Diet Intervention for Intestinal Failure Patients

September 30, 2011Mary Jo Porter RD LD CNSCDigestive Disease Institute, Center for Human NutritionIntestinal Rehabilitation and Transplant Program

• Diet

• Soluble Fiber

• Oral Rehydration Solutions

• Medications

• Specialized Nutrients

• Enteral Nutrition

• Growth Factors

• Reconstructive Surgery

• Small Bowel or Multivisceral Transplant

IRTP Therapies

Nutrition Plan: Anatomical Considerations

• Short Bowel Syndrome (SBS)• < 200 cm of small bowel (SB) or malabsorption despite intact GI

tract • > 100 cm SB to avoid parenteral nutrition (PN)

• Presence of Colon• Increases absorptive capacity

• Baseline nutritional status• Malnutrition will decrease absorption

• Overall clinical picture• Ability to take oral diet• Active infections• Disease in remnant bowel

Dietary Modification

Colon• High Starch• High Salt• Low Simple Sugar

• CHO 50-60% • PRO 20%• FAT 20-30%

• Meals 5-6 daily• Avoid oxalates• Isotonic fluids• Fiber as tolerated• Lactose as tolerated

Byrne et al. NCP 15:3-6=311, 2000

No Colon• High Starch• High Salt• Low Simple Sugar

• CHO 40-50% • PRO 20%• FAT 30-40%

• Meals 5-6 daily• Oxalates: no restriction• Isotonic, high Na fluids• Fiber as tolerated• Lactose as tolerated

Simple vs Complex Carbohydrates

AVOID• Sugar

• Candy

• Cakes, cookies, pies

• Regular soda pop

• Juice

• Jelly, jam, syrup

• Ice cream, sherbet

• Sorbet

• Sugar-containing supplements

INCLUDE• Pasta

• Potato

• Breads

• Cereals

• Rice

• Whole grains as tolerated

• Fruits and vegetables as tolerated

Salty Starchy Snacks

Colon & No Colon

• Pretzels

• Banana

• Crackers & Cheese

• Animal Crackers

• Graham crackers & light yogurt

• Low sugar cereal

• Noodle mix

• Bagels

No Colon (All to the left, plus):

• Potato chips

• Fritos

• Cheeseburger

• Fries

• Pizza

• High fat additives on sandwiches and breads (butter, PB, mayo)

Oral Rehydration Solutions

Sodium-glucose Co-transport

-Osmolarity 200-300 mosm/L

-Sodium 60-90 mEq/L

Home-Made ORS Recipe

• 1 Liter (33 ounces/4 cups) water

• 2/3 teaspoon table salt (sodium chloride)

• 2 Tablespoons of sugar (sucrose/table sugar)

• Sugar-free Kool-Aid or Crystal Light to taste

Gatorade ORS

G2 ORS• 32 oz G2 • ½ tsp salt

Gatorade ORS• 2 cups Gatorade • 2 cups water• ½ tsp salt

ORS and Other Beverages

Na Carbohydrate OsmolalitymEq/L g/L mOm/kg

WHO-ORS 75 13.5 245

G2 with ½ tsp salt/L 70 20 260

Ginger ale 3 90 540

Apple juice 3 124 730

Chicken broth 250 0 450

Ensure Plus 32 165 680

Soluble Fiber: Benefiber

1 packet mixed with fluid or food, three times daily

1 packet = 1 heaping Tbsp

(5 grams soluble fiber)

Carbohydrate Salvage

Undigested carbohydrates and soluble fiber are fermented by colonic bacteria into short chain fatty acids (SCFAs)

• Used as an additional source of energy

• Enhance sodium and water absorption

• Stimulate mucosal adaptation in SB and colon

Jeppesen et al. JPEN. 1999;23:S101-S105.

Diet Order during admission?

• Gastrointestinal: Low Residue, 10 g Sugar

• Gastrointestinal: Low Residue, 10 g Sugar, 50 g Fat.

• Fluid: G2, no juice, limit free water

• SNACKS: – Pretzels, cheese and crackers, sandwich– Low sugar graham crackers, lorna dunes, angel food

• Supplements:– Benefiber, Glucerna, No added sugar Carnation Instant

Breakfast

Oxalate NephrolithiasisNormal

circumstances After extensive bowel resection

Excretion Malabsorption

Fat +

Ca

Free oxalates

Kidney

Oxalate +

Calcium

Calcium oxalate stones

Colon Colon

Low Oxalate Diet

Chocolate, cocoa, tofu, soy, nutsBeverages

Beans, greens, spinach, squash, tomato

Vegetables

Berries, grapes, citrus, plums, prunesFruits

Bran, whole wheatStarches

Food to AvoidGood Group

High Jejunostomy Diet?

• Limit oral intake – 1 serving of starch, three times daily– No sweets

• Implement fluid restriction 500-1000 ml’s daily– Eliminate hypo and hypertonic fluids.

Intake and Output Records

• Hydration

• Enteral Balance

• Plan of Care

Patient Name ___________________________

IRTP Physician __________________________

IRTP Dietitian ___________________________

The Cleveland Clinic FoundationINTESTINAL REHAB & TRANSPLANT PROGRAM

Daily Intake/Output RecordFAX to: 216-636-1529Intestinal Rehab & Transplant Program

or SEND to: 9500 Euclid Avenue A-80Cleveland, OH 44195

DateWt (lbs.)Goal Wt (lbs.)Temperature

INTAKE (ml)Oral FluidENTPNIV FluidTOTAL INTAKE

OUTPUT (ml)UrineStoma

OTHER OUTPUT (ml) (circle)

GT JT PEGDrain FistulaEmesis Diarrhea

TOTAL OUTPUTUrine Glucose (circle) Accu Check

Intake and Output Record Keeping

Antidiarrheals

6 mL0.5-1.5 mL0.5 mLTincture of Opium

80 mL5-20 mL5 mL

240 mg15-60 mg15 mg tabCodeine

40 mL5-10 mL5 mL

8 tabs1-2 tabs2.5 mg tabDiphenoxylate(Lomotil)

80 mL10-20 mL10 mL

8 tabs1-2 tabs2 mg tabLoperamide(Imodium)

Max Dose/DayStarting Dose PO QIDOne DoseMedication

* All antidiarrheal meds should be given ½ hr to 1 hr before meals

Take Home Points

• Diet: High starch, high salt, low simple sugar foods with 5-6 small frequent meals – Low fat diet for pt’s with colon in continuity

• ORS: Encourage ORS throughout the day– Minimize non-ORS fluids to maximize intestinal absorption

• Benefiber: 1 packet (1 Tbsp) 3 times daily

• Antidiarrheals: 30 – 60 minutes before meals and at bedtime

• I & O records help maximize plan of care

Optimal Management of Intestinal Failure

Gastroenterology

Digestive Disease Institute

General Surgery & Transplant

Colorectal Surgery

Intestinal Rehabilitation

&Transplantation

Medical Management

Home Nutrition Support

Inpatient Nutrition Support

Surgical Reconstruction

Nursing

Thank You – IRTP 2011