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REVIEW
Competing With Crohn's Disease

Management Issues in Active Patients

Victor K. Ng, MSc; Wanda M. Millard, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 11 - NOVEMBER 2022

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In Brief: Crohn's disease is a chronic inflammatory bowel disorder that has genetic and environmental risk factors. Although moderate physical activity seems to reduce the risk of developing Crohn's disease, some high-performance athletes live with the disease. Uncontrolled Crohn's disease predisposes patients to numerous nutrient deficiencies and associated health issues such as anemia and osteoporosis. Low-intensity exercise has been shown to decrease flare-ups in sedentary patients; however, high-intensity exercise may lead to increased symptoms. Physicians play a crucial role in coordinating a team approach among the athlete, parents, coach, and athletic trainers to provide the best possible management of diet, training schedule, and treatment.

Crohn's disease or regional enteritis is an inflammatory bowel disease with a bimodal onset typically at age 15 to 25 or age 55 to 65. Healthcare providers and team physicians will likely encounter athletes who have this chronic and debilitating disease. We review the literature on active patients who have Crohn's disease to help sports physicians manage these difficult cases.

Historically, few systematically documented cases of Crohn's disease are known; however, ancient texts show that this disease has existed for thousands of years. In ancient China, scrolls document symptoms of bloody diarrhea, weight loss, abdominal pains, and brittle bones—all of which are consistent with Crohn's disease. The first scientifically documented case of regional enteritis or Crohn's disease was probably discussed by Morgagni in 1776.1 Throughout the eighteenth and nineteenth centuries, numerous physicians and scientists recorded the signs and symptoms consistent with this disease.1

The official identification and discussion of Crohn's disease is credited to a 1932 paper by Crohn et al2 that led to widespread recognition of the disease. When the paper was presented in New Orleans in 1932, J. Arnold Bargen, MD, from the Mayo Clinic suggested the name regional ileitis, thus anticipating the recognition of the variable location of the disease in the small and large bowel.2

The cause of Crohn's disease may be a combination of familial and environmental influences, including the effects of diet and postinfectious response. Crohn's disease is an inflammation of all layers of the gut and can occur anywhere in the alimentary tract, most commonly in the distal ileum. In contrast, ulcerative colitis involves inflammation of the inner lining of the bowel and occurs mainly in the colon. These two factors are the main difference between Crohn's disease and ulcerative colitis. In ileocecal Crohn's disease, the pain is localized, and the right lower quadrant of the abdomen is often tender to the touch; abdominal distention and/or visible small-bowel peristalsis may also be seen. As inflammation progresses, thickened loops of bowel may form a tender palpable mass.

The onset of Crohn's disease symptoms can vary and may mimic acute appendicitis. In contrast, ulcerative colitis affects only the colon, and the pain and site of disease activity is most commonly found in the distal end of the large bowel. In the past, Crohn's disease was often diagnosed during an operation for presumed appendicitis, but modern computed tomography and ultrasound techniques have enabled earlier diagnosis. The generic gastrointestinal symptoms of cramping and diarrhea can often lead to confusion of Crohn's disease with the more prevalent irritable bowel syndrome.

Preparticipation Physical Exams

The management of Crohn's disease in athletes is complex. Many athletes are embarrassed about their condition and conceal their symptoms from their parents, coach, and physician. A coach, athletic trainer, or parent may detect nonspecific changes, such as unexplained weight loss, increased tiredness, poor performance, or increased frequency of toilet use. During the preparticipation physical exam, the team physician must be vigilant and not assume that athletes are immune to gastrointestinal disorders.3 Reports of unintentional weight loss, chronic diarrhea, or abdominal pain should prompt further investigation.

Athletes often use nonsteroidal anti-inflammatory drugs or antibiotics that may cause gastrointestinal irritation. If the symptoms are not the result of these drugs or other known irritants (eg, caffeine, alcohol, tobacco, certain foods) and do not resolve when the suspected offender is eliminated, further investigation is warranted (table 1). Laboratory tests for anemia and iron deficiency, erythrocyte sedimentation rate, and C-reactive protein, as well as stool samples for occult blood, should be performed. If the test results are positive, persistent, and unexplained, referral to a gastroenterologist is prudent.

TABLE 1. Recommendations for Patients Who Have Crohn's Disease
Symptom or Sign Treatment
Heartburn, nausea, acid reflux Avoid alcohol and smoking
Try antacids, H2-blockers, or proton pump inhibitors
Bloating Avoid gas-producing foods (eg, broccoli, beans, eggs)
Check for lactose intolerance
Try an antigas product
Diarrhea Avoid antibiotics, NSAIDs, caffeine, and high-carbohydrate sport drinks
Reduce high-glycemic-index foods, especially before exercise
GI bleeding* Avoid aspirin and other NSAIDs
Stay hydrated
*Any person with GI bleeding or other symptoms that persist for more than 2 weeks should seek medical attention.
GI = gastrointestinal; NSAIDs = nonsteroidal anti-inflammatory drugs

Psychological Concerns

A chronic condition such as Crohn's disease can be catastrophic for anyone, including athletes. Mild to severe depressive symptoms are common.4 The physician plays an important role in educating athletes, parents, coaches, and athletic trainers about the therapeutic and emotional needs of the patient. Anecdotally, patients with Crohn's disease have said that the first year after diagnosis is the most agonizing. Patients may have to make lifestyle changes to accommodate the disease, often reducing the number of daily athletic and social activities. This can be particularly traumatizing for athletes, who are by nature hard workers and determined to succeed (table 2).

TABLE 2. Crohn's Disease Factors That Can Impede Athletic Performance
Abdominal pain or bloating
Feeling of inevitable soiling during intense training or competition
Frequent diarrhea (may cause dehydration)
Frequent or sudden urge to defecate
Irrational fear of eating certain foods (affects nutrient intake, reduces energy levels, and may lead to malnutrition)
Preoccupation with potential difficulty in finding a toilet (distracts from concentration on sport or game)

In light of the inevitable emotional stresses, surprisingly few studies have looked at the effect of counseling in Crohn's disease. In a recent study by Smith et al,5 psychological morbidity improved when counseling increased the perception among patients that their problems were fully addressed, analyzed, and supported. Although the quality of life improvement was not sustained 1 year after the study, the immediate benefit of counseling is encouraging and merits further study.

Lifestyle Changes

Patients who have Crohn's disease may sense a loss of control, not only of their bowel habits, but also over other aspects of their lives. Physicians may offer a ray of hope by encouraging these patients to cope with the disease by taking control of the factors they can control.

Smoking. One of the recommended lifestyle changes for Crohn's disease patients is smoking cessation. Smoking is a risk factor for Crohn's disease and also affects the course of the disease. Smokers who have Crohn's disease have more exacerbations and require more immunosuppressive therapy and more surgical resections.6 While the proportion of athletes who smoke is probably smaller than the general population, the estimated number of European patients who have Crohn's disease and smoke is about 50%.7,8

In a study by Cosnes et al,9 patients with Crohn's disease who stopped smoking had a 65% lower risk of flare-up compared with those who continued to smoke. For athletes, smoking cessation could translate into reduced flare-ups, increased training time, a prolonged competitive season, and improved overall quality of life.

Diet. In recent years, improving the nutritional status of patients who have Crohn's disease has received more attention, because diet can have a profound impact on the course of the disease. Some factors that can lead to malnutrition in Crohn's disease are reduced food intake, malabsorption, increased nutrient losses from the gut, drug-nutrient interactions, and potentially increased nutritional requirements.10 Many researchers have looked at nutrient deficiencies, analyzed the primary causes and effects of these deficiencies, and proposed treatment options. The role of nutrition for the athlete who has Crohn's disease cannot be underestimated.

Compared with sedentary individuals, athletes expend more energy and require increased caloric intake. Training stresses the body; therefore, athletes tend to require more protein and other nutrients. In an athlete who already has a compromised alimentary tract, adequate absorption of nutrients can be difficult. Health practitioners should monitor the diet of an athlete who may fear eating certain foods after many bouts of diarrhea and constant abdominal pain. Loss of appetite and refusal to eat are common. Every patient who has Crohn's disease is different, and it will be up to the individual patient to discover which foods are more tolerable. Generally, lean meat, chicken, and fish are well tolerated. Cooked vegetables are less fibrous and create less gas than raw vegetables, and therefore they trigger fewer symptoms. Gastrointestinal irritants such as coffee and alcohol should be avoided.

In a study by Jones et al,11 patients did not tolerate an unrefined-carbohydrate, fiber-rich diet. The extra fiber in foods can irritate the intestinal mucosa. In a healthy individual, the irritation causes mucus secretion that aids in desired regularity. However, in patients who have Crohn's disease, this irritation can cause copious amounts of mucous production and increased diarrhea. Furthermore, a high-fiber diet increases the likelihood of flare-ups, and none of the patients studied were able to stay in remission after starting the fiber-rich diet. In the study, 7 of 10 patients with Crohn's disease who ate a diet that excluded specific foods to which they were intolerant remained in remission for 6 months.

Iron intake. Crohn's disease patients are commonly iron deficient.12,13 Frequent bloody diarrhea, poor iron absorption by the diseased bowel, and avoiding fiber-rich and iron-rich foods can lead to reduced iron levels.14 Iron depletion, or the more severe iron deficiency anemia, may cause diminished performance in endurance events and generalized weakness, tiredness, palpitation, shortness of breath, dizziness, or headaches.15

Iron depletion and anemia can be health concerns for sedentary patients, but for athletes the effect can be devastating. Strenuous activities require sustained oxygen transport, particularly in endurance sports. In a study by Dubnov and Constantini,15 elite male and female basketball players were examined for signs of anemia and low iron levels. Laboratory tests, including a complete blood count and plasma ferritin, were performed. The researchers found iron depletion among 22% of the study participants (defined by a ferritin level below 20 µg/L), and 7% of the athletes had iron deficiency anemia (defined by a ferritin level below 12 µg/L). Given these numbers in healthy athletes, those with Crohn's disease may have an even greater risk of iron insufficiency.

Supplementation must be considered if patients show signs of iron depletion or anemia; however, oral iron supplements may cause gastrointestinal irritation. Supplementation is a delicate process that must be done under close medical supervision. Occasionally, parenteral iron supplementation may be necessary if a patient is unable to tolerate or poorly absorbs oral supplements.

Bone Density Concerns

Since ancient times, brittle bones have been a recognized symptom of this disorder. Playing contact sports may have additional risks, and the cause of decreasing bone density in patients who have Crohn's disease is probably multifactorial.

Corticosteroids are often prescribed to help mitigate inflammatory symptoms. In a study of the relationship between corticosteroid use, Crohn's disease, and bone density by Thodis et al,16 osteopenia or osteoporosis was reported in 30% to 50% of patients with Crohn's disease. The study concluded that patients who had Crohn's disease for more than 2 years had higher rates of bone loss than those who had a more recent onset of the disease. Although corticosteroid therapy may be a contributory factor, Thodis et al found no significant correlation between cumulative steroid use and the amount of bone loss in the study patients.

Nutrient deficiencies may also play a role. Decreased bone mineral density and osteoporosis associated with calcium malabsorption, secondary hyperparathyroidism resulting from calcium and/or vitamin D deficiency, and poor vitamin D absorption alone have been alluded to in the literature.17,18

Weight-bearing exercise affects bone density. Gravitational and muscular forces during exercise produce a strain on the skeleton that promotes bone formation. For the sedentary but otherwise healthy individual, the impact of exercise on bone health has been studied for a number of years. However, to our knowledge, only one study19 has looked at the effects of exercise on bone mineral density in patients who have Crohn's disease. This randomized controlled trial recruited patients with Crohn's disease to participate in a 12-month study of low-impact exercise on bone density in the hip and lumbar regions. The authors found that the increase in bone mineral density was related to the number of completed exercise sessions. This suggests a dose-response effect of exercise on bone density in patients who have Crohn's disease and underscores that progressive low-impact exercise is beneficial for them.

Female athlete triad issues may put female athletes at particular risk of complications in Crohn's disease. The female athlete triad is a combination of disordered eating, menstrual dysfunction, and decreased bone mineral density present in both collegiate and adolescent athletes.20,21 In some sports, over half the female collegiate and adolescent athletes reported one or more of the triad conditions.20 The development of Crohn's disease in addition to pre-existing low bone mineral density and nutrient deficiencies can complicate an already poor state of health. This is one reason why the preparticipation physical exam, with special attention on female triad-related issues, is so crucial in establishing a baseline health status for adolescents.

Exercise Pros and Cons

Physical activity has traditionally been prescribed for a wide array of chronic ailments, including other inflammatory diseases, but guidelines for patients with Crohn's disease are nearly nonexistent. This presents a problem for the medical team who need to advise an athlete on exercise intensity and training.

In a study of physical activity in rheumatoid arthritis patients by Lyngberg et al,22 limited exercise showed some benefits. Although the laboratory inflammatory markers remained the same as in the control (nonexercising) group, the work capacity doubled, and the disease activity did not increase in the exercise group. The authors recommend individually adapted exercise programs for rheumatoid arthritis patients. Both rheumatoid arthritis and Crohn's disease have inflammatory components; therefore, this study may have some relevance. Further studies are needed.

New technologies make it possible to study motility in various parts of the gastrointestinal tract, but more studies are needed on the effects of exercise on gastrointestinal symptoms. Conflicting observations are not well understood regarding the effect of physical activity intensity on gastrointestinal motility, blood flow, motor function, neuroendocrine changes, and mechanical effects.23

In a review, Simren23 reported colonic transit times to be unchanged or decreased following exercise. For patients with Crohn's disease who often have abdominal pains and diarrhea, an increase in motility caused by exercise could prove problematic. Furthermore, the studies on colonic transit times were done with moderate intensity exercise, which means that higher intensity training could be even more uncomfortable for athletes.

In addition, the gut ischemia that results from blood flow redistribution during heavy exercise may lead to intestinal mucosal damage. Pals et al24 found that small intestinal permeability increased during running at 80% VO2max compared with rest, 40%, and 60% intensities of exercise, thus supporting the theory that heavy exercise may lead to mucosal changes. We speculate that, for the athlete with Crohn's disease who trains at a high intensity, constant exercise-induced inflammation and flow of irritants caused by increased intestinal permeability across the bowel mucosa could bring about more flare-ups. Therefore, the medical team may need to reduce the intensity of the training regimen.

Three other groups researched the actual impact of exercise on Crohn's disease. In an early epidemiologic study, Persson et al25 explored the association between risk indicators and inflammatory bowel disease. Questionnaires about habitual physical activity were mailed to research participants. The authors found that the relative risk of Crohn's disease was inversely related to regular daily or weekly physical activity. Therefore, it seems that physical activity is safe for Crohn's disease patients and may reduce the risk of developing the disease.

In a study by Loudon et al,26 sedentary patients with inactive or mildly active Crohn's disease adhered to a low-intensity walking program for 12 weeks. During the poststudy evaluations, most participants reported that their life satisfaction had increased and that their illness was less of a factor in causing fatigue and tiredness. In terms of absolute physical health, the participants experienced an increase in aerobic capacity (VO2max) and a decrease in body mass index. Because this study involved only low-intensity exercise, the recommendations apply only to that intensity range. Although elite athletes will be training above this intensity, recreational athletes could benefit from the results of this study. The data from the study show that low-intensity exercise elicits positive physical and psychological benefits and has no adverse effects on disease activity.

One study27 looked at Crohn's disease and moderate to heavy exercise. Research participants exercised to their maximal capacity on a treadmill, rested for 1 hour, and then exercised at 60% VO2max. Compared with the nonexercise control group, the treatment group experienced no increase in stool frequency and no increased incidence of relapse. It appears that moderate exercise and short-bout heavy-intensity exercise do not produce undesirable changes in gut physiology and function in patients who have Crohn's disease.

A number of elite athletes who have Crohn's disease have risen to the top of their sport, including Theo Fleury and Kevin Dineen of the National Hockey League. Both have suffered flare-ups during their athletic careers. In a determined athlete, Crohn's disease need not be a disqualifying factor; however, vigilance by the athlete and medical team is essential in monitoring symptoms and adapting training.

Recommendations for athletes regarding specific sport participation are difficult to answer with evidence-based accuracy. The scant literature on exercise and Crohn's disease is mostly based on sedentary individuals who were introduced to activity. For the athlete who is newly diagnosed with Crohn's disease while actively competing, clinical judgment and supporting diagnostics must guide recommendations.

Participation in collision sports, such as football, hockey, rugby, and soccer, raises concern for presumed increased risk of fracture related to low bone mineral density. However, if nutritional goals are being met and glucocorticoid use is negligible, it does not seem reasonable to remove athletes from their sport. Using the same guidelines, strength training for athletes who have Crohn's disease need not differ from their teammates'. Athletes who have Crohn's disease should be reminded to include fluid losses caused by diarrhea when determining how much fluid replacement is necessary during and after activity.

Pharmacologic Mainstays

Careful management of diet and activity are often adequate to keep symptoms of Crohn's disease in remission in patients with mild disease. For those who suffer with more aggressive disease or for acute exacerbations, intervention is often necessary. Both the athlete and the coaching staff must understand that Crohn's disease is a chronic illness, and no definitive cure is available.

For decades, the mainstay of pharmacotherapy has been aminosalicylates such as sulfasalazine and 5-aminosalicylic acid (5-ASA). Antibiotics such as metronidazole and ciprofloxacin are often necessary to treat rectal and perianal disease. Glucocorticoids are the mainstay of treatment for acute disease flare, but, because long-term side effects can be severe, a rapid taper is desirable after symptoms are suppressed. Immunomodulatory agents 6-mercaptopurine and azathioprine and the newer agent infliximab are fourth- and fifth-line agents in the treatment of acute flares and aggressive disease. Methotrexate sodium, thalidomide, and interleukin are other agents that may benefit some patients with persistent disease. Symptom modifiers such as antidiarrheals, antispasmotics, histamine-1 blockers, and protein pump inhibitors are also useful in improving comfort for patients with Crohn's disease.

Treatment of athletes with Crohn's disease should follow the same principles as for nonathletes. Of the above-listed pharmacotherapies, the World Anti-Doping Agency (WADA) considers only glucocorticoids as prohibited substances. Most international sporting federations allow for therapeutic exemptions when a glucocorticoid is proven necessary for the health of the competing athlete. The WADA website and the local agency for ethics in sports in your jurisdiction have regional and sport-specific guidelines and information on obtaining therapeutic exemption and confirmation of nonprohibited status of any new pharmaceutical products.

Digesting the Facts

Crohn's is a chronic disease but need not be debilitating for the athlete. Low-intensity exercise of moderate duration is likely to benefit most patients with Crohn's disease. Athletes can likely continue to train at moderate intensity with occasional bouts of high-intensity exertion for short duration. High-intensity, long-duration sports such as marathon running or triathlons are likely to produce gastrointestinal symptoms and exacerbations. The athlete and physician must consider the risks versus benefits of these types of activities. All physical activity needs to be reduced during a flare-up of disease. The increased caloric and nutritional needs of the athlete must be evaluated and monitored to ensure chronic conditions such as iron deficiency anemia and low bone density are identified and addressed early. Psychological support and education of the athlete, family, coaches, and training staff can assist athletes in their pursuit of sports while coping with Crohn's disease.

References

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  8. Russel MG, Volovics A, Schoon EJ, et al: Inflammatory bowel disease: is there any relation between smoking status and disease presentation? European Collaborative IBD Study Group. Inflamm Bowel Dis 1998;4(3):182-186
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  13. Gasche C, Dejaco C, Waldhoer T, et al: Intravenous iron and erythropoietin for anemia associated with Crohn disease: a randomized, controlled trial. Ann Intern Med 1997;126(10):782-787
  14. Lomer MC, Kodjabashia K, Hutchinson C, et al: Intake of dietary iron is low in patients with Crohn's disease: a case-control study. Br J Nutr 2004;91(1):141-148
  15. Dubnov G, Constantini NW: Prevalence of iron depletion and anemia in top-level basketball players. Int J Sport Nutr Exerc Metab 2004;14(1):30-37
  16. Thodis E, Rossos P, Habal FI, et al: Negative impact of Crohn's disease on bone mineral mass. J Musculoskelet Neuronal Interact 2003;3(3):246-250
  17. Tuohy KA, Steinman TI: Hypercalcemia due to excess 1,25-dihydroxyvitamin D in Crohn's disease. Am J Kidney Dis 2005;45(1):e3-e6
  18. Vestergaard P: Prevalence and pathogenesis of osteoporosis in patients with inflammatory bowel disease. Minerva Med 2004;95(6):469-480
  19. Robinson RJ, Krzywicki T, Almond L, et al: Effect of a low-impact exercise program on bone mineral density in Crohn's disease: a randomized controlled trial. Gastroenterology 1998;115(1):36-41
  20. Beals KA, Manore MM: Disorders of the female athlete triad among collegiate athletes. Int J Sport Nutr Exerc Metab 2002;12(3):281-293
  21. American Academy of Pediatrics Committee on Sports Medicine and Fitness: Medical concerns in the female athlete. Pediatrics 2000;106(3):610-613
  22. Lyngberg KK, Harreby M, Bentzen H, et al: Elderly rheumatoid arthritis patients on steroid treatment tolerate physical training without an increase in disease activity. Arch Phys Med Rehabil 1994;75(11):1189-1195
  23. Simren M: Physical activity and the gastrointestinal tract. Eur J Gastroenterol Hepatol 2002;14(10):1053-1056
  24. Pals KL, Chang RT, Ryan AJ, et al: Effect of running intensity on intestinal permeability. J Appl Physiol 1997;82(2):571-576
  25. Persson PG, Leijonmarck CE, Bernell O, et al: Risk indicators for inflammatory bowel disease. Int J Epidemiol 1993;22(2):268-272
  26. Loudon CP, Corroll V, Butcher J, et al: The effects of physical exercise on patients with Crohn's disease. Am J Gastroenterol 1999;94(3):697-703
  27. D'Inca R, Varnier M, Mestriner C, et al: Effect of moderate exercise on Crohn's disease patients in remission. Ital J Gastroenterol Hepatol 1999;31(3):205-210

Mr Ng is a graduate student and Dr Millard is a primary care physician at Fowler Kennedy Sport Medicine Clinic at the University of Western Ontario in London, Ontario, Canada. Address correspondence to Wanda M. Millard, MD, Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London Ontario Canada N6A 3K7; e-mail to [email protected].

Disclosure information: Mr Ng and Dr Millard disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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