Exclude or Expose in Irritable Bowel Syndrome: What Works for Whom and How?
- Conditions
- Irritable Bowel Syndrome (IBS)Intestinal DiseasesGastrointestinal Disease
- Registration Number
- NCT06940596
- Lead Sponsor
- University of Melbourne
- Brief Summary
This research project will assess how two treatments for irritable bowel syndrome (one dietary and one behavioral) work and for whom. This will be done by assessing moderators (what treatment works for who and in what context) and mediators (how treatment works). Investigators will also assess how the diet and behavioral treatments affect IBS symptoms during treatment. Participants will be randomized to either: i. A FODMAP diet online program that focuses on modifying the consumption of foods high or moderate in fermentable carbohydrates (FODMAPS) to manage IBS symptoms. or, ii. An Exposure-based Cognitive Behavioral Therapy (E-CBT) online program for IBS that focuses on changing symptom-related behaviors which are known to worsen IBS symptoms.
- Detailed Description
This research uses a randomized controlled trial to investigate the treatment of irritable bowel syndrome (IBS). A range of treatments for IBS are available, but each work for only a portion of patients, and it is unclear why. This research project will assess how two treatments (one dietary and one behavioral) work and for whom. Investigators will do this by assessing moderators (what treatment works for who and in what context) and mediators (how treatment works). This project will also assess how the diet and behavioral treatments affect IBS symptoms during treatment. Participants will be randomized to either: i. A FODMAP diet online program that focuses on modifying the consumption of foods high or moderate in fermentable carbohydrates (FODMAPS) to manage IBS symptoms. This treatment involves 3-phases: FODMAP restriction (phase 1), FODMAP re-introduction (phase 2), and FODMAP personalization (phase 3), or, ii. An Exposure-based Cognitive Behavioral Therapy (E-CBT) online program for IBS that focuses on symptom-related behaviors such as avoidance of activities and foods, excessive toilet visits, and behaviors to control symptoms which are known to worsen IBS symptoms. E-CBT uses daily self-observation and exposure exercises to change these behaviors to relieve IBS symptoms. Investigators believe that both treatments, FODMAP diet and E-CBT, will lead to an improvement in IBS gastrointestinal symptoms. Primary moderators and mediators to be assessed include gastrointestinal symptom anxiety, food avoidance behaviour and FODMAP intake.
Recruitment & Eligibility
- Status
- NOT_YET_RECRUITING
- Sex
- All
- Target Recruitment
- 200
Each participant must meet all of the following criteria to be enrolled in this trial:
- Living in Australia or the United States
- Aged 18 years or older
- Body Mass Index (BMI) [Equation]18.5kg/m2 and [Equation] 34.9kg/m2
- Diagnosed with IBS by a General Practitioner, Family Physician, or Gastroenterologist, or Advanced Specialist Dietitian
- Currently fulfill Rome IV criteria for IBS
- Symptomatic at the time of recruitment (IBS-SSS > 175)
- Access to a computer and internet
- Sufficient English language and computer skills to complete a text-based online treatment
- Willing to make dietary or behavioral changes in line with the allocated treatment program
- Ability to provide informed consent
Patients meeting any of the following criteria will be excluded from the trial:
- Presence or known history of other GI disease (e.g. coeliac disease, Inflammatory Bowel Disease) or history of gastrointestinal cancer
- History of major gastrointestinal surgery (not appendectomy, cholecystectomy or hemorrhoidectomy)
- Individuals who report alarm symptoms (e.g., blood in stool, recent unexplained/unintentional weight loss >5% body weight, a recent change in bowel habits if >50 years, family history of gastrointestinal cancer or gastrointestinal diseases, large volumes of diarrhea occurring at night, fever associated with gut symptoms, recurrent vomiting, persistent unexplained iron deficiency) will be excluded if appropriate medical investigations have not been conducted, unless written medical approval is provided from a general practitioner, family physical, or gastroenterologist.
- Diagnosis of major disease that could explain current gastrointestinal symptoms such as severe diabetic, cardiac, liver, neurological, neuropathy disease
- History or current diagnosis of psychotic disorder or bipolar disorder
- Current diagnosis of substance abuse disorder or major depressive disorder or active suicidal ideation
- History or current diagnosis of an eating disorder
- Current enteral/parenteral feeding or use of supplemental feeds (e.g. Ensure)
- Pregnant or lactating or planning to become pregnant during the 12-week intervention period
- Commenced or change in dose of antibiotics and medications that potentially affect the gastrointestinal transit (e.g. anti-diarrheals and laxatives) in the 3 months preceding study commencement.
- Commenced taking or changed dose of probiotics, prebiotics, fibre supplements and digestive enzymes in the 3 months preceding study commencement
- Commenced or change dose in psychotropic medication in the 3 months preceding study commencement
- Are currently undertaking behavioral therapy for IBS (including cognitive behavioral therapy, CBT), or have undertaken clinician-delivered behavioral therapy for the treatment of IBS
- Are currently undertaking or have undertaken a dietitian-prescribed and delivered restrictive diet for IBS (e.g., FODMAP diet).
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Primary Outcome Measures
Name Time Method Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome (GSRS-IBS ) Measured weekly between baseline (prior to intervention) and after intervention completed (week 12). The GSRS-IBS is a 13-item measure of IBS symptom severity to reflect the last 7 days. The items are scored between 1 (no discomfort at all) and 7 (very severe discomfort), rendering a total score between 13 and 91.
- Secondary Outcome Measures
Name Time Method Change from baseline in Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome (GSRS-IBS) Baseline and 3-and 6 month follow up time points after intervention completed (week 12). The GSRS-IBS is a 13-item measure of IBS symptom severity to reflect the last 7 days. The items are scored between 1 (no discomfort at all) and 7 (very severe discomfort), rendering a total score between 13 and 91.
Change from baseline in Irritable Bowel Syndrome - Symptom Severity Score (IBS-SSS) questionnaire Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. The IBS-SSS is a 5-item measure of the severity of IBS symptoms: frequency and severity of abdominal pain, severity of bloating, dissatisfaction with bowel habits and impact on life in general. Questions ask about IBS and gut symptoms during the past 7 days except question 4 which asks participants to enter the number of days they get pain in every 10. days. A total score ranging from 0 to 500. Mild, moderate and severe cases are indicated by scores of 75 to \<175, 175 to \<300 and \>300 respectively
Change from baseline in IBS quality of life (IBS-QOL) questionnaire Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. IBS-QOL is used to assess the impact on quality of life for patients with IBS and consists of 34 items scored between 1 and 5, resulting in a maximum score of 170.
Change from baseline in Nine Item ARFID (Avoidant Restrictive Food Intake Disorder) Screen (NIAS) questionnaire Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. NIAS is a 9-item measure of ARFID symptoms. The scale has 9 questions, scored from 0 (strongly disagree) to 5 (strongly agree) and summed into three subscales (fear of adverse consequences, lack of interest/appetite, and sensory sensitivity); each range = 0-15), with higher scores indicating greater severity.
Change from baseline in Fear of Food Questionnaire (FFQ) questionnaire Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. The Fear of Food Questionnaire (FFQ) is an 18-item measure of food-related fears averaged into five subscales (GI fears, food fears, food avoidance, social impairment, and distress/loss of pleasure) and a total score between 0 and 90 (each range = 0-5), with higher scores indicating greater food related fears.
Change from baseline in Patient Health Questionnaire-12 (PHQ-12) (derived from PHQ-15) questionnaire Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. PHQ-15 is a validated measure of somatization. Questions reflect the previous 4 weeks. It comprises 15 somatic symptoms with each symptom scored from 0 ("not bothered at all") to 2 ("bothered a lot"). The PHQ-15 will be administered to facilitate assessment of PHQ-12. The PHQ-12 is a commonly used modification of the PHQ-15 without three GI-related items; constipation, loose bowels, or diarrhea; nausea, gas, or indigestion. The PHQ-12 represents non-GI or extraintestinal somatic symptoms.
Change from baseline in Generalized anxiety disorder (GAD-7) questionnaire Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. GAD-7 is a 7-item questionnaire used for screening and measuring the severity of anxiety symptoms. Questions reflect the previous 14 days and responses are measured on a 4-point Likert scale; 0=not at all sure; 1=several days; 2=more than half the days; 3=nearly every day. Total GAD-7 scores range from 0-21 with higher scores indicating greater severity of symptoms.
Change from baseline in Patient Health Questionnaire (PHQ-9) questionnaire Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. The Patient Health Questionnaire (PHQ-9) is a 9-item measure of depression severity. Questions reflect the previous 14 days. Each of the 9 items can be scored from 0 (not at all) to 3 (nearly every day) and severity score can range from 0 to 27. PHQ-9 scores of 5, 10, 15, and 20 indicate mild, moderate, moderately severe, and severe depression, respectively.
Change from baseline in Gastrointestinal Specific Anxiety (GSA) measured using Visceral Sensitivity Index (VSI) Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. The VSI is a 15-item measure of gastrointestinal-specific anxiety, scored on a Likert scale of 1 to 6 with 1=strongly agree; 2=moderately agree; 3=mildly agree; 4=mildly disagree; 5=moderately disagree and 6=strongly disagree.
Change from baseline in Avoidance behavior measured using Irritable Bowel Syndrome-Behavioural Responses Questionnaire (IBS-BRQ) Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. IBS-BRQ is a 26-item measure of avoidance behavior. The scale has 26 items, scored from 1 (never) to 7 (always), indicating how persistently the particular avoidance or toilet behavior is carried out.
Change from baseline in Total FODMAP intake measured using 3-day food diary Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. Participants will record their food intake for 3 days (including one weekend day) using paper or an app. Total FODMAP intake will be calculated g/day.
Change from baseline in stool frequency and consistency using 7-day stool diary based on Bristol Stool Form Scale (BSFS) Baseline, after intervention completed (week 12), and at follow up time points of 3-and 6 months following the 12-week intervention. The stool diary will be completed over 7 days and is based on the Bristol Stool Form Scale (BSFS) for IBS subtyping and bowel habit assessment i.e. stool frequency and consistency. Stool consistency will be quantified according to ROME classifications.
Gastrointestinal microbiome composition and function using stool sample using OMNIgene GUT Gastrointestinal microbiome composition and function will be measured 2nd weekly between baseline (prior to intervention) and after intervention completed (week 12) as exploratory mediators. Gut microbiome composition (i.e., alpha diversity, beta diversity, relative abundance) and function 16S rRNA and shotgun sequencing. Measured as exploratory mediators.
Individual FODMAPs' intake using 3-day food diary Will be measured 2nd weekly between baseline (prior to intervention) and after intervention completed (week 12) as exploratory mediators. Participants will record their food intake for 3 days (including one weekend day) using paper or an app. Individual FODMAPs' intake will be calculated g/day. Measured as exploratory mediators.
Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome GSRS-IBS Baseline (prior to start of intervention) as an exploratory moderator. The GSRS-IBS is a 13-item measure of IBS symptom severity to reflect the last 7 days. The items are scored between 1 (no discomfort at all) and 7 (very severe discomfort), rendering a total score between 13 and 91. Measured as an exploratory moderator.
IBS quality of life (IBS-QOL) questionnaire Baseline (prior to start of intervention) as an exploratory moderator. Description: I IBS-QOL is used to assess the impact on quality of life for patients with IBS and consists of 34 items scored between 1 and 5, resulting in a maximum score of 170. Measured as an exploratory moderator.
Fear of Food Questionnaire (FFQ) questionnaire Baseline (prior to start of intervention) as an exploratory moderator. The Fear of Food Questionnaire (FFQ) is an 18-item measure of food-related fears averaged into five subscales (GI fears, food fears, food avoidance, social impairment, and distress/loss of pleasure) and a total score between 0 and 90 (each range = 0-5), with higher scores indicating greater food related fears. Measured as an exploratory moderator.
Nine Item ARFID (Avoidant Restrictive Food Intake Disorder) Screen (NIAS) questionnaire Baseline (prior to start of intervention) as an exploratory moderator. NIAS is a 9-item measure of ARFID symptoms. The scale has 9 questions, scored from 0 (strongly disagree) to 5 (strongly agree) and summed into three subscales (fear of adverse consequences, lack of interest/appetite, and sensory sensitivity); each range = 0-15), with higher scores indicating greater severity. Measured as an exploratory moderator.
Patient Health Questionnaire-12 (PHQ-12) (derived from PHQ-15) questionnaire Baseline (prior to start of intervention) as an exploratory moderator. PHQ-15 is a validated measure of somatization. Questions reflect the previous 4 weeks. It comprises 15 somatic symptoms with each symptom scored from 0 ("not bothered at all") to 2 ("bothered a lot"). The PHQ-15 will be administered to facilitate assessment of PHQ-12. The PHQ-12 is a commonly used modification of the PHQ-15 without three GI-related items; constipation, loose bowels, or diarrhea; nausea, gas, or indigestion. The PHQ-12 represents non-GI or extraintestinal somatic symptoms. Measured as an exploratory moderator.
Patient Health Questionnaire (PHQ-9) questionnaire Baseline (prior to start of intervention) as an exploratory moderator. The Patient Health Questionnaire (PHQ-9) is a 9-item measure of depression severity. Questions reflect the previous 14 days. Each of the 9 items can be scored from 0 (not at all) to 3 (nearly every day) and severity score can range from 0 to 27. PHQ-9 scores of 5, 10, 15, and 20 indicate mild, moderate, moderately severe, and severe depression, respectively. Measured as an exploratory moderator.
Generalized anxiety disorder (GAD-7) questionnaire Baseline (prior to start of intervention) as an exploratory moderator. GAD-7 is a 7-item questionnaire used for screening and measuring the severity of anxiety symptoms. Questions reflect the previous 14 days and responses are measured on a 4-point Likert scale; 0=not at all sure; 1=several days; 2=more than half the days; 3=nearly every day. Total GAD-7 scores range from 0-21 with higher scores indicating greater severity of symptoms. Measured as an exploratory moderator.
Gastrointestinal microbiome composition and function using stool sample using a stool sample collection kit. Baseline (prior to start of intervention) as an exploratory moderator. Gut microbiome composition (i.e., alpha diversity, beta diversity, relative abundance) and function 16S rRNA and shotgun sequencing . Measured as an exploratory moderator.
IBS subtype using 7-day stool diary based on Bristol Stool Form Scale (BSFS). Baseline (prior to start of intervention) as an exploratory moderator. The stool diary will be completed over 7 days and is based on the Bristol Stool Form Scale (BSFS) for IBS subtyping and bowel habit assessment i.e. stool frequency and consistency. Stool consistency will be quantified according to ROME classifications. Measured as a exploratory moderator.
Client Satisfaction Questionnaire End of the 12-week intervention and at 3-and 6 months follow up time points after 12-week intervention.. The Client Satisfaction Questionnaire is an 8-question brief global measure of client satisfaction. The eight questions are measured on a 4-point Likert scale with questions 1, 3, 6 and 7 measured on a positive scale and questions 2, 4, 5 and 8 on a negative scale. Total scores range from 8 to 32, with the higher number indicating greater satisfaction.
Proportion of participants who achieve a change from baseline in Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome (GSRS-IBS) of >30% total score Baseline and after intervention completed (week 12) The GSRS-IBS is a 13-item measure of IBS symptom severity to reflect the last 7 days. The items are scored between 1 (no discomfort at all) and 7 (very severe discomfort), rendering a total score between 13 and 91.
Proportion of participants who achieve a change from baseline in Irritable Bowel Syndrome - Symptom Severity Score (IBS-SSS) of ≥50 points total score. Baseline and after intervention completed (week 12) The IBS-SSS is a 5-item measure of the severity of IBS symptoms: frequency and severity of abdominal pain, severity of bloating, dissatisfaction with bowel habits and impact on life in general. Questions ask about IBS and gut symptoms during the past 7 days with the exception of question 4 which asks participants to enter the number of days they get pain in every 10. days. A total score ranging from 0 to 500. Mild, moderate and severe cases are indicated by scores of 75 to \<175, 175 to \<300 and \>300 respectively