Download NUTRITIONAL CONSIDERATIONS FOR THE GASTROINTESTINAL PATIENT CONSIDÉRATIONS DIÉTÉTIQUES POUR DES PATIENTS

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NUTRITIONAL CONSIDERATIONS
FOR THE GASTROINTESTINAL PATIENT
CONSIDÉRATIONS DIÉTÉTIQUES POUR DES PATIENTS
ATTEINTS D’AFFECTIONS GASTROINTESTINALES
By Denise A. ELLIOTT(1)
SUMMARY
Nutrition is a fundamental component in the management of gastrointestinal disease. However, the
diverse nature of gastrointestinal disease clearly indicates that different nutritional strategies need to
be applied according to the pathophysiology of the underlying disease process. It is beneficial to approach
the nutritional management of gastrointestinal disease by considering four approaches – diseases that
respond to novel or hydrolyzed protein, diseases that respond to low dietary fat, diseases that
respond to high energy, and diseases that respond to fiber. This review will address each of these key
areas. In addition, emerging nutrients of interest to the management of gastrointestinal disease such
as probiotics, long-chain omega-3 fatty acids and prebiotic fibers will be discussed.
Key words: nutrition, inflammatory bowel disease, fructooligosaccharides, hydrolyzed protein, gastrointestinal
disease, fiber, protein, prebiotics, probiotics, glutamine, arginine.
RÉSUMÉ
La diététique est un aspect fondamental de la gestion des patients atteints d’affections gastrointestinales. Différentes stratégies nutritionnelles sont à utiliser selon la physiopathologie des processus pathologiques sous-jacents et la revue porte sur les quatre approches à prendre en considération :
les maladies réagissant à de nouvelles protéines ou à des protéines hydrolysées ; celles réagissant à
un régime à faible taux de matières grasses ; celles traitées par un régime riche en énergie et celles
répondant à un régime riche en fibres. Un point sera en outre fait sur les nutriments émergents tels
que les probiotiques, les acides gras oméga-3 à longue chaîne et les fibres prébiotiques.
Mots-clés : diététique, affections intestinales inflammatoires, fructooligosaccharides, protéine hydrolysée,
maladies digestives, fibre, protéine, probiotiques, prébiotiques, glutamine, arginine.
(1) BVSc PhD Dipl ACVIM Dipl ACVN, Royal Canin USA, Inc.
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INTRODUCTION
Dietary therapy is an important aspect of the management of
gastrointestinal (GI) disease in dogs and cats. Therapeutic
recommendations have classically focused on dietary rest followed by implementation of a highly digestible or “bland” diet.
However, as our understanding of the pathophysiology of gastrointestinal disease unfolds, it is clear that that no single diet
is likely to be effective for every patient. As a result, there is now
strong interest in nutrients such as protein source, fat concentration, prebiotics, probiotics, omega three fatty acids, short
chain fatty acids, glutamine, arginine, nucleotides, zeolite,
and other nutraceuticals to optimize gastrointestinal tract
(GIT) function. The purpose of this review is to review the function and application of these emerging nutrients for the management of patients with gastrointestinal disease. The overall
objectives of dietary modification are to enhance digestion and
absorption of nutrients, overcome potential nutrient deficiencies associated with mucosal damage, support the mucosal
barrier function, promote normal GIT motility and function,
decrease inflammation, and aid healing.
DIETARY REST
Traditionally, patients with vomiting and/or diarrhea have been
managed with dietary rest followed with small amounts of
highly digestible “bland” diets. However, recent evidence suggests that the presence of food in the GIT provides trophic signals
in addition to direct nutrition to the enterocytes. The trophic
signals increase mesenteric blood flow, stimulate the release of
digestive enzymes and enterohormones which influence intestinal cell proliferation, differentiation, and the rate of mucosal
cell turnover. Studies in piglets have suggested that small bowel
atrophy begins within days of nil per os (Remillard et al, 1998a,
b). The signs of atrophy that have been noted include decreased villus height, decreased absorption and a reduction in brush
border enzymes. These changes ultimately compromise the
intestinal barrier. Enteral feeding has been shown to be a powerful mechanism to prevent gastrointestinal atrophy in piglets.
A recent randomized controlled clinical trial investigated the
effect of enteral nutrition on intestinal permeability, intestinal
protein loss and outcome in dogs with parvo-viral enteritis, compared to nil per os (Mohr et al, 2003). Enteral nutrition was associated with a shorter time to recovery, increased body weight
gain, and improved gut barrier function. This study suggests that
feeding, rather than dietary rest should be considered for some
patients with gastrointestinal disease.
DIET DIGESTIBILITY
Highly digestible diets typically have digestibility values that
exceed 90%. A highly digestible diet requires less gastric, pancreatic, biliary and intestinal secretions for digestion. This results
in almost complete digestion and absorption in the upper
small intestine so that minimal residue is presented to the lower
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bowel. Minimal residue reduces bacterial byproducts that may
contribute to inflammation and osmotic diarrhea. In addition,
less residue is available to trigger an abnormal immune response.
A variety of commercial highly digestible low residue diets are
available. These diets will differ in the protein and carbohydrate
sources, fat levels and other gastrointestinal nutrients. There
have not been any studies published to date to compare the
effect of one diet over another. Nevertheless, these diets enjoy
widespread anecdotal evidence of success for the management
of a variety of gastrointestinal diseases.
PROTEIN AND AMINO ACIDS
Dietary sensitivity, an adverse reaction to food, is a term used to
describe a clinically abnormal response to the ingestion of a particular food. Food allergy or hypersensitivity is an immunological response to the food. Most basic food ingredients, including
proteins, lipoproteins, glycoproteins, and lipopolysaccharides,
have the potential to induce an allergic response. The predominant allergenic glycoproteins are water-soluble, largely heat
resistant, acid stable, and commonly in the range of 10 to 60 kDa.
The reason an immunological response against a specific protein
(or food allergen) is mounted in certain individuals is not fully
understood. Genetics, age, poor digestibility of proteins, a defective mucosal barrier, defective oral tolerance, and increased mucosal permeability are all predisposing factors for food allergy.
The true prevalence of food sensitivity is not fully known.
Elimination diets and subsequent re-challenge with the original diet are the only way to confirm a diagnosis of food allergy
in pets. The aim is to feed a complete and balanced diet while
strictly feeding a protein and carbohydrate source to which the
pet has never been previously exposed. Therefore, a detailed diet
history is necessary to identify foods not previously fed to the
pet. This information is used to create an elimination diet that
is hypoallergenic for that particular pet. Gluten sensitivity is a
specific example of food hypersensitivity that has been documented in Irish Setters. Treatment requires a gluten (gliadin)
free diet, therefore carbohydrates such as wheat, oats, barley, rye
or buckwheat should be avoided. Gluten free carbohydrate
sources include corn, potato, rice and soy flour.
Guilford et al. (2001) evaluated 55 cats with chronic idiopathic gastrointestinal disease. Twenty-nine percent of the cats
were diagnosed with food hypersensitivity on the basis of dietary elimination-challenge studies using commercial selected
protein diets as the elimination diet. Clinical signs of an additional 20% of cats resolved on the elimination diet, but did not
recur after challenge with the previous diet. Fifty percent of cats
were sensitive to more than one food ingredient.
The debate continues on what is the ideal approach for an elimination diet, i.e. a homemade diet versus a commercial product, an intact protein diet versus a hydrolyzed protein diet. It
is clear that it is in the best interests of the owner and the pet
to feed a complete and balanced diet. This is often difficult to
achieve with homemade diets, particularly when owners begin
to drift from the formula originally provided for the pet.
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Proteins that are incompletely digested have more potential to
incite an immune response to the residual antigenic proteins and
large polypeptides. Conversely, highly digestible proteins are
completely digested to free amino acids and small peptides, which
have less potential to elicit an allergic response. Therefore highly
digestible protein should be selected for the elimination diet.
The antigenicity of dietary proteins can be minimized by enzymatic hydrolysis to produce low molecular weight protein
hydrolysates. Decreasing the size of the proteins that are ingested reduces the chances of immunoglobulin cross-linking and
subsequent mast cell degranulation. Hypoallergenic diets have
been recommended for both the diagnosis and management of
food hypersensitivity in dogs and cats.
Monomeric or elemental diets have been recommended for
human patients with severe gastrointestinal disease. Marks et
al. (1997) evaluated the effects of a purified diet on intestinal
structure and function in cats with methotrexate-induced
enteritis. The purified diet was associated with marked villus
blunting and increased bacterial translocation compared with
a diet containing intact protein. The results of this study suggest that a purified diet containing free amino acids cannot be
recommended for cats with methotrexate induced enteritis. In
addition, there are no commercially available monomeric
diets for pets. Therefore, a human formula would need to be
selected, but these are typically not complete or balanced for
dogs or cats. In this situation, the diet would need to be modified to ensure that factors such as protein requirement, taurine
and arachidonic acid requirements are met.
Novel protein, hydrolyzed protein, and monomeric diets have
been recommended by various authors for pets with inflammatory bowel disease, even though the role of dietary sensitivity in inflammatory bowel disease has not been elucidated.
Given that the chosen diet is complete and balanced for the
pet, there appears to be minimal risk associated with this decision. However, Guilford et al. (2001) has suggested that the initial protein selected for the IBD patient may indeed be a
“sacrificial protein” as the IBD patient is at risk of developing
sensitivity to the undigested food proteins entering the lamina
propria from increased mucosal permeability. A second novel
protein diet may be required after 4 weeks of therapy. Marks et
al.(2002) evaluated the effect of a hydrolyzed protein diet in
six dogs with inflammatory bowel disease. Dietary therapy
alone improved clinical signs in four dogs, concurrent medical
therapy was required in two dogs. Histopathological improvements were also noted in duodenal biopsies after therapy.
Long considered a non-essential amino acid, it has been suggested that glutamine is particularly beneficial for intestinal
health. Glutamine preserves the intestinal barrier function,
increases brush border enzyme activity, promotes protein synthesis and aids recovery from intestinal injury. Glutamine is the
preferred fuel source for enterocytes. It is also used as a substrate
for denovo synthesis of purine and pyrimidine nucleotides for
DNA and RNA synthesis. GIT epithelial have very a high turnover rate, therefore glutamine now appears to be a conditio-
nally essential nutrient for optimal GIT function in starvation
and stress. Glutamine supplementation has been reported to
improve nitrogen balance, decrease mucosal atrophy, decrease
bacterial translocation, and stimulate the immune system in
humans and laboratory species.
A few clinical studies have supported the use of novel, highly
digestible protein sources for the management of gastrointestinal disease in dogs and cats. Nelson et al.(1988) reported that
clinical signs resolved in 13 dogs with lymphocytic, plasmocytic
idiopathic chronic colitis when they were fed a cottage cheese
and rice diet. In 11 dogs, two commercial diets not previously
fed to these dogs were successfully substituted for the initial test
diet, without causing recurrence of signs. Only two of these 11
dogs subsequently tolerated a switch to diets that had been fed
at the time of onset of signs of colitis. Resolution of clinical signs
has also been reported in 6 cats with lymphocytic-plasmocytic
colitis fed a diet of lamb and rice or horsemeat, or a prescription diet. Likewise, Paterson (1995) reported that 20 dogs that
exhibited both a non-seasonal puritus and gastrointestinal
signs had either improvement or complete resolution when fed
either a homemade fish and potato or commercial fish and soy
based diet. Nineteen of the dogs were subsequently maintained
successfully on the commercial food. Simpson et al. (1994a) evaluated the effect of a selected protein chicken and rice diet for
the management of idiopathic chronic colitis. Within one
month, clinical signs of straining, fecal blood, fecal mucus and
fecal consistency were significantly improved. Within two
months of dietary therapy, 90% of 11 dogs were stabilized and
did not require drug therapy to control clinical signs of disease.
FAT
Of the energy-providing nutrients, fat is the most difficult to
digest. It requires an interplay between the intestine, liver and
pancreas. A deficiency of pancreatic enzymes (as occurs with exocrine pancreatic insufficiency and pancreatitis) impairs digestion
and results in malabsorption of dietary nutrients. Although the
digestion of protein and carbohydrate will be affected, the
digestion of fat is most severely impaired since lipases are absent
from the normal array of intestinal brush border enzymes.
Bacteria in the intestinal tract can metabolize undigested fat to
hydroxy-fatty acids, which can lead to secretory diarrhea in the
large intestine. Bacteria also deconjugate bile acids, further impairing fat digestion and absorption. For this reason, fat restriction
is beneficial in conditions where fat may become available for
microbial metabolism, for example in malabsorption syndrome,
small intestinal bacterial overgrowth, bile acid deficiency, and/or
gastroenteritis. Unlike amino acids and monosaccharides, which
are absorbed directly into the blood stream, fat is discharged from
enterocytes into lacteals and transported to the systemic circulation via mesenteric lymph vessels and the thoracic duct.
Lymphangiectasia, a disorder characterized by congestion and/or
dilatation of lymphatic vessels, will impair fat transport.
Restriction of dietary fat is clearly indicated for the management
of several gastrointestinal disorders. However, what constitutes
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a restricted fat diet varies considerably among manufacturers.
Nutritionists consider a restricted fat diet to be one that contains
less than 18% of the energy from fat. Using this recommendation, it is clear that many diets formulated for the management
of gastrointestinal disease are not actually low fat diets.
Simpson et al. (1994b) evaluated the effect of a low fat diet in
the management of 20 dogs with exocrine pancreatitic insufficiency. Clinical signs resolved in all 20 dogs, and there was an
average 24% increase in body weight.
Polyunsaturated fatty acids are essential for the maintenance
of membrane integrity as constituents of membrane phospholipids and the provision of substrates for eicosanoid synthesis;
e.g. prostaglandins (PG), thromboxanes, and leukotrienes
(LT). Long chain ω-3 fatty acids such as eicosapentaenoic acid
and docosahexaenoic acid, directly compete with arachidonic
acid for the lipoxygenase and cycloxygenase enzymes.
Subsequent metabolism of eicosapentaenoic acid generates less
inflammatory mediators such as LTB5, and PGE3 compared to
the metabolism of arachidonic acid. In addition, the metabolism of eicosapentaenoic acid produces hydroxy-fatty acids that
block the production of LTB4, a potent chemotatic factor, from
arachidonic acid. Therefore, in general, ω-3 fatty acids are antiinflammatory compared with the derivatives of ω-6 fatty acids.
Fish oils have been suggested to improve the clinical status of
human patients with ulcerative colitis and Crohn’s disease.
Indeed, many diets formulated for the management of gastrointestinal disease in pets have been enhanced with ω-3 fatty
acids. However, there have not been any published studies to
evaluate the effect of ω-3 fatty acid supplementation on gastrointestinal disease in dogs and cats. The ideal dose of the long
chain fatty acids is not yet known and there is certainly no evidence to support an ideal ratio of ω-6 to ω-3.
Medium chain triglyerides (MCT’s) which contain 8-12 carbons, have been recommended for some gastrointestinal
diseases. It has been suggested that are less dependent on
micelle formation and the lymphatic vasculature for digestion
and absorption. It has been suggested that MCT’s reduce the
palatability of the diet. In addition, MCT’s have been associated
with the development of hepatic lipidosis in cats.
CARBOHYDRATES
Mucosal atrophy typically leads to a decreased availability of
disacchardases and carbohydrate malabsorption. Bacterial
overgrowth and decreased transport of monsaccharides by
malfunctioning enterocytes can also contribute to carbohydrate
malabsorption. Regardless of the mechanism, malabsorption of
carbohydrates contributes to osmotic diarrhea. Therefore, diets
formulated for pets with gastrointestinal disease should use reduced quantities of highly digestible carbohydrate. Rice has long
been considered the ideal carbohydrate of gastrointestinal
disease. White rice is highly digestible, gluten free, and has rarely
been implicated in food hypersensitivity.
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DIETARY FIBER
Fiber, which is the non-digestible carbohydrate of plants, can
be classified according to solubility or fermentability. Soluble
fibers form a gel in water which delays gastric emptying and inhibits absorption in the small intestine. Insoluble fibers such as cellulose and oat fiber increase fecal bulk and fecal water content,
absorb toxins and normalize both segmental and propulsive motility. Both insoluble and soluble dietary fiber may be beneficial
in the symptomatic treatment of certain large bowel diarrheas
since fiber helps to normalize transit time and increase fecal water
content. As they normalize intestinal transit time, insoluble fibers
are often recommended for patients with constipation.
Fermentable fibers such as beet pulp, pectin, guar gum, gum arabic, and fructo-oligosaccharides may have a positive effective
on the mucosal barrier by stimulating the growth of intestinal
bacteria such as lactobacilii and bifidobacter. These bacterial species have been shown to be beneficial to gastrointestinal health
by decreasing the growth of pathogens such as Clostridia and
E.coli. In addition, they produce the short chain fatty acids butyrate, acetate and propionate, which provide fuel for the colonocytes. Short chain fatty acids enhance sodium and water
absorption, increase mucosal blood flow and increase gastrointestinal hormone release. These mechanisms contribute to the
trophic role that short chain fatty acids have on the intestinal
mucosa, stimulating enterocyte and colonocyte proliferation.
High amounts of fermentable fiber may lead to excessive gas production (flatulence) and, by increasing fecal water, may lead to
unacceptably loose stools. Thus, when selecting a high fiber diet,
it is important to know the quantity and type of fiber present,
as the response seen in an individual animal will vary depending on the diet used. Leib et al. (2000) reviewed the medical
records of 37 dogs diagnosed with chronic idiopathic large-bowel
diarrhea. Twenty-three of 27 dogs were classified as having a very
good to excellent response to a soluble fiber (Metamucil) supplementation. Diarrhea returned in 6 of 11 dogs when fiber supplementation was withdrawn.
PREBIOTICS/PROBIOTICS
The gastrointestinal tract provides a home to a diverse population of bacteria. Recent research is focusing on methods to
manipulate the gastrointestinal bacterial population to improve
health (Sparkes et al., 1998a, 1998b, Zentek et al., 2002).
Prebiotics are dietary substances, such as fructooligosaccharides
(FOS), mannanoligosaccharides (MOS), inulin, resistant
starch, or arabinogalactans (AG) that promote the health of
beneficial bacteria in the gut and deter the growth of pathogenic
bacteria, such as E. coli, Salmonella and Campylobacter. Human
studies support a beneficial effect of added FOS or MOS in diets
for prevention or control of infectious diarrhea. Willard et al.
(1994) evaluated the effect of 1% fructooligosaccharides in 16
IgA-deficient German Shepherd dogs with small intestinal bacterial overgrowth. FOS supplementation resulted in significantly
lower aerobic/facultative anaerobic bacterial colony-forming
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units in the small intestine. The results of this study indicated
that FOS could affect the population of bacteria in the small
intestine in dogs with small intestinal bacterial overgrowth.
Swanson et al. (2002a and b) reported that supplemental fructooligosaccharides (FOS) and (or) mannanoligosaccharides
(MOS) have beneficial effects on colonic health and immune
status of dogs.
Probiotics are live microbial feed supplements that are administered to improve the microbiological balance in the intestine. To be effective, a probiotic must survive the acidic environment of the upper gastrointestinal tract, and must be
capable of proliferating and colonizing the large intestine. In
humans, there is increasing evidence that intestinal bacteria are
important in the pathogenesis of IBD. Studies in mice indicate
that probiotics can inhibit inflammation and prevent the
development of colonic adenocarcinoma.
The ability of a probiotic strain to survive transit through the feline
(Marshall-Jones et al., 2004) and canine (Baillon et al., 2006) gastrointestinal tracts has been reported. In addition, several markers of intestinal health and systemic health were evaluated.
Potential health promoting effects of the probiotic noted included increased phagocytic capability of neutrophils, a substantial
reduction in serum endotoxin levels, and a lowering of erythrocyte fragility indices. Furthermore there was a significant decrease
in the number of Clostridia reflecting a change in the colonic microflora towards a healthier balance. These changes are indicative
of beneficial changes in immune function and gastrointestinal barrier integrity, suggesting the possibility that probiotics could play
an important role in protecting from disease. Indeed, probiotics
have been demonstrated to significantly decrease the shedding of
Campylobacter bacteria from infected cats (Baillon et al., 2003),
and probiotic supplementation was associated with a lower rate
of reinfection, suggesting that it could strengthen the resistance
of healthy cats to infection with Campylobacter species.
ANTIOXIDANTS
In humans, supplementation with antioxidants, especially
vitamin E, has been utilized in the management, and perhaps
prevention, of various gastrointestinal diseases. Antioxidants
such as vitamin E, vitamin C, caratoids and taurine appear to
be safe in pets, but the clinical use of these antioxidants in gastrointestinal disease has not been evaluated.
COBALAMIN
Recent studies have clearly shown that cats and dogs with severe
or chronic GI disease may become deficient in cobalamin
(Simpson et al. 2001). The deficiency is documented by serum
analysis of cobalamin levels, usually along with measurement of
serum folate. This deficiency must be corrected with parenteral supplementation as the vitamin is important in a number of
cellular processes, including GI epithelial cell turnover and repair.
ZEOLITE
Zeolite, or sodium silico aluminate, a tetrahedral clay, is capable
of absorbing bacterial toxins, bile acids, and gases. By forming
a protective film on the intestinal mucosa, zeolite helps to
enhance the intestinal mucosal barrier. Zeolite has been used
in piglets and calves in the management of weaning diarrheas.
Grandjean & Crépin (1992) reported that the addition of
clays to food decreased the duration and the severity of diarrhea
in sled dogs. Clays have also been shown by Fioramonti & DrozLefaiz (1987) to reduce diarrhea induced by cholera toxin in dogs.
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