FN 255: Introduction to MNT
  Teresa McFerran, MS, RD
Health Professions Division
Lane Community College
Eugene, Oregon
Unit 8 Preparations, Chapter 11
Gastrointestinal, Pancreatic, and Liver Dysfunction

Unit 8 Study Questions DUE before midnight (11:55 pm) SUNDAY

You do NOT need to print this document, if you have printed the Unit 8 Outline.

ACTIVITIES AT A GLANCE. Check them off as you complete them.
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 By midnight (11:55 pm) SUNDAY, complete Unit 8 Study Questions for 10 points (be certain you've FIRST done ALL of the Unit Outline Questions.) (If you have any questions, post them in our "Forum Week 8" in Moodle.)
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 Sometime BEFORE SUNDAY, participate in our "Forum Week 8" by making at least two postings throughout the week with at least one of the postings BEFORE Friday evening. So the total MINIMUM is 2 postings on TWO different days. (A posting can be either posting a question you have or replying to a classmate's question or comment. You don't have to respond to all of the threads if you don't feel you have anything to add. You can also choose to respond more often.)


OBJECTIVES

After reading the assigned reading, filling out the Unit Outline, participating in the "Forum Week 8", and completing the Unit 8 Study Questions, you will be able to:
 RESOURCES

WEEKLY FORUMS:
Each week, there will be a FORUM that will allow you to post any questions you have about the lecture or materials covered as well as allow the instructor to post any changes or corrections that need to be communicated.

FORUM WEEK 8: (Go to our Moodle classroom and click on "Forum Week 8" to participate.)
  1. "Student Questions": Do you have any questions about the Unit 8 Preparations? Please post your questions/concerns in the forum for others to be able to respond.

  2. "GI Conditions Table": Were any of the conditions new/unfamiliar? Which one(s) and what did you learn? (Please be specific.)

  3. "Common Threads": After completing the Unit Preparations, consider making a forum posting about the following: Between Part I and Part II of the Unit Prep there's a blurb on page 105 of the packet about some of the common themes woven throughout Chapter 11. Do you have any additional common themes you've noticed? If so, which theme(s) did you notice?

  4. "Food Intolerance or Sensitivity and Food Allergy or Hypersensitivity": How would you paraphrase the definition of each condition and what is the difference between the two? Provide an example of each.

  5. "Understanding Celiac Disease": Celiac disease is currently a hot topic in nutrition. This week's Unit Prep discusses celiac disease with the goal being to differentiate between the current "gluten-free" fad and celiac disease and it's implications. Please share anything new you learned or what you thought about the information shared.

  6. "Whole Grain Glossary Cooking Challenge": After reviewing the whole grain glossary, see if you can find a recipe that features a grain you've never cooked, or would like to learn how to cook better. Post the grain you selected, the recipe you used, and a picture of your final meal, if you can. It would be so fun to share all of our recipes while also promoting a variety of grains and an opportunity to cook.

  7. CORRECTIONS / CLARIFICATIONS: (Please check our weekly forum for additional corrections and clarifications.)
Unit 8 Preparations, Chapter 11
Gastrointestinal, Pancreatic, and Liver Dysfunction
The Unit 8 Study Questions will be based on the answers you obtain from filling in ALL of the blanks in your Unit 8 Outline and checking out the links for the Unit 8 Preparations below. Filling out the unit Outline is the best way to prepare for the SQ, and considering all quizzes are timed, you will not have ample time to complete the quiz if the Unit Outline is not completed first.

The following topics will be covered this week:
I.  Chapter 11: Gastrointestinal, Pancreatic, and Liver Dysfunction

II. Food Intolerances and Food Allergies

III. Diverticulosis, Diverticulitis and Fiber Recommendations


I. Chapter 11: Gastrointestinal, Pancreatic, and Liver Dysfunction

This week's Unit Preparations are organized a little differently because this week we will START with reading the textbook. Please keep in mind that there is a LOT of medical terminology concentrated in Chapter 11, and you are encouraged to look up the definitions for words that may be unfamiliar.

Read chapter 11 in your text and answer the following questions:

A variety of disorders that affect the GI tract and it's accessory organs--the _____________, _________________, and _____________ can impair nutritional status.

*Click on the following link: Chapter 11 GI Conditions Table*
(Refer to pages 112-116 of your packet for a hard copy of the table. If you would like to reprint/format the table, and the link above does not work, check out Week 8 in Moodle for a copy.)

Fill in ALL of the blank cells in the table as you read Chapter 11, except for the cells with --, which should include the Intervention/Education cell for each condition as well as one other cell for each condition. (For example, the two blank cells for GERD are the (1) treatment and (2) intervention/education sections.) Many of this week's SQ will be pulled from your answers in the table as well as the questions that follow.


GERD is a major risk factor for the development of what precancerous condition?

GERD is especially common in individuals with __________________.

Esophageal dysfunction places the patient at risk for ________________________________ and subsequent _________________.

Dietary measures should be ______________, because no one type of food stimulates reflux in all individuals with GERD.

Which of the intervention and education recommendations for preventing or reducing reflux may decrease LES pressure? (pg 308)




Using Box 11-1 on pages 304-308, a history of steatorrhea may be related to which conditions?




Using Box 11-1 on pages 304-308, what can lead to a vitamin B12 deficiency?




What may cause fat malabsorption after a gastrectomy?




What is dumping syndrome? (Refer to page 309-310.)




According to page 310, although fresh fruits are high in simple carbohydrates, they are often well tolerated because of their content of _________________, such as ___________. They CAN be used as desserts and snacks.

According to page 311, __________________ and ________________, both produced in the stomach, are required for the absorption of _____________.

What are the three phases that occur after the small bowel has undergone a massive resection? (Include information describing what is occurring during each phase and the average time span required before moving onto the next phase.)






Massive small bowel resection can be expected to affect absorption of almost ___________ nutrient(s) and to have great potential for causing _________________.

What is hyperoxaluria and which foods should be avoided? (pg 316)




According to Box 11-2 on page 312, which calcium supplement has higher bioavailability?


According to page 312, what are the risks associated with vitamin D supplementation?


Use Table 11-1 on page 315 to answer the following question. An individual with severe steatorrhea describes what he ate for breakfast and asks if any of the following foods should be avoided: pancakes, fresh blueberries, butter, maple syrup, coffee, and cream. Which foods do you recommend avoiding and what do you recommend including instead? (Note: avoid is not the same as eliminate.)




What is one serving of fat? (Include the examples of foods provided and the amount.)




Why do individuals with celiac disease have a decreased capacity for digesting disaccharides and peptides?



What is dermatitis herpetiformis?



What is the most definitive way to diagnose celiac disease?


The gluten-free diet is ___________ to follow because grain products are so widely used in ___________ foods and because they form the ______________ of many common dishes.

Which grains should be avoided for restricting gluten?




When it is unclear whether a product contains gluten, what is recommended?


According to the bottom of page 320, the Canadian Celiac Association advises that adults can safely consume up to ______ grams (1/2 to 3/4 cup) of pure _______ per day.

Which two diseases are considered to be different types of inflammatory bowel disease and how are they similar and different?






Resection of the colon is often performed after _________ acute exacerbations of ulcerative colitis because of the risk of developing _________________.

What B vitamin supplement may be needed if the terminal ileum is involved in an individual with IBD (inflammatory bowel disease)?


IBS is not life threatening, but in its severe form, it can interfere with being able to _______, participate in ______________, and carry out many _______________________.


Taking pancreatic enzymes with meals and snacks can ______________ the ________________ for the pancreas to release _____________ and therefore reduce pancreatic damage and pain.


NAFLD is often associated with metabolic syndrome, which includes ____________________, _____________________, _______________, _______________________, and ___________________.


What are the three possible explanations of hepatic encephalopathy?






How are the causes of cirrhosis and pancreatitis similar and different?







An individual with hepatic encephalopathy is 5'8" tall and weighs ~160#. He is given a 60-gram protein diet per day. Is 60 grams of protein more or less than the RDA of 0.8 grams of protein per kg of body weight? (Round to the nearest 5 grams per day.) Refer to page 329 of your text.




Additional insight: The liver is involved in MANY of the body's metabolic processes, including regulation of protein, fat, and carbohydrate metabolism, vitamin storage and activation, and detoxification and excretion of waste products. Thus, impaired liver function can lead to nutrient deficiencies, and eventually, protein-energy malnutrition. Conversely, malnutrition can further impair liver function by affecting the liver's structural integrity. The topic of protein recommendations for individuals with liver disease is highly controversial. Recent evidence suggests that protein restriction should not be instituted during periods of episodic encephalopathy; however, dietary intervention may be considered if hepatic encephalopathy persists. Dietary protein may be restricted in hopes to lower plasma ammonium levels because ammonia, a by-product of protein metabolism, can contribute to the development of hepatic encephalopathy. Drastic, long-term protein restriction is NOT indicated because many of these patients are protein depleted already and often have a diminished appetite and poor po intake. Therefore, additional protein deprivation may promote catabolism (breakdown) of lean body tissue, contribute to malnutrition, and reduce host defenses to infection. Sodium and fluid recommendations are also hotly debated, but in the severely sodium-retentive patient who has liver disease with ascites, sodium and fluid restrictions are often necessary. Moderate sodium restriction of 2-3grams/day, coupled with the use of diuretics (water pills) can make the diet more palatable while minimizing risk of potential fluid retention. (The textbook refers to the use of MCTs, which may be necessary in the presence of fat malabsorption. MCTs are more efficiently absorbed than long-chain triglycerides because they are absorbed directly into the portal vein and subsequently are transported to the liver.)

Many GI disorders have substantial nutritional impacts and require complex dietary changes. A ______________________ can make an invaluable contribution to their care and instruction.


Some of the common "themes" woven throughout Chapter 11 included the following main points:

II.  Food Intolerances and Food Allergies

Food Allergy Overview

Click on the link and read about food allergies. Answer the questions that follow:

According to the first page of the article, true food allergies are estimated to affect less than ____ % of the population.

Under the section "Defining Food Allergy", "A food allergy is any adverse reaction to an otherwise harmless food or food component that involves the body's ___________ system."

In the same section "Defining Food Allergy", "A single food can contain multiple food ____________, the majority of which are likely to be _____________, NOT __________________ or ___________."

Under the section " Food Allergy Symptoms", what three areas of the body are usually affected?



True or False: Symptoms of a food allergy reaction are highly predictable as they manifest themselves in the same way in one person as the next.

What are the top 8 food allergens? (Note: These 8 allergens comprise approximately 90% of all food-allergic reactions.)




Under the section "Food Allergy Diagnosis", who is the most qualified professional to determine whether the symptoms are related to a food allergy or other medical disorder?

Elimination diets and food challenges are often used in conjunction with skin and blood tests to facilitate a definitive diagnosis. According to the article, elimination diets should be tried only under __________________________ to ensure objective evaluation of symptoms and to avoid ______________.

Under the section "Food Allergy Management", once a food allergy is diagnosed, what is the only proven therapy?


To successfully follow an elimination diet, individuals must become adept at reading _______________________.

Under the section "Other Causes of Food Reactions", some adverse reactions to foods do NOT involve the IMMUNE system and are known as _________________________.

What is the difference between a food intolerance or sensitivity and a food allergy or hypersensitivity? (Provide an example of each.)






True or False: Although anyone can develop a food allergy, the ability to become allergic is inherited.

True or False: A mother-to-be should restrict her diet in attempts to prevent food allergy in her offspring because the mother's diet during pregnancy may cause food allergy in her infant.

True or False: Most food allergy reactions are not life threatening.


Lactose Intolerance (covered in detail in FN 225)

Recap: Lactose intolerance is NOT a food allergy. A food intolerance is an unfavorable reaction to a food substance or additive that involves digestion or metabolism (breakdown of food in the body) but does not involve the immune system. Reactions are generally localized, temporary, and rarely life threatening. On the other hand, a food allergy is an immune system response to specific proteins in foods, and it can be life threatening, such as an allergy to the protein in milk, which is different than lactose intolerance. Lactose intolerance is a problem with the digestion of the milk sugar.


Celiac Disease (Previously introduced on pgs 317-321 of the text)

Gluten-sensitive enteropathy (GES) is another disease associated with malabsorption and is also known as celiac disease, celiac sprue, or nontropical celiac. Gluten is a protein present in wheat and some other grains. Gluten has two components: gliadin and glutenin. It is the gliadin fraction that causes serious damage to the intestinal mucosa, causing malabsorption of many nutrients to occur. As the disease progresses, the villi of the intestinal mucosa are damaged. The end result of this damage is that the surface area for absorption of nutrients decreases by as much as 95%. Symptoms include diarrhea, weight loss, anemia, and other nutrient deficiencies.

The primary treatment for GES is a gluten-free diet. Nutrition counseling is the cornerstone of treatment for clients with GSE. The gluten-restricted diet is a difficult diet to follow and requires intensive education and support with a board-certified allergist and registered dietitian.

Click on the link and read more about celiac disease. Answer the questions that follow:

(Note: Shelley Case, the author of the article, is an RD who is considered to be an expert on gluten-free diets and celiac disease.  If you have a personal interest in this subject, I strongly recommend any of Shelley Case's materials, which are available through http://www.glutenfreediet.ca.)

What is celiac disease?



If untreated, what can happen to an individual with CD (Celiac Disease)?




Studies by Columbia University in New York and the Canadian Celiac Association revealed that patients suffer with CD for an average of how many years before being correctly diagnosed? Why aren't they diagnosed sooner?



True or False: A gluten free diet should be started as soon as an individual thinks that they may have CD.


True or False: Gluten is found in a wide variety of foods such as beer, flavored coffees and teas, some candies and chocolate bars, as well as some nutrition supplements and medications.

On August 2, 2004, the FALCPA became law. What did this law require? (Note: Careful review of ingredient lists on food and drug labels to determine if gluten-containing ingredients are present is important.)



What are the eight dietary guidelines recommended in order for the intestinal villi to regenerate and reverse likely nutritional deficiencies?












Note: It is paramount to train and educate all foodservice staff about food intolerances and food allergies and how to prevent "cross-contamination". Foodservice operations from preschools to hospitals should have policies, procedures, and protocols in place to handle food allergies. For example, most hospitals have a "gluten-free diet" available for patients with celiac disease, and care must be taken to prevent cross-contamination, such as NOT toasting rice bread in a toaster used for wheat bread. For additional resources, check out the online resource list at the end of this week's Unit Preparations.

III.  Diverticulosis, Diverticulitis and Fiber Recommendations

Diverticulitis is a disease of the intestine in which the intestinal walls become weakened and bulge out into pockets called diverticula. About 10% of Americans over 40, and half of Americans over 60 have diverticula. Most do not know it and there are no symptoms unless one or more of these pouches become infected or inflamed due to fecal matter collecting in the pockets. This condition develops in about 1 or 2 out of every 10 people who have diverticula, and it is called diverticulitis. (Note: The word ending -osis or -asis means "presence of", so diverticulosis means presence of diverticula. The word ending -itis means "inflammation of", so diverticulitis means "inflammation of diverticula".)

Click on the link and read more about diverticulosis and diverticulitis. Answer the questions that follow:

What is the difference between diverticulosis and diverticulitis?




What is a fistula?



According to the article, what is the dominant theory regarding what causes diverticular disease?



Does current scientific data support avoidance of nuts, popcorn, and other seeds for individuals with diverticulosis? (Why do physicians often recommend this dietary modification?)



Which food on the list "What foods have fiber" is the HIGHEST in fiber content per serving and which food is LOWEST?



How are the dietary recommendations for an individual with diverticulosis versus diverticulitis different?



What is a colostomy? Is this usually temporary or permanent?



Most acute care facilities provide both high-fiber and low-fiber menus and diets to patients, depending on their diagnosis and treatment. On the other hand, most long-term care facilities only provide high fiber menus and diets to patients because long-term use of a fiber-restricted diet is generally not recommended as it is believed to be associated with constipation, diverticular disease, endometrial cancer, type 2 diabetes, and may aggravate symptoms during non-acute phases of disease. (Note: Fiber intake should be increased gradually and adequate amounts of liquid should be consumed.)

According to the AND diet manual, a fiber-restricted diet is often ordered to reduce the frequency and volume of fecal output while prolonging intestinal transit time and to prevent blockage of a stenosed GI tract. The diet can be used during acute phases of ulcerative colitis, Chron's disease, and diverticulitis. The diet may also be used preoperatively to minimize fecal volume and residue and postoperatively during the progression to a "general" diet. Ingestible carbohydrate intake is reduced by using limited amounts of well-cooked or canned vegetables and canned, cooked, or very ripe fruits, and by replacing whole-grain breads and cereals with refined products. Legumes, seeds, and nuts are omitted. Adherence to the guidelines generally results in a diet that contains <10 grams of fiber per day.

On the other hand, a high-fiber diet is used to increase fecal bulk and promote regularity, normalize serum lipid levels, and stabilize blood sugar levels. A high-fiber diet can be used in the prevention or treatment of various GI, cardiovascular, and metabolic diseases and conditions including diverticular disease, cancer of the colon, diabetes, endometrial cancer, constipation, IBS, Chron's disease, hypercholesterolemia, and obesity. The high-fiber diet is a general diet with an emphasis on fiber-rich food sources including fruits, legumes, vegetables and whole-grain breads, cereals, and other products made from whole grains. Experts recommend a daily dietary fiber intake of 20-35 grams from a variety of food rather than supplement sources as part of a healthful diet.

According to page 6 of the IMPAC diet manual, first introduced in Unit 4 Preparations, what is the description of a high-fiber diet?



According to page 11 of the IMPAC diet manual, when is a high-fiber diet appropriate?




According to the ADA, how many grams of fiber should be included in a high fiber diet per day?


Does the IMPAC diet manual have a low-fiber diet? Why do you think this is the case?




Most low-fiber diets do NOT restrict soluble fibers. Why do you think this is the case? (This question is asking you to draw on your previous nutrition course knowledge base when soluble and insoluble fibers were discussed. Note: Most foods contain a combination of BOTH soluble and insoluble fiber.)




Categorize the following foods as either high-fiber or low-fiber:

Choose one of the online nutrition resources below and answer the questions that follow:
   1. Which online resource did you choose?

   2. What was the most interesting or surprising thing you learned? (Be specific.)






End of Week 8 Unit Preparations

After filling in ALL of the blanks to the questions in your Outline go to the
 "Unit 8 Study Questions" under Week 8 in Moodle to submit your answers.
(Note: If you take the quiz after the due date, please send me a message. It will probably not be graded
until you do that as I may not realize it was done. I can do this ONE time.)