Nutrition Research in Inflammatory Bowel Disease

Kathy Vagianos is a Research Dietitian at the Health Sciences Centre. She has collaborated with the IBD Clinical and Research Centre since 2002 on research projects that involve nutritional assessments and IBD as described below:

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1. Nutritional Assessment of Patients with Inflammatory Bowel Disease.

The results of this study have been published in Journal of Parenteral and Enteral Nutrition (2007) 31:311-319

 http://www.ncbi.nlm.nih.gov/pubmed/17595441

Background of the project:
It has been well documented that nutritional deficiencies exist among patients with IBD. In order to assess nutrition status comprehensively, body composition, dietary intake, energy expenditure and biochemical indices of nutritional status all need to be measured. Interestingly, when we reviewed the literature prior to 2002, there was no study that looked at all these measurements.

Objectives: This study was conducted between 2002 and 2005. We set out to examine the nutrient intake of individuals with Crohn’s disease and ulcerative colitis in relation to the recommended nutrient intake values, anthropometric measures and blood markers of nutrition to determine the extent to which reduced food/nutrient intake contributes to the nutritional deficiencies seen in this population. We also aimed to compare the nutritional intake of crohn’s vs. colitis and those with active disease vs. inactive disease.

Results: 126 patients with IBD from our outpatient gastroenterology clinic at the Health Sciences centre enrolled into our study. Each patient met with the research dietitian and had a complete nutritional assessment conducted which consisted of: weight, muscle mass and body fat measurements; each patient provided a 4 day food diary that was analyzed for nutritional content; blood tests were conducted to measure albumin, protein, hemoglobin, vitamin B12, ferrite, folate, carotene, zinc, vitamin A and vitamin B6; and each patient had their energy requirements measured using a metabolic cart.

Key findings: A key finding from this project was that patients with IBD appeared well nourished according to their body weight and that the majority of our patients were within a healthy weight range with no differences between those with active disease and those in remission. However, several nutrient deficiencies were observed in the blood of our patients namely, iron, vitamin B6 and vitamin D. We found that 40% of our patients had iron deficiency, 29% of our patient had vitamin B6 deficiency and 18% of our patients had vitamin D deficiency in their blood.  In addition to blood measures, there were a large percentage of patients who consumed inadequate amounts of vitamin E, vitamin D, vitamin A, calcium, folate, iron and vitamin C from their diet.

Our recommendations based on our study results are that although patients with IBD presenting to an outpatient clinic may seem well nourished, they may have deficiencies in the diet and in the blood that can not be detected without a thorough assessment.  A multivitamin supplementation is warranted in IBD in view of the several nutrition deficiencies observed via both blood and dietary markers, regardless of the disease type or disease activity. Patients with IBD should be aware of these potential nutritional deficiencies and should be assessed by a dietitian and / or screened and treated for any nutritional deficiencies with diet and/or supplements.

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2. Homocysteinemia and B Vitamin Status among Adult Patients with Inflammatory Bowel Disease: A one year prospective follow up study. Inflammatory Bowel Diseases 2012;18:718-24.

The results of this study have been published in Inflammatory Bowel Diseases (2011): http://www.ncbi.nlm.nih.gov/pubmed/21604334

The “homocysteine and vitamin B study” was the follow up study to our nutritional assessment study and was conducted between 2007 and 2009.

Background of the project:
High levels of homocysteine have been noted to be an established risk factor for “blood clotting.” The breakdown of homocysteine and “clearing from the blood” requires B vitamins, namely B12, B6 and folic acid. Patients with IBD have been shown to have higher levels of homoycysteine levels and also lower levels of B6 and B12. We set out to study whether homoycysteine levels and B vitamin levels fluctuate with disease activity and dietary assessment among our IBD patients.

Results: 100 patients with IBD enrolled in the study and were asked to see the research dietitian 3 times over the course of one year. At each appointment, blood tests were taken to measure B vitamins and homocysteine levels. Also, disease activity (Flare up of IBD vs. IBD in remission) was recorded. Patients provided a 3 day food diary that was analyzed for B vitamin intake.

We reported that 10 of our subjects had high homocysteine levels at enrollment and 13 had high levels at least once during the study. We showed that our patients overall had a lower existence of hyperhomocysteine compared to what is reported in the literature which could be argued that we have a healthier IBD group compared to other studies (as also noted in our 2007 publication).

We also report a 0% deficiency for folic acid in our patients which may be due in part to the mandatory folic acid supplementation of our food supply in Canada since the late 1990’s.

Overall homocysteine levels did not fluctuate over time and with disease activity and so we support that routine measuring of homocysteine is not warranted. We confirmed in this study that approximately 30% of our patients have vitamin B6 deficiency however there is no correlation of this to homocysteine. The rationale behind this remains unclear.

3. A Comparison of food intake among patient with IBD vs. the healthy Canadian population.

A food frequency questionnaire developed for a large Canadian national health survey (Canadian Health Measures Survey) was integrated into the IBD cohort study. Our goal was to examine the food intake among adults with IBD in comparison to the non IBD Canadian population. Although we are currently in the process of analyzing the responses, preliminary analysis shows that: 1) Patients with IBD consume red meat, salt water fish, shellfish, eggs, dried beans, nuts, pasta, rice, fruit, tomatoes/tomato sauce, salad, fried potatoes, potato chips and fruit juices less often than healthy Canadians; and 2) Patients with IBD consume sausages and bacon, fresh water fish, milk, cottage cheese spinach, diet soft drinks and water more often than the healthy population. How all of this data translates into nutritional implications is currently being analyzed by our group.

Another area we investigated was the relationship of dietary sugar and IBD disease activity. It is thought that increased dietary sugar may be associated with a flare up of IBD. The IBD cohort was asked to report from a list of high sugar foods, how much of each food item they regularly consumed. Our preliminary results show that the amount of ingested sugar through consumption of sweetened beverages (sports drinks and sweetened drinks – excluding soft drinks/pop) is greater among those with recently active IBD compared to those with inactive disease. Whether increased sugar intake is a marker for another dietary excess or deficiency, a product or contributor to disease flare up, or if there are associated changes in bowel micro flora resulting in increased symptoms all warrant further investigation.

Duerksen DR, Fallows G, Bernstein CN. Vitamin B12 malabsorption in patients with limited ileal resection. Nutrition 2006; 22: 1210-1213.

Patients with Crohn’s disease who have terminal ileal resections are at risk for vitamin B12 malabsorption. Vitamin B12 is important for maintaining nerve function and red blood cells. This study was led by Dr. Don Duerksen. One can become vitamin B12 deficient if too much ileum is removed because that is the site of vitamin B12 absorption.

The length of small bowel removed for those who had Crohn’s related surgery (56 patients) was determined by review of their pathology report. Patients who had a Schilling test (a test used to determine the nature of vitamin B12 malabsorption) within 3 month of surgery or who had a documented normal terminal ileum at the time of the Schilling test were included in the study. Of the 14 patients who had <20 cm of terminal ileum removed, none developed an abnormal Schilling test results. Of the remaining 42, 52% had abnormal Schilling test results but there was no clear correlation between resection length and abnormal Schilling test result. This study concluded that patients with Crohn’s disease and terminal ileal resections <20 cm are not at risk of developing vitamin B12 deficiency. For patients with resections of 20-60 cm, options include doing a Schilling test and treating those with abnormal results, or empirically treating patients on the presumption that they are at high risk of developing deficiency, or monitoring for biochemical evidence of deficiency.

Further studies are needed to determine whether oral supplementation is effective in these patients