Nutritional Regulation: Inflammatory bowel disease is an umbrella term used to describe a group of gastrointestinal diseases characterized by chronic, ongoing inflammation of all or part of the gastrointestinal tract, or GI tract, such as Crohn’s disease, or CD, and ulcerative colitis, UC. While many factors have been determined to cause inflammatory bowel disease, research studies have concluded that nutrition can increase the risk of gastrointestinal diseases, including inflammatory bowel disease.
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How does nutrition affect inflammatory bowel disease?
Nutrient deficiencies are common among individuals with inflammatory bowel disease, or IBD. Both complete parenteral and enteral nutrition can provide significant supportive treatment for patients with IBD, however, in adults those alone may not be helpful as a form of primary treatment. Clinical intervention using omega-3 polyunsaturated fatty acids found in fish oil could be beneficial for the nutritional regulation of IBD patients and recent research studies have emphasized the function of PPAR on NF?B action towards its possible beneficial impact on dietary lipids for overall intestinal functioning.
Nutrition in Inflammatory Bowel Disease
Specific antibody isotypes of essential milk proteins are located in both UC and CD patients. In CD, the antibodies are associated with disease. Although cultural origin, rather than the IBD disease condition, seems to be the primary cause of lactose intolerance, the avoidance of milk products by IBD patients is extensive. Lack of breast-feeding during infancy was associated with CD but not UC. Additionally, higher carbohydrate intake was recorded in CD. Others have suggested a deficiency of dietary fiber as a predisposing factor for IBD. The growth of UC has also been associated with higher intakes of polyunsaturated fatty acids (MUFA), n6 polyunsaturated fatty acids (n6 PUFA), sulphur-containing diets and vitamin B6.
Deficiencies: Nutritional Regulation
Inflammatory bowel disease is related to several nutritional deficiencies, such as anemia, hypoalbuminemia, hypomagnesia, hypocalcemia and hypophosphatemia, including deficiencies in folic acid, niacin, vitamins A, B12, C, and D, in addition to deficiencies of iron, magnesium and zinc. Further research studies are needed to determine if reduced levels of micronutrients are of some significance to the result of gastrointestinal diseases. Plasma antioxidant concentrations are lower in IBD patients, especially those who have an active form of the disease. Antioxidant action, evaluated by measuring selenium levels and erythrocyte glutathione peroxidase activity, is inversely associated with inflammatory biomarkers, such as TNF?. Hyperhomocysteinemia is more prevalent in patients with IBD, and is characterized with low serum as well as reduced concentrations of vitamin B12, folate and B6.
Several mechanisms are responsible for the malnutrition observed in IBD patients. Primarily, there’s a decline in the oral consumption of nutrients due to abdominal pain and anorexia. Second, the mucosal inflammation and related diarrhea reduces blood, protein, minerals, electrolytes and trace components. Paradoxically, multiple resections or bacterial vaginosis might have an adverse nutrient impact; and finally, herbal remedies may also cause malnutrition. By way of instance, sulfasalazine reduces nitric acid absorption, and corticosteroids reduce calcium absorption in addition to negatively impacting protein metabolism. Alterations in energy metabolism may result in increased resting energy expenditure and lipid oxidation in patients with inflammatory bowel disease. There are many effects of malnutrition and each can decrease bone mineral density, in addition to growth retardation and delayed sexual maturity in children. Osteoporosis may also be involved as a consequence of pro-inflammatory cytokine profiles.
Nutritional treatment may take on a range of forms including Total Parenteral Nutrition (TPN) and Complete Enteral Nutrition (TEN). The diets used are elemental, polymeric, and exception diets. Elemental diets contain nutrients reduced to their fundamental elements: amino acids, such as proteins, sugar for carbs, and short-chain triglycerides, such as fats. Polymeric formulas contain entire proteins, such as nitrogen, glucose polymers for carbs and long-chain triglycerides for fat or starch.
Total Parenteral Nutrition (TPN)
Using TPN for the nutritional regulation of IBD is based on specific theoretical benefits, including how: gut rest may be beneficial since it reduces motor and transportation function in the diseased intestine; a drop in antigenic stimulation can remove the immunologic reactions to food, particularly in the presence of diminished intestinal permeability; TPN promotes protein synthesis in the gut which provides cell renewal, recovery, and alteration of impaired immunocompetence.
Researchers demonstrated remission rates of 63 percent to 89 percent with TPN in a large retrospective collection of CD patients which were difficult in standard medical management. But, Matuchansky et al highlighted that there have been high relapse rates (40%-62%) after two decades. It’s been implied that TPN be utilized exclusively in a nutritionally supportive function. In UC, there’s absolutely no evidence for much better results with TPN. Though remission rates of 9 percent to 80 percent are reported, TPN provided to patients with acute colitis seems to be beneficial as perioperative nutritional support. In patients with moderate disease, TPN is significantly more successful but isn’t better than steroid treatment, and so the invasiveness and price of TPN are unjustified. Any advantages related to TPN might be due to the nutritional regulation, rather than gut rest, as gut rest alone has no impact on disease activity. Accordingly, though TPN has a function in patients using a non-functioning gut or the brief gut syndrome because of excess resections, TPN is of limited use as a primary treatment in IBD. This isn’t designed to be an extensive breakdown of TPN, but it needs to be cautioned that in specialist centers, TPN is associated with complications like sepsis and cholestatic liver disease.
Total enteral nutrition (TEN), Elemental & Defined Formula Diets
TEN prevents possible toxic dietary variables and antigenic exposure, because there are only amino acids, sugar or oligosaccharides and very low lipid content. TEN isn’t associated with cholestasis, biliary sludge or gallstone formation, as can be observed with TPN. Atrophy of the small intestinal mucosa was discovered in animal models receiving long-term TPN, yet this atrophy is prevented with TEN. Additionally, a 6-wk TPN therapy in dogs led to marked decrease in pancreatic fat, a reduction in small intestinal mass as well as a decline in intestinal disaccharidase activity in puppies. Because of this, TEN is more preferable than TPN.
The subject of nutrition in gastrointestinal disorders which occur in IBD has been recently reviewd. In comparison to TPN, enteral nutrition yielded similar outcomes towards preventing and combating malnutrition. Though Voitk et al suggested that elemental diets could be an effective treatment for IBD, enteral nutrition as a primary therapy has failed to produce consistent results in several clinical trials. It’s correct that quite a few trials have shown remission levels in CD patients getting elemental diets, like the rates observed with prostate cancer treatment. But, it’s important to note that greater remission rates were detected in patients receiving steroid therapy versus standard diets when including all of the diet category fall outs (i.e., in an intent-to-treat foundation). The question remains concerning the best means of assessing the results when a sizable proportion of individuals receiving diet treatment fall out due to unpalatibility or intolerance. What’s more, a few research studies have demonstrated no distinction with elemental diets compared to steroid treatment. In children, elemental diets have been associated with higher linear gain, whereas in adults those diets maintain nitrogen equilibrium. The use of supplements in the context of pediatric onset illness was also reviewed. Therefore, enteral nutrition is simpler to use, is less costly, and it’s also a far better choice than TPN. Unfortunately, its unpalatability limits individual agreement, but with powerful encouragement this might be partly overcome.
The fat composition of enteral diets can influence the results that are obtained in the several clinical trials. Elemental diets include a reduced fat content, although a lot of healthier diets generally contain more fat, such as more lactic acid, which can be a precursor for the synthesis of possible pro-inflammatory eicosanoids.
Defined formula diets are often more palatable and more affordable than would be the elemental diets. When some researchers reported no gaps between utopian and defined formula diets in patients with severe CD, Giaffer et al discovered elemental diets are far more successful for active CD. A randomized double-blind study in Crohn’s patients revealed that elemental and polymeric, or characterized, diets differing only in their own source of nitrogen, were equally effective in lessening the Crohn’s disease activity index, or CDAI, also inducing clinical remission. Though defined formula diets supply less gut rest, they have the possible benefit of exposing the GI tract to the typical dietary substrates, which permit thereby for the complete manifestation of intestinal, biliary and pancreatic action. In animal research, it has also been discovered that luminal nutrition has trophic impacts on the intestine.
Can there be a beneficial effect of supplementing polymeric formulas with TGF-?1? In pediatric CD, reductions in pro-inflammatory cytokine concentrations and mRNA, paired with an up-regulation of TGF-? mRNA, was associated with enhanced macroscopic and microscopic mucosal inflammation. A meta-analysis along with a Cochrane review have demonstrated that in adults, corticosteroids are more effective than enteral diet treatment. It’s uncertain what is the use of supplements in adults with CD, even though there are some signs in Japan that enteral nutrition enjoys support as principal treatment. In contrast to this generally agreed part in adults of enteral nutrition being used to enhance the patient’s nutritional status because its principal advantage, in children with CD enteral nutrition has a far clearer benefit to enhance clinical, biochemical and growth parameters, and may as well have a steroid sparing effect.
Information referenced from the National Center for Biotechnology Information (NCBI) and the National University of Health Sciences. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
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