key: cord-297768-tjqpiyp1
authors: Day, Alice S.; Wood, Jessica A.; Halmos, Emma P.; Bryant, Robert V.
title: Practical guidance for dietary management of patients with inflammatory bowel disease during the SARS-CoV2 pandemic
date: 2020-07-20
journal: J Acad Nutr Diet
DOI: 10.1016/j.jand.2020.07.019
sha: 
doc_id: 297768
cord_uid: tjqpiyp1

Abstract The recent outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic has affected almost every nation worldwide. Coronavirus disease (COVID-19) has resulted in considerable morbidity and mortality along with major disruption to global financial markets and social function with mandated social isolation precautions in many countries. Severe COVID-19 have been reported in older people and those with medical comorbidities, raising concern for those with pre-existing gastrointestinal illness.

resulted in considerable morbidity and mortality along with major disruption to global 8 financial markets and social function with mandated social isolation precautions in many 9 countries. Severe COVID-19 have been reported in older people and those with medical 10 comorbidities, raising concern for those with pre-existing gastrointestinal illness. Health Organization and there are >13 million reported cases worldwide (13 th July 2020).

Although the majority of patients will experience a mild disease course, around 10% of 33 symptomatic patients will require hospitalization or intensive care treatment, with a mortality 34 rate of around 5% overall. 1 The clinical manifestations of COVID-19 include fever, chills, Despite theoretical risks, current evidence does not suggest that patients with IBD have an 47 increased risk of developing The international SECURE-IBD Registry reported 48 on 1696 cases of COVID-19 in patients with IBD (on 13 th July 2020), with marginally higher 49 rates in those with Crohn's disease (CD) (943/1696, 55%). 5 Most patients had mild disease 50 and were managed as outpatients (70%). Sixty deaths (4%) amongst this cohort were 51 reported, fourteen of whom were receiving biologic therapy, which is comparable with non-52 IBD populations. Current guidelines therefore advocate for minimizing exposure to COVID-53 19 infection while continuing therapy for their underlying IBD to prevent flares and 54 complications, including escalation of immunosuppression as clinically indicated. 6, 7 It must 55 be acknowledged that it is unlikely any high quality evidence will allow timely production of 56 guidelines specific for IBD patients during the COVID-19 pandemic, so observational data 57 and anecdotal lessons learned from the first countries affected by the novel coronavirus are 58 providing direction for the rest of the world. 2 59 60 Despite reassuring registry data and published guidelines, many patients with IBD and their 61 treating clinicians alike may be reticent to persist with immunosuppressive therapy in the 62 setting of the COVID-19 pandemic. 1 Anxiety as to therapy-related vulnerability may lead to 63 widespread and often inappropriate cessation of medical therapy, as well as exploration of 64 non-immunosuppressive alternatives for management of IBD. Dietary strategies represent an 65 appealing option for those determined to avoid immunosuppression and for those in whom 66 escalation of medical therapy is indicated for a disease flare. Exclusive enteral nutrition 67 therapy (EEN), involving consumption of only nutritional formula without intake of food for 68 a defined period, has a strong evidence base for remission induction in CD when barriers to 69 adherence are overcome. 8 Moreover, EEN has been shown to delay or avoid IBD surgery, 70 which is critical at a time when hospitalization increases risk of COVID-19 exposure as well 71 as in the setting of stretched health care resources. 8, 9 Beyond dietary management of IBD, 72 nutritional optimization, and evaluation and treatment of both malnutrition and obesity-73 related illness are important to best equip patients to face 11 The need for 74 dietary management of functional gut symptoms, already common in patients with IBD, is 75 likely to increase during this period of enormous psychological stress. 12 There is not a diet to prevent virus transmission or to reduce the severity of respiratory 89 illness, however, there is evidence to suggest that malnutrition worsens outcomes for 90 critically ill patients or those with respiratory disease, whilst obesity increases risk of more 91 severe disease, and increases risk of hospitalization in younger patients. 14-16 Therefore, both Conversely, overweight and obesity is also highly prevalent in IBD populations, with 15-118 62% reported as overweight or obese. 18, 24 Isolation restrictions are reported to broadly influence unhealthy dietary habits including less fresh food, increased snacking on ultra-120 processed foods, increased alcohol consumption and less physical activity, therefore weight 121 gain and over nutrition in individuals with IBD is of concern during this pandemic. 17, 25, 26 122 Obesity is associated with persistent disease activity, has been shown to negatively impact 123 biologic therapy and surgical outcomes, and is associated with poorer mental health (anxiety 124 and depression). 27, 28 Routine nutrition screening will also assist in early identification of Table   132 1). 29, 30 It must be acknowledged that these guidelines do not take into account the with a view to protracted use during the pandemic without consideration of these practical 183 points of difference, as the duration of this pandemic is uncertain but likely to be prolonged.

Rather, EEN is best used to avoid corticosteroid therapy for remission induction, acting as a 185 bridge to a suitable maintenance therapy. 11

A major barrier to EEN is adherence, particularly in adults, although remission rates of 60- 280 The global pandemic has resulted in a huge change in almost all of our activities of daily 281 living, including work, studies, social interactions, physical activity, and even access to 282 essential shopping items and services. It is foreseeable that this pandemic may increase 283 exacerbations of mental health disorders and associated conditions. 12 Indeed, survey data on 304 In many countries, safety measures have been put in place to limit community transmission 305 of coronavirus, including use of telehealth for medical services and restrictions on use of 306 endoscopy for IBD disease activity assessment. 11 Fortunately, dietitians have the advantage 307 of not needing to physically examine patients, so a switch to telehealth is generally 308 straightforward, aside from an inability to assess nutritional status by physical examination.

Cost and/or waiting lists may be a barrier to this new format of health care delivery, 8. Consider telehealth dietetic consultation for IBD patients to ensure safe and equitable access to dietetic services during this pandemic, the cost of which may be mitigated by Government supported healthcare schemes.

In these unprecedented times, established paradigms for delivery of care must be re-evaluated 320 and a pragmatic and practical approach to dietary management must be taken. Existing 321 dietary recommendations must be adapted to current social, financial and health service 322 disruptions with a specific focus on safe, adequate nutrition, and optimization of nutritional 323 status. Access to an experienced IBD Dietitian is an essential service for IBD patients who 324 may need their nutrition care plans adapted during this global health crisis. 

Management of IBD during the COVID-19 outbreak

Thank you to Christopher P. Filosi who kindly designed the graphic published as Figure 1 .