Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland

Whole grains are recommended but

can everyone eat them?
Project worker Leena Putkonen, authorized nutritionist
The Consumers Association of Finland
Whole grains for Health
Finlandia Hall
November 5th, 2013
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Clinical perspective
Ummm should I go
for the broccoli dish
or the juicy raw steak
today?
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Background
Qualifications
The low FODMAP diet course, Kings College, London
2010/2011
Practical training at Monash University Department of
Gastroenterology 06-09/2012
The low FODMAP diet headquarter

Clinical practice on esp. the low FODMAP diet since 05/2010

Conflict of interest: none
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Topics of the presentation
Why are grains perceived problematic?
Whole grains in different diets
Coeliac disease
Irritable bowel syndrome and the low FODMAP
diet
Non-celiac gluten sensitivity (NCGS) vs. wheat
intolerance
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Reminder:
Definition of
whole grain
Typical grains are
energy dense and can
vary in starch content
(typically 5080%),
depending on the
species, origin and
environmental growing
conditions.
Source: Healthgrain Forum
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Negative symptoms related to eating
foods made from (whole) grains
Which component in food
causing symptoms?
Compare milk protein allergy vs. lactose
intolerance
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Is there a timely correlation
between eaten foods and
symptoms?

Most patients ignore a few factors...
Negative symptoms related to eating
foods made from (whole) grains
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Individual transit time
Amount of foods
I get symptoms straight after lunch!
When I make pancakes, I eat
at least a dozen.
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Wheat is to blame
Being addictive
Causing overeating and obesity, visceral fat
Sudden alteration in blood glucose levels
The root cause of non-communicable diseases
facing us


No data to support these suggestions.
Brouns et al. Does wheat make us fat and sick? Journal of Cereal Science
58 (2013) 209e215, open access
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Whole grains and celiac disease
Buckwheat
3.5 g fibre/portion
Rye
2. 9 g fibre/slice
4.8 g/porridge portion
Gluten free oats
2 g fibre/portion
4 g/porridge portion
Wheat, pasta
2.6 g fibre/portion
Quinoa
4.2 g fibre/portion
Portion 150 g
cooked product

Porridge portion
300 g
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Irritable bowel syndrome
Prevalence in a modern Western
population: 10-15 %
Symptoms: abdominal pain, bloating,
wind, constipation and/or diarrhea
Most patients associate symptoms with
foods


Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
The low FODMAP diet
Approx. 70-75 % of people with IBS benefit from the
diet

Shepherd and Gibson (J Am Diet Assoc 2006; 106:1631-1639)
Retrospective study of 64 IBS patients on the low FODMAP diet
77% adhered
3/4 had marked improvement of all IBS abdominal symptoms

Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
The low FODMAP diet
Staudacher et al. 2011 (J Hum Nutr Diet, 24: 487495)
In the UK
Parallel groups, the low FODMAP diet (n=43) vs. NICE guidelines
(n=39)
79 % in the low FODMAP group satisfied with symptoms control
vs. 54 % in the NICE group

Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Staudacher et al. 2012 (J Nutr. 142(8):1510-8)
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Roest et al. 2013 (Int J Clin Pract, 67, 9: 895903)

In New Zealand
90 IBS patients
Mean follow-up
15.7 months
Significant
improvement in
symptoms
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Halmos et al. 2013
Halmos et al. A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel
Syndrome, Gastroenterology (2013). Online, ahead of press.
Comparing a typical Australian diet to the low FODMAP diet
Randomized, controlled, single-blind, cross-over trial
30 IBS subjects, 8 healthy controls
Both trials lasted for 21 days, in between at least 21 day wash-out
period
Results: gastrointestinal symptom scores (VAS) significantly lower
during the low FODMAP trial in IBS subjects


Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
The FODMAP acronym
FRUCTAN INULIIN FRUCTO-OLIGOSACCHARIDES (FOS)/OLIGOFRUCTOSE
DP 10 DP 3-9
GALACTAN GALACTO-OLIGOSACCHARIDES (GOS)
Fermentable Oligo-, Di- and Monosaccharides And Polyols
Poorly absorbed, fermentable short-chain carbohydrates.
LACTOSE
FRUCTOSE IN EXCESS OF GLUCOSE
POLYOLS (e.g. sorbitol, mannitol, maltitol, xylitol, erythritol)

Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Motility changes Bloating Pain/discomfort Wind
Symptom
induction
Luminal
distension
Fructose Fructans Lactose GOS Polyols Diet
Osmotically active
Rapidly fermented
water
delivery
Physiological
effects
gas
production
How do they trigger symptoms?
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Symptom mechanism
FODMAPs
Small intestine
Gut explansion
Altered motility
Large intestine
Water drawn to the lumen
Gas
Pain, bloating, flatus, diarrhea
(and/or constipation)
Animation by J essica Biesiekierski
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
How do they trigger symptoms?
Osmotically active
Barrett JS et al (2010) Dietary poorly absorbed, short-
chain carbohydrates increase delivery of water and
fermentable substrates to the proximal colon. Aliment
Pharmacol Ther 31, 874-882.
Stimulate gas production
Ong DK et al (2008) The intestinal fermentative
response to dietary FODMAPs; failure to switch to
methane production in patients with irritable bowel
syndrome. J Gastroenterol Hepatol 23(s4), A219.


0 1 2 3 4
all bran
cornflakes
muesli
oats
rice bubbles
sustain
weetbix
GF bread
rye bread
spelt bread
white bread
wholemeal bread
couscous
gnocchi
pasta - gluten free
pasta - quinoa
pasta - wheat
Rice, brown
Rice, white
Excess fructose
Polyols
GOS
Fructans
Gram FODMAP/serve
Levels of FODMAPs in grains/breads/cereals
0.5
Graph: Dr Jane Muir, Monash University
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
The intake of fructans from the diet

The intake of fructans from a regular Westernised diet
ranges from 1-11 g/day (van Loo et al 1995, Roberfroid &
Delzenne 1998).
The most common sources of inulin and oligofructose in
an American population were wheat (70 % of intake)
and onion (23-24 % intake) (Moshfegh et al 1999).
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Calculations on fructan intake
Breakfast Lunch Snack Dinner Evening snack
- Oatmeal, 3 dl
- Sugar-free berry soup
(commercial)
1
,
1.5 dl
- Rye bread, 1 slice

Fructans 3,2 g

- Pasta
- Rye bread,
1 slice



Fructans 1,3 g
- All bran, 40 g
- Vitalinea-
yoghurt, 2 dl



Fructans ~3,5 g
- Rye-crusted
small white fish
- Rye bread, 1
slice


Fructans ~1 g
-Whole grain
wheat roll, 50 g



Fructans, 0.5 g
Total fructan intake: 9,5 g /day

+ fructan, GOS and polyols from vegetables, fruits and legumes!
estimated total 30-40 g/day


1
added fibre (oligofructose)
Calculations by Jenni Lappi, University of Eastern Finland
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Halmos et al. 2013
Halmos EP, Power VA, Shepherd SJ , Gibson PR, Muir J G, A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel
Syndrome, Gastroenterology (2013). Online ahead of print.
Comparing a typical Australian diet to the low FODMAP diet
Randomized, controlled, single-blind, cross-over trial
30 IBS subjects, 8 healthy controls
Both trials lasted for 21 days, in between at least 21 day wash-out
period
Amount of FODMAPs/day (all food provided, FODMAP-
content analyzed)
The typical Australia diet The low FODMAP diet
23.7 g/day 3.05 g/day
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
J. Nutr. 142: 1510-1518, 2012
The effect on gut microbiota?
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
The whole grain containing low
FODMAP diet - How to do it?
Things to consider:
Fibre
B vitamins, esp. folic acid
Level of activity, the amount of
carbohydrate-rich food needed
In some cases: affordability or access to
suitable products
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
RDI for fibre, 25-35 g
100 % oat bread, 2 slices 5 g
maize-rice crisp bread, 2 pieces 4 g
a portion of oatmeal porridge 4 g
70 % oat fibre, 1 tbsp 3.5 g
a portion of wholegrain rice 4.5 g
an orange 4 g
billberries, 2 dl 4 g
half a kilogram of vegetables 10 g
nuts and seeds, 2 tbsp 1.5
Total 38.5 g
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Non-celiac gluten sensitivity (NCGS)
Carbohydrate Protein
Fructans
Starch
Non-starch polysaccharides
Gluten
Non-gluten proteins
I feel stuffy after eating bread or pasta.

But what component in those food is to blame?

Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
34 patients (aged 29 59 years, 4 men)
Coelic disease ruled out, IBS that was under control on a
gluten-free diet
19 received gluten, 15 placebo
1 muffin + 2 slices of bread (16 g of gluten/day or none), 6 weeks,
to be consumed daily
No wheat
Am J Gastroenterol. 2011 Mar;106(3):508-14
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
- Aiming to reproduce the initial findings (=existence of
NCGS)
- Aiming to inspect the dose-dependency of gluten
- Aiming to find out if gluten is the only triggerer how
about FODMAPs?
Gastroenterology. 2013 Aug;145(2):320-8
Results (n=40)
Effect of low FODMAP diet Overall Symptoms
VAS symptom severity score:
0=none
100=worst
P<0.0001
Wilcoxon signed rank test
Slides by Jessica Biesiekierski
Summary Trial 2
Gluten did not specifically induce symptoms in
patients with self-reported NCGS
Only a minority (n=3) positively responded to gluten
in blinded challenge
Dose-dependent effects unable to be assessed
Despite satisfaction that symptoms were well
controlled by GFD, restriction of FODMAPs
uniformly reduced symptoms
A subject-expectancy (order effect) was found
Slides by Jessica Biesiekierski
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Intolerance to fructans?
Wheat intolerance?
NCGS ?
FODMAPs?
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Read all about it:
Catassi et al. Non-Celiac Gluten Sensitivity: The New
Frontier of Gluten Related Disorders (Nutrients 2013, 5,
3839-3853)


Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
weetabix muesli bar a sandwich
threshold
symptoms
morning afternoon
Individual threshold level
Remove a group of FODMAPs and you may go below an
individual threshold level same for gluten if NCGS?
For some it might be fructans from wheat, and for the
other sorbitol from apple juice thats consumed daily.
Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Discussion: A patient profile
The Modern Day Factor
Stress, anxiousness
Interested in health and welfare access to information made
easy but perhaps lack of skills to apply that information
Sitting all day in front of the computer/patients/the steering
wheel
Seeking help for symptoms that reflect the need for a complete
lifestyle change
Challenging for practitioners! A good patient-
dietician/doctor/nurse relationship key.


Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Discussion: Whole grains are
recommended
and should be
recommended dispite the
need for special diets
Numerous, healthy
alternatives to choose from
Requires good
knowledge on
available products on
the market

Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Discussion:
Dietary counselling advisable (authorized
nutritionist/registered dietitians)
Risk of not meeting dietary needs
in coeliac disease (Wild et al. Aliment Pharmacol Ther 2010;
32: 573-581; Martin et al. Digestion 2013; 32: 573-581)
in IBS when on the low FODMAP diet (Fe and Ca,
Staudacher et al. 2011, J Hum Nutr Diet, 24: 487495)

Kuluttajaliitto - Konsumentfrbundet The Consumers' Association of Finland
Thank you! Questions or comments?
Very special thanks to:

Monash University, Melbourne, Department of Gastroenterology
Professor Peter Gibson, Dr Jane Muir, Dr Jessica Biesiekierski, CK Yao


Kings College: Diabetes and Nutritional Sciences Division
Dep.of Gastroenterology&Dep. Of Nutrition&Dietetics,
Guys and St Thomas NHS
Dr Miranda Lomer, Heidi Staudacher, Professor Kevin Wheelan

Jenni Lappi, University of Eastern Finland
The Association of Clinical and Public Health Nutritionists in
Finland, RTY