LAS VEGAS — Malnutrition in patients with inflammatory bowel disease poses risks for disease progression and surgical complications, but careful screening and proactive nutrition management can help, according to an expert presenting at the Crohn’s and Colitis Congress 2019.
“How do you know if your patient is at nutrition risk and would benefit from a referral to a dietitian? We should be screening our patients,” Kelly Issokson, MS, RD, CNSC, from Cedars Sinai, said during her presentation. “All you need to do is ask them two simple questions: have you lost weight recently without trying and are you eating less because of a poor appetite. If they say ‘Yes’ to any of those questions, you really should be referring to a dietitian.”
Issokson touched on the various areas in which a patient can be deficient in nutrition or nutrients and where a physician can intervene to improve care, emphasizing that macronutrient needs increase with disease activity, wounds, fistula and surgery.
“Even in our patients who had what would seem like a small weight loss ... that’s going to increase our risk for surgical complications,” she said. “Something that may not seem like a big number could have a big impact on your patient surgically.”
In the ERAS (enhanced recovery after surgery) plan, patients undergo “prehabilitation” where they receive preoperative counseling and nutrition optimization. Oral nutritional supplements, Issokson said, are linked to reduced infections while carbloading with 100 g of carbohydrates 6 hours prior to surgery and 50 g with a clear liquid around 2 hours prior attenuates the catabolic response postoperatively. Issokson noted that carbloading should be avoided in certain conditions like gastroparesis.
Postoperatively, patients with IBD should minimize narcotic use and be encouraged to be mobile.
Outside of surgical preparation and recovery, Issokson said, “When you find your patient is not able to meet their nutrition goals by mouth – say they are eating less than 60% of their energy needs or they are continuing to lose weight despite perceived adequate intake – first consider oral nutrition supplementation. Recommending ONS to my patients three times a day about an hour after their scheduled meals helps them get the additional nourishment, they need to maintain their weight ... but if they still can’t meet their nutrition needs, you might want to consider nutrition support.” Issokson also discussed micronutrients that should be considered when caring for a patient with IBD. Iron, B12, B9, B6, zinc and fat-soluble vitamins can be deficient in IBD. Vitamins like B6 are low in 26% of patients with IBD and can contribute to risk for deep vein thrombosis. Up to 100% of patients with IBD are low in vitamin D, she added, which has been inversely associated with disease activity and positively associated with quality of life.
Bone health, fiber intake and dairy avoidance should also be monitored in patients with IBD, Issokson said.
“Malnutrition is common in IBD and we know that it is a predictor of poor prognosis in our hospitalized IBD patients but I don’t think we do a great job about identifying and treating malnutrition in our patients and we know it also leads to things like growth failure, decreased response to pharmacotherapy, increased risk for sepsis and increases our patients’ morbidity and mortality,” she said. – by Katrina Altersitz
Issokson K. Nutritional Therapy for IBD: From Theory to Your Practice. Presented at: Crohn’s & Colitis Congress; Feb. 7-9, 2019; Las Vegas.
Disclosures: Issokson acts as a consultant for AGA, Crohn’s & Colitis Foundation, Academy of Nutrition and Dietitics, and the United Ostomy Association.