The Royal Victoria Hotel in Sheffield, with its imposing red brick facade and the faded grandeur of its interior has not changed much since Oscar Wilde stayed there over a hundred years ago. Only the station has gone, demolished to make space for a car park.
Once the venue for grand civic receptions, today the ballroom hosted The National Dietetic Gastroenterology Symposium. I dropped in at coffee time to chat to friends and learn the latest updates on diet and IBS from the experts.
What a difference a year makes? Opinions about diets for IBS seem to have softened; less reiteration of dogma and more clinical observation and honest reflection of the patients’ experience.
Professor David Sanders appealed to the common sense of his audience as he outlined the spectrum of wheat intolerance in IBS; all the way from undiagnosed coeliac disease, to what he called coeliac lite, where the requirements for gluten restriction were not as great, to non-coeliac gluten sensitivity (NCGS), where people have the genetic markers for coeliac disease, but no antibodies or villous atrophy, to people who may be on a gluten free diet but are probably sensitive to the fructans (FODMAPs) in wheat or just the idea of wheat (the nocebo effect). ‘Having excluded coeliac disease’, Professor Sanders said, ‘I offer patients the choice of whether to take a low FODMAP or gluten free diet’. Many find a gluten free diet simpler and do quite well’.
While talking over coffee, others recommended an adapted low FODMAP diet, low in pulses and onions, or low in fruit reduces symptoms without going through the total exclusion, piecemeal reintroduction protocol. Specialist dietitian, Yvonne Mackenzie, offered the intelligent expedient of taking a detailed diet history and reducing the FODMAP components that were most prevalent in the diet. When all is said and done, the success of any diet depends upon the ease to which patients can adapt it to suit themselves.
By no means, A Woman of No Importance, Marianne Williams runs a dietary clinic for patients with IBS not far from East Coker, in Yeovil. Somerset. She treats most of her patients with a low FODMAP diet, but she illustrated the importance of taking a careful medical, dietary and family history by two detailed case studies. The first patient had suffered from rashes, joint pains, abdominal pains, bowel upset, migraines and chronic fatigue for most of her life. Her brother also had extensive eczema. This suggested a familial allergy. Within two weeks of starting a gluten free diet, the joint pains disappeared and over the next month or so, the rest of the symptoms also vanished. Two years later, she remains on a gluten free diet and is free of symptoms. Another woman had colic in infancy and has endured a lifetime of severe constipation. On the basis of her history, Ms Willams suspected milk allergy. She excluded dairy from her diet and for the first time in her life, started to pass normal stools. These case histories prompted the conclusion: Don’t assume that everybody will respond to a low FODMAP diet; take a detailed history and keep an open mind.
Today’s keynote lecture was delivered by Kevin Whelan, Professor of Nutrition and Dietetics at Kings College, London. His major interests are the microbiome and probiotics, but in recent years his department has become the UK centre for educating dietitians and patients about the low FODMAP diet. Dr Whelan’s presentation epitomised The Importance of Being Earnest’. While emphasising the effectiveness of a low FODMAP diet for relieving the symptoms of IBS, he nevertheless indicated his concern over the effect of the diet in depleting and destabilising the microbiome, as noted in a recent post in this blog.
Data on probiotics for IBS are mixed; some studies show good results; others less good, but firm conclusions are prevented by the enormous variety of probiotics and the combinations of delivery systems. It would seem on theoretical and experimental grounds that a liquid based live suspension in a prebiotic medium might have advantages, but this has not been sufficiently established by clinical trials. Recent studies, published in abstract form for meetings have shown that giving probiotics at the same time as the low FODMAP diet restored bacterial counts in some but not all individuals, while giving beta galacto-oligosaccharide (Bimuno), a non gas-producing prebiotic, with a low FODMAP diet caused a slightly greater reduction of symptoms, but did not restore the depleted bacterial counts. In view of the variable responses of IBS patients to dietetic treatment, Dr Whelan’s team has now embarked on studies to define which the characteristics of the faecal microbiome that would predict response to probiotics or a low FODMAP diet. This might allow treatment to be customized, ushering the concept of personalised dietary therapy for IBS.
Experimental evidence suggests that although foods high in FODMAPs can retain fluid in the gut and/or generate gas, they only tend to cause symptoms if the gut is sensitive. This begs the question, ‘What makes the gut sensitive in the first place and can that be reversed?’ Three major factors would seem to cause long term sensitization of the gut. These are: a previous attack of gastroenteritis, a traumatic experience and depletion of the microbiome by, for example, courses of broad spectrum antibiotics. They often occur in combination. As a psychotherapist, I find that trauma, ongoing stress and existential issues such as lack of personal freedom, entrapment, being ignored, feelings of emptiness, fear of death, can appear to play an important role in generating symptoms and it seems likely that these might act via the autonomic nervous system to enhance visceral sensitivity. So perhaps the personalised approach to treating IBS is not just about a detailed diet history and investigation of differences in the microbiome, it might also encompass enquiry into the developmental and traumatic circumstances that may have predisposed to visceral sensitivity. Like The Picture of Dorian Gray, illness can never ignore the things that people do or what happens to them.