FODMAPs. Presented by: Joanna Baker Date: 18 th May 2018

Size: px

Start display at page:

Download "FODMAPs. Presented by: Joanna Baker Date: 18 th May 2018"

Willis Anthony
5 years ago
Views:

1 FODMAPs Presented by: Joanna Baker Date: 18 th May 2018

2 FODMAP approach to managing Irritable Bowel Syndrome (IBS) What is IBS & how is it managed FODMAPs & IBS Wheat & FODMAPs How much wheat is an issue for IBS? Identifying Fructan tolerance Identifying dietary sources of Fructans

Irritable Bowel Syndrome (IBS) 1 in 7 Australians or 15% of the population however estimated that 70% do not seek medical advice - Self diagnosis is common 2 in 3 are female Diagnosis usually

3 Irritable Bowel Syndrome (IBS) 1 in 7 Australians or 15% of the population however estimated that 70% do not seek medical advice - Self diagnosis is common 2 in 3 are female Diagnosis usually between years Chronic Functional Gastro Intestinal condition characterised by pain, bloating, excessive wind and altered bowel habits. Visceral Hypersensitivity & Gut-Brian axis play a large role

4 IBS diagnosis IBS does not involve the immune system nor cause damage. No biomarker currently identified to diagnose IBS. The cause is unknown & there is currently no cure NICE guidelines recommend diagnosis is made by: excluding medical conditions considering symptoms in relation to ROME IV criteria

Exclude medical conditions: Coeliac disease IBD (Crohn's & Colitis) Bowel Cancers

5 Diagnosis medical investigations IBS can have identical symptoms to other conditions, it is essential to: 1. Exclude medical conditions: Coeliac disease IBD (Crohn's & Colitis) Bowel Cancers Gynaecological conditions (PID, ovarian cancer, endometriosis) 2. Investigate Red Flags : Anaemia Unintentional weight loss Rectal bleeding Family history Nocturnal diarrhoea

6 Diagnosis ROME IV criteria Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following criteria: 1. Related to defecation 2. Associated with a change in frequency of stool 3. Associated with a change in the form (appearance) of stool NB: criteria should be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. Lacy BE, Patel NK. (2017) Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome. Weber HC, ed. Journal of Clinical Medicine; 6(11):99. doi: /jcm

7 Diagnosis IBS subtypes Moayyedi P et al. Irritable bowel syndrome diagnosis and management: A simplified algorithm for clinical practice. United European Gastroenterology Journal. 2017;5(6): doi: /

8 Managing IBS If medical conditions are excluded, diet may help to manage symptoms. A diet low in FODMAPs is evidenced to significantly and consistently improve symptoms of IBS in 75% of people. It is currently the most well researched and strongly evidenced approach for managing IBS. Recommended as 2 nd line treatment for IBS (1 st line = general healthy eating): National Institute of Healthcare excellence (NICE guidelines) National institute of diabetes, digestive & kidney diseases (NIDDK) British Dietetic Association (BDA) New Zealand best practice guidelines Marsh et al. (2016): Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and metaanalysis. Eur J Nutr; April;55(3): doi: /s

9 What are FODMAPs? Short chain carbohydrates that are poorly absorbed in the small intestine & continue along the digestive tract. 1. FODMAPs are osmotic 2. FODMAPs are rapidly fermented by colonic microbiota

10 What are FODMAPs?

Alessio Fasano. Sci Am. 2009 Aug;301(2):54-61. Surprises from celiac disease.

11 Alessio Fasano. Sci Am Aug;301(2): Surprises from celiac disease. Bran the outer skin of the edible kernel is the fibre or roughage Insoluble, adds bulk and increases stool weight, decreases transit time. High in fructans & poorly tolerated in IBS Haska L, Nyman M, Andersson R Distribution and characterisation of fructan in wheat milling fractions. J Cereal Sci; 48: Germ the sprouting section of the seed Endosperm lower in fructans Milled to make wheat flour Fructan: bran and germ contain more fructan than endosperm, but make up less of conventional flour

12 Fructans in Wheat Fructans are chains of 2-10 fructose molecules with or without a terminal glucose molecule Since fructan chains cannot be separated by humans, they become indigestible carbohydrates that act as dietary fibre Many people will notice an increase in gas after eating foods high in Fructans People with IBS, who have visceral hypersensitivity feel this more than someone with low visceral sensitivity. Giovanni, B et al 2007: Mast Cell-Dependent Excitation of Visceral-Nociceptive Sensory Neurons in Irritable Bowel Syndrome; Gastroenterology, Volume 132, Issue 1, 26-37

containing grains are naturally higher in Fructans Switching to a gluten free diet

13 Grain Fructan Content The cut off for Fructans is 0.3g per serve Many gluten free grains are naturally lower in Fructans Many gluten containing grains are naturally higher in Fructans Switching to a gluten free diet will significantly lower Fructan load NB: 1 serve = 2 slices of bread or 1 cup of cooked grain Image ref: Monash University

14 Fructan equivalents in Food < 0.3g of Fructans per serve can be found in: 1 slice of wheat bread 2 slices of spelt or wheat sourdough bread 2 slices of FODMAP certified bread e.g. Bakers Delight, Brumby s, Alpine bread ½ cup wheat pasta ½ cup of rolled Oats

15 Fructan Sensitivity Fructan sensitivity is variable form person to person and can change over a life time. Since Fructans don t cause physical damage, management is based on minimising symptoms and optimising quality of life. Fructans provide nourishment for gut microbiota, as little as three months on a low FODMAP diet can cause changes in gut bacteria. Important to identify a persons threshold of tolerance and establish a balance between mild vs moderate vs severe symptoms. Goal: Minimise symptoms + optimise variety to Improve quality of life & ensure long term health & wellbeing

16 Fructan sensitivity Monash University quantified 0.3g of Fructans is well tolerated by 95% of people with IBS. Many people will tolerate more than this

17 Reported EXPERIENCE with threshold Low FODMAP Australia Facebook group poll 422 respondents How much wheat bread do you tolerate? 193 people (46%) tolerate 2 or more slices of wheat bread per serve. About 0.5g of Fructans or more. 67 people (16%) only tolerate 1 slice <0.3g 46% 40% None 162 people (40%) tolerate no wheat at all 1 slice NB: this is a Facebook group, many members are self diagnosed. Some could have undiagnosed coeliac disease or other intolerances. 16% 2 or more slices

18 Identifying FODMAP Tolerance Phase 1: Low FODMAP phase does removing high FODMAP foods result in a significant and consistent reduction in symptoms? Phase 2: Rechallenge phase Challenge each FODMAP subgroup to identify level of tolerance. Phase 3: Adapted low FODMAP phase: Reintroduce well tolerated FODMAP subgroups and establish modified FODMAP diet. NB: Rechallenge regularly to assess for changes in tolerances.

Trivia Question Fructans can be found in foods such as artichokes, leeks, garlic, onions (including spring onions), persimmon, rye, barley and wheat.

19 Trivia Question Fructans can be found in foods such as artichokes, leeks, garlic, onions (including spring onions), persimmon, rye, barley and wheat. What are three other non-grain foods or ingredients that contain Fructans? a. Pomegranate, avocado & pistachios b. Grapefruit, custard apple & inulin c. Dried fruit, chicory root & asparagus d. Wheat, beetroot & savoy cabbage

FODMAP Education Resource Pack The Everyday Nutrition Low FODMAP Resource Pack is a comprehensive briefcase to use with your clients through their FODMAP journey.

20 FODMAP Education Resource Pack The Everyday Nutrition Low FODMAP Resource Pack is a comprehensive briefcase to use with your clients through their FODMAP journey. It contains over 35 resources arranged into three broad phases of the diet. 1. Starting out strict & simple instructions, label reading, eating out, meal & snack ideas and more 2. Challenging Challenge instructions & schedules simple & strict options 3. Liberalization how to reintroduce, long term, fibre, calcium, vegan, vegetarian, gluten challenge, probiotics and more Available at & DINER for $49 Use code #DAA2018 for 20% off until this Saturday!

Identifying FODMAPs B/F: Weet bix + milk + banana + latte Low FODMAP swap: GF weet bix + lactose free milk Lunch: Sandwich (w/m bread) + chicken, lettuce, tomato, cheese Low FODMAP swap: Bakers

21 Identifying FODMAPs B/F: Weet bix + milk + banana + latte Low FODMAP swap: GF weet bix + lactose free milk Lunch: Sandwich (w/m bread) + chicken, lettuce, tomato, cheese Low FODMAP swap: Bakers Delight LoFo bread Dinner: pasta (large bowl) + chicken, pesto, zucchini, snow peas, spinach, cherry tomatoes Low FODMAP swap: Gluten free pasta & limit snow peas to 5 pods Snacks: muffin (café), apple, muesli bar, cheese + crackers, chocolate, chips Low FODMAP swap: h/m muffin with The Healthy Baker flour or FODMAP certified cookie/muesli bar e.g. Kez s Kitchen (gluten free) Carmen s (oat base no honey/inulin), low FODMAP fruit (check Monash app), rice crackers, dark chocolate is lower in lactose limit portion to <90g per serve, check for seasoning on chips no onion or garlic powder

Irritable Bowel Syndrome

Irritable Bowel Syndrome Irritable bowel syndrome (IBS) has a variety of symptoms, most commonly cramping, abdominal pain, bloating, constipation, and diarrhea. Symptoms can vary from person to person,