Nutritional Deficiencies
& Management in IBD
Kathy Vagianos, RD, MSc
Research Dietitian – Health Sciences Centre
Presentation Overview
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The Types of IBD
Basics of Digestion and Absorption
Key Nutrient Deficiencies in IBD
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Calories, Protein & Fat
Calcium
Vitamin D
Iron
Folic Acid
Vitamin B12
Electrolytes & Fluid
Nutritional Assessment – How can a dietitian help?
Nutrition Research in Winnipeg
Questions & Answers
The Different Types of IBD
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Crohn’s disease
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Ulcerative colitis
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Crohn’s disease can affect the entire digestive tract
(mouth  small and large intestine).
Affects only the large intestine.
Active Disease - “Flare Up”
Remission - “Inactive Disease”
The Different Types of IBD – con’t
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The natural course of IBD is characterized by flare ups
(active disease) alternating with periods of feeling well
(remission).
Some people have long periods of remission.
Others have ongoing flare ups.
The course of your IBD affects nutritional status:
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Inflammation, complications (surgeries, fistulas, blockages),
pain, nausea, diarrhea  changes in food intake,
malabsorption affects nutritional status.
Digestion and Absorption
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You absorb most of the nutrients from your
food in the small intestine.
The prevalence of nutritional deficiencies has
been well documented, especially in Crohn’s
disease (small intestine).
Most Common Nutritional
Deficiencies in IBD
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Calories, Protein & Fat
Calcium
Vitamin D
Iron
Folic Acid
Vitamin B12
Electrolytes and Fluid
Calories, Protein & Fat:
“Macronutrients”
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Eating adequate calories, protein and fat are
essential for maintaining body weight, muscle
and fat.
Macronutrient Deficiency:
Why does it happen in IBD?
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Decreased intake of food during times of active
IBD, pain, nausea, diarrhea, etc  lower
calories, protein & fat consumed.
Common side effect of poor intake: Weight loss
Macronutrient Deficiency:
What is the risk?
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Severe weight loss is associated with nutritional
deficiencies – often ones that can not be “seen.”
Weight loss is linked to poor outcomes for
patients going in for surgeries.
Fatigue, quality of life.
Macronutrient Deficiency:
What can you do?
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What can I do to increase my intake?
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Nutritional supplements (Ensure, Boost) can be used to
replace meals or in between meals.
Homemade “shakes” and nutrient dense soups.
Small, frequent meals throughout the day.
Eat when you feel well – keep emergency foods on hand for
flare ups.
Protein rich foods: Milk and milk products, meats and
alternatives.
Avoid fat free, sugar-free, diet products.
Combine food groups for a better balance.
Canada’s Food Guide
Calcium
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Primarily found in milk and milk products.
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Other food sources exist.
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Critical nutrient involved in bone health in
combination with vitamin D.
Calcium Deficiency:
Why does it happen in IBD?
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Lactose Intolerance  decreased milk intake.
Many patients with lactose intolerance and IBD
tolerate some milk products.
 Having IBD does not increase your risk of lactose
intolerance.
 Controversial data as to whether lactose intolerance
is in fact greater among IBD vs. general population.
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Trigger food  Food Avoidance
Calcium Deficiency:
What is the risk?
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Osteopenia (soft bones)
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Osteoporosis (porous bones)
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Fractures
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This could be compounded with periodic
exposure to steroids  osteoporosis.
Calcium Deficiency:
What can you do?
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Supplemental calcium to reach a total intake (diet + supplement)
of 1500 mg per day may be required depending on your risk.
Diet: May require 3-4 servings per day of milk
products/alternates:
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1 cup milk = 300 mg calcium
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1 cup yogurt
1.5 oz hard cheese
1.5 cups ice cream
2 cups broccoli
4 oz tofu
8 oz calcium fortified orange juice
4 oz canned salmon with bones
3-4 oz almonds
Vitamin D
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Involved with calcium in the development and
maintenance of bone.
Prevention of osteopenia and osteoporosis.
Extensive research in vitamin D shows a role in
prevention of various disease states.
Vitamin D Deficiency:
Why does it happen in IBD?
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IBD Research Study (Winnipeg): 18% patients
had vitamin D deficiency (blood).
*Deficiency is common across all Canadians.
Combination of factors: malabsorption, poor
intake, food avoidance (milk).
Vitamin D Deficiency:
What is the risk?
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Poor bone health.
Evidence linking vitamin D to other diseases
(cancer, IBD, MS, IBD flare up?).
Vitamin D Deficiency:
What can you do?
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Key sources of Vitamin D:
Fish
 Fortified milk
 Sunlight
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Suggest 800 – 1000 IU per day.
Supplementation is most likely needed (in
addition to diet).
Iron
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IBD Research Study (Winnipeg):
40% of patients had iron deficiency.
 Using blood markers: hemoglobin and ferritin.
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Iron deficiency is the most common nutrient
deficiency noted in IBD.
Iron Deficiency:
Why does it happen in IBD?
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Iron deficiency can result from:
Blood loss (stool).
 Poor dietary intake (meat products).
 Chronic disease (“Anemia of chronic disease”).
 Malabsorption – iron is absorbed in the small
intestine.
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Iron Deficiency:
What is the risk?
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Fatigue.
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Affects your quality of life.
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Surgical outcomes are poor.
Iron Deficiency:
What can you do?
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Iron supplementation should be provided with a
documented iron deficiency.
Get a blood test.
What can I eat?
Meat and alternatives to meat (egg yolks, nuts).
 Red meat are your best sources.
 Legumes – beans, lentils.
 Grains have some iron – combine with vitamin C
foods.
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Folic Acid
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Folic acid is a B vitamin.
Involved with the development of the red blood
cell.
Blood levels of folic acid are low in IBD
(literature).
Folic Acid Deficiency:
Is it common in IBD?
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Are patients with IBD really deficient?
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Use of sulfasalazine or methotrexate reduce the
ability of the intestine to absorb folic acid.
A deficiency now is rare. Food supply is
supplemented with folic acid (late 1990’s).
IBD Research Study (Winnipeg): among 250
patients with IBD, 0% deficiency.
Vitamin B12
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B vitamin involved in the healthy formation of
the red blood cell.
Common deficiency observed in Crohn’s
disease.
Vitamin B12 Deficiency:
Why does it happen in IBD?
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Absorbed in the ileum of the small intestine
(last portion of the small intestine).
Ileal resections  risk of vitamin B12
deficiency.
Active inflammation of the ileum  risk of
vitamin B12 deficiency.
Vitamin B12 Deficiency:
What is the risk?
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Deficiency may have no symptoms, but should be
corrected.
Can lead to a type of anemia that makes you feel tired.
Fatigue and quality of life.
Other common symptoms:
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Memory problems.
Difficulty thinking and concentrating.
Loss of balance.
Numbness or tingling of fingers and toes.
Vitamin B12 Deficiency:
What can you do?
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Have your vitamin B12 levels checked.
Oral or monthly injections may be needed.
Diet alone may not be enough if you are
deficient.
Food Sources: animal products
Fish, meat, poultry, eggs, milk and milk products.
 Fortified products.
 Vegetarians are at higher risk for deficiency.
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Electrolytes and Fluid
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Potassium, magnesium and phosphate.
Hospital patients are supplemented if these are
low.
Deficiencies may arise depending on:
Malnutrition.
 Severity of fluid loss (diarrhea, fistulas).
 Lead to dehydration.
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Electrolytes and Fluid
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Drink adequate fluid throughout the day
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All sources of fluids count
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More of a concern during a flare up.
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If unable to eat, ensure adequate fluids are consumed.
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Sports Drinks may be needed in cases of severe fluid
losses.
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Homemade drinks: ½ orange juice, ½ water + salt
Nutritional Assessment for IBD
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Assessment – A complete nutritional assessment is
essential.
A Registered Dietitian can complete the ABCD’s of
nutrition.
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Anthropometrics: Weight, height, muscle and fat mass.
Biochemical: Blood tests.
Clinical: How do you look?
Diet: A complete dietary assessment to look at overall diet
plus the micronutrients.
Nutritional Assessment for IBD:
The role of a dietitian
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There is no diet for IBD.
“Diets” usually are related to functional gut symptoms.
Identify and treat nutritional deficiencies via diet and
recommend supplements as needed.
Symptom management:
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Constipation, diarrhea, pain.
Trigger Foods:
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What foods are triggers for you?
Keeping a food diary.
You may be avoiding foods of high nutritional value – need
to identify a replacement to prevent deficiencies.
What has IBD nutrition research in
Winnipeg taught us?
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Most patients in remission have a normal nutritional
status, consume adequate calories, protein, fat and
carbohydrate.
Specific “micro” nutrient deficiencies can still exist
(vitamins and minerals).
Active Disease – more extensive deficiencies related to
inflammation, bowel resections (surgeries), fistulas,
blockages.
What has IBD nutrition research in
Winnipeg taught us? – con’t
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Even when there is a healthy weight, nutritional
deficiencies can exist either in the diet and / or in the
blood.
A multivitamin is warranted – you can start this even
without a nutritional assessment.
Homocysteine does not need to be routinely
monitored (related to blood “clotting” and B vitamins).
What has IBD nutrition research in
Winnipeg taught us? – con’t
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In a survey of over 300 patients with IBD, more than
25% always avoid:
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Nuts and seeds
Legumes
Deep fried foods
Processed meat
Alcohol
Popcorn
Reason for avoiding:
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“Cause gastrointestinal upset that lasts 24 hours.”
What has IBD nutrition research in
Winnipeg taught us? – con’t
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Newly diagnosed patients with IBD feel that it is
very important to have information on:
Diet changes when the disease is active.
 Risk of nutritional deficiencies.
 Foods that offer the best nutritional value.
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However, few patients actually received the
information that they needed.
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Talk to your doctor about seeing a dietitian.
Do you have a question?