Irritable Bowel Syndrome

Nutrition in IBS should be individualised

The low FODMAP diet (fermentable oligo-, di-, and monosaccharides and polyols) has been shown to improve symptom management and quality of life in a number of patients with IBS.

But is this type of elimination diet suitable for everyone?

There is a small percentage of patients where eating disorder may be present and this can be associated with functional gut symptoms. There is also emerging research on the comorbidity of functional gut disorders and eating disorders.

Kate Scarlata, along with other authors have written from the dietitian’s perspective about how the Low FODMAP Diet (LFD) may not be suitable for some patients who are at risk for maladaptive eating, eating disorders or with mental health conditions.

The article encourages screening of individuals for eating disorder risk before prescribing an elimination diet, making nutritional approaches for IBS individualised.

Avoidant or restrictive food intake disorder (AFRID)

Avoidant or restrictive food intake disorder is a “diagnosis of eating or feeding disturbance due to lack of interest in eating, avoidance of sensory characteristics of food, or fear of adverse eating consequences (ie. digestive distress)” and was introduced in the DSM-5. (The DSM-5 is a revised Diagnostic and Statistical Manual of Mental Disorders handbook used by health care professionals as a guide to mental disorders assessment and diagnosis).

Feeding disorders like ARFID differs to other eating disorders and the research indicates that patients with IBS are meeting the criteria for ARFID. Prescribing of the LFD in this population needs to be carefully considered along with appropriate screening. Validated screening tools for ARFID in the IBS population need to be developed and with more research in this area is required. Registered dietitians and mental health providers with expertise in this area need to co-ordinate care to reduce risk to nutrient intake and mental health. More about this in our last article here.

Whether a LFD diet is prescribed or not, the overall recommendation is to reduce diet-related anxiety, stabilise or improve nutritional status, and enhance food-related quality of life, all while offering symptom benefit.

The FODMAP-gentle approach

If maladaptive eating is present and a full LFD is not indicated, a FODMAP-gentle approach may be considered. This allows for more flexibility with a reduction a few foods that are highly concentrated in FODMAPs from a patient’s diet.

Reference is made to the review paper by Emma Halmos & Peter Gibson in 2019, where the possible contraindications for diet therapy in IBS populations are discussed.  They describe the basis of a FODMAP-gentle diet, including the main high FODMAP foods to restrict.

A “top-down” approach has been described as a strategy for IBS diet treatment and includes a structured protocol of three phases, namely FODMAP restriction, reintroduction and personalisation involving a long-term plan of dietary manipulation. On the other hand, the FODMAP-gentle approach is a “bottom-up” method where there is mild FODMAP restriction, with a reduction of a few foods very high in FODMAPs and/or a reduction of a few targeted FODMAPs.

Thereafter there will be further restrictions only if required. The authors explain that the traditional published FODMAP protocol should be utilised in the majority of IBS sufferers unless there is indication to use the FODMAP-gentle approach. They note that with the FODMAP-gentle method, there may not be clarity of response which may be due to insufficient FODMAP restriction rather than wrong therapy.

Recognising the patients at risk.

Scarlata et al goes on to describe how to assess good candidates for the LFD diet. Factors to consider include diagnosis; diet and lifestyle history; and behavioural history.

An example of a poor candidate for a LFD would include a patient with current maladaptive eating avoidance. In order to evaluate for maladaptive food avoidance in IBS there are certain key factors that can be considered. These include the following: 

  • Body weight
  • Energy and nutrient intake  
  • Eating behaviours
  • Psychological distress
  • Patient beliefs/attitudes.

These factors can also be used for monitoring a patient during an elimination diet.

Take home messages:

  • Assess emotional and physical health to best select for LFD candidates.
  • Involve an experienced gastro-intestinal dietitian to assist in evaluating whether a patient is a good candidate for the LFD.
  • Encourage first line dietary advice for IBS as a starting point.
  • Refer on to a dietitian or behavioural health specialist with eating disorder expertise for supportive nutrition and psychological care if eating disorders or maladaptive eating are present.

Here is the article.

INTEGRATED CARE IS BEST FOR IBS

The world leaders in IBS research have come together and published a review paper on behavioural and diet therapies in integrated care for the IBS patient.

The diet therapy part of the study reviews the low FODMAP diet as a treatment option in an integrated care model, supporting its use as an evidence based dietary therapy. This summary will not delve into the LFD specifically as this has been done before but rather on the psychotherapy side of integrated care and what options exist for the IBS patient.

“Integrated care is becoming the rule not the exception” in IBS treatment

IBS is a chronic condition of diverse pathogenesis.

It is well known that IBS patients experience reduced quality of life. This arises from a combination of symptoms generated in the gastrointestinal tract but also centrally in the form of fatigue, insomnia, depression and anxiety to mention just a few.

The traditional Western management model which is not collaborative fails to deliver results and patient dissatisfaction is high

There is however now compelling research to support a team based collaborative care model where patients have access to dietitian and /or a behavioural therapist along with the clinician.

Most convincing research was an unblinded randomized study (MANTRA study) of 188 patients where a gastroenterologist led integrated, multidisciplinary care model showed significally improved clinical outcomes (84% in integrated care vs 57% in standard care) quality of life, psychological health and cost effectiveness.

Lets look at some of the behavioural therapies that work:

Behavioural Therapies

Research and efficacy data is limited but growing in this field.

The Gastrointestinal behavioural therapies available can be divided into 2 primary pathways:

Ascending Gut – Brain Pathway
This treatment focusses on reinterpreting benign sensations from the gut that could trigger maladaptive cognitive or affective process in the brain.
Various techniques exist with varying levels of evidence (Table 1 of the study, refence at end).

Mechanism

IBS patients have been shown to have heightened sympathetic nervous system arousal, lower heart rate variability and higher levels of circulating stress hormones – these can all lead to mechanical and chemical stimulation of the colon and activation of the emotional motor system. Under real or perceived stress these patients perceive normal gut signals as painful. IBS patients also have a reduced thickness of the prefrontal cortex. This limits their ability to ignore gut sensations, they are more susceptible to visceral hypersensitivity, attentional bias and hypervigilance.

The following therapies in various ways are able to reverse or decrease the effect of these mechanisms:

  • Gut directed hypnotherapy
  • Gastrointestinal CBT
  • Mindfullness based stress reduction programmes
  • Psychodynamic interpersonal psychotherapy – best for early trauma , personality characteristics (neuroticism and alexithymia – (inability to recognize or describe one’s own emotions)).

Descending Brain-Gut Pathway
Here gastrointestinal symptoms occur in response to cognitive and affective triggers that arise from fear of symptoms, lack of acceptance of disease or external environment stressors.

Mechanism
IBS patients demonstrate a reduced activity in the limbic system which is the emotional response network of the brain. This can result in ineffective down regulation of the gut signals and amplification of abdominal pain. Abnormalities of the emotional response system is common in depression and anxiety which often occurs alongside IBS.
There could also be reduced grey matter density and an altered resting state. This has been associated with cognitive errors in “pain catastrophizing” and “negative prediction overestimation” in some chronic conditions similar to IBS.

Good research exists for:

  • Gastrointestinal  Cognitive Behavioural Therapy , which includes acceptance based therapies that aim to focus on living a meaningful balanced life  in spite of chronic pain.
  • Gut directed hypnotherapy where the focus is on normalising the pain threshold.

It is important to stress that the success of behavioural therapy in IBS rests on the clinicians relationship with their patient and their ability to select the right patients for the right treatment routes.

WHO WOULD RESPOND BETTER TO BEHAVIOURAL THERAPY 

GOOD CANDIDATES are those who:BAD CANDIDATES ae those who:
Understand the diagnosis and the gut -brain dysregulation and are open to brain-gut psychotherapies as treatmentAre fixated on a single cause or solution.
Refuse to accept their IBS diagnosis
Identify the impact symptoms have on Quality Of Life and functioningCannot perceive impact of IBS on their lives
Want to take control and responsibilityPlace responsibility for a solution on others
Have symptom – specific anxietyAre under significant psychological distress – may be better with traditional psychotherapy
Have somatic symptoms – poor sleep, non-gut painAre not able to maintain a collaborative therapeutic relationship
Realise stress is linked to gut symptomsAre in need of case management- social work
Are willing to commit the time and effortNot able to commit or prioritize behavioural treatment

Please read the full paper here :

https://doi.org/10.1053/j.gastro.2020.06.099

New & updated IBS management guidelines.

Hot off the press in April 2021, Gut journal has published the latest guidelines for the management of IBS, commissioned by the British Society of Gastroenterology (BSG). The last publication of these guidelines was in 2007 and this update has been much anticipated.

A diverse working group was involved in reviewing the guidelines, with the strength and quality of the evidence graded. We can use these updated guidelines to guide our clinical practice and to make sure the standards of care is the same for all with IBS.

A disorder of gut-brain interaction


First off to note is the re-classification of IBS, now being considered as a disorder of gut-brain interaction, rather than a functional gastrointestinal disorder. The emphasis on the bidirectional link between the gut and the brain in IBS is now very much part in helping to diagnose this complex condition.

Foundations of IBS Treatment

As part of first line, emphasis is placed on:

  • Good communication
  • Simple lifestyle
  • Dietary advice

First Line Dietary Advice

Traditional dietary advice is considered first line and is based on National Institute for Health and Care Excellence and British Dietetic Association (BDA). See the link to the BDA Food Fact sheet here: https://www.bda.uk.com/resource/irritable-bowel-syndrome-diet.html

  • Healthy eating patterns
  • Regular meals
  • Adequate nutrition
  • Limiting alcohol
  • Caffeine intake
  • Adjusting fibre intake: Fibre was shown to have benefit in IBS, more specifically limited to soluble fibre, such as isphagula. Start with a low dose and build up gradually. Insoluble fibre, like wheat bran, may exacerbate abdominal pain and bloating.
  • Reducing consumption of fatty and spicy foods

Second Line Treatment

The low FODMAP diet is recommended as a second-line diet for IBS. These include short-chain fermentable carbohydrates found in variety of fruits, vegetables, dairy products, artificial sweeteners and wheat. New trials comparing a low FODMAP diet helped with a reduction in symptoms when compared to control interventions.

Another exciting development is that a response to a low FODMAP diet may be predicted. Preliminary data from faecal bacterial profiling and metabolomics activity could be used as a tool to identify those who may benefit.

To learn more about how the low FODMAP diet works and the EATFIT low FODMAP program, click here: http://www.eatfitsa.com/fodmap-diet/

What about Probiotics?

We all want to know whether to advise our patients to supplement with probiotics and if so, which strain would be beneficial.
It is now known that the faecal microbiome of patients with IBS may differ significantly from that of healthy individuals. New trial data showed significant effects on global symptoms or abdominal pain for combinations of probiotics but it was difficult to give specific recommendations on species or strain.

Patients who would like to try probiotics can take them for up to 12 weeks and discontinue if there is no improvement in symptoms.

Psychotherapy

With a growing interest in non-diet therapies for our patients with IBS, there is compelling evidence for cognitive behavioural therapy (CBT) and gut-directed hypnotherapy. Both are recommended by the NICE guidelines when symptoms have not improved after 12 months of drug treatment.

Cognitive Behavioural therapy:

Successes from two recent and large trials, using CBT developed specifically for IBS, show benefit for both mental health and gastrointestinal symptoms. IBS-specific CBT may be an efficacious treatment for global symptoms in IBS.
For more guidance on what CBT is exactly: https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/cognitive-behavioural-therapy-cbt/overview/

Gut-directed hypnotherapy:

This therapy aims to induce a deep state of relaxation and it may also be an efficacious treatment for global symptoms in IBS. The exact mechanisms in IBS are still uncertain primary aim of treatment is to lower the severity and impact of abdominal pain and to help regulate bowel habit.
If you would like more information on this type of therapy, check out this link: https://www.hypnotherapists.org.uk/hypnotherapy/hypnotherapy-for-ibs/

Other noteworthy recommendations

As part of first line drug therapy, peppermint oil could be of benefit in IBS. Peppermint oil could be effective for abdominal pain and global symptoms but gastro-oesphageal reflux is a possible side effect.

There was also no conclusive evidence for human gut microbiome profiling, the use of elimination diets based on IgG allergy testing and gluten free diets in IBS.

Finally, to be aware of those at high risk of overly restrictive eating behaviours and using simple screening tools if indicated before undertaking the low FODMAP diet.

Conclusion

All in all, a comprehensive review to guide our clinical practice to manage our IBS patients. Or course, the full article can be viewed here: https://gut.bmj.com/content/gutjnl/early/2021/05/24/gutjnl-2021-324598.full.pdf

IBS

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic condition of the digestive system. Symptoms present are: abdominal pain, stomach cramps, bloating, excessive wind, change in stool consistency or frequency (diarrhoea and/or constipation).

For an IBS diagnosis:
You should have recurrent abdominal pain on average at least 1 day a week in the last 3 months; along with two or more of the following:

  • Related to going to the toilet
  • Associated with a change in a frequency of stool
  • A change in form (consistency) of stool

Symptom type and severity may vary between individuals but the condition is often lifelong. Symptoms may also become more prevalent during times of stress or after eating certain foods.

IBS South Africa

There is very little data to tell us how many people suffer from Irritable Bowel Syndrome in South Africa. IBS is, however, a very common condition worldwide, affecting 1 in 5 people. It is thought to be a disease of urbanization and industrialization. Around twice as many women are affected as men. Irritable Bowel Syndrome affects all ages, even children and the elderly but is less common in those over 50 years of age.

Digestive problems and sensitive tummies

The exact cause of Irritable Bowel Syndrome is unknown, but most experts think that one cause is digestive problems related to gut motility. Increased gut motility causes food to pass too quick through the digestive system and there is not enough tiirritable bowel syndromeme to absorb the water from your food and the end result is diarrhoea. If food moves too slowly, then too much water is absorbed and this can lead to constipation. These changes in motility may be due to disruptions in the signals travelling back and forward between the gut and the brain. Studies have also shown that people suffering from Irritable Bowel Syndrome also have oversensitive guts and feel pain more acutely than those without Irritable Bowel Syndrome.

Bile acid malabsorption (where bile produced by the liver builds up in the digestive system) may be responsible for some cases of IBS, where diarrhoea is the predominant symptom. Certain foods may also exacerbate IBS symptoms of bloating, wind, abdominal distension and diarrhoea.

IBS FODMAP

A new diet called the Low FODMAP diet has been shown to help Irritable Bowel Syndrome sufferers. Researchers have found that certain foods contain a group of fermentable carbohydrates. These cause symptoms such as bloating, wind, abdominal pain, diarrhoea in Irritable Bowel Syndrome patients. The term FODMAP stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides And Polyols. Examples of culprit foods includes onion, garlic, beans, pulses, honey and plums.

Bloating diet

The low FODMAP diet can be particularly helpful at beating the bloat! Bacteria in the large bowel readily ferment High FODMAP foods contributing to the production of gas. However, there are other things that may be link with bloating – swallowing too much air when eating, chewing gum, drinking fizzy drinks or eating too fast. Constipation can also lead to bloating.

Irritable Bowel Syndrome dietitian/dietician

Everyone is individual and so there’s no single dietary strategy for IBS. Before trialling the Low FODMAP diet it is important to get your diet and eating habits properly assessed by an Irritable Bowel Syndrome dietitian. They can advise on key initial changes needed to your diet before embarking on a lengthy elimination diet, such at the Low FODMAP Diet. The low FODMAP Diet is not suitable for everyone and there are nutritional and gut health risks by following the diet for long periods of time (especially if not done under the supervision of a FODMAP dietitian). Get in touch with us if you’re looking for assistance.

Irritable Bowel Syndrome

What is Irritable Bowel Syndrome (IBS)?

Irritable Bowel Syndrome (IBS) is a common chronic gastrointestinal condition. It affects 1 in 5 of us on a daily basis. Abdominal pain, discomfort, wind, bloating, diarrhoea, constipation, rumbling noises, fatigue, backache, nausea, depression and anxiety are all symptoms.

irritable bowel syndrome

The medical definition of IBS is recurrent abdominal pain or discomfort at least 3 days a month in the past 3 months, associated with two or more of the following;hummus recipe

  • A change in frequency of stool
  • A change in appearance of stool
  • An improvement in symptoms after a bowel movement

Symptoms affect some people more severely than others and symptoms do vary between individuals. More women seem to be affected by IBS than men.

IBS can affect your quality of life as it is unpredictable. It can stop you going to work, socializing and eating the foods you enjoy. It is also often associated with low self-confidence or self esteem.

Triggers

Several factors may play a role – such as an increased sensitivity of the gut to pain, a change in bowel motility and problems digesting certain foods, but the exact cause of IBS is unknown. Other factors also linked with IBS symptoms are gastroenteritis or psychological factors like stress.

Diagnosis

Consult your doctor if you suspect you may have IBS. There are no tests for IBS, so a diagnosis may take time. To ensure nothing else might be causing your symptoms, like coeliac disease or bowel cancer, your doctor will need to follow a process of elimination. This might involve a gastroscopy, colonscopy and some blood tests. Your doctor can advise you on the next steps to take after he/she has diagnosed you with IBS.

Irritable Bowel Syndrome Treatment

IBS symptoms can be maibs south africanaged through medication, changes to your lifestyle and dietary therapy. The low FODMAP diet is a new diet designed to assist IBS sufferers. Fermentable carbohydrates are removed and reintroduced has been shown to help 3 out of 4 IBS sufferers. Please speak to your doctor about this diet. This diet should be done under careful supervision, so ask for a referral to a FODMAP trained dietitian. It is difficult to cut down on so many foods, and still eat a nutritionally balanced diet without specialist dietary advice. Help alleviate IBS symptoms by making other changes to your lifestyle such as exercise and managing stress.

Please contact EatFit Dietitians  for more information on IBS & FODMAP.

IBS – Some Facts

6 Facts about IBS

As we come to the end of IBS Awareness Month, we thought we would share some interesting facts about this common but little understood condition.

  1. Up to 1 in 5 people may have IBS
  2. There is no single test For IBS
  3. The exact cause of IBS is not known
  4. Treatments are available for IBS to help manage symptoms
  5. The Low FODMAP Diet may help
  6. IBS is a recognized disorder

Our key takeaway message is that you don’t need to suffer in silence with Irritable Bowel Syndrome. There are medical professionals that can help so get in touch with them.

 

 

April is IBS Awareness Month

Don’t Suffer Alone

April is Irritable Bowel Syndrome (IBS) Awareness Month. IBS is a fairly common digestive disorder that affects upto 20% of people. It causes symptoms such as abdominal pain, wind, bloating, diarrhoea, constipation and fatigue. Many people suffer in silence with IBS because they don’t realize that their symptoms are a medically recognized disorder nor that there is medical treatment that can help alleviate their symptoms. If you think you may have IBS, please see a doctor to get an accurate diagnosis.

Diagnosing and Treating IBS

There is no test for IBS so please see a doctor if you suspect you may have it. Your doctor may need to rule out other conditions such as coeliac disease or bowel cancer before you are given a diagnosis of IBS. You will then work together on a treatment plan that best fits your needs. There’s no single diet or medicine that works for all IBS sufferers. But symptoms can be managed through medication, changes to your lifestyle and diet. The exact cause of IBS is unknown but certain foods, food poisoning and stress are common triggers.

Dietary Management of IBS

A diet low in FODMAPs (“a Low FODMAP Diet”) has shown promising results in the research and is now internationally recognized as an effective dietary therapy for Irritable Bowel Syndrome. 50-80% of patients following the diet reporting an improvement in their symptoms.

FODMAPs are a group of fermentable carbohydrates found in a range of foods and researchers have discovered that these aggravate symptoms such as bloating, wind, abdominal pain, diarrhoea in individuals suffering from IBS. The term ‘FODMAP’ was coined by Australian researchers Susan Shepherd and Peter Gibson at Monash University in Australia and stands for;

  • Fermentable – they are fermented by the bacteria in your gut
  • Oligosaccharides – “oligo” means “few” and “saccharide” means sugar. These molecules are made up of a few sugars joined together in a chain. Fructans are a type of oligosaccharide and is a type of fibre found in wheat, onions and garlic.
  • Di-saccharides – “di” means two so there are two sugars in this molecule. Lactose (the sugar found in milk) is a disaccharide.
  • Mono-saccharides – “mono” means single and so this is a single-sugar molecule. An example is fructose (a sugar commonly found in fruit and fruit juice)
  • And
  • Polyols – these are sugar alcohols commonly used as sweeteners in diet products but also found naturally in some fruits and vegetables e.g. Xylitol.

A Specialist IBS Diet

The low FODMAP Diet is not for the faint hearted and should only be done under the supervision of a dietitian with training in the Low FODMAP diet. It is difficult to cut down on so many foods, and still eat a nutritionally balanced diet without receiving support from a registered nutrition professional. A FODMAP dietitian can guide you through the full elimination and re-challenge process.

Take Away Message

If you think you may have IBS, be reassured that you are not alone and there are health professionals that can help you with the diagnosis and management of this condition.