SCIENTIFIC BASIS AND CLINICAL IMPLEMENTATION OF THE LOW FODMAP DIET - - PowerPoint PPT Presentation

SCIENTIFIC BASIS AND CLINICAL IMPLEMENTATION OF THE LOW FODMAP DIET IN PATIENTS WITH FUNCTIONAL DIGESTIVE DISORDERS

Dr Sue Shepherd

B.App.Sci. (Health Promotion), M. Nut & Diet., PhD.

Advanced Accredited Practising Dietitian

REPRESENTATIONS AND AFFILIATIONS

DISCLOSURE

• Author of Cookbooks for Coeliac Disease and IBS.

– “Irresistibles for the Irritable”, “Two Irresistible for the Irritable”, “Gluten Free Cooking”, “The Gluten Free Kitchen”, “Allergy Free Cooking”, “Food Intolerance Management Plan”, “Gluten and Wheat Free Diabetes” and “Low FODMAP Recipes”.

• Co-author of “Gastrointestinal Nutrition”.

– Resource manual for dietetic management of gastrointestinal conditions

• Consultant to Gluten Free Food Show in Melbourne, Sydney,

Brisbane, Launceston.

– For coeliac disease, low FODMAP diet.

• Consultant dietitian to food companies for development of

specialty food products.

• Co-ownership of FODMAP Friendly certification trademark
• Co-director of company producing FODMAP Friendly food

products.

FODMAPS

Poorly absorbed short-chain carbohydrates

F O D M A P

ermentable ligosaccharides isaccharide

• nosaccharide

nd

• lyols

THE SPECTRUM OF FODMAPS

F O D M A P

ermentable – meaning they can

be broken down by bacteria in the bowel.

ligosaccharides

• e.g. fructans and GOS.

ermentable

F O D M A P

THE SPECTRUM OF FODMAPS

ligosaccharides

• e.g. fructans and GOS.

saccharide’ means ‘sugar’ ‘oligo means ‘many’

ermentable

F O D M A P

THE SPECTRUM OF FODMAPS

ermentable isaccharide – e.g. Lactose.

F O D M A P

THE SPECTRUM OF FODMAPS

ermentable

• nosaccharide e.g. Fructose

(in excess of glucose)

F O D M A P

THE SPECTRUM OF FODMAPS

ermentable nd

F O D M A P

THE SPECTRUM OF FODMAPS

ermentable

• lyols – e.g. Sorbitol, mannitol

F O D M A P

THE SPECTRUM OF FODMAPS

HOW WAS THE LOW FODMAP DIET DEVELOPED?

1) I was frustrated by why it was that so many people (without coeliac disease) experienced functional gut symptoms when eating wheat. If it wasn’t gluten, what else was in wheat that could be a trigger? Search of the literature: FRUCTANS? 2) I received a referral for a patient with IBS symptoms and +ve fructose breath test. Referral note: “Please teach the fructose malabsorption diet”. However, there were no dietary guidelines! 1)Search of the literature: fructose was well absorbed in the presence of glucose (sugar solutions) – extrapolated to food… EXCESS FRUCTOSE?

She hephe pherd d Wo Works 1999 1999

As a dietitian working in the field of GI nutrition, I was already aware of lactose intolerance, so LACTOSE was a potential symptom trigger. Also knew too many baked beans, etc., were symptom triggers (GOS). And was well aware of the role of POLYOLS – after all there is a warning statement on packaged food…..

• I hypothesised the mechanism of action and put together an

“experimental diet”. It was the first time that fructans, excess fructose, lactose, polyols and GOS were pieced together as a dietary intervention for the management of functional gut symptoms.

• I implemented the diet after developing lists of foods to avoid

and foods to include. The diet worked!

• I taught it for four years in my private practice (Shepherd

Works) and then went on to confirm the efficacy in my PhD (Monash University) by undertaking a well designed clinical

• trial. This generated the first of a growing list of supportive

evidence.

• The low FODMAP diet is now evidence based.

HOW WAS THE LOW FODMAP DIET DEVELOPED?

SO WHY THE LOW FODMAP DIET FOR IBS?

• FODMAPs induce symptoms of IBS. (Shepherd & Gibson 2008)
• The mechanism of how FODMAPs cause symptoms is

clear and well understood. (Barrett, et al 2009, Ong et al 2010)

• The Low FODMAP Diet provides symptom relief in

~75% of IBS patients. (Shepherd & Gibson 2006)

• The Low FODMAP Diet is sustainable – patients have

continued to follow the diet since it was developed.

• Efficacy as primary therapy for IBS has been shown in

settings outside Australia. (Staudacher et al 2011)

DIETARY TRIGGERS OF ABDOMINAL SYMPTOMS IN PATIENTS WITH IRRITABLE BOWEL SYNDROME: RANDOMISED PLACEBO-CONTROLLED EVIDENCE

Sue J Shepherd, Francis C Parker, Jane G Muir, Peter R Gibson

Clinical Gastroenterology and Hepatology 2008; 6: 765-771

METHOD

• Randomised double-blinded, quadruple

arm, cross-over, placebo-controlled rechallenge trial.

• Test substances:

– Fructose (14g tds), or – Fructans (7g tds), or – Fructose and fructans (14g + 7g tds), or – Glucose (placebo) (7g tds)

Dos

• ses ch

chosen on

• n b

basis of

• f ave

average age A Australian di dietar ary y intak ake.

Shepherd, SJ 2008, Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71

METHOD - PATIENTS

• n = 25.
• Ages 23-60 years, 16% male.
• IBS (Rome III).
• FM +ve breath test.
• Previously responded to FODMAP diet –

de-challenged.

• Provided with every meal and snack for 22

weeks (max) FODMAP diet – re-challenge

• Symptom diaries.

Shepherd, SJ 2008, Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71

LOW F O D M A P D I E T (sup supplied ed t to patien ent)

>2 week run-in

Patients asymptomatic before starting each test period.

Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71

STUDY DESIGN

> 2 w > 2 w > 2 w

2 w Shepherd, SJ 2008, Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71 2 w 2 w 2 w

• Fru

ructa tan 7g 7g td tds

• Fructose

14g 14g td tds

• Fructose +

+ fru ructa tan 14 + 14 + 7g 7g td tds

• Glu

lucose ( e (pla laceb ebo) 7g td tds

50m 50ml x x 3/day ay 100m 100ml x 3 3/day ay 170m 170ml x x 3/day ay

STUDY DESIGN

LOW F O D M A P D I E T (sup supplied ed t to patien ent)

>2 week run-in

> 2 w > 2 w > 2 w

2 w 2 w 2 w 2 w

• Fru

ructa tan 7g 7g td tds

• Fructose

14g 14g td tds

• Fructose +

+ fru ructa tan 14 + 14 + 7g 7g td tds

• Glu

lucose ( e (pla laceb ebo) 7g td tds

STUDY DESIGN

LOW F O D M A P D I E T (sup supplied ed t to patien ent)

>2 week run-in

Shepherd, SJ 2008, Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71 Rando dom a allocat ation n of d drink nk Dri rinks ta s taken wi with th m meals Volu lume e in increased ed e every 3 3 days – 3 ste steps Daily y food d diary y (tick ck b box) for co comp mpliance ce

Global symptom question (1o) S y m p t o m d i a r y (VAS) (2o)

> 2 w > 2 w > 2 w

2 w 2 w 2 w 2 w

• Fru

ructa tan 7g 7g td tds

• Fructose

14g 14g td tds

• Fructose +

+ fru ructa tan 14 + 14 + 7g 7g td tds

• Glu

lucose ( e (pla laceb ebo) 7g td tds

STUDY DESIGN

LOW F O D M A P D I E T (sup supplied ed t to patien ent)

>2 week run-in

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Fructan Fructose Fructose and Fructans Glucose

P < 0.001

SYMPTOMS NOT ADEQUATELY CONTROLLED

% OF PATIENTS Shepherd, SJ 2008 (1O END-POINT)

MEDIAN SYMPTOM SCORES

p<0.001, Fisher’s exact

10 20 30 40 50 60 70 80

Fructan Fructose Fructose & Fructans Glucose Overall Pain Bloating Wind p<0.001 vs glucose Wilcoxon

*Median scores on VAS

p<0.05 Shepherd, SJ 2008

(2O END-POINT)

MEDIAN OVERALL SYMPTOM SCORE IN RELATION TO VOLUME – EFFECT OF DOSE

p<0.001, Fisher’s exact

10 20 30 40 50 60 70

Fructan Fructose Fructose & Fructans Glucose

50ml 100ml 170ml

Fisher’s exact

*Median scores on VAS

p<0.001, cf glucose

p<0.001, across groups

Shepherd, SJ 2008

CONCLUSION

• Rechallenge experiments support the efficacy of the

low FODMAP diet in IBS as:

– Not due to placebo – But due to fructans, fructose or both – Not due to low chemical or other food components

• Symptom induction with fructose &/or fructans:

– All test drinks induced symptoms greater than placebo (p<0.001) – Dose-dependent – Effect of fructose and fructans additive

MANIPULATION OF DIETARY SHORT CHAIN CARBOHYDRATES ALTERS THE PATTERN OF GAS PRODUCTION AND GENESIS OF SYMPTOMS IN IRRITABLE BOWEL SYNDROME

Derrick K Ong, Shaylyn B Mitchell, Jacqueline S Barrett, Sue J Shepherd, Peter M Irving, Jessica R Biesiekierski, Stuart Smith, Peter R Gibson and Jane G Muir.

Journal of Gastroenterology and Hepatology, 2010; 25: 1366–1373

AIM

• To

compare breath H2 production and induction

• f

gastrointestinal symptoms in individuals with IBS and healthy controls after high FODMAP and low FODMAP diet consumption.

Ong, et al 2010

STUDY DESIGN

• Randomised, single blinded, crossover

intervention study.

• Participants:

–15 IBS (Rome III) –15 Healthy volunteers (no GI symptoms)

Ong, et al 2010

Dai aily sy sympt ptom

• m qu

quest stion

• nnaire:

Abdominal nal pain/ n/di disco comfort, a abdominal nal b bloat ating/ ng/ di distension, w wind nd, nau nausea, he hear artbu burn and n and letha hargy

(Lik ikert s scale ale 0 0-3, 0= 3, 0=none, 1= , 1=mild, 2= , 2=moderate, 3= , 3=severe)

STUDY PROTOCOL

2-day day Hi High FO FODM DMAP 2 day day Low F

• w FODMAP

7-day day bas baseline 7-day day wa washou

• ut

Brea eath sa samples es c collec ected ed ever every hour f for 14 14 hou

• urs (D

(Day 2 y 2 of

• f diet)

t)

Ong, et al 2010

FOODS PROVIDED

Ong, et al 2010

PROFILES OF BREATH HYDROGEN OVER 14 HOURS OF LOW AND HIGH FODMAP INTAKE IN IBS AND HEALTHY CONTROLS

High FODMAP - Healthy Low FODMAP - Healthy Low FODMAP - IBS High FODMAP - IBS Ong, et al 2010

COMPOSITE SCORE ON DIETARY REGIMENS IN IBS PATIENTS

5 10 15 20 25 30 35 40

Abdo Pain Abdo Bloating Excessive Flatus Nausea Heartburn Tired/Lethargy

LFD HFD Total Composite Symptom Score ** ** ** * * * * = p<0.05, ** = p<0.001 Ong, et al 2010

SUMMARY AND CONCLUSION

• FODMAPs are fermented by intestinal microflora

resulting in rapid gas production across the day. CONCL CLUSIO ION

• This

data, in conjunction with study in ileostomates,1 we now have a physiological explanation as to how FODMAPs trigger symptoms in patients with IBS and why a low FODMAP diet improves functional gut symptoms.

• 1. Barrett, 2009 Aliment Pharm Ther. Ong, et al 2010

HOW DO FODMAPS TRIGGER SYMPTOMS OF IBS?

Luminal distension and altered bowel motility

Abdo pain, distension, excess wind, diarrhoea +/- constipation

Adapted from Barrett, et al 2009

HOW DO FODMAPS TRIGGER SYMPTOMS OF IBS?

A LOW FODMAP DIET REDUCES SYMPTOMS IN PATIENTS WITH IRRITABLE BOWEL SYNDROME

Emma Halmos, Claus Christophersen, Anthony Bird, Victoria Power, Susan Shepherd, Jane Muir, Peter Gibson.

Gastroenterology 2014; 146: 67-75

STUDY DESIGN

A randomised controlled trial of efficacy for the low FODMAP diet in unselected IBS and healthy subjects during a low FODMAP diet and a diet representing a typical dietary intake and where all food is provided to control for confounding dietary factors (e.g., fibre).

Halmos, et al 2014

HYPOTHESES

• IBS symptoms are reduced by the low

FODMAP diet compared to typical Australian intake of FODMAPs in unselected IBS patients.

• Differences in FODMAP intake have no effect
• n GI symptoms in healthy subjects.

Halmos, et al 2014

STUDY DESIGN

• Randomised, single-blinded, cross-over

controlled trial where all food is provided.

• Primary endpoint.

–Overall GI symptoms on low vs typical Australian diet.

Halmos, et al 2014

Daily food record and visual analogue scale: Overall symptoms, abdominal pain, bloating, passage

• f wind & dissatisfaction of stool consistency

STUDY PROTOCOL

21-day Low FODMAP 21-day Typical Aust. 7-day baseline

≥ 21-day washout

100 None at all Worst ever Halmos, et al 2014

STUDY DIETS

Typical Aust. FODMAP diet Low FODMAP diet Breakfast

Weet-bix & lactose-free milk, wheat bread with spread Corn flakes & lactose-free milk, spelt bread with spread

Morning tea

Pear Orange

Lunch

High FODMAP frittata apple juice Low FODMAP frittata cordial

Afternoon tea

Ryvita with cheese Rice cakes with cheese

Dinner

Salmon with vegetable couscous Salmon with vegetable quinoa

Supper

Apple crumble Berry crumble Corn flakes spelt bread w Rice cakes w Salmon w quinoa Weet-bix & milk, wheat bread w Salmon with ve couscous Ryvita wit Orange Berry c cordial Apple c Pear apple juice Low FODMAP frittata High FODMAP frittata

Halmos, et al 2014

OVERALL SYMPTOMS IBS (n=30)

Mean 22.8mm 95%CI [16.7-28.8] 45.7mm 95%CI [37.2-54.3] P<0.001; repeated measures ANOVA

Halmos, et al 2014

IMPROVEMENT IN GI SYMPTOMS IN IBS

• Effect on overall symptoms independent of

Rome III sub-type: –IBS-D (n=10): 46% improvement; p=0.016 –IBS-C (n=13): 61% improvement; p=0.003 –IBS-M (n=5): 24% improvement; p=0.078 –IBS-U (n=2): 49% improvement

Halmos, et al 2014

OVERALL SYMPTOMS HEALTHY CONTROLS (N=8)

Mean 8.4mm 95%CI [4.3-12.4] 10.7mm 95%CI [3.9-17.4] P=0.153; repeated measures ANOVA

Halmos, et al 2014

P< 0.001 Repeated measures ANOVA P< 0.001 Repeated measures ANOVA P< 0.001 Repeated measures ANOVA P< 0.001 Repeated measures ANOVA

EFFECT ON SPECIFIC SYMPTOMS IN IBS (N=30)

Halmos, et al 2014

ADHERENCE TO THE DIET

Definition: ≥17 of 21 days adherent.

• Typical Australian diet – 100% adherent.
• Low FODMAP diet:
• 80% of IBS.
• 100% of healthy subjects.

Halmos, et al 2014

POTENTIAL BIASES

• Blinding of diet successful:

–71% of healthy controls did not correctly identify ‘diet for IBS management’

• No order effect for overall GI symptoms:

–Ratio low: Australian diet

• 1st diet low FODMAP: 0.73 [0.41-1.04]*
• 2nd diet low FODMAP: 0.74 [0.46-1.01]*

*Mean [95%CI]

Halmos, et al 2014

SUMMARY AND CONCLUSION

• The low FODMAP diet halves gastrointestinal

symptoms in IBS patients compared to a typical Australian diet.

• Gastrointestinal symptoms are unaffected by

FODMAP content in the healthy population. CONCL NCLUSIO SION

• Efficacy of low FODMAP diet now has high

quality evidence for unselected patients with IBS.

Halmos, et al 2014

• In Australia and
• Overseas

and

A large number of scientific studies, from 2003-today, have consistently proven that the Low FODMAP Diet relieves symptoms of irritable bowel syndrome. The first was my PhD research, involving a double- blinded, randomised, quadruple arm, placebo- controlled, cross-over rechallenge trial. This proved that 3 out of 4 people who try the diet have symptom relief, and it was not due to any

• ther dietary factor – it was FODMAPs.

Overseas

In a study performed in Guys Thomas Hospital in London (Staudacher et al 2013), researchers taught two groups of 40 IBS patients different diets, and measured the symptoms before and 6 weeks after. The first group were taught the UK’s GI experts’ diet (the NICE guidelines). 53% of patients improved. The second group were taught the Low FODMAP Diet. 78% of patients improved. This is important as it shows it is not just an Australian

• phenomenon. It also shows the Low FODMAP Diet is superior

to any dietary advice ever previously offered.

THE LOW FODMAP DIET IS SUPPORTED BY SCIENTIFIC RESEARCH

Now used around the world

THE LOW FODMAP DIET IS SUPPORTED BY SCIENTIFIC RESEARCH

Danish cookbook International online media International print media

GLOBAL UPTAKE OF THE LOW FODMAP DIET

IMPLEMENTING THE LOW FODMAP DIET

• Two phases:

–Elimination phase –Reintroduction/liberalisation phase

THE ELIMINATION PHASE

• Identify which FODMAPs are likely or known culprits

– use breath test results if available.

• Avoid all foods known to be high in each problem

FODMAP .

• Restrict for 6-8 weeks.
• Improvement should be seen in two weeks, with
• ngoing improvement.
• Review appointment with nutritionist with view to

reintroducing some FODMAP-containing foods.

EXAMPLES OF HIGH FODMAP FOODS

Excess Fructose Polyols Lactose Fructans

Galacto-

• ligosaccharides

Apples, pears, mangoes, nashi fruit, boysenberry, watermelon, cherries, asparagus, Jerusalem artichokes, sugar snap peas, honey, high fructose corn syrup, agave. Apple, apricot, avocado, blackberry, cherry, nashi fruit, peach, pear, plum, prune, watermelon, cauliflower, mushrooms Milk, ice cream, custard, yoghurt, ricotta cheese, cream cheese, cottage cheese. Custard apple, persimmon, nectarine, watermelon, globe artichoke, asparagus, garlic, legumes, lentils, leek, onion, shallot, spring

• nion (white

part), cashew, pistachio, wheat, rye, barley (in large amounts). Legumes, lentils, chickpeas.

EXAMPLES OF LOW FODMAP FOODS

Fruit* Vegetables Cereals and Grains Milk Products

Other foods

Banana, kiwifruit, strawberry, blueberry,

• range,

mandarin, lemon, lime, honeydew melon, grapes, pineapple, passionfruit. *Limit serving size. Potato, carrot, spinach, capsicum, eggplant, zucchini, lettuce, tomato, cucumber, turnip, swede, green beans, parsnip, squash Rice, cornflour, quinoa, millet, sorghum, oats, polenta. Lactose free milk, lactose free yoghurt, fermented cheeses (block cheese) e.g. parmesan, cheddar, gouda, edam, brie, camembert, fetta, mozarella. Small amounts

• f cream and

soft cheeses. Sugar, maple syrup, golden syrup. Small handful of nuts and seeds (all except cashews and pistachios), unprocessed meat, fish, chicken, eggs. Garlic-infused

• live oil.

THE RE-INTRODUCTION (LIBERALISATION) PHASE

• Goal is to liberalise the diet so that the diet is not

unnecessarily restricted.

– Eat a greater variety of foods whilst still maintaining symptom control.

• Important as FODMAPs are pre-biotics.

– Restricting all FODMAPs from the diet may have a negative effect on microbiota.

• Decreased diversity and faecal pH but not faecal SCFA

levels (Halmos, 2014). – Including FODMAPs in the diet is encouraged, as tolerated.

• Commence this phase at the review appointment

assess symptom response to elimination phase.

• If symptoms well managed, then reintroduce

FODMAPs in a controlled re-introduction to determine TYPE and AMOUNT of FODMAPs tolerated.

– It is possible that more foods were avoided than an individual may have needed to achieve symptom relief.

THE RE-INTRODUCTION (LIBERALISATION) PHASE

WHEN TO TREAT?

Treat the GI symptomatic patients only

KEYS ASPECTS OF FODMAP RESTRICTION

• Symptoms are due to dose r

response

• nse.
• All patients with IBS have different FODMAP

tolerance levels.

• Not every person has a problem with every type
• f FODMAP

.

• The liberalisation phase in consultation with a

nutritionist is important and should be encouraged.

WHAT IF THE LOW FODMAP DIET DOES NOT ADEQUATELY RESOLVE SYMPTOMS?

In people in whom the low FODMAP diet is not effective, consider:

• Alternative dietary triggers:

– Excessive fat – Alcohol – Caffeine – Food chemicals (e.g. salicylates, amines, etc.)

• Psychological triggers:

– Referral to a gut-focused hypnotherapist is often valuable

PRACTICAL IMPLICATIONS

• The low FODMAP diet is the most efficacious

dietary therapy for IBS.

• Specialist nutritionist education required for

BOTH phases of implementation (elimination and reintroduction phases).

• Gut-focussed hypnotherapy for patients who do

not respond or have insufficient response to dietary intervention.

ACKNOWLEDGEMENTS

Thanks to Ms Emma Halmos for use of her slides regarding the “A low FODMAP diet reduces symptoms in patients with irritable bowel syndrome” study.

• www.shepherdworks.com.au/shop/category/books
• www.fodmap.com

FURTHER INFORMATION AND FOOD LISTS