Long-term symptom severity in people with irritable bowel syndrome following dietetic treatment in primary care: A service evaluation

Exploring Dietitians' Perspectives Toward Current Practices and Services in Relation to Irritable Bowel Syndrome Management in Clinical Settings Across the United Kingdom: A Qualitative Study

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic and relapsing gastrointestinal condition that negatively impacts quality of life. Dietary triggers are common and dietary management is central to the IBS treatment pathway, and dietitians are the main education providers for patients.

OBJECTIVE

The aim of this study was to explore dietitians' perspectives on current practices and services in relation to IBS management in clinical settings across the United Kingdom.

DESIGN

Qualitative semi-structured interviews were undertaken from May to October 2021 via videoconferencing software. Eligible participants were dietitians specializing in gastroenterology and working in National Health Service (NHS) Trusts in the United Kingdom. Interviews were audio recorded and transcribed following intelligent transcription. Template analysis guided by naïve realism and its underlying epistemological assumptions was used.

PARTICIPANTS/SETTING

Dietitians (N = 13) working in various NHS Trusts across the United Kingdom with at least 1 year of clinical experience in IBS management were included.

QUALITATIVE DATA ANALYSIS

Template analysis, a form of thematic analysis with hierarchical coding, was used to explore dietitians' perspectives of IBS practices.

RESULTS

Participating dietitians were mostly female (92.3%), of White race (84.6%), working in various NHS Trusts across the United Kingdom, and had more than 5 years of clinical experience (69.2%). The following 3 main themes emerged: 1) dietetics services as part of IBS referral pathways; 2) practices in relation to dietetics services; and 3) patients' expectations and feelings. Each main theme had subthemes to facilitate the description and interpretation of data. The increasing number of IBS referrals to dietitians and the need for accurate and timely IBS diagnosis and specialist dietitians were reported, along with the use of digital innovation to facilitate practice and access to dietetic care. The use of internet as a source of (mis)information by patients and the limited time available for educating patients were identified as potential barriers to dietetic practice. Dietitians follow a patient-centered approach to dietary counseling and recognize the negative implications of perceived IBS-related stigma by patients on their feelings and treatment expectations.

CONCLUSIONS

The study identified areas and practices that can facilitate access to dietetic services and patient-centered care in IBS management, as outlined in UK-based guidelines.

DOMINO trial post hoc analysis: evaluation of the diet effects on symptoms in IBS subtypes

Background

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction characterized by recurrent abdominal pain related to defecation and/or associated to a change in bowel habits. According to the stool type, four different IBS subtypes can be recognized, constipation predominant (IBS-C), diarrhea predominant (IBS-D), mixed (IBS-M), and undefined (IBS-U). Patients report that their IBS symptoms are exacerbated by food. Thus, it is important to find a nutritional approach that could be effective in reducing IBS symptoms.

Objective

The present work is a post hoc analysis of the previously published DOMINO trial. It aimed to evaluate the effects of a self-instructed FODMAP-lowering diet smartphone application on symptoms and psychosocial aspects in primary care IBS stratifying the results for each IBS subtypes.

Design

Post hoc analysis.

Methods

Two hundred twenty-two primary care IBS patients followed a FODMAP-lowering diet for 8 weeks with the support of a smartphone application. Two follow-up visits were scheduled after 16 and 24 weeks. IBS-Symptoms Severity Score (IBS-SSS), quality of life (QoL), and adherence and dietary satisfaction were evaluated.

Results

After 8 weeks, IBS-SSS improved in all IBS subtypes (p < 0.0001). Physician Health Questiionnaire (PHQ-15) improved only in IBS-D (p = 0.0006), whereas QoL improved both in IBS-D (p = 0.01) and IBS-M (p = 0.005).

Conclusion

This post hoc analysis showed that the app is useful in all IBS subtypes; thus, it could be used as an effective tool by both general practitioners and patients to manage symptoms in primary care.

Trial registration

Ethical Commission University Hospital of Leuven reference number: S59482. Clinicaltrial.gov reference number: NCT04270487.

The efficacy and real-world effectiveness of a diet low in fermentable oligo-, di-, monosaccharides and polyols in irritable bowel syndrome: A systematic review and meta-analysis

BACKGROUND & AIMS

A diet low in fermentable oligo-, di-, monosaccharides, and polyols (LFD) has been shown to effectively reduce irritable bowel syndrome (IBS) symptoms. Effects resulting from real-world studies may differ from those seen in efficacy studies because of the diversity of patients in real-world settings. This systematic review and meta-analysis aimed to compare the effect of the LFD on reducing IBS symptoms and improving the quality of life (QoL) in efficacy trials and real-world studies.

METHODS

Major databases, trial registries, dissertations, and journals were systematically searched for studies on the LFD in adults with IBS. Meta-analysis was conducted using a random effects model with standardized mean differences (SMD) and 95% confidence intervals (CI). Outcomes of interest were all patient-reported: stool consistency, stool frequency, abdominal pain, overall symptoms, adequate symptom relief, IBS-specific QoL and adherence to the LFD.

RESULTS

Eleven efficacy and 19 real-world studies were reviewed. The meta-analysis results for abdominal pain (SMD 0.35, 95% CI 0.16 to 0.54) and QoL (SMD 0.23, 95% CI -0.05 to 0.50) showed the LFD was beneficial in efficacy studies with no statistically significant results for stool frequency (SMD 0.71, 95% CI 0.34 to 1.07). Real-world studies found improvements in abdominal pain and QoL. Due to heterogeneity, no meta-analysis was done for stool consistency and overall symptoms. In these outcomes, results were mostly supportive of the LFD, but they were not always statistically significant.

CONCLUSIONS

The results of this systematic review and meta-analysis suggest the LFD improves outcomes compared to a control diet (efficacy studies) or baseline data (real-world studies). Because of diverse study designs and heterogeneity of results, a clear superiority of the LFD over control diets could not be concluded. There are no indications of an efficacy-effectiveness gap for the LFD in adults with IBS.

A dietitian-led low-FODMAP diet webinar: a pre-post study evaluating its impact on symptoms of irritable bowel syndrome

BACKGROUND

Evidence suggests that the low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet improves irritable bowel syndrome (IBS) symptoms when delivered by a dietitian. However, demand for dietetic appointments exceeds supply. Prerecorded webinars are acceptable and cost-effective for delivering first-line IBS dietary advice.

METHODOLOGY

This study, using a pre-post design, aimed to evaluate the effectiveness of a low-FODMAP diet restriction phase webinar at improving IBS symptoms. Participants with self-reported IBS symptoms were asked to report their IBS symptoms, stool frequency, stool consistency and IBS medication use, before and 8 weeks postwebinar via an online questionnaire. The presence and severity of participants' symptoms and bowel habits were captured using validated tools and a global symptom question.

RESULTS

In total 228 participants responded to both pre- and postsurveys. A statistically significant improvement in all symptoms was observed 8 weeks postwebinar (p < 0.05). The proportion of participants rating their overall symptoms as moderate-to-severe reduced from 85.5% at baseline to 34.6% postwebinar (50.9% reduction [p < 0.001]). The proportion of participants reporting normal stool consistency and frequency significantly increased postwebinar (23.2%-39.9% [p < 0.001] and 76.3%-89% [p < 0.001], respectively). Satisfactory relief of symptoms increased from 16.7% to 53.1%, (p < 0.001) 8 weeks postwebinar.

CONCLUSIONS

These results are comparable with literature on the efficacy of face-to-face delivery of low-FODMAP diet education. Dietitians should consider directing triaged patients with IBS, who have tried first-line dietary advice, to this webinar as an alternative or alongside current practice.

The low FODMAP diet in clinical practice: where are we and what are the long-term considerations?

A diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) improves functional bowel symptoms and is a second-line dietary management strategy for the treatment of irritable bowel syndrome (IBS). The diet is complex and involves three stages: restriction, reintroduction and personalisation and clinical effectiveness is achieved with dietitian-led education; however, this is not always available. The aim of this review is to provide an update on the evidence for using the low FODMAP diet, with a focus on the impact of FODMAP restriction and reintroduction considering long-term management of IBS in a clinical setting. Randomised controlled trials have assessed symptom response, quality of life, dietary intake and changes to the gut microbiota during FODMAP restriction. Systematic reviews and meta-analyses consistently report that FODMAP restriction has a better symptom response compared with control diets and a network analysis reports the low FODMAP diet is superior to other dietary treatments for IBS. Research focused on FODMAP reintroduction and personalisation is limited and of lower quality, however common dietary triggers include wheat, onion, garlic, pulses and milk. Dietitian-led delivery of the low FODMAP diet is not always available and alternative education delivery methods, e.g. webinars, apps and leaflets, are available but remove the personalised approach and may be less acceptable to patients and may introduce safety concerns in terms of nutritional adequacy. Predicting response to the low FODMAP diet using symptom severity or a biomarker is of great interest. More evidence on less restrictive approaches and non-dietitian-led education delivery methods are needed.

A 1 year course of starch- and sucrose-reduced diet used by irritable bowel syndrome patients with diarrhoea and the effect of genetic variants

Background

Irritable bowel syndrome is a heterogeneous syndrome and it is difficult to find an effective treatment. Previously, a starch- and sucrose-reduced diet (SSRD) demonstrated promising short-term outcomes. It was proposed that genetic variants in the sucrose-isomaltase gene might influence this success. Our aim in this work was to extend the follow-up study to 1 year and to analyse the effect of the genetic variants of genes involved in starch and sucrose metabolism.

Methods

IBS-SSS questionnaire, IBS-QoL questionnaire and questionnaires about adherence, difficulty and food assessment were sent to 34 patients after 6 months and 1 year after the end of the dietary intervention. In addition, 11 genes involved in sucrose and starch metabolism were sequenced.

Results

Twenty-three participants responded to the 6 months follow-up and 16 to the 1 year follow-up. IBS-SSS total value increased 59.71% in the 6 months follow-up compared with the end of the intervention (p = 0.0018), and 55.39% in the 1 year follow-up (p = 0.0166); while IBS-QoL score decreased 24.09% (p = 0.0002) and 18.07% (p = 0.0022), respectively. The adherence decreased by 29.11% (p = 4.8 × 10-5) and 27.21% (p = 0.0054), respectively. In addition, carriers of pathogenic variants on the SI gene showed a slightly better performance than non-carriers. Finally, the participants showed less satisfaction over time with 18 allowed foods in the diet.

Conclusion

Over time the SSRD is difficult to follow and the genotype might affect the performance of the diet. Since this diet could be a promising therapeutic option, a larger cohort needs to be analysed to validate the results and to compare it with other diets.

A case study of the impact of a dietitian in the multi-disciplinary team within primary care: a service evaluation

BACKGROUND

Expanding the primary care workforce to alleviate general practitioner (GP) workload, improve access and improve quality of care is a current UK strategy. Evidence suggests dietitians can improve patient outcomes and make cost savings. The present study aimed to evaluate a dietitian working as an expert generalist and first contact practitioner (FCP) in a general practice multi-disciplinary team (MDT) to provide appropriate care to patients and reduce GP workload.

METHODS

A dietitian was employed for 6 months at 0.6 full-time equivalents in a group of general practices in Devon, UK. Data were collected on the referral source, patient satisfaction, health outcomes and changes in prescribing data for all patients seen by the dietitian. Focus groups and interviews provided data to understand the experience of introducing a dietitian into the team.

RESULTS

This model of service delivery showed the dietitian acting as an expert generalist, a FCP and able to educate the MDT. A range of professionals within the MDT referred patients with a wide range of diagnoses (both paediatric and adults) and the dietitian acted as a FCP for 29% of patients. Saving were made for the optimisation of medicine management.

CONCLUSIONS

The dietitian can improve patient-centred care for several patient groups; enhance learning for staff around nutrition and dietary issues; and contribute to more efficient working and cost savings around prescription of nutritional products. This was an evaluation of one service and further research is needed to understand the value dietitians can contribute and the factors supporting effective and efficient working in this context.

The Long-Term Effects of a Low-Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols Diet for Irritable Bowel Syndrome Management

Short-term studies indicate that low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diets (LFDs) can improve symptoms for patients with irritable bowel syndrome (IBS). However, long-term (≥6 mo) effectiveness, safety, and sustainability of an LFD are not well understood and remain controversial. The primary purpose of the current review was to consider the published research on the effectiveness, safety, and sustainability of an LFD for patients with IBS. The secondary aim was to develop an infographic for dissemination to outpatient registered dietitian nutritionists and other healthcare professionals who work with patients with IBS. Three electronic databases (PubMed, Scopus, and Web of Science) were searched through December 2022, using the terms irritable bowel syndrome, FODMAP, and long-term. Following article selection, a total of 14 studies were included. Nine of 9 studies reported significant improvements in symptoms, 7 of 7 studies showed significant improvements in bowel habits, 1 of 1 study showed significantly improved disease course, and 6 of 6 studies showed significantly improved quality of life, compared to baseline. One study showed that improvement in gastrointestinal symptoms was significantly correlated with improvements in quality of life. Two of 3 studies and body composition measures indicated that nutritional adequacy was not compromised. Two of 2 studies showed that gut microbiota did not change, but 1 study showed decreased short-chain fatty acids. Adherence rates ranged from 50% to 82%, and 1 study showed that greater adherence was significantly correlated with improved IBS symptoms. Three of 3 studies showed that better adherence to an LFD was associated with improved symptom relief, and 70%-89% of participants reported satisfaction with the LFD for IBS management. The main difficulties reported were the higher expense and adhering to the diet when eating at restaurants, with family and friends, or while traveling. Overall, a long-term LFD for IBS management can be effective, safe, and sustainable.

Nutritional practices and dietetic provision in the endometriosis population, with a focus on functional gut symptoms

BACKGROUND

Endometriosis is a common condition causing chronic pain, fatigue and gut symptoms. Research suggests that dietary changes may improve symptoms; however, evidence is lacking. The present study aimed to investigate the nutritional practices and needs of individuals with endometriosis (IWE) and the management of endometriosis by dietitians in the UK, focusing on gut symptoms.

METHODS

Two online questionnaires were distributed via social media: a survey of dietitians working with IWE and functional gut symptoms and a survey of IWE.

RESULTS

All respondents to the dietitian survey (n = 21) used the low fermentable oligosaccharides disaccharides monosaccharides and polyols (FODMAP) diet in IWE, with the majority 69.3% (n = 14), reporting positive adherence and patient benefit. Dietitians recommended more training (85.7%, n = 18) and resources (81%, n = 17) for IWE. Of those who completed the IWE questionnaire (n = 1385), 38.5% (n = 533) had coexisting irritable bowel syndrome. Only 24.1% (n = 330) had satisfactory relief of gut symptoms. The most common symptoms were tiredness, bloating and abdominal pain, experienced by 85.5% (n = 1163), 75.3% (n = 1025) and 67.3% (n = 917), respectively. Some 52.2% (n = 723) had tried dietary modifications to relieve their gut symptoms; 36.7% (n = 500) ate a restricted diet at present; 13.5% (n = 184) experienced recent unintentional weight loss and 29.8% (n = 407) a decreased appetite Some 13.2% (n = 183) had seen a dietitian regarding their gut symptoms. Of those who had not seen a dietitian, 57.7% (n = 693) would find it useful to.

CONCLUSIONS

Gut symptoms and dietary restriction are very common in IWE; however, dietetic input is not. More research on the role of nutrition and dietetics in the management of endometriosis is recommended.

Gut Symptoms during FODMAP Restriction and Symptom Response to Food Challenges during FODMAP Reintroduction: A Real-World Evaluation in 21,462 Participants Using a Mobile Application

BACKGROUND

There is limited evidence regarding the use of low FODMAP diet apps. This study aimed to evaluate the effectiveness of an app intended to reduce symptoms in FODMAP restriction and symptoms and tolerance of high FODMAP food challenges during FODMAP reintroduction and personalisation.

METHODS

Data were collected from 21,462 users of a low FODMAP diet app. Self-reported gut symptoms during FODMAP restriction, reintroduction, and personalisation and dietary triggers were identified from symptom response data for FODMAP food challenges.

RESULTS

Compared with baseline, at the end of FODMAP restriction, participants (n = 20,553) reported significantly less overall symptoms (11,689 (57%) versus 9105 (44%)), abdominal pain (8196 (40%) versus 6822 (33%)), bloating (11,265 (55%) versus 9146 (44%)), flatulence (10,318 (50%) 8272 (40%)), and diarrhoea (6284 (31%) versus 4961 (24%)) and significantly more constipation (5448 (27%) versus 5923 (29%)) (p < 0.001 for all). During FODMAP reintroduction, participants (n = 2053) completed 8760 food challenges; the five most frequent challenges and n/N (%) of dietary triggers identified were wheat bread 474/1146 (41%), onion 359/918 (39%), garlic 245/699 (35%), milk 274/687 (40%), and wheat pasta 222/548 (41%). The most frequently reported symptoms during food challenges were overall symptoms, abdominal pain, bloating, and flatulence.

CONCLUSIONS

In a real-world setting, a low FODMAP diet app can help users improve gut symptoms and detect dietary triggers for long-term self-management.

Diet and irritable bowel syndrome: an update from a UK consensus meeting

There has been a renewed interest in the role of dietary therapies to manage irritable bowel syndrome (IBS), with diet high on the agenda for patients. Currently, interest has focussed on the use of traditional dietary advice (TDA), a gluten-free diet (GFD) and the low FODMAP diet (LFD). A consensus meeting was held to assess the role of these dietary therapies in IBS, in Sheffield, United Kingdom.Evidence for TDA is from case control studies and clinical experience. Randomised controlled trials (RCT) have demonstrated the benefit of soluble fibre in IBS. No studies have assessed TDA in comparison to a habitual or sham diet. There have been a number of RCTs demonstrating the efficacy of a GFD at short-term follow-up, with a lack of long-term outcomes. Whilst gluten may lead to symptom generation in IBS, other components of wheat may also play an important role, with recent interest in the role of fructans, wheat germ agglutinins, as well as alpha amylase trypsin inhibitors. There is good evidence for the use of a LFD at short-term follow-up, with emerging evidence demonstrating its efficacy at long-term follow-up. There is overlap between the LFD and GFD with IBS patients self-initiating gluten or wheat reduction as part of their LFD. Currently, there is a lack of evidence to suggest superiority of one diet over another, although TDA is more acceptable to patients.In view of this evidence, our consensus group recommends that dietary therapies for IBS should be offered by dietitians who first assess dietary triggers and then tailor the intervention according to patient choice. Given the lack of dietetic services, novel approaches such as employing group clinics and online webinars may maximise capacity and accessibility for patients. Further research is also required to assess the comparative efficacy of dietary therapies to other management strategies available to manage IBS.

Low FODMAP diet in irritable bowel syndrome: a review of recent clinical trials and meta-analyses

PURPOSE OF REVIEW

The low fermentable oligosaccharides, disaccharides, monosaccharides and polyol (FODMAP) diet is widely used in the dietary management of irritable bowel syndrome (IBS). The aim of this review is to summarize recent evidence regarding the use of the low FODMAP diet in IBS and other gastrointestinal disorders from recent clinical trials and meta-analyses.

RECENT FINDINGS

Several recent systematic reviews and meta-analyses support the use of low FODMAP restriction for global symptoms in IBS in the short term. Uncontrolled follow-up studies show that at least 50% of individuals experience symptom relief following restriction, reintroduction and personalization in the long term. Although evidence from comparative trials in IBS suggests potential benefit of less burdensome approaches (e.g. standard IBS diet and low lactose diet) many studies are insufficiently powered. One established mechanism is colonic gas production that may induce pain signalling measurable in the brain, however altered gastrointestinal epithelial integrity and shifts in microbiome composition and function may also be involved.

SUMMARY

Quality trials of the low FODMAP diet are emerging and have been transformational in supporting the widespread application to IBS management in some areas (e.g. short-term effectiveness), whereas other areas still require considerable improvements in research evidence (e.g. long-term effectiveness, mechanisms and educational delivery).

Attitudes, work roles and barriers to nutrition care - Interviews with Australian and UK-based medical doctors

BACKGROUND

Poor diet is implicated in multiple chronic diseases. While doctors may be well-placed to facilitate nutrition care, nutrition remains a low priority in medical education internationally. Consensus is required on nutrition competencies as a benchmark for education with a regulatory framework to ensure implementation. The aim of this qualitative study was to explore work roles, attitudes, barriers, and enablers in the delivery of nutrition care amongst a cohort of Australian and UK doctors.

METHODOLOGY

Semi-structured interviews were conducted with primary care doctors/GPs (n=14) and medical specialists (n=8) based in Australia and the United Kingdom to explore work roles, attitudes, barriers and enablers in the delivery of nutrition care.

RESULTS

Framework analysis identified five key themes: 1) Knowledge and skills in nutrition to support medical nutrition care, 2) The delivery of nutrition education, 3) Multidisciplinary and interdisciplinary care, 4) Systemic barriers and facilitators to care and, 5) The need for a paradigm shift. Participants acknowledged nutrition as an important component of medical care but recognised they are currently ill-equipped to support such care, identifying limitations to the systems supporting integrated care. Participants identified that nutrition sits within both a health promotion and medical/treatment model, but they currently work only within the latter.

CONCLUSION

Participants highlighted a lack of knowledge and training around nutrition, without which change is not possible. Efforts to improve the nutrition capacity of the medical workforce must be matched by increased investments in primary prevention, including nutrition - a paradigm shift from the medical model. This article is protected by copyright. All rights reserved.

Dietitians: roles in the community and contribution to patient care

This article focuses on the main areas in which dietitians can impact patient care, particularly within a community setting, as well as discussing the contribution from dietitians in extended roles and working at advanced practice. A range of research papers and national guidance on dietetic practice are discussed to develop a summative article on the scope of their practice. This article aims to provide insight into the work of dietitians in the community - strengthening the understanding of the roles and to demonstrate how dietetic practice can influence patient care as part of a community multidisciplinary team.