Food: The Forgotten Factor in the Irritable Bowel Syndrome
Section snippets
The scope of the problem
Adverse reactions to food are acknowledged by 5% to 45% of the general population,3, 4, 5 and GI complaints are predominant in approximately one-third to one-half of those affected.1, 6 Offending foods are often referred to as trigger foods, dietary triggers, or culprit foods,7 sometimes leading to a nutritionally inadequate diet.3 Although food intolerance is a common perception among the general population, it can be demonstrated in only a relatively small proportion of the population when
How does food cause IBS symptoms?
Food processing is the primary function of the gastrointestinal (GI) tract, and food ingestion, through mechanosensation and nutrient sensing, causes major changes in GI sensorimotor and secretory function, which may contribute to symptom generation in IBS. On ingestion of nutrients, the proximal stomach relaxes and upper GI motility switches from interdigestive to fed state motility, characterized by phasic contractions in the antrum and the small bowel.24 In addition, food ingestion
Food allergy versus food intolerance
Up to 25% of the general US population believes they have an FA.48 True FA, however, occurs in approximately 4% to 8% of children and 1% to 4% of adults in the United States. Although controversial, there are data to suggest that the prevalence of FA is increasing.49, 50, 51, 52, 53 Few children retain their FA into adulthood, which accounts for the decrease in prevalence between children and adults. Many studies demonstrate that 50% to 90% of presumed food allergies are not actually allergies
Food allergy and food intolerance in IBS
Many studies have tried to examine the prevalence of FA in patients with GI symptoms. In one study of patients with IBS and inflammatory bowel disease (IBD), 32% complained of adverse reactions to food as a cause of their GI symptoms.8 FA was suspected, however, according to several criteria in only 14% and could be confirmed by endoscopic allergen provocation and/or elimination diet and rechallenge in only 3.2% of patients. Similar results were reported by Dainese and colleagues10 who found no
Elimination diets
Many investigators have investigated dietary manipulation as a potential treatment strategy for patients with IBS. In 1982, Jones and colleagues12 were among the first to demonstrate symptom improvement after an elimination diet in two-thirds of their IBS patients. Based on such results, they and others hypothesized that food intolerance was the major factor underlying the pathogenesis of IBS and that a therapy based on a diet that excluded certain foods could be effective in IBS patients11
Fiber Supplements
Although increasing dietary fiber continues to be a standard recommendation for patients with IBS, the efficacy of fiber for IBS is more nuanced than appreciated by most clinicians. A recent systematic review and meta-analysis, which evaluated the efficacy of fiber as a treatment for IBS, included 12 trials and 591 patients.76 Included studies compared various forms of fiber with placebo or, in one study, a low-fiber diet. Two of the studies included only IBS-C patients and another had 49%
Concluding comments
Many of the therapeutic options commonly used for IBS have proved unsatisfactory both to patients and providers, likely due to the inherent complexity and heterogeneity of the disorder. In a subset of patients, diet seems to play a role in the development of symptoms. Many patients are now demanding a more holistic approach to their care. Although dietary interventions may be the low-hanging fruit for such patients, their success is highly dependent on the presence of a motivated patient and
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Conflicts of Interest: The authors declare no conflict of interest and have nothing to disclose.