PHILADELPHIA—Withholding diet from patients with inflammatory bowel disease hospitalized with a flare is common practice but does not appear to improve their outcomes and may be unnecessary, especially in those who are especially prone to malnutrition, according to new research.
To estimate the frequency of dietary withholding in hospitalized IBD patients and gauge its effect on IBD-related outcomes, researchers conducted a retrospective study of patients hospitalized with flares at eight different hospitals between 2015 and 2020.
After excluding patients hospitalized with obstruction, active intraabdominal fistula, new diagnoses of IBD and those undergoing elective surgery, researchers identified 337 patients: 148 with Crohn’s disease, 185 with ulcerative colitis and four with unidentified IBD.
“Thankfully, at our hospitals, a lot of IBD patients get a nutritional assessment when they’re admitted,” said Vincent Phan, MD, a second-year internal medicine resident at The University of Texas at Austin Dell Medical School, who presented his team’s research as a poster at ACG 2024 (P4290). About 40% of the patients evaluated by a registered dietitian were diagnosed with malnutrition, he added.
Dr. Phan and his co-investigators calculated time spent nil per os (NPO) or on a clear liquid diet (CLD) as a percentage of each patient’s length of stay and divvied them into quartiles ranging from lowest to highest amount of time NPO/CLD. Diet was withheld from 91% of patients, and the average length of time NPO or CLD comprised about one-third of their hospital stays.
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In most cases, the reasons for keeping patients NPO/CLD were not entirely clear, Dr. Phan said. “Nausea and vomiting were specified in one or two patients and abdominal pain was specified in another one or two, but for the most part, it was flare symptoms for over 95% of the patients.”
Comparing the highest and lowest quartiles of time spent NPO/CLD, the researchers found no differences in 30- or 90-day readmission, in-hospital mortality, inpatient treatment with a biologic or need for unplanned surgery.
“A lot of these patients with IBD are at very high risk for malnutrition. Many of them are admitted with a diagnosis of malnutrition. By withholding diet unnecessarily, we’re putting them at increased risk,” Dr. Phan said.
He acknowledged that hospitalized IBD patients often undergo colonoscopy as part of their evaluation, and that clinicians often might err on the side of caution and withhold food in preparation for that procedure. “But it might take two or three days before that happens,” Dr. Phan said, “and we just keep them starving.”
The researchers concluded that empiric bowel rest for hospitalized IBD patients is unnecessary. Patients should be fed and their gastrointestinal evaluation expedited.
Carolyn Newberry, MD, the director of the GI nutrition program at Weill Cornell Medical Center, in New York City, said keeping food from patients is common across the board—not just in IBD patients—and that can be problematic from a nutritional perspective.
“We’re definitely concerned when patients have prolonged NPO, and multiple studies have shown this is a problem in hospitalized patients, whether it’s withholding their diet in anticipation of a procedure that gets postponed or they have a symptom that takes a while to be evaluated and, using an abundance of caution, we put them on a restrictive diet,” she said.
Dr. Newberry also noted that IBD patients who are sick enough to require hospitalization are especially prone to develop malnutrition due to the effect small bowel inflammation has on absorption.
“It’s very important to recognize that this is a common practice in the hospital for IBD patients. We withhold diets much more often than we really should, and that can impede their ability to get better,” she said, pointing out that old data supporting withholding food in IBD patients with a flare have come under some scrutiny, with many patients with active inflammation benefiting from continued feeding.
Dr. Newberry applauded Dr. Phan’s group on conducting their research and shedding some light on the topic. “I think it’s great that people are recognizing the role of malnutrition in patients’ critical care plans.”
This article is from the December 2024 print issue.