Irritable Bowel Syndrome

Irritable bowel syndrome is a complex disorder whose pathophysiology involves alterations in the enteric microbiota, visceral hypersensitivity, gut immune/barrier function, hypothalamic‐pituitary‐adrenal axis regulation, neurotransmitters, stress response, psychological factors, and more. The importance of diet in the management of irritable bowel syndrome has taken center stage in recent times as the literature validates the relationship of certain foods with the provocation of symptoms. Likewise, a number of elimination dietary programs have been successful in alleviating irritable bowel syndrome symptoms. Knowledge of the dietary management strategies for irritable bowel syndrome will help guide nutritionists and healthcare practitioners to deliver optimal outcomes. This tutorial reviews the nutrition management strategies for irritable bowel syndrome.     

Effects of a high-fiber diet on symptoms of irritable bowel syndrome: a randomized clinical trial

OBJECTIVE: We investigated the effects of dietary fiber on symptoms of irritable bowel syndrome. METHODS: A single-blind randomized clinical trial was designed. Fifty-six subjects with irritable bowel syndrome were prospectively and randomly assigned to one of two groups: group 1 received a diet containing 10.4 g/d of fiber and group 2 received a diet containing 30.5 g/d of fiber. Patients' body weights, nutritional intakes as assessed with 3-d written food records, and symptom scores were assessed at baseline and at 3 mo. RESULTS: There were no dropouts during the study. Total energy intake and the distribution of macronutrients were not significantly different between groups. Total dietary fiber intake did not reach recommended levels in either group but was higher in group 2 than in group 1 (25.95 +/- 2.12 g/d versus 6.06 +/- 2.7 g/d, P < 0.05). Initial fiber intake did not differ significantly between groups. Pain scores, bowel scores, and general scores improved in both groups (from baseline to 3 mo), and no significant differences were detected between groups. CONCLUSIONS: A modest fiber intake in patients with irritable bowel syndrome relieved symptoms, but this therapeutic benefit of fiber may have been due to a placebo effect because the results were similar in the low-fiber group.     

某校大学生饮食习惯对肠易激综合征的影响

目的 了解饮食对肠易激综合征的影响。方法 对2018年10月—2019年4月来校医院就诊的1 207名在校本科生进行问卷调查,问卷依据罗马Ⅳ诊断标准,数据分析采用SPSS 22.0卡方检验、单因素分析、Logistic多因素回归分析。结果 来校医院就诊的在校大学生中,肠易激综合征的患病率为5.1%(60/1207)。在单因素分析中,进食生冷(P=0.070)、高纤维(P=0.367)、乳制品(P=0.414)、果蔬(P=0.784)与肠易激综合征的患病差异无统计学意义。进食辛辣(P=0.002)、高脂饮食(P<0.001)与肠易激综合征的患病差异有统计学意义。进一步Logistic多因素回归分析显示,高频率进食高脂食物比低频率(≤1次/周)进食高脂食物更容易引起肠易激综合征。P值为0.003,OR:1.545。结论 本调查样本中,肠易激综合征的患病率为5.1%。肠易激综合征的患病与进食辛辣、高脂饮食有关。高频率的进食高脂食物是肠易激综合征患病的危险因素。基层医生应着重做好相关病人的饮食指导,尽量减少肠易激综合征被诱发。     

Dietary fiber in pancreatic disease: effect of high fiber diet on fat malabsorption in pancreatic insufficiency and in vitro study of the interaction of dietary fiber with pancreatic enzymes

The effect of high fiber diet on fat malabsorption was evaluated in twelve patients with exocrine pancreatic insufficiency secondary to chronic alcoholic pancreatitis. Additionally, the effect of dietary fiber on pancreatic enzymes was examined in vitro, employing different concentrations of cellulose, pectin, and wheat bran incubated with amylase, lipase, and trypsin. Ingestion of a high fiber diet was associated with a small but significant (p less than 0.01) increase in fecal weight and fecal fat excretion. All patients complained of increased abdominal flatulence with high fiber diet, however, no significant increase in frequency of bowel movements was noted. In vitro studies demonstrated reduction in pancreatic enzyme activity by increasing concentration of dietary fiber and its components. These data suggest that steatorrhea may be enhanced with the ingestion of high fiber diet in patients with exocrine pancreatic insufficiency on oral pancreatic enzyme therapy. Increase in fecal fat excretion may, in part, be related to reduction in the activity of pancreatic enzymes by the dietary fiber.     

Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management

Dietary fructose induces abdominal symptoms in patients with fructose malabsorption, but there are no published guidelines on its dietary management. The objective was to retrospectively evaluate a potentially successful diet therapy in patients with irritable bowel syndrome and fructose malabsorption. Tables detailing the content of fructose and fructans in foods were constructed. A dietary strategy comprising avoidance of foods containing substantial free fructose and short-chain fructans, limitation of the total dietary fructose load, encouragement of foods in which glucose was balanced with fructose, and co-ingestion of free glucose to balance excess free fructose was devised. Sixty-two consecutively referred patients with irritable bowel syndrome and fructose malabsorption on breath hydrogen testing underwent dietary instruction. Dietary adherence and effect on abdominal symptoms were evaluated via telephone interview 2 to 40 months (median 14 months) later. Response to the diet was defined as improvement of all symptoms by at least 5 points on a -10- to 10-point scale. Forty-eight patients (77%) adhered to the diet always or frequently. Forty-six (74%) of all patients responded positively in all abdominal symptoms. Positive response overall was significantly better in those adherent than nonadherent (85% vs 36%; P<0.01), as was improvement in individual symptoms (P<0.01 for all symptoms). This comprehensive fructose malabsorption dietary therapy achieves a high level of sustained adherence and good symptomatic response.     

Partially hydrolyzed guar gum: clinical nutrition uses

OBJECTIVE: This paper provides a review of research on partially hydrolyzed guar gum that is relevant to clinical nutrition practice. METHODS: All relevant papers published on partially hydrolyzed guar gum were reviewed and the results summarized. RESULTS: Partially hydrolyzed guar gum (PHGG) is a water-soluble dietary fiber with a wide range of uses in clinical nutrition. Its low viscosity allows its use in enteral products and beverages. PHGG can be added to enteral formulas and food products as a dietary fiber source. PHGG provides the benefits associated with dietary fiber ingestion. Addition of PHGG to the diet reduced laxative dependence in a nursing home population. PHGG also reduced the incidence of diarrhea in septic patients receiving total enteral nutrition and reduced symptoms of irritable bowel syndrome. PHGG also increased production of Bifidobacterium in the gut. CONCLUSION: The ease of use of PHGG and its clinical effectiveness make it a good choice in clinical nutrition practice.     

井下煤矿工人肠易激综合征患病现状分析

目的探讨煤矿井下工人肠易激综合征的患病现状及患病的危险因素,为煤矿工人胃肠疾病的研究提供流行病学资料。方法采用单纯随机抽样问卷方法进行肠易激综合征相关症状调查,根据结果决定是否进行结肠镜检查。结果肥城矿区井下作业煤矿工人肠易激综合征患病率为22.69%,矿区附近一般人群患病率为15.04%。两组患病率比较,差异有显著性(P<0.05)。结论井下作业煤矿工人肠易激综合征患病率高于一般人群。井下作业环境、心理障碍及不良生活习惯是患病的危险因素。     

The Role of Diet in Symptoms of Irritable Bowel Syndrome in Adults: A Narrative Review

This review summarizes what is known about the effect of diet on irritable bowel syndrome (IBS) symptoms emphasizing data from randomized, controlled clinical trials. Studies suggest that IBS symptoms in one quarter of patients may be caused or exacerbated by one or more dietary components. Recent studies indicate that a diet restricted in fermentable, poorly absorbed carbohydrates, including fructose, fructans (present in wheat and onions), sorbitol, and other sugar alcohols is beneficial, but confirmatory studies are needed. Despite a long history of enthusiastic use, fiber is marginally beneficial. Insoluble fiber may worsen symptoms. Some patients with IBS, especially those with constipation, will improve with increased intake of soluble fiber. Prebiotic fibers have not been adequately tested. Daily use of peppermint oil is effective in relieving IBS symptoms. The usefulness of probiotics in the form of foods such as live-culture yogurt and buttermilk for IBS symptoms is not established. In clinical practice, it is very difficult to establish that a patient's symptoms result from an adverse reaction to food. A double blind placebo-controlled food challenge is the most reliable method, but it is not suitable for routine clinical use. A modified exclusion diet and stepwise reintroduction of foods or trials of eliminating classes of food may be useful.     

Effects of dietary arabinogalactan on gastrointestinal and blood parameters in healthy human subjects

OBJECTIVES: Arabinogalactan (AG) is a non-digestible soluble dietary fiber that resists hydrolytic enzyme action and enters the large bowel intact where it is fermented by resident microflora. To determine whether AG has similar physiological properties to other soluble dietary fibers, we examined the effect of 15 and 30 g per day of a commercially available AG from Western Larch on several gastrointestinal and blood parameters. METHODS: Gastrointestinal parameters included fecal microflora, fecal enzyme activity, fecal short-chain fatty acids, fecal pH, fecal weight, transit time and bowel frequency. Blood parameters included total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, Apo-A1, Apo-B, glucose and insulin. The study consisted of two three-week diet treatments with no washout period. Participants (n=20, 11 males, 9 females) consumed their usual diet in addition to 15 or 30 g AG in a beverage sweetened with aspartame as compared to their usual diet with the control beverage. RESULTS: Significant increases in total fecal anaerobes were observed with 15 g (p=0.01) and 30 g AG (p=0.001). A significant increase (p=0.02) in Lactobacillus spp. was observed when subjects consumed AG for a total of six weeks regardless of dose. There were no significant changes in other microflora, fecal enzyme activity, transit time, frequency, fecal weight, fecal pH and short-chain fatty acids. Fecal ammonia levels decreased with 15 g (p=0.001) and 30 g (p=0.002) AG. No significant changes in blood lipids or blood insulin were observed. CONCLUSIONS: These data suggest that dietary AG is easily incorporated into the diet, well tolerated in subjects and has some positive effects on fecal chemistry.     

Carbohydrate Maldigestion and Intolerance

This review summarizes dietary carbohydrate intolerance conditions and recent advances on the possible role of carbohydrate maldigestion and dietary outcomes in patients with functional bowel disease. When malabsorbed carbohydrates reach the colon, they are fermented by colonic bacteria, with the production of short-chain fatty acids and gas lowering colonic pH. The appearance of diarrhoea or symptoms of flatulence depends in part on the balance between the production and elimination of these fermentation products. Different studies have shown that there are no differences in the frequency of sugar malabsorption between patients with irritable bowel disease (IBS) and healthy controls; however, the severity of symptoms after a sugar challenge is higher in patients than in controls. A diet low in ‘Fermentable, Oligo-Di- and Monosaccharides and Polyols’ (FODMAPs) is an effective treatment for global symptoms and abdominal pain in IBS, but its implementation should be supervised by a trained dietitian. A ‘bottom-up’ approach to the low-FODMAP diet has been suggested to avoid an alteration of gut microbiota and nutritional status. Two approaches have been suggested in this regard: starting with only certain subgroups of the low-FODMAP diet based on dietary history or with a gluten-free diet.     

How much does partially hydrolyzed guar gum affect the weight, moisture and hardness of feces?

OBJECTIVE: The ministry of Health, Labor and Welfare recommends Japanese people to intake a certain amount of dietary fiber, believing that incorporating more dietary fiber into our diet can reduce the risk of colorectal cancer. The present study aimed to demonstrate and confirm the theory's validity by applying it to reality-to what extent is the intake of partially hydrolyzed guar gum (PHGG) useful in promoting bowel movements, and what problems are involved? We therefore investigated to what extent PHGG affects the weight, moisture and hardness of feces when healthy female students consumed PHGG as a supplement. METHOD: During two fourteen-day sessions in spring and autumn, 9 healthy female students took the same diets. During the first session, the students were provided a strict dietary formula, while during the second session, they were administered an amount of 12.5 g/day PHGG (purity 80%, equivalent to 10 g of dietary fiber) dissolved in adequate amount of water at the end of each meal. Feces of the subjects were collected and weighted just after defection. A moisture meter was used to measure fecal moisture and a rheometer was used to measure fecal hardness. Fecal conditions and intestinal motility were also examined. RESULTS: (1) Due to the PHGG intake, the fecal bulk increased in 4 subjects and decreased in 2 subjects, significantly, out of 9. (2) Due to the PHGG intake, the fecal condition softened in 3 subjects while significantly hardening in 4 subjects. (3) The PHGG intake induced an increased of fecal moisture in 5 subjects, while moisture decreased in 2 subjects. (4) Fecal hardness measured more than 150 g/cm when it is classified as "frozen hard". (5) A significant inverse correlation could be seen between fecal hardness and fecal bulk, and between fecal hardness and its moisture. When PHGG was administered a significant inverse correlation could be seen between fecal hardness and its moisture. CONCLUSION: The conclusion is that the PHGG intake resulted in increase of the fecal bulk for 4 subjects and fecal moisture for 5 out of 9 subjects, but decrease of fecal hardness in 3 subjects; the benefit of bowel movements provided by the PHGG intake, however, varied greatly among the subjects.     

Effects of Dietary Arabinogalactan on Gastrointestinal and Blood Parameters in Healthy Human Subjects

Objectives: Arabinogalactan (AG) is a non-digestible soluble dietary fiber that resists hydrolytic enzyme action and enters the large bowel intact where it is fermented by resident microflora. To determine whether AG has similar physiological properties to other soluble dietary fibers, we examined the effect of 15 and 30 g per day of a commercially available AG from Western Larch on several gastrointestinal and blood parameters.

Methods: Gastrointestinal parameters included fecal microflora, fecal enzyme activity, fecal short-chain fatty acids, fecal pH, fecal weight, transit time and bowel frequency. Blood parameters included total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, Apo-A1, Apo-B, glucose and insulin. The study consisted of two three-week diet treatments with no washout period. Participants (n=20, 11 males, 9 females) consumed their usual diet in addition to 15 or 30 g AG in a beverage sweetened with aspartame as compared to their usual diet with the control beverage.

Results: Significant increases in total fecal anaerobes were observed with 15 g (p=0.01) and 30 g AG (p=0.001). A significant increase (p=0.02) in Lactobacillus spp. was observed when subjects consumed AG for a total of six weeks regardless of dose. There were no significant changes in other microflora, fecal enzyme activity, transit time, frequency, fecal weight, fecal pH and short-chain fatty acids. Fecal ammonia levels decreased with 15 g (p=0.001) and 30 g (p=0.002) AG. No significant changes in blood lipids or blood insulin were observed.

Conclusions: These data suggest that dietary AG is easily incorporated into the diet, well tolerated in subjects and has some positive effects on fecal chemistry.     

Food intolerance and the Irritable Bowel Syndrome

Thirty-eight patients with particularly troublesome irritable bowel syndrome (IBS) were selected for trial on a 2-week exclusion diet. Eighteen patients improved dramatically and, with two exceptions, subsequently identified foods to which they were intolerant. Follow-up by postal questionnaire showed that at least 10 were still following their dietary restrictions 3–45 months later.
Twelve of the 16 food intolerant patients were intolerant to more than one food. Fifteen patients found their symptoms did not improve on the exclusion diet. Five patients refused to try or were unable to complete the exclusion diet. The use of an appropriate exclusion diet for selected patients with IBS is recommended.     

Lactose Intolerance and Irritable Bowel Syndrome

A recent study on lactose intolerance and irritable bowel syndrome has shown that subjective lactose intolerance is increased in patients with irritable bowel syndrome, despite no increase in the prevalence of lactose maldigestion.     

Methane production and bowel function parameters in healthy subjects on low- and high-fiber diets.

Colon cancer patients are more likely than healthy subjects to excrete breath methane, and methane production has been suggested as a screening method to predict risk of developing colon cancer. To assess whether methane production is related to fiber ingestion and bowel function, we measured end-alveolar breath methane in 126 healthy subjects; 36% produced methane (greater than 3 ppm). Fifteen methane producers and nine controls were selected to participate in a 17-day study: a self-selected diet for 7 days, followed by the same diet plus 24 g/day dietary fiber (Fiber One Cereal) for 10 days. Methane was measured three times per day on three days during each diet. Two subjects screened as methane producers stopped excreting methane during the study, and one control started to excrete methane. Radiopaque pellets were given at the start and end of each diet, and feces were collected, homogenized, and dried. Mean transit time (p less than 0.0001) and fecal pH (p less than 0.0003) were significantly decreased with fiber, whereas fecal hydration scale (p less than 0.003), fecal dry (p less than 0.0001) and wet (p less than 0.0001) weight, and frequency of defecation (p less than 0.0006) were significantly increased with fiber. No significant change in methane excretion (p less than 0.057) was seen with added fiber. Thus, in this study methane excretor status was not constant in healthy subjects and was not significantly changed by 24 g/day dietary fiber as Fiber One Cereal.     

Diet Quality and Dietary Inflammatory Index in Dutch Inflammatory Bowel Disease and Irritable Bowel Syndrome Patients

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) share common culprit foods and potential pathophysiological factors. However, how diet may contribute to disease course and whether this differs between both entities is unclear. We therefore investigated the association of dietary indices with intestinal inflammation and gastrointestinal symptoms in both IBD and IBS patients. Food frequency questionnaires from 238 IBD, 261 IBS and 195 healthy controls (HC) were available to calculate the overall diet quality by the Dutch Healthy Diet-Index 2015 (DHD-2015) and its inflammatory potential by the Adapted Dietary Inflammatory Index (ADII). Intestinal inflammation and symptoms were evaluated by faecal calprotectin and the Gastrointestinal Symptom Rating Scale, respectively. The DHD-2015 was lower in IBD and IBS versus HC (p < 0.001), being associated with calprotectin levels in IBD (b = −4.009, p = 0.006), and with abdominal pain (b = −0.012, p = 0.023) and reflux syndrome (b = −0.016, p = 0.004) in IBS. ADII scores were comparable between groups and were only associated with abdominal pain in IBD (b = 0.194, p = 0.004). In this side-by-side comparison, we found a lower diet quality that was differentially associated with disease characteristics in IBD versus IBS patients. Longitudinal studies are needed to further investigate the role of dietary factors in the development of flares and predominant symptoms.     

Lactose Intolerance in Adults: Biological Mechanism and Dietary Management

Lactose intolerance related to primary or secondary lactase deficiency is characterized by abdominal pain and distension, borborygmi, flatus, and diarrhea induced by lactose in dairy products. The biological mechanism and lactose malabsorption is established and several investigations are available, including genetic, endoscopic and physiological tests. Lactose intolerance depends not only on the expression of lactase but also on the dose of lactose, intestinal flora, gastrointestinal motility, small intestinal bacterial overgrowth and sensitivity of the gastrointestinal tract to the generation of gas and other fermentation products of lactose digestion. Treatment of lactose intolerance can include lactose-reduced diet and enzyme replacement. This is effective if symptoms are only related to dairy products; however, lactose intolerance can be part of a wider intolerance to variably absorbed, fermentable oligo-, di-, monosaccharides and polyols (FODMAPs). This is present in at least half of patients with irritable bowel syndrome (IBS) and this group requires not only restriction of lactose intake but also a low FODMAP diet to improve gastrointestinal complaints. The long-term effects of a dairy-free, low FODMAPs diet on nutritional health and the fecal microbiome are not well defined. This review summarizes recent advances in our understanding of the genetic basis, biological mechanism, diagnosis and dietary management of lactose intolerance.     

Bowel function of long-term tube-fed patients consuming formulae with and without dietary fiber

Diarrhea, constipation and subsequent laxative use are chronic problems in long-term enterally fed patients. We have conducted a double-blind randomized crossover study to evaluate the effects of two enteral formulae (Enrich, 12.8 g of dietary fiber per 1000 kcal and Ensure, fiber-free) on stool frequency, fecal weight, laxative use, gastrointestinal tolerance and bowel function in chronic care tube-fed patients. Twenty-eight subjects (24 male, 4 female) completed the study. Mean daily number of stools and mean daily fecal wet weight in Enrich-fed patients were not significantly different from those of patients receiving Ensure. Ensure-fed patients required significantly more laxatives (p = 0.02) than those receiving Enrich. There were 26 reports of diarrhea in the Ensure-fed group as compared to 6 in the Enrich-fed group, and this difference was significant (p = 0.006). Reporting rates for constipation were not significantly different in the two groups. At the end of the study, the bowel function of 57.1% of patients receiving Enrich was improved when compared with that of 14.3% of Ensure-fed patients, and this difference was significant (p = 0.005). These results suggest that the addition of dietary fiber to enteral formulae improves gastrointestinal tolerance and bowel function, and reduces laxative use in long-term enterally fed patients.