Transcript Food For Thought: Malnutrition and Inflammatory Bowel Disease

Roberta Gershner M.S., RD, CDN
December 5, 2013
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Difference between Inflammatory Bowel
Disease (IBD) and Irritable Bowel Syndrome
(IBS)
Nutritional impacts of IBD
Effects of Herbs and Drugs
MNT for IBD
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When you leave today you should:
 Know the questions to ask your IBD patients
 Have a better understanding of IBD from a
nutrition perspective
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IBD
 Group of chronic, autoimmune diseases
▪ Functional AND Structural
▪ Inflammation and other physiologic issues
▪ Ulcerative Colitis and Crohn’s Disease
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IBS
 Functional symptoms only
▪ Similar to those experienced in IBD
▪ NO structural changes
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Crohn’s Disease (CD)
 May occur throughout the GI
tract
 If small intestine is affected
digestion and absorption of
nutrients may be affected
 Poor absorption and
inflammation in the colon
may also cause diarrhea
Ulcerative Colitis (UC)
Limited to colon/rectum
Small intestine works
normally
Inflamed colon causes
urgency and poor reabsorption of water causing
diarrhea
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MYTH: IBD is caused/cured by certain foods
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REALITY:
– There is no conclusive evidence that foods can cause
or cure IBD
– Many with IBD cannot tolerate certain foods when
well or experiencing a flare
– Diet may effect the symptoms but NOT the disease
– Nutrition and diet are important in management of
IBD
 Severity of the disease
 Portion of the bowel that is affected
 Degree of malabsorption and malnutrition
ACUTE Malnutrition
CHRONIC Malnutrition
Weight Loss
Cachexia
Anemia
Iron
Folic Acid
B12
Multiple Nutritional Deficiencies
Mineral/electrolyte
Vitamin
Hyperalbumenia
Growth Retardation
 Weight loss
 Hypoalbuminenia
 Vitamin D
 Magnesium
 Negative nitrogen
imbalance
 Anemia
Iron
B12
Folic Acid
 Potassium
 Calcium
 Lactose Intolerance
Deficiencies Result in
Physical Outcomes
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Protein calorie malnutrition is the most
common nutrition problem in patients with
IBD
Additional Outcomes Include
 Impaired growth in children & decreased bone
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mineral density
Dehydration
Poor fat absorption
Bone mineral disease
Muscle wasting
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Portion of bowel effected
Malabsorption
Decreased nutrient intake
Excessive losses
Increased requirements
Other Factors
 Drug/ Nutrient interactions
BOWEL PORTION LOST
NUTRITIONAL DEFICIENCY
Duodenum
Iron deficiency
Jejunum
The ileum can compensate
Ileum
Fat intolerance /malabsorption
Malabsorption of bile salts
Fat soluble vitamin deficiencies
Hypocalcemia, Hypomagnesemia
B12 deficiency
Water soluble vitamins (C + folate)
Ileocecal Valve
Bacterial overgrowth, vitamin
deficiency, diarrhea, bile salt
deconjugation
Colon
Diarrhea (fluids and electrolytes)
Mucosal abnormalities
Poor digestion of carbohydrates
Diminished absorptive surfaces
Surgery
Extensive disease
Bacterial overgrowth
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Anorexia
Vomiting
Diarrhea
Nausea
Abdominal cramps
Altered tastes
Bloating
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Dietary Restrictions
 No Lactose
 No Red Meat
 No Wheat
 No Gluten
 Low Residue
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Feeling Full Easily
Pain or Inflammation
Strictures
Gas and Bloating
Food Allergy / Intolerance
Diarrhea
Protein losing enteropathy
Bleeding
Fistula output
Surgery
Diarrhea/vomiting
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Water is essential for the IBD patient
Water replaces fluids that are lost through diarrhea,
vomiting and blood loss
 Important to protect kidney function
Water hydrates cells, cools the body and helps flush
waste products
 Risk for dehydration always exists
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Hyper-Catabolic states
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Fever
Sepsis
Growth in children/teens
Pregnancy
Other Factors
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Surgical complications
Drug/Nutrient Interactions
DEFICIENT NUTRIENT
CONDITION
Iron
Anemia, fatigue, interruption of
menstruation
Vitamin K
Bleeding & bruising, osteopenia,
osteoporosis, reduced clotting time
Protein, Vitamin D,
Calcium
Osteopenia, bone fractures & pain
Vitamin B12,Folate/Folic
Acid
Anemia, lip & mouth sores
Electrolytes (calcium,
magnesium, water)
Muscle spasms, tetany
Electrolytes (calcium,
magnesium, water)
Muscle spasms, tetany
MEDICATION
NUTRITIONAL EFFECT
Azulfadine & Sulfasalazine
Reduce folic acid
Corticosteroids Therapy
Cause hormone deficiency
Decrease intestinal absorption of calcium and
protein
May decrease bone forming cells
Increased activity of cells responsible for
reabsorption (due to amount and duration)
Increased risk of diabetes and cateracts
Cholestryamine
Interferes with absorption of fat soluble
vitamins – Pain killers
Antibiotics
Interfere with absorption of Vitamin K & Biotin
Histamine H2 Receptor
Antagonists
Proton Pump Inhibitors
Reduce absorption of Calcium
May reduce absorption of Iron & Vitamin B12
Pain Killers, Tranquilizers
Causes constipation in the G.I. tract
Metronidazole
Can produce a metallic taste increasing
anorexia
 May diminish OR increase symptoms
 Herbal supplements can interact with
prescription and over the counter drugs or
cause serious side effects
MAY REDUCE SYMPTOMS
MAY INCREASE SYMPTOMS
(ANTI-INFLAMMATORY)
(LAXATIVE OR SLOW MOTILITY)
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Boswellia
Chamomille
Ginger
St John’s Wort
Slippery Elm
Milk Thistle
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Alder buckthorn
Aloe latex
Cascara
Castor Oil
European Buckthorn
Fo-ti
Rhubarb
Senna
Medicinal Herb
Affected Drugs
Interactions
Chamomile
Anticoagulants
May increase the risk of bleeding
Barbiturates
May intensify or prolong the effect of
sedatives
Iron
May reduce Iron absorption
Ginger
Anticoagulants
May increase the risk of bleeding
St. John’s wort
Cyclosporine
May reduce blood levels of
cyclosporine, making it less effective,
with potentially dangerous results
(such as rejection of an organ
transplant)
Iron
May reduce Iron absorption
Gastrointestinal disturbances
Milk Thistle
Statins, Glucuronidates
May effect breakdown in liver
Slippery Elm
Oral drugs
May decrease absorption
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Are live microorganisms (Intestinal Bacteria) in yogurts,
cheese, baby food, and supplements.
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Attempt to modify the disease by favorably altering bacterial
composition, immune status and inflammation process in
the GI tract.
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Used to treat digestive diseases: certain types of diarrhea,
and forms of inflammatory bowel disease (pouchitis and
necrotizing entercolitis) in preterm infants
 Frequently seen in patients with IBD
 Glucosamine may be helpful
 Increased
intake of calcium & vitamin D
supplement may be beneficial
 Fish oils & Omega 3 Fatty Acids can be
beneficial
 GOAL: to maintain an adequate nutrient intake
while modifying the patients diet in order to
decrease G. I. symptoms
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The disease, patient, and medication change over
time
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The nutrient needs and the MNT will have
to change accordingly
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Add calories when the patient is severely ill or has serious
malabsorption, causing energy loss in the stool
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Maintain an adequate nutrient intake with a texture
modified diet to decrease G I symptoms & increase
absorption
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Patient needs to eat 3 small–moderate size meals and 2-3
small snacks
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Fruits and Vegetables
– Lower fiber, thin skin
– Cooked, pureed or peeled
– Not gas producing
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Carbohydrates
– More refined, less insoluble fiber
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Proteins
– Lean protein sources
– May need up to 50% increase to compensate
for losses
 If protein loss is present during active
inflammation approximately 50% more
protein is needed in the diet
 An active child/adolescent with IBD may
require 45 calories per lb. of body weight
(normal requirement 30 calories/lb.)
Eat a variety of foods
Eat a low fiber/ low residue diet during an
acute flare up or if strictures are present
Reduce fatty & high spiced foods
Eat a high protein diet
Eat foods that are nutrient dense
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Consume adequate calcium (1200-1500mg daily)
and vitamin D in their diet (1000-2000 IU).
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Take a therapeutic multivitamin providing 1–5 times
the recommended daily allowance of specific
vitamins
 Ensure a good potassium, sodium and magnesium intake.
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Drink plenty of clear fluid daily at least (8 8oz
glasses daily). It can be a sports drink.
 Limit lactose in diet during flares and if the
patient is diagnosed as lactose intolerant
 Keep snacks handy
 Make food preparation easy
 Be made aware of food/nutrient, drug/drug,
and food/drug interactions
 Avoid alcohol!
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There is no one diet for the patient with IBD
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Patients at risk for protein calorie malnutrition and
arthritis
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MNT must be specific and highly individualized to
effectively manage the symptoms of IBD
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Chrohn’s &Colitis Foundation of America
 www.cfa.org
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HealingWell.com
 www.healingwell.com/ibd/
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National Digestive Disease Clearinghouse
 http://digestive.niddk.nih.gov/ddiseases/topics/IBD.aspx
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United Ostomy Association
 www.uoa.org
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Probiotics
 http://www.onhealth.com/probiotics/article.htm
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VSL#3
 www.vsl3.com