Sunday, January 26, 2014

Vitamin Rich Food and IBD - Iron

Dietary Iron with Crohn's and Colitis


The previous post on vitamin and mineral deficiencies and IBD covered the major deficiencies that impact those with Crohn’s Disease and Ulcerative Colitis.  As noted in that post, a routine (annual) workup on potential deficiencies is warranted, with more regular monitoring if there are recurrent and high impact deficiencies.  The post discussed multivitamins, but good nutrition through diet, if the foods are tolerated, is a better alternative in many cases.  While those with deficiencies in multiple areas should consult a clinical dietician (ideally a Registered Dietician) for overall diet help, there are some key foods that can supplement target areas.

The most likely deficiency to be encountered is iron.  The amount of iron necessary for healthy individuals varies based on age, gender, and pregnancy status.  Additionally, the amounts noted are for healthy individuals – those with IBD may need additional iron to counteract increased loss and malabsorption.

Age
Males
(mg/day)
Females
(mg/day)
Pregnancy
(mg/day)
Lactation
(mg/day)
7 to 12 months
11
11
N/A
N/A
1 to 3 years
7
7
N/A
N/A
4 to 8 years
10
10
N/A
N/A
9 to 13 years
8
8
N/A
N/A
14 to 18 years
11
15
27
10
19 to 50 years
8
18
27
9
51+ years
8
8
N/A
N/A
Source:  US NIH (1)

It should also be noted that iron toxicity can occur at 45mg/day – care should be taken to not go above or even approach this limit without doctor’s approval.  Unlike many other vitamins, not all iron is absorbed equally.  Heme iron, that bound in hemoglobin and available from animal sources, is more easily absorbed than non-heme iron from vegetable sources.  Up to 35% of heme iron and 20% of non-heme iron is absorbed by healthy individuals (and as low as 2% of non-heme iron).  Because of this, vegetarians frequently have a more difficult time with iron regulation than non-vegetarians, though it is still very possible to maintain adequate levels with a carefully planned vegetarian diet. (2,3)  Iron absorption is further effected by what it is taken in with – Vitamin C and meat meat proteins positively impact non-heme iron absorption, while tea, calcium, legumes, and whole grains negatively impact absorption.  This can be used for more careful dietary planning – taking that calcium supplement with your chicken isn’t the best idea, and tea may be better off well after dinner.  Additionally, adding lean protein with a vegetable can have a positive synergy.(4)

What foods have the best iron availability?  On the heme side, organ meats tend to have the highest values, and on the non-heme side, fortified cereal products have the highest.  While Rice Krispies, Cheerios, and Cap’N’Crunch come in at half of the USRDI per serving, and chicken liver hits over 50%, having chicken livers and cereal for dinner isn’t necessarily a meal plan. 


Food
mg/Serving

Source
Ready-to-eat cereal, 100% iron fortified, ¾ cup
18
100
Non-heme
Chicken liver, pan-fried, 3 ounces
11
61
Heme
Oatmeal, instant, fortified, prepared with water, 1 packet
11
61
Non-heme
Soybeans, mature, boiled, 1 cup
8.8
48
Non-heme
Lentils, boiled, 1 cup
6.6
37
Non-heme
Oysters, canned, 3 ounces
5.7
32
Heme
Beef liver, pan-fried, 3 ounces
5.2
29
Heme
Beans, kidney, mature, boiled, 1 cup
5.2
29
Non-heme
Ready-to-eat cereal, 25% iron fortified, ¾ cup
4.5
25
Non-heme
Beans, lima, large, mature, boiled, 1 cup
4.5
25
Non-heme
Blackeye peas, (cowpeas), mature, boiled, 1 cup
4.3
24
Non-heme
Beans, navy, mature, boiled, 1 cup
4.3
24
Non-heme
Beans, pinto, mature, boiled, 1 cup
3.6
21
Non-heme
Beans, black, mature, boiled, 1 cup
3.6
20
Non-heme
Tofu, raw, firm, ½ cup
3.4
19
Non-heme
Spinach, fresh, boiled, drained, ½ cup
3.2
18
Non-heme
Beef, chuck, blade roast, lean only, braised, 3 ounces
3.1
17
Heme
Spinach, canned, drained solids ½ cup
2.5
14
Non-heme
Beef, ground, 85% lean, patty, broiled, 3 ounces
2.2
12
Heme
Turkey, dark meat, roasted, 3 ounces
2
11
Heme
Spinach, frozen, chopped or leaf, boiled ½ cup
1.9
11
Non-heme
Raisins, seedless, packed, ½ cup
1.6
9
Non-heme
Beef, top sirloin, steak, lean only, broiled, 3 ounces
1.6
9
Heme
Grits, white, enriched, quick, prepared with water, 1 cup
1.5
8
Non-heme
Tuna, light, canned in water, 3 ounces
1.3
7
Heme
Turkey, light meat, roasted, 3 ounces
1.1
6
Heme
Chicken, dark meat, meat only, roasted, 3 ounces
1.1
6
Heme


Looking at the table above, it is easy to see how intake iron levels can be below the recommended  values for those with IBD.  Liver is high in fat and may be avoided for that reason, and the fortified cereals are sometimes avoided by those with lactose intolerance (not much fun eating plain Rice Krispies).  Lean meats, while good for you in general, have well below the recommended allowance. Finally, many with IBD have reported difficulties with beans and soy – two excellent sources of iron.  Instead of the standard recommendations that you’ll get from your dietician, here are a few creative ways to supplement your iron if you have IBD (note – the numbers below assume the 18mg/day level of iron – adjust accordingly if you are in a different category):

·         Peanut Butter Rice Krispy Treats (http://www.ricekrispies.com/recipes/peanut-butter-treats).  These puppies are easy to make and pack approximately 23% of the USRDA for iron into each treat.
·         Subway 6” Roast Beef Sub with Spinach.  Adding spinach instead of iceberg lettuce brings this sandwich up to 30% of the daily iron allowance.   
·         Orange Juice with Your Flintstones.  The ascorbic acid (one form of Vitamin C) in OJ can improve absorption of non-heme iron by up to 9%.  A small glass of OJ instead of a glass of water can help.
·         Skip the Egg White Omelette.  Most of the iron in eggs is in the yolk (and Vitamins D, B-12, and B-6). 
·         Build-Your-Own Energy Bar.  You Bars (http://www.youbars.com) allow you to customize the contents of your energy bar – great for those with specific dietary needs, and it’s easy to hit a bar with 13% of the USRDA of iron.  If they are too pricey for your needs – you can make your own at home.
·         Apple Crisp.  Instead of apple pie, try apple crisp.  An enriched oatmeal version has 23% of the iron you need per serving, and it tastes great (http://allrecipes.com/recipe/apple-crisp-with-oat-topping/). 
·         BlackJack Brisket.  Blackstrap molasses (not to be confused with light or dark molasses) is a sucrose-free extract from sugar can, containing lots of iron in addition to calcium, potassium, magnesium, selenium, and B-6.  Brisket is likewise high-iron.  Add them together in a delicious recipe (http://allrecipes.com/recipe/blackjack-brisket/) – skipping the beer – you get a whopping 66% of your RDA for iron.

 As with everything, iron is only one item to balance.  Eating a diet of pure Rice Krispy treats isn’t nutritionally sound, and the suggestions above are meant as creative additions to a well-rounded diet. 

Bottom Line


·         Those with IBD may need more than the normal USRDA for iron due to malabsorption and bleeding loss.
·         Not all iron is absorbed the same.  Meat-based iron is easier to absorb than vegetable-based.
·         Taking vitamin C and iron together is helpful.  Taking calcium supplements and iron together is not.
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2.       Miret, Silvia, Robert J. Simpson, and Andrew T. McKie. "Physiology and molecular biology of dietary iron absorption." Annual review of nutrition 23, no. 1 (2003): 283-301.
3.       Tapiero, H., L. Gate, and K. D. Tew. "Iron: deficiencies and requirements."Biomedicine & pharmacotherapy 55, no. 6 (2001): 324-332.

4.       Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc. Washington, DC: National Academy Press, 2001

Sunday, January 19, 2014

Multivitamins and IBD

Vitamin and Mineral Deficiencies with Crohn's Disease and Ulcerative Colitis

A recent study on multivitamins confirmed what previous studies have increasingly found – for healthy individuals there is no reason whatsoever to take a multivitamin.  In fact, taking too many vitamins can lead to toxic levels – more isn’t better when it comes to the trace vitamins and minerals our body needs.  Additionally, there is the cost factor – spending money on multivitamins that have no benefit and a possible downside doesn’t make sense.  The study above looked at healthy individuals, though.(1)  What about those with IBD, where malabsorption is one of the common issues?

A previous blog post (http://evidencebasedibd.blogspot.com/2013/05/malabsorption-and-ibd.html) covered the areas of the small and large intestine that cause malabsorption when active disease is present.  What specific vitamin deficiencies are most common in the IBD population? 

A preliminary study found that general deficiencies existed in:

·         Biotin
·         Folate
·         Beta-carotene
·         Vitamin A
·         Vitamin C
·         Vitamin B1
·         Vitamin B6

Additionally, individuals with small bowel specific Crohn’s had lower Vitamin B12 levels compared to a control group.(2)  A second study largely confirmed the results above, and found that those with Ulcerative Colitis had additional serum deficiencies in the minerals magnesium, selenium and zinc.(3)  Crohn’s serum levels of copper, niacin, and zinc were found to be low in a separate study.(4)

Another vitamin that gets a lot of attention and has marked deficiencies in long term Crohn’s patients is Vitamin D.  While only a fraction of patients will be Vitamin D deficient (between 10 and 25%), the long term impact on osteoporosis can be high.(5,6)

Perhaps the most frequent deficiency is related to the most common complication with IBD - anemia. Anemia is generally directly associated with disease activity – increased intestinal bleeding being the primary cause.  Anywhere from 25% to 43% of patients with IBD will have an iron deficiency present.(7,8)  Unlike other deficiencies, there is some evidence that taking oral iron may increase disease activity through the Fenton reaction, and intravenous iron supplementation is the preferred option in many cases.(9)

Why individuals with IBD are vitamin deficient can have a range of causes:

·         Malabsorption due to inflammation in the intestinal areas responsible for uptake
·         Loss of vitamins and minerals through gastrointestinal bleeding
·         Poor nutrition through unnecessary food avoidance (eating a limited diet out of fear)
·         Poor nutrition through necessary food avoidance
·         Generally increased intestinal transit time
·         Side effects of medication

Whatever the reason for the deficiency, the general treatment will be with vitamin supplementation – either through a multivitamin or even better through targeted vitamin enhancement.

 IBD is one of the exceptions to the rule about not taking multivitamins, but doing so should only occur after a complete blood workup by your physician.  This should happen at your annual checkup, and more frequently if recurring deficiencies are identified.  Additionally, patients may want to consider seeing a Registered Dietician (RD) to better round out their diet to address deficiencies in lieu of the multivitamin approach (except where the deficiency is severe).  IBD patients are not immune from taking too much in the way of vitamins – mega-dose vitamins should be avoided unless specifically prescribed by your doctor for short term use.

Bottom Line


·         Individuals with both Crohn’s and Ulcerative Colitis frequently have vitamin and mineral deficiencies not present in the normal population.
·         Having at least an annual screening for deficiencies should be part of all treatment regimes.
·         Taking multivitamins to address deficiencies may be warranted, but dietary changes are also a possibility in most cases.

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1.       Guallar E, et al. Enough is enough: stop wasting money on vitamin and mineral supplements. Ann Intern Med 2013;159:850-851.
2.       Fernandez-Banares, F., A. Abad-Lacruz, X. Xiol, J. J. Gine, C. Dolz, E. Cabre, M. Esteve, F. Gonzalez-Huix, and M. A. Gassull. "Vitamin status in patients with inflammatory bowel disease." The American journal of gastroenterology 84, no. 7 (1989): 744.
3.       Geerling, B. J., A. Badart-Smook, R. W. Stockbrügger, and R. J. Brummer. "Comprehensive nutritional status in recently diagnosed patients with inflammatory bowel disease compared with population controls." European journal of clinical nutrition 54, no. 6 (2000): 514-521.
4.       Filippi, Jérôme, Rima AlJaouni, JeanBaptiste Wiroth, Xavier Hébuterne, and Stéphane M. Schneider. "Nutritional deficiencies in patients with Crohn's disease in remission." Inflammatory bowel diseases 12, no. 3 (2006): 185-191.
5.       Tajika, Masahiro, Akira Matsuura, Tsuneya Nakamura, Takashi Suzuki, Akira Sawaki, Tetsuya Kato, Kazuo Hara et al. "Risk factors for vitamin D deficiency in patients with Crohn’s disease." Journal of gastroenterology 39, no. 6 (2004): 527-533.
6.       Siffledeen, Jesse S., Kerry Siminoski, Hillary Steinhart, Gordon Greenberg, and Richard N. Fedorak. "The frequency of vitamin D deficiency in adults with Crohn's disease." Canadian journal of gastroenterology= Journal canadien de gastroenterologie 17, no. 8 (2003): 473.
7.       Thomson, A. B. R., R. Brust, M. A. M. Ali, M. J. Mant, and L. S. Valberg. "Iron deficiency in inflammatory bowel disease." The American journal of digestive diseases 23, no. 8 (1978): 705-709.
8.       Brozović, B., N. H. Dyer, D. L. Mollin, and A. M. Dawson. "The diagnosis of iron deficiency in patients with Crohn's disease." Gut 14, no. 8 (1973): 642-648.
9.       Gasche, Christoph, Arnold Berstad, Ragnar Befrits, Christoph Beglinger, Axel Dignass, Kari Erichsen, Fernando Gomollon et al. "Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases." Inflammatory bowel diseases 13, no. 12 (2007): 1545-1553.