Low FODMAP Dietary Approach For FGD/IBS. Our Experience. Charlotte McCamphill 19 th February 2015

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1 Low FODMAP Dietary Approach For FGD/IBS Our Experience Charlotte McCamphill 19 th February 2015

2 CONTENTS What Is IBS What are FODMAPs Service Provision Audit Results Future Work

3 WHAT IS IBS The Rome III diagnostic criteria defines Irritable bowel syndrome (IBS) as: Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with one or more of the following: Improvement with defaecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool. (Gastroenterology 2006; 130: )

4 WHAT IS IBS IBS is best viewed as an interaction of important biological and psychosocial factors. Altered motility, visceral hyperalgesia, disturbance of brain-gut interaction, abnormal central processing, autonomic and hormonal event, genetic and environmental factors, post infections sequels, and psychosocial disturbance are variably involved, depending on the individual. (Gastroenterology 2002; 123: ).

5 ECONOMIC CONSEQUENCES 10-15% in industrialised countries NHS spending 45.6 million per year on IBS (Inadomi, 2003). Approximately 12% of all GP visits are due to IBS. Of the disorders seen by Gastroenterologists 35% are for IBS (Russo et al, 1999). 49% of clients had blood tests 47% having imaging and endoscopic procedures 75% of clients using prescription drugs. (Maxion- Bergemann et al, 2006)

6 EVIDENCE FOR FODMAPS An innovative approach to the treatment of IBS has recently been developed that comprises a reduction in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) in the diet (Barrett & Gibson, 2007; Shepherd et al., 2008). Staudacher et al (2011) found through a UK service evaluation that composite symptom score data showed better overall symptom response in the low FODMAP group (86%) compared to the standard group (49%, P < In 2012, Staudacher et al completed the first randomised controlled trial (RCT) of a low FODMAP diet versus controls and found that 68% of clients reported adequate relief of symptoms after 4 weeks, compared to 23% in control. British Dietetic Association (BDA) 2010 developed a professional guidance document on how to achieve successful dietary management of IBS across the UK. The second line of advice refers to advanced dietary interventions to improve symptoms based on dietary fibre, fermentable carbohydrates and probiotics

7 WHAT ARE FODMAPS FODMAPs are a group of short chain fermentable carbohydrates which are poorly absorbed within the gastrointestinal tract. FRUCTANS POLYOLS GOS They are osmotically active and undergo bacterial fermentation, leading to loose stools and gas production (Barrett et al., 2010; Ong et al., 2010). FRUCTOSE FODMAPS LACTOSE

8 SERVICE PROVISION Training from September January 2013 Referrals all received via Dr Graham Morrison Consultant Gastroenterologist Funding initially for 6 months (pilot audit period) February August 2013 Further funding from August 2013 to October 2014

9 LOCAL CAREPATHWAY Initial Appointment (duration 1.0 hours) Second appointment 8 weeks post initial (duration 45 minutes) Third and Final Appointment 4-8 weeks post second appointment (duration 45 minutes)

10 Audit Results

11 ATTENDANCE RATES A total of 16 out of the potential 19 clients were included in the audit data. 94.7% (18/19) at appointment one. 5.6% (1/18) of clients that did attend appointment one, were only seen once as it was not appropriate to proceed further. Attendance at second OPD was 82.4%. However when these clients were contacted via telephone, 2/17 had forgotten about the appointment due to not receiving a reminder letter via central bookings in the post, both agreed to a further 3 rd appointment. 1/17 patients failed to respond to telephone calls and messages and thus were discharged. Potential attendance rate of 94% (16/17) at appointment two. 14/16 had three appointments, thus 88% adherence to the care-pathway.

12 RESULTS

15 % Weight loss between 1st and 3rd OPD 8 7 The average BMI at the first appointment (16 clients) was 27.62kg/m². The range was from 21.48kg/m² 37.5kg/m² % Weight loss between 1st and 3rd OPD 1 The average BMI at the third appointment (14 clients) was kg/m 2. The range was from kg/m Average 3.55% weight loss. 1/8 found diet restrictive, 7/8 had reduced snacks

18 Was CRP Level Checked? Was ESR Level Checked? , 88% 12 12, 75% , 25% 2 2, 88% 2 0 Yes No 0 Yes No

20 Subjective question Asked as part of my assessment Clients own perception

21 Medications Number of Clients who Previously Trialled Taking at 1st Appointment Taking at 2nd Appointment Taking at 3rd Appointment Antispasmodics Laxatives Proton Pump Inhibitors Tricyclics SSRI Anti-Diarrheal

22 Some expressed immediate improvement Others took longer

23 SYMPTOM EVALUATION REPORT Symptom Improvement Between Appointment one and three(excluding those who reported not having the symptom). The most prominent improvement in symptoms was: 79% improvement in flatulence/wind 79% improvement in bloating/distention 71% improvement in heartburn 64% improvement in incomplete evacuation 64% improvement in the urgency to open bowels 64% improvement in stomach/abdominal gurgling 64% improvement in pain/bloating 57% improvement in tiredness/lethargy 57% improvement in nausea 50% improvement in acid regurgitation 50% improvement in belching/burping

24 PATIENT SATISFACTION QUESTIONNAIRE AT APPOINTMENT 3 85% improved in bloating 77% flatulence/wind improvement 70% improved in abdominal/discomfort 69% diarrhoea improvement 62% improvement in energy levels 46% improvement in constipation 46% improvement in nausea

25 OVERALL QUESTION

26 PATIENT SATISFACTION QUESTIONNAIRE At the 3rd appointment clients involved in the audit made the following comments: I found the written information easy to understand I found the diet easy to follow Overall I am satisfied with the improvement in my symptoms % % % Strongly disagree 1 8% 0 0% 1 8% Disagree 0 0% 0 0% 0 0% Neutral 2 15% 2 15% 2 15% Agree 4 31% 6 46% 5 38% Strongly agree 6 46% 5 39% 5 38%

27 Was the Client Re-referred back to the Gastro Team by the Dietitian? No 81% Not Recorded 6% Yes 13%

28 CONCLUSION Job satisfaction! Gastroenterology Support Excellent response rates Need to be appropriate referrals Need dedicated time for each appointment

29 FUTURE WORK Business Case for further funding Carepathway for GP s for IBS/FGD clients Relook at our carepathway/protocol Regional Care Pathway for FGD Future audits/service evaluation/patient satisfaction questionnaires

30 Thank You

The long-term impact of the low-fodmap diet for management of irritable bowel syndrome. Dr Miranda Lomer RD.

The long-term impact of the low-fodmap diet for management of irritable bowel syndrome Dr Miranda Lomer RD Email: miranda.lomer@kcl.ac.uk What is IBS - ROME IV Criteria A functional bowel disorder in which