Sodexo Distance Dietetic Internship
GI Learning Activity
Name: Melanie Wheeland
Fiber
1. What is the difference between dietary fiber and dietary residue?
Dietary residue includes fiber and any other foods that may increase bowel
activity stool output. Dietary fiber is the nondigestible carbohydrates and lignin
that are intrinsic and intact in plants. Fibers can be fermented in the large
intestine or can pass through the digestive tract unfermented.
2. List the physiological function and food sources of both water-soluble and waterinsoluble fiber.
a. Soluble fiber: attracts water and turns into gel during digestion. This
slows digestion. It delays the emptying of your stomach and makes you
feel full. Found in oat bran, barley, nuts, seeds, beans, lentils, peas, and
some fruits and vegetables.
b. Insoluble fiber: adds bulk to the stool and appears to help food pass more
quickly through the stomach and intestines. Found in wheat bran,
vegetables, and whole grains.
3. When counseling an individual regarding increasing the fiber in their diet, what
recommendations would you make to assure better tolerance?
I would recommend slowly increasing the amount of fiber you eat until you
reach 25-35g per day and to drink plenty of fluids. Suddenly adding a large
amount of fiber to your diet can cause abdominal cramping, gas, bloating, or
diarrhea. Adequate physical activity is also beneficial.
4. How may a higher fiber diet help prevent the development of diverticulosis?
Diverticular disease results from the formation of small pouches in the colon wall
and lining due to chronic constipation. Chronic constipation can be prevented by
following a high fiber diet to add bulk to stool and help food pass through the GI
tract.
5. Bulking agents are often used to control the symptoms of irritable bowel
syndrome (IBS) and to help prevent constipation. Explain the rationale for this
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treatment and list common bulking agents available.
Bulking agents increase peristalsis of the GI tract, which prevents constipation.
They must always be taken with water. Common bulking agents available are:
sylium (Metamucil, Effersyllium, Peridem Fiber), Benefiber (with guar gum),
methylcellulose (Citrucel), calium polycarbophil (Fibercon), Fiberall, Fiber-lax,
Equilactin, Konsyl, Sertuan.
6. After a thorough work-up by a physician, an individual was diagnosed with IBS.
What diet and lifestyle modifications should be considered when counseling this
individual?
Therapies focus on specific GI dysfunctions and medications should only be used
when non-prescription remedies do not work or when symptoms are severe.
Regular eating patters, regular bowel hygiene, adequate rest, and relaxation
should be encouraged. Avoid constipation by increasing physical activity and
consuming adequate fluids and fiber. Monitor for food intolerances. Avoid high
fat foods which may increase cholecystokinin release, and avoid sugar intake
which increases osmolarity.
7. List the common causes of diarrhea.
Antibiotic-induced such as C. diff, chronic diarrhea (celiac disease, cow’s milk
allergy, cystic fibrosis, or post infectious gastroenteritis), dysentery (from poor
sanitation), functional (from irritation or stress), organic (from intestinal lesion),
osmotic (from carbohydrate intolerance), and secretory (from bacteria, viruses,
bile acids, laxatives, or hormones).
8. Diarrhea can cause dehydration. What are the symptoms of dehydration and
how should it be treated?
Watch for decreased skin turgor, dry mucos membranes, thirst, 2% weight loss
or more, low BP, postural hypotension, increased H/H, and decreased urinary
output. Fluids need to be replaced, by IV if severe.
9. List the common causes of constipation.
The common causes of constipation are a lack of physical activity, overconsumption of foods high in fat and sugar, lack of high fiber foods, lack of water
and other fluids, intake of alcohol or caffeine, certain medications, certain
disease stages, and aging.
GERD / Hiatal Hernia
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Mrs. Y is a 69 year old female, 5'2", 195 pounds, who has frequent complaints of
heartburn and indigestion. Her diagnosis is gastrointestinal reflux disease (GERD). Her
usual dietary intake is as follows:
Breakfast:
2 donuts
2 cups coffee with sugar and half & half
Lunch:
Salad with low calorie Italian dressing
Coffee with sugar and half & half
Dinner:
Meat
Potato with gravy
Carrots with butter
Ice cream
Coffee with sugar and half & half
Evening:
Potato chips
Coke Classic
1. What Medical Nutrition Therapy is recommended for GERD?
It is recommended to exercise 3-4 times per week, wear loose fitting clothes, do
not smoke, raise the head of your bed 6-9 inches, wait 3 hours after eating
before lying down, eat several small meals throughout the day, eat in a calm,
relaxed space, and sit down while you eat. Avoid peppermint, spearmint,
chocolate, alcohol, caffeinated beverages, decaffeinated coffee and regular tea,
pepper, high fat foods, and fruits or vegetables that cause symptoms.
2. What changes would you recommend the patient make to her usual daily intake?
I would recommend a breakfast lower in fat than donuts, such as oatmeal. The
pt is currently consuming 4 cups of coffee and 1 coke, which is too much
caffeine, so I would recommend switching to other beverages such as water or
low fat milk. The butter, gravy, ice cream, and chips are all high in fat and
probably aggravating the GERD so I would recommend substituting for frozen
yogurt, margarine, low fat gravy, pretzels etc.
3. Define the types of medications a physician might prescribe as listed below. List
the reason for being prescribed, potential side effects, and names of drugs within
the classification.
a. Antacids
Agents that neutralize gastric acid and raise the gastric pH. Prescribed to
treat heartburn, GERD, acid ingestion, peptic ulcers, dyspepsia. Potential
side effects include diarrhea, constipation, kidney stones, and increased
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risk for osteoporosis. Examples include alka-seltzer, Equaate, Maalox,
Milk of Magnesia, and Pepto Bismol, and Tums.
b. H-2 blockers
Used to block the action of histamine on parietal cells in the stomach,
decreasing the production of acid by these cells. Prescribed to treat
peptic ulcer disease, GERD, dyspepsia, and prevention of stress ulcer.
Potential side effects include hypotension, headache, dizziness, tiredness,
confusion, diarrhea, constipation, and rash. Examples include Tagamet,
Pepcid, Axid, Zantac
c. Proton-pump inhibitor
Used for pronounced and long lasting reduction of gastric acid
production. Prescribed to treat dyspepsia, peptic ulcer disease, GERD<
larygopharangeal reflux, Barrett’s esophagus. Potential side effects
include headache, nausea, diarrhea, abdominal pain, fatigue, and
dizziness. Examples include Prilosec, Prevacid, Nexium, and Protonix.
d. Motility altering
Used in the management of intestinal motility disorders, such as
antidiarrheals which inhibit peristalsis. Prescribed to treat diarrhea,
including travelers diarrhea. Side effects include stomach pain or
bloating, diarrhea that is watery or bloody, dizziness, drowsiness,
constipation. Examples include Imodium, Lomotil, and Motofen.
Inflammatory Bowel Disease
1. Differentiate between Crohn’s Disease and Ulcerative Colitis. Include the area(s)
affected, degree of inflammation, complications, age of onset and treatment in
your answer. (Setting this up as a table may be helpful.)
Disease
Anatomy affected
Depth of involvement
Distribution of disease
What is it
Complications
Medications
Age of Onset
Crohn’s Disease
Rectum, colon
Mucosa, submucosa
Continuous
Inflammatory disease in the
terminal ileum
Weight loss, anorexia,
diarrhea, B12 deficiency
Antibiotics, sulfasalazine,
corticosterioids
15-30 years of age, and 6080 years of age
Ulcerative Colitis
Mouth to anus
Transmural
Segmental
Ulcerative disease of the
colon
Bloody diarrhea, weight
loss, anorexia
Mesalamine,
corticosteroids,
antidiarrheals
15-25 years of age, and 5565 years of age
Nutrition Intervention
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Replace fluid and
Bowel rest, low fiber diet,
electrolytes, correct
replenish depleted
nutrient malabsorption or
nutrition stores, provide
anemia, monitor lactose or sufficient dietary
gluten intolerances, bowel
antioxidents and omega-3
rest, supplement with
fatty acids
vitamins and minerals
2. Listed below are common medications to treat inflammatory bowel disease.
State the rationale for their use, potential food and drug interaction and any
other significant side effects.
Prednisone: A synthetic corticosteroid drug that is effective as an
immunosuppressant, and is used to treat inflammatory diseases. Decrease Na
and increase Ca, Vit D, and protein. Use caution with grapefruit and limit
caffeine. Increases appetite. Potential side effects include nervousness, acne,
rash, appetite gain, increased thirst, diarrhea.
Sulfasalazine: An iantinflammatory drug, reduces irritation and swelling in the
large intestines. Side effects may include depression, temporary infertility,
kidney stones
Cholestyramine: A bile acid sequestrant, which binds bile in the GI tract to
prevent its reabsorption. Commonly used to treat diarrhea resulting from bile
acid malabsorption. Can also be used in the treatment for C. diff. Side effects
include constipation, tooth decay, and increased plasma triglycerides. May
interfere with the absorption of vitamins A, D, E, K.
Antibiotics: A type of antimicrobial used specifically against bacteria. Side effects
may include fever, nausea, allergic reactions, and diarrhea. Adverse reactions
when taken with alcohol.
Immunomodulators: Used to help regulate or normalize the immune system.
Used for the treatment of Crohn’s disease and ulcerative colitis. Common side
effects include nausea, vomiting, or loss of appetite, diarrhea, itching, or rash. Do
not drink alcohol when taking this medication.
Antidiarrheals: inhibit peristalsis. Prescribed to treat diarrhea, including travelers
diarrhea. Side effects include stomach pain or bloating, diarrhea that is watery or
bloody, dizziness, drowsiness, constipation. Negative interaction with alcohol.
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3. Patients with IBD are at the greatest risk for deficiencies of the following
nutrients. List the reason(s) why the deficiency may occur in patients with IBD
Iron: People with IBD often experience blood loss in their stool, which can result
in a loss of iron stores. Malabsorption may also contribute to a lack of iron. This
is particularly true for those who have Crohn’s disease of the small intestine.
Zinc: Zinc is lost through diarrhea and can occur in people with IBD, expecially
those with chronic diarrhea. Other reasons for poor zinc absorption include GI
surgery and short bowel syndrome.
Folate: People with Crohn’s disease in their small intestine are at risk for
malabsorption of folate. Folate is absorbed by the jejunum and the ileum.
Sulfasalazine and Methotrexate, 2 medications used to treat IBD, may interfere
with the metabolism of folate.
Vitamin B12: Vit B12 is absorbed in the small intestine, and those who have had
surgery to remove sections of their small intestine may not be able to absorb
enough B12
Protein: Patients with IBD may have increased protein needs due to losses from
inflammation of the intestinal tract, catabolism when an infection is present, and
possible for healing if patient requires surgery.
Fat-Soluble vitamins: Cholecystramine decreases absorption of fat soluble
vitamins A, D, E, K
Calories: Calorie needs may increase after surgery. Also a loss of appetite may
occur as a result of nausea, abdominal pain, fear of eating, and altered taste
sensation.
4. What dietary considerations are necessary with an ileostomy?
During ileostomy surgery, the entire colon, rectum, and anus are removed or
bypassed. The part of the small intestine called the ileum is brought through the
abdominal wall, creating a stoma. The stoma is an opening in the abdomen that
must be covered with a bag to collect stools at all times. It can be temporary or
permanent depending on the surgery. After surgery, your bowel will be swollen.
Your eating plan will begin with a diet of clear liquids. As you recover, you will
start eating solid foods, beginning with foods low in fiber. Avoiding high fiber
foods allos the bowel to heal and prevent blockage of the ileostomy. Plan to
have your largest meal in the middle of the day. Do not eat large amounts in the
evening. This can help decrease stool output at night. To reduce gas, avoid
chewing gum, drinking with straws, and drinking carbonated beverages, smoking
or chewing tobacco, eating too fast, and skipping meals. Aim for 8-10 cups of
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liquid per day. Watch for signs and symptoms of electrolyte imbalance.
5. What is Short Bowel Syndrome?
Short bowel syndrome involves the surgical resection of a portion of the small
bowel, compromising the absorptive surface and resulting in malabsorption.
Malnutrition from maldigestion, malabsorption diarrhea, and steattorhea may
result. A bowel resection that results in SBS may be due to Crohn’s disease,
intestinal cancer, scleroderma, or fistula in adults. Normal bowel length is about
600cm. SBS generally leaves less than 150cm of small intestine.
6. What is the minimal length of functional bowel believed to be necessary for
provision of enteral nutrition?
The minimal length of functional bowel needed for enteral feeding is over 100cm
in the absence of an intact colon and over 60 cm in continuity with the colon.
Celiac Disease
1. Define Celiac Disease, including the frequency of the condition and
causes.
CD is a common, lifelong, genetically based autoimmune disorder that
causes inflammation of the proximal small intestine. CD is characterized
by inappropriate T cell-mediated immune response to ingested gluten
from wheat, barley, and rye that leads to inflammation, villous atrophy,
and crypt hyperplasia in the small intestine. A major consensus panel
determined that 1% of Caucasians (upwards of 3 million people) may
have CD. While screening suggests that 1 in 133 people have it, the
frequency may be closer to 1 in 100.
2. What types of foods must be avoided by patients with Celiac Disease?
Any foods that contain wheat (all types including einkorn, emmer, spelt,
and kamut), barley, rye, malt, oats (unless gluten free)
3. What nutrients might be deficient in this diet?
Deficiencies of iron, folate, calcium, and vitamin D may be found.
4. Write a one-day menu for a patient on a gluten-free diet.
Breakfast
Lunch
Dinner
Snack
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Egg omelet with low fat natural cheese and veggies, rice cake, jam,
orange juice
Black beans, corn tortilla, low fat natural cheese, salsa, fresh
veggies, selter water with lime
Chicken, Stir fried veggies, plain brown rice, sherbet, fresh fruit,
seltzer water, cranberry juice
All-natural yogurt, blueberries
Gallbladder Disease
1. Define the following terms:
Cholecystitis: is inflammation of the gallbladder. It is a class of related
disease states with different causes, degrees of severity, clinical courses,
and management strategies.
Cholelithiasis: The presence of gallstones. Gallstones are a hepatobilary
disorder due to biochemical imbalances in the gallbladder bile. Some
gallbladders can concentrate bile normally but cannot acidify it. The
result is that calcium may be less solube in bile and precipitates out.
Gallstones contain primarily cholesterol, bilirubin, and calcium salts
formed into either cholesterol or pigment stones.
Cholecystectomy: Surgical removal of the gallbladder
2. You are asked to counsel an individual regarding a diet post cholecystectomy.
What diet modifications would you recommend both short and long term?
After a cholecystectomy, fat intake should be limited for several months
to allow the liver to compensate for the gallbladder’s absensce. Fats should be
introduced gradually; excessive amounts at one meal should be avoided. Use
more unrefined carbohydrates as well. If diarrhea persists after surgery, try using
antidiarrheal medications and a high fiber diet for more bulk. Avoid fasting and
rapid weight loss schemes. People who have had their gallbladders removed
should have their cholesterol levels checked periodically.