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Navigating Inflammatory Bowel Diseases Using a Nutrition Care Pathway Sponsored by the Crohn’s & Colitis Foundation through an educational grant from Nestlé Health Science **Note that this presentation file is for educational purposes only. Viewing of the file does not offer CPE credit. Alteration or reproductions of the presentation slide or file content is not permitted.

Disclosures Caroline Hwang, MD Employee Keck School of Medicine of USC – Assistant Professor of Clinical Medicine Paid Consultant Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway

Disclosures Kelly Issokson, MS, RD, CNSC Employee Cedars-Sinai Medical Center – Clinical Dietitian Paid Consultant Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway

Disclosures Catherine Giguere-Rich, RDN, LD Employee Dartmouth Hitchcock Medical Center – Clinical Dietitian Consultant Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway

At the end of the session, the participant will be able to: Explain the steps in the Crohn’s & Colitis Foundation’s Inflammatory Bowel Disease (IBD) Nutrition Care Pathway including the importance of the MDRD partnership in caring for IBD patients Describe the unique characteristics of IBD patients that meet malnutrition criteria as recommended by the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) Explain how IBD disease course and treatment impact the macronutrient and micronutrient needs in the IBD patient and identify strategies for restoring nutritional balance

Audience Response Question Please indicate your professional designation: A. B. C. D. E. Registered Dietitian Nutritionist Dietetic Technician, Registered MD Nurse NP/PA

Audience Response Question What percentage of your total patient population is made up of IBD patients? A. 0% B. 1-20% C. 21-40% D. 41-60% E. 60% F. Not applicable

Audience Response Question How confident are you in your ability to appropriately screen patients with IBD for malnutrition? A. B. C. D. E. Not at all confident Somewhat confident Moderately confident Very confident Completely confident

Audience Response Question How often do you follow an evidence-based pathway for the screening and management of IBD patients who are at risk for or are diagnosed with malnutrition? A. B. C. D. E. Never Rarely Sometimes Very often Always

Audience Response Question How confident are you in your ability to appropriately intervene and monitor patients with IBD and malnutrition? A. B. C. D. E. Not at all confident Somewhat confident Moderately confident Very confident Completely confident

Inflammatory Bowel Diseases: A Primer on Disease Manifestations & Treatment Caroline Hwang, MD

Audience Response Question Which of the following is true about IBD? A. Low-dose steroids remains the mainstay for both Crohn’s disease and ulcerative colitis B. About 40% of Crohn’s disease patients will require surgery within the first 10 years of their disease course C. If a patient responds to a new biologic, you would expect symptoms to improve by 2 months D. Crohn’s disease always involves the small intestine (ileum) and thus malnutrition risk is higher than with ulcerative colitis

Epidemiology Approximately 1.6-3.1 million pts in U.S. Prevalence is 1 in 200 Classically a disease of industrialized nations (N. America, NW Europe) Changing IBD trends Growing incidence in developing nations (Asia, S. America, Middle East) Also higher rates in immigrants in U.S/Europe Dietary/environmental cause?

Relapsing Remitting Disease Course Patterns of disease 55% UC, 43% CD 6% UC, 19% CD Cumulative Bowel Damage 1% UC, 3% CD 55% UC, 43% CD Crohn’s Probability of Surgery for CD

Differentiating IBD Subtypes: Ulcerative Colitis

UC: Extent of Disease

UC: Severity of Disease

UC: Severity of Disease

Characteristics of Crohn’s Disease

Wide Spectrum of Crohn’s Disease Manifestations

Complications of Crohn’s Disease SURGERY

Medication Options for IBD Conventional/Non-targeted (Pills) Steroids Antibiotics Aminosalicylates (anti-inflammatories) Immunomodulators (6MP, azathioprine, methotrexate) Biologics/Targeted (Injections, Infusions) TNF-blockers Integrin-blockers IL-12/IL-23 blockers Jak2-Kinase inhibitors

Medical Management Ulcerative Colits Severe Moderate Mild Surgery Biologic/SM Steroids 6MP/AZA Mesalamine, SSZ (Budesonide) (Antibiotics) Crohn’s Disease Topical Steroids Surgery (Budesonide) Biologic Early Biologics 6MP/AZA Steroids Surgery Late

Targeted Therapies: (Steroid-Sparing) Blocking Cytokines (Cell signaling proteins, i.e TNF, IL-12, IL-23) Blocking Intracellular messengers (JAK kinase) Blocking vascular Trafficking (Integrins

New Era of Targeted Therapies (Steroid-Sparing)

Expected Response to Therapies: Interpreting Clinical Trials for Real Life INDUCTION (First 6-12 weeks) Trial endpoints: 20-50% symptom improvement Efficacy rates: 30-60% (wide range) MAINTENANCE (Long-term 30-52 weeks) Trial endpoints: Clinical/endoscopic remission Efficacy rates: 20-40% (wide range)

Audience Response Question Which of the following is true about IBD? A. Low-dose steroids remains the mainstay for both Crohn’s disease and ulcerative colitis B. About 40% of Crohn’s disease patients will require surgery within the first 10 years of their disease course C. If a patient responds to a new biologic, you would expect symptoms to improve by 2 months D. Crohn’s disease always involves the small intestine (ileum) and thus malnutrition risk is higher than with ulcerative colitis

Malnutrition in IBD and the development of a nutrition care pathway

IBD Increases Risk of Malnutrition Reduced Nutritional Intake Anorexia, Nausea, Pain Restrictive diets Increased Nutritional Needs Inflammation, Infection, Surgery Causes of Malnutrition with IBD Increased Nutrient Losses Malabsorption, Diarrhea, Vomiting, Fistulas, Intestinal protein losses Medications Surgery Corticosteroids, Drugnutrient interactions Reduced absorptive area, short bowel Malnutrition reported in 40-70% of hospitalized IBD pts & 20-50% of IBD outpts

Complications of Malnutrition in IBD Few studies on the impact malnutrition has on IBD course/complications Single large Canadian study using the Nationwide Inpatient Sample: Malnutrition in IBD patients ( 6% of UC, 7% of CD) associated with: In-hospital mortality (OR 3.49, % CI: 2.89-4.23) Length of stay LOS (11.9d versus 5.8 days, P 0.00001) Total cost of hospitalization ( 45,188 versus 20,295, P 0.0001). IBD patients with low albumin: - Higher rates of wound infections, anastomotic leak - Increased risk of anti-TNF failure 1. Nguyen GC et al: Inflamm Bowel Dis 2008 2. Telem DA et al: Arch Surg 2010

Importance of Addressing Disease-Related Malnutrition Dearth of studies about the utility of nutritional support in IBD Better supported in other at-risk populations Cystic fibrosis Aggressive nutritional rehab at CF centers avg life expectancy/lung function Surgical Cancer Patients Adoption of “enhanced recovery algorithms” (preop carb loading, earlier postop feeding less operative complications, shorter hospital stays Hospitalized Malnourished Elderly Oral supplements Mortality infections/pressure wounds, shorter hospital stays 1. Castellani C et al: J Cyst Fib 2018 2. Burden S et al: Cochr Syst Rev 2012 3. Milne et al: Ann Int Med 2006

Challenges in Recognizing Malnutrition in ASPEN/Academy Clinic Diagnostic Criteria (Any 2) Malnutrition Actually a complex diagnosis No single anthropometric or laboratory test/biomarker Insufficient time (average clinic visit 10-20 minutes, spent predominantly on discussing symptoms/meds Most physician lack formal training on nutrition Weight Loss Loss of Fat/Muscle, Edema Insufficient Energy Intake Lack of dietitians in clinic / insurance coverage Mueller C et al: JPEN 2011 Decreased Function (Handgrip)

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway In 2015, the Crohn’s & Colitis Foundation launched an effort to develop a Nutrition Care Pathway as part of IBD Qorus (quality-of-care program) Multiple step process - Focus groups conducted (providers, patients) - Major barriers Limited provider time, access to dietitian ( , expertise in IBD) - Steering committee formed (Gastroenterologists/Dietitians w/ expertise in IBD) - In-person moderated workshop (nutrition scientists, care pathway experts) - Literature review - Weekly phone conference consensus

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway SCREENING Low Risk At Risk ASSESSMENT INTERVENTION Monitoring

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway Easy to implement in busy clinic SCREENING Low Risk At Risk ASSESSMENT INTERVENTION Monitoring Recognizes access to dietitians may be limited

Step 1: Malnutrition Screening Required by Joint Commission in all patients hospitalized within first 24 hrs. of admission Multiple screening tools have been developed to identify presence or risk of malnutrition Ideal screen is sensitive, simple, and reliable For IBD patients, important to take into consideration of disease acuity/activity Malnutrition Universal Screening Tool (MUST) Validated instrument in inpatients and also ambulatory clinics (elderly, cancer, ESRD) Predictive of mortality, worse QOL, hospitalizations, LOS, clinic visits 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on ’MUST' see www.bapen.org.uk 1. Raslan M et al: Nutrition 2010 2. Boleo-Tome C et al: Br J Nutr 2012 3. Skipper A et al: J Parenter Enteral Nutr 2012

Step 1: Malnutrition Screening Required by Joint Commission in all patients hospitalized within first 24 hours of admission Multiple screening tools have been developed to identify presence or risk of malnutrition Ideal screen is sensitive, simple, and reliable For IBD patients, important to take into consideration of disease acuity/activity Malnutrition Universal Screening Tool (MUST) Validated instrument in inpatients and also ambulatory clinics (elderly, cancer, ESRD) Predictive of mortality, worse QOL, hospitalizations, LOS, clinic visits, 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on ’MUST' see www.bapen.org.uk 1. Raslan M et al: Nutrition 2010 2. Boleo-Tome C et al: Br J Nutr 2012 3. Skipper A et al: J Parenter Enteral Nutr 2012 BMI % Wt loss Acute Disease Effect ( 20, 18.5) ( 5%, 10%) (Acute illness, Poor po intake

Malnutrition Self-Screening Feasible In a single IBD center, self-screen MUST completed by over 500 patients correlated well with MUST screen by physicians (Κ 0.86)1 Foundation’s IBD Qorus experience (7 IBD centers/GI practices in the U.S.)2 - 2,388 IBD outpatients completed self-screen MUST - 86% reported MUST self-screen as either very easy or easy to complete 72% 80% 40% 1. Sandhu A et al: JPEN 2015. 10% 18% 0% Hwang C et al: Abstract presented AIBD 2016 Low 2. Moderate High

Step 2: Nutritional Assessment Comprehensive nutritional assessment most often requires assessment by dietitian - Anthropometrics, Dietary History (diaries, etc.), Laboratory testing Basic assessment can be done by physician/nurses, though many may feel unprepared - Recent Foundation focus group – Only 41% of gastroenterologists rated knowledge of nutrition as very good, many cited lack of awareness of standardized malnutrition tools Subjective Global Assessment (SGA) One of the most widely-used nutrition tools, initially developed in cancer patients but validated since in multiple inpatient/outpatient populations Shorter patient self-generated version (PG-SGA) feasible to implement in clinic Weight loss (6 mo., 1 mo., 2 weeks) Gastrointestinal symptoms impacting intake Dietary intake Functional/activity level Presence of other factors that affect nutritional status Active IBD Prednisone use ( or 10mg/day) Presence of fever

PG-SGA Additional Factors (SGA): 1. Contributing disease: Active IBD ( 1), Fistula ( 1) 2. Steroid use: 10mg ( 1), 10-30mg ( 2), 30mg ( 3)

Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway Screening all IBD patients for Malnutrition Risk (MUST) SCREEN Low-Risk High-Risk Moderate-Risk No Action PRIMARY ASSESSMENT PG-SGA 4 Assessment of Nutritional Status (PG-SGA) Immediately or can consider Observation/Education & F/U 1-2mo PG-SGA 4-8 ROUTINE SECONDARY ASSESSMENT & INTERVENTION Assessment of Nutritional Status (PG-SGA) Immediately PG-SGA 9 URGENT Dietitian Assessment & Multidisciplinary Intervention Dietary Education/Counseling Enteral & Parenteral Support Monitoring

Malnutrition in IBD: Looks Can Be Deceiving Kelly Issokson, MS, RD, CNSC

Audience Response Question The BMI of an IBD patient compared to a healthy control tends to be: A. Lower than healthy controls B. Higher than healthy controls C. Not different from healthy controls

Malnutrition An acute or chronic state of under or overnutrition that leads to a change in body composition and function. A predictor of poor prognosis in hospitalized IBD patients Inflamm Bowel Dis (2008) 14:8

Malnutrition in IBD Malnutrition in IBD results in poor clinical outcomes Growth failure Reduced response to pharmacotherapy Increased risk for sepsis Mortality Decreased oral intake common in active IBD (anorexia, sitophobia) Lower fiber and phosphorus intake in inactive CD Maldigestion, malabsorption, enteric loss of nutrients, rapid transit, increased energy needs w inflammation or infection, adverse effects of medical therapy Curr Gastroenterol Rep (2016) 18: 55 Inflamm Bowel Dis (2008) 14:8

Malnutrition Criteria (Academy/ASPEN) Moderate Malnutrition (ICD 10 E44.0) Severe Malnutrition (ICD 10 E43) Weight loss 1-2% in 1 week 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 months 2% in 1 week 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 months Energy Intake 75% intake in 7 days 75% intake in 1 month 75% intake in 3 months 50% intake in 5 days 50% intake in 1 month 50% intake in 1 month Subcutaneous Fat Loss Mild Moderate to Severe Subcutaneous Muscle Loss Mild Moderate to Severe General or Local Fluid Accumulation Mild to Severe Moderate to Severe Hand Grip Strength (Dynamometer) Not Applicable Measurably reduced Adapted from Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)

Characteristics of the IBD vs. non-IBD patient IBD Non-IBD BMI: 26.54 BMI 21.34 Malnutrition incidence: 6-7%1 Sarcopenia: 42%2 1. Inflamm Bowel Dis. 2008 14:8 2. Inflamm Bowel Dis. 2018 Jun 7 Epub ahead of print 3. Curr Opin Gastroenterol. 2018 Jul;34(4):217-225 4. Eur J Intern Med. 2010 Aug;21(4):315-9. Malnutrition incidence: 1.8%1 Sarcopenia (muscle mass begins to decline around age 40; can lose 3-8% muscle mass per decade)

BMI is Associated with IBD Systematic Review and Meta Analysis (Dong et al) of 24 studies, n 1442 BMI significantly lower in CD compared to healthy controls Medical therapy improved BMI in CD (not UC) Active IBD BMI was significantly lower than healthy controls PLOS One (2015) 10:12

Fat-free Mass and Fat Mass Reduced in IBD Systematic Review (Bryant et al) of 19 studies, n 631 CD, 295 UC Reduced fat-free mass in 28% CD and 13% UC Reduced fat mass in 31% CD and 13% UC No consistent association between body composition and disease activity, duration, extent or therapies. BMI did not accurately predict body composition Aliment Pharmacol Ther 2013; 38: 213–225

Malnutrition in IBD Nationwide study1 of hospitalized IBD vs non-IBD hospitalized patients Greater prevalence of malnutrition in CD and UC (6.1% and 7.2% vs 1.8%, p 0.0001) Adjusted odds ratio for malnutrition among IBD admissions compared to non-IBD was 5.57 (95% CI: 5.29-5.86) More IBD discharges than non-IBD discharges received PN (26% vs 6%, p 0.0001) Increased likelihood of malnutrition in those with fistulizing CD (OR 1.65) and in those with bowel resections (OR 1.37) Malnutrition was associated with increased hospital mortality 3.49, length of stay (11.9 days vs 5.8 days, p 0.00001), and total charges ( 45k vs 20k, p 0.0001) 1. Inflamm Bowel Dis (2008) 14:8

Demographic and Clinical Predictors of Malnutrition Males, non-Hispanic whites Those receiving Medicare or Medicaid Active fistulizing disease (active obstructive disease had lower likelihood of malnutrition) Bowel resection Inflamm Bowel Dis (2008) 14:8

Food Restriction & Malnutrition One cause for malnutrition: diet adjustment based on patient experience and beliefs Recent survey in IBD patients (n 104) looked at those with food exclusions (FE) vs none Anthropometrics and nutritional status (SGA) Diet beliefs and food restriction Nutrient intake Clin Nutr Res. 2018 Jan; 7(1): 48-55

Clin Nutr Res. 2018 Jan; 7(1): 48-55

Clin Nutr Res. 2018 Jan; 7(1): 48-55

Food Restriction & Malnutrition Malnutrition rate significantly higher in food exclusion group (p 0.007) 59% held diet beliefs and reported modifying their diet because of these 83% (FE) and 67% (non FE) wanted nutrition education and management Most common restrictions: Milk, dairy products (32%), raw fish (24%), deep spicy foods (22%), ramen (18%) Calcium (p 0.002), vitamin A (p 0.001), and zinc (p 0.001) mean intake was significantly lower in food exclusion group Clin Nutr Res. 2018 Jan; 7(1): 48-55

Sarcopenia in IBD Systematic Review, 5 studies, n 658 patients 42% had sarcopenia Did not assess anatomical/functional components of sarcopenia Sarcopenic IBD patients had higher probability of requiring surgery Rate of major complications was significantly higher in patients with sarcopenia Inflamm Bowel Dis. 2018 Jun 7. doi: 10.1093/ibd/izy212. [Epub ahead of print]

Approaches for Improving Outcomes IBD BMI 21.34 Malnutrition incidence: 6-7%1 Sarcopenia: 42%2 Nutrition Screening Early RD intervention Diet liberalization Strategies to restore nutrition balance and preserve lean body mass Multidisciplinary Collaboration MD/Surgeon Physical Therapist RN 1. Inflamm Bowel Dis. 2008 14:8 2. Inflamm Bowel Dis. 2018 Jun 7 Epub ahead of print 3. Curr Opin Gastroenterol. 2018 Jul;34(4):217-225 4. Eur J Intern Med. 2010 Aug;21(4):315-9.

Audience Response Question The BMI of an IBD patient compared to a healthy control tends to be: A. Lower than healthy controls B. Higher than healthy controls C. Not different from healthy controls

Impact of Inflammatory Bowel Disease on Nutrition and Strategies for Restoring Balance Catherine Giguere-Rich, RDN, LD

Audience Response Question Patients with IBD have increased protein needs in which clinical situation (s): A. B. C. D. Steroid therapy High output enterocutaneous fistula During flare All of the Above

How can disease and treatment affect nutrition? 1. 2. 3. 4. 5. 6. 7. Common dietary recommendations and trends Macronutrient needs Cases Micronutrient deficiencies EEN (exclusive enteral nutrition) Parenteral nutrition Hydration

How Does Treatment Affect Nutrition? IBD patients are at risk for malnutrition because of many factors: 1) Increased losses—Diarrhea (electrolytes), bleeding (iron), Ostomy 2) Decreased intake—Poor appetite, limited diet (fruits, vegetables) 3) Malabsorption—Inflammation, surgery, fistulas surface area, SBS 4) Catabolic state—Inflammation causes in metabolic/protein needs 5) Drug interference—Steroids block calcium absorption, Methotrexate blocks folate Malnutrition can occur with: Macronutrients—protein, calories Micronutrients—Vitamins, mineral, trace elements Forbes A, Goldesgeyme E. Journal Parenteral and Enteral Nutrition. 2011;35(5): 571-580 . 62

Calorie and Protein Needs in IBD EE NOT SIGNIFICANTLY ELEVATED IN IBD REE SLIGHTLY INCREASED DURING ACTIVE INFLAMMATION Usually occurs during flares—weight loss and loss of lean muscle Many equations are available to estimate energy requirements Protein—needs may increase slightly during flare (1-1.5 g/kg/day) Prednisone, need to gain weight, or losses Fluid 30-35 ml/kg/day Holiday Segar Equation (1500 ml 20 ml/kg for each kg 20 kg) If diarrhea or high ostomy output—suggest ORS Electrolytes—sodium, potassium, magnesium 1. Gong J, Zuo L, Guo Z. J Parenteral Enteral Nutr. 2015;39(6):713-718. 2. Eiden KA. Nutrition Issues in Gastroenterology. 2003; series #5: 33-54 63

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Goals of Nutrition Therapy Identify and treat nutritional deficiencies Provide some relief for GI symptoms (diarrhea, Bloating, and abdominal pain) No diet to date has been scientifically shown to prevent/cure IBD 65

Common Diet Recommendations Low Fiber - Minimal fresh fruits &vegetables, nuts, seeds - Helpful for relieving abdominal pain, diarrhea - Especially important to avoid if you have stricture - No controlled trials that show low fiber diet leads to symptom improvement or decreased admissions to the hospital High Fiber Diets - Ulcerative Colitis in remission - Short Chain Fatty acids (SCFA)-butyrate, acetate, proprionate Lactose Avoidance if Intolerant - Common among IBD patients - But can happen temporarily during flare Overall, individualized healthy diet Seidner DL, Lashner BA, Brzezinski A. Clin Gastroenterol Hepatol. 2005;3:358-369 66

Diet Trends Gluten-free - Protein found in foods processed from wheat, barley or rye - Celiac Disease - Gluten intolerance relatively common in Irritable Bowel Syndrome (IBS) - Gluten Free diet may help alleviate symptoms not related to inflammation but further research is needed. Low FODMAPS diet - Short-chain carbs poorly absorbed and thus fermented by bacteria gas/diarrhea - Shown in several clinical trials to be effective in irritable bowel syndrome (IBS) - Some limited evidence for effectiveness in functional symptoms for IBD - Quite restrictive, encourage working with registered dietitian familiar with low fodmap diet - Further research is needed Herarth HH, Martin CF, Kappelmann MD. Inflamm Bowel Dis. 2014;20(17): 1194-1197 Prince AC, Myers CE, Joyce T. Inflamm Bowel Dis. 2016;22(5): 1129-1136 67

Diet Trends Specific Carbohydrate Diet (SCD) Trial of Specific Carbohydrate and Mediterranean Diets to Induce Remission of Crohn’s Disease (DINE-CD) Study Case series found SCD to be a potential effective tool in management of colonic and ileocolonic Crohn’s disease in remission. KakokkarS, FarooquiA, Mikolaitis SL. J.Academy of Nutr and Dietetics. 2015;15(80): 1226-1232 68

Turmeric (Curcumin) and Ulcerative Colitis Anti-inflammatory and antioxidant properties Small study shows: May be effective and safe for maintaining remission for people with inactive disease. May help induce remission in mild to moderate UC Hiroyuki H, Takayuki I, Ken T. Clinical Gastroenterology and Hepatology. 2006;4:1502-1506

Probiotics Science on probiotics is inconclusive Probiotics may or may not be beneficial May reduce risk of C.Diff Specific probiotics have been shown to be beneficial in mild ulcerative colitis, pouchitis, recurrent C. diff infections (VSL-3, florastor) Recent meta-analysis concluded that efficacy on probiotic use in CD remains uncertain Probiotics supplements There are many brands (e.g VSL #3, Florastor, Culturelle, Align) And many species (e.g Lactobacillus vs Acidophilus vs Saccharomyces Boulardii) Fermented foods just as good? Kefir or yogurt Kimchi or saurkraut Kombucha Be Careful!!! Supplements are not regulated by the FDA Fedorak RN, Gastroenterology & Hepatology. 2010;6(11):688-690 Derwa Y, Gracie DJ. Aliment Pharmacol Ther. 2017;46(4):309-400. 70

Case #1 30 year old female with Crohn’s disease since the age of 19 presents to outpatient clinic for nutrition consultation. She had been doing well with her IBD until about 6 months ago. Her most recent colonoscopy demonstrated ulcerations of the ileum and colon. She experiences 6-10 loose bowel movements daily and abdominal pain with eating. She states she feels she is in a flare. She has required prednisone to help relieve her symptoms. Her gastroenterologist recently changed her biologic medical therapy to help better treat her disease. She is having difficulty with eating. She is avoiding dairy products due to lactose intolerance. She is not eating raw fruits and vegetables because they cause too much pain, and she can only eat small amounts of bread, pasta, and chicken. She has lost about 15 lbs over the last 3 months with BMI now of 17. She is very motivated to do whatever she needs to do to get better. 71

Which micronutrient deficiencies would you be concerned about with this patient? a)Calcium and Vitamin D b)Vitamin B12 c) Iron d)All of the above 72

Calcium and Vitamin D EVIDENCE OF RISK FOR DEFICIENCY Calcium Risk factors: chronic steroid use, diarrhea, vitamin D deficiency, restricted diet Osteoporosis is common in IBD—approximately 18-42% Bone Mineral Density Study/DXA scan (high risk) Vitamin D Risk factors: Steroids, restricted diet, decreased sunlight 25% of adults with CD were found to have Vitamin D levels 10 ng/mL IBD poses increased risk of vitamin D deficiency and metabolic bone disease Bernstein CN, Leslie WD, Leboff MS. Gastroenterology. 2003;124(3):795 73

Calcium and Vitamin D TREATMENT Calcium - Diet sources: Milk, cheese, yogurt, tofu - Supplement: Most IBD patients 1000mg in women aged 18-25, men 65 1200mg in women age 25-menopause 1500mg in postmenopausal women, men 65 Vitamin D - Diet sources: Salmon, tuna, milk, eggs - Supplement: Most IBD patients 600-2000IU daily -If level 20: 50,000 IU D2 or D3 for 12 weeks -Maintenance dose of 1500-2000 IU/d D3 -higher maintenance doses of 3000-6000 IU/d for patients on glucocorticoids, those with malabsorption, BMI 30, or in those with small bowel involvement Holick, M. F., et al. Journal of Clinical Endocrinology & Metabolism. 2011; 96(7), 1911-30. Basson, A. Journal of Parenteral and Enteral Nutrition. 2014; 38(4), 438-458. 17

Vitamin B12 and Folate EVIDENCE OF RISK FOR DEFICIENCY Vitamin B12 Risk factors: Ileitis/small bowel surgery, small intestinal bacterial overgrowth, gastritis About 20% of patients (adult and pediatric) with Crohn’s disease Pernicious anemia, macrocytosis, cognitive symptoms, glossitis Folate Risk Factors: SB resection, Meds: methotrexate (MTX), sulfasalazine (SSZ) Older studies showed 20-60% of patients with IBD to be deficient More recently has become uncommon Megaloblastic anemia, macrocytosis, smooth sore tongue Type of Anemia Microcytic Macrocytic Normocytic HGB HCT MCV (cell volume) Normal Headstrom PD, Rulyak SJ, Lee SD. Inflamm bowel Dis. 2008 14 (2) 217. 75

Vitamin B12 and Folate TREATMENT Vitamin B12 Diet sources: Trout, tuna, beef, milk All pts with ileal surgery ( 60cm) intramuscular vit B12 for life (1000 mcg/mo) Oral—1000 mcg daily (various options) Folate Diet sources: Fortified cereals, spinach, cantaloupe 1 mg Folic Acid daily All patients on MTX or SSZ Eiden, K. A. Nutrition Issues in Gastroenterology. 2003; Series #5, 33-54. 76

Iron EVIDENCE FOR RISK OF DEFICIENCY 35-60% of patients with IBD are deficient Risk factors: Active inflammation/chronic blood loss, Ulcerative Colitis, SIBO Significant negative impact on quality of life Microcytic anemia Crohn’s & Colitis Foundation’s IBD Anemia Care Pathway ml Gisbert JP, Gomollon F. AmJGastroenterology.2008;103(5):1299. 77

Iron Deficiency Anemia TREATMENT Diet Sources: Meat, Fish, Leafy Greens, Fortified Cereals Patient with IBD pose unique challenge for supplementation Oral iron tolerance Oral iron in setting of inflammation Absorption IV iron is used if determined best for the patient by the MD In inactive IBD/normal CRP: 100 mg oral iron daily in divided doses. Additional vitamin C may help enhance iron absorption Gomollon F, Gisbert JP. Curr Opin Gastroenterol. 2013;29(2):201 78

EEN (Exclusive Enteral Nutrition) For Crohn’s not UC Highly effective in newly diagnosed children Weaker evidence in adults (compliance and tolerability) Goal: Induce mucosal healing Elemental diets extremely difficult to follow, taste fatigue Polymeric versus elemental? Exact mechanism of action unknown Immune modulation Intestinal inflammation Microbiome Duration of treatment is 6-8 weeks Ashton JJ, Gavin J, Beattie RM. Clinical Nutrition.2018;1-10 World J Gastroenterol 2013 November 21; 19(43): 7652-7660 79

EEN Future work on personalized therapy is needed Food reintroduction—varies, lack of evidence for recommendation Maintenance enteral nutrition? Role of the dietitian Calculate energy needs and goals for intake/nutrition prescription Regular contact to help ensure compliance and provide support Collaboration with the MD Monitor patient’s weight Partial Enteral Nutrition (PEN) 80

Case #2 53 year old male diagnosed with ulcerative colitis at the age of 12. He underwent total colectomy with end ileostomy at the age of 38. He was diagnosed with Crohn’s disease at that time based on symptoms and further testing. Since the age of

B. About 40% of Crohn's disease patients will require surgery within the first 10 years of their disease course C. If a patient responds to a new biologic, you would expect symptoms to improve by 2 months D. Crohn's disease always involves the small intestine (ileum) and thus malnutrition risk is higher than with ulcerative colitis

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