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 ermentable O ligosaccharides D isaccharide M onosaccharide A nd P olyols

THE SPECTRUM OF FODMAPS F ermentable – meaning they can be broken down by bacteria in O the bowel. D M A P

THE SPECTRUM OF FODMAPS F ermentable O ligosaccharides - e.g. fructans and GOS. D M A P

THE SPECTRUM OF FODMAPS F ermentable O ligosaccharides - e.g. fructans and GOS. D M saccharide’ means ‘sugar’ ‘oligo means ‘many’ A P

THE SPECTRUM OF FODMAPS F ermentable O D isaccharide – e.g. Lactose. M A P

THE SPECTRUM OF FODMAPS F ermentable O D M onosaccharide e.g. Fructose (in excess of glucose) A P

THE SPECTRUM OF FODMAPS F ermentable O D M A nd P

THE SPECTRUM OF FODMAPS F ermentable O D M A P olyols – e.g. Sorbitol, mannitol

HOW WAS THE LOW FODMAP DIET DEVELOPED? 2) I received a referral for a patient with IBS symptoms 1) I was frustrated by why it and +ve fructose breath test. was that so many people Referral note: “Please teach (without coeliac disease) the fructose malabsorption experienced functional gut diet”. However, there were She hephe pherd d symptoms when eating wheat. no dietary guidelines! If it wasn’t gluten, what else Wo Works 1)Search of the literature: was in wheat that could be a 1999 1999 fructose was well absorbed trigger ? in the presence of glucose Search of the literature: (sugar solutions) – FRUCTANS ? extrapolated to food… EXCESS FRUCTOSE ? 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…..

HOW WAS THE LOW FODMAP DIET DEVELOPED? • 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.

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 oses ch chosen on on b basis of of 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

STUDY DESIGN 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

• Fru ructa tan 7g 7g td tds STUDY DESIGN • Fructose 14g 14g td tds • Fructose + + fru ructa tan 14 + 14 + 7g 7g td tds • Glu lucose ( e (pla laceb ebo) 7g td tds 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 50ml x 50m x 100m 100ml 170m 170ml x x 3/day ay x 3 3/day ay 3/day ay Shepherd, SJ 2008, Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71

• Fru ructa tan 7g 7g td tds STUDY DESIGN • Fructose 14g 14g td tds • Fructose + + fru ructa tan 14 + 14 + 7g 7g td tds • Glu lucose ( e (pla laceb ebo) 7g td tds 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 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 Shepherd, SJ 2008, Shepherd, SJ et al, Clin Gast Hep 2008 Jul;6(7):765-71

• Fru ructa tan 7g 7g td tds STUDY DESIGN • Fructose 14g 14g td tds • Fructose + + fru ructa tan 14 + 14 + 7g 7g td tds • Glu lucose ( e (pla laceb ebo) 7g td tds 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 S y m p t o m d i a r y (VAS) (2 o ) Global symptom question (1 o )

SYMPTOMS NOT ADEQUATELY CONTROLLED (1 O END-POINT) 100% 90% 80% P < 0.001 70% % OF PATIENTS 60% 50% 40% 30% 20% 10% 0% Fructan Fructose Fructose and Glucose Fructans Shepherd, SJ 2008

MEDIAN SYMPTOM SCORES (2 O END-POINT) 80 Overall 70 Pain p<0.05 *Median scores on VAS Bloating 60 Wind 50 40 p<0.001 vs glucose p<0.001, Fisher’s exact Wilcoxon 30 20 10 0 Fructan Fructose Fructose & Fructans Glucose Shepherd, SJ 2008

MEDIAN OVERALL SYMPTOM SCORE IN RELATION TO VOLUME – EFFECT OF DOSE 70 p<0.001, across groups 50ml 60 100ml *Median scores on VAS 170ml 50 40 Fisher’s exact p<0.001, Fisher’s exact 30 p<0.001, cf glucose 20 10 0 Fructan Fructose Fructose & Glucose Fructans 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 H 2 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