Chapter 13

anorexia

• Defined as a lack of appetite

• Common symptom of many physical conditions

• Side effect of certain drugs

• Emotional issues

• Actions: Aim to stimulate appetite to maintain adequate nutritional intake

Interventions that may help anorexia

• Serve food attractively and season according to individual taste.

• Schedule procedures and medications when they are least likely to interfere with meals, if possible.

• Control pain, nausea, depression with meds as ordered.

• Provide small, frequent meals.

• Withhold beverages for 30 minutes before and after meals.

• Offer liquid supplements between meals.

• Limit fat intake if fat is contributing to early satiety

Nausea & Vomiting

Short-term concern is fluid and electrolyte balance

Vomiting

prolonged periods of this, dehydration & weight loss are concerns

Nutrition intervention for nausea

• Food is withheld until it subsides.

• Clear liquid diet, then progress to regular diet as tolerated.

• Small meals of easily digested carbohydrates.

• Serve foods at room temperature or chilled.

• Avoid high-fat & spicy foods if they contribute to this

Gastroesophageal Reflux Disease (GERD)

• Abnormal reflux of gastric contents into esophagus r/t an abnormal relaxation of lower esophageal sphincter.

• Indigestion, heartburn, and regurgitation are common.

• Pain frequently worsens when the person lies down, bends over after eating, or wears tight-fitting clothing.

• Other contributing factors:

  • Increased intra-abdominal pressure.

  • Decreased esophageal motility.

Treatment of GERD

Lifestyle modification, including nutrition therapy.

• Elevate head of bed 6-8 in. & avoid lying down for 3 hours after meals to limit esophageal acid exposure.

• Avoid alcohol, limit caffeine, chocolate, & peppermint.

• Avoid spicy food.

• Limit fat intake.

Drug Therapy

• Take ant reflux medications, antacids, or PPI’s.

Surgical Intervention (if necessary)

Peptic Ulcer Disease

• Characterized by erosion in the mucosa in the stomach, duodenum, or esophagus.

• Most common cause is an H. pylori infection. Second leading cause is the use of NSAIDs. 

• Most common symptom is epigastric pain, described as gnawing or burning usually worse at night or when the stomach is empty.

• Less frequent symptoms include bloating, early satiety, bleeding, tarry stools, and nausea.

• Pain, food intolerances, or loss of appetite may impair intake and lead to weight loss

• Iron-deficiency anemia can develop from blood loss.

• No evidence that diet causes this or speeds ulcer healing

Treatment/How to alleviate symptoms of Peptic Ulcer Disorder

• Avoid liquids with meals bc liquids promote feeling of fullness.

• No evidence that diet causes this or speeds healing.

• Some evidence suggests that a high-fiber diet, especially soluble fiber, may reduce the risk of duodenal ulcer.

• Avoid foods that stimulate gastric acid secretion— namely, coffee (decaffeinated and regular), alcohol, and pepper.

• Avoid eating 3 hours before bed.

• Avoid individual intolerances.

  • Alcohol, smoking, black pepper, caffeine, coffee, tea, mint, chocolate, and tomatoes.

• Probiotics may be a helpful adjunct to antibiotic therapy in eradicating H. pylori.

Dumping Syndrome

• Rapid emptying of stomach contents into the intestine.

• Can cause nausea, vomiting, diarrhea, and abdominal pain.

• Weakness, dizziness, hypotension, tachycardia, bc volume of circulating blood decreases.

• Maldigestion, malabsorption, & decreased intake which causes weight loss and increases the risk of malnutrition

Nutrition therapy for dumping syndrome

• Small, frequent meals with protein and fat at each meal

• Avoid concentrated sugars.

• Restrict lactose.

• Consume liquids 1-hour before or after eating instead of with meals.

Constipation

less than 3 bowel movements a week and passing stools that are hard, and excessive straining during defecation.

Nutrition therapy for constipation

• Increasing fiber/fluid intake effectively relieves and prevents constipation.

• High-fiber diet. Gradually increased

• Adequate intake set for fiber is 25-38 g/day spread throughout the day.

• Fiber supplements may be necessary

Lifestyle changes to promote bowel regularity

• drinking more fluid (64 oz/day)

• increasing aerobic exercise.

• consuming probiotics or prebiotics daily.

Diarrhea

• Increase in frequency of bowel movements and/or water content of stools.

• Can lead to dehydration, hyponatremia, hypokalemia (potassium), acid–base imbalance, & metabolic acidosis.

• Chronic = malnutrition, impaired digestion, absorption, and intake.

Nutrition therapy for diarrhea

• Primary concern is maintaining or restoring fluid and electrolyte balance.

• Mild diarrhea lasting 24 to 48 hours usually requires no intervention other than fluid intake. For more serious cases, commercial or homemade oral rehydration solutions may be used.

• May be improved by avoiding foods that stimulate GI motility.

• Low-fiber, fat & lactose may help decrease bowel stimulation.

• Probiotics may help.

Malabsorption Disorders

• the body fails to properly absorb nutrients from food, often due to issues in the small intestine, leading to deficiencies and symptoms like diarrhea and weight loss

• goal is control steatorrhea (fat in poop) & promote normal bowel elimination

• restore optimal nutritional status

• lactose intolerance, IBD (crohn’s & ulcerative colitis), celiac disease

• promote healing, when applicable

Lactose malabsorption/intolerance

• Occurs when the level of lactase is absent or deficient.

• Lactose digestion is impaired.

• Undigested lactose increases the osmolality of the intestinal contents.

• Produces bloating, cramping, and flatulence.

• May be asymptomatic when less than 12 g of lactose consumed (⅓ to 1 cup of milk) or when lactose is consumed as part of a meal.

Lactose

fermented in the colon

Nutrition therapy for lactose malabsorption/intolerance

• Lactose-reduced milk & enzyme tablets or liquid may be used.

• Reduce lactose to the maximum amount tolerated by the individual.

• A lactose-free diet is not realistic

Inflammatory Bowel Disorder

• Periods of exacerbation and remission

• Includes Crohn’s disease and ulcerative colitis. These cause chronic inflammation of the digestive tract leading to symptoms such as severe diarrhea, abdominal pain, and weight loss.

• Nutrition therapy depends on the S/S, presence of complications, & nutritional status.

• Diet restrictions kept to a minimum.

• Patients are often reluctant to eat

Crohn’s Disease

• inflammation in the small intestine

• characterized by periods of exacerbation and remission

• Vitamin D & zinc may lower the risk

• Increases risk of malnutrition

• more likely to cause nutritional complications.

Diet for Crohn’s Disease and Ulcerative Colitis

• A diet rich in fruits, vegetables, and omega-3 fatty acids and low in omega-6 fatty acids is associated with a decreased risk

• low residue, high protein, high calorie

Ulcerative colitis

• the ulceration of the lining in the large intestine. 

• Avoid high-fiber foods, high-fat foods, spicy foods, dairy products, & alcohol, as these can irritate the GI tract & worsen symptoms.

• A diet rich in fruits, vegetables, and omega-3 fatty acids and low in omega-6 fatty acids is associated with a decreased risk

• Low fiber is recommended to minimize bowel stimulation.

• Protein & calorie needs are elevated to facilitate healing.

• Diet modifications are made according to symptoms.

Celiac Disease

• Genetic autoimmune disorder characterized by chronic inflammation of the proximal small intestine mucosa.

  • people who have an autoimmune disease are at risk for this

• S/S in children = diarrhea, abdominal distention, and failure to thrive.

• Adults = diarrhea, constipation, weight loss, weakness, flatus, abdominal pain, and vomiting.

• Related to a permanent intolerance to certain proteins found in wheat, barley, and rye.

• Malabsorption of nutrients may occur, resulting in diarrhea, flatulence, weight loss, and vitamin and mineral deficiencies.

• Only proven treatment is to eliminate gluten.

foods to avoid with celiac disease

• Grains: Wheat, rye, barley, oats spelt, couscous, semolina, & products
  made from these grains (bread, pasta, crackers, etc.)

• Processed Foods: May contain hidden gluten, check ingredients.

• Condiments and Sauces: Some sauces, dressings, and condiments may contain gluten.

• Alcohol: Certain alcohol, like beer and ale, are not gluten-free.

• Certain Medications: Some meds/multivitamins may contain gluten as a filler.

• Cosmetic products: Lip glosses or lip balms might contain gluten

foods that are okay for those with celiac disease

• Naturally Gluten-Free: Fruits, vegetables, meat, fish, poultry, eggs, dairy products, nuts, seeds, beans, lentils, rice.

• Gluten-Free Grains: Corn, rice, quinoa, amaranth, buckwheat,
  sorghum, millet.

• Gluten-Free Versions: of grains, like bread, pasta, and baked goods, are available.

• Gluten-Free Chocolate: Pure chocolate (dark, milk, or white) is naturally gluten-free.

Irritable Bowel Syndrome (IBS)

• A disorder that causes abdominal pain or discomfort, bloating, and a change in bowel habits that cannot be explained by any underlying cause.

• Most frequently diagnosed GI disorder in the U.S.

• S/S: Lower abdominal pain, constipation, diarrhea, alternating constipation & diarrhea, bloating, & mucus in the stools. Can impair quality of life.

Nutrition Therapy for People with IBS

• Restriction of FODMAPs has been shown to be effective

• A low FODMAP diet restricts certain carbohydrates that are hard to digest to see if symptoms improve. 

• Eat smaller, more frequent meals.

• Reduce fat intake. Avoid caffeine, chocolate, and alcohol.

• Slowly increase soluble fiber intake.

FODMAP

fermentable oligosaccharides, disaccharides, monosaccharides and polyols

Low FODMAP Foods

Foods include those low in carbs

• Fruits: Grapes, strawberries, blueberries, bananas, pineapples, and oranges (in moderation).

• Vegetables: Carrots, zucchini, cucumbers, bell peppers, green beans, spinach, and bok choy.

• Grains: Rice, quinoa, oats, and gluten-free bread (in moderation).

• Nuts and Seeds: Macadamia nuts, peanuts, pine nuts, and pumpkin seeds.

• Proteins: Plain-cooked meats, tofu, eggs, and fish.

• Dairy: Hard and aged cheeses, crème fraîche, and sour cream (in moderation).

• Other: Almond milk, rice milk

High FODMAP Foods

• Fruits: Apples, watermelon, stone fruits (peaches, plums), & mangoes.

• Vegetables: Artichokes, asparagus, cabbage, onions, garlic, and cauliflower.

• Grains: Wheat, barley, rye, and amaranth.

• Nuts and Seeds: Cashews and pistachios.

• Legumes: Beans, lentils, and chickpeas.

• Dairy: Milk, yogurt, and soft cheeses (high in lactose).

• Other: Artificial sweeteners containing polyols.

Diverticular Disease

• Encompassing diverticulosis and diverticulitis, is a condition affecting the large intestine characterized by small pouches (diverticula) forming in the colon wall, which can become inflamed or infected

• Typically, asymptomatic.

• Uncomplicated (inflammation of 1 or more diverticula) or complicated if abscess, perforation, fistula formation, or obstruction occur.

• Dietary factors that increase the risk include red meat intake, particularly unprocessed red meat

• Avoid popcorn, nuts, and foods that contain seeds because these can collect in the diverticula and cause inflammation.

diverticulosis

• A condition where small pouches or sacs called diverticula develop in the colon (typically in the lower part). It is extremely common in older adults. 

  • characterized by the presence of diverticula

• Risk factors: diet low in fiber and high in red meat, lack of exercise, obesity, smoking, medications like NSAIDs and steroids, and a family history of diverticulosis. 

• A high fiber diet can prevent this

• Majority of people do not have any symptoms, however some may experience bloating, constipation, and mild cramping. 

diverticulitis

• Occurs when diverticula (the pouches that form off of the colon) become inflamed or infected (could be from fecal matter).

• s/s: pain in the lower left side of the abdomen, fever & chills, nausea & vomiting, fever & chills, and possibly blood in the stool.

• A high fiber diet can prevent this

complications of diverticulitis

• Includes bleeding, abscess, intestinal blockage, perforation (tear or hole in the colon), and peritonitis (inflammation of the lining of your abdominal cavity). This will require hospitalization where IV fluids will be administered as well as IV antibiotics and pain medication.

• Blood transfusions may be necessary for patients who have bleeding and surgery may be required for abscesses and perforation. In some cases part of the colon may be removed. 

treatment for diverticulitis

• Treatment depends on the severity of symptoms. For uncomplicated _________, a clear liquid diet is typically recommended to rest the colon. Pain can be resolved with over the counter pain reliever and an oral antibiotic can be prescribed. When the symptoms start to get better, you can slowly start adding solid food back in your diet, specifically low fiber foods (white bread, eggs, chicken). When your symptoms are completely resolved you need to start adding high-fiber foods back into your diet gradually. 

• Lifestyle changes: consume a high-fiber diet and a diet low in red meat, physical activity, maintaining a healthy weight, quitting smoking.  

Ileostomies

•  A stoma is created from the small intestine

• Performed after part or all the colon, anus, & rectum are removed.

• Cause a decrease in fat, bile acid, and vitamin B12 absorption.

• Results in 1200 mL of output each day. Stools are liquid to semi-liquid (because the stoma is higher up in the intestine so less water is absorbed)

• Consume a low fiber diet for the first 6 weeks after the procedure, increase fluids, chew foods thoroughly to prevent stomal blockage, and consume meals on a schedule to promote a regular bowel movement. 

• Foods that cause gas like alcohol, cabbage, dairy, broccoli, beans, and eggs should be avoided. 

colostomy

• the stoma is created from the large intestine/colon

• there is little or no nutrient loss.

• Output out 200 to 600 mL/day.

• Stools range from semi-liquid to hard

• Consume a low fiber diet for the first 6 weeks after the procedure, increase fluids, increase soluble fiber, chew foods thoroughly to prevent stomal blockage, and consume meals on a schedule to promote a regular bowel movement. 

• Foods that cause gas like alcohol, cabbage, dairy, broccoli, beans, and eggs should be avoided. 

Nutrition therapy for ileostomoies and colostomies

• Avoid mushrooms, nuts, corn, coconut, celery, and dried fruit for the first 2 weeks after surgery.

• Slowly reintroduce these foods, as desired, in moderation.

• Eat a source of protein at each meal and snack.

• Consume adequate fluid.

  • At least 80 oz/day may be needed to protect kidney function.

• Consume a low fiber diet for the first 6 weeks after the procedure, increase fluids, increase soluble fiber, chew foods thoroughly to prevent stomal blockage, and consume meals on a schedule to promote a regular bowel movement. 

• Foods that cause gas like alcohol, cabbage, dairy, broccoli, beans, and eggs should be avoided. 

Liver

• After absorption, almost all nutrients are transported to the ———-.

• Vital for detoxifying drugs, alcohol, ammonia, and other poisonous substances.

• Damage can have profound and devastating effects on the metabolism of almost all nutrients.

• Failure can occur from chronic liver disease or secondary to critical illnesses.

Pancreatitis

• inflammation of the pancreas; can be acute or chronic

• Often triggered by drugs, alcohol, gallstones, or hypertriglyceridemia.

  • In 70% of acute cases, alcohol use and gallstones are major causes

  • Chronic results from acute that is not resolved

• Characterized by loss of organ function, diabetes, steatorrhea, and malabsorption with resulting diarrhea and malnutrition.

• Patient may be NPO for acute ________

• Patient may need an NG tube for bowel rest.

• In severe cases, early initiation of EN via NG route is recommended

Nutritional Therapy for Gallbladder Disease (Cholecystitis)

• Consume a low-fat diet.

  • it reduces the strain on the gallbladder, allowing it to rest and potentially heal, and minimizes the risk of triggering painful contractions

• Increase soluble fiber intake.

  • Soluble fiber absorbs water and adds bulk to stools, promoting regular bowel movements and preventing constipation. 

• Consider prebiotics and probiotics, especially if the client has diarrhea.

• Consume small meals if reflux is a problem.

• Avoid any foods not tolerated, which may or may not include spicy foods and caffeine.

• Consider micronutrient supplements.

Choleslithiasis

• A fancy name for gallstones.

• Most people with gallstones do not have s/s, however gallstones can obstruct the cystic duct leading to inflammation of the gallbladder which is cholecystitis. 

cholecystitis

• gallstones can obstruct the cystic duct leading to inflammation of the gallbladder which is... 

• s/s include right upper quadrant abdominal pain, pain after the ingestion of high-fat foods, nausea & vomiting, bloating, and gas. 

Cirrhosis

• A disorder characterized by damage and scarring of the liver

• Key causes include alcoholism, non-alcoholic fatty liver disease, and chronic hepatitis. 

• S/S: fatigue, nausea & vomiting, jaundice, ascites (the accumulation of fluid within the peritoneal cavity, the space between the lining of the abdomen and the abdominal organs), and bleeding.

• Limit sodium intake, consume small and frequent meals, take vitamin and mineral supplements, and abstain from alcohol. 

gallbladder

stores and concentrates bile, which is essential for digesting fats

Nutrition therapy for Disorders of the Accessory GI Organs (cirrhosis, pancreatitis, gallbladder)

• Encourage an oral diet.

  • Clear liquid diets are not necessary.

• Most clients managed with an oral diet and pancreatic enzyme replacement.

• Low fat diets to reduce abdominal pain.

• A carbohydrate-controlled diet is indicated for clients with diabetes.

• Oral nutrition supplements can help promote an adequate intake of protein and calories.