Malnutrition in ibd

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The occurrence of malnutrition in both ulcerative colitis and Crohn's disease is common (Table 3.3). Weight loss in regional ileitis (Crohn's disease) was described in the early observations of Crohn [27]. Indeed, death as a result of malnutrition in those with Crohn's disease was not unusual in the first half of the last century. Protein-calorie malnutrition is still seen in up to 80% of those with Crohn's disease and in as many as 50-60% of those with ulcerative colitis. Hypoalbuminemia is present in 25-80% of those with Crohn's disease and in 25-50% of patients with ulcerative colitis, but it has been identified that this primarily reflects disease activity rather than nutritional deficiency per se [28].

Growth failure in children and adolescents with Crohn's disease is a classical presentation. In addition to inadequate caloric intake, this may result from a growth-inhibiting effect of pro-inflammatory cytokines [29]. This topic will be addressed later in this chapter.

Anemia is present in a high percentage of individuals with IBD. This usually is the result of iron, vitamin B12 or folate deficiency. Iron

Table 3.3

Prevalence of Malnutrition in Inflammatory Bowel Disease

Table 3.3

Prevalence of Malnutrition in Inflammatory Bowel Disease

colitis

Crohn's disease

Ulcerative

Weight Loss

65-76%

18-62%

Growth retardation

40%

-

Hypoalbuminemia

25-80%

25-50%

Anemia

29%

-

Iron

39%

81%

Folate

54%

36%

Vitamin B12

48%

5%

Calcium

13%

-

Magnesium

14-88%

-

Potassium

6-20%

-

Zinc

40-50%

-

Kelly DG, Fleming CR. Nutritional considerations in inflammatory bowel diseases. Gastroenterology Clinics of North America 1995,24:597-611. With permission from the publisher.

Kelly DG, Fleming CR. Nutritional considerations in inflammatory bowel diseases. Gastroenterology Clinics of North America 1995,24:597-611. With permission from the publisher.

deficiency anemia is found in over 80% of patients with ulcerative colitis, primarily resulting from blood loss. It is seen in nearly 40% of anemic patients with Crohn's disease, especially in disease involving the colon. By contrast, vitamin B12 deficiency is found predominantly in patients who have distal ileal Crohn's disease or a history of ileal resection with only a small prevalence occurring in ulcerative colitis. Folate deficiency is found in one-third to one-half of those with IBD with a somewhat higher prevalence in Crohn's disease. Three studies have measured the status of multiple vitamins in patients with IBD [30, 31, 32]. Blood levels less than the 15th percentile of normal controls for biotin, folate, thiamine, vitamin A, E, C and p-carotene were present in 40-90% of patients with IBD. These were identified in patients who had no clinical signs [31] and who did not have apparently decreased intakes [32], making clinical suspicion of importance in monitoring patients at risk for impending deficiency states. Fat soluble vitamin deficiencies are found particularly in patients with decreased bile salt pools, in those with cholestasis, as occurs in sclerosing cholan-gitis, and in those with bacterial overgrowth syndrome (30% of those with Crohn's disease). Vitamin A deficiency has been of concern, in part because of its relationship to immune function. In pediatric patients with both Crohn's disease and ulcerative colitis an increased prevalence of vitamin A deficiency has been reported that is correlated with the severity of disease [33].

Selenium deficiencies are of particular concern in patients with IBD, as it along with vitamins E, A and C is an antioxidant. Oxidative stress is likely involved in the IBD process. In an evaluation of 26 patients with Crohn's disease, serum selenium and glutathione peroxidase levels in red blood cells were decreased, leading Reimund and colleagues to suggest that selenium deficiency may facilitate inflammatory and immune activation in the disease [34].

Magnesium deficiency is particularly common in Crohn's disease, especially following distal small bowel resection and colectomy. Additionally, zinc is frequently deficient in those with Crohn's disease with associated fistulae.

Metabolic bone disease is commonly observed in those with inflammatory bowel disease. Clearly malnutrition contributes to this phenomenon. Hypocalcemia is seen in more than 10% of those with inflammatory bowel disease. This is often associated with decreased levels of vitamin D and in those patients on corticosteroid therapy. Osteopenia has been reported in more than half of patients with deficient 25-OH vitamin D levels (less than 25 nmol/l). However, a recent study of 242 patients with Crohn's disease low bone mineral density (BMD) was not more frequent in those with the low 25-OH vitamin D levels, although parathyroid hormone and alkaline phosphatase were significantly higher in this group [35]. Decreased sunlight exposure, compromised nutritional status (as indicated by low levels of red blood cell folate and serum iron) and smoking were associated with lower levels of 25-OH vitamin D in this geographically localized population of northwestern Canadian patients with Crohn's disease. Vitamin D levels measured in winter were four-fold lower than those measured in the spring and summer. Another large study examined the frequency of clinical consequences of bone disease, specifically vertebral fractures, in patients with Crohn's disease [35]. Of the 293 consecutive patients evaluated, 156 (53%) had lumbar osteopenia or osteoporosis, and of these, 34 (22%) patients had 63 osteoporotic vertebral fractures with one-third of them occurring in patients under 30 years of age. Other studies have attempted to document risk factors for metabolic bone disease in IBD. Habtezion et al. identified age, body mass index and serum magnesium levels to be correlated with BMD, while lifetime steroid use was a poor predictor [37]. In fact, 40 patients in this study had never used steroids, and of them 48% had osteopenia of the femur and 30% of the spine. In contrast, Deer and colleagues found that patients with Crohn's disease who had a low lifetime corticosteroid use as a result of steroid sparing approaches to treatment, including diet, had BMD levels similar to normal controls, while those patients receiving steroids had a significantly lower BMD [38]. An investigation by de Jong and coworkers identified 48% of patients with osteopenia and 30% with osteoporosis [39]. In this study steroid use, long duration of Crohn's disease, body mass index and history of intestinal resection were indicators determined by univariate analysis, but with multiple regression analysis, only body mass index and history of intestinal resection were independent predictors of decreased BMD. Clinicians must be aware of the potential for osteoporosis in patients with IBD, monitor BMD and treat with calcium and vitamin D replacement as needed, as well as give consideration to bisphophonates in those affected.

Geerling et al. identified that there is already a risk of nutritional compromise in patients at the beginning of the IBD course [40]. A cohort of Dutch patients that was within 6 months of the initial diagnosis of IBD (23 Crohn's disease and 46 ulcerative colitis) demonstrated that those with Crohn's disease were taller than controls selected randomly from a patient database, yet the body mineral content, measured by absorptiometry, was lower in the patients with Crohn's. Those with ulcerative colitis had a significantly higher body mass index than controls. Fat free mass was higher in those with Crohn's disease and lower in patients with ulcerative colitis than in the respective control groups. Experienced dietitians assessed the daily nutrient intake by doing food intake interviews and analyzing frequency reports. From this analysis it was found that patients with Crohn's disease had a lower intake of polyunsaturated fatty acids, but a high intake of mono- and disaccharides than the control group. Those with ulcerative colitis took in a lower percentage of calories as protein, as well as lower amounts of phosphorus, calcium, riboflavin and vitamin C than controls. Both patient groups also consumed less alcohol than either control group. Biochemical markers identified significantly lower albumin and vitamin B12 levels among those with Crohn's disease and lower albumin, ^-carotene, magnesium and zinc levels in patients with ulcerative colitis. A high percentage of these patients were judged to be in clinical remission (83% of those with Crohn's disease and 92% of patients with ulcerative colitis) based on the Crohn's disease activity index (CDAI) and Truelove and Witt's criteria, respectively.

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