方法:饮食在人类健康中起着至关重要的作用,但尤其是炎症性肠病(IBD)患者。关于IBD患者饮食的指导通常是有争议的,并且是许多医生和患者的不确定性来源。饮食的作用已被研究为IBD病因的危险因素和活动性疾病的治疗方法。饮食限制,随着IBD的临床并发症,会导致营养不良,在这些患者人群中,这是一个未被认识到的情况。本美国胃肠病学协会(AGA)临床实践更新(CPU)的目的是提供最佳实践建议声明,主要是临床胃肠病学家,涵盖IBD管理中的饮食和营养疗法主题,同时强调这些患者营养不良的识别和治疗。我们为IBD缓解期间量身定制的饮食方法提供指导,活动性疾病,和肠道衰竭。健康的地中海饮食将使IBD患者受益,但可能需要在肠道狭窄或阻塞的情况下适应食物质地。克罗恩病的新数据支持使用肠内液体营养来帮助手术患者缓解和纠正营养不良。肠外营养在面临急性和/或慢性肠衰竭的IBD患者中起着至关重要的作用。注册营养师是跨学科团队方法的重要组成部分,可用于IBD患者人群的最佳营养评估和管理。
方法:本专家审查是由AGA临床实践更新委员会和AGA管理委员会委托并批准的,目的是就对AGA成员具有重要临床意义的主题提供及时指导,并通过CPU委员会进行内部同行审查,并通过胃肠病学的标准程序进行外部同行审查。通过回顾现有文献并结合专家意见得出最佳实践建议,以提供有关饮食和营养疗法在IBD患者中的作用的实用建议。因为这不是一个系统的审查,没有对所提出的考虑因素的证据质量或强度进行正式评级.最佳实践建议声明最佳实践建议1:除非有禁忌症,应建议所有IBD患者遵循富含各种新鲜水果和蔬菜的地中海饮食,单不饱和脂肪,复杂的碳水化合物,和瘦肉蛋白质,超加工食品含量低,加糖,和盐为他们的整体健康和总体福祉。一直没有发现饮食可以降低IBD成年人的耀斑发生率。低红肉和加工肉的饮食可以减少溃疡性结肠炎的耀斑,但尚未发现减少克罗恩病的复发。最佳实践建议2:有症状的肠狭窄的IBD患者可能不能耐受纤维,植物性食品(即,生水果和蔬菜)由于它们的质地。一个强调仔细咀嚼和烹饪和加工的水果和蔬菜的软,较低的纤维蛋白稠度可能有助于合并肠道狭窄的IBD患者在饮食中加入更多植物性食物和纤维.最佳实践建议3:使用液体营养制剂的独家肠内营养是诱导克罗恩病临床缓解和内镜反应的有效疗法,儿童比成人有更强的证据。对于克罗恩病患者,独家肠内营养可被视为一种保留类固醇的桥梁疗法。最佳实践建议4:克罗恩病排除饮食,一种部分肠内营养疗法,可能是诱导轻度至中度克罗恩病的临床缓解和内镜反应的有效疗法。最佳实践建议5:在接受克罗恩病择期手术之前,独家肠内营养可能是营养不良患者的有效治疗方法,以优化营养状况并减少术后并发症。最佳实践建议6:患有腹内脓肿和/或痰质炎症的IBD患者,限制了通过消化道获得最佳营养的能力,短期肠外营养可用于在术前提供肠道休息,以减少感染和炎症,作为明确手术治疗的桥梁,并优化手术结局.最佳实践建议7:我们建议使用肠外营养治疗高产量胃肠瘘,肠梗阻延长,短肠综合征,对于严重营养不良的IBD患者,当口服和肠内营养已经试验但失败时,或者当肠内途径不可行或禁忌时。最佳实践建议8:IBD和短肠综合征患者,长期肠外营养应过渡到定制的水合管理(即,静脉内电解质支持和/或口服补液)并尽可能口服摄入,以降低发生长期并发症的风险。用胰高血糖素样肽-2激动剂治疗可以促进这种转变。最佳实践建议9:所有IBD患者都应通过评估体征和症状,由其提供者定期筛查营养不良。包括意外的减肥,水肿和液体潴留,脂肪和肌肉质量损失。观察时,表示由注册营养师对营养不良进行更完整的评估。由于血清蛋白缺乏对营养状况的特异性和对炎症的高度敏感性,因此不再推荐用于营养不良的识别和诊断。最佳实践建议10:所有IBD患者都应进行维生素D和缺铁监测。患有广泛回肠疾病或先前回肠手术(切除或回肠袋)的患者应监测维生素B12缺乏。最佳实践建议11:所有患有复杂IBD的门诊患者和住院患者都应与注册营养师共同管理,尤其是那些营养不良的人,短肠综合征,肠外瘘,和/或需要更复杂的营养疗法(例如,肠外营养,肠内营养,或独家肠内营养),或者那些接受克罗恩病排除饮食的人。我们建议所有新诊断的IBD患者都可以使用注册营养师。最佳实践建议12:母乳喂养与儿童期诊断IBD的风险较低相关。一个健康的,平衡,富含各种水果和蔬菜的地中海饮食和超加工食品摄入量的减少与患IBD的风险较低有关。
Diet plays a critical role in human health, but especially for patients with inflammatory bowel disease (IBD). Guidance about diet for patients with IBD are often controversial and a source of uncertainty for many physicians and patients. The role of diet has been investigated as a risk factor for IBD etiopathogenesis and as a therapy for active disease. Dietary restrictions, along with the clinical complications of IBD, can result in malnutrition, an underrecognized condition among this patient population. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the topics of diet and nutritional therapies in the management of IBD, while emphasizing identification and treatment of malnutrition in these patients. We provide guidance for tailored dietary approaches during IBD remission, active disease, and intestinal failure. A healthy Mediterranean diet will benefit patients with IBD, but may require accommodations for food texture in the setting of intestinal strictures or obstructions. New data in Crohn\'s disease supports the use of enteral liquid nutrition to help induce remission and correct malnutrition in patients heading for surgery. Parenteral nutrition plays a critical role in patients with IBD facing acute and/or chronic intestinal failure. Registered dietitians are an essential part of the interdisciplinary team approach for optimal nutrition assessment and management in the patient population with IBD.
This expert
review was commissioned and approved by the AGA Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer
review by the CPU Committee and external peer
review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet and nutritional therapies in patients with IBD. Because this was not a systematic
review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Unless there is a contraindication, all patients with IBD should be advised to follow a Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultraprocessed foods, added sugar, and salt for their overall health and general well-being. No diet has consistently been found to decrease the rate of flares in adults with IBD. A diet low in red and processed meat may reduce ulcerative colitis flares, but has not been found to reduce relapse in Crohn\'s disease. BEST PRACTICE ADVICE 2: Patients with IBD who have symptomatic intestinal strictures may not tolerate fibrous, plant-based foods (ie, raw fruits and vegetables) due to their texture. An emphasis on careful chewing and cooking and processing of fruits and vegetables to a soft, less fibrinous consistency may help patients with IBD who have concomitant intestinal strictures incorporate a wider variety of plant-based foods and fiber in their diets. BEST PRACTICE ADVICE 3: Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn\'s disease, with stronger evidence in children than adults. Exclusive enteral nutrition may be considered as a steroid-sparing bridge therapy for patients with Crohn\'s disease. BEST PRACTICE ADVICE 4: Crohn\'s disease exclusion diet, a type of partial enteral nutrition therapy, may be an effective therapy for induction of clinical remission and endoscopic response in mild to moderate Crohn\'s disease of relatively short duration. BEST PRACTICE ADVICE 5: Exclusive enteral nutrition may be an effective therapy in malnourished patients before undergoing elective surgery for Crohn\'s disease to optimize nutritional status and reduce postoperative complications. BEST PRACTICE ADVICE 6: In patients with IBD who have an intra-abdominal abscess and/or phlegmonous inflammation that limits ability to achieve optimal nutrition via the digestive tract, short-term parenteral nutrition may be used to provide bowel rest in the preoperative phase to decrease infection and inflammation as a bridge to definitive surgical management and to optimize surgical outcomes. BEST PRACTICE ADVICE 7: We suggest the use of parenteral nutrition for high-output gastrointestinal fistula, prolonged ileus, short bowel syndrome, and for patients with IBD with severe malnutrition when oral and enteral nutrition has been trialed and failed or when enteral access is not feasible or contraindicated. BEST PRACTICE ADVICE 8: In patients with IBD and short bowel syndrome, long-term parenteral nutrition should be transitioned to customized hydration management (ie, intravenous electrolyte support and/or oral rehydration solutions) and oral intake whenever possible to decrease the risk of developing long-term complications. Treatment with glucagon-like peptide-2 agonists can facilitate this transition. BEST PRACTICE ADVICE 9: All patients with IBD warrant regular screening for malnutrition by their provider by means of assessing signs and symptoms, including unintended weight loss, edema and fluid retention, and fat and muscle mass loss. When observed, more complete evaluation for malnutrition by a registered dietitian is indicated. Serum proteins are no longer recommended for the identification and diagnosis of malnutrition due to their lack of specificity for nutritional status and high sensitivity to inflammation. BEST PRACTICE ADVICE 10: All patients with IBD should be monitored for vitamin D and iron deficiency. Patients with extensive ileal disease or prior ileal surgery (resection or ileal pouch) should be monitored for vitamin B12 deficiency. BEST PRACTICE ADVICE 11: All outpatients and inpatients with complicated IBD warrant co-management with a registered dietitian, especially those who have malnutrition, short bowel syndrome, enterocutaneous fistula, and/or are requiring more complex nutrition therapies (eg, parenteral nutrition, enteral nutrition, or exclusive enteral nutrition), or those on a Crohn\'s disease exclusion diet. We suggest that all newly diagnosed patients with IBD have access to a registered dietitian. BEST PRACTICE ADVICE 12: Breastfeeding is associated with a lower risk for diagnosis of IBD during childhood. A healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultraprocessed foods have been associated with a lower risk of developing IBD.