Mistakes in... 2022 - 13

ueg education
Mistakes in... 2022
Positive diagnosis of IBS in the absence of red flags
* Diarrhoea: screen for coeliac disease and consider measuring
faecal calprotectin and CRP levels
* Faecal pathogens: no routine stool testing recommended
* Food allergies: no routine testing recommended
* Food intolerance: no routine H2
breath testing recommended
40% of patients with IBS have symptoms of
anxiety or even an anxiety disorder.34
Taking
this into account, the risk of exacerbating
pre-existent or developing new disordered eating
and nutritional deficiencies in patients with IBS
are important considerations prior to prescribing
elimination diets.35
The development of eating disorders in
Dietary treatment
Know your patient:
* Predominant symptoms, medical social and
psychological history
* Patient preferences/expectations
* Previous dietary adaptations
* Overall diet quality
* Lifestyle, daily routine
* Beliefs, food-related anxiety, concerns
* Intolerances, relationship to gastrointestinal
symptoms
First line
* Expectation management
* Patient education
* Advice according to NICE guideline
* NCWS: consider restricting fructans, for gluten find
level of tolerance
* Consider adding psyllium fibre
* Tailor advice based on patient history and
preference
* Focus on diet quality, minimise elimination,
reintroduction
Second line
* Low FODMAP diet, consider a bottom-up approach*
* Follow-up:
* Effective - reintroduction
* Not effective - consider non-dietary therapy
Figure 1 | Flowchart summarizing the dietary management of irritable bowel syndrome, as discussed in the
current article. *A bottom-up low-FODMAP approach = targeted elimination of specific FODMAPs first, rather
than all at once. CRP, c-reactive protein; FODMAP, fermentable oligosaccharides, disaccharides,
monosaccharides and polyols; NCWS, non-coeliac wheat sensitivity.
Mistake 8 Not taking the potential
long-term effects of a low-FODMAP diet
into account
A low-FODMAP diet is, by definition, a diet low
in nondigestible carbohydrates and may result
in an altered gut microbiota composition and
activity and, in particular, a lower production of
short-chain fatty acids. It has the opposite effect
to prebiotic supplementation, and may cause
a reduction in bifidobacteria and an increase in
bacteria associated with dysbiosis.31
to food may change over time in patients with
IBS, elimination of specific FODMAPs is never
lifelong advice.
In addition, whether based on certain
patient characteristics, such as ethnicity,32
or
on biomarkers, such as gut microbiota composition,33
References:
careful
patient selection, whereby a
'bottom-up' approach of targeted elimination of
specific FODMAPs, rather than all of them, may be
more successful, as this personalized approach is
more patient friendly.
While in the
short term the low-FODMAP diet may reduce the
symptoms in IBS patients, the long-term effects
on health have not been studied yet. This shows,
once again, that it is important to reintroduce
FODMAPs into the diet after initial elimination,
at least those FODMAPs that don't contribute
to symptom reduction in the specific patient.
Furthermore, as both symptoms and tolerability
Mistake 9 Being unaware of the risks of
restrictive diets on the development
of eating disorders
Elimination of food that may cause symptoms is
often a cornerstone of dietary advice in those with
IBS. Also, patients themselves eliminate food
for that reason.3,5
On the other hand, up to
1. Van den Houte K, et al. Prevalence and impact of
self-reported irritable bowel symptoms in the
general population. United European Gastroenterol J
2019; 7: 307-315.
2. Tornkvist NT, et al. Health care utilization of
individuals with Rome IV irritable bowel syndrome in
the general population. United European
Gastroenterol J, 2021; 9: 1178-1188.
3. Bohn L, et al. Self-reported food-related
gastrointestinal symptoms in IBS are common and
associated with more severe symptoms and
reduced quality of life. Am J Gastroenterol 2013;
108: 634-641.
4. Sayuk GS, Wolf R and Chang L. Comparison of
symptoms, healthcare utilization, and treatment in
diagnosed and undiagnosed individuals with
diarrhea-predominant irritable bowel syndrome.
Am J Gastroenterol 2017; 112: 892-899.
3
Other treatments
patients with IBS is not associated with altered
body image, as is the case with classic eating
disorders. In this scenario, it is rather the
negative anticipation of gastrointestinal
symptoms after food intake that is responsible.
The DSM-5 (Diagnostic and Statistical Manual
of Mental Disorders) has given this type of eating
disorder its own specific classification: avoidant/
restrictive food intake disorder (ARFID). Although
the exact prevalence of ARFID in IBS patients is
still unknown, food-related anxiety is common.35
Therefore, before advising that an elimination diet
be implemented, the identification of patients
at risk of developing food-related anxiety is
important, to evaluate whether the benefits of
the diet will outweigh the risks, and whether
psychological treatment is indicated.
Mistake 10 Treating IBS according to a 'one
size fits all' approach
IBS is a heterogeneous disorder that has a
broad range of symptoms and different patient
characteristics. Various pharmacological and
nonpharmacological treatments, including dietary
interventions, are available, all of which are only
effective in a subgroup of patients.
Unfortunately, to date there are no objective
markers to guide the choice of treatment. But
this does not mean that a tailormade approach is
not possible. Taking the time to understand the
patient's predominant symptoms, history,
social and psychological state, concerns and
preferences is crucial for a treatment to have
any chance of success.10
As shown in Figure 1, in
dietary counselling, it is preferable to start from
a healthy balanced diet, and then select a
personalized approach based on local availability
of expertise and, in particular, patient preference.

Mistakes in... 2022

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