Heather Zhou, RD, LD

Nutrition Management of Inflammatory Bowel Disease

Heather Zhou, R.D., L.D.

Clinical Science Liaison Emmaus Medical, Inc.

Presentation Overview
1. Describe the potential causes of malnutrition in inflammatory bowel disease (IBD) 2. Identify nutrients at risk for deficiency in IBD 3. Discuss dietary guidelines for managing IBD symptoms

Heather Zhou, RD, LD

Inflammatory Bowel Disease

Crohn's disease (CD)
Occur anywhere along digestive tract Mouth anus Mostly affects terminal ileum

Ulcerative colitis (UC)

Involves colon and rectum
Adapted from An in-depth look at IBD. Nursing. 2002;32:36.

Potential Causes of Malnutrition

Inadequate food intake nutritional requirements Altered digestion and absorption intestinal losses Disease activity Surgical resections Drug-nutrient interactions

Heather Zhou, RD, LD

Sites of Nutrient Absorption

Small Intestines
Major site of nutrient absorption
Duodenum iron, calcium, magnesium, zinc Jejunum B vitamins, vitamins A, D, E, K Ileum vitamin B12, bile salts/acids

Large Intestines (Colon)

Completion of absorption
Absorption of remaining water and electrolytes Formation & expulsion of stool Production of vitamin K & short-chain fatty acids by bacteria

Vitamin/Mineral Deficiencies
B vitamins
Folate, vitamin B12

Fat-soluble vitamins
Vitamins A, D, E, K

Minerals
Calcium, iron, zinc

Heather Zhou, RD, LD

Drug-Nutrient Interactions
Steroids may affect vitamin D activity in GI tract
calcium absorption: risk for osteoporosis

Anti-inflammatory drugs
folate absorption

Lipid-lowering agents bind bile acids

fat-soluble vitamin absorption

Antibiotics may vitamin K availability

Folate
Absorption
Primarily in jejunum

Deficiency
intake from food and intestinal losses

Drug-Nutrient Interactions
Anti-inflammatory (sulfasalazine) and immunosuppressant drugs (methotrexate)

Prevention
Multivitamin (MVI) supplementation with 400 mcg/day or 1 mg folate/day

Heather Zhou, RD, LD

Vitamin B12
Absorption
Terminal ileum

Deficiency
consumption or intolerance to red meat and dairy products; malabsorption

Drug-Nutrient Interactions
Antacids: H2-blockers, PPIs

Management
Monthly vitamin B12 injections if terminal ileum resected/diseased

Vitamin D
Absorption
Duodenum

Deficiency
Inadequate sunlight exposure, intake of milk products, or malabsorption

Drug-Nutrient Interactions
Corticosteroids

Prevention
400-800 IU/d vitamin D

Heather Zhou, RD, LD

Calcium
Absorption
Duodenum primary site of absorption

Deficiency
absorption of vitamin D Poor tolerance of milk and dairy products

Drug-Nutrient Interactions
Corticosteroids; absorption with iron

Prevention
1000 1500 mg/day calcium + vitamin D

Iron
Absorption
Duodenum primary site

Deficiency
Chronic intestinal blood loss, inadequate intake of iron-rich foods (red meat), or inflammation

Interactions
absorption with tea or coffee intake absorption with calcium

Prevention
Iron supplement warranted only if deficient MVI with iron or ferrous sulfate plus vitamin C

Heather Zhou, RD, LD

Zinc
Absorption
Duodenum main site of absorption

Deficiency
Food intolerances (meats, milk); chronic diarrhea

Interactions
Competitive absorption with iron

Prevention
Supplementation only when indicated with 15 mg/day elemental zinc

Nutritional Supplementation
Daily multivitamin and mineral supplement in a chewable or liquid form may be beneficial with malabsorption and intestinal losses Take supplements daily with meals and spaced throughout the day Take calcium at least 2 hours apart from MVI + iron to prevent absorption of both

Heather Zhou, RD, LD

Goals of Nutrition Therapy

CD
Replace fluid and electrolytes Replenish nutrient stores Low residue diet with strictures or fistulas Elemental diets may be beneficial

UC
Ensure adequate calorie and protein intake Replenish electrolyte losses from diarrhea Low residue diet may help irritation of infected colon

Role of Diet in IBD

Insufficient evidence that specific foods can cause IBD Individual food tolerances may vary Limit intake of certain foods and beverages that may worsen symptoms during a flare

Heather Zhou, RD, LD

Nutrition Management
Active disease (flare)
Diet should be individualized to specific tolerances and type of disease (CD vs. UC) Small, frequent meals Diet low in fiber and residue Fat-controlled diet for malabsorption Lactose-controlled diet if lactose intolerant

Asymptomatic (remission)
Small, frequent meals Progression to regular diet

Low-Fiber, Low-Residue Diet Guidelines

Residue refers to dietary compounds not broken down by the body Designed to stool rate and output
May be useful for acute phases of IBD or partial bowel obstruction

Contains ~ 10 grams of fiber Follow diet on a temporary basis only Progress to regular, well-balanced diet once symptoms disappear

Heather Zhou, RD, LD

Lactose-Controlled Diet Guidelines

Severity of lactose intolerance may vary Some lactose intolerant individuals can tolerate ~10 grams of lactose per day Try small amounts of lactose at a time
cup milk = 6 grams lactose/serving

Check food labels for hidden sources of lactose

Dry milk solids, whey, non-fat dry milk powder

Lactose-Controlled Diet Guidelines

Fermented or cultured dairy products have lactose content due to bacterial action
Aged cheeses (cheddar, Swiss), yogurt, acidophilus milk

Consider using lactose-free products

Lactaid, calcium-fortified, soy or rice milk

Include maximum amount of milk as tolerated

Key source of calcium, protein, vitamins A and D, riboflavin, and phosphorus

Heather Zhou, RD, LD

Complementary and Alternative Medicine (CAM)

Nontraditional approaches that may be used along with traditional treatments or used in place of conventional therapies >50% of IBD Pts have used some form of CAM Herbal & nutritional supplements, probiotics, and fish oil are commonly used Intolerable side effects and ineffectiveness of standard treatments are main reasons cited Inform your doctor about use of CAM

Probiotics
Live microbial food supplements that beneficially affect the host by improving its intestinal microbial balance >20 trials have been published in last few years studying role of probiotics in prevention, treatment, & maintenance of IBD Benefits of probiotics in IBD are not definite

Heather Zhou, RD, LD

Omega-3 Fatty Acids (-3 FA) (

May have anti-inflammatory properties Fish oil improved intestinal damage and inflammation in rats with experimental UC May need or dose for corticosteroid therapy in IBD patients A large North American study by Dr. WolfAGA was part of showed no benefit of fish oil in CD

Medical Food Supplements

Palatability Cost Tolerance Osmolality isotonic Elemental (amino acid-based) vs. polymeric (whole protein-based) formula Fat profile MCT vs. LCT

Heather Zhou, RD, LD

Conclusion
Malnutrition often occurs as a consequence of IBD Diet and nutrition therapy play a vital role in the management of IBD Patients adherence to suggested medical and nutrition guidelines may lead to success

In the words of Hippocrates:

"Let food be thy medicine." "He who does not know foodhow can he cure the disease of man?"

Heather Zhou, RD, LD

References
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El-Matary W. Enteral nutrition as a primary therapy of crohn's disease: The pediatric perspective. Nutr Clin Pract. 2009;24:91-97. Review. Lichtenstein GR, Hanauer SB, Sandborn WJ; Practice Parameters Committee of American College of Gastroenterology. Management of Crohn's disease in adults. Am J Gastroenterol. 2009;104:465-483. Issa M, Binion DG. Bowel rest and nutrition therapy in the management of active crohn's disease. Nutr Clin Pract. 2008;23:299-308. Wiese D, Lashner B, Seidner D. Measurement of nutrition status in crohn's disease patients receiving infliximab therapy. Nutr Clin Pract. 2008;23:551-556.

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Vagianos K, Bector S, McConnell J, Bernstein CN. Nutrition assessment of patients with inflammatory bowel disease. JPEN. 2007;31:311-319. Goh J, O'Morain CA. Nutrition and adult inflammatory bowel disease. Aliment Pharmacol Ther. 2003;17:307-320. Reiff C, Kelly D. Inflammatory bowel disease, gut bacteria and probiotic therapy. Int J Med Microbiol. 2010;300:25-33. Douglas LC, Sanders ME. Probiotics and prebiotics in dietetics practice. J Am Diet Assoc. 2008;108:510-521. Clarke JO. Mullin, GE. A review of complementary and alternative approaches to immunomodulation. Nutr Clin Pract. 2008;23:49-62.

Heather Zhou, RD, LD

References
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Bibiloni R, Fedorak RN, Tannock GW, Madsen KL, Gionchetti P, Campieri M, De Simone C, Sartor RB.VSL#3 probioticmixture induces remission in patients with active ulcerative colitis. Am J Gastroenterol. 2005;100:1539-1546. Nieto N, Torres NI, Rios A, Gil A. Dietary polyunsaturated fatty acids improve histological and biochemical alterations in rats with experimental ulcerative colitis. J Nutr. 2002;132:11-19. Crohn's and Colitis Foundation of America. Diet and nutrition. http://www.ccfa.org/info/diet. Accessed February 28, 2010. National Institute of Diabetes & Digestive & Kidney Diseases. Ulcerative colitis. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/index.htm. Accessed July 27, 2009.

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Mayo Clinic. Crohns disease. Available at: http://mayoclinic. com/health/crohns-disease/DS00104/DSECTION=treatments -and-drugs. Accessed August 8, 2009. Mayo Clinic. Ulcerative colitis. Available at: http://mayoclinic.com/health/ulcerative-colitis/DS00598/ DSECTION=lifestyle-and-home-remedies. Accessed August 8, 2009. Mayo Clinic. Lactose intolerance. Available at: http://mayoclinic.com/health/lactoseintolerance/DS00530/DS ECTION=lifestyle-and-home-remedies. Accessed February 16, 2010.