Nutrition 101: When, What, How to Feed

Nutrition 101: When, What, How to Feed

A Case-based Approach to Gastroenterology

Kimberly Carter, MS, PA-CDivision of Gastroenterology

University of PennsylvaniaKimberly.Carter2@uphs.upenn.edu

Nutrition: Why should we care….

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

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.

Nutritional Therapy

Nutrition Support

Nutritional Status

Nutrition in GI Disease: Nutritional Status

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.

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

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.

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.

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.

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

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.

Physical SignsSigns Deficiencies

Alopecia Protein energy malnutrition

Brittle Hair Biotin

Follicular keratosis Vitamin A

Ecchymosis Vitamin C or K

Seborrheic dermatitis Vitamin B2, Niacin, Vitamin B6

Spoon-shaped nails Iron

Cheilosis Vitamin B2, Vitamin B6

Bleeding gums Vitamin C

Glossitis Niacin, Folate, Vit B12, Vit B2, Vit B6

Magenta Tongue Vitamin B2

Loss of DTRs Vitamins 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).

Poor nutrient intake and excessive losses may contribute to malnutrition.

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

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

Assessment: Is this patient malnourished?

Nutrition in GI Disease:Nutrition Support

Nutrition Intervention• Oral nutrition supplements• Enteral Nutrition• Parenteral Nutrition

Nutrition Support

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

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

Nutrition Support• Multi-disciplinary team• Refeeding Syndrome

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.

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

Clinical Consequences SGSTable 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

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

Short Gut Syndrome Medical Nutrition Therapy (MNT)

Table 2. General Management Strategies for SBSFluids

Avoid drinking water without foodSpread fluid intake throughout the daySip liquidsRestrict hypotonic fluidsDrink oral rehydration solution containing salt and carbohydrates

DietEat small, frequent meals balanced in nutrient contentAdd salt to the diet (only for patient with colon in continuity)Increase quantity of food intakeFollow 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

Short Gut Syndrome MNT• Hypomotility agents• Rotating antibiotics• Enzyme replacement

Short Gut Syndrome

Site Nutrient (s) absorbedStomach Cu, IDuodenum Fe, Zn, Cu, Se, Vit D,

E, K, B1, B2, B3, folate, Ca

Jejunum Zn, Se, Fe, Ca, Cr, Mn, Vit A, D, E, K, B1, B2, B3, B5, B6, folate, Vit C

Ileum Vit C, D, K, B-12, folate

Shortgutsupport.com

Nutrition in GI Disease:Nutritional Therapy

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

Nutrition and RYGB Malabsorption• Many patients stop supplements after

bariatric surgery• Look for other micronutrient deficiencies• Often subtle deficiencies are asymptomatic

Nutrition and Malabsorption• Hypoalbuminemia• Steatorrhea• Fe deficiency anemia• B 12 deficiency• Thiamine deficiency

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.

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.

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 intakeHeber 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.

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

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

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

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

Nutrition and Celiac Disease• Micronutrient deficiencies• Pancreatic insufficiency

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

Management of Celiac Disease

C Consultation with a skilled dietitianE Education about the disease

L Lifelong adherence to a gluten-free diet

I Identification and treatment of nutritional deficiencies

A Access to an advocacy group

C Continuous 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.

Nutrition in GI Disease:Nutritional Therapy

Nutrition and IBS• Multifactorial: visceral hypersensitivity, gut

flora, diet

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

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.

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.

FODMAP Diet

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

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

FODMAP Approach• Provides therapeutic strategy to manage

symptoms.• Use of dietitian is paramount.• Address long-term efficacy and safety of

dietary intervention.

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

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

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

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

Nutrition and Eosinophilic Esophagitis• Chronic allergic disease• Elimination diet

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

Therapeutic Approach• Treat underlying etiology• Diet• Vitamin/Mineral supplementation• Nutrition support• Pharmacotherapy

• If underlying etiology is irreversible-target symptoms• Anti-diarrheal• PERT

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