Dietetic patient care of digestive health – IBS
The following blog is a summary of key learning points from a talk given at Digestive Health and Wellbeing: The Patient Journey in 2021. This blog provides a comprehensive overview of the key advice and approaches used in the management of IBS in dietetics.
Meet the speaker
Laura Tilt is an experienced freelance dietitian and health writer. She has extensive experience writing for brands, magazines and newspapers, and is a monthly columnist for Women’s Health magazine. Laura’s specialist interests include weight management, gut health and performance nutrition. Trained to deliver the low-FODMAP diet, Laura is the host of The Gut Loving Podcast and is co-author of The IBS Guide, a 12-weekselfcareprogramme for IBS.
Clinical application: Dietetic patient care of digestive health – IBS
Around 1 in 7 people suffer with irritable bowel syndrome (IBS) globally, yet it is often poorly understood and managed. In combination, this can leave patients feeling frustrated and unsupported. In the presentation, Laura discusses the historical approach to dietary management of the condition, and the current best practice guidelines in the UK., including first- and second-line interventions. Laura also explores how these can be delivered and by which practitioners. Laura outlines the pros and cons of the FODMAP diet, which is often considered the current ‘gold standard’ dietary management of IBS, and where pre and probiotics fit into the picture. Laura concludes with an explanation of the emerging evidence for non-dietary approaches as adjuvant therapies.
Historically with the treatment of Irritable Bowel Syndrome, patients were told to just live with their symptoms as IBS was considered a benign disease. Laura began advocating for patients with IBS when she realised the debilitating long-term effect that IBS and functional gut disorders were having on patients. IBS has a high prevalence – it is estimated that around 1 in 7 people have IBS in the UK. It is a chronic condition, that can have a debilitating and lasting effect on quality of life. While there’s no known ‘cure’ for IBS, treatment and management can be separated into several categories and approaches, including:
Diet and lifestyle
Novel self-help tools
Dietetic awareness is so important in IBS, as two thirds of people with IBS restrict intake of certain foods due to symptoms, which can of course have long term nutritional effects. There is no easy answer as to why certain food might trigger IBS symptoms; there area number of mechanisms at work. Examples include caffeine increasing gut motility.
Receptors in the gut may be activated by food molecules that then send pain signals through the nervous system. Certain foods can influence the gut microbiome, the community of bacteria and microbes in the gut. Beneficial gut bacteria produce compounds that can be advantageous to the body, but there are some foods that trigger less favourable compounds. In the past there were no evidence-based dietary guidelines for IBS, just a recommendation to eat more fibre, which is not helpful or practical for many patients. In 2012, the first evidence-based guidelines were drafted and updated in 2016. With this, the British Dietetic Association (BDA) now has a resource to use with patients with IBS for dietary guidelines.
First line advice
First line advice is initially given to patients. This usually comprises diet and lifestyle tips that may help with managing symptoms of IBS. Good quality evidence on first line advice is scarce, and some of it is from research with healthy populations, which makes it difficult to apply the same conclusions to IBS individuals. Laura suggests focusing on the below areas initially as they can help support patients:
Eating patterns – Regular meal schedules and avoiding eating late at night
Caffeine intake – Reduced intake – max 2-3 caffeinated drinks per day
Alcohol – Affects gut motility, aggravates acid reflux, and has negative effects on gut microbiota – advising patients/clients to stick to low-risk drinking guidelines
Fluid – 8 cups per day – water or non-caffeinated beverage, limiting fizzy drinks – fluids soften stools and rehydrate after diarrhoea
Spicy food – Patients may wish to trial reducing spicy food
Fat – Can increase gut motility and gastrocolic reflex and can be hypersensitive in those with IBS. Particularly fatty foods may inhibit gas clearance. Advise patients to limit creamy sauces and fried foods, biscuits and crisps to a small part of their diet.
Fibre intake - Depending on their IBS subtype, the BDA IBS factsheet has specific suggestions. Individuals with constipation as a prevalent symptom can benefit from soluble fibre and linseeds.
Diarrhoea – Reducing insoluble fibre in diet may be suggested by a healthcare professional.
There is currently no evidence for suggesting a gluten-free diet for people with IBS. Gluten-containing foods contain FODMAPs, and it is likely that it is the FODMAPs causing symptoms, not gluten. The patient may be referred to a dietitian for second line advice.
The low-FODMAP diet was developed by Monash University for people with IBS-sensitive tummies. The diet reduces intake ofFermentableOligosaccharidesDisaccharidesMonosaccharidesandPolyols. For the majority of individuals, there is nothing unhealthy about foods containing FODMAPs. In fact, many good fruits and vegetables contain FODMAPs, but people with IBS may be much more sensitive to these food compounds. Low-FODMAP is not a diet for life – the elimination phase is the shortest part of the 3-stage process, only restricting FODMAP foods for 2-6 weeks. The aim is to find ‘symptom control’ and later, a more relaxed diet can be used.
There are pros and cons to the low-FODMAP diet. It can help to manage symptoms and improve quality of life as a result, but it must only be delivered by a trained dietitian. It is restrictive, so is not right for everyone and takes time commitment to prepare foods that adhere strictly to low-FODMAP. It also does not always give complete symptom control. There are risks to nutritional intake, particularly if people do not have access to professional dietetic support. One such issue is reducing dietary fibre that feeds beneficial gut bacteria. Through this, a low-FODMAP diet could have a potentially negative impact on the gut microbiome.
Where prebiotics and probiotics fit in?
Diversity in the gut microbiome is just like a lush rainforest making it more beneficial to our body and more resilient. With well-supported beneficial bacteria, short chain fatty acids are produced which have positive effects on the gut and on digestive health.
Prebiotics are a substrate that is selectively used by the beneficial microbes in the gut. They can be found in foods such as onion, garlic, Jerusalem artichoke and leeks. In addition to occurring naturally, inulin, FOS and GOS prebiotics are also available in supplement form. Little is known about the connection between prebiotics and IBS, but prebiotic foods contain FODMAPs so may aggravate symptoms in some IBS patients. There are different types of prebiotics available and some types such as inulin might increase gas production. However, evidence suggests that galactooligosaccharides (GOS) feed beneficial gut bacteria that are not gas producing, so should not increase gas production and may also be suitable for use in IBS patients.
There is weak evidence for probiotics as an intervention for management of IBS symptoms. They are considered safe to use which is important as they are relatively affordable and simple to include in the daily routine. Probiotics might be useful when using dietary options like low-FODMAP, when known changes to the microbiome are found.
Fermented foods such as sauerkraut or kimchi should not be considered the same thing as probiotics. More research is needed, as it is unknown what strains of microbes they contain or if they even contain probiotic microbes. The majority of research today is with milk Kefir. There is a place for prebiotics and probiotics in dietetic patient care. For example, if the patient is on a long waiting list, prebiotics and probiotics could be recommended to give the gut a chance to adjust.
In these instances, individuals would start with low intakes, which could be steadily increased. This can be cost effective approach for the patient, and no diet restriction needed. As an HCP, it is good to know about the research and to find a few products that you could recommend based on sufficient research to patients/clients, should it be appropriate to them.
Gut-directed hypnotherapy – Considered to be useful for symptom control, can be expensive but apps such as Nerva can deliver gut directed hypnotherapy.
Exercise – Beneficial for gut motility and stress management, at low to moderate intensity.
Cognitive behavioural therapy –An approach that considers how thoughts and feelings affect the body.Zemedy is an app that can be useful for this purpose.
Remember - non-diet therapies should be considered first alongside diet.