Food Choices and Alternative Techniques in Management of IBS: Fad Versus Evidence

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1 Food Choices and Alternative Techniques in Management of IBS: Fad Versus Evidence Maria Vazquez Roque, MD, MSc Assistant Professor Gastroenterology and Hepatology 2010 MFMER slide-1 Objectives Gluten-free diet and non-celiac gluten sensitivity (NCGS) Low fermentable oligo- and disaccharides, monosaccharides and polyols (FODMAPs) diet Psychological therapies Hypnotherapy Cognitive behavioral therapy Acupuncture 2010 MFMER slide-2 Copyright 2015 American College of Gastroenterology 1

Food allergy, intolerances and sensitivity Food allergies are rare in adults IgE mediated

nutrient Symptoms secondary to fermentation of sugars by the colon bacteria Lactose intolerance,

cause GI and extra-gi symptoms Gluten in NCGS or wheat sensitivity Fasano A, et. Al.

2 Food allergy, intolerances and sensitivity Food allergies are rare in adults IgE mediated food-hypersensitivity Peanut, seafood Food intolerances Lack of enzyme to digest a particular nutrient Symptoms secondary to fermentation of sugars by the colon bacteria Lactose intolerance, fructose intolerance Food sensitivities Immune-mediated reactions to nutrient-derived antigens that cause GI and extra-gi symptoms Gluten in NCGS or wheat sensitivity Fasano A, et. Al. Gastro, in press, MFMER slide-3 What is the connection between these? Copyright 2015 American College of Gastroenterology 2

Change in symptom severity from baseline in the gluten and placebo-treated groups over 6 weeks: "Non-celiac gluten intolerance" may exist, but no clues to the mechanism were elucidated N=34 IBS

3 Change in symptom severity from baseline in the gluten and placebo-treated groups over 6 weeks: "Non-celiac gluten intolerance" may exist, but no clues to the mechanism were elucidated N=34 IBS patients with prior history of being symptomatically controlled with a GFD There were no significant changes in fecal lactoferrin, levels of celiac antibodies, highly sensitive C- reactive protein, or intestinal permeability. There were no differences in any end point in individuals with or without DQ2 or DQ8. Biesiekierski JR, et al. Am J Gastroenterology 2011 IBS-D: Gluten free diet and bowel frequency Randomized clinical trial, N= 45 patients Non-CD, IBS-D patients, GCD vs. GFD x 30 days Vazquez-Roque M, et al. Gastroenterology MFMER slide-6 Copyright 2015 American College of Gastroenterology 3

Spectrum of gluten related disorders Gluten related disorders Pathogenesis

) Celiac disease (CD) Gluten ataxia Dermatitis herpetiformis Wheat allergy (WA)

BMC Medicine 2012;10:13 2010 MFMER slide-7 IBS-like symptoms Spectrum CD IBS

complications Gluten sensitivity (GS) / Non-celiac GS / non-celiac wheat

Intraepithelial lymphocytes (IEL) Secreted Ab against gliadin (AGA in ~ 50%)

4 Spectrum of gluten related disorders Gluten related disorders Pathogenesis Autoimmune Allergic Not allergic, not autoimmune (innate immunity?) Celiac disease (CD) Gluten ataxia Dermatitis herpetiformis Wheat allergy (WA) Gluten sensitivity Adapted from Sapone A, et al. BMC Medicine 2012;10: MFMER slide-7 IBS-like symptoms Spectrum CD IBS Lactose intolerance Food intolerance SIBO Potential CD Latent CD CD and complications Gluten sensitivity (GS) / Non-celiac GS / non-celiac wheat sensitivity Negative wheat IgE Negative CD serology Normal duodenal histology / Intraepithelial lymphocytes (IEL) Secreted Ab against gliadin (AGA in ~ 50%) Symptoms overlap with CD or WA Resolution of symptoms on GFD Adapted from Verdu et al., Sapone A, et al. BMC Medicine 2012;10:13 Copyright 2015 American College of Gastroenterology 4

Gastrointestinal and extraintestinal symptoms in patients with gluten sensitivity Volta, U. and De Giorgio, R. Nat. Rev. Gastroenterol Hepatol 2012;9:295-299.

5 Gastrointestinal and extraintestinal symptoms in patients with gluten sensitivity Volta, U. and De Giorgio, R. Nat. Rev. Gastroenterol Hepatol 2012;9: MFMER slide-9 Summary of gluten related disorders Celiac disease Gluten Wheat allergy sensitivity Onset of symptoms Days to weeks Hours to days Minutes to hours Pathogenesis Autoimmunity Innate Immunity? Allergic Immune HLA HLA DQ2/8 restricted Not HLA DQ2/8 restricted Not HLA DQ2/8 restricted Auto-antibodies Almost always Always absent Always absent Enteropathy Almost always Always absent Always absent Symptoms Complications Intestinal and extra-intestinal Co-morbidities Long term complications Intestinal and extra-intestinal Co-morbidities Long term complications? Intestinal and extra-intestinal No-comorbidities Anaphylaxis Adapted from Fasano A, et. Al. Gastro, in press, MFMER slide-10 Copyright 2015 American College of Gastroenterology 5

6 Maria I. Vazquez-Roque, MD Clinical implications Gluten free foods sales to top $2.6 billion dollars by b 2012, 2012 and d tto nearly l double to $5.5-billion by 2015, forecast to grow by a further 61% by 2017! No adequate diagnostic marker to identify gluten sensitive subjects Natural history of gluten sensitivity is not known Eventually develop celiac disease? Underlying immune mechanism seems to be distinct from celiac disease (innate vs. adaptive?) Controversy of its existence 2010 MFMER slide-11 Objectives Gluten-free diet Low L FODMAP diet di t Psychological therapies Hypnotherapy Cognitive behavioral therapy Acupuncture 2010 MFMER slide-12 Copyright 2015 American College of Gastroenterology 6

short-chain fatty acids (SCFA) Dietary starch is a

stimulate colonic motility y and transit Staudacher, H. M.

advance online publication 21 January 2014 2010 MFMER

FODMAP: Fermentable oligosaccharides, disaccharides,

intestine Lead to production of SCFA in the colon by

7 Maria I. Vazquez-Roque, MD Maldigested nutrients: A case for short-chain fatty acids (SCFA) Dietary starch is a substrate for colonic bacteria to produce SCFA SCFA stimulate colonic motility y and transit Staudacher, H. M. et al. Nat. Rev. Gastroenterol. Hepatol. advance online publication 21 January MFMER slide-13 Solution: Low FODMAP diet? FODMAP: Fermentable oligosaccharides, disaccharides, monosaccharides and polyols Poorly absorbed in the small intestine Lead to production of SCFA in the colon by bacteria Diets low in FODMAPs have been promising in reducing symptoms in a subset of IBS-D patients but the exact mechanism has not been elucidated Copyright 2015 American College of Gastroenterology 7

8 Maria I. Vazquez-Roque, MD A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome Halmos EP, et al. Gastroenterology 2014; MFMER slide-16 Copyright 2015 American College of Gastroenterology 8

9 Maria I. Vazquez-Roque, MD 2010 MFMER slide-17 Objectives Gluten-free diet FODMAP diet di t Psychological therapies Hypnotherapy Cognitive behavioral therapy Acupuncture 2010 MFMER slide-18 Copyright 2015 American College of Gastroenterology 9

10 Psychological therapies for IBS ~ 50% of patients with severe IBS have dissatisfaction with standard medical therapy Psychological stress increases the symptoms of IBS Psychological methods to treat IBS Biofeedback Cognitive therapy Psychodynamic therapy Hypnosis treatment 2010 MFMER slide-19 Hypnotherapy Induce and make use of a special mental state, mind is focused and receptive Verbal suggestions and imagery on physical and mental functioning. Unclear how it specifically works to improve IBS symptoms Proposed effects on GI function Slow down propulsive contractions Effect on gastric acid secretion Reduce or eliminate nausea and vomiting Improve long-term management of functional dyspepsia 2010 MFMER slide-20 Copyright 2015 American College of Gastroenterology 10

Hypnosis treatment 4-12 sessions, weekly or every other week 30-40 minutes each session Induction of hypnosis followed by deep relaxation Improvement may last up to 2 years

11 Hypnosis treatment 4-12 sessions, weekly or every other week minutes each session Induction of hypnosis followed by deep relaxation Improvement may last up to 2 years Improvement: Abdominal pain Diarrhea/constipation Bloating 2010 MFMER slide MFMER slide-22 Copyright 2015 American College of Gastroenterology 11

12 Cognitive behavioral therapy (CBT) Goal is to have patients change their habitual thoughts, feelings and behaviors that may magnify stress responses and negative moods Achieved by applying a series of selfexploration exercises and stress reducing strategies. Recent meta-analysis evaluating 9 trials using CBT for IBS have showed it as an effective therapy for IBS. Reducing abdominal pain, diarrhea and constipation Ford et al. Am J of Gastro Sept MFMER slide-23 CBT for IBS Cognitive approaches Identifying and challenging irrational thoughts Visualization Calming Self Talk Imaginal Exposure (using the imagination to face a fear) Thought-stopping Behavioral therapies Deep Breathing Exercises Progressive Muscle Relaxation Assertiveness Training Desensitization (gradual exposure to something that is feared) 2010 MFMER slide-24 Copyright 2015 American College of Gastroenterology 12

is disrupted 2010 MFMER slide-25 World J Gastroenterol 2014 February

13 Acupuncture Ancient Chinese medicine Channels of energy (Qi) called meridians, throughout our bodies In disease, energy flow in these meridians is disrupted 2010 MFMER slide-25 World J Gastroenterol 2014 February 21;20(7): MFMER slide-26 Copyright 2015 American College of Gastroenterology 13

14 Summary Gluten exclusion and/or a low FODMAP diet can help improve IBS symptoms in a subset of patients. Psychological therapies such as hypnosis, CBT and acupuncture are reasonable treatment alternatives for a subset of patients with IBS that do not respond to conventional medical therapy MFMER slide-27 Thank you! 2010 MFMER slide-28 Copyright 2015 American College of Gastroenterology 14

6 men) with NCGS and irritable bowel syndrome (based on Rome III criteria), but not celiac disease Biesiekierski

15 No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates Double-blind crossover trial of 37 subjects (aged y, 6 men) with NCGS and irritable bowel syndrome (based on Rome III criteria), but not celiac disease Biesiekierski JR, et al. Gastroenterology 2013;145: MFMER slide-29 Copyright 2015 American College of Gastroenterology 15

Non coeliac gluten sensitivity: Clinical relevance and recommendations for future research

Non coeliac gluten sensitivity: Clinical relevance and recommendations for future research Valencia 2014 Professor David S Sanders Royal Hallamshire Hospital & University of Sheffield, UK Why is the prevalence