Etiology, Assessment and Treatment

Transcription

1 Etiology, Assessment and Treatment Andrew Tinsley MD, MS Associate Director of IBD Center Assistant Professor of Medicine Penn State College of Medicine Abbvie Janssen Nestle 1

2 To review the prevalence of malnutrition in IBD and reasons why patients are at increased risk To explore how to evaluate IBD patients for malnutrition and intervene when necessary Appetizer Definitions Digestion, absorption & IBD Why we care Etiology Did my diet make me sick Doc? Assess A MUST do approach Treatment The pathway to success Food for Thought 2

3 Today s nutrition facts are often tomorrows nutrition fallacies Unknown Diet refers to the foods we eat Nutrition refers to properly absorbing foods and staying healthy Well balanced diet is necessary for nutrition Malnutrition = decline in lean body mass with the potential for functional impairment Malnutrition synonymous with undernutrition JPEN J Parenter Enteral Nutr. 2009;33:

4 Nutrition Risk Identified Compromised intake or loss of body mass Inflammation present? No / Yes No Yes Mild to Moderate Inflammatory Response Yes Marked Inflammatory Response Starvation Related Malnutrition (pure chronic starvation, anorexia nervosa) Chronic Disease Related Malnutrition (pancreatic cancer, rheumatoid arthritis, IBD) Acute Disease or Injury Related Malnutrition (major infection, burns, trauma, closed head injury) JPEN J Parenter Enteral Nutr. 2009;33:710 Characteristics Recommended for the Diagnosis of Adult Malnutrition Insufficient energy intake Weight loss Serum proteins such as albumin and pre albumin are not included! Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may sometimes mask weight loss Diminished functional status as measured by hand grip strength A minimum of 2 of the 6 characteristics is recommended for diagnosis of either severe or non severe malnutrition J Acad Nutr Diet 2012;36:

5 Salivary Glands Saliva moistens / lubricates food. Amylase digests polysaccharides Esophagus Transports food Pancreas Hormones regulate glucose levels. Bicarbonate neutralize stomach acid. Trypsin and chymotrypsin digest proteins. Amylase digests polysaccharides. Lipase digests lipids Liver Metabolizes and synthesizes many biologic molecules. Stores vitamins and iron. Destroys old blood cells. Produces bile acids. Small Intestine Completes digestion Absorbs nutrients, most water Peptidases digests proteins Sucrases digest Sugars Amylase digests polysaccharides Stomach Stores and churns food. Pepsin digests protein. HCL activates enzymes, breaks up food, kills bacteria. Mucus protects stomach wall. Limited absorption Large Intestine Reabsorbs some water and ions. Forms, stores and expels feces Crohn s disease Ulcerative colitis Persistent inflammation of the gastrointestinal tract 5

6 IBD and Malnutrition Risk Malnutrition Why We Care: 30% of outpatient IBD patients with malnutrition IBD patients 5.57 times more likely to have malnutrition than those without IBD IBD patients often have low Vitamin D, B12, iron and more! Malnutrition negatively impacts clinical outcomes Post operative complications, decreased quality of life, longer hospital stays & higher health costs CCFA: % of malnourished patients a key outcome measure JPEN J Parenter Enteral Nutr 2010;34: N Engl J Med 1991;325: JPEN J Parenter Enteral Nutr 2009;33: Inflamm Bowel Dis 2013;19(3): JPEN J Parenter Enteral Nutr 2007;31: Gut 1986;27 Suppl 1:616 Semin Gastrointest Dis 1998;9:21 30 JPEN J Parenter Enteral Nutr 2006;30:

7 Why We Care: MUST Score for 247 IBD Patients Over 1/3 of IBD patients at risk! 0 Low Risk Submitted for CCFA Advances conference, 2016 Moderate Risk High Risk Why We Care: Gastroenterologist 40 Dietician 20 0 Nurse / Nurse Practitioner IBD Patients "Very Good" Knowledge of Nutrition in IBD Nutrition "Very Important" in IBD "Routinely" screen for Malnutrition in IBD care Inflamm Bowel Dis (10)

8 Why We Care: Our Patients Need Help 100% 80% 60% 40% 20% 0% 19% 11% 49% 61% 33% 28% 40% 39% 21% 16% 23% 23% 31% 31% 61% 62% 80% 58% 63% 16% 15% 11% 6% 4% No access, but have need for No access, and have no need for Have access to Nutrition & IBD Etiology Resolution Downregulation Initiation Bacterial Microflora Dietary antigens Normal host Genetically Susceptible host Acute inflammation Chronic inflammation Amplification World J Gastroenterol (3);

9 An Apple a day Keeps the Doctor away English Proverb Nutrition and IBD Etiology: Increased risk of IBD with high intake of digestible sugars (OR 2.5) Increased sugar consumption associated with earlier onset IBD High fiber diet may be protective against IBD (OR 0.5) Low starch diet in ankylosing spondylitis decreased inflammation and symptoms Simple Carbohydrate Diet associated with improved inflammatory markers and symptoms J pediatr Gatroenterol Nutr 2014; 59: J Crohns Colitis 2014; 8: J Crohns Colitis 2011; 5: J Crohns Colitis 2013; 7: Clin Rheumatol 1996; 15 Suppl 1:

10 Nutrition and IBD Etiology: Fast food may be a risk factor for Tea, coffee and wine? Crohn s disease High animal fat associated with Conflicting data increased due to study risk of UC (OR 4.57) Processed meat may design increase differences, inherent bias, Crohn s risk (OR 7.9) heterogeneous patients and multifactorial Fruits effect negatively of foods! associated with IBD Vitamin D intake may protect against IBD Preservatives and additives linked with UC and Crohn s World J Gastroenterol (3); Gastroenterol Hepatol 2013; 9: Gut 1997; 40: J Crohns Colitis 2012; 6: Validated nutrition assessments not widely used in IBD More than 1/3 of providers do not routinely screen IBD patients for malnutrition Wide variability in malnutrition criteria Assessment tools area available The Malnutrition Universal Screening Tool (MUST) is a validated 5 step approach The Patient Generated Subjective Global Assessment (PG SGA) is a validated patient assessment tool with a nutrition focus Inflamm Bowel Dis (10) global.org/?page_id=13 Editor: Professor Marinos Elia. BAPEN, ISBN X 10

11 Assessment: BMI > 20 = = 1 <18.5 = 2 % Wt Loss <5% = % = 1 > 10% = 2 Yes to Q5 and Q6 = 1 Otherwise = 0 Editor: Professor Marinos Elia. BAPEN, ISBN X Assessment: All risk categories: Treat underlying condition and provide help and advice on food choices, eating and drinking when necessary. Obesity: Record presence of obesity. Editor: Professor Marinos Elia. BAPEN, ISBN X 11

12 Assessment: global.org/?page_id=13 12