2013 The Importance & Practical Implementation of the Low Fodmap Diet

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The Importance and Practical Implementation of the Low FODMAP Diet Marianne Williams, BSc Hons, RD, PGCert Allergy Community Gastroenterology Specialist Dietitian, Somerset Partnership NHS Foundation Trust, and Secretary of the BDA Food Allergy & Intolerance Specialist Group

What is the FODMAP diet?

In the UK, we first started to hear about a new revolutionary diet for irritable bowel syndrome (IBS) in 2009, when a team from Guys & St Thomas’ NHS Foundation Trust and Kings College London began investigating Australian research into the Low Fermentable Carbohydrate Diet, also known as the ‘Low FODMAP Diet’.

The term ‘FODMAP’ was simply an acronym created from the list of specific foods that had been found to cause physiological effects in IBS patients, namely Fermentable, Oligo-saccharides, Di-saccharides, Mono-saccharides and Polyols.

FODMAPs appear in a range of foods, including wheat, certain fruit and vegetables, and some milk-based products. A full range of the foods is well described elsewhere1 and in patient resources. Much of the data thus far comes from one centre in Australia, and more UK composition data is required. In Western Europe, oligo-saccharides such as ‘fructans’ and the mono-saccharide, ‘fructose’, are the most common FODMAPs in the diet,1 with wheat being the largest contributor of fructans in the UK. The diet was developed by a team from Monash University in Melbourne, Australia, and started to gain prominence following the publication of research in 2008, showing that dietary fermentable carbohydrates (FODMAPs) did indeed act as symptom triggers in IBS patients.2 Research has followed which shows that the diet is not only useful in IBS,3 but that it could also be helpful in ameliorating the functional gut symptoms in other conditions such as inflammatory bowel disease.4 Potential benefits in enteral feeding diarrhea,5, 6 and

reducing stool frequency in high output ileostomy or in ileal pouch patients, is also reported although more data is required.7 The mechanisms by which these fermentable carbohydrates provoke gut symptoms is due to two underlying physiological processes: firstly, these carbohydrates are indigestible and subsequently fermented by the bacteria in the colon which leads to gas production. This gas can alter the luminal environment and cause visceral hypersensitivity in those who are susceptible to gut pain.8 Secondly, there is an osmotic effect whereby fermentable carbohydrates increase water delivery to the proximal colon leading to altered bowel habit.9 Research in both Australia and the UK is now suggesting that in excess of 75 per cent of IBS patients will improve on the FODMAP diet.2, 3 In response to the research and an obvious need for trained healthcare professionals nationally, a FODMAP training course for UK dietitians was launched in 2010.

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Big Story | Low FODMAP Diet

Clinical Commissioning Groups: Why is the FODMAP diet potentially important to a financially cash-strapped NHS? Functional bowel disorders, and specifically IBS, affects up to 10 to 15 per cent of the general population in industrialised countries.10 Research shows that IBS patients are costly:10, 11 IBS patients incur 51 per cent more total costs per year than a non-IBS control group:10, 12 Lieberman showed in 2005 that 23 per cent of all colonoscopies were for IBS patients;13 while other research indicated that as much as 25 per cent of gastroenterology outpatients were given a principal diagnosis of IBS.14 Since 2008, the UK financial crisis has meant that secondary care gastroenterologists are under increasing pressure to reduce their outpatient referrals.

Hence, a successful dietary approach for ‘non-red flag’ IBS patients in primary care could mean significantly reducing their costs15 (NB: ‘Non red flag’ patients are those patients without signs or symptoms that may be suggestive of an alternative pathology such as bowel cancer). An audit of gastroenterology outpatients in two Somerset hospitals demonstrated that over £100,000 could potentially be saved in secondary care if specialist primary care dietitians used dietary intervention as a first line approach with non-red flag IBS patients. But the savings do not end there: improved patients outcomes will also inevitably result in reduced medication costs, reduced GP visits, and reduced revolving door costs – a scenario that may be appealing to many Clinical Commissioning Groups throughout the UK.

Practical Implementation of the Low FODMAP Diet Good compliance is required for optimal effectiveness of the low FODMAP diet, meaning that patient motivation is key.3 Indeed, from our clinical experience in Somerset, having advised over 250 patients on a low FODMAP diet, we would agree that motivation and the level to which symptoms affect quality of life is fundamental to dietary adherence, i.e. the lower the quality of life, the more likely the patient is to adhere to the diet.

The low FODMAP diet is a complex diet, which requires sufficient initial consultation time, i.e. 45 minutes to 1 hour,16, 17 and the expertise of a FODMAP trained dietitian18 with good communication skills.3 Appropriate tools, such as symptom questionnaires and the Bristol Stool Chart, should be used to assess symptom severity and stool frequency and output. A carefully taken diet and medical history is vital to ensure that the patient is suitable for this dietary approach and that there is not another underlying cause for their symptoms, e.g. gastrointestinal allergy, coeliac disease, or red flags requiring further investigation.

Detailed patient literature is vital3 and research showing the effectiveness of the diet in the UK has so far utilised high quality resources based on the most recent composition data available. When patients use these resources they find the diet easy to understand and follow.3 It is strongly advised that the resources are always used in conjunction with dietetic input as the questions from patients are often numerous and can be challenging. This combination of resources with dietetic input is important and will lead to a higher level of adherence to the diet.1 Supplying contact details for the dietitian may also make the patient feel more

confident in their ability to follow the diet.

Explanations for the scientific basis of the diet in layman’s terms provide the patient with a fuller understanding and are likely to increase compliance.1 Practical help with lists of suitable foods, showing packaging/photos of ideal alternatives, meal plans and ideas for eating away from home, all provide positive food messages that make the patient more confident in being able to follow the diet and allow for better self-management.1

Our experience in the Somerset Dietetic-Led Gastroenterology Clinic of implementing the low FODMAP diet IBS patients are seen initially in general community dietetic clinics for first line advice and only sent to our specialist dietetic-led gastroenterology clinic if this fails to help. In our experience, patients who attend this specialist clinic are generally keen and motivated to try alternative interventions.

In Somerset, over 85 per cent of our patients will complete their dietary intervention. Of those patients who were referred for IBS and who completed the diet, over 78 per cent have shown positive outcomes. These are similar results to those found in Australia and the UK.2, 3 Within the clinical environment we have found it useful to advise patients to read the literature numerous times and not to attempt to start the diet for seven days. This allows the patient time to assimilate the complexities of the diet, ask questions if necessary, and to stock their food cupboards appropriately before commencing. A review appointment is booked at the end of the initial appointment for eight weeks time, with the date

Table One: Somerset Clinical Experience: What factors appear to effect whether a patient completes FODMAP dietary intervention?

1. Patient motivation is paramount – the more severely their quality of life is affected then the more likely they are to comply with the diet.

2. Patient confidence in the practitioner ie. does the patient ‘believe’ what they are being told? This will be heavily influenced by the confidence with which the dietitian explains the diet and their ability to answer all associated questions. Having FODMAP specific training is vital.

3. A specialist dietitian will need to have sufficient time (45 minutes to 1 hour) to take a full case history and to explain the dietary intervention and the rationale for the diet in layman’s terms.

4. A specialist dietitian will need to have access to clear, professionally produced information booklets written in layman’s terms. These will reinforce the information given in the initial consultation and act as a reference tool for the patient throughout the dietary intervention period allowing for better patient self management.

5. A specialist dietitian will increase patient confidence by explaining that the diet is being thoroughly researched within the medical profession and that it is not a ‘fad’ diet.

6. Patients benefit from having realistic expectations, which involves the specialist dietitian being open about the rates of success and failure of the diet i.e. roughly 75% success/25% failure. It is also important that the dietitian explains that symptoms are unlikely to completely resolve but may alter to a level that significantly improves quality of life.

7. Patients are likely to benefit from being asked to read and re-read the booklet at home until it is fully understood and not to start the diet for 1 week to allow time to assimilate the information and prepare their food stores – this reduces anxiety about the apparent complexity of the diet at the initial appointment.

8. Patients should be given the dietitians contact email so that they can ask questions and so that they do not feel ‘cut off’ from dietetic support.

9. Patients should be given photo and information sheets/booklets of suitable products so that shopping seems less daunting – this allows for better patient self management.

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Low FODMAP Diet | Big Story and time agreed by the patient. This potentially leads to a subconscious expectation that the diet will be completed.

If symptom response has occurred after eight weeks then reintroduction of fermentable carbohydrates to tolerance is encouraged.

The challenge process is clearly explained and resources are provided at the review appointment.

Even when patients have difficult work circumstances and limited time availability, motivated patients will generally complete the dietary intervention. When the patient leaves the initial consultation we are often concerned that they will fail to follow the low FODMAP diet, but they constantly surprise us. However, their symptoms need to be having a significant effect on their quality of life for them to adhere to the diet strictly for eight weeks. Most of the patients we see have already spent many months or years seeking help and are grateful for professional, constructive and clear rationalised advice and support. Many are particularly keen to try a dietary approach,19 and so are very willing to embrace the complexities of the low FODMAP diet. See Table one.

Recording before and after symptom scores also helps to show the patient just how much they have improved. They complete the ‘after’ scores without visual reference to their initial scores to prevent bias. It is often difficult for them to remember just how bad their symptoms were eight weeks previously.

Equally, these sheets also act as a good benchmark to show if the diet has not worked and when an alternative dietary intervention or referral may be appropriate.

As we are a primary care based clinic, many of our patients have never been assessed in secondary care and may arrive with a vague diagnosis of IBS. As a result, we will initially check for red flags (see Table Two) to determine if the patient should be referred on for further investigation. Our case history will also assess the patient for a differential diagnosis, including gastrointestinal allergy or coeliac disease – the symptoms are almost

identical. We have found in our latest audit that of those sent with an initial diagnosis of IBS, over seven per cent were in fact allergy patients, and just over two per cent were undiagnosed coeliac patients.

Final thoughts…

This is an exciting time for dietitians and a golden opportunity for the dietetic profession to be at the forefront of important changes in clinical practice and research. As more dietitians are FODMAP trained in the UK and more specialist clinics are established, it would seem prudent for us to look further into compliance, the reality of financial savings in the NHS, and long-term outcomes. It is a vital opportunity for integration between primary and secondary care and a chance for dietitians to lead the way in the treatment of this chronic and debilitating condition.

However, be aware that poor quality consultations with poor quality resources, or the handing out of dietary literature without the input of a dietitian, run the risk of leading to poor patient results, disillusionment, and, will ultimately undermine the credibility of what is a highly successful treatment for IBS.1 It would perhaps be a false economy to save money on resources or expect untrained or poorly trained dietitians to treat these patients.

After all, would we consider it reasonable to ask an untrained dietitian to undertake any other specialist dietetic role? Patients will often email numerous questions and for successful implementation of the diet the dietitian needs skilled training and access to specialist dietetic support and resources.

As the emphasis for outcome measures intensifies, it becomes increasingly important that we can show clear consistent outcome success. Implementing this diet professionally and giving patients good quality practical support and guidance can only benefit the long-term security of our profession in an ever-changing world.

References: 1. Gibson PR, Shepherd SJ (2010). Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology.; 25(2): 252-8. 2. Shepherd SJ, Muir JG, Gibson PR (2008). Dietary Triggers of Abdominal Symptoms in Patients with Irritable Bowel Syndrome: Randomized Placebo-Controlled Evidence. Clinical Gastroenterology and Hepatology.; 6(7): 765-71. 3. Staudacher HM, et al (2011). Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. Journal of Human Nutrition and Dietetics; 24(5): 487-95. 4. Gearry RB, et al (2009). Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease - a pilot study. Journal of Crohns and Colitis.; 3(1): 8-14. 5. Barrett JS, Shepherd SJ, Gibson PR (2009). Strategies to Manage Gastrointestinal Symptoms Complicating Enteral Feeding. Journal of Parenteral & Enteral Nutrition; 33(1): 21-6. 6. Halmos EP, et al (2010). Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohyrates (FODMAP) content of the formula. Aliment Pharmacol Ther.; 32(7): 925-33. 7. Croagh C, et al (2007). Pilot study on the effect of reducing dietary FODMAP intake on bowel function in patients without a colon. Inflammatory Bowel Diseases.; 13(12): 1522-8. 8. Ong DK MS, et al (2010). Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. Journal of Gastroenterology and Hepatology.; 25(8): 1366-73. 9. Barrett JS, et al (2010). Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon. Aliment Pharmacol Ther.; 31(8): 87482.10. Maxion-Bergemann S, at al (2006). Costs of irritable bowel syndrome in the UK and US. Pharmacoeconomics.; 24(1): 21-37. 11. Wells NE, Hahn BA, Whorwell PJ (1997). Clinical economics review: irritable bowel syndrome. Aliment Pharmacol Ther.; 11: 1019-30. 12. Longstreth GF, et al (2006). Functional bowel disorders. Gastroenterology.; 130(5): 1480-91. 13. Lieberman DA, et al (2005). Utilization of colonoscopy in the United States: results from a national consortium. Gastrointestinal Endoscopy.; 62(6): 875-83. 14. Inadomi JM, Fennerty MB, Bjorkman D (2003). Systematic review: the economic impact of irritable bowel syndrome. Aliment Pharmacol Ther.; 18: 671-82. 15. Irving PM. Email Personal Communication. In: M W, editor. London2010. 16. British Dietetic Association (2010). UK evidence-based practice guidelines for the dietetic management of irritable bowel syndrome (IBS) in adults. Birmingham. 17. NICE (2008). Irritable Bowel Syndrome: Costing report implementing NICE guidance. London. 18. McKenzie YA, et al (2012). British Dietetic Association evidence-based guidelines for the dietary management of irritable bowel syndrome in adults. Journal of Human Nutrition and Dietetics; 25(3): 260-74. 19. Halpert A, et al (2007). What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ). The American Journal of Gastroenterology.; 102(9): 1972-82.

Table Two: Red Flags/Alarm Symptoms in IBS patients that may be suggestive of need for onward referral for further investigation for alternative pathology • • • • • • •

Blood in stools Unintentional weight loss Nocturnal symptoms Unexplained anaemia Significant family history of bowel or ovarian cancer Sudden onset of symptoms Onset of symptoms over the age of 45 years

Useful resources and information • Kings College London: this institution runs training for UK dietitians and their website has general information on the FODMAP diet including a detailed list of references. They also produce a series of 3 useful patient information booklets which can be purchased by dietitians. These booklets are particularly helpful for patient self management and they cover the basis of the diet, the suitable alternative foods and the reintroduction process. www.kcl.ac.uk/fodmaps • Monash University, Melborne Austrialia: This website has clear, reliable basic information on the FODMAP diet and may well be a helpful link for patients when they are first investigating the background to the diet. http://med.monash.edu.au/cecs/g astro/fodmap/ • Monash University FODMAP mobile phone app: This was released in December 2012. It is presently only available for iPhones but is planned for release on android phones and the iPad shortly. This may be useful for patient self-management after the initial consultation and during the reintroduction phase although the emphasis is on Australian foods.

Patients will still require in-person dietetic support.

• British Dietetic Association IBS Fact Sheet: Newly revised in January 2013 and available for anyone to download from the BDA website.

This is an ideal first line advice sheet for IBS before the FODMAP diet is being considered and would be useful for GPs, community dietitians and other healthcare professionals. www.bda.uk.com/foodfacts/ • Nutrition and Diet Resources UK (NDR-UK) are in the process of producing an IBS diet sheet called Healthy Living and Lifestyle Advice for Irritable Bowel Syndrome. Due to be published shortly. Code number: 9040 • IBS Network: Very useful resource covering all treatments for IBS and a good support service for IBS patients. www.theibsnetwork.org • British Dietetic Association Professional Guideline 2010: UK evidence-based practice guidelines for the dietetic management of irritable bowel syndrome (IBS) in adults. This is an extremely useful document for dietitians or other healthcare professionals who wish to look at the evidence surrounding the different dietary approaches to IBS treatment.

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