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01
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2016
by Annemette Jepsen, MCSP
Chartered Physiotherapist and nutritionist

Basic client information:
• John, Male
• 42 years old
• No significant medical history
• 15 lbs above normal weight (around 6
...


Symptoms:
• Nausea
• Indigestion (dyspepsia)
• Belching
• Wind (flatus)
The symptoms remains between 2-3 hours after eating his lunch meal (1)
...

• The size of his lunch meal is big, and he eats it fast to be able to be back at work on time
after his lunch break(1)
...
Which particular organs in the digestive system are involved in fat digestion? How
do these organs work together to digest fat
...
Then there is the throat (pharynx); the esophagus; the stomach; the small intestine, which
consist connectively of the duodenum, the jejunum, and the ileum; and the large intestine (colon),
consisting of the cecum, the ascending colon, the transverse colon, the descending colon, and the
sigmoid colon, ending with the rectum
...
All of
these organs and glands contribute to the physical and chemical breaking down of ingested food
and to the eventual elimination of nondigestible wastes(1,2)
...


Oral cavity:
Chewing is the first mechanical process to which food is subjected
...
Chewing is not the most essential part of

01
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2016
by Annemette Jepsen, MCSP
Chartered Physiotherapist and nutritionist
adequate digestion, but it does aid digestion by reducing food to small particles and mixing it with
the saliva secreted by the salivary glands
...

The tongue:
Is a mobile structure and is an important for chewing, and swallowing
...
Furthermore, the tongue’s glands produce some of the saliva necessary
for swallowing
...
Saliva is slightly acidic, but the bicarbonates and phosphates
within it protects the oral cavity, inhibiting the growth of bacteria and maintains the pH level(2)
...
The bolus is prevented by entering the
nasal by the elevation of the soft palate against the posterior wall of the throat(2)
...
It has two sphincters; one upper and
one lower
...
The lower
oesophageal sphincter has an important role, in protecting the oesophagus from the reflux of
gastric contents with changes in body position or with alterations of intragastric pressure
...

The Stomach:
The stomach receives ingested food and liquids from the oesophagus and retains them for grinding
and mixing with gastric juice so that food particles are smaller and more soluble
...

Gastric secretion:
1
...
5 litres of gastric juice is secreted per day
...
Gastric juice is a mixture of water,
hydrochloric acid, electrolytes (sodium, potassium, calcium, phosphate, sulfate, and bicarbonate),
and organic substances (mucus, pepsins, and protein)
...

Absorption and emptying of the stomach:
The rate of emptying of the stomach depends upon the physical and chemical composition of the
meal, where gastric emptying is delayed especially if the meal consist of a lot of fats
...
When food particles have been reduced in size and nearly soluble, the area of attachment
between the duodenum and the stomach relaxes, allowing emptying of the stomach to start
...


01
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2016
by Annemette Jepsen, MCSP
Chartered Physiotherapist and nutritionist

The small intestine:
The main functional segments of the small intestine are the duodenum, the jejunum, and the ileum
...
The primary functions of the small
intestine are mixing and transporting of chyme, production of enzymes and other constituents
essential for digestion, and absorption of nutrients
...

Two types of motor activity have been recognized within the small intestine: segmenting transport
and peristaltic(1,2)
...
The contraction happens over a small segment
of the intestinal wall, about 1 to 2 cm (1 inch)
...


•

Peristaltic contraction; is a wave of contractions passing along the segments within the
gastrointestinal tract, it occurs over approximately every 6 cm
...


Within the small intestine there are projections called villi, they multiply the surface area
...
The inner structure of the
individual villus consists of loose connective tissue containing a rich network of blood vessels, a
central lacteal (channel for lymph), smooth muscle fibres, and various types of cells
...

Secretions:
The most effective stimuli for secretion are local mechanical or chemical stimulations in the form of
chyme and food particles
...
One of
the major sources of digestive secretion is the pancreas, producing both digestive enzymes and
hormones
...
Pancreatic
juice contains enzymes that digest proteins, fats, and carbohydrates
...

The large intestine (Colon):
The large intestine can be divided into the cecum, ascending colon, transverse colon, descending
colon, and sigmoid colon
...
The primary
functions of the colon is to absorb water of the blood by excreting and absorbing electrolytes from
the chyme; to store faecal material until defecation; secretes mucus, which aids in lubricating the
intestinal contents and facilitates their transport through the bowel
...
The colon also contains large numbers of bacteria that combines some important vitamins

01
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2016
by Annemette Jepsen, MCSP
Chartered Physiotherapist and nutritionist
like vitamin K
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The layers of the wall of the colon are similar to those of the small
intestine, but lacks the villi characteristic
...

The gastrointestinal tract ends at the rectum
...
The rectum is normally empty, but when it is filled
with gas, liquids, or solids to the extent that the pressure is raised to a certain level, the impulse to
defecate occurs(1,2)
...
The liver is important in the metabolism of
proteins and fat; to combine cholesterol and bile acids; to initiate the formation of bile; to engage in
the transport of bilirubin and to control transport and storage of carbohydrates
...

Bile:
The primary digestive function of bile is to aid in the digestion of fat in the small intestine
...
The rate with which it is formed depends on how fast bile acids are
secreted into the bile channels
...

Pancreas:
The pancreas is both an exocrine (ductal) and endocrine (ductless) gland
...
Bicarbonate is secreted by the pancreas and neutralizes the acid secreted by the
stomach, this keeps the intestinal contents to an optimal pH, allowing the various digestive
enzymes to act efficiently
...

John:
The process of digestion fat already starts within the oral cavity as chewing aid to digestion by
reducing food to small particles and mixing it with the saliva secreted by the salivary glands,
producing the enzyme lipase
...
Is resulting in the bolus not being
mixed enough with the secretes, especially lipase, of the salivary glands and the food is left to dry
when swallowed
...
Excessive air in the stomach often can cause mild abdominal discomfort, where belching
often relieves this
...
Protein and fats requires longer time for gastric digestion, not because
they are more difficult or harder for the body to digest, it is due to that each of these components
has a different digestion process (3,4), which is why different enzymes and chemicals are released
within the oral cavity (amylase and lipase), stomach (lipase and pepsin), the bile salts from the liver
and the pancreas (pancreatic amylase and lipase, trypsin and chymotrypsin)(1) and all of the
others mentioned above(2)
...
John is having a fast food meal high in saturated fat, and big portion size, which will fill up
his stomach
...
When the stomach is filled up with too much food after a meal,
it stretches the stomach, causing John to feel "stuffed
...
It will
take longer time for John's body to digest his meal due to the meal consisting of a lot of fat, which
can explain why his symptoms remain for 2-3 hours after finishing his lunch
...
04
...
John is also feeling nauseas, which often is seen accompanied by
indigestion(6)
...
The composition of intestinal gas is a mix of
nitrogen, oxygen, hydrogen, methane, and carbon dioxide
...
The
symptoms of flatus, in Johns case, is due to him eating quickly as this apart from the belching also
increases rectal flatus
...
Carbon dioxide is being produced when stomach acid is mixed together bicarbonate in
bile and pancreatic juices
...

The residues passing on to the colon is acted upon by bacteria’s through fermentation, this
produces hydrogen, methane, carbon dioxide and other gases
...

As John is on no medication or antibiotics, has no digestive disorder or intolerances, his intestinal
gas is caused by either to much food residue in the colon, poor absorption of carbohydrates, which
can upset the balance of helpful bacteria in the digestive system, he is swallowing a lot of air, it
could also be if he is struggling with constipation, the longer food waste remains in the colon, the
more time it has to ferment(8)
...

These molocules needs to be broken down which is done by amylose, a starch that accounts for
20 percent of dietary carbohydrates
...
There are several
forms of amylase in pancreatic juice whose function is to break down complex carbohydrates(2)
...
The pepsins are enzymes secreted by the stomach in the
presence of acid that breaks down proteins
...
They are most active in the first hour of digestion, and their ability to break down
protein is restricted by the necessity for an acidic environment
...

Fats:
Lipases require the presence of bile acids for optimal digestion of fat
...
Colipase, which is another pancreatic enzyme, binds to the bile
salts, making lipase available to break down the fat more easily
...
The liver also plays a role in the
storage of fats whenever carbohydrates, protein, or fat exceeds the requirements for glucose or the
livers needs for glycogen(2)
...
04
...
There is a big difference when comparing societies living on a diet low in saturated
fats, with fresh fruit and vegetables, and the typical western diet, with the first one showing a 73%
reduction in the risk of new major cardiac events
...
High level of LDL in the blood
can build up in the artery walls and close the arteries, this usually happens when to much LDL is
present for the cells to use(9)
...
Worldwide it is
estimated that a diet high in saturated fat causes 31% of coronary heart disease and 11% of
stroke(10)
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A healthy balanced diet increases high-density lipoprotein (HDL), which is carrying
cholesterol from the cells to the liver, where it is broken down or excreted as a waste product from
the body
...

Saturated fat intake should not exceed 10% of total energy, 30g a day for men, adults(10)
...
In the study they selected 18 thin, healthy volunteers, 12
men and 6 women
...
The
participants in this intervention group also had to restrict their level of physical activity to 5000 daily
steps
...

A comparison group, matched for age and sex, ate a normal diet and maintained normal exercise
levels
...
The researchers checked fat levels and liver enzymes through analyzing blood samples
taken before the research started and at regular intervals throughout the four-week study period
...
Usually abnormal high levels of ALT levels are seen
when consuming a lot of alcohol or by infection of hepatitis C virus
...
The outcome of the study: Fast-food consumers put on an average of 6
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3
lbs
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ALT rose to liver damage levels in 11 participants and 1 developed fatty
liver disease
...

The increases in ALT levels were due to weight gain and increased sugar and carbohydrates
within the diet
...
Insulin resistance is also linked to an increased risk
of diabetes and cardiovascular disease(11)
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04
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Friendly bifidobacteria is seen to decrease
and loss of species diversity(12)
...


2
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For John to succeed and make it manageable to change his diet, I will start, in partnership with
John, to make him develop 3 SMART goals
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SMART goals are also valuable as they encourage the importance of
small steps the client makes towards a better lifestyle(16)
...
Also lower intake of beer or
carbonated drinks, if this is part of his diet
...
The big gas producers of bacterial production of hydrogen within the colon is
elevated when the diet contains an excess of vegetable saccharides found in beans, lentils,
cabbage, onions for example(7)
...
They contain certain carbohydrates
called oligosaccharides which cannot be digested in the small intestine but are like food to the
bacterias within the colon(17)
...
I am not interesting in putting him on a strict diet, I want his goals and
diet to become part of his lifestyle, therefore I find it very important not to deny or restrict him of
something he really loves, as I want him to succeed in changing
...
Also he could try sharing his meal with a
friend/colleague or ordering a half-sized portion along with a small salad
...
Lamb or remove the skin from the chicken
...
But removing the chicken skin lowers the intake of calories, so John can lose

01
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2016
by Annemette Jepsen, MCSP
Chartered Physiotherapist and nutritionist
some weight(18)
•
•
•
•
•
•
•

Consider opting for chicken and fish rather than red meat
Eat less cheese – use a strong tasting cheese such as mature Cheddar
...

Educate him in labelling so he knows how to go for lower food snacks and meals
Grill or bake meals rather than fry them
...

Lower his portions of high fat foods and introduce more foods that are low in saturated fat,
but high in nutrition like fruit, vegetables and wholegrain starchy foods
...

Milk and diary (19):

Meat (19):

01
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2016
by Annemette Jepsen, MCSP
Chartered Physiotherapist and nutritionist

Bread, cakes and cereal (19):

Fats, oils and spreads (19):

01
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2016
by Annemette Jepsen, MCSP
Chartered Physiotherapist and nutritionist

Potatoes and savoury snacks (19):

Lunch for work - Sandwich:
Making his own healthy options isn’t hard work if I provide him with some ideas
...
04
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I would suggest he tries hummus instead
of mayonnaise or ketchup, hummus is also high in proteins due the chickpeas
...

Pasta and grains:
Use wholegrain pasta and encourage John to make 100-150gram little more pasta when cooking it
for dinner or if he cooks couscous or rice, so that he can bring some leftovers with him the next
day
...
He could also use potatoes, make large portions of extra
potatoes for dinner, and bring a healthy potato salad by adding tuna, green beans or olives, and
other veg
...
He could use a low fat yoghurt as dressing, as the dressings
you buy are normally high in fat, sugar and salt
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Then combine it with some chicken
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3
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I would advise him to eat smaller portion sizes or stop when half through the
plate
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I would advise him give the
meal 20 minutes to settle in his stomach after eating it as it takes between 15-20 min for satiety
signals to reach the brain
...
It is important to feel full (satiety) after each meal as it
suppresses the urge to eat for a period of time
...
If he does
not feel full, he will quickly start to feel hungry again and may be tempted to snack or eat more at
the next meal
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The brain response
to signals from the expansion of the stomach, sensory system and the brain’s perceptions of the
food and drink consumed
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Some of these hormones informs the brain on how much fat
we have stored in the body, which affect satiety over the longer term
...
Even though the body has this
system in place to control energy intake, in our society we still tent to eat even though we feel full
or refrain from eating when hungry(20)
...
x
...
Including
protein at every meal like chicken, ham, beef, fish, eggs, beans and pulses
...

• Foods that are high in fibre like wholegrain bread and cereals, beans and pulses and fruit
and vegetables
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Cut down on alcohol
consumption especially when drinking it with a meal
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04
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Lower energy
density foods provide less energy per gram of food so you can eat more of them without
consuming too many calories
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(20)

As John is not chewing very well and struggles with a lot of flatus I would ask regarding his
defecating, if he suffers from constipation
...
Kefir, high in probiotics which can help
restore the balance of friendly bacteria in the gut(22) or ryazhenka(23), preferrable it is best if it is
raw and unpasteurized
...
In Johns case he is having to much saturated fat and trans fat which is only
recommended to be 30g a day for men
...
John doesn't seem to have any problems with his cholesterol, but
to avoid any complications and for the health of his liver, it would be good for him to cut down on
the unhealthy fats
...
I think it
would be good to look at Johns overall salt intake and lower it
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When grocery shopping, food labels only give the figure for sodium, there is a method to
calculate how much salt John is eating from the sodium figure:
Salt = sodium x 2
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5g salt (0
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• Low is 0
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1g sodium) or less per 100g → colour-coded green
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3g and 1
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If he regularly add salt to food when cooking, he
could try adding less
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Regarding sugar, they usually add a lot of sugar to fast food dishes, depending on what kind of
restaurant it is
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Natural
sweeteners such as fruit juice and honey can be added to food
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As he is overweight I will make him do a weekly food diary of his diet and calculate his caloric
intake to see how many calories he is consuming per day, the average male, if not active, should
have 2
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With John, I would first have to see how many calories he is consuming,
if he consumes more than 2
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Apart from his diet, I would recommend and advise John to start exercising, find out what kind of
sports or exercising he likes to do and help him start doing it
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04
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For most people,
exercising means workouts that is involving a gym, equipment or special clothing
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By being physical active John
would burn calories and improves his body's ability to use insulin
...
It can be difficult with Johns work to find the time to add exercise to his
schedule, but he is much more likely to succeed and sustain his lifestyle changes if he could find a
way to integrate more physical activity into his daily routine(27)
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• Cut back on e-mails and deliver the message in person if possible
...

• Park a bit further away from the supermarket or work place
...

It is important to set achievable goals for John, as he is not used to being physical active, there are
also ways to make it a bit more fun, he could start swimming, bowling, or play tennis
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Gather some friends or colleagues and walk together a lunch break at work
or start a walking club
...
A
pedometer could be an example of a tool to help him measure how much change this makes to his
daily routine(27)
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According to government recommendation, adults aged 19-64 should try to
be daily active with at least 150 minutes of moderate activity such as cycling or walking fast a week
and strength exercise on at least two days a week(28)
...
Physical inactivity on the other hand increases the risk of heart disease and stroke
by 50%
...
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Hightower C, Nicholas Carr
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Human digestive
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