THE SCIENCE OF NUTRITION SERIES · nutrition impacts on it. The booklets take a conventional...

Lecture 6 - Nutritional Physiology Part 1

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THE SCIENCE OF NUTRITION SERIES

LECTURE 6 – SON

NUTRITIONAL PHYSIOLOGY – PART 1


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CONTENTS

INTRODUCTION TO NUTRITIONAL PHYSIOLOGY

NUTRITION ASSESSMENT

Evaluating Dietary Intake

Food diary

Food Frequency

24-hour recall

Determination of Nutritional Requirements

Medical History

Psychosocial History

Diet History

Anthropometric Data

Biochemical Tests

Clinical Data

THE DIGESTIVE SYSTEM Healthy Gut and digestion review

Absorption review

IMPAIRED DIGESTION Hypochlorhydria and Achlorhydria

Pancreatic exocrine hypofunction

MEDICAL MALABSORPTION DISORDERS Pancreatitis

Liver disease

Biliary Tract disorders

INTESTINAL DISORDERs

Irritable bowel syndrome

Inflammatory bowel disease

Ulcerative colitis

Crohn’s disease

APPENDIX 1 Nutrition relevancy in common biochemical tests

APPENDIX 2 Signs and Symptoms with nutritional implications

APPENDIX 3 Causes of Poor Digestion


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INTRODUCTION TO NUTRITIONAL PHYSIOLOGY

Welcome to the fascinating world of Nutritional Physiology! Nutritional

Physiology is the study of all the functions of a living organism or any of its

parts; with particular reference to the process by which that living organism

assimilates food and then uses it, for example, for growth and for

replacement of tissues. Just like your ‘straight’ Anatomy and Physiology,

these booklets are really intended to give you underpinning knowledge of

the workings of the amazing human body but with especial attention to how

nutrition impacts on it. The booklets take a conventional viewpoint of

nutrition and therefore it is important to filter the information through the

Nutritional Healing philosophy before applying it. There are three modules in

this section, of which this is the first, which cover the physiology of the

particular system; the disorders or diseases of that body system; what is

actually required nutritionally by that system to meet its needs; conventional

tests carried out to check for deficiencies and the suggested standard

nutrition approach, which will be interesting for you to compare and contrast

with the philosophy. You will also notice the jargon, used by the medical

profession and conventional dieticians and nutritionists, so that the language

used by clients who have been down this pathway will be less confusing!

These booklets will also be a useful reference source after you have trained,

although it is important to acknowledge that research is constantly

uncovering new information about the wonderful body!


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NUTRITIONAL ASSESSMENT

Nutritional assessment is an approach for defining nutritional status using

medical, social, nutrition and medication histories, physical examination,

anthropometric measurements and laboratory data (as defined by the

American Dietetic Association 1994). Why assess? As we know, nutritional

problems are at the root of the leading causes of death such as heart

disease, diabetes and cancers. Nutrition assessment can identify potential

deficiencies before they cause irreversible damage.

Goals of nutritional assessment are:

1. Identify nutrients which may be deficient or in excess and health

problems the client may be at-risk for.

2. Create a plan to restore or maintain the individual’s nutritional status. 3. Monitor efficacy of these strategies over time.

Nutrient deficiencies go in stages. For example, if an essential nutrient, such

as B12, is not consumed for a few months, body stores may decrease, but

there is still enough of it to serve all vital functions. After a few years of

inadequate intake, biochemical tests will reveal reduced B12 levels, but with

no evidence of clinical anaemia or loss of energy. At the clinical stage,

energy levels will sharply decline and anaemia will be apparent. Early

nutritional assessment can catch a potential nutrient deficiency even before

biochemical tests do, thus preventing the clinical manifestations.

Certain categories of people are at risk of malnutrition. Nutritional screening

can flag certain individuals at being at risk of various nutrient deficiencies

and chronic diseases linked to diet.


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EVALUATING DIETARY INTAKE

Nutrient intake is determined by evaluation of food eaten. Various strategies

used in an outpatient setting include a 24-hour recall, food frequency

questionnaires or food diaries. With practice, a skilled nutritionist can assess

problem areas in a diet including potential deficiencies and excesses.

Protein, hydration, energy, lipids, some vitamins and minerals can be

assessed on the spot. Many clinicians use more sophisticated computer

databases which calculate precise nutrient values of food. Evaluation of

nutrient intake is a valuable tool for catching any deficiencies before they

reach clinical status. However it is limited by 4 main things: Accuracy of diet

record, actual nutrient composition of food (compared to database values),

recording methods and absorption. Next we will discuss the three main

methods of evaluating dietary intake.

1. Food diary

In a food diary, the client is asked to record their total food and beverage

intake over a period of time (typically 3-7 days). The data is averaged

over time to account for ‘bad days’ and ‘good days’. Strengths: This is the most accurate method, as it relies less on a person’s memory, it gives more information on meal times and amounts, using multiple days make it more

representative of usual intake than other methods. Perhaps the greatest

strength is that it makes the client more aware of their dietary patterns.

Limitations: Requires high degree of cooperation on the part of the client,

burden can result in low response rates, the act of recording may alter

diet, analysis of multiple days is labour intensive.

2. Food frequency

This is a retrospective review of intake frequency. Either verbally, or using a

written questionnaire, foods are grouped according to nutrient categories

and the client reports how many servings per day/week they have of

various foods. Strengths: the nutrition professional can easily look at the

sheet and evaluate basic deficiencies and excesses because foods are

grouped by common nutrients, provides good overall picture of intake, is

easily standardized (for research) and may be more representative of

usual intake than a diet record. It is preferred for research purposes.

Limitations: It may not represent usual foods or portion sizes, it depends on

the ability of a client to describe their diet, does not include time of day

meals are consumed, depends on memory, and it’s not appropriate for determining absolute nutrient intake. This method works best when

combined with ‘typical day’ summary.


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3. 24-hour recall

This is commonly used when you have had no previous contact with the

client, but want an idea of what a typical day looks like. One interviews

the client to recount what has been consumed in the past 24 hours.

Strengths: This is a convenient method that does not rely on patient

compliance, it is quick, inexpensive, does not place a burden on the

client, and does not alter the usual diet. Limitations: One day is seldom

representative of a person’s usual intake, memory is rarely reliable, under- and over reporting is common, frequently omits dressings, sauces,

beverages and snacks and relies on good interviewing skills.

DETERMINATION OF NUTRITIONAL REQUIREMENTS

Determining an individual’s nutritional requirements is a complex process. Information gathered must include a combination of medical, psycho-social

and dietary history, anthropometric data, biochemical data and clinical

data. All of these aspects are vital to the assessment process, as none alone

are used to diagnose deficiencies.

1. Medical History

Chief complaints, present and past illness, current health, allergies,

surgeries, family medical history, patient’s review of problems. Medication: Food/nutrient interactions: Many drugs when taken for

prolonged periods can induce nutritional deficiencies. Some foods, in

turn, may alter the function of certain drugs. Look back to your

micronutrients section for information on this. There are also convenient

handbooks on Food medication interactions. List in recommended

reading

2. Psycho-social history

Socio-economic status, ability to purchase own food, living along/shared,

disabilities, smoking, drug/alcohol addiction can all affect access to food.

With the elderly, confusion, housing, socialization, poverty can be major

issues affecting health.


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DETERMINATION OF NUTRITIONAL REQUIREMENTS Continued……

3. Diet history

A diet history is used to assess an individual’s usual dietary intake over an extended period of time, such as a month, year. It can also be used to

look at the history of diet over a lifetime. It evaluates weight reduction

diets, eating disorders, physical problems with eating, food

aversions/intolerances, cultural factors, beliefs around food, frequency

eating out, fluid intake, and alcohol/drug intake. This can help the

nutritionist determine what role food has had in the aetiology of disease,

as well as what strategies would be most appropriate for the individual.

Diet history should look at childhood diet (where patterns are formed),

then changes over the years.

A diet history often includes a 1-3 day food record and questioning a

client about food preferences, appetite, or a food frequency

questionnaire. These can then be cross-referenced to see if a client’s thoughts on what they eat match up with what they are actually eating.

Strengths: It assesses usual nutrient intake, can detect seasonal changes,

data on all nutrients can be obtained and can correlate well with

biochemical measures. Limitations: Lengthy interview process requires

well-trained interviewers, difficult to standardize, requires cooperation to

complete food records and recall past diet patterns.

Included in diet history are other factors influencing food intake and

absorption. Some other factors to consider when taking a client’s history include:

Significant weight changes

Usual meal pattern

Appetite

Satiety

Discomfort after eating

Chewing/swallowing ability

Likes/dislikes

Taste changes/aversions

Allergies

Nausea/vomiting

Bowel habits – diarrhoea, constipation, steatorrhea Source: Lee & Nieman


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Nutritional relevance of historical information Mechanism of

deficiency

If history of: Suspect deficiency of:

Inadequate

intake

Alcoholism Energy, protein, thiamine,

niacin, folate, pyridoxine,

riboflavin

Avoidance of fruit, vegetables,

grains

Vitamin C, thiamin, niacin,

folate

Avoidance of meat, diary, eggs Protein, B12

Constipation, haemorrhoids,

diverticulosis

dietary fibre

Isolation, poverty, dental disease,

food idiosyncrasies

Various nutrients

Weight loss Energy, other nutrients

Inadequate

absorption

Drugs (especially antacids,

anticonvulsants, cholestyramine,

laxatives, neomycin, alcohol)

Various nutrients depending

on DNI

Malabsorption (diarrhoea, weight

loss, steatorrhea)

Vitamins A, D, K, energy,

protein, calcium, magnesium,

zinc

Parasites Iron, vitamin B12

Pernicious anaemia B12

Gastrectomy B12, iron

Small bowel resection B12 (if distal ileum) others as in

malabsorption

Decreased

utilization

Drugs (esp. anticonvulsants, anti-

metabolites, oral contraceptives,

isoniazid, alcohol)

Various nutrients depending

on drug/nutrient interaction

Inborn errors of metabolism (by

family history)

Various nutrients

Increased losses Alcohol abuse Magnesium, zinc

Blood loss Iron

Centesis (ascitic, pleural taps) protein

Diabetes, uncontrolled Energy

Diarrhoea Protein, zinc, electrolytes

Draining abscesses, wounds Protein, zinc

Nephrotic syndrome Protein, zinc

Dialysis Protein, water-soluble

vitamins, zinc

Increased

requirements

Fever Energy

Hyperthyroidism Energy, protein

Physiologic demands (infancy,

adolescence, pregnancy, lactation)

various nutrients

Surgery, trauma, burns, infection Energy, protein, vitamin C,

zinc

Tissue hypoxia Energy

Cigarette smoking Vitamin C, folic acid Source: Weinsier RL, Morgan SL, Perrin VG. 1993. Fundamentals of clinical nutrition. St. Louis: Mosby. In Lee &

Nieman.


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4. Anthropometric data

Anthropometric data gives the professional more objective information

about body composition. One can calculate approximate ‘ideal body weight’ in order to estimate nutrient needs and to assess risk of health

problems linked with obesity. This data will also call attention to protein-

energy malnutrition, which may be relevant in children, elderly, homeless

and those with eating disorders.

Anthropometry uses physical measurements including height, head

circumference, weight, skin fold thicknesses, other girth measurements.

Ethnic, familial, birth weight, and environmental factors affect these

parameters and so should be taken into consideration when interpreted.

Our ideal weight

This is largely a clinical method, which is not necessarily shared with the

client. Too often this feeds into the emphasis on everyone having the

same slim shape. These calculations, as we’ve said, are used to assess risk of malnutrition and obesity-related disease. There are two main methods

which dieticians use to determine an individual’s ideal body weight: Body mass index and ideal body weight calculation. These are used to

determine energy needs, which is vital in the situation of tube feeding and

total parental nutrition calculation. Some also use it for weight loss

strategies. However, when working with those not critically ill, it becomes

less important.

1. The body mass index (BMI)

This has become a popular guide for people to determine if they are a

healthy weight. It is a factor of weight for height using the simple

calculation below. Strengths: This is a quick and easy guide to assess the

appropriateness of an individual’s weight for their height. The major drawback is that it does not account for body composition.

BMI = weight (kg)/height (metres)2 or

wt (lb)/height (in)2 x 705 *

BMI value Interpretation

20-25 Ideal body weight

25-29.9 Grade 1 obesity

30-40 Grade 2 obesity

40+ Grade 3 obesity *Conversions: 2.2 pounds/kilogram, 14 pounds/stone, 2.5cm/inch


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2. Ideal body weight (IBW) calculation

Like BMI, this is difficult due body composition variability. It can, however,

take frame-size into account. The calculations are below.

Ideal body weight:

Women: 100lb for the first 5 feet of height and 5 lb for every inch over 5 feet

Men: 106lb for the first 5 feet of height and 5 lb for every inch over 5 feet

Frame size adjustment: Large frame + 10%, small frame –10%.

Frame size is determined by wrist measurement

Frame size calculation (r)

r = height (cm)/wrist circumference (cm)

r value Men Women

Small frame >10.4 >11.0

Medium frame 9.6-10.4 10.1-11.0

Large frame <9.6 <10.1

Example: 5’4” woman: 100lb + 5lb(4inches) = 100lb + 20 = 120lbs

Large frame + 10% = (120lbs + 12) = 132lbs

Often, people will use desired weight, or a previous weight, if more

realistic, when determining energy needs.

Body composition

Body composition is defined, generally by the proportion of weight which is

fat tissue, compared to lean body mass (muscle, bone, etc). Body

composition can vary widely between two individuals at the same BMI. For

example, we know that muscle mass weighs more that the same volume of

fat. Therefore, a muscular person will have the same BMI as a non-muscular

person who is much larger. Body composition is more accurately

determined by measuring skin-fold thickness (subcutaneous fat),

circumference measurements, bioelectrical impedance, or water

displacement.


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1. Skin-fold tests: This method used callipers to measure subcutaneous fat

in areas it is typically deposited such as triceps, biceps, sub-scapular

region, above iliac crest and upper thigh. While this is practical in a

clinical setting, it is somewhat time consuming, often uncomfortable to

the client as they must partially undress, and relies on accuracy of

measuring technique.

2. Waist-hip ratios: Where an individual stores their body weight shows

their risk factor for certain diseases such as diabetes and heart disease.

A higher waist-hip ratio (larger waist) suggests insulin-resistance and

increased risk of diabetes. These are easy to measure with a

measuring tape, though finding exactly where the waist and hip are

and being consistent takes practice.

3. Bioelectrical impedance analysis (BIA): It is based on the principle

that lean body tissue has a higher electrical conductivity, and lower

impedance, than fatty tissue. The accuracy of this can vary with

fever, electrolyte imbalance, obesity and hydration status.

4. Water displacement: This method is based on the fact that muscle and

bone mass is more dense than fatty tissue. The volume of water

displaced by the submerged body, combined with body weight data,

will give a more accurate picture of body composition. The major

drawback is cumbersome equipment.


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Energy needs

In a laboratory, on can directly measure how much energy is being

expended by an individual in the resting state. In the clinic, more indirect

estimates must be used. Dieticians must use formulas to evaluate a patient’s precise caloric needs to sustain weight, for example, in tube feeding or in

total parenteral nutrition (TPN). Most healthy people learn their functional

energy needs by knowing how much food they can consume while

maintaining weight. A clinician can calculate this based on the person’s basal metabolic rate (BMR) or resting energy expenditure (REE). The effects

of different levels of activity or disease states are then adjusted for. The main

calculation used for this is the Harris-Benedict equation. There are also a

variety of tables from the World Health Organization and other health-

promotion organizations.

Harris Benedict Equation

Females: REE = 655.1 + 9.6W + 1.9S – 4.7A

Males: REE = 66.5 + 13.8W + 5.0S – 6.8A W=body weight in kg, S=stature in centimetres, A=age in years.

Factors which affect REE:

Activity levels: Increased activity increases REE

Muscle mass: Increased muscle mass increases REE

Disease and injury can increase REE, and starvation can

decrease it.

Protein needs

The basic calculation for protein needs is 0.8g/kg body weight for adults. If

significantly overweight, one can use ideal body weight to calculate needs.

Protein needs are increased by: trauma, burn patients, pregnancy, lactation

and periods of growth (children). Refer to the protein section of your

macronutrients module for more detail.

Protein-energy malnutrition (PEM)

This is seen in certain diseases such as cancer and AIDS, homeless persons

and children who fail to thrive. Primary PEM is due to inadequate intake.

Secondary PEM may be due to other diseases leading to insufficient food

intake, inadequate nutrient absorption or utilization, increased nutritional

requirement and increased nutrient losses. Evaluate with a combination of

dietary intake, anthropometric measures, clinical findings and biochemical

data including serum albumin.


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5. Biochemical tests

Biochemical tests are a valuable tool in assessing and managing nutritional

status. They do have their limitations, most notable being the influence of

non-nutritional factors on test results. Biochemical tests must be used in

conjunction with measures of dietary intake, anthropometric measurements

and clinical data to be accurate.

Laboratory tests are frequently used in hospitals. But for the independent

practitioner, they are not often used. You can, however, ask clients for

results of past laboratory tests ordered by their GP/consultants, and on some

occasions, ask a client to request certain tests if you provide sound reasoning

for the expenditure. Alternatively, there are a variety of independent labs

which provide laboratory tests for a fee.

Most of the tests will are for acute disease states that will be dealt with by the

GP such as kidney failure, electrolyte imbalance, diabetes, hormone

imbalance, anaemia, cancer or liver disease. As a nutritionist, some of them

will have nutritional significance as well, which you can use. The table below

shows nutritional relevance of common biochemical tests your clients may

have information on.

Common biochemical tests include:

Albumin

Prealbumin

C-reactive protein

Some mineral tests (see micronutrients section for this)

Electrolyte tests (see micronutrients section)

Haematology (see iron section in micro module)

Fasting blood sugar

HbA1c: glycosylated haemoglobin

Fasting lipids

Total bilirubin, Direct/conjugated

Other tests;

Liver function tests

AST (GOT), ALT (GPT)

Alkaline phosphatase

Homocysteine (to determine folic acid, B12, B6 levels)

Thyroid hormone levels: decreased: may explain why difficult to

lose weight. Borderline levels can be addressed by increased

protein, vitamin and mineral intake to build lean body mass.

See appendix one for a list of common biochemical tests and their

corresponding nutritional relevance.

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Lecture 6 – Nutritional Physiology Part 1

6. Clinical Data

Signs and symptoms gathered by questioning and examining the hair,

face, eyes, lips, tongue, teeth, fingernails, gums, glands and nervous

system are excellent ways to assess nutritional status. Traditional healing

modalities, such as Chinese and Ayurvedic systems, have long relied on

the use of these methods, in addition to pulse diagnosis, to accurately

diagnose the state of health. These methods are simple, non-invasive

and inexpensive. They just require knowledge and practice on the part

of the practitioner to know how to interpret them. The table below is an

example of a list of signs and symptoms with nutritional implications. An

excellent resource can be made by taking this as a template, and

going through your micronutrients section, and other sources, to

compile a list for use in clinical practice.

See appendix 2 for the nutritional implications of various signs and symptoms.

Clinical practice exercise

Create a prototype intake form for a nutrition client. Include a dietary intake

question are (choose whichever format you prefer), and questions for

medical, psychosocial and dietary history, biochemical data (from previous

tests), clinical information and anthropometric data. Find a person to

experiment on to see how long it takes to administer and how useful the

information is in making a nutritional assessment. Note: Your methods of

interviewing and assessment will no-doubt change over time as your skills and

knowledge evolve.

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THE DIGESTIVE SYSTEM

Adequate nutrition relies on having a healthy gut. The integrity and proper

functioning of the stomach, small intestine and large intestine are vital to the

optimal absorption of essential nutrients, and exclusion of potential

pathogens. In this section, we will review how the gut functions in relation to

absorption of nutrients and the role of intestinal microbes.

HEALTHY GUT AND DIGESTION REVIEW

Digestion begins in our minds……

Most people think digestion starts in the stomach or the mouth. But

really, it begins in the mind. The preparation and anticipation of a

meal begins to set the stage for proper digestion. It’s quite common for people to have a lot of digestive problems day to

day, only to feel fine on holiday. This can be their first clue that

their mental state could be playing a role. Our minds can control

our nervous system. We have two main branches of our nervous

system: the parasympathetic and the sympathetic nervous system.

The parasympathetic system is responsible for the calm, relaxed

state we are in when we sit down to eat a meal. The sympathetic

nervous system kicks in when we are stressed. It evolved to help us

jump up from our meal and escape from dangerous predatory

animals. It redirects blood away from the organs of digestion and

towards skeletal muscles so that we can run or defend ourselves

(i.e. fight or flight).

Quiet the mind. In modern days, we perceive different things as

stressful and flip ourselves into the sympathetic nervous system.

Often we do this just by over-thinking or worrying to ourselves

quietly. We must learn how to consciously reduce over-thinking

and quiet the mind. This is not easy, but it is possible and critical.

People take meditation, yoga, tai-chi, breathing and stress-

reduction classes to train themselves to do it. These

relaxation/mindfulness techniques allow us to control what branch

of the nervous system is dominant. It is critical that before we begin

eating, that we switch off from work and spend time eating in a

relaxed environment. Then after a meal, give ourselves at least 30

minutes before returning to anything overly stressful or physically

demanding.

While this may not sound like ‘nutrition’ per se, it is often the main cause of impaired digestion in the modern human.

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For proper physical digestion, all parts of the digestive system must be doing

their part.

Mouth: When we eat food, amylase in the saliva begins to

enzymatically breakdown starch molecules, while mastication

(chewing) mechanically breaks down large particles into smaller

molecules with a greater surface are to facilitate future enzyme

breakdown.

Stomach: The stomach secretes hydrochloric acid and proteases to

break down large protein molecules. It has a minimal absorptive role.

Small intestine: The stomach contents empty into the duodenum

(beginning of the small intestine), where the acidic stomach contents

are neutralized by bicarbonate secreted by the pancreas, along with

more digestive enzymes to break down macronutrients. Bile salts are

secreted by the gall bladder to facilitate absorption of lipid

components. Food particles are further broken down and most of the

nutrients are absorbed in the small intestine.

Large intestine: The large intestine contains large populations of

microorganisms which also contribute to our digestion and nutrition.

They ferment some unabsorbed starches and fibres. They also make

some essential nutrients such as biotin and Vitamin K as well as short

chain fatty acids. When food reaches the large intestine, water and

electrolytes are absorbed along with nutrients produced by colonic

microbes. When any of these functions becomes impaired, it can

affect the balance of the whole system.

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IMPAIRED DIGESTION

Most people do not experience optimal digestion. From the top down,

problems arise due to stress, lifestyle, genetics or illness. We will discuss some

of the critical points where things tend to go awry, and some strategies to

improve the situation.

Impaired digestion may occur as the result of some of these conditions:

Gastric acid hypersecretion or hyposecretion

Gastric resection

Pancreatic insufficiency

Pancreatitis

Liver and biliary disease

Bacterial overgrowth

Disaccharidase deficiency (i.e. lactose intolerance)

Celiac disease

Crohn’s disease

Ulcerative colitis

HYPOCHLORHYDRIA AND ACHLORHYDRIA

Indigestion and heartburn are very common and typically treated with

antacids, under the suspicion that excessive stomach acid is the culprit.

However, it is actually more common in cases of indigestion for people to

have low stomach acid, or hypochlorhydria. Some individuals have a

complete lack of gastric acid secretion and are said to have achlorhydria.

Gastric acid secretion naturally decreases for many with age. Over half of

those over 60 years old have low stomach acid. This correlates well with the

reduced B12 absorption seen in the elderly and increased need for

intramuscular injections of the vitamin.

In order to diagnose hypochlorhydria, one can use laboratory tests or signs

and symptoms. The best laboratory test is Heidelberg gastric analysis. This

involves an electronic capsule attached to a string, which is swallowed to

measure the acidity of the stomach. Most practitioners can assess it from

signs and symptoms.

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Signs and symptoms of low gastric acid

A sense of fullness after eating

Acne

Bloating, belching, burning and flatulence immediately after meals

Chronic candida infections (rectal itching, thrush or vaginal yeast infections)

Chronic intestinal parasites or abnormal flora

Dilated blood vessels in the cheeks and nose.

Indigestion, diarrhoea, constipation

Iron deficiency

Multiple food allergies

Nausea after taking supplements

Undigested food in the stool

Upper digestive track gassiness Weak, peeling and cracked fingernails Source: Murray and Pizzorno

Consequences of hypochlorhydria

Low stomach acid can cause an imbalance downstream, to the rest of the

digestive track. Some of these imbalances are due to impaired digestion

and absorption of essential nutrients. The stomach acid is essential in

protein digestion. The acid activates pro-enzymes responsible for the initial

stages of protein breakdown. Hydrochloric acid is also needed for the

absorption of vitamin B12 (review in micronutrients). Other minerals such as

calcium and iron, which benefit from the acidity of the stomach to

increase their solubility, suffer from poor absorption rates when stomach

acid is low. For this reason, multiple nutrient deficiencies can result, often

leading to some form of anaemia.

Stomach acid is the first line of defence against pathogenic microbes.

Without the destructive capacity of hydrochloric acid, microbes can more

easily survive passage through the stomach colonising the small intestine.

Microbial colonisation of the small intestine can interfere with digestive

enzymes, nutrient absorption and gut immunity. In other cases, it can allow

parasites and pathogens to enter, causing acute disease states.

Diseases associated with low gastric acidity

Addison’s disease

Asthma

Chronic autoimmune disorders

Celiac disease

Dermatitis herpetiformis

Diabetes mellitus

Eczema

Gallbladder disease

Graves’s disease

Hepatitis

Chronic hives

Lupus erythematosis

Myasthenia gravis

Osteoporosis

Pernicious anaemia (B12

deficiency)

Psoriasis

Rheumatoid arthritis

Rosacea

Sjogren’s syndrome

Thyrotoxicosis

Hyper and hypothyroidism

Vitiligo Source: Murray and Pizzorno

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Causes of hypochlorhydria

As stated earlier, gastric acid secretion often diminishes with age. As

hydrochloric acid secretion is zinc-dependent, some feel zinc deficiencies

may contribute. However, growing evidence indicates a major cause is

the overgrowth of the bacteria Helicobacter pylori. Low acidity

encourages the colonization of H. pylori, and H. pylori, in turn, lowers

stomach acidity... a downward spiralling feedback loop. But we might ask,

‘What leads to the infection in the first place, and why doesn’t everyone with H. pylori get ulcers or hypochlorhydria?’ It may be that other predisposing conditions are present such as lowered immunity or

decreased nutrient levels, particularly antioxidants to protect the gastric

mucosa from damage. While antibiotics are typically prescribed to

eradicate H. pylori, there are two natural approaches commonly used to

eliminate the infection. Deglycyrrhizinated licorice (DGL) helps to heal

both duodenal and gastric ulcers. It improves the health of the intestinal

cells in general. The second, bismuth, is a naturally occurring mineral which

can act as an antacid and exert antibiotic activity against H. pylori. The

most effective form is bismuth subcitrate, but the most common form is

bismuth subsalicylate – commonly sold as Pepto-Bismol at the chemist. (Source: Blaser MJ. The Bacteria behind Ulcers. Scientific American February 1996.)

Treatment for hypochlorhydria and achlorhydria

Hydrochloric acid tablets are available in supplement form. While it may

sound dangerous or painful to swallow hydrochloric acid, the tablets are in

a form which is not harmful at all. They typically come in the form betaine-

hydrochloride. Individuals must assess their own dosage by trial and error.

Often, betaine hydrochloride is included in digestive aid supplements

along with enzymes and herbs.

How to take hydrochloric acid supplements:

Betaine hydrochloride capsules should be taken at the beginning of a large meal.

If there is no effect on symptoms within the first few days, increase the dose one

tablet at a time, taking them throughout the meal. Try two tables at the next

meal, then three until you feel a warmth in your stomach, or notice elimination of

symptoms.

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PANCREATIC EXOCRINE HYPOFUNCTION (Pancreatic enzyme insufficiency)

The role of the pancreas is to produce and secrete various digestive enzymes

and hormones involved in food metabolism. When functioning properly,

ingestion of food stimulates the release of a medley of enzymes which act on

lipids, carbohydrates and proteins, along with bicarbonate to neutralize the

stomach acid.

Pancreatic enzymes require specific conditions in order to do their job:

Enzymes need a fairly neutral pH, which the bicarbonate provides.

They need to be in a high enough concentration, relative to the mass

of food, in order to act on all the foodstuffs. For this reason, large meals

and meals consumed with excessive liquids make it difficult for the

enzymes to be effective.

The food also needs to be in small enough pieces, to provide adequate

surface area for the enzymes to completely breakdown the food.

Complete mastication is responsible for this.

The pancreas also needs adequate stimulation to produce these

enzymes. The smell of food, a calm nervous system, chewing food and

ingestion of moderate amounts of dietary lipids all stimulate production

of the enzymes.

However, even under optimal conditions, some people suffer from impaired

pancreatic function. This can be due to a disease state. Inflammation of the

pancreas or cancer can impair its proper functioning. Cystic fibrosis, a rare

genetic disease, causes the most severe pancreatic insufficiency. Elderly

individuals commonly experience a mild to moderate reduction in pancreatic

function. However, it is also common to have younger people experience

reduced enzyme function. This may be due to decreased pancreatic

production, or the interference of small bowel microbial overgrowth.

Diagnosis of pancreatic insufficiency

A diagnosis can be made from laboratory tests or signs and symptoms.

Laboratory diagnosis includes CDSA (comprehensive digestive stool

analysis), which can be ordered from an independent laboratory (see

appendix). Symptoms include abdominal bloating and discomfort,

gas, indigestion and passing of undigested food in the stool. It may

manifest in malabsorption problems and nutrient deficiencies. The

abdominal discomfort is largely due to the sensation that food is not

being broken down properly. But equally uncomfortable may be the

excess gas produced because the colonic microflora receive more

starches to ferment. If there is impaired fat absorption, there will be

reduced absorption of fat-soluble vitamins. There may also be

increased diarrhoea in the form of steatorrhea (soapy diarrhoea) due

to the binding of dietary lipids to calcium.

24


Symptoms if pancreatic enzyme insufficiency

Abdominal bloating

Flatulence

Indigestion

Undigested food in stools

Malabsorption/nutrient deficiency symptoms

Steatorrhea

Treatment of pancreatic enzyme insufficiency

One will always want to look at predisposing factors for impaired

digestion first. This may include stress, frequent snacking, poor food

combining, eating on the run, overeating, consuming excessive liquids

with meals, dysbiosis and medical conditions such as cancer and

inflammation of the pancreas.

However, many would not hesitate to add supplemental digestive

enzymes at mealtimes. Improving digestion and absorption can itself

improve digestion. It improves the feeling of wellness, contributes to a

healthy gut flora and improves nutrition in general. Supplementation

with digestive enzymes, like hydrochloric acid is unlike most other

supplementation. These are supplements which are designed to

facilitate the normal digestive process. Many commercial enzyme

preparations are from fresh hog pancreas and called pancreatin. These

contain enzymes, often given with ox bile to improve fat absorption, are

very similar to our own digestive juices and are highly effective. It is the

one most recommended to those with cystic fibrosis. However, some

prefer to use plant-based products. While less similar to our own

enzymes, many have proven to be highly effective. Effective products

must list enzymes such as amylase, protease and lipase. These are very

effective with mild pancreatic insufficiency.

Many ‘digestive aid’ supplements on the market contain bromelain and papain, which are protein-digesting enzymes from pineapple and

papaya, respectively. They are not as effective as the enzymes, but

may be helpful to those wishing to avoid animal products. They may be

combined with herbs, which aid digestion for a less expensive product.

These may be effective in very mild situations, but are less effective

when actual enzyme insufficiency is present.

Many enzyme products are enteric-coated to prevent them from being

denatured in the stomach, however, non-enteric-coated preparations

have worked very well.

25


MEDICAL MALABSORPTIVE DISORDERS

PANCREATITIS

Pancreatitis is the inflammation of the pancreas, which can present in

an acute or chronic form. In this disease, the digestive enzymes

normally secreted into the intestine (such as protease and lipase) are

instead pathologically released inside the pancreas itself. This causes

damage to the surrounding tissues, leading to inflammation and

eventually cirrhosis (fibrotic destruction of cells). In acute forms, it can

be life-threatening and requires prompt medical treatment. Chronic

forms are slower and can be accompanied by intermittent abdominal

pain radiating to the back. Pancreatitis most commonly accompanies

alcoholism and gall stones, however half of all patients have no

predisposing influences.

Nutritional implications of pancreatitis: Pancreatic enzyme

insufficiency, malabsorption of all nutrients, protein malnutrition,

multiple nutrient deficiencies and steatorrhea.

Nutritional support: The use of digestive enzymes in the form of

pancreatin, along with ox bile to facilitate lipid digestion. Nutrient

dense foods and supplements can replace lost nutrients.

LIVER DISEASE

Three main types of liver disease are seen. Viral hepatitis caused by various

hepatitis viruses, alcoholic liver disease, and cholestatic liver disease.

Liver disease Caused by Results in Viral Hepatitis Hepatitis virus. Hep C is most

likely to continue chronically

and cause liver disease.

Inflammation of the liver, possibly

cirrhosis.

Alcoholic liver

disease/hepa

titis

Acetaldehyde, the toxic by-

product of alcohol

metabolism.

Damaged liver tissues, impaired

structure and function of the liver.

Fatty liver and cirrhosis.

Cholestatic

liver disease

Blockage of bile ducts Steatorrhea, malabsorption of

nutrient, back-up of bile in liver,

impaired elimination of cholesterol

and fat-soluble toxins.

Clinical consequences of liver disease

Jaundice and cholestasis

Low serum albumin (carrier

protein)

Build-up of ammonia

Hypoglycaemia

Spider angiomas

Hypogonadism

Muscle wasting

Portal hypertension from cirrhosis

Ascites

Haemorrhoids

Hepatic failure: Multiple organ

failure

Weight loss

26


Nutritional Support for liver disease

Promote adequate caloric intake w/ small, frequent, energy-dense

diet to spare protein and support anabolism.

Restrict sodium and give moderate fluid intake if supporting

treatment of ascites and oedema.

Medium-chain triglycerides (MCT)

Avoid overfeeding

EFA’s and fat-soluble vitamins in water-miscible forms

Injections of: Thiamin, B12, and folate. Source: Beverly Kindblade MNT in Liver disease, direct communication

Other helpful herbs and nutrient

Milk thistle (silybum marianum) stimulates production of new liver

cells to replace damaged cells, inhibits free radical damage. Use

for Alcoholic liver disease, cirrhosis, viral hepatitis, gallstones.

Licorice derivatives (glycyrrhiza glabara)

SAMe, L-Cysteine, L-Glycine

Lecithin

Vitamin E

Gamma-Linoleic acid, Linoleic acid, dietary saturated fats

Moderate exercise Source: Mullen KD and Dasarathy S. Alcoholic Liver Disease: Potential New therapies for Alcoholic Liver

disease. Clinics in Liver disease. 2(4) 1998.

BILIARY TRACT DISEASE

The biliary tract refers to the pathway of bile flow from the liver, to the

gall bladder and finally to the small intestine. Any obstruction in the

biliary track, blocking the flow of bile, can have serious consequences

to both the liver and the digestion of nutrients.

Hepatic (in the liver) bile ducts can be damaged as a result of liver

disease in drug toxicity, viral hepatitis or transplantation. Extrahepatic

bile duct obstruction, typically in the gallbladder, are most commonly

caused by gallstones. Gallstones affect 10%-20% of the adult

populations, and the incidence increases significantly with age. The

effect on the liver is explained earlier in liver disease. The lack of bile

secretion following ingestion of a meal will impair digestion and

absorption of lipids, essential fatty acids and fat-soluble vitamins. The

resulting steatorrhea may also lead to calcium and magnesium

deficiencies. Nutritional support is similar to that for liver disease.

27


INTESTINAL DISORDERS

Intestinal disorders are an increasingly common medical complaint. More

and more people are silently enduring painful bloating after meals, gas,

diarrhoea and constipation, without knowing why or what to do about it. As

we have learned thus far, there can be many causes for intestinal disorders.

What follows is a categorization of some of the medical terminology

associated with symptoms.

There are two major categories of bowel disorder:

1. Irritable bowel syndrome (IBS)

2. Inflammatory bowel disease (IBD)

IRRITABLE BOWEL SYNDROME (IBS)

IBS is a disease of the large intestine, which is medically less severe than IBD.

Patients tend to get this diagnosis when they come to their GP with

gastrointestinal problems, but when the results of endoscopy and other

tests reveal no clinically relevant symptoms, the diagnosis gets lumped into

the broad category that is IBS. While this is good news from the perspective

that there is no cancer or serious damage to the intestine itself, it can be

difficult because people are left with a very ambiguous diagnosis and

nothing to do about it.

Individuals may experience some or

all of these symptoms. It is not

known what causes or aggravates

the symptoms, because everyone is

so unique in their patterns. But

there is a collection of common triggers. Life stressors are the most

common and can override all other attempts to improve digestion. Life

stressors can include working 60 hours a week or going through a divorce.

But more often it entails the constant worrying and hidden anxiety about

things, not being able to let things go and relax. These are mental patterns,

which can be deeply imbedded and more difficult to change than ones

job

Triggers for IBS symptoms

Life stressors

Anxiety and worrying

Laxative use (and other over-the-counter medications)

Antibiotic use

Caffeine

Previous intestinal illness

Lack of regular sleep and rest

Inadequate fluid intake

Symptoms associated with IBS include

Alternating diarrhoea, and constipation

Abdominal pain

Bloating, flatulence

Sensations of incomplete evacuation

Mucus in the stool

28


Dietary /lifestyle recommendations for IBS

1. Regular schedule of sleeping (8 hours minimum), eating,

exercise and relaxation. Help your body tune into the natural

rhythms of life.

2. Address external life stressors and internal stressors. Tools like

therapy, meditation, tai chi, yoga and other methods of

relaxation and mind training.

3. Improve digestion. See table and address all relevant factors.

4. Clean up diet. Eliminate processed and pre-packaged foods,

reined sugar, refined carbohydrates, caffeine, alcohol,

preservatives and food colourings.

5. Address any food intolerances which may be present. With IBS,

wheat is the most common food trigger. With IBD look at wheat,

dairy, corn or eggs. Brassica vegetables may be a trigger as

well.

6. Increase dietary fibre slowly though well-cooked whole grains,

lentils, kelp and other seaweeds, whole fruit and vegetables,

especially dark leafy greens. Raw vegetables may be difficult to

digest and excessive fruit may promote diarrhoea.

The IBS-Serotonin connection

An old friend of mine, who is a GP in Alaska, sees quite a few patients with IBS. She

has noted that most of these people also suffer from anxiety, depression and

headaches. Now, it’s always a question about what causes what. But her research turned up a connection between serotonin levels and bowel spasms. Serotonin is a

neurotransmitter, which, to be simplistic, gives us that good feeling of calm, happy,

alertness. It also helps the digestive system to function normally by a) stimulation of

intestinal movement caused by smooth muscle in the gut and b) inhibiting secretions

in the gut; particularly water which helps to soften stools. Serotonin can get depleted

by over-stimulation and poor nutrition. Indulging in things that trigger serotonin

release, like eating sugary foods, stimulants (coffee, tea, and amphetamines) and

alcohol, slowly deplete our store of serotonin. We need adequate nutrition to make

enough replacement serotonin, which requires adequate daily protein, B vitamin and

mineral intake. In addition, when under stress, our adrenal glands produce

adrenaline. This stimulates a ‘flight-or-fight’ response. Adrenaline narrows blood

vessels in the intestines so that increased blood flow reaches the muscles. The

combination of low serotonin and high adrenaline release can trigger this

diarrhoea/constipation cycle and generally impair proper digestion. One final note:

One large meta-analysis of herbal and pharmaceutical treatments used to treat IBS

found that the only treatment with reproducible clinical efficacy was a selective-

serotonin reuptake inhibitor (SSRI) such as Prozac. This doesn’t necessarily mean we should rush to treat IBS with this drug, but it does add weight to the role of not only

serotonin, and the powerful connection between our physical body and our

mental/emotional well being.

29


INFLAMMATORY BOWEL DISEASE

IBD is a more medically serious situation and can be further divided into two

categories: Crohn’s disease and ulcerative colitis. These two are similar in a few ways.

The onset of both is typically between the ages of 15-30 years. Initial

onset commonly follows a period of intense stress (divorce, university,

bereavement) or illness.

Diarrhoea is very common in both and vomiting is occasionally seen as

well.

The important point with IBD is that there is inflammation present in the

mucosal lining of the intestinal track.

The intestine houses a large portion of the immune system, which is constantly

surveying and protecting us from the outside world that we consume in the

form of food and drink. In a healthy individual, when there is something

potentially harmful in the food, like pathogenic bacteria, the gut immune

system mounts an attack to the bacteria, and then backs off once the

pathogen is destroyed. This attack includes the release of potent

inflammatory molecules that, when left unchecked, can damage healthy

tissue as well as invading bacteria. Well, it seems that in some people, this

inflammatory process is turned on when needed, but fails to get ‘turned off’. The inflammation causes discomfort, cramping, fevers/sweating and can

begin to cause damage to the intestinal track. The cause is uncertain, but

can involve antibiotic misuse/overuse, stress, poor diet and genetic factors.

ULCERATIVE COLITIS

Is only in the colon, spreading from the rectum. Sufferers frequently

see blood in their stools, and have bloody diarrhoea. Although the

onset is 15-30 years of age, many begin or relapse in their 50’s. Liver problems and difficulties digestion fat may also occur.

CROHN’S DISEASE

Is more serious still. It may involve any part of the gut from the

mouth to anus. It can involve narrowing of the intestines and bowel

causing obstruction. 50% to 70% of those with Crohn’s disease will undergo surgery to remove affect segments of the gut.

Unfortunately, many of these people will require additional gut

resections in the future. Nutritional therapy should reflect the area

of damage or resection to replace nutrients absorbed in

associated segments.

30


Nutritional support for IBD

Both of these conditions are serious and should be dealt with as such. With

both of these illnesses, the most common medical treatments are steroids

and sulfasalazine. These act as potent anti-inflammatory agents to halt the

damage being done to the wall of the gut. While these drugs have their

place in severe illness, they may interfere with an individual’s own healing process. Studies have concluded that dietary and lifestyle changes are

imperative and an important first action to take. Early use of steroids can

impair ones own innate ability to heal. If found early enough, the affected

individual can be monitored by their doctor and work with the necessary

dietary and lifestyle changes, so as to keep the more powerful drugs for

later if things get out of hand. It is important to remember when working

with IBD that the inflammation can cause permanent damage to the gut,

so skilful balancing of pharmaceuticals and nutritional healing can often

provide the best benefit.

During acute stages of the disease, diet must be customized to the

individual. Often, a low-fibre diet, low-lactose and easily digested meals

are appropriate. Small, frequent meals which are easy to absorb such as

soup broths, well-cooked grains, vegetable soups, and medium-chain

triglyceride oils. During less acute phases, one can work towards improving

health with the following recommendations.

Nutritional therapy for IBD

1. Follow the recommendations for IBS, and also include the following:

2. Add a high-quality multi-vitamin and mineral supplement to address

the malnutrition that results. This can include improving the nutrient

density of foods. Emphasize foods such as seaweeds (especially for

vegetarians), broken bone broths, organic liver and egg yolks to

maximize nutrition.

3. If fat malabsorption is impaired, supplement with vitamins A, D, E and

K, and increase food sources and sun exposure.

4. Due to inflammation, protein needs may increase by 25% or more.

Women do well to obtain 80grams per day and men, 90grams.

5. Folic acid supplement AND increase food sources. Both steroids and

sulfasalazine inhibit folic acid absorption and utilization.

6. Zinc and Copper supplementation/food sources.

7. Iron: test for deficiency and increase food sources.

8. Essential fatty acids: Omega-3 fatty acids, in particular, are thought to

help with inflammatory diseases. Sources include cold-water fish, fish

oil, cod liver oil, linseed oil, linseeds, walnuts, pumpkin seeds and hemp

seeds.

9. Probiotics and prebiotics: Help keep the gut flora balanced and

improve gut immunity. Caution with these, as excessively high doses

can cause wind, which may exacerbate symptoms in people with

acute symptoms. Work with small doses on regular intervals.

31


APPENDIX 1

NUTRITIONAL RELEVANCE IN COMMON BIOCHEMICAL TESTS Test Elevated levels Decreased levels

Electrolytes Dehydration Vomiting, diarrhoea, bulimia,

other metabolic disorders.

Fasting blood

glucose

Diabetes or insulin resistance Excess insulin, other disease

states.

Albumin Dehydration Protein malnutrition (long-

term), malabsorption, liver

insufficiency.

Transferrin Pregnancy, oestrogen

therapy and acute hepatitis.

Better indicator of short-term

protein malnutrition. May

also fall with chronic

infections, surgery and

trauma.

Calcium Various cancers,

hyperthyroidism, excess

vitamin D, medications

Hypoparathyroidism,

malabsorption, pancreatitis,

low albumin

Total cholesterol Hypothyroidism, insulin

resistance, obstructive liver

disease, diabetes, genetic

disorder

Liver failure, hyperthyroidism,

anaemia, malabsorption

Uric acid Gout, kidney failure,

hypothyroidism

Aspirin usage, cortisone

usage, other disease states.

Total bilirubin Liver disease, other Anaemia, low albumin

Homocysteine

levels

B12, folate or B6 deficiency.

Increased risk of heart

disease.

Modified from Harborview Medical Centre Department of Nutrition and Foodservices.

Note: These tests have other medical implications which will be interpreted by the GP. Only issues relevant to

nutritional status are included here.

32


APPENDIX 2

SIGNS AND SYMPTOMS WITH NUTRITIONAL IMPLICATIONS

Possible deficiency Excess Frequency

Hair, nails

Flag sign (traverse

depigmentation of hair

Protein Rare

Easy pluckable hair Protein Common

Sparse hair Protein, biotin, zinc Vitamin A Occasional

Corkscrew hairs and

unemerged coiled hairs

Vitamin C Common

Traverse ridging of nails Protein Occasional

Skin

Scaling Vitamin A, zinc, EFA Vitamin A Occasional

Cellophane appearance Protein Rare

Cracking (flaky paint) Protein Rare

Follicular hyperkeratosis Vitamins A, C Occasional

Petechiae Vitamin C Occasional

Purpura Vitamins C, K Common

Pigmentation, desquamation

of sun-exposed areas

Niacin Rare

Yellow pigmentation-sparing

aclerae (benign)

Carotene Common

Eyes

Papilledema Vitamin A Rare

Night blindness Vitamin A Rare

Pale conjunctiva Anaemia (iron)

Mouth

Angular stomatitis Riboflavin, B6, niacin Occasional

Cheilosis (dry, cracking,

ulcerated lips)

Riboflavin, B6, niacin Rare

Glossitis (scarlet, raw tongue) Riboflavin, niacin, B6,

folate, B12

Occasional

Hypogeusesthesia, hyposmia zinc occasional

Swollen, retracted bleeding

gums

Vitamin C Rare

Bones, joints

Beading of ribs, bow legs Vitamin D Rare

Tenderness Vitamin C Rare (seen in

children)

Glands

Thyroid enlargement (front of

throat)

Iodine

Parotid enlargement (swollen

cheeks)

starvation, bulimia,

protein, B vitamins

Source: Weinsier RL, Morgan SL, Perrin VG. 1993 Fundamentals of clinical nutrition. St. Louis: Mosby. In Lee & Nieman

and Mahan Escott-Stump.

33


APPENDIX 3

CAUSES OF POOR DIGESTION

1. Serious medical problems: Rule our serious medical problems like pancreatic,

gall bladder and liver problems, as well as colon cancer. This will give you

some peace of mind so you can concentrate on your diet and lifestyle

changes.

2. Stress. Continual stimulation and not stopping to eat can impair digestion.

We need to learn how to quiet our minds for periods of time and enjoy our

meals. Always factor in time to digest after a meal!

3. Hydrochloric acid deficiency. Can correct with betaine hydrochloride.

4. Enzyme insufficiency. This can be corrected by taking enzyme replacements

with your meals in the short-term.

5. Dysbiosis. Repopulate with good bacteria. Discussed next.

6. Over eating. Eating until we are stuffed may be a cause of poor digestion. If

there is more food than enzymes, a lot of food will go undigested.

7. Liquids: Drinking with meals can dilute enzymes and hydrochloric acid. Drink

water between meals, or 30 minutes before you sit down to eat.

8. Medication. Many prescribed and over-the-counter medications such as

antacids interfere with digestion.

9. Caffeine: Caffeine is a stimulant and can trigger your sympathetic nervous

system, thus impairing your digestion. Try cutting it out for 5 days and see how

your digestion improves. As an aside, coffee is traditionally taken at the end

of a heavy meal. Used this way, it can actually stimulate digestion. If you

must have it, drink your coffee AFTER a meal only.

10. Food combination. When your digestion is already compromised, the order of

foods can make a difference. Heavy, high-protein foods take longer to

digest. Fruit and sweet cakes are quick to digest. If we eat fruit or cakes after

a heavy meal, we may find that the sugars and starches just become food for

hungry microbes and we get bloated and gassy. Try having fruit alone or

before a meal and avoid eating cakes and flapjacks after your meal.

11. Excessive Sacking. Excessive snacking can interrupt the natural cycles of your

digestion. Your digestive system needs a chance to rest after meals. Most

people do better with proper meals and waiting until they are hungry to eat

again. Allow 3-6 hours between meals, depending on your needs.

12. Hard-to-digest food. Some foods are inherently more difficult to digest and

need to be properly prepared. Dairy is more easily digestible in a cultured

food like yogurt and cottage cheese. Whole grains should be pre-soaked or

sprouted to improve digestibility.

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