Nutritional Status and Dietary Patterns of Patients with Crohn’s Disease in Clinical Remission: Insights from a Sri Lankan Cohort

Nutritional Status and Dietary Patterns of Patients with Crohn’s Disease in Clinical Remission: Insights from a Sri Lankan Cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nutritional Status and Dietary Patterns of Patients with Crohn’s Disease in Clinical Remission: Insights from a Sri Lankan Cohort T G Samarasekera, Jesuthasan Mithushan, Renuka Jayatissa, Nilesh Fernandopulle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6396478/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Malnutrition is common in Crohn’s Disease (CD) and diet plays a vital role in its clinical course and pathogenesis. Diet is a contributing factor for aggravation of symptoms. Though the assessment of nutritional status and dietary patterns are crucial in the management of CD, literature in this regard is limited in Asia. Methods This descriptive cross-sectional study was carried out at a gastroenterology unit in a tertiary care centre in Sri Lanka over one-year duration. 150 patients diagnosed with Crohn's disease and in remission were included in the study. The data were gathered using an interviewer-administered questionnaire and physical examination of anthropometric measures. Results The mean age (SD) was 33 (8.4) years with the M:F ratio of 2:1. Forty-six percent of the population (n = 69) had a normal BMI range according to standard WHO criteria for Asian populations, while 36% were underweight and 18% overweight. The mean (± SD) intake of energy and protein was 1477.5 ± 241.1 kcal per day (male – 1562.6 ± 205.9; female – 1326.1 ± 228.9, P < 0.001) and 44.8 ± 9.4 g per day (male – 45.9 ± 8.0; female – 43.0 ± 11.5, P = 0.3), respectively. The mean (SD) albumin level was 21.6 g/l (17.6), suggestive of chronic malnutrition of the cohort; however, the mean of other micronutrients is within the normal range. The majority of (98%) patients believed that certain foods made symptoms worse, and the common dietary triggers were red meat and carbonated drinks. Red meat (86%), Samaposha (82%) and peanuts (70%) were identified as the most avoided food items in a local context. Self-experience of food triggers was the most influential source to prevent relapses (n = 135, 90%), followed by medical advice (76%), social media and internet (50%). None of the sociodemographic factors and disease characteristics were significantly associated with the dietary pattern and food avoidance (p > 0.05). Malnutrition was associated with early onset disease and younger age < 40 years (p < 0.05). Conclusion Malnutrition is prevalent among Sri Lankan Crohn’s disease patients, with a significant proportion being underweight and having low energy and protein intake. Despite normal micronutrient levels, the low mean albumin suggests chronic malnutrition. Patients are relying primarily on personal experience to guide food avoidance. Malnutrition was significantly associated with early onset of disease and younger age. These findings highlight the need for targeted nutritional assessment and dietary guidance in CD management. Crohn’s disease dietary pattern nutritional status Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Crohn’s disease (CD) is an inflammatory bowel disease (IBD) that follows a remitting and relapsing course. It can involve any part of the gastrointestinal tract from oral to caudal [ 1 ]. Crohn's disease has a complex etiopathogenesis that includes genetic risk factors, host immunological dysregulation, environmental influences, and gut dysbiosis [ 1 ]. Additionally, the adoption of a western diet, such as refined carbohydrates, hydrogenated fats, sulphur-rich foods, and diets low in fibre, vitamin C, and omega-3 fatty acids, and irrational use of antibiotics may have contributed to the global rise in prevalence, particularly in Asia [ 2 ]. In the western population, the prevalence of Crohn's disease ranges from 0.6 to 322 cases per 100,000 individuals [ 3 ]. Although CD was rare in Asia a decade ago, with the current rising trend, aggressive disease behavior and increased morbidity have contributed to a substantial impact on the IBD population in this part of the world. According to a community-based study conducted in 2011–2012 by Mettananda et al., Sri Lanka's age-adjusted incidence rate of CD is 0.56 per 100,000 [ 4 ]. Crohn's disease (CD) is characterized by a range of clinical symptoms, including abdominal pain, bloody diarrhea, fatigue, unintentional weight loss. Patients with CD are at an higher risk of macro and micronutrient deficiencies, both during active disease phases (relapses) and periods of remission. These deficiencies arise due to factors such as reduced oral intake, drug-nutrient interactions, malabsorption, and nutrient losses via the small intestine [ 2 ]. Structural bowel damage and intestinal complications—such as strictures, fissures, fistulae, and abscesses—further exacerbate gastrointestinal losses through impaired nutrient absorption and increased nutrient excretion. Additional contributors to malnutrition in CD include reduced dietary intake due to abdominal pain, early satiety, depression, self-imposed dietary restrictions, and adverse drug-nutrient interactions [ 3 ]. Consequently, the disease imposes a significant burden, manifesting as increased morbidity, mortality, and prolonged hospital stays. Several studies have been done to ascertain the prevalence of malnutrition among Crohn’s disease patients worldwide [ 3 , 5 ]. Weight loss in Crohn's disease patients has been widely reported, occurring in 70–80% of patients and 20–40% of outpatients, according to Greeling BJ et al. [ 5 ]. However, more recent research found that among CD patients, the prevalence of malnutrition was 16% (95% CI: 12–20%) in a prospective, multicenter Spanish study that included only the participants who attended outpatient clinics [ 6 ]. According to a study by Prakash et al., malabsorption, growth retardation, immunosuppressant medication, preoperative anaemia, and mid-small bowel resection were all associated with post-operative anastomotic leakage in 21% of CD patients [ 7 ]. The remission phase presents an optimal opportunity to enhance nutritional status and improve the quality of life for individuals, as they typically exhibit normal appetite, energy expenditure, and an absence of symptoms, similar to the general population. Therefore, it would be rational to perform a thorough assessment of nutritional status during periods of remission to optimize their nutritional status [ 5 ]. Therefore, identifying low dietary intake and inappropriate dietary patterns in CD patients can help to detect nutritional deficiencies early. In essence, assessing nutrient consumption and the overall nutritional status is paramount in establishing whether they are consuming nutrients at recommended amounts and whether they need to take specific supplements. However, there is a scarcity of research examining the dietary pattern of CD patients during remission both locally and globally [ 8 ]. Thus, this study was carried out to fill the knowledge gap on the nutrition profile and dietary pattern of CD patients in remission and to make recommendations for improving the nutritional components to enable a better prognosis. Materials & Methods Study design and study population This descriptive cross-sectional study was conducted among 150 patients with Crohn’s disease attending the gastroenterology outpatient clinic at the National Hospital of Sri Lanka (NHSL), the largest hospital and the most utilized referral center in the country. The study was carried out over one year period, from June 2022 to June 2023. The study included adult patients aged 18 to 65 years with a confirmed diagnosis of Crohn’s disease who were in remission, as indicated by a Crohn’s Disease Activity Index (CDAI) of < 150. Patients were excluded if they had metabolic conditions affecting body mass index (BMI) or dietary restrictions, such as hypertension, diabetes mellitus, thyroid disorders, dyslipidemia, chronic kidney disease, or liver diseases. Additional exclusion criteria included cancer, recent steroid therapy (within the past six weeks), major abdominal surgery in the preceding three months, short bowel syndrome, pregnancy, lactation, and lack of consent to participate in the study. Study instrument and data collection Disease activity was assessed using the Crohn's Disease Activity Index (CDAI) [ 9 ], with clinical remission defined as a CDAI score of 150 or less. The study instrument consisted of two components. The first part was an interviewer-administered questionnaire (Annexure 1) that collected data on demographic characteristics, clinical history, laboratory findings, and dietary behaviors patterns, including a 24-hour dietary recall over three consecutive days. Participants were guided on estimating food portions using standard teacups, coconut shell spoons, and plates, following a model book published by the Medical Research Institute [ 10 ] In the second part of the study, all consenting participants were referred to the nutrition clinic at the National Hospital of Sri Lanka (NHSL) for anthropometric measurements. Energy and protein intake were calculated and analyzed using NUTRISURVEY 2007 software [ 11 ]. Laboratory tests were conducted at NHSL, and results obtained within one month prior to data collection were considered valid for the study. Data analysis Data analysis was done using SPSS version 27 [ 12 ]. Descriptive data were presented as frequencies, percentages, and means with standard deviations. Univariate analysis was used to determine the association between socio-demographic factors, dietary patterns and nutritional profile. Findings were presented with chi-square value and T test value and a p < 0.05 was considered a statistically significant difference. Results There were 150 patients with CD in clinical remission included. The Mean age (SD) was 33 (8.4) years with the M:F ratio of 2:1. Table 1 General demographic characteristics Characteristics Frequency Percentage (%) Gender Male 96 64 Female 54 36 Ethnicity Sinhala 117 78 Tamil 21 14 Muslim 09 06 Other 03 02 Educational level Graduate 45 30 Secondary 75 50 Primary 30 20 Income (LKR) > 40000 75 50 25000–40000 30 20 < 25000 06 04 None 39 26 Marital status Married 84 56 Unmarried 63 42 Divorced 03 02 Location (province) Western 90 60 Southern 12 08 Central 15 10 North Central 03 02 Northern 03 02 Eastern 09 06 Sabaragamuwa 15 10 Uva 03 02 Northwestern 0 0 Smoking Smoker 03 02 Nonsmoker 147 98 Total 150 100 As shown in Table 1 , the majority (n = 117, 78%) were Sinhalese. Most of the patients (n = 120, 80%) had an education level up to secondary level or above, and half of the patients have an income level > 40,000 LKR. Eighty-four patients (56%) were married. Many of the enrolled patients were from the western province (n = 90, 60%), followed by central and sabaragamuwa provinces (n = 15, 10% each). The majority (n = 147, 98%) were non-smokers. Disease characteristics According to the Montreal classification [ 13 ], CD was mostly diagnosed between 17 and 40 years (n = 114, 76%), and the majority had it in the ileocolonic (n = 78, 52%) area, while others had it in the colonic (n = 39, 26%) and ileal (n = 33, 22%) areas. In terms of disease behavior, perineal disease modifier was the most common disease behavior (n = 63, 42%). Many of the patients were on azathioprine (n = 99, 66%) and infliximab (n = 33, 22%). Sixty-six (44%) had undergone surgical intervention. Disease characteristics are summarized in Table 2 . As shown in Table 3 , the mean (SD) albumin level, Mg 2+ , and PO4 3− were 21.6 g/l (17.6), 0.9 mmol/l (0.7), and 1.2 mmol/l (0.6), respectively. Table 2 Disease characteristics Disease characteristics Frequency (n) Percentage (%) Disease duration (years) 10 42 28 Age at diagnosis (years) 40 03 02 Location Ileal 33 22 Colonic 39 26 Ileocolonic 78 52 Behaviour Non-stricture, non-penetrating 39 26 Stricture 33 22 Penetrating 15 10 Perineal disease modifier 63 42 Medications Not in medications 03 02 Azathioprine 99 66 Sulphasalazine 06 04 Infliximab 33 22 Other 09 06 Surgical intervention Yes 66 44 No 84 56 Total 150 100 Table 3 Biochemical profile of CD patients Parameter Mean SD Albumin (g/l) 21.6 17.6 C-Reactive Protein (mg/l) 25.7 21.3 Mg (mmol/l) 0.9 0.7 Vitamin D (mmol/l) 16.7 8.6 Hb (g/dl) 12.7 4.6 PO 4 (mmol/l) 1.2 0.6 Nutrition status and dietary patterns Mean BMI (SD) of the population was 20.6 (4.4) kg/m2. Forty six percent of the population (n = 69) had a normal BMI range while 36% (n = 48) were underweight and 18% (n = 27) overweight. None of the participants was in the obese group according to the WHO BMI categorization for Asian population (Fig. 1 ). The majority of participants (147, 98%) were non-vegetarian, and a similar proportion (147, 98%) believed that certain food items worsen the symptoms of Crohn’s disease. Anyhow, food appetite increased in 60% of patients, remained unchanged in 32%, and decreased in 6% during remission. The consumption and avoidance patterns of various food categories were analyzed and are summarized in Fig. 2 . Patients with Crohn’s disease demonstrated a wide range of dietary preferences: over 80% avoided consuming red meat and Samaposha, a Sri Lankan food supplement containing corn, soya, rice and many micronutrients. Additionally, 70% and 60% of participants avoided spicy and fatty foods, respectively. Nearly half of the participants (72, 48%) did not consume milk or milk products. The frequency of avoidance for specific food items was further analyzed, and the results are presented in Table 6. Figure 3 illustrates the various factors influencing dietary patterns among Crohn's Disease patients in their efforts to prevent a disease relapse. The majority of patients (n = 135, 90%) rely on personal experience as a guiding factor in their dietary choices. Additionally, a substantial proportion (n = 114, 76%) adhere to recommendations provided by medical professionals. Notably, social media and internet sources also play a significant role, influencing the dietary habits of half of the patients surveyed. Fourty-eight (32%) stated that there was no change in their appetite. However, 90 patients (60%) had increased their appetite during remission. Energy and protein intake The energy intake of patients ranged from 1000 to 1900 kcal per day, with a mean (± SD) intake of 1477.5 ± 241.1 kcal per day (Male – 1562.6 ± 205.9; Female – 1326.1 ± 228.9, P < 0.001). Protein intake varied between 21 and 70 g per day, with a mean (± SD) of 44.8 ± 9.4 g per day (Male – 45.9 ± 8.0; Female – 43.0 ± 11.5, P = 0.3). Both energy and protein intake were categorized into specific ranges and are illustrated in Figs. 4 and 5 , respectively. Factors associated with the nutritional status and dietary pattern of the patients Table 4 demonstrates a significant association between patient age and malnutrition (p = 0.009), with younger patients (< 40 years) being more susceptible to malnutrition. However, other demographic factors did not show a significant correlation with nutritional status. Similarly, early-onset disease (< 17 years) was associated with an increased risk of malnutrition within the cohort (p = 0.005). Notably, neither medication use, nor surgical interventions were found to have a significant impact on patients' nutritional status. Table 4 Factors associated with nutritional status Characteristics Nutrition status Significance (p-value) Normal (n) Malnutrition (n) Demographics Gender Male 45 51 0.87 Female 24 30 Age 40 years 30 9 Education level Graduates 21 24 0.95 Others 48 57 Marital status Married 48 36 0.08 Others 21 45 Ethnicity Sinhala 48 69 0.18 Others 21 12 Income > 40000 39 36 0.40 < 40000 30 45 Disease characteristics Disease duration 5 years 39 51 Age at diagnosis 17 66 51 Location Isolated (Ileal/ Colonic) 36 36 0.59 Ileocolonic 33 45 Behaviour Perineal disease modifier 24 39 0.34 Others 45 42 Medications Azathioprine 42 57 0.48 Others 27 24 Surgical intervention Yes 24 42 0.23 No 45 39 None of the sociodemographic factors, such as age, educational level, ethnicity, marital status, income, and disease factors, were significantly associated with dietary patterns and specific food avoidance behaviours (p > 0.05). Discussion This study was conducted at NHSL, one of the largest teaching hospitals in Sri Lanka, which serves as a referral center for Crohn's disease patients from across the country. This ensures a more representative sample of Sri Lankan patients. In our study, 98% of participants believed certain foods exacerbate Crohn’s Disease (CD) symptoms. Similar findings were reported in an Indian study of 316 IBD patients, where 44% identified diet as a risk factor and 52% considered dietary habits critical for disease management [ 14 ]. A UK study found that 51% of participants believed diet initiated their IBD, and 63% attributed dietary components to disease relapse [ 15 ]. Similarly, a survey in France of 244 IBD patients revealed 15.6% linked diet to disease onset, and 57.8% believed it contributed to relapses [ 16 ]. We assessed the consumption and avoidance of specific foods, and found that red meat (86%), Samposha (82%), and peanuts (70%) were the most avoided items. Samaposha is an endemic pre-cooked cereal based nutritious supplement food which consists of corn, soya, green gram and rice. It is enriched with lots of vitamins and minerals. Similarly, a large internet-based cohort study by Cohen et al. involving 6,768 IBD patients reported that various foods aggravated symptoms, while some, like rice and yogurt, provided relief [ 17 ]. Respondents frequently modified their diets to avoid symptom-triggering foods, and commonly mentioned food included vegetables (leafy and non-leafy), spicy and fried foods, fruits, nuts, milk, and red meat [ 17 ]. A study of British South Asian IBD patients also revealed that 89% avoided certain foods at least occasionally, with spicy foods (74%), fatty foods (44%), red meat (42%), milk (42%), alcohol (35%), and coffee (32%) identified as common triggers for relapses [ 15 ]. Our study focused exclusively on Crohn's disease (CD) patients in remission. A Canadian IBD cohort study found that food avoidance is more prevalent among individuals with active IBD. Additionally in this same study, patients with active IBD consumed significantly more sports drinks and sweetened beverages compared to those in remission [ 18 ]. Similarly, components of a Western diet—such as red meat, processed foods, additives, fatty foods, and sugary foods—were commonly reported as triggers potentially increasing the risk of IBD [ 19 ]. A Canadian study identified gastrointestinal upset as the primary reason for avoiding certain foods [ 18 ]. Medical advice influenced up to 15% of patients, with milk and dairy products being the most avoided items based on recommendations. In contrast, our study explored the factors influencing dietary patterns to prevent relapses and found that personal experience was cited by 90% of participants, followed by medical advice (76%), social media and the internet (50%), and family and friends (16%). In our study cohort, appetite increased in 60% of patients, remained unchanged in 32%, and decreased in 6% during remission. These findings differ from those of Zallot et al., where 47.5% of respondents (n = 116) reported a reduced pleasure in eating and a comparable decrease in appetite, particularly during relapse compared to remission [ 16 ]. Similarly, Limdi et al. found that 73% (n = 292) of patients experienced changes in appetite and eating pleasure [ 20 ]. In our study, the mean daily energy intake among Crohn’s disease (CD) patients was 1477.5 ± 241.1 kcal/d (males: 1562.6 ± 205.9 kcal/d; females: 1326.1 ± 228.9 kcal/d, P < 0.001), while the mean protein intake was 44.8 ± 9.4 g/d (males: 45.9 ± 8.0 g; females: 43.0 ± 11.5 g, P = 0.3). Compared to national estimates of the Sri Lankan adult population reported by Jayawardena et al., where the average energy intake was 1913 ± 567 kcal/day for males and 1514 ± 458 kcal/day for females, CD patients demonstrated a significantly lower energy intake [ 21 ]. Although the mean daily protein intake in our cohort (44.8 g) was similar to the national average (44.6 g), gender-specific analysis revealed that both males and females with CD had lower protein intake compared to the general population (52.8 g for males and 40.0 g for females) [ 21 ]. These findings indicate that CD patients, particularly males, have a notable energy deficit, which may have implications for disease management and nutritional interventions. A previous study assessing self-reported energy intake among Crohn's disease patients during both active and quiescent phases reported mean energy intakes of 1829 ± 260 kcal/day for males and 1452 ± 224 kcal/day for females during remission, with no significant variation between disease phases [ 5 ]. The same study reported mean protein intakes of 78.3 ± 19.6 g/day for males and 61.7 ± 13.5 g/day for females during remission. The mean energy intake in our cohort was comparable to that of females in the previous study, but protein intake was notably lower. In our study, 46% of participants had a normal BMI, 36% were underweight, and 18% were overweight, with a mean BMI of 20.59 kg/m² (SD 4.36). Similarly, Pieczyńska et al. reported a mean BMI of 21.7 kg/m² (range 15.2–33.1) among Crohn's disease patients in remission [ 2 ]. They also assessed malnutrition risk using the Mini Nutritional Assessment, finding that 36% had adequate nutritional status, 51% were at risk of malnutrition, and 13% were malnourished. In contrast, another study of 50 Crohn's disease patients reported that 82% had normal weight, while only 8% were underweight [ 22 ]. We evaluated factors influencing the nutritional status and dietary patterns of Crohn’s disease (CD) patients. While previous studies have identified gender, prior surgeries, and disease duration as key determinants of dietary patterns [ 1 ], our findings indicate that only younger age (< 40 years) and early-onset disease (< 17 years) were significantly associated with malnutrition. In contrast, other sociodemographic factors, including gender, income, education level, marital status, ethnicity, and disease characteristics, showed no significant correlation with nutritional status. Crooks B et al. reported that food avoidance was significantly higher among females than males (p = 0.02), with females more likely to avoid sweet foods (p = 0.001) and raw fruits and vegetables (p = 0.04) [ 15 ]. Tamor et al. identified age, gender, socioeconomic status, disease activity, family size, and BMI as factors influencing dietary patterns in IBD patients [ 14 ]. Anyhow, notably, none of the sociodemographic factors and disease characteristics were associated with dietary pattern and food avoidance in our cohort. Our study has several limitations. Even though our study was carried out in the largest referral center in the country, with single-center experience, it has limited inferential capacity. This can be overcome by considering either a multicenter study or carrying out the study in a larger sample size. Additionally, dietary intake was self-reported using a 3-day diet diary, which may have led to overestimation or underestimation of nutrient intake, despite clear instructions provided to participants. Furthermore, patients may have reported food avoidance based on personal factors such as dislikes or beliefs, rather than solely in relation to IBD symptoms. Conclusions Malnutrition and nutrition deficiencies are major concerns in patients with Crohn’s disease. Nutrition therapy plays an integral role in patient care. Patients with CD should be screened regularly for malnutrition and nutrient deficiencies. Nutrition strategies should be tailored for each patient. It should begin with nutrition assessment, supplementation of micronutrients when clinically indicated and individualized nutrition counseling. Abbreviations CD Crohn’s Disease IBD Inflammatory bowel disease BMI Body mass index CDAI Crohn's Disease Activity Index NHSL National Hospital Sri Lanka Declarations Ethics approval and consent to participate Ethical clearance was obtained from the Ethics Review Committee, NHSL, Colombo (ERC No: AAJ/ETH/COM/2021/JUNE). All patients provided written consent for both the procedures performed and their participation in this study. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding Not applicable CRediT authorship contribution statement T G Samarasekera- Writing - original draft– writing- review and editing. Jesuthasan Mithushan- Writing - original draft– writing- review and editing. Nilesh Fernandopulle - Writing – review and editing, supervision. 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Medicine, University of Colombo","correspondingAuthor":false,"prefix":"","firstName":"Jesuthasan","middleName":"","lastName":"Mithushan","suffix":""},{"id":447258228,"identity":"cd0e4534-7013-4d73-b6e7-24335f5bcf42","order_by":2,"name":"Renuka Jayatissa","email":"","orcid":"","institution":"Department of Nutrition, Medical Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Renuka","middleName":"","lastName":"Jayatissa","suffix":""},{"id":447258229,"identity":"2f3cf277-78c2-4698-ac9d-136aa10585c8","order_by":3,"name":"Nilesh Fernandopulle","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIie3RMQrCMBSA4TwKOpWugQ5eoeJQhGqu0lBw6x0igXR07eDgERw7pmQtdlW66BHUqZttRXRq6iaYfwhJyAcJQchk+sUsiyFgwXMBrNviGgItWX0S0BDUEfUF8cewvtRZSfzNDm6nDE0cBtzrI3MOfGYXFd0ez5YbF2iaSuBhH/EUCBdEFWIsR1YsEOybi0kNSepaHMiLkCFEIFtISB3WEdoS3cW4a4uIpriZxAWOUqV5vleq/FqLJcGOyu9xFiw2CVe4j7zDlLVj87nDzjc5cvBRk8lk+rMee8lIDJEacBgAAAAASUVORK5CYII=","orcid":"","institution":"Department of Surgery, Faculty of Medicine, University of Colombo","correspondingAuthor":true,"prefix":"","firstName":"Nilesh","middleName":"","lastName":"Fernandopulle","suffix":""}],"badges":[],"createdAt":"2025-04-07 17:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6396478/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6396478/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82077900,"identity":"d9d3630d-aef6-48dc-965e-d1c66b02aa23","added_by":"auto","created_at":"2025-05-06 14:06:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22153,"visible":true,"origin":"","legend":"\u003cp\u003eNutritional status of patients\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6396478/v1/813e0f1ec01528324a910b5c.png"},{"id":82080029,"identity":"a7f5a62e-d6b2-4b3e-b377-f6d0ec196ff3","added_by":"auto","created_at":"2025-05-06 14:22:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35662,"visible":true,"origin":"","legend":"\u003cp\u003eConsumption/ Avoidance of food categories among patients with CD\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6396478/v1/f4c64a47ac4bc3a1290598fd.png"},{"id":82077901,"identity":"9db61bed-2e25-4f2f-95a0-6f25304f6c99","added_by":"auto","created_at":"2025-05-06 14:06:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":26028,"visible":true,"origin":"","legend":"\u003cp\u003eFactors influencing dietary patterns to prevent relapses among patients with CD\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6396478/v1/3557daed63cf72d0ea9ed0db.png"},{"id":82077904,"identity":"105e3294-fb02-40b8-b018-dfa90304ae48","added_by":"auto","created_at":"2025-05-06 14:06:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32507,"visible":true,"origin":"","legend":"\u003cp\u003eEnergy intake of patients with Crohn’s disease during remission\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6396478/v1/2a8f27e1b9e52427c946d734.png"},{"id":82079535,"identity":"e669e19a-b59c-47be-8f9f-64c6aec68391","added_by":"auto","created_at":"2025-05-06 14:14:30","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":29228,"visible":true,"origin":"","legend":"\u003cp\u003eProtein intake of the patients with Crohn’s disease during remission\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6396478/v1/7472aff6e14e8ece4903949b.png"},{"id":100547183,"identity":"a9505f07-48cc-4347-a67d-b3576276bb0e","added_by":"auto","created_at":"2026-01-19 08:14:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1016302,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6396478/v1/bde685e4-4df8-4b96-b77f-711eed825f44.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nutritional Status and Dietary Patterns of Patients with Crohn’s Disease in Clinical Remission: Insights from a Sri Lankan Cohort","fulltext":[{"header":"Background","content":"\u003cp\u003eCrohn\u0026rsquo;s disease (CD) is an inflammatory bowel disease (IBD) that follows a remitting and relapsing course. It can involve any part of the gastrointestinal tract from oral to caudal [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Crohn's disease has a complex etiopathogenesis that includes genetic risk factors, host immunological dysregulation, environmental influences, and gut dysbiosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Additionally, the adoption of a western diet, such as refined carbohydrates, hydrogenated fats, sulphur-rich foods, and diets low in fibre, vitamin C, and omega-3 fatty acids, and irrational use of antibiotics may have contributed to the global rise in prevalence, particularly in Asia [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the western population, the prevalence of Crohn's disease ranges from 0.6 to 322 cases per 100,000 individuals [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although CD was rare in Asia a decade ago, with the current rising trend, aggressive disease behavior and increased morbidity have contributed to a substantial impact on the IBD population in this part of the world. According to a community-based study conducted in 2011\u0026ndash;2012 by Mettananda et al., Sri Lanka's age-adjusted incidence rate of CD is 0.56 per 100,000 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCrohn's disease (CD) is characterized by a range of clinical symptoms, including abdominal pain, bloody diarrhea, fatigue, unintentional weight loss. Patients with CD are at an higher risk of macro and micronutrient deficiencies, both during active disease phases (relapses) and periods of remission. These deficiencies arise due to factors such as reduced oral intake, drug-nutrient interactions, malabsorption, and nutrient losses via the small intestine [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Structural bowel damage and intestinal complications\u0026mdash;such as strictures, fissures, fistulae, and abscesses\u0026mdash;further exacerbate gastrointestinal losses through impaired nutrient absorption and increased nutrient excretion. Additional contributors to malnutrition in CD include reduced dietary intake due to abdominal pain, early satiety, depression, self-imposed dietary restrictions, and adverse drug-nutrient interactions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Consequently, the disease imposes a significant burden, manifesting as increased morbidity, mortality, and prolonged hospital stays.\u003c/p\u003e \u003cp\u003eSeveral studies have been done to ascertain the prevalence of malnutrition among Crohn\u0026rsquo;s disease patients worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Weight loss in Crohn's disease patients has been widely reported, occurring in 70\u0026ndash;80% of patients and 20\u0026ndash;40% of outpatients, according to Greeling BJ et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, more recent research found that among CD patients, the prevalence of malnutrition was 16% (95% CI: 12\u0026ndash;20%) in a prospective, multicenter Spanish study that included only the participants who attended outpatient clinics [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. According to a study by Prakash et al., malabsorption, growth retardation, immunosuppressant medication, preoperative anaemia, and mid-small bowel resection were all associated with post-operative anastomotic leakage in 21% of CD patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe remission phase presents an optimal opportunity to enhance nutritional status and improve the quality of life for individuals, as they typically exhibit normal appetite, energy expenditure, and an absence of symptoms, similar to the general population. Therefore, it would be rational to perform a thorough assessment of nutritional status during periods of remission to optimize their nutritional status [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, identifying low dietary intake and inappropriate dietary patterns in CD patients can help to detect nutritional deficiencies early. In essence, assessing nutrient consumption and the overall nutritional status is paramount in establishing whether they are consuming nutrients at recommended amounts and whether they need to take specific supplements.\u003c/p\u003e \u003cp\u003eHowever, there is a scarcity of research examining the dietary pattern of CD patients during remission both locally and globally [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Thus, this study was carried out to fill the knowledge gap on the nutrition profile and dietary pattern of CD patients in remission and to make recommendations for improving the nutritional components to enable a better prognosis.\u003c/p\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and study population\u003c/h2\u003e \u003cp\u003eThis descriptive cross-sectional study was conducted among 150 patients with Crohn\u0026rsquo;s disease attending the gastroenterology outpatient clinic at the National Hospital of Sri Lanka (NHSL), the largest hospital and the most utilized referral center in the country. The study was carried out over one year period, from June 2022 to June 2023.\u003c/p\u003e \u003cp\u003eThe study included adult patients aged 18 to 65 years with a confirmed diagnosis of Crohn\u0026rsquo;s disease who were in remission, as indicated by a Crohn\u0026rsquo;s Disease Activity Index (CDAI) of \u0026lt;\u0026thinsp;150. Patients were excluded if they had metabolic conditions affecting body mass index (BMI) or dietary restrictions, such as hypertension, diabetes mellitus, thyroid disorders, dyslipidemia, chronic kidney disease, or liver diseases. Additional exclusion criteria included cancer, recent steroid therapy (within the past six weeks), major abdominal surgery in the preceding three months, short bowel syndrome, pregnancy, lactation, and lack of consent to participate in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy instrument and data collection\u003c/h3\u003e\n\u003cp\u003eDisease activity was assessed using the Crohn's Disease Activity Index (CDAI) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], with clinical remission defined as a CDAI score of 150 or less. The study instrument consisted of two components. The first part was an interviewer-administered questionnaire (Annexure 1) that collected data on demographic characteristics, clinical history, laboratory findings, and dietary behaviors patterns, including a 24-hour dietary recall over three consecutive days. Participants were guided on estimating food portions using standard teacups, coconut shell spoons, and plates, following a model book published by the Medical Research Institute [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn the second part of the study, all consenting participants were referred to the nutrition clinic at the National Hospital of Sri Lanka (NHSL) for anthropometric measurements. Energy and protein intake were calculated and analyzed using NUTRISURVEY 2007 software [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Laboratory tests were conducted at NHSL, and results obtained within one month prior to data collection were considered valid for the study.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis was done using SPSS version 27 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Descriptive data were presented as frequencies, percentages, and means with standard deviations. Univariate analysis was used to determine the association between socio-demographic factors, dietary patterns and nutritional profile. Findings were presented with chi-square value and T test value and a p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered a statistically significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 150 patients with CD in clinical remission included. The Mean age (SD) was 33 (8.4) years with the M:F ratio of 2:1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSinhala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTamil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome (LKR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25000\u0026ndash;40000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation (province)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouthern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth Central\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorthern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSabaragamuwa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUva\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorthwestern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNonsmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the majority (n\u0026thinsp;=\u0026thinsp;117, 78%) were Sinhalese. Most of the patients (n\u0026thinsp;=\u0026thinsp;120, 80%) had an education level up to secondary level or above, and half of the patients have an income level\u0026thinsp;\u0026gt;\u0026thinsp;40,000 LKR. Eighty-four patients (56%) were married. Many of the enrolled patients were from the western province (n\u0026thinsp;=\u0026thinsp;90, 60%), followed by central and sabaragamuwa provinces (n\u0026thinsp;=\u0026thinsp;15, 10% each). The majority (n\u0026thinsp;=\u0026thinsp;147, 98%) were non-smokers.\u003c/p\u003e\n\u003ch3\u003eDisease characteristics\u003c/h3\u003e\n\u003cp\u003eAccording to the Montreal classification [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], CD was mostly diagnosed between 17 and 40 years (n\u0026thinsp;=\u0026thinsp;114, 76%), and the majority had it in the ileocolonic (n\u0026thinsp;=\u0026thinsp;78, 52%) area, while others had it in the colonic (n\u0026thinsp;=\u0026thinsp;39, 26%) and ileal (n\u0026thinsp;=\u0026thinsp;33, 22%) areas. In terms of disease behavior, perineal disease modifier was the most common disease behavior (n\u0026thinsp;=\u0026thinsp;63, 42%). Many of the patients were on azathioprine (n\u0026thinsp;=\u0026thinsp;99, 66%) and infliximab (n\u0026thinsp;=\u0026thinsp;33, 22%). Sixty-six (44%) had undergone surgical intervention. Disease characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the mean (SD) albumin level, Mg\u003csup\u003e2+\u003c/sup\u003e, and PO4\u003csup\u003e3\u0026minus;\u003c/sup\u003e were 21.6 g/l (17.6), 0.9 mmol/l (0.7), and 1.2 mmol/l (0.6), respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDisease characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDisease characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDisease duration (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge at diagnosis (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIleal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIleocolonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBehaviour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-stricture, non-penetrating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePenetrating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerineal disease modifier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eMedications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot in medications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAzathioprine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSulphasalazine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfliximab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSurgical intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBiochemical profile of CD patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin (g/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-Reactive Protein (mg/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMg (mmol/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVitamin D (mmol/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb (g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePO\u003csub\u003e4\u003c/sub\u003e (mmol/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNutrition status and dietary patterns\u003c/h2\u003e \u003cp\u003eMean BMI (SD) of the population was 20.6 (4.4) kg/m2. Forty six percent of the population (n\u0026thinsp;=\u0026thinsp;69) had a normal BMI range while 36% (n\u0026thinsp;=\u0026thinsp;48) were underweight and 18% (n\u0026thinsp;=\u0026thinsp;27) overweight. None of the participants was in the obese group according to the WHO BMI categorization for Asian population (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe majority of participants (147, 98%) were non-vegetarian, and a similar proportion (147, 98%) believed that certain food items worsen the symptoms of Crohn\u0026rsquo;s disease. Anyhow, food appetite increased in 60% of patients, remained unchanged in 32%, and decreased in 6% during remission.\u003c/p\u003e \u003cp\u003eThe consumption and avoidance patterns of various food categories were analyzed and are summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Patients with Crohn\u0026rsquo;s disease demonstrated a wide range of dietary preferences: over 80% avoided consuming red meat and Samaposha, a Sri Lankan food supplement containing corn, soya, rice and many micronutrients. Additionally, 70% and 60% of participants avoided spicy and fatty foods, respectively. Nearly half of the participants (72, 48%) did not consume milk or milk products. The frequency of avoidance for specific food items was further analyzed, and the results are presented in Table\u0026nbsp;6.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates the various factors influencing dietary patterns among Crohn's Disease patients in their efforts to prevent a disease relapse. The majority of patients (n\u0026thinsp;=\u0026thinsp;135, 90%) rely on personal experience as a guiding factor in their dietary choices. Additionally, a substantial proportion (n\u0026thinsp;=\u0026thinsp;114, 76%) adhere to recommendations provided by medical professionals. Notably, social media and internet sources also play a significant role, influencing the dietary habits of half of the patients surveyed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFourty-eight (32%) stated that there was no change in their appetite. However, 90 patients (60%) had increased their appetite during remission.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnergy and protein intake\u003c/h3\u003e\n\u003cp\u003eThe energy intake of patients ranged from 1000 to 1900 kcal per day, with a mean (\u0026plusmn;\u0026thinsp;SD) intake of 1477.5\u0026thinsp;\u0026plusmn;\u0026thinsp;241.1 kcal per day (Male \u0026ndash; 1562.6\u0026thinsp;\u0026plusmn;\u0026thinsp;205.9; Female \u0026ndash; 1326.1\u0026thinsp;\u0026plusmn;\u0026thinsp;228.9, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Protein intake varied between 21 and 70 g per day, with a mean (\u0026plusmn;\u0026thinsp;SD) of 44.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 g per day (Male \u0026ndash; 45.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0; Female \u0026ndash; 43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5, P\u0026thinsp;=\u0026thinsp;0.3). Both energy and protein intake were categorized into specific ranges and are illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, respectively.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eFactors associated with the nutritional status and dietary pattern of the patients\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e demonstrates a significant association between patient age and malnutrition (p\u0026thinsp;=\u0026thinsp;0.009), with younger patients (\u0026lt;\u0026thinsp;40 years) being more susceptible to malnutrition. However, other demographic factors did not show a significant correlation with nutritional status. Similarly, early-onset disease (\u0026lt;\u0026thinsp;17 years) was associated with an increased risk of malnutrition within the cohort (p\u0026thinsp;=\u0026thinsp;0.005). Notably, neither medication use, nor surgical interventions were found to have a significant impact on patients' nutritional status.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with nutritional status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNutrition status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003cp\u003e(p-value)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNormal (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMalnutrition (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGraduates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSinhala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIncome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eDisease characteristics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDisease duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge at diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsolated (Ileal/ Colonic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIleocolonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBehaviour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerineal disease modifier\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAzathioprine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSurgical intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNone of the sociodemographic factors, such as age, educational level, ethnicity, marital status, income, and disease factors, were significantly associated with dietary patterns and specific food avoidance behaviours (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was conducted at NHSL, one of the largest teaching hospitals in Sri Lanka, which serves as a referral center for Crohn's disease patients from across the country. This ensures a more representative sample of Sri Lankan patients.\u003c/p\u003e \u003cp\u003eIn our study, 98% of participants believed certain foods exacerbate Crohn\u0026rsquo;s Disease (CD) symptoms. Similar findings were reported in an Indian study of 316 IBD patients, where 44% identified diet as a risk factor and 52% considered dietary habits critical for disease management [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A UK study found that 51% of participants believed diet initiated their IBD, and 63% attributed dietary components to disease relapse [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, a survey in France of 244 IBD patients revealed 15.6% linked diet to disease onset, and 57.8% believed it contributed to relapses [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe assessed the consumption and avoidance of specific foods, and found that red meat (86%), Samposha (82%), and peanuts (70%) were the most avoided items. Samaposha is an endemic pre-cooked cereal based nutritious supplement food which consists of corn, soya, green gram and rice. It is enriched with lots of vitamins and minerals. Similarly, a large internet-based cohort study by Cohen et al. involving 6,768 IBD patients reported that various foods aggravated symptoms, while some, like rice and yogurt, provided relief [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Respondents frequently modified their diets to avoid symptom-triggering foods, and commonly mentioned food included vegetables (leafy and non-leafy), spicy and fried foods, fruits, nuts, milk, and red meat [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A study of British South Asian IBD patients also revealed that 89% avoided certain foods at least occasionally, with spicy foods (74%), fatty foods (44%), red meat (42%), milk (42%), alcohol (35%), and coffee (32%) identified as common triggers for relapses [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study focused exclusively on Crohn's disease (CD) patients in remission. A Canadian IBD cohort study found that food avoidance is more prevalent among individuals with active IBD. Additionally in this same study, patients with active IBD consumed significantly more sports drinks and sweetened beverages compared to those in remission [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, components of a Western diet\u0026mdash;such as red meat, processed foods, additives, fatty foods, and sugary foods\u0026mdash;were commonly reported as triggers potentially increasing the risk of IBD [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA Canadian study identified gastrointestinal upset as the primary reason for avoiding certain foods [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Medical advice influenced up to 15% of patients, with milk and dairy products being the most avoided items based on recommendations. In contrast, our study explored the factors influencing dietary patterns to prevent relapses and found that personal experience was cited by 90% of participants, followed by medical advice (76%), social media and the internet (50%), and family and friends (16%).\u003c/p\u003e \u003cp\u003eIn our study cohort, appetite increased in 60% of patients, remained unchanged in 32%, and decreased in 6% during remission. These findings differ from those of Zallot et al., where 47.5% of respondents (n\u0026thinsp;=\u0026thinsp;116) reported a reduced pleasure in eating and a comparable decrease in appetite, particularly during relapse compared to remission [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, Limdi et al. found that 73% (n\u0026thinsp;=\u0026thinsp;292) of patients experienced changes in appetite and eating pleasure [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, the mean daily energy intake among Crohn\u0026rsquo;s disease (CD) patients was 1477.5\u0026thinsp;\u0026plusmn;\u0026thinsp;241.1 kcal/d (males: 1562.6\u0026thinsp;\u0026plusmn;\u0026thinsp;205.9 kcal/d; females: 1326.1\u0026thinsp;\u0026plusmn;\u0026thinsp;228.9 kcal/d, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the mean protein intake was 44.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 g/d (males: 45.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0 g; females: 43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 g, P\u0026thinsp;=\u0026thinsp;0.3). Compared to national estimates of the Sri Lankan adult population reported by Jayawardena et al., where the average energy intake was 1913\u0026thinsp;\u0026plusmn;\u0026thinsp;567 kcal/day for males and 1514\u0026thinsp;\u0026plusmn;\u0026thinsp;458 kcal/day for females, CD patients demonstrated a significantly lower energy intake [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although the mean daily protein intake in our cohort (44.8 g) was similar to the national average (44.6 g), gender-specific analysis revealed that both males and females with CD had lower protein intake compared to the general population (52.8 g for males and 40.0 g for females) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These findings indicate that CD patients, particularly males, have a notable energy deficit, which may have implications for disease management and nutritional interventions. A previous study assessing self-reported energy intake among Crohn's disease patients during both active and quiescent phases reported mean energy intakes of 1829\u0026thinsp;\u0026plusmn;\u0026thinsp;260 kcal/day for males and 1452\u0026thinsp;\u0026plusmn;\u0026thinsp;224 kcal/day for females during remission, with no significant variation between disease phases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The same study reported mean protein intakes of 78.3\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6 g/day for males and 61.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5 g/day for females during remission. The mean energy intake in our cohort was comparable to that of females in the previous study, but protein intake was notably lower.\u003c/p\u003e \u003cp\u003eIn our study, 46% of participants had a normal BMI, 36% were underweight, and 18% were overweight, with a mean BMI of 20.59 kg/m\u0026sup2; (SD 4.36). Similarly, Pieczyńska et al. reported a mean BMI of 21.7 kg/m\u0026sup2; (range 15.2\u0026ndash;33.1) among Crohn's disease patients in remission [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. They also assessed malnutrition risk using the Mini Nutritional Assessment, finding that 36% had adequate nutritional status, 51% were at risk of malnutrition, and 13% were malnourished. In contrast, another study of 50 Crohn's disease patients reported that 82% had normal weight, while only 8% were underweight [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe evaluated factors influencing the nutritional status and dietary patterns of Crohn\u0026rsquo;s disease (CD) patients. While previous studies have identified gender, prior surgeries, and disease duration as key determinants of dietary patterns [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], our findings indicate that only younger age (\u0026lt;\u0026thinsp;40 years) and early-onset disease (\u0026lt;\u0026thinsp;17 years) were significantly associated with malnutrition. In contrast, other sociodemographic factors, including gender, income, education level, marital status, ethnicity, and disease characteristics, showed no significant correlation with nutritional status.\u003c/p\u003e \u003cp\u003eCrooks B et al. reported that food avoidance was significantly higher among females than males (p\u0026thinsp;=\u0026thinsp;0.02), with females more likely to avoid sweet foods (p\u0026thinsp;=\u0026thinsp;0.001) and raw fruits and vegetables (p\u0026thinsp;=\u0026thinsp;0.04) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Tamor et al. identified age, gender, socioeconomic status, disease activity, family size, and BMI as factors influencing dietary patterns in IBD patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Anyhow, notably, none of the sociodemographic factors and disease characteristics were associated with dietary pattern and food avoidance in our cohort.\u003c/p\u003e \u003cp\u003eOur study has several limitations. Even though our study was carried out in the largest referral center in the country, with single-center experience, it has limited inferential capacity. This can be overcome by considering either a multicenter study or carrying out the study in a larger sample size. Additionally, dietary intake was self-reported using a 3-day diet diary, which may have led to overestimation or underestimation of nutrient intake, despite clear instructions provided to participants. Furthermore, patients may have reported food avoidance based on personal factors such as dislikes or beliefs, rather than solely in relation to IBD symptoms.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMalnutrition and nutrition deficiencies are major concerns in patients with Crohn\u0026rsquo;s disease. Nutrition therapy plays an integral role in patient care. Patients with CD should be screened regularly for malnutrition and nutrient deficiencies. Nutrition strategies should be tailored for each patient. It should begin with nutrition assessment, supplementation of micronutrients when clinically indicated and individualized nutrition counseling.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrohn\u0026rsquo;s Disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIBD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInflammatory bowel disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCDAI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrohn's Disease Activity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHSL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Hospital Sri Lanka\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Ethics Review Committee, NHSL, Colombo (ERC No: AAJ/ETH/COM/2021/JUNE). All patients provided written consent for both the procedures performed and their participation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCRediT authorship contribution statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT G Samarasekera- Writing - original draft– writing- review and editing.\u003c/p\u003e\n\u003cp\u003eJesuthasan Mithushan- Writing - original draft– writing- review and editing.\u003c/p\u003e\n\u003cp\u003eNilesh Fernandopulle - Writing – review and editing, supervision.\u003c/p\u003e\n\u003cp\u003eRenuka Jayatissa- Writing – review and editing, supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ede Castro MM, Corona LP, Pascoal LB, Miyamoto J\u0026Eacute;, Ignacio-Souza LM, de Lourdes Setsuko Ayrizono M, Torsoni MA, Torsoni AS, Leal RF, Milanski M. 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Int Archives Med. 2014;7(1):1\u0026ndash;1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1755-7682-7-34\u003c/span\u003e\u003cspan address=\"10.1186/1755-7682-7-34\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElramli SS. Study The Prevalence Of Malnutrition Among Crhon'S Disease Patients During Clinical Remission. Int J Health Sci. 2020;3(1):1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Crohn’s disease, dietary pattern, nutritional status","lastPublishedDoi":"10.21203/rs.3.rs-6396478/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6396478/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMalnutrition is common in Crohn\u0026rsquo;s Disease (CD) and diet plays a vital role in its clinical course and pathogenesis. Diet is a contributing factor for aggravation of symptoms. Though the assessment of nutritional status and dietary patterns are crucial in the management of CD, literature in this regard is limited in Asia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis descriptive cross-sectional study was carried out at a gastroenterology unit in a tertiary care centre in Sri Lanka over one-year duration. 150 patients diagnosed with Crohn's disease and in remission were included in the study. The data were gathered using an interviewer-administered questionnaire and physical examination of anthropometric measures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age (SD) was 33 (8.4) years with the M:F ratio of 2:1. Forty-six percent of the population (n\u0026thinsp;=\u0026thinsp;69) had a normal BMI range according to standard WHO criteria for Asian populations, while 36% were underweight and 18% overweight. The mean (\u0026plusmn;\u0026thinsp;SD) intake of energy and protein was 1477.5\u0026thinsp;\u0026plusmn;\u0026thinsp;241.1 kcal per day (male \u0026ndash; 1562.6\u0026thinsp;\u0026plusmn;\u0026thinsp;205.9; female \u0026ndash; 1326.1\u0026thinsp;\u0026plusmn;\u0026thinsp;228.9, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 44.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 g per day (male \u0026ndash; 45.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0; female \u0026ndash; 43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5, P\u0026thinsp;=\u0026thinsp;0.3), respectively. The mean (SD) albumin level was 21.6 g/l (17.6), suggestive of chronic malnutrition of the cohort; however, the mean of other micronutrients is within the normal range. The majority of (98%) patients believed that certain foods made symptoms worse, and the common dietary triggers were red meat and carbonated drinks. Red meat (86%), Samaposha (82%) and peanuts (70%) were identified as the most avoided food items in a local context. Self-experience of food triggers was the most influential source to prevent relapses (n\u0026thinsp;=\u0026thinsp;135, 90%), followed by medical advice (76%), social media and internet (50%). None of the sociodemographic factors and disease characteristics were significantly associated with the dietary pattern and food avoidance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Malnutrition was associated with early onset disease and younger age\u0026thinsp;\u0026lt;\u0026thinsp;40 years (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMalnutrition is prevalent among Sri Lankan Crohn\u0026rsquo;s disease patients, with a significant proportion being underweight and having low energy and protein intake. Despite normal micronutrient levels, the low mean albumin suggests chronic malnutrition. Patients are relying primarily on personal experience to guide food avoidance. Malnutrition was significantly associated with early onset of disease and younger age. These findings highlight the need for targeted nutritional assessment and dietary guidance in CD management.\u003c/p\u003e","manuscriptTitle":"Nutritional Status and Dietary Patterns of Patients with Crohn’s Disease in Clinical Remission: Insights from a Sri Lankan Cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 14:06:25","doi":"10.21203/rs.3.rs-6396478/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2901f04b-224b-44c5-a2d5-644e1bf41bb7","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T15:08:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 14:06:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6396478","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6396478","identity":"rs-6396478","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}