Irritable Bowel Syndrome

Transcription

1 Irritable Bowel Syndrome Dietary Management Practicalities Dearbháile O Hanlon Senior Specialist Gastroenterology Dietitian

2 Outline Diagnosis & Red Flags Initial assessment Tips to help implement diet Dietary considerations Challenging and reintroducing What to do with non-responders Other uses

3 Red Flags exclude prior to diagnosis Unintentional weight loss Rectal bleeding Family history of bowel or ovarian cancer Change in bowel habit for more than 6 weeks in person older than 60 Anaemia Abdominal Mass Rectal Masses Raised inflammatory markers for inflammatory bowel disease CA125 if suspicion of ovarian cancer.

4 Diagnosis Good history Exclude Coeliac disease Full Blood Count, exclude anaemia C-Reactive Protein, exclude inflammation Often invasively over investigated. Reassure!

5 New IBS Guidelines

6 Updated dietary guidelines GSG BDA 2016 McKenzie et al J Hum Nutr Diet 2016

7 Change in Guidelines First & Second line advice only. Review & grading of evidence for: Healthy eating & lifestyle Restricting milk and dairy products Dietary fibre modification Fermentable carbohydrates Gluten Probiotic products Elimination diet/food hypersensitivity Separate systematic review for probiotics.

8 Clinical practice recommendations McKenzie et al J Hum Nutr Diet 2016

9 First Line any health professional Healthy eating Regular meals Do not skip meals or eat late at night Take time when eating meals Sit down to eat and chew food well Regular exercise Time to relax

10 Second Line: Low FODMAPs Diet Dietitian led 2 Appointments Strict Low FODMAPs diet 6-8 weeks Challenge 8-12 weeks Group or 1:1 as effective (Whigham et al J Hum Nutr Diet 2015)

11 Assessment Coeliac negative Serology +/- Biopsy Faecal calprotectin Endoscopy Anthropometry Baseline FBC Symptoms Social history Psychosocial Medications Diet - sources

12 Functional Symptom Evaluation Form Highlights main issues. Breaks down symptoms and severity. Global symptoms question adequate relief Good for before and after comparison. Complete in clinic sometimes needs explanation. Other types available and used in research e.g. IBS SSS Useful for service evaluation.

13 Suitability Must have: Baseline healthy diet Basic food knowledge / cooking skills Ability to understand and implement Literacy Adequate finances Self caring and mobile

14 Barriers to Compliance Eating out Convenience foods Family meals Previous food beliefs Slow improvement Expense Availability

15 Allow at least a week to prepare. Finish tempting non-fodmaps foods in larder. Update relevant people and get support. Allow time for shopping. Plan: Meal & snacks In case of emergency foods Social engagements

16 Resources KCL booklets FODMAP App Monash dmap/ Build your own list of resources.

17 Reintroduction Why? Identify food triggers. Expand diet and enjoy meals. Increase non-symptom inducing fermentable carbohydrates. Barriers: Worried about symptom relapse. Timing of challenges. How to incorporate.

18 How long does take? Depends on: How many foods are being challenged. Reactions to foods. Well tolerated: minimum 3 days per food. Symptom triggered: additional 3 days minimum = 6

19 Dietary considerations Calcium: reduced on LFD (Staudacher et al, J Nutr, 2012) Lactose free same calcium Fortified alternatives Non dairy sources ++ required to meet RDA Fruit and vegetable 5 per day swap don t stop Carbohydrate Many alternatives Vegetarian diet Focus on protein sources

20 Non-responders Reassess diet: Compliance? Dietary adequacy: fibre, fluid. Psychological issues? Probiotics? True non-responder: back to referrer.

21 Other Diseases considerations Limited evidence to support use Inflammatory bowel disease. Quiescent Nutritional status Stricturing/low fibre diet High stoma / pouch output Infective/inflammatory causes Optimised medical management Stricturing Coeliac disease Stress strict gluten free Calcium

22 Questions?