ADVANCED DIPLOMA IN PRINCIPLES OF NUTRITION

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Biomedicine and Nutrition Course Educators: Thomas

1 ADVANCED DIPLOMA IN PRINCIPLES OF NUTRITION BY AMANDA BRODERICK BSc ANutR BSC HONS Sports Biomedicine and Nutrition Course Educators: Thomas Woods, William BY AMANDA BRODERICK LESSON: 2

2 Special Diets Semester : Lesson 5 Nutritional Management of Digestive Disorders Course Educator: Amanda Broderick Course Educator B.A. amandabroderick@shawacademy.com

3 Lesson 5 Learning Outcomes What is digestion? Malabsorption Lactose Intolerance Coeliac disease Irritable bowel syndrome (IBS) Case Study 2

4 The Digestive System

5 What is Digestion? Breakdown of food into smaller particles or individual nutrients The major organs that coordinate digestion include: Mouth Oesophagus Stomach Small intestine Large intestine Liver Digestion:

6 What Happens in The Mouth? 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)

7 Oesophagus 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

Stomach 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

8 Stomach 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 Digestion in the stomach:

villi Duodenum: chemical digestion- enzymes digest nutrients into smaller forms for absorption

10 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

11 Small Intestine- Enzyme Action Enzymes involved in 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

13 Which Enzymes Digest What:

of nutrients occurs in the Ileum Substances that

14 Small Intestine 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

Large Intestine Also known as the colon Divided into ascending, transverse and descending portions (each 1foot long) Primary functions: 1) Absorb water 2) Store, process and eliminate residue

15 Large Intestine Also known as the colon Divided into ascending, transverse and descending portions (each 1foot long) Primary functions: 1) Absorb water 2) 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

Liver Important role in processing products of human digestion Removes excess glucose from bloodstreamconverts to Glycogen for storage Converts amino acids to compounds that can be used in energy

16 Liver Important role in processing products of human digestion Removes excess glucose from bloodstreamconverts 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

17 Digestive Disorders

18 Malabsorption Inability to absorb nutrients 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 Stool abnormality not always distinct or present Different types: Fat malabsorption steatorrhoea - pale, malodourous, greasy, unformed stool Carbohydrate malabsorption-watery and frothy stool due to fermented sugars

19 Causes of Malabsorption Signs of deficiency: Anaemia Folate deficiency or vitamin B12 deficiency Bleeding, resulting from low vitamin K Oedema, which occurs in protein/energy malnutrition

20 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

viscosity, CRP Vitamin B12 level Red cell folate Iron status Clotting screen for vitamin K deficiency Serum albumin

21 Stool tests Abdominal ultrasound Barium follow - through may show structural abnormalities Ileocolonoscopy including biopsies of colon and ileum Breath hydrogen tests Testing for Malabsorption 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

22 Dietary Treatment of Malabsorption Aims of Nutritional Intervention 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

Fat Malabsorption 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

23 Fat Malabsorption 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 longterm 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

Carbohydrate Malabsorption Lactose Intolerant: Deficiency of the enzyme lactase - impaired ability to digest dietary lactose 3 Main forms: 1) Hereditary alactasia- complete absence of lactase and

25 Carbohydrate Malabsorption Lactose Intolerant: 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

26 Symptoms of Lactose Intolerance 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

27 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 unnecessarymay compromise calcium intake Symptoms should stabilise at a low intake and lactose-containing foods can be reintroduced gradually in increasing amounts

Tests and Diagnosis 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

28 Tests and Diagnosis 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

Coeliac Disease (CD) 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

29 Coeliac Disease (CD) 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 1 st degree relative with CD, autoimmune thyroid disease, Type 1 Diabetes Mellitus and Down Syndrome Flattening of villi - reduced absorption of nutrients

Symptoms of Coeliac Disease Diarrhoea- most common Abdominal discomfort Malabsorption Gastrointestinal upset Silent presentations Unexplained iron deficiency/anaemia Osteoporosis

31 Symptoms of Coeliac Disease 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

Long-Term Consequences Malignancy: of Coeliac Disease At risk of intestinal lymphoma, mainly non-hodgkin s lymphoma Risk is reduced by adherence to gluten free diet After approx.

32 Long-Term Consequences Malignancy: of Coeliac Disease 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

Tests and Diagnosis Screening recommended for people with associated symptoms or family history of coeliac disease Most widely available test - tissue transglutaminase IgA antibody test Estimated

33 Tests and Diagnosis Screening recommended for people with associated symptoms or family history 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

most likely increased sensitivity of the entire gut, possible psychological cause Important to rule out: infection,

34 Irritable Bowel Syndrome Common disorder of the digestive system 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 No cure exists for IBS: the symptoms can be managed by making changes to diet and lifestyle

35 Differential Diagnoses Diagnosis-patient characteristics Patient characteristics more frequently associated with organic pathology Coeliac disease Presentation <24 months > 50 years Food intolerance Elderly >60 years Weight loss red flags indicative of other serious or malignant pathology Disaccharide intolerance Bowel Cancer Persistent diarrhoea, flatulence, wind Night time diarrhoea/symptoms disturbing sleep Occult blood in faeces Family history of bowel cancer Diverticular disease Sudden onset Family history of IBD Bacterial overgrowth Inflammatory bowel disease infection Bile acid-related diarrhoea >5kg weight loss Faecal mass.225g/ 24 hours Abnormal blood results (ESR, Hb, albumin, CRP) Steatorrhoea or explosive, malodorous stools

or pain that has 2 of 3 features: 1. relieved with defecations and/or 2.

36 ROME I and II criteria for diagnosis of IBS 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)

Supportive (non-essential) symptoms of the irritable bowel syndrome Fewer than 3 bowel movements/week more than 3 bowel movements/day hard or lumpy stools loose or

37 Supportive (non-essential) symptoms of the irritable bowel syndrome Fewer than 3 bowel movements/week more 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

38 Living with IBS Psychological distress Depression Anxiety Embarrassment Pain Discomfort

Triggers of IBS Alcohol fizzy drinks chocolate drinks that contain caffeine, such as tea, coffee or cola processed snacks, such as crisps and biscuits

39 Triggers of 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

40 Diet for 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: oats barley rye fruit, such as bananas and apples root vegetables, such as carrots and potatoes golden linseeds Foods that contain insoluble fibre include: wholegrain bread bran cereals nuts and seeds (except golden linseeds)

41 Lifestyle Factors for IBS Exercise can help to relieve symptoms of IBS Aim to do a minimum of 30 mins 5 times a week

Food Intolerances and 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.

42 Food Intolerances and 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 confirmedsuggesting 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

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

43 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

44 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

45 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

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

46 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

47 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

Next Steps 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

48 Next Steps 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

49 To expand upon the subjects covered in todays lesson: Further Learning Basic nutrition- Diploma in Nutrition Weight loss- Ultimate weight Loss Programme

Advanced Course Resources Free Short Videos Topical Items that Pop Up Frequently Easy way of communicating that free content is available without

50 Advanced Course Resources Free Short Videos Topical Items that Pop Up Frequently Easy way of communicating that free content is available without spamming you!!!! Facebook: Before we begin let us gauge your experience level

51 Contact us anytime on: UK: +44 (0)

52 Further Reading 1) 2) Manual of Dietetic Practice, 4 th edition by Briony Thomas and Jacki Bishop (3) (4) (5) (6) (7) (9) (10) (11) (12)

Objective 4- Digestion

Objective 4- Digestion 1. Describe why cells require nutrients Supply energy for metabolism (cell activities), matter for synthesis of new materials, cell reproduction, secretion and to regulate cell processes