Low FODMAP Diet
for the
Treatment of IBS
Thanit Vinitchagoon, B.Sc., CDT. Clinical Dietitian, Nutrition Support Department Bumrungrad International Hospital
What is Irritable Bowel Syndrome? Irritable bowel syndrome (IBS) is a functional disorder of the large intestine. Although there are no visible damage to the GI tract, patients with IBS experienced symptoms including abdominal cramping, bloating, flatulence, constipation, and diarrhea.
Pathogenic mechanisms in IBS • • • • •
Visceral hypersensitivity Altered luminal microbiota Altered motility Altered gas handling Brain-gut axis dysregulation
(Staudacher HM et al. Nat Rev Gastroenterol Hepatol. 2014.)
Pathogenic mechanisms in IBS
(Staudacher HM et al. Nat Rev Gastroenterol Hepatol. 2014.)
What are FODMAPs? FODMAPs is the name for a group of short chain carbohydrates found in food that are generally poorly absorbed by our digestive system.
What are FODMAPs? F ermentable O ligosaccharides D isaccharides M onosaccharides A nd P olyols
Fructans, Galactans Lactose Fructose (in excess of glucose) Sorbitol
Double-blinded, randomized controlled re-challenge trial in 25 patients. Outcome measures are symptoms monitored by daily diary entry, and responses to a VAS global symptom question. Challenged with - Fructose - Fructans - Glucose/placebo
14, 28, 50 g 7, 14, 19 g 7, 14, 20 g
Proportion of patients who answered positively to the global symptom question at the maximal test dose they achieved * PP = per-protocol analysis ITT = intention-to-treat analysis
Question: â&#x20AC;&#x153;Were your symptoms adequately controlled in this phase?â&#x20AC;? * Different from other groups (p< .0039) using McNemar test
(Shepherd SJ et al. Clin Gastro Hepatol. 2008.)
Scores on the VAS for abdominal symptoms of low dose vs. maximum dose
Low dose High dose
data based on intention-to-treat analysis Dose-dependent differences were found for all test drinks except glucose (p<.002) with Wilcoxon matched pair signed rank test
(Shepherd SJ et al. Clin Gastro Hepatol. 2008.)
Non-randomized controlled trial in 82 patients who received either standard (n=39) or low FODMAPs advice (n=43) for 6-8 weeks follow-up.
Symptom responses of standard and FODMAP group *
*
*
*
*
* p<.05, statistical difference between standard and FODMAP group (Staudacher HM et al. J Hum Nutr Diet. 2011.)
*
Studies of low FODMAPs diet in IBS
(Staudacher HM et al. Nat Rev Gastroenterol Hepatol. 2014.)
Following the Low FODMAPs Diet Start from restricting high FODMAP foods for at least 6-8 weeks. Following this period, FODMAPs are slowly reintroduced to gauge individual tolerance level. Due to difference in the individualâ&#x20AC;&#x2122;s threshold for certain FODMAPs, follow-up visit with dietitian is recommended.
Nutrition Care Process Nutrition Assessment • Current intake of FODMAPs • Gastrointestinal symptoms • Knowledge regarding low FODMAPs diet • Health-and-food-related quality of life • Negative breath-test for lactose and/or fructose
(Academy of Nutrition and Dietetics, IDNT. 2013.)
Nutrition Diagnosis • Inappropriate food choice • Inadequate/ excessive carbohydrate intake • Altered gastrointestinal function • Knowledge deficit about food and nutrition
Functional bowel symptoms Is breath hydrogen testing available?
Y
Breath hydrogen testing with fructose & lactose to assess absorptive capacity
Core diet (restriction of fructans, GOS, polyols)
Restriction of lactose if lactose malabsorption
N
Complete FODMAP restriction
Restriction of fructose if fructose malabsorption
Reintroduction program to determine dose tolerated (Gibson PR et al. J Gastroenterol Hepatol. 2011.)
Nutrition Intervention • Substitute high FODMAPs foods with lower options regarding patient’s usual intake, preference, situation and social. • Provide vary and expanded food choices. • Educate reading nutrition labels • Advice balanced, nutrient-adequate diet for proper eating behavior and appropriate body weight • Gradually introduce the limited foods in a small amount that could be tolerated. • Psychosocial support including cognitive behavioral therapy and mindfulnessbased stress reduction seems to be useful.
FODMAPs Food Guide FODMAP
Excess fructose
Problematic (high FODMAP food source)
Fruits: apples, pears, peaches, mango, watermelon, tinned fruit in natural juice Honey Sweeteners: fructose, high fructose corn syrup Large total fructose dose: concentrated fruit sources ex. Large serves of fruit, dried fruit, fruit juice
Suitable alternatives (low FODMAP food sources)
Fruit: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwi, lemon, lime, mandarin orange, passionfruit, paw paw, raspberry, rockmelon, strawberry, tangelo Honey substitutes: maple syrup, golden syrup Sweeteners: any except polyols
(Gibson PR et al. J Gastro Hepatol. 2010.)
FODMAPs Food Guide FODMAP
Lactose
Problematic (high FODMAP food source)
Milk: cow, goat, and sheep (regular & low fat ice-cream) Yoghurt (regular & low fat) Cheese: soft & fresh (ex. ricotta, cottage)
Suitable alternatives (low FODMAP food sources)
Milk: lactose-free, rice milk Cheese: â&#x20AC;&#x153;hardâ&#x20AC;? cheese including brie, camembert Yoghurt: lactose-free Ice-cream substitutes: gelati, sorbet Butter
(Gibson PR et al. J Gastro Hepatol. 2010.)
FODMAPs Food Guide FODMAP
Oligosaccharides
Problematic (high FODMAP food source)
Vegetables: artichokes, asparagus, beetroot, Brussels sprout, broccoli, cabbage, fennel, garlic, leeks, okra, onions, peas, shallots Cereals: wheat & rye when eaten in large amounts (ex. bread, pasta, couscous, crackers, biscuits) Legumes: chickpeas, lentils, red kidney beans, baked beans Fruits: watermelon, custard apple, white peaches, rambutan, persimmon
Suitable alternatives (low FODMAP food sources)
Vegetables: bamboo shoots, bokchoy, carrot, celery, capsicum, choko, choy sum, corn, eggplant, green beans, lettuce, chives, parsnip, pumpkin, silverbeet, spring onion (green only), tomato Onion/garlic substitutes: garlic-infused oil Cereals: gluten free & spelt bread/cereal products
(Gibson PR et al. J Gastro Hepatol. 2010.)
FODMAPs Food Guide FODMAP
Polyols
Problematic (high FODMAP food source)
Fruits: apples, apricots, cherries, longon, lychee, nashi pears, nectarine, pears, peaches, plums, prunes, watermelon Vegetables: avocado, cauliflower, mushrooms, snow peas Sweeteners: sorbitol, mannitol, xylitol, maltitol, isomalt & others ending in “-ol”
Suitable alternatives (low FODMAP food sources)
Fruits: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwi, lemon, lime, mandarin, orange, passionfruit, paw paw, raspberry, rockmelon Sweeteners: sugar (sucrose), glucose, other artificial sweeteners not ending in “-ol”
(Gibson PR et al. J Gastro Hepatol. 2010.)
FODMAPs on Mobile
Take-home message Low FODMAPs diet seems to improve gastrointestinal symptoms in patients with IBS, but however, the data are limited. Carefully dietary management must be planned to help maintain good nutrition status.
Thank you :>