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Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome
Abstract
BackgroundA low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is effective in treating irritable bowel syndrome (IBS). AimTo compare the effects of gut-directed hypnotherapy to the low FODMAP diet on gastrointestinal symptoms and psychological indices, and assess additive effects. Methods
Irritable bowel syndrome patients were randomised (computer-generated list), to receive hypnotherapy, diet or a combination. Primary end-point: change in overall gastrointestinal symptoms across the three groups from baseline to week 6. Secondary end-points: changes in psychological indices, and the durability of effects over 6 months. ResultsOf 74 participants, 25 received hypnotherapy, 24 diet and 25 combination. There were no demographic differences at baseline across groups. Improvements in overall symptoms were observed from baseline to week 6 for hypnotherapy [mean difference (95% CI): -33 (-41 to -25)], diet [-30 (-42 to -19)] and combination [-36 (-45 to -27)] with no difference across groups (P = 0.67). This represented 20 mm improvement on visual analogue scale in 72%, 71% and 72%, respectively. This improvement relative to baseline symptoms was maintained 6 months post-treatment in 74%, 82% and 54%. Individual gastrointestinal symptoms similarly improved. Hypnotherapy resulted in superior improvements on psychological indices with mean change from baseline to 6 months in State Trait Personality Inventory trait anxiety of -4(95% CI -6 to -2) P < 0.0001; -1(-3 to 0.3) P = ns; and 0.3(-2 to 2) P = ns, and in trait depression of -3(-5 to -0.7) P = 0.011; -0.8(-2 to 0.2) P = ns; and 0.6(-2 to 3) P = ns, respectively. Groups improved similarly for QOL (all p 0.001). Conclusions
Durable effects of gut-directed hypnotherapy are similar to those of the low FODMAP diet for relief of gastrointestinal symptoms. Hypnotherapy has superior efficacy to the diet on psychological indices. No additive effects were observed.
... As for FODMAP-containing diets, Peters et al. conducted a trial in seventy-four adult patients (14 of them were men) suffering from IBS [39]. They were divided into three groups: I-who received hypnotherapy (a hypnosis-based healing method used for the treatment of certain diseases), II-who adopted a LFD diet and III-who received a combination of both. ...
... However, two important facts should not be taken lightly. First, in the study by Peters et al. [39] the LFD did not produce changes in anxiety or depression according to the STPI scale, but it did using HADS. This fact could give rise to doubts as to the selection of the method or scale used for its assessment in clinical practice, when a LFD follow-up is recommended. ...
... Second, in the clinical trial carried out by Eswaran et al. [41], when a LFD intervention was compared with a healthy diet, the magnitude of the improvement was significantly greater for anxiety, while this outcome was not reached for depression (95% CI, −0.70 to −1.30). This isolated result could be considered circumstantial, but in the study by Peters et al. [39] the lack of effect was also confirmed when the intervention in IBS patients was prolonged for 6 months, based on the HADS. Therefore, it could be concluded that following a LFD is more effective against anxiety than depression. ...
Nowadays, gluten and FODMAP food components (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) are increasingly studied due to their possible relation with extraintestinal-associated conditions. In recent years, gluten-free diets (GFD) and low-FODMAP diets (LFD) are becoming more popular not only in order to avoid the food components that cause intolerances or allergies in some people, but also due to the direct influence of marketing movements or diet trends on feeding habits. Likewise, neurological and psychiatric diseases are currently of increasing importance in developed countries. For this reason, a bibliographic systematic review has been carried out to analyse whether there is a pathophysiological relationship between the dietary intake of gluten or FODMAPs with mental disorders. This review collects 13 clinical and randomized controlled trials, based on the PRISMA statement, which have been published in the last ten years. Based on these results, limiting or ruling out gluten or FODMAPs in the diet might be beneficial for symptoms such as depression, anxiety (7 out of 7 articles found any positive effect), or cognition deficiency (improvements in several cognition test measurements in one trial), and to a lesser extent for schizophrenia and the autism spectrum. Nevertheless, further studies are needed to obtain completely reliable conclusions.
... Twelve studies 20 in eleven papers 17,18,20,[47][48][49][50][51][52][53][54] met the inclusion criteria, seven provided sufficient data for meta-analysis and subgroup analysis. ...
... 54 All the non-gender specific studies had predominantly female participants (63.3% 17 -86.3%). 51 The number of sessions varied from three 18 to twelve, 17,20 with most of them lasting around an hour, but ranged from thirty 48 to ninety minutes, 17 delivered weekly, 17,20,50,53 approximately every other week 47-49, 51, 54 or less frequently. 18 ...
... A wide variety of outcome measures were reported. One study 47 used the binary 'adequate relief question' 55 to measure symptoms, however continuous measures of J o u r n a l P r e -p r o o f GGS were most common, such as the IBS severity scoring system (IBS-SSS), 56 used by three studies, 17,18,47 with another using just the visual analogue scale element of it, 53 the Bowel Symptom Scale (BSSI-5) was used by one, 51 and a number of studies used ad hoc measures. 20,48,49 Several studies reported QoL measures, the IBS QoL (IBS-QoL) 57 measure was used by four trials, 20,47,52,53 the SF-36 QoL scale 58 was used by two 48,50 , and the Functional Digestive Disorder QoL questionnaire (FDD-QoL) 59 was used in one. ...
Background
Hypnotherapy has been shown to be effective at relieving global gastrointestinal symptoms (GGS) in irritable bowel syndrome (IBS). This study examines the impact of hypnotherapy delivery and participant characteristics on IBS outcomes.
Methods
This systematic review searched CINAHL, Cochrane Library, Conference Citation Index, Embase, PubMed, PsycARTICLES, PsychINFO, Science Citation index-expanded, Social Science Citation Index. Titles and abstracts, then full-text articles were screened against inclusion criteria: trials with a concurrent comparator of hypnotherapy in adults with IBS diagnosed using Manning or ROME criteria, which provided symptom data. Included studies were extracted and assessed for bias using Cochrane Collaboration 2011 guidance. Random-effects meta-analysis was conducted with sub-group analysis to assess the impact of delivery characteristics on outcomes.
Results
Twelve trials were included, 7 in the meta-analyses. Hypnotherapy reduced the risk of GGS, but this was not statistically significant, (standardised mean difference (SMD) 0.24, [-0.06, 0.54], I² 66%). Higher frequency of sessions (≥1/week) reduced GGS (SMD 0.45 [0.23,0.67] I² 0%), as did higher volumes of intervention (≥8 sessions with ≥6 hours of contact) (SMD 0.51 [0.27,0.76] I² 0%) and group interventions (SMD 0.45 [0.03, 0.88] I² 62%). Only volume of intervention produced a significant effect between the subgroups.
Conclusion
This review suggests that high volume hypnotherapy is more beneficial than low and should be adopted for GDH. Both high frequency and group interventions are effective in reducing GGS in IBS. However, the sample size is small and more studies are needed to confirm this.
... 47 Less is known about which therapies are best for which patients because there is a lack of comparative effectiveness research in this area. However, an RCT from Australia evaluated the comparative effectiveness of gutdirected hypnotherapy and a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs), 66 which is discussed later in this review. Notably, when behavioral therapies are evaluated using the same domains as medication trials, they are criticized for methodologic weaknesses, such as lack of blinding (which is not possible). ...
... Full FODMAP restriction has been compared with gutdirected hypnotherapy 66 and yoga 111 in randomized, comparative effectiveness studies. In a study from Australia, both hypnosis and a low-FODMAP diet led to statistically significant improvement in IBS symptoms at 6 weeks and at 6 months when compared to baseline. ...
... The magnitude of benefit was similar for the 2 interventions. 66 In another trial, yoga and the low-FODMAP diet both improved IBS symptoms at 3 and 6 months compared to baseline with no different in the magnitude of benefit between interventions. 111 Comparisons of the low-FODMAP diet with other active dietary interventions have been less easy to interpret. ...
Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.
... Six of these studies compared the LFD against other dietary interventions including traditional dietary advice (12), modified National Institute for Health and Care Excellence (NICE) guidelines (13), high FODMAP diet (14), gluten-free diet and Mediterranean diet (15), generalized dietary advice and (8,16). Two studies compared the LFD to probiotics (17,18) and two studies compared a LFD to non-diet interventions-gut directed hypnotherapy (19) or yoga (20). One study (17) used a factorial design with participants allocated to either the shame diet/ probiotic, sham diet/placebo, the LFD/probiotics, or the LFD/ placebo; however, no interaction effect for symptoms or microbiota changes were noted, so data for the LFD compared to probiotics was not reported. ...
... All except two studies were randomized controlled trials (RCTs) (8,15). Of these studies, four were single-blind RCTs (12,14,16,20), one was double-blind (17), with the remainder being open-label (13,18,19). Four studies (8,13,18,19) were adequately powered (12,(14)(15)(16)(17)(18)20). ...
... Of these studies, four were single-blind RCTs (12,14,16,20), one was double-blind (17), with the remainder being open-label (13,18,19). Four studies (8,13,18,19) were adequately powered (12,(14)(15)(16)(17)(18)20). Data for IBS subtypes were not available for all studies, but where available (8,12,14,(17)(18)(19), the evidence has been discussed in relation to its applicability to the specific subtype. ...
Irritable bowel syndrome (IBS) is the most prevalent functional gastrointestinal disorder with a worldwide prevalence of 11%. It is characterized by abdominal pain and altered bowel habits in the absence of underlying unique pathology. The condition is associated with poor quality of life and high use of healthcare resources required for management. The low FODMAP diet (LFD) is a recognized treatment for symptom management of IBS; however, approximately 30% of patients do not respond. The aim of this review was to understand the effectiveness and application of the LFD compared with other dietary and non-dietary interventions. Ten studies were included, eight of which assessed the LFD against other dietary interventions including traditional dietary advice, modified National Institute for Health and Care Excellence guidelines, a high FODMAP diet, gluten-free diet and Mediterranean diet, generalized dietary advice, probiotics, and a sham diet. Two studies compared a LFD to non-diet interventions of gut directed hypnotherapy or yoga. The findings clearly support the LFD as an effective treatment in IBS, and although it highlights the role for microbiota and current psychosocial state, it remains challenging to identify what combination of treatments may be best to ensure a personalized approach and overall higher response rates to IBS therapy.
... A study in 90 patients with IBS, with a mean follow-up of 16 months, demonstrated that symptom improvement was maintained during longer term follow-up, with adherence reported at 76% [53]. Likewise, a RCT in 74 patients with IBS demonstrated sustained symptom response at 6 months in 82% of patients on a LFD [54]. More recently, two studies from the UK have demonstrated ongoing symptom relief with the LFD during long-term follow-up, with adequate relief of symptoms reported in 57% (6-18 months follow-up) and 60% (44 months mean follow-up) of individuals, respectively [55,58]. ...
... The efficacy of dietary therapies compared to other treatments in IBS, including drug and psychological therapies, remains unclear. One RCT randomised participants to receive either hypnotherapy, dietary management or a combination and noted no significant difference in overall symptom improvement between groups (p = 0.67) [54]. Similarly, a RCT comparing yoga to the LFD failed to show differences in absolute IBS-SSS at either 12 (p = 0.151) or 24 weeks (p = 0.081) [70]. ...
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.
... 5,6 A wide variety of treatments are utilized in IBS management. This includes a range of pharmacological and non-pharmacological therapies such as gut-directed hypnotherapy 7 and dietary modifications such, as the low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet. 8 Taking an integrated approach through utilizing a range of treatments has recently become the preferred option due to lack of ability to predict response in the individual. ...
... The dietitian may then refer the patient back to the gastroenterologist or primary care physician who may recommend alternative therapies such as gut-directed hypnotherapy or pharmacological support for specific symptoms. 7 In integrated care, such referrals may occur directly from the dietitian. For those patients continuing the diet, depending on the requirements of the individual, regular short-term follow-ups may occur throughout the "reintroduction" phase to assist with implementation and addressing challenges with reintroduction. ...
Background/aims:
The 3-phase fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet has shown a high level of efficacy in irritable bowel syndrome, largely based on dietitian delivered education. However, access to dietitians can be limited, and challenges exist when applying the diet to a wide range of cultures, such as limited FODMAP analysis of local foods. This review aims to discuss ways to optimally use the FODMAP diet in practice in a wide range of cultures, directed at gastroenterologists from a dietitian's perspective.
Methods:
Recent literature was analysed via search databases including Medline, CINAHL, PubMed and Scopus.
Results:
The dietetic process involves detailed assessment and follow-up through the 3 stages of the FODMAP diet (restriction, re-introduction, and long-term maintenance). Emerging evidence suggests the diet can be delivered by other health professionals such as the gastroenterologist or nurse, but training on how to do so successfully would be needed. Self-guided approaches through use of technology or specialised food delivery services may be an alternative when dietitians are not available, but efficacy data is limited. Regardless of delivery mode, nutritional and psychological risks of the diet must be mitigated. Additionally, culturally appropriate education must be provided, with accommodations necessary when the FODMAP content of local foods are unknown.
Conclusion:
While the diet has shown improved irritable bowel syndrome outcomes across studies, it is important to acknowledge the essential role of dietitians in implementing, tailoring, and managing the diet to achieve the best outcome for each individual.
... Portanto, a melhora da dor e o alívio de forma geral podem ser obtidos por meio do uso de algumas cepas como por exemplo: B. infantis para dor e distensão, e B. lactis para constipação (ORGANIZAÇÃO MUNDIAL DE GASTROENTEROLOGIA, 2015). Assim, parece possível reduzir sintomas da SII através do tratamento dietoterápico pobre em FODMAPs combinado com intervenção farmacológica e/ou a partir de abordagens terápêuticas alternativas/integrativas (CATINEAN et al., 2019) com hipnoterapia dirigida para o intestino, abrangendo efeitos psicológicos até modificações gastrointestinais fisiológicas, por exemplo (PETERS et al., 2016). Dessa forma, este estudo teve como objetivo descrever os efeitos da restrição de FODMAPs na redução de sintomas da SII. ...
... Na SII, não só a alimentação, mas também fatores emocionais (apesar de não serem considerados causa da SII) devem ser investigados e avaliados, pois são condições agravantes do quadro na doença (LIMA et al., 2018). Nesse sentido, Peters et al. (2016) investigaram o envolvimento de fatores psicológicos através da comparação entre hipnoterapia, dieta com baixo conteúdo de FODMAPs e da combinação das duas intervenções. Os autores constataram que a hipnoterapia dirigida ao intestino para o tratamento da SII apresentou efeito semelhante à dieta pobre em FODMAPs no alívio de sintomas e pareceu ter um efeito superior de modular positivamente os índices psicológicos a longo prazo. ...
... En el año 2016, Peters (Australia) publicó un estudio realizado con la intención de comparar los efectos de la hipnoterapia con la dieta baja en FODMAP en 74 pacientes con SII. La población del estudio fue asignada de forma aleatoria a tres grupos: el primero recibió hipnoterapia, el segundo dieta baja en FODMAP y el tercero una combinación de ambas intervenciones 25 . Los resultados de este estudio mostraron que los efectos de la hipnoterapia dirigida al intestino fueron similares a los de la dieta baja en FODMAP para el alivio de los síntomas gastrointestinales, sin embargo, la hipnoterapia mostró eficacia superior a la dieta en los índices psicológicos, con cambios favorables en rasgos como ansiedad y depresión 25 . ...
... La población del estudio fue asignada de forma aleatoria a tres grupos: el primero recibió hipnoterapia, el segundo dieta baja en FODMAP y el tercero una combinación de ambas intervenciones 25 . Los resultados de este estudio mostraron que los efectos de la hipnoterapia dirigida al intestino fueron similares a los de la dieta baja en FODMAP para el alivio de los síntomas gastrointestinales, sin embargo, la hipnoterapia mostró eficacia superior a la dieta en los índices psicológicos, con cambios favorables en rasgos como ansiedad y depresión 25 . ...
... Whilst there have been several studies demonstrating the efficacy of the LFD, the majority of these studies have assessed the LFD in the short term (strict restriction phase) [15][16][17][18][19][20][21][22] . Recently, there has been emerging evidence for the use of the LFD in the long term [23][24][25][26][27][28] . However, studies to date have been small single centre studies, some have been performed in specialist centres, with a relatively short duration of follow up, with the longest follow up period being 18 months [23][24][25][26][27][28] . ...
... Recently, there has been emerging evidence for the use of the LFD in the long term [23][24][25][26][27][28] . However, studies to date have been small single centre studies, some have been performed in specialist centres, with a relatively short duration of follow up, with the longest follow up period being 18 months [23][24][25][26][27][28] . In addition, to our knowledge, only one study has assessed both nutritional and FODMAP intake at long term [23] . ...
Background
The low FODMAP diet (LFD) is effective in managing irritable bowel syndrome (IBS) in the short term. This study assessed the long-term effect of the LFD on symptoms, nutritional composition and socialising.
Methods
Patients with IBS who received dietetic-led LFD advice were approached at long term follow up (>6 months post LFD advice) from six centres across the United Kingdom. Participants completed questionnaires assessing gastrointestinal symptoms, adherence, nutritional intake, dietary acceptability and food related quality of life (QOL).
Results
205 participants completed the study, with a mean follow up of 44 months (3.7 years). Adequate symptom relief was noted in 60% of individuals at long term follow up, with 76% being on the personalisation phase of the LFD (pLFD). Mean nutritional intake did not differ between individuals on the pLFD versus habitual diet, with no difference in fructan intake (2.9 g/d vs 2.9 g/d, p = 0.96). The majority (80%) of individuals on the pLFD consumed specific ‘free-from’ products at the long term, with the purchase of gluten or wheat free products being the commonest (68%).
Conclusion
The majority of patients follow the pLFD in the long term, with a large proportion purchasing gluten or wheat free products to manage their symptoms.
... A suggested explanation for this was that these two treatments should attract different type of subgroups of people with IBS. However, randomized control trials have shown that both hypnotherapy and yoga were equally effective as a low FODMAP diet (28,29), indicating that the effectiveness of these different treatment regimen is not related to specific subtypes of IBS. ...
... Im Vergleich mit anderen Therapiemethoden für das RDS, wie der Hypnotherapie und Bewegungstherapie im Sinn von Yoga, schneidet die Low-FODMAP-Diät gleich gut ab [27,28]. Der Vergleich mit anderen Ernährungstherapien ist schwerer zu führen: So belegten 2 Studien aus Schweden und den USA, dass eine auf den Standardernährungsempfehlungen für RDS basierende Diät (mit allerdings ebenfalls niedrigem FODMAP-Gehalt) einer Low-FODMAP-Therapie nahezu gleichwertig war [29,30]. ...
Das Thema Ernährung ist für Patienten mit einem Reizdarmsyndrom hochrelevant, da Nahrungsmittel als symptomauslösend empfunden werden. Die Abkürzung FODMAP steht für „fermentierbare Oligosaccharide, Disaccharide, Monosaccharide und Polyole“, also kurzkettige Kohlenhydrate, die im Dünndarm schlecht absorbiert werden und durch Fermentationsprozesse Blähungen und Stuhlunregelmässigkeiten hervorrufen können. Die FODMAP-Diät ist bei Reizdarmsyndrom(RDS)-Patienten zur Symptomkontrolle effektiv und verläuft in 3 Phasen (Reduktion – Reexposition – Personalisierung) und sollte von einer geschulten Ernährungsberatung in enger Zusammenarbeit mit dem behandelnden Gastroenterologen/in erfolgen um eine Fehl- oder Mangelernährung zu vermeiden.
... The nature of the hypnotic induction has not been described in detail making replication difficult and the description of the hypnotic intervention has been poor: hypnotizability has not been measured, and there is no prospective plan for subject entry (5). Based on our previous study, we have found hypnotherapy to be an effective and complementary method that decreases resting pain and re-experience (6). Re-experience is one of the complications of post trauma stress syndrome 'PTSD' ...
Background: Hypnosis is used increasingly for healthcare applications in hospitals, clinics, and psychotherapy practice. Thesubconscious mind which is extremely complex contains all of our emotions, creativity, intuition, and a whole host of resources that control our bodily functions such as breathing, heart rate and metabolism. Then our body learns to relax into a trance state. Relaxation and suggestion increase parasympathetic and decrease sympathetic functions because of a direct effect of the hypnosis state. So, hypnotic treatment possible to control pain intensity. Purpose: To evaluate the effects of hypnotic treatment on pain after episiotomy in post partum periods. Methods: A single blind randomized clinical trial was performed on six eligible women who were at the beginning of post partum periods. The participants were matched by 24 hours duration after birthing, nulliparas. There was no additional administration of analgesics during the study period. The women received hypnotic treatment for 15 minutes. Theintensity of pain were measured by using the Visual Analogue Sc ale for Pain (VASP). VASP measured before and immediately after treatment. Then, were compared between the paired groups and statistical analyses were performed using SPSS 20. Results: Six patients (100%) were nulliparas. The mean of ages was (28 ± 5,94 years old). The mean of pain score before treatment was (84, 29 ± 15, 65 mm) and mean of pain score after treatment was (64,57 ± 15,80 mm) There were significant differences between two the groups in intensity of pain before and immediately after treatment. The pain intensity after the treatment was significantly decrease than before (p = 0.04). Conclusion: Hypnotic treatment reduced the severity of pain at the beginning of post partum periods after episiotomy. These findings showed that hypnotic treatment was effective for reducing pain. Hypnotic treatment can be an effective pain management for Indonesia women in post partum periods.
... Lifestyle modifications and simple dietary changes [33,34] can improve symptoms for almost 50% of patients with IBS Pharmacological therapies recommended for IBS include low-dose tricyclic antidepressants and antispasmodics; however, these may improve some but not all symptoms [35]. Psychological therapies such as cognitive behavioural therapy [36] and gut-directed hypnotherapy [37] may also be effective for some people. First-line lifestyle approaches include managing stress, eating regularly, and limiting caffeine, alcohol, high-fat foods, and high-fibre foods. ...
Chronic diarrhoea affects up to 10% of older adults, impacts quality of life and has potential adverse medical outcomes. Dietary changes can be effective but, if not managed correctly, could negatively impact health. This review summarises the prevalence, potential causes, and complications of chronic diarrhoea in older people. The evidence for dietary treatments, and the nutritional implications, are described.
... Physicians should consider the potential food-related psychological distress that these patients might experience. When Peters et al. compared the effect of gut-directed hypnotherapy, the low FODMAP diet or a combination therapy, no significant differences in efficacy were found between the treatments [44]. However, in this study, there were no differences in the psychological measurements at baseline between the treatment arms. ...
(1) Background: Predictors of dietary treatment response in irritable bowel syndrome (IBS) remain understudied. We aimed to investigate predictors of symptom improvement during the low FODMAP and the traditional IBS diet for four weeks. (2) Methods: Baseline measures included faecal Dysbiosis Index, food diaries with daily energy and FODMAP intake, non-gastrointestinal (GI) somatic symptoms, GI-specific anxiety, and psychological distress. Outcomes were bloating, constipation, diarrhea, and pain symptom scores treated as continuous variables in linear mixed models. (3) Results: We included 33 and 34 patients on the low FODMAP and traditional IBS diet, respectively. Less severe dysbiosis and higher energy intake predicted better pain response to both diets. Less severe dysbiosis also predicted better constipation response to both diets. More severe psychological distress predicted worse bloating response to both diets. For the different outcomes, several differential predictors were identified, indicating that baseline factors could predict better improvement in one treatment arm, but worse improvement in the other treatment arm. (4) Conclusion: Psychological, nutritional, and microbial factors predict symptom improvement when following the low FODMAP and traditional IBS diet. Findings may help individualize dietary treatment in IBS.
... 17 Three RCTs have reported IBS symptoms during the low FODMAP diet in the long term, all reporting sustained symptom improvement, albeit only at 4-6 months. [18][19][20] With regard to dietary adequacy, nutrient intake is somewhat restored when individuals move from the restriction phase of the low FODMAP diet to FODMAP personalization in the long term. ...
Background
Short-term trials demonstrate the low FODMAP diet improves symptoms of irritable bowel syndrome (IBS) but impacts nutrient intake and the gastrointestinal microbiota. The aim of this study was to investigate clinical symptoms, nutrient intake, and microbiota of patients with IBS 12 months after starting a low FODMAP diet.
Methods
Participants enrolled in a previous short-term clinical trial and who had been through structured FODMAP restriction, reintroduction, and personalization were invited to participate in a follow-up study at one time point at 12 months. Gastrointestinal symptoms, stool output, dietary intake, and quality of life were recorded. Stool samples were collected and analyzed for microbiota (qPCR) and short-chain fatty acids (SCFA). Data were compared with baseline (prior to any intervention in the original clinical trial) using non-parametric statistics.
Key Results
Eighteen participants were included in the study. Adequate relief of symptoms occurred in 5/18 (28%) at baseline and increased to 12/18 (67%) following long-term personalized low FODMAP diet (p = 0.039). There was a reduction in IBS-SSS total score between baseline (median 227, IQR 99) and long term (154, 89; p < 0.001). Bifidobacteria abundance was not different between baseline (median 9.29 log10 rRNA genes/g, IQR 1.45) and long term (9.20 log10 rRNA genes/g, 1.41; p = 0.766, q = 0.906); however, there were lower concentrations of total SCFA, acetate, propionate, and butyrate.
Conclusions
In this long-term analysis, two thirds of patients reported adequate relief of symptoms after 12 months of personalized low FODMAP diet that did not result in differences from baseline in Bifidobacteria. FODMAP reintroduction and personalization may normalize some of the effects of short-term FODMAP restriction.
... 3 Gut-directed hypnotherapy is recommended and is being increasingly applied to patients with IBS, which can achieve an effect similar to that of the low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet; it can further be applied to inflammatory bowel disease to a lesser extent via its potential mechanism of action on the brain-gut axis. [16][17][18] Cognitivebehavioral therapy delivered by telephone or internet has also been shown superior to the usual treatment methods and is recommended for treating IBS. 19,20 Four classes of psychotherapy hold the most promise in CAPS: cognitive-behavioral therapy, psychodynamic interpersonal therapy, mindfulness/acceptance-based therapies and hypnotherapy, 1 although related clinical research is lacking. ...
Background
Centrally mediated abdominal pain syndrome (CAPS) is characterized by continuous or frequently recurring abdominal pain and can result in functional loss across several life domains. The efficacy of the present management methods has not been established yet. We performed a prospective randomized controlled trial to explore the short-term efficacy of local analgesic (lidocaine) and opioid analgesic (sufentanil) in patients with CAPS.
Methods
We consecutively enrolled 130 patients who met the Rome IV CAPS criteria and divided them into the sufentanil + lidocaine (S + L) group and sufentanil (S) group. Patients completed the pain rating scales, including the numeric rating scale (NRS) and verbal rating scale (VRS), 60 min before colonoscopy. All the patients were initially administered sufentanil. In the S + L group, we sprayed a 5 ml solution of lidocaine on the surface of ascending, transverse, descending, and sigmoid colon during colonoscope withdrawal, while 5 ml saline was sprayed in the S group. Follow up was performed 1 day, 3 days, 1 week, 2 weeks, 1 month, and 3 months after colonoscopy, to complete the pain scaling.
Results
A comparison of the NRS and VRS showed that there were no significant differences between the S + L and S groups and within each group ( p > 0.05).
Conclusions
Local analgesic lidocaine and opioid analgesic sufentanil showed negative efficacy during short-term observation. The opioid receptor blocker sufentanil did not worsen symptoms in patients with CAPS after colonoscopy under general anesthesia in the short term. [chictr.org.cn, Chinese Clinical Trial Identifier, ChiCTR-IOR-16008187]
... Stosowane są również leki o działaniu przeciwdepresyjnym oraz preparaty serotoninergiczne [14]. Leczenie farmakologiczne w zespole jelita drażliwego jest szeroko opisywane w literaturze, jednak nie stanowi ono tematu niniejszej pracy [15][16][17][18]. ...
The symptoms of irritable bowel syndrome are estimated in 10-20% of the population, and the disease is currently one of the most common diseases of the digestive system. Thus, it is a significant diagnostic problem for doctors and nutritionists in terms of the selection the appropriate diet therapy and for pharmacists in terms of potential pharmaceutical care and consultation on basic nutritional errors. Research shows that the prevalence of IBS contributes to a significant deterioration in the quality of life, and the type of food consumed has a significant impact on the well-being and health of the patient. The prevelance of symptoms is strongly related to the food consumed. About 60% of patients diagnosed with Irritable Bowel Syndrome notice an exacerbation in symptoms and a deterioration of well-being soon after eating a meal. Among them, 28% of people report symptoms as early as 15 minutes after eating, while in over 93% of patients, severe symptoms persist for about 3 hours after stopping eating.
The main treatments for IBS are diet modification and pharmacotherapy. Diet modification consists in temporarily eliminating the intake of certain foods (e.g. containing fermentable carbohydrates, lactose, gluten) or increasing the intake of dietary fiber or short-chain fatty acids.
The Low-FODMAP diet draws particular attention in the nutritional treatment of irritable bowel syndrome.Its main assumption is the elimination of fermentable components in the intestinal lumen, which significantly reduces the symptoms of IBS. Medical data do not give a clear answer about the effectiveness of the Low-FODMAP diet, indicating many inaccuracies in the methodology of the conducted research, as well as pointing to the potential bias of the results. However, it seems paausible to say that the diet seems to be effective for the relief of single symptoms (abdominal pain, flatulence). An improperly implemented Low-FODMAP diet can induce deficiencies of certain vitamins and minerals and reduce the diversity of the bacterial microflora. Unfortunately, it is disturbing that, according to statistics, only 21% of doctors recommend that their patients consult a dietitian for nutrition, and there is no objective data in the field of pharmacy advice.
The aim of the work was to present the principles and assumptions of the Low-FODMAP diet and dietary interventions that can be implemented in the treatment of IBS.
... In a randomized controlled trial comparing the low FODMAP diet to gut-directed hypnotherapy (GDH) for patients with IBS, researchers found that both groups experienced improvements associated with their health-specific quality of life (Peters et al., 2016). However, this research highlighted that GDH is an excellent option for individuals with a history of disordered eating as it takes the focus off restrictive diets and eating practices (Hill, 2017). ...
... 7 However, because small bowel dysmotility and the luminal contents, via affecting duodenal hypersensitivity, are involved in the pathophysiology of FD, 2 it is plausible that a low-FODMAPs diet to be helpful in the management of FD symptoms as well. In addition, a low-FODMAPs diet could effectively reduce anxiety score in a 6-wk randomized controlled trial, 8 and considering the role of brain-gut axis in the pathophysiology of FD, it might also affect functional dyspeptic symptoms. ...
Background:
Assessing the potential effects of a low- fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) diet on functional gastrointestinal symptoms, particularly upper gastrointestinal symptoms, is not clearly understood. The current study aimed at exploring the association of a diet low in FODMAPs with uninvestigated chronic dyspepsia (UCD) and functional dyspeptic symptoms in a large population of Iranian adults.
Methods:
This cross-sectional study was conducted on 2987 adults. Dietary FODMAPs intake estimated using a validated food-frequency questionnaire. UCD, early satiation, postprandial fullness and gastric pain were determined using a modified and validated version of the Rome III questionnaire.
Results:
After controlling for various confounders, consumption of a diet low in FODMAPs was associated with increased risk of UCD in the whole population (OR=1.85; 95% CI: 1.23, 2.78; P=0.009) and women (OR=2.41; 95% CI: 1.46, 3.95; P=0.004), but not in men. Higher consumption of a low-FODMAPs diet was related to increased risk of postprandial fullness (OR=1.38; 95% CI: 1.08, 1.78; P=0.046). The inverse association between FODMAPs and epigastric pain tended to be significant after controlling for eating behaviors (OR=1.31; 95% CI: 0.98, 1.76; P=0.084). No significant association was observed for early satiation.
Conclusions:
Our data suggest that consumption of a low-FODMAPs diet may increase the risk of UCD and postprandial fullness; however, well-planned randomized controlled trials and prospective cohorts are required to ascertain the effect of FODMAPs on upper gastrointestinal symptoms.
... Studies reported that at long-term follow-up (> 6 months) 50-70% of patients on LFD had a satisfactory relief of symptoms [17][18][19][20][21]. Patients reintroduced one FODMAP subgroup per week and followed reappearance of symptoms in order to identify triggering foods, that should be avoided. ...
Background and aims:
The nonpharmacological therapy in irritable bowel syndrome (IBS) is expanding rapidly. Practitioners and medical educators need to be aware of progress and changes in knowledge of this topic. The Romanian Society of Neurogastroenterology aimed to create guidelines based on best evidence on the use of nonpharmacological therapy in IBS.
Methods:
A group of experts was constituted. This was divided in eleven subgroups dedicated to eleven categories of nonpharmacological therapy. The subgroups searched the literature and formulated statements and recommendations. These were submitted to vote in order to obtain consensus.
Results:
The outcome of this activity is represented by the guidelines of the Romanian Society of Neurogastroenterology, presented in this paper. The recommendations are seen as complementary to the pharmacological therapy and are not intended to recommend avoiding pharmacological drugs.
Conclusions:
These guidelines were elaborated by a Delphi process and represent a useful tool for physicians managing patients with IBS.
... 59,66 Patients may consider evidence-based psychological interventions such as gut-directed hypnotherapy with a trained mental health expert. 66,67 In patients not meeting criteria for EDs, a multidisciplanary approach to aid a patient in expanding his or her diet can include the patient's gastroenterologist, a mental health professional specializing in the treatment of GI conditions, and a registered dietitian (Figure 4). 68 Given the complexity of patients with GI conditions, when available, early integrative psychogastroenterology treatment should be considered. ...
... 31 The majority of available evidence demonstrates the benefits of diet, including the low FODMAP diet, on IBS symptoms immediately following implementation, and up to 9 months afterwards. [15][16][17][32][33]24 However, little has been reported on the benefits of diet beyond 11 months of implementation. Studies examining the longer-term effects of the low FODMAP diet on IBS symptoms [34][35][36] have primarily delivered the dietary advice in secondary care. ...
Background:
Evidence suggests that dietary interventions can improve symptoms in people with irritable bowel syndrome (IBS), although most data explore the short-term (immediate) impact. Data on long-term (>6 months) impact are limited, especially from primary care settings. The present study aimed to investigate the long-term effect of dietetic-led interventions for IBS delivered in primary care.
Methods:
A service evaluation of a dietetic-led IBS clinic was completed, analysing data on symptom severity, stool frequency and consistency, and healthcare input. Data were collected before and immediately after dietary intervention as part of patients' routine clinical appointments. Long-term data were collected via a postal questionnaire at least 11 months later.
Results:
In total, 211 patients responded to the long-term follow-up questionnaire at a median of 13 months (interquartile range 12-16 months) post follow-up appointment. Of these, 84% had been advised to follow a low FODMAP (i.e., fermentable oligosaccharides, disaccharides, monosaccharides and polyols carbohydrates) diet. All symptoms were reported significantly less frequently short term, and all except heartburn and acid regurgitation remained so over the long term. The four most commonly reported bowel symptoms reduced in frequency were abdominal pain (62%), bloating (50%), increased wind (48%) and urgency to open bowels (49%) (p < 0.001). The percentage of patients reporting satisfactory relief of gut symptoms was 10% at baseline and 55% at long-term follow-up (p < 0.001). Visits to a general practitioner were reduced (from 96% to 34%; p < 0.001), as were those to the gastroenterologist (from 37% to 12%; p = 0.002), during the year prior to long-term follow-up compared to the year prior to dietary intervention.
Conclusions:
Patients with IBS who received dietetic-led interventions in primary care reported long-term symptoms improvements that may result in reduced healthcare usage.
... Im Vergleich mit anderen Therapiemethoden für das RDS, wie der Hypnotherapie und Bewegungstherapie im Sinn von Yoga, schneidet die Low-FODMAP-Diät gleich gut ab [27,28]. Der Vergleich mit anderen Ernährungstherapien ist schwerer zu führen: So belegten 2 Studien aus Schweden und den USA, dass eine auf den Standardernährungsempfehlungen für RDS basierende Diät (mit allerdings ebenfalls niedrigem FODMAP-Gehalt) einer Low-FODMAP-Therapie nahezu gleichwertig war [29,30]. ...
Zusammenfassung
Das Thema Ernährung ist für Patienten mit einem Reizdarmsyndrom hochrelevant, da Nahrungsmittel als symptomauslösend empfunden werden. Die Abkürzung FODMAP steht für „fermentierbare Oligosaccharide, Disaccharide, Monosaccharide und Polyole“, also kurzkettige Kohlenhydrate, die im Dünndarm schlecht absorbiert werden und durch Fermentationsprozesse Blähungen und Stuhlunregelmässigkeiten hervorrufen können. Die FODMAP-Diät ist bei Reizdarmsyndrom(RDS)-Patienten zur Symptomkontrolle effektiv und verläuft in 3 Phasen (Reduktion – Reexposition – Personalisierung) und sollte von einer geschulten Ernährungsberatung in enger Zusammenarbeit mit dem behandelnden Gastroenterologen/in erfolgen um eine Fehl- oder Mangelernährung zu vermeiden.
... RCTs for GDH trials are smaller and fewer but show similar outcomes to CBT (256,257). Finally, a recent RCT of hypnotherapy vs low FOD-MAPs suggested equivalence (258). ...
Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.
... In line with the previous study, Iacovou et al. showed that breastfeeding mothers who followed a low-FODMAP diet had reductions in crying-fussing durations of infants with colic [18]. Other treatment modalities, such as gut-directed hypnotherapy, were also shown to improve gastrointestinal symptoms similarly to the low FODMAP diet [19]. The fact that treatments aimed at the central nervous system also improve symptoms speaks of the role of the gut-brain axis in FGIDs. ...
Functional Gastrointestinal Disorders (FGIDs) are common. In the United States alone, approximately 25 million Americans are estimated to have at least one FGID. Nonpharmacological treatment options include psychological/behavioral approaches, and dietary interventions that can vary across countries. The aim of this review is to evaluate the available evidence for dietary interventions for the treatment of childhood FGIDs amongst various cultures and regions of the world. This review includes clinical trials of dietary therapies for the treatment of FGIDs in children posted on or before 13 July 2020 in PubMed. Overall, the consensus view suggests that the westernization of diets is linked to the development of FGIDs, and diets low in Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAPs) may reduce abdominal symptoms. However, more work is needed to confirm these findings.
... A recent study of hypnotherapy for the treatment of IBS with 1,000 adult patients reported that 76% of the patients improved from the treatment; treatment was slightly more effective among patients with anxiety (Peters et al., 2016). In addition to bowel symptom improvement, "non-gastrointestinal symptoms also improved significantly on average after treatment, and hypnotherapy also improved quality of life scores" (Peters et al., 2016, p. 447). ...
Recent advances in the understanding of the autonomic nervous system have identified that optimization of health promoting parasympathetic activity is dependent on the experience of safety. As the experience of safety and its related neuroception has been associated with activation of the ventral vagal complex and its positive impact on gastric activity and pain modulation, it was predicted that abdominal pain and gastrointestinal symptoms would decrease. The results of this study confirmed this prediction and demonstrated a decrease in abdominal pain and bowel symptoms characteristic of IBS. Through visual analytics depicting changes in reported pain and process measures of Safety, Relaxation Positive Affects, the data revealed that hypnotic intervention for promotion of a sense of safety was associated with symptom reduction and predicted changes in process measures.
... Partial lactose intolerance, characterized by incomplete absorption by the intestinal walls, is called lactose malabsorption [2]. Regardless of the cause, lactase deficiency leads to the formation of unabsorbed lactose in the intestinal tract, which can lead to IBS [3]. ...
This paper presents rheological and organoleptic studies of emulsion systems using a semi-finished product based on condensed low-lactose whey and fermented pumpkin pulp puree (SPCLLW). The positive influence of SPCLLW on the structure of emulsion systems was found, which was confirmed by expert sensory evaluation. The research confirms the component compatibility of SPCLLW and vegetable oil as a part of emulsion systems. This paper scientifically proves the influence of technological factors on the parameters of emulsification of a semi-finished product based on condensed low-lactose whey and fermented pumpkin pulp to ensure its target properties as an emulsifier and stabilizer in the technology of emulsion sauces. The experiments revealed the change in the quantitative values of the determinants of emulsion systems, such as viscosity and inversion stability, depending on the values of the pH of the medium, the emulsification temperature, the rate of oil dripping and the rotation of the working body of the mixer. It was proved that the acidification of the medium increases the viscosity of the emulsion system, therefore it is advisable to use SPCLLW in the composition of salty sauces of the emulsion type. There is a direct relationship between the manifestations of inversion instability and the increase in temperature of the emulsification process. The research reveals the inversely proportional effect of the rotation speed of the working body of the mixer on the increase in viscosity of the studied systems. Mathematical optimization is carried out for certain ranges of numerical values of parameters of separate indicators of the technological process. Rational parameters of the emulsification process are determined: temperature index – 18 °С, emulsification rate – 0.09…0.11 ml/s, pH from 5.0 to 5.5, rotation speed of the working organism of the mixer – 500 rpm. The research confirms the possibility of using SPCLLW as a part of emulsion systems, in particular sauces of emulsion type.
... Generally, these studies show that the low-FODMAP is effective in reducing IBS symptoms, though it is not superior to NICE guidelines (traditional IBS diet) (Böhn, Störsrud et al., 2015), or hypnotherapy (Peters, Yao et al., 2016). Although another study shows an increased effect on abdominal pain, bloating, stool consistency, stool frequency, and urgency in IBS-D patients, compared to modified NICE guidelines, but not on general adequate relief (AR) (Eswaran, Chey et al., 2016). ...
Le syndrome de l’intestin irritable (SII) est un trouble gastro-intestinal fonctionnel caractérisé par des douleurs abdominales, des ballonnements et des troubles du transit intestinal. Cette pathologie digestive a une prévalence mondiale importante d'environ 11%. Elle entraîne un coût économique important : perte de productivité et absentéisme au travail. De plus, elle entraine une forte dégradation de la qualité de la vie des patients. Les causes de ce trouble fonctionnel ne sont pas bien comprises rendant le traitement thérapeutique difficile. Au cours des dernières années, un régime alimentaire à faible teneur en FODMAPs (Fermentable Oligo-, Di-, Mono-saccharides And Polyols) s’est révélé efficace dans la réduction des symptômes du SII. Sur le plan mécanistique ces effets positifs restent à élucider. Toutefois, on cite le plus souvent une réduction de la distension entérique due à une réduction de la production de gaz et du volume d’eau intestinale par des effets osmotiques. Campbell et al. pose l’hypothèse qu’une fermentation anaérobie de carbohydrates non-absorbés par le microbiote intestinal provoque la formation endoluminale de métabolites tels que les alcools, les cétones et les aldéhydes, responsables d'intolérances alimentaires comme l'intolérance au lactose. Nous avons émis l’hypothèse que ce mécanisme pourrait être étendu aux FODMAPs pour expliquer l’efficacité du régime alimentaire pauvre en FODMAPs chez les patients SII.Nos études montrent un rôle complexe des FODMAPs sur des modèles murins qui reflètent la physiopathologie du SII. Les traitements par FODMAPs (lactose et fructo-oligosaccharides) provoquent une hypersensibilité viscérale et abdominale et une dysfonction de la barrière de mucus au niveau de la muqueuse intestinale.Nous avons démontré que ces effets étaient dûs à la production d’agents de glycation par le microbiote intestinal. En effet, ces effets étaient prévenus par un co-traitement à la pyridoxamine. Le nombre de mastocytes muqueux était également augmenté chez les animaux traités par FODMAPs et significativement réduit par un co-traitement à la pyridoxamine. Les mastocytes sont connus pour être impliqués dans l’hypersensibilité viscérale et dans la dysrégulation de la barrière de mucus de l’intestin. Par ailleurs, une augmentation du nombre et/ou de l'activité des mastocytes est retrouvée sur des biopsie de patients SII.Ce travail de thèse original permet donc de faire un lien entre l'efficacité du régime alimentaire à faible teneur en FODMAPs, la symptomatologie et l'implication des mastocytes intestinaux chez le patient SII.
... Generally, these studies show that the low-FODMAP is effective in reducing IBS symptoms, though it is not superior to NICE guidelines (traditional IBS diet) (Böhn, Störsrud et al., 2015), or hypnotherapy (Peters, Yao et al., 2016). Although another study shows an increased effect on abdominal pain, bloating, stool consistency, stool frequency, and urgency in IBS-D patients, compared to modified NICE guidelines, but not on general adequate relief (AR) (Eswaran, Chey et al., 2016). ...
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder (FGID) characterized by abdominal pain, bloating, and erratic bowel habits. It is an affliction with a high prevalence of around 11% worldwide. It carries a significant economic cost in lost productivity and work absence, and more importantly, it has a strong negative impact on quality of life. Because it is a functional disorder of which the causes are not well understood, treatment is difficult. In recent years, a low-FODMAP diet (low in Fermentable Oligo-, Di-, Mono-saccharides And Polyols) has been successfully used to reduce symptoms of IBS. The efficacity of this approach is not completely understood, but a reduction in enteric distension by reduced gas production and small intestinal water bulk by osmotic effects are most often cited. The bacterial metabolic toxin hypothesis, proposed by Campbell et al. poses that anaerobic fermentation of unabsorbed carbohydrates by the colonic gut microbiota, producing such metabolites as alcohols, ketones, and aldehydes, are responsible for food intolerances such as lactose intolerance. We hypothesized that this same mechanism could be extended to FODMAPs to explain the efficacity of the low-FODMAP diet.
In this thesis, we looked for complementary mechanisms on how FODMAPs could influence IBS symptoms, besides distension related complaints. Our studies in a healthy mouse model show a complex role for FODMAPs in IBS physiopathology; FODMAP treatments cause a visceral and abdominal hypersensitivity, and a mucus barrier dysregulation, characterized using an innovative approach.
We hypothesized that this is due to generation of glycating agents by the intestinal microbiota, and the prevention of these effects by co-treatment with pyridoxamine indicates that this hypothesis is correct. Mucosal mast cell counts were increased in FODMAP treated animals, but not in animals co-treated with pyridoxamine. Mast cells are implicated in visceral hypersensitivity, as well as in mucus barrier dysregulation, and increased mucosal mast cell numbers or activity are often linked to IBS.
This work thus offers a link between the efficacy of the low-FODMAP diet and the involvement of intestinal mast cells in IBS.
Purpose of review:
Diet appears to trigger symptoms in the majority of individuals with irritable bowel syndrome (IBS) and is associated with a reduced quality of life. There has been a recent focus on the role of dietary therapies to manage individuals with IBS. The aim of this review is to discuss the utility of traditional dietary advice (TDA), low-FODMAP diet (LFD) and gluten-free diet (GFD) in IBS.
Recent findings:
Several recent randomized controlled trials (RCTs) have been published demonstrating the efficacy of the LFD and GFD in IBS, with the evidence base for TDA being predominantly based on clinical experience, with emerging RCTs evaluating TDA. Only one RCT has been published to date comparing TDA, LFD and GFD head to head, with no difference noted between diets in terms of efficacy. However, TDA has been noted to be more patient-friendly and is commonly implemented as a first-line dietary therapy.
Summary:
Dietary therapies have been demonstrated to improve symptoms in patients with IBS. In view of insufficient evidence to recommend one diet over another currently, specialist dietetic input in conjunction with patient preference is required to determine implementation of dietary therapies. Novel methods of dietetic delivery are required in view of the lack of dietetic provision to deliver these therapies.
Purpose
Inflammatory Bowel Diseases (IBD) are disorders intensively studied in the literature as a model of gut-brain interactions within the so-called gut-brain axis. A non-negligible proportion of patients with IBD have psychological and psychiatric comorbidities and show non-low levels of depressive and anxiety symptoms. The remitting-recurrent course of IBD poses the need for therapeutic intervention that not only serves to induce clinical remission of the disease but also has an impact on maintenance. Therefore, therapeutic adherence is certainly a cornerstone of the management of these patients.
Material and methods
A literature search was conducted to identify studies that had psychotherapy as an intervention and therapeutic adherence to IBD-specific therapy as one of the outcomes.
Results
There are not many studies in the literature that have specifically explored the role of psychotherapy in improving therapeutic adherence in patients with IBD. Of the available trials, most have focused on cognitive-behavioral psychotherapeutic interventions and are directed toward basically oral therapies. Other few studies focused on interventions delivered under telemedicine or mindfulness or hypnotherapy techniques.
Conclusions
This narrative review leans toward a probable beneficial effect of psychotherapy in therapeutic adherence although new and more organic studies need to be conducted to generate stronger evidence.
Background:
Gut-directed hypnotherapy (GDH) has high rates of durable efficacy for treating irritable bowel syndrome (IBS) but its widespread use is limited due to high costs and poor access. A smartphone app delivering GDH was developed to fill gaps in accessibility but has not been assessed in IBS patients. The current retrospective evaluation aims to assess the efficacy of app-delivered GDH in managing IBS symptoms and to investigate associating factors that predict response.
Methods:
Irritable bowel syndrome patients who downloaded the app between June 2019 and April 2020 were retrospectively evaluated. The first seven sessions were free. Daily GDH, psycho-education, and breathing exercises were included. Overall and individual gastrointestinal symptoms were assessed at baseline and completion using a 100-mm visual analogue scale. Clinical data were extracted.
Key results:
2843 patients with self-reported IBS commenced the free sessions, 1428 (50%) purchased the app and 253 (9%) completed all 42 sessions. Outcome data were available for 190 users who completed all 42 sessions. 64% of patients who completed the GDH and provided outcome data responded (defined as >30% reduction in abdominal pain). Abdominal pain reduced from 60mm (50-73mm) at baseline to 26mm (13-50mm) on study completion (p<0.001 Wilcoxon). Similar results were seen for overall and individual symptoms. On multivariable analysis, symptom response was positively associated with being ≥ 40 years (estimated OR 0.398, p=0.025) and negatively associated with trying probiotics (0.323, p=0.042).
Conclusions & inferences:
Adherence to app-delivered gut-directed hypnotherapy was low but users who completed the program saw notable improvements in their IBS symptoms. Patients ≥40 years, with symptoms for ≥5 years, may respond better. A controlled trial comparing face-to-face to app-delivered GDH is indicated.
Hypnotherapy is one of the treatments for irritable bowel syndrome (IBS).Meta-analysis was to evaluate the effectiveness of its use and to identify the most optimal conditions for its implementation. We analyzed Scientific medical databases PubMed, EMBASE, eLibrary for the period from 2005 to 2022. Studies performed on adult samples of patients with a confirmed diagnosis of IBS on the basis of Rome II–IV with a control group were selected. Included studies were analyzed for risks of bias and publication bias. Clinical efficacy was assessed by comparing data on gastrointestinal symptoms reduction and psychological condition. A subgroup analysis was used to compare the effectiveness of group and individual hypnotherapy, as well as the number of sessions conducted. Nine studies (867 patients) were included in the final meta-analysis. Hypnotherapy was significantly more effective in reducing gastrointestinal symptoms in patients with IBS compared to controls (SMD=0.25 [95% CI 0.02–0.49], I2=53%, p=0.03), with positive effects persisting up to one year (SMD=0.34[95% CI 0.07–0.60], p=0.01). Hypnotherapy resulted in an equalization of the psychological distress (MD=1.09[95% CI from –1.27 to 3.44], p=0.37), but the results were not significant. Group hypnotherapy (SMD=0.35[95% CI 0.01–0.70], p=0.05) and higher amount of hypnotherapy sessions during treatment (SMD=0.35 [95%CI 0.14–0.57], p=0.001) were more effective. Based on the results of this systematic review, it is fair to assume that the most effective use of hypnotherapy in patients with IBS, including those with therapy-resistant forms, is more than 7 sessions of group hypnotherapy more than once a week with a minimum session time of 45 minutes.
Excluding oligo-, di-, monosaccharides and polyols (FODMAPs) from the diet is increasingly being used to treat children with gastrointestinal complaints. The aim of this position paper is to review the available evidence on the safety and efficacy of its use in children and provide expert guidance regarding practical aspects in case its use is considered . Members of the Gastroenterology Committee, the Nutrition Committee and the Allied Health Professionals Committee of the European Society for Pediatric Gastroenterology Hepatology and Nutrition contributed to this position paper. Clinical questions regarding initiation, introduction, duration, weaning, monitoring, professional guidance, safety and risks of the diet are addressed. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. The systematic literature search revealed that the low-FODMAP diet has not been comprehensively studied in children. Indications and contraindications of the use of the diet in different pediatric gastroenterological conditions are discussed and practical recommendations are formulated. There is scarce evidence to support the use of a low-FODMAP diet in children with Irritable Bowel Syndrome and no evidence to recommend its use in other gastrointestinal diseases and complaints in children. Awareness of how and when to use the diet is crucial, as a restrictive diet may impact nutritional adequacy and/or promote distorted eating in vulnerable subjects. The present article provides practical safety tips to be applied when the low-FODMAP diet is considered in children.
Background:
We sought to determine how a low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet (LFD) affected high FODMAP food intake, nutrient intake, and diet quality in children with functional abdominal pain disorders (FAPD).
Methods:
Children (ages 7-13 years) with Rome IV FAPD began a dietitian-guided LFD. Three-day food records were captured at baseline and 2-3 weeks into the LFD. Intake of high FODMAP foods, energy, macronutrients, micronutrients, food groups, and ultra-processed foods were determined.
Key results:
Median age of participants was 11 years, and 19/31 (61%) were female. Twenty-eight (90%) decreased high FODMAP food intake on the LFD: overall median (25-75%) high FODMAP foods/day decreased from 5.7 (3.6-7.3) to 2 (0.3-3.7) (p < 0.001). A more adherent subset (n = 22/71%) of participants consumed on average ≤3 high FODMAP foods per day during the LFD. Baseline nutritional intake and quality were generally poor with several micronutrient deficiencies identified. Diet quality improved on the LFD with increased servings of vegetables and protein and decreased consumption of ultra-processed foods, trans-fatty acids, and added sugars. On the LFD, there were significant decreases in total carbohydrates and thiamin (remained within recommended intake) and significant increases in vitamin B6 (p = 0.029), vitamin C (p = 0.019), and vitamin E (p = 0.009). Children more adherent to the LFD further increased vitamin D, magnesium, potassium, and fat servings.
Conclusions and inferences:
The majority of children with FAPD on a dietitian-led LFD successfully decreased high FODMAP food intake. Children with FAPD on the LFD (vs. baseline) modestly improved micronutrient intake and diet quality.
In this world of fast moving day to day activities, it is of utmost importance that every individual is aware of their personal well- being and take steps towards improving these over the course of time (Al-Asmi et al., 2015; Amato et al., 2001). The state of well – being can be described as understanding the quality of life led by various individuals (Statham & Chase, 2010). The concept of well- being in humans is broadly classified into two aspects - the first one is associated with having life satisfaction and a positive effect in one’s life.the study here is only focused towards the use of hypnotherapeutic interventions in the process of promoting a positive psychological heath scenario all across. The study undertakes a systematic review approach with 51 articles and aims to put forward a summarised version of the literature in the aspect of hypnotherapeutic interventions.The result of the study identifies a total of three themes from the systematic literature review conducted. It is found that the three identified themes have been put forward by researchers as the most effective impact of hypnotherapeutic interventions.
The current study sought to (1) compare the efficacies of Ericksonian hypnotherapy, traditional hypnotherapy, and educational talk in treating irritable bowel syndrome (IBS), and to (2) evaluate the impacts of hypnotic susceptibility on participants' responses to hypnotherapy. The study adopted a three-arm randomized controlled trial design and achieved an effective sample size of 144. Self-reported psychological questionnaires were used to assess participants' IBS symptom severity, health-related quality of life, and coping patterns at baseline, immediately post-intervention, and 3 months after intervention. The evaluation focused primarily on IBS symptom severity and health-related quality of life, as well as on the illness coping patterns of symptom catastrophizing and symptoms-related social hypervigilance.The findings showed that significant improvements in IBS symptom severity occurred in all three types of study groups immediately after completion of the intervention (p < .05, ηρ2 = .20). However, only the traditional hypnotherapy groups and the Ericksonian hypnotherapy groups still had a notably significant decrease in symptoms 3 months after the intervention, whereas the educational talk groups had dropped back to pre-treatment symptom levels at the 3-month follow-up. The amplitude of change of symptom catastrophizing in the traditional hypnotherapy groups was stronger than that in the Ericksonian hypnotherapy groups after completion of the intervention, and the two types of hypnotherapy groups were significantly lower in symptom catastrophizing both immediately after the intervention and also 3 months post-intervention (p < .001, ηρ2 = .17). The other coping mechanism studied, symptoms-related social hypervigilance, showed a significant decline only in the Ericksonian hypnotherapy groups (ps < .001, ηρ2 = .45). Interestingly, in the traditional hypnotherapy groups, persons with higher hypnotic susceptibility showed significant improvement in symptom severity, health-related quality of life, and coping patterns following treatment. Notably, the effects from Ericksonian hypnotherapy for IBS diverged from the effects from traditional hypnotherapy. Finally, both Ericksonian hypnotherapy and traditional hypnotherapy appeared to have greater positive effects than educational talk did, but at different levels.
Description
Irritable bowel syndrome (IBS) is a commonly diagnosed gastrointestinal disorder that can have a substantial impact on quality of life. Most patients with IBS associate their gastrointestinal symptoms with eating food. Mounting evidence supports dietary modifications, such as the low–fermentable oligo-, di-, and monosaccharides and polyols (FODMAP) diet, as a primary treatment for IBS symptoms. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) is to provide best practice advice statements, primarily to clinical gastroenterologists, covering the role of diet in IBS treatment.
Methods
This expert review was commissioned and approved by the AGA CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. The best practice advice statements were drawn from reviewing existing literature combined with expert opinion to provide practical advice on the role of diet in treating patients with IBS. Because this was not a systematic review, formal rating of the quality of evidence or strength of the presented considerations was not performed.
Best Practice Advice Statements
Best Practice Advice 1
Dietary advice is ideally prescribed to patients with IBS who have insight into their meal-related gastrointestinal symptoms and are motivated to make the necessary changes. To optimize the quality of teaching and clinical response, referral to a registered dietitian nutritionist (RDN) should be made to patients who are willing to collaborate with a RDN and patients who are not able to implement beneficial dietary changes on their own. If a gastrointestinal RDN is not available, other resources can assist with implementation of diet interventions.
Best Practice Advice 2
Patients with IBS who are poor candidates for restrictive diet interventions include those consuming few culprit foods, those at risk for malnutrition, those who are food insecure, and those with an eating disorder or uncontrolled psychiatric disorder. Routine screening for disordered eating or eating disorders by careful dietary history is critical because they are common and often overlooked in gastrointestinal conditions.
Best Practice Advice 3
Specific diet interventions should be attempted for a predetermined length of time. If there is no clinical response, the diet intervention should be abandoned for another treatment alternative, for example, a different diet, medication, or other form of therapy.
Best Practice Advice 4
In preparation for a visit with a RDN, patients should provide dietary information that will assist in developing an individualized nutrition care plan.
Best Practice Advice 5
Soluble fiber is efficacious in treating global symptoms of IBS.
Best Practice Advice 6
The low-FODMAP diet is currently the most evidence-based diet intervention for IBS. Healthy eating advice as described by the National Institute of Health and Care Excellence Guidelines, among others, also offers benefit to a subset of patients with IBS.
Best Practice Advice 7
The low-FODMAP diet consists of the following 3 phases: 1) restriction (lasting no more than 4–6 weeks), 2) reintroduction of FODMAP foods, and 3) personalization based on results from reintroduction.
Best Practice Advice 8
Although observational studies found that most patients with IBS improve with a gluten-free diet, randomized controlled trials have yielded mixed results.
Best Practice Advice 9
There are limited data showing that selected biomarkers can predict response to diet interventions in patients with IBS, but there is insufficient evidence to support their routine use in clinical practice.
Irritable bowel syndrome (IBS) patients often resort to dietary interventions to manage their symptoms, as these are frequently exacerbated by various food items. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) is now considered by many a first-line treatment option for IBS, as it has been found to be superior to alternative dietary interventions. However, concerns have been raised as restricting fermentable carbohydrates might result in nutritional deficits or alter composition and function of the gut microbiome in the long term. The study by Staudacher et al., published in this issue of the journal, is the first prospective study to follow IBS patients after completing all three phases of the low FODMAPs diet (restriction, reintroduction, and personalization), demonstrating that this is safe and effective in long-term, when patients are supervised by a dietician. This mini-review provides an up-to-date overview of the use of fermentable carbohydrate's restrictions for symptom management in IBS patients, while summarizing the current knowledge on the possible mechanisms of action behind low fermentable carbohydrate diet efficacy.
Background and Aim
Diet is a powerful tool in the management of gastrointestinal disorders, but developing diet therapies is fraught with challenge. This review discusses key lessons from the FODMAP diet journey.
Methods
Published literature and clinical experience were reviewed.
Results
Key to designing a varied, nutritionally adequate low FODMAP diet was our accurate and comprehensive database of FODMAP composition, made universally accessible via our user-friendly, digital application. Our discovery that FODMAPs coexist with gluten in cereal products, and subsequent gluten/fructan challenge studies in non-celiac gluten sensitive populations highlighted issues of collinearity in the nutrient composition of food and confirmation bias in the interpretation of dietary studies. Despite numerous challenges in designing, funding and executing dietary randomised controlled trials, efficacy of the low FODMAP diet has been repeatedly demonstrated, and confirmed by real-world experience, giving this therapy credibility in the eyes of clinicians and researchers. Furthermore, real-world application of this diet saw the evolution of a safe and effective three-phased approach. Specialist dietitians must deliver this diet to optimise outcomes as they can target and tailor the therapy, and mitigate the key risks of compromising nutritional adequacy and precipitating disordered eating behaviours, skills outside the gastroenterologist’s standard tool kit. While concurrent probiotics are ineffective, specific fiber supplements may improve short- and long-term outcomes.
Conclusions
The FODMAP diet is highly effective, but optimal outcomes are contingent on the involvement of a gastroenterological dietitian who can assess, educate and monitor patients and manage risks associated with implementation of this restrictive diet.
Background:
The low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet is an effective dietitian-led treatment for irritable bowel syndrome (IBS). An increasing demand of IBS patient referrals has warranted group FODMAP education led by specialist dietitians. Psychological co-morbidities are common in IBS, although how the low FODMAP diet influences psychological outcomes is not understood. The present study aimed to evaluate symptom related outcomes of the diet following group education and assess its effect on psychological profiles.
Methods:
An observational, prospective study was conducted in 55 IBS patients who attended FODMAP Restriction and FODMAP Reintroduction group sessions. Data were collected at baseline and follow-up after FODMAP Restriction and analysed using descriptive and McNemar's tests. Primary outcome was evaluated by IBS Symptom Severity Score (IBS-SSS). Secondary psychological outcomes included anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and risk of eating disorder questionnaire (SCOFF).
Results:
After FODMAP Restriction, 27 of 55 (54%) patients reported clinically relevant symptom improvement, as defined by a reduction in the IBS-SSS ≥50 points, whereas no differences were recorded in the proportion of patients identified with clinical anxiety (p = 1.000) or clinical depression (p = 0.375). Positively, no increased risk of an eating disorder was observed.
Conclusions:
The present study provides data supporting the efficacy of the low FODMAP diet in IBS patients who attended dietitian led group education settings in tertiary care. Clinically significant improvements in gastrointestinal symptoms were observed, although with no impact on clinical levels of anxiety, depression or the risk of an eating disorder.
There has been a surge in the interest of the role of gluten outside the diagnosis of celiac disease, with a particular interest in the role of a gluten free diet (GFD) in irritable bowel syndrome (IBS). IBS is common, with diet being known to be a trigger for symptoms in the majority of patients. There is evidence for the use of a GFD to manage patients with IBS. In addition to the GFD, there are other dietary therapies available to manage IBS, including the low FODMAP diet (LFD) and traditional dietary advice. There have been several trials assessing the LFD to date, with evidence for its use in patients with IBS. Areas of uncertainty remain with the LFD and GFD, including nutritional adequacy, effects on the gut microbiota and long-term outcomes. Choice of dietary therapy should be determined by patient choice, in conjunction with dietetic input. The purpose of this chapter is to give an overview of the role of a GFD in IBS, as well as other dietary therapies.
We conducted a meta-analysis exploring the effect of a low fermentable oligo-, di-, monosaccharides, and polyols diet (LFD) on the overall symptoms, quality of life, and stool habits of irritable bowel syndrome (IBS) patients. The meta-analysis was performed using a random-effects method. The effect size was presented as weighted standardized mean difference (SMD) and 95% confidence interval (CI). Subgroup analyses were conducted to determine the potential effects of covariates on the outcome. Twenty-two papers were included. The LFD group showed a moderate reduction in symptom severity and a slight improvement in quality of life compared to the control group (SMD, −0.53 and 0.24; 95% CI, −0.68, −0.38 and 0.02, 0.47, respectively). IBS symptom improvement was consistent between subgroups stratified according to proportions of female patients, study durations, IBS subtypes, assessment methods, and control interventions. Three studies regarding stool habits change in IBS-D patients showed a significant decrease in stool frequency (mean differences [MD], −5.56/week; 95% CI, −7.40, −3.72) and a significant improvement in stool consistency (MD, −0.86; 95% CI, −1.52, −0.19) in the LFD group compared to the control group. This is the most updated meta-analysis including studies that adopted diverse control interventions such as dietary interventions, supplementation, habitual diets, and lifestyle changes.
Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction (DGBI) that is associated with significant physical, emotional, and occupational burden. Factors such as early life stress, sleep disruption, maladaptive coping strategies, symptom hypervigilance, and visceral hypersensitivity negatively affect gut-brain communication and increase the likelihood of developing IBS or worsen IBS severity. Behavioral strategies, such as cognitive behavioral therapy, gut-directed hypnosis, and mindfulness-based treatments, have shown benefit in improving gastrointestinal (GI)-specific quality of life, as well as reducing GI symptoms. Partnering with a GI-specific mental health provider can assist gastroenterologists in providing comprehensive treatment of IBS and other DGBIs.
Psychogastroenterology is the specialty treatment of patients living with chronic illnesses that affect the digestive tract using evidence-based methods, the most often being cognitive behavioral therapy tailored to the digestive illness and gut-directed hypnotherapy. While patients with all digestive conditions are referred for services, the most common are irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Clinical interventions target disease processes, including visceral hypersensitivity and autonomic nervous system arousal, while leveraging resilience and coping strategies to enhance patient self-management of their disease. Opportunities exist for psychologists both in integrated gastroenterology clinics and in private practice settings. The protocols and clinical process of working with the patient are described in detail.
Purpose:
Previous randomized controlled trials (RCT) found that mind-body therapy can improve the health outcomes of patients with irritable bowel syndrome (IBS). The purpose of this meta-analysis was to identify the combined effects of mind-body therapy on patients' IBS symptoms, quality of life, anxiety, and depression.
Methods:
A systematic literature search was conducted using various databases such as PubMed, EMBASE, CINAHL CENTRAL, DBpia, RISS, and KISS. The primary outcome variables were IBS symptoms and quality of life; the secondary outcome variables were anxiety and depression. Comprehensive Meta-Analysis version 3.0 was used to analyze the extracted data. The effect size was calculated using standardized mean difference (SMD) and 95% confidence interval (CI).
Results:
Eleven final RCTs were used for this meta-analysis. Mind-body therapy was found to have a significant effect on the IBS patients' symptoms (SMD, -0.63; 95% CI, -0.77 to -0.48), quality of life (SMD, 1.03; 95% CI, 0.40 to 1.66), anxiety (SMD, -0.28; 95% CI, -0.47 to -0.09), and depression (SMD, -0.31; 95% CI, -0.06 to -0.12).
Conclusion:
This meta-analysis reveals that mind-body therapy significantly improves IBS patients' symptoms, quality of life, anxiety, and depression. The results suggest that, in the future, appropriate mind-body therapy should be applied to Koreans suffering from IBS. Moreover, the therapy's long-term effects should be assessed.
Stwardnienie rozsiane (MS) to zapalna autoimmunologiczna choroba ośrodkowego układu nerwowego. Występuje w czterech postaciach, z których najczęstszą jest postać rzutowo-remisyjna (RRMS). Choroba objawia się u młodych dorosłych i występuje w postaci rzutów. Pomimo dostępnych wielu terapii, wciąż nie istnieje lek, który całkowicie zahamowałby rozwój choroby. Okrelizumab jest jedynym ludzkim przeciwciałem monoklonalnym wiążącym limfocyty B i spowalniającym rozwój dwóch postaci MS. Z tego powodu jego wprowadzenie na rynek uważane jest za przełom w leczeniu MS.
Objective:
To gain mechanistic insights, we compared effects of low fermentable oligosaccharides, disaccharides and monosaccharides and polyols (FODMAP) and high FODMAP diets on symptoms, the metabolome and the microbiome of patients with IBS.
Design:
We performed a controlled, single blind study of patients with IBS (Rome III criteria) randomised to a low (n=20) or high (n=20) FODMAP diet for 3 weeks. Symptoms were assessed using the IBS symptom severity scoring (IBS-SSS). The metabolome was evaluated using the lactulose breath test (LBT) and metabolic profiling in urine using mass spectrometry. Stool microbiota composition was analysed by 16S rRNA gene profiling.
Results:
Thirty-seven patients (19 low FODMAP; 18 high FODMAP) completed the 3-week diet. The IBS-SSS was reduced in the low FODMAP diet group (p<0.001) but not the high FODMAP group. LBTs showed a minor decrease in H2 production in the low FODMAP compared with the high FODMAP group. Metabolic profiling of urine showed groups of patients with IBS differed significantly after the diet (p<0.01), with three metabolites (histamine, p-hydroxybenzoic acid, azelaic acid) being primarily responsible for discrimination between the two groups. Histamine, a measure of immune activation, was reduced eightfold in the low FODMAP group (p<0.05). Low FODMAP diet increased Actinobacteria richness and diversity, and high FODMAP diet decreased the relative abundance of bacteria involved in gas consumption.
Conclusions:
IBS symptoms are linked to FODMAP content and associated with alterations in the metabolome. In subsets of patients, FODMAPs modulate histamine levels and the microbiota, both of which could alter symptoms.
Trial registration number:
NCT01829932.
Background
Application of modern rapid DNA sequencing technology has transformed our understanding of the gut microbiota. Diet, in particular plant-based fibre, appears critical in influencing the composition and metabolic activity of the microbiome, determining levels of short-chain fatty acids (SCFAs) important for intestinal health.AimTo assess current epidemiological, experimental and clinical evidence of how long-term and short-term alterations in dietary fibre intake impact on the microbiome and metabolome.MethodsA Medline search including items ‘intestinal microbiota’, ‘nutrition’, ‘diet’, ‘dietary fibre’, ‘SCFAs’ and ‘prebiotic effect’ was performed.ResultsStudies found evidence of fibre-influenced differences in the microbiome and metabolome as a consequence of habitual diet, and of long-term or short-term intervention (in both animals and humans).Conclusions
Agrarian diets high in fruit/legume fibre are associated with greater microbial diversity and a predominance of Prevotella over Bacteroides. ‘Western’-style diets, high in fat/sugar, low in fibre, decrease beneficial Firmicutes that metabolise dietary plant-derived polysaccharides to SCFAs and increase mucosa-associated Proteobacteria (including enteric pathogens). Short-term diets can also have major effects, particularly those exclusively animal-based, and those high-protein, low-fermentable carbohydrate/fibre ‘weight-loss’ diets, increasing the abundance of Bacteroides and lowering Firmicutes, with long-term adherence to such diets likely increasing risk of colonic disease. Interventions to prevent intestinal inflammation may be achieved with fermentable prebiotic fibres that enhance beneficial Bifidobacteria or with soluble fibres that block bacterial–epithelial adherence (contrabiotics). These mechanisms may explain many of the differences in microbiota associated with long-term ingestion of a diet rich in fruit and vegetable fibre.
Orthorexia nervosa describes a pathological obsession with proper nutrition that is characterized by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods believed to be unhealthy or impure. Although prompted by a desire to achieve optimum health, orthorexia may lead to nutritional deficiencies, medical complications, and poor quality of life. Despite its being a distinct behavioral pattern that is frequently observed by clinicians, orthorexia has received very little empirical attention and is not yet formally recognized as a psychiatric disorder. In this review, we synthesize existing research to identify what is known about the symptoms, prevalence, neuropsychological profile, and treatment of orthorexia. An examination of diagnostic boundaries reveals important points of symptom overlap between orthorexia and anorexia nervosa, obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD), somatic symptom disorder, illness anxiety disorder, and psychotic spectrum disorders. Neuropsychological data suggest that orthorexic symptoms are independently associated with key facets of executive dysfunction for which some of these conditions already overlap. Discussion of cognitive weaknesses in set-shifting, external attention, and working memory highlights the value of continued research to identify intermediate, transdiagnostic endophenotypes for insight into the neuropathogenesis of orthorexia. An evaluation of current orthorexia measures indicates a need for further psychometric development to ensure that subsequent research has access to reliable and valid assessment tools. Optimized assessment will not only permit a clearer understanding of prevalence rates, psychosocial risk factors, and comorbid psychopathology but will also be needed to index intervention effectiveness. Though the field lacks data on therapeutic outcomes, current best practices suggest that orthorexia can successfully be treated with a combination of cognitive-behavioral therapy, psychoeducation, and medication.
Objective A low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols) diet reduces symptoms of IBS, but reduction of potential prebiotic and fermentative effects might adversely affect the colonic microenvironment. The effects of a low FODMAP diet with a typical Australian diet on biomarkers of colonic health were compared in a single-blinded, randomised, cross-over trial.
Design Twenty-seven IBS and six healthy subjects were randomly allocated one of two 21-day provided diets, differing only in FODMAP content (mean (95% CI) low 3.05 (1.86 to 4.25) g/day vs Australian 23.7 (16.9 to 30.6) g/day), and then crossed over to the other diet with ≥21-day washout period. Faeces passed over a 5-day run-in on their habitual diet and from day 17 to day 21 of the interventional diets were pooled, and pH, short-chain fatty acid concentrations and bacterial abundance and diversity were assessed.
Results Faecal indices were similar in IBS and healthy subjects during habitual diets. The low FODMAP diet was associated with higher faecal pH (7.37 (7.23 to 7.51) vs 7.16 (7.02 to 7.30); p=0.001), similar short-chain fatty acid concentrations, greater microbial diversity and reduced total bacterial abundance (9.63 (9.53 to 9.73) vs 9.83 (9.72 to 9.93) log10 copies/g; p<0.001) compared with the Australian diet. To indicate direction of change, in comparison with the habitual diet the low FODMAP diet reduced total bacterial abundance and the typical Australian diet increased relative abundance for butyrate-producing Clostridium cluster XIVa (median ratio 6.62; p<0.001) and mucus-associated Akkermansia muciniphila (19.3; p<0.001), and reduced Ruminococcus torques.
Conclusions Diets differing in FODMAP content have marked effects on gut microbiota composition. The implications of long-term reduction of intake of FODMAPs require elucidation.
Trial registration number ACTRN12612001185853.
To draw causal conclusions about the efficacy of a psychological intervention, researchers must compare the treatment condition with a control group that accounts for improvements caused by factors other than the treatment. Using an active control helps to control for the possibility that improvement by the experimental group resulted from a placebo effect. Although active control groups are superior to "no-contact" controls, only when the active control group has the same expectation of improvement as the experimental group can we attribute differential improvements to the potency of the treatment. Despite the need to match expectations between treatment and control groups, almost no psychological interventions do so. This failure to control for expectations is not a minor omission-it is a fundamental design flaw that potentially undermines any causal inference. We illustrate these principles with a detailed example from the video-game-training literature showing how the use of an active control group does not eliminate expectation differences. The problem permeates other interventions as well, including those targeting mental health, cognition, and educational achievement. Fortunately, measuring expectations and adopting alternative experimental designs makes it possible to control for placebo effects, thereby increasing confidence in the causal efficacy of psychological interventions.
© The Author(s) 2013.
Gut-directed hypnotherapy has been found to be effective in irritable bowel syndrome (IBS). However, randomized, controlled studies are rare and few have been performed outside highly specialized research centers. The objective of this study was to study the effect of gut-directed hypnotherapy in IBS in different clinical settings outside the traditional research units.
The study population included IBS patients refractory to standard management. In study 1, patients were randomized to receive gut-directed hypnotherapy (12 sessions, 1 h/week) in psychology private practices or supportive therapy, whereas patients were randomized to receive gut-directed hypnotherapy in a small county hospital or to serve as waiting list controls in study 2. Gastrointestinal symptom severity and quality of life were evaluated at baseline, at 3 months follow-up and after 1 year.
We randomized 138 IBS patients refractory to standard management, 90 in study 1 and 48 in study 2. In both the studies, IBS-related symptoms were improved at 3 months in the gut-directed hypnotherapy groups (P<0.05), but not in the control groups (ns). In study 1, a significantly greater improvement of IBS-related symptom severity could be detected in the gut-directed hypnotherapy group than in the control group (P<0.05), and a trend in the same direction was seen in study 2 (P=0.17). The results seen at 3 months were sustained up to 1 year.
Gut-directed hypnotherapy is an effective treatment alternative for patients with refractory IBS, but the effectiveness is lower when the therapy is given outside the highly specialized research centers.
Reduction of short-chain poorly absorbed carbohydrates (FODMAPs) in the diet reduces symptoms of irritable bowel syndrome (IBS). In the present study, we aimed to compare the patterns of breath hydrogen and methane and symptoms produced in response to diets that differed only in FODMAP content.
Fifteen healthy subjects and 15 with IBS (Rome III criteria) undertook a single-blind, crossover intervention trial involving consuming provided diets that were either low (9 g/day) or high (50 g/day) in FODMAPs for 2 days. Food and gastrointestinal symptom diaries were kept and breath samples collected hourly over 14 h on day 2 of each diet.
Higher levels of breath hydrogen were produced over the entire day with the high FODMAP diet for healthy volunteers (181 +/- 77 ppm.14 h vs 43 +/- 18; mean +/- SD P < 0.0001) and patients with IBS (242 +/- 79 vs 62 +/- 23; P < 0.0001), who had higher levels during each dietary period than the controls (P < 0.05). Breath methane, produced by 10 subjects within each group, was reduced with the high FODMAP intake in healthy subjects (47 +/- 29 vs 109 +/- 77; P = 0.043), but was not different in patients with IBS (126 +/- 153 vs 86 +/- 72). Gastrointestinal symptoms and lethargy were significantly induced by the high FODMAP diet in patients with IBS, while only increased flatus production was reported by healthy volunteers.
Dietary FODMAPs induce prolonged hydrogen production in the intestine that is greater in IBS, influence the amount of methane produced, and induce gastrointestinal and systemic symptoms experienced by patients with IBS. The results offer mechanisms underlying the efficacy of the low FODMAP diet in IBS.
Fructose malabsorption is characterized by the inability to absorb fructose efficiently. As a consequence fructose reaches the colon were it is broken down by bacteria to short fatty acids, CO2 and H2. Bloating, cramps, osmotic diarrhea and other symptoms of irritable bowel syndrome are the consequence and can be seen in about 50% of fructose malabsorbers. Having made the observation that persons with fructose malabsorption very often seem to present not only with signs of irritable bowel syndrome but also with signs of pre-menstrual syndrome and mental depression, it was of interest to establish whether such an association could be demonstrated in patients. Fifty-five adults with gastrointestinal complaints of unknown origin (12 males, 43 females) were analyzed by measuring breath hydrogen concentrations after an oral dose of 50 g fructose and were classified as normals or fructose malabsorbers according to their breath H2 concentrations. All patients filled out a Beck s depression inventory - questionnaire. Fructose malabsorption was detected in 36 of 55 individuals (65.5%). Subjects with fructose malabsorption (DeltaH2 concentrations >10 p.p.m. after fructose load) showed a significantly higher score in the Beck s depression inventory than normal fructose absorbers. This was true especially for females. Fructose malabsorption may play a role in the development of depressed mood. Fructose malabsorption should be considered in patients with symptoms of major depression or pre-menstrual syndrome. Further studies are needed to clarify the background of this association.
There has been growing interest in the investigation of health-related quality of life (HRQOL) among patients with gastrointestinal (GI) disorders. We recently reported on the development and preliminary validation of the IBS-QOL, a specific quality-of-life measure for irritable bowel syndrome (IBS). The aim of this study was to determine the longitudinal construct validity (responsiveness) of the IBS-QOL.
Female patients enrolled in a multicenter treatment trial for functional bowel disorders were studied pre- and posttreatment with the IBS-QOL and other health status measures. Based on the response to treatment for several variables (pain/14-day score, daily function, and days in bed/3 months), patients were stratified into Responders, Partial Responders, and Nonresponders. Change scores in the IBS-QOL were then statistically compared with changes in the other variables to determine their correlation and whether Responders were significantly different from non- and Partial Responders on the IBS-QOL.
There was a significant correlation between change scores on the IBS-QOL and the other measures of treatment effect (Pain/14 days, r = 0.25, p < 0.002; Sickness Impact Profile [SIP] Total Score, r = 0.28, p < 0.0004). In addition, the IBS-QOL scores significantly differentiated Responders from Nonresponders for most of the variables tested (regression trend test for Pain/14 days, p < 0.04; SIP Total, p < 0.0001; SIP Physical, p < 0.0001; SIP Psychosocial, p < 0.002, and SIP Eating, p < 0.04).
The IBS-QOL is responsive to treatment in a referral-based clinical population of patients with functional bowel disorders.
Fructose malabsorption is characterized by the inability to absorb fructose efficiently. As a consequence fructose reaches the colon where it is broken down by bacteria to short fatty acids, CO2 and H2. Bloating, cramps, osmotic diarrhea and other symptoms of irritable bowel syndrome are the consequences and can be seen in about 50% of fructose malabsorbers. We have previously shown that fructose malabsorption is associated with early signs of mental depression and low serum tryptophan concentrations. It was therefore of interest whether a fructose-reduced diet could not only improve gastrointestinal complaints but also depressive signs seen in fructose malabsorbers.
Fifty-three adults (12 males, 41 females), who were identified as fructose malabsorbers according to their breath-H2 concentrations, filled out a Beck's depression inventory-questionnaire, and a questionnaire with arbitrary scales for measurement of meteorism, stool frequency and quality of life for a 4-week period before dietary intervention and 4 weeks after dietary change as for fructose- and sorbitol-reduced diet.
Depression scores were reduced by 65.2% after 4 weeks of diet (P < 0.0001), and there was a significant reduction of meteorism (P < 0.0001) and stool frequency (P < 0.01). Improvement of signs of depression and of meteorism was more pronounced in females than in males.
Fructose- and sorbitol-reduced diet in subjects with fructose malabsorption does not only reduce gastrointestinal symptoms but also improves mood and early signs of depression.
BackgroundA low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet can ameliorate symptoms in adult irritable bowel syndrome (IBS) within 48 h.AimTo determine the efficacy of a low FODMAP diet in childhood IBS and whether gut microbial composition and/or metabolic capacity are associated with its efficacy.Methods
In a double-blind, crossover trial, children with Rome III IBS completed a 1-week baseline period. They then were randomised to a low FODMAP diet or typical American childhood diet (TACD), followed by a 5-day washout period before crossing over to the other diet. GI symptoms were assessed with abdominal pain frequency being the primary outcome. Baseline gut microbial composition (16S rRNA sequencing) and metabolic capacity (PICRUSt) were determined. Metagenomic biomarker discovery (LEfSe) compared Responders (≥50% decrease in abdominal pain frequency on low FODMAP diet only) vs. Nonresponders (no improvement during either intervention).ResultsThirty-three children completed the study. Less abdominal pain occurred during the low FODMAP diet vs. TACD [1.1 ± 0.2 (SEM) episodes/day vs. 1.7 ± 0.4, P < 0.05]. Compared to baseline (1.4 ± 0.2), children had fewer daily abdominal pain episodes during the low FODMAP diet (P < 0.01) but more episodes during the TACD (P < 0.01). Responders were enriched at baseline in taxa with known greater saccharolytic metabolic capacity (e.g. Bacteroides, Ruminococcaceae, Faecalibacterium prausnitzii) and three Kyoto Encyclopedia of Genes and Genomes orthologues, of which two relate to carbohydrate metabolism.Conclusions
In childhood IBS, a low FODMAP diet decreases abdominal pain frequency. Gut microbiome biomarkers may be associated with low FODMAP diet efficacy.ClinicalTrials.gov identifier: NCT01339117.
Background:
Functional gastrointestinal symptoms such as abdominal pain, bloating, distension, constipation, diarrhea and flatulence have been noted in patients with irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD). The diversity of symptoms has meant that finding an effective treatment has been challenging with most treatments alleviating only the primary symptom. A novel treatment option for IBS and IBD currently generating much excitement is the low fermentable, oligo-, di-, mono-saccharides and polyol (FODMAP) diet. The aim of this meta-analysis was to determine the evidence of the efficacy of such a diet in the treatment of functional gastrointestinal symptoms.
Methods:
Electronic databases were searched through to March 2015 to identify relevant studies. Pooled odds ratios (ORs) and 95 % confidence intervals were calculated for the effect of a low FODMAP diet on the reduction in IBS [Symptoms Severity Score (SSS)] score and increase in IBS quality of life (QOL) score for both randomized clinical trials (RCTs) and non-randomized interventions using a random-effects model.
Results:
Six RCTs and 16 non-randomized interventions were included in the analysis. There was a significant decrease in IBS SSS scores for those individuals on a low FODMAP diet in both the RCTs (OR 0.44, 95 % CI 0.25-0.76; I (2) = 35.52, p = 0.00) and non-randomized interventions (OR 0.03, 95 % CI 0.01-0.2; I (2) = 69.1, p = 0.02). In addition, there was a significant improvement in the IBS-QOL score for RCTs (OR 1.84, 95 % CI 1.12-3.03; I (2) = 0.00, p = 0.39) and for non-randomized interventions (OR 3.18, 95 % CI 1.60-6.31; I (2) = 0.00, p = 0.89). Further, following a low FODMAP diet was found to significantly reduce symptom severity for abdominal pain (OR 1.81, 95 % CI 1.13-2.88; I (2) = 0.00, p = 0.56), bloating (OR 1.75, 95 % CI 1.07-2.87; I (2) = 0.00, p = 0.45) and overall symptoms (OR 1.81, 95 % CI 1.11-2.95; I (2) = 0.00, p = 0.4) in the RCTs. In the non-randomized interventions similar findings were observed.
Conclusion:
The present meta-analysis supports the efficacy of a low FODMAP diet in the treatment of functional gastrointestinal symptoms. Further research should ensure studies include dietary adherence, and more studies looking at greater number of patients and long-term adherence to a low FODMAP diet need to be conducted.
Gut-directed hypnotherapy is being increasingly applied to patients with irritable bowel syndrome (IBS) and to a lesser extent, inflammatory bowel disease (IBD).
To review the technique, mechanisms of action and evidence for efficacy, and to identify gaps in the understanding of gut-directed hypnotherapy as a treatment for IBS and IBD.
A review of published literature and a systematic review of clinical trials in its application to patients with IBS and IBD were performed.
Gut-directed hypnotherapy is a clearly described technique. Its potential mechanisms of action on the brain-gut axis are multiple with evidence spanning psychological effects through to physiological gastrointestinal modifications. Six of seven randomised IBS studies reported a significant reduction (all P < 0.05) in overall gastrointestinal symptoms following treatment usually compared to supportive therapy only. Response rates amongst those who received gut-directed hypnotherapy ranged between 24% and 73%. Efficacy was maintained long-term in four of five studies. A therapeutic effect was also observed in the maintenance of clinical remission in patients with ulcerative colitis. Uncontrolled trials supported the efficacy and durability of gut-directed hypnotherapy in IBS. Gaps in understanding included to whom and when it should be applied, the paucity of adequately trained hypnotherapists, and the difficulties in designing well controlled-trials.
Gut-directed hypnotherapy has durable efficacy in patients with IBS and possibly ulcerative colitis. Whether it sits in the therapeutic arsenal as a primary and/or adjunctive therapy cannot be ascertained on the current evidence base. Further research into efficacy, mechanisms of action and predictors of response is required.
© 2015 John Wiley & Sons Ltd.
A diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is often used to manage functional gastrointestinal symptoms in patients with irritable bowel syndrome (IBS), yet there is limited evidence of its efficacy, compared with a normal Western diet. We investigated the effects of a diet low in FODMAPs compared with an Australian diet, in a randomized, controlled, single-blind, cross-over trial of patients with IBS.
In a study of 30 patients with IBS and 8 healthy individuals (controls, matched for demographics and diet), we collected dietary data from subjects for 1 habitual week. Participants were then randomly assigned to groups that received 21 days of either a diet low in FODMAPs or a typical Australian diet, followed by a washout period of at least 21 days, before crossing over to the alternate diet. Daily symptoms were rated using 0-100 mm visual analogue scale. Almost all food was provided during the interventional diet periods, with a goal of <0.5 g intake of FODMAPs per meal for the low-FODMAP diet. All stools were collected from days 17-21 and assessed for frequency, weight, water content, and King's Stool Chart (KSC) rating.
Subjects with IBS had lower overall gastrointestinal symptoms scores (22.8; 95% confidence interval, 16.7-28.8 mm) while on a diet low in FODMAPs, compared with the Australian diet (44.9; 95% confidence interval, 36.6-53.1 mm; P<.001) and the subjects' habitual diet. Bloating, pain, and passage of wind were also reduced while IBS patients were on the low-FODMAP diet. Symptoms were minimal and unaltered by either diet among controls. Patients of all IBS subtypes had greater satisfaction with stool consistency while on the low-FODMAP diet, but diarrhea-predominant IBS was the only subtype with altered fecal frequency and KSC scores.
In a controlled, cross-over study of patients with IBS, a diet low in FODMAPs effectively reduced functional gastrointestinal symptoms. This high-quality evidence supports its use as a first-line therapy. Clinical Trial number: ACTRN12612001185853.
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.
Background & aims:
Patients with non-celiac gluten sensitivity (NCGS) do not have celiac disease but their symptoms improve when they are placed on gluten-free diets. We investigated the specific effects of gluten after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates (fermentable, oligo-, di-, monosaccharides, and polyols [FODMAPs]) in subjects believed to have NCGS.
Methods:
We performed a double-blind cross-over trial of 37 subjects (aged 24-61 y, 6 men) with NCGS and irritable bowel syndrome (based on Rome III criteria), but not celiac disease. Participants were randomly assigned to groups given a 2-week diet of reduced FODMAPs, and were then placed on high-gluten (16 g gluten/d), low-gluten (2 g gluten/d and 14 g whey protein/d), or control (16 g whey protein/d) diets for 1 week, followed by a washout period of at least 2 weeks. We assessed serum and fecal markers of intestinal inflammation/injury and immune activation, and indices of fatigue. Twenty-two participants then crossed over to groups given gluten (16 g/d), whey (16 g/d), or control (no additional protein) diets for 3 days. Symptoms were evaluated by visual analogue scales.
Results:
In all participants, gastrointestinal symptoms consistently and significantly improved during reduced FODMAP intake, but significantly worsened to a similar degree when their diets included gluten or whey protein. Gluten-specific effects were observed in only 8% of participants. There were no diet-specific changes in any biomarker. During the 3-day rechallenge, participants' symptoms increased by similar levels among groups. Gluten-specific gastrointestinal effects were not reproduced. An order effect was observed.
Conclusions:
In a placebo-controlled, cross-over rechallenge study, we found no evidence of specific or dose-dependent effects of gluten in patients with NCGS placed diets low in FODMAPs.
Objectives:
Gut-directed hypnotherapy (GHT) in individual sessions is highly effective in the treatment of irritable bowel syndrome (IBS). This study aimed to assess the long-term effect of GHT in group sessions for refractory IBS.
Methods:
A total of 164 patients with IBS (Rome-III-criteria) were screened, and 100 refractory to usual treatment were randomized 1:1 either to supportive talks with medical treatment (SMT) or to SMT with GHT (10 weekly sessions within 12 weeks). The primary end point was a clinically important improvement on several dimensions of daily life (assessed by IBS impact scale) after treatment and 12-month follow-up. The secondary end point was improvement in general quality of life (QOL; Medical Outcome Study Short-Form-36), psychological status (Hospital Anxiety Depression Scale) and reduction of single IBS symptoms. Analysis was by intention to treat.
Results:
A total of 90 patients received allocated intervention. After treatment, 28 (60.8%) out of 46 GHT patients and 18 (40.9%) out of 44 SMTs improved (absolute difference 20.0%; 95% confidence interval (CI): 0-40.2%; P=0.046); over 15 months, 54.3% of GHT patients and 25.0% of controls improved (absolute difference 29.4%; 95% CI 10.1-48.6%; P=0.004). GHT with SMT improved physical and psychological well being significantly more than SMT alone (P<0.001). Gender, age, disease duration and IBS type did not have an influence on the long-term success of GHT.
Conclusions:
GHT improves IBS-related QOL, is superior to SMT alone, and shows a long-term effect even in refractory IBS.
Preliminary studies indicate that dietary restriction of fermentable short-chain carbohydrates improves symptoms in irritable bowel syndrome (IBS). Prebiotic fructo-oligosaccharides and galacto-oligosaccharides stimulate colonic bifidobacteria. However, the effect of restricting fermentable short-chain carbohydrates on the gastrointestinal (GI) microbiota has never been examined. This randomized controlled trial aimed to investigate the effects of fermentable carbohydrate restriction on luminal microbiota, SCFA, and GI symptoms in patients with IBS. Patients with IBS were randomized to the intervention diet or habitual diet for 4 wk. The incidence and severity of symptoms and stool output were recorded for 7 d at baseline and follow-up. A stool sample was collected and analyzed for bacterial groups using fluorescent in situ hybridization. Of 41 patients randomized, 6 were withdrawn. At follow-up, there was lower intake of total short-chain fermentable carbohydrates in the intervention group compared with controls (P = 0.001). The total luminal bacteria at follow-up did not differ between groups; however, there were lower concentrations (P < 0.001) and proportions (P < 0.001) of bifidobacteria in the intervention group compared with controls when adjusted for baseline. In the intention-to-treat analysis, more patients in the intervention group reported adequate control of symptoms (13/19, 68%) compared with controls (5/22, 23%; P = 0.005). This randomized controlled trial demonstrated a reduction in concentration and proportion of luminal bifidobacteria after 4 wk of fermentable carbohydrate restriction. Although the intervention was effective in managing IBS symptoms, the implications of its effect on the GI microbiota are still to be determined.
Emerging evidence indicates that the consumption of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) may result in symptoms in some patients with irritable bowel syndrome (IBS). The present study aimed to determine whether a low FODMAP diet is effective for symptom control in patients with IBS and to compare its effects with those of standard dietary advice based on the UK National Institute for Health and Clinical Excellence (NICE) guidelines.
Consecutive patients with IBS who attended a follow-up dietetic outpatient visit for dietary management of their symptoms were included. Questionnaires were completed for patients who received standard (n = 39) or low FODMAP dietary advice (n = 43). Data were recorded on symptom change and comparisons were made between groups.
In total, more patients in the low FODMAP group reported satisfaction with their symptom response (76%) compared to the standard group (54%, P = 0.038). Composite symptom score data showed better overall symptom response in the low FODMAP group (86%) compared to the standard group (49%, P < 0.001). Significantly more patients in the low FODMAP group compared to the standard group reported improvements in bloating (low FODMAP 82% versus standard 49%, P = 0.002), abdominal pain (low FODMAP 85% versus standard 61%, P = 0.023) and flatulence (low FODMAP 87% versus standard 50%, P = 0.001).
A low FODMAP diet appears to be more effective than standard dietary advice for symptom control in IBS.
Functional gut symptoms are induced by inclusion and reduced by dietary restriction of poorly absorbed short-chain carbohydrates (FODMAPs), but the mechanisms of action remain untested.
To determine the effect of dietary FODMAPs on the content of water and fermentable substrates of ileal effluent.
Twelve ileostomates without evidence of small intestinal disease undertook two 4-day dietary periods, comprising diets differing only in FODMAP content in a randomized, cross-over, single-blinded intervention study. Daytime (14 h) ileal effluent was collected on day four of each diet. Patients rated effluent volume and consistency on a 10-cm visual analogue scale. The FODMAP content of the diet and effluent was measured.
Ingested FODMAPs of 32% (range 6-73%) was recovered in the high FODMAP diet effluent. Effluent collection weight increased by a mean of 22% (95% CI, 5-39), water content by 20% (2-38%) and dry weight by 24% (4-43%) with the high compared to low FODMAP diet arm. Output increased by 95 (28-161) mL. Volunteers perceived effluent consistency was thicker (95% CI, 0.6-1.9) with the low FODMAP diet than with the high FODMAP diet (3.5-6.1; P = 0.006).
These data support the hypothetical mechanism; FODMAPs increase delivery of water and fermentable substrates to the proximal colon.
Postprandial symptoms are common in patients with irritable bowel syndrome with diarrhea (IBS-D) and could be diet related. We studied postprandial changes in distribution of water in the upper gastrointestinal tract of healthy volunteers (HVs) and patients with IBS-D after contrasting meals.
In study 1, 11 HVs consumed 350-mL test meals with 5% mannitol (unabsorbable) or 5% glucose (readily absorbed). In study 2, 17 HVs consumed a 331-kcal meal, with or without 15 g bran. In study 3, 26 patients with IBS-D consumed the study 2 diet with bran meal. All subjects underwent serial magnetic resonance imaging analysis.
In study 1, subjects' small bowel water content (SBWC) increased after the mannitol but not glucose meals, reaching 381 mL (interquartile range, 343-491 mL) and 47 mL (18-78 mL), respectively, 40 minutes after eating (P < .001). In study 2, SBWC initially decreased after both meal types and then increased, plateauing at 180-405 minutes and was greater after the bran meal (P = .02). In study 3, fasting and postprandial SBWC was lower in IBS-D than in HVs (P < .05 and P < .0001, respectively). Patients with IBS-D had faster orocecal transit times (135 minutes; 90-180 minutes) compared with HVs (225 minutes; 203-293 minutes; P < .0001) and reduced terminal ileum diameter (P < .003).
Postprandial SBWC initially decreases, because of rapid, nutrient-driven fluid absorption, and then increases after a mixed liquid/solid meal. Patients with IBS-D have reduced fasting and postprandial SBWC with faster transit, possibly indicating increased small intestinal tone.
30 patients with severe refractory irritable-bowel syndrome were randomly allocated to treatment with either hypnotherapy or psychotherapy and placebo. The psychotherapy patients showed a small but significant improvement in abdominal pain, abdominal distension, and general well-being but not in bowel habit. The hypnotherapy patients showed a dramatic improvement in all features, the difference between the two groups being highly significant. In the hypnotherapy group no relapses were recorded during the 3-month follow-up period, and no substitution symptoms were observed.
A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
More than 200 published studies from most medical settings worldwide have reported experiences with the Hospital Anxiety and Depression Scale (HADS) which was specifically developed by Zigmond and Snaith for use with physically ill patients. Although introduced in 1983, there is still no comprehensive documentation of its psychometric properties. The present review summarizes available data on reliability and validity and gives an overview of clinical studies conducted with this instrument and their most important findings. The HADS gives clinically meaningful results as a psychological screening tool, in clinical group comparisons and in correlational studies with several aspects of disease and quality of life. It is sensitive to changes both during the course of diseases and in response to psychotherapeutic and psychopharmacological intervention. Finally, HADS scores predict psychosocial and possibly also physical outcome.
The clinical assessment and investigation of irritable bowel syndrome would be greatly facilitated by the introduction of a simple, easy to use severity scoring system. Such a system, developed in our department over a number of years, has been submitted to validation in a total of 141 patients and 40 healthy controls.
The system, incorporating pain, distension, bowel dysfunction and quality of life/global well-being, was assessed for its ability to reliably score patients previously classified as mild, moderate or severe. The reproducibility and sensitivity to change of the system was also assessed.
The maximum achievable score was 500. Mild, moderate and severe cases were indicated by scores of 75 to 175, 175 to 300 and > 300 respectively. Controls scored below 75 and patients scoring in this range can be considered to be in remission. There was a highly significant difference between controls and patients as a whole (P = 0.0001) as well as significant differences (P < 0.01) between all severity categories. Scores repeated within 24 h were very reproducible and sensitivity to change was also extremely good (P < 0.001) with a change of 50 reliably indicating improvement.
These results suggest that this scoring system should prove to be a valuable instrument in helping to meet the many challenges offered by irritable bowel syndrome.
Prevalence of irritable bowel syndrome shows great variation among epidemiological studies, which may be due to different diagnostic criteria.
To assess prevalence of irritable bowel syndrome according to various diagnostic criteria and to study differences in symptom severity, psychopathology, and use of health care resources between subjects fulfilling different diagnostic criteria.
A questionnaire was mailed to 5000 randomly selected adults. Presence of irritable bowel syndrome was assessed by four diagnostic criteria: Manning 2 (at least two Manning symptoms), Manning 3 (at least three Manning symptoms), Rome I and Rome II.
Response rate was 73%. Prevalence of irritable bowel syndrome by Manning 2, Manning 3, Rome I and Rome II criteria was 16.2%, 9.7%, 5.6%, and 5.1% respectively. Of those fulfilling Rome II criteria, 97% fulfilled Manning 2. Severe or very severe abdominal pain was reported by 27-30% of Manning-positive subjects, and 44% of Rome-positives. Prevalence of depression in Manning 2, and Rome II groups was 30.6 and 39.3%.
Prevalence of irritable bowel syndrome by Rome II criteria is considerably lower than by Manning criteria. Subjects fulfilling Rome criteria form a subgroup of Manning-positive subjects with more severe abdominal symptoms, more psychopathology, and more frequent use of the health care system.
Hypnosis treatment often improves irritable bowel syndrome (IBS), but the costs and reliance on specialized therapists limit its availability. A 3-month home-treatment version of a scripted hypnosis protocol previously shown to improve all central IBS symptoms was completed by 19 IBS patients. Outcomes were compared to those of 57 matched IBS patients from a separate study receiving only standard medical care. Ten of the hypnosis subjects (53%) responded to treatment by 3-month follow-up (response defined as more than 50% reduction in IBS severity) vs. 15 (26%) of controls. Hypnosis subjects improved more in quality of life scores compared to controls. Anxiety predicted poor treatment response. Hypnosis responders remained improved at 6-month follow-up. Although response rate was lower than previously observed in therapist-delivered treatment, hypnosis home treatment may double the proportion of IBS patients improving significantly across 6 months.
In western populations irritable bowel syndrome (IBS) affects between 10% and 30% of the population and has a significant effect on quality of life. It generates a substantial workload in both primary and secondary care and has significant cost implications. Gut-directed hypnotherapy has been demonstrated to alleviate symptoms and improve quality of life but has not been assessed outside of secondary and tertiary referral centres.
To assess the effectiveness of gut-directed hypnotherapy as a complementary therapy in the management of IBS.
Randomised controlled trial.
Primary care patients aged 18-65 years inclusive, with a diagnosis of IBS of greater than 6 weeks' duration and having failed conventional management, located in South Staffordshire and North Birmingham, UK.
Intervention patients received five sessions of hypnotherapy in addition to their usual management. Control patients received usual management alone. Data regarding symptoms and quality of life were collected at baseline and again 3, 6, and 12 months post-randomisation.
Both groups demonstrated a significant improvement in all symptom dimensions and quality of life over 12 months. At 3 months the intervention group had significantly greater improvements in pain, diarrhoea and overall symptom scores (P<0.05). No significant differences between groups in quality of life were identified. No differences were maintained over time. Intervention patients, however, were significantly less likely to require medication, and the majority described an improvement in their condition.
Gut-directed hypnotherapy benefits patients via symptom reduction and reduced medication usage, although the lack of significant difference between groups beyond 3 months prohibits its general introduction without additional evidence. A large trial incorporating robust economic analysis is, therefore, urgently recommended.
Dietary fructose induces abdominal symptoms in patients with fructose malabsorption, but there are no published guidelines on its dietary management. The objective was to retrospectively evaluate a potentially successful diet therapy in patients with irritable bowel syndrome and fructose malabsorption. Tables detailing the content of fructose and fructans in foods were constructed. A dietary strategy comprising avoidance of foods containing substantial free fructose and short-chain fructans, limitation of the total dietary fructose load, encouragement of foods in which glucose was balanced with fructose, and co-ingestion of free glucose to balance excess free fructose was devised. Sixty-two consecutively referred patients with irritable bowel syndrome and fructose malabsorption on breath hydrogen testing underwent dietary instruction. Dietary adherence and effect on abdominal symptoms were evaluated via telephone interview 2 to 40 months (median 14 months) later. Response to the diet was defined as improvement of all symptoms by at least 5 points on a -10- to 10-point scale. Forty-eight patients (77%) adhered to the diet always or frequently. Forty-six (74%) of all patients responded positively in all abdominal symptoms. Positive response overall was significantly better in those adherent than nonadherent (85% vs 36%; P<0.01), as was improvement in individual symptoms (P<0.01 for all symptoms). This comprehensive fructose malabsorption dietary therapy achieves a high level of sustained adherence and good symptomatic response.
Observational studies suggest dietary fructose restriction might lead to sustained symptomatic response in patients with irritable bowel syndrome (IBS) and fructose malabsorption. The aims of this study were first to determine whether the efficacy of this dietary change is due to dietary fructose restriction and second to define whether symptom relief was specific to free fructose or to poorly absorbed short-chain carbohydrates in general.
The double-blinded, randomized, quadruple arm, placebo-controlled rechallenge trial took place in the general community. The 25 patients who had responded to dietary change were provided all food, low in free fructose and fructans, for the duration of the study. Patients were randomly challenged by graded dose introduction of fructose, fructans, alone or in combination, or glucose taken as drinks with meals for maximum test period of 2 weeks, with at least 10-day washout period between. For the main outcome measures, symptoms were monitored by daily diary entries and responses to a global symptom question.
Seventy percent of patients receiving fructose, 77% receiving fructans, and 79% receiving a mixture reported symptoms were not adequately controlled, compared with 14% receiving glucose (P < or = 0.002, McNemar test). Similarly, the severity of overall and individual symptoms was significantly and markedly less for glucose than other substances. Symptoms were induced in a dose-dependent manner and mimicked previous IBS symptoms.
In patients with IBS and fructose malabsorption, dietary restriction of fructose and/or fructans is likely to be responsible for symptomatic improvement, suggesting efficacy is due to restriction of poorly absorbed short-chain carbohydrates in general.
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