Wednesday, March 23, 2016

Transcription

1 Wednesday, March 23, 2016

2 Welcome! Kathleen Newbould Waite Crohn s & Colitis Foundation of America, Northwest Chapter Regional Education & Support Manager On staff since October 2011 Crohn s patient since age 11

3 Crohn s & Colitis Foundation of America Our Mission: To cure Crohn's disease and ulcerative colitis, and to improve the quality of life of children and adults affected by these diseases.

4 Research CCFA supports IBD research projects at the country s leading facilities More than $270 million invested CCFA has played a role in every major scientific breakthrough in IBD

5 The IBD Help Center Offers treatment, diet, flare management & other helpful information about Crohn s disease and ulcerative colitis Free brochures & fact sheets Guide for Teachers Find doctors, support groups & education programs Info on financial resources Get help in 170 different languages Phone: (888) MY.GUT.PAIN ( ) & Live Chat info@ccfa.org Website:

6 Patient Education Update Crohn s disease and ulcerative colitis patients updated on treatment options, coping strategies, advocacy, research and advances while connecting them with the IBD community Educational Webcasts Participate live or watch replay National experts speaking in lay terms Interactive Q&A

7 Connects those seeking support to volunteers who have gone through similar experiences with Crohn s or colitis They speak twice on the phone or by Open to patients and caregivers, ages 10+ Applications at CCFA.org Find a Support Group

8 Camp Oasis CCFA s summer program for kids and teens entering grades 2-12 with medically stable Crohn s disease or ulcerative colitis. At Camp Oasis, kids with IBD can just BE KIDS trying new things, making lifelong friends, hearing stories that sound familiar, and having the time of their lives.

9 Pediatric GI medical professionals on-site 24/7 Many cabin counselors are adults with IBD Focus is not on the disease Accommodations for campers on special diets $ registration fee; scholarships available for all those who request

10 Feedback from Campers: It is an amazing opportunity to meet people who understand what you are going through. The people I meet at camp immediately connect with me and we are able to form lifelong friendships and be role models for the younger campers who are just starting their journey with this disease. Camp Oasis is a place where everyone understands your individual experiences and they inspire you too. Last year at Camp Oasis, I met a nice older girl who was getting medicine infusions and told me how kind and supportive they were and how it didn't hurt very much. Then when my doctor recommended I start getting the infusions, I wasn t so scared and now I've been in remission for almost a year already!

11 Feedback from Parents: He is 100 percent more mature, confident, joyful, solid than before. He looks forward to it all year and comes home very strong and refreshed and ready to face the world. There is nothing more difficult for a young girl than to feel alone and not understood. Camp Oasis has shown not her that she is not alone and actually has given her a reason to be thankful for her disease. She loves her friends from Camp Oasis! I do not even want to think of where we would be without it. It has been a relief to see my child not always carrying the weight of his disease on his shoulders. We see his viewpoint starting to change course, to a happy desire to move on in life despite his challenges.

12 12 Camp Oasis Sites Around the Country Washington: June 26-July 2 California: June Colorado: July Minnesota: July Wisconsin: August Missouri: August 7-11 Michigan: July New York: August Pennsylvania: August West Virginia: June Texas: August Georgia: June

13 Campus Connection For students and their families looking to learn more about the resources available to IBD patients attending college. Accommodations on campus, emotional & social issues Connect with other college students

14 GI Buddy Disease management tool for tracking symptoms, treatment, diet, and lifestyle factors Report capability to view history, patterns, and share with doctor Accessible online and for download as an app for iphone or Android for on-the-go management! Check it out at or download it today!

15 Registry of patient-reported outcomes More than 14,000 patients enrolled To see results or participate in the registry and be a part of your cures, go to:

16 TAKE STEPS - The nation s largest event dedicated to finding cures for Crohn s disease and ulcerative colitis - An incredible day for family, friends and the community to celebrate all of the efforts that have been put forth in raising funds towards our mission - A day that combines high energy and fun with access to valuable information and education Learn more and register your team now!

17 Run or Walk a Half Marathon with a Coach, a Team, and a Purpose! Team Challenge is a fundraising and endurance training program that benefits the Crohn s & Colitis Foundation of America.

18 Diagnosis: 27 - Crohn s 6 - UC 2 - indeterminate colitis 1 - has not been diagnosed When diagnosed: 11 Within the last 6 months 8 6 months-1 year ago years ago years ago years ago 1 n/a Child s age: 2-5 or younger years old years old years old Who s on the Call Participated in CCFA education program before? 15 Yes 21 No Child attended Camp Oasis before? 8 Yes 28 No Residence: 13 from Washington 7 from California 3 from Oregon 2 in North Carolina 1 in Alaska, 1 in Arizona, 1 in Louisiana, 1 in Montana, 1 in Nevada, 1 in Ontario, 1 in Pennsylvania, 1 in South Carolina, 1 in Texas, 1 in Virginia, 1 in New York

19 GoToWebinar Program How to ask questions Raising your hand Polls during presentation Program recording

20 Meet Our Presenter Dale Lee, MD, MSCE Seattle Children's Hospital Inflammatory Bowel Disease Center Medical School: UT Southwestern Medical School, in Dallas & University of Pennsylvania, Epidemiology Residency: Pediatrics, UT Southwestern Medical School in Dallas Fellowship: Pediatric Gastroenterology & Pediatric Nutrition, Children's Hospital of Philadelphia CCFA Northwest Chapter Medical Advisory Committee CCFA Camp Oasis Volunteer Doctor

21 Pediatric IBD: What Parents Need to Know CCFA Dale Lee, MD, MSCE Seattle Children s Hospital March 2016 Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

22 Objectives Provide an overview of IBD in the pediatric population Discuss how IBD impacts the pediatric patient: Physically, psychologically, and socially Outline various therapies for IBD Discuss special considerations for children & teens Describe the role of nutrition in pediatric IBD Discuss the importance of getting the pediatric patient involved in care Highlight several resources for children with IBD 22

23 Overview of IBD in Children Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

24 What is Inflammatory Bowel Disease (IBD)? (UC) Future will be more specific classification based on cause and predicted disease course Images courtesy of Monroe Carrell Jr. Children s Hospital at Vanderbilt Pediatric IBD Program. 1. Levine A, et al. Inflamm Bowel Dis. 2011;17(6) Vermeire S, et al. Curr Opin Gastroenterol. 2012;28(4):

25 How Many Children Have IBD? Estimated 1.4 million people in the United States have IBD Nearly 440 per 100,000 people carry diagnosis of IBD 25% of IBD diagnosed in pediatric age group Incidence: 7-10 children out of 100,000 develop IBD each year Prevalence: ~ 50,000 children in the US have IBD 50% increase in children with IBD over past decade Overall cost of IBD greater in children vs. adults 1. Kugathasan S, et al. J Pediatr. 2003;143(4): Baldassano RN, et al. Gastroenterol Clin North Am. 1999;28(2): Kappelman MD, et al. Clin Gastroenterol Hep. 2007;5(12): Kappelman MD, et al. Gastroenterol. 2008;135(6):

26 Symptoms of IBD Common symptoms: Frequent/urgent bowel movements Diarrhea (or constipation) Bloody stool Abdominal cramping Presentation is more severe in children UC: Higher incidence of pancolitis (>80%) Crohn s disease: ~20% risk of surgery or complicated disease within 3 years of diagnosis More likely to have upper gastrointestinal (GI) tract involvement In adolescents, ratio of Crohn s to ulcerative colitis (UC) is 2-3:1 (vs. 1:1 in adults) Delay in growth and puberty Unique psychological and social concerns 26

27 Potential Causes of IBD Genetic Predisposition IBD Environmental Triggers Abnormal Immune Response Children of an adult with IBD has increased risk of having IBD 2-10 times greater 15%-20% of patients have close relatives with IBD Higher for children Identical twins: 50% in Crohn s disease, 15% in ulcerative colitis 1. Sartor RB. Nat Clin Pract Gastroenterol Hepatol. 2006;3(7): Khor B, et al. Nature. 2011;474(7351): Jostins L, et al. Nature. 2012;49(7422): Sartor RB. Gastroenterology. 2008;134(2): Ananthakrishnan AN. Curr Gastroenterol Rep. 2013;14(1):

28 Role of Microbiota Trillions of bacteria in the intestines Bacteria change with genes, food, antibiotics Bacteria are different in IBD patients, and are main activator of immune system No bacteria Bacteria No immune activation No Colitis IL-1β TNFα Immune activation TNFα IFNγ 1. Farrell M. IBD Family Day Lewis J. Breakthroughs in IBD Research webcast TH 1 Colitis 28

29 Impact of IBD on Children Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

30 Effect Of IBD On Growth Growth often affected in children with IBD, may appear before other symptoms Decreased rate of growth and height percentiles Adult height compromised Crohn s disease: 32-88% UC: 9%-34% Causes Inflammation Steroids Poor nutrition Growth is good marker for disease activity 1. Sawczenko A, et al. Pediatrics. 2006;118(1): Heuschkel R, et al. Inflamm Bowel Dis. 2008;14(6):

31 Bone Health in Children & Teens Decreased bone mineral density common in children and adolescents with IBD Poor calcium absorption/intake; vitamin D deficiency Decreased physical activity Steroid use Inflammation Maximum accumulation of calcium in your bones occurs in mid-teen years Important to ensure adequate calcium and vitamin D intake, as well as weight-bearing exercises 31

32 Impact on Puberty Medical and psychological impact Similar factors affect growth and onset of puberty Poor nutrition Pro-inflammatory cytokines May or may not be made up later in life Delayed age of peak height velocity (middle of puberty) ~25% children with Crohn s Delay usually 6-12 months 1. Pappa H, et al. J Pediatr Gastroenterol Nutr. 2011;53(1):

33 Psychological and Social Effects Specific issues facing children and teens with IBD Defining what it means to have a chronic illness Coping with procedures, clinic visits, hospitalizations Adhering to complicated medical + dietary regimens Quality of life and social interactions impacted Need for support systems at home and at school 33

34 Psychological and Social Effects Children and teens with chronic disease are at greater risk of psychological stressors Low self-esteem Poor social functioning Depression Quality of life and support resources are key 34

35 Treating IBD in Children Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

36 Goals of Therapy Treat inflammation Induce remission of symptoms Prevent complications and surgeries Restore or maintain normal growth and development Provide safe, cost-effective treatment Improve quality of life 36

37 Difficulty with Pediatric Treatments Limited data in pediatric IBD therapy Treatment extrapolated from adult studies Not one size fits all Concerns of drug toxicity Infections Cancer Impact of lifetime therapy duration Outcomes for clinical trials needs to consider pediatric-specific outcomes 37

38 Treatment approaches Medications Surgery Diet 38

39 Types of Medication Crohn s Disease Antibiotics Immunomodulators Steroids Biologics Ulcerative Colitis 5-ASAs Immunomodulators Steroids Biologics 39

40 Induction vs. Maintenance Therapy Flare Induction Therapies Prednisone Cyclosporine/ Tacrolimus Exclusive Enteral Nutrition (EEN) Induction or Maintenance Medications Biologics (infliximab, adalimumab) 5-aminosalicylates Disease Activity Maintenance Medications 6-MP or azathioprine Methotrexate Remission 40

41 Steroids Examples: prednisone, budesonide (Entocort, Uceris ), hydrocortisone (Cortenema, Cortifoam ) Benefits Effective at inducing remission Risks Side effects Infection, acne, weight gain, mood/psychological disturbances, muscle wasting, bone loss, hypertension, diabetes Concerns of dependency Take home points Use for induction only If multiple courses needed per year, re-evaluate treatment plan 41

42 Immunomodulators Examples: 6-MP (Purinethol ), azathioprine (Imuran, Azasan ), methotrexate (Rheumatrex, Mexate ) Benefits Used effectively as steroidsparing agents Common maintenance treatment in children Effective at maintaining remission with or without biologics Risks Risk of serious infection Teratogenicity in pregnancy (fetal abnormalities) with methotrexate Need to monitor white blood cell count and liver function Low risk of lymphoma 42

43 Biologics Examples: Adalimumab (Humira ), Infliximab (Remicade ) Benefits Effective induction and maintenance medications Support growth Treat fistulas and perianal disease Risks Risk of serious infection Injection site issues (pain, swelling, etc.) Psoriasis Low risk of lymphoma 43

44 Putting Risks In Perspective Event Risk Baseline risk of lymphoma 2 in 10,000 Lymphoma from 6-MP or infliximab 4-6 in 10,000 Death from an automobile accident 38 in 10,000 Major surgery from Crohn s within 5 years 1,780 in 10,000 Take home points Increased risk of lymphoma is very small compared to potential benefit from medications If young male, evaluate risk vs. benefit of combination therapy (increased risk of hepatosplenic T-cell lymphoma) 1. Siegel CA, et al. Clin Gastroenterol Hep. 2009;7(8): Kotlyar DS, et al. Clin Gastroenterol Hepatol. 2011;9(1): _statistics/documents/injury_facts_43.pdf. Accessed: 8/07/13. 44

45 Questions to Ask the Health Care Team What are the risks of the current treatment plan? What are the risks of not treating the disease? How do we manage side effects of treatment? What if the plan if the current regimen stops working? Which vaccines are allowed? If taking immunomodulators or biologics, certain vaccines may need to be given before starting treatment 45

46 Direction of Future Therapies Comparative effectiveness Head-to-head comparison of management strategies Predicting disease course Children with deep ulcers 2.7x more likely to have active disease at the end of 1 year than those without If treated with anti-tnf therapy within 3 months of diagnosis, more than 10x less likely to have active disease at one year Predicting risk of therapy Renewed interest in diet How does diet influence microbiota? New targets for treatment Anti-α4 therapy (vedolizumab) Anti-IL-12 and IL-23 Oral inhibitor of Janus kinases 1, 2, and 3 1. Hyams JS, et al. Gastroenterology. 2012;143(2): Lewis J. Breakthroughs in IBD Research webcast

47 The Future of IBD Treatment IBD Panel Serology Genetics Microbial IBD Subtype Disease Prognosis Patient-Specific Treatment Plan Targeted-Specific Therapy 47

48 Surgery for Pediatric IBD Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

49 Goals of Surgery Surgery and medications can combine for better quality of life Primary goals of surgery Prevent complications Alleviate symptoms Achieve best possible quality of life Bowel conservation 49

50 Indications of Surgery Medically unresponsive disease/steroid dependency Disabling side effects of medications Obstruction or abscess formation Severe perianal disease Growth failure Better quality of life 50

51 Types of Surgery Crohn s Disease Strictureplasty Resection of small intestinal segment Colectomy (partial or complete) Proctocolectomy (removal of the colon and rectum) Unlike UC, Crohn s cannot be cured with surgery Ulcerative Colitis Proctocolectomy With ileostomy Restorative (ileoanal or J pouch) Disease is cured once the colon is removed 51

52 Risks of Surgery Crohn s Disease Recurrence of symptoms Psychological implications for those with ileostomy Ulcerative Colitis Potential complications specific to ileal pouch anal-anastomosis (IPAA) surgery include: Pouchitis Pouch failure (8%-10% of patients) Psychological implications for those with ileostomy **For both: complications, as with any surgery 52

53 Special Considerations for Children Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

54 Special Considerations for Children Very few studies have address this issue directly Overall, children tolerate procedures and surgery very well Based on quality of life (QoL) studies, children appeared to have better functional outcomes than adults However, parents assessments of their child s QoL suggest difficulties in both physical and psychological health domains 1. Zmora O, et al. Dis Colon Rectum. 2013;56(2): Stavlo et al. J Pediatr Surg. 2003;38(6):

55 Nutritional Concerns Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

56 The Critical Role of Nutrition Including good nutrition in your diet is essential to quality of life and improved long-term outcomes Diet = the food you eat on a daily basis Nutrients = fat, protein, carbohydrates, vitamins, minerals Careful food choices may: Decrease symptoms Prevent disease exacerbation IBD patients are at risk of becoming malnourished Loss of appetite (caused by nausea, pain) Increased caloric needs caused by chronic disease Poor digestion and absorption of nutrients 56

57 Principles of Good Nutrition Good nutrition is key to: Healing, immune system, and energy levels Preventing or minimizing GI symptoms Medications being more effective Normal bowel function Preventing growth delays 57

58 Dietary therapy for Crohn s disease Exclusive enteral nutrition (EEN) therapy: a formula-based diet with exclusion of table foods Effective at inducing remission of Crohn s Difficult to maintain long-term Can be used to minimize steroid exposure Important to talk to your doctor about using and monitoring dietary therapy 58

59 Popular Diets: Fact vs. Fiction No specific diet has been proven to treat IBD Many options exist and are promoted on the internet but Few well-controlled published studies Can be difficult and complicated to follow Potentially risky restrictions may lead to poor growth, poor healing, and/or nutrient deficiencies May actually worsen symptoms Talk to your doctor or a registered dietitian before considering an IBD diet Do not abandon conventional treatment! 59

60 Good Nutritional Choices Strive for a well-balanced, healthy diet when feeling well that includes hydration and adequate nutrient intake Discuss specific intake and dosage with your doctor and dietitian Foods Grains with ingredient lists that have whole as the first word Protein (eggs, lean meats, Greek yogurt, smooth nut butters) Deeply colored fruits and vegetables Supplements A daily multivitamin Low-fat dairy (includes hard cheeses) Vitamin D Vitamin B12 (monthly injection may be given to patients with ileitis) Calcium ( mg/day, in 3 doses) Healthy fats (canola or olive oil) Folic acid 60

61 Eating During a Flare Limit insoluble fiber Insoluble fiber: Adds bulk to stool and speeds transit through intestines - Examples: Leafy vegetables, wheat bran, fruit peels Soluble fiber: Dissolves in water, forms gel, slows digestion Decrease concentrated sweets Eat smaller, more frequent meals Avoid nuts, seeds, and kernels, especially if the child has strictures Consider lactose-free diet, and a lower fat diet 61

62 Nutrition Support Therapy Supplementation may become necessary: Weight loss, poor oral intake, surgery, obstruction, severe inflammation Liquid nutritional supplements PediaSure, Ensure, Boost, Boost Kid Essentials Enteral nutrition Nutrient-rich liquid formula administered through - Nasogastric tube (NG tube): from nose to stomach - Gastrostomy tube (G-tube): from abdominal wall to stomach Parenteral nutrition (intravenous) Delivered through catheter placed into large blood vessel Requires specialized training to administer 62

63 Transition Planning Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

64 Transition and Transfer of Care Transition = process Message of empowerment and initiative Sends message of optimism to young adults Imparts confidence the patient is capable of accessing care in the adult healthcare system Transfer of care = single act 64

65 Why Transition to Adult Providers? Social Age-appropriate care Privacy Autonomy Environment Work (not school) Resources/Insurance Relationships Marriage Children Medical Comorbidities Hypertension Thyroid Screening/Complications Colon cancer Thrombosis Interactions Smoking Alcohol Drugs 65

66 Transition Should Occur in Several Phases Pediatric provider is the caregiver outlining patient responsibilities Phase 1 Phase 2 Overlap occurs between pediatric and adult spheres; begin to practice independence Adult provider assumes responsibility for care; patient should begin to take charge Phase 3 1. Philpott JR. Gastroenterol Hepatol. 2011;7(1):

67 School Resources Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

68 The 504 Plan Section 504 of the federal Rehabilitation Act ensures accommodations for children with disabilities. IBD is a chronic medical condition. Initial Diagnosis Contact List School nurse Guidance counselor School social worker Teachers Administrators Student File Letter Definition of IBD Symptoms, cyclical nature of disease Home tutoring option Gym considerations Mind-gut connections 69

69 Requesting a 504 Plan Make the request in writing Template available at Include supporting medical documentation Parents, patient (if age-appropriate), school nurse, administrator, and guidance counselor should meet to develop a workable plan Sample 504 Plan Accommodations Bathroom pass Nurse s office pass Nurse s training for med administration Food/drink in class Stop-the-clock testing Postponement of cumulative term grades Revised seating chart Extra set of books Increased time between classes Copies of syllabi, lesson plans Permission to copy class notes In-home/after school tutoring prior to prolonged absence Field trip/extracurricular transportation 70

70 Requesting Support in College All public, government-funded colleges and universities expected to comply with Section 504 Most colleges have disability services office Accommodations may include: Dorm with close bathroom access or a private bathroom Mid-morning or late classes if you have bathroom activity in the early morning Test accommodations Speak to the disability services office before heading to school Visit to learn more tips! 71

71 Self-Management Supported by an educational grant from Janssen Biotech, Inc., administered by Janssen Services, LLC.

72 Involving Children in their IBD Care Screening Is there a support network of family members/friends? Is a counselor or psychologist needed? Are school accommodations needed and/or in place? Does child/adolescent need help with stress reduction? Self-management Disease education and knowledge - Encourage use of resources available on the web - Review educational materials together Learn necessary skills Prepare for independence Understand their central role in managing their illness 73

73 Importance of Treatment Adherence Adherence is associated with improved outcomes Reduced inflammation in GI tract Decreased risk of disease progression Decreased risk of colorectal cancer Patients who continue their maintenance medications are less likely to experience flares 74

74 To Increase Treatment Adherence Remain informed and educated Simplify the treatment regimen if possible Engage children in self-management Find support for emotional and social issues CCFA support groups, Community site: Medical social workers 1. Hall A, et al. Gastrointestinal Nurs. 2006;4: López-Sanromán, et al. Aliment Pharmacol Ther. 2006;24(Suppl 3): Kane SV. Aliment Pharmacol Ther. 2006;23:

75 CCFA Resources CCFA website: Pediatric-focused publications (teacher s guide, parent s guide, comic book, activity book) Camp Oasis: Safe and supportive summer camp for children ages camps throughout the US Campus Connection: Connect with other college students and learn tips for campus life Support Groups and Power of Two Connect with other parents or children with IBD Looking for mentors! Contact your chapter at 76

76 NASPGHAN North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Several resources for families with IBD Locate a pediatric GI team Learn about pediatric IBD research - IBD publications and podcasts - Transitions checklists - College site: 77

77 Other Resources ImproveCareNow A collaborative Learning Health Care system of 87 pediatric centers in the US and England developing standardized care with collaboration between caregivers, patients, and researchers 78

78 Conclusion IBD is a chronic medical condition that uniquely impacts children and adolescents Therapy may involve medications, diet, and possibly surgery Involving children in their IBD care is important Resources are available through the CCFA and NASPGHAN 79

79 Contributors Janice Arnold, MA, LICSW, Children s Hospital Boston Lisa Cimperman, MS, RD, LD, University Hospitals Case Medical Center Michael Farrell, MD, Cincinnati Children s Hospital Laurie Fishman, MD, Children s Hospital Boston Maureen Kelly, MS, RN, CPNP, UNC at Chapel Hill; Co-Chair, CCFA Nursing Initiative Committee Sandra Kim, MD, Nationwide Children s Hospital; Chair, CCFA Pediatric Affairs Committee Michael Rosen, MD, Children s Hospital at Vanderbilt Shehzad Saeed, MD, Cincinnati Children s Hospital 80

80 Questions? 81

81 Post-Program Questions 1. What is NOT true about the differences in IBD between children and adults? a. Children are more likely to have pancolitis. b. Adults are less likely to have inflammation in the upper gastrointestinal tract. c. Ulcerative colitis is more common in children compared to adults. d. The presentation of IBD tends to be more severe in children compared to adults. 82

82 Post-Program Questions (Cont) 2. Which of the following is a reason for the difficulty with treatments for pediatric IBD? a. Children cannot participate in clinical trials. b. Most of the recommended treatments are based on studies in adult patients. c. Clinical trials do not assess safety or toxicity of medications. d. It is hard to determine appropriate doses for children. 83

83 Post-Program Questions (Cont) 3. Steroids like prednisone and Solu-Medrol are primarily used as: a. Induction medications only b. Maintenance medications only c. Both induction and maintenance medications d. Neither induction or maintenance medications in children 84

84 Post-Program Questions (Cont) 4. Possible side effects/risks of biologics include all of the following EXCEPT: a. Fetal abnormalities b. Injection site issues, such as pain or swelling c. Psoriasis d. Allergic reactions 85

85 Post-Program Questions (Cont) 5. Which of the following is a recommendation for eating well during a flare? a. Increase consumption of fats to ensure adequate caloric intake b. Increase consumption of insoluble fiber, such as wheat bran, to slow movement of food c. Eat only 3 meals per day in equal amounts d. Try a lactose-free diet 86