Nutrition and Digestive Health -


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Nutrition and Digestive Health -

  1. 1. ASN/AAFP webinar series: Putting Nutrition Science to Work in Family Medicine<br />Nutrition and Digestive Health <br /><ul><li>TopicKey PointsResources/ReferencesHelp patients make small, evidence-based dietary changes to promote digestive healthDefinition of Digestive Health from American Gastroenterological Association: Ability to process nutrients through properly functioning gastrointestinal organs, including the stomach, intestines, liver, pancreas, esophagus and gallbladder, Most people who are in good digestive health are of appropriate weight and don’t regularly experience symptoms like heartburn, gas, constipations, diarrhea, nausea or stomach pain. In addition: GI tract is first line of defense against invading pathogens and 70% of immune cells are associated with the gut. To get good digestive health: Achieve and maintain appropriate weightEat a balanced and varied dietReduce stressBe physically activeOther tips: Stay hydrated; include beverages with meals or snacks.Eat mindfully, how you eat is just as important as what, eat slowly,Avoid bloating by introducing fiber slowly into the diet.Incorporating fiber and probiotics in the diet to help keep healthy people healthy. For Fiber: Primary recommendation is to follow the Dietary Guidelines and MyPyramid to incorporate adequate fruits, vegetables, whole grains and legumes as part of the diet to get the recommended fiber. Following MyPyramid eating plan would bring majority of North American adult population close to recommended range of 14g /1000 cals. Additionally, a higher fiber diet will likely translate to a less calorically dense diet, therefore, impacting weight management.However, most Americans get only ½ the recommended 25 grams of fiber per day. Looking for foods with added fibers is an important way to get fiber benefits. For Probiotics: Look for products that indicate what strain of bacteria is provided. Look for products with strains that have proven science for a digestive health benefit, such as improved transit time. Position of the American Dietetic Association: Health Implications of Dietary Fiber J Am Diet Assoc 2008;108:1716-1731.Role of Nutrition in trt/prevention of GERD & IBSRole of fiber (prebiotics) and probiotics in IBS: Probiotics may be efficacious for use in IBS, but still more work to be done to understand the best strain and magnitude of benefit.Composition of colonic microbiota affects the fermentation of carbohydrates which impacts motility. Dietary fiber may improve symptoms of patients with IBD. Clinical Endpoints Using Probiotics and Prebiotics for IBD, IBS, and Infectious DiarrheaFergus Shanahan, MD (May 27th) CJ et al Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2004;19:245-251.Position of the American Dietetic Association: Health Implications of Dietary Fiber. J Am Diet Assoc 2008;108:1716-1731.Moayyedi P et al. The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review. Gut 2010;59:325-332 Types of fiber and how to introduce into a healthy diet Why: Populations who consume more dietary fiber have less chronic disease. The intake of dietary fiber has beneficial effects on risk factors for developing several chronic diseases such as diabetes and heart disease, and also plays a role in weight management. Evidence regarding the relationship of fiber and cancer needs further research. Adequate fiber from foods may: ameliorate constipation & diverticular disease, provide fuel for colon cells, reduce blood glucose and lipid levels, provide source of nutrient-rich, low-energy –dense foods that could contribute to satiety. Oat bran, barley bran, pysllium have heart health claims related to ability to lower LDL-C.Wheat bran commonly linked to laxation effect.How much:14 g/1000kcal or roughly AT LEAST 25 g/day. Most Americans getting only 15 g/day. Need all kinds of fiber insoluble like from whole grains and soluble like from oat bran and dried beans. A varied diet is important. Types of Fiber:There are several definitions of and ways to classify fibers.Fiber can be characterized in different ways, either by analytical methods used to isolate and quantify dietary fiber or by physiological basis; solubility, fermentability or viscosity.2002 Institute of Medicine Definition: Total Fiber= Dietary + FunctionalDietary fiber : Non-digestible carbohydrate and lignin that are intrinsic and intact in plants.Functional fiber: isolated non digestible CHO that have beneficial physiological effects in humans. Physiological effectiveness is valuable way to look at fibers for example the research on inulin’s beneficial impact on digestive health.Fiber and bowel function: There is a lack of data examining the impact of fiber from whole foods on outcomes in gastrointestinal diseases (studies are difficult to conduct). Fiber supplements may produce benefits in the laxation of healthy people. Many fibers sources (cereal brans, psyllium seed husks, methylcellulose and a mixed high-fiber diet) increase stool weight, thus promoting normal laxation. If fiber is fully and rapidly fermented in the large bowel (most soluble fibers are) there is no increase in stool weight. Stool weight varies greatly, Westernized populations range from 80-120 g/day. Tolerance: Fiber is not digested and absorbed in the small intestine, it can have a laxative effect and increase the ease and/or frequency of laxation. Fiber is undigested. It is however utilized by gut microbes as an energy source with gas production as a byproduct of the fermentation process. Some effects potentially include: Diarrhea, flatulence, bloating, and abdominal discomfort. This may impact perception of well-being and acceptance of high fiber foods as part of the diet so it is important to couple increased fiber recommendations with education of what to expect. When dietary fiber is increased, fluid intake should also be increased. Fiber should be increased gradually to allow the GI tract time to adapt.Other roles of fiber in health: Prebiotics International Scientific Association for Probiotics and Prebiotics definition of prebiotics: Prebiotics are selectively fermented, dietary ingredients that result in specific changes in thecomposition and/or activity of the gastrointestinal microbiota, thus conferring benefit(s) upon host health. (i.e. providing fuel for only beneficial types of bacteria at expense of potentially pathogenic bacteria: “feed the grass, not the weeds”)Inulin is one of the best characterized prebiotics.Fructooligosaccharide (FOS) is rapidly fermented by intestinal bacteria that then produce short chain fatty acids (SCFA). SCFA stimulate water and electrolyte absorption and may help treat diarrhea. FOS is also a preferred substrate for bifidobacteria; selectively stimulating growth of only beneficial microorganism (again at the expense of potentially pathogenic ones) so can help maintain and restore balance of healthful gut flora. Role of Fiber in Diverticulosis: Adequate intake of dietary fiber may prevent formation of diverticula by providing bulk in the colon. Case control and case studies report success with high-fiber intakes and diverticulosis, however it is not clear if dietary fiber can prevent diverticulitis. Position of the American Dietetic Association: Health Implications of Dietary Fiber. J Am Diet Assoc 2008;108:1716-1731.Cummings JH. Spiller GA ed CRC Handbok of Dietary Fiber in Human nUtirtion. 2nd ed. Boca Taton, FL CRC Press: 1993:263-349.Grabitske HA and Slavin JL. J Am Diet Assoc. 2008;108:1677-1681Grabitske HA and Slavin JL. Laxation and the Like: Assessing Digestive Health Nutrition Today 2008; 43(5):193-198.Roberfroid M. J Nutr 2007;137 (suppl);830S-837S.Aldorri et al. Can Fam Physician 2002;48:1632-1637Institute of Medicine Food and Nutrition Board. Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington D.C., National Academies Press; 2002.Attach spreadsheet of inulin research. role in a healthy immune system There are more and more probiotic product options on the market in the form of medical foods, supplements or foods. Not all probiotic containing products are regulated the same way; supplements less rigorously than foods.There is potential to use food providing prebiotics and probiotics to positively modulate the gut microflora to help maintain health. Probiotics have been shown to impact immune function by different mechanisms:Via colonization resistance: probiotics create an environment that is more conducive to beneficial bacteria growth which then crowd-out potentially pathogenic microorganisms in the alimentary tract.Ex: Reduction in GI infection Interacting directly with the immune cells in the gut. Ex: some probiotic strains have been shown to reduce incidence of atopic dermatitis/allergies in childrenResearch is rapidly evolving regarding the influence of commensal (resident) bacteria on shaping the immune system. This could eventually lead to food based solutions in the near future to impact immunity. Guarner et al., Nature Clinical Practice Gastroenterology & Hepatology 2006; 3(5): 275-284Artis, D. nature Reviews Immunology 2008; 8:411-420 (commensal bacteria and immunity)Reid et al., Clinical Microbiology Reviews 2003; 16(4): 658–672Servin A.L. Antagonistic activities of Lactobacilli and Bifidobacteria against microbial pathogens. FEMS Microbiol Rev 2004; 28:405-440 (colonization resistance paper)Merenstein D, et al. Europ J Clin Nutr; 2010. (reduction in GI infection)Weizman et al., Pediatrics 2005;115:5–9; (infections study)Chouraqui, et al., J Ped Gastroenterol Nutr; 2004. 38: 288-292 (infections study)Smerud, H., et al., Microbial Ecology in Health and Disease, 2008; 20:80-85 (infections study)Kalliomaki, M., et al., Lancet; 2001. 357(9262): 1076-1079 (atopic dermatitis study)