DIFM-The Integrative RDNs Dietitians in Integrative and Functional Medicine

Size: px

Start display at page:

Download "DIFM-The Integrative RDNs Dietitians in Integrative and Functional Medicine"

Harvey Skinner
6 years ago
Views:

1 DIFM-The Integrative RDNs Dietitians in Integrative and Functional Medicine June 25, 2014 Gerard E. Mullin MD Associate Professor of Medicine Johns Hopkins University School of Medicine Division of Gastroenterology & Hepatology

2 Objectives To examine the pathophysiology of IBS as the foundation for integrative solutions To review the herbal therapies, dietary supplements and special diets that have proven efficacy in the irritable bowel syndrome To know the mind-body modalities that improve outcomes for the irritable bowel syndrome.

3 Rome III Criteria for IBS A chronic disorder characterized by abdominal pain or discomfort associated with disordered defecation Symptoms should have developed at least 6 months before the patient first presents for formal evaluation Abdominal pain or discomfort should be present at least 3 days per month for 3 months and should be associated with two or more of the following: improvement with defecation, onset associated with a change in stool frequency, and/or onset associated with a change in stool form.

4 Epidemiology of IBS Prevalence is 10-15% of US population, F>>>M Annual direct costs for IBS=$1.35 billion Estimated impact on the U.S. of $30 billion annually (excluding prescription and OTC meds)(leong, 2003;Inadomi, 2003;Hulisz, 2004). IBS adversely impacts quality of life, and, thus, significantly affects work productivity (Dean, 2005; Quigley, 2006). Consequently, IBS continues to be the second most common cause of work and school absenteeism (Drossman, 1993). Two decades ago, about 16% of IBS patients had sought out CAM practitioners (Smart, 1986). More recent data indicates that up to 51 percent of patients with IBS report using CAM (Haas, 2000;Kong, 2005).

5 The Pathogenesis of IBS

6 Emerging Options for IBS Supplements Gut Microbiome

7 Pathophysiology of IBS

8 Pathophysiology of IBS The Immune System in Irritable Bowel Syndrome. Barbara et al Neuro Gastro Motility October ;4:349.

9 Evidence to Support a Pivotal Role of Gut Microbiome in IBS Post-infectious IBS Altered Colonic Microbiome in IBS Probiotics Small Intestine Bacterial Overgrowth

10 Clinical Features Associated with SIBO Gas-bloat Flatulence Abdominal discomfort Diarrhea Steatorrhea Weight loss Features associated with micronutrient deficiencies

11 Treatment Options for SIBO The goal is to treat the underlying cause(s), eradicate the bacterial overgrowth and nutritional support Antibiotic therapy Herbs (berberine, wormwood) Prokinetic agents Elimination Diet-FODMAPs

12 Results of IBS Subjects Undergoing Intervention for Positive Lactulose Breath Hydrogen Testing for SIBO (n=104) Glob Adv Health Med May;3(3): Characteristics Rifaximin Herbs P value Number na Age (yr), sd, range Gender Female N (%) Male n (%) /-14.8 (19-81) 48 (71) 19 (29) / (19-76) 29 (78) 8 (22) 0.33 Responses (n) na Responses Rate (%) Adverse Events (n, %) 2, 2.9 1, Mullin et al Global Advances in Health and Medicine May, 2014

13 Treatment of IBS with TCM IBS SYMPTOM INDEX P= P=0.03 N=35 Baseline End of Tx 14 weeks follow up Placebo Standard Individual N=38 A Bensoussan, NJ Talley, M Hing et al. Treatment of irritable bowel syndrome with Chinese herbal medicine. A randomized * controlled * study. JAMA : N=43 Level A

14 Traditional Chinese Herbal Medicine to Treat IBS Authors N Trial Design Treatment Time Outcome Bensoussan et al 1998 Wang et al 2008 Leung et al R,D,P Standard TCM, Individualized herbs, placebo 24 R, non-d,p 24 gm Shugan Jianpi granules +/- Smecta TID or CBT + lacetin 119 R,D,P Concoction of Chinese herbs vs. placebo (IBS-D) Bian Z et al 1125 Meta-analysis Tong xie yao fang (TXYF) (IBS-D) Sallon S et al 61 R,D,P Padma Lax (IBS-C) Altern Med Rev Jun;16(2): weeks Significant reduction in symptom scores and QOL 2 weeks Significant reduction in serotonin positive cells in herbal groups 8 weeks No significant improvement in SF-36 or global symptoms days More effective than placebo (RR 1.35, 95% CI ) 12 weeks More effective than placebo 76% vs. 31%

15 Iberogast PLANT NAME HERB-EXTRACT RATIO IN 100 ML OF IBEROGAST Bitter candytuft 1: ml Angelica root 1: ml Chamomile flowers 1: ml Caraway fruits 1: ml Milk thistle 1: ml Lemon balm 1: ml Peppermint leaves 1: ml Celandine 1: ml Licorice root extract 1: ml

16 Iberogast Improves IBS Symptoms Madisch, A., Holtmann, G., Plein, K. & Hotz, J. Treatment of irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial. Alimentary Pharmacology & Therapeutics 19 (3), Irritable bowel syndrome (IBS) symptom score (± s.d.) for the various treatment groups at baseline and after 2 and 4 weeks of treatment. Intentionto-treat population. *P = , P = , **P = and P = vs. placebo. STW 5, commercially available herbal preparation (nine plant extracts) STW 5-II, research herbal preparation (six plant extracts) BCT, bitter candytuft mono-extract. Level A

17 Iberogast Improves IBS Pain Madisch, A., Holtmann, G., Plein, K. & Hotz, J. Treatment of irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial.alimentary Pharmacology & Therapeutics 2004; 19 (3), Abdominal Pain score (± s.d.) for the various treatment groups at baseline and after 2 and 4 weeks of treatment. Intention-to-treat population. *P = , P = , **P = and P = vs. placebo. STW 5, commercially available herbal preparation (nine plant extracts) STW 5-II, research herbal preparation (six plant extracts) BCT, bitter candytuft mono-extract. Level A

18 Pharmacological Effects of Iberogast Botanical Inhibition of Acid secretion Anti- Inflammation Oxidative stress Hypomotility Hypermotility Peppermint W S S N M Chamomile S W M M S Licorice root W S W N M Angelica root M W M N S Caraway M S W N W Milk thistle M M M N M Melissa leaf M M S N W Celandine N M M M N Bitter candytuft M S W M W Wagner H. Multitarget therapy-the future for more than just functional dyspepsia. Phytomedicine 2006;13 suppl 5:

Peppermint Animal model studies demonstrate: relaxation effect on gastrointestinal (GI) tissue analgesic and anesthetic effects in the central and peripheral nervous system immunomodulating

19 Peppermint Animal model studies demonstrate: relaxation effect on gastrointestinal (GI) tissue analgesic and anesthetic effects in the central and peripheral nervous system immunomodulating actions chemopreventive potential Blocks calcium channels in gastrointestinal smoothe muscle to produce spasmolytic response Wald A, Rakel D. Nutr Clin Pract Jun-Jul;23(3): Review

20 Cochrane Collaboration 2011 Issue 11.

21 ACG Task Force: Management of IBS-D Agents Grade RR of IBS symptoms not improving Antispasmodics Hyoscine, cimetropium, pinaverium: provide short-term relief of abdominal pain/discomfort ini BS Peppermint oil: superior to placebo in IBS in a small number of studies Alosetron: more effective than placebo at relieving global IBS symptoms in male and female IBS-D patients. Potentially serious side effects of constipation and colon ischemia (Grade 2A) Grade 2C not given Grade 2B 0.43 Grade 2B (M) Grade 2A (F) 0.79 ACG IBS Task Force, Am J Gastro 2009; 104 (S1): S1-S35

22 Efficacy of Therapies for IBS Therapy Trials NNT Peppermint Oil 8 2 Hycosamine Alosetron 6 7 Tegaserod 8 17 BMJ 2008;337: a2313 TCAs 8 4

23 Other Herbal Therapies for IBS Herb/ Reference Sample size Sample characteristics Study design Dose of active Duration Outcome Tumeric Bundy et al 2004 Artichoke leaf extract Walker et al 2001 Bundy et al All forms IBS R, non-d, non-p 279 All IBS forms R, non-d, non-p 208 All forms IBS R, non-d, non-p 2 doses, 72 mg (1 tablet) or 144 mg (2 tablets) daily 320 mg artichoke leaf extract per cap; 2 TID 320 mg (1 capsule) or 640 mg (2 capsules) of 1:5 artichoke leaf extract Altern Med Rev Jun;16(2): daily 8 weeks Significant improvement in IBS QOL at end of trial vs. baseline both Tx groups 6 weeks Significant reduction of IBS symptoms vs. baseline 8 weeks Significant reduction in QOL, symptom score vs. baseline

24 Melatonin Sleep Anxiety Depression IBS???

25 Is Melatonin involved in IBS? JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2009, 60, Suppl 3, 67-70

26 Melatonin in IBS Author-Year Trial Outcome Lu WZ. Aliment Pharmacol Ther 2005 Nov 15;22;10: Lu WZ et al. Dig Dis Sci 2009; 54;5: Saha L et al J Clin Gastro 2007;41;1: Song GH et al Gut 2005;54;10: DB, RCT 3 mg melatonin vs. placebo 8 weeks, 4 week washout, 8 week crossover n=17 IBS-C colonic transit study. O3 mg melatonin vs. placebo 8 weeks, 4 week washout, 8 week crossover n=17 Blue dye, radiopaque markers, bristol stools IBS, 3 mg melatonin vs. placebo, 8 weeks, DB RCT N=18 3 mg melatonin vs. placebo vs. 2 weeks IBS with sleep disturbances N=40 Improved overall IBS scores, Decreased abdominal pain, decreased abnormal to defecation, decreased distention CTT prolonged in IBS-C vs. controls Melatonin increased CTT in vs. placebo No difference in prolongation of CTT with melatonin in Controls vs. IBS-D Improved overall IBS score, improved extra-colonic symptoms and QOL Improved abdominal pain, decreased rectal pain thresholds

27 Emerging Options for IBS Supplements Gut Microbiome

28 Distribution of Intestinal Bacterial Flora in Normal Gut and in Small Intestinal Bacterial Overgrowth Lin, H. C. JAMA 2004;292: Origin of gas/bloating of IBS patients with SIBO

29 IBS Patients on High FODMAP Diet Produce Breath Methane

30 Treatment Options for SIBO The goal is to treat the underlying cause(s), eradicate the bacterial overgrowth, and nutritional support Antibiotic therapy Prokinetic agents Herbs (berberine, oregano oil, wormwood) Mullin et al Global Advances in Health and Medicine May 2014 Diet Enzymes/HCl

31 Results of IBS Subjects Undergoing Intervention for Positive Lactulose Breath Hydrogen Testing for SIBO (n=104) Characteristics Rifaximin Herbs P value Number na Age (yr), sd, range Gender Female N (%) Male n (%) /-14.8 (19-81) 48 (71) 19 (29) / (19-76) 29 (78) 8 (22) 0.33 Responses (n) na Responses Rate (%) Adverse Events (n, %) 2, 2.9 1, Mullin et al Global Advances in Health and Medicine May, 2014

32 Meta-analysis for Probiotic Use in IBS Over 20 RCT s and 5 meta-analysis for probiotics use in IBS Most systematic reviews indicate that probiotics have a beneficial impact on global IBS symptoms, abdominal pain and flatulence but not bloating. Strain specific? Current Opinion in Clinical Nutrition & Metabolic Care. 14(6): , November DOI: /MCO.0b013e32834b8082

33 Meta-analysis for Probiotic Use in IBS Over 20 RCT s and 5 meta-analysis for probiotics use in IBS Most systematic reviews indicate that probiotics have a beneficial impact on global IBS symptoms, abdominal pain and flatulence but not bloating. Strain specific? Current Opinion in Clinical Nutrition & Metabolic Care. 14(6): , November Gut Mar;59(3):

34 Summary of Evidence for Herbal and Micronutrient-based Therapies for IBS INTERVENTION Peppermint oil Melatonin Iberogast TCM Artichoke leaf extract Tumeric BODY OF EVIDENCE 3 meta-analyses of 5, 4 and 3 RCTs 2 RCTs 1 RCT 2 RCTs(+) 1 RCT(-) 1 meta(+) 2 RCTs 1 RCT

35 Summary of Adverse Effects for Herbal and Micronutrient-based Therapies for IBS INTERVENTION Peppermint oil Melatonin Iberogast TCM Artichoke leaf extract Tumeric ADVERSE EFFECT Worsening of GERD Drowsiness Allergy Adulteration (meds, metals) none GI intolerance (Pepperdine)

36 Summary of Evidence for Herbal and Nutraceutical-based Therapies for IBS Mullin et al JPEN 2014 In Press Therapy Description Level of Evidence Probiotics IA Bifidobacterium infantis B5624 and VSL#3 Other species IA Grades of Recommendations A B Prebiotics Food sources include bananas, artichokes, onions, asparagus, and chicory. Low doses (3-5 gm) of inulin FOS, GOS. IB C Fiber Isphagla IA D Peppermint Oil ml enteric-coated capsules 3 times daily IA A Melatonin 3 mg at night IB B Iberogast 20 drops 2-3 times daily IB B

37 Gas Bloating Abdominal Pain Diarrhea Constipation > 60% IBS patients report worsening symptoms after meals, 28% within 15 minutes, 93% within 3 hours Eswaran S, Tack J & Chey W. Food: The Forgotten Factor in the Irritable Bowel Syndrome. Gastroenterol Clin N Am 40 (2011)

38 Self-Reported GI Food-Related GI Symptoms in IBS 197 patients with IBS 84% report food-related symptoms 70% (138) incompletely absorbed carbohydates 49% dairy products 36% Beans and Lentils 58% biogenic amines: salami (22%), cheese (20%) High Histamine foods: milk (43%), wine/beer (31%), pork (21%) 52% Fried and fatty foods Bohn L. Am J Gastroenterol 2013; 108: ;

39 Do carbohydrates produce symptoms in IBS? Dairy Grains Fruits and Vegetables

40 Prevalence of Lactose Intolerance in IBS 38% 26% IBS patients (n=251) Controls (n=174)

41 Fructose and Fructans as Dietary Triggers for IBS symptoms * * * Shepherd, et al, Clin Gastro Hepatol 2008;6:765

42 Very Low CHO Diet for IBS SD SD VLC VLC 15 females, mean age 46 yrs, BMI 32 Dietary interventions: 2 wks standard (55% CHO, 30% Fat, 15% Protein) 4 wks VLC (4% CHO, 51% Fat, 45% Protein) Responder rate: 100% Improvements in stool frequency p<0.001),consistency (p<0.001), pain (p<0.001), QoL (p=0.02) Mean weight loss of 3.1 kg Austin et al. Clin Gastro Hepatol 2009;7:706

43 Emerging Options for IBS Supplements Gut Microbiome Elimination Diets

44 What s The Difference? Food Allergy an adverse immune response to the proteins in a food; may occur as the result of a humoral response (immunoglobulin E [IgE] antibody), a cellular response (i.e. T cells), or both Food Intolerance/sensitivity not a true food allergy: could be enzyme deficiency (e.g. lactase deficiency), chemical reactions, aversion. May also refer to IgG mediated reactions or other immune reactions to food.

45 Food Allergy vs. Food Sensitivity Food Allergy Type I Hypersensitivity IgE mediated Immediate, rapid onset Systemic, potentially life threatening Shared Symptoms: Nausea, vomiting, diarrhea, abdominal pain Different symptoms: Hives, tingling or itching in the mouth, swelling of the lips, face, tongue and throat, SOB, wheezing, nasal congestion, anaphylaxis Food Sensitivity Type III hypersensitivity IgG mediated Gradual, delayed response Localized, generally limited to the GI tract Shared Symptoms: Nausea, vomiting, diarrhea, abdominal pain Different symptoms: Gas, cramps, bloating, heartburn, headaches, irritability, nervousness

46 Food Allergy vs. Food Sensitivity Common Food Allergies: Dairy Eggs Wheat Soy Peanuts and tree Nuts Fish Chicken Corn Common Food Sensitivities: Dairy Wheat Peanuts Tree Nuts Lack G. NEJM.2008;359:1252

47 Exclusion-Based Diets Based on Food Hypersensitivity Testing Dairy (IgG4, ALCAT, etc) Top 8 Food Allergens Carbs, Lactose, Fructose, FODMAPs, Gluten Caffeine, Additives, Amines Elimination Diet

48 Studies of Elimination Diets Evidence that elimination diets based on IgG and IgE food antibodies have shown benefit in IBS

49 Food elimination based on IgG antibodies in irritable bowel syndrome: a randomized controlled trial. P<0.001 Atkinson, W et al. Gut 2004;53: Level A

50 Results of Studies of Immunoglobulin G (IgG) Antibody-Elimination Diets for Irritable Bowel Syndrome (IBS). Mullin GE, Lipski L. et al. Nutr Clin Pract 2010;25:

51 IgG Elimination Diet in Migraine + IBS 21 patients (85.7% women) IgG for 270 foods RCT/cross-over: usual diet, elimination and provocation Elimination Diet < in attack duration, severity, # of migraines < pain-bloating severity,< occurrence, > QOL Aydinlar EI. Headache Mar;53(3):

52 A Spectrum of Disease With Overlap? IBS Motility/Visceral Sensation Brain-Gut Interactions Immune activation Altered Gut Microbiome Altered Permeability Non-Celiac Gluten Sensitivity Mild gluten sensitivity Gluten Sensitivity Motility/Visceral Brain-Gut Interactions Neurological Musculoskeletal pain Altered Permeability? Gluten hypersensitivity Celiac Disease Adapted from Verdu EF, et al. Am J Gastroenterol 2009;104: ; & Nijeboer P. J Gastrointestin Liver Dis, December 2013 Vol. 22 No 4: Motility/Visceral Sensation Brain-Gut Interactions Neurological Immune activation Altered Gut Microbiome Altered Permeability Celiac Disease Gluten Intolerance Allergic Rx

53 IBS patients received either gluten or placebo in the form of two bread slices plus one muffin per day with a gluten-free diet for up to 6 weeks. Symptoms were evaluated using a visual analog scale and markers of intestinal inflammation, injury, and immune activation were monitored. Non-celiac gluten sensitivity: 30% Biesiekierski JR et al. Am J Gastro (3)

54 Gluten Induces Symptoms in IBS uncontrolled symptoms 13/19 (68%) gluten 6/15 (40%) placebo (P=0.0001) patients were significantly worse with gluten within 1 week overall symptoms (P=0.047) pain (P=0.016) bloating (P=0.031) satisfaction with stool consistency (P=0.024) tiredness (P=0.001) Biesiekierski JR et al. Am J Gastro (3)

55 Non-Celiac Wheat Sensitivity in IBS: A Distinct Clinical Condition IBS pts N=920 IBS patients N=276 gluten sensitivity but non-celiac 2 weeks on wheatcontaining diet and 2 weeks on placebo Carroccio A. et al. Am J Gastroenterol 2012; 107: Changes in symptom severity over baseline during DBPC wheat challenge

56 Diets For Microbiome Restoration Specific carbohydrate diet Undigested carbohydrates feed downstream bacteria further dysbiosis FODMAP Diet: -- Low prebiotic, lactose, fructans, galactans, polyols (fermentable oligo- and disaccharides, monosaccharides, polyols) Soluble fiber (e.g., modified citrus pectin, vegetable fibers) Paleolithic man consumed > 100 g fiber/day Increases beneficial short-chain fatty acids (SCFAs) Fermented foods (e.g., Body Ecology Diet) Restore and maintain inner ecology through: Cultured foods Decreasing sugars and carbohydrates

57 Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols Family of poorly absorbed, short-chain carbohydrates Lactose Fructose Polyols Fructans Galactans (galacto-oliogsaccharides ) Highly fermentable in the presence of gut bacteria De Roest, Int J Clin Prac, 2013; Gibson, J Gastroenterol Hepatol, 2010; Gibson Am J Gastroenterol, 2012: Ong, et al, J Gastroenterol Hepatol, 2010; Staudacher J Hum Nutr Diet, 2011

59 FODMAP Fructose Polyols Lactose Fructans and Galactans High FODMAP food sources Apples, pears, watermelon, honey, fruit juices, dried fruits, highfructose corn syrup Sugar alcohols (sorbitol, maltitol, mannitol, xylitol, and isomalt), stone fruits, avocado, mushrooms, cauliflower Milk (cow, goat, sheep), yogurt, soft cheeses (ricotta, cottage) Wheat, rye, garlic, onions, artichokes, asparagus, inulin, soy, leeks, legumes, lentils, cabbage, Brussels sprouts, broccoli Alternative lower FODMAP food sources Citrus, berries, bananas, grapes, honeydew, cantaloupe, kiwifruit Sweeteners, such as sugar, glucose, other artificial sweeteners not ending in -ol (Stevia) Lactosefree dairy products, rice milk, hard cheeses Starches, such as rice, corn, potato, quinoa. Vegetables, such as winter squash, lettuce, spinach, cucumbers, bell peppers, green beans, tomato, eggplant

60 FODMAPs Elimination Approach 1. Eliminate all high FODMAPs foods from the diet for a trial period of 2-6 weeks. FODMAPs food classes: Lactose Fructose Fructans Polyols Galactooligosaccharides 2. Challenge - Add foods from one FODMAP class using a small and then larger load and observe for symptoms continue through all categories Catsos P. IBS Free at Last! Portland, ME: Pond Cove Press; 2009, 2012; Shepherd SJ, Gibson PR. Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc. 2006;106:

61 Low FODMAP vs. Standard Diet for IBS Staudacher HM, et al. J Hum Nutr Diet 2011

62 Staudacher HM et al. J. Nutr. 142: , Baseline fecal bifidobacteria concentration in IBS patients compared with change in bifidobacteria concentration after 4 wk of fermentable CHO restriction

63 Proportion of patients showing improvement (%) * * p<0.05 * * * Improvement of mean daily symptom score after 4 wk of habitual diet (control) or fermentable CHO restriction (intervention) Staudacher HM et al. J. Nutr. 142: , 2012.

64 Halmos et al Gastro Jan 2014;146: Mean overall gastrointestinal symptoms from the (A) IBS cohort and the (B) healthy cohort using a VAS during baseline, low FODMAP and typical Australian diets. Symptoms improved significantly on low FODMAP compared with baseline and the typical Australian diet for the IBS cohort. No differences were observed between any of the diets in the healthy cohort

65 Mean symptoms of (A) bloating, (B) abdominal pain, and (C) passage of wind from the IBS cohort using a VAS while following a typical Australian and low FODMAP diet. Mean dissatisfaction with stool consistency in (D) IBS-D and (E) IBS-C after 8 21 days of typical Australian and low FODMAP diets are indicated with a bold line. Symptoms were significantly lower on low FODMAP compared with a typical Australian diet in all measured symptoms

66 Bloating, Abdominal Pain, Dissatisfaction With Stool Consistency, and Composite Scores of All Three Symptoms in IBS and Healthy Participants While Following Low FODMAP and Typical Australian Diets Halmos et al Gastro Jan 2014;146:67-75.

67 Food Reactions and IBS Summary Patients with IBS-D/M should be screened for celiac disease Expected US prevalence in IBS pts is 1% but likely varies based upon population genetics Lactose intolerance may be more common in IBS Clinical implications of CHO intolerance may be different in persons with than without IBS Food can affect GI function and sensation Mounting evidence suggests that dietary & lifestyle interventions can improve symptoms in a subset of IBS sufferers

68 British Dietetic Association IBS Management Guidelines Review study, 30 papers met inclusion criteria. 1. Remove milk and dairy products: lactose intolerance 2. Avoid wheat bran. Ground flax may be tried for 3 month trial for IBS-C. 3. Try low FODMAP diet and institute challenge of foods to individualize plan 4. Probiotics: consider after FODMAP diet. Results vary, so try one product at a time for 4 weeks. 5. Empirical and elimination diets: Initial phase 2-4 weeks Reevaluate McKenzie Y.A. (2012) J Hum Nutr Diet. 25,

69 Figure 3. Proposed Algorithm for the Management of Suspected Food Intolerances in the Irritable Bowel Syndrome (IBS). Mullin et al JPEN 2014 In Press

70 Nutritional Tools for Your IBS Patient Anti-anxiety Herbs Anti-microbials for SIBO Artichoke leaf extract Elimination Diet Soluble Fiber FODMAP restricted diet/carbohydrate restricted diet Melatonin Peppermint Oil Probiotics Tumeric

71 Summary Evidence for the Complementary of Nutrition Therapies in the Irritable Bowel Syndrome (IBS). Mullin et al JPEN 2014 In Press

Irritable Bowel Syndrome

Irritable Bowel Syndrome Irritable bowel syndrome (IBS) has a variety of symptoms, most commonly cramping, abdominal pain, bloating, constipation, and diarrhea. Symptoms can vary from person to person,