Malnutrition Awareness Week™ 2024

Malnutrition is common in patients with IBD and is worsened when surgery is needed. This article summarizes the main nutritional highlights to consider when managing malnutrition in IBD on behalf of the involvement of Nutritional Therapy for IBD as an ambassador of the ASPEN Malnutrition Awareness Week^TM on September 16-20, 2024.

Both under and overnutrition are common in IBD

Malnutrition is the lack of proper nutrition and refers to either not getting enough nutrients or getting more nutrients than needed. It is as common in Crohn’s disease as ulcerative colitis. Undernutrition is common in patients with IBD, both in those living in the community and those hospitalized. In most countries, people with IBD are not underweight. Obesity rates are increasing worldwide, and it explains that up to one-fifth of patients with IBD have obesity. However, those with IBD are more likely to have lower muscle mass and higher fat mass than their non-IBD peers.¹

Patients with IBD are at risk of malnutrition, especially those with active disease and those who require surgery.¹ Inflammation results in reduced appetite, which leads to decreased intake of nutrients from food, and increased breakdown of body muscle and fat. Both of these factors can lead to weight loss.² 

Malnutrition can manifest in different ways:

• Protein calorie malnutrition (classically defined as “undernutrition”): patients with IBD are three times more likely to have protein-calorie malnutrition, which is estimated to affect 50% of hospitalized patients with IBD and 15% of adults with IBD living in the community.³

• Sarcopenia: defined as a low muscle mass and impaired muscle function, in patients with IBD is associated with more hospitalizations, increased need for surgery, and postoperative complications, and even high mortality rates⁴.

• Micronutrient deficiencies (also known as “hidden hunger”): are common in people with IBD and occur due to inflammation, avoidance of sunlight, and poor nutrient intake from foods. The most common deficiencies are iron and vitamin D, and in people who have had small bowel surgery, vitamin B₁₂. 

• Obesity: high amounts of fat around the organs in the abdomen increases the risk of more severe IBD, reduced response to biologic medications, and high risk of Crohn’s disease recurring after surgery.^5,6

Available malnutrition screening tools for patients with IBD

Screening for malnutrition in patients with IBD should be done at the time of diagnosis, on every hospital admission and during the admission, at follow-up appointments with healthcare providers, and before surgery.¹ Different tools are used depending on the location of the screening. The Malnutrition Screening Tool (MST) is commonly used in the hospital, and it is based on involuntary weight loss and reduced appetite. In addition, the Malnutrition Universal Screening Tool (MUST) is more appropriate in the community, based on body mass index, unplanned weight loss in the last 3-6 months, and the inability to eat for at least five days.⁷z 

Other screening tools specifically assess malnutrition in IBD⁷:

• Saskatchewan IBD-Nutrition Risk: based on digestive symptoms, unintentional weight loss, decreased appetite, and restriction of foods

• Malnutrition Inflammation Risk Tool: based on body mass index, weight loss over the past three months, and C-reactive protein)

• Nutritional Screening-IBD: based on body mass index, unintentional weight loss, chronic diarrhea and ileostomy, and previous surgery for IBD

• IBD nutrition self-screening tool: includes body mass index, unintentional weight loss, flare of symptoms, and food and nutrition concerns.⁸

Any patient with IBD at high risk of malnutrition should be referred to an IBD experienced dietitian for a clinical nutrition assessment and treatment plan.⁹ 

How to manage malnutrition before and after surgery

Treating malnutrition has many benefits, including improving patient quality of life, improving response to medical therapies, shortening the number of days in hospital, and reducing the risk of surgery complications. All members of the IBD team, including physicians, dietitians, and nurses, should screen patients with IBD for risk of malnutrition and those identified at risk of malnutrition should be referred to an IBD dietitian for nutritional assessment and a personalized treatment plan.

Most patients with IBD who need surgery are at increased risk of malnutrition. It is recommended that to optimise nutritional status, all patients having bowel surgery should drink 600 kcal of oral nutrition supplements for 7-10 days prior to surgery.¹⁰ 

Patients at high risk of malnutrition should have a comprehensive nutritional assessment before surgery. Malnourished patients will need a longer period of nutritional optimization. For patients undergoing elective Crohn’s disease surgery at least 4 weeks of exclusive enteral nutrition has been shown to improve nutritional status and reduce bowel inflammation.⁹

Protein intake of 1.2-1.5 g/kg/day for 1-2 weeks, immune-modulating nutrients, and a carbohydrate load lead to improved postoperative complications and attenuated muscle mass loss after surgery. The load consists of 100 g of carbohydrates on a drink the night before surgery and 50 g on a drink the day of surgery 2-3 hours before the induction of anesthesia. Clear liquids are safe to consume up to two hours before surgery, and solids are safe until six hours before anesthesia.^11,12

If neither oral nutrition nor tube feeding is possible, intravenous feeding is sometimes needed before surgery to ensure adequate nutrition.

After surgery most people are able to start drinking within 24 hours of the surgery. Eating and drinking soon after surgery is safe, helps to get the bowel working again, reduces the time spent in hospital and helps with recovery from surgery. A high protein diet, that may include oral nutritional supplements to help to meet energy and protein needs, helps with recovery after surgery. Energy, protein, and micronutrient needs after surgery should be personalized based on which parts of the gut have been removed.⁹

Resources to help improve malnutrition

Below are resources to help patients with IBD and healthcare providers identify and manage malnutrition on behalf of ASPEN Malnutrition Awareness Week^TM 2024:

• Malnutrition and IBD

• More than 1000 dietitian-vetted recipes that adapt to your needs

• ASPEN resources free to download and share:.

Nutritional Therapy for IBD is an official ambassador of ASPEN Malnutrition Awareness Week™. Malnutrition Awareness Week™ is a mark of the American Society for Parenteral and Enteral Nutrition (ASPEN). Name and image used with permission from ASPEN.

Reference:

^{1. Bischoff SC, Bager P, Escher J, et al. ESPEN guideline on clinical nutrition in inflammatory bowel disease. Clin Nutr. 2023; 42(3):352-379. doi: 10.1016/j.clnu.2022.12.004.}

^{2. Cederholm T, Bosaeus I. Malnutrition in adults. N Eng J Med. 2024; 391(2):155-165. doi: 10.1056/NEJMra2212159.}

^{3. Speedy AP, Wall CL. Editorial: Interdisciplinary and multidisciplinary approach to malnutrition in patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2023; 57(8):907-908. doi: 10.1111/apt.17413.}

^{4. Neelam PB, Sharma A, Sharma V. Sarcopenia and fraily in inflammatory bowel disease: Emerging concepts and evidence. JGH Open. 2024; 8(1):e13033. doi: 10.1002/jgh3.13033.}

^{5. Johnson AM, Harmsen WS, Aniwan S, et al. Prevalence and impact of obesity in a population-based cohort of patients with Crohn’s disease. J Clin Gastroenterol. 2024; 58(2):176-182. doi: 10.1097/MCG.0000000000001821.}

^{6. Mahmoud M, Syn WK. Impact of obesity and metabolic syndrome on IBD outcomes. Dig Dis Sci. 2024; 69(8):2741-2753. doi: 10.1007/s10620-024-08504-8.}

^{7. Vanderstappen J, Hoekx S, Bislenghi G, et al. Preoperative optimization: Review on nutritional assessment strategies in IBD. Curr Opin Pharmacol. 2024; 77:102475. doi: 10.1016/j.coph.2024.102475.}

^{8. Wall CL, Wilson B, Lomer MCE. Development and validation of an inflammatory bowel disease nutrition self-screening tool (IBD-NST) for digital use. Front Nutr. 2023; 10:1065592. doi: 10.3389/fnut.2023.1065592.}

^{9. Lomer MCE, Wilson B, Wall CL. British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with inflammatory bowel disease. J Hum Nutr Diet. 2023; 36(1):336-377. doi: 10.1111/jhn.13054.} 

^{10. Weimann A, Braga M, Carli F, et al. ESPEN practical guidelines: Clinical nutrition in surgery. Clin Nutr. 2021; 40(7):4745-4761. doi: 10.1016/j.clnu.2021.03.031.}

^{11. Wischmeyer PE, Carli F, Evans DC, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesth Analg. 2018; 126(6):1883-1895. doi: 10.1213/ANE.0000000000002743.} 

^{12. Yuill KA, Richardson RA, Davidson HIM, et al. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively – a randomized clinical trial. Clin Nutr. 2005; 24(1):32-37. doi: 10.1016/j.clnu.2004.06.009.}

‍Dr. Andreu Prados is a science and medical writer specializing in making reliable evidence of non-prescription therapeutics for gastrointestinal conditions understandable, engaging and ready for use for healthcare professionals and patients.

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‍Catherine Wall, PhD, NZRD ,has an undergraduate degree in Human Nutrition and a postgraduate diploma in dietetics. Her PhD research focused on nutritional therapy for adults with active Crohn's disease.

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