Sunshine and Inflammatory Bowel Disease

A recent provocative study (EA Holmes et al. JPGN 2019; 69: 182-88) describes an inverse association between sunshine exposure and the development of pediatric inflammatory bowel disease (IBD).  Among a cohort of 99 children with IBD and 396 controls, the authors used questionnaires to estimate past sun exposure along with other variables.

Key finding:

  • “For each 10 min increment in leisure-time sun exposure in summer or winter there was a linear 6% reduction in the odds of having IBD (P=0.002)”

There was no corresponding data with regard to vitamin D status.

My take:  Being active and going outside are likely good for one’s health and there have been other studies suggesting more sun exposure could reduce the rate of Crohn’s disease. Does Sun Exposure Lower the Risk of Crohn Disease? | gutsandgrowth  Despite this, in my view, this study’s findings have limited value.

  1. There may be many confounders that separate children with more sun exposure from those with less exposure, including diets, exercise, camping, exposure to animals and soil, and many other variables. In addition, there may have been problems with recall bias.
  2. The role of vitamin D was not studied. In previous studies, the importance of vitamin D in its effect on the IBD/immune system have yielded inconsistent results.
  3. In those with IBD, suggesting that more sun exposure may have prevented IBD would not be helpful; this is due to the flimsy evidence and this information could be interpreted  as blaming the family.
  4. Correlation does not prove causation.  For example, a far-fetched association of correlation that is not likely to have a causal association: Rates of Drowning by Falling in Pools and Nicholas Cage Films (National Geographic: Nicholas Cage Movies vs. Drownings)

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View from Wahkeenah Falls Trail, OR

 

 

Vitamin D Supplementation Did Not Improve Postsurgical Outcomes in Patients with Crohn’s Disease

Link from Kipp Ellsworth Twitter Feed: Healio Gastro: Vitamin D does not prevent Crohn’s recurrence after resection

Re: Duijvestein M, et al. Abstract 144. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.

Background: “Researchers conducted a placebo-controlled trial comprising 143 patients with CD to assess the potential anti-inflammatory effects of vitamin D. Patients were randomly assigned to receive either 25,000 International Units of vitamin D3 (n = 72) or placebo (n = 71) weekly for 6 months after their first or second ileocolonic resection.”

Key Finding: “While serum vitamin D levels increased in the vitamin D group and remained unchanged in the placebo group, investigators found no difference in the incidence or severity of endoscopic recurrence at week 26 between the two groups. Cumulative clinical recurrence rates at week 26 were also comparable.”

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Madrid view from Círculo de Bellas Artes

 

 

Time to Revise ImproveCareNow Micronutrient Recommendations

With ImproveCareNow, there have been efforts to minimize variation in care.  As such, there have been suggestions to monitor labs like vitamin D, vitamin B12, and folate routinely. I have voiced concern that some of this testing is unnecessary.  For vitamin B12, deficiency in pediatrics is rare; at risk populations include those with extensive small bowel resections, gastric resections or strict vegan diet.

A recent article (J Fritz et al. Inflamm Bowel Dis 2019; 25: 445-59) which is a systematic review of micronutrients in pediatric inflammatory bowel disease provides further support for the approach of less testing.

Key points:

  • A total of 39 studies were included in the final review (2903 subjects, 1115 controls)
  • Iron deficiency and vitamin D deficiency are common in pediatric patients with IBD
  • Vitamin B12 and folate deficiency are rare
  • Zinc deficiency is uncommon but increased in patients with Crohn’s disease compared to healthy controls.
  • The authors recommend routine (at least yearly) testing for iron, vitamin D and zinc and that there is “insufficient evidence to support routine screening for other micronutrient deficiencies.”

My take: Except in patients with surgical resections and in those with unusual diets (eg. vegan), routinely checking vitamin B12, folate and most other micronutrients is unnecessary & low value care.

Related blog posts:

Vitamin B12:

Vitamin D:

Iron:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Why I Don’t Check Vitamin D Levels During IBD Flare-ups

A recent study (C Striscuiglio et al. JPGN 2018; 67: 501-6) helps explain the role of inflammation on vitamin D levels in pediatric patients (n=51) with inflammatory bowel disease (IBD).

Key findings:

  • The free/total 25-OH D ratio was higher in patients with newly-diagnosed IBD compared to healthy controls (P< .001)
  • A significant direct correlation was found between free/total 25-O D ratio and the activity index of disease (P= .01)
  • While there was frequent deficiency in total vitamin D levels,  the free 25-OH D which is the active form of vitamin D was normal or elevated in patients with newly-diagnosed IBD; this, in turn, was due to a decrease in vitamin-D binding protein which is related to inflammation. The authors hypothesized that at the cellular level in the intestine, there may be peripheral resistance due to inflammation and even supratherapeutic levels of free vitamin D could be needed to produce the active form (1,25-OH D).

My take: This study shows that 25-OH D levels (total) have almost no value at the onset of IBD.  Even normal or elevated free levels of 25-OH D which were found in this study does not preclude the potential need to supplement with vitamin D according to the study authors. In addition, as noted in previous posts, Vitamin D levels can normalize without supplementation when the patient’s IBD responds to therapy.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Dangerous animal –seen on our hike to the tea house, Banff

Vitamin D and Ulcerative Colitis Remission

A recent study (J Gubatan et al. Clin Gastroenterol Hepatol 2017; 15: 240-6) examined a prospective study of 70 patients with ulcerative colitis (UC).  These patients (average age 48.6 yrs) were initially in clinical remission.  Key findings:

  • Mean baseline vitamin D (25-OH) level was lower among patients with subsequent relapse (29.5 ng/mL) than those without relapse (50.3 ng/mL)
  • Over 12 months, a 25-OH D value <35, was associated with a small increased risk of relapse (odds ratio1.25). 20% of patients with a value <35 had clinical relapse compared with 9% (P= .003) who had values >35.

Because vitamin D levels are inversely related to UC disease activity, this study is particularly intriguing.  By enrolling patients prospectively while in remission, this study suggests that good vitamin D levels may directly have immunoprotective and anti-inflammatory properties.

The AGA Journals blog provides an excellent summary of this study: Can Vitamin D Affect Risk of Ulcerative Colitis Relapse?

“In an editorial that accompanies the article, Stephen Hanauer reminds readers that the mean vitamin D level in the entire cohort was 44 ng/mL, and 60% of the subjects were taking vitamin D supplements. A normal vitamin D level is considered to be 20–40 ng/mL in healthy individuals, and the 35 ng/mL cut-off level used in the study was within this range.

Hanauer also mentions that in assessing the confidence intervals for risk of relapse at lower or higher vitamin D levels, there does not appear to be a dose–response effect in the odds ratios according to levels. Based on these findings, Hanauer says it would be premature to target a level of 35 ng/mL. He states that the best predictors of clinical relapse are still endoscopic and histologic markers of inflammation.”

My take: At this time, trying to maintain a normal vitamin D level is likely to be worthwhile; though, values obtained during acute flares remain unreliable.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

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Celiac Studies

Three reports on celiac disease:

  • KM Simmons et al. J Pediatr 2016; 169: 44-8.
  • NR Reilly et al. J Pediatr 2016; 169: 40-54
  • MMS Wessels et al. J Pediatr 2016; 169: 55-60.

In the first study, the authors examined bone mineral density (BMD), glycemic control with hemoglobin A1c, and celiac autoimmunity in children with type 1 diabetes (T1D).  This was a cross-sectional study of 252 children with T1D; 123 had positive serology were anti-tissue transglutaminase (tTG) antibody.  In addition, another cohort (n=141) of children without T1D were examined who carried HLD-DR, DQ genotypes with (n=71) and without (n=70) tTG.  Key findings:

  • Children with T1D: those positive for tTG had significantly worse BMD L1-L4 (-0.45 ± 1.22 vs 0.09 ± 1.10, P= .0003).  Higher tTG and higher HgbA1c were independent predictors of lower BMI.
  • In children without T1D: no differences in BMD were found based on tTG status.
  • The authors concluded that celiac autoimmunity and hyperglycemia had synergistic effects on low BMD.

In the second study, the researchers used a population-based cohort study and compared 958 individuals with both T1D and celiac disease (CD) to 4598 similar individuals with T1D alone. Key finding: Over a 13 year period, 12 patients with both T1D and CD had a fracture (1 osteoporotic fracture). CD did not influence the risk of any fracture (aHR 0.77) in patients with T1D.  The researches concluded: “CD does not seem to influence fracture risk in young patients with T1D.”

My take: Looking at these studies in juxtaposition shows how important it is to consider multiple studies and how frequent discrepant results occur.  While the second study does not show a significant fracture risk, the preponderance of evidence does show an association between celiac disease and low BMD particularly in adults. In addition, a gluten free diet has been shown to reverse low BMD in those with CD.

Relevant studies:

  1. Gastroenterology 2010; 139: 763.
  2. Aliment Pharmacol Ther 2000; 14: 35-43.
  3. JPGN 2003; 37: 434-6.
  4. Gut 1996; 38: 322-7.

In the third study, the investigators looked at “complementary” investigation in children with CD.  These included tests like hemoglobin, ferritin, folate, vitamin B12, calcium, vitamin D, and thyroid assays.  Between 2009-2014, 182 children were evaluated included 119 with new diagnosis. Key findings:

  • At time of diagnosis: Iron deficiency (28%), iron deficiency anemia (9%), folate deficiency (14%), vitamin B12 (1%), and vitamin D deficiency (27%) were identified. No hypocalcemia or thyroid dysfunction was found.
  • At followup: iron deficiency (8%), iron deficiency anemia (2%), folate (3%), vitamin D (25%) were identified and no other abnormalities were evident.
  • The investigators concluded that these complementary tests “are relevant at the time of diagnosis of CD but have little diagnostic yield during followup-visits” after institution of gluten-free diet.

My take: Particularly at followup, identification of nutrient deficiencies is typically similar to the general population.

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