sites of nutrient absorption

8/6/2019 Sites of Nutrient Absorption

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Heather Zhou, RD, LD

Nutrition ManagementNutrition Managementof Inflammatory Bowelof Inflammatory Bowel

DiseaseDisease

Heather Zhou, R.D., L.D.Heather Zhou, R.D., L.D.

Clinical Science LiaisonClinical Science Liaison

Emmaus Medical, Inc.Emmaus Medical, Inc.

Presentation OverviewPresentation Overview

1. Describe the potential causes ofmalnutrition in inflammatory boweldisease (IBD)

2. Identify nutrients at risk for deficiency in

IBD

3. Discuss dietary guidelines for managingIBD symptoms


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Crohn's disease (CD)

Occur anywhere along digestive tract

Mouth anus

Mostly affects terminal ileum

Ulcerative colitis (UC)

Involves colon and rectum

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Adapted from An in-depth look at IBD. Nursing. 2002;32:36.

Potential Causes of Malnutrition

Inadequate food intake

nutritional requirements

Altered digestion and absorption

intestinal losses

Disease activity Surgical resections

Drug-nutrient interactions


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Sites of Nutrient AbsorptionSites of Nutrient Absorption

Small Intestines

Major site of nutrient

absorption

Duodenum iron,

calcium, magnesium,

zinc

Jejunum B vitamins,

vitamins A, D, E, K Ileum vitamin B12,

bile salts/acids

Large Intestines (Colon)

Completion of absorption

Absorption of remainingwater and electrolytes

Formation & expulsionof stool

Production of vitamin K& short-chain fatty acids

by bacteria

Vitamin/Mineral DeficienciesVitamin/Mineral Deficiencies

B vitamins

Folate, vitamin B12

Fat-soluble vitamins

Vitamins A, D, E, K

Minerals

Calcium, iron, zinc


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DrugDrug--Nutrient InteractionsNutrient Interactions

Steroids may affect vitamin D activity in

GI tract

calcium absorption: risk for osteoporosis

Anti-inflammatory drugs

folate absorption

Lipid-lowering agents bind bile acids

fat-soluble vitamin absorption

Antibiotics may vitamin K availability

Folate

Absorption

Primarily in jejunum

Deficiency

intake from food and intestinal losses

Drug-Nutrient Interactions

Anti-inflammatory (sulfasalazine) and

immunosuppressant drugs (methotrexate) Prevention

Multivitamin (MVI) supplementation with

400 mcg/day or 1 mg folate/day


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Vitamin B12

Absorption

Terminal ileum

Deficiency

consumption or intolerance to red meat anddairy products; malabsorption


Antacids: H2-blockers, PPIs

Management Monthly vitamin B12 injections if terminal ileum

resected/diseased

Vitamin D

Absorption

Duodenum

Deficiency

Inadequate sunlight exposure, intake of milk

products, or malabsorption


Corticosteroids

Prevention

400-800 IU/d vitamin D


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CalciumCalcium

Absorption

Duodenum primary site of absorption

Deficiency

absorption of vitamin D

Poor tolerance of milk and dairy products


Corticosteroids; absorption with iron

Prevention 1000 1500 mg/day calcium + vitamin D

Iron

Absorption Duodenum primary site

Deficiency Chronic intestinal blood loss, inadequate intake of

iron-rich foods (red meat), or inflammation

Interactions absorption with tea or coffee intake

absorption with calcium

Prevention Iron supplement warranted only if deficient

MVI with iron or ferrous sulfate plus vitamin C


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ZincZinc

Absorption

Duodenum main site of absorption

Deficiency

Food intolerances (meats, milk); chronic diarrhea

Interactions

Competitive absorption with iron

Prevention Supplementation only when indicated with

15 mg/day elemental zinc

Nutritional SupplementationNutritional Supplementation

Daily multivitamin and mineral supplement in a

chewable or liquid form may be beneficial with

malabsorption and intestinal losses

Take supplements daily with meals and spaced

throughout the day

Take calcium at least 2 hours apart from MVI +

iron to prevent absorption of both


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Goals of Nutrition Therapy

CD

Replace fluid and

electrolytes

Replenish nutrient

stores

Low residue diet with

strictures or fistulas

Elemental diets may be

beneficial

UC

Ensure adequate

calorie and protein

intake

Replenish electrolyte

losses from diarrhea

Low residue diet may

help irritation ofinfected colon

Role of Diet in IBDRole of Diet in IBD

Insufficient evidence that specific foods can

cause IBD

Individual food tolerances may vary

Limit intake of certain foods and beverages

that may worsen symptoms during a flare


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Nutrition ManagementNutrition Management

Active disease (flare)

Diet should be individualized to specific tolerances

and type of disease (CD vs. UC)

Small, frequent meals

Diet low in fiber and residue

Fat-controlled diet for malabsorption

Lactose-controlled diet if lactose intolerant

Asymptomatic (remission) Small, frequent meals

Progression to regular diet

LowLow--Fiber, LowFiber, Low--Residue DietResidue DietGuidelinesGuidelines

Residue refers to dietary compounds not broken

down by the body

Designed to stool rate and output

May be useful for acute phases of IBD or partial bowel

obstruction

Contains ~ 10 grams of fiber Follow diet on a temporary basis only

Progress to regular, well-balanced diet once

symptoms disappear


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LactoseLactose--Controlled Diet GuidelinesControlled Diet Guidelines

Severity of lactose intolerance may vary

Some lactose intolerant individuals can tolerate~10 grams of lactose per day

Try small amounts of lactose at a time cup milk = 6 grams lactose/serving

Check food labels for hidden sources of lactose Dry milk solids, whey, non-fat dry milk powder

Lactose-Controlled Diet Guidelines

Fermented or cultured dairy products have

lactose content due to bacterial action

Aged cheeses (cheddar, Swiss), yogurt, acidophilusmilk

Consider using lactose-free products

Lactaid, calcium-fortified, soy or rice milk

Include maximum amount of milk as tolerated

Key source of calcium, protein, vitamins A and D,riboflavin, and phosphorus


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Complementary and Alternative

Medicine (CAM) Nontraditional approaches that may be used

along with traditional treatments or used in placeof conventional therapies

>50% of IBD Pts have used some form of CAM

Herbal & nutritional supplements, probiotics, andfish oil are commonly used

Intolerable side effects and ineffectiveness of

standard treatments are main reasons cited

Inform your doctor about use of CAM

ProbioticsProbiotics

Live microbial food supplements thatbeneficially affect the host by improving itsintestinal microbial balance

>20 trials have been published in last fewyears studying role of probiotics inprevention, treatment, & maintenance of IBD

Benefits of probiotics in IBD are not definite


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OmegaOmega--3 Fatty Acids (3 Fatty Acids (-3 FA)

May have anti-inflammatory properties

Fish oil improved intestinal damage and inflammation in rats with experimental UC

May need or dose for corticosteroidtherapy in IBD patients

A large North American study by Dr. Wolf-

AGA was part of showed no benefit of fishoil in CD

Medical Food SupplementsMedical Food Supplements

Palatability

Cost

Tolerance

Osmolality isotonic

Elemental (amino acid-based) vs. polymeric

(whole protein-based) formula Fat profile MCT vs. LCT


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ConclusionConclusion

Malnutrition often occurs as a consequence

of IBD

Diet and nutrition therapy play a vital role

in the management of IBD

Patients adherence to suggested medical

and nutrition guidelines may lead to success

In the words of Hippocrates:

"Let food be thy medicine."

"He who does not know foodhow can he

cure the disease of man?"


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ReferencesReferences

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4. Wiese D, Lashner B, Seidner D. Measurement of nutritionstatus in crohn's disease patients receiving infliximab therapy.

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5. Vagianos K, Bector S, McConnell J, Bernstein CN. Nutrition

assessment of patients with inflammatory bowel disease.JPEN.

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probiotic therapy.Int J Med Microbiol. 2010;300:25-33.

8. Douglas LC, Sanders ME. Probiotics and prebiotics in dietetics

practice. J Am Diet Assoc. 2008;108:510-521.

9. Clarke JO. Mullin, GE. A review of complementary and

alternative approaches to immunomodulation.Nutr Clin Pract.

2008;23:49-62.


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10. Bibiloni R, Fedorak RN, Tannock GW, Madsen KL, Gionchetti

P, Campieri M, De Simone C, Sartor RB.VSL#3 probiotic-

mixture induces remission in patients with active ulcerative

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11. Nieto N, Torres NI, Rios A, Gil A. Dietary polyunsaturated fatty

acids improve histological and biochemical alterations in rats

with experimental ulcerative colitis.J Nutr. 2002;132:11-19.

12. Crohn's and Colitis Foundation of America. Diet and nutrition.

http://www.ccfa.org/info/diet. Accessed February 28, 2010.

13. National Institute of Diabetes & Digestive & Kidney Diseases.

Ulcerative colitis. Available at:http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/index.htm.

Accessed July 27, 2009.

ReferencesReferences14. Mayo Clinic. Crohns disease. Available at: http://mayoclinic.

com/health/crohns-disease/DS00104/DSECTION=treatments

-and-drugs. Accessed August 8, 2009.

15. Mayo Clinic. Ulcerative colitis. Available at:http://mayoclinic.com/health/ulcerative-colitis/DS00598/DSECTION=lifestyle-and-home-remedies. Accessed August8, 2009.

16. Mayo Clinic. Lactose intolerance. Available at:http://mayoclinic.com/health/lactoseintolerance/DS00530/DS

ECTION=lifestyle-and-home-remedies. Accessed February16, 2010.

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