Diet Tips:NEW PUBLICATION ALERT: Consistent prebiotic effect on gut microbiota with altered FODMAP intake in patients with Crohn’s disease: a randomised, controlled cross-over trial of well-defined diets

By CK Yao (Accredited Practising Dietitian, PhD candidate)

Research by our team has recently identified that a reduction in FODMAP intake in individuals with Crohn’s disease who were in remission produced significant changes in the gut bacteria, particularly selected species with beneficial roles in gut health.

The effectiveness of a low FODMAP diet therapy in inflammatory bowel disease (IBD) had only been explored in a group of patients with IBS-like symptoms and inactive IBD. Considerable improvement in symptoms occurred in > 50% patients after 6 weeks of the diet. However, it is not known whether a low FODMAP diet there may be potential negative changes as seen in a recent study in IBS. An ‘imbalance’ in gut bacteria may already be occurring in some individuals with inflammatory bowel disease.

We recently studied the habitual FODMAP intake and gut bacteria of 8 participants with stable Crohn’s disease and the effects of altering their diets. They were fed diets containing either low FODMAP or a ‘typical Australian’ diet (see sample meal plan) for 3 weeks, followed by a 3-week break before crossing over to the other diet. Daily gut symptoms were measured as well as changes in stool bacteria during both dietary periods.

Sample meal plan	Typical Australian diet	Low FODMAP
Breakfast	Honey quick oats or wheat flakes with dried fruit cereal with ½ cup lactose-free milk Packaged peaches	Brown sugar and cinnamon quick oats or rice bubbles with ½ cup lactose-free milk 2 kiwi fruit
Morning tea	Lactose-free yoghurt 2 rye vita crackers with cheese	Lactose-free yoghurt 2 rice cakes with cheese
Lunch	Wheat sandwich Vegetable fritata Apple juice	Spelt sandwich Low FODMAP vegetable frittata Cordial
Afternoon tea	Pear 2 chocolate biscuits	Banana 2 gluten-free chocolate biscuits
Dinner	Braised lamb shanks with vegetables Salmon and vegetable couscous	Braised lamb shanks with low FODMAP vegetables Salmon with low FODMAP vegetables and quinoa
Supper	Apple sorbet	Raspberry sorbet

Study findings:

•       When on a typical Australian diet, there was a significant increase in beneficial bacteria associated with favourable health outcomes compared to a low FODMAP diet, consistent with a ‘prebiotic’ effect.
•       However, overall symptoms, abdominal pain, bloating and excess flatulence were almost doubled than symptoms on a low FODMAP diet.
• Interestingly, the habitual FODMAP intake in participants with Crohn’s disease was low, similar to levels on a low FODMAP diet. Not surprisingly, the low FODMAP diet did not improve the severity of gut symptoms compared to symptoms on their habitual diet.  

Take home messages:  A high FODMAP diet may produce beneficial prebiotic effects for gut health in Crohn’s disease. It suggests that trialling this diet during periods of active inflammation may not necessarily be ideal for the large bowel.  On the contrary, a low FODMAP diet may be beneficial in reducing residual IBS-like symptoms in individuals with inactive Crohn’s disease.  A specialist gastrointestinal dietitian will be able to advise on finding a balance between consuming adequate prebiotic FODMAPs and maintaining good symptom control.

Read the full article here.

 

Diet Tips:Timing of symptoms

By Dr Jaci Barrett (APD)

IBS is very common, but the symptoms are varied – constipation, diarrhoea, alternating bowel habit, bloating, abdominal distension, abdominal pain, excessive gas and borborygmi (intestinal noises). Some people experience all of these symptoms at some time or another, while others have more specific symptoms, for example where bloating is the major symptom. When symptoms are experienced, people often consider what they most recently ate to determine the trigger food. Were there FODMAPs in that meal? What other foods could have contributed? Many times we hear patients state that within minutes of food hitting their stomach, they are on the toilet with urgency, diarrhoea and abdominal cramps. Is this possible?

Let’s consider the anatomy of the human gastrointestinal system:

Bowel transit studies indicate that in healthy individuals, the time taken for a substance to move from the mouth to the anus is somewhere between 12 and 48 hours.

The small intestine is particularly long – 6 metres in fact. The large intestine is ~1.5 metres long. So given the time it takes for food to move through the gut, symptoms experienced immediately after swallowing a suspect food cannot be attributed to the fermentation of FODMAPs ….

So how does this immediate symptom induction occur in some people?

The most likely explanation is the impact of hormones and nerve regulators that are triggered when we eat. For instance, when food enters the stomach, hormones such as cholecystokinin and secretin are released. These hormones stimulate the production of enzymes that aide digestion. In addition, when the stomach is stretched by the entry of food, nerves in the digestive system are stimulated. These nerves stimulate the movement of intestinal muscles which push food and digestive juices through the gut.

Because digestion takes many hours to days, the intestinal tract is always full of digestive contents from previous meals, and as a meal is consumed, these existing intestinal contents are moved through the intestines. So if the existing intestinal contents contain FODMAPs or other problem food components, symptoms may be experienced upon eating that have nothing to do with the current meal and everything to do with the previous meal/s. These delayed symptoms can be confusing and may have you pinpointing the wrong trigger food.

So what is the take home message? Consider previous meals you have eaten and whether they could have played a role, or whether there are other complicating factors such as stress that has had an impact on bowel function. If you are still confused and unable to work out what is causing your symptoms, keep a list of foods you have eaten over the 48 hours prior to experiencing symptoms and show this to your dietitian to utilise his/her food detective expertise!

 

 

Diet Tips:Alleviating Symptoms Part 3

Abdominal Pain and Bloating
By Shirley Webber

This week we are highlighting some strategies to manage abdominal pain and bloating that generally occur due to a build up of gas in the intestinal tract. These are the most common IBS symptoms.

·       Often a heat pack placed on the area of pain can help to loosen up the muscles and alleviate some of the pain and discomfort with cramping. A heat pack also allows more blood to flow to the area where the heat is placed and can assist in relieving the cramping.

·       Over the counter medication such as Buscopan or Mintec may help with managing symptoms. Ask your pharmacist what they would recommend.

·       Stretch it out – sometimes a bit of Pilates or yoga stretching can help with relieving some of the gas that is built up in the gastrointestinal tract reducing the pressure on the gut and therefore reducing the pain.

·       Better out than in. If you do have gas then it is okay to let it out. If you’re in a closed environment and feeling uncomfortable to deflate, go for a walk outside or move away from others. Remember gas is a sign of a healthy gut – see a previous blog post on this http://fodmapmonash.blogspot.com.au/2016/02/a-bit-of-bloating-is-beneficial.html

           

Diet Tips:NEW US RESEARCH: The Low FODMAP diet superior for the relief of abdominal pain and bloating

The Low FODMAP Diet & mNICE Diet Compared

By Dr Jane Varney

 

An interesting study was published by our colleagues at the University of Michigan this week (1). The US study compared the effect of two dietary interventions on IBS symptoms in people with diarrhoea predominant IBS (IBS-D). The interventions in question were the low FODMAP diet and a more traditional dietary approach, known as mNICE (modified guidance from the National Institute for Health and Care Excellence).

Ninety-two eligible subjects were recruited into the study, all of whom had IBS-D and most of whom were female (71%). Participants were randomised to either a low FODMAP diet or the mNICE diet for 4 weeks. Because this was also not a feeding study, a dietitian taught participants how to follow their respective diets, but participants were required to put this advice into practice and prepare their own meals. Resources developed at Monash and Michigan Universities were used to teach participants how to follow the low FODMAP diet. Guidance given to the mNICE group included to eat small frequent meals, to avoid trigger foods and to avoid excess alcohol and caffeine. This guidance was considered ‘modified’, because high FODMAP foods were not specifically excluded as would typically be the case on this diet.

 

 The study revealed a number of interesting findings:

·         The diets were equally effective at providing ‘adequate relief’ of overall IBS symptoms, with improvements experienced in 41% of participants in the mNICE group and 52% of participants in the low FODMAP group.

·         More participants in the low FODMAP group experienced an improvement in abdominal pain, 51% versus 23%, p=0.008.

·         The greatest benefit of the low FODMAP diet was for relief of abdominal pain and bloating, with improvements in stool consistency, stool frequency and urgency also observed in this group.

Take home messages:

·         The low FODMAP and mNICE diets improve symptom control in roughly half of all people with IBS-D.

·         The low FODMAP diet may be a superior choice for the relief of some symptoms, namely abdominal pain and bloating

 

1. Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. Am J Gastroenterol. 2016.

Link to full research article: http://www.nature.com/ajg/journal/vaop/ncurrent/full/ajg2016434a.html