Nutritional characteristic of children with inflammatory bowel disease in the nationwide inflammatory bowel disease registry from the Mediterranean region

It is well established that weight loss and underweight are a common manifestation of pediatric inflammatory bowel disease at diagnosis. But, the prevalence of undernutrition varies in the reports according to method used for evaluation of nutritional status, disease type, and time.

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Backround

Nutritional impairments  due to the nature of the disease are common in children with inflammatory bowel disease (IBD). Although these alterations  are more common in patients with Crohn disease (CD) compared to patients with ulcerative colitis (UC), there are conflicting results in the literature (1,2). In addition, studies conducted in recent years have reported that the incidence of obesity at the time of diagnosis increases as well as malnutrition in this patient group, especially in children with UC (2-4). Most of these studies are from western countries, and data from other parts of the world are limited.

Our study design

The nutritional status of 936 children under 18 years of age who were diagnosed with IBD in 41 centers in Turkey and registered in the Nationwide Registry for pediatric IBD between 1998 and 2016 were evaluated. 

Patients with another chronic disease known to affect nutritional status or those missing major outcome variables including symptom duration, weight, height, disease activity, disease location, and phenotype at the diagnosis were excluded from the analysis. Nutritional status of the participants was evaluated according to anthropometric parameters. Weight status was assessed by weight for height in children younger than 2 years of age and BMI for age in children 2 years and older. Height status was evaluated as height/height for age in all cases. The z-score for all anthropometric parameters was calculated using WHO standards and references. The nine nutritional states were defined as in Table 1,  with a combination of HFA and WFL/BMI z-scores with three categories (< − 2, − 2 to 2 and  > 2 SD). Patients with an HFA z-score or a WFL/BMI z-score of less than -2.0 were defined as malnourished. Univariate and multivariate regression analysis was used to identify risk factors for malnutrition.

Table 1. Assesment of nutritional status

HFA z score

WFL /BMI z score

 

Normal

(≥−2 to ≤2)

Low

(<− 2)

High

(> 2)

Normal

(≥−2 to ≤2)

Eutrophy 

Wasting/thinness

Overweight

Low

 (<− 2)

Stunting 

Concurrent stunting and wasting/thinness 

Stunted and overweight 

High

 (>2)

Tall stature

Tall stature with wasting/thinness

Tall stature with overweight

HFA, length/height-for-age; WFL, weight-for-length; BMI, body mass index

 

Our results

After excluding 112 patients, a total of 824 patients [498 UC; 289 CD; 37 Indeterminate colitis (IC); 412 male; the median age 12.5 years (IQR: 9.2-14.9)] were included in this study. The median interval between the first clinical presentation and diagnosis was 3 months (IQR: 2-8 months). While UC and IC’s most common form of presentation was pancolitis, frequent forms of CD presentation were ileocolonic involvement and non-stricture/non-penetrating behavior.  Two-thirds of the participants had mild or moderate disease. The nutritional status of participants at the time of diagnosis are presented in Figure 1.

Figure 1. Nutritional status of children with IBD at the time of diagnosis

Figure 1. Nutritional status of children with IBD at the time of diagnosis

IBD, Inflammatory bowel disease; CD, Crohn’s disease; UC, Ulcerative colitis; IC, Indeterminate colitis;

The prevalence of malnutrition was 32.7%, indicating a higher prevalence in CD  (CD:36.6%, UC:18.4%, IC:26%, p<0.001). Similarly, being overweight was less common in CD than UC and IC (1.7%, 5.6%, and 5.4%, respectively p<0.001). Multivariate analysis revealed that age of onset (>10 years), prepubertal stage, severe disease activity, perianal involvement, and high C reactive protein level were independently associated with malnutrition in pediatric IBD.

Conclusion

At the diagnosis, two-thirds of children with IBD had normal nutritional status, but one-third of cases were malnourished, and children with CD were more vulnerable to malnutrition. However, the prevalence of overweight was lower than in other studies. We have demonstrated that the age of onset, disease activity, CRP level, perianal involvement, and pubertal stage were associated with a higher risk for developing malnutrition.

For more details on our work, please see the article to be published on the EJCN (https://rdcu.be/cG6Q4)

References

  1. Geerling BJ, Badart-Smook A, Stockbrugger RW, Brummer RJ. Comprehensive nutritional status in recently diagnosed patients with inflammatory bowel disease compared with population controls. EJCN 2000; 54: 514-521.
  2. Kugathasan S, Nebel J, Skelton JA, Markowitz J, Keljo D, Rosh J, et al. Body mass index in children with newly diagnosed inflammatory bowel disease: observations from two multicenter North American inception cohorts. J Pediatr. 2007; 151: 523–527.
  3. Pituch-Zdanowska A, Banaszkiewicz A, Dziekiewicz M, Lazowsak-Pzzeorek I, Gawronska A, Kowalska-Duplaga K, et al. Overwight and obesity in children with newly diagnosed inflammatory bowel disease. Adv Med Sci. 2016; 61: 28-31.
  4. Chandrakumar A, Wang A, Grover K, El-matary W. Obesity is more common in children newly diagnosed with ulcerative colitis as compered to those with Crohn’s disease. JPGN 2020; 70: 593-597.

Zarife Kuloglu

Professor, Ankara University School of Medicine, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition

To learn more about my research, see my ORCID page: https://orcid.org/my-orcid?orcid=0000-0001-9442-7790