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Fiber-Modified Diets for Lower GI Tract Disorders Chapter 18 Nutrition & Diet Therapy (7th Edition) I. Modifying Fiber Intake • Modification may require either increase or decrease in dietary fiber; RDI is 38 g/day – Insoluble fibers: increase fecal weight & promote rapid passage of wastes through large intestine (aka dietary fiber, found in whole grains) – 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 Nutrition & Diet Therapy (7th Edition) Diets high in soluble fibers can lower blood cholesterol levels Nutrition & Diet Therapy (7th Edition) II. Disorders of Bowel Function • Constipation – Difficulty passing stools (straining) 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 Nutrition & Diet Therapy (7th Edition) Disorders of Bowel (cont’d) • 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 Nutrition & Diet Therapy (7th Edition) Disorders of Bowel (cont’d) • Diarrhea – Passage of frequent, watery stools – Severe or persistent diarrhea can cause dehydration & electrolyte imbalance – Causes • Complication of medical problems • Infection, medications, dietary substances – 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 & Diet Therapy (7th Edition) Disorders of Bowel (cont’d) • Diarrhea (con’t) – 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 – Rehydration therapy • The replacement of fluids and electrolytes (water, salts, and glucose or sucrose) if diarrhea is severe. Nutrition & Diet Therapy (7th Edition) Nutrition & Diet Therapy (7th Edition) Disorders of Bowel (cont’d) • 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 – Possible Causes: May be associated with colonic response to meals, GI hormones & stress – Treatment • Dietary adjustments • Stress management & behavioral therapies • Medications for management of symptoms Nutrition & Diet Therapy (7th Edition) Disorders of Bowel (cont’d) • Irritable bowel syndrome (con’t) – Medical nutrition therapy • Complete diet history to reveal behaviors that improve or worsen symptoms • 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 • Small, frequent meals • Possible low fat diet Nutrition & Diet Therapy (7th Edition) III. Inflammatory Bowel Diseases (IBD) • 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 B12 deficiency, anemia Nutrition & Diet Therapy (7th Edition) Inflammatory Bowel Diseases (cont’d) • 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 Nutrition & Diet Therapy (7th Edition) • In Crohn’s, the mucosa has a “cobblestone” appearance due to deep fissuring in the inflamed mucosal tissue Nutrition & Diet Therapy (7th Edition) • In UC, the colon appears inflamed and reddened, and ulcers are visible Nutrition & Diet Therapy (7th Edition) 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 Nutrition & Diet Therapy (7th Edition) Inflammatory Bowel Diseases • 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 Nutrition & Diet Therapy (7th Edition) – 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 IV. Diverticular Disease of the Colon • Diverticulosis: presence of pebblesize outpockets in intestinal wall (diverticula) – Incidence increases with age – May remain symptomfree until complication develops – Increased fiber in diet (increased stool weight & bulk) may decrease development Nutrition & Diet Therapy (7th Edition) • 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 Nutrition & Diet Therapy (7th Edition) 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 Nutrition & Diet Therapy (7th Edition) V. 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 Nutrition & Diet Therapy (7th Edition) Nutrition & Diet Therapy (7th Edition) 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 • 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 • 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 Nutrition & Diet Therapy (7th Edition) Nutrition Therapy for Ostomies • • • 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 Nutrition & Diet Therapy (7th Edition) • • • • Reducing gas & odors A concern for all ostomy patients Avoid foods that are gasproducing Avoid foods that produce odors – – – – – – Fish Eggs Dried beans & peas Onions & garlic Asparagus & Brussels sprouts Beer – – – – Smoking Gum or tobacco chewing Use of drinking straws Eating quickly Avoid practices that increase gas production Nutrition & Diet Therapy (7th Edition) 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 Nutrition & Diet Therapy (7th Edition) 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 • Possible help for medical problems: - May prevent & treat some gastric & intestinal disorders Nutrition & Diet Therapy (7th Edition) – 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 Probiotics • 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 antibioticassociated diarrhea in infants & children – Reduced occurrence of pouchitis (inflammation of surgical pouch created in patients with ileostomy or colostomy) Nutrition & Diet Therapy (7th Edition) Probiotics • 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 Nutrition & Diet Therapy (7th Edition)