Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome

A diet low in fermentable oligo-, di-, monosaccharides and polyols improves abdominal and overall symptoms in persons with all subtypes of irritable bowel syndrome

BACKGROUND

A diet low in fermentable oligo-, di-, monosaccharides and polyols (LFD) improves symptoms in patients with irritable bowel syndrome (IBS). Previous studies have focused on patients with IBS and diarrhea (IBS-D). It is unclear whether LFD is effective for IBS with constipation (IBS-C) or IBS with mixed bowel habits (IBS-M). This open-label, real-world study evaluates the relative effectiveness of the LFD among IBS subtypes.

METHODS

This study analyzes data from a service that provides low-FODMAP meals to individuals with IBS. Participants met with a registered dietitian and completed the IBS symptom severity survey (IBS-SSS) before and after undergoing a 2-4-week period of FODMAP restriction. The primary endpoint was the proportion of participants with ≥50-point decrease in IBS-SSS between the three IBS subtypes.

KEY RESULTS

After FODMAP restriction, 90% of participants with IBS-D, 75% with IBS-C, and 84% with IBS-M met the primary endpoint (p = 0.045). Similar improvement was seen for a 100-point decrease, but the difference between IBS subtypes was not significant (p = 0.46). After FODMAP restriction, all groups had statistically significant improvement in total IBS-SSS as well as individual symptom categories. Improvement in IBS-SSS subcategories was similar among the groups except for the categories of bloating severity (IBS-M had greatest improvement) and bowel movement satisfaction (IBS-C had less improvement).

CONCLUSION & INFERENCES

Though the proportion of responders was highest for IBS-D and lowest for IBS-C, the LFD led to robust improvement in overall symptoms in all IBS subtypes. Key individual symptoms also showed significant improvements in all IBS subtypes.

Effectiveness of a novel diet in attenuation of clinical activity of disease in patients with ulcerative colitis: a randomized, clinical trial

Dietary intake plays a pivotal role in ulcerative colitis (UC) initiation and prognosis. The aim of this study was to investigate the effect of a combined Mediterranean, low-FODMAP diet accompanied with partial enteral nutrition (PEN) on clinical and para-clinical characteristics of patients with UC. Fifty patients with active mild to moderate UC were received either a combined diet or a regular diet for 6 weeks. Before and after the intervention, disease activity index, quality of life and some inflammatory and oxidative stress factors were measured using valid and reliable questionnaires and blood sampling. Disease activity index was significantly decreased in the combined diet group in comparison to control diet group (p = 0.043), and baseline data (p < 0.001). Moreover, the quality of life score increased significantly in the combined diet group compared to the control group, and the baseline data (p < 0.001). Serum level of high sensitive C-reactive protein (hs-CRP) decreased significantly in the combined group (p < 0.01), while it increased in the control group non-significantly. Serum total anti-oxidant capacity (TAC) changes were not statistically significant in two groups. This study indicates that this combination diet has the potential to be used as a safe and highly effective approach in patients with significant intestinal symptoms. Further clinical trial studies with different duration of intervention are needed to confirm these results.Trial registration: The study was registered on IRCT.ir with registration number of IRCT20100524004010N38, on 25/04/2023.

Organization of Neurogastroenterology and Motility units with a multidisciplinary, patient-centered perspective

Neurogastroenterology and Motility is a Gastroenterology subspecialty dealing with the management of gastrointestinal (GI) motor diseases and disorders of gut-brain interaction (DGBI). Both types of conditions may impair the nutritional status of patients - In the case of motility disorders, because deficient gastrointestinal motility may impair appropriate food digestion and absorption; in DGBI because development of gastrointestinal symptoms may impair appropriate patient nutrition. In both cases, different studies have shown that patients start restrictive diets on their own, without supervision of a dietician, which leads to nutritional deficits in many cases. Likewise, psychological factors like stressful situations or anxiety may trigger gastrointestinal symptoms in these patients, mainly in those with DGBI. Recent studies comparing a patient-centered approach that includes medical treatment, dietary modifications, and behavioural interventions with gastroenterologist-only standard care have shown a greater proportion of improved symptoms, psychological status, and quality of life, as well as reduced costs in patients allocated to the multidisciplinary treatment arm. In conclusion, there is growing evidence in favour of dietary and behavioural interventions by specialized professionals, coupled with appropriate medical evaluation and treatment by a gastroenterologist. Hence the importance of developing reference units in which comprehensive, individualized management may be offered. Multidisciplinary models improve clinical outcomes and patient satisfaction, which should result in a reduction of direct and indirect costs.  .

Engagement in GI Behavioral Health Is Associated with Reduced Portal Messages, Phone Calls, and ED Visits

BACKGROUND AND AIMS

Chronic digestive disorders are associated with increased costs for healthcare systems and often require provision of both urgent care and non-face-to-face (non-F2F) care, such as responding to patient messages. Numerous benefits of integrated gastroenterology (GI) behavioral health have been identified; however, it is unclear if integrated care impacts healthcare utilization, including urgent care and non-F2F contact. We sought to investigate the association between patient engagement with GI behavioral health and healthcare utilization.

METHODS

We performed a retrospective chart review study of adult patients who were referred for and completed at least one behavioral health appointment between January 1, 2019 and December 21, 2021 in the Gastroenterology and Hepatology department of a large academic medical center. Data on electronic medical record (EMR) messages, phone calls, and Emergency Department utilization were collected 6 months before and 9 months after patient engagement with GI behavioral health.

RESULTS

466 adult patients completed at least one behavioral health visit from 2019 to 2021. Overall, messages, phone calls, and ED visits all decreased significantly from the 6 months before behavioral health treatment to 6 months after (all P values < 0.001).

CONCLUSION

Engagement with integrated GI behavioral health is associated with reduced non-F2F care and emergency department utilization in patients with chronic digestive disorders. Increasing access to GI behavioral health may result in reduced provider workload and healthcare system costs.

Treating disorders of brain-gut interaction with multidisciplinary integrated care. Moving towards a new standard of care

Disorders of brain-gut interaction (DGBI) are highly prevalent in our community with a negative burden on the quality of life and function. Symptoms are frequently food-induced, and psychological disorders are commonly co-morbid and contribute greatly to symptom severity and healthcare utilization, which can complicate management. Pathophysiological contributors to the development and maintenance of DGBI are best appreciated within the biopsychosocial model of illness. Established treatments include medical therapies targeting gastrointestinal physiology, luminal microbiota or visceral sensitivity, dietary treatments including dietary optimization and specific therapeutic diets such as a low-FODMAP diet, and psychological interventions. The traditional "medical model" of care, driven predominantly by doctors, poorly serves sufferers of DBGI, with research indicating that a multidisciplinary, integrated-care approach produces better outcomes. This narrative review explores the current evidence for multidisciplinary care and provides the best practice recommendations for physicians and healthcare systems managing such patients.

Exploration of differential responses to FODMAPs and gluten in people with irritable bowel syndrome- a double-blind randomized cross-over challenge study

INTRODUCTION

There is large variation in response to diet in irritable bowel syndrome (IBS) and determinants for differential response are poorly understood.

OBJECTIVES

Our aim was to investigate differential clinical and molecular responses to provocation with fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) and gluten in individuals with IBS.

METHODS

Data were used from a crossover study with week-long interventions with either FODMAPs, gluten or placebo. The study also included a rapid provocation test. Molecular data consisted of fecal microbiota, short chain fatty acids, and untargeted plasma metabolomics. IBS symptoms were evaluated with the IBS severity scoring system. IBS symptoms were modelled against molecular and baseline questionnaire data, using Random Forest (RF; regression and clustering), Parallel Factor Analysis (PARAFAC), and univariate methods.

RESULTS

Regression and classification RF models were in general of low predictive power (Q2 ≤ 0.22, classification rate < 0.73). Out of 864 clustering models, only 2 had significant associations to clusters (0.69 < CR < 0.73, p < 0.05), but with no associations to baseline clinical measures. Similarly, PARAFAC revealed no clear association between metabolome data and IBS symptoms.

CONCLUSION

Differential IBS responses to FODMAPs or gluten exposures could not be explained from clinical and molecular data despite extensive exploration with different data analytical approaches. The trial is registered at www.

CLINICALTRIALS

gov as NCT03653689 31/08/2018.

Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is a common, debilitating disorder characterized by abdominal pain and disordered bowel habits. Current pharmacologic treatments often provide incomplete symptom relief and may be poorly tolerated. Furthermore, alleviation of gastrointestinal symptoms does not always translate into improved quality of life for IBS patients. Current treatment guidelines recommend brain-gut behavior therapy (BGBT) in conjunction with other IBS therapies, and, in randomized controlled trials, BGBT has been shown to improve symptoms, patient satisfaction, functioning, and quality of life. Access to BGBT is limited by lack of adequately trained gastrointestinal psychologists, patient time constraints, and cost. Furthermore, clinician knowledge that BGBT is specific, and different from psychotherapy approaches for common mental health disorders, may limit referrals even where available. This review provides an overview of the pathophysiology of IBS, disease burden, unmet therapeutic needs, evidence base of novel digital therapeutics for IBS, and guidance on the introduction and appropriateness of these interventions for patients.

METHODS

We searched the literature for available published data relating to the use of novel digital therapeutics to provide cognitive behavioral therapy and gut-directed hypnotherapy in the treatment of irritable bowel syndrome.

RESULTS

Clinical trial data support the development and utility of digital therapeutics designed to deliver self-guided cognitive behavioral therapy and hypnotherapy for the treatment of IBS.

CONCLUSIONS

BGBTs are effective, guideline-recommended treatments for IBS. Digital therapeutic devices offer accessible, cost-effective treatment options for delivery of adjunctive BGBT for the treatment of IBS. The decision to recommend digital BGBTs should be guided by careful patient assessment that includes mental health screening and risk assessment.

The Role of the FODMAP Diet in IBS

The low FODMAP (fermentable oligosaccharide, disaccharide, monosaccharide, and polyol) diet is a beneficial therapeutic approach for patients with irritable bowel syndrome (IBS). However, how the low FODMAP diet works is still not completely understood. These mechanisms encompass not only traditionally known factors such as luminal distension induced by gas and water but also recent evidence on the role of FOMAPs in the modulation of visceral hypersensitivity, increases in intestinal permeability, the induction of microbiota changes, and the production of short-chain fatty acids (SCFAs), as well as metabolomics and alterations in motility. Although most of the supporting evidence is of low quality, recent trials have confirmed its effectiveness, even though the majority of the evidence pertains only to the restriction phase and its effectiveness in relieving abdominal bloating and pain. This review examines potential pathophysiological mechanisms and provides an overview of the existing evidence on the effectiveness of the low FODMAP diet across various IBS subtypes. Key considerations for its use include the challenges and disadvantages associated with its practical implementation, including the need for professional guidance, variations in individual responses, concerns related to microbiota, nutritional deficiencies, the development of constipation, the necessity of excluding an eating disorder before commencing the diet, and the scarcity of long-term data. Despite its recognized efficacy in symptom management, acknowledging these limitations becomes imperative for a nuanced comprehension of the role of a low FODMAP diet in managing IBS. By investigating its potential mechanisms and evidence across IBS subtypes and addressing emerging modulations alongside limitations, this review aims to serve as a valuable resource for healthcare practitioners, researchers, and patients navigating the intricate landscape of IBS.

Age Differences in Upper Gastrointestinal Symptoms and Vagal Modulation in Women With Irritable Bowel Syndrome

BACKGROUND/AIMS

Patients with irritable bowel syndrome (IBS) often report upper gastrointestinal (GI) (e.g., nausea and heartburn), somatic, and emotional symptoms. This study seeks to examine the relationships among younger and older women with IBS and indicators of autonomic nervous system (ANS) function and daily nausea and heartburn symptoms.

METHODS

Women were recruited through clinics and the community. Nocturnal heart rate variability (HRV) was obtained using ambulatory electrocardiogram Holter monitors. Individual symptom severity and frequency were collected using 28-day diaries. All variables were stratified by younger (<46 years) and older (≥46 years) age groups.

RESULTS

Eighty-nine women with IBS were included in this descriptive correlation study (n = 57 younger; n = 32 older). Older women had reduced indices of vagal activity when compared to younger women. In older women, there was an inverse correlation between nausea and vagal measures (Ln RMSSD, r = -.41, p = .026; Ln pNN50, r = -.39, p = .034). Heartburn in older women was associated with sleepiness (r = .59, p < .001) and anger (r = .48, p = .006). Nausea was significantly correlated with anger in the younger group (r = .41, p = .001). There were no significant relationships between HRV indicators and nausea and heartburn in younger women.

CONCLUSIONS

Age-related differences in ANS function that are associated with nausea may portend unique opportunities to better understand the vagal dysregulation in women with IBS.

Gut liver brain axis in diseases: the implications for therapeutic interventions

Gut-liver-brain axis is a three-way highway of information interaction system among the gastrointestinal tract, liver, and nervous systems. In the past few decades, breakthrough progress has been made in the gut liver brain axis, mainly through understanding its formation mechanism and increasing treatment strategies. In this review, we discuss various complex networks including barrier permeability, gut hormones, gut microbial metabolites, vagus nerve, neurotransmitters, immunity, brain toxic metabolites, β-amyloid (Aβ) metabolism, and epigenetic regulation in the gut-liver-brain axis. Some therapies containing antibiotics, probiotics, prebiotics, synbiotics, fecal microbiota transplantation (FMT), polyphenols, low FODMAP diet and nanotechnology application regulate the gut liver brain axis. Besides, some special treatments targeting gut-liver axis include farnesoid X receptor (FXR) agonists, takeda G protein-coupled receptor 5 (TGR5) agonists, glucagon-like peptide-1 (GLP-1) receptor antagonists and fibroblast growth factor 19 (FGF19) analogs. Targeting gut-brain axis embraces cognitive behavioral therapy (CBT), antidepressants and tryptophan metabolism-related therapies. Targeting liver-brain axis contains epigenetic regulation and Aβ metabolism-related therapies. In the future, a better understanding of gut-liver-brain axis interactions will promote the development of novel preventative strategies and the discovery of precise therapeutic targets in multiple diseases.

Association between dietary factors, symptoms, and psychological factors in adults with dyspepsia: A cross-sectional study

BACKGROUND

Evidence-based dietary management approaches for symptoms of dyspepsia are lacking. This study aimed to compare dietary factors, symptoms, quality of life (QOL) and salivary cortisol in dyspepsia participants and healthy controls.

METHODS

A cross-sectional survey was completed by adults with dyspepsia (n = 121) meeting Rome IV criteria and healthy controls (n = 52). Outcome measures included self-reported questionnaires about dietary habits, triggers, restrictions, dietary management approaches, nutritional intake, psychological variables, QOL, gastrointestinal symptoms, and optional cortisol awakening response (CAR) via saliva samples. Data were analyzed using Chi-square or Mann-Whitney U. Cortisol awakening response data was analyzed using moderated regression controlling for age, gender and distress.

KEY RESULTS

Fermentable carbohydrates (FODMAPs) (55%) were the most reported trigger in adults with dyspepsia. The dyspepsia group (88%) followed special diets more than controls (47%; p < 0.001), with a low FODMAP diet being most common (69%). The dyspepsia group consumed less fiber (p = 0.014), calcium (p = 0.015), and total FODMAPs (p < 0.001) than controls. There was a greater prevalence of comorbid anxiety (41%) and depression (31%) in dyspepsia compared to controls (15% and 12%, respectively, p < 0.001 and p = 0.006). The dyspepsia group had poorer QOL and greater gastrointestinal symptom severity than controls (p < 0.001). There was a negative association between anxiety and CAR (p = 0.001) in dyspepsia but not in controls.

CONCLUSIONS & INFERENCES

Adults with dyspepsia follow special diets more than controls and perceive FODMAPs as a key dietary trigger. These findings highlight the importance of monitoring nutritional adequacy and QOL, and emphasize mechanisms of depleted stress response in dyspepsia, warranting further exploration.

A Randomized Parallel-group Study of Digital Gut-directed Hypnotherapy vs Muscle Relaxation for Irritable Bowel Syndrome

BACKGROUND & AIMS

Gut-directed hypnotherapy (GDH) is effective for treating irritable bowel syndrome (IBS), but access limits its widespread use. We report the first randomized controlled trial comparing the safety and efficacy of a self-administered, digital GDH treatment program with that of digital muscle relaxation (MR) in adults with IBS.

METHODS

After a 4-week run-in period, patients were randomized to 12 weeks of treatment with digital GDH (Regulora), or digital MR accessed via a mobile app on a smartphone or tablet. The primary endpoint was abdominal pain response, defined as ≥30% reduction from baseline in average daily abdominal pain intensity in the 4 weeks following treatment. Key secondary outcomes included mean change from baseline in abdominal pain, stool consistency, and stool frequency.

RESULTS

Of 378 randomized patients, 362 were treated and included in the efficacy analysis. A similar proportion of the GDH (30.4%) and MR (27.1%) groups met the primary endpoint, with no significant difference between the groups (P = .5352). Significantly more patients treated with GDH than MR were abdominal pain responders during the last 4 weeks of treatment (30.9% vs 21.5%; P = .0232) and over the entire treatment period (29.3% vs 18.8%; P = .0254). Improvements in abdominal pain, stool consistency, and stool frequency were consistent across IBS subtypes. No patients experienced serious adverse events or adverse events leading to study discontinuation.

CONCLUSIONS

Treatment with a digital GDH program led to an improvement in abdominal pain and stool symptoms in patients with IBS, supporting a role for this intervention as part of integrated care for IBS.

CLINICALTRIALS

gov identifier NCT04133519.

Irritable bowel syndrome and mental health comorbidity - approach to multidisciplinary management

Irritable bowel syndrome (IBS) affects 5-10% of the global population. Up to one-third of people with IBS also experience anxiety or depression. Gastrointestinal and psychological symptoms both drive health-care use in people with IBS, but psychological comorbidity seems to be more important for long-term quality of life. An integrated care approach that addresses gastrointestinal symptoms with nutrition and brain-gut behaviour therapies is considered the gold standard. However, best practice for the treatment of individuals with IBS who have a comorbid psychological condition is unclear. Given the rising prevalence of mental health disorders, discussion of the challenges of implementing therapy for people with IBS and anxiety and depression is critical. In this Review, we draw upon our expertise in gastroenterology, nutrition science and psychology to highlight common challenges that arise when managing patients with IBS and co-occurring anxiety and depression, and provide recommendations for tailoring clinical assessment and treatment. We provide best practice recommendations, including dietary and behavioural interventions that could be applied by non-specialists and clinicians working outside an integrated care model.

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.

Faecal and urine metabolites, but not gut microbiota, may predict response to low FODMAP diet in irritable bowel syndrome

BACKGROUND

The low FODMAP diet (LFD) leads to clinical response in 50%-80% of patients with irritable bowel syndrome (IBS). It is unclear why only some patients respond.

AIMS

To determine if differences in baseline faecal microbiota or faecal and urine metabolite profiles may separate clinical responders to the diet from non-responders allowing predictive algorithms to be proposed.

METHODS

We recruited adults fulfilling Rome III criteria for IBS to a blinded randomised controlled trial. Patients were randomised to sham diet with a placebo supplement (control) or LFD supplemented with either placebo (LFD) or 1.8 g/d B-galactooligosaccharide (LFD/B-GOS), for 4 weeks. Clinical response was defined as adequate symptom relief at 4 weeks after the intervention (global symptom question). Differences between responders and non-responders in faecal microbiota (FISH, 16S rRNA sequencing) and faecal (gas-liquid chromatography, gas-chromatography mass-spectrometry) and urine (1 H NMR) metabolites were analysed.

RESULTS

At 4 weeks, clinical response differed across the 3groups with adequate symptom relief of 30% (7/23) in controls, 50% (11/22) in the LFD group and 67% (16/24) in the LFD/B-GOS group (p = 0.048). In the control and the LFD/B-GOS groups, microbiota and metabolites did not separate responders from non-responders. In the LFD group, higher baseline faecal propionate (sensitivity 91%, specificity 89%) and cyclohexanecarboxylic acid esters (sensitivity 80%, specificity 78%), and urine metabolite profile (Q2 0.296 vs. randomised -0.175) predicted clinical response.

CONCLUSIONS

Baseline faecal and urine metabolites may predict response to the LFD.

The national prevalence of disorders of gut brain interaction in the United Kingdom in comparison to their worldwide prevalence: Results from the Rome foundation global epidemiology study

BACKGROUND

There are minimal epidemiological data comparing the burden of disorders of gut brain interaction (DGBI) in the UK with other countries. We compared the prevalence of DGBI in the UK with other countries that participated in the Rome Foundation Global Epidemiology Study (RFGES) online.

METHODS

Participants from 26 countries completed the RFGES survey online including the Rome IV diagnostic questionnaire and an in-depth supplemental questionnaire with questions about dietary habits. UK sociodemographic and prevalence data were compared with the other 25 countries pooled together.

KEY RESULTS

The proportion of participants with at least one DGBI was lower in UK participants compared with in the other 25 countries (37.6% 95% CI 35.5%-39.7% vs. 41.2%; 95% CI 40.8%-41.6%, p = 0.001). The UK prevalence of 14 of 22 Rome IV DGBI, including irritable bowel syndrome (4.3%) and functional dyspepsia (6.8%), was similar to the other countries. Fecal incontinence, opioid-induced constipation, chronic nausea and vomiting, and cannabinoid hyperemesis (p < 0.05) were more prevalent in the UK. Cyclic vomiting, functional constipation, unspecified functional bowel disorder, and proctalgia fugax (p < 0.05) were more prevalent in the other 25 countries. Diet in the UK population consisted of higher consumption of meat and milk (p < 0.001), and lower consumption of rice, fruit, eggs, tofu, pasta, vegetables/legumes, and fish (p < 0.001).

CONCLUSIONS AND INFERENCES

The prevalence and burden of DGBI is consistently high in the UK and in the rest of the world. Opioid prescribing, cultural, dietary, and lifestyle factors may contribute to differences in the prevalence of some DGBI between the UK and other countries.

Smartphone app-delivered gut-directed hypnotherapy improves symptoms of self-reported irritable bowel syndrome: A retrospective evaluation

BACKGROUND

Gut-directed hypnotherapy (GDH) has high rates of durable efficacy for treating irritable bowel syndrome (IBS) but its widespread use is limited due to high costs and poor access. A smartphone app delivering GDH was developed to fill gaps in accessibility but has not been assessed in IBS patients. The current retrospective evaluation aims to assess the efficacy of app-delivered GDH in managing IBS symptoms and to investigate associating factors that predict response.

METHODS

Irritable bowel syndrome patients who downloaded the app between June 2019 and April 2020 were retrospectively evaluated. The first seven sessions were free. Daily GDH, psycho-education, and breathing exercises were included. Overall and individual gastrointestinal symptoms were assessed at baseline and completion using a 100-mm visual analogue scale. Clinical data were extracted.

KEY RESULTS

2843 patients with self-reported IBS commenced the free sessions, 1428 (50%) purchased the app and 253 (9%) completed all 42 sessions. Outcome data were available for 190 users who completed all 42 sessions. 64% of patients who completed the GDH and provided outcome data responded (defined as >30% reduction in abdominal pain). Abdominal pain reduced from 60mm (50-73mm) at baseline to 26mm (13-50mm) on study completion (p<0.001 Wilcoxon). Similar results were seen for overall and individual symptoms. On multivariable analysis, symptom response was positively associated with being ≥ 40 years (estimated OR 0.398, p=0.025) and negatively associated with trying probiotics (0.323, p=0.042).

CONCLUSIONS & INFERENCES

Adherence to app-delivered gut-directed hypnotherapy was low but users who completed the program saw notable improvements in their IBS symptoms. Patients ≥40 years, with symptoms for ≥5 years, may respond better. A controlled trial comparing face-to-face to app-delivered GDH is indicated.

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.

Multi-omics profiles of the intestinal microbiome in irritable bowel syndrome and its bowel habit subtypes

BACKGROUND

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that is thought to involve alterations in the gut microbiome, but robust microbial signatures have been challenging to identify. As prior studies have primarily focused on composition, we hypothesized that multi-omics assessment of microbial function incorporating both metatranscriptomics and metabolomics would further delineate microbial profiles of IBS and its subtypes.

METHODS

Fecal samples were collected from a racially/ethnically diverse cohort of 495 subjects, including 318 IBS patients and 177 healthy controls, for analysis by 16S rRNA gene sequencing (n = 486), metatranscriptomics (n = 327), and untargeted metabolomics (n = 368). Differentially abundant microbes, predicted genes, transcripts, and metabolites in IBS were identified by multivariate models incorporating age, sex, race/ethnicity, BMI, diet, and HAD-Anxiety. Inter-omic functional relationships were assessed by transcript/gene ratios and microbial metabolic modeling. Differential features were used to construct random forests classifiers.

RESULTS

IBS was associated with global alterations in microbiome composition by 16S rRNA sequencing and metatranscriptomics, and in microbiome function by predicted metagenomics, metatranscriptomics, and metabolomics. After adjusting for age, sex, race/ethnicity, BMI, diet, and anxiety, IBS was associated with differential abundance of bacterial taxa such as Bacteroides dorei; metabolites including increased tyramine and decreased gentisate and hydrocinnamate; and transcripts related to fructooligosaccharide and polyol utilization. IBS further showed transcriptional upregulation of enzymes involved in fructose and glucan metabolism as well as the succinate pathway of carbohydrate fermentation. A multi-omics classifier for IBS had significantly higher accuracy (AUC 0.82) than classifiers using individual datasets. Diarrhea-predominant IBS (IBS-D) demonstrated shifts in the metatranscriptome and metabolome including increased bile acids, polyamines, succinate pathway intermediates (malate, fumarate), and transcripts involved in fructose, mannose, and polyol metabolism compared to constipation-predominant IBS (IBS-C). A classifier incorporating metabolites and gene-normalized transcripts differentiated IBS-D from IBS-C with high accuracy (AUC 0.86).

CONCLUSIONS

IBS is characterized by a multi-omics microbial signature indicating increased capacity to utilize fermentable carbohydrates-consistent with the clinical benefit of diets restricting this energy source-that also includes multiple previously unrecognized metabolites and metabolic pathways. These findings support the need for integrative assessment of microbial function to investigate the microbiome in IBS and identify novel microbiome-related therapeutic targets. Video Abstract.

Practical Approaches to Working with a Gastrointestinal Psychologist

Integrated models of care for chronic digestive conditions, such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), are becoming the standard of care and require patients to have access to brain-gut behavior therapies. Further progress is needed to implement this approach across GI practice settings and will require gastroenterologists to build collaborative relationships with GI Psychologists. This review provides guidance on practical steps for integrating brain-gut behavior therapy into a GI practice, including guidance on assessing patients for their appropriateness for referral, effective communication strategies to recommend brain-gut behavior therapy, and tips on how to develop a referral pathway and successful collaboration with a GI Psychologist.

Efficacy and Acceptability of Dietary Therapies in Non-Constipated Irritable Bowel Syndrome: A Randomized Trial of Traditional Dietary Advice, the Low FODMAP Diet, and the Gluten-Free Diet

BACKGROUND & AIMS

Various diets are proposed as first-line therapies for non-constipated irritable bowel syndrome (IBS) despite insufficient or low-quality evidence. We performed a randomized trial comparing traditional dietary advice (TDA) against the low FODMAP diet (LFD) and gluten-free diet (GFD).

METHODS

Patients with Rome IV-defined non-constipated IBS were randomized to TDA, LFD, or GFD (the latter allowing for minute gluten cross-contamination). The primary end point was clinical response after 4 weeks of dietary intervention, as defined by ≥50-point reduction in IBS symptom severity score (IBS-SSS). Secondary end points included (1) changes in individual IBS-SSS items within clinical responders, (2) acceptability and food-related quality of life with dietary therapy, (3) changes in nutritional intake, (4) alterations in stool dysbiosis index, and (5) baseline factors associated with clinical response.

RESULTS

The primary end point of ≥50-point reduction in IBS-SSS was met by 42% (n = 14/33) undertaking TDA, 55% (n = 18/33) for LFD, and 58% (n = 19/33) for GFD (P = .43). Responders had similar improvements in IBS-SSS items regardless of their allocated diet. Individuals found TDA cheaper (P < .01), less time-consuming to shop (P < .01), and easier to follow when eating out (P = .03) than the GFD and LFD. TDA was also easier to incorporate into daily life than the LFD (P = .02). Overall reductions in micronutrient and macronutrient intake did not significantly differ across the diets. However, the LFD group had the greatest reduction in total FODMAP content (27.7 g/day before intervention to 7.6 g/day at week 4) compared with the GFD (27.4 g/day to 22.4 g/day) and TDA (24.9 g/day to 15.2 g/day) (P < .01). Alterations in stool dysbiosis index were similar across the diets, with 22%-29% showing reduced dysbiosis, 35%-39% no change, and 35%-40% increased dysbiosis (P = .99). Baseline clinical characteristics and stool dysbiosis index did not predict response to dietary therapy.

CONCLUSIONS

TDA, LFD, and GFD are effective approaches in non-constipated IBS, but TDA is the most patient-friendly in terms of cost and convenience. We recommend TDA as the first-choice dietary therapy in non-constipated IBS, with LFD and GFD reserved according to specific patient preferences and specialist dietetic input.

CLINICALTRIALS

gov: NCT04072991.

Future of Brain-Gut Behavior Therapies: Mediators and Moderators

With growing evidence to support their efficacy, brain-gut behavior therapies are increasingly viewed as a key component to integrated care management of disorders of gut-brain interaction. However, the types of brain-gut behavior therapies differ in how and for whom they purportedly work. We provide a conceptual review of these brain-gut behavior therapies, with an emphasis on describing how (ie, mechanisms) and for whom (ie, moderators) they work as hypothesized and/or supported by evidence. Based on evidence to date, we recommend that brain-gut behavior therapies prioritize gastrointestinal-specific targets, such as gastrointestinal-specific anxiety.

The Pervasive Impact of the Stigmatization of Gastrointestinal Diseases-A Patient's Perspective

Stigma is a centuries-old phenomenon that pervades chronic digestive diseases, regardless of classification. Patients with gastrointestinal (GI) illness perceive others hold stigmatizing beliefs about them and their illness, including from medical professionals, and may go on to internalize or believe these negative stereotypes as true. These perceptions seem to be based on the thought that the public views GI diseases negatively. The effects of GI stigma are substantial and influence quality of life, psychological distress, treatment adherence, disease severity, and health-care utilization. These realities underscore the need for stigma to be addressed by the GI community and measures taken to mitigate its impacts.

Potential of natural products in the treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a kind of functional bowel disease that is characterized by bellyache, abdominal distension, and diarrhea. Although not life-threatening, IBS has a long course and recurrent attacks and seriously affects the life quality of patients. Current drugs for treating IBS possess remarkable limitations, such as limited efficacy and severe adverse reactions. Therefore, developing novel medications to treat IBS is quite essential, and natural products may be a substantial source.

PURPOSE

This is the first systematic review elaborating the recent advancement of natural products as potential drugs for the therapy of IBS.

METHODS

A comprehensive retrieval of studies was carried out in scientific databases including PubMed, Web of Science, Elsevier, and CNKI. By using ("irritable bowel syndrome" OR "IBS") AND ("natural product" OR "natural compound" OR "phytochemical") as keywords, the eligible studies were screened, and the relevant information about therapeutic action and mechanism of natural products treating IBS was extracted.

RESULTS

Natural products against IBS consisted of four categories, namely, terpenoids, flavonoids, alkaloids, and phenols. Furthermore, the underlying mechanisms for natural products treating IBS were tightly associated with increased TJs and mucus protein expression, regulation of the brain-gut axis and gut microbiota structure, and inhibition of inflammatory response and intestinal mucosal damage.

CONCLUSION

Natural products could be extremely prospective candidate drugs used to treat IBS, and further preclinical and clinical researches are needed to guarantee their efficacy and safety.

Dietary management of adults with IBD - the emerging role of dietary therapy

Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.

Modest Conformity Between Self-Reporting of Bristol Stool Form and Fecal Consistency Measured by Stool Water Content in Irritable Bowel Syndrome and a FODMAP and Gluten Trial

INTRODUCTION

Altered bowel habits constitute a criterion of irritable bowel syndrome (IBS), with the Bristol Stool Form Scale (BSFS) as the recommended tool for assessment of fecal consistency. However, BSFS is devoid of a comprehensive objective evaluation in subjects with IBS. Therefore, we aimed to evaluate the concordance between subjective reporting of BSFS and objective stool water content in subjects with IBS. Furthermore, we evaluated whether intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) or gluten would affect stool water content.

METHODS

Data from a previous crossover trial in IBS with 1-week provocations of FODMAPs, gluten, or placebo were subanalyzed. After each intervention, fecal consistency was subjectively assessed using the BSFS and stool samples were collected. The stool water content was analyzed, where ≤68.5% water content was classified as hard stool, while ≥78% was classified as diarrhea.

RESULTS

BSFS correlated to stool water content ( r = 0.36, P < 0.0001). The BSFS score increased in parallel with increasing water content, but with considerable overlap between BSFS scores. Stool water content differed between the BSFS categories 1-2, 3-5, and 6-7 (hard, normal, and loose, respectively) ( P < 0.0001). For BSFS categories 1-2, 77% had water content ≤68.5%, whereas for BSFS categories 6-7, 52% had water content ≥78%. There was no difference in stool water content after consumption of FODMAPs, gluten, or placebo ( P = 0.94).

DISCUSSION

Subjective reporting of BSFS conforms only modestly with stool water content in IBS, warranting caution when subtyping IBS according to the BSFS. High intake of FODMAPs and gluten does not affect stool water content.

Long-Term Outcome of Multidisciplinary Versus Standard Gastroenterologist Care for Functional Gastrointestinal Disorders: A Randomized Trial

BACKGROUND & AIMS

Functional gastrointestinal disorders are common and costly to the healthcare system. In the Multidisciplinary Treatment of Functional Gastrointestinal Disorders study, we demonstrated that multidisciplinary care resulted in superior clinical and cost outcomes, when compared with standard gastroenterologist-only care at end of treatment. In this study we evaluate the longer-term outcomes.

METHODS

In a single-center, pragmatic trial patients with Rome IV criteria-defined functional gastrointestinal disorders were randomized 1:2 to a gastroenterologist-only standard care vs a multidisciplinary clinic comprising gastroenterologists, dietitians, gut hypnotherapists, psychiatrists, and biofeedback physiotherapists. Outcomes in this study were assessed 12 months after the end of treatment. Global symptom improvement was assessed by using a 5-point Likert scale. Symptoms, specific disorder status, psychological state, quality of life, and cost were additional outcomes. A modified intention-to-treat analysis was performed.

RESULTS

Of 188 randomized patients, 143 (46 standard care, 97 multidisciplinary) formed the longer-term modified intention-to-treat analysis. Sixty-two percent of multidisciplinary clinic patients saw allied clinicians. Sixty-five percent (30/46) standard care versus 76% (74/97) multidisciplinary clinic patients achieved global symptom improvement 12 months after end of treatment (P = .17), whereas 20% (9/46) versus 37% (36/97) rated their symptoms as "5/5 much better" (P = .04). A ≥50-point reduction in Irritable Bowel Syndrome Severity Scoring System occurred in 38% versus 66% (P = .02), respectively, for irritable bowel syndrome patients. Anxiety and depression were greater in the standard care than multidisciplinary clinic (12 vs 10, P = .19), and quality of life was lower in standard care than the multidisciplinary clinic (0.75 vs 0.77, P =·.03). An incremental cost-effectivness ratio found that for every additional 3555AUD spent in the multidisciplinary clinic, a further quality-adjusted life year was gained.

CONCLUSIONS

Twelve months after the completion of treatment, integrated multidisciplinary clinical care achieved a greater proportion of patients with improvement of symptoms, psychological state, quality of life, and cost, compared with gastroenterologist-only care.

CLINICAL TRIALS

gov: number NCT03078634.

Efficacy and safety of fecal microbiota transplant in irritable bowel syndrome: An update based on meta‐analysis of randomized control trials

Background and Aims

Fecal microbiota transfer (FMT) is a potential treatment for irritable bowel syndrome (IBS). Several randomized trials have tested FMT effects using different routes of administration, doses, and sample sizes. We aim to assess the overall efficacy of FMT for IBS patients and the safety of the intervention.

Methods

We systematically searched four databases for randomized control trials that studied the efficacy and safety of FMT in IBS patients.

Results

We included 8 randomized trials (472 patients) that compared FMT with placebo in IBS patients. Pooled results showed no statistically significant difference between FMT and control groups in the overall change in IBS symptom severity (IBS‐SSS) at 1 month (p = 0.94), 3/4 months (p = 0.82), and at the end of trials (p = 0.67). No significant difference in the total number of respondents between the FMT and control groups (risk ratios = 1.84, [95% confidence interval (CI) = 0.82–2.65], p = 0.19). Although the oral route of administration showed a significant difference in the number of respondents (p = 0.004), there was no statistically significant difference in the IBS‐SSS when subgrouping the oral route of administration (mean difference = 47.57, [95% CI = −8.74–103.87], p = 0.10).

Conclusion

FMT is not an effective treatment to relieve all the symptoms of IBS. Even in the groups that showed relatively significant improvement after FMT, the effect was proven to wear off over time and the re‐administration carries a low success rate. Future research should consider different bacterial‐based interventions such as probiotics or specific antibiotics.

Hypermobile Ehlers-Danlos syndrome and disorders of the gastrointestinal tract: What the gastroenterologist needs to know

BACKGROUND AND AIM

Hypermobile Ehlers-Danlos syndrome (hEDS) and the hypermobility spectrum disorders (HSD) can be challenging to diagnose and manage. Gastrointestinal symptoms and disorders of gut-brain interaction are common in this cohort and multifactorial in origin. The primary aim of this review is to arm the gastroenterologist with a clinically useful understanding of HSD/hEDS, by exploring the association of gastrointestinal disorders with HSD/hEDS, highlighting current pathophysiological understanding and providing a pragmatic approach to managing these patients.

METHODS

Literature relevant to the gastrointestinal system and hypermobile Ehlers-Danlos syndrome was systematically searched, critically appraised, and summarized.

RESULTS

Diagnosis is based upon clinical criteria and a genetic basis is yet to be defined. The prevalence of many gut symptoms, including abdominal pain (69% vs 27%, P < 0.0001), postprandial fullness (34% vs 16%, P = 0.01), constipation (73% vs 16%, P < 0.001), and diarrhea (47% vs 9%, P < 0.001) are significantly higher in HSD/hEDS compared with non-HSD/hEDS individuals. Disorders of gut-brain interaction are also common, particularly functional dyspepsia. The pathophysiology of gut symptoms is poorly understood but may involve effects of connective tissue laxity and its functional consequences, and the influence of autonomic dysfunction, medication and comorbid mental health disorders. Awareness is the key to early diagnosis. Management is limited in evidence-base but ideally should include an integrated multidisciplinary approach.

CONCLUSIONS

HSD/hEDS is a multisystemic disorder in which gastrointestinal symptoms, particularly related to disorders of gut-brain interaction are common. Deficiencies in knowledge regarding the pathophysiological processes limit evidence-based interventions and remain important areas for future research.

Studies on irritable bowel syndrome associated with anxiety or depression in the last 20 years: A bibliometric analysis

Irritable bowel syndrome (IBS) associated with anxiety or depression is ubiquitous in clinical practice, and multiple related articles have been published. However, studies that utilize bibliometric analyses to address this topic are rare. In our study, we aimed to reveal research trends in IBS with anxiety or depression. Publications on IBS in relation to anxiety or depression in the last 20 years were obtained from the Web of Science Core Collection (WoSCC). CiteSpace software (5.8.R3) and GraphPad Prism 8 were used to perform bibliometric analysis of authors, countries, institutions, journals, keywords, and references involved in this topic. A total of 2,562 publications from 716 academic journals were included in this study. The majority of publications (n = 833, 32.51%) were from the USA, and the University of California, Los Angeles, contributed the most publications (n = 97, 3.79%). Active cooperations among countries and institutions were observed. Neurogastroenterology and Motility [impact factor (IF) 2020 = 3.598] published the most papers (170 publications, 6.64%), followed by Alimentary Pharmacology Therapeutics (IF 2020 = 8.171; 88 publications; 3.44%). The literatures related to IBS and anxiety or depression were primarily published in journals related to medicine/medical/clinical, neurology/sports/ophthalmology, and molecular/biology/immunology. Cryan JF and Drossman DA, with the largest number of articles (84 publications) and citations (917 citations), respectively, were considered as the most influential authors in this field. A total of 336 co-cited references were divided into 17 clusters, and #1 fecal microbiota transplantation contained most of the documents published in recent years. Moreover, the keyword "psychosocial factor" had the largest burst strength of 13.52, followed by the keyword "gut microbiota" with a burst strength of 11.71. This study shows the research performance of IBS related to anxiety or depression from 2002 to 2021 and helps researchers master the trend in this field, which should receive more attention.

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.

How to Implement the 3-Phase FODMAP Diet Into Gastroenterological Practice

Background/Aims

The 3-phase fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet has shown a high level of efficacy in irritable bowel syndrome, largely based on dietitian delivered education. However, access to dietitians can be limited, and challenges exist when applying the diet to a wide range of cultures, such as limited FODMAP analysis of local foods. This review aims to discuss ways to optimally use the FODMAP diet in practice in a wide range of cultures, directed at gastroenterologists from a dietitian's perspective.

Methods

Recent literature was analysed via search databases including Medline, CINAHL, PubMed and Scopus.

Results

The dietetic process involves detailed assessment and follow-up through the 3 stages of the FODMAP diet (restriction, re-introduction, and long-term maintenance). Emerging evidence suggests the diet can be delivered by other health professionals such as the gastroenterologist or nurse, but training on how to do so successfully would be needed. Self-guided approaches through use of technology or specialised food delivery services may be an alternative when dietitians are not available, but efficacy data is limited. Regardless of delivery mode, nutritional and psychological risks of the diet must be mitigated. Additionally, culturally appropriate education must be provided, with accommodations necessary when the FODMAP content of local foods are unknown.

Conclusion

While the diet has shown improved irritable bowel syndrome outcomes across studies, it is important to acknowledge the essential role of dietitians in implementing, tailoring, and managing the diet to achieve the best outcome for each individual.

Gastrointestinal effects of diets low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols

PURPOSE OF REVIEW

Food ingestion is an exacerbator of gastrointestinal symptoms, regardless of origin. Sufferers mistakenly assume that they have suffered an allergic reaction to a given food. Although classical IgE-mediated allergic reactions are rarely culpable, evidence for a role for intolerance to certain carbohydrates in irritable bowel syndrome (IBS) and related conditions increases. This review assesses the status of a commonly implicated group of poorly absorbed carbohydrates (fermentable oligosaccharides, disaccharides, monosaccharides and polyols - FODMAPs) in gastrointestinal pathophysiology.

RECENT FINDINGS

Although evidence of efficacy for low FODMAP diets in IBS accumulates, the magnitude of this effect has declined in recent studies. Comparisons to other dietary approaches have revealed conflicting results; some suggest superiority, others find parity. Concerns had been raised regarding long-term nutritional, psychological and microbiological impacts of FODMAP restriction; providing that the diet is administered in the recommended manner, these do not appear to be clinically important. The mechanisms whereby FODMAPs cause gastrointestinal symptoms continue to be explored.

SUMMARY

FODMAPS induce gastrointestinal symptoms in susceptible individuals and their restriction provides clinical benefits. The magnitude of these benefits, the superiority of FODMAP restriction over other dietary approaches and the mechanisms of its effects continue to be defined.

Irritable bowel syndrome with food-related symptoms: Future directions in the clinical management

The majority of patients with irritable bowel syndrome (IBS) experiences food-related symptoms, which are associated with high symptom burden, reduced quality of life, increased healthcare consumption and reduced intake of certain nutrients. In this review we aimed to describe a clinically useful approach for physicians, by presenting the latest progress in knowledge and its translation to management in IBS patients with food-related symptoms, as well as the underlying mechanisms involved. The research tools currently available that can be used in the future for a better characterization of this subgroup of patients are also discussed. Working towards this approach could lead to a more individualised work-up and management of IBS patients with food-related symptoms.

Review article: rethinking the "ladder" approach to reflux-like symptom management in the era of PPI "resistance" - a multidisciplinary perspective

BACKGROUND

Despite widespread adoption of potent acid suppression treatment with proton pump inhibitors (PPI) for reflux-like symptoms, persistent symptoms are commonly reported in primary care and community studies.

AIMS

This multidisciplinary review critically evaluates how the management of reflux-like symptoms could better reflect their multifactorial pathophysiology.

METHODS

A panel of experts (from general practice, gastroenterology and gastropsychology) attended a series of workshops to review current management and propose a framework for the provision of more individualised care.

RESULTS

It was agreed that the perceptual (as well as the physiological) causes of reflux-like symptoms should be considered at the start of management, not as a last resort when all else has failed. A short course of PPI is a pragmatic approach to address reflux-like symptoms, but equally important is counselling about the gut-brain axis and provision of symptom-specific behavioural interventions for those who show signs of somatisation, hypervigilance or co-existing disorders of gut-brain interaction. Other low-harm interventions such as lifestyle and dietary advice, should also be better integrated into care at an early stage. Multidisciplinary care management programmes (including dietary, weight loss, exercise and behavioural intervention) should be developed to promote greater self-management and take advantage of the general shift toward the use of remotely accessed health care resources.

CONCLUSIONS

Management of reflux-like symptoms should be adapted to reflect the advances in knowledge about the multifactorial aetiology of these symptoms, addressing both acid-related and behavioural components early in management. The time has come to treat the patient, not the "disease".

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

BACKGROUND & AIMS

Neither food intake nor the clinical characteristics of irritable bowel syndrome (IBS) patients with severe food avoidance and restriction have been investigated. The aim of our study was to identify those patients and to characterize their symptoms, quality of life, and nutrient intake.

METHODS

IBS patients who completed the IBS Quality of Life Instrument (IBS-QOL) at our secondar and tertiary center were included. The 3 questions constituting the food domain were used to identify patients with reported severe food avoidance and restriction. The patients also completed validated questionnaires to assess stool form (Bristol Stool Form), gastrointestinal (GI) symptom severity (z score of IBS Severity Scoring System and Gastrointestinal Symptom Rating Scale-IBS), psychological distress (Hospital Anxiety and Depression Scale), GI-specific anxiety (Visceral Sensitivity Index), and somatic symptom severity (z score of Symptom Checklist-90-Revised and Patient Health Questionnaire-15). A 4-day food diary was used to analyze food intake in 246 patients.

RESULTS

We included 955 IBS patients (75 % women; mean age 38.3 ± 13.3 years). In total, 13.2 % of the patients reported severe food avoidance and restriction, and in these patients all aspects of quality of life were lower (P < .01) and psychological, GI, and somatic symptoms were more severe (P < .05). Reported severe food avoidance and restriction was associated with lower total energy intake (P = .002) and lower intake of protein (P = .001) and carbohydrates (P = .005). In a logistic regression analysis, loose stools were found to be independently associated with reported severe food avoidance and restriction (R² = 0.062).

CONCLUSIONS

IBS patients with severe food avoidance and restriction constitute a subgroup with more severe symptoms overall, reduced quality of life, and reduced intake of nutrients. This needs to be acknowledged in the clinical management of these patients.

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.

Utilization of Dietitians in the Management of Irritable Bowel Syndrome by Members of the American College of Gastroenterology

INTRODUCTION

The aim of this study was to identify benefits and barriers to using a gastroenterology (GI) dietitian for irritable bowel syndrome (IBS) care.

METHODS

A 25-question survey was electronically distributed to the members of the American College of Gastroenterology. Information pertaining to demographics, barriers, and values to using a GI dietitian for IBS patient care was collected.

RESULTS

Two hundred seventy-nine survey responses were collected. Although 56% of the GI providers feel they are trained to provide nutrition education, almost half (46%) sometimes, rarely, or never provided information to aid menu planning, label reading, or grocery shopping, and 77% spent ≤10 minutes for nutrition counseling. Of those with access to a local dietitian, 91% strongly agreed or agreed that having access to a GI dietitian would help them manage their IBS patient care more effectively, but 42% lack access to a local GI dietitian.

DISCUSSION

Our survey identified gaps in nutrition-based interventions for IBS care.

Experience and clinical efficacy of gut‐directed hypnotherapy in an Asian population with refractory irritable bowel syndrome

Background and Aim

Recent studies have highlighted the high worldwide prevalence of irritable bowel syndrome (IBS) and disparities in its management between ethnic groups. For instance, gut‐directed hypnotherapy (GDH), one of the most effective evidence‐based treatments for IBS, is not recommended in Asian countries partly due to lack of population‐specific outcome data. In this context, we evaluated the outcomes of GDH in an Asian population.

Methods

Consecutive British Asian patients with refractory IBS who received 12‐sessions of GDH using the Manchester protocol were included. Patients were treated by a team including a therapist able to speak several Asian languages. All patients prospectively completed the following questionnaires before and after GDH: IBS symptom severity score (IBS‐SSS), hospital anxiety and depression scale (HADS), non‐colonic symptom score, and the quality‐of‐life (QOL) score. The primary outcome measure was response to GDH defined by ≥50‐point reduction in IBS‐SSS. Pre‐ and post‐treatment data were compared statistically.

Results

Forty‐four Asian patients with IBS (age 49 ± 13 years; 29 [66%] female; baseline IBS‐SSS: 332.8 ± 94.6) completed GDH. Overall, 37 of 44 (84%) achieved a ≥50‐point reduction in IBS‐SSS and 25 of 44 (57%) achieved ≥30% reduction in abdominal pain scores. Following GDH, there were also significant mean improvements in IBS‐SSS (−132.1, P < 0.0001), non‐colonic symptom score (P < 0.0001), QOL score (P < 0.0001), HADS‐anxiety (P < 0.0001), and HADS‐depression (P < 0.0001), compared with baseline.

Conclusion

Regardless of the ethnicity of the therapist, GDH was highly effective with similar response rates to outcomes in other IBS populations, supporting the development of GDH in Asian countries.

Delivery Methods of Cognitive Behavior Therapy for Patients With Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is the most commonly diagnosed gastrointestinal disorder and negatively impacts individuals' quality of life. Cognitive behavioral therapy appears effective for reducing symptoms in many irritable bowel syndrome patients. However, the optimal methods to deliver cognitive behavioral therapy and the effective treatment dosage for patients with IBS remain unclear. This article aims to provide an update on cognitive behavioral therapy research in IBS, particularly considering the dose of treatment, route of delivery (in-person vs. web- and telephone-based delivery), and outcome measures. A systematic literature review was conducted using databases of PubMed, CINAHL Complete, and Web of Science from 2008 through 2021. Twelve studies reporting randomized clinical trials comparing cognitive behavioral therapy delivered with in-person, telephone, and web for the management of IBS symptoms among adults with irritable bowel syndrome were found. The dose of treatment varied from 4 to 10 sessions. Six different scales measured various outcomes. No severe adverse reactions to cognitive behavioral therapy were reported. Cognitive behavioral therapy is an effective treatment for IBS symptoms regardless of the dose and the route of treatment. However, it is difficult to compare the effectiveness of these randomized clinical trials due to the various cognitive behavioral therapy protocols, combined routes of therapy delivery, and different outcome measures used.

AGA Clinical Practice Update on the Role of Diet in Irritable Bowel Syndrome: Expert Review

DESCRIPTION

Irritable bowel syndrome (IBS) is a commonly diagnosed gastrointestinal disorder that can have a substantial impact on quality of life. Most patients with IBS associate their gastrointestinal symptoms with eating food. Mounting evidence supports dietary modifications, such as the low-fermentable oligo-, di-, and monosaccharides and polyols (FODMAP) diet, as a primary treatment for IBS symptoms. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the role of diet in IBS treatment.

METHODS

This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet in treating patients with IBS. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Dietary advice is ideally prescribed to patients with IBS who have insight into their meal-related gastrointestinal symptoms and are motivated to make the necessary changes. To optimize the quality of teaching and clinical response, referral to a registered dietitian nutritionist (RDN) should be made to patients who are willing to collaborate with a RDN and patients who are not able to implement beneficial dietary changes on their own. If a gastrointestinal RDN is not available, other resources can assist with implementation of diet interventions. BEST PRACTICE ADVICE 2: Patients with IBS who are poor candidates for restrictive diet interventions include those consuming few culprit foods, those at risk for malnutrition, those who are food insecure, and those with an eating disorder or uncontrolled psychiatric disorder. Routine screening for disordered eating or eating disorders by careful dietary history is critical because they are common and often overlooked in gastrointestinal conditions. BEST PRACTICE ADVICE 3: Specific diet interventions should be attempted for a predetermined length of time. If there is no clinical response, the diet intervention should be abandoned for another treatment alternative, for example, a different diet, medication, or other form of therapy. BEST PRACTICE ADVICE 4: In preparation for a visit with a RDN, patients should provide dietary information that will assist in developing an individualized nutrition care plan. BEST PRACTICE ADVICE 5: Soluble fiber is efficacious in treating global symptoms of IBS. BEST PRACTICE ADVICE 6: The low-FODMAP diet is currently the most evidence-based diet intervention for IBS. Healthy eating advice as described by the National Institute of Health and Care Excellence Guidelines, among others, also offers benefit to a subset of patients with IBS. BEST PRACTICE ADVICE 7: The low-FODMAP diet consists of the following 3 phases: 1) restriction (lasting no more than 4-6 weeks), 2) reintroduction of FODMAP foods, and 3) personalization based on results from reintroduction. BEST PRACTICE ADVICE 8: Although observational studies found that most patients with IBS improve with a gluten-free diet, randomized controlled trials have yielded mixed results. BEST PRACTICE ADVICE 9: There are limited data showing that selected biomarkers can predict response to diet interventions in patients with IBS, but there is insufficient evidence to support their routine use in clinical practice.

The effects of slow deep breathing on microvascular and autonomic function and symptoms in adults with irritable bowel syndrome: A pilot study

BACKGROUND

Irritable bowel syndrome (IBS) is linked to disruptions in sympathovagal balance, which could impair vascular homeostasis and cause IBS symptoms. Studies have shown reductions in sympathetic activity following a single slow, deep breathing (SDB) bout in healthy adults; however, no studies have investigated its chronic effects in IBS. The purpose of this study was to evaluate the feasibility and impact of a SDB intervention on microvascular and autonomic function and symptoms in adults with IBS.

METHODS

Fourteen participants (ages 18-65 years) with IBS were randomly assigned to 4-week SDB or control conditions. The SDB group completed a 20-min video 5 times weekly while the control group maintained their normal activities. Microvascular endothelial function was measured using laser Doppler in response to thermal provocation and expressed as cutaneous vascular conductance at 39°C relative to a maximum response at 43.5°C (%CVC_max ). Heart rate variability (HRV) and post-exercise heart rate recovery (HRR) were employed as surrogate measures of autonomic function. IBS symptoms were assessed using the IBS-Severity Scale (IBS-SS).

KEY RESULTS

Thirteen participants (6 controls and 7 SDB) completed the study. Age (p = 0.541) and body mass index (p = 0.157) were similar between groups. In the SDB group, %CVC_max increased from 45% to 59% (p < 0.00001) after the 4-week intervention. HRV, HRR, and IBS-SS scores were unaltered.

CONCLUSIONS

and Inferences. These results demonstrate the feasibility of a SDB intervention in adults with IBS and suggest improvements in microvascular function in the absence of changes in symptoms or autonomic function in this population.