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