High prevalence of overweight and obesity in adults with Crohn's disease: Associations with disease and lifestyle factors

Journal of Crohn's and Colitis (2013) 7, e241–e248

Available online at www.sciencedirect.com

High prevalence of overweight and obesity in adults with Crohn's disease: Associations with disease and lifestyle factors Treasa Nic Suibhne a , Tara C. Raftery a , Orla McMahon a , Cathal Walsh b , Colm O'Morain a , Maria O'Sullivan a,⁎ a b

Department of Clinical Medicine, Trinity College Centre for Health Sciences, Adelaide & Meath Hospital, Dublin, Ireland Department of Statistics, Trinity College Dublin, Ireland

Received 15 December 2011; received in revised form 8 September 2012; accepted 8 September 2012

KEYWORDS Crohn's disease; Inflammatory bowel disease; Body Mass Index; Obesity; Overweight; Nutrition

Abstract Background and aims: Obesity and overweight are major public health issues. Although traditionally associated with weight loss, there is now evidence that increasing Body Mass Index (BMI) and overweight are emerging features of Crohn's disease (CD) and may be associated with more severe disease course. The aim of the study was to determine the prevalence of overweight and obesity in patients with CD compared with matched healthy controls and to identify disease-specific and generic factors associated with current BMI in this group. Methods: This was a prospective case–control study (n=200), comprising 100 CD outpatients and 100 age-, sex- and socioeconomically-matched healthy controls. BMI, Crohn's disease activity index (CDAI), clinical and lifestyle factors and circulating inflammatory markers were assessed. Results: Overall, 40% of patients with CD were overweight/obese (BMI≥25 kg/m2) compared with 52% of controls (P=0.206). On regression analysis, higher current BMI was significantly associated with disease specific factors, namely lower disease activity (CDAI) and lower white cell count, suggesting stable disease, as well as older age and lower physical activity. BMI was not significantly associated with the need for surgery or the need for corticosteroids. We identified a novel association between higher BMI and higher CRP, a marker linked both with obesity in the general population and with CD. Conclusions: Overweight was common in out-patients with CD and appeared to reflect current wellness, older age and sedentary lifestyles. The potential long-term implications of high BMI for CRP and inflammatory load merit further study. © 2012 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

⁎ Corresponding author at: Department of Clinical Medicine, Trinity Centre for Health Sciences, Adelaide & Meath Hospital, Dublin 24, Ireland. Tel.: +353 1 896 3843; fax: +353 1 896 2988. E-mail address: [email protected] (M. O'Sullivan). 1873-9946/$ - see front matter © 2012 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.crohns.2012.09.009

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1. Introduction Obesity and overweight are major public health issues in Western populations. 1,2 Although Crohn's Disease (CD) is traditionally associated with weight loss and low Body Mass Index (BMI), there is evidence that this may be changing. Weight loss and malnutrition are well-documented features of CD, affecting an estimated 80% of patients during acute flare-ups and hospital admissions 3–5 and are associated with higher mortality, 3 longer hospital stays and higher health care costs. 4 Paradoxically, overweight is now emerging as a further nutritional issue affecting people with CD. 6,7 Sousa Guerreiro et al. 6 noted that 32% of CD patients with mild or inactive CD were overweight, of which 8% were obese. Steed et al. 8 found that over half (55%) of CD patients were overweight/obese, in a cohort that included both active and inactive disease. In a large study of children with newly diagnosed CD, most (66–69%) were in the normal range for BMI and 10% were classed as overweight or at risk for overweight. 7,9 Similarly in established CD, 20% of children were reportedly overweight or obese. 9 The question remains as to the clinical relevance of overweight and obesity in adult CD. In particular, does a higher BMI have a negative impact on disease course and severity, as some studies suggest? 10,11 There are limited published data on this issue. In adults with CD, Blain et al., 10 reported that obese patients were more prone to developing active disease. Haas et al. 11 found that surgery was required sooner for overweight/obese compared with underweight CD patients. In children with CD, higher rates of surgery have been reported in overweight/obese than in normal weight patients. 9 Furthermore, recovery from surgery may be impaired by high BMI, post-operatively obese patients with ulcerative colitis (UC) had significantly longer hospital stays and a higher incidence of complications. 12 Taken together, the existing data suggest that overweight/obesity may have a negative impact on disease course in CD, but this area remains largely unexplored. The mechanisms underlying the putative effects of overweight and obesity on CD are not known. While there is a long-established link between adipose tissue and inflammation in CD, this has predominantly focussed on intra-abdominal (mesenteric) fat as opposed to systemic body fat characteristic of obesity. A build up of intra-abdominal fat is a known feature of CD, 13 reportedly acting as a source of adipocytokines and implicated in the pathogenesis of intestinal inflammation. 14–16 This phenomenon of intra-abdominal fat, however, appears to be independent of overweight and obesity and not necessarily associated with changes in BMI. 16,17 How excessive systemic adipose tissue influences inflammatory processes in CD is less clear. In the general population, obesity is associated with higher C-reactive protein (CRP) 18–20 and Tumour Necrosis Factor-alpha (TNF-alpha) levels 21,22 and obesity is considered an inflammatory state. 21 In the longer term, overweight in CD may increase the risk of co-morbid diseases such as diabetes, cardiovascular diseases and cancer, as in the general public. Coronary heart disease, for example, may be more common in IBD than controls 23,24 but its aetiology appears to be complex and is driven by chronic inflammation 23 as well as conventional risk factors, such as obesity. Considering that overweight is now endemic in Western populations and is an emerging issue in CD, we set out to investigate the role of increasing BMI in this disease. This study aimed to identify the characteristics that distinguish

T. Nic Suibhne et al. overweight from normal weight CD and to determine if current high BMI was associated with markers of more severe CD, as has been suggested by previous studies.

2. Methods 2.1. Patient selection and recruitment Adult patients (N 18 years) with a confirmed diagnosis 25 of CD (n = 100) for a minimum of 3 months were prospectively recruited from the IBD out-patient clinics of the Adelaide & Meath Hospital, Dublin, Ireland. Age-, sex- and socioeconomically-matched healthy controls (n = 100) were recruited from non-medical departments and businesses within the hospital's catchment area. The study was approved by the ‘St James's Hospital and the Adelaide & Meath Hospital, incorporating the National Children's Hospital Dublin, Research Ethics Committee'. All participants gave written informed consent.

2.2. Demographic, clinical and lifestyle data Data on demographics, socioeconomic status 26 and smoking habits were recorded at interview for all participants. Clinical variables, including previous need for CD related surgery and corticosteroid usage in past year were documented. Physical activity was estimated using the European Prospective Investigation into Cancer Physical Activity Questionnaire (EPAQ2) 27 and data expressed as metabolic equivalent (MET) per week. Hours spent watching television (including computer games, DVDs) was further used as a simple marker of physical inactivity and sedentary lifestyles. 28

2.3. Weight and Body Mass Index Height, weight and Body Mass Index (BMI) (kg/m 2) were recorded. Height was measured to the nearest 0.1 cm using a portable stadiometer (Seca Ltd., UK) and body weight to the nearest 0.1 kg using electronic scales (Seca Ltd., UK). Weight and height measures were performed on subjects wearing light indoor clothing and without shoes. Weight status was classified according to BMI, where underweight was defined as a BMI of b 18.5 kg/m 2, normal weight as 18.5–24.9 kg/m 2, overweight was defined as BMI of 25–29.9 kg/m 2 and obese as ≥ 30 kg/m 2. 29 The general term overweight/obese was used to describe BMI ≥ 25 kg/m 2.

2.4. Adiposity Adiposity (body fat stores) was assessed using two anthropometric parameters, namely triceps skinfold thickness (TST) and arm fat area (AFA), both performed and interpreted in accordance with standard protocols 30 and was measured in triplicate using a skinfold calliper (Holtain Ltd, Pembrokeshire, UK). AFA was calculated from triceps skinfold thickness values combined with measurements of the mid upper-arm circumference. 31

Overweight/obesity in Crohn’s disease Table 1

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Characteristics of the study population.

Age, years, mean (s.d.) Gender (male:female) Weight, kg, mean (s.d.) Height (m), mean (s.d.) BMI, kg/m 2 , mean (s.d.) Age at onset, 36 years, % A1 A2 A3 Disease duration, years (IQR) Disease location, 36 % L1 L2 L3 L4 Disease behaviour, 36 % B1 B2 B3 Perianal disease, % B2 + BP Previous surgery for CD, (%) Disease activity CDAI, median (IQR) CRP mg/L, median (IQR) Remission by CDAI b 150, (%) Assessment of adiposity TST mm, mean (s.d.) AFA mm 2, mean (s.d.) Smoking (%) Current smoker Ex-smoker Non-smoker TV hours per week, mean (s.d.) Medication (%) Current steroid use Prednisolone Budesonide Other Steroid use in the past 12 months Current immosuppressant use Current 5-ASA use Current biologics use Family history of IBD (%)

CD (n = 100)

Controls (n = 100)

p

35.7 (10.9) 40:60 71.2 (17.1) 1.68 (0.1) 25.08 (5.5)

37.9 (11.0) 40:60 72.6 (13.9) 1.69 (0.1) 25.43 (3.8)

0.153 1.000 0.523 0.853 0.596

13 71 16 6.5 (3.0–12.8)

– – – –

46 28 24 2

– – – –

56 25 19

– – –

6 29

– –

91.1 (38.4–173.9) 3.7 (2.9–8.0) 67

– – –

20.7 ± 7.5 2666.6 ± 1123.3

20.5 ± 7.2 2636.53 ± 978.2

0.855 0.840

25 29 46 21.1 (9.7)

16 32 52 16.7 (8.2)

0.288

22 11 10 1 37 45 77 15 42

– – – – – – – –

0.010

BMI, Body Mass Index; TST, triceps skinfold thickness; AFA, arm fat area; IBD, Inflammatory bowel disease; CDAI, Crohn's disease activity index, IQR, inter-quartile range. A1, age at diagnosis younger than 17 years; A2, age at diagnosis 17 to 40 years; age at diagnosis older than 40 years; B1, nonstricturing, nonpenetrating disease; B2, stricturing disease; B3, penetrating disease; BP, perianal disease; L1, terminal ileum; L2, colon; L3, ileocolonic; L4, upper gastrointestinal tract (by Montreal classification36).

2.5. Inflammatory markers Disease activity was determined using the Crohn's disease activity index (CDAI) 32 where values less than 150 represented clinical remission. A venous blood sample was taken from patients at study entry. CRP and white blood cell count (WCC) were measured with normal ranges considered less than 5 mg/L and 4–11 cells × 10 9/L respectively. Serum

TNF-alpha (pg/mL) was measured by an enzyme linked immunosorbent assay (Biosource, Belgium) in duplicate and in accordance with the manufacturer's protocol.

2.6. Statistical analysis Data were analysed using SPSS (version 14). Comparisons between groups were performed using Student's t-test or analysis

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of variance (ANOVA) with Scheffé correction for parametric data. Chi-square and Kruskal–Wallis tests were used for nonparametric data. Backward stepwise multiple linear regression analysis was performed to assess the relationship between BMI and disease-specific and lifestyle factors (CDAI, WCC, family history of IBD, previous need for CD related surgery, need for corticosteroid therapy, age at diagnosis, CRP, sedentary lifestyle and smoking status) were explored in the model.

3. Results 3.0.1. Characteristics of the study group The study comprised 200 participants. Patients (n = 100) and controls (n = 100) were matched for age, gender and socioeconomic status. Patients were predominantly in disease remission (67%), as defined by a CDAI b 150 (Table 1). 32 Fifteen percent of patients had CDAI values of 150–199 and no participant had extremely severe disease (CDAI ≥ 450).

3.1. Prevalence of overweight/obesity in CD and controls Overall the prevalence of overweight/obesity (BMI≥ 25 kg/m 2) in CD was 40% compared with 52% in the control group (P= 0.206) (Fig. 1). Correspondingly, mean values for BMI and body fat stores were similar in patients and healthy controls (Table 1). The breakdown of weight category according to BMI in patients and controls is illustrated in Fig. 1. A similar proportion of patients (17%) and controls (12%) were classified as obese (NS, P = 0.353). Overweight (BMI 25–29.9 kg/m 2) was significantly less common in CD patients than in controls, at 23% and 40% respectively (P = 0.032). Underweight was documented in only 2 CD patients and none of the controls. Patients with CD were considerably more likely to be overweight/obese than underweight in this clinical setting (40% overweight v. 2%).

3.2. Profile of overweight/obese CD patients compared with normal weight Table 2 shows the characteristics of patients with CD according to the BMI category. Overweight and obese patients were significantly older than those in the healthy weight category. Age at onset of disease was important, for only 7% of healthy weight CD patients disease onset occurred at age 40 or older, compared with 35% in the obese group. Other distinguishing features were the significantly lower CDAI in overweight and obese compared with healthy weight CD, and lower WCC in obese compared with healthy weight patients. Obese CD patients were more sedentary, with a significantly lower physical activity as estimated by TV watching hours and METs expended/week. There was a non-significant trend towards a higher rate of elevated CRP in the obese compared with healthy weight patients. Other disease related variables (including surgery and steroid use) did not appreciably distinguish overweight/obese CD patients from those classified as healthy weight according to BMI.

3.3. Factors associated with BMI in CD: regression analysis Regression analysis (Table 3) confirmed that BMI was positively associated with age and sedentary lifestyle and negatively associated with both CDAI and WCC. Furthermore, higher BMI was significantly associated with elevated CRP. In line with this, CRP showed a significant but weak correlation with adiposity as determined by TST (r = 0.2, P = 0.04) and AFA (r = 0.3, P = 0.01) respectively. Other variables that did not significantly contribute to the model were: previous need for CD related surgery, need for corticosteroid therapy in previous year, family history of IBD, age at diagnosis, disease location and smoking status.

4. Discussion p value 100

0.353

Obese

80 0.032

Overweight

60

%

Normal weight Underweight

0.331

40

20

0

CD

Controls

Figure 1 Weight classification according to BMI in CD patients and healthy controls. CD, Crohn's disease; underweight, BMI of b 18.5 kg/m 2 ; normal weight (healthy weight), BMI of 18.5– 24.9 kg/m 2 ; overweight, BMI of 25–29.9 kg/m 2 , obese; BMI of ≥ 30 kg/m 2 .

This study reports a high prevalence (40%) of overweight (BMI ≥ 25 kg/m 2) among adults with CD in an out-patient setting. The prevalence was lower, but not significantly (P = 0.206), than age-, sex- and socioeconomically-matched healthy controls (52%). While CD is traditionally associated with underweight, paradoxically there now appears to be a shift towards overweight in this disease, notably in mild or well controlled CD. Sousa-Guerreiro et al., 6 identified excess body weight as the most prevalent form of malnutrition in CD, with 32% classified as overweight/obese in a study of 78 Portuguese adults with CD. In a more recent study by Yarur et al., 23 46% of IBD patients compared with 72% of controls were overweight, predominantly based on a cohort of Hispanic adults. As illustrated in Table 4, studies that report overweight or obesity in CD 6,8,10,11,23,33 vary considerably from a methodological standpoint, deriving from several geographic regions, employing different study designs, sample sizes and outcome measures. Despite these differences, however, our data taken in the context of these studies suggest that low BMI is no longer a dominant characteristic of adult CD especially in quiescent disease.

Overweight/obesity in Crohn’s disease Table 2

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Characteristics of patients with CD stratified by BMI category.

n Gender, M:F Age, years, mean (95% CI) Current At diagnosis Age class at onset of CD, 36 (%) A1 b 17 A2 17–40 A3 40 + Years since diagnosis, mean (95% CI) Previous surgery for CD (%) No family history of IBD (%) Disease location, 36 (%) L1 L2 L3 L4 Disease behaviour, 36 (%) B1 B2 B3 Perianal disease, 36 (%) B2 + BP CDAI, mean (95% CI) CDAI N 150, % CRP, mg/L, median (IQR) Elevated CRP N 5 mg/L, % Elevated CRP N 10 mg/L, % Use of steroids in the past 12 months, % No. of steroid courses in past year, mean (s.d) TNF-alpha pg/mL, mean (95% CI) WCC, 10 9/L, mean (95% CI) Smoking (%) Current smoker Ex‐smoker Non‐smoker Physical activity TV watching hours per week, mean (95% CI) Total METs/week, mean (95% CI)

BMI 18.5–24.9 kg/m 2 BMI 25–29.9 kg/m 2 healthy weight overweight

BMI ≥ 30 kg/m 2 obese

58 22:36

23 12:11

17 5:12

NS

32.8 (30.2, 35.3) ab 25.9 (23.5, 28.4) ab

40.1 (35.8, 44.3) a 30.6 (25.7, 35.3) a

40.5 (33.7, 47.2) b 30.5 (23.2, 37.8) b

0.02 a; 0.03 b 0.22 a; 0.30 b

9 85 b 7 ab 6.8 (5.2, 8.5) ab 31 50 ab

17 57 26 a 10.0 (7.4, 12.7) a 26 77 a

18 47 b 35 b 10.0 (6.1, 13.9) b 23 69 b

NS 0.02 b 0.01 a,0.010 b 0.13 a; 0.21 b 0.70 0.06 a, 0.07 b

48.3 25.9 22.4 3.4

52.2 30.4 17.4 –

29.4 35.3 35.3 –

NS

53.4 27.6 19.0

56.6 21.7 21.7

64.7 17.6 17.6

NS

8.6 136.5 (101.0, 162.8) a 38 3.6 (2.9, 8.9) 35 b 21.8 56.9 1.21 (2.0) 6.4 (5.7, 6.9) 7.7 (6.9, 8.3) b

4.3 71.1 (36.4, 105.8) a 22 2.9 (2.9, 7.4) 39 4.3 39 0.96 (2.2) 6.2 (5.3, 7.2) 6.6 (5.7, 7.4) a

5.9 104.1 (48.1, 160.0) 35 6.0 (2.9, 10.6) 52 b 23.5 35.3 0.47 (0.8) 5.9 (4.9, 6.9) 5.7 (4.8, 6.6) b

NS 0.029 a NS NS 0.083 b 0.148 NS NS NS 0.016 b, 0.2 a

29 29 41

17 26 57

24 29 47

NS

P value

21.3 (17.3, 35.3) 27.3 (21.6, 33.0) b 0.015 b 19.5 (17.0, 21.9) b b 138.9 (117.2, 160.6) 140.0 (114.3, 165.7) 87.3 (48.9, 125.0) b 0.07 b

A1, age at diagnosis younger than 17 years; A2, age at diagnosis 17 to 40 years; age at diagnosis older than 40 years; B1, nonstricturing, nonpenetrating disease; B2, stricturing disease; B3, penetrating disease; BP, perianal disease; L1, terminal ileum; L2, colon; L3, ileocolonic; L4, upper gastrointestinal tract (Montreal classifications36); CDAI, Crohn's disease activity index; CRP, C reactive protein; TNF, tumour necrosis factor; WCC, white cell count; METs, metabolic equivalents; CI, confidence interval; IQR, inter-quartile range. P value for χ2 tests, analysis of variance (ANOVA) with Scheffé correction and Kruskal–Wallis and shown for comparisons between healthy weight versus overweighta and versus obeseb respectively. NS, not-statically significant PN 0.05.

A key unresolved question remains — does a high BMI impact on disease severity or course in patients with CD? In this study we identified that overweight/obesity was common in adults with CD, but unlike previous reports we did not find evidence of an association with more severe disease. In the present study, there was a significant inverse association between current BMI and disease activity (CDAI) and with WCC which we suggest reflected ‘wellness’ and well controlled disease in this out-patient setting. Consistent with this, BMI was not associated with other parameters previously used as

markers of severe disease such as number of previous CD related surgeries and steroid use. In line with the healthy control group, and with population trends, regression analysis confirmed that BMI was significantly positively associated with age and sedentary lifestyles in CD. BMI and disease severity outcomes in CD are collated in Table 4. Two of the cited studies 10,11 suggest a negative impact, while a third suggested a possible positive impact for obesity. 8 Haas et al., 11 in line with our findings, reported that BMI was not associated with the need for surgery or numbers of

e246 Table 3

T. Nic Suibhne et al. Multiple linear regression analysis of factors associated with BMI in CD.

Variable

Standardized coefficient β

P value

95% confidence interval

Age, years White cell count, 10 9/L, CDAI Physical activity (hours of TV watching at weekends) Elevated CRP (N 5 mg/L)

0.310 − 0.218 − 0.205 0.262 0.229

0.001 0.026 0.036 0.007 0.017

0.061, 0.244 − 0.899, -0.059 − 0.021, -0.001 0.122, 0.727 0.474, 4.596

R square value is 0.30. CDAI; Crohn's disease activity index.

surgeries. The negative impact highlighted by the authors was that overweight/obese CD patients required surgery sooner than underweight patients, however underweight is not desirable in IBD either and is associated with increased morbidity. 3 In a retrospective study, Blain et al. 10 reported that obese patients had an increased need for medical therapy and surgery than matched non-obese CD. We found that higher BMI was associated with lower current disease activity (CDAI), but was not related to corticosteroid usage, surgery or more severe disease phenotype. In contrast, Steed et al. 8 reported what may be interpreted as a positive effect of higher BMI, documenting lower levels of previous surgeries in obese compared with normal weight CD patients. Lack of available data combined with differences in study designs and endpoints limits the interpretation of the role of higher BMI on CD. Our data suggest that higher current BMI was associated with stable disease in the short term. An interesting finding was the positive association between BMI and CRP. Higher CRP has been linked to obesity in the general population 18,19 and obesity may be viewed as an inflammatory condition. 21 Moreover, higher CRP is a marker of inflammation in CD. The present study was not designed to distinguish cause and effect, and whether elevated CRP levels are a consequence of higher body fat stores or the core disease cannot be fully determined. In the present study, however, the association between higher BMI and higher CRP occurs against a background of lower CDAI, lower WCC, older age and more sedentary lifestyles in an out-patient setting. While our data show an association between higher systemic body fat/ BMI and CRP in stable CD, others 34 recently showed an association between CRP levels and mesenteric fat in refractory CD of normal weight. In this study, however, we found no association between current BMI and disease activity as measured by CDAI or with characteristics of more severe disease phenotypes based on the Montreal criteria, suggesting that current systemic fat mass does not appear to have a negative impact on CD severity. The high prevalence of overweight (40%), combined with cigarette smoking (54% current or previous smokers) and low levels of physical activity observed in this study is a concern for the long term general health of adults with CD. This would be expected to contribute to increased risk of known obesity related diseases such as diabetes, cardiovascular diseases and colon cancer. Well-controlled disease, as seen in this cohort, however is also desirable to prevent inflammatory drivers of co-morbid diseases such as colon cancer and cardiovascular disease. 23 While beyond the scope of this study, the increasing rates of overweight and obesity in CD may begin to blur the lines between inflammatory and traditional risk factors for co-morbid diseases in CD. 35

A strength of this study was the prospective design and assessment of BMI and collection of detailed clinical and lifestyle data. In addition, the data can be viewed in the context of age-, gender- and socioeconomically-matched healthy controls from the same geographic region. We also include several measures of disease activity and inflammation (CDAI, CRP, WCC and TNF-alpha). WCC, however, may also be influenced by medications, although in the present study WCC in patients taking immunosuppressants were not significantly different than those not taking (mean 6.37 × 10 9/L and 7.6 × 10 9/L, P = 0.976). Larger studies may identify if different BMI categories reflect different disease phenotypes or genotypes and additional variables such as weight history, bioimpedance, intra-abdominal fat and dietary intake data may give further insights into BMI in CD. In conclusion, this study shows that people with stable CD are influenced by the background population trends toward overweight and obesity and sedentary lifestyles. The prevalence of overweight/obesity was 40% and underweight was rare in this setting. Higher BMI was associated with lower CDAI scores and WCC, suggesting stable disease, as well as older age and less physical activity. Current BMI was not associated with prior need for surgery, corticosteroid usage or more severe disease phenotype. We identified a novel association between higher BMI and higher CRP, a marker implicated in both obesity and CD. Given that obesity is now endemic in the Western world, future studies are needed to investigate the long-term implications of high BMI and increasing adiposity on CRP and inflammatory load in the CD population.

5. Authors' contributions TNC contributed to the study design, collected the data and performed the analysis and interpretation. TR performed the data analysis and interpretation and co-wrote the paper. OMM contributed to the data collection, data analysis and interpretation. CW contributed to the data analysis and interpretation. COM contributed to the data acquisition and interpretation. MOS contributed to the study design, data analysis and interpretation and wrote the paper. All authors approved the final draft of the submitted manuscript.

Conflict of interest The authors have no conflicts of interest.

Prevalence of overweight/obesity in adult Crohn's disease and postulated effect on disease specific outcomes.

Study

Country Methods

CD n

Blain et al. 10

France

Retrospective chart study

2065 None

Haas et al. 11

USA

Retrospective cohort study

148 None

Sousa Guerreiro et al. 6 Portugal Case control study

Controls n

78 80

Prevalence of overweight/ obesity in CD

Prevalence of overweight/obesity in matched controls — comparison with CD.

Higher BMI linked with more severe CD? (as denoted by need for steroids or surgery and by complications)

3% a

n/a

32%

n/a

32%

34% 61% Lower rate of overweight/obesity in IBD v controls 72% Significantly lower rate of overweight/ obesity and obesity in IBD v controls. 15% a Significantly higher rate of obesity in CD v controls at diagnosis in 50–70 age group. 52% No difference for overweight/obesity combined. Significantly lower rate of overweight in CD v controls.

Yes Higher levels of medical and surgical therapy and more frequent perianal complications in obese CD. Yes Shorter time to first surgery for overweight v. underweight. Not assessed Not a study objective. No Lower levels of surgery (19%) in obese v. normal weight CD (46%). Not assessed Not a study objective.

Steed et al. 8

UK

Retrospective study

295 Population data

55%

Yarur et al. 23

USA

Retrospective longitudinal study

173 712

46%

Mendall et al. 33

UK

Retrospective questionnaire study

246 480 b

Nic Suibhne et al. (present study)

Ireland

Prospective case control study

100 100

33% a

40%

Overweight/obesity in Crohn’s disease

Table 4

Not assessed Not a study objective.

No BMI not associated with the need for surgery or steroids. Higher BMI associated with lower CDAI and WCC, but also with elevated CRP.

Overweight/obesity signifies a BMI ≥ 25 kg/m2. n/a, not applicable. v, versus. a b

Represents obese only, BMI N 30. Controls were aged 50–70 years.

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Acknowledgements We acknowledge the grant funding from the Meath Foundation, Dublin, Ireland. TNC was supported by the Meath Foundation and TR by the Irish Research Council. These organisations had no involvement in the study other than the grant funding.

18.

19.

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