Dichotomous effect of dietary fiber in pediatrics: a narrative review of the health benefits and tolerance of fiber

Dietary fibers are associated with favorable gastrointestinal, immune, and metabolic health outcomes when consumed at sufficient levels. Despite the well-described benefits of dietary fibers, children and adolescents continue to fall short of daily recommended levels. This gap in fiber intake (i.e., "fiber gap") might increase the risk of developing early-onset pediatric obesity and obesity-related comorbidities such as type 2 diabetes mellitus into adulthood. The structure-dependent physicochemical properties of dietary fiber are diverse. Differences in solubility, viscosity, water-holding capacity, binding capability, bulking effect, and fermentability influence the physiological effects of dietary fibers that aid in regulating appetite, glycemic and lipidemic responses, and inflammation. Of growing interest is the fermentation of fibers by the gut microbiota, which yields both beneficial and less favorable end-products such as short-chain fatty acids (e.g., acetate, propionate, and butyrate) that impart metabolic and immunomodulatory properties, and gases (e.g., hydrogen, carbon dioxide, and methane) that cause gastrointestinal symptoms, respectively. This narrative review summarizes (1) the implications of fibers on the gut microbiota and the pathophysiology of pediatric obesity, (2) some factors that potentially contribute to the fiber gap with an emphasis on undesirable gastrointestinal symptoms, (3) some methods to alleviate fiber-induced symptoms, and (4) the therapeutic potential of whole foods and commonly marketed fiber supplements for improved health in pediatric obesity.

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

Nutritional Considerations in Colorectal Surgery in Diverting Ileostomy Patients: A Review

Colorectal surgery often results in a temporary or permanent ileostomy construction. The general nutritional status and intake of patients with an ileostomy have not received much attention and scientific evidence is lacking. Nutritional complications associated with ileostomy formation and colonic exclusion include fluid (dehydration) and electrolyte abnormalities (mainly hyponatremia), impaired renal function occurring from plasma volume depletion, and reduced energy absorption due to the role of the large bowel in energy assimilation. People with ileostomies frequently avoid specific foods, due to concerns of possible malfunction or food blockages of their stoma, which may produce a negative effect on their overall dietary intake and nutritional status. The present article reviews the existing literature on nutritional considerations for those with an ileostomy and discusses measures to optimize overall nutritional status of this category of patients.

Nutritional Issues Faced by Patients with Intestinal Stoma: A Narrative Review

The incidences of colorectal cancer and inflammatory bowel diseases are increasing in the developed countries of Western Europe and North America, and consequently, the prevalence rate of temporary or permanent stomas has increased in recent years. Nevertheless, the amount of research in the nutrition field in the case of patients with stoma is rather limited. This review article aims to assess the impact of nutrition on an intestinal stoma and possible sequelae resolved with nutritional therapy. The research analyses conducted thus far indicate a significantly increased risk of developing malnutrition, vitamin deficiency (especially group B), and an increased number of discharges from the stoma and its relevance with abnormalities found in electrolyte concentrations.

Blood group B and decreased risk of coronary artery disease in hypertensive elderly

Although ABO blood groups have been associated with cardio-vascular disease, little is known about whether ABO blood groups contribute to the risk of the presence and severity of coronary artery disease (CAD) in elderly individuals with hypertension. This study was aimed to explore this as-sociation. A total of 793 hypertensive patients aged ≥60 years out of 2095 patients who underwent primary coronary angiography were retrospectively included. They were divided into CAD and non-CAD groups. Demographic and clinical characteristics, ABO blood groups and other biochemical parameters were compared. Further evaluation was performed to determine the impact of ABO blood groups on CAD severity using the Gensini score and the number of significantly diseased vessels. A logistic regression model was constructed to identify the association of ABO blood groups with CAD. There was a substantial difference in the distribution of ABO blood groups in elderly and hypertensive adults with and without CAD (p=0.022). Hypertensive patients with CAD had a significantly lower proportion of the blood group B than those without CAD (p=0.008). Compared to those with non-Blood group B, hypertensive elderly with a blood group B tended to have significantly lower concentrations of TC, LDL -C and Apo B, and a lower number of significantly stenosed vessels. The blood group B was found to be an independent protective factor for CAD in elderly with hypertension. The blood group B is significantly associated with a decreased risk of CAD and is inversely correlated with the severity of coronary stenosis in the elderly with hypertension.

Postoperative risks of stoma formation in patients with dementia

Stoma formation for patients with dementia presents an increasing problem in a global ageing population. While potentially lifesaving, stomas impose significant, long-term postoperative burdens on patients, and may particularly challenge those with cognitive impairment.In this case, a patient was considered for colostomy to manage a colovesical fistula. The patient's cognitive status significantly influenced clinicians' beliefs concerning suitability for stoma formation.The relevance of dementia to stoma formation is underdiscussed within the literature. In this report, we outline the postoperative risks to which those with dementia undergoing stoma formation are particularly vulnerable. These include increased risk of psychological harm, of relocation to a nursing home, and of stoma-related complications.We hope an increased appreciation of these postoperative challenges will inform decisions concerning suitability for stoma formation in this patient group.

Dietary management for people with an ileostomy: a scoping review

OBJECTIVE

The objective of this review was to identify and map the evidence for oral dietary management of ileostomies.

INTRODUCTION

Dietary advice is commonly provided for ileostomy management but can be inconsistent, conflicting, and inadequate. There is a lack of high-quality research investigating dietary management of ileostomies. This scoping review highlights gaps in the literature that need addressing to inform practice, and identifies dietary strategies and outcomes to be investigated in future studies.

INCLUSION CRITERIA

Evidence relating to the use of oral dietary strategies to manage complications and nutritional consequences associated with having an ileostomy was included. Evidence included all types of original research (ie, quantitative and qualitative methodologies, expert opinion articles, and consensus guidelines).

METHODS

This review followed JBI methodology for scoping reviews. A pre-determined search of 13 databases, including MEDLINE, Embase, and Web of Science, was conducted in August 2019. The search was not limited by date, but during screening, expert opinion evidence was limited to 2008 onward. Data extraction was carried out by two reviewers for each study/article using a database tool designed specifically for this review. Results are presented using a combination of tabular summaries and narrative reports.

RESULTS

Thirty-one research studies were included: 11 experimental (including four crossover randomized controlled trials), three pre-post design, 13 observational (12 cross-sectional, one longitudinal), and four qualitative. Forty-four expert opinion articles/guidelines were also included. In experimental studies, nine nutrient modifications and 34 individual foods/drinks were investigated. In pre-post studies, 10 nutrient modifications, 80 foods/drinks, and 11 eating-related behaviors were investigated. In observational studies, eight nutrient modifications, 94 foods/drinks, and five eating-related behaviors were reported. In qualitative studies, two nutrient modifications, 17 foods/drinks, and one eating-related behavior were reported. In expert opinion articles/guidelines, recommendations relating to 51 nutrient modifications, 339 foods/drinks, and 23 eating-related behaviors were reported. Although large numbers of individual foods and drinks were suggested to be associated with outcomes relating to ileostomy management, findings from observational studies showed these were generally reported by <50% of people with an ileostomy. The most common nutrients reported in association with outcomes related to ileostomy management were fiber, fat, and alcohol. Across most outcomes and studies/expert opinion, low fiber and low fat were suggested to be beneficial, while alcohol was detrimental. Other nutrient associations frequently reported in expert opinion (but with minimal attention in research studies) included negative consequences of caffeinated drinks and positive effects of white starchy carbohydrates on stoma output. Output volume and consistency were the most commonly reported outcomes relating to ileostomy management across all study types. Flatulence and odor were also common outcomes in observational studies.

CONCLUSIONS

This review found an abundance of literature, particularly expert opinion, reporting on dietary management for people with an ileostomy. However, this literature was highly heterogeneous in terms of dietary strategies and outcomes reported. It is likely that most dietary advice provided in practice is based on expert opinion with some supported by limited research. High-quality research investigating the effect of the dietary strategies identified in this review on commonly associated outcomes relating to ileostomy management is needed to improve evidence-based advice.

Stoma care: procedures, appliances and nursing considerations

Several diseases and operations may necessitate the need for the formation of a stoma. Patients who are affected may be concerned about the effect of the stoma on their ability to carry out activities of daily living, as well as how it will affect their quality of life. Nurses who may be involved in the care of patients with a stoma should have an understanding of the reasons for stoma formation, and the types of stoma and appliances available, to enable them educate and support patients, and to allay any concerns.

Provision of dietary advice for people with an ileostomy: a survey in the UK and Ireland

AIM

The aim was to explore whether people with an ileostomy in the UK and Ireland receive the dietary advice they require.

METHOD

An online survey with multiple-choice questions asked people with an ileostomy about the dietary advice they received and would have preferred to receive. Participants were recruited via websites of the Ileostomy and Internal Pouch Association and Crohn's and Colitis UK and via social media. People with a current ileostomy, age 16 years or over, and living in the UK or Ireland were eligible for inclusion. Responses were analysed using descriptive statistics.

RESULTS

In all, 291 eligible responses were received and included in the analysis; 201 (69%) received advice on diet for their ileostomy from a healthcare professional or the internet. Of the 90 who did not receive dietary advice, 82 (91%) would have liked advice. Stoma nurses were the most common source of dietary advice (55%), but many other sources were frequently reported. Most (62%) felt that at least some dietary advice they received was conflicting. Over half (55%) felt anxious about managing their diet with a new ileostomy, 39% were confused, and 31% frustrated. Of 291 respondents, 29% received advice from a dietitian compared to 60% who would have preferred advice from a dietitian.

CONCLUSION

Many people undergoing ileostomy surgery do not receive the dietary advice and support they require. Healthcare professionals working with people with an ileostomy should be mindful they are often anxious about their diet and require clear and consistent dietary advice and support.

Can Postoperative Nutrition be Favourably Maintained by Oral Diet in Patients with Emergency Temporary Ileostomy? A Tertiary Hospital Based Study

INTRODUCTION

Temporary ileostomy is an emergency procedure performed in cases having septic peritonitis in presence of perforation or obstruction or gangrene of small intestine. These patients usually suffer from gross malnutrition following surgery.

AIM

To measure nutritional status of patients with emergency temporary ileostomy and to determine whether their postoperative nutrition can be favourably maintained by oral diet alone.

MATERIALS AND METHODS

Sixty patients were enrolled for the study on the basis of inclusion and exclusion criteria during the study period from January 2012 to December 2013. Oral feeding was started as soon as ileostomy started functioning and patients expressed hunger, about 48-72 hours postoperatively. An individualized diet chart was formulated for each patient using Harris Benedict Equation. Nutritional assessment was done on 1) 1(st) day of oral feeding, 2) After 7 days of oral feeding, 3). After three months of oral feeding. Nutritional parameters (anthropometric, biochemical) employed were tabulated and statistically analysed with SPSS v 17, Chicago.

RESULTS

Out of 60 patients, 36 males and 24 females were enrolled in the study. The patients were in the age group of 20-60 years with a mean age of 45 years. After 7 days of oral nutrition the nutritional status deteriorated with a significant decrease in body weight (p<0.001) and serum haemoglobin (p <0.001). However, at the end of the study, the patients had their nutritional status restored satisfactorily with normalization of basic parameters like bodyweight, haemoglobin and serum albumin (p<0.001).

CONCLUSION

Proper dietary advice and oral nutrition were found to be sufficient for gradual restoration and maintenance of satisfactory nutritional status in the postoperative period.

Nutritional status of pediatric patients submitted to ostomy procedures

OBJECTIVE

To assess the nutritional status of children submitted to ostomy for intestinal discharge.

METHODS

A descriptive case series was carried out including 30 children aged up to ten years old submitted to colostomy or ileostomy at the pediatric surgery unit of Institute of Medicine Professor Fernando Figueira, Recife, Pernambuco. Socioeconomic, clinical, anthropometric, and laboratorial (hemoglobin and hematocrit) data were collected using a structured questionnaire. Nutritional status was determined based on anthropometric indicators (height/age, weight/age, and body mass index/age), which were stratified by gender, with World Health Organization standards as reference. Arm circumference and triceps skinfold were measured for the evaluation of body composition. Chest and head perimeters were measured on children aged up to five years-old. The Student's t-test was applied to compare two independent groups, considering p<0.05 as significant.

RESULTS

All anthropometric indicators revealed nutritional deficit, especially in the height/age index, which revealed a frequency of 24.1% of short statue. Patients submitted to ileostomy presented lower mean Z score of anthropometric indicators, hemoglobin, hematocrit and ostomy time in comparison to those submitted to colostomy, with significant differences only for the Z score of body mass index/age (p=0.016), hemoglobin (p=0.025), and hematocrit (p=0.023).

CONCLUSIONS

There is a substantial frequency of nutritional deficit in the analyzed sample, especially based on the height/age index. Although ileostomized patients had less time of ostomy, they had higher nutritional deficit compared to the colostomized ones, likely due to greater risk of postoperative complications, with consequent nutritional impairment.

Rehabilitation needs following stoma formation: a patient survey

This article reports the findings from a patient survey which examined rehabilitation needs following stoma formation at an acute NHS trust within Greater London. Of the 203 questionnaires sent, 100 were returned (49% response rate). Two-thirds of the sample (71%) reported experiencing stoma-related complications, and a third of the sample (33%) experienced difficulties receiving their stoma prescriptions on time. Information and support requirements were reported to be most acute during the first six weeks following discharge. Additionally, return to work was a major transition for those of working age, testing their physical health and social confidence. Accessible specialist support is essential during the first few weeks of this rehabilitation process and much perceived benefit is gained from continued nursing support in the community.

Providing information and advice on diet to stoma patients

The community nurse will encounter many queries and requests for advice in the work environment. This article offers information on diet related to the stoma. Specific advice for the three different types of stoma, and for certain situations that might arise after the ostomate (person with a stoma) is discharged home, is provided. Much of the advice is common sense, but it might prevent the use of medication such as laxatives. Nutrition is essential for recovery following surgery and in the long-term. By using the information provided, the community nurse can give better care to this group of patients.

Nutrition considerations surrounding restorative proctocolectomy

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for patients with ulcerative colitis and familial polyposis coli syndromes. Pouch construction uses the distal 30-40 cm of ileum, and there exists a potential for postoperative nutrition consequences. These include vitamin B(12) deficiency, iron deficiency, bile acid malabsorption, and abnormalities of trace elements, fluids, and electrolytes. Patients who have undergone an ileal pouch-anal anastomosis procedure often describe specific food sensitivities that may require diet alteration, even more so than do patients with permanent ileostomy. There may be roles for postoperative probiotic supplementation in an attempt to decrease the rate of "pouchitis" and appropriate preoperative nutrition support to minimize the risk of perioperative complications.

Managing a colostomy or ileostomy in community nursing practice

After stoma formation the patient should be independent with their own stoma care. However, with emphasis being placed on community nurses for ongoing aftercare of ostomates: Skingley (2004) has asserted that many community nurses did not feel confident undertaking stoma care. This article is ideally placed for the community nurses to obtain a broad overview of some of the key points pertaining to stoma care. The article looks at care of ostomates and ileostomates in relation to available appliances and also discusses dietary recommendations.