NMT150 Upper And Lower GI Symptoms PDF

UPPER AND LOWER GI SYMPTOMS AUTHOR: DR. MARYAM YAVARI, MD, PH.D., ND NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance for patients with GI disorders Dietary recommendations: Examples Diet: focus on intermittent fasting Supplements: focus...

UPPER AND LOWER GI SYMPTOMS AUTHOR: DR. MARYAM YAVARI, MD, PH.D., ND NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance for patients with GI disorders Dietary recommendations: Examples Diet: focus on intermittent fasting Supplements: focus on Zinc TREATMENT GOALS Address presenting symptoms and improve patient comfort Support full and speedy recovery to return to regular activities Patient education Monitor and Prevent sequelae  Examples of dietary recommendations for GI disorders Irritable bowel syndrome (IBS): The low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet is often recommended for people with IBS. This involves avoiding foods high in certain carbohydrates that may trigger IBS symptoms. Additionally, a diet rich in soluble fiber and probiotics may also be beneficial. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467063/  Examples of dietary recommendations for GI disorders Inflammatory bowel disease (IBD): For people with IBD, a low residue diet is often recommended during a flare-up to reduce inflammation and promote healing. This involves avoiding foods that are high in fiber and difficult to digest, such as raw fruits and vegetables, nuts, and seeds. A diet rich in protein and healthy fats may also be recommended to support healing. https://www.ucsfhealth.org/education/nutrition-tips-for-inflammatory-bowel-disease Examples of dietary recommendations for GI disorders Gastroesophageal reflux disease (GERD): For people with GERD, a diet low in acidic and spicy foods is often recommended to reduce symptoms. Additionally, eating smaller, more frequent meals and avoiding eating before bedtime may also be beneficial. Examples of dietary recommendations for GI disorders Celiac disease: A gluten-free diet is necessary for people with celiac disease, as consuming gluten can damage the small intestine and lead to various complications. This involves avoiding foods that contain wheat, barley, and rye, and opting for gluten-free alternatives.  Examples of dietary recommendations for GI disorders Diverticulitis: During a flare-up of diverticulitis, a low fiber diet is often (conflicting evidence) recommended to reduce inflammation and promote healing. This involves avoiding foods high in fiber, such as fruits, vegetables, and whole grains. Once symptoms have subsided, gradually increasing fiber intake may be recommended to prevent future flare-ups. According to some research, avoiding red meat and foods high in FODMAPs, sugar, and fat can help prevent diverticulitis flare-ups. Stam MA, Draaisma WA, van de Wall BJ, Bolkenstein HE, Consten EC, Broeders IA. An unrestricted diet for uncomplicated diverticulitis is safe: results of a prospective diverticulitis diet study. Colorectal Disease. 2017 Apr;19(4):372-7. Intermittent Fasting Intermittent Fasting Types of Intermittent Fasting Time-restricted feeding: Eating only during a certain time period, typically 8-10 hours per day. Alternate-day fasting: Fasting every other day or restricting calorie intake to 500-600 calories on fasting days. 5:2 fasting: Eating normally for five days and restricting calorie intake to 500-600 calories on two non- consecutive days. Potential side effects Hunger and cravings Digestive issues Irritability and other mood changes Sleep disturbances Headaches Fatigue Dehydration Who should avoid IF? People who are pregnant or nursing a child. Children and adolescents. Elderly individuals who suffer from feebleness. People with weakened immune systems. Individuals who have had or currently have eating disorders. Individuals with cognitive impairments or dementia. Those who have a history of traumatic brain injuries or post- concussive syndrome. Intermittent Fasting Health Benefits  Improved gut microbiome diversity IF may lead to remodeling and increased taxonomic diversity in the human gut microbiome. In particular, the Lachnospiraceae family of anaerobic bacteria increased during fasting. This family, in the order Clostridiales, promotes butryogenesis in the gut, a process that is associated with healthful metabolic and prolongevity effects. https://pubmed.ncbi.nlm.nih.gov/34039011/ https://pubmed.ncbi.nlm.nih.gov/33842951/  Reduced inflammation: IF reduced the levels of pro-inflammatory cytokines, such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), in the blood of participants. This reduction in inflammation was associated with improvements in insulin sensitivity and metabolic health. Reference: Vasconcelos AR, Yshii LM, Viel TA, et al. Intermittent fasting attenuates lipopolysaccharide-induced neuroinflammation and memory impairment. J Neuroinflammation. 2014;11:85. doi: 10.1186/1742-2094-11-85. https://clindiabetesendo.biomedcentral.com/articles/10.1186/s40842-020-00116-1  Improved insulin sensitivity Intermittent fasting diet intervention reduces fasting blood glucose, glycosylated hemoglobin, insulin plasma levels, and HOMA-IR, and improves insulin resistance in patients with disorders of glucose and lipid metabolism. Intermittent fasting diet intervention leads to a reduction in BMI, body weight, and waist circumference in these patients. Intermittent fasting diet intervention effectively reduces total cholesterol, low- density lipoprotein, and triglyceride levels in patients with metabolic syndrome. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8970877/ https://journals.physiology.org/doi/full/10.1152/japplphysiol.00683.2005  Reduced acid reflux: Post prandial acid exposure and reflux events were not increased in those who underwent intermittent fasting. Participants with borderline reflux at baseline showed a stronger trend toward benefit with intermittent fasting. Intermittent fasting was associated with a reduction in GERD symptom scores of heartburn and regurgitation. https://journals.lww.com/ajg/Fulltext/2021/10001/S485_The_Effects_of _Intermittent_Fasting_on.485.aspx  Effect of intermittent fasting on weight loss Meta-analyses showed that intermittent energy restriction was more effective than no treatment for weight loss (-4.14 kg). Intermittent energy restriction was comparable to continuous energy restriction for short-term weight loss in overweight and obese adults. Intermittent energy restriction may be an effective strategy for the treatment of overweight and obesity. Reference: Harris L, Hamilton S, Azevedo LB, et al. Intermittent fasting interventions for treatment of overweight and obesity in adults: a systematic review and meta-analysis. Obes Rev. 2018;19(1):1-13. doi: 10.1111/obr.12696.  Improved cardiovascular health Body weight and energy intake decreased in the time- restricted feeding group compared to controls over 12 weeks. Systolic blood pressure decreased in the time- restricted feeding group (-7 ± 2 mm Hg) compared to controls. Fat mass, lean mass, visceral fat mass, diastolic blood pressure, LDL cholesterol, HDL cholesterol, triglycerides, fasting glucose, fasting insulin, HOMA- IR, and homocysteine were not significantly different from controls after 12 weeks. Reference: Gabel K, Hoddy KK, Haggerty N, et al. Effects of 8-hour tim e restricted feeding on body weight and m etabolic disease risk factors in obese adults: A pilot study. Nutr Healthy Aging. 2018;4(4):345-353. doi: 10.3233/NHA-170036.  Decreased risk of chronic disease: Intermittent fasting may help to control diabetes, thyroid dis, and high blood pressure, elevated lipid levels, and maintained the body mass index; also, studies have shown its efficacy for treatment and prevention of cancer and neurodegenerative diseases. https://pubm ed.ncbi.nlm.nih.gov/34961463/  Effect on hormones Insulin: Intermittent fasting can improve insulin sensitivity and reduce insulin resistance. This can lead to lower blood sugar levels and a reduced risk of type 2 diabetes. Growth hormone: Intermittent fasting can increase growth hormone levels in the body, which may promote fat burning and muscle growth. Cortisol: Intermittent fasting can increase cortisol levels in the body, which is a stress hormone. However, this increase is typically short-term and may not have a negative impact on overall health. https://www.tandfonline.com/doi/full/10.4161/auto.6.6.12376  GI Disorders and Intermittent fasting Irritable bowel syndrome (IBS): Intermittent fasting has been found to reduce symptoms of IBS, such as bloating, gas, and abdominal pain. https://pubmed.ncbi.nlm.nih.gov/17078771/  GI Disorders and Intermittent fasting IBD: Studies on mice with colitis have shown that different types of intermittent fasting diets can improve gut inflammation, gut barrier function, and gut bacteria. Time restricted feeding and modified fasting have shown to be effective, while alternate day fasting showed potential harm and worsening of disease. The food eaten after fasting may impact intestinal health. One human study on participants with IBD who fasted for Ramadan did not show any correlation between fasting and quality of life, psychological state, or disease severity. https://www.ibdcentrebc.ca/2021/07/intermittent-fasting-on-ibd/  GI Disorders and Intermittent fasting Gastroesophageal reflux disease (GERD): Intermittent fasting has been found to improve symptoms of GERD, such as heartburn and regurgitation. https://www.medscape.com/viewarticle/984377#:~:text=%22Intermittent%20fasti ng%20may%20be%20recommended,work%20in%20patients%20with%20GERD.%22  GI Disorders and Intermittent fasting NAFLD: Potential mechanisms of action for effects of intermittent fasting in fatty liver dis. includes modulation of circadian rhythm, adipose tissue and adipokines, gut microbiome, and autophagy. Preclinical, epidemiological, and clinical trial data suggested clinical benefits of intermittent fasting on metabolic and inflammatory markers. Intermittent fasting is beneficial for weight management and liver enzyme improvement. https://pubm ed.ncbi.nlm.nih.gov/34322514/ https://www.m dpi.com /2072-6643/14/21/4655 Considerations for Intermittent Fasting Intermittent fasting may not be appropriate for everyone, especially those with certain medical conditions or taking certain medications. It's important to stay hydrated and consume nutrient-dense foods during the eating periods. Zinc and Digestive Health  Sources Shellfish, beef, and other red meats are rich sources of zinc and nuts and legumes are relatively good plant sources of zinc. Risk of Deficiency o Burns or prolonged diarrhea o Chronic alcohol abuse o Premature and low-birth-weight infants o Adolescents o Pregnant and lactating women o The elderly o Those with inflammatory bowel diseases o Strict vegetarians. Deficiency: Signs & symptoms Dermatitis, especially around orifices, impaired wound healing Diarrhea Impaired immune function Hair loss https://www.nejm.org/doi/full/10.1056/NEJMicm2003516 Deficiency: Signs & Symptoms Growth retardation and skeletal abnormalities Delayed sexual maturation Dysgeusia (impaired sense of taste) Night blindness White spots on fingernails https://pharmeasy.in/blog/signs-you-might-have-a-zinc- deficiency/  Clinical Indication: Common Cold The use of zinc lozenges within 24 hours of the onset of cold symptoms, and continued every two to three hours while awake until symptoms resolve, has been suggested for reducing the duration of the common cold. A systematic review and meta-analysis of 17 trials reported that compared with adult patients given placebo, those receiving zinc had a shorter duration of cold, but this was not the case with children. Singh M, Das RR. Zinc for the common cold. Cochrane Database Syst Rev. 2013;(6):CD001364. doi:10.1002/14651858.CD001364.pub4  Clinical Indications Diarrhea Taking zinc by mouth reduces the duration and severity of diarrhea in children who are undernourished. Zinc 20 mg daily is the most common dose used. But doses of 5-10 mg also seem to work and cause less vomiting. Stomach ulcers Taking zinc acexamate orally was effective in treating and preventing stomach ulcers. Bhutta ZA, Nizami SQ, Isani Z. Zinc supplementation in malnourished children with persistent diarrhea in Pakistan. Pediatrics. 1998;102(4 Pt 1):e42. doi:10.1542/peds.102.4.e42 Jácome-Pinilla D, Gutiérrez JM , Castro-M artínez EM , et al. Zinc acexamate reduces the severity of acetic acid-induced colitis in rats: A comparative study with sulfasalazine and olsalazine. Eur J Pharmacol. 2017;811:1-8. doi:10.1016/j.ejphar.2017.05.041.  Clinical Indications Acne Orally taking zinc may be beneficial in treating acne, although the efficacy of zinc compared to acne medications like tetracycline or minocycline is still not well understood. However, topical application of zinc alone through an ointment is not effective for treating acne. Child growth Taking zinc by mouth during pregnancy seems to help improve the growth of the infant during the first year of life. M ichaelsson G, Juhlin L, Vahlquist A. Effects of oral zinc and vitamin A in acne. Arch Dermatol. 1977;113(1):31-36. doi:10.1001/archderm.1977.01640010033006 King JC. Zinc: an essential but elusive nutrient. Am J Clin Nutr. 2011;94(2):679S-684S. doi:10.3945/ajcn.110.005744  Clinical Indications Age-related macular degeneration or AMD Zinc supplementation through oral intake, particularly when combined with antioxidant vitamins, may help slow down the progression of vision loss and prevent advanced age-related macular degeneration in individuals at high risk. Attention deficit-hyperactivity disorder (ADHD) In children, taking zinc orally in conjunction with ADHD medication was found to alleviate certain symptoms of the disorder such as hyperactivity, impulsivity, and impaired socialization. J Child Adolesc Psychopharmacol. 2014;24(6):311-318 (Arch Ophthalmol. 2001;119(10):1417-1436)  Clinical Indications Depression Taking zinc supplements orally in combination with antidepressant medication can improve symptoms of depression. It may also be effective for individuals who have not responded well to antidepressant treatment alone. Diabetes Zinc supplementation leads to a small but statistically significant reduction in fasting blood glucose levels in people with type 2 diabetes. https://academic.oup.com/advances/article/12/1/141/5877442 Swardfager W, Herrmann N, McIntyre RS, Mazereeuw G, Goldberger K, Cha DS, Schwartz Y, Lanctôt KL. Potential roles of zinc in the pathophysiology and treatment of major depressive disorder. Neurosci Biobehav Rev. 2013 Mar;37(5):911-29. doi: 10.1016/j.neubiorev.2013.03.018. Epub 2013 Apr 2. PMID: 23557911.  Clinical Indications Cold sores (herpes labialis) Topical application of zinc sulfate or zinc oxide alone or in combination with other ingredients may help to reduce the severity and duration of cold sores (herpes labialis). Reduced ability to taste (hypogeusia) Oral supplementation with zinc may improve taste function in individuals experiencing hypogeusia. a) Hemila H. Zinc lozenges and the common col:d a meta-analysis comparing zinc acetate and zinc gluconate, and the role of zinc dosage. JRSM Open. 2017 Feb;8(2):2054270417694291. doi: 10.1177/2054270417694291. PMID: 28246570. b) Godfrey HR, Godfrey NJ, Godfrey JC, Riley D. A randomized clinical trial on the treatment of oral herpes with topical zinc oxide/glycine. Altern Ther Health Med. 2001 Mar-Apr;7(2):49-54, 56-8. PMID: 11297004.  Therapeutic Dosage In deficiency 25-30 mg 1-3 times daily with meals is often supplemented for 2-3 months and then the dose is decreased to 10-20 mg per day for maintenance. When treating the common cold approximately 10 mg (in lozenge form) should be taken every 2-3 waking hours for up to 5 days.  Therapeutic Dosage Copper should be added when supplementing zinc for extended periods of time to prevent a copper deficiency. Dr. Alan Gaby suggests the following dosing: 1-2 mg/d copper for 15-30 mg/d zinc 2-3 mg/d copper for 30-60 mg/d zinc 3-4 mg/d copper for >60 mg/d zinc  Toxicity The primary consequence of consuming excessive amounts of zinc over the long term is a deficiency of copper. To prevent this, the Institute of Medicine has set a tolerable upper intake level of 40 mg/day for adults, which includes both dietary and supplemental zinc intakes. The intranasal application of zinc can result in permanent anosmia, or the loss of smell. As such, intranasal zinc gels and sprays should be avoided. a) US Food and Drug Administration. FDA W arns Consumers About Zicam Nasal Cold Remedy. Accessed M arch 2, 2023. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm16 6747.htm a) King JC, Cousins RJ. Zinc. In: Erdman JW , M acdonald IA, Zeisel SH, eds. Present Knowledge in Nutrition. 10th ed. John W iley & Sons, Inc.; 2012:442-457. doi: 10.1002/9781119946045.ch14. Toxicity UL = 40 mg Acute toxicity seen with ingestion of 225-450 mg Metallic taste Headache Nausea & vomiting Abdominal cramps Bloody diarrhea Nutrient Interactions Copper High zinc intake for an extended period of time can lead to a copper deficiency. Zinc intake stimulates the synthesis of thionine/metallothionine which has a higher binding affinity for copper than zinc and traps copper in the enterocyte which will be lost with the sloughing off of intestinal cells. Nutrient Interactions Vitamin A Zinc is required for the conversion of retinol to retinal. Zinc is also required for the synthesis of retinol binding protein therefore a zinc deficiency could result in decreased mobilization of retinol from liver stores. Calcium, magnesium, and iron may decrease zinc absorption and vice versa. REFERENCES CDC: https://www.cdc.gov/ Online source Center for Disease Control and Prevention Updates 2022 Prousky J. Textbook of Integrative Clinical Nutrition. CCNM Press Inc.; 2012. Katz D. Nutrition in Clinical Practice. 2nd Edition. Lippincott Williams & Wilkins; 2008. Katsilambros N. Clinical Nutrition in Practice. WileyBlackwell; 2010. Pizzorno J and Katzinger J. Clinical Pathophysiology. Mind Publishing; 2012. Marz RB. Medical Nutrition from Marz. 2nd edition. Quiet Lion Press; 1999. Murray MT. Encyclopedia of Nutritional Supplements. Prima Health; 1996. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 7th Ed. Cengage Learning; 2018. Gaby A. Nutritional Medicine.; Perlberg Publishing 2011. Hoffer A, Prousky J. Naturopathic Nutrition: A Guide to Nutrient-Rich Food & Nutritional Supplements for Optimal Health. CCNM Press; 2006. Prasad AS. Zinc: role in immunity, oxidative stress and chronic inflammation. Curr Opin Clin Nutr Metab Care. 2009;12(6):646-652. doi: 10.1097/MCO.0b013e3283312956 Patterson RE, Sears DD. Metabolic effects of intermittent fasting. Annu Rev Nutr. 2017;37:371-393. doi: 10.1146/annurev- nutr-071816-064634 Anton SD, Moehl K, Donahoo WT, et al. Flipping the Metabolic Switch: Understanding and Applying the Health Benefits of Fasting. Obesity (Silver Spring). 2018;26(2):254-268. doi: 10.1002/oby.22065 Mattson MP, Longo VD, Harvie M. Impact of intermittent fasting on health and disease processes. Ageing Res Rev. 2017;39:46-58. doi: 10.1016/j.arr.2016.10.005 de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381(26):2541- 2551. doi: 10.1056/NEJMra1905136 Vasconceloneuroinflammations AR, Yshii LM, Viel TA, et al. Intermittent fasting attenuates lipopolysaccharide- induced and memory impairment. J Neuroinflammation. 2014;11:85. doi: 10.1186/1742-2094-11-85 Klempel MC, Kroeger CM, Varady KA. Alternate day fasting (ADF) with a high-fat diet produces similar weight loss and cardio-protection as ADF with a low-fat diet. Metabolism. 2013;62(1):137-143. doi: 10.1016/j.metabol.2012.07.002 Alirezaei M, Kemball CC, Flynn CT, et al. Short-term fasting induces profound neuronal autophagy. Autophagy. 2010;6(6):702-710. doi: 10.4161/auto.6.6.12376 Varady KA, Hellerstein MK. Alternate-day fasting and chronic disease prevention: a review of human and animal trials. Am J Clin Nutr. 2007;86(1):7-13. doi: 10.1093/ajcn/86.1.7 Horne BD, Muhlestein JB, Anderson JL. Health effects of intermittent fasting: hormesis or harm? A systematic review. Am J Clin Nutr. 2015;102(2):464-470. doi: 10.3945/ajcn.115.109553 Wessells KR, Brown KH. Estimating the global prevalence of zinc deficiency: results based on zinc availability in national food supplies and the prevalence of stunting. PLoS One. 2012;7(11):e50568. doi: 10.1371/journal.pone.0050568 Chasapis CT, Spiliopoulou CA, Loutsidou AC, Stefanidou ME. Zinc and human health: an update. Arch Toxicol. 2012;86(4):521-534. doi: 10.1007/s00204-011-0775-1 THANK YOU!