Tag Archives: irritable bowel syndrome

Eating the Right Foods and Weight Loss

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In a recent NY Times article, Rethinking Weight Loss and the Reasons We’re ‘Always Hungry’, the idea that too many calories causes obesity is challenged:

“…overeating doesn’t make you fat. The process of getting fat makes you overeat.”

Here’s an excerpt:

Dr. Ludwig, an obesity expert and professor of nutrition at the Harvard T.H. Chan School of Public Health, argues that weight gain begins when people eat the wrong types of food, which throws their hormones out of whack and sets off a cycle of cravings, hunger and bingeing. In his new book, “Always Hungry?,” he argues that the primary driver of obesity today is not an excess of calories per se, but an excess of high glycemic foods like sugar, refined grains and other processed carbohydrates…

Simply cutting back on calories as we’ve been told actually makes the situation worse. When we cut back on calories, our body responds by increasing hunger and slowing metabolism. It responds in an effort to save calories…

It’s the low fat, very high carbohydrate diet that we’ve been eating for the last 40 years, which raises levels of the hormone insulin and programs fat cells to go into calorie storage overdrive.

My take: The idea of changing the types of foods that we consume is not new in the fight against excessive weight gain.  Some of the best data on healthy eating is associated with the Mediterranean diet.

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Another review (from the NY Times) of the book ‘Happy Gut’ describes a diet promoted by a NY internist to help with problems like irritable bowel: Seeking a ‘Happy Gut’ for Better Health. “Cutting out dairy and gluten reversed many of his symptoms. Replacing processed foods with organic meats, fresh vegetables and fermented foods gave him more energy and settled his sensitive stomach.”

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Banning Mills

 

Should Patients with IBS be Screened for Celiac Disease?

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Despite widespread expert opinion that those with irritable bowel syndrome (IBS) should be screened for celiac disease, whether it is a good idea is not settled.  A recent study (RS Choung et al. Clin Gastroenterol Hepatol 2015; 13: 1937-43) showed that celiac disease has a low prevalence in US patients (mean age 61 yrs in this cohort) with IBS.

Here’s an excerpt of a summary of this report from the AGA Blog: “Should all Patients with IBS be Screened for Celiac Disease?”

Rok Seon Choung et al investigated whether subjects with positive results from serologic tests for celiac disease are frequently diagnosed with IBS or other functional gastrointestinal disorders (FGIDs).

They sent self-report bowel disease questionnaires to 7217 residents of Olmsted County, Minnesota, to collect data on symptoms compatible with functional GI disorders, including IBS, collecting data on symptoms compatible with functional GI disorders, including IBS. These symptom data were linked to surveys of undiagnosed celiac disease conducted among more than 47,000 individuals from the same region, based on results of tests for immunoglobulin A tissue transglutaminase and then endomysial antibody.

Among the 3202 subjects who completed the questionnaires and had their serum sample analyzed, 13.6% had IBS and 55.2% had some gastrointestinal symptoms.

The prevalence of celiac disease, based on serologic markers, was 1.0%. However, whereas 3% of patients with celiac disease met the criteria for IBS, 14% of patients without celiac disease met the criteria for IBS.

Abdominal pain, constipation, weight loss, and dyspepsia were the most frequent symptoms reported by subjects who tested positive for celiac disease, but none of the gastrointestinal symptoms or disorders were significantly associated with results of serologic test for celiac disease.

My take: This study along with others show that celiac disease is infrequent in patients with IBS.  Since the symptoms of celiac disease overlap with IBS, I doubt this study will dissuade practitioners from screening for celiac despite the low yield.

Also, this fall I posted several blogs on GMOs.  An interesting article (from Vox/Grist) on this subject explains how GMOs are a lot like pornography: It’s practically impossible to define “GMOs”

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The Science Behind IBS Dietary Interventions

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A succinct review (BE Lacy. Clin Gastroenterol Hepatol 2015; 13: 1899-1906) reviews the topic of dietary interventions for irritable bowel syndrome (IBS).

Here are some of the points:

  • “True food allergies are present in 1% to 4% of the US population, but are not more prevalent in IBS patients.”
  • One study found that “more than 1 in 4 patients with self-reported NCGS [nonceliac gluten sensitivity] actually fulfill the diagnosis.”  In other words, most patients with self-reported NCGS do not have NCGS.
  • “The prevalence of lactase deficiency is similar, or slightly higher, in IBS patients compared with healthy subjects; however, the self-reporting of symptoms attributed to lactose intolerance is not reliable.”
  • Potential mechanisms of food triggering GI symptoms were discussed, including intestinal permeability, visceral hypersensitivity, small intestine bacterial overgrowth, and gut microbiome.

Another article which covers the same topic: PR Gibson et al. Gastroenterol 2015; 148: 1158-74.

 

Which Diet is Best for Irritable Bowel Syndrome?

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As noted in this blog previously, there has been increasing evidence that a low FODMAPs (fermentable oligo-, di-, monosaccharides and polyols) diet is an effective option for irritable bowel syndrome (IBS) in adults and children. Now, a study (L Bohn et al. Gastroenterol 2015; 149: 1399-1407) directly compares a low FODMAPs diet with an IBS diet in a multicenter, parallel, single-blind study of 75 patients (adults) with Rome III criteria for IBS.

The comparison IBS diet recommended regular meal patterns, avoidance of large meals, reduced intake of fat and reduced insoluble fibers, caffeine, and gas-producing foods, such as beans, cabbage and onions.  In addition, this diet recommended avoidance of spicy foods, coffee, alcohol, soft drinks, and sweeteners that end with “-ol.” This diet has been recommended by the British Dietetic Association and by the National Institute for Health and Care Excellence (NICE).  NICE Guidelines for IBS

Key findings:

  • 67 patients completed the study.  The severity of IBS symptoms improved in both groups (P<.0001) without a difference between the two groups
  • 19 (50%) of low FODMAPs had reductions in IBS severity scores of >50 compared with baseline and 17 patients (46%) in the ‘traditional’ IBS diet group had this degree of improvement.

My take: Diet changes often result in symptom improvement in IBS.  Both of these diets can be recommended in patients with IBS.

Atlanta Sky

Atlanta Sky

FODMAPS Advice From Harvard

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A recent post from Harvard Health Publications offers a succinct explanation of a low FODMAPs diet for irritable bowel syndrome.

Here’s the link: Try a FODMAPs diet to manage irritable bowel syndrome

 

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Low FODMAPs Diet in Pediatric Irritable Bowel

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A low FODMAPs diet has been associated with clinical improvement in adults with irritable bowel syndrome and “gluten sensitivity” (see links below).  Now, there is more data that this diet can be effective in the pediatric population (Chumpitazi BP, et al. Aliment Pharm Ther DOI: 10.1111/apt.13286. Article first published online: 24 JUN 2015 -Thanks to KT Park for this reference).  In addition, this small study (n=33) tries to correlate changes in symptoms with changes in the gut microbiome. Interestingly, the dietary trials were only 48 hours.

From the methods: Following a 7-day baseline period, “we employed a randomised, double-blind, crossover study design. Subjects received either a low FODMAP or typical American childhood diet (TACD) for 48 h. After 48 h on the first assigned diet, they returned to their habitual diet for 5 days. Following this 5-day washout period, they were crossed over to the other intervention diet for 48 h.”

Here is the abstract and a link to the full text: Randomised clinical trial: gut microbiome biomarkers are associated with clinical response to a low FODMAP diet in children with the irritable bowel syndrome

Abstract:

Background

A low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet can ameliorate symptoms in adult irritable bowel syndrome (IBS) within 48 h.

Aim

To determine the efficacy of a low FODMAP diet in childhood IBS and whether gut microbial composition and/or metabolic capacity are associated with its efficacy.

Methods

In a double-blind, crossover trial, children with Rome III IBS completed a 1-week baseline period. They then were randomised to a low FODMAP diet or typical American childhood diet (TACD), followed by a 5-day washout period before crossing over to the other diet. GI symptoms were assessed with abdominal pain frequency being the primary outcome. Baseline gut microbial composition (16S rRNA sequencing) and metabolic capacity (PICRUSt) were determined. Metagenomic biomarker discovery (LEfSe) compared Responders (≥50% decrease in abdominal pain frequency on low FODMAP diet only) vs. Nonresponders (no improvement during either intervention).

Results

Thirty-three children completed the study. Less abdominal pain occurred during the low FODMAP diet vs. TACD [1.1 ± 0.2 (SEM) episodes/day vs. 1.7 ± 0.4, P < 0.05]. Compared to baseline (1.4 ± 0.2), children had fewer daily abdominal pain episodes during the low FODMAP diet (P < 0.01) but more episodes during the TACD (P < 0.01). Responders were enriched at baseline in taxa with known greater saccharolytic metabolic capacity (e.g. Bacteroides, Ruminococcaceae, Faecalibacterium prausnitzii) and three Kyoto Encyclopedia of Genes and Genomes orthologues, of which two relate to carbohydrate metabolism.

Conclusions

In childhood IBS, a low FODMAP diet decreases abdominal pain frequency. Gut microbiome biomarkers may be associated with low FODMAP diet efficacy.

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Baseball Broadcast with a Sense of Humor

FDA Approves Rifaximin and Eluxadoline for IBS-D

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From FDA (5/27/15): Two New FDA-Approved Treatments for adults with IBS-D

Excerpt:

The U.S. Food and Drug Administration today approved Viberzi (eluxadoline) and Xifaxan (rifaximin), two new treatments, manufactured by two different companies, for irritable bowel syndrome with diarrhea (IBS-D) in adult men and women….

“For some people, IBS can be quite disabling, and no one medication works for all patients suffering from this gastrointestinal disorder,” said Julie Beitz, M.D., director of the Office of Drug Evaluation III in FDA’s Center for Drug Evaluation and Research. “The approval of two new therapies underscores the FDA’s commitment to providing additional treatment options for IBS patients and their doctors.”

Viberzi, which contains a new active ingredient, is taken orally twice daily with food. Viberzi activates receptors in the nervous system that can lessen bowel contractions. Viberzi is intended to treat adults with IBS-D.

Xifaxan can be taken orally three times a day for 14 days, for the treatment of abdominal pain and diarrhea in patients with IBS-D. Patients who experience a recurrence of symptoms can be retreated with a 14 day treatment course, up to two times. Xifaxan, an antibiotic derived from rifampin, was previously approved as treatment for travelers’ diarrhea caused by E. coli and for reduction of the risk in adult patients of recurring overt hepatic encephalopathy, the changes in brain function that occur when the liver is unable to remove toxins from the blood. The exact mechanism of action of Xifaxan for treatment of IBS-D is not known, but is thought to be related to changes in the bacterial content in the gastrointestinal tract.

The safety and effectiveness of Viberzi for treatment of IBS-D were established in two double-blind, placebo-controlled clinical trials…Results showed Viberzi was more effective in simultaneously reducing abdominal pain and improving stool consistency than placebo over 26 weeks of treatment.

The safety and effectiveness of Xifaxan for treatment of IBS-D were established in three double-blind, placebo-controlled trials.

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Headlines and Shorts for IBD and IBS

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“Higher Levels of Knowledge Reduce Health Care Costs in Patients with Inflammatory Bowel Disease.” Inflamm Bowel Dis 2015; 21: 615-22.  This retrospective observational cohort study asked 91 patients to complete a questionnaire about their knowledge on the disease after 1 year of follow-up. The authors noted an association between higher levels of knowledge and lower health care costs. While their are many limitations to this study, it is hard to argue with the conclusion that better education is worthwhile; it may also improve outcome and costs.

“Surgery and Postoperative Recurrence in Children with Crohn Disease.” Hansen LF et al. JPGN 2015; 60: 347-51. In a retrospective study dating back to 1978, the authors noted a high recurrence of surgery in children (n=115) with Crohn disease (CD).  More than 1 bowel resection was needed in 39%. The use of biologics occurred late in the study and its potential effect on lowering recurrent resection is unclear in this study. Related post:  More Lessons in TNF Therapy (Part 1) | gutsandgrowth

“Risk of Drug-Induced Liver Injury from Tumor Necrosis Factor Antagonists.” Bjornsson ES, et al. Clin Gastroenterol Hepatol 2015; 13: 602-08.  9 cases of DILI associated with infliximab (1 in 120 patients), 1 case (of 270) with adalimumab, and 1 case (of 430) associated with etanercept. 8 of 11 patients who were tested for ANA were positive. DILI was treated with steroids in 5 patients. 8 patients went on to receive a different anti-TNF without recurrent liver dysfunction. Related blog posts:

“The Prevalence of Intestinal Parasites is Not Greater Among Individuals with Irritable Bowel Syndrome: A Population-based Case-control Study” Clin Gastroenterol Hepatol 2015; 13: 507-13. Related post: Does it make sense to look for parasites in RAP …

Will I Have This Stomach Pain Forever? (Part 2)

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The article reviewed earlier today on this blog (Clinical Gastroenterology and Hepatology 2014; 12: 2026-32) has been reviewed on the AGA blog as well (some of this information is redundant from earlier post):

Here’s a link to a summary of the article: AGA blog on RAP and here’s an excerpt: Sara Horst et al investigated whether pediatric functional abdominal pain leads to functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS) in adulthood. They performed a longitudinal analysis of 392 children (8−16 years old) initially seen at a subspecialty clinic for recurrent abdominal pain. Horst et al assessed the contribution of gastrointestinal symptoms, extra-intestinal somatic symptoms, and depressive symptoms to FGIDs 5−15 years later. They found that on average 9 years later, 41% met symptom criteria for FGID—mostly irritable bowel syndrome and functional dyspepsia. Levels of depressive symptoms in childhood correlated a greater likelihood of FGID later in life (see figure).   The probability of FGID in adolescence or young adulthood increases with each increase in Children's Depression Inventory (CDI) score up to a score of 13—the cut-off point used in screening children for depression. At CDI scores higher than 13, the probability of FGID remained fairly constant.

Amplified Pain Syndromes in Children

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A recent review (Curr Opin Rheumatol 2014; 23: 1-12 -thanks to our pain team for sending reference) makes a number of important points regarding the pathogenesis and management of amplified pain syndromes (APS).

Table 1 lists the diagnosis and pain presentations.  These include complex regional pain syndromes, juvenile fibromyalgia, diffuse idiopathic pain, concomitant conditions (including irritable bowel syndrome, chronic fatigue syndrome, interstitial cystitis, chronic headache, functional abdominal pain, and conversion symptoms/disorder).

Key points:

  • Pediatric APS are widespread and under-recognized
  • Pathophysiology is complex with numerous contributors “including central sensitization, abnormal cytokine production, sympathetic-sensory disorders, autoimmune responses, altered blood flow, genetic predisposition, and psychosocial factors.”
  • “The clinical effectiveness of medication management in pediatric APS remains unclear and controversial.”  It is noted that preoperative gabapentin and pregabalin may reduce the incidence of chronic post surgical pain (in adults); this has not been documented in a pediatric population.
  • “Exercise-based and cognitive-based treatments remain the cornerstone of therapy.” Intensive multidisciplinary pain rehabilitation “restores functioning rapidly, reduces pain in the long run, improves comorbid psychological distress, and reduces medical utilization.”
  • Potential elements of treatment noted in Table 2 (geared more towards rheumatology), including exercise, desensitization, self-regulation (eg. diaphragmatic breathing, guided imagery), and stress management/counseling.

Bottomline: For children with severe pain symptoms, multidisciplinary pain teams can be very helpful.  However, there is not a simple pill that will fix everything.

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