Download IBS-2007-Winnipeg

Nutritional Management of
Irritable Bowel Syndrome
Janice Joneja, Ph.D., RD
Irritable Bowel Syndrome
• Irritable bowel syndrome (IBS) tends to
be an umbrella term for a variety of minor
bowel disturbances of unknown origin
• Sometimes called:
– “irritable colon”
– “spastic colon”
2
Symptoms of IBS
• Symptoms include:
– Change in bowel habit
• often alternating constipation and diarrhea
– Abdominal bloating and distension
– Sometimes abdominal pain, frequently relieved
by defecation
– Feeling of incomplete defecation
3
IBS Characteristics
• There is usually no sign of structural damage to
the wall of the intestine (frequently indicated by
blood in the stool)
• Weight loss or nighttime fever are not experienced
• A diagnosis of irritable bowel syndrome is made
when all organic disease has been ruled out by
appropriate medical tests
• The Manning Criteria or the Rome II
questionnaires are often used for diagnosis
4
Initial Triggers of IBS
• Infection in the digestive tract:
– Viruses
– Bacteria
– Parasites (amoeba; intestinal worms)
• Pathology in the digestive tract
– Inflammatory bowel disease
– Coeliac disease
• Surgical procedures in the digestive tract
5
Triggers of IBS (continued)
• Stress:
– Stress hormones are released
– Neuropeptides may trigger the release of
inflammatory chemicals
• Hormone fluctuations:
– Menstrual cycle
– Pregnancy
– Thyroid
6
Triggers of IBS (continued)
• Change in types of micro-organisms in the large
intestine due to:
– Oral antibiotics
– Other oral medications
– Change in substrate (ie type of food passing into the
bowel)
• Alteration in microbial flora results in:
– Different products resulting from the action of microorganisms on undigested food material:
• Gases
• Organic acids
• Others
7
Mechanisms Responsible for Symptoms
• Key factors in IBS resulting in symptoms include:
– Inflammation
• Resulting from release of inflammatory mediators
– Increased sensitivity to pain
• Neuropeptides (tachykinins) generated by the
central nervous system interact with neurokinin
receptors on the spinal cord
• May also result from a response to inflammatory
mediators (e.g. histamine)
8
Mechanisms Responsible for Symptoms
(continued)
– Motility dysfunction
• Resulting from changes in autonomic
nervous system signals
• Resulting from products of microbial
fermentation
– Fermentation
• Of undigested food in the large bowel
• As a consequence of abnormal motility
• As a consequence of altered microbial flora
9
Inflammation
• Inflammation is rarely visible in tissue
viewed under the microscope in IBS
• However, there is research evidence of the
presence of inflammatory activity in IBS,
based on the presence of chemicals (e.g.
PGE2) that indicate that inflammation is
occurring
10
Causes of Inflammation in IBS
• Infection: bacterial; viral; parasitic
– Infective microorganism may have been successfully
eradicated, but inflammation of the intestinal tissues
may persist, especially as food is continually passing
through
• Autoimmune processes
• Food protein enteropathy
– Cow’s milk protein enteropathy
– Soy protein enteropathy
– Gluten-sensitive enteropathy (coeliac disease)
• Food allergy and food intolerance
11
Stress and Inflammation
• Neuropeptides are released into the digestive tract
• Vasoactive intestinal peptide (VIP), Substance P,
somatostatin, and others can cause degranulation
of mast cells
• Mast cells exist in large numbers in the digestive
tract, and are intimately associated with nerves
• Mast cells store inflammatory mediators designed
to protect the body from invasion
• Release of inflammatory mediators triggers
inflammation
12
Altered Motility of the G.I. Tract
• Altered speed of food passing through the
G.I. tract can result in disturbance of the
normal process of digestion and absorption
of nutrients:
– Increased speed in the small intestine results in
incomplete breakdown of food components in
the small intestine
– Food is not in contact with digestive enzymes
long enough for molecules to be broken down
to the size and state required for absorption
13
Increased Motility in the Small Intestine
• Incomplete breakdown of fats and oils by
pancreatic lipases
– Results in steatorrhoea (fatty stool)
• Incomplete breakdown of carbohydrates
– Results in complex sugars passing into the large
bowel
– Damage to cells lining the digestive tract results
in deficiency of enzymes that digest sugars
(lactase; sucrase; isomaltase)
– Undigested sugars pass into the large bowel
14
Effects of Increased Motility
in the Small Intestine
• Incomplete protein digestion
– Evidence of passage of fairly large polypeptides
into circulation, especially if digestive tract
lining is damaged by inflammatory processes
– Undigested and unabsorbed proteins pass into
large bowel
– There are acted on by micro-organisms,
resulting in production of organic acids, gases
15
Altered Motility in the Large Bowel
• Increased speed through the large bowel results in
watery stool as fluid is not resorbed
– Causes diarrhea
• Results in net fluid loss, with accompanying loss
of electrolytes
• Results in dehydration and electrolyte imbalance
• Requires rehydration and restoration of
electrolytes
16
Altered Motility in the Large Bowel (continued)
• Decreased speed of movement through
results in:
– Increased microbial metabolism of food
materials, resulting in production of:
• Gases (hydrogen, carbon dioxide, methane, and
others)
• Organic acids
• Other products of microbial activity
– Increased resorption of fluid
• Results in dry, hard stool
• Constipation
17
Fermentation
• All food materials not absorbed through the lining
of the small intestine pass into the large bowel
• Millions of bacteria colonise the organ
• Perform “end-stage digestion”
• Products of microbial activity can be important
nutrients:
– some B vitamins (pantothenic acid; biotin)
– vitamin K
18
Colonic Fermentation
• Plant foods contain two broad classes of
carbohydrates
1. Free sugars (glucose, fructose, sucrose)
2. Polysaccharides
• Free sugars are found mainly in fruit and
vegetables and are rapidly absorbed from the
small intestine in healthy humans
• Sugar is also present in milk, in the form of
lactose
19
Causes of Intestinal Symptoms:
Carbohydrates
• Non-digested carbohydrates pass into the large
intestine causing:
– Osmotic imbalance: causes excess fluid in the
lumen of the large bowel resulting in loose stool
– Increased bacterial fermentation resulting in
production of:
• organic acids (acetic, lactic, butyric, propionic)
– increase osmotic imbalance
• gases such as carbon dioxide and hydrogen
– cause bloating and flatulence
20
Causes of Intestinal Symptoms:
Carbohydrates (continued)
– Increased bulk results in increased stool volume
– Increased fluid and acid environment stimulate
intestinal motility and accelerate intestinal
transit time.
– Increased speed of intestinal transit results in:
• loose stool since fluid is not absorbed from
food
• Incomplete absorption of fat
21
Symptoms of Excessive Fermentation of
Carbohydrate
• Patients complain of abdominal fullness, bloating,
and cramping pain, sometimes within 5-30
minutes, sometimes several hours after ingesting
carbohydrate
• Watery diarrhoea occurs from 5 minutes to 5 hours
after ingestion
• Excoriation of perianal skin and buttocks due to
acid (pH less than 6) stool in children
– Adults do not consistently experience such a low stool
pH
22
Examples of Fermentation of Undigested Sugars:
Lactose Intolerance
•
•
Milk sugar, lactose, is digested by lactase enzyme
produced in the cells lining the digestive tract
Lactose is a disaccharide (double sugar) which
cannot be absorbed through the lining of the
digestive tract until it is broken down into its two
single sugars (monosaccharides):
–
–
•
Glucose
Galactose
Lack of lactase reserves makes lactose
particularly vulnerable to maldigestion
23
Sucrase-Isomaltase Deficiency
• Primary deficiency is rare: it is inherited as an
autosomal recessive gene
• Greenland and Canadian Inuit have an unusual
incidence of 10% of the population
• Appears when sucrose enters the child’s diet,
usually as fruit or fruit juice
• Severity of symptoms depends on the quantity of
sucrose in the diet
• In practice sucrose must be avoided
24
Fermentation of Undigested Polysaccharides:
Starch and Fibre
• Plant polysaccharides can be separated into two
broad categories:
1. Starch
2. Non-starch
Starch is:
–
–
a storage polysaccharide
the major carbohydrate of cereal grains and potatoes
Non-starch polysaccharides are:
–
–
structural components of the plant cell wall
considered the dietary fiber of foods
25
Starch
• Starch is found in many of the world’s staple
foods such as cereals, legumes, potatoes, and
bananas
• Usually starch in foods is readily digested in the
small intestine by enzymes produced in the
pancreas
• The products of digestion of starch are absorbed
into the body
• The process can be speeded up by cooking: starch
is gelatinized and rendered more available to the
enzymes
26
Resistant and Non-resistant Starch
• In the 1980s, research showed that a significant
portion of dietary starch may resist digestion and
pass intact into the colon
• Food processing can render some starch partly
resistant to enzymatic digestion
• This was classified as resistant starch
• Starch that is readily digested was called nonresistant starch
27
Resistant and Non-resistant Starch
(continued)
• All fibre and starch entering the large intestine is a
suitable substrate for bacterial fermentation
• Gas, bloating, pain may result from excessive
microbial fermentation
• Organic acids may be a source of irritation of
mucosal tissues
• Microbial fermentation of resistant starch and
fibre can produce volatile fatty acids which are
absorbed into the body from the colon, and may
help in protecting against disease such as colon
cancer
28
Resistant and Non-resistant Starch
(continued)
Cooking and processing can affect the digestibility
of starch:
• The quantity of some types of resistant starch in
foods is critically dependent on processing
conditions such as heating, cooling, freezing, or
drying:
– Starch from cereal products and freshly cooked potato
is well digested
– Cooled, cooked potato is less well digested than freshly
cooked potato
29
Resistant and Non-resistant Starch
(continued)
• This may also occur with other starches such as
rice and pasta
• Up to 89% of the starch from raw banana escapes
digestion in the small intestine
• A high percentage of other raw fruits and
vegetables may also be resistant to digestion in the
small intestine and can provide a rich source of
substrate for microbial fermentation
30
Comparison of Dietary Starch
a) Fed
b) Recovered after digestion in the small intestine
Food
Starch
Fed
(grams)
Starch
Recovered
(grams)
Percentage
Starch
Recovered
(%)
White bread
62
1.6
3
Oats
58
1.2
2
Cornflakes
74
3.7
5
Banana (raw)
19
17.2
89
Potato
freshly cooked 45
cooled
47
reheated
47
4.5
5.8
3.6
3
12
8
Englyst and Kingman 1994
31
Factors Affecting Amount of Starch
in the Colon
• Cooking
– Disrupts starch granules
– Facilitates digestion by enzymes in saliva and the small
intestine
– When foods with a high level of resistant starch are
eaten raw, more undigested starch passes into the colon
• e.g. Banana
– Retrograded starch increases on cooling: eat foods with
high level of resistant starch when it is hot
32
Factors Affecting Amount of Starch in the
Colon (continued)
• Chewing
– Amylase (ptyalin) in saliva is first enzyme to
start process of starch digestion
• The more the food is chewed, the greater the
exposure of the starch to enzymes in the mouth and
the small intestine
• Speed of transit of food
– The faster the food transits the small intestine,
the less exposure to enzymes
• High fat slows transit
• High fluid (water with the meal) speeds the transit
33
Dietary Fiber
“The sum of the non-starch polysaccharides in food”
• Not affected by food processing
• Includes a mixture of polymers such as cellulose,
pectin, and hemicellulose
• Resistant to human digestive enzymes and escape
breakdown in the small intestine
• May be classified as
– “soluble” (becomes gelatinized in water, especially
when heated)
– “insoluble” (remains unchanged in water)
34
Dietary Fiber (continued)
• Fibre resists digestion
• All types of fibre pass completely
undigested through the small intestine and
into the colon
• All carbohydrates that are not digested and
absorbed from the small intestine move into
the large intestine where they are fermented
by micro-organisms
35
Accessibility of Starch and Fibre in the Colon
• Physical accessibility
•
•
•
•
Cell walls of plant cells entrap starch
Prevents its swelling and dispersion
Delays or prevents digestion by enzymes
Includes whole grains, nuts, seeds:
– vegetables with “skins”: sweet corn, peas, beans
– partly milled grains and seeds: “whole grain” breads and
cereals
– If the rigid structures of the plant are physically
removed, the starch is exposed to the action of
enzymes in the small intestine
36
Role of Food in IBS
• Food does not cause IBS
• Food passing through “damaged organ”
continues or exacerbates the condition
• Food interacts with gastrointestinal tissues
in several ways:
– Immunologically
– Physiologically
– Biochemically
37
Diet for Management of Irritable
Bowel Syndrome
General Guidelines for Dietary Management
of IBS
1. Reduce inflammation in all parts of
the digestive tract
– Avoid inflammatory triggers
2. Reduce the amount of fermentable
substrate passing into the colon
– Increase digestion and absorption in the
small intestine
39
Dietary Management of IBS (continued)
Triggers and exacerbators of inflammation
include:
–
–
–
–
–
Allergens
Chemicals that enhance release of
inflammatory mediators (e.g. benzoates)
Raw foods
Alcohol
Caffeine and other methylxanthines
40
General Instructions
• It is important to eat a balanced diet complete in
all essential nutrients
• Eat three meals a day, with two or three snacks as
desired
• For each food avoided, substitute one of equal
nutritional value
• Supplemental micronutrients (vitamins and
minerals) can be taken
• Choose ones without additives (colour, sugar,
preservatives)
41
Summary of Dietary Guidelines:
Milk
AVOID: All milk and milk products
• Eliminate:
–
–
–
–
–
Milk
Cheese of all types
Yoghurt
Butter
Any food containing milk solids or derivatives
• Consume protein to level usually consumed as
milk products
• Add calcium and Vitamin D supplements to ageappropriate level
42
Summary of Dietary Guidelines:
Grains
• AVOID: Specific cereal grains and flours: wheat,
rye, oats, barley, and corn
• Use alternative grains to provide equivalent
nutrients:
–
–
–
–
Millet
Tapioca
Arrowroot
Sago
– Quinoa
– Amaranth
– Rice
43
Summary of Dietary Guidelines:
Fruit and Vegetables
COOK All:
–
–
•
Vegetables (including salad vegetables)
Fruits
Fruit and vegetable juices
Raw vegetables, raw salads, raw fruit, raw juices, are
not allowed
Corn is a grain, not a vegetable
Substitute with:
–
–
Tinned fruit
Pasteurised juices
44
Summary of Dietary Guidelines:
Spices and Herbs
AVOID: Spices (root, seed, bark of plant); examples:
– Cinnamon
– Coriander seed
– Curry spices
– Mustard seed
– Chilli seasoning spices
– Pepper
– Others
Substitute with:
• Herbs (leaves and flowers); examples:
–
–
–
–
Thyme
Sage
Rosemary
Oregano
– Mint
– Parsley
– Others
– Basil
– Coriander leaves
• Cooked garlic and ginger are allowed, if tolerated
45
Summary of Dietary Guidelines:
Disaccharides
Avoid:
•
Sucrose (Table sugar)
–
–
–
–
–
•
Granulated
Castor
Demerara
Brown
Syrup of any type
Substitute with:
–
–
–
Honey
Fructose (“fruit sugar”; laevulose)
Glucose (dextrose) is allowed but is not very sweet
46
Summary of Dietary Guidelines:
Legumes
AVOID: Legumes with indigestible, hard, outer skins;
examples:
– Dried peas and beans
– Green peas, sugar peas, lima beans, broad beans
Substitute with:
Runner beans, French beans, yellow wax beans, green
beans
– Dried legumes without outer skins (lentils, split peas)
– Legumes ground into flours (chick pea flour, soy flour,
black or red bean flour)
–
47
Summary of Dietary Guidelines:
Nuts and Seeds
AVOID: Whole nuts and seeds
• Eat as “butters” (paste) only; examples
–
–
–
–
–
–
Peanut butter (without any added sweeteners)
Almond butter
Cashew butter
Sesame butter and tahini
Sunflower seed butter
Pumpkin seed butter
48
Summary of Dietary Guidelines:
Meat and Fish
AVOID: “Deli meats” such as:
– Fermented sausages (salami, bologna,
pepperoni, hot dog wieners)
– Smoked meat or fish
Cook all meats and fish from fresh or frozen
sources
– No breaded, battered, sweet cured meats
– No smoked fish or meat
– Do not add cream sauces
49
Summary of Dietary Guidelines:
Fermented Foods and Beverages
AVOID: Alcoholic beverages of all types
AVOID: Vinegar and foods containing vinegar:
–
–
–
–
Pickles
Relish
Prepared mustard
Ketchup
AVOID: Fermented foods such as:
–
–
Sauerkraut
Soy sauce
50
Summary of Dietary Guidelines:
“Irritating” Foods and Beverages
AVOID: Caffeine and benzoates
Avoid coffees and regular tea
– Herbal tea (without spices) are allowed. Some
decaffeinated coffees contain chemicals to
which sensitive individuals react
– Note: If several cups of coffee or black tea are
consumed per day, reduce intake gradually;
sudden total withdrawal can produce
unpleasant side effects
51
Summary of Dietary Guidelines:
Vitamin and Mineral Supplements
To ensure adequate intake of micronutrients, a
multivitamin/mineral supplement is recommended
Supplement should be free from:
• Wheat
• Yeast
• Lactose
• Corn
• Additives such as artificial colours, flavours, and
preservatives.
52
Summary of Dietary Guidelines (continued)
–
–
–
People differ in their degree of reactivity to
some of the restricted foods
Many individuals do not react adversely to
vinegar and fermented foods
Some people can drink coffee and eat chocolate
but react adversely to tea (probably indicating
benzoate sensitivity rather than a reaction to
caffeine)
53
General Guidelines
• The diet is initially followed for four weeks
• If no improvement, keep a careful record of foods
consumed and symptoms experienced for a further
seven days
• Based on the food/symptom record, increase
restrictions for a further two weeks
• If still no improvement, proceed to reintroduction
of foods
54
Dietary Management of IBS
• Clinical experience has shown that a certain
degree of “healing” of the digestive tract may take
place, and over time some of the restricted foods
can be reintroduced into the diet
• When the initiating circumstances are repeated
(e.g. increased stress, recurrence of infection or
pathology), returning to the basic IBS diet often
again provides relief of GI tract symptoms
55
Dietary Management of IBS:
The Next Stage
If significant improvement is achieved open food
challenge may be initiated
• Use sequential incremental dose challenge (SIDC)
to determine sensitivity and limit of tolerance to
each eliminated food in its purest form
• Symptom-free status may be maintained by
avoiding the culprit foods and obtaining complete
balanced nutrition from alternative sources
56
Probiotics in Management of IBS
Lactobacilli, bifidobacteria and Streptococcus
thermophilus, assist in reducing the symptoms of
lactose intolerance
• Produce the enzyme beta-galactosidase (lactase) in
yogurt
• Microbial lactase breaks down lactose
• The fermented milk itself delays gastrointestinal
transit, thus allowing a longer period of time in
which both the human and microbial lactase
enzyme can act on the milk lactose.
57
Microflora and Lactose Intolerance
• Lactose tolerance in people who are deficient in
lactase may be improved by continued ingestion of
small quantities of milk
• Does not improve or affect the production of lactase
in the brush border cells of the small intestine
• Continued presence of lactose in the colon contributes
to the establishment and multiplication of bacteria
capable of synthesizing the beta-galactosidase
enzyme over time
• Resident micro-organisms will break down the
undigested lactose in the colon
• Reduces the osmotic imbalance within the colon that
is the cause of much of the distress of lactose
intolerance
58