Micronutrient deficiencies in inflammatory bowel disease: from A to zinc

Diet and Nutrition in Pediatric Inflammatory Bowel Diseases

Both genetic and environmental factors are involved in the onset of inflammatory bowel disease (IBD). In particular, diet composition is suspected to significantly contribute to IBD risk. In recent years, major interest has raised about the role of nutrition in disease pathogenesis and course, and many studies have shown a clear link between diet composition and intestinal permeability impairment. Moreover, many IBD-related factors, such as poor dietary intake, nutrients loss and drugs interact with nutritional status, thus paving the way for the development of many therapeutic strategies in which nutrition represents the cornerstone, either as first-line therapy or as reversing nutritional deficiencies and malnutrition in IBD patients. Exclusive enteral nutrition (EEN) is the most rigorously supported dietary intervention for the treatment of Crohn's Disease (CD), but is burdened by a low tolerability, especially in pediatric patients. Promising alternative regimens are represented by Crohn's Disease Exclusion Diet (CDED), and other elimination diets, whose use is gradually spreading. The aim of the current paper is to provide a comprehensive and updated overview on the latest evidence about the role of nutrition and diet in pediatric IBD, focusing on the different nutritional interventions available for the management of the disease.

Influence of Severe Vitamin D Deficiency on the Clinical Course of Inflammatory Bowel Disease

BACKGROUND

Previous studies have shown vitamin D status to be associated with disease activity in patients with inflammatory bowel disease (IBD), but its influence on the clinical course of IBD has not been established.

AIMS

We aimed to analyze whether the serum 25-hydroxyvitamin D3 [25(OH)D] status is associated with clinical characteristics and affects the risk of surgery in patients with IBD.

METHODS

From the IBD registry of the Asan Medical Center, we identified all patients who had at least one 25(OH)D measurement; we then analyzed the association between clinical factors and 25(OH)D status. 25(OH)D was considered borderline deficient, deficient, and severely deficient at levels of < 30, < 20, and < 10 ng/mL, respectively.

RESULTS

We included 711 Crohn's disease (CD) and 764 ulcerative colitis (UC) patients who had not undergone surgery before 25(OH)D was measured. Both in CD and in UC patients, reduced 25(OH)D was associated with higher disease activity scores and CRP levels (p < 0.001). Severe 25(OH)D deficiency was associated with ileocolonic disease and complicated behavior in CD (p < 0.05) and was relevant to the disease extent in UC (p < 0.001). Additionally, severe 25(OH)D deficiency was associated with CMV colitis in patients with UC (p < 0.001). In multivariable analysis, severe deficiency of 25(OH)D was an independent risk factor for surgery in both CD (HR 1.93, 95% confidence interval [CI] 1.38-2.70) and UC (HR 2.77, 95% CI 1.14-6.74).

CONCLUSION

Severe 25(OH)D deficiency may be a marker of a more aggressive clinical course of IBD.

Impact of titanium dioxide nanoparticles on intestinal community in 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced acute colitis mice and the intervention effect of vitamin E

Titanium dioxide nanoparticles (TiO2-NPs) are widely applied as additives in foods due to their excellent whitening and brightening capability. Although the toxicity and antibacterial activity of TiO2-NPs have been extensively studied, their impact on the gut microbiota in vivo still remains unclear, especially in animals with gastrointestinal disorders. In the present study, healthy mice and TNBS-induced colitis mice were administered with TiO2-NPs (38.3 ± 9.3 nm) orally at a dose of 100 mg per kg bw daily for 10 days to study the impact of TiO2-NPs on the gut microbiota and colitis development. Moreover, the mechanism of TiO2-NPs on the gut microbiota was also discussed when the colitis mice were additionally administered with vitamin E to remove ROS. Changes in the microbiota community structure and gut-associated function prediction were analyzed through bioinformatics. The result showed that the oral administration of TiO2-NPs mitigated colitis symptoms by reducing the DAI and CMDI scores and TNF-α level. Furthermore, 16S rDNA sequencing analysis showed that the structure and function prediction of gut microbiota could be modified in healthy mice and colitis mice after exposure to TiO2-NPs, but the opposite physiological effect occurred since the dominant flora varied in these two groups. Moreover, vitamin E intervention did not change the effects of TiO2-NPs on the microbiota community structure and gut-associated function, which indicates that the mechanism of the biological effects of TiO2-NPs on the gut microbiota may not be associated with their ability to induce the generation of ROS. In summary, our work firstly found that TiO2-NPs could regulate the gut microbiota of colitis mice and participate in the mitigation of TNBS-induced acute colitis, and the capability of TiO2-NPs to induce the generation of ROS inducement did not contribute to this process.

Effectiveness of administering zinc acetate hydrate to patients with inflammatory bowel disease and zinc deficiency: a retrospective observational two-center study

Background/Aims

Inflammatory bowel disease (IBD) patients frequently have zinc deficiency. IBD patients with zinc deficiency have higher risks of IBD-related hospitalization, complications, and requiring surgery. This study aimed to examine the effectiveness of zinc acetate hydrate (ZAH; Nobelzin) in IBD patients with zinc deficiency.

Methods

IBD patients with zinc deficiency who received ZAH from March 2017 to April 2020 were registered in this 2-center, retrospective, observational study. Changes in serum zinc levels and disease activity (Crohn’s Disease Activity Index [CDAI]) before and after ZAH administration were analyzed.

Results

Fifty-one patients with Crohn’s disease (CD, n = 40) or ulcerative colitis (UC, n = 11) were registered. Median serum zinc level and median CDAI scores significantly improved (55.5–91.0 μg/dL, P<0.001; 171.5–129, P<0.001, respectively) in CD patients 4 weeks after starting ZAH administration. Similarly, median serum zinc levels and CDAI scores significantly improved (57.0–81.0 μg/dL, P<0.001; 177–148, P=0.012, respectively) 20 weeks after starting ZAH administration. Similar investigations were conducted in groups where no treatment change, other than ZAH administration, was implemented; significant improvements were observed in both serum zinc level and CDAI scores. Median serum zinc levels in UC patients 4 weeks after starting ZAH administration significantly improved from 63.0 to 94.0 μg/dL (P=0.002), but no significant changes in disease activity were observed. One patient experienced side effects of abdominal discomfort and nausea.

Conclusions

ZAH administration is effective in improving zinc deficiency and may contribute to improving disease activity in IBD.

Incidence and risk factors of micronutrient deficiency in patients with IBD and intestinal Behçet's disease: folate, vitamin B12, 25-OH-vitamin D, and ferritin

BACKGROUND

Patients with inflammatory bowel disease (IBD) and intestinal Behçet's disease (BD) are vulnerable to micronutrient deficiencies due to diarrhea-related gastrointestinal loss and poor dietary intake caused by disease-related anorexia. However, few studies have investigated the incidence and risk factors for micronutrient deficiency.

METHODS

We retrospectively analyzed 205 patients with IBD who underwent micronutrient examination, including folate, vitamin B12, 25-OH-vitamin D, and/or ferritin level quantification, with follow-up blood tests conducted 6 months later.

RESULTS

Eighty patients (39.0%), who were deficient in any of the four micronutrients, were classified as the deficiency group, and the remaining 125 (61.0%) were classified as the non-deficient group. Compared to those in the non-deficiency group, patients in the deficiency group were much younger, had more Crohn's disease (CD) patients, more patients with a history of bowel operation, and significantly less 5-amino salicylic acid usage. Multivariate analysis revealed that CD and bowel operation were significant independent factors associated with micronutrient deficiency.

CONCLUSIONS

The incidence of micronutrient deficiency was high (39.0%). Factors including CD, bowel operation, and younger ages were found to be associated with higher risks of deficiency. Therefore, patients with IBD, especially young patients with CD who have undergone bowel resection surgery, need more attention paid to micronutrition.

Calcium physiology, metabolism and supplementation: a glance at patients with ankylosing spondylitis

The aim of this review is to describe the metabolism of calcium in ankylosing spondylitis compared to physiologic conditions, and to present the current evidence on the benefits and disadvantages of calcium supplementation in these patients. A narrative review of the literature was conducted using the PubMed database and a total of 65 articles were selected. Calcium is involved in many physiopathological processes, including inflammation, bone loss and bone formation, all of which occur in ankylosing spondylitis. Many ankylosing spondylitis patients suffer from concomitant osteopenia or osteoporosis, which represent indications for calcium supplementation. Conversely, there are still concerns about the use of calcium salts for the prevention of bone fragility in non-osteoporotic or non-osteopenic patients. In these cases, biologic agents may indirectly normalize calcium dysmetabolism by rebalancing the cytokine milieu, in turn associated with bone remodeling. Calcium supplements may be disadvantageous for entheseal calcifications, but so far there are no clear data confirming that such an association exists.

A missense variant in SLC39A8 confers risk for Crohn's disease by disrupting manganese homeostasis and intestinal barrier integrity

SLC39A8 A391T exhibits remarkable pleiotropic effects on multiple conditions, including cardiovascular diseases, Parkinson’s disease, and Crohn’s disease. However, how this single coding variant impacts such a wide range of pathologies has not been investigated. We generated Slc39a8 A391T knockin mice and show that they exhibit severe Mn deficiency in the colon, and impaired intestinal barrier integrity due to glycoprotein barrier structure defects, leading to indolent inflammation that can prime further inflammation driven by epithelial injury. Thus, we highlight the importance of Mn in gut homeostasis, and mechanistically unravel how A391T impacts intestinal barrier integrity.

Common genetic variants interact with environmental factors to impact risk of heritable diseases. A notable example of this is a single-nucleotide variant in the Solute Carrier Family 39 Member 8 (SLC39A8)geneencoding the missense variant A391T, which is associated with a variety of traits ranging from Parkinson’s disease and neuropsychiatric disease to cardiovascular and metabolic diseases and Crohn’s disease. The remarkable extent of pleiotropy exhibited by SLC39A8 A391T raises key questions regarding how a single coding variant can contribute to this diversity of clinical outcomes and what is the mechanistic basis for this pleiotropy. Here, we generate a murine model for the Slc39a8 A391T allele and demonstrate that these mice exhibit Mn deficiency in the colon associated with impaired intestinal barrier function and epithelial glycocalyx disruption. Consequently, Slc39a8 A391T mice exhibit increased sensitivity to epithelial injury and pathological inflammation in the colon. Taken together, our results link a genetic variant with a dietary trace element to shed light on a tissue-specific mechanism of disease risk based on impaired intestinal barrier integrity.

Effectiveness of Mediterranean Diet's Adherence in children with Inflammatory Bowel Diseases

BACKGROUND

Nutritional support is very important in the treatment of Paediatric Inflammatory Bowel Disease (IBD). The role of the Mediterranean Diet (MD) has been understudied in children with IBD. The aims of this study were to assess the dietary intakes of IBD children in comparison with healthy controls (HCs), their adherence to MD; and the relationship between inflammation and dietary behaviors.

METHODS

Paediatric IBD patients in clinical remission and HCs were enrolled. The nutritional status and adherence to the Mediterranean Diet was evaluated through a 3-day food diary and the Mediterranean Diet Quality Index for Children and Adolescents (KIDMED).

RESULTS

The analysis of food diaries showed a significantly higher kilocalorie intake in IBD patients compared to HCs (p = 0.012), an increase in carbohydrates (p = 0.015) and in protein intake (p = 0.024). Both IBD and HCs have an intermediate adherence to MD. The comparison between Crohn's disease (CD) and Ulcerative colitis (UC) patients showed significant difference in protein intake in CD patients (p = 0.047), as well as for vitamin D (p = 0.044) and iron intake (p = 0.023). Interestingly; in IBD patients we found a significant association between adherence to MD and a low level of fecal calprotectin (p = 0.027).

CONCLUSION

Children with IBD in remission have a sub-optimal food intake compared to HCs. MD seems to correlate to decreased intestinal inflammation.

Clinical Manifestations of Copper Deficiency: A Case Report and Review of the Literature

BACKGROUND

Copper is a mineral that is absorbed in the stomach, duodenum, and jejunum. Gastric bypass surgery, gastrectomy, and short-bowel syndrome commonly lead to copper malabsorption. Copper deficiency primarily presents with hematological and neurological sequelae, including macrocytic anemia and myelopathy. Although hematological disturbances often correct with copper supplementation, neurological manifestations of copper deficiency may be irreversible. We present the case of copper deficiency secondary to malabsorption and management strategies to prevent irreversible neurological sequelae.

PRESENTATION

A 48-year-old female with a history of hypothyroidism, ischemic stroke, and Crohn's disease, complicated by subtotal colectomy and small-bowel resections, was admitted for fatigue and progressive neurological deficiencies. Her vital signs were stable, and physical examination was remarkable for weakness of both upper and lower extremities, ataxia, and upper extremities paresthesia. Computed tomography scan of the head without contrast was unremarkable. Magnetic resonance imaging enterography revealed a focal area of narrowing of the remaining small bowel. Copper level was low at 39 µg/dL. After 5 days of intravenous replacement using trace element within parenteral nutrition, her copper level corrected to 81 µg/dL. Her ataxia improved after intravenous copper supplementation and did not recur.

CONCLUSIONS

Our patient presented with copper deficiency secondary to malabsoprtion. This case highlights the importance of copper testing in the bariatric surgery population and in patients with short-bowel syndrome. Given the irreversible nature of neurological symptoms when compared with the expense of nutrition supplements, routine copper testing should be considered in patients with malabsorptive states or altered anatomy, regardless of initial presentation.

Diet and Nutrients in Gastrointestinal Chronic Diseases

Diet and nutrition are known to play key roles in many chronic gastrointestinal diseases, regarding both pathogenesis and therapeutic possibilities. A strong correlation between symptomatology, disease activity and eating habits has been observed in many common diseases, both organic and functional, such as inflammatory bowel disease and irritable bowel syndrome. New different dietary approaches have been evaluated in order improve patients’ symptoms, modulating the type of sugars ingested, the daily amount of fats or the kind of metabolites produced in gut. Even if many clinical studies have been conducted to fully understand the impact of nutrition on the progression of disease, more studies are needed to test the most promising approaches for different diseases, in order to define useful guidelines for patients.

Phytochemicals affect T helper 17 and T regulatory cells and gut integrity: implications on the gut-bone axis

The pathology of osteoporosis is multifactorial, but a growing body of evidence supports an important role of the gut-bone axis, especially in bone loss associated with menopause, rheumatoid arthritis, and periodontal disease. Aberrant T cell responses favoring an increase in the ratio of T helper 17 cells to T regulatory cells play a critical role in the underlying etiology of this bone loss. Many of the dietary phytochemicals known to have osteoprotective activity such as flavonoids, organosulfur compounds, phenolic acids, as well as the oligosaccharides also improve gut barrier function and affect T cell differentiation and activation within gut-associated lymphoid tissues and at distal sites. Here, we examine the potential of these phytochemicals to act as prebiotics and immunomodulating agents, in part targeting the gut to mediate their effects on bone.

Vitamin C Deficiency: An Under-Recognized Condition in Crohn's Disease

Although many nutritional deficiencies are associated with Crohn's disease (CD), vitamin C deficiency is less frequently diagnosed and reported despite its prevalence. Vitamin C deficiency may be more difficult to diagnose in patients with CD because symptoms from active CD may overlap with scurvy. Identification of the deficiency is vital, however, because treatment can lead to swift, marked resolution of symptoms. We present a patient with long-standing CD who presented with gum bleeding and was found to have scurvy.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

Safety and Efficacy of Bariatric Surgery in Inflammatory Bowel Disease Patients: a Systematic Review and Meta-analysis

BACKGROUND

The safety and efficacy of bariatric surgery in inflammatory bowel disease (IBD) patients is poorly understood. We conducted a systematic review and meta-analysis studying safety and efficacy of bariatric surgery in IBD patients as well as the impact of bariatric surgery on IBD course.

METHODS

We conducted a comprehensive search of multiple databases (through September 2019) to identify studies that reported outcome of bariatric surgery in IBD patients. Outcomes assessed included the pooled rate of adverse events, change in medications after bariatric surgery, and 12-month excess weight loss (EWL) and body mass index (BMI) reduction after bariatric surgery.

RESULTS

A total of 10 studies were included in final analysis. The pooled rate of early and late adverse events was 15.9% (95% CI, 9.3-25.9) and 16.9% (95% CI, 12.1-23.1), respectively. The rate of adverse events in Roux-en-Y gastric bypass was 45.6% (95% CI, 21.9-71.4) compared with 21.6% (95% CI, 11.1-38) in sleeve gastrectomy (p = 0.11). The pooled rate of 12-month EWL and BMI reduction after surgery was 66.1% (95% CI, 59.8-72.3%) and 13.7 kg/m² (95% CI, 12.5-14.9), respectively. The pooled rate of decrease, increase, and no change of IBD medications were 45.6% (95% CI, 23.8-69.2), 11% (95% CI, 6.3-18.4), and 57.6% (95% CI, 39.2-74.1), respectively.

CONCLUSIONS

Bariatric surgery has acceptable safety and efficacy profile in IBD patients. Nearly half of patients had decrease in their IBD medications after bariatric surgery, and only 10% experienced therapeutic escalation following bariatric surgery. Sleeve gastrectomy may be the preferred procedure in this population.

Nutrients in the Prevention of Osteoporosis in Patients with Inflammatory Bowel Diseases

The chronic character of inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis, results in various complications. One of them is osteoporosis, manifested by low bone mineral density, which leads to an increased risk of fractures. The aetiology of low bone mineral density is multifactorial and includes both diet and nutritional status. Calcium and vitamin D are the most often discussed nutrients with regard to bone mineral density. Moreover, vitamins A, K, C, B12; folic acid; calcium; phosphorus; magnesium; sodium; zinc; copper; and selenium are also involved in the formation of bone mass. Patients suffering from inflammatory bowel diseases frequently consume inadequate amounts of the aforementioned minerals and vitamins or their absorption is disturbed, resulting innutritional deficiency and an increased risk of osteoporosis. Thus, nutritional guidelines for inflammatory bowel disease patients should comprise information concerning the prevention of osteoporosis.

Comorbidities in adolescents with inflammatory bowel disease: findings from a population-based cohort study

BACKGROUND

Inflammatory bowel diseases are associated with various immune- and non-immune-mediated conditions. We aimed to assess the association of inflammatory bowel diseases with comorbidities at late adolescence.

METHODS

Jewish Israeli adolescents who underwent a general health evaluation prior to enlistment to the Israeli Defense Forces from 2002 to 2016 were included.

RESULTS

Overall, 891 subjects (595 Crohn's disease, 296 ulcerative colitis, median age 17.1 years) and 1,141,841 controls were analyzed. Crohn's disease was associated with arthritis (odds ratio (OR) 4.7, 95% confidence interval (CI) 2.4-9.1), thyroid disease (OR 2.6, 95% CI 1.2-5.5), atopic dermatitis (OR 2, 95% CI 1.1-3.6), autoimmune hepatitis (OR 4.4, 95% CI 2.3-8.6), nephrolithiasis (OR 3.6, 95% CI 1.2-11.4), and pancreatitis (OR 41.8, 95% CI 17.2-101.9). Ulcerative colitis was associated with arthritis (OR 3.6, 95% CI 1.0-9.8), thyroid disease (OR 4.8, 95% CI 1.2-19.4), autoimmune hepatitis (OR 8, 95% CI 4-16.2), and pancreatitis (OR 51, 95% CI 16.1-158.9). Primary sclerosing cholangitis was associated with both diseases. Asthma, celiac, type 1 diabetes, psoriasis, and bone fractures were not more common in both diseases. Male predominance was noted for most associations.

CONCLUSIONS

At adolescence, both Crohn's disease and ulcerative colitis are associated with multiple comorbidities, not limited to autoimmune disorders.

Study of Metal-Metal Interactions and Their Biomarkers Using an Intestinal Human Cell Line

From the time of dietary intake to their utilization, the number of important interactions occurs among mineral elements, which can affect their bioavailability because of similarity in physicochemical properties and common absorptive pathways. However, the studies that have analyzed the interactions among copper, iron, and zinc have conflicting results and need further exploration. HT-29 cells grown to confluence in 6-well plates were incubated with increasing concentrations (0 to 200 μM) of Cu, Fe, and Zn for 3 and 6 h for uptake studies. Interaction studies involved measuring the uptake of metal in the presence of 0:1-4:1 ratio of the other metal for 3 h using atomic absorption spectrophotometer. The concentration of metal biomarkers and cytokines was also measured in the cell lysate following extracellular supplementation. The presence of 50 μM Zn significantly decreased (P < 0.05) cellular Cu uptake in HT-29 cells at 0.5:1 Cu:Zn ratio and also the cellular Fe uptake at the ratios 0.5:1, 2:1, and 4:1 Fe:Zn. The presence of 50 μM Fe significantly (P < 0.05) decreased cellular Cu uptake at the ratios 1:1, 2:1, and 4:1 Cu:Fe. The concentration of metallothionein responded significantly (P < 0.05) to changes in extracellular Zn concentration (supplementation and depletion). There was a decrease in concentration of IL-1β and TNF-α (P < 0.05) with an increasing extracellular concentration of Cu and Fe. The results of the study indicated that the presence of one mineral in the diet and multi mineral supplement may influence the bioavailability of the other mineral. Copper and iron may find application in promoting gut health.

Examination of food consumption in United States adults and the prevalence of inflammatory bowel disease using National Health Interview Survey 2015

Various diets and food components have been implicated as one of the environmental factors associated with inflammatory bowel disease (IBD). Patients are often recommended nutritional guidelines to manage disease symptoms. However, the current food consumption pattern of US adults with IBD that are nationally representative is unclear. A secondary analysis of National Health Interview Survey 2015 was performed to characterize the estimated US adults with IBD and their food intake and consumption frequency using bivariate and multivariate logistic regression. Fries were consumed by a greater number of people with IBD. IBD population drank less 100% fruit juice and ate more cheese and cookies than non-IBD population. Intake of fries (OR 1.60, 95% CI 1.14-2.25) and sports and energy drinks (OR 1.46, 95% CI 1.07-1.97) and more frequent drinking of regular soda were significantly associated with the likelihood of having been told one have IBD, while popcorn (OR 0.73, 95% CI 0.548-0.971) and milk (OR 0.70, 95% CI 0.497-0.998) were associated with smaller odds, adjusting for covariates. Foods typically labeled as junk food were positively associated with IBD. Nonetheless, of the assessed 26 foods, we found eating patterns between IBD and non-IBD population to be mostly analogous. It is unclear whether the results reflect potential change in food intake in IBD population long before the survey interview. Understanding the role of food intake in IBD risk/prevalence would benefit from identifying other environmental factors (i.e. food desert), food processing (i.e. frying), and potential bioactive food components that can induce intestinal inflammation that can increase the individual's susceptibility to IBD.

Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease

BACKGROUND AND AIM

Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research.

METHODS

A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified.

RESULTS

An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed.

CONCLUSION

EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.

Presentation and Management of Arterial Thromboembolisms during Active Inflammatory Bowel Disease: Case Series and Literature Review

BACKGROUND

Active inflammatory bowel disease (IBD) is associated with considerable risk for thromboembolism; however, arterial thromboembolism is rare and associated with considerable morbidity and mortality. Their management requires careful coordination between multiple providers, and as a consequence, much of the published literature is limited to case reports published across specialties.

METHODS

We examined our recent institutional experience with aortoiliac, mesenteric, and peripheral arterial thromboembolisms in patients with either Crohn's disease or ulcerative colitis. To supplement our experience, a comprehensive literature review was performed using MEDLINE and EMBASE databases from 1966 to 2019. Patient demographics, flare/thromboembolism management, and outcomes were abstracted from the selected articles and our case series.

RESULTS

Fifty-two patients with IBD, who developed an arterial thromboembolism, were identified (49 from published literature and 3 from our institution). More than 82% of patients presented during an active IBD flare. Surgical intervention was attempted in 77% of patients, which included open thromboembolectomy, catheter-directed thrombolysis, or bowel resection. Thromboembolism resolution was achieved in 76% of patients with comparable outcomes with either catheter-directed thrombolysis or open thrombectomy (83.3% vs. 68.2%). Nearly one-third of patients underwent small bowel resection or colectomy. In 2 patients, thromboembolism resolution was achieved only after total abdominal colectomy for severe pancolitis. Multiple thromboembolectomies were associated with higher risk for amputation. Overall mortality was 11.5% but was greatest for occlusive aortoiliac and mesenteric thromboembolism (14.3% and 57%, respectively). All survivors of occlusive superior mesenteric artery thromboembolism suffered short gut syndrome requiring small bowel transplant.

CONCLUSIONS

Patients with IBD, who develop an arterial thromboembolism, can expect overall poor outcomes. Catheter-directed thrombolysis achieved comparable outcomes with open thromboembolectomy without undue bleeding risk. Total abdominal colectomy for moderate-to-severe pancolitis is an emerging strategy in the management of refractory arterial thromboembolism. Successful surgical management may include open thromboembolectomy, catheter-directed thrombolysis, and bowel resection when indicated.

Nutritional Aspects in Inflammatory Bowel Diseases

Crohn’s disease (CD) and ulcerative colitis (UC) are chronic, relapsing, inflammatory disorders of the digestive tract that characteristically develop in adolescence and early adulthood. The reported prevalence of malnutrition in inflammatory bowel disease (IBD) patients ranges between 20% and 85%. Several factors, including reduced oral food intake, malabsorption, chronic blood and proteins loss, and intestinal bacterial overgrowth, contribute to malnutrition in IBD patients. Poor nutritional status, as well as selective malnutrition or sarcopenia, is associated with poor clinical outcomes, response to therapy and, therefore, quality of life. The nutritional assessment should include a dietetic evaluation with the assessment of daily caloric intake and energy expenditure, radiological assessment, and measurement of functional capacity.

The Copper/Zinc Ratio Correlates With Markers of Disease Activity in Patients With Inflammatory Bowel Disease

BACKGROUND

Zinc (Zn) and copper (Cu) are trace elements that serve as cofactors in catalytic processes with impact on immune responses. In patients with inflammatory bowel disease (IBD), decreased levels of serum Zn and Cu have been observed. Here, we investigated the effect of inflammation on serum concentrations of these trace elements in patients with IBD.

METHODS

In this cross-sectional study, 98 patients with Crohn disease (CD) and 56 with ulcerative colitis (UC) were prospectively enrolled. Disease activity parameters, such as C-reactive protein (CRP) and fecal calprotectin (FC) were compared to serum Zn, Cu, and Cu/Zn ratio.

RESULTS

Zinc insufficiency was observed in 11.2% of patients with CD and 14.3% with UC, Cu insufficiency in 20.4% with CD and 7.1% with UC. Anemia, hypoalbuminemia, increased FC, and elevated CRP were more frequently present in Zn-insufficient patients with IBD. In contrast, lower serum CRP values and a trend to lower FC were observed in Cu-insufficient patients. In multiple linear regression models adjusted for age, gender, and serum albumin, CRP positively correlated with serum Cu (P < 0.001) and the Cu/Zn ratio in both CD and UC (P < 0.001) but not with serum Zn concentrations. FC levels correlated only with the Cu/Zn ratio in patients with UC (P < 0.038).

CONCLUSION

Systemic inflammation inversely affected the serum Zn and Cu concentrations and, consequently, resulted in an increased Cu/Zn ratio.

Fatigue in Inflammatory Bowel Diseases: Etiologies and Management

Fatigue is a burdensome, multidimensional, and multifactorial symptom that is associated with a wide array of chronic illnesses, specifically occurring in nearly 50% of patients with inflammatory bowel disease (IBD). Although common, given its subjective nature, physicians often under-recognize and undertreat this debilitating symptom. There are multiple etiologies that can contribute to fatigue in patients with IBD, including disease activity, anemia, medications, psychosomatic symptoms, and alterations to the gut–brain axis. The management of fatigue in IBD can be challenging, as it is often times multifaceted. In this review, we summarize the available tools for the diagnosis and measurement of fatigue, discuss etiologies, and make recommendations for their management. We identify knowledge gaps for the workup and treatment of fatigue and propose an algorithm to aid physicians in the evaluation and management of fatigue in this unique population. However, future research is needed to address several areas of knowledge deficits and improve the management of fatigue in IBD.

Effect of Oral Nutrition Supplements and TGF-β2 on Nutrition and Inflammatory Patterns in Patients With Active Crohn's Disease

BACKGROUND

Crohn's disease (CD) is often associated with nutrition disorders. Many nutrition therapeutic alternatives have been studied. Nevertheless, the actual role of nutrition therapy is still controversial. The objective of this study was to assess the effects of nutrition supplementation with and without transforming growth factor-beta 2 (TGF-β2) on inflammatory, endoscopic, histopathologic, and nutrition parameters in active CD.

MATERIALS AND METHODS

Thirty-eight patients were allocated into 3 groups: group 1 (patients who received only nutrition orientation), group 2 (nutrition orientation and a normoproteic, normocaloric nutrition supplement), and group 3 (nutrition orientation and the nutritional supplement with TGF-β2). Clinical and nutrition evaluation, C-reactive protein (CRP) levels, and assessment of endoscopic and histologic parameters in the intestinal mucosa were performed before and after nutrition intervention.

RESULTS

The mean follow-up period was 3 months. In the beginning of the study, groups were homogeneous regarding age, gender, CD behavior and localization, and medication in use. In the end of the study, the Clinical Disease Activity Index score was reduced in groups 2 and 3; in group 3, a reduction in CRP levels and an improvement in histologic findings were observed. Among patients who received nutritional supplement, some anthropometric patterns were improved.

CONCLUSION

The results of the study indicate that nutritional supplementation improved nutrition and inflammatory patterns in patients with active CD. However, only patients receiving TGF-β2-enriched formula showed improvement in histologic parameters and significant reduction in CRP levels.

Mechanisms Underlying Bone Loss Associated with Gut Inflammation

Patients with gastrointestinal diseases frequently suffer from skeletal abnormality, characterized by reduced bone mineral density, increased fracture risk, and/or joint inflammation. This pathological process is characterized by altered immune cell activity and elevated inflammatory cytokines in the bone marrow microenvironment due to disrupted gut immune response. Gastrointestinal disease is recognized as an immune malfunction driven by multiple factors, including cytokines and signaling molecules. However, the mechanism by which intestinal inflammation magnified by gut-residing actors stimulates bone loss remains to be elucidated. In this article, we discuss the main risk factors potentially contributing to intestinal disease-associated bone loss, and summarize current animal models, illustrating gut-bone axis to bridge the gap between intestinal inflammation and skeletal disease.

Inflammatory Bowel Disease Is Not a Contraindication for Bariatric Surgery

BACKGROUND

Inflammatory bowel diseases (IBD) are listed as a contraindication for bariatric surgery in various guidelines due to a theoretical higher complication risk. Therefore, little is known about safety and efficacy of bariatric surgery in IBD patients.

AIM

We assessed the safety and efficacy of bariatric surgery and postoperative quality of life (QoL) in IBD patients.

SETTING

The study was conducted in a large peripheral hospital in the Netherlands.

METHODS

All IBD patients who underwent bariatric surgery in our facility were included. Complications, mortality, reoperations, and micronutrient deficiencies were analyzed. Weight loss was assessed 6, 12, and 24 months after surgery. Postoperative QoL was assessed using a disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ).

RESULTS

Forty-five patients were included in this study, all diagnosed with IBD (16 ulcerative colitis (UC) and 29 Crohn's disease (CD)) prior to bariatric surgery. Bariatric procedures included Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, and revisional surgery. There was no mortality in the entire follow-up period and there were no major perioperative complications. Two major complications in two CD patients occurred during follow-up, gastro-enterostomy bleeding and pyelonephritis with secondary pancreatitis. Mean percentage (± SD) of overall excess weight loss (%EWL) and total body weight loss (%TBWL), 12 months after surgery, were 62.9 ± 27.1 and 26.2 ± 10.6%, respectively. Twenty-four months postoperatively, mean overall %EWL and %TBWL were similar for both UC and CD patients and were 62.9 ± 31.0 and 26.6 ± 12.2, respectively. Mean Bariatric Analysis and Reporting Outcome System (BAROS) score was 3.34 ± 2.42. Median total IBDQ score was 170.8 (min. 77; max. 218). Both scores did not differ significantly between UC and CD patients.

CONCLUSION

As bariatric procedures appear safe and effective in this CU and CD population, one could question why bariatric surgery is contraindicated in the patients. Nevertheless, close lifelong monitoring to assure safety and a favorable outcome remains essential.

Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease

Liver, pancreatic, and inflammatory bowel diseases are often associated with nutritional difficulties and necessitate an adequate nutritional therapy in order to support the medical treatment. As most patients with non-alcoholic fatty liver disease are overweight or obese, guidelines recommend weight loss and physical activity to improve liver enzymes and avoid liver cirrhosis. In contrast, patients with alcoholic steatohepatitis or liver cirrhosis have a substantial risk for protein depletion, trace elements deficiency, and thus malnutrition. Patients with chronic pancreatitis and patients with inflammatory bowel disease have a similar risk for malnutrition. Therefore, it clearly is important to screen these patients for malnutrition with established tools and initiate adequate nutritional therapy. If energy and protein intake are insufficient with regular meals, oral nutritional supplements or artificial nutrition, i.e., tube feeding or parenteral nutrition, should be used to avoid or treat malnutrition. However, the oral route should be preferred over enteral or parenteral nutrition. Acute liver failure and acute pancreatitis are emergencies, which require close monitoring for the treatment of metabolic disturbances. In most patients, energy and protein requirements are increased. In acute pancreatitis, the former recommendation of fasting is obsolete. Each disease is discussed in this manuscript and special recommendations are given according to the pathophysiology and clinical routine.

Dietary Management of Pediatric Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a life-long relapsing and remitting condition characterized by inflammation of the intestine. While the exact pathogenesis of IBD is unclear, the current belief is that both genetic and environmental factors play a role in development of disease. Management options include nutritional, pharmacological, and surgical therapies. In particular, nutritional therapies for IBD have garnered significant interest due to their limited side effect profile, bowel-sparing nature, and naturalistic approach. This review will examine the role of diet in the pathogenesis and malnutrition in IBD, and will discuss dietary approaches to management of IBD, including exclusive enteral nutrition, specific carbohydrate diet, anti-inflammatory diet, and food supplements (specifically curcumin and long-chain n-3 polyunsaturated fatty acids). Past and recent literature on these subjects were reviewed in Medhub and Scopus databases for this review article with a focus on pediatric and high-quality publications. At this time, these approaches seem to be safe and show promise of an efficacious sole or supplemental role in the treatment of IBD, but randomized, prospective studies are lacking. Additional studies investigating these diets and food supplements are needed to provide more information on their efficacy, mechanism, applicability, and safety.

Therapeutic effect of gold nanoparticles on DSS-induced ulcerative colitis in mice with reference to interleukin-17 expression

Ulcerative colitis (UC) is among the most challenging human diseases. Nanotechnology has incontestable promising outcomes in inflammatory bowel diseases. This study aimed to investigate the therapeutic effect of naked gold nanoparticles (AuNPs) on dextran sodium sulphate (DSS) induced ulcerative colitis in mice. We also examined the expression of interleukin-17 (IL-17) following AuNPs treatment. Mice were randomly divided into control, DSS and DSS+ AuNPs groups. Severity of colitis was assessed by disease activity index (DAI) measurement. At the end of the experiment, the final body weights were recorded. The colon was dissected and processed for histopathological examinations by light and electron microscopes. Colon homogenates were prepared for assay of tissue malondialdehyde (MDA) and real-time PCR analysis of IL-17A. Immunohistochemical localization of IL-17A was carried out. Scanning electron microscopy (SEM) and Energy Dispersive X-ray (EDX) detector were used to detect the presence of AuNPs in the colonic tissue of DSS+ AuNPs groups. Our results showed that AuNPs effectively targeted the colonic tissue, and reduced changes induced by DSS. The underlying mechanisms could be related to anti-oxidant effect (as evident by decreasing tissue MDA) and anti-inflammatory potential of AuNPs. Our study draws attention to as a novel therapeutic strategy for treating UC.

Dietary Support in Elderly Patients with Inflammatory Bowel Disease

Ageing of the human population has become a big challenge for health care systems worldwide. On the other hand, the number of elderly patients with inflammatory bowel disease (IBD) is also increasing. Considering the unique clinical characteristics of this subpopulation, including many comorbidities and polypharmacy, the current therapeutic guidelines for the management of IBD should be individualized and applied with caution. This is why the role of non-pharmacological treatments is of special significance. Since both IBD and older age are independent risk factors of nutritional deficiencies, appropriate dietary support should be an important part of the therapeutic approach. In this review paper we discuss the interrelations between IBD, older age, and malnutrition. We also present the current knowledge on the utility of different diets in the management of IBD. Considering the limited data on how to support IBD therapy by nutritional intervention, we focus on the Mediterranean and Dietary Approaches to Stop Hypertension diets, which seem to be the most beneficial in this patient group. We also discuss some new findings on their hypothetical anti-inflammatory influence on the course of IBD.

Effective Use of the Laboratory in the Management of Patients with Inflammatory Bowel Diseases

Inflammatory bowel disease (IBD) comprises a group of chronic, intestinal inflammatory disorders, including ulcerative colitis and Crohn's disease. IBD is characterized by periods of relapse and remission. Long-term progressive intestinal inflammation can result in severe and devastating complications, such as intestinal strictures and/or fistulae. Immune suppressive medications with potent side effects are often used to control inflammation and limit disease activity. Laboratory tests guide various decisions in clinical management of IBD. We discuss tests used to diagnose IBD, assess for relapse or remission, monitor the effectiveness of therapeutic regimen, screen for the maintenance of health, and diagnose or prevent complications.

Clinical significance of low transaminase levels in children with inflammatory bowel disease

BACKGROUND

Low alanine aminotransaminase (LALT) levels may be seen in patients with inflammatory bowel disease (IBD), but there has been no study about the frequency and its clinical significance. We aimed to analyze the frequency of LALT, and its clinical significance in children with IBD.

METHODS

The study included the 89 patients with IBD without hepatobiliary involvement. LALT was defined as ALT levels < 5 U/L. Demographic and clinical findings and outcome of the patients with and without LALT were compared.

RESULTS

LALT was found 47.1% of the patients. At initial examination, it was more common in female patients (92.3 vs. 41.3%, P < 0.001) and patients with CD (57.7 vs. 30.2%, P = 0.01). 75% of the patients with penetrating Crohn's disease (CD) had LALT (P = 0.002). Hemoglobin (10.4 ± 2.1 vs. 11.7 ± 1.9 g/dL, P = 0.01), folic acid (5.2 ± 3.3 vs. 8.6 ± 5.9 ng/mL, P = 0.02) and serum albumin levels (3.6 ± 0.8 vs. 4.7 ± 5 g/dL, P = 0.002) were significantly low in patients with LALT. LALT was associted with the disease relapse within 2 weeks in 12 of the 16 patients with LALT whereas it was seen in 16 of the 73 patients without LALT during the follow-up (75 vs. 21.9%, P < 0.001). Additionally, steroid dependency was more common in patients with LALT during the follow-up (62.5 vs. 12.3%, P < 0.001).

CONCLUSIONS

LALT is common in children with IBD especially in CD and associated with low hemoglobin, albumin and folic acid levels. It may be a marker of relapse and steroid dependency.

Metagenomic analysis of microbe-mediated vitamin metabolism in the human gut microbiome

BACKGROUND

Human gut microbial communities have been known to produce vitamins, which are subsequently absorbed by the host in the large intestine. However, the relationship between species with vitamin pathway associated functional features or their gene abundance in different states of health and disease is lacking. Here, we analyzed shotgun fecal metagenomes of individuals from four different countries for genes that are involved in vitamin biosynthetic pathways and transport mechanisms and corresponding species' abundance.

RESULTS

We found that the prevalence of these genes were found to be distributed across the dominant phyla of gut species. The number of positive correlations were high between species harboring genes related to vitamin biosynthetic pathways and transporter mechanisms than that with either alone. Although, the range of total gene abundances remained constant across healthy populations at the global level, species composition and their presence for metabolic pathway related genes determine the abundance and functional genetic content of vitamin metabolism. Based on metatranscriptomics data, the equation between abundance of vitamin-biosynthetic enzymes and vitamin-dependent enzymes suggests that the production and utilization potential of these enzymes seems way more complex usage allocations than just mere direct linear associations.

CONCLUSIONS

Our findings provide a rationale to examine and disentangle the interrelationship between B-vitamin dosage (dietary or microbe-mediated) on gut microbial members and the host, in the gut microbiota of individuals with under- or overnutrition.

Diet and inflammatory bowel disease: The Asian Working Group guidelines

INTRODUCTION

These Asian Working Group guidelines on diet in inflammatory bowel disease (IBD) present a multidisciplinary focus on clinical nutrition in IBD in Asian countries.

METHODOLOGY

The guidelines are based on evidence from existing published literature; however, if objective data were lacking or inconclusive, expert opinion was considered. The conclusions and 38 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

Diet has an important role in IBD pathogenesis, and an increase in the incidence of IBD in Asian countries has paralleled changes in the dietary patterns. The present consensus endeavors to address the following topics in relation to IBD: (i) role of diet in the pathogenesis; (ii) diet as a therapy; (iii) malnutrition and nutritional assessment of the patients; (iv) dietary recommendations; (v) nutritional rehabilitation; and (vi) nutrition in special situations like surgery, pregnancy, and lactation.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 38 recommendations.

Inflammatory bowel disease: Looking beyond the tract

Inflammatory bowel disease is a chronic inflammatory condition that encompasses Crohn's disease and ulcerative colitis. Inflammatory bowel disease is not exclusive to the gastrointestinal system, as it has been identified to be associated with extraintestinal manifestations that encompass every other organ system in the human body. This review article will comprehensively review the current knowledge on extraintestinal manifestations of inflammatory bowel disease. In addition, it will discuss the recommendations for screening and surveillance for extraintestinal manifestations in these patients since early appropriate diagnosis is imperative in preventing morbidity and cancer development.

Dietary Magnesium Alleviates Experimental Murine Colitis Through Upregulation of the Transient Receptor Potential Melastatin 6 Channel

BACKGROUND

Magnesium (Mg) is essential for human health and is absorbed mainly in the intestine. In view of the likely occurrence of an Mg deficit in inflammatory bowel disease (IBD) and the documented role of Mg in modulating inflammation, the present study addresses whether Mg availability can affect the onset and progression of intestinal inflammation.

METHODS

To study the correlation between Mg status and disease activity, we measured magnesemia by atomic absorption spectroscopy in a cohort of IBD patients. The effects of dietary Mg modulation were assessed in a murine model of dextran sodium sulfate (DSS)-induced colitis by monitoring magnesemia, weight, fecal occult blood, diarrhea, colon length, and histology. Expression of the transient receptor potential melastatin (TRPM) 6 channel was assessed by real-time reverse transcription polymerase chain reaction and immunohistochemistry in murine colon tissues. The effect of Mg on epithelial barrier formation/repair was evaluated in human colon cell lines.

RESULTS

Inflammatory bowel disease patients presented with a substantial Mg deficit, and serum Mg levels were inversely correlated with disease activity. In mice, an Mg-deficient diet caused hypomagnesemia and aggravated DSS-induced colitis. Colitis severely compromised intestinal Mg2+ absorption due to mucosal damage and reduction in TRPM6 expression, but Mg supplementation resulted in better restoration of mucosal integrity and channel expression.

CONCLUSIONS

Our results highlight the importance of evaluating and correcting magnesemia in IBD patients. The murine model suggests that Mg supplementation may represent a safe and cost-effective strategy to reduce inflammation and restore normal mucosal function.

New Insights into the Role of Trace Elements in IBD

Micronutrient deficiencies are common in inflammatory bowel disease and have clinical impact, being both a sign of complicated disease and a cause of morbidity. The involved systemic inflammatory response is responsible for altering the concentration of a wide range of trace elements in the serum, including zinc and selenium. This review summarizes recent advances and evidence-based knowledge regarding the impact of selenium and zinc on oxidative stress and microbiota changes in IBD patients. Getting new insight into the impact of malnutrition, particularly on the micronutrients' impact on the development, composition, and metabolism of microbiota, as well as the influence of oxidative stress and the mucosal immune response, could help in implementing new management strategies for IBD patients, with focus on a more integrated approach.

Hair Mineral and Trace Element Contents as Reliable Markers of Nutritional Status Compared to Serum Levels of These Elements in Children Newly Diagnosed with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) are at high risk for nutritional deficiencies because of long-term inflammation in the gut mucosa and decreased oral intake. Because inflammation responses affect serum micronutrient concentrations, serum levels are limited in reflecting body nutrient status in acute and chronic illness. We investigated the usefulness of measuring trace elements in hair as reliable markers of nutritional status compared to serum levels in children with IBD. We retrospectively analyzed pediatric patients newly diagnosed with Crohn's disease (n = 49) and ulcerative colitis (n = 16) and controls (n = 29) from 2012 to 2016. Serum micronutrient levels, inflammatory markers, and hair trace element content were evaluated and compared at the time of diagnosis and before initiating treatment. Serum calcium (p < 0.001), iron (p < 0.001), zinc (p = 0.013), selenium (p = 0.008), albumin (p < 0.001), prealbumin (p < 0.001), hemoglobin and hematocrit (p < 0.001), and WBC (p = 0.001) and lymphocytes (p < 0.001) differed significantly between the groups. After adjustment for the erythrocyte sedimentation rate, serum zinc and selenium levels were no longer significantly different between the groups (p < 0.062 and p < 0.057, respectively). Following hair analysis for mineral and trace elements, iron (p = 0.033), selenium (p = 0.017), and manganese (p = 0.009) differed significantly between the groups. Serum micronutrient levels need cautious interpretation in conjunction with inflammatory markers. Hair mineral and trace element measurement may support understanding micronutrient status in children with IBD.

Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn's disease patients: a meta-analysis

OBJECTIVES

Crohn's disease (CD) patients frequently develop complications that require surgery for management. The high prevalence of malnutrition in CD patients presents a challenge because poor preoperative nutritional status has been shown to increase postoperative complications. In this study, we assessed whether preoperative enteral nutrition (EN) or total parenteral nutrition (TPN) decreases postoperative complications in CD patients.

MATERIALS AND METHODS

A three-point systematic and comprehensive literature search was carried out on multiple databases followed by a meta-analysis with results presented as odds ratio (OR) using two models, the Mantel-Haenszel model and the DerSimonian and Laird model. The I measure of inconsistency was utilized to assess heterogeneity. If statistically significant heterogeneity was identified, the results underwent a separate sensitivity analysis.

RESULTS

Five studies met inclusion criteria totaling 1111 CD patients. The rate of postoperative complications in the group receiving preoperative nutrition (EN or TPN) support was 20.0% compared with 61.3% in the group who had standard care without nutrition support [OR=0.26, 95% confidence interval (CI): 0.07-0.99, P<0.001]. Postoperative complications occurred in 15.0% of patients in the group who received preoperative TPN compared with 24.4% in the group who did not (OR=0.65, 95% CI: 0.23-1.88, P=0.43). Postoperative complications occurred in 21.9% in the group who received preoperative EN compared with 73.2% in the group that did not received preoperative EN (OR=0.09, 95% CI: 0.06-0.13, P<0.001).

CONCLUSION

Preoperative nutrition supplementation reduces postoperative complications in CD patients. In particular, EN in CD patients before undergoing surgery is superior to standard of care without nutrition support with a number needed to treat of 2. There is a trend toward TPN being superior to standard of care without nutrition support, but this trend did not reach statistical significance. Further studies are necessary to evaluate specific components in EN or TPN that may be most beneficial for CD patients requiring surgical intervention.

The Relevance of Vitamin and Iron Deficiency in Patients with Inflammatory Bowel Diseases in Patients of the Swiss IBD Cohort

BACKGROUND ANDAIMS

Vitamin and iron deficiencies are common in patients with inflammatory bowel disease (IBD) as a result of chronic intestinal inflammation, increase in demand, or dietary restrictions. Here, we assessed the frequency of complications in relation to deficiency of iron, folate acid, and vitamin B12 in patients enrolled in the nationwide Swiss Inflammatory Bowel Disease Cohort Study (SIBDCS).

METHODS

A total of 2666 patients were included in the study, 1558 with Crohn's disease (CD) and 1108 with ulcerative colitis (UC).

RESULTS

Iron deficiency anemia was detected in 19.6% of CD patients and 21.6% of UC patients. In CD patients low BMI and nonsmoker status were positively associated with anemia. In both CD and UC, malabsorption syndrome, defined as failure of the GI tract to absorb 1 or more substances from the diet, was found to be significantly associated with anemia (6.2% and 3.8%, respectively) and current steroid use (40% CD, 52.7% UC). In CD patients with ileal (31.7% vs 20%) and colonic (29.9% vs 25%) disease location folate deficiency was significantly higher than in patients with ileocolonic CD or upper GI involvement. In CD patients, vitamin B12 deficiency was associated with the onset of stenosis and intestinal surgery (42.9% vs 32.8% and 46% vs 33% for patients with versus without B12 deficiency).

CONCLUSION

Our data indicate that due to frequent occurrence of deficiency states, regular monitoring and substitution of vitamins and iron are mandatory and may prevent long-term intestinal and extraintestinal complications in IBD patients.

Inflammatory bowel disease and immunonutrition: novel therapeutic approaches through modulation of diet and the gut microbiome

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract, thought to at least in part reflect an aberrant immune response to gut bacteria. IBD is increasing in incidence, particularly in populations that have recently immigrated to western countries. This suggests that environmental factors are involved in its pathogenesis. We hypothesize that the increase in IBD rates might reflect the consumption of an unhealthy Western diet, containing excess calories and lacking in key nutritional factors, such as fibre and vitamin D. Several recent studies have determined that dietary factors can dramatically influence the activation of immune cells and the mediators they release through a process called immunonutrition. Moreover, dietary changes can profoundly affect the balance of beneficial versus pathogenic bacteria in the gut. This microbial imbalance can alter levels of microbiota-derived metabolites that in turn can influence innate and adaptive intestinal immune responses. If the diet-gut microbiome disease axis does indeed underpin much of the 'western' influence on the onset and progression of IBD, then tremendous opportunity exists for therapeutic changes in lifestyle, to modulate the gut microbiome and to correct immune imbalances in individuals with IBD. This review highlights four such therapeutic strategies - probiotics, prebiotics, vitamin D and caloric restriction - that have the potential to improve and add to current IBD treatment regimens.

Pregnant Women with Inflammatory Bowel Disease Are at Increased Risk of Vitamin D Insufficiency: A Cross-Sectional Study

BACKGROUND AND AIMS

Vitamin D insufficiency is prevalent in individuals with inflammatory bowel disease [IBD], as well as in pregnant women; however, the prevalence of vitamin D insufficiency in pregnant women with IBD is unknown. This study assessed the prevalence of vitamin D insufficiency in pregnant women with IBD and the adequacy of recommended supplementation.

METHODS

A cross-sectional study was conducted in pregnant women with inflammatory bowel disease [Crohn's disease = 61, ulcerative colitis = 41] and without inflammatory bowel disease [n = 574]. Chi square tests and log binomial regression were used to examine the prevalence of vitamin D insufficiency. Covariates included ethnicity and season. Adequacy of vitamin D supplementation during pregnancy was also assessed.

RESULTS

The prevalence of vitamin D insufficiency [25-OHD ≤75 nmol/L] in those with Crohn's disease was 50.8% (95% confidence interval [CI]: 38.4%-63.2%) and 60.9% [95% CI: 45.3%-74.7%] with ulcerative colitis compared with 17.4% [95% CI: 14.6%-20.8%] without inflammatory bowel disease. Women with inflammatory bowel disease were more likely to be vitamin D insufficient after adjusting for ethnicity and season (Crohn's disease-adjusted relative risk [aRR] = 2.98,;: 2.19-4.04; ulcerative colitis-aRR = 3.61; 95% CI: 2.65-4.93). Despite vitamin D supplementation, 32.3% [95% CI: 17.8%-51.2%] of those with Crohn's disease, 58.3% [95% CI: 37.1%-76.9%] of those with with ulcerative colitis, and 10.8% [95% CI: 6.9%-16.6%] of those without inflammatory bowel disease were still vitamin D insufficient.

CONCLUSIONS

Pregnant women with inflammatory bowel disease are at increased risk of vitamin D insufficiency compared with those without inflammatory bowel disease. The current guidelines for vitamin D supplementation may be inadequate for pregnant women with inflammatory bowel disease.

Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND AND AIMS

A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients.

METHODS

A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature.

RESULTS

A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD.

CONCLUSIONS

This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.

Risk Factors for Vitamin D, Zinc, and Selenium Deficiencies in Korean Patients with Inflammatory Bowel Disease

Background/Aims

Studies on the micronutrient status of Asian patients with inflammatory bowel disease (IBD) are scarce. We evaluated the prevalence of micronutrient deficiency and verified the risk factors for micronutrient deficiency in Korean patients with IBD.

Methods

We measured the serum levels of 25-hydroxyvitamin D3 [25-(OH)D], zinc, and selenium to analyze the clinical risk factors for micronutrient levels below the reference values. In addition, we compared the 25-(OH)D levels of patients with IBD to those of age- and sex-matched healthy controls.

Results

Among the 83 patients, 74 (89.2%) had suboptimal serum 25-(OH)D levels. The mean plasma 25-(OH)D level in patients with IBD was significantly reduced compared to that of the healthy controls (12.3±6.2 ng/mL vs 20.0±6.7 ng/mL; p<0.001). The proportions of patients with lower serum zinc and selenium levels were 39.0% and 30.9%, respectively. Female sex (p=0.012) and Crohn’s disease (p=0.012) were associated with vitamin D deficiency. Patients younger than 40 years were at increased risk for zinc deficiency (p=0.045). Female sex (p=0.015) and low serum albumin level (<3.3 g/dL) (p=0.047) were risk factors for selenium deficiency.

Conclusions

Many Korean patients with IBD have vitamin D, zinc, and selenium deficiencies, suggesting the necessity for monitoring levels of these micronutrients.

Relation of body mass index to risk of developing inflammatory bowel disease amongst women in the Danish National Birth Cohort

BACKGROUND

Crohn's disease (CD) has traditionally been associated with weight loss and low BMI, yet paradoxically obesity has recently been suggested as a risk factor for CD, but not for ulcerative colitis (UC). We therefore hypothesized that the relation between BMI and CD is U shaped.

AIM

To conduct a large population-based prospective cohort study of BMI and later risk of IBD, taking age at IBD diagnosis into account.

METHODS

A cohort of 74,512 women from the Danish National Birth Cohort, with BMI measured pre-pregnancy and 18 months after delivery, was followed for 1,022,250 person-years for development of IBD, according to the Danish National Patient Register. Associations were tested by Cox regression.

RESULTS

Overweight subjects (25≤BMI<30 kg/m2) had the lowest risk of CD, whereas obesity (BMI≥30kg/m2) increased the risk of CD at all ages, and low BMI (BMI<18.5kg/m2) associated with CD diagnosed at age 18-<40 years. Hence, using normal weight subjects as the reference, adjusted HRs for risk of developing CD (at age 18-<40 years) were 1.8(95%CI, 0.9-3.7) for underweight, 0.6(0.3-1.2) for overweight, and 1.5(0.8-2.7) for obese individuals (pre-pregnancy BMI). HRs were greater for BMI determined 18 months after delivery. Splines for CD risk according to waist:height ratio confirmed a U-shaped relationship with CD occurring <40 years, and a linear relationship with CD diagnosed at age 40+. There was no relationship between BMI and risk of UC.

CONCLUSION

For the first time, we demonstrate that both high BMI and low BMI are risk factors for CD. Underweight may be a pre-clinical manifestation of disease being present many years before onset with obesity being a true risk factor. This raises the question as to whether there may be two distinct forms of CD.