Carbohydrate FatModified Diets for Malabsorption Chapter 19 Nutrition

Carbohydrate- & Fat-Modified Diets for Malabsorption Chapter 19 Nutrition & Diet Therapy (7 th Edition)

I. Malabsorption Syndromes • Malabsorption disorders- most harmful to nutrition status and result in: – Nutrient deficiencies – Weight loss – Serious complications • Disorders associated with malabsorption – – – Genetic disorders Pancreatic disorders Intestinal infections Liver disease (bile insufficiency) Surgeries • Rarely involves single nutrient • Treatment of malabsorption disorders (surgery and medications) may also weaken nutritional status Nutrition & Diet Therapy (7 th Edition)

Nutrition & Diet Therapy (7 th Edition)

Malabsorption Syndromes cont’d • Fat malabsorption – Causes • Illness that interferes with production or secretion of bile (severe liver disease) or pancreatic lipase (pancreatitis, cystic fibrosis) • Damage to intestinal mucosa (inflammatory disorders or radiation treatments) • Motility disorders causing rapid gastric emptying or intestinal transit Nutrition & Diet Therapy (7 th Edition) – Consequences: losses of food energy, essential fatty acids, fat-soluble vitamins, some minerals • Weight loss • Deficiencies of fat-soluble vitamins • Formation of soaps by some minerals & unabsorbed fatty acids • Bone loss from calcium deficiency • Increased risk of kidney stones (Ca oxalates)

• Fat malabsorption (con’t) – Dietary adjustments: fat-restricted diet • Relief of abdominal symptoms (diarrhea & flatulence) • Minimize loss of vitamins & minerals • Fats should not be restricted more than necessary • Alternative source of dietary fat: mediumchain triglycerides (MCT) Nutrition & Diet Therapy (7 th Edition) MCT Triglycerides with fatty acids that do not require digestion; can be absorbed without lipase or bile

Malabsorption Syndromes cont’d • Bacterial overgrowth – Gastric acid & peristalsis protect stomach & small intestine from bacterial overgrowth – When overgrowth does occur, disrupts fat digestion & absorption – Eventually results in deficiencies of fat-soluble vitamins – Bacteria compete with vitamin B 12, impairing its absorption – Symptoms: chronic diarrhea, abdominal discomfort, bloating, weakness, weight loss Nutrition & Diet Therapy (7 th Edition)

• Bacterial overgrowth (con’t) – Causes • Impaired intestinal motility – Some types of gastric surgery – Strictures, obstructions & diverticula in small intestine • Reduced secretion of gastric acid – Atrophic gastritis – Acid-suppressing medications – Acid-reducing surgery – Treatment • Antibiotics • Surgical correction of anatomical defects • Dietary supplements-fat soluble vitamins, Ca, vit B 12 Nutrition & Diet Therapy (7 th Edition)

II. Lactose Intolerance • High incidence: approximately 75% of population worldwide – Rarely serious – Most individuals (with lactose intolerance) can tolerate milk if consumed with other foods & limit amount consumed at one time • Cause: reduction or loss of lactase, enzyme that digests lactose in milk products • Prevalent among certain ethnic groups: Asians, African Americans, Native Americans, Ashkenazi Jews, Latinos Nutrition & Diet Therapy (7 th Edition) • Dietary management – Gradually increased consumption of lactosecontaining products – Divide milk intake throughout the day – Consume milk with meals – Chocolate milk may be better tolerated than plain – Aged cheeses well tolerated (little lactose content) – Yogurts with live bacterial cultures that aid in lactose digestion – Low lactose or acidophilus milk? – Addition of lactase preparation to milk or use of enzyme tablet before consumption

III. Disorders of the Pancreas • Maldigestive and malabsorption problems due to impaired secretion of digestive enzymes • Pancreatitis – Inflammatory disease, resulting in damage to pancreatic tissue & release of enzymes – Acute pancreatitis • Usually caused by gallstones, excessive alcohol use; also caused by high blood triglycerides, exposure to toxins • Symptoms: severe abdominal pain, nausea & vomiting, abdominal distention • Usually resolves within a week without complications • MNT: NPO>clear liquids>low fat diet or hydrolyzed TF Nutrition & Diet Therapy (7 th Edition)

• Pancreatitis (con’t) – Chronic pancreatitis may cause irreversible damage & loss of pancreatic function – Majority of cases (70%) of chronic pancreatitis caused by excessive alcohol consumption – Symptoms: severe abdominal pain; may be unrelenting & worsens when eating Nutrition & Diet Therapy (7 th Edition) – Consequences • Fat maldigestion • Maldigestion of protein & carbohydrate • Steatorrhea in advanced cases • Weight loss & malnutrition due to food avoidance • Reduction in insulin & glucagon secretions, resulting in diabetes • Medical nutrition therapy – Dietary supplements to correct nutrient deficiencies – Avoidance of all alcohol – Pancreatic enzyme replacement

Disorders of the Pancreas cont’d • Cystic fibrosis – Genetic disorder characterized by abnormally thick exocrine secretions; often leads to respiratory illness & pancreatic insufficiency – Consequences • Major complications: involve lungs, pancreas, sweat glands • Persistent respiratory infections, causing inflammation of bronchial tissues & progressive airway obstruction • Accumulation of digestive enzymes in pancreas due to thick pancreatic secretions that obstruct pancreatic ducts • Malabsorption of protein, fat & fat-soluble vitamins • Excessive loss of salt in sweat, increasing dehydration • Chronic undernourishment, poor growth, difficulty maintaining body weight • Pancreatitis, Hyperglycemia & diabetes Nutrition & Diet Therapy (7 th Edition)

• Cystic fibrosis (con’t) – Medical nutrition therapy • Increased energy intake (children may need 120150% of recommended energy intake for normal growth & nutrition status) • High-kcalorie & high-fat foods • Frequent meals & snacks • Supplement meals with milk shakes or liquid dietary supplements • Supplemental tube feedings if energy intake is inadequate • Pancreatic enzyme replacement at every meal or snack • Multivitamin & fat-soluble vitamin supplements • Liberal use of table salt & salty foods Nutrition & Diet Therapy (7 th Edition)

IV. Disorders of the Small Intestine • Malabsorption common consequence when intestinal mucosa damaged due to inflammation or infection • Celiac disease – Abnormal immune response to wheat gluten, causing severe intestinal damage & nutrient malabsorption – Also referred to as gluten-sensitive enteropathy or celiac sprue – Symptoms: GI disturbances such as diarrhea, steatorrhea & flatulence; symptoms exacerbated by milk products Nutrition & Diet Therapy (7 th Edition)

Comparison of Villi Healthy Intestine-Villi Nutrition & Diet Therapy (7 th Edition) Celiac Intestine-Villi

• Celiac disease (con’t) – Consequences • Immune reaction to gluten causing changes in intestinal tissue – Reduction in mucosal surface area & digestive enzymes – May be restricted to duodenum or involve entire small intestine • Malabsorption of all nutrients, especially macronutrients, fat-soluble vitamins, electrolytes, calcium, magnesium, zinc, iron, folate, vitamin B 12 • Stunted growth in children, severe underweight • Iron-deficiency anemia • Low bone mineral density Nutrition & Diet Therapy (7 th Edition)

• Celiac disease (con’t) – Medical nutrition therapy • Life-long adherence to gluten-free diet • Symptom relief usually evident within weeks, but mucosal healing may take years • Avoidance of lactosecontaining foods if lactose intolerant • Dietary supplements Nutrition & Diet Therapy (7 th Edition) Gluten-free diet • Elimination of foods containing wheat, rye, barley • Careful review of all ingredients on food labels (even small amounts of gluten can aggravate symptoms) • Use of gluten-free products

MNT for Celiac Disease Nutrition & Diet Therapy (7 th Edition)

Nutrition & Diet Therapy (7 th Edition)

Disorders of the S. I. cont’d • Short-bowel syndrome – Malabsorption syndrome that follows resection of small intestine, causing insufficient absorptive capacity in remaining intestine – Surgical resection of major portion of small intestine (treatment of Crohn’s disease, small intestinal cancers, other intestinal disorders) – Results in fluid & electrolyte imbalances, multiple nutrient deficiencies – Symptoms: diarrhea, steatorrhea, dehydration, weight loss, growth impairment (in children) Nutrition & Diet Therapy (7 th Edition)

Nutrition & Diet Therapy (7 th Edition)

• Short-bowel syndrome (con’t) – Intestinal adaptation: process of intestinal recovery, after resection, leading to improved absorptive capacity – Ileum has greater adaptive capacity than jejunum • Permanent effects on vitamin B 12 nutrition & bile acid reabsorption if ileum removed—worsens fat malabsorption & diarrhea • Removal of sphincter between ileum & cecum may result in infiltration of colonic bacteria into small intestine, causing bacterial overgrowth Nutrition & Diet Therapy (7 th Edition)

• Short-bowel syndrome (con’t) – Medical nutrition therapy • Immediately after surgery: fluid & electrolyte replacement (intravenous) • First weeks: rehydration of diarrheal fluid losses • Total parenteral nutrition, gradually reduced as oral feeding resumes • Introduction of oral feedings as soon as possible to promote intestinal adaptation – – – Sips of liquid formulas, progressing to larger amounts Solid foods, as tolerated Small, frequent feedings Low-fat, high-carbohydrate diet, if steatorrhea Vitamin & mineral supplements Low-oxalate diet to reduce risk of kidney stone development Nutrition & Diet Therapy (7 th Edition)

Nutrition in Practice— Anemia in Illness • Anemia: condition of having too few red blood cells – Frequently first sign of another illness – May be reason for seeking medical attention – Develops when red blood cells (erythrocytes) are not produced in sufficient quantity, destroyed too quickly, lost due to bleeding – Red blood cells contain hemoglobin that carries oxygen to tissues – Produced in bone marrow (erythropoiesis) – Causes: Blood loss, malabsorption, chronic illnesses, medications Nutrition & Diet Therapy (7 th Edition)

Red Blood Cell Production Nutrition & Diet Therapy (7 th Edition)

Nutrient Deficiencies & Anemia Nutrient Actions Result of Deficiency Iron Required for hemoglobin production Microcytic anemia: small, hypochromic cells Vitamin B 12 & Folate Maintains cell membrane integrity Macrocytic anemia: large, immature cells Vitamin E Role in hemoglobin Hemolytic anemia: RBC breakdown production Vitamin B 6 Role in hemoglobin production Microcytic anemia Vitamin C Supports blood vessel integrity Fragile, bleeding capillaries Protein Energy Malnutrition Protein synthesis needed for RBC development Anemia Nutrition & Diet Therapy (7 th Edition)