Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome

doi:10.1053/j.gastro.2020.06.099

Gastroenterology

Volume 160, Issue 1, January 2021, Pages 47-62

https://doi.org/10.1053/j.gastro.2020.06.099 Get rights and content

Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.

Section snippets

Integrated Care Is Becoming the Rule Not the Exception for Irritable Bowel Syndrome

The main goals of treating patients with IBS are to improve overall symptoms, sense of well-being, and quality of life. Frustratingly, there is often discord between gastrointestinal (GI) symptom alleviation and improvements in quality of life. For instance, satisfaction with bowel movements is often not associated with objective change in the appearance or water content of feces.⁹ Likewise, reducing stool frequency with loperamide in patients with IBS with diarrhea (IBS-D) has a poor record of

Diet Therapies: Focus on the Low-FODMAP Diet

A number of diet interventions are utilized by patients with IBS and health care providers in the hope of improving symptoms and quality of life.⁷¹ Limited numbers of studies with small numbers of patients with IBS have evaluated the effectiveness of a gluten-free diet⁷² and elimination diets based on IgG antibody testing,⁷³ leukocyte activation testing⁷⁴ and confocal laser endomicroscopy after food challenges.⁷⁵ Of the available diet options for patients with IBS, the low-FODMAP diet is

Future Directions for Integrated Care

There is a growing body of evidence that supports the benefits of behavioral and diet interventions in patients with IBS. It is important for providers to understand the indications, benefits, and potential risks of these interventions. Questions around the effectiveness of these treatments are giving way to practical questions regarding proper implementation. In particular, access to adequately trained psychogastroenterologists and GI dietitians, as well as reimbursement for their services,

CRediT Authorship Contributions

William D. Chey, Professor of GI and Nutrition (Conceptualization: Lead; Project administration: Lead; Writing – original draft: Lead; Writing – review & editing: Lead). Laurie Keefer, PhD (Conceptualization: Equal; Writing – original draft: Supporting; Writing – review & editing: Supporting). Kevin Whelan, PhD (Conceptualization: Equal; Writing – original draft: Supporting; Writing – review & editing: Supporting). Peter R. Gibson, Professor of GI (Conceptualization: Equal; Writing – original

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Cited by (79)

Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome
2024, Clinical Gastroenterology and Hepatology
Irritable bowel syndrome (IBS) is a common, debilitating disorder characterized by abdominal pain and disordered bowel habits. Current pharmacologic treatments often provide incomplete symptom relief and may be poorly tolerated. Furthermore, alleviation of gastrointestinal symptoms does not always translate into improved quality of life for IBS patients. Current treatment guidelines recommend brain–gut behavior therapy (BGBT) in conjunction with other IBS therapies, and, in randomized controlled trials, BGBT has been shown to improve symptoms, patient satisfaction, functioning, and quality of life. Access to BGBT is limited by lack of adequately trained gastrointestinal psychologists, patient time constraints, and cost. Furthermore, clinician knowledge that BGBT is specific, and different from psychotherapy approaches for common mental health disorders, may limit referrals even where available. This review provides an overview of the pathophysiology of IBS, disease burden, unmet therapeutic needs, evidence base of novel digital therapeutics for IBS, and guidance on the introduction and appropriateness of these interventions for patients.
We searched the literature for available published data relating to the use of novel digital therapeutics to provide cognitive behavioral therapy and gut-directed hypnotherapy in the treatment of irritable bowel syndrome.
Clinical trial data support the development and utility of digital therapeutics designed to deliver self-guided cognitive behavioral therapy and hypnotherapy for the treatment of IBS.
BGBTs are effective, guideline-recommended treatments for IBS. Digital therapeutic devices offer accessible, cost-effective treatment options for delivery of adjunctive BGBT for the treatment of IBS. The decision to recommend digital BGBTs should be guided by careful patient assessment that includes mental health screening and risk assessment.
Dietary Interventions and Brain–Gut Disorders
2024, The Gut-Brain Axis, Second Edition
Several lines of evidence suggest that the gut microbiome may represent a valid target for new therapeutic interventions in relation to disorders of the gut–brain axis. Indeed, the concept of a microbiome–gut–brain axis has gained considerable traction in recent years. While several diseases and disorders may reflect disruption of, or dysfunction along, the microbiome–gut–brain axis this chapter will focus on one very common and challenging disorder long perceived as representing dysfunction along the gut–brain axis: irritable bowel syndrome (IBS). Recognizing the frequency with which patients report exacerbation of their IBS symptoms on eating there has been, of late considerable interest in diet in the treatment of IBS. A variety of dietary approaches have been advocated with the diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) achieving most traction. The physiological basis for its efficacy as well as evidence to support its efficacy are reviewed. While comparisons between the low FODMAP diet and other dietary approaches to IBS have yielded variable results, interest in the gluten-free diet has receded somewhat though it may be of benefit to certain select populations. Various therapeutic strategies have been employed to address gut microbial factors that may contribute to IBS and include probiotics, prebiotics, and postbiotics. With regard to prebiotics and probiotics, while a considerable volume of experimental data attests to their ability to address various pathophysiologic parameters relevant to IBS, the interpretation of clinical trials continues to pose challenges. Thus, while probiotics, in general, appear to be beneficial in IBS, less is known about ideal strain, preparation, and dosage; for prebiotics and postbiotics, data are scant but appear promising. More high-quality clinical trials are needed.
A Randomized Parallel-group Study of Digital Gut-directed Hypnotherapy vs Muscle Relaxation for Irritable Bowel Syndrome
2023, Clinical Gastroenterology and Hepatology
Gut-directed hypnotherapy (GDH) is effective for treating irritable bowel syndrome (IBS), but access limits its widespread use. We report the first randomized controlled trial comparing the safety and efficacy of a self-administered, digital GDH treatment program with that of digital muscle relaxation (MR) in adults with IBS.
After a 4-week run-in period, patients were randomized to 12 weeks of treatment with digital GDH (Regulora), or digital MR accessed via a mobile app on a smartphone or tablet. The primary endpoint was abdominal pain response, defined as ≥30% reduction from baseline in average daily abdominal pain intensity in the 4 weeks following treatment. Key secondary outcomes included mean change from baseline in abdominal pain, stool consistency, and stool frequency.
Of 378 randomized patients, 362 were treated and included in the efficacy analysis. A similar proportion of the GDH (30.4%) and MR (27.1%) groups met the primary endpoint, with no significant difference between the groups (P = .5352). Significantly more patients treated with GDH than MR were abdominal pain responders during the last 4 weeks of treatment (30.9% vs 21.5%; P = .0232) and over the entire treatment period (29.3% vs 18.8%; P = .0254). Improvements in abdominal pain, stool consistency, and stool frequency were consistent across IBS subtypes. No patients experienced serious adverse events or adverse events leading to study discontinuation.
Treatment with a digital GDH program led to an improvement in abdominal pain and stool symptoms in patients with IBS, supporting a role for this intervention as part of integrated care for IBS.
ClinicalTrials.gov identifier NCT04133519
Reply
2023, Clinical Gastroenterology and Hepatology
Role of Nutrition in Gastroesophageal Reflux, Irritable Bowel Syndrome, Celiac Disease, and Inflammatory Bowel Disease
2023, Gastro Hep Advances
There remains a paucity of data on the efficacy of nutritional interventions in luminal gastrointestinal disorders. This review appraises the evidence supporting dietary modification in gastroesophageal reflux disease (GERD), irritable bowel syndrome, Celiac disease, and inflammatory bowel disease.
Alhough the use of elimination diets; high fat/low carb; low fermentable oligosaccharides, disaccharides, monosaccharides and polyols; and lactose-free diets in GERD have been studied, the evidence supporting their efficacy remains weak and mixed. Patients with GERD should avoid eating within 3 hours of lying recumbent.
Studied dietary interventions for disorders of gut-brain interaction include low fermentable oligosaccharides, disaccharides, monosaccharides and polyols and gluten-restricted and lactose-free diets. While all can be effective in carefully, individually selected patients, the evidence for each intervention remains low.
In patients with inflammatory bowel disease, enteral nutrition is established in pediatric populations as useful in reducing inflammation and partial enteral nutrition has a growing evidence base for use in adults and children. Specific carbohydrate diets and the Crohn’s disease exclusion diet show promising evidence but require further study to validate their efficacy prior to recommendation.
Overall, the evidence supporting nutritional therapy across luminal gastrointestinal disorders is mixed and often weak, with few well-designed randomized controlled trials (RCTs) demonstrating consistent efficacy of interventions. RCTs, particularly cross-over RCTs, show potential to compare dietary interventions.
In Vitro Efficacy of Targeted Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols Enzymatic Digestion in a High-Fidelity Simulated Gastrointestinal Environment
2023, Gastro Hep Advances
Irritable bowel syndrome (IBS) is characterized by abdominal pain and changes in bowel habits. Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) are poorly absorbed short-chain carbohydrates that may drive commensal microbial gas production, promoting abdominal pain in IBS. Low-FODMAP diet can result in symptomatic improvement in 50%–80% of IBS patients. However, this diet is not meant to be sustained long term, with concern for downstream nutrition and microbial issues. In this study, we evaluate the function of a targeted FODMAP enzymatic digestion food supplement FODMAP enzymatic digestion (FODZYME) containing a fructan-hydrolase enzyme (with significant inulinase activity) in a simulated gastrointestinal environment.
Using SHIME (Simulator of the Human Intestinal Microbial Ecosystem), a multi-compartment simulator of the human gut, FODZYME dose finding assay in modeled gastrointestinal conditions assessed enzymatic ability to hydrolyze 3 g of inulin. Full intestinal modeling assessing digestion of inulin, absorption of fructose, gas production, and other measures of commensal microbial behavior was completed using 1.125 g of FODZYME.
After 30 minutes, 90% of the inulin was converted to fructose by 1.125 g of FODZYME. Doubling dosage showed no significant improvement in conversion, whereas a half dose decreased performance to 77.2%. Seventy percent of released fructose was absorbed during simulated small intestinal transit, with a corresponding decrease in microbial gas production, and a small decrease in butyrate and short-chain fatty acid production.
FODZYME specifically breaks down inulin in representative gastrointestinal conditions, resulting in decreased gas production while substantially preserving short-chain fatty acid and butyrate production in the model colon. Our results suggest dietary supplementation with FODZYME would decrease intestinal FODMAP burden and gas production.

View all citing articles on Scopus

: Conflicts of interest The authors disclose the following: William D. Chey: consultant for Allakos, Allergan, Alnylam, Arena, Biomerica, Cosmo, IM Health, Ironwood, Phathom, QOL Medical, Redhill, Ritter, Salix/Valeant, Takeda, Urovant Vibrant; research funding from Biomerica, Commonwealth Diagnostic International, QOL Medical, Salix, Vibrant; stock options with GI on Demand, Modify Health, Ritter. Laurie Keefer: consultant for Pfizer; research funding from Abbvie; stock options with metaMe Health, Trellus Health. Kevin Whelan: research grants from Almond Board of California; Clasado, Danone, International Nut and Dried Fruit Council; consultant with Danone; co-inventor of mobile application to assist patients following low-FODMAP diet. Peter R. Gibson: consultant or advisory board member for Allergan, Janssen, MSD, Pfizer, Anatara, Atmo Biosciences, Immunic Therapeutics, Novozymes, and Takeda; his institution has received speaking honoraria from Janssen, Shire, Bristol-Meyers Squibb, and Pfizer; he has received research grants for investigator-driven studies from MSD; stock options with Atmo Biosciences; his department financially benefits from the sales of a digital application and booklets on the FODMAP diet; and he has published 2 educational/recipe books on diet.

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Reviews and PerspectivesReviews in Basic and Clinical Gastroenterology and HepatologyBehavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome

Section snippets

Integrated Care Is Becoming the Rule Not the Exception for Irritable Bowel Syndrome

Diet Therapies: Focus on the Low-FODMAP Diet

Future Directions for Integrated Care

CRediT Authorship Contributions

Clin Nutr ESPEN

Clin Gastroenterol Hepatol

Clin Gastroenterol Hepatol

Pain

Neuroimage Clin

Behav Res Ther

Behav Res Ther

J Pain

Gastroenterology

Behav Res Ther

J Psychosom Res

Compr Psychiatry

J Psychosom Res

Pain

Gastroenterology

Clin Psychol Rev

Clin Gastroenterol Hepatol

Lancet Gastroenterol Hepatol

Behav Res Ther

Gastroenterology

Am J Clin Nutr

Gastroenterology

Am J Clin Nutr

Gastroenterology

Clin Gastroenterol Hepatol

Rome IV: the functional bowel disorders

Gastroenterology

Management of irritable bowel syndrome

JAMA

What causes functional gastrointestinal disorders? A proposed disease model

Am J Gastroenterol

American College of Gastroenterology monograph on the management of IBS

Am J Gastroenterol

What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ)

Am J Gastroenterol

The intestinal microenvironment and functional gastrointestinal disorders

Gastroenterology

Low FODMAP diet for irritable bowel syndrome: what we know and what we have yet to learn

Ann Rev Med

Anxiety, depression and distress among irritable bowel syndrome and their subtypes: an epidemiological population based study

Adv Biomed Res

Inaccuracy of patient-reported descriptions of and satisfaction with bowel actions in irritable bowel syndrome

Neurogastroenterol Motil

Management of irritable bowel syndrome with diarrhea: a review of nonpharmacological and pharmacological interventions

Therap Adv Gastroenterol

Burden of gastrointestinal symptoms in the United States: results of a nationally representative survey of over 71,000 Americans

Am J Gastroenterol

Fatigue in irritable bowel syndrome: a systematic review and meta-analysis of pooled frequency and severity of fatigue

Asian Nurs Res

Sleep disturbances in irritable bowel syndrome: a systematic review

Neurogastroenterol Motil

The increased level of depression and anxiety in irritable bowel syndrome patients compared with healthy controls: systematic review and meta-analysis

J Neurogastroenterol Motil

Integrated medical-psychiatric outpatient care in functional gastrointestinal disorders improves outcome: a pilot study

Eur J Gastroenterol Hepatol

Collaborative management of chronic illness

Ann Intern Med

Change in quality of life for patients with irritable bowel syndrome following referral to a gastroenterologist: a cohort study

PLoS One

Outcome of hospital outpatient treatment of functional gastrointestinal disorders

Intern Med J

Referrals to a tertiary hospital: a window into clinical management issues in functional gastrointestinal disorders

JGH Open

Delivery of care for functional gastrointestinal disorders: a systematic review

J Gastroenterol Hepatol

The potential of integrated nurse-led models to improve care for people with functional gastrointestinal disorders: a systematic review

Gastroenterol Nurs

The activities of a dietitian-led gastroenterology clinic using extended scope of practice

BMC Health Serv Res

Nurse-led clinics can manage faecal incontinence effectively: results from a tertiary referral centre

Colorectal Dis

Snapshot of an integrated psychosocial gastroenterology service

World J Gastroenterol

Performance of an algorithm-based approach to the diagnosis and management of functional gastrointestinal disorders: a pilot trial

Reviews and Perspectives
Reviews in Basic and Clinical Gastroenterology and Hepatology
Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome