Short Bowel Syndrome: How to Eat When You Can't Eat

SHORT BOWEL SYNDROME: HOW TO EAT

WHEN YOU CAN'T EAT

LAURA E. MATARESE PHD, RD, LDN, CNSC, FADA, FASPEN, FAND

PROFESSOR

DIVISION OF GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION

DIVISION OF INFECTIOUS DISEASES AND TRAVEL HEALTH

ADJUNCT PROFESSOR OF SURGERY

BRODY SCHOOL OF MEDICINE

AT

EAST CAROLINA UNIVERSITY

GREENVILLE, NC

DISCLOSURES

Takeda

Speaker Bureau

Grant Support

Abbott Nutrition

Nestle

All material presented is based on

best known clinical evidence.

LEARNING

OBJECTIVE

Describe the dietary interventions

to enhance absorption and reduce

output

THE STANDARD

AMERICAN DIET

High sugar, high

fat

Can you imagine

eating this way if

you have SBS?

Likely to cause

increased output

SO HOW DO WE TIP THE SCALES SO THERE IS INCREASED ABSORPTION AND DECREASED OUTPUT?

More absorptionLess output

Diet Modification: The Foundation of Therapy

Nutrition prescription must be based on the remnant GI anatomy to enhance

absorption

Most potent stimulus to intestinal adaptation

Comparison of Two Nutrition Prescriptions

Colon No Colon

Carbohydrate50-60% of total calories

(limit simple sugars)

40-50% of total calories

(restrict simple sugars)

Protein 20-30% of total calories 20-30% of total calories

Fat20-30% of total calories

(primarily essential fats)



FluidIsotonic fluids or

Hypo-osmolar fluids

Isotonic, high sodium oral

rehydration solution

Soluble Fiber5-10 grams / day

(if stool output is > 3L/day)

5-10 grams / day


Oxalates Limit intake ---

Meals 5-6 meals per day 4-6 meals per day

Byrne et al. NCP 15:306, 2000

Simple vs. Complex CHO

LIMIT

Sugar

Candy

Cakes, cookies, pies

Regular soda pop

Sweet tea

Jelly, jam, syrup

Ice cream, sherbet

Sorbet

INCLUDE

Pasta

Potato

Breads

Cereals

Whole grains as tolerated

Fruits and vegetables as tolerated

Matarese, L. et al; J Clin Gastroent 40(Supp 2):S85-S93, 2006.

Non-nutritive Sweeteners

Non-nutritive sweeteners are intense, very low-calorie sweeteners that do not have an adverse effect on stool output. These sweeteners can be used as an alternative in order to reduce simple sugars in the diet.

The sweeteners currently approved by the FDA are:

Acesulfame K (Sunett®, Sweet & Safe, Sweet One®)

Aspartame (Nutrasweet®, Sugar Twin®, Equal®)

Neotame (used by manufacturers in combination with other nutritive and non-nutritive sweeteners to enhance the flavor of food and beverages)

Saccaharin (Sweet’N Low® and Sweet Twin)

Stevia-based sweeteners (Truvia®, Pure Via®)

Sucralose (Splenda®)

U.S. Food & Drug Administration. http://www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm397725.htm

Sugar Alcohols: Look for the “ol”

Sugar alcohols are also used as low-calorie

sweeteners. Unlike the non-nutritive sweeteners,

they are designed to be malabsorbed and therefore

cause uncomfortable side effects like abdominal

gas, bloating and diarrhea. Consumers with SBS

should limit these.

Sugar alcohols can be found in the ingredient list

on food labels as sorbitol, mannitol, xylitol.

A product labeled “sugar-free” must contain a

separate line for sugar alcohols under the

carbohydrate section on the food label.

U.S. Food & Drug Administration. http://www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm397725.htm


Colon No Colon











Hypo-osmolar fluids





5-10 grams / day





BIOLOGICAL VALUE (BV) OF PROTEIN

Biological Value: Measure of the

proportion of absorbed protein from

a food which becomes incorporated

into the proteins of body cells

Higher BV indicates that less is

needed

Protein BV*

Whey Protein, Whole Soy

Bean

96

Human milk 95

Chicken egg 94

Soybean milk 91

Cow’s milk 90

Cheese 84

Quinoa, rice 83

Fish 76

Beef 74

Soybean curd (tofu) 64

*percent nitrogen incorporated

Protein


Colon No Colon











Hypo-osmolar fluids





5-10 grams / day





Fat

Fat should be included in the diet to

prevent essential fatty acid deficiency.

Use smaller amounts if your colon is

connected.

But…not all fats are alike

Essential fats or essential fatty acids

(EFAs) should be included since the

body cannot make EFAs on its own.

Foods high in animal fat and saturated

fat should be limited since they have

been associated with atherosclerosis

and cardiac diseases.

Omega-6 & Omega-3

Proinflammatory

Series 2

Prostaglandins

Series 4

Leukotrienes

Anti-inflammatory

Series 3

Prostaglandins

Series 5

Leukotrienes

Food Sources of

Essential vs. Non-

Essential Fats

Essential Fatty Acids: alpha-linolenic

acid (ALA) and linoleic acid (LA)

Nonessential Fats

Canola oil Butter

Cold water fish (salmon, trout, mackerel,

sardines)

Cocoa butter

Corn oil Coconut oil

Flaxseed oil Palm oil

Grapeseed oil Peanut oil

Mayonnaise Red meat

Safflower oil Whole milk and cheeses

Soybean oil

Sunflower oil


Colon No Colon











Hypo-osmolar fluids





5-10 grams / day





Types of Fluids

Matarese et al; NCP, 20:493-502, 2005.

Hyper-

osmolar

• Contain many particles of glucose and little to no

sodium

• Cause fluid to be pulled into the intestinal tract to

dilute the concentration of the beverage, therefore

causing watery diarrhea

• Example: Coke, Pepsi, Mt. Dew, Sweet tea

Hypo-

osmolar

• Contain little to no particles of glucose and sodium

(not concentrated)

• Are not always absorbed entirely, known as free

fluids

• Examples: Water, decaffeinated and sugar-free

beverages

Iso-

osmolar

• Contain sodium, potassium and glucose in same

concentration as blood and extracellular fluid

• Will not cause fluid to shift into the GI tract

• Oral rehydration solution, Cera-Lyte, Pedialyte®,

G2®

• Usually the beverage of choice for those with SBS

Beverage Approximate Osmolarity

(m0sm/L)

Type of Fluid

Prune Juice 1265 Hyper-osmolar

Grape Juice 863 Hyper-osmolar

Apple Juice 680 Hyper-osmolar

Orange Juice 614 Hyper-osmolar

Regular Soda 550–700 Hyper-osmolar

Popsicle 720 Hyper-osmolar

Jell-o® 730 Hyper-osmolar

Diet Soda 0 Hypo-osmolar

Water 0–28 Hypo-osmolar

Tea (sugar free) 13-44 Hypo-osmolar

ORS salts 300 Iso-osmolar

CeraLyte 220–260 Iso-osmolar

Pedialyte® 250 Iso-osmolar

Gatorade® 330–380 Iso-osmolar

Fluid Comparison

Parrish, C; The Clinician’s Guide to Short

Bowel Syndrome; Practical

Gastroenterology, 2005.

Oral

Rehydration

Solutions

Sodium-glucose Co-transport

Oral Rehydration Solutions

Sodium Balance with Short Bowel Syndrome

Rodriguez CA et al. Clin Sci 1988;74(suppl18):69

Sodium Balance

(Na intake – fecal

output) mMol/L

Oral Rehydration

Solutions

CHO

g/L

Na+

mEq/L

K+

mEq/L

HCO3

mEq/L

Osmo

mOsm/L

ORS

WHO Standard Formula 20 90 20 30 310

WHO Reduced-Osmolality

Formula

13.5 75 20 30 245

CeraLyte 70 40 70 20 30 235

CeraLyte 90 40 90 20 30 260

CVS Adult Electrolyte

Solution

25 45 20

DripDrop 25 60 20 160 (citrate) 215

Jianas Brothers 20 90 20 10 300

Pedialyte (Abbott) 25 45 20 30 300

Speedlyte (Einsof

Biohealth)

75 45 20 9 (citrate) 188

Trioral Rehydration Salts

(Trifecta)

13.5 20 20 10 (citrate) 245

Sports Drinks

Gatorade 60 20 3 340

Gatorade 2 + ½ tsp salt 29 63 3 254

Prescription for ORS+

No Potassium

Water 1 liter

Sodium Chloride ½ tsp

Bicitra solution* 2 TBSP

Glucose polymer

powder* (polycose) 4 TBSP

Low Potassium

Water 1 liter

Sodium Chloride ½ tsp

Polycitra solution* 3 tsp

Glucose polymer

powder* (polycose) 4 TBSP*By prescription

+UPMC protocol

#Sugar-free artificial flavoring or sweetener

http://www.oag.state.ny.us/family/kids/images/rx.gif

Recipe for ORS

1 liter water

¾ teaspoon table salt

3 tablespoons sugar (sucrose)

1 teaspoon baking powder (or ½ teaspoon baking soda)

½ teaspoon 20% potassium chloride* or salt substitute#

Sugar-free artificial flavoring or sweetener

* By prescription

# Concentration: 7-14 mEq potassium per gram; one teaspoon: 5 grams (1/6 oz) = 35-70 mEq potassium

Mayo Clin Proc, 1992; 67:755-760.

http://www.lrdnutrition.com/recipe.gif

Recipe for ORS

1. Gatorade Base

2 cups Gatorade

2 cups water

½ teaspoon salt

2. Grape or Cranberry Juice

½ cup juice

3 ½ cups water

½ teaspoon salt

3. Apple Juice

1 cup juice

3 cups water

½ teaspoon salt Parrish, C. Pract Gastroenterol 2005; 14:67


Colon No Colon











Hypo-osmolar fluids





5-10 grams / day





Types of Fiber

Choose Limit

Soluble Fiber Insoluble Fiber

Oatmeal cereals and breads Whole wheat cereals and breads

Oatbran cereals and breads Wheat bran cereals and breads

Apple (without skin), applesauce,

banana, orange, grapefruit,

tangerine without seeds,

strawberries as tolerated

Grapes, blueberries, cherries,

rhubarb, figs, blackberries,

raspberries

Cooked, peeled and/or seedless

vegetables such as carrots,

butternut squash, asparagus tips,

canned green beans

Corn, celery, cucumber, mushroom,

cauliflower, lettuce, cabbage,

peppers, eggplant, broccoli &

asparagus stems, spinach, turnip

greens, kale,

Brussels sprouts

Refried low-fat beans, shelled

beans (i.e., garbanzo beans, black

beans)

Nuts, large seeds (pumpkin,

sunflower), lentils, peas


Colon No Colon











Hypo-osmolar fluids





5-10 grams / day





Types of foods and the way

the food is consumed affects

absorption…

2400 kcal, 50% CHO, 20% Protein, 30% Fat

Breakfast

1 cup oatmeal

2 oz lactose-free milk

1 egg

1 English muffin

2 tsp margarine

1 tsp diet jelly

4 oz coffee

Morning Snack

1 bagel w/½ oz cheese

1 tsp margarine

1 small banana

4 oz water

Breakfast

8 oz orange juice

1 cheese and fruit-

filled Danish

Byrne et al., NCP 15:309, 2000


Lunch

3 oz baked ham

½ cup cooked rice

½ cup carrots

2 small dinner rolls

2 tsp margarine

4 oz water or diet soda

Lunch

1 thin slice cheese pizza

12 oz regular soda



Dinner

4 oz roasted chicken

1 large baked potato

2 dinner rolls

2 tsp margarine


Evening Snack

1 roast beef sandwich

2 slices bread, 1 oz meat, 1 tsp mayo

1 tsp mustard

1 oz pretzels


Dinner

12 oz T-bone steak

1 large baked potato

1 cup spinach

12 oz beer

Evening Snack

3-4 cups popcorn

1 cup raspberry sorbet

12 oz diet soda


Putting it all

together…

Plan a balanced diet

Include complex carbohydrates, proteins and fat (especially essential fat) at each meal

Limit or avoid simple sugars

Distribute the food throughout the day

Chew foods well

Use salt liberally especially if your colon is in circuit

Limit fluids to 4 oz. per meal and sip fluids that are either hypo-osmolar or isotonic throughout the day.

And most importantly, enjoy meals with family and friends!

Cheating Guidelines

Yes, it is OK to taste your favorite foods now and then. But, be smart about it.

For example, if you must have a regular soda, have it with a soft pretzel with the large salt granules on it. And don’t drink the entire 2 liter bottle!

Make sure you are home or at least close to a bathroom

Sample the food; do not overindulge

There is often a dose response. You may be able to tolerate small amounts of that “forbidden” favorite food.

CONCLUSION

“Takeaway” message

Diet is the foundation of

therapy for SBS

Fluid and nutrient absorption

can be enhanced when oral

intake is based on the GI

anatomy

Further Reading

Byrne, T et al. Clinical Observations: Beyond the Prescription: Optimizing the Diet of Patients with Short Bowel Syndrome. Nutri Clin Pract 15:309, 2000

Matarese LE, O'Keefe SJ, Kandil HM, et al. Short bowel syndrome: clinical guidelines for nutrition management. Nutr Clin Pract. 2005;20:493-502.

Matarese LE. Short bowel syndrome. In: Mullin GE, Matarese LE, Palmer M, editors. The Gastrointestinal and Liver Disease Nutrition Desk Reference. Boca Raton, FL: CRC Press; 2012: p. 35-49.

Matarese L.E., Steiger E. and Seidner, DL (eds) Intestinal Failure and Rehabilitation. A Clinical Guide. CRC Press, Boca Raton, Florida, 2005

Matarese LE. Nutrition and Fluid Optimization for Patients With Short Bowel Syndrome. JPEN J Parenter Enteral Nutr. 2013 37 (2)161 – 170

Parrish CR, DiBaise J. Part III: Hydrating the Adult Patient with Short Bowel Syndrome. Practical Gastroenterology 2015;XXXIX(2):10.

Parrish CR. The Clinician's Guide to Short Bowel Syndrome. Practical Gastroenterology 2005;XXIX(9):67

CONTACT INFORMATION

LAURA MATARESE, PHD, RDN

[email protected]

37

Short Bowel Syndrome: How to Eat When You Can't Eat

Documents

Short Bowel Syndrome: How to Eat When You Can't Eat