1 Author: Palmer, Mary J Title: Assessment of Nutritional Status in Endurance Runners with Crohn’s Disease The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial completion of the requirements for the Graduate Degree/ Major: MS Food and Nutritional Sciences Research Adviser: Laura Knudsen, RD Submission Term/Year: Spring, 2012 Number of Pages: 55 Style Manual Used: American Psychological Association, 6 th edition I understand that this research report must be officially approved by the Graduate School and that an electronic copy of the approved version will be made available through the University Library website I attest that the research report is my original work (that any copyrightable materials have been used with the permission of the original authors), and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office. My research adviser has approved the content and quality of this paper. STUDENT: NAME Mary Palmer DATE: 4/24/2012 ADVISER: NAME Laura Knudsen DATE: 4/24/2012 --------------------------------------------------------------------------------------------------------------------------------- This section to be completed by the Graduate School This final research report has been approved by the Graduate School. Director, Office of Graduate Studies: DATE:
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1
Author: Palmer, Mary J
Title: Assessment of Nutritional Status in Endurance Runners with Crohn’s
Disease
The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial
completion of the requirements for the
Graduate Degree/ Major: MS Food and Nutritional Sciences
Research Adviser: Laura Knudsen, RD
Submission Term/Year: Spring, 2012
Number of Pages: 55
Style Manual Used: American Psychological Association, 6th
edition
I understand that this research report must be officially approved by the Graduate School and
that an electronic copy of the approved version will be made available through the University
Library website
I attest that the research report is my original work (that any copyrightable materials have been
used with the permission of the original authors), and as such, it is automatically protected by the
laws, rules, and regulations of the U.S. Copyright Office.
My research adviser has approved the content and quality of this paper.
STUDENT:
NAME Mary Palmer DATE: 4/24/2012
ADVISER:
NAME Laura Knudsen DATE: 4/24/2012
---------------------------------------------------------------------------------------------------------------------------------
This section to be completed by the Graduate School This final research report has been approved by the Graduate School.
Director, Office of Graduate Studies: DATE:
2
Palmer, Mary J. Assessment of Nutritional Status in Endurance Runners with Crohn’s
Disease
Abstract
The purpose of this study was to investigate the nutritional deficiencies of endurance runners
with Crohn’s disease, as well as the potential implications this may have on the individual.
Subjects for this study consisted of 8 endurance runners with Crohn’s disease (M = 26.7 years,
SD = 1.78 years) and 12 endurance runners without Crohn’s disease (M = 25.3 years, SD = 1.92
years). A nutrition assessment consisting of a 3-day dietary record and self-reported height,
weight, and number of minutes/miles run per week was achieved for each athlete.
This study found statistically significant evidence that endurance runners with Crohn’s
disease may be more deficient than endurance runners without Crohn’s disease in vitamin D
(p = .019), vitamin E (p = .042), fiber (p = .018), and total caloric intake (p = .049). This study
also revealed that the extent of nutrient deficiency related to vitamin E and vitamin D
consumption may be most concerning for endurance runners with Crohn’s disease.
In conclusion, it appears that nutrition education efforts in regards to fat soluble vitamin
consumption, fiber, and total caloric intake may be beneficial for this already vulnerable
population. Overall, early detection of nutrient deficiencies may lead to early treatment, which
may aid in improving the endurance runners with Crohn’s disease performance and quality of
life.
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Acknowledgments
I would like to mention my sincere gratitude to those people who helped me complete my
research and writing of this thesis, especially my thesis advisor, Laura Knudsen, for her
longstanding support in making my thesis possible. Without her knowledge, professional
experience and commitment to learning, I may have never gotten to this point. The decision to
take on this research was a first for the both of us, and I cannot thank her enough for her
understanding, motivation, and inspiration.
I would also like to genuinely thank Dr. Carol Seaborn for always reassuring me that “I
can do this.” Not only has she assisted with my thesis work, but also served as my professor,
graduate study advisor, and mentor for the past two years. Without her help and guidance
throughout this process, I would not have been successful. Carol is always pushing me to go
above and beyond expectations, and there is no designated limit; for that I am eternally grateful.
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Table of Contents
…………………………………………………………………………………………………Page
Abstract…...……………………………………………………………………………………….2
List of Tables……………………………………………………………………………………...6
Chapter 1: Introduction…………………………………………………………………………....7
Purpose of the Study…………………………………………………………………........9
Definition of Terms………………………………………………………………………10
Assumptions and Limitations……………………………………………………………11
Chapter II: Literature Review……………………………………………………………………13
Background........................................................................................................................13
Quality of Life……………………………………………………………………………15
Exercise…………………………………………………………………………………..17
Diet……………………………………………………………………………………….20
Fat-Soluble Vitamins…………………………………………………………………….22
Fiber……………………………………………………………………………………...25
Iron……………………………………………………………………………………….26
Protein……………………………………………………………………………………27
Calories…………………………………………………………………………………..27
Chapter III: Methodology………………………………………………………………………..29
Subject Selection and Description……………………………………………………….29
Instrumentation…………………………………………………………………………..30
Data Collection Procedures………………………………………………………………30
Data Analysis…………………………………………………………………………….31
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Limitations……………………………………………………………………………….32
Chapter IV: Results………………………………………………………………………………33
Age, Gender, and Ethnicity………………………………………………………………34
Nutrient Deficiencies…………………………………………………………………….35
Figure 1: Mean percent of nutrient deficiencies among endurance runners with Crohn’s
disease……………………………………………………………………………………37
Chapter V: Discussion…………………………………………………………………………...39
Limitations……………………………………………………………………………….39
Conclusions………………………………………………………………………………40
Recommendations for Future Studies……………………………………………………43
References………………………………………………………………………………..45
Appendix A: Institutional Review Board Approval……………………………………………..49
Appendix B: Consent Form……………………………………………………………………...50
Appendix C: 3-Day Dietary Record……………………………………………………………..52
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List of Tables
Table 1: Summary of Subject Characteristics for Interval Data…………………………………34
Table 2: Nutrient Deficiencies Among Control and Experimental Endurance Runners………...36
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Chapter I: Introduction
An estimated 1.4 million Americans suffer from Crohn’s disease or ulcerative colitis;
together recognized as inflammatory bowel diseases (Crohn’s and Colitis Foundation [CCFA],
2009a). Specifically, Crohn’s disease is a confirmed cause of persistent or recurring
inflammation in one or more parts of the intestine (Banks, Present, & Steiner, 1983). As this
disease may affect any part of the gastrointestinal (GI) system, from the mouth to the anus, the
effects may reap havoc on the individual living with this condition. While genetics, gender, age,
and environment may play a large role in contributing to this callous disease, the implications
and severity may differ between individuals (Steinhart, 2006). With no known cure for Crohn’s
disease, an individual with this condition must be forced to rely on dietary restrictions, drug
therapy, or surgery to minimize the austerity of this disease and moderate any further symptoms
(Steinhart, 2006).
Crohn’s disease is recognized for being a precipitating cause of diarrhea, rectal bleeding,
abdominal pain, and fever for individuals (Sabil, 1996). As this disease can begin slowly or
develop abruptly, these symptoms produced may or may not affect the entire body. Regardless
of onset, Crohn’s disease is a severe condition that plays a significant role in an individual’s
daily lifestyle, as well as overall health and well-being. Social events, traveling and working are
occasions that may directly be affected by this condition, as a “flare-up” may occur at any time
and deter the individual from taking part in these activities. Subsequently, nutritional intake and
physical activity levels are largely affected by Crohn’s disease, and are important constituents of
typical daily activities. Research relative to the nutritional intake and physical activity for
individuals with Crohn’s disease is therefore extremely prudent and supportive in outlining
considerations that must be taken into account when attempting to manage this condition.
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Individuals with Crohn’s disease often experience a decrease in appetite, which can affect
their ability to receive adequate nutrition (Steinhart, 2006). Sound nutrient intake is prudent for
supporting the body’s basic mechanisms, metabolic pathways, as well as overall good health and
healing. This insufficiency of nutrient intake of individuals with Crohn’s disease also directly
relates to activity level, as athletes require ample nutrition to support these basic body
mechanisms, combined with the increased caloric and nutrient requirements that are directly
related to their training level. Thus, athletes with Crohn’s disease may notably be suffering even
more so than a sedentary individual with Crohn’s due to an increased level of malnourishment.
Crohn’s disease is also directly correlated with diarrhea, pain, nausea and poor absorption
of essential macronutrients and micronutrients that are vital to maintaining vitality, energy and
immunity (Sabil, 1996). While no singular diet has been proven to be effective for treating or
preventing Crohn’s disease, it is extremely important for individuals with Crohn’s disease to
follow a nutritious diet and avoid certain foods that may exacerbate symptoms (CCFA, 2009b).
An area of great interest to individuals with Crohn’s disease is diet, as many may be
forced to withstand from foods rich in fat, fiber, various meat sources, or lactose (Steinhart,
2006). Consequently, if the effects of eating a solid diet are harsh enough, an individual with
Crohn’s may be forced to consume a full-fluid diet in an attempt to limit the various illnesses and
consequences related to Crohn’s. While a restricted diet for individuals with Crohn’s disease
may be developed, such as avoiding lactose in dairy products, the overall goal of any
individual’s diet is to provide adequate nutrition levels to support the fundamental needs of the
human body (Steinhart, 2006).
Despite the suggested and proven benefits of exercise in the management and prevention
of chronic diseases, trace data exist regarding the safety and benefits of exercise in Crohn’s
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disease and whether or not the exercise may have positive or negative effects on an individual’s
health. Low-intensity exercise of moderate duration for sedentary individuals has been shown to
elicit physiologic benefits such as a slight reduction in BMI as well as psychological benefits,
without aggravating disease symptoms (Ng, Millard, Lebrun, Howard, 2007). However, a
potential gap in knowledge of the positive and negative effects of high impact exercising, such as
endurance running, in individuals with Crohn’s disease still exists.
By examining the symptoms of individuals with Crohn’s disease, it appears that nutrient
deficiencies are likely within this population, and endurance runners may be at an even more
increased risk for malnourishment. Thus, an assessment of the endurance runners with Crohn’s
disease typical dietary intake and training regimen would be a prudent step in addressing issues
particularly relevant and unique to this population. By also addressing which nutrient
deficiencies are most prevalent within endurance runners with Crohn’s disease, efforts can be
focused in areas that will most readily help in the prevention of nutrient deficiencies and
malnourishment. Also, early detection of dietary deficiencies for these individuals can lead to
early intervention, which may aid in improving the athletes’ training regimen, and overall health.
Purpose of the Study
The primary purpose of this study was to examine the dietary intake of endurance runners
with Crohn’s disease so that exact dietary deficiencies would be identified. During the winter of
2012, a 3-day dietary record was conducted on each athlete, which also consisted of self-reported
height, weight, and number of minutes/miles run per week. More specifically, the following
questions were addressed in the research.
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1. Is there a specific prescribed diet for endurance runners with Crohn’s disease that may
counteract nutrient deficiencies, and increase overall health?
2. What special considerations need to be made when combining long distance running and
attempting to manage Crohn’s?
3. How does the presence of Crohn’s disease affect the endurance runners’ training regimen
and overall quality of life?
4. Are endurance runners with Crohn’s disease at an increased risk for vitamin A, vitamin
D, vitamin E, vitamin K, fiber, iron and caloric deficiencies?
5. What is the extent of nutrient deficiencies in endurance runners with Crohn’s disease,
specifically related to vitamin A, vitamin D, vitamin E, vitamin K, fiber, iron, protein,
and calorie consumption?
Definition of Terms
For clarity of understanding and for conveying the operational definition used by the researcher,
these following terms are defined:
Crohn’s disease. An inflammatory disease which affects any region of the
gastrointestinal system, from the mouth to the anus, but most commonly affects the ileum portion
of the small intestine. Inflammation within the intestinal area extends deep into the layers of the
intestinal wall, and generally causes nausea, cramping, and abdominal pain. Potential limitations
include: diet, physical activity levels, daily functions, and medication impairment (CCFA,
2009a).
Endurance runner. An individual who runs at least 30 miles a week on average,
generally training at above 60% of maximum heart rate.
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Flare-up. Intermittent periods of the active Crohn’s disease, with symptoms such as
nausea, cramping, bloating, and abdominal pain. Generally a flare-up will not heal itself,
therefore immediate treatment is advised (CCFA, 2009a).
Inflammatory Bowel Disease (IBD). Refers to a group of inflammatory conditions that
affect the colon and the small intestine. The two most common types of IBD include Crohn’s
disease and ulcerative colitis. There is no known cure for IBD, and therefore it is considered to
be an idiopathic disease. Inflammatory bowel disease is notably not the same phenomena as
irritable bowel disease (Mayo Clinic, n.d.).
Low-intensity exercise. Includes all forms of exercise performed at about 40-60% of
maximum heart rate. Examples include: walking, slow jog, yoga, pilates and water aerobics.
Quality of life. Refers to an individual’s overall well-being; including all physical,
mental, social, and emotional aspects of life.
Remission. Periods in which symptoms disappear or decrease and good health returns.
Sedentary. A lifestyle categorized by irregular or no physical activity.
Ulcerative colitis. An inflammatory disease of the large intestine or colon region,
exclusively. The inner lining of the intestine becomes inflamed and is often most severe within
the rectal area. Ulcerative colitis only affects the lining of the bowel, and may have potential
implications with diet, physical activity levels, daily functions, and medications (Mayo Clinic,
n.d.).
Assumptions and Limitations
It is prudent to consider several underlying assumptions and limitations within this
research study. First, it was assumed that the 3-day dietary record completed by each athlete was
precise and that the individual did not inaccurately estimate the portion sizes consumed. It was
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also assumed that the athletes answered each question regarding height, weight, medication
usage, and number of minutes/miles run per week honestly. Limitations to the study included not
only the intentional recruitment of participation to this study but also the accuracy of the 3-day
record used to evaluate the athletes’ diets because of day-to-day and seasonal variation in diets.
Also, the findings in this study may not apply to other endurance runners with Crohn’s disease.
This research study also solely focused on deficiencies relative to dietary intake, rather than
deficiencies as a result of absorption. To be more accurate and precise with measuring nutrient
deficiencies, blood work among the study participants would need to be achieved; however, this
is outside the scope of this study. Finally, there could be additional variables that this study did
not anticipate that could have altered the results and conclusions.
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Chapter II: Literature Review
This chapter provides a background on Crohn’s disease and also examines the harsh
implications of Crohn’s disease on quality of life, exercise, and diet. The specific nutrients that
will be highlighted include: vitamin A, vitamin D, vitamin E, vitamin K, fiber, iron, protein, and
calories.
Background
Crohn's disease is a chronic disorder that causes inflammation within the digestive or
gastrointestinal (GI) tract (CCFA, 2009a). Although it can involve any area of the GI tract from
the mouth to the anus, the commonly affected areas include the small intestine and/or colon. In
1932, Crohn’s disease was named after Dr. Burrill B. Crohn, after he and two colleagues
published a landmark report hailed as a major advance in the identification and definition of
ileitis, an inflammation of the GI tract (Waggoner, 1983). Dr. Crohn was renowned for being the
first to describe the features of what is known today as Crohn's disease.
Crohn's disease and ulcerative colitis collectively embody a larger group of illnesses
coined as inflammatory bowel disease (IBD). Because the symptomology of these two diseases
are strikingly similar, it is sometimes difficult to establish the diagnosis definitively, and can
therefore lead to misdiagnosis of an individual. According to the Crohn’s and Colitis Foundation
of America (2009a), 10% of ulcerative colitis cases are unable to be pinpointed as either
ulcerative colitis or Crohn's disease and are called indeterminate colitis.
It is widely known that both Crohn’s disease and ulcerative colitis have one strong
feature in common; both conditions are marked by an abnormal response by the body's immune
system. The immune system is composed of various cells and proteins that normally protect the
body from infection. In people with Crohn's disease, however, the immune system reacts
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improperly and researchers believe that the immune system mistakes microbes, such as bacteria
that are normally found in the intestines, for foreign or invading substances, and launches an
attack (Mayo Clinic, n.d.). In the process, the body sends white blood cells into the lining of the
intestines, where chronic inflammation is then produced. These cells then generate harmful
products that ultimately lead to ulcerations and bowel injury. When this happens, the patient
experiences the symptoms of IBD (CCFA, 2009a).
Although Crohn's disease most commonly affects the ileum portion of the small intestine
and the colon, it may involve any part of the GI tract. However, in an individual with ulcerative
colitis, the GI involvement is limited to the colon. In Crohn's disease, all layers of the intestine
may be involved, and there can be normal healthy bowel in between patches of diseased bowel.
In contrast, ulcerative colitis affects only the superficial layers (the mucosa) of the colon in a
more even and continuous distribution, which starts at the level of the anus (Mayo Clinic, n.d.).
While considerable progress has been made in research relative to these two conditions,
investigators do not yet know what causes this disease. Studies indicate that the inflammation in
IBD involves a complex interaction of factors: the genes the individual has inherited, the
immune system, and something in the environment (Binder, 2004). Foreign substances known
as antigens in the environment may be the direct cause of the inflammation, or the antigens may
stimulate the body's defenses to produce an inflammation that continues without control.
Researchers believe that once the IBD patient's immune system is "turned on," and does not
know how to properly "turn off" at the right time (Binder, 2004). As a result, inflammation
damages the intestine and causes the symptoms of IBD, which is why the main goal of medical
therapy is to help patients effectively regulate the immune system.
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As IBD tends to run in families, genes definitely play a role in the IBD research. Studies
have shown that about 20 to 25% of patients may have a close relative with either Crohn's or
ulcerative colitis (National Institutes of Health, 2007). If a person has a relative with the disease,
the risk is about 10 times greater than that of the general population. If that relative happens to be
a brother or sister, the risk is 30 times greater.
Researchers have been working actively for some time to find a link to specific genes that
control the transmission of Crohn’s disease. An important breakthrough was achieved when the
first gene for Crohn's disease was identified by a team of IBD investigators. The researchers
were able to pick out an abnormal mutation or alteration in a gene known as NOD2/CARD 15
(McGovern, Van Heel, Ahmad, & Jewell, 2001). This mutation, which limits the ability to
recognize bacteria as harmful, occurs twice as frequently in Crohn's patients as in the general
population. However, there is no way to predict which, if any, family members will develop
Crohn's disease. The data further suggests that more than one gene may be involved, and
additional research relative to identifying specific genes in individuals with Crohn’s disease is
warranted.
Quality of Life
Crohn’s disease and ulcerative colitis collectively embody inflammatory bowel diseases
affecting an estimated 1.4 million Americans (CCFA, 2009a). Regarded as a chronic, relapsing
inflammatory condition of the gastrointestinal tract, Crohn’s disease manifestations are capable
of producing considerable harsh effects and potential morbidity. With no known cure for
Crohn’s, an individual facing this disease must rely on dietary restrictions, drug therapy, or
surgery to minimize the austerity of this disease (Steinhart, 2006). The constraints placed on
individuals with Crohn’s disease have wide-ranging implications in managing a considerably
16
normal, healthy life, and therefore entail potential limitations with daily tasks, overall diet, and
physical activities. Together, limitations in these arenas directly affect overall quality of life
(Knutson, Greenberg, Cronau, 2003).
There is complete truth in the idea that the quality of life should be the most important
consideration in the management of patients with any disease. Unfortunately, this is not
necessarily true for life-long diseases such as Crohn’s, which is not curable, and the individual is
likely subject to remissions and relapses, in combination with the probability of excess mortality
throughout life. The quality of life of an individual largely depends on many pre-existing and
unalterable factors such as socioeconomic status, intelligence, age and premorbid personality.
However, according to Gazzard (1987), the prospects of an individual with Crohn’s disease will
also be affected by the knowledge the patient has about the disease, the perceived future of the
individual as indicated by medical personnel, and perhaps most importantly, the treatment.
Research relative to the impacts of Crohn’s disease on quality of life has identified
several core limitations for these individuals. A study undertaken to identify and describe the
meaning of quality of life in patients with Crohn’s disease using a grounded theory methodology
approach assessed 11 interviewees, ages 28-83, all suffering with Crohn’s disease (Pihl-
Lesnovska, Hjortswang, El, & Frisman, 2010). The experience of quality of life was associated
with limitations in daily activity, the major theme that emerged from the analysis. Quality of life
varied depending on how the patient managed limitations related to the symptoms of the disease.
The categories of self-image, confirmatory relations, powerlessness, attitude toward life, and
sense of well-being were conceptualized as the dominant themes affected on a daily basis,
according to the respondents.
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The Mayo Clinic (2011) notes that Crohn’s disease does not just affect an individual
physically, but rather it takes an emotional toll as well. If signs and symptoms are severe and an
individual is experiencing a harsh flare-up, anxiety will only exacerbate the symptoms.
Therefore, factors such as stress should be managed with exercise, bio-feedback, regular
relaxation and breathing exercises, hypnosis, or other techniques such as listening to music,
reading, or just soaking in a warm bath (Mayo Clinic, 2011). Alternative therapies such as
acupuncture and Aloe vera have some support regarding their effectiveness in managing this
condition.
Assuming an individual is able to persevere with the signs and symptoms of Crohn’s
disease, to overall stabilize and even enhance their quality of life, exercise may be another
mediator of stress, which may in turn lessen the austerity of Crohn’s disease on the individual
(Mayo Clinic, 2011).
Exercise
Research relevant to the proven benefits of exercise and activity levels in the
management of chronic disease is widespread. Unassailable evidence has been presented
confirming the effectiveness of regular physical activity in the primary and secondary prevention
of devastating chronic diseases such as cardiovascular disease, diabetes, cancer, hypertension,
obesity, depression and osteoporosis (Warburton, Nicol, & Bredin, 2006). However, the
research specifically relevant to Crohn’s disease and physical activity levels either focus solely
on low-impact exercise or is extremely limited. Based upon preliminary studies, low-impact
exercise hosts various potential benefits such as decreasing Crohn’s disease activity, reducing
psychological stress, and improving overall quality of life (Ng, Millard, Lebrun, & Howard,
2007).
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One study evaluated the effects of a low-intensity walking program on individuals with
Crohn’s disease, and at the end of the three-month period measured drastic improvements in
maximum aerobic capacity as well as Body Mass Index (BMI) (Ng, Millard, Lebrun, Howard,
2006). This walking program also notably did not worsen gastrointestinal symptoms commonly
experienced in individuals with Crohn’s disease, and the disease condition did not deteriorate in
the measured group. However, even with these research results, a recommendation for exercise
does not currently exist for individuals with Crohn’s disease (Ng, Millard, Lebrun, & Howard,
2006).
The American College of Sports Medicine (2009) directly states that a main objective of
any exercise regimen for individuals with chronic disease includes optimizing an individual’s
functional capacity within the physiological limitations of the disease. Assumingly,
recommendations would specify only exercising if the conditions of the disease were not
intensified and adverse effects were not experienced. Therefore, low-impact exercise for
individuals with Crohn’s disease is likely to be prescribed, as improvements in quality of life,
BMI, and muscle mass have all shown improvements to exercise programs for individuals with
Crohn’s disease (Ng, Millard, Lebrun, & Howard, 2006; Loudon, Corroll, Butcher, Rawsthorne,
& Bernstein, 1999).
However, even if a low-impact exercise regimen is prescribed for individuals with
Crohn’s disease, is the individual likely to participate? A research study was performed to assess
population-based estimates of leisure-time physical activity in individuals with Crohn’s disease
or ulcerative colitis (Mack, Wilson, Gilmore, Gilmore, & Gunnell, 2011). The most prevalent
forms of leisure-time physical activity included walking, gardening, and yard work, and notably
these individuals were more likely to be classified as inactive. Despite unassailable evidence and
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claims that leisure-time physical activity may benefit ameliorating complications associated with
Crohn’s disease or ulcerative colitis, prevalence estimates from this population-based sample
suggest that the majority does not participate in any activities.
As mentioned previous, research is limited relative to more moderate and high-intensity
forms of exercise, such as running, on individuals with Crohn’s. One study was performed to
examine the effect of moderate physical exercise on gastrointestinal function in a group of
Crohn’s disease patients in remission (D’Inca et. al., 1999). The study measured specifically the
effect of one-hour’s exercise at 60% oxygen consumption in six males with Crohn’s disease on
the individual’s orocaecal transit time (breath test to lactulose), intestinal permeability,
peripheral blood chemiluminescence, lipoperoxidation, and antioxidant trace elements. Six
healthy age-matched subjects served as controls for this experiment. The results of this study did
not elicit subjective symptoms or changes in intestinal permeability, nor the other gastrointestinal
parameters examined except for output urinary excretion of Zinc. However, the researchers did
note a basal neutrophil activation in the individuals with Crohn’s, which may trigger excessive
production of oxygen metabolites. Moreover, the study notes also that exercise may contribute
to an increased risk of zinc deficiency for the Crohn’s individuals, and further research was
suggested.
Overall research relative to the implications of high-intensity aerobic exercise on
individuals with Crohn’s disease is limited, and therefore future research is suggested. From this
future research, an established upper tolerable exercise limit for individuals with Crohn’s disease
could be formulated.
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Diet
Prior research and evidence has readily indicated that inflammatory bowel diseases, such
as Crohn’s disease, are directly linked to overall diet (Mishkin, 1997; Steinhart & Cepo, 2008).
Studies have illustrated that diets considered to be westernized, marked by high consumption of
animal proteins, fats and sugars, and decreased consumption of fruits, vegetables, grains, and
olive oils, may result in a decrease in the beneficial bacteria within the intestine (Chiba, et al.,
2010). Probiotics, which host beneficial bacteria, are commonly prescribed for inflammation
within the intestinal tract and may reduce the effects of inflammatory bowel diseases (Chiba et
al., 2010). However besides probiotics, another pathway illustrated to be effective in treating the
harsh consequences of Crohn’s disease is diet, which has been claimed to keep IBD patients free
from relapse without medication.
Much research and controversy exists on the recommended diet for individuals with
Crohn’s disease, as many modified diets relative to Crohn’s disease have not been replicated.
Limiting lactose, fiber, residue-causing foods, fatty foods, and protein-rich sources are just some
of the specific diet limitations that are commonly suggested for individuals with Crohn’s disease
(Chiba et al., 2010). According to the Academy of Nutrition and Dietetics’ Crohn’s disease and
ulcerative colitis nutrition therapy manual (n.d. a), an individual may have severe difficulty with
digesting and absorbing the foods consumed, therefore vitamin and mineral supplementation is
likely recommended. The guidelines also suggest that the individual abides by the following: eat
small meals or snacks every 3 hours, when symptoms are exacerbated stick to the recommended
foods chart provided, drink enough fluids to prevent dehydration, eat foods with probiotics and
prebiotics, use a multivitamin, and during periods when symptoms do not persist, include whole
grains and a variety of fruits and vegetables in the diet.
21
While limiting foods that worsen gastrointestinal symptoms is warranted, an individual
with Crohn’s disease must be aware that deficiencies may result as a result of restriction related
to diet, and supplementation may be needed to achieve nutritional adequacy. Specific goals for
individuals with Crohn’s disease should not only address symptom management related to the
disease, but also help the individual with physical and emotional health. Goals of diet
modification for individuals with Crohn’s disease should be established to assist the individual
with feeling normal. Preventing malnutrition, normalizing bowel function, minimizing
gastrointestinal symptoms such as cramping, bloating and pain, maintaining electrolyte and fluid
balances, maintaining or improving nutritional status, and continuing social participation should
be largely considered when making any adjustments to a typical diet (Steinhart & Cepo, 2008).
Diet is one of the underlying means to preventing clinical malnutrition, especially for
individuals with Crohn’s disease (Steinhart & Cepo, 2008). Nutrient deficiencies can result over
a period of time from a lack of overall energy or caloric intake or lack from essential nutrients
such as protein, fats, vitamins, minerals, or trace elements. Malnutrition is not only a concern
because it can compromise immune function, but it also can increase susceptibility to infections,
slow wound healing, lead to poor dental health and increased bone loss, and contribute to overall
long-term health complications (Sabil, 2003).
In general, specific nutrient components and supplements should be taken into
consideration for individuals with Crohn’s disease. Calories are considered to be a top priority
as maintaining energy levels and a healthy weight is vital for a healthy lifestyle, regardless of
existence of Crohn’s disease (Sabil, 2003). Protein and iron may also be nutrients of concern, as
high-dose steroids or ongoing blood loss through diarrhea and stool may contribute to protein
and iron loss. Vitamin B12 is absorbed only in the terminal ileum portion of the small intestine,
22
so an individual with Crohn’s disease in that regional section may require supplementation due
to malabsorption of this vitamin (Steinhart & Cepo, 2008). Sodium and potassium are specific
electrolytes that are lost via feces, and should therefore be replenished within the diet. Calcium
and vitamin D are largely affected in individuals with Crohn’s disease as steroid medications
may interfere with the absorption of these nutrients (Sabil, 2003). It may be necessary for an
individual with Crohn’s disease to replace or supplement nutrients if malabsorption problems do
exist. Ultimately, the goal of any specific Crohn’s disease diet is to provide symptom
management, as well as the achievement of better physical and emotional health.
Fat-Soluble Vitamins
Sound nutrition is essential for any individual with a chronic disease, but is also
especially important in Crohn’s disease for several reasons. Firstly, an individual’s appetite is
often reduced with the nausea and discomfort experienced, which can directly result in overall
decreased nutrient intake. Secondly, chronic diseases tend to increase the energy or caloric
needs of the body, especially during an episodic flare-up. Lastly, Crohn’s disease is associated
with diarrhea and poor absorption of dietary protein, fat, carbohydrates, electrolytes, fat-soluble
vitamins, and water (CCFA, 2009b). The specific nutrients of interest within this research study,
which may be of most concern for individuals with Crohn’s disease are detailed below.
The upper segment of the small intestine known as the jejunum is where fats, fat-soluble
vitamins (A, D, E, and K), protein breakdown products, and some trace elements are absorbed.
The insufficient absorption and resulting loss of bile acids in the small intestine may adversely
affect the digestion and absorption of fats and fat-soluble vitamins in the upper small intestine,
and therefore are a major concern for individuals with Crohn’s disease (CCFA, 2009b). The fat-
soluble vitamins, A, D, E, and K will therefore be a specific focus of this research analysis.
23
The Dietary Reference Intake (DRI) is a system of nutrition recommendations from the
Institute of Medicine of the U.S. National Academy of Sciences (USDA, 2011). A DRI system
is used by both the United States and Canada and is intended both for the general public and
health professionals. The DRI was introduced in 1997 to further broaden the Recommended
Dietary Allowances (RDA) and is recognized as a conglomerate of nutritional recommendations
composed of the following: the Estimated Average Requirements, Recommended Dietary
Allowances/Recommended Daily Intake, Adequate Intake, and Tolerable Upper Intake levels
(USDA, 2011).
The vitamin A DRI for males 14-70 years of age is 900 µg/day and females 14-70 years
of age is 700 µg/day (USDA, 2011). This fat-soluble vitamin plays a significant role in both
vision and various systematic functions, including cell recognition, growth and development,
immune function and reproduction. One of the first symptoms of vitamin A deficiency is
impaired vision from the loss of visual pigments, and may also result in impaired embryonic
development, anemia, and impaired immunocompetence. Vitamin A deficiency also leads to the
keratinization of the mucous membranes that line the respiratory tract, alimentary canal, urinary
tract, skin, and epithelium of the eye. Lastly, vitamin A deficiency may also lead to impairments
in certain aspects of cell-mediated immunity, ultimately increasing the risk for infection,
particularly respiratory infection (Mahan & Escott-Stump, 2008). For individuals with Crohn’s
disease, insufficient absorption or decreased consumption of this important fat-soluble vitamin
may have many deleterious effects.
The vitamin D DRI for both males and females 14-70 years of age is 15 µg/day (USDA,
2011). Vitamin D is known as the sunshine vitamin because modest exposure to sunlight is
usually sufficient for most people to produce vitamin D through ultraviolet light and cholesterol
24
in the skin. Brief and casual exposure of the face, arms, and hands to sunlight is thought to equal
about 5 µg of vitamin D. Holick (2004) identifies sensible sun exposure as 5 to 10 minutes of
exposure of the arms and legs or the hands, arms, and face, 2 to 3 times per week. This type of
casual exposure seems to provide sufficient vitamin D to last through the winter months, when
exposure is much less. According to Huotari and Herzig (2008), since the production of vitamin
D in the skin depends on exposure to UVB-radiation via the sunlight, the level of vitamin D is of
crucial importance for the health of inhabitants who live in the Nordic latitudes where there is
diminished exposure to sunlight during the winter season. Therefore, fortification or
supplementation of vitamin D is necessary for most of the people living in the northern latitudes
during the winter season to maintain optimal body function and prevent diseases.
Vitamin D plays a significant role in various bodily functions and mechanisms including:
maintaining calcium balance, cellular differentiation and specialization, boosting immunity,
promoting insulin secretion, and blood pressure regulation. The most common effect of vitamin
D deficiency is marked by osteomalacia, also known as the reduction of overall bone density
(Mahan & Escott-Stump, 2008). For endurance runners with Crohn’s disease, this may be a
serious risk.
The vitamin E DRI for both males and females 14-70 years of age is 15 mg/day (USDA,
2011). Vitamin E plays a fundamental role in protecting the body against highly reactive oxygen
species and other free radicals. This antioxidant function suggests that vitamin E may be
extremely important in protecting the body against and treating conditions related to oxidative
stress, such as: aging, arthritis, cardiovascular disease, cataracts, diabetes, infections, and some
mild cases of Alzheimer’s disease. While vitamin E deficiency symptoms are uncommon in
humans, changes in neuromuscular functions such as balance and coordination, muscle weakness
25
and visual disturbances have been reported (Mahan & Escott-Stump, 2008). While this
deficiency may be more uncommon than the other fat-soluble vitamins, individuals who are
deficient in this antioxidant vitamin may be more susceptible to long-term oxidative stress.
The vitamin K DRI for males 14-18 years of age is 75 µg/day and males 19-70 years is
120 µg/day. For females 14-18 years of age, this value is slightly decreased at 75 µg/day and
females 19-70 years is 90 µg/day (USDA, 2011). In addition to playing an essential role in
blood clotting, vitamin K has also been recognized in the important role it also plays in bone
formation and regulation of multiple enzyme systems. The predominant sign of a vitamin K
deficiency is a hemorrhage, which in severe cases may cause fatal anemia. Notably, vitamin K
deficiencies among humans are rare, but have been associated with lipid malabsorption (Mahan
& Escott-Stump, 2008). For individuals with Crohn’s disease who are susceptible to increased
lipid malabsorption, this important fat-soluble vitamin may represent increased concern.
Fiber
Dietary fiber, also known as roughage or bulk, includes the plant component of food that
an individual’s body is unable to digest. Unlike other food components that are broken down
and digested by an individual’s body, fiber passes relatively intact throughout the stomach, small
intestine and colon (Mayo Clinic, 2009). Not only is fiber renowned for normalizing bowel
movements, but other benefits of this nutrient include: controlling blood sugar levels, lowering
cholesterol, maintaining bowel integrity and health, and also aiding in weight loss. The fiber
DRI for healthy men ages 14-50 years of age is 38 grams per day, healthy women ages 14-18
years is 26 grams per day, and healthy women ages 19-50 is 25 grams per day.
However, according to the CCFA (2009b), about two-thirds of individuals with Crohn’s
disease develop a stricture of the ileum, and therefore a low-fiber, low-residue diet or special
26
liquid diet may be beneficial in minimizing abdominal pain and other symptoms. Thus, many
individuals with Crohn’s disease are unable to achieve the fiber recommendation because of the
negative symptoms associated with increased fiber intake. Therefore, individuals with Crohn’s
disease are likely missing out on the other positive health benefits of increased fiber intake.
Notably, according to the Academy of Nutrition and Dietetics’ Crohn’s disease and
ulcerative colitis nutrition therapy manual (n.d.a), during periods of remission where an
individual is not experiencing exacerbating symptoms, whole grains and a variety of fruits and
vegetables are highly encouraged. These whole grains and fruits and vegetables are likely higher
in fiber than less nutrient-dense foods, but may exacerbate symptoms. According to the Mayo
Clinic (2009), if the high-fiber foods do not host exacerbating effects on the individual, then
these foods may be incorporated slowly. Steaming, baking, or stewing the vegetables is also
warranted rather than just consuming these foods raw. In general, most individuals have
problems digesting: broccoli, cauliflower, corn, and popcorn.
Iron
Iron is a component of red blood cells and muscles that assist in the transportation of
oxygen throughout the body. Considered to be an essential nutrient, iron is essential for the
formation of hemoglobin and certain enzymes, immune activity, proper functioning of the liver,
protection against free radicals, and transporting oxygen in the blood to all parts of the body
(Mayo Clinic, 2011). Iron deficiency, the precursor of iron deficiency anemia, is the most
common of all nutritional deficiency diseases. According to Mahan and Escott-Stump (2008),
female athletes, especially cross-country runners and others involved in endurance sports often
have an iron deficiency at some point in training if iron supplements are not used, or if a diet
lacking in iron is consumed.
27
The iron DRI for healthy men ages 14-18 years of age is 11 mg per day, 19-70 years of
age is 8 mg per day, healthy women ages 14-18 years is 15 grams per day, and healthy women
ages 19-50 is 18 grams per day (USDA, 2011). While iron deficiency is the most common of all
nutritional deficiencies, this nutrient is of major concern among endurance athletes, especially
endurance runners with Crohn’s disease.
Protein
Protein is an important nutrient, essential for growth and development of cells within the
human body. According to the USDA (2011), protein serves as the major structural component
of all the cells in the body and functions as enzymes, in membranes, as transport carriers and
some hormones. Selected animal food sources of complete protein sources include: meat,
poultry, fish, milk, cheese, and yogurt. Protein from plants, legumes, grains, nuts and vegetables
tend to be deficient in one or more of the essential amino acids and are referred to as incomplete
proteins. Regardless, the protein RDA for healthy men ages 14-18 years of age is 52 grams per
day, 19-70 years of age is 56 grams per day, healthy women ages 14-70 years is 46 grams per
day (USDA, 2011). However, these RDA values are based on 0.8 grams per kilogram of body
weight for these age groups, and athletes have increased protein needs compared to sedentary
people, but some argue how much protein athletes truly need. The protein recommendations for
endurance athletes agreed on by most researchers are 1.2 grams-1.8 grams of protein per
kilogram of body weight (USADA, n.d.).
Calories
In technical terms, a calorie can be described as the quantity of heat required to raise the
temperature of 1 gram of water by 1ºC from a standard initial temperature (Mahan & Escott-
Stump, 2008). However, a calorie is most commonly referred to when speaking about specific
28
dietary and nutrient intake among individuals, and providing the overall energy an individual
needs to accomplish daily tasks. The energy, or calorie needs, of endurance athletes are high.
According to the Academy of Nutrition and Dietetics (n.d.b), every athlete’s calorie needs are
different depending on factors such as: gender, age, body composition, training regimen, and
daily activities. During heavy training and racing cycles, an individual should avoid extreme
changes in weight. Smaller athletes in light training may need fewer than 1,600 calories per day;
larger athletes and those in heavy training may need well over 5,000 calories per day. A severe
deficiency in total calorie intake may result in: dramatic weight loss, unresponsiveness,
weakness, cachexia, irritability, loss of appetite, apathy, and a compromised immune systems.
For individuals with Crohn’s disease, who are likely at increased risk of nutrient deficiencies,
total calorie intake is extremely prudent in maintaining the body’s basic mechanisms and
functions.
By examining the symptoms of individuals with Crohn’s disease, it appears that nutrient
deficiencies are likely within this population, and endurance runners may be at an even more
increased risk for malnourishment. Thus, an assessment of the typical dietary intake and training
regimen of endurance runners with Crohn’s disease would be a prudent step in addressing issues
particularly relevant and unique to this population.
29
Chapter III: Methodology
The purpose of this study was to examine the dietary intake of endurance runners with
Crohn’s disease so that exact dietary deficiencies would be identified. During the winter of
2012, a 3-day dietary record was conducted on each athlete, which also consisted of self-reported
height, weight, and number of minutes/miles run per week. This chapter includes a description
of how the subjects were selected, a description of the sample, and a description of the
instrumentation used. The method for collecting the data and data analysis are discussed,
followed by limitations in the methodology.
Subject Selection and Description
Subject selection and data collection only began after gaining approval from the
University of Wisconsin-Stout Institutional Review Board (IRB) (See Appendix A). As this
research was a convenient sample study, endurance runners with and without Crohn’s disease, at
least 18 years of age, that currently run at least 35 miles per week, were recruited for this study.
All control subjects recruited for this study were selected from the Eastern Minnesota, Western
Wisconsin area. For the experimental group, because endurance runners with Crohn’s disease is
an extremely limited population, the researcher contacted the Team Challenge for Crohn’s and
Colitis endurance training and fundraising group for volunteers. Therefore, the experimental
group contains individuals with Crohn’s disease not specific to the Eastern, Minnesota, Western
Wisconsin area, but the entire United States as a whole.
Recruitment was completed throughout January 2012. The researcher had an initial goal
of recruiting eight endurance runners with Crohn’s disease that would serve as the experimental
group, and 12 endurance runners without Crohn’s disease that would serve as the control group.
30
The goal number was not derived from sampling calculations for statistical analyses, rather the
number was a realistic goal given the research objectives and available resources.
Endurance runners who were interested in participating in the study were informed by the
researcher about the purpose, risks, procedures, and requirements of the study by reading the
IRB approved consent form (See Appendix B). Participants signed the consent form to
acknowledge the purpose of the research and the completely voluntary role as a participant.
Participants also had the option of withdrawing at any time during the course of this research
without any adverse consequences.
Instrumentation
The researcher developed a 3-day dietary record form (See Appendix C) that included a
short questionnaire. The dietary record form that was used by the researcher was used to assess
each subject’s average caloric, macronutrient, and micronutrient intake. The form also included
several questions addressing the following information: the subject’s gender, height, weight,
estimated miles and minutes run per week, and medications and nutritional supplements
consumed. There were concise, specific directions located at the top of the sheet that reminded
the subjects to be specific when recording the type and amount of the foods and fluids consumed.
Data Collection Procedures
Individuals with Crohn’s disease for this study were selected from the Team Challenge
for Crohn’s and Colitis training group, an endurance training and fundraising program for
Crohn’s disease research. The control group subjects for this study were selected from the
Eastern Minnesota, Western Wisconsin area. All athletes were defined as currently endurance
training, and running more than 35 miles per week or 200 minutes per week if miles were not
reported, and at least 18 years of age.
31
Data was collected throughout January 2012. The nutrition assessment aimed at
identifying specific nutrient deficiencies among the experimental group and control group.
Data Analysis
The Food Processor SQL Edition version 9.9 computer software program was used to
analyze the 3-day dietary records. This software program employs calorie and protein
recommendations that are based on calculations from the Dietary Reference Intakes (DRI) for
Macronutrients, 2002 and also the DRI 1997-2001 for all vitamins, minerals, and associated
compounds. The dietary intake of an individual, upon being entered, is compared to the
Recommended Dietary Allowance (RDA) of a given nutrient, which is the average daily dietary
nutrient intake level that is sufficient enough to meet the nutrient requirement of nearly all (97 to
98 percent) healthy individuals in a particular life stage and gender group.
Also, the program uses DRI formulas to calculate calorie needs for all age groups, taking
into account the sex, age, height, weight, and activity level of individuals. The total basic calorie
formula is as follows: TEE = (Total Energy Expenditure) = A = B x age + PA x (D x weight + E
x height), where: TEE = calories per day, age = years, weight = kilograms, height = meters, A =
constant term, B = age coefficient, PA = physical activity coefficient, which depends on whether
the individual fits into the sedentary, low active, active, or very active category, D = weight
coefficient, and E = height coefficient. For consistency, when entering each individual’s 3-day
dietary record into the Food Processor SQL Edition 9.9 computer program, an activity level of
very active was used for each individual.
The Statistical Program for Social Sciences (SPSS) version 20.0 computer software
program was used to analyze the data for specific nutrient deficiencies among the endurance
runners with Crohn’s disease. Descriptive statistics including the mean, median, and standard
32
deviation were conducted on the interval and ratio data. The Fisher’s exact test was used to
identify if endurance runners with Crohn’s disease were more susceptible to specific nutrient
deficiencies: vitamin A, vitamin D, vitamin E, vitamin K, fiber, iron, protein, and total caloric
intake.
Limitations
Participants in this study were intentionally recruited; however, it is unlikely that the
small sample in this research study is representative of all endurance runners with Crohn’s
disease. Although all individuals who met the participation criteria were eligible to participate,
not everyone chose to participate. The results of this study cannot be extended to all endurance
runners and the sample selection could be biased.
Another major limitation to this study was the small sample size (N = 20); thus the
statistics should be considered with caution. Notably, only two men (n = 2) from the
experimental group and four men (n = 4) from the control group participated in this study.
Therefore, the results may be lacking in representing male endurance runners specifically, but
may be more representative of female endurance runners. The study also assumed that the
nutrition assessment performed was both valid and reliable in assessing risk of nutrient
deficiencies.
33
Chapter IV: Results
The primary purpose of this study was to examine the dietary intake of endurance runners
with Crohn’s disease so that exact dietary deficiencies may be identified. During the winter of
2012, a 3-day dietary record was conducted on each athlete, which also consisted of self-reported
gender, height, weight, and number of miles run per week; minutes were reported if exact miles
were not reported. More specifically, the following questions were addressed in the research.
1. Is there a specific prescribed diet for endurance runners with Crohn’s disease that may
counteract nutrient deficiencies, and increase overall health?
2. What special considerations need to be made when combining long distance running and
attempting to manage Crohn’s?
3. How does the presence of Crohn’s disease affect the endurance runners’ training regimen
and overall quality of life?
4. Are endurance runners with Crohn’s disease at an increased risk for vitamin A, vitamin
D, vitamin E, vitamin K, fiber, iron, protein, and caloric deficiencies?
5. What is the extent of nutrient deficiencies in endurance runners with Crohn’s disease,
specifically related to vitamin A, vitamin D, vitamin E, vitamin K, fiber, iron, protein,
and calorie consumption?
While the first three questions were addressed in the review of literature, in order to
answer the last two research questions, the 3-day dietary records were analyzed. This chapter
discusses the outcomes of this study looking specifically at the nutritional deficiencies in
endurance runners with Crohn’s disease and the extent of each nutrient deficiency. Table 1
summarizes the demographics of the control and experimental subject characteristics for the
interval data collected.
34
Table 1
Summary of Subject Characteristics for Interval Data
Characteristic Control Runners with Crohn’s
Number of individuals 12 8
Age 25.3 (1.92) 26.7 (1.78)
Height (inches) 66.08 (2.58) 66.00 (3.12)
Weight (pounds) 131.58 (17.36) 132.88 (16.6)
Miles run per week 48.12 (9.19) 43.44 (8.23)
Note. Numbers listed in parentheses indicate standard deviation.
Age, Gender, and Ethnicity
All 20 subjects contacted were asked to participate in this study and all 20 consented to
participate. The subjects ranged in age from 22 to 31 years in the control group of endurance
runners without Crohn’s disease (M = 25.3 years, SD = 1.92), and ranged in age from 21 to 33
years in the experimental group of endurance runners with Crohn’s disease (M = 26.7 years, SD
= 1.78). This study looked at both males and females; however, there was a larger proportion of
female subjects in both groups. There were four male subjects (n = 4) and eight female subjects
(n = 8) in the control group, and two male subjects (n = 2) and six female subjects (n = 6) in the
experimental group. The subjects ranged in height from 62 to 71 inches in the control group
(M = 66.08, SD = 2.58) and from 62 to 70 inches in the experimental group (M = 66.00, SD =
3.12); the weight of the subjects in the control group ranged from 106 pounds to 160 pounds
(M = 131.58, SD = 17.36), and from 104 to 152 pounds in the experimental group (M = 132.88,
SD = 16.6). The subjects ranged in number of miles run per week from 35 to 70 miles in the
control group (M = 48.12, SD = 9.19), and 35 miles to 60 miles in the experimental group (M =
35
43.44, SD = 8.23). Ethnicity was not assessed within this research study, therefore, specific
ethnicities were not reported.
Nutrient Deficiencies
The 3-day dietary record received from each athlete was entered into the Food Processor
SQL version 9.9 computer program and analyzed for nutrient deficiencies. The fourth research
question examined if endurance runners with Crohn’s disease were at an increased risk for
vitamin A, vitamin D, vitamin E, vitamin K, fiber, iron, protein, and caloric deficiencies. To
answer this question, the individual assessed was noted as deficient if the specific nutrient
consumed was less than or equal to 66% of the Recommended Daily Intake (RDI). The RDI is
the daily intake level of a specific nutrient that is considered to be sufficient to meet the
requirements of 97-98% of healthy individuals in every demographic in the United States. An
RDI is a major subcategory of the Dietary Reference Intake (DRI) issued by the Institute of
Medicine.
Table 2 illustrates a comparison of the specific nutrients of focus among the control and
the experimental group. The Fisher’s exact test was conducted to assess statistical significance
in the specific nutrient deficiencies among these two groups. The Chi-squared statistical test
would have been employed, however due to the small sample size in both the control and
experimental group, the Fisher’s exact test was more appropriate.
Table 2 identifies that endurance runners with Crohn’s disease in this research study were
more likely to be deficient in vitamin D (p = 0.19), vitamin E (p = .042), fiber (p = .018), and
total calories (p = .049) when compared to the control group of endurance runners without
Crohn’s disease. While endurance runners with Crohn’s disease were not more likely to be
deficient in vitamin A, vitamin K, and iron than the control group, iron may still be a nutrient of
36
concern in both groups, as 6 of the 8 experimental subjects (75.0%) were deficient in iron
consumption from the 3-day dietary record.
Also, while statistically significant results were not reported regarding iron deficiency
among endurance runners with Crohn’s disease compared to endurance runners without Crohn’s
disease, it is noteworthy to mention that among the experimental group, 75.0% (n = 6) and
among the control group, 33.3% (n = 4) individuals were still iron deficient. Notably, 0% (n = 0)
of the individuals among the experiment group currently consume an iron supplement, whereas
58.3% (n = 7) of the individuals among the control group indeed consume an iron supplement.
Table 2
Nutrient Deficiencies Among Control and Experimental Endurance Runners
Nutrient Control Runners with Crohn’s Significance
Yes No Yes No
Vitamin A 6(50.0) 6(50.0) 3(37.5) 5(62.5) NS
Vitamin D 2(16.7) 10(83.3) 6(75.0) 2(25.0) p=.019*
Vitamin E 6(50.0) 6(50.0) 8(100.0) 0(0.0) p=.042*
Vitamin K 3(25.0) 9(75.0) 4(50.0) 4(50.0) NS
Fiber 1(8.3) 11(91.7) 5(62.5) 3(37.5) p=.018*
Iron 4(33.3) 8(66.7) 6(75.0) 2(25.0) NS
Protein
Calories
2(16.7)
0(0.0)
10(83.3)
12(100.0)
0(0.0)
3(37.5)
8(100.0)
5(62.5)
NS
p=.049*
Note. NS= Not significant; *= significance, as p <.05, two-tailed. Numbers listed in parentheses
represent percent among the group. “Yes” implies deficient, “No” implies not deficient.
The fifth question addressed the extent of nutrient deficiencies in endurance runners with
Crohn’s disease, specifically related to vitamin A, vitamin D, vitamin E, vitamin K, fiber, iron,
protein, and calorie consumption. To answer this question, the endurance runners with Crohn’s
disease that were deficient in each specific nutrient were assessed, and the mean percentage
37
deficiency was calculated. For the protein intake calculation, rather than using the RDA for
protein consumption of 0.8 grams of protein per kilogram of bodyweight for a healthy, sedentary
individual, 1.4 grams of protein per kilogram of bodyweight was used based upon the most
recent average recommended intake for athletes (USADA, n.d.). Figure 1 displays that of the
endurance runners deficient in each specific nutrient, on average, vitamin D (28.77%) and
vitamin E (34.25%) may be the most concerning, where the percent deficient in vitamin K
(20.3%), iron (17.89%), fiber (14.8%), vitamin A (2.88%), total calories (1.31%), and protein
(0.0%) may be less concerning.
Figure 1. Mean percent of nutrient deficiencies among endurance runners with Crohn’s
disease.
Also, the 3-day dietary questionnaire revealed that of the 12 control subjects, 41.6%
(n = 5) consumed a multivitamin, whereas only 12.5% (n = 1) individual from the experimental
group consumed a multivitamin. Other reported vitamin/mineral supplements reported among
the control group include: fish oil, 16.7% (n = 2), and B-complex, 5.0% (n = 1). There were no
2.88
28.7
34.25
20.3
14.8
17.89
0 1.31
0
5
10
15
20
25
30
35
40
Vitamin A Vitamin D Vitamin E Vitamin K Fiber Iron Protein Calories
Pe
rce
nt
de
fici
en
t (%
)
Nutrient
38
other reported vitamin/mineral supplements consumed among the experimental group. However,
in terms of medication usage, 50% (n = 4) of the endurance runners with Crohn’s disease
reported consuming Remicade medication for Crohn’s disease. The implications of these results
are discussed further in Chapter 5.
39
Chapter V: Discussion
This study explored the nutritional intake of endurance runners with Crohn’s disease so
that exact dietary deficiencies would be identified. During the winter of 2012, a 3-day dietary
record was conducted on each athlete, which also consisted of self-reported height, weight, and
number of miles run per week; minutes per week were reported if exact miles were not reported.
This chapter starts the limitations to the study, draws conclusions from the results and compares
the findings to other research, and makes recommendations for future studies.
Limitations
As mentioned previous, it is prudent to consider several underlying assumptions and
limitations within this research study. First, it was assumed that the 3-day dietary record
completed by each athlete was precise and that the individual did not inaccurately estimate the
portion sizes consumed. It was also assumed that the athletes answered each question regarding
height, weight, medication usage, and number of minutes/miles run per week honestly.
Limitations to the study included not only the intentional recruitment of participation to this
study but also the accuracy of the 3-day record used to evaluate the athletes’ diets because of
day-to-day and seasonal variation in peoples’ diets. Also, the findings in this study may not
apply to other endurance runners with or without Crohn’s disease. This research study also solely
focused on deficiencies relative to dietary intake, rather than deficiencies as a result of
absorption. To be more accurate and precise with measuring nutrient deficiencies, blood work
among the study participants would need to be achieved; however, this is outside the scope of
this study. Finally, there could be additional variables that this study did not examine that could
alter the results and conclusions.
40
Conclusions
As this study examined the dietary intake of endurance runners with Crohn’s disease,
each endurance athlete with Crohn’s disease presented a risk factor for nutrient deficiencies.
According to the Beth Israel Deaconess Medical Center (2012), nutritional complications are
commonly witnessed in patients with Crohn’s disease, including deficiencies of proteins,
calories, or vitamins. These deficiencies are most commonly attributed to inadequate dietary
intake, intestinal loss of protein, or poor absorption of nutrients as a consequence of the
underlying inflammation.
Within this research, statistically significant results report that endurance runners with
Crohn’s disease are more likely to be deficient in the following nutrients than endurance runners
without Crohn’s disease: vitamin D, vitamin E, fiber, and total caloric intake. The largest
nutrient deficiencies among the control group included three out of the four fat-soluble vitamins,
respectively: vitamin E, vitamin D, and vitamin K. This directly relates to the ideology of the
CCFA (2009b), which states that affecting as many as 68% of people, vitamin D deficiency is
one of the most common nutrient deficiencies seen in association with Crohn’s disease; however,
fat-soluble vitamins in general tend to be less absorbed than the water-soluble vitamins in
individuals with Crohn’s disease.
While statistically significant results were not reported regarding iron deficiency among
endurance runners with Crohn’s disease compared to endurance runners without Crohn’s disease,
it is noteworthy to mention that among the experimental group, 75.0% (n = 6) and among the
control group, 33.3% (n = 4) individuals were still iron deficient. This draws a major red flag, as
iron is the nutrient essential for the transportation of oxygen to from the lungs to the rest of the
body, which is extremely prudent for endurance runners.
41
According to the Linus Pauling Institute (2006), daily iron losses have been found to be
greater in athletes in intense endurance training. This may be due to increased microscopic
bleeding from the gastrointestinal tract or increased fragility and hemolysis of red blood cells.
According to the Food and Nutrition Board (2001), the average requirement for iron may be 30%
higher for those individuals who engage in regular intense exercise. Notably, 0% (n = 0) of the
individuals among the experimental group currently consume an iron supplement, whereas
58.3% (n = 7) of the individuals among the control group indeed consume an iron supplement.
This may relate to research performed by Jeejeebhoy (2002), which states that while iron
deficiency is general treated with iron supplements starting with doses of 300 mg once a day,
individuals with inflammatory bowel disease, such as Crohn’s disease, often do not tolerate oral
iron. In addition, there is some evidence that iron in the colon increases oxidative stress and may
exacerbate inflammation. For these reasons, if necessary, administration of iron by intravenous
infusion or intramuscular injection may be warranted.
While medications and nutritional supplements consumed were not the major focus of
this research study, it may be noteworthy to mention. Fifty percent (n = 4) of the individuals in
the experimental group were currently consuming a medication prescribed for Crohn’s disease,
more specifically Remicade. Remicade (Infliximab injection) is an injection used to relieve the
symptoms of certain autoimmune disorders, such as Crohn’s disease, and is in a class of
medications called tumor necrosis factor-alpha (TNF-alpha) inhibitors (National Institutes of
Health, 2012). This medication works by blocking the action of TNF-alpha, a substance in the
body that causes inflammation. As a result of consuming this medication, individuals with
Crohn’s disease often experience decreased inflammation along the gastrointestinal tract, and
42
therefore experience fewer flare-ups. Thus, these individuals are likely able to maintain a
relatively normal diet, quality of life, and exercise regimen.
Also notable, 41.6% (n = 5) of the individuals from the control group currently reported
consuming a multivitamin, whereas only 12.5% (n = 1) individual from the experimental group
currently reported consuming a multivitamin. This may draw a major red flag, as according to
the Academy of Nutrition and Dietetics’ Crohn’s disease and ulcerative colitis nutrition therapy
manual (n.d.a), a multivitamin is warranted for individuals with Crohn’s disease to counteract
any risk of malnutrition for these individuals. This is similar to the recommendations
encouraged by the University of Maryland Medical Center (2011), in that decreased appetite,
malabsorption, diarrhea, side effects of medications, and surgical removal of parts of the
intestine may increase vitamin and mineral deficiencies in individuals with Crohn’s disease.
Therefore, multivitamin consumption is strongly encouraged.
Based on this study, endurance runners with Crohn’s disease exhibit nutritional intake-
related deficiencies with regards to: vitamin D, vitamin E, fiber, and total caloric intake.
However, the most dramatic deficiencies among the experimental group members who elicited a
nutritional deficiency included three out of the four fat-soluble vitamins: vitamin D, vitamin E,
and vitamin K. Notably, although not statistically significant, iron is a nutrient of concern
among both the experimental and control group as 50% of the endurance runners from each
group were nutritionally deficient.
In conclusion, by addressing which nutrient deficiencies are most prevalent within
endurance runners with Crohn’s disease, such as vitamin D, vitamin E, fiber, and calories, efforts
can be focused in areas that will most readily help in the prevention of nutrient deficiencies and
malnourishment. Also, early detection of dietary deficiencies for these individuals can lead to
43
early intervention, which may aid in improving the athletes’ training regimen, quality of life, and
overall health. Possible nutrient supplementation is warranted and encouraged for those
individuals who are likely to be nutritionally deficient, and unable to consume adequate intake
from the diet, both endurance runners with Crohn’s disease and endurance runners without
Crohn’s disease.
Recommendations for Future Studies
As this research study utilized a relatively selective, small sample size, it may be wise to
include a larger sample size of endurance runners with Crohn’s disease. While this study did
include both male and female endurance runners, the proportion of females heavily outweighed
the proportion of male endurance runners. Therefore, it is recommended to include a larger
sample of both male and female endurance runners with and without Crohn’s disease. Also, the
population was relatively homogenous in terms of height, weight, body stature, and number of
minutes/miles run per week. It is encouraged to encompass a more diverse population sample
that would better reflect all endurance runners with Crohn’s disease. Lastly, while this study
solely focused on the nutrition-related deficiencies of endurance runners with Crohn’s disease,
determining the actual absorption-related deficiency through measured blood testing would be a
better indicator of the specific deficiencies, if funds permit.
44
References
Academy of Nutrition and Dietetics. (n.d.a). Crohn’s disease and ulcerative colitis nutrition
therapy. Retrieved from
http://sipuebla.com/discus/messages/7/ADA_Crohn_s_and_Ulcerative_Colitis-82.pdf
Academy of Nutrition and Dietetics. (n.d.b). Eat right for endurance. Retrieved from
http://www.eatright.org/Public/content.aspx?id=7085
American College of Sports Medicine. (2009). ACSM’s exercise management for persons with
chronic disease and disabilities (3rd
ed.). Champaign, IL: Human Kinetics.
Banks, P. A., Present, D. H., & Steiner, P. (1983). The Crohn's disease and ulcerative colitis fact
book. New York, NY: Macmillan.
Beth Israel Deaconess Medical Center. (2012). What are the complications of Crohn’s disease?
Retrieved from
http://www.bidmc.org/CentersandDepartments/Departments/DigestiveDiseaseCenter/Infl
ammatoryBowelDiseaseProgram/CrohnsDisease/WhatarethecomplicationsofCrohnsdisea
se.aspx
Binder, V. (2004). Epidemiology of IBD during the twentieth century: An integrated view.
Clinical Gastroenterology, 18(3), 463-479. Retrieved from
http://www.mendeley.com/research/epidemiology-of-ibd-during-the-twentieth-century-
an-integrated-view/
Chiba, M., Abe, T., Tsuda, H., Sugawara, T., Tsuda, S., Tozawa,… Imai, H. (2010). Lifestyle-
related disease in Crohn's disease: Relapse prevention by a semi-vegetarian diet. World
Journal of Gastroenterology, 16(20), 2484-2495. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877178/pdf/WJG-16-2484.pdf
45
Crohn’s and Colitis Foundation of America (CCFA). (2009a). About Crohn’s disease. Retrieved
from http://www.ccfa.org/info/about/crohns
Crohn’s and Colitis Foundation of America (CCFA). (2009b). Diet and nutrition. Retrieved from
http://www.ccfa.org/info/diet?LMI=5.2
D’Inca, R., Varnier, M., Mestriner, C., Martines, C., Martines, D., D’Odorico, A., & Sturniolo,
G. C. (1999). Effect of moderate exercise on Crohn’s disease patients in remission.
Italian Journal of Gastroenterology and Hepatology, 31(3), 205-210. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/10379481
Food and Nutrition Board, Institute of Medicine. (2001). Dietary reference intakes for vitamin A,
vitamin K, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel,
silicon, vanadium, and zinc. Washington DC: National Academy Press.
Gazzard, B. G. (1987). The quality of life in Crohn’s disease. International Journal of
Gastroenterology and Hepatology, 28(4) 378-381. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1432820/
Holick, M. F. (2004). Sunlight and vitamin D for bone health and prevention of autoimmune
diseases, cancers and cardiovascular disease. American Journal of Clinical Nutrition,
80(6), 1678S.
Huotari, A. & Herzig, K. H. (2008). Vitamin D and living in northern latitudes-an endemic risk
area for vitamin D deficiency. International Journal of Circumpolar Health, 67(2-3),
164-178.
Jeejeebhoy, K. N. (2002). Clinical nutrition: 6. Management of nutritional problems of patients
with Crohn’s disease. Canadian Medical Association Journal, 166(7) 913-918.
Retrieved from http://www.cmaj.ca/content/166/7/913.full.pdf+html
46
Knutson, D, Greenberg, G, & Cronau, H. (2003). Management of Crohn's disease-a practical
approach. American Family Physician, 68(4), 707-715. Retrieved from
http://www.aafp.org/afp/2003/0815/p707.html
Linus Pauling Institute. (2006). Micronutrient information center. Retrieved from
http://lpi.oregonstate.edu/infocenter/minerals/iron
Loudon, C. P., Corroll, V., Butcher, J., Rawsthorne, P., & Bernstein, C.N. (1999). The effects of
exercise on patient's with Crohn's disease. The American Journal of Gastroenterology,
94(3), 697-703. Retrieved from
http://www.sciencedirect.com/science/article/pii/S000292709800820X
Mack, D., Wilson, P. M., Gilmore, J. C., & Gunnell, K. E. (2011). Leisure-time physical activity
in Canadians living with Crohn’s disease and ulcerative colitis: Population-based
estimates. Gastroenterology Nursing, 34(4). 288-294. doi:
10.1097/SGA.0b013e3182248732
Mahan, L. K., & Escott-Stump, S. (2008). Krause’s food and nutrition therapy. St. Louis, MO:
Saunders, Elsevier.
Mayo Clinic. (2009). Dietary fiber: Essential for a healthy diet. Retrieved from
http://www.mayoclinic.com/health/fiber/NU00033
Mayo Clinic. (n.d.). Inflammatory bowel disease. Retrieved from
http://www.mayoclinic.org/ibd/
Mayo Clinic. (2011). Iron supplement (oral route, parenteral route). Retrieved from
http://www.mayoclinic.com/health/drug-information/DR602285
47
McGovern, D. P., Van Heel, D. A., Ahmad, T., & Jewell, D. P. (2001). NOD2 (CARD15), the
first susceptibility gene for Crohn’s disease. Gut, 49(6), 752-754. Retrieved from
http://gut.bmj.com/content/49/6/752.full
Mishkin, S. (1997). Dairy sensitivity, lactose malabsorption, and elimination diets in
inflammatory bowel diseases. The American Journal of Clinical Nutrition, 65(2), 564-
567. Retrieved from http://www.ajcn.org/content/65/2/564.full.pdf+html?sid=ad7bc0ae-
f208-4cec-820f-2edd72df6b09
National Institutes of Health. (2007). Crohn’s disease. Retrieved from
http://www.ghr.nlm.nig.gov/condition/crohns-disease
National Institutes of Health. (2012). Inflixmab injection. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000267/
Ng, V., Millard, W., Lebrun, C., & Howard, J. (2006). Exercise and Crohn's disease:
Speculations on potential benefits. Canadian Journal of Gastroenterology, 20(10), 657-
660. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660794/pdf/cjg200657.pdf
Ng, V., Millard, W., Lebrun, C., & Howard, J. (2007). Low-intensity exercise improves quality
of life in patients with Crohn's disease. The Clinical Journal of Sports Medicine, 17(5),
384-388. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17873551
Pihl-Lesnovska, K., Hjortswang, H., El, A., & Frisman, G. H. (2010). Patients’ perspectives of
factors influencing quality of life while living with Crohn’s disease. Gastroenterology
Nursing, 33(1) 37-44. doi: 10.1097/SGA.0b013e3181cd49d0
Sabil, F. (1996). Crohn's disease and ulcerative colitis: Everything you need to know. Buffalo,
NY: Firefly Books Inc.
48
Steinhart, A.H. (2006). Crohn's and colitis: Understanding and managing IBD. Toronto,
Ontario: Robert Rose Inc.
Steinhart, A. H., & Cepo, J. (2008). Crohn's and colitis diet guide. Toronto, Ontario: Robert
Rose Inc.
United States Department of Agriculture (USDA) (2011). Dietary reference intakes:
Recommended intakes for individuals. Retrieved from
http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrit
ion/DRIs/RDA%20and%20AIs_Vitamin%20and%20Elements.pdf
United States Anti-Doping Agency (USADA) (n.d.). Optimal dietary intake. Retrieved from
http://www.usada.org/diet
University of Maryland Medical Center. (2011). Crohn’s disease treatment. Retrieved from
http://www.umm.edu/patiented/articles/how_symptoms_managed_000103_8.htm
Waggoner, W. (1983). Dr. Burrill B. Crohn, 99, an expert of the intestinal tract. The New York
Times. Retrieved from http://www.nytimes.com/1983/07/30/obituaries/dr-burrill-b-
crohn-99-an-expert-on-diseases-of-the-intestinal-tract.html
Warburton, D., Nicol, C.W., & Bredin, S. (2006). Health benefits of physical activity: The
evidence. Canadian Medical Association Journal, 174(6) 801-809. Retrieved from
http://www.canadianmedicaljournal.ca/cgi/content/full/174/6/801 doi:
10.1503/cmaj.051351
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Appendix A: Institutional Review Board Approval
November 9, 2011
Mary Palmer
Food and Nutritional Sciences Department
UW-Stout
Title: “As assessment of nutritional status in endurance runners with and without Crohn's Disease”
Subject: Protection of Human Subjects
Dear Mary,
In accordance with Federal Regulations, your project, “As assessment of nutritional status in endurance runners
with and without Crohn's Disease” was reviewed on November 9, 2011, by a member of the Institutional Review
Board and was approved under Expedited Review through November 8, 2012.
If your project involves administration of a survey or interview, please copy and paste the following message
to the top of your survey/interview form before dissemination:
If you are conducting an online survey/interview, please copy and paste the following message to the top of the
form:
“This research has been approved by the UW-Stout IRB as required by the Code of Federal regulations Title
45 Part 46.”
Responsibilities for Principal Investigators of IRB-approved research:
1. No subjects may be involved in any study procedure prior to the IRB approval date or after the expiration
date. (Principal Investigators and Sponsors are responsible for initiating Continuing Review proceedings.)
2. All unanticipated or serious adverse events must be reported to the IRB.
3. All protocol modifications must be IRB approved prior to implementation, unless they are intended to
reduce risk.
4. All protocol deviations must be reported to the IRB.
5. All recruitment materials and methods must be approved by the IRB prior to being used.
6. Federal regulations require IRB review of ongoing projects on an annual basis.
Thank you for your cooperation with the IRB and best wishes with your project.
Should you have any questions regarding this letter or need further assistance, please contact the IRB office at 715-
232-1126 or email [email protected].
Sincerely,
Susan Foxwell
Research Administrator and Human Protections Administrator,
UW-Stout Institutional Review Board for the Protection of Human Subjects in Research (IRB)
*NOTE: This is the only notice you will receive – no paper copy will be sent
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Appendix B: Consent form
UW-Stout Signed Consent Form
for Research Involving Human Subjects
Consent to Participate In UW-Stout Approved Research
Title: An assessment of nutritional status in endurance athletes with Crohn’s disease.
Investigator: Research Sponsor:
Mary Joann Palmer Laura Knudsen
[email protected] [email protected]
715-573-6316 715-232-3491
Description: The objective of this study is to identify direct nutritional implications and deficiencies of
endurance runners with Crohn's disease by collecting data from both endurance runners with
Crohn's disease and endurance runners without Crohn's disease. From this data, the potential
implications related to dietary intake such as specific nutritional deficiencies may be identified.
Risks and Benefits: Potential risks from this study may include invasion of privacy by collecting the 3-day dietary
recall information, or risk to dignity and self-respect. These issues may be a concern if the
individual feels that it is intrusive to share every aspect of their diet and may feel embarrassed in
doing so. However, as mentioned previous, this information will be held completely
confidential. Nutrient deficiencies or high caloric intake may be identified from the 3-day
dietary recall. This may affect the individuals' dignity or self-respect in a negative manner. The
overall potential benefit is a better understanding of a specific diet for endurance runners with
Crohn's disease; therefore the potential benefit may outweigh the risks of this study and should
therefore be strongly considered.
Time Commitment and Payment: Each subject is asked to complete the signed consent form, and 3-day dietary recall form. This
may require an estimated one hour time commitment; however it is prudent to achieve precision
and accuracy in collecting this data, as it directly affects each individual’s specific results.
Inaccuracy may distort typical dietary intake, and thus overall results.
Confidentiality: Your name will not be included on any documents. We do not believe that you can be identified
from any of this information, as each individual will be assigned an anonymous numeric code by
an individual not associated with this study. The data collected during the assessment will be
kept in a locked safe in which only the researcher and researcher’s advisor will have access.
This informed consent will not be kept with any of the other documents completed with this
project, and all data and information collected will be destroyed upon completion of thesis
research.
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Right to Withdraw:
Your participation in this study is entirely voluntary. You may choose not to participate without
any adverse consequences to you. Should you choose to participate and later wish to withdraw
from the study, you may discontinue your participation at this time without incurring adverse
consequences.
IRB Approval:
This study has been reviewed and approved by The University of Wisconsin-Stout's Institutional
Review Board (IRB). The IRB has determined that this study meets the ethical obligations
required by federal law and University policies. If you have questions or concerns regarding this
study please contact the Investigator or Advisor. If you have any questions, concerns, or reports
regarding your rights as a research subject, please contact the IRB Administrator.
Investigator: Mary Joann Palmer IRB Administrator
715-573-6316, [email protected] Sue Foxwell, Director, Research Services
152 Vocational Rehabilitation Bldg.
Advisor: Laura Knudsen UW-Stout
715-232-3491, [email protected] Menomonie, WI 54751
715-232-2477
Statement of Consent: By signing this consent form you agree to participate in this assessment of nutritional status in
endurance runners with and without Crohn’s disease.
_________________________________________________
Signature (must be at least 18 years of age) Date
52
Appendix C: 3-day Dietary Record Form
Research Subject’s Name
Gender________
Height_______
Weight________
Estimated miles and minutes run per week_______
Medications and nutritional supplements consumed_______
For this 3-day food record please record everything that you eat and drink for three consecutive
days, including two week days and one weekend day. Eat as you normally would as this will
help in doing a more accurate assessment of your diet.
Please record the time of day that you eat, the type and amount of food you eat, the type and
amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as
possible, noting brand name and/or how the food was prepared will help in the assessment
process. Feel free to use the back of this page if you run out of room to write.
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Research Subject’s Name
Day 1 Date Day of the Week
Please record the time of day that you eat, the type and amount of food you eat, the type and
amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as
possible, noting brand name and/or how the food was prepared will help in the assessment
process. Feel free to use the back of this page if you run out of room to write.
Time of Day Food/Fluid Amount Notes
(Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant
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Research Subject’s Name Day 1 Date Day of the Week Please record the time of day that you eat, the type and amount of food you eat, the type and amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as possible, noting brand name and/or how the food was prepared will help in the assessment process. Feel free to use the back of this page if you run out of room to write. Time of Day Food/Fluid Amount Notes (Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
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Research Subject’s Name Day 1 Date Day of the Week Please record the time of day that you eat, the type and amount of food you eat, the type and amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as possible, noting brand name and/or how the food was prepared will help in the assessment process. Feel free to use the back of this page if you run out of room to write. Time of Day Food/Fluid Amount Notes (Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
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Research Subject’s Name
Day 2 Date Day of the Week
Please record the time of day that you eat, the type and amount of food you eat, the type and
amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as
possible, noting brand name and/or how the food was prepared will help in the assessment
process. Feel free to use the back of this page if you run out of room to write.
Time of Day Food/Fluid Amount Notes
(Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant
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Research Subject’s Name
Day 3 Date Day of the Week
Please record the time of day that you eat, the type and amount of food you eat, the type and
amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as
possible, noting brand name and/or how the food was prepared will help in the assessment
process. Feel free to use the back of this page if you run out of room to write.
Time of Day Food/Fluid Amount Notes
(Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant
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Research Subject’s Name Day 2 Date Day of the Week Please record the time of day that you eat, the type and amount of food you eat, the type and amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as possible, noting brand name and/or how the food was prepared will help in the assessment process. Feel free to use the back of this page if you run out of room to write. Time of Day Food/Fluid Amount Notes (Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
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Research Subject’s Name Day 3 Date Day of the Week Please record the time of day that you eat, the type and amount of food you eat, the type and amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as possible, noting brand name and/or how the food was prepared will help in the assessment process. Feel free to use the back of this page if you run out of room to write. Time of Day Food/Fluid Amount Notes (Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
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Research Subject’s Name Day 2 Date Day of the Week Please record the time of day that you eat, the type and amount of food you eat, the type and amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as possible, noting brand name and/or how the food was prepared will help in the assessment process. Feel free to use the back of this page if you run out of room to write. Time of Day Food/Fluid Amount Notes (Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
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Research Subject’s Name Day 3 Date Day of the Week Please record the time of day that you eat, the type and amount of food you eat, the type and amount of fluids you drink, as well as the seasonings and condiments you use. Be as specific as possible, noting brand name and/or how the food was prepared will help in the assessment process. Feel free to use the back of this page if you run out of room to write. Time of Day Food/Fluid Amount Notes (Ex) 8:00 a.m. Peaches n Cream Oatmeal ½ cup instant __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
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