Clinical and
           Therapeutic Nutrition             PRACTICAL6 NUTRITIONAL
                                                                             MANAGEMENTOF
                                                                             GASTROINTESTINAL
                                                                             DISORDERS
                                             Structure
                                             6.1    Introduction
                                             6.2    Peptic Ulcers
                                                    6.2.1  Pathophysiology
                                                    6.2.2  PrinciplesofDietaryManagement
                                             6.3    UlcerativeColitis
                                                    6.3.1  Pathophysiology
                                                    6.3.2  PrinciplesofDietaryManagement
                                             6.4    Lactose Intolerance
                                             6.5    Review Exercises
                                             Activity 1: Diet Plan for Peptic Ulcer
                                             Activity 2: Diet Plan for Ulcerative Colitis
                                             Activity 3: Diet Plan for Lactose Intolerance
                                             6.1     INTRODUCTION
                                             Disorders of the gastrointestinal tract encompass a wide range of diseases which may
                                             beasmildandubiquitousinprevalencesuchasdyspepsia,gastritis,nausea,vomitting,
                                             diarrhoea to not so frequent in occurrence such as carcinomas, inflammatory bowel
                                             disorders, lactose intolerance, gluten enteropathy etc.    The dietary management of
                                             someof the disorders can be as simple as modification in consistency to as complex
                                             aseliminationofcertainnutrientorprovidingelemental/hydrolyzedformulas. Diseases
                                             such as peptic ulcers can be life threatening whereas; diseases such as ulcerative
                                             colitis can progress towards the development of carcinomas (requiring surgery). In
                                             this unit we shall learn and practice the dietary management of peptic ulcers and
                                             ulcerative colitis. Let us first begin with their pathophysiology and the impact of the
                                             disease condition on the nutritional status of the patient. Before we begin, we suggest
                                             youlookupUnit6intheAppliedPhysiologyCourse(MFN-001)torevisethephysiology
                                             of the gastrointestinal system. Also review Unit 14 in the Clinical and Therapeutic
                                             NutritionCourse(MFN-005)torecapitulatethecauses,importantsignsandsymptoms
                                             and the dietary management of peptic ulcer and ulcerative colitis.
                                             Objectives
                                             After undertaking this practical, you will be able to:
                                                 discuss few disorders linked with the gastrointestinal tract,
                                                 describe the principles of dietary management for peptic ulcer and ulcerative
                                                  colitis, and lactose intolerance, and
                                                 plandietsfor individualssufferingfromthesedisordersi.e.pepticulcer, ulcerative
                                                  colitis and lactose intolerance.
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                                                                                      Nutritional Management
        6.2     PEPTICULCERS                                                              of Gastrointestinal
                                                                                                 Disorders
        Peptic ulcer, you may be aware by now, is any localized erosion or a break in the
        gastric/duodenal mucosa that arises when the normal mucosal defensive factors are
        impaired or are overwhelmed by aggressive luminal factors such as acid and pepsin.
        Let us first review the pathophysiology of peptic ulcers followed by the principles of
        dietary management.
        6.2.1   Pathophysiology
        Ulcers may develop in the stomach/jejunum (gastric ulcers) or /and in the duodenum
        (duodenal ulcers). Let us review these conditions.
        Gastric Ulcers occur most frequently along the lesser curvature of the stomach.
        Look up Figure 6.8 in Unit 6 in the Applied Physiology Course (MFN-001) which
        illustrates the stomach. Gastric ulcers are associated with gastritis, inflammatory
        involvement of the oxyntic (acid producing) cells and atrophy of the acid and pepsin-
        producingcellswithadvancingage. Morbidityandmortalityarehigher amonggastric
        ulcers due to haemorrhages as compared to in duodenal ulcers.
        Duodenal Ulcers generally occur within the first few centimeters of the duodenal
        bulb, in an area immediately below the pylorus. They are characterized by increased
        acidsecretionparticularlynocturnalacidsecretionanddecreasedbicarbonatesecretion.
        The major causes of ulcers are:
            Chronic infection of helicobacter pylori
            Consumption of hypersecretory agents such as non-steroidal anti-inflammatory
             drugs
            Alcohol, tobacco consumption and cigarette smoking
            Tea, coffee, spices
            Physical/emotional stress
        Thesign and symptoms which may adversely affect the nutritional status of patients
        suffering fromulcers include:
            Epigastricpainwhichisfrequentlydescribedasgnawing,dull,achingor“hunger-
             like”
            Nocturnalpain
            Nausea, anorexia, dyspepsia
            Gastrointestinal haemorrhage (melena)
            Weight loss
        Symptomsofulcersarecharacterizedby rhythmicityandperiodicity. Approximately
        half of the patients report relief of pain with food or antacids (especially duodenal
        ulcers) and a recurrence of pain 2-4 hours later. This is an important factor which
        must be taken into consideration while deciding the meal timings and frequency for
        the patient.
        Thetreatment of the problem is based on:
            Alleviation of the underlying cause,
            Drugs (anti secreatory, enhance mucosal defense),
            Providingrelief fromsymptoms/complications, and
            Dietary management to promote a good nutritional status.
        Inthesubsequentsub-sectionweshalllearnabouttheessentialsofdietarymanagement
        during the various stages of peptic ulcers and also for the successful management of
        complications that mayariseas a result of gastric surgeryperformedfor thetreatment
        of complicated cases of peptic ulcers.                                                          107
           Clinical and                     6.2.2     Principles of Dietary Management
           Therapeutic Nutrition
                                            The dietary management regime of peptic ulcers has witnessed several changes.
                                            The mostpopular conservativediet therapy was the Sippy’s diet wherein 6 small 1-2
                                            hourly feedings comprising of mainly cream and milk were given to the patient.
                                            However, this resulted in the elicitation of nutritional disorders such as
                                            hypercholesterolemia, scurvy, alkalosis and tetany(Milk-Alkali Syndrome) toname a
                                            few. At present we are following a more liberal approach which was initiated by
                                            Meulen Gracht. We shall now discuss in detail the various aspects of dietary
                                            managementforpepticulcers. However,letusfirstidentifytheobjectivesofnutritional
                                            care for a peptic ulcer patient.
                                            Objectives
                                            Theobjectives of nutritional care for a peptic ulcer patient include:
                                                 to prevent further erosion and promote healing of the mucosal lining,
                                                 to maintain an optimumpH inthealimentarytract,
                                                 to coordinate acid secretion with food intake, and
                                                 to correct nutritional deficiencies and promote a good nutritional status.
                                            Inlight of theabovementionedobjectivesweshalldiscusstherequirementsforvarious
                                            nutrients. We will first discuss the energy needs for the patient.
                                            Energy:Therequirements for energy should be based upon the existing health status
                                            of the patient.  Majority of the patients are malnourished due to abdominal pain
                                            associated with food intake and to poor digestion/absorption. Thus, if the patient is
                                            ambulatory; it is recommendedtoincreasetheenergyintakebyabout 10%. However,
                                            in case of hospitalized (bed-rest) patients; normal energy intake (as per RDI) would
                                            suffice for the extra needs. Providing 35 Kcal/kg IBW to promote weight gain may
                                            not be feasible during the active phase. This is generally recommended during the
                                            recovery stage (latent).
                                            Let us now learn how to provide the recommended energy through various
                                            macronutrients viz. proteins, fats and carbohydrates.
                                            Proteins: The protein intake should be increased by about 25% to 50% above the
                                            RDI. Proteins should be increased to:
                                                 promote synthesis of new tissues and thus healing of eroded mucosa,
                                                 replenish the blood proteins lost due to gastrointestinal bleeding, and
                                                 providebufferingeffect – sinceproteins have a longer intestinal transit timethan
                                                  carbohydrates.
                                            High biological value proteins, which are at the same time easy to digest, should be
                                            provided. While eggs and washed pulses can be included liberally; meat and milk
                                            should be given in moderation (since calciumpresent in milk and meat stimulate acid
                                            secretion). Wholepulses andlegumes, if given, shouldbeina soft cooked/ blendedor
                                            pureed form (boiled, fermented, sprouted and steamed etc.). Protein supplements
                                            such as complan, casilan, Pro Mode, threptin biscuits may be included in the menus.
                                            Sprouts/dalkhichdi, uttapam, idly, eggnog, soufflé,bakedcustard, puddings, poached/
                                            boiled egg, porridge, baked/steamed chicken/fish etc. (small serving) can be given to
                                            patient.
                                            Carbohydrates: Nearly60%ofthetotalenergyshouldbeprovidedfromcarbohydrates
                                            to ensure maintenance of body weight and to ensure spairing of proteins for tissue
                                            synthesis. However, emphasis should be laid on foods rich in mono/disaccharides
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           and/or starches. The intake of dietary fibre, particularly insoluble fibre (husk, bran,           Nutritional Management
           peels etc.) should be avoided to prevent irritation to the ulcers. For the same reason                  of Gastrointestinal
           foodshouldbewellcookedandblended/pureedtomakeitmechanicallybland. Fruits                                        Disorders
           should be steamed before serving. Care should be taken to exclude harsh sources of
           fibre such as seeds of citrus fruits and vegetables. Tomatoes if used as soups/purees
           can be tolerated in moderation (seeds get crushed). For the same reason wheat flour
           should be sifted through a fine mesh and whole cereal (bajra, jowar, ragi etc.) flours
           should not be included in the diet. Among the cereals rice, semolina, refined flour,
           sago, pasta, arrowroot/potato powder would be good options.
           Fat: Nearly 20-25% of the total energy should be provided from fat because fat in
           anyformdelays gastricemptying, suppresses gastric acid secretionand motility. The
           quality of fat however should be selected according to the age and present health
           status of the patients. It is generally recommended to lay stress on emulsified fats
           andthoserichinmediumchaintriglycerides(oliveoil, coconutoil). Foodstuffs richin
           emulsifiedfats(eggs,wholemilk,cream,butter)aregenerallygoodsourcesofsaturated
           fattyacids etc. Thus, middleagedulcer patients, especiallythoseatriskofdeveloping
           coronary artery diseases, should lay greater emphasis on MCT’s or vegetable oils
           rich in MUFA’s/PUFA’s rather than emulsified fats.
           Vitamins/Minerals:Therequirements ofiron, calcium, andvitamin C increaseduring
           ulcers. While iron deficiency may arise due to bleeding; calcium reserves may get
           depleted (chronic cases) as milk/milk products are used in moderation. Fresh but
           cookedfruits and vegetables should be consumed in good amounts to get an adequate
           intake of vitamin C.
           Besides the nutrient requirements discussed above, let us also review a few other
           considerations to be kept in mind while planning diets for ulcer patients.
           General Considerations
           The following general considerations need to be considered:
               Small, easy to digest meals should be given to the patient at very short intervals.
                An eight meal pattern is generally recommended during the acute phase while
                duringrecovery/latent phases, thepatient shouldpreferablyadhereto a 5-6 meal
                pattern.
               Regular meal timings should be followed.
               The patient should be counseled to consume meals in a relaxed and calm
                environment.
               Fasting and long intervals between meals should be avoided.
               Themeals shouldbechemically, mechanically andthermally bland i.e.:
                    Foodsconsumedshouldnotstimulategastricacidsecretion. Thus,stimulating
                     beveragessuchastea,coffee,cocoa,carbonateddrinks,spices,condiments,
                     should be avoided. Patients may be given small servings of decaffeinated
                     tea/coffee. Studies have shown that small amounts of condiments in the
                     formofpowder(cardamom)donotpromote/aggravateacidsecretion. Red
                     andblackpepperhavebeenassociatedwithmucosaldamageandincreased
                     gastric acid secretion.
                    Mechanicallyirritatingfoodsshouldbeavoidedastheymaycausephysical
                     damagetotheulceratedregions.Thus,foodrichininsolublefibreshouldbe
                     avoided. Raw food should not be served. Similarly, alcoholic beverages
                     (ethanol) may cause physical inquiry to the mucosal lining of the stomach
                     and should therefore be avoided.
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