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Functional digestive disorders and the role of diet
Prof. Giovanni Barbara
University if Bologna, Italy
Functional digestive disorders
and the role of diet
Giovanni Barbara
Department of Medical and Surgical Sciences
Alma Mate...
Up to 60% of the Population Reports GI Symptoms
Heartburn
Abdominal
pain /
bloating
Early satiety,
nausea
Constipation
Dia...
Burden of Gastrointestinal Disease
Peery AF et al., Gastroenterology 2012;143:1179–1187
Functional Gastro-Intestinal Disorders (FGID)
(Symptoms arising from the GI tract not explained by any detectable disease)...
The Common View of FGIDs
• The term ‘functional’ is often
improperly use to indicate an
‘idiopathic’ or ‘cryptogenetic’
co...
IBS Definition (Rome III Criteria)
Recurrent abdominal pain or discomfort for at least
3 days per month, during the last 3...
World Prevalence of IBS is High
Pooled global prevalence = 11.2% (range: 1.1 - 45%)
Enck P et al., Nature Reviews Disease ...
Incidence of IBS
Jones et al., Aliment Pharmacol Ther 2006;24:879-86
Age (years)
 Move out, leave home
 Change diet
 Start a new job
 Start & end relationships
Why Young Adults?
Why women?
IBS Subtypes
Longstreth GF et al. Gastroenterology 2006;130:1480-91
Bristol Stool Form Scale
% BM
hard or
lumpy
% BM loose...
Correlation between Transit Time and BSS
O'Donnell et al Br Med J 1990;300:439-40
Colonic
Transit
Time
(h)
Bristol stool f...
IBS Subgroups
 IBS-C: IBS with constipation; IBS-A: Alternating IBS; IBS-D: IBS with diarrhea
• 75% will experience excha...
Functional Constipation is Very Common
Rome II definition
 15% Canada
 14% Spain
 10% US
Longstreth et al., Gastroenter...
IBS-C and Functional Constipation Overlap
18%
Ford AC et al., Aliment Pharmacol Ther 2014;39:312-321
• Younger
• >Single
•...
Impact of IBS on Quality of Life (SF-36)
0
10
20
30
40
50
60
70
80
90MeanScore
HC (n=1.412)
IBS (n=1.302)
IBD (n=546)
Hear...
Work Productivity (WPAI: IBS-C)
(European IBIS-C Study)
0
10
20
30
40
50
60
Italy France Germany Spain Sweden UK
Presentei...
Total costs of IBS-C (direct and indirect)
(European IBIS-C Study)
0 500 1000 1500 2000 2500 3000
Total direct and indirec...
Mechanisms involved in irritable FGID
Psychosocial factors
Peripheral factors
Top – down
Bottom – up
Brain Gut Axis
IBS, i...
Colonic motor response to stress
Motility
3+
2+
1+
0
“Reassurance”
10 20 30 40
Time (min)
“Disease discovery”
Almy TP et a...
Intestinal Transit Times in IBS-C and FC
0
10
20
30
40
50
60
70
80
Small Bowel Total Colon Right Colon Left Colon Rectosig...
Visceral hypersensitivity in FGID
(decreased threshold for perception of stimuli)
Sensation  Discomfort  Pain
1 Richter ...
IBS is a micro-organic disease
Barbara G et al. Gastroenterology, in press
What diet are you on?
IBS Patient’s Perception on the Efficacy of Treatments
82%
67%
45%
27%
5%
10%
27%
16%
9%
17%
23%
53%
0%
10%
20%
30%
40%
50...
Perceived Food Intolerance in IBS
There is something wrong with food
84%
Böhn et al, Am J Gastro 2013; 108:634 – 641
 Management based on nature (IBS subtype) and severity of symptoms
 First line
• Dietary and lifestyle advice [eg, physi...
Simren M. Gastroenterology 2014;146:10-12
FODMAPS and IBS
Fermentable Oligo-, Di-, Mono-sAccharides and Polyols
= wheat, d...
Halmos EP et al., Gastroenterology 2014;146:67-75
Low FODMAD vs. Standard Diet
Controlled Cross-Over Study in 30 IBS Patie...
Chages in Microbiota
with a Diet Low in FODMAPs
Halmos EP, et al. Gut 2015;64:93–100
What do you think you’re gonna eat then?
The Low FODMAP Diet Concept
• All foods with a high content of
FODMAPs are replaced with low-
FODMAP foods from the same
g...
35
Benefits of dietary fibre in constipation
• Reduces intestinal transit
time
• Increases faecal mass
• Stool softening
Mechanisms of action
Eswaran et al 2013 Am J Gastroenterol
4g for every g dietary fibre
Tonini et al., Neuroscience 1996;73:287-97
Peristalsis and Related Neuronal Circuitries
Kiwifruit stimulates the growth
of beneficial colonic bacteria
Types of dietary fibre
Soluble and insoluble fibre often co-exist in intact plant cell walls
Short-chain Long-chain
Oligos...
Effect of fibre on global symptom improvement
Bijkerk et al, Aliment Pharmacol Ther 2004;19:245
SOLUBLE FIBRE
INSOLUBLE FI...
Response to fiber in patients with constipation
according to underlying mechanism
0
10
20
30
40
50
60
70
80
90
Slow Transi...
Kiwifruit in IBS-C and CIC
Study Design
• Non-randomized, placebo (non double
dummy) controlled study
• Two kiwifruit dail...
Effect of Kiwifruit on Colonic Transit Time
0
10
20
30
40
50
60
HC IBS - Pla IBS - Kiwi
Before After
Colonictransit(hrs)
P...
Results - Bowel Habit & Fecal Volume
Bowel Habit Frequency Fecal Volume
Asia Pac J Clin Nutr 2010;19 (4):451-457
• An open, non-controlled and
non-randomized longitud
• 46 patients with constipation
(Rome III criteria).
• Weeks 1 and 2...
Bowel Habit Characteristics
Frequency Ease of defecation Fecal Volume
Day Day Day
Cunillera O et al., Rev Esp Nutr Hum Die...
Functional Digestive Disorders and the Role of Diet by Giovanni Barbara
Functional Digestive Disorders and the Role of Diet by Giovanni Barbara
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Functional Digestive Disorders and the Role of Diet by Giovanni Barbara

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Prof. Giovanni Barbara, Professor of Medicine and Gastroenterology at the University of Bologna, Italy: http://www.kiwifruitsymposium.org/presentations/functional-gastrointestinal-disorders-and-the-role-of-diet/

Roughly 30% of the population is affected by at least one of the several functional gastrointestinal disorders (FGIDs) with functional dyspepsia, irritable bowel syndrome (IBS) and chronic constipation (CC) being the most common.

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Functional Digestive Disorders and the Role of Diet by Giovanni Barbara

  1. 1. Functional digestive disorders and the role of diet Prof. Giovanni Barbara University if Bologna, Italy
  2. 2. Functional digestive disorders and the role of diet Giovanni Barbara Department of Medical and Surgical Sciences Alma Mater Studiorum, University of Bologna, Italy (1088 – 2016)
  3. 3. Up to 60% of the Population Reports GI Symptoms Heartburn Abdominal pain / bloating Early satiety, nausea Constipation Diarrhea If you are symptom-free, you are in the minority! Thompson WG et al. Dig Dis Sci 2002; 47:225
  4. 4. Burden of Gastrointestinal Disease Peery AF et al., Gastroenterology 2012;143:1179–1187
  5. 5. Functional Gastro-Intestinal Disorders (FGID) (Symptoms arising from the GI tract not explained by any detectable disease) Gastro-Duodenal • Functional dyspepsia • Belching Disorders • Nausea and Vomiting Disorders Functional Bowel Disoders • Irritable Bowel Syndrome • Functional Constipation • Functional Bloating • Functional Diarrhea • Functional Abdominal Pain Ano-Recutum • Functional Incontinence • Functional Anorectal Pain • Dischezia Gallbladder/Sphincter of Oddi • Functional galbladder disorder • Functional SO disorder Esophagus • Functional heartburn • Gastro-Esophageal Reflux • Functional Dysphagia • Globus Drossman DA. Gastroenterology 2006;130:1377-90
  6. 6. The Common View of FGIDs • The term ‘functional’ is often improperly use to indicate an ‘idiopathic’ or ‘cryptogenetic’ condition • Patients are labelled as ‘neurotic’, ‘apprehensive’, otherwise healthy individuals with ‘an imaginary disease’
  7. 7. IBS Definition (Rome III Criteria) Recurrent abdominal pain or discomfort for at least 3 days per month, during the last 3 months associated with at least 2 of the following symptoms: Improvement with bowel movement Onset associated with changes in the frequency of bowel movements Onset associated with changes in the form of stool Longstreth et al., Gastroenterology 2006;130:1480-91
  8. 8. World Prevalence of IBS is High Pooled global prevalence = 11.2% (range: 1.1 - 45%) Enck P et al., Nature Reviews Disease Primers 2016;2:1-24
  9. 9. Incidence of IBS Jones et al., Aliment Pharmacol Ther 2006;24:879-86 Age (years)
  10. 10.  Move out, leave home  Change diet  Start a new job  Start & end relationships Why Young Adults?
  11. 11. Why women?
  12. 12. IBS Subtypes Longstreth GF et al. Gastroenterology 2006;130:1480-91 Bristol Stool Form Scale % BM hard or lumpy % BM loose or watery 0 25 50 75 100 0 25 50 75 100 IBS-U IBS-C IBS-M IBS-D 25% of BM is the threshold for classification Bristol types 1 and 2 Bristol types 1 and 6 Bristol types 6
  13. 13. Correlation between Transit Time and BSS O'Donnell et al Br Med J 1990;300:439-40 Colonic Transit Time (h) Bristol stool form score 1 2 3 4 5 6 7 80 40 0 Water contentFast
  14. 14. IBS Subgroups  IBS-C: IBS with constipation; IBS-A: Alternating IBS; IBS-D: IBS with diarrhea • 75% will experience exchange in subgroup over tim (more likely from IBS-A to IBS-C than to IBS-D Talley NJ et al. Am J Epidemiol.1995; 142:76 Guilera M et al., Am J Gastroenterol 2005;100:1174-84 Ersryd A t al., Aliment Pharmacol Ther 2007;26:953-61 IBS-A 19-49% IBS-D 15-36% IBS-C 19-44%
  15. 15. Functional Constipation is Very Common Rome II definition  15% Canada  14% Spain  10% US Longstreth et al., Gastroenterology 2006;130:1480-91
  16. 16. IBS-C and Functional Constipation Overlap 18% Ford AC et al., Aliment Pharmacol Ther 2014;39:312-321 • Younger • >Single • >Female • >Anxious Pain No pain Functional Constipation (n=513) IBS-C (n=173)
  17. 17. Impact of IBS on Quality of Life (SF-36) 0 10 20 30 40 50 60 70 80 90MeanScore HC (n=1.412) IBS (n=1.302) IBD (n=546) Heart failure (n=216) Hahn BA et al., Digestion 1999;60:77-81  Uso di risorse sanitarie  Produttività lavorativa
  18. 18. Work Productivity (WPAI: IBS-C) (European IBIS-C Study) 0 10 20 30 40 50 60 Italy France Germany Spain Sweden UK Presenteism Absenteism Barbara et al., FISMAD 2015
  19. 19. Total costs of IBS-C (direct and indirect) (European IBIS-C Study) 0 500 1000 1500 2000 2500 3000 Total direct and indirect costs Direct costs (NHS) Direct costs (Patient) Indirect costs € / patient / 12 months (mean ± 95% CI) Barbara et al., FISMAD 2015
  20. 20. Mechanisms involved in irritable FGID Psychosocial factors Peripheral factors Top – down Bottom – up Brain Gut Axis IBS, irritable bowel syndrome
  21. 21. Colonic motor response to stress Motility 3+ 2+ 1+ 0 “Reassurance” 10 20 30 40 Time (min) “Disease discovery” Almy TP et al. Gastroenterology 1949;12:437-49
  22. 22. Intestinal Transit Times in IBS-C and FC 0 10 20 30 40 50 60 70 80 Small Bowel Total Colon Right Colon Left Colon Rectosigmoid HC IBS-C FC TransitTime(h) * * * * * * Rao SSC et al., Neurogastroenterol Motil (2011) 23, 8–23
  23. 23. Visceral hypersensitivity in FGID (decreased threshold for perception of stimuli) Sensation  Discomfort  Pain 1 Richter J et al., Gastroenterology 1986;91:845-52 2 Tack J et al., Gastroenterology 2001;121:526-35 3 Mertz H et al., Gastroenterology 1995;109:40-52 4 Azpiroz F et al., Neurogastroenterol Motil 2007;19 (S1):62-88NCCP, non-cardiac chest pain Normosensitive Hypersensitive 50 0 %ofpatientswith hypersensitivity 100 NCCP(1) FD(2) IBS(3,4)
  24. 24. IBS is a micro-organic disease Barbara G et al. Gastroenterology, in press
  25. 25. What diet are you on?
  26. 26. IBS Patient’s Perception on the Efficacy of Treatments 82% 67% 45% 27% 5% 10% 27% 16% 9% 17% 23% 53% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Diet Drugs (Prescription) Drugs (OTC) Alternative Therapies Yes No Don't Know Lacy BE et al., Aliment Pharmacol Ther 2007;25:1329-41
  27. 27. Perceived Food Intolerance in IBS There is something wrong with food 84% Böhn et al, Am J Gastro 2013; 108:634 – 641
  28. 28.  Management based on nature (IBS subtype) and severity of symptoms  First line • Dietary and lifestyle advice [eg, physical activity, low FODMAP, probiotics]: IBS • Anti-spasmodics [eg, otilonium bromide]: IBS pain / bloating • Laxatives [eg, PEG]: IBS-C • Anti-diarrhoeals [loperamide]: IBS-C  Second line • Antidepressants [TCA or SSRIs]: IBS (pain / psychological impairment) • Linaclotide [guanylate cyclase-C agonist]: IBS-C • Lubiprostone [Cl- channel-2 agonist]: IBS-C • Cholestiramine [bile acid sequestrant] if BAM suspected: IBS-D • Rifaximin [non-absorbable antibiotic]: IBS-D / IBS-M • Ondansetron / alosetron [5HT-3 antagonists]: IBS-D Irritable Bowel Syndrome – NICE Guidance Hookway C et al., Br Med J 2015;350
  29. 29. Simren M. Gastroenterology 2014;146:10-12 FODMAPS and IBS Fermentable Oligo-, Di-, Mono-sAccharides and Polyols = wheat, dairy, onions, celery and many processed foods
  30. 30. Halmos EP et al., Gastroenterology 2014;146:67-75 Low FODMAD vs. Standard Diet Controlled Cross-Over Study in 30 IBS Patients Overall symptoms
  31. 31. Chages in Microbiota with a Diet Low in FODMAPs Halmos EP, et al. Gut 2015;64:93–100
  32. 32. What do you think you’re gonna eat then?
  33. 33. The Low FODMAP Diet Concept • All foods with a high content of FODMAPs are replaced with low- FODMAP foods from the same groups • If the response is excellent, then patients follow an individualized, step-down food reintroduction plan to determine their tolerance to specific FODMAPs Gibson et a., Gastroenterology 2015;148:1158-74 Fruit Lactose containing foods Vegetables LOW FODMAP High FODMAP Food Category
  34. 34. 35 Benefits of dietary fibre in constipation • Reduces intestinal transit time • Increases faecal mass • Stool softening
  35. 35. Mechanisms of action Eswaran et al 2013 Am J Gastroenterol 4g for every g dietary fibre
  36. 36. Tonini et al., Neuroscience 1996;73:287-97 Peristalsis and Related Neuronal Circuitries
  37. 37. Kiwifruit stimulates the growth of beneficial colonic bacteria
  38. 38. Types of dietary fibre Soluble and insoluble fibre often co-exist in intact plant cell walls Short-chain Long-chain Oligosaccharides FOS, GOS Resistant starch Pectin Inulin Guar gum Psyllium Ispaghula Oats Wheat bran Lignin Some fruit & vegetables Cellulose Sterculia Methylcellulose Fermentability      Solubility     
  39. 39. Effect of fibre on global symptom improvement Bijkerk et al, Aliment Pharmacol Ther 2004;19:245 SOLUBLE FIBRE INSOLUBLE FIBRE Arthurs and Fielding, 1983 Jalihal and Kurian, 1999 Longstreth et al., 1981 Nigam et al., 1984 Prior and Whorwell, 1987 Toskes et al., 1993 Ritchie and Truelove, 1979 Ritchie and Truelove, 1980 Cook et al., 1990 Fowlie et al., 1992 Snook and Shepherd, 1994 Soltoft et al., 1976 Subtotal (95%CI) (56% pla vs 50% treatment) Test for heterogeneity chi square=0.68; P=0.88 Test for overall effect z=-1.01; P=0.3 Subtotal (95%CI) (41% pla vs 64% treatment) Test for heterogeneity chi square=13.44; P=0.062 Test for overall effect z=6.31; P<0.0001 Favours control Favours treatment Total (95%CI) (45% pla vs 60% treatment) Test for heterogeneity chi square=27.97; P=0.0033 Test for overall effect z=4.93; P<0.00001 -2-1 1 105
  40. 40. Response to fiber in patients with constipation according to underlying mechanism 0 10 20 30 40 50 60 70 80 90 Slow Transit Disordered defecation No pathological findings %Responders Voderholzer WA et al., Am J Gastroenterol 1997;92:95–8
  41. 41. Kiwifruit in IBS-C and CIC Study Design • Non-randomized, placebo (non double dummy) controlled study • Two kiwifruit daily intervention (Actinida deliciosa) • Two weeks run-in; four weeks intervention; 1 week follow-up • Fifty-four patients with IBS/C and 16 healthy adults Asia Pac J Clin Nutr 2010;19 (4):451-457
  42. 42. Effect of Kiwifruit on Colonic Transit Time 0 10 20 30 40 50 60 HC IBS - Pla IBS - Kiwi Before After Colonictransit(hrs) P=0.079 P=0.493 P=0.012 ** Asia Pac J Clin Nutr 2010;19 (4):451-457
  43. 43. Results - Bowel Habit & Fecal Volume Bowel Habit Frequency Fecal Volume Asia Pac J Clin Nutr 2010;19 (4):451-457
  44. 44. • An open, non-controlled and non-randomized longitud • 46 patients with constipation (Rome III criteria). • Weeks 1 and 2 no kiwifruit and weeks 3-5 three kiwifruit per day (Green kiwifruit, Actinidia • deliciosa var Hayward) Kiwifruit in IBS-C and Constipation Study Design Cunillera O et al., Rev Esp Nutr Hum Diet. 2015;19: 58-67
  45. 45. Bowel Habit Characteristics Frequency Ease of defecation Fecal Volume Day Day Day Cunillera O et al., Rev Esp Nutr Hum Diet. 2015;19: 58-67

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