Malnutrition in inflammatory bowel disease patients in northern India: frequency and factors influencing its development

Inflammatory bowel disease (IBD), comprising ulcerative colitis (UC) and Crohn’s disease (CD) is common in the developed and developing worlds.[1,2,3] This disease is chronic in nature with acute exacerbations from time to time. Patients with IBD often have associated under nutrition.[4] Though there are several studies on nutritional assessment in patients with IBD from the developed world,[4,5,6] the data from developing countries, where under nutrition is common, are insufficient. Patients with IBD in remission are likely to have a better nutritional status than those with active relapse as the latter are hospitalised and are often on restricted diets due to the advice of the physician, have associated anorexia resulting from the active disease and the drugs used in treatment, and are in a hypercatabolic state.[7] Patients with CD more often have small bowel involvement causing malabsorption and resulting under nutrition;[8] the clinical course of patients with CD is also more protracted resulting in greater nutritional compromise than in patients with UC. Therefore, it is expected that patients with CD may have a more severe degree of under nutrition than those with UC.

Accordingly, we undertook a prospective study with the following aims, (a) to estimate the prevalence of under nutrition in patients with IBD when compared with healthy subjects, (b) to compare the nutritional status of patients with active disease as compared to those in remission, (c) to compare the nutritional status of patients with UC as compared to those with CD.

Methods

Sixty-two patients with IBD and 42 healthy subjects (staff members and healthy relatives of patients) were evaluated for nutrition using dietary survey, anthropometric and biochemical parameters. Patients with IBD (UC and CD) were diagnosed using standard criteria.[9] The activity of IBD was assessed using Truelove-Witt’s criteria and the Harvey- Bradshaw activity index.[10, 11] More than 4 stools per day was considered as active UC. A Harvey- Bradshaw score > 3 was considered as active CD. [11]The study protocol was approved by the Ethics Committee of the Institute. Informed consent was taken from each patient.

Nutritional assessment: Each patient was interviewed by a trained dietician using the 72-h recall method for calculating the amount of cereals, pulses, milk and milk products, vegetables, fruits, fats and oils consumed during that period as described previously in another Indian study in patients with chronic liver disease.[12] The amount of foods consumed by the patients during each meal (i.e. breakfast, lunch, evening tea and dinner) were noted down either in terms of weight or in terms of household measures (standard cup set). The nutrient contents of the diet was calculated using nutritive value of Indian foods[13] for calories, protein, calcium and iron during each 24-h bracket; an average of 3 days was taken as the dietary intake per day.

Anthropometry: Body mass index (BMI) was calculated according to the standard formula. Triceps and biceps skinfold (TSF and BSF) thickness were measured in the nondominant arm using a skin fold caliper by the standard technique. Mid-arm muscle circumference (MAMC) was measured in the non-dominant arm at a mid-point between the tip of the acromion and the olecranon process using a measuring tape.[14] Patients were described as undernourished if anthropometric measurements were loweer as compared to healthy subjects, asdescribed previously.[12]

Laboratory parameters: Total protein and albumin in serum and haemoglobin values were estimated using standard techniques.

Statistical analysis: Continuous data were depicted as median and range. Inter-group comparisons between continuous variables were analysed using the Mann-Whitney U test. P values less than 0.05 were considered significant.

Results

Patients with IBD were comparable to healthy subjects with respect to age (median 35, range 16 to 70 years, vs. 38, range 22 to 60) and gender distribution (43/62 vs. 31/41 male among patients with IBD and healthy volunteers, respectively). Of 62 patients with IBD, 55 had UC and 7 had CD. Of the patients with IBD, 23 (37%) had active disease and 39 (63%) were in remission at the time of inclusion into the study. Amongst 7 patients with CD, 5 had small bowel involvement in addition to colonic disease.

Table I shows the dietary, anthropometric and laboratory parameters of patients with IBD and healthy subjects. Daily intake of calorie and proteins was significantly lower though that of calcium was comparable in the two groups. BMI, biceps and triceps skin-fold thickness and mid-arm muscle circumference were significantly lower in the IBD patients.

Patients with UC (n=55) were comparable to patients with CD (n=7) with respect to age (median 35 years, range 16 to 70 vs. 38 years, range 33 to 56, respectively) and gender distribution (39/55 vs. 4/7 male among patients with IBD and CD, respectively). Though CD patients had a lower level of haemoglobin (median 9.2 g, range 7-11 vs. 10.8 g, range 3- 15, respectively; p<0.05) and total serum proteins (median 6 g, range 3-7 vs. 7 g, range 3-9, respectively; p<0.05), serum albumin, BMI, BSF and TSF thicknesses, MAMC and daily intake of protein, calories, calcium and iron were comparable between the two groups.

Table II shows the dietary, anthropometric and laboratory parameters of patients with active IBD and those with remission. Though daily dietary intake was comparable between the two groups, patients with active disease had significantly lower BMI, MAMC and serum protein level.

Discussion

The present study showed that under nutrition is common in patients with IBD from northern India and might result from reduced dietary intake as was evidenced by low intake in them as compared with healthy controls; however, patients with IBD in acute exacerbation were more undernourished than those in remission despite no difference in dietary intake between the two groups suggesting other factors such as reduced assimilation, increased losses and increased requirement during the acute episode.

Several previous studies have shown that patients with IBD are often malnourished as compared to healthy subjects.[4, 5, 15,16,17] Several authors suggested specific dietary and nutritional intervention to correct the under nutrition[18,19,20,21,22,23] as the outcome of medical and surgical management of IBD may be influenced by the nutritional status of the patients.[24] Some authors even suggested that specific dietary factors and nutritional abnormalities may be aetiologically related to IBD.[25,26,27,28,29] In children with IBD, under nutrition may result in growth failure which may result in permanent and irreversible morbidity.[30] Under nutrition in patients with IBD can result from several factors, such as reduced food intake, intestinal losses, malabsorption, hypercatabolic state and medication. Hence, importance of nutrition in management of patients with IBD can not be overestimated. This is perhaps the first study on nutritional assessment of patients with IBD from India.

The limitations of the present study are small number of patients, particularly in the subgroup with CD, the use of the recall method for nutritional assessment and limited biochemical parameters studied to assess under nutrition. Patients with CD are expected to be more malnourished that those with UC. Though patients with CD had lower haemoglobin and total serum protein levels, other parameters of nutrition in these two groups were comparable. However, in view of the small number of patients with CD, a possibility of statistical error is quite likely and therefore, this issue requires further study. Despite these limitations, presence of under nutrition among patients as compared to healthy subjects is quite obvious. There is a need to keep nutritional assessment and management in mind while treating patients with IBD.

We conclude that under nutrition is common in patients with IBD and might result from reduced dietary intake. Patients with IBD in acute exacerbation were more undernourished than those in remission despite no difference in dietary intake between the two groups suggesting other factors such as reduced assimilation, increased losses and greater requirement.

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