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
1. Presentation 1
University of Alabama
2. Crohn’s Disease
Causes of Symptoms
Diagnosis & Treatment
• Inflammatory Bowel Diseases
• 1 million Americans are affected
• 2 major forms
– Crohn’s Disease
– Ulcerative Colitis
Source: NIDDK website
– Both cause inflammation in intestines
– Ulcerative Colitis: generally affects lower bowel (colon
– 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.
Altered immune function; Arthritis
Abdominal pain, diarrhea, fever
Inflammation in the eyes or mouth
Oral aphthous ulcerations, pyroderma gangrenosa
6. Nutrition Management
• 60-70% of patients with Crohn’s disease
• 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
• Dietary recommendation must be individualized to Pt’s
needs/risk based on the nutrition assessment.
– Estimated energy range for adults 25-35 kcal/kg, depending on
– 1.0 – 1.5 g/kg/d, depending on disease state
– Use DRIs, Pts may need higher levels of Vitamin B12, Folate,
Thiamin, Riboflavin, Niacin, Vitamin C, E, D, and K
– 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,
– 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.
10. Glutamine and whey protein improve
– Increased intestinal permeability (IP) has been
implicated in the disease activity and relapse of
– Glutamine is the major fuel and nitrogen source for
– 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
• Study Design
– A Randomized, Controlled Open-Label Trial
11. Glutamine and whey protein improve
• 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
• Groups(0.5 g/kg ideal body weight / day)
– 1. Glutamine group (GG) – Oral glutamate
– 2. Active Control Group (ACG) – Whey Protein
– 2 months
– IP was assessed by (1) lactulose mannitol excretion ration (LMR)
in urine and (2) morphometry
12. Glutamine and whey protein improve
13. Glutamine and whey protein improve
• 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
Lactulose Mannitol Excretion Ration (LMR)
15. Glutamine and whey protein improve
Significant increase in
Villous Crypt Ratio (VCR)
2 mo 2.68
2 mo 2.49
Intra Epithelial Lymphocytes
16. Glutamine and whey protein improve
• Plasma Glutamine
– No significant difference in Pts and HC (Healthy
Control) at baseline and at the end of 2 months
– 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
– 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
MedlinePlus: Crohn's Disease. U.S. National Library of Medicine National
Institutes of Health. Web site. Accessed on October 29, 2013.
Crohn's Disease. National Digestive Diseases Information Clearinghouse (NDDIC).
Web site. Accessed on October 29, 2013.
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.
Nutrition Care Manual: Crohn's Disease & Ulcerative Colitis. Academy of
Nutrition and Dietetics. Web site. Accessed on October 29, 2013.
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.
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