# UNC Nutritional Intervention for IBS



## eric (Jul 8, 1999)

With permission Fall 2005 Nutritional Intervention for IBS Bette Bischoff Fourth Year Medical Student University of Kansas Medical Center IBS Bette Bischoff Background Prior to medical school when I was a practicing dietician, I had the privilege of working with many patients who had irritable bowel syndrome (IBS). I found the subject of nutritional intervention related to IBS to be very rewarding and often challenging because there is no â€œperfectâ€ diet for this syndrome. In light of the different etiologies potentially at work in each patient with IBS, nutrition therapy should be carefully and thoughtfully tailored to each person. This can be likened to times past when a cobbler hand-made each personâ€™s shoes. Since each IBS patient can differ dramatically, careful documentation of exacerbating factors listed in the IBS diary maintained by patients may yield important clues to an effective approach to diet and nutrition. One of the issues is that patients with IBS may have a lower threshold to stressors compared to people without IBS. An example of this is patients with carbohydrate intolerances as well as a diagnosis of IBS, who experience an even greater response to problematic carbohydrates such as lactose or fructose as compared to someone who does not have IBS. Another important issue is being alert to unnecessary food aversions. Individuals may experience abdominal discomfort and associate this with eating a certain food, so they decide to avoid eating that particular item, even for life. This may lead to excessive food restriction and the potential for a full-blown eating disorder. What must be kept in mind is that IBS is characterized by increased gut and central nervous system (CNS) reactivity to stressors, and that these stressors can include any dietary excesses as well as chain fatty acids. Good sources of soluble fiber include oats, psyllium seed, pectin, and guar gum. Insoluble fibers consist of the outer husk of the grain and generally tend to decrease transit time. The national nutrition guidelines recommend an intake of 20-30 grams of fiber per day, yet the typical American consumes less than 10 grams of fiber per day. Fiber intake should be increased gradually in IBS patients with constipation, with an emphasis on including adequate water consumption (5). The overall fiber picture can become a bit more confusing than a simple recommendation to increase fiber intake. Insoluble fiber may have a high content of cereal bran, which is the outer husk of the grain. A recent paper investigated the effects of adding or omitting bran and found conflicting results. It appears the primary care provider may see a greater benefit from patients adding fiber to their diet than the gastroenterologist, possibly because primary care physicians see mostly milder forms of IBS and gastroenterologists see patients with more severe IBS. Whorwell studied 100 patients in a primary care setting that were encouraged to increase cereal bran. The results in the primary care provider scenario produced a â€œmixedâ€ picture -- 22% reported worsening of IBS symptoms while 27% who showed improvement. This may be the result of visceral hypersensitivity triggered by bran consumption. Whorwell recommends that patients identified with IBS and visceral hypersensitivity should be counseled to exclude cereal (insoluble) fibers for a brief period to see if symptoms improve, especially if this is within the care of a specialty clinic. Another study found that cereal fibers were associated with a 55% worsening of symptoms (6, 7). Thus, if the goal is to increase transit rate and increase the frequency of bowel movements (for IBS-C), one could add insoluble fiber to the diet; however, since IBS is also associated with visceral hypersensitivity, if discomfort/pain or bloating occurs, the patient may need to switch solely to soluble fiber. Caffeine is a gastrointestinal stimulant. For IBS patients with diarrhea, a period of caffeine sensitivities to particular foods that are unique to the individual rather than to the IBS condition. This article reviews some of the literature in this area and then presents some treatment options to be considered in the nutritional management of IBS. It should be noted that the research and peer-reviewed published literature regarding IBS and diet is still very limited and, therefore, some of the resources cited in this article will date back several years. Nutritional Factors Influencing Motility: Fiber, Fat and Caffeine IBS is the most common of the functional GI disorder, affecting approximately 10-15% of the US population (1). IBS is a multifactorial illness with several different emerging pathophysiologies, including disorders of motility, visceral hypersensitivity, central processing dysfunctions, psychological factors, and post-infectious inflammation. Fiber: A recent survey reported that close to 95% of general practitioners believe that fiber deficiency is the main cause of IBS. In fact, the most common dietary advice offered to patients with IBS is for them to increase their intake of fiber, primarily to address the constipation that may be associated with IBS. However, since IBS is also associated with visceral hypersensitivity, luminal distension -- as might be caused by the bacterial fermentation of insoluble fiber -- can also produce discomfort (2). Dietary fiber is a non- starch polysaccharide derived from plant foods that are poorly digested by human enzymes. A fiber-enriched diet can relieve constipation, accelerate intestinal transit time, and may reduce intracolonic pressure. Furthermore, the intake of fiber is associated with a reduction in the intraluminal concentration of bile acids, which may reduce the contractile activity of the colon (3, 4). There are two types of fiber -- soluble and insoluble. Soluble fiber is derived from fruits and grains, and is fermented in the colon to form short exclusion may prove beneficial. The total intake of caffeine-containing beverages by many adults and children often reaches levels that can induce pharmacological effects. Evidence associating caffeine with GI symptoms suffered by patients with IBS is limited in the current literature, but one study revealed that caffeinated coffee stimulated colonic motor activity in a magnitude similar to that of an entire meal and had a 60% stronger effect than ingesting water (. Dietary fat is also a potent modulator of gut motor function. This macronutrient delays gastric emptying time and accelerates small bowel transit rates. Symptoms of bloating are commonly reported after consuming a high-fat meal. Serra et al. found that after an infusion of enteral fat, the volume of retained gas increased from 298 to 505 ml (9, 10). For patients who need to limit their fat intake, counting actual fat grams in the diet can be an excellent way to identify high-fat food sources. In general, IBS patients should aim for only 40-50 grams of fat per day. If weight loss becomes an issue with fat restriction, medium chain triglycerides (MCT) are an excellent source of calories. Unfortunately, MCT oils are expensive and, due to taste issues, are generally not wellreceived by patients. Food Allergy, Hypersensitivity and Intolerance Although up to 45% of the population reports adverse reactions to food, the actual prevalence of immune-mediated food allergy is unknown. Symptoms are more common in atopic individuals who often have allergies to non-food antigens as well, such as pollens, and in young children who tend to outgrow an allergy. The role of food allergy in IBS has not been studied well. Surveys indicate that 40-70% of food-allergic patients report GI symptoms including nausea, vomiting, abdominal pain, bloating, and diarrhea. Stefanini et al. conducted a 4-week multi-center study comparing the efficacy of the mast cell stabilizing agent sodium cromoglycate at 1500 mg per day with an elimination diet, and 67% of the patients reported improvement in their symptoms (11). Attempts to â€œtestâ€ for food hypersensitivity in IBS have largely focused on the classic food allergy, which is based on the presence of IgE -- immunoglobulins of the â€œimmediate typeâ€. These antibodies attach to certain cells in the body that release chemicals that cause anaphylaxis. Present speculation in the literature suggests that adverse reactions to food in patients with IBS might be due to forms of immunological mechanisms other than a dietary allergy, namely IgG antibodies. These tend to have a delayed response following exposure to a particular antigen and have been implicated in some cases of food hypersensitivity. IgG studies surfacing in the IBS literature are promising, but the issue of the validation of serum IgG testing is often raised. Atkinson et al. observed significant improvement in IBS symptoms in elimination diets using Elisa IgG antibody testing. Their results suggest that IgG antibodies may have a role in helping patients identify candidate foods for elimination (12). Collins et al. also found significant change in patients receiving the IgG exclusion diet. The foods that were most frequently associated with elevated IgG levels were yeast, milk, eggs, wheat, cashew nuts, peas, almonds, and barley. The mechanism by which the IgG antibodies have a detrimental effect is unclear, but most likely is associated with low-grade inflammation (12,13). For the most part, most patients with IBS do not have immune-mediated allergies to food and, more likely, have increased sensitivity to the direct effects of food on digestive function including increased food volume ingestion and the addition of fats, caffeine, carbohydrates, alcohol, etc. Food Intolerance and Exclusion Diets Niec recently summarized the literature on clinical trials using food elimination diets followed by rechallenge. Of the seven studies included in their review, positive response rates varied from 15 to 75 percent. A higher rate of response was correlated with diarrhea-predominant IBS. Milk, wheat and eggs were the most frequently implicated foods (14). Although the principle of food elimination or exclusion appears straightforward, it can be very demanding for the patient. If the patient appears hesitant or confused about food choices, physician referral to a registered dietitian may be helpful. With the exclusion of entire food groups, such as dairy products, the risk of developing a nutritional deficiency must be considered. Carbohydrate Malabsorption Carbohydrate intolerance can be seen in many patients with IBS. Fructose, lactose and sorbitol malabsorption are common among patients who have IBS, and dietary restriction of these sugars may improve symptoms (15,16). One study found that 42% of IBS patients developed symptoms from sorbitol-fructose mixtures compared to 3.5 % in the control group (1. This could be an important factor when patients are consuming large amounts of weight-loss products or have diarrhea-predominant IBS. Lactose malabsorption occurs when lactose, the primary sugar in dairy products, is not completely digested and absorbed in the small bowel. Lactase, the enzyme required to hydrolyze lactose for intestinal absorption, is found primarily in the tips of the jejunum. When unabsorbed lactose reaches the colon, colonic bacteria uses this substrate for fermentation, producing gas and short chain fatty acids. The unabsorbed lactose also affects osmolality, causing water to be drawn into the bowel and accelerating the intestinal transit time. If lactose intolerance is suspected, it can be confirmed with a hydrogen breath test. Lactose intolerance appears to be dose dependant. This means that many patients can tolerate small amounts of dairy products throughout the day, such as Â½ cup of milk, but not larger amounts. Although it may seem obvious which foods contain lactose, some sources may be difficult to discern. Patients should look for hidden sources in baked goods, salad dressings, and powdered mixes. Labels with the following words contain lactose: nonfat dry milk, milk powder, dry milk solids, whey curds, and caseinate milk sugar. Contrary to popular belief, acidophilus milk does not have the lactose sugar digested and is, therefore, a poor substitute for regular milk. Soymilk and rice milk do not contain lactose and are, therefore, good dairy substitutes. However, these products are often low in calcium and vitamin D. Hard cheeses and cultured yogurt are usually acceptable alternatives. For patients who do not tolerate lactose but want to consume dairy products, supplemental lactase enzymes are available. Several studies have shown that patients with lactose intolerance have significantly less calcium intake than those who tolerate lactose. In one study, patients who were lactose intolerant had a calcium intake of approximately 300 mg per day (1, which is only 20-40% of the recommended calcium intake for adults. Patients with lactose intolerance have also exhibited decreased bone mass density (19). In light of the potential for compromised calcium and vitamin D intake, it would be prudent to evaluate all patients with lactose intolerance for a calcium supplement if needed. Fructose is a hexose sugar that is highly utilized in the western diet. In the past 20 years, there has been a 10-fold increase due to its use in highly processed food products. It is often used as high fructose corn syrup in soda, fruit juices, cookies, baked goods, jellies, and candy. Unlike glucose, which is completely absorbed, fructose absorption capacity is limited. Therefore, when ingested in small quantities, dietary fructose will probably not be an issue. However, when consumed in larger amounts, fructose may serve to osmotically draw fluid into the intestinal lumen. This may cause distension of the small intestine and produce symptoms such as abdominal pain, bloating and discomfort. Furthermore, after reaching the colon, unabsorbed fructose may be fermented by colonic bacteria, producing excessive gas (20). Probiotics Several studies now exist defining the potential role of probiotics in IBS. These papers have exhibited a great degree of variability, possibly due to the use of different probiotic strains, their ability to adhere and colonize in the GI tract, and the number of colony-forming units actually ingested by the individual. The probiotics most often studied are lactobacillus, bidifobacterium, and some non-pathogenic forms of e-coli. In a recent study, bifidobacterium 35624 significantly alleviated symptoms of abdominal pain and discomfort, bloating, and distension. There was also a normalization of IL-10/IL-12 ratios (this skewed cytokine ratio may be indicative of a proinflammatory Th-1 state). The bifidobacterium used in this study is currently unavailable in the US marketplace in the concentrations used in this study (21,22). Food products that are high in probiotics include fermented milk, pourable yogurt, and yogurt with live active cultures. Currently, there is no federal agency in the US that routinely tests or â€œpolicesâ€ the market to ensure standardization and quality of probiotic products. Independent tests have revealed that up to 30% of probiotics on the market are â€œlacedâ€ with reasonably adequate live bacteria. One study used DNA extraction to test five probiotic products at a local health food store. The PCR analysis revealed that 2 of the 5 products did not contain the bifidobacterium claimed on the label (23). I called a well-known dairy in the Midwest several years ago. The technician responsible for mixing the probiotic in the yogurt explained that the bacteria are added to a very large vat of product. The yogurt is then packaged in individual cartons and there is no final definitive measurement to ensure that the amount of probiotic stated on the label is actually in each individual container. Putting It All Together Due to the complex underlying pathophysiologies in patients with IBS, nutritional intervention will vary with each patient. The following general IBS categories attempt to help â€œmapâ€ an approach for dietary manipulation in the patient with IBS. For individuals with diarrhea predominant IBS, consider limiting nutrients that exacerbate GI motility or intestinal secretion -- caffeine, fat and some carbohydrates (fructose, lactose and alcohol sugars). Probiotics can also be of benefit, especially if post-infectious IBS or bacterial overgrowth is suspected, or the patient has had numerous antibiotic therapies in the past. If constipation is the main issue, make sure the patient has had an adequate trial of increased insoluble fiber. This usually means that the patient needs to count fiber grams and seek to attain 20 grams of fiber per day. When visceral hypersensitivity is suspected, ask the patient to limit the amount of food eaten in one session and instead to eat three small meals per day with snacks. A low-fat diet and avoidance of insoluble fiber may also be helpful for these patients. Targeting nutritional intervention in the patient with IBS can be challenging due to the many different etiologies of this syndrome and the fact that some patients have heightened responses to different foods. A food diary kept by IBS patients can be a particularly helpful way to ascertain which foods may be problematic. It is recommended that the clinician look for food â€œtrendsâ€ in the journal, with the goal of steering the patient away from excessive food restriction behaviors. References Drossman DA, Camilleri M, Mayer EA, et al. AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002;123(6):2108-2131. Bijkerk CJ, de Wit NJ, Stalman WA, et al. Irritable Bowel Syndrome in Primary Care: the Patient and Doctors Views on Symptoms, Etiology, and Management. Can J Gastroenterology 2003;17(6):363-368. Muller-Lissner SA. Effect of Wheat Bran on Weight of Stool and Gastrointestinal Transit Time: A Meta Analysis. Br Med J 1988;296:615- 617. Villaneva A, Dominguez-Munoz J, Mearin F. Update in the Therapeutic Management of Irritable Bowel Syndrome. Dig Dis 2001;19:244-250. Floch MH, Narayan R. Diet in Irritable Bowel Syndrome. J Clin Gastroenterol 2002;35:S48. Francis CY, Whorwell P. Bran and Irritable Bowel Syndrome: Time for Reappraisal. Lancet 1994;344(8914):39-40. Lea R, M Bch B, Whorwell P. The Role of Food Intolerance in Irritable Bowel Syndrome. Gastroenterol Clin N Am 2005;34:247-255. Rao S, Welcher K, Zimmerman B, et al. Is Coffee a Colonic Stimulant? Eur J Gastroenterol Hepatol 1998;10:113-118. Serra J, Salvioli B, Azpiroz F, et al. Lipid Induced Intestinal Gas Retention in Irritable Bowel Syndrome. Gastroenterology 2002;123(3):700-706. Jones VA, McLaughlin P, Shorthouse M, et al. Food Intolerance: a Major Factor in the Pathogenesis of Irritable Bowel Syndrome. Lancet 1982;2(8308):1115-1117. Stefanini GF, Saggioro A, Alvisi V, et al. Oral Cromolyn Sodium in Comparison with Elimination Diet in Irritable Bowel Syndrome, Diarrheic Type. Muti Center Study of 428 patients. Scand J Gastroenterol 1995;30(6):535-541. Atkinson W, Sheldon T, Shaath N, et al. IgG Antibodies to Food: a Role in Irritable Bowel syndrome. Gut 2004;53: 1459-1464. Collins SM, Vallance B, Barabra G, et al. Putative Inflammatory and Immunological Mechanisms in Functional Bowel Disorders. Bailleres Best Pract Res Clin Gastroenterol 1999;13(3):429-436. Niec AM, Frankum B, Talley NJ. Are Adverse Food Reactions Linked to Irritable Bowel Syndrome? Am J Gastroenterol 1998;93(11):2184-2190. Fernadez-Banares F, Esteve-Pardo M, de Leon R, et al. Sugar Malabsorption in Functional Bowel Disease: Clinical Implications. Am J Gastroenterol 1993;88(12): 2044-2050. Nelis GF, Vermeeren MA, Jansen W. Role of Fructose-sorbitol Malabsorption in the Irritable Bowel Syndrome. Gastroenterology 1990; 99(4):1016-1020. Symons P, Jones MP, Kellow J. Symptom Provocation in Irritable Bowel Syndrome. Effects of Differing Doses of Fructose-sorbitol. Scand J Gastroenterol 1992;27:940-944. Carroccio A, Montalto G, Cavera G, et al. Lactose Intolerance and Selfreported Milk Intolerance: Relationship with Lactose Maldigestion and Nutrient Intake. Lactase Deficiency Study Group J Am Coll Nutr 1998;17:631-636. Di Stefano MD, Veneto G, Malservis S, et al. Lactose Malabsorption and Intolerance and Peak Bone Mass. Gastroenterology 2002;122:1793- 1799. Choi YK, Johlin F, Summers R, et al. Fructose Intolerance: An Underrecognized Problem. Am J Gastroenterol 2003;98:1348-1353. Oâ€™Sullivan MA, Oâ€™Morain CA. Bacterial Supplementation in the Irritable Bowel Syndrome. A Randomized Double-blind Placebo Controlled Crossover Study. Dig Liver Dis 2000;32(4):294-301. Mahoney L, McCarthy J, Kelly P, et al. Lactobacillus and Bifidobacterium in Irritable Bowel Syndrome: Symptom Responses and Relationship to Cytokine Profiles. Gastroenterology 2005; 128(3):541-551. Drisko J, Bischoff B, Giles C, et al. Evaluation of Five Probiotic Products for Label Claims by DNA Extraction and Polymerase Chain Reaction Analysis. Digestive Disease and Sciences 2005;50: 1113-1117. http://www.med.unc.edu/wrkunits/2depts/med...2005_digest.pdf


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## eric (Jul 8, 1999)

With permission Fall 2005 Nutritional Intervention for IBS Bette Bischoff Fourth Year Medical Student University of Kansas Medical Center IBS Bette Bischoff Background Prior to medical school when I was a practicing dietician, I had the privilege of working with many patients who had irritable bowel syndrome (IBS). I found the subject of nutritional intervention related to IBS to be very rewarding and often challenging because there is no â€œperfectâ€ diet for this syndrome. In light of the different etiologies potentially at work in each patient with IBS, nutrition therapy should be carefully and thoughtfully tailored to each person. This can be likened to times past when a cobbler hand-made each personâ€™s shoes. Since each IBS patient can differ dramatically, careful documentation of exacerbating factors listed in the IBS diary maintained by patients may yield important clues to an effective approach to diet and nutrition. One of the issues is that patients with IBS may have a lower threshold to stressors compared to people without IBS. An example of this is patients with carbohydrate intolerances as well as a diagnosis of IBS, who experience an even greater response to problematic carbohydrates such as lactose or fructose as compared to someone who does not have IBS. Another important issue is being alert to unnecessary food aversions. Individuals may experience abdominal discomfort and associate this with eating a certain food, so they decide to avoid eating that particular item, even for life. This may lead to excessive food restriction and the potential for a full-blown eating disorder. What must be kept in mind is that IBS is characterized by increased gut and central nervous system (CNS) reactivity to stressors, and that these stressors can include any dietary excesses as well as chain fatty acids. Good sources of soluble fiber include oats, psyllium seed, pectin, and guar gum. Insoluble fibers consist of the outer husk of the grain and generally tend to decrease transit time. The national nutrition guidelines recommend an intake of 20-30 grams of fiber per day, yet the typical American consumes less than 10 grams of fiber per day. Fiber intake should be increased gradually in IBS patients with constipation, with an emphasis on including adequate water consumption (5). The overall fiber picture can become a bit more confusing than a simple recommendation to increase fiber intake. Insoluble fiber may have a high content of cereal bran, which is the outer husk of the grain. A recent paper investigated the effects of adding or omitting bran and found conflicting results. It appears the primary care provider may see a greater benefit from patients adding fiber to their diet than the gastroenterologist, possibly because primary care physicians see mostly milder forms of IBS and gastroenterologists see patients with more severe IBS. Whorwell studied 100 patients in a primary care setting that were encouraged to increase cereal bran. The results in the primary care provider scenario produced a â€œmixedâ€ picture -- 22% reported worsening of IBS symptoms while 27% who showed improvement. This may be the result of visceral hypersensitivity triggered by bran consumption. Whorwell recommends that patients identified with IBS and visceral hypersensitivity should be counseled to exclude cereal (insoluble) fibers for a brief period to see if symptoms improve, especially if this is within the care of a specialty clinic. Another study found that cereal fibers were associated with a 55% worsening of symptoms (6, 7). Thus, if the goal is to increase transit rate and increase the frequency of bowel movements (for IBS-C), one could add insoluble fiber to the diet; however, since IBS is also associated with visceral hypersensitivity, if discomfort/pain or bloating occurs, the patient may need to switch solely to soluble fiber. Caffeine is a gastrointestinal stimulant. For IBS patients with diarrhea, a period of caffeine sensitivities to particular foods that are unique to the individual rather than to the IBS condition. This article reviews some of the literature in this area and then presents some treatment options to be considered in the nutritional management of IBS. It should be noted that the research and peer-reviewed published literature regarding IBS and diet is still very limited and, therefore, some of the resources cited in this article will date back several years. Nutritional Factors Influencing Motility: Fiber, Fat and Caffeine IBS is the most common of the functional GI disorder, affecting approximately 10-15% of the US population (1). IBS is a multifactorial illness with several different emerging pathophysiologies, including disorders of motility, visceral hypersensitivity, central processing dysfunctions, psychological factors, and post-infectious inflammation. Fiber: A recent survey reported that close to 95% of general practitioners believe that fiber deficiency is the main cause of IBS. In fact, the most common dietary advice offered to patients with IBS is for them to increase their intake of fiber, primarily to address the constipation that may be associated with IBS. However, since IBS is also associated with visceral hypersensitivity, luminal distension -- as might be caused by the bacterial fermentation of insoluble fiber -- can also produce discomfort (2). Dietary fiber is a non- starch polysaccharide derived from plant foods that are poorly digested by human enzymes. A fiber-enriched diet can relieve constipation, accelerate intestinal transit time, and may reduce intracolonic pressure. Furthermore, the intake of fiber is associated with a reduction in the intraluminal concentration of bile acids, which may reduce the contractile activity of the colon (3, 4). There are two types of fiber -- soluble and insoluble. Soluble fiber is derived from fruits and grains, and is fermented in the colon to form short exclusion may prove beneficial. The total intake of caffeine-containing beverages by many adults and children often reaches levels that can induce pharmacological effects. Evidence associating caffeine with GI symptoms suffered by patients with IBS is limited in the current literature, but one study revealed that caffeinated coffee stimulated colonic motor activity in a magnitude similar to that of an entire meal and had a 60% stronger effect than ingesting water (. Dietary fat is also a potent modulator of gut motor function. This macronutrient delays gastric emptying time and accelerates small bowel transit rates. Symptoms of bloating are commonly reported after consuming a high-fat meal. Serra et al. found that after an infusion of enteral fat, the volume of retained gas increased from 298 to 505 ml (9, 10). For patients who need to limit their fat intake, counting actual fat grams in the diet can be an excellent way to identify high-fat food sources. In general, IBS patients should aim for only 40-50 grams of fat per day. If weight loss becomes an issue with fat restriction, medium chain triglycerides (MCT) are an excellent source of calories. Unfortunately, MCT oils are expensive and, due to taste issues, are generally not wellreceived by patients. Food Allergy, Hypersensitivity and Intolerance Although up to 45% of the population reports adverse reactions to food, the actual prevalence of immune-mediated food allergy is unknown. Symptoms are more common in atopic individuals who often have allergies to non-food antigens as well, such as pollens, and in young children who tend to outgrow an allergy. The role of food allergy in IBS has not been studied well. Surveys indicate that 40-70% of food-allergic patients report GI symptoms including nausea, vomiting, abdominal pain, bloating, and diarrhea. Stefanini et al. conducted a 4-week multi-center study comparing the efficacy of the mast cell stabilizing agent sodium cromoglycate at 1500 mg per day with an elimination diet, and 67% of the patients reported improvement in their symptoms (11). Attempts to â€œtestâ€ for food hypersensitivity in IBS have largely focused on the classic food allergy, which is based on the presence of IgE -- immunoglobulins of the â€œimmediate typeâ€. These antibodies attach to certain cells in the body that release chemicals that cause anaphylaxis. Present speculation in the literature suggests that adverse reactions to food in patients with IBS might be due to forms of immunological mechanisms other than a dietary allergy, namely IgG antibodies. These tend to have a delayed response following exposure to a particular antigen and have been implicated in some cases of food hypersensitivity. IgG studies surfacing in the IBS literature are promising, but the issue of the validation of serum IgG testing is often raised. Atkinson et al. observed significant improvement in IBS symptoms in elimination diets using Elisa IgG antibody testing. Their results suggest that IgG antibodies may have a role in helping patients identify candidate foods for elimination (12). Collins et al. also found significant change in patients receiving the IgG exclusion diet. The foods that were most frequently associated with elevated IgG levels were yeast, milk, eggs, wheat, cashew nuts, peas, almonds, and barley. The mechanism by which the IgG antibodies have a detrimental effect is unclear, but most likely is associated with low-grade inflammation (12,13). For the most part, most patients with IBS do not have immune-mediated allergies to food and, more likely, have increased sensitivity to the direct effects of food on digestive function including increased food volume ingestion and the addition of fats, caffeine, carbohydrates, alcohol, etc. Food Intolerance and Exclusion Diets Niec recently summarized the literature on clinical trials using food elimination diets followed by rechallenge. Of the seven studies included in their review, positive response rates varied from 15 to 75 percent. A higher rate of response was correlated with diarrhea-predominant IBS. Milk, wheat and eggs were the most frequently implicated foods (14). Although the principle of food elimination or exclusion appears straightforward, it can be very demanding for the patient. If the patient appears hesitant or confused about food choices, physician referral to a registered dietitian may be helpful. With the exclusion of entire food groups, such as dairy products, the risk of developing a nutritional deficiency must be considered. Carbohydrate Malabsorption Carbohydrate intolerance can be seen in many patients with IBS. Fructose, lactose and sorbitol malabsorption are common among patients who have IBS, and dietary restriction of these sugars may improve symptoms (15,16). One study found that 42% of IBS patients developed symptoms from sorbitol-fructose mixtures compared to 3.5 % in the control group (1. This could be an important factor when patients are consuming large amounts of weight-loss products or have diarrhea-predominant IBS. Lactose malabsorption occurs when lactose, the primary sugar in dairy products, is not completely digested and absorbed in the small bowel. Lactase, the enzyme required to hydrolyze lactose for intestinal absorption, is found primarily in the tips of the jejunum. When unabsorbed lactose reaches the colon, colonic bacteria uses this substrate for fermentation, producing gas and short chain fatty acids. The unabsorbed lactose also affects osmolality, causing water to be drawn into the bowel and accelerating the intestinal transit time. If lactose intolerance is suspected, it can be confirmed with a hydrogen breath test. Lactose intolerance appears to be dose dependant. This means that many patients can tolerate small amounts of dairy products throughout the day, such as Â½ cup of milk, but not larger amounts. Although it may seem obvious which foods contain lactose, some sources may be difficult to discern. Patients should look for hidden sources in baked goods, salad dressings, and powdered mixes. Labels with the following words contain lactose: nonfat dry milk, milk powder, dry milk solids, whey curds, and caseinate milk sugar. Contrary to popular belief, acidophilus milk does not have the lactose sugar digested and is, therefore, a poor substitute for regular milk. Soymilk and rice milk do not contain lactose and are, therefore, good dairy substitutes. However, these products are often low in calcium and vitamin D. Hard cheeses and cultured yogurt are usually acceptable alternatives. For patients who do not tolerate lactose but want to consume dairy products, supplemental lactase enzymes are available. Several studies have shown that patients with lactose intolerance have significantly less calcium intake than those who tolerate lactose. In one study, patients who were lactose intolerant had a calcium intake of approximately 300 mg per day (1, which is only 20-40% of the recommended calcium intake for adults. Patients with lactose intolerance have also exhibited decreased bone mass density (19). In light of the potential for compromised calcium and vitamin D intake, it would be prudent to evaluate all patients with lactose intolerance for a calcium supplement if needed. Fructose is a hexose sugar that is highly utilized in the western diet. In the past 20 years, there has been a 10-fold increase due to its use in highly processed food products. It is often used as high fructose corn syrup in soda, fruit juices, cookies, baked goods, jellies, and candy. Unlike glucose, which is completely absorbed, fructose absorption capacity is limited. Therefore, when ingested in small quantities, dietary fructose will probably not be an issue. However, when consumed in larger amounts, fructose may serve to osmotically draw fluid into the intestinal lumen. This may cause distension of the small intestine and produce symptoms such as abdominal pain, bloating and discomfort. Furthermore, after reaching the colon, unabsorbed fructose may be fermented by colonic bacteria, producing excessive gas (20). Probiotics Several studies now exist defining the potential role of probiotics in IBS. These papers have exhibited a great degree of variability, possibly due to the use of different probiotic strains, their ability to adhere and colonize in the GI tract, and the number of colony-forming units actually ingested by the individual. The probiotics most often studied are lactobacillus, bidifobacterium, and some non-pathogenic forms of e-coli. In a recent study, bifidobacterium 35624 significantly alleviated symptoms of abdominal pain and discomfort, bloating, and distension. There was also a normalization of IL-10/IL-12 ratios (this skewed cytokine ratio may be indicative of a proinflammatory Th-1 state). The bifidobacterium used in this study is currently unavailable in the US marketplace in the concentrations used in this study (21,22). Food products that are high in probiotics include fermented milk, pourable yogurt, and yogurt with live active cultures. Currently, there is no federal agency in the US that routinely tests or â€œpolicesâ€ the market to ensure standardization and quality of probiotic products. Independent tests have revealed that up to 30% of probiotics on the market are â€œlacedâ€ with reasonably adequate live bacteria. One study used DNA extraction to test five probiotic products at a local health food store. The PCR analysis revealed that 2 of the 5 products did not contain the bifidobacterium claimed on the label (23). I called a well-known dairy in the Midwest several years ago. The technician responsible for mixing the probiotic in the yogurt explained that the bacteria are added to a very large vat of product. The yogurt is then packaged in individual cartons and there is no final definitive measurement to ensure that the amount of probiotic stated on the label is actually in each individual container. Putting It All Together Due to the complex underlying pathophysiologies in patients with IBS, nutritional intervention will vary with each patient. The following general IBS categories attempt to help â€œmapâ€ an approach for dietary manipulation in the patient with IBS. For individuals with diarrhea predominant IBS, consider limiting nutrients that exacerbate GI motility or intestinal secretion -- caffeine, fat and some carbohydrates (fructose, lactose and alcohol sugars). Probiotics can also be of benefit, especially if post-infectious IBS or bacterial overgrowth is suspected, or the patient has had numerous antibiotic therapies in the past. If constipation is the main issue, make sure the patient has had an adequate trial of increased insoluble fiber. This usually means that the patient needs to count fiber grams and seek to attain 20 grams of fiber per day. When visceral hypersensitivity is suspected, ask the patient to limit the amount of food eaten in one session and instead to eat three small meals per day with snacks. A low-fat diet and avoidance of insoluble fiber may also be helpful for these patients. Targeting nutritional intervention in the patient with IBS can be challenging due to the many different etiologies of this syndrome and the fact that some patients have heightened responses to different foods. A food diary kept by IBS patients can be a particularly helpful way to ascertain which foods may be problematic. It is recommended that the clinician look for food â€œtrendsâ€ in the journal, with the goal of steering the patient away from excessive food restriction behaviors. References Drossman DA, Camilleri M, Mayer EA, et al. AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002;123(6):2108-2131. Bijkerk CJ, de Wit NJ, Stalman WA, et al. Irritable Bowel Syndrome in Primary Care: the Patient and Doctors Views on Symptoms, Etiology, and Management. Can J Gastroenterology 2003;17(6):363-368. Muller-Lissner SA. Effect of Wheat Bran on Weight of Stool and Gastrointestinal Transit Time: A Meta Analysis. Br Med J 1988;296:615- 617. Villaneva A, Dominguez-Munoz J, Mearin F. Update in the Therapeutic Management of Irritable Bowel Syndrome. Dig Dis 2001;19:244-250. Floch MH, Narayan R. Diet in Irritable Bowel Syndrome. J Clin Gastroenterol 2002;35:S48. Francis CY, Whorwell P. Bran and Irritable Bowel Syndrome: Time for Reappraisal. Lancet 1994;344(8914):39-40. Lea R, M Bch B, Whorwell P. The Role of Food Intolerance in Irritable Bowel Syndrome. Gastroenterol Clin N Am 2005;34:247-255. Rao S, Welcher K, Zimmerman B, et al. Is Coffee a Colonic Stimulant? Eur J Gastroenterol Hepatol 1998;10:113-118. Serra J, Salvioli B, Azpiroz F, et al. Lipid Induced Intestinal Gas Retention in Irritable Bowel Syndrome. Gastroenterology 2002;123(3):700-706. Jones VA, McLaughlin P, Shorthouse M, et al. Food Intolerance: a Major Factor in the Pathogenesis of Irritable Bowel Syndrome. Lancet 1982;2(8308):1115-1117. Stefanini GF, Saggioro A, Alvisi V, et al. Oral Cromolyn Sodium in Comparison with Elimination Diet in Irritable Bowel Syndrome, Diarrheic Type. Muti Center Study of 428 patients. Scand J Gastroenterol 1995;30(6):535-541. Atkinson W, Sheldon T, Shaath N, et al. IgG Antibodies to Food: a Role in Irritable Bowel syndrome. Gut 2004;53: 1459-1464. Collins SM, Vallance B, Barabra G, et al. Putative Inflammatory and Immunological Mechanisms in Functional Bowel Disorders. Bailleres Best Pract Res Clin Gastroenterol 1999;13(3):429-436. Niec AM, Frankum B, Talley NJ. Are Adverse Food Reactions Linked to Irritable Bowel Syndrome? Am J Gastroenterol 1998;93(11):2184-2190. Fernadez-Banares F, Esteve-Pardo M, de Leon R, et al. Sugar Malabsorption in Functional Bowel Disease: Clinical Implications. Am J Gastroenterol 1993;88(12): 2044-2050. Nelis GF, Vermeeren MA, Jansen W. Role of Fructose-sorbitol Malabsorption in the Irritable Bowel Syndrome. Gastroenterology 1990; 99(4):1016-1020. Symons P, Jones MP, Kellow J. Symptom Provocation in Irritable Bowel Syndrome. Effects of Differing Doses of Fructose-sorbitol. Scand J Gastroenterol 1992;27:940-944. Carroccio A, Montalto G, Cavera G, et al. Lactose Intolerance and Selfreported Milk Intolerance: Relationship with Lactose Maldigestion and Nutrient Intake. Lactase Deficiency Study Group J Am Coll Nutr 1998;17:631-636. Di Stefano MD, Veneto G, Malservis S, et al. Lactose Malabsorption and Intolerance and Peak Bone Mass. Gastroenterology 2002;122:1793- 1799. Choi YK, Johlin F, Summers R, et al. Fructose Intolerance: An Underrecognized Problem. Am J Gastroenterol 2003;98:1348-1353. Oâ€™Sullivan MA, Oâ€™Morain CA. Bacterial Supplementation in the Irritable Bowel Syndrome. A Randomized Double-blind Placebo Controlled Crossover Study. Dig Liver Dis 2000;32(4):294-301. Mahoney L, McCarthy J, Kelly P, et al. Lactobacillus and Bifidobacterium in Irritable Bowel Syndrome: Symptom Responses and Relationship to Cytokine Profiles. Gastroenterology 2005; 128(3):541-551. Drisko J, Bischoff B, Giles C, et al. Evaluation of Five Probiotic Products for Label Claims by DNA Extraction and Polymerase Chain Reaction Analysis. Digestive Disease and Sciences 2005;50: 1113-1117. http://www.med.unc.edu/wrkunits/2depts/med...2005_digest.pdf


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## eric (Jul 8, 1999)

FYIDr Drossman's comments on foods for IBS Health.Shawn,To say that people with IBS may get symptoms from food intolerances is an acceptable possibility, since the gut will over react to stressors of all types including food (high fat or large volumes of food in particular). Futhermore, there can be specific intolerances. So if you have a lactose intolerance for example, it can exacerbate, or even mimic IBS. Other examples of food substances causing diarrhea would be high consumers of caffeine or alcohol which can stimulate intestinal secretion or with the latter, pull water into the bowel (osmotic diarrhea). The same would be true for overdoing certain poorly absorbed sugars that can cause an osmotic type of diarrhea Sorbitol, found in sugarless gum and sugar substituted foods can also produce such an osmotic diarrhea. Even more naturally, people who consume a large amount of fruits, juices or other processed foods enriched with fructose, can get diarrhea because it is not as easily absorbed by the bowel and goes to the colon where it pulls in water. So if you have IBS, all of these food items would make it worse. However, it is important to separate factors that worsen IBS (e.g., foods as above, stress, hormonal changes, etc.) from the cause or pathophysiology of IBS. Just like stress doesn't cause IBS, (though it can make it worse), foods must be understood as aggravating rather than etiological in nature. The cause of IBS is yet to be determined. However, modern research understands IBS as a disorder of increased reactivity of the bowel, visceral hypersensitivity and dysfunction of the brain-gut axis. There are subgroups being defined as well, including post-infectious IBS which can lead to IBS symptoms. Other work using brain imaging shows that the pain regulation center of the brain (cingulate cortex) can be impaired, as well as good evidence for there being abnormalities in motility which can at least in part explain the diarrhea and constipation. So finding a specific "cause" of IBS has grown out of general interest in place of understanding physiological subgroups that may become amenable to more specific treatments. Hope that helps.Doug http://www.ibshealth.com/ibs_foods_2.htmhttp://www.ibshealth.com/ibsfoodsinfo.htmDr Wood's comments for me"Dr. Jack Wood, a renowned physiologist at The Ohio State University calls the ENS â€œthe little-brain-in-the-gut.â€ "Dear Shawn:Sorry for the delayed reply to your question. I generally agree with Dr. Drosssmanâ€™s response. A subgroup of individuals when they become sensitized to specific molecules in certain foods respond to ingestion of the molecules with symptoms of cramping abdominal pain, fecal urgency and explosive watery diarrhea. These are also the primary symptoms of diarrhea-predominant IBS. Enteric mast cells, by mechanisms we donâ€™t understand, become sensitized to the food molecule and respond to its presence by releasing a signal to the brain-in-the-gut (ENS) which is interpreted as a threat. The ENS responds by â€œrunningâ€ a program which organizes secretion and motility into a behavior pattern of the bowel, which rapidly clears the threat from the lumen. Because to be effective secretion occurs in large volumes and the contractions that accomplish rapid propulsion are strong, running of the program has the side effects of diarrhea and cramping pain. Big brain input to mast cells during stress activates the mast cells to evoke the symptoms resulting from exposure of the mast cells to sensitizing food antigens. Aside from food allergens and mast cells, certain chemicals such as those in hot peppers, stimulate sensory nerves in the ENS and we are beginning to understand how this can also lead to food-related symptoms that might mimic or exacerbate IBS.Hope this helps,Jackie (Jack) D. Wood "You have two brains: one in your head and another in your gut. Dr. Jackie D. Wood is a renowned physiologist at The Ohio State University. He calls the second brain, "the-little-brain-in-the-gut." This enteric nervous system is part of the autonomic nervous system and contains over one hundred million neurons, which is as many as are in the spinal cord. This complex network of nerves lines the walls of the digestive tract form the esophagus all the way down to the colon. This little brain in the gut is connected to the big brain by the vagus nerves, bundles of nerve fibers running from the GI tract to the head. All neurotransmitters, such as serotonin that are found in the brain are also present in the gut.Dr Wood has discovered that this little-brain-in-the-gut has programs that are designed for our protection and which are very much like computer programs. They respond to perceived threats in the same way that the limbic system or the emotional brain does. So the threat of a gastrointestinal infection can activate the program that increases gut contractions in order to get rid of the infection. The symptoms are abdominal cramping and diarrhea. Dr. Wood has determined that a type of cell found in the body and the gut, called the mast cell, is a key to understanding the connection of the big brain in the head with the little-brain-in-the-gut. Mast cells are involved in defense of the body. In response to certain threats or triggers, such as pollen or infection, mast cells release chemicals, such as histamine, that help to fight off the invader. Histamine is one of the chemicals that causes the symptoms of an allergy or a cold. When an infection of the gut occurs, such as food poisoning or gastroenteritis, the mast cells of the gut release histamine. The little-brain-in-the-gut interprets the mast cell signal of histamine release as a threat and calls up a protective program designed to remove the threat â€" at the expense of symptoms: abdominal pain and diarrhea. The brain to mast cell connection has a direct clinical relevance for irritable bowel syndrome and other functional gastrointestinal syndromes. It implies a mechanism for linking allostasis and the good stress response to irritable states (e.g., abdominal pain and diarrhea) of the gut. Mast cells can be activated to release histamine in response to perceived psychological stress, whether the stressor or trigger is consciously perceived or not. So the end result is the same as if an infection activated the program in the-little-brain-in-the-gut: abdominal pain and diarrhea."http://www.parkviewpub.com/nuggets/n5.html


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