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Advanced Nutritionand Dietetics inGastroenterologyEditorMiranda Lomer PhD RDSeries EditorKevin Whelan PhD RD

This edition first published 2014 2014 by John Wiley & Sons, LtdRegistered OfficeJohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UKEditorial Offices9600 Garsington Road, Oxford, OX4 2DQ, UK111 River Street, Hoboken, NJ 07030–5774, USAFor details of our global editorial offices, for customer services and for information about how to apply for permissionto reuse the copyright material in this book please see our website at right of the author to be identified as the author of this work has been asserted in accordance with theUK Copyright, Designs and Patents Act 1988.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, inany form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted bythe UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.Designations used by companies to distinguish their products are often claimed as trademarks. All brand names andproduct names used in this book are trade names, service marks, trademarks or registered trademarks of their respectiveowners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on theunderstanding that the publisher is not engaged in rendering professional services. If professional advice or other expertassistance is required, the services of a competent professional should be sought.The contents of this work are intended to further general scientific research, understanding, and discussion only and arenot intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatmentby health science practitioners for any particular patient. The publisher and the author make no representations orwarranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim allwarranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoingresearch, equipment modifications, changes in governmental regulations, and the constant flow of information relatingto the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided inthe package insert or instructions for each medicine, equipment, or device for, among other things, any changes in theinstructions or indication of usage and for added warnings and precautions. Readers should consult with a specialistwhere appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potentialsource of further information does not mean that the author or the publisher endorses the information the organizationor Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listedin this work may have changed or disappeared between when this work was written and when it is read. No warrantymay be created or extended by any promotional statements for this work. Neither the publisher nor the author shall beliable for any damages arising herefrom.Library of Congress Cataloging-in-Publication DataAdvanced nutrition and dietetics in gastroenterology / editor, Miranda Lomer.1 online resource.Includes bibliographical references and index.Description based on print version record and CIP data provided by publisher; resource not viewed.ISBN 978-1-118-87289-5 (ePub) – ISBN 978-1-118-87291-8 (Adobe PDF) – ISBN 978-0-470-67132-0I. Lomer, Miranda, editor.[DNLM: 1. Digestive System Diseases. 2. Dietetics. 3. Digestive System Physiological Phenomena.4. Nutrition Therapy. 5. Nutritional Status. WI 140]RC801616.3′3–dc232014006436A catalogue record for this book is available from the British Library.Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not beavailable in electronic books.Set in 9/11.5pt Times by SPi Publisher Services, Pondicherry, India12014

Advanced Nutrition and Dietetics BOOK SeriesDietary recommendations need to be based on solid evidence, but where can you find this information?The British Dietetic Association and the publishers of the Manual of Dietetic Practice present an essentialand authoritative reference series on the evidence base relating to advanced aspects of nutrition and dieteticsin selected clinical specialties. Each book provides a comprehensive and critical review of key literaturein the area. Each covers established areas of understanding, current controversies and areas of future development and investigation, and is oriented around six key themes: Disease processes, including metabolism, physiology and genetics Disease consequences, including morbidity, mortality and patient perspectives Clinical investigation and management Nutritional consequences of disease Nutritional assessment, including anthropometric, biochemical, clinical, dietary, economic and socialapproaches Nutritional and dietary management of disease

ContentsPreface Foreword Editor biographies Contributors SECTION 1  Physiology and function of the gastrointestinal andhepatobiliary tract and function of the mouth Physiology and function of the oesophagus Physiology and function of the stomach Physiology and function of the small intestine Physiology and function of the colon Physiology and function of the pancreas Physiology and function of the hepatobiliary tract Gastrointestinal microbiota Gastrointestinal tract and appetite control viiixxxi13815212833364148SECTION 2 Dietary components relevant to gastrointestinal health 552. and gastrointestinal health Short-chain fermentable carbohydrates Probiotics and the gastrointestinal microbiota Prebiotics and gastrointestinal health SECTION 3 Gastrointestinal disorders granulomatosis and nutrition Eosinophilic oesophagitis and nutrition Gastro-oesophageal reflux disease and nutrition Oesophageal cancer and nutrition 9395101105111

. cancer and nutrition Gastroparesis and nutrition Pancreatitis and nutrition Pancreatic cancer and nutrition Cystic fibrosis and nutrition Lymphangiectasia and nutrition Coeliac disease and nutrition Inflammatory bowel disease pathogenesis Inflammatory bowel disease nutritional consequences Inflammatory bowel disease dietary management Lactose malabsorption and nutrition Intestinal failure and nutrition Stomas and nutrition Irritable bowel syndrome pathogenesis Irritable bowel syndrome dietary management Diverticular disease and nutrition Constipation and nutrition Colorectal cancer and nutrition 9255SECTION 4Hepatobiliary disorders 2634.14.2Gallbladder disease and nutrition Primary biliary cirrhosis and primary sclerosing cholangitisand nutrition Alcohol-related liver disease and nutrition Autoimmune hepatitis and viral hepatitis and nutrition Non-alcoholic fatty liver disease and hereditary haemochromatosisand nutrition Decompensated liver disease and nutrition Hepatocellular carcinoma and nutrition Liver transplantation and nutrition 265Index 3174.

PrefaceIn recent years there has been an overwhelminginterest in the role of diet and nutrition in gastrointestinal health and disease. There are a number ofgeneral books that focus on combining these topicsbut not specifically at an advanced level. The aim ofthis book is to be an essential and authoritative reference and review for an international audience ofhealth professionals involved in the management orresearch of patients with gastrointestinal disorders.The book is divided into four main sections: The first section is devoted to the physiology andfunction of the gastrointestinal and hepatobiliarytract including all the major organs, the gastro intestinal microbiota and the role of the gut neuroendocrine system in appetite regulation. The second section covers specific dietary components including fibre, short-chain fermentablecarbohydrates, probiotics and the gastrointestinalmicrobiota and prebiotics in relation to gastro intestinal health. The third and fourth sections focus on gastrointestinal and hepatobiliary disorders respectively.These are comprehensive sections reviewing theevidence base relating to the pathogenesis, nutritional consequences and dietary management ofdisease.The book provides a cutting-edge review of the evidence base relating to the basic aspects (for example,mechanistic aspects of physiology, immunology,microbiology, etc.) and applied aspects (for example, dietary impact and intervention) of diet and nutritionin gastrointestinal health and extensive focus on dietin the causation and treatment of gastrointestinaldisease.Each chapter provides a critical review of thekey literature in each area, focussing on established areas of understanding and also on currentcontroversies and areas of current and futuredevelopment and investigation. The chaptersextensively draw upon the literature with a focuson mechanisms as well as critical reviews of theefficacy of interventions and, where available, reference systematic reviews and meta-analyses.The book is pitched at an advanced level to reflectthe expertise of the readership. The intended readership is practitioners, researchers and educators inthe area of gastrointestinal health and disease. Thiswill include an interprofessional mix of dietitians,gastroenterologists, hepatologists, nutritionists,specialist nurses and surgeons. Due to the advancedlevel of the book, it may also be an invaluableresource for students in the final year of a Bachelorsor Masters Degree in dietetics, nutrition, medicineor nursing, especially those undertaking relevantcourse units or research projects. It will also be ofinterest to those doing applied research in the areasof gastrointestinal immunology or microbiology.The book will also be of use for u niversity educators preparing teaching materials in the above areas.Miranda Lomer PhD RDSenior Consultant DietitianGuy’s and St Thomas’ NHS Foundation TrustHonorary Senior LecturerKing’s College LondonEditorAdvanced Nutrition and Dietetics inGastroenterology

viiiPrefaceThis book is the first title in a series commissioned aspart of a major initiative between the British DieteticAssociation and the publisher, Wiley. Each book inthe series provides a comprehensive and criticalreview of the key literature in each clinical area. Eachbook is edited by one or more experts who havethemselves undertaken extensive research and published widely in the relevant topic area. Each bookchapter is written by experts drawn from an international audience and from a variety of disciplines asrequired of the relevant chapter (for example, dietetics, medicine, public health, basic sciences). We areproud to present the first title in the series: AdvancedNutrition and Dietetics in Gastroenterology. Wehope that it impacts on health professionals’ understanding and application of nutrition and dietetics inthe management of people with gastrointestinal disease and improves outcomes for such patients.Kevin Whelan PhD RDProfessor of DieteticsKing’s College LondonSeries EditorAdvanced Nutrition and Dietetics Book Series

ForewordIt is an honour and a privilege to write a forewordfor this exceptional book devoted to nutrition anddietetics in gastrointestinal health and disease.Nutrition is a major discipline in gastroenterologyand is often overlooked.The first question a patient asks when faced withgastrointestinal problems is regarding diet. Up tonow gastroenterologists have been poorly informedin answering this question. Nutrition should be anintegral part of the undergraduate curriculum. Itshould also be included as a module for trainees ingastroenterology. This is largely ignored. Dietitianshave a key role in the multidisciplinary team thatcares for patients with gastrointestinal conditionsand are experts in food and nutrition.This book is very welcome as it has contributionsfrom key opinion leaders in gastroenterologywho have contributed significantly to the field ofnutrition. Advanced Nutrition and Dietetics inGastroenterology is edited by Miranda Lomerwho has extensive knowledge and an enviableCurriculum Vitae in both research and clinical management of dietary challenges.This book is a comprehensive text, and reviewsconcisely and succinctly, carefully annotated sections relating to the physiology and function of thegastrointestinal and hepatobiliary tract; dietarycomponents relevant to gastrointestinal health; andthe role diet plays in gastrointestinal and hepatology disorders. It is logical that diet has an effect onthe microenvironment of the gut. Diet can affect thegastrointestinal mucosa directly and indirectly byaltering the gastrointestinal microbiota. Nutrition ingastroenterology is a vast area to cover and in addition to practical aspects, this book thoroughlyreviews the evidence base and proposes new areasfor research.This book is the result of close collaborationbetween dietitians, gastroenterologists and scientists dedicated to gastroenterology. It highlights theimportance of diet in the multidisciplinary management of patients with gastrointestinal and hepatobiliary disease. It explores the therapeutic dietarystrategies required and will improve patient care.I would recommend Advanced Nutrition andDietetics in Gastroenterology as essential readingfor dietitians, physicians, surgeons and scientistswith an enquiring mind on the role of diet in healthand disease, and it should be mandatory for traineesin gastroenterology.Professor Colm O’MorainEmeritus Professor of MedicineTrinity College DublinPresident of the United EuropeanGastroenterology Federation 2011–2013

Editor biographiesMiranda Lomer PhD RDMiranda Lomer is a Senior Consultant Dietitian forGastroenterology at Guy’s and St Thomas’ NHSFoundation Trust and an Honorary Senior Lecturerin the Diabetes and Nutritional Sciences Division atKing’s College London. Her clinical speciality andresearch interests include the dietary managementof functional gastrointestinal disorders and inflammatory bowel diseases. Dr Lomer was formerlychairperson of the Gastroenterology SpecialistGroup of the British Dietetic Association and ledthe writing of the British Dietetic Association evidence-based guidelines for the dietary managementof irritable bowel syndrome in adults and the BritishDietetic Association evidence-based guidelines forthe dietary management of Crohn’s disease inadults. Dr Lomer is on the panel of the NationalIBD Standards Group and represented the BritishDietetic Association on a National Institute for Healthand Clinical Excellence guideline for the diagnosisand management of irritable bowel syndrome in primary care. For her contribution to clinical practice,education and research, Dr Lomer was awardedthe British Dietetic Association Elsie Widdowsonprestigious annual lecture in 2014.Kevin Whelan PhD RDKevin Whelan is the Professor of Dietetics in theDiabetes and Nutritional Sciences Division at King’sCollege London. He is a Principal Investigator leading a research programme exploring the interactionbetween the gastrointestinal microbiota, diet andhealth and disease. Professor Whelan undertakesclinical trials of probiotics, prebiotics, fibre and fermentable carbohydrates, together with molecularmicrobiology to measure their impact on the microbiota. In 2012 he was awarded the Nutrition SocietyCuthbertson Medal for research in clinical nutrition.Professor Whelan is the Associate Editor-in-Chieffor the Journal of Human Nutrition and Dietetics andis on the International Editorial Board for AlimentaryPharmacology and Therapeutics.

ContributorsStuart Allan MBBS MRCSNorthumbria NHS TrustNorth Shields, UKSimran Arora MSc RDSpecialist Hepatology and Liver Transplant DietitianRoyal Free London NHS Foundation TrustLondon, UKStephen E. Attwood MD FRCSConsultant SurgeonNorthumbria NHS TrustNorth Shields, UKImran Aziz MBChB MRCPGastroenterology Clinical Research FellowRoyal Hallamshire HospitalSheffield, UKQasim Aziz PhD FRCPProfessor of NeurogastroenterologyWingate Institute of NeurogastroenterologyQueen Mary University of LondonLondon, UKGudrun De Boeck PhDProfessorUniversity of AntwerpAntwerp, BelgiumSorrel Burden PhD RDLead DietitianCentral Manchester NHS Foundation TrustManchester, UKHelen Campbell PhD RDResearch DietitianGuy’s and St Thomas’ NHS Foundation Trustand King’s College LondonLondon, UKEmma V. Carrington MSc MRCSClinical Research FellowWingate Institute of Neurogastroenterology,Queen Mary University of LondonLondon, UKYolande M. Causebrook BSc RNutrNutritionistNewcastle UniversityNewcastle upon Tyne, UKPaul A. Blaker BSc MRCPClinical Fellow in GastroenterologyGuy’s and St Thomas’ NHS Foundation TrustLondon, UKJaimini Cegla MSc MRCPWellcome Trust Clinical Research FellowImperial College LondonLondon, UKStephen R. Bloom FRSHead of Division of Diabetes, Endocrinologyand MetabolismImperial College LondonLondon, UKSaira Chowdhury BSc RDHighly Specialist Upper Gastrointestinal GI SurgeryDietitianGuy’s and St Thomas’ NHS Foundation TrustLondon, UK

xiiContributorsAlison Culkin PhD RDResearch DietitianSt Mark’s HospitalHarrow, UKGillian Gatiss MSc RDSpecialist Hepatology and Liver Transplant DietitianCambridge University Hospitals NHS TrustCambridge, UKEmma Currie MSc RDSpecialist Gastroenterology DietitianAddenbrooke’s HospitalCambridge, UKLiljana Gentschew MScGenetic ScientistUniversity of KielKiel, GermanyBarbara Davidson RDLead Specialist Dietitian Nutrition SupportFreeman HospitalNewcastle upon Tyne, UKKonstantinos Gerasimidis PhD APHNutrLecturer in Clinical NutritionUniversity of Glasgow and Glasgow RoyalHospital for Sick ChildrenGlasgow, UKAshish P. Desai FRCSConsultant Paediatric SurgeonKing’s College Hospital NHS Foundation TrustLondon, UKFrances Dorman BSc RDSpecialist Hepatology DietitianKing’s College Hospital NHS Foundation TrustLondon, UKMichael P. Escudier MD FDSRCSReader and Consultant in Oral MedicineKing’s College London and Guy’s andSt Thomas’ NHS Foundation TrustLondon, UKAdam D. Farmer PhD MRCPClinical Research FellowWingate Institute of Neurogastroenterology,Queen Mary University of LondonLondon, UKLynnette R. Ferguson DPhil DScProfessor and Head of Department of NutritionUniversity of AucklandAuckland, New ZealandMark Fox MD MRCPProfessor of GastroenterologyUniversity Hospital ZürichZürich, SwitzerlandUniversity of NottinghamNottingham, UKPascale Gerbault PhDResearch AssociateUniversity College LondonLondon, UKGlenn R. Gibson PhDProfessor of Food MicrobiologyUniversity of ReadingReading, UKHenriette Heinrich MDClinical Research FellowUniversity Hospital ZürichZürich, SwitzerlandMary Hickson PhD RDResearch Dietitian and Honorary Senior LecturerImperial College Healthcare NHS Trust andImperial College London,London, UKOrla Hynes BSc RDHighly Specialist Upper GI Surgery DietitianGuy’s and St Thomas’ NHS Foundation TrustLondon, UKPeter Irving MD FRCPConsultant GastroenterologistGuy’s and St Thomas’ NHS Foundation Trust andKing’s College LondonLondon, UK

ContributorsSanthini Jeyarajah MD FRCSClinical Research FellowKing’s College Hospital NHS Foundation TrustLondon, UKYiannis N. Kallis PhD MRCPConsultant HeptalogistBarts Health NHS Trust, Royal London Hospital,London, UKRegina Keenan BScSenior Dietitian in Hepatobiliary SurgerySt Vincent’s University HospitalDublin, IrelandRichard Keld MD MRCPConsultant GastroenterologistWrightington, Wigan and Leigh NHSFoundation TrustWigan, UKTan

Advanced Nutrition and Dietetics Book Series. Foreword. It is an honour and a privilege to write a foreword for this exceptional book devoted to nutrition and dietetics in gastrointestinal health and disease. Nutrition is a majo

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