Comparison of symptom response following advice for a

diet low in fermentable carbohydrates (FODMAPs) versus

standard dietary advice in patients with irritable bowel

syndromeH. M. Staudacher, K. Whelan, P. M. Irving & M. C. E. Lomer

Presented by Victoria Scholl

Irritable Bowel Syndrome

Most common gastrointestinal condition

Most commonly diagnosed in women and patients under 50

Assessment based on Rome III criteria/NICE Criteria

No biochemical, histopathological or radiological diagnostic test for IBS exists

Symptoms include: constipation, diarrhea, abdominal pain and distention.

IBS The condition usually causes long-term symptoms

May occur in episodes.

Symptoms vary and may be meal-related.

Symptoms interfere with daily life and social functioning in many patients.

Symptoms sometimes seem to develop as a consequence of a severe intestinal infection or to be precipitated by major life events, or in a period of considerable stress.

Pathogenesis IBS patients present with GI complaints which physicians can find no

organic cause

Brain-gut interaction

Heritability/Genetics

Dietary and intestinal flora

Abnormalities in neuroendocrine system of the gut

Management of IBS Pharmacotherapy:

No drug fits all

Antispasmodics

Antidepressants

Anti diarrhea agents

Antibiotics

Alternative Therapies Aloe

Peppermint oil

probiotics

Fiber IBS-D

IBS-C

Why research on IBS is important Quality of life

Current health care costs to manage IBS

Ability to cope with symptoms more effectively

Research into dietary management of symptoms

is promising

FODMAPs

Stands for: Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols.

These are short chain carbohydrates that are poorly absorbed in the small intestine

This malabsorption is common to everyone however, with altered gut flora, motility disorders, and hypersensitivity in IBS, the outcome can induce symptoms.

Low-FODMAP Diet Reduction in high fructan foods (e.g. wheat, onion) and substitution with wheat

free and other low fructan alternatives

Reduction in high galactooligosaccharide foods (e.g. chickpeas, lentils)

Reduction in high polyol foods and avoid polyol-sweetened sources- Replace with suitable fruits and vegetables

In those with lactose malabsorption, reduction in high lactose foods (e.g. milk, yoghurt) by restricting volume in one sitting or substitution with lactose free products.

In those with fructose malabsorption, reduction in excess fructose foods (e.g. honey)

NICE Guidelines Healthy eating principles (e.g. regular eating, taking time to eat).

Limit high fat foods, ensure a good intake of non caffeinated fluids, limit fizzy drinks

Limit insoluble fiber for diarrhea and increase gradually for constipation

Limit sugar free sweets and foods containing sorbitol

Limit fruit to 3 portions a day

Avoiding resistant starch may be useful (e.g. pulses, sweet corn, green bananas, part-baked and reheated bread)

Addition of oats and linseeds may be helpful

Purpose To compare the clinical effectiveness of a low-FODMAP

diet with the standard NICE guidelines for dietary therapy for IBS.

Materials and Methods

low-FODMAP dietetic service established with the assistance of a dietitian

Resources tailored to the UK context

Dietitians working in secondary and primary care trained in delivering low-FODMAP dietary advice.

Materials and Methods: Study Population A total of 82 patients completed the study n=39 standard group, n=43 low-FODMAP group

Consecutive adult patients returning for a follow up dietetic outpatient visit were included

Common to all patients selected: diagnosed with IBS by primary care physician/gastroenterologist

Had been referred for dietary advice

Seen by a dietitian within the previous 2-6 months

Materials and Methods: Participants

Symptoms, dietary assessments and diet history's were assessed for all participants

The same group of dietitians were used throughout the study

Patients seen prior to June 2009 were placed in the “Standard” group.

Patients seen after implementation of low-FODMAP diet were placed in the low-FODMAP group.

Materials and Methods: Intervention Fructooligosaccharides, galactooligosaccharides and

polyols were restricted in all patients

9 month evaluation period

Written information was given to both groups at initial consultation was specific to the dietary advice given. Standard group= 2 page written resource

Low-FODMAP group= color booklet

Questionnaire 16 point questionnaire

Verbal responses were collected regarding symptom change and satisfaction

Likert scale taken from validated IBS Global Improvement Scale was used to rate symptom change

Four point statements relating to satisfaction with symptom response were also asked

All answers were anonymous and confidential

Statistical Analysis Data analyzed using SPSS

Descriptive statistics for demographic data, baseline symptom comparisons, and types of standard dietary advice

Chi-squared test- symptom response and satisfaction comparison between groups

Symptoms responses collapsed into improved and not improved

Magnitude of improvement response collapsed into : worsened, no change, slightly improved, moderately improved, substantially improved.

Results: Symptom change More patients in the low-FODMAP group reported improvements in

bloating, abdominal pain, and flatulence compared to standard.

low-FODMAP group less likely to report deterioration or lack of improvement for symptoms than standard.

More patients in low-FODMAP group reported symptom improvements for diarrhea

No significant difference in proportion of participants reporting improvements in constipation between groups

More patients in the low-FODMAP group had improvements in nausea and energy levels

Satisfaction with symptom response and dietary advice 76% of patients in low-FODMAP group reported satisfaction with

symptom response compared to 54% in standard dietary advice group

There was no difference between groups in ease of understanding of written information

More patients in low-FODMAP group showed interest in implementing further change to their diet than standard group

Most patients reported following the diet strictly

Symptom resolution mean time= 3.5 weeks.

Discussion

More patients in the low-FODMAP group reported satisfaction with symptom response

There was a better overall symptom response in low-FODMAP group

More patients in the low-FODMAP group reported improvements in bloating, flatulence, and abdominal pain compared to standard.

Strengths and WeaknessesStrengths

•Used dietitians

•Gave participants information to take home with them

•Individual assessment of each symptom

•Patients were similar at baseline

•Use of a control group

Weaknesses

•No random selection

•No assessment of dietary intake

•Medications/ change in use of medications not recorded

•Probiotic intake not recorded

•Multiple dietitians conducting interviews- differing ways to communicate information

•Overlap between diets

Conclusion and Implications for Future Research

This study suggests that a low-FODMAP diet may be more effective than standard dietary advice for the management of IBS symptoms.

Future research on implementation and patient efficacy of a low-FODMAP diet is needed.

Implementation of a low-FODMAP diet in American patients still needed.

Studies on reintroducing low-FODMAP foods after a period of exclusion needed.

Questions????

Judith-  ”I know that this is a completely different disease, but I am curious if in your research you found that any IBS sufferers experience cyclic symptoms and if so do you believe this is diet related? If so could this be due to the vegetables/fruits that are in season?”

Aubrey- “While Likert scales have been validated and effective, do you think there are any other questionnaire or collection methods that would have been more efficient? I thought that maybe food diaries would have been helpful for the RD's so they could track patient diets and make sure they were consuming the right foods.”

Kirstie- “In this study they stated that fiber intake was not recorded.  Do you think that recording fiber intake would have changed the results of the study?”

Questions???

Sarah E.-  ”Could this "diet" work for other stomach/intestine/colon issues such as after gastric bypass surgery to prevent bloating, or fiber-related advice after diverticulitis surgery?”

Sarah S. “Do you know if this diet is implemented anywhere in the US? If not, can you see this becoming more of a “standard” diet prescription for individuals with IBS who do not see improvement with a standard nutrition prescription?”

Katie-  Do you think patients in the U.S. would have a difficult time following a low FODMAP diet??

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