Food is Medicine: A Nutritional Approach to IBS and More. Kathleen N. Mueller, M.D. CAFP Scientific Symposium 2017

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1 Food is Medicine: A Nutritional Approach to IBS and More Kathleen N. Mueller, M.D. CAFP Scientific Symposium 2017

2 Nutritional approaches to IBS:FODMaP. New insight into food influences and gout. Breast cancer and cruciferous vegetables.

4 200

6 90M Americans 76% have a significant change in QOL Digestive disease #2 for disability claims 50% seek alternative medicine

7 Rome Criteria for Diagnosis of IBS Recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with 2 of the following criteria: Related to defecation Associated with a change in frequency of stool Associated with a change in form (appearance) of stool Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis

8 IBS-C constipation predominant IBS-D diarrhea predominant IBS-M mixed subtypes IBS-U unclassified, neither diarrhea nor constipation

9 Genetic predisposition Inflammatory changes/ Alteration of the microbiome 5-HT and other NT 5-HT and other NT Altered gut-brain signaling Gut motor/secretory activity with barrier function Gut motor/secretory activity with barrier function IBS-D IBS-C Homeostatic imbalance IBS-M

10 Etiology of IBS

11 Testing for IBS Mannitol/Lactulose testing Measures urine for increased mannitol/lactulose which indicated permeability of the intestinal lining Often not covered by insurance approx. $90

12 Approach to IBS Dietary Changes Vitamin C Prunes/Psyllium Probiotics Peppermint Oil Medications

13 FODMaP Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols Short-chain carbohydrates Poorly absorbed Rapidly fermented Osmotic activity increases fluid in the gut Fermentation releases gas Pain, bloating, impaired absorption, altered gut function

14 Halmos EP, et al. A diet low in fodmaps reduces symptoms of irritable bowel syndrome. Gastroenterol 2014; 146(1)67-75.e5

15 Examples of FODMAP-Containing Foods Fermentable Oligosaccharides Fructans, galactooligosaccharides Wheat, barley, rye, onion, leek, white part of spring onion, garlic, shallots, artichokes, beetroot, fennel, peas, chicory, pistachio, cashews, legumes, lentils, chickpeas Disaccharides Lactose Milk, ice cream, yogurt, dairy products Monosaccharides And Polyols Free Fructose (fructose in excess of glucose) Sorbitol, mannitol, maltitol, xylitol Apples, pears, mangoes, cherries, watermelon, asparagus, sugar snap peas, honey, HFCS Apples, pears, apricots, cherries, nectarines, peaches, plums, watermelon, mushrooms, cauliflower, artificial sweeteners

19 Common foods that cause bloating and gas Apricots Bagels Bananas Beans Brussels sprouts Caffeine B Carrots Celery Onions Pretzels Prunes Raisins Wheat germ

20 Start with ½-1 tsp psyllium/day Prunes/dried plums (7 fruits/11g/day) more effective than psyllium A Average American just 6-12 g/day Goal 25-35g/day

21 CBT A Hypnosis B Relaxation techniques C

22 Movement C

23 Probiotics Bifidobacterium longum, B. bifidum, B. lactis, Lactobacillus acidophilus, B L. rhamnosus, Streptococcus thermophilus After 4 weeks, modest improvement

24 Peppermint Oil ml enteric coated capsules 3 times daily B

26 Polyethylene glycol (PEG) B Meds for IBS-C Linaclotide (Linzess) guanylate cyclase-c agonist 25% improvement in bloating, pain cramping, A abdominal fullness Diarrhea Lubiprostone (Amitiza) prostaglandin E1 analogue that activated type-2-chloride channels BID for 2 weeks C 12 weeks 17.9% v. 10.1% Diarrhea, nausea, abdominal pain

27 Eluxadoline (Viberzi) mixed mu opioid receptor agonist and dela opioid receptor antagonist Rifaximin (Xifaxan) minimally absorbed antibiotic 2500, better than placebo for pain and stool consistency 26 week period Nausea, constipation, abd pain rare pancreatitis TARGET1 and CTARGET2 trials, 4 weeks showed improvement abd pain, bloating, stool consistency Headache, acute URI, nausea, abdominal pain, diarrhea, UTI Meds for IBS-D Alosetron (Lotronex) selective 5-HT3 receptor antagonist released in 2000 and widely used, withdrawn from market due to ischemic colitis Significant improvement in QOL Ischemic colitis 1.03 cases/1000 pt/yrs Other meds tricyclics (low quality evidence) SSRIs, antispasmodics Loperamide small studies, helps with diarrhea but no data on gas/bloating

28 Gout The Disease of Kings Inflammatory arthritis with crystal deposition in the synovial joints Elevation of serum uric acid

29 Gout Associated Risk Metabolic syndrome 62.8% (25.4%) Obesity 11.4% (3.4%) CVD risk 25% Risk of MI 26%

30 Purine rich foods Meats, organ meat, seafood, legumes, yeast, mushrooms, gravies Highest intake of meat 1.41 (95% CI risk Low purine diet only reduces uric acid 1 mg/dl Not associated with total protein intake 7% 21%

Alcohol 0.46 mg/dl Not associated with acute attacks RR 1.15 (95% CI 1.04-1.

31 Alcohol 0.46 mg/dl Not associated with acute attacks RR 1.15 (95% CI ) per shot of liquor/day RR 1.49 (95% CI ) per 12 oz beer/day 0.29 mg/dl

32 Gout continues HFCS up to 800% increase since since 1950the 1970 s

34 Low-Fat Dairy Intake Milk and yogurt (daily or QOD) lower risk of gout Incidence of attacks inversely related to intake of dairy products

35 Coffee/tea 4-5 and >6 c/day reduced urate 0.26 mg/dl Inverse relationship with decaf and urate so maybe not the caffeine

36 Vitamin 500 mg/day Vitamin C for 2 months Mean in urate 0.5 mg/dl 500 mg shows maximum benefit (more not better)

Cherries/Cherry extract 200-300 g/day (1.5 c) 35% lower risk when ingested in a hazard period 1.

37 Cherries/Cherry extract g/day (1.5 c) 35% lower risk when ingested in a hazard period 1.91 vs flares (p=0.047) Singh JA, Bharat A, Edwards NL. J Clin Rheumatol 2015; 21(4):

38 Weight loss Mr. Fit Trial Kg loss Odds Ratio of Achieving Normal urate Serum Urate

39 Dietary recommendations Diet Goals for Flares 6-8 c water/day No alcohol Meat <4-6 oz/day Protein from Low fat dairy Tofu Eggs Nuts and nut butters Long term diet principles Weight loss and daily exercise Increased plant proteins nuts, fruit, whole grains 1-2 servings low fat dairy/day Decrease/eliminate beer, liquor, HFCS sweetened drinks Consider Vitamin C 500 mg/d If drinking coffee, continue if desired Consider cherries or cherry extract

41 Cruciferous Vegetables Rich sources of glucosinolates Chopping or chewing activates glucosinolate into isothiocyanates and indole-3-carbinol (I3C) I3C affects the development of cancer cells in animals

cancer events by as much as 52% (Thomson, 2010) Effect was not

42 Breast Cancer Cohort of 3000 survivors Higher intake of CVs and total vegetables in women taking tamoxifen new or recurrent breast cancer events by as much as 52% (Thomson, 2010) Effect was not present for non-tamoxifen users More research necessary Goal - 5 weekly servings

48 HFCS up 800% since 1950

Key Recommendations from the U.S. RDA for 2015-2020 Previously, the Dietary Guidelines for Americans recommended that cholesterol intake be limited to no more than 300 mg/day.

50 Key Recommendations from the U.S. RDA for Previously, the Dietary Guidelines for Americans recommended that cholesterol intake be limited to no more than 300 mg/day. The 2015 DGAC will not bring forward this recommendation because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol. Cholesterol is not a nutrient of concern for overconsumption.

51 With every meal and snack

52 Eat food. Not too much. Mostly plants. -Michael Pollan

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,