Partnering With Dietitians Can Bridge Gaps in IBD Care

Marcia Frellick

December 11, 2020

Working with a registered dietitian (RD) can help ensure that changing the way patients with inflammatory bowel disease (IBD) eat won't deprive them of the nutrients they need.

Depending on the location and resources of a medical practice, calling in a dietitian may seem like a luxury. But making those connections can be more accessible during the COVID-19 pandemic as more dietitians are working virtually.

Kelly Issokson, MS, RD, clinical nutrition coordinator for IBD at Cedars Sinai Medical Center in Los Angeles, California, suggested two websites that allow users to search for RDs by ZIP code or by those working virtually: the International Foundation for Gastrointestinal Disorders and eatright.org, the website for the professional body for the dietetics community, which also has a searchable database.

Ashwin N. Ananthakrishnan, MD, MPH, director of the Crohn's and Colitis Center at Massachusetts General Hospital in Boston, said it's key for gastroenterologists to communicate what exactly they want the dietitian to address and not merely refer the patient.

The provider should know what therapies exist and then have the dietitian walk the patient through the plan, he said.

Mark Mattar, MD, with MedStar Georgetown University Hospital in Washington, DC, said that in addition to connecting patients with dietitians, "I always refer my patient to the Crohn's and Colitis Foundation for the most recently updated patient education materials on nutrition."

Panelists at the Advances in Inflammatory Bowel Diseases 2020 Annual Meeting on Wednesday weighed in on dietary considerations for two patient scenarios posed by Maria Abreu, MD, director of the Crohn's & Colitis Center at the University of Miami Miller School of Medicine.

The first scenario involved a 54-year-old man with long-standing fibrostenotic Crohn's disease, recently hospitalized for obstruction and discharged with a prescription for prednisone 40 mg daily. The patient had been on infliximab (Remicade), and now is taking now adalimumab (Humira) weekly. He will undergo surgery to remove an ileal stricture. Abreu asked what dietary changes the panelists would make to ensure adequate nutrition prior to surgery and prevent another obstruction.

Ananthakrishnan said he would check vitamin B₁₂, vitamin D, iron, and albumin levels to see if any micronutrients need to be replaced.

He said that although he thinks low-fiber diets are used too often as the default for Crohn's and ulcerative colitis, in this case he would recommend low fiber and urge the patient to avoid raw fruits, vegetables, nuts, and seeds.

The patient can remove the skins and still have shakes and smoothies to get the benefits of fiber-containing foods without the fiber component, he said.

Discussing a pediatric version of that scenario, Andrew Grossman, MD, a pediatric gastroenterologist at the Children's Hospital of Philadelphia, said he would turn to enteral nutrition therapy.

"We would strongly encourage using a formula to try to improve nutritional status, which we know can improve surgical outcomes," he said.

The second case was a 15-year-old girl with growth stunting. She was diagnosed at age 10 with Crohn's disease, currently has moderate disease, and continues to have five to seven liquid bowel movements daily, along with abdominal pain after meals. She is starting adalimumab induction.

Grossman said, "first, I would not be managing this alone. I would be managing this with a dietitian and working together to improve outcomes. We need to consider aggressive therapy, and to me that would include consideration of biological therapy but also possible dietary therapy — the Crohn's Disease Exclusion Diet or enteral nutrition therapy as possibilities."

He pointed out that in pediatrics there must be consideration both for what the parent wants the child to do and what the child is willing to do.

"My primary focus would be on improving caloric intake, working with the dietitian to avoid foods that bother the most," he said.

Issokson said she would recommend either exclusive enteral nutrition or a specific carbohydrate diet (SCD) for the teen.

"We see [SCD] doesn't impair growth in our patients as long as they are being followed by a dietitian and we're making sure they are getting adequate nutrient intake," she said.

Abreu told Medscape Medical News that "diet is important in patients with IBD; it is a complement to the therapies that we use and a potential opportunity to solidify a long-lived remission."

"Although studies of diet are only now being done," she said, "we already have some good foundational ideas about diet and its role in reducing inflammation and reducing symptoms." And she added that treating gastroenterologists should certainly avoid telling patients that "diet does not matter."

Abreu has relationships with Boehringer Ingelheim, Cosmo Biopharma, Eli Lilly, Gilead, Janssen, Landos Biopharma, Prometheus Bioscience, Takeda, UCB Biopharma, Pfizer, and Prometheus Laboratories. Ananthakrishnan, Grossman, and Issokson have disclosed no relevant financial relationships.

Advances in Inflammatory Bowel Diseases (AIBD) 2020 Annual Meeting. Presented December 9, 2020.

Marcia Frellick is a freelance journalist based in Chicago . She has previously written for the Chicago Tribune, Science News and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud ( Minnesota ) Times. Follow her on Twitter at @mfrellick

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