IBD in older patients / IBD and nutrition

Dr. Jeroen Maljaars

IBD in older patients

As a consequence of the ageing population and the increasing prevalence of inflammatory bowel diseases (IBD) worldwide, the number of older patients with Crohn’s disease (CD) or ulcerative colitis (UC) is increasing and is expected to increase further in the coming decades.1 Current guidelines in IBD care are increasingly focussing on mucosal healing as a treatment goal, and a minimized use of corticosteroids is propagated, with rapid introduction of immunosuppressant or biological drugs when necessary.2 Recent papers found that prescribers appear reticent to employ these ‘steroid-sparing’ strategies in older patients .3 Current guidelines recommend that patients using steroids more than once per year should be considered for escalation to steroid-sparing therapies. However, this escalation occurs less frequently in older patients compared to younger patients. In addition, a number of studies have shown that older patients are more prone to develop adverse events after medical therapy compared to younger patients. Serious infections were increased in the older IBD patients, but also the number of patients that had to stop anti-TNF therapy due to adverse events was higher in the older patients groups. Moreover, efficacy of treatment may also be reduced in older patients.4 In the currently published studies, age alone was used as a cut-off, whereas older patients are heterogenic with respect to their physical, mental and social functioning (hereafter: functioning). In other domains of medicine it has been established that the reduced levels of functioning and the presence of frailty are predictors of poor outcome.5 In addition, the outcome of assessments of patient functioning are tentatively used to guide treatment decisions. One study showed that in older patients with a lower degree of functioning, use of adapted therapy reduced treatment-related toxicities and treatment failures compared to conventional therapy without affecting patient survival.6 The increase in older IBD patients and the subsequent increase in treatment decisions in clinical practice, taken together with the high costs of IBD drugs warrant new approaches to rationalize and individualize decision making in older patients and strive towards a more personalized treatment.7 Our current research program has the following objectives:

1. To gain insight in how therapy strategies differ between older and younger IBD patients, and how this relates to the preferences of patients and physicians, with special attention for the treatment outcomes and goals that are relevant to older IBD patients.

2. To assess the prevalence of reduced functioning among older IBD patients, and whether reduced functioning is predictive of poor health outcomes and serious adverse events.

3. To compare the occurrence of serious infections and all adverse events between older and younger IBD patients, and between older patients with and without exposure to anti-TNF drugs

 

IBD and nutrition

The healthcare impact of non-communicable lifestyle-related diseases is increasing worldwide. In recent years there has been an increased interest in employing lifestyle interventions as both a treatment for patients with these chronic diseases as well as a method to prevent the occurrence of chronic diseases, such as cardiovascular disease, obesity, hypertension and type 2 diabetes (see for instance: Kennissynthese voeding als behandeling van chronische ziekten, by ZonMw) and the use of these interventions is increasingly propagated.

 

Although patients are interested in lifestyle advice and a subset of physicians is eager to employ lifestyle-related interventions, the current application of lifestyle interventions in clinical practice is limited. This has a number of causes, such as lack of evidence-based interventions (which intervention works) and evidence-based practices (how to apply the intervention in clinical practice). What is clear is that networks have to be established, with physicians of different backgrounds, dieticians, physical therapists and (physician-)scientists as participants. These collaborations will facilitate development and implementation of these interventions.

Inflammatory bowel diseases (IBD) is an example of a chronic disease where patients are very interested in dietary interventions. Many patients ask whether eating the right foods can make a difference in their disease course, but high quality data to answer this question is lacking. Studies employing exclusive enteral nutrition (EEN) have shown that EEN is more effective than steroids to induce remission than steroids. However, no other dietary intervention has been studied to this extent. However, there are robust data that diet can reduce complaints and improve quality of life. Additionally, convincing evidence exists, in non-IBD patients, that dietary interventions can reduce body weight, reduce the risk for cardiovascular events and other metabolic conditions.

 

There are currently three active studies in the IBD and Nutrition program:

The first, a prospective cohort study, aims to identify IBD-specific factors in developing NAFL with a focus on IBD medication and disease activity. Subsequent research students have included over 100 patients in this study, and biomaterials are biobanked for a large subset of these patients.

The second project entails a pilot study on the introduction of an anti-inflammatory diet in patients with active Crohn’s disease (CD). A CD cookbook has been developed in close cooperation with the department of Dietetics and students of the Haagse Hogeschool.

In the third project, a dietary intervention is offered to patients with IBD that are in remission. An external partner, Voeding Leeft, has developed a diet for patients with IBD and the goal of this pilot study is to test the feasibility of such an approach in IBD patients.

 

Apart from parameters such as disease control and quality of life, we will assess how the nutritional interventions influence liver fat and fibrosis and cardiovascular risk.

 

www.voedingleeft.nl

 

Biosketch

After obtaining his medical degree, Jeroen Maljaars (1976) performed a research project at the department of Gastroenterology in the LUMC and later at the University of Maastricht. He focused on the effect of small bowel fat exposure on food intake, hunger feelings, and gastroenintestinal hphysiology.  The focus of this projects was on the ileal brake-mechanism, showing that ileal fat exposure reduces hunger feelings and food intake in healthy volunteers.

After obtaining his Ph.D at the University of Maastricht (2010), he followed the gastroenterology training program (Orbis Medical centre for Internal Medicine, Gastroenterology in the LUMC). He was appointed a staff member at the department of gastroenterology in 2015, joining dr. Andrea van der Meulen- de Jong in the IBD unit.

His research focuses on:

•             Care for older IBD patients

o             Ph.D. student Vera Asscher, MD

•             Nutrition and lifestyle in IBD patients

o             Post Doc researcher: Ilse Molendijk, Ph.D

•             PSC and other liver complications of IBD

 

He is a member of the Nutrition Taskforce of the Dutch Society of Gastroenterologists

 

Internships:

Student research projects are always available. Students are welcome to join one of the research projects and participate in studies.

 

Publications

1: Visschedijk MC, Spekhorst LM, Cheng SC, van Loo ES, Jansen BHD, Blokzijl T,

Kil H, de Jong DJ, Pierik M, Maljaars J, van der Woude CJ, van Bodegraven AA,

Oldenburg B, Löwenberg M, Nieuwenhuijs VB, Imhann F, van Sommeren S, Alberts R,

Xavier RJ, Dijkstra G, Faber KN, Aldaz CM, Weersma RK, Festen EAM. Genomic and

expression analyses identify a disease modifying variant for fibrostenotic

Crohn's disease. J Crohns Colitis. 2018 Jan 19. doi: 10.1093/ecco-jcc/jjy001.

[Epub ahead of print] PubMed PMID: 29361163.

 

 

2: Spekhorst LM, Imhann F, Festen EAM, van Bodegraven AA, de Boer NKH, Bouma G,

Fidder HH, d'Haens G, Hoentjen F, Hommes DW, de Jong DJ, Löwenberg M, Maljaars

J, van der Meulen-de Jong AE, Oldenburg B, Pierik MJ, Ponsioen CY, Stokkers PC,

Verspaget HW, Visschedijk MC, van der Woude CJ, Dijkstra G, Weersma RK;

Parelsnoer Institute (PSI) and the Dutch Initiative on Crohn and Colitis (ICC).

Cohort profile: design and first results of the Dutch IBD Biobank: a prospective,

nationwide biobank of patients with inflammatory bowel disease. BMJ Open. 2017

Nov 8;7(11):e016695. doi: 10.1136/bmjopen-2017-016695. PubMed PMID: 29122790;

PubMed Central PMCID: PMC5695377.

 

3: de Jong MJ, van der Meulen-de Jong AE, Romberg-Camps MJ, Becx MC, Maljaars P,

Cilissen M, van Bodegraven AA, Mahmmod N, Markus T, Hameeteman WM, Dijkstra G,

Masclee AA, Boonen A, Winkens B, van Tubergen A, Jonkers DM, Pierik MJ.

Telemedicine for management of inflammatory bowel disease (myIBDcoach): a

pragmatic, multicentre, randomised controlled trial. Lancet. 2017 Sep

2;390(10098):959-968. doi: 10.1016/S0140-6736(17)31327-2. Epub 2017 Jul 14.

PubMed PMID: 28716313.

 

 

4: Westerouen van Meeteren MJ, Hayee B, Inderson A, van der Meulen AE, Altwegg R,

van Hoek B, Pageaux GP, Stijnen T, Stein D, Maljaars J. Safety of Anti-TNF

Treatment in Liver Transplant Recipients: A Systematic Review and Meta-analysis.

J Crohns Colitis. 2017 Sep 1;11(9):1146-1151. doi: 10.1093/ecco-jcc/jjx057.

Review. PubMed PMID: 28482085.

 

5: Barendregt J, de Jong M, Haans JJ, van Hoek B, Hardwick J, Veenendaal R, van

der Meulen A, Srivastava N, Stuyt R, Maljaars J. Liver test abnormalities predict

complicated disease behaviour in patients with newly diagnosed Crohn's disease.

Int J Colorectal Dis. 2017 Apr;32(4):459-467. doi: 10.1007/s00384-016-2706-3.

Epub 2016 Nov 29. PubMed PMID: 27900523; PubMed Central PMCID: PMC5355514.

 

6: van Schaik T, Maljaars J, Roopram RK, Verwey MH, Ipenburg N, Hardwick JC,

Veenendaal RA, van der Meulen-de Jong AE. Influence of combination therapy with

immune modulators on anti-TNF trough levels and antibodies in patients with IBD.

Inflamm Bowel Dis. 2014 Dec;20(12):2292-8. doi: 10.1097/MIB.0000000000000208.

PubMed PMID: 25230167.

 

7: Maljaars J. Overeating makes the gut grow fonder; new insights in

gastrointestinal satiety signalling in obesity. Curr Opin Gastroenterol. 2013

Mar;29(2):177-83. doi: 10.1097/MOG.0b013e32835d9fe0. Review. PubMed PMID:

23295637.

 

8: Maljaars J, van der Wal RJ, Wiersma T, Peters HP, Haddeman E, Masclee AA. The

effect of lipid droplet size on satiety and peptide secretion is intestinal

site-specific. Clin Nutr. 2012 Aug;31(4):535-42. doi: 10.1016/j.clnu.2011.12.003.

Epub 2012 Jan 2. PubMed PMID: 22217980.

 

9: Maljaars J, Peters HP, Kodde A, Geraedts M, Troost FJ, Haddeman E, Masclee

AA. Length and site of the small intestine exposed to fat influences hunger and

food intake. Br J Nutr. 2011 Nov;106(10):1609-15. doi: 10.1017/S0007114511002054.

Epub 2011 Jun 7. PubMed PMID: 21736790.

 

10: Maljaars J, Keszthelyi D, Masclee AA. An ileal brake-through? Am J Clin

Nutr. 2010 Sep;92(3):467-8. doi: 10.3945/ajcn.2010.30180. Epub 2010 Aug 4. PubMed

PMID: 20685954.

 

11: Foltz M, Maljaars J, Schuring EA, van der Wal RJ, Boer T, Duchateau GS,

Peters HP, Stellaard F, Masclee AA. Intragastric layering of lipids delays lipid

absorption and increases plasma CCK but has minor effects on gastric emptying and

appetite. Am J Physiol Gastrointest Liver Physiol. 2009 May;296(5):G982-91. doi:

10.1152/ajpgi.90579.2008. Epub 2009 Mar 26. PubMed PMID: 19325050.

 

 

12: Maljaars J, Romeyn EA, Haddeman E, Peters HP, Masclee AA. Effect of fat

saturation on satiety, hormone release, and food intake. Am J Clin Nutr. 2009

Apr;89(4):1019-24. doi: 10.3945/ajcn.2008.27335. Epub 2009 Feb 18. PubMed PMID:

19225118.

 

13: Maljaars J, Symersky T, Kee BC, Haddeman E, Peters HP, Masclee AA. Effect of

ileal fat perfusion on satiety and hormone release in healthy volunteers. Int J

Obes (Lond). 2008 Nov;32(11):1633-9. doi: 10.1038/ijo.2008.166. Epub 2008 Sep 16.

PubMed PMID: 18794896.

 

14: Maljaars J, Peters HP, Mela DJ, Masclee AA. Ileal brake: a sensible food

target for appetite control. A review. Physiol Behav. 2008 Oct 20;95(3):271-81.

doi: 10.1016/j.physbeh.2008.07.018. Epub 2008 Jul 21. Review. PubMed PMID:

18692080.

 

15: Maljaars J, Peters HP, Masclee AM. Review article: The gastrointestinal

tract: neuroendocrine regulation of satiety and food intake. Aliment Pharmacol

Ther. 2007 Dec;26 Suppl 2:241-50. doi: 10.1111/j.1365-2036.2007.03550.x. Review.

PubMed PMID: 18081667.