Pancreatitis: What’s fibre got to do with it?
Pancreatitis is inflammation of the pancreas. There are two main types of pancreatitis: acute (abrupt onset) and chronic (long-standing disease). The inflammation can damage pancreatic tissue and cause symptoms such as abdominal pain, nausea, weight loss, diabetes, and malabsorption.
You may have already heard about the role of fat in the management of pancreatitis, but what about the role of fibre? Is there one? Newer research is showing that fibre may very well play an important role in the management of pancreatic disorders, including acute and chronic pancreatitis. The latest evidence in this area remains controversial, and more studies are needed to confirm these findings, but it is still interesting to check out what they are discovering. Keep reading to learn more about what science has shown so far about the nutrition management of pancreatitis, and how to apply these findings to your everyday life and practice.
Acute Pancreatitis
In the hospital setting, when an individual is admitted with acute pancreatitis, the doctor will write a nil per os (NPO) diet order, which is Latin for “nothing by mouth”. The person will get plenty of intravenous (IV) fluids to stay hydrated, as they will often have symptoms of nausea, vomiting, and abdominal pain that prevent them from eating or wanting to eat. Eating when the pancreas is inflamed will stimulate the pancreas and trigger these undesirable symptoms. If the case is mild, then the diet will be gradually advanced from liquids to solids (low-fat with or without a low-fibre restriction, or regular diet as tolerated) over the next few days, and in very mild cases, within 24 hours.1 The ultimate goal is to return to a regular diet over time. In cases of severe acute pancreatitis, nutrition support (e.g., tube feeding) is necessary for those who are not able to, or not expected to, tolerate oral intake anytime soon.2 This is because these individuals will have increased energy and protein needs that can only be met through nutrition support. Nutrition is also key for preserving gut barrier function. When the gut barrier function is compromised, it can lead to the translocation of bacteria across the gut barrier, which can cause infection of the pancreas and, worst case scenario, systemic inflammatory response syndrome (SIRS).1
Fibre, specifically prebiotic fibre, has been shown to help preserve gut barrier function and integrity. This helps prevent the translocation of bacteria across the gut barrier that can lead to the increased infection rates seen in acute pancreatitis.1 A prebiotic-rich diet is associated with lower rates of pancreatic infection, hospital stay, SIRS and multiorgan failure.1 One randomized, double-blind study of 30 participants with severe acute pancreatitis found that those given nutrition support (tube feeding) with a prebiotic formula had a shorter hospital stay and fewer complications than those given standard nutrition support without prebiotics.3 Prebiotics act as food for our healthy gut bacteria. They feed and stimulate the growth of the friendly bacteria that live in the gut, helping to keep the immune system strong and healthy. Prebiotic-rich foods include asparagus, artichokes, beans, bananas, garlic, green peas, oats, and onions. A banana topped oatmeal, banana oat smoothie, or banana oat bars, could be easier prebiotic-rich foods to tolerate during recovery. You can also find prebiotics in supplement form, which is okay, but, if you can tolerate prebiotics in food form, why not start with food first? That way, you get all the beneficial nutrients found in the food, instead of just the isolated prebiotic in supplement form.
Chronic Pancreatitis
There is a greater risk of malnutrition in chronic pancreatitis. This is due to malabsorption caused by a decreased level and/or activity of pancreatic enzymes, which are needed to digest food for optimal absorption.1 However, pancreatic enzyme supplementation can help. Individuals with pancreatic insufficiency take these enzymes with meals to optimize nutrient absorption. While some foods do contain natural digestive enzymes (e.g., pineapple), they are not in amounts high enough to prevent malabsorption in chronic pancreatitis. Also, we need a mix of enzymes to break down all the macronutrients (protein, carbohydrates, and fat), and this mix cannot be found in one single food. Chewing foods really well, taking the time to eat, and enjoying smaller, frequent meals (e.g., eat half a sandwich and then eat the other half a few hours later) can also help optimize absorption, because the body will have more time to process and properly digest these foods.
Fat can stimulate the pancreas and trigger abdominal pain; however, health experts still recommend that you try to eat some fat. Avoiding fat completely can make it even more difficult to tolerate when you do add it to your diet because the enzyme that breaks down fat (lipase) needs to have some fat in order to stay active and working well.4 In addition, fat is crucial to good health and is needed to absorb the fat-soluble vitamins A, D, E, and K. The recommended macronutrient range for fat is 20-35% of total daily calories, and a 30% range is reasonable for someone with chronic pancreatitis. It is important to know that since a keto diet is up to 80% of total calories from fat, it would not be a good dietary option for individuals who have pancreatitis.
Fibre may decrease the activity of pancreatic enzymes in people who have pancreatic enzyme insufficiency. This association of a high-fibre diet on decreased pancreatic enzyme activity has been shown mostly through laboratory (in vitro) studies, and human (in vivo) studies are needed to confirm these findings.1 A high-fibre diet in people with pancreatic exocrine insufficiency can also increase fat excretion in the stool, meaning that less fat will be absorbed and used by the body. Fibre may also stimulate the pancreas through an undefined neurohormonal mechanism, which could trigger symptoms.1 Again, these findings are associations, and more research is needed before making any drastic changes. That being said, a very-high-fibre diet (> 50 g/day) may not be a good idea, especially if more symptoms are triggered.
Ten Nutrition Goals for Pancreatitis
- ensure nutritional adequacy of meals
- correct nutrient deficiencies (e.g., vitamins A, D, E, K)
- limit malabsorption (e.g., pancreatic enzymes)
- prevent weight loss
- eat smaller, frequent meals to optimize digestion and absorption
- manage symptoms (abdominal pain, bloating, nausea, vomiting, diarrhea, steatorrhea) by choosing well tolerated foods
- preserve gut barrier function and integrity (e.g., prebiotics)
- avoid unnecessary food restrictions (e.g., very low-fat diet)
- control blood sugars as needed (higher risk of diabetes with chronic pancreatitis)
- avoid alcohol
Conclusion
Pancreatitis is a complex disease and nutrition management depends on whether it is acute or chronic. Although there is still a lot to learn about fibre in pancreatitis, a low-fibre diet is initially recommended in the early stages of acute pancreatitis until symptoms subside. Afterward, prebiotic fibre could be encouraged in acute pancreatitis to help preserve the integrity of the gut barrier and help reduce the risk of infection and other complications. It may be prudent to avoid a very-high-fibre diet in cases of chronic pancreatitis because fibre may reduce pancreatic enzyme function, increase fat malabsorption, and trigger symptoms. Ultimately, it will be interesting to see what the future research will show and if the use of prebiotic fibre may become a standard in the treatment of acute pancreatitis.