Nutrition assessment of patients with inflammatory bowel disease

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.

The association between index of nutritional quality and ulcerative colitis: A case-control study

Background

Ulcerative colitis (UC) is a chronic inflammatory bowel disease. Recent studies have shown that dietary factors play an important role in the development of UC. Index of Nutritional Quality (INQ) is a suitable method that analyzes quantitatively and qualitatively single foods, meals, and diets. The aim of this study was to determine the association between INQ and UC.

Materials and Methods

Overall, 62 newly diagnosed cases with UC and 124 healthy age- and sex-matched controls were studied in a referral hospital in Tabriz, Iran. INQ scores were calculated based on information on the usual diet that was measured by a valid and reliable Food Frequency Questionnaire consisting of 168 food items. Logistic regression analysis adjusting for age, gender, body mass index, education, smoking, Helicobacter pylori, family history of UC, appendectomy, alcohol, and total energy intake was used to estimate multivariable odds ratios (ORs).

Results

After controlling for several covariates, we found inverse associations between UC risk and INQs of Vitamin C (OR = 0.34 [0.16-0.73]) and folate (OR = 0.11 [0.01-0.99]). In crude model of analysis, cases had a higher intake of total energy, protein, carbohydrate, total fat, saturated fatty acid, monounsaturated fatty acid, polyunsaturated fatty acid, niacin, Vitamin B6, Vitamin B12, magnesium, zinc, copper, selenium, and iron compared to controls, whereas controls had higher intakes of Vitamin C, Vitamin D, folate, and biotin compared to cases.

Conclusion

Our results indicate that enough consumption of Vitamin C and folate was associated with lower risk of UC.

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.

A probiotic complex, rosavin, zinc, and prebiotics ameliorate intestinal inflammation in an acute colitis mouse model

Background

An altered gut microbiota balance is involved in the pathogenesis of inflammatory bowel disease (IBD), and several probiotic strains are used as dietary supplements to improve intestinal health. We evaluated the therapeutic effect of 12 probiotics in combination with prebiotics, rosavin, and zinc in the dextran sodium sulfate (DSS)-induced colitis mouse model.

Methods

The probiotic complex or the combination drug was administered orally to mice with DSS-induced colitis, and the body weight, disease activity index, colon length, and histopathological parameters were evaluated. Also, the combination drug was applied to HT-29 epithelial cells, and the expression of monocyte chemoattractant protein 1 (MCP-1) was evaluated by real-time polymerase chain reaction.

Results

Administration of the combination drug attenuated the severity of DSS-induced colitis. Moreover, the combination drug significantly reduced the levels of the proinflammatory cytokines tumor necrosis factor-α, interleukin (IL)-6, IL-1β, and IL-17, and significantly increased the levels of Foxp3 and IL-10 in colon sections. Additionally, treatment with the combination drug reduced MCP-1 expression in HT-29 cells. Treatment with the combination drug decreased the levels of α-smooth muscle actin and type I collagen compared with vehicle treatment in mice with DSS-induced colitis.

Conclusion

These results suggest that the combination of a probiotic complex with rosavin, zinc, and prebiotics exerts a therapeutic effect on IBD by modulating production of pro- and anti-inflammatory cytokines and the development of fibrosis.

Low serum zinc levels predict presence of depression symptoms, but not overall disease outcome, regardless of ATG16L1 genotype in Crohn's disease patients

BACKGROUND

Zinc deficiency (ZD) in Crohn's disease (CD) is considered a frequent finding and may exacerbate CD activity. ZD is associated with depression in non-CD patients. We aimed to assess the prevalence of ZD in CD patients in clinical remission, its association with mood disturbances and to analyze a potential impact on future disease course.

METHODS

Zinc levels from CD patients in clinical remission at baseline and an uncomplicated disease course within the next 3 years (n = 47) were compared with those from patients developing complications (n = 50). Baseline symptoms of depression and anxiety were measured with the Hospital Anxiety and Depression scale.

RESULTS

Mean zinc level in the 97 patients (40.4 ± 15.7 years, 44.3% males) was 18.0 ± 4.7 μmol/l. While no ZD (<11 μmol/l) was observed, we found low zinc levels (<15.1 μmol/l) in 28 patients (28.9%). Males had higher zinc levels compared with females (19.4 ± 5.7 versus 16.8 ± 3.3, p = 0.006). Patients with low zinc levels more often reported depression symptoms compared with patients with higher levels (27.3 versus 9.4%, p = 0.047). In a multivariate analysis, zinc levels were an independent negative predictor for depression symptoms [odds ratio (OR) 0.727, 95% confidence interval (CI) 0.532-0.993, p = 0.045]. Zinc levels of patients with a complicated disease course were not different from those of patients without (17.7 ± 4.3 versus 18.3 ± 5.1, n.s.). Baseline zinc levels did not predict disease outcome regardless of ATG16L1 genotype.

CONCLUSION

Low-normal zinc levels were an independent predictor for the presence of depression symptoms in CD patients. Zinc levels at baseline did not predict a complicated disease course, neither in CD patients overall, nor ATG16L1^T300A carriers.

Diet as a Therapeutic Option for Adult Inflammatory Bowel Disease

There are many mechanisms to explain how food may drive and ameliorate inflammation. Although there are no consistent macronutrient associations inflammatory bowel disease (IBD) development, many exclusion diets have been described: IgG-4 guided exclusion diet; semivegetarian diet; low-fat, fiber-limited exclusion diet; Paleolithic diet; Maker's diet; vegan diet; Life without Bread diet; exclusive enteral nutrition (EEN), the Specific Carbohydrate Diet (SCD) and the low FODMAP diet. The literature on diet and IBD is reviewed with a particular focus on EEN, SCD, and low FODMAP diets. Lessons learned from the existing observations and strengths and shortcomings of existing data are presented.

Vitamins and Minerals in Inflammatory Bowel Disease

Indiscriminate use of multivitamin/mineral supplements in the general population may be misguided, but patients with chronic Inflammatory Bowel Diseases (IBD) should be monitored and compensated for nutritional deficiencies. Mechanistic links between vitamin/mineral deficiencies and IBD pathology has been found for some micronutrients and normalizing their levels is clinically beneficial. Others, like vitamin A, although instinctively desirable, produced disappointing results. Restoring normal levels of the selected micronutrients requires elevated doses to compensate for defects in absorptive or signaling mechanisms. This article describes some aspects of vitamin and mineral deficiencies in IBD, and summarizes pros and cons of supplementation.

Fat-soluble Vitamin Deficiencies and Inflammatory Bowel Disease: Systematic Review and Meta-Analysis

BACKGROUND

Vitamin deficiency is frequently associated with inflammatory bowel disease (IBD). Supplementation of vitamins could thus serve as an adjunctive therapy. The present meta-analysis reviews the deficiencies and alterations in serum fat-soluble vitamins (A, D, E, and K) reported in IBD patients.

MATERIALS AND METHODS

PubMed database search was performed to identify all primary studies up to January 2015 that evaluated the serum concentrations of fat-soluble vitamin levels in IBD patients compared with healthy individuals. We estimated pooled mean differences between groups and estimated their relations with some compounding variables (age, disease duration, C-reactive protein, albumin), using a meta-regression analysis.

RESULTS

Nineteen case-control studies met selection criteria. In patients with Crohn's disease (CD), vitamin A, D, E, K status was lower than in controls [D=212 μg/L.92; 95% confidence interval (CI), 95.36-330.48 μg/L, P=0.0002; D=6.97 nmol/L, 95% CI, 1.61-12.32 nmol/L, P=0.01; D=4.72 μmol/L, 95% CI, 1.60-7.84 μmol/L, P=0.003; D=1.46 ng/mL, 95% CI, 0.48-2.43 ng/mL, P=0.003, respectively]. Patients with ulcerative colitis had lower levels of vitamin A than controls (D=223.22 μg/L, 95% CI, 44.32-402.12 μg/L, P=0.01). Patients suffering from CD for a longer time had lower levels of vitamins A (95% CI=7.1-67.58 y, P=0.02) and K (95% CI, 0.09-0.71 y, P=0.02). Meta-regression analysis demonstrated statistically significant associations between the levels of inflammatory biomarkers: C-reactive protein (P=0.03, 95% CI, -9.74 to -0.6 mgl/L) and albumin (P=0.0003, 95% CI, 402.76-1361.98 g/dL), and vitamin A status in CD patients.

CONCLUSION

Our meta-analysis shows that the levels of fat-soluble vitamins are generally lower in patients with inflammatory bowel diseases and their supplementation is undoubtedly indicated.

Inflammatory bactericidal lectin RegIIIβ: Friend or foe for the host?

In the inflamed gut, the bactericidal lectin RegIIIβ is massively produced by intestinal mucosa. RegIIIβ binds peptidoglycan and lipid A respectively, and thus can kill certain Gram-positive and Gram-negative bacteria, including the gut commensal microbiota and enteropathogenic bacteria. Considering the expression pattern and bactericidal activity, RegIIIβ is believed to be a host defense factor for protecting against the infection with enteropathogenic bacteria. However, it was poorly understood how RegIIIβ recognizes the target bacteria and kill them, and how RegIIIβ plays role(s) in infectious diarrhea. Therefore, our recent study has focused on RegIIIβ-target recognition, killing of Gram-negative bacteria, and host protective functions of RegIIIβ for infectious diarrhea inflicted by Salmonella Typhimurium. Here, we discuss novel insights into the protective role of RegIIIβ in infectious diarrhea, and propose avenues towards novel therapeutic interventions for Salmonella diarrhea.

An evaluation of the feasibility and validity of a patient-administered malnutrition universal screening tool ('MUST') compared to healthcare professional screening in an inflammatory bowel disease (IBD) outpatient clinic

BACKGROUND

Malnutrition is common in inflammatory bowel disease (IBD) and is associated with poor health outcomes. Despite this, screening for malnutrition in the outpatient-setting is not routine and research in the area is limited. The present study aimed to evaluate whether agreement between malnutrition screening completed by patients and healthcare professionals (HCPs) could be achieved by comparing patient self-administered 'MUST' ('MUST'-P) with HCP administered 'MUST' ('MUST'-HCP) in a single tertiary IBD outpatient clinic.

METHODS

We conducted a feasibility and validity study on adult outpatients with IBD. We collected anthropometric, nutritional and clinical data from patients. All patients completed 'MUST'-P using a self-administered questionnaire, followed by 'MUST'-HCP. 'MUST'-P was timed and feedback on ease-of-use was obtained. The risk of malnutrition was classified as low (score = 0), medium (score = 1) and high (score ≥ 2) and agreement was tested using kappa statistics (κ).

RESULTS

Eighty patients were recruited (Crohn's disease: n = 49, ulcerative colitis: n = 29, unclassified: n = 2), with a mean (SD) age of 39.9 (15.1) years (51.2% were males). Seventy-one (92%) of patients found 'MUST'-P either easy or very easy. The mean (SD) time to complete 'MUST'-P was 3.1  (1.8) min (range 1-10 min). Sixty-eight (85%) of patients were at low risk of malnutrition when screened by the HCP. There was moderate agreement (κ = 0.486, P < 0.001) between 'MUST'-P and 'MUST'-HCP, with 100% agreement in scoring for medium- and high-risk categories.

CONCLUSIONS

The results of the present study suggests that self-screening using 'MUST' could be effectively used in an IBD outpatient clinic to identify those at medium and high risk of malnutrition. The patient friendly version of 'MUST' ('MUST'-P) was considered quick and easy to use by patients. Implementation of self-screening with 'MUST' could improve the nutritional management of IBD patients.

Zinc treatment is efficient against Escherichia coli α-haemolysin-induced intestinal leakage in mice

Zinc homoeostasis exerts protective effects in inflammatory intestinal diseases and zinc supplementation has been successfully used for treating infectious diarrhoea. This study aimed at a characterisation of zinc effects on focal leak induction by α-haemolysin (HlyA)-producing Escherichia coli (E. coli) as protective mechanism for colitis. We conducted in vivo experiments by oral challenge of gnotobiotic mice colonised with HlyA-expressing E. coli-536. Mice were either fed a defined normal or high zinc diet to analyse effects of zinc as a therapeutic regimen. HlyA-deficient E. coli-536 mutants were used as controls. Mice infected with HlyA-producing E. coli showed impaired barrier integrity when receiving normal zinc. High zinc supplementation in HlyA-producing E. coli-infected mice reduced epithelial dysfunction as indicated by ameliorated macromolecule permeability. Reduced size of focal leaks with diminished bacterial translocation was observed as inherent mechanisms of this zinc action. In human colon cell monolayers application of zinc rescued the HlyA-dependent decline in transepithelial electrical resistance via reduction of the calcium entry into HlyA-exposed cells. Calcium-dependent cell exfoliation was identified as mechanism for focal leak induction. In conclusion, zinc supplementation protects from HlyA-induced barrier dysfunction in vivo and in vitro, providing an explanation for the protective efficacy of zinc in intestinal disorders.

Food avoidance in patients with inflammatory bowel disease: What, when and who?

BACKGROUND & AIMS

Patients with inflammatory bowel diseases avoid a variety of foods. However, it remains unclear how this behavior varies across patients. This cross-sectional study investigated how the food avoidance pattern in inflammatory bowel disease varies according to disease's activity, disease's subtype, Crohn's location, and prior history of bowel resection, strictures, and fistulae.

METHODS

Outpatients with Crohn's disease (n = 173) and ulcerative colitis (n = 72) reported which food they avoid when they perceive they are in remission or in active disease using a list of 82 food items classified in 10 categories. Medical charts were reviewed for patients' characteristics. Linear regression analyses were used to compare food exclusion rates between patients' subgroups and food categories.

RESULTS

During remission, food exclusion rates varied from 1 to 39%. Most avoided foods were those with capsaicin, meat alternatives, and raw vegetables. Overall, food exclusion rates were 38% higher in Crohn's disease than ulcerative colitis (P < 0.001), and 50% higher in stricturing than non-stricturing Crohn's disease (P < 0.001). During active disease, food exclusion rates were 69% higher than in remission (P < 0.001). Similar differences between subgroups were again observed during active disease though less noticeable than in remission. No association was found with other disease characteristics. Avoided foods were very similar across patients except for alcoholic beverages and foods rich in dietary fibers/residue, which were avoided more specifically during active disease and in Crohn's disease, respectively.

CONCLUSIONS

Food avoidance is common among patients with inflammatory bowel diseases, and most particularly in those with stricturing Crohn's disease. Specificities in avoidance pattern suggest that the clinical response to dietary restrictions may differ according to the disease's characteristics.

Preoperative hypoalbuminemia is associated with an increased risk for intra-abdominal septic complications after primary anastomosis for Crohn's disease

Objective

The aim of this study was to evaluate the impact of preoperative hypoalbuminemia on the development of intra-abdominal septic complications (IASCs) after primary anastomosis for patients with Crohn’s disease (CD).

Methods

All CD patients undergoing bowel resection with a primary anastomosis during the study period from 2007 to 2015 were enrolled. The association of preoperative hypoalbuminemia (<30 g/L) with the risk for IASCs were assessed using both univariate and multivariate analyses.

Results

A total of 124 eligible patients were included, 117 (94.4%) of whom had available preoperative albumin level. Preoperative hypoalbuminemia occurred in 13 (11.7%) patients. The duration from diagnosis to surgery was longer for patients with preoperative hypoalbuminemia than those without (p = 0.012). Patients with preoperative hypoalbuminemia were more likely to have a history of preoperative use of 5-aminosalicylic acid (p = 0.013) and have an intraoperative finding of small bowel obstruction (p = 0.015). Of all patients, 24 (19.4%) developed postoperative IASCs. Univariate analysis showed that patients with preoperative hypoalbuminemia had an increased risk for IASCs (p = 0.012). Multivariate analysis confirmed the association between preoperative hypoalbuminemia and IASCs (odds ratio 4.67, 95% confidence interval: 1.28–17.04, p = 0.02). Similar findings were also obtained when preoperative albumin level was analysed as a continuous variable (p = 0.019).

Conclusions

Preoperative hypoalbuminemia is a significant predictor for the development of postoperative IASCs in CD patients after bowel resection with a primary anastomosis. Favorable preoperative nutrition status might lessen the risk for IASCs.

Vitamin D deficiency in patients with inflammatory bowel disease

There are over 300 000 people in the UK affected by inflammatory bowel disease (IBD). Though vitamin D deficiency is common in patients with IBD, National Institute for Health and Care Excellence (NICE) guidance regarding vitamin D supplementation does not address the needs of patients with chronic inflammatory diseases. However, there is growing evidence that vitamin D plays an important role in the management of IBD. Nurses caring for patients with IBD should have an understanding of the causes and consequences of vitamin D deficiency in this patient group. This article looks at the role vitamin D plays in the body and the challenges of treating deficiency. Consideration is given to diet, sun exposure and supplementation as possible treatments and acknowledges the limitations of treatments for patients with IBD. With a lack of clear national guidance, it is hoped that raising awareness of these issues will inform nursing practice and ensure a holistic approach to care.

Zinc Deficiency is Associated with Poor Clinical Outcomes in Patients with Inflammatory Bowel Disease

BACKGROUND

Zinc plays a pivotal role in wound repair, tissue regeneration, and the immune response. Although zinc deficiency is common in patients with inflammatory bowel disease (IBD), the impact of low serum zinc levels on disease course is not known.

METHODS

Patients enrolled in a prospectively collected IBD registry with at least 2 serum zinc measurements were included in the analysis. Using a logistic regression model, rates of IBD-related surgeries, IBD-related hospitalizations, and IBD-related complications were evaluated after a diagnosis of zinc deficiency (serum concentration <0.66 μg/mL) compared with those with normal zinc concentrations. In patients who were zinc deficient, outcomes were also analyzed between those who had normalization of zinc levels within 12 months and those who remained deficient.

RESULTS

A total of 773 patients with Crohn's disease (CD) and 223 with ulcerative colitis (UC) were included in the analysis. After adjusting for covariates, zinc deficiency was associated with an increased risk of subsequent hospitalizations, surgeries, and disease-related complications in patients with CD and UC (CD: hospitalizations, odds ratio 1.44, 95% confidence interval [1.02-2.04]; surgeries, 2.05 [1.38-3.05]; complications, 1.50 [1.04-2.15]; UC: hospitalizations, 2.14 [1.07-4.29]; surgeries, 1.64 [0.59-4.52]; complications, 1.97 [0.94-4.11]). Normalization of zinc was associated with improvement in these outcomes in patients with both CD and UC.

CONCLUSIONS

Patients with IBD with serum zinc deficiency are more likely to have adverse disease-specific outcomes. As these outcomes improve with normalization of zinc, the results from this study support the role for close monitoring and replacement of zinc in patients with IBD.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

INTRODUCTION

The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD).

METHODOLOGY

The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).

[Nutritional impact of inflammatory bowel diseases on children and adolescents]

OBJECTIVE:

To perform a sistematiy review of the literature about the nutritional impact of inflammatory bowel diseases in children and adolescents.

DATA SOURCES:

A systematic review was performed using PubMed/MEDLINE, LILACS and SciELO databases, with inclusion of articles in Portuguese and in English with original data, that analyzed nutritional aspects of inflammatory bowel diseases in children and adolescents. The initial search used the terms "inflammatory bowel diseases" and "children" or "adolescents" and "nutritional evaluation" or "nutrition deficiency". The selection of studies was initially performed by reading the titles and abstracts. Review studies and those withouth data for pediatric patients were excluded. Subsequently, the full reading of the articles considered relevant was performed.

RESULTS:

237 studies were identified, and 12 of them were selected according to the inclusion criteria. None of them was performed in South America. During the analysis of the studies, it was observed that nutritional characteristics of patients with inflammatory bowel disease may be altered; the main reports were related to malnutrition, growth stunting, delayed puberty and vitamin D deficiency.

CONCLUSION:

There are nutritional consequences of inflammatory bowel diseases in children and adolescents, mainly growth stunting, slower pubertal development, underweight and vitamin deficiencies. Nutritional impairments were more significant in patients with Crohn's disease; overweight and obesity were more common in patients with ulcerative rectocolitis. A detailed nutritional assessment should be performed periodically in children and adolescents with inflammatory bowel disease.

Crohn's Disease Is Associated with the Risk for Thyroid Cancer

BACKGROUND

It is known that inflammatory bowel disease (IBD) is associated with a high risk for some of extraintestinal cancers. The aim of this study was to identify whether IBD is associated with thyroid cancer using a large national database.

METHODS

We performed a case-control study using the 2012 National Inpatient Sample (NIS) database. The study group included all patients with Crohn's disease (CD) (ICD-9 Code: 555) and ulcerative colitis (UC) (ICD-9 Code: 556), and the control group included all patients with diverticulitis (ICD-9 Code: 562.11, 562.13). Both univariable and multivariable analyses were performed to assess the risk factors associated with thyroid cancer.

RESULTS

We analyzed more than 28 million hospitalizations in 2012, with 289,935 being IBD-related admissions and 315,145 being diverticulitis-related admissions. Subjects who had IBD were found to be significantly more likely to have thyroid cancer than those with diverticulitis (odds ratio = 1.97 [1.5-2.6], P = 0.033). There was no difference between men and women in the prevalence of thyroid cancer in IBD (P = 0.6). There was no difference between CD and UC (P = 0.14) and between UC and diverticulitis (P = 0.93). In multivariate analysis, CD was found to be associated with thyroid cancer (odds ratio = 2.3 [1.06-5.1], P = 0.034). Age was shown to be a protective factor in the presence of thyroid cancer (P < 0.005), and a higher Charlson comorbidity index was associated with the presence of thyroid cancer (odds ratio, 1.5 [1.3-1.7]; P < 0.001).

CONCLUSIONS

Our study showed that CD, not UC, is associated with a higher risk for thyroid cancer. It is recommended that patients with CD may need a close monitoring of thyroid diseases.

Knowledge, Attitudes, and Beliefs Regarding the Role of Nutrition in IBD Among Patients and Providers

BACKGROUND

Malnutrition is common in inflammatory bowel disease (IBD). Identifying patients who are malnourished or at risk for malnutrition may lead to early intervention and improve patient outcomes. To date, little is known about the role of nutritional assessment and management in IBD care. We aimed to evaluate knowledge, attitudes, and beliefs regarding nutrition in IBD among patients and providers.

METHODS

Surveys were mailed electronically to patients and providers identified through their membership in the Crohn's & Colitis Foundation of America. In addition, patient and provider focus groups were conducted to explore nutrition-related themes. These surveys and focus groups were designed to evaluate knowledge and perceived importance of nutrition, patient-provider interactions regarding nutrition and use of nutritional resources.

RESULTS

There were 223 provider respondents (65.5% gastroenterologists, 15.2% nurses, and 6.7% dietitians). Forty-one percent of the gastroenterologists rated their knowledge of nutrition in IBD as "very good" compared with 87% of dietitians and 16% of nurses (P < 0.001). Thirty-three percent of the gastroenterologists reported not routinely screening their IBD patients for malnutrition. The patient survey had 567 respondents with 27% rating their knowledge of nutrition in IBD as "very good." In the focus groups, a lack of adequate IBD nutritional resources was evident along with a desire for improved access to nutrition specialists.

CONCLUSIONS

Significant gaps in knowledge relating to nutrition in IBD seem to exist. Targeted educational initiatives and improved access to nutritional experts are warranted. In addition, a standardized process for the assessment of malnutrition among patients with IBD should be developed.

Lycopene, Lutein and Zeaxanthin May Reduce Faecal Blood, Mucus and Pus but not Abdominal Pain in Individuals with Ulcerative Colitis

BACKGROUND

The main symptom of ulcerative colitis is diarrhoea, which is often accompanied by painful tenesmus and faecal blood and mucus. It sometimes co-occurs with abdominal pain, fever, feeling of fatigue, loss of appetite and weight loss. Some dietary factors have been indicated as important in the treatment of ulcerative colitis. The aim of the study was to analyse the association between retinoid intake (total vitamin A, retinol, β-carotene, α-carotene, β-cryptoxanthin, lycopene, lutein and zeaxanthin) and ulcerative colitis symptoms (abdominal pain, faecal blood, faecal mucus, faecal pus) in individuals with ulcerative colitis in remission.

METHODS

Assessment of diet was based on self-reported data from each patient's dietary records taken over a period of three typical, random days (2 weekdays and 1 day of the weekend).

RESULTS

A total of 56 individuals with ulcerative colitis in remission (19 males and 37 females) were recruited for the study. One in every four individuals with ulcerative colitis in remission was characterised as having inadequate vitamin A intake. Higher lycopene, lutein and zeaxanthin intakes in individuals with ulcerative colitis in remission were associated with lower faecal blood, mucus and pus but not with lower incidence of abdominal pain. Higher carotene intake in individuals with ulcerative colitis in remission may contribute to higher incidence of faecal mucus.

CONCLUSIONS

Optimising intake of specific retinoids may enhance disease control in individuals with ulcerative colitis. Prospective studies, including patient reported and objective outcomes, are required to confirm this.

The Inflammatory Bowel Disease Specialty Medical Home: A New Model of Patient-centered Care

New models of health care have emerged over the past decade. Accountable care organizations and patient-centered medical homes are designed to improve the patient experience, enhance health care quality, and decrease cost. These models have been developed in the primary care domain and have yet to be tested in specialty care. Certain chronic diseases require principal care by a specialist or health care team. The specialty medical home would provide patient-centered care for specific populations of patients whose health care derives from a single chronic disease. This article defines the parameters for a specialty medical home and provides a specific payer-provider experience for the comprehensive care of an inflammatory bowel disease population.

Cellular zinc is required for intestinal epithelial barrier maintenance via the regulation of claudin-3 and occludin expression

Intracellular zinc is required for a variety of cell functions, but its precise roles in the maintenance of the intestinal tight junction (TJ) barrier remain unclear. The present study investigated the essential roles of intracellular zinc in the preservation of intestinal TJ integrity and the underlying molecular mechanisms. Depletion of intracellular zinc in both intestinal Caco-2 cells and mouse colons through the application of a cell-permeable zinc chelator N,N,N',N'-tetrakis(2-pyridylmethyl)ethylenediamine (TPEN) induced a disruption of the TJ barrier, as indicated by increased FITC-labeled dextran flux and decreased transepithelial electrical resistance. The TPEN-induced TJ disruption is associated with downregulation of two TJ proteins, occludin and claudin-3. Biotinylation of cell surface proteins revealed that the zinc depletion induced the proteolysis of occludin but not claudin-3. Occludin proteolysis was sensitive to the inhibition of calpain activity, and increased calpain activity was observed in the zinc-depleted cells. Although quantitative PCR analysis and promoter reporter assay have demonstrated that the zinc depletion-induced claudin-3 downregulation occurred at transcriptional levels, a site-directed mutation in the egr1 binding site in the claudin-3 promoter sequence induced loss of both the basal promoter activity and the TPEN-induced decreases. Reduced egr1 expression by a specific siRNA also inhibited claudin-3 expression and transepithelial electrical resistance maintenance in cells. This study shows that intracellular zinc has an essential role in the maintenance of the intestinal epithelial TJ barrier through regulation of occludin proteolysis and claudin-3 transcription.

A cross-sectional study on nutrient intake and -status in inflammatory bowel disease patients

Background and aims

Inflammatory bowel disease (IBD) can be associated with nutritional problems. The aim of this study was to investigate diet and nutritional status of IBD patients.

Methods

A total of 78 participants (35 men and 43 women aged 18–74 years) were included in this cross-sectional study. The majority (80 %) of the participant received infliximab treatment. Participants filled out disease related questionnaires and 31 participants also a 3-day food record. Body composition was measured and blood samples analysed in order to estimate nutritional status.

Results

The majority (87 %) claimed that diet affects digestive tract symptoms and 72 % had changed diet accordingly. The most common foods restricted were dairy products (60 %), processed meat (55 %), soft drinks (46 %), alcohol (45 %) and fast food (44 %). Body mass index was mostly in the overweight range but 46 % of the participants had been diagnosed with some nutritional deficiency since IBD diagnosis (most common was iron deficiency: 39 %). Patients who restricted meat products had lower ferritin values (48 ± 39 vs. 95 ± 74 μg/L, P = 0.011). Intake of vitamin D and calcium were not adequate (65 % below recommeded intake for both) and 60 % had poor vitamin D status.

Conclusion

IBD patients often change their dietary intake in order to affect digestive tract symptoms. Many patients have a history of nutrient deficiency. Restriction of dairy and meat consumption is common and is negatively associated with intake or status of micronutrients like calcium and iron. Dietary advice by a dietitian and use of potentially helpful dietary supplements is indicated.

High-resolution Quantitative Computed Tomography Demonstrates Structural Defects in Cortical and Trabecular Bone in IBD Patients

BACKGROUND AND AIMS

To investigate the macro- and microstructural changes of bone in patients with inflammatory bowel disease [IBD] and to define the factors associated with bone loss in IBD.

METHODS

A total of 148 subjects, 59 with Crohn's disease [CD], 39 with ulcerative colitis [UC], and 50 healthy controls were assessed for the geometric, volumetric and microstructural properties of bone using high-resolution peripheral quantitative computed tomography. In addition, demographic and disease-specific characteristics of IBD patients were recorded.

RESULTS

IBD patients and controls were comparable in age, sex, and body mass index. Total [p = 0.001], cortical [p < 0.001], and trabecular volumetric bone mineral density [BMD] [p = 0.03] were significantly reduced in IBD patients compared with healthy controls. Geometric and microstructural analysis revealed significantly lower cortical area [p = 0.001] and cortical thickness [p < 0.001] without differences in cortical porosity, pore volume, or pore diameter. CD showed a more severe bone phenotype than UC: cortical bone loss was observed in both diseases, but CD additionally showed profound trabecular bone loss with reduced trabecular BMD [p = 0.008], bone volume [p = 0.008], and trabecular thickness [p = 0.009]. Multivariate regression models identified the diagnosis of CD, female sex, lower body mass index, and the lack of remission as factors independently associated with bone loss in IBD.

CONCLUSION

IBD patients develop significant cortical bone loss, impairing bone strength. Trabecular bone loss is limited to CD patients, who exhibit a more severe bone phenotype compared with UC patients.

Nutritional Support of Patient with Inflammatory Bowel Disease

Ideally, surgical patients should be nutritionally optimized, as better nutritional status correlates with favorable outcomes during the perioperative period. As inflammatory bowel disease often leads to overall malnutrition, special consideration should be given to this patient population by surgeons. In this article, we review methods for nutritional assessment and provide nutritional recommendations for this special surgical population.

Practical Guideline for Fatigue Management in Inflammatory Bowel Disease

During active inflammatory bowel disease (IBD) fatigue is a common symptom, which seems related to active gut inflammation. However, even in remission many patients suffer from fatigue that negatively affects quality of life and work productivity. Currently, robust knowledge on the pathogenesis and treatment of IBD-related fatigue is lacking. In order to alleviate the burden of IBD-related fatigue, a systematic approach is mandatory. We propose a fatigue attention cycle to enhance identification, evaluation and management of fatigued IBD patients. The benefits of the cycle are twofold. Firstly, it allows the systematic and uniform identification of patients with severe fatigue, in turn allowing tailored non-pharmacological and pharmacological interventions. Secondly, uniform identification of such patients creates a well-defined patient base to investigate the underlying pathogenesis of fatigue, resulting in a greater understanding of this debilitating phenomenon and possibly resulting in the discovery of predictive factors and new treatment interventions.

Vitamin D status in relation to Crohn's disease: Meta-analysis of observational studies

OBJECTIVES

Inconsistent findings have been published regarding vitamin D status among patients with Crohn's disease (CD) and the association with disease severity. We aimed to perform a meta-analysis evaluating serum 25-hydroxy vitamin D and 1,25 dehydroxyvitamin D among CD patients compared with healthy and non-healthy controls, the prevalence of vitamin D deficiency, and the association with disease.

METHODS

We searched MEDLINE, SCOPUS, EMBASE, and Google Scholar up to March 2015 for observational studies assessing serum vitamin D levels in CD patients. A total of 63 studies were included in the following four meta-analyses: 1) a meta-analysis on the mean difference of 25(OH)D levels in CD patients compared with healthy (number of studies = 27) and non-healthy (n = 25) controls; 2) a meta-analysis on the mean difference of 1,25(OH)2 D3 levels in CD patients compared with healthy (n = 7) and non-healthy (n = 8) controls; 3) a meta-analysis on the prevalence of vitamin D deficiency (n = 34); 4) a meta-analysis on the correlation coefficients between vitamin D status severity of CD (n = 6). Subgroup analysis and meta-regression were used to discover possible sources of between-study heterogeneity.

RESULTS

It was found that CD patients had lower levels of 25(OH)D compared with healthy (-3.99 ng/mL; 95% confidence interval [CI]: -5.91 to -2.08) but not non-healthy controls (-1.07 ng/mL; 95% CI: -2.84 to 0.70). There was also no significant mean difference for 1,25(OH)2 D3 for both healthy and non-healthy controls. Meta-analysis on the prevalence of vitamin D deficiency showed an overall prevalence of 57.7% (95% CI: 0.502-0.649). An inverse association was observed between serum vitamin D and severity of CD (-0.36; 95% CI: -0.48 to -0.24). Meta-regression showed that mean levels of 25(OH)D were decreased 0.09 for each unit change of latitude among CD patients compared with healthy controls (B = -0.09, P = 0.004, I(2) residual = 86.08%).

CONCLUSIONS

We found that patients with Crohn's disease had lower serum 25(OH)D concentrations compared with their healthy counterparts, and more than half of them have hypovitaminosis D. Moreover, there was an inverse correlation between circulating 25(OH)D concentrations and severity of Crohn's disease.

Dietary intake of inulin-type fructans in active and inactive Crohn's disease and healthy controls: a case-control study

BACKGROUND AND AIMS

Prebiotic inulin-type fructans are widely consumed in the diet and may have contrasting effects in Crohn's disease by stimulating gut microbiota and/or by generating functional gastrointestinal symptoms. The aim of this study was to measure fructan and oligofructose intakes in patients with active and inactive Crohn's disease compared with healthy controls.

METHODS

Patients with active Crohn's disease (n = 98), inactive Crohn's (n = 99) and healthy controls (n = 106) were recruited to a case-control study. Dietary intake of inulin-type fructans was measured using a specific food frequency questionnaire and was compared between the three groups and between patients with different disease phenotypes (Montreal classification). Associations between intakes and disease activity (Harvey-Bradshaw Index, HBI) were also undertaken.

RESULTS

Patients with active Crohn's disease had lower fructan intakes (median 2.9 g/d, interquartile range [IQR] 1.8) than those with inactive Crohn's (3.6 g/d, 2.1, p = 0.036) or controls (3.9 g/d, 2.1, p = 0.003) and lower oligofructose intakes (2.8 g/d, 1.8) than those with inactive Crohn's (3.5 g/d, 2.2, p = 0.048) or controls (3.8 g/d, 2.1, p = 0.003). There were no differences in intakes related to disease site or behaviour. There were negative correlations between HBI well-being score and fructan intake (ρ = -0.154, p = 0.03) and oligofructose intake (ρ = -0.156, p = 0.028) and for the HBI abdominal pain score and fructan (ρ = -0.164, p = 0.021) and oligofructose intake (ρ = -0.157, p = 0.027).

CONCLUSIONS

Patients with active Crohn's disease consume lower quantities of fructans and oligofructose than their inactive counterparts and healthy controls. The impact of lower intakes of prebiotic fructans on gut microbiota is unknown and warrants further research.

Micronutrient deficiencies in inflammatory bowel disease

PURPOSE OF REVIEW

Malnutrition, protein-energy, and micronutrient deficiencies are common among patients with inflammatory bowel disease (IBD). The deficiencies are a manifestation of the complicated disease and a cause of morbidity. The present review summarizes recent advances and evidence-based knowledge regarding micronutrients in relation to patients with IBD.

RECENT FINDINGS

Micronutrient deficiencies occur in more than half of patients with IBD. Most common are deficiencies of iron, B12, vitamin D, vitamin K, folic acid, selenium, zinc, vitamin B6, and vitamin B1. Deficiencies are more common in Crohn's disease than in ulcerative colitis, and more in active disease than at times of remission. Micronutrient deficiency is associated with prolonged and complicated course of disease. Iron deficiency is the most common cause for anemia. Definite diagnosis of B12 deficiency cannot be established by serum levels alone. Vitamin D and vitamin K deficiencies are thought to be associated with heightened inflammatory state. The relationship of these deficiencies with bone disease is controversial. The present review focuses on the significance, epidemiology, treatment options, and recommendations regarding micronutrient deficiencies in IBD.

SUMMARY

Micronutrient deficiencies are common and have clinical significance. High suspicion for micronutrient deficiencies is advocated so that treatable causes of morbidity are treated appropriately and late and irreversible sequlae are prevented.

Vitamin D Deficiency Increases the Risk for Moderate to Severe Disease Activity in Crohn's Disease Patients in South Africa, Measured by the Harvey Bradshaw Index

OBJECTIVE

Vitamin D has immunoregulatory properties and appears to influence disease outcomes in patients with Crohn's disease (CD). The primary aim of this study was to evaluate the association between vitamin D status and CD activity in South Africa.

METHODS

In a cross-sectional study performed between September 2011 and January 2013, serum 25-hydroxyvitamin D (25(OH)D) was measured in 186 consecutive patients with CD seen at 2 inflammatory bowel disease (IBD) centers and 199 healthy controls in the Western Cape, South Africa. Lifestyle and clinical variables were identified using an investigator-administered questionnaire, as well as clinical examination and patient case notes. Vitamin D status was evaluated in 2 ways: ≤ 20 ng/mL vs ≥ 21 ng/mL and ≤ 29 ng/mL vs ≥ 30 ng/mL. Disease activity was measured by the Harvey Bradshaw Index (HBI). Various 25(OH)D threshold concentrations for predicting a higher HBI score were also investigated.

RESULTS

On multiple log-binomial regression analysis, higher HBI scores and not having taken vitamin D supplementation in the 6 months prior to enrollment were identified as risk factors for vitamin D deficiency in patients with CD, defined either as ≤ 20 ng/mL or as ≤ 29 ng/mL (p < 0.03). Compared to patients with HBI < 5, those with HBI ≥ 8 were 2.5 times more likely to have 25(OH)D concentrations ≤ 21 ng/mL (prevalence risk [PR] = 2.5; 95% confidence interval [CI], 1.21-6.30). The risk was similar, though not as high, when defined as ≤ 29 ng/mL (PR = 2.0; 95% CI, 1.13-3.51). When vitamin D deficiency was defined as <20, <30, <40, and <50 ng/mL, the sensitivity and specificity obtained were 44.9% and 78.8%; 75.5% and 62.4%; 86.7% and 44.7%; and 92.9% and 23.5%, respectively (area under the curve = 0.71; p < 0.0001).

CONCLUSION

Low serum 25(OH)D was associated with increased CD activity in a South African cohort.

Robust Association Between Inflammatory Bowel Disease and Generalized Anxiety Disorder: Findings from a Nationally Representative Canadian Study

BACKGROUND

Although the link between inflammatory bowel diseases (IBD) and depression is well accepted, less is known about the relationship between IBD and anxiety disorders and factors associated with anxiety among those with IBD.

METHODS

Data were derived from the nationally representative 2012 Canadian Community Health Survey-Mental Health. The survey response rate was 68.9%. Two sets of analyses were undertaken. First, a series of logistic regression analyses were used to estimate the odd ratios of generalized anxiety disorder among those with IBD compared with those without (n = 22,522). The fully adjusted model controlled for sociodemographics, depression, substance abuse/dependence, pain, and adverse childhood experiences. Second, among those with IBD (n = 269), significant correlates of generalized anxiety disorder were identified using logistic regression. The presence of generalized anxiety disorder was determined using the WHO-CIDI lifetime criteria, and IBD was assessed by a self-reported health professional diagnosis.

RESULTS

Individuals with IBD had over twice the odds of anxiety compared with those without IBD, even when controlling for a range of potential explanatory factors (odds ratio = 2.18; 95% confidence interval, 1.50-3.16). Controlling for chronic pain and childhood adversities attenuate the relationship the most. Among those with IBD, a history of childhood sexual abuse, female gender, and chronic pain are the strongest correlates of anxiety. Those with Crohn's and ulcerative colitis were equally vulnerable to generalized anxiety disorder.

CONCLUSIONS

Our findings show that IBD is robustly related to generalized anxiety disorder. Health care professionals should be aware of the increased prevalence of generalized anxiety disorder among their patients with IBD, particularly women, those in chronic pain, and those with a history of childhood sexual abuse.

Physical methods for evaluating the nutrition status of hemodialysis patients

This article aims to provide an overview of the different nutritional markers and the available methodologies for the physical assessment of nutrition status in hemodialysis patients, with special emphasis on early detection of protein energy wasting (PEW). Nutrition status assessment is made on the basis of anamnesis, physical examination, evaluation of nutrient intake, and on a selection of various screening/diagnostic methodologies. These methodologies can be subjective, e.g. the Subjective Global Assessment score (SGA), or objective in nature (e.g. bioimpedance analysis). In addition, certain biochemical tests may be employed (e.g. albumin, pre-albumin). The various subjective-based and objective methodologies provide different insights for the assessment of PEW, particularly regarding their propensity to differentiate between the important body composition compartments-fluid overload, fat mass and muscle mass. This review of currently available methods showed that no single approach and no single marker is able to detect alterations in nutrition status in a timely fashion and to follow such changes over time. The most clinically relevant approach presently appears to be the combination of the SGA method with the bioimpedance spectroscopy technique with physiological model and, additionally, laboratory tests for the detection of micro-nutrient deficiency.

Dietary management of IBD--insights and advice

The current general interest in the use of food choice or diet in maintaining good health and in preventing and treating disease also applies to patients with IBD, who often follow poor or nutritionally challenging dietary plans. Unfortunately, dietary advice plays only a minor part in published guidelines for management of IBD, which sends a message that diet is not of great importance. However, a considerable evidence base supports a focused and serious attention to nutrition and diet in patients with IBD. In this Review, a step-wise approach in the evaluation and management of these patients is proposed. First, dietary intake and eating habits as well as current nutritional state should be documented, and corrective measures instituted. Secondly, dietary strategies as primary or adjunctive therapy for the reduction of inflammation and/or prevention of relapse of IBD should be seriously contemplated. Thirdly, use of diet to improve symptoms or lessen the effects of complications should be considered. Finally, dietary advice regarding disease prevention should be discussed when relevant. An increasing need exists for applying improved methodologies into establishing the value of current and new ways of using food choice as a therapeutic and preventive tool in IBD.

High prevalence of vitamin A deficiency in Crohn's disease patients according to serum retinol levels and the relative dose-response test

AIM: To assess the vitamin A status of patients with Crohn’s disease (CD) by evaluating serum retinol levels and the relative dose response (RDR) test (liver retinol stores).

METHODS: Vitamin A nutritional status was measured by serum retinol obtained by high performance liquid chromatography and the RDR test for evaluation of the hepatic stores. Body composition was performed by densitometry by dual-energy X-ray absorptiometry. Vitamin A dietary intake was assessed from a semi-quantitative food frequency questionnaire.

RESULTS: This study included 38 CD patients and 33 controls. Low serum retinol concentrations were detected in 29% of CD patients vs 15% in controls (P < 0.005). The RDR test was positive in 37% of CD patients vs 12% in controls, which indicated inadequate hepatic vitamin A stores (P < 0.005). Individuals with hypovitaminosis A had lower BMI and body fat compared with those without this deficiency. There was no association between vitamin A deficiency and its dietary intake, ileal location, presence of disease activity and prior bowel resections.

CONCLUSION: Patients with CD have higher prevalence of vitamin A deficiency, as assessed by two independent methods.

The effect of body weight on the severity and clinical course of ulcerative colitis

PURPOSE

Obesity is a risk factor for inflammatory diseases such as nonalcoholic steatohepatitis, pancreatitis, and Crohn's disease. The effect of being overweight or obese on the severity and clinical course of ulcerative colitis (UC) was assessed in a retrospective analysis of data from 2000-2006.

METHODS

Two hundred and two consecutive UC patients were categorized according to body mass index (BMI). Patient and disease characteristics were compared between BMI categories using chi-square or Kruskal-Wallis tests. The percentage of patients with active UC, complications, steroid therapy, or immunosuppressive therapy was calculated for each group, and matched pair analyses were performed.

RESULTS

Ten patients (5%) were underweight, 111 (55%) were normal weight, 54 (26.7%) were overweight, and 27 (13.4%) were obese. Pancolitis was inversely related to weight. BMI was also inversely correlated to disease severity, with a significantly smaller proportion of years with chronic active disease among overweight subjects versus normal-weight subjects (17.6 versus 23.9%, p = 0.05). More overweight than normal-weight patients had no chronic active disease in any year (66 versus 49%, p = 0.06), and the proportion of years with disease complications was higher in normal weight than in overweight subjects (1.8 versus 0.4%, p = 0.08). Disease activity during 2000-2006 was higher for underweight versus normal-weight patients, and only 20% of underweight subjects had no hospital admission compared to 80% of normal-weight patients (p = 0.07).

CONCLUSIONS

This first study to explore the influence of obesity on UC showed that high BMI had rather a favorable effect on the prognosis, whereas low BMI pointed to a more severe course of the disease.

Mucosal healing in inflammatory bowel diseases: is there a place for nutritional supplementation?

Advanced mucosal healing (MH) after intestinal mucosal inflammation coincides with sustained clinical remission and reduced rates of hospitalization and surgical resection, explaining why MH is increasingly considered as a full therapeutic goal and as an endpoint for clinical trials. Intestinal MH is a complex phenomenon viewed as a succession of steps necessary to restore tissue structure and function. These steps include epithelial cell migration and proliferation, cell differentiation, restoration of epithelial barrier functions, and modulation of cell apoptosis. Few clinical studies have evaluated the needs for specific macronutrients and micronutrients and their effects on intestinal MH, most data having been obtained from animal and cell studies. These data suggest that supplementation with specific amino acids including arginine, glutamine, glutamate, threonine, methionine, serine, proline, and the amino acid-derived compounds, polyamines can favorably influence MH. Short-chain fatty acids, which are produced by the microbiota from undigested polysaccharides and protein-derived amino acids, also exert beneficial effects on the process of intestinal MH in experimental models. Regarding supplementation with lipids, although the effects of ω-3 and ω-6 fatty acids remain controversial, endogenous prostaglandin synthesis seems to be necessary for MH. Finally, among micronutrients, several vitamin and mineral deficiencies with different frequencies have been observed in patients with inflammatory bowel diseases and supplementation with some of them (vitamin A, vitamin D3, vitamin C, and zinc) are presumed to favor MH. Future work, including clinical studies, should evaluate the efficiency of supplementation with combination of dietary compounds as adjuvant nutritional intervention for MH of the inflamed intestinal mucosa.

Optimal vitamin D levels in Crohn's disease: a review

Vitamin D deficiency is common among patients with Crohn's disease. Serum 25-hydroxyvitamin D (25(OH)D) is the best measure of an individual's vitamin D status and current cut-off ranges for sufficiency are debatable. Several factors contribute to vitamin D deficiency in Crohn's disease. These include inadequate exposure to sunlight, inadequate dietary intake, impaired conversion of vitamin D to its active metabolite, increased catabolism, increased excretion and genetic variants in vitamin D hydroxylation and transport. The effects of low 25(OH)D on outcomes other than bone health are understudied in Crohn's disease. The aim of the present review is to discuss the potential roles of vitamin D and the possible levels required to achieve them. Emerging evidence suggests that vitamin D may have roles in innate and adaptive immunity, in the immune-pathogenesis of Crohn's disease, prevention of Crohn's disease-related hospitalisations and surgery, in reducing disease severity and in colon cancer prevention. The present literature appears to suggest that 25(OH)D concentrations of ≥75 nmol/l may be required for non-skeletal effects; however, further research on optimal levels is required.

Nutritional impact of inflammatory bowel diseases on children and adolescents

OBJECTIVE: To perform a sistematiy review of the literature about the nutritional impact of inflammatory bowel diseases in children and adolescents.DATA SOURCES: A systematic review was performed using PubMed/MEDLINE, LILACS and SciELO databases, with inclusion of articles in Portuguese and in English with original data, that analyzed nutritional aspects of inflammatory bowel diseases in children and adolescents. The initial search used the terms "inflammatory bowel diseases" and "children" or "adolescents" and "nutritional evaluation" or "nutrition deficiency". The selection of studies was initially performed by reading the titles and abstracts. Review studies and those withouth data for pediatric patients were excluded. Subsequently, the full reading of the articles considered relevant was performed.RESULTS: 237 studies were identified, and 12 of them were selected according to the inclusion criteria. None of them was performed in South America. During the analysis of the studies, it was observed that nutritional characteristics of patients with inflammatory bowel disease may be altered; the main reports were related to malnutrition, growth stunting, delayed puberty and vitamin D deficiency.CONCLUSION: There are nutritional consequences of inflammatory bowel diseases in children and adolescents, mainly growth stunting, slower pubertal development, underweight and vitamin deficiencies. Nutritional impairments were more significant in patients with Crohn's disease; overweight and obesity were more common in patients with ulcerative rectocolitis. A detailed nutritional assessment should be performed periodically in children and adolescents with inflammatory bowel disease.

Anaemia from a patient perspective in inflammatory bowel disease: results from the European Federation of Crohn's and Ulcerative Colitis Association's online survey

OBJECTIVE

Anaemia is frequently seen in inflammatory bowel disease (IBD) and needs appropriate treatment. This online questionnaire investigated the patients' perceptions of anaemia: symptoms, prevalence, treatment and impact on quality of life.

METHODS

Patients participated in this survey in 2012. Respondents were mainly from Europe, but also from North America and Asia Pacific.

RESULTS

A total of 631 patients completed the questionnaire; most had Crohn's disease, and 41.2% were in remission, 29.8% had mildly active flares, 16.8% had moderately active flares, and 5.4% had severely active flares. When asked about anaemia, 67% believed that anaemia occurred frequently in IBD and was associated with blood loss (45%), iron deficiency (31%), or inflammation (18%). Symptoms commonly reported by patients with anaemia were fatigue and weakness. Fatigue associated with anaemia occurred daily in 53% of patients and negatively impacted the quality of life.A number of patients had not discussed anaemia with a healthcare professional, and 33% of patients with anaemia had not received treatment. Of those treated, 42% took oral prescription iron, 27% intravenous iron, 19% nonprescription iron supplements and 10% prescription liquid or syrup iron. The majority of patients taking liquid or syrup iron (77%), oral iron (74%) and iron supplements (68%) were dissatisfied with their treatment, primarily because of poor tolerability. In contrast, 72% were satisfied with intravenous iron treatment.

CONCLUSION

IBD patients are mostly aware of the main signs and symptoms of anaemia. Oral iron is most commonly prescribed, but may cause dissatisfaction because of tolerability issues. Most patients prescribed intravenous iron are satisfied with treatment.

Evaluation of dairy allergy among ulcerative colitis patients

The intestine is the largest mucosal organ of the body and also the first line immune homeostasis. Inflammatory bowel disease or IBD is divided into ulcerative colitis and Crohn's disease. One of the problems that can occur with UC is dietary allergy to some foods. This study aimed to evaluated the dairy allergy among patients with ulcerative colitis. This study is a Case - control study, that studied 72 patients with Ulcerative Colitis, after recording history of the disease, colonoscopy and confirmed by biopsy and 72 person without history of colitis. In this study, in order to investigate of food allergy, used of the EUROMMUM kit with an international code number DP3420-1601-11E. We used chi-square and Monte Carlo method for analysis of data. Among UC patients, 30.6% mild, 52.8% moderate and 16.6% of cases were in sever stage. 9.7% of them reported a history of abdominal surgery due to disease. According to the chi-square and Monte Carlo methods, dairy allergy (including: cow milk, cow milk UHT and casein) in UC group was significant (P=0.00). This study indicated that there is significant relationship between UC and cow milk, cow milk UHT and casein. UC patients who are allergic to dairy products and the use of dairy products can increase the severity of UC.

Zinc and gastrointestinal disease

This review is a current summary of the role that both zinc deficiency and zinc supplementation can play in the etiology and therapy of a wide range of gastrointestinal diseases. The recent literature describing zinc action on gastrointestinal epithelial tight junctions and epithelial barrier function is described. Zinc enhancement of gastrointestinal epithelial barrier function may figure prominently in its potential therapeutic action in several gastrointestinal diseases.