1. Note Exam 180 minutes 120 multiple choice questions-120 points -4 short answer question-60 points multiple choice-lecture 7a-12c inclusive short answer-whole Nutrition 2105 course

2. Note CNS Diet technician and dietitian positions anita.binder@compass-canada.com

3. Lecture 9a 10 March 2014 Disorders of the Upper GI tract

4. Mouth Chewing Impaired due to: -sedation and pain Solution -mechanical soft diet, food selection or pureed foods -what is the difference between these three solutions?

5. Mouth Impaired Chewing continued Solution -pureed foods -can be boring -bore factor may be overcome by commercially available thickeners -thickeners allow one to shape foods so that look like the original food but are much easier to chew

6. Mouth Impaired Chewing continued Solution -pureed foods -make more appealing by: variety colour serve foods at right temperature seasonings and spices supplement with nutritious liquids like milk, instant breakfasts, or liquid formulas

7. Mouth ulcers -caused by? Solutions -moist soft textured foods and eliminate spicy, salty and acid foods -example of each of these food types

8. Inflammation of throat and lips -solutions- nutritional approaches-see mouth ulcers Reduced flow of saliva: solutions -moisten foods with sauces and gravies -problem with this? -avoid salty foods and snacks (examples) that dry mouth -give sugarless candy

9. Dysphagia -difficulty swallowing -due to aging, neurological disorders, developmental disabilities and strokes -muscles cannot not push food back to back of throat or push foods down the esophagus into stomach

10. Achalasia -cardiac sphincter does not open up-it fails to relax -food backs up until sphincter opens or there is regurgitation

11. Indications of dysphagia -pain on swallowing, weight loss, feeling food is sticking in mouth -tendency to hold food in mouth rather than swallowing -choking or coughing during meals -frequent throat clearing, drooling or change in voice quality

12. Dysphagia Dietary interventions -mono-texture meals -mildly spiced and moderately sweet foods served at room temperature -avoid sticky foods and foods that break into small pieces when eaten -avoid true liquids – thickened liquids are better (eg milkshakes and puddings) as they slide down more easily

13. Dysphagia Solutions -posture- sit up, feet flat on floor, head tilted slightly forward to avoid choking -tube feedings –intestinal tubes may be better than stomach tubes to avoid aspiration

14. Esophageal reflux-solutions -eat small meals and drink liquids one hour before or after a meal -limit foods that weaken cardiac sphincter (fat,alcohol,caffeine) -lose weight -avoid cigarettes -during reflux avoid acidic foods like citric acid juices, tomatoes, spices, very hot or very cold foods

15. Nausea and vomiting Nausea-solutions -avoid foods and aromas that make one nauseous -do not overeat -drink cold or carbonated liquids upon first sensation of nausea -eat carbohydrate-rich, low fat foods before getting out of bed in morning -if cyclical, one is avoid food at critical times -ginger or peppermint teas provide relief for some people -relax after eating

16. Vomiting-solutions -if vomiting resolves, consume clear fluids to replace water and electrolytes -otherwise use intravenous (iv) feedings

17. Gastritis-solutions Except as tolerated avoid: -alcohol and caffeine -decaffeinated coffee -pepper and spicy foods -fatty and greasy foods -any other offending agent give B 12 as required (injection or prescription nasal spray) as clinically indicated

18. Ulcers-solutions Post-onset -eat slowly, chew well -avoid overeating and any foods than irritate the ulcer e.g. -alcohol and caffeine -chocolate -pepper and spicy foods

20. Class activity Design a diet for the pathology/problem of your choice than meets the dietary principles of adequacy, variety, moderation, nutrient density, energy control, and balance

21. Lecture 9b 10 March 2014 Disorders of the Lower GI tract

22. Constipation-solutions At least 25 grams of fibre Lots of fluids Eating prunes Drinking prune juice

23. Foods containing fibre suitable to assist in the relief of constipation 1 slice whole wheat bread 1 oz of ready to eat cereal (100 % bran cereals contain 10 grams of fibre) 1 cup raw bean sprouts ½ cup cooked broccoli, brussel sprouts, carrots, cauliflower ½ cup chopped raw carrots 1 medium apple, banana, kiwi, orange, pear ½ cup apple sauce, blackberries, blueberries, strawberries fruit juices contain very little fibre

24. Foods containing fibre suitable to assist in the relief of constipation ½ cup baked beans, blackbeans, blackeyed peas, kidney beans, navy beans (about 8 grams of fibre) ½ cooked garbanzo beans, lentils, lima beans, split peas (about 5 grams of fibre)

25. Foods containing fibre suitable to assist in the relief of constipation most whole grain products contain about 1-2 grams of fibre per serving most vegetables contain 2 grams-3 grams of fibre per serving fresh, dried and frozen fruits contain about 2 grams per serving many legumes contain about 8 grams of fibre per serving

26. Relief of constipation via fibre consumption fibre adds volume and weight to the stool which normalises the transit of undigested materials through the intestine and minimises the pressure within the colon

27. Gas Everybody responds differently to different foods Eliminate foods, one by one, to discover offending foods

28. Diarrhoea-solutions -replace lost fluids and electrolytes -consume diluted fruit juices, sports drinks and caffeine free-carbonated beverages for mild cases -use oral rehydration formulas- (salts, sugar and water)-mild to moderate cases -severe cases combined with vomiting require intravenous solutions -if eating aggravates the situation then withhold food and diarrhoea should resolve in a day or two- patient should drink only clear fluids in this case

29. Irritable bowel syndrome Common motility disorder characterised by abdominal pain associated with diarrhoea, constipation i.e. alternating episodes of diarrhoea and constipation or both diarrhoea and constipation occurring at the same time Cause unclear but stress and anxiety have been suggested Solutions-Avoid eating too much, too fast or swallowing without chewing enough

30. Irritable bowel syndrome-solutions continued Keep track of fluid and food intake and stool consistency associated with that fluid and food intake Also keep track of other gastrointestinal tract symptoms at particular times people may benefit from reduced fat and liberal fibre and fluid intake However fibre intake has to be watched-why?

31. Inflammatory bowel diseases Crohn’s disease and ulcerative colitis are two of the most prevalent In children, Crohn’s gives protein energy malnutrition (PEM), vitamin and mineral deficiencies nutritional interventions -food during day and tube feedings at night -or tube feedings day and night in severe cases All Crohn’s patients regardless of age should reduce lactose intake and avoid high fibre foods

32. Inflammatory bowel diseases-solutions For ulcerative colitis no dietary interventions seem to lessen symptoms For all inflammatory bowel syndromes- fluid and electrolytes may have to be replaced by iv

33. Lactose intolerance-covered in first term

34. Malabsorption syndromes Steatorrhea -malabsorption of fat and energy, essential fatty acids, fat soluble vitamins and some minerals -also get binding of calcium to fatty acids -this means that binding of calcium to oxalate in gut is lost-how does this relate to the last lecture?

35. Malabsorption syndromes-solutions -treatment- high kcal and high protein diets are given-why? -enzyme supplements given to aid digestion (pancreatic enzymes given) -medium chain fatty acids are given- easier to digest -frequent small meals- why? -fat soluble vitamins given in water soluble form -restrict oxalate in diet-why?

36. Pancreatitis Acute-solutions -fluids and electrolytes given iv -suctioning of gastric secretions to help relieve pain and distension -oral intake allowed after abdominal discomfort subsides and serum amylase returns to normal levels -oral feeding starts off with liquid progressing to fat restricted diet to normal diet as tolerated

37. Chronic Pancreatitis Absorption of fat can be permanently impaired solution to this?

38. Cystic fibrosis-solutions High kcal diet and high protein diet up to tolerance limits for protein and energy As pancreas is damaged fat absorption is reduced but do not limit fats Enzyme replacements for fat digestion Multivitamin and fat soluble vitamins supplements are routinely given

39. Cystic fibrosis –solutions continued Liberal use of table salt to make up for losses in sweating Oral diets in day and tube feedings at night for some people Breast milk, standard infant formulas and hydrolysed infant formulas work for infants provided that enzyme supplements are given

40. Bacterial overgrowth in stomach Signs include chronic diarrhea, gas, malnutrition and weakness Fat restricted diets to bring down bacterial growth Oral mineral and vitamin supplements except B 12 which cannot be absorbed as the result of this overgrowth (injections of B 12 or prescription B 12 nasal sprays required)

41. Coeliac disease Avoid gluten (wheat, rye and barley are out-even trace amounts) Lactose intolerance may be permanent

42. Intestinal surgeries-solutions IV fluids to restore fluid and electrolyte imbalances after surgery then tube feedings and finally regular oral meals (low fibre, soft diets to prevent irritation and obstruction) -low fibre, soft diets means avoiding dried fruits, raw apples and corn, stringy foods (celery, spinach for example), seeds, mushroom and nuts

43. Intestinal surgeries-nutritional interventions B 12 supplementation (injection or nasal spray) if necessary If diarrhea then give foods that thicken stool -apple sauce, bananas, cheese, creamy peanut butter and starchy foods such as white bread and potatoes -avoid apple, grape and prune juice, highly seasoned foods, foods that cause gas and avoid alcohol and caffeine

44. Diverticulitis-solutions Prevent by avoiding low fibre diets and constipation -strain of pushing hard stools creates pockets in intestine Liquid diets until symptoms subside

45. Class activity Design a diet for the pathology/problem of your choice than meets the dietary principles of adequacy, variety, moderation, nutrient density, energy control, and balance