An update on dietary considerations for inflammatory bowel disease

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1 An update on dietary considerations for inflammatory bowel disease Miranda Lomer MBE PhD RD Senior Consultant Dietitian in Gastroenterology Honorary Senior Lecturer Dietary considerations IBD service standards Undernutrition Nutritional assessment Exclusive and partial enteral nutrition Food reintroduction Dietary fibre Pre surgical nutritional optimisation Functional gastrointestinal symptoms Inflammatory bowel disease (IBD) Outcome measures in IBD Subjective Disease activity index CDAI, HBI Quality of life IBDQ Food related quality of life Symptom assessment Objective Inflammatory markers (CRP, faecal calprotectin) Endoscopic score Histology Radiology CT, MRI Complications, length of stay, cost The need for increased dietetic services All patients with IBD should have access to a dietitian Minimum 0.5WTE Dietitian allocated to Gastroenterology IBD standards Lomer J Hum Nutr Diet 2009:22;

2 Aetiology & mechanisms of undernutrition in IBD Assessment of nutritional status Body composition Muscle strength and function Micronutrients Self assessment Gerasimidis K In: Advanced Nutrition and Dietetics in Gastroenterology 2014; P183 Body composition: Anthropometry Body composition: Bio electrical impedance BMI Crohn s disease Ulcerative colitis Healthy subjects 16 studies No significant differences between groups in 16 studies 8 studies Crohn s BMI but not clinically significant and Crohn s mean BMI>18.5 BMI not useful as one off measure Direct anthropometry Crohn s disease Healthy subjects 1 study Geerling 1998 Fat mass and muscle mass similar for CD in remission and healthy subjects No data for active disease BIA (n=8 studies) Benjamin et al Capristo et al. 1998a, Capristo et al. 1998b, Filippi et al. 2006, Mingrone et al. 1998, Valentini et al Capristo et al. 1998a, Capristo et al. 1998b, Filippi et al. 2006, Katznelson et al. 2003, Mingrone et al. 1998, Valentini et al Wiroth et al Crohn s disease Ulcerative colitis FM in CD versus UC and healthy subjects FFM did not differ between groups Healthy subjects Benjamin et al FFM in CD versus healthy subjects (active/remission) Non invasive, no radiation, portable 2

3 Muscle strength and function Geerling et al Valentini et al Crohn s disease Ulcerative colitis Healthy subjects Hamstring strength in remission CD versus healthy subjects Handgrip strength (HGS) in remission CD/UC versus healthy subjects Wiroth et al HGS did not differ between remission CD and healthy subjects Salacinski et al strength endurance and repetition in remission CD versus Wiroth et al healthy subjects No data for active disease 40% remission patients versus 75% active disease report fatigue (Graff et al. 2013) IBD patients with nutritional deficiencies (%) Assessment of micronutrient status Nutrient/problem Crohn s disease Ulcerative colitis Anaemia Iron Folate Vitamin B Calcium 13 + Vitamin D Magnesium Zinc Filippi et al 2006 (CD in remission) Geerling et al 1999 (IBD) Vagianos et al 2007 (IBD) Valentini et al 2008 (IBD in remission) Reviews: Kulnigg & Gasche 2006, Wilson et al 2004, Lomer 2012 Clinical interpretation of plasma micronutrients depends on degree of inflammation CRP <20 mg/l plasma zinc CRP <10 mg/l plasma selenium, vitamins A and D CRP <5 mg/l vitamin B6 and vitamin C 3

4 Dietary management in IBD Crohn s disease or ulcerative colitis Disease severity active and remission Symptom control Diet to treat active CD (to induce remission) Enteral nutrition compared with steroids Which enteral formula? Comparison of elemental versus non elemental diet Low fat versus high fat Zachos et al 2007 Cochrane Database Syst Rev Zachos et al 2007 Cochrane Database Syst Rev 4

5 Polymeric diet 4 weeks N=13 Oral and nasogastric overnight 11 clinical remission CDAI IBDQ significant improvement 8 patients expressed willingness to use EN again if relapsed Exclusive enteral nutrition 6 8 weeks (n=17) Modulen IBD Lean mass but not fat mass improved Carotenoids depleted levels in enteral feed insufficient? Other micronutrients improved Mechanisms: How does enteral nutrition work? ITT Remission: oral n= (75%) enteral (85%; P = 0.157) Significant decrease in PCDAI (P < ) Significant improvements in anthropometry and inflammatory indices No difference between oral versus enteral route except weight increase higher in enteral group (P = 0.041) Subgroup of patients (n=16) mucosal healing on follow up endoscopies showing a clear correlation to remission (7/8 oral 5/8 enteral) Compliance rates (87% and 90%) were similar. Noncompliant patients had lower mucosal healing and remission rates. Nutrients are major components of the luminal contents Bowel rest Lochs et al 1983; Greenberg et al 1988 Reduced antigenic load Lomer et al 2001 Improve nutritional status Gorard et al 1993; Teahon et al 1995 Supplementation of nutrients glutamine Zoli et al 1995; Akobeng et al 2000 TGF Fell et al 2000 Fatty acid content Gassull et al 1995; Geerling et al 2000 Change in gut microbiota Formula 2000kcal Modulen IBD Fortisip Vital E028 Extra Volume It is good practice to 2000 offer ml patients 1340ml a choice of formula 1340ml types to aid tolerance 2325 ml and compliance. For some patients it may be helpful to discuss the difference Protein between (g) elemental, 72g semi elemental 80g and polymeric 90g formulas and to 58g discuss [% special of energy] components [14.4%] of some enteral [16%] nutrition therapies [18%] e.g. those with [11.6%] TGF β. Fat (Lee(g) et al, 2014) 94g 78g 74g 81g [% of energy] [42.3%] [35%] [33%] [36.6%] LCT 32% 35% 36% 24% % of total energy Type Whole protein TGF Whole protein Caseinate, whey protein hydrolysate Elemental Presentation Powder Liquid Liquid Liquid and powder Osmolarity Cost (BNF)

6 Practical considerations Suppl 2 p28 35 Side effects and reasons for early cessation MD team approach and patient choice Primary or adjunctive treatment Outcome measures clinical response or mucosal healing Calculate requirements: predictive equation +/ stress factor /PAL Manage refeeding risk Gradual introduction over 3 days and minimum 10 days Wean off food and caffeine Manage risk of obstruction in stricturing disease Monitoring side effects, clinical response, nutritional status Oral versus nasogastric 2014: 27; Recommendations exclusive enteral nutrition Steroids are considered to be a first line treatment option for induction of remission in adults with active Crohn s disease. Enteral nutrition can be offered as an alternative primary or adjunctive treatment option to induce remission When enteral nutrition is used for induction of remission: Elemental or non elemental formulas can be used The formula can be given orally or via an enteral feeding tube The formula should be given for a minimum period of ten days SIGN B B Gomollón F, Dignass A, Annese V, Tilg H, Van Assche G, LindsayJO, Peyrin BirouletL, Cullen GJ, Daperno M, Kucharzik T, Rieder F, Almer S, Armuzzi A, Harbord M, Langhorst J, Sans M, Chowers Y, Fiorino G, Juillerat P, Mantzaris GJ, Rizzello F, Vavricka S, Gionchetti P J Crohns Colitis Sep 22. pii: jjw168. [Epub ahead of print] 6

7 Food Reintroduction 3 approaches Elimination Diet (Riordan et al1993) LOFFLEX diet low fibre, fatlimited exclusion (Woolner et al 1998) Rapid Food Reintroduction (Faiman et al 2014) Elimination Diet (Riordan et al 1993) Following disease remission achieved with EEN Reintroduce one new food daily Monitor symptoms Exclude foods that cause symptoms Remission rate at 2 years = 79% (62% in steroids) LOFFLEX Woolner et al 1998 Fat <50g/day Fibre NSP <10g/day Modified exclusion diet avoidance of foods symptoms in >5% patients Baseline diet for 2 weeks Individual foods tested for 4 days each Food and symptom diary Remission rate 59% at 2 years Woolner et al 1998 Retrospective cohort study 6 weeks EEN 5 weeks food reintroduction (SFR) versus 3 days rapid food reintroduction (RFR) No significant differences in relapse between groups 6M relapse: SFR 35% versus RFR 37% 12M relapse: SFR 50% versus RFR 47% 2014: 27; Recommendations food reintroduction diets SIGN Following induction of remission by nutritional means, food reintroduction diets such as elimination or LOFFLEX diet can be considered for B maintenance of remission High fibre diets should not be recommended as a food reintroduction diet D 7

8 Partial enteral nutrition (PEN) Suppl 2 p28 35 Side effects and reasons for early cessation Increasing interest in PEN No need to stop all food Less taste fatigue Improved adherence in adults Elemental or whole protein formula Oral versus nasogastric Variability in energy provided 35 75% Other dietary constituents a free or restrictive diet Exclusion diet Sigall Boneh et al Inflamm Bowel Dis patients 0 6 weeks 50% enteral nutrition (Modulen or paediasure) 50% exclusion diet 6 12 weeks 25% enteral nutrition (Modulen or paediasure) 75% exclusion diet Exclusion diet in Crohn s disease Sigall Boneh et al Inflamm Bowel Dis adults CD in recent remission (CDAI<150) PEN (elemental, 50% energy) plus normal diet for up to 2 years versus normal diet for up to 2 y Relapse rate PEN 35% versus normal diet 64% 8

9 66 patients with CD in remission (CDAI<150) PEN (polymeric, 420 kcal/d) and normal diet for 6 months versus Mesalazine plus normal diet for 6 months 95 adults with CD in remission (CDAI 150) PEN (elemental, 900 kcal/d) plus normal diet versus 6 MP plus normal diet versus Normal diet (control) Maintenance of remission at 2 years PEN 44% versus 6 MP 57% versus control 21% No difference in relapse rates at 6 months PEN 31% versus mesalazine 40% Surgery and IBD Gomollón F, Dignass A, Annese V, Tilg H, Van Assche G, LindsayJO, Peyrin BirouletL, Cullen GJ, Daperno M, Kucharzik T, Rieder F, Almer S, Armuzzi A, Harbord M, Langhorst J, Sans M, Chowers Y, Fiorino G, Juillerat P, Mantzaris GJ, Rizzello F, Vavricka S, Gionchetti P J Crohns Colitis Sep 22. pii: jjw168. [Epub ahead of print] Up to 70% of patients with Crohn s disease require abdominal surgery Lifetime surgery rates in ulcerative colitis 23 30% Post operative complications more commonly seen in IBD than other diseases Suboptimal nutritional status impairs surgical outcome Nutritional optimisation of pre surgical Crohn s disease patients with enteral nutrition significantly decreases length of stay and need for a stoma K.V. Patel, A.M. Sandall, D.V. O'Hanlon, A.A. Darakhshan, A.B. Williams, S.H. Anderson, P.M. Irving, M.C. Lomer, J.D. Sanderson JCC 2016:10(Suppl1);S P=0.001 P=0.005 P= P=0.002 % P=0.002 Optimised n=35 Not optimised n= Abnormal Albumin Abnormal CRP Pre operative CS Stoma Complications 9

10 2017: 45; /51 EEN avoided surgery 38 EEN matched to 76 controls Energy requirements Henry equation + activity + stress factor Modulen IBD 1kcal/ml or if limited tolerance concentrated to reduce volume 3 patients unable to tolerate >4 weeks EEN Prednisolone and bridged to thiopurine Food reintroduction after 6 weeks Postoperative complications Prospective study Complicated CD high risk (n=35) Obstructive symptoms Steroids >10% weight loss EEN (n=34/35) 1 nausea and vomiting at 7 days Uncomplicated surgery low risk (n=21) Complicated CD high risk (n=35) D Discontinuation of steroids n=10/16 Postoperative complications High risk 8/35 v low risk 5/21 (p=1) Temporary ileocolostomy High risk 4/35 v low risk 5/21 (p=0.286) Dietary fibre and IBD Optimise nutritional status pre operatively Surgical resection more successful if carried out when nutritional status has been optimised Prevent and treat undernutrition before surgery Maintain nutritional status post surgery Initiate nutritional support in patients where it is anticipated that surgery will mean 60 75% of oral intake cannot be maintained. (Preferably use enteral route) 10

11 23 RCTs 1296 patients 3/10 studies in UC reported benefit of fibre supplementation on outcome 0/12 studies in CD 1/1 study in pouchitis Prevalence of functional bowel symptoms in IBD 2014: 27; Recommendation for dietary fibre and stricturing disease Fibrous foods are contraindicated in the presence of strictures due to the risk of mechanical obstruction (Meier & Gassull, 2004) SIGN Grading E Management of functional bowel symptoms in IBD Dietary triggers:79% of IBD patients Food avoidance Nutritional status Cohen et al Dig Dis Sci 2013; 58(5): Prince et al J Crohns Colitis. 2011; 5:

12 Conclusions Acknowledgements Dietitians in IBD under resourced High prevalence of undernutrition in IBD Nutritional assessment in IBD vital A role for exclusive enteral nutrition as primary and adjunctive treatment Food reintroduction needs careful consideration Partial enteral nutrition and exclusion diets Pre surgical nutritional optimisation Avoid unnecessary dietary fibre restriction Manage functional bowl symptoms through dietary means 12