Diet Tips:The super sensitive in IBS

By Caroline Tuck (APD, PhD Candidate)

Irritable Bowel Syndrome (IBS) can express itself in many different ways, resulting in different symptoms that may change over time. Therefore, IBS is not a straightforward condition to treat and the IBS management does not suit a ‘one-size-fits-all’ approach.

There are many IBS treatments available, including medications, dietary change, hypnotherapy and herbal remedies, with varying levels of evidence supporting their use. 

Therefore, two people (even with the same type of IBS – constipation predominant, diarrhoea predominant or mixed) may not respond to the same treatment.

At Monash University, we focus on diet therapies because this is our area of research expertise. We recommend people follow a low FODMAP diet for a short period of time followed by a period of rechallenges, during which higher FODMAP foods are reintroduced enabling people to assess their tolerance to the various FODMAP subgroups. Most people should not need to stay on a strict low FODMAP diet for life. The reason we suggest rechallenging with higher FODMAP foods is discussed in previous blog posts: 

http://fodmapmonash.blogspot.com.au/2015/06/just-2-6-weeks-it-is-not-diet-for-life_8.html and http://fodmapmonash.blogspot.com.au/2015/04/low-fodmap-diet-not-lifetime-diet.html

But for some people, reintroducing foods is not easy or straightforward. In fact, in more sensitive individuals, reintroducing higher FODMAP foods can be very hard. Some people find that symptoms return even if they reintroduce very small quantities of higher FODMAP foods. This may require the person to follow a strict low FODMAP diet for longer to maintain symptom control.

The complexities of treating IBS mean that consultation with a Dietitian is very important, especially in people very sensitive to dietary factors such as FODMAPs. 

How a Dietitian can help:

•          They can suggest other strategies (both dietary and non-dietary) to help improve food tolerance.
•          They can ensure your diet remains nutritionally adequate if you need to remain on a low FODMAP diet for longer periods.
•          They can recommend other dietary and non-dietary therapies that may improve symptoms further.
•          They can identify food triggers other than FODMAPs
•          They can work with your doctor/gastroenterologist to find the best treatment for you.

You may also find this blog post helpful: http://fodmapmonash.blogspot.com.au/2015/05/top-5-reasons-why-you-should-see_22.html

In the long term, we advise that a strict low FODMAP diet is not continued, even in super sensitive individuals. We also recommend you repeat unsuccessful food challenges because IBS symptoms and tolerance to different foods changes over time. Reintroducing foods very gradually can also improve your tolerance.

Diet Tips:What is IBS and how is it diagnosed?

By Caroline Tuck (PhD Candidate and APD)

Irritable Bowel Syndrome (IBS) is a condition of the gastrointestinal tract. IBS causes symptoms such as abdominal pain, bloating, wind, constipation and diarrhoea. However, these symptoms can be caused by other more sinister conditions, so it is important to get the correct diagnosis. IBS cannot be diagnosed via a test e.g. blood test, scan or bowel biopsy (tissue sample which is sent to a laboratory for analysis). Instead, it is diagnosed based on symptom criteria after the exclusion of all other gastrointestinal disorders.

How do you know if you have it?

Firstly, we recommend you speak with your GP. Your GP may recommend some investigations or that you see a Gastroenterologist. This is to ensure that other gastrointestinal disorders are ruled out, for instance coeliac disease and inflammatory bowel disease (i.e. Crohn’s disease or ulcerative colitis). These diseases cause inflammation of the gut wall and left untreated, can lead to other serious problems including nutritional deficiencies and some cancers, so it is important they are excluded. If you have had other conditions ruled out, a diagnosis of IBS might be made.

Your doctor should use “Rome III” criteria to diagnose your IBS. These criteria provide specific guidelines on the type and frequency of symptoms that should be present for a diagnosis of IBS to be made. Your doctor will compare your symptoms to the criteria to determine if you have IBS.

What is IBS and what causes it?

The cause of IBS is not known. While many factors are likely to contribute to disease onset, one specific cause has not been identified and it is likely that multiple factors are involved. Factors thought to cause IBS include visceral hypersensitivity (i.e. a more sensitive gut); changes in the way the gut moves food through the gut; changes in gut bacteria populations, and disturbances in the way the brain processes information from the gut. We also know that lifestyle factors, such as diet, stress and exercise can affect IBS symptoms.

There are many IBS treatments available, including the low FODMAP diet, which was developed by our team at Monash University. The low FODMAP diet has been shown to improve symptoms in around 70% of patients, but it is not the only therapy for IBS. Because each person may respond to therapies differently, it is important to talk to your doctor about the treatment options available.

What do I do if I suspect I have IBS?

First things first – see your GP! It is especially important not to make any changes to your diet before undergoing any tests, because changing your diet may interfere with the results. If you or your GP think diet may have affect your condition, then see your local Dietitian who has experience in this area (see also our related blog post: Top 5 reasons why you should see a dietitian before initiating a low FODMAP diet).

To find a gut-specialist dietitian in Australia, visit www.daa.asn.au - Find an Accredited Practising Dietitian page and select "Gastrointestinal (Bowel) disorders" in the area of practice dropdown box.

For all other countries, visit the webpage and search under "gastrointestinal" or "digestive disorders"

Canada: http://www.dietitians.ca/Find-a-Dietitian.aspx

New Zealand http://dietitians.org.nz/find-a-dietitian/

UK https://www.bda.uk.com/improvinghealth/yourhealth/finddietitian

USA  http://www.eatright.org/programs/rdnfinder

Diet Tips:Research update: long-term improvement in symptoms of IBS and IBD patients treated with a low FODMAP diet- A retrospective Study

By Lyndal McNamara (APD)

Background

New research about the long-term effectiveness of a low-FODMAP diet to reduce the symptoms of irritable bowel syndrome (IBS) has just been published! This retrospective study provides data regarding the longest follow up to date of patients with IBS (some of which also had IBD) using the low FODMAP diet approach. One hundred and eighty patients were included in the study. All patients had been assessed by a gastroenterologist and previously received dietary education from a dietitian regarding a low FODMAP diet. Participants were surveyed to collect information about the effectiveness of the diet, symptoms, adherence to the diet, their satisfaction with dietary treatment, disease activity, changes in stool type and quality of life over an average follow-up time of 16 months.

Results

Symptoms:

The study found that 86% of patients had a significant improvement in their IBS symptoms on a low-FODMAP diet, with the greatest relief in symptoms of bloating and abdominal pain. Overall, stool form normalised with a low FODMAP diet in the majority of patients.

Adherence and satisfaction with the diet:

Eighty four percent of patients had expanded their low FODMAP diet at follow up, where some higher FODMAP foods had been re-introduced after the identification of trigger FODMAP foods. The most common foods not reintroduced by participants were wheat, onion and lactose containing products. Despite the fact that the vast majority were following a very relaxed version of the low FODMAP diet, they still reported satisfaction with the treatment and good symptom control.

IBS severity and quality of life:

Most patients reported good quality of life and only mild-moderate IBS severity at follow up. Furthermore, 37% of IBS patients who started the trial with more severe IBS (type B, C or D in graphs below) tended towards a milder IBS (type A) at follow-up. A similar effect was noted in the group with IBS in the setting of IBD.

Study Limitations:

A major limitation of this study was that it was conducted retrospectively, meaning that the results rely on the patients’ memory and recall of events, which introduces a potential source of error. A large percentage of patients (48%) invited to take part in the study also declined to participate. This introduces a type of bias known as selection bias, meaning that those who agreed to participate may be more likely to have had a positive experience with the diet being tested. Additionally, the researchers used tools that were not validated, such as the IBS severity graphs shown in the above figures. As these are not validated, they have not been tested for their accuracy and cannot be relied upon to form firm conclusions.

Take home messages:

·         This is the first study to demonstrate the long-term effectiveness of a low-FODMAP diet for improved symptom management in IBS (alone or with coexisting IBD) patients

·         This study also supports the importance of the reintroduction phase of the diet and demonstrates that for most patients, symptom management remains satisfactory on a modified low FODMAP diet in the long-term (where some high FODMAP foods have been successfully reintroduced)

·         When looking at research studies, the tools used should be validated, and if not, outcomes should be read with caution

·         This type of retrospective study has several important limitations that need to be considered

Larger, prospective trails are now required to further investigate the long-term effectiveness and determine other effects of a low FODMAP diet in IBS and IBD patients, particularly any negative effect on the gut microbiota

1.    Maagaard L, Ankersen DV, Végh Z, Burisch J, Jensen L, Pedersen N, et al. Follow-up of patients with functional bowel symptoms treated with a low FODMAP diet. World Journal of Gastroenterology. 2016 Apr 21;22(15):4009-19.