Resting and total energy expenditure in patients with inflammatory bowel disease

Dietary intake and nutritional status in patients with newly diagnosed inflammatory bowel disease: insights from the IBSEN III study

BACKGROUND

Dietary recommendations in inflammatory bowel disease (IBD) are inconclusive, and patients may follow restrictive diets with increased risk of malnutrition. The aim of this study was to compare dietary intakes and nutritional status in men and women with newly diagnosed IBD with a general population sample, and to investigate whether intakes were in line with the Nordic Nutrition Recommendations.

METHODS

This was a cross-sectional study including adults≥ 40 years with IBD from the Inflammatory Bowel Disease in South-Eastern Norway (IBSEN) III cohort study. A validated food frequency questionnaire (FFQ) was used in dietary data collection, and a sample from the seventh survey of the Tromsø Study was included as a comparison group.

RESULTS

A total of 227 men and women with IBD were included. IBD patients had higher intake of grain products, sweetened beverages, energy, fat and polyunsaturated fat (PUFA), but lower intake of dairy products, alcohol and iodine compared to adults from the comparison sample (p < 0.01). Intakes of saturated fat and carbohydrates in both genders, and vitamin D in women were not within recommended levels. Anemia and hypoalbuminemia were more prevalent in IBD patients than in the comparison sample.

CONCLUSIONS

Dietary intakes in newly diagnosed IBD patients were mostly in line with Nordic Nutrition Recommendations. Higher proportion of IBD patients exceeded recommended allowances of fat and added sugar than the comparison sample. Insufficient micronutrient intake, anemia and hypoalbuminemia are present challenges in IBD patients that require monitoring.

Poor performance of predictive equations to estimate resting energy expenditure in patients with Crohn's disease

Studies exploring the accuracy of equations calculating Resting Energy Expenditure (REE) in patients with Crohn's disease are lacking. The aim of this study was to investigate the accuracy of REE predictive equations against indirect calorimetry in Crohn's disease patients. REE was measured using indirect calorimetry (mREE) after an overnight fasting. Fourteen predictive equations, with and without body composition analysis parameters, were compared with mREE using different body weight approaches. Body composition analysis was performed using dual X-ray absorptiometry. 186 Crohn's disease outpatients (102 males) with mean age 41.3±14.1 years and 37.6% with active disease were evaluated. Mean mREE in the total sample was 1734±443 kcal/day. All equations under-predicted REE and showed moderate correlations with mREE (Pearson's r or Spearman's rho 0.600-0.680 for current weight, all p-values<0.001). Accuracy was low for all equations at the individual level (28-42% and 25-40% for current and adjusted body weight, respectively, 19-33% for equations including body composition parameters). At the group level, accuracy showed wide limits of agreement and proportional biases. Accuracy remained low when sample was studied according to disease activity, sex, body mass index and medication use. All predictive equations underestimated REE and showed low accuracy. Indirect calorimetry remains the best method for estimating REE of patients with Crohn's disease.

Nutrition Considerations in Inflammatory Bowel Disease

The purpose of this article is to provide an updated review of the definition, prevalence, causes, and clinical management of malnutrition in inflammatory bowel disease (IBD). Prevalence of malnutrition in IBD is estimated to be between 6.1% and 69.7% depending on the definition used, the type of IBD, the clinical setting, and whether the IBD is active or in remission. Whereas older definitions of malnutrition have been found to be correlated with mortality and length of hospital stay, the more recent European Society for Clinical Nutrition and Metabolism (ESPEN) 2015 and the Global Leadership Initiative on Malnutrition (GLIM) definitions provide significantly different prevalence estimates of malnutrition when applied to the same patient population, and further work is needed to validate these two definitions against clinical outcomes. In patients with IBD with identified malnutrition, oral nutrition supplementation, enteral nutrition, or parenteral nutrition should be started. In malnourished patients with Crohn's disease undergoing surgery, preoperative enteral nutrition has been demonstrated to reduce the rate of postoperative complications. Overall, patients with IBD are at significant risk for malnutrition and should be screened for malnutrition by using a validated screening tool. The management of malnutrition in IBD is complex, and studies are often limited in their size or their ability to demonstrate an improvement in clinical outcomes based on specific nutrition-related interventions. Future studies particularly regarding the validation of new screening tools and perioperative management of malnutrition may provide insight into the standardization of diagnosis and management of malnutrition in IBD.

Total and activity-induced energy expenditure measured during a year in children with inflammatory bowel disease in clinical remission remain lower than in healthy controls

BACKGROUND

Pediatric inflammatory bowel disease (IBD) is often associated with growth retardation due to malnutrition. However, knowledge on total energy expenditure (TEE), active-induced energy expenditure (AEE) and physical activity remains limited in children with IBD.

OBJECTIVE

Assessment of TEE using the doubly labelled water (DLW) method, resting energy expenditure (REE) using indirect calorimetry, and physical activity level using the actigraph GT3X+ in children with IBD (in remission) and healthy controls.

METHODS

TEE, REE, AEE and physical activity were measured in 21 children with IBD and 24 healthy controls at baseline. IBD children parameters were monitored further after 6 and 12 months. Predicted REE and TEE values (using Schoefield and the actigraph GT3X+, for REE and TEE respectively) were compared to measured values.

RESULTS

Mean ages at baseline were 14.8 ± 1.5 and 13.2 ± 2 years in children with IBD and in healthy control children, respectively. Measured TEE_DLW was significantly lower (P < 0.001) in children with IBD compared to the healthy control group. REE corrected by FFM^0.5, REE and AEE were also significantly lower in children with IBD. Children with IBD had AEE of 17.5% of TEE and had a significantly higher sedentary behaviour as compared to healthy children.

CONCLUSIONS

This study suggests that TEE and AEE are reduced in children with IBD in clinical remission which may result in a reduced moderate and vigorous physical activity level. Our result also highlights that the actigraph GT3X + might give good prediction of TEE in children with IBD at group level but it remains highly variable at individual level.

New Predictive Equations for Estimating Resting Energy Expenditure in Adults With Crohn's Disease

BACKGROUND

Increased resting energy expenditure (REE) has been hypothesized to be a potential cause of weight loss in individuals with Crohn's disease (CD). This study aimed to develop and validate new predictive equations for estimating REE in adults with CD.

METHODS

Adults, ages 18-65 years, with CD were recruited. Anthropometry, indirect calorimetry, and bioimpedance analysis were performed in all patients. Disease activity was assessed by Crohn's Disease Activity Index. The new predictive equations were generated using different regression models. Prediction accuracy of the new equations was assessed and compared with the most commonly used equations.

RESULTS

A total of 270 CD patients (159 males, 111 females) were included and randomly assigned to the calibration (n = 180) and validation groups (n = 90). REE was directly correlated with weight and bioimpedance index, whereas the relation with both age and disease activity was inverse. The new equations were suitable for estimating REE at population level (bias: -0.2 and -0.3, respectively). Individual accuracy was good in both models (≥80%, respectively), especially in females; and similar results were shown by some of the selected equations. But, when accuracy was set within ±5%, the new equations gave the highest prediction.

CONCLUSION

The new, disease-specific, equations for predicting REE in individuals with CD give a good prediction accuracy as far as those proposed in the literature for the general population. However, the new ones performed better at the individual level. Further studies are needed to verify the reliability and usefulness of these new equations.

Sarcopenia and Inflammatory Bowel Disease: A Systematic Review

BACKGROUND

Sarcopenia is associated with increased morbidity and mortality in oncologic and transplant surgery. It has a high incidence in chronic inflammatory states including inflammatory bowel disease (IBD). The validity of existing data in IBD and of sarcopenia's correlation with surgical outcomes is limited.

METHODS

We performed a systematic review to assess the correlation of sarcopenia with the requirement for surgery and surgical outcomes in patients with IBD. Observational studies of patients with IBD in whom an assessment of sarcopenic status/skeletal muscle index was undertaken, a proportion of whom proceeded to surgical management, were selected.

RESULTS

A total of 5 studies with a combined 658 IBD patients met the inclusion criteria. The majority (70%) had a diagnosis of Crohn's disease. Median (range) body mass index and skeletal muscle index were reported in 4 studies and were 16.58 (13.66-22.50) kg/m2 and 44.52 (42.90-50.64) cm2/m2, respectively. Forty-two percent of IBD patients had sarcopenia. Notably, none of the studies assessed both the anatomical and functional component required for a correct assessment of sarcopenia. Three studies noted that sarcopenic IBD patients had a higher probability of requiring surgery. The rate of major complications (Clavien-Dindo grade ≥IIIa) was significantly higher in patients with sarcopenia. Improved perioperative nutrition management may mitigate the risk of complications.

CONCLUSION

Many IBD patients are young, may be malnourished, and commonly require emergent surgery. There is considerable heterogeneity in the assessment of sarcopenia. Sarcopenia is common in the IBD population and can predict the need for surgical intervention. Sarcopenia correlates with an increased rate of major postoperative complications. Improved perioperative intervention may diminish this risk. A formal assessment, screening by a dedicated IBD dietician, and preoperative physical therapy may facilitate early intervention.

Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND AND AIMS

A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients.

METHODS

A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature.

RESULTS

A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD.

CONCLUSIONS

This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.

Sarcopenia Is Common in Overweight Patients with Inflammatory Bowel Disease and May Predict Need for Surgery

BACKGROUND

Inflammatory bowel disease (IBD) is associated with altered body composition, such as low muscle mass, which affects clinical outcomes. Body composition changes in overweight patients with IBD are less understood. The study aim was to determine the prevalence of sarcopenic overweight and obese patients in a cohort of patients with IBD starting new anti-tumor necrosis factor-α therapy and examine differences in response.

METHODS

This is a retrospective review of patients with IBD starting a new anti-tumor necrosis factor-α medication that had computed tomography within 3 months of initiation. L3 vertebral slice was used for segmentation of body composition and identification of sarcopenia. CRP, ESR, Harvey Bradshaw Index, albumin, 25-OH vitamin D, and body mass index at anti-tumor necrosis factor-α initiation and at 6 months were collected. Outcomes included hospitalization, need for surgery, or new biological medication.

RESULTS

Ninety patients were studied. Forty-one of ninety (45%) were sarcopenic; of these, 17 (41.5%) had a normal body mass index and 8 (19.5%) were overweight/obese. More men were sarcopenic (68% versus 32%, P < 0.001). CRP was higher and albumin lower in sarcopenic subjects. Sarcopenia did not predict outcomes in the cohort but was the only significant predictor of need for surgery in overweight and obese subjects (P = 0.002).

CONCLUSIONS

Almost half of our cohort was sarcopenic. Most of these patients are normal or overweight and would not be identified as malnourished by traditional measures. Sarcopenia was a predictor of surgery in patients with a body mass index ≥ 25. Identification of sarcopenia has implications for medical nutrition therapy as typically efforts are focused on underweight patients.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

INTRODUCTION

The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD).

METHODOLOGY

The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).

Dietary energy requirements in relatively healthy maintenance hemodialysis patients estimated from long-term metabolic studies

BACKGROUND

Studies that examined dietary energy requirements (DERs) of patients undergoing maintenance hemodialysis (MHD) have shown mixed results. Many studies reported normal DERs, but some described increased energy needs. DERs in MHD patients have been estimated primarily from indirect calorimetry and from nitrogen balance studies. The present study measured DERs in MHD patients on the basis of their dietary energy intake and changes in body composition.

OBJECTIVE

This study assessed DERs in MHD patients who received a constant energy intake while changes in their body composition were measured.

DESIGN

Seven male and 6 female sedentary, clinically stable MHD patients received a constant mean (±SD) energy intake for 92.2 ± 7.9 d while residing in a metabolic research ward. Changes in fat and fat-free mass, measured by dual-energy X-ray absorptiometry, were converted to calorie equivalents and added to energy intake to calculate energy requirements.

RESULTS

The average DER was 31 ± 3 kcal · kg(-1) · d(-1) calculated from energy intake and change in fat and fat-free calories, which was 28 ± 197 kcal/d over the 92 d of the study. DERs of MHD patients correlated strongly with their body weight (r = 0.81, P = 0.002) and less closely with their measured resting energy expenditure expressed as kcal/d (r = 0.69, P = 0.01). Although the average observed DER in MHD patients was similar to published estimated values for normal sedentary individuals of similar age and sex, there was wide variability in DER among individual patients (range: 26-36 kcal · kg(-1) · d(-1)).

CONCLUSIONS

Average DERs of sedentary, clinically stable patients receiving MHD are similar to those of sedentary normal individuals. Our data do not support the theory that MHD patients have increased DERs. Due to the high variability in DERs, careful monitoring of the nutritional status of individual MHD patients is essential. This trial was registered at clinicaltrials.gov as NCT02194114.

Resting energy expenditure in adult patients with Crohn's disease

BACKGROUND & AIMS

Crohn's disease (CD) is a chronic intestinal disorder of unknown etiology involving any section of the gastrointestinal tract often associated with protein-energy malnutrition (PEM). Increased resting energy expenditure (REE) unmatched by adequate dietary intake is amongst the pathogenetic mechanisms proposed for PEM. Aim of this study was to evaluate REE in CD patients receiving or not immuno-suppressive therapy as compared to controls.

METHODS

36 CD patients (22 M and 14 F, age range 18-55 years) clinically stable and without complications since at least 6 month were studied. REE was evaluated by indirect calorimetry and body composition by BIA. Full biochemistry was performed. Patients were divided into two groups: Group 1 (G1 = 12 patients) without and Group 2 (G2 = 24 patients) with immuno-suppressive therapy.

RESULTS

The two groups were similar for age, height and BMI whereas significantly differed for weight (G1 vs G2: 56.9 ± 7.44 vs 62.3 ± 8.34 kg), fat free mass (FFM: 40.4 ± 5.73 vs 48.2 ± 7.06 kg), fat mass (FM: 17.0 ± 3.55 vs 13.9 ± 5.54 kg) and phase angle (PA: 5.6 ± 1.4 vs 6.5 ± 1.0°). Serum inflammation parameters were significantly higher in G1 than in G2: hs-PCR: 7.76 ± 14.2 vs 7.16 ± 13.4 mg/dl; alfa 2-protein: 11.7 ± 3.69 vs 9.74 ± 2.08 mg/dl; fibrinogen: 424 ± 174 vs 334 ± 118 mg/dl (p < 0.05). REE was higher in G2 vs G1: 1383 ± 267 vs 1582 ± 253kcal/die (p < 0.05) both in men: 1579 ± 314 vs 1640 ± 203 and women: 1267 ± 140 vs 1380 ± 132. Nevertheless, when corrected for FFM, REE resulted higher in G1 than G2 (34.8 ± 4.89 vs 33.0 ± 4.35 kcal/kg, p < 0.05) group, also higher compared to our, age and sex matched, control population (REE/FFM: 30.9 ± 4.5 kcal/kg).

CONCLUSIONS

Our preliminary results show that REE when adjusted for FFM is increased in clinically stable CD patients and mildly reduced by immunosuppressive therapy possibly through a direct action on inflammation and on body composition characteristics.

Comparison of energy metabolism and nutritional status of hospitalized patients with Crohn's disease and those with ulcerative colitis

This study aimed to compare the nutritional status and energy expenditure of hospitalized patients with Crohn’s disease (CD) and those with ulcerative colitis (UC). Twenty-two hospitalized patients with CD and 18 patients with UC were enrolled in this study. We analyzed nutritional status upon admission by using nutritional screening tools including subjective global assessment, malnutrition universal screening tool, and laboratory tests. We measured resting energy expenditure (mREE) of the patients with indirect calorimetry and predicted resting energy expenditure (pREE) was calculated by using the Harris-Benedict equation. Results presented here indicate no significant difference in nutritional parameters and energy metabolism between CD and UC patients. In UC patients, a significant correlation was observed between mREE/body weight and disease activity detected by the Lichtiger and Seo indices. However, there was no correlation between mREE/body weight and Crohn’s disease activity index in CD patients. Inflammatory cytokine interleukin-6 levels correlated with mREE/pREE in CD and UC patients while tumor necrosis factor-α was not. In conclusion, energy expenditure significantly correlated with disease activity in UC patients but not in CD patients. These results indicate that establishing daily energy requirements based on disease activity of UC is imperative for improving the nutritional status of patients.

Changes in energy metabolism after induction therapy in patients with severe or moderate ulcerative colitis

We investigated the changes in energy expenditure during induction therapy in patients with severe or moderate ulcerative colitis. Thirteen patients (10 men, 3 women; mean age, 36.5 years) with ulcerative colitis admitted to the Shiga University Hospital were enrolled in this study. We measured the resting energy expenditure and respiratory quotients of these patients before and after induction therapy with indirect calorimetry. We analyzed the changes of nutritional status and serum inflammatory cytokine levels and also evaluated the relationship between energy metabolism and disease activity by using the Seo index and Lichtiger index. The resting energy expenditure was 26.3 ± 3.8 kcal/kg/day in the active stage and significantly decreased to 23.5 ± 2.4 kcal/kg/day after induction therapy (p<0.01). The resting energy expenditure changed in parallel with the disease activity index and C-reactive protein and inflammatory cytokine levels. The respiratory quotient significantly increased after induction therapy. Thus, moderate to severe ulcerative colitis patients had a hyper-metabolic status, and the energy metabolism of these patients significantly changed after induction therapy. Therefore, we recommend that nutritional management with 30–34 kcal/kg/day (calculated as measured resting energy expenditure × activity factor, 1.3) may be optimal for hospitalized ulcerative colitis patients.

Changes of energy metabolism, nutritional status and serum cytokine levels in patients with Crohn's disease after anti-tumor necrosis factor-α therapy

We investigated the effects of treatment with antibodies against tumor necrosis factor (TNF)-α on energy metabolism, nutritional status, serum cytokine levels in patients with Crohn’s disease (CD). Twelve patients were enrolled. Resting energy expenditure (REE) levels were measured by indirect calorimetry. Crohn’s disease activity index (CDAI) significantly decreased after treatment with anti-TNF-α therapy. Anti-TNF-α therapy did not affect REE, but respiratory quotient (RQ) significantly increased after treatment. Serum interleukin-6 levels were significantly decreased and RQ were significantly increased in high REE (≥25 kcal/kg/day) group as compared to low REE (<25 kcal/kg/day) group. In conclusion, high REE value on admission is a predictive factor for good response to treatment with anti-TNF-α antibodies in active CD patients.

Systematic review: body composition in adults with inflammatory bowel disease

BACKGROUND

There is a paucity of data on body composition in patients with inflammatory bowel disease (IBD). Alterations of fat and muscle may affect bone health, muscle performance, quality of life (QoL) and overall morbidity.

AIMS

To systematically review the literature on body composition in adults with IBD, and to discuss potential contributory factors and associations.

METHODS

A systematic search was performed in July 2012 of OVID SP MEDLINE, OVID EMBASE and National Library of Medicine's PubMed Central Medline (Limitations: English, humans, from 1992). A total of 19 articles comparing body composition in patients with IBD with healthy age- and sex-matched control populations were included in the primary analysis.

RESULTS

A total of 631 patients with Crohn's disease (CD) and 295 with ulcerative colitis (UC), mean age 37.1 (s.d. ± 9.2) years; 485 (52%) female, were reported upon. Data were heterogeneous and methodology varied. Compared with controls, a statistically significant reduction in body mass index (BMI) was reported in 37% of CD and 20% of UC patients; reduced fat-free mass in 28% CD and 13% UC patients, and reduced fat mass in 31% CD and 13% UC patients. There was no consistent association between body composition and disease activity, duration, extent or therapies. BMI did not accurately predict body composition.

CONCLUSIONS

Current data, although heterogeneous, suggest that many patients with IBD are affected by aberrations in fat and lean mass, which may not be detected during routine clinical assessment. The prevalence and impact of altered body composition amongst this population warrant further investigation.

No relation between disease activity measured by multiple methods and REE in childhood Crohn disease

BACKGROUND AND AIMS

Increased resting energy expenditure (REE) unmatched by dietary intake is implicated as a cause of poor nutrition in childhood inflammatory conditions. Adequate description of disease activity and correction of REE data for body composition are important to reach reliable conclusions about changes in REE associated with disease. The present study aimed to determine the effect of disease activity measured by clinical status, systemic and stool inflammatory markers on REE in children with Crohn disease using appropriate correction for confounding factors.

METHODS

Sixty children with Crohn disease were recruited from the regional paediatric gastroenterology unit and studied on 1 occasion. REE was measured by indirect calorimetry. Fat-free mass (FFM) was estimated by skinfold thickness. Disease activity was measured using systemic (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) and faecal markers of inflammation (lactoferrin, calprotectin) and clinical scores (Paediatric Crohn Disease Activity Index).

RESULTS

Using a multiple regression model, there was no significant change in REE from active or inactive disease (β = 0.03, P = 0.7) nor from CRP (β = -0.05, P = 0.52), ESR (β = -0.07, P = 0.43), faecal calprotectin (β = -0.07, P = 0.38), and faecal lactoferrin (β = 0.01, P = 0.88). REE/kg FFM was not associated with the Paediatric Crohn Disease Activity Index (r = 0.1, P = 0.44), CRP (r = -0.3, P = 0.84) or ESR (r = 0.12, P = 0.4), faecal calprotectin (r = 0.04, P = 0.97), or faecal lactoferrin (r = 0.02, P = 0.87).

CONCLUSIONS

REE corrected for physiologically relevant confounders is not associated with degree of disease activity using clinical tools or systemic and local inflammatory markers, and therefore is an unlikely mechanism for poor nutritional state.

Energy expenditure in Japanese patients with severe or moderate ulcerative colitis

We investigated the energy expenditure in hospitalized patients with severe or moderate ulcerative colitis (UC), and compared them to healthy controls. Thirteen patients (5 women and 8 men; mean age 31.8 years; mean BMI 19.0 kg/m²) and 10 healthy volunteers were enrolled in this study. The resting energy expenditure (mREE) levels were determined by indirect calorimetry. The mREEs of the UC patients were significantly higher than those of healthy controls (26.4 ± 3.6 vs 21.8 ± 1.7 kcal/kg/day), although the mREEs of the UC patients were almost the same as the predicted REEs (pREEs) calculated by the Harris-Benedict equation (26.4 ± 2.4 kcal/kg/day vs 26.5 ± 2.6 kcal/kg/day). The mREE/pREE ratio, which reflects stress, was 1.0 ± 0.15. In the UC patients, a significant correlation was observed between the mREEs and the clinical activity index. In conclusion, UC patients showed a hyper-metabolic status as evaluated by their mREE/body weight. Energy expenditure was significantly correlated with disease activity. From our observations, we recommend that nutritional management with more than 30–35 kcal/ideal body weight/day (calculated by the mREE × activity factor) may be optimal for active severe or moderate ulcerative colitis.

Nutritional follow-up of patients with ulcerative colitis during periods of intestinal inflammatory activity and remission

CONTEXT: Ulcerative colitis is an inflammatory bowel disease involving superficial inflammation of the mucosa of the colon, rectum, and anus, sometimes including the terminal ileum. When in clinical activity, the disease is characterized by various daily evacuations containing blood, mucus and/or pus alternating periods of remission. OBJECTIVE: To compare nutritional parameters (dietary, biochemical and anthropometric) among patients with ulcerative colitis followed up on an outpatient basis over a period of 1 year and during periods of intestinal inflammatory activity and remission. METHODS: Sixty-five patients were studied over a period of 1 year and divided into two groups: group 1 with inflammatory disease activity (n = 24), and group 2 without disease activity (n = 41). Anthropometric measures, biochemical parameters, quantitative food intake, and qualitative food frequency were analyzed. RESULTS: A significant reduction in body mass index and weight and in the intake of energy, proteins, lipids, calcium, iron and phosphorus was observed in the group with inflammatory activity (group 1) when compared to the period of clinical remission. The most affected food groups were cereals, legumes, oils, and fats. In contrast, in group 2 significant differences in triceps and sub scapular skin fold thickness, total protein, hemoglobin and hematocrit were observed between the first and final visit. Calcium and vitamin B6 intake, as well as the consumption of legumes, meat and eggs, and sugar and sweets, was significantly higher than on the first visit. CONCLUSION: Patients with ulcerative colitis followed up on an outpatient basis tend to be well nourished. However, the nutritional aspects studied tend to worsen during the period of inflammatory disease activity.

Energy metabolism in Japanese patients with Crohn's disease

We investigated energy expenditure in hospitalized patients with Crohn’s disease (CD), and determined optimal energy requirements for nutritional therapy. Sixteen patients (5 women and 11 men, mean age 36 year old, mean BMI 18.7 kg/m²) and 8 healthy volunteers were enrolled in this study. Measured resting energy expenditure (mREE) levels were determined by indirect calorimetry. The mREEs in CD patients were significantly higher than those of healthy controls (24.4 ± 2.4 kcal/kg/day vs 21.3 ± 1.7 kcal/kg/day). However, mREEs in CD patients were significantly lower than predicted REEs (pREEs) calculated by the Harris-Benedict equation (26.4 ± 2.5 kcal/kg/day). Furthermore, mREE/pREE values were lower in undernourished patients than in well-nourished patients. CD patients had hyper-metabolic statuses evaluated by mREE/body weight, but increased energy expenditure did not contribute to weight loss in these patients. In conclusion, nutritional therapy with 25–30 kcal/ideal body weight/day (calculated by mREE × active factor) may be optimal for active CD patients, while higher energy intake values pose the risk of overfeeding.

ESPEN Guidelines on Parenteral Nutrition: gastroenterology

Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.

Dietary intakes of children with Crohn's disease

Approximately 25 % of individuals with Crohn's disease (CD), a life-long relapsing-remitting disease, are diagnosed during childhood and adolescence. Symptoms of CD, including abdominal pain, nausea and diarrhoea, can lead to reduced food intake, which may negatively have an impact on nutritional status during this critical period of growth and development. The aims of the present study were to assess the growth and adequacy of dietary intakes of children with CD at Sydney Children's Hospital, Randwick, and compare with healthy controls. Sixty-three subjects aged 10-16 years were recruited, including: children with active CD (n 18), children with CD in remission (n 23) and healthy controls (n 22). Dietary intake was assessed using a FFQ and compared with current Australian recommended dietary intakes (RDI). Growth and dietary intakes were compared between groups. Subjects with active CD had lower weight and BMI Z scores than children in remission and controls. The energy intakes of children with active CD and those in remission were significantly lower than estimated energy requirements (P = 0.001 and P = 0.03 respectively). Children with active CD did not meet the RDI for Fe and their Ca intake was lower than the RDI (P = 0.04). In conclusion, the dietary intake of children with active CD was impaired, with inadequate intakes of energy, Ca and Fe. Reduced energy intakes during active disease may contribute to poor weight gain and impaired growth. Quantifying nutrient intake and ascertaining requirements for nutritional supplementation are essential components of successful management in paediatric CD.

Malabsorption is a major contributor to underweight in Crohn's disease patients in remission

OBJECTIVE

Undernutrition has been reported in 65-75% of patients with Crohn's disease. The present study aimed at identifying the relative contribution of malnutrition-causing factors in patients with Crohn's disease in remission.

METHODS

Sixteen patients with Crohn's disease (age 19-57 y) in remission (Crohn's Activity Disease Index < 150) were included in the study. Their weight was stable for >3 mo and they were off steroids. They all completed 3-d food records and concomitantly collected stools. Self-reported food records were analyzed and energy content in stools was determined by a direct bomb calorimeter. Resting energy expenditure (REE) was studied by indirect calorimetry and body composition by dual-energy X-ray absorptiometry. The study cohort was divided into two groups, with a body mass index (BMI) equal to 18.5 kg/m(2) serving as a cutoff point.

RESULTS

Subjects with lower BMIs tended to have less lean body mass (P = 0.006), less bone mineral density (P = 0.006), and lower REE (P = 0.003). No correlation was found between BMI and energy intake but the percentage of malabsorption was negatively correlated with BMI (P = 0.07). When dividing the study based on a BMI of 18.5 kg/m(2), no difference was found in caloric intake or REE between groups but subjects with lower BMIs had significant prominent malabsorption compared with the others (21.1 +/- 9.8% versus 11.7 +/- 3.5%, P = 0.015).

CONCLUSION

In the presence of similar energy intake, REE does not seem to contribute to lower BMI, although nutrient malabsorption is higher in malnourished patients with Crohn's disease in remission. We suggest that malabsorption be evaluated in patients with Crohn's disease who fail to gain weight during disease remission to establish their extra caloric requirements.

Positive impact of blocking tumor necrosis factor alpha on the nutritional status in pediatric Crohn's disease patients

BACKGROUND

TNFalpha seems to contribute to inflammation and malnutrition in Crohn's disease (CD) patients. In CD patients, the comparative effects on nutritional status of infliximab and traditional therapy have not yet been determined. The aim of our study was to assess the effects of infliximab as compared with those of standard therapy on nutritional status, disease activity, resting energy expenditure (REE), and food intake in CD children and adolescents.

METHODS

From September 1999 to September 2005, all CD patients treated with infliximab (group A) were reviewed and matched with CD patients treated with traditional therapy (mesalazine and azathioprine) (group B).

RESULTS

Fourteen CD patients from group A and 14 from group B were included; median interval before follow-up investigation was 10 months. Baseline and final values of weight, height, body mass index (BMI), pediatric CD activity index (pCDAI), REE, and food intake were studied. In treated patients, but not in control group, mean baseline weight (kg) and BMI values, 39.7 +/- 13.1 and 17.9 +/- 3.3, respectively, were significantly lower than their final values 42.6 +/- 13.2 and 18.9 +/- 3.1, and median pCDAI values 23.5 were significantly higher than their final values 10 (P < 0.05). Significant changes in height, REE, and food intake were not found in either group.

CONCLUSIONS

In pediatric CD patients, infliximab seems to impact positively on the nutritional status as demonstrated by the improvement in weight and BMI, but not in linear growth; effects on nutritional status seem to be due to amelioration of disease activity, rather than to REE reduction or food intake increase.

Measurement of nutrition status in Crohn's disease patients receiving infliximab therapy

AIM

There is limited information on the nutrition impact of antitumor necrosis factor-alpha treatment in adult Crohn's disease (CD). This study was performed to examine the effect of a 6-month course of infliximab on enterocyte function, nutrient status, metabolism, and body composition in these patients.

METHODS

Seven CD patients were assessed for disease activity, enterocyte function, and body composition prior to, after 6 weeks, and after 6 months of infliximab treatment. Measurements included (1) disease activity: Inflammatory Bowel Disease Questionnaire, Harvey Bradshaw Index, and C-reactive protein; (2) enterocyte function: folate, homocysteine, vitamin B(12), citrulline, vitamin D, beta-carotene, d-xylose absorption; (3) Prognostic Inflammatory and Nutritional Index (PINI); and (4) body composition and metabolism: body mass index (BMI), fat and lean body mass, resting energy expenditure (RRE), and respiratory quotient.

RESULTS

Most patients had improvement in disease activity with infliximab. PINI decreased in all patients (-3.35, P = .04). Plasma folate concentration significantly increased. There was an increase in BMI, fat mass, and lean body mass. The respiratory quotient increased in most patients. Changes in citrulline level and REE were inconsistent.

CONCLUSIONS

Crohn's disease patients have improvements in an index that measures both inflammation and nutrition (PINI) with infliximab therapy. Increases in plasma folate suggest improvement in enterocyte function and/or increased oral intake. The increase in respiratory quotient suggests decreased lipolysis and the lack of a starvation state. It was unclear whether weight gain was predominantly fat or lean muscle mass. These finding also support the use of PINI in Crohn's patients as an overall marker of inflammation and nutrition, and as a measure of response to infliximab therapy.

Resting energy expenditure in children with inflammatory bowel disease

OBJECTIVES

There is controversy in the literature regarding the effect of inflammatory bowel disease (IBD) on resting energy expenditure (REE). In many cases this may have resulted from inappropriate adjustment of REE measurements to account for differences in body composition. This article considers how to appropriately adjust measurements of REE for differences in body composition between individuals with IBD.

PATIENTS AND METHODS

Body composition, assessed via total body potassium to yield a measure of body cell mass (BCM), and REE measurements were performed in 41 children with Crohn disease and ulcerative colitis in the Royal Children's Hospital, Brisbane, Australia. Log-log regression was used to determine the power function to which BCM should be raised to appropriately adjust REE to account for differences in body composition between children.

RESULTS

The appropriate value to "adjust" BCM was found to be 0.49, with a standard error of 0.10.

CONCLUSIONS

Clearly, there is a need to adjust for differences in body composition, or at the very least body weight, in metabolic studies in children with IBD. We suggest that raising BCM to the power of 0.5 is both a numerically convenient and a statistically valid way of achieving this aim. Under circumstances in which the measurement of BCM is not available, raising body weight to the power of 0.5 remains appropriate. The important issue of whether REE is changed in cases of IBD can then be appropriately addressed.

Insights into energy requirements in disease

Accurate information about the energy needs of a range of acute and chronic diseases and morbidity is lacking and often complicated by the medication prescribed to treat the condition and also because of the presence of pre-existing malnutrition. Assessing the energy requirements of patients with acute and chronic diseases is more complex than for those in good health. These requirements not only depend on the aggressiveness of the disease and level of inactivity it causes, but also on the treatment, and the presence of prior malnutrition. It used to be generally believed that the energy requirements were increased in a number of diseases. It is now realised that this is not usually the case. Therefore, it is necessary to put these changing ideas into context by considering a wide range of acute and chronic diseases which this paper proposes to do. This paper is almost exclusively restricted to studies that have measured total energy expenditure (TEE) using tracer techniques in both hospital and the community (mostly doubly labelled water and to a lesser extent bicarbonate–urea), and continuous 24–hour indirect calorimetry in artificially ventilated patients in hospital.

Competing with Crohn's disease: management issues in active patients

Crohn's disease is a chronic inflammatory bowel disorder that has genetic and environmental risk factors. Although moderate physical activity seems to reduce the risk of developing Crohn's disease, some high-performance athletes live with the disease. Uncontrolled Crohn's disease predisposes patients to numerous nutrient deficiencies and associated health issues such as anemia and osteoporosis. Low-intensity exercise has been shown to decrease flare-ups in sedentary patients; however, high-intensity exercise may lead to increased symptoms. Physicians play a crucial role in coordinating a team approach among the athlete, parents, coach, and athletic trainers to provide the best possible management of diet, training schedule, and treatment.

Energy intakes of children with Crohn's disease treated with enteral nutrition as primary therapy

BACKGROUND

Enteral nutrition (EN) is widely used and is effective in the treatment of children with Crohn's disease given as an exclusive feed for 6-8 weeks. Current dietetic practice during EN is to recommend an energy intake based on estimated average requirement (EAR) for energy for age.

AIMS

To examine factors affecting energy intake and weight gain during EN in relation to disease site and nutritional status.

METHODS

A retrospective cohort study examining energy intake and weight gain during the exclusive EN feeding period in 40 patients newly diagnosed with Crohn's in relation to EAR, nutritional status, disease site.

RESULTS

All patients improved clinically and gained weight during EN with improvement in the CRP as a marker of the systemic inflammatory response. Energy intake was higher than EAR in 82% (33/40 patients), with the median 117.5% of EAR. Weight gain correlated with body mass index standard deviation score (P = 0.001) at start of treatment, but not energy intake or CRP.

CONCLUSION

Estimated average requirement underestimates energy intakes in most children with newly diagnosed Crohn's disease. During EN, an energy intake in the range of 100-149% (median 117.5%) EAR for energy for age may be required. Energy balance studies in children with active disease are required.

Resting energy expenditure, oxygen consumption and carbon dioxide production during sleep in children with atopic dermatitis

BACKGROUND

Pruritus and scratching are cardinal symptoms of atopic dermatitis (AD). Sleep and growth may also be affected in children with moderate-to-severe AD. We evaluated whether resting energy expenditure (REE), oxygen consumption (VO2) and carbon dioxide production (VCO2) in various stages of sleep were influenced by the disease severity.

METHODS

Disease severity was evaluated by the scoring atopic dermatitis (SCORAD) index. All-night polysomnography was performed and REE, VO2 and VCO2 were measured.

RESULTS

Twenty children (13 boys and seven girls) with AD and eight controls were recruited. The median overall SCORAD for our AD patients was 36.8. The total sleep efficiency was lower in patients with severe AD than that obtained in the control group (median: 72% versus 88%; p = 0.039). When compared with mild-to-moderate disease (SCORAD40) and controls, REE, VO2 and VCO2 in patients with severe AD (SCORAD > 40) did not differ in sleep stages I and II combined, stages III and IV combined or the rapid eye movement (REM) stage. REE, VO2 and VCO2 in these sleep stages did not show significant correlation with the overall and the three components of the SCORAD scores.

CONCLUSIONS

Children with AD do not appear to have significant disturbance in their resting energy consumption, oxygen consumption and carbon dioxide production during sleep. These parameters do not appear to correlate with the symptomatology of pruritus and sleep disturbance. We speculate that deranged metabolism during sleep is unlikely in children with AD.

Effect of malnutrition and short-term refeeding on peripheral blood mononuclear cell mitochondrial complex I activity in humans

BACKGROUND

Previous investigations in rats have shown that the first enzyme of the mitochondrial electron transport chain (complex I) is altered in peripheral blood mononuclear cells (PBMCs) and muscle by dietary manipulations.

OBJECTIVE

We hypothesized that similar changes would occur in human PBMCs as a result of dietary malnutrition and short-term refeeding irrespective of the presence or absence of active inflammatory bowel disease (IBD).

DESIGN

Fourteen malnourished patients with active IBD, 13 malnourished patients without IBD, and 42 healthy subjects were investigated. Complex I activity, body mass index, body composition, energy and protein intakes, and resting energy expenditure were measured. Five patients without IBD and 6 patients with IBD were investigated after 7 d of refeeding.

RESULTS

In patients without IBD, weight loss was mainly due to a loss of fat mass. In contrast, weight loss in IBD patients was due to a loss of both fat-free mass and fat mass. Complex I activity was reduced to the same degree in both groups of patients and was significantly lower than that observed in healthy subjects. In both groups of patients, complex I activity correlated significantly with body weight, body mass index, percentage weight loss, and fat mass. Complex I activity increased significantly after 1 wk of refeeding in both groups of patients before observed changes of measured nutritional assessment indexes.

CONCLUSION

Our study showed that mitochondrial complex I activity measured in PBMCs seems to be a specific marker of dietary malnutrition and responds rapidly to refeeding.

Review article: nutrition and adult inflammatory bowel disease

Major advances in the understanding of the aetio-pathogenesis and genetics of inflammatory bowel disease have been accompanied by an escalation in the sophistication of immunomodulatory inflammatory bowel disease therapeutics. However, the basic 'triple' therapy (5-aminosalicylates, corticosteroids, azathioprine) and nutrition have maintained their central role in the management of patients with inflammatory bowel disease over recent decades. This review provides an overview of the supportive and therapeutic perspectives of nutrition in adult inflammatory bowel disease. The objective of supportive nutrition is to correct malnutrition in terms of calorie intake or specific macro- or micronutrients. Of particular clinical relevance is deficiency in calcium, vitamin D, folate, vitamin B12 and zinc. There is justifiably a growing sense of unease amongst clinicians and patients with regard to the long-term use of corticosteroids in inflammatory bowel disease. This, rather than arguments about efficacy, should be the catalyst for revisiting the use of enteral nutrition as primary treatment in Crohn's disease. Treatment failure is usually related to a failure to comply with enteral nutrition. Potential factors that militate against successful completion of enteral nutrition are feed palatability, inability to stay on a solid-free diet for weeks, social inconvenience and transient feed-related adverse reactions. Actions that can be taken to improve treatment outcome include the provision of good support from dietitians and clinicians for the duration of treatment and the subsequent 'weaning' period. There is evidence to support a gradual return to a normal diet through exclusion-re-introduction or other dietary regimen following the completion of enteral nutrition to increase remission rates. We also review the evidence for emerging therapies, such as glutamine, growth factors and short-chain fatty acids. The future may see the evolution of enteral nutrition into an important therapeutic strategy, and the design of a 'Crohn's disease-specific formulation' that is individually tailored, acceptable to patients, cost-effective, free from adverse side-effects and combines enteral nutrition with novel pre- and pro-biotics and other factors.

Effect of steroids on energy expenditure and substrate oxidation in women with Crohn's disease

OBJECTIVE

Patients with Crohn's disease (CD) have increased energy expenditure and fat oxidation. Steroids, commonly used to treat flare-up of CD, induce weight gain. This study was designed to evaluate the effects of prednisone and budesonide on energy expenditure and substrate oxidation in patients with CD.

METHODS

Twenty-nine women with CD and 10 healthy controls were studied. Ten patients received prednisone (0.75-1.0 mg/kg/day), nine received budesonide (9 mg/ day), and 10 did not receive steroids. Resting energy expenditure and substrate oxidation were measured by indirect calorimetry in a fasting state and after a standard diet.

RESULTS

In the fasting state, resting energy expenditure was higher in patients without steroids than in the controls. Lipid oxidation was lower (p < 0.01) in patients with prednisone (0.46 +/- 0.39 mg/kg/min) than in patients with budesonide (0.97 +/- 0.28 mg/kg/min) and without steroids (1.06 +/- 0.32 mg/kg/min), but was similar with control subjects (0.47 +/- 0.20 mg/kg/min). Postprandially, lipid oxidation was lower (p < 0.01) in patients with prednisone (0.32 +/- 0.23 mg/kg/min) than in patients with budesonide (0.75 +/- 0.20 mg/kg/min), without steroids (0.82 +/- 0.23 mg/kg/min), and controls (0.58 +/- 0.15 mg/kg/min). Protein oxidation was significantly higher in patients with prednisone than in the other subjects.

CONCLUSIONS

In women with CD, prednisone decreases lipid oxidation and increases protein oxidation. These effects are not observed with budesonide and may contribute to the weight gain and side effects commonly observed with prednisone. A low-fat/high-protein diet could be proposed during a course of prednisone.

Nutrition in inflammatory bowel disease

Nutritional derangements are frequent in inflammatory bowel disease. In the past year significant work has been published examining the mechanisms of impaired food intake in animal models of inflammatory bowel disease, which allow a better understanding of these processes. Data from the same laboratory have shed further light on the relative role of underfeeding and inflammation on the growth retardation associated with intestinal inflammation. Other studies have provided further data on the risk factors and predictive biomarkers of bone loss in patients with inflammatory bowel disease. The potential role of enteral nutrition as primary therapy for Crohn's disease is particularly addressed in this review. Recent contributions to the field emphasized the special importance of this modality of therapy in paediatric patients. The possible mechanisms for such a therapeutic action are not well understood. Other nutrients may have a therapeutic potential in inflammatory bowel disease. In particular, recent data on the in-vivo anti-inflammatory actions of butyrate merit special mention. Finally, novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta2-enriched enteral feeding, or hydrothermally processed cereals have recently been explored.

Altered subjective appetite parameters in Crohn's disease patients

BACKGROUND AND AIM

Altered appetite and early satiety may promote anorexia associated with Crohn's disease. The aim of this study was to assess the impact of disease activity on subjective appetite parameters in Crohn's disease patients.

METHODS

Seventeen patients with Crohn's disease and 15 healthy controls (8 M: 7 F, 34 (20-35) years) were studied. Subjects rated their hunger, desire to eat, fullness and level of satiety using visual analogue scales after an overnight fast. Subjects were reassessed after ingestion of 500 and 1000 ml water. Anthropometry was used to determine percentage body fat. Serum leptin & TNF- alpha levels were assessed using immunoassay. Disease activity was determined using the Harvey-Bradshaw index.

RESULTS

Hunger ratings for active Crohn's disease patients were significantly lower than controls at baseline (P<0.05). Desire to eat was lower in patients with active Crohn's disease than controls both at baseline (95% CI, 0.3 mm, 40.7 mm) and after ingestion of 500 ml water (95% CI, 1.25 mm, 51.9 mm) (P<0.05). Serum leptin concentrations were significantly associated with percent body fat (r=0.57;P<0.001) and, after correcting for body fat status, tended to be higher in patients with active Crohn's disease (mean 0.9 ng/ml/% body fat; SD 0.8 ng/ml/% body fat) compared with either patients with inactive disease (mean 0.4 ng/ml/% body fat; SD 0.3 ng/ml/% body fat) or healthy controls (mean 0.3 ng/ml/% body fat; SD 0.2 ng/ml/% body fat) (P=0.15, ns). Appetite parameters and serum leptin concentrations showed no significant correlation.

CONCLUSIONS

Subjective appetite parameters were altered in patients with active Crohn's disease. At baseline, patients with active Crohn's disease were less hungry than healthy controls and had less desire to eat. After ingestion of 500 ml of water, desire to eat was significantly less in patients with active disease as compared with healthy controls. Serum leptin concentration corrected for percent body fat tended to be higher in patients with active Crohn's disease compared with inactive Crohn's disease and healthy controls, but the differences did not reach statistical significance.

Nutrition in inflammatory bowel disease: impact on disease and therapy

Nutritional derangements are frequent in inflammatory bowel disease. In the last year, significant work was published examining the mechanisms of impaired food intake in animal models of inflammatory bowel disease, which allow a better understanding of these processes. These data have shed new light on the relative role of underfeeding and inflammation on the growth retardation associated with intestinal inflammation. Other studies have provided further information on the risk factors and predictive biomarkers of bone loss in patients with inflammatory bowel disease. The potential role of enteral nutrition as primary therapy for Crohn disease is particularly addressed in the present review. Recent contributions emphasized the special importance of this therapeutic modality in pediatric patients, but the possible mechanisms for such therapeutic effect are still not well understood. Other nutrients may have a therapeutic potential in inflammatory bowel disease. In particular, recent data on the in vivo antiinflammatory action of butyrate merit special mention. Finally, novel nutritional therapeutic strategies for inflammatory bowel disease, such as transforming growth factor-beta2-enriched enteral feeding or hydrothermally processed cereals, have recently been explored.

Energy expenditure in disease: time to revisit?

Knowledge of energy expenditure is especially important in disease, and may in fact help in the understanding of the pathophysiology of wasting associated with disease. Energy requirements in a clinical setting are often 'prescribed' by health professionals, either directly through enteral or parenteral feeding, or perhaps controlled through a hospital diet. Studies initially suggested an increase in energy expenditure, and thus energy requirements, as a direct result of an increase in basal metabolic rate often seen in disease. However, many problems exist in the measurement of BMR in a disease situation, due to the effects of drugs, clinical practice, feeding or possibly anxiety either as a cause of the disease or the measurement itself. These problems could in themselves contribute to the rise in metabolism seen in disease. More recently, however, with the use of tracer techniques such as doubly-labelled water and the bicarbonate-urea method, more accurate estimates of energy expenditure, and thus energy requirements, have been made. Some such measurements have in fact shown that even with an elevated BMR, free-living total energy expenditure can in fact be reduced in many disease situations, suggesting a reduced rather than an increased energy requirement. The present review investigates measurements of total energy expenditure in disease to explore the hypothesis that energy expenditure in disease, even with an elevated BMR, can in fact be reduced due to a concurrent reduction in physical activity.

Energy metabolism and substrate oxidation in patients with Crohn's disease

Weight loss and malnutrition are common features in patients with Crohn's disease. This study was designed to evaluate diet-induced thermogenesis and substrate oxidation in patients with Crohn's disease. Twenty-three patients (17 women, 6 men; age 34 +/- 2 y) and 17 healthy control subjects (13 women, 4 men; age 36 +/- 3 y) were studied. Resting energy expenditure and fasting substrate oxidation were measured by indirect calorimetry in the morning after an overnight fast. After a standard homogenized test meal (10 kcal/kg), indirect calorimetry was performed every 30 min for 3 h to measure the diet-induced thermogenesis and the postprandial substrate oxidation. In the fasting state, resting energy expenditure was significantly higher in patients than in control subjects (1433 +/- 43 versus 1279 +/- 53 kcal/24 h). Lipid oxidation was higher in patients with Crohn's disease than in control subjects (1.17 +/- 0. 07 versus 0.61 +/- 0.11 mg. kg(-1). min(-1), P < 0.01). Postprandially, diet-induced thermogenesis was significantly lower in patients with Crohn's disease than in control subjects (4.6% +/- 0.5 versus 6.3% +/- 0.5 of energy intake, P < 0.01). Lipid oxidation was significantly higher in patients with Crohn's disease than in control subjects (0.78 +/- 0.05 versus 0.56 +/- 0.08 mg. kg(-1). min(-1), P < 0.05), and glucose oxidation was lower in patients with Crohn's disease than in control subjects. In patients with Crohn's disease, lipid oxidation positively correlates with the disease activity evaluated by the Crohn's Disease Activity Index (r = 0.48, P150), fasting and postprandial lipid oxidation was significantly higher than in patients with inactive Crohn's disease (P < 0.05). In conclusion, patients with Crohn's disease have increased fat oxidation, which correlates with disease activity and this may explain the reduced fat stores in patients with Crohn's disease.

Validation of bioimpedance analysis as a measure of change in body cell mass as estimated by whole-body counting of potassium in adults

BACKGROUND

The body cell mass (BCM) is an important measure of macronutrient status, but measurements are difficult to obtain outside of sophisticated research laboratories. Bioimpedance analysis (BIA) is a simple technique that holds promise as a means of estimating body composition. The purpose of this study was to evaluate the ability of BIA to estimate changes in BCM as measured by whole body counting of 40K (TBK).

METHODS

Paired studies of BCM, including both TBK and BIA, were compared in 87 human immunodeficiency virus-positive subjects and in 62 healthy, weight-stable control adults. Potential errors in the predictions were examined.

RESULTS

BCM change by TBK and BIA correlated closely (r = .755). After accounting for errors related to repeat measures of TBK, the correlation coefficient was .784, with a standard error of the estimate of 1.24 kg. The differences between predicted and measured BCM change were consistent with a normal distribution. However, there was a systematic error in prediction, with BIA underpredicting the magnitudes of both gains and losses in BCM by TBK.

CONCLUSIONS

BIA is a useful surrogate for measuring changes in BCM in clinical circumstances. Because TBK assesses only intracellular potassium, whereas BIA reflects all intracellular cations, the underprediction of BCM change by BIA compared with TBK could be related to changes in intracellular potassium concentration as a result of malnutrition or its treatment.

Energy and substrate metabolism in patients with active Crohn's disease

The aim of the study was to evaluate the possible contribution of changes in energy metabolism and substrate oxidation rates to malnutrition in Crohn's disease and to assess the effect of enteral nutrition on these parameters. Energy metabolism was evaluated by indirect calorimetry in 32 patients with active Crohn's disease and 19 age- and sex-matched healthy individuals. Measurements were done in the postabsorptive state. Seven out of 32 patients received enteral nutrition via a nasogastric tube. In these patients, resting energy metabolism was determined at d 0 (postabsorptive), 7, 14 (during full enteral nutrition) and 15 (postabsorptive). Resting energy expenditure was not significantly different between patients and controls, whereas the respiratory quotient (RQ) was lower in patients (0.78 +/- 0.05 vs. 0.86 +/- 0.05; P < 0.05). During enteral nutrition in 7 patients with Crohn's disease, the RQ increased on d 7 compared with d 0 and remained high even after cessation of enteral nutrition (d 0, 0.78 +/- 0.03; d 7, 0.91 +/- 0.04; d 15, 0. 84 +/- 0.05; P < 0.05; d 7 and 15 vs. d 0). No effects of enteral nutrition on resting energy expenditure were found. Active Crohn's disease is associated with changes in substrate metabolism that resemble a starvation pattern. These changes appear not to be specific to Crohn's disease but to malnutrition and are readily reversed by enteral nutrition. Enteral nutrition did not affect resting energy expenditure. Wasting is a consequence of malnutrition but not of hypermetabolism in Crohn's disease.

Elevated diet-induced thermogenesis and lipid oxidation rate in Crohn disease

BACKGROUND

Although malnutrition is frequently observed in Crohn disease (CD), its cause is not clear. Regulation of energy metabolism and diet-induced thermogenesis (DIT) have not been adequately studied in CD.

OBJECTIVE

The aim was to study DIT and substrate oxidation in patients with inactive ileal CD.

DESIGN

After a test meal providing 50.2 kJ/kg body wt, DIT was assessed by indirect calorimetry performed over 360 min in 18 CD patients and 12 healthy volunteers matched for age, sex, weight, and height. Body composition was evaluated with the labeled-water-bolus injection technique.

RESULTS

Fat-free mass did not differ significantly between groups, but CD patients had markedly lower fat mass than control subjects (13.8+/-5.63 compared with 19.0+/-3.49 kg; P < 0.001). Nonprotein respiratory quotient was lower in CD patients than control subjects (0.80+/-0.04 compared with 0.86+/-0.03; P < 0.001). Average respiratory quotient between 75 and 150 min after the test meal was 0.85+/-0.03 in CD patients and 0.91+/-0.02 in control subjects (P < 0.001). Lipid oxidation rate was higher in CD patients than in control subjects (2.26+/-1.13 compared with 1.50+/-0.75 kJ/min; P < 0.05). DIT was higher in CD patients than in control subjects (9.89+/-1.93% compared with 5.67+/-0.91% of energy intake; P < 0.001).

CONCLUSIONS

Patients with inactive ileal CD had significantly higher DIT and lipid oxidation rate than do healthy volunteers. These results may explain why CD patients have difficulty maintaining adequate nutritional status, and the findings also suggest that a diet relatively rich in fat may attain better energy balance.

Effect of disease localization on the anthropometric and metabolic features of Crohn's disease

OBJECTIVE

We conducted this study to evaluate the effect of disease localization on the anthropometric and metabolic characteristics of inactive Crohn's disease (CD).

METHODS

Forty-three patients with biopsy or radiology proven CD (23 men; age, 33.8 yr; range, 18-54 yr) in clinical remission (simplified Crohn's diseases activity index [SCDAI] < 3) and not receiving steroid therapy or nutritional support were enrolled in the study. Patients were separated into three subgroups according to disease localization: ileal (n = 16), ileo-colonic (n = 13), and colonic CD (n = 14). Sixty healthy volunteers (26 men; age, 32.0 yr; range, 18-60 yr), matched for age and height were used as control subjects. Body composition was assessed by both anthropometry and bioimpedance analysis and indirect calorimetry was performed to measure energy expenditure and substrate oxidation rates.

RESULTS

CD patients showed a lower body weight than controls, both as a whole (61.5 kg; range, 41.5-74.0 vs 66.9 kg; range, 55.0-86.0 kg; p < 0.001) and separated by disease localization (ileal; p < 0.001; ileo-colonic; p < 0.001; and colonic; p < 0.05 vs controls). Fat-free mass (FFM) did not differ between the groups, whereas fat mass was significantly lower in CD patients than in controls (p < 0.001), with the lowest values in ileal and ileo-colonic patients. Basal metabolic rate by kg of FFM was higher in CD patients than in healthy individuals (p < 0.01). Nonprotein respiratory quotient was significantly lower in CD than in controls as a whole (0.79; range, 0.73-0.84 vs 0.83; range, 0.79-0.89; p < 0.001) or separated by disease localization (p < 0.001 each subgroup vs controls), with a consequent higher lipid oxidation rate. A lower dietary lipid intake was found in patients than in controls (p < 0.01).

CONCLUSIONS

Regardless of disease localization, CD patients showed a lower fat mass and a higher utilization of lipids than control subjects. Patients with ileal and ileo-colonic disease showed the greater reduction in body weight, compared with control subjects, suggesting they were at a higher risk of malnutrition, probably as a consequence of the simultaneous occurrence of both malabsorption and decreased energy intake.

Nutritional issues in inflammatory bowel disease

Malnutrition is a very common problem in patients with chronic inflammatory bowel diseases. This article discusses the incidence, causes, and clinical consequences of malnutrition in these patient groups. The role of nutritional support administered enterally or parenterally either as primary or adjunctive therapy is highlighted, based on past and more recent controlled studies. Additional attention is given to the roles of glutamine, short-chain fatty acids, fish oil, and alternative nutritional therapy.

Metabolic features of inflammatory bowel disease in a remission phase of the disease activity

OBJECTIVES

To evaluate the anthropometric and metabolic characteristics of patients with Crohn's disease (CD) and ulcerative colitis (UC), comparing both groups with healthy volunteers.

DESIGN

A cross-sectional study.

SETTING

The Department of Internal Medicine, Catholic University Hospital, Rome, Italy.

SUBJECTS

Thirty-four patients with biopsy-proven inflammatory bowel disease (18 CD; 16 UC) in clinical remission (SCDAI < 3 and Powell-Tuck index < 4) not receiving steroid therapy.

INTERVENTIONS

All patients had a clinical examination.

MAIN OUTCOME MEASURES

Blood indicators of inflammation and nutritional status. Body composition was assessed by both anthropometry and bioimpedance and metabolic variables were measured by indirect calorimetry over a 60-90 min period.

RESULTS

CD had a lower body weight than both controls (58.1 kg, range 41.5-71.0 vs. 66.4 kg, range 57.0-76.0; P < 0.001) and UC) 58.1 kg, range 41.5-71.0 vs. 69.6 kg, range 50.5-94.0; (P < 0.001). Fat-free mass (FFM) did not differ between the groups, whilst fat mass was significantly lower in CD than in UC (P < 0.05) and controls (P < 0.001). Normalizing the basal metabolic rate by FFM, a higher value was found in CD compared with UC (143 kJ kg-1) d-(-1), range 97.5-179 vs. 133 kJ kg-1 d-1, range 123-148; P < 0.05) and control subject 143 kj kg-1 d-1, range 97.5-179 vs. 134 kj kg-1 d-1, range 122-162; P < 0.05). The nonprotein respiratory quotient was significantly lower in CD compared to UC 0.80, range 0.73-0.84 vs. 0.84, range 0.79-0.91; P < 0.01) and controls (0.80, range 0.73-0.84 vs. 0.83, range 0.81-0.87; P < 0.001), with a consequently higher lipid oxidation rate in CD.

CONCLUSIONS

CD subjects showed a decreased fat mass and enhanced utilization of lipids compared with UC and controls. These data could be explained by the larger intestinal involvement and considered as a contribution to lipid tissue wasting in CD.

Increased energy expenditure in growing adolescents with Crohn's disease

Undernutrition is considered to have a central role in the pathogenesis of growth retardation in Crohn's disease. This may occur as a consequence of inadequate food intake, increased energy expenditure, or both. Ten growing adolescents with inactive Crohn's disease were assessed with respect to anthropometric parameters and resting energy expenditure, measured by indirect calorimetry during remission, repeated in relapse (N = 5), and compared to that predicted from the Harris-Benedict formula. Mean energy intake was assessed with seven-day diaries in five patients and compared to recommended intake for age, sex, weight, and physical activity. Ten healthy, growing, age- and sex-matched adolescents served as controls. Nine patients with inactive Crohn's disease, who had ceased growing, were matched for disease site and duration and acted as disease controls. Patients and disease controls had lower body mass index (19.2 +/- 0.6; 20.9 +/- 0.7) than healthy controls (23.7 +/- 0.6; P < 0.001). Percent body fat was lower in patients (13.2 +/- 1.9%) compared to healthy controls (20.5 +/- 2.4%; P < 0.05) but not to disease controls (17.0 +/- 2.6%). Patients had higher resting energy expenditure per kilogram of fat-free mass than disease or healthy controls (36.9 +/- 5.1; 32.9 +/- 2.6; 30.9 +/- 2.1 kcal; P < 0.02). Measured resting energy expenditure in patients, but not in disease or healthy controls, was higher than the predicted (measured: predicted 1.15, 1.03, 0.9, respectively; P < 0.03). Energy intake in patients was 97% of recommended intake but the measured ratio of energy intake/resting energy expenditure was lower than the predicted ratio (1.49 vs 1.71; P < 0.05). During subsequent relapse in five patients resting energy expenditure was unchanged. In growing adolescents with inactive Crohn's disease, there is increased energy expenditure that is not accompanied by an increase in energy intake. Relapse of disease does not appear to increase resting energy expenditure further but may "divert" energy from growth to disease activity. This suggests that nutritional therapy should be directed towards increasing caloric intake to maximize growth potential.

Resting energy expenditure before and after surgical resection of gut lesions in pediatric Crohn's disease

In pediatric Crohn's disease (CD), resection of gut lesions is necessary to remove stenoses and when frequent relapses occur despite nutritional support and medical treatment. After surgery, improved nutritional status and accelerated growth usually follow increased nutritional intake and lower doses of steroids. The aim of this study was to compare energy balance before and after surgery while nutritional intake and steroid therapy were unchanged. Eleven patients, aged 14.5 +/- 2.5 years and with mildly active CD, were explored 1 week before and 1 month after gut resection for stenosis (n = 7) and medical treatment failure (n = 4). Eleven matched children participated in the study as controls. Disease activity was assessed by the Pediatric Crohn's Disease Activity Index and serum orosomucoid concentration. Resting energy expenditure (REE) was measured by indirect calorimetry, and fat-free body mass (FFM) was measured by anthropometry. The patients' mean REE decreased from 46.6 +/- 10.5 kcal/kg FFM/day before surgery to 42.6 +/- 10.3 kcal/kg FFM/day after surgery, while the controls' mean REE was 39 +/- 7 kcal/kg FFM/day (analysis of variance, p = 0.02). After surgery, body weights were not significantly different, but the mean protein oxidation rate was reduced and arm muscle area was increased. Changes in REE per kilogram of FFM per day were not correlated with changes in orosomucoid serum concentrations (r2 = 0.35; p = 0.4). In conclusion, in children with mildly active CD, while nutritional intake and steroid therapy were maintained at preoperative levels, a significant decrease in REE and improved nitrogen utilisation were observed 1 month after resection of the CD gut lesion. This finding suggests better use of energy substrates when CD lesions are removed.

Increased resting lipid oxidation in Crohn's disease

Resting energy expenditure (REE) was measured by indirect calorimetry and body composition was assessed by both direct (bioimpedance) and indirect (anthropometry) methods in 20 hospitalized patients with biopsy-proven ileal Crohn's disease and in a group of 16 healthy volunteers matched for sex, age, and height with the patient group. The Crohn's disease activity index was below 120 in all patients studied, who were treated with a low dose of corticosteroids (0.2-0.3 mg/kg body wt of prednisone). The average weight of Crohn's patients was significantly lower than that of controls (55.70 vs 70.50 kg, P < 0.001) due to both lower fat mass (9.97 vs 18.30 kg, P < 0.001) and lower lean body mass (45.72 vs 52.20 kg, P < 0.02). The average REE was significantly higher in the control group (1785.42 +/- 7.503 vs 1559.1 +/- 48.39 kcal/day, P < 0.001). However, these differences disappeared when REE was normalized by lean body mass (LBM) (34.49 +/- 2.56 vs 34.704 +/- 3.75 kcal/kg LBM P = NS). The nonprotein respiratory quotient was significantly lower in the patient group (0.823 +/- 0.031 vs 0.882 +/- 0.012, P < 0.025), indicating an increased lipid oxidation. This increased lipid oxidation might explain the reduced fat stores found in the group of Crohn's patients, suggesting also that a sufficiently lipid-rich diet could be useful in their nutritional management.