beyond belly aches - kellogg's nutrition healthcare ... · cho definitions chemical mono-,...

Joanne Slavin, PhD, RD University of Minnesota

Beyond Belly Aches: The implementation of FODMAPs

in clinical practice

Nutritional Solutions CNE, South Africa

- 11 April 2013 -

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Outline

1. Introduction

2. Definitions

3. Examples of FODMAPs

4. Benefits of FODMAPs

5. FODMAPs as prebiotics

6. Research limitations

7. Tolerance to FODMAPs

8. FODMAPs and IBS

9. Conclusions

1. Introduction

Introduction

Gibson PR, Shepherd SJ. Am J Gastro 2012; 107: 659

2. Definitions

CHO definitions

Chemical Mono-, di-, oligo-, polysaccharides

Nutritional Absorbable

Digestible

Fermentable

Non-fermentable

Physiological Low-glycaemic, non-glycaemic

A wide range of characteristics…

Fermentable CHO

• Incompletely digested and partially

absorbed in small intestine

- Bonds resistant to digestive enzymes

• Fermented by bacteria in large intestine

- Short Chain Fatty Acids (SCFAs)

- Gases such as H2, CH4, CO2

• And/or excreted in faeces

FODMAPs

Acronym that stands for

Fermentable Oligo-, Di-, and Monosaccharides, And Polyols (FODMAP) Term coined in 2005 by Australian researchers who theorize that foods containing these carbohydrates worsen symptoms of digestive disorders: Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD)

Gibson PR, Shepherd SJ. Aliment Pharmacol Ther 2005; 21: 1399 - 1409

Classifications

Four categories of Fermentable Carbohydrates

1. Oligosaccharides Fructo-oligosaccharides (FOS)

Galacto-oligosaccharides (GOS)

2. Dissacharides Lactose

3. Monosaccharides Fructose

4. Polyols Sorbitol, mannitol, xylitol

Absorption

1. Oligosaccharides Can’t digest chemical bond

2. Dissacharides Lactose in lactose intolerant

Lactulose because beta bond can’t be split

3. Monosaccharides Free fructose is slowly absorbed when consumed

alone

4. Polyols Incompletely absorbed

FODMAPs have different absorptive patterns and physiological effects and shouldn’t be grouped together

3. Examples of FODMAPs

Oligosaccharides

FOS or Fructans

• Degree of polymerisation (DP): 2 – 9 units

• Inulin: DP > 10 units

• Isolated sources of FOS / inulin

- Chicory root, Jerusalem artichoke

• Food sources of FOS / inulin

- Peach, watermelon, Jerusalem artichoke, brussels sprouts, fennel, garlic, leek, onion, wheat, rye, barley, legumes, lentils, chickpeas

Oligosaccharides

Other Oligosaccharides

• GOS

- Found in human milk

- Isolated and added to infant formula and other foods

• Stachyose, raffinose, verbascose

- Found naturally in legumes

- Efforts to remove because of

intestinal gas concerns

Dissacharides

• Lactose: glucose + galactose

• Only a FODMAP when there is insufficient intestinal lactase activity

• Lactase deficiency more common in certain ethnicities

- Asian, Hispanic, African American

• Highest lactose exposure from milk

- Also found in ice-cream, yoghurt , custard, soft cheeses

- Studies show that yoghurt is better tolerated in many

Monossacharides

• Free fructose

• Simple sugar and requires no digestion

• When consumed in higher quantities than glucose, absorption is impaired and malabsorption may occur

• Can be purchased and added to foods and drinks – low glycaemic

• Foods naturally high in fructose include:

- Apple, pear, mango, cherry, watermelon, asparagus,

Jerusalem artichokes, sugarsnap peas, honey

Polyols

• Examples of polyols

- Erythritol, xylitol, sorbitol, mannitol, lactitol, isomalt, maltitol,

polyglycitol syrup

• Slowly absorbed, only about a third absorbed

• Naturally occurring in

- Apples, pears, cherries, prunes, avocado, mushrooms

• Added to

- Sugar-free mints, chewing gum and sweets

4. Benefits of FODMAPs

Added to foods

• FODMAPs are used as sugar and fat replacers in:

- Hard sweets

- Chocolate

- Cookies and other baked goods

- Ice-cream

- Yoghurt

- Jams and preserves

- Chewing gum

Benefits

• Reduced energy value

- 1 – 3.5 kcal / g or 4.2 – 14.6 kJ / g (sucrose provides 17 kJ / g)

• Low glycaemic response

• Non-cariogenic

• Prebiotic effects

• Other potential health benefits

5. FODMAPs as prebiotics

Gut microbiota

Gut microbiota influence metabolism and body composition

Vrieze et al. Diabetologia 2010; 53: 606 - 613

Gut microbiota

• Low grade inflammation contributes to the development of

obesity

• Gut microflora alter energy metabolism

• Gut microflora play a role in immunity

Cani PD, Delzenne NM. Curr Phar Des 2009; 15: 1546 - 1558

Gut microbiota

• Some evidence suggests fibre fermentation in the gut provides

physiological benefits such as:

- Increased mineral absorption

- Stimulation of beneficial microbes (prebiotic)

- Decrease survival of pathogenic bacteria through reduction in pH

- Providing nourishment to colonocytes (SCFAs, butyrate) for increased

cell growth and maintenance

Slavin JL. J Am Diet Assoc 2008; 108: 1716 - 1731

Definition

“Prebiotics are non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth and / or

activity of one or a limited number of bacteria in the colon and thus improve host health”

• Neither hydrolysed nor absorbed in the upper part of the GI tract

• Selective substrate for one or a limited number of beneficial bacteria

• Able to alter the colonic flora in favour of a healthier composition

Brownawell AM. J Nutr 2012; 142: 962 - 974

Prebiotics

• Not an accepted in vitro method to determine ‘Prebiotic Index’

• Only FOS and GOS qualify

Roberfroid M. J Nutr 2007; 137: 830S-837S

Prebiotics

Figueroa-Gonzalez I et al. J Sci Food Agric 2011; 91: 1341

• The main candidates for prebiotic status are:

- Inulin

- FOS

- GOS

- Soy-oligosaccharides

- Xylo-oligosaccharides

- Isomalto-oligosaccharides

- Polydextrins

Prebiotics

• No prospective, cohort studies that link changes in microbiota

with health outcomes

- Faecal samples not collected in epidemiological studies

• Disagreement on how to quantitatively measure in human studies

• Prebiotic standard protocols needed

Brownawell AM, Caers W, Gibson GR, Kendall CW, Lewis KO, Ringel Y, Slavin JL. J Nutr 2012; 14(5): 962 - 974

Long term restriction of FODMAPs may lead to a decrease in prebiotic intake

6. Research Limitations

Faecal samples

Limitations to faecal samples

• Not practical in epidemiological studies

• No accepted standard

- Stool weights

- Stool chemistry

- Microflora – methods, what is best?

- Stool frequency – easy to collect

- Quality of life – used in IBS trials

Grabitske , Slavin JL Review Paper. Cr Rev Food Sci Nutr 2009; 49: 327 - 360

Side effects

Side effects of gut fermentation

• Abdominal pain / cramps

• Bloating

• Distention

• Flatulence / borborygmi

• Laxation

- Stool weights

- Stool chemistry

• Diarrhoea


Methodology

Subjective methods

• Symptom questionnaires where subjects report the severity or intensity of GI

symptoms and frequency and consistency of bowel movements

• Need to define bloating, diarrhoea, flatulence and need to describe rating scale

• Vary greatly among studies / subjects


Further to research limitations, FODMAP recommendations have mainly been based on clinical observations and not trials

7. Tolerance to FODMAPs

Factors Factors affecting the tolerance to FODMAPs

• FODMAP characteristics

• Diet

- Consumption pattern – amount, frequency, food / beverages

- Background FODMAPs

- Drug treatments – antibiotics, laxatives

• Host

- Age, gender, psyche, composition of microbiota, diseases, GI transit time, enzyme activity,

visceral sensitivity

Cummings et al. Brit J Nutr 2001; 85 (Suppl 1): S59-60

Assessment FODMAPs Assessment

Direct

• Objective

- Stool samples

- Anal gas

- Abdominal girth

• Subjective

- Questionnaires: symptoms, bowel movements, intensity


Assessment FODMAPs Assessment

Indirect

• Malabsorption

- Intubation and ileostomy

- Breath hydrogen - fermentation

• Other

- Blood glucose, SCFAs

- Faecal pH, carbohydrates


Results Wide range of study characteristics

• Protocol

- FODMAPs in foods, beverages, tablets and gum

- Fasted and non-fasted conditions

- Meal / snack replacement or with meal / snack

- Adapted or unadapted

- Background FODMAPs – low to high

• Measurement of endpoints

- Stool collections

- Questionnaires, diaries or interviews - description of effects, intensity (none to severe, normal to considerably

more than usual, acceptable)


Tolerance data Summary of tolerance data

Dietary fibre Up to 80 g / day in vegetarians

No upper limit

Polydextrose 50 g / day

FOS 10 – 15 g / day

Diarrhoea at 40 g / day

Fructose Tolerance problems when fed in isolation

Sugar alcohols No effect dose – 20 – 50 g / day

Laxation threshold – 50 – 70 g / day


Tolerance data

Bonnema et al. J Am Diet Assoc 2010; 110: 865 - 868

GI tolerance of chicory inulin products

• Fed short (oligofructose) and long chain inulin to human subjects

at breakfast (n=26)

- 5 g well tolerated

- 10 g of short chain increased GI symptoms compared to control

- Most frequently reported symptoms were flatulence followed by

bloating

8. FODMAPs and IBS

IBS

• IBS is a common chronic GI disorder that involves problems with

motility and sensitivity

• Experience pain, bloating, irregular bowel pattern including

constipation, diarrhoea, resulting in decreased quality of life

• Affects 20% of women in North America

- Recommendation to reduce FODMAPs

Gibson PR, Shepherd SJ. Am J Gastro 2012; 107: 657 - 666

Dietary strategy


IBS

Symptom response with low FODMAP diet vs. standard IBS diet

• Compared symptoms between standard IBS dietary advice (n=39) vs. low FODMAP

(n=43)

• More in FODMAP group (76%) than standard diet (54%) were satisfied with

symptoms

• FODMAP group had less bloating, abdominal pain and flatulence than standard diet

Staudacher et al. J Hum Nutr Diet 2011; 24: 487 - 495

FODMAPs may increase adverse symptoms in patients with IBS

IBS

Fermentable carbohydrate restriction reduced Bifidobacteria and

symptoms in IBS

• Randomised controlled trial in IBS patients

• Intervention group were asked to reduced fructans (wheat, onions), GOS (legumes),

polyols (pears, sugar-free gum), lactose (milk) and excess fructose (honey)

• Symptoms improved in intervention group but Bifidobacteria in faeces was

significantly less

Staudacher et al. J Nutr 2012; 142: 1510 - 1518

Restriction of FODMAPs could result in reduced prebiotic intake, affecting beneficial gut flora

9. Conclusions

Conclusions

• FODMAPs may increase adverse GI symptoms in patients with

IBS

• Concerns with the FODMAP concept

- Recommendations based on clinical observations, not research trials

- Efficacy of FODMAP concept not documented

- Grouping of all FODMAPs together, although perhaps easier for the

patient, ignores physiological differences among FODMAPs

Conclusions

• Safety of long term FODMAP restriction has not been reported

and such dietary restrictions could decrease consumption of:

- Prebiotics (oligosaccharides)

- Low GI carbohydrate foods (fructose)

- Nutrient-rich foods (dairy)

- Low energy foods (polyols)

Evidence base


References Bonnema et al. J Am Diet Assoc 2010; 110: 865 - 868

Brownawell AM. J Nutr 2012; 142: 962 – 974

Brownawell AM, Caers W, Gibson GR, Kendall CW, Lewis KO, Ringel Y, Slavin JL. J Nutr 2012; 14(5): 962 - 974

Cani PD, Delzenne NM. Curr Phar Des 2009; 15: 1546 – 1558

Cummings et al. Brit J Nutr 2001; 85 (Suppl 1): S59-60

Figueroa-Gonzalez et al. J Sci Food Agric 2011; 91: 1341

Gibson PR, Shepherd SJ. Am J Gastro 2012; 107:657 - 666

Gibson PR, Shepherd SJ. Aliment Pharmacol Ther 2005; 21: 1399 – 1409


Marcason W. J Acad Nutr Diet 2012; 1696

Roberfroid M. J Nutr 2007; 137: 830S – 837S

Slavin JL. J Am Diet Assoc 2008; 108: 1716 – 1731

Staudacher et al. J Hum Nutr Diet 2011; 24: 487 – 495

Staudacher et al. J Nutr 2012; 142: 1510 - 1518

Vrieze et al. Diabetologia 2010; 53: 606 - 613

Thank you

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