sites of nutrient absorption
TRANSCRIPT
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Heather Zhou, RD, LD
Nutrition ManagementNutrition Managementof Inflammatory Bowelof Inflammatory Bowel
DiseaseDisease
Heather Zhou, R.D., L.D.Heather Zhou, R.D., L.D.
Clinical Science LiaisonClinical Science Liaison
Emmaus Medical, Inc.Emmaus Medical, Inc.
Presentation OverviewPresentation Overview
1. Describe the potential causes ofmalnutrition in inflammatory boweldisease (IBD)
2. Identify nutrients at risk for deficiency in
IBD
3. Discuss dietary guidelines for managingIBD symptoms
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Heather Zhou, RD, LD
Crohn's disease (CD)
Occur anywhere along digestive tract
Mouth anus
Mostly affects terminal ileum
Ulcerative colitis (UC)
Involves colon and rectum
Inflammatory Bowel DiseaseInflammatory Bowel Disease
Adapted from An in-depth look at IBD. Nursing. 2002;32:36.
Potential Causes of Malnutrition
Inadequate food intake
nutritional requirements
Altered digestion and absorption
intestinal losses
Disease activity Surgical resections
Drug-nutrient interactions
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Sites of Nutrient AbsorptionSites of Nutrient Absorption
Small Intestines
Major site of nutrient
absorption
Duodenum iron,
calcium, magnesium,
zinc
Jejunum B vitamins,
vitamins A, D, E, K Ileum vitamin B12,
bile salts/acids
Large Intestines (Colon)
Completion of absorption
Absorption of remainingwater and electrolytes
Formation & expulsionof stool
Production of vitamin K& short-chain fatty acids
by bacteria
Vitamin/Mineral DeficienciesVitamin/Mineral Deficiencies
B vitamins
Folate, vitamin B12
Fat-soluble vitamins
Vitamins A, D, E, K
Minerals
Calcium, iron, zinc
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DrugDrug--Nutrient InteractionsNutrient Interactions
Steroids may affect vitamin D activity in
GI tract
calcium absorption: risk for osteoporosis
Anti-inflammatory drugs
folate absorption
Lipid-lowering agents bind bile acids
fat-soluble vitamin absorption
Antibiotics may vitamin K availability
Folate
Absorption
Primarily in jejunum
Deficiency
intake from food and intestinal losses
Drug-Nutrient Interactions
Anti-inflammatory (sulfasalazine) and
immunosuppressant drugs (methotrexate) Prevention
Multivitamin (MVI) supplementation with
400 mcg/day or 1 mg folate/day
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Vitamin B12
Absorption
Terminal ileum
Deficiency
consumption or intolerance to red meat anddairy products; malabsorption
Drug-Nutrient Interactions
Antacids: H2-blockers, PPIs
Management Monthly vitamin B12 injections if terminal ileum
resected/diseased
Vitamin D
Absorption
Duodenum
Deficiency
Inadequate sunlight exposure, intake of milk
products, or malabsorption
Drug-Nutrient Interactions
Corticosteroids
Prevention
400-800 IU/d vitamin D
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Heather Zhou, RD, LD
CalciumCalcium
Absorption
Duodenum primary site of absorption
Deficiency
absorption of vitamin D
Poor tolerance of milk and dairy products
Drug-Nutrient Interactions
Corticosteroids; absorption with iron
Prevention 1000 1500 mg/day calcium + vitamin D
Iron
Absorption Duodenum primary site
Deficiency Chronic intestinal blood loss, inadequate intake of
iron-rich foods (red meat), or inflammation
Interactions absorption with tea or coffee intake
absorption with calcium
Prevention Iron supplement warranted only if deficient
MVI with iron or ferrous sulfate plus vitamin C
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ZincZinc
Absorption
Duodenum main site of absorption
Deficiency
Food intolerances (meats, milk); chronic diarrhea
Interactions
Competitive absorption with iron
Prevention Supplementation only when indicated with
15 mg/day elemental zinc
Nutritional SupplementationNutritional Supplementation
Daily multivitamin and mineral supplement in a
chewable or liquid form may be beneficial with
malabsorption and intestinal losses
Take supplements daily with meals and spaced
throughout the day
Take calcium at least 2 hours apart from MVI +
iron to prevent absorption of both
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Goals of Nutrition Therapy
CD
Replace fluid and
electrolytes
Replenish nutrient
stores
Low residue diet with
strictures or fistulas
Elemental diets may be
beneficial
UC
Ensure adequate
calorie and protein
intake
Replenish electrolyte
losses from diarrhea
Low residue diet may
help irritation ofinfected colon
Role of Diet in IBDRole of Diet in IBD
Insufficient evidence that specific foods can
cause IBD
Individual food tolerances may vary
Limit intake of certain foods and beverages
that may worsen symptoms during a flare
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Nutrition ManagementNutrition Management
Active disease (flare)
Diet should be individualized to specific tolerances
and type of disease (CD vs. UC)
Small, frequent meals
Diet low in fiber and residue
Fat-controlled diet for malabsorption
Lactose-controlled diet if lactose intolerant
Asymptomatic (remission) Small, frequent meals
Progression to regular diet
LowLow--Fiber, LowFiber, Low--Residue DietResidue DietGuidelinesGuidelines
Residue refers to dietary compounds not broken
down by the body
Designed to stool rate and output
May be useful for acute phases of IBD or partial bowel
obstruction
Contains ~ 10 grams of fiber Follow diet on a temporary basis only
Progress to regular, well-balanced diet once
symptoms disappear
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LactoseLactose--Controlled Diet GuidelinesControlled Diet Guidelines
Severity of lactose intolerance may vary
Some lactose intolerant individuals can tolerate~10 grams of lactose per day
Try small amounts of lactose at a time cup milk = 6 grams lactose/serving
Check food labels for hidden sources of lactose Dry milk solids, whey, non-fat dry milk powder
Lactose-Controlled Diet Guidelines
Fermented or cultured dairy products have
lactose content due to bacterial action
Aged cheeses (cheddar, Swiss), yogurt, acidophilusmilk
Consider using lactose-free products
Lactaid, calcium-fortified, soy or rice milk
Include maximum amount of milk as tolerated
Key source of calcium, protein, vitamins A and D,riboflavin, and phosphorus
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Complementary and Alternative
Medicine (CAM) Nontraditional approaches that may be used
along with traditional treatments or used in placeof conventional therapies
>50% of IBD Pts have used some form of CAM
Herbal & nutritional supplements, probiotics, andfish oil are commonly used
Intolerable side effects and ineffectiveness of
standard treatments are main reasons cited
Inform your doctor about use of CAM
ProbioticsProbiotics
Live microbial food supplements thatbeneficially affect the host by improving itsintestinal microbial balance
>20 trials have been published in last fewyears studying role of probiotics inprevention, treatment, & maintenance of IBD
Benefits of probiotics in IBD are not definite
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OmegaOmega--3 Fatty Acids (3 Fatty Acids (-3 FA)
May have anti-inflammatory properties
Fish oil improved intestinal damage and inflammation in rats with experimental UC
May need or dose for corticosteroidtherapy in IBD patients
A large North American study by Dr. Wolf-
AGA was part of showed no benefit of fishoil in CD
Medical Food SupplementsMedical Food Supplements
Palatability
Cost
Tolerance
Osmolality isotonic
Elemental (amino acid-based) vs. polymeric
(whole protein-based) formula Fat profile MCT vs. LCT
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ConclusionConclusion
Malnutrition often occurs as a consequence
of IBD
Diet and nutrition therapy play a vital role
in the management of IBD
Patients adherence to suggested medical
and nutrition guidelines may lead to success
In the words of Hippocrates:
"Let food be thy medicine."
"He who does not know foodhow can he
cure the disease of man?"
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Heather Zhou, RD, LD
ReferencesReferences
1. El-Matary W. Enteral nutrition as a primary therapy of
crohn's disease: The pediatric perspective.Nutr Clin Pract.
2009;24:91-97. Review.
2. Lichtenstein GR, Hanauer SB, Sandborn WJ; Practice
Parameters Committee of American College of
Gastroenterology. Management of Crohn's disease in adults.
Am J Gastroenterol. 2009;104:465-483.
3. Issa M, Binion DG. Bowel rest and nutrition therapy in the
management of active crohn's disease.Nutr Clin Pract.
2008;23:299-308.
4. Wiese D, Lashner B, Seidner D. Measurement of nutritionstatus in crohn's disease patients receiving infliximab therapy.
Nutr Clin Pract. 2008;23:551-556.
ReferencesReferences
5. Vagianos K, Bector S, McConnell J, Bernstein CN. Nutrition
assessment of patients with inflammatory bowel disease.JPEN.
2007;31:311-319.
6. Goh J, O'Morain CA. Nutrition and adult inflammatory bowel
disease.Aliment Pharmacol Ther. 2003;17:307-320.
7. Reiff C, Kelly D. Inflammatory bowel disease, gut bacteria and
probiotic therapy.Int J Med Microbiol. 2010;300:25-33.
8. Douglas LC, Sanders ME. Probiotics and prebiotics in dietetics
practice. J Am Diet Assoc. 2008;108:510-521.
9. Clarke JO. Mullin, GE. A review of complementary and
alternative approaches to immunomodulation.Nutr Clin Pract.
2008;23:49-62.
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ReferencesReferences
10. Bibiloni R, Fedorak RN, Tannock GW, Madsen KL, Gionchetti
P, Campieri M, De Simone C, Sartor RB.VSL#3 probiotic-
mixture induces remission in patients with active ulcerative
colitis.Am J Gastroenterol. 2005;100:1539-1546.
11. Nieto N, Torres NI, Rios A, Gil A. Dietary polyunsaturated fatty
acids improve histological and biochemical alterations in rats
with experimental ulcerative colitis.J Nutr. 2002;132:11-19.
12. Crohn's and Colitis Foundation of America. Diet and nutrition.
http://www.ccfa.org/info/diet. Accessed February 28, 2010.
13. National Institute of Diabetes & Digestive & Kidney Diseases.
Ulcerative colitis. Available at:http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/index.htm.
Accessed July 27, 2009.
ReferencesReferences14. Mayo Clinic. Crohns disease. Available at: http://mayoclinic.
com/health/crohns-disease/DS00104/DSECTION=treatments
-and-drugs. Accessed August 8, 2009.
15. Mayo Clinic. Ulcerative colitis. Available at:http://mayoclinic.com/health/ulcerative-colitis/DS00598/DSECTION=lifestyle-and-home-remedies. Accessed August8, 2009.
16. Mayo Clinic. Lactose intolerance. Available at:http://mayoclinic.com/health/lactoseintolerance/DS00530/DS
ECTION=lifestyle-and-home-remedies. Accessed February16, 2010.