Nutrition for the Gastroenterologist

Transcription

1 Nutrition for the Gastroenterologist Octavia Pickett-Blakely, MD, MHS September 25, 2016 None Disclosures 1

2 Nutrition: Who Cares? Nutrition: Why we should care Divisions of Gastroenterology, Hepatology and Nutrition? 2

3 Objectives To learn the impact of nutritional status on gastrointestinal disease To learn the nutritional considerations with respect gastrointestinal disease Nutritional Status Nutritional Therapy Gastrointestinal Disease Nutrition support 3

4 Acid hyposecretion achlorhydria PPI use in GERD B-12 A classic example Pancreatic insufficiency acid milieu w/decreased pancreatic juice secretion in PI Enteropathy TI Crohn s disease/resection impaired absorption impaired mucosal absorption in celiac disease or short gut Nutritional Considerations in GI Disease 4

5 BMI is linked to GERD Ayazi,S. J Gastrointest Surg :

6 Nutritional Considerations encourage weight loss when appropriate LES relaxation avoid: mint, chocolate, high fat foods, alcohol, coffee decrease esophageal and gastric acid avoid: coffee, alcohol, pepper, citrus, tomato, large meals deficiencies to watch for calcium, iron, Mg Nutritional status and IBD Overweight/Obesity abdominal adiposity associated with inflammatory mediators high fat diet linked to Crohn s disease 1 obesity (by BMI) not associated with incident Crohn s disease 2 but body weight linked to disease course 1. PLoS One Aug 16;8(8):e Am J Gastroenterol Apr;108(4):

7 CD- shorter time to 1 st surgery 1 CD- loss of response to Infliximab 2 UC- loss of response to Infliximab Hass et al. Clin Gastro Hep 2006;4: Harper et al Inflamm Bowel Dis ;19(10): No association between increasing BMI and annual prednisone use, emergency department visits, hospitalization, and surgery Seminerio et al. Inflamm Bowel Dis Dec;21(12):

8 Diet behavioral patterns- UC 49% exclude foods, even more avoid foods lower energy intake lower CHO/fiber intake higher protein, total fat and saturated fat intake lower iron and Ca intake (women) excess Vit C intake (women) Walton, M.British J Nutr Nutritional recommendations IBD patients monitor patients for excess nutrient intake height, weight, BMI slope of weight gain overweight is prevalent 1 weight loss counseling, surgery for severe obesity 2 screen for deficiencies: calcium, iron, folate, B12, zinc, selenium 3 1.Weisshof Cur Opinion Clin Nutr Metab Care Obes Surg Jun;26(6): Vidarsdottir Nutr Journal

9 Obesity well nourished POVERTY POVERTY Obesity well nourished overall macronutrient excess but can occur alongside micronutrient deficits iron, Zn, calcium, B12 (10%), Folate (25%), Cu, Vit D (71%) 1,2 targeted screening based on ROS screen for deficiencies post bariatric surgery *less common after restrictive procedures iron, B-12, B1/thiamine, folate, ca, fat soluble vitamins (A,D,E, K), Zn, Se, Cu 1. De Luis Surg Obes Relat Dis Mar-Apr;9(2): Sanchez Obes Surg Feb;26(2):

10 Celiac Disease Nutrition considerations Gluten-free diet no wheat, rye, and barley OK: rice, corn, millet, potato, buckwheat, and soybeans Other gluten free foods: fresh fish, meats, milk, cheese, fruits and veggies Ann Med Dec;45(8): nutrient excess can be a problem nutrient deficiencies may occur Ca, B vitamins, iron, folate Case 1 37 yo woman CC: rash, rule out celiac disease/ibd severe skin rash no GI symptoms no FamHx of GI disease Eval: low Zn, iron, Vit D normal endoscopic eval repletion with Zn sulfate improvement in rash 10

11 Case 2 42 yo woman CC: GI bleed In SICU s/p MVA w/multiple fractures; coffee ground OGT RYGB 12 years ago, lost 100 lbs; doing well multiple falls (wrist fracture)- tripping over her puppy taking no meds at home except Prilosec OTC for mild GERD Labs: Hb 9, MCV 75; Ca 7.6; Alk Phos slightly elevated Repeat NG lavage is neg Putting the case together no long term follow-up Falls/MVA impaired night vision from Vitamin A deficiency vitamin D deficiency/ca malabsorption contributing to metabolic bone disease well reported after WLS Anemia 10% body mass loss 1-2% bone loss not from GI bleed in her case iron deficiency from impaired absorption 11

12 Name the vitamin deficiency Zinc Selenium Vitamin C Poor wound healing, perifollicular hemorrhage, gingivitis, anemia, joint pain Name the nutritional deficiency B1 (thiamine) Zinc Vitamin D Anorexia, dysguesia, rash, alopecia, diarrhea, nail dystrophic changes archderm.ama-assn.org 12

13 Final Points Nutrition is apart of most of what we do as gastroenterologists Nutritional status can impact GI disease Not only does GI disease impact nutritional status, but diet modifications in the setting of disease can further impact nutritional status Otherwords.org 13

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