*2.5.1 Oral nutrition*

Low-fat oral diets are widely used in clinical practice especially for the purpose of reducing postprandial abdominal pain. However, these diets, in addition to being poorly accepted by patients, can induce a state of malnutrition [63]. In fact, it is estimated that a patient with Chronic Pancreatitis has a REE 30–50% higher than healthy patients. As an indication, diets with high energy (35 kcal/kg/24 hours), high

### **Figure 7.**

*Nutritional assessment in chronic pancreatitis.*

protein (1.0 to 1.5 g/kg/24 hours), rich in carbohydrates, and with moderate amounts of fat (0.7 to 1.0 g/kg/24 hours) should be recommended. Low-fat diets are discouraged by a number of scholars, since they may reduce steatorrhea, thus masking the onset of fat malabsorption, induce a weight loss due to insufficient caloric intake and cause deficiencies in fat-soluble vitamins. Fats should be limited if it is not possible to control steatorrhea (generally associated with flatulence, bloating, dyspepsia, urgency to pass stools, cramping, abdominal pain) with proper oral Pancreatic Enzyme Replacement Therapy (PERT). Typically, 500 units/lipase/kg are recommended for each meal and adapted to the symptoms or the type of diet recommended for the patient. The dose can be doubled or even tripled but should never exceed 10,000 units/kg/day or 4000 units/g of fat per day [64].

In some circumstances (i.e: mixture of enzymes with meal; gastric emptying with meal; rapid release of enzymes in duodenum by chyme and bile acids) enzymatic supplementation appears scarcely effective, so it is necessary to accurately educate patients to use these products according to the quality of food intake, to its rate of intake, to its distribution and time of consumption. Benefits have also been observed by combining these therapies with antagonist H2 drugs or Proton pump inhibitor to prevent enzymatic degradation [65, 66]. To counteract the patient's weight loss, a supplementation of medium-chain triglycerides (MCT) that are absorbed in the absence of lipases, co-lipases, and bile salts is also suggested in combination with increased caloric intake. However, their use is limited by their poor palatability and the possibility of prescribing them up to a maximum of 50 g/day. Higher dosages may induce ketogenesis and intestinal disorders (cramps, nausea, diarrhoea). MCTs are found in coconut oils or in the form of oral supplements. In Chronic Pancreatitis carbohydrates and proteins should not be limited. Only in case of Diabetes should the proportion of carbohydrates, which will be balanced according to the hypoglycaemic

## *Dietary Interventions for Pancreatitis DOI: http://dx.doi.org/10.5772/intechopen.107319*

therapy, be evaluated. A number of scholars recommend high-calorie and highprotein diets, divided into five or six small meals throughout the day, and discourage diets very rich in fibres, being fibres able to absorb or block the action of pancreatic lipase, thus modifying the absorption of nutrients, due to a still poorly known mechanism. Pancreatic enzymes are thought to be possibly absorbed or trapped by fibres and be inactivated by anti-nutrient compounds present in some foods (i.e.: aponins, trypsin end lectins in soybeans; lectins and trypsin inhibitors in legumes; polyphenols in extracts of citrus fruits, Grape seeds, tea, peanut shells and apples). Finally, it is worth remembering that in about 10% of patients the use of caloric-protein supplementation by means of oral nutritional supplements enriched with micro-nutrients and vitamins in order to prevent a significant weight loss is recommended before considering artificial nutrition treatment of enteral or parenteral type. In patients with hyperglycaemia, the treatment is similar to that described for Acute Pancreatitis. In case of preserved beta cell function, metformin is the first choice treatment also in Chronic Pancreatitis. Given the higher risk of pancreatic tumour in patients with Chronic Pancreatitis and Diabetes, the choice of metformin is further supported by its anti-neoplastic effect. Data on SGLT2-inhibitors use in Chronic Pancreatitis are still controversial; since this class of drugs could increase the risk of euglycaemic ketoacidosis in insulin-deficient patients and induce catabolic effects and dehydratation, it should be used with caution.
