Monthly Key Publication Reviews

Publication: Saibeni S, Zanetti M, Bezzio C, Pironi L, Armuzzi A, Riso S, Caprioli F, Lezo A, Macaluso FS, Pugliese D, Daperno M, Giorgetti GM; Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) and Italian Society of Artificial Nutrition and Metabolism (SINPE). Nutritional care at centres managing patients with inflammatory bowel disease: A nationwide survey in Italy. Dig Liver Dis. 2023 Aug;55(8):1028-1033. doi: 10.1016/j.dld.2023.05.029. Epub 2023 Jun 22. PMID: 37355395.

Reviewer: Kunzah Syed, DO, Nutrition Specialist; Medical Pancreatology Fellow, The Johns Hopkins University School of Medicine  

Why is This Paper Important: It is known that malnutrition is tied to adverse outcomes and increased morbidity and mortality1 in inflammatory bowel disease (IBD). Despite the rising prevalence of IBD across the world2, the nutritional management of patients at specialized IBD centers remains heterogeneous and understudied. This national study scrutinized the organization and delivery of nutrition care in Italy in both the outpatient and hospital settings. Information on clinicians’ perceptions of nutritional care was also collected. The paper is helpful for increasing clinician awareness of the status of nutrition care in a major European country and may serve to inspire similar investigative efforts elsewhere.¬

Summary: A 22-question survey was created by the Italian Society of Artificial Nutrition and Metabolism (SINPE) and the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD). Among the 120 IBD centers the researchers formally invited to participate via e-mail, 76 completed the questionnaire on a dedicated website. Seventeen centers were located at private hospitals, 26 at public academic hospitals, while the majority (51%) were at nonacademic/public community hospitals. All IBD centers offered care to adult patients, but a handful offered pediatric care. The most frequently occurring case load was <500 cases per center. 

Just over one-third of participating centers had nutritionists specifically for IBD patients. Though more than half of respondents had a multidisciplinary IBD team at their center, only 22 centers had nutritionists. However, 67.1% of centers replied that they could obtain nutritional evaluations for their IBD patients with ease. Less than one-third of centers (30.3%) conducted a systematic or daily assessment of malnutrition risk in the outpatient setting, while all other centers reported that they at least conducted as-needed assessments. Interestingly, the malnutrition risk assessment was predominantly done by gastroenterologists as compared to nutritionists, dieticians, or nurses. Greater than 50% of centers used anthropometry and biochemistry as parameters of malnutrition risk, and a higher percentage employed these parameters over bioelectrical impedance and evaluation tools to assess nutritional status. The choice to provide oral nutrition support in the outpatient setting was made jointly by a nutritionist and a gastroenterologist at 35.5% of centers, versus by a gastroenterologist alone at the same percentage of centers. At 50% of outpatient IBD centers, the choice to initiate enteral or parenteral nutrition was handled jointly by a nutritionist and a gastroenterologist. Upon hospital admission, patients at 38 centers underwent a malnutrition risk assessment and a nutritional status assessment at 40 centers. The choice to begin enteral or parenteral nutrition was made by a nutritionist with a gastroenterologist at 46% of centers. On a 100 mm visual analogue scale, the relevance of nutritional care scored a mean of 86.5. The necessity to incorporate nutritional care via “an integrated care pathway” scored higher at 87.3. 

Overall, findings illuminate that two-thirds of Italian IBD centers do not have nutritionists and only assess nutritional status in active disease, complicated cases, or when there is apparent or suspected malnutrition. Resource limitations are thought to underlie the selective screening for and assessment of malnutrition, which carry implications for potential undertreatment. 

Commentary: The paper underscores a need to integrate more nutritionists into the multidisciplinary teams at IBD centers in Italy to ultimately improve management, an effort that arguably must be undertaken in other countries as well due to the global disease burden. Study limitations include the inherent biases of survey-based methodology and its observational nature. More research is needed to establish the specific benefits of increasing the recruitment of nutritionists at centers for IBD. Nonetheless, this article highlights an opportunity for nutritionists (and others with formal nutrition training) to be consulted beyond the neediest cases with the goal of optimizing outcomes in IBD. At a number of institutions where gastroenterologists initiate enteral or parenteral nutrition at IBD centers, unaided by nutritionists, integrating formal nutrition training into gastroenterology fellowships is one possible way to bridge the gap. The authors have successfully contributed to the body of literature on the nutritional care of the IBD patient and exposed an important disparity between clinician perceptions and the practical implementation of health care. 

References:

  1. Nguyen GC, Munsell M, Harris ML. Nationwide prevalence and prognostic significance of clinically diagnosable protein-calorie malnutrition in hospitalized inflammatory bowel disease patients. Inflamm Bowel Dis. 2008 Aug;14(8):1105-11. doi: 10.1002/ibd.20429. PMID: 18302272.
    doi: 10.1002/IBD.20429.
  2. Caviglia GP, Garrone A, Bertolino C, Vanni R, Bretto E, Poshnjari A, Tribocco E, Frara S, Armandi A, Astegiano M, Saracco GM, Bertolusso L, Ribaldone DG. Epidemiology of Inflammatory Bowel Diseases: A Population Study in a Healthcare District of North-West Italy. J Clin Med. 2023 Jan 13;12(2):641. doi: 10.3390/jcm12020641. PMID: 36675570; PMCID: PMC9860659.

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