Introduction

Approximately 15-19% of patients suffering from irritable bowel syndrome (IBS) have an eating disorder (ED) based on a screening score or dietary assessment (1). Avoidant/restrictive food intake disorder (ARFID), a long-recognised eating disorder in children, is now recognised in adults. In a Swedish study, 13.2% of patients suffering from IBS reported severe dietary avoidance or restriction, suggestive of ARFID (2). A screening questionnaire for this disorder has recently been validated in French (NIAS-Fr, for Nine Item ARFID Screen in French) (3).

Aims & Methods

This study aims to assess the prevalence of ARFID in IBS in France, by comparing the NIAS-Fr questionnaire and the assessment by a specialised dietitian, and to look for links between its presence and the clinical phenotype of patients. This study was conducted between February and September 2024 in consecutive patients suffering from IBS and evaluated in a multidisciplinary day hospital structure. Clinical characteristics (age, gender, BMI, IBS subtype and its severity [IBS-SSS], presence of functional dyspepsia, diet and disease duration) and presence of ARFID (clinically or one abnormal NIAS-Fr subscale) were collected. A dietitian assessed the presence of “clinical ARFID”. The NIAS subscales allow for the diagnosis of patients as “picky eaters” (score ≥10), with “poor appetite” (score ≥9) and/or with a “fear of eating” (score ≥10). Patients with a history of ED diagnosed by a psychiatrist and/or an abnormal ED screening score (SCOFF ≥ 3 and/or global EDE-Q8 ≥ 4.0) were excluded from the analysis.

Results

Of the 95 patients with IBS according to Rome IV, 55 (57.9%) had at least one positive NIAS-Fr subscale, with 10 (10.5%) having an abnormal “picky eater” subscale, 16 (16.8%) an abnormal “poor appetite” subscale, and 49 (51.6%) an abnormal “fear of eating” subscale. Of these 95 patients, 15 were excluded from the analysis because of a history of eating disorders or an abnormal screening score. We therefore included 80 patients for analysis (77.5% women; mean age 48.5 ± 16.8 years, BMI 22.6 ± 4.6 kg/m²; 40.0% IBS-D, 38.8% IBS-C, and 20.0% IBS-M; 51.3% had associated dyspepsia; 62.5% were on a special diet at the time of assessment). The mean IBS-SSS score was 319.5 ± 88.2 points (severe forms in 61.2%). Among these 80 patients, 43 (53.8%) had at least one positive NIAS-Fr subscale, including 10.0% of "picky eaters," 16.3% of "poor appetite," and 48.8% of "fear of eating." Patients with at least one positive NIAS-Fr subscale had more frequent functional dyspepsia than those with a negative NIAS (65.1 vs. 35.1%, p = 0.013), but there were no differences in the other parameters assessed. According to the dietitian's assessment, 19 (23.8%) patients in our cohort had clinical ARFID, i.e., 44.2% of those with at least one positive NIAS-Fr subscale. In an IBS population, the specificity of the NIAS-Fr questionnaire for diagnosing clinical ARFID was 55.8% (95% CI: 41.1-69.6). None of the assessed parameters distinguished patients with and without clinical ARFID (p > 0.05).

Conclusion

ARFID symptoms are found in more than half of IBS patients treated in a tertiary care centre based on an abnormal NIAS-Fr screening questionnaire, after excluding other eating disorders. These patients frequently have associated functional dyspepsia and a normal BMI. Based on a dietary assessment, clinical ARFID is found in approximately one-quarter of IBS patients. The specificity of the NIAS-Fr in IBS is too low to allow a diagnosis of ARFID in this population.

References

(1) Wuestenberghs et coll. Intérêt du dépistage des troubles du comportement alimentaire au cours du syndrome de l’intestin irritable. JFHOD 2024 (number 000694)
(2) Melchior et coll. Food Avoidance and Restriction in Irritable Bowel Syndrome: Relevance for Symptoms, Quality of Life and Nutrient Intake. Clin Gastroenterol Hepatol. 2022;20(6):1290-1298.e4.
(3) Van Ouytsel et coll. Translation of the nine item avoidant/restrictive food intake disorder screen (NIAS) questionnaire in French (NIAS-Fr). Neurogastroenterology & Motility 2024 ; 36 (4) : e14757.

Disclosure

Nothing to disclose.

Introduction

Functional dyspepsia (FD) is one of the most frequent disorders of the gut-brain interaction with a worldwide prevalence of around 7%.¹ Our group showed that a diet excluding fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) improved symptoms in the majority of FD patients.² FODMAPs have been studied in irritable bowel syndrome, where poor intestinal absorption may lead to osmotic effects and fermentation, contributing to symptoms. However, this has not been studied in FD to date. In this study, we assessed pathophysiological parameters after ingestion of mannitol and a control meal in FD patients and healthy volunteers (HV).

Aims & Methods

FD patients (N=11) that responded to the low FODMAP diet and showed symptom triggers by mannitol during reintroduction were recruited. Also, 11 HV participated in this trial. FD and HV had a similar age (47 (24-55) vs. 25 (21-46), p=0.14) and BMI (22 (21-31) vs. 23 (21-25), p=0.85), but FD cohort included more females (100% vs 55%, p=0.04). After an overnight fast, abdominal magnetic resonance imaging (MRI) was performed in patients and HV. MRI images, gastrointestinal (GI) symptoms and blood samples were collected at baseline and at six separate time points after a challenge meal (0, 15, 30, 45, 60, 120, 240 min). The meal was an oat porridge breakfast containing either mannitol or glucose, as a control, in a randomized, double blind cross-over fashion. MRI images were analyzed for gastric emptying T_1/2 (GE T_1/2), duodenal volume, small bowel water content (SBWC) and colonic gas volume. Blood samples were analyzed for glucose like peptide-1 (GLP-1), peptide YY (PYY), and GIP.

Results

FD patients exhibited more FD symptoms compared to HV after consuming both the glucose-rich meal (54 ± 10 vs 24 ± 7, p=0.02) and the mannitol-rich meal (64±13 vs 23±7, p=0.01). No differences were found for GE T_1/2 in FD and HV, as indicated in Table 1. Colonic gas volume was significantly increased in patients compared to HV. Duodenal volumes tended to increase more after intake of mannitol compared to glucose in both groups, but reached significance only in HV. SBWC was increased after mannitol in both HV (p=0.01) and FD (p=0.01). After intake of mannitol, postprandial GLP-1 levels were significantly lower in FD compared to HV, after 15 (p=0.02) and 30 min (p=0.001). Also, the AUC of GLP-1 was significantly lower in FD versus HV after mannitol (p=0.04), as well as after glucose-rich (p=0.04) meal. In FD, AUC of GIP levels was significantly lower after mannitol versus glucose (p=0.002). GI symptom scores did not correlate with PYY, GLP-1, and GIP levels. GLP-1 and GIP values did not correlate with GE T_1/2.

Conclusion

In this pilot study no difference in symptom triggering in FD was observed between mannitol and glucose (control) supplemented meals, but compared to HV the meals were associated with higher symptom burden, lower release of GLP-1 and GIP, and larger colonic gas volumes. The mechanisms underlying decreased peptide hormone release and their relevance to symptom generation deserve further studies.

References

1. Sperber AD, Bangdiwala SI, Drossman DA, Ghoshal UC, Simren M, Tack J, Whitehead WE, Dumitrascu DL, Fang X, Fukudo S, Kellow J, Okeke E, Quigley EMM, Schmulson M, Whorwell P, Archampong T, Adibi P, Andresen V, Benninga MA, Bonaz B, Bor S, Fernandez LB, Choi SC, Corazziari ES, Francisconi C, Hani A, Lazebnik L, Lee YY, Mulak A, Rahman MM, Santos J, Setshedi M, Syam AF, Vanner S, Wong RK, Lopez-Colombo A, Costa V, Dickman R, Kanazawa M, Keshteli AH, Khatun R, Maleki I, Poitras P, Pratap N, Stefanyuk O, Thomson S, Zeevenhooven J, Palsson OS. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114.e3. doi: 10.1053/j.gastro.2020.04.014. Epub 2020 Apr 12. PMID: 32294476.
2. Van den Houte K. et al. OUTCOME OF A LOW FODMAP ELIMINATION DIET WITH BLINDED REINTRODUCTION IN FUNCTIONAL DYSPEPSIA / POSTPRANDIAL DISTRESS SYNDROME. Under review Gut 2025

Introduction

The low FODMAP diet (LFD) is an efficacious dietary intervention for reducing symptoms in patients with irritable bowel syndrome (IBS). Although effective, the LFD is complex, requires guidance from a trained dietitian and may be associated with decreased caloric intake and weight loss. A less strict diet intervention, by a self-guided smartphone application (FODMAP-light DOMINO app), showed superiority compared to standard medical therapy in primary care IBS patients¹. The efficacy of the FODMAP-light app in tertiary care patients has not been evaluated.

Aims & Methods

We aim to evaluate the efficacy of the FODMAP-light app for managing IBS in tertiary care. To this end, we assessed its impact on IBS symptoms, nutritional intake and psychosocial comorbidities.
After a two-week baseline period, IBS patients were instructed to follow the FODMAP-light diet app during eight weeks. A symptom diary, including the Bristol stool scale (BSS), was filled out daily. IBS symptoms were scored on a 0-100mm Likert scale. Stool consistency was reported as days per BSS types (1-7) over two weeks. Seven-day food diaries were collected during baseline and diet period. Questionnaires to assess IBS symptom severity (IBS-SSS) and psychosocial comorbidities (PHQ and GAD-7) were filled out at baseline and after diet. Data are reported as mean±SD or median (IQR).

Results

Among 53 patients with IBS (81% female, age 32 (28-42) years, BMI 23 (20-29) kg/m²), the diet significantly reduced IBS-SSS (287±72 vs. 172±91, p < 0.0001) with an 81% responder rate (≥50 points improvement). Compared to baseline, duration (41 (30-54) vs. 17 (7-31)) and severity (39 (26-52) vs. 14 (6-33)) of abdominal pain, bloating (44 (27-55) vs. 19 (8-31)), flatulence (46 (29-57) vs. 18 (9-30)), and impact on daily life (38 (24-51) vs. (16 (6-37)), significantly improved during the diet (all p < 0.0001). Stool frequency remained unchanged, but there was a significant shift from loose (BSS type 6 and 7) to normal stools (BSS type 2,3 and 4) (p < 0.0001), and episodes of urgency significantly decreased (p < 0.01). Nutritional analysis, shown in table 1, revealed a decreased caloric intake (∆-186.1 kcal/d, p < 0.0001), but no weight loss. Intake of FODMAPs decreased significantly, except for lactose and mannitol. Psychosocial outcomes improved significantly, with reduction in somatization (11 (8–14) vs. 8 (6-12), p < 0.0001), depression (5 (3–11) vs. 4 (2–6), p < 0.0001), and anxiety (6 (3–9) vs. 4 (1–6), p < 0.001).

Conclusion

The DOMINO FODMAP-light app is an effective treatment option for improving gastrointestinal as well as psychosocial factors in tertiary care IBS, providing a promising alternative to more restrictive dietary approaches.

References

1 Carbone F and Van den Houte K et al. Gut. 2022

Introduction

Confocal laser endomicroscopy (CLE) can detect acute duodenal epithelial disruption in response to food application, potentially identifying personalized elimination diets (1). A pilot study in functional dyspepsia (FD) showed that the 6-food elimination diet (6FED) provided symptom relief. (2). Earlier research in FD, however, showed that the high rate of acute food-induced mucosal alterations on CLE were not associated with altered permeability or changes in mast cell activation ex vivo (3).

Aims & Methods

To evaluate a personalized elimination diet in patients living with FD based on results of CLE, assessing duodenal mucosal changes to locally applied food solutions from the 6FED.
A randomized, double-blind, cross-over, sham-controlled trial was conducted in 17 Rome IV FD patients, in whom immunoglobulin E (IgE) sensitization to nutrients was excluded via food-specific serum IgEs. Baseline symptoms were assessed using the Leuven Postprandial Distress Scale (LPDS) and Patient Assessment of GI Disorders–Symptom Severity Index (PAGI-SYM). Index upper GI endoscopy (EGD) was followed at least 2 weeks later by an EGD with CLE. During CLE, duodenal mucosa was visualized at baseline and after consecutive, random administration of egg white, soy, milk, wheat, lyophilized fish/shellfish and nuts solutions. In case of a reaction to the first 2 food solutions, an additional CLE was scheduled. All patients underwent a crossover dietary intervention excluding foods to which they tested positively (real diet, RD) and negatively (sham diet, SD) in random order. Following 4 weeks of diet, LPDS and PAGI-SYM scores were reevaluated. Missing data were considered non-responder, based on an extreme case approach. Data are reported as mean ± SEM. Comparisons were done using a paired t-test or related-Samples Wilcoxon test, as applicable. Response rate was evaluated using a McNemar test. P<.05 is considered significant.

Results

Dietary outcome was available from 17 patients (age 35±3.7y, 16 female, BMI 22±0.7 kg/m2). In 7% of exams (n=2), acute alterations were already present at baseline. Twelve patients (71%) underwent a second CLE procedure. One patient dropped out after the first diet (which was RD). Three patients did not have a reliable RD/SD comparison due to non-response (n=1) or early response on CLE (n=2), underwent a standardized control diet, and were excluded from the analysis. Among the 14 patients in the cross-over dietary intervention, the proportion with a clinically significant 0.7 decrease in LPDS was similar for both diets (RD 4/14 vs. SD 2/14, p=0.41). No significant differences were found in LPDS subdomains or in the total PAGI-SYM score or PAGI-SYM fullness domain between the two diets (all p>.05).

Conclusion

In patients with FD, without systemic IgE-sensitization, CLE visualized a high rate of acute, food-induced, mucosal alterations, which could not be translated in symptom benefit following a dietary intervention excluding these foods vs. foods that did not trigger a reaction in this double-blind, controlled diet intervention study. None of the analyzed clinical outcome measures differed between the two diets. Given the results of this first double-blind controlled diet intervention in patients living with FD, CLE-based diets cannot be recommended in this population.

References

1. Fritscher-Ravens A, Schuppan D, Ellrichmann M, Schoch S, Rocken C, Brasch J, et al. Confocal endomicroscopy shows food-associated changes in the intestinal mucosa of patients with irritable bowel syndrome. Gastroenterology. 2014;147(5):1012-20 e4.
2. Schol J, Vanuytsel T, Routhiaux K, Huang I, Balsiger L, Van Den Houte K, et al. The six-food elimination diet improves symptoms of functional dyspepsia. Submitted for publication. 2025.
3. Van de Bruaene C, Schol J, Balsiger L, Raymenants K, Toth J, Farre R, et al., editors. Observation of local, food-induced changes of the duodenal mucosa in functional dyspepsia cannot be translated in permeability alterations or changes in mast cell activation ex vivo. F; 2024; Bangkok, Thailand: Neurogastroenterology And Motility.

Introduction

Advances in non-celiac wheat sensitivity (NCWS) have proved that it should be considered a protean condition in which several potential triggers [e.g. gluten, wheat amylase-trypsin inhibitors, etc.] might determine an intestinal mucosal damage with increased permeability and exposure of foods/microbial peptides to immune cells (1,2), resulting in both a local and systemic inflammatory activation responsible for its gastrointestinal and extraintestinal manifestations (3,4). Up to 75% of NCWS subjects complain of multiple foods hypersensitivities (MFH) (5). These patients usually have clinical, immunological and histological features similar to wheat allergy patients, although without positive gluten/wheat IgE assays, allowing to hypothesize the existence of a non-IgE mediated hypersensitivity. In addition, several studies have reported an association between atopic diseases and NCWS.

Aims & Methods

This study aimed to define the presence and features of atopic diseases and other hypersensitivities (primarily food allergies/intolerances) in NCWS compared with celiac disease (CD) and irritable bowel syndrome/functional dyspepsia (IBS/FD) and to analyze a possible correlation between these diseases and NCWS clinical manifestations. This retrospective, multicenter study included NCWS patients diagnosed by double-blind placebo-controlled challenge with wheat. Their clinical, laboratory and histology data at diagnosis (i.e. before the start of a wheat-free diet) were analyzed and compared to control subjects with CD and IBS/FD. Specific allergology data, other than clinical/laboratory features typical of NCWS, were collected and analyzed: family and personal history of atopic diseases, type of allergens responsible, positivity of skin prick tests (SPT), patch tests and total and food-specific IgE.

Results

Atopic disease prevalence was higher in NCWS (32.8%) than in CD (19.3%) and IBS/FD (21.5%) (P=.001 for both). Similarly, NCWS subjects had a higher frequency of MFH (39.8%) and self-reported milk intolerance (SRMI) (65.9%) compared to the controls (P <.001 for both). Allergic asthma, either alone (P=.03) or associated with allergic rhinitis (P=.005), was more prevalent in NCWS compared to IBS/FD, which was more often associated with allergic conjunctivitis (P=.004) or allergic rhinitis alone (P=.02). Graminaceae hypersensitivity and nickel allergic contact dermatitis (Ni-ACD) were more frequent in patients with NCWS (70.1% and 17.8%) vs both CD (48.7% and 9.4%, P=.03 and P=.01, respectively) and IBS/FD (50.8% and 6.7%, P=.01 and P<.001, respectively). On multiple logistic regression analysis, a coexistent atopic disease (OR 1.481), MFH (OR 3.882) and SRMI (OR 2.259) were associated with the NCWS diagnosis. NCWS subjects with atopy compared to those without more frequently had Ni-ACD (P<.001) and SRMI (P=.03), positive patch test (P<.001), SPT for foods (P=0.001) and both total and food-specific serum IgE (P=.02 and P=.002, respectively). On multiple logistic regression analysis, positivity to patch test (OR 2.955), SPT for foods (OR 5.799), and food-specific serum IgE (OR 3.101) were confirmed as differentiating the 2 subgroups.

Conclusion

NCWS subjects have a higher frequency of atopic disease, MFH and SRMI compared to both CD and IBS/FD ones. These conditions could be expression of an underlying hypersensitivity milieu characterizing NCWS and might be of support in the differential diagnosis between NCWS and functional gastrointestinal disorders, if inserted into a broader diagnostic panel.

References

1) Zevallos VF, Raker V, Tenzer S, Jimenez-Calvente C, Ashfaq-Khan M, Rüssel N, et al. Nutritional Wheat Amylase-Trypsin Inhibitors Promote Intestinal Inflammation via Activation of Myeloid Cells. Gastroenterology. 2017;152:1100-1113.e12.
2) Uhde M, Ajamian M, Caio G, De Giorgio R, Indart A, Green PH, et al. Intestinal cell damage and systemic immune activation in individuals reporting sensitivity to wheat in the absence of coeliac disease. Gut. 2016;65:1930–7.
3) Volta U, De Giorgio R, Caio G, Uhde M, Manfredini R, Alaedini A. Nonceliac Wheat Sensitivity. Gastroenterol Clin North Am. 2019;48:165–82.
4) Catassi C, Elli L, Bonaz B, Bouma G, Carroccio A, Castillejo G, et al. Diagnosis of Non-Celiac Gluten Sensitivity (NCGS): The Salerno Experts’ Criteria. Nutrients. 2015;7:4966–77.
5) Carroccio A, Mansueto P, Iacono G, Soresi M, D’Alcamo A, Cavataio F, et al. Non-Celiac Wheat Sensitivity Diagnosed by Double-Blind Placebo-Controlled Challenge: Exploring a New Clinical Entity. American Journal of Gastroenterology. 2012;107:1898–906.

Disclosure

This study is funded by the European Union - Next Generation EU, Mission 4, Component 1 CUP B53D23031860001, Project Code: P2022Z9RZY_001.

Introduction

Non-alcoholic fatty liver disease (NAFLD) is a significant public health concern. Social media (SoMe) is increasingly popular in lower-middle-income countries and can potentially influence perceptions and understanding of illness. Approximately one-third of Sri Lanka's population uses SoMe for health information. We assessed the quality of NAFLD-related content on SoMe.

Aims & Methods

This observational, cross-sectional study aimed to assess the accuracy, completeness and quality of SoMe content relating to NAFLD across Facebook, YouTube, TikTok, Instagram and X (Twitter) from Sri Lanka, in Sinhala, English, and Tamil languages. Posts containing keywords related to NAFLD published between January 2005 to December 2024 were evaluated. Specialist gastroenterologists independently reviewed the content using standardized scales for accuracy (0-3), completeness (0-5), and global quality score (GQS) (0-5). Posts were categorized by source profile [healthcare institution (HI), healthcare professional (HP), alternative healthcare professionals (AHP), non-healthcare person (NHP), or undisclosed identity (UI)] and content type [health education (HEd), health promotion (HProm), HEd and HProm or product endorsement]. User interactions (likes, shares, views) were also analyzed and correlated with reviewer scores.

Results

The analysis included 289 SoMe posts [158 (54.7%) YouTube, 101 (34.9%) Facebook, 14 (4.8%) TikTok, 11 (3.8%) X, 5 (1.7%) Instagram] relating to NAFLD in three languages [214 (74.0%) Sinhala, 54 (18.7%) Tamil, 21 (7.3%) English]. Posts from UI (36.0%) and NHP (26.0%) comprised the majority of content sources. HP (22.1%), AHP (14.2%), and HI (1.7%) represented the remainder. HProm (61.9%) was the predominant content type followed by HEd and HProm (17.6%), HEd alone (11.8%), and product endorsement (8.7%).
The mean accuracy score was 1.78/3(59.3%), with significant differences between sources (HP: 2.35/3(78.5%), AHP: 1.53/3(51.0%), NHP:1.65/3(55.1%), UI: 1.63/3(54.3); p<0.001). Completeness scores averaged 2.1/5(42%), with content in English scoring higher [2.52/5(50.4%)] than Sinhala [2.05/5(40.97%)] and Tamil [2.17/5(43.33%)]. GQS averaged 2.4/5(48.4%). 82% of posts were classified as "Rotten" (<60% composite reviewer score for accuracy, completeness, and global quality). Content quality by platform was compared using ANOVA (mean) and Kruskal-Wallis (median) tests. Posts on Facebook and YouTube showed significantly higher completeness and GQS compared to other platforms (p<0.05).
User interaction analysis was conducted using both Pearson’s and Spearman’s correlation tests. There were no significant correlations observed between accuracy, completeness, or GQS and views or likes. Inter-reviewer variation was assessed using ANOVA and non-parametric tests. There was no statistically significant inter-reviewer variation in scoring patterns, indicating consistency within reviewer groups.

Conclusion

The majority of the SoMe content was from NHP sources. HP delivered the most accurate content. Facebook and YouTube emerged as platforms with relatively higher-quality content compared to others. Overall accuracy, completeness and GQS remained suboptimal across platforms. Most posts (82%) failed to meet adequate quality standards. Notably, user engagement metrics did not correlate with content quality. These findings highlight the need for improved quality control measures and health literacy initiatives to enhance the reliability of information regarding NAFLD on SoMe platforms.

Disclosure

All authors confirm no conflicts of interests to declare.