"Nutrition and Inflammatory Bowel Disease" presented by Stephanie Gold, MD.
A virtual course series created by Dr. Jean-Frederic Colombel and his team to provide medical education on IBD management to IBD physicians practicing in Ukraine, addressing the lack of educational opportunities available as a result of the war.
Chapters (Click to go to chapter start)
Importance of Nutrition in IBD Management Clinical Nutrition Assessment Current Dietary Recommendations Use of Diet as a Therapeutic Tool in IBD Conclusions And thanks again to pro dr Colin Bell for inviting me to speak this morning. So as a great transition I'm going to spend the next 20 to 30 minutes or so talking about the impact of nutrition on IBD and our practices. And we have a specialized nutrition IBD clinic here at Mount Sinai. I have no disclosures. So as a brief outline we're going to start off by talking about the importance of diet and nutrition care and patients with IBD and will specifically discuss various nutrition assessment tools and how to detect malnutrition in this high risk patient population. Will then transition to discuss our current dietary recommendations and how we are managing patients here at Mount Sinai. And finally, as lizzie learned to we were going to discuss the evidence supporting the use of diet as a therapeutic tool for induction in IBD and I would love for this to be interactive. So please feel free to ask any questions as they come up. So it's a brief introduction. The interaction between diet and IBD and the mechanisms by which food can alter the immune response in the microbiome are not fully understood. However, there are numerous studies supporting the fact that diet can impact the pathogenesis of IBD, both as an environmental trigger as well as changes through the host immune response and the microbiome. And as we'll discuss later on to talk, there are quite a few studies demonstrating the efficacy of diet as a therapeutic tool in the IBD and this can be either as monotherapy as we were talking about or in combination with more traditional biologics and other meds in patients with active disease and in those with persistent symptoms despite minimal inflammation. Diet actually can be a very powerful tool to help improve gi symptoms, irrespective of changes in the inflammatory process. And in the last decade, the impact of malnutrition on clinical outcomes in patients with IBD has been an area of great focus and this has triggered a large discussion in our nutrition community about how we should be best assessing malnutrition in this patient population and how to intervene to prevent disease complications. And finally, I always say that, you know, survey studies have demonstrated that our patients are very eager to know how diet impacts their disease and what they can do to reduce their symptoms as well as improve their outcomes. We often have patients coming in and new diagnosis and consistently thereafter saying, what should I be eating, what can I do? And patients are very convinced that there's a connection between what they're eating and they're disease course. So malnutrition is typically defined as a lack of proper nutrition and the term is therefore quite broad and can include many different types of malnutrition. When thinking about an IBD patient. I like to break malnutrition down into four categories. So there are those with undernutrition, which is classically protein calorie malnutrition. There are those with obesity or over nutrition, those with micro nutrient deficiencies and then those with sarka pina, which is defined as a loss of muscle mass or function, these forms of malnutrition can occur in isolation but they most commonly occur in combination with each other. And this came up earlier in the talk as you mentioned it as well. But just to say again, it's important to remember that while we associate malnutrition with undernutrition, we should not forget our obese patients. They can still suffer from nutrition deficiencies. They can have Sarka pina and so they need to be screened just like every other patient. So malnutrition is estimated to affect anywhere from 20 to 80% of patients with IBD. And I understand that this range is incredibly broad and part of that is because our diagnostic tools are pretty inaccurate. But patients with groans disease are certainly at higher risk than those with you see and this is likely secondary to small bowel involvement, impaired absorption. However, patients with UC can certainly be malnourished as well. There are estimates in the literature that up to 80% of those who are admitted to the hospital have been identified as malnourished. They often have unintentional weight loss. They've been n. p. o. For a while. In addition we've estimated that about 30% of patients who are seen in the IBD clinic. So that's for active disease or just routine care are actually malnourished. So we need screening programs not only in the hospital but also in our clinics and while those with active disease are likely to uh to have higher rates of malnutrition, their studies have identified micronutrient deficiencies, sarka pina and even unintentional weight loss in those with quiescent disease. So it can affect the entire IBD population, patients with IBD are at increased risk for malnutrition due to a whole host of concerns, including decreased oral intake. Some have malabsorption. You have chronic and Terek losses with diarrhea or vomiting. Many have altered anatomy due to prior surgeries and that can affect absorption, medications such as steroids can affect nutritional needs. And our patients generally just have increased nutritional needs in the setting of a higher cata bolic state, malnutrition is important. It's been independently associated with poor clinical outcomes in our patients with IBD. They have higher rates of disease flares, impaired response to medical therapies, increased risk of post op complications. If you're looking at infections, fistula formations leaks and they often have increased rates of uh thrombosis, embolism or clots. In addition, malnutrition has been associated with increased costs of care in the surgical literature. So it's certainly an important topic all around. So how do we assess for malnutrition? It's actually not so simple. There are numerous tools on the market that are designed to assess for malnutrition and I would say 95% of them are intended for use in the general population. There are two tools that were developed to screen for patients for, malnutrition that were specific to IBD. However, both of them came from very small studies and neither of them have been studied really in a large way or neither have been validated for use in this population. So the only screening tool to date that is validated for use in patients with IBD is the malnutrition universal screening tool which we commonly refer to as the must and you'll see that on the left side of your screen this can be actually completed by the provider or the patient. You're seeing the provider version here but there's a very similar version for the patient. The patient version requires the patient to know their weight which I will tell you when we ask patients their weight. There's a pretty significant variability to what when we see when we actually weigh them. So that is a caveat. The must takes into account their B. M. I. Any history of unintentional weight loss. And then there's this acute acute illness component which is defined as being N. P. O. For five days or more. This is generally aimed towards patients in the hospital. But when we use this tool in the outpatient clinic studies have shown that you can replace this acute illness tool with diarrhea or food restriction in the past two weeks and patients will get points for those. Instead in our practice we recommend micronutrient testing and referral to a malnutrition or nutrition clinic for those who are identified as high risk of malnutrition and we just carefully follow those who are at medium risk. It's also super important to evaluate our patients for micronutrient deficiencies. These deficiencies can cause symptoms that are often confounding the IBD symptoms such as fatigue gum bleeding and very useful therefore to identify them and treat them early. We traditionally think of iron, vitamin D. And vitamin B. 12 deficiencies and our patients with Crohn's disease. But it's really important to think outside of this paradigm and consider other like fat and water soluble vitamins and as well as minerals. It's also important to know that these lab studies in the serum can be impacted by inflammation there often acute phase reactant. And so we need to take that into account in a very inflamed patient if we're checking these levels and we suspect clinically that they are deficient to use our clinical suspicion and not just rely on the lab testing in patients with high output Elias Tommy's and chronic diarrhea. We should consider zinc deficiency. It's very common. There are many practices that prophylactically treat zinc um and give zinc supplementation in these patients without even checking A level here at Mount Sinai. We tend to check before treating that is generally our philosophy those patients with official it's really important to consider vitamin A. And vitamin C. As well as zinc and magnesium. You really want to maximize wound healing in these patients. If there's anyone with a sign of fat malabsorption. We should be checking the fat soluble vitamins which are A. D. E. And K. In those with illegal receptions. We almost all think of A. B 12 deficiency but we also need to think of B one B nine and that's fully. And this is especially true. I'm not sure what the fortification is like in the Ukraine in terms of food supply. Um Some greens are fortified in the U. S. But I know that's not consistent throughout. And so B vitamins are are an issue in this patient population in patients on a low fiber, a low residue diet. We see a lot of vitamin C deficiency. And so this should be identified and treated when you see it. Um We actually have seen a bunch of clinical cases of scurvy at the Mount Sinai IBD Center and that's in patients who are restricting their fruits and vegetables pretty aggressively. You'll sometimes see patients on a gluten free diet. Sometimes they feel we'll talk a little bit about diets in a minute. But these patients are also at risk for B vitamin deficiencies similar to above because these gluten free alternatives are often not well fortified. So something to consider. And then we always consider medications. When we talk about micronutrient deficiencies, patients on methotrexate on self housing should be getting fully supplementation in patients on steroids. We always need to think about deficiencies, Those on I. NH and cholesterol mean as well. So nutrition and muscle health are intimately tied together. And this is a new component of malnutrition care that's been emerging Sarka pena as we mentioned is formally defined as a loss of muscle mass or function. And screening and diagnostic tools are therefore designed to evaluate either the muscle mass, how much muscle is there or how well is the muscle functioning? How strong are the patients? Traditionally, Sarka pena is diagnosed by looking at the soas muscle or the total skeletal muscle on A C. T. Or an M. R. I. However as you mentioned it's not that feasible to routinely get scans on are generally young and otherwise healthy patients. And so we as a community have been looking to other modalities to assist in identifying Sarka pina. I'll mention two and I don't know what kind of readily available bio electrical impedance and handgrip analysis can be used to estimate muscle function although I will note that B. A. Is an estimate. It's a calculation of muscle mass. It's not a direct evaluation. We use hand grip in our clinic regularly. This is done very easily and inexpensively with a hand held dynamometer can be completed by medical assistant or any provider on the medical team and in patients who identified as Sarka Penick. I think the big question is what do we do for those patients? We know that we need to maximize their protein intake. So we're talking about up to two g per kilo per day of protein. Their studies looking at the impact of vitamin D. Looking at loosen supplementation and the impact of that on muscle mass. So this may become a treatment for us in the future. And in addition for these patients we were we recommend increasing physical activity including resistance training and cardio activities. And we have a program set up with our physical rehab center where we can refer patients who are sarko Penick. Okay, great. So we talked about malnutrition and now let's switch gears a little bit and talk about current dietary recommendations for patients with IBD. There are hundreds of diets that have been proposed to improve gi symptoms to treat underlying IBD which will get back to towards the end of the talk but we generally do not prescribe a specific diet to patients and instead will offer some general guiding principles on healthy eating. When you look at dietary recommendations for patients with IBD over the past decade, I think the pendulum has really swung from more restrictive diets limiting fibers, fruits and vegetables to more very diets with less restrictions and a focus on texture modification. If they're active symptoms. As lizzie had alluded to. The very restrictive diets are not sustainable. They can lead to significant nutrient deficiencies and can be incredibly socially isolating. So when we see patients in our nutrition clinic here at Sinai, our goal is actually to liberalize the diet, increase the diversity of food groups and we're adding back the foods that patients are restricting in a safe way as opposed to providing further restrictions. So our general recommendations to patients are to eat an overall healthy diet that's mediterranean in style. And I'll say that in quotes, we recommend plentiful fresh fruits and vegetables, lean proteins such as chicken, fish, whole grains and olive oil. We try to limit our saturated fats and processed foods. There's some suggestion that thickeners and emulsifiers seen in processed foods including Karajan in can contribute to symptoms and maybe even inflammation. We often recommend protein shakes for our patients. These can be pre made or they can be made at home. Pre made protein shakes are a really reliable way for patients to increase their calories by 252, per day. They get consistent nutrition every day and specifically make sure they're getting adequate protein. We also recommend that all of our patients take a multivitamin and we specifically recommend a chewable if possible, just to increase absorption in our patients with active disease. We recommend texture modification. We'll talk a little bit more about this, but this really will help improve symptoms. So we tell patients that their fruits and vegetables should be peeled and cooked until they're soft enough that they can be cut with the edge of a fork. In addition, if they need further texture modification. If this causes symptoms, will recommend pureeing the fruits and the vegetables, perhaps into the protein shake or to make a soup or a smoothie. We recommend avoiding hard nuts and instead having nut butters and avoiding corn and instead having corn flour, polenta or corn tortillas. We generally avoid low fat diets because this is not designed for long term and it can be very restrictive. However, if there is a question about concomitant, I. B. S or C. Bo, we do consider restricting some of the various bad maps. And finally it's very important to remember that the IBD guidelines recommend calcium and vitamin D. Supplementation for all patients with IBD is part of general care regardless of their nutritional status. So as you see, instead of saying no peanuts, no corn, we're just offering alternatives in different textures so that they're getting the nutrition from those foods but not avoiding and not having symptoms. So a few specific patient populations to mention in patients with a history of an obstruction or known structuring disease, we are more cautious about fiber and residue in the diet. In the past, these patients were told to never eat fruits and vegetables and many of our patients are completely restricting them but we now know that that's actually not helpful and we should focus instead on texture modification. So we still have them avoid specific hard roughage. We don't recommend kale, which can be very hard to break down if you're chewing it and not taking in corn. We avoid popcorn, whole knots as well. This patient population I'm just going to note often has a lot of anxiety about food. They associate specific food items with a recent hospitalization or requiring surgery and they can significantly restrict their diet. So I urge you. It's so important to talk to these patients and ask them what they're eating and ensure that they're not at risk for malnutrition due to a very restrictive nature of the diet and refer to a dietician when possible In our Elias. To me patients, as we've talked about this morning, we have slightly different dietary recommendations and they vary during the surgical course. So the most restrictive in the first two weeks and then we kind of broaden our diet thereafter. While patients in the hospital here at Mount Sinai, we provide them with a nutrition hand that includes what foods to avoid what foods to use to thicken the Ostuni output and how to hydrate themselves. One thing we're aiming to do is to provide these recommendations to our patients before they go to the hospital to have their surgery, assuming it's not an emergent procedure so that they can have these items in the house for when they get home for hydration. We recommend a product called drip drop. Um I'm not sure what's available. This is a powder electrolyte base that can be added to water will often use gatorade but we prefer the low sugar and sometimes we will water it down and add a little bit of salt to improve absorption. And we also have recipes for homemade oral rehydration, therapies and the World Health Organization has a bunch of recipes online as well. And these are the patients you really want to make sure if you have access to a dietician that you're working with that dietician and kind of in constant communication with the surgeon as well. Alright so just the final switching here we're going to switch gears and talk briefly about the use of diet as a therapeutic treatment for patients with IBD. And there are three main ways to modify the diet in order to use this as a treatment for IBD. So the first and this is from dr lewis we can add foods to the diet or add supplements to a baseline diet. Second we can remove foods or food groups from the diet. So this can include include restricting certain foods such as red meat or excluding entire food groups such as dairy or gluten. And finally we can actually modify the baseline diet without adding or removing anything. So this can be as simple as the texture modification we talked about or as complicated as complete modification of the diet where we turn foods into nutritional formulas and these can be given either orally or intravenously. So enter all formulas come up when you talk about nutrition therapy and i. v. d. um and central formulas can be used in many ways including as a caloric supplement. So that would mean they represent less than 50% of your caloric intake. It can be used for partial entering nutrition, which means they represent 50-60% of your calories. And then they can be used for exclusive central nutrition where they represent more than 90% of the caloric intake. There are a ton of different brands and I'm not sure what you have is available. But essentially the big differentiating factor between the types is the type or the method of breaking down the protein. So proteins can be elemental, they can be semi elemental or pollen eric are polymorphic proteins are those that are not broken down their whole as if you are eating and they're the most palatable. And these formulas can be given without energy tube. Many of these formulas contain different sources of glucose and triglycerides. They're almost entirely lactose free but not necessarily dairy free. We do have vegan options available using pea proteins and other vegetable proteins. I say that the majority of the shapes were using contained little to no fiber and almost no sodium as well. And there's a lot of variability in terms of the cost and availability. Some of the products we use, we send patients to the local supermarket to pick up while others are prescription and our mail to patients. So this is from a Cochrane review on entering nutrition for the induction of remission in patients with Crohn's from 2008 and then it was updated in 2018 and it demonstrated that there was no difference between elemental and non elemental formulas when looking at remission rates for induction of Thrones. And so therefore even palatability and reduced cost of non elemental formulas. These are really the formulas that should be used. We should not be using um hydrolyzed formulas. Although these studies were performed in the early nineties and two thousand's, I want to just call your attention to the remission rates in red. Um the study showed remission rates of up to 70% which is incredibly high as compared to other clinical trials for medications to induce remission in IBD. So this is a very effective option if you're going to use it. When these studies were designed. Some critics came out and said maybe these patients are just feeling better because they looked at clinical remission and you're not actually impacting the inflammation. So, pediatric randomized control trial was done in 2006 that demonstrated that central nutrition with a standard palla metric column eric formula had significant improvement not only in symptoms, but also in Crp and histological activity on illegal and colonic biopsies, which suggests that the diet resulted not only in clinical but also histological improvement. So these patients aren't just feeling better when considering diet as a therapeutic option in patients with IBD. It's important to just briefly talk about the Crohn's disease exclusion diet or what we refer to as c dead. This is a somewhat restrictive diet initially and is used in combination with an entropy formula. You'll often see either formula used as modeling but it doesn't have to be. That's just how some of these studies were designed. So the initial diet you get 50% of your calories from food and then 50% from formula. And then the formula is tapered down while increasing the amount of diversity and food as you approach a maintenance space in this diet. There are mandatory foods which is unique compared to other diets and these are things like chicken, eggs, apples and bananas. And then you'll see on the bottom right. Other foods are kind of slowly introduced to the diet as patients tolerate it. The data supporting the use of this diet comes mostly from the pediatric literature in 2019 there was a very randomized control trial comparing see dead to um exclusive enter all nutrition and pediatric patients with mild to moderate Crohn's. And you'll see the results on the bottom left of the screen, the study showed a statistically significant increase in clinical remission rates, significantly higher rates of normalization of Crp and higher rates of sustained remission. And in the once again, I just want to point out the incredibly high clinical remission rates and rates of normalization of Crp as many in the nutrition community world would say if this had been a novel biologic therapy or other medication. It would be considered a blockbuster drugs. It's important to realize that this is a viable option for our patients. You don't use a lot of exclusive ventral nutrition or nutrition therapeutics at Mount Sinai, but certainly across the U. S. There are many centers that are using this. And finally, when talking about diet treatment patients with IBD, we kind of can't skip the dying study. Uh This is the most recent large dietary study which compared the specific carbohydrate diet to the mediterranean diet. In patients with Crohn's. These are patients who have mild to moderate symptoms. A brief uh description of the two diets is on the left for those who are not so familiar with them. This was a 12 week study in which patients were provided with food for the first six weeks and then they prepare their own meals for the second sense, primary outcomes at six weeks showed no significant difference in symptomatic response. No difference and changes in people help protecting or in crp between the two diets as you see in the blue and the orange. In our practice, we really moved away from the use of the specific carbohydrate diet. It's incredibly restrictive and it can be hard for patients to follow a long term, especially in light of the findings in the study. So just a brief summary of what we discussed and I'm happy to take any questions. We recommend that all patients with IBD diagnosis thereafter, patients should also be screened for micronutrient deficiencies. And I'm sorry, Professor Colombo, I think you accidentally and muted. So we generally recommend an overall healthy mediterranean diet with fruits and vegetables, lean proteins such as chickens, fish, whole grains and we try to avoid saturated fats, emulsifiers and thickeners and those with active symptoms and those with strictures or history of an obstruction or an Elias. To me think about texture modification over restriction to really allow patients to have a broad diet without worsening symptoms or risk of obstruction. And always remember that diet is an option as an adjunctive therapy or primary therapy in patients with IBD. If you're going to pursue a dietary therapy remember to choose a pollen eric formula which is better tolerated. Does not need an N. G. Tube and always work with a dietician for support if that's available to you and I help we tell everyone remember to treat diet the same way you would treat any other therapy. You set a goal and evaluate the efficacy of the treatment as you would a biologic. We routinely discuss this concept of treat to target scopes at six months of a new biologic and we should therefore similarly consider and eat to target and traffic evaluation six months after a dietary intervention to make sure it's working and if it's not then we should be pivoting and switching from there. Thank you so much. This was I was just saying this is an amazing amazing and I'm the best I've heard on a nutrition in uh in 30 minutes. Thank you so much.