18.1 The Impact of Nutrition on Gastrointestinal Wellness Across the Lifespan

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.

Figure 18.2 Prebiotic foods like this grilled asparagus, which is also high in fiber, can promote gastrointestinal health during pregnancy. (credit: “Ett par sparrisar och några bitar paprika på en klotgrill” By VisbyStar/Wikimedia Commons, Public Domain)

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 B₁₂ (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 B₁₂ (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).

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.

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).