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Low FODMAP Approach in the Management of IBS
MELISSA HUGHES, DIETETIC INTERN
Objectives
✓List 2 common characteristics of FODMAPs that can cause abdominal discomfort in those with IBS
✓Name 4 high FODMAP foods
✓State one of the potential risks of following a FODMAP-restricted diet
High FODMAP Low FODMAPYogurt
Trail Mix
Cherries
Mushrooms
Whole Wheat Pasta
Hummus
Agave
Pineapple (s.p.)
Cheddar Cheese
Potatoes
Quinoa
Maple Syrup (s.p.)
Edamame
Chives
Irritable Bowel
Syndrome (IBS)
• Symptoms: abdominal pain, bloating, constipation, diarrhea, and flatulence
• Impacts 15% of adults in the U.S.• More common in women than in
men• 2nd leading cause of work
absence
*The effect on quality of life is so significant that, on average, patients would sacrifice between 10-15 years of their remaining life expectancy for an immediate cure.
-American Journal of Gastroenterology, 2009
Diagnosis of IBSThe GI symptoms must occur at least 3 days per month for 3 months coupled with two of the three following occurrences:
1. Discomfort alleviated by defecation2. Onset associated with a change in stool frequency3. Onset associated with a change in the form of the
stool
*As many as ½ of individuals with IBS go undiagnosed and untreated which can greatly impact their day-to-day activities and quality of life
Fermentable, Oligo-, Di-, and
Monosaccharides and Polyols
FODMAPs
Three Common Characteristics
FODMAPs
Poorly Absorbed
Rapidly Fermentable
Osmotically Active
Fructose
• Monosaccharide • Small intestine limited in the
amount of fructose it can absorb
• Also found in high-fructose corn syrup, honey, agave, fruit juice, figs, mangos, and artichokes
Lactose • Disaccharide• Digestion requires the enzyme
lactase• Diminished lactase activity
leads to malabsorption• Undigested lactose travels to
the large intestine where it is readily fermented by intestinal bacteria
Fructans& Galactans
• Oligosaccharides• Small intestine lacks the
digestive enzymes• Rapidly fermented by intestinal
bacteria• Due to small molecular size, they
increase osmolarity in the lumen triggering water uptake
• Abdominal distention
Polyols – Sugar Alcohols• Absorbed by passive diffusion• Unabsorbed polyols travel to the
large intestine where they are rapidly fermented by intestinal bacteria
• Other sources include plums, avocado, and mushrooms
Low FODMAP Diet Plan
1. Elimination Phase: eliminate all FODMAPs from the diet for a trial period of 2-8 weeks
2. Reintroduction/Re-Challenge Phase: reintroduce FODMAPs one class at a time using a disciplined process
3. Monitor symptoms to gauge tolerance4. Modify diet as needed
Tips for Reintroduction• Keep a food diary including foods
eaten, quantity of food, and symptoms
• Re-challenge a new food in the early evening to allow enough time to notice symptoms before bed
• Provide a reintroduction protocol▪ Lee Martin, MS, RD specializes
in FODMAP reintroduction
Does the diet work?
Evidence points to YES!
Low FODMAP vs Habitual Diet
• 2012, randomized, controlled study • Compare effects of FODMAP restriction on the
microbiome and GI symptoms in patients with IBS• Patients randomly chosen to follow low FODMAP (19 pts)
or their habitual diet (22 pts) for 4 weeks• Symptoms, stool output, and dietary intake were
recorded for 1 week at baseline & 1 week at follow up• Stool samples were collected to analyze the amount of
luminal microbiota
Low FODMAP vs Habitual Diet
Staudacher HM, Lomer MC, Anderson JL, et al. Fermentable carbohydrate restriction reduces luminal bifidobacterial and gastrointestinal symptoms in patients with irritable bowel syndrome. J Nutr. 2012;142(8):1510-1518.
More patients in the low FODMAP group reported adequate symptom control when compared to the control group (P = 0.005).
However, bifidobacteria was seen in lower concentrations in the low FODMAP group❖ Studies have shown an association between low
bifidobacterial and abdominal pain❖ It would be beneficial to see whether a bifidobacterial
probiotic in addition to FODMAP restriction would enhance the symptom response
Efficacy of low FODMAP diet
• 2013, prospective, uncontrolled study • Participants (90) had breath testing for fructose and
lactose malabsorption• Received dietary advice including lists of safe/restricted
foods, recipes/shopping guides, and reintroduction recommendations
• Received follow up 6 weeks later to review symptoms and progress
Efficacy of low FODMAP diet
de Roest RH, Dobbs BR, Chapman BA, et al. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract. 2013;67(9):895-903.
75% of participants were satisfied with symptoms after low FODMAP dietary intervention
Adherence to the diet was associated with:❖ Breath test results helped to understand the role of the
diet❖ Liked the taste of the diet❖ Found the diet easy to incorporate❖ Found the diet easy to follow
Low FODMAP vs Australian Diet • 2014, randomized, controlled, single-blind crossover• 38 participants – 30 with IBS and 8 without IBS• 21 days of either low FODMAP or typical Australian diet,
followed by a washout period (21 days), before crossing over to the alternate diet
• All meals were provided – 3 meals and 3 snacks
Overall GI symptoms were significantly lower for those on the low FODMAP diet (P < 0.001). The greatest symptom control was achieved and maintained after 7 days on the low FODMAP diet.
Halmos EP, Pwer VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014;146(1):67-75.
Efficacy of low FODMAP in Children
• 2015, double-blind, randomized crossover• 33 children were randomly assigned to low FODMAP diet
or typical American childhood diet for 48 hours, followed by 5 day washout period before crossing over
A reduction in abdominal pain was seen during the low FODMAP diet when compared to typical American childhood diet (P < 0.05)
Efficacy of low FODMAP in Children
This study also suggested that a difference in the microbiome composition at baseline may determine responders and nonresponders to the diet. ❖ Responders had greater saccharolytic capacity at
baseline to break down sugars ❖ Opportunity for further research – Can differences in the
gut microbiome lead to personalized low FODMAP dietary interventions?
Chumpitazi BP, Cope JL, Hollister EB, et al. Randomized clinical trial: gut microbiome biomarkers are associated with clinical response to a low FODMAP diet in children with the irritable bowel syndrome. Aliment Pharmacol Ther. 2015;42(4):418-427.
Low FODMAP vs Traditional Dietary Advice for IBS
• 2015, randomized, controlled, single-blind• 67 participants – 33 low FODMAP, 34 traditional IBS diet
for 4 weeks• Low FODMAP participants received dietary advice on
foods to avoid and alternative options• Traditional IBS diet participants received dietary advice
on eating regular meals, healthy eating, avoiding large meals, reducing fat intake, and avoiding insoluble fiber, caffeine, and “windy vegetables”
Low FODMAP vs Traditional Dietary Advice for IBS
IBS symptom severity was significantly reduced in both groups when compared to baseline (P < 0.001)
❖ Results indicate that combining the elements from the 2 treatment strategies may further reduce symptoms of IBS, but more research is needed
Bohn L, Storsrud S, Liljebo T, et al. Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 2015;149(6):1399-1407.
Risks• Inadequate fiber intake• Decreased luminal bifidobacteria
Vegan▪ Inadequate protein, vitamin B12, and zinc intake
Gluten-free▪ Inadequate B vitamin intake
Dairy-free▪ Inadequate calcium
Recognize Good Candidates• Appropriate symptoms and/or diagnosis▪ Rule out Celiac Disease and SIBO
• Failure to respond to standard IBS treatment
Poor Candidates• No control over food purchasing or preparation• Inflexible food preferences• Poor cognitive skills• At risk for or active eating disorder
Resources for RDs➢ Kate Scarlata, RDN:
www.katescarlata.com➢ Patsy Catsos, MS, RDN, LD:
www.ibsfree.net➢ Monash University app and blog:
fodmapmonash.blogspot.com/au• Recipes, Food Guide, & Diary
➢ www.alittlebityummy.com• Dietitian-reviewed blog that follows
Monash University guidelines
Conclusion• The restriction of FODMAPs can be a successful way to
manage IBS symptoms• List of high/low FODMAP foods isn’t enough. Patients
need a strategy and a plan▪ Dietitians play a starring role!▪ Guide each patient toward the most nutritious and
varied diet that he/she can tolerate• Although the low FODMAP diet has been shown to help
manage IBS symptoms, it doesn’t work for everyone so IBS treatment should always be individualized