Nutrition for Patients with Upper Gastrointestinal Disorders

Check Your Knowledge

True	False
□	□	1	People who have nausea should avoid liquids with meals.
□	□	2	Thin liquids, such as clear juices and clear broths, are usually the easiest items to swallow for patients with dysphagia.
□	□	3	All patients with dysphagia are given solid foods in pureed form.
□	□	4	Central obesity is more closely correlated to gastroesophageal reflux disease (GERD) than is body mass index (BMI).
□	□	5	High-fat meals may trigger symptoms of GERD.
□	□	6	Ulcer pain is often worse when the stomach is empty.
□	□	7	Spicy foods cause ulcers in susceptible people.
□	□	8	A bland diet promotes healing of peptic ulcers.
□	□	9	People with dumping syndrome should avoid sweets and sugars.
□	□	10	Pernicious anemia is a potential complication of gastric surgery.

Learning Objectives

Upon completion of this chapter, you will be able to

1 Give examples of ways to promote eating in people with anorexia.

2 Describe nutrition interventions that may help maximize intake in people who have nausea.

3 Compare the three levels of solid food textures included in the National Dysphagia Diet.

4 Compare the four liquid consistencies included in the National Dysphagia Diet.

5 Describe nutrition therapy recommendations for someone with gastroesophageal reflux disease (GERD).

6 Teach a patient about the role of nutrition therapy in the treatment of peptic ulcer disease.

7 List possible nutrition strategies for patients with gastroparesis.

8 Give examples of nutrition therapy recommendations for people experiencing dumping syndrome.

Table 17.1 The Role of the Upper Gastrointestinal Tract in the Mechanical and Chemical Digestion of Food

Site	Mechanical Digestion	Chemical Digestion
Mouth	Chewing breaks down food into smaller particles. Food mixes with saliva for ease in swallowing.	Saliva contains lingual lipase, which has a limited role in the digestion of fat, and salivary amylase, which begins the process of starch digestion. Food is not held in the mouth long enough for significant digestion to occur there.
Esophagus	Propels food downward into the stomach Lower esophageal sphincter relaxes to move food into stomach.	None
Stomach	Churns and mixes food with digestive enzymes to reduce it to a thin liquid called chyme Forward and backward mixing motion at the pyloric sphincter pushes small amounts of chyme into the duodenum.	Secretes pepsin, which begins to break down protein into polypeptides Secretes gastric lipase, which has a limited role in fat digestion Secretes intrinsic factor, necessary for the absorption of vitamin B₁₂ Absorbs some water, electrolytes, certain drugs, and alcohol

Nutrition therapy is used in treating many digestive system disorders. For many disorders, diet merely plays a supportive role in alleviating symptoms rather than altering the course of the disease. For other gastrointestinal (GI) disorders, nutrition therapy is the cornerstone of treatment. Frequently, nutrition therapy is needed to restore nutritional status that has been compromised by dysfunction or disease.

This chapter begins with disorders that affect eating and covers disorders of the upper GI tract (mouth, esophagus, and stomach) that have nutritional implications. Table 17.1 outlines the roles these sites play in the mechanical and chemical digestion of food. Problems with the upper GI tract affect nutrition mostly by affecting food intake and tolerance to particular foods or textures. Nutrition-focused assessment criteria for upper GI tract disorders are listed in Box 17.1.

BOX 17.1 Nutrition-Focused Assessment for Upper Gastrointestinal Disorders

GI symptoms that interfere with intake such as anorexia, early satiety, difficulty chewing and swallowing, nausea and vomiting, heartburn
Changes in eating made in response to symptoms
Complications that affect nutritional status, such as weight loss, aspiration pneumonia, diarrhea
Usual pattern of eating and frequency of meals and snacks
Adequacy of intake according to MyPlate recommendations, including fluid intake
Use of tobacco, over-the-counter drugs for GI symptoms, and alcohol
Food allergies or intolerances, such as high-fat foods, citrus fruits, spicy food
Use of nutritional supplements including vitamins, minerals, fiber, and herbs
Client’s willingness to change his or her eating habits

DISORDERS THAT AFFECT EATING

Anorexia

Anorexia is a common symptom of many physical conditions and a side effect of certain drugs. Emotional issues, such as fear, anxiety, and depression, frequently cause anorexia. The aim of nutrition therapy is to stimulate the appetite to maintain adequate nutritional intake. The following interventions may help:

Anorexia lack of appetite; it differs from anorexia nervosa, a psychological condition characterized by denial of appetite.

Serve food attractively and season according to individual taste. If decreased ability to taste is contributing to anorexia, enhance food flavors with tart seasonings (e.g., orange juice, lemonade, vinegar, lemon juice) or strong seasonings (e.g., basil, oregano, rosemary, tarragon, mint).
Schedule procedures and medications when they are least likely to interfere with meals, if possible.
Control pain, nausea, or depression with medications as ordered.
Provide small, frequent meals.
Withhold beverages for 30 minutes before and after meals to avoid displacing the intake of more nutrient-dense foods.
Offer liquid supplements between meals for additional calories and protein if meal consumption is low.
Limit fat intake if fat is contributing to early satiety.

Nausea and Vomiting

Nausea and vomiting may be related to a decrease in gastric acid secretion, a decrease in digestive enzyme activity, a decrease in GI motility, gastric irritation, or acidosis. Other causes include bacterial and viral infection; increased intracranial pressure; equilibrium imbalance; liver, pancreatic, and gallbladder disorders; and pyloric or intestinal obstruction. Drugs and certain medical treatments may also contribute to nausea.

The short-term concern of nausea and vomiting is fluid and electrolyte balance, which can be maintained by intravenous (IV) administration until an oral intake resumes. With prolonged or intractable vomiting, dehydration and weight loss are concerns.

Intractable Vomiting vomiting that is difficult to manage or cure.

Nutrition intervention for nausea is a commonsense approach. Food is withheld until nausea subsides. When the patient is ready to eat, clear liquids are offered and progressed to a regular diet as tolerated. Small, frequent meals of low-fat, readily digested carbohydrates are usually best tolerated. Other strategies that may help are to

Encourage the patient to eat slowly and not to eat if he or she feels nauseated
Promote good oral hygiene with mouthwash and ice chips
Limit liquids with meals because they can cause a full, bloated feeling
Encourage a liberal fluid intake between meals with whatever liquids the patient can tolerate, such as clear soup, juice, gelatin, ginger ale, and popsicles
Serve foods at room temperature or chilled; hot foods may contribute to nausea
Avoid high-fat and spicy foods if they contribute to nausea

DISORDERS OF THE ESOPHAGUS

Symptoms of esophageal disorders range from difficulty swallowing and the sensation that something is stuck in the throat to heartburn and reflux. Dysphagia and gastroesophageal reflux disease are discussed next.

Dysphagia impaired ability to swallow.

Figure 17.1 ▶ Swallowing phases and symptoms of impairments.

Dysphagia

Swallowing is a complex series of events characterized by three basic phases (Fig. 17.1). Dysphagia is an impairment in the swallowing process. It can have a profound impact on intake, hydration status, and nutritional status and greatly increases the risk of aspiration and its complications of bacterial pneumonia and bronchial obstruction.

Although aging causes natural changes in the ability to swallow, dysphagia is often related to neurologic impairments, such as cerebral vascular accident, dementia, amyotrophic lateral sclerosis (ALS), myasthenia gravis, brain tumor, traumatic brain injury, cerebral palsy, Parkinson disease, and multiple sclerosis. Mechanical causes include obstruction, inflammation, edema, and surgery of the throat. Refer patients with actual or potential swallowing impairments to the speech pathology department for a swallowing evaluation.

Nutrition Therapy for Dysphagia

Viscosity the condition of being resistant to flow; having a heavy, gluey quality.

The goal of nutrition therapy for dysphagia is to modify the texture of foods and/or viscosity of liquids to enable the patient to achieve adequate nutrition and hydration
while decreasing the risk of aspiration. Solid foods may be minced, mashed, ground, or pureed, and thin liquids may be thickened to facilitate swallowing, but these measures often dilute the nutritional value of the diet and make food and beverages less appealing. Emotionally, dysphagia can affect quality of life; patients with dysphagia may feel panic at mealtime, avoid eating with others, and stop eating even when they still feel hungry. Meeting nutritional needs is a challenge, and in some instances, enteral nutrition may be necessary.

The National Dysphagia Diet, developed through consensus by a group of dietitians, speech-language pathologists (SLP), and researchers, standardized nutrition therapy for dysphagia on a national level (National Dysphagia Diet Task Force, 2002). The National Dysphagia Diet is composed of three levels of solid textures and four liquid consistencies (Table 17.2).

The levels of solid food and liquids are ordered separately to allow maximum flexibility and safety in meeting the patient’s needs. The patient may start at any of the levels. The solid food consistencies include pureed, mechanically altered, and a more advanced consistency of mixed
textures. The liquids are described as “thin,” “nectar-like,” “honey-like,” or “spoon-thick,” which means they are thick enough to require the use of a spoon.

Table 17.2 National Dysphagia Diet

Level of Diet	Description	Foods Allowed
Three levels of solid textures
Level 1: Pureed	Foods are totally pureed to a smooth, homogenous, and cohesive consistency. Eliminates sticky foods, such as peanut butter, and coarse-textured foods, such as nuts and raw fruits and vegetables	Smooth cooked cereals; slurried or pureed bread products; milk; smooth desserts such as yogurt, pudding, custard, and applesauce; pureed fruits, vegetables, meats, scrambled eggs, and soups
Level 2: Mechanically altered	Soft-textured, moist foods that are easily formed into a bolus. Eliminates coarse textures, nuts, and raw fruits and vegetables (except bananas)	Cooked cereals may have a little texture; some well-moistened, ready-to-eat cereals; well-moistened pancakes with syrup; slurried bread; moist well-cooked potatoes, noodles, and dumplings; soft poached or scrambled eggs; soft canned or cooked fruit; soft, well-cooked vegetables with 1/2 pieces (except no corn, peas, and other fibrous vegetables). Moist ground or minced tender meat in pieces no larger than 1/4 in, soft casseroles, cottage cheese, tofu; moist cobblers and moist soft cookies; soups with easy-to-chew meat or vegetables
Level 3: Advanced	Near-normal textured foods; excludes crunchy, sticky, or very hard foods. Food is bite-sized and moist.	All breads are allowed except for those that are crusty; moist cereals; most desserts except those with nuts, seeds, coconut, pineapple, or dried fruit; soft, peeled fruit without seeds; moist tender meats or casseroles with small pieces of meat; moist potatoes, rice, and stuffing; all soups except those with chewy meats or vegetables; most cooked, tender vegetables, except corn; shredded lettuce. No nuts, seeds, coconut, and chewy candy.
Four standard liquid consistencies
Thin	All regular unthickened beverages and supplements	Clear juices, frozen yogurt, ice cream, milk, water, coffee, tea, soda, broth, plain gelatin, liquidy fruits such as watermelon
Nectar-like	Liquids thicker than water but thin enough to sip through a straw	Nectars, vegetable juices, chocolate milk, buttermilk, thin milkshakes, cream soups, other properly thickened beverages
Honey-like	Liquids that are too thick to sip through a straw; can be eaten with a spoon but do not hold their shape	Honey, tomato sauce, yogurt
Spoon-thick	Liquids thickened to pudding consistency that need to be eaten with a spoon	Pudding, custard, hot cereal
*Source:* National Dysphagia Diet Task Force. (2002). The national dysphagia diet: Standardization for optimal care. Chicago, IL: American Dietetic Association.

Generally, a SLP performs a swallowing evaluation on the patient to determine the appropriate consistency of food and liquids and recommends feeding techniques based on the patient’s individual status. Changes to the diet prescription are made as the patient’s ability to swallow improves or deteriorates.

Solid Textures

Generally, moist, semisolid foods are easiest to swallow, such as pudding, custards, scrambled eggs, and yogurt, because they form a cohesive bolus that is more easily controlled. Dry, crumbly, and sticky foods are avoided. Some foods, such as bread, are slurried to create a texture easily swallowed while retaining the appearance of “regular” bread.

Pureed food is often described as having poor sensory appeal with items indistinguishable from one another (Keller & Duizer, 2014). Commercial thickeners added to pureed foods can allow pureed foods to be molded into the appearance of “normal” food (Fig. 17.2). However, a study comparing the acceptability of molded pureed meats and vegetables to the same items but in scooped form found the scooped pureed food was more acceptable and identifiable (Lepore, Sims, Gal, & Dahl, 2014). Although no one chooses to eat a pureed diet, many patients are grateful they can consume food orally.

Slurried a slurry is a thickener dissolved in liquid that is added to dry or pureed foods to produce a texture that is soft and cohesive.

Liquid Consistencies

Thickened liquids are more cohesive than thin liquids and are easier to control. Commercial thickening agents provide instructions on how to mix the product with liquids to achieve the desired consistency, yet wide variations in consistency occur depending on the beverage type,
type of thickener (e.g., starch based or gum based), temperature of the liquid, and time between thickened fluid preparation and service to the patient (Adeleye & Rachal, 2007). Commercially prepared thickened beverages eliminate issues related to quality control.

Figure 17.2 ▶ Examples of pureed and molded foods.

Thickened beverages are often poorly accepted, making it difficult to maintain an adequate fluid intake. Potential complications include dehydration, decreased compliance with swallowing guidelines, increased risk of aspiration pneumonia due to aspiration of thickened liquids, and decreased quality of life (Panther, 2005). Although thickened liquids may reduce the risk of aspiration in some patients, research suggests that drinking plain water alone is less likely to cause problems if it is aspirated than if it is consumed with food or other liquids. Consequently, free water protocols (FWP), such as the Frazier Free Water Protocol, are being used to permit patients with documented aspiration to drink plain water between meals (Garcia & Chambers, 2010). A randomized controlled trial of an FWP showed no adverse events from using the FWP and identified increased fluid intake and reported high quality of life outcomes among the FWP participants (Carlaw et al., 2011).

Only gold members can continue reading. Log In or Register to continue

Nurse Key

Fastest Nurse Insight Engine

Nutrition for Patients with Upper Gastrointestinal Disorders

Related

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree

Nurse Key

Fastest Nurse Insight Engine

Nutrition for Patients with Upper Gastrointestinal Disorders

Share this:

Related

Related posts:

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree