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| Dental Diseases and Mouth Problems |
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Definition
| Carbohydrates start being broken down in the mouth. Bacteria reside in our mouth which ferments sugars, and in the process produces acid which can dissolve tooth enamel. The bacteria can grow on teeth as a gummy mass, called dental plaque. After a while, the plaque and bacteria expose the teeth to enough acid that the teeth begin to decay, resulting in dental caries (cavities). To prevent cavities you should limit between meal snacks containing sugars and starches, and brush and floss teeth regularly (at least twice a day). If brushing and flossing are not possible after eating, you should at least rinse the mouth with water. Bi-annual oral exams and cleaning with your dentist and dental hygienist are also recommended to assess dental health. |
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Periodontal disease may develop if the teeth are not kept clean and healthy. Periodontal disease refers to inflammatory conditions involving the periodontium, tissues that support the tooth in its bony socket (gingiva, connective tissues, and bone underneath). Gingivitis is a disease characterized by redness, bleeding, and swelling of gum tissue. Periodontitis is the inflammation of tissues surrounding the tooth, which may cause tooth loss if untreated. Factors that increase one's risk of getting periodontal disease include dental plaque, smoking, and impaired immunity. Signs and symptoms include gingivitis (bleeding, swollen, tender gums), the gaps between infected gum and tooth deepen, and a bad taste in the mouth and/or persistent bad breath can develop. Treatments for these problems include more frequent exams and cleanings, anti-microbial rinses, antibiotics, and possibly surgery.
During childhood, minerals such as calcium and phosphorus are important because they help with tooth formation. Vitamin D is also important for the absorption of calcium. Magnesium helps hold calcium into the tooth enamel. Fluoride is also important, especially during the childhood years while the teeth are forming, because it can help prevent tooth decay. Deficiencies of several vitamins and minerals have been linked to periodontal disease. In particular, a deficiency of vitamin C, especially among smokers, significantly increases the risk and is one of the primary causes of bleeding gums. Chewable vitamin C supplements should be avoided however, since vitamin C is an acid which can break down tooth enamel. |
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| Diabetes mellitus. Periodontal disease is more prevalent among people with diabetes mellitus, especially those whose diabetes is poorly controlled. People with diabetes often have impaired immune responses and a greater susceptibility to infections. Diabetes also favors the growth of bacteria that tend to infect periodontal tissues. People with diabetes tend to have higher plaque accumulations and dry mouth. In addition, the damaging effects of hyperglycemia weaken the collagen structure of dental tissues, making them more vulnerable to destruction. |
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| Human immunodefi ciency virus |
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Definition
| Human immunodefi ciency virus (HIV)/AIDS. HIV infection is characterized by compromised immunity, and the risk of developing periodontal disease is closely linked to the extent of HIV infection. Th ose at greatest risk include smokers, individuals who decline therapy, and patients in the advanced stages of disease.In untreated persons, fungal and viral infections are common and may cause burning in the mouth and painful ulcerations. HIV-infected individuals oft en have dry mouth as a result of medications or salivary gland dysfunction. |
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| Oral cancers. Radiation treatment of oral cancers often causes serious oral and dental complications.Inflammation and tissue damage can be so severe that the radiation treatment may need to be halted or the intensity signifi cantly reduced. Dry mouth is a common side eff ect of radiation therapy. Other complications include fungal and viral infections, changes in taste sensation, and tissue and muscle scarring (which often reduces chewing ability). To minimize complications, dental care is often initiated before radiation therapy begins. |
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| Smoking is one of the biggest risk factors for periodontal disease. It depletes calcium, vitamin C and the B vitamins, especially folic acid which is important for tissue healing. It also diminishes the number of small blood vessels, which decreases the ability of our gum tissue to remove toxins and receive nutrients and infection-fighting antibodies. Obesity has also been shown to be a risk factor for periodontal disease in several studies. The link is thought to be a hyper-inflammatory response as a result of increased body fat. Bone loss, as seen with osteoporosis, has been linked to periodontal disease as well. |
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Definition
| Dry mouth is another condition that can affect teeth and the oral cavity. Many medications reduce saliva production. Other conditions and treatments like poorly controlled diabetes, radiation therapy, and problems with the salivary glands can cause this. Dry mouth can impair health by interfering with speech, and can cause bad breath, mouth infections, difficulty chewing or swallowing, discomfort, and ulcerations from dentures. |
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| Periodontal Disease Can Increase Diseases |
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Definition
| Poor dental health can increase one's risk for other diseases. The bacteria in the mouth can enter the bloodstream and cause other infections and respiratory problems. The blood vessel cells attacked by bacteria as seen with gingivitis can cause arteriosclerosis and heart disease. In patients with diabetes mellitus, periodontal disease can make it difficult to obtain blood glucose control. Tooth loss related to periodontal disease can obviously increase the risk for malnutrition, due to limited food choices. |
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Definition
| Systemic inflammation. The inflammatory process induced by periodontal disease increases levels of cytokines and other mediators that have systemic effects. Systemic inflammation may contribute to the development of certain chronic illnesses, including heart disease and diabetes. |
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Term
| Atherosclerosis and heart disease |
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Definition
| Atherosclerosis and heart disease. Oral bacteria are frequently found residing in the arteries of people with atherosclerosis, where they may induce the release of infl ammatory mediators that promote atherosclerosis. Studies suggest that severe periodontal disease may increase the risk of cardiovascular disease by 25 to 90 percent.11 |
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| Diabetes mellitus. Th e chronic infl ammation caused by periodontal disease is a potential risk factor for the development of type 2 diabetes. Severe periodontal disease has also been linked to poor glycemic control in persons with diabetes. |
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| Respiratory illnesses. The teeth of hospital patients often become colonized with bacteria that cause respiratory illnesses. In one research study, only patients whose teeth were colonized by respiratory pathogens ended up with pneumonia. |
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| Diet to Prevent Periodontal Disease |
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Definition
Sugar intake is a concern in regards to tooth decay. Sugar helps form plaque which sticks to the teeth and can erode the tooth enamel, leading to cavities. Of particular concern are foods that are sticky, such as candy. Frequent consumption of juice, soda, and other sugary beverages can also greatly increase the risk of tooth decay. Tooth decay can be avoided by brushing the teeth after meals and snacks. On the other hand, some carbohydrate or high sugar foods such as apples and dairy have been shown to actually decrease the risk of tooth decay.
All simple sugars can cause tooth decay, but several factors determine whether or not caries are likely to develop. Foods that stick to the teeth (such as caramel candies and 'fruit chews') are more likely to stay longer allowing the bacteria to act on it for longer. Sugar in liquid form tend to leave the mouth quickly and are less likely to lead to tooth decay. However, sugary drinks such as orange juice, soft drinks and some sports drinks have a high acidity that also increases likelihood of dental caries developing. How often a person consumes sugar also plays a role in it. Bacteria produce acid for approximately 20-30 minutes after consuming high-sugar foods. The more often sugary foods are eaten, the longer the acid is produced, increasing the erosion of the enamel. Non-sugary foods can help decrease the effects of the acid, so eating sugar with meals is better than between meals. Milk and cheese products also have been shown to protect and restore the enamel of teeth. |
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| Diet for Dental and Mouth Problems |
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Definition
| When dentition or mouth pain interferes with the ability to consume adequate nutrients, a change in diet consistency should be considered. Either a mechanical soft or pureed diet can be used to provide the comfort and safety necessary. The mechanical soft diet provides foods that require less chewing. The diet limits meat and chicken to ground consistency, and allows only well cooked vegetables, and canned fruits. In more severe dental problems, a pureed diet may be chosen. This diet requires all solid foods to be blended into a pureed consistency. |
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Dysphagia, or difficulty swallowing, can be caused by aging, nervous system diseases, injuries, developmental disabilities, and stroke. It sometimes goes undiagnosed and is dangerous. Aspiration, the drawing of food, gastric secretions or liquids into the lungs, may occur with dysphagia. A speech language pathologist (SLP) will assess if a person has dysphagia by administering swallowing tests. He/she will also treat and teach the person how to swallow safely again, if possible.
Signs of dysphagia include an unexplained decrease in food intake or appetite, pneumonia, pain on swallowing, weight loss, fear of eating, feeling that food gets stuck, tendency to hold food in mouth, coughing or choking during meals, frequent throat clearing, drooling, and change in voice quality (voice sounds wet or gurgled). Diagnosis can be done by providing the person with different food consistencies. The person will eat the food and the SLP can assess visually and by feeling the throat if there are any signs of swallowing problems. If it appears that there may be dysphagia, a MBS (modified barium swallow test) will be ordered. Here, barium is placed in different consistency foods. The person swallows this food and is X-rayed. The test will show if the food is being swallowed properly or if it is entering the lungs. |
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| The physician, speech therapist, and dietitian work together to prescribe the most appropriate diet. Dysphagia diets typically include diet consistency changes in food and thickened liquids. Appropriate body positioning during meals, such as sitting upright at a 90-degree angle with supervision at all meals may also be needed. Sometimes it will be determined that it is unsafe for a patient to eat orally. The patient's diet order will be NPO (nothing by mouth), and the person will need to obtain nutrition via an alternate route, usually by a feeding tube. The dysphagia diet varies depending on the facility. The National Dysphagia diet is divided into three levels with an option of a Dysphagia Pureed, Dysphagia Mechanically Altered, and Dysphagia Advanced. With each of these levels the patient may tolerate one of four liquid consistencies including thin, nectarlike, honeylike. and spoonthick. |
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| Level 1: Dysphagia Pureed |
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Definition
Level 1: Dysphagia Pureed
Foods should be pureed or well mashed, homogeneous, and cohesive. This diet is for patients with moderate to severe dysphagia and poor oral or chewing ability.
Sample menus:
Breakfast: Cream of wheat, slurried muffi ns or pancakes,a pureed scrambled eggs, plain or vanilla yogurt, well-mashed bananas, fruit juice without pulp (thickened as needed), coffee or tea (if thin liquids are acceptable).
Lunch or dinner: Pureed tomato soup, slurried crackers, pureed meat or poultry, zucchini souffl é, mashed potatoes with gravy, pureed carrots or green beans, smooth applesauce, pureed peaches, chocolate pudding.
Foods to avoid: Dry breads and cereals, oatmeal, rice, fruit yogurt, cheese (including cottage cheese), peanut butter, nuts and seeds, raw fruits and vegetables, chunky applesauce, fruit preserves with chunks or seeds, tomato sauce with seeds, beverages with pulp,
coarsely ground pepper, herbs. |
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| Level 2: Dysphagia Mechanically Altered |
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Definition
Foods should be moist, cohesive, and soft textured and should easily form a bolus. This diet is for patients with mild to moderate dysphagia; some chewing ability is required.
Sample menus:
Breakfast: Moist oatmeal, cornfl akes or puffed rice cereal with milk (thickened as needed), moist pancakes or muffi ns (with butter, margarine, or jam; without nuts or seeds), soft scrambled eggs, cottage cheese, ripe bananas or cooked fruit without skin or seeds, fruit juice (thickened as needed), coffee or tea (if thin liquids are allowed).
Lunch or dinner: Soup with easy-to-chew meat and vegetables; slurried bread or crackers; minced, tender-cooked meat; wellcooked pasta with moist meatballs and meat sauce; baked potato with gravy; soft, tender-cooked vegetables (not fi brous or rubbery); canned peach slices; soft fruit pie (with bottom crust only); soft, smooth chocolate bar.
Foods to avoid: Dry or coarse foods; breads and cereals with nuts, seeds, or dried fruit; frankfurters and sausages; hard-cooked eggs; corn and clam chowders; sandwiches; pizza; sliced cheese; rice; potato skins; french fries; raw vegetables; fi brous, rubbery, or nontender cooked vegetables such as asparagus, broccoli, brussels sprouts, cabbage, celery, corn, and peas; peanut butter;coconut; nuts and seeds; raw fruit (except banana); cooked fruits with skin or seeds; pineapple; mango; uncooked dried fruit; popcorn; chewy candies (such as caramel or licorice). |
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| Level 3: Dysphagia Advanced |
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Definition
Foods should be moist and be in bite-sized pieces when swallowed; foods with mixed textures are included. This diet is for patients with mild dysphagia and adequate chewing ability.
Sample menus:
Breakfast: Cereal with milk, moist pancakes or muffi ns (with butter, margarine, or jam; without nuts or seeds), poached or scrambled eggs, fruit yogurt, soft fresh fruit (peeled) or berries, coffee or tea (if thin liquids are tolerated).
Lunch or dinner: Chicken noodle soup; moistened crackers or moist bread; thin-sliced tender meat; cheese; moist, soft-cooked potatoes or rice; tender-cooked vegetables; shredded lettuce with dressing; fresh, peeled peach or melon; canned fruit salad; moist chocolate chip cookie (without nuts).
Foods to avoid: Dry or coarse foods; breads and cereals with nuts, seeds, or dried fruit; corn and clam chowders; potato skins; raw vegetables (except shredded lettuce); corn; chunky peanut butter; coconut; nuts and seeds; hard fruit (such as apples or pears); fruit with skin, seeds, or stringy textures (such as mango or pineapple); uncooked dried fruit; fruit leathers; popcorn; chewy candies (such as caramel or licorice). |
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Thin: Watery fl uids; may include milk, coffee, tea, juices, carbonated beverages.
Nectarlike: Fluids thicker than water that can be sipped through a straw; may include buttermilk, eggnog, tomato juice.
Honeylike: Fluids that can be eaten with a spoon but do not hold their shape; may include honey, tomato sauce, yogurt.
Spoon-thick: Thick fl uids that must be eaten with a spoon and can hold their shape; may include milk pudding, thickened applesauce. |
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| Concerns with Consistency-Altered Diets |
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Definition
| When the diet consistency is changed, individuals frequently do not eat as much. Some of the loss of oral intake is attributed to not liking the consistency of the food, but many times it is related to loss of appetite do to medications or to illness. Whatever the reason, careful monitoring of oral intakes in the population is essential. If changes in the liquid thickness are made, careful observation of hydration status must monitored (especially if a simple IV is not infusing). Health care staff should monitor fluid intakes and outputs, labs and weights. |
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Term
| The Esophagus and Stomach |
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Definition
| The esophagus is the tube that carries the food (a swallow bolus) to the stomach. Once in the stomach, water, hydrochloric acid, and additional mucus is added, the food becomes liquefied, and is now called chyme. Conditions such as gastrointestinal reflux disease (GERD) can cause chyme to back up into the esophagus and irritate it, causing symptoms such as pain, burning (often called "heartburn"), and chest pains. Because the the stomach contents are highly acidic, chronic GERD that is not treated can lead to esophagitis (inflammation of the esophagus), bleeding, and possibly esophageal cancer. Much of the condition of GERD is attributed to lifestyle. Over filling the stomach (overeating) allows contents of the stomach to reflux up into the esophagus more easily. There are several factors that decrease the Lower Esophageal Sphincter (LES) muscle, allowing stomach contents to reflux more easily such as: alcoholic beverages, caffeine, chocolate, cigarette smoking, garlic, high fat foods, ions, peppermint/spearmint and several medications. |
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Definition
Gastritis is the inflammation of the stomach lining, which can be very painful. Common complaints with this include weight loss, lack of appetite, vomiting, and epigastric pain. Acute Gastritis often occurs with the repeated use of some medications that can irritate the stomach, such as aspirin. Alcohol abuse, food irritants, food allergies, food poisoning, radiation therapy, metabolic stress, and bacterial infections can cause acute gastritis as well. Helicobacter pylori infection is the most common cause of gastritis. Chronic Gastritis may be associated with aging and is characterized by cellular destruction. Many people with chronic gastritis also have pernicious anemia, caused by vitamin B12 deficiency. Vitamin B12 is unable to be absorbed from the diet due to the lack of intrinsic factor. Iron deficiency anemia is also common because of possible blood loss and difficulty absorbing iron due to the lack of stomach acid. Treatment includes no foods by mouth for 2-3 days if nausea and vomiting exist, and then advance the diet as tolerated to a bland diet. A more liberal bland diet can be followed for those with the chronic form of gastritis. The liberal bland diet goal is to aid the neutralization of gastric acidity. Spices and highly seasoned foods are omitted. Broth, coffee, tea and pepper are usually avoided since they stimulate gastric secretion. Whole grain products and foods containing nuts, skins and seeds are omitted. Antacids, anti-secretory medications, and antibiotics may also be used.
Liberal Bland Diet patient education. (opens in new window) |
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| Ulcers are open sores or lesions, which can be very painful. Infection with Helicobacter Pylori bacteria is the number one cause of peptic ulcers because it destroys the mucosal cells. Other possible causes of peptic ulcers include abuse of anti-inflammatory medications (such as aspirin) and excessive gastric excretions such as with Zollinger–Ellison Syndrome. Stress can also aggravate peptic ulcers. Zollinger-Ellison syndrome results from a tumor of the pancreas that produces the hormone gastrin, which stimulates an increase in gastric juices. Treatment for peptic ulcers can involve drug therapy, primarily using antibiotics to kill the helicobacter pylori bacteria, and anti-secretory medications to decrease hydrochloric acid production. Behavioral changes, along with following a liberal bland and/or a low fat diet, may also be recommended. If left untreated, gastrointestinal bleeding may result. |
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| Gastric surgery has become very popular as an effective treatment for severe obesity. It is also used to treat severe cases of stomach problems, such as peptic ulcers. It may be necessary in the treatment of stomach cancer. It is possible to live without a stomach, although the person will have many complications and nutritional challenges. If possible, only the damaged areas of the stomach are removed. A Gastrectomy is surgery to remove all or part of the stomach. Pyloroplasty is surgery that enlarges the pyloric sphincter (junction between stomach and small intestine), and vagotomy is surgery that prevents the stimulation of gastric secretions. The three types of gastrectomy are seen in the graphic below. Note that with each of these surgeries, the pyloric sphincter (bottom of the stomach that controls the rate at which chyme enters the small intestine) is removed. In two of the surgeries, the second portion of the small intestine (duodenum) is bypassed as well, leaving a blind loop. Generally, surgeons leave the blind loop because the gallbladder secretes bile directly into it. Unfortunately, bacterial overgrowth can occur in this area. Bypassing these two important sections of the intestinal tract present additional complications that will be discussed later in this module. |
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Bariatric surgery is any type of elective stomach surgery to treat obesity. For example, Gastric Partitioning or Gastric Bypass surgeries limit the size of the stomach (about 1/2 cup) to decrease food intake, in order to treat the morbidly obese. Like any surgery, bariatric surgery is not without risks. Although most people that elect bariatric surgery lose a substantial amount of weight, complications such as life-threatening infections and gastrointestinal problems can occur, and the person needs to be informed of the risks before undergoing the procedure.
In most cases, to be approved for bariatric surgery the person needs to have a BMI above 40 (morbidly obese) or BMI 35-40 with at least one co-morbid condition associated with the obesity. Physicians need to document the surgery as "medically necessary". Most insurance companies also require the patient to undergo both nutrition counseling and psychological counseling before approving the surgery. In many cases, bariatric surgery is considered the "last resort" for some people to lose weight and increase the odds of having a normal life expectancy.
A person who elects bariatric surgery needs to have realistic expectations. Although most people will lose a dramatic amount of weight quickly, it is not a "quick fix" for their medical problems, and most people do not live happily ever after. If the person is suffering from binge-eating disorder related to psychological issues, the surgery may actually make their problems worse and they would not be a good candidate for the surgery. The person also needs to realize that after extensive weight loss, they will have a considerable amount of skin hanging and may need further surgeries to remove the excess skin. Unfortunately, most insurance companies consider surgeries such as a "tummy tuck" as cosmetic, and do not pay for the procedure. |
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| Types of Gastric Partitioning |
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Definition
Two of the most common types of gastric partitioning include Vertical Banded Gastroplasty and Gastric Bypass.
The Vertical banded gastroplasty is referred to as restrictive surgery. It forms a small pouch with staples and a band forcing the individual to eat smaller amounts of food. This procedure has less success with weight loss (only 30% achieve ideal weight) than with the Gastric Bypass. Successful results depend on the patient's willingness to adopt a long-term plan of healthy eating and regular physical activity. Gastric Bypass is referred to as malabsorptive surgery. This procedure creates a small pouch at the top of the stomach with staples, then reroutes the jejumum (second portion of the small intestine) to attach directly to the pouch. The result is restriction of food through the smaller stomach and malabsorption of nutrients by eliminating use of the lower portion of the stomach and the first portion of the small intestine. This produces a more successful weight loss (most lose 2/3 of their weight in 2 years), but has much more severe complications including more nutrient losses. |
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| Consequences of Gastric Surgery |
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Definition
Ten to 20 percent of patients who have weight-loss surgery require follow-up operations to correct complications. After gastric surgery, many people experience weight loss, nutrient deficiencies, early satiety, pain, reflux, dumping syndrome, fat malabsorption, steatorrhea, and bacterial overgrowth. Dumping Syndrome is a common complication which refers to a group of symptoms resulting from abnormally rapid gastric emptying into the small intestines. Dumping Syndrome occurs after surgery (whether gastric bypass or gastrectomy) when the pyloric sphincter is bypassed. Partially digested foods rapidly enter the jejunum and create a concentrated mass. Due to the increased concentration in the jejunum, fluid from the intestinal capillaries enters the jejunum resulting hyperperistalasis and diarrhea. This leaves diminishing blood volume resulting in low blood pressure and weakness. The simple sugars in the jejunum are quickly absorbed into the blood stream causing a release of insulin. Unfortunately, since the entire stomach contents dumped into the small intestine, there is no more carbohydrate to enter the blood stream. With the high levels of insulin, blood sugars plummet causing hypoglycemia and dizziness. Not all people have these side effects and some can adapt with treatment. However, most are likely to exhibit this complication, so a specialized diet is generally ordered anytime the pyloric sphincter is bypassed.
To prevent dumping syndrome, the person should limit concentrated sweets and avoid excess carbohydrate. Instead, meals should be higher in fat and protein. Fluids should not be consumed with meals.
Nearly 30 percent of patients who have weight-loss surgery develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease secondary to poor intakes. Fat malabsorption is a common problem when the duodenum is bypassed. During digestion, bile enters the small intestine as fat is released into the duodenum. In the case of a blind loop, no food contents enter that section of the intestine to notify the gall bladder. Without adequate bile, fat is not absorbed well, and fat malabsorption can occur. Over time, the body is likely to adapt, but distention, weight loss, and diarrhea may occur for a period of time. Bacterial overgrowth that occurs in blind loop can also cause fat malabsorption as will be discussed later in this module.
Anemia can result after gastric surgery for several reasons. Inability to absorb vitamin B12 can occur because of the lack of intrinsic factor being produced in the stomach. Iron is also less absorbed without the acidic environment of the stomach. Bone disease can develop due to the malabsorption of fat and fat-soluble vitamins, especially vitamin D. Lactose intolerance is also very common. Dietary adjustments can help minimize or prevent these consequences.
Nutrition-related concerns include the following:
Protein intake. Th e protein recommendation for bariatric patients is 1.5 grams of protein per kilogram of body weight per day; however, intakes are oft en lower than recommended.27 Patients are generally instructed to eat high-protein foods before consuming other foods in a meal and to consume liquid protein supplements regularly.
Vitamin and mineral defi ciencies. Bariatric patients have a high risk of developing nutrient defi ciencies due to reduced food intake and nutrient malabsorption. Supplemental vitamin B12, iron, and calcium are usually recommended after surgery. In addition, a daily multivitamin/mineral supplement ensures that patients meet their needs for other nutrients.
Foods to avoid. Some foods must be avoided because they may obstruct the gastric outlet. Problematic foods include doughy or sticky foods such as pasta, soft breads, dried fruit, and melted cheese; fi brous vegetables such as asparagus and celery; foods with seeds, peels, or skins; and tough or chewy meats.
Dumping syndrome. To avoid symptoms of dumping syndrome, gastric bypass patients must carefully control food portions, avoid foods high in sugars, and consume liquids between meals.
Other complications that can occur with gastric surgeries include wound infections, leaks from staple line breakdown, marginal ulcers and various pulmonary problems.
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| Diet Following Gastric Surgery |
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Definition
ollowing gastric surgery, the individual must slowly adjust to introduction of foods. Initially, a patient's post surgical care includes no foods by mouth for about 1-7 days. This allows the surical site a chance to heal before food is introduced. Although not common, the person may be given nutrition intravenously while NPO. On post-operative day 1 or 2, the person may be given sips of water as tolerated. If all is going well medically, the diet will slowly advance. Each stage is very important to introduce correctly. The stomach has been altered and reduced to a smaller size. One of the main functions of the stomach is mixing and churning, which is part of the mechanical breakdown of food. Post surgery, we takes weeks to get those muscles back into shape to take over the function again. On day 3 or 4, clear liquids can be attempted. See module 1 for more information on the foods allowed within this diet. Liquids are retricted to sugar-free, low sodium and caffeine free products. On post-operative day 4 or 5, a "no concentrated sweets" full liquid diet can be started. In this stage, liquids with a higher protein content can be included. Approximately 2 weeks after surgery, pureed foods such as cottage cheese, pureed eggs, and blended soups can be added. If tolerated, the consistency can be advanced to semi-sold foods such as tuna fish and canned fruits in water. From the 6th-13th week after surgery, solid foods are included. The person must follow a postgastrectomy diet for the rest of their life.
A postgastrectomy diet limits carbohydrate and simple sugars. Intake is very small at first and includes about 3-5 ounces per meal. The person needs to chew food very carefully due to part of the stomach and its mechanical function being absent. The person must eat slowly and have small, frequent meals because of the decreased stomach size. The person can only drink liquids in small amounts and cannot have liquids with meals. Beverages should be consumed 45 minutes before or after a meal to prevent fullness. The person is advised not to lie down right after eating, and may need to limit lactose.
People must be made aware that high fat and high calorie foods will cause a regain of the weight lost after bariatric surgery. They need to follow the prescribed diet and choose foods that are nutrient dense, especially foods that are high in calcium, protein, vitamin D, and the B vitamins in order to prevent deficiencies. |
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Constipation is the condition of having infrequent or difficult bowel movements. Dehydration, aging, hormonal imbalances, certain GI tract diseases, chronic laxative abuse, lack of physical activity, and some herbal products can cause constipation. Medications that can impair GI mobility, such as narcotics, aluminum containing antacids, and blood pressure medications are also likely to cause constipation. Expectant mothers may also suffer from constipation. With pregnancy, hormonal changes can affect the gastrointestinal tract, alter muscle tone, and the growing baby can crowd the intestinal organs.
Treatment for constipation includes an increase in physical activity, increased intake of dietary fiber, and an increase in fluids. The use of laxatives may be needed, but only as a last resort if the other treatments fail. The use of laxatives too frequently can cause laxative dependency, and in the long run make constipation worse. |
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| High fiber diets include foods such as whole grain breads, cereals, fruits, vegetables, and legumes. This diet adds bulk to the diet and normalizes transit time, the time it takes from food consumption to excretion. Fiber should be increased gradually in the diet, and extra fluids should be consumed with it as well. Most people should try to consume 20-35 grams of fiber daily. An intake of more than 40 grams of fiber daily is not recommended because it can prevent the absorption of some nutrients. An uncomfortable side effect of high fiber diets is excessive gas production, which can cause a bloated feeling, abdominal pain, and flatus. Increasing Dietary Fiber (opens in new window) |
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| Flatus is the expelling of gas from the intestinal tract. Bacteria in the intestines metabolize fiber and produces gas in the process. Also, any undigested and unabsorbed food (especially resistant starches) can cause intestinal gas. High fat foods, fructose, and sugar alcohols consumed in large amounts are likely to cause gas. |
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Definition
Acute Diarrhea is likely caused by a viral, bacterial, or protozoal infection. It is a common side effect of medications or herbs. It can also occur when a person starts eating or using tube-feeding after a long period of fasting and/or intravenous fluids. Infants sometimes develop diarrhea when a new formula is started that is not appropriate for the immature GI tract, or when they are ill. Chronic diarrhea can occur as a result of GI disorders such as irritable bowel syndrome, lactose intolerance, and infection. Intractible diarrhea is chronic diarrhea that does not respond to treatment.
The main treatment for diarrhea is to eliminate what is causing the problem, such as a food, medication, or infection. Antidiarrheal medications should only be used if the diarrhea is caused by something other than a toxin in the body, such as with emotional stress. People experiencing diarrhea caused by toxins such as bacteria (foodborne illnesses) and viruses are advised to let the diarrhea run its course in order to remove the undesired substance from the body. The main nutritional goal is to replace lost fluids and electrolytes in order to prevent dehydration. This can be achieved by using fruit juices, caffeine free soda, teas, broth, and crackers.
With chronic diarrhea, the person may want to avoid eating and instead get intravenous nutrition until using the gastrointestinal tract can be tolerated. The diet for diarrhea is highly individualized. Foods that tend to aggravate diarrhea include spicy foods, high fat foods, gas forming foods, lactose, and foods and beverages containing caffeine. It may be helpful to include soluble fiber in the diet to bulk up the stool and absorb water. |
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Definition
Steatorrhea is diarrhea containing unabsorbed fat, due to fat malabsorption. Feces containing excess fat typically have an exceptionally foul odor and will float on the surface of water. Along with the steatorrhea, the person may also have bloating and upset stomach with fat malabsorption. Weight loss and nutritional deficiencies are likely to occur with chronic cases.
Fat malabsorption disorders can involve the stomach, pancreas, intestine, gallbladder, and liver, and can lead to malnutrition. The loss of fat means loss of energy (calories), essential fatty acids, fat-soluble vitamins, and some minerals (calcium & magnesium). Nutrition therapy for steatorrhea includes a high calorie, high protein diet when the person is malnourished. A low fat diet is often needed, especially when steatorrhea is present. A low oxalate diet may be indicated to decrease the risk of kidney stones. Fat-soluble vitamin supplementation is recommended. Digestive enzyme supplementation with meals is needed if the condition is due to chronic and severe damage to the pancreas. |
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Definition
The colon (large intestine) normally contains a certain amount of bacteria. The small intestine is protected from bacterial overgrowth by gastric acid in the stomach and peristaltic actions. However, any condition that can alter gastric acid production may cause bacterial overgrowth. Examples include gastric surgery, anti-secretory medications used with gastritis, HIV infection, bowel obstruction, and nerve dysfunction associated with diabetes, which can alter peristalsis. The high levels of bacteria can dismantle bile salts and therefore cause fat malabsorption. The bacteria also can compete with vitamin B12 and folate absorption.
The treatment for bacterial overgrowth includes surgery, antibiotics to kill the bacteria, and vitamin and mineral supplements. Adding MCT (medium chain triglycerides) oil is often recommended to prevent an essential fatty acid deficiency. MCT oil is a type of fat which is easily absorbed because it does not require bile for absorption. A low fat diet, folic acid supplementation, and vitamin B12 injections are also often included in the treatment. |
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Pancreatitis is a condition where the pancreas is inflamed. The digestive enzymes are activated within the pancreas and begin to damage the organ itself. The blood picks up some of the enzymes, and serum amylase and lipase levels rise and can be an indicator or pancreatitis. Acute pancreatitis most often develops as a consequence of gallstones or alcoholism, and some medications or toxins can also cause it. Nutrition therapy for acute pancreatitis includes an NPO diet with intravenous fluids. Nasogastric suction may be needed to relieve gastric distention and nausea and vomiting. Sometimes jejunal feedings with hydrolyzed formulas may be used. Intravenous nutrition may also be used if there is an ileus, the intestine is not functioning, and there is no peristalsis. Once levels of amylase and lipase normalize, the person can begin consuming liquids. The diet can be advanced as tolerated to a diet low in fat (as fat can increase pancreatic enzymes), and then to a regular diet.
When 'acute attacks' become a chronic condition, permanent damage can occur to the pancreas. Alcohol consumption is responsible for most chronic pancreatitis cases. Nausea, vomiting, and abdominal distention occur. Dietary treatment is the same as acute pancreatitis when the individual experiences an 'attack'. Once alleviated the diet can be advanced. In chronic cases, the permanent damage can lead to diabetes. Nutrition therapy for chronic pancreatitis includes a low fat diet, a low-sugar or diabetic diet, and likely use of digestive enzymes. Alcohol must also be completely avoided, which is obviously difficult for an alcoholic to do. |
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Cystic fibrosis is a genetic disorder characterized by the production of thick mucus that affects many organs, including the pancreas, liver, heart, gallbladder, small intestine, lungs and sweat glands. The thick mucus clogs the ducts of the entire gastrointestinal system, making digestion very difficult. Individuals with cystic fibrosis often have very large appetites, but due to inadequate digestion, they are unable to absorb the nutrients resulting in weight loss, poor bone and muscle mass, and large stools. They sweat excessively with large amounts of electrolyte losses. The life expectancy of a person with cystic fibrosis is only in the 50's. Death most often occurs from respiratory problems. Children with cystic fibrosis tend to have stunted growth and be underweight. Diabetes is also likely to occur. The nutritional goal for cystic fibrosis patients is to obtain and maintain a weight within normal limits, and not go below 85% of the ideal body weight.
High calorie and high protein diets are needed due to the elevated metabolic rate and breathing problems. Enzyme replacement therapy with meals is also needed. A low fat diet is NOT indicated due to the high-energy needs. Generous salt use is recommended because of the excess sweating that occurs, and therefore sodium losses. Breast milk combined with enzymes is appropriate for an infant with cystic fibrosis. Multivitamin and fat-soluble vitamin supplementation is recommended. Many children with cystic fibrosis are given supplemental tube feedings at home, in between normal oral meals, in order to achieve a healthy weight. |
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| Celiac disease (celiac sprue, gluten sensitive enteropathy) is a genetic disorder characterized by a sensitivity to gluten, a protein found in wheat. Celiac disease causes flattening of the intestinal villi, and therefore malabsorption of nutrients. If foods with gluten are consumed, the villi are damaged and malnutrition can result. Therefore, nutrition therapy includes strict compliance of a gluten free diet. The symptoms of celiac disease include distention, bloating, gas, pain, and diarrhea. Having such common symptoms makes diagnosis much more difficult and severe symptoms may not develop until intestinal damage is extensive. |
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| Inflammatory Bowel Disease (IBD) |
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Inflammatory bowel diseases are characterized by inflammation of the bowel (large intestine). They are considered autoimmune disorders where the immune system mistakenly attacks healthy cells. Little is known about what causes any of the autoimmune disorders, but with continued research more is learned each year. There are two types of IBD: Crohn's and Ulcerative Colitis. In Crohn's Disease, there is inflammation and ulceration along the length of the gastrointestinal tract, often with granulomas (tumors or growths that contain foreign organisms surrounded by immune system cells and covered with a fibrous coat). Crohn's disease typically affects the ileum and colon and sometimes the whole GI tract. Symptoms include fatigue, weight loss, abdominal pain, and bloody diarrhea. In Ulcerative Colitis there is inflammation and ulceration of the colon. Symptoms include continuous and sometimes bloody diarrhea, cramping, abdominal pain, anorexia, and weight loss. Iron deficiency anemia may also result in both conditions from the blood loss.
Complications arise as the disease progresses. Fibrous tissues develop, reducing absorption area, and narrowing of the intestines which can cause obstruction. The intestines can also rupture. A fistula, an opening between 2 organs, may develop if an inflamed area of the intestines sticks to another part of the intestine. Treatment includes diet, medications, and sometimes even surgery. Medications are used to decrease inflammation and diarrhea, and to minimize complications. Surgery may be needed if part or parts of the intestine are severely damaged. Nutrition therapy includes an NPO diet while in the active state, and then the diet can be advance as tolerated. Tube feedings may be needed to bypass fistulas or obstructions. Low fiber diets may be recommended to prevent obstructions and decrease diarrhea. Multivitamin supplementation is typically recommended. During the non-active times, a healthy diet is warranted. Food allergies and intolerances are very common in people with IBD, which makes a lot of sense since the immune system is involved. Overall, an individualized diet plan is set-up with a Registered Dietitian to prevent malnutrition. |
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| Dental Diseases and Mouth Problems |
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| Carbohydrates start being broken down in the mouth. Bacteria reside in our mouth which ferments sugars, and in the process produces acid which can dissolve tooth enamel. The bacteria can grow on teeth as a gummy mass, called dental plaque. After a while, the plaque and bacteria expose the teeth to enough acid that the teeth begin to decay, resulting in dental caries (cavities). To prevent cavities you should limit between meal snacks containing sugars and starches, and brush and floss teeth regularly (at least twice a day). If brushing and flossing are not possible after eating, you should at least rinse the mouth with water. Bi-annual oral exams and cleaning with your dentist and dental hygienist are also recommended to assess dental health. |
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| Dental Diseases and Mouth Problems |
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Definition
| Carbohydrates start being broken down in the mouth. Bacteria reside in our mouth which ferments sugars, and in the process produces acid which can dissolve tooth enamel. The bacteria can grow on teeth as a gummy mass, called dental plaque. After a while, the plaque and bacteria expose the teeth to enough acid that the teeth begin to decay, resulting in dental caries (cavities). To prevent cavities you should limit between meal snacks containing sugars and starches, and brush and floss teeth regularly (at least twice a day). If brushing and flossing are not possible after eating, you should at least rinse the mouth with water. Bi-annual oral exams and cleaning with your dentist and dental hygienist are also recommended to assess dental health. |
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Each part of the intestine absorbs different nutrients and is specialized. Short bowel syndrome is the malabsorption that may occur when surgery is done to a part of the intestine. It may result in diarrhea, weight loss, bone disease, anemia, and low blood levels of calcium and magnesium. About 50% of the intestines can be removed without any major complications, and in some people, up to 80% resection may also be tolerated if the last section of the small intestine connecting to the bowel is intact.
After surgery, bowel adaptation causes the remaining portion of bowel to get longer, thicker and wider. It also adapts to absorb nutrients it didn't before. Bowel adaptation is initiated by the presence of undigested food material, so early nutrition intervention is ideal. Adaptation is also enhanced by the amino acid glutamine, short chain fatty acids, and growth hormone. Initially after surgery, the bowel must rest and heal for a period of time. Therefore, the patient will be NPO. Intravenous nutrition may be necessary, but oral nutrition or tube feeding should be started as soon as possible to stimulate bowel adaptation. The diet can be advanced to an oral diet as tolerated. An individual food plan is needed, as nutrients may need to be supplemented or restricted in respect to the portion of the intestines that was removed. |
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Irritable Bowel Syndrome is an intestinal disorder of unknown causes. Here, there is an alteration in stool frequency and consistency, so the person can alternate back and forth between diarrhea and constipation. Other signs and symptoms can include abdominal pain, flatulence, and bloating, which is likely to occur after a meal. Stress and anxiety are associated with the onset and worsening of symptoms. Unlike with inflammatory bowel diseases, there is no damage to the gastrointestinal tract.
The main treatment is stress management, but can also include medications such as antidepressants, laxatives, and diarrhea medications. Individual diet planning also needs to be included. The diet may include an increase in dietary fiber and a decrease or avoidance of foods high in fat, spices, lactose, caffeine, and alcohol. People with IBS are advised to monitor their symptoms and avoid the foods that seem to cause them. In contrast to most conditions, IBS tends to get better with age.
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Diverticula are sacs or pouches that develop in the weakened areas of the intestinal wall. Diverticulosis is the condition of having diverticula, although some people are unaware that they have the disease. The prevalence of diverticulosis increases with age, occurring in about half of adults over 60 years of age. Sometimes fecal material and bacteria can get trapped in the diverticula and become inflamed and often infected.. This condition of diverticulitis, can be very painful with accompanying diarrhea, constipation, and bleeding. Often fistulas develop when the infection spreads to adjoining organs. Management of the two disorders are uniquely different. Low fiber diets are the main cause associated with diverticular disease.
A high fiber diet is necessary to stimulate the muscles and maintain the bowel walls. Often a physician will recommend avoiding nuts, seeds and corn in an attempt to prevent them getting trapped in the diverticula (pouches) leading to diverticulitis. However, research cannot dispute or justify this recommendation. Hardened stool irritating the mucosal lining is another likely cause of diverticulitis. The primary nutritional goal in diverticular disease is preventing diverticulitis by preventing constipation. If a person fears consuming high-fiber foods containing skins and seeds, they will need to find alternate fiber sources. The emphasis should be on obtaining adequate fiber (25-35 grams per day) and avoiding the small, hard seeds and unpopped hulls that are not chewed. Obviously, adequate fluid intake and regular physical activity will be important in preventing constipation. However, when the bowel is inflamed (diverticulitis), the area must be allowed to heal. Usually, the person will be hospitalized and may be NPO upon diagnosis, and then the diet will be advanced to a low residue diet, as tolerated. Within a few weeks, a high fiber diet can be resumed. The temporary low residue diet limits the amount of fruits, vegetables, whole grains and milk. It can be very confusing to someone who has always been told to eat a diet high in fiber to prevent complications. Explaining the importance of allowing the bowel to heal and providing dates for how long the diet is followed can help alleviate some of the confusion. |
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| Colostomies & Ileostomies |
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Definition
Surgery may be needed to temporarily allow the intestines to heal. In some cases the intestines may be severely damaged and can never be used again. A colostomy is a surgery that creates an opening (a stoma) in the colon through the abdominal wall and out through the skin. An ileostomy is a surgery that creates an opening from a portion of the ileum of the small intestines through the abdominal wall and out through the skin. A pouch placed over the stoma collects feces. Permanent colostomies are performed when there is intestinal obstruction, lesions, tumors and part or all of the colon is removed. Temporary ostomies allow the bowel to heal. Nutrition therapy post-operatively includes an NPO diet and slowly progresses to a low residue diet in order to prevent obstructions. Stringy or tough foods such as celery, spinach, bean sprouts, dried fruits, and big pieces of any food should be avoided because they can obstruct the stoma.
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People who wear colostomy or ileostomy bags need to consume more fluids because they are absorbing less from the colon. The person is instructed to include foods that control diarrhea and avoid those that create odors and gas, which can be embarrassing. Insoluble fiber does not need to be included in the diet since there is no risk for constipation. People who wear colostomy and ileostomy bags should eat three meals per day to prevent malnutrition.
The stool collected will be very liquidly and odorous. The bags will need to be emptied after each meal. Foods that produce intestinal gas include beans, asparagus, beer, broccoli, brussel sprouts, cabbage, soda, eggs, cauliflower, fish, garlic, and onions. Foods that reduce the odor of intestinal gas include buttermilk, cranberry juice, parsley and yogurt. |
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| Food Safety and Foodborne Ilness |
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Foodborne illness is a concern of public health experts and the food industry. Although the United States has the safest and most plentiful food supply in the world, as many as 76 million Americans experience foodborne illness yearly, and an estimated 5,000 deaths yearly occur from these foods. Many cases of foodborne illness are not even reported, because the symptoms may be mild, or the person assumes they have the flu or other virus. The symptoms of most foodborne illnesses are very similar to those of the flu and include nausea, vomiting, diarrhea, and abdominal pain.
Microorganisms are very prevalent in foods, but luckily a healthy body can defend itself against small amounts. Most foodborne diseases are caused by improper food handling such as poor cooking and storage of food, which can cause microorganisms to multiply on food. Foods left in the "danger zone" too long are likely to grow bacteria. The danger zone of food is 40-140 degrees fahrenheit. Many foodborne illnesses are transmitted by protein-rich foods such as meat, poultry, eggs, cheese, and seafood. Protein encourages bacterial growth if the food is not kept at the proper temperature.
Foodborne diseases can be classified into two types: intoxications and infections. A food intoxication occurs when a chemical or toxin transmitted by food causes the body to malfunction. A foodborne infection occurs as a result of eating a food that contains living microorganisms, such as bacteria, viruses, and parasites. Usually, a food must contain thousands of microorganisms before it will make us sick. People most prone to serious foodborne illnesses include young children, the elderly, and those with compromised immune systems. There are many different types of food intoxications and infections that can affect us. |
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The following guidelines can help prevent a foodborne illness:
Wash hands thoroughly before preparing food
Keep hot foods hot (above 140 degrees Fahrenheit)
Keep cold foods cold (below 40 degrees Fahrenheit)
Do not leave food out at room temperature for more than 2 hours
Thaw meat properly (not on the kitchen counter)
Prevent cross-contamination by sanitizing counters, cutting boards, utensils, etc (with high heat or bleach
Thoroughly reheat leftovers
Thoroughly wash produce before eating
Dispose of food that does not smell right
Thoroughly cook meat, poultry, and eggs before eating
Transfer foods from the grocery store to the home refrigerator or freezer quickly
Do not purchase foods that are not properly sealed
Eat most leftovers within 3 or 4 days
Avoid raw seafood (including oysters)
Do not purchase canned foods that have dents, cracks, or bulges
Throw away store bought foods (especially dairy) if past the expiration date
Frequently clean and sanitize kitchen counters
Thaw meat on the bottom shelf of the refrigerator
Do not thaw frozen foods and then refreeze
Keep raw meats and ready to eat foods separate
Heat canned foods to a high temperature before eating
Don't eat food at a buffet that does not seem to be kept hot enough or cold enough
Do not handle food if you are sick or have a severe acne outbreak |
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Some of the most serious or most common foodborne illnesses include:
Although rare, one of the most deadly foodborne illnesses is botulism. It is caused by an anaerobic bacteria (clostridium botulinum), which produces a toxin in the absence of oxygen. Botulism spores are common in the environment. If botulism spores get into a can of food though, especially a food without much acid, they can multiply rapidly. Canned foods should be heated to a high temperature before the can is sealed to kill any botulism spores. Also, people should heat canned foods to a high temperature before eating. Honey can also contain botulism spores, but is usually not enough to make a healthy person sick. Infants under one year of age should never be fed honey, however.
Another dangerous pathogen that is a serious public health threat is Escherichia coli. E. coli has been associated with large foodborne illness outbreaks over the years, especially with foods such as undercooked meat, sprouts, onions, milk, and fresh apple cider. E. coli is a bacteria that is present in the feces of animals, but it only takes a little to make a person sick from eating it. Illness from E. coli can cause abdominal pain, bloody diarrhea, and possibly kidney failure and death in young children or the elderly. The best way to prevent infection with E. coli is careful food handling.
The two most common foodborne illnesses are Salmonellosis and Campylobacteriosis. The Salmonella bacteria is usually transmitted by cross-contamination, such as spreading it from food to food via cutting boards and utensils. Raw meat, especially poultry, is a known carrier of the bacteria. Eggs are also likely to carry Salmonella, so they should not be eaten raw, and you should always wash your hands after touching eggs. Similar to Salmonella, the Campylobacter jejuni bacteria is by far the most common cause of foodborne illness. Unfortunately, many cases go unreported because the symptoms are similar to the flu, and may not appear until a few days after a person eats the contaminated food.
Listeriosis is an illness caused by consumption of listeria monocytogenes bacteria, which is known to be very dangerous for pregnant women since it will usually cause miscarriage. The food and drug administration (FDA) recommends that pregnant women avoid soft, imported cheeses (such as feta and brie), protein-type spreads, unpasteurized milk and juices, and imported and raw seafood. Pregnant women should also avoid consuming luncheon meats unless they are heated in the microwave first. As with anyone, leftovers should be reheated thoroughly before consuming.
A foodborne illness contracted from a restaurant should always be reported to both the restaurant and the local health department. Your doctor can properly diagnose a foodborne illness from a stool sample. To prevent others from becoming sick, the restaurant should be notified immediately so they can pull the suspected foods and investigate. It is not always the restaurant that is to blame, however. Sometimes poor food handling at home is the cause. |
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Injecting hormones into dairy cows to increase milk production has been a large controversy over the last decade. While it is understandable to be concerned about contaminants in our food, the use of bovine hormones is found to be safe. Even if the milk did contain hormones (natural or synthetic), there is no way for our bodies to absorb a whole protein into our blood stream. It would be broken down in the digestive tract, like all proteins.
The Facts About rbST
Bovine somatotropin (bST) is a hormone that is naturally produced by cows; it directs how energy and nutrients are used for growth and milk production. rbST is a synthesized copy of this naturally occurring hormone
Considerable testing was done before rbST was commercially released, and the FDA has determined that there is no difference between milk from cows treated with rbST and those not given rbST.
Milk from rbST-supplemented cows is safe for human consumption. This has been affirmed and reaffirmed since the use of rbST was approved in the early 1990s.
There are several reasons why bST, which is naturally present in cow's milk, does not have any physiological effect on humans consuming the milk. bST is species-specific, which means that it is biologically inactive in humans. Also, pasteurization destroys 90% of bST in milk. The remaining, trace amounts of bST in milk are broken down into inactive fragments (i.e., constituent amino acids) by enzymes in the human gastrointestinal tract, just like any other protein.
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