FODMAPs

1. FODMAPs Tracey BlahyDietetic InternSouthcoast May 2014

2. 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 What are you going to learn?

3. FermentableOligosaccharidesDisaccharidesMonosaccharidesandPolyols FODMAPs- small chainsugars/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) What does FODMAPs stand for ?

4. 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, bloatingand pain. O is for Oligosaccharides - Oligosaccharides are short-chain carbohydrates- Fructans- Fructooligosaccharides (FOS)- Oligo-galactans. - Xylo-oligosaccharides What does FODMAPs stand for ?

5. 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. What does FODMAPs stand for ?

6. Absorbing and breakdown carbs

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 absorbedPerfectly controlled by the:ENTERIC NERVOUS SYSTEM (ENS)The brain can influence the “tuning” of the ENS

9. 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. Digestion and FODMAPs

10. 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! Gut Reactions

11. 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 womenIBS 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: www.ibsrelief.org What is Irritable Bowel Syndrome?

12. 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 IBSAbdominal painBloatingChanges in bowel habits. Diagnosing patients with IBS

13. Barostat TestInserting 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 LactoseHydrogen/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 DietTrail the low FODMAP diet - monitoring symptoms. Research Test - Ileostomy modelPatients 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). Diagnosing IBS - Tests

14. 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). • 2008 - Developed a FODMAP diet and tested it on patients with IBS (4). • 2011 – FODMAP diet tested in UK – (5). • 2013 - More research conducted in (1,6, 7). • 2014 - First line therapy for the treatment of IBS (8). FODMAP – The History

15. Key Studies (IBS) – Original Research

16. Key Studies – Original Research

17. Key Studies – Review Articles

18. FODMAP ‘s foods

20. 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 oligsaccharidesWatermelon, apples, pears, mushrooms, cauliflower, onions High FODMAP foods - AVOIDGeneral Guidelines

22. Low FODMAP shopping list

23. Is a dietitian needed ?

24. 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? Your role as a dietitian

25. 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 In Interview

26. Patients with small intestinal bacterial overgrowth (SIBO)Patients with Gluten Intolerance(Celiac) Patients with IBD (Crohns’s disease) (9)Patients with suffering from chronic stressEnteral Feedings (12,13)Infants with colicLacovou M et al., Dietary Management of infantile colic: a systematic review. Matern Child Health Journal. 2012;16 (6):1319-1331 What patients might benefit from following a low FODMAP diet

27. BreakfastFiber one cereal with milk SnackWheat thins and hummus AppleLunch½ tuna sandwich with red onion on fiber one breadSalad with Italian dressing (onions, broccoli, lettuce, bean salad)DinnerPasta with tomato sauce and meat ballsSugar free frozen yogurt Food Recall

28. 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! Communication

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

30. 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. How to proceed

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 • https://www.pinterest.com/pcatsos/

34. Breakfast2 eggs with hash browns and banana or Lactose free yogurt and strawberriesLunchMillet bread with peanut butter and sugar sweetened jamCarrot sticks SnackOrange or smoothie with lactose free milk, pineapple, berries, and chia seedsDinnerSalmon and “Jacket Potato” with cheeseSalad greens, olive oil and vinegar Meal Plan

35. 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 yoghurtFructose – ½ mango or 1 tsp. of honeyFructans – 2 slices of wheat bread, 1 clove garlic then ¼ onionGalactans – 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 ??? Challenge Diet

36. 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” ? Challenge Diet

37. 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 Challenge Diet

38. 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 Coping Strategies

39. 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 http://youtu.be/Z0fW0WyhHVA Resources

40. www.thelowfodmapdiet.comSue Shepherd and Peter Gibson www.shepherdworks.com.auLarge practice specializing in gastro (Australia)www.katescarlata.comblog - http://blog.katescarlata.com (Boston)www.ibsfree.netPatsy Catsos, MS, RDwww.ibsgroup.orgwww.iffgd.org International Foundation for Functional Gastrointestinal Disorders Useful web sites

41. Books

42. Books

43. 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 wellRef:8 Summary

44. 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 $225.00 http://www.eventbrite.com/e/what-every-rd-needs-to-know-about-fodmaps-providence-ri-registration-9796817545 How to become a FODMAP expert

45. Irritable Bowel Syndrome: Fodmaps, Fat, Fiber and FloraKate Scarlata, RD, LDN 8 CPEUs HARD COPY $84.958 CPEUs ELECTRONIC $79.95 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.http://www.wolfrinke.com/cefiles/C226CPEcourse.htm How to become a FODMAP expert

46. 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. Next Steps – The Future

47. Questions???