learning how to help patients & clients with irritable ... · carb/paleo/atkins/scd/gaps diet....
TRANSCRIPT
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HOW TO HELP PATIENTS & CLIENTS
WITH IRRITABLE BOWEL SYNDROME
© 2012 GoodBelly
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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
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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
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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
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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
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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
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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).
© Copyright 2012 IBS Self Help and Support Group © 2012 Jeffrey D. Roberts
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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
© Copyright 2012 IBS Self Help and Support Group © 2012 Jeffrey D. Roberts
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Treatment for IBS
• Diarrhea
• Severe pain
• Constipation
• Cognitive behavioral
therapy
• Diet
• Low FODMAP diet
© Copyright 2012 IBS Self Help and Support Group © 2012 Jeffrey D. Roberts
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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
© Copyright 2012 IBS Self Help and Support Group © 2012 Jeffrey D. Roberts
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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
© Copyright 2012 IBS Self Help and Support Group © 2012 Jeffrey D. Roberts
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FODMAP DIET
FOR IBS
Patsy Catsos MS, RD, LD
Author of IBS-Free at Last, Second Edition
www.ibsfree.net
© 2012 Patsy Catsos
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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
© 2012 Patsy Catsos
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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
© 2012 Patsy Catsos
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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.
© 2012 Patsy Catsos
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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.
© 2012 Patsy Catsos
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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.
© 2012 Patsy Catsos
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Three Common Characteristics
Poorly absorbed
Rapidly Fermentable
Osmotically Active
FODMAP sugars
and fibers
© 2012 Patsy Catsos
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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)
© 2012 Patsy Catsos
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Effects are Additive
Illustration from IBS—Free at Last! Second Edition (2012, Pond Cove Press) used with permission.
© 2012 Patsy Catsos
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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.”
© 2012 Patsy Catsos
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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.
© 2012 Patsy Catsos
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Diet History
• Soda, milk, fruit juice, sports
beverages?
• Sugar-free gum or candy?
• Legumes and soy?
• Large portions?
• High-fiber bars or cereals?
© 2012 Patsy Catsos
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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.
© 2012 Patsy Catsos
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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
© 2012 Patsy Catsos
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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.
© 2012 Patsy Catsos
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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.
© 2012 Patsy Catsos
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Goals of Nutrition Therapy
• Most liberal, nutritious
diet possible.
• Reduce or eliminate
symptoms.
© 2012 Patsy Catsos
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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
© 2012 Patsy Catsos
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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
© 2012 Patsy Catsos
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IBS AND PROBIOTICS
Gunilla Önning
Ph.D.
Senior Scientist at Probi AB
© 2012 Gunilla Önning
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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
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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
© 2012 Gunilla Önning
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Probi AB Probi AB is situated in Lund,
Sweden (University since 1666)
2012-05-16 © 2012 Gunilla Önning
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Lactobacillus plantarum 299v (Lp299v)
© 2012 Gunilla Önning
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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 Gunilla Önning
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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)
© 2012 Gunilla Önning
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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.
© 2012 Gunilla Önning
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Lp299v and Irritable Bowel
Syndrome (IBS)
© 2012 Gunilla Önning
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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
© 2012 Gunilla Önning
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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 Gunilla Önning
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2012-05-16 42
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
Start After 4 Weeks 12 months
VA
S L.plantarum
Placebo
Ref: Nobaek et al., 2000 Am J Gastroenterol 95: 1231-1238
Abdominal Pain
*
**
* **
© 2012 Gunilla Önning
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43
0
1
2
3
4
5
6
Start After 4 Weeks 12 months
VA
S
L.plantarum
Placebo group
Ref: Nobaek et al., 2000 Am J Gastroenterol 95: 1231-1238
Overall GI Function
* **
© 2012 Gunilla Önning
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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
© 2012 Gunilla Önning
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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:
© 2012 Gunilla Önning
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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
© 2012 Gunilla Önning
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47
Significant Decrease of the Frequency of IBS Symptoms: Results at 4 Weeks
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48
Significant Decrease of the Intensity of IBS Symptoms
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-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 (%)
© 2012 Gunilla Önning
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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
© 2012 Gunilla Önning
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QUESTIONS?
© 2012 GoodBelly
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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