Dietary advice for patients with GI conditions  

Patients often present to their GP with gut symptoms or specific gastrointestinal disorders in which diet can play a significant role.
This article addresses common conditions and provides advice on how they can be improved through simple diet and lifestyle changes

Patients with chronic pancreatitis in particular benefit from dietetic input, especially if they are underweight or at risk of malnutrition.

Generally speaking, small regular meals are better tolerated than large meals and doses of pancreatic enzyme replacement therapy (PERT) can be easily adjusted depending on the patient’s symptoms and goals. It is no longer advised that people with chronic pancreatitis follow a low-fat diet. It is important, however, that patients are educated about which foods are high in fat, so that they can adjust their dose of PERT accordingly.

Dietary fat restriction may be considered if symptoms of steatorrhoea cannot be controlled (ESPEN Guideline, 2020). In these patients, personalised advice on reducing fat intake whilst maintaining adequate nutrition is important as not doing so increases the risk of nutritional deficiencies. Restricting fat intake can be particularly challenging for a patient who is already underweight or at risk of malnutrition, so dietetic support may be considered to help the patient manage their symptoms and nutritional intake effectively.

Heartburn/acid reflux

Simple diet and lifestyle adjustments can be hugely helpful in the successful management of heartburn and acid reflux.

Exploring eating habits as a potential contributor to symptoms will be relevant for most patients. Those who eat their food very quickly, or who do not chew their food thoroughly, are more likely to experience upper GI symptoms. Therefore, encouraging patients to slow down their speed of eating and to spend at least 10 minutes eating a meal while sitting at the table can help to significantly reduce symptoms. Sipping on fluids at meals is allowed, but drinking very large volumes alongside eating should be discouraged.

It is important to consider portion sizes as a potential trigger also, as many patients may be consuming large volumes of food in a short space of time, overfilling the stomach, and increasing pressure on the lower oesophageal sphincter.

Alongside the advice above, patients may benefit from a period of eliminating or reducing their intake of specific foods that are commonly known culprits for acid reflux. Some examples include fatty foods, spicy foods, chocolate, peppermint, and acidic foods such as tomatoes and citrus fruits. Liquids such as caffeine, alcohol, and carbonated drinks, also have potential to exacerbate symptoms, so limiting these can prove successful for many.

Stress is another very common but often overlooked contributor to acid reflux. Raising awareness of this with patients and encouraging them to identify and address key stressors in their lives can be a lifelong strategy for managing heartburn/acid reflux and any lower gut symptoms they may be experiencing alongside. Some people will have the ability to manage their stress through subtle changes and regular relaxation/exercise, while others may benefit from a referral for additional support, if needed.

Finally, additional strategies that can minimise symptoms include:

• Avoid wearing very tight clothing as this can put a lot of pressure on the digestive system.

• Leave at least two-to-three hours between eating and going to bed.

• Be mindful of leaning over soon after eating when the stomach is full.

• Stop smoking.

• Resolve constipation, if present. (Please see the section below on the diet and lifestyle management of constipation).

Diverticular disease

This condition is best managed through a high-fibre diet, with the ultimate goal of promoting regular comfortable bowel movements, to prevent constipation and flare-ups. In the case of diverticulitis, the opposite is true, where a low-fibre diet is advised until symptoms have settled down.

A high-fibre diet is considered to be one that provides 25-to-35g of fibre daily. Approximately 80 per cent of Irish adults do not eat enough fibre, so it is likely that the majority of patients with diverticular disease would benefit from increasing their fibre intake.

Educating patients about dietary fibre sources and encouraging them to eat more fruit, vegetables, nuts, seeds, wholegrains, and pulses will support them in optimising their fibre intake and managing diverticular disease successfully. There can often be concern about eating nuts and seeds in patients with diverticular disease, so in this case, milled seeds, nut butters, and ground nuts are good alternatives. Including nuts and seeds in these forms instead of eliminating all nuts and seeds completely ensures that patients are not missing out on the fibre, healthy fats, and the abundance of vitamins and minerals that nuts and seeds have to offer.

Below are some examples of fibre-containing foods and their fibre content per 100g:

• Oats = 7.8g;

• Wholegrain bread = 7g;

• Wholewheat pasta = 4.4g;

• Almonds = 15.9g;

• Hazelnuts = 9.4g;

• Sunflower seeds = 7.1g;

• Baked beans = 4.9g;

• Lentils = 3.8g;

• Chickpeas = 4.8g;

• Broccoli = 4.8g;

• Carrots = 3.9g

• Sweet potato = 2.2g

• Bananas = 1.4g;

• Strawberries = 3.8g;

• Plums = 2.3g.

Patients should be advised to increase their fibre intake slowly and ensure adequate hydration as a high fibre diet alongside poor fluid intake can cause constipation and exacerbate gut symptoms.

Constipation

Some of the most common causes of constipation are related to inadequate fibre intake, not drinking enough fluids, or being physically inactive. So when it comes to constipation, think: Fibre, fluid, movement.

As well as the high fibre diet outlined in the section on diverticular disease, below are some additional strategies that are beneficial for constipation.

Encouraging patients to have a high fibre breakfast in the morning is advisable as this takes advantage of the natural gastro-colic reflex that is strongest at this time. Having regular and structured meal times, avoiding long gaps between meals, and limiting ‘grazing’ on foods throughout the day, all help to support a healthy bowel routine.

Educating patients on correct toilet positioning can be helpful in general, and particularly useful for patients complaining of incomplete evacuation or straining when they open their bowels. Pelvic floor dysfunction may also be considered and a referral to physiotherapy for assessment should be arranged, if required.

Below are some examples of quick-wins for constipation:

• Eating two kiwi fruits per day. Kiwis have been studied in constipation and have been shown to increase the number of bowel movements and improve the consistency of stools in those with constipation (when eaten daily on a consistent basis).

• Linseed/flaxseed has also been shown to help relieve constipation. Starting with a small amount; eg, one teaspoon and building up over a few weeks to one-to-two tablespoons. Note that additional fluid will need to be consumed when taking flaxseed/linseed as they absorb a lot of water.

• Certain foods such as prunes/prune juice have a natural laxative effect, so adding these to the diet daily can aid more comfortable bowel movements.

In some cases, certain fibre supplements such as psyllium husk may be recommended for constipation. This type of fibre is helpful for constipation because it helps to soften the stool, making it easier to pass.

[Diverticular disease] is best managed through a high-fibre diet, with the ultimate goal of promoting regular comfortable bowel movements, to prevent constipation and flare-ups

IBS/bloating/wind

Irritable bowel syndrome (IBS) and its associated symptoms are a common reason for patients to visit their GP.

There is a myriad of reasons why a person may be experiencing bloating, wind, or abdominal pain. Some common causes may be a high-fibre intake, high intake of animal protein, large portions, fermented foods, alcohol, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) foods – the list goes on and it often takes time to figure out what specifically is triggering symptoms.

Below are some suggestions to offer patients, depending on their suspected triggers:

• Adjust fibre intake (up or down, depending on baseline intake).

• Adjust intake of FODMAP foods with dietetic support.

• Reduce intake of cruciferous vegetables.

• Reduce fatty and processed foods.

• Reduce portion sizes – tuning into hunger and fullness cues.

• Slow down eating and chew each mouthful of food to puree consistency.

• Reduce intake of fermented foods (if large amounts eaten).

• Limit caffeine, alcohol, and carbonated drinks.

• Avoid chewing gum.

• Avoid drinking through a straw.

• Manage chronic stress, particularly taking deep breaths before and after meals to encourage ‘rest and digest’ and blood flow to the gut.

• Eat meals at the table and without distractions, eg, away from TV or phone.

• Reduce intake of animal proteins or protein supplements (if intake is high).

• Resolve constipation or consider other causes of bloating/wind, eg, small intestinal bacterial overgrowth (SIBO).

• Establish a regular meal pattern.

• Get regular exercise.

• Trial a probiotic that has been shown to have beneficial effects in IBS.

If first-line diet and lifestyle advice is unsuccessful, referring the patient to a dietitian for advice on the low FODMAP diet may be beneficial. It is important that patients are made aware that the low FODMAP diet is temporary and is part of the three-step low FODMAP process to identify their personal food intolerances.