Risk of impaired nutritional status and flare occurrence in IBD outpatients

Malnutrition Defined by the Global Leadership Initiative on Malnutrition (GLIM) Criteria in Hospitalized Patients with Ulcerative Colitis and Its Association with Clinical Outcomes

(1) Background: The Global Leadership Initiative on Malnutrition (GLIM) was published in 2019, and its application has been explored in several diseases. However, the data on malnutrition based on the GLIM in ulcerative colitis (UC) patients are sparse. (2) Methods: This single-center, retrospective cohort study included 605 hospitalized UC patients. Demographics and clinical data were collected from electronic medical records. Nutritional Risk Screening 2002 (NRS 2002) was used as a screening tool, and malnutrition was diagnosed according to the GLIM criteria. The skeletal muscle area of the third lumber cross-section in abdominal computed tomography was used to evaluate muscle mass within one week before or after admission. (3) Results: The prevalence of malnutrition was 64.1% in this cohort, and the prevalences were 34.2, 57.7, and 86.7% in UC patients with mild, moderate, and severe disease activity, respectively. Malnourished patients tended to need surgical treatment (p = 0.080) and had a 2.4 times greater risk of opportunistic infection. The multivariate logistic regression analysis showed that UC patients with malnutrition had a 1.7-fold increased risk of readmission. (4) Conclusions: Nutritional problems deserve more attention in hospitalized UC patients. Malnutrition identified through the GLIM criteria was associated with opportunistic infection, tended to be associated with surgical treatment, and showed a prognosis value for readmission.

Adjunctive therapeutic effects of micronutrient supplementation in inflammatory bowel disease

Growing evidence suggests that micronutrient status may have some impact on the course of inflammatory bowel disease (IBD). However, micronutrient deficiencies are easily overlooked during the treatment of IBD patients. There have been many studies on micronutrient supplementation, in which several clinical trials have been conducted targeting vitamin D and iron, but the current research is still preliminary for other vitamins and minerals. This review provides an overview of the adjunctive therapeutic effects of micronutrient supplementation in IBD, to summarize the available evidence, draw the attention of clinicians to micronutrient monitoring and supplementation in patients with IBD, and also provide some perspectives for future research directions.

ECCO Topical Review: Roadmap to Optimal Peri-Operative Care in IBD

BACKGROUND AND AIMS

Despite the advances in medical therapies, a significant proportion of patients with inflammatory bowel diseases [IBD] require surgical intervention. This Topical Review aims to offer expert consensus practice recommendations for peri-operative care to optimize outcomes of IBD patients who undergo surgery.

METHODS

A multidisciplinary panel of IBD healthcare providers systematically reviewed aspects relevant to peri-operative care in IBD. Consensus statements were developed using Delphi methodology.

RESULTS

A total of 20 current practice positions were developed following systematic review of the current literature covering use of medication in the peri-operative period, nutritional assessment and intervention, physical and psychological rehabilitation and prehabilitation, and immediate postoperative care.

CONCLUSION

Peri-operative planning and optimization of the patient are imperative to ensure favourable outcomes and reduced morbidity. This Topical Review provides practice recommendations applicable in the peri-operative period in IBD patients undergoing surgery.

ESPEN guideline on Clinical Nutrition in inflammatory bowel disease

The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

Deficits in Geriatric Assessment Associate With Disease Activity and Burden in Older Patients With Inflammatory Bowel Disease

BACKGROUND & AIMS

We aimed to perform geriatric assessment in older patients with inflammatory bowel disease (IBD) to evaluate which IBD characteristics associate with deficits in geriatric assessment and the impact of deficits on disease burden (health-related quality of life).

METHODS

A prospective multicenter cohort study including 405 consecutive outpatient patients with IBD aged ≥65 years. Somatic domain (comorbidity, polypharmacy, malnutrition), impairments in (instrumental) activities of daily living, physical capacity (handgrip strength, gait speed), and mental (depressive symptoms, cognitive impairment) and social domain (life-partner) were assessed. Deficits in geriatric assessment were defined as ≥2 abnormal domains; 2-3 moderate deficits and 4-5 severe deficits. Clinical (Harvey Bradshaw Index >4/partial Mayo Score >2) and biochemical (C-reactive protein ≥10 mg/L and/or fecal calprotectin ≥250 μg/g) disease activity and disease burden (short Inflammatory Bowel Disease Questionnaire) were assessed.

RESULTS

Somatic domain (51.6%) and activities of daily living (43.0%) were most frequently impaired. A total of 160 (39.5%) patients had moderate deficits in their geriatric assessment; 32 (7.9%) severe. Clinical and biochemical disease activity associated with deficits (clinical: adjusted odds ratio, 2.191; 95% confidence interval, 1.284-3.743; P = .004; biochemical: adjusted odds ratio, 3.358; 95% confidence interval, 1.936-5.825; P < .001). Deficits in geriatric assessment independently associate with lower health-related quality of life.

CONCLUSION

Deficits in geriatric assessment are highly prevalent in older patients with IBD. Patients with active disease are more prone to deficits, and deficits associate with lower health-related quality of life, indicating higher disease burden. Prospective data validating impact of frailty and geriatric assessment on outcomes are warranted to further improve treatment strategies.

QiangGuYin Modulates the OPG/RANKL/RANK Pathway by Increasing Secretin Levels during Treatment of Primary Type I Osteoporosis

QiangGuYin (QGY) is a common Traditional Chinese medicine prescription for the treatment of osteoporosis. Previous clinical studies have found that QGY effectively improves bone mineral density (BMD) in postmenopausal women, but its underlying mechanism remains unclear. The osteoprotegerin (OPG)/receptor activator of nuclear factor kappa B ligand (RANKL)/receptor activator of nuclear factor kappa B (RANK) pathway is a classic pathway involved in osteoporosis. Secretin levels are a serum marker of osteoporosis, but their effect on the OPG/RANKL/RANK pathway has not been reported. Hence, we investigated the relationship between the OPG/RANKL/RANK pathway and secretin and further revealed the mechanism underlying the effect of QGY in the treatment of osteoporosis. Mice were divided into secretin knockdown, secretin overexpression, and corresponding control groups. Micro-computed tomography was used to detect BMD in different groups, and the results show that QGY significantly improved BMD in mice of the secretin knockdown group. To further verify this, the serum levels of OPG, RANKL, RANK, and secretin were measured by enzyme-linked immunosorbent assays, and femur levels of OPG, RANKL, RANK, and secretin were evaluated by real-time quantitative PCR and western blotting. The results show that the expression of OPG was inhibited and that of RANKL and RANK was increased in mice from the secretin knockdown group, whereas the expression of OPG was upregulated and that of RANKL and RANK was downregulated after QGY intervention. Therefore, QGY inhibited bone resorption by promoting the expression of secretin and modulating the OPG/RANKL/RANK pathway. In addition to the effect of QGY, we also revealed the general regulatory effect of secretin on the OPG/RANKL/RANK pathway. We conclude that QGY modulates the OPG/RANKL/RANK pathway by increasing secretin levels during treatment of primary type I osteoporosis. This work provides a theoretical basis for the clinical use of QGY in the treatment of osteoporosis.

Dietary Intake Pattern is Associated with Occurrence of Flares in IBD Patients

BACKGROUND

Diet is associated with the onset of inflammatory bowel disease [IBD]. Up to half of IBD patients believe that diet contributes to flares. However, studies on this topic are sparse and merely focus on specific nutrients, food items or food groups. We aimed to analyse the association between dietary patterns and flare occurrence in two geographically distinct Dutch cohorts.

METHODS

In this longitudinal study, 724 IBD patients [Northern cohort: n = 486, Southern cohort: n = 238] were included and followed for 2 years. Habitual dietary intake was obtained via semi-quantitative food frequency questionnaires at baseline. Principal component analysis [PCA] was conducted on 22 food groups to identify dietary patterns. Flare occurrence was analysed in 427 patients in remission at baseline, using multivariable Cox proportional hazards.

RESULTS

Compared to the Southern cohort, patients in the Northern cohort were younger at diagnosis, comprised more females, and had lower overall energy intakes [all p < 0.05]. PCA revealed three dietary patterns explaining 28.8% of the total variance. The most pronounced pattern [explaining 11.6%] was characterized by intake of grain products, oils, potatoes, processed meat, red meat, condiments and sauces, and sugar, cakes and confectionery. Of the 427 patients, 106 [24.8%] developed an exacerbation during follow-up. The above dietary pattern was associated with flare occurrence (hazard ratio [HR]: 1.51, 95% confidence interval [CI]: 1.04-2.18, p = 0.029), as was female sex [HR: 1.63, 95% CI 1.04-2.55, p = 0.032].

CONCLUSIONS

A dietary pattern, which can be seen as a 'traditional [Dutch]' or "Western' pattern was associated with flare occurrence. Confirmation in prospective studies is needed.

Impact of Body Mass Index on the Development of Inflammatory Bowel Disease: A Systematic Review and Dose-Response Analysis of 15.6 Million Participants

Background: A growing trove of literature describes the effect of malnutrition and underweight on the incidence of inflammatory bowel disease (IBD). However, evidence regarding the association between underweight or obesity and IBD is limited. The study aimed to assess the association of body mass index (BMI) with a risk of IBD (Crohn’s disease (CD) and ulcerative colitis (U.C.)) incidence. Methods: We systematically searched PubMed/Medline, Cochrane, Web of Science, and Scopus for observational studies assessing the association between BMI and IBD that were published up to 30 June 2020. We estimated pooled hazard ratios (HR) with corresponding 95% confidence intervals (CI). Random effect dose-response meta-analysis was performed using the variance weighted least-squares regression (VWLS) models to identify non-linear associations. Results: A total of ten studies involving 15.6 million individuals and 23,371 cases of IBD were included. Overall, obesity was associated with an increased IBD risk (HR: 1.20, 95% CI: 1.08–1.34, I² = 0%). Compared to normal weight, underweight (BMI < 18.5 kg/m²) and obesity (BMI ≥ 30 kg/m²) were associated with a higher risk of CD, and there was no difference in the risk of U.C. among those with BMI < 18.5 kg/m² and BMI ≥ 30 kg/m². There was a significant non-linear association between being underweight and obesity and the risk of development of CD (Coef₁ = −0.0902, p₁ < 0.001 Coef₂ = 0.0713, p₂ < 0.001). Conclusions: Obesity increases the risk of IBD development. Underweight and obesity are independently associated with an increased risk of CD, yet there is no evident association between BMI and the risk of U.C. Further studies are needed to clarify the underlying mechanism for these findings, particularly in CD.

Diagnosis of malnutrition in patients with gastrointestinal diseases: recent observations from a Global Leadership Initiative on Malnutrition perspective

PURPOSE OF REVIEW

To review recent reports on techniques and tools for screening and diagnosis of malnutrition in gastrointestinal disease, in the light of the newly published definition of malnutrition by the Global Leadership Initiative on Malnutrition (GLIM).

RECENT FINDINGS

In 2019, the GLIM concept of malnutrition was published advocating a two-step procedure; first, screening, and second confirmation of the diagnosis that requires a combination of phenotypic and etiologic criteria. Three studies in patients with gastrointestinal disorders so far published utilize the GLIM criteria. Otherwise, traditional tools, as Nutrition Risk Screening-2002, Malnutrition Universal Screening Tool or Subjective Global Assessment are used, and confirm that malnutrition is observed in a substantial number of patients with inflammatory bowel diseases (IBDs), serious liver disorders and various forms of pancreatitis. Common for these disorders is an extensive loss of muscle mass, which is one of the GLIM phenotypic criteria. Such patients often undergo abdominal computed tomography scans that enable psoas muscle mass at L3 or L4 level to be calculated.

SUMMARY

The GLIM criteria for the diagnosis of malnutrition are feasible for IBD, liver and pancreas diseases. Pending studies expect to provide data on the clinical relevance to diagnose malnutrition by the GLIM concept.

Vitamin C Deficiency and the Risk of Osteoporosis in Patients with an Inflammatory Bowel Disease

Recent research studies have shown that vitamin C (ascorbic acid) may affect bone mineral density and that a deficiency of ascorbic acid leads to the development of osteoporosis. Patients suffering from an inflammatory bowel disease are at a risk of low bone mineral density. It is vital to notice that patients with Crohn’s disease and ulcerative colitis also are at risk of vitamin C deficiency which is due to factors such as reduced consumption of fresh vegetables and fruits, i.e., the main sources of ascorbic acid. Additionally, some patients follow diets which may provide an insufficient amount of vitamin C. Moreover, serum vitamin C level also is dependent on genetic factors, such as SLC23A1 and SLC23A2 genes, encoding sodium-dependent vitamin C transporters and GSTM1, GSTP1 and GSTT1 genes which encode glutathione S-transferases. Furthermore, ascorbic acid may modify the composition of gut microbiota which plays a role in the pathogenesis of an inflammatory bowel disease.

Nutritional Assessment in Inflammatory Bowel Disease (IBD)-Development of the Groningen IBD Nutritional Questionnaires (GINQ)

Diet plays a key role in the complex etiology and treatment of inflammatory bowel disease (IBD). Most existing nutritional assessment tools neglect intake of important foods consumed or omitted specifically by IBD patients or incorporate non-Western dietary habits, making the development of appropriate dietary guidelines for (Western) IBD patients difficult. Hence, we developed a food frequency questionnaire (FFQ), the Groningen IBD Nutritional Questionnaires (GINQ-FFQ); suitable to assess dietary intake in IBD patients. To develop the GINQ-FFQ, multiple steps were taken, including: identification of IBD specific foods, a literature search, and evaluation of current dietary assessment methods. Expert views were collected and in collaboration with Wageningen University, division of Human Nutrition and Health, this semi-quantitative FFQ was developed using standard methods to obtain a valid questionnaire. Next, the GINQ-FFQ was digitized into a secure web-based environment which also embeds additional nutritional and IBD related questions. The GINQ-FFQ is an online self-administered FFQ evaluating dietary intake, taking the previous month as a reference period. It consists of 121 questions on 218 food items. This paper describes the design process of the GINQ-FFQ which assesses dietary intake especially (but not exclusively) in IBD patients. Validation of the GINQ-FFQ is needed and planned in the near future.