IBD Siddhartha Parker, MD Catherine Giguere-Rich RD, CNSC 2 Goals - - PowerPoint PPT Presentation

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IBD Siddhartha Parker, MD Catherine Giguere-Rich RD, CNSC 2 Goals - - PowerPoint PPT Presentation

Aug 01, 2023 242 likes •460 views

When and What Dietary Modifications might help IBD Siddhartha Parker, MD Catherine Giguere-Rich RD, CNSC 2 Goals of Nutrition Therapy Identify and treat nutritional deficiencies Provide some relief for GI symptoms (diarrhea, bloating,

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When and What Dietary Modifications might help IBD

Siddhartha Parker, MD Catherine Giguere-Rich RD, CNSC

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Goals of Nutrition Therapy

  • Identify and treat nutritional deficiencies
  • Provide some relief for GI symptoms

(diarrhea, bloating, and abdominal pain)

  • No diet to date has been scientifically shown

to prevent/cure IBD

  • Minimize inflammation and promote healing

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IBD and Nutrition

  • Malnutrition (including vitamins and minerals)
  • Common dietary recommendations and trends
  • EEN (exclusive enteral nutrition)
  • Other Nutrition Therapies
  • Hydration
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Malnutrition and IBD

Malnutrition can occur with:

  • Macronutrients—calories from protein, fats and carbohydrates
  • Micronutrients—Vitamins, mineral, trace elements

IBD patients are at risk for malnutrition because of:

  • Increased losses: Diarrhea/Ostomy output (electrolytes), bleeding (iron)
  • Decreased intake: Poor appetite, limited diet (fruits, vegetables)
  • Malabsorption: Inflammation, fistulas, loss of surface area (surgical resection)
  • Catabolic state: Inflammation causes ↑↑ metabolic/protein needs
  • Drug interference: Steroids block calcium absorption, Methotrexate blocks

folate

Forbes A, Goldesgeyme E. Journal Parenteral and Enteral Nutrition. 2011;35(5): 571-580.

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Common Diet Recommendations

Low Fiber Diet

  • Minimize fresh fruits

&vegetables, nuts, seeds

  • Helpful for relieving abdominal

pain, diarrhea

  • Especially important to avoid if

you have stricture

  • No controlled trials that show

low fiber diet leads to symptom improvement or decreased admissions to the hospital

High Fiber Diet

  • Ulcerative Colitis in remission
  • Short Chain Fatty acids

(SCFA)-butyrate, acetate, proprionate

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Seidner DL, Lashner BA, Brzezinski A. Clin Gastroenterol Hepatol. 2005;3:358-369

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Common Diet Recommendations

Gluten-free (low-carb)

  • Protein found in foods

processed from wheat, barley

  • r rye
  • Gluten intolerance relatively

common in Irritable Bowel Syndrome (IBS) (and IBD?) – Inflammation? – Non-celiac Gluten Sensitivity (NCGS) – Culprit (carbs vs protein)?

  • Further research is needed.

Lactose Intolerance

  • Common among IBD patients
  • Poorly digested sugar
  • Highly fermentable in colon
  • Can be temporary during flare

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Herarth HH, Martin CF, Kappelmann MD. Inflamm Bowel Dis. 2014;20(17): 1194-1197 Prince AC, Myers CE, Joyce T. Inflamm Bowel Dis. 2016;22(5): 1129-1136

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Common Diet Recommendations

Low FODMAP diet

  • Short-chain carbs poorly absorbed

and thus fermented by bacteria gas/diarrhea

  • Shown in several clinical trials to

be effective in irritable bowel syndrome (IBS)

  • Some limited evidence for

effectiveness in functional symptoms for IBD

  • Quite restrictive, lots of resources
  • Consider working with registered

dietitian familiar w/ low FODMAP diet

Small Intestinal Bacterial Overgrowth (SIBO) Diet

  • Crohn’s disease in particular

– Especially Ileocecal resection, strictures and enteric fistula – Also associated w/antibiotic use, constipation

  • Similar to low FODMAP diet

– No consensus, overlaps with low FODMAP – Focus on easily digested food

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Seidner DL, Lashner BA, Brzezinski A. Clin Gastroenterol Hepatol. 2005;3:358-369

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Specific Carbohydrate Diet (SCD): DINE-CD Study

SCD vs Mediterranean-style Diet to help induce remission in Crohn’s Disease

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Turmeric (Curcumin) and IBD

  • Anti-inflammatory and antioxidant

properties

  • Available in pill and powder form
  • Small studies show:
  • May help induce remission in mild to

moderate UC

  • May be effective and safe for

maintaining remission for people with inactive disease.

  • Data supports use in UC, no data for

a role in Crohn’s

Hiroyuki H, Takayuki I, Ken T. Clinical Gastroenterology and Hepatology. 2006;4:1502-1506 Lang et al. Clinical Gastroenterology and Hepatology. 2015;8:1444-1449e

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Probiotics

  • Science on probiotics is

inconclusive

  • Benefit is unclear, could worsen

symptoms

  • May reduce risk of C.Diff
  • Meta-analysis concluded that

efficacy on probiotic use in CD remains inconclusive

Be Careful!!! Supplements are not regulated by the FDA

  • Many brands (e.g Visbiome,

VSL #3, Florastor, Culturelle, Align)

  • Many species (e.g Lactobacillus

vs Acidophilus vs Saccharomyces Boulardii)

  • Prebiotics (e.g. fiber) promote

healthy microbiome

  • Fermented foods just as

good?

  • Kefir or yogurt
  • Kimchi or sauerkraut
  • Kombucha (measurable

alcohol)

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Fedorak RN, Gastroenterology & Hepatology. 2010;6(11):688-690 Derwa Y, Gracie DJ. Aliment Pharmacol Ther. 2017;46(4):309-400.

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Calcium Deficiency

  • Risk factors: chronic steroid use, diarrhea,

vitamin D deficiency, restricted diet

  • Osteoporosis is common in IBD—approximately 18-42%
  • Bone Mineral Density Study/DXA scan (high risk)

Sources of Calcium:

  • Diet: Milk, cheese, yogurt, tofu
  • Supplement: Most IBD patients

– 1000mg in women aged 18-25, men<65 – 1200mg in women age 25-menopause – 1500mg in postmenopausal women, men>65

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Bernstein CN, Leslie WD, Leboff MS. Gastroenterology. 2003;124(3):795

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Vitamin D Deficiency

  • Risk factors: Steroids, restricted diet, decreased

sunlight, northern latitudes

  • 25% of adults with CD were found to have Vitamin D levels <10

ng/mL

  • IBD poses increased risk of vitamin D deficiency and metabolic

bone disease Sources of Vitamin D

  • Diet sources: Salmon, tuna, milk, eggs
  • Supplement: Most IBD patients 600-2000IU daily

– If level<20: 50,000 units D2 or D3 weekly for 12 weeks – Maintenance dose of 1500-2000 units per day of D3 – Higher doses of 3000-6000 units per day may be necessary 17

Holick, M. F., et al. Journal of Clinical Endocrinology &

  • Metabolism. 2011; 96(7), 1911-30.

Basson, A. Journal of Parenteral and Enteral Nutrition. 2014; 38(4), 438-458.

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Vitamin B12

  • Risk factors: Ileitis/small bowel surgery, small intestinal bacterial
  • vergrowth, gastritis
  • About 20% of patients (adult and pediatric) with Crohn’s disease
  • Pernicious anemia, cognitive symptoms, glossitis

Sources of Vitamin B12

  • Diet sources: Trout, tuna, beef, milk
  • All pts with ileal surgery (>60cm) intramuscular vitamin B12 for life (1000

mcg monthly or every other month)

  • Oral: 1000 mcg daily (various options)
  • Sublingual – 500-1000 mcg daily

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Headstrom PD, Rulyak SJ, Lee SD. Inflamm bowel Dis. 2008 14 (2) 217.

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Folate

  • Risk Factors: SB resection
  • Meds: methotrexate (MTX), sulfasalazine (SSZ)
  • Deficiency less common due to fortification in food
  • Megaloblastic anemia, smooth sore tongue

Sources of Folate

  • Diet: Fortified cereals, spinach, cantaloupe
  • 1 mg Folic Acid daily
  • All patients on methotrexate and sulfasalazine

Eiden, K. A. Nutrition Issues in Gastroenterology. 2003; Series #5, 33-54.

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Iron

  • 35-60% of patients with IBD are deficient
  • Risk factors: Active inflammation/chronic blood loss, Ulcerative Colitis,

SIBO

  • Deficiency > Significant negative impact on quality of life
  • Difficult to supplement due to side effects

Sources of Iron

  • Diet: Meat, Fish, Leafy Greens, Fortified Cereals
  • Unique challenge for supplementation
  • IV iron if determined best for the patient by the MD
  • Vitamin C may help enhance iron absorption
  • Cook with cast iron

Gisbert JP, Gomollon F. AmJGastroenterology.2008;103(5):1299.

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Zinc

  • Risk Factors: ostomies, fistulas,

profuse diarrhea

  • Symptoms: skin changes-scaly

eczematous plaques, taste changes, growth failure Sources of Zinc

  • Diet: red meat, dark meat chicken, seafood, fortified

cereals

  • 50 mg elemental zinc for 10 days
  • Caution: copper deficiency for those on long term zinc

supplementation

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Alkhouri RH, Hashmi H, Baker RD. J Ped Gastroenterology Nutr. 2013 Jan;56(1):89-92 Filippi J, Al-Jaouni R, Wiroth JB. Inflamm Bowel Dis. 2006;12(3):185

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EEN (Exclusive Enteral Nutrition)

  • For Crohn’s not UC
  • Highly effective in newly diagnosed children
  • Weaker evidence in adults (compliance and tolerability)
  • Goal: Induce mucosal healing
  • Elemental diets extremely difficult to follow, taste fatigue
  • Duration of treatment is 6-8 weeks
  • Exact mechanism of action unknown
  • Immune modulation
  • Intestinal inflammation
  • Microbiome
  • Which is best formula?

Ashton JJ, Gavin J, Beattie RM. Clinical Nutrition.2018;1-10 Wall et al. World J Gastroenterol 2013 November 21; 19(43): 7652-7660

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Parenteral Nutrition (TPN)

  • Not primary therapy in IBD (Crohn’s disease)
  • What is total parental nutrition (TPN)?
  • Parenteral (IV) nutrition, or intravenous feeding, is a

method of getting nutrition into your body through your veins.

  • Can provide total nutritional support or supplemental
  • Who needs TPN?
  • SBS (short bowel syndrome)
  • Persistent SBO (small bowel obstruction)
  • Inability to tolerate table food or

Enteral Nutrition (EN)

  • Chronic Enteric fistula

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Oral Rehydration Solutions

  • Most effective and least

expensive way to prevent and treat dehydration from diarrhea

  • Less sugar and more electrolytes

than sports drinks

  • Ingredients are important
  • Water
  • Sugar (dextrose, glucose)
  • Salts
  • Potassium
  • WHO ORS
  • Oley Foundation: oley.org/
  • Commercial brands
  • Drip Drop, Nuun, Pedialyte
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Conclusions

  • Disease and Treatment (both medical and surgical) can affect nutrition
  • Nutrition support plays a key role in severe disease
  • Important to identify and treat both macro and micronutrient deficiencies:

– know when to check and how to supplement

  • Modified “Diets” may help alleviate GI symptoms not directly related to inflammation
  • Natural remedies may effective (and usually safe) for limited/mild disease
  • Exclusive enteral nutrition (EEN) can be an effective therapy and requires support

from a dietitian

  • A healthy diet is key but may need to be individualized based on disease and clinical

course

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INFLAMMATORY BOWEL DISEASE AND NUTRITION