Transcript Low FODMAP Diet Latest Treatment of IBS

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.*
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*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.
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1. Camillieri, M. Am J Physiol Gastrointest Liver Physiol, 2012.
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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. (causing IBS)
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2. Boettcher E, Crowe SE. Am J Gastroenterology, 2013.
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Possible causes
• Malabsorption of carbohydrates causing onset
of symptoms.
• Non Celiac Gluten Sensitivity (NCGS)- new
clinical condition.
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3. Sheparhd SJ, et al. Clin Gastroenterol Hepatol, 2008
4. Biesiekierski JR, et al. Am J Gastroenterol, 2011
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Beneficial bacteria
• Patients with IBS may have lower Lactobacillus
and Bifidiobacterium species in their intestinal
flora.
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5. Kassinen A, et al. Gastroenterology. 2007
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Alteration of bacterial contents
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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)
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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.
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6. Gibson PR, Shepard SJ. Aliment Pharmacol Ther. 2005.
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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.
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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.
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Published reviews (small sample)
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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
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Fructose and Fructans
• Largest amount in North American and
Western European diets
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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
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Fructose Malabsorption
• 40% of the population are considered to have
fructose malabsorption.
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• 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.
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Fructose
• Fruits: Apples, cherries, mangoes, pears,
watermelon
• Vegetables: asparagus, artichokes, sugar snap
peas
• Honey, HFCS
More intensified in dried fruits and overall
amounts
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Lactose Digestion
• A di-saccharide (Glucose and Galactose)
- Requires lactase enzyme to break it down
- Typically occurs in quantities greater than 7g
1. Varying enzymes amounts in the gut are
influenced by:
Genetics
Ethnic background
Gut disorders
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Lactose
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Milk: cow, goat and sheep
Yogurt
Ice cream
Custard
Soft Cheeses: Ricotta, cottage
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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
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Fructans
• Peach, persimmon, watermelon
• Artichokes, asparagus, Brussels sprouts,
chicory, fennel, garlic, onions, leeks
• Wheat, rye, barley
• Pistachios, cashews
• Beans
• Inulin
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GOS
• Beans- raffinose
- Lacking the enzyme a-galactosidase
Baked beans, kidney beans, chick peas, Brussels
sprouts and cabbage
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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
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A Bucket Effect- all FODMAPs
are consumed at once
causing a cumulative effect!
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High FODMAP Food Crossover
Lactose
Fructose
Fructans/
GOS
Polyols
Milk
Artichoke
Artichoke
Cauliflower
Yogurt
Asparagus
Garlic
Mushrooms
Ice cream
Tomatoes
Onions
Peas
Ricotta
Apples
Beans
Apples
Cottage
Cherries
Apples
Pears
Custard
Figs
Figs
Plums
Pears
Plums
Watermelon
Watermelon
Wheat
Sorbitol
Agave
Inulin
Xylitol
Honey
Pistachios
HFCS
Watermelon
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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
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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 12categories 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
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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,
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
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Moderate FODMAPs
• Fructans: (limited to 1 choice per meal) beet root4 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
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Proficient Label Reading!
• A label may contain a high FODMAP
ingredient, but look where it falls on the list
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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
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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
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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
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There’s an APP for that
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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
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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!
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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
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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
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THANK YOU!
Laura Manning
[email protected]
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