GI Around the World: A Look at IBS in Asia

Dr. Buch:
Welcome to GI Insights on ReachMD. I’m your host, Dr. Peter Buch. Since irritable bowel syndrome, or IBS for short, varies by geography, culture, and environment, today we’re going to take a look at IBS in the Asian population with Dr. Andrew Ong, who’s a consultant gastroenterologist at Singapore General Hospital. 

Dr. Ong, welcome to the program. 

Dr. Ong:
Thank you so much, Dr. Buch. 

Dr. Buch:
Let’s begin with some background, Dr. Ong. What are the statistics and clinical differences in irritable bowel between the Asian population and that in North America? 

Dr. Ong:
Well, irritable bowel syndrome is very common in Asia. There is a prevalence of around 10% in most Asian countries, so the numbers are not too far off from the West. Now across Asia, the population tends to be younger, which could be a reflection of the underdiagnosis in the older population rather than a true predominance in the young, although we know that irritable bowel syndrome tends to affect younger patients worldwide. 

Now other interesting notes that were found was that there are the gender differences in the West where there are more females affected by irritable bowel syndrome. It’s not that obvious in Asia. We somehow have a 1:1 ratio between males and females. And to understand the difference in epidemiology and presentation of irritable bowel syndrome in Asians, we have to understand how culture influences many things. So the effect of culture on health and healthcare manifests itself as illness, beliefs, symptom expression, and learned coping patterns, and this inevitably results in differences in the patient/physician relationship, the diagnostic process, and openness to treatment modalities. So, for example, in countries such as India and Sri Lanka, men are more likely to be diagnosed. 

Now the probable reasons behind this could be that females just have difficulty in accessing medical care and expressing their problems to doctors as well, and the males, who are predominantly working, are the ones who are exposed to high-pressure situations, and therefore, they might be more susceptible to irritable bowel syndrome, so these are some of the differences that we’ve noticed. 

Dr. Buch:
Thank you. Eye-opening. And can you comment on the dyspepsia/IBS overlap in Asia? 

Dr. Ong:
So we have noticed over the years as well that Asians tend to present differently from patients in the West.  One of the key differences is bloating is a very big symptom among irritable bowel syndrome patients in Asia.  It occurs almost as commonly as abdominal pain and is a huge reason for patient consultation. Another difference that we’ve noticed is that Asians tend to present with epigastric discomfort as compared to lower GI symptoms in the West. And to make things more complicated, some studies have shown that around 60% of Asian IBS patients have an overlapping upper and lower GI problem, so they have both irritable bowel syndrome and functional dyspepsia. 

Now this has implications on how we diagnose patients and take histories because often, even if they present with very clear upper GI symptoms, we have to scrutinize the bowel movement history to be sure whether we’re dealing with a purely lower GI issue or an overlapping upper and lower GI problem, and this is not always easy to do. What we’ve also noticed is that there’s less constipation and more diarrhea it seems in most of the Asian patients that we see, and we’re not sure whether this is related to their diet, innate physiology, or both, but studies have shown that a mean intestinal transit time in Asians were much faster than the Western counterparts, probably because of the diet that they are taking. 

Dr. Buch:
Do you think culture or language play a role here as well? 

Dr. Ong:
I’m sure it does play a huge role. So if the listeners are familiar, irritable bowel syndrome is diagnosed by the ROME criteria, which is a symptom-based criteria, and there’s a huge difficulty in applying some of these criterias in Asians because it was written by native English speakers. So, for example, bloating is primarily an English term, whereas in most cultures, the term distension is used for the same symptom, and other terms, such as constipation and fullness, are also very difficult to define in certain languages and to differentiate these terms from one another; it’s challenging at times. 

So, for example, in many Chinese patients, which is the large ethnic majority in Singapore, patients are not able to distinguish between gastric fullness and intestinal bloating, and they often regard both these symptoms as the same thing. Therefore, pictorial representations, such as the Bristol Stool Chart or pictograms as created by Professor Jan Tack from Leuven, Belgium, these are very helpful in keeping things objective when we are talking about symptoms with patients. 

Dr. Buch:
So based on the ROME criteria, should we be having a worldwide conference to just figure out ROME criteria based on different regions of the world? 

Dr. Ong:
That would be very nice to have, but I presume it would be a very challenging task. It’s very difficult to align everyone’s understanding of different symptoms, even just within a few countries, let alone dealing with many countries worldwide. The ROME Foundation is moving towards that direction. They are having a group of members from different representations from different parts of the world. So I think we understand that this is a huge importance in understanding our patients better, and therefore, cultural competence, which is a skill which we hope many physicians start to develop, is something that we really have to get into our training programs. 

Dr. Buch:
Absolutely. That’s what we’re teaching our medical students right now; but again, those physicians who have been in practice for a while, absolutely, that’s why we’re doing this recording today. So let’s move on. Dr. Ong, are low-FODMAP diets effective in your IBS population? 

Dr. Ong:
Thank you for that question, Dr. Buch. So I had the privilege of working with Peter Gibson from Monash, a famed founder of low FODMAP diet. So I worked with him for half a year in Monash and really enjoyed the time I had with him. So low-FODMAP diets are very challenging in Asians, and there are two main reasons.  Firstly, some of the staples in Asian diet, for example, a Chinese diet, are very high in FODMAPs, so onions, garlics, and mushrooms are what we use in our diet a lot. And Asian diets unfortunately are often rice-based, so they offer some advantage of using a low-FODMAP diet, so that’s the first challenge that we have because it’s a big part of what we eat.  Now in a country like Singapore where it’s often both husband and wife are working throughout the day so eating out is a common practice—and it’s not expensive, so most individuals will eat out—there’s very little control that you can have to choose the kind of food that you consume, and therefore, it’s difficult to apply a low-FODMAP diet into the lifestyle of many of these individuals. 

Another big factor is how food in most cultures play a prominent role in the way patients attribute their symptoms. So cultural factors can impart positive or negative meanings to food, so it’s almost like a placebo and nocebo effect that food can have on one’s symptoms. So for example, Chinese people believe that diseases are caused by imbalance of hot and cold principles, and they classify diseases in foods in terms of their hot and cold characteristics. So for example, ginger is one of the common foods in Asian diet, and it’s considered to have a warm efficacy and is used to supplement many prescription medicines. So when we give nutritional counseling, especially to elderly patients, we cannot ignore these perceptions. Instead, we try and merge these concepts together and offer a hybrid solution. So it is challenging, but it is doable. 

Dr. Buch:
For those just tuning in, you’re listening to GI Insights on ReachMD. I’m Dr. Peter Buch, and I’m speaking with Dr. Andrew Ong about irritable bowel syndrome in the Asian population. 

So, Dr. Ong, when in your treatment algorithms do you use rifaximin to treat IBS? 

Dr. Ong:
Some oncological treatment principles in Asians are generally the same with some smaller important differences as compared to the West. So I use rifaximin a lot, mainly in patients with diarrhea and bloating, because that’s where the evidence lies. So bloating, as mentioned, is a huge part of our work, and therefore, we use rifaximin a lot. So I find it difficult at times to predict which patients will respond, but those that do can respond remarkably well. Some studies have suggested that we do hydrogen breath test to select outpatients, but I don’t find this cost-effective in most cases, so I just prefer to treat them empirically, and when their symptoms recur, especially if they responded the first time around, they usually respond to a second or third treatment cycle. 

Dr. Buch:
And just following up on that question in particular, do you use rifaximin early in the treatment algorithm or later in your treatment algorithm? 

Dr. Ong:
So most of the patients that are referred to me eventually have already been tried on different therapies by their primary care physicians, and so I often use rifaximin quite early in my practice, just simply because the patients have been suffering with the symptoms for quite some time. 

Dr. Buch:
Thank you very much. And as a quick follow-up to that, do you have any favorite complementary or alternative medicines to treat IBS? 

Dr. Ong:
Right, so thank you for that question again. So acupuncture is a fantastic adjunct to chronic pain conditions, so I wouldn’t pretend to know that pathophysiology or intricacies that acupuncture alters in the human body, but I have found that it is an extremely helpful adjunct to neuromodulating drugs and psychological therapies, so it plays a huge role in the arsenal of weapons that we have for patients with chronic abdominal pain. So we do have an acupuncturist in our hospital who works with our pain management team, so I found that they are extremely helpful for multiple pain conditions, from fibromyalgia, migraines, chronic abdominal pain, so that’s the first complementary therapy that I’m really enamored with. 

The other one is traditional Chinese medicine. And when you go to different cultures, you find that there are many traditional herbal supplements that people have used for centuries, so Chinese medicine has played a huge role in our elderly population for centuries. And these Chinese physicians, I have immense respect for them, and I try to work together with them in many cases but we have to understand how the physicians from the different cultures actually think. So a traditional Chinese physician regards illnesses in the human body differently from a Western physician. They categorize illnesses into 4 main syndromes: cold syndrome, heat syndrome, deficiency syndromes, excess syndromes. And then they are differentiated further along the lines of the yin and the yang, the chi, and the blood, so there’s a lot of intricacies of how they think about the human body. 

So for example, IBS-diarrhea is considered a liver chi stagnation or spleen chi deficiency syndrome, and they call it a cold and deficiency syndrome. So when we understand how our colleagues from traditional medicine think, sometimes we can actually work together. So one of the medications that they use is called Tong Xie Yao Fang, which is a kind of medication traditional physicians use for IBS-diarrhea, and it at least shows quite wonderful results in many of the patients that I’ve encountered, so I do try and get my patients to appreciate that there is value in mixing Western and Chinese medicines together. 

So I’ve enjoyed working with my colleagues from the traditional physicians, and they have used these medications for centuries. So even though we don’t have good, rigorous studies for some of these medications, they do work in my experience. So it’s still a work in progress to try and find ways for us to collaborate together. 

Dr. Buch:
Before we conclude, Dr. Ong, are there any other thoughts you would like to share with our audience?  

Dr. Ong:
So as I mentioned earlier, cultural competence is a huge and important ability we want our physicians to have, especially if they are working in a multicultural environment, which is actually most places these days. So cultural competence is defined as an ability to interact effectively with people of different cultures, and it adds another layer to a biopsychosocial model. So this is a model whereby we understand the patient’s biological state as well as their psychosocial state, and then we try to contextualize what their symptoms are like in view of this model. So, for example, conditions such as irritable bowel syndrome with unclear etiology, sometimes, they’re more likely to be influenced by these cultural factors as compared to disorders with a clear diagnostic criteria, and therefore, it’s important that we see these cultural backgrounds of the individuals as part of the treatment process because it will eventually affect their health beliefs, their health-seeking behavior, all which can affect the cause of their disease.  

Dr. Buch:
That’s great. This was an eye-opening discussion on the importance of considering cultural differences when approaching IBS. And I want to thank my guest, Dr. Andrew Ong, for this very important podcast. Dr. Ong, it was a pleasure having you on the program today.  

Dr. Ong:
Thank you so much, Dr. Buch. It’s been a privilege to have appeared on your show as well. 

Dr. Buch:
For ReachMD, I’m Dr. Peter Buch. To access this and other episodes in these series, visit ReachMD.com/GIInsights where you can Be Part of the Knowledge. Thanks for listening and see you next time.