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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 onosaccharide nd olyols
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 DM A P
THE SPECTRUM OF FODMAPS
ermentable
isaccharide – e.g. Lactose.
F O DM A P
THE SPECTRUM OF FODMAPS
ermentable
onosaccharide e.g. Fructose (in excess of glucose)
F O DM A P
THE SPECTRUM OF FODMAPS
ermentable
nd
F O D M A P
THE SPECTRUM OF FODMAPS
ermentable
olyols – 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?
Shepherd Works 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)
Doses chosen on basis of average Australian dietary intake.
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 (supplied to patient)
>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
• Fructan 7g tds
• Fructose 14g tds
• Fructose + fructan 14 + 7g tds
• Glucose (placebo) 7g tds
50ml x 3/day
100ml x 3/day
170ml x 3/day
STUDY DESIGN
LOW F O D M A P D I E T (supplied to patient)
>2 week run-in
>2 w >2 w >2 w 2 w 2 w 2 w 2 w
• Fructan 7g tds
• Fructose 14g tds
• Fructose + fructan 14 + 7g tds
• Glucose (placebo) 7g tds
STUDY DESIGN
LOW F O D M A P D I E T (supplied to patient)
>2 week run-in
Shepherd, SJ 2008, Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71
Random allocation of drink Drinks taken with meals Volume increased every 3 days – 3 steps Daily food diary (tick box) for compliance
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
• Fructan 7g tds
• Fructose 14g tds
• Fructose + fructan 14 + 7g tds
• Glucose (placebo) 7g tds
STUDY DESIGN
LOW F O D M A P D I E T (supplied to patient)
>2 week run-in
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Fructan Fructose Fructose andFructans
Glucose
P < 0.001
SYMPTOMS NOT ADEQUATELY CONTROLLED %
OF
PATI
ENTS
Shepherd, SJ 2008
(1O END-POINT)
MEDIAN SYMPTOM SCORES
p<0.001, Fisher’s exact
0
10
20
30
40
50
60
70
80
Fructan Fructose Fructose & Fructans Glucose
Overall
Pain
Bloating
Wind
p<0.001 vs glucose Wilcoxon
*Med
ian
scor
es o
n VA
S 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
0
10
20
30
40
50
60
70
Fructan Fructose Fructose &Fructans
Glucose
50ml100ml170ml
Fisher’s exact
*Med
ian
scor
es o
n VA
S
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 of 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
Daily symptom questionnaire: Abdominal pain/discomfort, abdominal bloating/ distension, wind, nausea, heartburn and lethargy (Likert scale 0-3, 0=none, 1=mild, 2=moderate, 3=severe)
STUDY PROTOCOL 2-day
High FODMAP 2 day
Low FODMAP 7-day
baseline
7-day washout
Breath samples collected every hour for 14 hours (Day 2 of diet)
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
0
5
10
15
20
25
30
35
40
Abdo Pain Abdo Bloating ExcessiveFlatus
Nausea Heartburn Tired/Lethargy
LFDHFD
Tota
l Com
posi
te S
ympt
om S
core
**
**
**
* *
*
* = 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.
CONCLUSION • 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 on 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 of wind & dissatisfaction of stool consistency
STUDY PROTOCOL 21-day
Low FODMAP 21-day
Typical Aust. 7-day
baseline ≥ 21-day washout
0 100 None at all Worst ever
bloatinistenc
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 & lactose
spelt bread with spread
Rice cakes with cheese
Salmon with vegetable quinoa
Weet-bix & lactosemilk,wheat bread with spread
Salmon with vegetable couscous
Ryvita with cheese
Orange
Berry crumble
cordial
Apple crumble
Pear
apple juiceLow FODMAP frittataHigh 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.
CONCLUSION • 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
other dietary factor – it was FODMAPs.
Overseastttttttttttttttttfrom 2003 today have consistently proven that thettttttttttthefrom 2003-today have consistently proven that the
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
ongoing improvement. • Review appointment with nutritionist with view to
reintroducing some FODMAP-containing foods.
EXAMPLES OF HIGH FODMAP FOODS Excess
Fructose Polyols Lactose Fructans Galacto-
oligosaccharides
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 onion (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, orange, 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 of 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 olive 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 response. • All patients with IBS have different FODMAP
tolerance levels. • Not every person has a problem with every type
of 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
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