Maintaining Nutrition in Inflammatory Bowel Disease

1
Maintaining Nutrition inInflammatory Bowel
Disease

• By
• Rachel Lees
• Specialist Dietitian HEFT

2
Introduction

• Crohns Disease and Ulcerative Colitis are
  chronic, progressive inflammatory bowel diseases
  (IBD) characterised by periods of exacerbation
  and remission.
• Crohns Disease can occur anywhere between the
  gut and anus but is most common in the terminal
  ileum and the colon. Complications of Crohns
  Disease include fistulae and strictures. The
  incidence is 3.9 to 9.8per 100,000 in Europe.
  (Gower- Rousseau et all 1994)

3
Introduction ctd

• Ulcerative Colitis occurs only in the colon or
  rectum. The incidence is 1.5-14.8 per 100,000 in
  Europe (Gower- Rousseau et al. 1994)

4
Symptoms and treatment

• Symptoms include -
• Diarrhoea with/without blood and mucus
• Abdominal pain
• Nausea
• Vomiting
• Weight loss
• Treatment
• mainly steroids and 5 amino salicilate
  compounds,eg sulfasalazine, mesalazine.
• Long term management often uses Azothiaprine.
• Intractable disease may require methyltrexate or
  Infliximab

5
Treatment 2

• Ulcerative Colitis can be cured by colectomy
• in Crohns Disease, re-occurence is common after
  resection, especially at the anastamosis site.

6
Dietary Management

• Diet
• Is used to support the patient but may be used
  as a primary therapy in Crohns Disease to induce
  remission.
• Aims of Dietary management
• To achieve or maintain good nutritional status
  during both active disease and remission
• To help improve clinical symptoms, in combination
  with medical treatment.

7
Dietary Management 2

• To help treat clinical complications, in
  combination with medical treatment
• To help achieve clinical remission in certain
  Crohns patients.

8
Malnutrition

• Malnutrition is common in IBD (Geerling et al
  2000a)
• Causes -
• Inadequate intake
• Nausea, vomiting diarrhoea
• Depression
• Food restriction, often self imposed
• Low residue diet folate, Vit C
• Increased requirements
• Infection
• Surgery
• Growth (Paediatrics)
• Inflammation

9
Malnutrition 2

• Malabsorption
• Reduced surface area (inflammation, resection)
  Mg, Zn
• Bile salt malabsorption
• Fistulae
• Steatorrhoea Ca
• Increased losses
• Bleeding anaemia
• Diarrhoea
• Vomiting
• Drug interference
• Steroids growth, Ca absorption, bone mineral
  loss
• Salazopyrine folic acid
• Cholestyramine fat, soluble vitamins

10
Effects of Malnutrition

• Poor growth in children
• Impaired immune response
• Decline in muscle function
• Impaired wound healing
• Apathy/ low mood
• Increased anaesthetic risk
• (Geerling et al 2000a)

11
Assessment of Patient

• Weight BMI
• - ideal body weight
• - percentage weight loss
• - current status wt stable, ??
• Food and symptom diary
• Anthropometry
• Mid arm muscle circumference
• Triceps skinfold
• Grip Strength single user
• Dietary history macro nutrients, vitamins
  trace elements

12
Treatment of Malnutrition

• The choice of nutritional support depends on the
  individual patient
• Consider -
• Nutritional status
• Current food intake
• Clinical condition of patient-active disease?
• Presence of complications
• Disease state, presence of strictures,
  osteoporosis etc

13
Treatment cont.

• Options -
• Small frequent meals and snacks
• Fortification of food
• Sip feeds
• Overnight enteral feeding
• PEG/ PEJ for long term support
• TPN used in total obstruction or short bowel

14
Food Fortification

• Add extra nutrients to existing food
• Limited use in active Crohns when intake already
  reduced
• Important to achieve a balanced diet
• Commercial Protein powders
• Energy supplements- CHO
• - Fat
• Energy supplementation alone should be used with
  caution (NICE 2006)

15
Sip Feeds

• Most contain milk protein but are clinically
  lactose free
• Milk based sips can usually be sole source of
  nutrition, complete in 1500 kcals
• Juice,
• semi solid,
• powders
• Taste fatigue
• Dental health

16
Enteral Feeding as Nutrition Support

• To meet whole requirements or supplementary
• Often given overnight
• Usually Naso Gastric feed
• PEGs are usually well tolerated in Crohns
  failure is of enteral nutrition not the route
• (Thomas 2000,
  Anstee Forbes 2000)

17
Enteral Feeding Issues

• Feeding Time/length
• Choice of feed
• Affect on oral intake
• Patient safety
• Home Enteral Feeding

18
Monitoring of Nutrition Support

• Weight
• Anthropometry
• Mid arm circumference
• Mid arm muscle circumference
• Triceps skinfold thickness
• Grip strength
• Biochemistry
• General assessment

19
Dietary Modifications

• Lactose (some patients intolerant)
• - ethnic origin
• - dose related
• Most feeds and sip feed are clinically lactose
  free.
• Can be proved with lactose tolerance test
• (Bernstein 1994
• Food Intolerances
• Traditionally, food exclusion has been used as a
  treatment
• Can be effective after remission is induced
• (Riordan 1993)

20
Dietary Modification 2

• Low Fibre
• may give symptomatic relief in patients with
  strictures/ sub total obstruction)
• Used in acute exacerbations and post surgery
• Need to check diet is adequate in Vitamin C and
  folate

21
Dietary Modification 3

• Special feed including TGFß (Transforming Growth
  Factor), single protein source 25 MCT
  (Modulen). Used especially in Paediatrics
• Fish oils (n-3)may have a role as an adjunctive
  treatment, but more research is needed
  (Forbes 2002)
• 
  (Macdonald 2006)

22
Low/ Modified Fibre Diet

• Foods allowed
• Milk, eggs, meat, cheese (up to 2oz/day)
• Fats/oil in moderation
• Vegetables remove all skin, peel, pips, stalks.
  Use tinned, fresh or frozen. Serve well cooked.
• Fruit remove all skin, peel, pips and stones.
  Avoid under-ripe fruit. Tinned or fresh

23
Low/ Modified Fibre Diet cont.

• Foods to Avoid
• Overcooked, tough meats
• High fibre breakfast cereals
• Wholegrain/ wholemeal bread, pasta, rice
• Vegetables all pulses, nuts, raw vegetables and
  salads
• Fruit dried fruit, figs, citrus fruits,
  raspberries, blackberries, currants

24
Minimal Lactose Diet

• Foods Allowed
• Reduced lactose milk
• Yogurt
• Soya milk
• Butter, some margarines
• Double cream
• Cheese

25
Minimal Lactose Diet cont.

• Foods to Avoid
• Milk
• Ice cream
• Margarine (need to check ingredients)
• Cream (except double cream)
• Cottage cheese, processed cheese and cheese
  spreads
• Malted milk drinks and drinking chocolate
• Milk chocolate, fudge, toffee
• Check ingredients for lactose, milk, milk powder
  etc.

26
Complications of IBD

• Total obstruction TPN
• - /- surgery
• Fistulas may heal with bowel rest with
• TPN, or need a temporary stoma
• - elemental/semi-elemental feeds
• - low fibre diet
• Strictures
• May be inflammatory (treat inflammation) or
  fibrotic
• - often surgery (stricturoplasties, resection)

27
Complications cont

• Stomas- may be reversible
• Post surgery low fibre
• Aim for normal diet but watch fluid and
  electrolytes
• May need to avoid specific foods which cause
  pain, wind odour e.g. baked beans, spicy foods,
  brassicas and onions
• Output may be too watery use bananas or
  marshmallow . Often Codeine Phosphate is used
  (best in liquid form)

28
Complications

• IBD patients on regular steroids are at increased
  risk of Osteoporosis. All patients on steroids
  should be covered with a Calcium Vitamin D
  preparation
• (British Society
  of Gastroenterology)

29
Ileo-anal pouches

• Only used in U.C.
• - initially soft, low fibre diet
• - adequate fluid and salt
• - regular eating pattern food and pouch
  activity diary
• - after one month, reintroduce other foods,
  chewing well.
• Aim normal diet, avoid as few foods as
  possible. Try problem foods on several occasions

30
Short Bowel Syndrome

• Often as a result of repeated surgery. Usually
  defined as less than 150cm viable small bowel or
  90cm healthy colon
• may require TPN
• gut can adapt
• fluid losses high Na fluids gt90mmol
• restrict other fluids to 1 litre
• anti-diarrhoeal agents, codeine phosphate
  loperamide as liquids
• low fibre diet
• add salt to food

31
Diet as Treatment for an Exacerbation of Crohns
Disease 1

• Bowel rest does not improve outcome
• Diet may be used alone or more usually in
  conjunction with steroids
• It has been found to be effective as a primary
  treatment but does not affect long-term outcome
• Which type?
• TPN only used in subacute/ total obstruction,
  short bowel syndrome and high output fistulas/
  stoma
• Elemental vs Peptides vs Polymeric?
• 
  (Griffiths 1995 OMorain 1997)
• Traditionally elemental has been used and it is
  safe in pregnancy (Teaho 1991)

32
Diet as Treatment for an Exacerbation of Crohns
Disease2

• Meta analysis (Zachos et al 2007)
• Corticosteroid therapy more effective than
  enteral nutrition for treating active Crohns
  disease
• Comparing one form of enteral feeding with
  another has not shown any difference in
  effectiveness for treating active Crohns disease
• There is a non statistically significant trend
  favouring low fat formulations
• More research is needed!

33
Diet in Remission

• Aim to have as normal a diet as possible with the
  minimum number of foods excluded.
• Ensure adequate energy, protein, fluid, vitamins
  and minerals
• May require nutritional /or vitamin/mineral
  supplements
• Fibre as tolerated except for those with tight
  strictures
• Patients with U.C. need as much fibre as possible
  to avoid constipation ensure adequate fluid
• Some centres use Lofflex, a low fibre fat limited
  exclusion diet post elemental/ peptide. (Woolner
  1998)

34
Summary

• IBD is a debilitating disease
• Malnutrition is common even in patients with
  relatively quiescent disease. It significantly
  impairs the clinical status and quality of life
  of the individual (Jeejeebhoy 1995)
• Dietary management is aimed at
• reversing/ preventing malnutrition
• reducing symtoms
• promoting remission in active Crohns disease
• ensuring a balanced diet /- supplements