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Advanced Diploma in Nutrition

PART-FOUR: Digestive Disorders www.shawacademy.com2

Advanced Diploma in NutritionPart-Four: Digestive Disorders

By Michelle LoughlinRegistered Dietitian



The Digestive System Explained

Digestion is the breakdown of food into smaller particles or individual nutrients.The human digestive system is a complex process that consists of breaking down large organicmasses into smaller particles that the body can use as fuel. The breakdown of the nutrients requiresthe coordination of several enzymes secreted from specialized cells within the mouth, stomach, in-testines, and liver. The major organs or structures that coordinate digestion within the human bodyinclude the mouth, oesophagus, stomach, small intestine, large intestine and liver.(1)

What happens in the mouth?In the human body, the mouth (oral cavity) is a specialized organ for receiving food and breaking up large organic masses.

In the mouth, food is changed mechanically by biting and chewing. Humans have four kinds of teeth: incisors are chisel-shaped teeth in the front of the mouth for biting; canines are pointed teeth for tearing; and premolars and molars are flattened, ridged teeth for grinding, pounding, and crushing food.

In the mouth, food is moistened by saliva, a sticky fluid that binds food particles together into a soft mass. Three pairs of salivary glands—the parotid glands, the sub maxillary glands, and the sublin-



gual glands—secrete saliva into the mouth. The saliva contains an enzyme called amylase, which digests starch molecules into smaller molecules of the disaccharide maltose.During chewing, the tongue moves food about and manipulates it into a mass called a bolus. The bolus is pushed back into the pharynx (throat) and is forced through the opening to the oesophagus. (1)

What happens in the oesophagus?

The oesophagus is a thick-walled muscular tube located behind the windpipe that extends through the neck and chest to the stomach. The bolus of food moves through the oesophagus by peristalsis: a rhythmic series of muscular contractions that propels the bolus along. The contractions are assisted by the pull of gravity. (1)

What happens in the stomach?

The oesophagus joins the stomach at a point just below the diaphragm. A valve like ring of muscle called the cardiac sphincter surrounds the opening to the stomach. The sphincter relaxes as the bolus passes through and then quickly closes.The stomach is an expandable pouch located high in the abdominal cavity. Layers of stomach muscle contract and churn the bolus of food with gastric juices to form a soupy liquid called chyme. The stomach stores food and prepares it for further digestion. In addition, the stomach plays a role



in protein digestion. Gastric glands called chief cells secrete pepsinogen. Pepsinogen is converted to the enzyme pepsin in the presence of hydrochloric acid. Hydrochloric acid is secreted by parietal cells in the stomach lining. The pepsin then digests large proteins into smaller proteins called peptides. To protect the stomach lining from the acid, a third type of cell secretes mucus that lines the stomach cavity. An overabundance of acid due to mucus failure may lead to an ulcer. (1)

What happens in the small intestine?

The soupy mixture called chyme spurts from the stomach through a sphincter into the small intestine.

An adult’s small intestine is about 23 feet long and is divided into three sections: the first 10 to 12 inches form the duodenum; the next 10 feet form the jejunum; and the final 12 feet form the ileum.

The inner surface of the small intestine contains numerous finger like projections called villi. Each villus has projections of cells called micro- villi to increase the surface area.

Most chemical digestion takes place in the duodenum. In this region, enzymes digest nutrients into simpler forms that can be absorbed.

Intestinal enzymes are supplemented by enzymes from the pancreas, a large, glandular organ lying near the stomach. In addition, bile enters the small intestine from the gall bladder to assist in fat digestion.

The enzymes functioning in carbohydrate digestion include amylase (for starch), maltase (for maltose), sucrase (for sucrose) and lactase (for lactose).



For fats, the principal enzyme is lipase. Before this enzyme can act, the large globules of fat must be broken into smaller droplets by bile. Bile is a mixture of salts, pigments, and cholesterol that is produced by the liver and stored in the gall bladder, a saclike structure underneath the liver.

Protein digestion is accomplished by several enzymes, including two pancreatic enzymes: trypsin and chymotrypsin. Peptides are broken into smaller peptides, and peptidases reduce the enzymes to amino acids.

Nucleases digest nucleic acids into nucleotides in the small intestine also.

Most absorption in the small intestine occurs in the jejunum.

The products of digestion enter cells of the villi, move across the cells, and enter blood vessels called capillaries. Diffusion accounts for the movement of many nutrients, but active trans- port is responsible for the movement of glucose and amino acids. The products of fat digestion pass as small droplets of fat into lacteals, which are branches of the lymphatic system.

Absorption is completed in the final part of the small intestine, the ileum.

Substances that have not been digested or absorbed then pass into the large intestine. (1)

What happens in the large intestine?

Large intestineThe small intestine joins the large intestine in the lower right abdomen of the body. The two organsmeet at a blind sac called the cecum and a small finger like process called the appendix. Evolu-tionary biologists believe the cecum and appendix are vestiges of larger organs that may have beenfunctional in human ancestors.

The large intestine is also known as the colon. It is divided into ascending, transverse, and descend- ing portions, each about one foot in length.

The colon’s chief functions are to absorb water and to store, process, and eliminate the residue following digestion and absorption.



The intestinal matter remaining after water has been reclaimed is known as faeces.Faeces consist of non-digested food (such as cellulose), billions of mostly harmless bacteria, bilepigments, and other materials.

The faeces are stored in the rectum and passed out through the anus to complete the digestion process. (1)

What happens in the liver?

The liver has an important function in processing the products of human digestion. For example, cells of the liver remove excess glucose from the bloodstream and convert the glucose to a polymer called glycogen for storage.

The liver also functions in amino acid metabolism. In a process called deamination, it converts some amino acids to compounds that can be used in energy metabolism. In doing so, the liver removes the amino groups from amino acids and uses the amino groups to produce urea. Urea is removed from the body in the urine. Fats are processed into two-carbon units that can enter the Krebs cycle for energy metabolism. The liver also stores vitamins and minerals, forms many blood proteins, synthesizes cholesterol, and produces bile for fat digestion.



Digestive Disorders

Common Causes for MalabsorptionCystic fibrosis Chronic pancreatitis Coeliac diseaseMilk intolerance Fructose intolerance InfectionInflammatory bowel disease Immune deficiency HIV enteropathyLymphatic obstruction Medications Crohn’s diseaseShort bowel syndrome Diverticular disease Thyroid problemsEating disorders Collagen diseases DiabetesMalnutrition Collagen diseases Addison’s disease

Aims of Nutritional Intervention

1. Dietary treatment of the primary disorder2. Dietary measures to provide symptom relief3. Daily replacement of large losses of fluid and electrolytes4. Restoration of optimal nutritional status- by supplementation if necessary

Carbohydrate Malabsorption

Lactose Intolerance

Lactose intolerance is a common type of Carbo-hydrate malabsorption. It Results from varying degrees of deficiency of the enzyme lactase and consequent impaired ability to digest dietary lactose.

Symptoms of Lactose Intolerance

In lactase- deficient people, undigested lactose and the products of its bacterial fermentation can cause the gastrointestinal symptoms. Lac-tose remaining in the intestine can cause

• Osmotic diarrhoea• Abdominal distension• Flatulence• Explosive diarrhoea

Symptoms can be painful, embarrassing, and socially difficult to manage to the point that it can significantly impact one’s quality of life. Symptoms can be painful, embarrassing, and socially difficult to manage to the point that it can significantly impact one’s quality of life.

Many people who suffer from lactose intoler-ance can tolerate moderate intakes of milk and milk products.

Complete avoidance of lactose is therefore un-necessary and is also undesirable because the risk of compromising calcium intake.

Instead, symptoms should be stabilised at a low intake and lactose-containing foods then rein-troduced in gradually increasing amounts.



- Yogurt and hard cheese are usually better tol-erated than milk. This is because bacteria in these foods produce their own lactase to digest any lactose in the food. Not all dairy products have the same amount of lactose. For example, hard cheeses, such as Swiss or cheddar, have small amounts of lactose and generally cause no symptoms. You may be able to tolerate cultured milk products, such as yogurt, because the bac-teria used in the culturing process naturally pro-duce the enzyme that breaks down lactose.- Take Probiotics daily. Probiotics are living organisms present in your intestines that help maintain a healthy digestive system. Probiotics are also available as active or “live” cultures in some yogurts and as supplements in capsule form. They are sometimes used for gastrointes-tinal conditions, such as diarrhea and irritable bowel syndrome. They may also help your body digest lactose. Probiotics are generally consid-ered safe and may be worth a try if other meth-ods don’t help.- There are lactose-free or lactose-reduced prod-ucts on the market, for example Rice milk and Soya milk. Try your local supermarket or phar-macy.

Hidden Lactose

Look out for ‘milk’ and ‘lactose’ in the ingre-dients list. Other words to look out for include ‘whey, curds, butter milk, milk by-products, ca-seinate, milk sugar, dry milk solids, and non-fat dry milk powder’. If any of these words appear on a label, it is best to avoid the product if you have hereditary intolerance. Be wary of it if you have primary or secondary intolerance. Lactose can be added to cereals, soups, salad dressings, chocolate and other processed foods. Many medications or tablets also contain lactose -speak with your pharmacist about lactose-free alternatives if you find are having symptoms.

Lactose Intolerant Diet

If you have hereditary lactose intolerance, you need to follow a lifelong lactose-free diet.

If you have primary or secondary intolerance however, you do not need to avoid lactose completely. You will be able to tolerate small amounts of lactose daily. You must start off by testing yourself with increasing amounts of lac-tose (e.g. 100ml -> 200ml-> 500mls milk) to find your maximum tolerance level.

Try the following suggestions to increase your tolerance and reduce symptoms:- Drink milk with meals and not in isolation.- Take smaller portions of lactose-containing food or drink at a time. Spread your intake evenly over the day.



What about calcium?

If you wish to avoid dairy products which contain lactose you can choose to drink soya, almond and other alternative milks. Just ensure to check that they have been fortified with calcium and vitamin D.

Try the following suggestions to help increase your calcium intake:Eat more non-dairy calcium-rich foods. Examples include fish with soft bones (e.g. sardines or salmon), calcium-enriched orange juice, dark green vegetables, bread, or tofu.

Foods high in oxalate such as beetroot, nuts, chocolate, rhubarb, spinach, and tea can reduce the absorption of calcium. These should be reduced or cut out completely.

Get out in the sunshine for 30 minutes daily to ensure adequate Vitamin D. This vitamin helps to absorb calcium from your diet.

*If you feel as though you are not getting enough calcium you can speak to your Doctor about taking a daily calcium and vitamin D supplement.

Enzyme Supplements

Enzyme supplements are available but are mainly used by those with hereditary intolerance or severe primary/secondary intolerance. Lactase enzymes can be added to lactose-containing food items, or taken with meals, to prevent symptoms. These are available in health food shops and phar-macies - always read the label for guidelines on how to use.

Calcium Content of Some Common FoodsMilk and milk alternatives are excellent sources of calcium. If you do not include milk or milk al-ternatives in your diet, there are other foods which contain calcium as well. This table will show you which foods are a source of calcium.

Food Serving Size Calcium (mg)Vegetables and FruitsVegetablesCollards, frozen, cooked 125 mL (½ cup) 189Spinach, frozen, cooked 125 mL (½ cup) 154Collards, cooked 125 mL (½ cup) 141Turnip greens, frozen, cooked 125 mL (½ cup) 132Spinach, cooked 125 mL (½ cup) 129Turnip greens, cooked 125 mL (½ cup) 104Kale, frozen, cooked 125 mL (½ cup) 95Fruit



Orange juice, fortified with calcium

125 mL (½ cup) 155

Grains Products This food group contains very little of this nutrient.

Milk and Alternatives Milk and Milk Alternatives Buttermilk 250 mL (1 cup) 370Soy beverage, fortified with calcium

250 mL (1 cup) 321-324

3.3% homo, 2%, 1%, skim, chocolate milk

250 mL (1 cup) 291-322

Dry powdered milk 24 g (4 Tbsp.) of powder will make 250mL of milk

302

Cheese Gruyere, Swiss, goat, low fat cheddar, mozzarella

50 g (1½ oz.) 396-506

Processed cheese slices (Swiss, cheddar, low fat Swiss or ched-dar)

50 g (1½ oz.) 276-386

Cheddar, Colby, edam, gouda, mozzarella, blue

50 g (1½ oz.) 252-366

Ricotta cheese 125 mL (½ cup) 269-356Cottage cheese 250 mL (1 cup) 146-217MiscellaneousYogurt, plain 175 g (¾ cup) 292-332Yogurt, fruit bottom 175 g (¾ cup) 221-291Yogurt, soy 175 g (¾ cup) 206Yogurt beverage 200 mL 190Kefir 175 g (¾ cup) 187Meats and Alternatives Fish and Seafood Sardines, Atlantic, canned in oil, with bones

75 g (2 ½ oz.) 286

Salmon (pink/humpback, red/sockeye), canned, with bones

75 g (2 ½ oz.) 179-208

Mackerel, canned 75 g (2 ½ oz.) 181Sardines, Pacific, canned in tomato sauce, with bones

75 g (2 ½ oz.) 180

Anchovies, canned 75 g (2 ½ oz.) 174Meat Alternatives



Tofu, prepared with calcium sulphate

150 g (¾ cup) 234-347

Beans (white, navy), canned or cooked

175 mL (¾ cup) 93-141

Tahini/sesame seed butter 30 mL (2 Tbsp.) 130Baked beans, canned 175 mL (¾ cup) 89-105Almonds, dry roasted, un-blanched

60 mL (¼ cup) 93

Other Goat's milk or rice beverage, fortified with calcium

250 mL (1 cup) 319-345

Blackstrap molasses 15 mL (1 Tbsp.) 179

Source: “Canadian Nutrient File 2010” .www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index-eng.php

[Accessed April 5, 2012]

Coeliac Disease (CD)

Celiac disease is an immune-mediated systemic disorder. It develops in people who are genet-ically predisposed and it is triggered by gluten (a protein found in wheat, rye, barley and trit-icale). No real progress was made until 1950 after the 2nd world war when a Dutch paedia-trician described how coeliac children had ben-efited dramatically during the war when wheat, rye and oats flours were unavailable and were replaced with maize and oats. The children re-lapsed when wheat was air-lifted into Holland.

Much remains to be learnt about how and why gluten harms the intestine. Coeliac disease re-sults from an immune reaction to antigenic fractions within gluten. The fraction of gluten in wheat responsible for the damage is known to be gliadin, an alcohol-soluble prolamin. Gliadin itself is a mixture of proteins. Current knowl-edge indicates that different gluten peptides are involved in different ways. Some peptides cause mucosal damage by triggering an immunolog-ical pathway that has a rapid effect (innate im-mune response), whereas others stimulate a dif-ferent immunological response. (2)

Symptoms

• Diarrhoea- most common• Abdominal discomfort• Malabsorption• Gastrointestinal upset• “Silent” presentations• Unexplained iron deficiency/anaemia• Osteoporosis• Fatigue/irritability/depression• Breathlessness• Bloating• Unexplained weight loss• Bone and joint symptoms• Constipation• Dental enamel defects• Infertility• Dermatitis Herpetiformis- skin disorder

IMPORTANT:• The nature of these symptoms explains why the condition is not always recognised. • A common misdiagnosis is irritable bowel syndrome. • CD should therefore be considered in any pa-tient with anaemia or symptoms of tiredness, especially when there is a family history of the disease.



Long-term Health Consequences

MalignancyCD is associated with a small increase in the risk of malignant small intestinal lymphomas, main-ly non-Hodgkin’s lymphoma. The risk of lym-phoma is reduced by adherence to the gluten free diet and after approximately 5 years the risk is likely to have been reduced to the level of the general population. CD also increases the risk of small bowel adenocarcinoma. (5)

OsteoporosisCD is a strong factor for osteoporosis. Several studies have shown evidence of decreased bone mineral density in 20-25% of patients newly di-agnosed with CD compared with age and sex matched controls, making it the most common complication of CD.

The reduced bone mineral density is thought to be due to;• Chronic malabsorption of calcium prior to di-agnosis leading to increased parathormone se-cretion, which in turn increases bone turnover and cortical bone loss.• A reduced intake of calcium following diag-nosis. Since in the average UK diet bread and cereal foods normally contribute about 30% of daily calcium intake, avoidance of these foods can result in a considerable reduction in calcium intake. Adult coeliac patients with a low bone mineral density have been found to have a lower intake of calcium (860mg/day) than those with normal bone mineral density (1054mg/day)• Non-compliance with a gluten free diet (so subclinical malabsorption continues to occur)Institution of a gluten free diet helps to optimise calcium absorption and improve bone mineral density, although it may not restore it to the lev-el found in comparable non-coeliac people. A calcium-rich, gluten free diet can achieve even better remineralisation. Guidelines for the pre-vention and treatment of osteoporosis in CD recommend a daily target intake of 1500mg of calcium for adults. (5)

Tests and Diagnosis

• Most widely available test- tissue transglutam-inase IgA antibody test• Estimated 90%-96% sensitivity and specificity of 95%• All adults with abnormal screening result should undergo small-bowel biopsy to confirm diagnosis of coeliac disease• Adopting a gluten free diet is not recommend-ed unless diagnosis is confirmed

Gluten Free Diet

A strict gluten-free diet must be followed for life. Here are some of the main points to note about the diet:

Dietary objectives:

• Exclude all dietary sources of gluten• Know which food and ingredients are natural-ly free from gluten• Substitute gluten-containing foods and ingre-dients with gluten-free alternatives to improve dietary acceptability, nutritional adequacy and compliance• Consume a balanced diet which helps main-tain health and prevent or manage associated diseases, particularly osteoporosis.• Be cautious with all processed foods and read food labels carefully. A lot of products are la-belled gluten free or very low gluten, these are ok to eat. Others might say may contain gluten or contains gluten so they should be avoided.• Look out for the following ingredients: wheat starch, modified wheat starch, modified starch of unknown origin, wheat germ, malt, malt ex-tract, barley malt, oat bran, and wheat rusk. • Foods that require substitution with special gluten-free products include bread, cereals, crackers, cakes, pastry, biscuits, pasta, pizza bas-es, baking powder and flour. Gluten-free sau-sages and pudding can also be purchased.• Foods naturally free from gluten include meat,



fish, poultry, eggs, cheese, cream, milk, yogurt, butter, oil, vegetables, fruit, potatoes, rice, sugar, salt, and pepper. Avoid any food that is breaded, battered or stuffed• Suitable alcoholic beverages include glu-ten-free beer, cider, wine, spirits, sherry, port and champagne. Avoid stout, beer, ale and some alcopops• Osteoporosis is a thinning of the bones. It is a complication of coeliac disease due to reduced absorption of calcium in the gut when the gut is damaged. • Stick to the gluten-free diet to en-sure your gut is healthy and can absorb calcium well• Take 1500mg of calcium daily by consuming at least 5 portions of calcium rich foods daily. Dairy products (milk, cheese, and yoghurt) are the richest source of dietary calcium• Consider a calcium supplement if you cannot take enough calcium from food alone as per the Irish nutrition and dietetics institute• Ensure that you get adequate Vit D to aid the absorption of calcium• Include regular weight-bearing exercise like walking, jogging or dancing for 30 minutes most days of the week• Be a healthy weight• If you smoke, try to quit

Cross contamination

Gluten-free foods can become contaminated if they come into contact with ordinary foods. For example, crumbs of ordinary toast can get into a butter dish and this can contaminate glu-ten-free bread if the same butter is then used. Contamination can cause just as much damage to your gut as knowingly eating gluten-contain-ing foods.

• Store gluten free products and ingredients in separate sealed containers, and clearly label all foods in the pantry, refrigerator and freez-er once they have been removed from original packaging.• Separate butter and condiment containers may

be necessary if you find that gluten containing crumbs are being left in the condiment.• Thoroughly clean bread boards, knives and other cooking utensils used in food preparation.• Ensure appliances such as toasters, sandwich makers and grills are clean before preparing glu-ten free foods.• Use separate water in a clean pot for cooking or re-heating gluten free pasta. Use a separate strainer for gluten free pasta or strain it first.• Do not dust meats or fish with flour prior to cooking.• Do not dust cake tins with gluten containing flour (including wheaten corn flour).



• Icing sugar mixture commonly contains wheat. Keep this in mind when dusting cakes and slices. Gluten free icing sugar mixture is available.• Clean deep frying oil regularly to remove visible batter or crumbs. This will ensure gluten free fried food is not contaminated.

Foods naturally free from gluten• Natural Raw Meat (fresh, smoked, frozen)

• Natural Raw Fish (fresh, smoked, frozen)

• Shellfish (fresh, frozen)

• Fruit (fresh, frozen, tinned in syrup or natural juice)

• Fresh herbs and plain individual spices

• Dried beans, peas, lentils and pulses

• Plain natural nuts and seeds

• Eggs

• Dairy products including milk, cream, butter, natural yo-ghurt, natural cheese, crème fraiche

• Pure oils and fats

• Rice (all varieties of natural rice)

Gluten Free FlourPolenta Rice FlourBuckwheat Maize/cornmealTapioca starch Corn starchChickpea/gram flour Soya flourQuinoa Lentil flourSorghum MilletBrown rice flour Potato flourTeff Cassava Potato starch Chestnut flour

Foods To AvoidWheat Barley RyeOats Spelt KamutKhorasan wheat Bulgar wheat Cereal fillerWheat starch Wheat bran Wheat germ oilSemolina Cous cous Durum wheatFarina Kibbled wheat Malt/malt extract/malt flavouring



Irritable bowel Syndrome: (IBS)

Irritable bowel syndrome is a common condition of the digestive system.

Typical symptoms include stomach cramps, bloating, diarrhoea and constipation. Symptoms vary between individuals and some people experience with constipation or diarrhoea or a combina-tion of both. The symptoms of IBS usually appear for the first time between the ages of 20 and 30 years. They tend to come and go in bouts, often during times of stress or after eating certain foods.

IBS is thought to be twice as common in women as men and is estimated to affect between 10% and 20% of the population. (6)

Although the symptoms of IBS can be troublesome, the condition does not pose a serious threat to your health. For example, it will not increase your chances of developing cancer or other bow-el-related conditions.

What causes IBS?

The exact cause of IBS is unknown, but most experts agree it’s related to an increased sensitivity of the entire gut, which can occasionally be linked to a prior food-related illness.

ROME I and II Criteria for Diagnosis of IBS

• Rome I: as below but without time criteria• ROME II • At least 12 weeks, do not need to be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 of 3 features:• 1. relieved with defecations and/or• 2. onset associated with a change in frequency of stool and/or• 3. onset associated with a change in form (appearance of stool)• Supportive (non-essential) symptoms of the irritable bowel syndrome• Fewer than 3 bowel movements/week• More than 3 bowel movements/day• Hard or lumpy stools• Loose or watery stools• Straining during a bowel movement• Urgency• Feeling of incomplete emptying• Passing mucus during a bowel movement• Abdominal fullness, bloating or swelling (2)



Diet for IBS

People with IBS should be given information that explains the importance of self-help in effectively managing their IBS. This should include information on general lifestyle, phys- ical activity, diet and symptom-targeted medication.

• Fibre: it may be helpful to limit intake of high-fibre food (such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)• If suffering from diarrhoea it may be helpful to decrease intake of insoluble fibre

• If suffering from constipation it may be help-ful to increase soluble fibre• Have regular meals• Take time eating• Drink 6-8 cups of fluid a day (non-caffeinatedpreferred)• Restrict caffeine intake from tea or coffee- 3cups a day• Avoid alcohol and fizzy drinks• Limit fruit to 2-3 portions per day (80g/day)• Avoid sorbitol- an artificial sweetener foundin sugar- free sweets and drinks and in someslimming products (can cause diarrhoea).• Wind and bloating-consider stopping intakeof cereals for 6 weeks and increase intake oflinseeds (1tbsp/day)• Be cautious with exclusion diets that elimi-nate a food group as it may lead to malnutri-tion

Review fibre intake and adjust it regularly whilst monitoring symptoms.

People with IBS can try probiotics. Try them for at least 4 weeks and monitor the effect. Probiotics should be taken at the dose recom- mended by the manufacturer.

NICE guidelines recommend discouraging the use of aloe vera in the treatment of IBS.

If diet and lifestyle do not improve symptoms it is worth seeing a Doctor to discuss pharmaco- logical intervention. (6)

Therapies to relieve stress and anxiety can also be helpful.

ConstipationConstipation is a very common condition that affects people of all ages. It can mean that you are not passing stools (faeces) as often as you normally do, you have to strain more than usu- al or you are unable to completely empty your bowels.



Constipation can also cause your stools to be unusually hard, lumpy, large or small.The severity of constipation can vary greatly. Many people only experience constipation for a short period of time with no lasting effects on their health.

Chronic constipationFor others, constipation can be a chronic (long-term) condition that causes significant pain and discomfort. Chronic constipation can also lead to complications, such as faecal impaction (where dry, hard stools collect in your rectum) or faecal incontinence (where you leak liquid stools).

Who is affected?Constipation can occur in babies, children and adults, and affects twice as many women as men.

Older people are five times more likely than younger adults to have constipation, usually be-cause of dietary factors, lack of exercise, use of medication and poor bowel habits.

Approximately 40% of pregnant women experi-ence constipation during their pregnancy.Everyone has their own normal bowel habits, which can be different from other people’s habits.

For example, some adults normally go to the toilet more than once a day, whereas others normally go only every three or four days. Some infants pass stools several times a day, while others normally pass stools only a few times a week.

As well as causing a change in your normal bowel habits, constipation can also cause the following symptoms:stomach ache and cramps• feeling bloated• feeling nauseous• loss of appetite

ChildrenAs well as infrequent or irregular bowel move-ments, a child with constipation may also have the following signs and symptoms:• loss of appetite• lack of energy• being irritable, angry or unhappy• foul-smelling wind and stools• abdominal pain and discomfort• soiling their clothes• generally feeling unwell



Diarrhoea

Diarrhoea is passing looser or more frequent stools than is normal for the individual.It affects most people from time to time and is usually nothing to worry about.

Causes• Gastroenteritis- bowel infection caused by a virus, bacteria or a parasite• Side effect of medication• Malabsorption or maldigestion• Irritable bowel syndrome• Motility disorders• Coeliac disease• Inflammatory bowel disease• Cancer• Anxiety• Drinking too much coffee or alcohol• Medications e.g. antihypertensives, NSAIDs, antibiotics

The symptoms associated with diarrhoea can vary depending on the cause. For example, if your diarrhoea is caused by an infection, you may also have a fever and severe stomach cramps.

In adults, bouts of diarrhoea can sometimes be the result of anxiety or drinking too much coffee or alcohol. Diarrhoea can also be a side effect of certain types of medication.

Treating diarrhoeaMost cases of diarrhoea clear up after a few days without treatment.

In adults, it usually improves after two to four days. In children, it often lasts slightly longer, between five and seven days.

Diarrhoea can lead to dehydration if it’s severe, frequent or both, so you should drink plenty of fluids (small, frequent sips of water) while you have diarrhoea. It is very important that babies and small children do not become dehydrated.

When to see your GPIn adults, diarrhoea that lasts more than a few weeks may be a sign of a more serious condi-tion, such as bowel cancer, crohn’s or IBS.

People should be encouraged to:

Maintain a good fluid intake at times when symptoms are acute i.e. 10-15 cups of fluid per day. The choice of drinks is a matter of individual tolerance and preference. Clear fluids such as sweetened soft drinks, clear soups or savoury drinks are likely to be better tolerated than milk or undiluted fruit juices, and cold drinks are less likely to trigger diarrhoea than hot drinks. However, the important aspect is that good fluid intake is maintained in whatever way suits the patient. Provided that they do not exacerbate symptoms, any drink which helps



maintain energy or nutrient intake (e.g. glucose drinks, milk supplement drinks, and diluted fruit juices) will always be an added nutritional bonus

As symptoms remit, soft or easily digested e.g. white bread or toast, white fish, mashed potato, plain biscuits, jelly, sorbets, low-fat yoghurt, milk puddings or ice cream can be introduced. Once these are tolerated, variety should gradually be widened as appropriate for the under- lying condition. Highly fibrous foods such as wholegrain breads and cereals, and nuts, seeds and fruit and vegetable skins will usually need to be avoided

Inflammatory Bowel Disease

Inflammatory bowel disease is the collective term used to describe Crohn’s disease, ulcer- ative colitis and indeterminate colitis. Although these are distinct disorders with differencesin their presentation and management, they share a number of common features. IBD is a relapsing-remitting inflammatory disorder of unknown aetiology. Nutrition therapy is pivotal in IBD, whether as the primary treatment or in a supportive role.

Nutritional Implications of IBDNutritional Deficiency Common causes

Dietary energy Poor appetite, catabolic effects of chronic in-flammation, malabsorption

Protein Increased nitrogen losses, high requirements for tissue repair

Vitamin D and K Bile salt deficiencyIron Poor intake, poor absorption, chronic blood

loss (especially in UC)Folate Impaired absorption, use of sulfasalazine (in

UC)Vitamin C Low consumption of fruit and vegVitamin B12 Ileal resection, small bowel overgrowthCalcium, magnesium and zinc Malabsorption and chronic diarrhoea, short

bowel syndrome, avoidance of dairy foodSodium and potassium Persistent diarrhoea and vomiting

The aims of dietary management in IBD patients include:

• Achieving and maintaining good nutritional status during both active disease and remission• Helping to alleviate clinical symptoms in combination with medical treatment• Helping to treat clinical complications with medical treatment• Achieving remission in crohn’s patients, when used as a primary treatment• Allowing for extra energy needed• Patients should be encouraged to follow as normal a diet as possible • Most will benefit from smaller meals of high energy and nutrient density• Consumed at frequent intervals• At times when appetite is poor- food fortification strategies or nutritional supplement use may



be necessary• The importance of adequate fluid intake in the presence of diarrhoea, pyrexia or fistulae should be stressed• Regular assessment is important

Diverticular Disease

• Diverticula: Small bulges develop on the lining of the intestine the become inflamed or infected• Common and associated with ageing• Approx. 50% of people have diverticula by age 50 and 70% have them by age 80• Diverticulosis: Diverticula with no symptoms• Diverticular disease: 1 in 4 will experience symptoms• Symptoms:• Lower abdominal pain• Diarrhoea• Constipation• Feeling bloated• Diverticulitis: describes infection that occurs when bacteria become trapped inside one of the bulges triggering more severe symptoms: severe abdominal pain, high temperature

References1) http://www.cliffsnotes.com/sciences/biology/biology/nutrition-and-digestion/human-diges-tive-system

2) Manual of Dietetic Practice, 4th edition by Briony Thomas and Jacki Bishop

(3) http://www.patient.co.uk/doctor/gastrointestinal-malabsorption

(4) http://www.cmaj.ca/content/185/1/60#sec-4

(5) http://www.coeliac.ie/coeliac_disease/dermatitis_herpetiformis

(6) http://www.nice.org.uk/guidance/CG61

(7) http://www.nice.org.uk/guidance/cg99/chapter/key-priorities-for-implementation

(8) http://www.hse.ie/portal/eng/health/az/C/Constipation/

(9) http://www.nice.org.uk/guidancemenu/conditions-and-diseases/digestive-tract-conditions

(10) http://www.nice.org.uk/guidance/cg84/chapter/1-guidance

(11) http://www.nice.org.uk/guidance/cg152/chapter/1-guidance#maintaining-remis-sion-in-crohns-disease-after-surgery

(12) http://www.nice.org.uk/guidance/cg166/chapter/key-priorities-for-implementation

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