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Dietary Fiber and Pediatric Intestinal Dysfunction: Breaking Old Myths

Dietary Fiber and Pediatric Intestinal Dysfunction: Breaking Old Myths. Jose M. Saavedra, MD Medical and Scientific Director, Nestle Nutrition & Associate Professor of Pediatrics Division of Gastroenterology and Nutrition Johns Hopkins University School of Medicine.

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Dietary Fiber and Pediatric Intestinal Dysfunction: Breaking Old Myths

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  1. Dietary Fiber and Pediatric Intestinal Dysfunction:Breaking Old Myths Jose M. Saavedra, MD Medical and Scientific Director, Nestle Nutrition & Associate Professor of Pediatrics Division of Gastroenterology and Nutrition Johns Hopkins University School of Medicine

  2. Goals of Enteral Nutrition • Maximize nutrient delivery • Maximize nutritional quality • Enhance nutrient absorption (transport) • Minimize adverse effects of feedings (maximize tolerance) • Facilitate gastric emptying (upper intolerance) • Decrease chances for diarrhea (lower intolerance)’ …. By USING THE GI TRACT

  3. The Other Goal of Enteral Nutrition: And to use the GI tract… Support GI structure and function • Motility • Barrier function • Immune function

  4. We can not feed the host if we do not feed the gut.

  5. Factors to Consider in Enteral Nutrition 1) To support host growth, repair, immunity • Macronutrient profile • Protein, Fats, CHO • Micronutrient profile 2) To support GI structure and function • Functional dietary ingredients Feed the host Feed the GI tract

  6. Nitrogen Sources for Enteral Nutrition • Cow proteins • Casein • Whey • Soy proteins • Others (Rice, Meat)

  7. Acid Digestion of Cow Proteins Casein Curd Whey Casein containing Formulation 100% Whey Based Formulation Curd forming properties of intact casein containing Feeding formulation simulating gastric conditions, at 370, pH 4.5, for 30 minutes

  8. Curd formation from intact cow casein in stomach Whey, a More Soluble Protein Source Whey/Casein formula at 37C for 30 min, acidified to pH4 (Gastric conditions)

  9. Whey, a Higher Quality Protein

  10. Whey, a Higher Quality Protein

  11. “Elemental” Enteral Feedings to Maximize Nitrogen Delivery • Choices: • Intact proteins • Peptides (hydrolyzed protein) • Amino acids • Tendency has been to maximize nutrient delivery • Manipulation of proteins to maximize delivery has led to development of “elemental” enteral feedings.

  12. Nitrogen Delivery: Intact Protein to Hydrolyzed Protein to Amino Acids Peptide Predominant Amino Acid Predominant Intact Protein

  13. Protein Source and Hydrolysis • Intact Protein • Formulations • Require extensive digestion • prior to absorption • Intact casein: slower gastric emptying • High Amino Acid • Formulations • Increased osmolality and intolerance • Less support for mucosa structure • and function Whey Peptide Predominant Amino Acid Predominant Intact Protein Excellent Nutritional quality In the compromised Gut: • Improved upper GI tolerance • Reduced diarrhea • Improved nutritional parameters and outcomes • Supports improvement in gut structure and function

  14. Meeting Goals of Enteral Nutrition • What is absorbed into circulation • Macronutrients • Micronutrients • What is not absorbed • “Residue” • “Roughage” • Fiber Helps feed the host Helps feed the GI tract

  15. Enteral Feedings: Macro and Micronutrients plus Amino Acid Predominant Intact Protein Peptide Predominant or or • “Elemental” , “Semielemental” and most Polymeric diets: • Concentrated on what is absorbed • Were designed to “decrease digestive work” and “decrease digestive residue”

  16. So What is Missing in Most “Elemental” and “Semi-Elemental” Diets? NON ABSORBABLE DIETARY COMPONENTS… • “Residue” • “Roughage” • Fiber

  17. The origin… NASA Space Program

  18. … and demise Atlantis … of “low residue” diets

  19. The “Low Residue” or “Low Roughage” Diet… • No seeds • No popcorn Indication: Strictures in GI tract Interpretation: “No fiber in diseased gut”

  20. Myth 1 “Fiber in enteral formulations can cause obstructions” Fact: • Seeds and other particles, nor refined fibers can cause obstructions in strictured bowel

  21. The Fiber Component of Modern Enteral Formulations • Not seeds • Not unrefined bran, etc • Fine powdered products from • Soy • Pea • Chicory, etc

  22. Defining Fiber • Dietary derivative of vegetable or plant • Resist human digestion & absorption • A major dietary component, NOT a NUTRIENT • Direct effect in the intestinal lumen • Indirect effects on the health of the host

  23. Dietary Fiber Soluble Insoluble Pectin, Hemi-cellulose (B) Mucilages, Gums Oligosaccharides Lignin Cellulose Hemicellulose (A) Chemical Constituents Inner Pea fiber Guar gum Oat Bran Inulin - FOS Wheat Bran Soy Polysaccharide Outer pea fiber Examples • Add bulk to stool • Hold water • Regulate stool consistency & frequency • Fermentation & its effects • Can alter absorption (glucose, fat) • Some are prebiotic Function

  24. Insoluble Fiber • Most common: • Cellulose, Hemicellulose, Lignin • Key functions •  fecal mass •  fecal moisture • Regulates colonic transit time • Less fermentable by bacteria

  25. Soluble Fiber • Most common types: • Gums, Pectins, Mucilages, Fructans • Key functions • Usually gel-forming, viscous • Increases fecal moisture • Easily fermented by bacteria

  26. Myth 2 “Fiber in enteral formulations may not be tolerated in the “gut at rest” Fact: • There is NO ADEQUATE DATA TO SUPPORT THIS • There IS DATA TO SUPPORT OTHERWISE

  27. Intestinal Bulk from Insoluble Fiber is Necessary for Normal Peristalsis • Bulk of intestinal contents helps organized peristaltic waves • Don’t expect normal peristalsis with no intestinal bulk….

  28. Myth 3 “Fiber is a laxative” Fact: • Insoluble and soluble fiber add bulk and fluid content of colonic contents, and regulate intestinal transit

  29. Fiber (soluble & insoluble) Supplementation Decreases Loose Stools During Antibiotic Treatment in Children Burks AW et al J Pediatr 2001;139:578-82 Soy polysaccharide N=45 children, 10-day study p=0.0013 Diarrhea duration (hrs)

  30. Effects of Insoluble Fiber on Gut Function • Regulate stool consistency (water holding capacity) • Softens hard stool • Increases consistency of watery stool (IE in loose stools in infants) • Facilitates intestinal motility • Regulates intestinal transit Clinical Nutrition: enteral and tube feeding. Rombeau and Rolandelli 3rd ed. 1984

  31. Myth 4 • Fiber may “irritate” the diseased or inflamed gut… Fact: • Fiber actually helps maintain gut function and integrity and gut immune function

  32. Indications for “Low Fiber” or “Low Residue” Diets? Medical Management of Inflammatory Bowel Disease “Total parenteral nutrition (TPN) should be used in malnourished patients who do not improve quickly or are unable to tolerate oral intake; as symptoms improve, patients can be transitioned from TPN to a low-residue diet. “ Conn's Current Therapy 2006, 58th ed.

  33. CATEGORY LOW RESIDUE DIET “A low residue diet is a diet designed to reduce the frequency and volume of stools while prolonging intestinal transit time. It is similar to a low fiber diet, but typically includes restrictions on foods that increase bowel activity, such as milk and milk products and prune juice…..”

  34. Adult Microbiota: A Complex Ecosystem Esophagus No own microbiota Microbes from food and oral cavity Stomach 104 CFU/g Candida albicans Helicobacter pylori Lactobacillus Streptococcus 500 - 1000 species Duodenum 103-104 CFU/g Bacteroides Candida albicans Lactobacillus Streptococcus Jejunum 105-107 CFU/g Bacteroides Candida albicans Lactobacillus Streptococcus Colon 1010-1011 CFU/g Bacteroides Bacillus Bifidobacterium Clostridium Enterococcus Eubacterium Fusobacterium Peptostreptococcus Ruminococcus Streptococcus Ileum 107-108 CFU/g Bacteroides Clostridium Enterobacteriaceae Enterococcus Lactobacillus Veillonella

  35. Role of a Balanced Intestinal Microbiota Compete with other potential pathogens Fermentation of substrates Metabolism of proteins, bile acids Vitamin synthesis Modulate gut immune function What is the “food” for maintaining a healthy intestinal microbiota?

  36. Intestinal Bacteria Use Substrate (Fiber) for Energy via Fermentation • Short Chain • Fatty Acids • Acetate • Propionate • Butyrate Microbiota Fermentation

  37. Effects of Short Chain Fatty Acids from Bacteria on Gut Function • Fuel for colonocytes (specially butyrate) • Metabolic energy source • Increase sodium absorption • Improve colonic blood flow • GI hormones • Lower colonic pH • unfavorable for pathogens

  38. The Type of Fiber Can Determine the Type of Bacteria that Predominate in the Intestine • Fiber • Fermentable • substrates • Effect on • Microbiota • Bacterial mass • Type of bacteria Fermentation Dietary substrates can influence intestinal microbiota

  39. Role of a Balanced Intestinal Microbiota Compete with other bacteria Fermentation of substrates Metabolism of proteins, bile acids Vitamin synthesis Modulate gut immune function

  40. Intestinal Microbiota (A Balanced Ecosystem) • Potentially Harmful Bacteria • Diarrhea/constipation • Infections • Production of Toxins • Potentially Helpful Bacteria • Inhibition of exogeneous and/or harmful bacteria • Stimulation of immune functions • Aid in digestion and/or absorption • Synthesis of vitamins Pseudomonas Proteus Staphylococci Clostridia Enterococci E. coli Lactobacilli Streptococci Eubacteria Bifidobacteria Bacteroides From: Gibson GR. J Nutrition 1995; 125:1401-1412.

  41. Intestinal Microbiota of Individuals with IBDDiffers from Normal Controls • Stool of patients with Crohn’s disease has less Bifidobacteria compared to healthy controls Favier C., et al. Dig Dis Sci 1997;42:817-822. • Stool of patients with active pouchitis has less Bifidobacteria and lactobacilli and more clostridia than controls Ruseler-van Embden JGH., et al. Gut 1994;35:658-664.

  42. Intestinal Microbiota of Individuals with IBDDiffers from Normal Controls • Increases in E. coli and bacteroides species have been noted in patients with Crohn’s disease compared to controls Giaffer MH., et al. J Med Microbiol 1991;238-243. • Colonic biopsies from patients with active UC have decreased anaerobic bacteria and lactobacilli compared to controls Fabia R., et al. Digestion 1993;54:248-255.

  43. Bifidobacteria and Lactobacilli:A More Desirable, Balanced Intestinal Microbiota • Lower pH and inhibit potential pathogens • Compete with pathogens • Reduction of pathogen population (clostridia and bacteroides) • Competition with pathogens for substrate/ receptors • Immunomodulation

  44. Certain Soluble Fibers (Prebiotics) Can Favor a More Beneficial Type of Microbiota • Effect on • Microbiota • Bacterial mass • Type of bacteria • FOS • Inulin Fermentation Dietary substrates can influence intestinal microbiota

  45. Certain Soluble Fibers (Prebiotics) Can Favor a More Beneficial Type of Microbiota • FOS • Inulin Bifidobacteria Lactobacilli Fermentation Dietary substrates can influence intestinal microbiota

  46. Intestinal Bacteria and GI Immunity Gut immune function: • Balanced GALT response to intestinal bacteria • A balanced intestinal microbiota stimulates development of the immune mucosal barrier, decreasing chances for pathogen growth

  47. Intestinal Microbiota in GI Disease • Altered by change in diet • Parenteral nutrition • Change in substrate • Altered by antibiotics • Altered by microbial environment • Loss of gut trophism • Decreased barrier • function • Increased risk for • infection Altered Bacterial Populations

  48. Fiber in Pediatric GI Dysfunction Dysmotility/ Diarrhea/ Constipation • Insoluble + soluble prebiotic fiber: Regulate motility and fecal flow Altered GI integrity and permeability • Insoluble + soluble prebiotic fiber: Beneficial in gut trophism, integrity and permeability Altered intestinal microbiota • Soluble prebiotic fiber:: maintain a favorable microbial ecosystem

  49. Fiber and Prebiotics in Pediatrics • An important part of maintaining gut health • An important dietary adjunct in managing GI compromise

  50. Thank you

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