Food Choices and Alternative Techniques in Management...

Maria Vazquez Roque, MD, MSc

Food Choices and Alternative Techniques in Management of IBS: Fad Versus Evidence

©2010 MFMER | slide-1

Assistant Professor

Gastroenterology and Hepatology

Objectives

• Gluten-free diet and non-celiac gluten sensitivity (NCGS)

• Low fermentable oligo- and disaccharides, monosaccharides and polyols(FODMAPs) diet

• Psychological therapies• Hypnotherapy• Hypnotherapy• Cognitive behavioral therapy• Acupuncture


Maria I. Vazquez-Roque, MD

ACG/FGS Spring Symposium - Naples, FL Copyright 2015 American College of Gastroenterology

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Food allergy, intolerances and sensitivity

• Food allergies are rare in adults• IgE mediated food-hypersensitivity

• Peanut, seafood

• Food intolerances• Lack of enzyme to digest a particular nutrient• Symptoms secondary to fermentation of sugars by

the colon bacteria• Lactose intolerance, fructose intolerance

F d iti iti• Food sensitivities• Immune-mediated reactions to nutrient-derived

antigens that cause GI and extra-GI symptoms• Gluten in NCGS or wheat sensitivity


Fasano A, et. Al. Gastro, in press, 2015

What is the connection between these ?



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Change in symptom severity from baseline in the gluten and placebo-treated groups over 6 weeks: "Non-celiac gluten intolerance" may exist, but no clues to the mechanism were elucidated

•N=34 IBS patients with prior history of beingprior history of being symptomatically controlled with a GFD

•There were no significant changes in fecal lactoferrin, levels of celiac antibodies, highly sensitive C-reactive protein, or

Biesiekierski JR, et al. Am J Gastroenterology 2011

intestinal permeability.

•There were no differences in any end point in individuals with or without DQ2 or DQ8.

IBS-D: Gluten free diet and bowel frequency

• Randomized clinical trial, N= 45 patients

• Non-CD, IBS-D patients, GCD vs. GFD x 30 days


Vazquez-Roque M, et al. Gastroenterology 2013



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Spectrum of gluten related disorders

Gluten related disorders

Pathogenesis

Autoimmune AllergicNot allergic, not

autoimmune (innate immunity?)

Celiac disease (CD) Gluten ataxia Dermatitis

herpetiformisWheat allergy

(WA) Gluten sensitivity


Adapted from Sapone A, et al. BMC Medicine 2012;10:13

Spectrum CD

IBS

Lactose intolerance

Potential CD

Latent CD

IBS-like symptoms

Food intolerance

SIBO

CD and complications

Adapted from Verdu et al., 2009. Sapone A, et al. BMC Medicine 2012;10:13

Gluten sensitivity (GS) / Non-celiac GS / non-celiac wheat sensitivity

• Negative wheat IgE• Negative CD serology• Normal duodenal histology / ↑

Intraepithelial lymphocytes (IEL)

↑ Secreted Ab against gliadin(AGA in ~ 50%)Symptoms overlap with CD or WAResolution of symptoms on GFD



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Gastrointestinal and extraintestinal symptoms in patients with gluten sensitivity


Volta, U. and De Giorgio, R. Nat. Rev. Gastroenterol Hepatol 2012;9:295-299.

Summary of gluten related disorders

Celiac disease Glutensensitivity

Wheat allergy

Onset of symptoms Days to weeks Hours to days Minutes to hoursOnset of symptoms Days to weeks Hours to days Minutes to hours

Pathogenesis Autoimmunity Innate Immunity? Allergic Immune

HLA HLA DQ2/8 restricted

Not HLA DQ2/8 restricted

Not HLA DQ2/8 restricted

Auto-antibodies Almost always Always absent Always absent

Enteropathy Almost always Always absent Always absent

Symptoms Intestinal and extra-intestinal

Intestinal and extra-intestinal

Intestinal and extra-intestinal

Complications Co-morbiditiesLong term complications

Co-morbiditiesLong term complications?

No-comorbiditiesAnaphylaxis


Adapted from Fasano A, et. Al. Gastro, in press, 2015.



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Clinical implications

• Gluten free foods sales to top $2.6 billion dollarsb 2012 d t lby 2012, and to nearly double to $5.5-billion by 2015, forecast to grow by a further 61% by 2017!

• No adequate diagnostic marker to identify gluten sensitive subjects

• Natural history of gluten sensitivity is not known• Eventually develop celiac disease?• Underlying immune mechanism seems to be distinct

from celiac disease (innate vs. adaptive?)• Controversy of its existence


Objectives

• Gluten-free diet

L FODMAP di t• Low FODMAP diet• Psychological therapies

• Hypnotherapy• Cognitive behavioral therapy• Acupuncture




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Maldigestednutrients: A case for short-chain fatty acids (SCFA)• Dietary starch is aDietary starch is a

substrate for colonic bacteria to produce SCFA

• SCFA stimulate colonic motility and


Staudacher, H. M. et al. Nat. Rev. Gastroenterol. Hepatol. advance online publication 21 January 2014

ytransit

Solution: Low FODMAP diet ?

• FODMAP: Fermentable oligosaccharides, disaccharides, monosaccharides and polyolsmonosaccharides and polyols

• Poorly absorbed in the small intestine

• Lead to production of SCFA in the colon by bacteria

• Diets low in FODMAPs have• Diets low in FODMAPs have been promising in reducing symptoms in a subset of IBS-D patients but the exact mechanism has not been elucidated



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A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome

Halmos EP, et al. Gastroenterology 2014;67-75




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Objectives

• Gluten-free diet

FODMAP di t• FODMAP diet

• Psychological therapies• Hypnotherapy• Cognitive behavioral therapy• Acupuncture




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Psychological therapies for IBS

• ~ 50% of patients with severe IBS have dissatisfaction with standard medical therapy

Psychological stress increases the symptoms of• Psychological stress increases the symptoms of IBS

• Psychological methods to treat IBS• Biofeedback• Cognitive therapy• Psychodynamic therapyPsychodynamic therapy• Hypnosis treatment


Hypnotherapy

• Induce and make use of a special mental state, mind is focused and receptive

V b l ti d i h i l d• Verbal suggestions and imagery on physical and mental functioning.

• Unclear how it specifically works to improve IBS symptoms

• Proposed effects on GI function• Slow down propulsive contractions• Effect on gastric acid secretion• Reduce or eliminate nausea and vomiting• Improve long-term management of functional dyspepsia




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Hypnosis treatment

• 4-12 sessions, weekly or every other week

• 30-40 minutes each session

• Induction of hypnosis followed by deep relaxation

• Improvement may last up to 2 years

• Improvement:• Abdominal pain• Abdominal pain• Diarrhea/constipation• Bloating


www.ibshypnosis.com




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Cognitive behavioral therapy (CBT)

• Goal is to have patients change their habitual thoughts, feelings and behaviors that may

if t d ti dmagnify stress responses and negative moods

• Achieved by applying a series of self-exploration exercises and stress reducing strategies.

• Recent meta-analysis evaluating 9 trials using CBT for IBS have showed it as an effective therapy for IBS.

• Reducing abdominal pain, diarrhea and constipation


Ford et al. Am J of Gastro Sept. 2014

CBT for IBS

• Cognitive approaches• Identifying and challenging irrational thoughts• VisualizationVisualization• Calming Self Talk• Imaginal Exposure (using the imagination to face a fear)• Thought-stopping

• Behavioral therapies• Deep Breathing Exercises• Progressive Muscle Relaxation• Assertiveness Training• Desensitization (gradual exposure to something that is

feared)




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Acupuncture

• Ancient Chinese medicine

• Channels of energy (Qi) called idi th h t b dimeridians, throughout our bodies

• In disease, energy flow in these meridians is disrupted



World J Gastroenterol 2014 February 21;20(7):1871-1877



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Summary

• Gluten exclusion and/or a low FODMAP diet can help improve IBS symptoms in a subset ofcan help improve IBS symptoms in a subset of patients.

• Psychological therapies such as hypnosis, CBT and acupuncture are reasonable treatment alternatives for a subset of patients with IBS that do not respond to conventional medical therapy.


Thank you!




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No effects of gluten in patients with self-reported non-celiac glutensensitivity after dietary reduction of fermentable, poorly absorbed,short-chain carbohydrates

Double-blind crossover trial of 37 subjects (aged 24-61 y, 6 men) with NCGS and irritable bowel syndrome y(based on Rome III criteria), but not celiac disease

©2010 MFMER | slide-29Biesiekierski JR, et al. Gastroenterology 2013;145:320–328.



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