Introduction

Sleep disturbances are more common in individuals with Irritable Bowel Syndrome (IBS) compared to healthy subjects. Sleep quality is an independent factor affecting gastrointestinal (GI) symptoms but the directionality of effects is unknown.

Aims & Methods

Our aim was to investigate relationships between subjective sleep quality, objective sleep measures and GI symptoms using actigraphy and the Experience Sampling Method (ESM). Single-centre, prospective, cross-sectional study conducted at the Wingate Institute of Neurogastroenterology in London, from March 2020 to May 2021. IBS patients were recruited from a tertiary neurogastroenterology clinic and the community. GI symptoms and mood were recorded on a smartphone application, ten times per day, over seven consecutive days (i.e. ESM). Subjective sleep quality was recorded every morning to reflect the night before. Objective measures of sleep quality were estimated from wrist-worn actigraphy. Cross-lagged structural equation models were built to assess the directionality of sleep-symptom relationships over time.

Results

Eighty IBS patients completed the study (mean age: 37 (range 20 – 68), 89% female, 78% community). The median IBS - Symptom Severity Score (IBS-SSS) score indicated moderate IBS severity (279 (IQR: 237-350)). Sixty-six % had a Pittsburgh Sleep Quality Index (PSQI) score ≥ 8 indicating a clinically significant sleep disturbance. Eighty-two % (95% CI: 72-90) screened positive for a sleep disorder, most commonly insomnia. Sleep efficiency, measured by actigraphy, was at the lower end of normal range (median: 86% (CI 95%: 85-87). In cross-lagged analysis, poor subjective sleep quality predicted next day abdominal pain (0.036 < p < 0.040) and lower GI symptoms (0.030 < p < 0.032), but not vice versa. Although the direction of the effect was the same for abdominal pain and lower GI symptoms, it was not significant for upper GI symptoms. No significant relationship with GI symptoms was found for any objective sleep measure.

Conclusion

Poor subjective sleep quality is associated with higher next day abdominal pain and lower GI symptom scores in IBS patients, but not vice versa. Objective sleep measures did not predict next day abdominal symptoms, potentially supporting the conclusion that it is the perception of sleep quality which is most influential. This study supports the use of real-time patient reported outcome measures when interpreting potential influencers of IBS symptoms and may be used to guide future research into the effect of sleep interventions on GI symptoms.

Disclosure

DK has received research funding from Grunenthal, Allergan, Will Pharma, Rome Foundation, ZonMw, MLDS, UEG, Horizon 2020, Horizon Europe, and speaker’s fee from Dr Falk (paid to host institution).
QA undergoes consulting work for Takeda Pharmacueticals, and Classado Biosciences Ltd.

Introduction

Irritable bowel syndrome (IBS) has a profound impact on health-related quality of life. Increasing evidence suggests psychological factors have a large impact in the development and course of IBS, and in particular quality of life, with large individual heterogeneity. This observational study aims to investigate the influence of personality traits using the Big Five Inventory (BFI) and examine their associations with abdominal pain, general and gastrointestinal-specific anxiety, and quality of life in patients with IBS.

Aims & Methods

Data from a large observational study in patients with IBS (Rome III criteria) was used, in which patients completed questionnaires with regards to personality traits (BFI-44), symptom severity, general anxiety, GI-specific anxiety, and quality of life. Multivariable regression models and a network correlation analysis were used to determine underlying associations.

Results

194 patients were included for analysis (74.7% female, mean age 51.36 years). There was a positive association of neuroticism to GI-specific anxiety (B 7.234, P = 0.040) and general anxiety (B 0.954, P = 0.040) with a strong negative association to mental quality of life (B – 3.576, P = 0.007). In addition, a strong negative association of agreeableness to mental quality of life was found (B – 4.266, P = 0.001). Although there were no significant associations of personality traits to abdominal pain, positive associations were found regarding general anxiety (B 6.304, p < 0.001) and GI-specific anxiety (B 0.034, P <0.001) of abdominal pain. There were no associations found with regards to the other personality traits openness, conscientiousness or extroversion.

Conclusion

IBS patients with a higher level of neuroticism were more likely to experience higher levels of GI-specific and general anxiety. The trait neuroticism and/or agreeableness was more likely to have a significant lower mental quality of life in IBS. These findings emphasize the contribution of personality traits in the pathophysiology and course of IBS, pleading for a more personalized approach in patient management.

Introduction

Irritable bowel syndrome (IBS) is a heterogeneous disorder of gut-brain interactions characterised by pain and altered bowel habits¹. The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet is efficacious for improving symptoms and quality of life (QoL)², however not all individuals will have a therapeutic response resulting in adequate symptom relief³. Behavioural, emotional and cognitive predictors of response have been explored in psychological therapies, but not in dietary treatments of IBS⁴.

Aims & Methods

The aim of this study was to identify psychological predictors of treatment response to the low FODMAP diet. Participants underwent a three-phase dietitian-led low FODMAP diet between August 2018 and July 2021. Participants completed questionnaires to obtain scores for psychological factors and symptoms (predictor variables). Data on depression, anxiety, gastrointestinal (GI) specific anxiety, somatic symptoms, illness perceptions, behavioural avoidance, treatment beliefs and expectations, symptom severity and QoL was collected at five time points; pre dietitian (week 0), post dietitian (week 1), post FODMAP restriction (week 5), post FODMAP reintroduction (week 13) and personalisation (week 25). Linear mixed models (LMM) were used to test the effect of baseline psychological scores on IBS symptoms and QoL over time. Cross lag panel models (CLPM) were used to identify directional relationships between predictor variables on the one hand, and IBS symptoms and QoL on the other.

Results

112 participants, (89% female, median age 30 ± 17 years) were included. LMM showed that higher treatment beliefs predicted a stronger initial symptom response (effect on linear slope p=0.036). Of the illness perceptions, lower emotional representations predicted a stronger initial and later QoL response (effect on linear (p=0.006) and quadratic (p=0.049) slopes). Increased cyclical time beliefs predicted poorer initial and later QoL response (effect on linear (p=0.015) and quadratic (p=0.029) slopes). CLPM showed that lower GI specific anxiety predicted a stronger reduction in symptoms from week 0 to 25. Of the illness perceptions, positive perceptions relating to higher personal and treatment control predicted a stronger reduction in symptoms from week 0 to week 25. Increased QoL predicted reductions in GI specific anxiety and stress from week 0 to week 25 and week 1 to week 25, respectively. Increased personal and treatment control predicted improved QoL across all time points.

Conclusion

Negative illness perceptions were associated with poorer symptom and QoL response, whereas positive illness perceptions and treatment beliefs predicted better QoL and symptom responses to the low FODMAP diet in adults with IBS. Illness perceptions and treatment beliefs can be easily assessed in clinical practice and should be considered when determining if the low FODMAP diet is a suitable treatment, and may serve as targets to enhance treatment response.

References

¹Camileri, M & Dilmaghani, S. (2023). Update on treatment of abdominal pain in irritable bowel syndrome: a narrative review. Pharmacology and therapeutics, 245, 108400-108400. http://doi.org/10.1016/j.pharmthera.2023.108400
²van Lanen, A.S., de Bree, A & Greyling, A. (2021). Efficacy of a low FODMAP diet in adult irritable bowel syndrome: a systematic review and meta-analysis. Eur J Nutr, 60(6), 3505-3522. doi:10.1007/s00394-020-02437-0
³Wilson, B., Cox, S.R. & Whelan, K. (2021). Challenges of the low FODMAP diet for managing irritable bowel syndrome and approaches to their minimisation and mitigation. Proc Nutr Soc, 80(1), 19-8. doi:10.1017/s0029665120006990
⁴ Radu, M., Moldovan, R., Pintea, S., Baban, A & Dumitrascu. (2018). Predictors of outcome in cognitive and behavioural interventions for irritable bowel syndrome. A meta-analysis. Journal of Gastrointestinal and Liver Diseases, 27(3), 257-263. http://dx.doi.org/10.15403/jgld.2014.1121.273.bab

Introduction

Patients with IBS often report meal-related symptoms. These symptoms can negatively affect IBS-related quality of life, psychological health, and lead to food-avoidant behaviours¹. Developing our understanding of the impact of meal-related symptoms in IBS could lead to better treatment.

Aims & Methods

We aimed to compare the characteristics of patients with and without meal-related symptoms in IBS. Participants were recruited from the NIHR research register ContactME-IBS². We collected data for demographics, gastrointestinal symptoms^3,4,5, psychological health⁶, quality of life^7,8, and impact on work and daily activities⁹ using validated questionnaires among adults with IBS, as defined using the Rome IV criteria. We dichotomised the cohort according to whether they experienced meal-related symptoms, defined as being present ≥50% of the time, or not. We compared the characteristics of the two groups and used logistic regression to explore predictors of meal-related symptoms in IBS.

Results

Of 752 respondents with Rome IV IBS, 561 (74.6%) were affected by meal-related symptoms. 89.3% of individuals with meal-related symptoms were female vs 80.6% of those without (p =0.002). A significantly higher proportion of those with meal-related symptoms reported bloating or distension as their most troublesome symptom (31.2% vs 22.5%, p =0.008), and had a higher prevalence of functional dyspepsia, especially postprandial distress syndrome (49.1% vs 30.2%, p <0.001). Individuals affected by meal-related symptoms reported higher levels of gastrointestinal symptom-specific anxiety, had lower levels of IBS-related quality of life, and significantly higher levels of work productivity and activity impairment (p <0.001 for all analyses). Logistic regression analysis controlling for all other data showed that females (OR 2.3, 95% CI 1.30 - 4.08) and those with functional dyspepsia, both post-prandial distress syndrome (OR 2.0, 95% CI 1.3 - 3.3) and epigastric pain syndrome (OR 2.0, 95% CI 1.19 - 3.22), were more likely to report IBS meal-related symptoms. Conversely, IBS sufferers with abnormal depression scores were less likely to report meal-related symptoms (OR 0.4, 95% CI 0.20 - 0.72). This could reflect low mood leading to poor appetite. Overall, the model explained 22.8% of the variance of the data.


Table 1. Characteristics of Individuals with Rome IV IBS according to presence or absence of meal-related symptoms.

Conclusion

Individuals with Rome IV IBS who report meal-related symptoms experience significantly worse gastrointestinal symptom-specific anxiety and are more adversely affected at work compared to those without meal-related symptoms. These findings suggest that people with IBS and meal-related symptoms may benefit from early multidisciplinary treatment with dietary and psychological therapies.

References

1. Böhn L et al. Am J Gastroenterol. 2013 May;108(5):634-41.
2. ContactME-IBS. https://www.contactme-ibs.co.uk/. Accessed 23/4/2024.
3. Palsson OS et al. Gastroenterology. 2016;150:1481-91.
4. Whitehead WE et al. Rome III: The functional gastrointestinal disorders. Virginia: Degnon Associates Inc 2006. p. 835-53.
5. Labus JS et al. Aliment Pharmacol Ther. 2004;20:89-97
6. Spiller RC et al. Aliment Pharmacol Ther. 2010;32(6):811-20
7. Patrick DL et al. Dig Dis Sci. 1998;43(2):400-11.
8. Drossman DA et al. Am J Gastroenterol. 2000;95(4):999-1007.
9. Reilly MC et al. Aliment Pharmacol Ther. 2004;20(4):459-67

Introduction

Irritable bowel syndrome (IBS) is subtyped based on bowel habits. However, an alternative based on combined gastrointestinal (GI), non-GI somatic and psychological symptom profiles has been proposed ^1,2.

Aims & Methods

This study aimed to validate the novel more comprehensive way to subgroup IBS and investigate differences in symptoms and gut physiology in these groups. In total, 760 IBS patients (Rome III and IV) from six study cohorts were included. Subgroups were based on Gaussian mixture model analysis using 13 single-item GI symptom scores (GSRS-IBS), stool frequency and consistency (Bristol Stool Form Scale), 11 single-item non-GI somatic symptom scores (PHQ-12, excluding menstruation problems), and anxiety and depression scores (HADS). Differences between subgroups were investigated for fatigue (MFI), GI-specific anxiety (VSI), IBS-specific quality of life (IBS-QOL), and measurements of gut physiology, including oro-anal transit time (OATT) assessed by radiopaque markers, visceral sensitivity assessed by a rectal barostat procedure and lactulose nutrient challenge test (LNCT), and breath hydrogen and methane production during LNCT as markers for microbial fermentation.

Results

Six subgroups based on GI and non-GI symptom profiles were identified: diarrhea with low comorbidities (n=67), constipation with low comorbidities (n=120), overall mild severity (n=166), diarrhea with high comorbidities (n=231), constipation with high comorbidities (n=89), and mixed GI symptoms with high comorbidities (n=87). The groups with high comorbidities had higher levels of fatigue and GI-specific anxiety, and lower QOL compared to the low comorbidities groups, Table 1. OATT was longer in constipation with low comorbidities vs diarrhea with low comorbidities (1.7 [1.0-2.7] vs 0.9 [0.5-1.3] days (median [IQR]), p<0.01), but there was no difference in OATT comparing constipation with high comorbidities vs. diarrhea with high comorbidities. Visceral sensitivity and postprandial hydrogen and methane production did not differ between groups, but with a tendency of methane production to be highest in constipation with high comorbidities.

Conclusion

We have confirmed previously reported IBS subgroups based on combinations of GI and non-GI symptom profiles. Demonstrated associations with fatigue, GI-specific anxiety, and oro-anal transit time, suggest different pathophysiological mechanisms in these novel subgroups. Our results suggest that the presence or absence of non-GI symptoms could be important when planning IBS treatment strategies.

References

1. Black CJ, Ng CE, Goodoory VC, Ford AC. Novel Symptom Subgroups in Individuals With Irritable Bowel Syndrome Predict Disease Impact and Burden. Clin Gastroenterol Hepatol. 2024;22(2):386-396.e310.
2. Polster A, Van Oudenhove L, Jones M, Öhman L, Törnblom H, Simrén M. Mixture model analysis identifies irritable bowel syndrome subgroups characterised by specific profiles of gastrointestinal, extraintestinal somatic and psychological symptoms. Aliment Pharmacol Ther. 2017;46(5):529-539.