Nutrition and Diet Therapy in Gastrointestinal Disease

485 Pages·1981·16.31 MB·English

by  Martin H. Floch M.S.

NUTRITION AND DIET THERAPY
IN GASTROINTESTINAL DISEASE
TOPICS IN GASTROENTEROLOGY
Series Editor: Howard M. Spiro, M.D.
Yale University School of Medicine
PANCREATITIS
Peter A. Banks, M.D.
MEDICAL ASPECTS OF DffiTARY FIBER
Edited by Gene A. Spiller and Ruth McPherson Kay
NUTRITION AND DIET mERAPY IN GASTROINTESTINAL DISEASE
Martin H. Floch, M.S., M.D., F.A.C.P.
A Continuation Order Plan is available for this series. A continuation order will bring
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upon actual shipment. For further information please contact the publisher.
NUTRITION AND DIET THERAPY
IN GASTROINTESTINAL DISEASE
Martin H. Floch, M.S., M.D., F.A.C.P.
Clinical Professor of Medicine
Yale University School of Medicine and
Chairman, Department of Medicine and
Chief, Section of Gastroenterology and Nutrition,
Norwalk Hospital
PLENUM MEDICAL BOOK COMPANY
NEW YORK AND LONDON
Library of Congress Cataloging in Publication Data
Floch, Martin H
Nutrition and diet therapy in gastrointestinal disease.
(Topics in gastroenterology)
Includes index.
1. Digestive organs-Diseases-Diet therapy. 2. Digestive organs- Diseases-
Nutritional aspects. 3. Nutrition. I. Title. II. Series.
RC802.F46 616.3'30654 80-20721
ISBN 978-1-4684-3793-5 ISBN 978-1-4684-3791-1 (eBook)
DOl 10.1007/978-1-4684-3791-1
© 1981 Plenum Publishing Corporation
Softcover reprint of the hardcover 1st edition 1981
233 Spring Street, New York, N. Y. 10013
Plenum Medical Book Company is an imprint of Plenum Publishing Corporation
All righ ts reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
To my wife, Gladys,
and our children,
Jeffrey, Craig, Lisa, and Neil
Foreword
A physician with a broad consultative practice, Dr. Floch combines his clinical
experience with a zeal for exploring what has been written by others. Chief of
Medicine at the Norwalk Hospital for the past decade and still an active consult
ing gastroenterologist, Dr. Floch has given us a volume which every clinician
dealing with digestive disorders will want to have at his or her desk.
Not everyone will agree with all that Dr. Floch has prescribed in the way of
detailed dietary help for the common afflictions of mankind's gut, but in this
book the reader can get at the background of the controversy. All clinicians have
had problems in assessing when to use elemental diets, how to apply advances in
peripheral and intravenous alimentation, and in many other matters which are
discussed in detail in this fine volume. Dr. Floch displays what is available in
dietary therapy, evaluates the nutritional inadequacies surrounding most diges
tive disturbances, and calmly evaluates competing claims. He gives a brief
overview of gastrointestinal physiology pertaining to an understanding of nutri
tional complications as well as the genesis of the major gastrointestinal dis
orders. In this sense his book can be read as a mini-physiological text.
I am delighted to have this book in our gastrointestinal series and I hope that
the reader will profit from it as much as I have. It should be of interest to medical
students, internists, and family practitioners, as well as to nutritionists, dieti
tians, and nurses for whom the vivid summaries of medical knowledge should
provide fine background information.
Howard M. Spiro, M.D.
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Preface
My involvement in the development of the field of gastroenterology during the
last 25 years has led me to the writing of this book. In the 1950s the invention of
peroral small-bowel biopsy techniques plunged gastroenterologists into inten
sive study of digestion and absorption of nutrients as they relate to small-bowel
structure and physiology. Diseases of malnutrition and malabsorption, e.g.,
tropical sprue and gluten enteropathy, were redefined.
In the 1960s the field turned to research on bile acids and the microflora.
The pathophysiology of gallstones was clarified and a possible medical therapy
developed. Quantitative and qualitative relationships of organisms within the
gut were more clearly defined and information came forth to explain some
important disease processes, e.g., hypersecretion in cholera.
In the 1970s the field of nutrition received a great thrust of interest with the
realization that lipids have a role in arteriosclerotic disease, and that the so
called underdeveloped societies of Asia and Africa have little of the degenera
tive diseases plaguing Western societies. While nutritionists were gaining
strength for their theories from these epidemiologic observations, most gas
troenterologists were ecstatically developing their new diagnostic flexible fiber
optic endoscopes so that the depths of the gut could be probed from without.
However, some continued to study nutrient metabolism as it related to the
intestine, while others opened new vistas by discovering a whole host of gut
proteins. These polypeptides were definitely classified as hormones and found
to be produced and involved in intestinal physiology, and hence related to
nutritional factors. It is at this point in history that the fields of gastroenterol
ogy and nutrition cross, and where I hope this book can help bring them
together.
The first section discusses basic gastrointestinal physiology as it relates to
nutrition. It includes chapters on eating; normal nutrient requirements; obser
vations on relationships of fiber to luminal metabolism; and how weight loss
occurs and is diagnosed.
The second section on pathophysiology relates disease processes to diet
therapy, an aspect of medicine that is still in its infancy. Diet therapy should
become the most important approach if the observations indicating that the gut
is the source of early control of metabolic disease are correct. The advent of
enteral and parenteral feedings changed the outlook in the early treatment of
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x PREFACE
anorexia nervosa. An understanding of the effects of foods on the lower eso
phageal sphincter gives us a new approach to the diet therapy of inflammatory
esophageal disease. The quandary that exists in dietary therapy of peptic dis
ease of the stomach and duodenum persists, but a realization that frequent
feeding of foods is helpful is now accepted as clinical fact. The treatment of
chronic liver disease with specific amino acids (branched chain) holds promise,
and, certainly, the manipulations of fluid and salt intake in conjunction with
vitamin and mineral replacement can be effective in maintaining cirrhotic sub
jects. The vast amount of information concerning physiologic factors in small
bowel disease is reviewed. The chapter on colon disease discusses the recent
advances in fiber and carbohydrate metabolism. The relationship of the irrita
ble bowel syndrome and food allergies to the gut is reviewed in detail.
A disease long considered primarily a hormonal metabolic disturbance,
diabetes mellitus, now appears to be modified by a high-carbohydrate diet. This
revolution in diet therapy in diabetes epitomized the role of the gut in systemic
disease.
The final section of the book reviews methods of nutrition therapy includ
ing enteral formulas, total parenteral nutrition, and 32 diet plans. Review of the
literature and diet manuals was a challenging event. The author would like to
point out the many different diet plan forms included in the book. Those se
lected have all been proven therapeutically successful, either in the literature
or in the author's own experience. Tables are included that I hope will be
useful. Each diet is cross-referenced to the text and recommended for specific
disease entities.
I would like to stress that diet therapy never causes a dramatic, rapid
response and both the patient and the therapist must have patience with it.
When the gastrointestinal evaluation is correct, there must be a valid trial
period that should not be rushed. A true test of the diet takes at least a fortnight
to a month. Only after that period of time can dietary failure be accepted.
Finally, success is dependent on patient education, an area that has been
greatly neglected. Often the diet is handed to a patient and that is the end of the
role of the nutritionist, dietitian, or physician. If diet therapy is to succeed, it
must include careful patient education, a process that includes appropriate
instruction, reevaluation, and testing of patient compliance.
I have had a strong commitment to help popularize the field of nutrition as
it relates to the gastrointestinal tract and hope that this book helps to accom
plish that goal.
Martin H. Floch
Norwalk, Connecticut
Acknowledgments
I would first like to thank my mentors. As a Master's student, I learned how to
approach a research project under the tutelage of Dr. Wilbur Bullock and the
late Dr. George Moore at the University of New Hampshire. It was there I
learned the effectiveness of a single cell in the digestive and excretory process
while studying the snail digestive gland. At New York Medical College, the late
Dr. Lois LiIlick taught me the role of microorganisms in the human body. I
then learned the gross and functional anatomy of the GI tract from Dr. Abra
ham Geffen at Beth Israel Hospital. I shall be eternally grateful for the oppor
tunity offered me by Drs. Milton Rubini and William Meroney to study the
small bowel at the United States Army Tropical Research Laboratory in Puerto
Rico. It was there I learned about tropical and small-bowel disease from many
Puerto Rican physicians, and Dr. Thomas Sheehy to whom I am grateful for
teaching me to enjoy thinking out a protocol and researching a clinical project.
Later, Dr. Rubini again helped further my interests by offering me the oppor
tunity to be one of the assistant editors of the American Journal of Clinical
Nutrition.
At Yale, Dr. Howard Spiro has unselfishly given me (as well as hundreds
of others) the opportunity to work, the encouragement to fulfill my ambition,
and the guidance necessary to be successful.
Finally, when discussing mentors, I am presently, and hope to be in com
ing years, taught by the fellows in our training program. It is the youth of our
training programs who continually teach us the most.
My next acknowledgment must go to the colleagues-members of the
Norwalk Medical Group-who were instrumental in helping me develop the
initial clinical experience in gastroenterology that I hope I have captured in
parts of this book. At the Norwalk Hospital, my close associate, Dr. John
Sacco, has been an invaluable confidant in both clinical and philosophic mat
ters in education and the practice of medicine. My good friends in pathology,
Dr. Roy Barnett and Dr. Irwin Weisbrot, have added ongoing information in
their observations in the field of gastrointestinal pathology. Dr. Ricrard Sallick
has been a constant friend and colleague in the field of education. I am also
grateful for the support received from the Broad of Trustees at Norwalk Hospi
tal, its president, Mr. Norman Brady, and the Department of Medicine at Yale
and its chairman, Dr. Samuel Thier.
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