33 Clinical Nutrition

Question 1

FODMAP Diet for Irritable Bowel Syndrome (IBS) (p.5)

• IBS
  
  • ?
  • symptoms
  • 75% of all patients can decrease their symptoms by/
• FODMAP
  
  • stands for/
  • These are/
  • major contributor to symptoms

Answer 1

• IBS
  
  • chronic abdominal pain, gas, bloating, diarrhea, or constipation
  • symptoms can greatly impact quality of life.
  • 75% of all patients can decrease their symptoms by following a diet where they remove FODMAPS.
• FODMAP
  
  • stands for [Fermentable Oligo- Di- and Monosaccharides and Polyols]
  • These short-chain carbohydrates are poorly absorbed in the small intestine and rapidly fermented by bacteria in the gut.
  • The production of gas by these bacteria is a major contributor to symptoms.

Question 2

Several different types of short-chain carbohydrates make up the FODMAP family:
Oligosaccharides

• Oligosaccharides comprise/
• Humans lack the enzymes to/
• Fructans
  
  • made up of/
  • found in/
  • Inulin
    
    • ?
    • extracted from
    • acts as/
• Galactans
  
  • ?
  • include/

Answer 2

• Oligosaccharides comprise
  
  • fructans (fructo-oligosaccharides or FOS)
  • galacto-oligosaccharides (GOS),
• Humans lack the enzymes to break down oligosaccharides.
  
  • Hence, they are not absorbed in the small intestine by anyone and, therefore, can cause problems especially for patients with irritable bowel syndrome (IBS).
• Fructans
  
  • made up of short chains of fructose with a glucose on the end
  • found in asparagus, Jerusalem artichokes, young barley kernels, garlic, onions, leeks, rye bran/grain, and wheat bread/flour/pasta.
  • Inulin
    
    • one of the dietary fibers that is a fructan.
    • extracted from chicory.
    • acts as
      
      • a way for some plants to store energy in their roots or rhizomes.
      • a prebiotic and a form of insoluble fiber in the colon.
• Galactans
  
  • short chains of sucrose and galactose units
  • include mainly the fibrous coating of legumes–chickpeas, lentils, and various other beans and peas.

Question 3

Several different types of short-chain carbohydrates make up the FODMAP family:
Disaccharide:
Lactose

• The primary disaccharide that causes trouble for individuals with/
• ?
  
  • made up of/
  • cleaved into/
• only a FODMAP when/
  
  • can be influenced by factors such as/

Answer 3

• The primary disaccharide that causes trouble for individuals with IBS
• a disaccharide,
  
  • made up of two sugar units, glucose and galactose,
  • cleaved into individual sugar units by the enzyme lactase prior to absorption.
• only a FODMAP when there are insufficient levels of lactase,
  
  • can be influenced by factors such as genetics, ethnicity, and various GI disorders.

Question 4

Several different types of short-chain carbohydrates make up the FODMAP family:
Monosaccharide

• Fructose
• the absorption of fructose relies on/
• Fructose malabsorption or Dietary Fructose Intolerance

Answer 4

• Fructose
  
  • The monosaccharide that often needs to be removed from the diet
  • a simple sugar that requires no digestion.
• the absorption of fructose relies on the activity of sugar transporter GLUT5 that is located on the apical border of enterocytes.
• Fructose malabsorption or Dietary Fructose Intolerance
  
  • a dietary disability of the small intestine, where the amount of fructose carrier in enterocytes is deficient.
  • About 30–40% of all people malabsorb excess fructose.

Question 5

Several different types of short-chain carbohydrates make up the FODMAP family:
Polyols

• ?
• found naturally in /
• The absorption of polyols/
  
  • The portion that remains in the GI tract can cause/

Answer 5

• monomeric substances that add sweetness.
• found naturally in
  
  • some fruits and vegetables, such as peaches, pears, watermelon, bell peppers, and mushrooms.
  • Sugar alcohols; ethylene glycol, glycerin, sucrose, xylitol, erythritol, sorbitol and isomalt
• The absorption of polyols is slow across the intestinal barrier so that only about one-third of what is consumed is actually absorbed.
  
  • The portion that remains in the GI tract can cause gas, cramping, and diarrhea.

Question 6

How the FODMAP diet works (p.14-15)

• Individuals/
• People with IBS are typically recommended to/
  
  • If symptoms are improved/
  • If symptoms recur/
• The low FODMAP diet has been shown to improve/

Answer 6

• Individuals eliminate all foods containing FODMAPs from their diet.
• People with IBS are typically recommended to stop eating FODMAP-foods for at least 6-8 weeks to see if it makes a difference in their symptoms.
  
  • If symptoms are improved, individuals can try adding back some of these foods gradually, one at a time.
  • If symptoms recur, then the foods should be omitted again.
• The low FODMAP diet has been shown to improve
  
  • IBS
  • GI symptoms in more than 50% of patients with inflammatory bowel disease who are experiencing ongoing GI symptoms despite having inactive disease.
  • Loose stool production in patients without a colon
  • Celiac disease
    
    • an immunologic reaction of the enteric mucosa to gluten.
    • Gluten is found primarily in the grains wheat, rye, and barley

Question 7

How the FODMAP diet works:
Individuals with celiac disease should avoid the following foods unless they’re labeled as gluten-free or made with corn, rice, soy or another gluten-free grain (p.17)

Answer 7

• Beer, ale, lager, malt beverages, some diet sodas, sports drinks
• Breads (including cornbread), croutons, crackers, matzo
• Cakes, cookies, pies (cheesecake filling often contains flour)
• Candy
• French fries
• Gravy
• Processed poultry, meat, fish, or seafood
• Pasta, udon noodles, soba, egg noodles (rice noodles and mung bean noodles are GF)
• Many luncheon meats
• Salad dressings, sauces, roux, foods processed with dressings or sauces (beef jerky)
• Seasoned side dishes
• Some snack foods, such as potato and tortilla chips
• Soups and soup bases (especially creamed soups, soups with tiny pasta)
• Vegetables in sauce
• Granola and granola bars, protein/power bars

Question 8

How the FODMAP diet works

• Meat substitutes
• Watch out for food additives and preservatives
• avoid cross contamination

Answer 8

• Meat substitutes made with seitan (wheat gluten) such as vegetarian burgers, vegetarian sausage, imitation bacon, and imitation seafood.
  
  • Tofu is gluten-free, but be cautious of soy sauce marinades and cross-contamination when eating out, especially when the tofu is fried
• Watch out for food additives and preservatives.
  
  • Caramel color can be natural or artificial and the artificial may contain wheat.
  • Modified food starch is often made from wheat; modified corn starch is safe.
  • Most medications and vitamins/supplements are now gluten-free but there may be exceptions.
• avoid cross contamination.
  
  • Oats are themselves gluten-free but often can be contaminated with other grains.
  • Clean dishes well.
  • Don’t bake a gluten-free cake or brownies in the same bake ware that are used to make cakes or other pastries made with typical brands of flour.
  • Don’t share the toaster with someone using normal bread.
  • Don’t stir gluten-free soup with the same soup you just used to stir regular soup.
  • Don’t share cutting boards.
  • Watch condiments (jelly, peanut butter, mayonnaise, etc where bread crumbs may cross-contaminate).

Question 9

Catabolic patients (how to increase caloric intake)

• Catabolism is characterized by/
  
  • Conditions can be
• There are numerous catabolic conditions that are chronic in nature for which nutritional intervention will be provided on an outpatient basis. Examples include:

Answer 9

• Catabolism is characterized by weight loss and loss of skeletal muscle.
  
  • Conditions can be acute, such as in critical injury, multi-system organ failure, burn and severe infections (sepsis)
• There are numerous catabolic conditions that are chronic in nature for which nutritional intervention will be provided on an outpatient basis. Examples include:
  
  • Infectious diseases, such as tuberculosis (onset to cure = ~3 years)
  • Collagen vascular diseases
  • Amyloidosis
  • Inflammatory bowel disease (Crohn’s disease especially)
  • Cancer
  • Cystic Fibrosis
  • COPD

Question 10

Catabolic patients (how to increase caloric intake)

• To gain weight, catabolic patients should/
• For instance, in general:
  
  • Children
  • Adults
  • For patients with end-stage disease

Answer 10

• To gain weight, catabolic patients should eat nutritious foods that are also calorie-dense.
  
  • The diet should be tailored to the individual.
• For instance, in general:
  
  • Children: primary aim is healthy growth and maturation, meeting developmental milestones
  • Adults: maintenance of wellness; recovery and restoration of strength/endurance following acute stage of a chronic disease (such as a flare of Crohn’s disease or lupus)
  • For patients with end-stage disease such as advanced cancer or ALS, diet should be geared towards avoiding sarcopenia (muscle loss), lengthening the patient’s survival while maintaining quality of life.

Question 11

Catabolic patients (how to increase caloric intake):
The dilemma

• Catabolic patients often have/
• Thus, it’s recommended that these individuals:

Answer 11

• Catabolic patients often have less of an appetite for a big meal, due to the symptoms of disease as well as fatigue.
  
  • It is not as easy for them to sit down and eat a 12 oz steak.
• Thus, it’s recommended that these individuals:
  
  • Eat 6-8 smaller meals, including a protein source in each. Good protein sources include: eggs, whole or 2% dairy milk, cheese, soy milk, fish, poultry, meat, tofu, tempeh, and nut butters such as peanut and almond butter.
  • Choose nutrient-rich foods. As part of an overall healthy diet, choose whole-grain breads, pastas and cereals; fruits and vegetables; dairy products; lean protein sources; and nuts and seeds.
  • Drink calories, including milkshakes and smoothies. Avoid diet soda, black coffee and other drinks with few calories and little nutritional value. Instead, drink smoothies or healthy shakes made with milk and fresh or frozen juice, and sprinkle in some ground flaxseed meal. Add protein powder or powdered milk to cereal, shakes, and smoothies.
  • Pay attention to how fluids affect your appetite. If you get full easily when you drink, to sip higher calorie beverages along with a meal or snack. Otherwise, drink about 30-40 minutes after you eat a meal.
  • Add condensed milk, half and half, or coconut milk to recipes when possible. Add milk powder or protein powder to breakfast foods such as pancakes. Add wheat germ and ground flaxseed meal to baked goods and cereals.
  • Fat is calorie dense so don’t go non fat: add olive oil to pasta, dip bread in flavored olive oil; add grated cheese or shredded cheese to noodles, casseroles, vegetables, sandwiches, wraps, tacos, enchiladas, etc; use real butter in baked goods; eat full fat (whole milk) yogurt when possible.
  • Snack on nuts, crackers with peanut butter or cheese, dried fruits, small dishes of chicken salad or tuna salad and avocados (guacamole with chips). Have a bedtime snack, such as a whole milk yogurt, a peanut butter and jelly sandwich, or a wrap sandwich with hummus or sliced avocado and lean meat or cheese.

Question 12

Wound healing (p.29-30)

• Wound healing and tissue building have been shown to improve by using/
• Juven

Answer 12

• Wound healing and tissue building have been shown to improve by using the supplement Juven which contains glutamine, arginine, and calcium ß-hydroxy-ß-methylbutyrate (which they have patented in some form under the name Revigor®).
• Juven
  
  • has been shown to increase wound healing in the healthy elderly, to build collagen, and also to increase lean body mass [LBM] in cancer cachexia patients.
  • comes as a dried powder in either orange, fruit punch, or unflavored
  • sweetened with acesulfame potassium, and either aspartame or sucralose so it’s not to be given to phenylketourics.
  • lactose free, gluten free, kosher, and halal.
  • The flavored powder can be mixed with appx. 8 oz of water or juice, or the unflavored can be mixed into soup or any other beverage.

Question 13

Short bowel syndrome

• short bowel syndrome (SBS).
• The SBS diet is based on the patient’s gastrointestinal anatomy.
  
  • If the patient’s colon is in circuit/
  • If the SBS patient has a jejunostomy/
• Simple sugars are found in/
  
  • If patients with SBS consume large amounts simple carbohydrates, they often experience/
  • Complex carbohydrates/
• Soluble fibers/
  
  • short chain fatty acids (SCFA)
  • One can get fiber naturally through
• Citrucel

Answer 13

• Individuals who have had intestinal surgery and have had more than 2/3 of their small intestine removed are described as having short bowel syndrome (SBS).
• The SBS diet is based on the patient’s gastrointestinal anatomy.
  
  • If the patient’s colon is in circuit, they will maximize your absorption by following a diet that is low in simple carbohydrates and low in fat.
  • If the SBS patient has a jejunostomy, there is no need to restrict fat, but limiting simple carbohydrates will help to decrease ostomy output.
• Simple sugars are found in foods such as candy, cakes, cookies, pies, regular soda pop, jelly, jam, honey, syrup, ice cream, sherbet, and sorbet.
  
  • If patients with SBS consume large amounts simple carbohydrates, they often experience more diarrhea.
  • Complex carbohydrates (pasta, potatoes, breads, cereals, whole grains, fruits, and vegetables) contain larger starch molecules and tend not to cause diarrhea in SBS patients.
• Soluble fibers are very important to someone with SBS, particularly if the colon is connected.
  
  • Any undigested soluble fibers that reach the colon are metabolized into short chain fatty acids (SCFA).
    
    • SCFA are then absorbed through the mucosa of the colon and used as a source of energy.
    • SCFA also help with sodium and water absorption.
  • One can get fiber naturally through food (i.e., oatmeal, whole grains, fruits, and vegetables) or through various fiber supplements.
• Citrucel is the fiber supplement we use most often in GI.
  
  • If the patient’s colon is not connected, fiber can be used to help thicken up ostomy output and give the patient a little bit more control.

Question 14

Low residue (low fiber) diet

• A low residue diet contains/
• The diet is often prescribed for/
• A low residue diet will/
• People following a low-residue diet need to eat/

Answer 14

• A low residue diet contains a limited amount of ‘residue’ or fiber so that very little non-digestible material is delivered to the small and large intestine.
• The diet is often prescribed for individuals who have undergone GI tract surgery, those getting chemotherapy and radiation, as well as IBD patients, especially those with strictures and fistulae, and individuals with gastroparesis.
• A low residue diet will decrease the speed of transit through the GI tract and also decrease the bulk of stool.
• People following a low-residue diet need to eat fewer than 10 to 15 grams of fiber per day.
  
  • Tender and lean meat, fish, chicken and pork are considered to be fine on a low residue diet, as are eggs and dairy products (although lactose intolerance can be an issue so dairy should be monitored).
  • Patients can eat low fiber grains, such as white rice, white bread, waffles and pancakes, cake, and low fiber cereals such as Rice Krispies, corn flakes, and Special K

Question 15

On a low-residue diet, individuals should generally avoid these (p.39-40)

• Bread and Cereals
• Fruits
• Dairy
• Vegetables
• Meat/Fish/Protein source
• Snacks, sweets, condiments, etc

Answer 15

• Bread and Cereals
  
  • Breads or rolls with nuts, seeds, or fruit
  • Whole wheat, pumpernickel bread, and cornbread
  • Potatoes with skin, brown or wild rice, and kasha (buckwheat)
  • Whole grain cereals, bran cereals, granola-type cereals, and cereals that contain nuts, seeds, coconut, or dried fruit (including raisins)
• Fruits
  
  • Prunes and prune juice
  • Raw or dried fruit
  • All berries and raisins
• Dairy—Avoid yogurt with mango, raspberries, nuts, dried fruit, or seeds
• Vegetables
  
  • Raw or partially cooked (steamed) vegetables
  • Vegetables with seeds
  • Sauerkraut
  • Cooked peas, winter squash, broccoli, Brussels sprouts, cabbage, onions, cauliflower, baked beans and corn
• Meat/Fish/Protein source
  
  • Tough, fibrous meats with gristle
  • Beans, peas, and lentils
  • Peanut butter
• Snacks, sweets, condiments, etc
  
  • Nuts, seeds, and coconut
  • Jam, marmalade, and preserves
  • Pickles, olives, relish, and horseradish
  • Desserts containing nuts, seeds, dried fruit, coconut, or made from whole grains or bran
  • Candy made with nuts or seeds
  • Popcorn