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Nutritional Management
of Crohn’s Disease
By Stephanie Fawbush
Why Crohn’s Disease?
Family history of GI problems
Friends with Crohn’s
Many questions about nutritional
guidance from these friends and
family
Crohn’s:
Discussion of Disease
What is Crohn’s Disease?
 Form of inflammatory bowel disease (IBD)
 Autoimmune, chronic inflammatory condition of
the GI tract
 Marked by an abnormal response by the body’s
immune system
 Diseased segments separated by normal bowel
segments
o “skip lesions”
IBD: Crohn’s vs. Ulcerative Colitis
Facts About Crohn’s
 Affects an estimated 0.1-16/100,000 people
 IBD has an overall health care cost of more
than $1.7 billion
o One of the 5 most prevalent GI disease burdens
in the US
 75% of Crohn’s patients will need surgery in
their lifetime
The GI Tract
 Upper GI
o Esophagus
o Stomach
o Duodenum
 Lower GI
o Small Intestine
o Large Intestine
o Colon
The GI Tract
The main functions of the GI system
are:
oDigestion
oAbsorption
Digestion
 Oral phase
o Mastication and mixing of food with salivary fluid and
enzymes.
 Gastric phase
o Pepsin and gastric acid start to form the bolus into
chyme.
o Chyme delivered to the small intestine for mixing with
enzymes.
 Intestinal phase
o Disaccharides, peptidases, and cholecystokinin
Stomach
 Secretes protease and
hydrochloric acid
 The food bolus is
churned in the
stomach through
peristalsis.
o 40 minutes to 4 hours
 Main function is
digestion
o Small amounts of
absorption
Absorption
 Passage of molecular nutrients into the bloodstream
from the intestinal cells
Small Intestine
 Site of chemical
digestion and
absorption
 Three sections:
o Duodenum
o Jejunum
o Ileum
Large Intestine
 Three sections:
o Caecum
o Colon
o Rectum
 Compacts and stores
fecal matter before it
is passed from the
anus.
A
B
S
O
R
P
T
I
O
N
Pathophysiology
 Cause is not completely understood
 Involves the interaction of the GI immunologic
system and genetic and environmental factors
 Increased exposure, decreased defense
mechanisms, or decreased tolerance to some
component of the GI microflora may occur
 Major environmental factors include:
o Resident and transient microorganisms in the GI tract
o Dietary components
Pathophysiology
 Chronic inflammation from T-cell activation
leading to tissue injury is implicated.
 T-cells stimulate the inflammatory response.
o Release nonspecific inflammatory substances,
which result in direct injury to the intestine.
Pathophysiology
 Transmural inflammation
results in thickening of the
bowel wall and narrowing of
the lumen.
 As Crohn’s disease
progresses, it is complicated
by:
o Obstruction or deep
ulceration leading to
fistulization
o Microperforation
o Abscess formation
o Adhesions
o Malabsorption
Signs & Symptoms


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
Cramps
Loss of appetite
Tenesmus
Diarrhea
Weight loss
Constipation
Fistulas
Ulcers
Rectal bleeding
Swollen gums
Anemia
 Mouth sores
 Nutritional
deficiencies
 Abscesses
 Anal fissures
 Hemorrhoids
 Fever
 Fatigue
 Eye inflammation
 Joint pain
Diagnosis
 Multistep process
 Includes assessing:
o Patient’s medical history
o Physical exam
o Lab values
o Medical tests
Diagnosis
 Main risk factors include:
o Genetics (Jewish population)
o Smoking (doubles the risk)
o Diet
o Infectious agents
o Immunological factors
Diagnosis:
Physical Exam
 Signs include:
 Abdominal mass
 Skin rash
 Swollen joints
 Weight loss
 Mouth ulcers
 Diarrhea
 Constipation
 Loss of appetite
Diagnosis:
Lab Tests
 Albumin
 C-reactive protein
 Erythrocyte sedimentation rate
 Fecal fat
 Hgb
 Complete blood count
Diagnosis:
Procedures
 Colonoscopy
 Barium enema
 CT scan
 Endoscopy
 MRI
 Enteroscopy
 Stool culture
Prognosis
 No cure for Crohn’s disease
 Treatments available to make Crohn’s more
manageable for patients
 Times between flare-ups can be decreased
through medical and nutritional management
Complications of Crohn’s
 Fistulas
 Malabsorption
 Obstruction
 Colon cancer
Medication Management
 Anti-diarrheal agents
o Diphenoxylate, loperamide, and
codeine
 Anti-inflammatory drugs
o 5-ASA agents (Asacol, Canasa,
Pentasa), Sulfasalazine
(Azulfidine)
 Constipation management
o Laxatives, Metamucil, Citrucel
 Pain management
o Tylenol
 Corticosteroids
o Budesonide
 Antibiotics
o Ampicillin, sulfonamide,
cephalosporin, tetracycline,
metronidazole
 Anti-TNF alpha therapy
o Remicade
 Biologic therapy
o Humira, Cimzia, Tysabri
Surgical Management
 Bowel resection
 Total abdominal colectomy
 Colostomy
 Ileostomy
 Total proctocolectomy with
ilesotomy
Crohn’s:
Medical Nutrition Therapy
MNT
 Patients are considered to be at significant
nutritional risk:
o Est. 60-75% of patients will experience malnutrition
 Nutrition therapy is used to:
o Reduce the inflammatory response in the disease
o Correct deficiencies
o Ensure adequate maintenance of nutritional status
 Multidisciplinary approach
MNT:
Objectives







Restore and maintain the patient’s nutritional status.
Replace fluid and electrolytes lost
Monitor mineral and trace element levels carefully
Promote weight gain or prevent losses
Reduce the inflammatory process
Replenish nutrient reserves
Promote healing
Assessment
 First step in the Nutrition Care Process
 Includes:
o Anthropometrics
o Biochemical data
o Clinical data
o Diet history
Assessment:
Calorie Needs
 Kcal/kg
o Range from 15 kcal/kg-45 kcal/kg
 Harris-Benedict equation:
o Men: 66 + 13.7W + 5H - 6.8A=REE x stress factor x
activity factor
o Women: 65.6 + 9.6W + 1.8H – 4.7A= REE x stress factor x
activity factor
Assessment:
Protein Needs
 Protein is important to prevent muscle wasting and
malnutrition.
 Impact of protein-calorie malnutrition as a
prognostic factor is demonstrated as greater
mortality in IBD patients.
 Calculated using gm protein/kg
o Range from 1-2 gm/kg
Diagnosis
 ‘PES statement’
o Problem/nutrition diagnosis, etiology, and
signs/symptoms.
 Diagnoses that could apply to a patient with Crohn’s:
o
o
o
o
o
o
Inadequate oral intake (NI-2.1)
Inadequate fluid intake (NI-3.1)
Malnutrition (NI-5.2)
Inadequate mineral intake (NI-5.10.1)
Underweight (NC-3.1)
Unintended weight loss (NC-3.2)
Interventions
 Improved nutritional status can reduce side effects of
Crohn’s and improve quality of life.
 Nutrition education is key
 Extent of nutrition intervention will depend on:
o
o
o
o
o
Functional status of the GI tract
Extent of diarrheal output
Obstruction
Surgical procedures
Bleeding
Interventions
 When a patient is admitted with a severe Crohn’s
flare, the following nutritional progression is
recommended:
o Nutrition support: enteral feedings or total parenteral
nutrition.
o Progress to low-fat, low-fiber, high-protein, highkilocalorie, small, frequent meals with return to normal
diet as tolerated.
Interventions:
Low Fiber Diet
 Maintain a low-fiber diet while experiencing a flair.
 Once flairs have been resolved, return to a normal
diet.
 Gradually add small amounts of foods with fiber back
into diet as tolerated.
o Small amounts of whole grain foods
and higher-fiber fruits and
vegetables.
Interventions:
Low Fiber Diet
 Recommended foods during a Crohn’s flair:
o Milk: Low fat milk products (skim milk, low fat cottage cheese,
low fat yogurt)
o Grains: Grains with less than 2 grams of fiber per serving (refined
grains, white rice, white bread)
o Vegetables: Well cooked vegetables without seeds, potatoes
without skin, and lettuce
o Fruit: Fruit juice without pulp, canned fruit in juice/light syrup,
peeled fruits
o Fat: Less than 8 tsp fats per day
o Meat: Well cooked meats, eggs, smooth nut butters, and tofu
Interventions:
Low Fat Diet
 Helpful if the patient has trouble digesting or
absorbing fat.
 Can help prevent uncomfortable side effects, such as
diarrhea, bloating, and cramping.
 However, some studies
recommend that fat should
only be avoided if the patient is
experiencing steatorrhea.
Interventions:
Other Recommendations
 Maximize calorie and protein intake.
 Encourage the patient to eat small meals or snacks every 3-4
hours.
 Other recommendations could include:
o
o
o
o
Avoiding foods high in oxalate
Increasing antioxidant intake
Supplementation with omega-3-fatty acids and glutamine
Using probiotics and prebiotics
Interventions:
Nutrition Support
 TEN with a liquid formula
 TEN can be used in combination with
oral feeds.
o Tube feeds with added glutamine
o Polymeric formulas
o Low fiber formulas
 Nocturnal tube feeds
 Times when the gut cannot be used
 Perioperative PN may reverse
malnutrition
Interventions:
Exclusive Enteral Nutrition (EEN)
 Providing the patient with liquid formulas only and stopping
oral feedings.
o Carried out six-to-eight weeks
 Demonstrated to lead to mucosal healing.
o Result in fewer exacerbations and trips to the hospital.
 Well-proven therapy for the management of Crohn’s disease
in the pediatric population.
Interventions:
Supplementation
 Vitamin D
 Vitamin E
 Zinc
 Calcium
 Magnesium
 Folate
 Thiamine
 Vitamin B12
 Ferritin
 Iron
Interventions:
Supplementation
 Four labs to pay special
attention to:
o Vitamin D
o Ferritin
o Iron
o Zinc
Monitoring & Evaluation
 Nutrition care indicators will reflect a change as a
result of nutrition care.
 Things that can be monitored and evaluated include:
o Food/nutrition-related history outcomes
o Anthropometric measurement outcomes
o Biochemical data, medical tests, and procedure
outcomes
o Nutrition-focused physical finding outcomes
Crohn’s:
Presentation of the
Patient
The Patient: J.P.
 J.P. was a 43 year old white
female
 Admitted to PPMC on October
25, 2012
 Dx: Crohn’s flair
o She presented with several weeks
of loose stools containing mucous
and blood along with abdominal
pain.
 PMH: Crohn’s disease & asthma
 PSH: Tonsillectomy
About J.P.
 Diagnosed with Crohn’s in 2006
 Controlled on Pentasa ever since with only
intermittent symptoms
 Began to have increased symptoms of abdominal
pain, frequent blood/mucous bowel movements, and
oral ulcers in August 2012.
 At admission, having blood/mucous bowel
movements every hour.
 Decreased oral intake 2/2 abdominal pain
Crohn’s:
Medical Hospital Course
Medical Hospital Course
 J.P. experienced interventions
regarding the following medical
problems while in the hospital:
o
o
o
o
o
Crohn’s flare
New enterovaginal fistula
Hemorrhoids
Anal fissure
Bilateral avascular necrosis w/o
collapse of subchondral plate
Medical Hospital Course
 October 26, 2012
o C diff, crypto, and giardia negative.
o HBV & HCV negative.
o Colonoscopy







External skin tags
Ulceration of the entire rectum from anus to 25cm
Ulcerated mucosa sigmoid in the descending and transverse colon
Areas of normal-appearing mucosa between the affected areas.
Area of mucosal tag/polyps that numbered >10 in the transverse colon.
The terminal ileum appeared to be normal to 10cm.
Cecum and rectosigmoid colon showed acute/chronic inflammation,
cryptitis, crypt abscess, and architectural disarray.
o Mild gastritis in the antrum.
o Lastly, an EGD was performed, which showed mildly erythematous antral
mucosa.
Medical Hospital Course
 October 28, 2012
o Stool culture, PPD read, & hepatitis B surface antibody negative
 November 1, 2012
o MRI of the pelvis
 Fistula between the anterior aspect of the distal rectum to the left side of
the posterior vagina with small collection.
 Mildly active Crohn’s disease involving the region of the terminal ileum.
 B/l femoral avascular/osteonecrosis without the collapse of the
subchondral plate.
 November 2, 2012
o Blood cultures were negative to date; urinalysis benign
 November 7, 2012
o Discharged
J.P.’s Labs
10/25
10/27
10/28
10/29
10/30
10/31
11/2
11/4
11/6
Na
135 (L)
135 (L)
139
138
138
139
134 (L)
137
137
K
4.3
5
4
3.9
3.6
4.1
4.1
4
3.9
Cl
102
104
107
103
105
105
98 (L)
106
105
CO2
26
23
24
29
27
26
29
25
27
BUN
4 (L)
3 (L)
5 (L)
4 (L)
3 (L)
6 (L)
7(L)
4(L)
6(L)
Creatinine 0.61
0.73
0.86
1.15 (H)
0.7
0.76
0.79
0.68
0.82
Ca
8.7 (L)
8.9
8.6 (L)
8.4 (L)
8.4 (L)
8.6 (L)
8.2 (L)
8.3 (L)
8.7 (L)
Glucose
77
200 (H)
98
94
117
112
92
108
30
Mg
2.1
Phosphate 4
Crohn’s:
Nutrition Hospital Course
Nutrition Hospital Course
 J.P. was picked up by clinical nutrition
on day 7 of her admission.
 Clinical nutrition was consulted for
decreased PO intake
o Wanted a calorie count to be initiated.
 J.P. was assessed three times during her
stay at PPMC.
Initial Assessment:
11/1/12
Nutrition Assessment
Height
Weight
UBW
Wt change prior to admission
BMI
Significant Medications
Labs
Complementary Therapies
Skin Integrity
Current Diet Order
Nutrition Requirements
Total daily calorie needs
Daily protein needs
Daily fluid needs
11/1/2012 14:29 by SF
68 in
154 lb/69.9 kg
155 lb
None per pt
23.4
SSI, Methylprednisolone, Dilaudid, Pentasa
11/1-BUN 6 (Low), Ca 8.6 (Low)
Multivitamin
Intact
GI soft/Low fiber
2097 kcals (using 30 kcals/kg)
69.9 g (1 kcal/kg)
2097 (using 1 kcal/ml)
Initial Assessment:
11/1/12
Assessment/
Diagnosis
Nutrition Summary
Nutrition Diagnosis
Nutrition consult for calorie count.
Pt reports ok appetite PTA.
Appetite has been improving and PO intake of ~75% over the past day.
Pt denied any recent wt loss.
Denies N/V.
Loose stools w/ blood/mucous.
Calorie count starting at lunch.
Pt agreed to some nutrition education so discussed Crohn’s nutrition
education with patient.
Discussed Low Fiber Nutrition Therapy and IBD Nutrition Therapy
Altered GI function related to alterations in GI tract structure and
function secondary to Crohn’s disease as evidenced by loose stools
with blood/mucous.
Initial Assessment:
11/1/12
Nutrition Interventions Nutrition Prescription: GI soft/low fiber diet
Interventions:
1) Diet w/ goal to meet >75% estimated energy needs by
reassessment
Clinical Nutrition
-Continue with current diet regimen
Recommendations
-Continue calorie count for 3 days
-Recommend Omega 3 supplement
-Recommend multivitamin
-Encourage PO intake
-If calorie count reveals pt is not meeting calorie needs,
consider adding supplement
Complexity of Care
Level 1 (follow up in 3 days)
Monitoring and
Indicators: total energy intake
Evaluation
Criteria: Pt to meet >75% estimated energy needs by
reassessment
Follow Up:
11/2/12
 Medications: Methylprednisolone, Dilaudid, MVI, Fish oil
supplement, Ca+Vit D supplement, Pentasa, Prednisone,
Remicade
 Labs: Na 134 (Low), BUN 7 (Low), Ca 8.2 (Low)
 Summary: 24 hour calorie count- 1233 kcals, 53.4 g protein
(meets 59% kcal needs, 76% protein needs)
 Recommendations:
o Continue with current diet regimen
o Continue calorie count through breakfast 11/4; will determine
need for supplement
o Encourage PO intake
2ND Follow Up:
11/4/12
 Medications: Dilaudid, MVI, Fish oil supplement,
Ca+Vit D supplement, Pentasa, Prednisone, Remicade
 Labs: BUN 4 (Low), Ca 8.3 (Low)
 Summary: 3 day calorie count met 54% kcal needs, 74%
protein needs. Discussed supplements with patient to
help her meet her energy goals. Pt agreeable to try
Ensure with meals.
 Recommendations:
o Continue with current diet regimen
o Add Ensure TID
o Encourage PO intake
Crohn’s:
Critical Comments
Critical Comments
 Ask for a lab panel that includes vitamin D, zinc, iron,
and ferritin.
 Re-assess protein needs
o I would estimate her protein needs to be about 1.3-1.5
g/kg instead of 1 g/kg in original assessment.
 Implement an oral supplement earlier into her stay
Crohn’s:
Summary
Summary
 Recommendations are constantly changing in the
world of nutrition.
o Vital to remain knowledgeable and up to date on current
research in order to provide the best patient care.
 Dietitians are an integral part of the multidisciplinary
team in treating patients with Crohn’s.
o RD’s need to make sure that they stay involved in the
patient’s care and provide valuable insight to the team.
THANKS TO:
-Elizabeth Stabler RD, LDN
-Lauren Ginipro RD, LDN
-Erin Gerlach RD, LDN
-Arpana Bidnur RD, LDN
-Theodora Wong RD, LDN
And all the dietitians at:
-Nazareth Hospital
-Children’s Hospital of Philadelphia
-Hospital of the University of
Pennsylvania
References
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

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


Crohn’s disease and ulcerative colitis overview. Academy of Nutrition and Dietetics, Nutrition Care Manual. 2012.
Available at: http://www.nutritioncaremanual.org/ content.cfm?ncm_content_id=91936. Accessed December 27, 2012.
Crohn’s disease. U.S. National Library of Medicine. 2012. Available at: http://www.
ncbi.nlm.nih.gov/pubmedhealth/PMH0001295/. Accessed December 27, 2012.
Mosby’s Dictionary of Medicine, Nursing, and Health Professions. 8th ed. St. Louis: Mosby Elsevier; 2009.
Inflammatory bowel disease (IBD). Centers for Disease Control and Prevention. 2012. Available at:
http://www.cdc.gov/ibd. Accessed December 27, 2012.
Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis: Saunders Elsevier; 2008.
Images. Clinical Care Options. 2012. Available at: www.clinicaloptions.com. Accessed December 27, 2012.
Digestive disorders health center. WebMD. 2009. Available at: http://www.webmd. com/digestive-disorders/picture-ofthe-stomach. Accessed January 4, 2013.
Mandal A. What does the small intestine do? News-Medical. 2012. Available at: http://www.newsmedical.net/health/What-Does-the-Small-Intestine-Do.aspx. Accessed December 28, 2012.
Large intestine. Medline Plus. 2012. Available at: http://www.nlm.nih.gov/ medlineplus/ency/imagepages/19220.htm.
Accessed January 4, 2013.
Ghazi L. Crohn’s disease. Medscape. 2013. Available at: http://emedicine.medscape.com /article/172940overview#a0104. Accessed January 4, 2013.
Waye JD, Palmon R. Colonoscopy in inflammatory bowel disease. Pract Gastroenterol. 2006; 25: 14-29.
Barrett JC et al. Genome-wide association defines more than 30 district susceptibility loci for Crohn’s disease. Nat
Genet. 2008; 8: 955-962.
Shanahan F. Crohn’s disease. The Lancet. 2002; 359: 62-69.
Crohn’s disease. US News Health. 2009. Available at: http://health.usnews.com/health-conditions/digestivedisorders/crohns-disease/tests. Accessed January 5, 2013.
Crohn’s disease health center. WebMD. 2012. Available at: http://www.webmd.com/ ibd-crohns-disease/crohnsdisease/inflammatory-bowel-disease-and-colon-cancer. Accessed January 4, 2013.
Escott-Stump S. Nutrition and Diagnosis-Related Care. 7th ed. Baltimore: Lippincott Williams & Williams; 2012.
Total abdominal colectomy. Medline Plus. 2013. Available at: http://www.nlm.nih.gov/
medlineplus/ency/article/007379.htm. Accessed January 4, 2013.
Total proctocolectomy with ileostomy. Medline Plus. 2013. Available at: http://www.
nlm.nih.gov/medlineplus/ency/article/007381.htm. Accessed January 4, 2013.
Krok KL, Lichenstein GR. Nutrition in Crohn disease. Curr Opin Gastroenterol. 2003; 19: 148-153.
References
Crohn’s disease and ulcerative colitis nutrition prescription. Academy of Nutrition and Dietetics, Nutrition Care Manual.
2012. Available at: http://www.nutritioncaremanual .org/content.cfm?ncm_content_id=92004. Accessed February 1, 2013.
Naik AS, Venu N. Nutritional care in adult inflammatory bowel disease. Pract Gastroenterol. 2012; 106: 18-28.
Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology Reference Manual. 3rd ed. Chicago:
American Dietetic Association; 2011.
Eiden K. Nutritional considerations in inflammatory bowel disease. Pract Gastroenterol. 2003; 33-50.
Crohn’s disease and ulcerative colitis nutrition prescription. Academy of Nutrition and Dietetics, Nutrition Care Manual.
2012. Available at: http://www.nutritioncaremanual. org/content.cfm?ncm_content_id=92005. Accessed February 1, 2013.
Crohn’s disease and ulcerative colitis overview. Academy of Nutrition and Dietetics, Nutrition Care Manual. 2012. Available at:
Nutrition therapy
for inflammatory bowel
diseae. Academy of
Nutrition
Dietetics, Nutrition Care Manual. 2012.
http://www.nutritioncaremanual.org/
content.cfm?ncm_content_id=91936.
Accessed
Decemberand
27, 2012.

Crohn’s
disease.
U.S.
National
Library
of
Medicine.
2012.
Available
at:
http://www.
ncbi.nlm.nih.gov/pubmedhealth/PMH0001295/.
Accessed December
27, 2012. February 1,
Available at: http://www.nutritioncaremanual.org /vault/editor/Docs/Crohns_IBDNutritionTherapy1.pdf.
Access

Mosby’s Dictionary of Medicine, Nursing, and Health Professions. 8th ed. St. Louis: Mosby Elsevier; 2009.
2013.

Inflammatory bowel disease (IBD). Centers for Disease Control and Prevention. 2012. Available at: http://www.cdc.gov/ibd. Accessed December 27, 2012.

Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis: Saunders Elsevier; 2008.
Fat-restricted
nutrition therapy. Academy of Nutrition and Dietetics, Nutrition Care Manual. 2012. Available at:

Images. Clinical Care Options. 2012. Available at: www.clinicaloptions.com. Accessed December 27, 2012.

Digestive disorders health center. WebMD. 2009. Available at: http://www.webmd. com/digestive-disorders/picture-of-the-stomach.
AccessedFebruary
January 4, 2013.
http://www.nutritioncaremanual.org/vault/editor/Docs/Fat-RestrictedNutritionTherapy2.pdf.
Access
1, 2013.

Mandal A. What does the small intestine do? News-Medical. 2012. Available at: http://www.news-medical.net/health/What-Does-the-Small-Intestine-Do.aspx.
Johnson T, etAccessed
al. Treatment
of active Crohn’s disease in children using partial enteral nutrition with liquid formula: a
December 28, 2012.

Large intestine. Medline Plus. 2012. Available at: http://www.nlm.nih.gov/ medlineplus/ency/imagepages/19220.htm. Accessed January 4, 2013.
randomized
control
trial.
Gut.Medscape.
2006; 2013.
55: Available
356. at: http://emedicine.medscape.com /article/172940-overview#a0104. Accessed January 4, 2013.

Ghazi L. Crohn’s
disease.

Waye
JD,
Palmon
R.
Colonoscopy
in
inflammatory
bowel disease.
Pract Gastroenterol.
2006; 25:
14-29.
Newby EA, et al. Interventions for growth failure
in childhood
Crohn’s
disease.
Cochrane Database Syst Rev. 2005;

Barrett JC et al. Genome-wide association defines more than 30 district susceptibility loci for Crohn’s disease. Nat Genet. 2008; 8: 955-962.
3:CD003873.

Shanahan F. Crohn’s disease. The Lancet. 2002; 359: 62-69.

disease. US News Health. 2009. Available at: http://health.usnews.com/health-conditions/digestive-disorders/crohns-disease/tests. Accessed January 5,
Day AS, OtleyCrohn’s
AR. Exclusive
enteral nutrition: a nutritional approach to Crohn’s disease. Pract Gastroenterol. 2009; 51: 342013.

Crohn’s
disease
health
center.
WebMD. 2012. Available at: http://www.webmd.com/ ibd-crohns-disease/crohns-disease/inflammatory-bowel-disease-and-colon40.
cancer. Accessed January 4, 2013.

Escott-Stump
S. Nutrition andcolitis
Diagnosis-Related
Care. 7th ed.and
Baltimore:
Lippincottissue.
Williams Academy
& Williams; 2012.of Nutrition and Dietetics, Nutrition Care
Crohn’s disease
and ulcerative
biochemical
nutrient

Total abdominal colectomy. Medline Plus. 2013. Available at: http://www.nlm.nih.gov/ medlineplus/ency/article/007379.htm. Accessed January 4, 2013.
Manual. 2012.
Available
at: http://www.
nutritioncaremanual.org/content.cfm?ncm_content_id=91939.
February 1,

Total
proctocolectomy
with ileostomy. Medline
Plus. 2013. Available at: http://www. nlm.nih.gov/medlineplus/ency/article/007381.htm. Accessed Access
January 4, 2013.

Krok
KL,
Lichenstein
GR.
Nutrition
in
Crohn
disease.
Curr
Opin
Gastroenterol.
2003;
19:
148-153.
2013.
Sylvester FA, et al. Natural history of bone metabolism and bone mineral density in children with inflammatory bowel
disease. Inflamm Bowel Dis. 2007; 13: 42.
Dietary supplement fact sheet: iron. Office of Dietary Supplements-National Institutes of Health. 2012. Available at:
http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/. Accessed February 15, 2013.
Link between low zinc and Crohn’s disease symptoms studied. Baylor College of Medicine. 2004. Available at:
http://www.bcm.edu/cnrc/consumer/archives/zinc-chrons.htm. Accessed February 1, 2013.