Professional Documents
Culture Documents
Abstract
Let food be thy medicine and medicine be thy food.
Hippocrates
Can food really take the place of medicine? While modern medicine certainly has its place and does more than its fair share of good, there is no
denying that many of societys most perilous chronic diseases are exacerbated by poor diets. Whereas earlier infectious diseases used to cause the
most death, the impact of chronic diseases now far overshadows that of
infectious diseases. Diet plays a significant role in the development of a
number of types of chronic disease, such as heart disease, diabetes, and
certain types of cancer. This title explores the impact of dietary choices
on the prevention, management, and treatment of a number of medical
conditions and disease states including the gastrointestinal tract, musculoskeletal disorders, rheumatic disease, anemias, hepatobiliary, gallbladder, pancreatic, and kidney diseases. The topics of nutrition and cardiovascular disease, diabetes and metabolic stress, critical illness, cancer and
HIV/AIDS are covered in the subsequent title Diet and Disease I.
Keywords
Medical nutrition therapy, diet and disease, nutrition care process, diet
therapy, gastrointestinal disorders, musculoskeletal diseases, osteoporosis,
kidney disease diet, liver disease diet
Contents
List of Tables ........................................................................................ ix
Chapter 1
Chapter 2
Chapter 3
Index.................................................................................................111
List of Tables
Table 1.1
Table 1.2
Table 1.3
Table 1.4
Table 1.5
Table 1.6
Table 1.7
Table 1.8
Table 1.9
LIST OF TABLES
Table 2.2
Table 2.3
Table 2.4
Table 2.5
Table 2.6
LIST OF TABLES
xi
Table 2.7
Table 2.8
Table 2.9
Table 3.2
Table 3.3
Table 3.4
Table 3.5
xii
LIST OF TABLES
Table 3.6
Table 3.7
Table 3.8
Table 3.9
CHAPTER 1
Nutrition and
Gastrointestinal Disorders
Chapter Abstract
A healthy digestive system is imperative for an optimal nutritional status.
Injury or compromise to any segment of the gastrointestinal (GI) tract can
quickly undermine the normal processes of nutrient digestion, transport,
and absorption. As dietetics practitioners are often faced with a wide variety
of GI complaints, the importance of having a thorough understanding of
both the digestive process and the relevant diet therapy for gastrointestinal
disorders cannot be understated. Every year, digestive diseases affects between 60 to 70 million people in the U.S., requiring over 48 million ambulatory visits and 21.7 million hospitalizations. Digestive diseases are
responsible for nearly 250,000 deaths per year and cost $141.8 billion in
indirect and direct medical costs in 2004 (the last year for which cost data
was available) (National Institute of Diabetes and Digestive and Kidney
Diseases 2014).
The term digestive disorders casts a wide net. Because the GI tract
stretches from the mouth to the anus, the probability of something going
awry in this arrangement of anatomy over the course of a lifetime is high.
Underlying disease pathology, medication use, surgical and therapeutic
interventions along with lifestyle choices, and exercise patterns, all impact
gut health. Regardless of the origin or severity of disruption in the GI
tract, dietary alteration is quite commonly a component of digestive disorder management. By understanding the digestive process, where various nutrients are absorbed in the GI tract, and what dietary practices can
be employed to minimize pain and maximize nutritional status, practitioners can help patients use food and nutrition to prevent, manage, and
mitigate a variety of GI disorders. This chapter will introduce the reader
After its journey through the stomach, the resultant chyme then
transits to the small intestine. The majority of digestion and absorption
of nutrients occurs within the first 100 cm of the small intestine (Mahan
and Escott-Stump 2008). With the exception of fiber and some carbohydrate, digestion and absorption of nutrients is generally completed by
the time food remnants exit the small intestine. The large intestine is the
site of reabsorption of water, electrolytes, and some vitamins. It is here
in the large intestine where food residue remaining after digestion becomes the semisolid waste product called feces or stool. Fecal matter is
stored in the rectum until muscular contractions move the material into
the anal canal in preparation for excretion via the anus.
Nutrient Absorption
No nutrient absorption occurs in the mouth or esophagus. There is a
small amount of absorption that takes place in the stomach, primarily of
alcohol and some medications. The small intestine is where most nutrient
absorption takes place, and the anatomy of the small intestine is uniquely
constructed to maximize nutrient digestion and absorption. The mucosa
of the small intestine is arranged in a pattern of numerous folds that contain fingerlike projections called villi. The villi are constantly moving,
trapping food, and absorbing nutrients. Enterocytes refer to the absorptive
cells that form the outer layer of the villus. Each fingerlike villus projection contains many additional, smaller hairlike projections called microvilli
that also facilitate absorption. The numerous structures of the small intestine increases its capacity for absorption by up to 600 times compared to
that of a simple tube (Wardlaw and Smith 2011).
The process of absorbing nutrients through the wall of the small intestine is dependent on a number of factors such as the type and amount of
nutrient present. Nutrient absorption can occur by simple diffusion, facilitated diffusion, active transport, osmosis, or endocytosis. In simple
diffusion, the nutrient moves down the concentration gradient from the
area of higher concentration in the lumen to the area of lower concentration. This process does not require any energy or protein carriers and is
the process used to absorb many of the water-soluble vitamins, fats, and
some minerals. Facilitated diffusion requires the assistance of a carrier
Stomach
Water
Alcohol
Minerals: copper, iodide, fluoride, molybdenum
Small intestine
Duodenum Minerals: calcium, phosphorus, magnesium, iron, copper
Vitamins: thiamin, riboflavin, niacin, biotin, folate, vitamins A, D, E, K
Jejunum
Organ
Ileum
Minerals: Magnesium
Vitamins: vitamin C, B12, D, K, folate
Bile salts and acids
Large intestine
Minerals: sodium, chloride, potassium
Vitamins: vitamin K, biotin
Short chain fatty acids
Water
Nutrient Transport
When nutrients enter the bloodstream or the lymphatic system, they are
transported with the assistance of the circulatory system Blood is carried
to the digestive system via the arteries, which branch into capillaries to
reach every cell in the body. Blood exiting the digestive system travels
via the veins, with the hepatic portal vein directing blood to and from
the liver. The liver is the bodys major metabolic organ, and it plays a
vital role in digestion as it receives and packages absorbed nutrients and
filters out harmful agents.
Lipid absorption proves difficult in the watery environment of the GI
tract, since fats must utilize protein carriers to facilitate their absorption
and transport. The cluster of fat and protein required to transport fats is
called a chylomicron, which is a type of lipoprotein. Chylomicrons move
throughout the body, with surrounding cells picking off their lipid
contents. The shrinking chylomicron eventually travels to the liver,
where different lipoproteins are produced. As a result of this lipid
transport and absorption process, many diseases of the small intestine can
interrupt normal fat digestion and absorption.
...is made
up of
Mostly
triglycerides
LDL:
Low-Density
Lipoproteins
Mostly
cholesterol
HDL:
High-Density
Lipoproteins
Mostly
protein
Health
implications
...and does:
Takes triglycerides
(TG) from liver to
body tissues
Made by liver
Carries cholesterol
VLDLs
Carries cholesterol
back to the liver from
the bodys cells
Artificial saliva
Gum chewing
Oral care
practices
Pharmacologic
Amifostine
Inorganic
Mouth rinse: to
1 teaspoon
Products to
avoid
Sucrosecontaining &
Nutrition &
lifestyle
Sugarless candy
Increased fluid
intake/frequent
sips of water
Sucking on ice
cubes
Consumption of
foods with high
fluid content
Use of
humidifier
during sleep
Oral care
practices
Pharmacologic
thiophosphate,
broad-spectrum
cytoprotectant
Artificial saliva;
available as sprays,
lozenges, gels, and
swabs
baking soda + 8
ounces water
every 2 hours
while awake
Biotene products
by Laclede, Inc.;
include
toothpaste,
mouth rinse,
chewing gum
Chapstick and
moisturizing gels
to lips
Pilocarpine
Products to
avoid
carbohydrates
that stick to
teeth & lead to
dental caries
Citrus & spicy
foods
Dry and hard,
non-moist
foods
Caffeine; limit
coffee & tea
Tobacco
Alcohol
Alcohol-based
mouth washes
Dysphagia
Proper swallowing is a complex action that requires the adequate functioning of a number of pieces of anatomy. The term dysphagia refers to
difficulty with swallowing or improper swallowing. Dysphagia is not a
specific diagnosis or disease, but rather, the disruption of swallowing
that may be an indicator or symptom of any one of a number of disorders. Oropharyngeal dysphagia refers to the inability to transfer food
from the mouth and pharynx to the esophagus. This is usually caused by
a neuromuscular disorder that disrupts the swallowing reflex or renders
the muscles involved in swallowing unable to move. Signs of oropharyngeal dysphagia include presence of a gurgling noise following swallow, a
hoarse or wet voice or a resultant speech disorder. This is the type of
dysphagia that is commonly seen in the elderly following a stroke.
Esophageal dysphagia refers to interference with the actual passage of
food or beverage down the esophagus and into the stomach. This may
occur as a result of an obstruction in the esophagus or a motility disorder. People with esophageal dysphagia often complain of food getting
stuck in the esophagus following swallow. The obstruction may be the
result of a stricture, tumor or compression of the esophagus due to impairments in surrounding anatomy.
10
Dysphagia can negatively impact nutritional status if it affects dietary intake. Complications of dysphagia include choking and aspiration.
Reduced ability to swallow food safely can result in a variety of nutritional deficiencies. Potential nutritional impacts of untreated dysphagia
are outlined in Table 1.4.
11
Food is nearly regular texture with the exception of very hard, sticky, or crunchy foods
Allows breads, rice, moist cakes, shredded lettuce, and tender moist whole meats
Avoids hard fruits and vegetables, corn, skins, nuts, and seeds
Regular
All foods are allowed
Dysphagia affects not only solid food swallowing capabilities but also
the ability to safely swallow liquids of varying consistency. NDD proposes
four frequently used terms to label levels of liquid viscosity. Speech language
pathologists determine the viscosity of fluid that a patient can tolerate separately from solid food recommendations. The classification of liquid types is
12
Inclusions
Thin liquid
Nectar-like
Falls slowly from a spoon and can be sipped through a straw or cup
Includes nectars, vegetable juices, chocolate milk, buttermilk,
thin milkshakes, cream soups, other properly thickened beverages
Honey-like
Spoon-thick
based on measurements using a viscometer. As most commercial establishments do not have a viscometer, commercial thickening agents are generally
used to achieve the appropriate level of thickness. The four liquid types in
the NDD are presented in Table 1.6, in order of least restrictive to most
restrictive.
Dehydration risk increases with dysphagia because fluid intake is often limited or suboptimal. While an individuals fluid needs are dictated
by disease state, a general rule of thumb is that 30 mL of fluid per kilogram of body weight will provide normal daily fluid requirements. Fluid
requirements may vary for those with cardiac problems, renal failure,
dehydration, obesity, or in those who require fluid restrictions (AND,
2015a).
13
pressure can allow the acidic contents of the stomach to re-enter the
esophagus, causing dysphagia, heartburn, belching, and increased salivation (Nelms 2011). Because the lower esophageal sphincter serves as the
gateway between the lower portion of the esophagus and the upper
compartment of the stomach, any compromise to the sphincter muscle
may result in reflux. GERD is more commonly seen during pregnancy,
in obese individuals, and those with hiatal hernia (a condition wherein
the top part of the stomach protrudes above the diaphragm).
The presence of gastric acid in the esophagus can impair the esophageal lining, resulting in inflammation called reflux esophagitis. Prolonged
inflammation can cause esophageal ulcers, which in turn may bleed and
cause pain. When ulcerated tissue eventually heals, it can cause scarring
which will narrow the inner lumen of the esophagus and further restrict
access. Aspiration is a risk and lung disease may occur if food is aspirated
into the lungs. Chronic exposure to acid in the esophagus can lead to
Barretts esophagus, a condition characterized by esophageal cells that are
damaged by exposure to stomach acid becoming replaced by cells similar
to those in the stomach or small intestine and that are occasionally cancerous. Other consequences of GERD include damage to tissue in the
mouth, erosion of tooth enamel, sore throat, cough, and laryngitis (Falk
and Katzka 2012).
14
Table 1.8 Diet therapy for patients with GERD (AND, 2015b),
(Hasler 2015)
Diet therapy for GERD
Restrict foods that increase gastric acidity, including black pepper, red pepper, coffee
(includes decaffeinated), and alcohol.
Eliminate foods and agents that reduce lower esophageal sphincter pressure, including
chocolate, mint, high-fat foods, and tobacco.
Lose weight if indicated.
Stop smoking.
Refrain from lying down after eating; remain upright.
Restrict eating within three hours of bedtime.
Avoid tight-fitting clothing.
Elevate head of bed while sleeping.
Substitute large, high-fat meals with smaller, more frequent lower-fat meals.
Hiatal Hernia
As mentioned previously, a hiatal hernia occurs when the top portion of
the stomach and the lower esophageal sphincter protrude through the
esophageal hiatus into the thoracic cavity. The presence of a hiatal hernia
facilitates easy reflux of acid into the esophagus. Hiatal hernia symptoms
are similar to those of GERD, and the primary dietary interventions for
GERD also apply (see Tables 1.7 and 1.8). Because hiatal hernias and
15
associated GERD are more prevalent in the obese, weight loss efforts
should be undertaken if indicated (Barak et al., 2002). Those with hiatal
hernias should be advised to avoid high-fat meals and to avoid laying
down less than three hours after eating.
16
Table 1.9 Factors that exacerbate peptic ulcer disease (AND, 2015c)
Factors that may affect mucosal integrity
Peptic ulcer-associated pain can impede nutritional intake and reduce appetite, resulting in unintended weight loss and potential nutrient
deficiencies. Iron deficiency can occur as a result of blood loss. Longterm use of medications that suppress acid secretion can lead to suboptimal absorption of calcium, iron, and vitamin B12 (Yang et al., 2006),
(O'Connell et al., 2005).
Abdominal discomfort with PUD generally occurs when the stomach
is empty. Common complaints include feelings of an upset stomach and
dull or burning pain either between meals or during the night. In the case
of duodenal ulcers, food is likely to help relieve the pain. Antacid use can
alleviate pain with both gastric and duodenal ulcers. Patients should be
encouraged to identify and avoid foods that are not well tolerated or that
easily irritate the gastric mucosa. In addition to individualized food recommendations, all people with PUD should be advised to avoid foods
that may increase gastric acid secretion or that are known to harm the
gastric mucosa, including pepper, alcohol, and caffeine from colas, coffee,
decaffeinated coffee, tea, and chocolate.
17
Table 1.10 Foods not recommended for people with peptic ulcer
disease (AND, 2015c)
Food groups
Whole milk
Cream
Dairy products from whole milk or cream
Chocolate milk
Cola
Coffee (including decaffeinated)
Green or black tea (including decaffeinated)
All caffeinated beverages
Alcohol
Butter
Lard
Stick margarine
Hydrogenated oils
Fried foods
Spices
Pepper
Encouraging small, frequent meals, avoiding fried foods, and smoking cessation are advisable for PUD. Many individuals find that avoiding food for at least two hours before bedtime also helps minimize
PUD-associated discomfort. Previous diet therapy was based on the notion that milk and milk products could coat the stomach and protect
against gastric secretions, a therapy formerly called the sippy diet. It is
now known that milk, with its protein content, actually increases gastric
secretions. Generally, with active PUD, reduced-fat (2%) milk, whole
milk, cream, chocolate milk, and high-fat yogurt are discouraged
(Nelms 2011), (AND, 2015c). If tolerated, some patients may wish to
include nonfat (skim) milk, low-fat (1%) milk, buttermilk, or low-fat
and nonfat yogurt. Table 1.10 outlines foods that are to be avoided or
minimized in individual with PUD.
18
Gastric Surgery
An individual may require gastric surgery for one of a number of reasons: malignancy, PUD, or surgical weight loss. Regardless of the diagnosis or condition necessitating gastric surgery, understanding how such
Table 1.11 Gastric surgical procedures
Gastric surgery
procedure
Anatomical effects
Vagotomy
Pyloroplasty
Billroth I
Bilroth II
Roux-en-Y
surgeries impact nutrient digestion and absorption can help predict where
particular nutrient deficiencies or deficits may arise. Patients undergoing
gastric surgery are at increased nutritional risk from potentially poor oral
intake, maldigestion, and malabsorption of nutrients. Table 1.11 provides
a brief overview of the various surgical procedures.
Normal digestive processes are disrupted with any gastric surgery,
either by reducing the capacity of the stomach or altering the transit
time for contents in the gut. Altering the normal digestive process in the
stomach leads to resultant reduction in the production of intrinsic
factor. Intrinsic factor is produced by the parietal cells of the stomach
and is required for optimal vitamin B12 absorption. Gastric surgery
often results in suboptimal vitamin B12 status due to reduced intrinsic
factor. Hydrochloric acid (HCl) production is also affected by gastric
surgery, resulting in further disruption of the normal digestive process.
19
Dumping Syndrome
Dumping syndrome is a cluster or symptoms resulting from the rapid
emptying of an osmotic load from the stomach into the small intestine;
it is a common side effect of gastric surgery. Dumping syndrome can be
initiated by alterations in the rate of gastric emptying, innervation to the
stomach, and fluctuating stimulation of GI hormones. If normal gastric
emptying rates cannot be achieved, a higher osmotic load dumps into
the small intestine too quickly, which results in much more volume than
can be comfortably accommodated.
Dumping results in abdominal cramping and pain, diarrhea, dizziness,
weakness, and tachycardia. These symptoms are present in early dumping
syndrome, occurring within the first 10 to 20 minutes following a meal.
Undigested food then moves to the large intestine, where colonic fermentation produces gas, abdominal pain, cramping, and diarrhea. Late dumping
syndrome takes place between one and three hours following food intake,
particularly after the consumption of simple carbohydrates. The rapid rate
of absorption in the small intestine stimulates insulin release. Insulin, in the
presence of hypermotility and decreased transit time, finds no remaining
substrate on which to act, causing subsequent hypoglycemia. The symptoms of hypoglycemia, and ultimately, late dumping syndrome, include
confusion, weakness, shakiness, and sweating (AND, 2015d).
Dumping syndrome can be managed by dietary modification. Eating small and frequent meals, avoiding simple carbohydrates (including
clear liquids with simple sugars), drinking fluids separate from solid
foods, and incorporating supplemental pectin or guar gum to promote
increased viscosity of food can all help minimize symptoms. The presence of sugars and sugar alcohols in the GI tract may exacerbate associated GI symptoms. As such, patients are generally advised to avoid sucrose, fructose, and sugar alcohols such as sorbitol, mannitol, and xylitol
(ingredients often found in sugar-free and diet foods, candies, chewing
20
Copper
Folate
Thiamin
Calcium
Vitamin A
Vitamin B12
Vitamin D
21
22
23
24
Constipation
The American Gastroenterological Association maintains that it is not
necessary to have at least one bowel movement per day. They define regular motility as having from three bowel movements per day to three per
week (AGA, 2013). Constipation can arise from a lack of dietary fiber or
as a secondary occurrence related to another condition or disease. Common causes of constipation include obesity, pregnancy, inactivity, and
irritable bowel syndrome. Less common causes may include laxative
abuse, hormonal disturbances, loss of body salts, mechanical compression,
nerve damage, or other diseases such as diabetes, Parkinsons disease, multiple sclerosis, stroke, spinal cord injuries, disorders of the thyroid gland,
lupus, and scleroderma. Medication may induce constipation, with diuretics, calcium or aluminum antacids, pain medications containing codeine, antidepressants, antihistamines, and iron and calcium supplements
being particularly constipating (AND, 2015e). The use of fiber supplements without adequate fluid intake may also contribute to constipation.
Table 1.16 contains potential nutrition diagnoses for constipation.
25
per day (King, Mainouse and Lambourne 2012), (Alaimo et al., 1998).
The Institute of Medicines Dietary Reference Intake (DRI) for fiber is
based on 14 grams per 1,000 calories consumed (Institute of Medicine
2005). Based on the DRI recommended calorie intake levels, this level is
25 grams per day for adult women and 38 grams for men. Table 1.17
contains the DRI for fiber for different age and gender groups (Institute
of Medicine 2005).
Gathering accurate data about average fiber intake may be challenging in the clinical environment; however, taking a quick survey of a persons previous 24-hour intake can yield substantial information about
the nature (or absence) of dietary fiber in the diet. Diets that are low in
fiber also tend to be low in fruits, vegetables, whole grains, and legumes.
These same diets tend to be high in dairy, meat, refined carbohydrate
foods, and fats. While it is the insoluble fibers that appear to have the
greatest effect on constipation, there is no clear evidence with regards to
the best type of fiber to alleviate constipation (Tan and Seow-Choen
2007). Insoluble fibers are found in the skins of fruits and vegetables,
and in whole grains. Table 1.18 offers a quick way to estimate fiber intake from a persons food record.
26
Table 1.18 Quick estimation for determining daily fiber from food
records (Marlett and Cheung 1997)
To quickly estimate fiber intake from a food record:
1. Multiply number of fruit and vegetable servings by 1.5 g.
2. Multiply number of servings of whole grains by 2.5 g.
3. Multiply number of servings of refined grains by 1.0 g.
4. Add specific fiber amounts for nuts, legumes, seeds, and high-fiber cereals.
5. Total to estimate fiber intake per day.
Functional Fibers
Encouraging individuals to increase their dietary fiber intake can be a challenging undertaking in todays food environment. As consumers interest in
fiber grows, so do food manufacturers offerings of fiber-containing packaged and processed foods. Isolated are being increasingly added to many
packaged and processed foods that are normally low in fiber. They contain
ingredients such as maltodextrin, oat fiber, resistant starch, pectin, gum,
polydextrose, and inulin (from chicory root), among others. In high concentrations, these additives may cause gastrointestinal distress in some individuals (Bonnema et al., 2010), (Storey et al., 2007) although they may be
tolerated at lesser levels by others (Stewart et al., 2010).
27
On the topic of functional fibers, the Academy of Nutrition and Dietetics maintains in its position paper that, [w]hether isolated, functional
fibers provide protection against cardiovascular disease remains controversial. The paper goes on to say, longer-term studies of fiber intake which
examine the effects of both intrinsic [intact] and functional [isolated]
fibers are required (ADA, 2008).
Nutrition practitioners should work with clients to increase dietary
fiber intake from naturally occurring sources of dietary fiber as opposed
to synthetic fibers added to processed foods. Naturally occurring sources
of fiber include fresh and frozen fruits and vegetables, whole grains,
dried peas and beans, and lentils. When choosing bread products made
with flour, counsel patients and consumers to look for the word whole
in the first ingredient in the ingredient list. Avoid bread products with
enriched wheat flour as the first ingredient, as these are made with
refined, low-fiber wheat flour. Table 1.19 contains additional tips for
increasing dietary fiber from food (and not supplement) sources.
28
to at least 64 ounces (eight cups) per day (AND, 2015e). The best indicator of hydration status is urine color: light yellow or clear urine that is not
pungent indicates adequate hydration in most cases. Urine that is dark
yellow or orange and urine that has a pungent odor indicates the presence
of concentrated waste product and insufficient hydration status.
Three other ways of estimating fluid needs are based on calorie intake, body weight, or calorie intake plus nitrogen consumed. Providing
one mL of fluid per calorie consumed per day is estimated to meet hydration needs in otherwise healthy people. Alternatively, providing 35 to
40 mL/kg for people aged 16 to 30, 30 to 35 mL/kg for healthy adults,
30 mL/kg for those 55 to 65 years old, and 25 mL/kg for those over 65
can also meet fluid needs. Lastly, a less commonly used practice bases
fluid recommendations on nitrogen and energy intake by providing
1 mL/kcal + 100 mL/g nitrogen consumed (AND, 2015f). Table 1.20
summarizes a variety of approaches to estimate daily fluid requirements.
Table 1.20 Approaches to determine adequate fluid intake
(AND, 2015f)
Approaches to determine adequate fluid intake
Observe color of urine
29
Intestinal Gas
As is the case with constipation, the presence of gas and flatulence may
be caused by either an underlying condition or as a result of a separate
therapeutic medication or treatment. Foods and agents that cause gas
vary greatly between individuals; and because of the highly individualized nature of such a condition, there is not one given therapy that will
be beneficial for all who experience this uncomfortable GI problem.
Gas can be caused by one of two things: from the swallowing of air or
from the breakdown of certain undigested foods by colonic bacteria. The
best nutrition advice for gas and flatulence is also the simplest: avoid the
offending food or foods. Gas-causing foods include simple sugars, starches,
and fiber (Shepherd et al., 2008). Simple carbohydrates that are known to
be gas inducing, and their sources can be found in Table 1.21.
Most starches give off gas as they are broken down in the large intestine; rice is the only starch known to not cause gas (National Digestive
Diseases Information Clearing House 2013). Dietary fiber, despite its
varied benefits can contribute to gas. Soluble fiber, found in foods like oat
bran, beans, peas, and most fruits, is not digested by the body, but rather
fermented by bacteria in the colon, where it can cause gas. Insoluble fiber
is less likely to cause gas as it passes unchanged through the intestines and
30
Lactose
Also called milk sugar
Raffinose
Sorbitol
31
Vegetables
Beans
Bagels
Beets
Black-eyed peas
Barley
Broccoli
Bog beans
Breakfast cereals
Granola
Cabbage
Chickpeas
Oat bran
Cauliflower
Lentils
Pasta
Corn
Lima beans
Rice bran
Cucumbers
Mung beans
Rye
Leeks
Sorghum
Lettuce
Pinto beans
Wheat bran
Onions
Parsley
Diarrhea
As is also the case with the previously mentioned GI maladies, diarrhea
is often a sign or symptom of another problem. Diarrhea affects nutritional status as it may cause rapid weight loss, dehydration, electrolyte
abnormalities, and acid-base imbalance, or it can also be indicative of a
malabsorptive disorder. Diarrhea is defined as the presence of loose,
watery stools passed at least three times per day. Diarrhea can also be
defined as >200 g/day stool weight passed by an adult. Acute diarrhea is
less than two weeks in duration, persistent diarrhea two to four weeks,
and chronic diarrhea lasts for more than four weeks (Camilleri and
Murray 2015).
Identifying the etiology and treating the underlying cause of diarrhea
is the primary goal of treatment. If infectious diarrhea is present, antibiotic therapy becomes the primary treatment. While the cause of diarrhea
can be attributed to many things, foods that may be related to diarrhea
include beans and legumes, high-fiber foods, high-fat foods, alcohol,
lactose, fructose, caffeine, and sorbitol (AND, 2015g). Clear liquids are
32
33
Celiac Disease
Celiac disease is an autoimmune disease also called gluten-sensitive enteropathy, or celiac sprue. In celiac disease, gluten (a protein found in
wheat, rye, and barley) ingested from the diet causes damage in the absorptive areas of the small intestine, resulting in villus atrophy. There is
no medication or surgical procedure that can reverse the effects of celiac
disease; in fact, the only therapeutic approach to managing celiac disease
is the maintenance of a gluten-free diet.
While estimations of the prevalence of celiac disease vary between
populations, higher rates are traditionally seen among Caucasians and
those of European descent. Prevalence rates of celiac disease in the United
States are thought to be 1:133 in the general population, and as high as
1:22 for those who have a first-degree relative (parent, sibling, or child)
who also has celiac disease (Fasano et al., 2003). Emerging evidence also
34
35
36
Diverticular Disease
In both the developed and developing parts of the world, rates of diverticular disease are rising alongside the increased reliance on and consumption of processed and packaged foods. Diverticular disease includes
diverticulosis (the presence of many small individual out-pouchings in
the colon called diverticulum), and diverticulitis (inflammation of the
diverticula that causes severe abdominal pain). Risk factors for the development of diverticulosis include having a history of constipation, low
fiber intake, high intakes of red meat, presence of obesity, and lack of physical activity (AND, 2015h). It is estimated that 10 percent of Americans ages
40 and older have diverticulosis and that one-quarter of those will develop
diverticulitis (Bogardus 2006).
From a dietary standpoint, fiber is the most important nutritional
component in the prevention of the development of diverticula, and
both soluble and insoluble fibers are involved here. Soluble fiber, which
absorbs water, adopts a soft, gel-like texture in the intestinal tract. Insoluble fiber, which is not absorbed, passes through the intestine unchanged and contributes to stool bulk. Manipulating both the texture
and bulk of the stools by increasing fiber in the diet helps to maintain
bowel regularity and prevents the development of diverticula (Tarleton
and DiBaise 2011).
While the importance of dietary fiber in the prevention of diverticular
disease cannot be overstated, it is important to note that the diet therapy for
the treatment of diverticulosis differs dramatically from that of diverticulitis.
With diverticulosis, the goal is to prevent the development of inflammation
and progression to diverticulitis. Diet therapy for diverticulosis includes a
high-fiber diet, with 6 to 10 grams of fiber per day encouraged above the
standard 20 to 35 gram recommendations. Recall that the average North
American eats only about 15 grams of fiber per day (ADA, 2008). A fiber
supplement consisting primarily of insoluble fiber may be helpful in meeting needs. In addition to assuring a high fiber intake, diverticulosis management may also be aided by the use of probiotic and prebiotic foods,
although again, current research does not substantiate recommended dosage
amounts (AND, 2015h). In the initial phase of diverticulitis, a nothing by
mouth diet order with bowel rest is advised until bleeding and diarrhea
37
resolve. The diet is then progressed to a clear liquid diet and may require
oral nutritional supplementation to help achieve optimal nutrition status. A
low-fiber therapy is initially recommended until the inflammation and
bleeding associated with diverticulitis are no longer a risk. After the acute
episode has resolved, dietary fiber intake should gradually be increased along
with water intake to the diverticulosis diet levels (6 to 10 grams above 20 to
35 gram recommendations). One recommended regimen is to advance the
diet by five grams of fiber per week until the goal is reached (Tarleton and
DiBaise 2011). Table 1.24 outlines the diet therapy recommendations for
the treatment of diverticulosis versus diverticulitis.
High-fiber diet of 610 g dietary fiber above NPO with bowel rest until bleeding and
standard 2035 g per day levels
diarrhea resolve
Consider use of a fiber supplement with
insoluble fiber to help meet needs
38
No need to avoid nuts, seeds, corn, popcorn Initiate a low-fiber diet until inflammation
and bleeding no longer of concern
Increase fluid intake alongside increasing
fiber intake
Milk
Bread, white
Pasta, white
Cottage cheese
Peaches, canned
Pears, canned
Egg
Pudding or tapioca
Fruit juice
Rice, white
Ice cream
Spinach
Lactose-free milk
Tofu
Lettuce
Tuna, canned
Mashed potatoes
39
40
41
but not all, individuals may also experience malabsorption with the presence
of fructose and lactose in the gut (Gibson 2011). It is important to note that
the presence of FODMAPs in the diet does not necessarily result in higher
rates of IBS-related symptoms, and FODMAPs are not the cause of functional bowel disorders. The approach to minimizing FODMAPs represents a
dietary approach to helping manage IBS symptoms, provided that all
FODMAPs, not just some, are addressed. Scientists at Monash University in
Australia originated the concept and have been leaders in the field with regards to publishing research regarding the effectiveness of the FODMAPs
approach.
The primary dietary sources of FODMAPs are found in foods with
fructose in excess of glucose, honey, apples and pears; fructans in wheat, rye,
onion, and garlic; galactans in cabbage and legumes; lactose in milk and
milk products; and polyols such as sorbitol and mannitol in stone fruits
(e.g., plums, cherries, mangos, peaches, apricots, and nectarines), mushrooms, and certain artificial sweeteners (Barrett and Gibson 2010). Referring candidates to a Registered Dietitian Nutritionist (RDN) trained in
developing a low-FODMAP diet may be an efficacious dietary approach to
minimizing IBS-related symptoms. The involvement of a specially trained
nutrition professional is essential as a low-FODMAP diet must be carefully
planned to meet patients individual needs and to identity any potential
nutrient deficiencies arising from eliminated foods and food groups.
42
Energy
Protein
Fluid &
Electrolytes
Iron
Magnesium &
Zinc
Calcium &
Vitamin D
Long-term steroid use & reduced intake of dairy foods with lactoserestricted diet
Vitamin B12
Folate
43
44
Chocolate drink mixes, soy milk, Ovaltine, instant iced tea, fruit juices
of fruits from this table
Fruits
Vegetables
Beans (wax, dried), beets and beet greens, chives, collard greens,
eggplant, escarole, dark greens of all kinds, kale, leeks, okra, parsley,
rutabagas, spinach, Swiss chard, tomato paste, watercress, zucchini
Breads, Cereals, Amaranth, barley, white corn flour, fried potatoes, fruitcake, grits,
and Grains
soybean products, sweet potatoes, wheat germ and bran, buckwheat
flour, All-Bran cereal, graham crackers, pretzels, whole wheat bread
Meat and
Proteins
Desserts and
Sweets
Fats, Oils, Nuts, Nuts (peanuts, almonds, pecans, cashews, hazelnuts), nut butters, sesame
Seeds
seeds, tahini, poppy seeds
45
Notes
Dairy
Buttermilk
Evaporated, skim, powdered or low-fat milk
Smooth, nonfat or low-fat yogurt
Low-fat or reduced fat cheese
Low-fat ice cream or sherbet
Proteins
Tender, well-cooked meats, poultry, fish,
eggs and soy prepared without added fat
Smooth nut butter
Grains
Bread, bagels, rolls, crackers, cereals, and
pasta made from white or refined flour
Vegetables
Most well-cooked vegetables without seeds
Potatoes without skin
Lettuce
Strained vegetable juice
Fruits
Fruit juice without pulp (except prune juice) Choose canned fruit in juice or light syrup
Ripe banana or melons
Most canned, soft fruits
Peeled apples
Fats and Oils
Limit to less than 8 tsp per day
Beverages
Water
Decaffeinated coffee
Caffeine-free tea
Soft drinks without caffeine
46
Proteins
Grains
Vegetables
Beets
Broccoli
Brussels sprouts
Cabbage and sauerkraut
Cauliflower
Corn
Greens
Lima beans
Mushrooms
Okra
Onions
Parsnips
Peppers
Potato skins
Spinach
Squash
Fruits
Beverages
Beverages with caffeine: tea, cola, coffee, energy and sports drinks
Alcohol
Sweet fruit juices and soft drinks
Other
47
References
Academy of Nutrition and Dietetics. 2015. Xerostomia Treatment.
Nutrition Care Manual. http://www.nutritioncaremanual.org.
Accessed August 15, 2015.
.
___ 2015a. Dysphagia. Nutrition Care Manual. http://www.nutrition
caremanual.org. Accessed August 15, 2015.
___. 2015b. Gastroesophageal Reflux Disease. Nutrition Care Manual.
http://www.nutritioncaremanual.org. Accessed 2015, 15 August.
Accessed August 15, 2015.
___. 2015c. Peptic Ulcer Disease. Nutrition Care Manual. http://www
.nutritioncaremanual.org. Accessed August 15, 2015.
___. 2015d. Gastric Surgery. Nutrition Care Manual. http://www.
nutritioncaremanual.org. Accessed August 15, 2015.
___ 2015e. Constipation. Nutrition Care Manual. http://www.
nutritioncaremanual.org. Accessed August 15, 2015.
___. 2015f. Fluid Requirements. Nutrition Care Manual. http://www
.nutritioncaremanual.org. Accessed August 15, 2015.
___. 2015g. Diarrhea. Nutrition Care Manual. http://www.nutrition
caremanual.org. Accessed August 15, 2015..
___. 2015h. Diverticular Conditions. Nutrition Care Manual. http://
www.nutritioncaremanual.org. Accessed August 15, 2015.
___. 2015i. Inflammatory Bowel Disease. Nutrition Care Manual.
http://www.nutritioncaremanual.org. Accessed August 15, 2015.
___. 2015. Renal. Nutrition Care Manual. http://www.nutritioncare
manual.org. Accessed August 15, 2015.
Alaimo, K, et al. 1998. Dietary intake of vitamins, minerals, and fiber
of persons ages 2 months and over in the United States: Third
National Health and Nutrition Examination Survey, Phase 1, 19881991. Advance Data from Vital and Health Stastistics.
American Dietetic Association. 2010. International Dietetics and
Nutrition Terminology (IDNT) Reference Manual, 3rd ed. Chicago:
American Dietetic Association.
American Dietetic Association. 2008. Position Paper on Dietary
Fiber. Journal of the American Dietetic Association, 1716-1731.
48
49
50
51
Index
Academy of Nutrition and Dietetics,
27, 70, 93, 100, 101
Acute diarrhea, 31
Acute hepatitis, 95
Alcohol abuse, chronic
cirrhosis and, 94
nutrition supplements
recommended for, 94t
Alcohol, gout and, 71
American Academy of Pediatrics, 64
American Gastroenterological
Association, 24
American Liver Foundation, 91
Anemia, 7685
iron deficiency, 7681
megaloblastic, 8184
pernicious, 8182
sickle cell, 8485
Animal protein, role of, 65
Antibiotic therapy, PUD and, 15
Antiendomysium antibodies (EMA), 34
Anti-tissue transglutaminase
antibodies (tTGA), 34
Aspiration, GERD and, 13
Aspirin, peptic ulcer disease and, 15
Atrophic gastritis, 82
Beano, 30
Bean-zyme, 30
Bone density
dual energy x-ray absorptiometry
for, 56
guide for understanding T-scores, 57t
test for, 57
Bone loss, animal protein and, 65
Bone mineral density (BMD), 56
Calcium
for chronic kidney disease, 100
dairy foods and content, 59t
on dialysis, 100
dietary reference intakes:
recommended dietary
allowances for, 58t
intake and recommendations for
weakened bones, 5861
non-dairy foods and content, 60t
practical method for estimating
individual daily intake, 61t
recommendations for
postmenopausal women and
men aged 50 and older, 6667
supplements, 6162, 62t
Calcium acetate, 107
Calcium carbonate, 62, 62t, 107
Calcium citrate, 62, 62t, 107
Calcium oxalate, 98
Calcium phosphate, 98
Calories
for chronic kidney disease, 100
on dialysis, 100
Celecoxib, 68
Celiac disease, 3334, 82
for dietary therapy, 35
estimations of prevalence of, 33
gluten-free diet, 35
nutritional implications of, 3435
prevalence rates of, 33
symptoms of, 34
Celiac sprue. See Celiac disease
Children
iron deficiency in, 76
with sickle cell disease, 84
Chondroitin, for osteoarthritis, 6869
Chronic diarrhea, 31
Chronic kidney disease (CKD), 98107
characterization of, 98
definition of, 98
goal of management of
phosphorus, 104
112
INDEX
INDEX
113
114
INDEX
Glutamine, 43, 44
Gluten-free diet, 35
Gluten-sensitive enteropathy. See
Celiac disease
Gout, 7174
low, moderately high and very high
purine foods, 7273t
nutrition interview considerations
for the individual with, 72t
nutrition recommendations for
acute attacks and between
gouty flare-ups, 7374t
risk of, 71
Gouty flare-ups, 71
Helicobacter pylori, 15
Heme iron, 78
Hemochromatosis, 81
Hemodialysis (HD), 99
potassium needs and restrictions
in, 101
Hemoglobin, 80
Hepatitis, 95
Hiatal hernia, 1415
GERD and, 14
High-density lipoproteins (HDLs),
7, 7t
Hip fracture, 54
Hydrochloric acid (HCl), 18
Hyperkalemia, 101
Ileocecal sphincter, 3
Ileum, 2, 5
Infectious diarrhea, 31
Inflammatory bowel disease (IBD),
4144. See also Crohns
disease; Ulcerative colitis
diet therapy in, 43
food diary for, 43
foods to avoid with, 46t
global rates of, 41
high-oxalate foods to avoid with, 44t
nutritional management of, 4344
nutrition concerns in person with, 42t
presence of, 42
recommended foods for, 45t
Insoluble fiber
in fruits and vegetables, 25
gas and, 29
Institute of Medicines Food and
Nutrition Board, 58
Institutes of Medicine (IOM), 64
Intestinal gas, 2931
foods producing, 31t
precautions for reducing, 30
simple sugars causing, 30t
Intrinsic factor, pernicious anemia
and, 8182
Iron, 7681
absorption, 78
approaches to enhancing, 79t
factors limiting, 78t
childhood poisoning and toxicity,
81
for chronic kidney disease, 100
containing foods, 79t
dietary sources of, 78
factors increasing risk of deficiency,
77
recommended dietary allowances
for, 77t
supplements, 7981
tolerable upper intake level for, 81
Irritable bowel syndrome (IBS),
3841
causes of, 39
FODMAPs approach to
management, 4041
nutrition assessment for, 39
nutrition interventions for, 40t
triggers and symptoms, 39
Jejunum, 2, 5
Kidney stones, 9798
nutrition prescription for, 98
types of, 97
Kyphosis, 54
INDEX
Lact-Aid, 30
Lactose, 30t
Large intestine, 2
Lipid absorption, 6
Lipoproteins, 7, 7t
Low-density lipoproteins (LDLs), 7, 7t
Lower esophageal sphincter (LES), 3,
1213
Low-fiber therapy, 37
Low residue diet, diverticular disease,
3738t
Lupus, 7576
causes of, 75
diet and, 75
Lupus Foundation of America, 75
Mannitol, 41
Medical nutrition therapy
for gout, 72
of lower GI tract, 2346
Megaloblastic anemia
characterization of, 83
by folate deficiency, 8384
by vitamin B12 deficiency, 8283
Metabolic syndrome, fatty liver and, 92
Microvilli, 23
Minerals, in IBD management, 4344
Muscular sphincters, digestion and, 3
National Center for Complementary
and Alternative Medicine
(NCCAM), 68
National Dysphagia Diet (NDD), 10
food considerations, 11t
liquid consistencies, 12t
National Health and Nutrition
Examination Survey
(NHANES), 62
National Institute of Arthritis and
Musculoskeletal and Skin
Diseases (NIAMS), 68
National Institute of Diabetes and
Digestive and Kidney
Diseases, 91
National Institutes of Health (NIH), 68
115
116
INDEX
INDEX
117
Vertebrae, osteoporosis-related
fractures of, 54
Very low-density lipoproteins
(VLDLs), 7, 7t
Vitamin B12, 3435
and folic acid, 82
megaloblastic anemia by
deficiency, 8283
pernicious anemia and, 8182
treatment for deficiency, 83
Vitamin C, iron and, 78, 80
Vitamin D
for chronic kidney disease, 100
content of various foods, 63, 63t
dietary reference intakes for, 64t
intake and recommendations for
weakened bones, 6364
roles of, 63
supplements, 6465
Vitamins, in IBD management, 4344
Weight-bearing exercises, bone loss
and, 57
Xerostomia. See Dry mouth
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