1. Managing Crohn’s Disease through Nutritional Intervention
Kristy Singlestad
Concordia College
Moorhead, MN

2. Objectives Be able to describe Crohn’s disease
Identify common nutrient deficiencies in Crohn’s disease
Be able to describe treatment goals for Crohn’s disease
Identify the medical nutrition therapy for Crohn’s disease

3. Anatomy of Gastrointestinal System
Oral cavity
Esophagus
Stomach
Small intestine
Duodenum
Jejunum
Ileum
Large intestine
Rectum
Anus

4. Inflammatory Bowel Diseases (IBD)
Crohn’s Disease
Involves any part of digestive tract
Affects all layers of intestine
Patches of inflammation
Ulcerative Colitis
Only involves colon
Affects only mucosa layer of intestine
Continuous distribution of inflammation
Source: Crohn’s and Colitis Foundation of America (2009)

5. 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 enteritis
Ileum and colon most commonly affected
No cure, but treatments available

6. Definition continued…
May damage all 3 layers of GI tract
May cause fistula and abscess
Causes nutritional problems

7. Disease Pathology
Approximately ½ million Americans are currently diagnosed with Crohn’s disease
Affects children and adults
Prevalence 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)

8. Causes Unknown cause Possible causes: Autoimmune response
Environmental triggers
Smoking
Infectious agents
Intestinal flora
Genetics ~20% have a relative with IBD

9. Symptoms Abdominal pain, lower right quadrant Diarrhea
Loss of appetite
Fever
Rectal bleeding
Weight loss

10. 5 Types of Crohn’s Disease
Ileocolitis – ileum and colon
Ileitis – ileum only
Gastroduodenal – stomach and duodenum
Jejunoileitis - jejunum
Crohn’s colitis – colon only

11. 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

12. Stages of Crohn’s Disease
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

13. Diagnosis Endoscopy (colonoscopy – examine large intestine)
Blood tests
Anemia indicates intestinal bleeding
Increased white blood cell count indicates inflammation
Barium X-ray
Stool sample
"Cobblestoning" in colonoscopy
Source:

14. Treatment Forms of treatment: Goals of treatment:
Medical Nutrition Therapy (MNT)
Medications
Surgery
Goals of treatment:
Control inflammation
Correct nutritional deficiencies
Relieve symptoms

15. Medical Nutrition Therapy
Currently, no specific diet is used for treatment in Crohn’s disease
Diet is individualized
Multivitamin recommended due to nutrient deficiencies

16. Common Nutrient Deficiencies
Nutrient Deficiency
Probable Cause
Calories
Insufficient intake
Anorexia
Fear 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 use
Decreased 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

17. Calorie Needs
Calculate using Harris-Benedict or Mifflin- St. Jeor equation
Stress factor ( )
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

18. 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, calcium
Conclusion: additional dietary counseling necessary
Source: Aghdassi (2007)

19. Study: Adequacy of dietary intake in children with Crohn’s
Objective: 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 growth
Source: Pons (2009)

20. Protein Needs Recommended intake:
Adults: g/kg
Children: g/kg
Protein needs may increase by 150% of normal recommendations
Factors to consider:
Lean body mass wasting
Measurement of prealbumin and albumin

21. 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)

22. 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

23. MNT: Increased Severity of Disease
Sudden flare-ups:
Parenteral or enteral nutrition support with chemically defined formula
Glutamine and arginine supplements aid in decreasing inflammatory response

24. MNT: Enteral and Parenteral Nutrition
Allows bowel rest to reduce inflammation
Used to prepare people for surgery to improve health
Used when medications are unable to control symptoms

25. Study: Enteral vs. Parenteral Feeding
Evidence 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)

26. Study: Enteral Nutrition for Children
Objective: 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 % of EAR for energy for age.
Source: Aghdassi (2007)

27. MNT: Remission
Goal: maximize calorie and protein intake for rehabilitation
Obtain healthy weight with physical activity
Obtain normal dietary patterns
Consume foods high in antioxidants and Omega-3 fatty acids
Probiotics and Prebiotics

28. Study: Use of Omega-3 Fatty Acids in Inflammation Reduction
Objective: 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)

29. 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)

30. Key Interventions Increase nutrient intake
Correct malabsorption or anemia
Monitor lactose and gluten intolerances
Rest bowel to promote healing and prevent protein mass loss
Promote weight gain

31. MNT: Basic Guidelines Eat small, frequent meals Drink plenty of fluids
Consider a multivitamin
Choose foods with added probiotics and prebiotics
Consume low-fiber foods when symptoms arise
Avoid foods that aggravate symptoms
Source: American Dietetic Association (2010) client handout

32. Drug Therapy: Medications
Anti-inflammatories
Immunosuppressants
Antibiotics
Other – anti-diarrheal, laxatives, pain relievers

33. Drug Therapy: Medications
Anti-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

34. 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

35. Surgery About 60% of patients require surgery
Ileostomy, most common form
Used 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

37. Complications Blockage of small intestine
Development of fistulas and fissures
Nutritional deficiencies
Arthritis
Kidney stones
Diseases of the liver
Skin problems
Osteoprosis

38. Ethical Issues Stem cell therapy used for Crohn’s disease treatment
Withholding or with drawing nutritional support with enteral and parenteral nutrition

39. Reimbursement Issues
Lack of coverage for nutrition counseling services in Crohn’s disease patients
Source: Medx Publishing (2008)

40. Summary Crohn’s disease definition Common nutrient deficiencies
Treatment goals
Medical nutrition therapy for Crohn’s

41. Questions?

42. References
Aghdassi, 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), doi: /j.jada
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://
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/crohnsdisease 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),
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), doi: /j.clnu

43. References
Landsman, K. (2010). My WebMD: A college student controls her crohn's. Retrieved September 28, 2010, fromhttp://
Medx Publishing. (2008). Medical nutrition therapy. Retrieved October 6, 2010, from 
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, doi: /S
Position of the american dietetic association: Health implications of dietary fiber. (2008). Journal of the American Dietetic Association, 108(10), doi: /j.jada
Rajendran, N., & Kumar, D. (2010). Role of diet in the management of inflammatory bowel disease. World Journal of Gastroenterology, 16(12), doi: /wjg.v16.i
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), doi: /j.nut