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Diet and the Gut

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Diet and the Gut World Gastroenterology Organisation Global Guidelines Diet and the Gut April 2018 Review Team Govind Makharia (chair, India), Peter Gibson (co-chair, Australia), Julio Bai (Argentina), Sheila Crowe (USA), Tarkan Karakan (Turkey), Yeong Yeh Lee (Malaysia), Lyndal McNamara (Australia), Jane Muir (Australia), Nevin Oruc (Turkey), Eamonn Quigley (USA), David Sanders (UK), Caroline Tuck (Australia), Cihan Yurdaydin (Turkey), Anton LeMair (Netherlands ) Funding and conflict of interest statements • The following authors reported that they have no conflicts of interest in relation to the development of this guideline: Govind Makharia, Julio Bai, Sheila Crowe, Tarkan Karakan, Yeong Yeh Lee, Nevin Oruc, Eamonn Quigley, David Sanders, Cihan Yurdaydin. • Peter Gibson has written a recipe/education book on the low FODMAP diet. Monash University sells a digital application, booklets, and on-line education on the low FODMAP diet. • Caroline Tuck, Lyndal McNamara, and Jane Muir reported that Monash University sells a digital application and booklets on the low FODMAP diet, and an online course to train dietitians in how to implement the low FODMAP diet. Funds raised contribute to research in the Department of Gastroenterology at Monash University. The authors receive no personal remuneration. • Anton LeMair acts as guidelines development consultant for WGO. WGO Global Guidelines Diet and the Gut 2 Contents 1 Key recommendations and cascades ........................................................................................ 4 1.1 Introduction ............................................................................................................................... 4 1.2 Cascades of diet options and alternatives ................................................................................. 5 2 Fiber in the diet ........................................................................................................................ 7 2.1 Introduction ............................................................................................................................... 7 2.1.1 Types of dietary fiber ........................................................................................................ 8 2.1.2 Beneficial effects of dietary fibers .................................................................................... 8 2.1.3 Interaction of dietary fibers with the gut microbiota ..................................................... 10 2.2 Role of dietary fiber in gastrointestinal conditions .................................................................. 10 2.2.1 Constipation.................................................................................................................... 10 2.2.2 Irritable bowel syndrome (IBS) ....................................................................................... 11 2.2.3 Inflammatory bowel disease (IBD) ................................................................................. 11 2.2.4 Diverticular disease ........................................................................................................ 11 2.2.5 Colorectal cancer ............................................................................................................ 12 2.2.6 Clinical indications for a low-fiber diet ........................................................................... 12 2.3 Fiber intake and recommendations ......................................................................................... 13 2.4 Addressing the “fiber gap” ....................................................................................................... 14 2.5 Cascade guidelines—dietary fiber ............................................................................................ 16 3 The low FODMAP diet ............................................................................................................. 16 3.1 Introduction ............................................................................................................................. 16 3.1.1 What is the low FODMAP diet? ...................................................................................... 16 3.1.2 How to implement a low FODMAP diet: reintroduction and problems/limitations ...... 17 3.2 Gastrointestinal conditions and the low FODMAP diet ........................................................... 20 3.2.1 Indications for low FODMAP diet ................................................................................... 20 3.2.2 The low FODMAP diet, functional dyspepsia (FD), and IBS ............................................ 21 3.3 Cascade guidelines—FODMAP ................................................................................................. 21 4 Carbohydrate intolerance ....................................................................................................... 21 4.1 Lactose intolerance / lactase deficiency .................................................................................. 21 4.1.1 Definition of terms.......................................................................................................... 21 4.1.2 Lactose intolerance in perspective: when is it relevant?................................................ 21 4.1.3 Symptoms of lactose intolerance ................................................................................... 22 4.1.4 How to diagnose: in resource-limited and well-resourced settings ............................... 22 4.1.5 How to treat ................................................................................................................... 23 4.2 Fructose intolerance ................................................................................................................ 24 4.2.1 Definition of terms.......................................................................................................... 24 4.2.2 Proposed mechanisms .................................................................................................... 25 4.2.3 Intake of fructose............................................................................................................ 25 4.2.4 Use of dietary modification ............................................................................................ 25 4.2.5 Recommendations .......................................................................................................... 25 4.3 Sucrase–isomaltase deficiency ................................................................................................. 26 4.3.1 Congenital sucrase–isomaltase deficiency ..................................................................... 26 4.3.2 Secondary or acquired sucrase–isomaltase deficiency .................................................. 26 4.3.3 Diagnosis ......................................................................................................................... 26 4.3.4 Treatment ....................................................................................................................... 27 © World Gastroenterology Organisation, 2018 WGO Global Guidelines Diet and the Gut 3 4.4 Cascade guidelines ................................................................................................................... 27 5 Other dietary interventions in IBS ........................................................................................... 27 6 Appendix ................................................................................................................................ 29 6.1 Abbreviations ........................................................................................................................... 29 6.2 Organizations publishing relevant guidelines .......................................................................... 30 6.3 References ................................................................................................................................ 30 List of tables Table 1 Cascade of guidelines on dietary fiber ........................................................... 5 Table 2 Cascade of recommendations on FODMAP ................................................... 5 Table 3 Cascade of recommendations on carbohydrate intolerance ......................... 6 Table 4 Definitions ...................................................................................................... 8 Table 5 Summary of the physiological effects of different types of fiber .................. 9 Table 6 Recommended and actual fiber intake in different countries ..................... 13 Table 7 Possible barriers to dietary change and solutions ....................................... 15 Table 8 Clinical management flowchart for using the low FODMAP diet ................ 18 Table 9 Three-step process for implementing the low FODMAP diet ...................... 19 Table 10 Food sources of FODMAPs and suitable alternatives ................................ 19 Table 11 Clinical symptoms and pathophysiology of lactose intolerance ................ 22 Table 12 Food items that are restricted or allowed in lactose intolerance .............. 24 Table 13 Abbreviations used in this WGO guideline ................................................. 29 List of figures Fig. 1 Dietary intake fiber by region (data from 2010) ............................................. 14 Fig. 2 Classification of indigestible and slowly absorbed carbohydrates relevant in IBS .............................................................................................................
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