ESPEN Congress Copenhagen 2016 · Iron supplementation is recommended in all IBD patients when iron...

ESPEN Congress Copenhagen 2016 ESPEN GUIDELINES

INFLAMMATORY BOWEL DISEASES

A. Forbes (UK)

Nutrition in IBD

Guidelines for ESPEN

Alastair Forbes

For the ESPEN IBD guidelines

working group

Introduction

Malnutrition

Treatment of malnutrition

Nutrition in aetiology

Nutrition in primary therapy

Existing guidelines

2009

2006

Introduction

New methodology for ESPEN guidelines

Disease focus – not technique

Multidisciplinary, multinational approach

remains

More structured

Dependent on systematic review

when this is possible

Expert opinion when it is not

Nutrition in IBD


Commissioned in April 2012

To be launched in August 2013

Nutrition in IBD


Recruitment of expert writing panel

Retention of key contributors to previous

guidelines by mutual consent

Choice of new faces

Choice of chair and deputy

Nutrition in IBD


Intended integrated approach with

ECCO

ESPGHAN

Positive attitudes but practical obstacles

Much discussion

Panel chosen with representatives

But not joint guidelines

start

Nutrition in IBD


Nutrition in IBD


Chair resigned

Deputy became chair

Nutrition in IBD


Nutrition in IBD


Plan for guidelines in 2 parts

a) introductory elements - opinion

b) elements susceptible to systematic

review

Team discussions and agreements

PICO listing for systematic review devised

PICO ??

Population

Intervention

Comparison

Outcome

Nutrition in IBD


Jan-Feb 2013 writing of introductory

elements commenced

Data from systematic review due mid April

For general circulation

Plan for work-in-progress meeting in June

Final guidelines to ESPEN in July

Public launch in August at Congress

Publication in Clin Nutr in Autumn

Nutrition in IBD


But …….

Writing of introductory elements

first drafts essentially complete

Nutrition in IBD


But …….



Receipt of systematic analysis ….

Nutrition in IBD


But …….



Receipt of systematic analysis ….

on 25/8/13

Headlines from systematic review

• 1299 papers assessed

• The data almost uniformly poor or absent

• Studies are small and underpowered

• Few strong recommendations possible

• Major need for new and better research

ostr


Grade A recommendations

• Omega-3 supplementation not supported

in maintenance of UC

• High fibre diet not supported in

maintenance of Crohn’s

• Treatment of iron deficiency anaemia in

IBD is valuable (oral or iv)

Progress


No reliable evidence for

• Bowel rest

• Exclusion diets

• Enteral feeding as primary therapy

• Special feeds (includes glutamine)

dream

Nutrition in IBD


Re-recruitment of expert writing panel

Loss of key members

Loss of direct support from ECCO and

ESPGHAN

Essentially a new start in 2015

We have a dream !

Nutrition in IBD

Guidelines for ESPEN – 2015-16

Re-evaluation of systematic review

Challenge to 1 of 3 evidence-based

conclusions as fibre includes prebiotics!

Recognition that entire project relied on

expert judgment of publications

Complete revision of PICOs

Nutrition in IBD

Guidelines for ESPEN – 2014-16

Abandonment of separate sections

New literature searches on each PICO

Not systematic but thorough

Full Delphi process, public consultation

and meeting 2016

Final revisions now with Guidelines Group

Awaiting final version for submission

Nutrition in IBD

Guidelines for ESPEN – 2016

PICO questions have generated 64

recommendations

Nutrition in IBD

Guidelines for ESPEN – 2016 Recommendation 1

A diet rich in fruit and vegetables, rich in n-3 fatty acids, and low in n-6 fatty acids is associated with a decreased risk of

developing Crohn's disease or ulcerative colitis and is therefore recommended. Grade of recommendation C, strong

consensus.

Recommendation 2

Breastfeeding can be recommended, because it is the optimal food for infants and it reduces the risk of IBD. Grade of

recommendation B, strong consensus.

Recommendation 3

Patients with IBD are at risk and therefore should be screened for malnutrition at the time of diagnosis and thereafter on a

regular basis. Grade of recommendation GPP, strong consensus.

Recommendation 4

Documented malnutrition in patients with IBD should be treated appropriately, because it worsens prognosis, complication

rates, mortality and quality of life. Grade of recommendation GPP, strong consensus.

Recommendation 5

In general, the energy requirements of patients with IBD are similar to those of the healthy population; provision should be

in line with this. Grade of recommendation GPP, strong consensus.

Recommendation 6

Protein requirements are increased in active IBD, and intake should be increased (to 1.2-1.5 g/kg/d in adults) relative to that

recommended in the general population. Grade of recommendation GPP, strong consensus.

Recommendation 7

The protein requirements in remission are generally not elevated and provision should be similar (about 1.0 g/kg/d in adults)

to that recommended for the general population. Grade of recommendation GPP, strong consensus.

Recommendation 8

Patients with IBD should be checked for micronutrient deficiencies on a regular basis and specific deficits should be

appropriately corrected. Grade of recommendation GPP, consensus.

Nutrition in IBD - highlights

Recommendation 6

Protein requirements are increased in active IBD, and intake should

be increased (to 1.2-1.5 g/kg/d in adults) relative to that

recommended in the general population.

Recommendations 9-11

Iron supplementation is recommended in all IBD patients when iron

deficiency anaemia is present. The goal of iron supplementation is to

normalize haemoglobin levels and iron stores. Oral iron should be

considered as first-line treatment in patients with mild anaemia,

whose disease is clinically inactive, and who have not been

previously intolerant to oral iron. Intravenous iron should be

considered as first-line treatment in patients with clinically active

IBD, those with previous intolerance to oral iron, those with

haemoglobin below 100 g/L, and in patients who need

erythropoiesis-stimulating agents.


Recommendation 19

Exclusion diets cannot be recommended to achieve remission in

active CD, even if the patient suffers from individual intolerances.

Recommendation 20

Probiotic therapy using E. coli Nissle 1917 or VSL#3, but not

necessarily other probiotics, can be considered for use in patients

with mild to moderate UC for the induction of remission.

Recommendation 21

Probiotics should not be used for treatment of active CD.

.


Recommendation 25

Exclusive EN is effective and is recommended as the first line of

treatment to induce remission in children and adolescents with

active CD.

Recommendation 28

Standard EN (polymeric, moderate fat content, no particular

supplements) can be employed for primary and supportive

nutritional therapy in active IBD.

Recommendation 29

Specific formulations or substrates (e.g. glutamine, omega-3-fatty

acids) are not recommended in use of EN or PN in IBD patients.

Nutrition in IBD – conclusions

No surprises and little dogma

Consolidation of previous advice

Common-sense approach

Includes recommendations on (inter alia)

osteoporosis, obesity, and surgical and

obstetric practice

Areas for research better defined

We hope this will be during 2016

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