The complexities of approaching nutrition in inflammatory bowel disease: current recommendations and future directions

Micronutrient Deficiencies in Pediatric IBD: How Often, Why, and What to Do?

Inflammatory bowel disease (IBDs), including Crohn's disease (CD), and ulcerative colitis (UC) are complex diseases with a multifactorial etiology, associated with genetic, dietetic, and other environmental risk factors. Children with IBD are at increased risk for nutritional inadequacies, resulting from decreased oral intake, restrictive dietary patterns, malabsorption, enhanced nutrient loss, surgery, and medications. Follow-up of IBD children should routinely include evaluation of specific nutritional deficits and dietetic and/or supplementation strategies should be implemented in case deficiencies are detected. This narrative review focuses on the prevalence, risk factors, detection strategy, and management of micronutrient deficiencies in pediatric IBD.

Association between avoidant/restrictive food intake disorder risk, dietary attitudes and behaviors among Chinese patients with inflammatory bowel disease: a cross-sectional study

BACKGROUND

Restrictive eating behaviors are common among patients with inflammatory bowel disease (IBD), which may may develop nutritional and/or quality of life impairments into avoidant/restrictive food intake disorder (ARFID). The objective of this study is to estimate the prevalence and characteristics of ARFID in Chinese patients with IBD, and to investigate the current perceptions and dietary behaviors of patients with and without ARFID.

METHODS

A cross-sectional study was conducted in gastroenterology clinics of four tertiary hospitals in China. Patients with IBD were asked to complete a structured questionnaire including demographic characteristics, dietary attitudes and behaviors. The diagnosis of ARFID was established using Chinese version of the Nine-Item Avoidant/Restrictive Food Intake Disorder Screen questionnaire.

RESULTS

A total of 483 patients with IBD completed the questionnaires, and 20.3% met clinical criteria for ARFID. The average score of ARFID was 21.9 (interquartile range = 17.0-26.0). Multivariable binary logistic regression results showed that patients with Crohn's disease (OR = 0.483, 95%CI = 0.280-0.835; p = 0.009), being in an active disease state (OR = 0.220, 95%CI = 0.123-0.392; p < 0.001), holding dietary attitudes regarding symptom control (OR = 2.431, 95%CI = 1.299-4.548; p = 0.005), and reporting a specific dietary history (OR = 27.158, 95%CI = 3.679-200.456; p = 0.001) were significant more likely to suffer from ARFID.

CONCLUSIONS

ARFID is a common problem among patients with IBD. The incidence of ARFID is particularly high among patients with Crohn's disease, during relapse, and those who hold restrictive dietary attitudes or have a history of specific diets. Therefore, it is imperative to prioritize routine screening and early identification of ARFID, especially among high-risk populations, in future research and clinical practice.

TRIAL REGISTRATION

ChiCTR2100051539, on 26 September 2021.

Design strategies, advances and future perspectives of colon-targeted delivery systems for the treatment of inflammatory bowel disease

Inflammatory bowel diseases (IBD) significantly contribute to high mortality globally and negatively affect patients' qualifications of life. The gastrointestinal tract has unique anatomical characteristics and physiological environment limitations. Moreover, certain natural or synthetic anti-inflammatory drugs are associated with poor targeting, low drug accumulation at the lesion site, and other side effects, hindering them from exerting their therapeutic effects. Colon-targeted drug delivery systems represent attractive alternatives as novel carriers for IBD treatment. This review mainly discusses the treatment status of IBD, obstacles to drug delivery, design strategies of colon-targeted delivery systems, and perspectives on the existing complementary therapies. Moreover, based on recent reports, we summarized the therapeutic mechanism of colon-targeted drug delivery. Finally, we addressed the challenges and future directions to facilitate the exploitation of advanced nanomedicine for IBD therapy.

Self-reported food intolerance, dietary supplement use and malnutrition in chronic inflammatory bowel diseases: Findings from a cross-sectional study in Lebanon

BACKGROUND/AIMS

Chronic inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis are known for a combination of food intolerance, decreased oral intake, and malabsorption which all predispose patients to malnutrition and suboptimal dietary intake. The present study was conducted to 1) examine self-reported food intolerances and dietary supplement use 2) assess nutritional intake 3) assess the nutritional status and screen for malnutrition among patients with chronic inflammatory bowel disease (CIBD).

METHODS

48 patients with CIBDs (28 Crohn's disease, 15 ulcerative colitis and 7 with atypical forms of IBD) took part in this cross-sectional study. Participants completed a food frequency questionnaire targeting dietary intakes and food trends over time. A questionnaire about food intolerance was also used. The nutritional status of patients with CIBDs was evaluated by a detailed history (medical diagnosis and medications and supplements administered) and by using the subjective global assessment (SGA) tool. Anthropometric data including height, weight, and BMI with body composition assessment using automated scales and stadiometer, while Bio-impedancemetry was used to measure body fat and visceral fat. Statistical analysis was conducted using SPSS 27, employing mean values, standard deviations, absolute and relative frequencies and Pearson's chi-square test, with significance set at p ≤ 0.05.

RESULTS

Food intolerance was equally common in all the types of CIBD specifically for dairy products, spicy foods, and high-fiber food items (beans and raw vegetables). Individuals with CIBD were also complaining about meat and chicken products (68%), followed by alcohol and soda (64%) and fish and sea foods (59%). 17% of the patients were malnourished. A significant percentage of malnourished patients with CIBD had to follow a diet outside the flare, had a nutritional follow up, were currently taking corticosteroids and had a severe form of the disease compared to patients who were well nourished.

CONCLUSIONS

This study has contributed valuable insights into the understanding that some food items could be associated to periods of increased disease activity in CIBD patients and that awareness/intervention regarding nutrition must be provided by healthcare professionals (dietitians, physicians…) to decrease the need for second line therapy. In addition, this self-reported food intolerance paper gives an insight for patients on food items usually avoided by CIBD patients during flares.

Current Management of Acute Severe Ulcerative Colitis: New Insights on the Surgical Approaches

Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity. Despite recent advances in medical IBD therapy, colectomy rates for ASUC remain high. A scoping review of published articles on ASUC was performed. We collected data, such as general information of the disease, diagnosis and initial assessment, and available medical and surgical treatments focusing on technical aspects of surgical approaches. The most relevant articles were considered in this scoping review. The management of ASUC is challenging; currently, personalized treatment for it is unavailable. Sequential medical therapy should be administrated, preferably in high-volume IBD centers with close patient monitoring and indication for surgery in those cases with persistent symptoms despite medical treatment, complications, and clinical worsening. A total colectomy with end ileostomy is typically performed in the acute setting. Managing rectal stump is challenging, and all individual and technical aspects should be considered. Conversely, when performing elective colectomy for ASUC, a staged surgical procedure is usually preferred, thus optimizing the patients' status preoperatively and minimizing postoperative complications. The minimally invasive approach should be selected whenever technically feasible. Robotic versus laparoscopic ileal pouch-anal anastomosis (IPAA) has shown similar outcomes in terms of safety and postoperative morbidity. The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) is a recent technique for creating an ileal pouch-anal anastomosis via a transanal route. Early experiences suggest comparable short- and medium-term functional results of the transanal technique to those of traditional approaches. However, there is a need for additional comparative outcomes data and a better understanding of the ideal training and implementation pathways for this procedure. This manuscript predominantly explores the surgical treatment of ASUC. Additionally, it provides an overview of currently available medical treatment options that the surgeon should reasonably consider in a multidisciplinary setting.

BODY FAT COMPOSITION IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES: A COMPARATIVE STUDY BETWEEN SKINFOLDS AND ULTRASONOGRAPHY

BACKGROUND

Inflammatory bowel diseases (IBD) are associated with important changes in nutritional status.

OBJECTIVE

The aim of the study was to compare body fat composition between two anthropometric methods: skinfolds and ultrasonography, in patients with IBD.

METHODS

Single-center cross-sectional study with IBD patients in remission or active disease. For the agreement analysis between the body fat assessment methods, the Bland Altman method was used.

RESULTS

A total of 101 patients with IBD were included, 75 with Crohn's disease and 26 with ulcerative colitis. Approximately 56% of the patients with Crohn's disease and 65.4% of those with ulcerative colitis had a body fat composition above normal levels, with no significant difference between the diseases (P=0.63). The Bland-Altman concordance analysis showed that the methods for assessing the percentage of fat by the adipometer and ultrasound were not in full agreement (P=0.001), despite both presented good correlation (CC 0.961; P=0.000).

CONCLUSION

The analysis of body fat percentage in patients with IBD was different between the skinfolds and ultrasound. Both methods can be used to assess the of body fat percentage of patients with IBD. However, monitoring of body fat sequentially and longitudinally should always be performed using the same method throughout the disease course. Prospective longitudinal studies are warranted to precisely define the role of these two methods of measuring body composition in patients with IBD.

BACKGROUND

• Inflammatory bowel diseases are associated with changes in nutritional status.

BACKGROUND

• Skinfolds measurements and ultrasound are valid methods for assessing body composition and body fat.

BACKGROUND

• These methods despite comparable are not identical and are useful in clinical nutritional practices in IBD.

The effect of percentage of ideal body weight on outcomes in ileo-anal pull through for ulcerative colitis

PURPOSE

Ileo-anal pull through (IAPT) is a commonly performed operation for the surgical management of ulcerative colitis. The effect of body weight on outcomes for patients undergoing this operation has not been extensively studied.

METHODS

This was a prospective cohort study at a single tertiary care inflammatory bowel disease (IBD) center. A total of 457 patients who were operated on at the Mount Sinai Medical Center between 1983 and 2015 were included. Demographic characteristics, the patients' body weight at the time of IAPT, and postoperative outcome data were collected.

RESULTS

For each patient, body weight was calculated as a percentage of the ideal body weight (IBW) for that patient's height. The mean percentage of ideal body weight was 93.9% with a standard deviation of 20%. The range for the population was 53.1 to 175%. Four hundred forty (96%) of the patients had a weight within two standard deviations of the mean, indicating a normal distribution. Seventy-nine patients developed a Clavien-Dindo class III complication necessitating a procedural treatment. The most common of these was a stricture at the anastomotic site (n = 54). Our study identified an association between a percentage of ideal body weight in the lowest quartile of our population and development of an anastomotic stricture. This association was statistically significant on multivariate analysis.

CONCLUSION

Low body weight at the time of ileo-anal pull through for treatment of UC may be a risk factor for development of anastomotic stricture requiring dilation.

Nutritional aspects of inflammatory bowel disease

INTRODUCTION

The number of people diagnosed with inflammatory bowel disease (IBD) continues to increase in most parts of the world. Although the exact etiology of this chronic intestinal disease is not fully understood, nutritional factors appear to play key roles. Furthermore, individuals with IBD are at increased risk of adverse nutritional impacts, including micronutrient deficiencies.

AREAS COVERED

This review aims to summarize recent reports focusing on nutritional factors relevant to the development of IBD and to also review data on nutritional deficiencies seen in individuals with IBD.

EXPERT OPINION

The typical western diet, characterized by high-fat/high-sugar foods, along with food additives, appears to contribute to the etiopathogenesis of IBD. In contrast, some reports indicate that some foods are likely protective. However, there are inconsistencies in the currently available data, reflecting study design and other confounding factors. Furthermore, some of the conclusions are inferred from animal or in vitro studies. The presence of IBD can compromise the nutrition of individuals with one of these disorders: ongoing monitoring is critical. Nutrition and diet in the setting of IBD remain key areas for further and ongoing study.

Diet fuelling inflammatory bowel diseases: preclinical and clinical concepts

The diet and gut microbiota have been extensively interrogated as a fuel for gut inflammation in inflammatory bowel diseases (IBDs) in the last few years. Here, we review how specific nutrients, typically enriched in a Western diet, instigate or deteriorate experimental gut inflammation in a genetically susceptible host and we discuss microbiota-dependent and independent mechanisms. We depict the study landscape of nutritional trials in paediatric and adult IBD and delineate common grounds for dietary advice. Conclusively, the diet reflects a critical rheostat of microbial dysbiosis and gut inflammation in IBD. Dietary restriction by exclusive enteral nutrition, with or without a specific exclusion diet, is effectively treating paediatric Crohn's disease, while adult IBD trials are less conclusive. Insights into molecular mechanisms of nutritional therapy will change the perception of IBD and will allow us to enter the era of precision nutrition. To achieve this, we discuss the need for carefully designed nutritional trials with scientific rigour comparable to medical trials, which also requires action from stake holders. Establishing evidence-based dietary therapy for IBD does not only hold promise to avoid long-term immunosuppression, but to provide a widely accessible therapy at low cost. Identification of dietary culprits disturbing gut health also bears the potential to prevent IBD and allows informed decision making in food politics.

Soybean Meal-Dependent Acute Intestinal Inflammation Delays Osteogenesis in Zebrafish Larvae

Foods are known to be modulators of inflammation and skeletal development. The intestine plays an essential role in the regulation of bone health mainly through the regulation of the absorption of vitamin D and calcium; in fact, inflammatory bowel diseases are often related to bone health issues such as low bone mineral density, high fracture risk, osteoporosis and osteopenia. Considering the complexity of the pathways involved, the use of a simple animal model can be highly useful to better elucidate the pathogenic mechanisms. Soybean flour with a high saponin content has been used in many studies to induce intestinal inflammation in zebrafish larvae. Using a 50% soybean meal (SBM), we analyzed the effects of this soy-induced inflammatory bowel disease on zebrafish larval osteogenesis. Soybean meal induces intestinal functional alterations and an inflammatory state, highlighted by neutral red staining, without altering the general development of the larvae. Our data show that the chondrogenesis as well as endochondral ossification of the head of zebrafish larvae are not affected by an SBM-diet, whereas intramembranous ossification was delayed both in the head, where the length of the ethmoid plate reduced by 17%, and in the trunk with a delayed vertebral mineralization of 47% of SBM larvae. These data highlight that diet-dependent bowel inflammation can differently modulate the different mechanisms of bone development in different zones of the skeleton of zebrafish larvae.