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Evidence-Based Approach to Fiber Supplements and Clinically Meaningful Health Benefits, Part 2: What to Look for and How to Recommend an Effective Fiber Therapy. ACTA ACUST UNITED AC 2015; 50:90-97. [PMID: 25972619 PMCID: PMC4415970 DOI: 10.1097/nt.0000000000000089] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dietary fiber that is intrinsic and intact in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) is widely recognized to have beneficial effects on health when consumed at recommended levels (25 g/d for adult women, 38 g/d for adult men). Most (90%) of the US population does not consume this level of dietary fiber, averaging only 15 g/d. In an attempt to bridge this “fiber gap,” many consumers are turning to fiber supplements, which are typically isolated from a single source. Fiber supplements cannot be presumed to provide the health benefits that are associated with dietary fiber from whole foods. Of the fiber supplements on the market today, only a minority possess the physical characteristics that underlie the mechanisms driving clinically meaningful health benefits. In this 2-part series, the first part (previous issue) described the 4 main characteristics of fiber supplements that drive clinical efficacy (solubility, degree/rate of fermentation, viscosity, and gel formation), the 4 clinically meaningful designations that identify which health benefits are associated with specific fibers, and the gel-dependent mechanisms in the small bowel that drive specific health benefits (eg, cholesterol lowering, improved glycemic control). The second part (current issue) of this 2-part series will focus on the effects of fiber supplements in the large bowel, including the 2 mechanisms by which fiber prevents/relieves constipation (insoluble mechanical irritant and soluble gel-dependent water-holding capacity), the gel-dependent mechanism for attenuating diarrhea and normalizing stool form in irritable bowel syndrome, and the combined large bowel/small bowel fiber effects for weight loss/maintenance. The second part will also discuss how processing for marketed products can attenuate efficacy, why fiber supplements can cause gastrointestinal symptoms, and how to avoid symptoms for better long-term compliance.
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Balandrán-Quintana RR, Mercado-Ruiz JN, Mendoza-Wilson AM. Wheat Bran Proteins: A Review of Their Uses and Potential. FOOD REVIEWS INTERNATIONAL 2015. [DOI: 10.1080/87559129.2015.1015137] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Turnbull JL, Adams HN, Gorard DA. Review article: the diagnosis and management of food allergy and food intolerances. Aliment Pharmacol Ther 2015; 41:3-25. [PMID: 25316115 DOI: 10.1111/apt.12984] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 05/23/2014] [Accepted: 09/16/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND Adverse reactions to food include immune mediated food allergies and non-immune mediated food intolerances. Food allergies and intolerances are often confused by health professionals, patients and the public. AIM To critically review the data relating to diagnosis and management of food allergy and food intolerance in adults and children. METHODS MEDLINE, EMBASE and the Cochrane Database were searched up until May 2014, using search terms related to food allergy and intolerance. RESULTS An estimated one-fifth of the population believe that they have adverse reactions to food. Estimates of true IgE-mediated food allergy vary, but in some countries it may be as prevalent as 4-7% of preschool children. The most common food allergens are cow's milk, egg, peanut, tree nuts, soy, shellfish and finned fish. Reactions vary from urticaria to anaphylaxis and death. Tolerance for many foods including milk and egg develops with age, but is far less likely with peanut allergy. Estimates of IgE-mediated food allergy in adults are closer to 1-2%. Non-IgE-mediated food allergies such as Food Protein-Induced Enterocolitis Syndrome are rarer and predominantly recognised in childhood. Eosinophilic gastrointestinal disorders including eosinophilic oesophagitis are mixed IgE- and non-IgE-mediated food allergic conditions, and are improved by dietary exclusions. By contrast food intolerances are nonspecific, and the resultant symptoms resemble other common medically unexplained complaints, often overlapping with symptoms found in functional disorders such as irritable bowel syndrome. Improved dietary treatments for the irritable bowel syndrome have recently been described. CONCLUSIONS Food allergies are more common in children, can be life-threatening and are distinct from food intolerances. Food intolerances may pose little risk but since functional disorders are so prevalent, greater efforts to understand adverse effects of foods in functional disorders are warranted.
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Affiliation(s)
- J L Turnbull
- Department of Paediatrics, John Radcliffe Hospital, Headington, Oxford, UK
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Halmos EP, Christophersen CT, Bird AR, Shepherd SJ, Gibson PR, Muir JG. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut 2015; 64:93-100. [PMID: 25016597 DOI: 10.1136/gutjnl-2014-307264] [Citation(s) in RCA: 456] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE A low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols) diet reduces symptoms of IBS, but reduction of potential prebiotic and fermentative effects might adversely affect the colonic microenvironment. The effects of a low FODMAP diet with a typical Australian diet on biomarkers of colonic health were compared in a single-blinded, randomised, cross-over trial. DESIGN Twenty-seven IBS and six healthy subjects were randomly allocated one of two 21-day provided diets, differing only in FODMAP content (mean (95% CI) low 3.05 (1.86 to 4.25) g/day vs Australian 23.7 (16.9 to 30.6) g/day), and then crossed over to the other diet with ≥21-day washout period. Faeces passed over a 5-day run-in on their habitual diet and from day 17 to day 21 of the interventional diets were pooled, and pH, short-chain fatty acid concentrations and bacterial abundance and diversity were assessed. RESULTS Faecal indices were similar in IBS and healthy subjects during habitual diets. The low FODMAP diet was associated with higher faecal pH (7.37 (7.23 to 7.51) vs. 7.16 (7.02 to 7.30); p=0.001), similar short-chain fatty acid concentrations, greater microbial diversity and reduced total bacterial abundance (9.63 (9.53 to 9.73) vs. 9.83 (9.72 to 9.93) log10 copies/g; p<0.001) compared with the Australian diet. To indicate direction of change, in comparison with the habitual diet the low FODMAP diet reduced total bacterial abundance and the typical Australian diet increased relative abundance for butyrate-producing Clostridium cluster XIVa (median ratio 6.62; p<0.001) and mucus-associated Akkermansia muciniphila (19.3; p<0.001), and reduced Ruminococcus torques. CONCLUSIONS Diets differing in FODMAP content have marked effects on gut microbiota composition. The implications of long-term reduction of intake of FODMAPs require elucidation. TRIAL REGISTRATION NUMBER ACTRN12612001185853.
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Affiliation(s)
- Emma P Halmos
- Department of Gastroenterology, Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claus T Christophersen
- Food Futures National Research Flagship, Commonwealth Scientific and Industrial Research Organisation, Food, Animal and Health Sciences, Adelaide, South Australia, Australia
| | - Anthony R Bird
- Food Futures National Research Flagship, Commonwealth Scientific and Industrial Research Organisation, Food, Animal and Health Sciences, Adelaide, South Australia, Australia
| | - Susan J Shepherd
- Department of Gastroenterology, Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jane G Muir
- Department of Gastroenterology, Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia Department of Gastroenterology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Furnari M, de Bortoli N, Martinucci I, Bodini G, Revelli M, Marabotto E, Moscatelli A, Del Nero L, Savarino E, Giannini EG, Savarino V. Optimal management of constipation associated with irritable bowel syndrome. Ther Clin Risk Manag 2015; 11:691-703. [PMID: 26028974 PMCID: PMC4425337 DOI: 10.2147/tcrm.s54298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a common chronic functional disorder of the gastrointestinal tract, meanly characterized by recurrent abdominal pain or discomfort and altered bowel habit. It is a complex disorder involving biological, environmental, and psychosocial factors. The diagnosis is achieved according to the Rome III criteria provided that organic causes have been excluded. Although IBS does not constitute a life-threatening condition, it has a remarkable prevalence and profoundly reduces the quality of life with burdening socioeconomic costs. One of the principal concerns about IBS is the lack of effective therapeutic options. Up to 40% of patients are not satisfied with any available medications, especially those suffering from chronic constipation. A correct management of IBS with constipation should evolve through a global approach focused on the patient, starting with careful history taking in order to assess the presence of organic diseases that might trigger the disorder. Therefore, the second step is to examine lifestyle, dietary habits, and psychological status. On these bases, a step-up management of disease is recommended: from fiber and bulking agents, to osmotic laxative drugs, to new molecules like lubiprostone and linaclotide. Although new promising tools for relief of bowel-movement-related symptoms are being discovered, a dedicated doctor-patient relationship still seems to be the key for success.
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Affiliation(s)
- Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
- Correspondence: Manuele Furnari, Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Viale Benedetto XV, 6, 16132 Genoa, Italy, Tel +39 010 353 8956, Fax +39 010 353 8956, Email
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Irene Martinucci
- Division of Gastroenterology, Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Matteo Revelli
- Department of Radiology, San Bartolomeo Hospital, Sarzana, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Alessandro Moscatelli
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Lorenzo Del Nero
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Edoardo G Giannini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Raskov H, Pommergaard HC, Burcharth J, Rosenberg J. Colorectal carcinogenesis-update and perspectives. World J Gastroenterol 2014; 20:18151-18164. [PMID: 25561783 PMCID: PMC4277953 DOI: 10.3748/wjg.v20.i48.18151] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 08/18/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is a very common malignancy in the Western World and despite advances in surgery, chemotherapy and screening, it is still the second leading cause of cancer deaths in this part of the world. Numerous factors are found important in the development of CRC including colonocyte metbolism, high risk luminal environment, inflammation, as well as lifestyle factors such as diet, tobacco, and alchohol consumption. In recent years focus has turned towards the genetics and molecular biology of CRC and several interesting and promising correlations and pathways have been discovered. The major genetic pathways of CRC are the Chromosome Instability Pathway representing the pathway of sporadic CRC through the K-ras, APC, and P53 mutations, and the Microsatellite Instability Pathway representing the pathway of hereditary non-polyposis colon cancer through mutations in mismatch repair genes. To identify early cancers, screening programs have been initiated, and the leading strategy has been the use of faecal occult blood testing followed by colonoscopy in positive cases. Regarding the treatment of colorectal cancer, significant advances have been made in the recent decade. The molecular targets of CRC include at least two important cell surface receptors: the epidermal growth factor receptor and the vascular endothelial growth factor receptor. The genetic and molecular knowledge of CRC has widen the scientific and clinical perspectives of diagnosing and treatment. However, despite significant advances in the understanding and treatment of CRC, results from targeted therapy are still not convincing. Future studies will determine the role for this new treatment modality.
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Abstract
Chronic constipation is a very common disease in children. Successful treatment of constipation can be achieved not only with medication but also with lifestyle changes, including a proper diet. Diets including fruits, fluids, and probiotics are good for constipation. Some dietary components are helpful for constipation, and some are harmful. In this study, we present diets related to constipation from the literature, and propose some perspectives regarding diets related to constipation.
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Affiliation(s)
- Sun Hwan Bae
- Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea
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258
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Pedersen N, Andersen NN, Végh Z, Jensen L, Ankersen DV, Felding M, Simonsen MH, Burisch J, Munkholm P. Ehealth: Low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome. World J Gastroenterol 2014; 20:16215-16226. [PMID: 25473176 PMCID: PMC4239510 DOI: 10.3748/wjg.v20.i43.16215] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/14/2014] [Accepted: 07/25/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effects of a low fermentable, oligosaccharides, disaccharides, monosaccharides and polyols diet (LFD) and the probiotic Lactobacillus rhamnosus GG (LGG) in irritable bowel syndrome (IBS).
METHODS: Randomised, unblinded controlled trial on the effect of 6-wk treatment with LFD, LGG or a normal Danish/Western diet (ND) in patients with IBS fulfilling Rome III diagnostic criteria, recruited between November 2009 and April 2013. Patients were required to complete on a weekly basis the IBS severity score system (IBS-SSS) and IBS quality of life (IBS-QOL) questionnaires in a specially developed IBS web self-monitoring application. We investigated whether LFD or LGG could reduce IBS-SSS and improve QOL in IBS patients.
RESULTS: One hundred twenty-three patients (median age 37 years, range: 18-74 years), 90 (73%) females were randomised: 42 to LFD, 41 to LGG and 40 to ND. A significant reduction in mean ± SD of IBS-SSS from baseline to week 6 between LFD vs LGG vs ND was revealed: 133 ± 122 vs 68 ± 107, 133 ± 122 vs 34 ± 95, P < 0.01. Adjusted changes of IBS-SSS for baseline covariates showed statistically significant reduction of IBS-SSS in LFD group compared to ND (IBS-SSS score 75; 95%CI: 24-126, P < 0.01), but not in LGG compared to ND (IBS-SSS score 32; 95%CI: 18-80, P = 0.20). IBS-QOL was not altered significantly in any of the three groups: mean ± SD in LFD 8 ± 18 vs LGG 7 ± 17, LFD 8 ± 18 vs ND 0.1 ± 15, P = 0.13.
CONCLUSION: Both LFD and LGG are efficatious in patients with IBS.
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259
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Huamán JW, Felip A, Guedea E, Jansana M, Videla S, Saperas E. [The diet low in fermentable carbohydrates short chain and polyols improves symptoms in patients with functional gastrointestinal disorders in Spain]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 38:113-22. [PMID: 25458546 DOI: 10.1016/j.gastrohep.2014.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Revised: 08/18/2014] [Accepted: 08/27/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Successful treatment of patients with irritable bowel syndrome (IBS) often remains elusive. Recent studies in Australia, the United Kingdom and New Zealand have suggested the efficacy of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) in the management of these patients. The aims of this study were to determine whether a diet low in FODMAPs improves symptoms in patients with functional gastrointestinal disorders (FGID) in Spain and to analyze the predictors of a good response. PATIENTS AND METHODS A prospective study was carried out in consecutive patients with FGID type IBS and functioanl abdominal bloating. At inclusion all patients underwent an assessment through a baseline demographic questionnaire of symptoms of anxiety and depression and quality of life. A hydrogen breath test with lactose and fructose was performed and a low FODMAPs diet was indicated for 2 months by expert dietitians. These tests were taken as a reference. A positive response was defined as an improvement of at least 5 points out of a possible 10 in the symptom questionnaire. RESULTS We included 30 patients (24 women, 39 [12] years). The response to the low FODMAPs diet was positive in controlling overall symptoms and specific symptoms such as functioanl abdominal bloating, abdominal pain, diarrhea, flatulence, nausea and fatigue in more than 70% of patients (P<.05). By contrast, constipation was controlled in only 48% of patients (P>.05). Adherence to the diet was good in 87% of patients and was a predictor of positive response in the univariate analysis. CONCLUSIONS A diet low in FODMAPs is associated with symptom improvement in patients with IBS and functioanl abdominal bloating. Adherence to the diet was a determining factor.
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Affiliation(s)
- José Wálter Huamán
- Servicio de Aparato Digestivo, Hospital General de Catalunya, Universidad Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, España
| | - Ana Felip
- Servicio de Endocrinología, Hospital General de Catalunya, Sant Cugat del Vallès, Barcelona, España
| | - Elena Guedea
- Servicio de Endocrinología, Hospital General de Catalunya, Sant Cugat del Vallès, Barcelona, España
| | - Marta Jansana
- Servicio de Endocrinología, Hospital General de Catalunya, Sant Cugat del Vallès, Barcelona, España
| | - Sebastián Videla
- Departamento de Ciencias Experimentales y de la Salud, Facultad de Ciencias de la Salud y de la Vida, Universitat Pompeu Fabra, Barcelona, España
| | - Esteban Saperas
- Servicio de Aparato Digestivo, Hospital General de Catalunya, Universidad Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, España.
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Abstract
PURPOSE OF REVIEW Irritable bowel syndrome (IBS) is a condition affecting approximately 10-15% of Western populations. The Rome III criteria are applied to many studies to validate the diagnosis of IBS. The low fermentable oligo, di, monosaccharides and polyol (FODMAP) diet has been the subject of many robust clinical trials and is now used as the primary dietary therapy internationally. This review examines the current evidence for the role of the low FODMAP diet in IBS. RECENT FINDINGS Detailed commentary on original research involving FODMAPs and IBS symptoms from 2013 to 2014 is provided. SUMMARY The low FODMAP diet has been shown to be an efficacious therapy for reduction of functional gastrointestinal symptoms seen in IBS. Recent publications provide randomized controlled trial and prospective observational evidence in support of the diet for symptom management. The low FODMAP diet appears to be superior to a gluten-free diet in people with self-reported nonceliac gluten sensitivity. Although the low FODMAP diet has not been shown to reduce the prebiotic effect in the colon, total colonic bacterial load was reduced. Further research investigating the potential health implications of both this and the nutritional adequacy of the liberalized low FODMAP diet is required.
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Affiliation(s)
- Susan J Shepherd
- aDepartment of Dietetics and Human Nutrition, La Trobe University, Bundoora bShepherd Works P/L, Box Hill North cDepartment of Gastroenterology, Northern Hospital, Epping, Victoria, Australia
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261
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Park KS. [Can low FODMAP diet be considered as first-line therapy in the management of irritable bowel syndrome?]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2014; 64:311-314. [PMID: 25581942 DOI: 10.4166/kjg.2014.64.5.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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262
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The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis. Am J Gastroenterol 2014; 109:1367-74. [PMID: 25070054 DOI: 10.1038/ajg.2014.195] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/03/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Fiber has been used for many years to treat irritable bowel syndrome (IBS). This approach had fallen out of favor until a recent resurgence, which was based on new randomized controlled trial (RCT) data that suggested it might be effective. We have previously conducted a systematic review of fiber in IBS, but new RCT data for fiber therapy necessitate a new analysis; thus, we have conducted a systematic review of this intervention. METHODS MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched up to December 2013. Trials recruiting adults with IBS, which compared fiber supplements with placebo, control therapy, or "usual management", were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy as well as number needed to treat (NNT) with a 95% confidence interval (CI). RESULTS We identified 14 RCTs involving 906 patients that had evaluated fiber in IBS. There was a significant benefit of fiber in IBS (RR=0.86; 95% CI 0.80-0.94 with an NNT=10; 95% CI=6-33). There was no significant heterogeneity between results (I(2)=0%, Cochran Q=13.85 (d.f.=14), P=0.46). The benefit was only seen in RCTs on soluble fiber (RR=0.83; 95% CI 0.73-0.94 with an NNT=7; 95% CI 4-25) with no effect seen with bran (RR=0.90; 95% CI 0.79-1.03). CONCLUSIONS Soluble fiber is effective in treating IBS. Bran did not appear to be of benefit, although we did not uncover any evidence of harm from this intervention, as others have speculated from uncontrolled data.
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263
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Vanuytsel T, Tack JF, Boeckxstaens GE. Treatment of abdominal pain in irritable bowel syndrome. J Gastroenterol 2014; 49:1193-205. [PMID: 24845149 DOI: 10.1007/s00535-014-0966-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 04/20/2014] [Indexed: 02/04/2023]
Abstract
Functional abdominal pain in the context of irritable bowel syndrome (IBS) is a challenging problem for primary care physicians, gastroenterologists and pain specialists. We review the evidence for the current and future non-pharmacological and pharmacological treatment options targeting the central nervous system and the gastrointestinal tract. Cognitive interventions such as cognitive behavioral therapy and hypnotherapy have demonstrated excellent results in IBS patients, but the limited availability and labor-intensive nature limit their routine use in daily practice. In patients who are refractory to first-line therapy, tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors are both effective to obtain symptomatic relief, but only TCAs have been shown to improve abdominal pain in meta-analyses. A diet low in fermentable carbohydrates and polyols (FODMAP) seems effective in subgroups of patients to reduce abdominal pain, bloating, and to improve the stool pattern. The evidence for fiber is limited and only isphagula may be somewhat beneficial. The efficacy of probiotics is difficult to interpret since several strains in different quantities have been used across studies. Antispasmodics, including peppermint oil, are still considered the first-line treatment for abdominal pain in IBS. Second-line therapies for diarrhea-predominant IBS include the non-absorbable antibiotic rifaximin and the 5HT3 antagonists alosetron and ramosetron, although the use of the former is restricted because of the rare risk of ischemic colitis. In laxative-resistant, constipation-predominant IBS, the chloride-secretion stimulating drugs lubiprostone and linaclotide, a guanylate cyclase C agonist that also has direct analgesic effects, reduce abdominal pain and improve the stool pattern.
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Affiliation(s)
- Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, O&N1, Box 701, Herestraat 49, 3000, Louvain, Belgium
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264
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Eswaran S, Guentner A, Chey WD. Emerging Pharmacologic Therapies for Constipation-predominant Irritable Bowel Syndrome and Chronic Constipation. J Neurogastroenterol Motil 2014; 20:141-51. [PMID: 24840367 PMCID: PMC4015201 DOI: 10.5056/jnm.2014.20.2.141] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/07/2013] [Accepted: 11/20/2013] [Indexed: 12/15/2022] Open
Abstract
Irritable bowel syndrome with constipation and chronic functional constipation are common digestive disorders that negatively impact quality of life and account for billions of dollars in health care costs. Related to the heterogeneity of pathogenesis that underlie these disorders and the failure of symptoms to reliably predict underlying pathophysiology, traditional therapies provide relief to only a subset of affected individuals. The evidence surrounding new and emerging pharmacologic treatments, which include both luminally and systemically acting drugs, is discussed here. These include agents such as lubiprostone, bile acid modulations, guanylate cyclase-C receptor agonists, serotonin receptor modulators and herbal therapies.
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Affiliation(s)
- Shanti Eswaran
- University of Michigan Health System, Ann Arbor, MI, USA
| | | | - William D Chey
- University of Michigan Health System, Ann Arbor, MI, USA
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265
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Gibson PR, Barrett JS, Muir JG. Functional bowel symptoms and diet. Intern Med J 2014; 43:1067-74. [PMID: 24134168 DOI: 10.1111/imj.12266] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/03/2013] [Indexed: 12/17/2022]
Abstract
It is well recognised that ingestion of food is a trigger for functional bowel symptoms, particularly those associated with irritable bowel syndrome (IBS). Patients often use manipulation of diet as a means of controlling symptoms. Despite description of multiple dietary methods, few have scientific backing or quality evidence of efficacy. One approach is to define how specific food components influence the pathophysiology of IBS and then rationally design dietary approaches. For example, short-chain poorly absorbed carbohydrates (fermentable oligo-, di- and mono-saccharides and polyols (FODMAP)) cause luminal distension, which is a major stimulus for the development of symptoms in patients with visceral hypersensitivity. By determining food content of FODMAP, a diet in which foods low in FODMAP are favoured over those high in FODMAP can be designed. Observational, comparative and randomised controlled treatment and rechallenge studies have shown that such an approach is efficacious in the majority of patients with IBS. The low FODMAP diet is now the primary dietary therapy for such patients. Similar approaches can be applied to other food components, including proteins (such as gluten), fats and natural bioactive food chemicals. Such approaches have suggestions of efficacy, but the evidence base remains underdeveloped. An additional and important consideration for any dietary therapy is its nutritional adequacy and potential adverse health effects. Dietary manipulation is now a key management strategy in patients with functional bowel symptoms. Future well-designed interventional studies will lead to refinement of dietary approaches taken and to a better understanding of their long-term safety.
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Affiliation(s)
- P R Gibson
- Department of Gastroenterology, Monash University and Alfred Hospital, Melbourne, Victoria, Australia
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266
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McElhanon BO, McCracken C, Karpen S, Sharp WG. Gastrointestinal symptoms in autism spectrum disorder: a meta-analysis. Pediatrics 2014; 133:872-83. [PMID: 24777214 DOI: 10.1542/peds.2013-3995] [Citation(s) in RCA: 433] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In pediatric settings, parents often raise concerns about possible gastrointestinal (GI) symptoms in autism spectrum disorder (ASD), yet the specificity of these concerns are not well studied. OBJECTIVE To conduct a meta-analysis of research investigating GI symptoms among children with ASD. METHODS We searched Medline, PsycINFO, and PubMed databases (1980-2012) in peer-reviewed journals. Analysis involved studies with a comparison group presenting quantitative data on GI symptoms using combinations of terms for ASD and GI indicators. The systematic search yielded 15 studies. We calculated effect sizes and 95% confidence intervals (CIs) using a random-effects model. RESULTS Children with ASD experience significantly more general GI symptoms than comparison groups, with a standardized mean difference of 0.82 (0.24) and a corresponding odds ratio (OR) of 4.42 (95% CI, 1.90-10.28). Analysis also indicated higher rates of diarrhea (OR, 3.63; 95% CI, 1.82-7.23), constipation (OR, 3.86; 95% CI, 2.23-6.71), and abdominal pain (OR, 2.45; 95% CI, 1.19-5.07). CONCLUSIONS Results indicate greater prevalence of GI symptoms among children with ASD compared with control children. Identified studies involved high methodological variability and lack of comprehensive data prohibited analysis of GI pathophysiologies (eg, gastroesophageal reflux) typically associated with organic etiologies, limiting conclusions about the underpinnings of the observed association. Future research must address critical questions about the causes and long-term impact of GI symptoms in ASD. Such analyses will require more systematic research and clinical activities, including improved diagnostic screening, standardized assessment, and exploration of potential moderators (eg, dietary restrictions).
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Affiliation(s)
- Barbara O McElhanon
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and
| | - Saul Karpen
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and
| | - William G Sharp
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and Marcus Autism Center, Atlanta, Georgia
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267
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Staudacher HM, Irving PM, Lomer MCE, Whelan K. Mechanisms and efficacy of dietary FODMAP restriction in IBS. Nat Rev Gastroenterol Hepatol 2014; 11:256-66. [PMID: 24445613 DOI: 10.1038/nrgastro.2013.259] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IBS is a debilitating condition that markedly affects quality of life. The chronic nature, high prevalence and associated comorbidities contribute to the considerable economic burden of IBS. The pathophysiology of IBS is not completely understood and evidence to guide management is variable. Interest in dietary intervention continues to grow rapidly. Ileostomy and MRI studies have demonstrated that some fermentable carbohydrates increase ileal luminal water content and breath hydrogen testing studies have demonstrated that some carbohydrates also increase colonic hydrogen production. The effects of fermentable carbohydrates on gastrointestinal symptoms have also been well described in blinded, controlled trials. Dietary restriction of fermentable carbohydrates (popularly termed the 'low FODMAP diet') has received considerable attention. An emerging body of research now demonstrates the efficacy of fermentable carbohydrate restriction in IBS; however, limitations still exist with this approach owing to a limited number of randomized trials, in part due to the fundamental difficulty of placebo control in dietary trials. Evidence also indicates that the diet can influence the gut microbiota and nutrient intake. Fermentable carbohydrate restriction in people with IBS is promising, but the effects on gastrointestinal health require further investigation.
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Affiliation(s)
- Heidi M Staudacher
- King's College London, School of Medicine, Diabetes and Nutritional Sciences Division, Franklin Wilkins Building, 150 Stamford Street, London SE1 9NH, UK
| | - Peter M Irving
- Guys and St Thomas NHS Foundation Trust, Department of Gastroenterology, College House, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Miranda C E Lomer
- Guys and St Thomas NHS Foundation Trust, Department of Gastroenterology, College House, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Kevin Whelan
- King's College London, School of Medicine, Diabetes and Nutritional Sciences Division, Franklin Wilkins Building, 150 Stamford Street, London SE1 9NH, UK
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268
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Wedlake L, Slack N, Andreyev HJN, Whelan K. Fiber in the treatment and maintenance of inflammatory bowel disease: a systematic review of randomized controlled trials. Inflamm Bowel Dis 2014; 20:576-86. [PMID: 24445775 DOI: 10.1097/01.mib.0000437984.92565.31] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Dietary fiber may favorably influence fermentation, gastrointestinal inflammation, and disease progression in Crohn's disease, ulcerative colitis (UC), and pouchitis and offer an attractive therapeutic addition to pharmacological treatment. This systematic review appraised data from randomized controlled trials of fiber in the management of inflammatory bowel disease. METHODS The review followed Cochrane and PRISMA recommendations. Seven electronic databases were searched along with hand searching and contacting experts. Inclusion criteria were randomized controlled trials of the effects of fiber on clinical endpoints (primarily disease activity for treatment or maintenance) or physiological outcomes in patients with inflammatory bowel disease. RESULTS In total, 23 randomized controlled trials fulfilled the inclusion criteria (UC, 10; Crohn's disease, 12; and pouchitis, 1) recruiting 1296 patients. In UC, 3/10 studies reported fiber supplementation to benefit disease outcomes. In Crohn's disease, 0/12 studies and in pouchitis 1/1 study reported a benefit on disease activity. Despite this, a number of studies reported favorable intragroup effects on physiological outcomes including fecal butyrate, fecal calprotectin, inflammatory cytokines, microbiota, and gastrointestinal symptom indices. Meta-analysis was not possible. CONCLUSIONS There is limited weak evidence for the efficacy of fiber in improving disease outcomes in UC and pouchitis. The potential antiinflammatory role of fiber is intriguing and merits further investigation in adequately powered clinical trials. Excluding overt gastrointestinal obstruction, there was no evidence that fiber intake should be restricted in patients with inflammatory bowel disease.
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Affiliation(s)
- Linda Wedlake
- *Department of Nutrition and Dietetics, The Royal Marsden NHS Foundation Trust, London, United Kingdom; †Diabetes and Nutritional Sciences Division, School of Medicine, King's College London, London, United Kingdom; and ‡Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Kim JH, Sung IK. Current Issues on Irritable Bowel Syndrome: Diet and Irritable Bowel Syndrome. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 64:142-7. [DOI: 10.4166/kjg.2014.64.3.142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jeong Hwan Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - In-Kyung Sung
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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270
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Affiliation(s)
- Anne M. Birkett
- The Kellogg Company, Battle Creek, MI, U.S.A
- Corresponding author
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271
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Is Gluten a Cause of Gastrointestinal Symptoms in People Without Celiac Disease? Curr Allergy Asthma Rep 2013; 13:631-8. [DOI: 10.1007/s11882-013-0386-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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272
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