Mistakes in ... 2021 - 10

ueg education
Mistakes in... 2020
Zinc
Selenium
Copper
Vitamin A
Vitamin D
Vitamin E
Vitami B2
Vitami B6
Vitamin B12
Vitamin C
Lutein
Lycopene
α-carotene
β-carotene
-100 -90 -80 -70 -60
-50 -40 -30 -20
-10
Percentage change in micronutrient concentration
Figure 2 | Magnitude of effect (percentage change) of the systemic inflammatory response effect on the
concentration of plasma vitamin and trace elements (data from Gerasimidis et al.50
).
levels when no significant systemic inflammatory
response is present (figure 3).
Although generally not readily available, red
blood cell levels of various VTEs are far more
representative than the highly fluctuant plasma
levels, and some, including selenium and
B2/B6, remain very accurate in the face of acute
inflammation.50
Bottom line: Testing for VTE deficiency should
ideally be avoided in the setting of a systemic
inflammatory response unless necessitated by
the specific clinical context. Significantly low VTE
levels may accompany systemic inflammation
and it is prudent to reassess if relevant in a more
quiescent state before replacing them. Use dietary
assessment to compliment the results from
biomarkers.
Mistake 9 Failing to recognise and treat
nutritional deficiencies
A systematic approach to the diagnosis and
management of some nutritional deficiencies
(e.g. iron, vitamin D and B12) is essential given
28
their high frequency. Iron deficiency, for example,
has a reported prevalence of 36-90% in patients
with IBD, up to a third of patients may have
vitamin D deficits with similar rates of B12
deficiency in those specifically with ileal resections
These deficits have considerable implications for
patient outcomes.44,52
Evidence-based guidelines provide a useful
framework for day-to-day clinical practice.44,53
IBD patients with anaemia have equivalent QoL
impairments as those with anaemia in the
setting of advanced malignancy.54
As a major
contributor to anaemia, iron deficiency
must be treated accordingly, but it is important
to distinguish iron deficiency anaemia from
anaemia of chronic disease. No longer is
expectant management of iron deficiency
anaemia sufficient-expeditious use of
intravenous preparations when active disease is
present and treating to normalise haemoglobin
and iron stores is now recommended.55,56
It is important, particularly for paediatric
gastroenterologists, to be aware that reference
ranges for nutritional deficiencies may be based
on data that is not entirely relevant for all patients.
10
20
Indeed, reference ranges are often based on
adult cohorts or small samples, at times from
populations in which deficiencies are more of a
public health concern, and do not reflect the
biological variations with age.50
Interpretation in
both adult and paediatric patients must consider
the specific metabolic and nutritional context,
including highly malabsorptive states and
treatment with medications such as methotrexate
that antagonises folate metabolism. Anatomic
variants of disease, such as ileal inflammation or
resection, that may necessitate lifelong B12
therapy must also be considered, as should
sodium loss in protracted diarrhoea.
Consequently, treatment must be individualised
and patients may require significantly higher doses
than typically prescribed to maintain homeostasis.
Bottom line: Have a systematic approach to
testing and treating deficiencies of iron, vitamin D
and B12 given their very high prevalence
in IBD patients. For less common deficiencies
individualise testing and treatment regimes where
they are indicated.
Mistake 10 Neglecting exercise as a key
part of the nutritional management
of IBD
It can be a mistake to ignore exercise as a
therapeutic strategy when looking to optimise the
nutritional and overall well-being of patients with
IBD. Gastroenterologists may learn from oncology
colleagues who have recently formalised
'prescriptions' of exercise as 'medicine'
and published guidelines on overcoming
barriers to exercise referrals.57,58
This includes
prescribing structured, supervised or highly
supported exercise regimes. Several large clinical
trials show significant benefits in morbidity,
mortality and QoL metrics for patients-cancers
of the gastrointestinal tract being some of
the most heavily studied.59-61
Barriers to exercise
that are often also seen in IBD patients (e.g.
nausea, diarrhoea, anorexia, stomas, fatigue)
were overcome.
While large-scale RCTs are lacking in the field of
IBD, there is a growing body of evidence supporting
exercise as feasible, safe and beneficial
particularly for osteopenia, sarcopenia and quality
of life in this population.62,63
However, a 2020
Cochrane review assessing interventions for
fatigue in IBD did not find sufficient evidence to
support a specific recommendation for exercise.64
A 2015 prospective study of almost 2,000 patients
showed those with Crohn's disease in
remission who had increased exercise levels as
part of the study were significantly less likely to
flare at 6 months [adjusted RR 0.72, 95%
CI 0.55-0.94, p=0.02].65
A 2010 systematic review
and other more recent studies similarly report
reduced disease activity secondary to increased
physical activity in patients with IBD.66
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Mistakes in ... 2021

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