04. ILSI GLNC CHO FODMAPS story - J Muir.pdf

Medicine, Nursing and Health Sciences

What are the risks/benefits of

fermentable carbohydrates?

The FODMAP story. Dr Jane Muir

ILSI SEAR Aasia (www.ilsi.org/SEA Region) and GLNC (www.glnc.org.au) - Carbohydrate intakes - high, low or irrelevant? Australia - March 2013

BENEFITS of Restricting some carbohydrates:

Management of Irritable Bowel Syndrome (IBS)

• It is the most common reason for people being referred

to a specialist gastroenterologist.

• In Australia IBS affects ~ 15% of the population

• Characteristic gastrointestinal symptoms include;

abdominal pain, bloating, wind, constipation and/or

diarrhoea.

2


What are the causes of IBS?

• Altered gut mircroflora.

• Presence of small intestinal overgrowth of gut bacteria

(SIBO).

• Hypersensitivity of the gut to luminal distension.

• Some foods known to trigger symptoms

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Benefits of Restricting some carbohydrates:

What are the treatments for IBS?

• Treatment is aimed at the control of the symptoms.

• The team at Monash have developed the Low FODMAP

diet therapy that is based on restricting certain

carbohydrates from the diet.

• what does FODMAP stand for…………..

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FODMAPs

• An ‘umbrella term’- describe the range of short-chain

carbohydrates that can be poorly absorbed and rapidly

fermented

• It stands for…

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6

FODMAPs Fermentable


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FODMAPs Fermentable

Oligosaccharides

Fructans (including fruct0-oligosaccharides (FOS), & galacto-0ligosaccharides

(GOS)


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FODMAPs

Fermentable

Oligosaccharides

Disaccharides

Lactose


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FODMAPs

Fermentable

Oligosaccharides

Disaccharides

Monosaccharides Free Fructose

(fructose in XS of glucose)


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FODMAPs

Fermentable

Oligosaccharides

Disaccharides

Monosaccharides

And

Polyols Sorbitol, mannitol


http://images.google.com.au/imgres?imgurl=http://www.bctree.com/images/photos/summer-peaches.jpg&imgrefurl=http://www.bctree.com/products/summer/peaches.php&usg=__-Wo8fwVIJMYFA0j-AFC1YM4DgY0=&h=360&w=360&sz=21&hl=en&start=1&tbnid=Cub6W2R7WwLOxM:&tbnh=121&tbnw=121&prev=/images?q=Peaches&gbv=2&hl=en

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Small intestine

FODMAPs

Large intestine

gas production

water delivery

Luminal distension

Altered motility

Pain, bloating, distension, wind,

constipation +/- diarrhoea

How FODMAPs act in the gut.


12 12

0 5 10 15 20

watermelon

pineapple

pear

peach

orange

mango

kiwifruit

grapes

banana

apple

Excess fructose

Polyols

Fructans

Gram FODMAP/serve

Levels of FODMAPs in fruit


13 13

0 0.5 1 1.5 2 2.5 3

zucchini

onion

mushroom

lettuce

garlic

carrot

capsicum

broccoli

bok choyExcess fructose

Polyols

GOS

Fructans

Gram FODMAP/serve

Levels of FODMAPs in vegetables


14

0 1 2 3 4

all brancornflakes

mueslioats

rice bubblessustainweetbix

GF breadrye bread

spelt breadwhite bread

wholemeal bread

couscousgnocchi

pasta - gluten freepasta - quinoapasta - wheat

Rice, brownRice, white

Excess fructose

Polyols

GOS

Fructans

Gram FODMAP/serve

Levels of FODMAPs in grains/breads/cereals


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The Low FODMAP diet


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References

• Skoog et al Neurogastroenterol 2008; Beyer et al JADA 2005; Choi et al Am J Gastroenterol 2003;

• Goldstein et al Isr Med Assoc J 2000; Rumessen et al Am J Clin Nutr 1998;

• Evans et al Scand J Gastroenterol 1998; Mishkin et al Dig Dis Sci 1997;

• Fernandez-Banares et al Gastroenterol 1991; Rumessen et al Gastroenterol 1988;

• Stone-Dorshow et al Am J Clin Nutr 1987

• A low FODMAP diet improves symptoms in 74% of IBS patients (Shepherd et al JADA 2006)

• A low FODMAP diet improves functional symptoms in 70% of IBD patients (Gearry et al JCC 2009)

• Rechallenge of fructose, fructans or both, results in significant exacerbation of symptoms after a low FODMAP diet. (Shepherd et al CGH 2008)

• Digestion and fermentation of FODMAPs: A study in volunteers with an ileostomy (Barrett et al. Aliment Pharmacol Ther. 2010; 31:874-82.)

• Breath hydrogen and abdominal symptom production in volunteers consuming foods either low or high in FODMAPs (Ong et al. J Gastroenterol. Hepatol. 2010;25:1366-1373.)


Is the Low FODMAP diet for the

long-term?

• No - not for the long-term

• The Low FODMAP diet is followed for 2-6

weeks, followed by review by a dietitian

• …this is why it important to be aware of potential

downsides of dietary restriction of some carbohydrates

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Potential RISKS of Restricting FODMAP

carbohydrates:

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28th February 2011 Presentation title 19

• Substrates of bacterial fermentation SCFA

– Butyrate important for colonic health (antinflammatory & anticarcinogenic)

• Prebiotics (GOS, fructans) selectively promote

growth of ‘good’ bacteria putative health benefits e.g.,

– Bifidobacteria

– Butyrate-producing bacteria (F. prausnitzii, C. coccoides)

Potential health benefits of FODMAPs

The low FODMAP diet may have a negative

impact on these


Evidence for potential ‘downside ‘ of the

low FODMAP diet

• Staudacher et al (King’s College Group)- With low FODMAP diet showed

improved symptoms in IBS patients over 4 weeks. However, lower

numbers of bifidobacteria with low FODMAP diet in patients with IBS. (ref.

Staudacher et al Journal of Nutrition, 2012;142;1510-8.)

• Halmos et al (Monash University Group) -Showed improvements in

symptoms in IBS patients over 3 weeks on the low FODMAP diet. However,

on the low FODMAP diet, proportion of ‘good’ bacteria decreased-

Bifidobacteria and Butyrate-producing (F prausnitzii, C. coccoides). (manuscript in preparation)-

28th February 2011 Presentation title 20


Presentation title 21

Summary:

• BENEFITS- of restricting FODMAP carbohydrates for patients with

IBS

• RISKS- However, restricting FODMAPs – also may lead to loss of

prebiotic effect, this may have health implications in the long term.

• RISKS – This may also have implications for individuals following a gluten-free, wheat-free diets



0 1 2 3 4 5

rye

Kamut

wheat

spelt

sorghum

teff

quinoa

buckwheat

maize flour

chia

oat

rice

corn flour

GOS

Fructan

(Muir, Suter, Mills, Biesiekierski, Bekes: unpublished data)

FODMAP Content

Low FODMAP

Grains suitable for

people with IBS

FODMAP content of grains



0 1 2 3 4 5

rye

Kamut

wheat

spelt

sorghum

teff

quinoa

buckwheat

maize flour

chia

oat

rice

corn flour

(Muir, Suter, Mills, Biesiekierski, Bekes: unpublished data)

FODMAP Content

Low FODMAP

Grains suitable for

people with IBS

FODMAP content of grains

Gluten free grains


Presentation title 24 Presentation title 24

Summary (cont.):

POTENTIAL RISKS

• Low FODMAP diet (and gluten-free diet) cannot be recommended

for health in asymptomatic population.

• Strategies reversing the changes in microbiota should be

investigated.


Research Team- Monash


Acknowledgements The Monash team: Peter Gibson, Jaci Barrett,

Emma Halmos, Jessica Biesierkierski, CK Yao, Kelly

Liels, Debbie King, Vicki Power, Sue Shepherd, Jessie

Mills, Nia Rosella, Rosemary Rose, Richard Gearry,

Peter Irving, Sally James, Debbie Nathan, Melissa

Haines, Evan Newnham, Catherine Croagh, Daniel van

Langenberg, Derrick Ong, Shaylyn Mitchell,

CSIRO: Dr Tony Bird, Dr Claus Christophersen

The funding: NHMRC, ARC, Eva and Les Erdi

Foundation, Monash University,

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04. ILSI GLNC CHO FODMAPS story - J Muir.pdf