14:55 PM

444 - Diet and IBS, Geriatric Diagnostic Excellence, Play Time

Take 3 – Practical Practice Pointers©

From the American Gastroenterology Association (AGA)

1) Dietary Best Practices for Irritable Bowel Syndrome (IBS)


Irritable Bowel Syndrome (IBS) has multiple potential causes, and medication therapy works only 7-15% above placebo effects. Because most patients associate their symptoms with food, a specific strategy for dietary recommendations may improve our efforts to treat this condition.

The American Gastroenterology Association has recently published “best practice recommendations” on the dietary treatment of irritable bowel syndrome (both IBS-C, constipation predominant, and IBS-D, diarrhea predominant). These guidelines are “evidence-informed” – i.e., research evidence is quoted throughout, but there are no systematic methods for its use and reporting.

Best Practice Recommendations for Dietary Intervention in IBS (paraphrased):

·       Dietary consultation is recommended for those who are engaged and willing to work with a gastroenterology-trained dietitian.

·       Very restrictive diet interventions are potentially harmful in people who are at risk for malnutrition, have food insecurity, or have an eating disorder or other uncontrolled psychiatric disorder.

·       Give any one dietary intervention a specific length of time to work, then try something else. Avoid “open-ended” restrictions without re-assessment.

·       When meeting with a dietitian, patients should ideally complete a three-day dietary history and clinicians should forward medical information so that the dietitian can make the best comprehensive plan for that patient.

·       Soluble fiber (psyllium, ispaghula husk, corn fiber, calcium polycarbophil, methylcellulose, oat bran, and the flesh of fruits and vegetables) helps IBS-C symptoms but insoluble fiber (wheat bran, whole grains, and fruit and vegetable skins and seeds) does not and may worsen symptoms.

·       Low FODMAP (fermentable oligo-, di- and monosaccharides and polyphenols) diets are the most evidence-based treatments for IBS-D, but do not help with IBS-C. [We discussed low FODMAP diets in Take 3 # 424.]

·       Low FODMAP diet therapy does not mean simply eliminating those foods forever but restricting them initially as a diagnostic test. If no benefit is found after 4-6 weeks, other therapies should be considered. If symptoms are improved, gradual and careful re-introduction of FODMAP foods should be attempted in order to personalize the recommendations.

·       Observational studies of gluten-free diets have shown promise for IBS, but randomized, controlled trials with re-challenge methods (restarting the food to see if symptoms return) have not consistently shown benefit.

·       Biomarkers (antibody testing, stool testing, breath testing, etc.) inconsistently predict response to dietary intervention in IBS, so are not yet recommended for routine use.

John’s Comments:

Only one of the guideline authors is a dietitian, and two of the four authors had some industry conflict of interest, but overall this “evidence-informed” guideline seems reasonable as “best practice advice.” The difference in effect between soluble and insoluble fiber was a learning point for me, and the advice to select the right patients for what can be very restrictive diets seems very important. Advocating for better access to dietitians is also important as we increasingly recognize the contribution of our dietary habits to significant illness.


·       Chey WD, Hashash JG, Manning L, Chang L. AGA Clinical Practice Update on the Role of Diet in Irritable Bowel Syndrome: Expert Review. Gastroenterology. Published online March 2022:S0016508521040841. Link

From the Literature

2)  Principles for Achieving Diagnostic Excellence in Older Patients


Between 1900 and 2020, life expectancy in the US has gone from 46.3 to 74.5 years for men, and from 48.3 to 80.2 years from women.  Presently, over 20% of the population is older than 65 and those older than 85 are the fastest growing population segment.   

There are many unique challenges in caring for this population that clinicians need to cognizant of these and take them into consideration as a manner of habit in their care.  Some significant ones include:

·       Symptom presentations often do not fit traditional diagnostic patterns due to both age-related changes and the overlap of multiple chronic disease processes. 

o   This often includes subtle and/or vague signs and symptoms

o   Diseases for which this commonly occurs include UTIs, pneumonia, peritonitis, and myocardial infarction

·       Medical complexity increases as people age, often including multiple chronic diseases, multiple medications, and multiple healthcare clinicians. 

o   These add a level of unpredictability when a specific symptom is manifest

o   Many vague symptoms are treated with additional medications, amplifying the complexity

·       Communication challenges are common, including hearing, visual, and cognitive impairment as well as technological challenges for the patient. 

o   Among older adults with impaired hearing, only between 14-30% receive hearing aids due to cost and perceived stigma

o   Early cognitive impairment can be overlooked without regular screening

·       Additionally, the complexity of healthcare communication across multiple clinicians, clinical specialties, and health systems adds to the challenges.

o   Many elderly don’t have access to computers and even when they do, often experience discomfort in using it.

·       Stereotypes and negative attitudes toward older adults can obscure clear diagnostic thinking and may result in premature closure of a diagnostic exploration.

o   This can become particularly challenging when it comes to defining “futility”

·       On the other hand, fear of missing something due to the many challenges can result in overly aggressive intervention not in line with a patient’s wishes. 

o   This can become particularly challenging when deciding when to stop screening tests/procedures, and depends on skilled communication

o   Clinical time pressures often make recommending the test to be the expedient path

·       Families are more involved in care and this can provide important information but also brings additional complexity with often communicating with multiple parties.  This becomes even more challenging when they are not aligned with each other or with the patient. 

o   This also requires both time and resources that the busy clinician is hard-pressed to find.

For the above reasons, both overdiagnosis and underdiagnosis are common and undertreatment and overtreatment often occur.  Clinicians must become even more comfortable with uncertainty and more skilled in patient and family centered care serving in multiple roles, including healthcare facilitator, educator, advisor, and partner.

Mark’s Comments:

The care of the older patient, particularly those with multiple co-morbidities and sensory and/or cognitive deficits, can be a significant challenge.  I used the well-written referenced article below as a take-off point for this Pointer, and made some additions based on my own clinical experience.  Maintaining vigilance on the part of both the patient’s care and an awareness of our particular tendencies can help enhance care excellence.


Cassel C and Fulmer T.  Achieving Diagnostic Excellence for Older Patients.  JAMA 17 February 2022;327(10):919-920.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  What Do You Do … For Play?


“We don’t stop playing because we grow old; we grow old because we stop playing.”  George Bernard Shaw

While I believe that “All work and no play makes Mark a dull boy,” I must confess I don’t put that wisdom into practice often enough.  And my sense is this is the case for many other physicians as well.  Indeed, when I ask colleagues, “What do you do for fun?,” the most common response I get is an initial blank stare, often followed by one of two common responses: “I don’t really do much for fun” or “I used to have fun doing ____.”  If this at all describes you, please read on, because the subject of play is actually quite serious business.     

Stuart Brown, MD is a psychiatrist who has devoted his career to understanding the importance of play for healing and health.  In his book Play: How it Shapes the Brain, Opens the Imagination, and Invigorates the Soul, Brown writes; “ … in analyzing thousands of case studies that I call play histories, I have found that remembering what play is all about and making it part of our daily lives are probably the most important factors in being a fulfilled human being. The ability to play is critical not only to being happy, but also to sustaining social relationships and being a creative, innovative person.” 


Wow!  The practice of playing is certainly not “kid’s stuff!”  As I’ve done further “play” research, it has become apparent that I am not the only adult who has been left feeling a bit “dulled” over the past 2 years.  To that end, I found the ideas on blogger Marelisa Fabrega’s entry “Adults Need Play” to provide some wonderful tips for “pressing play” more often in our lives (website link).  Here are some edited highlights: 

·        Set the Goal of Playing More – Intention is an important first step.

·        Decide What Fun Means For You – Make a list of what would be fun to do. 

·        Put Fun In Your Schedule – Who said we had to give up recess as an adult?

·        Create a Play Drawer – Keep some “toys” close at hand, such as a coloring book, some juggle balls, a puzzle, Play-Doh, or LEGOs and pull them out when you need a “work” break.

·        Combine Fun With Other Activities – No reason exercise or preparing dinner can’t be fun! 

·        Have More Fun at Work – Play shouldn’t be absent from a place where you spend a good portion of your life (go here for some creative ideas - Link )

·        Have Play-Dates With Your Significant Other or Friends – Don’t fall into a predictable rut. 

·        Befriend a Fun Person – Even as adults we need play mates, someone who will ask “Can ___ (insert your name here) come out and play?”

·        Hang Out With a Kid – No better way to be reminded what play looks like than to watch the masters of play.  

As we begin to emerge from the past 2 pandemic years, incorporating regular play into your day will be essential to your “recovery.”  So, this week and in the weeks to come, make an intention to “come out and play” more often in your life.  Not only will it make you feel more alive, but doing so will likely make you even more effective and fulfilled in your work and allow for it to be sustainable over the long-haul.  In case you needed it, that sure seems to be a good “excuse” for playing more!   Time for recess ….


Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org