1. Nutrition 101: When, What, How to Feed A Case-based Approach to Gastroenterology Kimberly Carter, MS, PA-C Division of Gastroenterology University of Pennsylvania Kimberly.Carter2@uphs.upenn.edu

2. Nutrition: Why should we care….

3. Nutrition is an essential component of healthcare and is apart of most of what we do as GI specialists.

4. Objective Discuss the impact of gastrointestinal disease on nutrition status. Outline key elements of a nutrition assessment. Appraise various nutrition therapies as it pertains to dietary modifications and nutrition requirements. Discuss the appropriateness of nutrition support.

5. Nutritional Therapy Nutrition Support Nutritional Status

6. Nutrition in GI Disease: Nutritional Status

7. Nutritional Assessment Food and Nutrition related history Medical, Surgical, and Social history Anthropometric measurements Nutrition focused physical exam findings Biochemical data Bueche J, Charney P, Pavlinac J, et al. Nutrition Care Process and Model Part I: The 2008 Update. Journal of the American Dietetic Association. 2008;108(7)1113-1117.

8. Food and Nutrition Related History Dietary intake: 24 hour recall Use of dietary supplements Eating difficulties : poor dentition, taste disturbances, dysphagia Gastrointestinal complaints: Nausea, vomiting, abdominal pain, diarrhea, constipation

9. Medical History Critical illness or chronic disease Pancreatic insufficiency IBD Celiac disease Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.

10. Surgical History Major abdominal surgery, trauma Previous GI surgery Fistula, ostomy, mesenteric ischemia, short bowel syndrome Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.

11. Social History Living environment Caregiver Functional status Alcohol or substance abuse Mental health Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5):S29-S33.

12. Anthropometric Measurements Height Weight Usual Body Weight (UBW) Weight loss 10 lbs. weight loss over 6 months is noteworthy >10% of UBW BMI <18.5 underweight

13. Nutrition focused PE findings Loss of muscle mass and subcutaneous fat Edema and ascites Hair, skin, nails, perioral exam Jensen G, Binkley, J. Clinical Manifestations of Nutrient Deficiency. Journal of Parenteral and Enteral Nutrition. 2002;26(5): S29-S33.

14. Physical Signs SignsDeficiencies AlopeciaProtein energy malnutrition Brittle HairBiotin Follicular keratosisVitamin A EcchymosisVitamin C or K Seborrheic dermatitisVitamin B2, Niacin, Vitamin B6 Spoon-shaped nailsIron CheilosisVitamin B2, Vitamin B6 Bleeding gumsVitamin C GlossitisNiacin, Folate, Vit B12, Vit B2, Vit B6 Magenta TongueVitamin B2 Loss of DTRsVitamins B1 and B12 Phillips, SM. Jensen, C. Micronutrient deficiencies associated with malnutrition in children. In: UpToDate, Motil, KJ (Ed), UpToDate, Waltham, MA. (Accessed on April 30, 2014).

15. Poor nutrient intake and excessive losses may contribute to malnutrition.

16. Case Study # 1 76-year-old male with lung cancer is referred by his oncologist for anorexia and weight loss in setting of dysphagia and odynophagia. Endorses 30 lbs weight loss over the past 3 months. Medications: Megace Medical/Surgical history: HTN Family history: unremarkable Social History: Lives alone and able to perform ADL. Active community member. Strong family support. Fixed income. ROS: fatigue, taste disturbances and weakness

17. Case Study # 1 Physical Exam: Afebrile, 61 inches, 104 lbs. BMI 20 Cachectic man with temporal, chest and deltoid wasting Edentulous Otherwise normal exam Data: PET/CT suggestive of extrinsic compression on the distal esophagus EGD with evidence of esophagitis Serology: Albumin 2.3, Prealbumin 15.6

18. Assessment: Is this patient malnourished?

19. Nutrition in GI Disease: Nutrition Support

20. Nutrition Intervention Oral nutrition supplements Enteral Nutrition Parenteral Nutrition

21. Nutrition Support

22. Enteral Nutrition Support Functioning GI tract Short vs. Long Term NG/NJ vs. PEG/PEJ Gastric: Bolus feedings Jejunal: Continuous feedings Disease Specific Formulas

23. Parenteral Nutrition Support Non-functioning GI tract Central or PICC EN vs. PN (Complications)

24. Nutrition Support Multi-disciplinary team Refeeding Syndrome

25. Case Study # 2 50-year-old male with ulcerative colitis and mesenteric ischemia s/p total abdominal colectomy with end ileostomy and small bowel resection on chronic TPN referred for nutrition evaluation.

26. Prognosis of Short Gut Syndrome (SGS) Presence of residual underlying disease Length of remaining small intestine Presence or absence of colon in continuity O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

27. Clinical Consequences SGS Table 1. Jejunal resection of 50-60% is usually well tolerated. Greater than 30% ileal resection is poorly tolerated. Severe malabsorption occurs with residual small bowel < 60 cm. Deficiencies include fluid and electrolytes (mild to moderate cases)/plus nutrient absorption (severe cases). Severe fluid and electrolyte loss is associated with end jejunostomy. Magnesium, calcium, and zinc deficiencies are common. O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

28. Bowel Adaptation SGS Gastric hypersecretion Increased pancreaticobiliary secretions Mucosal hyperplasia Increased mucosal blood flow Improved segmental absorption O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

29. Short Gut Syndrome Medical Nutrition Therapy (MNT) Table 2. General Management Strategies for SBS Fluids Avoid drinking water without food Spread fluid intake throughout the day Sip liquids Restrict hypotonic fluids Drink oral rehydration solution containing salt and carbohydrates Diet Eat small, frequent meals balanced in nutrient content Add salt to the diet (only for patient with colon in continuity) Increase quantity of food intake Follow a high complex-carbohydrate diet (patients with a colon) Avoid osmotically active sweeteners, which might cause diarrhea O’Keefe S, Buchman A, Fishbein T, et al. Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and Overview. Clinical Gastroenterology and Hepatology. 2006;4:6-10

30. Short Gut Syndrome MNT Hypomotility agents Rotating antibiotics Enzyme replacement

31. Short Gut Syndrome SiteNutrient (s) absorbed StomachCu, I DuodenumFe, Zn, Cu, Se, Vit D, E, K, B1, B2, B3, folate, Ca JejunumZn, Se, Fe, Ca, Cr, Mn, Vit A, D, E, K, B1, B2, B3, B5, B6, folate, Vit C IleumVit C, D, K, B-12, folate Shortgutsupport.com

32. Nutrition in GI Disease: Nutritional Therapy

33. Case Study # 3 29-year-old female with history of RYGB referred for evaluation of iron deficiency anemia in the absence of overt GI blood loss. Celiac and H Pylori serology negative Endoscopic evaluation unremarkable Micronutrient deficiencies: Calcium, Zinc, Vitamin D, B12

34. Nutrition and RYGB Malabsorption Many patients stop supplements after bariatric surgery Look for other micronutrient deficiencies Often subtle deficiencies are asymptomatic

35. Nutrition and Malabsorption Hypoalbuminemia Steatorrhea Fe deficiency anemia B 12 deficiency Thiamine deficiency

36. Nutritional Therapy 60-120 grams of protein daily Long-term vitamin/mineral supplementation Periodic clinical and biochemical monitoring Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95(11):4823-4843.

37. Biochemical Monitoring 6, 12, 18, 24 months then annually Fe, B12, Folate, Calcium, Vitamin D, Albumin, pre-albumin Optional Vitamin A, Zinc, B1 Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95 (11):4823-4843.

38. Dietary modifications Consume small frequent meals Avoid ingestion of liquids within 30 min of solid food Avoid simple sugars Increase intake of fiber and complex carbohydrates Increase protein intake Heber D, Greenway F, Kaplan L, et al. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95(11):4823-4843.

39. Case Study # 4 26-year-old male with ileocolonic Crohn’s disease presents with fatigue, low energy and weight loss. Iron, B 12 and Vitamin D deficiency

40. Nutrition and IBD Nutrient deficiencies Hypoalbuminemia Fe B12 Vitamin D Folic acid Calcium Magnesium

41. Nutritional Therapy Vitamin/Mineral Repletion Elimination Diet Lactose Free Low Residue Probiotic

42. Case Study # 5 23-year-old female with history of Type I DM presents with bloating, flatulence, and diarrhea in the setting of anemia Positive celiac serology with duodenal biopsy c/w villous atrophy

43. Nutrition and Celiac Disease Micronutrient deficiencies Pancreatic insufficiency

44. Gluten-free diet Eliminates wheat, rye, and barley Rice, corn, millet, potato, buckwheat, and soybeans are safe Common gluten free foods fresh fish, meats, milk, cheese, fruits, vegetables Gluten-free substitutes are often expensive and may be difficult to access

45. Management of Celiac Disease CConsultation with a skilled dietitian EEducation about the disease LLifelong adherence to a gluten-free diet IIdentification and treatment of nutritional deficiencies AAccess to an advocacy group CContinuous long-term follow-up by a multidisciplinary team Milito T, Muri M, Oakes J, et al. Celiac disease: Early diagnosis leads to the best possible outcome. Journal of the American Academy of Physician Assistants. 2012;25(11):43-47.

46. Nutrition in GI Disease: Nutritional Therapy

47. Nutrition and IBS Multifactorial: visceral hypersensitivity, gut flora, diet

48. Nutritional Therapy Lactose Free diet Probiotics Fiber Supplements (Psyllium) FODMAP Diet

49. FODMAP Fermentable OligoDiMonosaccharides and Polyols Poor absorption Osmotic effect Bacterial fermentation Simren M. Diet as a Therapy for irritable bowel syndrome: progress at last. Gastroenterology. 2014;146(1):10-12.

50. Absorption of FODMAPs Presence or absence of enzymes Small intestinal transit time Dose of carbohydrate Presence of underlying mucosal disease Food Composition Simren M. Diet as a Therapy for irritable bowel syndrome: progress at last. Gastroenterology. 2014;146(1):10-12.

51. FODMAP Diet Fedewa A, Rao S. Dietary Fructose Intolerance, Fructan Intolerance and FODMAPS. Current Gastroenterology Reports. 2014;16(1):370.

52. FODMAP Approach Barrett, J. Extending our knowledge of Fermentable, Short-Chain Carbohydrates for Managing Gastrointestinal Symptoms. Nutrition in Clinical Practice. 2013;28(3):300-306

53. FODMAP Approach Provides therapeutic strategy to manage symptoms. Use of dietitian is paramount. Address long-term efficacy and safety of dietary intervention.

54. Nutrition and GERD Chronic acid exposure Reflux triggering foods Spicy Acidic Citrus Fried/Fatty Caffeine, coffee, cola Spearmint/Peppermint Chocolate Alcohol

55. Nutritional Therapy Dietary/Behavioral Modifications Avoidance of reflux triggering foods Small frequent meals throughout the day Avoid tobacco use Avoid tightly fitting clothing Raise head of bed 6-9 inches Stay upright 2-3 hours after meals H2 blockers/PPIs

56. Nutrition and Gastroparesis Hypomotility disorder Etiology: Idiopathic, post-viral, diabetic

57. Nutritional Therapy Dietary/Behavioral Modifications Several small frequent meals Avoid high fat and fiber foods Chew food slowly/thoroughly Sit upright Active Digestive Enzymes/Probiotics

58. Nutrition and Eosinophilic Esophagitis Chronic allergic disease Elimination diet

59. Nutritional Therapy Six-Food-Elimination Diet Milk Eggs Nuts Wheat Fish/Shellfish Soy

60. Therapeutic Approach Treat underlying etiology Diet Vitamin/Mineral supplementation Nutrition support Pharmacotherapy If underlying etiology is irreversible-target symptoms Anti-diarrheal PERT

61. In Summary Recognize nutrition is apart of most of what we do as GI specialists Understand the impact of GI disease on nutritional status Utilize a nutrition assessment to dictate intervention Consult with a dietitian Work with multi-disciplinary team