"Dear Heather: I have a question regarding an article you included in your last newsletter. In the article, "American Academy of Family Physicians Releases New Guidelines for Management of IBS," it says that there is "no association between IBS and food intolerance." Why are you endorsing this view by publishing it to thousands of people who have found in their own experience quite the opposite? Many have found that once they eliminate certain problem foods, their symptoms improve, just like your books purport. Certainly you do not take the view of the author of this article, otherwise you would be making a mockery of your own books and cooking show. I am all for having both sides of a story told; however, you alienate your readers by including an article which tells them the symptom relief they have found by eliminating certain foods is all in their heads. This article also undermines all the hard work you've put forth to change the opinions of people like the author and effect change in IBS research. Can we have a more enlightened view, please?

Sincerely,

Sheila Townsend"


Thank you very much, Sheila, for your letter. I was hoping to receive responses exactly like yours as a result of the Academy article in the last newsletter. I, too, was completely dismayed by the Academy's "updated" guidelines, but their release is fairly significant news and warranted inclusion in the IBS Newsletter. I report all legitimate IBS news and research stories in the newsletter, and don't want to exclude stories altogether just because I find fault with them. I want my readers to draw their own conclusions on the current state of affairs in the IBS field, and they need to be aware of what's going on in order to do that. I hope everyone understands why I included the article in my newsletter, even though I certainly do not agree with their dietary guidelines nor do I consider them to be at all helpful for doctors to use in treating IBS patients.

As a follow up to the article, I have written a response to both the primary author of the guidelines, Anthony J. Viera, and to the editor of American Family Physician. My letter to them is as follows:


"Dear Dr. Viera and the American Academy of Family Physicians:

I'm an author who writes on the subject of Irritable Bowel Syndrome. I send a twice-monthly newsletter to over 11,000 people with IBS, and in a recent issue I included reference to your November article "Management of Irritable Bowel Syndrome." Many readers let me know that they were quite upset by the Dietary Recommendations section of this article, and, in my opinion, rightly so.

In fact, I would like to take this chance to express my own dismay with your article. As it seems to be intended for use by family physicians in their diagnosis and treatment of IBS, you had a tremendous opportunity to address the lack of information and outright misinformation that has characterized dietary recommendations for IBS in the past. Unfortunately, you failed to seize this opportunity, quite likely to the severe detriment of IBS patients across America. I hope that you will redress this situation so that your article may instead live up to its honorable intentions.

As you are well aware, and as you explicitly state, a "strong physician-patient relationship is paramount in an effective management strategy for irritable bowel syndrome." This relationship simply must include accurate and effective dietary information for preventing and alleviating IBS symptoms, or it is of limited value to the patient. You surely know from your own personal experience treating IBS patients that dietary questions are always foremost among their concerns. If patients do not receive legitimate dietary guidance from their physicians, there is no foundation (or trust) on which to build a strong physician-patient relationship in the first place. Unlike in the very recent past, doctors today are actually in a position to address these concerns and provide detailed, comprehensive, and accurate answers to their patients' dietary questions. They are in this position, that is, if they have been made aware of current research and publications in this area. Your article was the perfect forum for giving family physicians notice of these new advances in dietary information for IBS; how unfortunate that it failed to do so. I find this very disheartening, and I know for a fact that thousands of other IBS sufferers feel the same way. I hope that you would like to rectify this situation.

To begin, you state outright that "in general, there is no association between IBS and food intolerance." This is simply false. Your earlier note that patients are often advised to "limit alcohol, caffeine, sorbitol, and fat intake" actually contradicts the lack of association you assert, and rightly so. You could have then elaborated on these common IBS food intolerances, explained why these foods should be limited or avoided entirely (there are valid and logical reasons, and I'm confident that you are aware of them), and expanded the list to include other well-known offenders (such as acidic and sulfur-containing foods).

I'm sure you do actually realize that alcohol, caffeine, sorbitol, and fats are in fact problematic for IBS because they are all either powerful GI tract stimulants or irritants. Clearly, a digestive disorder you accurately describe as characterized by "an exaggerated gastrocolic reflex and increased small bowel contractions exacerbated by food intake" will not respond well to foods that are stimulants and irritants. Why you did not explain this connection does, however, give me pause. Why, also, you neglected to mention the fact that insoluble fiber (again, a powerful GI tract stimulant) is another common offender puzzles me as well. Your statement that "lactose should be eliminated only in those with proven lactase deficiency" is, I must admit, outright surprising. There is no advantage whatsoever to including lactose in the diet, and lactose is in fact just one of many potential IBS triggers found in dairy (fat, casein, and whey are among the others). Why not simply state this and make it clear that avoiding dairy altogether is helpful for almost all IBS patients, and at the very least not remotely harmful? If, perhaps, there was a low comfort or confidence quotient dealing with the dietary arena in managing IBS (and this is understandably not a chosen field of in-depth study for most physicians), why not assign this particular portion of the article to a co-author with dietary expertise? Or, simply refer your readers to a more comprehensive and accurate outside source of dietary guidelines for IBS. I really do feel that this whole issue was instead sidestepped, and dismissed altogether after just a few sentences of generalities. I hope you would agree that this does a grave disservice to the IBS patients who are the intended beneficiaries of your article.

I am most disappointed of all in your fiber information, which should have been one of the most helpful sections of your article. Unfortunately, you make no distinction made between soluble and insoluble fibers and their (often dramatically) different effects upon IBS. There is voluminous and ongoing clinical research in this area. There is also no note that soluble fiber therapy is just as useful for diarrhea as constipation, and can help alleviate IBS pain as well. While this speaks specifically to soluble vs. insoluble fiber supplements, there is also a world of soluble and insoluble fiber foods that you neglected to address entirely. This is crucial information for IBS patients, and had your article included this information doctors could now be disseminating it and helping patients as you obviously intended.

I honestly don't know what to make of the assertion that, "If dietary advice and fiber supplementation do not adequately relieve abdominal pain, a short-term trial of an antispasmodic agent may be tried." It would be quite surprising indeed if any patient given the scarce dietary and fiber information in this article experienced relief from their abdominal pain. I must say it again: IBS patients need real help in this area, and despite your good intentions you failed to provide it.

I would hope that you wish to redress this situation and offer legitimately helpful dietary guidelines to family physicians for treating their IBS patients. As a starting point, for clinical research in the soluble/insoluble fiber area, may I suggest you review "Partially hydrolyzed guar gum: a fiber as coadjuvant in the irritable colon syndrome" [Clin Ter 2001 Jan-Feb;152(1):21-5] and "High-Fiber Diet Supplementation in Patients with IBS" [Dig Dis Sci 2002 Aug;47(8):1697-704]. In addition, you could look specifically to the multiple articles Dr. P.J. Whorwell has published over many years in this area as well. For overwhelming patient feedback regarding specific dietary advice that has been shown to be efficacious, I would invite you to peruse the reader reviews of the books Eating for IBS and The First Year: IBS at amazon.com, as well as the reviews posted in the "Reader Review" section of the Eating for IBS website, at http://www.eatingforibs.com/reviews.htm. You may also be interested in the ongoing clinical research of Dr. Noel Hershfield, a gastroenterologist in hospital practice in Calgary, Canada, who is conducting trials of the specific dietary advice in Eating for IBS with his patients. His trials were prompted by the dramatic improvement he personally experienced with his own IBS (he now considers himself "an ex-patient") after following the book's dietary guidelines. In addition, there are now over 100 family physicians and gastroenterologists across the US providing their IBS patients with dietary information excerpted from Eating for IBS. This information has also been licensed by Novartis Pharmaceuticals for use in association with their drug Zelnorm. Finally, the specific dietary advice in Eating for IBS has resulted in my inclusion in the 4th Edition of Marquis Who's Who in Medicine and Healthcare. Efficacious is an understatement; the proper IBS dietary information is nothing short of life-saving to patients who suffer from this disorder.

In summary, there is most assuredly a direct association between IBS and food intolerance. Ask any IBS patient and she or he will tell you this. The problem has been that no one had previously pulled together comprehensive and accurate dietary guidelines specifically addressing IBS needs. Eating for IBS has done this, and I hope to see many more clinical trials supporting the book in addition to Dr. Hershfield's. I also hope to see future articles in the journal of the American Family Physician that acknowledge current dietary information and recognize its critical importance in the successful management of IBS. This is my wish not just as an author on the subject, but as an IBS patient. I would not be able to live a normal life without following the proper diet for IBS, and having learned that the same detailed dietary guidelines apply to virtually all IBS sufferers, it upsets me tremendously to see yet another lost opportunity to provide others with the help I have already received but they have not. Patients and doctors both are desperate for accurate dietary information for IBS. You had a chance to provide such information and it truly saddens me that you did not. I hope you understand the importance of correcting these oversights, and that you believe me when I say how many IBS patients will be eternally grateful to you for doing so. The severe pain and debilitation IBS causes so many people continues to be tragically underestimated, and I am pleading with you to use your position to help remedy this situation.

Sincerely,

Heather Van Vorous

P.S. Why was hypnotherapy completely unaddressed as a safe and highly effective treatment for IBS? There are so many years of clinical studies in support of hypnotherapy at this point that it has been declared "the treatment of choice for IBS" by the National Women?s Health Network in Washington, D.C. Surely you know this."


I would like to urge my readers to write a response to the Academy article as well, drawing on their own opinions and experiences. Dr. Viera, the article's author, can be reached at anthonyjviera@yahoo.com. To submit a letter to the editor of American Family Physician, email Jay Siwek, M.D., Editor, at afplet@aafp.org. Dr. Siwek can also be reached at American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672, or at fax number 913-906-6080. Please include your complete address and telephone number.

I'm also writing a press release about the Academy dietary guidelines and will hope to see some media attention from that.

- Heather Heather & Company is dedicated to serving people with IBS. Our mission is to offer education, services, and products that allow people with IBS to successfully manage their symptoms through lifestyle modifications. We currently offer the books
Eating for IBS and First Year IBS, web site resources, seminars and classes, and Heather Cooks!, a healthy cooking show on the internet and television. We will soon have other IBS services available. Heather Van Vorous, an IBS sufferer since age 9, is the company founder and president.

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