1 Nutritional Deficiencies & Management in IBD Kathy Vagianos, RD, MSc Research Dietitian Health Sciences Centre
2 Presentation Overview The Types of IBD Basics of Digestion and Absorption Key Nutrient Deficiencies in IBD Calories, Protein & Fat Calcium Vitamin D Iron Folic Acid Vitamin B12 Electrolytes & Fluid Nutritional Assessment How can a dietitian help? Nutrition Research in Winnipeg Questions & Answers
3 The Different Types of IBD Crohn s disease Crohn s disease can affect the entire digestive tract (mouth small and large intestine). Ulcerative colitis Affects only the large intestine. Active Disease - Flare Up Remission - Inactive Disease
4 The Different Types of IBD con t The natural course of IBD is characterized by flare ups (active disease) alternating with periods of feeling well (remission). Some people have long periods of remission. Others have ongoing flare ups. The course of your IBD affects nutritional status: Inflammation, complications (surgeries, fistulas, blockages), pain, nausea, diarrhea changes in food intake, malabsorption affects nutritional status.
5 Digestion and Absorption You absorb most of the nutrients from your food in the small intestine. The prevalence of nutritional deficiencies has been well documented, especially in Crohn s disease (small intestine).
6 Most Common Nutritional Deficiencies in IBD Calories, Protein & Fat Calcium Vitamin D Iron Folic Acid Vitamin B12 Electrolytes and Fluid
7 Calories, Protein & Fat: Macronutrients Eating adequate calories, protein and fat are essential for maintaining body weight, muscle and fat.
8 Macronutrient Deficiency: Why does it happen in IBD? Decreased intake of food during times of active IBD, pain, nausea, diarrhea, etc lower calories, protein & fat consumed. Common side effect of poor intake: Weight loss
9 Macronutrient Deficiency: What is the risk? Severe weight loss is associated with nutritional deficiencies often ones that can not be seen. Weight loss is linked to poor outcomes for patients going in for surgeries. Fatigue, quality of life.
10 Macronutrient Deficiency: What can you do? What can I do to increase my intake? Nutritional supplements (Ensure, Boost) can be used to replace meals or in between meals. Homemade shakes and nutrient dense soups. Small, frequent meals throughout the day. Eat when you feel well keep emergency foods on hand for flare ups. Protein rich foods: Milk and milk products, meats and alternatives. Avoid fat free, sugar-free, diet products. Combine food groups for a better balance.
11 Canada s Food Guide
12 Calcium Primarily found in milk and milk products. Other food sources exist. Critical nutrient involved in bone health in combination with vitamin D.
13 Calcium Deficiency: Why does it happen in IBD? Lactose Intolerance decreased milk intake. Many patients with lactose intolerance and IBD tolerate some milk products. Having IBD does not increase your risk of lactose intolerance. Controversial data as to whether lactose intolerance is in fact greater among IBD vs. general population. Trigger food Food Avoidance
14 Calcium Deficiency: What is the risk? Osteopenia (soft bones) Osteoporosis (porous bones) Fractures This could be compounded with periodic exposure to steroids osteoporosis.
15 Calcium Deficiency: What can you do? Supplemental calcium to reach a total intake (diet + supplement) of 1500 mg per day may be required depending on your risk. Diet: May require 3-4 servings per day of milk products/alternates: 1 cup milk = 300 mg calcium 1 cup yogurt 1.5 oz hard cheese 1.5 cups ice cream 2 cups broccoli 4 oz tofu 8 oz calcium fortified orange juice 4 oz canned salmon with bones 3-4 oz almonds
16 Vitamin D Involved with calcium in the development and maintenance of bone. Prevention of osteopenia and osteoporosis. Extensive research in vitamin D shows a role in prevention of various disease states.
17 Vitamin D Deficiency: Why does it happen in IBD? IBD Research Study (Winnipeg): 18% patients had vitamin D deficiency (blood). *Deficiency is common across all Canadians. Combination of factors: malabsorption, poor intake, food avoidance (milk).
18 Vitamin D Deficiency: What is the risk? Poor bone health. Evidence linking vitamin D to other diseases (cancer, IBD, MS, IBD flare up?).
19 Vitamin D Deficiency: What can you do? Key sources of Vitamin D: Fish Fortified milk Sunlight Suggest IU per day. Supplementation is most likely needed (in addition to diet).
20 Iron IBD Research Study (Winnipeg): 40% of patients had iron deficiency. Using blood markers: hemoglobin and ferritin. Iron deficiency is the most common nutrient deficiency noted in IBD.
21 Iron Deficiency: Why does it happen in IBD? Iron deficiency can result from: Blood loss (stool). Poor dietary intake (meat products). Chronic disease ( Anemia of chronic disease ). Malabsorption iron is absorbed in the small intestine.
22 Iron Deficiency: What is the risk? Fatigue. Affects your quality of life. Surgical outcomes are poor.
23 Iron Deficiency: What can you do? Iron supplementation should be provided with a documented iron deficiency. Get a blood test. What can I eat? Meat and alternatives to meat (egg yolks, nuts). Red meat are your best sources. Legumes beans, lentils. Grains have some iron combine with vitamin C foods.
24 Folic Acid Folic acid is a B vitamin. Involved with the development of the red blood cell. Blood levels of folic acid are low in IBD (literature).
25 Folic Acid Deficiency: Is it common in IBD? Are patients with IBD really deficient? Use of sulfasalazine or methotrexate reduce the ability of the intestine to absorb folic acid. A deficiency now is rare. Food supply is supplemented with folic acid (late 1990 s). IBD Research Study (Winnipeg): among 250 patients with IBD, 0% deficiency.
26 Vitamin B12 B vitamin involved in the healthy formation of the red blood cell. Common deficiency observed in Crohn s disease.
27 Vitamin B12 Deficiency: Why does it happen in IBD? Absorbed in the ileum of the small intestine (last portion of the small intestine). Ileal resections risk of vitamin B12 deficiency. Active inflammation of the ileum risk of vitamin B12 deficiency.
28 Vitamin B12 Deficiency: What is the risk? Deficiency may have no symptoms, but should be corrected. Can lead to a type of anemia that makes you feel tired. Fatigue and quality of life. Other common symptoms: Memory problems. Difficulty thinking and concentrating. Loss of balance. Numbness or tingling of fingers and toes.
29 Vitamin B12 Deficiency: What can you do? Have your vitamin B12 levels checked. Oral or monthly injections may be needed. Diet alone may not be enough if you are deficient. Food Sources: animal products Fish, meat, poultry, eggs, milk and milk products. Fortified products. Vegetarians are at higher risk for deficiency.
30 Electrolytes and Fluid Potassium, magnesium and phosphate. Hospital patients are supplemented if these are low. Deficiencies may arise depending on: Malnutrition. Severity of fluid loss (diarrhea, fistulas). Lead to dehydration.
31 Electrolytes and Fluid Drink adequate fluid throughout the day All sources of fluids count More of a concern during a flare up. If unable to eat, ensure adequate fluids are consumed. Sports Drinks may be needed in cases of severe fluid losses. Homemade drinks: ½ orange juice, ½ water + salt
32 Nutritional Assessment for IBD Assessment A complete nutritional assessment is essential. A Registered Dietitian can complete the ABCD s of nutrition. Anthropometrics: Weight, height, muscle and fat mass. Biochemical: Blood tests. Clinical: How do you look? Diet: A complete dietary assessment to look at overall diet plus the micronutrients.
33 Nutritional Assessment for IBD: The role of a dietitian There is no diet for IBD. Diets usually are related to functional gut symptoms. Identify and treat nutritional deficiencies via diet and recommend supplements as needed. Symptom management: Constipation, diarrhea, pain. Trigger Foods: What foods are triggers for you? Keeping a food diary. You may be avoiding foods of high nutritional value need to identify a replacement to prevent deficiencies.
34 What has IBD nutrition research in Winnipeg taught us? Most patients in remission have a normal nutritional status, consume adequate calories, protein, fat and carbohydrate. Specific micro nutrient deficiencies can still exist (vitamins and minerals). Active Disease more extensive deficiencies related to inflammation, bowel resections (surgeries), fistulas, blockages.
35 What has IBD nutrition research in Winnipeg taught us? con t Even when there is a healthy weight, nutritional deficiencies can exist either in the diet and / or in the blood. A multivitamin is warranted you can start this even without a nutritional assessment. Homocysteine does not need to be routinely monitored (related to blood clotting and B vitamins).
36 What has IBD nutrition research in Winnipeg taught us? con t In a survey of over 300 patients with IBD, more than 25% always avoid: Nuts and seeds Legumes Deep fried foods Processed meat Alcohol Popcorn Reason for avoiding: Cause gastrointestinal upset that lasts 24 hours.
37 What has IBD nutrition research in Winnipeg taught us? con t Newly diagnosed patients with IBD feel that it is very important to have information on: Diet changes when the disease is active. Risk of nutritional deficiencies. Foods that offer the best nutritional value. However, few patients actually received the information that they needed. Talk to your doctor about seeing a dietitian.
38 Do you have a question?