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

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

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

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)

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

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

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)

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

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

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

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: www.medgadget.com

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

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

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

Calorie Needs Calculate 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, calcium Conclusion: additional dietary counseling necessary Source: Aghdassi (2007)

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)

Protein Needs Recommended 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 Disease Sudden flare-ups: Parenteral or enteral nutrition support with chemically defined formula Glutamine and arginine supplements aid in decreasing inflammatory response

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

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)

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 100-149% of EAR for energy for age. Source: Aghdassi (2007)

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

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)

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 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

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

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

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

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

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

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

Ethical Issues Stem cell therapy used for Crohn’s disease treatment Withholding 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 definition Common nutrient deficiencies Treatment goals Medical nutrition therapy for Crohn’s

Questions?

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), 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

References Landsman, 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