managing crohns disease through nutritional intervention kristy singlestad concordia college...

Managing Crohn’s Disease through Nutritional Intervention

Kristy SinglestadConcordia CollegeMoorhead, MN

ObjectivesBe able to describe Crohn’s

diseaseIdentify common nutrient

deficiencies in Crohn’s diseaseBe able to describe treatment

goals for Crohn’s diseaseIdentify the medical nutrition

therapy for Crohn’s disease

Anatomy of Gastrointestinal System Oral cavityEsophagusStomachSmall intestine

◦ Duodenum◦ Jejunum◦ Ileum

Large intestineRectumAnus

Inflammatory Bowel Diseases (IBD)

Ulcerative Colitis

Only involves colon

Affects only mucosa layer of intestine

Continuous distribution of inflammation

Crohn’s Disease

Involves any part of digestive tract

Affects all layers of intestine

Patches of inflammation

Source: Crohn’s and Colitis Foundation of America (2009)

Crohn’s Disease (CD)A chronic inflammatory bowel disease

(IBD) affecting any part of the gastrointestinal tract from mouth to anus

Also known as regional enteritisIleum and colon most commonly

affectedNo cure, but treatments available

Definition continued…May damage all 3 layers of GI

tractMay cause fistula and abscessCauses nutritional problems

Disease PathologyApproximately ½ million

Americans are currently diagnosed with Crohn’s disease

Affects children and adultsPrevalence higher in North

America and Northern European countries

Common among American Jews of European descent, African Americans, and whites Source: Crohn’s and Colitis Foundation of America

(2009)

CausesUnknown causePossible causes:

◦Autoimmune response◦Environmental triggers

Smoking Infectious agents Intestinal flora

◦Genetics ~20% have a relative with IBD

SymptomsAbdominal pain, lower right

quadrantDiarrheaLoss of appetiteFeverRectal bleedingWeight loss

5 Types of Crohn’s DiseaseIleocolitis – ileum and colonIleitis – ileum only Gastroduodenal – stomach and

duodenum Jejunoileitis - jejunumCrohn’s colitis – colon only

Crohn’s Disease Activity Index

Criteria used to identify the disease progression of CD patients ◦<150 inactive disease◦>150 active disease◦>450 extremely severe disease

Source: Nelms (2007), 491

Stages of Crohn’s DiseaseStage Definition

Mild-Moderate Disease Individual tolerates oral supplements without development of dehydration, obstruction, abdominal tenderness, or <10% weight loss

Moderate-Severe Disease Individual has increased symptoms of fever, vomiting, significant weight loss, abdominal pain, or anemia

Severe-Fulminant Disease Individual has persisting symptoms despite steroid use, evidence of intestinal blockage or abscess

Remission Individual successfully responds to medication treatment, surgical resection, and currently without inflammatory symptoms

Source: Nelms (2007), 492

DiagnosisEndoscopy (colonoscopy –

examine large intestine)Blood tests

◦Anemia indicates intestinal bleeding◦Increased white blood cell count

indicates inflammationBarium X-rayStool sample

"Cobblestoning" in colonoscopySource: www.medgadget.com

TreatmentForms of treatment:

◦Medical Nutrition Therapy (MNT)◦Medications◦Surgery

Goals of treatment:◦Control inflammation◦Correct nutritional deficiencies ◦Relieve symptoms

Medical Nutrition TherapyCurrently, no specific diet is used

for treatment in Crohn’s diseaseDiet is individualized Multivitamin recommended due

to nutrient deficiencies

Common Nutrient DeficienciesNutrient Deficiency Probable Cause

Calories Insufficient intakeAnorexiaFear of abdominal pain and diarrhea after eating

Protein Increased protein needs (losses from GI tract caused by inflammation)Catabolism (when infection or abscesses present)Healing from surgery

Fluid and electrolytes Short bowel syndrome

Iron Blood loss

Magnesium, zinc Intestinal losses, especially from short bowel syndrome

Calcium and Vitamin D Long-term steroid useDecreased intake of dairy food as a result of lactose-restricted diets

B12 Surgical resections of stomach (loss of intrinsic factor) and/or terminal ileum (site of absorption)

Folate Medications used to treat IBD

Source: Nelms (2007), 495

Calorie NeedsCalculate using Harris-Benedict

or Mifflin-St. Jeor equation◦Stress factor (1.3-1.5)◦Consider previous weight loss and

infection when determining calorie needs

Infants/Children – consider growth needs◦Infants may need 120 kcal/kg◦Adolescents may need 80 kcal/kg

Study: Adequacy of dietary intake in adults with Crohn’s Objective: identify the adequacy of

dietary intake of adults with Crohn’s disease

Results: Intake of macronutrients and micronutrients were below recommended levels despite normal BMI and adequate energy intake◦Lacked folate, vitamin C, vitamin E,

calciumConclusion: additional dietary

counseling necessarySource: Aghdassi (2007)

Study: Adequacy of dietary intake in children with Crohn’sObjective: assess the growth and

adequacy of dietary intakes of children with Crohn’s disease

Results: individuals with active CD had a lower caloric intake than those in remission

Conclusion: active CD patients had an inadequate dietary intake of energy, calcium, and iron◦Lack of intake can lead to poor weight

gain and impaired growthSource: Pons (2009)

Protein NeedsRecommended intake:

◦Adults: 1.5-1.75 g/kg◦Children: 2.0-2.5 g/kg

Protein needs may increase by 150% of normal recommendations

Factors to consider:◦Lean body mass wasting ◦Measurement of prealbumin and

albumin

Role of Dietary Fiber in Crohn’s

Diarrhea is a common symptom in Crohn’s patients◦Diarrhea causes an increase in

osmotic load as a result of an inflamed GI tract

“Dietary fiber intake may improve symptoms of patients with inflammatory bowel disease.”

Source: Position of ADA: Health implications of dietary fiber (2008)

MNT: Tolerating an Oral Intake

Low-reside, lactose-free diet Presence of steatorrhea

◦Reduced fat diet with MCT supplements

Advancement of diet◦Add small amounts of fiber, then

lactose◦Add other foods initially restricted

Increase levels of antioxidants

MNT: Increased Severity of DiseaseSudden flare-ups:

◦Parenteral or enteral nutrition support with chemically defined formula

◦Glutamine and arginine supplements aid in decreasing inflammatory response

MNT: Enteral and Parenteral NutritionAllows bowel rest to reduce

inflammationUsed to prepare people for

surgery to improve healthUsed when medications are

unable to control symptoms

Study: Enteral vs. Parenteral FeedingEvidence supports using

elemental diets for growth in children

Maintenance of remission:◦Enteral feedings prevent relapse in

inactive CD patients, particularly children

◦In a Japanese study, 145 patients with CD had a lower risk of CD flaring up through the use of elemental/polymeric nutrition, particularly when CD targeted the small intestine.

Source: Rajendran (2010)

Study: Enteral Nutrition for ChildrenObjective: identify factors affecting

energy intake and weight gain during enteral nutrition in relation to disease site and nutritional status.

Results: all patients improved nutritionally through weight gain

Conclusion: EAR, an underestimate of energy needs for children◦Recommended intake of 100-149% of

EAR for energy for age.

Source: Aghdassi (2007)

MNT: RemissionGoal: maximize calorie and

protein intake for rehabilitationObtain healthy weight with

physical activityObtain normal dietary patternsConsume foods high in

antioxidants and Omega-3 fatty acids

Probiotics and Prebiotics

Study: Use of Omega-3 Fatty Acids in Inflammation ReductionObjective: gradual replacement

of Omega-3 fatty acids with Omega-6 fatty acids

Results: increased incidence of CD

Conclusion: the ratio of Omega-3 fatty acids may be effective in reducing inflammation in CD

Source: Rajendran (2010)

Study: Food Sensitivity and Exclusion Diet Induction of remission in CD

◦Outcome: food intolerances vary among individuals

◦Most common food intolerances included cereals, dairy products, yeast

Maintenance of remission in CD◦Objective: identify the impact exclusion diets

has in maintaining remission in CD patients◦Results: Believed that personalized diets aid

in maintenance of remission◦Conclusion: larger, controlled studies need to

be conducted

Source: Rajendran (2010)

Key InterventionsIncrease nutrient intakeCorrect malabsorption or anemiaMonitor lactose and gluten

intolerancesRest bowel to promote healing

and prevent protein mass lossPromote weight gain

MNT: Basic GuidelinesEat small, frequent meals Drink plenty of fluidsConsider a multivitaminChoose foods with added

probiotics and prebioticsConsume low-fiber foods when

symptoms ariseAvoid foods that aggravate

symptomsSource: American Dietetic Association (2010) client handout

Drug Therapy: MedicationsAnti-inflammatoriesImmunosuppressantsAntibioticsOther – anti-diarrheal, laxatives,

pain relievers

Drug Therapy: MedicationsAnti-inflammatory drugs

◦Aminosalicylate – used when ileal and colon are involved

◦Corticosteroids – reduce inflammation Not recommended for long-term use

especially in children as it can affect their growth

Risk of becoming steroid dependent

Drug Therapy: Medications

Immunosuppresants◦Most widely used for IBD treatment◦Heal fistulas from Crohn’s

Antibiotics◦Heal fistulas

Biologic Therapy◦Infliximab blocks the tumor necrosis

factor-alpha (TNF-alpha) which causes inflammation in intestine

SurgeryAbout 60% of patients require surgeryIleostomy, most common formUsed when diet, medications, and

other treatment do not relieve symptoms

May involve:◦Removal of damaged digestive tract◦Close fistulas, drain abscesses◦Remove scar tissue◦Strictureplasty – widening segment of

intestine which has narrowed

ComplicationsBlockage of small intestineDevelopment of fistulas and

fissuresNutritional deficienciesArthritisKidney stonesDiseases of the liver Skin problemsOsteoprosis

Ethical IssuesStem cell therapy used for

Crohn’s disease treatmentWithholding or with drawing

nutritional support with enteral and parenteral nutrition

Reimbursement Issues Lack of coverage for nutrition

counseling services in Crohn’s disease patients

Source: Medx Publishing (2008)

Summary Crohn’s disease definitionCommon nutrient deficienciesTreatment goalsMedical nutrition therapy for

Crohn’s

Questions?

ReferencesAghdassi, E., Wendland, B. E., Stapleton, M., Raman, M., & Allard, J. P. (2007). Adequacy of nutritional intake in a canadian population of patients with Crohn’s disease. Journal of the American Dietetic Association, 107(9), 1575-1580. doi: 10.1016/j.jada.2007.06.011

American Dietetic Association. (2010). Crohn's disease and ulcerative colitis nutrition therapy

Crohn's and Colitis Foundation of America. (2009). About crohn's disease. Retrieved September 28, 2010, fromhttp://www.ccfa.org/printview?pageUrl=/info/about/crohns

Crohn's and Colitis Foundation of America. (2009). Diet & nutrition. Retrieved September 28, 2010, fromhttp://ccfa.org/printview?pageUrl=/info/diet

Enteral nutrition for maintenance of remission in crohn's disease. (2007). Cochrane Database of Systematic Reviews, (3)

FDA Consumer Health Information. (May 2, 2008). Facts about crohn's disease. Retrieved September 28, 2010, fromwww.fda.gov/consumer/updates/crohnsdisease050208.html

Gavin, J., Anderson, C. E., Bremner, A. R., & Beattie, R. M. (2005). Energy intakes of children with crohn's disease treated with enteral nutrition as primary therapy. Journal of Human Nutrition & Dietetics, 18(5), 337-342.

Knight, C., El-Matary, W., Spray, C., & Sandhu, B. K. (2005). Long-term outcome of nutritional therapy in paediatric crohn's disease. Clinical Nutrition, 24(5), 775-779. doi:10.1016/j.clnu.2005.03.005

ReferencesLandsman, K. (2010). My WebMD: A college student controls her crohn's. Retrieved September 28, 2010, fromhttp://www.webmd.com/ibd-crohns-disease/crohns-disease/features/my-webmd-a-college-student-controls-her-crohns?src=RSS_PUBLIC

Medx Publishing. (2008). Medical nutrition therapy. Retrieved October 6, 2010, from http://www.medicare.com/services-and-procedures/medical-nutrition-therapy.html

Nelms, M., Sucher, K., & Long, S. (2007). In Marshall P. (Ed.), Nutrition therapy and pathophysiology. Belmont: Thomson.

Pons, R., Whitten, K. E., Woodhead, H., Leach, S. T., Lemberg, D. A., & Day, A. S. (2009). Dietary intakes of children with crohn's disease. British Journal of Nutrition, 102, 1052-1057. doi:10.1017/S0007114509085

Position of the american dietetic association: Health implications of dietary fiber. (2008). Journal of the American Dietetic Association, 108(10), 1716-1731. doi: 10.1016/j.jada.2008.08.007

Rajendran, N., & Kumar, D. (2010). Role of diet in the management of inflammatory bowel disease. World Journal of Gastroenterology, 16(12), 1442. doi:10.3748/wjg.v16.i12.1442

Vaisman, N., Dotan, I., Halack, A., & Niv, E. (2006). Malabsorption is a major contributor to underweight in Crohn’s disease patients in remission. Nutrition, 22(9), 855-859. doi: 10.1016/j.nut.2006.05.013