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The prevalence of obesity has increased to epidemic proportions and has become an urgent public health problem. Obesity causes significant morbidity and mortality and its impact on health-care costs in the United States is growing dramatically. Apart from bariatric surgery treatment, options are limited. Future advances in treatment will rely on a better understanding of the pathogenesis and physiology of obesity. Alterations in gastrointestinal (GI) sensory-motor function and symptoms have been associated with obesity. GI neuroendocrine communications between the periphery and the brain regulate energy balance and ingestive behaviors. These interactions are largely mediated by the gut-brain peptides through negative and positive feedback loops that maintain energy homeostasis. Bariatric surgery has been shown effective, but the mechanisms of weight loss following these procedures clearly require further studies and a better understanding of the affects of bariatric surgery on the gut-brain neuropeptide homeostasis. Gut-brain peptides may provide attractive therapeutic targets in the fight against this very morbid disease. We review alterations in GI function and some of the more important gut-brain neuropeptides that occur in obesity.

Background: Among adults with functional gastrointestinal disorders, psychological distress influences who consults a physician, but little is known about predictors of consultation when the patient is a child. Objective: To determine the relative contributions of psychological symptoms of the mother, psychological symptoms of the child, severity of child abdominal pain, and family stress to consultation. Design: Observational study. Setting: Health maintenance organization. Participants:Twohundredseventy-fivemothersof334 children who had abdominal pain in the past 2 weeks, as per child self-report. Main Outcome Measures: Mothers completed questionnaires about themselves (Symptom Checklist 90– Revised) and their children (school absences, medication use, and the Child Behavior Checklist). Children completed the Pain Beliefs Questionnaire to assess perceived pain severity. Results:Thirty-ninechildrenhadbeentakentotheclinic for abdominal pain symptoms at least once in the past 3 months (consulters), whereas 295 were nonconsulters. Logisticregressionanalysesrevealedthatboththechild’s self-report of perceived pain severity (P.001) and maternal psychological symptoms (P=.006) predicted consultation. Although children who visited physicians had significantly more psychological symptoms, this was not a significant predictor of consultation after adjusting for maternal psychological symptoms. Family stress did not predict consultation. Conclusion: The decision to take a child to the clinic for abdominal pain is best predicted by maternal psychological distress and the child’s perceived pain severity.

Summary Background Studies suggest that the positive predictive value of the Rome II criteria for diagnosing irritable bowel syndrome can be enhanced by excluding red flag symptoms suggestive of organic diseases. Aim We assessed the utility of red flags for detecting organic diseases in patients diagnosed irritable bowel syndrome by their physicians. Methods Systematic chart reviews were completed in 1434 patients with clinical diagnoses of irritable bowel syndrome, abdominal pain, diarrhoea or constipation, who also completed questionnaires to identify Rome II criteria for irritable bowel syndrome and red flag symptoms. Results The overall incidence of gastrointestinal cancer was 2.5% (but 1.0% in those with irritable bowel syndrome), for inflammatory bowel disease 2.0% (1.2% in irritable bowel syndrome), and for malabsorption 1.3% (0.7% in irritable bowel syndrome). Red flags were reported by 84% of the sample. The positive predictive value of individual red flags for identifying organic disease was 7–9%. Excluding any patient with a red flag improved the agreement between Rome II and clinical diagnosis by a modest 5%, but left 84% of patients who were diagnosed with irritable bowel syndrome by their physicians, without a diagnosis. Conclusions Red flags may be useful for identifying patients who require additional diagnostic evaluation, but incorporating them into the Rome criteria would not improve sensitivity and would result in too many missed irritable bowel syndrome diagnoses.

Recurrent abdominal pain is a common childhood disorder characterized by multiple episodes of stomachaches severe enough to interrupt daily activities. Recurrent abdominal pain is a difficult diagnosis for parents, children, and clinicians since there is no definitive cause of the symptoms. Research has shown recurrent abdominal pain is at least partly learned through social modeling. The purpose of this study was to understand parental worries and fears of recurrent abdominal pain that explain parental reinforcement of illness behavior. In-depth interviews were held with 15 parents of children diagnosed with recurrent abdominal pain. Parental cognitions were identified and thematically grouped. Two independent judges coded the interviews for the categories (88% inter-judge reliability). Six major categories of worries were identified. Parental cognitions about recurrent abdominal pain revolved around the fear of a disease and a desire for diagnosis and effective treatment. Many parents stated they felt helpless to know how to deal with their child's suffering. These fears and worries may explain why parents reinforce illness behavior by showing empathy for a supposedly sick child. The findings also identified areas of possible miscommunications between clinicians and parents. This study adds to our understanding of parents' view on recurrent abdominal pain and gives us tools to address cognitions that can perpetuate symptoms in children.

Background & Aims: Studies on the relationship between gastrointestinal (GI) symptoms and obesity are limited. Research on the relationship between GI symptoms (including irritable bowel syndrome [IBS]), weight, and weight-related behaviors are rare. This study assessed rates of GI symptoms in a sample of obese patients in a weight-loss program and explored relationships among GI symptoms and obesity, binge eating, dieting (fat and fruit/fiber consumption), and physical activity. Methods: A total of 983 participants (70% women) had a mean body mass index (BMI) of 33.2 ± 5.7 kg/m2 (range, 25.1–60.8 kg/m2) and a mean age of 52.7 ± 12.4 years (range, 20.4–89.8 y). Participants completed a questionnaire about diet and physical activity and a standardized self-report Rome II questionnaire assessing IBS status and GI symptoms. Results: In bivariate analyses BMI was associated positively with abdominal pain and diarrhea whereas healthier diet (lower fat and higher fruit/fiber intake) and higher physical activity were associated with fewer GI symptoms. In multivariate models BMI was not associated with GI symptoms; physical activity remained a protective factor. Conclusions: Although physiologic mechanisms still need to be explored, associations between GI symptoms and diet and exercise behaviors may have implications for the treatment of both obesity and GI symptoms.

This report reviews recent research on the psychosocial aspects of the functional gastrointestinal disorders (FGIDs). A review and evaluation of existing literature was conducted by a multidisciplinary committee of experts in this field. This report is a synopsis of a chapter published in the Rome III book. The committee reached consensus in finding considerable evidence supporting the association between psychological distress, childhood trauma and recent environmental stress, and several of the FGIDs but noted that this association is not specific to FGIDs. There is also considerable evidence that psychosocial variables are important determinants of the outcomes of global well-being, health-related quality of life, and health care seeking. In line with these descriptive findings, there is now increasing evidence that a number of psychological treatments and antidepressants are helpful in reducing symptoms and other consequences of the FGIDs in children and adults. The FGIDs are a result of complex interactions between biological, psychological, and social factors, and they can only be treated satisfactorily when all these factors are considered and addressed. Therefore, knowledge about the psychosocial aspects of FGIDs is fundamental and critical to the understanding, assessment, and treatment of these disorders. More extensive physician training is needed if these aspects of treatment are to be used effectively and widely in clinical practice.

Background & Aims: A randomized clinical trial was used to test the effectiveness of an 8-session multicomponent program (Comprehensive) compared to a Brief (single session) version and Usual Care for women with irritable bowel syndrome. Methods: Menstruating women, ages 18–48 years, were recruited from a health maintenance organization as well as community advertisements. Psychiatric nurse practitioners delivered both programs. The primary outcomes were improved symptoms, psychological distress, health-related quality of life, and indicators of stress-related hormones. Outcome indicators were measured at 3 points: (1) immediately after the Comprehensive program or 9 weeks after entry into the Usual Care and Brief Self-Management groups, (2) at 6 months, and (3) at 12 months. Results: Compared to Usual Care, women in the Comprehensive program had reduced gastrointestinal symptoms, psychological distress indicators, interruptions in activities because of symptoms, and enhanced quality of life that persisted at the 12-month follow-up evaluation. Women in the Brief group also demonstrated statistically significant improvements in quality of life and smaller nonsignificant improvements in other outcome variables than observed in the Comprehensive group. There were no group differences in urine catecholamines and cortisol levels. Conclusions: A comprehensive self-management program is an important therapy approach for women with irritable bowel syndrome. The Brief 1-session version is also moderately helpful for some women with IBS.

OBJECTIVE: To examine binge eating, depression, weight self-efficacy, and weight control success among obese individuals seeking treatment in a managed care organization. DESIGN: Gender-stratified analyses of associations between binge eating, depression, weight self-efficacy, and weight change, using data from a randomized clinical trial that compared low-cost telephone-based, mail-based, and usual care interventions for weight loss. SUBJECTS: A total of 1632 overweight individuals (460 men, 1172 women; mean age: 50.7 y; mean body mass index: 34.2 kg/m2) were recruited from a large Midwestern US managed care organization. MEASUREMENTS: Height and weight were measured by study personnel at baseline, and self-reported weight was assessed at 6 and 12 months; self-reported depression status, binge eating, and self-efficacy for weight control were assessed at baseline. RESULTS: Lifetime prevalence rates for depression and probable binge eating disorder were high. Weight self-efficacy was inversely related to weight in both men and women. For women, depression was associated with lower weight self-efficacy and higher body weight. Women reporting depression or lower weight self-efficacy at baseline had less weight loss success at 6 and 12 months. Depression, binge eating disorder, and weight self-efficacy were not significantly associated with weight loss success in men. CONCLUSION: Negative emotional states are highly prevalent and predict poor treatment outcomes, particularly for obese women. As obese women with clinical depression typically are excluded from intervention studies, further research on how to address the intersection of obesity intervention and mood management may be warranted.

The aims of this study were: 1) to determine the total costs of care and costs related to lower GI-related problems for patients who received a diagnosis of irritable bowel syndrome (IBS), and 2) to compare them to age- and sex-matched population controls and patients treated for inflammatory bowel disease (IBD) or gastroesophageal reflux disease (GERD).Use and cost data were obtained through the computerized information systems of a large staff-model health maintenance organization on three groups of patients diagnosed in 1994 or 1995 with IBS, IBD, or GERD; and an age- and sex-matched control group of patients without any of these listed diagnoses. The IBS patient group was compared to the three comparison groups on components of total and IBS-related costs.Total costs of care for IBS patients were 49% higher than population controls during the year starting with the visit at which IBS patients were identified. In the index year, every component of total costs except inpatient care was significantly higher for IBS patients than for population controls. The costs of care for lower GI problems were significantly higher for patients with IBS than for population controls across a range of services. However, only 33% of the difference in total costs of care between IBS patients and population controls was due to lower GI-related services in the index year. In the subsequent years, lower GI-related services accounted for 18% and 20% of the total cost difference between IBS patients and population controls. The total costs of care as well as the components of costs of care were generally higher for IBD patients than for IBS patients, but were comparable for GERD and IBS patients.Patients with IBS show sustained increases in health care costs relative to population controls for both lower GI services and care unrelated to lower GI problems. However, the majority of the excess in health care costs resulted from medical care not directly related to lower GI problems.

The distinctiveness of social work in health care settings is that people served are clients rather than patients; that the focus of work is on the social effects of illness, not illness; that problem formulation and intervention rests on clear understanding of social cause, social manifestation, and social intervention as group phenomena. (Falck, 1984, p. 167)

Irritable Bowel Syndrome (IBS) is a common problem affecting a significant portion of the U.S. population. Nurses are involved directly in the planning and implementing of therapeutic interventions for this patient population. Using a Human Response Model, the authors of this article review intervention studies for IBS. This model provides a context for integration of Person (vulnerability) and Environment (risk) factors that may modify the patient's response to a given therapeutic regimen. Human responses are categorized as Physiological, Pathophysiological, and Behavioral/Experiential. Interdisciplinary therapeutic strategies include motility manipulations via pharmacological agents, dietary modifications, and self-care enhancement. Areas for nursing research are described.

What constitutes standard medical care for irritable bowel syndrome (IBS) in U.S. primary care and gastroenterology clinics?

G A A b st ra ct s preferred causal attribution and the ranking of attributions did not vary over one year. Subjective illness attributions such as “dysfunctional stress regulation” (β = 0.65, P < 0.01) and “interpersonal reasons” (β = 0.58, P < 0.01) aim towards a higher anxiety in patients at T2. Naming “social reasons“ as attribution at T1 was a significant predictor for severity of symptoms at T2 (β = 0.47, P < 0.01). Furthermore, the attributions “dysfunctional stress regulation“ and “fatalism“ at T1 affected physical quality of life at T2. These coherences were independent from variables such as age, sex and IBS subgroup and were still present after controlling for the respective starting level of outcome variables.Conclusions: Subjective theories of illness are of prognostic value for clinical and psychological outcome in IBS patients. The knowledge of content and significance of concepts that patients develop to explain their disease will enable the healthcare professional to better understand patient expectations and improve doctor-patient-relationship as well as treatment approaches in irritable bowel syndrome.

Curcumin, the active component of turmeric, a common spice used in Indian cooking, has been used for medicinal purposes for centuries due to its anti-inflammatory properties. Curcumin regulates multiple molecular targets, including transcription factors, such as nuclear factor κ-light-chain-enhancer of activated B cells and activator protein 1, which promote the production of inflammatory cytokines. The traditional treatment for gastroesophageal reflux (GERD) has involved mainly acid suppression. Recent literature (Souza et al, Gastroenterology 2009; 137:1776-1784) suggests that cytokine mediated inflammation may play a role in the pathophysiology of GERD. A small prospective pilot study was conducted consisting of 14 typical GERD patients who are dependent on proton-pump inhibitors (PPIs) or H2-receptor antagonists (H2 blockers) on a daily basis for complete symptomatic relief. Our aim was to evaluate curcumin as a replacement therapeutic agent in place of PPIs and H2 blockers. These patients were started on curcumin (2 g/day) and their PPI or H2 blockers therapy was discontinued at 2 weeks after the initiation of curcumin therapy. They were then followed for 2 months. 11 out of 14 patients (about 79% of patients with a 95% confidence interval ranging from 45% 95%) were asymptomatic on curcumin therapy alone without their daily use of PPI or H2 blocker therapy. Of the 3 patients who were non-responders, 1 patient was able to have complete symptomatic relief on a lower dose of PPI therapy than the previous dose while on curcumin therapy. No patient had worsening symptoms during the first 2 weeks while on both curcumin and their usual PPI or H2 blocker therapy. There were also no reports of side effects from curcumin. Based on our small pilot study, curcumin appears to be a promising therapeutic agent for GERD patients. Further larger scale studies are needed to fully elucidate the potential of curcumin as an effective treatment alternative for GERD. Patient Data

Background Drossman et al. (Gastroenterology 2007) previously reported that patients frequently transition between IBS-M and C categories over the course of one year, thus indicating a close relationship between these two IBS subtypes relative to IBS-D. Aim This study utilizes ecological momentary assessment (EMA) in an effort to quantify gastrointestinal symptoms using repeated measures assessed over a two week period. Methods A total of 46 subjects diagnosed by physicians with IBS D,C or M contributed a total of 4349 ratings of abdominal pain, bloating, stool consistency (Bristol Stool Scale BSS), straining at bowel movement, urgency at bowel movement, rectal fullness, stress and well being over a two week period using a pocket pc based data collection system. Results Participants diagnosed with IBS-M and IBS-C did not differ significantly on any variable except for BSS where subjects with IBS-C reported more constipated stools, Mean BSS (IBS-C = 3.42 vs. IBS-M = 4.01, p

Our stance on the importance of tasks is simple: We do not see tasks as an adjunct, even a critical adjunct to brief psychotherapy. Rather, we see them as the basis for action in brief psychotherapy. If therapy is to be effective in a short period of time, the therapist must encourage the efficient conduct of the client’s therapeutic activities—both in and outside of the therapy session. The opportunity that tasks provide for the productive use of time outside regularly scheduled hours is extensive. Therapists and clients may use this time for such activities as the observation of naturally occurring events or the practice of skills learned during the therapeutic session. (A more extensive discussion of different types of tasks follows in the next section.)