treating ibs symptoms – is the low fodmap diet an option? · dietary management of ... bowel...

Treating IBS symptoms – Is the low FODMAP diet an option? Heidi Staudacher,

King’s College London and Guy’s and St Thomas’ NHS Foundation Trust

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People who suffer from IBS are constantly searching for new ways of managing their symptoms. The low FODMAP diet is an innovative evidence-based approach that has been shown to be very effective in improving IBS symptoms. Heidi Staudacher, Research Dietitian, reveals the science behind this dietary approach. What is Irritable Bowel Syndrome (IBS)? IBS is a common debilitating condition that affects up to 20% of the western world, with females predominantly being affected 1-3. It has a major impact on quality of life4 and contributes significantly to healthcare burden5 in the UK. It is characterised by abdominal pain or discomfort and a change in bowel habit, as defined by the Rome III criteria3. Many individuals are labelled as having IBS but don’t technically fit under the umbrella of the Rome III criteria. They might exhibit symptoms such as significant bloating, flatulence and alternating bowel habits. These symptoms aren’t ‘normal’, and are due to a change in the function of the gastrointestinal tract but not any physiological abnormality. Hence, they are often labelled as ‘functional’ symptoms. Functional symptoms may present in people without any other gastrointestinal conditions or in people with coeliac disease or inflammatory bowel disease (IBD). What treatments are available? The predominant underlying cause of functional symptoms appears to be related to the nervous system, which results in hypersensitivity of the bowel and changes in motility. Psychological factors are also considered to contribute to symptoms. Treatments such as stool bulking agents, anti-diarrhoeals, anti-spasmodics and low dose anti-depressants can be of some use. Input from psychologists and hypnotherapists may also be of benefit. Does diet make a difference? Dietary management of functional gastrointestinal symptoms, in previous years has generally focused on adjusting dietary fibre content, restricting caffeine and alcohol and avoiding high lactose loads. Recently we showed that the National Institute for Health and Clinical Excellence IBS dietary guidelines6 are useful in a proportion of patients seeing a dietitian for their IBS7. However, there is little or poor quality randomised controlled evidence that any of these strategies are effective8;9. Does the low FODMAP diet work? It has been shown that the low FODMAP diet is highly effective in treating the symptoms of IBS, with approximately 75% of patients who are prescribed the diet reporting a sustained symptom response10. Other studies also confirm its success7;11 .

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Largeintestine

Smallintestine

Gas

GasGas Gas

Gas

Gas

FODMAPs

Deliveryofwaterthroughthebowel

Gasproduction

Diarrhoea Bloating,distension,flatulence,abdominalpain,constipation

What are FODMAPs? A group of indigestible carbohydrates or sugars, including oligosaccharides, disaccharides, monosaccharides and polyols have been shown to be osmotically active and rapidly fermentable in the gastrointestinal tract. Various studies show these sugars are considerable triggers of gastrointestinal symptoms in patients with IBS individually or in combination12-15. Recently a group in Australia have developed a diet low in all of the fermentable sugars, termed the low FODMAP diet (Figure 1). Figure 2 demonstrates how FODMAPs pass through the bowel unabsorbed and can trigger functional symptoms. Figure 2: What healthcare professionals are able to give low FODMAP dietary advice? The evidence shows that patients should be seen on a one-on-one basis by a specifically trained dietitian. The dietitian should obtain a full patient history, an understanding of the IBS symptom(s) experienced and assess the diet in detail. The patient is then taught about how the FODMAP system in a step-by-step process. The diet is invidualised for each patient, providing suitable alternatives for foods they

Figure 1: FODMAPs Fermentable Oligo-saccharides (e.g. fructans) Di-saccharides (e.g. lactose) Mono-saccharides (e.g. fructose) And PolyolS (e.g. sorbitol)

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need to avoid. Menu plans and appropriate information on label reading, eating out and recipe adaptation should be provided. Patients will often have many questions and require reassurance. A full hour is usually needed for each patient. Dietitians require specific training to be able to advise patients effectively. A service has recently been set up which encompasses training of gastroenterology specialist dietitians and development of comprehensive and relevant patient information. A recent evaluation has shown that the diet is highly effective when implemented by trained dietitians7. Group sessions have been used successfully in Australia. What does the diet involve? Analysis of the FODMAP composition of foods has been led by the Australian centre and is an ongoing process (see Figure 3). This directs the suitability of foods in the diet. The main sources of FODMAPs include various fruits, vegetables, grains and dairy products. FODMAPs are also added to packaged foods to enhance sweetness (e.g. fructose or polyols in sauces) or to improve mouth feel (e.g. inulin in low fat dairy products). Figure 3:

Is the diet easy and how long should it be followed? Patients often report that aspects of the diet are difficult to follow, but compliance rates are high, with 77% following the diet most of the time10. Skilled dietitians will be able to individualise the diet accordingly for patients who may struggle with certain aspects of the diet. It is likely that the more strictly the diet is followed the quicker the symptom response will be, but most people take between 2-8 weeks to improve. See Figure 4 for a case study of a patient recently seen in clinic.

Some Foods High in FODMAPs Apple Pear Mango Artichoke Onion Garlic Sugar free gums and mints Pulses e.g. lentils, chickpeas

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Figure 4:

What should we tell our IBS patients? Patients with functional symptoms should be referred to a dietitian that is trained in the low FODMAP approach. There is growing interest in this new exciting approach. Dietitians should contact www.kcl.ac.uk/fodmaps for further information on the next training course.

Reference List

(1) Locke GR, III, Zinsmeister AR, Fett SL, Melton LJ, III, Talley NJ. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol Motil 2005; 17(1):29-34.

(2) Saito YA, Locke GR, Talley NJ, Zinsmeister AR, Fett SL, Melton LJ, III. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol 2000; 95(10):2816-2824.

(3) Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology 2006; 130(5):1480-1491.

(4) Koloski NA, Talley NJ, Boyce PM. The impact of functional gastrointestinal disorders on quality of life. Am J Gastroenterol 2000; 95(1):67-71.

(5) Maxion-Bergemann S, Thielecke F, Abel F, Bergemann R. Costs of irritable bowel syndrome in the UK and US. Pharmacoeconomics 2006; 24(1):21-37.

Case Study: Mr X Medical History Investigations ruled out coeliac disease, IBD and any other GIT disorder Symptoms Urgent loose stools 3-4 times a day Severe bloating Medications Nil

Diet 3 meals a day, nutritionally adequate Moderate-high FODMAP diet Treatment Low FODMAP diet Symptom response At 4 weeks, 1 formed stool/day, no bloating

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(6) http://guidance.nice.org.uk/index.jsp?action=download&o=40608. 15-5-0208.

(7) Staudacher H.M, Lomer M.C.E, Whelan K, Irving P. Implementation of the low FODMAP diet in the UK:How easy is it and does it work? Gut 2010; 59(supplement 1):A149.

(8) Burden S. Dietary treatment of irritable bowel syndrome: current evidence and guidelines for future practice. J Hum Nutr Diet 2001; 14(3):231-241.

(9) Heizer WD, Southern S, McGovern S. The role of diet in symptoms of irritable bowel syndrome in adults: a narrative review. J Am Diet Assoc 2009; 109(7):1204-1214.

(10) Shepherd SJ, Gibson PR. Fructose malabsorption and symptoms of irritable bowel syndrome: guidelines for effective dietary management. J Am Diet Assoc 2006; 106(10):1631-1639.

(11) Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol Hepatol 2008; 6(7):765-771.

(12) Goldstein R, Braverman D, Stankiewicz H. Carbohydrate malabsorption and the effect of dietary restriction on symptoms of irritable bowel syndrome and functional bowel complaints. Isr Med Assoc J 2000; 2(8):583-587.

(13) Hyams JS. Sorbitol intolerance: an unappreciated cause of functional gastrointestinal complaints. Gastroenterology 1983; 84(1):30-33.

(14) Jain NK, Rosenberg DB, Ulahannan MJ, Glasser MJ, Pitchumoni CS. Sorbitol intolerance in adults. Am J Gastroenterol 1985; 80(9):678-681.

(15) Rumessen JJ, Gudmand-Hoyer E. Functional bowel disease: malabsorption and abdominal distress after ingestion of fructose, sorbitol, and fructose-sorbitol mixtures. Gastroenterology 1988; 95(3):694-700.

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treating ibs symptoms – is the low fodmap diet an option? · dietary management of ... bowel...

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