30June2020

The role of the dietitian in the Inflammatory Bowel Disease Multidisciplinary Team

Dearbhaile O'Hanlon, D-ECCO Member

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Dearbhaile O'Hanlon 
© ECCO

D-ECCO is committed to promoting the essential role of dietitians within the Inflammatory Bowel Disease Multidisciplinary Team (IBD MDT). Specialist IBD dietitians in IBD units are integral to the MDT, but not all IBD units have a specialist dietitian. Dietetic services and clinical roles are likely to differ slightly from country to country, but the core roles will remain the same. The European Federation of the Associations of Dietitians (EFAD) has adopted the International Congress of Dietetic Associations (ICDA) definition of the role of the dietitian: “A person with a qualification in Nutrition & Dietetics recognized by national authority(s). The dietitian applies the science of nutrition to the feeding and education of groups of people and individuals in health and disease.”

Patients often feel that nutrition is not being prioritised or is being overlooked by their clinicians [1]. Many patients assume that diet affects their disease and consider it to be as important as, or even more important than, their medical treatment. This is reflected in the fact that patients commonly try to control their symptoms and manage flare ups by making dietary changes which are often self-directed [1–3]. Many clinicians provide dietary advice to patients, but the frustration for patients is that this information is often heterogeneous and conflicting [1]. We know that malnutrition is more prevalent in patients with IBD and that it leads to poorer outcomes. While its causes are multifactorial, it has been observed that patients who self-restrict some foods to manage their disease have a higher prevalence of malnutrition [4].

We know that exclusive enteral nutrition (EEN) is an effective treatment for Crohn’s Disease and is frequently used as primary therapy in paediatric patients and less commonly but almost as effectively in adults [5]. While EEN improves nutritional status and disease activity, the challenges of having only a prescribed liquid diet for 2–8 weeks impact significantly on social interaction and quality of life. To successfully comply with this regimen, close monitoring and support are required and must be of an intensity that cannot be delivered by other members of the MDT. Such support should be provided by a trained dietitian. ESPEN suggest that ideally the dietitian should have a specialist interest in IBD [6, 7]. In order to provide holistic, patient-centred care and avoid needless exacerbation of malnutrition, the patient’s nutritional concerns must be addressed.

Typically a specialist IBD dietitian should lead on all aspects of the patient’s nutritional care. IBD dietitians may further specialise in the life stages from paediatric to transition to adulthood as patients’ nutritional, social and psychological needs will vary across their lifespan. They should assess nutritional status at diagnosis, during admissions and flare ups, and pre-operatively and should support postoperative recovery. They should provide personalised plans for diet modification to manage small bowel strictures or EEN for Crohn’s Disease as well as for oral, enteral or parenteral nutrition support, as appropriate, for all IBD patients. Their attendance at medical, surgical and joint ward rounds allows the provision of updates on nutritional status and the development of joined-up care plans. In the outpatient setting they provide ongoing support in face-to-face, phone, video and group clinics by debunking dietary myths, explaining research and novel diets, and monitoring nutritional status and requirements as the disease course changes. Close communication with the MDT is required to keep its members up to date on disease activity, which may require an adjustment of nutrition plans, and to highlight red flags. As a core member of the MDT and as a nutritional advocate, the dietitian should regularly participate in multidisciplinary meetings and surgical pathway coordination.

The dietitian’s role in the MDT has been recognised for many years. UK NICE guidelines suggest that assessment of nutritional status requires at least the measurement and interpretation of anthropometry and dietary intake, making dietitians integral members of the MDT caring for patients with IBD [8]. When it comes to the management of complex surgical patients, dietitians should be core members of the MDT along with colorectal surgeons, radiologists, gastroenterologists, nurse specialists, histopathologists and coordinators [9]. The recent ECCO Topical Review on Perioperative Dietary Therapy in IBD supports the interdisciplinary approach to pre-operative optimisation and the importance of tailored nutritional therapy [10]. Postoperative complications may be reduced with adequate pre-operative nutritional assessment. Over- or undernutrition should be corrected. Implementation of EEN for luminal Crohn’s surgical patients should be considered and agreed amongst the MDT. Oral, enteral or parenteral nutrition should be offered for malnourished patients. Dietitians are best placed to implement these diets, support these patients and liaise with the MDT regarding their nutritional status and readiness for surgery. Like other practitioners, dietitians have a responsibility to evaluate and audit their input and continue to improve and develop their services.

Our role as dietitians is not limited to patient facing. Specialist IBD dietitians are best placed to provide the most up-to-date evidence-based advice and it is part of their role to disseminate this advice through education and training to other dietitians and the wider MDT. Their involvement extends beyond the hospital walls, too. They are vital to research. The D-ECCO-led Topical Review “Research Gaps in Diet and Nutrition in Inflammatory Bowel Disease” highlighted the complexity and challenges of diet-related research and the most relevant areas of research on which we should focus now and in the future [11].

In this era of COVID-19, our IBD patients, often immunosuppressed, may be more vulnerable and isolated. It is worth considering diet, particularly EEN, as an interim option for symptom and inflammation management. If all members of the MDT understand the complexity of the disease and treatment options, including their risks and benefits, they will be able to identify and flag clinical concerns. It is important, now more than ever, that we make every contact count.

For centres that do not have dietetic representation on their MDT it can be challenging to know where to start. The British Gastroenterology Society (BSG) consensus on the management of IBD suggests that 0.5 whole-time equivalent dietitians should be allocated to gastroenterology per population of 250,000 [12]. If your team does not currently include a dietitian, consider engaging with the dietetic team and putting a case together to recruit one. If you already have a dietitian on your team or in your hospital who has an interest in IBD, then please encourage their involvement in your MDM, ward rounds, joint clinics and research. Nurturing their interest will pay dividends for your patients and your service. To further their training and expertise you can direct them to ECCO’s educational resources and to D-ECCO’s networking and learning opportunities at the annual D-ECCO Workshop at the ECCO Congress.

References

  1. Holt DQ, Strauss BJ, Moore GT. Patients with inflammatory bowel disease and their treating clinicians have different views regarding diet. J Hum Nutr Diet. 2017;30:66–72.
  2. de Vries JHM, Dijkhuizen M, Tap P, et al. Patient's dietary beliefs and behaviours in inflammatory bowel disease. Dig Dis. 2019;37:131–9.
  3. Limdi JK, Aggarwal D, McLaughlin JT. Dietary practices and beliefs in patients with inflammatory bowel disease. Inflamm Bowel Dis 2016;22:164–170.
  4. Casanova MJ, Chaparro M, Molina B, et al. Prevalence of malnutrition and nutritional characteristics of patients with inflammatory bowel disease. J Crohns Colitis. 2017;11:1430–9.
  5. Narula N, Dhillon A, Zhang D, et al. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2018, Issue 4. Art. No.: CD000542. DOI: 10.1002/14651858.CD000542.pub3.
  6. Forbes A, Escher J, Hebuterne X, et al. ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Clin Nutr. 2017;36:321–47.
  7. Bischoff SC, Escher J, Hebuterne X, et al. ESPEN practical guideline: clinical nutrition in inflammatory bowel disease. Clin Nutr. 2020;39:632–53.
  8. National Institute for Health and Care Excellence. NICE quality standard [qs81]. Inflammatory Bowel Disease. London: NICE, 2015.
  9. Morar PS, Sevdalis N, Warusavitarne J, et al. Establishing the aims, format and function for multidisciplinary team-driven care within an inflammatory bowel disease service: a multicentre qualitative specialist-based consensus study. Frontline Gastroenterol. 2018;9:29–36.
  10. Adamina M, Gerasimidis K, Sigall-Boneh R, et al. Perioperative dietary therapy in inflammatory bowel disease. J Crohns Colitis. 2020;14:431–44.
  11. Sigall-Boneh R, Levine A, Lomer M, et al. Research gaps in diet and nutrition in inflammatory bowel disease. A topical review by D-ECCO Working Group [Dietitians of ECCO]. J Crohn's Colitis. 2017;11:1407–19.
  12. Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019:68(Suppl 3):s1–s106.

Posted in ECCO News, Committee News, D-ECCO, Volume 15, Issue 2

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