GP Tips: FODMAPS
and IBS
By Simon Curtis
and Yvonne McKenzie, Specialist Dietitian and co-author of the British Dietetic
Association guidelines on IBS
‘Doctor, I just feel so bloated!’
Once we have excluded bowel pathology, coeliac disease
and ovarian cancer we are left with the patient who still has the misery of
abdominal bloating (‘I feel like I’m
pregnant doctor’) and the other symptoms of IBS. It is so common, so hard
to help and the response to drugs is often so disappointing. The good news is
that whilst dietary change can be hard, and requires commitment, there is
increasing evidence that it can have a dramatic benefit….
We covered IBS on our blog over a year ago
GP
Tips on IBS but since then
new
evidence-based guidelines by the British Dietetic Association have been
published, and in particular there is great interest in the role of fermentable
carbohydrates or
FODMAPS.
What were the key points of the BDA
guideline?
Key recommendations (ideally dietitian led) based on the
evidence are:
·
First
line dietary management
o Check
for food intolerance, especially lactose (and consider low lactose trial)
o Provide
general healthy eating advice, including on fluid, caffeine, alcohol and modifying
dietary fibre intake
·
Second
line, if symptoms continue despite the above
o For
IBS-C (constipation dominant) consider daily supplementation with linseeds
o Try
a 4 week trial of probiotics
o For
all IBS types, advise reducing fermentable carbohydrates (FODMAPs), guided by
an appropriately trained dietitian
FODMAP stands for Fermentable
Oligosaccharides, Disaccharides, Monosaccharides and Polyols.
These are short-chain fermentable carbohydrates. They trigger symptoms in
susceptible individuals such as bloating, pain, flatus and erratic bowel
function due to poor small bowel absorption, high osmotic activity and rapid colonic
bacterial fermentation producing gases. The low FODMAP diet was developed at Monash
University in Melbourne.
Four clinical trials have been published and
up to 86% of patients have achieved relief of symptoms (when the advice was
given by appropriately trained dietitians) compared to traditional IBS advice, with benefits seen after
only 4 weeks. The paper concludes that ‘the evidence is now sufficient
to confirm the efficacy of this approach for IBS’.
For a podcast discussing FODMAPS and this research
click here
So, what should we advise patients?
Once we have excluded other pathology, as
a first-line treatment refer patients with
mild symptoms to the
BDA
Food Fact Sheet on IBS
As a
second-line
approach, refer moderately to severely affected patients to specialist dietitians
who are trained on the low FODMAP approach. Patients are best not to
self-manage their condition because this can lead to nutritional inadequacy
(e.g. calcium), and they need guidance on systematically re-introducing
FODMAPS, to help verify causality and support long-term symptom control and
food variety. However, if specialist help is not available the
FODMAPS review paper 2013
has a useful table of high FODMAP foods and suitable alternatives, and the team
at Monash have also developed an iphone and ipad app
low
FODMAP app, and recipe books (from Australia and the US) are available. For example, with fruit apples and pears are high in FODMAPS, whilst bananas, grapes and strawberries are suitable alternatives.
A community
dietetic led IBS clinic would be a great thing for your CCG or organisation
to commission. GPs are able to safely exclude significant pathology in the vast
majority of patients, thereafter dietitian led management (which can be in
groups and not necessarily 1 to 1) has the potential not only to be highly
effective but also to reduce specialist REFERRAL costs and save patients from
further unnecessary investigation. Such a clinic has already been set up in
Somerset and is reporting excellent results.
Simon Curtis and
Yvonne McKenzie, Oxford July 2013
