Mistakes in ... 2021 - 9

ueg education
Mistakes in... 2020
Nonvolitional weight loss
Reduced assimilation
must be paid to the consideration, diagnosis and
optimisation of nutritional status wherever
possible. A 2019 study reported that just over half
of adult patients at high risk for malnutrition in
dedicated IBD treatment centres in the UK and
Greece had nutrition discussed at routine
outpatient visits.46
Nowadays, obesity has become the number
one nutritional issue in patients with established
Crohn's disease.44
Obesity, and sarcopenic
OR
OR
Reduced food intake
Low BMI
+
obesity in particular, are independent risk factors
for osteopenia, more rapid disease progression,
metabolic syndrome and cardiovascular disease.47
The cumulative effects of obesity and systemic
inflammation heighten the cardiovascular risks
in IBD patients, who already have a significantly
increased cardiovascular risk based on disease
status alone. 48
Covert deficits in fat free mass (FFM) and
increased abdominal adiposity are common in
both Crohn's disease and ulcerative colitis
and may persist despite remission.49
These
OR
OR
Muscle loss
Inflammation/
disease burden
important measures may be missed using
common anthropometrics, such as BMI.
Incorporating measures of lean tissue mass-
through simply modifying protocols of frequently
utilised cross-sectional imaging modalities, using
DXA or other surrogate markers-into nutritional
assessment may improve the detection and
management of malnutrition in IBD.
Malnutrition
Figure 1 | Diagnosis of malnutrition. The ESPEN global consensus for diagnosis of malnutrition (GLIM) has
indentified several key features that contribute to the diagnosis of malnutrition.67,68
loss/sarcopenia must not be forgotten.
The role of muscle
acids has epidemiological links with IBD
and has been regarded as having therapeutic
potential-eliciting anti-inflammatory properties
and ameliorating gut inflammation in mouse
models.36
benefit in both Crohn's disease and ulcerative
colitis is lacking.37,38
Red meat consumption has for some time
been regarded as a contributing dietary factor for
relapse in Crohn's disease.39
By contrast, a well-conducted
In a study from Japan,
a semi-vegetarian diet was shown to dramatically
improve remission rates at 2 years versus a regular
omnivorous diet.40
RCT from 2019 in patients with Crohn's disease in
remission showed there were no significant
differences in relapse rates between participants
on a high versus low red meat diet.41
Bottom line: Evidence from animal and
epidemiological studies does not necessarily
equate to efficacy of dietary interventions in IBD
practice. Don't make the mistake of prescribing
or supporting restrictive diets in the absence
of good clinical data and that are potentially
harmful.
Currently, however, evidence for clinical
Mistake 7 Missing malnutrition in patients
with IBD
Malnutrition, both undernutrition and overnutrition,
should be considered as a systemic
and serious complication of IBD and should not
be overlooked (figure 1).42
It may be present in
approximately 2 out of every 3 patients with IBD,
but is more common in those with new-onset
disease.43
In hospitalised patients, malnutrition is
a risk factor for multiple comorbidities, including;
infection, thromboembolism, emergency surgery,
prolonged length of stay and mortality, although
this may be related to its association with
disease severity.44
For children, the effects of malnutrition on
puberty and growth velocity are well described
and may have translational effects that persist into
adulthood. Growth failure is present in 15-40% of
paediatric IBD patients.45
Specific attention
Bottom line: Obesity is now the overwhelming
nutritional problem in patients with IBD. Sarcopenic
obesity especially should be considered a key
comorbidity that needs to be managed. Regular
dietetic multidisciplinary team involvement
is key and measures of lean tissue mass may
be targeted to improve nutritional and overall
outcomes.
Mistake 8 Not taking the inflammatory
state into account when assessing
micronutrient deficiency
Vitamin and trace element (VTE) deficits are
often only clinically apparent when stores are
already significantly depleted. Interpretation of
clinical signs and laboratory biomarkers can be
challenging and misleading. Interpretation of
serum levels is complicated by the frequent
co-existence of a systemic inflammatory response,
which may lead to the erroneous diagnosis of VTE
deficiencies.50
The variations can be extreme
(figure 2).51
Aside from ferritin and ceruloplasmin,
VTE levels are often grossly underestimated,
particularly for selenium, zinc, vitamins A, B6, C
and D. Levels for selenium, B6 and C may be
significantly depressed, with CRP levels as low
as 5-10mg/L. Results must be interpreted in
parallel with CRP and albumin levels and the
current clinical state. Unless the specific context
dictates, avoid the temptation to give megadoses
acutely to replace low levels and ideally assess
27
Proteins
Carbohydrates
Fats
Vitamins
Minerals
Mistakes in ... 2021

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