olive oil and is low in red meats, ultra-processed foods, and added sugar.¹

There is emerging evidence that this dietary pattern may induce remission in those with Crohn’s disease.¹

A 2021 study randomized 197 US adults with mild to moderate Crohn’s disease symptoms to 2 dietary plans and looked at their clinical and symptomatic remission and inflammatory bowel markers. 43.5% of 92 patients consuming a Mediterranean diet were in symptomatic remission after 6 weeks. This was similar to the 46.5% who followed a more formally restrictive therapeutic diet regimen known as the Specific Carbohydrate Diet.²²

[10:07]

1. The Crohn’s Disease Exclusion Diet (or CDED) is another diet option used in patients with Crohn’s.¹ It is a 3-phase exclusion diet that incorporates more food over time.¹

The AGA recommends the Crohn’s disease exclusion diet for some patients with active mild to moderate disease of short duration.^1,23 This diet excludes or limits certain foods thought to promote inflammation and adversely affect the microbiome and/or alter function of the intestinal barrier.^1,17

There may be times when nutrition needs cannot be met through food-based diets alone and additional nutrition support methods may be needed.¹ 

Nutritional support methods for patients with IBD may include oral supplementation, as well as both enteral and parenteral support.^1,4

Oral nutritional supplementation (or ONS) may be the first step for patients with IBD if the patient is not getting enough nutrition from oral intake alone.⁴

It may also be considered when patients with IBD do not meet energy or protein needs from normal food during the perioperative period.⁴

[11:12]

If oral intake continues to be low despite trials of ONS, enteral nutrition or tube feeding may be considered.⁴

Partial enteral nutrition (or PEN) is where at least 50% of nutrition is obtained from a complete nutrition formula, and the remainder of nutrition comes from whole foods.²⁴

There may be times when a patient with IBD needs to obtain 100% of their nutrition using enteral nutrition. This is called the exclusive enteral nutrition (or EEN) approach.^1,4

It should be noted that EEN is more common in pediatric patients with CD due to poor adherence in adult patients.¹

According to the AGA guidelines, EEN can be prescribed for 6 to 8 weeks and can be considered as a steroid-sparing bridge therapy in children.¹

The guidelines also note that EEN is not as widely prescribed for adult patients with CD, but when tolerated, may be effective in adults as well as children.¹

[12:14]

Studies have shown that an EEN approach can help induce remission in patients with CD.^25,26

In 2019, a prospective, randomized pediatric French study examined effects of EEN vs corticosteroids in new-onset CD. Results of this study demonstrated that 13 of the 13 pediatric patients who completed an 8-week course of EEN and 5 of the 6 patients who received corticosteroids achieved clinical remission. ²⁵

An Australian retrospective observational study looked at 60 adult patients with CD between 2016 and 2018. 28 of these patients had completed EEN therapy per-protocol and were included in the analysis. It was found that of those patients who could adhere per protocol, 22 achieved clinical remission after completing a course of EEN for a median duration of 41 days. ²⁶

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There is evidence that EEN may have the potential to achieve mucosal healing.²⁷ For example, a prospective, observational, single-center study in China that included both children and adults evaluated mucosal healing, defined as the absence of ulcerations in bowel segments (or SES-CD less than or equal to 1), in 18 patients with active CD and 11 patients with CD in remission who initiated EEN.²⁸ 79% of the 29 patients evaluated achieved complete mucosal healing using EEN. A lower mucosal healing rate of 72% was seen in patients with active disease at baseline, and a higher rate of 91% was seen in patients who were in remission at baseline. It was reported that the mean time to mucosal healing was 123 days, with mucosal healing occurring as early as 50 days.

[14:11]

There is emerging evidence that EEN can help patients with acute severe ulcerative colitis as well.²⁹

An open-label, randomized study at a single center in India evaluated the 6-month outcomes of 48 adult patients with acute severe UC who were treated with 7 days of EEN with standard of care or standard of care alone. The group who had completed the 7-day course of EEN had a lower composite rate of colectomy and rehospitalization than those who did not go through the 7-day course, supporting the possibility that EEN may have benefits for patients with UC.²⁹

Having looked at EEN, let’s examine another nutritional support method: parenteral support.

[14:58]

Parenteral nutrition is a method by which patients receive nutrients by bypassing the digestive system.³⁰

Parenteral nutrition might be considered when attempts to nourish the individual via oral and enteral routes have failed or are not feasible, such as in cases where there is intolerance to enteral nutrition, ileus, short bowel syndrome, or if there is an anastomotic leak or high output intestinal fistula.^1,4

Despite all efforts—dietary or otherwise—a patient may still require surgery as part of their disease treatment.^31,32

If a patient with active IBD is about to undergo surgery, they are likely at high risk for malnutrition.⁴ 

Considering the detrimental effects that malnutrition can have on surgical outcomes, it’s prudent to try to optimize or prehabilitate nutrition before surgery.¹

In patients with IBD who are already malnourished or at severe risk for malnutrition, the European Nutritional guidelines recommend delaying surgery for 7 to 14 days to allow nutrition optimization, if feasible.⁴

[16:06]

The European Nutritional guidelines also provide an enhanced recovery protocol that can be explored in patients undergoing elective surgery. Aspects of perioperative care to consider include avoiding long periods of fasting, advancing an oral diet after surgery, integrating a dietitian into patient management, implementing measures to mitigate stress-related catabolism and facilitate GI function, and promoting early mobilization to promote protein synthesis and muscle function.⁴

I hope you have a better understanding of the role that nutrition plays in IBD and that I have provided you with practical management strategies for better addressing the nutritional needs of your patients with IBD.

[16:51]

Today we have reviewed the following key points:

Malnutrition is common in IBD and worsens outcomes; screening and assessment are recommended for all patients with IBD¹

Evidence-based approaches for diet therapies differ for Crohn’s disease and ulcerative colitis; therefore, dietitians are essential for the development of personalized nutrition plans^1,4,17,33

Patients with IBD who are planning to undergo surgery should be nutritionally optimized, as this has been shown to improve outcomes^1,4

Thank you for your interest and for spending some time with IBDIQ today to help adapt to the evolving care needs of all patients with IBD.