Dietary Sources of Inflammation or Relief in Crohn’s DiseaseSupatra HannaSodexo Distance Dietetics InternHollywood Presbyterian Medical CenterApril 2015

QuizWhat is the difference between Crohn’s Disease and Ulcerative

Colitis?

QuizWhat is the difference between Crohn’s Disease and Ulcerative

Colitis?

QuizWhat is the difference between Crohn’s Disease and Ulcerative

Colitis?

Objectives1.To learn the pathophysiology and common

symptoms of CD

2.To learn the current dietary sources of inflammation and relief in CD

3.To discuss current MNT for CD

Pathophysiology

● An inflammatory bowel disease (IBD)

● Inflammation of the lining of digestive tract, which can lead to abdominal pain, severe diarrhea, and malnutrition

● Found to be associated with malnutrition in approximately 20-85% of patients with small bowel disease

● Affect any portion of GI tract, most commonly affects the ileum and colon

Nutritional Indicators

• Rectal bleeding

• Generalized fatigue

• Impaired oral

intake/inadequate nutritional

intake

• Nausea

• Vomiting

• Diarrhea

• Abdominal pain

• Evidence of malabsorption

(increased gas or bloating)

• Fat in stools

Nutritional Indicators

• Weight loss/underweight

BMI/overweight

• Inadequate growth

• Reduced skeletal muscle

• Vitamin and mineral

deficiencies, including anemia

• Potential for multiple

medications and drug-nutrient

interactions

• Evidence of comorbid

conditions as extra-intestinal

disease, ie. oxalate kidney

stones

Etiology● Etiology of this disease remains unclear● Theories

o genetics and family historyo obesityo dietary inflammatory foodso environmental stressors: Infectious agents, GI microbiomeo lifestyle factors: Antibiotics, NSAIDs, Stress, Diet, oral

contraceptive useo theorized that in genetically susceptible individuals,

environmental triggers cause an abnormal inflammatory autoimmune response within the gastrointestinal (GI) tract. The excessive inflammation damages the mucosa of the GI tract, resulting in CD.

Testing● Blood tests

o Check for anemia● Fecal occult blood test

o Test for blood in stool● Colonoscopy

o View entire colon using a thin tube with an attached camera. During procedure, doctor can take small samples of tissue (biopsy) for laboratory analysis, which may help confirm a diagnosis

● Flexible sigmoidoscopyo a flexible tube to examine the sigmoid, the last section of colon

● Computerized tomography (CT)o View entire bowel as well as tissues outside the bowel that can't be

seen with other tests.

Lab Values of Concern

• CD specific:

• C-reactive protein

• Erythrocyte sedimentation rate

• Lactoferrin

• Antisacchromyces and Antineutrophil cytoplasmic

antibodies – immune proteins that are frequently present

in people who have inflammatory bowel disease (IBD)

• Micronutrient Assessment

Lab Values of Concern

• Albumin

• Prealbumin

• Hemoglobin

• Hematocrit

• Mean corpuscular

• Mean corpuscular

hemoglobin

• Mean corpuscular

hemoglobin

concentration

• Red cell distribution

• Total iron-binding

capacity

• Ferritin

• Transferrin

• Vitamin B-12

• Folate

• Vitamin D, 25-

hydroxy

• Zinc

• Glucose, fasting

• Blood urea nitrogen

• Creatinine

• Sodium

• Potassium

• Phosphorous

• Chloride

• Magnesium

• Calcium, serum

• PaCO2

• Osmolality, serum

Pertinent Lab Findings• Leukocytosis and increased sedimentation rate in inflammatory

phase• Hypochromic, microcytic anemia• Blood in the stool• Decreased serum albumin, total protein• Increased alkaline phosphatase, serum glutamic-oxaloacetic

transaminase, AST, bilirubin due to liver malfunction• C-reactive protein, Erythrocyte sedimentation rate, Lactoferrin,

WBC• Increased urine oxalate and calcium oxalate renal calculi due to

increased colonic oxalate absorption• Crohn’s Disease Activity Index

Stages of CD

Commonly Prescribed Drugs• Aminosalicylates (act locally in the GI tract - reduce inflammation):

sulfasalazine, mesalamine, balsalazide

• Immunomodulators (prevent inflammation by suppressing immune system): azathioprine, cyclosporine, methotrexate

• Antibiotics (reduce intestinal bacteria and treat infections related to abscesses, fistulas, and medications that cause immunosuppression): ciprofloxacin, flagyl

• Biological modifiers (help reduce the inflammation in colon by targeting TNF proteins involved in the inflammatory response): infliximab, adalimumab, certolizumab—antitumor necrosis factor medication

• Corticosteroids (rapidly produce immunosuppression): prednisone, methylprednisolone, hydrocortisone

Surgical Treatments

● Removes a damaged portion of digestive tract and then reconnect the healthy sections

● Strictureplasty, widens a segment of the intestine which has become too narrow

● Benefits of surgery for Crohn's are usually temporaryo best approach is to follow surgery with medication to

minimize the risk of recurrence

Common Nutrient Deficiencies

High prevalence of overweight and obesity in adults with Crohn's disease: Associations with disease and lifestyle factorsSuibhne, T. N., Raftery, T. C., McMahon, O., Walsh, C., O'Morain, C., & O'Sullivan, M. (2013)

● Aim: Link between adipose tissue and inflammation in CD + higher C-reactive protein, Tumor Necrosis factor-alpha, adipocytokines lead to intestinal inflammation. Compared overweight and obese CD patients with healthy weight patients - identify genetics & etiology

● Participants: 200 participants, (n=100) with Crohn’s disease, (n=100) healthy (control)- 3 months

● Methods: Demographics, SES, smoking habits, physical activity, hours spent watching TV, height, weight, BMI, adiposity, disease activity

● Results & Conclusions: patterns of obesity in conjunction with CD followed obesity changes in society, association between lower Crohn’s Disease Activity Index (CDAI) scores (<150 in remission) and white blood cell count, & this came with higher BMI =>lowering in physical activity level with an increase in age

Carbohydrate intake in the etiology of Crohn’s disease and ulcerative colitisChan, S.M., Luben, R., van Schaik, F., Oldenburg, B., Bueno-de-Mesquita, B., et. al. (2014)

● Aim: To analyze associations between increase intakes of carbohydrates, sugar, starch, and inflammatory bowel disease.

● Participants: 401,326 men and women recruited between 1991 and 1998

● Methods: Used FFQ to evaluate consumption of carbohydrates and etiology of CD and UC

● Results & Conclusions: 110 cases of CD and 244 cases of UC identified. No significant associations between total carbohydrate, sugar, or start intakes and development of CD or UC

A prospective study of long-term intake of dietary fiber and risk of crohn's disease and ulcerative colitisAnanthakrishnan, A. N., Khalili, H., Konijeti, G. G., Higuchi, L. M., De Silva, P., Korzenik, J. R., . . . Chan, A. T. (2013)

•Aim: examine the long-term effects of dietary fiber intake on the risk of CD and UC •Participants: 170,776 women from Nurses’ Health Study - 26 years •Methods: Dietary information prospectively determined via administration of validated semi-quantitative FFQ every 4 years, CD and UC was self-reported •Results: Out of 269 confirmed cases of CD, highest quintile of average dietary fiber intake from fruits was associated with an average of 40% reduction in risk of CD, fiber from cereals, whole grains, or legumes did not affect the risk of CD, no association found with fiber and UC •Conclusions: Long-term fiber intake from fruit is associated with a lower risk of developing or exacerbating CD

The effects of an oral supplement enriched with fish oil, prebiotics,and antioxidants on nutrition status in crohn’s disease patientsWiese, D. M., Lashner, B. A., Lerner, E., DeMichele, S. J., & Seidner, D. L. (2011).

•Aim: to examine if a nutritionally balanced IBD nutrition formula (IBDNF) enriched with fish oil, prebiotics, and antioxidants has potential to improve nutrition status and disease activity in CD•Participants: 28 active CD patients on stable medication•Methods: patients were asked to consume 16 ounces of IBDNF formula per day over 4 month period; Nutrition status assessed using dual-energy X-ray absorptiometry scans and serum-nutrient levels; disease activity and quality of life were measured using CDAI surveysResults: 20 patients completed treatment. Significant decrease in plasma phospholipid levels of arachidonic acid and increases in EPA and DHA. Vitamin D levels improved in all patients. Those with greater EPA levels had a lower CDAI values compared to those with lower EPA levels.•Conclusions: IBDNF has the potential lower CDAI levels, improve vitamin D status, and improve quality of life in CD patients.

Oral vitamin D3 supplementation reduces monocyte-derived dendritic cell maturation and cytokine production in Crohn’s disease patientsBartels, L.E., Bendix, M., Hvas, C.L.,Jorgensen, S.P., Agnholt, J., Agger, R., Dahlerup, J.F. (2013)

● Aim: To analyze the changes in monocyte-derived dendritic cell maturation marker expression and cytokine production after 26 weeks of vitamin D3 supplementation.

● Participants: 10 CD patients who supplemented with D3 and have increased 25-hydroxy vitamin D levels and 10 matched placebo treated patients

● Methods: Analyzed the effects of vitamin D supplementation on decreasing inflammation in IBD. Two groups compared.

● Results & Conclusions: Patients with oral vitamin D3 supplementation exhibited reduced expression of maturation markers and lower production of cytokines.

Inflammatory Foods

• Non-leafy vegetables• Spicy foods• Nuts• High-fiber foods• Corn• Fatty foods• Leafy vegetables• Fried foods• Milk• Red meat

• Soda• Popcorn• Dairy• Alcohol• Seeds• Coffee• Beans

Non-Inflammatory Foods

• Bananas • White rice• Cheese (if not lactose

intolerant)• Applesauce• Smooth peanut butter• Protein through lean

meats and soy • Potatoes without skin

• Boiled or steamed fish (herring, salmon, halibut, flounder, swordfish, or pollack)

• Plain cereals• Broth• Canned fruit• Cooked veggies• Fiber from fruit

High Oxalate Foods to Avoid

• Spinach • Rhubarb • Beets • Potato chips • French fries • Nuts and

nut butters

PES Statements:● Malnutrition R/T increased nutrient needs due to inflammation AEB ___#

weight loss (___% weight change) in ___ months.

● Altered nutrition related laboratory values R/T Crohn’s disease AEB

elevated levels of C-reactive protein, ESR ,and transferrin,and low levels

of ferritin.

● Inadequate oral intake R/T discomfort after eating as evidenced by 1/3

normal intake for past 5 days.

● Inadequate mineral intake (iron) related to increased needs resulting from

blood loss with diarrhea as evidenced by estimated intake approximately

50% of requirements.

MNT

• Kcal: Usually 25-35 kcal/kg in adults

• PRO: Needs should be based on disease state, body weight, inflammation in

GI, catabolism, surgical wounds. Protein recommendation is 1.0 to 1.5

g/kg/d

• Enteral feedings or total parenteral nutrition. Enteral nutrition – minimal

fiber content. Progress to low-fat, low-fiber, high-protein, high-kilocalorie,

small, frequent meals with return to normal diet as tolerated.

• Low residue, lactose free diet

• Treating protein-calorie malnutrition

• Avoid large meals

• Reduce fat, dairy, sugar, and gas-producing foods

SupplementationVitamins: Use Dietary Reference Intakes (DRI) baseline recommendations. The patient may need higher levels of the following:• Vitamin B-12• Folate• Thiamin• Riboflavin• Niacin• Vitamin C• Vitamin E• Vitamin D

• Vitamin KIron: often related to blood loss, though should be thoroughly evaluated

Minerals: Use DRIs as baseline recommendations. The patient may need higher levels of the following:• Zinc• Magnesium• Selenium

• Potassium

Specific nutrient supplementation: • n-3 fatty acids• Glutamine• Prebiotics/probiotics

Multiple Choice

1. The following are inflammatory foods except:

a. Fried foods

b. Red meat

c. Fiber from fruit

Multiple Choice

1. The following are inflammatory foods except:

a. Fried foods

b. Red meat

c. Fiber from fruit

Multiple Choice

2. Crohn’s disease is characterized by inflammation of:

a. The pancreas

b. The kidneys

c. The GI tract

Multiple Choice

2. Crohn’s disease is characterized by inflammation of:

a. The pancreas

b. The kidneys

c. The GI tract

Multiple Choice

3. Patients with Crohn’s disease have increased protein and energy needs due to:

A. increased appetite

B. anorexia

C. inflammation and malabsorptionD. intake needs are not increased.

Multiple Choice

3. Patients with Crohn’s disease have increased protein and energy needs due to:

A. increased appetite

B. anorexia

C. inflammation and malabsorptionD. intake needs are not increased.

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