Correcting the harms of malnutrition in inflammatory bowel disease often leads to better response to biologic therapies and shorter hospital stays, so physicians should screen every IBD patient for malnutrition risk and conduct a more rigorous assessment on anyone identified as high risk, according to speakers at the ASPEN 2024 Nutrition Science & Practice Conference.

“Sarcopenia, obesity, undernutrition and micronutrient deficiencies are all components of malnutrition. It’s not just your underweight patient,” said Stephanie Gold, MD, an assistant professor of medicine and a gastroenterologist at the Icahn School of Medicine at Mount Sinai, in New York City.

Although the rates of obesity are rising in patients with IBD, Dr. Gold said, patients with Crohn’s disease and ulcerative colitis are commonly underweight due to surgeries that reduce absorptive capacity, or symptoms such as diarrhea that result in high enteric loss.

Every IBD patient seen in the Mount Sinai IBD center is screened for malnutrition using the validated Malnutrition Universal Screening Tool (MUST) (Br J Nutr 2006;95[2]:325-330), Dr. Gold said. The MUST includes a body mass index less than 18.5 kg/m2, but higher BMIs also can mean malnutrition if a patient had unplanned weight loss in the last three to six months or is unlikely to eat for at least five days.

image

Anyone found at risk for malnutrition based on the MUST undergoes assessment with the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria to determine whether they are malnourished (Front Nutr 2022;9:826028).

“The GLIM is much more comprehensive compared to other malnutrition diagnostic tools, because it isn’t solely based on BMI or weight loss. It also includes metrics of muscle health/sarcopenia, as well as the etiologic criteria of reduced intake or chronic inflammation,” Dr. Gold said.

Micronutrient deficiencies commonly are measured in blood serum, which Dr. Gold noted are not perfect because chronic inflammation associated with IBD may depress or increase micronutrient levels artificially. But if micronutrient levels appear low, physicians can offer multivitamins or specific nutrient supplements and test again until levels are normal.

“Sarcopenia is not related to BMI,” Dr. Gold stressed, noting that two different people with the same BMI can have different muscle mass. A handgrip test is a functional diagnosis of sarcopenia, Dr. Gold said, but a complete diagnosis should include either an ultrasound or CT of someone’s underlying muscle.

“Resistance training and higher protein diets are great tools for combating sarcopenia,” Dr. Gold said. For IBD patients who are underweight, changing the texture of restricted foods to make them more easily tolerated—moving from whole berries to a berry smoothie, for example—can be helpful for gaining weight and adding variety back to the diet.

“Enteral nutrition formulas can be useful for some patients as well,” Dr. Gold said, either temporarily or for an extended time, depending on how well people can absorb nutrients from eating and their weight-restoration goals.

Nutritional Considerations For IBD Surgery

Some people with IBD—around 7% of people with ulcerative colitis and 18% with Crohn’s disease—will require surgery within five years of diagnosis (Clin Gastroenterol Hepatol 2021;19[10]:2031-2045). Surgery presents unique nutritional challenges, particularly for patients who already are malnourished.

“A lot of IBD patients who come in for surgery have been malnourished potentially for months, some even have a BMI as low as 13 to 15,” said speaker Christina Fasulo, MS, RD, CNSC, the GI senior dietitian in the Division of Digestive Diseases at the Ronald Reagan UCLA Medical Center, in Los Angeles.

For most patients, a high-protein diet with oral nutrition supplements should be started within 24 hours of surgery instead of remaining NPO (nothing by mouth) or on clear liquids. As a rule of thumb, patients should aim for a range 25 to 30 kcal/kg of calories and 1.2 to 2 g/kg per day after surgery, Ms. Fasulo said, but these goals must be customized to the patient’s anatomy.

Ms. Fasulo said she encourages postoperative patients to eat slowly and chew thoroughly, eating protein and fruits with vegetables, as well as grains that have soluble fiber, with texture or particle size modifications, if tolerated. She recommends customizing this advice based on which parts of the gut remain. For example, removing the terminal ileum makes it harder to absorb vitamin B12, leading to the potential need for daily sublingual B12 supplementation or monthly injections.

For patients who can’t eat normally or are deeply malnourished, enteral nutrition is the first choice. “Let the gut do its work. Enteral nutrition is lower cost and has fewer complications than parenteral nutrition. But if a patient is meeting less than 60% to 75% of their nutritional needs by 10 days after surgery, adding on parenteral nutrition can help ensure patients are being fed adequately to aid in recovery,” Ms. Fasulo said.

She noted that preoperative fasting can be of short duration, with clear liquids safe to consume up to two hours before surgery and solids safe until six hours prior to receiving anesthesia (Anesth Analg 2018;126[6]:1883-1895). Carbohydrate loading—100 g of carbohydrates the night before surgery and 50 g as a clear liquid two to three hours before—could potentially preserve muscle mass and lead to a reduction in insulin resistance after surgery (Clin Nutr 2005;24[1]:32-37).

“Some of my patients worry that adding these carbs will spike their blood sugars,” Ms. Fasulo said. “But I tell them it’s like training for a marathon.”

—Marcus A. Banks

Ms. Fasulo reported no relevant financial disclosures. Dr. Gold reported a financial relationship with Nestlé and Nutritional Therapy for IBD.

This article is from the August 2024 print issue.