1. Nutrition & Diet Therapy (7 th Edition) Fiber-Modified Diets for Lower GI Tract Disorders Chapter 18

2. Nutrition & Diet Therapy (7 th Edition) Modifying Fiber Intake Modification may require either increase or decrease in dietary fiber –Insoluble fibers: increase fecal weight & promote rapid passage of wastes through large intestine –Soluble fibers: more viscous; slow passage of food –Health recommendation: most people should increase fiber intake by increasing consumption of whole grains –Side effects of high-fiber diet: increased intestinal gas (flatulence)—should be added gradually & portions increased as tolerance improves Diets high in soluble fibers can lower blood cholesterol levels

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5. Disorders of Bowel Function Constipation –Difficulty passing stools or infrequent bowel movements; often diagnosed when individual has fewer than 3 bowel movements/week –Causes: Food intake & activity-related causes: low fiber &/or food intake, inactivity Medical & neurological conditions: diabetes mellitus, chronic renal failure, hypothyroidism, Parkinson’s disease, spinal cord injury, multiple sclerosis Pregnancy Some medications & dietary supplements

6. Nutrition & Diet Therapy (7 th Edition) Constipation (con’t) –Treatment Gradual increase in fiber intake, especially –Wheat bran –Fruits & vegetables –Fiber supplements Adequate fluid intake Foods with mild laxative effects: prunes & prune juice Laxatives, enemas & suppositories Medical treatment –Medications to increase peristalsis –Surgical intervention (colon resection, colostomy) as last resort

7. Nutrition & Diet Therapy (7 th Edition) Diarrhea –Passage of frequent, watery stools –Severe or persistent diarrhea can cause dehydration & electrolyte imbalance –Causes Complication of medical problems Infection, medications, dietary substances Motility disorders: accelerate entry of fluids into colon, resulting in inadequate absorption Osmotic diarrhea: results from nutrient malabsorption Secretory diarrhea: intestines stimulated to secrete excessive fluid into colon

8. Nutrition & Diet Therapy (7 th Edition) Diarrhea (con’t) –Treatment Correction of underlying medical disorder Change in medication or omission of offending foods Bulk-forming agents to reduce liquidity of stool Antidiarrheal drugs for chronic diarrhea Parenteral nutrition for severe, intractable diarrhea –Nutrition therapy Depends on cause, severity & duration of diarrhea & degree of fluid loss Rehydration therapy: replacement of fluid & electrolytes for severe diarrhea Fiber restriction for some individuals Foods & beverages containing fructose, sugar alcohols & lactose may aggravate symptoms Avoidance of caffeine- containing products

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10. Irritable bowel syndrome –Characterized by chronic, recurrent & unexplainable intestinal symptoms –Symptoms Both diarrhea & constipation Flatulence, bloating, distention Mild to severe, often interfering in routine daily activities Individuals may eventually become asymptomatic –May be associated with colonic response to meals, GI hormones & stress –Treatment Dietary adjustments Stress management & behavioral therapies Medications for management of symptoms

11. Nutrition & Diet Therapy (7 th Edition) Irritable bowel syndrome (con’t) –Medical nutrition therapy Complete diet history to reveal behaviors that improve or worsen symptoms (placebo effect has strong influence on food tolerance & influences behavior) Dietary changes that help one symptom may aggravate another Increase fiber intake to reduce constipation & improve stool bulk Bulking agent Avoidance of milk products (if lactose intolerant) Caffeine & alcohol can exacerbate symptoms

12. Nutrition & Diet Therapy (7 th Edition) Inflammatory Bowel Diseases Crohn’s disease –Involves small intestine & may result in nutrient malabsorption –Complications Can occur in any region of GI tract—usually affects ileum &/or colon Deep inflammation, ulcerations, fissures & fistulas Intestinal obstruction, intestinal cancers Malnutrition Malabsorption of fat, fat-soluble vitamins, calcium, magnesium, zinc Vitamin B 12 deficiency, anemia

13. Nutrition & Diet Therapy (7 th Edition) Ulcerative colitis –Affects colon; always involves rectum & may extend into additional segments of colon –Complications Tissue erosion or ulceration (primarily affecting mucosa & submucosa) Mild disease results in few complications, unless colon involved Weight loss, fever, weakness Anemia Dehydration & electrolyte imbalance Protein loss

14. Nutrition & Diet Therapy (7 th Edition) In Crohn’s, the mucosa has a “cobblestone” appearance due to deep fissuring in the inflamed mucosal tissue In UC, the colon appears inflamed and reddened, and ulcers are visible

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16. Treatment of Inflammatory Bowel Diseases Drug treatment –Medications to control symptoms: reduce inflammation & minimize complications Antidiarrheal agents Immunosuppressants Anti-inflammatory drugs –Help to achieve remission but associated with side effects (diet-drug interactions) detrimental to nutrition status

17. Nutrition & Diet Therapy (7 th Edition) Medical Nutrition Therapy –Crohn’s disease: aggressive dietary management –Manage symptoms & complications High-kcalorie, high-protein Liquid supplements Restriction of fiber & lactose Vitamin & mineral supplements –Ulcerative colitis: requires little dietary adjustment –In severe illness, manage symptoms & complications Restoration of fluid & electrolytes (possible intravenous replacement) Correct deficiencies resulting from protein & blood losses Low-fiber diet Bowel rest (withhold foods) Parenteral nutrition support

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19. Diverticular Disease of the Colon Diverticulosis: presence of pebble- size outpockets in intestinal wall (diverticula) –Incidence increases with age –May remain symptom- free until complication develops –Increased fiber in diet (increased stool weight & bulk) may decrease development Diverticulitis: inflammation or infection developing around a diverticulum –Common complication of diverticulosis –Spread of infection to adjacent organs may result in development of fistula –Infection may spread to peritoneal cavity (rare occurrence) –Symptoms: persistent abdominal pain, fever, alternating constipation & diarrhea

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21. Treatment for Diverticular Disease Focuses on symptom relief –Reducing pain –Alleviating constipation –Increasing fiber to prevent disease progression Add wheat bran to meals Use bulk-forming agents Some recommend avoidance of nuts, popcorn & foods containing seeds—no evidence that this will reduce complications –Antibiotics to treat infection –Clear liquid diet, progressed to solid foods as tolerated –Bowel rest when necessary; intravenous fluid treatment –Surgical intervention to treat complications, including removal of colon

22. Nutrition & Diet Therapy (7 th Edition) Colostomies & Ileostomies Ostomy: surgically created opening (stoma) in abdominal wall for elimination of dietary waste; may be permanent or temporary –Colostomy: creation of stoma from section of colon –Ileostomy: creation of stoma from section of ileum –Dietary waste collected in disposable bag affixed to skin surrounding stoma; or interior pouch may be surgically constructed behind stoma –Stool consistency varies according to functional capacity of remaining length of colon Removal of small portion of colon: stools may continue to be semi-solid Removal or bypass of entire colon: absorption of fluid & electrolytes reduced substantially, resulting in liquid stool

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24. Nutrition Therapy for Ostomies Gradual progression of diet following surgery –Clear liquids, low in sugars, progressing to low-fiber diet as tolerated –Small, frequent meals better tolerated initially –Addition of questionable foods slowly & one at a time Ileostomy –Chew thoroughly to ensure adequate digestion & to prevent obstruction –Avoidance of insoluble fibers—reduce intestinal transit time & may increase output –Inclusion of at least 8 cups of liquid/day Colostomy –Dietary concerns depend on length of colon removed –High-fiber diet to improve stool consistency & promote regularity –Removal of large segment: recommendations may be same as ileostomy

25. Nutrition & Diet Therapy (7 th Edition) Obstructions A primary concern of ileostomy patients Cut food into small pieces, carefully chew Foods that may cause problems –Corn –Celery –Coconut –Dried fruit –Grapes –Nuts & popcorn –Raw cabbage –Unpeeled apples Reducing gas & odors A concern for all ostomy patients Avoid foods that are gas- producing Avoid foods that produce odors –Fish –Eggs –Dried beans & peas –Onions & garlic –Asparagus & Brussels sprouts –Beer Avoid practices that increase gas production –Smoking –Gum or tobacco chewing –Use of drinking straws –Eating quickly

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27. Nutrition in Practice—Probiotics & Intestinal Health Shortly after birth, GI tract is colonized with wide variety of bacteria (flora) –Majority reside in colon –Populations vary within different regions of GI tract –Benefits to health Degrade undigested or unabsorbed dietary carbohydrate, including fibers resistant to digestion Stimulate immune defenses to prevent overgrowth of pathogenic bacteria

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29. Probiotics Foods & supplements supplying live, nonpathogenic bacteria in sufficient numbers to benefit health Resistant to destruction by stomach acid, bile, other digestive substances Alter intestinal environment to benefit human host –Produce antimicrobial substances –Alter immune defenses –Metabolize undigested foodstuffs –Adhere to intestinal wall Possible help for medical problems –May prevent & treat some gastric & intestinal disorders –Improve lactose digestion –Improve availability & digestibility of various nutrients –Alter susceptibility to food allergens & alleviate some allergy symptoms –Help prevent or reverse infections in urethra & vagina Benefits to health not conclusive in research— therefore should be considered adjuncts to primary medical treatment for illness

30. Nutrition & Diet Therapy (7 th Edition) Intestinal disorders helped by probiotics –Shortened duration of diarrhea caused by rotavirus in infants & children –Decreased incidence of traveler’s diarrhea in tourists visiting high-risk areas –Prevent recurrence of infectious diarrhea in hospitalized patients –Reduced incidence & duration of antibiotic- associated diarrhea in infants & children –Reduced occurrence of pouchitis (inflammation of surgical pouch created in patients with ileostomy or colostomy)

31. Nutrition & Diet Therapy (7 th Edition) Sources of probiotic bacteria –Foods—provided mainly by fermented foods In U.S.—yogurt & acidophilus milk (produced using species of Lactobacilli & Bifidobacteria) In Europe & Asia—yogurt, milk, ice cream, oatmeal gruel, soft drinks –Dietary supplements –Prebiotics in foods that may stimulate growth in large intestine Safety –Infection in immune-compromised individuals –Lack of industry standards for probiotics in foods & supplements