Alimentary TractBran and irritable bowel syndrome: The primary-care perspective
Introduction
Irritable bowel syndrome (IBS) is characterised by the presence of abdominal pain or discomfort associated with an alteration in bowel habit, usually together with bloating. Despite sometimes being regarded as a trivial condition, IBS is in fact a major and under recognised health problem. Recent studies have revealed that in severely affected patients quality of life is comparable with that of life threatening conditions such as end stage renal failure and diabetes mellitus [1]. In the US each year approximately 3.5 million physician visits are made because of IBS [2], resulting in the administration of prescription medication in 75% of these visits and follow-up being arranged in a similar proportion [3]. Therefore, it is perhaps not surprising that the cost of treating IBS is large, having been estimated at 8 billion US dollars each year [4].
Gastroenterologists spend up to 50% of their clinic time dealing with IBS patients and make the diagnosis more frequently than any other single condition [5], [6]. Nevertheless these specialists only see about one quarter of patients with IBS with the majority being managed in primary-care [7]. Furthermore tertiary centres only see in the region of 10–15% of IBS patients [8], although paradoxically much of the data relating to IBS is obtained from this subgroup. Whether this information can be accurately extrapolated to the wider IBS population, particularly in primary-care, is doubtful.
Standard treatment for IBS in primary-care involves giving dietary advice and offering the use of simple medications such as antispasmodics [9], although the evidence of benefit using these approaches is limited, with some investigators even suggesting that there is little evidence to support the use of many current therapies [10].
Ever since Burkitt et al. [11] first suggested that fibre might protect people in un-industrialised areas from certain gastrointestinal disorders, the practice of advising fibre supplementation in IBS has become widespread. However, it has been our clinical impression that bran actually exacerbates IBS in patients in secondary-care, a view that was confirmed in a study we published in 1994 [12]. Nevertheless a recent survey found that most general practitioners believe that fibre deficiency is the main cause of IBS symptoms and 94% would institute dietary therapy based on this assumption [13]. If patients in primary-care benefit from bran they would be unlikely to reach secondary-care, with only those failing to respond or being exacerbated by such an approach being referred. The aim of the current study was to assess the effect of fibre on IBS symptomatology in the primary-care setting, comparing it with that previously obtained in secondary-care.
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Study subjects
Patients attending seven local general practices representative of an urban but not inner city population were approached and asked if they would participate in the study. Patients fulfilling Rome 1 criteria for IBS were recruited in order to make them comparable to the secondary-care population. Subjects without concomitant disease were recruited consecutively until 100 had completed questionnaires. Exactly the same questions about the effect of bran and commercial fibre on IBS symptomatology
Results
One hundred primary-care IBS patients, 87 female aged 20–67 (mean 43.0) years and 13 male aged 32–59 (44.1) years were studied. Twenty-one patients were classified as having diarrhoea predominant IBS, 24 as constipation predominant and 55 as having an alternating bowel pattern. The secondary-care group consisted of 82 females aged 20–77 (mean 40.5) and 18 males aged 23–73 (mean 43.7). Twenty-nine were classified as diarrhoea predominant, 26 as constipation predominant and 45 as having an
Discussion
We have previously shown that fibre, particularly in the form of bran, appears to exacerbate the symptoms of patients attending secondary-care with IBS [12]. This finding has been supported by a recent systematic review of 17 studies of fibre supplementation in IBS [14] which concluded that although it may sometimes help constipation, there is little evidence that it is especially beneficial in relieving any of the other symptoms associated with the condition. Pain [13], bloating [12], [15] and
Conflict of interest statement
None declared.
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Cited by (20)
Treatment of Irritable Bowel Syndrome in Women
2011, Gastroenterology Clinics of North AmericaCitation Excerpt :This observation was widely believed to be the primary cause of IBS.57 That conviction has been slow to change despite numerous studies to the contrary spurred on by reports that cereal fiber worsened symptoms in 55% of secondary care IBS patients58 and 22% of primary care IBS patients.59 Nevertheless, fiber supplementation has remained the most extensively and carefully studied dietary treatment for IBS.
Current Medical Treatments of Dyspepsia and Irritable Bowel Syndrome
2010, Gastroenterology Clinics of North AmericaCitation Excerpt :The first-line treatment for constipation in IBS is fiber (12 to 20 g per day) in the form of dietary fiber or supplements. Several studies actually show that fiber aggravates several symptoms of IBS, including bloating.57,58 For this reason, an alternative first-line therapy for constipation in IBS is the class of osmotic laxatives, such as magnesium salts (typically 1 g up to 4 times per day) or polyethylene glycol (typically 17 g in 240 mL water up to twice per day).
Irritable bowel syndrome in the elderly: An overlooked problem?
2009, Digestive and Liver DiseaseCitation Excerpt :It is commonly recommended that subjects with bowel dysfunction should increase their fibre intake, particularly in the form of cereals. Unfortunately this approach can considerably exacerbate the symptoms of IBS particularly in the secondary care setting [15,16] and is another reason why it is important to identify these individuals so that they can be appropriately advised, especially as elderly patients often increase their fibre intake in order to try and improve their bowel habit. It may also help to reduce the high prevalence of faecal urgency and incontinence which were so prevalent in these elderly IBS sufferers and can often be improved by restricting fibre.
The Role of Diet in Symptoms of Irritable Bowel Syndrome in Adults: A Narrative Review
2009, Journal of the American Dietetic AssociationCitation Excerpt :Fiber deficiency was widely believed to be the primary cause of IBS (40). That conviction has been slow to change despite numerous studies to the contrary spurred on by reports that cereal fiber worsened symptoms in 55% of secondary care IBS patients (41,42) and 22% of primary care IBS patients (43). Nevertheless, fiber supplementation is the most extensively and carefully studied dietary treatment for IBS.
Oral administration of a lecithin-based delivery form of boswellic acids (Casperome®) for the prevention of symptoms of irritable bowel syndrome: A randomized clinical study
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