20

KEY TERMS
ascites
cholecystectomy
cholecystitis
DIET AND GASTROINTESTINAL
PROBLEMS
cholelithiasis
cirrhosis
colostomy
Crohn’s disease
diaphragm
diverticulitis
diverticulosis
duodenal ulcer
dyspepsia OBJECTIVES
esophagitis
fibrosis
After studying this chapter, you should be able to:
gastric ulcer
gastroesophageal reflux (GER) { Explain the uses of diet therapy in gastrointestinal disturbances
gluten
Helicobacter pylori { Identify the foods allowed and disallowed in the therapeutic diets
hepatitis discussed
hiatal hernia { Adapt normal diets to meet the requirements of clients with these
ileostomy conditions
inflammatory bowel diseases (IBDs)
jaundice
necrosis The gastrointestinal (GI) tract is where digestion and absorption of food occur.
nontropical sprue The primary organs include the mouth, esophagus, stomach, and small and
pancreatitis large intestine. The liver, gallbladder, and pancreas are accessory organs that
peptic ulcers
are also involved in these processes.
stasis
Numerous disorders of the gastrointestinal system cause countless indi-
steatorrhea
stoma viduals distress and consequently affect the nation’s economy because they
total parenteral nutrition (TPN) keep so many people home from work. Some problems are physiologically
ulcerative colitis caused; others can be psychological in origin. It is sometimes difficult to deter-
mine the cause or causes of a GI problem. Consequently, controversy exists in
some cases about proper treatment.

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DISORDERS OF THE PRIMARY ORGANS
Dyspepsia
¶ dyspepsia Dyspepsia, or indigestion, is a condition of discomfort in the digestive tract
gastrointestinal discomfort of vague that can be physical or psychological in origin. Symptoms include heartburn,
origin bloating, pain and, sometimes, regurgitation. If the cause is physical, it can be
due to overeating or spicy foods, or it may be a symptom of another problem,
such as appendicitis or a kidney, gallbladder, or colon disease or possibly cancer.
If the problem is organic in origin, treatment of the underlying cause will be the
normal procedure.
Psychological stress can affect stomach secretions and trigger dyspepsia.
Treatment should include counseling to help the client:
{ Find relief from the underlying stress
{ Allow sufficient time to relax and enjoy meals
{ Learn to improve eating habits

Esophagitis
¶ esophagitis Esophagitis is caused by the irritating effect of acidic gastric reflux on the
inflammation of mucosal lining of the mucosa of the esophagus. Heartburn, regurgitation, and dysphagia (diffi-
esophagus culty swallowing) are common symptoms. Acute esophagitis is caused by
ingesting an irritating agent, by intubation, or by an infection. Chronic, or
¶ gastroesophageal reflux reflux, esophagitis is caused by recurrent gastroesophageal reflux (GER).
(GER) This can be caused by a hiatal hernia, reduced lower esophageal sphincter (LES)
backflow of stomach contents into the pressure, abdominal pressure, recurrent vomiting, alcohol use, overweight, or
esophagus smoking. Cancer of the esophagus and silent aspiration may be life-threatening
for those with gastroesophageal reflux disease (GERD).

Hiatal Hernia
¶ hiatal hernia Hiatal hernia is a condition in which a part of the stomach protrudes through
condition wherein part of the stomach the diaphragm into the thoracic cavity (Figure 20-1). The hernia prevents the
protrudes through the diaphragm into the food from moving normally along the digestive tract, although the food does mix
chest cavity
somewhat with the gastric juices. Sometimes the food will move back into the
esophagus, creating a burning sensation (heartburn), and sometimes food will be
¶ diaphragm
thin membrane or partition
regurgitated into the mouth. This condition can be very uncomfortable.

Medical Nutrition Therapy. The symptoms can sometimes be alle-

viated by serving small, frequent meals (from a well-balanced diet) so that the
amount of food in the stomach is never large. Avoid irritants to the esophagus
such as carbonated beverages, citrus fruits and juices, tomato products, spicy
foods, coffee, pepper, and some herbs. Some foods can cause the lower esopha-
geal sphincter to relax, and these should be avoided. Examples are alcohol,
garlic, onion, oil of peppermint and spearmint, chocolate, cream sauces,
gravies, margarine, butter, and oil. If the client is obese, weight loss may be
recommended to reduce pressure on the abdomen. It may also be helpful if
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Figure 20-1 A hiatal hernia prevents food from moving through the diaphragm into the thoracic cavity.

clients avoid late-night dinners and lying down for 2 to 3 hours after eating.
When they do lie down, they may be more comfortable sleeping with their
heads and upper torso somewhat elevated and wearing loose-fitting clothing.
If discomfort cannot be controlled, surgery may be necessary.

Peptic Ulcers
An ulcer is an erosion of the mucous membrane (Figure 20-2). Peptic ulcers ¶ peptic ulcers
may occur in the stomach (gastric ulcer) or the duodenum (duodenal ulcers of the stomach or duodenum
ulcer). The specific cause of ulcers is not clear, but some physicians believe
that a number of factors including genetic predisposition, abnormally high ¶ gastric ulcer
ulcer in the stomach
secretion of hydrochloric acid by the stomach, stress, excessive use of aspirin
or ibuprofen (analgesics), cigarette smoking, and, in some cases, a bacterium
¶ duodenal ulcer
called Helicobacter pylori may contribute to their development. ulcer occurring in the duodenum
A classic symptom is gastric pain, which is sometimes described as
burning, and in some cases, hemorrhage is also a symptom. The pain is typi- ¶ Helicobacter pylori
cally relieved with food or antacids. A hemorrhage usually requires surgery. bacteria that can cause peptic ulcer
Ulcers are generally treated with drugs such as antibiotics and cimeti-
dine. The antibiotics kill the bacteria, and cimetidine inhibits acid secretion
in the stomach and thus helps to heal the ulcer. Antacids containing calcium
carbonate can also be prescribed to neutralize any excess acid. Stress manage-
ment may also be beneficial in the treatment of ulcers.
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Gastric ulcer

Duodenal
ulcer

Figure 20-2 Peptic ulcers are erosion of the mucous

membrane in the stomach or the duodenum.

Sufficient low-fat protein should be provided but not in excess because

of its ability to stimulate gastric acid secretion. It is recommended that clients
receive no less than 0.8 gram of protein per kilogram of body weight. However,
if there has been blood loss, protein may be increased to 1 or 1.5 grams per
kilogram of body weight. Vitamin and mineral supplements, especially iron if
there has been hemorrhage, may be prescribed.
Although fat inhibits gastric secretions, because of the danger of athero-
sclerosis, the amount of fat in the diet should not be excessive. Carbohydrates
have little effect on gastric acid secretion.
Spicy foods may be eaten as tolerated. Coffee, tea, or anything else that
contains caffeine or that seems to cause indigestion in the client or stimulates
gastric secretion should be avoided. Alcohol and aspirin irritate the mucous
membrane of the stomach, and cigarette smoking decreases the secretion of
the pancreas that buffers gastric acid in the duodenum. Currently, a well-
balanced diet of three meals a day consisting of foods that do not irritate the
client is generally recommended.

Diverticulosis/Diverticulitis
¶ diverticulosis Diverticulosis is an intestinal disorder characterized by little pockets in the
intestinal disorder characterized by sides of the large intestine (colon) (Figure 20-3). When fecal matter collects in
little pockets forming in the sides of the these pockets instead of moving on through the colon, bacteria may breed, and
intestines; pockets are called diverticula
inflammation and pain can result, causing diverticulitis. If a diverticulum
ruptures, surgery may be needed. This condition is thought to be caused by
¶ diverticulitis
inflammation of the diverticula
a diet lacking sufficient fiber. A high-fiber diet is commonly recommended for
clients with diverticulosis.
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Perforation 18%

Hemorrhage 25%

Figure 20-3 Diverticulosis is a disorder characterized

by little pockets forming in the sides of the large intestine.
Rupture of the pockets may result in the need for corrective
surgery.

Along with antibiotics, diet therapy for diverticulitis may begin with a
clear liquid diet, followed by a low-residue diet that allows the bowel to rest
and heal. Then a high-fiber diet will be a initiated. The bulk provided by the
high-fiber diet increases stool volume, reduces the pressure in the colon, and
shortens the time the food is in the intestine, giving bacteria less time to grow.

Inflammatory Bowel Disease

Inflammatory bowel diseases (IBDs) are chronic conditions causing inflam- ¶ inflammatory bowel
mation in the gastrointestinal tract. The inflammation causes malabsorption diseases (IBDs)
that often leads to malnutrition. The acute phases of these diseases occur at chronic condition causing inflammation
irregular intervals and are followed by periods in which clients are relatively in the gastrointestinal tract

free of symptoms. Neither cause nor cure for these conditions is known.
Two examples are ulcerative colitis and Crohn’s disease (Table 20-1). ¶ ulcerative colitis
Ulcerative colitis causes inflammation and ulceration of the colon, the rectum, disease characterized by inflammation
or sometimes the entire large intestine. Crohn’s disease is a chronic progres- and ulceration of the colon, rectum, and
sometimes entire large intestine
sive disorder that can affect both the small and large intestines. The ulcers can
penetrate the entire intestinal wall, and the chronic inflammation can thicken
¶ Crohn’s disease
the intestinal wall, causing obstruction. a chronic progressive disorder that
Both conditions cause bloody diarrhea, cramps, fatigue, nausea, anorexia, causes inflammation, ulcers, and
malnutrition, and weight loss. Electrolytes, fluids, vitamins, and other minerals thickening of intestinal walls, sometimes
are lost in the diarrhea, and the bleeding can cause loss of iron and protein. causing obstruction
Treatment may involve anti-inflammatory drugs plus medical nutri-
tion therapy. Usually a low-residue diet is required to avoid irritating the
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Table 20-1 Crohn’s Disease and Ulcerative Colitis
CROHN’S DISEASE ULCERATIVE COLITIS

Involvement Patchy areas; can involve small and Starts in lower colon and spreads
large intestines progressively throughout colon
Tissue affected Entire thickness of bowel Mucosal lining of the bowel
Major complication Malabsorption Toxic megacolon
Long-term Intestinal obstruction, fistulas, Fissures, abscesses, increased risk for
complications abscesses, perforations; cancer risk colorectal cancer
increases with age
Surgical intervention Usually needed at some point to repair Ileostomy performed in approximately
structural damage; does not cure or 20% of cases to remove the colon;
limit the progress of the disease cures the disease
Cause Unknown; possibly altered immune state Unknown; possibly enteric bacterium
Escherichia coli
Stools 3 to 4 semisoft/day; rarely bloody; 15 to 20 liquid/day; blood present;
steatorrhea (fat in stool), mucus no steatorrhea (fat in stool)
Source: White, L. Foundations of Health and Nursing (2nd ed.) Cengage/Delmar Learning, Clifton Park, NY. 2005.

inflamed area and to avoid the danger of obstruction. When tolerated, the
diet should include about 100 grams of protein, additional calories, vitamins,
and minerals.
¶ total parenteral nutrition In severe cases, total parenteral nutrition (TPN) (a process in which
(TPN) nutrients are delivered directly into the superior vena cava; see Chapter 22)
process of providing all nutrients may be necessary for a period. As the client begins to regain health, the diet
intravenously may be increasingly liberalized to suit the client’s tastes while maintaining
good nutrition.

In The Media
WHAT ARE PROBIOTICS?
Probiotics are live microorganisms (in most cases, bacteria) that are
similar to beneficial microorganisms found in the human gut. They are
also called “friendly bacteria” or “good bacteria.” Probiotics are available
in foods and dietary supplements. Foods that contain probiotics are
yogurt, fermented and unfermented milk, miso, tempeh, and some juices
and soy beverages. In probiotic foods and supplements, the bacteria may
have been present originally or added during preparation. Probiotics are
not the same as prebiotics—nondigestible ingredients that selectively
stimulate the growth and/or activity of beneficial microorganisms
already in the colon. The bacteria “balancing act” can be thrown off in
two major ways: by antibiotics when they kill friendly bacteria as well as
unfriendly bacteria and by “unfriendly” microorganisms, such as disease-
causing bacteria, yeast, fungi, and parasites.
(Source: Adapted from the National Center for Complementary and
Alternative Medicine, National Institutes of Health, 2009.)
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Ileostomy or Colostomy
Clients with severe ulcerative colitis or Crohn’s disease frequently require a
surgical opening from the body surface to the intestine for the purpose of
defecation. The opening that is created is called a stoma and is about the size of ¶ stoma
a nickel. An ileostomy (from the ileum to abdomen surface) is required when surgically created opening in the
the entire colon, rectum, and anus must be removed. A colostomy (from the abdominal wall
colon to abdomen surface) can provide entrance into the colon if the rectum
and anus are removed. This can be a temporary or a permanent procedure. ¶ ileostomy
opening from ileum to abdomen surface
Clients with ileostomies have a greater-than-normal need for salt and
water because of excess losses. A vitamin C supplement is recommended and, ¶ colostomy
in some cases, a B12 supplement may be needed. Eating a well-balanced indi- opening from colon to abdomen surface
vidualized diet will prevent a nutritional deficiency for clients with ileostomies
and colostomies.

Celiac Disease
Celiac disease, also called nontropical sprue or gluten sensitivity, is a disorder ¶ nontropical sprue
characterized by malabsorption of virtually all nutrients. It is thought to be due a disorder of the gastrointestinal tract
to heredity. characterized by malabsorption; also
called gluten sensitivity
Symptoms include diarrhea, weight loss, and malnutrition. Stools are
usually foul-smelling, light-colored, and bulky. The cause is unknown, but
it has been found that the elimination of gluten from the diet gives relief. ¶ gluten
Untreated, it is life-threatening because of the severe malnutrition and weight protein found in grains
loss it can cause.
A gluten-controlled diet (Table 20-2) is used in the treatment of celiac
disease. Gluten is a protein found in barley, oats, rye, and wheat. All products

Table 20-2 Sources of Gluten

FOODS THAT DO NOT FOODS THAT FOODS THAT
FOOD GROUP CONTAIN GLUTEN CONTAIN GLUTEN MAY CONTAIN GLUTEN

Beverage Coffee, tea, decaffeinated Cereal beverages (e.g., Commercial chocolate milk,
coffee, carbonated beverages, Postum), malt, Ovaltine, cocoa mixes, other
chocolate drinks made with beer, ale beverage mixes, dietary
pure cocoa powder, wine, supplements
distilled liquor
Meat and meat Pure meat, fish, fowl, eggs, Commercially breaded Meatloaf and patties, cold
substitutes cottage cheese, and peanut meats cuts and prepared meats,
butter stuffing, cheese foods
and spreads; commercial
souffles, omelets, and
fondue; soy protein meat
substitutes
Fat and oil Butter, margarine, vegetable Commercial gravies, white Commercial salad dressing
oil and cream sauces and mayonnaise, nondairy
creamer

(continued)
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Table 20-2 Continued
FOODS THAT DO NOT FOODS THAT FOODS THAT
FOOD GROUP CONTAIN GLUTEN CONTAIN GLUTEN MAY CONTAIN GLUTEN

Milk Whole, low-fat, fat-free milk; Milk beverages that contain Commercial chocolate milk
buttermilk malt
Grains and grain Specially prepared breads Bread, crackers, cereal and Commercially seasoned rice
products made with wheat starch, rice, pasta that contain wheat, and potato mixes
potato, or soybean flour or oats, rye, malt, malt
cornmeal; pure corn or rice flavoring, graham flour,
cereals; hominy grits; white, durham flour, pastry flour,
brown, and wild rice; quinoa; bran, or wheat germ; barley;
millet; amaranth; sorghum; buckwheat; pretzels;
popcorn; low-protein pasta communion wafers
made from wheat starch
Vegetable All fresh vegetables, plain Commercially breaded vege- Commercial seasoned
commercially frozen or tables or vegetables with a vegetable mixes, canned
canned vegetables cream or cheese sauce baked beans
Fruit All plain or sweetened fruits, Commercial pie fillings
fruit thickened with tapioca or
cornstarch
Soup Soup thickened with Most commercial soup and
cornstarch, wheat starch, or soup mixes; soup that
potato, rice, or soybean flour; contains barley, wheat
pure broth pasta; soup thickened with
wheat flour or other gluten-
containing grains
Desserts Gelatin; custard; fruit ice; Commercial cakes, cookies, Commercial ice cream and
specially prepared cakes, and pastries; commercial sherbet, puddings
cookies, and pastries made dessert mixes
with gluten-free flour or
starch; pudding and fruit
filling thickened with tapioca,
cornstarch, or arrowroot flour
Sweets Commercial candies,
especially chocolates
Miscellaneous Monosodium glutamate, salt, Ketchup, prepared mustard,
pepper, pure spices and soy sauce, commercially
herbs, yeast, pure baking prepared meat sauces and
chocolate or cocoa powder, pickles, white vinegar,
carob, flavoring extracts, flavoring syrups (syrups
artificial flavoring, cider and for pancakes or ice cream)
wine vinegar
Source: Mayo Clinic Diet Manual: A Handbook of Nutrition Practices (7th ed.), by J. K. Nelson, K. E. Moxness, C. F. Gastineau, and
M. D. Jenson, 1994, St. Louis, MO: Mosby. Reprinted with permission of Mayo Foundation for Medical Education and Research.
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Table 20-3 High-Calories, High-Protein, Low-Residue Diet Menus
BREAKFAST LUNCH DINNER

Orange juice Baked chicken Ground beef patty

Poached egg Rice Mashed potato
Rice toast Pureed green beans Mashed acorn squash
Butter and jelly Rolls made from wheat starch Rice bread and butter
Coffee with milk and sugar and butter Applesauce with sponge cake
Lemon chiffon pudding made from wheat starch
Tea with milk and sugar Coffee with milk and sugar
SNACK SNACK SNACK

Eggnog, if tolerated Sugar cookies baked with Beef broth

gluten-free flour Rice cakes
Pineapple juice

containing these grains are disallowed. Rice and corn may be used. A reduc-
tion in the fiber content is also frequently recommended. If the client is
under weight, the diet should also be high in calories, carbohydrates, and
protein (Table 20-3). Fat may be restricted until bowel function is normalized.
Vitamin and mineral supplements may be prescribed. Lactose intolerance
sometimes develops with celiac disease.
It is not easy to avoid food products containing wheat. Breads, cereals,
crackers, pasta products, desserts, gravies, white sauces, and beer contain
wheat or other cereal grains with gluten. The client will have to learn to read
food labels carefully and to avoid restaurant foods such as breaded meats or
fish, meatloaf, creamed vegetables, and cream soups.

DISORDERS OF THE ACCESSORY ORGANS

Cirrhosis
The liver is of major importance to, and plays many roles in, metabolism.
Except for a few of the fatty acids, all nutrients that are absorbed in the intes-
tines are transported to the liver. The liver dismantles some of these nutrients,
stores others, and uses some to synthesize other substances.
The liver determines where amino acids are needed and synthesizes
some proteins, enzymes, and urea. It changes the simple sugars to glycogen,
provides glucose to body cells, and synthesizes glucose from amino acids if
needed. It converts fats to lipoproteins and synthesizes cholesterol. It stores
iron, copper, zinc, and magnesium as well as the fat-soluble vitamins and B
vitamins. The liver synthesizes bile and stores it in the gallbladder. It detoxifies
many substances such as barbiturates and morphine. ¶ cirrhosis
Liver disease may be acute or chronic. Early treatment can usually generic term for liver disease
lead to recovery. Cirrhosis is a general term referring to all types of liver characterized by cell loss
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disease characterized by cell loss. Alcohol abuse is the most common cause of
cirrhosis, but it can also be caused by congenital defects, infections, or other
toxic chemicals.
Although the liver does regenerate, the replacement during cirrhosis
does not match the loss. In addition to the cell loss during cirrhosis, there
¶ fibrosis is fatty infiltration and fibrosis. These developments prevent the liver from
development of tough, stringy tissue functioning normally. Blood flow through the liver is upset, and a form of
hypertension, anemia, and hemorrhage in the esophagus can occur. The
normal metabolic processes will also be disturbed to such a degree that, in
severe cases, death may result.
The dietary treatment of cirrhosis provides at least 25 to 35 calories
or more and 0.8 to 1.0 gram of protein per kilogram of weight each day,
depending on the client’s condition. If hepatic coma appears imminent,
the lower amount is advocated. Supplements of vitamins and minerals are
usually needed. In advanced cirrhosis, 50% to 60% of the calories should be
from carbohydrates.
In some forms of cirrhosis, clients cannot tolerate fat well, so it is restricted.
In another form, protein may not be well tolerated, so it is restricted to 35 to
¶ ascites 40 grams a day. Sometimes cirrhosis causes ascites. In such a case, sodium
abnormal collection of fluid in the and fluids may be restricted. If there is bleeding in the esophagus, fiber can
abdomen be restricted to prevent irritation of the tissue. Smaller feedings will be better
accepted than larger ones. No alcohol is allowed.

Hepatitis
¶ hepatitis Hepatitis is an inflammation of the liver. It is caused by viruses or toxic agents
inflammation of the liver caused by such as drugs and alcohol. Necrosis occurs, and the liver’s normal metabolic
viruses, drugs, or alcohol activities are constricted. Hepatitis may be acute or chronic.
Hepatitis A virus (HAV) is contracted through contaminated drinking
¶ necrosis water, food, and sewage via a fecal-oral route. Hepatitis B virus (HBV) and
tissue death due to lack of blood supply
hepatitis C virus (HCV) are transmitted through blood, blood products, semen,
and saliva. Hepatitis B and C can lead to chronic active hepatitis (CAH), which
is diagnosed by liver biopsy. Chronic active hepatitis can lead to liver failure
and end-stage liver disease (ESLD).
In mild cases, the cells can be replaced. In severe cases, the damage can
be so extensive that the necrosis leads to liver failure and death. There can be
¶ stasis bile stasis and decreased blood albumin levels. Clients experience nausea,
stoppage or slowing headache, fever, fatigue, tender and enlarged liver, anorexia, and jaundice.
Weight loss can be pronounced.
¶ jaundice Treatment is usually bed rest, plenty of fluids, and medical nutrition
yellow cast of the skin and eyes therapy. The diet should provide 35 to 40 calories per kilogram of body weight.
Most of the calories should be provided by carbohydrates; there should be
moderate amounts of fat and, if the necrosis has not been severe, up to 70 to
80 grams of protein for cell regeneration. If the necrosis has been severe and
the proteins cannot be properly metabolized, they must be limited to prevent
the accumulation of ammonia in the blood. Clients may prefer frequent, small
meals rather than three large ones.
Clients with liver disease require a great deal of encouragement because
their anorexia and consequent feelings of general malaise can be severe. Their
recovery takes patience, rest, and time.
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Cholecystitis and Cholelithiasis
The dual function of the gallbladder is the concentration and storage of bile.
After bile is formed in the liver, the gallbladder concentrates it to several times
its original strength and stores it until needed. Fat in the duodenum triggers the
gallbladder to contract and release bile into the common duct for the digestion
of fat in the small intestine. If this flow is hindered, there may be pain.
The precise etiology of gallbladder disease is unknown, but heredity
factors may be involved. Women develop gallbladder disease more often than
men do. Obesity, total parenteral nutrition (TPN), very low calorie diets for
rapid weight loss, the use of estrogen, and various diseases of the small intestine
are frequently associated with gallbladder disease.
Cholecystitis (inflammation) and cholelithiasis (gallstones) may ¶ cholecystitis
inhibit the flow of bile and cause pain. Cholecystitis can cause changes in the inflammation of the gallbladder
gallbladder tissue, which in turn can affect the cholesterol (a constituent of
¶ cholelithiasis
bile), causing it to harden and form stones. It is also thought that chronic over-
gallstones
indulgence in fats may contribute to gallstones because the fat stimulates the
liver to produce more cholesterol for the bile, which is necessary for the diges-
tion of fat. In addition to pain, which can be severe, there may be indigestion
and vomiting, particularly after the ingestion of fatty foods.
Treatment may include medication to dissolve the stones and diet therapy.
If medication does not succeed, surgery to remove the gallbladder (cholecys- ¶ cholecystectomy
tectomy) may be indicated. removal of the gallbladder
Medical nutrition therapy includes abstinence during the acute phase.
This is followed by a clear liquid diet and, gradually, a regular but fat-restricted
diet. Amounts of fats allowed run from 40 to 45 grams a day. In chronic cases,
fat may be restricted on a permanent basis. For obese clients, weight loss
is recommended in addition to a fat-restricted diet. (For information on fat-
restricted diets, see Chapter 18.) Clients with chronic gallbladder conditions
may require the water-miscible forms of fat-soluble vitamins. ¶ pancreatitis
inflammation of the pancreas

Pancreatitis ¶ steatorrhea
In addition to the hormone insulin, the pancreas produces other hormones and abnormal amounts of fat in the feces
enzymes that are important in the digestion of protein, fats, and carbohydrates.
When food reaches the duodenum, the pancreas sends its enzymes to the small
intestine to aid in digestion. EXPLORING THE WEB
Pancreatitis is an inflammation of the pancreas. It may be caused Choose one of the disorders
by infections, surgery, alcoholism, biliary tract (includes bile ducts and gall- discussed and thoroughly
bladder) disease, or certain drugs. It may be acute or chronic. research on the Internet.
Abdominal pain, nausea, and steatorrhea are symptoms. Malabsorp- Create a list of the signs
tion (particularly of fat-soluble vitamins) and weight loss occur, and, in cases in and symptoms, the possible
which the islets of Langerhans are destroyed, diabetes mellitus may result. causes, and the treatment
choices for the disorder.
Diet therapy is intended to reduce pancreatic secretions and bile. Just as
Identify the nutritional needs
fat stimulates the gallbladder to secrete bile, protein and hydrochloric acid stim- for a person with this
ulate the pancreas to secrete its juices and enzymes. During acute pancreatitis, disorder. Can the disorder(s)
the client is nourished strictly parenterally. Later, when the client can tolerate be controlled through proper
oral feedings, a liquid diet consisting mainly of carbohydrates is given because, nutrition?
of these three nutrients, carbohydrates have the least stimulatory effect on
pancreatic secretions.
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As recovery progresses, small, frequent feedings of carbohydrates and
protein with little fat or fiber are given. The fat is restricted because of deficiencies
of pancreatic lipase. The client is gradually returned to a less restricted diet as
tolerated. Vitamin supplements may be given. Alcohol is forbidden in all cases.

RESIDUE-CONTROLLED DIETS
Fiber is that part of food that is not broken down by digestive enzymes. It is
called dietary fiber. Most dietary fiber is found in plant foods. Some is soluble,
and some is insoluble (see Chapter 4). Examples of dietary fiber in plants include
the outer shells of corn kernels, strings of celery, seeds of strawberries, and the
connective tissue of citrus fruits.
Residue is the solid part of feces. Residue is made up of all the undigested
and unabsorbed parts of food (including fiber), connective tissue in animal
foods, dead cells, and intestinal bacteria and their products. Most of this residue
is composed of fiber.
Diets can be adjusted to increase or decrease fiber and residue. The specific
names of these diets vary among health care facilities. The specific foods allowed
and thus the amount of fiber and residue allowed will depend on the physician’s
experience and the client’s condition.

The High-Fiber Diet

High-fiber diets containing 30 grams or more of dietary fiber are believed
to help prevent diverticulosis, constipation, hemorrhoids, and colon cancer.
They also are helpful in the treatment of diabetes mellitus (see Chapter 17) and
atherosclerosis (see Chapter 18).
It is currently estimated that the normal diet in the United States contains
about 11 grams of dietary fiber each day. A high-fiber diet is often 25 to 35 grams
and should not exceed 50 grams a day. The recommended foods for this diet include
coarse- and whole-grain breads and cereals, bran, all fruits, vegetables (especially
raw), and legumes. Milk, meats, and fats do not contain fiber (Table 20-4). The diet
is nutritionally adequate. High-fiber diets must be introduced gradually to prevent
the formation of gas and the discomfort that accompanies it. Eight 8-ounce glasses
of water also must be consumed along with the increased fiber.

SUPERSIZE USA
“Baseball games are an American institution. Couldn’t wait to eat the hot dogs,
peanuts, and nachos and, of course, drink soda to my heart’s content! There
were nine innings, and then the score was tied at the end of the ninth. I ate my
way through all nine and even into the extra innings. Upon leaving the ballpark,
I was feeling pain in the upper-right quadrant of my abdomen and straight
through to my back. I had had this pain before but never to this extent. What is
wrong with me? Did I eat something specifically to cause the pain? What should
I eliminate from my diet to prevent future pain?”
You may be having a gallbladder attack. All the foods that have a lot of
fat—hot dogs, nachos, peanuts—can cause it. Follow a low-fat diet to prevent
future pain.
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Table 20-4 Sample Menus for a High-Fiber Diet
BREAKFAST LUNCH DINNER
Stewed dried plums Fresh fruit cup Baked pork chops
Bran cereal with Roast beef sandwich on Baked potato
milk and sugar cracked wheat bread Fresh corn
Whole wheat toast Coleslaw Green salad with oil
with marmalade Carrot cake and vinegar dressing
Coffee Fat-free milk Whole-grain bread with
Coffee or tea margarine
Fresh pineapple
Fat-free milk
Tea

SPOTLIGHT on Life Cycle

Here are some suggestions for helping older adults increase fiber in the diet:
• Eat fresh fruits and vegetables. If the older adult has difficulty chewing raw
fruits and vegetables, gently steamed vegetables and soft fruits are appropriate.
• Eat some of the skins of potatoes, apples, pears, and other fruits or vegetables.
The outer portion of these foods contains fiber and valuable nutrients.
• Use whole-grain breads and cereals instead of refined white bread and
sugary cereals. Instead of meat, add beans (navy, lima, kidney, pinto), all of
which are high in fiber and can also be a less expensive source of protein.
Beans can also be used in casseroles, soups, stews, and other dishes.
• Try unbuttered air-popped popcorn or the reduced- or low-fat versions of
microwave popcorn for a snack. Remind the older adult that dentures and
teeth will need special attention during cleaning following a popcorn snack.
• Remember how important it is to increase the water in the diet when the
fiber content is increased. At least 8 cups of liquid are needed each day.
• Keep moving; being active helps bowel regularity.

The Low-Residue Diet

The low-residue diet of 5 to 10 grams of dietary fiber a day is intended to reduce
the normal work of the intestines by restricting the amount of dietary fiber and
reducing food residue. Low-fiber or residue-restricted diets may be used in cases
of severe diarrhea, diverticulitis, ulcerative colitis, and intestinal blockage and
in preparation for and immediately after intestinal surgery.
In some facilities, these diets consist of foods that provide no more than
3 grams of fiber a day and that do not increase fecal residue (Tables 20-5 and
20-6). Some foods that do not actually leave residue in the colon are considered
“low-residue” foods because they increase stool volume or provide a laxative
effect. Milk and prune juice are examples. Milk increases stool volume, and
prune juice acts as a laxative.