Nutri&on Assessment, Dietary Diversity, Composi&on and Impact on Outcomes in IBD

Transcription

1 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

2 Disclosure Faculty: Dr. Maitreyi Raman Rela&onships with commercial interests: Grants/Research Support: Baxter Speakers Bureau/Honoraria: Shire

3 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

4 4 Adult Starva4on and Disease- Related Malnutri4on Starva&on- related malnutri&on chronic starva4on without inflamma4on e.g. anorexia nervosa FS CD Chronic disease- related malnutri&on chronic starva4on with inflamma4on IBD COPD Acute or injury- related malnutri&on Starva4on Cri4cally Ill

5 Starva&on related malnutri&on (SRM) ± Nutri&onal support (NS) N.B. no inflammation Jensen et al. JPEN J Parenter Enteral Nutr 2010;

6 Acute vs chronic disease related malnutri&on ± Nutri&onal support (NS) (months) N.B. presence inflammatory process Jensen et al. JPEN J Parenter Enteral Nutr 2010;

7 Prevalence of malnutri&on in Canada Escapes official sta4s4cs 45% moderate or severe malnutri4on 1.2% on discharge summary Bernier, sheet P In IBD 75-90% of pa&ents are malnourished when admi]ed to hospital

8 Costs by Nutri4on Status Total N=958 Bed Days Nourished Moderately Malnourished Total N=958 Nourished Moderately Malnourished Severely Malnourished Severely Malnourished $ [512] $7931 [1.17]* [766]* $7989 [0.96]*[976]* [0.65] Medical Medical $ [593] $7825 [1.32]* [849]* $7823 [1.33]*[1042]* N=632 N=632 [0.95] Surgical Surgical $ [681] 9.62 $7154 [1.39]* [1660]* 8.75 $6744 [1.11]*[1435]* N=301 N=301 [0.65] Cur&s et al. Clinical Nutri&on

9 Length of stay (bed days) by nutri4on status Total N=958 Medical N=632 Surgical N=301 Nourished 8.43 [0.65] 8.20 [0.95] 6.98 [0.65] Moderately Malnourished Severely Malnourished [1.17]* [0.96]* [1.32]* [1.33]* 9.62 [1.39]* 8.75 [1.11]* Cur&s et al. Clinical Nutri&on

10 Day 1 Day 5 NPO admission CT scan discharge 66kg, 180cm tall 55kg LBM colonoscopy Afebrile Decreased CRP Admission with decreased intake for days/weeks at home 1.375kg of muscle loss (2.5%)

11 The Catabolic Crisis Hospitaliza4on #1 Hospitaliza4on #2 Hospitaliza4on #3 Muscle Mass Time

12 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

13 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):

14 Risk Factors Associated with Major Complica4ons Aoer Bowel Resec4on for Crohn s Disease Zhang et al. JPEN 2017;41(4):

15 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):

16 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: , First published: 20 January 2017, DOI: ( /apt.13934)

17 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: , First published: 20 January 2017, DOI: ( /apt.13934)

18 Screening tool Malnutrition Universal Screening Tool (MUST) Weight loss Parameters Poor appetite/ food intake others Care settings * * BMI, Acutely ill Outpatient clinics, hospital wards, in home and community care settings Nutrition Risk Screening (NRS) * * BMI, Severity of Disease Malnutrition Screening Tool (MST) Abridged patient-generated subjective global assessment (abpg-sga) Canadian Nutrition Screening Tool (CNST) Saskatchewan IBD-Nutrition Risk Hospital * * Hospital, oncology outpatient and community care settings * * Symptoms affecting food intake, physical activities Oncology outpatient and inpatient settings * * Hospital * * GI symptoms, food restriction IBD outpatient setting

19 Nutrition Assessment methods 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 *ASPEN: American Society of Enteral and Parenteral Nutrition

20 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

21 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

22 Suskind et al. J Clin Gastroenterol 2018;52(2):

23 Autoimmune Protocol diet Extension of Paleolithic Diet Avoidance Gluten, Refined sugar Food Addi4ves Ini4al phase dairy, eggs, legumes, nightshades Fresh, nutrient dense, fermented Konije4 GG et al. Inflamm Bowel Dis 2017;23(11):

24 Makki et al. Cell Host and Microbe 2018

25 Dietary Diversity is Associated With Greater B- Diversity of the Microbiome P = nmds WN MN MN WN nmds 1

26 Dietary Diversity is Associated with Increased F.Prausnitzii and Bifidobacteria Blautia wexlerae (Identity 100%) Ruminococcus gnavus (Identity 100%) * * WN MN Intestinibacter bartlettii (Identity 100%) Subdoligranulum variabile (Identity 99%) * * Lachnospiraceae (Family level) * Faecalibacterium prausnitzii (Identity 99%) * Eubacterium hallii (Identity 99%) * Dialister invisus (Identity 100%) * Bifidobacterium faecale/adolescentis/stercoris (Identity 100%) * Bacteroides vulgatus (Identity 99%) * Bacteroides uniformis_2 (Identity 99%) * Bacteroides uniformis_1 (Identity 99%) * Bacteroides thetaiotaomicron (Identity 100%) * Bacteroides dorei (Identity 100%) * Relative abundance %

27 AsCEND: Alberta s Center of Excellence for Nutri4on in Diges4ve Disease EXCELLENCE IN CLINICAL CARE NOVEL DISCOVERY and RESEARCH EDUCATION and KNOWELDGE TRANSLATION

28 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