Correcting deficiencies

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Unless the physician has particular expertise in nutrition and time to adequately address these issues, the assistance of a dietitian can be useful in identifying nutrient deficits, indicating which dietary practices may contribute and correcting them, motivating patients to comply with recommendations and monitoring the patient. Inadequate caloric and protein intakes require an understanding of the limitations in specific patients in order to develop effective and sometimes creative approaches to correction with the diet itself, as well as the use of caloric supplements and specific therapies. Availability of a chewable multivitamin containing water soluble forms of the fat soluble vitamins will frequently help in those with specific deficits of vitamins A, D, E and K. However, achieving 25-OH vitamin D levels deemed necessary to treat osteoporosis usually requires very high doses (50,000 international units several times weekly) of ergocalciferol. When such high doses are used, it must be kept in mind that monitoring of blood levels of the vitamin are necessary to be reassured that hypervitaminosis does not occur.

In many patients with low levels of vitamin B12, it is now known that oral dosing with very high doses of cyanocobalamin (1,000 mcg daily) will effectively replace the vitamin as a result of passive absorption of up to 10% of the dose [41]. However, it is important to monitor blood levels to be assured that oral replacement is adequate in a specific patient. Increased levels of homocysteine have been associated with decreased folate in patients with Crohn's disease [42]. This suggests that attention be given to replacement of the vitamin for purposes of decreasing deep venous thrombosis and coronary artery disease [43, 44]. Data from Lashner et al. suggest that folate supplementation may decrease the development of dysplasia in the intestinal mucosa of patients with IBD [45].

Mineral replacement, especially including zinc, may be achieved with available oral zinc supplements. In the case of magnesium replacement, the challenge is providing a magnesium salt that does not cause catharsis. Effective magnesium replacement can be achieved with organic salts of magnesium, such as magnesium gluconate, available as a tablet or as an elixir (magnesium heptagluconate in Canada—personal communication, Kursheed Jeejeebhoy, MD). These organic salts dissociate slowly in solution, limiting the osmotic load and improving therapeutic effectiveness.

Gassull suggests that sub-clinical deficiencies may play a role in the perpetuation of Crohn's disease [46]. This may occur as a result of defects in mechanisms of tissue repair causing decreased defense against damage resulting from oxygen free radicals, thus favoring lipid peroxidation [47, 48]. It is intriguing that anti-oxidant nutrient levels may be stressed in IBD. Certainly, this suggests that clinicians must be attentive to diet and patients' nutritional status and that there may possibly be a role for primary nutritional therapy maintenance of remission.

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