nutri&on)assessment,)dietary) diversity...

Nutri&on Assessment, Dietary Diversity, Composi&on and Impact

on Outcomes in IBD Maitreyi Raman MD MSc FRPC Clinical Associate Professor

Medical Director Nutri&on Services Director AsCEND

(Alberta’s Center of Excellence for Nutri&on in Diges&ve Diseases) Associate Director of Admissions, Cumming School of Medicine

University of Calgary Oct 2018

Disclosure

•  Faculty: Dr. Maitreyi Raman

•  Rela&onships with commercial interests:

–  Grants/Research Support: Baxter

–  Speakers Bureau/Honoraria: Shire

Objec4ves

•  Describe the prevalence of malnutri4on in IBD •  Discuss an approach to nutri4onal management for pa4ents admi=ed to hospital

•  Discuss the role for therapeu4c diets for ambulatory pa4ents

Adult Starva4on and Disease-‐Related Malnutri4on

Starva&on-‐related

malnutri&on •  chronic starva4on

without inflamma4on •  e.g. anorexia

nervosa •  FS CD

Acute or injury-‐related

malnutri&on •  Starva4on •  Cri4cally Ill

4

Chronic disease-‐related

malnutri&on •  chronic starva4on with inflamma4on

•  IBD •  COPD

Starva&on –related malnutri&on (SRM) ± Nutri&onal support (NS)

Jensen et al. JPEN J Parenter Enteral Nutr 2010;34 156-159 N.B. no inflammation

Acute vs chronic disease –related malnutri&on ± Nutri&onal support (NS)

Jensen et al. JPEN J Parenter Enteral Nutr 2010;34 156-159 N.B. presence inflammatory process

(months)

Prevalence of malnutri&on in Canada

Bernier, P. 1996

In IBD 75-‐90% of pa&ents are malnourished when admi]ed to hospital

Escapes official sta4s4cs 45% moderate or severe malnutri4on 1.2% on discharge summary sheet

Costs by Nutri4on Status

8 Cur&s et al. Clinical Nutri&on 2016

Bed Days Nourished Moderately Malnourished

Severely Malnourished

Total N=958

8.43 [0.65]

11.66 [1.17]* 11.70 [0.96]*

Medical N=632

8.20 [0.95]

12.05 [1.32]* 12.05 [1.33]*

Surgical N=301

6.98 [0.65]

9.62 [1.39]* 8.75 [1.11]*

Nourished Moderately Malnourished


Total N=958

$5074 [512] $7931 [766]* $7989 [976]*

Medical N=632

$4839 [593] $7825 [849]* $7823 [1042]*

Surgical N=301

$4303 [681] $7154 [1660]* $6744 [1435]*

Length of stay (bed days) by nutri4on status

Nourished Moderately Malnourished


Total N=958

8.43 [0.65]

11.66 [1.17]* 11.70 [0.96]*

Medical N=632

8.20 [0.95]

12.05 [1.32]* 12.05 [1.33]*

Surgical N=301

6.98 [0.65]

9.62 [1.39]* 8.75 [1.11]*

Cur&s et al. Clinical Nutri&on

admission

colonoscopy

CT scan

Afebrile Decreased CRP

discharge

NPO

Admission with decreased intake for days/weeks at

home

1.375kg of muscle loss (2.5%)

66kg, 180cm tall 55kg LBM

Day 1 Day 5

Hospitaliza4on #1

Hospitaliza4on #2

Hospitaliza4on #3

Muscle Mass

Time

The Catabolic Crisis

By One Year…

•  3-‐5kg LBW – Dispropor4onate strength loss – Fat deposi4on in muscle – Exacerbated by low protein, high fat, low CHO intake at home

•  Complains constantly of fa4gue, poor energy levels

•  Surgery –  Increased surgical risks of severe malnutri4on

Preopera4ve Nutri4on Management IBD

•  Objec4ves –  Evaluate impact of sarcopenia on postopera4ve outcomes

–  Evaluate impact of nutri4on therapy on outcomes

•  Sarcopenia defined by measuring skeletal muscles at the level of L3 –  2 SD below the norm for young healthy adults

•  Enteral Nutri4on indicated for pa4ents at nutri4on risk using NRS >3 OR Intes4nal Stenosis

Zhang et al. JPEN 2017;41(4):592-‐600

Risk Factors Associated with Major Complica4ons Aoer Bowel Resec4on for Crohn’s Disease

Zhang et al. JPEN 2017;41(4):592-‐600

Nutri4on Support using EEN impact in IBD

•  Retrospec4ve case control study to evaluate the incidence of post-‐opera4ve complica4ons in stricturing or penetra4ng Crohn’s who received EEN

•  Received at least 2 weeks of EEN prior to surgery •  Age, Sex, Disease Phenotype and Severity Matched

Heerasing N et al. APT 2017; 45(5):660-‐669

Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease

Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease, Volume: 45, Issue: 5, Pages: 660-669, First published: 20 January 2017, DOI: (10.1111/apt.13934)

Screening tool Parameters

Care settings Weight loss

Poor appetite/ food intake

others

Malnutrition Universal Screening Tool (MUST)

* * BMI, Acutely ill Outpatient clinics, hospital wards, in home and community care settings

Nutrition Risk Screening (NRS) * * BMI, Severity of Disease

Hospital

Malnutrition Screening Tool (MST)

* * Hospital, oncology outpatient and community care settings

Abridged patient-generated subjective global assessment (abPG-SGA)

* * Symptoms affecting food

intake, physical activities

Oncology outpatient and inpatient settings

Canadian Nutrition Screening Tool (CNST)

* * Hospital

Saskatchewan IBD-Nutrition Risk

* * GI symptoms, food restriction

IBD outpatient setting

In general practice, the nutritional assessment is most

commonly performed using:

  Subjective Global Assessment (SGA; an ASPEN*-

recommended malnutrition assessment)

  Anthropometric measurements including BMI, triceps

skinfold thickness (TSF), mid-arm circumference (MAC),

and mid-arm muscle circumference (MAMC)

  Hand-grip strength (HGS)

  Less common: Body composition measurements using

CT, BIA and DEXA

Nutrition Assessment methods

*ASPEN: American Society of Enteral and Parenteral Nutrition

Limita4ons of Dietary Studies in IBD

•  Largely Retrospec4ve, few prospec4ve, food recall studies –  Selec4on bias –  Pre-‐illness diet

•  Single nutrient interven4ons –  Fiber Supplements –  Probio4cs – Omega-‐3 Fa=y Acids

•  Few studies exploring efficacy of holis4c diverse diets

Exclusion Diets •  Specific

Carbohydrate Diet •  Low FODMAP Diet •  Semi-‐Vegetarian

Diet

Food Addi4ves

Specific carbohydrate diet (SCD)

  Evolved from a diet for celiac disease mid-‐20th century   Based on hypothesis that pa4ents

with IBD) have a dysfunc4on of disaccharidases, necessary to digest and absorb disaccharides and amylopec4n

  Therefore, higher amounts of disaccharides would enter the colon, leading to bacterial overgrowth, bowel injury and intes4nal permeability

Suskind et al. J Clin Gastroenterol 2018;52(2):155-‐163

Autoimmune Protocol diet

Konije4 GG et al. Inflamm Bowel Dis 2017;23(11):2054-‐2060.

Extension of Paleolithic Diet Avoidance •  Gluten, Refined sugar •  Food Addi4ves •  Ini4al phase – dairy, eggs, legumes,

nightshades •  Fresh, nutrient dense, fermented

Makki et al. Cell Host and Microbe 2018

-0.3 -0.2 -0.1 0.0 0.1 0.2 0.3

-0.2

-0.1

0.00.1

0.2

nMDS 1

nMDS

2

MNWN

WN

MN

P = 0.001

Dietary Diversity is Associated With Greater B-‐Diversity of the Microbiome

Dietary Diversity is Associated with Increased F.Prausnitzii and Bifidobacteria

0 1 2 3 4

Bacteroides dorei (Identity 100%)

Bacteroides thetaiotaomicron (Identity 100%)

Bacteroides uniformis_1 (Identity 99%)

Bacteroides uniformis_2 (Identity 99%)

Bacteroides vulgatus (Identity 99%)

Bifidobacterium faecale/adolescentis/stercoris (Identity 100%)

Dialister invisus (Identity 100%)

Eubacterium hallii (Identity 99%)

Faecalibacterium prausnitzii (Identity 99%)

Lachnospiraceae (Family level)

Subdoligranulum variabile (Identity 99%)

Intestinibacter bartlettii (Identity 100%)

Ruminococcus gnavus (Identity 100%)

Blautia wexlerae (Identity 100%)

Relative abundance %

MNWN*

*

**

*

*

*

*

*

*

*

*

*

*

AsCEND: Alberta’s Center of Excellence for Nutri4on in Diges4ve Disease

EXCELLENCE IN CLINICAL

CARE

NOVEL DISCOVERY

and RESEARCH

EDUCATION and KNOWELDGE TRANSLATION

Conclusions

•  The prevalence of malnutri4on in hospitalized pa4ents with IBD is high, approaching 90%

•  Early iden4fica4on of these pa4ents is important to 4mely nutri4on therapy

•  Nutri4on therapy improves clinical and periopera4ve outcomes

•  Dietary therapies that focus on pa=erns and composi4on represent a growing area of interest in the management of IBD

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