0. 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

1. 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

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. 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 % of GI visits are due to IBS.*
*International Foundation for Functional Gut Disorders (IFFGD)

5. 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.

6. 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

7. 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).

8. 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.

9. 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

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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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

16. 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.

17. 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

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

20. 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.

21. 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

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

23. 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

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

25. 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)

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

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

28. 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

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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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

37. 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

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

39. There’s an APP for that

40. 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

41. 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

42. 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

43. 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

44. 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.

45. 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

46. 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

47. 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.

48. 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.

49. 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

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

51. Published reviews (small sample)5
Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach - Journal of Gastroenterology and Hepatology 25 (2010)
Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management – Journal of the American Dietetic Association;2006;106:pp
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) pp
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: pp
Food for thought: Western Lifestyle and Susceptibility to Crohn’s Disease – The FODMAP Hypothesis – Alimentary Pharmacology & Therapeutics; 2005:21:
Review article: Fructose Malabsorption and The Bigger Picture – Alimentary Pharmacology. & Therapeutics. 2007;25(4) pp
For Celiac Disease, Diagnosis Is Not Enough- Clin. Gastroenterol. Hepatol. 2012;8:
Nutritional inadequacies of the gluten‐free diet in both recently‐diagnosed and long‐term patients with coeliac disease- J. Human. Nutr DOI: /jhn
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 Aug ;25(8):
Dietary FODMAPs increase delivery of water and fermentable substrates to the proximal colon - Aliment. Pharmacol. Therapeutics. 2010;31(8):
Comparison of the prevalence of fructose and lactose malabsorption across chronic intestinal disorders - Aliment. Pharmacol. Therapeutics 2009;30(2):
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
Short-Chain Carbohydrates and Functional Gastrointestinal Disorders- Am. J. Gastroenterol. 2013;108:
Design of Clinical Trials Evaluating Dietary Interventions in Patients With Functional Gastrointestinal Disorders- Am. J. Gastroenterol. 2013;108:
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):

52. THANK YOU!
Laura Manning