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ADVANCED DIPLOMA IN PRINCIPLES OF NUTRITION
@ShawPhotoTomCourse Educators: Thomas Woods, William Eames
BY AMANDA BRODERICK BSc ANutR
BSC HONS Sports Biomedicine and Nutrition
BY AMANDA BRODERICK LESSON: 2
Course Educator:
Amanda Broderick Course Educator
B.A. (Hons.)
Special Diets Semester :
Lesson 5Nutritional Management of Digestive Disorders
@ShawNutritionA [email protected]
Lesson 5 Learning Outcomes
What is digestion?
Malabsorption
Lactose Intolerance
Coeliac disease
Irritable bowel syndrome (IBS)
Case Study 2
The Digestive System
The major organs that coordinate digestion include:
• Mouth• Oesophagus• Stomach• Small intestine• Large intestine• Liver
Breakdown of food into smaller particles or individual nutrients
What is Digestion?
Digestion: http://www.youtube.com/watch?v=b20VRR9C37Q
Receives food and breaks it down into smaller molecules
Biting and chewing Food is moistened by saliva - secreted by
salivary gland Amylase (enzyme in saliva) digests starch
molecules to maltose (disaccharide)
What Happens in The Mouth?
Thick-walled muscular tube located behind the windpipe and extends through the neck and chest to the stomach
Peristalsis (muscle contraction) - transports bolus of food to stomach
Oesophagus
Muscle contractions in the stomach churn the bolus of food with gastric juices to form a liquid called “chyme”
Pepsinogen is released and converted to “pepsin” (enzyme) in the presence of stomach hydrochloric acid (HCL)
Pepsin digests proteins to peptides
Stomach
Digestion in the stomach: http://www.youtube.com/watch?v=URHBBE3RKEs
Small Intestine Chyme travels from stomach to small intestine
Adult small intestine is 23feet long
3 sections:
1) Duodenum,
2) Jejunum
3) Ileum
Inner surface is covered in finger like projections called
villi
Duodenum: chemical digestion- enzymes digest
nutrients into smaller forms for absorption
Intestinal enzymes provided by pancreas
Bile enters small intestine from gall bladder to assist in
fat digestion
Carbohydrates digested by amylase (for starch), maltase (for maltose), sucrose (for sucrose) and lactase (for lactose)
Fats digested by lipase after they are broken down into smaller droplets by bile
Bile: mixture of salts, pigments, and cholesterol produced by liver and stored in gall bladder
Proteins: digested by 2 pancreatic enzymes - Trypsin and Chymotrypsin…break peptides into smaller peptides
Peptidases reduces the enzymes to amino acids
Nucleases digest nucleic acids into nucleotides
Small Intestine- Enzyme Action
Enzymes involved in digestion:
Which Enzymes Digest What:
Jejunum: where most absorption occurs
Absorption occurs via villi
Final absorption of nutrients occurs in the Ileum
Substances that have not been digested or absorbed pass into Large Intestine
Small Intestine
Also known as the colon Divided into ascending, transverse and
descending portions (each 1foot long)
Primary functions:1) Absorb water2) Store, process and eliminate residue following
digestion and absorption
Faeces remain after water has been resorbed Faeces: non-digested food, bacteria, bile
pigments Faeces are stored in the rectum and passed out
through anus to complete digestion
Large Intestine
Removes excess glucose from bloodstream-converts to Glycogen for storage
Converts amino acids to compounds that can be used in energy metabolism in a process called Deamination
Produces urea which is excreted in urine
Liver: stores vitamins and minerals Forms blood proteins Synthesises cholesterol Produces bile for fat digestion
Liver
Important role in processing products of human digestion
Digestive Disorders
Can lead to malnutrition Can be nutrient specific (e.g. affecting fat or
carbohydrate) General (impairing the absorption of all nutrients)
Symptoms: Diarrhoea Abdominal distension Flatulence Weight loss Low albumin
Different types: Fat malabsorption – steatorrhoea - pale, malodourous,
greasy, unformed stool Carbohydrate malabsorption-watery and frothy stool
due to fermented sugars
Stool
abnormality
not always
distinct or
present
MalabsorptionInability to absorb nutrients
Anaemia Folate deficiency or vitamin B12 deficiency Bleeding, resulting from low vitamin K Oedema, which occurs in protein/energy
malnutrition
Causes of Malabsorption
Signs of deficiency:
Common Causes
Cystic fibrosis Chronic pancreatitis Coeliac disease
Milk intolerance Fructose intolerance Infection
Inflammatory bowel disease Immune deficiency HIV enteropathy
Lymphatic obstruction Medications Crohn’s disease
Short bowel syndrome Diverticular disease Thyroid problems
Eating disorders Collagen diseases Diabetes
Malnutrition Collagen diseases Addison’s disease
Blood tests Fasting blood count Plasma viscosity, CRP Vitamin B12 level Red cell folate Iron status Clotting screen for vitamin K deficiency Serum albumin Calcium (corrected for albumin level) Anti-endomyseal, anti-reticulin and alpha-gliadin
antibodies LFTs - liver function tests Serum magnesium
Stool tests Abdominal ultrasound Barium follow - through may show structural
abnormalities Ileocolonoscopy including biopsies of colon and ileum Breath hydrogen tests
Testing for Malabsorption
1. Dietary treatment of the primary disorder
2. Dietary measures to provide symptom relief
3. Daily replacement of large losses of fluid and electrolytes
4. Restoration of optimal nutritional status- by supplementation if
necessary
Dietary Treatment of Malabsorption
Aims of Nutritional Intervention
Results in loss of energy and fat-soluble vitamins A, D, E and K
Unabsorbed fatty acids may form complexes with minerals such as calcium, inhibiting their absorption
Can lead to nutritional deficiency and long-term health consequences e.g. osteoporosis
Pancreatic enzymes can be provided to aid fat malabsorption
Dietary fat intake may need to be reduced where medication has been unsuccessful
Fat Malabsorption
Deficiency of the enzyme lactase - impaired ability to digest dietary lactose
3 Main forms:
1) Hereditary alactasia- complete absence of lactase and requires lactose exclusion
2) Primary lactase deficiency- gradual reduction in lactase activity causing maldigestion
3) Secondary lactase deficiency- common, usually temporary- caused by damage to intestine
Carbohydrate Malabsorption
Lactose Intolerant:
Undigested lactose and products of its bacterial fermentation can cause gastrointestinal symptoms:
Lactose remaining in the intestine can cause: Abdominal pain Abdominal distension Flatulence/gas/cramps Explosive diarrhoea
Symptoms of Lactose Intolerance
Not everyone has physical symptoms
Many malabsorbers can tolerate moderate intakes of milk and milk products
Complete avoidance of lactose is unnecessary-may compromise calcium intake
Symptoms should stabilise at a low intake and lactose-containing foods can be reintroduced gradually in increasing amounts
Symptoms of Lactose Intolerance
Lactose tolerance test - tests body’s reaction to a liquid that contains high levels of lactose
Hydrogen breath test - if body doesn’t digest lactose, it will ferment in the colon releasing hydrogen and other gases
Stool acidity test - fermenting of undigested lactose creates lactic acid and other acids that can be detected in a stool sample
Tests and Diagnosis
Immune-mediated systemic disorder
Develops in genetically predisposed individuals
Triggered by gluten - protein found in wheat, rye, barley
Can be diagnosed at any age from early childhood to late old age
1 in 133 North Americans affected
Prevalence similar in Europe, South America, Africa and parts of Asia
Increased risk where 1st degree relative with CD, autoimmune thyroid disease, Type 1 Diabetes Mellitus and Down Syndrome
Flattening of villi - reduced absorption of nutrients
Coeliac Disease (CD)
Diarrhoea- most common
Abdominal discomfort
Malabsorption
Gastrointestinal upset
“Silent” presentations
Unexplained iron deficiency/anaemia
Osteoporosis
Fatigue/irritability/depression
Breathlessness
Bloating
Unexplained weight loss
Bone and joint symptoms
Constipation
Dental enamel defects
Infertility
Dermatitis Herpetiformis- skin disorder
IMPORTANT:
The nature of these
symptoms explains why the
condition is not always
recognised
A common misdiagnosis
is irritable bowel
syndrome
CD should therefore be
considered in any patient
with anaemia or symptoms
of tiredness, especially
when there is a family
history of the disease
Symptoms of Coeliac Disease
Malignancy:
At risk of intestinal lymphoma, mainly non-Hodgkin’s lymphoma
Risk is reduced by adherence to gluten free diet After approx. 5 years- risk reduced to that of general
population Increased risk of small bowel adenocarcinoma
Osteoporosis
Chronic malabsorption of calcium Reduced intake of calcium following diagnosis e.g. from
bread and cereals (fortified) Non-compliance with gluten free diet Daily target 1500mg calcium/day
Long-Term Consequences of Coeliac Disease
Most widely available test - tissue transglutaminase IgA antibody test
Estimated 90%-96% sensitivity and specificity of 95%
All adults with abnormal screening result should undergo small-bowel biopsy to confirm diagnosis of coeliac disease
Adopting a gluten free diet is not recommended unless diagnosis is confirmed
Tests and Diagnosis
Screening recommended for people with associated symptoms or family history of
coeliac disease
No cure exists
for IBS: the
symptoms can
be managed by
making changes
to diet and
lifestyle
Symptoms: Stomach cramps Bloating Diarrhoea Constipation Symptoms do not pose long-term health risks
Age of occurrence: Between 20 and 30 years
Cause: Unknown- most likely increased sensitivity of the entire
gut, possible psychological cause
Important to rule out: infection, coeliac disease or inflammatory bowel disease
Irritable Bowel Syndrome
Common disorder of the digestive system
Differential Diagnoses Patient characteristics more
frequently associated with organic
pathology
“red flags” indicative of other
serious or malignant pathology
Coeliac disease Presentation <24 months > 50 years
Food intolerance Elderly >60 years Weight loss
Disaccharide intolerance Persistent diarrhoea, flatulence,
wind
Occult blood in faeces
Bowel Cancer Night time diarrhoea/symptoms
disturbing sleep
Family history of bowel cancer
Diverticular disease Sudden onset Family history of IBD
Bacterial overgrowth >5kg weight loss
Inflammatory bowel disease Faecal mass .225g/ 24 hours
infection Abnormal blood results (ESR, Hb,
albumin, CRP)
Bile acid-related diarrhoea Steatorrhoea or explosive,
malodorous stools
Diagnosis-patient characteristics
Rome I: as below but without time criteria
ROME II At least 12 weeks, do not need to be consecutive,
in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features:
1. relieved with defecations and/or 2. onset associated with a change in frequency of
stool and/or 3. onset associated with a change in form
(appearance of stool)
ROME I and II criteria for diagnosis of IBS
Supportive (non-essential) symptoms of the irritable bowel syndrome
Fewer than 3 bowel movements/weekmore than 3 bowel movements/day hard or lumpy stools loose or watery stools straining during a bowel movement urgency feeling of incomplete emptying passing mucus during a bowel movement Abdominal fullness, bloating or swelling
Psychological distress
Depression
Anxiety
Embarrassment
Pain
Discomfort
Living with IBS
Alcohol
fizzy drinks
chocolate
drinks that contain caffeine, such as tea,
coffee or cola
processed snacks, such as crisps and
biscuits
fatty food
fried food
Keeping a food diary may be a useful way
of identifying possible triggers in your diet
Stress is another common trigger of IBS symptoms
Triggers of IBS
Fibre If suffering from diarrhoea it may be helpful to decrease
intake of insoluble fibre If suffering from constipation it may be helpful to increase
soluble fibre Avoid resistant starch Have regular meals Take time eating Drink 6-8 cups of fluid a day Restrict caffeine intake from tea or coffee - 3 cups a day Avoid alcohol and fizzy drinks Limit fruit to 2-3 portions per day Avoid sorbitol, an artificial sweetener Wind and bloating-consider stopping intake of cereals for
6 weeks and increase intake of linseeds (1tbsp/day) Linseeds are a source of fibre and n-3 fatty acid which
may help with symptoms of wind and bloating Be cautious with exclusion diets
Soluble fibre include:oatsbarleyryefruit, such as bananas and applesroot vegetables, such as carrots and potatoesgolden linseeds
Foods that contain insoluble fibre include:wholegrain breadbrancerealsnuts and seeds (except golden linseeds)
Diet for IBS
Exercise can help to relieve
symptoms of IBS
Aim to do a minimum of 30
mins 5 times a week
Lifestyle Factors for IBS
True food allergy is rare Food intolerances are commonly implicated in
IBS- with wheat, dairy products, coffee, potatoes, corn, onions and white wine etc.
Perceived intolerances rarely confirmed-suggesting psychological involvement
Lactose intolerance has been reported in 10% of IBS patients
However lactose exclusion rarely confers significant benefit unless consumed in substantial amounts
Lesson 5 we will be covering food allergy and intolerance in detail
Food Intolerances and IBS
Case Study 2
John is 50 years old and he has just been
diagnosed with coeliac disease
He is a big fan of fast food, doesn’t cook,
lives alone, drinks alcohol frequently, and
has no knowledge of what coeliac disease
is. He also has subsequent lactose
intolerance. He has terrible stomach
cramps, diarrhoea, stomach aches and
malabsorption.
• Please advise him of the changes which
he will need to make to his diet
• What is he at risk of if he does not
change his diet
• Please provide a 3 day diet plan
John is 50 years old and he has just been
diagnosed with coeliac disease
He is a big fan of fast food, doesn’t cook,
lives alone, drinks alcohol frequently, and
has no knowledge of what coeliac disease
is. He also has subsequent lactose
intolerance. He has terrible stomach
cramps, diarrhoea, stomach aches and
malabsorption.
• Please advise him of the changes which
he will need to make to his diet
• What is he at risk of if he does not
change his diet
• Please provide a 3 day diet plan
Case Study 2
In Conclusion
The digestive system is a complex system comprising of the mouth,
oesophagus, stomach, small intestine, large intestine, liver and more
Problems can occur at all stages of the digestive system resulting in
digestive disorders. These can be very challenging to an individual
and in some cases detrimental to health
Malabsorption can occur of a single nutrient or of many nutrients
Lactose intolerance is a common form of carbohydrate
malabsorption
Lactose intolerance does not require lactose to be eliminated from
the diet. Doing so can result in calcium deficiency and subsequent
osteoporosis in later life
Coeliac disease is an intolerance to the protein gluten and requires a
gluten free diet for life
Irritable bowel syndrome is very common
There is not definitive diagnosis and it is commonly associated with
psychological disorders such as stress
Diet and lifestyle factors can help to relieve symptoms which are not
life threatening
The digestive system is a complex system comprising of the mouth, oesophagus, stomach, small intestine, large intestine, liver and more
Problems can occur at all stages of the digestive system resulting in digestive disorders. These can be very challenging to an individual and in some cases detrimental to health
Malabsorption can occur of a single nutrient or of many nutrients
Lactose intolerance is a common form of carbohydrate malabsorption
In Conclusion
Lactose intolerance does not require lactose to be eliminated from the diet. Doing so can result in calcium deficiency and subsequent osteoporosis in later life
Coeliac disease is an intolerance to the protein gluten and requires a gluten free diet for life
Irritable bowel syndrome is very common There is not definitive diagnosis and it is
commonly associated with psychological disorders such as stress
Diet and lifestyle factors can help to relieve symptoms which are not life threatening
In Conclusion
Try attend all of the sessions live and see your knowledge grow
Practical lesson 5 will continue on this subject
Complete case study 2- Discussed in practical lesson 5
Recordings are uploaded within 24 hours of the completion of each live session
Further reading links are available if you wish to learn more
Next Steps
Further Learning
To expand upon the subjects covered in todays lesson:
• Basic nutrition- Diploma in Nutrition
• Weight loss- Ultimate weight Loss Programme
Advanced Course Resources
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1) http://www.cliffsnotes.com/sciences/biology/biology/nutrition-and-digestion/human-digestive-system
2) Manual of Dietetic Practice, 4th edition by Briony Thomas and Jacki Bishop
(3) http://www.patient.co.uk/doctor/gastrointestinal-malabsorption
(4) http://www.cmaj.ca/content/185/1/60#sec-4
(5)http://www.coeliac.ie/coeliac_disease/dermatitis_herpetiformis
(6) http://www.nice.org.uk/guidance/CG61
(7) http://www.nice.org.uk/guidance/cg99/chapter/key-priorities-for-implementation
http://www.hse.ie/portal/eng/health/az/C/Constipation/
(9) http://www.nice.org.uk/guidancemenu/conditions-and-diseases/digestive-tract-conditions
(10) http://www.nice.org.uk/guidance/cg84/chapter/1-guidance
(11) http://www.nice.org.uk/guidance/cg152/chapter/1-guidance#maintaining-remission-in-crohns-
disease-after-surgery
(12) http://www.nice.org.uk/guidance/cg166/chapter/key-priorities-for-implementation
Further Reading
