Nutrition & Diet Therapy (7 th Edition) Consistency-Modified & Other Diets for Upper GI Disorders Chapter 17

Nutrition & Diet Therapy (7 th Edition) Gastrointestinal Disorders Significant reason for hospitalization & visits to health practioners annually Diagnosis may be difficult –GI complaints may not be associated with physical abnormalities –Detailed evaluation of symptoms & responses to dietary adjustment necessary GI complications frequently accompany other illness

Nutrition & Diet Therapy (7 th Edition) Modifications in Food Texture & Consistency Modifications in food texture & consistency may be helpful for people with difficulty chewing or swallowing Modifications may also be necessary for patients as they resume foods orally Diets can be altered as patient’s condition changes

Nutrition & Diet Therapy (7 th Edition) Modifications in Food Texture and Consistency Mechanically altered diets –Routinely prescribed for individuals with chewing or swallowing difficulties –Pureed diet: contains foods pureed to pudding-like consistency –Mechanical soft diet: contains ground or minced foods or moist, soft-textured foods –Blenderized diet: includes foods from all food groups, often with added liquid

Nutrition & Diet Therapy (7 th Edition)

Liquid Diets Clear liquid diet –Requires minimal digestion; easily tolerated –Consists of clear fluids & foods that are liquid at room temperature; leaves little intestinal residue –Limited energy & nutrient content—must be supplemented if used for more than 1-2 days Full liquid diet –Includes milk & other opaque liquids –May be transitional diet between clear liquid & solid foods Diet progression: change in diet to adapt to patient’s tolerance to foods

Nutrition & Diet Therapy (7 th Edition)

Conditions Affecting the Mouth & Esophagus Dry mouth (xerostomia) –Causes Reduced salivary flow Autoimmune diseases Radiation therapy Mouth breathing –Consequences Impairment of health & quality of life Associated with increased plaque, tooth decay, gum disease, mouth infections Interferes with speech Makes chewing & swallowing more difficult Discomfort of denture fit; development of ulcerations in mouth

Nutrition & Diet Therapy (7 th Edition)

Conditions Affecting the Mouth & Esophagus, con’t Dysphagia –Causes Neurological diseases & disorders Surgical procedures involving head & neck Physiological or anatomical abnormalities restricting movement of food in the throat or esophagus –Types Oropharyngeal dysphagia: inability to transfer food from the mouth & pharynx to the esophagus; often caused by neurological or muscular disorder Esophageal dysphagia: inability to move food through the esophagus; usually caused by obstruction or motility disorder

Nutrition & Diet Therapy (7 th Edition) Dysphagia con’t –Complications Aspiration Airway obstruction Choking Respiratory infections Reduced food consumption, malnutrition & weight loss –Dietary intervention Careful assessment of swallowing abilities Modification of physical properties of foods & beverages Alternative feeding methods

Nutrition & Diet Therapy (7 th Edition) National Dysphagia Diet (Table 17-4) Level 1: Dysphagia Pureed –Foods pureed, homogeneous & cohesive –Diet for patients with moderate-to-severe dysphagia & poor oral or chewing ability Level 2: Dysphagia Mechanically Altered –Foods moist & soft textured; foods easily form a bolus –Diet for patients with mild-to-moderate dysphagia; some chewing ability required Level 3: Dysphagia Advanced –Foods moist & in bite-sized pieces when swallowed –Individuals using diet need to tolerate mixed food textures –Diet for patients with mild dysphagia

Nutrition & Diet Therapy (7 th Edition) Dysphagia Diet(con’t) Liquid Consistencies - Thin=watery - Nectarlike=fluids thicker than water -Honeylike=fluids that can be eaten with a spoon, don’t hold their shape -Spoonlike=Thick fluids that hold their shape –Feeding strategies Depends on nature of swallowing problem Strengthening exercises of jaws, tongue or larynx Changing position of head & neck while eating Learn new methods of swallowing –Speech & language therapists often responsible for teaching patients techniques & strategies to improve feeding

Nutrition & Diet Therapy (7 th Edition) Conditions Affecting the Mouth & Esophagus con’t Gastroesophageal Reflux Disease (GERD) –Reflux of stomach acid into esophagus (& mouth) –Results in frequent discomfort & may cause tissue damage –Often referred to as heartburn or acid indigestion –Causes Weakening of lower esophageal sphincter Medical conditions that interfere with sphincter’s mechanism or prevent rapid clearance of acid from the esophagus High rates of GERD associated with pregnancy, asthma, hiatal hernia

Nutrition & Diet Therapy (7 th Edition)

GERD (con’t) Consequences –Damage to esophageal lining—resulting in reflux esophagitis –Esophageal ulcers –Esophageal stricture –Painful swallowing –Pulmonary disease (if gastric contents are aspirated into lungs) –Chronic reflux: Barrett’s esophagus Treatment –Aimed at alleviation of symptoms & facilitating healing of damaged tissue –Medications Proton-pump inhibitors Histamine-2 receptor blockers

Nutrition & Diet Therapy (7 th Edition) Conditions Affecting the Stomach Dyspepsia (indigestion) –General discomfort in upper abdominal region –Often associated with specific foods –Symptoms Stomach pain Heartburn Fullness, bloating Nausea –Symptoms may indicate more serious condition, including GERD or peptic ulcer –Causes Difficult to pinpoint exact cause Complete exam necessary if symptoms severe Medical conditions Medications & dietary supplements Intestinal conditions can mimic: irritable bowel syndrome, lactose intolerance Potential food intolerances

Nutrition & Diet Therapy (7 th Edition) Dyspepsia (con’t) –Potential food intolerances Not substantiated by research Individual responses to certain foods & spices –Coffee –Spicy foods –High-fat meals –Minimizing symptoms Consume small meals with well-cooked foods Avoid heavy seasoning Consume meals in relaxed atmosphere

Nutrition & Diet Therapy (7 th Edition) Conditions Affecting the Stomach con’t Nausea & vomiting –Accompany many illnesses & are common side effects to medications –Prolonged vomiting can cause fluid & electrolyte imbalance –Chronic vomiting may reduce food intake, leading to malnutrition & nutrient deficiencies –Timing of vomiting gives clues to cause –Treatment Diagnose & treat underlying disorder Restoring hydration Taking medication(s) with food Symptomatic treatment with medications that suppress nausea & vomiting Intractable vomiting: Vomiting that resists usual treatment

Nutrition & Diet Therapy (7 th Edition) Nausea & vomiting con’t –Dietary interventions—may prevent or improve nausea Eating & drinking slowly Eating small meals that do not distend the stomach Drinking clear, cold beverages such as carbonated drinks or fruit juices Selecting foods that reduce nausea, such as dry, salty foods (crackers, pretzels), foods at room temperature Some individuals have strong food aversions & tolerances vary considerably

Nutrition & Diet Therapy (7 th Edition) Conditions Affecting the Stomach con’t Gastritis –General term referring to inflammation of stomach mucosa –Causes Infection Irritating substances Diseases & treatments that damage stomach lining Acute erosive gastritis: associated with hemorrhage, tissue erosion or ulcers –Complications Disruption of gastric secretory functions Impaired absorption of nonheme iron & vitamin B 12 Pernicious anemia –Dietary interventions Dependent on symptoms Avoidance of irritating foods & beverages Avoidance of food intake if food consumption causes increased pain or nausea & vomiting Nutrition support if food intolerance persists

Nutrition & Diet Therapy (7 th Edition) Conditions Afffecting the Stomach con’t Peptic ulcer disease –Results from destructive effects of hydrochloric acid & pepsin –Causes Helicobacter pylori infection Use of NSAIDs Disorders that cause excessive acid secretion –Increased risk from cigarette smoking, emotional stress & genetic factors A peptic ulcer damages mucosal tissue & may cause pain & bleeding

Nutrition & Diet Therapy (7 th Edition) Peptic ulcer disease (con’t) –Signs & symptoms May be asymptomatic or cause only mild discomfort Ulcer “pain” similar to hunger pain—gnawing or burning sensation in stomach region Symptoms aggravated by food –Complications Gastrointestinal bleeding Perforation of stomach or duodenum Gastric outlet obstruction

Nutrition & Diet Therapy (7 th Edition) Peptic ulcer disease (con’t) –Drug therapy-first line of treatment Goals: relieve pain, promote healing & prevent recurrence Antibiotics to eradicate H. pylori Discontinuation of aspirin & other NSAIDs Antisecretory drugs—proton-pump inhibitors, H 2 blockers, antacids –Diet considerations Only if symptoms are affected by foods; then individualized Avoidance of foods that irritate GI lining: alcohol, coffee & caffeine-containing beverages, spicy foods Small meals

Nutrition & Diet Therapy (7 th Edition) Gastric Surgery Indications for surgery –Popular treatment for obesity –Treatment of peptic ulcers that resist drug therapy –Correction of ulcer complications –Treatment of stomach cancer Gastrectomy –Surgical removal of diseased portions of the stomach (partial gastrectomy) or entire stomach (total gastrectomy) –Other gastric resection procedures to treat complications of ulcers Vagotomy Pyloroplasty

Nutrition & Diet Therapy (7 th Edition) Gastrectomy (con’t) –Postgastrectomy diet All foods & fluids withheld until some healing has occurred Immediately after surgery: IV fluids, with careful monitoring of fluid balance hours after surgery: ice chips or small sips of water 4-5 th day after surgery: liquids, progressing to solid foods when tolerated; tube feedings if unable to progress to solid foods Adjustments influenced by size of remaining stomach & rapid gastric emptying that results

Nutrition & Diet Therapy (7 th Edition) Gastrectomy (con’t) –Dietary adjustments Smaller stomach limits meal size; affects food tolerance because of potential for dumping syndrome Several small meals & snacks containing only one or two food types Inclusion of protein, fats, complex carbohydrates Slow progression to 5-6 meals per day Avoidance of sugars & sweets Avoidance of milk products if lactose intolerant Addition of fiber to delay stomach emptying and reduce diarrhea Some patients experience problems with fatty foods, highly spiced foods, carbonated beverages, caffeine-containing beverages, alcohol, extreme temperatures, peppermint & chocolate

Nutrition & Diet Therapy (7 th Edition) Gastrectomy (con’t) –Complications & nutrition status Substantial weight loss Fat malabsorption Bone disease Anemia

Nutrition & Diet Therapy (7 th Edition) Gastrectomy con’t Dumping syndrome –Common complication of gastrectomy & gastric bypass surgery –Group of symptoms resulting from abnormally rapid gastric emptying –Hypertonic gastric contents rush into small intestine more quickly after meals, resulting in unpleasant effects –Symptoms of dumping syndrome may occur within 30 minutes of meal

Nutrition & Diet Therapy (7 th Edition)

Gastric Surgery con’t Bariatric surgery –Surgical treatment for severe obesity –Gastric bypass surgery (roux-en-Y) popular option Creation of small gastric pouch Reduces gastric capacity, restricting meal size Also creates bypass of part of small intestine, restricting absorptive capacity Helps to achieve long-term weight loss –Dietary guidelines after bariatric surgery Gradual expansion of gastric pouch to increase capacity to approximately 1 cup; initially only few tablespoons Initially post-op: ice chips & sips of water Progress to liquid diet for first 1-2 weeks (small, frequent meals) Followed by pureed foods, progressing to soft, then regular foods Some foods difficult to manage

Nutrition & Diet Therapy (7 th Edition) Bariatric surgery (con’t) –Patient education & counseling critical for weight loss & management Food portion control to avoid dumping syndrome & to maintain weight loss Elements of healthy diet Foods that may cause discomfort, vomiting or dumping Dietary supplements –Post-surgical concerns Dumping syndrome Fat malabsorption Multiple nutrient deficiencies Rapid weight loss increasing risk of gallbladder disease Plastic surgery to remove extra skin after weight loss

Nutrition & Diet Therapy (7 th Edition)

Nutrition in Practice—Helping People with Feeding Disabilities Multitude of coordinated motions required for eating & drinking Injury or disability can interfere with any of these movements, leading to feeding problems & inadequate food intake Difficulties that affect feeding can also lower food intake, leading to malnutrition & weight loss Feeding difficulties lead to problems with independence Problems affect both the individual & family— affecting family life

Nutrition & Diet Therapy (7 th Edition) Inability to grasp Special equipment to assist with feeding –Adaptive devices make remarkable difference in person’s ability to eat independently; usually assessed by the Occupational Therapist Utensils Plates Cups Specialized chairs & bolsters –If food consumption remains inadequate, tube feedings may be required