Nutrition in Crohn Disease

Karen L. Krok, MD, Gary R. Lichtenstein, MD

Disclosures

Curr Opin Gastroenterol. 2003;19(2) 

In This Article

Nutritional Assessment

When assessing a patient, it is important to conduct a detailed physical examination and elicit a thorough history. The subjective global assessment is a method of qualitatively assessing a patient's nutritional status. With this method, the patient is classified as generally well nourished, moderately malnourished, or severely malnourished, based on the patient's weight loss, dietary intake, gastrointestinal symptoms, CD activity, functional capacity, muscle mass, subcutaneous fat, edema, and ascites[16] ( Table 2 ). The subjective global assessment has been shown to be reproducible among observers, with better than 80% agreement when two independent observers assessed the same patient.[16,17]

As can be seen, both the history and physical examination are of paramount importance; however, laboratory studies also are integral components to the assessment of a patient's nutritional status when assimilating data regarding the cause of the patient's malnutrition. Anemia is common in CD and its cause is often multifactorial. It can be difficult to determine if the patient has an iron-deficient anemia or an anemia of chronic disease. In both, iron is low, but the ferritin concentration can be increased independently of iron status by infectious, inflammatory, malignant, and other disorders. The total iron-binding capacity (TIBC or transferrin concentration) can be useful in distinguishing between the two causes of anemia. In uncomplicated iron deficiency, the TIBC increases and in the anemia of chronic disease the TIBC decreases. A combined microcytic and macrocytic anemia can be present, as is seen in some patients with CD who are deficient in vitamin B12 or folate. Vitamin B12-intrinsic factor complex is absorbed in the last half of the small intestine, but the greatest density of intrinsic factor receptors is in the distal ileum; hence, patients with ileal resections will require vitamin B12 parenterally (intramuscularly or intranasally). Sulfasalazine competitively inhibits the jejunal folate conjugate enzyme, often producing folate malabsorption and requiring concurrent oral folate supplementation.[6] Even patients not taking sulfasalazine should be considered for folate supplements as a result of frequent poor dietary intake of folate. Additionally, data exist to suggest that folate supplementation conveys protection against the development of colorectal cancer in patients with inflammatory bowel disease (IBD).[18,19,20]

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