Review article: exclude or expose? The paradox of conceptually opposite treatments for irritable bowel syndrome.
Review article: exclude or expose? The paradox of conceptually opposite treatments for irritable bowel syndrome.
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评论文章：排除还是揭露？
DOI：
10.1111/apt.17111
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发表时间：
2022
影响因子：
7.6
通讯作者：
VanOudenhove,Lukas
中科院分区：
文献类型：
--
作者：
Biesiekierski,JessicaR;Manning,LaurenP;Murray,HelenBurton;Vlaeyen,JohanWS;Ljótsson,Brjánn;VanOudenhove,Lukas
肠易激综合征(IBS)是一种由生物、心理和社会过程相互作用所致的异质性肠脑相互作用障碍。有趣的是，有两种截然不同的循证治疗方法来减轻IBS症状：排除饮食，如那些低可发酵的寡糖、二糖、单糖和多元醇(FODMAP)和基于暴露的认知行为疗法(CBT)。排除性饮食建议患者避免食用被认为是引起症状的食物，而基于暴露的CBT鼓励患者暴露于食物中。目的为了解决概念上相反的排除性饮食和基于暴露的CBT对IBS的悖论。方法在这篇概念性综述中，我们描述了每种治疗方法的原理、实际实施、证据基础和优缺点。我们进行了关于低FODMAP饮食和CBT的最新文献搜索，并对先前进行的一项试验进行了二次分析，以说明我们综述中的一个关键点。结果低FODMAP饮食显示出疗效，但在坚持、营养妥协和胃肠道特异性焦虑加剧方面的问题值得警惕。基于暴露的CBT已经证明了有效性，大量证据表明胃肠道特异性焦虑是一种关键的作用机制。中介分析还显示，增加FODMAP摄入量在基于暴露的CBT中减轻症状严重程度的中介作用。然而，很少有证据支持哪种治疗“对谁最有效”，以及这些方法如何最好地结合。结论尽管排除饮食和基于暴露的CBT在概念上是相反的，但它们都已被证明有效。临床医生应该熟悉这两种治疗方法。需要对治疗结果的预测因素、机制和调节因素进行进一步研究。
BackgroundIrritable bowel syndrome (IBS) is a heterogeneous disorder of gut‐brain interaction (DGBI) maintained by interacting biological, psychological, and social processes. Interestingly, there are two contrasting yet evidence‐based treatment approaches for reducing IBS symptoms: exclusion diets such as those low in fermentable oligo‐, di‐, monosaccharides and polyols (FODMAPs) and exposure‐based cognitive‐behavioural therapy (CBT). Exclusion diets recommend patients avoid foods thought to be symptom‐inducing, whereas exposure‐based CBT encourages patients to expose themselves to foods.AimsTo address the paradox of conceptually opposite exclusion diets and exposure‐based CBT for IBS.MethodsIn this conceptual review, we describe the rationale, practical implementation, evidence base and strengths and weaknesses of each treatment. We conducted up‐to‐date literature search concerning the low FODMAP diet and CBT, and performed a secondary analysis of a previously conducted trial to illustrate a key point in our review.ResultsThe low FODMAP diet has demonstrated efficacy, but problems with adherence, nutritional compromise, and heightened gastrointestinal‐specific anxiety raise caution. Exposure‐based CBT has demonstrated efficacy with substantial evidence for gastrointestinal‐specific anxiety as a key mechanism of action. Mediation analysis also showed that increased FODMAP intake mediated decreased symptom severity in exposure‐based CBT. However, there is minimal evidence supporting which treatment “works best for whom” and how these approaches could be best integrated.ConclusionsEven though exclusion diets and exposure‐based CBT are conceptually opposite, they each have proven efficacy. Clinicians should familiarise themselves with both treatments. Further research is needed on predictors, mechanisms and moderators of treatment outcomes.