Diet and IBS, Diet and IBS, Fibromyalgia, and Fibromyalgia, and MigraineMigraine

What Is Irritable What Is Irritable Bowel Syndrome?Bowel Syndrome?

Symptom Based Symptom Based Diagnosis of ExclusionDiagnosis of Exclusion

Diarrhea Predominant IBSDiarrhea Predominant IBS Constipation Predominant Constipation Predominant

IBSIBS Cyclic IBSCyclic IBS

Rome II Criteria for IBSRome II Criteria for IBS

Relief after defecationRelief after defecation Onset associated with a change in Onset associated with a change in

stool consistencystool consistency Onset associated with a change in Onset associated with a change in

stool frequencystool frequency

Rome II ContinuedRome II Continued    Other symptoms that are not essential butOther symptoms that are not essential but

support the diagnosis of IBS: support the diagnosis of IBS:    Abnormal stool frequency Abnormal stool frequency

– greater than 3 bowel movements/day greater than 3 bowel movements/day – less than 3 bowel movements/weekless than 3 bowel movements/week

Abnormal stool formAbnormal stool form– lumpy/hard lumpy/hard – loose/watery stoolloose/watery stool

Abnormal stool passage (straining, urgency, or Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)feeling of incomplete evacuation)

Passage of mucusPassage of mucus Bloating or feeling of abdominal distension. Bloating or feeling of abdominal distension.

Source: International Foundation of Functional Gastrointestinal Source: International Foundation of Functional Gastrointestinal DisordersDisorders

When You Should Ask When You Should Ask The Doctor to Double-The Doctor to Double-Check Check IBS Diagnosis: IBS Diagnosis: Profound weight loss, anemia or Profound weight loss, anemia or

blood/occult in stoolblood/occult in stool Travel to places with parasitic endemicsTravel to places with parasitic endemics Hx of colon cancerHx of colon cancer Skin abnormalitiesSkin abnormalities Signs of malabsorptionSigns of malabsorption Thyroid dysfunctionThyroid dysfunctionThis list is not exhaustive, but is helpful…This list is not exhaustive, but is helpful…

Consequences of IBSConsequences of IBS

Patients with IBS averaged 15 of 30 Patients with IBS averaged 15 of 30 days with poor physical or mental days with poor physical or mental health. health.

These average overall unhealthy days These average overall unhealthy days exceeded those of respondents with exceeded those of respondents with arthritis, diabetes, heart disease/stroke, arthritis, diabetes, heart disease/stroke, cancer, and class III obesity (body mass cancer, and class III obesity (body mass index > or =40 kg/m2) from the U.S. index > or =40 kg/m2) from the U.S. survey.survey.

Traditional TherapiesTraditional Therapies

MedicationMedication Side EffectsSide Effects Band-Aid solution- only Band-Aid solution- only

addresses symptom of diarrhea, addresses symptom of diarrhea, not underlying problems so other not underlying problems so other problems continue.problems continue.

IBS is not a distinct entity buta collection of disorders

““Food intolerance represents Food intolerance represents an important proportion of an important proportion of conditions which together conditions which together make up IBS”make up IBS”

John Hunter, MD, FCRPDirector or Gastroenterology

“Food Allergies and Food Intolerance”Brostoff & Challacombe, Second Edition,

2002

IBS not only symptomIBS not only symptom

Lancet 2000 Jul 29;356(9227):400-1Lancet 2000 Jul 29;356(9227):400-1 “We found that food provocation in “We found that food provocation in

food intolerant patients was food intolerant patients was characterized by a characterized by a general and general and systemic immune activation systemic immune activation

accompanied by an increase in accompanied by an increase in systemic symptoms…systemic symptoms…

important for the understanding of the important for the understanding of the mechanisms involved in the mechanisms involved in the

pathogenesis of food intolerance.”pathogenesis of food intolerance.”

Food sensitivities ushered in Food sensitivities ushered in by IBS lead to feeling bad all by IBS lead to feeling bad all

over…over…

FOOD INTOLERANCE CAUSESFOOD INTOLERANCE CAUSES IBS SYMPTOMS IN CERTAIN PATIENTSIBS SYMPTOMS IN CERTAIN PATIENTS

Merck Manual pg 1051

Food Intolerance was found to be responsible for symptoms of some patients with the IRRITABLE BOWEL SYNDROME

Trial and Error as a TherapyTrial and Error as a Therapy

““But through But through ‘Trial and Error’‘Trial and Error’ many people find many people find they feel better when they stop eating certain they feel better when they stop eating certain foods. These foods cause the intestines to foods. These foods cause the intestines to contract, which can aggravate contract, which can aggravate IBSIBS in people who in people who have have diarrheadiarrhea as their main symptom.” as their main symptom.”

Nicholas Talley, MD., Patrice Burgess, MD Nicholas Talley, MD., Patrice Burgess, MD ““Controlling I.B.S. With Diet” Controlling I.B.S. With Diet”

Healthwise Information LibraryHealthwise Information Library

But meanwhile, life goes on….. Without But meanwhile, life goes on….. Without remission….remission….

The IBS Employee’s Average Combined Work Time Lost to

Absenteeism and Work Cut Backs due to IBS Symptoms was found to average ONE WEEK per MONTH, for a total of 12 WEEKS per YEAR of lost

productivity.

This represents a loss of nearly 25% of productivity PLUS the costs of accompanying sick leave pay.*

American Gastroenterological Association Position Statement

““Education and Reassurance”Education and Reassurance” ““Dietary and Lifestyle Modifications”Dietary and Lifestyle Modifications” ““Symptom Monitoring”Symptom Monitoring” ““Symptom-Directed Medication Symptom-Directed Medication

PRN”PRN” ““Psychological Treatment” Psychological Treatment”

Dietary Trial and ErrorDietary Trial and Error Caffeinated drinksCaffeinated drinks Tyramine and phenylethylamine- pressor aminesTyramine and phenylethylamine- pressor amines HistamineHistamine Solanine: naturally occurring toxicant in the Solanine: naturally occurring toxicant in the

nightshade plant familynightshade plant family Nitrates and NitritesNitrates and Nitrites Benzoic Acid: also benzoin, gum benzoin, Benzoic Acid: also benzoin, gum benzoin,

benzoate and naturally occurring diet.benzoate and naturally occurring diet. Sorbitol Family: sorbitol, sorbitan, polysorbate

80, polysorbate 60 Lectins (in beans, lentils, peas, peanuts, snails,

wheat). Peptides: small protein-like molecules Proteolytic Enzymes (raw pineapple, raw papaya

most common Eating Habits Scrutinized : Too much at one time

and too high fat content too much stress especially when you eat

1515

IF food Intolerance IS important to IBS symptoms, WHY do most Diets fail to make much difference?

Unlike allergies, food sensitivity reactions are:

1. Dose Dependent

2. Delayed Onset (up to 72 hours post ingestion)

3. Multiple foods can cause symptoms (single elimination trials are useless)

4. NO Universal Bad Food- Very patient specific

Until now, it was just hard to find those “triggers”

Double blind, placebo controlled food reactions Double blind, placebo controlled food reactions do not correlate to IgE allergydo not correlate to IgE allergy in the in the

diagnosis of staple food related gastrointestinal diagnosis of staple food related gastrointestinal symptoms.symptoms.

Bengtsson U, Nilsson-Balknas U, Hanson LA, Ahlstedt SBengtsson U, Nilsson-Balknas U, Hanson LA, Ahlstedt SAllergy Centre, University of Goteborg, SwedenAllergy Centre, University of Goteborg, Sweden

Gut. 1996 Jul;39(1):130-5.

In adult patients with staple food induced gastrointestinal symptoms, objectively verified by DBPCFC, there were no indications of IgEno indications of IgE mediated allergy to the relevant foods, suggesting other mechanisms in adults than in children.

Should we test for allergies Should we test for allergies (IgE)?(IgE)?

Intestinal Perfusion Intestinal Perfusion StudiesStudies

BalloonBalloon

JejunumStomach

Catheter

Knutson et al, J. of Allergy and Clin. Immunology 93; 91(2): 553-9

Intestinal Perfusion Intestinal Perfusion StudiesStudies

Segment of jejunum is endoscopically Segment of jejunum is endoscopically isolated by placement of two balloonsisolated by placement of two balloons

Segment of jejunum between balloons Segment of jejunum between balloons is perfused with potential food allergen is perfused with potential food allergen and then jejunal contents are collectedand then jejunal contents are collected

Knutson et al, J. of Allergy and Clin. Immunology 93; 91(2): 553-9

Anatomy of a Food Anatomy of a Food SensitivitySensitivity

Intestinal Perfusion Intestinal Perfusion StudiesStudies Patients with known sensitivity to the Patients with known sensitivity to the

food had increased production of food had increased production of cytokines found in the washings after cytokines found in the washings after positive challenge. positive challenge.

No increased cytokines seen in controlsNo increased cytokines seen in controls Found no IgE to specific offending foods Found no IgE to specific offending foods

in sensitive patient groupin sensitive patient group

Knutson et al, J. of Allergy and Clin. Immunology 93; 91(2): 553-9

Anatomy of a Food Anatomy of a Food SensitivitySensitivity

To summarize:To summarize:

No physical evidence of damage in No physical evidence of damage in the jejunumthe jejunum

No evidence of an allergy: No IgE No evidence of an allergy: No IgE in the aspirated contents of the in the aspirated contents of the jejunumjejunum

BUTBUT Evidence of an immune reaction, Evidence of an immune reaction,

i.e., presence of cytokines.i.e., presence of cytokines.

Food elimination based on IgG antibodies in irritable Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial.bowel syndrome: a randomised controlled trial.Atkinson W, Sheldon TA, Shaath N, Whorwell PJ.Atkinson W, Sheldon TA, Shaath N, Whorwell PJ.

150 outpatients with IBS 150 outpatients with IBS Randomized X 3 months Randomized X 3 months Test: diet excluding all foods which raised IgG Test: diet excluding all foods which raised IgG Control: sham diet excluding the same number of Control: sham diet excluding the same number of

foods but not those to which they had antibodies. foods but not those to which they had antibodies. Outcome measured: IBS and global symptomsOutcome measured: IBS and global symptoms

Gut. 2004 Oct;53(10):1459-64.

What about IgG testing?What about IgG testing?

Food elimination based on IgG antibodies in irritable Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial.bowel syndrome: a randomised controlled trial.Atkinson W, Sheldon TA, Shaath N, Whorwell PJ.Atkinson W, Sheldon TA, Shaath N, Whorwell PJ.

In 12 weeksIn 12 weeks Elimination diet resulted in a 10% Elimination diet resulted in a 10%

greater reduction in symptom score greater reduction in symptom score than the sham dietthan the sham diet

CONCLUSION: Food elimination based CONCLUSION: Food elimination based on IgG antibodies may be effective in on IgG antibodies may be effective in reducing IBS symptoms and is worthy reducing IBS symptoms and is worthy of further biomedical research.of further biomedical research.

Gut. 2004 Oct;53(10):1459-64.

What about IgG Testing? p2What about IgG Testing? p2

IgG –Based EliminationIgG –Based Elimination

Well, yes, statistically significant butWell, yes, statistically significant but

Only 10% improvement in 12 weeks?Only 10% improvement in 12 weeks?

Can we do better if we get a broader Can we do better if we get a broader picture….. Did they miss something?picture….. Did they miss something?

Types of Types of Adverse Adverse Food Food ReactionsReactions

Allergy-IgE Sensitivity-Non-IgE Intolerance

What Is It?What Is It? Immediate Immune reactions

Delayed immune reaction Enzyme Deficiency

Unique Unique Characteristics:Characteristics:

Usually about 30 minutes to first reaction

EASY to detect

Dose-related, time delayed

Cause-effect confusing without helpful testing.

Treated With Digestive Enzymes

Target Organs Target Organs Affected:Affected:

Skin, Airways, Digestive Tract

Any Organ System Can Be Affected

Gastrointestinal Tract

Cells Involved:Cells Involved: IgE

Measure IgE!

IgG, IgM,C3, C4, Platelets, and more (about 90 different cells)

Direct Cellular Reactions

Toxins

None

EASY to treat

# of Reactive # of Reactive 1 - 4 10 - 20 1

Involved in IBS?Involved in IBS? Co-morbid 8-10%

Estimated 30-40% ?

Other symptoms….Other symptoms….

15% identified muscle and joint 15% identified muscle and joint pain, not IBS symptoms, as pain, not IBS symptoms, as the major cause of their the major cause of their activity limitation.activity limitation.

Psychosom Med. 2006 Mar-Apr;68(2):312-20.Psychosom Med. 2006 Mar-Apr;68(2):312-20.

Comorbid to IBSComorbid to IBS

MigraineMigraine FibromyalgiaFibromyalgia SinusitisSinusitis Rheumatoid ArthritisRheumatoid Arthritis GERDGERDSome of these symptoms persist

long after IBS-D remits if food sensitivity not treated.

Why measure mediators?Why measure mediators?

Because they are agents of chemical warfare Because they are agents of chemical warfare released by cells to fight off invaders or released by cells to fight off invaders or perceived invadersperceived invaders

Because they can cause collateral damage Because they can cause collateral damage – Smooth muscle contraction (evacuation)Smooth muscle contraction (evacuation)– Inflammation (leak WBC to point of infection)Inflammation (leak WBC to point of infection)– Fever (in total flu-like symptoms)Fever (in total flu-like symptoms)

Cells sometimes attack otherwise benign Cells sometimes attack otherwise benign substances like foods and additivessubstances like foods and additives

Measuring MediatorsMeasuring Mediators

MRT Tested- 123 foods and 27 MRT Tested- 123 foods and 27 chemicalschemicals

Plasma to solids ratio (indirect Plasma to solids ratio (indirect measure of mediator release) is measure of mediator release) is measured on all tested foods to give a measured on all tested foods to give a ratio. ratio.

If the volume of the plasma increases If the volume of the plasma increases dramatically, that's considered a dramatically, that's considered a 'highly' reactive food. If there's no or 'highly' reactive food. If there's no or very little volume change, that food is very little volume change, that food is considered 'non-reactive.‘considered 'non-reactive.‘

Formation of the DietFormation of the Diet

Results put in graphical and diet Results put in graphical and diet formform

Diet book sent to patientDiet book sent to patient Results and pt history sent to Results and pt history sent to

dietitiandietitian

Short TermShort TermData-Driven ProtocolsData-Driven Protocols Symptom SurveySymptom Survey

– Did we address Did we address the chief the chief complaints?complaints?

– Did the Did the symptoms that symptoms that respond best to respond best to elimination elimination disappear with disappear with good compliance?good compliance?

Long-TermLong-TermData-Driven ProtocolsData-Driven Protocols SF-36SF-36

– Does the person Does the person have better have better functioning?functioning?

– Can the person Can the person have a life?have a life?

– Is the person Is the person happier?happier?

•39 y.o. male• IBS, GERD, and intestinal parasites•Extreme stomach pains, cramps, intestinal pain, constipation, gas, diarrhea, and nausea for a period of 8 months. •Unable to go to work, suffered constant pain, and was demoted once. His job was in jeopardy. • He scored 68 on the symptom survey.•Consuming 20 medications and supplements per day. •No relief of IBS attacks, gas which he described as so bad that his abdomen was “rock hard” with bloating. He had difficulty sleeping, always feeling fatigued and miserable.

LEAP Case Study- IBS

•The dietitian asked the patient if he had ever experienced remission of symptoms during these 8 months. He replied that he had once felt “ok” for ½ of one day.•According to LEAP protocol, the patient eliminated all supplements and medications except those to ease GERD and treat intestinal parasites. Within 1 week, his symptoms had decreased dramatically, with complete remission of diarrhea and bloating (his symptom score was down from a 68 to an 11) and he was able to go back to work.•Able to identify isolated foods which seemed to still trigger GERD episodes. By the time he reached 2 ½ months his GERD also dissipated.•Able to go off of all medication at that point.Pt was successfully discharged

LEAP Case Study- IBS pg 2

LEAP Case Study- Migraine

•54 y.o. female with migraine headaches, tension headaches, controlled hypertension, fatigue, fibromyalgia, lack of sleep, confusion, lactose intolerance, colitis. Patient worked as a consulting psychologist.•Treatment, to date, included Toprol, Flexeril, Maxalt, Xanax and Ambien, daily, Tylenol or Excedrine PRN. Supplements included Centrum, Calcium, Magnesium Glyconate, Her height was 5’0” and weight was 94#. Blood pressure was 130/80.•Significant effects to lifestyle included inability to hold a thought, difficulty doing work, difficulty enjoying vacations. The patient said that migraine headaches would last several days at a time and occur more than 4 times per month. The patient was very distressed, having difficulty waiting for her referring physician to release the results of the test, becoming agitated. She threated suicide

•The dietitian checked with the referring physician to see if this threat was authentic. The physician said the patient made this statement frequently. Still, the dietitian scheduled this highly agitated patient ASAP.•According to LEAP protocol, the patient suspended all supplements to be tested in later phases. She was started in Phase 1, of her personalized elimination diet. •Within 8 days, her symptoms had decreased dramatically (his symptom score was down from a 59 to 13) and she was migraine-free, with no GI problems, reduced joint stiffness and muscle pain, able to sleep and was no longer taking PRN sleeping medication.

LEAP Case Study- Migraine pg 2

•Husband got on the phone and thanked the dietitian Dietitian made suggestions for menu selection and ordering at her favorite restaurants. •The patient would try to occasionally eat small amounts of reactive foods, but since they caused migraines, the patient quickly returned to her diet. •Pt was successfully discharged from the LEAP program and said that she would like to make this test available to her relatives in Mexico (currently LEAP testing is available in the United States and Europe)

LEAP Case Study- Migraine pg 3

LEAP Case Study- Fibromyalgia

•52 y.o. female with fibromyalgia pain in shoulders, neck knees, hips, ankles, s/p cholecystectomy, s/p appendectomy, c-section, vaginal cyst, vaginal hysterectomy, diverticulitis, asthma and chronic rhinits. Patient smokes cigarettes and uses oxygen at night to treat COPD. •Her treatment, to date, included Q Dall, Clonazipam, Duoneb, Advair and Ibuprophen. Her height was 5’1/2” and weight was 185#. •Significant effects to lifestyle included inability to get out of bed in the morning upon awakening, constant pain and self-recrimination for weight gain. Works in a job as cashier.

•According to LEAP protocol, the patient suspended all supplements to be tested in later phases. She was started in Phase 1, of her personalized elimination diet. •Within 8 days, her symptoms had decreased dramatically (his symptom score was down from a 105 to 36), she had lost 8 #, with reduction in muscle and joint pain, gastrointestinal symptoms, and nasal symptoms.• At the third follow-up, she declared that she was “pain free” with her symptom scores decreasing another 16 points to a score of 36. •At the fourth follow-up, her chest congestion was completely gone and patient was functioning at a much higher level. Her daughter- who gave birth to a premature baby was assisted by a more energetic mom•At the fifth follow-up, patient related that she got a new job as a manager and got double her previous pay.

At the third follow-up, she declared that she was “pain free” with her symptom scores decreasing another 16 points to a score of 36. At the fourth follow-up, her chest congestion was completely gone and patient was functioning at a much higher level. Her daughter- who gave birth to a premature baby was assisted by a more energetic mom.At the fifth follow-up, patient related that she got a new job as a manager and got double her previous pay.

LEAP Case Study- Fibromyalgia- pg 2

Stats on 127 PatientsStats on 127 Patients

In therapy for 1 monthIn therapy for 1 month One baseline survey and two follow-One baseline survey and two follow-

up on schedule, to provide us an up on schedule, to provide us an overall “symptom score”overall “symptom score”

Fit our patient selection criteriaFit our patient selection criteria

(IBS, Fibromyalgia, Migraine)(IBS, Fibromyalgia, Migraine)

RESULTS

10 day 54.89 % Average Symptom Reduction

1 mo. 74.82 % Average Symptom Reduction

Protocol Diet Therapy

-100%

-80%

-60%

-40%

-20%

0% PatientsD

ec

rea

se

s i

n s

ym

pto

m s

urv

ey

s

co

res

10 day change

1 month change