18.2: The Impact of Nutrition on Gastrointestinal Wellness Across the Lifespan
By the end of this section, you should be able to:
- 18.1.1 Describe the impact of nutrition on the gastrointestinal system during pregnancy.
- 18.1.2 Describe the impact of nutrition on the gastrointestinal system during infancy.
- 18.1.3 Describe the impact of nutrition on the gastrointestinal system during childhood.
- 18.1.4 Describe the impact of nutrition on the gastrointestinal system during adolescence.
- 18.1.5 Describe the impact of nutrition on the gastrointestinal system during adulthood.
- 18.1.6 Describe the impact of nutrition on the gastrointestinal system during later adulthood.
Pregnancy
Pregnancy adds nutritional needs to the pregnant client that were not required before conception, and the client’s gastrointestinal health can impact the pregnancy even if they were healthy at the start. When a pregnant client has a gastrointestinal system illness, the stress of the pregnancy only adds to their nutritional needs. It is important that the expectant client maintain optimal nutrition during the pregnancy to ensure proper gastrointestinal development of the fetus as well.
The Healthy Pregnant Client
The healthy pregnant client without gastrointestinal illness should maintain a healthy diet and increase their caloric intake by 340 calories from their non-pregnant caloric intake amount daily starting the second trimester of a singleton fetal pregnancy (American College of Obstetricians and Gynecologists, 2023). During the third trimester, the caloric intake should increase by 450 calories from their non-pregnant caloric intake amount daily (Office of Disease Prevention and Health Promotion, 2023). Other recommendations for pregnancy include increasing water intake, decreasing caffeine intake, and adding a prenatal multivitamin with folic acid and iron (American College of Obstetricians and Gynecologists, 2022). It is also recommended that the pregnant client consume food and drinks that are low in added sugars, saturated fats, and sodium (Office of Disease Prevention and Health Promotion, 2023. Pregnant clients can follow the recommendations found using My Pregnancy Plate to ensure that they are eating well for their pregnancy (Oregon Health and Science University, 2023).
Specific recommendations can also be included to maintain the pregnant individual’s gastrointestinal health and support fetal development. The microbiome , or collection of microorganisms that reside primarily in the gastrointestinal tract, needs to be maintained during pregnancy to maintain overall gastrointestinal health . The gut microbiome promotes immune function and intestinal homeostasis by reducing production of inflammatory mediators (Tabani & Olendzki, 2019), which encourages normal mucosal functioning. Normal mucosal function is needed to ensure optimal intestinal absorption of nutrients.
Additions to the diet that can be recommended by those caring for the client include prebiotic and probiotic foods. Probiotic foods are nondigestible substances that stimulate the growth of “good” gut bacteria and include fermented foods that contain live bacteria and yeast, such as yogurt, miso, kefir, kimchi, and honey (Tabani & Olendzki, 2019). Prebiotic foods are foods that contain live microorganisms intended to maintain good gut bacteria and include garlic, onions, asparagus, leeks, and bran. See Figure 18.2.
Another important addition for the gastrointestinal system during pregnancy is 25–35 g of fiber daily. Fiber, with adequate water intake, helps to prevent constipation and hemorrhoid development, remove excess cholesterol in the diet, and maintain the gut microbiome (Tabani & Olendzki, 2019). The pregnant client can obtain fiber from barley, flaxseed, oats, lentils, and beans.
The microbiome can also be protected by limiting foods that contain lactose, wheat, corn, and refined sugars that feed harmful bacteria in the gut (Tabani & Olendzki, 2019). These foods promote systemic inflammation and upset the balance of the microbiome.
The fetus will develop their own microbiome based on the maternal microbiome during pregnancy, interaction with the environment after birth, and the diet and lifestyle they develop after birth. Maternal dysbiosis , or an imbalance in the microbiome that is associated with unhealthy conditions, can contribute to infant dysbiosis (Garcia-Montero et al., 2023; Martinez et al., 2021). Reducing gluten-containing foods while pregnant can help increase the number of Akkermansia muciniphila , Saccharibacteria (formerly known as TM7 bacteria ), and Proteobacteria in the fetus, reducing low-grade inflammation in the infant and the risk for developing diabetes (Tabani & Olendzki, 2019).
Infants exposed to unhealthy maternal microbiomes, especially in conjunction with unhealthy childhood diets, are at increased risk for having lean (lower than optimal bacterial amounts), defective intestinal microbiota, which leads to dysbiosis in the gut (Tabani & Olendzki, 2019). This can lead to dysfunction in genes that are active in both glucose and lipid metabolism (Tabani & Olendzki, 2019). Infants exposed to an unhealthy maternal microbiome are also more likely to have issues with immune system development, develop long-term health issues, and even be predisposed to developing immune-modulated diseases and Crohn’s disease , a chronic inflammatory disease that affects the intestines (UMass Chan Medical School, n.d.), particularly the colon and ileum, and can cause ulcerations and fistulas.
The method of delivery can also affect the infant, regardless of the health of the mother’s microbiome. When delivered vaginally, the newborn develops a microbiome higher in Lactobacillus and Prevotella , which is similar to the vaginal flora (Tabani & Olendzki, 2019). Newborns born via cesarean section will have higher levels of Staphylococcus , Corynebacterium , and Propionibacterium , more similar to the mother’s skin flora, which increases risk for developing dairy allergies (Zhang, et al., 2021).
Promotion of a healthy maternal gut microbiome may also prevent preeclampsia as it has been shown to play a role in preeclampsia and decrease the risk for premature birth (Jin et al., 2022). This is important for the overall health of the infant’s gastrointestinal system because prematurity can result in immature development of this system.
The lactating client should continue to maintain their gut health to help prevent issues with their infant. Prebiotics in foods such as kefir consumed by lactating women have been shown to reduce infant risks for developing colic, allergies, and other gastrointestinal problems (Garcia-Montero et al., 2023).
The Pregnant Client With Preexisting Gastrointestinal illness
Diseases that can heavily affect the nutritional status of the pregnant client and fetus include Crohn’s disease; ulcerative colitis (UC) , an inflammatory disease that causes ulcerations in the superficial lining of the large intestine; cholelithiasis; gastroesophageal reflux disease (GERD); pancreatic insufficiency; and diabetes types 1 and 2 (Balestrieri et al., 2020; Lifespan Health System, n.d.) .When the pregnant client already has a gastrointestinal illness, eating properly for the health of the pregnancy becomes more difficult because intestinal absorption may not be optimal.
Gastrointestinal issues that arise in an uncomplicated pregnancy can pose additional problems for these clients. Conditions such as nausea, vomiting, constipation, heartburn, diarrhea, hemorrhoids, and hyperemesis gravidarum (persistent and severe vomiting caused by pregnancy that can lead to weight loss and dehydration) can worsen these clients’ ability to absorb and metabolize nutrients.
Managing gastrointestinal issues that commonly occur during pregnancy can help alleviate some of the additional burden placed on these clients. Interventions commonly used during a healthy pregnancy include a healthy diet, increased fluids, and exercise, with medications usually reserved as a last resort. However, the usual treatments will not always address the underlying chronic issues in clients with preexisting conditions, who may need to be initially treated with more advanced treatments, including medication.
These clients face will likely be advised to stop the suppressive medications they take to keep their chronic condition under control. Clients with GERD may have to be switched to less effective medications such as calcium carbonate to manage symptoms during pregnancy. Cholelithiasis can be manageable during pregnancy provided it does not cause infection or cholecystitis. Even if the gallbladder loses the ability to release enough of the needed digestive enzymes due to this condition, clients can be treated with supplemental enzymes.
The gastrointestinal issues that pose the greatest threat to the health of the pregnancy are Crohn’s disease and UC. The medications used to treat these may be stopped due to fetal risks. Clients with these diseases are at higher risk for iron (Mahadevan et al., 2019), vitamin D, and vitamin B 12 (Mahadevan et al., 2019) deficiency during pregnancy due to malabsorption , a digestive disorder that causes the body not to absorb nutrients from food effectively, which occurs because of the inflammation process these illnesses cause. These clients will also be higher risk for folate deficiency during exacerbation periods due to the need for a low-residue diet during this time, as well as the potential for ileal involvement or the need to take medications that interfere with folic acid absorption (Mahadevan et al., 2019). Due to these issues, supplementation is imperative, and serum levels should be monitored for iron, vitamin D, and vitamin B 12 (Balestrieri, 2020). Although iron supplementation is necessary, it can also increase the risks for constipation and abdominal pain (Mahadevan et al., 2019). These clients should be educated about increasing water intake and using acceptable laxatives during pregnancy.
During pregnancy, these clients should be followed closely by a gastroenterologist. There are significant risks to the fetus because these diseases can impact fetal development . These clients have a greater risk for miscarriage, preeclampsia, poor maternal weight gain, placenta abruption, premature delivery, cesarean delivery, birth of a small-for-gestational-age newborn, and other delivery complications (Mahadevan et al., 2019).
Diet recommendations for clients with Crohn’s disease or UC are the same during pregnancy. These clients should be educated about additional needs of the pregnancy in conjunction with the requirements for their diagnosis for maintaining gut microbiome health. These clients need to avoid trigger foods. Although such foods may be different for each individual, common triggers include (Crohn’s and Colitis Foundation, n.d.):
- Foods high in insoluble fiber (raw kale, apple skins, sunflower seeds)
- High-fiber foods (cabbage, asparagus, cauliflower)
- High-lactose foods (cow’s milk, ice cream, custard)
- Sugar alcohols and artificial sweeteners (sorbitol, saccharin, aspartame)
- Sugary foods and foods with added sugars (cookies, pastries, syrup)
- High-fat foods (butter, cheesy foods, fried foods)
- Spicy foods (sriracha, chili powder)
- Alcohol
- Caffeine (soda, tea, coffee)
- Sugar-sweetened beverages (soda, juices, drinks with syrup)
These clients should also avoid foods that can increase, or play a role in, intestinal inflammation (Crohn’s and Colitis Foundation, n.d.):
- Red meat (beef, lamb, pork, bison)
- Processed meat (lunch/deli meat, bacon, hot dogs)
- Coconut oil, dairy fats, palm oil
- Processed foods containing the following additives may also play a role: carboxymethylcellulose, polysorbate-80, carrageenan, maltodextrin, titanium dioxide, sulfates, guar gum
Some foods can be increased in the diet to decrease inflammation (Crohn’s and Colitis Foundation, n.d.):
- Fruits (bananas, raspberries, applesauce, blended fruit)
- Vegetables (squashes, green beans, fork-tender cooked carrots)
- Foods rich in omega-3 fatty acids (fatty fish [salmon, tuna, mackerel], walnut butter, chia seeds, flaxseed oil, flaxseed meal)
- Cooked and cooled or reheated starches (potatoes, sweet potatoes, rice, oatmeal) to form retrograde starch (Bedosky, 2022)
- Leafy green vegetables
The Fetus
A pregnant client with preexisting gastrointestinal disease should closely follow the prescribed dietary recommendations. Adherence will decrease the chances of fetal underdevelopment or premature delivery, which can have lifelong effects for the child.
The fetus’s gastrointestinal system begins development at 3 weeks’ gestation and continues to mature through the third trimester up to 32 weeks (Bhatia, Shatanof, and Bordoni, 2023). The pregnant client’s nutritional intake is the sole source of fetal nutrition, so they should eat foods that are necessary for proper fetal development. Folic acid, iron, calcium, vitamin D, DHEA, and iodine all play vital roles in this development (Getz, 2022). The nurse can educate the pregnant client about specific foods to ensure that their fetus will get these needed nutrients (Table 18.1).
| Nutrient | Foods |
|---|---|
| Folic acid |
|
| Iron |
|
| Calcium |
|
| Vitamin D |
|
| DHEA |
|
Infancy
In infancy, nutrition needed for the health of the gastrointestinal tract depends on whether the infant has any congenital abnormalities or early diagnosed illnesses related to the gastrointestinal system. Healthy eating patterns that start with the introduction of solid foods constitute the best start a parent can give their child to ensure the future of their gastrointestinal health because early eating patterns are often carried throughout an individual’s life. This is true for all infants regardless of the presence or absence of gastrointestinal issues.
The Healthy Infant
It is extremely important to optimize nutrition during infancy for proper growth and development of the gastrointestinal system because this period in life involves very rapid growth. Infants who were born prematurely or had a low birth weight and have continued undernutrition , even in the absence of gastrointestinal illness or abnormality, require additional nutrition to ensure proper growth and development because they are at much higher risk for developing postnatal growth failure, failure to thrive, childhood obesity, and diabetes. They also have a higher mortality risk in the future. These increased risks may be a result of having a low birth weight and rapidly gaining weight as a compensatory measure (Patel & Rouster, 2023). For example, a healthy term infant requires 100 kcal/kg/day, but a preterm or low birth weight infant requires 110–135 kcal/kg/day to establish a healthy growth and development pattern (Patel & Rouster, 2023). (Note: The use of “kcal” matches the wording in the source material and, for the purpose of this chapter, is the same as “cal.”)
The nutrition infants receive comes primarily from breast milk or formula. Protein provided in their diet is needed for proper growth and system development and should be 15% of their daily intake (Patel & Rouster, 2023). Breast milk is a more nutritious option because the protein is more bioavailable than the cow’s milk or soy protein in infant formula, allowing for greater absorption.
Infant formula in concentrated forms (both powder and liquid forms) should be mixed as instructed, using the appropriate measurements of formula concentrate and water. Adding additional water to formula concentrate can be dangerous because the resulting diluted formula can lead to suboptimal caloric intake and electrolyte and mineral imbalances. Suboptimal caloric intake can slow growth and development, and imbalances in electrolytes and minerals can cause serious health problems, including seizures, and can also lead to death. (source: Abrams, 2022).
Carbohydrates should be 40–55% of an infant’s daily intake. Carbohydrates are used for energy and must be provided in correct amounts because the body will use protein for energy when not enough carbohydrates are available (Patel & Rouster, 2023). Another portion of daily intake comes from fats (lipids), which also provide energy to the body. Low birth weight and premature infants may require higher amounts of carbohydrates and lipids because they lack sufficient body fat stores. One reason breast milk has been shown to be a healthier option for infants is because it contains higher levels of medium and short-chain triglycerides , which are easier to absorb (Patel & Rouster, 2023) than long chain fatty acids found in formula. When infants are born too early to have developed a proper sucking reflex, it may be necessary for the breastfeeding parent to pump breast milk for feeding via nasogastric or orogastric tube.
Micronutrients are also needed to ensure the health of the gastrointestinal system. These trace elements, absorbed in the gastrointestinal tract, require age-, weight-, and disease-specific adjustments to ensure proper nutrition (Patel & Rouster, 2023). Of these micronutrients, preterm and low birth weight infants require higher levels of iron, zinc, and copper than healthy full-term infants do.
The Infant with Gastrointestinal Abnormalities
Infants with gastrointestinal system illness or abnormality require individualized nutritional considerations to ensure that they grow and develop properly. This is especially true when the gastrointestinal issue causes malabsorption. These infants require similar amounts of macronutrients but may become deficient in micronutrients more easily due to malabsorption.
Breast milk has a higher content of more easily absorbed, more bioavailable forms of proteins and fats, making it the optimal choice for infants, especially those with gastrointestinal issues. If the absorption issues do not allow nutritional needs to be met, the infant may require parenteral nutrition for healthy development until the issue can be controlled. Parenteral nutrition does put the infant at higher risk for toxicity from micronutrients. This makes it imperative that the infant be transitioned to enteral feedings as soon as possible and monitored closely for toxicity.
Iron is not needed in higher concentrations in infant with GI abnormalities unless they are preterm or are specifically not absorbing the appropriate amounts, as absorption occurs in the duodenum and proximal jejunum (Patel & Rouster, 2023). Infants with short bowel syndrome , a group of problems related to ineffective absorption of nutrients, or with congenital abnormality of zinc absorption are at highest risk for zinc deficiency. They may require higher amounts of zinc in their diet (Patel & Rouster, 2023).
Although large amounts of selenium are not recommended, it is important that premature infants and infants with gastrointestinal issues receive optimal amounts. Selenium is an antioxidant that reduces a wide range of inflammatory issues such as necrotizing enterocolitis (Patel & Rouster, 2023), an intestinal tract disease in which the intestinal lining becomes inflamed and dies and then is sloughed off.
Breastfeeding is the optimal source of nutrients for infants, but it is even more important for infants with gastrointestinal issues the first year of life. Breastfeeding reduces risks for diarrhea, food allergies, inflammatory bowel disease, obesity, and diabetes (Patel & Rouster, 2023).
Breastfeeding is contraindicated in infants with galactosemia , a genetic disorder in which the galactose-1-phosphate uridylyltransferase (GALT) enzyme is missing or does not function properly (Patel & Rouster, 2023). This enzyme, produced in the liver, is needed to break down galactose, a sugar by-product of lactose, into glucose. It is found in breast milk, cow’s milk, and other dairy foods. These infants must be on a lactose-free diet . All infants born in the United States are tested for galactosemia through mandatory blood testing soon after birth.
Read the following clinical scenario and then answer the questions that follow. This case study will evolve throughout the chapter.
Hein Nhung has had a difficult pregnancy. She has experienced hyperemesis gravidarum and worsening of her gastroesophageal reflux disease. Because of her inability to gain the recommended amount of weight and to consume nutrient-rich foods during the pregnancy, Hein’s gut microbiome has severely changed. These difficulties contributed to her baby, Bao Nhung, being delivered at 37 weeks’ gestation, with a low birth weight for age.
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Parenteral nutrition
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High-calorie formula
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Additional water to prevent constipation
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None until later in life
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An increase in the number of breastfeedings daily
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A switch to a low-protein formula
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A switch to a lactose-free formula
Childhood
Solid foods should be introduced into the diet at 6 months of age. After 1 year of age, most of the infant’s diet should be solid foods . It is important to initiate healthy eating patterns because many of the habits started during this time will continue throughout the lifespan. Proper nutritional practices will encourage healthy growth and development, resulting in a healthy gastrointestinal system.
Young children tend to be extremely active and are growing, so they need high- energy foods, mostly from carbohydrates (Thomas, 2023). Children aged 5–10 years old require 1500–2000 kcal/day (Thomas, 2023). Their daily diet should contain appropriately sized portions of 5 or 6 servings of vegetables (in a mix of colors and including both leafy and nonleafy vegetables) and fruits (of different varieties), 4–6 servings of whole grains, 1 or 2 servings of protein (lean meat, fish, nuts, seeds, tofu), and 2–4 servings of dairy products (Thomas, 2023). They should receive whole milk until age 2 and then 2% or lower-fat milk daily, with plenty of water and very limited added sugars and snacks (Ben-Joseph, 2023; Table 18.2).
| Food Group | Daily Servings | Portion Size (Ages 1–3) | Portion Size (Ages 4–6) | Portion Size (Ages 7–10) |
|---|---|---|---|---|
| Meats/proteins | 2 |
|
|
|
| Dairy | 2–3 |
|
|
|
| Fruits | 2–3 |
|
|
|
| Vegetables | 2–3 |
|
|
|
| Grains | 6–11 |
|
|
|
An adequate amount of fiber is needed in the diet for gastrointestinal health (Thomas, 2023). Prebiotic and probiotic foods should be introduced when solid foods are introduced. Some child-friendly foods containing probiotics are yogurt with live cultures, pickles, kombucha, and cheese; child-friendly foods containing prebiotic s include kiwi, bananas, and apples (Garcia-Montero, et al., 2023). Processed and artificially sweetened foods should be avoided (Stanford Medicine Children’s Health, n.d.). Another important consideration for gut health is to avoid unnecessary antibiotics because they can damage and kill helpful bacteria in the gut.
Adolescence
Many expected body changes as well as a growth spurt occur during adolescence . These changes require an increase in caloric intake to about 2200 kcal/day for females and 2500–3000 kcal/day for males, depending on activity level such as participation in rigorous sporting activities (Nesta, 2019).
This age group has much more autonomy over their food choices and often eat fast foods because they do not like to sit and eat but prefer fast convenience. Fast foods can contribute to constipation and need to be balanced with nutrient-dense foods, high-fiber foods, prebiotics, probiotics, and high-calcium foods to support a healthy growth and development pattern (Stanford Medicine Children’s Health, n.d.). A good addition to encourage gut health and increase calcium are leafy green vegetables (Johns Hopkins Medicine, n.d.).
Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Part A.
Bao has adjusted well to the special diet at birth and transitioned well in late infancy and childhood to an altered diet. At the age of 13, he begins having diarrhea, blood in the stool, fatigue, and abdominal pain and eventually is diagnosed with Crohn’s disease. Bao is here today for a wellness visit with Hein.
3
Hein asks how Bao has gotten Crohn’s disease because it does not run in their family. Given Bao’s history, what put him at increased risk for developing Crohn’s disease?
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Inability to consume lactose
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Hein’s pregnancy complications
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Bao had no increased risk
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Bao’s lack of adherence to the prescribed diet
4
The nurse is educating Hein and Bao about managing inflammatory periods. Which food should be avoided during inflammatory periods?
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Beans
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Yogurt
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White rice
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Chicken
Adulthood
During adulthood, calorie requirements decrease. Current recommendations are 1800–2400 kcal/day for women and 2400–3000 kcal/day for men, depending on activity level (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). Gastrointestinal health requires more of a maintenance approach during adulthood because this system is fully developed at this point in life. Prebiotics and probiotics are still recommended to maintain gut microbiome health.
Clients should be educated to limit or avoid alcohol and to reduce fats and sodium in the diet for gut health (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). Additions for nutritional health include foods rich in iron and calcium (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). People who smoke should be encouraged to stop because one of the negative effects of smoking is decreased blood flow to the intestines, which can have a negative impact on gut health.
Later Adulthood
As in early life stages, prebiotic and probiotic foods should be continued in later adulthood, along with a low-sugar diet. During this stage in the lifespan, men should consume 2000–2600 kcal/day, and women should consume about 1600–2200 kcal/day because energy expenditure is less than in younger adulthood (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). It is still important for clients in this age group to continue a high-calcium diet for bone health.
For gut health, clients should eat a diet high in fiber and water and low in sodium (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). During this stage in life, constipation may be common. High fiber will help prevent it, and water is required for the fiber to work effectively. Eating adequate protein is important in combination with physical exercise because muscle mass can decrease in older adults (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). Blood flow is increased with muscle mass and is important for gut health and intestinal health.