Background: Inadequate dietary intake of vitamin D, vitamin K, and calcium, as well as sub-optimal sunlight exposure, can lead to bone loss in the general population, and more so in patients with ulcerative colitis, who are burdened by additional predisposing factors for osteoporosis, such as chronic inflammation and cortisone use. However, micronutrient deficiencies, if present, are easily corrected by nutritional intervention. While the relation between calcium and vitamin D and bone metabolism is well known, fewer data are available for vitamin K, for both healthy individuals and patients. The aim of this review is to provide an overview of recent reports focusing on nutritional deficits relevant to the development of osteoporosis/osteopenia in patients affected by ulcerative colitis. Methods: A systematic electronic search of the English literature up to January 2025 was performed using Medline and the Cochrane Library. Results: Despite being central in bone mineralization, data on dietary calcium intake in ulcerative colitis are relatively scarce, deriving mostly from mixed inflammatory bowel disease cohorts. Although lower than controls, dietary calcium intake approaches the recommended daily allowance, which establishes the necessary daily intake of nutrients. Conversely, vitamin D and vitamin K deficiencies are highly prevalent in ulcerative colitis patients. The widely shared opinion that milk and lactose-containing foods, as well as vegetables, worsen diarrhea is a prime determinant of inadequate vitamin D and vitamin K intake. Conclusions: Increased awareness of the importance of nutrition and the common occurrence of nutritional deficits represents the first step for the development of dietary intervention strategies to counteract the increased risk of osteoporosis in ulcerative colitis patients.

Reaching the Selecting Therapeutic Targets in Inflammatory Bowel Disease-II (STRIDE-II) therapeutic targets for inflammatory bowel disease (IBD) requires an interdisciplinary approach. Lifestyle interventions focusing on enhancing and preserving health-related physical fitness (HRPF) may aid in improving subjective health, decreasing disability, or even controlling inflammation. However, ambiguity remains about the status and impact of HRPF (i.e. body composition, cardiorespiratory fitness, muscular strength, muscular endurance, and flexibility) in IBD patients, hindering the development of physical activity and physical exercise training guidelines.

To review HRPF components in IBD patients and the impact of physical activity and physical exercise training interventions on HRPF.

A systematic search in multiple databases was conducted for original studies that included patients with IBD, assessed one or more HRPF components, and/or evaluated physical activity or physical exercise training interventions.

Sixty-eight articles were included. No study examined the complete concept of HRPF, and considerable heterogeneity existed in assessment methods, with frequent use of non-validated tests. According to studies that used gold standard tests, cardiorespiratory fitness seemed to be reduced, but findings on muscular strength and endurance were inconsistent. A limited number of studies that evaluated physical activity or physical exercise training interventions reported effects on HRPF, overall showing a positive impact.

We performed a scoping review using a systematic and iterative approach to identify and synthesize an emerging body of literature on health-related physical fitness in patients with IBD, highlighting several research gaps and opportunities for future research. Findings of this review revealed a gap in the literature regarding the accurate assessment of HRPF in patients with IBD and highlighted important methodological limitations of studies that evaluated physical activity or physical exercise training interventions. This scoping review is a step towards performing studies and systematic reviews in the future, which was not possible at present given the heterogeneity in endpoints and designs of the available studies on this topic. Future well-designed studies are required to determine the optimal training paradigm for improving HRPF in patients with IBD before guidelines can be developed and integrated into the therapeutic strategy.

The causes of chronic antibiotic refractory pouchitis (CARP) and pouch failure in inflammatory bowel disease (IBD) patients remain unknown. Our previous small study showed peripouch fat area measured by MRI was associated with pouchitis.

To explore the relationship between peripouch fat area on CT imaging and pouch outcomes.

This is a historical cohort study. Demographic, clinical, and radiographic data of IBD patients with abdominal CT scans after pouch surgery between 2002 and 2017 were collected. Peripouch fat areas and mesenteric peripouch fat areas were measured on CT images at the middle pouch level.

A total of 435 IBD patients were included. Patients with higher peripouch fat areas had a higher prevalence of CARP. Univariate analyses demonstrated that long duration of the pouch, high weight or body mass index, the presence of primary sclerosing cholangitis or other autoimmune disorders, and greater peripouch fat area or mesenteric peripouch fat area were risk factors for CARP. Multivariable analyses demonstrated that the presence of primary sclerosing cholangitis or autoimmuned disorders, and greater peripouch fat area (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.016-1.047, P < 0.001) or mesenteric peripouch fat area were independent risk factors for CARP. Of the 435 patients, 139 (32.0%) had two or more CT scans. Multivariable Cox proportional hazard analyses showed that "peripouch fat area increase ≥ 15%" (OR 3.808, 95%CI 1.703-8.517, P = 0.001) was an independent predictor of pouch failure.

A great peripouch fat area measured on CT image is associated with a higher prevalence of CARP, and the accumulation of peripouch fat is a risk factor for pouch failure. The assessment of peripouch fat may be used to monitor the disease course of the ileal pouch.

This case study examined changes in body composition, resting metabolic rate (RMR), aerobic capacity, and daily physical activity in a patient who had ulcerative colitis and underwent ileal pouch-anal anastomosis (IPAA) surgery. Body composition, RMR, and peak oxygen consumption (VO₂peak) were assessed prior to surgery and four, eight, and 16 weeks after IPAA surgery. Daily physical activity data were extracted from a wrist-worn activity tracker preoperatively and 16 months postoperatively. At baseline, total body mass was 95.3 kg; body fat, 11.6%; lean body mass, 81.1 kg; RMR, 2416 kcal/d; and VO₂peak, 42.7 mL/kg/min. All values decreased from baseline at four weeks postoperatively, body mass was 85.2 kg (-10.5%); body fat, 10.9% (-6.0%); lean body mass, 73.1 kg (-9.9%); RMR 2210 kcal/d (-8.5%) and VO₂peak, 25.5 mL/kg/min (-40.3%). At 16 weeks postoperatively, most parameters were near their baseline levels (within 1-7%), exceptions were VO₂peak, which was 20.4% below baseline, and RMR, which increased to nearly 20% above baseline. After the patient had IPAA surgery, his total and lean body masses, RMR, and aerobic capacity were markedly decreased. Daily physical activity decreased postoperatively and likely contributed to the decreased aerobic capacity, which may take longer to recover compared to body composition and RMR parameters.

The body composition of patients with ulcerative colitis (UC) remains unclear. This study evaluated body composition in adult patients with UC and the associations of body composition with disease activity and surgical intervention.

This study included 99 patients with UC, 105 with Crohn's disease (CD) and 60 controls. Skeletal muscle area (SMA), visceral fat area (VFA) and subcutaneous fat area (SFA) of the third lumbar vertebrae were evaluated by abdominal computed tomography. The effects of medical therapy and surgery on body composition in UC patients were determined.

Sarcopenia was more frequent in UC patients (27.3%) than in controls (8.3%), but less frequent than in CD patients (59.0%). The prevalence of sarcopenia was significantly higher (33.8% vs. 4.5%, p < 0.001), and SMA (144.26 vs. 182.32 cm², p < 0.001), skeletal muscle index (SMI) (52.22 vs. 65.52 cm²/m², p < 0.001) significantly lower, in UC patients with high (≥6) than low (<6) Mayo score, but SFA and VFA were similar. The prevalence of sarcopenia and alterations in body composition were reversed, along with UC disease activity, following medical treatment or surgery. SMA and SMI correlated significantly with disease activity in UC patients. Multivariate analysis showed that sarcopenia (odds ratio, 8.49; 95% confidence interval, 1.80-40.10; p = 0.007) was a negative predictor of high Mayo score in UC patients. Sarcopenic patients with UC had high probability of need for colectomy in Kaplan-Meier survival curves.

Sarcopenia is associated with high disease activity and poor clinical outcome in UC patients. Medical treatment and colectomy have positive effects on sarcopenia and skeletal muscle depletion.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for ulcerative colitis (UC). Little is known of how the operation affects bone metabolism and fracture risk. The aim of this retrospective cohort study was to investigate fracture risk and serum markers of bone metabolism following IPAA in a national cohort of Danish UC patients.

Diagnostic codes for 1757 patients and 8785 controls were obtained from the National Patient Register while blood results were collected from a regional database. Postoperative fracture free survival was evaluated on a Kaplan-Meier plot. Fracture hazard ratios (HR) after IPAA were calculated from Cox proportional hazards regression analysis.

Fracture risk after IPAA was significantly reduced (adjusted HR = 0.49, 95% CI: 0.43; 0.55, p<0.001). Prior fractures and alcoholism independently increased fracture risk significantly. Osteoporotic fracture risk after IPAA was reduced, significantly for wrist fractures (aHR = 0.39, 95% CI: 0.22; 0.71, p = 0.002), and borderline insignificantly for spine fractures (aHR = 0.51, 95% CI: 0.26; 1.01, p = 0.054). Vitamin D and calcium levels were significantly higher in the patient group (61.2 nmol/L vs. 58.9 nmol/L, p = 0.04 and 1.24 mmol/L vs. 1.21 mmol/L, p<0.01, respectively), while parathyroid hormone and phosphate levels were significantly lower (4.9 pmol/L vs. 6.2 pmol/L, p<0.01 and 1.08 mmol/L vs. 1.12 mmol/L, p<0.01, respectively).

Fracture risk after IPAA is significantly reduced compared to the general population. Prospective studies are needed to verify the biochemical results.

Patients with ulcerative colitis (UC) are at an increased risk for low bone mineral density (BMD). It is unclear whether proctocolectomy with ileal pouch-anal anastomosis (IPAA) for UC alters the risk of bone loss. The aim of this study was to compare BMD in UC patients with and without IPAA.

A total of 267 patients with UC and IPAA (study group) were compared to 119 UC patients without IPAA (control group) in this cross-sectional study. The demographic and clinical variables including dual-energy X-ray absorptiometry scan results were compared. Patients were classified as having normal or low BMD, based on the criteria by the International Society for Clinical Densitometry. Univariate and multivariate analyses were performed to assess risk factors associated with low BMD. Age, gender, race, smoking status, steroid use, alcohol use, body mass index, years of absent estrogen protection, use of calcium, vitamin D supplements and disease duration were selected as covariates.

83 (31.1%) had low BMD in the study group vs. 18 (15.1%) in the control group (p=0.001). 2/13 (15.4%) had low BMD before surgery. The mean age of patients in the study and control groups were 44.7 ± 14.1 vs. 52.4 ± 17.7 years, respectively (p<0.001). The hip BMD was lower in the study group (0.93 ± 0.17 g/cm2) than that in the control group (0.98 ± 0.17 g/cm2) (p=0.038). Fragility fracture was documented in 23 (8.6%) patients in the study group vs. 3 (2.5%) in the control group (p=0.038) Sixty-four (24.0%) of the study group patients were using corticosteroids after surgery in contrast to 93 (78.2%) in the control group (p<0.001). On multivariable analyses, covariate adjusted factors associated with a low BMD in UC patients were advanced age [odds ratio (OR) 1.51 per 5 years; 95% confidence interval [CI], 1.34-1.71], low body mass index (OR=2.37 per 5 kg/m(2) decrease; 95% CI, 1.68-3.36), and the presence of IPAA (OR=6.02; 95% CI, 2.46-14.70). For the 13 IPAA patients who had information available, BMD before IPAA was low. After a median of 46 (Range 7-84) months after IPAA, BMD improved in 7/13 patients (53.8%), while it continued to be low in 6/13 (46.2%) patients.

Low BMD is common in patients with UC. The risk appears to persist even after colectomy and IPAA surgery suggesting that these patients need to be monitored for bone loss.

Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.

Bone mineral density (BMD) can be adversely affected by the chronic nature of inflammatory bowel disease. Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with ulcerative colitis (UC) who require proctocolectomy. There are few data on BMD in UC patients with IPAA. The aim of the study was to assess the prevalence and risk factors associated with low BMD in UC patients after IPAA.

A total of 327 eligible patients with UC and IPAA from the Pouchitis Clinic were enrolled. Dual-energy X-ray absorptiometry was performed. Patients were classified as having normal or low BMD, based on the criteria by the International Society for Clinical Densitometry. A total of 39 demographic and clinical variables were evaluated with logistic regression models.

Of 327 patients with a median of 4 years after IPAA, 105 (32.1%) had low BMD. Fragility fracture was documented in 11 patients (10.5%) in the low BMD group and in 13 of 222 patients (5.9%) in the normal BMD group (P=0.14). In the multivariable analysis, covariate-adjusted factors associated with a low BMD were advanced age (odds ratio (OR) =1.64 per 5 years; 95% CI, 1.44-1.87), low body mass index (OR=0.43 per 5 kg/m(2); 95% CI, 0.30-0.62), and non-use of daily calcium supplement (OR=0.53; 95% CI, 0.29-0.96). Pouch-associated factors were not found to be significantly associated with the bone loss.

Low BMD was common in patients with UC, even after colectomy and IPAA. Low BMD in this patient population was associated with certain risk factors, some of which may be modifiable.

Lean body mass wastage in active Crohn's disease is not only related to malnutrition, but also to local and systemic inflammation. Altered bowel permeability can represent a source of pro-inflammatory cytokines, that have been shown to produce muscle wastage by several mechanisms such as apoptosis. In our study we have evaluated the body composition and the pathological changes of skeletal muscle in patients with Crohn's disease to see whether a relationships between altered gut permeability, proinflammatory cytokines production and muscle wastage existed.

Thirteen consecutive steroid-free patients with active Crohn's disease underwent evaluation of body composition, sugar test for intestinal permeability, determination of serum levels of TNF-alpha, sphingosine, bacterial lipopolysaccaride, and biopsy of gastrocnemius. In bioptic samples we determined fibres cross sectional area, distribution of myosin heavy chains and apoptosis. Twenty healthy subjects formed the control group.

In patients lean body mass was reduced and intestinal permeability increased (p<0.01 for both). TNFalpha, sphingosine and lipopolysaccaride were increased (p<0.01). Fibres size was reduced (p<0.01), with shift of Myosin Heavy Chains from the slow to the fast type. Apoptosis was found in 5 patients' biopsies, never in controls.

Crohn's patients have a myopathy characterized by myocyte apoptosis, modifications of myosin and muscle atrophy. TNF-alpha and sphingosine, that are increased because of the enhanced lipopolysaccaride concentration due to altered gut permeability, may play a pathophysiological role in the development of this myopathy.

Restorative proctocolectomy with an ileal pouch-anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery.

The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control.

Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted.

Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B(12) anemia and hypomagnesaemia.

The following are guidelines for evaluation and consideration for treatment of patients with inflammatory bone disease (IBD) after bone mineral density (BMD) measurements. The Crohn's & Colitis Foundation of America (CCFA) has indicated that its recommendations are intended to serve as reference points for clinical decision-making, not as rigid standards, limits, or rules. They should not be interpreted as quality standards.