Symposium on 'The challenge of translating nutrition research into public health nutrition'. Session 3: Joint Nutrition Society and Irish Nutrition and Dietetic Institute Symposium on 'Nutrition and autoimmune disease'. Nutrition in Crohn's disease. Proc Nutr Soc. 2009;68:127-134. [PMID: 19208269 DOI: 10.1017/s0029665109001025]

Role of micronutrients in inflammatory bowel disease

Inflammatory bowel disease (IBD) is an autoimmune intestinal disease that includes ulcerative colitis, Crohn's disease, and indeterminate colitis. Patients with IBD are often at risk for malnutrition, including micronutrient deficiencies, due to dietary restrictions and poor intestinal absorption. Micronutrients, including vitamins and minerals, play an important role in the human body's metabolism and maintenance of tissue functions. This article reviews the role of micronutrients in IBD. Micronutrients can affect the occurrence and progression of IBD by regulating immunity, intestinal flora, oxidative stress, intestinal barrier function, and other aspects. Monitoring and timely supplementation of micronutrients are important to delay progression and improve clinical symptoms in IBD patients.

Macrophage Polarization Towards M2 Phenotype by Curcuminoids Through NF-κB Pathway Inhibition in Adjuvant-Induced Arthritis

Macrophage polarization is decisive for homeostasis maintenance and tissue repair. Anti-inflammatory properties of curcumin (CUR) have been demonstrated in several studies. It used in the treatment of bone disorders includingrheumatoid arthritis. The present study aims to explore the potential mechanisms of curcumin on macrophage polarization, expression, activation, and cytokine secretion in adjuvant-induced arthritis as well as its possible role in enhancing the therapeutic action of methotrexate (MTX) together with minimizing MTX initiated side-effects. Rats were divided into eight groups as follows; Control group, MTX group: was weekly injected with MTX, CUR group: was treated with a daily oral dose of curcumin, MTX + CUR group: was treated with both methotrexate and curcumin, Adjuvant arthritis group (AIA): was injected with complete Freund's adjuvant for arthritis induction, AIA/MTX group: arthritic rats treated with methotrexate, AIA/CUR group: arthritic rats treated with curcumin and AIA/MTX + CUR: arthritic rats treated with both methotrexate and curcumin. Paw swelling, haematological analysis, immunological studies, histological observations and quantitative immunohistochemical investigations were performed. The present results showed that treating arthritic rats with curcumin either alone or in combination with methotrexate resulted in amelioration in paws inflammation, growth rate, absolute and relative spleen weights, and haematological analyses. Antinuclear antibodies, IL-1β, IL-8, IL-10, NF-kB levels, and CD68 + joint expression were also ameliorated. The microscopic examination of joint and spleen showed more improvement as apparently normal tissues in treated groups. It can be concluded that curcumin seems to be most promising in regulating macrophage expression, activation, cytokine secretion, and polarization, thus providing a novel insight in the application of curcumin-based treatments.

Assessment of Dietary Adequacy and Quality in a Sample of Patients with Crohn's Disease

Both under-and over-nutrition are prevalent in patients with Crohn's Disease (CD). The aim of the present study was to evaluate dietary intake and compare it with relevant recommendations during active disease and remission, also taking into consideration the adequacy of energy reporting. Dietary quality was assessed through adherence to the Mediterranean diet and to the European dietary guidelines for cardiovascular disease prevention (CVD-score). Malnutrition was diagnosed with the GLIM criteria. There were 237 patients evaluated (54.9% males, 41.3 ± 14.1 years and 37.6% with active disease). In the total sample, high prevalence of overweight/obesity (61.6%) and low prevalence of malnutrition (11.4%) were observed, whereas 25.5% reported low protein intake in the sub-sample of adequate energy reporters. The mean MedDietScore was 28.0 ± 5.5 and the mean CVD-score was 5.25 ± 1.36, both reflecting moderate dietary quality. Patients with active disease reported higher prevalence of low protein intake, lower carbohydrate, fibers, fruits, vegetables, legumes, and sweets consumption and a lower MedDietScore compared to patients in remission. Consumption of fibers, fruits, vegetables, and legumes while in remission did not result in reaching the recommended intakes, and dietary quality was low as reflected by the MedDietScore. In conclusion, both protein undernutrition and energy overconsumption were prevalent in the current sample and overall patients adhered to a moderate quality diet irrespective of disease stage.

Perioperative micronutrients, macroscopic benefits?

'Micronutrients' are vitamins and minerals vital for healthy metabolic function, wound healing and disease and infection prevention. Micronutrients may play a role in significantly improving postoperative recovery and indices of patient comfort; however, minimal research exists for surgical patients. Furthermore, current guidelines on perioperative nutrition have a macronutrient focus which may fail to guide detection and treatment of the subclinical micronutrient deficiency in a patient who is not obviously malnourished. Limited research into supplementation of some micronutrient deficiencies shows favourable results; however, given the financial implications of wound care, the prevalence of micronutrient deficiency and possible benefits from attention to micronutrition for postoperative recovery, further research into this area is urgently warranted. Interventions to guide optimal future clinical practice are suggested.

Hair EDX Analysis-A Promising Tool for Micronutrient Status Evaluation of Patients with IBD?

Micronutrient deficiencies can arise in various conditions, including inflammatory bowel diseases (IBD), and diagnosing these deficiencies can be challenging in the absence of specific clinical signs. The aim of this study was to evaluate the status of various trace elements hair concentration in IBD patients compared to a healthy control group and to identify potential correlations between the micronutrient status and relevant parameters related to disease activity. The concentrations of iron, magnesium, calcium, zinc, copper, manganese, selenium and sulfur in the hair of 37 IBD patients with prior diagnosed IBD (12 Crohn's disease and 25 ulcerative colitis) and 31 healthy controls were evaluated by Energy Dispersive X-Ray spectroscopy (EDX). Significant differences in hair concentration profile of studied trace elements were identified for IBD patients compared to healthy controls. A significantly decreased hair concentration of iron, magnesium, calcium and selenium and a significantly increased sulfur hair concentration were observed in IBD patients at the time of evaluation. A decreased hair calcium concentration (r = -0.772, p = 0.003) and an increased sulfur concentration (r = 0.585, p = 0.046) were significantly correlated with disease activity. Conclusion: Hair mineral and trace elements evaluation may contribute to a proper evaluation of their status in IBD patients and improving the management of nutritional status of IBD patients.

Sarcopenia in Inflammatory Bowel Disease: A Narrative Overview

Malnutrition is a common condition encountered in patients with inflammatory bowel disease (IBD) and is often associated with sarcopenia (the reduction of muscle mass and strength) which is an ever-growing consideration in chronic diseases. Recent data suggest the prevalence of sarcopenia is 52% and 37% in Crohn's disease and ulcerative colitis, respectively, however it is challenging to fully appreciate the prevalence of sarcopenia in IBD. Sarcopenia is an important consideration in the management of IBD, including the impact on quality of life, prognostication, and treatment such as surgical interventions, biologics and immunomodulators. There is evolving research in many chronic inflammatory states, such as chronic liver disease and rheumatoid arthritis, whereby interventions have begun to be developed to counteract sarcopenia. The purpose of this review is to evaluate the current literature regarding the impact of sarcopenia in the management of IBD, from mechanistic drivers through to assessment and management.

Micronutrient Deficiencies in Medical and Surgical Inpatients

Inpatients are threatened by global malnutrition, but also by specific micronutrient (i.e., trace element and vitamins) deficiencies that frequently are overseen in the differential diagnosis of major organ dysfunctions. Some of them are related to specific geographic risks (iodine, iron, selenium, zinc, vitamin A), while others are pathology related, and finally many are associated with specific feeding patterns, including low dose enteral feeding. Among the pathologies in which laboratory blood investigations should include a micronutrient outwork, anemia is in the front line, followed by obesity with bariatric surgery, chronic liver disease, kidney disease, inflammatory bowel disease, cardiomyopathies and heart failure. The micronutrients at the highest risk are iron, zinc, thiamine, vitamin B12 and vitamin C. Admission to hospital has been linked with an additional risk of malnutrition—feeding below 1500 kcal/day was frequent and has been associated with a structural additional risk of insufficient micronutrient intake to cover basal needs. Although not evidence based, systematic administration of liberal thiamine doses upon admission, and daily complementation of inpatients’ food and enteral feeding solutions with multi-micronutrient tablets might be considered.

Roles for selenium and selenoprotein P in the development, progression, and prevention of intestinal disease

Selenium (Se) is a micronutrient essential to human health, the function of which is mediated in part by incorporation into a class of proteins known as selenoproteins (SePs). As many SePs serve antioxidant functions, Se has long been postulated to protect against inflammation and cancer development in the gut by attenuating oxidative stress. Indeed, numerous studies over the years have correlated Se levels with incidence and severity of intestinal diseases such as inflammatory bowel disease (IBD) and colorectal cancer (CRC). Similar results have been obtained with the Se transport protein, selenoprotein P (SELENOP), which is decreased in the plasma of both IBD and CRC patients. While animal models further suggest that decreases in Se or SELENOP augment colitis and intestinal tumorigenesis, large-scale clinical trials have yet to show a protective effect in patient populations. In this review, we discuss the function of Se and SELENOP in intestinal diseases and how research into these mechanisms may impact patient treatment.

Hair Mineral and Trace Element Contents as Reliable Markers of Nutritional Status Compared to Serum Levels of These Elements in Children Newly Diagnosed with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) are at high risk for nutritional deficiencies because of long-term inflammation in the gut mucosa and decreased oral intake. Because inflammation responses affect serum micronutrient concentrations, serum levels are limited in reflecting body nutrient status in acute and chronic illness. We investigated the usefulness of measuring trace elements in hair as reliable markers of nutritional status compared to serum levels in children with IBD. We retrospectively analyzed pediatric patients newly diagnosed with Crohn's disease (n = 49) and ulcerative colitis (n = 16) and controls (n = 29) from 2012 to 2016. Serum micronutrient levels, inflammatory markers, and hair trace element content were evaluated and compared at the time of diagnosis and before initiating treatment. Serum calcium (p < 0.001), iron (p < 0.001), zinc (p = 0.013), selenium (p = 0.008), albumin (p < 0.001), prealbumin (p < 0.001), hemoglobin and hematocrit (p < 0.001), and WBC (p = 0.001) and lymphocytes (p < 0.001) differed significantly between the groups. After adjustment for the erythrocyte sedimentation rate, serum zinc and selenium levels were no longer significantly different between the groups (p < 0.062 and p < 0.057, respectively). Following hair analysis for mineral and trace elements, iron (p = 0.033), selenium (p = 0.017), and manganese (p = 0.009) differed significantly between the groups. Serum micronutrient levels need cautious interpretation in conjunction with inflammatory markers. Hair mineral and trace element measurement may support understanding micronutrient status in children with IBD.

Important effect of micronutrient deficiency in inflammatory bowel disease

As is known to all, deficiencies of protein and other nutrients are common symptoms of inflammatory bowel disease (IBD). Nutrient deficiency is not only a manifestation of complicated diseases but also a cause of morbidity. Micronutrient is also the essential material for human health. However, there are few articles elaborating the influence of micronutrient deficiency. At present, choosing available food to keep healthy and to treat diseases is very popular, which is also suitable for IBD patients. Recent studies show that micronutrient deficiencies occur in more than half of patients with IBD, and deficiencies are more common in Crohn's disease than in ulcerative colitis, and in active disease than in disease in remission. Micronutrient deficiencies are associated with prolonged and complicated course of disease. The present review summarizes the effect of micronutrient deficiencies in IBD with regard to the definition of micronutrient, the deficiency status of micronutrient in IBD, the reasons for the lack of micronutrient and the role of micronutrient in the treatment of IBD.

Micronutrient deficiencies in inflammatory bowel disease

PURPOSE OF REVIEW

Malnutrition, protein-energy, and micronutrient deficiencies are common among patients with inflammatory bowel disease (IBD). The deficiencies are a manifestation of the complicated disease and a cause of morbidity. The present review summarizes recent advances and evidence-based knowledge regarding micronutrients in relation to patients with IBD.

RECENT FINDINGS

Micronutrient deficiencies occur in more than half of patients with IBD. Most common are deficiencies of iron, B12, vitamin D, vitamin K, folic acid, selenium, zinc, vitamin B6, and vitamin B1. Deficiencies are more common in Crohn's disease than in ulcerative colitis, and more in active disease than at times of remission. Micronutrient deficiency is associated with prolonged and complicated course of disease. Iron deficiency is the most common cause for anemia. Definite diagnosis of B12 deficiency cannot be established by serum levels alone. Vitamin D and vitamin K deficiencies are thought to be associated with heightened inflammatory state. The relationship of these deficiencies with bone disease is controversial. The present review focuses on the significance, epidemiology, treatment options, and recommendations regarding micronutrient deficiencies in IBD.

SUMMARY

Micronutrient deficiencies are common and have clinical significance. High suspicion for micronutrient deficiencies is advocated so that treatable causes of morbidity are treated appropriately and late and irreversible sequlae are prevented.

Regulation of Dendritic Cell Function by Vitamin D

Studies over the last two decades have revealed profound immunomodulatory aspects of vitamin D on various aspects of the immune system. This review will provide an overview of Vitamin D metabolism, a description of dendritic cell subsets, and highlight recent advances on the effects of vitamin D on dendritic cell function, maturation, cytokine production and antigen presentation. The active form of vitamin D, 1,25(OH)₂D₃, has important immunoregulatory and anti-inflammatory effects. Specifically, the 1,25(OH)₂D₃-Vitamin D₃ complex can affect the maturation and migration of many dendritic cell subsets, conferring a special immunoregulatory role as well as tolerogenic properties affecting cytokine and chemokine production. Furthermore, there have been many recent studies demonstrating the effects of Vitamin D on allergic disease and autoimmunity. A clear understanding of the effects of the various forms of Vitamin D will provide new opportunities to improve human health.

Vitamin D as a novel therapy in inflammatory bowel disease: new hope or false dawn?

There is increasing scientific interest in the field of vitamin D research, moving the focus beyond bone health to other disease processes. Low circulating vitamin D levels have been reported as a risk factor for several pathophysiologically divergent diseases, including cancers, diabetes, CVD, multiple sclerosis and inflammatory diseases, including rheumatoid arthritis and inflammatory bowel disease (IBD). But, therein, remains the challenge: can any single nutrient contribute to multiple complex disease mechanisms and, ultimately, have therapeutic potential? The aim of this review is to critically evaluate several strands of scientific evidence surrounding vitamin D and inflammation, primarily focusing on IBD. Epidemiological studies suggest an increased incidence of IBD and rheumatoid arthritis in countries of more northern latitudes, mirroring sunlight patterns. A considerable body of evidence supports the anti-inflammatory effects of vitamin D, at least in animal models of IBD. Although it is accepted that suboptimal vitamin D status is common in IBD, some studies suggest that this associates with more severe disease. With regard to treatment, the data are only beginning to emerge from randomised controlled trials to suggest that people with IBD may remain in remission longer when treated with oral vitamin D. In conclusion, several strands of evidence suggest that vitamin D may modify the immune response in IBD. There is a continued need for large well-designed clinical trials and mechanistic studies to determine if, and how, this emerging promise translates into tangible clinical benefits for people with chronic debilitating diseases such as IBD.

High prevalence of overweight and obesity in adults with Crohn's disease: associations with disease and lifestyle factors

BACKGROUND AND AIMS

Obesity and overweight are major public health issues. Although traditionally associated with weight loss, there is now evidence that increasing Body Mass Index (BMI) and overweight are emerging features of Crohn's disease (CD) and may be associated with more severe disease course. The aim of the study was to determine the prevalence of overweight and obesity in patients with CD compared with matched healthy controls and to identify disease-specific and generic factors associated with current BMI in this group.

METHODS

This was a prospective case-control study (n=200), comprising 100 CD outpatients and 100 age-, sex- and socioeconomically-matched healthy controls. BMI, Crohn's disease activity index (CDAI), clinical and lifestyle factors and circulating inflammatory markers were assessed.

RESULTS

Overall, 40% of patients with CD were overweight/obese (BMI ≥ 25 kg/m(2)) compared with 52% of controls (P = 0.206). On regression analysis, higher current BMI was significantly associated with disease specific factors, namely lower disease activity (CDAI) and lower white cell count, suggesting stable disease, as well as older age and lower physical activity. BMI was not significantly associated with the need for surgery or the need for corticosteroids. We identified a novel association between higher BMI and higher CRP, a marker linked both with obesity in the general population and with CD.

CONCLUSIONS

Overweight was common in out-patients with CD and appeared to reflect current wellness, older age and sedentary lifestyles. The potential long-term implications of high BMI for CRP and inflammatory load merit further study.