What to expect? What IBS is and how this manifests as functional symptoms. How IBD creates functional symptoms for individuals in remission

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2 What to expect? By the end of this webinar you can expect to know: What IBS is and how this manifests as functional symptoms How IBD creates functional symptoms for individuals in remission The strong link between mental health and functional symptoms Practical tips for holistic assessment of patients with functional symptoms First line intervention for functional symptom management How The Low FODMAP Diet can support functional symptom management The use of probiotics in management of functional symptom management Practical tips of how to use behaviour change techniques in this patient group

3 How this will work! 1. Functional symptoms 2. Dietary management & the evidence base 3. Engaging & empowering the patient through assessment 4. Demonstrating your worth with impact 5. Question time

4 Functional Symptoms

5 Irritable Bowel Syndrome: Diagnosis Rome IV Criteria 1 - Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following: Related to defecation Associated with a change in frequency of stool Associated with a change in form (consistency) of stool No presence of red flag indicators 2 : Unexplained weight loss Rectal bleeding Over 60 years old Biochemistry returned normal 3 : Coeliac Screen Tissue transglutaminase IBD Screen CRP & ESR OR Faecal Calprotectin Full blood count

6 Irritable Bowel Syndrome: What is it? Visceral hypersensitivity 4 - the experience of pain within the inner organs (viscera) at a level that is more intense than normal. Multifactorial contribution: Biological Factors Psychological Factors Altered gut motility Stress, anxiety & depression Altered micro-flora Disordered sleep Increased nerve endings Dysfunctional coping Genetics Childhood trauma Infections Perfectionism Medications Psychiatric disorders Altered gut-brain axis

7 Irritable Bowel Syndrome: Treatment Dietary management coming up! Lifestyle management: Minimising symptom induced anxiety Support networking Physical Activity Relaxation Mindfulness Cognitive behavioural therapy

8 Inflammatory Bowel Disease: Diagnosis Presence of additional symptoms to those shared with IBS: Extreme fatigue anaemia Mouth ulcers vit B12 deficiency Fever Unexplained weight loss Blood, mucus and/or pus in stool Inflammatory markers returned abnormal: C-reactive protein & ESR Faecal calprotectin Secondary care investigations: Endoscopy and biopsy X-ray and barium meal MRI

9 Inflammatory Bowel Disease: What is it? Crohns Disease 5 inflammation and ulceration can occur in any part of the gastrointestinal (GI) tract. This can affect just a few centimetres or a length of the GI tract. As well as affecting the lining of the bowel, Crohn s may also go deeper into the bowel wall. Ulcerative colitis 6 - inflammation and ulceration of the inner lining of the rectum and colon, tiny ulcers develop on the surface of the lining and these may bleed and produce pus. If UC only affects the rectum, it is called proctitis, while if it affects the whole colon it may be called total colitis or pancolitis. Microscopic colitis this is miscroscopic inflammation of the colon. There are 2 main forms: Lymphocytic Colitis - an increased number of lymphocytes (white blood cells) within the lining of the colon. Collagenous Colitis - the lining of the colon develops a thicker than normal layer of collagen there may also be an increased number of lymphocytes in the lining of the colon.

10 Inflammatory Bowel Disease: Treatment IBD has 2 disease states, each requires a slightly different approach to symptom management. Active disease state when inflammation is present this requires antiinflammatory and immunosuppressant medical therapy. Where stricture, perforation or fistula present surgery is required. In some cases this will lead to the requirement of a temporary/permanent colostomy/ileostomy. Remission this is when there is no inflammation present following medical or surgical present. The surgery and/or healing process causes increased nerve endings in the GI tract heightening visceral sensitivity 4. Therefore IBD in remission can be treated in the similar way as IBS.

11 The Evidence Base

12 IBS: 1st line advice7

13 IBS: The Low FODMAP Diet % of Responders Comparator Reference Comparator FODMAP Usual Diet Staudacher 2012 J Nutr Typical Diet Halmos 2014 Gut 9-70 High FODMAP Diet Mcintoch 2016 Gut Placebo diet Staudacher 2016 DDW 11 Rossi 2017 BSG 12 NICE Staudacher 2011 Hum Nut D NICE Bohn 2015 Gastroenterology NICE Eswaran 2016 Am J Gastro (With thanks to Prof. Whelan)

14 IBS: Probiotics 16 Probiotics are unlikely to provide substantial benefit to IBS symptoms. Individuals choosing to try probiotics are advised to select one product at a time, and monitor the effects. They should try it for a minimum of 4 weeks at the dose recommended by the manufacturer

15 IBD: The Low FODMAP Diet Reference Paper Type Conclusion Cox RCT Fructans worsen FGS in quiescent IBD Zhan Meta-analysis Systematic Review Low FODMAP Diet improves FGS in quiescent IBD Prince Service Evaluation Clinical practice identifies Low FODMAP Diet improves FGS in IBD Gearry Pilot Study Low FODMAP Diet offers an effective strategy for improving FGS in IBD (With thanks to Prof. Whelan)

16 The Low FODMAP Diet NICE update of CG Exclusion Diet 8 weeks Reintroduction Recommended to be delivered by specialist Dietitian Tailored to individual needs, ensuring optimised nutritional intake RCTs demonstrate a 70% effectiveness of the diet 13

17 The Low FODMAP Diet Fermentable Oligosaccharides Disaccharides Monosaccharide - Fructans, GOS - Lactose - Fructose And Polyols - Sugar alcohols

18 How FODMAPS Trigger Symptoms FODMAPS Actions Osmotically Active Rapidly Fermented Physiological Effects Increased Water Delivery VISCERAL HYPERSENSITIVITY Increased Gas Production Symptom Induction Motility Changes Pain Bloating Wind

19 Empower /em-pow-er/ def. Give someone Engaging & empowering the patient through assessment authority or power to do something

20 Scared Frustrated Fed-up Unheard Anxious Confused Angry Let down

21 Initial Consultation Time to tell their story; active listening in a non-judgemental way Minimal encouragers Verbal following Choose not to address inaccuracies at this point Gain control of the consultation; choose not to follow patient agenda Summarise patient story Reflect their feelings Ask permission before asking questions Clarify when symptoms started Take a detailed symptom evaluation Confirm investigations completed Ask when medications are used Prior to dietary assessment address all inaccurate beliefs and concerns with neutral explanations

22 Would you like me to explain how we know it is irritable bowel syndrome?

23 Is it definitely IBS? Would you like me to explain how we know this? When someone goes to their GP with symptoms similar to yours, the GP should do a few blood tests to see if there is anything dangerous going on inside of your body. The blood tests check for any inflammation in the bowel, and if you have coeliac disease or anaemia. If any of these come back positive it is important you pop to hospital so you can get checked more thoroughly. If these blood tests come back normal we know your body is not in any danger. If the blood tests come back normal we know the symptoms are functional. What I mean by functional is that the symptoms are very real, there is something different about your body, though the symptoms are not causing you any harm at all. We call these functional symptoms IBS.

24 Would you like me to explain what irritable bowel syndrome is?

25 Would you like me to explain what irritable bowel syndrome is? (1) IBS is an increased sensitivity of the lower bowel, it is when the lower bowel (the colon) becomes a lot more sensitive than it used to be. This can come on for different people for different reasons. Some people get their sensitivity if they have had a stomach bug, virus or food poisoning. Some people get this if they have been on high doses or multiple courses of IBS. Some people get this if they have had surgery in their abdomen, because everything is very close together there, this can impact on sensitivity of the bowel...

26 Would you like me to explain what irritable bowel syndrome is? (2) For us ladies, a whole host of reasons. Hormonal fluctuations in the body can have an impact on the sensitivity of the bowel, so depending on where we are in our menstrual cycle our symptoms can differ. Pre/post child birth, pre/post menopause this can affect gut sensitivity too for the same reason. If we have any gynae concerns such as fibroids or endometriosis this can affect the sensitivity of our colon, again because everything is very close together down there...

27 Would you like me to explain what irritable bowel syndrome is? (3) Though I would say for most people that come to see me for IBS they experience their sensitivity as a result of a stress mechanism that happens inside of the body. As we know, we can experience stress for a whole host of reasons, but lets take chronic back pain as an example. If we are in pain our body will send out stress hormones and signals to help us cope with the pain. The signals and hormones will help us cope with the pain a little better, though at the same time they act on the gut making it much much more sensitive. This response in the body is the same for all types of stress where there its physiological or emotional related...can YOU RELATE TO ANY OF THE ABOVE?

28 In terms of managing the symptoms we want to treat the IBS from 2 angles.

29 In terms of managing the symptoms we want to treat the symptoms from 2 angles. OK so when we have got this sensitivity we want to look at things from 2 angles. Any thing we can do to support our wellbeing to dampen down that stress response will reduce the sensitivity of the lower bowel. I know this is easier said than done...so any remaining sensitivity we can work on adapting the diet to reduce pressure placed on this sensitivity from the inside, making your tummy more comfortable.

30 Would you like me to explain how the digestive system works?

31 Would you like me to explain how the digestive system works? When we eat something it takes 4-6 hours to move all the way through the digestive system before it reaches the lower bowel (the colon). Believe it or not, and I appreciate sometimes it doesn t feel this way, but until the food is in the lower bowel it can t cause us a symptom. So it s never what we have just eaten. But when it gets to the colon it can spend up to 2 days there. So when we get a symptom, it might not be what we had to eat that morning, or the day before. It maybe something we had the day before that. This is the reason it gets so confusing as to what is going on. You get symptoms just after you ve eaten though right? So to explain this to you, when we eat some thing and we swallow it, and it hits our stomach; whether it is guilt or innocent this will send a downward pressure on the digestive system. So any potential lurking symptoms in the lower bowel are more likely to be triggered off.

32 For this reason I work in a really structured way to support people in addressing their symptoms.

33 For this reason I work in a really structured way to support people in addressing their symptoms. As the way the digestive system works can make this all a bit confusing and a bit of a puzzle we work in a really structured way. Today we will talk through how food fits into your life, and go through the basics to support digestive comfort. If you are already achieving this, or your symptoms are really stopping you from achieving this there is a lovely structured diet you can work through to truly get to the bottom of all of this. So what would be lovely is, would you be able to talk me through a typical day and how food fits into your day please?

34 Dietary Assessment Typical day Clarification of the following per day: Portions of fruit & veg Portions of wholegrains Portions of calcium Volume of fluid Number of caffeinated beverages How ETOH fits into their lifestyle Justify rationale for dietary assessment to allow time to explain the following: Importance of regular meal pattern Role of dietary fibre (soluble/insoluble), and fluid with recommendations Importance of calcium and recommendations The influence caffeine/alcohol has on digestive comfort

35 Goal Setting Ensure patient agreed goals what would you like to focus on? Support to set SMART and practical goals - how could you do this? Specific e.g. have a portion off fruit with breakfast Measurable Achievable Realistic Timely If first line advice already in place OR anxiety of worsening symptoms is a barrier to getting this in place The Low FODMAP Diet delivery at second appointment.

36 Demonstrating your worth with impact

37 Outcomes Weight change towards healthy BMI Symptom change: Abdominal pain, bloating, wind, stomach gurgling, nausea, vomiting, heartburn, reflux, urgency, incomplete evacuation, musus in stool, tiredness. Likert scaling (none 0, mild 1, moderate 2, severe 3) Percentage Symptom improvement (after score/beforescorex100) Stool frequency improvement yes/no Stool consistency improvement yes/no Medication changes no change/reduced medication/stopped medication Secondary investigations complete prior to referral calculate wasted spend Collect for each patient, report on this, and use to show case your services!

38 Question Time

39 References 1. Dossman DA, Hassler WL Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 2016;150(6): NICE CG12 Suspected Cancer: recognition and referral. (Update 2017). 3. NICE: CG61 Irritable Bowel Syndrome in adults: Diagnosis and Management. (Update 2017). 4. Farmer AD, Aziz Q Gut pain & visceral hypersensitivity. Br J Pain Feb; 7(1): NICE CG152 Crohn s Disease: Management. (Update 2016). 6. NICE CG166 Ulcerative Colitis: Management. 7. McKenzie YA, Bowyer RK, Leach H, Gulia P, Horobin J, O Sullivan NA, Pettitt C, Reeves LB, Seamark L, Williams M, Thompson J, Lomer MCE (IBS Dietetic Guideline Review Group on behalf of Gastroenterology Specialist Group of the British Dietetic Association) British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update). J Hum Nutr Diet. doi: /jhn Staudacher HM, Lomer MC, Anderson JL, Barrett JS, Muir JG, Irving PM, Whelan K Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr Aug;142(8): Halmos EP, Christophersen CT, Bird AR, Shepherd SJ, Gibson PR, Muir JG Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut Jan;64(1): McIntosh K, Reed DE, Schneider T, Dang F, Keshteli AH, De Palma G, Madsen K, Bercik P, Vanner S FODMAPs alter symptoms and the metabolome of patients with IBS: a randomised controlled trial. Gut Jul;66(7): Staudacher HM, Lomer M, Louis P, Farquharson F, Lindsay JO, Irving PM, Whelan K The Low FODMAP Diet Reduces Symptoms in Irritable Bowel Syndrome Compared With Placebo Diet and the Microbiota Alterations May Be Prevented by Probiotic Co-Administration: A 2x2 Factorial Randomized Controlled Trial. Gastroenterology. April Volume 150, Issue 4, Supplement 1, Page S230 Abstract submitted for Digestive Disorders Week Rossi et.al Low FODMAP diet advice vs placebo diet advice. Who will respond to FODMAPs or probiotics. British Gastroenterology Society Abstract submission. 13. Staudacher HM, Whelan K, Irving PM, Lomer MC Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet Oct;24(5): Bohn L, Storsrud S, Liljebo T, Colin L, Lindfors P, Tornblom H, Simren M Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology Nov;149(6): Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. Am J Gastroenterol 2016; 111: McKenzie Y.A., Thompson J., Gulia P. & Lomer M.C.E. (2016) British Dietetic Association systematic review of systematic reviews and evidence-based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). J Hum Nutr Diet. doi: /jhn Cox SR, Prince AC, Myers CE, Irving PM, Lindsay JO, Lomer MC, Whelan K Fermentable carbohydrates (FODMAPs) exacerbate functional gastrointestinal symptoms in patients with inflammatory bowel disease: a randomised, double-blind, placebo-controlled, cross-over, re-challenge trial. Journal of Crohn's & Colitis 2017 May Zhan Yl, Zhan YA, Dai SX Is a low FODMAP diet beneficial for patients with inflammatory bowel disease? A meta-analysis and systematic review. Clinical Nutrition: Official Journal of the European Society of Parenteral and Enteral Nutrition 2017 May Prince AC, Myers CE, Joyce T, Irving P, Lomer M, Whelan K Fermentable Carbohydrate Restriction (Low FODMAP Diet) in Clinical Practice Improves Functional Gastrointestinal Symptoms in Patients with Inflammatory Bowel Disease. Inflammatory Bowel Diseases 2016, 22 (5): Gearry RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease-a pilot study. Journal of Crohn's & Colitis 2009, 3 (1): 8-14.