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

1. Facts about Irritable Bowel Syndrome (IBS)
Affects 25 to 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
Few seek medical care % of GI visits are due to IBS.*
*International Foundation for Functional Gut Disorders (IFFGD)

2. 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.

3. 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!
2. Boettcher E, Crowe SE. Am J Gastroenterology, 2013.

4. Possible causes
Malabsorption of carbohydrates causing onset of symptoms.3 FODMAPS
Non Celiac Gluten Sensitivity (NCGS)- new clinical condition.4
No longer beneficial to do a gluten free diet. We must start to look at the food system as a whole.
3. Sheparhd SJ, et al. Clin Gastroenterol Hepatol, 2008
4. Biesiekierski JR, et al. Am J Gastroenterol, 2011

5. Beneficial bacteria
Patients with IBS may have lower Lactobacillus and Bifidiobacterium species in their intestinal flora.5
These species do not produce gas upon fermenting carbs which meals that the more you have the easier it is to digest FODMAPs
5. Kassinen A, et al. Gastroenterology. 2007

7. Alteration of bacterial contents
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. You can test fructose, lactose and sorbitol via breath test but you cannot test fructans and galactans since they are always fermented and malabsorbed.

8. 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 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

9. 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.

10. 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.

11. Published reviews (small sample)5

12. 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

13. Fructose and Fructans
Largest amount in North American and Western European diets

15. 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.

16. 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 meal.
7. Douard V. J Physiol

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

18. Lactose Digestion A di-saccharide (Glucose and Galactose)
Requires lactase enzyme to break it down
Typically occurs in quantities greater than 7g
Varying enzymes amounts in the gut are influenced by:
Genetics
Ethnic background
Gut disorders

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

20. Oligosaccharide Digestion 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

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

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

23. 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

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

25. High FODMAP Food 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

26. Variations to consider
Clinical testing at Monash Univ. Formal list constructed-
Different degrees in foods depending on ripeness
Different volume of carb load in diet
Different levels of tolerance per person
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

28. 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 1-2categories 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

29. 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, 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

30. 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

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

32. 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

33. Let’s get into it 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, tea

34. 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. Grilled chicken, baked potato, steamed string beans.
Bring snacks, avoid being unprepared when starving
No need to worry about cross contamination

35. There’s an APP for that

36. 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

37. Reintroduction
1. As soon as the person starts to feel like their symptoms have significantly lessened, you can 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, start the next category!

38. Sample re-intro
Fructans Monday, Tuesday, Wednesday- add 1 teaspoon of chopped garlic to a meal Fructose Thursday, Friday, Saturday- add 2 tsp of honey

39. Important movers and shakers in the Low FODMAP method:
Patsy Catsos, MS, RDN, LD
Kate Scarlatta, RD
Monash University, Aurtralia:
Mark Pimentel, MD The New IBS Solution

40. THANK YOU!
Laura Manning