Learning How to Help Patients & Clients with Irritable ... · carb/paleo/Atkins/SCD/GAPS diet. I...

HOW TO HELP PATIENTS & CLIENTS

WITH IRRITABLE BOWEL SYNDROME

© 2012 GoodBelly

Welcome!

• Today you’ll learn:

• Symptoms of the condition

• How it occurs

• Best foods and diets for IBS sufferers

• Latest research on effective and natural

treatments

Ariel Scott

Marketing Manager at GoodBelly

© 2012 GoodBelly

Our Experts

• Jeffrey D. Roberts MSEd, BSc

• Founder of IBS Self Help and Support Group

• www.ibsgroup.org

• Patsy Catsos MS, RD, LD

• Author of IBS-Free at Last, Second Edition

• www.ibsfree.net

• Gunilla Önning Ph.D.

• Senior scientist at Probi AB, an international

probiotics manufacturer

• www.probi.se

© 2012 GoodBelly

http://www.ibsgroup.org/

http://www.ibsfree.net/

http://www.probi.se/

AN INTRODUCTION TO

IRRITABLE BOWEL

SYNDROME (IBS)

Jeffrey D. Roberts MSEd, BSc

Founder of IBS Self Help and Support Group

www.ibsgroup.org

© 2012 Jeffrey D. Roberts

http://www.ibsgroup.org/

IBS Myths

1. IBS is an uncommon condition.

2. IBS pain is not debilitating.

3. IBS is caused by stress.

4. IBS can lead to Inflammatory Bowel Disease (IBD) or

colon cancer.

5. IBS is the same as colitis.

6. Blood in the stool is a symptom of IBS.

7. IBS only causes diarrhea.

8. IBS only causes symptoms in the large intestine.

9. Enemas can be used to treat constipation.

10. There is no way to diagnose IBS.

© Copyright 2012 IBS Self Help and Support Group

Source: IBDCrohns.About.com

© 2012 Jeffrey D. Roberts

What is Irritable Bowel Syndrome?

• IBS

• Symptoms

• Visceral hypersensitivity

• Brain-gut axis

• “Good” bacteria vs. “bad”

bacteria

© Copyright 2012 IBS Self Help and Support Group © 2012 Jeffrey D. Roberts

IBS Demographics (epidemiology)

• 10 to 20% of all adults experience symptoms

like IBS. Only half of them see a doctor for

these symptoms.

• The frequency of IBS is the same worldwide.

• IBS is the 2nd most common cause of work

and school absenteeism; the first is the

common cold.

• Women are at greater risk than men of

developing IBS; it is reported in almost twice

as many women as men.

• Increased stress can make IBS symptoms

worse.

• A gastrointestinal infection can produce or

worsen IBS. This is called post-infectious IBS

(IBS-PI).


IBS Diagnosis

• Careful medical history and thorough physical exam

• Symptom-based Rome Criteria

• Length of symptoms for proper diagnosis

• Diagnostic testing

• “Red Flags”

• Confident diagnosis


Treatment for IBS

• Diarrhea

• Severe pain

• Constipation

• Cognitive behavioral

therapy

• Diet

• Low FODMAP diet


Evolving IBS Treatments

• Probiotics (good bacteria)

• 5-HT3 antagonist ramosetron

• Linaclotide

• Neurokinin-receptor antagonists

• Kappa-opiate agonist (visceral

analgesic)

• Antibiotics

• Newer-generation 5-HT4

agonists


Useful Resources & Sources

Resources:

• www.ibsgroup.org - The largest patient community for Irritable Bowel Syndrome and

digestive health sufferers

• ibs.about.com – A very insightful and fact-based website for patients and healthcare

professionals

• www.ibsfree.net – Premiere resource about the low FODMAP diet

• Controlling IBS the Drug-Free Way: A 10-Step Plan for Symptom Relief by Jeffrey M.

Lackner PhD, STC Healthy Living, 2007 ISBN 1584795751

• Curbside Consultation in IBS: 49 Clinical Questions by Brian E. Lacy MD, PhD, SLACK

Inc., 2011 ISBN 978-1-55642-985-9

• IBS For Dummies by Carolyn Dean, L. Christine Wheeler, John Wiley & Sons, 2005

ISBN 0764598147

Sources:

• 1. About Inflammatory Bowel Disease, ibdcrohns.about.com

• 2. The UNC Center for Functional GI and Motility Disorders, www.med.unc.edu/ibs


FODMAP DIET

FOR IBS

Patsy Catsos MS, RD, LD

Author of IBS-Free at Last, Second Edition

www.ibsfree.net

[email protected]

© 2012 Patsy Catsos

http://www.ibsfree.net/

mailto:[email protected]

Usual Lifestyle Therapy

• Manage stress

• Antidepressants

• Anti-spasmodics (peppermint

oil)

• Regular exercise

• Limit caffeine and alcohol

• Increase fluid intake

• Increase fiber intake

• Food and symptoms diary to

identify triggers


High Fiber Approach

• Sometimes

successful, especially

with constipation

• Increase intake of

whole grains, fruits

and vegetables

• Ispaghula husk or

psyllium fiber

supplements

• Yes, try it first


Not Always the Answer

Eight recent reviews have uniformly concluded

that fiber either has no efficacy for treatment

of IBS or has possible limited benefits for

patients who have IBS with constipation.


New Idea?

• Individual sugars and fibers have long been recognized

as causes of GI distress.

• FODMAPs: new and effective way to look at the big

picture.


FODMAPs

Fermentable Oligo-,

Di- and Mono-saccharides

and Polyols

• Barrett JS, Gibson PR. Clinical ramifications of malabsorption of fructose and other

short-chain carbohydrates. Pract Gastroenterol. 2007;51–65.


Three Common Characteristics

Poorly absorbed

Rapidly Fermentable

Osmotically Active

FODMAP sugars

and fibers


Specific Examples of FODMAPs

• Lactose (milk sugar)

• Fructose (fruit sugar)

• Sorbitol and other

sugar alcohols

• Fructans (complex

carbs found in wheat,

garlic, onions)

• Galactans/GOS

(complex carbs found

in beans)


Effects are Additive

Illustration from IBS—Free at Last! Second Edition (2012, Pond Cove Press) used with permission.


What Does the Patient Say?

“My symptoms occur mostly

in my gastrointestinal tract,

especially excess gas,

bloating, abdominal pain,

flatulence, diarrhea, or

constipation.”

“I might be lactose

intolerant, but I can’t

quite figure it out.”

“Bread makes me

feel bloated.”


More Patient Complaints:

I felt better when I tried a low-carb/paleo/Atkins/SCD/GAPS

diet.

I eat lots and lots of

fiber but my IBS

doesn’t get any better,

in fact it might be

getting worse.

The healthier I eat, the

sicker I get, so I just

stay away from fruit,

vegetables and milk

products.


Diet History

• Soda, milk, fruit juice, sports

beverages?

• Sugar-free gum or candy?

• Legumes and soy?

• Large portions?

• High-fiber bars or cereals?


FODMAP Approach • Eliminate all FODMAPs from the

diet for a trial period of 2-3 weeks.

• Restore FODMAPs to diet one

class at a time (challenge phase)

using a disciplined process.

• Observe symptoms to discover

worst offenders.

• Plan final diet to include

FODMAPs at tolerable level.

• Most liberal diet possible is

desired.


Typical Day During Elimination Phase Breakfast

• 1 cup Cheerios

• 1 cup lactose-free skim milk

• 2 tablespoons chopped walnuts

Morning Snack

• ½ ripe banana

• 1 hard boiled egg

Lunch

• 2 slices millet-potato bread

• 3 ounces turkey

• Lettuce and tomato

• 2 tablespoons light mayonnaise

• ½ cup blueberries

• ½ cup baby carrots

Afternoon Snack

• ½ cup lactose-free cottage cheese

• 8 cherry tomatoes

Dinner

• 4 ounces baked salmon

• Medium baked potato

• 1- ½ tablespoons sour cream

• 2 cups raw spinach

• 2 Tb. grated Parmesan cheese

• 1 teaspoon olive oil

• 1 tablespoon balsamic vinegar

Beverages

• Water, tea, 1 cup coffee/day


What Does a Challenge Look Like? Example: fructans challenge

• Day One: one serving from

the challenge group (i.e. one

piece of whole wheat toast).

• Day Two: eat liberally from

the challenge group, as you

have done in the past (i.e.

bagel + sandwich + fiber bar

+ spaghetti / onions / garlic /

broccoli). Observe

symptoms.


General Coping Strategies

• Limit FODMAP load in a

single meal or in single day

– balance portions and

timing.

• Selecting alternative, low

FODMAP foods.

• Employ tips and techniques

unique to each class of

FODMAPs.


Goals of Nutrition Therapy

• Most liberal, nutritious

diet possible.

• Reduce or eliminate

symptoms.


When to Refer

Many patients will benefit from assistance and ongoing

support from a registered dietitian:

Co-morbidities

Medications

Over- or under-weight

Poor nutritional status

Poor planning skills

Food- and nutrition-related knowledge deficit

Many questions


Suggested Reading • Gibson PR, Shepherd SJ. Evidence-Based Dietary Management of

Functional Gastrointestinal Symptoms: The FODMAP Approach. J Gastroenterol Hepatol. 2010;25(2):252-258.

• Heizer WD, Southern S, McGovern S. The Role of Diet in Symptoms of Irritable Bowel Syndrome in Adults: A Narrative Review. J Am Diet Assoc. 2009; 109:1204-1214

• Eswaran S, Tack J, Chey W. Food: The Forgotten Factor in the Irritable Bowel Syndrome. Gastroenterol Clin N Am 40 (2011) 141–162

• Eastern Health Clinical School, Monash University, Box Hill. The Low FODMAP Diet. www.med.monash.edu.au/ehcs

• Catsos, P. IBS—Free at Last! Second Edition 2012, Pond Cove Press (available on Amazon.com)

• Scarlata, K. The Complete Idiot’s Guide to Eating Well for IBS, Alpha, 2010


IBS AND PROBIOTICS

Gunilla Önning

Ph.D.

Senior Scientist at Probi AB

© 2012 Gunilla Önning

Probiotics: Definition

“Live microorganisms which when administered in

adequate amounts confer a health benefit on the host”

Lactobacillus Escherichia

Bifidobacterium Saccharomyces

Bacillus Streptococcus

Enterococcus

FAO/WHO (2001) Expert Consultation

http://www.fao.org/es/ESN/Probio/probio.htm

32 © 2012 Gunilla Önning

http://www.fao.org/es/ESN/Probio/probio.htm

Probiotics: Introduction • Used to be present in food

naturally

• Improves balance between good

and bad bacteria

• Improves the intestinal barrier

• Affects the immune response

Elie

Metjnikov

(1845-1916) Nobel price in

medicine - 1908

The Homo genus appears

Lactic acid fermentation

is invented

Fire is tamed

Agricultural

revolution

Industrial revolution

Antibiotics/Refrigeration

3 mill. years BC

1,5 mill. years BC

0,8 mill. years BC

10 000 years BC

Year

0

1850

1950

R&D in Probiotics takes off 1980


Probi AB Probi AB is situated in Lund,

Sweden (University since 1666)

2012-05-16 © 2012 Gunilla Önning

Lactobacillus plantarum 299v (Lp299v)


Unique Selection Process of Lp299v

• First selection process

• Human mucosal origin

• Genetic characterization and identification

• Transient colonization – re-isolation

• Safety

• Robustness in industrial processes

• Second selection process

• Efficacy in in vitro studies

• Effect in experimental animal models

• Efficacy in clinical studies


2012-05-16 37

References: Adlerberth et al., Appl. Environ Microbiol 1996;62;

2244-2251

Lactobacillus plantarum 299v bindcells

L. plantarum 299v

Protein on the bacterial surface

Mannose-containing receptor

on the intestinal epithelial cells

Signalling

Unlike most other lactobacilli and bifidobacteria!

Intestinal binding mechanisms to mucosa (mannose-specific binding)


Inhibition of enteropathogenic E.coli

adherence Increased production of mucins

38 2012-05-16

Binding of pathogenic E.coli

(EHEC and EPEC) to HT-29 cells

was inhibited.

Production of mucins (MUC2 and

MUC3) was stimulated.

Less lactobacilli and bifidobacteria

in IBS patient’s feces and

increased anaerobic bacteria,

E.coli and bacteroides.


Lp299v and Irritable Bowel

Syndrome (IBS)


Effect of Lp299v in Patients with

Irritable Bowel Syndrome - Nobaek et al. 2000

Study Design

• 60 patients fulfilling Rome criteria and no

organic colonic disease

• 2 weeks w/o + 4 weeks administration

• Follow up at 12 months

Randomization

• 400 ml/day fruit drink + Lp299v 5x107

cfu/ml

• 400 ml/day fruit drink without Lp299v


0

1

2

3

4

5

6

7

Start After 4 Weeks 12 months

VA

S L.plantarum

Placebo

Ref: Nobaek et al., 2000 Am J Gastroenterol 95: 1231-1238

Flatulence

** ***

*


2012-05-16 42

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5


VA

S L.plantarum

Placebo


Abdominal Pain

*

**

* **


43

0

1

2

3

4

5

6


VA

S

L.plantarum

Placebo group


Overall GI Function

* **


Effect of Lp299v in Patients with

Irritable Bowel Syndrome - Niedzielin et al. 2001

2012-05-16

Study Design

– 40 patients fulfilling the Manning criteria

Randomization

– 400 ml/day fruit drink + Lp299v (5x107per ml)

during 4 weeks

– 400 ml/day fruit drink without Lp299v during 4

weeks


100%

60%

95%

55%

18% 15%

Niedzielin et al, Eur J Gastroenterol Hepatol 2001;13:1-5

55%

18% 15%

100%

60%

95%

0%

20%

40%

60%

80%

100%

120%

Abdominal Pain Stool Frequency IBS Symptoms

% o

f p

ati

en

ts w

ith

im

pro

ve

me

nt

Placebo

L.plantarum

After 4 weeks of therapy:


Effect of Lp299v in Patients with Irritable Bowel

Syndrome – Maladkar et al., unpublished

2012-05-16

Study design

– 204 patients fulfilling the Rome criteria

Randomization

– Freeze-dried Lp299v (capsules) with 1x1010 cfu

per day during 4 weeks

– Placebo capsule without Lp299v during 4 weeks


47

Significant Decrease of the Frequency of IBS Symptoms: Results at 4 Weeks


48

Significant Decrease of the Intensity of IBS Symptoms


-35 -30 -25 -20 -15 -10 -5 0

Overall IBS symptoms

Abdominal pain

Flatulence

Bloating

Summary Lp299v and IBS (meta-analysis) Reduction compared to control group (%)


1. Are the strains properly identified (e.g. Lactobacillus plantarum 299v)?

Even in the family of L. plantarum strains, the genetical differences and effects are significantly different

2. Is the dose (cfu = nbr of bacteria) specified, for end of shelf life, and is the same dose used in scientific documentation?

3. If the product contains multiple strains, are scientific references made for the actual blend?

Clinicals on one or two specific ingoing strains is not enough to conclude on the effect of a total blend of strains.

Important For Consumers When Choosing a Probiotic Product


THANK YOU!

*Some studies suggest that GoodBelly's probiotics may help balance bacteria in your gut when consumed daily as

part of a nutritious diet and healthy lifestyle. GoodBelly is a food product and not a treatment or cure for any

medical disorder or disease. If you have any concerns about your digestive system, please consult your healthcare

professional.

**The views and opinions express by the speakers in this presentation are theirs alone, and do not reflect the

opinions of GoodBelly. All information offered in this presentation represent their own opinions.

© 2012 GoodBelly

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