Rima Al-Jaouni

Nutritional Deficiencies in Patients With Crohn's Disease in Remission

Background: Patients with Crohns disease (CD) are at risk of developing nutritional deficiencies, especially because of restrictive diets. The aim of our study was to assess food intake and the status for vitamins and trace elements in nonselected CD patients in clinical remission. Methods: A total of 54 consecutive CD patients (28 females, 26 males, 39 ± 2 years of age [mean ± SD]) in clinical remission for >3 months underwent body composition, resting energy expenditure, nutrient intake, and plasma concentration assessment, and were compared with 25 healthy controls (16 females, 9 males, 38 ± 3 years old). Results: According to the nutritional risk index, 37 patients (70%) were not malnourished, 12 were at moderate risk, and 4 were at severe risk for malnutrition. Fat mass was lower in patients in remission compared with controls (P = 0.04). The mean daily energy intake was comparable between patients (2218 ± 92 kcal/day) and controls (2066 ± 101 kcal/day), covering their needs. No significant difference was observed for macronutrient intake in comparison with controls; compared to controls, female CD patients had lower intakes of &bgr;‐carotene (P < 0.005), vitamins B1 (P < 0.05), B6 (P < 0.01), and C (P < 0.005), and magnesium (P < 0.01). They had significantly higher intakes of zinc (P < 0.01). Male CD patients had lower intakes of &bgr;‐carotene and vitamin C (P < 0.05). More than 50% of patients had low plasma concentrations of vitamin C (84%), copper (84%), niacin (77%), and zinc (65%). Conclusions: In CD patients in remission, macronutrient needs are usually covered by food intake. However, micronutrient deficiencies are frequent and call for specific screening and treatment.

Energy metabolism and substrate oxidation in patients with Crohn’s Disease

Weight loss and malnutrition are common features in patients with Crohns disease. This study was designed to evaluate diet-induced thermogenesis and substrate oxidation in patients with Crohns disease. Twenty-three patients (17 women, 6 men; age 34 +/- 2 y) and 17 healthy control subjects (13 women, 4 men; age 36 +/- 3 y) were studied. Resting energy expenditure and fasting substrate oxidation were measured by indirect calorimetry in the morning after an overnight fast. After a standard homogenized test meal (10 kcal/kg), indirect calorimetry was performed every 30 min for 3 h to measure the diet-induced thermogenesis and the postprandial substrate oxidation. In the fasting state, resting energy expenditure was significantly higher in patients than in control subjects (1433 +/- 43 versus 1279 +/- 53 kcal/24 h). Lipid oxidation was higher in patients with Crohns disease than in control subjects (1.17 +/- 0. 07 versus 0.61 +/- 0.11 mg. kg(-1). min(-1), P < 0.01). Postprandially, diet-induced thermogenesis was significantly lower in patients with Crohns disease than in control subjects (4.6% +/- 0.5 versus 6.3% +/- 0.5 of energy intake, P < 0.01). Lipid oxidation was significantly higher in patients with Crohns disease than in control subjects (0.78 +/- 0.05 versus 0.56 +/- 0.08 mg. kg(-1). min(-1), P < 0.05), and glucose oxidation was lower in patients with Crohns disease than in control subjects. In patients with Crohns disease, lipid oxidation positively correlates with the disease activity evaluated by the Crohns Disease Activity Index (r = 0.48, P150), fasting and postprandial lipid oxidation was significantly higher than in patients with inactive Crohns disease (P < 0.05). In conclusion, patients with Crohns disease have increased fat oxidation, which correlates with disease activity and this may explain the reduced fat stores in patients with Crohns disease.

Sarcopenia is prevalent in patients with Crohn's disease in clinical remission

Background: Patients with Crohns disease (CD) are prone to osteoporosis. A loss of muscle mass, called sarcopenia, is responsible for an increased risk of disability. Many factors associated with osteopenia also decrease muscle mass. The aim of the present study was to measure the prevalence of sarcopenia in CD patients in remission and uncover its relationship with osteopenia. Methods: In all, 82 CD patients (43 female / 39 male; 36 ± 14 years; body mass index [BMI] 21.1 ± 3.4) and 50 healthy volunteers (30F/20M; 39 ± 13 years; BMI 22.2 ± 2.5) were studied. Body composition was assessed using dual‐energy x‐ray absorptiometry. Sarcopenia was defined as an appendicular skeletal muscle index (ASMI) below 5.45 kg/m2 for women and 7.26 for men. Osteopenia was defined as a T‐score for bone mineral density (BMD) (g/cm2) below −1.0. Results: In all, 60% of CD patients were found to be sarcopenic and 30% osteopenic, compared to 16% and 4% of controls, respectively (P < 0.01). ASMI was significantly lower in patients than in controls (6.0 ± 1.1 versus 6.5 ± 1.2; P < 0.05). Sarcopenic patients had significantly (P < 0.01) lower BMI (20.0 ± 3.5 versus 22.7 ± 2.8 kg/m2), lean mass (41.5 ± 9.1 versus 48.1 ± 9.1 kg), and BMD (1.09 ± 0.12 versus 1.15 ± 0.08 g/cm2) than nonsarcopenic patients; 91% of sarcopenic patients were also osteopenic. ASMI correlated with BMD (r = 0.46; P < 0.01) and BMI (r = 0.38; P < 0.01). Conclusions: The prevalence of sarcopenia is high in young CD patients and strongly related to osteopenia. These 2 phenomena may share similar mechanisms. Simultaneous screening for sarcopenia and osteopenia may be useful in CD patients.

Muscle performance in patients with Crohn's disease in clinical remission.

Background: Because patients with Crohns disease (CD) often show increased energy expenditure, nutritional deficiencies, and general fatigue, all which may persist after a flare, we hypothesized that CD could alter muscle mass and function. This study aimed to assess muscle strength and endurance in CD patients in clinical remission and the influencing factors. Methods: Forty‐one outpatients (17 men and 24 women; age, 37 ± 10 yr), in remission (CD Activity Index < 150) for >3 months, and 25 age‐matched healthy controls (10 men and 15 women; age, 37 ± 13 yr) were evaluated. Evaluation included a sit‐up test, hand‐grip strength test, hand‐grip endurance test, lower limb strength test, and lower limb endurance test (LE), as well as a measure of physical activity. Results: No significant difference was found between CD and control groups regarding weight, height, body mass index, fat mass, and fat‐free mass. Strength performance was lower in CD subjects compared with controls, particularly for lower limb indexes: lower limb strength test (−24.6%, P < 0.001), LE (−25.8%, P < 0.001), and sit‐up test (−25.1%, P < 0.001). Previous disease severity, disease duration, the cumulative dose of glucocorticosteroids, current inflammation, and global habitual physical activity did not affect muscle performance. A recent use of steroids improved LE. Conclusions: CD patients in clinical remission have decreased muscle function that may affect their quality of life. This pattern is reflected by reduced strength and endurance indexes, particularly for lower limbs. The reasons for these changes need further study. Strength training should be assessed in these patients.

Effect of steroids on energy expenditure and substrate oxidation in women with crohn's disease

OBJECTIVE:Patients with Crohns disease (CD) have increased energy expenditure and fat oxidation. Steroids, commonly used to treat flare-up of CD, induce weight gain. This study was designed to evaluate the effects of prednisone and budesonide on energy expenditure and substrate oxidation in patients with CD.METHODS:Twenty-nine women with CD and 10 healthy controls were studied. Ten patients received prednisone (0.75–1.0 mg/kg/day), nine received budesonide (9 mg/day), and 10 did not receive steroids. Resting energy expenditure and substrate oxidation were measured by indirect calorimetry in a fasting state and after a standard diet.METHODS:In the fasting state, resting energy expenditure was higher in patients without steroids than in the controls. Lipid oxidation was lower (p < 0.01) in patients with prednisone (0.46 ± 0.39 mg/kg/min) than in patients with budesonide (0.97 ± 0.28 mg/kg/min) and without steroids (1.06 ± 0.32 mg/kg/min), but was similar with control subjects (0.47 ± 0.20 mg/kg/min). Postprandially, lipid oxidation was lower (p < 0.01) in patients with prednisone (0.32 ± 0.23 mg/kg/min) than in patients with budesonide (0.75 ± 0.20 mg/kg/min), without steroids (0.82 ± 0.23 mg/kg/min), and controls (0.58 ± 0.15 mg/kg/min). Protein oxidation was significantly higher in patients with prednisone than in the other subjects.CONCLUSION:In women with CD, prednisone decreases lipid oxidation and increases protein oxidation. These effects are not observed with budesonide and may contribute to the weight gain and side effects commonly observed with prednisone. A low-fat/high-protein diet could be proposed during a course of prednisone.

Effects of age, malnutrition and refeeding on the expression and secretion of ghrelin

BACKGROUND & AIMS Anorexia is frequent in the malnourished elderly. We studied the effects of age, nutritional status and refeeding on the expression and secretion of the orexigenic peptide ghrelin. METHODS Four groups were prospectively enrolled: 11 undernourished elderly (80+/-6 y, BMI: 17.4+/-1.9 [Mean+/-SD]), nine well-nourished elderly (76+/-9 y, 23.5+/-2.0), 10 undernourished young (26+/-6 y, 15.1+/-1.9) and 10 well-nourished young (34+/-8 y, 22.2+/-2.7). Fasting and postprandial plasma ghrelin and other hormones (every 30 min) were measured at baseline and after a 21-day enteral nutrition in malnourished patients. Gastric ghrelin mRNA levels were measured by RT-PCR at baseline in all subjects. RESULTS Ghrelin was significantly higher in undernourished (2151+/-871 ng/L) than in well-nourished (943+/-389 ng/L) adults, whereas there were no differences between undernourished (1544+/-758 ng/L) and well-nourished (1154+/-541 ng/L) elderly. Refeeding did not influence ghrelin levels. Gastric ghrelin mRNA levels were similar in all groups. CONCLUSIONS There is an absence of malnutrition-induced increase of plasma ghrelin levels in elderly subjects. This feature, post-transcriptional, may be important in the lack of adaptation of elderly subjects to malnutrition.

Effect of age on substrate oxidation during total parenteral nutrition

OBJECTIVE Parenteral nutrition is increasingly used in the elderly. Aging is accompanied by metabolic changes that can modify substrate use. We compared substrate oxidation during cyclic total parenteral nutrition (TPN) in elderly and middle-aged patients. METHODS Twelve elderly patients (eight women, four men; 72 +/- 5 y) and 12 middle-aged patients (nine women, three men; 39 +/- 13 y) who were on cyclic TPN for intestinal failure were investigated while in stable condition after at least 15 d of TPN. No patient was diabetic. Indirect calorimetry was performed during fasting and every 30 min during the 3 h of TPN infusion and 3 h after infusion, allowing the measurement of nutrient oxidation. Blood samples were obtained every hour for the measurement of glucose, insulin, triacylglycerols, and free fatty acids. RESULTS In the fasting state, resting energy expenditure was significantly higher in the elderly patients than in the middle-aged patients (39.3 +/- 8.1 versus 31.9 +/- 4.3 kcal/kg of fat-free mass per day, P = 0.008). During TPN, lipid oxidation was significantly higher in the elderly patients than in the middle-aged patients (1.09 +/- 0.17 versus 0.84 +/- 0.27 mg x kg(-1) x min(-1), P = 0.011); glucose oxidation was significantly lower in the elderly patients than in the middle-aged patients (2.19 +/- 0.93 versus 3.22 +/- 1.54 mg x kg(-1) x min(-1), P = 0.038). Areas under the curves of glycemia and free fatty acids were significantly higher in the elderly patients. CONCLUSION In the elderly, TPN was associated with significantly higher lipid oxidation and lower glucose oxidation than in younger patients. TPN formulas and flow rates should therefore be adapted in the elderly.

Nutritional consequences and nutrition therapy in Crohn's disease

75% of hospital patients with Crohns disease (CD) suffer from malnutrition and one third of CD patients have a body mass index below 20. Inflammatory bowel diseases (IBD) patients have many vitamin and nutrient deficiencies which can lead to important consequences such as hyperhomocysteinemia which is associated with a higher risk of thromboembolic disease. Nutritional deficiencies in IBD patients are the result of insufficient intake, malabsorption and protein-losing enteropathy as well as the metabolic distubances directly induced by the chronic disease and its treatments, in particular corticosteroids. Screening for nutritional deficiencies in chronic disease patients is warranted. Managing the deficiencies involves simple nutritional guidelines, vitamin supplements, and nutritional support in the worst cases, in particular in children in order to limit the impact of IBD on growth. In active CD, enteral nutrition is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible.

Effects of steroids on diet-induced thermogenesis, and substrate oxidation in Crohn's disease

Background: Patients with Crohns disease are known to have an increased fat oxidation that correlates with disease activity. Steroids are commonly used to treat flare ups of Crohns disease. However, this treatment frequently induces major weight gains, particularly in women. Aims: To evaluate the effects of steroids on diet-induced thermogenesis (DIT) and substrate oxidation in patients with Crohns disease. Methods: 14 women with ileal or ileo-colonic Crohns disease were studied. 7 were receiving steroids. The two groups were similar for age (28.4 ± 2.2 vs 34.3 ± 4.0 yrs), and Crohns disease activity index (205 ± 30 vs 216 ± 4), but CRP levels were higher in treated patients (33 ± 16 vs 7 ± 2 mg/L: P<0.05). BMI was higher in steroid-treated women (22.6 ± 1.6 vs 19.1 ± 1.0: P<0.05). Resting energy expenditure (REE) and fasting substrate oxidation were measured by indirect calorimetry in the morning after an overnight fast. After a standard homogenized test meal (10 kcal/kg of body weight), indirect calorimetry was performed every 30 min for 3 hours, allowing measurement of DIT, lipid oxidation (Lox) and glucose oxidation (Gox). For patients on steroids, prednisone (0.75-1.0 mglkglday) was given during the test meal. Fat free mass (FFM) was measured by bioelectric impedance analysis. Results are expressed as mean ± SEM. Results: In the fasting state, REE was lower in treated than in non-treated patients (29.6 ± 1.3 vs 33.2 ± 1.3 kcal/kgFFMIday: P<0.05). Lox was lower in treated than in non-treated (0.56 ± 0.16 vs 1.05 ± 0.14 mg/kg/min: P<0.05), and Gox was higher in treated than in non-treated patients. Postprandially: DIT was higher in treated than in non-treated patients (6.2 ± 0.6 vs 3.6 ± 0.5 % of energy intake: P<O.Ol). Lox was lower in treated than in non-treated patients (0.37 ± 0.10 vs 0.81 ± 0.09 mg/kg/min: P<O.OI), and Gox was higher in treated than in non-treated patients. 43.8% of administered lipids were oxidised in non-treated patients, versus 19.8% in patients receiving prednisone (P<O.OI). Conclusions: In women with Crohns disease, steroids decrease lipid oxidation and induce fat storage that may participate in the weight gain commonly observed during this treatment. A low-fat diet may be proposed to reduce steroid-induced weight gain in these patients.