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Bischoff SC, Bager P, Escher J, Forbes A, Hébuterne X, Hvas CL, Joly F, Klek S, Krznaric Z, Ockenga J, Schneider S, Shamir R, Stardelova K, Bender DV, Wierdsma N, Weimann A. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2023; 42:352-379. [PMID: 36739756 DOI: 10.1016/j.clnu.2022.12.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
Abstract
The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Johanna Escher
- Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Xavier Hébuterne
- Department of Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France.
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, CHU de Beaujon, APHP, University of Paris, Paris, France.
| | - Stansilaw Klek
- Surgical Oncology Clinic, Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland.
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre Zagreb, University of Zagreb, Croatia.
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Bremen FRG, Bremen, Germany.
| | - Stéphane Schneider
- Department of Gastroenterology and Clinical Nutrition, CHU de Nice, University Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Campus "Mother Theresa", University St Cyrul and Methodius, Skopje, North Macedonia.
| | - Darija Vranesic Bender
- Unit of Clinical Nutrition, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
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Nelson AD, Elkins JR, Stocchi L, Farraye FA, Hashash JG. Use and Misuse of Parenteral Nutrition in Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis 2022; 28:1592-1602. [PMID: 35472221 DOI: 10.1093/ibd/izac085] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Indexed: 12/09/2022]
Abstract
Malnutrition is a very common and often underrecognized condition among patients with inflammatory bowel diseases (IBD). This is most commonly due to increased nutritional requirements and gastrointestinal losses, along with reduced oral intake. Screening for malnutrition is an essential component of managing both inpatients and outpatients with IBD. Although enteral nutrition is the preferred route of supplementation, parenteral nutrition (PN) remains an important strategy and should be considered in certain situations, such as cases with short-bowel syndrome, high-output intestinal fistula, prolonged ileus, or small-bowel obstruction. Appropriate use of PN is critical in order to prevent associated complications. This review addresses the common indications for use of PN, the composition of PN, and the possible complications encountered with PN use, as well as scenarios of inappropriate PN use among patients with IBD. A clinical management algorithm for utilizing PN among patients with IBD is proposed in this review.
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Affiliation(s)
- Alfred D Nelson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Luca Stocchi
- Division of Colorectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jana G Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Karachaliou A, Anastasiou C, Bletsa M, Mantzaris GJ, Archavlis E, Karampekos G, Tzouvala M, Zacharopoulou E, Veimou C, Bamias G, Kontogianni M. Poor performance of predictive equations to estimate resting energy expenditure in patients with Crohn's disease. Br J Nutr 2022; 129:1-31. [PMID: 35249560 PMCID: PMC9870717 DOI: 10.1017/s000711452200068x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/17/2022] [Accepted: 02/25/2022] [Indexed: 02/03/2023]
Abstract
Studies exploring the accuracy of equations calculating Resting Energy Expenditure (REE) in patients with Crohn's disease are lacking. The aim of this study was to investigate the accuracy of REE predictive equations against indirect calorimetry in Crohn's disease patients. REE was measured using indirect calorimetry (mREE) after an overnight fasting. Fourteen predictive equations, with and without body composition analysis parameters, were compared with mREE using different body weight approaches. Body composition analysis was performed using dual X-ray absorptiometry. 186 Crohn's disease outpatients (102 males) with mean age 41.3±14.1 years and 37.6% with active disease were evaluated. Mean mREE in the total sample was 1734±443 kcal/day. All equations under-predicted REE and showed moderate correlations with mREE (Pearson's r or Spearman's rho 0.600-0.680 for current weight, all p-values<0.001). Accuracy was low for all equations at the individual level (28-42% and 25-40% for current and adjusted body weight, respectively, 19-33% for equations including body composition parameters). At the group level, accuracy showed wide limits of agreement and proportional biases. Accuracy remained low when sample was studied according to disease activity, sex, body mass index and medication use. All predictive equations underestimated REE and showed low accuracy. Indirect calorimetry remains the best method for estimating REE of patients with Crohn's disease.
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Affiliation(s)
- Alexandra Karachaliou
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Ave, 17671, Kallithea, Greece
| | - Costas Anastasiou
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Ave, 17671, Kallithea, Greece
| | - Maria Bletsa
- Department of Nutrition and Dietetics, ‘Sotiria’ Thoracic Diseases Hospital, 152 Mesogion Ave, 11527, Athens, Greece
| | - Gerassimos J. Mantzaris
- Department of Gastroenterology, ‘Evangelismos-Ophthalmiatreion Athinon-Polykliniki’ General Hospital, 45-47 Ypsilantou Str., 106 76, Athens, Greece
| | - Emmanuel Archavlis
- Department of Gastroenterology, ‘Evangelismos-Ophthalmiatreion Athinon-Polykliniki’ General Hospital, 45-47 Ypsilantou Str., 106 76, Athens, Greece
| | - George Karampekos
- Department of Gastroenterology, ‘Evangelismos-Ophthalmiatreion Athinon-Polykliniki’ General Hospital, 45-47 Ypsilantou Str., 106 76, Athens, Greece
| | - Maria Tzouvala
- Department of Gastroenterology, General Hospital of Nikaia Piraeus ‘Agios Panteleimon’-General Hospital Dytikis Attikis ‘Agia Varvara’, 3 Dim. Mantouvalou Str., 184 54, Athens, Greece
| | - Eirini Zacharopoulou
- Department of Gastroenterology, General Hospital of Nikaia Piraeus ‘Agios Panteleimon’-General Hospital Dytikis Attikis ‘Agia Varvara’, 3 Dim. Mantouvalou Str., 184 54, Athens, Greece
| | - Chrysoula Veimou
- Department of Gastroenterology, General Hospital of Nikaia Piraeus ‘Agios Panteleimon’-General Hospital Dytikis Attikis ‘Agia Varvara’, 3 Dim. Mantouvalou Str., 184 54, Athens, Greece
| | - Giorgos Bamias
- GI-Unit, 3rd Academic Department of Internal Medicine, ‘Sotiria’ Thoracic Diseases Hospital, Medical School, National and Kapodistrian University of Athens, 152 Mesogion Ave, 115 27, Athens, Greece
| | - Meropi Kontogianni
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Ave, 17671, Kallithea, Greece
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Abstract
INTRODUCTION the ESPEN guideline offers a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). METHODOLOGY the guideline is based on a extensive systematic review of the literature, but relies on expert opinion when objective data are 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 etiology 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 in 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).
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Marra M, Cioffi I, Morlino D, Vincenzo OD, Pagano MC, Imperatore N, Alfonsi L, Santarpia L, Castiglione F, Scalfi L, Pasanisi F. New Predictive Equations for Estimating Resting Energy Expenditure in Adults With Crohn's Disease. JPEN J Parenter Enteral Nutr 2020; 44:1021-1028. [PMID: 32010994 PMCID: PMC7496798 DOI: 10.1002/jpen.1790] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/09/2019] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Increased resting energy expenditure (REE) has been hypothesized to be a potential cause of weight loss in individuals with Crohn's disease (CD). This study aimed to develop and validate new predictive equations for estimating REE in adults with CD. METHODS Adults, ages 18-65 years, with CD were recruited. Anthropometry, indirect calorimetry, and bioimpedance analysis were performed in all patients. Disease activity was assessed by Crohn's Disease Activity Index. The new predictive equations were generated using different regression models. Prediction accuracy of the new equations was assessed and compared with the most commonly used equations. RESULTS A total of 270 CD patients (159 males, 111 females) were included and randomly assigned to the calibration (n = 180) and validation groups (n = 90). REE was directly correlated with weight and bioimpedance index, whereas the relation with both age and disease activity was inverse. The new equations were suitable for estimating REE at population level (bias: -0.2 and -0.3, respectively). Individual accuracy was good in both models (≥80%, respectively), especially in females; and similar results were shown by some of the selected equations. But, when accuracy was set within ±5%, the new equations gave the highest prediction. CONCLUSION The new, disease-specific, equations for predicting REE in individuals with CD give a good prediction accuracy as far as those proposed in the literature for the general population. However, the new ones performed better at the individual level. Further studies are needed to verify the reliability and usefulness of these new equations.
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Affiliation(s)
- Maurizio Marra
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Iolanda Cioffi
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Delia Morlino
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Olivia Di Vincenzo
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Maria Carmen Pagano
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Nicola Imperatore
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Lucia Alfonsi
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Lidia Santarpia
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Fabiana Castiglione
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Luca Scalfi
- Department of Public Health, Federico II University Hospital, Naples, Italy
| | - Fabrizio Pasanisi
- Internal Medicine and Clinical Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
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Bischoff SC, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Forbes A. ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2020; 39:632-653. [PMID: 32029281 DOI: 10.1016/j.clnu.2019.11.002] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023]
Abstract
The present guideline is the first of a new series of "practical guidelines" based on more detailed scientific guidelines produced by ESPEN during the last few years. The guidelines have been shortened and now include flow charts that connect the individual recommendations to logical care pathways and allow rapid navigation through the guideline. The purpose of the present practical guideline is to provide an easy-to-use tool to guide nutritional support and primary nutritional therapy in inflammatory bowel disease (IBD). The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. In 40 recommendations, general aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Krakow, Poland
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
| | - Kalina Stardelova
- University Clinic for Gasrtroenterohepatology, Clinal Centre "Mother Therese", Skopje, Macedonia
| | | | - Anthony E Wiskin
- Pediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Sood A, Ahuja V, Kedia S, Midha V, Mahajan R, Mehta V, Sudhakar R, Singh A, Kumar A, Puri AS, Tantry BV, Thapa BR, Goswami B, Behera BN, Ye BD, Bansal D, Desai D, Pai G, Yattoo GN, Makharia G, Wijewantha HS, Venkataraman J, Shenoy KT, Dwivedi M, Sahu MK, Bajaj M, Abdullah M, Singh N, Singh N, Abraham P, Khosla R, Tandon R, Misra SP, Nijhawan S, Sinha SK, Bopana S, Krishnaswamy S, Joshi S, Singh SP, Bhatia S, Gupta S, Bhatia S, Ghoshal UC. Diet and inflammatory bowel disease: The Asian Working Group guidelines. Indian J Gastroenterol 2019; 38:220-246. [PMID: 31352652 PMCID: PMC6675761 DOI: 10.1007/s12664-019-00976-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/17/2019] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India.
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 023, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 023, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Ramit Mahajan
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Varun Mehta
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Ritu Sudhakar
- Department of Dietetics, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Ajay Kumar
- BLK Super Speciality Hospital, New Delhi, 110 005, India
| | | | | | - Babu Ram Thapa
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Bhabhadev Goswami
- Department of Gastroenterology, Gauhati Medical College, Guwahati, 781 032, India
| | - Banchha Nidhi Behera
- Department of Dietetics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
| | - Deepak Bansal
- Consultant Gastroenterology, Bathinda, 151 001, India
| | - Devendra Desai
- P. D. Hinduja Hospital and Medical Research Centre, Mumbai, 400 016, India
| | - Ganesh Pai
- Department of Gastroenterology, Kasturba Medical College, Manipal, 576 104, India
| | | | - Govind Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110 023, India
| | | | | | - K T Shenoy
- Department of Gastroenterology, Sree Gokulum Medical College and Research Foundation, Trivandrum, 695 011, India
| | - Manisha Dwivedi
- Department of Gastroenterology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Manoj Kumar Sahu
- Department of Gastroenterology, IMS and Sum Hospital, Bhubaneswar, 756 001, India
| | | | - Murdani Abdullah
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 023, India
| | - Neelanjana Singh
- Dietician, Pushpawati Singhania Research Institute, New Delhi, 110 001, India
| | - Philip Abraham
- P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Cadel Road, Mahim, Mumbai, 400 016, India
| | - Rajiv Khosla
- Max Super Speciality Hospital, Saket, New Delhi, 110 017, India
| | - Rakesh Tandon
- Pushpawati Singhania Research Institute, New Delhi, 110 001, India
| | - S P Misra
- Department of Gastroenterology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, SMS Medical College, Jaipur, 302 004, India
| | - Saroj Kant Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Sawan Bopana
- Fortis Hospital, Vasant Kunj, New Delhi, 110 070, India
| | | | - Shilpa Joshi
- Dietician, Mumbai Diet and Health Centre, Mumbai, 400 001, India
| | - Shivram Prasad Singh
- Department of Gastroenterology, Sriram Chandra Bhanj Medical College and Hospital, Cuttack, 753 001, India
| | - Shobna Bhatia
- Department of Gastroenterology, King Edward Memorial Hospital, Mumbai, 400 012, India
| | - Sudhir Gupta
- Shubham Gastroenterology Centre, Nagpur, 440 001, India
| | - Sumit Bhatia
- Consultant Gastroenterology, Medanta The Medicity, Gurgaon, 122 001, India
| | - Uday Chand Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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Abstract
Twenty-five percent of inflammatory bowel disease (IBD) diagnoses present in childhood, with Crohn's disease (CD) being the most common type. Many children have poor nutrition status at presentation of the disease, which may worsen during the clinical course, with a significant number of children having impaired linear growth. The cause of this poor nutrition status is complex, and contributing factors include inadequate intake, malabsorption, altered energy demands, and losses through stool, particularly in colitis. The principal aim of medical management is to induce disease remission, with minimal side effects, thereby enabling normal growth and development. This must include active consideration of the nutrition needs of such children and how they may be best met. However, our understanding of the manner in which the disease process affects the energy demands of children with CD or how poor nutrition, in turn, may affect the disease course is limited. This may constrain the efficacy and effectiveness of standard therapeutic approaches to care. This review explores the many factors of relevance in the delivery of nutrition support to children with inflammatory bowel disease, and explores the role of exclusive enteral nutrition as a corticosteroid-sparing strategy to induce remission in children with active Crohn's disease.
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Affiliation(s)
- Anthony E Wiskin
- Paediatric Medical Unit, Southampton General Hospital, Southampton, UK
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9
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Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Bischoff SC. ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Clin Nutr 2016; 36:321-347. [PMID: 28131521 DOI: 10.1016/j.clnu.2016.12.027] [Citation(s) in RCA: 395] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/28/2016] [Indexed: 12/14/2022]
Abstract
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).
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Affiliation(s)
- Alastair Forbes
- Norwich Medical School, University of East Anglia, Bob Champion Building, James Watson Road, Norwich, NR4 7UQ, United Kingdom.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Office Sp-3460, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, 15 Tyniecka Street, 32-050, Skawina, Krakau, Poland.
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petach-Tikva, 49202, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Centre "Mother Therese", Mother Therese Str No 18, Skopje, Republic of Macedonia.
| | - Nicolette Wierdsma
- VU University Medical Center, Department of Nutrition and Dietetics, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Anthony E Wiskin
- Paediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, United Kingdom.
| | - Stephan C Bischoff
- Institut für Ernährungsmedizin (180) Universität Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
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Basson A. Nutrition management in the adult patient with Crohn’s disease. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2016. [DOI: 10.1080/16070658.2012.11734423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Sammarco R, Marra M, Pagano MC, Alfonsi L, Santarpia L, Cioffi I, Contaldo F, Pasanisi F. Resting energy expenditure in adult patients with Crohn's disease. Clin Nutr 2016; 36:467-470. [PMID: 26869381 DOI: 10.1016/j.clnu.2016.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 12/07/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND & AIMS Crohn's disease (CD) is a chronic intestinal disorder of unknown etiology involving any section of the gastrointestinal tract often associated with protein-energy malnutrition (PEM). Increased resting energy expenditure (REE) unmatched by adequate dietary intake is amongst the pathogenetic mechanisms proposed for PEM. Aim of this study was to evaluate REE in CD patients receiving or not immuno-suppressive therapy as compared to controls. METHODS 36 CD patients (22 M and 14 F, age range 18-55 years) clinically stable and without complications since at least 6 month were studied. REE was evaluated by indirect calorimetry and body composition by BIA. Full biochemistry was performed. Patients were divided into two groups: Group 1 (G1 = 12 patients) without and Group 2 (G2 = 24 patients) with immuno-suppressive therapy. RESULTS The two groups were similar for age, height and BMI whereas significantly differed for weight (G1 vs G2: 56.9 ± 7.44 vs 62.3 ± 8.34 kg), fat free mass (FFM: 40.4 ± 5.73 vs 48.2 ± 7.06 kg), fat mass (FM: 17.0 ± 3.55 vs 13.9 ± 5.54 kg) and phase angle (PA: 5.6 ± 1.4 vs 6.5 ± 1.0°). Serum inflammation parameters were significantly higher in G1 than in G2: hs-PCR: 7.76 ± 14.2 vs 7.16 ± 13.4 mg/dl; alfa 2-protein: 11.7 ± 3.69 vs 9.74 ± 2.08 mg/dl; fibrinogen: 424 ± 174 vs 334 ± 118 mg/dl (p < 0.05). REE was higher in G2 vs G1: 1383 ± 267 vs 1582 ± 253kcal/die (p < 0.05) both in men: 1579 ± 314 vs 1640 ± 203 and women: 1267 ± 140 vs 1380 ± 132. Nevertheless, when corrected for FFM, REE resulted higher in G1 than G2 (34.8 ± 4.89 vs 33.0 ± 4.35 kcal/kg, p < 0.05) group, also higher compared to our, age and sex matched, control population (REE/FFM: 30.9 ± 4.5 kcal/kg). CONCLUSIONS Our preliminary results show that REE when adjusted for FFM is increased in clinically stable CD patients and mildly reduced by immunosuppressive therapy possibly through a direct action on inflammation and on body composition characteristics.
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Affiliation(s)
| | | | | | | | | | | | - Franco Contaldo
- Department of Clinical Medicine and Surgery, Italy; Interuniversity Centre for Obesity and Eating Disorders (CISRODCA), Federico II University of Naples, Italy
| | - Fabrizio Pasanisi
- Department of Clinical Medicine and Surgery, Italy; Interuniversity Centre for Obesity and Eating Disorders (CISRODCA), Federico II University of Naples, Italy
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Takaoka A, Sasaki M, Kurihara M, Iwakawa H, Inoue M, Bamba S, Ban H, Andoh A, Miyazaki Y. Comparison of energy metabolism and nutritional status of hospitalized patients with Crohn's disease and those with ulcerative colitis. J Clin Biochem Nutr 2015; 56:208-14. [PMID: 26060351 PMCID: PMC4454083 DOI: 10.3164/jcbn.14-95] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 10/06/2014] [Indexed: 12/18/2022] Open
Abstract
This study aimed to compare the nutritional status and energy expenditure of hospitalized patients with Crohn’s disease (CD) and those with ulcerative colitis (UC). Twenty-two hospitalized patients with CD and 18 patients with UC were enrolled in this study. We analyzed nutritional status upon admission by using nutritional screening tools including subjective global assessment, malnutrition universal screening tool, and laboratory tests. We measured resting energy expenditure (mREE) of the patients with indirect calorimetry and predicted resting energy expenditure (pREE) was calculated by using the Harris-Benedict equation. Results presented here indicate no significant difference in nutritional parameters and energy metabolism between CD and UC patients. In UC patients, a significant correlation was observed between mREE/body weight and disease activity detected by the Lichtiger and Seo indices. However, there was no correlation between mREE/body weight and Crohn’s disease activity index in CD patients. Inflammatory cytokine interleukin-6 levels correlated with mREE/pREE in CD and UC patients while tumor necrosis factor-α was not. In conclusion, energy expenditure significantly correlated with disease activity in UC patients but not in CD patients. These results indicate that establishing daily energy requirements based on disease activity of UC is imperative for improving the nutritional status of patients.
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Affiliation(s)
- Azusa Takaoka
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan ; Kyoto Women's University, Graduate School of Home Economics, 35 Kitahiyoshi-cho, Imakumano, Higashiyama-ku, Kyoto 605-8501, Japan
| | - Masaya Sasaki
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | - Mika Kurihara
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | - Hiromi Iwakawa
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | - Mai Inoue
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | - Shigeki Bamba
- Department of Medicine, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | - Hiromitsu Ban
- Department of Medicine, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | - Yoshiko Miyazaki
- Kyoto Women's University, Graduate School of Home Economics, 35 Kitahiyoshi-cho, Imakumano, Higashiyama-ku, Kyoto 605-8501, Japan
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No relation between disease activity measured by multiple methods and REE in childhood Crohn disease. J Pediatr Gastroenterol Nutr 2012; 54:271-6. [PMID: 21921807 DOI: 10.1097/mpg.0b013e318236b19a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Sasaki M, Johtatsu T, Kurihara M, Iwakawa H, Tanaka T, Tsujikawa T, Fujiyama Y, Andoh A. Energy metabolism in Japanese patients with Crohn's disease. J Clin Biochem Nutr 2009; 46:68-72. [PMID: 20104267 PMCID: PMC2803135 DOI: 10.3164/jcbn.09-55] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 08/08/2009] [Indexed: 12/14/2022] Open
Abstract
We investigated energy expenditure in hospitalized patients with Crohn’s disease (CD), and determined optimal energy requirements for nutritional therapy. Sixteen patients (5 women and 11 men, mean age 36 year old, mean BMI 18.7 kg/m2) and 8 healthy volunteers were enrolled in this study. Measured resting energy expenditure (mREE) levels were determined by indirect calorimetry. The mREEs in CD patients were significantly higher than those of healthy controls (24.4 ± 2.4 kcal/kg/day vs 21.3 ± 1.7 kcal/kg/day). However, mREEs in CD patients were significantly lower than predicted REEs (pREEs) calculated by the Harris-Benedict equation (26.4 ± 2.5 kcal/kg/day). Furthermore, mREE/pREE values were lower in undernourished patients than in well-nourished patients. CD patients had hyper-metabolic statuses evaluated by mREE/body weight, but increased energy expenditure did not contribute to weight loss in these patients. In conclusion, nutritional therapy with 25–30 kcal/ideal body weight/day (calculated by mREE × active factor) may be optimal for active CD patients, while higher energy intake values pose the risk of overfeeding.
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Affiliation(s)
- Masaya Sasaki
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu 520-2192, Japan
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Van Gossum A, Cabre E, Hébuterne X, Jeppesen P, Krznaric Z, Messing B, Powell-Tuck J, Staun M, Nightingale J. ESPEN Guidelines on Parenteral Nutrition: gastroenterology. Clin Nutr 2009; 28:415-27. [PMID: 19515465 DOI: 10.1016/j.clnu.2009.04.022] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 04/29/2009] [Indexed: 12/14/2022]
Abstract
Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.
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Affiliation(s)
- André Van Gossum
- Hôpital Erasme, Clinic of Intestinal Diseases and Nutrition Support, Brussels, Belgium
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Hartman C, Eliakim R, Shamir R. Nutritional status and nutritional therapy in inflammatory bowel diseases. World J Gastroenterol 2009; 15:2570-8. [PMID: 19496185 PMCID: PMC2691486 DOI: 10.3748/wjg.15.2570] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Underweight and specific nutrient deficiencies are frequent in adult patients with inflammatory bowel disease (IBD). In addition, a significant number of children with IBD, especially Crohn’s disease (CD) have impaired linear growth. Nutrition has an important role in the management of IBD. In adults with CD, enteral nutrition (EN) is effective in inducing clinical remission of IBD, although it is less efficient than corticosteroids. Exclusive EN is an established primary therapy for pediatric CD. Limited data suggests that EN is as efficient as corticosteroids for induction of remission. Additional advantages of nutritional therapy are control of inflammation, mucosal healing, positive benefits to growth and overall nutritional status with minimal adverse effects. The available evidence suggests that supplementary EN may be effective also for maintenance of remission in CD. More studies are needed to confirm these findings. However, EN supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in CD. EN does not have a primary therapeutic role in ulcerative colitis. Specific compositions of enteral diets-elemental diets or diets containing specific components-were not shown to have any advantage over standard polymeric diets and their place in the treatment of CD or UC need further evaluation. Recent theories suggest that diet may be implicated in the etiology of IBD, however there are no proven dietary approaches to reduce the risk of developing IBD.
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Vaisman N, Dotan I, Halack A, Niv E. Malabsorption is a major contributor to underweight in Crohn's disease patients in remission. Nutrition 2009; 22:855-9. [PMID: 16928471 DOI: 10.1016/j.nut.2006.05.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Revised: 04/30/2006] [Accepted: 05/10/2006] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Undernutrition has been reported in 65-75% of patients with Crohn's disease. The present study aimed at identifying the relative contribution of malnutrition-causing factors in patients with Crohn's disease in remission. METHODS Sixteen patients with Crohn's disease (age 19-57 y) in remission (Crohn's Activity Disease Index < 150) were included in the study. Their weight was stable for >3 mo and they were off steroids. They all completed 3-d food records and concomitantly collected stools. Self-reported food records were analyzed and energy content in stools was determined by a direct bomb calorimeter. Resting energy expenditure (REE) was studied by indirect calorimetry and body composition by dual-energy X-ray absorptiometry. The study cohort was divided into two groups, with a body mass index (BMI) equal to 18.5 kg/m(2) serving as a cutoff point. RESULTS Subjects with lower BMIs tended to have less lean body mass (P = 0.006), less bone mineral density (P = 0.006), and lower REE (P = 0.003). No correlation was found between BMI and energy intake but the percentage of malabsorption was negatively correlated with BMI (P = 0.07). When dividing the study based on a BMI of 18.5 kg/m(2), no difference was found in caloric intake or REE between groups but subjects with lower BMIs had significant prominent malabsorption compared with the others (21.1 +/- 9.8% versus 11.7 +/- 3.5%, P = 0.015). CONCLUSION In the presence of similar energy intake, REE does not seem to contribute to lower BMI, although nutrient malabsorption is higher in malnourished patients with Crohn's disease in remission. We suggest that malabsorption be evaluated in patients with Crohn's disease who fail to gain weight during disease remission to establish their extra caloric requirements.
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Affiliation(s)
- Nachum Vaisman
- Unit of Clinical Nutrition, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Aghdassi E, Wendland BE, Stapleton M, Raman M, Allard JP. Adequacy of nutritional intake in a Canadian population of patients with Crohn's disease. ACTA ACUST UNITED AC 2007; 107:1575-80. [PMID: 17761234 DOI: 10.1016/j.jada.2007.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Indexed: 12/12/2022]
Abstract
Crohn's disease is frequently associated with nutritional deficiencies, often a result of disease activity and poor oral intake. This study investigated the adequacy of dietary intake, based on the Canadian Dietary Reference Intake, in ambulatory patients with Crohn's disease and a normal body mass index (BMI; calculated as kg/m(2)). This was a cross-sectional study of 74 patients with mean age of 35.7+/-1.4 years and BMI of 23.05+/-0.45. All patients completed a 7-day food record and a diary for the Crohn's Disease Activity Index. Mean Crohn's Disease Activity Index was 138.99+/-11.38. Energy and protein intakes were within the recommended levels of intake, but total carbohydrates, fat, and saturated fat intake exceeded the recommended levels of <55%, <35%, and <10% in 39.2%, 27%, and 59.5% of the patients, respectively. Micronutrient intakes were suboptimal most notably for folate, vitamins C, E, and calcium. There were no substantial differences between patients with active and inactive disease in terms of failure to meet the Dietary Reference Intake. In conclusion, in this population sample, a large number of ambulatory patients with Crohn's disease have suboptimal dietary patterns despite a normal BMI and inactive disease. Dietary counseling and supplementation may be warranted in this patient population.
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Abstract
Crohns disease is an inflammatory bowel disease that can have a significant impact on the health of those afflicted. The etiology of the disease is unknown, but genetic, environmental, dietary, and immunological factors are thought to be involved. Multiple nutrients can become depleted during active disease due to inadequate intake or malabsorption. Preventing these deficiencies is paramount in the care of those suffering from Crohns disease. Often the traditional treatments (medications) have limited effectiveness and negative side effects that inhibit their use. Enteral nutrition has promising therapeutic benefits, but its use is often limited to the pediatric population due to poor patient acceptability. Omega-3 fatty acids have been investigated for their anti-inflammatory properties as an alternative to traditional care. This article reviews the etiology of Crohns disease, nutritional deficiencies, traditional treatments, and the use of omega-3 fatty acids in the prevention of Crohns recurrence. The results from clinical trials have been conflicting, but a new fish oil preparation that limits the side effects of traditional fish oil therapy shows promise as an adjunctive treatment for Crohns disease. Continued research is needed to validate these findings.
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Affiliation(s)
- Angie Macdonald
- St. John Hospital and Medical Center, Detroit, Michigan 48236, USA.
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Lochs H, Dejong C, Hammarqvist F, Hebuterne X, Leon-Sanz M, Schütz T, van Gemert W, van Gossum A, Valentini L, Lübke H, Bischoff S, Engelmann N, Thul P. ESPEN Guidelines on Enteral Nutrition: Gastroenterology. Clin Nutr 2006; 25:260-74. [PMID: 16698129 DOI: 10.1016/j.clnu.2006.01.007] [Citation(s) in RCA: 233] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Accepted: 01/13/2006] [Indexed: 12/18/2022]
Abstract
Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.
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Affiliation(s)
- H Lochs
- Department of Gastroenterology, Charité-Universitätsmedizin, CCM, Berlin, Germany.
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Alberda C, Graf A, McCargar L. Malnutrition: etiology, consequences, and assessment of a patient at risk. Best Pract Res Clin Gastroenterol 2006; 20:419-39. [PMID: 16782522 DOI: 10.1016/j.bpg.2006.01.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Malnutrition results from the imbalance of nutrients and energy provided to the body (too low), relative to its needs (too high). These needs increase dramatically with illness. This is certainly the case for patients with gastrointestinal diseases. Sub-optimal dietary intake, metabolic stress, malabsorption and increased nutrient demands, put a patient with gastrointestinal disease, at high-risk for malnutrition. The causes, consequences and assessment and monitoring indicators of malnutrition are reviewed herein.
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Affiliation(s)
- Cathy Alberda
- Royal Alexandra Hospital, Capital Health Region, 670-1 CSC, 10240 Kingsway Ave, Edmonton, Alta., Canada T5H 3V9.
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Al-Jaouni R, Schneider SM, Piche T, Rampal P, Hébuterne X. Effect of steroids on energy expenditure and substrate oxidation in women with Crohn's disease. Am J Gastroenterol 2002; 97:2843-9. [PMID: 12425558 DOI: 10.1111/j.1572-0241.2002.07032.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Patients with Crohn's disease (CD) have increased energy expenditure and fat oxidation. Steroids, commonly used to treat flare-up of CD, induce weight gain. This study was designed to evaluate the effects of prednisone and budesonide on energy expenditure and substrate oxidation in patients with CD. METHODS Twenty-nine women with CD and 10 healthy controls were studied. Ten patients received prednisone (0.75-1.0 mg/kg/day), nine received budesonide (9 mg/ day), and 10 did not receive steroids. Resting energy expenditure and substrate oxidation were measured by indirect calorimetry in a fasting state and after a standard diet. RESULTS In the fasting state, resting energy expenditure was higher in patients without steroids than in the controls. Lipid oxidation was lower (p < 0.01) in patients with prednisone (0.46 +/- 0.39 mg/kg/min) than in patients with budesonide (0.97 +/- 0.28 mg/kg/min) and without steroids (1.06 +/- 0.32 mg/kg/min), but was similar with control subjects (0.47 +/- 0.20 mg/kg/min). Postprandially, lipid oxidation was lower (p < 0.01) in patients with prednisone (0.32 +/- 0.23 mg/kg/min) than in patients with budesonide (0.75 +/- 0.20 mg/kg/min), without steroids (0.82 +/- 0.23 mg/kg/min), and controls (0.58 +/- 0.15 mg/kg/min). Protein oxidation was significantly higher in patients with prednisone than in the other subjects. CONCLUSIONS In women with CD, prednisone decreases lipid oxidation and increases protein oxidation. These effects are not observed with budesonide and may contribute to the weight gain and side effects commonly observed with prednisone. A low-fat/high-protein diet could be proposed during a course of prednisone.
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Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002. [PMID: 11841046 DOI: 10.1177/0148607102026001011] [Citation(s) in RCA: 365] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Blain A, Cattan S, Beaugerie L, Carbonnel F, Gendre JP, Cosnes J. Crohn's disease clinical course and severity in obese patients. Clin Nutr 2002; 21:51-7. [PMID: 11884013 DOI: 10.1054/clnu.2001.0503] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Obesity is unusual in Crohn's disease and the particularities of the disease in obese patients have not been studied. METHODS 2065 patients were studied retrospectively. Obesity was defined by a BMI value >25.0 at disease onset and >30.0 at any time during the course of the disease. Disease characteristics, therapeutic needs, and year-by-year disease activity were determined in patients with and without obesity. RESULTS 62 patients (3%) were obese. When compared with non-obese patients, obese patients did not show differences regarding sex, intestinal disease location, and disease behavior, but at diagnosis they were older (32 vs 28 years, P = 0.01) and a larger proportion had anoperineal disease (35 vs 24%, P = 0.03). When the 62 obese patients were paired for sex, location of disease at onset, date of birth, and date of diagnosis with 124 non-obese patients, the disease severity assessed by the importance of medical therapy and excisional surgery did not differ in the two groups but time to development of anoperineal abscess or fistula was shorter in obese patients, and obese patients were more prone to develop an active disease (OR 1.50, 95% CI 1.07-2.11) and to require hospitalization (OR 2.35, 95% CI 1.56-3.52) CONCLUSION Obesity in Crohn's disease is associated with more frequent anoperineal complications and a more marked year-by-year disease activity, but does not alter significantly the long-term course of the disease.
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Affiliation(s)
- A Blain
- Service de Gastroentérologie et Nutrition, Hôpital Rothschild, 33 Boulevard de Picpus, Paris, France
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26
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Abstract
Nutritional derangements are frequent in inflammatory bowel disease. In the past year significant work has been published examining the mechanisms of impaired food intake in animal models of inflammatory bowel disease, which allow a better understanding of these processes. Data from the same laboratory have shed further light on the relative role of underfeeding and inflammation on the growth retardation associated with intestinal inflammation. Other studies have provided further data on the risk factors and predictive biomarkers of bone loss in patients with inflammatory bowel disease. The potential role of enteral nutrition as primary therapy for Crohn's disease is particularly addressed in this review. Recent contributions to the field emphasized the special importance of this modality of therapy in paediatric patients. The possible mechanisms for such a therapeutic action are not well understood. Other nutrients may have a therapeutic potential in inflammatory bowel disease. In particular, recent data on the in-vivo anti-inflammatory actions of butyrate merit special mention. Finally, novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta2-enriched enteral feeding, or hydrothermally processed cereals have recently been explored.
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Affiliation(s)
- M A Gassull
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain.
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27
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Abstract
Nutritional derangements are frequent in inflammatory bowel disease. In the last year, significant work was published examining the mechanisms of impaired food intake in animal models of inflammatory bowel disease, which allow a better understanding of these processes. These data have shed new light on the relative role of underfeeding and inflammation on the growth retardation associated with intestinal inflammation. Other studies have provided further information on the risk factors and predictive biomarkers of bone loss in patients with inflammatory bowel disease. The potential role of enteral nutrition as primary therapy for Crohn disease is particularly addressed in the present review. Recent contributions emphasized the special importance of this therapeutic modality in pediatric patients, but the possible mechanisms for such therapeutic effect are still not well understood. Other nutrients may have a therapeutic potential in inflammatory bowel disease. In particular, recent data on the in vivo antiinflammatory action of butyrate merit special mention. Finally, novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta2-enriched enteral feeding or hydrothermally processed cereals, have recently been explored.
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Affiliation(s)
- E Cabré
- Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
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28
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Abstract
Nutrition plays an important role in Crohn's disease. This review provides further insights into the relationship between nutrition and Crohn's disease and focuses on three different aspects: dietary aetiological factors, nutritional status and nutritional therapy in Crohn's disease.
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Al-Jaouni R, Hébuterne X, Pouget I, Rampal P. Energy metabolism and substrate oxidation in patients with Crohn's disease. Nutrition 2000; 16:173-8. [PMID: 10705071 DOI: 10.1016/s0899-9007(99)00281-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Weight loss and malnutrition are common features in patients with Crohn's disease. This study was designed to evaluate diet-induced thermogenesis and substrate oxidation in patients with Crohn's disease. Twenty-three patients (17 women, 6 men; age 34 +/- 2 y) and 17 healthy control subjects (13 women, 4 men; age 36 +/- 3 y) were studied. Resting energy expenditure and fasting substrate oxidation were measured by indirect calorimetry in the morning after an overnight fast. After a standard homogenized test meal (10 kcal/kg), indirect calorimetry was performed every 30 min for 3 h to measure the diet-induced thermogenesis and the postprandial substrate oxidation. In the fasting state, resting energy expenditure was significantly higher in patients than in control subjects (1433 +/- 43 versus 1279 +/- 53 kcal/24 h). Lipid oxidation was higher in patients with Crohn's disease than in control subjects (1.17 +/- 0. 07 versus 0.61 +/- 0.11 mg. kg(-1). min(-1), P < 0.01). Postprandially, diet-induced thermogenesis was significantly lower in patients with Crohn's disease than in control subjects (4.6% +/- 0.5 versus 6.3% +/- 0.5 of energy intake, P < 0.01). Lipid oxidation was significantly higher in patients with Crohn's disease than in control subjects (0.78 +/- 0.05 versus 0.56 +/- 0.08 mg. kg(-1). min(-1), P < 0.05), and glucose oxidation was lower in patients with Crohn's disease than in control subjects. In patients with Crohn's disease, lipid oxidation positively correlates with the disease activity evaluated by the Crohn's Disease Activity Index (r = 0.48, P150), fasting and postprandial lipid oxidation was significantly higher than in patients with inactive Crohn's disease (P < 0.05). In conclusion, patients with Crohn's disease have increased fat oxidation, which correlates with disease activity and this may explain the reduced fat stores in patients with Crohn's disease.
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Affiliation(s)
- R Al-Jaouni
- Gastroenterology, Unit of Nutrition, Archet Hospital, Nice, France
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Geerling BJ, Stockbrügger RW, Brummer RJ. Nutrition and inflammatory bowel disease: an update. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1999; 230:95-105. [PMID: 10499469 DOI: 10.1080/003655299750025615] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic inflammatory process, the aetiology of which remains unknown. Nutrition may play an important role in the pathogenesis and treatment of IBD. The evidence regarding the role of specific dietary components in the pathogenesis of IBD is still inconclusive. Many studies have been subject to methodological limitations; studies of better design are necessary to confirm the hypothesis that nutritional factors may indeed play a role in the development of IBD. Several studies have reported nutritional and functional deficiencies in IBD patients, especially in Crohn's disease. It is, however, hard to discriminate between disease-induced and malnutrition-induced changes in nutritional parameters. Maintaining adequate nutritional status has been suggested to be beneficial to the course of the disease in IBD. Studies have provided further insight into the possible beneficial effects of nutritional supplementation as primary and adjunctive therapy in IBD. The effects of specific nutritional therapy may be caused by alterations in intestinal flora and hence in the production of intraluminal proinflammatory substances. Immunonutrients such as n-3 fatty acids and antioxidants may also play a role in the treatment of IBD. In this paper, the relation between nutritional aetiological factors, nutritional status and nutritional therapy is discussed in detail.
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Affiliation(s)
- B J Geerling
- Dept. of Gastroenterology and Hepatology, University Hospital Maastricht, The Netherlands
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Han PD, Burke A, Baldassano RN, Rombeau JL, Lichtenstein GR. Nutrition and inflammatory bowel disease. Gastroenterol Clin North Am 1999; 28:423-43, ix. [PMID: 10372275 DOI: 10.1016/s0889-8553(05)70063-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This article reviews the nutritional aspects of inflammatory bowel disease (IBD) including the mechanisms and manifestations of malnutrition and the efficacy of nutritional therapies. Nutrient deficiencies in patients with IBD occur via several mechanisms and may complicate the course of the disease. Nutritional status is assessed by clinical examination and the use of nutritional indices such as the Subjective Global Assessment of nutritional status. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted, especially in patients presumed to need parenteral nutrition.
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Affiliation(s)
- P D Han
- University of Pennsylvania School of Medicine, Philadelphia, USA
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Affiliation(s)
- R L Fisher
- Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Capristo E, Addolorato G, Mingrone G, Greco AV, Gasbarrini G. Effect of disease localization on the anthropometric and metabolic features of Crohn's disease. Am J Gastroenterol 1998; 93:2411-9. [PMID: 9860401 DOI: 10.1111/j.1572-0241.1998.00696.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We conducted this study to evaluate the effect of disease localization on the anthropometric and metabolic characteristics of inactive Crohn's disease (CD). METHODS Forty-three patients with biopsy or radiology proven CD (23 men; age, 33.8 yr; range, 18-54 yr) in clinical remission (simplified Crohn's diseases activity index [SCDAI] < 3) and not receiving steroid therapy or nutritional support were enrolled in the study. Patients were separated into three subgroups according to disease localization: ileal (n = 16), ileo-colonic (n = 13), and colonic CD (n = 14). Sixty healthy volunteers (26 men; age, 32.0 yr; range, 18-60 yr), matched for age and height were used as control subjects. Body composition was assessed by both anthropometry and bioimpedance analysis and indirect calorimetry was performed to measure energy expenditure and substrate oxidation rates. RESULTS CD patients showed a lower body weight than controls, both as a whole (61.5 kg; range, 41.5-74.0 vs 66.9 kg; range, 55.0-86.0 kg; p < 0.001) and separated by disease localization (ileal; p < 0.001; ileo-colonic; p < 0.001; and colonic; p < 0.05 vs controls). Fat-free mass (FFM) did not differ between the groups, whereas fat mass was significantly lower in CD patients than in controls (p < 0.001), with the lowest values in ileal and ileo-colonic patients. Basal metabolic rate by kg of FFM was higher in CD patients than in healthy individuals (p < 0.01). Nonprotein respiratory quotient was significantly lower in CD than in controls as a whole (0.79; range, 0.73-0.84 vs 0.83; range, 0.79-0.89; p < 0.001) or separated by disease localization (p < 0.001 each subgroup vs controls), with a consequent higher lipid oxidation rate. A lower dietary lipid intake was found in patients than in controls (p < 0.01). CONCLUSIONS Regardless of disease localization, CD patients showed a lower fat mass and a higher utilization of lipids than control subjects. Patients with ileal and ileo-colonic disease showed the greater reduction in body weight, compared with control subjects, suggesting they were at a higher risk of malnutrition, probably as a consequence of the simultaneous occurrence of both malabsorption and decreased energy intake.
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Affiliation(s)
- E Capristo
- Department of Internal Medicine, Catholic University of Rome, Italy
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Duerksen DR, Nehra V, Bistrian BR, Blackburn GL. Appropriate nutritional support in acute and complicated Crohn's disease. Nutrition 1998; 14:462-5. [PMID: 9614313 DOI: 10.1016/s0899-9007(98)00019-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Crohn's disease is frequently complicated by protein-calorie malnutrition. Four common clinical presentations of Crohn's disease include acute exacerbations or flares of disease, intestinal obstruction, fistulizing disease, and perianal disease. In this review, we examine the role of nutritional support in these clinical scenarios. Nutritional support is important for maintaining functional status and preventing loss of lean tissue. Determinants of lean-tissue loss include severity of underlying injury, baseline nutritional status, and duration of inadequate nutrition. One of the clinically useful measures of nutritional status is the nutritional risk index (NRI) defined on the basis of the serum albumin and weight loss. Nutritional support is important in severely malnourished patients (NRI < 83). Enteral nutrition is the route of choice, provided there are no contraindications to using the gastrointestinal tract. In acute exacerbations of Crohn's disease, enteral nutrition also has a role in the primary management of disease although it is not as effective as corticosteroids in inducing remission. The mechanisms are poorly understood and the most effective enteral formulation needs to be determined. Total parenteral nutrition is justified in severely malnourished Crohn's disease patients who are unable to tolerate enteral feeding or in whom enteral feeding is contraindicated. More clinical studies are needed on the assessment of malnutrition in Crohn's disease, the effects of nutritional management on functional status, and the timing of nutritional intervention.
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Affiliation(s)
- D R Duerksen
- Department of Medicine, Beth Israel Deaconess Hospital, Boston, Massachusetts, USA
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Capristo E, Mingrone G, Addolorato G, Greco AV, Gasbarrini G. Metabolic features of inflammatory bowel disease in a remission phase of the disease activity. J Intern Med 1998; 243:339-47. [PMID: 9651555 DOI: 10.1046/j.1365-2796.1998.00254.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the anthropometric and metabolic characteristics of patients with Crohn's disease (CD) and ulcerative colitis (UC), comparing both groups with healthy volunteers. DESIGN A cross-sectional study. SETTING The Department of Internal Medicine, Catholic University Hospital, Rome, Italy. SUBJECTS Thirty-four patients with biopsy-proven inflammatory bowel disease (18 CD; 16 UC) in clinical remission (SCDAI < 3 and Powell-Tuck index < 4) not receiving steroid therapy. INTERVENTIONS All patients had a clinical examination. MAIN OUTCOME MEASURES Blood indicators of inflammation and nutritional status. Body composition was assessed by both anthropometry and bioimpedance and metabolic variables were measured by indirect calorimetry over a 60-90 min period. RESULTS CD had a lower body weight than both controls (58.1 kg, range 41.5-71.0 vs. 66.4 kg, range 57.0-76.0; P < 0.001) and UC) 58.1 kg, range 41.5-71.0 vs. 69.6 kg, range 50.5-94.0; (P < 0.001). Fat-free mass (FFM) did not differ between the groups, whilst fat mass was significantly lower in CD than in UC (P < 0.05) and controls (P < 0.001). Normalizing the basal metabolic rate by FFM, a higher value was found in CD compared with UC (143 kJ kg-1) d-(-1), range 97.5-179 vs. 133 kJ kg-1 d-1, range 123-148; P < 0.05) and control subject 143 kj kg-1 d-1, range 97.5-179 vs. 134 kj kg-1 d-1, range 122-162; P < 0.05). The nonprotein respiratory quotient was significantly lower in CD compared to UC 0.80, range 0.73-0.84 vs. 0.84, range 0.79-0.91; P < 0.01) and controls (0.80, range 0.73-0.84 vs. 0.83, range 0.81-0.87; P < 0.001), with a consequently higher lipid oxidation rate in CD. CONCLUSIONS CD subjects showed a decreased fat mass and enhanced utilization of lipids compared with UC and controls. These data could be explained by the larger intestinal involvement and considered as a contribution to lipid tissue wasting in CD.
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Affiliation(s)
- E Capristo
- Department of Internal Medicine, Sacred Heart Catholic University, Rome, Italy
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Abstract
Although first described more than two centuries ago, the increase in energy expenditure associated with feeding (nutrient induced thermogenesis (NIT) is still incompletely understood. Although the magnitude of the response and the effect of varying the composition of the diet, route and rate of feeding is still the subject of controversy, the importance of taking into account NIT when designing an optimal feeding regimen is well recognised. What is currently unclear is the effect that injury or sepsis have on NIT. This is of clinical significance because it is precisely this group of patients in whom adequate nutritional support is most difficult to achieve yet most important. Despite significant differences in the metabolic response to feeding, NIT appears to be similar in septic patients and healthy subjects. Excessive use of intravenous glucose in such patients however may lead to marked increases in energy expenditure and stimulation of the sympathetic nervous system and should be avoided.
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Affiliation(s)
- G L Carlson
- Department of Surgery, North West Injury Research Centre, Hope Hospital, Salford, UK
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Tjellesen L, Staun M, Nielsen PK. Body composition changes measured by dual-energy X-ray absorptiometry in patients receiving home parenteral nutrition. Scand J Gastroenterol 1997; 32:686-90. [PMID: 9246709 DOI: 10.3109/00365529708996519] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND To monitor changes in body composition in patients receiving home parenteral nutrition (HPN) and to ascertain whether changes were related to the amount of energy supplied by HPN, we studied prospectively patients with gut failure maintained on HPN. METHODS Patients were subjected to repeated measurement of body composition by dual-energy X-ray absorptiometry (DXA), the second investigation being performed after a mean period of 20 (range, 11-26) months. Thirty-two patients were included, one patient was excluded, and five patients died during the study period. At inclusion, the patients had received HPN for a mean period of 30 (range, 6-216) months. The indication for HPN was inflammatory bowel disease (n = 16), abdominal cancers (n = 5), and scleroderma and others (n = 11). The fat-free mass (FFM), fat mass (FM), and total body mineral content (TBMC) were measured by DXA. RESULTS Mean body mass index decreased from 21.18 to 20.96 kg/m2 (P = 0.36). The mean FFM showed a small, insignificant increase to 37.68 kg (P = 0.71). Mean TBMC was unchanged at 2.28 kg, and mean FM decreased from 19.25 to 18.17 kg (P = 0.055). During the study period the mean daily energy supply by HPN was reduced from kcal 1195 to kcal 959 (P = 0.004). There was a direct positive correlation between the individual changes in HPN energy supply and body weight and FFM (r = 0.437, r = 0.410, P < 0.05). CONCLUSION The body composition of HPN patients was stable, with no change in mean FFM, FM, or TBMC. Individual changes in body weight and FFM correlated with change in HPN energy supply.
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Affiliation(s)
- L Tjellesen
- Dept. of Gastroenterology CA, Rigshospitalet, University of Copenhagen, Denmark
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Varille V, Cézard JP, de Lagausie P, Bellaiche M, Tounian P, Besnard M, Faure C, Aigrain Y, Girardet JP, Navarro J. Resting energy expenditure before and after surgical resection of gut lesions in pediatric Crohn's disease. J Pediatr Gastroenterol Nutr 1996; 23:13-9. [PMID: 8811517 DOI: 10.1097/00005176-199607000-00003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In pediatric Crohn's disease (CD), resection of gut lesions is necessary to remove stenoses and when frequent relapses occur despite nutritional support and medical treatment. After surgery, improved nutritional status and accelerated growth usually follow increased nutritional intake and lower doses of steroids. The aim of this study was to compare energy balance before and after surgery while nutritional intake and steroid therapy were unchanged. Eleven patients, aged 14.5 +/- 2.5 years and with mildly active CD, were explored 1 week before and 1 month after gut resection for stenosis (n = 7) and medical treatment failure (n = 4). Eleven matched children participated in the study as controls. Disease activity was assessed by the Pediatric Crohn's Disease Activity Index and serum orosomucoid concentration. Resting energy expenditure (REE) was measured by indirect calorimetry, and fat-free body mass (FFM) was measured by anthropometry. The patients' mean REE decreased from 46.6 +/- 10.5 kcal/kg FFM/day before surgery to 42.6 +/- 10.3 kcal/kg FFM/day after surgery, while the controls' mean REE was 39 +/- 7 kcal/kg FFM/day (analysis of variance, p = 0.02). After surgery, body weights were not significantly different, but the mean protein oxidation rate was reduced and arm muscle area was increased. Changes in REE per kilogram of FFM per day were not correlated with changes in orosomucoid serum concentrations (r2 = 0.35; p = 0.4). In conclusion, in children with mildly active CD, while nutritional intake and steroid therapy were maintained at preoperative levels, a significant decrease in REE and improved nitrogen utilisation were observed 1 month after resection of the CD gut lesion. This finding suggests better use of energy substrates when CD lesions are removed.
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Affiliation(s)
- V Varille
- Department of Pediatric Gastroenterology and Nutrition, Hôpital Robert Debré, Paris, France
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Mingrone G, Greco AV, Benedetti G, Capristo E, Semeraro R, Zoli G, Gasbarrini G. Increased resting lipid oxidation in Crohn's disease. Dig Dis Sci 1996; 41:72-6. [PMID: 8565769 DOI: 10.1007/bf02208586] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Resting energy expenditure (REE) was measured by indirect calorimetry and body composition was assessed by both direct (bioimpedance) and indirect (anthropometry) methods in 20 hospitalized patients with biopsy-proven ileal Crohn's disease and in a group of 16 healthy volunteers matched for sex, age, and height with the patient group. The Crohn's disease activity index was below 120 in all patients studied, who were treated with a low dose of corticosteroids (0.2-0.3 mg/kg body wt of prednisone). The average weight of Crohn's patients was significantly lower than that of controls (55.70 vs 70.50 kg, P < 0.001) due to both lower fat mass (9.97 vs 18.30 kg, P < 0.001) and lower lean body mass (45.72 vs 52.20 kg, P < 0.02). The average REE was significantly higher in the control group (1785.42 +/- 7.503 vs 1559.1 +/- 48.39 kcal/day, P < 0.001). However, these differences disappeared when REE was normalized by lean body mass (LBM) (34.49 +/- 2.56 vs 34.704 +/- 3.75 kcal/kg LBM P = NS). The nonprotein respiratory quotient was significantly lower in the patient group (0.823 +/- 0.031 vs 0.882 +/- 0.012, P < 0.025), indicating an increased lipid oxidation. This increased lipid oxidation might explain the reduced fat stores found in the group of Crohn's patients, suggesting also that a sufficiently lipid-rich diet could be useful in their nutritional management.
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Affiliation(s)
- G Mingrone
- Cattedra di Medicina Interna, Policlinico A. Gemelli, Universita Cattolica del Sacro Cuoro, Rome, Italy
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Fleming CR. Nutrition in patients with Crohn's disease: another piece of the puzzle. JPEN J Parenter Enteral Nutr 1995; 19:93-4. [PMID: 7609286 DOI: 10.1177/014860719501900293] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Royall D, Greenberg GR, Allard JP, Baker JP, Jeejeebhoy KN. Total enteral nutrition support improves body composition of patients with active Crohn's disease. JPEN J Parenter Enteral Nutr 1995; 19:95-9. [PMID: 7609287 DOI: 10.1177/014860719501900295] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Previous studies using indirect calorimetry in Crohn's disease have suggested that with weight loss there is a proportionally greater decrease in body fat along with a spring of lean mass. This study analyzed body composition (compared with that of controls) by direct methods in a group of 30 patients with active Crohn's disease and further evaluated the effects of nutrition support on body composition. METHODS Total body protein was assessed by neutron activation, fat was assessed by dual energy x-ray absorptiometry, water was assessed by bioelectric impedance analysis, and potassium was assessed by gamma-ray technique. These measurements were repeated in patients with Crohn's disease after 3 weeks of enteral nutrition by feeding tube that provided 35 nonprotein kcal/kg of ideal body weight. RESULTS Compared with age- and sex-matched controls, patients had lost (on average) 11.3 kg (16%) of body weight (p < .0005), including 5.1 kg (30%) of fat (p < .0005), 2.2 kg (19%) of protein (p < .025), 3.7 kg (10%) of water (p = NS), and 24.9 g (21%) of total body potassium (p < .01). After enteral feeding, body weight increased by 1.9 +/- 0.3 kg (p < .0005). Weight gain was accompanied by an increase in body protein (0.3 +/- 0.1 kg), fat (0.3 +/- 0.1 kg), and water (1.1 +/- 0.4 kg) (all p < .025), and by a nonsignificant increase in total body potassium. The weight gain of approximately 2 kg consisted of 65% water, 18% fat, and 18% protein, thus comprising a normal proportion of body composition. CONCLUSIONS Reduced body weight in patients with Crohn's disease compared with that in controls was due to less fat tissue. With modest nutritional repletion, proportionate gains in all body compartments are possible.
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Affiliation(s)
- D Royall
- Department of Medicine, University of Toronto, Ontario, Canada
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Abstract
The mechanisms of nutritional therapy in inflammatory bowel disease have not been thoroughly established. It is likely that a further understanding of the underlying disease process will allow better understanding of these forms of therapy, with a sounder rationale for the construction of specific diet constituents for therapy. Regardless, nutritional therapy is likely to be multidimensional, and various forms may affect different aspects of the disease process. Decreased inflammatory factors, decreased antigenic stimuli, provision of essential nutrients, improved immune function, and other factors may all be of varying importance in different patients with inflammatory bowel disease. Little work has been done on the role of diet therapy in the long-term treatment of patients with inflammatory bowel disease as a method of preventing relapse. Parenteral nutrition and elemental diets appear to have limited roles in this area. Some investigation has been done to see if minor modifications of the normal diet can prolong remission periods. Low-fiber diets are frequently recommended for patients with strictures. Whether this has any significant effect on symptoms, inflammation, or complications is unclear. Heaton et al suggested that a high-fiber, unrefined carbohydrate diet resulted in fewer and shorter hospitalizations. In a prospective follow-up study by Ritchie et al, however, these results were not able to be reproduced. Exclusion diets have also been suggested as a means of reducing relapse rates in patients with Crohn's disease. In a small, randomized, controlled trial of an exclusion diet versus an unrefined carbohydrate, fiber-rich diet, there were significantly fewer relapses among the patients treated with the exclusion diet at 6 months. These diets require intensive patient cooperation, but the potential side effects are minimal. Clearly, these findings need to be reproduced in large, prospective, randomized, controlled studies before widespread use can be advocated. A great deal of data exists on the use of nutritional supplementation in the treatment of inflammatory bowel disease, although little of it is in the form of large, randomized, controlled studies. Nutritional manipulation currently has a limited role in patients with ulcerative colitis; a much broader role exists in patients with Crohn's disease. The mechanisms by which nutritional therapy affects these diseases may include a combination of factors--decreased antigenic exposure, improved immune function, and provision of essential nutrients and calories needed for bowel regeneration.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- J D Lewis
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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