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THE FODMAP DIET Christina Berberich, PharmD, MPH, RD

September 17 & 18, 2015

Disclosure

• The content of this program has met the continuing

education criteria of being evidence-based, fair and

balanced, and non-promotional.

• This educational event is supported by Abbott Nutrition

Health Institute, Abbott Nutrition.

• I am currently an employee of Abbott Nutrition

2

Learning Objectives

• List the 6 FODMAP groups and name one food source for

each

• Name the condition that the low FODMAP diet is used for

and describe how it is purported to reduce symptoms

• Describe how to initiate and manage a patient on a low

FODMAP diet and list 2 potential concerns

3

Overview

• Provide the definition of FODMAPs and examples of each

• Define functional bowel disorders, specifically irritable

bowel syndrome (IBS)

• Discuss the relationship between IBS and FODMAPs

• Review the current research on low FODMAP diets for

IBS

• How to start and manage a patient on a low FODMAPs

diet

• Describe the potential concerns with a low FODMAPs diet

4

Definition

• FODMAPs:

• Fermentable Oligo-, Di-, Monosaccharide and Polyols

• Short-chain carbohydrates and sugar alcohols

• Fructose, lactose, fructans, mannitol, sorbitol, galactans

• Used to ease symptoms of functional bowel disorders

5

Gibson PR, Shepherd SJ. Evidenced-based dietary management of functional gastrointestinal symptoms: the FODMAP approach. J Gastroenterol Hepatol. 2010 Feb;25(2):252-8.

Functional Bowel Disorders

• Bowel looks normal but has disordered actions

• Irritable bowel syndrome (IBS), chronic diarrhea or

constipation or bloating

• Cause(s) unknown

6

Gibson PR, Shepherd SJ. Evidenced-based dietary management of functional gastrointestinal symptoms: the FODMAP approach. J Gastroenterol Hepatol. 2010 Feb;25(2):252-8

Irritable Bowel Syndrome (IBS)

• Condition of hypersensitivity leading to an abnormal

reaction in the gut

• Characterized by abdominal pain, gas, bloating, diarrhea,

constipation

• Different subtypes

• Diarrhea-predominate

• Constipation-predominate

• Mixed

7

Mansueto P, Seidita A, D’Alcamo A, Carroccio A. Role of FODMAPs in patients with irritable bowel syndrome: a review. Nutr Clin Pract. 2015. pii: 0884533615569886. [Epub ahead of print]

Mullen GE, et al. Irritable Bowel Syndrome: Contemporary Nutrition Management Strategies. J Par Ent Nut. 2014;38(7):781-799.

Rome III Criteria

8

ROME III

Symptoms for at least 6 months

Positive diagnosis must include the following:

1. Abdominal pain/discomfort at least 3 days/mo for last 3

months, and 2 of the following true >25% of the time:

-Improvement with defecation

-Onset associated with change in

stool frequency

-Onset associated with change in

stool appearance

2. Symptoms not caused by an inflammatory, metabolic,

anatomical, or neoplastic condition

Drossman, DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology. 2006;130:1377-1390.

Drossman, DA. Rome III: The Functional Gastrointestinal Disorders. McLean, VA: Degnon Associates; 2006:896.

IBS

• Food can trigger symptoms

• No effect on underlying condition

• FODMAPs are potential triggers due to their effects within

the gut

• Potential to mitigate symptoms though avoiding offending

foods

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FODMAPs and IBS

• FODMAP carbohydrates are minimally absorbed in the

small intestine

• High osmolality

• Fermentable

• Normal process that is generally not problematic in

healthy individuals

• In an abnormally hypersensitive gut, can lead to

symptoms

10



Osmotic effect of FODMAPs

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GUT PERITONEAL SPACE PERITONEAL SPACE


12



13


Bacterial effect of FODMAPs

14



15


Other potential effects on the gut

• ↑ Gut motility

• Possible activation of hormonal/neural feedback pathways

during osmotic pressure changes and short chain fatty

acid production

• Abnormal GI endocrine cells in IBS

• Release hormones having endocrine effects leading to

increased GI motility and sensation

16

El-Salhy M, Gilja OH, Gundersen D, Hatlebakk JG, Hausken T. Interaction between ingested nutrients and gut endocrine cells in patients with irritable bowel syndrome. Int J Mol Med.

2014;34:363-371.

Piche T, Zerbib F, Varannes SB, et al. Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol. 2000;278:G578-G584.

Piche T, des Varannes SB, Sacher-Huvelin S, Holst JJ, Cuber JC, Galmiche JP. Colonic fermentation influences lower esophageal sphincter function in gastroesophageal reflux disease.

Gastroenterology. 2003;124:894-902.

FODMAPs and Gut Bacteria

• Gut bacteria generally fall into 3 categories:

• Both absolute number and species type affect health

• Many FODMAPs are prebiotics

• Encourage the growth of helpful bacteria

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Helpful Harmful Neither




• Condition of small intestinal bacterial overgrowth (SIBO)

• Occurs in some with IBS

• May lead to:

• ↑ Gut permeability

• Fermentation and gas production within the small intestine

• May delay transit time leading to constipation

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Pimentel M, Lin HC, Enayati P, et al. Methane, a gas produced by enteric bacteria, slows intestinal transit and augments small intestinal contractile activity. Am J Physiol Gastrointest

Liver Physiol. 2006;290:G1089-G1095.


• In the large intestine multitude of FODMAP-digesting

bacteria species

• Gas production may be hydrogen or methane

• Not all fermentation is gas producing

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Where’s the FOOD?

20

Foods - Examples

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Excess Fructose

• Apple, watermelon, pear, asparagus, sugar snap peas, high fructose corn syrup, honey, agave

Lactose

• Milk (cow, sheep, goat), evaporated, sweetened condensed, dry powder, custards, dairy desserts

Fructans

• Wheat, onion, leeks, FOS


Foods - Examples

22

Mannitol

• Watermelon, cauliflower, mushrooms, snow peas, sweetener

Sorbitol

• Apples, apricots, nectarines, peaches, pears, plums, sweetener

Galactans

• Chickpeas, legumes, lentils


Why Excess Fructose is a problem

23


Gibson PR, Newnham E, Barrett JS, Shepard SJ, Muir JC. Review article: fructose malabsorption and the bigger picture. Aliment. Pharmacol. Ther. 2007;25:349-63.

Small intestine

lumen Capillary

Enterocyte

GLUT2

GLUT5 Fructose

Glucose Fructose

SGLT1

Galactose

Apical membrane Basolateral membrane

GLUT2


24

Small intestine

lumen Capillary

Enterocyte

GLUT2

GLUT5

Glucose

Fructose

Na+

Glucose Fructose

SGLT1

Galactose


GLUT2




25

Small intestine

lumen Capillary

Enterocyte

Glucose

GLUT5

Glucose

Fructose

Na+

Fructose

SGLT1

Galactose


GLUT2



FODMAP Research

• Objective: to investigate the effects of a low FODMAP diet

vs typical Australian diet in IBS and healthy individuals

• Study Design:

• Randomized, controlled, single-blind, crossover

• n=38, 30 ROME III IBS, 8 healthy

• 21 d of study/control diet → 21 d washout → 21 d control/study diet

• Subjective/objective assessments

• Total FODMAP content in the study diet = <0.5 g per sitting

(meal/snack)

26

Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014 Jan;146(1):67-75.e5

Results

• IBS subjects (~70%)

• ↓GI symptom scores

• ↓Bloating, pain, gas

• ↑Satisfaction with stool consistency

• Only diarrhea predominate IBS subjects had significant changes to

stool

• Healthy subjects

• No significant changes between diets

27

Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology. 2014 Jan;146(1):67-75.e5

FODMAP Research

• Objective: evaluate the effects on colonic health after a

low FODMAP diet vs typical Australian diet

• Study Design:

• RCT

• n=33, 27 ROME III IBS, 6 healthy

• 21 d of study/control diet → 21 d washout → 21 d control/study diet

• Total FODMAP content in the study diet = average 3 g/day

• Measured stool pH, SCFA concentration, bacterial number and

species diversity

28

Halmos EP, Christophersen CT, Bird AR, Shepherd SJ, Gibson PR, Muir JG. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut. 2015

Jan;64(1):93-100.

Results

• Low FODMAP diet

• ↑pH (7.37 vs 7.16)

• ↓Bacterial number

• No difference in SCFA concentrations

• Typical Australian and habitual diets (washout)

• ↑ numbers of several species of health promoting bacteria

29

Halmos EP, Christophersen CT, Bird AR, Shepherd SJ, Gibson PR, Muir JG. Diets that differ in their FODMAP content alter the colonic luminal microenvironment. Gut. 2015

Jan;64(1):93-100.

FODMAP Review

• Objective: summarize evidence of a low FODMAP diet to

manage food intolerance in IBS

• Study design:

• 40 articles, 31 studies, 9 reviews

• Evaluated evidence on FODMAP possible mechanisms, benefits,

limitations, concerns, and dietary management

30

Mansueto P, Seidita A, D’Alcamo A, Carroccio A. Role of FODMAPs in patients with irritable bowel syndrome: a review. Nutr Clin Pract. 2015. pii: 0884533615569886. [Epub

ahead of print]

Results

• Evidence points to the role of food triggering IBS

symptoms

• Dietary changes potentially can decrease symptoms and

increase QOL

• Further study needed on:

• Nutrition concerns related to restrictive nature

• Specific populations where effect is greatest

• Identifying non-IgE-mediated food allergy biomarkers

• Evaluation of other foods that effect visceral hypersensitivity,

immunity

31

Mansueto P, Seidita A, D’Alcamo A, Carroccio A. Role of FODMAPs in patients with irritable bowel syndrome: a review. Nutr Clin Pract. 2015. pii: 0884533615569886. [Epub ahead of

print]

FODMAP Research

• Objective: to study the efficacy of a low FODMAP diet in

children and determine if microbial composition are

associated with diet efficacy

• Study Design:

• Randomized, double blind, crossover

• 33 children ROME III IBS

• 7 day habitual diet → 48 h FODMAP/typical American childhood

diet (TACD) → 5 day habitual diet → 48 h TACD/FODMAP diet

• Intervention diet food was provided (9 g/d vs. 50 g/d FODMAP

content)

• Stool were collected and analyzed for microbial composition prior

to interventional diets

32

Chumpitazi BP, Cope JL, Hollister EB, Tsai CM, McMeans AR, Luna RA, Versalovic J, Shulman RJ. Randomised 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 Aug;42(4):418-27. doi: 10.1111/apt.13286. Epub 2015 Jun 24

Results

• Pain

• Less abdominal pain during low FODMAPs vs habitual

• More pain episodes during TACD vs. habitual

• Stool microbial composition

• Responders had significantly different microbial biomes compared

to Nonresponders

• Taxa found in Responders known for high saccharolytic metabolic

capacity

• Potential for use as a biomarker to predict diet efficacy

33

Chumpitazi BP, Cope JL, Hollister EB, Tsai CM, McMeans AR, Luna RA, Versalovic J, Shulman RJ. Randomised 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 Aug;42(4):418-27. doi: 10.1111/apt.13286. Epub 2015 Jun 24

Implementation of low FODMAPs Diet

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Comprehensive diet assessment

Explain scientific basis

Give low FODMAPs diet

specifics

Teach ways to maintain

compliance away from home

Start Diet!

Low FODMAPs Diet

• 1. Diet Assessment:

• To get an accurate view of what patient is eating/patterns of

consumption

• Goal is find out which FODMAPs the patient consumes on a daily

basis

• Use to better direct the patients dietary choices to make the most

effective use of the restrictions

35



Low FODMAPs Diet

• Limitations to Diet Assessment

• Limited availability of published data on FODMAP content of

various foods

• No strong consensus on FODMAP content threshold

• What level is low?

• Low FODMAP content in excess

• How many low FODMAP foods does it take to make a high FODMAP

diet?

36



Low FODMAPs Diet

• 2. Explain scientific basics to patients:

• Better understanding can lead to better diet compliance

• Aim for providing an understanding of:

• The malabsorption that occurs

• How subsequent fermentation leads to symptoms

37



Low FODMAPs Diet

• 3. Give patients the specifics on the diet • High and low FODMAP content foods

• How long they should be on the diet

• Recording foods and symptoms

• Awareness that some chewing gums and beverages contain FODMAPs

too

• The good news – global restriction shouldn’t be long term

38



Low FODMAPs Diet

• 4. Teach patients strategies to deal when patient is not in

control of their food prep • Carry low FODMAP snacks

• Pack lunch

• Find an option or two on restaurant menu before going in

• Planning is the key

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Low FODMAP Food Examples

40

Grains:

• quinoa, rice, corn, oats

Fruits:

• banana, grapes, pineapple, strawberry, prickly pear

Vegetables:

• broccoli, potato, lettuce, tomato, zucchini

Dairy:

• ripened cheeses, butter, cream, lactose free dairy

Sweeteners:

• table sugar (sucrose), stevia, aspartame, glucose

Other:

• tofu, seeds, flax, herbs, nonstarch polysaccharides


Low FODMAPs Diet Example

41

• Oatmeal, banana Breakfast:

• Lettuce salad with tomato, grilled chicken, quinoa, and a herbed vinegar/oil dressing Lunch:

• Baked fish (or beef, pork, or tofu) with rice, mashed potatoes, steamed broccoli Dinner:

• grapes, strawberries, sunflower seeds, rice cakes Snacks:

Low FODMAPs Diet

• Continue until achieve symptom relief (no more than 6-8

weeks)

• Begin reintroduction to avoid unnecessary restriction

• If inadequate response:

• Determine compliance

• If compliance established:

• Reduce resistant starch, soluble/insoluble fiber

• Consider gluten, food chemicals, caffeine, fat, meal size and regularly

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Rechallenge Foods

43

• 2 tsp honey

Fructose

• 240 mL milk

Lactose

• 2 slices wheat bread

Fructans

• ½ cup lentils/legumes

Galactans

• 4 dried apricots

Sorbitol

• ½ cup mushrooms

Mannitol


Enteral Feeding-Associated Diarrhea

• Could it be related to FODMAP content?

• Review: majority of cases not related to the formula

• C. diff and other intestinal infections

• Antibiotics

• Hyperosmolar medications

• Inulin in large doses can cause excess gas

• FOS can enhance resistance to C. diff, large doses can

cause bloating

• Prebiotic fiber dose and mixture can improve tolerance

44

Barrett JS, Shepherd SJ, Gibson PR. Strategies to manage gastrointestinal symptoms complicating enteral feeding. JPEN J Parenter Enteral Nutr. 2009;133:21-26.

Heimburger DC, Sockwell DG, Geels WJ. Diarrhea with enteral feeding: prospective reappraisal of putative causes. Nutrition. 1994;10:392-396.

Sobotka L, Brátova M, Slemrová M, Manák J, Vizd’a J, Zadák Z. Inulin as the soluble fiber in liquid enteral nutrition. Nutrition. 1997;13:21-25.

Lewis S, Burmeister S, Brazier J. Effect of the prebiotic oligofructose on relapse of Clostridium difficile-associated diarrhea: a randomized, controlled study. Clin Gastroenterol Hepatol.

2005;3:442-448.

Elia M, Engfer MB, Green CJ, Silk DB. Systematic review and metaanalysis: the clinical and physiological effects of fibre-containing enteral formulae. Aliment Pharmacol Ther.

2008;15(27):120-145.

Potential Issues

• Quite restrictive, especially carbs and fiber

• Can be expensive

• No long term safety data

• Long term use not recommended

• Not recommended in healthy people or those without

bowel problems

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FODMAPs Summary

• Seem to show a modest decrease in IBS symptoms in

about 70% of patients

• Decreases in healthful gut bacteria are seen when

FODMAPs are restricted

• Some FODMAPs are prebiotics and have a beneficial

effects on gut health

• Long term use of a low FODMAPs diet has not been

studied at this time and is not recommended

46

Thank you!

• Questions?

47

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