HOW TO HELP PATIENTS & CLIENTS WITH IRRITABLE BOWEL SYNDROME

© 2012 GoodBelly

Welcome! Ariel Scott Marketing Manager at GoodBelly • 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

© 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

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

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

5. 6. 7. 8. 9. 10.

colon cancer. IBS is the same as colitis. Blood in the stool is a symptom of IBS. IBS only causes diarrhea. IBS only causes symptoms in the large intestine. Enemas can be used to treat constipation. There is no way to diagnose IBS.

Source: IBDCrohns.About.com

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

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

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

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

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

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

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

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

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

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

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

Three Common Characteristics Poorly absorbed

FODMAP sugars and fibers

Rapidly Fermentable

Osmotically Active

© 2012 Patsy Catsos

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

Effects are Additive

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

© 2012 Patsy Catsos

What Does the Patient Say? “Bread makes me feel bloated.”

“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.”

© 2012 Patsy Catsos

More Patient Complaints:

The healthier I eat, the sicker I get, so I just stay away from fruit, vegetables and milk products.

I felt better when I tried a lowcarb/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.

© 2012 Patsy Catsos

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

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

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

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

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

Goals of Nutrition Therapy • Most liberal, nutritious

diet possible. • Reduce or eliminate symptoms.

© 2012 Patsy Catsos

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

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

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 Bifidobacterium Bacillus Enterococcus

Escherichia Saccharomyces Streptococcus

FAO/WHO (2001) Expert Consultation http://www.fao.org/es/ESN/Probio/probio.htm

32

© 2012 Gunilla Önning

Probiotics: Introduction • Used to be present in food

naturally • Improves balance between good

and bad bacteria • Improves the intestinal barrier

1980 1950

1850 Year 0 10 000 years BC

R&D in Probiotics takes off Antibiotics/Refrigeration

Industrial revolution

Agricultural revolution

• Affects the immune response

0,8 mill. years BC

Elie Metjnikov (1845-1916) Nobel price in medicine - 1908

Fire is tamed

1,5 mill. years BC

Lactic acid fermentation is invented

3 mill. years BC

The Homo genus appears © 2012 Gunilla Önning

Probi AB Probi AB is situated in Lund, Sweden (University since 1666)

2012-05-16 © 2012

Gunilla Önning

Lactobacillus plantarum 299v (Lp299v)

© 2012 Gunilla Önning

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

Lactobacillus plantarum 299v bindcells Intestinal binding mechanisms to mucosa (mannose-specific binding) Unlike most other lactobacilli and bifidobacteria!

L. plantarum 299v Protein on the bacterial surface Mannose-containing receptor on the intestinal epithelial cells Signalling

References: Adlerberth et al., Appl. Environ Microbiol 1996;62; 2244-2251 37

2012-05-16

© 2012 Gunilla Önning

Inhibition of enteropathogenic E.coli adherence Increased production of mucins 

 

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.

2012-05-16 38

© 2012 Gunilla Önning

Lp299v and Irritable Bowel Syndrome (IBS)

© 2012 Gunilla Önning

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

Flatulence

7 6

5

*

4 VAS

***

3

**

L.plantarum Placebo

2

1 0 Start

After 4 Weeks

12 months

Ref: Nobaek et al., 2000 Am J Gastroenterol 95: 1231-1238 © 2012 Gunilla Önning

Abdominal Pain

4,5 4 3,5

* **

VAS

3

*

2,5

**

2

L.plantarum Placebo

1,5 1 0,5 0 Start

After 4 Weeks

12 months

Ref: Nobaek et al., 2000 Am J Gastroenterol 95: 1231-1238 42

2012-05-16 © 2012

Gunilla Önning

Overall GI Function

6

5

*

VAS

4

3

**

L.plantarum Placebo group

2

1

0 Start

After 4 Weeks

12 months

Ref: Nobaek et al., 2000 Am J Gastroenterol 95: 1231-1238 43

© 2012 Gunilla Önning

Effect of Lp299v in Patients with Irritable Bowel Syndrome - Niedzielin et al. 2001 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

2012-05-16 © 2012

Gunilla Önning

% of patients with improvement

After 4 weeks of therapy:

120% 100% 100%

100%

95% 95%

80%

60% 60%

55%

60% 40% 20%

55% 18%

18%

Placebo L.plantarum 15%

15%

0% Abdominal Pain Stool Frequency IBS Symptoms

Niedzielin et al, Eur J Gastroenterol Hepatol 2001;13:1-5 © 2012 Gunilla Önning

Effect of Lp299v in Patients with Irritable Bowel Syndrome – Maladkar et al., unpublished 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

2012-05-16 © 2012

Gunilla Önning

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

47

© 2012 Gunilla Önning

Significant Decrease of the Intensity of IBS Symptoms

48

© 2012 Gunilla Önning

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

Flatulence

Abdominal pain

Overall IBS symptoms

-35

-30

-25

-20

-15

-10

-5

0

© 2012 Gunilla Önning

Important For Consumers When Choosing a Probiotic Product 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.

© 2012 Gunilla Önning

QUESTIONS?

© 2012 GoodBelly

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