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Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder (FGID) that affects 10–20% of the Western population.1,2 IBS has peak incidence in those aged 25–54 years who experience symptoms such as abdominal pain, diarrhoea and constipation that lead to significant morbidity and reduced quality-of-life.1,3 FGIDs are one of the most common causes for presentation to general practice and therefore have significant direct and indirect healthcare costs.

Food has been identified as a symptom trigger by 70–80% of IBS patients.4 National Institute for Health and Care Excellence (NICE) suggest general healthy eating guidelines such as having regular meals, adequate fluids and reducing intake of caffeine and alcohol to improve the management of IBS.4 A study by Eswaran et al found that 40–50% of IBS predominant diarrhoea patients (n=92) reported adequate symptom relief with the low fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet or a diet based on the modified NICE Guidelines.5 However, the low FODMAP diet led to greater improvement in bloating and abdominal pain.5 There is strong evidence that a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is effective for the management of IBS.6,7 The mechanism by which FODMAPs contribute to IBS symptoms are well described. FODMAPs are poorly absorbed in the small intestine and rapidly fermented in the colon.8,9 This leads to increased delivery of fluid to the colon, luminal distension and abdominal pain.10 Observational and randomised controlled trials have shown that approximately 70% of patients experience significant symptom improvement after implementation of a low FODMAP diet led by a dietitian.6,7

The low FODMAP diet is traditionally taught in a one-to-one setting by a dietitian using a three-phase approach. First, patients are given in-depth dietary education on FODMAP restriction followed by dietary elimination of FODMAPs for up six weeks.11 Patients who achieve symptomatic improvement are then instructed on how to reintroduce individual FODMAPs into the diet while their symptoms are monitored.12 The overall aim of the low FODMAP diet is to identify the specific FODMAPs that trigger IBS symptoms while achieving a diverse and nutritionally adequate diet. Due to its restrictive nature, unguided implementation of the low FODMAP diet has the potential to develop restrictive eating behaviours, nutrient deficiencies and cause problems in specific populations such as vegetarians and pregnant women.

Given the restrictive nature of the diet, the high prevalence of IBS and the increasing popularity of the low FODMAP diet, dietetic capacity in the public health system to guide individuals through the diet is unable to meet demand. To address this problem, King’s College (London) implemented and evaluated a dietitian-led low FODMAP group education programme,13 that showed such an approach was clinically effective and more cost effective than traditional one-to-one education of patients. However, the study did not assess quality-of-life or psychometric measures, which are important aspects of IBS management.

In New Zealand, it is estimated that IBS affects approximately 10–20% of individuals.14 The aim of this study was to determine the feasibility and effectiveness of a dietitian-led low FODMAP diet group education programme in a community setting in adults with IBS in Christchurch, New Zealand. The objectives of the study were: 1) examine the practicalities and feasibility of dietitian-led low FODMAP group education, 2) assess patients’ gastrointestinal symptoms and psychological status before and after attending the education sessions and 3) record patients’ experiences with the low FODMAP diet.

Methods

Participants and recruitment

The primary outcomes of the study were the number of referrals to the education programme, types of recruitment method(s), attendance rates, and participant acceptability of the FODMAP diet and perceived changes in IBS symptoms. The study was a prospective observational design of 25 participants recruited to attend one or two education sessions nine weeks apart. Baseline characteristics including age, sex, IBS subtype, weight, height and body mass index (BMI) were recorded at baseline. The study was approved by the Human Ethics Committee of the University of Otago in March 2018 and all participants gave written informed consent before entering the study.

The study was undertaken with the assistance of the Canterbury Initiative (http://www.cdhb.health.nz/about-us/key-projects-and-initiatives/canterbury-initiative/). Initially, the study recruited participants from the community using general practices in the surrounding areas of the proposed venues. However, only a small number of referrals were received from these practices. However, further referrals were received following promotion of the study on Canterbury DHB websites including Community HealthPathways and HealthInfo Canterbury (http://www.cdhb.health.nz/wp-content/uploads/23631e22-healthpathways-healthinfo-programme-profile.pdf) and in an email newsletter to Pegasus Health practices.

Inclusion criteria for the study were aged 18 years or older, a diagnosis of IBS predominant diarrhoea (IBS-D) or IBS predominant constipation and diarrhoea (IBS-M) made by a physician using the ROME IV criteria and negative coeliac markers.17 Participants were excluded if they had inflammatory bowel disease, IBS with constipation only, diabetes mellitus, history of bowel resection, BMI ≤18.5kgm2 or ≥35kgm2, unintentional weight loss, limited comprehension of English, living in residential care and previous dietetic supervision on the low FODMAP diet.

Group education sessions

A New Zealand registered dietitian with experience in IBS dietary management led the education sessions. The initial 90-minute sessions focused on eliminating high FODMAP foods from the diet for six weeks and included discussion around how to overcome common challenges encountered on a low FODMAP diet. Opportunities for engagement between the participants was encouraged during the session including a label reading group activity. Validated questionnaires including the Assessment of Gastrointestinal Symptoms (SAGIS)16 and Hospital Anxiety and Depression Scores (HADS)17 that measured gastrointestinal and psychological symptoms, respectively were completed prior to the intervention and six weeks later. The SAGIS questionnaire uses a five-point rating scale to assess the severity of symptoms (no problem=0, mild=1, moderate=2, severe=3 and very severe=4), while the HADS questionnaire utilises a 4-point rating scale of 14 items divided into two domains, anxiety and depression.

A semi-structured interview was performed by telephone after six weeks to assess the group education sessions and resources provided and record the participant’s acceptability and attitudes towards following a low FODMAP diet. All the interviews were transcribed and a thematic inductive approach used to identify broad themes in the responses.18

If the patient’s symptoms had improved by ≥50%, they were invited to attend a second group education session. Participants with no improvement in symptoms were referred back to their GP. These 60 minute follow-up sessions were held nine weeks after the first and focused on how to safely and correctly challenge for each FODMAP group. Participants were advised to gradually introduce food containing each FODMAP, starting with small amounts and then increasing intake, and allow days between each challenge in order to monitor symptoms and determine their tolerance to the specific FODMAP.

In both sessions the class was taught using a PowerPoint presentation on a screen projector and given written information to take home. Participants were also encouraged to visit websites and web apps for meal and recipe ideas such as ‘A Little Bit Yummy’ and the Monash University low ‘FODMAP Diet app.19,20

Statistical analysis

The SAGIS and HADS data were analysed using the statistical software programme; IBM SPSS Statistics 25 (1998, 2017, US). The SAGIS questionnaire scores were analysed using paired t-tests, while the HADS scores were stratified into their domains, anxiety and depression an analysed using chi-square and paired t-tests. The study was not designed, or adequately powered to test clinical significance, but only numerical significance (p<0.05).

Results

Attendance

The flow of the patients from referral to attendance at the two education sessions is shown in Figure 1. Of the 25 referrals, three individuals reported they could no longer proceed with the referral, leaving 22 who were sent a booking for the first education session (elimination phase). However, only 17 of these individuals attended the first education session (attendance rate 77%). Those who did not attend were contacted regarding why they could not attend; one participant had not received any information or appointment, one could not take time off work, and another participant who was called into work unexpectedly. The baseline characteristics of the 17 participants who attended the first education session participants is shown in Table 1. All 17 participants were contacted by a member of the research team seven to eight weeks after the first education session who carried out a semi-structured interview. This showed 13 participants (76%) had a ≥50% improvement in their IBS symptoms, while two participants reported no improvement (12%) and two had not implemented the diet (12%). The 13 participants with symptomatic improvement were then given a booking for the second education session (Reintroduction phase), although only 11 attended.

Figure 1: Disposition of participants.

n; number of participants,
FODMAP; Fermentable Oligosaccharide Disaccharide Monosaccharide and Polyols,
IBS; irritable bowel syndrome.

Table 1: Baseline characteristics of study participants.

n; number, BMI; body mass index (weight (kg) divided by height squared (m)2 ).
a n=19. Three participants did not have heights recorded for BMI to be calculated.
b n=19. Three participants were unable to be contacted to determine IBS subtype.
c n= 18. Based on the SAGIS questionnaires answers completed by participants who returned the first questionnaire.

Semi-structured interviews to assess improvements in symptoms

Results from the telephone interviews showed a range of benefits in group education and the general response from participants about the low FODMAP diet were positive. Most participants felt that the information provided at the session was sufficient for them to implement the low FODMAP diet for six weeks. Table 2 shows a summary of the main and sub themes identified.

Table 2: Summary of themes derived from semi-structured interviews.

Participants expressed a change in their relationship with food and eating; one expressed that they “definitely changed some of my thinking” and another “I’m more aware what I’ve been eating but also how I’ve been eating”. More effort into meal planning was reported by the participants. Most of participants had used the ‘A Little Bit Yummy’ website, while some had purchased the Monash app and found its accessibility and convenience to be very helpful: “I downloaded the app, the FODMAP app, it sort of gave me enough products on there to give me an idea”. Most participants agreed that finding low FODMAP alternatives for foods that they often ate was really helpful.

Behavioural change proved to be the biggest challenge for most participants. One participant expressed that “It was harder at the beginning but towards the end it was quite simple now really”, while another reported that “(it was) really just changing my habits”. Another common challenge faced by the participants included social gatherings and eating out, with one stating that she “just wanted to fit in with other people” and another saying “they were distracted more than anything, conversations happen”. “The garlic and onion scenario” was a common challenge that participants experienced both at home and eating out.

Symptom-related questionnaires

A total of 32 SAGIS questionnaires and 31 HADS questionnaires were collected throughout the study. Participants were excluded from final data analysis if they had not attended the first education session or had not implemented the low FODMAP diet for a minimum of six weeks.

Table 3 summarises the mean scores of the 24 variables in the SAGIS questionnaire before and after the group low FODMAP diet intervention. There was a significant reduction (p<0.05) in scores for 19 of the 24 variables. The symptom with the greatest improvement was bloating (p<0.0001), while scores for belching, dysphagia, early satiety, loss of appetite and vomiting showed a non-significant improvement.

Table 3: Changes in gastrointestinal symptoms following group low FODMAP diet intervention.

*p<0.05.

Anxiety and depression was measured using the HADS. For both anxiety (11.2 [SD 4.3] vs 8.17 [SD 4.2], p<0.001) and depression (7.7 [SD 1.9] vs 5.3 [SD 1.8], p<0.001) there was a significant reduction in the total scores following the low FODMAP intervention. However, when analysing these results categorically (using predefined ‘normal’ [<7], ‘borderline abnormal’ [8–11] and ‘abnormal’ [>12] categories) there was no significant change (p>0.05).

Conclusions

To our knowledge, this is the one of the first studies to formally evaluate the feasibility and effectiveness of a dietitian-led low FODMAP group education programme for dietary management of IBS. Our results support those of Whigham et al and demonstrate that dietitian-led low FODMAP group education in a community-based setting is effective and feasible in the management of IBS.

Our initial recruitment method was similar to that currently used in clinical practice with GPs referring patients directly to dietitians. However, we achieved greater success when using a combination of recruitment strategies such as websites, clinic visits, and e-newsletters. The attendance rate of 77.3% for the first session and 85% for the second session are positive indicators that participants were willing to attend and were satisfied with the education they received. Seventy-six percent of participants reported ≥50% improvement in their IBS symptoms, whereas the remaining participants did not experience any improvement or did not start the diet. These participants who do not experience any improvement were referred back to their general practitioner or health provider for their individualised IBS care. We anticipated that not all patients would improve with a low FODMAP diet, as similar to other dietary therapies, there is evidence that this diet does not work for every individual.21

Results from the telephone interviews showed that participants were generally positive and found the group education programme enhanced their understanding and acceptability of the low FODMAP diet. Our results are consistent with other IBS or non-IBS group dietary interventions, which demonstrated that group settings increase patients’ acceptability of the treatment through sharing of experiences as well as comradery with other patients.13,22,23 Furthermore, suitable educational resources as well as references to websites and apps also increased adherence and acceptability of the low FODMAP diet, a finding consistent with published literature.25,26 Websites and web apps such as ‘A Little Bit Yummy’ and the ‘Monash University Low FODMAP Diet App’ are increasing in popularity as they provide a fast and accessible platform for FODMAP friendly meals and products. However, the increase in web-based education creates uncertainty and vulnerability for evidence-based advice on low FODMAP diets, with individuals without the necessary expertise possibly delivering misleading information. More research is therefore warranted on the efficacy and safety of emerging web-based platforms.

Participants who did not start the diet after attending the initial session, expressed that they had personal reasons for not doing so. Suggesting it was not due to the delivery of intervention, but rather personal reasons. Screening for those suitable for one-to-one delivery rather than group delivery should be of importance when delivering a group education programme. Whigham et al employed a triage system using a telephone screening clinic to allocate participants’ suitability for group versus one-to-one education.11 Anecdotal feedback from a dietitian-led low FODMAP group education session at Christchurch Public Hospital also emphasised the need for a more vigorous screening process. Although our study employed strict exclusion criterium, telephone screening may be more useful for identifying those participants suitable for group education.

Significant improvements were observed in most gastrointestinal symptoms in our participants, supporting the findings of Whigham et al.13 In their study, 54% of participants were satisfied with their gut health following the intervention. Comparatively, our study found that 87% (13/15) of participants who implemented the diet were satisfied with their symptomatic improvement at the end of intervention. Our study also found similar symptomatic improvement comparative to that of traditional one-to-one education. Improvements in abdominal symptoms such as bloating, loose bowel motions, stool consistency and flatulence in our study were found to be consistent and significant similar to studies that used the traditional one-to-one pathway.26,27

A positive effect of the group low FODMAP education programme on psychometric and psychosocial measures was also observed in this study. There is limited literature regarding the impact of IBS group education on anxiety, depression, and health related quality-of-life. Some studies suggest that individualised dietary education and counselling improves patients’ understanding of IBS and their dietary management of IBS and hence their overall mood and quality-of -life.28–30 However, Whigham et al did not measure psychometrics and health-related quality of life. In our study, between 45–50% of participants reported having anxiety or depression symptoms prior to entering the study. Although the anxiety and depression scores did not improve significantly, the nature of the intervention, pre-existing psychological disorders, and the small number of participants would not have been expected to provide the study with sufficient statistical power to investigate these changes. Long-term behavioural therapy, medications and other strategies besides dietary management and a longer follow-up period may possibly demonstrate more positive changes in mental health and hence HADS scores.

The mixed methods design of our study meant it was possible to assess both the feasibility and practicality of a low FODMAP group education programme. Our quantitative data needs to be viewed with caution and interpreted in context with the limitations of the study. There was also no comparator group and participants were not blinded to the intervention, although this is extremely difficult for a whole diet study. Despite these limitations, the results are promising with clinical improvement being seen across a wide range of relevant gastrointestinal symptoms.

Given that this study has demonstrated that low FODMAP group education in a community setting is feasible in a New Zealand context, future research should investigate the efficacy of low FODMAP group education in terms of reintroduction and diet modification. Efficacy in a range of ethnicities and IBS phenotypes should also be examined. Clinical trials powered to determine whether low FODMAP group education is effective at improving gastrointestinal and psychological symptoms in patients with functional gastrointestinal disorders such as IBS in a cost-effective way are warranted.

In conclusion, a dietitian-led low FODMAP diet group education programme in adults diagnosed with IBS-D or IBS-M is an effective and feasible intervention. A dietitian-led low FODMAP group education programme is worthy of consideration in routine clinical practice.

Summary

Abstract

Aim

To investigate the feasibility and effectiveness of dietitian-led education on using the low fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet in adults with irritable bowel syndrome (IBS) in Christchurch, New Zealand.

Method

Patients with IBS (n=25) were referred by their general practitioner to attend a group education programme. The number recruited and subsequent attendance were used to evaluate feasibility. The Structured Assessment of Gastrointestinal Symptoms (SAGIS) questionnaire and Hospital Anxiety and Depression Scale (HADS) were compared at baseline and at follow-up. Semi-structured telephone interviews assessed the acceptability of the education programme.

Results

Of the 25 recruited participants, 17 attended the group education programme. The SAGIS score decreased significantly (p<0.05) between baseline (mean 1.844) and follow-up (mean 0.607). Similarly, there was non-significant trend of lower HADS anxiety and depression scores from baseline to follow-up. Symptomatic improvement was reported by 13 participants (76.5%), while two participants (11.8%) did not improve and two others (11.8%) had not implemented the diet. Overall, participants were positive and grateful for the improvement the diet had made to their symptoms.

Conclusion

A dietitian-led low FODMAP group education programme in Christchurch adults with IBS was found to be both feasible and effective.

Author Information

Dorcas Chan, Human Nutrition and Medicine, University of Otago, Christchurch; Paula Skidmore, Human Nutrition and Medicine, University of Otago, Christchurch; Leigh O’Brien, Human Nutrition and Medicine, University of Otago, Christchurch; Sally Watson, The Canterbury Initiative, Canterbury District Health Board, Christchurch; Richard Gearry, Medicine, University of Otago, Christchurch.

Acknowledgements

The study would like to acknowledge the participant’s involvement in the study. The study would also like to acknowledge Dr Brett Shand, Clinical Writer and Analyst (Canterbury Initiative) for his expertise and contribution to the writing of this paper.

Correspondence

Professor Richard Gearry, University of Otago, 2 Riccarton Ave, Christchurch Central, Christchurch 8011.

Correspondence Email

richard.gearry@cdhb.health.nz

Competing Interests

Dr Gearry reports grants from Zespri, grants from AbbVie, outside the submitted work. Ms Watson reports personal fees from Canterbury DHB and personal fees as a self-employed dietitian, outside the submitted work.

1. Fass R, Longstreth GF, Pimentel M, et al. Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome. Arch Intern Med. 2001; 161(17):2081–8.

2. Lovell RM, Ford AC. Global Prevalence of and Risk Factors for Irritable Bowel Syndrome: A Meta-analysis. Clin Gastroenterol Hepatol. 2012; 10(7):712–721.

3. Hungin APS, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther. 2003; 17(5):643–50.

4. National Institute for Health and Care Excellence (NICE). Irritable bowel syndrome in adults: diagnosis and management [Internet]. United Kingdom: NICE; 2008 [cited 2019 July 12]. Available from: http://www.nice.org.uk/guidance/cg61

5. Eswaran SL, Chey WD, Han-Markey T, et al. A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. Am J Gastroenterol. 2016; 111(12):1824–1832.

6. Halmos EP, Power VA, Shepherd SJ, et al. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014; 146(1):67–75.e5.

7. Staudacher HM, Lomer MCE, Anderson JL, et al. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr. 2012; 142(8):1510–8.

8. Barrett JS, Gibson PR. Clinical ramifications of malabsorption of fructose and other short-chain carbohydrates. Prac Gastroenterol. 2007; 31(8):51–65.

9. Undseth R, Berstad A, Klow NE, et al. Abnormal accumulation of intestinal fluid following ingestion of an unabsorbable carbohydrate in patients with irritable bowel syndrome: an MRI study. Neurogastroenterol and Motil. 2014; 26(12):1686–93.

10. Ong DK, Mitchell SB, Barrett JS, et al. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010; 25(8):1366–73.

11. Barett JS. How to institute the low-FODMAP diet. Gastro Hepatol. 2017. http://doi.org/10.1111/jgh.13686

12. Barett JS, Tuck C. Re-challenging FODMAPs: the low FODMAP diet phase two. Gastro Hepatol. 2017. http://doi.org/10.1111/jgh.13687

13. Whigham L, Joyce T, Harper G, et al. Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome. J Hum Nutr Diet. 2015; 28(6):687–96.

14. Wyeth JW. Functional gastrointestinal disorders in New Zealand. J Gastroenterol Hepatol. 2011; 26:15–8.

15. Schmulson MJ, Drossman DA. What is new in Rome IV. J Neurogastroenterol Motil. 2017; 23(2):151–63.

16. Koloski NA. The Validity of a New Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS) for Evaluating Symptoms in the Clinical Setting. Dig Dis Sci. 2017; 62(8):1913–1922.

17. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica. 1983; 67(6):361–370.

18. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2):77–101.

19. A Little Bit Yummy. Low FODMAP Diet Recipes and Meal Plans- A Little Bit Yummy [Internet]. New Zealand: A Little Bit Yummy; 2019 [cited 2019 Jun 3]. Available from: http://alittlebityummy.com/

20. Monash University (AU). Monash University Low FODMAP Diet App. Version 3.0.2. Monash University, 2012. Monash University Get the App, http://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-app/

21. Patel SM, Stason WB, Legedza A, et al. The placebo effect in irritable bowel syndrome trials: A meta-analysis. Neurogastroenterol Motil. 2005; 17(3):332–40.

22. Odgers-Jewell K, Isenring EA, Thomas R, Reidlinger DP. Group participants’ experiences of a patient-directed group-based education program for the management of type 2 diabetes mellitus. PLoS ONE. 2017; 12(5):e0177688.

23. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self- management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005(2):CD003417.

24. Pedersen N, Andersen NN, Végh Z et al. Ehealth: Low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome. World J Gastroenterology. 2014; 20(43):16215–26.

25. Whelan K, Martin LD, Staudacher HM, Lomer MCE. The low FODMAP diet in the management of irritable bowel syndrome: an evidence-based review of FODMAP restriction, reintroduction and personalisation in clinical practice. J Hum Nutr Diet. 2018; 31(2):239–55.

26. Harvie RM, Chisholm AW, Bisanz JE, et al. Long- term irritable bowel syndrome symptom control with reintroduction of selected FODMAPs. World J Gastroenterol. 2017; 23(25):4632–43.

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Contact diana@nzma.org.nz
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Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder (FGID) that affects 10–20% of the Western population.1,2 IBS has peak incidence in those aged 25–54 years who experience symptoms such as abdominal pain, diarrhoea and constipation that lead to significant morbidity and reduced quality-of-life.1,3 FGIDs are one of the most common causes for presentation to general practice and therefore have significant direct and indirect healthcare costs.

Food has been identified as a symptom trigger by 70–80% of IBS patients.4 National Institute for Health and Care Excellence (NICE) suggest general healthy eating guidelines such as having regular meals, adequate fluids and reducing intake of caffeine and alcohol to improve the management of IBS.4 A study by Eswaran et al found that 40–50% of IBS predominant diarrhoea patients (n=92) reported adequate symptom relief with the low fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet or a diet based on the modified NICE Guidelines.5 However, the low FODMAP diet led to greater improvement in bloating and abdominal pain.5 There is strong evidence that a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is effective for the management of IBS.6,7 The mechanism by which FODMAPs contribute to IBS symptoms are well described. FODMAPs are poorly absorbed in the small intestine and rapidly fermented in the colon.8,9 This leads to increased delivery of fluid to the colon, luminal distension and abdominal pain.10 Observational and randomised controlled trials have shown that approximately 70% of patients experience significant symptom improvement after implementation of a low FODMAP diet led by a dietitian.6,7

The low FODMAP diet is traditionally taught in a one-to-one setting by a dietitian using a three-phase approach. First, patients are given in-depth dietary education on FODMAP restriction followed by dietary elimination of FODMAPs for up six weeks.11 Patients who achieve symptomatic improvement are then instructed on how to reintroduce individual FODMAPs into the diet while their symptoms are monitored.12 The overall aim of the low FODMAP diet is to identify the specific FODMAPs that trigger IBS symptoms while achieving a diverse and nutritionally adequate diet. Due to its restrictive nature, unguided implementation of the low FODMAP diet has the potential to develop restrictive eating behaviours, nutrient deficiencies and cause problems in specific populations such as vegetarians and pregnant women.

Given the restrictive nature of the diet, the high prevalence of IBS and the increasing popularity of the low FODMAP diet, dietetic capacity in the public health system to guide individuals through the diet is unable to meet demand. To address this problem, King’s College (London) implemented and evaluated a dietitian-led low FODMAP group education programme,13 that showed such an approach was clinically effective and more cost effective than traditional one-to-one education of patients. However, the study did not assess quality-of-life or psychometric measures, which are important aspects of IBS management.

In New Zealand, it is estimated that IBS affects approximately 10–20% of individuals.14 The aim of this study was to determine the feasibility and effectiveness of a dietitian-led low FODMAP diet group education programme in a community setting in adults with IBS in Christchurch, New Zealand. The objectives of the study were: 1) examine the practicalities and feasibility of dietitian-led low FODMAP group education, 2) assess patients’ gastrointestinal symptoms and psychological status before and after attending the education sessions and 3) record patients’ experiences with the low FODMAP diet.

Methods

Participants and recruitment

The primary outcomes of the study were the number of referrals to the education programme, types of recruitment method(s), attendance rates, and participant acceptability of the FODMAP diet and perceived changes in IBS symptoms. The study was a prospective observational design of 25 participants recruited to attend one or two education sessions nine weeks apart. Baseline characteristics including age, sex, IBS subtype, weight, height and body mass index (BMI) were recorded at baseline. The study was approved by the Human Ethics Committee of the University of Otago in March 2018 and all participants gave written informed consent before entering the study.

The study was undertaken with the assistance of the Canterbury Initiative (http://www.cdhb.health.nz/about-us/key-projects-and-initiatives/canterbury-initiative/). Initially, the study recruited participants from the community using general practices in the surrounding areas of the proposed venues. However, only a small number of referrals were received from these practices. However, further referrals were received following promotion of the study on Canterbury DHB websites including Community HealthPathways and HealthInfo Canterbury (http://www.cdhb.health.nz/wp-content/uploads/23631e22-healthpathways-healthinfo-programme-profile.pdf) and in an email newsletter to Pegasus Health practices.

Inclusion criteria for the study were aged 18 years or older, a diagnosis of IBS predominant diarrhoea (IBS-D) or IBS predominant constipation and diarrhoea (IBS-M) made by a physician using the ROME IV criteria and negative coeliac markers.17 Participants were excluded if they had inflammatory bowel disease, IBS with constipation only, diabetes mellitus, history of bowel resection, BMI ≤18.5kgm2 or ≥35kgm2, unintentional weight loss, limited comprehension of English, living in residential care and previous dietetic supervision on the low FODMAP diet.

Group education sessions

A New Zealand registered dietitian with experience in IBS dietary management led the education sessions. The initial 90-minute sessions focused on eliminating high FODMAP foods from the diet for six weeks and included discussion around how to overcome common challenges encountered on a low FODMAP diet. Opportunities for engagement between the participants was encouraged during the session including a label reading group activity. Validated questionnaires including the Assessment of Gastrointestinal Symptoms (SAGIS)16 and Hospital Anxiety and Depression Scores (HADS)17 that measured gastrointestinal and psychological symptoms, respectively were completed prior to the intervention and six weeks later. The SAGIS questionnaire uses a five-point rating scale to assess the severity of symptoms (no problem=0, mild=1, moderate=2, severe=3 and very severe=4), while the HADS questionnaire utilises a 4-point rating scale of 14 items divided into two domains, anxiety and depression.

A semi-structured interview was performed by telephone after six weeks to assess the group education sessions and resources provided and record the participant’s acceptability and attitudes towards following a low FODMAP diet. All the interviews were transcribed and a thematic inductive approach used to identify broad themes in the responses.18

If the patient’s symptoms had improved by ≥50%, they were invited to attend a second group education session. Participants with no improvement in symptoms were referred back to their GP. These 60 minute follow-up sessions were held nine weeks after the first and focused on how to safely and correctly challenge for each FODMAP group. Participants were advised to gradually introduce food containing each FODMAP, starting with small amounts and then increasing intake, and allow days between each challenge in order to monitor symptoms and determine their tolerance to the specific FODMAP.

In both sessions the class was taught using a PowerPoint presentation on a screen projector and given written information to take home. Participants were also encouraged to visit websites and web apps for meal and recipe ideas such as ‘A Little Bit Yummy’ and the Monash University low ‘FODMAP Diet app.19,20

Statistical analysis

The SAGIS and HADS data were analysed using the statistical software programme; IBM SPSS Statistics 25 (1998, 2017, US). The SAGIS questionnaire scores were analysed using paired t-tests, while the HADS scores were stratified into their domains, anxiety and depression an analysed using chi-square and paired t-tests. The study was not designed, or adequately powered to test clinical significance, but only numerical significance (p<0.05).

Results

Attendance

The flow of the patients from referral to attendance at the two education sessions is shown in Figure 1. Of the 25 referrals, three individuals reported they could no longer proceed with the referral, leaving 22 who were sent a booking for the first education session (elimination phase). However, only 17 of these individuals attended the first education session (attendance rate 77%). Those who did not attend were contacted regarding why they could not attend; one participant had not received any information or appointment, one could not take time off work, and another participant who was called into work unexpectedly. The baseline characteristics of the 17 participants who attended the first education session participants is shown in Table 1. All 17 participants were contacted by a member of the research team seven to eight weeks after the first education session who carried out a semi-structured interview. This showed 13 participants (76%) had a ≥50% improvement in their IBS symptoms, while two participants reported no improvement (12%) and two had not implemented the diet (12%). The 13 participants with symptomatic improvement were then given a booking for the second education session (Reintroduction phase), although only 11 attended.

Figure 1: Disposition of participants.

n; number of participants,
FODMAP; Fermentable Oligosaccharide Disaccharide Monosaccharide and Polyols,
IBS; irritable bowel syndrome.

Table 1: Baseline characteristics of study participants.

n; number, BMI; body mass index (weight (kg) divided by height squared (m)2 ).
a n=19. Three participants did not have heights recorded for BMI to be calculated.
b n=19. Three participants were unable to be contacted to determine IBS subtype.
c n= 18. Based on the SAGIS questionnaires answers completed by participants who returned the first questionnaire.

Semi-structured interviews to assess improvements in symptoms

Results from the telephone interviews showed a range of benefits in group education and the general response from participants about the low FODMAP diet were positive. Most participants felt that the information provided at the session was sufficient for them to implement the low FODMAP diet for six weeks. Table 2 shows a summary of the main and sub themes identified.

Table 2: Summary of themes derived from semi-structured interviews.

Participants expressed a change in their relationship with food and eating; one expressed that they “definitely changed some of my thinking” and another “I’m more aware what I’ve been eating but also how I’ve been eating”. More effort into meal planning was reported by the participants. Most of participants had used the ‘A Little Bit Yummy’ website, while some had purchased the Monash app and found its accessibility and convenience to be very helpful: “I downloaded the app, the FODMAP app, it sort of gave me enough products on there to give me an idea”. Most participants agreed that finding low FODMAP alternatives for foods that they often ate was really helpful.

Behavioural change proved to be the biggest challenge for most participants. One participant expressed that “It was harder at the beginning but towards the end it was quite simple now really”, while another reported that “(it was) really just changing my habits”. Another common challenge faced by the participants included social gatherings and eating out, with one stating that she “just wanted to fit in with other people” and another saying “they were distracted more than anything, conversations happen”. “The garlic and onion scenario” was a common challenge that participants experienced both at home and eating out.

Symptom-related questionnaires

A total of 32 SAGIS questionnaires and 31 HADS questionnaires were collected throughout the study. Participants were excluded from final data analysis if they had not attended the first education session or had not implemented the low FODMAP diet for a minimum of six weeks.

Table 3 summarises the mean scores of the 24 variables in the SAGIS questionnaire before and after the group low FODMAP diet intervention. There was a significant reduction (p<0.05) in scores for 19 of the 24 variables. The symptom with the greatest improvement was bloating (p<0.0001), while scores for belching, dysphagia, early satiety, loss of appetite and vomiting showed a non-significant improvement.

Table 3: Changes in gastrointestinal symptoms following group low FODMAP diet intervention.

*p<0.05.

Anxiety and depression was measured using the HADS. For both anxiety (11.2 [SD 4.3] vs 8.17 [SD 4.2], p<0.001) and depression (7.7 [SD 1.9] vs 5.3 [SD 1.8], p<0.001) there was a significant reduction in the total scores following the low FODMAP intervention. However, when analysing these results categorically (using predefined ‘normal’ [<7], ‘borderline abnormal’ [8–11] and ‘abnormal’ [>12] categories) there was no significant change (p>0.05).

Conclusions

To our knowledge, this is the one of the first studies to formally evaluate the feasibility and effectiveness of a dietitian-led low FODMAP group education programme for dietary management of IBS. Our results support those of Whigham et al and demonstrate that dietitian-led low FODMAP group education in a community-based setting is effective and feasible in the management of IBS.

Our initial recruitment method was similar to that currently used in clinical practice with GPs referring patients directly to dietitians. However, we achieved greater success when using a combination of recruitment strategies such as websites, clinic visits, and e-newsletters. The attendance rate of 77.3% for the first session and 85% for the second session are positive indicators that participants were willing to attend and were satisfied with the education they received. Seventy-six percent of participants reported ≥50% improvement in their IBS symptoms, whereas the remaining participants did not experience any improvement or did not start the diet. These participants who do not experience any improvement were referred back to their general practitioner or health provider for their individualised IBS care. We anticipated that not all patients would improve with a low FODMAP diet, as similar to other dietary therapies, there is evidence that this diet does not work for every individual.21

Results from the telephone interviews showed that participants were generally positive and found the group education programme enhanced their understanding and acceptability of the low FODMAP diet. Our results are consistent with other IBS or non-IBS group dietary interventions, which demonstrated that group settings increase patients’ acceptability of the treatment through sharing of experiences as well as comradery with other patients.13,22,23 Furthermore, suitable educational resources as well as references to websites and apps also increased adherence and acceptability of the low FODMAP diet, a finding consistent with published literature.25,26 Websites and web apps such as ‘A Little Bit Yummy’ and the ‘Monash University Low FODMAP Diet App’ are increasing in popularity as they provide a fast and accessible platform for FODMAP friendly meals and products. However, the increase in web-based education creates uncertainty and vulnerability for evidence-based advice on low FODMAP diets, with individuals without the necessary expertise possibly delivering misleading information. More research is therefore warranted on the efficacy and safety of emerging web-based platforms.

Participants who did not start the diet after attending the initial session, expressed that they had personal reasons for not doing so. Suggesting it was not due to the delivery of intervention, but rather personal reasons. Screening for those suitable for one-to-one delivery rather than group delivery should be of importance when delivering a group education programme. Whigham et al employed a triage system using a telephone screening clinic to allocate participants’ suitability for group versus one-to-one education.11 Anecdotal feedback from a dietitian-led low FODMAP group education session at Christchurch Public Hospital also emphasised the need for a more vigorous screening process. Although our study employed strict exclusion criterium, telephone screening may be more useful for identifying those participants suitable for group education.

Significant improvements were observed in most gastrointestinal symptoms in our participants, supporting the findings of Whigham et al.13 In their study, 54% of participants were satisfied with their gut health following the intervention. Comparatively, our study found that 87% (13/15) of participants who implemented the diet were satisfied with their symptomatic improvement at the end of intervention. Our study also found similar symptomatic improvement comparative to that of traditional one-to-one education. Improvements in abdominal symptoms such as bloating, loose bowel motions, stool consistency and flatulence in our study were found to be consistent and significant similar to studies that used the traditional one-to-one pathway.26,27

A positive effect of the group low FODMAP education programme on psychometric and psychosocial measures was also observed in this study. There is limited literature regarding the impact of IBS group education on anxiety, depression, and health related quality-of-life. Some studies suggest that individualised dietary education and counselling improves patients’ understanding of IBS and their dietary management of IBS and hence their overall mood and quality-of -life.28–30 However, Whigham et al did not measure psychometrics and health-related quality of life. In our study, between 45–50% of participants reported having anxiety or depression symptoms prior to entering the study. Although the anxiety and depression scores did not improve significantly, the nature of the intervention, pre-existing psychological disorders, and the small number of participants would not have been expected to provide the study with sufficient statistical power to investigate these changes. Long-term behavioural therapy, medications and other strategies besides dietary management and a longer follow-up period may possibly demonstrate more positive changes in mental health and hence HADS scores.

The mixed methods design of our study meant it was possible to assess both the feasibility and practicality of a low FODMAP group education programme. Our quantitative data needs to be viewed with caution and interpreted in context with the limitations of the study. There was also no comparator group and participants were not blinded to the intervention, although this is extremely difficult for a whole diet study. Despite these limitations, the results are promising with clinical improvement being seen across a wide range of relevant gastrointestinal symptoms.

Given that this study has demonstrated that low FODMAP group education in a community setting is feasible in a New Zealand context, future research should investigate the efficacy of low FODMAP group education in terms of reintroduction and diet modification. Efficacy in a range of ethnicities and IBS phenotypes should also be examined. Clinical trials powered to determine whether low FODMAP group education is effective at improving gastrointestinal and psychological symptoms in patients with functional gastrointestinal disorders such as IBS in a cost-effective way are warranted.

In conclusion, a dietitian-led low FODMAP diet group education programme in adults diagnosed with IBS-D or IBS-M is an effective and feasible intervention. A dietitian-led low FODMAP group education programme is worthy of consideration in routine clinical practice.

Summary

Abstract

Aim

To investigate the feasibility and effectiveness of dietitian-led education on using the low fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet in adults with irritable bowel syndrome (IBS) in Christchurch, New Zealand.

Method

Patients with IBS (n=25) were referred by their general practitioner to attend a group education programme. The number recruited and subsequent attendance were used to evaluate feasibility. The Structured Assessment of Gastrointestinal Symptoms (SAGIS) questionnaire and Hospital Anxiety and Depression Scale (HADS) were compared at baseline and at follow-up. Semi-structured telephone interviews assessed the acceptability of the education programme.

Results

Of the 25 recruited participants, 17 attended the group education programme. The SAGIS score decreased significantly (p<0.05) between baseline (mean 1.844) and follow-up (mean 0.607). Similarly, there was non-significant trend of lower HADS anxiety and depression scores from baseline to follow-up. Symptomatic improvement was reported by 13 participants (76.5%), while two participants (11.8%) did not improve and two others (11.8%) had not implemented the diet. Overall, participants were positive and grateful for the improvement the diet had made to their symptoms.

Conclusion

A dietitian-led low FODMAP group education programme in Christchurch adults with IBS was found to be both feasible and effective.

Author Information

Dorcas Chan, Human Nutrition and Medicine, University of Otago, Christchurch; Paula Skidmore, Human Nutrition and Medicine, University of Otago, Christchurch; Leigh O’Brien, Human Nutrition and Medicine, University of Otago, Christchurch; Sally Watson, The Canterbury Initiative, Canterbury District Health Board, Christchurch; Richard Gearry, Medicine, University of Otago, Christchurch.

Acknowledgements

The study would like to acknowledge the participant’s involvement in the study. The study would also like to acknowledge Dr Brett Shand, Clinical Writer and Analyst (Canterbury Initiative) for his expertise and contribution to the writing of this paper.

Correspondence

Professor Richard Gearry, University of Otago, 2 Riccarton Ave, Christchurch Central, Christchurch 8011.

Correspondence Email

richard.gearry@cdhb.health.nz

Competing Interests

Dr Gearry reports grants from Zespri, grants from AbbVie, outside the submitted work. Ms Watson reports personal fees from Canterbury DHB and personal fees as a self-employed dietitian, outside the submitted work.

1. Fass R, Longstreth GF, Pimentel M, et al. Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome. Arch Intern Med. 2001; 161(17):2081–8.

2. Lovell RM, Ford AC. Global Prevalence of and Risk Factors for Irritable Bowel Syndrome: A Meta-analysis. Clin Gastroenterol Hepatol. 2012; 10(7):712–721.

3. Hungin APS, Whorwell PJ, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharmacol Ther. 2003; 17(5):643–50.

4. National Institute for Health and Care Excellence (NICE). Irritable bowel syndrome in adults: diagnosis and management [Internet]. United Kingdom: NICE; 2008 [cited 2019 July 12]. Available from: http://www.nice.org.uk/guidance/cg61

5. Eswaran SL, Chey WD, Han-Markey T, et al. A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. Am J Gastroenterol. 2016; 111(12):1824–1832.

6. Halmos EP, Power VA, Shepherd SJ, et al. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014; 146(1):67–75.e5.

7. Staudacher HM, Lomer MCE, Anderson JL, et al. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr. 2012; 142(8):1510–8.

8. Barrett JS, Gibson PR. Clinical ramifications of malabsorption of fructose and other short-chain carbohydrates. Prac Gastroenterol. 2007; 31(8):51–65.

9. Undseth R, Berstad A, Klow NE, et al. Abnormal accumulation of intestinal fluid following ingestion of an unabsorbable carbohydrate in patients with irritable bowel syndrome: an MRI study. Neurogastroenterol and Motil. 2014; 26(12):1686–93.

10. Ong DK, Mitchell SB, Barrett JS, et al. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010; 25(8):1366–73.

11. Barett JS. How to institute the low-FODMAP diet. Gastro Hepatol. 2017. http://doi.org/10.1111/jgh.13686

12. Barett JS, Tuck C. Re-challenging FODMAPs: the low FODMAP diet phase two. Gastro Hepatol. 2017. http://doi.org/10.1111/jgh.13687

13. Whigham L, Joyce T, Harper G, et al. Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome. J Hum Nutr Diet. 2015; 28(6):687–96.

14. Wyeth JW. Functional gastrointestinal disorders in New Zealand. J Gastroenterol Hepatol. 2011; 26:15–8.

15. Schmulson MJ, Drossman DA. What is new in Rome IV. J Neurogastroenterol Motil. 2017; 23(2):151–63.

16. Koloski NA. The Validity of a New Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS) for Evaluating Symptoms in the Clinical Setting. Dig Dis Sci. 2017; 62(8):1913–1922.

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18. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2):77–101.

19. A Little Bit Yummy. Low FODMAP Diet Recipes and Meal Plans- A Little Bit Yummy [Internet]. New Zealand: A Little Bit Yummy; 2019 [cited 2019 Jun 3]. Available from: http://alittlebityummy.com/

20. Monash University (AU). Monash University Low FODMAP Diet App. Version 3.0.2. Monash University, 2012. Monash University Get the App, http://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-app/

21. Patel SM, Stason WB, Legedza A, et al. The placebo effect in irritable bowel syndrome trials: A meta-analysis. Neurogastroenterol Motil. 2005; 17(3):332–40.

22. Odgers-Jewell K, Isenring EA, Thomas R, Reidlinger DP. Group participants’ experiences of a patient-directed group-based education program for the management of type 2 diabetes mellitus. PLoS ONE. 2017; 12(5):e0177688.

23. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self- management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005(2):CD003417.

24. Pedersen N, Andersen NN, Végh Z et al. Ehealth: Low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome. World J Gastroenterology. 2014; 20(43):16215–26.

25. Whelan K, Martin LD, Staudacher HM, Lomer MCE. The low FODMAP diet in the management of irritable bowel syndrome: an evidence-based review of FODMAP restriction, reintroduction and personalisation in clinical practice. J Hum Nutr Diet. 2018; 31(2):239–55.

26. Harvie RM, Chisholm AW, Bisanz JE, et al. Long- term irritable bowel syndrome symptom control with reintroduction of selected FODMAPs. World J Gastroenterol. 2017; 23(25):4632–43.

27. McIntosh K, Reed DE, Schneider T, et al. FODMAPs alter symptoms and the metabolome of patients with IBS: A randomised controlled trial. Gut. 2017; 66(7):1241–51.

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Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder (FGID) that affects 10–20% of the Western population.1,2 IBS has peak incidence in those aged 25–54 years who experience symptoms such as abdominal pain, diarrhoea and constipation that lead to significant morbidity and reduced quality-of-life.1,3 FGIDs are one of the most common causes for presentation to general practice and therefore have significant direct and indirect healthcare costs.

Food has been identified as a symptom trigger by 70–80% of IBS patients.4 National Institute for Health and Care Excellence (NICE) suggest general healthy eating guidelines such as having regular meals, adequate fluids and reducing intake of caffeine and alcohol to improve the management of IBS.4 A study by Eswaran et al found that 40–50% of IBS predominant diarrhoea patients (n=92) reported adequate symptom relief with the low fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet or a diet based on the modified NICE Guidelines.5 However, the low FODMAP diet led to greater improvement in bloating and abdominal pain.5 There is strong evidence that a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is effective for the management of IBS.6,7 The mechanism by which FODMAPs contribute to IBS symptoms are well described. FODMAPs are poorly absorbed in the small intestine and rapidly fermented in the colon.8,9 This leads to increased delivery of fluid to the colon, luminal distension and abdominal pain.10 Observational and randomised controlled trials have shown that approximately 70% of patients experience significant symptom improvement after implementation of a low FODMAP diet led by a dietitian.6,7

The low FODMAP diet is traditionally taught in a one-to-one setting by a dietitian using a three-phase approach. First, patients are given in-depth dietary education on FODMAP restriction followed by dietary elimination of FODMAPs for up six weeks.11 Patients who achieve symptomatic improvement are then instructed on how to reintroduce individual FODMAPs into the diet while their symptoms are monitored.12 The overall aim of the low FODMAP diet is to identify the specific FODMAPs that trigger IBS symptoms while achieving a diverse and nutritionally adequate diet. Due to its restrictive nature, unguided implementation of the low FODMAP diet has the potential to develop restrictive eating behaviours, nutrient deficiencies and cause problems in specific populations such as vegetarians and pregnant women.

Given the restrictive nature of the diet, the high prevalence of IBS and the increasing popularity of the low FODMAP diet, dietetic capacity in the public health system to guide individuals through the diet is unable to meet demand. To address this problem, King’s College (London) implemented and evaluated a dietitian-led low FODMAP group education programme,13 that showed such an approach was clinically effective and more cost effective than traditional one-to-one education of patients. However, the study did not assess quality-of-life or psychometric measures, which are important aspects of IBS management.

In New Zealand, it is estimated that IBS affects approximately 10–20% of individuals.14 The aim of this study was to determine the feasibility and effectiveness of a dietitian-led low FODMAP diet group education programme in a community setting in adults with IBS in Christchurch, New Zealand. The objectives of the study were: 1) examine the practicalities and feasibility of dietitian-led low FODMAP group education, 2) assess patients’ gastrointestinal symptoms and psychological status before and after attending the education sessions and 3) record patients’ experiences with the low FODMAP diet.

Methods

Participants and recruitment

The primary outcomes of the study were the number of referrals to the education programme, types of recruitment method(s), attendance rates, and participant acceptability of the FODMAP diet and perceived changes in IBS symptoms. The study was a prospective observational design of 25 participants recruited to attend one or two education sessions nine weeks apart. Baseline characteristics including age, sex, IBS subtype, weight, height and body mass index (BMI) were recorded at baseline. The study was approved by the Human Ethics Committee of the University of Otago in March 2018 and all participants gave written informed consent before entering the study.

The study was undertaken with the assistance of the Canterbury Initiative (http://www.cdhb.health.nz/about-us/key-projects-and-initiatives/canterbury-initiative/). Initially, the study recruited participants from the community using general practices in the surrounding areas of the proposed venues. However, only a small number of referrals were received from these practices. However, further referrals were received following promotion of the study on Canterbury DHB websites including Community HealthPathways and HealthInfo Canterbury (http://www.cdhb.health.nz/wp-content/uploads/23631e22-healthpathways-healthinfo-programme-profile.pdf) and in an email newsletter to Pegasus Health practices.

Inclusion criteria for the study were aged 18 years or older, a diagnosis of IBS predominant diarrhoea (IBS-D) or IBS predominant constipation and diarrhoea (IBS-M) made by a physician using the ROME IV criteria and negative coeliac markers.17 Participants were excluded if they had inflammatory bowel disease, IBS with constipation only, diabetes mellitus, history of bowel resection, BMI ≤18.5kgm2 or ≥35kgm2, unintentional weight loss, limited comprehension of English, living in residential care and previous dietetic supervision on the low FODMAP diet.

Group education sessions

A New Zealand registered dietitian with experience in IBS dietary management led the education sessions. The initial 90-minute sessions focused on eliminating high FODMAP foods from the diet for six weeks and included discussion around how to overcome common challenges encountered on a low FODMAP diet. Opportunities for engagement between the participants was encouraged during the session including a label reading group activity. Validated questionnaires including the Assessment of Gastrointestinal Symptoms (SAGIS)16 and Hospital Anxiety and Depression Scores (HADS)17 that measured gastrointestinal and psychological symptoms, respectively were completed prior to the intervention and six weeks later. The SAGIS questionnaire uses a five-point rating scale to assess the severity of symptoms (no problem=0, mild=1, moderate=2, severe=3 and very severe=4), while the HADS questionnaire utilises a 4-point rating scale of 14 items divided into two domains, anxiety and depression.

A semi-structured interview was performed by telephone after six weeks to assess the group education sessions and resources provided and record the participant’s acceptability and attitudes towards following a low FODMAP diet. All the interviews were transcribed and a thematic inductive approach used to identify broad themes in the responses.18

If the patient’s symptoms had improved by ≥50%, they were invited to attend a second group education session. Participants with no improvement in symptoms were referred back to their GP. These 60 minute follow-up sessions were held nine weeks after the first and focused on how to safely and correctly challenge for each FODMAP group. Participants were advised to gradually introduce food containing each FODMAP, starting with small amounts and then increasing intake, and allow days between each challenge in order to monitor symptoms and determine their tolerance to the specific FODMAP.

In both sessions the class was taught using a PowerPoint presentation on a screen projector and given written information to take home. Participants were also encouraged to visit websites and web apps for meal and recipe ideas such as ‘A Little Bit Yummy’ and the Monash University low ‘FODMAP Diet app.19,20

Statistical analysis

The SAGIS and HADS data were analysed using the statistical software programme; IBM SPSS Statistics 25 (1998, 2017, US). The SAGIS questionnaire scores were analysed using paired t-tests, while the HADS scores were stratified into their domains, anxiety and depression an analysed using chi-square and paired t-tests. The study was not designed, or adequately powered to test clinical significance, but only numerical significance (p<0.05).

Results

Attendance

The flow of the patients from referral to attendance at the two education sessions is shown in Figure 1. Of the 25 referrals, three individuals reported they could no longer proceed with the referral, leaving 22 who were sent a booking for the first education session (elimination phase). However, only 17 of these individuals attended the first education session (attendance rate 77%). Those who did not attend were contacted regarding why they could not attend; one participant had not received any information or appointment, one could not take time off work, and another participant who was called into work unexpectedly. The baseline characteristics of the 17 participants who attended the first education session participants is shown in Table 1. All 17 participants were contacted by a member of the research team seven to eight weeks after the first education session who carried out a semi-structured interview. This showed 13 participants (76%) had a ≥50% improvement in their IBS symptoms, while two participants reported no improvement (12%) and two had not implemented the diet (12%). The 13 participants with symptomatic improvement were then given a booking for the second education session (Reintroduction phase), although only 11 attended.

Figure 1: Disposition of participants.

n; number of participants,
FODMAP; Fermentable Oligosaccharide Disaccharide Monosaccharide and Polyols,
IBS; irritable bowel syndrome.

Table 1: Baseline characteristics of study participants.

n; number, BMI; body mass index (weight (kg) divided by height squared (m)2 ).
a n=19. Three participants did not have heights recorded for BMI to be calculated.
b n=19. Three participants were unable to be contacted to determine IBS subtype.
c n= 18. Based on the SAGIS questionnaires answers completed by participants who returned the first questionnaire.

Semi-structured interviews to assess improvements in symptoms

Results from the telephone interviews showed a range of benefits in group education and the general response from participants about the low FODMAP diet were positive. Most participants felt that the information provided at the session was sufficient for them to implement the low FODMAP diet for six weeks. Table 2 shows a summary of the main and sub themes identified.

Table 2: Summary of themes derived from semi-structured interviews.

Participants expressed a change in their relationship with food and eating; one expressed that they “definitely changed some of my thinking” and another “I’m more aware what I’ve been eating but also how I’ve been eating”. More effort into meal planning was reported by the participants. Most of participants had used the ‘A Little Bit Yummy’ website, while some had purchased the Monash app and found its accessibility and convenience to be very helpful: “I downloaded the app, the FODMAP app, it sort of gave me enough products on there to give me an idea”. Most participants agreed that finding low FODMAP alternatives for foods that they often ate was really helpful.

Behavioural change proved to be the biggest challenge for most participants. One participant expressed that “It was harder at the beginning but towards the end it was quite simple now really”, while another reported that “(it was) really just changing my habits”. Another common challenge faced by the participants included social gatherings and eating out, with one stating that she “just wanted to fit in with other people” and another saying “they were distracted more than anything, conversations happen”. “The garlic and onion scenario” was a common challenge that participants experienced both at home and eating out.

Symptom-related questionnaires

A total of 32 SAGIS questionnaires and 31 HADS questionnaires were collected throughout the study. Participants were excluded from final data analysis if they had not attended the first education session or had not implemented the low FODMAP diet for a minimum of six weeks.

Table 3 summarises the mean scores of the 24 variables in the SAGIS questionnaire before and after the group low FODMAP diet intervention. There was a significant reduction (p<0.05) in scores for 19 of the 24 variables. The symptom with the greatest improvement was bloating (p<0.0001), while scores for belching, dysphagia, early satiety, loss of appetite and vomiting showed a non-significant improvement.

Table 3: Changes in gastrointestinal symptoms following group low FODMAP diet intervention.

*p<0.05.

Anxiety and depression was measured using the HADS. For both anxiety (11.2 [SD 4.3] vs 8.17 [SD 4.2], p<0.001) and depression (7.7 [SD 1.9] vs 5.3 [SD 1.8], p<0.001) there was a significant reduction in the total scores following the low FODMAP intervention. However, when analysing these results categorically (using predefined ‘normal’ [<7], ‘borderline abnormal’ [8–11] and ‘abnormal’ [>12] categories) there was no significant change (p>0.05).

Conclusions

To our knowledge, this is the one of the first studies to formally evaluate the feasibility and effectiveness of a dietitian-led low FODMAP group education programme for dietary management of IBS. Our results support those of Whigham et al and demonstrate that dietitian-led low FODMAP group education in a community-based setting is effective and feasible in the management of IBS.

Our initial recruitment method was similar to that currently used in clinical practice with GPs referring patients directly to dietitians. However, we achieved greater success when using a combination of recruitment strategies such as websites, clinic visits, and e-newsletters. The attendance rate of 77.3% for the first session and 85% for the second session are positive indicators that participants were willing to attend and were satisfied with the education they received. Seventy-six percent of participants reported ≥50% improvement in their IBS symptoms, whereas the remaining participants did not experience any improvement or did not start the diet. These participants who do not experience any improvement were referred back to their general practitioner or health provider for their individualised IBS care. We anticipated that not all patients would improve with a low FODMAP diet, as similar to other dietary therapies, there is evidence that this diet does not work for every individual.21

Results from the telephone interviews showed that participants were generally positive and found the group education programme enhanced their understanding and acceptability of the low FODMAP diet. Our results are consistent with other IBS or non-IBS group dietary interventions, which demonstrated that group settings increase patients’ acceptability of the treatment through sharing of experiences as well as comradery with other patients.13,22,23 Furthermore, suitable educational resources as well as references to websites and apps also increased adherence and acceptability of the low FODMAP diet, a finding consistent with published literature.25,26 Websites and web apps such as ‘A Little Bit Yummy’ and the ‘Monash University Low FODMAP Diet App’ are increasing in popularity as they provide a fast and accessible platform for FODMAP friendly meals and products. However, the increase in web-based education creates uncertainty and vulnerability for evidence-based advice on low FODMAP diets, with individuals without the necessary expertise possibly delivering misleading information. More research is therefore warranted on the efficacy and safety of emerging web-based platforms.

Participants who did not start the diet after attending the initial session, expressed that they had personal reasons for not doing so. Suggesting it was not due to the delivery of intervention, but rather personal reasons. Screening for those suitable for one-to-one delivery rather than group delivery should be of importance when delivering a group education programme. Whigham et al employed a triage system using a telephone screening clinic to allocate participants’ suitability for group versus one-to-one education.11 Anecdotal feedback from a dietitian-led low FODMAP group education session at Christchurch Public Hospital also emphasised the need for a more vigorous screening process. Although our study employed strict exclusion criterium, telephone screening may be more useful for identifying those participants suitable for group education.

Significant improvements were observed in most gastrointestinal symptoms in our participants, supporting the findings of Whigham et al.13 In their study, 54% of participants were satisfied with their gut health following the intervention. Comparatively, our study found that 87% (13/15) of participants who implemented the diet were satisfied with their symptomatic improvement at the end of intervention. Our study also found similar symptomatic improvement comparative to that of traditional one-to-one education. Improvements in abdominal symptoms such as bloating, loose bowel motions, stool consistency and flatulence in our study were found to be consistent and significant similar to studies that used the traditional one-to-one pathway.26,27

A positive effect of the group low FODMAP education programme on psychometric and psychosocial measures was also observed in this study. There is limited literature regarding the impact of IBS group education on anxiety, depression, and health related quality-of-life. Some studies suggest that individualised dietary education and counselling improves patients’ understanding of IBS and their dietary management of IBS and hence their overall mood and quality-of -life.28–30 However, Whigham et al did not measure psychometrics and health-related quality of life. In our study, between 45–50% of participants reported having anxiety or depression symptoms prior to entering the study. Although the anxiety and depression scores did not improve significantly, the nature of the intervention, pre-existing psychological disorders, and the small number of participants would not have been expected to provide the study with sufficient statistical power to investigate these changes. Long-term behavioural therapy, medications and other strategies besides dietary management and a longer follow-up period may possibly demonstrate more positive changes in mental health and hence HADS scores.

The mixed methods design of our study meant it was possible to assess both the feasibility and practicality of a low FODMAP group education programme. Our quantitative data needs to be viewed with caution and interpreted in context with the limitations of the study. There was also no comparator group and participants were not blinded to the intervention, although this is extremely difficult for a whole diet study. Despite these limitations, the results are promising with clinical improvement being seen across a wide range of relevant gastrointestinal symptoms.

Given that this study has demonstrated that low FODMAP group education in a community setting is feasible in a New Zealand context, future research should investigate the efficacy of low FODMAP group education in terms of reintroduction and diet modification. Efficacy in a range of ethnicities and IBS phenotypes should also be examined. Clinical trials powered to determine whether low FODMAP group education is effective at improving gastrointestinal and psychological symptoms in patients with functional gastrointestinal disorders such as IBS in a cost-effective way are warranted.

In conclusion, a dietitian-led low FODMAP diet group education programme in adults diagnosed with IBS-D or IBS-M is an effective and feasible intervention. A dietitian-led low FODMAP group education programme is worthy of consideration in routine clinical practice.

Summary

Abstract

Aim

To investigate the feasibility and effectiveness of dietitian-led education on using the low fermentable oligosaccharide, disaccharide, monosaccharide and polyols (FODMAP) diet in adults with irritable bowel syndrome (IBS) in Christchurch, New Zealand.

Method

Patients with IBS (n=25) were referred by their general practitioner to attend a group education programme. The number recruited and subsequent attendance were used to evaluate feasibility. The Structured Assessment of Gastrointestinal Symptoms (SAGIS) questionnaire and Hospital Anxiety and Depression Scale (HADS) were compared at baseline and at follow-up. Semi-structured telephone interviews assessed the acceptability of the education programme.

Results

Of the 25 recruited participants, 17 attended the group education programme. The SAGIS score decreased significantly (p<0.05) between baseline (mean 1.844) and follow-up (mean 0.607). Similarly, there was non-significant trend of lower HADS anxiety and depression scores from baseline to follow-up. Symptomatic improvement was reported by 13 participants (76.5%), while two participants (11.8%) did not improve and two others (11.8%) had not implemented the diet. Overall, participants were positive and grateful for the improvement the diet had made to their symptoms.

Conclusion

A dietitian-led low FODMAP group education programme in Christchurch adults with IBS was found to be both feasible and effective.

Author Information

Dorcas Chan, Human Nutrition and Medicine, University of Otago, Christchurch; Paula Skidmore, Human Nutrition and Medicine, University of Otago, Christchurch; Leigh O’Brien, Human Nutrition and Medicine, University of Otago, Christchurch; Sally Watson, The Canterbury Initiative, Canterbury District Health Board, Christchurch; Richard Gearry, Medicine, University of Otago, Christchurch.

Acknowledgements

The study would like to acknowledge the participant’s involvement in the study. The study would also like to acknowledge Dr Brett Shand, Clinical Writer and Analyst (Canterbury Initiative) for his expertise and contribution to the writing of this paper.

Correspondence

Professor Richard Gearry, University of Otago, 2 Riccarton Ave, Christchurch Central, Christchurch 8011.

Correspondence Email

richard.gearry@cdhb.health.nz

Competing Interests

Dr Gearry reports grants from Zespri, grants from AbbVie, outside the submitted work. Ms Watson reports personal fees from Canterbury DHB and personal fees as a self-employed dietitian, outside the submitted work.

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