LOW-FODMAP DIET K. Whelan (UK)Conflicts of interest Research funding Almond Board of California, Clasado Biosciences, International Nut and Dried Fruit Council, Nestle Consultancy

ESPEN Congress Krakow 2019

The Evidence Behind Diets

LOW-FODMAP DIET

K. Whelan (UK)

Low FODMAP diet

Kevin WhelanProfessor of DieteticsDepartment of Nutritional SciencesKing’s College London

@ProfWhelan

#ESPEN2019

Nutritional Sciences

Conflicts of interest

Research fundingAlmond Board of California, Clasado Biosciences, International Nut and Dried Fruit Council, Nestle

ConsultancyDanone

Speaker feesYakult, Alpro

Coinventor of app for the low FODMAP diet (FoodMaestro)

Irritable bowel syndrome

5 - 10% of the European population

37 - 74 million people in Europe

Significant impact on individuals, families and healthcare

Böhn et al, Am J Gastro 2013; 108:634 – 641

84% of adults with IBS reported gut symptoms related to at least one food

What foods induce symptoms in IBS?

Excluding all of these self-reported

food intolerances is not the answer!

Fermentable

Oligosaccharides (fructans and α-galacto-oligosaccharides)

Disaccharides (lactose)

Monosaccharides (fructose)

And

Polyols (sorbitol, mannitol, xylitol etc)

FODMAPs result in symptoms in some IBS:Re-challenge study in patients with IBS

Shepherd et al, Clin Gastro Hep, 2008: 6; 765-771

Fructose increases small bowel water Fructans increase colonic gas

Murray et al. Am J Gastro. 2014;109:110-19

FODMAPs and their impact on the gut

Major et al, Gastroenterology 2017;152:124–133

FODMAPs and their impact on the gut

Staudacher & Whelan, Gut, 2017; 66: 1517-1527@ProfWhelan

#ESPEN2019

FOD

MA

P in

take

FODMAP restriction4-8 weeks

FODMAP reintroduction6-10 weeks

FODMAP personalisation

Gu

t symp

tom

s

FODMAP tolerance threshold

What happens during the low FODMAP diet?

Whelan et al, J Hum Nutr Diet, 2018; 31: 239-255@ProfWhelan

#ESPEN2019

Low FODMAP diet:ACG meta-analysis

Dionne, Am J Gastro 2018; 29: 549-75

7 RCTs, 397 participants

Low FODMAP diet results in lower global IBS symptoms compared with ‘control’

RR = 0.69 (0.54 to 0.88)

ReferenceNumber of Responders

Comparators Comparator FODMAP

Usual diet Staudacher 2012 J Nutr 23% 68%

Typical diet Halmos 2014 Gastro - 70%

High FODMAP diet McIntosh 2016 Gut 21% 72%

Placebo diet Staudacher 2017 Gastro38%42%

57%73%

Active interventionNICENICENICE

Hypnotherapy

Staudacher 2011 J Hum Nut DBohn 2015, GastroEswaran, 2016, Am J Gastro

Peters 2016, Alim Pharm Ther

39%46%41%23%72%

76%50%52%51%71%

Evidence for the low FODMAP diet in IBS: Staudacher and Whelan, Gut 2017; 66: 1517-1527







57%73%


Hypnotherapy



39%46%41%23%72%

76%50%52%51%71%


Low FODMAP dietary advice vs usual diet: RCTImproves symptoms and normalises stool output

Staudacher et al, J Nutrition 2012; 142: 1510-8

Global symptom questionDo you have adequate relief of your IBS symptoms?

Controls 23%FODMAP 68%

P = 0.003

http://upload.wikimedia.org/wikipedia/commons/f/fc/Cornflower_blue_check.svg

http://upload.wikimedia.org/wikipedia/commons/f/fc/Cornflower_blue_check.svg







57%73%


Hypnotherapy



39%46%41%23%72%

76%50%52%51%71%


Halmos et al, Gastro, 2014; 146: 67–75

Low FODMAP feedingvs ‘typical Aussie diet’Improves symptoms

Challenge #1: Low FODMAP impacts microbiome

Staudacher et al, J Nutrition 2012; 142: 1510-8Halmos et al, Gut, 2015; 64: 93-100







57%73%


Hypnotherapy



39%46%41%23%72%

76%50%52%51%71%


2 x 2 factorial RCT

Dietary advice

Low FODMAP diet advice

Placebo “sham” diet advice

Supplement

Probiotic Both Probiotic only

Placebo Low FODMAP only Neither

Low FODMAP diet compared with placebo diet,

plus probiotics

Dr Heidi Staudacher

Staudacher et al, Gastroenterology, 2017; 153: 936-947



plus probiotics



plus probiotics







57%73%


Hypnotherapy



39%46%41%23%72%

76%50%52%51%71%


‘NICE diet’

www.bda.uk.com/foodfacts/IBSfoodfacts.pdf

Bohn, Gastroenterology 2015; 149: 1399-1407

324 to 246 P<0.001

302 to 236P<0.001

Low FODMAP diet advice vs NICE diet adviceBoth improve symptoms, no difference in effectiveness







57%73%


Hypnotherapy



39%46%41%23%72%

76%50%52%51%71%


Eswaran et al, Am J Gastro 2016; 111: 1824-1832

Proportion of patients reporting adequate relief of IBS-D symptoms

≥50% of intervention wks 3–4

≥30% reduction in mean daily pain score compared with baseline

Low FODMAP diet advice vs NICE diet adviceBoth improve symptoms, some differences in effectiveness

Low FODMAP diet advice vs NICE diet adviceBoth improve symptoms, some differences in effectiveness

Eswaran et al, Am J Gastro 2016; 111: 1824-1832

British Dietetic Association guidelines1st line advice (NICE diet, food-pattern, fibre, fluid, fat, flora)

2nd line advice (low FODMAP diet)

McKenzie, J Hum Nutr Diet 2016; 29: 549-75

Staudacher, J Acad Nutr Diet 2019 (in press)

Challenge #2: impact on nutrient intake

www.kcl.ac.uk/fodmapswww.foodmaestro.me/fodmap-app

Supporting patients on the low FODMAP diet

All clinical trials of low FODMAP diet in IBS were conducted with dietitian providing personaliseddietary counselling

@ProfWhelan#ESPEN2019

Dr Megan RossiKing’s College London

Prof Chris ProbertUniversity of Liverpool

Challenge #3: Knowing who will benefitPredicting response based upon volatile organic compounds in stool

Rossi et al, Clin Gastro Hepatol 2018; 16: 385-391

15 VOC features able to predict response to low FODMAP diet with 97% accuracy

Rossi et al, Clin Gastro Hepatol 2018; 16: 385-391

Challenge #3: Knowing who will benefitPredicting response based upon volatile organic compounds in stool

Low FODMAP diet in IBS

Nutritional SciencesKing’s College London

FODMAPs contribute to symptoms in some patients with IBS by increasing small intestinal luminal water and increasing colonic gas

Increasing numbers of RCTs demonstrate the low FODMAP diet improves overall symptoms in IBS, especially abdominal pain, bloating and flatulence

Low FODMAP diet impacts on the microbiota, presumably due to reductions in prebiotic intake (fructans, GOS), but may partially be prevented by probiotics

Low FODMAP diet may impact intakes of some nutrients, restriction should be short-term and FODMAPs should be reintroduced, the whole process being supported by a dietitian

Dr Heidi StaudacherDr Megan RossiDr Bridgette WilsonDr Miranda LomerDr Peter Irving

Prof Chris Probert (University of Liverpool)Dr Raphael Aggio (University of Liverpool)

@ProfWhelan#ESPEN2019

Documents

LOW-FODMAP DIET K. Whelan (UK)Conflicts of interest Research funding Almond Board of California, Clasado Biosciences, International Nut and Dried Fruit Council, Nestle Consultancy