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Issue 111 February 2016

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ISSN 1756-9567 (Online)

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Malabsorption

Beth Thompson

STUDENT CASE STUDY: Metabolic Syndrome Lori Warford-Woolgar

WEB WATCH RESOURCES AND UPDATES INTRODUCING OUR NEW EDITOR

EXTRA NHD ARTICLES FOR SUBSCRIBERS ONLY

Introducing NHD’s new Editor, Emma Coates . . .

Emma will be taking up the post of NHD Magazine’s Editor from the March issue and here she tells us a bit about her dietetic background and what she hopes for the future of NHD. It’s great to have you on board Emma.

Can you give us a brief outline of your dietetic background?

I studied for my BSc (Hons) in Dietetics at Leeds Metropolitan University, graduating in 2006 and was fortunate to find my first job that year, at the Countess of Chester Hospital. For around two and a half years I worked there as a Band 5 Dietitian, completing an excellent rotation through many specialisms, including surgical, cardiology, respiratory, renal, diabetes and my personal dietetic interest, paediatrics.

In 2008, a Band 6 paediatric position opened up at Wrexham Maelor Hospital, part of the Betsi Cadwaladr University Health Board (BCUHB) trust in North Wales, in my hometown. I jumped at the chance and applied. The following six years provided a large and varied paediatric caseload to manage in both the hospital and community setting.

Whilst at BCUHB, I embraced many opportunities to develop and expand my skills as a dietitian, including becoming part of the student training team, a BDA trade union representative, writing for NHD Magazine and guest lecturing for the University of Chester.

After eight and half years of working as an NHS dietitian, I moved into industry as metabolic dietitian/ brand manager for Dr Schar - Mevalia Low Protein. This is an exciting and challenging role where I manage the low protein brand for the company in the UK. My first year there been extraordinary, developing so many new skills and expanding my knowledge

greatly. I have no doubt that this next year with the company will bring even more opportunities to grow as a dietitian.

What are the hot topics in dietetics at present?

Depending on your specialism, anything can be a hot topic! However, the nutritional challenges at either end of the life span are always talking points.

Getting the best nutritional start in life is vital, as seen by the evidence from the www.thousanddays.org campaign. In contrast, the management of elderly care nutrition is a key issue to discuss, as the ageing population is ever increasing.

Keeping our nation healthy is always a source of great debate, whether it’s related to malnutrition (under nutrition) or the obesity/metabolic syndrome crisis. Amongst these discussions, there’s always the nitty gritty of how dietetics can offer efficient, effective, safe and value-for-money services. In the future, I see further developments in the use of ketogenic diets and possibly the role of nutrigenomics.

How do you see the NHD community supporting healthcare professionals in the field of nutrition and dietetics?

Over the years, NHD has been a great provider of current and relevant articles for the nutrition and dietetics community. Keeping abreast of hot topics and moving with the current trends, NHD is a good tool for topping up on the most recent information, research and guidelines in all things nutrition and dietetics. It provides an easy way NHDmag.com February 2016 - Issue 111

1

NHD’s new editor - NHD extra for dietitians and nutritionists to complete some CPD, learn something new, or just reinforce their current knowledge. Now, with excellent regular columns from contributors such as PENG and the NSPKU (IMD watch), as well as the great quality and variety of individual contributors we have, CPD has never been so easy or enjoyable!

Does technology have a major role to play in the industry?

Technology defines so much of what we do in our working lives. Accessing a wealth of information is a click of a button away, along with contacting or connecting with other dietitians and healthcare professionals around the world. The development and use of dietetic apps is growing and the role of social media has expanded over the last few years too. Having so much good quality information online at our fingertips, is a true feast for anyone with time to sit and read it!

NHD Magazine has embraced technological developments to ensure it stays up to date and creates the most accessible routes for its readers.

Our printed magazine is a handy digest size, compact enough to take along to clinics or on your commute to and from the office (not, however, if you’re driving!). Alternatively, if you prefer the paperless option, the NHD digital issues are great for reading on your smart phone

or tablet. Subscribers will be able to download this issue from our website (www.NHDmag.com) and will be able to print pages too. If it’s just a single article you’d like to read and keep, the magazine’s online CPD eArticle section is free for you to use - read the article, answer the questions, save and keep for your CPD portfolio.

NHD is also part of the online social media community via Facebook and Twitter. Unless you live in a cave, being part of the NHD readership is just so easy.

What’s your vision for NHD as you take over the role of Editor?

I am keen for all of the magazine’s current accolades to continue, but also to welcome new contributors, giving more dietitians, nutritionists and other healthcare professionals an opportunity to develop their skills as writers and share their information, experiences and best practice.

If you have an interest in writing for NHD, please email info@networkhealthgroup.co.uk.

We would love to hear from you.

Expanding our readership is important for me. Opening up NHD to students, dietetic assistants/technicians and nutritionists will hopefully encourage a new group of readers to enjoy all that NHD has to offer. Interaction with our readers is important; creating discussion and gaining feedback is key to the magazine’s ongoing success.

NH-eNews plus NHD eArticle with CPD

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ISSN 1756-956 (Online)

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STUDENT DIGEST - NHD extra

CASE STUDY: METABOLIC SYNDROME In the first of our case studies written with students of Nutrition and Dietetics in mind, Lori Warford-Woolgar provides us with an example case of a 64-year-old male with Metabolic Syndrome.

Lori WarfordWoolgar Registered Dietitian and Nutrition Research Consultant

Approximately one in five adult Canadians have metabolic syndrome.1 A person with metabolic syndrome is twice as likely to die from heart attack or stroke and three times as likely to have a heart attack or stroke when compared to people who do not have metabolic syndrome.2 The International Diabetes Federation (IDF) defines metabolic syndrome as a condition in which a person has central obesity in addition to any two of the following factors: elevated triglycerides (TG), reduced high den-sity lipoprotein (HDL) cholesterol, elevated blood pressure and elevated

fasting plasma glucose (FPG).3 The IDF recommends that primary intervention for the management of metabolic syndrome includes moderate restriction of energy intake to obtain a 5.0-10% decrease in body weight in the first year, increased physical activity and dietary changes

Case study RW is a 64-year-old male who works as a mine shaft hoist operator. He lives with his wife of 40 years who enjoys cooking and baking and packs his snacks/ lunches for work. His job is sedentary and he typically works 12-hour days. RW is 5’9” (175cm) tall and weighs 222lbs (100.8kg). The lowest weight he has been in the last five years is 215lbs (97.6kg). Although he tries to run on his treadmill at home, exercise is sporadic and is not part of his usual routine. RW was recently diagnosed with impaired fasting glucose (IFG) with a fasting plasma glucose (FPG) of 6.8mmol/L and dyslipidemia with a reduced HDL of 0.75mmol/L. He was diagnosed with hypertension (132/72 treated) about five years ago and has had gastro-oesophageal reflux disease (GORD) for several years.

RW is a non-smoker. He has a younger brother who survived a heart attack and underwent bypass surgery. RW’s current medications include Losaran 100mg OD to treat hypertension and Omeprazole 20mg BID to treat GORD.

Lori is a Registered Dietitian living in Canada. She has a Master’s Degree in Human Nutritional Sciences and enjoys critiquing nutrition research and analysing how the latest evidence can be applied to dietetic practice.

RW’s typical daily food intake: Breakfast: coffee with skimmed milk powder, two fried eggs and bacon, two slices wholemeal toast with non-hydrogenated butter and small glass of orange juice Snack: pudding cup (yoghurt/mousse) and apple Lunch: deli sandwich on wholemeal bread with lettuce, tomato and mayonnaise, chocolate chip cookies and tea with skimmed milk powder Snack: cheddar cheese, soda crackers and banana Supper: meat, potatoes, side vegetable and gravy or margarine, 1.0% milk and tea with skimmed milk powder and a bowl of cup of ice cream RW snacks before bed on processed cheese slices, ice cream, cookies and often has two evening drinks of rum and cola. RW admits he has a weakness for sweet foods. RW uses added salt at all meals.

NHDmag.com February 2016 - Issue 111

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STUDENT DIGEST - NHD extra Identification of nutritional need 1. Assessment Medical diagnosis: Metabolic syndrome (hypertension, dyslipidemia, IFG, obesity), GERD Anthropometric measurements: Height 5’9” (175cm); weight: 222lbs (100.8kg); BMI=32 indicating obesity; waist circumference 46” indicating very high risk for Type 2 diabetes, hypertension and cardiovascular disease.

Framingham Risk Score: 29.4% indicating high risk of cardiovascular event.

Dietary Intake Analysis: Food frequency questionnaire revealed total energy intake is approximate 3,600 calories/day with 30% of calories from total fat, 12% of calories from saturated fat and 20% of calories from sugar. Sodium intake 4,800mg/day. Fibre intake 25g/day Recommended body weight: 121lbs (55kg)-165lbs (75kg) based on BMI of 18-24.9. Client is 57lbs (25.9kg) over high end of ideal body weight range Estimated energy needs: 2,200 calories/day based on ideal body weight of 165lbs using Harris-Benedict Equation with activity factor of 1.3. Client is consuming 1,400 calories/day more than estimated energy needs. To initiate gradual weight loss 3,100 calories/day is recommended (current energy intake of 3,600 calories/day - 500 calories/day).

Nutrition Related Laboratory Values: FPG 6.8mmol/L, HDL 0.75mmol/L, blood pressure (treated) 132/72 Medications: Losartan 100mg OD, Omeprazole 20mg BID Readiness to change nutrition-related behaviours: Client is in the preparation stage of change. He monitors his blood glucose daily and is worried that he might develop Type 2 diabetes and/or have a heart attack. Client states morning FPG is usually 10mmol/L and two hours after a meal can range from 6.0-12mmol/L, which are slightly higher values than recommended by the Canadian Diabetes Association (FPG 4-7mmol/L and two hours post prandial 5.0-10mmol/L).4 Client is uncomfortable with his weight and is aware that he consumes too much sugary foods and requires more physical activity. Client admits that if he is aware there are sweets in the house it is difficult to resist the temptation of snacking on them in the evenings. Client is attempting to increase physical activity at home, but is finding it difficult to maintain a routine due to his long days at work.

2. Identification of nutrition and dietetic diagnosis Excess energy intake related to high fat and high sugar/sugary food consumption.

Excess saturated fat intake due to fried foods, large meat portions, high fat snack foods and added fats.

Excess sodium consumption related to added salt and select processed foods.

Moderate fibre intake.

Decreased physical activity.

3. Plan nutrition and dietetic intervention Nutrition prescription: 3,100 calories/day with 25% of calories from total fat, <7.0% of calories from saturated fat and 10% of calories from sugar. Limit sodium intake to 1,500-2,300mg/day. Increase fibre intake to 40g/day.

Motivational Interviewing: Meet with client and his wife to discuss alternatives to evening sugary snacks, such as almonds and grapes with milk or homemade low sugar/high fibre muffin and cheddar cheese with tea. Recipes provided. Discussed limiting two drinks of rum and cola to one evening a week. Provided examples of healthier breakfast choices, such as porridge and banana with tea or boiled egg with wholemeal toast and glass of fresh orange juice.

Discussed limiting the purchase of processed high fat and sugar foods. Suggested alternatives to salt in providing added flavour to foods and gave a list of how herbs and spices complement particular foods.

Reviewed portion sizes using food models so client could relate to what a healthy portion looks like. Explored ways to incorporate moderate exercise while at work, such as going for walks during breaks.

4

NHDmag.com February 2016 - Issue 111

STUDENT DIGEST- NHD extra 4. Implement nutrition and dietetic intervention Provided sample meal plan and discussed benefits of increased fibre intake and decreased, energy, fat, sugar and sodium intake. Plan to return to nutrition outpatient clinic in two weeks for continued lifestyle change intervention. Provided instruction on how to record three-day food intake record, which is to be completed three days prior to next follow-up appointment.

5. Monitor and review On a bi-weekly basis, monitor and review weight at home, record blood glucose values and dietary intake with particular emphasis on the need for decreased intake of energy, fat, sugar and sodium with increased intake of fibre. Discuss physical activity and how to include on a regular basis. Recheck FPG, HgA1C, blood lipids and blood pressure in 3/12.

6. Evaluation First two-week follow-up: Client has decreased weight by one pound. Three-day food record indicates daily caloric intake has decreased by 500 Calories/day to 3,100 calories/day with 28% of calories from total fat, 9.0% from saturated fat and 16% from sugar. Sodium intake has decreased to 3,000mg/day. Daily at-home recorded blood glucose values indicate FPG of 8.0mmol/L and two-hour post prandial of 8.0-10mmo/L. Client has been walking during breaks at work. Client has shown improvement in all areas of dietary intake and physical activity. Plan is continue two-week follow-up appointments to encourage lifestyle change.

References 1 Riediger ND, Clara I. Prevalence of metabolic syndrome in the Canadian adult population. CMAJ 2011; 184(15): E1127-E1134 2 Isomaa B, Almgren P, Tuomi T et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001; 24(4) 683-689 3 International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome. The International Diabetes Federation website.

Available at: www.idf.org/webdata/docs/MetS_def_update2006.pdf. Accessed October 19, 2015 4 Canadian Diabetes Association (2013). Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. The Canadian Diabetes Association website. Available at: http://guidelines.diabetes.ca/fullguidelines. Accessed December 8, 2015

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MALABSORPTION - NHD extra

Malabsorption examined: what, where and how?

Malabsorption is the term commonly used to describe the impairment of nutrient absorption, but it can also refer to the impairment of digestion, also known as maldigestion. It is the result of defects within either the membrane transport system or absorptive surface area of epithelial cells with in the small bowel.1 Beth Thompson Intestinal Failure and Acute Team Lead Dietitian, Royal Devon Exeter Hospital

There are three stages to normal nutrient absorption and malabsorption can occur at any of these (see Table 1).

Malabsorption can be split into the terms ‘Global’ or ‘Isolated’ malabsorption.2 Global refers to malabsorption which occurs due to either diffuse mucosal involvement or a reduction in the absorptive surface of the small bowel. A good example of this is coeliac disease, where damage to the brush border of the small bowel results in the impaired absorption of nearly all nutrients. 3 At the extreme, signs of global malabsorption include: pale; greasy; large volume foul smelling stools, along with weight loss despite

adequate nutritional intake. However, many patients may present with symptoms which mimic disorders such as Irritable Bowel Syndrome, therefore diagnosis may prove difficult. Signs of a single nutrient deficiency, such as Iron Deficiency Anaemia, may be an indicator of global malabsorption.2 Isolated malabsorption occurs due to interference to the absorption of a specific nutrient. This may result from bowel surgery and bowel resections and can be indicated by low serum concentrations of a specific nutrient (e.g. low B12 levels resulting in pernicious anaemia).2 This article is going to concentrate on the malabsorption of carbohydrates and

Table 1: Stages of absorption and what malabsorption can occur there.

Beth has seven years’ experience working in Gastroenterology and Colorectal Surgery. She has been working with Intestinal Failure patients for the last two and a half years and enjoys the challenge of working with this complex patient group.

6

Stage

Malabsorptive defect

Condition example

Luminal phase: This takes place at the brush border of epithelia cells within the small bowel.

Deficiency in digestive enzymes Diminished bile salt synthesis Impaired bile secretion Bile salt de-conjugation Increased bile salt loss Diminished gastric acid Diminished intrinsic factor Bacterial consumption of nutrients

Chronic pancreatitis

Mucosal (absorptive) phase: This is where nutrients are absorbed into the intestinal mucosa

Problems with Epithelial transport

Coeliac disease

Postabsorptive, processing phase: This is where nutrients are transported into the circulation

Increased mucosal permeability, or lymphatic obstruction

Protein losing enteropathy

NHDmag.com February 2016 - Issue 111

Cirrhosis Chronic cholestasis Bacterial overgrowth Ileal disease or resection Atrophic gastritis Pernicious anaemia vitamin B12 Bacterial overgrowth

MALABSORPTION - NHD extra fats. However, there are some general dietary principals to follow to help manage patients with malabsorption. These mainly concentrate on managing the symptoms of diarrhoea which occur in many cases of malabsorption. The most important factor is to identify the cause and, therefore, working in conjunction with a gastroenterologist is vital. The general dietary principles include: • Limit caffeinated drinks - caffeine is a gastric stimulant and may increase the transit of nutrients, promoting diarrhoea. Intakes of one to three cups a day are recommended. If patients normally consume more, then having decaffeinated alternatives is recommended.

• Limit fizzy, high sugar drinks. Again these can lead to increased volumes of diarrhoea. Diluting drinks with water may be beneficial if patients have difficulty in reducing their intakes.

• Replenish lost salt by adding salt to foods and having high salt foods such as crisps.

• Patients may benefit from an oral rehydration solution such as St Marks Solution or Diarolyte.

Checking urinary sodium levels (result <20) may help indicate if this is required.

• Increase patients’ energy intake. When patients are experiencing malabsorption, they may need to consume two to three times their estimated nutritional requirements to meet their nutritional needs. Therefore, there is a reliance on high energy foods and nutritional supplements may be beneficial.

• Liaise with physicians about the use of antidiarrhoeals such as Loperamide.

• In patients with known vitamin or mineral deficiencies, then supplementation at high levels may be required to replenish levels.

Supplementation should be monitored for maintenance levels.

Carbohydrate malabsorption

The most abundant carbohydrates in our diets are starch, sucrose and lactose. In order to be absorbed they need to be broken down into their monosaccharides and this occurs by both salivary and pancreatic amylase. For example, these enzymes break down starch into disaccharides and oligosaccharides which are then further degraded at the micro villus membrane. Here, brush border enzymes

(disaccharidases) hydrolyse the disaccharides into monosaccharides which are then absorbed by either active or passive processes.

Malabsorption of carbohydrates can, therefore, result from deficiencies in amylase (mainly pancreatic amylase), decreased disaccharidase activity in the epithelium of the small bowel or by a reduction in the absorptive area. Any carbohydrates which are not digested and absorbed in the small bowel, undergo bacterial degradation in the colon. This leads to fermentation and formation of short chain fatty acids, along with carbon dioxide, hydrogen and methane. When excessive fermentation occurs, it can lead to abdominal distension, excessive wind and acidic stools.

The diagnostic test for carbohydrate malabsorption is a hydrogen breath test. A malabsorption diagnosis is evidenced if the result is more than 20 parts per million above the patients baseline. This test is commonly used to diagnose lactose malabsorption.4 Lactose malabsorption

Lactose is the main sugar in all animal milk.

Lactose malabsorption is thought to be more common in people from India and South East Asia than people from northern Europe.5 In most people, the enzyme lactase has a reduced activity at the brush border once weaning has occurred and this reduced activity can cause symptoms after lactose indigestion. It is important to distinguish that malabsorption with regards to lactose refers to the inefficient digestion due to low lactase levels or other GI pathologies, whereas lactose intolerance refers to the symptoms caused by lactose malabsorption. These symptoms can range from diarrhoea, nausea, bloating, borborygmi, and abdominal pain.6 However lactose malabsorption has also been associated with skin disease, rheumatological complaints, chronic fatigue and failure to thrive in children.

Following a lactose-free diet will improve symptoms; however, in some cases, looking at the underlying disease may improve lactose absorption. For example, patients with small bowel Crohn’s disease are more likely to experience lactose intolerance than those with colonic Crohn’s. This is because it may occur due to bacterial overgrowth or increased transit, both of which may resolve with treatment.7 NHDmag.com February 2016 - Issue 111

7

MALABSORPTION - NHD extra Table 2: Lactose and calcium content of different milk products Food

Serving size

Lactose/calcium

Milk, full fat

1cup, 250ml

12g/285mg

Milk, semi-skimmed

1cup, 250ml

13g/340mg

Yoghurt, full fat

200g

9.0g/340mg

Yoghurt, low fat

200g

12g/420mg

Cheese, cheddar

30g

0.02g/260mg

Cheese, cottage Butter Ice cream

30g

0.1g/22mg

1 teaspoon

0.03 /1.0mg

2 scoops

50g/ 55mg

The dietary principles of managing lactose intolerance are as follows: • Reduce lactose intake to <12g/day (if taken with other food, patients may tolerate up to 18g/day).

• If having lactose-free alternatives such as soya, rice and oat milk, ensure that they are fortified with calcium.

• To ensure adequate calcium intakes, encourage intakes of calcium-containing foods such as: bread, dried fruit (figs), nuts, seeds, fish with edible bones and green vegetables such as broccoli.8 Fructose malabsorption

Like lactose, fructose intolerance arises from the symptoms caused by fructose malabsorption.

Fructose is highly fermented by bacteria in the gut which in some individuals leads to increased gas production, increased osmotic load and alterations in bowel habit, resulting in diarrhoea.

Recent research has shown that up to half the population cannot not completely absorb a loading does of 25g of fructose when tested by a hydrogen breath test.8 This appears to be more predominant in those who have a functional gut diagnosis such as Irritable Bowel Syndrome (IBS), a fact that has contributed to the success of the Low FODMAP diet in IBS treatment.9 Fructose in our diets appears in two forms, on its own as a monosaccharide and in its disaccharide form, sucrose. It is not known why, but fructose in its disaccharide form is more easily absorbed than in its monosaccharide form, which, therefore, suggests that it is not only the amount of fructose consumed which affects its absorption, but also what it is consumed with. Research has shown that fructose absorption is increased if it 8

NHDmag.com February 2016 - Issue 111

is consumed along with glucose, galactose and some amino acids, but its absorption is reduced if it is consumed with sorbitol.10 The dietary recommendations for fructose malabsorption are, therefore, to avoid: • fruits high in fructose, such as apples, pears, nectarines, peaches, plums, apricot, blackberry’s, watermelon and cherries; • have moderate amounts of other fruits - three portions a day, e.g. 1 banana, 1 orange, 10 grapes; • honey; • sugar-free items - generally these will contain sorbitol; • jams, yoghurts and spread that contain fructose - fructose syrup, glucose-fructose syrup, and high fructose corn syrup.

Fat malabsorption

Dietary fat mostly consists of triglycerides and digestion beginning in the upper GI with mastication and gastric mixing. The fat then undergoes hydrolysis by gastric lipase in the stomach and pancreatic lipase in the duodenum. It is these enzymes which break triglyceride molecules down into a two-monoglyceride and two fatty acid molecules. Bile salts then mix with these molecules to form liposomes, which are easily absorbed by enterocytes in the first two thirds of the jejunum.

The bile salts themselves are not absorbed, instead they enter the rest of the intestinal tract, where they are reabsorbed in the terminal ileum.11 Fat malabsorption presents as foul smelling, pale stools known as steatorrhea. Patients can experience this if they lack the necessary enzymes for fat digestion, or because they have a reduced absorptive area. Patients with short bowel syndrome are likely to experience a degree

MALABSORPTION - NHD extra Table 3: MCT Sip feeds and Shots Presentation

Kcal/ml

Protein g/ml

MCT%

Survimed® OPD Drink

200ml bottle

1.0

0.05

47.5

Vital® 1.5kcal

200ml bottle

1.5

0.07

63.6

Fresubin 5kcal Shot

120ml bottle

5.0

0

25.8

Liquigen

250ml bottle

4.5

0

96.4

400g can

0.9

0.03

75

MCT Pepdite 1+ Table 4: MCT Enteral Tube Feeds

Presentation

Kcal/ml

Protein g/ml

MCT%

Fresubin® HP Energy

Easybag

1.5

0.08

56.9

Reconvan®

Easybag

1.0

0.06

57.6

Survimed® OPD

Easybag

1.0

0.05

51.4

Survimed®OPD HN

Easybag

1.33

0.07

51.9

Tin

1.0-1.5

0.04-0.05

25.5

Peptamen® HN

Smartflex™

1.3

0.07

69.4

Peptamen® AF

Smartflex™

1.5

0.09

52.3

Peptamen®

Smartflex™

1.0

0.04

70.3

Nutrison Peptisorb

Glass bottle

1.0

0.04

47.1

Nutrison MCT

Glass bottle

1.0

0.05

60.6

Vital® 1.5kcal

RTH bottle

1.5

0.07

63.6

Perative®

RTH bottle

1.3

0.07

40

400g can

0.9

0.03

75

Modulen®

MCT Pepdite 1+

Table 5: Fat-free Sip Feeds & Shots Presentation

Kcal/ml

Protein g/ml

Fat g/ml

Ensure Plus juce

220ml bottle

1.5

0.05

0

Fresubin Jucy Drink

200ml bottle

1.5

0.04

0

Fortijuce

200ml bottle

1.5

0.04

0

Resource® Fruit

200ml bottle

1.3

0.04

0

ProSource Liquid

30ml pouch

3.3

0.33

0

of this if they have less than 100cm of jejunum left. Patients’ who have had their terminal ileum removed, may experience steatorrhea due to their inability to reabsorb bile salts (12). Patients with this usually respond to cholestyramine; however, those with a reduction in their terminal ileum may also experience bacterial overgrowth, which can defunction bile salts resulting in fat malabsorption. An empirical course of antibiotics can be used as treatment if this occurs.13 Those who malabsorb fat due to a lack of enzymes usually have pancreatic insufficiency.

This can be tested for by a faecal elastase test (<100ug Elastase/g stool = severe insufficiency)

and, therefore, have enzyme replacement therapy.14 This needs to be tailored to the patient who must be educated on identifying fat sources in their diets and the timings of the medications.15 There are no guidelines for the use of pancreatic enzymes, but it is recommended that doses are adjusted according to body weight and reported symptoms: • 500-2,500 units of lipase per kg body weight per meal • ≤10 000 units of lipase per kg/body weight per day • ≤4,000 units of lipase per g of dietary fat per day.16 NHDmag.com February 2016 - Issue 111

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MALABSORPTION - NHD extra In addition, the following recommendations for taking pancreatic enzymes are: • taken with meals and snacks containing fats, protein and carbohydrates (not simple sugars); • taken at the start of meals and with snacks or nutritious drinks; • only taken with cold drinks as hot ones may make them less effective; • for large meals or meal times lasting longer than 30 minutes take half the enzyme dose at the start of the meal and half in the middle of the meal.

In those experiencing fat malabsorption, a trial of reducing long chain fatty acids to less than 40g/day is thought to help reduce stool volume and fat content. This, however, may result in an inability to consume sufficient calories. Diets can be supplemented with medium chain fatty acids (MCT), to boost calorie intakes, but some MCT based supplements can cause nausea and osmotic diarrhoea so their use has to be carefully monitored.17 If fat malabsorption occurs due to short bowel syndrome, then the use of MCT is recommended in those who have a colon insitu, as this is their main absorptive site.18 Patients with fat malabsorption may experience a reduction in the absorption of fat

soluble vitamins (A, D, E and K). The excessive fatty acids in the intestinal lumen which occur due to malabsorption can bind to calcium and magnesium causing a loss of these minerals, therefore, monitoring of these levels should take place on a regular basis. If these are calcium and magnesium low, then parathyroid (PTH) function testing should take place. Low magnesium can lead to low PTH, which in turn lowers calcium, therefore, supplementing magnesium may help to increase calcium levels.

Calcium levels should also be monitored when supplementing vitamin D, as this can cause increased calcium levels.19 In summary, malabsorption is the impairment of nutrient absorption. It can arise from impaired enzyme activity, a reduction in the absorptive area or a disturbance to the epithelial cells in the small bowel. Management should concentrate on identifying the cause of the malabsorption and, therefore, working with the clinicians is vital. The dietitian’s role is to help aid symptom management and, once a diagnosis has been made, to educate the patient on the best dietary treatment to ensure their nutritional status is maintained. Treatment may involve education on food restrictions, the use of enzyme replacements and the supplementation of micronutrients.

References 1 Z Vaníčková et al (2012). New trends in classification, monitoring and management of gastrointestinal diseases handbook - Screening and confirmation of malabsorption The 12th EFLM Continuous Postgraduate Course in Clinical Chemistry book 2 Keller J, Layer P (2014). The pathophysiology of malabsorption, Viszeralmedizin Gastrointestinal medicine and surgery 30:150-154 3 Fasano A, Catassi C (2001). Current approaches to diagnosis and treatment of celiac disease: An evolving spectrum 120, 3:636-651 4 Lindberg DA (2010). Hydrogen breath testing in adults: what is it and why is it performed. Vol 33/2(8-13), 1042895X 5 Misselwitz B et al (2013). Lactose malabsorption and intolerance: pathogenesis, diagnosis and treatment. United European Gastroenterology Journal 1(3) 151-159 6 Hammer F (2012). Diarrhea caused by carbohydrate malabsorption. Gastroenterology clinics of North America, vol. 41, no. 3, p. 611-627 7 Zhao, J. (2010) Lactose intolerance in patients with chronic functional diarrhoea: the role of small intestinal bacterial overgrowth Aliment Pharmacol Ther 31, 892–900 8 Allergy UK [online] http://www.allergyuk.org/common-food-intolerances/dairy-intolerance#non-dairy-sources-of-calcium (accessed 2015) 9 Shepherd, S (2006) Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management Journal of the American Dietetic Association Volume 106 (10):1631–1639 10 Kyaw, M et al (2011) Fructose malabsorption: true condition or a variance from normality. Journal of clinical gastroenterology, vol. 45, no. 1, p. 16-21 11 Truswell, M et al (1988) Incomplete absorption of pure fructose in healthy subjects Am JC/in Nuir l988;48: 1424-30.

12 Gracie, D ,et al. (2012) Prevalence of, and predictors of, bile acid malabsorption in outpatients with chronic diarrhea. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society, vol. 24, no. 11, p. 983 13 Quigley, E. and Small, M. (2014) Intestinal bacterial overgrowth: what it is and what it is not Current opinion in gastroenterology, vol. 30, no. 2, p. 141-146 14 Fieker , A. (2011) Enzyme replacement therapy for pancreatic insufficiency: present and future Clinical and Experimental Gastroenterology 2011:4 55–73 15 Domínguez-Muñoz et al (2011) Pancreatic exocrine insufficiency: Diagnosis and treatment Journal of Gastroenterology and Hepatology 26 (2); 12–16 16 Stallings VA, et al (2008). Evidence-Based Recommendations for Nutrition Related Management of Children and Adults with Cystic Fibrosis and Pancreatic Insufficiency: Results of a Systematic Review. J American Diet Assoc.; 108: 832-839.

17 Meiera, R. (2006) ESPEN Guidelines on Enteral Nutrition: Pancreas Clinical Nutrition 25, 275–284 18 Tappenden, K. (2014) Pathophysiology of Short Bowel Syndrome: Considerations of Resected and Residual Anatomy Journal of Parenteral and Enteral Nutrition Volume 38(1): 14S–22S 19 Edmée C.et al, (2013) The prevalence of fat-soluble vitamin deficiencies and a decreased bone mass in patients with chronic pancreatitis Pancreatology Vol 3:238–242

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NHDmag.com February 2016 - Issue 111

resources & guidance

web watch Online resources and useful updates.

Visit www.NHDmag.com for full listings.

Physical activity in the UK: future plans ActiveUK has published Blueprint for an Active Britain, a report which sets out clear and achievable recommendations to get the nation moving. www.ukactive.com/ policy-insight/blueprint-for-anactive-britain Giving children a healthy start in life The Local Government Association has published Healthy beginnings: Giving our children the best start in life focusing on how councils from across the country intend to develop their plans following the transfer of public health commissioning responsibilities for under-fives to local government. www.local.gov. uk/documents/10180/6869714/ L15-430+Healthy+Beginnings+-+G iving+our+children+the+best+start +in+life/9758666a-1b31-40e7-bc8562751bc13a35 Tackling childhood obesity NHS Clinical Commissioners has published Local solutions to national challenges putting forward a series of key ‘asks’ to policymakers, regulators and the government, aimed at giving CCGs the freedoms and flexibilities they need to transform healthcare for their local populations and concentrate on the big issues: sickness prevention, health inequality and healthcare targeted to the needs of the patient. www.nhscc.org/latest-news/ localsolutions/

European Food and Nutrition Action Plan 20152020 The World Health Organisation Regional Office for Europe has published European Food and Nutrition Action Plan 2015–2020 intended to significantly reduce the burden of preventable diet-related non-communicable diseases, obesity and all other forms of malnutrition still prevalent in the WHO European Region. www. euro.who.int/en/publications/ abstracts/european-food-andnutrition-action-plan-20152020 DIET PILLS WARNING The Medicines and Healthcare products Regulatory Agency are warning of the dangers of buying diet pills online. When considering whether to buy a product that describes itself as herbal or natural, consumers are advised to look for products that display the Traditional Herbal Registration (THR) logo and a THR/PL number. These products have been assessed by the MHRA. www.gov.uk/government/news/ dangerous-diet-pills-not-the-answerto-new-years-resolutions

Change4Life Sugar Smart app Public Health England has developed a Change4Life Sugar Smart app to raise awareness of how much sugar is contained in everyday food and drink. The app works by scanning barcodes and revealing total sugar in cubes or grams. itunes. apple.com/gb/app/change4lifesugar-swaps/id1015850256?mt=8

NICE guidance: Care of dying adults in the last days of life This guideline (NG31) aims to improve end of life care by communicating respectfully and involving the patient and the people important to them, in decisions and by maintaining their comfort and dignity. It also covers how to manage common symptoms without causing unacceptable side effects and maintain hydration in the last days of life. www.nice.org. uk/guidance/ng31 NICE guidance: Intravenous fluid therapy in children and young people in hospital This guideline (NG29)covers general principles for managing intravenous (IV) fluids for children and young people under 16 years, including assessing fluid and electrolyte status and prescribing IV fluid therapy. www.nice.org.uk/guidance/ng29 Allied Health Professionals: interventions to improve public health Public Health England has published The role of Allied Health Professionals (AHPs) in public health: examples of interventions delivered by AHPs that improve the public’s health. This report describes the key findings of work carried out by a team of academics led by Sheffield Hallam University. www.gov.uk/government/ publications/allied-healthprofessionals-interventions-thatimprove-public-health

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