Food Avoidance and Restriction in Irritable Bowel Syndrome: Relevance for Symptoms, Quality of Life and Nutrient Intake

Irritable bowel syndrome: When food is a pain in the gut

Irritable bowel syndrome (IBS) is a chronic gastrointestinal condition associated with altered bowel habits and recurrent abdominal pain, often triggered by food intake. Current treatments focus on improving stool pattern, but effective treatments for pain in IBS are still lacking due to our limited understanding of pathophysiological mechanisms. Visceral hypersensitivity (VHS), or abnormal visceral pain perception, underlies abdominal pain development in IBS, and mast cell activation has been shown to play an important role in the development of VHS. Our work recently revealed that abdominal pain in response to food intake is induced by the sensitization of colonic pain-sensing neurons by histamine produced by activated mast cells following a local IgE response to food. In this review, we summarize the current knowledge on abdominal pain and VHS pathophysiology in IBS, we outline the work leading to the discovery of the role of histamine in abdominal pain, and we introduce antihistamines as a novel treatment option to manage chronic abdominal pain in patients with IBS.

Management of abdominal bloating and distension, from subjective to objective

Abdominal distension is a clinical occurrence that involves a measurable, objective increase in abdominal circumference, which patients report as feeling like pregnant or like having a balloon inside the abdomen. This sign is often preceded by a subjective feeling of abdominal heaviness or bloating, reported as the sensation of having a huge amount of gas trapped inside. These manifestations are highly prevalent and may reflect on their own a gut-brain axis condition, such as functional abdominal distension, or be part of other disorders such as functional dyspepsia or irritable bowel syndrome (IBS). The prevalence of abdominal distension and bloating is 3.5 %. However, when associated with other gut-brain axis disorders such as dyspepsia or IBS, prevalence grows above 50 %. The etiology and pathophysiology of abdominal bloating and distension are highly complex and represent a challenge for both the practitioner and the patient. The patient often associates these sensations with trapped gas, and attributes them to some food intolerance, hence he/she adopts a highly restrictive diet that fails to resolve distension while incurring the risk of nutritional deficiencies or secondary dysbiosis, making a directed treatment guideline necessary.

Gut microbiota and intestinal immunity-A crosstalk in irritable bowel syndrome

Irritable bowel syndrome (IBS), one of the most prevalent functional gastrointestinal disorders, is characterized by recurrent abdominal pain and abnormal defecation habits, resulting in a severe healthcare burden worldwide. The pathophysiological mechanisms of IBS are multi-factorially involved, including food antigens, visceral hypersensitivity reactions, and the brain-gut axis. Numerous studies have found that gut microbiota and intestinal mucosal immunity play an important role in the development of IBS in crosstalk with multiple mechanisms. Therefore, based on existing evidence, this paper elaborates that the damage and activation of intestinal mucosal immunity and the disturbance of gut microbiota are closely related to the progression of IBS. Combined with the application prospect, it also provides references for further in-depth exploration and clinical practice.

The Microbiome and Irritable Bowel Syndrome: An Emerging Hope for Treatment

Irritable bowel syndrome is a gastrointestinal disorder that affects 15%-20% of the US population. Its symptoms can have negative effects on a person's quality of life, and its treatment can be associated with high medical costs. An emerging area of irritable bowel syndrome research concerns the relationship between this condition and the gut microbiome. The purpose of this article is not only to review irritable bowel syndrome, and the role that the microbiome can play in its symptoms, but also to examine new emerging pathways that could blaze the trail for more individualized treatments. If equipped with this knowledge, gastrointestinal nurses and providers of care can be better prepared to help patients with irritable bowel syndrome in order to manage symptoms and improve their quality of life.

Comprehensive Assessment of Nutrition and Dietary Influences in Hypermobile Ehlers-Danlos Syndrome-A Cross-Sectional Study

INTRODUCTION

Disorders of gut-brain interaction (DGBI) are common in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorder (hEDS/HSD). Food is a known trigger for DGBI symptoms, which often leads to dietary alterations and, increasingly, nutrition support. We aimed to explore dietary behaviors and influencing factors in patients with hEDS/HSD.

METHODS

In a cross-sectional study, patients with hEDS/HSD were recruited from Ehlers-Danlos Support UK (nontertiary) and tertiary neurogastroenterology clinics to complete questionnaires characterizing the following: dietary behaviors, nutrition support, DGBI (Rome IV), gastrointestinal symptoms, anxiety, depression, avoidant restrictive food intake disorder (ARFID), mast cell activation syndrome, postural tachycardia syndrome (PoTS), and quality of life. We used stepwise logistic regression to ascertain which factors were associated with dietary behaviors and nutrition support.

RESULTS

Of 680 participants (95% female, median age 39 years), 62.1% altered their diet in the last year and 62.3% regularly skipped meals. Altered diet was associated with the following: reflux symptoms ( P < 0.001), functional dyspepsia ( P = 0.008), reported mast cell activation syndrome ( P < 0.001), and a positive screen for ARFID, specifically fear of eating and low interest ( P < 0.001). Approximately 31.7% of those who altered their diet required nutrition support. The strongest predictor of requiring nutrition support was a positive screen for ARFID, specifically fear of eating (OR: 4.97, 95% CI: 2.09-11.8, P < 0.001).

DISCUSSION

Altered diet is very common in the patients with hEDS/HSD we studied and influenced by functional dyspepsia, reflux symptoms, and ARFID. Those with ARFID have a 4-fold increased risk of requiring nutrition support, and therefore, it is paramount that psychological support is offered in parallel with dietary support in the management of DGBI in hEDS/HSD.

Translation of the nine item avoidant/restrictive food intake disorder screen (NIAS) questionnaire in French (NIAS-Fr)

BACKGROUND

The Nine Item Avoidant/Restrictive Food Intake Disorder (ARFID) Screen (NIAS) questionnaire is originally available in English. Given the significant overlap of ARFID-like symptoms in gastrointestinal (GI) diseases, ARFID screening becomes crucial in these patient populations. Consequently, the translation of the NIAS questionnaire into French is necessary for its utilization in French-speaking countries.

METHODS

Clinical experts in neuro-gastroenterology and dietetics from four medical centres in two French-speaking countries (France and Belgium) took part in a well-structured questionnaire translation procedure. This process involved six steps before final approval: translation from English to French, backward translation, comparison between the original and retranslated versions, testing the translated version on patients, making corrections based on patient feedback, and testing the corrected version on an additional sample of patients.

KEY RESULTS

The NIAS questionnaire in French (NIAS-Fr) was tested on 18 outpatients across the involved centres. For the majority of native French-speaking patients, the translated questionnaire was well understood and clear. After incorporating two relevant modifications suggested by the patients, the translated questionnaire was approved through testing on an additional sample of patients.

CONCLUSIONS AND INFERENCES

The involvement of two French-speaking countries was crucial for the harmonization and cultural adaptation of the questionnaire. As a result, the NIAS-Fr is now available for use in 54 French-speaking countries, serving approximately 321 million French speakers across five continents for screening ARFID, for both clinical and research purposes.

Effect of Prolong-life-with-nine-turn-method (Yan Nian Jiu Zhuan) Qigong on fatigue and gastrointestinal function in patients with chronic fatigue syndrome: Study protocol for a randomized controlled trial

INTRODUCTION

Chronic fatigue syndrome (CFS) is a physical and mental disorder in which long-term fatigue is the main symptom. CFS patients are often accompanied by functional gastrointestinal diseases (FGIDs), which lead to decreased quality of life and increased fatigue. Prolong-life-with-nine-turn-method (PLWNT) is a kind of physical and mental exercise. Its operation includes adjusting the mind, breathing and cooperating with eight self-rubbing methods and one upper body rocking method. PLWNT was used to improve the digestive function in ancient China and to treat FGIDs such as functional dyspepsia and irritable bowel syndrome in modern times. Previous studies have shown that PLWNT can reduce fatigue in patients with CFS. But it is unclear whether the effect of PLWNT on CFS fatigue is related to gastrointestinal function. The aim of this study was to explore the relationship between PLWNT and fatigue and gastrointestinal function in patients with CFS.

METHODS

This study is a non-inferiority randomized controlled trial (RCT). The whole study period is 38 weeks, including 2 weeks of baseline evaluation, 12 weeks of intervention and 6 months of follow-up. Ninety-six CFS patients will be stratified random assigned to the intervention group (PLWNT) and the control group (cognitive behavior treatment) in the ratio of 1:1 through the random number table generated by SPSS. In the evaluation of results, Multidimensional Fatigue Inventory-20 (MFI-20), Gastrointestinal Symptom Rating Scale (GSRS), Bristol Stool Form Scale (BSFS), and Short Form 36 item health survey (SF-36) will be evaluated at week 0 (baseline), week 6 (midterm), week 12 (endpoint) and month 9 (follow up). The intestinal flora will be evaluated at week 0 (baseline) and week 12 (endpoint). The data results will be processed by statistical experts. The data analysis will be based on the intention to treat principle and per-protocol analysis. In the efficacy evaluation, repeated measurement analysis of variance will be used for data conforming to normal distribution or approximate normal distribution. The data which do not conform to the analysis of repeated measurement variance will be analyzed by the generalized estimation equation Linear discriminant analysis will be used to clarify the difference species of intestinal flora. The significance level sets as 5%. The safety of interventions will be evaluated after each treatment session.

DISCUSSION

This trial will provide evidence to PLWNT exerting positive effects on fatigue and gastrointestinal function of CFS. It will further explore whether the improvement of PLWNT on CFS fatigue is related to gastrointestinal function.

TRIAL REGISTRATION

The trial was registered at Chinese Clinical Trial Registry http://www.chictr.org.cn/showproj.aspx?proj=151456 (Registration No.: ChiCTR2200056530). Date: 2022-02-07.

Gluten restriction in irritable bowel syndrome, yes or no?: a GRADE-assessed systematic review and meta-analysis

Background

More than half of patients with irritable bowel syndrome (IBS) report aggravating their symptoms with certain foods. Currently, Low fermentable oligo-, di-, and monosaccharides and polyols diet (LFD) is the most accepted dietary intervention for IBS. Recent randomized controlled trials (RCTs) have been suggested that gluten restriction may reduce the symptoms of patients with IBS. However, the results from these studies are conflicting. This study filled this knowledge gap by evaluating the impact of the gluten-free diet (GFD) on IBS symptoms.

Methods

A systematic search was carried out in Pubmed/Medline, Cochrane CENTRAL, Scopus, and Web of Science up to April 2023. A random-effect model was applied to estimate the standardized mean difference (SMD) and 95% confidence interval (95% CI) for each outcome.

Results

A total of nine controlled trials were included in the meta-analysis. In contrast to gluten-containing diet, GFD was unable to reduce overall symptoms (SMD - 0.31; 95% CI -0.92, 0.31), bloating (SMD -0.37; 95% CI -1.03, 0.30), and quality of life (SMD -0.12, 95% CI -0.64, 0.39); but had a slight trend to reduce abdominal pain (SMD -0.68; 95% CI -1.36, -0.00). Also, LFD significantly reduced the IBS-Severity score system (SMD 0.66, 95% CI 0.31, 1.01) and improved quality of life (SMD -0.36, 95% CI -0.70, -0.01), compared to GFD.

Conclusion

A GFD is not robust enough to be routinely recommended for IBS patients, and its efficacy is significantly lower than that of an LFD. Only a certain subgroup of IBS patients may benefit from GFD; further studies are needed to target this subgroup.

Nutrition, Physical Activity and Supplementation in Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS) is a chronic, recurrent functional disorder of the intestine diagnosed based on the Rome IV criteria. Individuals suffering from IBS often associate the severity of their symptoms with the food they consume, leading them to limit the variety of foods they eat and seek information that could help them determine the appropriate selection of dietary items. Clear nutritional recommendations have not been established thus far. NICE recommends a rational approach to nutrition and, if necessary, the short-term implementation of a low FODMAP diet. Currently, the FODMAP diet holds the greatest significance among IBS patients, although it does not yield positive results for everyone affected. Other unconventional diets adopted by individuals with IBS lack supporting research on their effectiveness and may additionally lead to a deterioration in nutritional status, as they often eliminate foods with high nutritional value. The role of physical activity also raises questions, as previous studies have shown its beneficial effects on the physical and mental well-being of every individual, and it can further help alleviate symptoms among people with IBS. Supplementation can be a supportive element in therapy. Attention is drawn to the use of probiotics, vitamin D, and psyllium husk/ispaghula. This review aims to analyze the existing scientific research to determine the impact of various food items, physical activity, and dietary supplementation with specific components through dietary supplements on the course of IBS.

The Intersection of Disorders of Gut-Brain Interaction With Avoidant/Restrictive Food Intake Disorder

High rates of overlap exist between disorders of gut-brain interaction (DGBI) and eating disorders, for which common interventions conceptually conflict. There is particularly increasing recognition of eating disorders not centered on shape/weight concerns, specifically avoidant/restrictive food intake disorder (ARFID) in gastroenterology treatment settings. The significant comorbidity between DGBI and ARFID highlights its importance, with 13% to 40% of DGBI patients meeting full criteria for or having clinically significant symptoms of ARFID. Notably, exclusion diets may put some patients at risk for developing ARFID and continued food avoidance may perpetuate preexisting ARFID symptoms. In this review, we introduce the provider and researcher to ARFID and describe the possible risk and maintenance pathways between ARFID and DGBI. As DGBI treatment recommendations may put some patients at risk for developing ARFID, we offer recommendations for practical treatment management including evidence-based diet treatments, treatment risk counseling, and routine diet monitoring. When implemented thoughtfully, DGBI and ARFID treatments can be complementary rather than conflicting.

Disordered eating and eating competence in members of online irritable bowel syndrome support groups

BACKGROUND

This study seeks to evaluate eating competence and disordered eating likelihood among members of online support groups for irritable bowel syndrome (IBS) and determine whether eating competence and disordered eating likelihood varies according to IBS symptom severity and subtype.

METHODS

This cross-sectional study is based on an anonymous survey conducted from August to September 2021. Adults with IBS (N = 225) were recruited from online and social media IBS support forums. IBS symptom severity was assessed using the validated IBS Severity Scoring System (IBS-SSS), likelihood of disordered eating was assessed using the validated Eating Attitudes Test (EAT-26), and eating competence was assessed using the validated Satter Eating Competence Inventory (ecSI 2.0™). Multiple linear regression was used to predict EAT-26 total score from IBS-SSS score, age, and IBS subtype. ANOVAs were used to examine the relationships between IBS severity level, IBS subtype, and ecSI 2.0™ total score.

KEY RESULTS

Eating competence among the sample was low at 17% while 27% was classified as likely or very likely disordered eating. IBS severity was positively associated with EAT-26 score (p = 0.011) and ecSI 2.0™ score was significantly lower in the severe IBS group compared to the moderate IBS group (p = 0.016). No relationship was detected between IBS subtype and EAT-26 or ecSI 2.0™ scores.

CONCLUSIONS & INFERENCES

IBS severity was positively associated with disordered eating likelihood and negatively associated with eating competence. This sheds light on the importance of assessing eating competence and screening for disordered eating prior to selecting therapies for patients with IBS, particularly in females with severe symptoms.

History of trying exclusion diets and association with avoidant/restrictive food intake disorder in neurogastroenterology patients: A retrospective chart review

BACKGROUND

Exclusion diets for gastrointestinal symptom management have been hypothesized to be a risk factor for avoidant/restrictive food intake disorder (ARFID; a non-body image-based eating disorder). In a retrospective study of pediatric and adult neurogastroenterology patients, we aimed to (1) identify the prevalence and characteristics of an exclusion diet history and (2) evaluate if an exclusion diet history was concurrently associated with the presence of ARFID symptoms.

METHODS

We conducted a chart review of 539 consecutive referrals (ages 6-90, 69% female) to adult (n = 410; January-December 2016) and pediatric (n = 129; January 2016-December 2018) neurogastroenterology clinics. Masked coders (n = 4) retrospectively applied DSM-5 criteria for ARFID and a separate coder assessed documentation of exclusion diet history. We excluded patients with no documentation of diet in the chart (n = 35) or who were not orally fed (n = 9).

RESULTS

Of 495 patients included, 194 (39%) had an exclusion diet history, and 118 (24%) had symptoms of ARFID. Of reported diets, dairy-free was the most frequent (45%), followed by gluten-free (36%). Where documented, exclusion diets were self-initiated by patients/parents in 66% of cases, and recommended by gastroenterology providers in 30%. Exclusion diet history was significantly associated with the presence of ARFID symptoms (OR = 3.12[95% CI 1.92-5.14], p < 0.001).

CONCLUSIONS

History of following an exclusion diet was common and was most often patient-initiated among pediatric and adult neurogastroenterology patients. As patients with self-reported exclusion diet history were over three times as likely to have ARFID symptoms, providers should be cognizant of this potential association when considering dietary interventions.

The intersection between eating disorders and gastrointestinal disorders: a narrative review and practical guide

Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. There is increasing recognition of the bi-directional relationship between eating disorders and gastrointestinal disease. Gastrointestinal symptoms and structural issues might arise from eating disorders, and gastrointestinal disease might be a risk factor for eating disorder development. Cross-sectional research suggests that individuals with eating disorders are disproportionately represented among people seeking care for gastrointestinal symptoms, with avoidant-restrictive food intake disorder in particular garnering attention for high rates among individuals with functional gastrointestinal disorders. This Review aims to describe the research to date on the relationship between gastrointestinal disorders and eating disorders, highlight research gaps, and provide brief, practical guidance for the gastroenterology provider in detecting, potentially preventing, and treating gastrointestinal symptoms in eating disorders.

Sociocultural Considerations for Food-Related Quality of Life in Inflammatory Bowel Disease

The prevalence of inflammatory bowel disease (IBD) is increasing substantially in non-White races and ethnicities in the United States. As a part of promoting quality of life in patients with IBD, the optimization of food-related quality of life (FRQoL) is also indicated. It is known that the practices of food avoidance and restrictive eating are associated with a reduced FRQoL in IBD. Gaining insight into sociocultural influences on FRQoL will aid in the provision of culturally competent interventions to improve FRQoL in patients with IBD.

Virtual Tai Chi program for patients with irritable bowel syndrome with constipation: Proof-of-concept feasibility trial

BACKGROUND

Satisfaction with current treatment options for irritable bowel syndrome with constipation (IBS-C) is low, with many patients turning to complementary treatments. Tai Chi is a mind-body medicine practice with proven efficacy in other functional disorders. As a proof-of-concept, we tested the feasibility and preliminary clinical outcomes associated with a Tai Chi program designed for IBS-C.

METHODS

A total of 27 IBS-C patients participated in a single-arm trial of 8 sessions of Tai Chi delivered weekly over 7 weeks via live videoconferencing in group format. Clinical improvement was assessed via change in IBS Symptom Severity Score (IBS-SSS) from baseline to 4 weeks posttreatment (week 11) with secondary outcomes exploring symptom ratings, IBS-related quality of life (IBS-QOL), GI-specific anxiety, abdominal distention, and psychological factors.

KEY RESULTS

Despite substantial dropout (n = 7; 26%), the treatment protocol had moderate to excellent feasibility for other criteria. Treatment satisfaction was excellent. Exit interviews confirmed high satisfaction with the program among completers, but a high burden of data collection was noted. One participant experienced an adverse event (mild, exacerbation of sciatica). There was a significant improvement in intra-individual IBS-SSS between baseline and posttreatment (average change -66.5, 95% CI -118.6 to -14.3, p = 0.01). Secondary outcomes were notable for improvements in other IBS symptom scoring measures, IBS-QOL, measured abdominal diameter, and leg strength.

CONCLUSIONS AND INFERENCES

Our data provide preliminary evidence of the feasibility of a Tai Chi intervention for IBS-C, show promise for improving outcomes, and identify more streamlined data collection as an area for further program improvement.

The use of SCL-k-9 to measure general psychopathology in women and men with skin conditions

Objectives

To measure general psychopathology in dermatologic outpatients using the Symptom-Checklist-K-9 (SCL-K-9); to investigate whether the SCL-K-9 is able to categorize patients with and without significant non-psychotic disorders; and to perform a single-item analysis of the SCL-K-9, with a focus on gender differences.

Methods

Cross-sectional study on consecutive dermatological patients. We used two self-administered questionnaires to assess general psychopathology symptoms: General Health Questionnaire-12 (GHQ-12) and SCL-K-9. Sociodemographic information was collected with standardized forms. The performance of the SCL-K-9 in classifying patients according to their current emotional distress severity was assessed using a ROC procedure. Finally, we measured differences in scores obtained among women and men in SCL-K-9 single items.

Results

A total of 292 patients were studied (71.2% women). We observed statistically significant differences in SCL-K-9 total mean scores and in most single items among genders. We found that it would be more appropriate to use gender-specific cut-offs when using SCL-K-9 to screen dermatological patients for general psychopathology.

Conclusion

The SCL-K-9, with its compact format could provide, in a short time, a wide range of information related to critical areas that challenge the mental health of patients with skin diseases.

The Relationship between Gastrointestinal Health, Micronutrient Concentrations, and Autoimmunity: A Focus on the Thyroid

Currently, there is a lack of understanding of why many patients with thyroid dysfunction remain symptomatic despite being biochemically euthyroid. Gastrointestinal (GI) health is imperative for absorption of thyroid-specific nutrients as well as thyroid function directly. This comprehensive narrative review describes the impact of what the authors have conceptualized as the “nutrient–GI–thyroid axis”. Compelling evidence reveals how gastrointestinal health could be seen as the epicenter of thyroid-related care given that: (1) GI conditions can lower thyroid-specific nutrients; (2) GI care can improve status of thyroid-specific nutrients; (3) GI conditions are at least 45 times more common than hypothyroidism; (4) GI care can resolve symptoms thought to be from thyroid dysfunction; and (5) GI health can affect thyroid autoimmunity. A new appreciation for GI health could be the missing link to better nutrient status, thyroid status, and clinical care for those with thyroid dysfunction.

Review article: exclude or expose? The paradox of conceptually opposite treatments for irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a heterogeneous disorder of gut-brain interaction (DGBI) maintained by interacting biological, psychological, and social processes. Interestingly, there are two contrasting yet evidence-based treatment approaches for reducing IBS symptoms: exclusion diets such as those low in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) and exposure-based cognitive-behavioural therapy (CBT). Exclusion diets recommend patients avoid foods thought to be symptom-inducing, whereas exposure-based CBT encourages patients to expose themselves to foods.

AIMS

To address the paradox of conceptually opposite exclusion diets and exposure-based CBT for IBS.

METHODS

In this conceptual review, we describe the rationale, practical implementation, evidence base and strengths and weaknesses of each treatment. We conducted up-to-date literature search concerning the low FODMAP diet and CBT, and performed a secondary analysis of a previously conducted trial to illustrate a key point in our review.

RESULTS

The low FODMAP diet has demonstrated efficacy, but problems with adherence, nutritional compromise, and heightened gastrointestinal-specific anxiety raise caution. Exposure-based CBT has demonstrated efficacy with substantial evidence for gastrointestinal-specific anxiety as a key mechanism of action. Mediation analysis also showed that increased FODMAP intake mediated decreased symptom severity in exposure-based CBT. However, there is minimal evidence supporting which treatment "works best for whom" and how these approaches could be best integrated.

CONCLUSIONS

Even though exclusion diets and exposure-based CBT are conceptually opposite, they each have proven efficacy. Clinicians should familiarise themselves with both treatments. Further research is needed on predictors, mechanisms and moderators of treatment outcomes.

Orthorexia nervosa is a concern in gastroenterology: A scoping review

There is concern that use of restrictive therapeutic diets, such as those used in disorders of the gut-brain interaction (DGBI), may increase disordered eating. In this issue of Neurogastroenterology and Motility, Burton Murray et al. and Peters et al. both demonstrate a high prevalence of disordered eating in patients with gastrointestinal conditions, particularly those with DGBI. Given these findings, it is likely that orthorexia is common in this patient group, although this was not directly examined in these studies. Orthorexia nervosa is described as an obsessive and unsafe focus on eating foods perceived as healthy. This mini-review therefore focuses on orthorexia by conducting a scoping review, as per the PRISMA extension for scoping reviews, aimed to assess the prevalence of orthorexia, and associations between orthorexia and restrictive eating practices. While a wide range of orthorexia prevalence has been reported (0%-97%) across the 57 studies included, no studies assessed prevalence specifically in gastrointestinal conditions. Four of eight studies describing diseases associated with specific dietary patterns suggested that participants who followed a diet for "digestive issues" or "food intolerances" were at higher orthorexia risk. These results suggest that dietary modifications may be a factor contributing to orthorexia. Additionally, we provide a commentary on the clinical implications of the findings for gastrointestinal conditions including a clinical flow chart. Clinicians should consider if a restrictive diet is appropriate for individuals with DGBI and include screening for disordered eating prior to implementation of dietary modifications. Future prospective studies should evaluate orthorexia within this patient group.

Psychological Considerations in the Dietary Management of Patients With DGBI

In this article, an expert team of 2 gastro-psychologists, a dietician, and an academic gastroenterologist provides insights into the psychological and social implications of evidence-based and "popular" dietary interventions in disorders of gut-brain interaction (DGBI). We focus on practical approaches for evaluating a patient's appropriateness for a dietary intervention, considering the nutritional, psychological, behavioral, and social context in which a patient may find themselves managing their DGBI with dietary intervention. We also discuss how to identify risk factors for and symptoms of avoidant/restrictive food intake disorder, a growing concern in the DGBI population.

Global prevalence and burden of meal-related abdominal pain

BACKGROUND

Patients with disorders of gut-brain interaction (DGBI) report meal intake to be associated with symptoms. DGBI patients with meal-related symptoms may have more severe symptoms overall and worse health outcomes, but this subgroup has not been well characterized. We aimed to describe the global prevalence of meal-related abdominal pain and characterize this subgroup.

METHODS

The data analyzed originated from the Internet survey component of the population-based Rome Foundation Global Epidemiology Study, completed in 26 countries (n = 54,127). Adult subjects were asked whether they had abdominal pain and how often this was meal-related. Respondents were categorized into "no," "occasional," and "frequent" meal-related abdominal pain groups based on 0%, 10-40%, and ≥50% of the pain episodes being meal-related, respectively. DGBI diagnoses, frequency of other GI symptoms, psychological distress, non-GI somatic symptoms, quality of life, and healthcare utilization were compared between groups. Mixed linear and ordinal regression was used to assess independent associations between psychological distress, non-GI somatic symptoms, quality of life, other GI symptoms, and meal-related abdominal pain.

RESULTS

Overall, 51.9% of the respondents reported abdominal pain in the last 3 months, and 11.0% belonged to the group with frequent meal-related abdominal pain, which included more females and younger subjects. DGBI diagnoses were more common in subjects with frequent meal-related abdominal pain, and the frequency of several GI symptoms was associated with having more frequent meal-related abdominal pain. Having meal-related abdominal pain more frequently was also associated with more severe psychological distress, non-GI somatic symptoms, and a poorer quality of life. The group with frequent meal-related abdominal pain also more often consulted a doctor for bowel problems compared to the other groups of meal-related abdominal pain.

CONCLUSION

Reporting frequent meal-related abdominal pain is common across the globe and associated with other GI and non-GI somatic symptoms, psychological distress, healthcare utilization, and a poorer quality of life. Individuals who frequently experience meal-related abdominal pain also more frequently fulfill the diagnostic criteria for DGBI. Assessing meal-related symptoms in all DGBI patients could be of major importance to improve and individualize symptom management.

Predictors of Symptom-Specific Treatment Response to Dietary Interventions in Irritable Bowel Syndrome

(1) Background: Predictors of dietary treatment response in irritable bowel syndrome (IBS) remain understudied. We aimed to investigate predictors of symptom improvement during the low FODMAP and the traditional IBS diet for four weeks. (2) Methods: Baseline measures included faecal Dysbiosis Index, food diaries with daily energy and FODMAP intake, non-gastrointestinal (GI) somatic symptoms, GI-specific anxiety, and psychological distress. Outcomes were bloating, constipation, diarrhea, and pain symptom scores treated as continuous variables in linear mixed models. (3) Results: We included 33 and 34 patients on the low FODMAP and traditional IBS diet, respectively. Less severe dysbiosis and higher energy intake predicted better pain response to both diets. Less severe dysbiosis also predicted better constipation response to both diets. More severe psychological distress predicted worse bloating response to both diets. For the different outcomes, several differential predictors were identified, indicating that baseline factors could predict better improvement in one treatment arm, but worse improvement in the other treatment arm. (4) Conclusions: Psychological, nutritional, and microbial factors predict symptom improvement when following the low FODMAP and traditional IBS diet. Findings may help individualize dietary treatment in IBS.

"If I could survive without eating, it would be a huge relief": Development and initial validation of the Fear of Food Questionnaire

BACKGROUND

Fear of food and behavioral avoidance of specific foods, food groups, and food related social situations can substantially reduce health related quality of life in individuals with a wide range of conditions that affect appetite, eating behavior, and digestion, including irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), vomit and choking phobias, and food allergies/sensitivities. When this avoidance leads to weight/nutritional and/or psychosocial impairment, the diagnostic criteria for Avoidant/restrictive food intake disorder (ARFID) are met. Fear of food is an important target for interventions designed to improve psychosocial functioning and quality of life in such individuals. The purpose of this research was to develop and validate a novel measure of fear of food.

METHODS

Participants (n = 1138) were recruited from ongoing clinical trials for both IBD and IBS, from Amazon's Mechanical Turk, from Reddit support forums for IBS, IBD, and vomit phobia, and from an undergraduate subject pool. Exploratory and confirmatory factor analysis, Pearson's correlations, one-way ANOVA, and intraclass correlation coefficients were used to assess the validity and reliability of the Fear of Food Questionnaire.

RESULTS

The final 18 item questionnaire showed excellent internal consistency, test-retest reliability, convergent validity, discriminative (known groups) validity, as well as good factor structure. Fear of food was highly correlated with visceral hypersensitivity, catastrophizing, GI symptom severity and health related quality of life, as well as with self-reported Fear-ARFID symptoms. Individuals meeting study criteria for Fear-ARFID reported the highest scores relative to control and other analogue clinical groups.

CONCLUSION

The Fear of Food Questionnaire appears to be reliable and valid across populations and may be a valuable tool in the assessment and treatment of Fear-ARFID.

Gluten and fructan intake and their associations with gastrointestinal symptoms in irritable bowel syndrome: A food diary study

BACKGROUND & AIMS

Wheat contains several components, including gluten and fructan, that may be associated with gastrointestinal symptoms (GI) in irritable bowel syndrome (IBS). The aims of the study were to determine the average daily intake of gluten, investigate the association of gluten and GI symptoms, as well as the association between fructan and GI symptoms in IBS subjects.

METHODS

We assessed dietary intake, including total energy, and calculated average gluten and fructan intake in this 4-day food diary study. The subjects reported GI symptoms using the validated Gastrointestinal Symptom Rating Scale-IBS (GSRS-IBS).

RESULTS

In total, 147 IBS subjects (116 females) were included in this study. The median (IQR) intake of gluten was 11.0 (7.5-15.4) (range: 0.6-52.1) g/day, and this intake was significantly higher for males (16.2 (11.5-18.8), g/day) compared with females (10.3 (7.3-13.2), g/day) (P ≤ 0.001). For analyses purposes, the subjects were stratified in tertiles of gluten intake. Median (IQR) overall GI symptom severity (GSRS-IBS) was significantly worse for the subjects with the lowest (52 (45-57)) and intermediate gluten intake (51 (43-58)), compared with the highest gluten intake (45 (37-50), P ≤ 0.05, and P ≤ 0.01 respectively). In addition, caloric intake was significantly lower in subjects with the lowest (1905 ± 446, kcal/day) and intermediate gluten intake (1854 ± 432, kcal/day), compared with subjects with the highest gluten intake (2305 ± 411, kcal/day), P < 0.001 for both. Analyses of the stratified fructan tertiles resulted in no significant differences in GSRS-IBS.

CONCLUSIONS

The mean intake of gluten varies substantially among subjects with IBS, and IBS subjects with more severe GI symptoms have lower intake of gluten and calories.

TRIAL REGISTRY

(http://www.clinicaltrials.gov): Registered under Clinical Trial number NCT02970591.