Navigating Inflammatory Bowel Diseases Using a Nutrition Care Pathway Sponsored by the Crohn’s & Colitis Foundation through an educational grant from Nestlé Health Science **Note that this presentation file is for educational purposes only. Viewing of the file does not offer CPE credit. Alteration or reproductions of the presentation slide or file content is not permitted.
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Navigating Inflammatory Bowel Diseases Using a Nutrition Care Pathway
Sponsored by the Crohn’s & Colitis Foundation through an educational grant from Nestlé Health Science
**Note that this presentation file is for educational purposes only. Viewing of the file does not offer CPE credit. Alteration or reproductions of the presentation slide or file content is not permitted.
Disclosures
• Paid Consultant
• Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway
Caroline Hwang, MD
• Employee
• Keck School of Medicine of USC – Assistant Professor of Clinical Medicine
Disclosures
• Paid Consultant
• Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway
Kelly Issokson, MS, RD, CNSC
• Employee
• Cedars-Sinai Medical Center – Clinical Dietitian
Disclosures
• Consultant
• Crohn’s & Colitis Foundation – Development of the Nutrition Care Pathway
Catherine Giguere-Rich, RDN, LD
• Employee
• Dartmouth Hitchcock Medical Center – Clinical Dietitian
At the end of the session, the participant will be able to:
• Explain the steps in the Crohn’s & Colitis Foundation’s Inflammatory Bowel
Disease (IBD) Nutrition Care Pathway including the importance of the MD-
RD partnership in caring for IBD patients
• Describe the unique characteristics of IBD patients that meet malnutrition
criteria as recommended by the Academy of Nutrition and Dietetics
(Academy) and the American Society for Parenteral and Enteral Nutrition
(ASPEN)
• Explain how IBD disease course and treatment impact the macronutrient
and micronutrient needs in the IBD patient and identify strategies for
restoring nutritional balance
Audience Response Question
Please indicate your professional designation:
A. Registered Dietitian Nutritionist
B. Dietetic Technician, Registered
C. MD
D. Nurse
E. NP/PA
Audience Response Question
What percentage of your total patient population is made up of IBD patients?
A. 0%
B. 1-20%
C. 21-40%
D. 41-60%
E. >60%
F. Not applicable
Audience Response Question
How confident are you in your ability to appropriately screen patients with IBD for malnutrition?
A. Not at all confident
B. Somewhat confident
C. Moderately confident
D. Very confident
E. Completely confident
Audience Response Question
How often do you follow an evidence-based pathway for the screening and management of IBD patients who are at risk for or are diagnosed with malnutrition?
A. Never
B. Rarely
C. Sometimes
D. Very often
E. Always
Audience Response Question
How confident are you in your ability to appropriately intervene and monitor patients with IBD and malnutrition?
A. Not at all confident
B. Somewhat confident
C. Moderately confident
D. Very confident
E. Completely confident
Inflammatory Bowel Diseases:A Primer on Disease Manifestations & Treatment
Caroline Hwang, MD
Audience Response Question
Which of the following is true about IBD?
A. Low-dose steroids remains the mainstay for both Crohn’s disease and ulcerative colitis
B. About 40% of Crohn’s disease patients will require surgery within the first 10 years of their disease course
C. If a patient responds to a new biologic, you would expect symptoms to improve by ~2 months
D. Crohn’s disease always involves the small intestine (ileum) and thus malnutrition risk is higher than with ulcerative colitis
• Few studies on the impact malnutrition has on IBD course/complications
• Single large Canadian study using the Nationwide Inpatient Sample:Malnutrition in IBD patients (~6% of UC, 7% of CD) associated with:
In-hospital mortality (OR 3.49, % CI: 2.89-4.23) Length of stay LOS (11.9d versus 5.8 days, P < 0.00001) Total cost of hospitalization ($45,188 versus $20,295, P < 0.0001).
• IBD patients with low albumin:
- Higher rates of wound infections, anastomotic leak
- Increased risk of anti-TNF failure
1. Nguyen GC et al: Inflamm Bowel Dis 20082. Telem DA et al: Arch Surg 2010
Importance of Addressing Disease-Related Malnutrition
• Dearth of studies about the utility of nutritional support in IBD
• Better supported in other at-risk populations
• Cystic fibrosis
• Aggressive nutritional rehab at CF centers ↑ avg life expectancy/lung function
• Surgical Cancer Patients
• Adoption of “enhanced recovery algorithms” (preop carb loading, earlier postop feeding less operative complications, shorter hospital stays
1. Castellani C et al: J Cyst Fib 20182. Burden S et al: Cochr Syst Rev 20123. Milne et al: Ann Int Med 2006
Challenges in Recognizing Malnutrition in Clinic
• Malnutrition = Actually a complex diagnosis
No single anthropometric or laboratory test/biomarker
Insufficient time (average clinic visit = 10-20 minutes,
spent predominantly on discussing symptoms/meds
• Most physician lack formal training on nutrition
• Lack of dietitians in clinic / insurance coverage
Weight Loss
Loss of Fat/Muscle, Edema
Decreased Function (Handgrip)
ASPEN/AcademyDiagnostic `Criteria
(Any 2)
InsufficientEnergyIntake
Mueller C et al: JPEN 2011
Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway
• In 2015, the Crohn’s & Colitis Foundation launched an effort to develop a Nutrition Care Pathway as part of IBD Qorus™ (quality-of-care program)
• Multiple step process
- Focus groups conducted (providers, patients)
- Major barriers Limited provider time, access to dietitian ($$, expertise in IBD)
- Steering committee formed (Gastroenterologists/Dietitians w/ expertise in IBD)
- In-person moderated workshop (nutrition scientists, care pathway experts)
- Literature review
- Weekly phone conference consensus
ASSESSMENT
INTERVENTION
M o n i t o r i n g
SCREENING
Low RiskAt Risk
Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway
√
Easy to implement in busy clinic
Recognizes access to dietitians may be limited
ASSESSMENT
INTERVENTION
M o n i t o r i n g
SCREENING
Low Risk At Risk
Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway
• Required by Joint Commission in all patients hospitalized within first 24 hrs. of admission
• Multiple screening tools have been developed to identify presence or risk of malnutrition
• Ideal screen is sensitive, simple, and reliable
• For IBD patients, important to take into consideration of disease acuity/activity
• Malnutrition Universal Screening Tool (MUST)
• Validated instrument in inpatients and also ambulatory clinics (elderly, cancer, ESRD)
• Predictive of mortality, worse QOL, hospitalizations, LOS, clinic visits
'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on ’MUST' see www.bapen.org.uk
1. Raslan M et al: Nutrition 20102. Boleo-Tome C et al: Br J Nutr 20123. Skipper A et al: J Parenter Enteral Nutr 2012
• Required by Joint Commission in all patients hospitalized within first 24 hours of admission
• Multiple screening tools have been developed to identify presence or risk of malnutrition
• Ideal screen is sensitive, simple, and reliable
• For IBD patients, important to take into consideration of disease acuity/activity
• Malnutrition Universal Screening Tool (MUST)
• Validated instrument in inpatients and also ambulatory clinics (elderly, cancer, ESRD)
• Predictive of mortality, worse QOL, hospitalizations, LOS, clinic visits,
'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). For further information on ’MUST' see www.bapen.org.uk
BMI(<20, <18.5)
% Wt loss(>5%, >10%)
Acute Disease Effect(Acute illness, Poor po intake
1. Raslan M et al: Nutrition 20102. Boleo-Tome C et al: Br J Nutr 20123. Skipper A et al: J Parenter Enteral Nutr 2012
In a single IBD center, self-screen MUST completed by over 500 patients correlated well with
MUST screen by physicians (Κ= 0.86)1
Foundation’s IBD Qorus experience (7 IBD centers/GI practices in the U.S.)2
- 2,388 IBD outpatients completed self-screen MUST
- 86% reported MUST self-screen as either very easy or easy to complete
1. Sandhu A et al: JPEN 2015.
2. Hwang C et al: Abstract presented AIBD 2016
Step 2: Nutritional Assessment• Comprehensive nutritional assessment most often requires assessment by
dietitian- Anthropometrics, Dietary History (diaries, etc.), Laboratory testing
• Basic assessment can be done by physician/nurses, though many may feel unprepared - Recent Foundation focus group – Only 41% of gastroenterologists rated knowledge of nutrition as very
good, many cited lack of awareness of standardized malnutrition tools
• Subjective Global Assessment (SGA) • One of the most widely-used nutrition tools, initially developed in cancer patients but validated since in
multiple inpatient/outpatient populations
• Shorter patient self-generated version (PG-SGA) feasible to implement in clinic• Weight loss (6 mo., 1 mo., 2 weeks)
Dietary Education/CounselingEnteral & Parenteral Support
High-Risk
M o n i t o r i n g
PRIMARYASSESSMENT
SCREEN
No ActionAssessment of
Nutritional Status (PG-SGA)Immediately
PG-SGA<4
PG-SGA 4-8ROUTINE
PG-SGA >9URGENT
Crohn’s & Colitis Foundation’s IBD Nutrition Care Pathway
Malnutrition in IBD: Looks Can Be Deceiving
Kelly Issokson, MS, RD, CNSC
Audience Response Question
The BMI of an IBD patient compared to a healthy control tends to be:
A. Lower than healthy controls
B. Higher than healthy controls
C. Not different from healthy controls
Malnutrition
An acute or chronic state of under or overnutrition that leads to a change in body composition and function.
A predictor of poor prognosis in hospitalized IBD patients
Inflamm Bowel Dis (2008) 14:8
Malnutrition in IBD
• Malnutrition in IBD results in poor clinical outcomes
• Growth failure
• Reduced response to pharmacotherapy
• Increased risk for sepsis
• Mortality
• Decreased oral intake common in active IBD (anorexia, sitophobia)
• Lower fiber and phosphorus intake in inactive CD
• Maldigestion, malabsorption, enteric loss of nutrients, rapid transit, increased energy needs w inflammation or infection, adverse effects of medical therapy
Weight loss 1-2% in 1 week5% in 1 month7.5% in 3 months10% in 6 months20% in 12 months
>2% in 1 week>5% in 1 month>7.5% in 3 months>10% in 6 months>20% in 12 months
Energy Intake <75% intake in >7 days<75% intake in >1 month <75% intake in >3 months
<50% intake in >5 days<50% intake in >1 month <50% intake in >1 month
Subcutaneous Fat Loss Mild Moderate to Severe
Subcutaneous Muscle Loss
Mild Moderate to Severe
General or Local Fluid Accumulation
Mild to Severe Moderate to Severe
Hand Grip Strength (Dynamometer)
Not Applicable Measurably reduced
Adapted from Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)
Sarcopenia (muscle mass begins to decline around age 40; can lose 3-8% muscle mass per decade)
Characteristics of the IBD vs. non-IBD patient
BMI is Associated with IBD
• Systematic Review and Meta Analysis (Dong et al) of 24 studies, n=1442
• BMI significantly lower in CD compared to healthy controls
• Medical therapy improved BMI in CD (not UC)
• Active IBD BMI was significantly lower than healthy controls
PLOS One (2015) 10:12
Fat-free Mass and Fat Mass Reduced in IBD
• Systematic Review (Bryant et al) of 19 studies, n=631 CD, 295 UC
• Reduced fat-free mass in 28% CD and 13% UC
• Reduced fat mass in 31% CD and 13% UC
• No consistent association between body composition and disease activity, duration, extent or therapies.
• BMI did not accurately predict body composition
Aliment Pharmacol Ther 2013; 38: 213–225
Malnutrition in IBD
• Nationwide study1 of hospitalized IBD vs non-IBD hospitalized patients
• Greater prevalence of malnutrition in CD and UC (6.1% and 7.2% vs 1.8%, p<0.0001)
• Adjusted odds ratio for malnutrition among IBD admissions compared to non-IBD was 5.57 (95% CI: 5.29-5.86)
• More IBD discharges than non-IBD discharges received PN (26% vs 6%, p <0.0001)
• Increased likelihood of malnutrition in those with fistulizing CD (OR 1.65) and in those with bowel resections (OR 1.37)
• Malnutrition was associated with increased hospital mortality 3.49, length of stay (11.9 days vs 5.8 days, p <0.00001), and total charges ($45k vs $20k, p <0.0001)
1. Inflamm Bowel Dis (2008) 14:8
Demographic and Clinical Predictors of Malnutrition
• Males, non-Hispanic whites
• Those receiving Medicare or Medicaid
• Active fistulizing disease (active obstructive disease had lower likelihood of malnutrition)
• Bowel resection
Inflamm Bowel Dis (2008) 14:8
Food Restriction & Malnutrition
• One cause for malnutrition: diet adjustment based on patient experience and beliefs
• Recent survey in IBD patients (n=104) looked at those with food exclusions (FE) vs none
• Anthropometrics and nutritional status (SGA)
• Diet beliefs and food restriction
• Nutrient intake
Clin Nutr Res. 2018 Jan; 7(1): 48-55
Clin Nutr Res. 2018 Jan; 7(1): 48-55
Clin Nutr Res. 2018 Jan; 7(1): 48-55
Food Restriction & Malnutrition
• Malnutrition rate significantly higher in food exclusion group (p=0.007)
• 59% held diet beliefs and reported modifying their diet because of these
• 83% (FE) and 67% (non FE) wanted nutrition education and management
• Most common restrictions: Milk, dairy products (32%), raw fish (24%), deep spicy foods (22%), ramen (18%)
• Calcium (p=0.002), vitamin A (p<0.001), and zinc (p=0.001) mean intake was significantly lower in food exclusion group
Clin Nutr Res. 2018 Jan; 7(1): 48-55
Sarcopenia in IBD
Systematic Review, 5 studies, n=658 patients
• 42% had sarcopenia
• Did not assess anatomical/functional components of sarcopenia
• Sarcopenic IBD patients had higher probability of requiring surgery
• Rate of major complications was significantly higher in patients with sarcopenia
Inflamm Bowel Dis. 2018 Jun 7. doi: 10.1093/ibd/izy212. [Epub ahead of print]
May be effective and safe for maintaining remission for people with inactive disease.
May help induce remission in mild to moderate UC
Hiroyuki H, Takayuki I, Ken T. Clinical Gastroenterology and Hepatology. 2006;4:1502-1506
Probiotics
Science on probiotics is inconclusive Probiotics may or may not be beneficial
May reduce risk of C.Diff Specific probiotics have been shown to be beneficial in mild ulcerative colitis, pouchitis, recurrent C. diff infections (VSL-3, florastor)
Recent meta-analysis concluded that efficacy on probiotic use in CD remains uncertain
Probiotics supplements There are many brands (e.g VSL #3, Florastor, Culturelle, Align) And many species (e.g Lactobacillus vs Acidophilus vs Saccharomyces Boulardii)
Fermented foods just as good? Kefir or yogurt Kimchi or saurkraut
Kombucha
Be Careful!!! Supplements are not regulated by the FDA
• 30 year old female with Crohn’s disease since the age of 19 presents to outpatient clinic for nutrition consultation. She had been doing well with her IBD until about 6 months ago. Her most recent colonoscopy demonstrated ulcerations of the ileum and colon.
• She experiences 6-10 loose bowel movements daily and abdominal pain with eating. She states she feels she is in a flare. She has required prednisone to help relieve her symptoms. Her gastroenterologist recently changed her biologic medical therapy to help better treat her disease.
• She is having difficulty with eating. She is avoiding dairy products due to lactose intolerance. She is not eating raw fruits and vegetables because they cause too much pain, and she can only eat small amounts of bread, pasta, and chicken. She has lost about 15 lbs over the last 3 months with BMI now of 17. She is very motivated to do whatever she
needs to do to get better.
71
Which micronutrient deficiencies would you be concerned about with this patient?
a)Calcium and Vitamin D
b)Vitamin B12
c) Iron
d)All of the above
72
Calcium and Vitamin D
Calcium
• Risk factors: chronic steroid use, diarrhea, vitamin D
deficiency, restricted diet
• Osteoporosis is common in IBD—approximately 18-42%
-higher maintenance doses of 3000-6000 IU/d for patients on glucocorticoids, those with malabsorption, BMI >30, or in those with small
bowel involvement
Holick, M. F., et al. Journal of Clinical Endocrinology & Metabolism. 2011; 96(7), 1911-30.Basson, A. Journal of Parenteral and Enteral Nutrition. 2014; 38(4), 438-458.
Weaker evidence in adults (compliance and tolerability)
Goal: Induce mucosal healing
Elemental diets extremely difficult to follow, taste fatigue
Polymeric versus elemental?
Exact mechanism of action unknown
Immune modulation
Intestinal inflammation
Microbiome
Duration of treatment is 6-8 weeks
EEN
80
Future work on personalized therapy is needed
Food reintroduction—varies, lack of evidence for recommendation
Maintenance enteral nutrition?
Role of the dietitian Calculate energy needs and goals for intake/nutrition prescription
Regular contact to help ensure compliance and provide support
Collaboration with the MD
Monitor patient’s weight
Partial Enteral Nutrition (PEN)
Case #2
• 53 year old male diagnosed with ulcerative colitis at the age of 12. He underwent total colectomy with end ileostomy at the age of 38. He was diagnosed with Crohn’s disease at that time based on symptoms and further testing. Since the age of 45, he required many small bowel resections due to stricturing disease. He now has 130 cm of remaining small bowel with no colon. More recently, he developed an enterocutaneous fistula, which was actively draining. This required NPO with Parenteral Nutrition Support.
• His fistula output has been decreasing with hope for closure. His doctor said he can start to eat, but struggles with high ostomy output. He has never followed a special diet, just eats based on how he feels. He saw a dietitian once while in the hospital but was not able to eat much at that time due to fistulas, so he doesn’t fully remember her helpful information.
81
Where should you start to help this patient come off TPN?
a)Educate him on short gut syndrome diet and oral rehydration solutions
b)Tell him to forget it, he will be on TPN forever
c)Suggest PEG tube placement
d)Give him vitamin supplements
82
Parenteral Nutrition
Not primary therapy in IBD (Crohn’s disease)
Indications are similar to those in other disease states SBS (short bowel syndrome)
Persistent SBO (small bowel obstruction)
Inability to tolerate Enteral Nutrition (EN)/Enteric fistula
In this case Provided 30 kcal/kg/day
1.5 g/kg/day protein
Maintenance fluid need
Cycled over 12 hours
83
USE IN IBD
Short Gut Syndrome Diet
Patients with ileostomies (no colon): higher fat diet (50% of calories)
Patient with intact colon: higher carbohydrate (50-60% of calories)
Avoid concentrated sweets and fluids
Chew foods well
No Colon—salty meals and snacks
Small frequent meals
Trial of Oral Rehydration Solutions/drink isotonic beverages
Separate solids and liquids at Meals as much as possible
Limit enteral stimulants such as alcohol and caffeine
Lactose restriction if needed
Enterocutaneous Fistula—closure can take time—variable
Magnesium
www.ginutrition.Virginia.edu 84
EVIDENCE BASED GUIDELINES
Oral Rehydration Solutions
85
Commercial Products Isotonic The WHO formula
Homemade Recipes
Also isotonic Oley Foundation Dilute sports drinks or juice and add salt and/or baking soda
• Referral received from MD, with noted medical management plan for continuing corticosteroids, and initiating biologic therapy. MD feels patient would be a good candidate for partial enteral nutrition to improve nutritional status and response to biologic therapy
• Significant recent weight loss of 10.4%
• Food recall reveals she is eating <60% of energy needs over the past month
• Limiting PO intake to try and prevent/control symptoms
• She is also avoiding dairy and gluten due to fear of worsening IBD
Weight loss 1-2% in 1 week5% in 1 month7.5% in 3 months10% in 6 months20% in 12 months
>2% in 1 week>5% in 1 month>7.5% in 3 months>10% in 6 months>20% in 12 months
Energy Intake <75% intake in >7 days<75% intake in >1 month <75% intake in >3 months
<50% intake in >5 days<50% intake in >1 month <50% intake in >1 month
Subcutaneous FatLoss
Mild Moderate to Severe
Subcutaneous Muscle Loss
Mild Moderate to Severe
General or Local Fluid Accumulation
Mild to Severe Moderate to Severe
Hand Grip Strength (Dynamometer)
Not Applicable Measurably reduced
Adapted from Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)
Nutrition Intervention
• Educate patient on disease effect on nutritional status• Increased energy and protein requirements with active disease and
diarrhea• Decreased absorption of B12 and possible fat/fat soluble vitamins with ileal
• Educate on macronutrient goals • Mifflin REE x 1.3 + kcals for weight gain; 1.5 g protein/kg body weight• Small/frequent meals, low fiber; consider lactose free (not dairy free)• Partial Enteral Nutrition (PEN) (to provide 30-50% of energy needs)
• Educate on micronutrient goals• Increased calcium, vitamin D needs on corticosteroids• Increased zinc needs with diarrhea and weight loss• Daily sublingual or monthly intramuscular B12• Increased fluid and sodium needs due to diarrhea
Formula Diets in IBD: PEN
• PEN: 30-50% of nutrient needs delivered by formula, remainder via diet
• Can be helpful for maintaining remission in CD
• PEN is more effective then regular diet, as effective as some medications (mercaptopurine, 5-ASA) in maintaining remission in inactive CD (El-Matary et al, 2015)
PEN – Lower Relapse Rates
• Lower relapse rates in PEN vs no PEN in CD patients (Takagi et al. 2006)
• RCT, free diet + PEN (elemental formula, 50% needs) vs free diet; on mesalamine or azathioprine
• The dosage for the half ED group per day was 900–1200 kcal (3–4 sachets in 900–1200mL water) of Elental (AJINOMOTO PHARMA Co., Tokyo, Japan) via self-inserted tube &/or oral intake
• Primary Outcome Measure = Relapse occurrence over 2-year period
• Relapse rates significantly lower in PEN group (34% vs 64%)
Combination Therapy: PEN + Infliximab
• Meta-analysis shows 2-fold increase in the odds of achieving clinical remission in
CD pts on combination therapy with specialized enteral nutrition and infliximab
compared with infliximab monotherapy
• The probability of maintaining clinical remission on combination therapy appears
to extend beyond 1 year
DL Nguyen, et al Ther Adv Gastroenterol 2015
Monitor/Evaluate
Goals:
• GI tolerance to PO diet
• Adequate energy and protein intake on low fiber & PEN diet (>75% of needs met daily)
• Weight maintenance/regain 0.5# weekly
• Check/replace 25-OHD, B12 levels baseline and annually
• DEXA
Case #2
• 52 year old male with newly diagnosed ulcerative colitis
• 6’2”, 180 lb; recent weight loss of 10 lb in 3 weeks (usual wt 190 lb)
• Good appetite, eating well. Regular diet.
• GI symptoms: bloody diarrhea with >15 BM daily
• Colonoscopy reveals: moderate-severe pan colitis, normal TI
• Labs: albumin 1.9, fecal calprotectin 980
• Not currently on medications. Wants to start SCD (Specific Carbohydrate Diet)
The Foundation’s IBD Nutrition Care Pathway
SCREEN
PRIMARYASSESSMENT
SECONDARY ASSESSMENT & INTERVENTION
Screen all IBD patients for Malnutrition Risk (MUST)
Moderate-Risk High-RiskLow-Risk
No Action
PG-SGA<4
Assessment ofNutritional Status (PG-SGA)Immediately or can consider
• Referral received from MD, with noted medical management plan for corticosteroids and vedolizumab, along with SCD
• Significant recent weight loss of 5.2% in <1 month
• Food recall reveals he is eating >75% of estimated energy needs, but is losing weight
• No current diet restrictions but is asking if he should start an alkaline vs SCD diet
Malnutrition Criteria (Academy/ASPEN)
Moderate Malnutrition (ICD 10 E44.0)
Severe Malnutrition (ICD 10 E43)
Weight loss 1-2% in 1 week5% in 1 month7.5% in 3 months10% in 6 months20% in 12 months
>2% in 1 week>5% in 1 month>7.5% in 3 months>10% in 6 months>20% in 12 months
Energy Intake <75% intake in >7 days<75% intake in >1 month <75% intake in >3 months
<50% intake in >5 days<50% intake in >1 month <50% intake in >1 month
Subcutaneous Fat Loss Mild Moderate to Severe
Subcutaneous Muscle Loss
Mild Moderate to Severe
General or Local Fluid Accumulation
Mild to Severe Moderate to Severe
Hand Grip Strength (Dynamometer)
Not Applicable Measurably reduced
Nutrition Intervention
• Educate patient on disease effect on nutritional status• Increased nutritional requirements with active disease and diarrhea• Absorptive capacity of macronutrients (and most micronutrients) not
affected as disease is limited to colon
• Educate on macronutrient goals • Mifflin REE x 1.3 + kcals for weight gain; 1.5 g protein/kg body weight• Education on evidence-based diets for IBD, including SCD (grain-free,
dairy-free diet increases risk of inadequate intake of thiamine, folate, pyridoxine, calcium, vitamin D, vitamin E); no need to avoid fiber
• Snacks for additional nourishment (nut butters, avocado, homemade smoothies)
• Educate on micronutrient goals• Multivitamin/mineral needed daily• Increased calcium, vitamin D needs on corticosteroids• Increased zinc needs with diarrhea and weight loss• Increased fluid and sodium needs due to diseased colon
Monitor/Evaluate
Goals:
• GI tolerance to PO diet
• Adequate energy and protein intake on Specific Carbohydrate diet (>75% of needs met daily)
• Weight maintenance/regain 0.5# weekly
• Adequate calcium intake (1000 mg daily)
• Check/replace 25-OHD levels
• Monitor inflammatory makers (CRP, ESR, fecal calprotectin) and micronutrient levels (B12, folate, zinc, vitamin D, selenium, magnesium, B6, thiamine) 6-12 months after start of SCD
Audience Response Question
A Partial Formula Diet:
A. Has been shown to maintain remission in Crohn’s disease
B. Can help improve response to biologic therapy
C. Is a diet that provides 30-50% energy from a formula, and the remainder of energy from general/healthy diet
D. All of the above
Panel Q & A
Crohn’s & Colitis Foundation Resources for Dietitians