Low FODMAP Diet Latest Treatment of IBS Laura Manning, MPH, RD, CDN Susan and Leonard Feinstein Center for IBD Department of Gastroenterology Mount Sinai Medical Center

Agenda 1. What is IBS and possible causes 2. Review-How do we digest short chain carbs 3. What is the Low FODMAP diet 4. How to implement it in your practice

Irritable Bowel Syndrome (IBS) A condition characterized by abdominal pain, bloating, flatus and altered bowel habits1. Induced by intestinal luminal distention in addition to visceral hypersensitivity. Dietary factors may alter luminal distention with increased water and gas volume, causing diarrhea. Other symptoms: tiredness, heartburn, nausea, fogginess. 1. Camillieri, M. Am J Physiol Gastrointest Liver Physiol, 2012.

Facts about Irritable Bowel Syndrome (IBS) Affects 25 to 45 million people in US, more common in females. Usually under the age of 50 Possible cause: disturbance in the gut-brain-nervous system interact. Impacts physical, emotional, financial and social well being. Typically brought on by stress. Few seek medical care- 20-40% of GI visits are due to IBS.* *International Foundation for Functional Gut Disorders (IFFGD) https://www.aboutibs.org/site/what-is-ibs/facts/

Allergy vs. Intolerance Food Allergy- the reproducible adverse reaction arising from specific immune responses occurring from specific food antigens. IgE mediated Food Intolerance- Similar reactions that occur without evidence of immunologic mechanisms.2 (causing IBS) Foods are not considered the cause, but a trigger! If you are not sure, send them to an allergist. Does it happen seasonally, Oral allergy syndrome, etc. any physical manifestations. 2. Boettcher E, Crowe SE. Am J Gastroenterology, 2013.

Possible causes Malabsorption of carbohydrates causing onset of symptoms.3 Non Celiac Gluten Sensitivity (NCGS)- new clinical condition.4 No longer beneficial to do just a gluten free diet. We must start to look at the food system as a whole. NCGS- a new term but there are no current biomarkers to diagnose it- just exclusion of it in the diet. Caused by: wheat proteins amylase trypsin inhibitors 3. Sheparhd SJ, et al. Clin Gastroenterol Hepatol, 2008 4. Biesiekierski JR, et al. Am J Gastroenterol, 2011

Current Food Trends Fructose-Our intake of fructose is increased to 22% of daily caloric intake-High fructose corn syrup (HFCS) in soda, candy and food products. Fructans- due to a wheat-heavy culture. Inulin- added in “Functional Foods”, formulas! Polyols- sugar free additives to lower calories and to protect teeth (gums and mints).

Fructose and Fructans Largest amount in North American and Western European diets Interesting to note about the differences in wheat comparing european breads and pastas to ours. The gluten load is much less, VITAL GLUTEN additive.

Changes in gut bacteria Patients with IBS may have lower Lactobacillus and Bifidiobacterium species in their intestinal flora.5 High meat and dairy diets are shown to change gut flora These species do not produce gas upon fermenting carbs which meals that the more you have the easier it is to digest FODMAPs: Lactobacillus GG- Culturelle/ B. Infantis: Align 5. Kassinen A, et al. Gastroenterology. 2007

Go to the Museum of Natural History to see exhibit on the microbiome

Alteration of Gut Bacteria High antibiotic use, especially in children C-sections High animal protein and dairy diet Intestinal surgeries: ICR, bariatric Celiac disease Motility disorders: gastroparesis Inflammatory Bowel Disease (IBD) Post infectious IBS: gastroenteritis Small Intestinal Bacterial Overgrowth (SIBO) SIBO: increased permeability in the small intestine and fermentation of malabsorbed carbohydrates causing abdominal pain and discomfort. Breath testing is needed. And a high output of breath hydrogen, methane. You can test fructose, lactose and sorbitol via breath test but you cannot test fructans and galactans since they are always fermented and malabsorbed.

Maybe they can’t digest certain carbohydrates? FIBER- long chain, non-digestible carbs in small intestine. Important for stool formation an proper bowel function STARCH- long chain carbs completely digested in the small intestine. SUGARS- short chain carbs that may or may not be easily digested. Depends on the type……. Glucose and sucrose are completely absorbed without problem.

How are they not digested Malabsorbed and pull water (osmotic shift) in to the small intestine and cause diarrhea. When sugars reach the large intestine, they ferment by bacteria and cause gas. The gas can slow movement through the bowel causing constipation. Additionally: nausea, bloating, and cramps.

Ingested fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) are poorly absorbed in the small intestine. Their small molecular size results in an osmotic effect, drawing water (H20) through to the large intestine. FODMAPs are then fermented by colonic microflora, producing hydrogen (H2) and/or methane gas (CH4). The increase in fluid and gas leads to diarrhea, bloating, flatulence, abdominal pain, and distension. http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=3966170_GH-11-739-g002.jpg

Fermentable Oligo-Di- Monosaccharides and Polyols (FODMAPs) A heterogeneous group of poorly absorbed, short-chain carbohydrates, which seem to be possible IBS symptom inducers. Restricting these from the diet could produce beneficial effects. Term coined in 2005 by a group of Australian researchers at Monash University claiming that these forms of carbs may worsen symptoms of IBS and IBD.6 Shepard ( an RD PhD) and team were the first to confirm the role of a low FODMAP diet in managing GI complaints with a research trial 6. Gibson PR, Shepard SJ. Aliment Pharmacol Ther. 2005.

Shepard, SJ. Et al. J Am Diet Assoc. 2006 Using a retrospective study-74% of patients reported symptom improvement utilizing the Low FODMAP diet regimen.

Halmos EP, Gastroenterology. 2014 Crossover study where patients with IBS effectively reduced functional GI symptoms when on a Low FODMAP diet. * FODMAPs are not the cause of functional bowel disorders, but will act as a trigger. Halmos is also an RD PhD, on Shepards team

FODMAPs Lactose- dairy Fructose- fruits Fructans/GOS- wheat, beans Polyols- sugar alcohols

Digestion of Fructose Free fructose, a simple sugar, requires no digestion. -Absorbed in the small intestine in 2 ways: 1. Co transport with GLUT-2 (a glucose/ fructose transporter). If equal amounts of glucose are available , fructose is efficiently taken up after sucrose hydrolysis. 2. And by alternative transporter GLUT 5 in excess fructose amounts which is present in the border of enterocytes in small intestine. * If fructose load is very large, malabsorption likely will occur Simple solution is to consume some extra gucose (dextrose) tablets. Or if making a smoothie with a high fructose fruit, protein powders may lower the gut load by sweeping fructose along the gi tract.

Fructose Malabsorption 40% of the population are considered to have fructose malabsorption.7 We can typically digest fruits if they have a 1:1 ratio of glucose to fructose. On the diet, 1 serving per day. 7. Douard V. J Physiol. 2013.

Fructose Fruits: Apples, cherries, mangoes, pears, watermelon Vegetables: asparagus, artichokes, sugar snap peas Honey, HFCS More intensified in dried fruits and overall volume amounts

Lactose A di-saccharide (Glucose and Galactose) Requires lactase enzyme to break it down in small intestine Typically occurs in quantities greater than 7g Varying enzymes amounts in the gut are influenced by: Genetics Ethnic background Gut disorders Gut disorder- typically seen in IBD where a pt is in a flare and cannot manage dairy products. Resolves after inflammation settles

Lactose Milk: cow, goat and sheep Yogurt Ice cream Custard Soft Cheeses: Ricotta, cottage

Oligosaccharides Fructans and Galactans (GOS) Fructans and Galactans are the storage carbohydrate of many vegetables Fructose polymer with a glucose terminal end We do not have the enzymes to break these down and therefore are rapidly fermented, causing gas and bloating Typically a great pre-biotic! Galactooligsaccharides/ Fructooligosaccharides (FOS)

Fructans Peach, persimmon, watermelon Artichokes, asparagus, Brussels sprouts, chicory, fennel, garlic, onions, leeks Wheat, rye, barley Pistachios, cashews Beans Inulin

GOS Beans- raffinose Lacking the enzyme a-galactosidase Baked beans, kidney beans, chick peas, Brussels sprouts and cabbage

Polyols The sugar alcohols/ sugar substitutes: Only 1/3 is absorbed in small intestine By passive diffusion dependent on molecular size and pore size in the small intestine. Sorbitol, Mannitol, Xylitol, Erythriol, Isomalt Foods: Apples, apricots, cherries, blackberries, plums, mushrooms, cauliflower Laxatives

A Bucket Effect- all FODMAPs are consumed at once causing a cumulative effect! Coined by Patsy Castos

Typical meal Breakfast: Frosted Mini Wheats and milk, tea with honey Lunch: wheat bread with turkey and American cheese and an apple, cranberry juice Snack: regular, peach flavored yogurt and pretzels Dinner: pasta with tomato sauce and meatballs with a side of asparagus Snack: handful of cashews

Loaded with FODMAPs Breakfast: Frosted Mini Wheats and milk, tea with honey Lunch: wheat bread with turkey and American cheese and an apple, cranberry juice Snack: regular, peach flavored yogurt Pretzels Dinner: pasta with tomato sauce and meatballs with a side of asparagus Snack: Handful of cashews

High FODMAP Foods & Crossover Lactose Fructose Fructans/GOS Polyols Milk Artichoke Cauliflower Yogurt Asparagus Garlic Mushrooms Ice cream Tomatoes Onions Peas Ricotta Apples Beans Cottage Cherries Pears Custard Figs Plums Watermelon Wheat Sorbitol Agave Inulin Xylitol Honey Pistachios HFCS

Variations to consider Clinical testing at Monash Univ. Formal list constructed from mechanical testing of foods Different levels in foods depending on ripeness Different volume of carb load per person Different levels of tolerance per person Some foods have not been tested yet Be aware of many lists that are on the web- they are conflicting and cause a lot of confusion in patients and those trying to do the diet on their own. Consult Monash U for the most up to date info and know the lists are constantly updating

Further Modifications Change the texture of the diet based on the patient symptoms. Ex: IBS-D Cook all vegetables, no salads Have nut butters over nuts Lower fat overall No fruits on an empty stomach

Low FODMAP Diet-Best approaches Work with a dietitian familiar with the diet Step 1: Elimination Phase. A global restriction will have better outcomes versus choosing 1-2 categories to limit.7 A temporary diet: 2-6 weeks max Step 2: Reintroduction Phase. Intro of one category at a time to test intolerance and volume limits Now that dietitian is you! The reintro phase begins when the person has shown that most symptoms have subsided for at least three days.

Low FODMAPs Lactose: Aged cheese, LF dairy, Brie, Mozzarella, kefir, LF yogurt- plain, rice milk, coconut milk Fructose: (1 serving per meal) bananas, blueberries, strawberries, grapes, honeydew, cantaloupe, maple syrup, table sugar Fructans/GOS: bok choy, bell peppers, Swiss chard, carrots, spinach, zucchini, GF breads, GF pasta, potatoes, quinoa, oats, polenta, 10-15 nuts: almonds, macadamia, peanuts, pine nuts, pumpkin seeds, flax and chia seeds. Firm tofu, tempeh Polyols: banana, blueberry, cantaloupe, coconut, lemon, limes, papaya, rhubarb, table sugar, maple syrup, aspartame, stevia

Moderate FODMAPs Fructans: (limited to 1 choice per meal) beet root- 4 slices, broccoli-1/2 cup, butternut squash-1/4 cup, peas -1/3 cup, pomegranate-1/2 small, sweet corn-1/2 cob, canned pumpkin -1/4 cup, canned chickpeas-1/4 cup, canned lentils-1/2 cup Polyols: (limited to 1 choice per meal) avocado-1/8, celery-1/4 stalk, sweet potato-1/2 cup Beverages: espresso, tea: black/white/green/mint, Alcohol: (limited to 1 drink per day) most wine and beer, vodka, gin and whisky

Proficient Label Reading! A label may contain a high FODMAP ingredient, but look where it falls on the list

There’s an APP for that

What about Fats and Proteins? All fats are fine- no carb in them The following proteins are acceptable: Poultry, beef, lamb, pork, eggs and fish Nuts, limited to a handful. Nut butters, 2 TBS Firm tofu, tempeh, seitan

Elimination phase- Sample diet Breakfast: 1 cup corn flakes 1 cup lactose free milk ½ ripe banana 1 cup coffee with lactose free milk and 1 tsp sugar Snack Handful of almonds Lunch 2 slices spelt sourdough bread 2 ounces of turkey 1 tablespoon real mayo Lettuce and tomato ½ cup fresh blueberries ½ cup baby carrots Snack ½ cup lactose free cottage cheese 8 cherry tomatoes Dinner 3 ounces baked salmon 1 cup cooked zucchini Medium baked potato 1.5 tbsp sour cream 2 cups raw spinach ½ cup sliced bell pepper 1 tsp evoo 1 tbsp balsamic vinegar Drinks: water, allowable tea Based on a diet by Patsy Catsos

Adding Flavor Garlic infused oils- cook garlic in oil and remove Herbs: (keep ‘em fresh) basil, cilantro, coriander, rosemary, parsley, tarragon, thyme Stock- made without garlic and onions

Eating out Review menus ahead of time on line and have a plan of action Give instruction about how you would like food to be cooked- baked, broiled, lemon and herbs. Bring snacks, avoid being un-prepared when starving No need to worry about cross contamination

Possible Negative Implications Avoid eliminating whole food groups May be low fiber content - Work in chia seeds, psyllium husk, ground flax and allowable whole grains Limited intake of Prebiotics may not be beneficial for extended periods of time, decreasing concentrations of bifidiobacteria. 8 More studies are needed to see if there are additional negative implications on altering gut flora via the diet. Staudacher, et al. J Nutr, 2012.

Reintroduction Phase 1. As soon as the person starts to feel like their symptoms have significantly lessened, start introducing foods back into to the diet- one category at a time 2. Do not use foods that cross over categories 3. Introduce a small amount, once a day for three days 4. Check in to see if there is any reoccurrence if no, return to Low FODMAP diet and start the next category! 5. Keep a log of symptoms as you go

Sample Re-Intro Fructans wheat, garlic and onions should be tested separately Monday, Tuesday, Wednesday- add 1 teaspoon of chopped garlic to one meal ONCE a day. If ok, resume Low FODMAP diet and go to next category Fructose Thursday, Friday, Saturday- add 1-2 tsp of honey once a day. Must do one test at a time and resume to the Low FODMAp diet- to get a true test and prevent the bucket effect.- Tedious but worth it

Re-Intro Lactose- drink ½ cup of milk Polyols- test Sorbitol and Mannitol separately Sorbitol, have 1 peach Mannitol, have ½ cup mushrooms once a day GOS- have ½ cup of kidney beans * If person failed a challenge, resume low FODMAP diet and wait three days without symptoms.

Diet Of Info! Person walks away with information on how to manage their condition and can choose to alter their diet as needed. * Gives a sense of empowerment! Maybe they will only change their diet if on a business trip/ or save offending foods for the weekend.

Important movers and shakers in the Low FODMAP method: Patsy Catsos, MS, RDN, LD Kate Scarlatta, RD Monash University, Aurtralia:http://www.med.monash.edu/cecs/gastro/fodmap/ Mark Pimentel, MD The New IBS Solution

Quote From A Friend What did we ever do before FODMAPs? - Tamara Duker Freuman

Published reviews (small sample)5 Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach - Journal of Gastroenterology and Hepatology 25 (2010) 252-258 Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management – Journal of the American Dietetic Association;2006;106:pp1631-1639. Dietary Triggers of Abdominal Symptoms in Patients With Irritable Bowel Syndrome: Randomized Placebo-Controlled Evidence – Randomized Placebo-Controlled Evidence – Clinical Gastroenterology and Hepatology, 2008:6 (7) pp765-771. Coeliac Disease and A Gluten Free Diet – Healthy and Heartwise Magazine. Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease – a pilot study – Journal of Crohn’s and Colitis 2008:3(1), pp8-14. Understanding the Gluten-free Diet For Teaching in Australia – Nutrition and Dietetics. 2006:63: pp155-165. Food for thought: Western Lifestyle and Susceptibility to Crohn’s Disease – The FODMAP Hypothesis – Alimentary Pharmacology & Therapeutics; 2005:21: 1399-1409. Review article: Fructose Malabsorption and The Bigger Picture – Alimentary Pharmacology. & Therapeutics. 2007;25(4) pp349-363. For Celiac Disease, Diagnosis Is Not Enough- Clin. Gastroenterol. Hepatol. 2012;8:900-901. Nutritional inadequacies of the gluten‐free diet in both recently‐diagnosed and long‐term patients with coeliac disease- J. Human. Nutr. 2012 DOI: 10.1111/jhn.12018. Food Choice as a Key Management Strategy for Functional Gastrointestinal Symptoms- Am. J. Gastroenterol. 2012; 107:657–666. Manipulation of dietary short chain carbohydrates alters the pattern of hydrogen and methane gas production and genesis of symptoms in patients with irritable bowel syndrome- J Gastroenterol. Hepatol. 2010 Aug ;25(8):1366-73. Dietary FODMAPs increase delivery of water and fermentable substrates to the proximal colon - Aliment. Pharmacol. Therapeutics. 2010;31(8):874-882. Comparison of the prevalence of fructose and lactose malabsorption across chronic intestinal disorders - Aliment. Pharmacol. Therapeutics 2009;30(2):165-74. A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome.- Gastroenterology 2014;146(1)67-75. Characterization of Adults With a Self-Diagnosis of Non-celiac Gluten Sensitivity. Nutrition in Clinical Practice- Nutr. Clin. Pract. 2014. Short-Chain Carbohydrates and Functional Gastrointestinal Disorders- Am. J. Gastroenterol. 2013;108:707-717. Design of Clinical Trials Evaluating Dietary Interventions in Patients With Functional Gastrointestinal Disorders- Am. J. Gastroenterol. 2013;108: 748-758. Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease—a pilot study - J. Crohn’s Colitis 2009;3(1):8-14. Pilot study on the effect of reducing dietary FODMAP intake on bowel function in patients without a colon. - Inflamm. Bowel Dis. 2007;13(12):1522-8 .

THANK YOU! Laura Manning Laura.manning@mountsinai.org