1
|
Nybacka S, Törnblom H, Josefsson A, Hreinsson JP, Böhn L, Frändemark Å, Weznaver C, Störsrud S, Simrén M. A low FODMAP diet plus traditional dietary advice versus a low-carbohydrate diet versus pharmacological treatment in irritable bowel syndrome (CARIBS): a single-centre, single-blind, randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9:507-520. [PMID: 38643782 DOI: 10.1016/s2468-1253(24)00045-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Dietary advice and medical treatments are recommended to patients with irritable bowel syndrome (IBS). Studies have not yet compared the efficacy of dietary treatment with pharmacological treatment targeting the predominant IBS symptom. We therefore aimed to compare the effects of two restrictive dietary treatment options versus optimised medical treatment in people with IBS. METHODS This single-centre, single-blind, randomised controlled trial was conducted in a specialised outpatient clinic at the Sahlgrenska University Hospital, Gothenburg, Sweden. Participants (aged ≥18 years) with moderate-to-severe IBS (Rome IV; IBS Severity Scoring System [IBS-SSS] ≥175) and no other serious diseases or food allergies were randomly assigned (1:1:1) by web-based randomisation to receive a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) plus traditional IBS dietary advice recommended by the UK National Institute for Health and Care Excellence (hereafter the LFTD diet), a fibre-optimised diet low in total carbohydrates and high in protein and fat (hereafter the low-carbohydrate diet), or optimised medical treatment based on predominant IBS symptom. Participants were masked to the names of the diets, but the pharmacological treatment was open-label. The intervention lasted 4 weeks, after which time participants in the dietary interventions were unmasked to their diets and encouraged to continue during 6 months' follow-up, participants in the LFTD group were instructed on how to reintroduce FODMAPs, and participants receiving pharmacological treatment were offered diet counselling and to continue with their medication. The primary endpoint was the proportion of participants who responded to the 4-week intervention, defined as a reduction of 50 or more in IBS-SSS relative to baseline, and was analysed per modified intention-to-treat (ie, all participants who started the intervention). Safety was analysed in the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02970591, and is complete. FINDINGS Between Jan 24, 2017, and Sept 2, 2021, 1104 participants were assessed for eligibility and 304 were randomly assigned. Ten participants did not receive their intervention after randomisation and thus 294 participants were included in the modified intention-to-treat population (96 assigned to the LFTD diet, 97 to the low-carbohydrate diet, and 101 to optimised medical treatment). 241 (82%) of 294 participants were women and 53 (18%) were men and the mean age was 38 (SD 13). After 4 weeks, 73 (76%) of 96 participants in the LFTD diet group, 69 (71%) of 97 participants in the low-carbohydrate diet group, and 59 (58%) of 101 participants in the optimised medical treatment group had a reduction of 50 or more in IBS-SSS compared with baseline, with a significant difference between the groups (p=0·023). 91 (95%) of 96 participants completed 4 weeks in the LFTD group, 92 (95%) of 97 completed 4 weeks in the low-carbohydrate group, and 91 (90%) of 101 completed 4 weeks in the optimised medical treatment group. Two individuals in each of the intervention groups stated that adverse events were the reason for discontinuing the 4-week intervention. Five (5%) of 91 participants in the optimised medical treatment group stopped treatment prematurely due to side-effects. No serious adverse events or treatment-related deaths occurred. INTERPRETATION Two 4-week dietary interventions and optimised medical treatment reduced the severity of IBS symptoms, with a larger effect size in the diet groups. Dietary interventions might be considered as an initial treatment for patients with IBS. Research is needed to enable personalised treatment strategies. FUNDING The Healthcare Board Region Västra Götaland, the Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare, AFA Insurance, grants from the Swedish state, the Wilhelm and Martina Lundgren Science Foundation, Skandia, the Dietary Science Foundation, and the Nanna Swartz Foundation.
Collapse
Affiliation(s)
- Sanna Nybacka
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Axel Josefsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johann P Hreinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lena Böhn
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Åsa Frändemark
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Weznaver
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stine Störsrud
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
2
|
Zamfir-Taranu A, Löscher BS, Husein DM, Hoter A, Garcia-Etxebarria K, Etxeberria U, Gayoso L, Mayr G, Nilholm C, Gustafsson RJ, Ozaydin O, Zheng T, Esteban-Blanco C, Bozzarelli I, Bonfiglio F, Rizk S, Franke A, Bujanda L, Naim HY, Ohlsson B, D'Amato M. Sucrase-isomaltase genotype and response to a starch-reduced and sucrose-reduced diet in IBS-D patients. Gut 2024; 73:706-708. [PMID: 36878682 PMCID: PMC10958263 DOI: 10.1136/gutjnl-2023-329695] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 03/08/2023]
Affiliation(s)
| | - Britt-Sabina Löscher
- Institute of Clinical Molecular Biology, Kiel University and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Diab M Husein
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Abdullah Hoter
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Koldo Garcia-Etxebarria
- Department of Gastrointestinal and Liver Diseases, Biodonostia HRI, San Sebastián, Spain
- Centro Investigación Biomédica Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Usune Etxeberria
- BCC Innovation, Technology Center in Gastronomy, Basque Culinary Center, San Sebastián, Spain
- Basque Culinary Center, Faculty of Gastronomic Sciences, Mondragon Unibertsitatea, San Sebastián, Spain
| | - Lucía Gayoso
- BCC Innovation, Technology Center in Gastronomy, Basque Culinary Center, San Sebastián, Spain
- Basque Culinary Center, Faculty of Gastronomic Sciences, Mondragon Unibertsitatea, San Sebastián, Spain
| | - Gabriele Mayr
- Institute of Clinical Molecular Biology, Kiel University and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Clara Nilholm
- Department of Internal Medicine, Lund University, Skåne University Hospital Malmö, Malmö, Sweden
| | - Rita J Gustafsson
- Department of Gastroenterology and Nutrition, Lund University, Skåne University Hospital Malmö, Malmö, Sweden
| | - Oliver Ozaydin
- School of Biological Sciences, Monash University, Clayton, Victoria, Australia
| | - Tenghao Zheng
- School of Biological Sciences, Monash University, Clayton, Victoria, Australia
| | | | | | - Ferdinando Bonfiglio
- CEINGE Biotecnologie Avanzate s.c.ar.l, Naples, Italy
- Department of Chemical, Materials and Production Engineering, University of Naples Federico II, Naples, Italy
| | - Sandra Rizk
- School of Natural Sciences, Lebanese American University - Byblos Campus, Byblos, Lebanon
| | - Andre Franke
- Institute of Clinical Molecular Biology, Kiel University and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Luis Bujanda
- Department of Gastrointestinal and Liver Diseases, Biodonostia HRI, San Sebastián, Spain
- Centro Investigación Biomédica Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Universidad del País Vasco (UPV/EHU), San Sebastián, Spain
| | - Hassan Y Naim
- Department of Biochemistry, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Bodil Ohlsson
- Department of Internal Medicine, Lund University, Skåne University Hospital Malmö, Malmö, Sweden
| | - Mauro D'Amato
- Gastrointestinal Genetics Lab, CIC bioGUNE - BRTA, Derio, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
- Department of Medicine and Surgery, LUM University, Casamassima, Italy
| |
Collapse
|
3
|
Niles SE, Blazy P, Cheuvront SN, Kenefick RW, Vidyasagar S, Smith AB, Fawkes N, Denman W. Effectiveness of an amino acid beverage formulation in diarrhea-predominant irritable bowel syndrome: A pragmatic real-world study. World J Gastrointest Pharmacol Ther 2023; 14:39-49. [PMID: 38174291 PMCID: PMC10758599 DOI: 10.4292/wjgpt.v14.i5.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/16/2023] [Accepted: 11/15/2023] [Indexed: 12/12/2023] Open
Abstract
BACKGROUND Amino-acid based medical foods have shown promise in alleviating symptoms of drug induced gastrointestinal side effects; particularly, diarrhea-predominant symptoms. Irritable bowel syndrome (IBS) is a gastrointestinal disorder that affects up to 9% of people globally, with diarrhea predominant IBS (IBS-D) being the most prevalent subtype. Further trials are needed to explore potential added benefits when integrated into standard care for IBS-D. AIM To assess the effectiveness of an amino acid-based medical food as an adjunct to standard of care for adults with IBS-D. METHODS This is a pragmatic, real world, open label, single arm study comparing a 2-week baseline assessment to a 2-week intervention period. One hundred adults, aged 18 to 65 years, with IBS-D, according to Rome IV criteria, were enrolled after completing a 2-week baseline assessment period and received a 2-week supply of an amino acid based medical food which was consumed at home twice daily on top of their standard of care. The primary outcome was an assessment of tolerability after 2-weeks of consumption, while secondary outcomes included changes in stool consistency (Bristol Stool Form Scale), severity of abdominal pain & discomfort, symptoms of urgency, Global Improvement Survey (GIS), and the IBS severity scoring system (IBS-SSS). RESULTS The test product was well-tolerated as each participant successfully completed the full 14-day trial, and there were no instances of dropouts or discontinuation of the study product reported. Forty percent of participants achieved a 50% or more reduction in the number of days with type 6-7 bowel movements (IBS-D stool consistency responders). Fifty-three percent of participants achieved a clinically meaningful reduction of 30% in mean weekly pain scores, and 55% experienced the same for mean weekly discomfort scores (IBS-D pain and discomfort responders). Participants experienced a mean -109.4 (95% confidence interval: -130.1, -88.8) point reduction on the IBS-SSS and 52% experienced a minimally clinically important difference of > 95 points. An IBS-SSS category shift from severe to moderate or mild occurred in 69% of participants. For functional symptoms, 76% of participants reported symptom relief on the GIS. CONCLUSION The amino acid-based medical food was well-tolerated, when added to the standard of care, and demonstrated improvements in both overall IBS symptom severity and IBS-D symptoms within just 2 wk.
Collapse
Affiliation(s)
- Samantha E Niles
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
| | - Phil Blazy
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
| | - Samuel N Cheuvront
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
| | - Robert W Kenefick
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
| | - Sadasivan Vidyasagar
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
- Department of Radiation Oncology, University of Florida, Gainesville, FL 32611, United States
| | - Adam B Smith
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
| | - Neil Fawkes
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
| | - William Denman
- Department of Research and Development, Entrinsic Bioscience, Norwood, MA 02062, United States
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA 02114, United States
| |
Collapse
|
4
|
Garcia-Etxebarria K, Gayoso L, Arzallus T, Montalvo I, Lizasoain J, Izagirre A, Ezkurra A, D’Amato M, Etxeberria U, Bujanda L. A 1 year course of starch- and sucrose-reduced diet used by irritable bowel syndrome patients with diarrhoea and the effect of genetic variants. Front Nutr 2023; 10:1268538. [PMID: 37955017 PMCID: PMC10639127 DOI: 10.3389/fnut.2023.1268538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Koldo Garcia-Etxebarria
- Biodonostia, Gastrointestinal Genetics Group, Donostia-San Sebastián, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Lucía Gayoso
- Technology Center in Gastronomy, Basque Culinary Center, BCC Innovation, Donostia-San Sebastián, Spain
- Basque Culinary Center, Faculty of Gastronomic Sciences, Mondragon Unibertsitatea, Donostia-San Sebastián, Spain
| | - Teresa Arzallus
- Biodonostia, Gastrointestinal Diseases Group, Universidad del País Vasco (UPV/EHU), Donostia-San Sebastián, Spain
| | - Isabel Montalvo
- Biodonostia, Gastrointestinal Diseases Group, Universidad del País Vasco (UPV/EHU), Donostia-San Sebastián, Spain
| | - Jacobo Lizasoain
- Biodonostia, Gastrointestinal Diseases Group, Universidad del País Vasco (UPV/EHU), Donostia-San Sebastián, Spain
| | - Arantzazu Izagirre
- Biodonostia, Gastrointestinal Diseases Group, Universidad del País Vasco (UPV/EHU), Donostia-San Sebastián, Spain
| | - Ander Ezkurra
- Biodonostia, Gastrointestinal Diseases Group, Universidad del País Vasco (UPV/EHU), Donostia-San Sebastián, Spain
| | - Mauro D’Amato
- Gastrointestinal Genetics Lab, CIC bioGUNE, Basque Research and Technology Alliance, Bilbao, Spain
- Ikerbasque, Basque Foundation for Sciences, Bilbao, Spain
- Department of Medicine and Surgery, LUM University, Bari, Italy
| | - Usune Etxeberria
- Technology Center in Gastronomy, Basque Culinary Center, BCC Innovation, Donostia-San Sebastián, Spain
- Basque Culinary Center, Faculty of Gastronomic Sciences, Mondragon Unibertsitatea, Donostia-San Sebastián, Spain
| | - Luis Bujanda
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
- Biodonostia, Gastrointestinal Diseases Group, Universidad del País Vasco (UPV/EHU), Donostia-San Sebastián, Spain
| |
Collapse
|