Malnutrition Universal Screening Tool (MUST) predicts disease activity in patients with Crohn’s disease

Background: Malnutrition in patients with inflammatory bowel disease (IBD) is common and under-recognized in patients with Crohn's disease (CD) and ulcerative colitis (UC). Aims: We examined the relationship between nutritional risk and disease activity in outpatient inflammatory bowel disease patients, using the Malnutrition Universal Screening Tool (MUST). Methods: The study was conducted in outpatient IBD clinics in London, Ontario over two months. We examined the association between the MUST scores and the Harvey Bradshaw Index (HBI) and the PMI (Partial Mayo Score), for CD and UC, respectively. Logistic regression was used to examine associations between demographic data, disease characteristics and laboratory values with nutritional risk score. Results: There were a 154 patients were studied over a 2 month period. A high MUST score was strongly associated elevated Harvey Bradshaw Index scores (p=0.005) for patients with Crohn’s disease, but not with the Partial Mayo Index scores (p=0.597) for patients with ulcerative colitis. Nutritional risk scoring did not correlate with lower levels of disease activity. We noted significant associations in the odds of elevated nutritional risk and decreased albumin (OR 1.96, p<0.001), decreased Vitamin D (OR 1.51 p=0.032), and decreased creatinine (OR 1.47 , p=0.050). Conclusions: The MUST predicts disease activity in patients with Crohn’s disease but there is a floor effect. Further studies are required to determine if targeted treatment and monitoring of the nutritional state affects clinical outcomes in patients with CD/IBD. AUTHOR CONFLICT OF INTEREST STATEMENT AND INFORMATION The author declares no conflict of interest Department of Medicine, Division of Gastroenterology, Western University, London, Ontario, Canada. 2 Lawson Health Research Institute, London, Ontario, Canada. Program of Experimental Medicine, Western University Department of Medicine. Department of Medicine, King Abdulaziz University, Jeddah, KSA. Corresponding Author Adam Rahman, MD MSc (EPID) FRCPC, Assistant Professor of Medicine, Division of Gastroenterology, Western University adam.rahman@sjhc.london.on.ca, 268 Grosvenor St. London, Ontario, N6A 4V2, Room B0-689, St. Joseph's Health Centre © Rahman et. al. This is an open access journal distributed under the terms of the Creative Common License BY NC Introduction Malnutrition in patients with inflammatory bowel disease (IBD) is common, under-recognized, and negatively influences clinical outcomes[1]. In the broadest sense, malnutrition is defined by deficiencies in macronutrients (protein, fat, carbohydrates) and/or micronutrients (vitamins, minerals) that adversely effect function at the tissue level, predisposing to negative outcomes. There is an intuitive relationship between reduced absorption of nutrients and the edematous and ulcerated small or large bowel mucosa. However malnutrition in IBD patients is multi-factorial and can often be insidious.[2] The causes of nutritional deficiencies include anorexia secondary to fear of inducing abdominal symptoms, cachexia related to inflammatory cytokines, increased energy requirements due to inflammation, dietary restrictions, and medication side effects.[3, 4] CLINICAL RELEVANCY STATEMENT We report that malnutrition risk screening in patients with Crohn’s disease predicts clinical outcomes at one year. We need studies examining targeted nutritional therapy and the effects of clinical outcomes in patients with inflammatory bowel disease. There are specific micronutrient deficiencies occur in patients with IBD depending upon their general nutritional status as well as the activity and location of their disease.[5] These micronutrient deficiencies may occur even in patients who otherwise appear well nourished.[6] Prevalence of malnutrition in IBD The reported rates of malnutrition in outpatient IBD clinics vary on how malnutrition is defined and measured [7]. The current literature focuses on protein-energy malnutrition and specific micronutrient deficiencies, such as Vitamin D deficiency.[6, 8] When utilizing validated assessment methods of assessing protein-energy malnutrition such as the Subjective Global Assessment (SGA) [9], rates of malnutrition have been reported to be as high as 24% in patients with IBD in clinical remission[10] and 64% of patients with active IBD.[7] Many reported prevalence rates of malnutrition are based on specific anthropometric and laboratory measures, such as body mass index (BMI), skinfold thickness, mid-arm circumference and serum protein levels.[7, 10, 11] However, these measures do not take into account decreased oral ‘intake and disease-related effects on the nutritional state. Furthermore, some of these measures are not practical in a setting of a busy outpatient clinic and relying exclusively on serum protein levels, such as serum albumin, can be misleading.[5] Rahman et al. Canadian Journal of Nutrition 2016 (1): 1-5; ISSN 2371-4808 2 | P a g e Figure 1: MUST Score Challenges in screening nutritional status The physician community in Canada has focused on the Subjective Global Assessment (SGA). The SGA was developed by Canadian researchers[9], but is more of an assessment tool rather than a screening tool, and requires expertise in nutritional assessment, limiting its ease of use. Although the SGA is a commonly recommended method in evaluating malnutrition in Canada, it often does not occur, due to the detailed nature of assessments, the need for clinical expertise, and high inter-rater variability[12]. In the setting of an academic center with a focus on drug trials, and multiple assessments performed by attending physicians, medical learners, nurses, research assistants, and other allied health professionals, the pressure to perform these tasks in a short time period can limit nutritional screening.[13] Additionally, the absence of objective values makes teaching the methodology of SGA difficult and resource intensive. The malnutrition universal screening tool (MUST) is a simple, threestep screening tool validated for use by health care providers in varied populations, which includes medical, surgical and oncological patients[14]. The MUST was developed to detect both under-nutrition and obesity in adults, and was designed for use in multiple settings including hospitals. The questionnaire focuses on body mass index (BMI), weight loss and the presence of serious disease. The final score is then derived to determine whether the nutrition intervention is required (See Figure 1). The tool has consistently been highly rated by healthcare workers for ease of use [12, 15, 16]. Given the favorable characteristics of the MUST screening system, we felt it was an ideal nutritional risk screening tool for outpatient IBD patients. However, for the MUST tool to gain more traction in clinical practice, we felt that demonstrating that MUST screening was predictive of disease severity, was a critical step moving forward. Our purpose is to determine if the MUST tool will predict disease activity in patients with inflammatory bowel disease. We also examined the relationship between malnutrition risk and traditional markers of nutritional status.