1
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Sia T, Tanaka RO, Mousad A, Narayan AP, Si K, Bacchus L, Ouerghi H, Patel A, Patel A, Cunningham E, Epstein T, Fu J, Liu S, Khuda R, McDonald P, Mallik S, McNulty J, Pan M, Leung J. Fructose malabsorption and fructan malabsorption are associated in patients with irritable bowel syndrome. BMC Gastroenterol 2024; 24:143. [PMID: 38654193 DOI: 10.1186/s12876-024-03230-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Food malabsorption and intolerance is implicated in gastrointestinal symptoms among patients with irritable bowel syndrome (IBS). Key triggers include fructose and fructan. Prior studies examined fructose and fructan malabsorption separately in IBS patients. None have concurrently assessed both within the same patient group. We aimed to investigate the association between fructose and fructan malabsorption in the same patients with IBS using hydrogen breath testing (HBT). METHODS We retrospectively identified patients with IBS who underwent fructose and fructan HBTs and abstracted their results from the electronic medical record. Fructose and fructan HBTs were performed by administering a 25 g fructose solution or 10 g fructan solution, followed by breath hydrogen readings every 30 min for 3 h. Patients were positive for fructose or fructan malabsorption if breath hydrogen levels exceeded 20 ppm. RESULTS Of 186 IBS patients, 71 (38.2%) were positive for fructose malabsorption and 91 (48.9%) were positive for fructan malabsorption. Of these patients, 42 (22.6%) were positive for fructose malabsorption and fructan malabsorption. Positive fructose HBT readings were significantly associated with positive fructan HBT readings (p = 0.0283). Patients positive for fructose malabsorption or fructan malabsorption had 1.951 times higher odds of testing positive for the other carbohydrate. CONCLUSIONS Our results reveal a clinically significant association between fructose malabsorption and fructan malabsorption in patients with IBS. Fructan malabsorption should be assessed in patients with fructose malabsorption, and vice versa. Further studies are required to identify the mechanisms underlying our findings.
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Affiliation(s)
- Twan Sia
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Riki O Tanaka
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Albert Mousad
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
| | - Aditya P Narayan
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Kristen Si
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Leeon Bacchus
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Hind Ouerghi
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Aashka Patel
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Arnav Patel
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Evan Cunningham
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Taylor Epstein
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Jerry Fu
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Stanley Liu
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Raisa Khuda
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Paige McDonald
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Shibani Mallik
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Joanna McNulty
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - Michelle Pan
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA
| | - John Leung
- Boston Specialists, 65 Harrison Ave #201, Boston, MA, 02111, USA.
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Capobianco I, Di Vincenzo F, Puca P, Becherucci G, Mentella MC, Petito V, Scaldaferri F. Adverse Food Reactions in Inflammatory Bowel Disease: State of the Art and Future Perspectives. Nutrients 2024; 16:351. [PMID: 38337636 PMCID: PMC10857040 DOI: 10.3390/nu16030351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Limited knowledge is available about the relationship between food allergies or intolerances and inflammatory bowel disease (IBD). Clinicians frequently encounter patients who report food allergies or intolerances, and gastroenterologists struggle distinguishing between patients with organic disorders and those with functional disorders, which the patients themselves may associate with specific dietary components. This task becomes even more arduous when managing patients with significant underlying organic conditions, like IBD. The aim of this review is to summarize and emphasize any actual associations between food allergies and intolerances and inflammatory diseases, such as ulcerative colitis and Crohn's disease. Through a narrative disceptation of the current literature, we highlight the increased prevalence of various food intolerances, including lactose, fructose, histamine, nickel, and non-celiac gluten sensitivity, in individuals with IBD. Additionally, we explore the association between increased epithelial barrier permeability in IBD and the development of food sensitization. By doing so, we aim to enhance clinicians' awareness of the nutritional management of patients with IBD when facing complaints or evidence of food allergies or intolerances.
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Affiliation(s)
- Ivan Capobianco
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.D.V.); (P.P.); (F.S.)
| | - Federica Di Vincenzo
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.D.V.); (P.P.); (F.S.)
| | - Pierluigi Puca
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.D.V.); (P.P.); (F.S.)
| | - Guia Becherucci
- UOC Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (M.C.M.)
| | - Maria Chiara Mentella
- UOC Nutrizione Clinica, Dipartimento di Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.B.); (M.C.M.)
| | - Valentina Petito
- IBD Unit, UOC CEMAD Centro Malattie dell’Apparato Digerente, Dipartimento di Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Franco Scaldaferri
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.D.V.); (P.P.); (F.S.)
- IBD Unit, UOC CEMAD Centro Malattie dell’Apparato Digerente, Dipartimento di Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
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3
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Tong W, Hannou SA, Sargsyan A, Zhang GF, Grimsrud PA, Astapova I, Herman MA. "Metformin Impairs Intestinal Fructose Metabolism". BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.17.537251. [PMID: 37131695 PMCID: PMC10153158 DOI: 10.1101/2023.04.17.537251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Objective To investigate the effects of metformin on intestinal carbohydrate metabolism in vivo. Method Male mice preconditioned with a high-fat, high-sucrose diet were treated orally with metformin or a control solution for two weeks. Fructose metabolism, glucose production from fructose, and production of other fructose-derived metabolites were assessed using stably labeled fructose as a tracer. Results Metformin treatment decreased intestinal glucose levels and reduced incorporation of fructose-derived metabolites into glucose. This was associated with decreased intestinal fructose metabolism as indicated by decreased enterocyte F1P levels and diminished labeling of fructose-derived metabolites. Metformin also reduced fructose delivery to the liver. Proteomic analysis revealed that metformin coordinately down-regulated proteins involved carbohydrate metabolism including those involved in fructolysis and glucose production within intestinal tissue. Conclusion Metformin reduces intestinal fructose metabolism, and this is associated with broad-based changes in intestinal enzyme and protein levels involved in sugar metabolism indicating that metformin's effects on sugar metabolism are pleiotropic.
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Affiliation(s)
- Wenxin Tong
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
| | - Sarah A. Hannou
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, Texas, USA
| | - Ashot Sargsyan
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
| | - Guo-Fang Zhang
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
- Division of Endocrinology, Metabolism, and Nutrition, Duke University, Durham, North Carolina, USA
| | - Paul A. Grimsrud
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
- Division of Endocrinology, Metabolism, and Nutrition, Duke University, Durham, North Carolina, USA
| | - Inna Astapova
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
- Division of Endocrinology, Metabolism, and Nutrition, Duke University, Durham, North Carolina, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, Texas, USA
| | - Mark A. Herman
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina, USA
- Division of Endocrinology, Metabolism, and Nutrition, Duke University, Durham, North Carolina, USA
- Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, Texas, USA
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4
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Jang J, Hwang S, Oh AR, Park S, Yaseen U, Kim JG, Park S, Jung Y, Cha JY. Fructose malabsorption in ChREBP-deficient mice disrupts the small intestine immune microenvironment and leads to diarrhea-dominant bowel habit changes. Inflamm Res 2023; 72:769-782. [PMID: 36813915 DOI: 10.1007/s00011-023-01707-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The mechanism by which incompletely absorbed fructose causes gastrointestinal symptoms is not fully understood. In this study, we investigated the immunological mechanisms of bowel habit changes associated with fructose malabsorption by examining Chrebp-knockout mice exhibiting defective fructose absorption. METHODS Mice were fed a high-fructose diet (HFrD), and stool parameters were monitored. The gene expression in the small intestine was analyzed by RNA sequencing. Intestinal immune responses were assessed. The microbiota composition was determined by 16S rRNA profiling. Antibiotics were used to assess the relevance of microbes for HFrD-induced bowel habit changes. RESULTS Chrebp-knockout (KO) mice fed HFrD showed diarrhea. Small-intestine samples from HFrD-fed Chrebp-KO mice revealed differentially expressed genes involved in the immune pathways, including IgA production. The number of IgA-producing cells in the small intestine decreased in HFrD-fed Chrebp-KO mice. These mice showed signs of increased intestinal permeability. Chrebp-KO mice fed a control diet showed intestinal bacterial imbalance, which the HFrD exaggerated. Bacterial reduction improved diarrhea-associated stool parameters and restored the decreased IgA synthesis induced in HFrD-fed Chrebp-KO mice. CONCLUSIONS The collective data indicate that gut microbiome imbalance and disrupting homeostatic intestinal immune responses account for the development of gastrointestinal symptoms induced by fructose malabsorption.
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Affiliation(s)
- Jinsun Jang
- Department of Health Science and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Inchon, Korea
| | - Soonjae Hwang
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, College of Medicine, Gachon University, 155 Gaetbeol-ro, Yeonsu-gu, Inchon, 21999, Korea
| | - Ah-Reum Oh
- Department of Health Science and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Inchon, Korea.,Department of Biomedical Sciences, College of Medicine, Inha University, Incheon, 22212, Korea
| | - Sohyeon Park
- Department of Health Science and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Inchon, Korea
| | - Uzma Yaseen
- Department of Health Science and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Inchon, Korea
| | - Jae Gon Kim
- Department of Microbiology, Lee Gil Ya Cancer and Diabetes Institute, College of Medicine, Gachon University, 155 Gaetbeol-ro, Yeonsu-gu, Inchon, 21999, Korea
| | - Sangbin Park
- Department of Health Science and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Inchon, Korea
| | - YunJae Jung
- Department of Health Science and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Inchon, Korea. .,Department of Microbiology, Lee Gil Ya Cancer and Diabetes Institute, College of Medicine, Gachon University, 155 Gaetbeol-ro, Yeonsu-gu, Inchon, 21999, Korea.
| | - Ji-Young Cha
- Department of Health Science and Technology, Gachon Advanced Institute for Health Science and Technology, Gachon University, Inchon, Korea. .,Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, College of Medicine, Gachon University, 155 Gaetbeol-ro, Yeonsu-gu, Inchon, 21999, Korea. .,Department of Biomedical Sciences, College of Medicine, Inha University, Incheon, 22212, Korea.
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5
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Portincasa P, Celano G, Serale N, Vitellio P, Calabrese FM, Chira A, David L, Dumitrascu DL, De Angelis M. Clinical and Metabolomic Effects of Lactiplantibacillus plantarum and Pediococcus acidilactici in Fructose Intolerant Patients. Nutrients 2022; 14:nu14122488. [PMID: 35745219 PMCID: PMC9231202 DOI: 10.3390/nu14122488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 12/10/2022] Open
Abstract
Fructose intolerance (FI) is a widespread non-genetic condition in which the incomplete absorption of fructose leads to gastro-intestinal disorders. The crucial role of microbial dysbiosis on the onset of these intolerance symptoms together with their persistence under free fructose diets are driving the scientific community towards the use of probiotics as a novel therapeutic approach. In this study, we evaluated the prevalence of FI in a cohort composed of Romanian adults with Functional Grastrointestinal Disorders (FGIDs) and the effectiveness of treatment based on the probiotic formulation EQBIOTA® (Lactiplantibacillus plantarum CECT 7484 and 7485 and Pediococcus acidilactici CECT 7483). We evaluated the impact of a 30-day treatment both on FI subjects and healthy volunteers. The gastrointestinal symptoms and fecal volatile metabolome were evaluated. A statistically significant improvement of symptoms (i.e., bloating, and abdominal pain) was reported in FI patient after treatment. On the other hand, at the baseline, the content of volatile metabolites was heterogeneously distributed between the two study arms, whereas the treatment led differences to decrease. From our analysis, how some metabolomics compounds were correlated with the improvement and worsening of clinical symptoms clearly emerged. Preliminary observations suggested how the improvement of gastrointestinal symptoms could be induced by the increase of anti-inflammatory and protective substrates. A deeper investigation in a larger patient cohort subjected to a prolonged treatment would allow a more comprehensive evaluation of the probiotic treatment effects.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica “A. Murri”, Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, 70124 Bari, Italy
- Correspondence: (P.P.); (D.L.D.); (M.D.A.)
| | - Giuseppe Celano
- Dipartimento di Scienze del Suolo, della Pianta e Degli Alimenti, Università Degli Studi di Bari Aldo Moro, 70126 Bari, Italy; (G.C.); (N.S.); (P.V.); (F.M.C.)
| | - Nadia Serale
- Dipartimento di Scienze del Suolo, della Pianta e Degli Alimenti, Università Degli Studi di Bari Aldo Moro, 70126 Bari, Italy; (G.C.); (N.S.); (P.V.); (F.M.C.)
| | - Paola Vitellio
- Dipartimento di Scienze del Suolo, della Pianta e Degli Alimenti, Università Degli Studi di Bari Aldo Moro, 70126 Bari, Italy; (G.C.); (N.S.); (P.V.); (F.M.C.)
| | - Francesco Maria Calabrese
- Dipartimento di Scienze del Suolo, della Pianta e Degli Alimenti, Università Degli Studi di Bari Aldo Moro, 70126 Bari, Italy; (G.C.); (N.S.); (P.V.); (F.M.C.)
| | - Alexandra Chira
- 2nd Department of Internal Medicine, ‘Iuliu Hatieganu’ University of Medicine and Farmacy, 400012 Cluj-Napoca, Romania; (A.C.); (L.D.)
| | - Liliana David
- 2nd Department of Internal Medicine, ‘Iuliu Hatieganu’ University of Medicine and Farmacy, 400012 Cluj-Napoca, Romania; (A.C.); (L.D.)
| | - Dan L. Dumitrascu
- 2nd Department of Internal Medicine, ‘Iuliu Hatieganu’ University of Medicine and Farmacy, 400012 Cluj-Napoca, Romania; (A.C.); (L.D.)
- Correspondence: (P.P.); (D.L.D.); (M.D.A.)
| | - Maria De Angelis
- Dipartimento di Scienze del Suolo, della Pianta e Degli Alimenti, Università Degli Studi di Bari Aldo Moro, 70126 Bari, Italy; (G.C.); (N.S.); (P.V.); (F.M.C.)
- Correspondence: (P.P.); (D.L.D.); (M.D.A.)
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6
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Leow CHW, Tan B, Miyashita M, Lee JKW. Cultural differences in hydration practices among physically active individuals: a narrative review. J Int Soc Sports Nutr 2022; 19:150-163. [PMID: 35599916 PMCID: PMC9116399 DOI: 10.1080/15502783.2022.2057196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
It is well-established that appropriate hydration practices are essential in promoting health and optimizing performance and recovery. However, evidence-based hydration guidelines may not be adopted due to cultural differences across countries, such as religious beliefs, traditions, preferences, and beverage availability. Examples of hydration practices influenced by culture include beer consumption after sports in Western countries, consumption of sugarcane juice in India and Ramadan fasting among Muslims. For most cultural hydration practices, there is limited scientific evidence on their effects on rehydration, exercise performance, and recovery. Despite possible benefits of various hydration practices on exercise performance and recovery, they are inconsistent with current evidence-based hydration recommendations. More research on the impacts of cultural hydration differences on physiology, performance, and recovery is warranted to allow evidence-based guidelines and advisories. Abbreviations: ABV: alcohol by volume, ACSM: American College of Sports Medicine, NATA: National Athletic Trainers’ Association, ROS: reactive oxygen species, TCM: Traditional Chinese Medicine
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Affiliation(s)
- Clarence Hong Wei Leow
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, 2 Medical Drive, National University of Singapore, Singapore
- Campus for Research Excellence and Technological Enterprise (CREATE), Singapore
| | - Beverly Tan
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, 2 Medical Drive, National University of Singapore, Singapore
| | | | - Jason Kai Wei Lee
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, 2 Medical Drive, National University of Singapore, Singapore
- Campus for Research Excellence and Technological Enterprise (CREATE), Singapore
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- N.1 Institute for Health, National University of Singapore, Singapore
- Global Asia Institute, National University of Singapore, Singapore
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7
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Hammer HF, Fox MR, Keller J, Salvatore S, Basilisco G, Hammer J, Lopetuso L, Benninga M, Borrelli O, Dumitrascu D, Hauser B, Herszenyi L, Nakov R, Pohl D, Thapar N, Sonyi M. European guideline on indications, performance, and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Neurogastroenterology and Motility, and European Society for Paediatric Gastroenterology Hepatology and Nutrition consensus. United European Gastroenterol J 2021; 10:15-40. [PMID: 34431620 PMCID: PMC8830282 DOI: 10.1002/ueg2.12133] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Measurement of breath hydrogen (H2) and methane (CH4) excretion after ingestion of test‐carbohydrates is used for different diagnostic purposes. There is a lack of standardization among centers performing these tests and this, together with recent technical developments and evidence from clinical studies, highlight the need for a European guideline. Methods This consensus‐based clinical practice guideline defines the clinical indications, performance, and interpretation of H2‐CH4‐breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 44 experts from 18 European countries. Eighty eight statements and recommendations were drafted based on a review of the literature. Consensus (≥80% agreement) was reached for 82. Quality of evidence was evaluated using validated criteria. Results The guideline incorporates new insights into the role of symptom assessment to diagnose carbohydrate (e.g., lactose) intolerances and recommends that breath tests for carbohydrate malabsorption require additional validated concurrent symptom evaluation to establish carbohydrate intolerance. Regarding the use of breath tests for the evaluation of oro‐cecal transit time and suspected small bowel bacterial overgrowth, this guideline highlights confounding factors associated with the interpretation of H2‐CH4‐breath tests in these indications and recommends approaches to mitigate these issues. Conclusion This clinical practice guideline should facilitate pan‐European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, it identifies areas of future research needs to clarify diagnostic and therapeutic approaches.
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Affiliation(s)
- Heinz F Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Mark R Fox
- Centre for Integrative Gastroenterology, Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Klinik Arlesheim, Arlesheim, Switzerland.,Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, Academic Hospital of the University of Hamburg, Hamburg, Germany
| | - Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy
| | - Guido Basilisco
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Johann Hammer
- Department of Gastroenterology and Hepatology, University Hospital of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Loris Lopetuso
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italia.,Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK
| | - Dan Dumitrascu
- Department of Gastroenterology, Clinica Medicala 2, Cluj-Napoca, Romania
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, KidZ Health Castle UZ Brussel, Brussels, Belgium
| | - Laszlo Herszenyi
- Department of Gastroenterology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Radislav Nakov
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK.,Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Marc Sonyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria.,Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
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8
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Kwiecień J, Hajzler W, Kosek K, Balcerowicz S, Grzanka D, Gościniak W, Górowska-Kowolik K. No Correlation between Positive Fructose Hydrogen Breath Test and Clinical Symptoms in Children with Functional Gastrointestinal Disorders: A Retrospective Single-Centre Study. Nutrients 2021; 13:2891. [PMID: 34445050 PMCID: PMC8401680 DOI: 10.3390/nu13082891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 12/04/2022] Open
Abstract
Fructose malabsorption is regarded as one of the most common types of sugar intolerance. However, the correlation between gastrointestinal symptoms and positive results in fructose hydrogen breath tests (HBTs) remains unclear. The aim of this study was to assess the clinical importance of positive fructose HBT by correlating the HBT results with clinical features in children with various gastrointestinal symptoms. Clinical features and fructose HBT results were obtained from 323 consecutive children (2-18 years old, mean 10.7 ± 4.3 years) that were referred to the Tertiary Paediatric Gastroenterology Centre and diagnosed as having functional gastrointestinal disorders. A total of 114 out of 323 children (35.3%) had positive HBT results, of which 61 patients were females (53.5%) and 53 were males (46.5%). Children with positive HBT were significantly younger than children with negative HBT (9.0 vs. 11.6 years old; p < 0.001). The most frequent symptom among children with fructose malabsorption was recurrent abdominal pain (89.5%). Other important symptoms were diarrhoea, nausea, vomiting, and flatulence. However, no correlation between positive fructose HBT results and any of the reported symptoms or general clinical features was found. In conclusion, positive fructose HBT in children with functional gastrointestinal disorders can be attributed to their younger age but not to some peculiar clinical feature of the disease.
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Affiliation(s)
- Jarosław Kwiecień
- Department of Paediatrics, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 41-800 Zabrze, Poland;
| | - Weronika Hajzler
- Faculty of Medical Sciences in Zabrze, Doctoral School, Medical University of Silesia, 41-800 Zabrze, Poland;
| | - Klaudia Kosek
- Faculty of Medical Sciences in Zabrze, Students’ Scientific Association of the Medical University in Silesia, 41-800 Zabrze, Poland; (K.K.); (D.G.); (W.G.)
| | - Sylwia Balcerowicz
- Clinical Hospital No 1 in Zabrze, Medical University of Silesia, 41-800 Zabrze, Poland;
| | - Dominika Grzanka
- Faculty of Medical Sciences in Zabrze, Students’ Scientific Association of the Medical University in Silesia, 41-800 Zabrze, Poland; (K.K.); (D.G.); (W.G.)
| | - Weronika Gościniak
- Faculty of Medical Sciences in Zabrze, Students’ Scientific Association of the Medical University in Silesia, 41-800 Zabrze, Poland; (K.K.); (D.G.); (W.G.)
| | - Katarzyna Górowska-Kowolik
- Department of Paediatrics, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 41-800 Zabrze, Poland;
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9
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Helwig U, Koch AK, Reichel C, Jessen P, Büning J, Schreiber S, Langhorst J. A Prospective Multicenter Study on the Prevalence of Fructose Malabsorption in Patients with Chronic Inflammatory Bowel Disease. Digestion 2021; 102:397-403. [PMID: 32516791 DOI: 10.1159/000507851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 04/12/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Patients with chronic inflammatory bowel disease (IBD) might have a higher prevalence of fructose malabsorption than healthy controls. This study's aim was to determine the prevalence and symptom severity of fructose malabsorption in patients with active and inactive IBD. METHODS The present study was a multicenter noninterventional diagnostic pilot trial. Two hundred fifty-one participants were recruited from 12 outpatient clinics for internal medicine across Germany and from the University of Kiel. Fructose malabsorption was diagnosed by hydrogen breath testing. Patients diagnosed with bacterial overgrowth, non-H2 producers, and patients who were tested positive for lactose malabsorption were excluded. Gastrointestinal symptoms during breath testing were evaluated using four-point subjective items to determine severity of bloating, abdominal pain, and diarrhea. RESULTS Two hundred five patients (45 with active IBD, 80 with IBD in remission, and 81 healthy controls) were analyzed. The number of patients diagnosed with fructose malabsorption - 35/44 (79.6%) in patients with active IBD, 59/80 (73.8%) inactive IBD, and 66/81 (81.5%) in healthy controls - did not differ between the groups (χ2 [2, N = 205] = 1.48, p = 0.48). However, abdominal pain was more frequent in patients with active IBD than patients with IBD in remission (z = -2.936, p = 0.010), and diarrhea was more frequent in patients with active IBD than in healthy controls (z = 2.489, p = 0.038). CONCLUSIONS Fructose malabsorption is not more common among patients with IBD than healthy subjects. However, the greater prevalence of patient-reported symptoms among patients with IBD may be of pathological and therapeutic relevance.
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Affiliation(s)
- Ulf Helwig
- Medical Practice for Internal Medicine Oldenburg, Oldenburg, Germany, .,Department of Internal Medicine, Christian-Albrechts University of Kiel, Kiel, Germany,
| | - Anna K Koch
- Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine Essen, University of Duisburg-Essen, Essen, Germany
| | - Christoph Reichel
- Rehabilitation Center Bad Brückenau, Clinic Hartwald, Bad Brückenau, Germany.,Institute of Hygiene and Public Health, Bad Brückenau, Germany
| | - Petra Jessen
- Medical Practice for Internal Medicine, Kiel, Germany
| | - Jürgen Büning
- Medical Practice for Gastroenterology Lübeck, Lübeck, Germany
| | - Stefan Schreiber
- Department of Internal Medicine, Christian-Albrechts University of Kiel, Kiel, Germany
| | - Jost Langhorst
- Department of Internal and Integrative Medicine, Klinikum Bamberg, Bamberg, Germany.,Chair for Integrative Medicine, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
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10
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Staubach P, Koch AK, Langhorst J, Schreiber S, Röcken C, Helwig U. Expression of the fructose transporter GLUT5 in patients with fructose malabsorption. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:531-539. [PMID: 34130330 DOI: 10.1055/a-1156-4386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with abdominal symptoms are frequently diagnosed with fructose malabsorption (FM). Fructose is absorbed by monosaccharide transporters located in the brush border of the human small intestine. The aim of this study was to investigate the histoanatomical distribution of the main fructose transporter GLUT5. MATERIALS AND METHODS We studied 223 patients diagnosed with FM by a hydrogen breath test and grouped according to their response to a fructose-free diet. The control group were 42 healthy individuals and 29 patients with celiac disease (CD). The fructose breath test was done with 50 g fructose. The expression of Glut5 in duodenal biopsy specimens was studied by immunohistochemistry. The Kruskal-Wallis-test and Mann-Whitney U-test were used to carry out the statistical analysis. RESULTS The histoanatomical expression pattern of GLUT5 did not differ significantly between those patients with FM who responded completely to a fructose-free diet (n = 183) and healthy individuals (n = 42); nor did it correlate to H2 production measured in fructose breath testing. In patients with FM, the GLUT5 expression pattern did not differ between those individuals responding to a fructose-free diet and those who did not. However, GLUT5 expression pattern was significantly different in patients with CD (n = 29) compared to patients with FM and to healthy individuals (p = 0.009). CONCLUSION GLUT5 expression patterns are not be related to adult patients with FM. However, in secondary malabsorption, a decreased GLUT5 expression was found. Further investigation is needed to understand the essential factors in FM and the influence on functional gastrointestinal disorders.
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Affiliation(s)
- Pia Staubach
- Department of Pathology, Christian-Albrechts-University Kiel, Germany
| | - Anna Katharina Koch
- Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, University of Duisburg-Essen, Germany
| | - Jost Langhorst
- Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, University of Duisburg-Essen, Germany
| | - Stefan Schreiber
- Department of Internal Medicine, Christian-Albrechts-University Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, Christian-Albrechts-University Kiel, Germany
| | - Ulf Helwig
- Specialist Practice for Internal Medicine, Oldenburg, Oldenburg Germany.,Department of Internal Medicine, Christian-Albrechts-University Kiel, Germany
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11
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Abstract
Volatolomics allows us to elucidate cell metabolic processes in real time. In particular, a volatile organic compound (VOC) excreted from our bodies may be specific for a certain disease, such that measuring this VOC may afford a simple, fast, accessible and safe diagnostic approach. Yet, finding the optimal endogenous volatile marker specific to a pathology is non-trivial because of interlaboratory disparities in sample preparation and analysis, as well as high interindividual variability. These limit the sensitivity and specificity of volatolomics and its applications in biological and clinical fields but have motivated the development of induced volatolomics. This approach aims to overcome issues by measuring VOCs that result not from an endogenous metabolite but, rather, from the pathogen-specific or metabolic-specific enzymatic metabolism of an exogenous biological or chemical probe. In this Review, we introduce volatile-compound-based probes and discuss how they can be exploited to detect and discriminate pathogenic infections, to assess organ function and to diagnose and monitor cancers in real time. We focus on cases in which labelled probes have informed us about metabolic processes and consider the potential and drawbacks of the probes for clinical trials. Beyond diagnostics, VOC-based probes may also be effective tools to explore biological processes more generally.
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12
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Triose Kinase Controls the Lipogenic Potential of Fructose and Dietary Tolerance. Cell Metab 2020; 32:605-618.e7. [PMID: 32818435 DOI: 10.1016/j.cmet.2020.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 04/16/2020] [Accepted: 07/28/2020] [Indexed: 01/01/2023]
Abstract
The surge in fructose consumption is a major factor behind the rapid rise of nonalcoholic fatty liver disease in modern society. Through flux and genetic analyses, we demonstrate that fructose is catabolized at a much higher rate than glucose, and triose kinase (TK) couples fructolysis with lipogenesis metabolically and transcriptionally. In the absence of TK, fructose oxidation is accelerated through the activation of aldehyde dehydrogenase (ALDH) and serine biosynthesis, accompanied by increased oxidative stress and fructose aversion. TK is also required by the endogenous fructolysis pathway to drive lipogenesis and hepatic triglyceride accumulation under high-fat diet and leptin-deficient conditions. Intriguingly, a nonsynonymous TK allele (rs2260655_A) segregated during human migration out of Africa behaves as TK null for its inability to rescue fructose toxicity and increase hepatic triglyceride accumulation. Therefore, we posit TK as a metabolic switch controlling the lipogenic potential of fructose and its dietary tolerance.
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13
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Sicchieri JMF, Junqueira G, Manca CS, Navarro AM, de Oliveira RB. High intestinal hydrogen production in runners after intake of fructose solution. J Breath Res 2020; 14:041002. [PMID: 32663815 DOI: 10.1088/1752-7163/aba5f4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Fructose intake is associated with increased consumption of processed foods, specifically in the context of nutritional supplements. To assess gastrointestinal symptoms and hydrogen production after the ingestion of a fructose solution in runners, healthy and sick persons. Hydrogen test (H2 test) was performed after the intake a solution with 50 g fructose along with the application of a questionnaire to evaluate the gastrointestinal symptoms during the H2 test in three groups: Athletes group (AG); control group (CG) with healthy subjects; and non-alcoholic fatty liver disease group (NAFLDG). Statistical analysis was performed with analysis of variance at a p < 0.05 significance level. The AG was the largest H2 producer followed by the CG with significant difference between the AG and NAFLDG (p ≤ 0.05). Most participants remained asymptomatic, but the strongest correlation was the symptom of bloating GC (R = 0.625), eructation in NAFLD (R = 0.481) and diarrhea in CG (R = 0.345) and AG (R = 0.338) The result of the present study suggests the production of hydrogen by the colon following the administration of fructose is higher in athletes compared with healthy individuals and persons with NAFLD, showing that fructose intake may be an interesting point of dietary management, especially in elite professionals.
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14
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Amieva-Balmori M, Coss-Adame E, Rao NS, Dávalos-Pantoja BM, Rao SSC. Diagnostic Utility of Carbohydrate Breath Tests for SIBO, Fructose, and Lactose Intolerance. Dig Dis Sci 2020; 65:1405-1413. [PMID: 31617133 DOI: 10.1007/s10620-019-05889-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/09/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Unexplained bloating, gas, and pain are common symptoms. If routine tests are negative, such patients are often labeled as irritable bowel syndrome. AIMS To determine the diagnostic utility of breath tests that assess for small intestinal bacterial overgrowth (SIBO), fructose or lactose intolerance, and the predictive value of symptoms. METHODS Patients with gas, bloating, diarrhea, abdominal pain (≥ 6 months), and negative endoscopy and radiology tests were assessed with symptom questionnaires, glucose (75 g), fructose (25 g), or lactose (25 g) breath tests. Breath tests were categorized as positive when H2 (≥ 20 ppm) or CH4 (≥ 15 ppm) increased above baseline values or as hypersensitive when symptoms changed significantly without rise in H2/CH4 or as negative. RESULTS 1230 patients (females = 878) underwent 2236 breath tests. The prevalence of SIBO was 33% (294/883), fructose intolerance was 34% (262/763), and lactose intolerance was 44% (260/590). Hypersensitivity was found in 16% and 9%, respectively, during fructose and lactose breath tests. Although gas (89%), abdominal pain (82%), and bloating (82%) were highly prevalent, pretest symptoms or their severity did not predict an abnormal breath test, but symptoms during the breath test facilitated diagnosis of SIBO, fructose, and lactose intolerance and hypersensitivity. CONCLUSIONS Approximately 45% of patients with unexplained gas and bloating had SIBO, fructose, or lactose intolerance; another 9-16% had visceral hypersensitivity. Pretest symptoms were poor predictors, but symptoms during the breath tests were useful. Breath tests are safe, provide significant diagnostic yield, and could be useful in routine gastroenterology practice.
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Affiliation(s)
- Mercedes Amieva-Balmori
- Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA.,Universidad Veracruzana, Veracruz, Mexico
| | - Enrique Coss-Adame
- Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA.,Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Nikilesh S Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Brisa M Dávalos-Pantoja
- Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Augusta University, 1120 15th Street, Augusta, GA, 30912, USA.
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15
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Wang XJ, Camilleri M, Vanner S, Tuck C. Review article: biological mechanisms for symptom causation by individual FODMAP subgroups - the case for a more personalised approach to dietary restriction. Aliment Pharmacol Ther 2019; 50:517-529. [PMID: 31309595 DOI: 10.1111/apt.15419] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/16/2019] [Accepted: 06/24/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Due to the paucity of targeted therapy for irritable bowel syndrome (IBS), many patients turn to dietary modifications for symptom management. The combination of five subgroups of poorly absorbed and rapidly fermented carbohydrates-fructans, galacto-oligosaccharides, lactose, excess fructose and polyols-are thought to trigger gastrointestinal symptoms and are referred to collectively as "FODMAPs". AIMS To examine the biological plausibility and mechanisms by which foods high in specific FODMAP subgroups cause symptoms, and to use this information to explore the possibility of targeting select dietary components to allow for a more personalised approach to dietary adjustment METHODS: Recent literature was analysed via search databases including Medline, PubMed and Scopus. RESULTS Lactose, fructans and galacto-oligosaccharides have strong biologic plausibility for symptom generation due to lack of hydrolases resulting in distention from osmosis and rapid fermentation. However, excess fructose and polyols may only cause symptoms in specific individuals when consumed in high doses, but this remains to be established. There is evidence to suggest that certain patient characteristics such as ethnicity may predict response to lactose, but differentiation of other subgroups is difficult prior to dietary manipulation. CONCLUSIONS While some clear mechanisms of action for symptom generation have been established, further research is needed to understand which patients will respond to specific FODMAP subgroup restriction. We suggest that clinicians consider in some patients a tailored, personalised "bottom-up" approach to the low-FODMAP diet, such as dietary restriction relevant to the patients' ethnicity, symptom profile and usual dietary intake.
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Affiliation(s)
- Xiao Jing Wang
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen Vanner
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Caroline Tuck
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
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16
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Laing BB, Lim AG, Ferguson LR. A Personalised Dietary Approach-A Way Forward to Manage Nutrient Deficiency, Effects of the Western Diet, and Food Intolerances in Inflammatory Bowel Disease. Nutrients 2019; 11:nu11071532. [PMID: 31284450 PMCID: PMC6683058 DOI: 10.3390/nu11071532] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/29/2019] [Accepted: 07/02/2019] [Indexed: 12/12/2022] Open
Abstract
This review discusses the personalised dietary approach with respect to inflammatory bowel disease (IBD). It identifies gene–nutrient interactions associated with the nutritional deficiencies that people with IBD commonly experience, and the role of the Western diet in influencing these. It also discusses food intolerances and how particular genotypes can affect these. It is well established that with respect to food there is no “one size fits all” diet for those with IBD. Gene–nutrient interactions may help explain this variability in response to food that is associated with IBD. Nutrigenomic research, which examines the effects of food and its constituents on gene expression, shows that—like a number of pharmaceutical products—food can have beneficial effects or have adverse (side) effects depending on a person’s genotype. Pharmacogenetic research is identifying gene variants with adverse reactions to drugs, and this is modifying clinical practice and allowing individualised treatment. Nutrigenomic research could enable individualised treatment in persons with IBD and enable more accurate tailoring of food intake, to avoid exacerbating malnutrition and to counter some of the adverse effects of the Western diet. It may also help to establish the dietary pattern that is most protective against IBD.
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Affiliation(s)
- Bobbi B Laing
- Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
- Nutrition Society of New Zealand, Palmerston North 4444, New Zealand
| | - Anecita Gigi Lim
- Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Lynnette R Ferguson
- Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand.
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17
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Güntner AT, Abegg S, Königstein K, Gerber PA, Schmidt-Trucksäss A, Pratsinis SE. Breath Sensors for Health Monitoring. ACS Sens 2019; 4:268-280. [PMID: 30623644 DOI: 10.1021/acssensors.8b00937] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Breath sensors can revolutionize medical diagnostics by on-demand detection and monitoring of health parameters in a noninvasive and personalized fashion. Despite extensive research for more than two decades, however, only a few breath sensors have been translated into clinical practice. Actually, most never even left the scientific laboratories. Here, we describe key challenges that currently impede realization of breath sensors and highlight strategies to overcome them. Specifically, we start with breath marker selection (with emphasis on metabolic and inflammatory markers) and breath sampling. Next, the sensitivity, stability, and selectivity requirements for breath sensors are described. Concepts are elaborated to systematically address these requirements by material design (focusing on chemoresistive metal oxides), orthogonal arrays, and filters. Finally, aspects of portable device integration, user communication, and clinical applicability are discussed.
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Affiliation(s)
- Andreas T. Güntner
- Particle Technology Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, CH-8092 Zurich, Switzerland
- Department of Endocrinology, Diabetes, and Clinical Nutrition, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Sebastian Abegg
- Particle Technology Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, CH-8092 Zurich, Switzerland
| | - Karsten Königstein
- Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, CH-4052 Basel, Switzerland
| | - Philipp A. Gerber
- Department of Endocrinology, Diabetes, and Clinical Nutrition, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Arno Schmidt-Trucksäss
- Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, CH-4052 Basel, Switzerland
| | - Sotiris E. Pratsinis
- Particle Technology Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, CH-8092 Zurich, Switzerland
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18
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Abstract
Fructose in the form of sucrose and high fructose corn syrup is absorbed by the intestinal transporter and mainly metabolized in the small intestine. However, excess intake of fructose overwhelms the absorptive capacity of the small intestine, leading to fructose malabsorption. Carbohydrate response element-binding protein (ChREBP) is a basic helix-loop-helix leucine zipper transcription factor that plays a key role in glycolytic and lipogenic gene expression in response to carbohydrate consumption. While ChREBP was initially identified as a glucose-responsive factor in the liver, recent evidence suggests that ChREBP is essential for fructoseinduced lipogenesis and gluconeogenesis in the small intestine as well as in the liver. We recently identified that the loss of ChREBP leads to fructose intolerance via insufficient induction of genes involved in fructose transport and metabolism in the intestine. As fructose consumption is increasing and closely associated with metabolic and gastrointestinal diseases, a comprehensive understanding of cellular fructose sensing and metabolism via ChREBP may uncover new therapeutic opportunities. In this mini review, we briefly summarize recent progress in intestinal fructose metabolism, regulation and function of ChREBP by fructose, and delineate the potential mechanisms by which excessive fructose consumption may lead to irritable bowel syndrome.
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Affiliation(s)
- Ho-Jae Lee
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, Gachon University College of Medicine, Incheon 21999, Korea
| | - Ji-Young Cha
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, Gachon University College of Medicine, Incheon 21999; Gachon Medical Institute, Gil Medical Center, Incheon 21565, Korea
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Oh AR, Sohn S, Lee J, Park JM, Nam KT, Hahm KB, Kim YB, Lee HJ, Cha JY. ChREBP deficiency leads to diarrhea-predominant irritable bowel syndrome. Metabolism 2018; 85:286-297. [PMID: 29669261 PMCID: PMC7400734 DOI: 10.1016/j.metabol.2018.04.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/04/2018] [Accepted: 04/10/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Fructose malabsorption is a common digestive disorder in which absorption of fructose in the small intestine is impaired. An abnormality of the main intestinal fructose transporter proteins has been proposed as a cause for fructose malabsorption. However the underlying molecular mechanism for this remains unclear. In this study, we investigated whether carbohydrate response element-binding protein (ChREBP) plays a role in intestinal fructose absorption through the regulation of genes involved in fructose transport and metabolism and ion transport. METHODS Wild type (WT) and Chrebp knockout (KO) mice (6 or 8 weeks old) were fed a control diet (55% starch, 15% maltodextrin 10) or high-fructose diet (HFrD, 60% fructose, 10% starch) for 3-12 days. Body weight and food intake were measured, signs of fructose malabsorption were monitored, and the expression of genes involved in fructose transport/metabolism and ion transport was evaluated. Furthermore, transient transfection and chromatin immunoprecipitation were performed to show the direct interaction between ChREBP and carbohydrate response elements in the promoter of Slc2A5, which encodes the fructose transporter GLUT5. RESULTS Chrebp KO mice fed the control diet maintained a constant body weight, whereas those fed a HFrD showed significant weight loss within 3-5 days. In addition, Chrebp KO mice fed the HFrD exhibited a markedly distended cecum and proximal colon containing both fluid and gas, suggesting incomplete fructose absorption. Fructose-induced increases of genes involved in fructose transport (GLUT5), fructose metabolism (fructokinase, aldolase B, triokinase, and lactate dehydrogenase), and gluconeogenesis (glucose-6-phosphatase and fructose-1,6-bisphosphatase) were observed in the intestine of WT but not of Chrebp KO mice. Moreover the Na+/H+ exchanger NHE3, which is involved in Na+ and water absorption in the intestine, was significantly decreased in HFrD-fed Chrebp KO mice. Consistent with this finding, the high-fructose diet-fed Chrebp KO mice developed severe diarrhea. Results of chromatin immunoprecipitation assays showed a direct interaction of ChREBP with the Glut5 promoter, but not the Nhe3 promoter, in the small intestine. Ectopic co-expression of ChREBP and its heterodimer partner Max-like protein X activated the Glut5 promoter in Caco-2BBE cells. CONCLUSIONS ChREBP plays a key role in the dietary fructose transport as well as conversion into lactate and glucose through direct transcriptional control of genes involved in fructose transport, fructolysis, and gluconeogenesis. Moreover, ablation of Chrebp results in a severe diarrhea in mice fed a high-fructose diet, which is associated with the insufficient induction of GLUT5 in the intestine.
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Affiliation(s)
- Ah-Reum Oh
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, GAIHST, Gachon University College of Medicine, Incheon 21999, Republic of Korea
| | - Seonyong Sohn
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, GAIHST, Gachon University College of Medicine, Incheon 21999, Republic of Korea
| | - Junghoon Lee
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, GAIHST, Gachon University College of Medicine, Incheon 21999, Republic of Korea
| | - Jong-Min Park
- CHA Cancer Prevention Research Center, CHA Bio Complex, CHA University, Seongnam 13488, Republic of Korea
| | - Ki Taek Nam
- Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ki-Baik Hahm
- CHA Cancer Prevention Research Center, CHA Bio Complex, CHA University, Seongnam 13488, Republic of Korea
| | - Young-Bum Kim
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA
| | - Ho-Jae Lee
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, GAIHST, Gachon University College of Medicine, Incheon 21999, Republic of Korea
| | - Ji-Young Cha
- Department of Biochemistry, Lee Gil Ya Cancer and Diabetes Institute, GAIHST, Gachon University College of Medicine, Incheon 21999, Republic of Korea; Gachon Medical Research Institute, Gil Medical Center, Incheon 21565, Republic of Korea.
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20
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Lattanzio SM, Imbesi F. Fibromyalgia Syndrome: A Case Report on Controlled Remission of Symptoms by a Dietary Strategy. Front Med (Lausanne) 2018; 5:94. [PMID: 29761101 PMCID: PMC5936760 DOI: 10.3389/fmed.2018.00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 03/23/2018] [Indexed: 12/27/2022] Open
Abstract
A 34-year-old woman suffered from significant chronic pain, depression, non-restorative sleep, chronic fatigue, severe morning stiffness, leg cramps, irritable bowel syndrome, hypersensitivity to cold, concentration difficulties, and forgetfulness. Blood tests were negative for rheumatic disorders. The patient was diagnosed with Fibromyalgia syndrome (FMS). Due to the lack of effectiveness of pharmacological therapies in FMS, she approached a novel metabolic proposal for the symptomatic remission. Its core idea is supporting serotonin synthesis by allowing a proper absorption of tryptophan assumed with food, while avoiding, or at least minimizing the presence of interfering non-absorbed molecules, such as fructose and sorbitol. Such a strategy resulted in a rapid improvement of symptoms after only few days on diet, up to the remission of most symptoms in 2 months. Depression, widespread chronic pain, chronic fatigue, non-restorative sleep, morning stiffness, and the majority of the comorbidities remitted. Energy and vitality were recovered by the patient as prior to the onset of the disease, reverting the occupational and social disabilities. The patient episodically challenged herself breaking the dietary protocol leading to its negative test and to the evaluation of its benefit. These breaks correlated with the recurrence of the symptoms, supporting the correctness of the biochemical hypothesis underlying the diet design toward remission of symptoms, but not as a final cure. We propose this as a low risk and accessible therapeutic protocol for the symptomatic remission in FMS with virtually no costs other than those related to vitamin and mineral salt supplements in case of deficiencies. A pilot study is required to further ground this metabolic approach, and to finally evaluate its inclusion in the guidelines for clinical management of FMS.
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Affiliation(s)
| | - Francesca Imbesi
- Neurological Department, Ospedale Niguarda Ca' Granda, Milan, Italy
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21
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Kim Y, Choi CH. Role of Fructose Malabsorption in Patients With Irritable Bowel Syndrome. J Neurogastroenterol Motil 2018; 24:161-163. [PMID: 29605972 PMCID: PMC5885715 DOI: 10.5056/jnm18057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Young Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chang Hwan Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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22
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Jung KW, Seo M, Cho YH, Park YO, Yoon SY, Lee J, Yang DH, Yoon IJ, Seo SY, Lee HJ, Park SH, Kim KJ, Ye BD, Byeon JS, Jung HY, Yang SK, Kim JH, Myung SJ. Prevalence of Fructose Malabsorption in Patients With Irritable Bowel Syndrome After Excluding Small Intestinal Bacterial Overgrowth. J Neurogastroenterol Motil 2018; 24:307-316. [PMID: 29433301 PMCID: PMC5885730 DOI: 10.5056/jnm17044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 09/07/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Fructose malabsorption (FM) mimics symptoms of irritable bowel syndrome (IBS), and its prevalence has increased. Diagnosing FM in IBS is challenging because of its overlap with small intestinal bacterial overgrowth (SIBO). We assessed the prevalence of FM by comparing patients with IBS with asymptomatic control individuals after excluding SIBO using the glucose hydrogen breath test (HBT). Methods Patients diagnosed with IBS and asymptomatic control individuals were enrolled prospectively. Dietary habits were assessed with the Food Frequency Questionnaire. After excluding SIBO, participants underwent HBTs with both 15 g and 25 g of fructose. Results Thirty-five patients with IBS and 35 age- and sex-matched asymptomatic control individuals were enrolled. The 15-g fructose HBT yielded positive results in 7 of the 35 (20.0%) patients with IBS and in 2 of 35 (5.7%) controls (P = 0.070). The 25-g fructose HBT was positive in 16 of the 35 (45.7%) patients with IBS and in 8 of the 35 (22.9%) controls (P = 0.040). Analysis of the Food Frequency Questionnaire responses showed no significant differences between the 2 groups in dietary intake, although patients with IBS showed a significantly higher mean fiber intake than controls (21.24 ± 11.35 g vs 15.87 ± 7.07 g, respectively, P = 0.040). Conclusions The 25-g fructose HBT identified FM in a significantly higher percentage of SIBO-negative patients with IBS than in asymptomatic control individuals, suggesting that FM may correlate with IBS. Education regarding dietary control of foods containing fructose may be useful for the management of patients with IBS.
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Affiliation(s)
- Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myeognsook Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hwan Cho
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Ok Park
- Department of Clinical Nutrition, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So-Yoon Yoon
- Department of Clinical Nutrition, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jungbok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Yoon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Young Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo Jeong Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lattanzio SM. Fibromyalgia Syndrome: A Metabolic Approach Grounded in Biochemistry for the Remission of Symptoms. Front Med (Lausanne) 2017; 4:198. [PMID: 29250522 PMCID: PMC5715322 DOI: 10.3389/fmed.2017.00198] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 10/27/2017] [Indexed: 12/11/2022] Open
Abstract
Fibromyalgia syndrome (FMS) is a chronic, complex, and heterogeneous disorder of still poorly understood etiopathophysiology associated with important musculoskeletal widespread pain, fatigue, non-restorative sleep, and mood disturbances. It is estimated to afflict 2–3% of the worldwide population, with clean prevalence among women. The objective of this paper is to propose a novel treatment for symptomatic remission of FMS, grounded in biochemistry and consisting in the withdrawal from the diet of molecules that can indirectly trigger the symptoms. The hypothesis develops from the evidence that low serotonin levels are involved in FMS. Serotonin is synthesized starting from the essential amino acid tryptophan. The presence of non-absorbed molecules in the gut, primarily fructose, reduces tryptophan absorption. Low tryptophan absorption leads to low serotonin synthesis that triggers FMS symptoms. Moreover not-absorbed sugars could also produce a microbiota deterioration activating a positive feedback loop: the increasing microbiota deterioration reduces the functionality of absorption both of fructose and tryptophan in the gut, entering a vicious circle. The therapeutic idea is to sustain serotonin synthesis allowing the proper tryptophan absorption. The core of the cure treatment is the exclusion from the diet of some carbohydrates and the marked reduction of some others. The main target is the limitation of total dietary fructose as marked as possible. It could be an effective strategy to get the remission of symptoms acting on the impaired biochemical pathways. The straying from the treatment is expected to cause the reappear of the symptoms.
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Portincasa P, Bonfrate L, de Bari O, Lembo A, Ballou S. Irritable bowel syndrome and diet. Gastroenterol Rep (Oxf) 2017; 5:11-19. [PMID: 28110300 PMCID: PMC5444258 DOI: 10.1093/gastro/gow047] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 12/23/2016] [Indexed: 12/13/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a chronic functional disorder of the gastrointestinal tract and is one of the most commonly diagnosed gastrointestinal diseases. The impact of IBS on the general population is large due to its high prevalence, suboptimal medical treatments and significant economic burden. The pathophysiology of IBS is complex and treatments are often symptom-specific. The most common therapeutic approaches for IBS include education and reassurance, lifestyles (especially nutrition-based interventions), peripherally acting medications (which typically target motility), centrally acting medications (which target visceral hypersensitivity and pain) and psychological interventions (which aim to reduce the effects of stress or symptom-specific anxiety). A beneficial dietary approach might include the following measures: a diet low in fermentable oligo-,di- and monosaccharides and polyols (FODMAPs), limitation or exclusion of gas-producing foods and/or lactose and gluten and fiber supplementation in selected cases. New therapeutic agents, namely nutraceutics, are also an interesting option in the management of IBS patients. This paper will focus on available dietary interventions for IBS and will review the evidence for nutrition-based therapies.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica A. Murri, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Leonilde Bonfrate
- Clinica Medica A. Murri, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Ornella de Bari
- Clinica Medica A. Murri, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Anthony Lembo
- Department of Medicine and Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah Ballou
- Department of Medicine and Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Shayto RH, Abou Mrad R, Sharara AI. Use of rifaximin in gastrointestinal and liver diseases. World J Gastroenterol 2016; 22:6638-6651. [PMID: 27547007 PMCID: PMC4970477 DOI: 10.3748/wjg.v22.i29.6638] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/17/2016] [Accepted: 07/06/2016] [Indexed: 02/06/2023] Open
Abstract
Rifaximin is a broad spectrum oral antibiotic with antimicrobial activity against Gram-positive and Gram-negative aerobic and anaerobic bacteria. It is poorly absorbed and thus has a highly favorable safety profile. Rifaximin has been shown to be effective in the treatment of traveler’s diarrhea, functional bloating and irritable bowel syndrome, small bowel bacterial overgrowth and in the prevention of recurrent overt hepatic encephalopathy. In addition, there is emerging evidence for a possible beneficial effect of rifaximin in the treatment of uncomplicated diverticular disease and in the prevention of recurrent diverticulitis. The use of rifaximin is associated with a low incidence of development, or persistence of spontaneous bacterial mutants. Moreover, the development of important drug resistance among extra-intestinal flora during rifaximin therapy is unlikely because of minimal systemic absorption and limited cross-resistance of rifaximin with other antimicrobials. This review addresses the current and emerging role of rifaximin in the treatment of gastrointestinal and liver disorders.
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Marie I, Leroi AM, Gourcerol G, Levesque H, Ménard JF, Ducrotte P. Fructose Malabsorption in Systemic Sclerosis. Medicine (Baltimore) 2015; 94:e1601. [PMID: 26426642 PMCID: PMC4616824 DOI: 10.1097/md.0000000000001601] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 12/11/2022] Open
Abstract
The deleterious effect of fructose, which is increasingly incorporated in many beverages, dairy products, and processed foods, has been described; fructose malabsorption has thus been reported in up to 2.4% of healthy subjects, leading to digestive clinical symptoms (eg, pain, distension, diarrhea). Because digestive involvement is frequent in patients with systemic sclerosis (SSc), we hypothesized that fructose malabsorption could be responsible for intestinal manifestations in these patients. The aims of this prospective study were to: determine the prevalence of fructose malabsorption, in SSc; predict which SSc patients are at risk of developing fructose malabsorption; and assess the outcome of digestive symptoms in SSc patients after initiation of standardized low-fructose diet. Eighty consecutive patients with SSc underwent fructose breath test. All SSc patients also completed a questionnaire on digestive symptoms, and a global symptom score (GSS) was calculated. The prevalence of fructose malabsorption was as high as 40% in SSc patients. We also observed a marked correlation between the presence of fructose malabsorption and: higher values of GSS score of digestive symptoms (P = 0.000004); and absence of delayed gastric emptying (P = 0.007). Furthermore, in SSc patients with fructose malabsorption, the median value of GSS score of digestive symptoms was lower after initiation of standardized low-fructose diet (4 before vs. 1 after; P = 0.0009). Our study underscores that fructose malabsorption often occurs in SSc patients. Our findings are thus relevant for clinical practice, highlighting that fructose breath test is a helpful, noninvasive method by: demonstrating fructose intolerance in patients with SSc; and identifying the group of SSc patients with fructose intolerance who may benefit from low-fructose diet. Interestingly, because the present series also shows that low-fructose diet resulted in a marked decrease of gastrointestinal clinical manifestations in SSc patients with fructose malabsorption, our findings underscore that fructose malabsorption may play a significant role in the onset of gastrointestinal symptoms in these patients. Finally, we suggest that fructose malabsorption may be due to reduced fructose absorption by enterocytes, impaired enteric microbiome, and decreased intestinal permeability.
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Affiliation(s)
- Isabelle Marie
- From the Department of Internal Medicine, CHU Rouen, and INSERM U 905 (IM, HL); Department of Digestive Physiology, CHU Rouen, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research (A-ML, GG); Department of Biostatistics, CHU Rouen (J-FM); and Department of Gastroenterology, CHU Rouen, and INSERM UMR 1073, University of Rouen IFRMP, Institute for Biochemical Research, Rouen, France (PD)
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Effects of dietary education, followed by a tailored fructose-restricted diet in adults with fructose malabsorption. Eur J Gastroenterol Hepatol 2015; 27:785-96. [PMID: 25919770 DOI: 10.1097/meg.0000000000000374] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Fructose is absorbed by GLUT transporters in the small intestine. If this process is inadequate, abdominal symptoms because of fructose intolerance may arise. The effect of a tailored fructose-restricted diet on gastrointestinal complaints was assessed in patients with fructose intolerance. MATERIALS AND METHODS Following an abnormal fructose breath test (50 g), 107 patients (64 also with lactose intolerance) entered three study periods: weeks 0-32 (free diet), weeks 32-36 (progressive increasing amount of fructose up to quantity inducing symptoms, 'trigger dose'), and weeks 36-48 (tailored fructose-restricted diet according to the 'trigger dose'). A subgroup of 15 patients underwent additional fructose breath tests (35, 25 g) to compare three different doses. RESULTS At baseline, the most frequent symptoms were bloating and abdominal pain, and were more severe with combined fructose and lactose intolerance. During the free diet, patients reported eliminating (48%) or reducing (52%) fructose-containing foods, with a significant improvement in symptoms (abdominal pain from 79.7 ± 1.3 to 19.3 ± 1.8 mm; bloating from 83.1 ± 1.3 to 19.4 ± 1.8 mm; number of evacuations/day from 3.9 ± 0.16 to 1.1 ± 0.04; Bristol score from 5.1 ± 0.14 to 3.8 ± 0.1, P < 0.00001). During the tailored fructose-restricted diet, the consistent improvement in symptoms persisted and was similar to the improvement on free diet (abdominal pain 23.6 ± 1.9 mm; bloating 19.4 ± 1.8 mm; number of evacuations/day 1.7 ± 0.07; Bristol score 3.5 ± 0.06, P<0.00001 vs. baseline). A dose-dependent effect of fructose was observed on symptoms during the fructose breath test. CONCLUSION In our setting, individuals with fructose intolerance show an inappropriate dietary self-management. By contrast, a tailored fructose-restricted diet improves gastrointestinal symptoms without senseless food deprivation.
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Is fructose malabsorption a cause of irritable bowel syndrome? Med Hypotheses 2015; 85:295-7. [PMID: 26059250 DOI: 10.1016/j.mehy.2015.05.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/28/2015] [Indexed: 01/01/2023]
Abstract
Irritable Bowel Syndrome (IBS) is a condition that may be marked by abdominal pain, bloating, fullness, indigestion, belching, constipation and/or diarrhea. IBS symptoms can result from malabsorption of fructose. Fructose is a monosaccharide found naturally in small quantities in fruits and some vegetables, and in much larger quantities in industrially manufactured sweets with added sugars (e.g. sucrose and high fructose corn syrup). Fructose malabsorption leads to osmotic diarrhea as well as gas and bloating due to fermentation in the colon. A low-fructose diet has been found to improve IBS symptoms in some patients. This paper discusses the prevalence of fructose malabsorption and considers fructose ingestion as a possible cause of--and fructose restriction as a possible dietary treatment for--IBS.
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Low-FODMAP Diet for Irritable Bowel Syndrome: Is It Ready for Prime Time? Dig Dis Sci 2015; 60:1169-77. [PMID: 25410635 DOI: 10.1007/s10620-014-3436-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/11/2014] [Indexed: 12/15/2022]
Abstract
Irritable bowel syndrome (IBS) is a chronic gastrointestinal disease, which adversely affects the quality of life. Its prevalence has been reported to be around 10-15 % in North America and constitutes the most common cause for gastroenterology referral. Unfortunately, the pathophysiology of IBS is not completely understood. Not surprisingly, the management strategies can leave the patients with inadequate symptom control, making IBS a debilitating gastrointestinal syndrome. Dietary interventions as a treatment strategy for IBS have been recently evaluated. One such intervention includes dietary restriction of fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs). FODMAPs define a group of short-chain carbohydrates that are incompletely absorbed in small intestine and later fermented in the colon. Evidence in the form of randomized controlled trials and observational studies have evaluated the mechanism of action and efficacy of low-FODMAP diet. This dietary intervention has showed promising results in symptom reduction in IBS patients. However, latest trials have also shown that the low-FODMAP diet is associated with marked changes in gut microbiota specifically reduction in microbiota with prebiotic properties. Implications of such changes on gastrointestinal health need to be further evaluated in future trials.
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Bawden SJ, Stephenson MC, Ciampi E, Hunter K, Marciani L, Macdonald IA, Aithal GP, Morris PG, Gowland PA. Investigating the effects of an oral fructose challenge on hepatic ATP reserves in healthy volunteers: A (31)P MRS study. Clin Nutr 2015; 35:645-9. [PMID: 25935852 DOI: 10.1016/j.clnu.2015.04.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 03/02/2015] [Accepted: 04/03/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Impaired homeostasis of hepatic ATP has been associated with NAFLD. An intravenous fructose infusion has been shown to be an effective challenge to monitor the depletion and subsequent recovery of hepatic ATP reserves using (31)P MRS. AIMS The purpose of this study was to evaluate the effects of an oral rather than intravenous fructose challenge on hepatic ATP reserves in healthy subjects. METHODS Self-reported healthy males were recruited. Following an overnight fast, baseline liver glycogen and lipid levels were measured using Magnetic Resonance Spectroscopy (MRS). Immediately after consuming a 500 ml 75 g fructose drink (1275 kJ) subjects were scanned continuously for 90 min to acquire dynamic (31)P MRS measurements of liver ATP reserves. RESULTS A significant effect on ATP reserves was observed across the time course (P < 0.05). Mean ATP levels reached a minimum at 50 min which was markedly lower than baseline (80 ± 17% baseline, P < 0.05). Subsequently, mean values tended to rise but did not reach statistical significance above minimum. The time to minimum ATP levels across subjects was negatively correlated with BMI (R(2) = 0.74, P < 0.005). Rates of ATP recovery were not significantly correlated with BMI or liver fat levels, but were negatively correlated with baseline glycogen levels (R(2) = 0.7, P < 0.05). CONCLUSIONS Depletion of ATP reserves can be measured non-invasively following an oral fructose challenge using (31)P MRS. BMI is the best predictor of postprandial ATP homeostasis following fructose consumption.
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Affiliation(s)
- S J Bawden
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK.
| | - M C Stephenson
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK
| | - E Ciampi
- Unilever Discover, Unilever, Colworth, UK
| | - K Hunter
- Unilever Discover, Unilever, Colworth, UK
| | - L Marciani
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - I A Macdonald
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - G P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - P G Morris
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK
| | - P A Gowland
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK
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Erdogan A, Rao SSC, Gulley D, Jacobs C, Lee YY, Badger C. Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test. Neurogastroenterol Motil 2015; 27:481-9. [PMID: 25600077 DOI: 10.1111/nmo.12516] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/22/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The diagnosis of small intestinal bacterial overgrowth (SIBO) remains challenging. Our aim was to examine the diagnostic yield of duodenal aspiration/culture and glucose breath test (GBT), and effects of gender, race and demographics on prevalence of SIBO. METHODS Patients with unexplained gas, bloating and diarrhea and negative endoscopy, imaging and blood tests were prospectively enrolled in two centers in USA. Randomly, within 1 week each patient underwent both duodenal aspiration/culture and GBT. The diagnostic yield of each test and relationship of symptoms, and effects of ethnicity, age, and gender on prevalence of SIBO were assessed and compared. KEY RESULTS Duodenal culture was positive in 62/139 (44.6%) subjects and GBT was positive in 38/139 (27.3%) subjects with an overall diagnostic agreement of 65.5%. The sensitivity, specificity, positive and negative predictive value of GBT was 42%, 84%, 68%, and 64%, respectively. Ethnicity or gender did not influence SIBO, but SIBO positive patients were older (p = 0.0018). Symptom patterns were similar except bloating was more prevalent in GBT positive and gas in culture positive subjects. CONCLUSIONS & INFERENCES Duodenal aspiration/culture identifies 45% of patients with suspected SIBO. GBT has lower sensitivity but good specificity for detection of SIBO. There were no ethnic or gender differences in the prevalence of SIBO, but patients with SIBO were older. Because GBT is non-invasive, it should be considered first in patients with suspected SIBO.
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Affiliation(s)
- A Erdogan
- Section of Gastroenterology and Hepatology, Georgia Regents University, Augusta, GA, USA
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Mansueto P, Seidita A, D’Alcamo A, Carroccio A. Role of FODMAPs in Patients With Irritable Bowel Syndrome. Nutr Clin Pract 2015; 30:665-82. [DOI: 10.1177/0884533615569886] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | | | | | - Antonio Carroccio
- Internal Medicine, Sciacca Hospital, Agrigento, and University of Palermo, Palermo, Italy
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Dushay JR, Toschi E, Mitten EK, Fisher FM, Herman MA, Maratos-Flier E. Fructose ingestion acutely stimulates circulating FGF21 levels in humans. Mol Metab 2014; 4:51-7. [PMID: 25685689 PMCID: PMC4314524 DOI: 10.1016/j.molmet.2014.09.008] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 09/30/2014] [Indexed: 01/09/2023] Open
Abstract
Objective Fibroblast growth factor 21 (FGF21) is a hormone with pleiotropic metabolic activities which, in rodents, is robustly regulated by fasting and ketogenic diets. In contrast, similar dietary interventions have either no or minimal effects on circulating FGF21 in humans. Moreover, no intervention or dietary challenge has been shown to acutely stimulate circulating FGF21 in either humans or animals. Recent animal data suggest that the transcription factor Carbohydrate Responsive-Element Binding Protein (ChREBP) stimulates hepatic FGF21 expression and that fructose may activate hepatic ChREBP more robustly than glucose. Here, we examined whether fructose ingestion can acutely stimulate FGF21 in humans. Methods We measured serum FGF21, glucose, insulin, and triglyceride levels in ten lean, healthy adults and eleven adults with the metabolic syndrome following oral ingestion of 75 g of glucose, fructose, or a combination of the two sugars. Results FGF21 levels rose rapidly following fructose ingestion, achieved a mean 3.4-fold increase at two hours (P < 0.01), and returned to baseline levels within five hours. In contrast, FGF21 did not increase in the first two hours following ingestion of a glucose load, although more modest increases were observed after three to four hours. Both baseline and fructose-stimulated FGF21 levels were 2–3 fold elevated in subjects with metabolic syndrome. Conclusions Fructose ingestion acutely and robustly increases serum FGF21 levels in humans in a pattern consistent with a hormonal response. While FGF21 appears to be critical for the adaptive response to fasting or starvation in rodents, these findings suggest that in humans, FGF21 may play an important role in fructose metabolism.
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Affiliation(s)
- Jody R. Dushay
- Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Elena Toschi
- Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Emilie K. Mitten
- Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Ffolliott M. Fisher
- Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Mark A. Herman
- Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
- Broad Institute, Cambridge, MA 02142, USA
- Corresponding author. Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA. Tel.: +1 617 667 9344; fax: +1 617 735 3323.
| | - Eleftheria Maratos-Flier
- Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
- Broad Institute, Cambridge, MA 02142, USA
- Corresponding author. Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA. Tel.: +1 617 735 3343; fax: +1 617 737 3323.
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Sharma A, Srivastava D, Verma A, Misra A, Ghoshal UC. Fructose malabsorption is not uncommon among patients with irritable bowel syndrome in India: a case-control study. Indian J Gastroenterol 2014; 33:466-70. [PMID: 25066182 DOI: 10.1007/s12664-014-0492-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/02/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fructose malabsorption (FM) is reported in 38 % to 75 % patients with irritable bowel syndrome (IBS). Most of these studies, however, had limitations due to use of variable dose of fructose, small sample size, and lack of control population. Moreover, there is no study on this issue from India. Hence, in this prospective study, we evaluated the frequency of FM on an adequately powered sample of patients with IBS and healthy controls (HC) from India. METHODS Ninety-seven patients with IBS (diagnosed using Rome III criteria) and 41 healthy controls were evaluated for FM by fructose hydrogen breath test (FHBT) using 25 g fructose. Persistent rise (at least two readings) in breath hydrogen 20 parts per million (PPM) above basal was considered diagnostic of FM. RESULTS Patients and controls were comparable in age (37 years [21-66] vs. 33 years [15-56]; p = 0.1) and gender (76/97 [78.4 %] vs. 29/41 [70.7 %] male; p = 0.3). Of 70 patients reporting data on Bristol's stool forms, 10 (14 %), 43 (61 %), and 17 (25 %) had constipation, diarrhea predominant and unclassified IBS (Asian classification), respectively. Patients with IBS more often had FM than controls on FHBT (14/97 [14.4 %] vs. 1/41 [2.4 %]; p = 0.04). Patients with FM more often had diarrhea-predominant IBS than those without FM (10/11 [91 %] vs. 33/59 [56 %]; p = 0.02). CONCLUSION Though FM was not very common among Indian patients with IBS, it was higher among them than controls. Patients with FM more often had diarrhea-predominant IBS.
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Affiliation(s)
- Atul Sharma
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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Abstract
Breath tests are non-invasive tests and can detect H2 and CH4 gases which are produced by bacterial fermentation of unabsorbed intestinal carbohydrate and are excreted in the breath. These tests are used in the diagnosis of carbohydrate malabsorption, small intestinal bacterial overgrowth, and for measuring the orocecal transit time. Malabsorption of carbohydrates is a key trigger of irritable bowel syndrome (IBS)-type symptoms such as diarrhea and/or constipation, bloating, excess flatulence, headaches and lack of energy. Abdominal bloating is a common nonspecific symptom which can negatively impact quality of life. It may reflect dietary imbalance, such as excess fiber intake, or may be a manifestation of IBS. However, bloating may also represent small intestinal bacterial overgrowth. Patients with persistent symptoms of abdominal bloating and distension despite dietary interventions should be referred for H2 breath testing to determine the presence or absence of bacterial overgrowth. If bacterial overgrowth is identified, patients are typically treated with antibiotics. Evaluation of IBS generally includes testing of other disorders that cause similar symptoms. Carbohydrate malabsorption (lactose, fructose, sorbitol) can cause abdominal fullness, bloating, nausea, abdominal pain, flatulence, and diarrhea, which are similar to the symptoms of IBS. However, it is unclear if these digestive disorders contribute to or cause the symptoms of IBS. Research studies show that a proper diagnosis and effective dietary intervention significantly reduces the severity and frequency of gastrointestinal symptoms in IBS. Thus, diagnosis of malabsorption of these carbohydrates in IBS using a breath test is very important to guide the clinician in the proper treatment of IBS patients.
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Biesiekierski JR. Fructose-induced symptoms beyond malabsorption in FGID. United European Gastroenterol J 2014; 2:10-3. [PMID: 24918003 DOI: 10.1177/2050640613510905] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 12/11/2022] Open
Abstract
The dietary carbohydrate fructose can be incompletely absorbed in the small intestine and is sometimes associated with gastrointestinal symptoms that include motility disturbances and abdominal pain. Fructose malabsorption has been well documented in variable but similar proportions of healthy and populations with functional gastrointestinal disorders. Recent work into the expression of the main intestinal fructose transporter proteins highlight that our understanding of the mechanistic basis for fructose malabsorption and how it differentiates in gastrointestinal patients is incomplete. Until we have further mechanistic insight, restricting dietary fructose intake and other poorly absorbed short-chain carbohydrates and polyols remains an efficacious approach for managing functional gastrointestinal symptoms.
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Sung HY, Kim YS. Fructose Malabsorption in Patients With Irritable Bowel Syndrome-like Symptoms: What Is the Role in the Pathogenesis and Clinical Implication? J Neurogastroenterol Motil 2014; 20:135-7. [PMID: 24840365 PMCID: PMC4015205 DOI: 10.5056/jnm.2014.20.2.135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 03/17/2014] [Accepted: 03/18/2014] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hye-Young Sung
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University Sanbon Hospital, Gunpo-si, Gyeonggi-do, Korea
| | - Yong Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University Sanbon Hospital, Gunpo-si, Gyeonggi-do, Korea
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Goebel-Stengel M, Stengel A, Schmidtmann M, Voort IVD, Kobelt P, Mönnikes H. Unclear abdominal discomfort: pivotal role of carbohydrate malabsorption. J Neurogastroenterol Motil 2014; 20:228-35. [PMID: 24840375 PMCID: PMC4015196 DOI: 10.5056/jnm.2014.20.2.228] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 02/26/2014] [Accepted: 02/27/2014] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Carbohydrate malabsorption is frequent in patients with functional gastrointestinal disorders and in healthy volunteers and can cause gastrointestinal symptoms mimicking irritable bowel syndrome (IBS). The aim of this study was to investigate the prevalence of symptomatic lactose and fructose malabsorption in a large population of patients with IBS-like symptoms based on Rome II criteria. Methods Patients with unclear abdominal discomfort (n = 2,390) underwent lactose (50 g) and fructose (50 g) hydrogen (H2) breath tests and depending on the results further testing with 25 g fructose or 50 g glucose, or upper endoscopy with duodenal biopsies. Additionally, this population was investigated regarding the prevalence of small intestinal bacterial overgrowth (SIBO) based on glucose breath test and celiac disease. Results Of the 2,390 patients with IBS-like symptoms, 848 (35%) were symptomatic lactose malabsorbers and 1,531 (64%) symptomatic fructose malabsorbers. A combined symptomatic carbohydrate malabsorption was found in 587 (25%) patients. Severe fructose malabsorbers (pathologic 25 g fructose test) exhaled significantly higher H2 concentrations in the 50 g test than patients with negative 25 g fructose test (P < 0.001). Out of 460/659 patients with early significant H2 increase in the lactose and fructose test who underwent a glucose breath test, 88 patients had positive results indicative of SIBO and they were significantly older than patients with negative test result (P < 0.01). Celiac disease was found in 1/161 patients by upper endoscopy. Conclusions Carbohydrate malabsorption is a frequent but underestimated condition in patients with IBS-like symptoms although diagnosis can be easily confirmed by H2 breath testing.
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Affiliation(s)
- Miriam Goebel-Stengel
- Department of Internal Medicine, Institute of Neurogastroenterology and Motility, Martin-Luther Hospital, Academic Teaching Institution of Charité - University Medical Center, Berlin, Germany
| | - Andreas Stengel
- Charité Center for Internal Medicine and Dermatology, Division of General Internal and Psychosomatic Medicine; Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Marco Schmidtmann
- Department of Internal Medicine, Institute of Neurogastroenterology and Motility, Martin-Luther Hospital, Academic Teaching Institution of Charité - University Medical Center, Berlin, Germany
| | - Ivo van der Voort
- Department of Internal Medicine, Institute of Neurogastroenterology and Motility, Martin-Luther Hospital, Academic Teaching Institution of Charité - University Medical Center, Berlin, Germany
| | - Peter Kobelt
- Charité Center for Internal Medicine and Dermatology, Division of General Internal and Psychosomatic Medicine; Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Hubert Mönnikes
- Department of Internal Medicine, Institute of Neurogastroenterology and Motility, Martin-Luther Hospital, Academic Teaching Institution of Charité - University Medical Center, Berlin, Germany
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Lozinsky AC, Boé C, Palmero R, Fagundes-Neto U. Fructose malabsorption in children with functional digestive disorders. ARQUIVOS DE GASTROENTEROLOGIA 2014; 50:226-30. [PMID: 24322196 DOI: 10.1590/s0004-28032013000200040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 06/26/2013] [Indexed: 12/18/2022]
Abstract
CONTEXT Fructose is a monosaccharide frequently present in natural and artificial juice fruits. When the concentration of fructose in certain food is present in excess of glucose concentration some individuals may develop fructose malabsorption. OBJECTIVES To report the frequency of fructose malabsorption utilizing the hydrogen breath test in children with gastrointestinal and/or nutritional disorders. METHODS Between July 2011 and July 2012, 43 patients with gastrointestinal and/or nutritional disorders, from both sexes, were consecutively studied, utilizing the hydrogen breath test with loads of the following carbohydrates: lactose, glucose, fructose and lactulose. Fructose was offered in a 10% aqueous solution in the dose of 1 g/kg body weight. Samples were collected fasting and at every 15 minutes after the intake of the aqueous solution for a 2 hour period. Malabsorption was considered when there was an increase of >20 ppm of hydrogen over the fasting level, and intolerance was diagnosed if gastrointestinal symptoms would appear. RESULTS The age of the patients varied from 3 months to 16 years, 24 were boys. The following diagnosis were established: irritable bowel syndrome with diarrhea in 16, functional abdominal pain in 8, short stature in 10, lactose intolerance in 3, celiac disease in 1, food allergy in 1 and giardiasis in 1 patient. Fructose malabsorption was characterized in 13 (30.2%) patients, and intolerance in 1 (2.3%) patient. The most frequent fructose malabsorption was characterized in 7 (16.3%) patients with irritable bowel syndrome and in 4 (9.3%) patients with functional abdominal pain. CONCLUSIONS Patients with irritable bowel syndrome and functional abdominal pain were the main cause of fructose malabsorption.
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Affiliation(s)
- Adriana Chebar Lozinsky
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Pediatria, SP, Brasil
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Abstract
OBJECTIVES The purpose of the present study was to ascertain whether pediatric patients with chronic abdominal pain had concurrent fructose intolerance as determined by a standardized dose breath hydrogen test (BHT), and whether symptoms would improve with a low-fructose diet. METHODS The fructose BHT test was administered to patients evaluated in clinic with unexplained chronic abdominal pain alone or associated with constipation, gas or bloating, and/or diarrhea. The patients were given a standard dose of 1 g/kg fructose to maximum of 25 g. Hydrogen and methane were measured at 8 time points. The test was presumed positive if breath hydrogen exceeded 20 ppm above baseline. If positive, patients were given a dietitian-prescribed low-fructose diet. RESULTS A total of 222 patients were part of the study. Ages ranged from 2 to 19 years with a mean of 10.5. BHT for fructose was performed in all of the patients and it was positive for fructose intolerance in 121 of 222 patients (54.5%). A total of 101 of 222 (45.5%) patients had negative BHT for fructose intolerance. All BHT-positive patients had a nutrition consult with a registered dietitian and were placed on a low-fructose diet. Using a standard pain scale for children, 93 of 121 patients (76.9%) reported resolution of symptoms on a low-fructose diet (P < 0.0001). Furthermore, 55 of 101 patients (54.4%) with negative BHT for fructose reported resolution of symptoms without a low-fructose diet (P = 0.37). CONCLUSIONS Fructose intolerance/malabsorption is common in children with recurrent/functional abdominal pain and a low-fructose diet is an effective treatment.
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Däbritz J, Mühlbauer M, Domagk D, Voos N, Henneböhl G, Siemer ML, Foell D. Significance of hydrogen breath tests in children with suspected carbohydrate malabsorption. BMC Pediatr 2014; 14:59. [PMID: 24575947 PMCID: PMC3975941 DOI: 10.1186/1471-2431-14-59] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 02/24/2014] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hydrogen breath tests are noninvasive procedures frequently applied in the diagnostic workup of functional gastrointestinal disorders. Here, we review hydrogen breath test results and the occurrence of lactose, fructose and sorbitol malabsorption in pediatric patients; and determine the significance of the findings and the outcome of patients with carbohydrate malabsorption. METHODS We included 206 children (88 male, 118 female, median age 10.7 years, range 3-18 years) with a total of 449 hydrogen breath tests (lactose, n = 161; fructose, n = 142; sorbitol, n = 146) into a retrospective analysis. Apart from test results, we documented symptoms, the therapeutic consequences of the test, the outcome and the overall satisfaction of the patients and families. RESULTS In total, 204 (46%) of all breath tests were positive. Long-term follow-up data could be collected from 118 patients. Of 79 patients (67%) who were put on a diet reduced in lactose, fructose and/or sorbitol, the majority (92%, n = 73) reported the diet to be strict and only 13% (n = 10) had no response to diet. Most families (96%, n = 113) were satisfied by the test and the therapy. There were only 21 tests (5%) with a borderline result because the criteria for a positive result were only partially met. CONCLUSIONS Hydrogen breath tests can be helpful in the evaluation of children with gastrointestinal symptoms including functional intestinal disorders. If applied for a variety of carbohydrates but only where indicated, around two-third of all children have positive results. The therapeutic consequences are successfully relieving symptoms in the vast majority of patients.
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Affiliation(s)
- Jan Däbritz
- Department of Pediatric Rheumatology and Immunology, University Children’s Hospital Münster, Röntgenstr 21, Münster 48149, NRW, Germany
- The Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute, Gastrointestinal Research in Inflammation & Pathology, Parkville 3052, VIC, Australia
- Melbourne Medical School, Department of Pediatrics, University of Melbourne, Parkville 3052 VIC, Australia
| | - Michael Mühlbauer
- Pediatric Surgery, Mathias Hospital Rheine, Rheine 48431, NRW, Germany
| | - Dirk Domagk
- Department of Gastroenterology (Medicine B), University Hospital Münster, Münster 48149, NRW, Germany
| | - Nicole Voos
- Center for Clinical Trials, University Hospital Münster, Münster 48149, NRW, Germany
| | - Geraldine Henneböhl
- Center for Clinical Trials, University Hospital Münster, Münster 48149, NRW, Germany
| | - Maria L Siemer
- Department of Gastroenterology (Medicine B), University Hospital Münster, Münster 48149, NRW, Germany
| | - Dirk Foell
- Department of Pediatric Rheumatology and Immunology, University Children’s Hospital Münster, Röntgenstr 21, Münster 48149, NRW, Germany
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Abstract
Dietary intolerances to fructose, fructans and FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are common, yet poorly recognized and managed. Over the last decade, they have come to the forefront because of new knowledge on the mechanisms and treatment of these conditions. Patients with these problems often present with unexplained bloating, belching, distension, gas, abdominal pain, or diarrhea. Here, we have examined the most up-to-date research on these food-related intolerances, discussed controversies, and have provided some guidelines for the dietary management of these conditions. Breath testing for carbohydrate intolerance appears to be standardized and essential for the diagnosis and management of these conditions, especially in the Western population. While current research shows that the FODMAP diet may be effective in treating some patients with irritable bowel syndrome, additional research is needed to identify more foods items that are high in FODMAPs, and to assess the long-term efficacy and safety of dietary interventions.
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Affiliation(s)
- Amy Fedewa
- Food and Nutrition Department, Georgia Regents University, Augusta, GA, USA
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Walker RW, Lê KA, Davis J, Alderete TL, Cherry R, Lebel S, Goran MI. High rates of fructose malabsorption are associated with reduced liver fat in obese African Americans. J Am Coll Nutr 2013; 31:369-74. [PMID: 23529994 DOI: 10.1080/07315724.2012.10720445] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE African Americans commonly have lower liver fat accumulation than Hispanics, despite a similar propensity for obesity. Both ethnicities exhibit high consumption of fructose-containing beverages, which has been associated with high liver fat owing to the lipogenic properties of fructose. Therefore, differences in fructose absorption may be an important factor in regulating liver fat deposition. We hypothesized that fructose malabsorption in African Americans may reduce hepatic delivery of fructose, thus contributing to lower liver fat deposition compared to Hispanics. METHODS Thirty-seven obese young adults aged 21.4 ± 2.1 years (16 African American, 21 Hispanic) underwent a 3-hour hydrogen (H2) breath test to assess fructose malabsorption. Magnetic resonance imaging was used to determine visceral and subcutaneous adipose tissue volume and liver fat. Fructose malabsorption was expressed as an area under the curve for H2 production (H2 AUC). RESULTS Compared to Hispanics, African Americans had lower liver fat (5.4% ± 5.0% vs 8.9% ± 2.3%, p = 0.02) and a higher prevalence of fructose malabsorption (75.0% vs 42.9%; p = 0.05). Liver fat was negatively related to the extent of fructose malabsorption in African Americans (r = -0.53, p = 0.03), and this relationship was independent of the volumes of total fat and subcutaneous and visceral adipose tissue. There were no significant relationships between liver fat and fructose malabsorption in Hispanics. CONCLUSION African Americans have both a higher prevalence and a greater magnitude of fructose malabsorption than Hispanics. In African Americans, fructose malabsorption was negatively correlated with liver fat, which may be protective against fatty liver disease.
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Affiliation(s)
- Ryan W Walker
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, USA
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de Roest RH, Dobbs BR, Chapman BA, Batman B, O'Brien LA, Leeper JA, Hebblethwaite CR, Gearry RB. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract 2013; 67:895-903. [PMID: 23701141 DOI: 10.1111/ijcp.12128] [Citation(s) in RCA: 212] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 01/01/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIM Current treatment for irritable bowel syndrome (IBS) is suboptimal. Fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs) may trigger gastrointestinal symptoms in IBS patients. Our aim was to determine whether a low FODMAP diet improves symptoms in IBS patients. METHODS Irritable bowel syndrome patients, who had performed hydrogen/methane breath testing for fructose and lactose malabsorption and had received dietary advice regarding the low FODMAP diet, were included. The effect of low FODMAP diet was prospectively evaluated using a symptom questionnaire. Furthermore, questions about adherence and satisfaction with symptom improvement, dietary advice and diet were assessed. RESULTS Ninety patients with a mean follow up of 15.7 months were studied. Most symptoms including abdominal pain, bloating, flatulence and diarrhoea significantly improved (p < 0.001 for all). 75.6%, 37.8% and 13.3% of patients had fructose, lactose malabsorption or small intestinal bacterial overgrowth respectively. Fructose malabsorption was significantly associated with symptom improvement (abdominal pain odds ratio (OR) 7.09 [95% confidence interval (CI) 2.01-25.0], bloating OR 8.71 (95% CI 2.76-27.5), flatulence OR 7.64 (95% CI 2.53-23.0) and diarrhoea OR 3.39 (95% CI 1.17-9.78), p < 0.029 for all). Most patients (75.6%) were adherent to the diet, which was associated with symptom improvement (abdominal pain, bloating, flatulence and diarrhoea all significantly associated with adherence, r > 0.27, p < 0.011). Most patients (72.1%) were satisfied with their symptoms. CONCLUSIONS The low FODMAP diet shows efficacy for IBS patients. The current strategy of breath testing and dietary advice provides a good basis to understand and adhere to the diet.
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Affiliation(s)
- R H de Roest
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Berg LK, Fagerli E, Martinussen M, Myhre AO, Florholmen J, Goll R. Effect of fructose-reduced diet in patients with irritable bowel syndrome, and its correlation to a standard fructose breath test. Scand J Gastroenterol 2013; 48:936-43. [PMID: 23834159 DOI: 10.3109/00365521.2013.812139] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To perform a validation of dairy registrations for use as diagnostic tool in IBS and fructose malabsorption (FM). To investigate the precision of the fructose breath test (FBT) as compared with symptom score reduction on fructose-reduced diet (FRD) in a cohort of patients with Rome II defined irritable bowel syndrome (IBS). DESIGN IBS patients diagnosed according to the Rome II criteria and with no organic gastrointestinal disease were enrolled. The patients were randomized in an open study design with a 2 week run-in on IBS diet, followed by 4 weeks w/wo additional FRD. FBT was performed in all patients. Dairy registrations of stool frequency and consistency as well as abdominal pain/discomfort and bloating on a visual analog scale (VAS) were performed during the whole study. RESULTS A total of 182 subjects performed the study according to protocol (88 FRD, 94 controls). The VAS symptom registration performed well in validation procedures, whereas stool data showed less impressive characteristics. FRD improved symptom scores (abdominal pain/discomfort and bloating) significantly whereas no changes were observed in the control group. The effect of FRD on the stool frequency was modest but no effect was observed on the stool consistency. The FBT did not discriminate between patients with and without effect of FRD, and even in the group with a negative FBT significant improvement of symptom scores was observed. CONCLUSION VAS measures yield reliable symptom evaluation in dairy registrations of IBS. FRD improves symptom scores in IBS patients independent of results from the FBT.
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Komericki P, Akkilic-Materna M, Strimitzer T, Weyermair K, Hammer HF, Aberer W. Oral xylose isomerase decreases breath hydrogen excretion and improves gastrointestinal symptoms in fructose malabsorption - a double-blind, placebo-controlled study. Aliment Pharmacol Ther 2012; 36:980-7. [PMID: 23002720 DOI: 10.1111/apt.12057] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 07/04/2012] [Accepted: 09/05/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Incomplete resorption of fructose results in increased colonic hydrogen production and is a frequent cause of abdominal symptoms. The only treatment available is diet. AIM To study whether orally administered xylose isomerase (XI), an enzyme that catalyses the reversible isomerisation of glucose and fructose, can decrease breath hydrogen excretion in patients with fructose malabsorption. METHODS Patients received 25 g fructose in 100 mL water together with either placebo or XI capsules. Primary endpoint was the reduction in breath hydrogen excretion, as assessed by the area under the breath hydrogen curve over 4 h (AUC). A secondary endpoint was the reduction in abdominal pain, bloating and nausea assessed on a visual analogue scale (VAS, range: 0-10). A P value <0.05 was considered statistically significant. RESULTS Sixty-five patients in whom fructose malabsorption had been diagnosed by positive breath hydrogen test within the previous year, were included in the study [15 males, 50 females; mean age 43.3 (s.d. = 14.4), range: 21-73 years]. The median AUC was 885 ppm/240 min in the XI group compared to 2071 ppm/240 min in the placebo group (P = 0.00). Median scores for abdominal pain (0.7 vs. 1.3) and nausea (0.2 vs. 0.6), but not for bloating (P = 0.053), were significantly improved after XI (P = 0.009 and P = 0.005) as compared with placebo. CONCLUSIONS Oral administration of xylose isomerase significantly decreased breath hydrogen excretion after ingestion of a watery fructose solution. Nausea and abdominal pain were significantly improved by xylose isomerase.
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Affiliation(s)
- P Komericki
- Department of Environmental Dermatology and Venereology, Medical University of Graz, Graz, Austria.
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Payne AN, Chassard C, Lacroix C. Gut microbial adaptation to dietary consumption of fructose, artificial sweeteners and sugar alcohols: implications for host-microbe interactions contributing to obesity. Obes Rev 2012; 13:799-809. [PMID: 22686435 DOI: 10.1111/j.1467-789x.2012.01009.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The Western diet, comprised of highly refined carbohydrates and fat but reduced complex plant polysaccharides, has been attributed to the prevalence of obesity. A concomitant rise in the consumption of fructose and sugar substitutes such as sugar alcohols, artificial sweeteners, even rare sugars, has mirrored this trend, as both probable contributor and solution to the epidemic. Acknowledgement of the gut microbiota as a factor involved in obesity has sparked much controversy as to the cause and consequence of this relationship. Dietary intakes are a known modulator of gut microbial phylogeny and metabolic activity, frequently exploited to stimulate beneficial bacteria, promoting health benefits. Comparably little research exists on the impact of 'unconscious' dietary modulation on the resident commensal community mediated by increased fructose and sugar substitute consumption. This review highlights mechanisms of potential host and gut microbial fructose and sugar substitute metabolism. Evidence is presented suggesting these sugar compounds, particularly fructose, condition the microbiota, resulting in acquisition of a westernized microbiome with altered metabolic capacity. Disturbances in host-microbe interactions resulting from fructose consumption are also explored.
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Affiliation(s)
- A N Payne
- Laboratory of Food Biotechnology, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, Zurich, Switzerland
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Latulippe ME, Skoog SM. Fructose malabsorption and intolerance: effects of fructose with and without simultaneous glucose ingestion. Crit Rev Food Sci Nutr 2011; 51:583-92. [PMID: 21793722 PMCID: PMC3471321 DOI: 10.1080/10408398.2011.566646] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Concern exists that increasing fructose consumption, particularly in the form of high-fructose corn syrup, is resulting in increasing rates of fructose intolerance and aggravation of clinical symptoms in individuals with irritable bowel syndrome. Most clinical trials designed to test this hypothesis have used pure fructose, a form not commonly found in the food supply, often in quantities and concentrations that exceed typical fructose intake levels. In addition, the amount of fructose provided in tests for malabsorption, which is thought to be a key cause of intolerance, often exceeds the normal physiological absorption capacity for this sugar. To help health professionals accurately identify and treat this condition, this article reviews clinical data related to understanding fructose malabsorption and intolerance (i.e., malabsorption that manifests with symptoms) relative to usual fructose and other carbohydrate intake. Because simultaneous consumption of glucose attenuates fructose malabsorption, information on the fructose and glucose content of foods, beverages, and ingredients representing a variety of food categories is provided.
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Affiliation(s)
- Marie E Latulippe
- International Life Sciences Institute, North American Branch, Washington, DC 20005, USA.
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Kim Y, Park SC, Wolf BW, Hertzler SR. Combination of erythritol and fructose increases gastrointestinal symptoms in healthy adults. Nutr Res 2011; 31:836-41. [DOI: 10.1016/j.nutres.2011.09.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 09/25/2011] [Accepted: 09/29/2011] [Indexed: 12/27/2022]
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Hawrelak JA, Myers SP. Effects of two natural medicine formulations on irritable bowel syndrome symptoms: a pilot study. J Altern Complement Med 2011; 16:1065-71. [PMID: 20954962 DOI: 10.1089/acm.2009.0090] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The study objective was to assess the effects and tolerability of two novel natural medicine formulations in improving bowel habit and abdominal symptoms in patients with irritable bowel syndrome (IBS). The DA-IBS formula was designed to treat diarrhea-predominant and alternating bowel habit IBS, and the C-IBS formula was designed to treat constipation-predominant IBS. DESIGN This was a two arm, open-label, uncontrolled pilot study. SETTINGS/LOCATION Subjects were recruited from the greater Lismore area (NSW, Australia) in 2001. SUBJECTS The study included 31 patients who fulfilled the Rome II criteria for IBS. Twenty-one (21) patients were classified as suffering from diarrhea-predominant or alternating bowel habit IBS and 10 patients were classified with constipation-predominant IBS. INTERVENTIONS The DA-IBS formula consisted of a mixture of dried, powdered bilberry fruit, slippery elm bark, agrimony aerial parts, and cinnamon quills. The C-IBS formula consisted of a mixture of dried powdered slippery elm bark, lactulose, oat bran, and licorice root. The aim of each formula was to normalize stool frequency and stool consistency. RESULTS Ingestion of the DA-IBS formula was associated with a small, but significant increase in bowel movement frequency (p = 0.027). Subjects in the DA-IBS group also experienced reductions in straining (p = 0.004), abdominal pain (p = 0.006), bloating (p < 0.0001), flatulence (p = 0.0001), and global IBS symptoms (p = 0.002) during the treatment phase of the trial. Subjects in the C-IBS group experienced a 20% increase in bowel movement frequency (p = 0.016) and significant reductions in straining (p < 0.0001), abdominal pain (p = 0.032), bloating (p = 0.034), and global IBS symptom severity (p = 0.0005), as well as improvements in stool consistency (p < 0.0001). Both formulas were well-tolerated. CONCLUSIONS The DA-IBS formula was not effective in improving bowel habit in individuals with diarrhea-predominant or alternating bowel habit IBS, although it did significantly improve a number of IBS symptoms. The C-IBS formula significantly improved both bowel habit and IBS symptoms in patients with constipation-predominant IBS. Further research is warranted on C-IBS, as a potentially useful therapeutic formula.
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