Ehealth:Low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome

AIM:To investigate the effects of a low fermentable,oligosaccharides,disaccharides,monosaccharides and polyols diet(LFD)and the probiotic Lactobacillus rhamnosus GG(LGG)in irritable bowel syndrome(IBS).METHODS:Randomised,unblinded controlled trial on the effect of 6-wk treatment with LFD,LGG or a normal Danish/Western diet(ND)in patients with IBS fulfilling Rome III diagnostic criteria,recruited betweenNovember 2009 and April 2013.Patients were required to complete on a weekly basis the IBS severity score system(IBS-SSS)and IBS quality of life(IBS-QOL)questionnaires in a specially developed IBS web selfmonitoring application.We investigated whether LFD or LGG could reduce IBS-SSS and improve QOL in IBS patients.RESULTS:One hundred twenty-three(median age 37years,range:18-74 years),90(73%)females were randomised:42 to LFD,41 to LGG and 40 to ND.A significant reduction in mean±SD of IBS-SSS from baseline to week 6 between LFD vs LGG vs ND was revealed:133±122 vs 68±107,133±122 vs 34±95,P<0.01.Adjusted changes of IBS-SSS for baseline covariates showed statistically significant reduction of IBS-SSS in LFD group compared to ND(IBS-SSS score75;95%CI:24-126,P<0.01),but not in LGG compared to ND(IBS-SSS score 32;95%CI:18-80,P=0.20).IBS-QOL was not altered significantly in any of the three groups:mean±SD in LFD 8±18 vs LGG 7±17,LFD 8±18 vs ND 0.1±15,P=0.13.CONCLUSION:LFD is efficacious for patients with IBS.

Low-FODMAP diet reduces irritable bowel symptoms in patients with inflammatory bowel disease

AIM To investigate the effect of a low-FODMAP diet on irritable bowel syndrome(IBS)-like symptoms in patients with inflammatory bowel disease(IBD).METHODS This was a randomised controlled open-label trial of patients with IBD in remission or with mild-to-moderate disease and coexisting IBS-like symptoms(Rome III) randomly assigned to a Low-FODMAP diet(LFD) or a normal diet(ND) for 6 wk between June 2012 andDecember 2013. Patients completed the IBS symptom severity system(IBS-SSS) and short IBD quality of life questionnaire(SIBDQ) at weeks 0 and 6. The primary end-point was response rates(at least 50-point reduction) in IBS-SSS at week 6 between groups; secondary end-point was the impact on quality of life. RESULTS Eighty-nine patients, 67(75%) women, median age 40, range 20-70 years were randomised: 44 to LFD group and 45 to ND, from which 78 patients completed the study period and were included in the final analysis(37 LFD and 41 ND). There was a significantly larger proportion of responders in the LFD group(n = 30, 81%) than in the ND group(n = 19, 46%);(OR = 5.30; 95%CI: 1.81-15.55, P < 0.01). At week 6, the LFD group showed a significantly lower median IBSSSS(median 115; inter-quartile range [IQR] 33-169) than ND group(median 170, IQR 91-288), P = 0.02. Furthermore, the LFD group had a significantly greater increase in SIBDQ(median 60, IQR 51-65) than the ND group(median 50, IQR 39-60), P < 0.01.CONCLUSION In a prospective study, a low-FODMAP diet reduced IBS-like symptoms and increased quality of life in patients with IBD in remission.

Follow-up of patients with functional bowel symptoms treated with a low FODMAP diet

AIM: To investigate patient-reported outcomes from, and adherence to, a low FODMAP diet among patients suffering from irritable bowel syndrome and inflammatory bowel disease.METHODS: Consecutive patients with irritable bowel syndrome(IBS) or inflammatory bowel disease(IBD) and co-existing IBS fulfilling the ROME Ⅲ criteria, who previously attended an outpatient clinic for low FODMAP diet(LFD) dietary management and assessment by a gastroenterologist, were invited to participate in a retrospective questionnaire analysis. The questionnaires were sent and returned by regular mail and gathered information on recall of dietarytreatment, efficacy, symptoms, adherence, satisfaction, change in disease course and stool type, and quality of life. Before study enrolment all patients had to sign an informed written consent.RESULTS: One hundred and eighty patients were included, 131(73%) IBS and 49(27%) IBD patients. Median age was 43 years(range: 18-85) and 147(82%) were females. Median follow-up time was 16 mo(range: 2-80). Eighty-six percent reported either partial(54%) or full(32%) efficacy with greatest improvement of bloating(82%) and abdominal pain(71%). The proportion of patients with full efficacy tended to be greater in the IBD group than in the IBS group(42% vs 29%, P = 0.08). There was a significant reduction in patients with a chronic continuous disease course in both the IBS group(25%, P < 0.001) and IBD group(23%, P = 0.002) along with a significant increase in patients with a mild indolent disease course of 37%(P < 0.001) and 23%(P = 0.002), respectively. The proportion of patients having normal stools increased with 41% in the IBS group(P < 0.001) and 66% in the IBD group(P < 0.001). One-third of patients adhered to the diet and high adherence was associated with longer duration of dietary course(P < 0.001). Satisfaction with dietary management was seen in 83(70%) IBS patients and 24(55%) IBD patients. Eightyfour percent of patients lived on a modified LFD, where some foods rich in FODMAPs were reintroduced, and 16% followed the LFD by the book without deviations. Wheat, dairy products, and onions were the foods most often not reintroduced by patients.CONCLUSION: These data suggest that a diet low in FODMAPs is an efficacious treatment solution in the management of functional bowel symptoms for IBS and IBD patients.

Systematic review of the prevalence and development of osteoporosis or low bone mineral density and its risk factors in patients with inflammatory bowel disease

BACKGROUND The inflammatory bowel diseases(IBD),Crohn’s disease(CD)and ulcerative colitis(UC)are chronic,immune-mediated disorders of the digestive tract.IBD is considered to be a risk factor for developing osteoporosis;however current literature on this matter is inconsistent.AIM To assess prevalence and development of osteoporosis and low bone mineral density(BMD),and its risk factors,in IBD patients.METHODS Systematic review of population-based studies.Studies were identified by electronic(January 2018)and manual searches(May 2018).Databases searched included EMBASE and PubMed and abstracts from 2014-2018 presented at the United European Gastroenterology Week,the European Crohn’s and Colitis Organisation congress,and Digestive Disease Week were screened.Studies were eligible for inclusion if they investigated either the prevalence of osteoporosis or osteopenia and/or risk factors for osteoporosis or low BMD in IBD patients.Studies on children under the age of 18 were excluded.Only population-based studies were included.All risk factors for osteoporosis and low BMD investigated in any included article were considered.Study quality and the possibility of bias were analysed using the Newcastle-Ottawa scale.RESULTS Twelve studies including 3661 IBD patients and 12789 healthy controls were included.Prevalence of osteoporosis varied between 4%-9%in studies including both CD and UC patients;2%-9% in studies including UC patients, and 7%-15% instudies including CD patients. Among healthy controls, prevalence ofosteoporosis was 3% and 10% in two studies. CD diagnosis, lower body massindex (BMI), and lower body weight were risk factors associated withosteoporosis or low BMD. Findings regarding gender showed inconsistent results.CD patients had an increased risk for osteoporosis or low BMD over time, whileUC patients did not. Increased age was associated with decreased BMD, and therewas a positive association between weight and BMI and BMD over time. Greatheterogeneity was found in the included studies in terms of study methodologies,definitions and the assessment of osteoporosis, and only a small number ofpopulation-based studies was available.CONCLUSIONThis systematic review found a possible increase of prevalence of osteoporosis inCD cohorts when compared to UC and cohorts including both disease types.Lower weight and lower BMI were predictors of osteoporosis or low BMD in IBDpatients. The results varied considerably between studies.

Ehealth monitoring in irritable bowel syndrome patients treated with low fermentable oligo-, di-, mono-saccharides and polyols diet

In the present study we report on changes in irritable bowel syndrome-severity scoring system(IBS-SSS)and irritable bowel syndrome-quality of life(IBS-QoL)in 19 IBS patients,aged 18 to 74 years(F/M:14/5),during 12 wk registering their symptoms on the webapplication(www.ibs.constant-care.dk).During a control period of the first 6-wk patients were asked to register their IBS-SSS and IBS-QoL on the web-application weekly without receiving any intervention.Thereafter,low fermentable oligo-,di-,mono-saccharides and polyols(FODMAP)diet(LFD)was introduced for the next6 wk while continuing the registration.Though a small sample size a significant improvement in disease activity(IBS-SSS)was observed during both the control period,median:278(range:122-377),P=0.02,and subsequently during the LFD period,median:151(range:29-334),P<0.01.The IBS-QoL solely changed significantly during the LFD period,median:67(37-120),P<0.01.The significant reduction in disease activity during the control period shows a positive effect of the web-application on IBS symptoms when presented as a"traffic light".However adding the diet reduced IBSSSS to<150,inactive to mild symptoms.In the future results from larger scale trials are awaited.

Individualized home-monitoring of disease activity in adult patients with inflammatory bowel disease can be recommended in clinical practice: A randomized-clinical trial

BACKGROUND The optimal way to home-monitor patients with inflammatory bowel disease(IBD)for disease progression or relapse remains to be found.AIM To determine whether an electronic health(eHealth)screening procedure for disease activity in IBD should be implemented in clinical practice,scheduled every third month(3M)or according to patient own decision,on demand(OD).METHODS Adult IBD patients were consecutively randomized to 1-year open-label eHealth interventions(3M vs OD).Both intervention arms were screening for disease activity,quality of life and fatigue and were measuring medical compliance with the constant care web-application according to the screening interventions OD or 3M.Disease activity was assessed using home measured fecal calprotectin(FC)and a disease activity score.RESULTS In total,102 patients were randomized(n=52/503M/OD)at baseline,and 88 patients completed the 1-year study(n=433M;n=45 OD).No difference in the two screening procedures could be found regarding medical compliance(P=0.58),fatigue(P=0.86),quality of life(P=0.17),mean time spent in remission(P>0.32),overall FC relapse rates(P=0.49),FC disease courses(P=0.61),FC time to a severe relapse(P=0.69)and remission(P=0.88)during 1 year.Median(interquartile range)numbers of FC home-monitoring test-kits used per patient were significantly different,3M:6.0(5.0-8.0)and OD:4.0(2.0-9.0),P=0.04.CONCLUSION The two eHealth screening procedures are equally good in capturing a relapse and bringing about remission.However,the OD group used fewer FC home testkits per patient.Individualized screening procedures can be recommended for adult IBD patients in clinical web-practice.

Epidemiology of inflammatory bowel disease in racial and ethnic migrant groups

AIM To summarise the current literature and define patterns of disease in migrant and racial groups.METHODS A structured key word search in Ovid Medline and EMBASE was undertaken in accordance with PRISMA guidelines. Studies on incidence, prevalence and disease phenotype of migrants and races compared with indigenous groups were eligible for inclusion. RESULTS Thirty-three studies met the inclusion criteria. Individual studies showed significant differences in incidence, prevalence and disease phenotype between migrants or race and indigenous groups. Pooled analysis could only be undertaken for incidence studies on South Asians where there was significant heterogeneity between the studies [95% for ulcerative colitis(UC), 83% for Crohn's disease(CD)]. The difference between incidence rates was not significant with a rate ratio South Asian: Caucasian of 0.78(95%CI: 0.22-2.78) for CD and 1.39(95%CI: 0.84-2.32) for UC. South Asians showed consistently higher incidence and more extensive UC than the indigenous population in five countries. A similar pattern was observed for Hispanics in the United States. Bangladeshis and African Americans showed an increased risk of CD with perianal disease. CONCLUSION This review suggests that migration and race influence the risk of developing inflammatory bowel disease. This may be due to different inherent responses upon exposure to an environmental trigger in the adopted country. Further prospective studies on homogenous migrant populations are needed to validate these observations, with a parallel arm for in-depth investigation of putative drivers.

Ethnic differences in inflammatory bowel disease: Results from the United Kingdom inception cohort epidemiology study

BACKGROUND The current epidemiology of inflammatory bowel disease(IBD)in the multiethnic United Kingdom is unknown.The last incidence study in the United Kingdom was carried out over 20 years ago.AIM To describe the incidence and phenotype of IBD and distribution within ethnic groups.METHODS Adult patients(>16 years)with newly diagnosed IBD(fulfilling Copenhagen diagnostic criteria)were prospectively recruited over one year in 5 urban catchment areas with high South Asian population.Patient demographics,ethnic codes,disease phenotype(Montreal classification),disease activity and treatment within 3 months of diagnosis were recorded onto the Epicom database.RESULTS Across a population of 2271406 adults,339 adult patients were diagnosed with IBD over one year:218 with ulcerative colitis(UC,64.3%),115 with Crohn's disease(CD,33.9%)and 6 with IBD unclassified(1.8%).The crude incidence of IBD,UC and CD was 17.0/100000,11.3/100000 and 5.3/100000 respectively.The age adjusted incidence of IBD and UC were significantly higher in the Indian group(25.2/100000 and 20.5/100000)compared to White European(14.9/100000,P=0.009 and 8.2/100000,P<0.001)and Pakistani groups(14.9/100000,P=0.001 and 11.2/100000,P=0.007).The Indian group were significantly more likely to have extensive disease than White Europeans(52.7%vs 41.7%,P=0.031).There was no significant difference in time to diagnosis,disease activity and treatment.CONCLUSION This is the only prospective study to report the incidence of IBD in an ethnically diverse United Kingdom population.The Indian ethnic group showed the highest age-adjusted incidence of UC(20.5/100000).Further studies on dietary,microbial and metabolic factors that might explain these findings in UC are underway.

Artificial intelligence assisted assessment of endoscopic disease activity in inflammatory bowel disease

Assessment of endoscopic disease activity can be difficult in patients with inflammatory bowel disease(IBD)[comprises Crohn's disease(CD)and ulcerative colitis(UC)].Endoscopic assessment is currently the foundation of disease evaluation and the grading is pivotal for the initiation of certain treatments.Yet,disharmony is found among experts;even when reassessed by the same expert.Some studies have demonstrated that the evaluation is no better than flipping a coin.In UC,the greatest achieved consensus between physicians when assessing endoscopic disease activity only reached a Kappa value of 0.77(or 77%agreement adjustment for chance/accident).This is unsatisfactory when dealing with patients at risk of surgery or disease progression without proper care.Lately,across all medical specialities,computer assistance has become increasingly interesting.Especially after the emanation of machine learning–colloquially referred to as artificial intelligence(AI).Compared to other data analysis methods,the strengths of AI lie in its capability to derive complex models from a relatively small dataset and its ability to learn and optimise its predictions from new inputs.It is therefore evident that with such a model,one hopes to be able to remove inconsistency among humans and standardise the results across educational levels,nationalities and resources.This has manifested in a handful of studies where AI is mainly applied to capsule endoscopy in CD and colonoscopy in UC.However,due to its recent place in IBD,there is a great inconsistency between the results,as well as the reporting of the same.In this opinion review,we will explore and evaluate the method and results of the published studies utilising AI within IBD(with examples),and discuss the future possibilities AI can offer within IBD.