A Cross-sectional Study of Nutritional Status, Diet, and Dietary Restrictions Among Persons With an Ileostomy or Colostomy
Little is known about the nutritional status and dietary habits of persons with an intestinal stoma, and no specific dietary guidelines have been established. A cross-sectional study was conducted among patients of a Stoma Patient Health Care Service in Juiz de Fora, Brazil, to compare the nutritional status of persons with an ileostomy or colostomy and to evaluate which foods are avoided most frequently and why.
Anthropometric measurements (weight, height, arm circumference, and triceps and subscapular skinfold thickness) and body fat were assessed. Habitual dietary intake (energy, protein, carbohydrate, fiber, fat, calcium, iron, sodium, potassium, thiamin, riboflavin, vitamin B6, vitamin B3 [niacin], and vitamin B12) was assessed using a validated quantitative food frequency questionnaire. Foods avoided and reasons for avoidance (increased odor, increased gas, increased output, constipation, appliance leakage, and feelings regarding leaving home) were assessed. All data were collected without personal identifiers and stored in electronic files. Data were analyzed descriptively, and the Student’s t test or Mann-Whitney test was used to compare the groups. Chi-squared analysis with Yates’ continuity correction or Fisher’s exact test was employed to examine the differences in the frequency of avoided foods by reasons for avoidance between the 2 groups. Of the 103 participants (52 [50.5%] men, 51 [49.5%] women; mean age 60.5 ± 12.9 years); 63 (61.2%) had a colostomy and 40 (38.8%) had an ileostomy. For both groups combined, time since surgery ranged from 1 to 360 months. Anthropometric measurements and body composition did not suggest nutritional deficiencies and did not differ significantly between groups. Persons with an ileostomy had a significantly lower fat and niacin intake than persons with a colostomy (P <.05). No other dietary intake differences were observed. Avoiding foods due to appliance leakage was more common among participants with an ileostomy (8, 20%) than a colostomy (3, 4.8%), and vegetables and fruits were reported as the most problematic foods. None of the other cited reasons was significantly different. The results of this study confirm that many persons with a stoma adjust their dietary intake and avoid certain foods which, especially in persons with an ileostomy, may increase their risk for nutritional deficiencies. Additional research to assess dietary intake and nutritional status variables as well as patient needs is needed to facilitate the development of specific nutritional status monitoring and dietary recommendations for persons with an ileostomy or colostomy.
The Greek word stoma describes a surgically created opening that allows externalization of digestive, respiratory, and urinary system functions. In the digestive system, a stoma is created when it is necessary to deviate (temporarily or permanently) the normal transit of food and/or elimination of stool.1-3 Patients are provided an ileostomy or colostomy as a result of a variety of medical conditions, including colorectal cancer, congenital disorders, trauma, inflammatory bowel disease, intestinal obstruction, diverticulitis, and trauma. Among the clinical situations mentioned, colorectal cancer is the most prevalent.4,5
The intestinal stoma negates voluntary control of physiological elimination,6 making the person with a stoma dependent on an external collection device (stoma pouch) that can affect body image and self-esteem as well as social activity and employment capability and productivity. According to a prospective study,7 persons with stomas may face problems adapting to and learning how to manage their new anatomy.
The stoma interrupts the absorptive process at the point where it is created, affecting the nature of output and the individual’s ability to absorb nutrients from food. It is necessary to evaluate the patient’s eating behavior because the stoma can bring specific changes depending on the intestinal region where it is formed (ileum or colon).8 An ileostomy is placed in the small intestine where nutrients are absorbed, resulting in liquid to semi-liquid stools with abundant digestive enzymes that continuously exit the body. According to an intervention study,9 a literature review,10 and a nutrition guide,11 persons with an ileostomy may incur nutritional losses of calcium; magnesium; iron; vitamins B12, A, D, E, and K; folic acid; water; protein; fat; and bile salts.9-11 A colostomy is placed in the colon region (sigmoid colon, ascending, descending, or transverse), and fecal formation is intermittent, with near normal defecation ranging from semi-liquid or hard stools with little or no nutritional loss.9-11
Eating habits can significantly affect the lives of ostomates, positively or negatively influencing the process of adaptation to a stoma. A qualitative, descriptive, exploratory study12 revealed it is common for persons with a stoma to stop eating or to stop eating foods essential to maintaining proper nutritional support in order to resume their social life. According to a review by Cronin,13 dietary advice provided to patients before and after stoma surgery, especially in the first month, is important for their rehabilitation. A cross-sectional study14 has shown patients with a colostomy or ileostomy need individualized nutritional guidance to make appropriate food choices over time.
The literature contains little information regarding nutritional status and dietary habits and does not put forth specific dietary recommendations for persons with a stoma. Within this context, the purpose of this study was to compare the nutritional status of patients with an ileostomy or colostomy and evaluate the foods they avoid most frequently and their reasons for doing so.
Methods and Procedures
Study design and sample. This was a cross-sectional study of patients served by the Stoma Patient Health Care Service in Juiz de Fora, a city of approximately 564 000 inhabitants in southeastern Brazil. This Service provided care for 428 patients monthly. The study was conducted between September 2014 and August 2015. All patients were contacted by telephone and invited to participate as volunteers in the research. The inclusion criteria stipulated participants must have an intestinal stoma (ileostomy or colostomy), be at least 18 years of age, and be physically and mentally capable of completing the interview. All volunteers gave their written informed consent after being provided with oral and written information about the study aims and protocol.
The study was approved by the Human Research Ethics Committee, Federal University of Juiz de Fora (protocol number 516.306).
Anthropometrics and body composition. Weight, height, arm circumference, and triceps and subscapular skinfold thickness were assessed by trained research personnel. Participants were instructed to wear light clothing and to remove any heavy objects before measurement sessions. Weight was measured using a digital weighing scale, and height was measured using a wall-mounted stadiometer. Body mass index (BMI) was calculated from weight and height measurements. Arm circumference was measured with a flexible measuring tape. Triceps and subscapular skinfold were measured using the Lange skinfold caliper. Body fat was measured via bioimpedance (Tanita Corporation, Tokyo, Japan).
Dietary intake assessment. Dietary intake was assessed using the quantitative Food Frequency Questionnaire (FFQ) adapted from the questionnaire developed by Ribeiro and Cardoso,15 which was previously validated for use in studies involving chronic diseases. Each patient completed the FFQ with the assistance of a trained researcher. Participants were asked to report their usual frequency of consumption of specific foods. The FFQ used for this study was composed of 106 items that focused on 11 food groups (dairy products, meats and by-products, cereals, breads, fruits, vegetables, legumes, nuts and oilseed, sweets, fats, and drinks). Portion size was assessed using standard food measurement utensils. FFQ data were analyzed using food composition tables.16-18 Additional information on nutritional composition was collected from food labels where applicable.
A questionnaire was developed to ascertain whether stoma patients excluded some food from their eating routine and the reasons for avoidance. The effects of food on the stoma were grouped into 6 possible reasons/responses: increased odor, increased gas, increased output, constipation, appliance leakage, and leaving home. Appliance leakage referred to the displacement of the collector pouch affixed to the abdomen. Leaving home referred to foods patients avoid consuming before leaving home to offset possible discomfort. Patients could choose more than 1 response, and they were asked to list such foods and highlight those that were the most problematic.
Data collection. The first author trained a team of nutrition students to participate in patient assessment on the selected measurement day. All data were collected using a standardized form developed for the study and stored electronically. Researchers completed the paper-and-pencil FFQ by individually asking patients the questions when they visited the Service for care. Information such as gender, age, type of ostomy, and duration of the stoma were obtained directly from medical records. Patient identity was kept anonymous, and patients had the option to refuse to participate with no repercussions.
Statistical analysis. Results from the anthropometrics and body composition data and dietary intake were entered, processed, and analyzed using SigmaPlot, version 12.0 (Systat Software, Inc, San Jose, CA). Demographic and clinical variables were descriptively analyzed. Parametric and nonparametric tests were used based on normality testing (Shapiro-Wilk) and variance homogeneity (Levene) tests. Data are represented as mean ± standard deviation (SD). The Student’s t test or Mann-Whitney test was used to compare the groups (patients with an ileostomy versus those with a colostomy). Chi-squared analysis with Yates’ continuity correction or Fisher’s exact test, where appropriate, was employed to examine the differences in the frequency of avoided foods according to the reason for ileostomy and colostomy patients. A 5% significance level was considered for analysis.
Of the 428 intestinal ostomy patients in the service, 103 met the inclusion/exclusion criteria and/or agreed to participate in the study; 51 (49.5%) were women, 52 (50.5%) were men, 40 (38.8%) had an ileostomy, and 63 (61.2%) had a colostomy. Mean patient age mean age was 60.5 ± 12.9 (range 25–94) years. Time living with the stoma varied greatly among patients (range 1–360 months). Most patients with ileostomy (23 [57.5%]) and colostomy (42 [66.7%]) had the stoma >1 year.
Anthropometric (weight, BMI, arm circumference, triceps and subscapular skinfold) and body composition (body fat) measurements did not differ significantly between groups (see Table 1). Eleven (11) patients (2 with an ileostomy and 9 with a colostomy) refrained from having their triceps, subscapular skinfold, and body fat measurements taken. The dietary data from the FFQ showed habitual dietary intake (energy, protein, carbohydrate, fiber, calcium, iron, sodium, potassium, thiamin, riboflavin, vitamin B6, and vitamin B12) was not different between groups, except for fat and niacin. In the present study, patients with an ileostomy had significantly lower fat intake (58.5 ± 38.5 g and 24.3% ± 7.9%) and niacin levels (13.7 ± 9.2 mg) compared to patients with a colostomy (fat: 82.5 ± 62.8 g and 27.9% ± 6.6%; niacin: 17.9 ± 12.4 mg) (see Table 2).
As might be expected, significantly more ileostomy patients (20%) avoided foods for fear of appliance leakage compared with colostomy patients (4.8%), and vegetables and fruits were reported as the most problematic (see Table 3). The other reasons (increased odor, increased gas, increased output, constipation, and leaving home) reported for avoiding food consumption were similar between groups.
Whether temporary or permanent, stomas result in physical changes and may result in dietary restrictions on patients. The amount of intestine remaining after an intestinal stoma is created will determine the individual’s capacity for normal nutritional absorption from food and beverages, making it crucial for health care professionals involved in caring for persons with a stoma to be aware of the type of stoma created, the length of proximal bowel remaining, and the implications for absorption of nutrients to provide optimal nutritional advice and support.19 To the authors’ knowledge, this is the first time the nutritional status, diet, and foods most frequently avoided have been compared between ileostomy and colostomy patients.
In the present research, the study population had an average age of 60.5 years, similar to other cross-sectional studies involving Italian20 and Brazilian21 patients with a stoma. Many patients undergoing stoma surgery are older and have colorectal cancer as the cause of the ostomy, which has a positive association with age, as shown in qualitative22 and prospective23 studies. In this study, anthropometric characteristics and body composition did not differ between persons with an ileostomy and those with a colostomy. Cross-sectional study data24 suggest that, based on the reported mean BMI (26.8 kg/m2) and body fat (33.8% for women and 21.5% for men), participants in this study did not have nutritional deficits. A BMI of 18.5 to 24.9 kg/m2 is generally accepted as the optimal range, although there is some debate about the ideal reference range for older adults. According to a cross-sectional study by Bahat et al,25 a BMI cutoff point of 25 kg/m2 may be restrictive for older adults. In fact, the patients in the present study must have a body reserve, considering their age. According to a review by Gary and Fleury,26 older patients often are unable to maintain a nutrient intake adequate to meet their rising metabolic demands when physiological demands increase, such as during an acute illness. As a result, protein and energy stores may be depleted, exacerbating weaknesses and contributing to a decline in functional status.26 Additionally, most persons with a stoma have an underlying disease with an impact on nutritional status.14
The authors used arm circumference, triceps, and subscapular skinfold measurements because of the difficulty of assessing any measure in the abdominal area due to the presence of the stoma itself, the collection pouch, and the potential presence of complications such as parastomal hernia.27 Despite not having specific anthropometric recommendations for this population, the measures assessed in this study are valid for monitoring nutritional status.
Energy intake was similar between the groups, although ileostomy patients had an energy intake approximately 20% lower than colostomy patients, owing to lower fat intake. Although no specific energy recommendations exist for stoma patients, daily energy intake of ileostomy patients (2046 kcal, on average, for men and women) was similar to World Health Organization28 (WHO) recommendations (2090 kcal, on average, for men and women). The mean energy intake of colostomy patients was 2579 kcal and the WHO recommendation28 was 2088 kcal — the usual intake was 23.5% higher than the recommendation. In fact, the anthropometric assessment showed no depletion of nutritional status or body weight as a result of energy intake.
Decreased fat consumption in the ileostomy group occurs because intestinal transit is faster and effluent are more liquid having not passed through the colon. As a result, persons with an ileostomy produce a higher volume of effluent.19 Fat may facilitate the stool movement, so ileostomy patients may consume less fat for fear of increased intestinal output. The potential consequences are deficiencies in calories, essential fatty acids, and fat-soluble vitamins.
The consumption of niacin (vitamin B3) also was lower in the ileostomy group. Due to the wide distribution of this vitamin in the food supply, niacin deficiencies are rare, but minor deficiencies of niacin can occur in chronic gastrointestinal disorders that lead to malabsorption.29 Because persons with a stoma (especially an ileostomy) have accelerated intestinal transit and may have malabsorption as a result of bowel resection,23,30 it is possible they have a loss of niacin absorption in addition to possible reduced intake shown in this study. Therefore, it is essential to monitor blood levels of this vitamin.
The intake of fiber and other nutrients did not differ between groups. Because no specific dietary recommendations exist for persons with a stoma, comparisons were not possible. However, it is essential for the nutritionist to be aware of possible nutritional deficiencies. For example, without a functioning colon, patients with ileostomy will lose 50 to 80 mmols of sodium daily.31 According to a review by Fulham,19 this generally can be replaced by adding the equivalent of an extra teaspoonful of salt daily to food. Screening and monitoring the nutritional status of individuals with a stoma should be an ongoing process, beginning preoperatively and continuing after discharge from hospital.
Because they fear leaking of effluent and injuries to peristomal skin, stoma patients have strong concerns about appliance leakage. These patients have a high-output stoma with a higher concentration of digestive enzymes that can dissolve the hydrocolloid and erode the skin.32 In this study, patients with an ileostomy showed greater fear of appliance leakage and subsequently avoided more foods, especially vegetables and fruits. From the nutritional point of view, maintenance of healthy peristomal skin is vital because it allows good stoma pouch adhesion.33 Accordingly, dietary guidance is required because it influences wound healing and alters stool quantity, frequency, and consistency.2
On average, ileostomy output consists of 600 mL to 800 mL liquid or very soft effluent per 24 hours, with little odor.32 The person with a colostomy naturally produces formed stools with a characteristic smell and tends to impose dietary restrictions for fear of odor.34 However, in this study no difference regarding fear of increased odor was noted between groups, suggesting that persons with an ileostomy are just as fearful of odor as persons with a colostomy. Dietary guidelines may increase patient confidence in food choices, including suggestions about foods that can control odor, such as buttermilk, yogurt, cranberry juice, parsley, and tomato juice.2 In addition, products such as activated charcoal added to the stoma pouch can help reduce odor.35
Fear of increasing stoma output was described as a reason for dietary restrictions by both study groups. It is not known whether the fear of increasing stoma output is related to a fear of loose stools or not. If loose stools are a problem that cannot be resolved with medication or dietary changes, a stoma specialist nurse should be consulted or the patient can try a binding agent such as loperamide under medical supervision.36 It is important to consider that often in the context of care for persons with a stoma, it is observed that eating habits are associated with various myths, and while some beliefs with no scientific basis on diet may be harmless, others may have serious implications for health and well-being.12 Fear of constipation was reported less frequently by study participants. Although a review of the literature36 found constipation is more common in colostomy patients, differences in the fear of this occurrence were not observed between groups in this study. If the person with a colostomy was prone to constipation or loose stool before the stoma-forming surgery, this issue will likely endure long-term.36,37 To prevent constipation, patients should be advised to consume adequate amounts of fluids and fiber, especially fruit and vegetables.36,37
In a cross-sectional study by Floruta,34 increased gas was among the main problems reported by both colostomy and ileostomy patients. This also was observed in the current study as the most reported fear, with no difference between the groups. Avoidance of certain foods such as green vegetables, onions, beans, and carbonated beverages might be useful. Moreover, it is beneficial to guide the patient to refrain from talking while eating to avoid swallowing air.1 However, the nutritionist should assess each patient individually so dietary self-restrictions do not harm nutritional status.
Several patients in both groups reported avoiding consuming food before leaving home. It is common to find that ostomy patients stop eating, influenced by feelings provided by their current condition.12,14 Anxiety, insecurity, fear, and doubt may negatively affect eating itself, an event that should be enjoyable.
The current study has limitations. The group was not heterogeneous in terms of the duration of the stoma, the reason for its creation, and nutritional status, which may affect the external validity of the results vis-à-vis all persons with an ileostomy or colostomy. The wide range in stoma history (1 to 360 months) may have affected the results and is a consequence of the various reasons for creating a stoma, as well as the patient’s previous nutritional status. Additionally, the absence of specific dietary recommendations and anthropometric measures for persons with a stoma as well as the absence of studies on this topic did not allow comparisons between the published literature and current results. Finally, an inevitable limitation of the FFQ is that all information depends on the respondents’ memory.
The results of this cross-sectional study involving 40 persons with an ileostomy and 63 with a colostomy suggest that, based on anthropometric characteristics, study participants did not have nutritional deficits. However, FFQ results showed persons with an ileostomy had significantly lower fat (g and percent) and niacin (mg) intake than persons with a colostomy. The study also confirmed both groups implement many dietary restrictions to reduce the risk of appliance loosening, increased odor, gas, stoma output, or constipation. Leaving home was also frequently cited as a reason for avoiding certain foods. Vegetables and fruits were included as foods avoided for every risk cited.
Living with a stoma can be challenging and patients need to learn what does and does not work for them to manage the side effects of food on the ostomy, including odor, gas, effluent, constipation, and leakage. Few studies have examined the nutritional status of persons with a stoma and the effects of diet on ostomy function. Longitudinal studies to assess these variables and patient needs are necessary to facilitate the development of specific nutritional recommendations for persons with an ileostomy or colostomy.
The authors thank the nurse responsible for the service (Alfeu Gomes de Oliveira Júnior) and his entire team, which provided all the technical assistance with data collection.
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Dr. Oliveira, Dr. Moreira, and Dr. Netto are Adjunct Professors, Department of Nutrition; and Dr. Leite is a CNPq Productivity Sponsorship (Process 301101/2016-7) and an Associate Professor, School of Medicine, Department of Public Health, Federal University of Juiz de Fora, Minas Gerais, Brazil. Please address correspondence to: Ana Lívia de Oliveira, Department of Nutrition, Federal University of Juiz de Fora – UFJF, José Lourenço Kelmer, s/n Campus Universitário, CEP 36036-330, Juiz de Fora, Minas Gerais, Brazil; email: firstname.lastname@example.org.