Introduction

Nutrition and nutritional status can be affected by IBD. If one looks at patients with IBD referred to an outpatient clinic or admitted to a ward, patients with ulcerative colitis usually do not have an overt impairment in nutritional status, but in acute and severe attacks it is possible that they only need nutritional support. Patients affected by Crohn's disease more frequently suffer from overt or subtle nutritional problems, both in childhood and as in the adult life. Despite the fact that most patients' survival expectancy is not impaired and most cases remain productive [1], Crohn's disease can be associated with impairment in QoL scores, disability, and failure to thrive, which is also frequently associated with nutritional problems. It has been estimated that 25-75% of patients suffer from varying degrees of malnutrition; however, the first figure appears more realistic. Impairment in nutritional status more frequently occurs in patients with unremitting and/or complicated disease, but others factors can contribute to malnutrition, particularly in children. Concomitant factors can be shared by the same patient: (1) anorexia and reduced calorie intake; (2) reduced ingestion of foods because of abdominal pain; (3) diarrhoea, malabsorption and protein-loosing enteropathy, especially if the disease is extensive and involves the jejunum; (4) bacterial overgrowth; (5) increased intestinal permeability and chronic inflammation contributing to a chronic hypermetabolic state, which is frequently found in malnourished patients with active disease; (6) GI fistulas, intestine narrowing and infections; (7) subtle deficiency of vitamins and oligoelements that complicate and/or are capable of favouring malnutrition; (9) aftermath of extensive surgical resection with chronic intestinal failure (short-bowel syndrome). Energy requirements and expenditure may increase in the presence of persisting inflammation, and protein synthesis and catabolism appear to correlate with disease activity, even doubling it in the moderate to severe activity phase [2]. An energy requirement of up to

40 KCal/kg/day with a protein requirement of 1.8 g/kg/day has been estimated [3]. However, in adult patients with Crohn's disease without fever and infections, the resting energy expenditure (REE) measured by indirect calorimetry appeared to correlate well with, and to be practically identical to, the expenditure estimated by the Harris-Benedict formula. This suggests, that in about 90% of patients, it is equal to 25±4 KCal/kg/day and that it exceeds 30 KCal/kg/day in only 10% of patients. Therefore, energy and protein requirements depend on the disease activity, the presence of complications, and in most patients, nutritional requirements are not significantly greater than might be theoretically expected.

Some topics deserve a lot of attention because of their frequency, impact on quality of life, therapeutic implications such as : (1) problems of malnutrition in children with IBD and the role of an early nutritional approach in improving growth not just as calorie administration, but as a real therapy; (2) indications and role of artificial nutrition in IBD and of enteral nutrition as primary care; (3) the effect of enteral formulas on some inflammation and mucosal mechanisms in IBD; (4) bone changes in IBD, prevention and treatment.

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