Carbohydrate-

1
Carbohydrate- Fat-Modified Diets for
Malabsorption Disorders

• Chapter 19

2
Malabsorption Syndromes

• Malabsorption disorders most detrimental to
  nutrition status
• Nutrient deficiencies
• Weight loss
• Serious complications
• Disorders associated with malabsorption
• Genetic disorders
• Pancreatic disorders
• Intestinal disorders
• Intestinal infections
• Liver disease (bile insufficiency)
• Surgeries
• Rarely involves single nutrient
• Treatment of malabsorption disorders may also tax
  nutritional status

3
(No Transcript)
4
Malabsorption Syndromes

• Evaluating Malabsorption
• Laboratory tests to determine malabsorption
  problems
• D-xylose test used to differentiate intestinal
  malabsorption from digestive pancreatic disorders
• Hydrogen breath test used to diagnose lactose
  intolerance malabsorption of other
  carbohydrates
• Schilling test used to diagnose malabsorption of
  vitamin B12 further testing determines whether
  vitamin B12 malabsorption is caused by intrinsic
  factor deficiency or pancreatic enzyme
  insufficiency
• Stool fat test detects excessive fat in the
  stool (steatorrhea)

5
Malabsorption Syndromes

• Fat malabsorption
• Causes
• Illness that interferes with production or
  secretion of bile (severe liver disease) or
  pancreatic lipase (pancreatitis, cystic fibrosis)
• Damage to intestinal mucosa (inflammatory
  disorders or radiation treatments)
• Motility disorders causing rapid gastric emptying
  or intestinal transit

• Consequences losses of food energy, essential
  fatty acids, fat-soluble vitamins, some minerals
• Weight loss
• Deficiencies of fat-soluble vitamins
• Formation of soaps by some minerals unabsorbed
  fatty acids
• Bone loss from calcium deficiency
• Increased risk of kidney stones

6
(No Transcript)
7
Malabsorption Syndromes

• Fat malabsorption (cont.)
• Dietary adjustments fat-restricted diet
• Relief of abdominal symptoms (diarrhea
  flatulence)
• Minimize loss of vitamins minerals
• Fats should not be restricted more than necessary
• Alternative source of dietary fat medium-chain
  triglycerides (MCT)

MCT Triglycerides with fatty acids that do not
require digestion can be absorbed in absence of
lipase or bile
8
Malabsorption Syndromes

• Bacterial overgrowth
• Gastric acid peristalsis protect stomach
  small intestine from bacterial overgrowth
• When overgrowth does occur, disrupts fat
  digestion absorption
• Eventually results in deficiencies of fat-soluble
  vitamins
• Bacteria compete with vitamin B12, impairing its
  absorption
• Symptoms chronic diarrhea, abdominal discomfort,
  bloating, weakness, weight loss

9
Malabsorption Syndromes

• Bacterial overgrowth (cont.)
• Causes
• Impaired intestinal motility
• Some types of gastric surgery
• Strictures, obstructions diverticula in small
  intestine
• Reduced secretion of gastric acid
• Atrophic gastritis
• Acid-suppressing medications
• Acid-reducing surgery
• Treatment
• Antibiotics
• Surgical correction of anatomical defects
• Dietary supplements

10
Lactose Intolerance

• High incidence approximately 75 of population
  worldwide
• Rarely serious
• Most individuals (with lactose intolerance) can
  tolerate milk if consumed with other foods
  limit amount consumed at one time
• Cause reduction or loss of lactase, enzyme that
  digests lactose in milk products
• Prevalent among certain ethnic groups Asians,
  African Americans, Native Americans, Ashkenazi
  Jews, Latinos

• Dietary management
• Gradually increased consumption of
  lactose-containing products
• Divide milk intake throughout the day
• Consume milk with meals
• Chocolate milk may be better tolerated than plain
• Aged cheeses well tolerated (little lactose
  content)
• Yogurts with live bacterial cultures that aid in
  lactose digestion
• Addition of lactase preparation to milk or use of
  enzyme tablet before consumption

11
Disorders of the Pancreas

• Maldigestive and malabsorption problems due to
  impaired secretion of digestive enzymes
• Pancreatitis
• Inflammatory disease, resulting in damage to
  pancreatic tissue release of enzymes
• Acute pancreatitis
• Usually caused by gallstones, excessive alcohol
  use also caused by high blood triglycerides,
  exposure to toxins
• Symptoms severe abdominal pain, nausea
  vomiting, abdominal distention
• Usually resolves within a week without
  complications
• Chronic pancreatitis may cause irreversible
  damage loss of pancreatic function

12
Disorders of the Pancreas

• Pancreatitis (cont.)
• Majority of cases of chronic pancreatitis caused
  by excessive alcohol consumption
• Symptoms severe abdominal pain may be
  unrelenting worsens when eating

• Consequences
• Fat maldigestion
• Maldigestion of protein carbohydrate
• Steatorrhea in advanced cases
• Weight loss malnutrition due to food avoidance
• Reduction in insulin glucagon secretions,
  resulting in diabetes
• Medical nutrition therapy
• Dietary supplements to correct nutrient
  deficiencies
• Avoidance of all alcohol
• Pancreatic enzyme replacement

13
Disorders of the Pancreas

• Cystic fibrosis
• Genetic disorder characterized by abnormally
  viscous exocrine secretions often leads to
  respiratory illness pancreatic insufficiency
• Consequences
• Major complications involve lungs, pancreas,
  sweat glands
• Persistent respiratory infections, causing
  inflammation of bronchial tissues progressive
  airway obstruction
• Accumulation of digestive enzymes in pancreas due
  to thick pancreatic secretions that obstruct
  pancreatic ducts
• Malabsorption of protein, fat fat-soluble
  vitamins
• Excessive loss of salt in sweat, increasing
  dehydration
• Chronic undernourishment, poor growth, difficulty
  maintaining body weight
• Hyperglycemia diabetes

14
Disorders of the Pancreas

• Cystic fibrosis (cont.)
• Medical nutrition therapy
• Increased energy intake (children may need
  120-150 of recommended energy intake for normal
  growth nutrition status)
• High-kcalorie high-fat foods
• Frequent meals snacks
• Supplement meals with milk shakes or liquid
  dietary supplements
• Supplemental tube feedings if energy intake is
  inadequate
• Pancreatic enzyme replacement at every meal or
  snack
• Multivitamin fat-soluble vitamin supplements
• Liberal use of table salt salty foods

15
Disorders of the Small Intestine

• Malabsorption common consequence when intestinal
  mucosa damaged due to inflammation or infection
• Celiac disease
• Abnormal immune response to wheat gluten, causing
  severe intestinal damage nutrient malabsorption
• Also referred to as gluten-sensitive enteropathy
  or celiac sprue
• Symptoms GI disturbances such as diarrhea,
  steatorrhea flatulence symptoms exacerbated by
  milk products

16
Disorders of the Small Intestine

• Celiac disease (cont.)
• Consequences
• Immune reaction to gluten causing changes in
  intestinal tissue
• Reduction in mucosal surface area digestive
  enzymes
• May be restricted to duodenum or involve entire
  small intestine
• Malabsorption of all nutrients, especially
  macronutrients, fat-soluble vitamins,
  electrolytes, calcium, magnesium, zinc, iron,
  folate, vitamin B12
• Stunted growth in children, severe underweight
• Iron-deficiency anemia
• Low bone mineral density

17
Disorders of the Small Intestine

• Celiac disease (cont.)
• Medical nutrition therapy
• Life-long adherence to gluten-free diet
• Symptom relief usually evident within weeks, but
  mucosal healing may take years
• Avoidance of lactose-containing foods if lactose
  intolerant
• Dietary supplements

• Gluten-free diet
• Elimination of foods containing wheat, rye,
  barley
• Careful review of all ingredients on food labels
  (even small amounts of gluten can aggravate
  symptoms)
• Use of gluten-free products

18
(No Transcript)
19
Disorders of the Small Intestine

• Short-bowel syndrome
• Malabsorption syndrome that follows resection of
  small intestine, causing insufficient absorptive
  capacity in remaining intestine
• Surgical resection of major portion of small
  intestine (treatment of Crohns disease, small
  intestinal cancers, other intestinal disorders)
• Results in fluid electrolyte imbalances,
  multiple nutrient deficiencies
• Symptoms diarrhea, steatorrhea, dehydration,
  weight loss, growth impairment (in children)

20
(No Transcript)
21
Disorders of the Small Intestine

• Short-bowel syndrome (cont.)
• Intestinal adaptation process of intestinal
  recovery, after resection, leading to improved
  absorptive capacity
• Ileum has greater adaptive capacity than jejunum
• Permanent effects on vitamin B12 nutrition bile
  acid reabsorption if ileum removedworsens fat
  malabsorption diarrhea
• Removal of sphincter between ileum cecum may
  result in infiltration of colonic bacteria into
  small intestine, causing bacterial overgrowth

22
Disorders of the Small Intestine

• Short-bowel syndrome (cont.)
• Medical nutrition therapy
• Immediately after surgery fluid electrolyte
  replacement (intravenous)
• First weeks rehydration of diarrheal fluid
  losses
• Total parenteral nutrition, gradually reduced as
  oral feeding resumes
• Introduction of oral feedings as soon as possible
  to promote intestinal adaptation
• Sips of liquid formulas, progressing to larger
  amounts
• Solid foods, as tolerated
• Small, frequent feedings
• Low-fat, high-carbohydrate diet, if steatorrhea
• Vitamin mineral supplements
• Low-oxalate diet to reduce risk of kidney stone
  development

23
Nutrition in PracticeAnemia in Illness

• Anemia condition of having too few red blood
  cells
• Frequently first sign of illness
• May be reason for seeking medical attention
• Develops when red blood cells (erythrocytes) are
  not produced in sufficient quantity, destroyed
  too quickly, lost due to bleeding
• Red blood cells contain hemoglobin that carries
  oxygen to tissues
• Produced in bone marrow (erythropoiesis)

24
(No Transcript)
25
Nutrient Deficiencies Anemia
Nutrient Actions Result of Deficiency
Iron Required for hemoglobin production Microcytic anemia small, hypochromic cells
Vitamin B12 Folate Maintains cell membrane integrity Macrocytic anemia large, immature cells
Vitamin E Role in hemoglobin production Hemolytic anemia RBC breakdown
Vitamin B6 Role in hemoglobin production Microcytic anemia
Vitamin C Supports blood vessel integrity Fragile, bleeding capillaries
Protein Energy Malnutrition Protein synthesis needed for RBC development Anemia
26
Anemia in Illness

• Causes of anemia
• Illness-related causes
• Blood loss
• Peptic ulcers
• Inflammatory bowel conditions
• Esophageal varices
• Coagulation disorders
• Surgical procedures
• Slow, chronic bleeding
• Malabsorptive disorders
• Chronic illnesses
• Medications