Nutri&on)Assessment,)Dietary) Diversity...
Transcript of Nutri&on)Assessment,)Dietary) Diversity...
Nutri&on Assessment, Dietary Diversity, Composi&on and Impact
on Outcomes in IBD Maitreyi Raman MD MSc FRPC Clinical Associate Professor
Medical Director Nutri&on Services Director AsCEND
(Alberta’s Center of Excellence for Nutri&on in Diges&ve Diseases) Associate Director of Admissions, Cumming School of Medicine
University of Calgary Oct 2018
Disclosure
• Faculty: Dr. Maitreyi Raman
• Rela&onships with commercial interests:
– Grants/Research Support: Baxter
– Speakers Bureau/Honoraria: Shire
Objec4ves
• Describe the prevalence of malnutri4on in IBD • Discuss an approach to nutri4onal management for pa4ents admi=ed to hospital
• Discuss the role for therapeu4c diets for ambulatory pa4ents
Adult Starva4on and Disease-‐Related Malnutri4on
Starva&on-‐related
malnutri&on • chronic starva4on
without inflamma4on • e.g. anorexia
nervosa • FS CD
Acute or injury-‐related
malnutri&on • Starva4on • Cri4cally Ill
4
Chronic disease-‐related
malnutri&on • chronic starva4on with inflamma4on
• IBD • COPD
Starva&on –related malnutri&on (SRM) ± Nutri&onal support (NS)
Jensen et al. JPEN J Parenter Enteral Nutr 2010;34 156-159 N.B. no inflammation
Acute vs chronic disease –related malnutri&on ± Nutri&onal support (NS)
Jensen et al. JPEN J Parenter Enteral Nutr 2010;34 156-159 N.B. presence inflammatory process
(months)
Prevalence of malnutri&on in Canada
Bernier, P. 1996
In IBD 75-‐90% of pa&ents are malnourished when admi]ed to hospital
Escapes official sta4s4cs 45% moderate or severe malnutri4on 1.2% on discharge summary sheet
Costs by Nutri4on Status
8 Cur&s et al. Clinical Nutri&on 2016
Bed Days Nourished Moderately Malnourished
Severely Malnourished
Total N=958
8.43 [0.65]
11.66 [1.17]* 11.70 [0.96]*
Medical N=632
8.20 [0.95]
12.05 [1.32]* 12.05 [1.33]*
Surgical N=301
6.98 [0.65]
9.62 [1.39]* 8.75 [1.11]*
Nourished Moderately Malnourished
Severely Malnourished
Total N=958
$5074 [512] $7931 [766]* $7989 [976]*
Medical N=632
$4839 [593] $7825 [849]* $7823 [1042]*
Surgical N=301
$4303 [681] $7154 [1660]* $6744 [1435]*
Length of stay (bed days) by nutri4on status
Nourished Moderately Malnourished
Severely Malnourished
Total N=958
8.43 [0.65]
11.66 [1.17]* 11.70 [0.96]*
Medical N=632
8.20 [0.95]
12.05 [1.32]* 12.05 [1.33]*
Surgical N=301
6.98 [0.65]
9.62 [1.39]* 8.75 [1.11]*
Cur&s et al. Clinical Nutri&on
admission
colonoscopy
CT scan
Afebrile Decreased CRP
discharge
NPO
Admission with decreased intake for days/weeks at
home
1.375kg of muscle loss (2.5%)
66kg, 180cm tall 55kg LBM
Day 1 Day 5
Hospitaliza4on #1
Hospitaliza4on #2
Hospitaliza4on #3
Muscle Mass
Time
The Catabolic Crisis
By One Year…
• 3-‐5kg LBW – Dispropor4onate strength loss – Fat deposi4on in muscle – Exacerbated by low protein, high fat, low CHO intake at home
• Complains constantly of fa4gue, poor energy levels
• Surgery – Increased surgical risks of severe malnutri4on
Preopera4ve Nutri4on Management IBD
• Objec4ves – Evaluate impact of sarcopenia on postopera4ve outcomes
– Evaluate impact of nutri4on therapy on outcomes
• Sarcopenia defined by measuring skeletal muscles at the level of L3 – 2 SD below the norm for young healthy adults
• Enteral Nutri4on indicated for pa4ents at nutri4on risk using NRS >3 OR Intes4nal Stenosis
Zhang et al. JPEN 2017;41(4):592-‐600
Risk Factors Associated with Major Complica4ons Aoer Bowel Resec4on for Crohn’s Disease
Zhang et al. JPEN 2017;41(4):592-‐600
Nutri4on Support using EEN impact in IBD
• Retrospec4ve case control study to evaluate the incidence of post-‐opera4ve complica4ons in stricturing or penetra4ng Crohn’s who received EEN
• Received at least 2 weeks of EEN prior to surgery • Age, Sex, Disease Phenotype and Severity Matched
Heerasing N et al. APT 2017; 45(5):660-‐669
Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease
Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease, Volume: 45, Issue: 5, Pages: 660-669, First published: 20 January 2017, DOI: (10.1111/apt.13934)
Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease
Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease, Volume: 45, Issue: 5, Pages: 660-669, First published: 20 January 2017, DOI: (10.1111/apt.13934)
Screening tool Parameters
Care settings Weight loss
Poor appetite/ food intake
others
Malnutrition Universal Screening Tool (MUST)
* * BMI, Acutely ill Outpatient clinics, hospital wards, in home and community care settings
Nutrition Risk Screening (NRS) * * BMI, Severity of Disease
Hospital
Malnutrition Screening Tool (MST)
* * Hospital, oncology outpatient and community care settings
Abridged patient-generated subjective global assessment (abPG-SGA)
* * Symptoms affecting food
intake, physical activities
Oncology outpatient and inpatient settings
Canadian Nutrition Screening Tool (CNST)
* * Hospital
Saskatchewan IBD-Nutrition Risk
* * GI symptoms, food restriction
IBD outpatient setting
In general practice, the nutritional assessment is most
commonly performed using:
Subjective Global Assessment (SGA; an ASPEN*-
recommended malnutrition assessment)
Anthropometric measurements including BMI, triceps
skinfold thickness (TSF), mid-arm circumference (MAC),
and mid-arm muscle circumference (MAMC)
Hand-grip strength (HGS)
Less common: Body composition measurements using
CT, BIA and DEXA
Nutrition Assessment methods
*ASPEN: American Society of Enteral and Parenteral Nutrition
Limita4ons of Dietary Studies in IBD
• Largely Retrospec4ve, few prospec4ve, food recall studies – Selec4on bias – Pre-‐illness diet
• Single nutrient interven4ons – Fiber Supplements – Probio4cs – Omega-‐3 Fa=y Acids
• Few studies exploring efficacy of holis4c diverse diets
Exclusion Diets • Specific
Carbohydrate Diet • Low FODMAP Diet • Semi-‐Vegetarian
Diet
Food Addi4ves
Specific carbohydrate diet (SCD)
Evolved from a diet for celiac disease mid-‐20th century Based on hypothesis that pa4ents
with IBD) have a dysfunc4on of disaccharidases, necessary to digest and absorb disaccharides and amylopec4n
Therefore, higher amounts of disaccharides would enter the colon, leading to bacterial overgrowth, bowel injury and intes4nal permeability
Suskind et al. J Clin Gastroenterol 2018;52(2):155-‐163
Autoimmune Protocol diet
Konije4 GG et al. Inflamm Bowel Dis 2017;23(11):2054-‐2060.
Extension of Paleolithic Diet Avoidance • Gluten, Refined sugar • Food Addi4ves • Ini4al phase – dairy, eggs, legumes,
nightshades • Fresh, nutrient dense, fermented
Makki et al. Cell Host and Microbe 2018
-0.3 -0.2 -0.1 0.0 0.1 0.2 0.3
-0.2
-0.1
0.00.1
0.2
nMDS 1
nMDS
2
MNWN
WN
MN
P = 0.001
Dietary Diversity is Associated With Greater B-‐Diversity of the Microbiome
Dietary Diversity is Associated with Increased F.Prausnitzii and Bifidobacteria
0 1 2 3 4
Bacteroides dorei (Identity 100%)
Bacteroides thetaiotaomicron (Identity 100%)
Bacteroides uniformis_1 (Identity 99%)
Bacteroides uniformis_2 (Identity 99%)
Bacteroides vulgatus (Identity 99%)
Bifidobacterium faecale/adolescentis/stercoris (Identity 100%)
Dialister invisus (Identity 100%)
Eubacterium hallii (Identity 99%)
Faecalibacterium prausnitzii (Identity 99%)
Lachnospiraceae (Family level)
Subdoligranulum variabile (Identity 99%)
Intestinibacter bartlettii (Identity 100%)
Ruminococcus gnavus (Identity 100%)
Blautia wexlerae (Identity 100%)
Relative abundance %
MNWN*
*
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*
*
*
*
*
*
*
*
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AsCEND: Alberta’s Center of Excellence for Nutri4on in Diges4ve Disease
EXCELLENCE IN CLINICAL
CARE
NOVEL DISCOVERY
and RESEARCH
EDUCATION and KNOWELDGE TRANSLATION
Conclusions
• The prevalence of malnutri4on in hospitalized pa4ents with IBD is high, approaching 90%
• Early iden4fica4on of these pa4ents is important to 4mely nutri4on therapy
• Nutri4on therapy improves clinical and periopera4ve outcomes
• Dietary therapies that focus on pa=erns and composi4on represent a growing area of interest in the management of IBD