Inflammatory bowel diseases: principles of nutritional therapy

British Society of Gastroenterology endorsed guidance for the management of immune checkpoint inhibitor-induced enterocolitis

Immune checkpoint inhibitors are a novel class of cancer treatment that have improved outcomes for a subset of cancer patients. They work by antagonising inhibitory immune pathways, thereby augmenting immune-mediated antitumour responses. However, immune activation is not cancer-specific and often results in the activation of immune cells in non-cancer tissues, resulting in off-target immune-mediated injury and organ dysfunction. Diarrhoea and gastrointestinal tract inflammation are common and sometimes serious side-effects of this type of therapy. Prompt recognition of gastrointestinal toxicity and, in many cases, rapid institution of anti-inflammatory or biologic therapy (or both) is required to reverse these complications. Management of organ-specific complications benefits from multidisciplinary input, including engagement with gastroenterologists for optimal management of immune checkpoint inhibitor-induced enterocolitis. In this British Society of Gastroenterology endorsed guidance document, we have developed a consensus framework for the investigation and management of immune checkpoint inhibitor-induced enterocolitis.

Obesity Is More Common in Children Newly Diagnosed With Ulcerative Colitis as Compared to Those With Crohn Disease

OBJECTIVE

This prospective observational study aimed to examine the prevalence of obesity in a population-based cohort of children and young adults newly diagnosed with inflammatory bowel disease (IBD) and assess their outcome in comparison to newly diagnosed normal/underweight patients.

METHODS

Our longitudinal population-based cohort comprised all children younger than 17 years diagnosed with IBD in the province of Manitoba, Canada between 2012 and 2018. Cox regression model with adjustment for a priori covariates was used to examine the time to first relapse among patients who were obese/overweight at the time of IBD diagnosis in comparison to patients who were normal or underweight.

RESULTS

A total of 139 patients with IBD were followed up for a median duration of 1.09 (interquartile range: 0.53-2.62) years. Obesity was more common in children newly diagnosed with ulcerative colitis (UC) compared to those with Crohn disease (CD) (12.7% vs 0.0%; P = 0.005). Age at diagnosis poorly correlated with the body mass index z score (R = 0.23; P = 0.01). The proportions of patients who were underweight at the time of IBD diagnosis among patients with UC and CD were 6.3% and 20.0%, respectively (P = 0.01). The time to initial relapse was not found to be significantly associated with weight category at diagnosis in UC (adjusted hazard ratio = 0.77; 95% confidence interval: 0.40-1.63) or CD (adjusted hazard ratio  = 0.83; 95% confidence interval: 0.20-3.51).

CONCLUSION

Obesity was more common in children and young adults newly diagnosed with UC. The majority of the underweight children had CD.

Relationship between selenium status and biomarkers of oxidative stress in Crohn's disease

OBJECTIVE

Crohn disease (CD) is characterized by chronic intestinal inflammation and various factors involved in its pathogenesis including oxidative stress. The oxidative stress in CD may compromise antioxidant nutrients, such as selenium. The aim of this study was to assess the status of selenium and its relationship with markers of oxidative stress in patients with CD in comparison to controls.

METHODS

The study included 47 patients with CD (20 with active disease and 27 in remission) and 25 healthy individuals. Blood samples were collected for the analysis of plasma and erythrocyte selenium concentrations using inductively coupled plasma optical emission spectrometry (ICP-OES). Selenoprotein P (SepP) was evaluated by sandwich enzyme-linked immunosorbent assay, erythrocyte glutathione peroxidase (GPx1) activity was assessed by using an automatic biochemistry analyzer, and the concentration of thiobarbituric acid reactive substances (TBARS) was measured. Comparative analyses were performed using one-way analysis of variance and Tukey's post hoc test. For correlations, Pearson's coefficient test was used. The determinants for CD and lipid peroxidation were indicated by odds ratio.

RESULTS

Plasma and erythrocyte selenium levels and SepP concentrations were lower in the CD patient groups than in the healthy group. GPx1 activity and the concentration of TBARS were significantly higher in the CD groups. In the univariate analysis, plasma and erythrocyte selenium and TBARS were associated with CD.

CONCLUSION

Patients with CD have impaired selenium status, which is related to the increased oxidative stress observed in these patients.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Anti-inflammatory intestinal activity of Combretum duarteanum Cambess. in trinitrobenzene sulfonic acid colitis model

AIM

To evaluate the anti-inflammatory intestinal effect of the ethanolic extract (EtOHE) and hexane phase (HexP) obtained from the leaves of Combretum duarteanum (Cd).

METHODS

Inflammatory bowel disease was induced using trinitrobenzenesulfonic acid in acute and relapsed ulcerative colitis in rat models. Damage scores, and biochemical, histological and immunohistochemical parameters were evaluated.

RESULTS

Both Cd-EtOHE and Cd-HexP caused significant reductions in macroscopic lesion scores and ulcerative lesion areas. The vegetable samples inhibited myeloperoxidase increase, as well as pro-inflammatory cytokines TNF-α and IL-1β. Anti-inflammatory cytokine IL-10 also increased in animals treated with the tested plant samples. The anti-inflammatory intestinal effect is related to decreased expression of cyclooxygenase-2, proliferating cell nuclear antigen, and an increase in superoxide dismutase.

CONCLUSION

The data indicate anti-inflammatory intestinal activity. The effects may also involve participation of the antioxidant system and principal cytokines relating to inflammatory bowel disease.

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

OBJECTIVE:

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

DATA SOURCES:

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

RESULTS:

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

CONCLUSION:

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

Overweight and obesity in children with newly diagnosed inflammatory bowel disease

PURPOSE

Determination of overweight and obesity prevalence in children with inflammatory bowel disease (IBD) at the time of diagnosis.

MATERIAL AND METHODS

This was a multicenter retrospective study. The study group consisted of children with new cases of IBD diagnosed in 2005-2013 according to the Porto criteria. Hospital admission records were reviewed for demographic and clinical characteristics. BMI-for-age and gender percentile charts were used to define overweight as ≥85th BMI percentile and obesity as ≥95th BMI percentile.

RESULTS

675 patients were evaluated: 368 with Crohn's disease (CD) and 307 with ulcerative colitis (UC). Of these, 54.8% were boys and 45.2% were girls. There were no statistically significant differences in age, weight, height and disease activity between the CD and UC patients. The UC patients had higher BMI values than the CD patients. The prevalence of overweight and obesity was higher in the UC than the CD patients (4.89% CI95 2.76-7.93 vs. 2.45% CI95 1.12-4.59 and 8.47% CI95 5.61-12.16 vs. 1.9% CI95 0.77-3.88, respectively); the differences were statistically significant (-2.44% CI95 -5.45 to 0.49 and -6.57% CI95 -10 to -3.1, respectively). The risk of overweight/obesity was 3.5 times higher for patients with UC (OR=0.272, CI95 0.14-0.49, p=0.0004).

CONCLUSIONS

The prevalence of overweight and obesity in newly diagnosed children with IBD was 8.4% and was higher in patients with UC than in patients with CD. The results of this study have shown that not only malnourished children may suffer from IBD but also children who are overweight or obese at the time of diagnosis.

Association Between Inflammatory Bowel Disease and Vitamin D Deficiency: A Systematic Review and Meta-analysis

BACKGROUND

Vitamin D plays a role in several immune-mediated diseases, but its association with inflammatory bowel disease (IBD) is unclear. We conducted a systematic review and meta-analysis to assess the association between IBD and vitamin D deficiency.

METHODS

We searched electronic databases from inception to December 2014 for observational studies reporting the presence of vitamin D deficiency (defined as serum 25-hydroxycholecalciferol [25(OH)D] level of ≤20 ng/mL) in IBD patients and having a control group without IBD. Odds ratios (ORs) were combined using a random-effects model. Meta-regression was performed using latitude as a moderator. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

Out of 816 citations, 14 eligible studies were identified, comprising 1891 participants (938 IBD cases and 953 controls). Meta-analysis showed that patients with IBD had 64% higher odds of vitamin D deficiency when compared with controls (OR = 1.64; 95% confidence interval, 1.30-2.08; I = 7%; P < 0.0001). Patients with ulcerative colitis had more than double the odds of vitamin D deficiency when compared with normal controls (OR = 2.28; 95% confidence interval, 1.18-4.41; I = 41%; P = 0.01). Latitude did not influence the association between IBD and vitamin D deficiency (P = 0.34). Generalizability of our results might be limited as we summarized unadjusted ORs, because of nonavailability of adjusted ORs in individual studies.

CONCLUSIONS

IBD is significantly associated with having higher odds of vitamin D deficiency. Well-designed randomized controlled trials and longitudinal studies are needed to further explain the role of vitamin D in IBD pathogenesis and its therapy.

The role of enteral nutrition in patients with inflammatory bowel disease: current aspects

Enteral nutrition (EN) is considered to be of great importance in patients with inflammatory bowel disease (IBD) and nutritional problems. This comprehensive review is aiming to provide the reader with an update on the role of EN in IBD patients. EN can reduce Crohn's disease (CD) activity and maintain remission in both adults and children. Nutritional support using liquid formulas should be considered for CD patients and in serious cases of ulcerative colitis (UC), especially for those who may require prolonged cycles of corticosteroids. Given that the ultimate goal in the treatment of CD is mucosal healing, this advantage of EN over corticosteroid treatment is valuable in therapeutic decision-making. EN is indicated in active CD, in cases of steroid intolerance, in patient's refusal of steroids, in combination with steroids in undernourished individuals, and in patients with an inflammatory stenosis of the small intestine. No differences between the efficiency of elemental diets and nonelemental formulas have been noticed. EN must be the first choice compared to TPN. EN has a restricted value in the treatment of patients with large bowel CD. In conclusion, it seems important not to underestimate the role of nutrition as supportive care in patients with IBD.

Nutritional impact of inflammatory bowel diseases on children and adolescents

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

The role of total parenteral nutrition in inflammatory bowel disease: current aspects

Total parenteral nutrition (TPN) represents a therapeutic modality that could save the life of a patient with inflammatory bowel disease (IBD) facing severe nutritional problems, by restoring the patient's impaired nutritional status. TPN does not compete with enteral nutrition (EN), the latter being the first choice for all patients having anatomically intact and functionally normal digestive tract. TPN allows bowel rest while supplying adequate calorific intake and essential nutrients, and removes antigenic mucosal stimuli. The value of TPN in malnourished patients with intestinal failure due to CD is beyond doubt. However, it is difficult to suggest TPN as a sole treatment for active CD. An increased rate of remission could not be expected by applying TPN. The utility of TPN is restricted to certain cases involving efforts to close enterocutaneous or other complicated fistulas in patients with fistulizing CD, the treatment of short bowel syndrome following extensive resections for CD, or when EN is impractical for other reasons. There are no advantages of TPN therapy over EN therapy regarding fistula healing. TPN has no influence on the surgical intervention rate and little benefit by bypassing the intestinal passage could be expected. Also TPN shows no advantage if the disease is chronically active. However, an optimal supply of nutrients improves bowel motility, intestinal permeability and nutritional status, and reduces inflammatory reactions. TPN might be associated with an increased risk of adverse events, although TPN undertaken by experienced teams does not cause more complications than does EN.

Aspectos epidemiológicos das doenças intestinais inflamatórias na macrorregião de saúde leste do Estado de Minas Gerais

A doença de Crohn e a colite ulcerativa são entidades clínicas distintas, porém relacionadas, que se incluem no grupo das doenças intestinais inflamatórias. Esse artigo trata-se de um estudo epidemiológico a fim de descrever a produção do conhecimento em doenças inflamatórias intestinais, levando em consideração os casos de internações registrados, decorrentes do agravamento da doença, nas unidades de saúde da macrorregião de saúde leste do Estado de Minas Gerais. As doenças inflamatórias intestinais são consideradas um dos grandes problemas da população moderna, uma vez que geram repercussões importantes na qualidade de vida de seus portadores, acarretando alterações no âmbito social, psicológico e profissional. Durante o período de 1998 a 2005, foram registradas 363 internações hospitalares, em função das doenças intestinais inflamatórias, distribuídas em 184 e 179 casos nos gêneros masculino e feminino, respectivamente. Em função da escassez de estudos e do número de internações na macrorregião leste do Estado de Minas Gerais, pesquisas devem ser conduzidas a fim de delinear o perfil dos pacientes portadores de doenças inflamatórias intestinais, bem como detectar as possíveis alterações biopsicossociais a fim de promover uma assistência multiprofissional, humanizada e baseada em evidências.

Comparison between handgrip strength, subjective global assessment, anthropometry, and biochemical markers in assessing nutritional status of patients with Crohn's disease in clinical remission

INTRODUCTION

Crohn's disease (CD) may lead to protein and calorie malnutrition (PCM) secondary to impaired digestive and absorptive functions of the small intestine and sometimes to the influence of diet taboos. The earlier the PCM is diagnosed, the higher are the odds of reversal. The objective of this study was to compare different methods of nutritional assessment in patients with CD and correlate them with the disease characteristics.

SAMPLE

The sample comprised 75 patients with CD from the Gastroenterology Service at the Hospital de Clínicas de Porto Alegre; 37 were male, with a mean age of 38.2 years old (SD = 13.3). All patients had been in clinical remission (CDAI <150) for over 3 months. They were not receiving enteral or parenteral nutrition. The nutritional assessment was considered: body mass index (BMI), triceps skin fold (TSF), arm circumference (MAC), arm muscle circumference (MAMC), subjective global assessment (SGA), non-dominating handgrip strength (HGS) and food intake inquiries.

RESULTS

When comparing the different nutritional assessment methods, 26.7% of the patients were malnourished according to the MAC, 29.3% according to the MAMC, 18.7% according to the SGA, 6.7% according to the BMI, 37.3% according to the TSF and 73.3% according to the HGS. No statistically significant associations were found for disease location, its behavior, drugs utilized, ESR, CRP, age of patients and disease time with the nutritional state verified by HGS, TSF, MAMC and SGA.

CONCLUSION

The prevalence of malnutrition is significant in patients with CD, even in clinical remission. The BMI should not be used as reference in this population. The HGS detected a high prevalence of nutritional risk in patients with CD in remission. Studies are required that correlate it with more sensitive methods, for the patients' effective nutritional state assessment.

Nutrition and Crohn's disease: an update of print and Web-based guidance

This article reviews the role of nutrition in Crohn's disease, one of the inflammatory bowel diseases. In addition to presenting a comprehensive review of the state-of-the-evidence on nutritional risks and nutritional therapies in Crohn's disease, and making specific nutrient recommendations, this article includes a list of Web-based resources, including websites, blogs, newsletters, and multimedia podcasts that can be utilized by patients and healthcare providers alike to learn more about the etiology, pathophysiology, and nutritional management of Crohn's disease.

Nutritional therapy for active Crohn’s disease

Nutritional therapy for active Crohn’s disease (CD) is an underutilized form of treatment in adult patients, though its use is common in the paediatric population. There is evidence that nutritional therapy can effectively induce remission of CD in adult patients. Enteral nutrition therapy is safe and generally well tolerated. Meta-analysis data suggest that corticosteroids are superior to nutritional treatment for induction of remission in active CD. However, the potential side effects of such pharmacotherapy must be taken into consideration. This review examines the evidence for the efficacy of elemental and polymeric diets, and the use of total parenteral nutrition in active CD.

[Socioeconomic and nutritional profile of patients with inflammatory bowel disease at a university hospital]

BACKGROUND

Inflammatory bowel diseases include chronic and relapsing inflammatory disorders, represented by ulcerative proctocolitis and Crohns disease, commonly associated with malnutrition.

AIM

Characterize the nutritional and socioeconomic profile of patients hospitalized at the Pernambuco "Hospital das Clínicas", Recife, PE, Brazil.

METHODS

Cross-sectional study carried out at the gastroenterology clinic, which was previously approved by the Ethics Commission for studies involving human beings. The methods included clinical history data, socioeconomic conditions and nutritional assessment. Data were subject to statistical analysis (Students t test for equal and unequal variables).

RESULTS

The sample consisted of 24 male and female patients, with a mean age of 43.83 +/- 16.13 years, mostly married, coming from Recife, with low income, who lived in their own house with relatives. We found a higher prevalence of ulcerative proctocolitis (62.5%), with diagnosis time of more than 5 years, symptoms of abdominal pain, bloody-mucous diarrhea with 6-9 evacuations/day, with the distal colon being the most affected part. Osteoporosis was present in 26.7% of cases. Nutritional status was assessed through the body mass index. The weight loss percentage corresponded to 41.7% and 70.8%, respectively, classified as malnourished, associated or not with high prevalence levels of anemia, hypoalbuminemia and hypocalcemia. Gender correlation evidenced higher triceps fold and arm circumference values in men.

CONCLUSIONS

Despite the study limitations, data suggest relevant information about the occurrence of these diseases in the northeast of Brazil, as well as about its frequent association with important nutritional deficiencies.

A comprehensive approach to evaluate nutritional status in Crohn's patients in the era of biologic therapy: a case-control study

OBJECTIVES

Evaluate the nutritional status of patients with inactive or mildly active Crohn's disease (CD), and identify possible causes for potential deficiencies.

METHODS

A total of 78 CD patients and 80 healthy controls were evaluated in respect of nutritional status, dietary intake, and life styles factors.

RESULTS

These 73/78 CD patients were on immunomodulating therapies. Mean body mass index (BMI) was lower in patients as compared to controls (P= 0.006) but 32% of CD patients and 33.8% of controls had a BMI > 25, whereas 8% and 23.8% in each group, respectively, were obese (BMI > 30Kg/m(2)). Fat free mass was significantly decreased in both genders (P < 0.05) whereas fat mass was decreased only in males (P= 0.01). Energy intake was significantly lower in CD patients (P < 0.0001) and we observed significantly lower adjusted mean daily intakes of carbohydrates, monounsaturated fat, fiber, calcium, and vitamins C, D, E, and K (P < 0.05). 29% of patients had excluded grains from their usual diet, 28% milk, 18% vegetables, and 11% fruits. Milk exclusion resulted in a significantly lower consumption of calcium and vitamin K (P < 0.001) and the exclusion of vegetables was associated to a lower consumption of vitamins C and E (P < 0.05). Physical activity was significantly lower in CD patients (P= 0.01) and this lack of physical activity was inversely correlated with increased fat mass percentage (r=-0.315, P= 0.001).

CONCLUSIONS

Results showed that the most prevalent form of malnutrition in CD patients was an excess of body weight, which was concomitant with an inadequate dietary intake, namely micronutrients, clearly related to dietary exclusion of certain foods.

Polymeric formula has direct anti-inflammatory effects on enterocytes in an in vitro model of intestinal inflammation

Exclusive enteral nutrition using polymeric formula (PF) is a well-established therapeutic option for active Crohn's disease; however, its mechanisms of action are unknown. We investigated the anti-inflammatory effects of PF in an in vitro model of epithelial cell inflammation. PF did not affect cell viability over a range of dilutions, but when PF was added to the culture medium the interleukin (IL)-8 response to proinflammatory stimuli was significantly reduced. This effect was due to PF acting directly on the cells as the IL-8 response was still reduced when PF was separated from the proinflammatory stimuli in a 2-compartment system. In the presence of PF, nuclear factor (NF)-kappaB nuclear migration was not inhibited; however, IkappaBalpha degradation was delayed. PF has direct anti-inflammatory effects upon immortalized colonic enterocytes. Therefore PF may, in part, modulate gut inflammation by directly reducing the inflammatory response of the intestinal epithelium.