“ I think most physicians right now are trying to manage diet by giving patients a sheet of paper with a list of foods to eliminate, and that’s simply inadequate.” —WILLIAM D. CHEY, MD
Successful management of irritable bowel syndrome (IBS) requires a comprehensive approach to care that combines the expertise of multiple health care professionals who specialize in dietary and behavioral counseling, in addition to medical treatments and pharmaceutical therapies.
“Over the last five years, we have identified and assembled the puzzle pieces that allow us to offer a more holistic approach to patients with IBS,” said William D. Chey, MD, who is a widely known expert on IBS.
That means thinking critically about how diet, lifestyle, and behavior might interact to bring about the symptoms of IBS. “We consider how we might offer interventions for each of those components of care to really maximize the benefit of medical treatments for patients with IBS,” he said.
“If you asked any of the gastroenterologists at the University of Michigan five years ago, diet and behavior would have been very low on their list of priorities,” Dr. Chey said. “Now, our gastroenterologists say they can’t imagine how we did it before we had these assets in place. It has really been a transformation in care over the past five years, and we’re extremely proud of that.”
Successful long-term management of IBS, it turns out, is a multidisciplinary affair.
PUZZLE PIECE A: EXPERT DIETARY COUNSELING
For many patients, symptoms of IBS are triggered by what they eat, and increasingly, physicians are recognizing the critical role of diet in managing the symptoms of IBS. Unfortunately, few physicians are trained to provide nutritional counseling.
“The reality is most gastroenterologists receive little to no training in nutrition or the practical elements of administering diet therapies for patients with IBS,” Dr. Chey said.
Emerging evidence suggests diets free of gluten and diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—commonly known as the low-FODMAP diet—can be beneficial for patients with IBS. The low-FODMAP diet, in particular, is a fairly complicated diet, Dr. Chey noted. Patients following this diet require the assistance of professional nutrition specialists.
“I think most physicians right now are trying to manage diet by giving patients a sheet of paper with a list of foods to eliminate, and that’s simply inadequate,” he said. “Diets are definitely more comprehensive and complicated than can be conveyed with a sheet of paper—even potentially dangerous if not administered in a medically responsible way.”
As a result, many diets do not work as well in clinical practice as evidence from clinical trials might suggest, he noted. In order to achieve similar results, diets need to be administered by experts who understand gastrointestinal (GI) nutrition and know how to help patients incorporate dietary changes into their daily routines, he said.
“One of the problems right now is there aren’t that many trained GI dietitians around. There are dietitians, but they’re not specially trained in gastroenterology,” Dr. Chey said.
“One of the things that needs to happen on a national level to improve the quality of care for patients with IBS is to train a population of dietitians that have expertise in GI disorders, and to have them work closely with gastroenterologists to administer dietary interventions in a medically responsible way,” he added.
This is just one of the many areas where the University of Michigan sets itself apart: the Division of Gastroenterology has the equivalent of four GI dietitians—two full-time GI dietitians at University Hospital and others who assist in caring for patients at offsite facilities that are part of the University of Michigan Health System.
PUZZLE PIECE B: FOCUSED BEHAVIORAL THERAPY
Just as diet has come into focus as an essential aspect of treatment for IBS, so have behavior and lifestyle. The way in which an individual responds to stress can greatly affect symptoms of IBS.
“There are certainly some things that gastroenterologists can recommend to try to facilitate changes in lifestyle or behavior,” Dr. Chey said. For example, yoga or a regular exercise plan can be very helpful in managing stressors that can lead to the symptoms of IBS, he noted.
But as in the case of diet, many gastroenterologists are not trained to provide more advanced behavioral counseling to patients with IBS. For example, cognitive-behavioral therapy, hypnosis and interpersonal psychotherapy can be very beneficial for patients with IBS. But these therapies require specialized training—even more specialized than many clinical psychologists are equipped to offer.
PUZZLE PIECE C: MEDICATIONS AND RESEARCH
“Medications still play the really important role,” Dr. Chey noted.
Therapy for IBS is symptom-driven, depending on a patient’s needs. “For patients with mild or moderate IBS symptoms, sometimes all they need is a little bit of medication, such as an over-the-counter antidiarrheal or antispasmodic on an as-needed basis, and they’ll do just fine. Patients with more severe IBS symptoms will almost always need one or more medications,” Dr. Chey said.
Notably, Dr. Chey’s group has been involved in some capacity in the research that led to the FDA approval of all five prescription drugs indicated for the treatment of IBS in the United States.
Because of its dedication to research, patients at the University of Michigan have the opportunity to participate in ongoing IBS clinical trials, such as those involving the low-FODMAP diet and an upcoming trial of prebiotics in patients with IBS.
Building on this foundation in GI nutrition and behavioral therapy, a new effort—the Digestive Disorders Nutrition and Lifestyle Program—will bring together the diverse elements necessary to provide support in nutrition and behavior, as well as “vertically integrate research from the bench to the bedside,” Dr. Chey said. “So we’re not only providing excellent quality of care for patients, we’re also striving to make discoveries that will transform the role of diet and behavior and how they interact with medications to maximize benefit for patients with IBS and other functional disorders.”
BEHAVIORAL THERAPIES FOUND INSTRUMENTAL FOR IBS MANAGEMENT
The University of Michigan offers patients with GI disorders an opportunity to address symptoms with a specially trained GI psychologist.
Megan Riehl, PsyD, is a clinical health psychologist at the University of Michigan, and the state’s only psychologist with a specific focus on GI disorders. IBS is the most common GI illness that brings patients to her clinic. “About 65 percent of patients present with IBS or a functional bowel disorder,” she said.
Typically, patients are referred to Dr. Riehl by a gastroenterologist who may have exhausted medical treatment options and/or believes a patient would benefit from stress and anxiety management techniques. Increasingly, behavioral therapy is becoming routine in the treatment of patients with IBS. “As more patients become aware of the GI behavioral health service, more of them are asking their gastroenterologists for a referral to the program,” Dr. Riehl said.
Behavioral therapy is personalized for each patient, but in general, therapy is designed to help patients deal with the “uncontrollable” and “unpredictable” aspects of IBS. Patients learn relaxation and stress management techniques they can apply to everyday life stressors.
“My goal is to help patients learn to cope effectively and efficiently with worries that can interfere with social, occupational, and family life,” Dr. Riehl said.
Most often, behavioral therapy for patients with IBS involves interventions based on cognitive-behavioral therapy (CBT), a short-term, collaborative treatment that is focused on a patient’s current problems.
“CBT involves helping patients find new ways of thinking and behaving to help in managing stressful situations,” Dr. Riehl explained. For example, patients with IBS may experience anxiety-provoking thoughts such as, “Where will a bathroom be if I need it?”, “What if I’m having symptoms before a big exam or presentation?”, or “How will I ever be intimate with a partner?” CBT teaches patients how to manage emotional responses to these potentially stress-inducing situations.
“My goal is to aid patients in self-management strategies that benefit GI health, emotional well-being, and overall quality of life,” Dr. Riehl said. “People learn tools to create long-term change, without remaining in treatment for long periods of time. It’s very rewarding.”
FOR COMMUNITY GASTROENTEROLOGISTS
The Division of Gastroenterology at the University of Michigan emphasizes a holistic approach to IBS treatment that incorporates modifications in diet, behavior, and lifestyle in the management of symptoms of IBS.
When a diagnosis of IBS has been confirmed, consider the following approaches to treatment:
- Are symptoms triggered or exacerbated by diet? Consider a referral to a dietitian with specialized training in the treatment of GI disorders.
- Are symptoms triggered or exacerbated by stress or a mood disorder? Consider a referral to a behavioral therapist with specialized training in the treatment of GI disorders.
- How frequent and severe are symptoms? Are symptoms comprised mainly of diarrhea, constipation, or both? Consider using medications that target the relevant symptoms in combination with strategies that address diet, lifestyle, and behavior.
- Are symptoms severe and/or medically refractory? Consider a referral to a tertiary referral center.
Morgan Blenkhorn missed high school several times because of symptoms that doctors said were related to irritable bowel syndrome (IBS).
“Anything I would eat, I would get sick,” she said. “I was nauseous; I would have headaches, stomachaches; I had diarrhea and I was just ill all day, every day.”
Morgan’s symptoms started a few months after a severe food poisoning incident in 2010 during her junior year of high school. She endured pain, particularly while dancing and playing soccer. She eventually turned to apples and honey for relief, but they only made her symptoms worse.
“It was really hard having to come home from school being sick all the time, waking up sick, and trying to go to school and act like everything was fine,” she said.
A CHANCE MEETING BEARS FRUIT
Over the next three years, several doctors told her she was exhibiting IBS symptoms and gave her probiotics for treatment. But a chance meeting on an airplane between her father and gastroenterologist William Chey, MD, would lead to a series of interviews, tests, and a final diagnosis from the University of Michigan’s gastroenterology and dietitian team.
Her first visit to the University of Michigan was in 2013, during the fall of her sophomore year of college. She had several blood tests done before meeting with Dr. Chey. Upon her first appointment with him, she was promptly told what to expect: a fructose test, a lactose test, more blood tests, and an endoscopy.
According to Morgan, Dr. Chey went above and beyond preliminary tests to find the root of the problem. The test that changed it all, she said, was the fructose test, which consisted of a fructose mixture, water, and a breath test. A few weeks after her appointment, Dr. Chey spoke with Morgan and her family and told them the diagnosis: fructose intolerance.
“We all cried,” Morgan said.
FINALLY, CONTROL …
This experience was unlike any other for Morgan. The team’s gastroenterologists were briefed on her case and knew exactly how to address her issues. The dietitian they referred her to mapped out a zero-fructose eating plan that catered to her vegetarian diet and her love for veggies, pasta, and curry.
“They listened to my specific wants, not just me as a patient but me as Morgan,” she said.
After being diagnosed with fructose intolerance, Morgan now plans out her own meals and has full control of her symptoms. She continues to dance and play sports. Last summer, she was even able to study abroad in the Netherlands.
“It was beautiful, life-changing, something I didn’t think I’d ever be able to do before because I couldn’t sit in a car for two hours without having to pull over,” she said. “Biking 10 miles to work and backpacking alone through Germany was something I thought I’d never be able to do because I was so sick.”
Morgan is finishing up her fourth year at Grand Valley State University in Allendale, Mich., with another year left to complete her special education degree. She still checks in with Dr. Chey every once in a while. For now, she hopes to be accepted into Grand Valley’s Consortium for Overseas Student Teaching program in Ireland this summer.