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Diet and IBS, Fibromyalgia, and Migraine

Diet and IBS, Fibromyalgia, and Migraine. What Is Irritable Bowel Syndrome?. Symptom Based Diagnosis of Exclusion Diarrhea Predominant IBS Constipation Predominant IBS Cyclic IBS. Rome II Criteria for IBS. Relief after defecation Onset associated with a change in stool consistency

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Diet and IBS, Fibromyalgia, and Migraine

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  1. Diet and IBS, Fibromyalgia, and Migraine

  2. What Is Irritable Bowel Syndrome? • Symptom Based Diagnosis of Exclusion • Diarrhea Predominant IBS • Constipation Predominant IBS • Cyclic IBS

  3. Rome II Criteria for IBS • Relief after defecation • Onset associated with a change in stool consistency • Onset associated with a change in stool frequency

  4. Rome II Continued Other symptoms that are not essential butsupport the diagnosis of IBS: • Abnormal stool frequency • greater than 3 bowel movements/day • less than 3 bowel movements/week • Abnormal stool form • lumpy/hard • loose/watery stool • Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation) • Passage of mucus • Bloating or feeling of abdominal distension. Source: International Foundation of Functional Gastrointestinal Disorders

  5. When You Should Ask The Doctor to Double-Check IBS Diagnosis: • Profound weight loss, anemia or blood/occult in stool • Travel to places with parasitic endemics • Hx of colon cancer • Skin abnormalities • Signs of malabsorption • Thyroid dysfunction This list is not exhaustive, but is helpful…

  6. Consequences of IBS • Patients with IBS averaged 15 of 30 days with poor physical or mental health. • These average overall unhealthy days exceeded those of respondents with arthritis, diabetes, heart disease/stroke, cancer, and class III obesity (body mass index > or =40 kg/m2) from the U.S. survey.

  7. Traditional Therapies Medication • Side Effects • Band-Aid solution- only addresses symptom of diarrhea, not underlying problems so other problems continue.

  8. IBS is not a distinct entity buta collection of disorders “Food intolerance represents an important proportion of conditions which together make up IBS” John Hunter, MD, FCRPDirector or Gastroenterology “Food Allergies and Food Intolerance” Brostoff & Challacombe, Second Edition, 2002

  9. Lancet 2000 Jul 29;356(9227):400-1“We found that food provocation in food intolerant patients was characterized by a general and systemic immune activation accompanied by an increase in systemic symptoms… important for the understanding of the mechanisms involved in the pathogenesis of food intolerance.” Food sensitivities ushered in by IBS lead to feeling bad all over… IBS not only symptom

  10. FOOD INTOLERANCE CAUSES IBS SYMPTOMS IN CERTAIN PATIENTS Merck Manual pg 1051 Food Intolerance was found to be responsible for symptoms of some patients with the IRRITABLE BOWEL SYNDROME

  11. Trial and Error as a Therapy “But through ‘Trial and Error’ many people find they feel better when they stop eating certain foods. These foods cause the intestines to contract, which can aggravate IBS in people who have diarrhea as their main symptom.” Nicholas Talley, MD., Patrice Burgess, MD “Controlling I.B.S. With Diet” Healthwise Information Library But meanwhile, life goes on….. Without remission….

  12. The IBS Employee’s Average Combined Work Time Lost to Absenteeism and Work Cut Backs due to IBS Symptoms was found to average ONE WEEK per MONTH, for a total of 12 WEEKS per YEARof lost productivity. This represents a loss of nearly 25% of productivity PLUS the costs of accompanying sick leave pay.*

  13. American Gastroenterological Association Position Statement • “Education and Reassurance” • “Dietary and Lifestyle Modifications” • “Symptom Monitoring” • “Symptom-Directed Medication PRN” • “Psychological Treatment”

  14. Dietary Trial and Error • Caffeinated drinks • Tyramine and phenylethylamine- pressor amines • Histamine • Solanine: naturally occurring toxicant in the nightshade plant family • Nitrates and Nitrites • Benzoic Acid: also benzoin, gum benzoin, benzoate and naturally occurring diet. • Sorbitol Family: sorbitol, sorbitan, polysorbate 80, polysorbate 60 • Lectins (in beans, lentils, peas, peanuts, snails, wheat). • Peptides: small protein-like molecules • Proteolytic Enzymes (raw pineapple, raw papaya most common • Eating Habits Scrutinized : Too much at one time and too high fat content too much stress especially when you eat

  15. IF food Intolerance IS important to IBS symptoms, WHY do most Diets fail to make much difference? • Unlike allergies, food sensitivity reactions are: • Dose Dependent • Delayed Onset (up to 72 hours post ingestion) • Multiple foods can cause symptoms (single elimination trials are useless) • NO Universal Bad Food- Very patient specific • Until now, it was just hard to find those “triggers”

  16. Should we test for allergies (IgE)? Double blind, placebo controlled food reactions do not correlate to IgE allergy in the diagnosis of staple food related gastrointestinal symptoms.Bengtsson U, Nilsson-Balknas U, Hanson LA, Ahlstedt SAllergy Centre, University of Goteborg, Sweden In adult patients with staple food induced gastrointestinal symptoms, objectively verified by DBPCFC, there were no indications of IgE mediated allergy to the relevant foods, suggesting other mechanisms in adults than in children. Gut. 1996 Jul;39(1):130-5.

  17. Intestinal Perfusion Studies Stomach Jejunum Catheter Balloon Balloon Knutson et al, J. of Allergy and Clin. Immunology 93; 91(2): 553-9

  18. Anatomy of a Food Sensitivity Intestinal Perfusion Studies • Segment of jejunum is endoscopically isolated by placement of two balloons • Segment of jejunum between balloons is perfused with potential food allergen and then jejunal contents are collected Knutson et al, J. of Allergy and Clin. Immunology 93; 91(2): 553-9

  19. Anatomy of a Food Sensitivity Intestinal Perfusion Studies • Patients with known sensitivity to the food had increased production of cytokines found in the washings after positive challenge. • No increased cytokines seen in controls • Found no IgE to specific offending foods in sensitive patient group Knutson et al, J. of Allergy and Clin. Immunology 93; 91(2): 553-9

  20. To summarize: No physical evidence of damage in the jejunum No evidence of an allergy: No IgE in the aspirated contents of the jejunum BUT Evidence of an immune reaction, i.e., presence of cytokines.

  21. What about IgG testing? Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial.Atkinson W, Sheldon TA, Shaath N, Whorwell PJ. • 150 outpatients with IBS • Randomized X 3 months • Test: diet excluding all foods which raised IgG • Control: sham diet excluding the same number of foods but not those to which they had antibodies. • Outcome measured: IBS and global symptoms Gut. 2004 Oct;53(10):1459-64.

  22. What about IgG Testing? p2 Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial.Atkinson W, Sheldon TA, Shaath N, Whorwell PJ. • In 12 weeks • Elimination diet resulted in a 10% greater reduction in symptom score than the sham diet CONCLUSION: Food elimination based on IgG antibodies may be effective in reducing IBS symptoms and is worthy of further biomedical research. Gut. 2004 Oct;53(10):1459-64.

  23. IgG –Based Elimination Well, yes, statistically significant but Only 10% improvement in 12 weeks? Can we do better if we get a broader picture….. Did they miss something?

  24. Other symptoms…. 15% identified muscle and joint pain, not IBS symptoms, as the major cause of their activity limitation. Psychosom Med. 2006 Mar-Apr;68(2):312-20.

  25. Comorbid to IBS • Migraine • Fibromyalgia • Sinusitis • Rheumatoid Arthritis • GERD Some of these symptoms persist long after IBS-D remits if food sensitivity not treated.

  26. Why measure mediators? Because they are agents of chemical warfare released by cells to fight off invaders or perceived invaders Because they can cause collateral damage • Smooth muscle contraction (evacuation) • Inflammation (leak WBC to point of infection) • Fever (in total flu-like symptoms) Cells sometimes attack otherwise benign substances like foods and additives

  27. Measuring Mediators • MRT Tested- 123 foods and 27 chemicals • Plasma to solids ratio (indirect measure of mediator release) is measured on all tested foods to give a ratio. • If the volume of the plasma increases dramatically, that's considered a 'highly' reactive food. If there's no or very little volume change, that food is considered 'non-reactive.‘

  28. Formation of the Diet • Results put in graphical and diet form • Diet book sent to patient • Results and pt history sent to dietitian

  29. Short TermData-Driven Protocols • Symptom Survey • Did we address the chief complaints? • Did the symptoms that respond best to elimination disappear with good compliance?

  30. Long-TermData-Driven Protocols • SF-36 • Does the person have better functioning? • Can the person have a life? • Is the person happier?

  31. LEAP Case Study- IBS

  32. LEAP Case Study- IBS pg 2 • The dietitian asked the patient if he had ever experienced remission of symptoms during these 8 months. He replied that he had once felt “ok” for ½ of one day. • According to LEAP protocol, the patient eliminated all supplements and medications except those to ease GERD and treat intestinal parasites. Within 1 week, his symptoms had decreased dramatically, with complete remission of diarrhea and bloating (his symptom score was down from a 68 to an 11) and he was able to go back to work. • Able to identify isolated foods which seemed to still trigger GERD episodes. By the time he reached 2 ½ months his GERD also dissipated. • Able to go off of all medication at that point. • Pt was successfully discharged

  33. LEAP Case Study- Migraine

  34. LEAP Case Study- Migraine pg 2 • The dietitian checked with the referring physician to see if this threat was authentic. The physician said the patient made this statement frequently. Still, the dietitian scheduled this highly agitated patient ASAP. • According to LEAP protocol, the patient suspended all supplements to be tested in later phases. She was started in Phase 1, of her personalized elimination diet. • Within 8 days, her symptoms had decreased dramatically (his symptom score was down from a 59 to 13) and she was migraine-free, with no GI problems, reduced joint stiffness and muscle pain, able to sleep and was no longer taking PRN sleeping medication.

  35. LEAP Case Study- Migraine pg 3 • Husband got on the phone and thanked the dietitian Dietitian made suggestions for menu selection and ordering at her favorite restaurants. • The patient would try to occasionally eat small amounts of reactive foods, but since they caused migraines, the patient quickly returned to her diet. • Pt was successfully discharged from the LEAP program and said that she would like to make this test available to her relatives in Mexico (currently LEAP testing is available in the United States and Europe)

  36. LEAP Case Study- Fibromyalgia

  37. At the third follow-up, she declared that she was “pain free” with her symptom scores decreasing another 16 points to a score of 36. At the fourth follow-up, her chest congestion was completely gone and patient was functioning at a much higher level. Her daughter- who gave birth to a premature baby was assisted by a more energetic mom. At the fifth follow-up, patient related that she got a new job as a manager and got double her previous pay. LEAP Case Study- Fibromyalgia- pg 2 • According to LEAP protocol, the patient suspended all supplements to be tested in later phases. She was started in Phase 1, of her personalized elimination diet. • Within 8 days, her symptoms had decreased dramatically (his symptom score was down from a 105 to 36), she had lost 8 #, with reduction in muscle and joint pain, gastrointestinal symptoms, and nasal symptoms. • At the third follow-up, she declared that she was “pain free” with her symptom scores decreasing another 16 points to a score of 36. • At the fourth follow-up, her chest congestion was completely gone and patient was functioning at a much higher level. Her daughter- who gave birth to a premature baby was assisted by a more energetic mom • At the fifth follow-up, patient related that she got a new job as a manager and got double her previous pay.

  38. Stats on 127 Patients • In therapy for 1 month • One baseline survey and two follow-up on schedule, to provide us an overall “symptom score” • Fit our patient selection criteria (IBS, Fibromyalgia, Migraine)

  39. RESULTS 10 day 54.89 % Average Symptom Reduction 1 mo. 74.82 % Average Symptom Reduction

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