angie jefferson rd consultant dietitian...fermented by gut bacteria helpful for cholesterol &...

Angie Jefferson RD Consultant Dietitian

Constipation & Haemorrhoids are two of the most common problems experienced by pregnant

women Incidence increases dramatically 40% women reported to become constipated

>320,000 women every year & 25-35% develop haemorrhoids

Women Constipation & haemorrhoids both incredibly uncomfortable & affect quality of life

Health Care Professionals should care: Patient wellbeing Straining can damage pelvic floor musculature

Dietary fibre is the edible parts of plants or analogous carbohydrates that are resistant to digestion and absorption in the human small intestine, with complete or partial fermentation in the large intestine. Dietary fibre includes polysaccharides, oligosaccharides, lignin, and associated plant substances. Dietary fibres promote beneficial physiologic effects including laxation, and/or blood cholesterol attenuation, and/or blood glucose attenuation.

(ref. American Association Cereal Chemists)

Soluble fibres dissolve in water to form a gel Fermented by gut bacteria Helpful for cholesterol & blood sugar control Found in legumes, oats, some fruits & vegetables

Insoluble Fibres – bulk forming Absorb water and swell to form soft mass Increase faecal mass & soften stools Speed transit of food and waste materials Ease defeacation Found in cereals e.g. wheat bran, nuts & seeds, some fruits & vegetables, esp. skins

The time taken for food to travel from the mouth through the digestive tract & out the other end! Ideal < 48 hours UK average 70+ hours

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Difficult to define as means different things to different people

Bowel habits vary a lot People have different ideas about what's normal. A change from your regular pattern of bowel movements is often the best way of telling if you're constipated Mild constipation due to low fibre intake is common Are you finding it more difficult or

uncomfortable to pass stools?

Usually use Rome III criteria Must include two or more of the following:* • Straining during at least 25% of defecations • Lumpy or hard stools in at least 25% of defecations • Sensation of incomplete evacuation for at least 25% of defecations • Sensation of anorectal obstruction/blockage for at least 25% of defecations • Manual manoeuvres to facilitate at least 25% of defecations (e.g., digital • evacuation, support of the pelvic floor) • Fewer than three defecations per week • Loose stools are rarely present without the use of laxatives • Insufficient criteria for irritable bowel syndrome

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

World Gastroenterology Organisation Constipation; A global perspective (2010)

Presenter

Presentation Notes

Constipation is typically defined using Rome III criteria to diagnose constipation – however these are based on long-term symptoms which may not be appropriate fro pregnancy In practise diagnosis in pregnancy is less rigid and in part dependent on the perception of normal bowel habits If a woman has less than 3 bowel actions a week or is straining and passing hard stools she is likely to benefit from a change in fibre intake

Constipation & Haemorrhoids

Increased hormone

levels Physical

in-activity

Pressure growing uterus

Iron supplements

Pressure of

growing foetus

Increased straining

Adequate Fibre & Fluid intake vital for good bowel health for ALL

WOMEN!

blood volume

Presenter

Presentation Notes

A number of factors are thought to contribute to the development of constipation & haemorrhoids during pregnancy – both hormonal and mechanical PERISTALSIS Increased hormone levels have a major impact on the bowel – one of the roles of progesterone is to dampen down contractions of the uterus – and it has exactly the same effect on the contractions of the bowel muscle that are important to propel food and waste products along the gastrointestinal tract – making the bowle sluggish and less efficient Physical activity levels may change due to nausea/fatigue in early pregnancy and physical discomforts as pregnancy progresses Intestinal water absorption increases during weeks 12-20 of pregnancy & so may contribute to harder stools Pressure of growing foetus on rectum slows transit time Role iron supplements well established In terms of haemorrhoids (purple circles) Blood volume increase by 20-40% during pregnancy resulting in more dilated enlarged blood vessels – putting them at greater risk Growing foetus places increases pressure on all pelvic structures including the blood vessels Constipation and harder stools increases straining

Satiety – prevent excess weight gain ? risk Pre-eclampsia

Blood glucose control incidence gestational diabetes insulin requirement in Type 1 Diabetes

Presenter

Presentation Notes

As yet there is insufficient evidence for these to be definitive – so these are areas of interest to keep an eye on over the coming years As long ago as 1953 Hipsley suggested that low fibres intake could be associated with pre-eclampsia – and recent work upholds this view

1. PREVENT with good advice

2. & TREAT with good advice

Trimester 1 Trimester 2 Trimester 3 Post-birth

UK 35% 39% 21% 17%

Spain 30% 19% 22% 25%

USA 24% 26% 16% 24%

Derbyshire et al 2006, Bradley et al 2007, Ponce et al 2008

Problem throughout the whole of pregnancy Advise on prevention (wheat bran & fluids) at first contact

Incidence of Constipation by trimester

Presenter

Presentation Notes

At what point of pregnancy is constipation most common? Common assumption is that late pregnancy is when problems occur as the baby gets bigger In reality rates are highest in the first two trimesters and if anything drop in the third trimester – suggesting that hormonal changes have a greater influence on the increased incidence of constipation rather than mechanical changes. Advice to prevent constipation is important right from conception onwards.

NICE GUIDELINES Antenatal care for uncomplicated pregnancies. Clinical Guideline 62 (2016)

1.4.3 Constipation Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation. 1.4.4 Haemorrhoids In the absence of evidence of the effectiveness of treatments for haemorrhoids in pregnancy, women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard haemorrhoid creams should be considered.

Wheat bran is one of the most effective fibres for stool bulking

Fibre Increase in grams

Wheat 5.4 g

Fruits and Vegetables 4.7 g

Psyllium 4.0 g Cellulose 3.5 g Oats 3.4 g Corn 3.3 g Legumes 2.2 g Pectin 1.2 g

Presenter

Presentation Notes

The following table, based on a meta-analysis of 140 studies, summarizes the ability of different fibres to increase stool weight. High capacity to absorb water, swell and provide soft bulky mass to pass easily along the digestive tract & eliminate from the colon – so for every 1g of wheat bran stool weight increases by 5.4g

• Wheat bran fibre contributes to an increase in faecal bulk

• Wheat bran fibre

contributes to a reduction in intestinal transit time

EU permitted Nutrition & Health claims

* Based on 10g Wheat Bran Daily

0

2

4

6

8

10

12

BRAN STICKS CEREAL WHOLEMEAL

PASTA BRAN BISCUITS BRAN FLAKES

WHOLEMEAL PITTA WHOLEMEAL

BREAD

New recommendation (2015) is for 30g fibre/day

No increase for pregnancy

Average female intake ~ 17g/day Need to increase fibre intake by around 13g/day

Presenter

Presentation Notes

Very little research among pregnant women and so most of what we know is from studies among a general not pregnant population Most countries around the globe recommend a fibre intake of at least 25g per day for both general well-being and pregnancy – however this is associated with stool weights of around 130-150g per day which is below the ideal stool weight of 160-200g/day. To achieve the ideal stool weight of 200g a higher fibre intake of around 35-45g/day is in fact required

Don’t be fooled by labels Wholegrain does not automatically equate to fibre Look for:

wheat bran source fibre (≥3g/100g) high fibre (≥6g /100g)

Read Nutrition panel

Choose a cereal rich in wheat bran or high in fibre Switch to high fibre snacks

Recipes: www.allbran.co.uk

Find on British Nutrition Foundation website RCM accreditation Access free of charge from Kellogg Alliance Partner hub on RCM website

Reference materials in delegate bags Visit the Kellogg’s stand & Spin the Wheel Info & Resources on RCM Alliance partner – Kellogg webpage Info & Resources on www.kelloggsnutrition.com For recipes see www.allbran.co.uk

http://www.kelloggsnutrition.com/

http://www.allbran.co.uk/

angie jefferson rd consultant dietitian...fermented by gut bacteria helpful for cholesterol &...

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