Nutrition Issues in Pediatric Crohn's Disease

Co-Development of Three Dietary Indices to Facilitate Dietary Intake Assessment of Pediatric Crohn's Disease Patients

Literature on dietary behaviours of the pediatric Crohn's Disease (CD) population and the relationship between dietary intake and CD activity is limited. Three dietary indices were developed and tested to conduct dietary pattern analysis in pediatric patients with CD consuming a free diet following remission induction via exclusive enteral nutrition (n = 11). Index scores underwent descriptive and inferential analysis. The mean adjusted scores (out of 100) for the Pediatric Western Diet Index, Pediatric Prudent Diet Index, and Pediatric-Adapted 2010 Alternate Healthy Eating Index (PA2010-AHEI) were 29.82 ± 15.22, 34.25 ± 15.18, and 51.50 ± 11.69, respectively. The mean Western-to-Prudent ratio was 0.94 ± 0.55. A significant correlation (r = -0.71) and relationship (F[1, 9] = 9.04, P < 0.05, R2 = 0.501) between the Western-to-Prudent ratio and PA2010-AHEI was found. The results suggest participants were not following a Western or Prudent diet, and were consuming foods not captured by the indices. More research is needed to describe dietary intake of individuals with CD, validate dietary indices in diverse samples, and explore the utility of these indices in CD assessment and treatment. The co-authors hope this work will stimulate/inspire subsequent interprofessional, dietitian-led research on this topic.

Diet and Anthropometrics of Children With Inflammatory Bowel Disease: A Comparison With the General Population

BACKGROUND

There is a lack of knowledge regarding the diet of children with inflammatory bowel disease (IBD). Therefore, we investigated dietary intake in pediatric IBD compared to the general population and assessed anthropometrics and food avoidance.

METHODS

In this cross-sectional cohort study, patients younger than 18 years with IBD were included (2014-2017). Dietary intake (total energy, macro nutrients, food types) was assessed using a Food Frequency Questionnaire (FFQ) and compared with a matched reference population (n = 306).

RESULTS

There were 102 patients included (55% male, median age 15.0 years). Median height Z-score was -0.39 (interquartile range [IQR]: -1.17 to 0.26). Growth failure (height Z-scores<-1.64) was present in 11% of patients. Median BMI Z-score was 0.36 (IQR: -0.70 to 0.96). Acute malnutrition (weight-for-height Z-score<-2) was present in 3% of patients. Energy intake was lower in pediatric IBD compared to the reference population (mean kilojoule/day: 8286 vs 9794, P < 0.001). Protein intake did not differ, while fat intake was higher in pediatric IBD (mean gram/day: 101 vs 91, P < 0.001), with higher intake of vegetable oils/fats. Carbohydrate intake was lower in pediatric IBD (mean gram/day: 267 vs 305, P < 0.001), with lower intake of food types high in sugar. Food avoidance was reported in 53% of patients, with frequent avoidance of spicy (46%), high-fat food (30%), and dairy (30%).

CONCLUSIONS

The diet of children with IBD differs from the general pediatric population, with lower energy intake and high rates of food avoidance. Evaluation of the dietary intake alongside anthropometrics may be important to prevent nutrition deficiencies and promote health.

Massachusetts Inpatient Medicaid Cost Response to Increased Supplemental Nutrition Assistance Program Benefits

OBJECTIVES

To investigate the impact of an increase in Supplemental Nutrition Assistance Program (SNAP) benefits on Medicaid costs and use in Massachusetts.

METHODS

Using single and multigroup interrupted time series models, I examined the effect of an April 2009 increase in SNAP benefits on inpatient Medicaid cost and use patterns. I analyzed monthly Medicaid discharge data from 2006 to 2012 collected by the Massachusetts Center for Health Information and Analysis.

RESULTS

Inpatient costs for the overall Massachusetts Medicaid population grew by 0.55 percentage points per month (P < .001) before the SNAP increase. After the increase, cost growth fell by 73% to 0.15 percentage points per month (-0.40; P = .003). Compared with the overall Medicaid population, cost growth for people with the selected chronic illnesses was significantly greater before the SNAP increase, as was the decline in growth afterward. Reduced hospital admissions after the SNAP increase drove the cost declines.

CONCLUSIONS

Medicaid cost growth fell in Massachusetts after SNAP benefits increased, especially for people with chronic illnesses with high sensitivity to food insecurity.

An update of the role of nutritional therapy in the management of Crohn's disease

Crohn's disease is an increasingly global health concern. Currently without a cure, it significantly alters the quality of life of Crohn's disease sufferers and places a heavy financial burden on the community. Recent reports show that the rising prevalence of Crohn's disease is no longer confined to Western countries, with considerable increases seen particularly in Asia. Nutritional problems are often associated with Crohn's disease, most notably in the paediatric population, with underweight and stunting commonly seen at presentation. In addition, linear growth retardation and pubertal delay can also manifest in these younger patients. Therefore, exclusive enteral nutrition has been used as a therapeutic option to treat Crohn's disease, in part to address the nutritional complications of the disease. Exclusive enteral nutrition can improve nutrition as well as induce remission at a rate equivalent to corticosteroids. It is safe particularly with long-term use and can induce mucosal healing, considered the gold standard for therapy, at a rate superior to corticosteroids. Exclusive enteral nutrition has thus become the preferred therapeutic option in many centres for the treatment of paediatric Crohn's disease. This review discusses the role of exclusive enteral nutrition as a therapeutic option for the treatment of Crohn's disease, as well as the latest findings into its mechanisms of action.

No relation between disease activity measured by multiple methods and REE in childhood Crohn disease

BACKGROUND AND AIMS

Increased resting energy expenditure (REE) unmatched by dietary intake is implicated as a cause of poor nutrition in childhood inflammatory conditions. Adequate description of disease activity and correction of REE data for body composition are important to reach reliable conclusions about changes in REE associated with disease. The present study aimed to determine the effect of disease activity measured by clinical status, systemic and stool inflammatory markers on REE in children with Crohn disease using appropriate correction for confounding factors.

METHODS

Sixty children with Crohn disease were recruited from the regional paediatric gastroenterology unit and studied on 1 occasion. REE was measured by indirect calorimetry. Fat-free mass (FFM) was estimated by skinfold thickness. Disease activity was measured using systemic (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) and faecal markers of inflammation (lactoferrin, calprotectin) and clinical scores (Paediatric Crohn Disease Activity Index).

RESULTS

Using a multiple regression model, there was no significant change in REE from active or inactive disease (β = 0.03, P = 0.7) nor from CRP (β = -0.05, P = 0.52), ESR (β = -0.07, P = 0.43), faecal calprotectin (β = -0.07, P = 0.38), and faecal lactoferrin (β = 0.01, P = 0.88). REE/kg FFM was not associated with the Paediatric Crohn Disease Activity Index (r = 0.1, P = 0.44), CRP (r = -0.3, P = 0.84) or ESR (r = 0.12, P = 0.4), faecal calprotectin (r = 0.04, P = 0.97), or faecal lactoferrin (r = 0.02, P = 0.87).

CONCLUSIONS

REE corrected for physiologically relevant confounders is not associated with degree of disease activity using clinical tools or systemic and local inflammatory markers, and therefore is an unlikely mechanism for poor nutritional state.

Enteral feeding therapy for newly diagnosed pediatric Crohn's disease: a double-blind randomized controlled trial with two years follow-up

BACKGROUND

This study compared the efficacy of an elemental formula (EF) to a polymeric formula (PF) in inducing remission for pediatric Crohn's disease (CD).

METHODS

Newly diagnosed CD children were randomized to EF or PF for 6 weeks. Change in the Pediatric Crohn's Disease Activity Index (PCDAI), fecal calprotectin, and plasma fatty acids were measured at 0 and 6 weeks. Patients were followed up for 2 years. Time and treatment choice for first relapse were documented.

RESULTS

Thirty-four children completed the study; EF: 15 (7 M, 8 F), PF: 19 (13 M, 6 F). The mean age was (years) EF: 12.6, PF: 11.7. Ninety-three percent of children (14/15) achieved remission in the EF group and 79% (15/19) in the PF group. One-third of patients maintained remission for 2 years. Mean time to relapse (days); EF: 183 (63-286), PF: 162 (53-301). Most children who relapsed used feed as a treatment for that relapse (EF: 9/10 and PF: 8/13). With PF, an increase of eicosapentanoic acid (EPA) and alpha linolenic acid was found with a reciprocal decrease in arachidonic acid (AA). With EF, AA and EPA levels were reduced with a significant decrease in docosahexaenoic acid. Fecal calprotectin measurements decreased significantly but did not normalize at the end of week 6.

CONCLUSIONS

There was no significant difference between EF and PF in inducing remission. One-third of children maintained remission. Changes in plasma polyunsaturated fatty acid status were subtle and may be relevant; however, further evaluation is recommended.

Symposium 6: Young people, artificial nutrition and transitional care: Nutrition, growth and puberty in children and adolescents with Crohn's disease

Of the individuals who present with Crohn's disease 25% are <18 years of age, mostly adolescent. Nutritional impairment and delayed growth are common at diagnosis and remain an issue during the disease course. Treatment has the primary aim to control symptoms, induce disease remission and achieve normal growth in the long term and includes nutritional support and early use of immunomodulation. Puberty may be discordant and is generally late and final adult height may not be achieved until the late teenage years. Chronic ill health and delayed growth may be accompanied by emotional and intellectual immaturity. These factors, including the varying rates of physical and emotional development, need to be considered during adolescence with multidisciplinary input to ensure that the young patient is appropriately supported. Transition to adult care requires close collaboration between paediatric and healthcare teams with careful attention to nutritional, emotional and educational issues, all of which are relevant in the progression from childhood, through adolescence and to adult life.

Impact of disease activity on resting energy expenditure in children with inflammatory bowel disease

BACKGROUND AND AIMS

Exclusive enteral nutrition is used as primary therapy in Crohn's disease. Nutrition support is frequently required in children with both Crohn's disease and Ulcerative Colitis when acutely unwell and during periods of recovery. There is considerable controversy about nutritional needs during phases of active and inactive disease. It is, for example, often assumed that in acute illness a child requires increased nutritional support however the precise relationship between illness severity and energy expenditure is uncertain. This study explores the relationship between disease activity and resting energy expenditure (REE) in children with inflammatory bowel disease.

METHODS

Patients were recruited from the regional paediatric gastroenterology unit at Southampton University Hospitals NHS Trust. Disease activity was assessed using standard scoring systems (Paediatric Crohn's Disease Activity Index; Simple Colitis Activity Index) and biochemical markers of inflammation (C-Reactive Protein, CRP). Fat free mass was estimated from skinfold thickness and Bioelectrical Impedance Analysis. Resting energy expenditure was measured by indirect calorimetry. A logarithmic correction and a linear regression model were used for analysis of REE corrected for body size.

RESULTS

55 children were studied; 37 (67%) with Crohn's disease and 18 (33%) with Ulcerative Colitis. Median PCDAI was 10 (range 0-60), 22 (59%) had PCDAI > or =10 (active disease). Median SCAI was 1.5 (range 0-12). Within disease groups there were strong correlations between REE/KgFFM(0.52) and disease activity; PCDAI (r -0.386, p 0.018) in Crohn's disease and SCAI (r -0.456, p 0.057) in Ulcerative Colitis. In the cohort as a whole there was no increase in REE/KgFFM(0.52) with increasing CRP (r 0.129, p 0.361). Using the regression model each mg/l increase in CRP was associated with a reduction in REE of nearly 1.5 kCal/day.

CONCLUSIONS

We were unable to demonstrate a significant relationship between REE and disease activity in children with inflammatory bowel disease.