Nutrient deficiencies in inflammatory bowel disease
- Jonathan E Teitelbaum, MD
Jonathan E Teitelbaum, MD
- Associate Professor of Pediatrics
- Drexel University School of Medicine
- Section Editors
- Paul Rutgeerts, MD, PhD, FRCP
Paul Rutgeerts, MD, PhD, FRCP
- Section Editor — Inflammatory Bowel Disease
- Emeritus Professor of Medicine
- University Hospital, Leuven, Belgium
- Timothy O Lipman, MD
Timothy O Lipman, MD
- Section Editor — Nutrition
- GI-Hepatology-Nutrition Section
- Washington DC Veterans Affairs Medical Center
- Kathleen J Motil, MD, PhD
Kathleen J Motil, MD, PhD
- Section Editor — Pediatric Nutrition
- Professor of Pediatric Nutrition
- Baylor College of Medicine
Individuals with inflammatory bowel disease (IBD) and, particularly, those with Crohn's disease (CD) are at risk for a variety of nutritional deficiencies because of decreased nutrient intake or absorption and/or increased losses. In adults, the most common problems are deficiencies of micronutrients (nutrients needed for life in small quantities) (table 1), including several water-soluble and fat-soluble vitamins, and minerals including calcium, iron, and other trace minerals.
Clinically important deficiencies in macronutrients (providing total energy and/or protein) are less common in adults. However, these are very important issues in children with IBD, as discussed in a separate topic review. (See "Growth failure and poor weight gain in children with inflammatory bowel disease".)
Micronutrient deficiencies in adults and children with inflammatory bowel disease will be reviewed here. Weight loss and other manifestations of macronutrient deficiency in adults will be mentioned briefly. Diet and Inflammatory Bowel Disease are discussed elsewhere. (See "Nutrition and dietary interventions in adults with inflammatory bowel disease".)
A combination of factors contributes to deficits in energy and protein in IBD. Reduced nutrient intake is common; it is associated with disease activity and may be mediated by proinflammatory cytokines, such as tumor necrosis factor alpha. Malabsorption, maldigestion, increased energy expenditure, and gastrointestinal protein loss also contribute to deficiencies of energy and protein, and are usually correlated with disease activity. These mechanisms are discussed in more detail separately. (See "Growth failure and poor weight gain in children with inflammatory bowel disease", section on 'Pathogenesis of growth failure'.)
Similar mechanisms also contribute to micronutrient deficiencies in IBD. In addition, because some nutrients are digested and absorbed within specific locations within the gastrointestinal tract, the activity and location of a patient's intestinal disease determines risk for specific micronutrient deficiencies. As examples, patients with disease of the terminal ileum are at risk for vitamin B12 deficiency, and those with disease of the proximal small intestine are more likely to malabsorb calcium and iron.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kulnigg S, Gasche C. Systematic review: managing anaemia in Crohn's disease. Aliment Pharmacol Ther 2006; 24:1507.
- Vagianos K, Bector S, McConnell J, Bernstein CN. Nutrition assessment of patients with inflammatory bowel disease. JPEN J Parenter Enteral Nutr 2007; 31:311.
- Heyman MB, Garnett EA, Shaikh N, et al. Folate concentrations in pediatric patients with newly diagnosed inflammatory bowel disease. Am J Clin Nutr 2009; 89:545.
- Alkhouri RH, Hashmi H, Baker RD, et al. Vitamin and mineral status in patients with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2013; 56:89.
- Lashner BA, Provencher KS, Seidner DL, et al. The effect of folic acid supplementation on the risk for cancer or dysplasia in ulcerative colitis. Gastroenterology 1997; 112:29.
- Phelip JM, Ducros V, Faucheron JL, et al. Association of hyperhomocysteinemia and folate deficiency with colon tumors in patients with inflammatory bowel disease. Inflamm Bowel Dis 2008; 14:242.
- Seidman E, LeLeiko N, Ament M, et al. Nutritional issues in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 1991; 12:424.
- Headstrom PD, Rulyak SJ, Lee SD. Prevalence of and risk factors for vitamin B(12) deficiency in patients with Crohn's disease. Inflamm Bowel Dis 2008; 14:217.
- Filippi J, Al-Jaouni R, Wiroth JB, et al. Nutritional deficiencies in patients with Crohn's disease in remission. Inflamm Bowel Dis 2006; 12:185.
- Abu-Qurshin R, Naschitz JE, Zuckermann E, et al. Crohn's disease associated with pellagra and increased excretion of 5-hydroxyindolacetic acid. Am J Med Sci 1997; 313:111.
- Pollack S, Enat R, Haim S, et al. Pellagra as the presenting manifestation of Crohn's disease. Gastroenterology 1982; 82:948.
- Main AN, Mills PR, Russell RI, et al. Vitamin A deficiency in Crohn's disease. Gut 1983; 24:1169.
- Driscoll RH Jr, Meredith SC, Sitrin M, Rosenberg IH. Vitamin D deficiency and bone disease in patients with Crohn's disease. Gastroenterology 1982; 83:1252.
- Pappa HM, Grand RJ, Gordon CM. Report on the vitamin D status of adult and pediatric patients with inflammatory bowel disease and its significance for bone health and disease. Inflamm Bowel Dis 2006; 12:1162.
- Sentongo TA, Semaeo EJ, Stettler N, et al. Vitamin D status in children, adolescents, and young adults with Crohn disease. Am J Clin Nutr 2002; 76:1077.
- Pappa HM, Langereis EJ, Grand RJ, Gordon CM. Prevalence and risk factors for hypovitaminosis D in young patients with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2011; 53:361.
- Prosnitz AR, Leonard MB, Shults J, et al. Changes in vitamin D and parathyroid hormone metabolism in incident pediatric Crohn's disease. Inflamm Bowel Dis 2013; 19:45.
- Vogelsang H, Schöfl R, Tillinger W, et al. 25-hydroxyvitamin D absorption in patients with Crohn's disease and with pancreatic insufficiency. Wien Klin Wochenschr 1997; 109:678.
- Kleinman RE, Baldassano RN, Caplan A, et al. Nutrition support for pediatric patients with inflammatory bowel disease: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology And Nutrition. J Pediatr Gastroenterol Nutr 2004; 39:15.
- American Gastroenterological Association medical position statement: guidelines on osteoporosis in gastrointestinal diseases. Gastroenterology 2003; 124:791.
- Institute of Medicine, Food and Nutrition Board. Dietary reference intakes for calcium and vitamin D. National Academy Press, Washington DC, 2010. Available at: http://books.nap.edu/openbook.php?record_id=13050.
- Nicholson I, Dalzell AM, El-Matary W. Vitamin D as a therapy for colitis: a systematic review. J Crohns Colitis 2012; 6:405.
- Jørgensen SP, Agnholt J, Glerup H, et al. Clinical trial: vitamin D3 treatment in Crohn's disease - a randomized double-blind placebo-controlled study. Aliment Pharmacol Ther 2010; 32:377.
- Hengstermann S, Valentini L, Schaper L, et al. Altered status of antioxidant vitamins and fatty acids in patients with inactive inflammatory bowel disease. Clin Nutr 2008; 27:571.
- D'Odorico A, Bortolan S, Cardin R, et al. Reduced plasma antioxidant concentrations and increased oxidative DNA damage in inflammatory bowel disease. Scand J Gastroenterol 2001; 36:1289.
- Bousvaros A, Zurakowski D, Duggan C, et al. Vitamins A and E serum levels in children and young adults with inflammatory bowel disease: effect of disease activity. J Pediatr Gastroenterol Nutr 1998; 26:129.
- Duggan P, O'Brien M, Kiely M, et al. Vitamin K status in patients with Crohn's disease and relationship to bone turnover. Am J Gastroenterol 2004; 99:2178.
- Schoon EJ, Müller MC, Vermeer C, et al. Low serum and bone vitamin K status in patients with longstanding Crohn's disease: another pathogenetic factor of osteoporosis in Crohn's disease? Gut 2001; 48:473.
- Wendland BE, Aghdassi E, Tam C, et al. Lipid peroxidation and plasma antioxidant micronutrients in Crohn disease. Am J Clin Nutr 2001; 74:259.
- Koutroubakis IE, Malliaraki N, Dimoulios PD, et al. Decreased total and corrected antioxidant capacity in patients with inflammatory bowel disease. Dig Dis Sci 2004; 49:1433.
- Aghdassi E, Wendland BE, Steinhart AH, et al. Antioxidant vitamin supplementation in Crohn's disease decreases oxidative stress. a randomized controlled trial. Am J Gastroenterol 2003; 98:348.
- Trebble TM, Stroud MA, Wootton SA, et al. High-dose fish oil and antioxidants in Crohn's disease and the response of bone turnover: a randomised controlled trial. Br J Nutr 2005; 94:253.
- Geerling BJ, Badart-Smook A, van Deursen C, et al. Nutritional supplementation with N-3 fatty acids and antioxidants in patients with Crohn's disease in remission: effects on antioxidant status and fatty acid profile. Inflamm Bowel Dis 2000; 6:77.
- Seidner DL, Lashner BA, Brzezinski A, et al. An oral supplement enriched with fish oil, soluble fiber, and antioxidants for corticosteroid sparing in ulcerative colitis: a randomized, controlled trial. Clin Gastroenterol Hepatol 2005; 3:358.
- Gisbert JP, Gomollón F. Common misconceptions in the diagnosis and management of anemia in inflammatory bowel disease. Am J Gastroenterol 2008; 103:1299.
- Cronin CC, Shanahan F. Anemia in patients with chronic inflammatory bowel disease. Am J Gastroenterol 2001; 96:2296.
- Wells CW, Lewis S, Barton JR, Corbett S. Effects of changes in hemoglobin level on quality of life and cognitive function in inflammatory bowel disease patients. Inflamm Bowel Dis 2006; 12:123.
- Gasche C, Berstad A, Befrits R, et al. Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases. Inflamm Bowel Dis 2007; 13:1545.
- Gasche C, Lomer MC, Cavill I, Weiss G. Iron, anaemia, and inflammatory bowel diseases. Gut 2004; 53:1190.
- Gasché C, Dejaco C, Waldhoer T, et al. Intravenous iron and erythropoietin for anemia associated with Crohn disease. A randomized, controlled trial. Ann Intern Med 1997; 126:782.
- Gasche C, Dejaco C, Reinisch W, et al. Sequential treatment of anemia in ulcerative colitis with intravenous iron and erythropoietin. Digestion 1999; 60:262.
- Katsanos K, Cavalier E, Ferrante M, et al. Intravenous iron therapy restores functional iron deficiency induced by infliximab. J Crohns Colitis 2007; 1:97.
- Reinisch W, Chowers Y, Danese S, et al. The management of iron deficiency in inflammatory bowel disease--an online tool developed by the RAND/UCLA appropriateness method. Aliment Pharmacol Ther 2013; 38:1109.
- Gasche C, Evstatiev R, Haas T, et al. [Diagnosis and treatment of iron deficiency and anaemia in inflammatory bowel diseases. Consensus of the Austrian IBD Working Party]. Z Gastroenterol 2011; 49:627.
- Stein J, Bager P, Befrits R, et al. Anaemia management in patients with inflammatory bowel disease: routine practice across nine European countries. Eur J Gastroenterol Hepatol 2013; 25:1456.
- Schreiber S, Howaldt S, Schnoor M, et al. Recombinant erythropoietin for the treatment of anemia in inflammatory bowel disease. N Engl J Med 1996; 334:619.
- García-López S, Bocos JM, Gisbert JP, et al. High-dose intravenous treatment in iron deficiency anaemia in inflammatory bowel disease: early efficacy and impact on quality of life. Blood Transfus 2016; 14:199.
- Jimenez K, Gasche C, Auerbach M. On both sides of the ocean. Blood Transfus 2016; 14:197.
- Crary SE, Hall K, Buchanan GR. Intravenous iron sucrose for children with iron deficiency failing to respond to oral iron therapy. Pediatr Blood Cancer 2011; 56:615.
- Plummer ES, Crary SE, McCavit TL, Buchanan GR. Intravenous low molecular weight iron dextran in children with iron deficiency anemia unresponsive to oral iron. Pediatr Blood Cancer 2013; 60:1747.
- Danko I, Weidkamp M. Correction of Iron Deficiency Anemia With Intravenous Iron Sucrose in Children With Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2016; 63:e107.
- Gasche C, Waldhoer T, Feichtenschlager T, et al. Prediction of response to iron sucrose in inflammatory bowel disease-associated anemia. Am J Gastroenterol 2001; 96:2382.
- McClain C, Soutor C, Zieve L. Zinc deficiency: a complication of Crohn's disease. Gastroenterology 1980; 78:272.
- Sturniolo GC, Di Leo V, Ferronato A, et al. Zinc supplementation tightens "leaky gut" in Crohn's disease. Inflamm Bowel Dis 2001; 7:94.
- Krawitt EL, Beeken WL, Janney CD. Calcium absorption in Crohn's disease. Gastroenterology 1976; 71:251.
- Thomson CD, Rea HM, Doesburg VM, Robinson MF. Selenium concentrations and glutathione peroxidase activities in whole blood of New Zealand residents. Br J Nutr 1977; 37:457.
- Ojuawo A, Keith L. The serum concentrations of zinc, copper and selenium in children with inflammatory bowel disease. Cent Afr J Med 2002; 48:116.
- Ringstad J, Kildebo S, Thomassen Y. Serum selenium, copper, and zinc concentrations in Crohn's disease and ulcerative colitis. Scand J Gastroenterol 1993; 28:605.
- Rannem T, Ladefoged K, Hylander E, et al. Selenium status in patients with Crohn's disease. Am J Clin Nutr 1992; 56:933.
- Kuroki F, Matsumoto T, Iida M. Selenium is depleted in Crohn's disease on enteral nutrition. Dig Dis 2003; 21:266.
- Johtatsu T, Andoh A, Kurihara M, et al. Serum concentrations of trace elements in patients with Crohn's disease receiving enteral nutrition. J Clin Biochem Nutr 2007; 41:197.
- Quercia RA, Korn S, O'Neill D, et al. Selenium deficiency and fatal cardiomyopathy in a patient receiving long-term home parenteral nutrition. Clin Pharm 1984; 3:531.
- Kawakubo K, Iida M, Matsumoto T, et al. Progressive encephalopathy in a Crohn's disease patient on long-term total parenteral nutrition: possible relationship to selenium deficiency. Postgrad Med J 1994; 70:215.
- Ishida T, Himeno K, Torigoe Y, et al. Selenium deficiency in a patient with Crohn's disease receiving long-term total parenteral nutrition. Intern Med 2003; 42:154.
- Geerling BJ, Badart-Smook A, Stockbrügger RW, Brummer RJ. Comprehensive nutritional status in patients with long-standing Crohn disease currently in remission. Am J Clin Nutr 1998; 67:919.
- Goldschmid S, Graham M. Trace element deficiencies in inflammatory bowel disease. Gastroenterol Clin North Am 1989; 18:579.
- Spiegel JE, Willenbucher RF. Rapid development of severe copper deficiency in a patient with Crohn's disease receiving parenteral nutrition. JPEN J Parenter Enteral Nutr 1999; 23:169.
- Galland L. Magnesium and inflammatory bowel disease. Magnesium 1988; 7:78.
- Habtezion A, Silverberg MS, Parkes R, et al. Risk factors for low bone density in Crohn's disease. Inflamm Bowel Dis 2002; 8:87.
- Park RH, Galloway A, Shenkin A, et al. Magnesium deficiency in patients on home enteral nutrition. Clin Nutr 1990; 9:147.
- Oliva MM, Lake AM. Nutritional considerations and management of the child with inflammatory bowel disease. Nutrition 1996; 12:151.
- Hyams JS, Treem WR, Carey DE, et al. Comparison of collagen propeptides as growth markers in children with inflammatory bowel disease. Gastroenterology 1991; 100:971.
- WATER-SOLUBLE VITAMINS
- Folic acid
- Vitamin B12
- FAT-SOLUBLE VITAMINS
- Vitamin A
- Vitamin D
- Vitamin E
- Vitamin K
- ANTIOXIDANT VITAMINS
- - Other causes of anemia
- - Assessment
- - Supplementation
- LABORATORY MEASURES
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS