faculty of medicine introduction to community medicine course … · 2020. 1. 22. · peptic ulcer...
TRANSCRIPT
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Faculty of Medicine Gastrointestinal System
Nutrition and Gastrointestinal System
Dietary roughage (Dietary Fiber)
By
Hatim Jaber MD MPH JBCM PhD
24+25-- 4--20178
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Nutrition and Gastrointestinal System Presentation outline 24-4-2017
Time
Introduction and Definitions 08:00 to 08:10
The use of nutritional terms, categorizing the nutrients as macro, micro, and essentials.
08:10 to 08:20
The use of Recommended Daily Allowance (RDA) tables.
08: 20 to 08:25
Different preventive strategies to maintain good digestive health.
08:25 to 08:30
General nutritional recommendations for patients with upper and lower gastrointestinal disorders.
08:30 to 08:50
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Nutrition definition
• “The science/study of nutrients (that come from food), their action, interaction, and balance in relation to health and disease; and the process by which the organism (body) ingests, digests, absorbs, transports, utilizes and execrates food substances”
• .. Science of food and its relationship to health…
• .. Is a dynamic process in which the food that is consumed is utilized for nourishing the body..
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Background definitions
• Nutrients: “Chemical substances in food that nourish the body by providing energy, building materials, and factors to regulate needed chemical reactions.”
• (Organic and inorganic complexes contained in food are called nutrients).
• Essential nutrients: Must be provided by food because the body does not produce them in sufficient quantities or can not make them at all.
• Nonessential nutrients: Healthy, well-nourished bodies can make them in sufficient quantities to satisfy their needs.
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NUTRIENT SUBSTRATES
Macronutrients • •Carbohydrates • •Fats • •Proteins Macrominerals • •Calcium • •Phosphorus • •Magnesium
Micronutrients • •Chromium • •Copper • •Iodine • •Iron • •Manganese • •Selenium • •Zinc
Vitamins •Water-Soluble • •Vitamin C • •Thiamine (Vitamin B1) • •Riboflavin • •Niacin • •Pantothenic Acid • •Biotin • •Folic Acid • •Vitamin B12 • •Vitamin B6 (Pyridoxine) •Fat-Soluble • •Vitamin A • •Vitamin D • •Vitamin E • •Vitamin K
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Adequate nutrition is characterized by:
1-Daily intake of nutrients, which are
(quantitatively and qualitatively).
2-Adequate nutrition should consider
physiological status and pathological
disorders.
3- Normal digestion, absorption, metabolism,
excretion.
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Daily exercise and weight control
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NUTRITION AND HEALTH
• Health professionals agree that the overall composition of the diet has an important effect on health.
• Eating too much fat, sat. fat and cholesterol and not eating enough vegetables, fruits, and fiber has been linked to an increase in heart disease and other cancers.
• In lean healthy people, death associated with weight loss >35%, protein storage loss >30%, and fat storage loss >70%
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NUTRITION AND HEALTH
• Approximately one third of people in the general population complain of some gut-related symptoms, such as:
- flatulence, bloating, heartburn, nausea, vomiting, constipation, diarrhea, food intolerance, incontinence, and abdominal pain.
• While most physicians look at these gut-related symptoms in the context of the gastrointestinal (GI) diseases, gut-health related symptoms occur more often in the absence of demonstrable functional and structural diseases in the GI tract.
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Vocabulary
Digestion - mechanical & chemical breakdown of food into nutrients Metabolism - chemical reactions breaking down food and releasing energy from nutrients
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Resources for Planning a Healthy Diet
• Dietary Reference Intakes (DRIs)
– Reference values for nutrients developed by the Food and Nutrition Board
– These reference values are used to:
• suggest nutrient intake levels for different population groups
• plan and evaluate the diets of healthy people
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Dietary Reference Intakes (DRIs)
• Focus on
– Maintaining good health
– Reducing the risk of developing chronic disease
– Avoiding unhealthy excess (toxic amounts of nutrients)
• Establish nutrient recommendations for different life stages
– Age
– Gender
– Pregnant
– Lactating
• Are periodically updated
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DRI Reference Values
• Recommended Dietary Allowance (RDA)
– Recommendation for each nutrient that should meet the needs of nearly all (97 to 98%) the healthy individuals in a specific gender and age group
– Allowances are set higher than the EARs
– Not established for all nutrients
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Recommended Daily Allowance (RDA) tables.
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NUTRITION IN GI DISORDERS
•Discuss nutrition in multiple gastrointestinal disorders
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INDICATORS OF HEALTHY GI System
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Preventive strategy to maintain good digestive health
General hygiene • - Maintenance of hygiene in food and water • - Proper washing of hands • Dietary advices • - Healthy and well-balanced diet • - Adequate amount of fibre in the diet • - Avoidance of processed food • - Low FODMAP diet (collection of short chain carbohydrates and
sugar alcohols found in foods naturally or as food additives) • - Eating of food slowly • - Avoidance of food that leads to food allergic symptoms • - Drinking of lot of fluids (non-sugar based) • Maintenance of healthy gut microbiota • - Probiotics and prebiotics • - Avoidance of proton pump inhibitors and nonsteroidal anti-
inflammatory drugs (NSAIDs) • – Maintenance of hygiene
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Preventive strategy to maintain good digestive health (Cont…)
• Avoidance of injurious agents to gut • - Smoking: predisposes to gastroesophageal reflux • - Drugs which damages intestinal mucosa, such as • -NSAIDs • - Excess and un indicated use of proton pump
inhibitors - Avoidance of excess of alcohol • Maintenance of epithelial integrity - Maintenance of healthy microbiome - Prevention of GI infections • Maintenance of enterocytes (intestinal absorptive cells)
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Common Symptoms of Gastrointestinal Diseases
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Gastroesophageal Reflux Disease (GERD)
• Backward flow of the stomach and/or duodenal contents into the esophagus
• Burning sensation after meals; heartburn
• Possible discomfort during and after eating, change in eating habits, especially in the evening
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Nutritional Care for GERD
• Maintain upright posture during and 45-60 minutes after eating
• Avoid eating within 2-3 hours before bedtime • Avoid clothing that is tight in the abdominal area • Stop smoking (lower LES pressure) • Limit caffeine intake • Avoid chocolate • Limit/avoid alcohol intake • Achieve and maintain a healthy weight • Elevate the head of bed (6-8 inches) when sleeping • Try problem foods in small quantities as part of a meal.
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Nausea & Vomiting
• Prolonged vomiting = hyperemesis – Loss of nutrients, fluids,
electrolytes
– Dehydration, electrolyte imbalance, wt. loss
• Meds: – Antinauseants
– Antiemetics
Nausea & Vomiting Dietary Measures
• NPO for several hours
• Clear liquids if tolerated, then progress as tolerated
• IV fluids if liquids not tolerated
• Parenteral nutrition if severe, though increasingly enteral nutrition is used for hyperemesis of pregnancy
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Dyspepsia Treatment
• Avoid offending foods
• Eat slowly
• Chew thoroughly
• Do not overindulge
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Peptic Ulcer Disease Treatment with Diet
• Reduce decaffeinated and regular coffee, cocoa, and tea intake
• Avoid alcohol or pepper • Avoid low-pH juices if they cause problems
(generally pH in foods is not an issue) • Avoid large meals, especially right before bedtime
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Peptic Ulcer Disease Treatment with Diet
• Meal frequency is controversal: small, frequent meals may increase comfort but may also increase acid output
• There is little evidence to support eliminating specific foods unless they cause repeated discomfort
• Overall good nutritional status helps H. pylori
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Dumping Syndrome • Complex physiologic response to the rapid
emptying of hypertonic contents into the duodenum and jejunum
• Dumping syndrome occurs as a result of total or subtotal gastrectomy and is associated with mild to severe symptoms including abdominal distention, systemic systems (bloating, flatulence, pain, diarrhea), and reactive hypoglycemia.
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Dumping Syndrome – Dietary Treatment
• Small meals spread throughout day
• High protein (20%), moderate fat (30 – 40%), complex CHO as tolerated
• Very small amts of concentrated sweets
• Food and drink should be moderate in temperature
• Use caution with high fiber foods – use pectin to decrease transit time, glucose absorption
• Take liquids between meals in small amounts (1/2 to 1 cup)
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Dumping Syndrome – Dietary Treatment
• Lactose transit – poorly tolerated
• Medium-chain triglycerides-steatorrhea
• Eat slowly, chew food thoroughly
• If dumping is a problem, have patient lie down 20-30 minutes after meals to retard transit to small bowel
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Principles of Nutritional Care
• Intestinal disorders & symptoms: – Motility
– Secretion
– Absorption
– Excretion
• Dietary modifications – To alleviate symptoms
– Correct nutritional deficiencies
– Address primary problem
– Must be individualized
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Constipation
• Defined as hard stools, straining with defecation, infrequent bowel movements
• Normal frequency ranges from one stool q 3 days to 3 times a day
• Occurs in 5% to more than 25% of the population, depending on how defined
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Treatment of Constipation
• Encourage physical activity as possible
• Bowel training: encourage patient to respond to urge to defecate
• Change drug regimen if possible if it is contributory
• Use laxatives and stool softeners judiciously
• Use stool bulking agents such as psyllium (metamucil) and pectin
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MNT for Constipation
• Depends on cause
• Use high fiber or high residue diet as appropriate
• If caused by medication, may be refractory to diet treatment
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Inflammatory Bowel Disease
• Crohn’s Disease and Ulcerative Colitis
• Autoimmune diseases of unknown origin
• Genetic component and environmental factors
• Onset usually between 15 to 30 years of age
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IBD Nutritional Management (acute)
• Low-residue, low-fiber liquid diet • “Bowel rest” with parenteral nutrition • Enteral nutrition may have better
success at inducing remission • Diet tailored to individual pt:
• Minimal residue for reducing diarrhea • Limited fiber to prevent obstruction • Small, frequent feedings • Supplements , MCT with fat malabsorption
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IBD Nutritional Management (chronic)
• High protein, high calorie diet with oral supplements
• Monitor vitamin-mineral status of iron, calcium, selenium, folate, thiamin, riboflavin, pyridoxine, vitamin B12, zinc, magnesium, vitamins A, D, E
• High fiber diet as tolerated
• Avoid unnecessary restrictions
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Diseases of Large Intestine
• Irritable Bowel Syndrome
• Diverticular Disease
• Colon Cancer and Polyps
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Irritable Bowel Syndrome (IBS)
• Not a disease – syndrome
• Abdominal pain, bloating, abnormal bowel movements
– Alternating diarrhea, constipation
– Abdominal pain, relieved by defecation
– Bloating w/ feeling of excess flatulence
– Feeling of incomplete evacuation
– Rectal pain, mucus in the stool
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WHAT IS THE ROLE OF FOOD IN IBS?
• Irritable bowel syndrome (IBS) is common, with a pooled global prevalence of 11.2%.
• The etiology of IBS is not entirely clear, but 40% to 84% of IBS patients believe that food-items are important triggers of their gastrointestinal symptoms.
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IBS: Incidence in U.S.
• 20% of women
• ~10 – 15% of men
• 20 – 40% of visits to gastroenterologists
• One of the most common reason pts first seek medical care
• Increased absenteeism, decreased productivity
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IBS: Nutritional Care • ID individual food intolerances
• Keep food record, include symptoms, time they occur in relation to meals
• Avoid offending foods, substances • Milk, milk products (lactose) only in
presence of lactose deficiency
• Fatty foods
• Gas-forming foods, beverages
• Caffeine, alcohol
• Foods w/ fructose or sorbitol
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IBS: Nutritional Care
• Eat small frequent meals at relaxed pace, regular times
• Gradually add dietary fiber to diet
– 20 – 30 g
– Fiber supplements may help (psyllium)
• Fluids – 2 – 3 qts w/ fiber supp.
• Regular physical activity to reduce stress
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What are FODMAPs?
• FODMAPs are a collection of short chain carbohydrates and sugar alcohols found in foods naturally or as food additives.
FODMAP is an acronym that stands for: • Fermentable – meaning they are broken down (fermented) by bacteria in
the large bowel • Oligosaccharides – “oligo” means “few” and “saccharide” means sugar.
These molecules made up of individual sugars joined together in a chain • Disaccharides – “di” means two. This is a double sugar molecule. • Monosaccharides – “mono” means single. This is a single-sugar molecule. • And • Polyols – these are sugar alcohols (however don’t lead to intoxication!)
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What are FODMAPs?
Description Details Examples of foods containing FODMAPs
F Fermentable By bacteria in the
large bowel
O Oligosaccharides Fructans and
Galacto-
oligosaccharides
Wheat, rye, barley, onions, leek, shallots, white
part of spring onion, garlic, legumes, lentils,
artichokes, chicory
D Disaccharides Lactose Milk, evaporated milk, yoghurt, custard and ice-
cream
M Monosaccharides Fructose (in excess
of glucose
Honey, mango, watermelon, apples, pears, high
fructose corn syrup
A And
P Polyols eg. Sorbitol,
Mannitol, Maltitol,
Xylitol
Apples, pears, apricots, nectarines, plums,
cauliflower, products (eg. gums & confectionery)
sweetened with polyols
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Lower GI Disorders Summary
• Food intolerances should be dealt with individually
• Patients should be encouraged to follow the least restrictive diet possible
• Patients should be re-evaluated frequently and the diet advanced as appropriate
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“وكُلوُاْ وَاشْرَبوُاْ وَلاَ تسُْرِفوُاْ إن الله لا ٌحب المسرفٌن: قال الله عز وجل• 31:الأعراف
ما ملأ ابن آدم وعاءً شرّاً من بطن، بحسب ابن آدم :الرسول محمد صلى الله عليه وسلم •لقٌمات ٌقمن صلبه، فإن كان لا محالة فثلث لطعامه، وثلث لشرابه،
5674:، وصححه الألبانً فً صحٌح الجامع4132:أخرجه أحمد. وثلث لنفسه
.أقلل طعامك ٌهنأ منامك :أحد الحكماء•
المعدة بٌت الداء والحمٌة رأس كل دواء :كلدةطبٌب العرب الحارث بن •
ابن سٌنا – .، فإن أكثر العلل إنما تتولد من فضول الطعامالبطنةاحذروا •
.ولٌكن الطب هو غذاؤك, الغذاء هو دواؤكلٌكن :أبقراط•
إن العلاج الغذائً السلٌم هو طب المستقبل وقد انتظرنا :كارل بفٌغر. د• .طوٌلاً حتى ٌسري مفعوله
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Dietary roughage (Dietary Fiber) Presentation outline 25-4-2017
Time
Introduction and Definitions 09:00 to 09:10
Mechanism by which dietary fibers affect normal functions.
09:10 to 09:20
Effect of fiber on nutrient absorption rates. 09: 20 to 09:30
The beneficial effects of dietary fiber in disease prevention and management.
09:30 to 09:50
47
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DIETARY FIBER; DEFINITION,
• Dietary fiber is the edible parts of plants or analogous carbohydrates that are resistant to digestion and absorption by the human intestine.
• Dietary fiber includes:
- polysaccharides oligosaccharides,
- lignin, and
- associated plant substances.
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Fiber
• Fiber is the structural part of plants and is found in vegetables, fruits, grains and legumes.
• Most dietary fibers are polysaccharides, like starch, but they are not digestible.
• The human body lacks the enzymes needed to digest and absorb fiber.
• As a result fibers reach the lower intestine intact where intestinal bacteria can ferment some fiber.
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Dietary fibre was known as
.’roughage‘النخالة
• It comprises groups of substances in plant foods which cannot be completely broken down by human digestive enzymes, including lignin, polysaccharides such as cellulose and pectin.
• It was originally thought that dietary fibre was not digestible and did not provide any energy.
• It is now known fibre is fermented in the large intestine by gut bacteria to provide a small amount of energy (2kcal/8kJ per gram
• Sources include wholegrain cereals and cereal products, vegetables, fruits, nuts, beans, lentils, potatoes
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There are several different classification systems for dietary fiber
Most common fiber classification categories include
• water-insoluble/less fermented fibers (cellulose, hemicellulose, lignin)
• and the watersoluble/ well fermented
fibers (pectin, gums, and mucilages)
• There are many different forms of fiber in food and there is also a wide range of foods delivering fiber.
• Dietary fibers can be extracted from edible material (intrinsic) or modified and added back into a food (extrinsic).
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Soluble Fibers
• Soluble fibers dissolve in water, form gels and are easily digested by bacteria in the lower intestine.
– Provides a feeling of fullness.
– Slow down the rate food leaves the stomach.
– May have a role with heart disease, diabetes and colon cancer
• Found in legumes and fruits
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Insoluble Fiber
• Insoluble fibers absorb water and swell up resulting in a larger softer stool that is easier and quicker to pass.
– Provides a feeling of fullness
– Helps with intestinal function
– May help with colon cancer
• Found in grains and vegetables
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Fiber • Nonstarch polysaccharide fibers
– Cellulose – Hemicellulose – Pectin – Gums – Mucilages
• Nonpolysaccharide fiber – Lignins – Cutins – Tannins
• Resistant Starches
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Current recommendations for dietary fiber intake are related to:
age, gender, and energy intake; and the general recommendation for adequate intake is 14
g/1000 kcal. • 30 g dietary fiber daily for adults based on protective
effects against cardiovascular disease
• Using the energy guideline of 2000 kcal/day for women and 2600 kcal/ day for men, the recommended daily dietary fiber intake is:
• 28 g/day for adult women and • 36 g/day for adult men.
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• For children provided the
following recommended
intakes:
• 15g/day (age 2-5);
• 20g/day (age 5-11);
• 25g/day (age 11-16);
• 30g/day (age 16-18).
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How much fiber do we need?
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How many ways can you think of
to increase fibre in your diet?
Some examples include:
1. Have a bowl of wholegrain breakfast cereals,
served with a handful of dried fruit.
2. Switch from white to wholemeal or granary
bread.
3. Add oats to fruit or vegetable crumble
toppings.
4. Serve a side salad with a sandwich or pasta
dish.
5. Add beans and pulses to casseroles and
soups.
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The different types of dietary fibre have different functions in the body, which include:
• Helping to prevent constipation (with an increased water intake) which reduces the risk of diverticulitis and bowel cancer;
• The maintenance of normal blood cholesterol levels;
• The reduction of the rise of blood glucose after a meal;
• The association with feelings of fullness to help control food intake, as foods which are high in fibre often are low in energy density.
Summary
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Fiber and Health
Both fiber types are important for health. • Fibers are beneficial for many conditions;
constipation, • diarrhea, • diverticular disease, • heart disease, • diabetes and • colon cancer. Fiber is only one factor involved in these
conditions.
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Fiber and Health
• Foods high fiber have many factors that may be factors in lowering disease risk.
– High fiber
– Low in fat
– High vitamins (antioxidants)
– High in minerals
– High in phytochemicals
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Beneficial effects of dietary fiber in disease prevention and management
• Increased laxation
• Decreased colonic transit time
• Increased colonic fermentation/short chain fatty acid production
• Positive modulation of colonic microflora
• Beneficial effect on mineral absorption
• A protective role in the prevention of colon cancer and other malignancies
• Improvement in immune function.
• Reduced total and/or LDL serum cholesterol levels
• Attenuation of postprandial glycaemia/insulinaemia
• Reduced blood pressure
• Weight loss, Increased satiety
• Decreased mortality
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Role of Fiber in Digestion and Absorption
• Prevent constipation
• Increase fecal volume
• Decrease GI transit time
• Slowed or decreased nutrient absorption
• Bind cholesterol and minerals
• Reduce the risk of cancer and GBS
• Modify serum lipid concentrations
–Short-chain fatty acids
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Question
• Dietary fibre is not digested in the small intestine.
• Dietary fibre is found in plant foods only.
True or false?
• True. Dietary fibre is not digested in the small intestine but may be fermented in the colon.
• True. Dietary fibre is a type of carbohydrate found exclusively in plants.
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How much Fiber is enough?
Here are some tips for increasing your fiber intake: • ▪ Eat a variety of high-fiber foods—let MyPlate be your guide. • ▪ Have legumes such as dried beans or peas two to three times per
week. • ▪ Choose whole grain breads, cereals, pasta, crackers, and flour. • ▪ Snack on fruits, vegetables, and high-fiber cereals and grains.
• Consume fresh fruits rather than fruit juices. • ▪ Scrub vegetables and fruit and leave the skin on instead of peeling
the skin off. • ▪ Substitute high fiber ingredients in recipes, such as adding
vegetables to casseroles, fruit to cereal, and oatmeal and beans to meatloaf, breads, and baked goods.
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Food Label Terminology
• Nutrition labels list a Daily Reference Value (DRV) for nutrients, including fiber. The DRV for fiber is 25 grams per day based on a 2,000 calorie diet and 30 grams per day based on a 2,500 calorie diet.
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Intestinal Function
• Insoluble fibers absorb water resulting in a larger, softer stool that is faster and easier to eliminate, which can help with: – Constipation
– Hemorrhoids
– Diverticular disease
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Colon Cancer
• Both insoluble and soluble fibers may protect against colon cancer – Insoluble fibers absorb water making a larger,
softer stool which can: • Dilute potential carcinogens
• Reduce transit time so the colon is exposed to any cancer causing substance for less time.
– Soluble fibers can bind bile acids, potential carcinogens, and increase their excretion.
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Heart Disease
• As mentioned, soluble fibers can bind to bile acids and increase their excretion.
• With fewer bile acids in the intestine, less fat is absorbed.
• Also by increasing bile acid excretion, the liver must use its cholesterol to make new bile acids.
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Diabetes
• Soluble fibers may have a favorable effect on blood glucose.
• Soluble fibers decrease the rate at which food is released from the stomach and delays glucose absorption into the blood.
• This may help prevent wide swings in blood glucose throughout the day.
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Weight Management
• Foods rich in complex carbohydrates tend to be low in fat and added sugars which can help with weight management by providing fewer calories.
• In addition, as fibers absorb water they swell up creating a feeling of fullness and delaying hunger.
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How Much Fiber
• The National Research Council set a Dietary Reference Intake (DRI) for dietary fiber.
• An adequate Intake (AI) for dietary fiber was set at 14 grams dietary fiber per 1,000 calories.
– Thus for a reference 2,000 calorie diet recommended intake would be 28 grams per day.
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Too Much Fiber
• Dietary fiber can bind some minerals and decrease their absorption.
• However, if mineral intake is adequate a recommended dietary fiber intake will not compromise mineral balance.
• Fiber intake is like all nutrients - “more” is not always “better.” Consuming a diet that provides a variety of nutrients is the key.
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Food Sources of Fiber
• Foods are the best source of fiber, get both soluble and insoluble fiber.
• Food sources of fiber include fruits, vegetables, whole grain products, legumes, nuts and seeds.
• Cooking processing and removing peels can lower fiber content.
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