Low FODMAP Diet Latest Treatment of IBS Laura

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

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-brainnervous system interact. • Impacts physical, emotional, financial and social well being • Few seek medical care- 20 -40% of GI visits are due to IBS. * 1 *International Foundation for Functional Gut Disorders (IFFGD) https: //www. aboutibs. org/site/what-is-ibs/facts/

Irritable Bowel Syndrome (IBS) • A condition characterized by abdominal pain, bloating, flatus and altered bowel habits. - 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 1. Camillieri, M. Am J Physiol Gastrointest Liver Physiol, 2012. 2

Allergy vs. Intolerance • Food Allergy- the reproducible adverse reaction arising from specific immune responses occurring from specific food antigens. Ig. E mediated • Food Intolerance- Similar reactions that occur without evidence of immunologic mechanisms. (causing IBS) 2 2. Boettcher E, Crowe SE. Am J Gastroenterology, 2013. 3

Possible causes • Malabsorption of carbohydrates causing onset of symptoms. • Non Celiac Gluten Sensitivity (NCGS)- new clinical condition. 3 FODMAPS 4 3. Sheparhd SJ, et al. Clin Gastroenterol Hepatol, 2008 4. Biesiekierski JR, et al. Am J Gastroenterol, 2011 4

Beneficial bacteria • Patients with IBS may have lower Lactobacillus and Bifidiobacterium species in their intestinal flora. 5 5. Kassinen A, et al. Gastroenterology. 2007 5

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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) 7

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 6. Gibson PR, Shepard SJ. Aliment Pharmacol Ther. 2005. 8

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. 9

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. 10

Published reviews (small sample) 5 11

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 12

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

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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 15

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. 2013. 16

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

Lactose Digestion • A di-saccharide (Glucose and Galactose) - Requires lactase enzyme to break it down - Typically occurs in quantities greater than 7 g 1. Varying enzymes amounts in the gut are influenced by: Ø Genetics Ø Ethnic background Ø Gut disorders 18

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

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 20

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

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

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 23

A Bucket Effect- all FODMAPs are consumed at once causing a cumulative effect! 24

High FODMAP Food Crossover Lactose Fructans/ GOS Polyols Milk Artichoke Cauliflower Yogurt Asparagus Garlic Mushrooms Ice cream Tomatoes Onions Peas Ricotta Apples Beans Apples Cottage Cherries Apples Pears Custard Figs Plums Pears Plums Watermelon Wheat Sorbitol Agave Inulin Xylitol Honey Pistachios HFCS Watermelon 25

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 person 26

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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 12 categories to limit. • A temporary diet: 2 -6 weeks max • Step 2: Reintroduction Phase. Intro of one category at a time to test intolerance and volume limits 7 28

Low FODMAPs • Lactose: Aged cheese, LF dairy, Brie, Mozzarella, kefir, LF yogurtplain, 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, 1015 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 29

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 30

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

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 32

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 33

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 34

There’s an APP for that 35

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 36

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! 37

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 38

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 39

THANK YOU! Laura Manning Laura. manning@mountsinai. org 40