short bowel syndrome: how to eat when you can't eat
TRANSCRIPT
SHORT BOWEL SYNDROME: HOW TO EAT
WHEN YOU CAN'T EAT
LAURA E. MATARESE PHD, RD, LDN, CNSC, FADA, FASPEN, FAND
PROFESSOR
DIVISION OF GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION
DIVISION OF INFECTIOUS DISEASES AND TRAVEL HEALTH
ADJUNCT PROFESSOR OF SURGERY
BRODY SCHOOL OF MEDICINE
AT
EAST CAROLINA UNIVERSITY
GREENVILLE, NC
DISCLOSURES
Takeda
Speaker Bureau
Grant Support
Abbott Nutrition
Nestle
All material presented is based on
best known clinical evidence.
LEARNING
OBJECTIVE
Describe the dietary interventions
to enhance absorption and reduce
output
THE STANDARD
AMERICAN DIET
High sugar, high
fat
Can you imagine
eating this way if
you have SBS?
Likely to cause
increased output
SO HOW DO WE TIP THE SCALES SO THERE IS INCREASED ABSORPTION AND DECREASED OUTPUT?
More absorptionLess output
Diet Modification: The Foundation of Therapy
Nutrition prescription must be based on the remnant GI anatomy to enhance
absorption
Most potent stimulus to intestinal adaptation
Comparison of Two Nutrition Prescriptions
Colon No Colon
Carbohydrate50-60% of total calories
(limit simple sugars)
40-50% of total calories
(restrict simple sugars)
Protein 20-30% of total calories 20-30% of total calories
Fat20-30% of total calories
(primarily essential fats)
30-40% of total calories
(primarily essential fats)
FluidIsotonic fluids or
Hypo-osmolar fluids
Isotonic, high sodium oral
rehydration solution
Soluble Fiber5-10 grams / day
(if stool output is > 3L/day)
5-10 grams / day
(if stool output is > 3L/day)
Oxalates Limit intake ---
Meals 5-6 meals per day 4-6 meals per day
Byrne et al. NCP 15:306, 2000
Simple vs. Complex CHO
LIMIT
Sugar
Candy
Cakes, cookies, pies
Regular soda pop
Sweet tea
Jelly, jam, syrup
Ice cream, sherbet
Sorbet
INCLUDE
Pasta
Potato
Breads
Cereals
Whole grains as tolerated
Fruits and vegetables as tolerated
Matarese, L. et al; J Clin Gastroent 40(Supp 2):S85-S93, 2006.
Non-nutritive Sweeteners
Non-nutritive sweeteners are intense, very low-calorie sweeteners that do not have an adverse effect on stool output. These sweeteners can be used as an alternative in order to reduce simple sugars in the diet.
The sweeteners currently approved by the FDA are:
Acesulfame K (Sunett®, Sweet & Safe, Sweet One®)
Aspartame (Nutrasweet®, Sugar Twin®, Equal®)
Neotame (used by manufacturers in combination with other nutritive and non-nutritive sweeteners to enhance the flavor of food and beverages)
Saccaharin (Sweet’N Low® and Sweet Twin)
Stevia-based sweeteners (Truvia®, Pure Via®)
Sucralose (Splenda®)
U.S. Food & Drug Administration. http://www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm397725.htm
Sugar Alcohols: Look for the “ol”
Sugar alcohols are also used as low-calorie
sweeteners. Unlike the non-nutritive sweeteners,
they are designed to be malabsorbed and therefore
cause uncomfortable side effects like abdominal
gas, bloating and diarrhea. Consumers with SBS
should limit these.
Sugar alcohols can be found in the ingredient list
on food labels as sorbitol, mannitol, xylitol.
A product labeled “sugar-free” must contain a
separate line for sugar alcohols under the
carbohydrate section on the food label.
U.S. Food & Drug Administration. http://www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm397725.htm
Comparison of Two Nutrition Prescriptions
Colon No Colon
Carbohydrate50-60% of total calories
(limit simple sugars)
40-50% of total calories
(restrict simple sugars)
Protein 20-30% of total calories 20-30% of total calories
Fat20-30% of total calories
(primarily essential fats)
30-40% of total calories
(primarily essential fats)
FluidIsotonic fluids or
Hypo-osmolar fluids
Isotonic, high sodium oral
rehydration solution
Soluble Fiber5-10 grams / day
(if stool output is > 3L/day)
5-10 grams / day
(if stool output is > 3L/day)
Oxalates Limit intake ---
Meals 5-6 meals per day 4-6 meals per day
Byrne et al. NCP 15:306, 2000
BIOLOGICAL VALUE (BV) OF PROTEIN
Biological Value: Measure of the
proportion of absorbed protein from
a food which becomes incorporated
into the proteins of body cells
Higher BV indicates that less is
needed
Protein BV*
Whey Protein, Whole Soy
Bean
96
Human milk 95
Chicken egg 94
Soybean milk 91
Cow’s milk 90
Cheese 84
Quinoa, rice 83
Fish 76
Beef 74
Soybean curd (tofu) 64
*percent nitrogen incorporated
Protein
Comparison of Two Nutrition Prescriptions
Colon No Colon
Carbohydrate50-60% of total calories
(limit simple sugars)
40-50% of total calories
(restrict simple sugars)
Protein 20-30% of total calories 20-30% of total calories
Fat20-30% of total calories
(primarily essential fats)
30-40% of total calories
(primarily essential fats)
FluidIsotonic fluids or
Hypo-osmolar fluids
Isotonic, high sodium oral
rehydration solution
Soluble Fiber5-10 grams / day
(if stool output is > 3L/day)
5-10 grams / day
(if stool output is > 3L/day)
Oxalates Limit intake ---
Meals 5-6 meals per day 4-6 meals per day
Byrne et al. NCP 15:306, 2000
Fat
Fat should be included in the diet to
prevent essential fatty acid deficiency.
Use smaller amounts if your colon is
connected.
But…not all fats are alike
Essential fats or essential fatty acids
(EFAs) should be included since the
body cannot make EFAs on its own.
Foods high in animal fat and saturated
fat should be limited since they have
been associated with atherosclerosis
and cardiac diseases.
Omega-6 & Omega-3
Proinflammatory
Series 2
Prostaglandins
Series 4
Leukotrienes
Anti-inflammatory
Series 3
Prostaglandins
Series 5
Leukotrienes
Food Sources of
Essential vs. Non-
Essential Fats
Essential Fatty Acids: alpha-linolenic
acid (ALA) and linoleic acid (LA)
Nonessential Fats
Canola oil Butter
Cold water fish (salmon, trout, mackerel,
sardines)
Cocoa butter
Corn oil Coconut oil
Flaxseed oil Palm oil
Grapeseed oil Peanut oil
Mayonnaise Red meat
Safflower oil Whole milk and cheeses
Soybean oil
Sunflower oil
Comparison of Two Nutrition Prescriptions
Colon No Colon
Carbohydrate50-60% of total calories
(limit simple sugars)
40-50% of total calories
(restrict simple sugars)
Protein 20-30% of total calories 20-30% of total calories
Fat20-30% of total calories
(primarily essential fats)
30-40% of total calories
(primarily essential fats)
FluidIsotonic fluids or
Hypo-osmolar fluids
Isotonic, high sodium oral
rehydration solution
Soluble Fiber5-10 grams / day
(if stool output is > 3L/day)
5-10 grams / day
(if stool output is > 3L/day)
Oxalates Limit intake ---
Meals 5-6 meals per day 4-6 meals per day
Byrne et al. NCP 15:306, 2000
Types of Fluids
Matarese et al; NCP, 20:493-502, 2005.
Hyper-
osmolar
• Contain many particles of glucose and little to no
sodium
• Cause fluid to be pulled into the intestinal tract to
dilute the concentration of the beverage, therefore
causing watery diarrhea
• Example: Coke, Pepsi, Mt. Dew, Sweet tea
Hypo-
osmolar
• Contain little to no particles of glucose and sodium
(not concentrated)
• Are not always absorbed entirely, known as free
fluids
• Examples: Water, decaffeinated and sugar-free
beverages
Iso-
osmolar
• Contain sodium, potassium and glucose in same
concentration as blood and extracellular fluid
• Will not cause fluid to shift into the GI tract
• Oral rehydration solution, Cera-Lyte, Pedialyte®,
G2®
• Usually the beverage of choice for those with SBS
Beverage Approximate Osmolarity
(m0sm/L)
Type of Fluid
Prune Juice 1265 Hyper-osmolar
Grape Juice 863 Hyper-osmolar
Apple Juice 680 Hyper-osmolar
Orange Juice 614 Hyper-osmolar
Regular Soda 550–700 Hyper-osmolar
Popsicle 720 Hyper-osmolar
Jell-o® 730 Hyper-osmolar
Diet Soda 0 Hypo-osmolar
Water 0–28 Hypo-osmolar
Tea (sugar free) 13-44 Hypo-osmolar
ORS salts 300 Iso-osmolar
CeraLyte 220–260 Iso-osmolar
Pedialyte® 250 Iso-osmolar
Gatorade® 330–380 Iso-osmolar
Fluid Comparison
Parrish, C; The Clinician’s Guide to Short
Bowel Syndrome; Practical
Gastroenterology, 2005.
Oral
Rehydration
Solutions
Sodium-glucose Co-transport
Oral Rehydration Solutions
Sodium Balance with Short Bowel Syndrome
Rodriguez CA et al. Clin Sci 1988;74(suppl18):69
Sodium Balance
(Na intake – fecal
output) mMol/L
Oral Rehydration
Solutions
CHO
g/L
Na+
mEq/L
K+
mEq/L
HCO3
mEq/L
Osmo
mOsm/L
ORS
WHO Standard Formula 20 90 20 30 310
WHO Reduced-Osmolality
Formula
13.5 75 20 30 245
CeraLyte 70 40 70 20 30 235
CeraLyte 90 40 90 20 30 260
CVS Adult Electrolyte
Solution
25 45 20
DripDrop 25 60 20 160 (citrate) 215
Jianas Brothers 20 90 20 10 300
Pedialyte (Abbott) 25 45 20 30 300
Speedlyte (Einsof
Biohealth)
75 45 20 9 (citrate) 188
Trioral Rehydration Salts
(Trifecta)
13.5 20 20 10 (citrate) 245
Sports Drinks
Gatorade 60 20 3 340
Gatorade 2 + ½ tsp salt 29 63 3 254
Prescription for ORS+
No Potassium
Water 1 liter
Sodium Chloride ½ tsp
Bicitra solution* 2 TBSP
Glucose polymer
powder* (polycose) 4 TBSP
Low Potassium
Water 1 liter
Sodium Chloride ½ tsp
Polycitra solution* 3 tsp
Glucose polymer
powder* (polycose) 4 TBSP*By prescription
+UPMC protocol
#Sugar-free artificial flavoring or sweetener
Recipe for ORS
1 liter water
¾ teaspoon table salt
3 tablespoons sugar (sucrose)
1 teaspoon baking powder (or ½ teaspoon baking soda)
½ teaspoon 20% potassium chloride* or salt substitute#
Sugar-free artificial flavoring or sweetener
* By prescription
# Concentration: 7-14 mEq potassium per gram; one teaspoon: 5 grams (1/6 oz) = 35-70 mEq potassium
Mayo Clin Proc, 1992; 67:755-760.
Recipe for ORS
1. Gatorade Base
2 cups Gatorade
2 cups water
½ teaspoon salt
2. Grape or Cranberry Juice
½ cup juice
3 ½ cups water
½ teaspoon salt
3. Apple Juice
1 cup juice
3 cups water
½ teaspoon salt Parrish, C. Pract Gastroenterol 2005; 14:67
Comparison of Two Nutrition Prescriptions
Colon No Colon
Carbohydrate50-60% of total calories
(limit simple sugars)
40-50% of total calories
(restrict simple sugars)
Protein 20-30% of total calories 20-30% of total calories
Fat20-30% of total calories
(primarily essential fats)
30-40% of total calories
(primarily essential fats)
FluidIsotonic fluids or
Hypo-osmolar fluids
Isotonic, high sodium oral
rehydration solution
Soluble Fiber5-10 grams / day
(if stool output is > 3L/day)
5-10 grams / day
(if stool output is > 3L/day)
Oxalates Limit intake ---
Meals 5-6 meals per day 4-6 meals per day
Byrne et al. NCP 15:306, 2000
Types of Fiber
Choose Limit
Soluble Fiber Insoluble Fiber
Oatmeal cereals and breads Whole wheat cereals and breads
Oatbran cereals and breads Wheat bran cereals and breads
Apple (without skin), applesauce,
banana, orange, grapefruit,
tangerine without seeds,
strawberries as tolerated
Grapes, blueberries, cherries,
rhubarb, figs, blackberries,
raspberries
Cooked, peeled and/or seedless
vegetables such as carrots,
butternut squash, asparagus tips,
canned green beans
Corn, celery, cucumber, mushroom,
cauliflower, lettuce, cabbage,
peppers, eggplant, broccoli &
asparagus stems, spinach, turnip
greens, kale,
Brussels sprouts
Refried low-fat beans, shelled
beans (i.e., garbanzo beans, black
beans)
Nuts, large seeds (pumpkin,
sunflower), lentils, peas
Comparison of Two Nutrition Prescriptions
Colon No Colon
Carbohydrate50-60% of total calories
(limit simple sugars)
40-50% of total calories
(restrict simple sugars)
Protein 20-30% of total calories 20-30% of total calories
Fat20-30% of total calories
(primarily essential fats)
30-40% of total calories
(primarily essential fats)
FluidIsotonic fluids or
Hypo-osmolar fluids
Isotonic, high sodium oral
rehydration solution
Soluble Fiber5-10 grams / day
(if stool output is > 3L/day)
5-10 grams / day
(if stool output is > 3L/day)
Oxalates Limit intake ---
Meals 5-6 meals per day 4-6 meals per day
Byrne et al. NCP 15:306, 2000
Types of foods and the way
the food is consumed affects
absorption…
2400 kcal, 50% CHO, 20% Protein, 30% Fat
Breakfast
1 cup oatmeal
2 oz lactose-free milk
1 egg
1 English muffin
2 tsp margarine
1 tsp diet jelly
4 oz coffee
Morning Snack
1 bagel w/½ oz cheese
1 tsp margarine
1 small banana
4 oz water
Breakfast
8 oz orange juice
1 cheese and fruit-
filled Danish
Byrne et al., NCP 15:309, 2000
2400 kcal, 50% CHO, 20% Protein, 30% Fat
Lunch
3 oz baked ham
½ cup cooked rice
½ cup carrots
2 small dinner rolls
2 tsp margarine
4 oz water or diet soda
Lunch
1 thin slice cheese pizza
12 oz regular soda
Byrne et al., NCP 15:309, 2000
2400 kcal, 50% CHO, 20% Protein, 30% Fat
Dinner
4 oz roasted chicken
1 large baked potato
2 dinner rolls
2 tsp margarine
4 oz water or diet soda
Evening Snack
1 roast beef sandwich
2 slices bread, 1 oz meat, 1 tsp mayo
1 tsp mustard
1 oz pretzels
4 oz water or diet soda
Dinner
12 oz T-bone steak
1 large baked potato
1 cup spinach
12 oz beer
Evening Snack
3-4 cups popcorn
1 cup raspberry sorbet
12 oz diet soda
Byrne et al., NCP 15:309, 2000
Putting it all
together…
Plan a balanced diet
Include complex carbohydrates, proteins and fat (especially essential fat) at each meal
Limit or avoid simple sugars
Distribute the food throughout the day
Chew foods well
Use salt liberally especially if your colon is in circuit
Limit fluids to 4 oz. per meal and sip fluids that are either hypo-osmolar or isotonic throughout the day.
And most importantly, enjoy meals with family and friends!
Cheating Guidelines
Yes, it is OK to taste your favorite foods now and then. But, be smart about it.
For example, if you must have a regular soda, have it with a soft pretzel with the large salt granules on it. And don’t drink the entire 2 liter bottle!
Make sure you are home or at least close to a bathroom
Sample the food; do not overindulge
There is often a dose response. You may be able to tolerate small amounts of that “forbidden” favorite food.
CONCLUSION
“Takeaway” message
Diet is the foundation of
therapy for SBS
Fluid and nutrient absorption
can be enhanced when oral
intake is based on the GI
anatomy
Further Reading
Byrne, T et al. Clinical Observations: Beyond the Prescription: Optimizing the Diet of Patients with Short Bowel Syndrome. Nutri Clin Pract 15:309, 2000
Matarese LE, O'Keefe SJ, Kandil HM, et al. Short bowel syndrome: clinical guidelines for nutrition management. Nutr Clin Pract. 2005;20:493-502.
Matarese LE. Short bowel syndrome. In: Mullin GE, Matarese LE, Palmer M, editors. The Gastrointestinal and Liver Disease Nutrition Desk Reference. Boca Raton, FL: CRC Press; 2012: p. 35-49.
Matarese L.E., Steiger E. and Seidner, DL (eds) Intestinal Failure and Rehabilitation. A Clinical Guide. CRC Press, Boca Raton, Florida, 2005
Matarese LE. Nutrition and Fluid Optimization for Patients With Short Bowel Syndrome. JPEN J Parenter Enteral Nutr. 2013 37 (2)161 – 170
Parrish CR, DiBaise J. Part III: Hydrating the Adult Patient with Short Bowel Syndrome. Practical Gastroenterology 2015;XXXIX(2):10.
Parrish CR. The Clinician's Guide to Short Bowel Syndrome. Practical Gastroenterology 2005;XXIX(9):67
CONTACT INFORMATION
LAURA MATARESE, PHD, RDN
37
Short Bowel Syndrome: How to Eat When You Can't Eat