Diets for GI diseases Family Practice Resident Education Series Mary Steffensmeier, MA,RD March, 2014

Objectives l Increase understanding of diet guidelines used to treat gastric or intestinal conditions l Identify diagnoses and diets that should be referred to a Registered Dietitian l Increase awareness of teaching tools that are available l Increase skills ordering diets

Reflux, GERD, Heartburn l Avoid large meals l avoid food 2 hours before lying down l avoid foods that relax lower esophageal sphincter l alcohol l mints, garlic, onion l chocolate l high fat food

GERD continued... l Avoid foods that can irritate damaged esophageal mucosa l carbonated beverages l citrus fruit and juices l coffee l tomato l pepper, chili powder

GERD continued l Avoid obesity, smoking tight clothing, and belts l elevate head of the bed l avoid temperature extremes in food

Reflux Diet for Inpatients l GERD DIET, 6 small meals or snacks l add any specific restrictions to order such as no caffeine, or carbonated beverages l add elevate head of bed to orders l *CONSULT DIETITIAN TO SEE AND MAKE RECOMMENDATIONS.

Low Fiber l Usually used for diverticulitis, partial bowel obstruction, ulcerative colitis, radiation enteritis l Restricts foods that have more than.5 grams fiber per serving or about 3 grams per meal l most raw fruits and vegetables l bran and whole grain breads, cereals l dried beans and peas

Low fiber continued…. l Limits high residue producing foods: l only 2 cups milk per day, l limits course meats, peanut butter, nuts, seeds l Smaller more frequent meals l Avoid prune juice

High Fiber Diet l Used to treat constipation, diverticulosis l 10 to 13 g. fiber per 1,000 calories l raw fruits, vegetables= 1 to 3 g. per serving l whole grain products 2 to 13 g. per serving l dried beans 2 to 5 g. per serving l Gradually increase fiber l Adequate fluids, 8 glasses water/day

High Fiber l Limit foods have little or no fiber include cheese, ice cream, meat, juices, and processed foods l Increase servings of high fiber foods: beans, bran, vegetables

Divertics l Diverticulitis-occurs in 10 to 25% of people with diverticulosis l Diverticulosis- occurs 50% of people 60 to 80, and almost everyone over 80 l Conditions started to appear in early 1900s, same time processed foods with less fiber were produced

Divertics/Inpatient Diet Orders l Diverticulosis: High Fiber, avoid nuts, seeds, hulls remains controversial l Constipation: high fiber diet l Diverticulitis: low fiber

Fiber Facts l Insoluble fibers: l Types; cellulose, hemicellulose, lignins, l Foods: Wheat bran, wheat products, bran rice, vegetables l Function: Increase fecal bulk, increase transit time

More Fiber Types l Soluble Fibers l Types: Pectins, gums, mucilages l Foods; oats, beans, carrots, fruits, barley l Function: delay gastric emptying, slow glucose absorption, lower cholesterol

Factors that Influence Stomach Emptying l Volume – greater volume, slower emptying l Chemical and physical property of meal l Positioning – emptying delayed due to antigravity and duodenal compression by spine l Medications – review med list with patients l Time of Day – satiety increases later in day

Gastric Emptying (continued) l Fiber – slows emptying, contributes to bezoar formations, limit to 10g./day when gastroparesis is present l Fat – especially solid forms l Alcohol – slows emptying l Nicotine – slows emptying l Carbonated Beverages* – may aggravate distention *permitted on most diet sheets

Gastric Emptying (continued) l Osmolality – may delay in test subjects but assumed to be clinically insignificant since clear liquid diet has an osmolarity of >1200 mOsm l Blood Glucose Levels – glucose >200 shown to delay emptying l Moderate Exercise may enhance gastric emptying

gastroparesis l 5 to 6 small meals l limit fiber sources l limit fat to 40 to 50 grams l in diabetes may need RD/diabetes ed consult to match meals and meds to prevent hypoglycemia

Steps to Diet-gastroparesis l Step 1 – Use if frequent nausea and vomiting l Gatorade, broth, saltine crackers, in small, frequent amount l Step 2 – Soups and starches stage, small amounts of low-fat, low-fiber foods, fat limited to 40 grams l Step 3 – Maintenance diet, up to 50g. fat, small, frequent meals and snacks

Summary of Maintenance Diet for delayed gastric emptying l Smaller, more frequent meals l More liquid calories l Try solids in the morning l Chew food well l Sit up for one hour after meals l Reduce fat to 40 to 50g., liquids fats best l Reduce fiber from meds, medications

Gluten Free Diet l Used to treat celiac sprue or gluten sensitivity l eliminate all sources of wheat, rye, barley l Uncontaminated oats allowed l rice, potato, corn, peas, soy allowed l avoid any foods that have any additive that may contain grains containing gluten l need RD consult, order gluten-free diet

Lactose Free Diet l Used to treat lactase deficiency l all dairy foods contain some lactose l many people can tolerate 1/2 c. milk per meal l lactase enzymes available l lactose better tolerated with other foods l example: cereal and milk

Lactose Free Diet l Acidophilus milk not a good substitute l calcium supplements will likely be needed l can increase use of calcium fortified foods such as orange juice l inpatient or outpatient order: lactose free diet l children may need RD consult

Fructose Restricted l Avoid high fructose fruits l Most fruits and juices are high fructose l Avoid products sweetened with high fructose corn syrup l Grains, vegetables also contain some fructose so are limited in portions l Use dextrose or sucrose to sweeten food l Equal amounts of glucose and fructose better absorbed

FODMAP DIET Elimination type diet for IBS Limits groups of carbohydrates which are different to break down Gradually add classes of carbohydrates back in and monitor symptoms Fermentable Oligo, Di and Mono Saccharides and Polyols (beans, wheat, sugar alcohols, lactose, fructose containing foods)

Low fat diet l Used to treat diseases related to gallbladder, or pancreas l Limit all sources of fat to 25 to 50 g. l May want to specify amount of fat grams l lipids ok in TPN solutions as GI system not used l Medium chain triglycerides like coconut oil easier to absorb

Liver related diets l Cirrhosis-High calorie, normal protein, to regenerate liver cells l Edema, ascites present-limit sodium to 2 g, fluid restriction 1.5L l Hepatic encephalopathy- adequate calories, lactulose to treat high ammonia levels l Diet often not restricted as patients poorly nourished

Liver Continued l Fatty liver-restrict alcohol, lose weight, adequate nutrition l acute hepatitis-adequate calories and protein l RD Referral

Post gastric surgery l Order: post gastric surgery diet l goal is to reduce dumping syndrome l low in simple carbohydrates l separate liquids and solids l increase soluble fibers

Gout l Low-fat l Limit alcohol l More water l Limit high fructose corn syrup l Low carb diets may contribute to gout l Reduce intake or high purine foods l Organ meats

Teaching Materials l Electronic health education sites l web sites; national digestive diseases information clearing house l -registered dietitians

5 minute nutrition tips l You are discharging a 63 y/o female after a 2 day hospitalization for diverticulitis. What nutrition information do you give her?

5 minute nutrition l You are seeing a 58 y/0 male for with GERD who has concerns about cost of medication. l What lifestyle changes would be helpful to encourage?