The Aging Gastrointestinal Tract
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An overview of the gastrointestinal tract, changes as a result of aging, and a description of how nutrition may prevent or improve common GI problems in the older adult. Note: this presentation is intended for a health/medical literate audience.
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The Aging Gastrointestinal Tract
- 1. The Aging Gastrointestinal Tract Megan Myrdal, RD, LRD Graduate Student North Dakota State University October 14, 2013
- 2. Objectives • Understand the components of the gastrointestinal (GI) tract • Understand how aging effects the GI • Understand problems associated with the aging GI • Understand dietary interventions to maintain adequate GI function throughout the lifespan
- 3. Gastrointestinal System – Oral cavity – Throat (oropharynx) – Esophagus – Stomach – Duodenum and small intestine – Gallbladder – Pancreas – Liver – Large intestine – Rectum – Anus
- 5. Age-Related Changes in the GI Tract • Aging affects absorption and metabolism of foods, vitamins and medications • Aging results in increased susceptibility to foodborne infections and other infections due to decreased immune function. • Table 7-1 pg. 103 – Age-Related Changes in the GI Tract
- 6. GI Tract Problems in Older Adults • The Oral Cavity – Gum disease • Teeth – Dental caries and periodontal disease • Oral and Throat Cancers – Major cause is tobacco and alcohol
- 7. Gum Disease vs. Health Teeth
- 8. Oral Health Problems & Food Avoidance/Food Modification • Oral health issues in older adults have been associated with comprised dietary quality, likely due to decreased fruit, vegetable, and nut intake. • Older adults adapt their diet (through food modification or avoidance) to address these health problems. • A report showed that having difficulty fixing meals was associated with a greater risk of mortality, even more than a lack of financial resources. Savoca, M.R., Arcury, T.A., Leng, X., Chen, H., Bell, R.A., Anderson, M.A., Kohrman, T., Gilbert, G. H., and Quandt, S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232.
- 9. Rural Nutrition and Oral Health Study (RUN-OH) • A population-based, cross sectional survey of the dietary intake with 635 adults aged 60 and older. – Food frequency questionnaire (HEI-500, based on the amount of food per 1000kcal of intake) – Food avoidance and food modification were measured. – Finally, oral health exams were completed for those with at least one natural tooth Savoca, M.R., Arcury, T.A., Leng, X., Chen, H., Bell, R.A., Anderson, M.A., Kohrman, T., Gilbert, G. H., and Quandt, S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232.
- 10. Rural Nutrition and Oral Health Study (RUN-OH) - RESULTS • Modifying foods in response to oral health problems is associated with improved dietary intake, even for those with severe oral health issues. • Strategies to minimize food avoidance and promote food modification may help personals with eating difficulties due to oral health issues. Savoca, M.R., Arcury, T.A., Leng, X., Chen, H., Bell, R.A., Anderson, M.A., Kohrman, T., Gilbert, G. H., and Quandt, S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232.
- 11. Methods to Prevent Dental Caries & Periodontal Disease 1. 2. 3. 4. 5. 6. 7. Drink fluoridated water Use fluoride toothpaste Brush teeth carefully with a soft brush after meals Professional oral care (even if no teeth are present) Avoid tobacco (all forms) Limit alcohol Watch for changes in taste and smell (notify health professional)
- 12. High Fiber Foods and Periodontal Disease Progression • Research from the Dental Longitudinal Study found that each serving of good to excellent sources of total fiber was associated with a lower risk of periodontal disease progression and tooth loss. • Fruit consumption was also associated with a lower risk of periodontal disease progression. • Results: higher intake of high-fiber foods, especially fruits, slow progress on periodontal disease for men aged 65 and older. Schwartz, N., Kaye, E.K., Nunn, M.E., Spiro, A., and Garcia, R.I. (2012). High-Fiber Foods Reduce Periodontal Disease Progression in Men Aged 65 and Older: The Veterans Affairs Normative Aging Study/Dental Longitudinal Study. Journal of the American Geriatric Society. 60:676–683.
- 13. Dysphagia & Odonophagia • Dysphagia – difficulty with swallowing – Signs: Pocketing of food in cheeks, speech abnormalities with slurring of words, orofacial changes, facial weakness, abnormal tongue movement and foods becoming stuck if swallowed • Odonophagia – pain upon swallowing – Both may be caused by GERD (gastroesophageal reflux disease)
- 14. Swallowing • A short video from Nestle Healthcare discussing the swallowing process, complications associated with dysphagia and the importance of proper dysphagia management. • http://www.youtube.com/watch?v=jK1o3LSQmB0
- 15. Management of Dysphagia • Management of dysphagia includes: – Targeting the cause (when possible) – Consult with a speech therapist – Beginning appropriate food and liquid consistencies – Have someone eat with the older adult – Monitor and control progression symptoms. – If esophageal spasm are present, calcium channel blockers may be prescribed.
- 16. Dysphagia Diet • • • • • Foods should be pureed, thickened or homogenous No raw foods except bananas Cut tender meat to 1cm or less Avoid nuts; raw, crispy food, stringy foods Liquids – thin, nectarlike (like eggnog, able to drink with a straw), honeylike (like yogurt - eaten rather than straw) or pudding-like.
- 17. Aspiration • Aspiration – a serious risk associated with dyphagia and dysphasia (difficulty speaking) – Caused by abnormal entry of food or fluid into the airway. – Foreign fluid or substance must be removed by suction from the airway to promote breathing when the airway is obstructed. • Can cause airway obstruction but more commonly results in pneumonia – Treatment is antibiotics
- 19. Management of Aspiration • Older adult must concentrate at meals and avoid social occasion at mealtime • Sit upright in a chair (no eating in bed) • Food should be taken and swallowed from the strongest side of the mouth (if paralysis or unilateral weakness is present) • Sit upright for 30 minutes following a meal • Choose foods which promote salivation • Smaller, more frequent meals
- 20. Gastroesophageal Reflux Disease (GERD) • GERD is a condition in which the gastric contents move backward (reflux) into the esophagus causing pain and tissue damage. – GERD is the most common GI disorder in older adults – Symptoms include heartburn, water brash, sour taste in mouth, belching, indigestion, dysphagia and regurgitation • 40% of older adults in the US experience these symptoms
- 21. GERD Management First Line: Nutritional/Positional • Avoid symptom-causing foods (fruits, chocolates, caffeine drinks or alcohol, fried/fatty foods, garlic and onions, mints, spicy foods, and tomato-based foods • Stop eating large meals • Avoid lying down 3 hours after eating • Avoid tight-fitting clothes • Lose weight if overweight • Stop smoking • Stop drugs that cause reflux (only with a consultation from a primary caregiver)
- 22. GERD Management Second & Third Line: Pharmacological • Second Steps: – Antacids – Maalox, Mylanta or Tums – H2 Antagonists – cimetadine (Tagamet), famotidine (Pepcid), or ranitidine hydrochloride (Zantac) • Third Steps: – Proton Pump Inhibitors (PPIs) – Prilosec/Nexium, Prevacid, and Protonix
- 23. Hiatal Hernia • Hiatal Hernia – a physical abnormality that allows the stomach to protrude through the diaphragm and up into the chest. Often caused by weakened musculature (specifically esophageal muscles around the opening of the diaphragm) – Caused by heavy lifting, coughing, lying flat in bed or performing a Valsalva maneuver
- 24. Peptic Ulcer Disease • Peptic Ulcer Disease (PUD) – a duodenal or stomach ulceration often caused by the bacterium Helicobacter pylori. – 80% of duodenal ulcers and 60% of gastric ulcers caused by H. pylori – Treatable with antibiotics. • Second cause of PUD is NSAIDs (Nonsteroidal antiinflammatory drugs) – Risk of ulcers 3x greater in NSAID users • Signs of PUD include epigastric pain and coffee-ground emesis.
- 25. Nausea & Vomiting • Nausea and Vomiting – Main concern is dehydration – If seriously ill, hospitalization and IV rehydration may be considered – Medication to stop nausea and vomiting may be considered • Caution: These drugs may cause confusion, sedation and delirium in the older adult.
- 26. Gastroparesis • Gastroparesis – delayed stomach empting – Normal stomach emptying – the stomach contracts (controlled by the Vagus nerve) and food moves down into the small intestine for digestion – Symptoms include nausea, early satiety, vomiting, pain and possibly heartburn from reflux – Common causes: diabetes, idiopathic, and postsurgical • Occurs in 30% of those with type 2 diabetes • Occurs in 27% to 58% of those with type 1
- 27. Management of Gastroparesis Dietary Recommendations: – First Diet: • Liquids to prevent dehydration, salt and mineral losses; avoid milk products, vegetables, fruits, and meat; eat saltine crackers and drink Gatorade – Second Diet: • Small amount of dietary fat, skim milk and yogurt; lowfat cheeses; fat-free bouillon and soups made with skim milk and with pasta; cream of wheat; white rice,; eggs; peanut butter; vegetable juice; well-cooked vegetables w/o skins; apple, cranberry, grape, pineapple and prune juices; canned fruits without skins – Avoid citrus fruits
- 28. Management of Gastroparesis • Third Diet – All items in Diet 2 with the addition of poultry, fish, and lean ground beef; breads and cereals; coffee, tea and water – <50 grams of fat/day – Restrict non-calorie fluids if calorie intake cannot be maintained • Enteral and parenteral nutrition if symptoms flare, weight loss (10% over 6 months), nutrient deficiencies, or electrolyte imbalances
- 29. Malabsorption • Some defect that occurs during digestion and absorption of food nutrients • Can occur at any of the three phases of digestion: – (1) Luminal Phases – dietary fats, proteins and carbohydrates are hydrolyzed and solubilized – (2) Mucosal Phase – brush-border membrane of intestinal epithelial cells transport digested nutrients from the lumen into cells – (3) Postabsorptive Phase – lipids and other nutrients are transported from epithelial cells via the lympatic system and portal circulation to other parts of the body
- 30. Malabsorption • Causes – Pancreatic insufficiency (20-30% of older adult malabsorption cases) – Anatomic abnormalities (30%) – stasis and predispose to bacterial overgrowth – Bacterial Overgrowth Syndrome w/o anatomic abnormalities (20%)– inadequate gastric acid secretion • Pernicious anemia and vitamin B12 deficiency are common • Treatment will be dependent on the cause.
- 31. Steatorrhea • Steatorrhea – production of stools containing an abnormally high amount of fat – Hallmark of malabsorption – Stool smells foul, bulky and difficult to flush down the toilet – >6% of dietary fat is excreted in feces – Clinical signs: anemia, deficiencies in iron, folate, B12, Vit K or a combination, easy bruising
- 32. Steatorrhea • Diagnosis: 72-Hour Stool Collection – If fecal fat is >40 g, pancreatic insufficiency or small intestine mucosal disease indicated • D-xylose test to differentiate • Treatment: Correct nutrient deficiencies and treat underlying causes – Iron supplement via ferrous sulfate or gluconate tablets – Monthly B12 injections – Supplement fat-soluble vitamins and calcium – High protein/calorie, low-fat diet prescribed – MCT supplement
- 33. Behavior Assessment Overeating/ stress Indigestion Lack of physical activity Constipation Nausea Constipation Constipation Bloating Heartburn Bloating Gas Bloating Indigestion Gas Heartburn Diarrhea Poor diet Irregular eating pattern Heartburn Indigestion Constipation Heartburn Used with permission from the “Nourish Your Digestive System” program by Julie Garden-Robinson, NDSU Extension Service
- 34. In Summary • Basic age-related gastrointestinal changes may impact absorption and metabolism of food, vitamins and medication • Special attention needs to be paid to oral health issues, including chewing and swallowing, which may impact nutritional status • Prevention is key to many age-related gastrointestinal issues
- 35. References 1. 2. 3. 4. 5. 6. Bernstein, M. and Schmidt Luggen, A. (2010). Nutrition for the older adult. Sudbury, MA: Jones and Barlett Publishers. DOI: www.jbpub.com National Institute of Dental and Craniofacial Research. Periodontal (Gum) Disease: Causes, Symptoms & Treatment Retrieved 17 September 2013. http://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalG umDisease.htm Nestle HealthCare - http://www.youtube.com/watch?v=jK1o3LSQmB0 “Nourish Your Digestive System.” Packaged program by Julie GardenRobinson, NDSU Extension Service. Savoca, M.R., Arcury, T.A., Leng, X., Chen, H., Bell, R.A., Anderson, M.A., Kohrman, T., Gilbert, G. H., and Quandt, S.A. (2010). Association between dietary quality of rural older adults and self-reported food avoidance and food modification due to oral health problems. Journal of the America Geriatric Society. 58: 201. 1225-1232. Schwartz, N., Kaye, E.K., Nunn, M.E., Spiro, A., and Garcia, R.I. (2012). High-Fiber Foods Reduce Periodontal Disease Progression in Men Aged 65 and Older: The Veterans Affairs Normative Aging Study/Dental Longitudinal Study. Journal of the American Geriatric Society. 60:676– 683.
Notas do Editor
- GI tract is a connected series of organs and structures used for the digestion of food and absorption of nutrients. The process of digestion includes ingesting foods, propulsion of food from the mouth, secretion of mucus, water, and enzymes; mechanical and chemical digestion; absorption of foods; and propulsion of wastes from the anus. The GI Tract includes the oral cavity; throat; oropharynx; esophagus, the stomach, duodenum and small intestine; gallbladder; pancreas; liver; large intestine; rectum and anus. Accessory organs include the liver, gallbladder and pancreas
- Mouth & Esophagus – responsible for ingestion and digestionStomach & small intestine – digestion and absorptionLarge intestine – absorption and eliminationRectum – eliminationLiver, gallbladder, bile duct and pancreas – produce and secrete substances that aid in digestion
- In comparison to other body systems, the GI tract maintains normal function with aging.The table on page 103 is a nice summary of the area, change, implication and what contributes to the changes
- Gum Disease causes infections and loosens the tooth’s structural support, may results in tooth loss or weak/brittle teeth making chewing difficult. Teeth – Dental caries and periodontal disease are two most common oral diseases. Periodontal disease is more common in men and most severe in the poorest people. The severity also increases with age. 23% of adults aged 65 to 74 have severe periodontal disease.Issues: Older adults often do not have dental insurance after retirement and pay for dental care out of pocket. Medicare does not cover dental care and Medicaid has limited coverage in some states.
- Gingivitis (swollen gums due to bacteria causing inflammation) can lead to periodontal disease if left untreated. In periodontitis, gums pull away from the teeth and form spaces (called “pockets”) that become infected. The body’s immune system fights the bacteria as the plaque spreads and grows below the gum line. Bacterial toxins and the body’s natural response to infection start to break down the bone and connective tissue that hold teeth in place. If not treated, the bones, gums, and tissue that support the teeth are destroyed. The teeth may eventually become loose and have to be removed.Source: National Institute of Dental and Craniofacial Research. Periodontal (Gum) Disease: Causes, Symptoms & TreatmentRetrieved 17 September 2013. http://www.nidcr.nih.gov/OralHealth/Topics/GumDiseases/PeriodontalGumDisease.htm
- Food avoidance or food modifications due to oral health issues have been associated with a variety of issues. Research has shown that it has been associated with a decline in nutrients of concern for the older adults (water- and fat-soluble vitamins, carotenoids and various trace minerals), likely due to decreased fruit, vegetable, and nut intake. Oral health issues have also been shown to increase cholesterol and fat in the diet. Foods shift to those easier to chew and swallow and away from those that are crunchy, stringy or dry (carrots, apples, steak, nuts, etc.)
- Food frequency questionnaire (HEI-500, based on the amount of food per 1000kcal of intake) where interviewers read subjects a list of 110 foods and asked them to assess usual intake. Food avoidance measure was utilized where subjects were read a list of foods and asked whether they avoided the food due to issues with their mouth, teeth or dentures. In addition, they were asked if there were any foods they avoided that were not listed. Respondents were asked if they prepared food in a special way due to conditions of their mouth, teeth or dentures. Further probing questions were asked to identify which foods were modified and how they were altered to accommodate oral health issues. Finally, participants who still retained at least one natural tooth underwent an in-home oral examination to attain tooth counts.
- Modifying foods in response to oral health problems is associated with higher HEI-2005 scores. These results indicate that individuals with severe oral health issues who modify foods can achieve improved dietary intake through food modification.These results call for future research to create a more complete picture of the ways older adults alter their dietary intake to address oral health issues. Further, this study calls for nutrition and health promotion to teach older adults living with oral health issues how to modify important nutrient dense foods (i.e. fruits, vegetables, nuts and meat) in order to maximize nutrient intake while still maintaining pleasure and enjoyment with food.
- Also could add to this list: clean between teeth (dental floss might be difficult in older adults). The American Dental Association recommends a fluoride containing mouth rinse may be helpful. Also, since we are in the nutrition arena, a balance diet limited in simple, sticky sugars (not so much an issue with soda but hard candies)
- The research related to fiber health benefits is strong regarding diabetes, cardiovascular disease and weight. This research further supports the benefits of consuming a diet rich in fiber but supporting the literature of the benefits to oral health. Fruit & Improved Periodontal health - The discussion suggests that fiber may be one piece of the puzzle but other nutrients not controlled for this this study (vitamin A, E, C, phytochemicals, etc.) may also play a role. The authors suggest this further supports the message of the synergistic effect of real food and to encourage consumption of fiber from its natural sources (i.e. fruits, vegetables, whole grains).One other important discussion was the proposed mechanisms by which fiber improves periodontal health. These being controlling blood glucose, insulin resistance and BMI. Additionally, fiber may remove plaque from teeth surface and also requires more chewing, which produces saliva removing food debris and introduces antibacterial agents.
- Dysphagia is difficulty with swallowing. It may result from a neurological disorder that impairs esophageal motility or from a mechanical obstruction of the esophagus. Other causes of dysphagia include stroke, Parkinson’s disease, head, neck, and chest injuries, Zenker diverticulum, oropharyngeal tumors, and prominent cervical osteophytes.
- Swallowing is very complex and utilizes 50 pairs of muscles and many nerves to move food from the mouth to the stomach.
- Texture Modifications:The National Dysphagia Diet recommends three levels—dysphagia pureed, dysphagia mechanically altered, and dysphagia advanced.Dysphagia pureed diet: Foods are pureed and homogenous, with all foods, including meats, vegetables, and breads, of pudding-like consistency.Dysphagia mechanically altered diet: Foods that are moist, soft textured, and easily formed into a food bolus for swallowing are allowed. Foods are well cooked and soft. Meats are ground or minced.Dysphagia advanced diet: Foods are of nearly regular texture, but very hard, sticky, or crunchy foods are not included.Thickened Liquids: Liquids are thickened to the consistency of honey, nectar (such as apricot nectar), or pudding. If thickened liquids are recommended, it is necessary to have every liquid consumed to the recommended consistency, including water, coffee, juices, and milk.How are liquids thickened?Speech and language pathologists recommend using a commercial thickener, which is a powder that is mixed into beverages to thicken them. Many health care facilities purchase pre-thickened water, milk, coffee, and juice. Source: Nutrition 411; Dysphagia, What is Dysphagia? Retrieved October 1, 2013. http://www.nutrition411.com/component/k2/item/28455-dysphagia-what-is-dysphagia
- Management of dysphagia is primarily concerned with prevention of aspiration. Aspiration pneumonia is associated with higher rates of morbidity and mortality than community-acquired pneumonia and should be prevented if at all possible.
- Management of aspiration is multifactorial if malnutrition and dehydration are to be avoided. Foods with strong taste increase salivation, which enhances bolus formation. Such things include lemon, herbs and seasonings, cold or warm foods, and serving water either before or after a meal (not during).
- Vjdeo – Mayo Clinic – Heartburn, Acid Reflux, GERD - https://www.youtube.com/watch?v=TdK0jRFpWPQ GERD is the result of an incompetent lower esophageal sphincter.Atypical symptoms of GERD include retrosternal chest pain, cough, wheezing, hoarseness, throat clearing, vomiting, halitosis and sore throat. Severe symptoms may occur if GERD is left untreated, such as erosive esophagitis, strictures with dysphagia, esophageal ulcers, and bleeding.
- Medications which may cause GERD includeanticholinergics, benzodiazepines, calcium channel blockers, dopamine, estrogen, isoproterenol, nicotine gum or patches, nitrates, and opiods.
- H2 Inhibitors are a class of drugs used to block the action of histamine on parietal cells in the stomach, decreasing the production of acid by these cells.Antacids contribute calcium but may cause constipation.The third step occurs when previous steps are unsuccessful. PPIs are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available. PPIs are most effective when taken 15 to 30 minutes prior to a meal.
- A sliding hiatal hernia occurs in 60% of adults over the age of 60
- Approximately 5 million cases of PUD occur each year in the United States. NSAIDS – prescribed to approximately 40% of older adults. NSAIDs include ibuprofen (Advil, Motrin), naproxyn (Aleve) and aspirin (Bayer).50% of adults with PUD have no pain. Observing blood in the stool or anemia in a blood test give rise to suspicion.
- Many possible causes for nausea/vomiting in the older adult including motion sickness, intracranial lesins; chemotherapy drugs for cancer, NSAIDs, opiates, antibiotics, digoxin, stomach inflammation, mechanical obstruction, gallbladder inflammation, motility disorders, dyspepsia or gastroparesis, viral or bacterial infections, hepatitis, meningitis, metabolic conditions, alcohol intoxication, and psychiatric disorders.The older adult with nausea and vomiting must be evaluated for dehydration and if seriously ill, hospitalized. Anti-emetic/anti-diarrheal medicals will likely be prescribed.
- Diabetes is a cause of gastroparesis due to high blood sugars causing damage to the vagus nerve.Post GI surgery often requires “nothing by mouth” and feeding through a nasogastric tube. Studies have evaluated the post surgical outcomes of individuals fed via nasogastric tube or by mouth. No differences in outcomes were found between the two groups. Postlaparotomydysmotility predominately affects the stomach and colon. Early feeding is associated with a risk of vomiting but is also associated with reduced length of hospital stays, fewer infections and a reduced risk of wound ruptures (dehiscence)
- First Diet: Also fat-freeconsomme is permitted.Second diet includes ingestion of more calories including small amount of dietary fat (<40 g per day), skim milk and yogurt; low-fat cheeses; fat-free bouillon and soups made with skim milk and with pasta; cream of wheat; white rice,; eggs; peanut butter; vegetable juice; well-cooked vegetables w/o skins; apple, cranberry, grape, pineapple and prune juices; canned fruits without skinsThe diet also includes hard candies, puddings, ice milk, jelly, soft drinks and Gatorade
- Unmanageable gastroparesis may require intermittent enteral or parenteral nutrition. This can result in improved overall health status, reduced symptoms, enhanced nutrition, and decreased hospitalizations. Medication management includes prescriptions to stimulate gastric emptying and antiemetics.
- Pancreatic insufficiency – chronic pancreatitis and pancreatic cancer. Anatomic abnormalities include small intestine diverticulosis, strictures, partial obstruction. These obstructions promote stasis and predispose to bacterial overgrowth. Malabsorption should be investigated when weight loss or failure to maintain weight occurs. Other signs/symptoms include diarrhea, greasy, malodorous stools (steatorrhea); abdominal bloating; and gas.
- Diagnosis of steatorrhea can be made by various blood tests. D-xylose test can differentiate pancreatitis from mucosal disease. Medium-Chain Triglycerides – hydrolyzed readily by pancreatic lipase. Also consider parenteral nutrition if severe malnutrition is present and they are unresponsive to oral feeding.
- Here is a list of behaviors that may cause you to experience digestive distress: 1) Overeating and stress: These may cause indigestion, nausea, constipation, heartburn, diarrhea, gas and bloating. 2) Lack of physical activity: Exercise helps move food through the digestive tract, so not getting enough physical activity could lead to constipation, gas, bloating or heartburn. 3) Poor diet: A diet high in fat and protein may cause more digestive upset. Some other “trigger foods” may include broccoli, cauliflower, carbonated beverages and baked beans. Excess intake of caffeine, alcohol and strong spices: These may irritate the digestive tract, causing heartburn. Lack of fluids and fiber: This may lead to constipation. Eating too fast, chewing gum or swallowing excess air: These may lead to gas and bloating. 4) Irregular eating, rushing meals, eating meals on the go constantly: These can lead to constipation, bloating and indigestion. And don’t forget age! As we age, we become more susceptible to digestive problems. Used with permission from the “Nourish Your Digestive System” program by Julie Garden-Robinson, NDSU Extension Service