4/25/18 D igestive Health in Children: Whats Fiber Got to Do With - - PDF document

4/25/18 1

Digestive Health in Children: What’s Fiber

Got to Do With It?

Renee Korczak PhD, RDN, CSSD, LD

Teaching Assistant Professor, Department of Food Science and Nutrition University of Minnesota Email: korcz005@umn.edu

Disclosures & Sponsorship

• Teaching Assistant Professor, Department of Food Science and Nutrition,

University of Minnesota

• Communications Director, MAND
• Consultant Dietitian, Premier Nutrition, LLC, Minneapolis, MN (received

funding or consultancy contracts from):

• MN Beef Council
• Nestlé Health Science
• Quaker Oats (A division of PepsiCo)
• Midwest Dairy Council
• MN United FC
• Acknowledgements: Hannah Paruzynski M.S., for her input on this presentation

A BIG THANK YOU to the Minnesota Beef Council for sponsoring this presentation!

Learning Objectives

• To describe common digestive health problems in children
• To compare and contrast current fiber recommendations for children
• To discuss common fiber sources in the diet and how they may

improve digestive problems in children

4/25/18 2

Definition of Digestive Health

“Appropriate nutrient absorption, intestinal motility, immune function, and a balanced microbiota” “Heartburn, rumbling, nausea, bloating, excessive flatulence, constipation, diarrhea,

• r abdominal pain and discomfort”

AGA Governing Board Approves New Definition of Digestive

• Health. American Gastroenterological Association, 2013.

Without Includes

American Gastroenterological Association. New Definition of Digestive Health. http://www.gastro.org/news_items/2013/09/26/aga-governing-board-approves-new-definition-of-digestive-health. Accessed April 15, 2018. American Gastroenterological Association, 2013.

What is the most common digestive health problem facing children today?

Pop Quiz

Constipation “I bet you didn’t think we’d be discussing

poop today” Answer……

4/25/18 3

Prevalence Rates of Childhood Constipation

Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional Constipation in children: challenges and solutions.

Ped Health Med & Therapeutics 2017;8: 19-27.

10-23% 1-12% 0.5- 30% 10-23%

The Viscous Cycle of Constipation

Retained stool becomes difficult to evacuate Rectum distends itself Fecal incontinence Abdominal distension Colonic mucosa absorbs water from feces Loss of the Normal Urge to Defecate

Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468.

Functional Causes

• Psychological
• Developmental
• Dietary
• Forced toilet training
• Negative feelings of using

public toilets

• Most constipation cases are

functional Organic Causes

• Side effects of drug use
• Diabetes Mellitus
• Allergy to cow’s milk
• Neuromuscular disorder
• Anatomical lesion

Causes of Constipation Are Either Functional or Organic

Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468.

4/25/18 4

Vomiting Disorders Cyclic vomiting Functional nausea/vomiting Rumination syndrome Aerophagia

Abdominal Pain Disorders

Dyspepsia IBS Abdominal migraine Functional Abdominal Pain-NOS

Functional Defecation Disorders

Constipation Non-retentive fecal incontinence

Overview of Common Functional GI Disorders (FGIDs)

• Common disorders that are characterized by persistent and

reoccurring GI symptoms

• Occur as a result of abnormal functioning of the GI tract

Hyams JS et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468.

Diagnostic Criteria for Functional Constipation

2 or more of the following must occur at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of IBS:

• ≤2 defecations in the toilet per week in a child of a developmental age at least 4 years
• At least 1 episode of fecal incontinence per week
• History of retentive posturing or excessive stool retention
• History of painful or hard bowel movements
• Presence of a large fecal mass in the rectum
• History of large diameter stools that can obstruct the toilet

Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468.

Pop Quiz

At what age does the incidence of constipation peak?

4/25/18 5

Answer:

Peak incidence of constipation occurs at the time of toilet training

Current Treatments for Childhood Constipation

Pharmacologic Approach to Treatment

2 Step Approach

• Rectal or oral disimpaction for children with fecal impaction
• Maintenance therapy to prevent reaccumulation of feces using

polyethylene glycol or lactulose

4/25/18 6

Educational Treatment Approaches

Counsel families to recognize withholding behaviors Use behavioral interventions including:

• Regular toileting
• Use of diaries to track stooling
• Reward systems for successful evacuations
• Recognize “normal” looking stool (Bristol Stool Scale)

Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468.

Types 3 and 4 are considered normal stool Chart has been validated in an adult population Other child sensitive charts are reported in the literature, but not yet validated

Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scan J Gastroenterol. 1997;32(9):920-924. Korczak R, Kamil A, Fleige L, Donovan S, Slavin JL. Dietary fiber and digestive health in children. Nutrition Reviews 2016; 75(4): 241-259

4/25/18 7

Sample Bowel Diary to Track Stools

Dietary Treatments for Constipation Fiber Defined

• Definitions differ among various scientific organizations and regulatory

authorities-fiber definitions today are changing due to actions by FDA

IOM Definition (2001) FDA Definition (2016) Dietary Fiber: Non-digestible carbohydrates and lignin that are intrinsic and intact in plants Non-digestible soluble and insoluble carbohydrates (with ≥3 monomeric units) and lignin that are intrinsic and intact in plants Functional Fiber: Isolated, non-digestible carbohydrates with beneficial physiological effects in humans Isolated and synthetic non-digestible carbohydrates (with ≥3 monomeric units) determined by FDA to have physiological effects that are beneficial to human health

Institute of Medicine Food and Nutrition Board. Dietary Reference Intakes: Proposed Definition of Dietary Fiber (2001)

• FDA. Food Labeling: Revision of the Nutrition and Supplement Facts Labels. May 27, 2016

4/25/18 8

Classification of Dietary Fiber

Dietary Fiber

Soluble (fermentable) Non-viscous Linear

Short chain fructo-

• ligosaccharide (scFOS)

FOS Inulin

Branched

Partially hydrolyzed guar gum (PHGG) Acacia gum Wheat dextrin

Viscous

Psyllium β-glucan Guar gum Pectins Inner pea (pectin, hemicellulose A)

Insoluble (non-viscous) Non- fermentable

Outer pea (lignin, cellulose, hemicellulose type B) Oat hull Wheat bran

Fermentable

Resistant starch Soy polysaccharides

Fiber and Digestive Health: What’s the Benefit?

• Believed to encourage more regular bowel

movements by increasing fecal volume and weight, which improves stool consistency and frequency

• Associated with lower incidence of

constipation, gastroesophageal reflux disease (GERD), and peptic ulcer disease

Weber et al., Journal of Pediatric Gastroenterology and Nutrition, 2014. & Kokke, et al., Journal of Pediatric Gastroenterology and Nutrition, 2008

Common Fiber Sources for the Treatment of Childhood Constipation

Fruit juices (apple, prune and pear)

• Contain sorbitol, fructose, phytochemicals & water

Whole fruits (kiwifruit, prunes, pears, plums, apples, grapes)

• Contain sorbitol, fructose, fiber & phytochemicals

Mixed fibers (PHGG, Bran, Oat b-glucan, Gum Acacia)

• Supportive evidence in ≥ 1 publication

Water

• Some evidence to support additional fluid during pharmacological

treatment for chronic functional constipation, improves stool frequency and stool consistency

Hwan Bae S. Diets for Constipation. PGHN 2014; 17(4): 203-208.

4/25/18 9

What Does the Science Tell us About Fibrous Foods or Supplements for the Treatment of Constipation? A Closer Look at Prunes & Prune Juice

• Systematic review to assess the effects of prunes on GI

function

• 4 trials met inclusion criteria
• All trials evaluated (except one) found improvements

in some constipation symptoms

• Prunes appear to relieve some constipation

symptoms, but the exact symptoms improved are not consistent across studies

• More research is needed before prunes can be

routinely recommended

Lever E et al. The Effect of Prunes on GI Function Aliment Pharmacol Ther 2014; 40(7): 750-8.

What Does the Science Tell us About Fibrous Foods or Supplements in the Treatment of Constipation? A Closer Look at Kiwifruit Literature search revealed

• Three studies in whole kiwi
• Two randomized crossover trials testing kiwi extract
• Promising results for improvements in stool consistency,

bothersomeness due to constipation, satisfaction of bowel habit and # of days taking laxatives

• Is it the kiwi fiber or the proteolytic enzyme in kiwi

(actinidin) providing a benefit? difficult to tell in nutrition studies

O Chan A, Leung G, Tong T, Wong N. Increasing dietary fiber in terms of kiwifruit improves constipation in Chinese patients. World J Gastroenterol 2007; 13(35): 4771-4775.

Use of Fibers in Childhood Constipation Treatment

Traditional approach=prescribe fibers for the initial treatment of constipation in children and adolescents

• Is there clear evidence to prescribe fiber supplementation as part of

functional constipation treatment?

• Recent recommendations on management of functional constipation in

children and adolescents from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN-NASPGHAN) describe that there was no evidence to justify the prescription of fiber

Piccoli de Mello P, Eifer DA, de Mello ED. Use of fibers in childhood constipation treatment: systematic review and meta-analysis. J Pediatr 2018 Article in Press

4/25/18 10

Current Fiber Consumption Patterns & Trends in Children & Adolescents

Children Don’t Eat Enough Fiber

• Consume about 14-15 grams per day
• DRI for children 4-13 years old is between 25-31 grams

< 1 serving ½ to 1 serving ½ to 1 serving

What We Eat in America, NHANES 2013-2014

What We Eat in America, NHANES 2013-2014

Global Fiber Intake Levels Recorded among Children and Adolescents (1995-2011) also Reveal that Children are Falling Short

Korczak R, Kamil A, Fleige L, Donovan S, Slavin JL. Dietary fiber and digestive health in children. Nutrition Reviews 2016; 75(4): 241-259

4/25/18 11

Common Food Sources in Children & Adolescents Diets-Where is the fiber?

McGill CR, Fulgoni VL, Devareddy L. Nutrients 2015;7(2): 1119-30.

Food Category 2001-2010 Intake g/day

Yeast breads/rolls 1.2 Quick breads 0.4 Cakes/cookies, pies, pastries 0.6 Crackers/salty grain snacks 0.9 Pancakes/waffles/French toast 0.2 Pastas 0.08 Hot cereals/rice 0.2 Ready-to-eat cereals 0.9 Grain mixtures/frozen meals/soups 2.3 Pulses, nuts, seeds 0.8 Fruits 1.6 Vegetables 2.1 All other foods 1.9

Current Fiber Recommendations for Children Vary

Korczak R, Kamil A, Fleige L, Donovan S, Slavin JL. Dietary fiber and digestive health in children. Nutrition Reviews 2016; 75(4): 241-259

*NO recommended daily dietary fiber intakes have been established for infants and children under the age of 2 years

“Fiber is an Under- consumed Nutrient of Public Health Concern”

What is more alarming?

• 9 million children in the U.S. live in

food insecure households

• Where does fiber fit into the diet of

someone who is food insecure?

• How do we deliver more fiber?

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 DGA’s. 8th Ed. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/.

4/25/18 12

Conclusions and Key Messages

• Children should be encouraged to get

adequate amounts of fiber through their diet to prevent common digestive health problems such as constipation

• Some conflicting evidence exists on the

prescription of dietary fiber and fiber supplements for the treatment of childhood constipation (more research in constipated children is needed)

• Current treatment approaches to

treating childhood constipation are pharmacological, dietary and behavioral (with education)

• Registered Dietitian Nutritionists

(RDNs) are integral parts of the healthcare team and can help in the prevention and treatment of common digestive health problems such as constipation

Key References

• Hwan Bae S. Diets for Constipation. Pediatr Gastroenterol Hepatol Nutr 2014; 17

(4): 203-208.

• Hyams JS et al. Childhood Functional GI Disorders: Child/Adolescent

Gastroenterology 2016;150:1456-1468.

• Korczak R, Kamil A, Fleige L, Donovan S, Slavin JL. Dietary fiber and digestive

health in children. Nutrition Reviews 2016; 75(4): 241-259.

• Levy EI, Lemmens R, Vandenplas Y, Devreker. Functional constipation in children:

challenges and solutions. Ped Health, Med & Therapeutics 2017;8: 19-27.

• Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time.

Scan J Gastroenterol. 1997;32(9):920-924.

Tools and Resources

North American Society for Pediatric Gastroenterology, Hepatology and Nutrition- GI Kids website (Help and Hope for Children with Digestive Disorders) https://www.gikids.org/index.cfm?contentID=9&lang=en&pagePath=nutrition International Foundation for Functional GI Disorders website https://www.aboutkidsgi.org/kids-dietary-fiber.html Rome Foundation website- https://theromefoundation.org

4/25/18 13

MN Beef Council & NCBA Resources

Minnesota Beef Council Website-Beef For All Ages section https://mnbeef.org/nutrition Beef It’s What’s For Dinner Website-Nutrition section https://www.beefitswhatsfordinner.com/nutrition

4/25/18 14