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Handle with care: Managing IBD in older patients
As the saying goes: "Age is a case of mind over matter: If you don't mind, it don't matter."
But for older patients with inflammatory bowel disease (IBD) and the clinicians who treat them, it’s hard to ignore the complications that aging can bring, such as comorbidities, functional limitations, and polypharmacy, said Nana Bernasko, CRNP, DNP, WHNP-BC, a nurse practitioner in the department of gastroenterology at Penn State Milton S. Hershey Medical Center in Hershey, Pa.
“We are seeing a large number of patients in our clinics that are being diagnosed later on in life,” she said in an oral presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
Between 10% and 30% of all patients with IBD are older than 60, and roughly 10%-15% of patients with IBD are diagnosed after age 60, she said.
The diagnosis of IBD is often delayed in older patients as well, with an estimated 60% of patients initially given an incorrect or incomplete diagnosis that may lead to significant delays in the initiation of appropriate therapy, she said.
Differential diagnoses for IBD in older patients include diverticulitis, ischemic colitis, infectious colitis, and radiation colitis.
Bharati Kochar, MD, MS, from the Crohn’s and Colitis Center at Massachusetts General Hospital in Boston, who was not involved in the presentation, agreed that older adults need special handling.
“The management of IBD in older adults is challenging for a number of reasons, but primarily because until very recently, we have not invested in understanding how IBD should be optimally managed at older ages,” she said in an interview.
“Additionally, like in all fields, older adults with IBD are disproportionately under-represented in clinical trials, meaning that we have less rigorous data guiding the management of older adults,” she added.
Clinical presentations
Older adults tend to differ in clinical presentation, compared with younger adults, Dr. Bernasko said.
For example, among patients with Crohn’s disease, rectal bleeding is a more common symptom among older adults, whereas diarrhea and weight loss are more common among younger adults.
Disease location may also differ, with more senior adults having predominantly colonic disease (L2 according to the Montreal Classification of IBD), compared with more prevalent ileocolonic disease (L3) among their more junior counterparts. And although both generations of patients have inflammatory behavior (B1) at diagnosis, younger patients have more prevalent structuring (B2) and penetrating disease (B3), Dr. Bernasko noted.
Among patients with ulcerative colitis, rectal bleeding, abdominal pain, and extraintestinal manifestations are more common among the younger set, whereas left-sided colitis is more common among older patients. In addition, extensive ulcerative colitis (E3) is more common in younger patients, compared with older patients.
Management considerations
Dr. Kochar noted that “older adults have higher baseline risks for all adverse events – like infections, malignancies, polypharmacy, procedural complications – than younger adults, so any additional risk conferred by treatments seem amplified, but that should not mean that we should avoid effectively treating older adults. It should mean we need to invest in understanding how to best mitigate those risks.”
While younger patients are sometimes on multiple medications prior to starting on IBD therapy, polypharmacy is common among the older set, who may be taking drugs for diabetes, hypertension, prostate disease, and so on.
“There’s just so much going on in terms of their medical background to start off with, so many medications, and then we’re adding more things to it,” Dr. Bernasko said.
She echoed Dr. Kochar in noting that older patients as a subgroup are under-represented in clinical trials, making it difficult to know what treatment approaches may work best for them.
In addition, older patients are at higher risk for malignancies, and for complications from surgery.
Medication adherence in older patients is frequently compromised by memory issues, she added, noting that “I can’t tell you enough how sometimes our older patients forget to take their medications.”
Other challenges for the management of older patients with IBD included psychosocial issues, cognitive decline, and malnutrition.
Medications and adverse events
Dr. Bernasko also discussed specific medications and potential adverse events and drug interactions in older patients.
For example, aminosalicylic acids (5-ASA) are associated with higher risk for nephrotoxicity and pancreatitis in older patients and can interact with thiopurines to cause leukopenia.
Steroids are associated with elevated risk for osteopenia, myopathy, cataracts, glaucoma, diabetes, and hypertension, and can interact with thiazide and loop diuretics to cause hypokalemia.
Methotrexate use in this population is linked to pancytopenia and hepatotoxicity, and it can interact with NSAIDs and multiple antibiotics to cause decreased renal secretion.
Thiopurines in older patients are associated with increased risk for leukopenia, myelosuppression, non-Hodgkin lymphoma, skin cancer, pancreatitis, and hepatotoxicity, and drugs in this class interact with allopurinol and angiotensin-converting enzyme inhibitors to increase risk for myelosuppression. Additionally, warfarin can inhibit the efficacy of thiopurines, and when these drugs are used in combination with tumor necrosis factor (TNF)–alpha inhibitors they can further increase risk of malignancy through immunosuppression.
Cyclosporine is associated with worsening hypertension and renal insufficiency among older patients.
TNF-alpha inhibitors are associated with increased risk for tuberculosis; hepatitis B; and fungal infections, malignant lymphoma, and New York Heart Association class 3 or 4 heart failure.
Ciprofloxacin in older patients with IBD has been linked to tendinopathy and increased risk for Clostridioides difficile infections. Metronidazole increases the likelihood of peripheral neuropathy in these patients.
Colon cancer screening
“When it comes to colon cancer screening, definitely assess the risk prior to doing this,” Dr. Bernasko recommended. “Weigh all the risks and benefits. Why are we doing this for these elderly patients, because there are definitely risks associated with this.”
Older patients with IBD may have difficulty with bowel prep and are at elevated risk, compared with younger patients, for cardiopulmonary complications, perforation, adverse events from sedation, and procedural complications, she cautioned.
“When it comes to our elderly patients, you want to focus on a more personalized approach – not all older people present the same way in terms of comorbidities or medications,” Dr. Bernasko advised in her summary.
Dr. Bernasko and Dr. Kochar reported having no relevant conflicts of interest to disclose. Dr. Kochar is a member of the board of editors for GI & Hepatology News.
This article was updated 2/18/22.
As the saying goes: "Age is a case of mind over matter: If you don't mind, it don't matter."
But for older patients with inflammatory bowel disease (IBD) and the clinicians who treat them, it’s hard to ignore the complications that aging can bring, such as comorbidities, functional limitations, and polypharmacy, said Nana Bernasko, CRNP, DNP, WHNP-BC, a nurse practitioner in the department of gastroenterology at Penn State Milton S. Hershey Medical Center in Hershey, Pa.
“We are seeing a large number of patients in our clinics that are being diagnosed later on in life,” she said in an oral presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
Between 10% and 30% of all patients with IBD are older than 60, and roughly 10%-15% of patients with IBD are diagnosed after age 60, she said.
The diagnosis of IBD is often delayed in older patients as well, with an estimated 60% of patients initially given an incorrect or incomplete diagnosis that may lead to significant delays in the initiation of appropriate therapy, she said.
Differential diagnoses for IBD in older patients include diverticulitis, ischemic colitis, infectious colitis, and radiation colitis.
Bharati Kochar, MD, MS, from the Crohn’s and Colitis Center at Massachusetts General Hospital in Boston, who was not involved in the presentation, agreed that older adults need special handling.
“The management of IBD in older adults is challenging for a number of reasons, but primarily because until very recently, we have not invested in understanding how IBD should be optimally managed at older ages,” she said in an interview.
“Additionally, like in all fields, older adults with IBD are disproportionately under-represented in clinical trials, meaning that we have less rigorous data guiding the management of older adults,” she added.
Clinical presentations
Older adults tend to differ in clinical presentation, compared with younger adults, Dr. Bernasko said.
For example, among patients with Crohn’s disease, rectal bleeding is a more common symptom among older adults, whereas diarrhea and weight loss are more common among younger adults.
Disease location may also differ, with more senior adults having predominantly colonic disease (L2 according to the Montreal Classification of IBD), compared with more prevalent ileocolonic disease (L3) among their more junior counterparts. And although both generations of patients have inflammatory behavior (B1) at diagnosis, younger patients have more prevalent structuring (B2) and penetrating disease (B3), Dr. Bernasko noted.
Among patients with ulcerative colitis, rectal bleeding, abdominal pain, and extraintestinal manifestations are more common among the younger set, whereas left-sided colitis is more common among older patients. In addition, extensive ulcerative colitis (E3) is more common in younger patients, compared with older patients.
Management considerations
Dr. Kochar noted that “older adults have higher baseline risks for all adverse events – like infections, malignancies, polypharmacy, procedural complications – than younger adults, so any additional risk conferred by treatments seem amplified, but that should not mean that we should avoid effectively treating older adults. It should mean we need to invest in understanding how to best mitigate those risks.”
While younger patients are sometimes on multiple medications prior to starting on IBD therapy, polypharmacy is common among the older set, who may be taking drugs for diabetes, hypertension, prostate disease, and so on.
“There’s just so much going on in terms of their medical background to start off with, so many medications, and then we’re adding more things to it,” Dr. Bernasko said.
She echoed Dr. Kochar in noting that older patients as a subgroup are under-represented in clinical trials, making it difficult to know what treatment approaches may work best for them.
In addition, older patients are at higher risk for malignancies, and for complications from surgery.
Medication adherence in older patients is frequently compromised by memory issues, she added, noting that “I can’t tell you enough how sometimes our older patients forget to take their medications.”
Other challenges for the management of older patients with IBD included psychosocial issues, cognitive decline, and malnutrition.
Medications and adverse events
Dr. Bernasko also discussed specific medications and potential adverse events and drug interactions in older patients.
For example, aminosalicylic acids (5-ASA) are associated with higher risk for nephrotoxicity and pancreatitis in older patients and can interact with thiopurines to cause leukopenia.
Steroids are associated with elevated risk for osteopenia, myopathy, cataracts, glaucoma, diabetes, and hypertension, and can interact with thiazide and loop diuretics to cause hypokalemia.
Methotrexate use in this population is linked to pancytopenia and hepatotoxicity, and it can interact with NSAIDs and multiple antibiotics to cause decreased renal secretion.
Thiopurines in older patients are associated with increased risk for leukopenia, myelosuppression, non-Hodgkin lymphoma, skin cancer, pancreatitis, and hepatotoxicity, and drugs in this class interact with allopurinol and angiotensin-converting enzyme inhibitors to increase risk for myelosuppression. Additionally, warfarin can inhibit the efficacy of thiopurines, and when these drugs are used in combination with tumor necrosis factor (TNF)–alpha inhibitors they can further increase risk of malignancy through immunosuppression.
Cyclosporine is associated with worsening hypertension and renal insufficiency among older patients.
TNF-alpha inhibitors are associated with increased risk for tuberculosis; hepatitis B; and fungal infections, malignant lymphoma, and New York Heart Association class 3 or 4 heart failure.
Ciprofloxacin in older patients with IBD has been linked to tendinopathy and increased risk for Clostridioides difficile infections. Metronidazole increases the likelihood of peripheral neuropathy in these patients.
Colon cancer screening
“When it comes to colon cancer screening, definitely assess the risk prior to doing this,” Dr. Bernasko recommended. “Weigh all the risks and benefits. Why are we doing this for these elderly patients, because there are definitely risks associated with this.”
Older patients with IBD may have difficulty with bowel prep and are at elevated risk, compared with younger patients, for cardiopulmonary complications, perforation, adverse events from sedation, and procedural complications, she cautioned.
“When it comes to our elderly patients, you want to focus on a more personalized approach – not all older people present the same way in terms of comorbidities or medications,” Dr. Bernasko advised in her summary.
Dr. Bernasko and Dr. Kochar reported having no relevant conflicts of interest to disclose. Dr. Kochar is a member of the board of editors for GI & Hepatology News.
This article was updated 2/18/22.
As the saying goes: "Age is a case of mind over matter: If you don't mind, it don't matter."
But for older patients with inflammatory bowel disease (IBD) and the clinicians who treat them, it’s hard to ignore the complications that aging can bring, such as comorbidities, functional limitations, and polypharmacy, said Nana Bernasko, CRNP, DNP, WHNP-BC, a nurse practitioner in the department of gastroenterology at Penn State Milton S. Hershey Medical Center in Hershey, Pa.
“We are seeing a large number of patients in our clinics that are being diagnosed later on in life,” she said in an oral presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
Between 10% and 30% of all patients with IBD are older than 60, and roughly 10%-15% of patients with IBD are diagnosed after age 60, she said.
The diagnosis of IBD is often delayed in older patients as well, with an estimated 60% of patients initially given an incorrect or incomplete diagnosis that may lead to significant delays in the initiation of appropriate therapy, she said.
Differential diagnoses for IBD in older patients include diverticulitis, ischemic colitis, infectious colitis, and radiation colitis.
Bharati Kochar, MD, MS, from the Crohn’s and Colitis Center at Massachusetts General Hospital in Boston, who was not involved in the presentation, agreed that older adults need special handling.
“The management of IBD in older adults is challenging for a number of reasons, but primarily because until very recently, we have not invested in understanding how IBD should be optimally managed at older ages,” she said in an interview.
“Additionally, like in all fields, older adults with IBD are disproportionately under-represented in clinical trials, meaning that we have less rigorous data guiding the management of older adults,” she added.
Clinical presentations
Older adults tend to differ in clinical presentation, compared with younger adults, Dr. Bernasko said.
For example, among patients with Crohn’s disease, rectal bleeding is a more common symptom among older adults, whereas diarrhea and weight loss are more common among younger adults.
Disease location may also differ, with more senior adults having predominantly colonic disease (L2 according to the Montreal Classification of IBD), compared with more prevalent ileocolonic disease (L3) among their more junior counterparts. And although both generations of patients have inflammatory behavior (B1) at diagnosis, younger patients have more prevalent structuring (B2) and penetrating disease (B3), Dr. Bernasko noted.
Among patients with ulcerative colitis, rectal bleeding, abdominal pain, and extraintestinal manifestations are more common among the younger set, whereas left-sided colitis is more common among older patients. In addition, extensive ulcerative colitis (E3) is more common in younger patients, compared with older patients.
Management considerations
Dr. Kochar noted that “older adults have higher baseline risks for all adverse events – like infections, malignancies, polypharmacy, procedural complications – than younger adults, so any additional risk conferred by treatments seem amplified, but that should not mean that we should avoid effectively treating older adults. It should mean we need to invest in understanding how to best mitigate those risks.”
While younger patients are sometimes on multiple medications prior to starting on IBD therapy, polypharmacy is common among the older set, who may be taking drugs for diabetes, hypertension, prostate disease, and so on.
“There’s just so much going on in terms of their medical background to start off with, so many medications, and then we’re adding more things to it,” Dr. Bernasko said.
She echoed Dr. Kochar in noting that older patients as a subgroup are under-represented in clinical trials, making it difficult to know what treatment approaches may work best for them.
In addition, older patients are at higher risk for malignancies, and for complications from surgery.
Medication adherence in older patients is frequently compromised by memory issues, she added, noting that “I can’t tell you enough how sometimes our older patients forget to take their medications.”
Other challenges for the management of older patients with IBD included psychosocial issues, cognitive decline, and malnutrition.
Medications and adverse events
Dr. Bernasko also discussed specific medications and potential adverse events and drug interactions in older patients.
For example, aminosalicylic acids (5-ASA) are associated with higher risk for nephrotoxicity and pancreatitis in older patients and can interact with thiopurines to cause leukopenia.
Steroids are associated with elevated risk for osteopenia, myopathy, cataracts, glaucoma, diabetes, and hypertension, and can interact with thiazide and loop diuretics to cause hypokalemia.
Methotrexate use in this population is linked to pancytopenia and hepatotoxicity, and it can interact with NSAIDs and multiple antibiotics to cause decreased renal secretion.
Thiopurines in older patients are associated with increased risk for leukopenia, myelosuppression, non-Hodgkin lymphoma, skin cancer, pancreatitis, and hepatotoxicity, and drugs in this class interact with allopurinol and angiotensin-converting enzyme inhibitors to increase risk for myelosuppression. Additionally, warfarin can inhibit the efficacy of thiopurines, and when these drugs are used in combination with tumor necrosis factor (TNF)–alpha inhibitors they can further increase risk of malignancy through immunosuppression.
Cyclosporine is associated with worsening hypertension and renal insufficiency among older patients.
TNF-alpha inhibitors are associated with increased risk for tuberculosis; hepatitis B; and fungal infections, malignant lymphoma, and New York Heart Association class 3 or 4 heart failure.
Ciprofloxacin in older patients with IBD has been linked to tendinopathy and increased risk for Clostridioides difficile infections. Metronidazole increases the likelihood of peripheral neuropathy in these patients.
Colon cancer screening
“When it comes to colon cancer screening, definitely assess the risk prior to doing this,” Dr. Bernasko recommended. “Weigh all the risks and benefits. Why are we doing this for these elderly patients, because there are definitely risks associated with this.”
Older patients with IBD may have difficulty with bowel prep and are at elevated risk, compared with younger patients, for cardiopulmonary complications, perforation, adverse events from sedation, and procedural complications, she cautioned.
“When it comes to our elderly patients, you want to focus on a more personalized approach – not all older people present the same way in terms of comorbidities or medications,” Dr. Bernasko advised in her summary.
Dr. Bernasko and Dr. Kochar reported having no relevant conflicts of interest to disclose. Dr. Kochar is a member of the board of editors for GI & Hepatology News.
This article was updated 2/18/22.
FROM CROHN’S & COLITIS CONGRESS
Malnutrition common in patients with IBD
Malnutrition is common among patients with inflammatory bowel disease (IBD) and is associated with worse outcomes that can prolong hospitalizations and increase patients’ risk for death.
As many as 85% of inpatients with IBD may be malnourished, with the severity of malnutrition affected by disease activity, extent, and duration, said Kelly Issokson, MS, RD, CNSC, clinical nutrition coordinator in the IBD program in the division of gastroenterology at Cedars-Sinai Medical Center, Los Angeles.
“Malnutrition is a severe complication of IBD, and it should not be overlooked,” she said during an oral presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
In patients with IBD, malabsorption, enteric losses, inadequate intake, and side effects of medical therapy can all lead to malnutrition, which in turn is an independent risk factor for venous thromboembolic events, nonelective surgery, longer hospital stays, and increased mortality.
In addition, malnutrition in IBD increases risk for infection and sepsis, and for perioperative complications, and can more than double the cost of care, compared with adequately nourished IBD patients, she said.
Ms. Issokson cited a definition of malnutrition from the American Society of Parenteral and Enteral Nutrition as “an acute or chronic state of overnutrition or undernutrition with or without inflammatory activity that has led to a change in body composition and diminished function.”
Lab findings of low albumin, low prealbumin, or isolated metrics such as weight loss or change in body mass index do not constitute malnutrition and should not be used to diagnosis it, Ms. Issokson cautioned.
Patients at low risk for malnutrition have no unintentional weight loss, are eating well, have minimal or no dietary restrictions, and no wasting. In contrast, high-risk patients have unintentional weight loss, decreased appetite and/or food intake, restrict multiple foods, or show signs of wasting.
Screening
“Nutrition screening is the first step in diagnosing a patient with malnutrition. This is a process of identifying individuals who may be at nutrition risk and benefit from assessment from a registered dietitian,” Ms. Issokson said.
The Malnutrition Screening Tool is quick, easy to administer, and requires minimal training. It can be used to screen adults for malnutrition regardless of age, medical history, or setting, she said.
The two-item instrument asks, “Have you recently lost weight without trying?” with a “no” scored as 0 and a “yes” scored as 2. The second question is, “Have you been eating poorly because of decreased appetite, with a “no” equal to 0 and a “yes” equal to 1. Patients with a score of 0 or 1 are not at risk, whereas patients with scores of 2 or 3 are deemed to be at risk for malnutrition and require further assessment by a dietitian.
Assessment
Assessment for malnutrition involves a variety of factors, including anthropometric factors such as weight and BMI changes; biochemical markers such as fat-soluble vitamins, water-soluble vitamins, minerals, and urinary sodium; symptoms such as decreased appetite, abdominal pain, cramping or bloating, diarrhea, or urgency or obstructive symptoms; and body composition measures such as handgrip strength, biochemical impedance analysis, skinfold thickness, bone mineral density, and muscle mass.
Other nutritional assessment tools may include 24-hour recall of nutrition intake, diet history, and questions about eating behaviors, food allergies or intolerances, and cultural or religious food preferences.
Assessing food security is also important, especially during the current pandemic, Ms. Issokson emphasized.
“Is your patient running out of food? Do they have money to purchase food? Are they able to go to the grocery store to buy food? This is essential to know when you’re developing a nutrition plan,” she said.
A nutrition-focused physical exam should include assessment of skin manifestation, secondary to malnutrition or malabsorption, such as dry skin, delayed wound healing, stomatitis, scurvy, seborrheic dermatitis, bleeding, and periorificial and acral dermatitis or alopecia.
Diagnosis
Currently available malnutrition criteria have not been validated for use in patients with IBD, and further studies are needed to affirm their applicability to this population, Ms. Issokson said.
The Academy of Nutrition and Dietetics–American Society for Parenteral and Enteral Nutrition (AND-ASPEN) malnutrition criteria require measures of weight loss, energy intake, subcutaneous fat loss, subcutaneous muscle loss, general or local fluid accumulation, and handgrip strength to determine whether a patient is moderately or severely malnourished.
Ms. Issokson said that she finds the European Society for Clinical Nutrition and Metabolism Global Leadership Initiative on Malnutrition (ESPEN GLIM) criteria somewhat easier to use for diagnosis, as they consist of phenotypic and etiologic criteria, with patients who meet at least one of each being considered malnourished.
“When identified, document malnutrition, and of course intervene appropriately by referring to a dietitian providing education and supporting the patient to help them optimize their nutrition and improve their outcomes,” she concluded.
In a discussion following the session, panelist Neha Shah, MPH, RD, CNSC, a dietitian and health education specialist at the University of California, San Francisco, commented on the importance of malnutrition assessment in patients with IBD being considered for surgery.
Patients should be screened for malnutrition, and if they have a positive screen, “should be automatically referred to a registered dietitian specializing in IBD for a nutrition assessment,” she said.
“Certainly, a nutritional assessment, as Kelly has highlighted really well, will encompass an evaluation of various areas of health – patient history, food and nutrition history, changing anthropometrics, alterations in labs – and certainly going into further nutrition history with net food intolerance, intake from each food group, portions, access, support, culture, eating environment, skills in the kitchen, relationship with diet.”
Ms. Issokson is a board member of the Crohn’s & Colitis Foundation and a digital advisory board member of Avant Healthcare. Ms. Shah had no disclosures.
Malnutrition is common among patients with inflammatory bowel disease (IBD) and is associated with worse outcomes that can prolong hospitalizations and increase patients’ risk for death.
As many as 85% of inpatients with IBD may be malnourished, with the severity of malnutrition affected by disease activity, extent, and duration, said Kelly Issokson, MS, RD, CNSC, clinical nutrition coordinator in the IBD program in the division of gastroenterology at Cedars-Sinai Medical Center, Los Angeles.
“Malnutrition is a severe complication of IBD, and it should not be overlooked,” she said during an oral presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
In patients with IBD, malabsorption, enteric losses, inadequate intake, and side effects of medical therapy can all lead to malnutrition, which in turn is an independent risk factor for venous thromboembolic events, nonelective surgery, longer hospital stays, and increased mortality.
In addition, malnutrition in IBD increases risk for infection and sepsis, and for perioperative complications, and can more than double the cost of care, compared with adequately nourished IBD patients, she said.
Ms. Issokson cited a definition of malnutrition from the American Society of Parenteral and Enteral Nutrition as “an acute or chronic state of overnutrition or undernutrition with or without inflammatory activity that has led to a change in body composition and diminished function.”
Lab findings of low albumin, low prealbumin, or isolated metrics such as weight loss or change in body mass index do not constitute malnutrition and should not be used to diagnosis it, Ms. Issokson cautioned.
Patients at low risk for malnutrition have no unintentional weight loss, are eating well, have minimal or no dietary restrictions, and no wasting. In contrast, high-risk patients have unintentional weight loss, decreased appetite and/or food intake, restrict multiple foods, or show signs of wasting.
Screening
“Nutrition screening is the first step in diagnosing a patient with malnutrition. This is a process of identifying individuals who may be at nutrition risk and benefit from assessment from a registered dietitian,” Ms. Issokson said.
The Malnutrition Screening Tool is quick, easy to administer, and requires minimal training. It can be used to screen adults for malnutrition regardless of age, medical history, or setting, she said.
The two-item instrument asks, “Have you recently lost weight without trying?” with a “no” scored as 0 and a “yes” scored as 2. The second question is, “Have you been eating poorly because of decreased appetite, with a “no” equal to 0 and a “yes” equal to 1. Patients with a score of 0 or 1 are not at risk, whereas patients with scores of 2 or 3 are deemed to be at risk for malnutrition and require further assessment by a dietitian.
Assessment
Assessment for malnutrition involves a variety of factors, including anthropometric factors such as weight and BMI changes; biochemical markers such as fat-soluble vitamins, water-soluble vitamins, minerals, and urinary sodium; symptoms such as decreased appetite, abdominal pain, cramping or bloating, diarrhea, or urgency or obstructive symptoms; and body composition measures such as handgrip strength, biochemical impedance analysis, skinfold thickness, bone mineral density, and muscle mass.
Other nutritional assessment tools may include 24-hour recall of nutrition intake, diet history, and questions about eating behaviors, food allergies or intolerances, and cultural or religious food preferences.
Assessing food security is also important, especially during the current pandemic, Ms. Issokson emphasized.
“Is your patient running out of food? Do they have money to purchase food? Are they able to go to the grocery store to buy food? This is essential to know when you’re developing a nutrition plan,” she said.
A nutrition-focused physical exam should include assessment of skin manifestation, secondary to malnutrition or malabsorption, such as dry skin, delayed wound healing, stomatitis, scurvy, seborrheic dermatitis, bleeding, and periorificial and acral dermatitis or alopecia.
Diagnosis
Currently available malnutrition criteria have not been validated for use in patients with IBD, and further studies are needed to affirm their applicability to this population, Ms. Issokson said.
The Academy of Nutrition and Dietetics–American Society for Parenteral and Enteral Nutrition (AND-ASPEN) malnutrition criteria require measures of weight loss, energy intake, subcutaneous fat loss, subcutaneous muscle loss, general or local fluid accumulation, and handgrip strength to determine whether a patient is moderately or severely malnourished.
Ms. Issokson said that she finds the European Society for Clinical Nutrition and Metabolism Global Leadership Initiative on Malnutrition (ESPEN GLIM) criteria somewhat easier to use for diagnosis, as they consist of phenotypic and etiologic criteria, with patients who meet at least one of each being considered malnourished.
“When identified, document malnutrition, and of course intervene appropriately by referring to a dietitian providing education and supporting the patient to help them optimize their nutrition and improve their outcomes,” she concluded.
In a discussion following the session, panelist Neha Shah, MPH, RD, CNSC, a dietitian and health education specialist at the University of California, San Francisco, commented on the importance of malnutrition assessment in patients with IBD being considered for surgery.
Patients should be screened for malnutrition, and if they have a positive screen, “should be automatically referred to a registered dietitian specializing in IBD for a nutrition assessment,” she said.
“Certainly, a nutritional assessment, as Kelly has highlighted really well, will encompass an evaluation of various areas of health – patient history, food and nutrition history, changing anthropometrics, alterations in labs – and certainly going into further nutrition history with net food intolerance, intake from each food group, portions, access, support, culture, eating environment, skills in the kitchen, relationship with diet.”
Ms. Issokson is a board member of the Crohn’s & Colitis Foundation and a digital advisory board member of Avant Healthcare. Ms. Shah had no disclosures.
Malnutrition is common among patients with inflammatory bowel disease (IBD) and is associated with worse outcomes that can prolong hospitalizations and increase patients’ risk for death.
As many as 85% of inpatients with IBD may be malnourished, with the severity of malnutrition affected by disease activity, extent, and duration, said Kelly Issokson, MS, RD, CNSC, clinical nutrition coordinator in the IBD program in the division of gastroenterology at Cedars-Sinai Medical Center, Los Angeles.
“Malnutrition is a severe complication of IBD, and it should not be overlooked,” she said during an oral presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
In patients with IBD, malabsorption, enteric losses, inadequate intake, and side effects of medical therapy can all lead to malnutrition, which in turn is an independent risk factor for venous thromboembolic events, nonelective surgery, longer hospital stays, and increased mortality.
In addition, malnutrition in IBD increases risk for infection and sepsis, and for perioperative complications, and can more than double the cost of care, compared with adequately nourished IBD patients, she said.
Ms. Issokson cited a definition of malnutrition from the American Society of Parenteral and Enteral Nutrition as “an acute or chronic state of overnutrition or undernutrition with or without inflammatory activity that has led to a change in body composition and diminished function.”
Lab findings of low albumin, low prealbumin, or isolated metrics such as weight loss or change in body mass index do not constitute malnutrition and should not be used to diagnosis it, Ms. Issokson cautioned.
Patients at low risk for malnutrition have no unintentional weight loss, are eating well, have minimal or no dietary restrictions, and no wasting. In contrast, high-risk patients have unintentional weight loss, decreased appetite and/or food intake, restrict multiple foods, or show signs of wasting.
Screening
“Nutrition screening is the first step in diagnosing a patient with malnutrition. This is a process of identifying individuals who may be at nutrition risk and benefit from assessment from a registered dietitian,” Ms. Issokson said.
The Malnutrition Screening Tool is quick, easy to administer, and requires minimal training. It can be used to screen adults for malnutrition regardless of age, medical history, or setting, she said.
The two-item instrument asks, “Have you recently lost weight without trying?” with a “no” scored as 0 and a “yes” scored as 2. The second question is, “Have you been eating poorly because of decreased appetite, with a “no” equal to 0 and a “yes” equal to 1. Patients with a score of 0 or 1 are not at risk, whereas patients with scores of 2 or 3 are deemed to be at risk for malnutrition and require further assessment by a dietitian.
Assessment
Assessment for malnutrition involves a variety of factors, including anthropometric factors such as weight and BMI changes; biochemical markers such as fat-soluble vitamins, water-soluble vitamins, minerals, and urinary sodium; symptoms such as decreased appetite, abdominal pain, cramping or bloating, diarrhea, or urgency or obstructive symptoms; and body composition measures such as handgrip strength, biochemical impedance analysis, skinfold thickness, bone mineral density, and muscle mass.
Other nutritional assessment tools may include 24-hour recall of nutrition intake, diet history, and questions about eating behaviors, food allergies or intolerances, and cultural or religious food preferences.
Assessing food security is also important, especially during the current pandemic, Ms. Issokson emphasized.
“Is your patient running out of food? Do they have money to purchase food? Are they able to go to the grocery store to buy food? This is essential to know when you’re developing a nutrition plan,” she said.
A nutrition-focused physical exam should include assessment of skin manifestation, secondary to malnutrition or malabsorption, such as dry skin, delayed wound healing, stomatitis, scurvy, seborrheic dermatitis, bleeding, and periorificial and acral dermatitis or alopecia.
Diagnosis
Currently available malnutrition criteria have not been validated for use in patients with IBD, and further studies are needed to affirm their applicability to this population, Ms. Issokson said.
The Academy of Nutrition and Dietetics–American Society for Parenteral and Enteral Nutrition (AND-ASPEN) malnutrition criteria require measures of weight loss, energy intake, subcutaneous fat loss, subcutaneous muscle loss, general or local fluid accumulation, and handgrip strength to determine whether a patient is moderately or severely malnourished.
Ms. Issokson said that she finds the European Society for Clinical Nutrition and Metabolism Global Leadership Initiative on Malnutrition (ESPEN GLIM) criteria somewhat easier to use for diagnosis, as they consist of phenotypic and etiologic criteria, with patients who meet at least one of each being considered malnourished.
“When identified, document malnutrition, and of course intervene appropriately by referring to a dietitian providing education and supporting the patient to help them optimize their nutrition and improve their outcomes,” she concluded.
In a discussion following the session, panelist Neha Shah, MPH, RD, CNSC, a dietitian and health education specialist at the University of California, San Francisco, commented on the importance of malnutrition assessment in patients with IBD being considered for surgery.
Patients should be screened for malnutrition, and if they have a positive screen, “should be automatically referred to a registered dietitian specializing in IBD for a nutrition assessment,” she said.
“Certainly, a nutritional assessment, as Kelly has highlighted really well, will encompass an evaluation of various areas of health – patient history, food and nutrition history, changing anthropometrics, alterations in labs – and certainly going into further nutrition history with net food intolerance, intake from each food group, portions, access, support, culture, eating environment, skills in the kitchen, relationship with diet.”
Ms. Issokson is a board member of the Crohn’s & Colitis Foundation and a digital advisory board member of Avant Healthcare. Ms. Shah had no disclosures.
FROM THE CROHN’S & COLITIS CONGRESS
Breakthrough COVID-19 milder in vaccinated patients with IBD
Vaccination against SARS-CoV-2 appears to protect people with inflammatory bowel disease (IBD) from the more serious consequences of breakthrough COVID-19 infections, but results may vary by which vaccine was received, results of a small study suggest.
In a study of patients with IBD who had completed a primary vaccine series but went on to develop COVID-19, there were trends toward worse outcomes for patients who received a non-mRNA vaccine, older patients, and those who were on combination therapy rather than monotherapy, reported Emily Spiera, a medical student at the Icahn School of Medicine at Mount Sinai, New York.
“Overall, we saw that vaccinated patients who subsequently developed COVID-19 had low rates of hospitalization, severe COVID, and death,” she said in an oral abstract at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
The study was conducted before the highly infectious Omicron variant of SARS-CoV-2 became dominant, however, and the sample size of 88 patients, combined with a low number of study events, was too small for statistical significance to emerge for most measures, Ms. Spiera acknowledged.
Nonetheless, the findings support the protective benefit of vaccines in this population, said Freddy Caldera, DO, associate professor of gastroenterology at the University of Wisconsin–Madison, who was not involved in the study.
“In my mind, when we think about COVID vaccines, the whole goal is to prevent severe disease,” he said.
Dr. Caldera and colleagues conducted an earlier study of humoral immunogenicity of mRNA COVID-19 vaccines in 122 patients with IBD and 60 healthy controls, and found that all controls and 97% of patients with IBD developed antibodies, although antibody concentrations were lower in patients with IBD, compared with controls (P < .001). Those who received the mRNA-1273 (Moderna) COVID-19 had significantly higher antibody concentrations than those who received the Pfizer-BNT vaccine series (P < .001).
They also found that patients on immune-modifying therapy had lower antibody concentrations, compared with those who were not on such therapy, or those who received aminosalicylates or vedolizumab (Entyvio; P = .003).
The protective effect of vaccines in this population became even more apparent after patients received an additional vaccine dose.
“We actually have a study in preprint of what happens after a third dose, where everyone made antibodies,” he said. “What we tell patients is that vaccines work.”
SECURE-IBD data
The investigators at Mount Sinai, the University of North Carolina at Chapel Hill, and Tel Aviv University analyzed data from the Surveillance Epidemiology of Coronavirus Under Research Exclusion in Inflammatory Bowel Disease (SECURE-IBD) database, an international web-based registry that includes reports from 74 countries, with data reported by 48 U.S. states.
The study sample consisted of patients enrolled from Dec. 12, 2020, to Oct. 1, 2021, who had completed a primary vaccination series with either mRNA vaccines (Pfizer or Moderna) adenoviral vector-based vaccines (AstraZeneca, Sputnik, CanSino, or Janssen/Johnson & Johnson), or an inactivated SARS-CoV-2 vaccine (Sinovac).
Of 2,477 patients with COVID-19 infections reported to SECURE-IBD, 160 reported being vaccinated. Of this group, 53 were excluded because they were only partially vaccinated, and 19 were excluded because of missing data on either vaccine type, number of doses, or COVID-19 outcomes, leaving 88 patients with completed primary vaccination series at the time of COVID-19 infection.
The median patient age was 40.1 years. Nearly two-thirds of the patients had a diagnosis of Crohn’s disease, and slightly more than one-third has a diagnosis of ulcerative colitis. The patients came from 18 countries, with 45.3% of the sample in the United States.
A total of 58% of patients were on biologic monotherapy, with either a tumor necrosis factor antagonist, integrin antagonist, or anti–interleukin-12/13. In addition, 3.4% were on immunomodulator monotherapy, 21.6% were on combination therapy, and 5.7% were receiving corticosteroids.
Lower severity
COVID-19 severity was numerically but not significantly lower among the 88 vaccinated patients, with a rate of 5.7%, compared with 9.3% among 2,317 patients with COVID-19 infections in the database who were not vaccinated.
COVID-19 severity defined as a composite of ICU admission, need for mechanical ventilation and/or death was actually slightly higher among the vaccinated patients, with a rate of 3.4% versus 1.9% for nonvaccinated patients, but this difference was not statistically significant.
There was 1 death among vaccinated patients (1.1%) versus 29 among the unvaccinated (1.2%).
There were trends toward fewer hospitalizations and less-frequent severe COVID-19 infection among patients who received a mRNA vaccine, compared with other vaccine types, but again these differences did not reach statistical significance.
As noted before, there was a higher frequency of severe COVID-19 among patients on combination therapy than on monotherapy, but this difference too was not statistically significant.
As seen with COVID-19 in the general population older patients tended to have worse outcomes, with a mean age of 53 for patients requiring hospitalization, compared with 39 years for patients who stayed out of the hospital (P = .04), and a mean age of 59 among patients with severe COVID-19 infections, compared with 39 for patients with moderate or mild infections (P = .03).
Ms. Spiera described the case of the single vaccinated patient who died. The 63-year-old woman had moderately active Crohn’s disease treated with corticosteroids, adalimumab (Humira) and azathioprine at the time of COVID-19 infection. She had received the AstraZeneca adenoviral-based vaccine more than 30 days prior to infection. She was hospitalized and intubated, and died from gastrointestinal bleeding.
Ms. Spiera noted that, although the sample size was small, and only patients known to have COVID-19 were included, it is one of the largest cohorts to date of vaccinated patients with IBD who developed COVID-19. She said that the study supports prior studies showing that combination therapy and tumor necrosis factor antagonists may result in reduced immunity, and that mRNA vaccines may offer better protection against severe illness in this population.
The study was supported by a Digestive Disease Research Foundation Fellowship. Ms. Spiera and Dr. Caldera reported no relevant disclosures.
Vaccination against SARS-CoV-2 appears to protect people with inflammatory bowel disease (IBD) from the more serious consequences of breakthrough COVID-19 infections, but results may vary by which vaccine was received, results of a small study suggest.
In a study of patients with IBD who had completed a primary vaccine series but went on to develop COVID-19, there were trends toward worse outcomes for patients who received a non-mRNA vaccine, older patients, and those who were on combination therapy rather than monotherapy, reported Emily Spiera, a medical student at the Icahn School of Medicine at Mount Sinai, New York.
“Overall, we saw that vaccinated patients who subsequently developed COVID-19 had low rates of hospitalization, severe COVID, and death,” she said in an oral abstract at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
The study was conducted before the highly infectious Omicron variant of SARS-CoV-2 became dominant, however, and the sample size of 88 patients, combined with a low number of study events, was too small for statistical significance to emerge for most measures, Ms. Spiera acknowledged.
Nonetheless, the findings support the protective benefit of vaccines in this population, said Freddy Caldera, DO, associate professor of gastroenterology at the University of Wisconsin–Madison, who was not involved in the study.
“In my mind, when we think about COVID vaccines, the whole goal is to prevent severe disease,” he said.
Dr. Caldera and colleagues conducted an earlier study of humoral immunogenicity of mRNA COVID-19 vaccines in 122 patients with IBD and 60 healthy controls, and found that all controls and 97% of patients with IBD developed antibodies, although antibody concentrations were lower in patients with IBD, compared with controls (P < .001). Those who received the mRNA-1273 (Moderna) COVID-19 had significantly higher antibody concentrations than those who received the Pfizer-BNT vaccine series (P < .001).
They also found that patients on immune-modifying therapy had lower antibody concentrations, compared with those who were not on such therapy, or those who received aminosalicylates or vedolizumab (Entyvio; P = .003).
The protective effect of vaccines in this population became even more apparent after patients received an additional vaccine dose.
“We actually have a study in preprint of what happens after a third dose, where everyone made antibodies,” he said. “What we tell patients is that vaccines work.”
SECURE-IBD data
The investigators at Mount Sinai, the University of North Carolina at Chapel Hill, and Tel Aviv University analyzed data from the Surveillance Epidemiology of Coronavirus Under Research Exclusion in Inflammatory Bowel Disease (SECURE-IBD) database, an international web-based registry that includes reports from 74 countries, with data reported by 48 U.S. states.
The study sample consisted of patients enrolled from Dec. 12, 2020, to Oct. 1, 2021, who had completed a primary vaccination series with either mRNA vaccines (Pfizer or Moderna) adenoviral vector-based vaccines (AstraZeneca, Sputnik, CanSino, or Janssen/Johnson & Johnson), or an inactivated SARS-CoV-2 vaccine (Sinovac).
Of 2,477 patients with COVID-19 infections reported to SECURE-IBD, 160 reported being vaccinated. Of this group, 53 were excluded because they were only partially vaccinated, and 19 were excluded because of missing data on either vaccine type, number of doses, or COVID-19 outcomes, leaving 88 patients with completed primary vaccination series at the time of COVID-19 infection.
The median patient age was 40.1 years. Nearly two-thirds of the patients had a diagnosis of Crohn’s disease, and slightly more than one-third has a diagnosis of ulcerative colitis. The patients came from 18 countries, with 45.3% of the sample in the United States.
A total of 58% of patients were on biologic monotherapy, with either a tumor necrosis factor antagonist, integrin antagonist, or anti–interleukin-12/13. In addition, 3.4% were on immunomodulator monotherapy, 21.6% were on combination therapy, and 5.7% were receiving corticosteroids.
Lower severity
COVID-19 severity was numerically but not significantly lower among the 88 vaccinated patients, with a rate of 5.7%, compared with 9.3% among 2,317 patients with COVID-19 infections in the database who were not vaccinated.
COVID-19 severity defined as a composite of ICU admission, need for mechanical ventilation and/or death was actually slightly higher among the vaccinated patients, with a rate of 3.4% versus 1.9% for nonvaccinated patients, but this difference was not statistically significant.
There was 1 death among vaccinated patients (1.1%) versus 29 among the unvaccinated (1.2%).
There were trends toward fewer hospitalizations and less-frequent severe COVID-19 infection among patients who received a mRNA vaccine, compared with other vaccine types, but again these differences did not reach statistical significance.
As noted before, there was a higher frequency of severe COVID-19 among patients on combination therapy than on monotherapy, but this difference too was not statistically significant.
As seen with COVID-19 in the general population older patients tended to have worse outcomes, with a mean age of 53 for patients requiring hospitalization, compared with 39 years for patients who stayed out of the hospital (P = .04), and a mean age of 59 among patients with severe COVID-19 infections, compared with 39 for patients with moderate or mild infections (P = .03).
Ms. Spiera described the case of the single vaccinated patient who died. The 63-year-old woman had moderately active Crohn’s disease treated with corticosteroids, adalimumab (Humira) and azathioprine at the time of COVID-19 infection. She had received the AstraZeneca adenoviral-based vaccine more than 30 days prior to infection. She was hospitalized and intubated, and died from gastrointestinal bleeding.
Ms. Spiera noted that, although the sample size was small, and only patients known to have COVID-19 were included, it is one of the largest cohorts to date of vaccinated patients with IBD who developed COVID-19. She said that the study supports prior studies showing that combination therapy and tumor necrosis factor antagonists may result in reduced immunity, and that mRNA vaccines may offer better protection against severe illness in this population.
The study was supported by a Digestive Disease Research Foundation Fellowship. Ms. Spiera and Dr. Caldera reported no relevant disclosures.
Vaccination against SARS-CoV-2 appears to protect people with inflammatory bowel disease (IBD) from the more serious consequences of breakthrough COVID-19 infections, but results may vary by which vaccine was received, results of a small study suggest.
In a study of patients with IBD who had completed a primary vaccine series but went on to develop COVID-19, there were trends toward worse outcomes for patients who received a non-mRNA vaccine, older patients, and those who were on combination therapy rather than monotherapy, reported Emily Spiera, a medical student at the Icahn School of Medicine at Mount Sinai, New York.
“Overall, we saw that vaccinated patients who subsequently developed COVID-19 had low rates of hospitalization, severe COVID, and death,” she said in an oral abstract at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
The study was conducted before the highly infectious Omicron variant of SARS-CoV-2 became dominant, however, and the sample size of 88 patients, combined with a low number of study events, was too small for statistical significance to emerge for most measures, Ms. Spiera acknowledged.
Nonetheless, the findings support the protective benefit of vaccines in this population, said Freddy Caldera, DO, associate professor of gastroenterology at the University of Wisconsin–Madison, who was not involved in the study.
“In my mind, when we think about COVID vaccines, the whole goal is to prevent severe disease,” he said.
Dr. Caldera and colleagues conducted an earlier study of humoral immunogenicity of mRNA COVID-19 vaccines in 122 patients with IBD and 60 healthy controls, and found that all controls and 97% of patients with IBD developed antibodies, although antibody concentrations were lower in patients with IBD, compared with controls (P < .001). Those who received the mRNA-1273 (Moderna) COVID-19 had significantly higher antibody concentrations than those who received the Pfizer-BNT vaccine series (P < .001).
They also found that patients on immune-modifying therapy had lower antibody concentrations, compared with those who were not on such therapy, or those who received aminosalicylates or vedolizumab (Entyvio; P = .003).
The protective effect of vaccines in this population became even more apparent after patients received an additional vaccine dose.
“We actually have a study in preprint of what happens after a third dose, where everyone made antibodies,” he said. “What we tell patients is that vaccines work.”
SECURE-IBD data
The investigators at Mount Sinai, the University of North Carolina at Chapel Hill, and Tel Aviv University analyzed data from the Surveillance Epidemiology of Coronavirus Under Research Exclusion in Inflammatory Bowel Disease (SECURE-IBD) database, an international web-based registry that includes reports from 74 countries, with data reported by 48 U.S. states.
The study sample consisted of patients enrolled from Dec. 12, 2020, to Oct. 1, 2021, who had completed a primary vaccination series with either mRNA vaccines (Pfizer or Moderna) adenoviral vector-based vaccines (AstraZeneca, Sputnik, CanSino, or Janssen/Johnson & Johnson), or an inactivated SARS-CoV-2 vaccine (Sinovac).
Of 2,477 patients with COVID-19 infections reported to SECURE-IBD, 160 reported being vaccinated. Of this group, 53 were excluded because they were only partially vaccinated, and 19 were excluded because of missing data on either vaccine type, number of doses, or COVID-19 outcomes, leaving 88 patients with completed primary vaccination series at the time of COVID-19 infection.
The median patient age was 40.1 years. Nearly two-thirds of the patients had a diagnosis of Crohn’s disease, and slightly more than one-third has a diagnosis of ulcerative colitis. The patients came from 18 countries, with 45.3% of the sample in the United States.
A total of 58% of patients were on biologic monotherapy, with either a tumor necrosis factor antagonist, integrin antagonist, or anti–interleukin-12/13. In addition, 3.4% were on immunomodulator monotherapy, 21.6% were on combination therapy, and 5.7% were receiving corticosteroids.
Lower severity
COVID-19 severity was numerically but not significantly lower among the 88 vaccinated patients, with a rate of 5.7%, compared with 9.3% among 2,317 patients with COVID-19 infections in the database who were not vaccinated.
COVID-19 severity defined as a composite of ICU admission, need for mechanical ventilation and/or death was actually slightly higher among the vaccinated patients, with a rate of 3.4% versus 1.9% for nonvaccinated patients, but this difference was not statistically significant.
There was 1 death among vaccinated patients (1.1%) versus 29 among the unvaccinated (1.2%).
There were trends toward fewer hospitalizations and less-frequent severe COVID-19 infection among patients who received a mRNA vaccine, compared with other vaccine types, but again these differences did not reach statistical significance.
As noted before, there was a higher frequency of severe COVID-19 among patients on combination therapy than on monotherapy, but this difference too was not statistically significant.
As seen with COVID-19 in the general population older patients tended to have worse outcomes, with a mean age of 53 for patients requiring hospitalization, compared with 39 years for patients who stayed out of the hospital (P = .04), and a mean age of 59 among patients with severe COVID-19 infections, compared with 39 for patients with moderate or mild infections (P = .03).
Ms. Spiera described the case of the single vaccinated patient who died. The 63-year-old woman had moderately active Crohn’s disease treated with corticosteroids, adalimumab (Humira) and azathioprine at the time of COVID-19 infection. She had received the AstraZeneca adenoviral-based vaccine more than 30 days prior to infection. She was hospitalized and intubated, and died from gastrointestinal bleeding.
Ms. Spiera noted that, although the sample size was small, and only patients known to have COVID-19 were included, it is one of the largest cohorts to date of vaccinated patients with IBD who developed COVID-19. She said that the study supports prior studies showing that combination therapy and tumor necrosis factor antagonists may result in reduced immunity, and that mRNA vaccines may offer better protection against severe illness in this population.
The study was supported by a Digestive Disease Research Foundation Fellowship. Ms. Spiera and Dr. Caldera reported no relevant disclosures.
FROM THE CROHN’S & COLITIS CONGRESS
ARFID or reasonable food restriction? The jury is out
Problems with eating and nutrition are common among patients with inflammatory bowel disease (IBD) and other gastrointestinal disorders, but clinicians who treat them should be careful not to automatically assume that patients have eating disorders, according to a psychologist who specializes in the psychological and social aspects of chronic digestive diseases.
On the other hand, clinicians must also be aware of the possibility that patients could have a recently identified syndrome cluster called avoidant restrictive food intake disorder (ARFID), said Tiffany Taft, PsyD, a research associate professor of medicine (gastroenterology and hepatology), medical social sciences, and psychiatry and behavioral sciences at Northwestern University, Chicago. In a recent study, she and her colleagues defined ARFID as “failure to meet one’s nutritional needs owing to sensory hypersensitivity, lack of interest in eating, or fear of aversive consequences from eating, and is associated with negative medical and psychosocial outcomes.”
ARFID “is a hot topic that we really don’t understand,” she said in an online presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
Nutritional deficiencies
Nutritional deficiencies are common among patients with IBD, “and nutritional deficiencies themselves can lead to symptoms or side effects that can cause people to eat less,” she said.
“As our vitamin B12 goes down, our cognitive functioning starts to decline, and we might not be making clear decisions in how we’re deciding what to eat, when to eat, if we should be eating at all – just something to think about in your patients who have nutritional deficiencies,” she told the audience.
Other common nutritional deficiencies that can affect eating and food choice among patients with IBD include low folate (B9) levels associated with sore tongue and weight loss, low iron levels leading to nausea and loss of appetite, and zinc deficiency leading to loss of appetite and alterations in taste and/or smell, she said.
Newly recognized in GI
She noted that “ARFID actually originates in the pediatric psychiatric literature, mostly in children with sensory issues [such as] autism spectrum disorder, so this is not a construct that started in digestive disease, but has been adapted and applied to patients with digestive disease, including IBD.”
The DSM-5 lists four criteria for ARFID: significant weight loss, significant nutritional deficiency, dependence on enteral nutrition or oral supplements, and marked interference with psychosocial functions.
Helen Burton Murray, PhD, director of the gastrointestinal behavioral health program in the Center for Neurointestinal Health at Massachusetts General Hospital, Boston, who is familiar with Dr. Taft’s work, said in an interview that inclusion of ARFID in DSM-5 has put a name to a syndrome or symptom cluster that in all likelihood already existed.
However, “the jury is still out about whether, if we do diagnose patients who have digestive diseases with ARFID, that then helps them get to a treatment that improves their relationship with food and improves nutritional issues that may have occurred as a result of a restricted food intake,” she said.
“We don’t know yet if the diagnosis will actually improve things. In our clinical practice, anecdotally, it has, both for patients with IBDs and for patients with other GI conditions, particularly GI functional motility disorders. We’re a little bit more confident about making the diagnosis of ARFID in GI functional motility disorders than we are in IBD of course,” she said.
Screening measures
To get a better sense of the prevalence of ARFID, compared with reasonable responses to digestive diseases, Dr. Taft and colleagues conducted their cross-sectional study in 289 adults with achalasia, celiac, eosinophilic esophagitis, or IBD.
They found that 51.3% of the total sample met the diagnostic criteria for ARFID based on the Nine-Item ARFID Screen (NIAS), including 75.7 % of patients with achalasia. But Dr. Taft had cautions
“I can tell you, working with achalasia patients, 75% do not have ARFID,” Dr. Taft said.
She noted that the 51.3% of patients with IBD identified by NIAS or the 53% identified by the ARFID+ scale as having ARFID was also highly doubtful.
Dr. Taft and colleagues determined that nearly half of the variance in the NIAS could be accounted for by GI symptoms rather than psychosocial factors, making it less than ideal for use in the clinic or by researchers.
She also noted, however, that she received an email from one of the creators of NIAS, Hana F. Zickgraf, PhD, from the University of South Alabama, Mobile. Dr. Zickgraf agreed that the scale had drawbacks when applied to patients with GI disease, and pointed instead to the Fear of Food Questionnaire, a newly developed 18-item GI disease-specific instrument. Dr. Taft recommended the new questionnaire for research purposes, and expressed hope that a shorter version could be made available for screening patients in clinic.
Dr. Burton Murray said that while the Fear of Food Questionnaire, perhaps in combination with NIAS, has the potential to be a useful screening tool, cutoffs for it have yet to be established.
“At the end of the day, the diagnosis would be made by a clinician who is able to determine whether the life impairment or if the nutritional impairment or restricted food intake are reasonable in the realm of their digestive disease, or could a treatment for ARFID be warranted to help them to make changes to improve their quality of life and nutrition,” she said.
Check biases at the door
Before arriving at a diagnosis of ARFID, clinicians should also consider biases, Dr. Taft said.
“Eating disorders are highly stigmatized and stereotyped diagnoses,” more often attributed to young White women than to either men or to people of racial or ethnic minorities, she said.
Cultural background may contribute to food restrictions, and the risk may increase with age, with 68% of patients with later-onset IBD restricting diets to control the disease. It’s also possible that beliefs about food and “clean and healthy” eating may influence food and eating choices after a patient receives an IBD diagnosis.
Dr. Taft also pointed out that clinicians and patients may have different ideas about what constitutes significant food avoidance. Clinicians may expect patients with IBD to eat despite feeling nauseated, having abdominal pains, or diarrhea, for example, when the same food avoidance might be deemed reasonable in patients with short-term GI infections.
“Severe IBD symptoms are a significant predictor of posttraumatic stress disorder symptoms, and PTSD is hallmarked by avoidance behaviors,” she added.
She emphasized the need for clinicians to ask the right questions of patients to get at the roots of their nutritional deficiency or eating behavior, and to refer patients to mental health professionals with expertise in disordered eating or GI psychology.
Dr. Taft and Dr. Burton Murray reported having no conflicts of interest to disclose.
This article was updated on Feb. 4, 2022.
Problems with eating and nutrition are common among patients with inflammatory bowel disease (IBD) and other gastrointestinal disorders, but clinicians who treat them should be careful not to automatically assume that patients have eating disorders, according to a psychologist who specializes in the psychological and social aspects of chronic digestive diseases.
On the other hand, clinicians must also be aware of the possibility that patients could have a recently identified syndrome cluster called avoidant restrictive food intake disorder (ARFID), said Tiffany Taft, PsyD, a research associate professor of medicine (gastroenterology and hepatology), medical social sciences, and psychiatry and behavioral sciences at Northwestern University, Chicago. In a recent study, she and her colleagues defined ARFID as “failure to meet one’s nutritional needs owing to sensory hypersensitivity, lack of interest in eating, or fear of aversive consequences from eating, and is associated with negative medical and psychosocial outcomes.”
ARFID “is a hot topic that we really don’t understand,” she said in an online presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
Nutritional deficiencies
Nutritional deficiencies are common among patients with IBD, “and nutritional deficiencies themselves can lead to symptoms or side effects that can cause people to eat less,” she said.
“As our vitamin B12 goes down, our cognitive functioning starts to decline, and we might not be making clear decisions in how we’re deciding what to eat, when to eat, if we should be eating at all – just something to think about in your patients who have nutritional deficiencies,” she told the audience.
Other common nutritional deficiencies that can affect eating and food choice among patients with IBD include low folate (B9) levels associated with sore tongue and weight loss, low iron levels leading to nausea and loss of appetite, and zinc deficiency leading to loss of appetite and alterations in taste and/or smell, she said.
Newly recognized in GI
She noted that “ARFID actually originates in the pediatric psychiatric literature, mostly in children with sensory issues [such as] autism spectrum disorder, so this is not a construct that started in digestive disease, but has been adapted and applied to patients with digestive disease, including IBD.”
The DSM-5 lists four criteria for ARFID: significant weight loss, significant nutritional deficiency, dependence on enteral nutrition or oral supplements, and marked interference with psychosocial functions.
Helen Burton Murray, PhD, director of the gastrointestinal behavioral health program in the Center for Neurointestinal Health at Massachusetts General Hospital, Boston, who is familiar with Dr. Taft’s work, said in an interview that inclusion of ARFID in DSM-5 has put a name to a syndrome or symptom cluster that in all likelihood already existed.
However, “the jury is still out about whether, if we do diagnose patients who have digestive diseases with ARFID, that then helps them get to a treatment that improves their relationship with food and improves nutritional issues that may have occurred as a result of a restricted food intake,” she said.
“We don’t know yet if the diagnosis will actually improve things. In our clinical practice, anecdotally, it has, both for patients with IBDs and for patients with other GI conditions, particularly GI functional motility disorders. We’re a little bit more confident about making the diagnosis of ARFID in GI functional motility disorders than we are in IBD of course,” she said.
Screening measures
To get a better sense of the prevalence of ARFID, compared with reasonable responses to digestive diseases, Dr. Taft and colleagues conducted their cross-sectional study in 289 adults with achalasia, celiac, eosinophilic esophagitis, or IBD.
They found that 51.3% of the total sample met the diagnostic criteria for ARFID based on the Nine-Item ARFID Screen (NIAS), including 75.7 % of patients with achalasia. But Dr. Taft had cautions
“I can tell you, working with achalasia patients, 75% do not have ARFID,” Dr. Taft said.
She noted that the 51.3% of patients with IBD identified by NIAS or the 53% identified by the ARFID+ scale as having ARFID was also highly doubtful.
Dr. Taft and colleagues determined that nearly half of the variance in the NIAS could be accounted for by GI symptoms rather than psychosocial factors, making it less than ideal for use in the clinic or by researchers.
She also noted, however, that she received an email from one of the creators of NIAS, Hana F. Zickgraf, PhD, from the University of South Alabama, Mobile. Dr. Zickgraf agreed that the scale had drawbacks when applied to patients with GI disease, and pointed instead to the Fear of Food Questionnaire, a newly developed 18-item GI disease-specific instrument. Dr. Taft recommended the new questionnaire for research purposes, and expressed hope that a shorter version could be made available for screening patients in clinic.
Dr. Burton Murray said that while the Fear of Food Questionnaire, perhaps in combination with NIAS, has the potential to be a useful screening tool, cutoffs for it have yet to be established.
“At the end of the day, the diagnosis would be made by a clinician who is able to determine whether the life impairment or if the nutritional impairment or restricted food intake are reasonable in the realm of their digestive disease, or could a treatment for ARFID be warranted to help them to make changes to improve their quality of life and nutrition,” she said.
Check biases at the door
Before arriving at a diagnosis of ARFID, clinicians should also consider biases, Dr. Taft said.
“Eating disorders are highly stigmatized and stereotyped diagnoses,” more often attributed to young White women than to either men or to people of racial or ethnic minorities, she said.
Cultural background may contribute to food restrictions, and the risk may increase with age, with 68% of patients with later-onset IBD restricting diets to control the disease. It’s also possible that beliefs about food and “clean and healthy” eating may influence food and eating choices after a patient receives an IBD diagnosis.
Dr. Taft also pointed out that clinicians and patients may have different ideas about what constitutes significant food avoidance. Clinicians may expect patients with IBD to eat despite feeling nauseated, having abdominal pains, or diarrhea, for example, when the same food avoidance might be deemed reasonable in patients with short-term GI infections.
“Severe IBD symptoms are a significant predictor of posttraumatic stress disorder symptoms, and PTSD is hallmarked by avoidance behaviors,” she added.
She emphasized the need for clinicians to ask the right questions of patients to get at the roots of their nutritional deficiency or eating behavior, and to refer patients to mental health professionals with expertise in disordered eating or GI psychology.
Dr. Taft and Dr. Burton Murray reported having no conflicts of interest to disclose.
This article was updated on Feb. 4, 2022.
Problems with eating and nutrition are common among patients with inflammatory bowel disease (IBD) and other gastrointestinal disorders, but clinicians who treat them should be careful not to automatically assume that patients have eating disorders, according to a psychologist who specializes in the psychological and social aspects of chronic digestive diseases.
On the other hand, clinicians must also be aware of the possibility that patients could have a recently identified syndrome cluster called avoidant restrictive food intake disorder (ARFID), said Tiffany Taft, PsyD, a research associate professor of medicine (gastroenterology and hepatology), medical social sciences, and psychiatry and behavioral sciences at Northwestern University, Chicago. In a recent study, she and her colleagues defined ARFID as “failure to meet one’s nutritional needs owing to sensory hypersensitivity, lack of interest in eating, or fear of aversive consequences from eating, and is associated with negative medical and psychosocial outcomes.”
ARFID “is a hot topic that we really don’t understand,” she said in an online presentation at the annual Crohn’s & Colitis Congress®, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association.
Nutritional deficiencies
Nutritional deficiencies are common among patients with IBD, “and nutritional deficiencies themselves can lead to symptoms or side effects that can cause people to eat less,” she said.
“As our vitamin B12 goes down, our cognitive functioning starts to decline, and we might not be making clear decisions in how we’re deciding what to eat, when to eat, if we should be eating at all – just something to think about in your patients who have nutritional deficiencies,” she told the audience.
Other common nutritional deficiencies that can affect eating and food choice among patients with IBD include low folate (B9) levels associated with sore tongue and weight loss, low iron levels leading to nausea and loss of appetite, and zinc deficiency leading to loss of appetite and alterations in taste and/or smell, she said.
Newly recognized in GI
She noted that “ARFID actually originates in the pediatric psychiatric literature, mostly in children with sensory issues [such as] autism spectrum disorder, so this is not a construct that started in digestive disease, but has been adapted and applied to patients with digestive disease, including IBD.”
The DSM-5 lists four criteria for ARFID: significant weight loss, significant nutritional deficiency, dependence on enteral nutrition or oral supplements, and marked interference with psychosocial functions.
Helen Burton Murray, PhD, director of the gastrointestinal behavioral health program in the Center for Neurointestinal Health at Massachusetts General Hospital, Boston, who is familiar with Dr. Taft’s work, said in an interview that inclusion of ARFID in DSM-5 has put a name to a syndrome or symptom cluster that in all likelihood already existed.
However, “the jury is still out about whether, if we do diagnose patients who have digestive diseases with ARFID, that then helps them get to a treatment that improves their relationship with food and improves nutritional issues that may have occurred as a result of a restricted food intake,” she said.
“We don’t know yet if the diagnosis will actually improve things. In our clinical practice, anecdotally, it has, both for patients with IBDs and for patients with other GI conditions, particularly GI functional motility disorders. We’re a little bit more confident about making the diagnosis of ARFID in GI functional motility disorders than we are in IBD of course,” she said.
Screening measures
To get a better sense of the prevalence of ARFID, compared with reasonable responses to digestive diseases, Dr. Taft and colleagues conducted their cross-sectional study in 289 adults with achalasia, celiac, eosinophilic esophagitis, or IBD.
They found that 51.3% of the total sample met the diagnostic criteria for ARFID based on the Nine-Item ARFID Screen (NIAS), including 75.7 % of patients with achalasia. But Dr. Taft had cautions
“I can tell you, working with achalasia patients, 75% do not have ARFID,” Dr. Taft said.
She noted that the 51.3% of patients with IBD identified by NIAS or the 53% identified by the ARFID+ scale as having ARFID was also highly doubtful.
Dr. Taft and colleagues determined that nearly half of the variance in the NIAS could be accounted for by GI symptoms rather than psychosocial factors, making it less than ideal for use in the clinic or by researchers.
She also noted, however, that she received an email from one of the creators of NIAS, Hana F. Zickgraf, PhD, from the University of South Alabama, Mobile. Dr. Zickgraf agreed that the scale had drawbacks when applied to patients with GI disease, and pointed instead to the Fear of Food Questionnaire, a newly developed 18-item GI disease-specific instrument. Dr. Taft recommended the new questionnaire for research purposes, and expressed hope that a shorter version could be made available for screening patients in clinic.
Dr. Burton Murray said that while the Fear of Food Questionnaire, perhaps in combination with NIAS, has the potential to be a useful screening tool, cutoffs for it have yet to be established.
“At the end of the day, the diagnosis would be made by a clinician who is able to determine whether the life impairment or if the nutritional impairment or restricted food intake are reasonable in the realm of their digestive disease, or could a treatment for ARFID be warranted to help them to make changes to improve their quality of life and nutrition,” she said.
Check biases at the door
Before arriving at a diagnosis of ARFID, clinicians should also consider biases, Dr. Taft said.
“Eating disorders are highly stigmatized and stereotyped diagnoses,” more often attributed to young White women than to either men or to people of racial or ethnic minorities, she said.
Cultural background may contribute to food restrictions, and the risk may increase with age, with 68% of patients with later-onset IBD restricting diets to control the disease. It’s also possible that beliefs about food and “clean and healthy” eating may influence food and eating choices after a patient receives an IBD diagnosis.
Dr. Taft also pointed out that clinicians and patients may have different ideas about what constitutes significant food avoidance. Clinicians may expect patients with IBD to eat despite feeling nauseated, having abdominal pains, or diarrhea, for example, when the same food avoidance might be deemed reasonable in patients with short-term GI infections.
“Severe IBD symptoms are a significant predictor of posttraumatic stress disorder symptoms, and PTSD is hallmarked by avoidance behaviors,” she added.
She emphasized the need for clinicians to ask the right questions of patients to get at the roots of their nutritional deficiency or eating behavior, and to refer patients to mental health professionals with expertise in disordered eating or GI psychology.
Dr. Taft and Dr. Burton Murray reported having no conflicts of interest to disclose.
This article was updated on Feb. 4, 2022.
FROM CROHN’S & COLITIS CONGRESS