Navigating Inflammatory Bowel Diseases Using a Nutrition Care Pathway

Sponsored by the Crohn’s & Colitis Foundation through an educational grant from Nestlé Health Science

**Note that this presentation file is for educational purposes only. Viewing of the file does not offer CPE credit. Alteration or reproductions of the presentation slide or file content is not permitted.

Disclosures

• Paid Consultant

• Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway

Caroline Hwang, MD

• Employee

• Keck School of Medicine of USC – Assistant Professor of Clinical Medicine

Disclosures

• Paid Consultant

• Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway

Kelly Issokson, MS, RD, CNSC

• Employee

• Cedars-Sinai Medical Center – Clinical Dietitian

Disclosures

• Consultant

• Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway

Catherine Giguere-Rich, RDN, LD

• Employee

• Dartmouth Hitchcock Medical Center – Clinical Dietitian

At the end of the session, the participant will be able to:

• Explain the steps in the Crohn’s & Colitis Foundation’s Inflammatory Bowel

Disease (IBD) Nutrition Care Pathway including the importance of the MD-

RD partnership in caring for IBD patients

• Describe the unique characteristics of IBD patients that meet malnutrition

criteria as recommended by the Academy of Nutrition and Dietetics

(Academy) and the American Society for Parenteral and Enteral Nutrition

(ASPEN)

• Explain how IBD disease course and treatment impact the macronutrient

and micronutrient needs in the IBD patient and identify strategies for

restoring nutritional balance

Audience Response Question

Please indicate your professional designation:

A. Registered Dietitian Nutritionist

B. Dietetic Technician, Registered

C. MD

D. Nurse

E. NP/PA

Audience Response Question

What percentage of your total patient population is made up of IBD patients?

A. 0%

B. 1-20%

C. 21-40%

D. 41-60%

E. >60%

F. Not applicable

Audience Response Question

How confident are you in your ability to appropriately screen patients with IBD for malnutrition?

A. Not at all confident

B. Somewhat confident

C. Moderately confident

D. Very confident

E. Completely confident

Audience Response Question

How often do you follow an evidence-based pathway for the screening and management of IBD patients who are at risk for or are diagnosed with malnutrition?

A. Never

B. Rarely

C. Sometimes

D. Very often

E. Always

Audience Response Question

How confident are you in your ability to appropriately intervene and monitor patients with IBD and malnutrition?

A. Not at all confident

B. Somewhat confident

C. Moderately confident

D. Very confident

E. Completely confident

Inflammatory Bowel Diseases:A Primer on Disease Manifestations & Treatment

Caroline Hwang, MD

Audience Response Question

Which of the following is true about IBD?

A. Low-dose steroids remains the mainstay for both Crohn’s disease and ulcerative colitis

B. About 40% of Crohn’s disease patients will require surgery within the first 10 years of their disease course

C. If a patient responds to a new biologic, you would expect symptoms to improve by ~2 months

D. Crohn’s disease always involves the small intestine (ileum) and thus malnutrition risk is higher than with ulcerative colitis

Epidemiology

Approximately 1.6-3.1 million pts in U.S.

≈ Prevalence is 1 in 200

Classically a disease of industrialized nations

(N. America, NW Europe)

Changing IBD trends

Growing incidence in developing nations

(Asia, S. America, Middle East)

Also higher rates in immigrants in U.S/Europe

Dietary/environmental cause?

Patterns of disease

55% UC, 43% CD 1% UC, 3% CD

6% UC, 19% CD 55% UC, 43% CD

Crohn’sProbability of Surgery for CD

Cumulative Bowel Damage

Relapsing Remitting Disease Course

Differentiating IBD Subtypes: Ulcerative Colitis

UC: Extent of Disease

UC: Severity of Disease

UC: Severity of Disease

Characteristics of Crohn’s Disease

Wide Spectrum of Crohn’s Disease Manifestations

Complications of Crohn’s Disease

SURGERY

Medication Options for IBD

• Conventional/Non-targeted (Pills)

• Steroids

• Antibiotics

• Aminosalicylates (anti-inflammatories)

• Immunomodulators (6MP, azathioprine, methotrexate)

• Biologics/Targeted (Injections, Infusions)

• TNF-blockers

• Integrin-blockers

• IL-12/IL-23 blockers

• Jak2-Kinase inhibitors

Medical Management

Ulcerative Colits Crohn’s Disease

Surgery

Biologic

Topical Steroids

(Budesonide)

Biologics

6MP/AZA

Steroids

Surgery

Severe

Moderate

Mild

Early

LateMesalamine, SSZ

(Budesonide)

(Antibiotics)

Steroids

6MP/AZA

Surgery

Biologic/SM

BlockingCytokines(Cell signaling proteins, i.e TNF, IL-12, IL-23)

BlockingIntracellular messengers(JAK kinase)

Blocking vascularTrafficking (Integrins

Targeted Therapies: (Steroid-Sparing)

New Era of Targeted Therapies (Steroid-Sparing)

Expected Response to Therapies: Interpreting Clinical Trials for Real Life

INDUCTION (First 6-12 weeks)Trial endpoints: 20-50% symptom improvementEfficacy rates: 30-60% (wide range)

MAINTENANCE (Long-term 30-52 weeks)Trial endpoints: Clinical/endoscopic remissionEfficacy rates: 20-40% (wide range)

Audience Response Question

Which of the following is true about IBD?

A. Low-dose steroids remains the mainstay for both Crohn’s disease and ulcerative colitis

B. About 40% of Crohn’s disease patients will require surgery within the first 10 years of their disease course

C. If a patient responds to a new biologic, you would expect symptoms to improve by ~2 months

D. Crohn’s disease always involves the small intestine (ileum) and thus malnutrition risk is higher than with ulcerative colitis

Malnutrition in IBD and the development of a nutrition care

pathway

IBD Increases Risk of Malnutrition

Malnutrition reported in 40-70% of hospitalized IBD pts & 20-50% of IBD outpts

Reduced Nutritional IntakeAnorexia, Nausea, Pain

Restrictive diets

IncreasedNutritional Needs

Inflammation, Infection, Surgery

IncreasedNutrient Losses

Malabsorption, Diarrhea, Vomiting, Fistulas, Intestinal

protein losses

Medications Corticosteroids, Drug-nutrient interactions

SurgeryReduced absorptive

area, short bowel

Causes of Malnutrition with

IBD

Complications of Malnutrition in IBD

• Few studies on the impact malnutrition has on IBD course/complications

• Single large Canadian study using the Nationwide Inpatient Sample:Malnutrition in IBD patients (~6% of UC, 7% of CD) associated with:

In-hospital mortality (OR 3.49, % CI: 2.89-4.23) Length of stay LOS (11.9d versus 5.8 days, P < 0.00001) Total cost of hospitalization ($45,188 versus $20,295, P < 0.0001).

• IBD patients with low albumin:

- Higher rates of wound infections, anastomotic leak

- Increased risk of anti-TNF failure

1. Nguyen GC et al: Inflamm Bowel Dis 20082. Telem DA et al: Arch Surg 2010

Importance of Addressing Disease-Related Malnutrition

• Dearth of studies about the utility of nutritional support in IBD

• Better supported in other at-risk populations

• Cystic fibrosis

• Aggressive nutritional rehab at CF centers ↑ avg life expectancy/lung function

• Surgical Cancer Patients

• Adoption of “enhanced recovery algorithms” (preop carb loading, earlier postop feeding less operative complications, shorter hospital stays

• Hospitalized Malnourished Elderly

• Oral supplements ↓Mortality ↓ infections/pressure wounds, shorter hospital stays

1. Castellani C et al: J Cyst Fib 20182. Burden S et al: Cochr Syst Rev 20123. Milne et al: Ann Int Med 2006

Challenges in Recognizing Malnutrition in Clinic

• Malnutrition = Actually a complex diagnosis

No single anthropometric or laboratory test/biomarker

Insufficient time (average clinic visit = 10-20 minutes,

spent predominantly on discussing symptoms/meds

• Most physician lack formal training on nutrition

• Lack of dietitians in clinic / insurance coverage

Weight Loss

Loss of Fat/Muscle, Edema

Decreased Function (Handgrip)

ASPEN/AcademyDiagnostic `Criteria

(Any 2)

InsufficientEnergyIntake

Mueller C et al: JPEN 2011

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway

• In 2015, the Crohn’s & Colitis Foundation launched an effort to develop a Nutrition Care Pathway as part of IBD Qorus™ (quality-of-care program)

• Multiple step process

- Focus groups conducted (providers, patients)

- Major barriers Limited provider time, access to dietitian ($$, expertise in IBD)

- Steering committee formed (Gastroenterologists/Dietitians w/ expertise in IBD)

- In-person moderated workshop (nutrition scientists, care pathway experts)

- Literature review

- Weekly phone conference consensus

ASSESSMENT

INTERVENTION

M o n i t o r i n g

SCREENING

Low RiskAt Risk

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway

√

Easy to implement in busy clinic

Recognizes access to dietitians may be limited

ASSESSMENT

INTERVENTION

M o n i t o r i n g

SCREENING

Low Risk At Risk

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway

• Required by Joint Commission in all patients hospitalized within first 24 hrs. of admission

• Multiple screening tools have been developed to identify presence or risk of malnutrition

• Ideal screen is sensitive, simple, and reliable

• For IBD patients, important to take into consideration of disease acuity/activity

• Malnutrition Universal Screening Tool (MUST)

• Validated instrument in inpatients and also ambulatory clinics (elderly, cancer, ESRD)

• Predictive of mortality, worse QOL, hospitalizations, LOS, clinic visits

'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on ’MUST' see www.bapen.org.uk

1. Raslan M et al: Nutrition 20102. Boleo-Tome C et al: Br J Nutr 20123. Skipper A et al: J Parenter Enteral Nutr 2012

Step 1: Malnutrition Screening

• Required by Joint Commission in all patients hospitalized within first 24 hours of admission

• Multiple screening tools have been developed to identify presence or risk of malnutrition

• Ideal screen is sensitive, simple, and reliable

• For IBD patients, important to take into consideration of disease acuity/activity

• Malnutrition Universal Screening Tool (MUST)

• Validated instrument in inpatients and also ambulatory clinics (elderly, cancer, ESRD)

• Predictive of mortality, worse QOL, hospitalizations, LOS, clinic visits,

'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on ’MUST' see www.bapen.org.uk

BMI(<20, <18.5)

% Wt loss(>5%, >10%)

Acute Disease Effect(Acute illness, Poor po intake

1. Raslan M et al: Nutrition 20102. Boleo-Tome C et al: Br J Nutr 20123. Skipper A et al: J Parenter Enteral Nutr 2012

Step 1: Malnutrition Screening

Malnutrition Self-Screening Feasible

0%

40%

80%

Low Moderate High

72%

10% 18%

In a single IBD center, self-screen MUST completed by over 500 patients correlated well with

MUST screen by physicians (Κ= 0.86)1

Foundation’s IBD Qorus experience (7 IBD centers/GI practices in the U.S.)2

- 2,388 IBD outpatients completed self-screen MUST

- 86% reported MUST self-screen as either very easy or easy to complete

1. Sandhu A et al: JPEN 2015.

2. Hwang C et al: Abstract presented AIBD 2016

Step 2: Nutritional Assessment• Comprehensive nutritional assessment most often requires assessment by

dietitian- Anthropometrics, Dietary History (diaries, etc.), Laboratory testing

• Basic assessment can be done by physician/nurses, though many may feel unprepared - Recent Foundation focus group – Only 41% of gastroenterologists rated knowledge of nutrition as very

good, many cited lack of awareness of standardized malnutrition tools

• Subjective Global Assessment (SGA) • One of the most widely-used nutrition tools, initially developed in cancer patients but validated since in

multiple inpatient/outpatient populations

• Shorter patient self-generated version (PG-SGA) feasible to implement in clinic• Weight loss (6 mo., 1 mo., 2 weeks)

• Gastrointestinal symptoms impacting intake• Dietary intake • Functional/activity level

• Presence of other factors that affect nutritional status• Active IBD• Prednisone use (> or <10mg/day)

• Presence of fever

PG-SGA

Additional Factors (SGA):1. Contributing disease: Active IBD (+1), Fistula (+1)

2. Steroid use: <10mg (+1), 10-30mg (+2), >30mg (+3)

Screening all IBD patients for Malnutrition Risk (MUST)

SECONDARY ASSESSMENT & INTERVENTION

Low-Risk Moderate-Risk

Assessment ofNutritional Status (PG-SGA)Immediately or can consider

Observation/Education & F/U 1-2mo

Dietitian Assessment & Multidisciplinary Intervention

Dietary Education/CounselingEnteral & Parenteral Support

High-Risk

M o n i t o r i n g

PRIMARYASSESSMENT

SCREEN

No ActionAssessment of

Nutritional Status (PG-SGA)Immediately

PG-SGA<4

PG-SGA 4-8ROUTINE

PG-SGA >9URGENT

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway

Malnutrition in IBD: Looks Can Be Deceiving

Kelly Issokson, MS, RD, CNSC

Audience Response Question

The BMI of an IBD patient compared to a healthy control tends to be:

A. Lower than healthy controls

B. Higher than healthy controls

C. Not different from healthy controls

Malnutrition

An acute or chronic state of under or overnutrition that leads to a change in body composition and function.

A predictor of poor prognosis in hospitalized IBD patients

Inflamm Bowel Dis (2008) 14:8

Malnutrition in IBD

• Malnutrition in IBD results in poor clinical outcomes

• Growth failure

• Reduced response to pharmacotherapy

• Increased risk for sepsis

• Mortality

• Decreased oral intake common in active IBD (anorexia, sitophobia)

• Lower fiber and phosphorus intake in inactive CD

• Maldigestion, malabsorption, enteric loss of nutrients, rapid transit, increased energy needs w inflammation or infection, adverse effects of medical therapy

Curr Gastroenterol Rep (2016) 18: 55Inflamm Bowel Dis (2008) 14:8

Malnutrition Criteria (Academy/ASPEN)Moderate Malnutrition

(ICD 10 E44.0)Severe Malnutrition

(ICD 10 E43)

Weight loss 1-2% in 1 week5% in 1 month7.5% in 3 months10% in 6 months20% in 12 months

>2% in 1 week>5% in 1 month>7.5% in 3 months>10% in 6 months>20% in 12 months

Energy Intake <75% intake in >7 days<75% intake in >1 month <75% intake in >3 months

<50% intake in >5 days<50% intake in >1 month <50% intake in >1 month

Subcutaneous Fat Loss Mild Moderate to Severe

Subcutaneous Muscle Loss

Mild Moderate to Severe

General or Local Fluid Accumulation

Mild to Severe Moderate to Severe

Hand Grip Strength (Dynamometer)

Not Applicable Measurably reduced

Adapted from Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)

IBD Non-IBD

BMI 21.34

Malnutrition incidence:6-7%1

Sarcopenia: 42%2

1. Inflamm Bowel Dis. 2008 14:82. Inflamm Bowel Dis. 2018 Jun 7 Epub ahead of print3. Curr Opin Gastroenterol. 2018 Jul;34(4):217-2254. Eur J Intern Med. 2010 Aug;21(4):315-9.

BMI: 26.54

Malnutrition incidence: 1.8%1

Sarcopenia (muscle mass begins to decline around age 40; can lose 3-8% muscle mass per decade)

Characteristics of the IBD vs. non-IBD patient

BMI is Associated with IBD

• Systematic Review and Meta Analysis (Dong et al) of 24 studies, n=1442

• BMI significantly lower in CD compared to healthy controls

• Medical therapy improved BMI in CD (not UC)

• Active IBD BMI was significantly lower than healthy controls

PLOS One (2015) 10:12

Fat-free Mass and Fat Mass Reduced in IBD

• Systematic Review (Bryant et al) of 19 studies, n=631 CD, 295 UC

• Reduced fat-free mass in 28% CD and 13% UC

• Reduced fat mass in 31% CD and 13% UC

• No consistent association between body composition and disease activity, duration, extent or therapies.

• BMI did not accurately predict body composition

Aliment Pharmacol Ther 2013; 38: 213–225

Malnutrition in IBD

• Nationwide study1 of hospitalized IBD vs non-IBD hospitalized patients

• Greater prevalence of malnutrition in CD and UC (6.1% and 7.2% vs 1.8%, p<0.0001)

• Adjusted odds ratio for malnutrition among IBD admissions compared to non-IBD was 5.57 (95% CI: 5.29-5.86)

• More IBD discharges than non-IBD discharges received PN (26% vs 6%, p <0.0001)

• Increased likelihood of malnutrition in those with fistulizing CD (OR 1.65) and in those with bowel resections (OR 1.37)

• Malnutrition was associated with increased hospital mortality 3.49, length of stay (11.9 days vs 5.8 days, p <0.00001), and total charges ($45k vs $20k, p <0.0001)

1. Inflamm Bowel Dis (2008) 14:8

Demographic and Clinical Predictors of Malnutrition

• Males, non-Hispanic whites

• Those receiving Medicare or Medicaid

• Active fistulizing disease (active obstructive disease had lower likelihood of malnutrition)

• Bowel resection

Inflamm Bowel Dis (2008) 14:8

Food Restriction & Malnutrition

• One cause for malnutrition: diet adjustment based on patient experience and beliefs

• Recent survey in IBD patients (n=104) looked at those with food exclusions (FE) vs none

• Anthropometrics and nutritional status (SGA)

• Diet beliefs and food restriction

• Nutrient intake

Clin Nutr Res. 2018 Jan; 7(1): 48-55

Clin Nutr Res. 2018 Jan; 7(1): 48-55

Clin Nutr Res. 2018 Jan; 7(1): 48-55

Food Restriction & Malnutrition

• Malnutrition rate significantly higher in food exclusion group (p=0.007)

• 59% held diet beliefs and reported modifying their diet because of these

• 83% (FE) and 67% (non FE) wanted nutrition education and management

• Most common restrictions: Milk, dairy products (32%), raw fish (24%), deep spicy foods (22%), ramen (18%)

• Calcium (p=0.002), vitamin A (p<0.001), and zinc (p=0.001) mean intake was significantly lower in food exclusion group

Clin Nutr Res. 2018 Jan; 7(1): 48-55

Sarcopenia in IBD

Systematic Review, 5 studies, n=658 patients

• 42% had sarcopenia

• Did not assess anatomical/functional components of sarcopenia

• Sarcopenic IBD patients had higher probability of requiring surgery

• Rate of major complications was significantly higher in patients with sarcopenia

Inflamm Bowel Dis. 2018 Jun 7. doi: 10.1093/ibd/izy212. [Epub ahead of print]

IBD

BMI 21.34

Malnutrition incidence: 6-7%1

Sarcopenia: 42%2

1. Inflamm Bowel Dis. 2008 14:82. Inflamm Bowel Dis. 2018 Jun 7 Epub ahead of print3. Curr Opin Gastroenterol. 2018 Jul;34(4):217-2254. Eur J Intern Med. 2010 Aug;21(4):315-9.

Approaches for Improving Outcomes

• Nutrition Screening

• Early RD intervention

• Diet liberalization

• Strategies to restore nutrition balance and preserve lean body mass

• Multidisciplinary Collaboration

• MD/Surgeon

• Physical Therapist

• RN

Audience Response Question

The BMI of an IBD patient compared to a healthy control tends to be:

A. Lower than healthy controls

B. Higher than healthy controls

C. Not different from healthy controls

Impact of Inflammatory Bowel Disease on Nutrition and Strategies for Restoring Balance

Catherine Giguere-Rich, RDN, LD

Audience Response Question

Patients with IBD have increased protein needs in which clinical situation (s):

A. Steroid therapy

B. High output enterocutaneous fistula

C. During flare

D. All of the Above

How can disease and treatment affect nutrition?

1. Common dietary recommendations and trends

2. Macronutrient needs

3. Cases

4. Micronutrient deficiencies

5. EEN (exclusive enteral nutrition)

6. Parenteral nutrition

7. Hydration

How Does Treatment Affect Nutrition?

62

IBD patients are at risk for malnutrition because of many factors:

1) Increased losses—Diarrhea (electrolytes), bleeding (iron), Ostomy

2) Decreased intake—Poor appetite, limited diet (fruits, vegetables)

3) Malabsorption—Inflammation, surgery, fistulas surface area, SBS

4) Catabolic state—Inflammation causes in metabolic/protein needs

5) Drug interference—Steroids block calcium absorption, Methotrexate blocks folate

Malnutrition can occur with:

Macronutrients—protein, calories

Micronutrients—Vitamins, mineral, trace elements

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

Calorie and Protein Needs in IBD

Usually occurs during flares—weight loss and loss of lean muscle

Many equations are available to estimate energy requirements

Protein—needs may increase slightly during flare (1-1.5 + g/kg/day) Prednisone, need to gain weight, or losses

Fluid 30-35 ml/kg/day Holiday Segar Equation (1500 ml + 20 ml/kg for each kg >20 kg)

If diarrhea or high ostomy output—suggest ORS

Electrolytes—sodium, potassium, magnesium

1. Gong J, Zuo L, Guo Z. J Parenteral Enteral Nutr. 2015;39(6):713-718.2. Eiden KA. Nutrition Issues in Gastroenterology. 2003; series #5: 33-54

63

• EE NOT SIGNIFICANTLY ELEVATED IN IBD

• REE SLIGHTLY INCREASED DURING ACTIVE INFLAMMATION

64

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

65

Common Diet Recommendations

• Low Fiber

- Minimal 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 Diets

- Ulcerative Colitis in remission

- Short Chain Fatty acids (SCFA)-butyrate, acetate, proprionate

• Lactose Avoidance if Intolerant- Common among IBD patients- But can happen temporarily during flare

Overall, individualized healthy diet

Seidner DL, Lashner BA, Brzezinski A. Clin Gastroenterol Hepatol. 2005;3:358-369 66

Diet Trends• Gluten-free

- Protein found in foods processed from wheat, barley or rye

- Celiac Disease

- Gluten intolerance relatively common in Irritable Bowel Syndrome (IBS)

- Gluten Free diet may help alleviate symptoms not related to inflammation but further research is needed.

• Low FODMAPS 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, encourage working with registered dietitian familiar with low fodmap diet

- Further research is needed

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

67

Diet Trends

Specific Carbohydrate Diet (SCD)

Trial of Specific Carbohydrate and Mediterranean Diets to Induce Remission of Crohn’s Disease (DINE-CD) Study

Case series found SCD to be a potential effective tool in management of colonic and ileocolonic Crohn’s disease in remission.

KakokkarS, FarooquiA, Mikolaitis SL. J.Academy of Nutr and Dietetics. 2015;15(80): 1226-123268

Turmeric (Curcumin) and Ulcerative Colitis

Anti-inflammatory and antioxidant properties

Small study shows:

May be effective and safe for maintaining remission for people with inactive disease.

May help induce remission in mild to moderate UC

Hiroyuki H, Takayuki I, Ken T. Clinical Gastroenterology and Hepatology. 2006;4:1502-1506

Probiotics

Science on probiotics is inconclusive Probiotics may or may not be beneficial

May reduce risk of C.Diff Specific probiotics have been shown to be beneficial in mild ulcerative colitis, pouchitis, recurrent C. diff infections (VSL-3, florastor)

Recent meta-analysis concluded that efficacy on probiotic use in CD remains uncertain

Probiotics supplements There are many brands (e.g VSL #3, Florastor, Culturelle, Align) And many species (e.g Lactobacillus vs Acidophilus vs Saccharomyces Boulardii)

Fermented foods just as good? Kefir or yogurt Kimchi or saurkraut

Kombucha

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

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

70

Case #1

• 30 year old female with Crohn’s disease since the age of 19 presents to outpatient clinic for nutrition consultation. She had been doing well with her IBD until about 6 months ago. Her most recent colonoscopy demonstrated ulcerations of the ileum and colon.

• She experiences 6-10 loose bowel movements daily and abdominal pain with eating. She states she feels she is in a flare. She has required prednisone to help relieve her symptoms. Her gastroenterologist recently changed her biologic medical therapy to help better treat her disease.

• She is having difficulty with eating. She is avoiding dairy products due to lactose intolerance. She is not eating raw fruits and vegetables because they cause too much pain, and she can only eat small amounts of bread, pasta, and chicken. She has lost about 15 lbs over the last 3 months with BMI now of 17. She is very motivated to do whatever she

needs to do to get better.

71

Which micronutrient deficiencies would you be concerned about with this patient?

a)Calcium and Vitamin D

b)Vitamin B12

c) Iron

d)All of the above

72

Calcium and Vitamin D

Calcium

• 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)

Vitamin D

• Risk factors: Steroids, restricted diet, decreased sunlight

• 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

Bernstein CN, Leslie WD, Leboff MS. Gastroenterology. 2003;124(3):79573

EVIDENCE OF RISK FOR DEFICIENCY

Calcium and Vitamin D

Calcium

- Diet sources: 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

Vitamin D

- Diet sources: Salmon, tuna, milk, eggs

- Supplement: Most IBD patients 600-2000IU daily

-If level<20: 50,000 IU D2 or D3 for 12 weeks

-Maintenance dose of 1500-2000 IU/d D3

-higher maintenance doses of 3000-6000 IU/d for patients on glucocorticoids, those with malabsorption, BMI >30, or in those with small

bowel involvement

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.

17

TREATMENT

Vitamin B12 and Folate

Vitamin B12

• Risk factors: Ileitis/small bowel surgery, small intestinal bacterial overgrowth, gastritis

• About 20% of patients (adult and pediatric) with Crohn’s disease

• Pernicious anemia, macrocytosis, cognitive symptoms, glossitis

Folate

• Risk Factors: SB resection, Meds: methotrexate (MTX), sulfasalazine (SSZ)

• Older studies showed 20-60% of patients with IBD to be deficient

• More recently has become uncommon

• Megaloblastic anemia, macrocytosis, smooth sore tongue

•

Headstrom PD, Rulyak SJ, Lee SD. Inflamm bowel Dis. 2008 14 (2) 217. 75

EVIDENCE OF RISK FOR DEFICIENCY

Type of Anemia Microcytic Macrocytic Normocytic

HGB

HCT

MCV (cell volume) Normal

Vitamin B12 and Folate

Vitamin B12

• Diet sources: Trout, tuna, beef, milk

• All pts with ileal surgery (>60cm) intramuscular vit B12 for life (1000 mcg/mo)

• Oral—1000 mcg daily (various options)

Folate

• Diet sources: Fortified cereals, spinach, cantaloupe

• 1 mg Folic Acid daily

• All patients on MTX or SSZ

Eiden, K. A. Nutrition Issues in Gastroenterology. 2003; Series #5, 33-54. 76

TREATMENT

Iron

35-60% of patients with IBD are deficient

Risk factors: Active inflammation/chronic blood loss, Ulcerative Colitis, SIBO

Significant negative impact on quality of life

Microcytic anemia

Crohn’s & Colitis Foundation’s IBD Anemia Care Pathway http://www.crohnscolitisfoundation.org/science-and-professionals/ibdqorus/ibd-qorus-care-pathways.html

Gisbert JP, Gomollon F. AmJGastroenterology.2008;103(5):1299. 77

EVIDENCE FOR RISK OF DEFICIENCY

Iron Deficiency Anemia

Diet Sources: Meat, Fish, Leafy Greens, Fortified Cereals

Patient with IBD pose unique challenge for supplementation Oral iron tolerance

Oral iron in setting of inflammation

Absorption

IV iron is used if determined best for the patient by the MD

In inactive IBD/normal CRP: 100 mg oral iron daily in divided doses. Additional vitamin C may help enhance iron absorption

Gomollon F, Gisbert JP. Curr Opin Gastroenterol. 2013;29(2):201

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TREATMENT

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

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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

Polymeric versus elemental?

Exact mechanism of action unknown

Immune modulation

Intestinal inflammation

Microbiome

Duration of treatment is 6-8 weeks

EEN

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Future work on personalized therapy is needed

Food reintroduction—varies, lack of evidence for recommendation

Maintenance enteral nutrition?

Role of the dietitian Calculate energy needs and goals for intake/nutrition prescription

Regular contact to help ensure compliance and provide support

Collaboration with the MD

Monitor patient’s weight

Partial Enteral Nutrition (PEN)

Case #2

• 53 year old male diagnosed with ulcerative colitis at the age of 12. He underwent total colectomy with end ileostomy at the age of 38. He was diagnosed with Crohn’s disease at that time based on symptoms and further testing. Since the age of 45, he required many small bowel resections due to stricturing disease. He now has 130 cm of remaining small bowel with no colon. More recently, he developed an enterocutaneous fistula, which was actively draining. This required NPO with Parenteral Nutrition Support.

• His fistula output has been decreasing with hope for closure. His doctor said he can start to eat, but struggles with high ostomy output. He has never followed a special diet, just eats based on how he feels. He saw a dietitian once while in the hospital but was not able to eat much at that time due to fistulas, so he doesn’t fully remember her helpful information.

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Where should you start to help this patient come off TPN?

a)Educate him on short gut syndrome diet and oral rehydration solutions

b)Tell him to forget it, he will be on TPN forever

c)Suggest PEG tube placement

d)Give him vitamin supplements

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Parenteral Nutrition

Not primary therapy in IBD (Crohn’s disease)

Indications are similar to those in other disease states SBS (short bowel syndrome)

Persistent SBO (small bowel obstruction)

Inability to tolerate Enteral Nutrition (EN)/Enteric fistula

In this case Provided 30 kcal/kg/day

1.5 g/kg/day protein

Maintenance fluid need

Cycled over 12 hours

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USE IN IBD

Short Gut Syndrome Diet

Patients with ileostomies (no colon): higher fat diet (50% of calories)

Patient with intact colon: higher carbohydrate (50-60% of calories)

Avoid concentrated sweets and fluids

Chew foods well

No Colon—salty meals and snacks

Small frequent meals

Trial of Oral Rehydration Solutions/drink isotonic beverages

Separate solids and liquids at Meals as much as possible

Limit enteral stimulants such as alcohol and caffeine

Lactose restriction if needed

Enterocutaneous Fistula—closure can take time—variable

Magnesium

www.ginutrition.Virginia.edu 84

EVIDENCE BASED GUIDELINES

Oral Rehydration Solutions

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Commercial Products Isotonic The WHO formula

Homemade Recipes

Also isotonic Oley Foundation Dilute sports drinks or juice and add salt and/or baking soda

depending on electrolyte needs

Zinc

Risk Factors: ostomies, fistulas, profuse diarrhea

Up to 65% of patients with CD have low serum zinc levels, however, affected by albumin

Alkaline Phosphatase (ALP)

Symptoms: skin changes-scaly eczematous plaques, taste changes, growth failure

TREATMENT

Diet sources: 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

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

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EVIDENCE FOR RISK OF DEFICIENCY

IBD in Remission

Crohn’s

• Healthy Diet

• Everyone’s will be slightly different

• Dietitian: help make sure to avoid deficiencies, keep healthy, and in some cases nutritionally rehabilitate

Ulcerative colitis

• High Fiber Diet

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Conclusions

• Treatment (both medical and surgical) affect nutrition

• Important to treat both macro and micronutrient deficiencies and know when to check

• Nutrition support plays a key role in severe disease

• Diet trends may help alleviate GI symptoms not directly related to inflammation

• Natural remedies may effective (and usually safe) but only in setting of extent of disease

• Exclusive enteral nutrition can be an effective therapy and requires support from dietitian

• A healthy individualized diet is key

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INFLAMMATORY BOWEL DISEASE

Audience Response Question

Patients with IBD have increased protein needs in which clinical situation (s):

A. Steroid therapy

B. High output enterocutaneous fistula

C. During flare

D. All of the Above

The Crohn’s & Colitis Foundation’sIBD Nutrition Care Pathway:

Patient Cases

Audience Response Question

A Partial Formula Diet:

A. Has been shown to maintain remission in Crohn’s disease

B. Can help improve response to biologic therapy

C. Is a diet that provides 30-50% energy from a formula, and the remainder of energy from a general/healthy diet

D. All of the above

Case #1

• 23 year old female with Crohn’s disease (dx age 21)

• 5’4”, 120 lb.; 14 lb. weight loss in past 1.5 months (usual weight 134 lb.)

• Reports fair appetite, eating a little less than normal

• GI symptoms: Abdominal pain, diarrhea, cramping, nausea, early satiety

• Colonoscopy: colon normal, moderate inflammation in TI with strictures

• Labs: albumin 3, CRP 42

• Medications: 5ASA, 30 mg prednisone

• MD plan: to start biologic therapy

The Foundation’s IBD Nutrition Care Pathway

SCREEN

PRIMARYASSESSMENT

SECONDARY ASSESSMENT & INTERVENTION

Screen all IBD patients for Malnutrition Risk (MUST)

Moderate-Risk High-RiskLow-Risk

No Action

PG-SGA<4

Assessment ofNutritional Status (PG-SGA)Immediately or can consider

Observation/Education & F/U 1-2mo

Assessment ofNutritional Status (PG-SGA)

Immediately

Dietitian Assessment & Multidisciplinary Intervention

Dietary Education/CounselingEnteral & Parenteral Support

M o n i t o r i n g

PG-SGA 4-8ROUTINE

PG-SGA >9URGENT

Case #1: MUST

• Question 1: BMI kg/m2 score = 0• >20 = score 0

• 18.5-20 = score 1

• <18.5 = score 2

• Question 2: weight loss score = 2• Unplanned weight loss on past 3-6 months

• <5% = score 0

• 5-10% = score 1

• >10% = score 2

• Question 3: acute illness score = 0• Acute illness AND no or likely to be no nutritional intake for >5 days

Total score = 2 (high risk)

PG-SGA

Additional Factors (SGA):1. Contributing disease: Active IBD (+1), Fistula (+1)2. Steroid use: <10mg (+1), 10-30mg (+2), >30mg (+3)

Urgent Referral to RD

• Referral received from MD, with noted medical management plan for continuing corticosteroids, and initiating biologic therapy. MD feels patient would be a good candidate for partial enteral nutrition to improve nutritional status and response to biologic therapy

• Significant recent weight loss of 10.4%

• Food recall reveals she is eating <60% of energy needs over the past month

• Limiting PO intake to try and prevent/control symptoms

• She is also avoiding dairy and gluten due to fear of worsening IBD

Malnutrition Criteria (Academy/ASPEN)Moderate Malnutrition

(ICD 10 E44.0)Severe Malnutrition

(ICD 10 E43)

Weight loss 1-2% in 1 week5% in 1 month7.5% in 3 months10% in 6 months20% in 12 months

>2% in 1 week>5% in 1 month>7.5% in 3 months>10% in 6 months>20% in 12 months

Energy Intake <75% intake in >7 days<75% intake in >1 month <75% intake in >3 months

<50% intake in >5 days<50% intake in >1 month <50% intake in >1 month

Subcutaneous FatLoss

Mild Moderate to Severe

Subcutaneous Muscle Loss

Mild Moderate to Severe

General or Local Fluid Accumulation

Mild to Severe Moderate to Severe

Hand Grip Strength (Dynamometer)

Not Applicable Measurably reduced

Adapted from Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)

Nutrition Intervention

• Educate patient on disease effect on nutritional status• Increased energy and protein requirements with active disease and

diarrhea• Decreased absorption of B12 and possible fat/fat soluble vitamins with ileal

disease • Strictures causing partial obstructive episodes

• Educate on macronutrient goals • Mifflin REE x 1.3 + kcals for weight gain; 1.5 g protein/kg body weight• Small/frequent meals, low fiber; consider lactose free (not dairy free)• Partial Enteral Nutrition (PEN) (to provide 30-50% of energy needs)

• Educate on micronutrient goals• Increased calcium, vitamin D needs on corticosteroids• Increased zinc needs with diarrhea and weight loss• Daily sublingual or monthly intramuscular B12• Increased fluid and sodium needs due to diarrhea

Formula Diets in IBD: PEN

• PEN: 30-50% of nutrient needs delivered by formula, remainder via diet

• Can be helpful for maintaining remission in CD

• PEN is more effective then regular diet, as effective as some medications (mercaptopurine, 5-ASA) in maintaining remission in inactive CD (El-Matary et al, 2015)

PEN – Lower Relapse Rates

• Lower relapse rates in PEN vs no PEN in CD patients (Takagi et al. 2006)

• RCT, free diet + PEN (elemental formula, 50% needs) vs free diet; on mesalamine or azathioprine

• The dosage for the half ED group per day was 900–1200 kcal (3–4 sachets in 900–1200mL water) of Elental (AJINOMOTO PHARMA Co., Tokyo, Japan) via self-inserted tube &/or oral intake

• Primary Outcome Measure = Relapse occurrence over 2-year period

• Relapse rates significantly lower in PEN group (34% vs 64%)

Combination Therapy: PEN + Infliximab

• Meta-analysis shows 2-fold increase in the odds of achieving clinical remission in

CD pts on combination therapy with specialized enteral nutrition and infliximab

compared with infliximab monotherapy

• The probability of maintaining clinical remission on combination therapy appears

to extend beyond 1 year

DL Nguyen, et al Ther Adv Gastroenterol 2015

Monitor/Evaluate

Goals:

• GI tolerance to PO diet

• Adequate energy and protein intake on low fiber & PEN diet (>75% of needs met daily)

• Weight maintenance/regain 0.5# weekly

• Check/replace 25-OHD, B12 levels baseline and annually

• DEXA

Case #2

• 52 year old male with newly diagnosed ulcerative colitis

• 6’2”, 180 lb; recent weight loss of 10 lb in 3 weeks (usual wt 190 lb)

• Good appetite, eating well. Regular diet.

• GI symptoms: bloody diarrhea with >15 BM daily

• Colonoscopy reveals: moderate-severe pan colitis, normal TI

• Labs: albumin 1.9, fecal calprotectin 980

• Not currently on medications. Wants to start SCD (Specific Carbohydrate Diet)

The Foundation’s IBD Nutrition Care Pathway

SCREEN

PRIMARYASSESSMENT

SECONDARY ASSESSMENT & INTERVENTION

Screen all IBD patients for Malnutrition Risk (MUST)

Moderate-Risk High-RiskLow-Risk

No Action

PG-SGA<4

Assessment ofNutritional Status (PG-SGA)Immediately or can consider

Observation/Education & F/U 1-2mo

Assessment ofNutritional Status (PG-SGA)

Immediately

Dietitian Assessment & Multidisciplinary Intervention

Dietary Education/CounselingEnteral & Parenteral Support

M o n i t o r i n g

PG-SGA 4-8ROUTINE

PG-SGA >9URGENT

Case #2: MUST

• Question 1: BMI kg/m2 score = 0• >20 = score 0

• 18.5-20 = score 1

• <18.5 = score 2

• Question 2: weight loss score = 1• Unplanned weight loss on past 3-6 months

• <5% = score 0

• 5-10% = score 1

• >10% = score 2

• Question 3: acute illness score = 0• Acute illness AND no or likely to be no nutritional intake for >5 days

Total score = 1 (moderate risk)

PG-SGA

Additional Factors (SGA):1. Contributing disease: Active IBD (+1), Fistula (+1)2. Steroid use: <10mg (+1), 10-30mg (+2), >30mg (+3)

Routine Referral to RD

• Referral received from MD, with noted medical management plan for corticosteroids and vedolizumab, along with SCD

• Significant recent weight loss of 5.2% in <1 month

• Food recall reveals he is eating >75% of estimated energy needs, but is losing weight

• No current diet restrictions but is asking if he should start an alkaline vs SCD diet

Malnutrition Criteria (Academy/ASPEN)

Moderate Malnutrition (ICD 10 E44.0)

Severe Malnutrition (ICD 10 E43)

Weight loss 1-2% in 1 week5% in 1 month7.5% in 3 months10% in 6 months20% in 12 months

>2% in 1 week>5% in 1 month>7.5% in 3 months>10% in 6 months>20% in 12 months

Energy Intake <75% intake in >7 days<75% intake in >1 month <75% intake in >3 months

<50% intake in >5 days<50% intake in >1 month <50% intake in >1 month

Subcutaneous Fat Loss Mild Moderate to Severe

Subcutaneous Muscle Loss

Mild Moderate to Severe

General or Local Fluid Accumulation

Mild to Severe Moderate to Severe

Hand Grip Strength (Dynamometer)

Not Applicable Measurably reduced

Nutrition Intervention

• Educate patient on disease effect on nutritional status• Increased nutritional requirements with active disease and diarrhea• Absorptive capacity of macronutrients (and most micronutrients) not

affected as disease is limited to colon

• Educate on macronutrient goals • Mifflin REE x 1.3 + kcals for weight gain; 1.5 g protein/kg body weight• Education on evidence-based diets for IBD, including SCD (grain-free,

dairy-free diet increases risk of inadequate intake of thiamine, folate, pyridoxine, calcium, vitamin D, vitamin E); no need to avoid fiber

• Snacks for additional nourishment (nut butters, avocado, homemade smoothies)

• Educate on micronutrient goals• Multivitamin/mineral needed daily• Increased calcium, vitamin D needs on corticosteroids• Increased zinc needs with diarrhea and weight loss• Increased fluid and sodium needs due to diseased colon

Monitor/Evaluate

Goals:

• GI tolerance to PO diet

• Adequate energy and protein intake on Specific Carbohydrate diet (>75% of needs met daily)

• Weight maintenance/regain 0.5# weekly

• Adequate calcium intake (1000 mg daily)

• Check/replace 25-OHD levels

• Monitor inflammatory makers (CRP, ESR, fecal calprotectin) and micronutrient levels (B12, folate, zinc, vitamin D, selenium, magnesium, B6, thiamine) 6-12 months after start of SCD

Audience Response Question

A Partial Formula Diet:

A. Has been shown to maintain remission in Crohn’s disease

B. Can help improve response to biologic therapy

C. Is a diet that provides 30-50% energy from a formula, and the remainder of energy from general/healthy diet

D. All of the above

Panel Q & A

Crohn’s & Colitis Foundation Resources for Dietitians

• Nutrition Webpage featuring: www.crohnscolitisfoundation.org/nutrition/provider

• Fact sheets

• Online education modules

• Research

• Video & audio podcasts

• Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway http://www.crohnscolitisfoundation.org/science-and-professionals/ibdqorus/ibd-qorus-care-pathways.html

• Malnutrition Universal Screening Tool (MUST) available at http://www.bapen.org.uk/pdfs/must/must_full.pdf

• Patient-Generated Subjective Global Assessment (PG-SGA©) available at http://pt-global.org/?page_id=13

• Crohn’s & Colitis Foundation’s IBD Anemia Care Pathway: www.crohnscolitisfoundation.org/assets/pdfs/anemiafactsheet.pdf

Crohn’s & Colitis Foundation Resources you can share with your patients

Diet and nutrition resources webpage for patients featuring:

• Educational videos and information on supplementation

• Nutritional support therapy

• Special IBD diets

www.crohnscolitisfoundation.org/nutrition

Visit our booth for IBD brochure order forms!! **2433

Audience Response Question

After participating in this activity, how confident are you in your ability to appropriately screen patients with IBD for malnutrition?

A. Not at all confident

B. Somewhat confident

C. Moderately confident

D. Very confident

E. Completely confident

Audience Response Question

After participating in this activity, how confident are you in your ability to appropriately intervene and monitor patients with IBD and malnutrition?

A. Not at all confident

B. Somewhat confident

C. Moderately confident

D. Very confident

E. Completely confident

Audience Response Question

Do you intend to use the Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway in your clinical practice?

A. Yes

B. No

C. Not Applicable

Audience Response Question

Thinking about how your participation in this activity will influence your patient care, what % of your IBD patients are likely to benefit?

A. 0%

B. 1-20%

C. 21-40%

D. 41-60%

E. >60%

F. Not applicable

As a result of this session, will you make any changes to your practice?

A. Yes

B. No

C. N/A

Thank You