(IBS). - Dietitians in Integrative and Functional Medicine

DIFM-The Integrative RDNs
Dietitians in Integrative and Functional
Medicine
June 25, 2014
Gerard E. Mullin MD
Associate Professor of Medicine
Johns Hopkins University School of Medicine
Division of Gastroenterology & Hepatology
Objectives
• To examine the pathophysiology of IBS as
the foundation for integrative solutions
• To review the herbal therapies, dietary
supplements and special diets that have
proven efficacy in the irritable bowel
syndrome
• To know the mind-body modalities that
improve outcomes for the irritable bowel
syndrome.
Rome III Criteria for IBS
• A chronic disorder characterized by abdominal pain or
discomfort associated with disordered defecation
• Symptoms should have developed at least 6 months
before the patient first presents for formal evaluation
• Abdominal pain or discomfort should be present at
least 3 days per month for 3 months and should be
associated with two or more of the following:
– improvement with defecation,
– onset associated with a change in stool frequency,
and/or
– onset associated with a change in stool form.
Epidemiology of IBS
• Prevalence is 10-15% of US population, F>>>M
• Annual direct costs for IBS=$1.35 billion
• Estimated impact on the U.S. of $30 billion annually
(excluding prescription and OTC meds)(Leong, 2003;Inadomi,
2003;Hulisz, 2004).
• IBS adversely impacts quality of life, and, thus, significantly
affects work productivity (Dean, 2005; Quigley, 2006).
• Consequently, IBS continues to be the second most common
cause of work and school absenteeism (Drossman, 1993).
• Two decades ago, about 16% of IBS patients had sought out
CAM practitioners (Smart, 1986). More recent data indicates
that up to 51 percent of patients with IBS report using CAM
(Haas, 2000;Kong, 2005).
The Pathogenesis of IBS
Emerging Options for IBS
• Supplements
• Gut Microbiome
Pathophysiology of IBS
Pathophysiology of IBS
The Immune System in Irritable Bowel Syndrome. Barbara et al
Neuro Gastro Motility October 2011 17;4:349.
Evidence to Support a Pivotal
Role of Gut Microbiome in IBS
•
•
•
•
Post-infectious IBS
Altered Colonic Microbiome in IBS
Probiotics
Small Intestine Bacterial Overgrowth
Clinical Features Associated with SIBO
•
•
•
•
•
•
•
Gas-bloat
Flatulence
Abdominal discomfort
Diarrhea
Steatorrhea
Weight loss
Features associated with micronutrient
deficiencies
Treatment Options for SIBO
The goal is to treat the underlying
cause(s), eradicate the bacterial
overgrowth and nutritional
support
• Antibiotic therapy
• Herbs (berberine, wormwood)
• Prokinetic agents
• Elimination Diet-FODMAPs
Results of IBS Subjects Undergoing Intervention for Positive Lactulose Breath
Hydrogen Testing for SIBO (n=104)
Glob Adv Health Med. 2014 May;3(3):16-24.
Characteristics
Rifaximin
Number
67
Age (yr), sd,
44.4 +/-14.8 (19range
81)
Gender
Female N (%)
48 (71)
Male n (%)
19 (29)
Responses (n)
26
Responses Rate
34
(%)
Adverse Events
2, 2.9
(n, %)
Herbs
37
41.3 +/- 14.8
(19-76)
29 (78)
8 (22)
P value
na
0.33
15
46
na
0.24
1, 2.7
.83
.97
Mullin et al Global Advances in Health and Medicine May, 2014
IBS SYMPTOM INDEX
Treatment of IBS with TCM
200
180
160
140
120
100
80
60
40
20
0
P=0.10
Placebo
Standard
Individual
P=0.03
Baseline
End of Tx
N=35
14 N=43
weeks follow up
N=38
Level A
A Bensoussan, NJ Talley, M Hing et al. Treatment of irritable bowel syndrome with Chinese herbal
*
medicine. A randomized *
controlled
study. JAMA 1998 280: 1585-1589
Traditional Chinese Herbal Medicine to Treat IBS
Authors
N
Trial Design
Treatment
Time
Outcome
Bensoussan et al
1998
116
R,D,P
Standard TCM,
Individualized
herbs, placebo
16 weeks
Significant
reduction in
symptom scores
and QOL
Wang et al
2008
24
R, non-D,P
24 gm Shugan
Jianpi granules +/Smecta TID or CBT +
lacetin
2 weeks
Significant
reduction in
serotonin
positive cells in
herbal groups
Leung et al
2006
119
R,D,P
Concoction of
Chinese herbs vs.
placebo
(IBS-D)
8 weeks
No significant
improvement in
SF-36 or global
symptoms
Bian Z et al
1125
Meta-analysis
Tong xie yao fang
(TXYF)
(IBS-D)
10-40
days
More effective
than placebo (RR
1.35, 95% CI
1.21-1.50)
Sallon S et al
61
R,D,P
Padma Lax
(IBS-C)
12 weeks
More effective
than placebo
76% vs. 31%
Altern Med Rev. 2011 Jun;16(2):134-51.
Iberogast
PLANT NAME
HERB-EXTRACT
RATIO
IN 100 ML OF
IBEROGAST
Bitter candytuft
1:1.5-2.5
15 mL
Angelica root
1:2.5-3.5
10 mL
Chamomile flowers
1:2.5-4.0
20 mL
Caraway fruits
1:2.5-3.5
10 mL
Milk thistle
1:2.5-3.5
10 mL
Lemon balm
1:2.5-3.5
10 mL
Peppermint leaves
1:2.5-3.5
5 mL
Celandine
1:2.5-3.5
10 mL
Licorice root
extract
1:2.5-3.5
10 mL
Iberogast
Improves IBS Symptoms
Madisch, A., Holtmann, G., Plein, K. & Hotz, J. Treatment of irritable bowel syndrome with
herbal preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial.
Alimentary Pharmacology & Therapeutics 19 (3), 271-279.
•
•
•
•
•
Irritable bowel syndrome (IBS)
symptom score (± s.d.) for the various
treatment groups at baseline and after
2 and 4 weeks of treatment. Intentionto-treat population.
*P = 0.0033, §P = 0.0035, **P = 0.0009
and §§P = 0.0005 vs. placebo.
STW 5, commercially available herbal
preparation (nine plant extracts)
STW 5-II, research herbal preparation
(six plant extracts)
BCT, bitter candytuft mono-extract.
Level A
Iberogast
Improves IBS Pain
Madisch, A., Holtmann, G., Plein, K. & Hotz, J. Treatment of irritable bowel syndrome with herbal
preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial.Alimentary
Pharmacology & Therapeutics 2004; 19 (3), 271-279.
Abdominal Pain score (± s.d.) for the
various treatment groups at baseline
and after 2 and 4 weeks of treatment.
Intention-to-treat population.
*P = 0.0085, §P = 0.0006, **P = 0.001 and
§§P = 0.0003 vs. placebo.
STW 5, commercially available herbal
preparation (nine plant extracts)
STW 5-II, research herbal preparation (six
plant extracts)
BCT, bitter candytuft mono-extract.
Level A
Pharmacological Effects of Iberogast
Botanical
Inhibition of
AntiAcid
Inflammation
secretion
Oxidative
stress
Hypomotility Hypermotility
Peppermint
W
S
S
N
M
Chamomile
S
W
M
M
S
Licorice root
W
S
W
N
M
Angelica root
M
W
M
N
S
Caraway
M
S
W
N
W
Milk thistle
M
M
M
N
M
Melissa leaf
M
M
S
N
W
Celandine
N
M
M
M
N
Bitter
candytuft
M
S
W
M
W
Wagner H. Multitarget therapy-the future for more than just
functional dyspepsia. Phytomedicine 2006;13 suppl 5:122-129.
Peppermint
• Animal model studies demonstrate:
– relaxation effect on gastrointestinal (GI) tissue
– analgesic and anesthetic effects in the central and peripheral
nervous system
– immunomodulating actions
– chemopreventive potential
• Blocks calcium channels in gastrointestinal smoothe muscle to
produce spasmolytic response
Wald A, Rakel D. Nutr Clin Pract. 2008 Jun-Jul;23(3):284-92. Review
Cochrane Collaboration 2011 Issue 11.
ACG Task Force: Management of IBS-D
Agents
Grade
Antispasmodics
RR of IBS
symptoms
not improving
-
0.68
Hyoscine, cimetropium, pinaverium:
provide short-term relief of abdominal
pain/discomfort inI BS
Grade 2C
not given
Peppermint oil: superior to placebo in IBS
in a small number of studies
Grade 2B
0.43
Alosetron: more effective than placebo at
relieving global IBS symptoms in male and
female IBS-D patients. Potentially serious
side effects of constipation and colon
ischemia (Grade 2A).
Grade 2B (M)
Grade 2A (F)
0.79
ACG IBS Task Force, Am J Gastro 2009; 104 (S1): S1-S35
Efficacy of Therapies for IBS
Therapy
BMJ 2008;337:
a2313
Trials NNT
Peppermint
Oil
Hycosamine
8
2
22
11
Alosetron
6
7
Tegaserod
8
17
TCAs
8
4
Other Herbal Therapies for IBS
Herb/
Reference
Sample size
Sample
characteristics
Study design
Dose of
active
Duration
Outcome
207
All forms IBS
R, non-D,
non-P
2 doses, 72
mg (1 tablet)
or 144 mg (2
tablets) daily
8 weeks
Significant
improvement
in IBS QOL at
end of trial
vs. baseline
both Tx
groups
Walker et al
2001
279
All IBS forms
R, non-D,
non-P
320 mg
artichoke leaf
extract per
cap; 2 TID
6 weeks
Significant
reduction of
IBS symptoms
vs. baseline
Bundy et al
2004
208
All forms IBS
R, non-D,
non-P
320 mg (1
capsule) or
640 mg (2
capsules) of
1:5 artichoke
leaf extract
daily
2011 Jun;16(2):134-51.
8 weeks
Significant
reduction in
QOL,
symptom
score vs.
baseline
Tumeric
Bundy et al
2004
Artichoke
leaf extract
Altern Med Rev.
Melatonin
Sleep
Depression
Anxiety
IBS???
Is Melatonin involved in IBS?
JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2009, 60, Suppl 3, 67-70
Melatonin in IBS
Author-Year
Trial
Outcome
DB, RCT 3 mg melatonin vs.
placebo 8 weeks, 4 week
washout, 8 week crossover
n=17
Improved overall IBS scores,
Decreased abdominal pain,
decreased abnormal to
defecation, decreased
distention
IBS-C colonic transit study. O3
mg melatonin vs. placebo 8
weeks, 4 week washout, 8
week crossover
n=17
Blue dye, radiopaque
markers, bristol stools
CTT prolonged in IBS-C vs.
controls
Melatonin increased CTT in
vs. placebo
No difference in prolongation
of CTT with melatonin in
Controls vs. IBS-D
Saha L et al J Clin Gastro
2007;41;1:29-32.
IBS, 3 mg melatonin vs.
placebo, 8 weeks, DB RCT
N=18
Improved overall IBS score,
improved extra-colonic
symptoms and QOL
Song GH et al Gut
2005;54;10:1402-7.
3 mg melatonin vs. placebo
vs. 2 weeks
IBS with sleep disturbances
N=40
Improved abdominal pain,
decreased rectal pain
thresholds
Lu WZ. Aliment Pharmacol
Ther 2005 Nov 15;22;10:92734
Lu WZ et al. Dig Dis Sci 2009;
54;5:1087-95.
Emerging Options for IBS
• Supplements
• Gut Microbiome
Distribution of Intestinal Bacterial Flora in Normal
Gut and in Small Intestinal Bacterial Overgrowth
Lin, H. C. JAMA 2004;292:852-858.
Origin of gas/bloating of IBS patients with SIBO
IBS Patients on High
FODMAP Diet Produce
Breath Methane
Treatment Options for SIBO
The goal is to treat the underlying cause(s),
eradicate the bacterial overgrowth, and
nutritional support
• Antibiotic therapy
• Prokinetic agents
• Herbs (berberine, oregano oil, wormwood)
Mullin et al Global Advances in Health and
Medicine May 2014
• Diet
• Enzymes/HCl
Results of IBS Subjects Undergoing Intervention for
Positive Lactulose Breath
Hydrogen Testing for SIBO (n=104)
Characteristics
Rifaximin
Number
67
Age (yr), sd,
44.4 +/-14.8 (19range
81)
Gender
Female N (%)
48 (71)
Male n (%)
19 (29)
Responses (n)
26
Responses Rate
34
(%)
Adverse Events
2, 2.9
(n, %)
Herbs
37
41.3 +/- 14.8
(19-76)
29 (78)
8 (22)
P value
na
0.33
15
46
na
0.24
1, 2.7
.83
.97
Mullin et al Global Advances in Health and Medicine May, 2014
Meta-analysis for Probiotic Use in IBS
• Over 20 RCT’s and 5 meta-analysis for
probiotics use in IBS
• Most systematic reviews indicate that
probiotics have a beneficial impact on global
IBS symptoms, abdominal pain and flatulence
but not bloating.
• Strain specific?
Current Opinion in Clinical Nutrition & Metabolic Care. 14(6):581-587, November 2011.
DOI: 10.1097/MCO.0b013e32834b8082
Meta-analysis for Probiotic Use in IBS
• Over 20 RCT’s and 5
meta-analysis for
probiotics use in IBS
• Most systematic
reviews indicate that
probiotics have a
beneficial impact on
global IBS symptoms,
abdominal pain and
flatulence but not
bloating.
• Strain specific?
Current Opinion in Clinical Nutrition &
Metabolic Care. 14(6):581-587, November
2011.
.
Gut. 2010 Mar;59(3):325-32
Summary of Evidence for Herbal and
Micronutrient-based Therapies for IBS
INTERVENTION
Peppermint oil
Melatonin
Iberogast
TCM
Artichoke leaf extract
Tumeric
BODY OF EVIDENCE
3 meta-analyses of 5, 4 and
3 RCTs
2 RCTs
1 RCT
2 RCTs(+) 1 RCT(-) 1 meta(+)
2 RCTs
1 RCT
Summary of Adverse Effects for
Herbal and Micronutrient-based
Therapies for IBS
INTERVENTION
ADVERSE EFFECT
Peppermint oil
Melatonin
Iberogast
TCM
Artichoke leaf extract
Tumeric
Worsening of GERD
Drowsiness
Allergy
Adulteration (meds, metals)
none
GI intolerance (Pepperdine)
Summary of Evidence for Herbal and
Nutraceutical-based Therapies for IBS
Therapy
Mullin et al JPEN 2014 In Press
Description
Level of Grades of
Evidence Recommendations
Bifidobacterium infantis B5624 IA
and VSL#3
Other species
IA
A
Prebiotics
Food sources include bananas, IB
artichokes, onions, asparagus,
and chicory. Low doses (3-5
gm) of inulin FOS, GOS.
C
Fiber
Isphagla
IA
D
Peppermint Oil
0.2-0.4 mL enteric-coated
capsules 3 times daily
IA
A
Melatonin
Iberogast
3 mg at night
IB
B
20 drops 2-3 times daily
IB
B
Probiotics
B
Gas
Bloating
Abdominal Pain
Diarrhea
Constipation
> 60% IBS patients report
worsening symptoms after meals,
28% within 15 minutes, 93% within
3 hours
Eswaran S, Tack J & Chey W. Food: The Forgotten Factor in the Irritable
Bowel Syndrome. Gastroenterol Clin N Am 40 (2011) 141–162
Self-Reported GI Food-Related GI
Symptoms in IBS
197 patients with IBS
• 84% report food-related symptoms
• 70% (138) incompletely absorbed carbohydates
• 49% dairy products
• 36% Beans and Lentils
• 58% biogenic amines: salami (22%), cheese (20%)
• High Histamine foods: milk (43%),
wine/beer (31%), pork (21%)
• 52% Fried and fatty foods
Bohn L. Am J Gastroenterol 2013; 108:634–641;
Do carbohydrates produce symptoms in IBS?
Dairy
Grains
Fruits and Vegetables
Prevalence of Lactose Intolerance in IBS
38%
26%
IBS patients (n=251)
Controls (n=174)
Fructose and Fructans as Dietary Triggers
for IBS symptoms
*
Shepherd, et al, Clin Gastro Hepatol 2008;6:765
*
*
Very Low CHO Diet for IBS
SD
VLC
SD
VLC
• 15 females, mean age 46 yrs,
BMI 32
• Dietary interventions:
– 2 wks standard (55% CHO,
– 30% Fat, 15% Protein)
– 4 wks VLC (4% CHO, 51%
Fat, 45% Protein)
• Responder rate: 100%
• Improvements in stool
frequency
p<0.001),consistency
(p<0.001), pain (p<0.001),
QoL (p=0.02)
• Mean weight loss of 3.1 kg
Austin et al. Clin Gastro Hepatol 2009;7:706
Emerging Options for IBS
• Supplements
• Gut Microbiome
• Elimination Diets
What’s The Difference?
Food Allergy
• an adverse immune response to the proteins in a food; may
occur as the result of a humoral response (immunoglobulin E
[IgE] antibody), a cellular response (i.e. T cells), or both
Food Intolerance/sensitivity
• not a true food allergy: could be enzyme deficiency (e.g.
lactase deficiency), chemical reactions, aversion. May also
refer to IgG‐mediated reactions or other immune reactions to
food.
Food Allergy vs. Food Sensitivity
Food Allergy
•
•
•
•
•
Type I Hypersensitivity
IgE mediated
Immediate, rapid onset
Systemic, potentially life threatening
Shared Symptoms:
– Nausea, vomiting, diarrhea,
abdominal pain
• Different symptoms:
– Hives, tingling or itching in the
mouth, swelling of the lips, face,
tongue and throat, SOB, wheezing,
nasal congestion, anaphylaxis
Food Sensitivity
Type III hypersensitivity
IgG mediated
Gradual, delayed response
Localized, generally limited to the GI
tract
• Shared Symptoms:
•
•
•
•
– Nausea, vomiting, diarrhea,
abdominal pain
• Different symptoms:
– Gas, cramps, bloating, heartburn,
headaches, irritability, nervousness
Food Allergy vs. Food Sensitivity
Common Food Allergies:
• Dairy
• Eggs
• Wheat
• Soy
• Peanuts and tree Nuts
• Fish
• Chicken
• Corn
Lack G. NEJM.2008;359:1252
Common Food Sensitivities:
• Dairy
• Wheat
• Peanuts
• Tree Nuts
Exclusion-Based Diets
• Based on Food Hypersensitivity Testing
Dairy (IgG4, ALCAT, etc)
• Top 8 Food Allergens
• Carbs, Lactose, Fructose, FODMAPs,
Gluten
• Caffeine, Additives, Amines
• Elimination Diet
Studies of Elimination Diets
Evidence that elimination diets based on
IgG and IgE food antibodies have
shown benefit in IBS
Food elimination based on IgG antibodies in
irritable bowel syndrome: a randomized controlled
trial.
P<0.001
Level A
Atkinson, W et al. Gut 2004;53:1459-1464
Results of Studies of Immunoglobulin G (IgG)
Antibody-Elimination Diets for Irritable Bowel
Syndrome (IBS).
Mullin GE, Lipski L. et al. Nutr Clin Pract 2010;25:192-198
IgG Elimination Diet in Migraine + IBS
• 21 patients (85.7% women)
• IgG for 270 foods
• RCT/cross-over: usual diet, elimination and
provocation
• Elimination Diet
– < in attack duration, severity, # of migraines
– < pain-bloating severity,< occurrence,
– > QOL
Aydinlar EI. Headache. 2013 Mar;53(3):514-25.
A Spectrum of Disease With Overlap?
Gluten Sensitivity
Motility/Visceral
Brain-Gut Interactions
Neurological
Musculoskeletal pain
Altered Permeability?
IBS
Motility/Visceral Sensation
Brain-Gut Interactions
Immune activation
Altered Gut Microbiome
Altered Permeability
Celiac Disease
Motility/Visceral Sensation
Brain-Gut Interactions
Neurological
Immune activation
Altered Gut Microbiome
Altered Permeability
Non-Celiac Gluten Sensitivity
Celiac Disease
Allergic Rx
Gluten hypersensitivity Gluten Intolerance
Mild gluten sensitivity
Adapted from Verdu EF, et al. Am J Gastroenterol 2009;104:1587-94; &
Nijeboer P. J Gastrointestin Liver Dis, December 2013 Vol. 22 No 4: 435-440
• IBS patients received either gluten or placebo in the form of
two bread slices plus one muffin per day with a gluten-free
diet for up to 6 weeks.
• Symptoms were evaluated using a visual analog scale and
markers of intestinal inflammation, injury, and immune
activation were monitored.
• Non-celiac gluten sensitivity: 30%
Biesiekierski JR et al. Am J Gastro 2011 106 (3)508-514.
Gluten Induces Symptoms in IBS
• uncontrolled symptoms
– 13/19 (68%) gluten
– 6/15 (40%) placebo (P=0.0001)
• patients were significantly worse with
gluten within 1 week
overall symptoms (P=0.047)
pain (P=0.016)
bloating (P=0.031)
satisfaction with stool consistency
(P=0.024)
– tiredness (P=0.001)
–
–
–
–
Biesiekierski JR et al. Am J Gastro 2011 106 (3)508-514.
Non-Celiac Wheat Sensitivity in IBS:
A Distinct Clinical Condition
• IBS pts N=920
• IBS patients N=276
“gluten sensitivity” but
non-celiac
• 2 weeks on wheatcontaining diet
and
• 2 weeks on placebo
• Changes in symptom
severity over baseline
during DBPC wheat
challenge
Carroccio A. et al. Am J Gastroenterol 2012; 107:1898–1906
Diets For Microbiome Restoration
Specific carbohydrate diet
– Undigested carbohydrates feed “downstream” bacteria 
further dysbiosis
FODMAP Diet:
-- Low prebiotic, lactose, fructans, galactans, polyols
(fermentable oligo- and disaccharides, monosaccharides,
polyols)
Soluble fiber (e.g., modified citrus pectin, vegetable fibers)
– Paleolithic man consumed > 100 g fiber/day
– Increases beneficial short-chain fatty acids (SCFAs)
Fermented foods (e.g., Body Ecology Diet) – Restore and
maintain “inner ecology” through:
– Cultured foods
– Decreasing sugars and carbohydrates
Fermentable Oligosaccharides,
Disaccharides, Monosaccharides
and Polyols
• Family of poorly absorbed, short-chain carbohydrates
– Lactose
– Fructose
– Polyols
– Fructans
– Galactans (galacto-oliogsaccharides )
• Highly fermentable in the presence of gut bacteria
De Roest, Int J Clin Prac, 2013; Gibson, J Gastroenterol Hepatol, 2010; Gibson – Am J Gastroenterol, 2012:
Ong, et al, J Gastroenterol Hepatol, 2010; Staudacher J Hum Nutr Diet, 2011
FODMAP Fructose
Polyols
Lactose
Fructans and Galactans
High
FODMAP
food sources
Apples, pears,
watermelon,
honey, fruit
juices, dried
fruits, highfructose corn
syrup
Sugar alcohols
(sorbitol,
maltitol,
mannitol,
xylitol,
and isomalt),
stone fruits,
avocado,
mushrooms,
cauliflower
Milk (cow,
goat,
sheep),
yogurt, soft
cheeses
(ricotta,
cottage)
Wheat, rye, garlic, onions,
artichokes, asparagus, inulin,
soy, leeks, legumes, lentils,
cabbage, Brussels sprouts,
broccoli
Alternative
lower
FODMAP
food sources
Citrus, berries,
bananas,
grapes,
honeydew,
cantaloupe,
kiwifruit
Sweeteners,
such as sugar,
glucose, other
artificial
sweeteners not
ending in
“-ol” (Stevia)
Lactosefree dairy
products,
rice milk,
hard
cheeses
Starches, such as rice, corn,
potato, quinoa. Vegetables,
such as winter squash,
lettuce, spinach, cucumbers,
bell peppers, green beans,
tomato, eggplant
FODMAPs Elimination Approach
1. Eliminate all high FODMAPs foods from the diet for a
trial period of 2 - 6 weeks. FODMAPs food classes:
Lactose
Polyols
Fructose
Fructans
Galactooligosaccharides
2. Challenge - Add foods from one FODMAP class using a
small and then larger load and observe for symptoms –
continue through all categories
Catsos P. IBS—Free at Last! Portland, ME: Pond Cove Press; 2009, 2012; Shepherd SJ, Gibson PR.
Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary
management. J Am Diet Assoc. 2006;106:1631–1639.
62
Low FODMAP vs. Standard Diet for IBS
Staudacher HM, et al. J Hum Nutr Diet 2011
Baseline fecal bifidobacteria
concentration in IBS patients
compared with change in
bifidobacteria concentration
after 4 wk of fermentable
CHO restriction
Staudacher HM et al. J. Nutr. 142: 1510–1518, 2012.
Proportion of patients showing
improvement (%)
* p<0.05
*
*
*
*
Improvement of mean daily symptom score after 4 wk of habitual
diet (control) or fermentable CHO restriction (intervention)
Staudacher HM et al. J. Nutr. 142: 1510–1518, 2012.
Halmos et al Gastro Jan 2014;146:67-75.
Mean overall gastrointestinal symptoms from the (A) IBS cohort and the (B)
healthy cohort using a VAS during baseline, low FODMAP and typical
Australian diets. Symptoms improved significantly on low FODMAP compared
with baseline and the typical Australian diet for the IBS cohort. No
differences were observed between any of the diets in the healthy cohort
Mean symptoms of (A)
bloating, (B) abdominal
pain, and (C) passage of
wind from the IBS cohort
using a VAS while following
a typical Australian and low
FODMAP diet. Mean
dissatisfaction with stool
consistency in (D) IBS-D and
(E) IBS-C after 8–21 days of
typical Australian and low
FODMAP diets are
indicated with a bold line.
Symptoms were
significantly lower on low
FODMAP compared with a
typical Australian diet in all
measured symptoms
Bloating, Abdominal Pain, Dissatisfaction With Stool
Consistency, and Composite Scores of All Three Symptoms in
IBS and Healthy Participants While Following Low FODMAP and
Typical Australian Diets
Halmos et al Gastro Jan 2014;146:67-75.
Food Reactions and IBS Summary
• Patients with IBS-D/M should be screened for celiac
disease
• Expected US prevalence in IBS pts is ≤1% but likely varies
based upon population genetics
• Lactose intolerance may be more common in IBS
• Clinical implications of CHO intolerance may be different
in persons with than without IBS
• Food can affect GI function and sensation
• Mounting evidence suggests that dietary & lifestyle
interventions can improve symptoms in a subset of IBS
sufferers
British Dietetic Association IBS
Management Guidelines
Review study, 30 papers met inclusion criteria.
1. Remove milk and dairy products: lactose intolerance
2. Avoid wheat bran. Ground flax may be tried for 3
month trial for IBS-C.
3. Try low FODMAP diet and institute challenge of foods
to individualize plan
4. Probiotics: consider after FODMAP diet. Results vary,
so try one product at a time for 4 weeks.
5. Empirical and elimination diets:
– Initial phase 2-4 weeks
– Reevaluate
McKenzie Y.A. (2012) J Hum Nutr Diet. 25, 260-274
Figure 3. Proposed Algorithm for the Management of Suspected Food Intolerances in
the Irritable Bowel Syndrome (IBS). Mullin et al JPEN 2014 In Press
Nutritional Tools for Your IBS Patient
• Anti-anxiety Herbs
• Anti-microbials for
SIBO
• Artichoke leaf
extract
• Elimination Diet
• Soluble Fiber
• FODMAP restricted
diet/Carbohydrate
restricted diet
• Melatonin
• Peppermint Oil
• Probiotics
• Tumeric
Summary Evidence for the Complementary of Nutrition Therapies in the Irritable
Bowel Syndrome (IBS). Mullin et al JPEN 2014 In Press