Canadian Digestive Health Foundation Public Impact Series 3: irritable bowel syndrome in Canada. Incidence, prevalence, and direct and indirect economic impact

Primary healthcare provider-perceived barriers to implementing an evidence-based pathway for undifferentiated lower gastrointestinal tract symptoms: A qualitative inquiry

BACKGROUND

Primary healthcare providers play a critical role in diagnosing and managing digestive disorders. Standardized clinical care guidelines have been developed, but with limited and inconsistent implementation. An evidence-based gastroenterology clinical care pathway (GUTLINK) has been proposed in one region of Canada; however, little is known in the medical literature about potential barriers to pathway implementation within primary care. We aimed to identify behavioral and environmental barriers and facilitators to implementation of evidence-based care pathways for undifferentiated lower gastrointestinal tract symptoms in primary care.

METHODS

One-on-one semi-structured interviews were conducted with primary healthcare providers between September 2021 and May 2022. Interview script development was guided by the COM-B framework. Interviews were transcribed and data were analyzed using an inductive thematic analysis approach.

RESULTS

A total of 15 primary healthcare provider interviews were conducted. Several key barriers to GUTLINK implementation were identified in all three domains of the COM-B framework. Key barriers included Capability (e.g., Physician Knowledge and Access to Allied Health), Opportunity (e.g., Access to diagnostic tools), and Motivation (e.g., Comfort with managing cases and optimism). Some of these barriers have not previously been identified in medical literature.

CONCLUSIONS

Evidence-based clinical care pathways have the potential to support access to quality gastroenterology care, yet primary healthcare providers in this study identified several barriers to implementation. Potential solutions exist at the individual and clinic levels (e.g., greater education, improved provider-specialist communication), but must be supported with systems-level changes (e.g., increased funding for gastrointestinal care and e-Health platforms) to support pathway implementation and improve quality of care.

The epidemiology and impact of disorders of gut-brain interaction in Canada: Results from the Rome Foundation Global Epidemiologic Study

BACKGROUND

Using data from the Rome Foundation Global Epidemiology Study examining prevalence of disorders of gut-brain interaction (DGBI) in 33 countries, this study explored the prevalence of all 22 disorders in Canada. It examined differences related to geography and sociodemographic factors, health impact and compared these findings to other countries.

METHODS

The Rome Foundation survey was conducted through the Internet, targeting 2000 Canadian participants. The survey used the validated ROME IV diagnostic questionnaire to identify the 22 DGBI and an in-depth supplemental questionnaire that included quality assurance techniques.

KEY RESULTS

There were 2029 respondents with a mean age of 48 years and 50% females. Diagnostic criteria for at least one of the 22 DGBI were met by 41.3%, similar to other countries. Functional constipation, functional diarrhea, and unspecified functional bowel disorders were most common. Irritable bowel syndrome prevalence was 4.2% using Rome IV and 10.1% using ROME III criteria. DGBI were associated with poorer quality of life and increased psychological symptom scores. Prevalence of DGBI ranged from 48% in Quebec to 36% in British Columbia. Prescription pain medication was reported by 17% with DGBI compared to 9% without DGBI and correlated negatively with mental health and physical well-being. Quebecers and francophones were in limited number but reported higher DGBI prevalence and symptom severity compared to others.

CONCLUSIONS & INFERENCES

A large proportion of Canadians suffer from DGBI which seriously impact their well-being. Findings highlight the need for further research and education, including understanding whether significant regional and cultural differences contribute to DGBI.

History of Functional Somatic Syndromes and Persistent Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Somatization is thought to underlie functional somatic syndromes (FSSs) and may also contribute to prolonged symptoms after mild traumatic brain injury (mTBI). The investigators evaluated the prevalence of FSSs in patients seeking specialty care after mTBI and whether a history of FSSs was associated with symptom persistence.

METHODS

A total of 142 patients with mTBI completed questionnaires regarding demographic information, injury characteristics, and medical history, including history of diagnosed FSSs at clinic intake (mean=41 days postinjury [SD=22.41]). Postconcussion symptoms were assessed at clinic intake and again 1 and 3 months later. A linear mixed-effects model was used to determine whether history of FSSs was related to persistent mTBI symptoms over time.

RESULTS

A history of at least one FSS was reported by 20.4% of patients. In the linear mixed model, postconcussion symptom scores were not significantly different over time among patients with a history of one or more FSSs or two or more FSSs from those with no FSSs. A history of one or more FSSs or two or more FSSs (versus no FSS) was not associated with increased odds of severe postconcussion symptoms at clinic intake (one or more FSSs: odds ratio=0.88, 95% CI=0.38-2.03; two or more FSSs: odds ratio=1.78, 95% CI=0.45-7.03), at the 1-month follow-up visit (one or more FSSs: odds ratio=0.57, 95% CI=0.22-1.45; two or more FSSs: odds ratio=0.57, 95% CI=0.14-2.37), or at the 3-month follow-up visit (one or more FSSs: odds ratio=0.97, 95% CI=0.36-2.63; two or more FSSs: odds ratio=1.27, 95% CI=0.29-5.65).

CONCLUSIONS

In this sample, the prevalence rates of FSSs were higher than rates previously reported for the general population. However, FSS history did not predict higher postconcussion symptom burden at clinic intake or persistence over the following 3 months. Further research is needed to clarify the potential role of somatization in poor mTBI outcome.

Tang-Ping-San Decoction Remodel Intestinal Flora and Barrier to Ameliorate Type 2 Diabetes Mellitus in Rodent Model

PURPOSE

Type 2 diabetes mellitus (T2DM) is a complex genetic disease associated with genetic and environmental factors. Previous studies have shown that changes in the gut microbiota may affect the development of host metabolic diseases and promote the progression of T2DM. Tang-ping-san (TPS) decoction can effectively treat T2DM. However, its specific mechanisms must be evaluated.

PATIENTS AND METHODS

In the present study, we established an animal model of T2DM using a high‑fat diet (HFD) with intraperitoneal injection streptozotocin injection.

RESULTS

The therapeutic effect of TPS decoction on T2DM in mice was initially evaluated. TPS decoction was found to improve hyperglycemia, hyperlipidemia, insulin resistance, and pathological liver, pancreatic, and colon changes. Moreover, it reduced the pro-inflammatory cytokine levels. Based on 16SrRNA sequencing, TPS decoction reduced the Firmicutes/Bacteroidetes ratio at the phylum level. At the genus level, it increased the relative abundances of Akkermansia, Muribaculaceae, and the Eubacterium coprostanoligenes group and decreased the relative abundance of Fusobacterium, Escherichia coli, Dubosiella, and Helicobacter.

CONCLUSION

TPS decoction improves T2DM and liver function and reduces the risk of hyperglycemia, hyperlipidemia, insulin resistance, pathological organ changes, and inflammatory reactions. The mechanism of TPS decoction in T2DM can be correlated with the reversal of gut microbiota dysfunction and repair of the intestinal mucosal barrier.

Dietary gluten avoidance in Canada: a cross-sectional study using survey data

BACKGROUND

A gluten-free diet (GFD) is required for the management of some conditions, whereas some Canadians may follow a GFD for discretionary reasons. We sought to estimate the prevalence of Canadians who adhere to a GFD, identify factors associated with adherence to a GFD, and describe and compare the location of food preparation and consumption for those who follow a GFD, those who report no dietary avoidances and those reporting other dietary avoidances.

METHODS

We used cross-sectional data from the 2015 Canadian Community Health Survey - Nutrition (n = 20 487). Demographic variables included sex, age group, ethnicity, highest level of household education and income adequacy. The relations between respondent characteristics and report of a GFD were estimated using logistic regression. Respondents were further categorized as avoiding dietary gluten, other dietary avoidances and no dietary avoidances.

RESULTS

An estimated 1.9% of Canadians follow a GFD. Women had 2 times higher odds (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.32 to 3.27) of reporting a GFD than men. After adjustment for income adequacy, household education, sex, age group and ethnicity, residents of Ontario and Quebec had about half the odds (OR 0.52, 95% CI 0.31 to 0.87, and OR 0.55, 95% CI 0.32 to 0.94, respectively) of reporting a GFD compared with residents of Atlantic Canada. Canadians who followed a GFD consumed significantly fewer calories from foods prepared at restaurants than both Canadians who reported no dietary avoidances and those who reported dietary avoidances other than gluten. Canadians following a GFD reported that 2.0% (95% CI 1.1% to 2.9%) of their daily kilocalories were from foods prepared at restaurants, compared with 6.7% (95% CI 5.4% to 7.9%) for Canadians reporting 1 or more dietary avoidances other than gluten, and 6.4% (95% CI 6.0% to 6.9%) for those reporting no avoidances.

INTERPRETATION

The estimated 1.9% prevalence of dietary gluten avoidance likely includes individuals with celiac disease, wheat allergies and nonceliac gluten sensitivity, as well as individuals excluding gluten in the management of irritable bowel syndrome or for reasons related to dietary trends. Canadians eating GFDs consume fewer daily calories from restaurant-prepared foods than other Canadians, which may have social implications.

Dietary Patterns in Runners with Gastrointestinal Disorders

Individuals with inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) and reflux frequently experience gastrointestinal symptoms (GIS), potentially enhanced by high-intensity running. Food avoidances, food choices, and GIS in runners with IBS/IBD (n = 53) and reflux (n = 37) were evaluated using a reliability and validity tested questionnaire. Comparisons to a control group of runners (n = 375) were made using a Fisher’s Exact test. Runners with IBS/IBD experienced the greatest amount of exercise-induced GIS followed by those with reflux. Commonly reported GIS were stomach pain/cramps (77%; 53%), bloating (52%; 50%), intestinal pain/cramps (58%; 33%), and diarrhea (58%; 39%) in IBS/IBD and reflux groups respectively. In the pre-race meal, those with IBS/IBD frequently avoided milk products (53%), legumes (37%), and meat (31%); whereas, runners with reflux avoided milk (38%), meat (36%), and high-fibre foods (33%). When considering food choices pre-race, runners with IBS/IBD chose grains containing gluten (40%), high fermentable oligo-, di-, mono-saccharides and polyols (FODMAP) fruits (38%), and water (38%). Runners with reflux chose water (51%), grains containing gluten (37%), and eggs (31%). In conclusion, while many runners with IBS/IBD and reflux are avoiding trigger foods in their pre-race meals, they are also consuming potentially aggravating foods, suggesting nutrition advice may be warranted.

Meeting the Motility Educational Requirements of the Gastroenterology Trainee in the 21st Century

BACKGROUND

Gastrointestinal (GI) motility and functional disorders comprise over two-third of referrals to GI specialists yet training programs are disproportionately focused on endoscopy, inflammatory bowel disease and liver disease. Trainees at many centres receive minimal or no formal training in motility disorders and have little or no exposure to motility testing. Our purpose was to develop an educational intervention to address this learning need.

METHODS

We designed a formal training program comprised of didactic sessions, workshops and hands-on motility sessions with live demonstrations designed to be held over the course of a weekend. Faculty for the course were experienced GI motility experts from across Canada. Resident trainees from all Canadian GI fellowship programs were invited to attend. Pre- and post-tests were administered to measure the baseline learning needs and the impact of the program. Course evaluations were completed by attendees.

RESULTS

Three annual courses were offered over the past 3 years. Both adult and paediatric gastroenterology trainees attended the programs. The majority of training programs from Canada were represented. Baseline testing of attendees revealed a fundamental lack of understanding of GI motility concepts and their clinical implications. Postcourse test scores demonstrated a significant improvement in motility knowledge. Course evaluations of the content and faculty presentations received uniformly positive reviews.

CONCLUSIONS

There is a pervasive lack of clinical knowledge of GI motility among Canadian GI subspecialty trainees. A focused weekend intensive course is one step in addressing this learning need.

Diarrhea-Predominant Irritable Bowel Syndrome: Medical Management Update

Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder, which impacts the quality of life, work productivity and social activities of patients. Diarrhea-predominant IBS (IBS-D) is one of several subtypes, and accounts for approximately one third of all cases. Currently available treatments are typically unable to alleviate the cardinal symptoms of IBS-D, including abdominal pain and diarrhea, and a clinical unmet need remains for an effective treatment which simultaneously relieves multiple symptoms. Patients may benefit from a multipronged, individualized approach, including dietary modifications, and psychological and pharmacological therapies. The aim of this review is to provide an update on the available and upcoming treatment options for IBS-D in Canada, with reference to the recently updated Canadian IBS consensus guidelines. Initial treatment approaches include lifestyle modifications, dietary modifications, and non-prescription therapies such as peppermint oil. While some medications such as tricyclic antidepressants are also used to treat IBS-D symptoms, eluxadoline and rifaximin are the only two pharmacological therapies approved for the treatment of IBS-D in Canada. Key clinical trial data for the currently available pharmacological options are presented to provide an overview of the efficacy and safety of these agents.

Review article: the incidence and risk factors for irritable bowel syndrome in population-based studies

BACKGROUND

In the absence of prior gastrointestinal infection, the risk factors for irritable bowel syndrome (IBS) are not well established.

AIM

To identify the incidence and risk factors for IBS in general population samples METHODS: Narrative review of population-based studies. Electronic databases were searched using the keywords "incidence," "onset," "epidemiology," "population," "risk factors" with "irritable bowel syndrome" with subsequent hand searching. Inclusion criteria were: population-based, adults, prospective design (including retrospective case cohorts), clinical or research diagnosis of IBS and exclusion of individuals who had IBS prior to recruitment.

RESULTS

Of 1963 papers, 38 were included; all provided data on risk factors, 27 reported incidence. The median incidence of physician-diagnosed IBS in 19 general population cohorts was 38.5 per 10 000 person-years (interquartile range = 20-45.3). In 14 cohorts with specific medical disorders, median incidence was 92 per 10 000 person-years (IQR: 73.9-119). Apart from gastroenteritis, the most common risk factors were other medical disorders, female sex, age (both young and old), anxiety and depression, life events/stress, frequent healthcare use, pain and sleep disorders. The results were conflicting for alcohol consumption, smoking and BMI. Incidence rates were similar in different countries but risk factors differed.

CONCLUSIONS

Incidence rates were generally lower than previous estimates reflecting physician-diagnosed IBS. The results highlight the importance of other medical and psychosocial problems in the onset of IBS in addition to prior gastrointestinal infections. Aetiological research could be enhanced by studying the underlying mechanisms relating to all of these risk factors.

Symptoms of Functional Intestinal Disorders Are Common in Patients with Celiac Disease Following Transition to a Gluten-Free Diet

BACKGROUND

Celiac disease and functional intestinal disorders may overlap, yet the natural history of functional symptoms in patients with celiac disease is unknown.

AIM

To investigate the prevalence of irritable bowel syndrome (IBS), functional dyspepsia (FD), and functional bloating (FB) symptoms among patients with celiac disease at diagnosis and during the first year of a gluten-free diet.

METHODS

Adults with a new diagnosis of celiac disease were surveyed at baseline, 6 months and 1 year using standardized measures for intestinal symptoms [Rome III diagnostic questionnaire and celiac symptom index (CSI)] and gluten-free diet adherence [gluten-free eating assessment tool (GF-EAT) and celiac diet adherence test].

RESULTS

At diagnosis, two-thirds fulfilled Rome III diagnostic questionnaire symptom criteria for IBS (52%), functional dyspepsia (27%), and/or functional bloating (9%). One year post-diagnosis, there was high adherence to a gluten-free diet as 93% reported gluten exposure less than once per month on the GF-EAT and only 8% had ongoing celiac disease symptoms (CSI score >45). The rates of those meeting IBS (22%) and functional dyspepsia (8%) symptom criteria both decreased significantly on a gluten-free diet. The prevalence of functional symptoms (any of IBS, FD or FB) at 1 year was 47%.

CONCLUSIONS

Long-term follow-up of patients with celiac disease is necessary because many patients with celiac disease who are adherent to a gluten-free diet have persistent gastrointestinal symptoms.

Sham acupuncture is as efficacious as true acupuncture for the treatment of IBS: A randomized placebo controlled trial

BACKGROUND

Irritable bowel syndrome (IBS) patients increasingly seek out acupuncture therapy to alleviate symptoms, but it is unclear whether the benefit is due to a treatment-specific effect or a placebo response. This study examined whether true acupuncture is superior to sham acupuncture in relieving IBS symptoms and whether benefits were linked to purported acupuncture mechanisms.

METHODS

A double blind sham controlled acupuncture study was conducted with Rome I IBS patients receiving twice weekly true acupuncture for 4 weeks (n=43) or sham acupuncture (n=36). Patients returned at 12 weeks for a follow-up review. The primary endpoint of success as determined by whether patients met or exceeded their established goal for percentage symptom improvement. Questionnaires were completed for symptom severity scores, SF-36 and IBS-36 QOL tools, McGill pain score, and Pittsburg Sleep Quality Index. A subset of patients underwent barostat measurements of rectal sensation at baseline and 4 weeks.

KEY RESULTS

A total of 53% in the true acupuncture group met their criteria for a successful treatment intervention, but this did not differ significantly from the sham group (42%). IBS symptom scores similarly improved in both groups. Scores also improved in the IBS-36, SF-36, and the Pittsburg Sleep Quality Index, but did not differ between groups. Rectal sensory thresholds were increased in both groups following treatment and pain scores decreased; however, these changes were similar between groups.

CONCLUSIONS & INFERENCES

The lack of differences in symptom outcomes between sham and true treatment acupuncture suggests that acupuncture does not have a specific treatment effect in IBS.

Effect of the probiotic strain Bifidobacterium animalis subsp. lactis, BB-12®, on defecation frequency in healthy subjects with low defecation frequency and abdominal discomfort: a randomised, double-blind, placebo-controlled, parallel-group trial

The aim of the present study was to investigate the effect of Bifidobacterium animalis subsp. lactis, BB-12^®, on two primary end points – defecation frequency and gastrointestinal (GI) well-being – in healthy adults with low defecation frequency and abdominal discomfort. A total of 1248 subjects were included in a randomised, double-blind, placebo-controlled trial. After a 2-week run-in period, subjects were randomised to 1 or 10 billion colony-forming units/d of the probiotic strain BB-12^® or a matching placebo capsule once daily for 4 weeks. Subjects completed a diary on bowel habits, relief of abdominal discomfort and symptoms. GI well-being, defined as global relief of abdominal discomfort, did not show significant differences. The OR for having a defecation frequency above baseline for ≥50 % of the time was 1·31 (95 % CI 0·98, 1·75), P=0·071, for probiotic treatment overall. Tightening the criteria for being a responder to an increase of ≥1 d/week for ≥50 % of the time resulted in an OR of 1·55 (95 % CI 1·22, 1·96), P=0·0003, for treatment overall. A treatment effect on average defecation frequency was found (P=0·0065), with the frequency being significantly higher compared with placebo at all weeks for probiotic treatment overall (all P<0·05). Effects on defecation frequency were similar for the two doses tested, suggesting that a ceiling effect was reached with the one billion dose. Overall, 4 weeks’ supplementation with the probiotic strain BB-12^® resulted in a clinically relevant benefit on defecation frequency. The results suggest that consumption of BB-12^® improves the GI health of individuals whose symptoms are not sufficiently severe to consult a doctor (ISRCTN18128385).