1. Tracey Blahy Dietetic Intern Southcoast May 2014
FODMAPs
Tracey Blahy Dietetic Intern Southcoast May 2014

2. What are you going to learn?
Introduction - What does FODMAP stand for - FODMAP’s and digestion - Research - FODMAP’s and IBS
FODMAP’s – application
Your role as a dietitian
Resources, Handouts and Questions

3. What does FODMAPs stand for ?
Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols
FODMAPs - small chain sugars/carbohydrates and fiber
poorly absorbed in small intestine - delivered to the large intestine - small osmotically active molecules - food for bacteria – when eaten gas is produced – fermentation
Poorly absorbed, rapidly fermentable, osmotically active dietary carbohydrates (FODMAPs)

4. What does FODMAPs stand for ?
F is for Fermentable - Carbohydrates that are fermented by bacteria in the large intestine instead of being broken down by our digestive enzymes. - Fermentation results in gas, bloating and pain.
O is for Oligosaccharides - Oligosaccharides are short-chain carbohydrates - Fructans - Fructooligosaccharides (FOS) - Oligo-galactans. - Xylo-oligosaccharides

5. What does FODMAPs stand for ?
D is for Disaccharides - These are pairs of sugar molecules. - Lactose, maltose
M is for Monosaccharides - This describes a single sugar molecule. - Fructose, glucose, galatose, xylose
A is for And - Every list needs a good conjunction.
P is for Polyols - Polyols include sugar alcohols like xylitol, sorbitol, or maltitol.

6. Absorbing and breakdown carbs
Carbohydrate
Why they might cause an issue
Disaccharide
Found in milk. Lactose intolerance is caused by partial or complete lack of the enzyme lactase..
Monosaccharide
Found in fruit. Fructose intolerance is is due to incomplete digestion in the GI track. The absorption of fructose is dependent on glucose. Monosaccharaides are poorly absorbed due to their low capacity transport across the epithelium. Low expression of GLUT5.
Fructans Oligosaccharide
Fructans are completely malabsorbed because the intestine lacks an enzyme to break their fructose-fructose bond. Wheat accounts for the majority of peoples fructan intake.
Galactans Oligosaccharide
Found mostly in beans and lentils. Galactans are malabsorbed as the intestine does not have the enzyme needed to break down galactans.
Polyols
Found naturally in some fruits and vegetables and added as sweeteners to candy, gum and meds. Polyols are too large for passive diffusion.

7. Digestion – The perfect world
Digestion takes place in the small intestine
Transporters take the sugar “energy” to the body
Sugar molecules in large intestine = food for gut flora - good
Short chain fatty acids produced
Fermentation
Osmosis
Salt and water absorbed Perfectly controlled by the: ENTERIC NERVOUS SYSTEM (ENS) The brain can influence the “tuning” of the ENS

9. Digestion and FODMAPs
When the “tuning” of the Enteric Nervous System is not perfect, the bowel may respond in an abnormal way to FODMAP foods. FODMAP foods may cause
Excess bloating and pain
Osmosis occurs - excess water in the colon – diarrhea
Fermentation – hydrogen, CO2 and methane produced
The increase in fluid and gas in the bowel leads to diarrhea, bloating, flatulence, abdominal pain and distension.

10. Gut Reactions
There are two different types of adverse reactions to food! 1/ Immunological reaction - reaction to the protein in the food and involve the immune system. This is often called a food allergy or hypersensitivity. 2/ Non-immunological reaction - do not involve the immune system and are normally referred to intolerance. Very common affecting 1 in 5 people. Reaction varies upon the amount of food consumed and other foods consumed in that day. IBS is in this class!

11. What is Irritable Bowel Syndrome?
IBS is defined as abdominal pain and discomfort with altered bowel habits, in the absence of any other medical explanation for the symptoms. IBS is one of the most common gastrointestinal disorders in the USA affecting 58 million people, approximately 10 to 20% of the entire population (1) IBS affects 5-27% of Western society (1) 80% of IBS suffers are women IBS can have a substantial impact on patients’ lives Pathology of IBS is not well understood however research has shown that patients often have a GI tract that is more sensitive and works more slowly or quickly than it should. The “tuning” is off! The ENS is not well tuned. Patients with IBS typically have hypersensitive nerve endings around the bowel. Management of IBS - drugs, stool softeners, diets that control fiber, fat, caffeine, alcohol, citrus foods, prescribing prebiotics or probiotics and hypnotherapy. Ref:

12. Diagnosing patients with IBS
Do you have recurrent abdominal pain ? Do you often feel bloated? Are you frequently constipated? Do you have frequent diarrhea? RED FLAGS Doctors will look for the “ABC” of IBS Abdominal pain Bloating Changes in bowel habits.
Doctors will look for RED FLAGs that may indicate another condition rather than IBS. If the symptom started after age 50, or if there is blood in the stool, fever, weight loss of more than 10 pounds family history of colorectal cancer, inflammatory colorectal disease, cancer. IBD – Some people who suffer from IBS like symptoms are diagnosed with INFLAMMATORY BOWEL DISEASE (IBD). This is an illness where the bowel becomes chronically inflamed. Two main types of IBD Chron’s disease and Ulcerative colitis. Treatment is controlling the inflammation. If bowel inflammation is well controlled IBD patients may benefit from following low FODMAP diet.

13. Diagnosing IBS - Tests
Barostat Test Inserting a tube with inflatable balloon into the rectum. If a person has IBS – experience pain No IBS – can inflate the balloon more without pain This test shows that people with IBS require less distension before their nerves send messages to their brain to indicate that they are in pain. Breath Test- Fructose or Lactose Hydrogen/Methane Breath testing – tool used to determine if a patient has fructose, or lactose malabsorption. Gas produced in colon – blood stream and then expelled by the lungs. Elimination Diet Trail the low FODMAP diet - monitoring symptoms. Research Test - Ileostomy model Patients with an end-ileostomy consume known amounts of dietary component. The effluent is then measured to calculate the degree of absorption in the small intestine(2).

14. FODMAP – The History
2005 – A study was published that hypothesized the FODMAP diet as a “cure’ for Crohns’s (3).
Research conducted to find out the FODMAP contents of foods(14).
Developed a FODMAP diet and tested it on patients with IBS (4).
2011 – FODMAP diet tested in UK – (5).
More research conducted in (1,6, 7).
First line therapy for the treatment of IBS (8).

15. Key Studies (IBS) – Original Research
Ref
Year
Journal
Author
Title
Comments 4
2008
Clinical Gastroenterology and Hepatology
Shepherd et al
Dietary triggers of abdominal symptoms in patients with IBS
Randomized placebo controlled study. N= wks. 2
2010
Alimentary pharmacology & therapeutics
Barrett et al
Dietary poorly absorbed, short chain carbohydrates increase delivery of water and fermentable substrates to the proximal colon
12 ileostomates – randomized cross-over, single blinded study 5
2011
Journal of Human Nutrition and Dietetics
Staudacher et al
Symptom response following advice for a diet low in FODMAPS vs. Standard dietary advice in patients with IBS. NICE guidelines.
London n=40 each group 76% satisfied with symptom change. 6
2013
Inter Journal of Clinical Pract
Roest et al
The low FODMAP diet improves gastrointestinal symptoms in patients with IBS
New Zealand – a prospective study 7
Curr Gastro Rep
Fedwa and Satish
Dietary Fructose Intolerance, Fructan intolerance and FODMAPS 1
Nutrition in Clinical Practice
Extending our knowledge of Fermentable, Short-Chain carbohydrates for managing gastrointestinal symptoms
Controlled cross over study with IBS pts. High quality evidence. 8
2014
Gastroenterology
Halmos et al
A diet low in FODMAPS reduces symptoms of IBS
Clinical study. High quality evidence supports FODMAP as fist line therapy.

16. Key Studies – Original Research
Code
Year
Journal
Authors
Title
Comments 3
2005
Aliment Pharmacol Ther
Gibson and Shepherd
Personal view: food for thought – Western life style and susceptibility to Crohn’s disease. The FODMAP hypothesis
1st study to look at FODMAPS. 9
2009
Journal of Crohn’s and Colitis
Gearry et al
Reduction of dietary poorly absorbed FODMAPS improves abdominal symptoms in patients with IBD
Study conducted on pt’s with Inflammatory bowel disease 14
Journal of Agriculture and Food Chemistry
Muir et al
Measurement of Short-chain carbohydrates in Common Australian vegetables and fruits by High Performance Liquid Chromatography.
FODMAP content of Food. * Another similar study was conducted in 2007 by Muir et al using HPLC 12 13
JPEN Aliment Pharmacology Ther
Barrett et al Halmos et al
Strategies to manage GI symptoms complicating enternal feeding Diarrhea during enteral nutrition is predicted by the poorly absorbed FODMAP content of the formula.

17. Key Studies – Review Articles
Ref
Year
Journal
Authors
Title
2006
Journal of the American Dietetic Association
Shepherd et al
Fructose Malabsorption and Symptoms of IBS: Guidelines for effective dietary management.
2009
Journal of Gastro and Hepatology
Gibson et al
Evidence based dietary management of functional gastrointestinal symptoms: The FODMAP approach 10
2010
Gibson and Shepherd
Evidence-based dietary management of functional gastro symptoms: The FODMAP approach 11
2013
The American Journal of Gastroenterology
Short Chain Carbohydrates and Functional Gastrointestinal Disorders

18. FODMAP ‘s foods .

20. High FODMAP foods - AVOID General Guidelines
Sweeteners - honey, agave nectar, maltitol, sorbitol, mannitol, and xylitol. Dairy that contains significant amounts of lactose, milk or soft cheeses, ice cream and cream. Rye and Wheat Products - a gluten free diet could improve symptoms of IBS because it removes wheat (a fructan). Beans and legumes – high in oligsaccharides Watermelon, apples, pears, mushrooms, cauliflower, onions

21. Fructose Fructans Lactose Oligosaccharides Polyols
Honey Apples Mango Pear
Watermelon Cherries Figs Asparagus
Artichokes Sugar snaps HFCS Corn Syrup Agave Honey Fruit juice
Apples Artichokes Asparagus Beets Chicory root Chamomile Dandelion leaves Dates Fennel
Garlic Garlic powder Leek Onion Radish Lettuce Watermelon Nectarines Beans Pistachio & cashew Wheat Rye Inulin (added to yogurt)
Milk Ice-cream
Custard
Dairy desserts Condensed milk
Evaporated milk
Milk Powder
Margarine Soft unripened cheeses (ricotta, cottage, cream or mascarpone)
Legume beans Baked Kidney Lentils Chickpeas Soybeans
Apples Apricots
Avocado Cherries
Lychee
Nectarines Pears
Plums
Prunes Blackberries Peaches Watermelon
Mushrooms Cauliflower Snow peas SF candy
Sorbitol Mannitol
Xylitol Maltitol Isomalt

22. Low FODMAP shopping list
Grains
Protein
Dairy
Vegetables
Fruits
Oats Quinoa Oat Bran
Brown rice
White rice
Gluten free pasta
Corn flour Potato starch Rice cakes
Tortilla chips
Beef
Chicken
Fish Eggs Tofu Tempeh* Nuts
Cheddar
Edam
Gouda
Blue
Swiss
Parmesan
Brie
Feta
Camembert Mozzarella
Lactose free free
Almond Milk*
Coconut milk
Rice Milk
Yogurt – Green Valley Kefir Butter
Alfalfa sprouts Bean Sprouts Bok Choy Bell peppers Broccoli (limit to ½ cup) Carrots Corn Chives
Cucumber Eggplant Green beans
Lettuce
Parsnips Peas
Potatoes Spinach Summer squash Tomato Zucchini
Banana Blueberries
Cantaloupe
Grapefruit
Grapes
Honeydew Melon Kiwi Lemon Lime Orange
Passion fruit Pineapple
Rhubarb
Strawberries Star fruit Maple syrup Sucrose Glucose

23. Is a dietitian needed ?

24. Your role as a dietitian
Use the FODMAP diet - “This high quality evidence supports its use as a first-line therapy. Clinical Trail number xxx” (8). - “The low FODMAP diet provides an effective approach to the management of patients with functional gut symptoms. The evidence base is now sufficiently strong to recommend its widespread application” (10) Offer this diet approach to appropriate patients. Individualize the diet for your patients. Test for tolerance – goal less strict version of the diet. Listen to your patients:- The healthier I eat the worse I feel?

25. In Interview Has pt been tested for celiac disease?
Has pt been tested for lactose and fructose intolerance and SIBO ?
Nutrition assessment – LISTEN CAREFULLY!
Diet recall – ask about some trigger foods
Teach elimination diet – find out what they are ready for
Start to challenge
Review results
Translate science into food and brand names – collect boxes and visuals – try products
Shopwell.com

26. What patients might benefit from following a low FODMAP diet
Patients with small intestinal bacterial overgrowth (SIBO) Patients with Gluten Intolerance (Celiac) Patients with IBD (Crohns’s disease) (9) Patients with suffering from chronic stress Enteral Feedings (12,13) Infants with colic Lacovou M et al., Dietary Management of infantile colic: a systematic review. Matern Child Health Journal. 2012;16 (6):

27. Food Recall Breakfast Fiber one cereal with milk
Snack Wheat thins and hummus Apple Lunch ½ tuna sandwich with red onion on fiber one bread Salad with Italian dressing (onions, broccoli, lettuce, bean salad) Dinner Pasta with tomato sauce and meat balls Sugar free frozen yogurt

28. Communication
Altered Gl function related to possible dietary carbohydrate intolerance as evidenced by 15 year history of IBS, recent GI evaluation unremarkable, negative for celiac disease, pt reports daily abdominal pain, bloating, gas, diarrhea, diet hx reveals routine consumption of rapidly fermentable, osmotically active carbohydrates (FODMAP’s). Intervention: Trail of FODMAP elimination diet for 3 weeks. Follow up: changes in symptoms. Document. Data is good!

29. PES statement
Altered GI function related to likely intolerance to certain dietary carbohydrates (FODMAPs) as evidenced by patient reports 80% decrease in bloating and gas and no episodes of abdominal pain or diarrhea on FODMAP restricted diet x 3 weeks.

30. How to proceed Use teaching tools appropriate for the patient
Elimination diet – 2 to 6 weeks (normally use 3 weeks)
Provide simple low FODMAP recipes.
Meal plan
Reintroduction of FODMAPs – dietitian comes into play. No validated protocol exists.

31. The cumulative effect

32. Reading Food Labels – Shopping tips
Look out for Inulin – this is added to many yogurts, cream cheese, organic valley vanilla milk, rice milks
Metamucil is 100% inulin. An alternative would be psyllium husk.
GF Is a good starting point as they are wheat free but make sure they don’t have apple, pear, honey or molasses
Apple juice and pear juice are often added to GF products to sweeten them. Beware as apples and pears are high in sorbitol.
Low polyol sweeteners are aspartame, stevia, sugar (sucrose) and maple syrup.
Onion powder and garlic powder – often added to salad dressings and broths. “Natural Flavoring” is often onion and garlic.

33. Shopping tips Nature Valley Crunchy Granola Bars
Environkidz Gorilla Munch
Aleia’s peanut butter cookies
Udi’s GF pizza
Choose high fiber foods that are low FODMAP such as oats, oat bran, brown rice, quinoa, strawberries, blueberries, oranges, spinach, baked potatoes with skin and chia seeds (2 TBS = 10g fiber)
Rao’s Sensitive formula – only Red Sauce without garlic and onion
Make your own salad dressings

34. Meal Plan
Breakfast 2 eggs with hash browns and banana or Lactose free yogurt and strawberries Lunch Millet bread with peanut butter and sugar sweetened jam Carrot sticks Snack Orange or smoothie with lactose free milk, pineapple, berries, and chia seeds Dinner Salmon and “Jacket Potato” with cheese Salad greens, olive oil and vinegar

35. Challenge Diet
1/ Following low FODMAP diet for 4 to 8 weeks. 2/ “Challenge” by reintroducing ONE of the FODMAP groups and observe symptoms. Chose an amount of food that you would normally consume. Suggested order:- Sugar alcohols – 4 dried apricots or 2 fresh apricots (polyols) Mannitol – ½ cup mushrooms (polyols) Lactose – ½ to 1 cup of milk or 6oz yoghurt Fructose – ½ mango or 1 tsp. of honey Fructans – 2 slices of wheat bread, 1 clove garlic then ¼ onion Galactans – ½ cup lentils or ½ cup kidney beans or chickpeas 3/ “Challenge” with ONE FODMAP per week. Eat the challenge food - no symptoms Eat the same challenge food – increase the amount Confirmation – the food is ok for patient! Next ???

36. Challenge Diet
If you don’t get symptoms: Try another food in the same FODMAP group. Try it twice in the same week and increase your amount. You could try one more food to confirm patient is ok with entire group. If you get symptoms: Wait 4 days and then try the food again – reduce the portion in half. DOSING is important! Wait 4 more days and then try ANOTHER food in the SAME GROUP - confirming intolerance to the group. It is important to reduce portions and re-challenge – remember the goal.
Goal is to find the most liberal and varied diet possible that keeps symptoms under control. How big is your patients “bucket” ?

37. Challenge Diet
Small portions of foods with increasing FODMAP content introduced.
Priority on high value foods – foods they miss
Continue with low FODMAP diet and then challenge with one FODMAP category such as polyols.
Use challenge list – items at the top contain most FODMAP’s

38. Coping Strategies Eat glucose or dextrose with high fructose foods
Use garlic oil instead of garlic
Boil and drain high fructan vegetables
Removing onions from soups and stews is not beneficial – water soluble therefore already leached out.
Galactans are water soluble so soak, drain, rinse. Canned lentils and chickpeas are relatively low
Use lactose free dairy
Carry lactase enzyme pills – no mannitol
To increase fiber use chia seeds and then psyllium husk

39. Resources iPhone (launch December 2012) Android (launch November 2013)
The Monash University (Australia) low FODMAP Diet app
Smartphone application which provides accurate information about foods that trigger IBS reactions in order to help sufferers manage their symptoms.
iPhone (launch December 2012)
Android (launch November 2013)
Fodmap video

40. Useful web sites
Sue Shepherd and Peter Gibson Large practice specializing in gastro (Australia) blog - (Boston) Patsy Catsos, MS, RD International Foundation for Functional Gastrointestinal Disorders

41. Books

42. Books

43. Summary
The FODMAP diet is now viewed as evidence-based first-line treatment strategy for patients with IBS. - scientifically proven - provides all the nutrients needed - reduces symptoms of IBS in ¾ of IBS suffers - wont cure IBS but it does help to prevent trigger symptoms - should be prescribed by a dietitian who is an expert - there is high compliance to the diet – if diet is delivered well Ref:8

44. How to become a FODMAP expert
What Every RD Needs to Know about FODMAPs, Providence, RI
Patsy Catsos, MS, RDN, LD and Kate Scarlata, RDN, LDN
Friday, March 21, 2014 from 9:00 AM to 4:00 PM (EDT)
Providence, RI
Registration Information $

45. How to become a FODMAP expert
Irritable Bowel Syndrome: Fodmaps, Fat, Fiber and Flora Kate Scarlata, RD, LDN
8 CPEUs HARD COPY $ CPEUs ELECTRONIC $ Up-to-date manual (85 pgs) will enable you to help your clients manage their IBS symptoms. More specifically you will learn how to:
Assess symptoms and discuss treatment options for your clients with IBS.
Distinguish between food allergy, food sensitivities, gluten sensitivity and celiac disease.
Recommend a low FODMAP diet for symptoms management when appropriate.
Develop IBS nutrition care plans with patient tolerable fiber-rich foods and supplements.
Create menu plans and grocery lists to assist IBS clients in lifestyle management.

46. Next Steps – The Future
Randomized control studies over longer periods of time – broader populations
Link - patients who believe they are gluten sensitive or wheat intolerant may indeed benefit from following the FODMAP diet.
Different cultures and foods.
Delivery of the message.

47. Questions???