UK guidelines for the dietary management of IBS in adultsGuidelines Live 2019, 19 November

Yvonne McKenzie MSc RD MBDA

Specialist Dietitian in Gastrointestinal Nutrition & IBSwww.digestiblenutrition.co.uk

@digestnutrition

Disclosure of Conflicts of Interest: none

IBS

Presentation focus

1. Quality Standard on irritable bowel syndrome in adults, QS114

2. UK guidelines for the dietary management of IBS in adultsBritish Dietetic Association

NICE QS114 Quality Standard

on irritable bowel syndrome

in adults

To contribute to improvements in the following outcomes:

• undiagnosed irritable bowel syndrome in adults• quality of life for adults with irritable bowel

syndrome• satisfaction with care received for irritable bowel

syndrome• unnecessary hospital attendances for symptoms

of irritable bowel syndrome

QS114 Quality statement 1.

Adults with symptoms of IBS

are offered tests for

inflammatory markers as first-

line investigation to exclude

inflammatory causes.

Faecal calprotectin testMA: Menees 2015. Am Jnl Gastroenterol. 110, 444-454

QS114 Quality statement 2.

Adults with symptoms of IBS are

given a positive diagnosis if no red

flag indicators are present and

investigations identify no other

cause of symptoms.

• Unexplained weight loss• Rectal bleeding• Change in bowel habit in

patients under 60 years of age • Family history of bowel/ovarian

cancer • Anaemia• Abdominal/rectal/pelvic mass• Raised inflammatory markers

1. IBS-D differential diagnosis? BAD

bile acid diarrhoea?

• UK prevalence >1%

• underdiagnosed

• SeHCAT study

Arasaradnam 2018. Gut; 0:1–20

Wedlake 2009. Alimentary pharmacology & therapeutics, 30(7), 707-717

Fernandes 2019. Frontline gastroenterology, 10(1), 72-76

Kurien 2018. Frontline gastroenterology, 9(2), 92-97

Psychological response in FGD/IBS:perception of food-related gut symptoms

0 10 20 30 40 50 60 70 80 90 100

Hayes 2014 (Ireland, n=121/135)

Bohn 2013 (Sweden, n=59/84)

Monsbakken 2006 (Norway, n=59/84)

Simren 2001 (Sweden, n=209/330)

Faresjo 2010 (Sweden, F: 127/251; M: 29/96)

Baht 2002 (UK, n=199/467)

Visceral hypersensitivity

Heightened perception of gastrointestinal sensationBrain-gut, gut-brain interactions

• Fat-induced VHSimrén et al. (2007) Nutrient-dependent enhancement of rectal sensitivity in irritable bowel syndrome (IBS). Neurogastroenterology & Motility, 19: 20-29

• ? Co-existing symptoms of BAD in IBSBajor et al. (2015) Increased colonic bile acid exposure: a relevant factor for symptoms and treatment in IBS. Gut, 64(1), 84-92

Luminal gut physiology: FODMAPs

Fructans increase gas in the large intestineMurray et al (2014) Am J Gastroenterol, 109(1), 110-119Major et al (2017) Gastroenterology, 152(1), 124-133

After 4 hours

2. Recognise the features of bloating

To avoid multiple negative investigations.

Visceral fatGasTriggering of distension –Abdomino-phrenic dyssynergia: brain-gut reflex

https://theromefoundation.org/bloating-and-distension-whats-the-difference

Luminal gut physiology: FODMAPsFructose increases water in the small intestineMurray et al (2014) Am J Gastroenterol, 109(1), 110-119

After 1 hour.

After 1 hour

3. Consider: increase dietary fibre intake before prescribing laxatives

For every + 7 g/day of fibre:

• 9% reduction in CVD (RR 0.91, P<0.001)

• 9% reduction in heart attacks (RR 0.91, P<0.001)

• 7% reduction in strokes (RR 0.93, P=0.002)

• 6% reduction in type 2 diabetes (RR 0.94, P=0.001)

• 8% reduction in colorectal cancers (RR 0.92, P=0.002)

SACN report 2015: Carbohydrates and Health

SACN report 2015: Carbohydrates and Health

Dietary fibre

‘All carbohydrates that are neither digested nor absorbed in the small intestine and have a degree of polymerisation of 3 or more monomeric units, plus lignin.’

Recommended intake > 30 g per dayActual intake (UK) c. 18 g per day

SACN report 2015: Carbohydrates and Health

A food is:‘high fibre’

if it contains ≥ 6g of fibre / 100g

a ‘source of fibre’ if it contains ≥ 3g of fibre / 100g

Out: ‘insoluble / soluble’ fibre

https://www.bda.uk.com › foodfacts › fibre

Case: M, 61 y 3 x ABx-> IBS-type symptoms: dysbiosis

LIF painloose stool increased frequency: 2-3x/dObese, T2DM

‘It’s the first time someone has talked constructively about diet in a way that makes sense and will help.In fact I had 30g of fibre yesterday and already things are better!’

LFD – not needed•

•

• Tim

4. Food exclusion? => Reintroduce

Monotonous diets -> reduction in gut microbiota biodiversityShanahan 2017. Feeding the microbiota: transducer of nutrient signals for the host. Gut; 66:1709-1717

Eswaran 2013. Fiber and functional gastrointestinal disorders. Am J Gastroenterol. 108, 718–727

Perceived food intolerances?Reinforce need to reintroduce

Second-line IBS advice: low FODMAP diet

Dietitian needed!

• Complex, unintuitive

• All 5 FODMAPs?

• Nutritional assessment

• Follow up

Case: F, 45 y IBS-M, diagnosed in her 30s

severe abdominal painbloating windBF: erratic

self-directed LFD, 12 m

dietitian counsellingsymptom resolution in 10

daysbowel function normalised

Would be content to stay on strict LFD

Step 2 and 3 explained

First-line advice: healthy eating & lifestyle,endorsed https://www.bda.uk.com/foodfacts/IBS

5. Dietary advice: 1st line first!

1. Eating habits2. Healthy diet3. Dietary fibre

Second-line second: • Intervention• Low FODMAP diet• Process Eatwell Guide, PHE 2016

Case: F, 29 y IBS-C

RIF painsevere bloatingBSFT: 1&2 reduced frequency: once every 3 days

HCP advised: lactose free, wheat free diet

1st line: Increased dietary fibre intake

bowel function normalisedbut …bloating & wind persisted

2nd line: trialled FODMAP restriction

QS114 Quality statement 3.

Adults with IBS are offered

advice on further dietary

management if their symptoms

persist after they have followed

general lifestyle and dietary

advice.

By HCPs with relevant expertise in dietary management or a referral may be made

adequate nutritional intake

From guidelines to clinical practice

Systematic Review and Evidence-based practice guidelines: dietary management of IBS in adultsMethodology

• Questions: Effect of ….... on IBS symptoms?• Update to 1st BDA IBS & Diet guidelines, 2012

• Literature search, Jan 1985-Oct 2015 • in duplicate, 12 dietitians

• Cochrane risk of bias• Australian NHMRC guidelines for evidence

statements• grades (A-D) for clinical recommendations• AMSTAR tool for probiotics SR of SRs QA

McKenzie 2012. J Hum Nutr Diet.25,260-74

1. alcohol 2. caffeine3. spicy food 4. fat5. fluid intakes 6. dietary habits7. milk and dairy8. dietary fibre9. fermentable

carbohydrates10. gluten11. probiotics12. elimination diets/food

hypersensitivity

Systematic Review and Evidence-based practice guidelines: dietary management of IBS in adults

Outcomes

• 86 studies met inclusion criteria: • 9 SRs, 67 RCTs, 10 non-RCTs• for probiotics SR of RCTs: a Diet risk of

bias • 46 evidence statements• 15 clinical practice recommendations

• and practical considerations• 4 research questions• 1 IBS dietary algorithm, update

IBS Dietary Algorithm First and second-line clinical & dietary assessments and interventions• McKenzie et al. 2016. J Hum Nutr Diet

First line

Clinical assessment Dietary & lifestyle assessment

Check diagnosis & investigations (rule out coeliac disease) Check healthy eating & lifestyle

Medical & family history, allergies, medication, weight, BMI

Check for food intolerance especially milk/lactose

IBS symptoms & subtype identified

Assess dietary fibre, fluid, fatty food, caffeine, spicy food, alcohol

intake

Second line

A low FODMAP diet

Evaluate diet & ensure nutritionally adequate during each of the 3 stages:

restriction, reintroduction and long-term self-management

Advise Review Adequate symptom

improvement?

Refer back for further

investigations

Continue dietary advice but do not

exclude gluten

Reintroduce high FODMAP

foods to personal tolerance threshold

Try second line

Discharge for long-term self-management

Return to normal diet & refer back to

referrer

Yes

Yes

No

No

No

Advise Review Adequate symptom

improvement?

IBS diagnosis

Healthy eating & lifestyle: clinical practice recommendations

Alcohol C PEN GradeAssess intake and screen for signs of binge drinking Ensure alcohol intake is in keeping with safe national limits

Caffeine DInsufficient evidence to make a recommendation

Spicy food CIf related to symptoms assess intake -> Trial restriction

Fat DIf related to symptoms during or after eating -> assess intake. Ensure intake is in line with national healthy eating guidelines

FluidNo evidence to make a recommendation

Elimination diets/Food hypersensitivity DNon-specific elimination diets are no longer valid to improve IBS symptoms

Restricting milk & dairy products: clinical practice recommendations

Where sensitivity to milk is suspected PEN Gradeand a lactose HBT is not available or appropriate,Trial a low lactose diet D

With a +ve lactose HBTUse a low lactose diet D

Dietary fibre modification: 10 RCTs, 1 non-RCT: poor evidence

Study

N, duration

Intervention

Outcome

Aller 2004 Spain

56 IBS 3 months

high fibre diet (30.5g) vs low fibre diet (10.4g)

No SS difference

Arffmann 1985 Denmark

20 IBS-C or IBS-M 6 weeks

wheat bran (30g) vs placebo: coloured breadcrumbs

No SS difference

Bijkerk 2009 Holland

275 IBS 12 weeks

wheat bran (4g) vs placebo: white rice psyllium (4g) vs placebo: white rice

No SS difference Psyllium reduced severity by 34% vs 18% at 12w, p=0.03, NNT 10

Cockerel 2012 UK

40 IBS 4 weeks

Whole linseeds (up to 7 g) vs ground linseeds (up to 6 g) vs control: no supplementation

No SS difference

Fowlie 1992 UK

Non-RCT 49 IBS-C 3 months

cereal and fruit fibre in 5 tablets (4.1g) vs placebo: starch, CaPO4, lactose in 5 tablets

No SS difference

Hebden 2002 UK

12 IBS 2 weeks

wheat bran (30g) vs placebo: plain biscuits

Bran increased pain and bloating p<0.02

Kruis 1986 Germany

80 IBS 16 weeks

wheat bran (15g) vs placebo

No SS difference

Lucey 1987 UK

38 IBS 16 weeks

12 wheat bran biscuits (15.6g NSP) vs placebo: 12 plain biscuits (2.76g)

No SS difference

Rees 2005 UK

28 IBS-C or IBS-M 12 weeks

wheat bran (3.64-7.28g) vs placebo: low fibre crispbread (0.22-0.44g)

No SS difference

Snook 1994 UK

80 IBS 7 weeks

wheat bran (12g) vs placebo: wheat & rice flour (negligible)

No SS difference Bran increased flatulence p<0.001

Tarpila 2004 Finland

55 IBS-C 3 months

Ground linseeds (≤10.6g) vs psyllium (≤13.5g)1

Ground linseeds improved constipation, p=0.05, NNT 2.1, and abdominal symptoms, p=0.001, NNT 2.4

Dietary fibre modification: clinical practice recommendations

Avoid wheat bran supplementation C PEN GradeDon’t increase intake above usual

For individuals with IBS-C:Trial dietary supplementation of linseeds Dup to 2 tablespoons/day (24g) for 3 monthsImprovements in constipation, abdominal pain and bloating may be gradual

Systematic review of the systematic reviews in the use of probioticsMcKenzie et al. 2016 Journal Human Nutrition & Dietetics. 29,576–592

Strain-specific probiotics: clinical practice recommendations

Advise: unlikely to provide substantial IBS symptom benefit

However, for individuals choosing to tryAdvise: select 1 product at a timetry for a minimum of 4 weeks dose as recommended by manufacturer

QS114 Quality statement 4.

Adults with IBS agree their follow-up with their HCP

• 1.2.1.8 … Such advice should only be given by aHCP with expertise in dietary management.

CG61 update (2015) for primary care

• Role in co-existing colonic hypersensitivity

• To treat IBS symptoms: abdominal pain, wind, tendency to diarrhoeaand mixed bowel function

Fermentable

Oligosaccharides (fructans) (α-galacto-oligosaccharides)

Disaccharides (lactose)

Monosaccharides (fructose)

And

Polyols (sorbitol, mannitol, xylitol)

Low FODMAP diet: clinical practice recommendations

Consider a low FODMAP diet for a minimum of 3 or 4 weeks B PEN Gradeto improve abdominal pain, bloating and/or diarrhoea.

Strict dietary adherence? No symptom improvement?Stop. Return to usual diet. Consider other therapeutic options

There may be individual tolerance levels to FODMAPs DPlanned and systematic reintroductionTo identify which foods can be reintroduced to the diet and what individual tolerance levels are.

6. Low FODMAP diet in IBS: not a DIY diet

FODMAPs generate symptoms in some people with IBS: gut hypersensitivity - SB osmotic effect/increase in colonic gasworks best for pain, bloating, wind, stool looseness

Appropriate restriction of FODMAPs? Understand symptom profile, current food choices, eating habits

May impact on nutrient intake: fibre, calcium

Impacts on colonic microbiota: ? reduction in fructans and GOS (prebiotics: fibre)

Restriction should be short-term. Reintroduce. Support by a dietitian

7. When to refer to a dietitian

1. Evidence for efficacy is from this setting

2. Nutritional adequacy - important

fibre, calcium intakes

3. Reintroduction stage – important food QoL, gut microbiota

4. Practical issues for successfully undertaking dietary change

5. At risk of disordered eating?

8. Agree follow up

1. Restriction should be short-term2. Food may not be problematic3. Reintroduce 4. Support by a dietitian5. Potential to reduce IBS medication?6. To support long-term symptom self-management

Second-line, LFD: • Dietitian education will improve patient reaching

therapeutic FODMAP intake target• Adherence improved with dietitian guidanceTuck 2019. Neurogastroenterol Motil. 00:e13730

Acknowledgements

Miranda Lomer Julie Thompson Niamh O’Sullivan

Poonam Gulia Claire Pettitt Jade Horobin

Rachel Bowyer Hannah Leach Leah Seamark

Marianne Williams Liane Reeves

Twitter: @digestnutrition