Objectives of the Seminar

1. 1 Welcome to SeminaronThe Role of Dietary Fibre and Probiotics (Synbiotics) in the Management of GI DiseasesbyMeera Kaur, PhD, RDkaur@cc.umanitoba.ca

2. 2 Objectives of the Seminar • Recognize functions of dietary fibre and probiotics • Understand the role of fibre and probiotics in GI diseases and the new term Synbiotics • Learn the clinical indications for a altered fibre and probiotics diet • Understand the role of diet in IBD Meera Kaur, PhD, RD

3. 3 Outline of the Seminar • GI responses to Fibre and Probiotics • Food Sources of Fibre and Probiotics • Fibre Requirements, Fibre in GI Disease • Management of Constipation/Diarrhea • IBS and IBD • Drug Nutrient Interactions • Common Problems and Suggestions • Role of probiotics in GI health and diseases • Checklist, Question and Answer session Meera Kaur, PhD, RD

4. 4 Fibre: A True Multitasker • Hypoglycemic effect • Hypolipidemic effect • Slows absorption of CHO • “Anti-toxic” effect ( colon cancer mortality) • Apparent reduction or control of GI disorders (diverticulitis, gallstones, IBS, IBD, constipation) • Satiety effect (helps some individuals better maintain their ideal body weight) Meera Kaur, PhD, RD

5. 5 Fibre: Soluble or Not • Soluble Fibres: “Soluble non-cellulosic polysaccharides” = Pectin, gums, mucilage and hydrocolloids) (i.e. guar gum, oats, barley • Insoluble Fibre: “Insoluble cellulosic polysaccharides” = lignin and cellulose (i.e bran) Meera Kaur, PhD, RD

6. 6 GI Response to Insoluble Fibre... •  Fecal bulk •  Intraluminal pressure •  Frequency of defecation •  Intestinal transit time •  Postprandial satiety Meera Kaur, PhD, RD

7. 7 GI Response to Insoluble Fibre... •  Glucose absorption • Changes in pancreatic and intestinal enzyme activity •  Bile-acid secretion (sequestering agent) Meera Kaur, PhD, RD

8. 8 Food Sources of Fibre • Whole grains • Fruits • Vegetables • Pulses and Legumes Meera Kaur, PhD, RD

9. 9 Fibre Requirements • 21 - 38 gm fibre a day (Harshman and Aldoori, 2006) • Both types are important -- soluble and insoluble * Harshman and Aldoori (2006), New dietary reference intakes for macronutrients and fibre,Can Fam Physician. 2006 February 10; 52(2): 177–179 Meera Kaur, PhD, RD

10. 10 Fibre in GI Disease • Clinical Indications: Gastrointestinal • constipation • diarrhea • diverticulitis • IBS • IBD Meera Kaur, PhD, RD

11. 11 Management of Constipation • Nutrition Habits • high fibre diet regular meal schedule • coarse wheat bran • decreased diuretic beverages bowel re-education • Increased water Regular exercise • 1-1.5 L per day additional Meera Kaur, PhD, RD

12. 12 Management of Diarrhea... • Nutrition... • avoid foods likely to cause diarrhea • dietetic foods • excessive coffee, tea, cola, alcohol • spicy food • ?lactose Meera Kaur, PhD, RD

13. 13 Management of Diarrhea • Nutrition • avoid foods likely to cause cramps • legumes, nuts, popcorn, onions, cabbage, radishes, Brussels sprouts, cauliflower, broccoli • low fat diet • consider food hypersensitivity • discontinue laxative, cathartics • Mucilage or Bran can be used (bulk) Meera Kaur, PhD, RD

14. 14 Irritable Bowel Syndrome • Treatment Includes • management of constipation and/or diarrhea • ease of spasms • reduction of intraluminal pressure • management of possible food intolerance • ease of mental stress • regulation of lifestyle with regard to rest, work, fluid intake, meal regulation, and elimination. Meera Kaur, PhD, RD

15. 15 Inflammatory Bowel Disease • Crohn’s Disease • Ulcerative Colitis Meera Kaur, PhD, RD

16. 16 Nutrition and IBD... • Malnutrition • nutrients lost through bleeding and diarrhea • medications take for IBD interact with nutrients • surgical removal of part of intestine • decreased intake due to pain Meera Kaur, PhD, RD

17. 17 Nutrition and IBD... • Mild Symptoms • normal diet • Moderate Symptoms • modifications may be required • Severe Symptoms • supplements may be necessary • Extreme Symptoms • enteral or parenteral feeding may be required Meera Kaur, PhD, RD

18. 18 Nutrition and IBD... • Carbohydrate • avoid simple sugars: diarrhea • avoid sugar alcohol: diarrhea • choose complex carbohydrates • Protein • due to losses, may need increased protein Meera Kaur, PhD, RD

19. 19 Nutrition and IBD • Fat • concentrated form of energy • if part of the bowel is rejected, possibility of fat malabsorption and steatorrhea • MCT oil and/or low fat diet Meera Kaur, PhD, RD

20. 20 Drug Nutrient Interactions • Drug Interactions • pain killers, tranquillizers constipation • Sulfasalazine  absorption of folic acid • Cholestyramine  absorption of vitamins A/D/E/K • Corticosteroids  absorption of protein and calcium • Antibiotics  absorption of vitamin K and biotin Meera Kaur, PhD, RD

21. 21 Common Problems: IBS/IBD... • Problems • Feeling full • pain • inflammation • strictures • Solutions • small frequent meals • snacks of nutritional supplements • not missing meals Meera Kaur, PhD, RD

22. 22 Common Problems: IBS/IBD... • Problems • Gas and bloating • Solutions • avoid gas causing foods • eat slowly • avoid stress • reduce fats • avoid ingesting air (gum, straws… Meera Kaur, PhD, RD

23. 23 Common Problems: IBS/IBD • Problems • Lactose Intolerance • Solutions • Try low lactose foods • Foods containing probiotics • Lactaid • Lactose free products • Calcium supplements or alternate source of calcium Meera Kaur, PhD, RD

24. 24 Other Suggestions for IBS/IBD • Avoid alcohol • Avoid caffeine, or have only with meals • Include multi vitamins • Elemental supplements for crohn’s • Vitamin B12 injections if ileum removed • TPN if required Meera Kaur, PhD, RD

25. 25 Probiotics • Definition • Probiotics are live microorganisms which when administered in adequate amount confer a health benefit on the host (FAO, 2001). Meera Kaur, PhD, RD

26. 26 Food Sources of Probiotics • Yogurt • Fermented soy products • Other fermented foods Meera Kaur, PhD, RD

27. 27 How do Probiotics work? • Modify GI Ecology because of its ability to • survive the harsh travel condition of upper GI tract • adhere to the epithelial of the intestine and colonize • compete with the pathogenic microorganisms for nutrient and colonization sites • secrete antibiotic-like substances called bacteriocins, and • provide nutritional services via synthesis of vitamins Meera Kaur, PhD, RD

28. 28 Why Probiotics?… • Research Suggests Probiotics Bacteria can • help reduce the risk of certain diarrhea, cancer, allergy, helicobacter pylori, UTIs • assist in managing lactose intolerance, IBD, hepatic encephalopathy, and • enhance the immune functions, overall health Meera Kaur, PhD, RD

29. 29 Why Probiotics? • Probiotics, GI-tract Functionality and Human Health Cluster -- experiences and prospects Meera Kaur, PhD, RD

30. 30 Nutrition Checklist... • Has there been a loss of more that 10% usual weight in the past 6 months? • For children and adolescents: Is growth slower than others of the same age? • Is the diet being limited in some way that may result in missing nutrients and energy? Meera Kaur, PhD, RD

31. 31 Nutrition Checklist • Is fibre being avoided? • Are milk or milk products being avoided? • Is a non-prescribed diet being followed? • Are meals or snacks being skipped, or is food consumption less than usual? • Are caffeine, alcohol, sugar or fat being substituted for other foods? Meera Kaur, PhD, RD

32. 32 Discussion Use of Synbiotics (probiotics+ plant fibre): Evidence of Significant Positive Outcome Topping (2007) :  risk of bowel cancer and ulcerative colitis Bengmark (2006) : Pancreatitis, trauma  immunoparalysis Bengmark (2005) : Critically ill  unwanted pathogens (c. diff) Bengmark (2005) : Clinical Medicine  reinforce immune system Rayes et al. (2005): Liver transplant  bacterial infection rate Bengmark (2004) : ITU  in septic morbidity Bengmark (2003) : Critically ill  research limited, but great hope for future; confirmed for LAB Olah et al. (2002 ): Acute pancreatitis pancreatic sepsis,  no. of surgical interventions Meera Kaur, PhD, RD

33. 33 My Mom • 70 year old widow, vegetarian. Since last 8 months she is suffering from episodes of copious diarrhea followed by constipation. Increasingly developed resistance to antidiarrhal medications. She is Diabetic (NIDDM) +BP and on medications. Poor GI functions. Can not tolerate most of the foods especially vegetables and fruits (cooked or raw). Oral Intake is always poor. My brother phoned me describing her chronic illness and asked dietary advise.What I did? Discussed with her doctor. We put her on a synbiotic capsule (one/day) for 40 days. Then I suggested to add plain yogurt (1-2 tsp) in most of the foods that she eats (rice, lentil, milk, stew,soup etc). Did it work? Meera Kaur, PhD, RD

34. 34 Implications for the Practitioners • Dietary fibre and probiotics (from natural sources such as yogurt) may be considered for the management of GI functions in health and diseases. • Whenever possible and applicable, LAB containing yogurt may be included in the diet of patients to improve liver function & to manage lactose intolerance, IBD and IBS. Meera Kaur, PhD, RD

35. 35 References • Topping, D (2007). “Cereal complex carbohydrates and their contribution to human health,”Journal of Cereal Science 46(3); 220-229 • Bengmark, S. (2006), “Aggressive management of surgical emergencies,” Annals of the Royal College of Surgeons of England 88(7); 624-629. • Bengmark, S.(2005), “Synbiotics and the mucosal barrier in critically ill patients,” Current opinionin gastroenterology 21(6); 712-716 • Bengmark, S. and Martindale R. (2005), “Prebiotics and synbiotics in clinical medicine,” Nutrition in Clinical Practice 20(2); 244-261 • Rayes N., Seehofer D. and Theruvath T., et al.(2005) , “Supply of pre- and probiotics reduces bacterial infection rates after liver transplantation - A randomized, double-blind trial,” American Journal of Transplantation 5(1); 125-130 • Bengmark, S.(2004), “Bio-ecological control of perioperative and ITU morbidity,”Langenbecks Archives of Surgery 389(2); 145-154 • Bengmark S.(2003), “Use of some pre-, pro- and synbiotics in critically ill patients,”Best Practice & Research in Clinical Gastroenterology17(5); 833-848 • Olah A., Belagyi T., Issekutz A., Gamal M. E. and Bengmark S.(2002), “ Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis,”The British journal of surgery 89(9); 1103-1107 Meera Kaur, PhD, RD

36. 36 Thank you for gracing the seminar!Any question? Meera Kaur, PhD, RD