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Managing Crohn’s Disease through Nutritional Intervention
Kristy SinglestadConcordia CollegeMoorhead, MN
ObjectivesBe able to describe Crohn’s
diseaseIdentify common nutrient
deficiencies in Crohn’s diseaseBe able to describe treatment
goals for Crohn’s diseaseIdentify the medical nutrition
therapy for Crohn’s disease
Anatomy of Gastrointestinal System Oral cavityEsophagusStomachSmall intestine
◦ Duodenum◦ Jejunum◦ Ileum
Large intestineRectumAnus
Inflammatory Bowel Diseases (IBD)
Ulcerative Colitis
Only involves colon
Affects only mucosa layer of intestine
Continuous distribution of inflammation
Crohn’s Disease
Involves any part of digestive tract
Affects all layers of intestine
Patches of inflammation
Source: Crohn’s and Colitis Foundation of America (2009)
Crohn’s Disease (CD)A chronic inflammatory bowel disease
(IBD) affecting any part of the gastrointestinal tract from mouth to anus
Also known as regional enteritisIleum and colon most commonly
affectedNo cure, but treatments available
Definition continued…May damage all 3 layers of GI
tractMay cause fistula and abscessCauses nutritional problems
Disease PathologyApproximately ½ million
Americans are currently diagnosed with Crohn’s disease
Affects children and adultsPrevalence higher in North
America and Northern European countries
Common among American Jews of European descent, African Americans, and whites Source: Crohn’s and Colitis Foundation of America
(2009)
CausesUnknown causePossible causes:
◦Autoimmune response◦Environmental triggers
Smoking Infectious agents Intestinal flora
◦Genetics ~20% have a relative with IBD
SymptomsAbdominal pain, lower right
quadrantDiarrheaLoss of appetiteFeverRectal bleedingWeight loss
5 Types of Crohn’s DiseaseIleocolitis – ileum and colonIleitis – ileum only Gastroduodenal – stomach and
duodenum Jejunoileitis - jejunumCrohn’s colitis – colon only
Crohn’s Disease Activity Index
Criteria used to identify the disease progression of CD patients ◦<150 inactive disease◦>150 active disease◦>450 extremely severe disease
Source: Nelms (2007), 491
Stages of Crohn’s DiseaseStage Definition
Mild-Moderate Disease Individual tolerates oral supplements without development of dehydration, obstruction, abdominal tenderness, or <10% weight loss
Moderate-Severe Disease Individual has increased symptoms of fever, vomiting, significant weight loss, abdominal pain, or anemia
Severe-Fulminant Disease Individual has persisting symptoms despite steroid use, evidence of intestinal blockage or abscess
Remission Individual successfully responds to medication treatment, surgical resection, and currently without inflammatory symptoms
Source: Nelms (2007), 492
DiagnosisEndoscopy (colonoscopy –
examine large intestine)Blood tests
◦Anemia indicates intestinal bleeding◦Increased white blood cell count
indicates inflammationBarium X-rayStool sample
"Cobblestoning" in colonoscopySource: www.medgadget.com
TreatmentForms of treatment:
◦Medical Nutrition Therapy (MNT)◦Medications◦Surgery
Goals of treatment:◦Control inflammation◦Correct nutritional deficiencies ◦Relieve symptoms
Medical Nutrition TherapyCurrently, no specific diet is used
for treatment in Crohn’s diseaseDiet is individualized Multivitamin recommended due
to nutrient deficiencies
Common Nutrient DeficienciesNutrient Deficiency Probable Cause
Calories Insufficient intakeAnorexiaFear of abdominal pain and diarrhea after eating
Protein Increased protein needs (losses from GI tract caused by inflammation)Catabolism (when infection or abscesses present)Healing from surgery
Fluid and electrolytes Short bowel syndrome
Iron Blood loss
Magnesium, zinc Intestinal losses, especially from short bowel syndrome
Calcium and Vitamin D Long-term steroid useDecreased intake of dairy food as a result of lactose-restricted diets
B12 Surgical resections of stomach (loss of intrinsic factor) and/or terminal ileum (site of absorption)
Folate Medications used to treat IBD
Source: Nelms (2007), 495
Calorie NeedsCalculate using Harris-Benedict
or Mifflin-St. Jeor equation◦Stress factor (1.3-1.5)◦Consider previous weight loss and
infection when determining calorie needs
Infants/Children – consider growth needs◦Infants may need 120 kcal/kg◦Adolescents may need 80 kcal/kg
Study: Adequacy of dietary intake in adults with Crohn’s Objective: identify the adequacy of
dietary intake of adults with Crohn’s disease
Results: Intake of macronutrients and micronutrients were below recommended levels despite normal BMI and adequate energy intake◦Lacked folate, vitamin C, vitamin E,
calciumConclusion: additional dietary
counseling necessarySource: Aghdassi (2007)
Study: Adequacy of dietary intake in children with Crohn’sObjective: assess the growth and
adequacy of dietary intakes of children with Crohn’s disease
Results: individuals with active CD had a lower caloric intake than those in remission
Conclusion: active CD patients had an inadequate dietary intake of energy, calcium, and iron◦Lack of intake can lead to poor weight
gain and impaired growthSource: Pons (2009)
Protein NeedsRecommended intake:
◦Adults: 1.5-1.75 g/kg◦Children: 2.0-2.5 g/kg
Protein needs may increase by 150% of normal recommendations
Factors to consider:◦Lean body mass wasting ◦Measurement of prealbumin and
albumin
Role of Dietary Fiber in Crohn’s
Diarrhea is a common symptom in Crohn’s patients◦Diarrhea causes an increase in
osmotic load as a result of an inflamed GI tract
“Dietary fiber intake may improve symptoms of patients with inflammatory bowel disease.”
Source: Position of ADA: Health implications of dietary fiber (2008)
MNT: Tolerating an Oral Intake
Low-reside, lactose-free diet Presence of steatorrhea
◦Reduced fat diet with MCT supplements
Advancement of diet◦Add small amounts of fiber, then
lactose◦Add other foods initially restricted
Increase levels of antioxidants
MNT: Increased Severity of DiseaseSudden flare-ups:
◦Parenteral or enteral nutrition support with chemically defined formula
◦Glutamine and arginine supplements aid in decreasing inflammatory response
MNT: Enteral and Parenteral NutritionAllows bowel rest to reduce
inflammationUsed to prepare people for
surgery to improve healthUsed when medications are
unable to control symptoms
Study: Enteral vs. Parenteral FeedingEvidence supports using
elemental diets for growth in children
Maintenance of remission:◦Enteral feedings prevent relapse in
inactive CD patients, particularly children
◦In a Japanese study, 145 patients with CD had a lower risk of CD flaring up through the use of elemental/polymeric nutrition, particularly when CD targeted the small intestine.
Source: Rajendran (2010)
Study: Enteral Nutrition for ChildrenObjective: identify factors affecting
energy intake and weight gain during enteral nutrition in relation to disease site and nutritional status.
Results: all patients improved nutritionally through weight gain
Conclusion: EAR, an underestimate of energy needs for children◦Recommended intake of 100-149% of
EAR for energy for age.
Source: Aghdassi (2007)
MNT: RemissionGoal: maximize calorie and
protein intake for rehabilitationObtain healthy weight with
physical activityObtain normal dietary patternsConsume foods high in
antioxidants and Omega-3 fatty acids
Probiotics and Prebiotics
Study: Use of Omega-3 Fatty Acids in Inflammation ReductionObjective: gradual replacement
of Omega-3 fatty acids with Omega-6 fatty acids
Results: increased incidence of CD
Conclusion: the ratio of Omega-3 fatty acids may be effective in reducing inflammation in CD
Source: Rajendran (2010)
Study: Food Sensitivity and Exclusion Diet Induction of remission in CD
◦Outcome: food intolerances vary among individuals
◦Most common food intolerances included cereals, dairy products, yeast
Maintenance of remission in CD◦Objective: identify the impact exclusion diets
has in maintaining remission in CD patients◦Results: Believed that personalized diets aid
in maintenance of remission◦Conclusion: larger, controlled studies need to
be conducted
Source: Rajendran (2010)
Key InterventionsIncrease nutrient intakeCorrect malabsorption or anemiaMonitor lactose and gluten
intolerancesRest bowel to promote healing
and prevent protein mass lossPromote weight gain
MNT: Basic GuidelinesEat small, frequent meals Drink plenty of fluidsConsider a multivitaminChoose foods with added
probiotics and prebioticsConsume low-fiber foods when
symptoms ariseAvoid foods that aggravate
symptomsSource: American Dietetic Association (2010) client handout
Drug Therapy: MedicationsAnti-inflammatoriesImmunosuppressantsAntibioticsOther – anti-diarrheal, laxatives,
pain relievers
Drug Therapy: MedicationsAnti-inflammatory drugs
◦Aminosalicylate – used when ileal and colon are involved
◦Corticosteroids – reduce inflammation Not recommended for long-term use
especially in children as it can affect their growth
Risk of becoming steroid dependent
Drug Therapy: Medications
Immunosuppresants◦Most widely used for IBD treatment◦Heal fistulas from Crohn’s
Antibiotics◦Heal fistulas
Biologic Therapy◦Infliximab blocks the tumor necrosis
factor-alpha (TNF-alpha) which causes inflammation in intestine
SurgeryAbout 60% of patients require surgeryIleostomy, most common formUsed when diet, medications, and
other treatment do not relieve symptoms
May involve:◦Removal of damaged digestive tract◦Close fistulas, drain abscesses◦Remove scar tissue◦Strictureplasty – widening segment of
intestine which has narrowed
ComplicationsBlockage of small intestineDevelopment of fistulas and
fissuresNutritional deficienciesArthritisKidney stonesDiseases of the liver Skin problemsOsteoprosis
Ethical IssuesStem cell therapy used for
Crohn’s disease treatmentWithholding or with drawing
nutritional support with enteral and parenteral nutrition
Reimbursement Issues Lack of coverage for nutrition
counseling services in Crohn’s disease patients
Source: Medx Publishing (2008)
Summary Crohn’s disease definitionCommon nutrient deficienciesTreatment goalsMedical nutrition therapy for
Crohn’s
Questions?
ReferencesAghdassi, E., Wendland, B. E., Stapleton, M., Raman, M., & Allard, J. P. (2007). Adequacy of nutritional intake in a canadian population of patients with Crohn’s disease. Journal of the American Dietetic Association, 107(9), 1575-1580. doi: 10.1016/j.jada.2007.06.011
American Dietetic Association. (2010). Crohn's disease and ulcerative colitis nutrition therapy
Crohn's and Colitis Foundation of America. (2009). About crohn's disease. Retrieved September 28, 2010, fromhttp://www.ccfa.org/printview?pageUrl=/info/about/crohns
Crohn's and Colitis Foundation of America. (2009). Diet & nutrition. Retrieved September 28, 2010, fromhttp://ccfa.org/printview?pageUrl=/info/diet
Enteral nutrition for maintenance of remission in crohn's disease. (2007). Cochrane Database of Systematic Reviews, (3)
FDA Consumer Health Information. (May 2, 2008). Facts about crohn's disease. Retrieved September 28, 2010, fromwww.fda.gov/consumer/updates/crohnsdisease050208.html
Gavin, J., Anderson, C. E., Bremner, A. R., & Beattie, R. M. (2005). Energy intakes of children with crohn's disease treated with enteral nutrition as primary therapy. Journal of Human Nutrition & Dietetics, 18(5), 337-342.
Knight, C., El-Matary, W., Spray, C., & Sandhu, B. K. (2005). Long-term outcome of nutritional therapy in paediatric crohn's disease. Clinical Nutrition, 24(5), 775-779. doi:10.1016/j.clnu.2005.03.005
ReferencesLandsman, K. (2010). My WebMD: A college student controls her crohn's. Retrieved September 28, 2010, fromhttp://www.webmd.com/ibd-crohns-disease/crohns-disease/features/my-webmd-a-college-student-controls-her-crohns?src=RSS_PUBLIC
Medx Publishing. (2008). Medical nutrition therapy. Retrieved October 6, 2010, from http://www.medicare.com/services-and-procedures/medical-nutrition-therapy.html
Nelms, M., Sucher, K., & Long, S. (2007). In Marshall P. (Ed.), Nutrition therapy and pathophysiology. Belmont: Thomson.
Pons, R., Whitten, K. E., Woodhead, H., Leach, S. T., Lemberg, D. A., & Day, A. S. (2009). Dietary intakes of children with crohn's disease. British Journal of Nutrition, 102, 1052-1057. doi:10.1017/S0007114509085
Position of the american dietetic association: Health implications of dietary fiber. (2008). Journal of the American Dietetic Association, 108(10), 1716-1731. doi: 10.1016/j.jada.2008.08.007
Rajendran, N., & Kumar, D. (2010). Role of diet in the management of inflammatory bowel disease. World Journal of Gastroenterology, 16(12), 1442. doi:10.3748/wjg.v16.i12.1442
Vaisman, N., Dotan, I., Halack, A., & Niv, E. (2006). Malabsorption is a major contributor to underweight in Crohn’s disease patients in remission. Nutrition, 22(9), 855-859. doi: 10.1016/j.nut.2006.05.013