3. Overview
• Inflammatory Bowel Diseases
(IBD)
• 1 million Americans are affected
• 2 major forms
– Crohn’s Disease
– Ulcerative Colitis
• Differences?
Source: NIDDK website
– Both cause inflammation in intestines
– Ulcerative Colitis: generally affects lower bowel (colon
and rectum)
– Crohn’s Disease: ANY portion of the GI tract
4. Causes of Symptoms
• Unknown – Genetics? Environmental factors?
• Associated with
–
–
–
–
–
Osteoporosis, Low vitamin K may cause osteopenia.
Malnutrition
Altered immune function; Arthritis
Gallstones
Liver disease
• Symptoms
–
–
–
–
Abdominal pain, diarrhea, fever
Inflammation in the eyes or mouth
Oral aphthous ulcerations, pyroderma gangrenosa
Fistula
6. Nutrition Management
• 60-70% of patients with Crohn’s disease
experience malnutrition.
• Food avoidance / Food aversions and
Misinformation / Confusion about Food are
prevalent in patients with IBD.
• Potential nutrient deficiencies of IBD include:
– Energy, Protein, Fluid, Electrolytes, Iron,
Magnesium, Calcium, Vitamin D, Vitamin B12,
Folate, Copper, Zinc, Vitamin A
7. Nutrition Management
• No diet has been specified for prevention or treatment of
Crohn’s disease.
• Dietary recommendation must be individualized to Pt’s
needs/risk based on the nutrition assessment.
• Energy
– Estimated energy range for adults 25-35 kcal/kg, depending on
disease state
• Protein
– 1.0 – 1.5 g/kg/d, depending on disease state
• Vitamins
– Use DRIs, Pts may need higher levels of Vitamin B12, Folate,
Thiamin, Riboflavin, Niacin, Vitamin C, E, D, and K
• Minerals
– Use DRIs, Pts may need higher levels of Zinc, Magnesium,
Selenium and Potassium
8. Nutrition Management
• During exacerbation:
– Nutrition support: Enteral feedings or TPN
– Return to normal diet, progress to low-fat, lowfiber, high-protein, high-kilocalorie, small,
frequent meals
– Vitamin/Mineral Suppl. Include: Vitamin D, Zinc,
Calcium, Magnesium, Folate, Vitamin B12, Iron
9. Primary Research
• Benjamin J, et al. Glutamine and whey protein
improve intestinal permeability and
morphology in patients with Crohn's disease:
a randomized controlled trial. Dig Dis Sci.
2012;57(4):1000-12.
10. Glutamine and whey protein improve
intestinal permeability
• Background
– Increased intestinal permeability (IP) has been
implicated in the disease activity and relapse of
Crohn’s disease.
– Glutamine is the major fuel and nitrogen source for
the enterocytes.
• Hypothesis
– Does oral glutamine supplementation improve IP in
patients with Crohn’s disease? What are the effect of
glutamine on IP and intestinal morphology Crohn’s
disease?
• Study Design
– A Randomized, Controlled Open-Label Trial
11. Glutamine and whey protein improve
intestinal permeability
• Inclusion criteria
– Pt’s with Crohn’s disease in remission phase
• Exclusion criteria
– Pt’s with Crohn’s disease in active phase, taking protein suppl.,
associated systemic diseases such as liver disease, kidney
disease, DM
• Groups(0.5 g/kg ideal body weight / day)
– 1. Glutamine group (GG) – Oral glutamate
– 2. Active Control Group (ACG) – Whey Protein
• Duration
– 2 months
• Method
– IP was assessed by (1) lactulose mannitol excretion ration (LMR)
in urine and (2) morphometry
12. Glutamine and whey protein improve
intestinal permeability
162
132
Glutamine
(n=15)
(n=14)
(n=30)
Whey Protein
(n=15)
(n=14)
13. Glutamine and whey protein improve
intestinal permeability
• Primary Outcome Parameters
– Improvement in intestinal permeability (IP) was
assessed by measuring lactulose mannitol
excretion ration (LMR)
• Secondary Outcome Parameters
– Changes in the intestinal morphology
– Changes in plasma glutamine levels
14. Glutamine and whey protein improve
intestinal permeability
Lactulose Mannitol Excretion Ration (LMR)
Median
0.071
0.029
Glutamine
Median
0.067
0.033
Whey Protein
15. Glutamine and whey protein improve
intestinal permeability
Significant increase in
Villous Crypt Ratio (VCR)
GG:
Baseline 2.33
2 mo 2.68
ACG:
Baseline 2.26
2 mo 2.49
Decrease in
Intra Epithelial Lymphocytes
(IELs)
16. Glutamine and whey protein improve
intestinal permeability
• Plasma Glutamine
– No significant difference in Pts and HC (Healthy
Control) at baseline and at the end of 2 months
• Activity
– Two patients in each group went to the active
phase from the remission phase
• Adverse Reaction
– 7 from Glutamine group and 2 from Whey group
had an increase of stool frequency.
17. Glutamine and whey protein improve
intestinal permeability
• Conclusion
– Showed glutamine as well as whey protein
improved IP and mucosal structure.
– Suggested glutamine is as effective as a high
protein diet to improve IP of Crohn’s disease
patients.
18. References
1.
MedlinePlus: Crohn's Disease. U.S. National Library of Medicine National
Institutes of Health. Web site. Accessed on October 29, 2013.
www.nlm.nih.gov/medlineplus/tutorials/crohnsdisease/ge159105.pdf.
2.
Crohn's Disease. National Digestive Diseases Information Clearinghouse (NDDIC).
Web site. Accessed on October 29, 2013.
http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/
3.
Moorthy D, Cappellano KL, Rosenberg IH. Nutrition and Crohn's disease: an
update of print and Web-based guidance. Nutr Rev. 2008;66(7):387-97.
4.
Nutrition Care Manual: Crohn's Disease & Ulcerative Colitis. Academy of
Nutrition and Dietetics. Web site. Accessed on October 29, 2013.
http://nutritioncaremanual.org/topic.cfm?ncm_toc_id=19449
5.
Wiese DM, Lashner BA, Lerner E, DeMichele SJ, Seidner DL. The effects of an oral
supplement enriched with fish oil, prebiotics, and antioxidants on nutrition
status in Crohn's disease patients. Nutr Clin Pract. 2011;26(4):463-73.
19. Thank you for your attention.
Please let me know if you have questions.
Notas do Editor
A group of conditions known as inflammatory Bowel DiseasesCrohn’s diseases are inflammatory condition of the gastrointenstinal tract
Cause is unknown but researchers believe it is the result of an abnormal reaction by the body’s immune systemGenetics – more prevalent in Jewish population.Environmental factors – Antibiotics, NSAIDs, Infectious agents, Stress, Diet, SmokingOral aphthous ulcerations: Recurrent oral ulcerationPyrodermagangrenosa: a condition that causes tissue to become necrotic, causing deep ulcers that usually occur on the legs. Fistula is an abnormal connection between two organs or between an organ and the outside
Factors that will influence nutritional requirements are;Severity of disease, Extent of stool output, malabsorption, etc., current medication regimen, previous medical and surgical history, quality and quantity of nutrient intake
Total Parental Nutrition
Increased IP is a common feature in Pts with CD (about 30-65%) It is suggested as a marker of impending relapseMagnitude of alteration in IP correlates with the activity of the disease
The total energy requirement was supplied in the form of 20 % from protein, 55 % from carbohydrate, and 25% from fats.1/3 (0.5 g/kg IBW/day) of the protein requirement was supplied in the form of glutamine or whey protein
All the patients were treated with standard drug regimen.
Intra epothelial lymphocytes (IELs) are seen in the epithelium as darkly stained nuclei
