Article by the expert: CA O'Morain
In recent decades, we have witnessed remarkable progress in the understanding of inflammatory bowel disease, from its etiology to its treatment. While anti-inflammatory drugs and immunosuppressants have been the cornerstone of medical treatment, nutrition has emerged as a crucial component in the clinical care of these patients. From correcting nutritional deficiencies to implementing specific dietary regimens, nutritional therapy can play both a supportive and primary role. This article provides a comprehensive review of the role of nutrition in the management of inflammatory bowel disease in adults, exploring its utility in both deficiency correction and primary treatment in specific clinical scenarios.
The pattern and severity of malnutrition in patients with inflammatory bowel disease (IBD) is influenced by the duration, activity, and geographic extent of the disease. Significant differences in the pattern of malnutrition are observed between Crohn's disease and ulcerative colitis, with a higher incidence of protein-energy and nutrient-specific malnutrition in diseases affecting the small intestine compared with those affecting the colon. While patients with Crohn's disease often develop malnutrition on a prolonged basis, those with ulcerative colitis may be well nourished during remission, but may experience acute nutritional deficiency during severe relapse and hospitalization.
IBD involves a variety of vitamin and mineral deficiencies, with diverse clinical implications, especially in bone mineral density, carcinogenesis and associated thrombophilia. Osteopenia and osteoporosis have been identified as major extraintestinal morbidities in patients with IBD. The prevalence of osteoporosis in IBD varies widely, but studies have shown an increased risk of fractures among these patients compared with the general population, particularly among women with Crohn's disease.
Clinicians should maintain a high index of suspicion for malnutrition in patients with IBD in both inpatient and outpatient settings. Nutritional assessment includes a combination of clinical history, physical examination, and laboratory testing. The primary goal of supportive nutrition is to improve the nutritional status of malnourished patients, preferring the enteral route whenever possible.
For patients in remission, a balanced diet with few restrictions is recommended, although a low-fiber diet is suggested to prevent obstructive episodes in patients with stenosing Crohn's disease. During relapses with diarrhea, it is advised to temporarily reduce dietary fiber intake, and in cases of inflammatory bowel disease coexisting with irritable bowel syndrome, a low-fiber diet may be beneficial. However, further prospective studies are needed to evaluate the effect of dietary fiber restriction on abdominal symptoms in patients with IBD in remission.
Adequate calcium intake is crucial for bone health in patients with inflammatory bowel disease (IBD), and a total daily dietary calcium intake of 1.5 g is recommended. In cases of inadequate intake, oral calcium supplements, such as Calcichew-D3 Forte, which provides 1000 mg of calcium and 800 IU of vitamin D, can be prescribed. In addition, vitamin D deficiency should be sought and treated as needed.
Oral folate has also been proposed as a supplement for IBD patients because of its possible effectiveness as an antineoplastic and antithrombotic agent. Although some studies suggest an association between folate deficiency and an increased risk of cancer in IBD, there are currently no prospective studies demonstrating a reduction in cancer risk in colitis following folate supplementation. However, indirect evidence suggests a possible reduction in the risk of neoplasia in patients with ulcerative colitis who receive folate supplementation.
In 1984, dietary replacement of patients with acute Crohn's ileitis with an elemental diet was found to produce remission rates comparable to those obtained with corticosteroids, suggesting an alternative treatment approach to conventional pharmacologic immunomodulation. Although enteral nutrition is well established in the treatment of Crohn's disease in children, its use in adults remains a matter of debate. Several meta-analyses and systematic reviews have examined the efficacy of enteral nutrition in Crohn's disease, including studies in both adults and children.
It is crucial to recognize the central role of nutrition in the comprehensive management of patients with inflammatory bowel disease (IBD). The active involvement of dietitians in the evaluation, counseling, treatment, and follow-up of these patients in both inpatient and outpatient settings is critical to improving clinical outcomes. The focus on nutrition as a primary treatment for IBD is gaining momentum, especially as the adverse effects associated with prolonged corticosteroid use are better understood. Enteral nutrition emerges as a promising option within the rapidly evolving field of nutraceutical immunotherapy. The exploration of a "Crohn's disease-specific formulation" that integrates enteral nutrition, prebiotics, probiotics and growth factors could offer a balanced solution that maximizes treatment efficacy while minimizing toxicity risks. This comprehensive approach reflects a positive evolution in IBD management toward more personalized, patient-centered strategies.
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