1. Copyright © 2003 Delmar Learning, a Thomson Learning company Section 3 Medical Nutrition Therapy

2. Copyright © 2003 Delmar Learning, a Thomson Learning company Chapter 20 Diet and Gastrointestinal Problems

3. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company3 Objectives  Explain the uses of diet therapy in the gastrointestinal disturbances discussed here  Identify the foods allowed and disallowed in the therapeutic diets discussed  Adapt normal diets to meet the requirements of clients with these conditions

4. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company4 GI Tract Digestion and absorption of food occurs in the gastrointestinal tract. Primary organs include mouth, esophagus, stomach, small and large intestine. Liver, gallbladder, and pancreas are accessory organs.

5. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company5 Dyspepsia Indigestion, discomfort in the digestive tract, can be physical or psychological in origin. “Heartburn”, bloating, pain, regurgitation. Psychological stress treatment includes: Finding relief from underlying stress Allowing sufficient time to relax and enjoy meals learning to improve eating habits

6. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company6 Esophagitis Irritating effect of acidic gastric reflux on mucosa of esophagus. Heartburn, regurgitation, and dysphagia. Chronic, or reflux esophagitis is caused by recurrent gastroesophageal reflux (GER) Causes include hiatal hernia, reduced lower esophogeal sphincter pressure, abdominal pressure, or recurrent vomiting.

7. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company7 Hiatal Hernia A part of the stomach protrudes through the diaphragm into the thoracic cavity. The hernia prevents the food from moving normally along the digestive tract. Food moves back into the esophagus, creating a burning sensation (heartburn), and sometimes food will be regurgitated into the mouth.

8. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company8 Hiatal Hernia

9. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company9 Nutrition Therapy for Hiatal Hernia Small, frequent meals; well-balanced diet. Avoid irritants such as carbonated beverages, citrus fruits and juices, tomato products, spicy foods, coffee, pepper, and some herbs. Avoid foods that relax sphincter such as alcohol, garlic, onion, oil or peppermint and spearmint, chocolate, cream sauces, gravies, margarine, butter, and oil.

10. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company10 Nutrition Therapy for Hiatal Hernia If client is obese, weight loss may be recommended. Avoid lying down 2 to 3 hours after eating. When lying down, sleep with head and upper torso elevated. Surgery may become necessary.

11. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company11 Peptic Ulcers Erosion of the mucous membrane. May occur in the stomach (gastric ulcer) or the duodenum (duodenal ulcer); cause unclear. Factors that predispose: genetics, high secretion of hydrochloric acid, stress, excessive use of aspirin or ibuprofen, smoking, Helicobacter Pylori bacteria.

12. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company12 Peptic Ulcers Symptoms include gastric pain (burning relieved with food or antacids), hemorrhage (usually requires surgery). Treatment: drugs such as antibiotics and cimetidine to kill bacteria and inhibit acid secretion respectively. Antacids neutralize excess acid. Rest and counseling.

13. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company13 Peptic Ulcers Sufficient low-fat protein should be provided. No less than 0.8g of protein per kilogram of body weight recommended. Avoid caffeine containing beverages, alcohol, aspirin, smoking. Well-balanced diet of three meals a day.

14. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company14 Ulcers

15. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company15 Diverticulosis/Diverticulitis Diverticulosis is an intestinal disorder characterized by little pockets in sides of the large intestine where food gets trapped. Diverticulitis can result from bacteria breeding in these pockets. Cause is diet lacking sufficient fiber. Diet treatment includes clear liquid diet, then low-residue progressing to high fiber over several weeks.

16. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company16 Diverticulosis

17. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company17 Residue-controlled Diets Residue is the solid part of feces. Residue is made up of all the undigested and unabsorbed parts of food (including fiber), connective tissue in animal foods, dead cells, and intestinal bacteria and their products. Most of this residue is composed of fiber. Diets can be adjusted to increase or decrease fiber and residue.

18. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company18 The High-fiber Diet 30g or more of dietary fiber is believed to help prevent diverticulosis, constipation, hemorrhoids, and colon cancer. A high-fiber diet is often 25 to 35g. Coarse and whole grain breads and cereals, bran, all fruits, vegetables (especially raw), and legumes.

19. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company19 Low-residue Diet 5 to 10g of fiber a day is intended to reduce the normal work of the intestines by restricting the amount of dietary fiber and reducing food residue. Low-fiber or residue-restricted diets may be used in cases of severe diarrhea, diverticulitis, ulcerative colitis, and intestinal blockage and in preparation for and immediately after intestinal surgery.

20. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company20 A client with severe diarrhea has been placed on a low-residue diet. What kinds of foods would you recommend for the client?

21. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company21 Milk, buttermilk (limit to 2 cups/day) Cottage cheese and some mild cheeses Butter and margarine Eggs, except fried Tender chicken, fish, sweetbreads, ground beef, and ground lamb Soup broth

22. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company22 Cooked, mild-flavored vegetables without coarse fibers Refined breads and cereals, white crackers, macaroni, spaghetti, and noodles. Custard, sherbet, vanilla ice cream. Coffee, tea, cocoa, carbonated beverage. Salt, sugar, small amount of spices as permitted.

23. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company23 Inflammatory Bowel Disease Inflammatory bowel disease (IBD) is a chronic condition causing inflammation in the GI tract. Two examples include ulcerative colitis and Crohn’s disease.

24. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company24 Ulcerative Colitis Causes inflammation and ulceration of the colon, the rectum or, sometimes, the entire large intestine.

25. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company25 Crohn’s Disease Chronic progressive disorder that can affect both the small and large intestines.

26. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company26 Symptoms of Inflammatory Bowel Disease Bloody diarrhea Cramps Fatigue Nausea Anorexia Malnutrition Weight loss

27. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company27 Treatment of Inflammatory Bowel Disease Anti-inflammatory drugs Medical nutrition therapy Low-residue diet 100g of protein, additional kcal, vitamins, and minerals Severe cases may require total parenteral nutrition (TPN)

28. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company28 Ileostomy or Colostomy Clients with inflammatory bowel disease may require a surgical opening, a stoma, from the body surface to the intestine for the purpose of defecation. Ileostomy: from ileum to abdomen surface. Colostomy: from colon to abdomen surface. May be temporary or permanent.

29. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company29 Ileostomy or Colostomy Clients with ileostomies have a greater than normal need for salt and water because of excess losses. A vitamin C supplement is recommended, and, in some cases, a B 12 supplement may be needed.

30. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company30 Celiac Disease Nontopical sprue or gluten sensitivity Characterized by malabsorption of virtually all nutrients. Thought to be hereditary. Symptoms include diarrhea, weight loss, and malnutrition. Stools are foul-smelling, light-colored, and bulky. Cause unknown.

31. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company31 Celiac Disease Elimination of gluten from diet gives relief. A gluten-controlled diet is used to treat celiac disease. Gluten is a protein found in barley, oats, rye, and wheat. Difficult to avoid these products. Rice and corn may be used. Read labels.

32. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company32 Cirrhosis Liver disease may be acute or chronic. Cirrhosis is a general term referring to all types of liver disease characterized by cell loss. Alcohol abuse is the most common cause of cirrhosis. Other causes include congenital defects, infections, or other toxic chemicals.

33. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company33 Cirrhosis Liver does regenerate, however, the replacement during cirrhosis does not match the loss. Complications include hypertension, anemia, hemorrhage in the esophagus.

34. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company34 Cirrhosis Dietary treatment of cirrhosis provides at least 25 to 35 kcal or more, and 0.8 to 1.0g of protein per kilogram of weight each day. Supplements of vitamins and minerals are usually needed. In advanced cirrhosis, 50 to 60% of the kcal should be from carbohydrates.

35. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company35 Cirrhosis Sometimes cirrhosis causes ascites. Sodium and fluids may be restricted. If there is bleeding in the esophagus, fiber can be restricted to prevent irritation of the tissue. Smaller feedings will be better accepted than larger ones. No alcohol is allowed.

36. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company36 Hepatitis Inflammation of the liver. Caused by viruses or toxic agents such as drugs and alcohol. Hepatitis A virus (HAV) contracted through contaminated drinking water, food, and sewage via a fecal-oral route.

37. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company37 Hepatitis Hepatitis B virus (HBV) and hepatitis C virus (HCV) are transmitted through blood, blood products, semen, and saliva. Hepatitis B and C can lead to chronic active hepatitis (CAH), which is diagnosed by liver biopsy. Chronic active hepatitis can lead to liver failure and end stage liver disease (ESLD).

38. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company38 Hepatitis Symptoms may include nausea, headache, fever, fatigue, tender and enlarged liver, anorexia, and jaundice (yellow cast of the skin and eyes). Weight loss can be pronounced. Treatment involves bed rest, plenty of fluids, diet therapy.

39. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company39 Diet Therapy for Hepatitis Diet should provide 35 to 40 kcal per kilogram of body weight. Most kcal should be provided by carbohydrates; moderate amounts of fat; and if the necrosis has not been severe, up to 70 to 80grams of protein for cell regeneration.

40. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company40 Diet Therapy for Hepatitis If the necrosis has been severe and the proteins cannot be properly metabolized, they must be limited to prevent the accumulation of ammonia in the blood. Clients may prefer frequent, small meals rather than three large ones.

41. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company41 Cholecystitis and Cholelithiasis Being female, obesity, total parenteral nutrition (TPN), very-low-calorie diets for rapid weight loss, the use of estrogen, and various diseases of the small intestine are frequently associated. Cholecystitis: Inflammation of gallbladder Cholelithiasis: Gallstones

42. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company42 Cholecystitis and Cholelithiasis Inhibit the flow of bile and cause pain. Symptoms include pain, which can be severe, indigestion, and vomiting (particularly after the ingestion of fatty foods). Treatment may include medication to dissolve the stones and diet therapy. Surgery may be indicated.

43. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company43 Cholecystitis and Cholelithiasis Diet therapy includes abstinence during acute phase. Followed by clear liquid diet and, gradually, a regular but fat-restricted diet. Fats allowed range from 40 to 45 grams a day.

44. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company44 Pancreatitis Inflammation of the pancreas. May be caused by infections, surgery, alcoholism, biliary tract (includes bile ducts and gallbladder) disease, or certain drugs. May be acute or chronic.

45. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company45 Pancreatitis Symptoms include abdominal pain, nausea and steatorrhea (abnormal amounts of fat in the feces). Malabsorption (particularly of fat-soluble vitamins) and weight loss. If islets of Langerhans are destroyed, diabetes mellitus may result.

46. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company46 Pancreatitis During acute pancreatitis, the client is nourished strictly parenterally. Later, when the client can tolerate oral feedings, a liquid diet consisting mainly of carbohydrates is given because, of these 3 nutrients, carbohydrates have the least stimulatory effect on pancreatic secretions.

47. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company47 Pancreatitis As recovery progresses, small, frequent feedings of carbohydrates and protein with little fat or fiber are given. Vitamin supplements may be given. Alcohol is forbidden in all cases.

48. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company48 Conclusion A wide variety of therapeutic diets are used for clients with GI disturbances. Peptic ulcers: drugs, avoidance of alcohol and caffeine. Diverticulosis: high-fiber diet. Diverticulitis: gradual progression from clear liquid to high-fiber diet.

49. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company49 Conclusion Ulcerative colitis: low-residue diet combined with high protein and high kcal. Cirrhosis: substantial, balanced diet, with occasional restrictions of fat, protein, salt, or fluids. Hepatitis: full, well-balanced diet, although protein may be restricted.

50. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company50 Conclusion Cholescystitis and cholelithiasis: fat- restricted diet and, in cases of overweight, a kcal-restricted diet as well. Pancreatitis: TPN to individualized diet as tolerated.