Low FODMAP Diet
Latest Treatment of IBS
Laura Manning, MPH, RD, CDN
Susan and Leonard Feinstein Center for IBD
Department of Gastroenterology
Mount Sinai Medical Center
Agenda
1. What is IBS and possible causes
2. Review-How do we digest short chain carbs
3. What is the Low FODMAP diet
4. How to implement it in your practice
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Irritable Bowel Syndrome (IBS)
• A condition characterized by abdominal pain,
bloating, flatus and altered bowel habits .
- Induced by intestinal luminal distention in
addition to visceral hypersensitivity.
- Dietary factors may alter luminal distention
with increased water and gas volume, causing
diarrhea.
- Other symptoms: tiredness, heartburn,
nausea, fogginess.
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1. Camillieri, M. Am J Physiol Gastrointest Liver Physiol, 2012.
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Facts about Irritable Bowel Syndrome
(IBS)
• Affects 25 to 45 million people in US, more
common in females.
• Usually under the age of 50
• Possible cause: disturbance in the gut-brainnervous system interact.
• Impacts physical, emotional, financial and social
well being. Typically brought on by stress.
• Few seek medical care- 20-40% of GI visits are
due to IBS.*
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*International Foundation for Functional Gut Disorders (IFFGD) https://www.aboutibs.org/site/what-is-ibs/facts/
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Allergy vs. Intolerance
• Food Allergy- the reproducible adverse
reaction arising from specific immune
responses occurring from specific food
antigens. IgE mediated
• Food Intolerance- Similar reactions that occur
without evidence of immunologic
mechanisms. (causing IBS)
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2. Boettcher E, Crowe SE. Am J Gastroenterology, 2013.
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Possible causes
• Malabsorption of carbohydrates causing onset
of symptoms.
• Non Celiac Gluten Sensitivity (NCGS)- new
clinical condition.
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3. Sheparhd SJ, et al. Clin Gastroenterol Hepatol, 2008
4. Biesiekierski JR, et al. Am J Gastroenterol, 2011
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Current Food Trends
• Fructose-Our intake of fructose is increased to
22% of daily caloric intake-High fructose corn
syrup (HFCS) in soda, candy and food
products.
• Fructans- due to a wheat-heavy culture.
• Inulin- added in “Functional Foods”, formulas!
• Polyols- sugar free additives to lower calories
and to protect teeth (gums and mints).
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Fructose and Fructans
• Largest amount in North American and
Western European diets
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Changes in gut bacteria
• Patients with IBS may have lower Lactobacillus
and Bifidiobacterium species in their intestinal
flora.
• High meat and dairy diets are shown to
change gut flora
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5. Kassinen A, et al. Gastroenterology. 2007
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Alteration of Gut Bacteria
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High antibiotic use, especially in children
C-sections
High animal protein and dairy diet
Intestinal surgeries: ICR, bariatric
Celiac disease
Motility disorders: gastroparesis
Inflammatory Bowel Disease (IBD)
Post infectious IBS: gastroenteritis
Small Intestinal Bacterial Overgrowth (SIBO)
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Maybe they can’t digest certain
carbohydrates?
• FIBER- long chain, non-digestible carbs in
small intestine. Important for stool formation
an proper bowel function
• STARCH- long chain carbs completely digested
in the small intestine.
• SUGARS- short chain carbs that may or may
not be easily digested. Depends on the
type…….
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How are they not digested
• Malabsorbed and pull water (osmotic shift) in
to the small intestine and cause diarrhea.
• When sugars reach the large intestine, they
ferment by bacteria and cause gas. The gas
can slow movement through the bowel
causing constipation.
• Additionally: nausea, bloating, and cramps.
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14
http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=3966
170_GH-11-739-g002.jpg
Fermentable Oligo-Di- Monosaccharides and
Polyols (FODMAPs)
• A heterogeneous group of poorly absorbed,
short-chain carbohydrates, which seem to be
possible IBS symptom inducers. Restricting
these from the diet could produce beneficial
effects.
• Term coined in 2005 by a group of Australian
researchers at Monash University claiming
that these forms of carbs may worsen
symptoms of IBS and IBD.
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6. Gibson PR, Shepard SJ. Aliment Pharmacol Ther. 2005.
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Shepard, SJ. Et al. J Am Diet Assoc.
2006
• Using a retrospective study-74% of patients
reported symptom improvement utilizing the
Low FODMAP diet regimen.
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Halmos EP, Gastroenterology. 2014
• Crossover study where patients with IBS
effectively reduced functional GI symptoms
when on a Low FODMAP diet.
* FODMAPs are not the cause of functional
bowel disorders, but will act as a trigger.
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FODMAPs
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Lactose- dairy
Fructose- fruits
Fructans/GOS- wheat, beans
Polyols- sugar alcohols
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Digestion of Fructose
• Free fructose, a simple sugar, requires no
digestion.
-Absorbed in the small intestine in 2 ways:
1. Co transport with GLUT-2 (a glucose/ fructose transporter).
• If equal amounts of glucose are available , fructose is efficiently taken up
after sucrose hydrolysis.
2. And by alternative transporter GLUT 5 in excess fructose amounts which is
present in the border of enterocytes in small intestine.
* If fructose load is very large, malabsorption likely will occur
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Fructose Malabsorption
• 40% of the population are considered to have
fructose malabsorption.
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• We can typically digest fruits if they have a 1:1
ratio of glucose to fructose. On the diet, 1
serving per day.
7. Douard V. J Physiol. 2013.
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Fructose
• Fruits: Apples, cherries, mangoes, pears,
watermelon
• Vegetables: asparagus, artichokes, sugar snap
peas
• Honey, HFCS
More intensified in dried fruits and overall
volume amounts
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Lactose
• A di-saccharide (Glucose and Galactose)
- Requires lactase enzyme to break it down in small
intestine
- Typically occurs in quantities greater than 7g
1. Varying enzymes amounts in the gut are
influenced by:
 Genetics
 Ethnic background
 Gut disorders
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Lactose
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Milk: cow, goat and sheep
Yogurt
Ice cream
Custard
Soft Cheeses: Ricotta, cottage
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Oligosaccharides
Fructans and Galactans (GOS)
Fructans and Galactans are the storage
carbohydrate of many vegetables
• Fructose polymer with a glucose terminal end
- We do not have the enzymes to break these
down and therefore are rapidly fermented,
causing gas and bloating
- Typically a great pre-biotic!
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Fructans
• Peach, persimmon, watermelon
• Artichokes, asparagus, Brussels sprouts,
chicory, fennel, garlic, onions, leeks
• Wheat, rye, barley
• Pistachios, cashews
• Beans
• Inulin
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GOS
• Beans- raffinose
- Lacking the enzyme a-galactosidase
Baked beans, kidney beans, chick peas, Brussels
sprouts and cabbage
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Polyols
• The sugar alcohols/ sugar substitutes:
• Only 1/3 is absorbed in small intestine
- By passive diffusion dependent on molecular size
and pore size in the small intestine.
Sorbitol, Mannitol, Xylitol, Erythriol, Isomalt
Foods: Apples, apricots, cherries, blackberries,
plums, mushrooms, cauliflower
Laxatives
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A Bucket Effect- all FODMAPs
are consumed at once
causing a cumulative effect!
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Typical meal
Breakfast: Frosted Mini Wheats and milk, tea with
honey
Lunch: wheat bread with turkey and American
cheese and an apple, cranberry juice
Snack: regular, peach flavored yogurt and
pretzels
Dinner: pasta with tomato sauce and meatballs
with a side of asparagus
Snack: handful of cashews
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Loaded with FODMAPs
Breakfast: Frosted Mini Wheats and milk, tea with
honey
Lunch: wheat bread with turkey and American
cheese and an apple, cranberry juice
Snack: regular, peach flavored yogurt
Pretzels
Dinner: pasta with tomato sauce and meatballs
with a side of asparagus
Snack: Handful of cashews
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High FODMAP Foods & Crossover
Lactose
Fructose
Fructans/
GOS
Polyols
Milk
Artichoke
Artichoke
Cauliflower
Yogurt
Asparagus
Garlic
Mushrooms
Ice cream
Tomatoes
Onions
Peas
Ricotta
Apples
Beans
Apples
Cottage
Cherries
Apples
Pears
Custard
Figs
Figs
Plums
Pears
Plums
Watermelon
Watermelon Wheat
Sorbitol
Agave
Inulin
Xylitol
Honey
Pistachios
HFCS
Watermelon
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Variations to consider
• Clinical testing at Monash Univ. Formal list
constructed from mechanical testing of foods
• Different levels in foods depending on
ripeness
• Different volume of carb load per person
• Different levels of tolerance per person
• Some foods have not been tested yet
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Further Modifications
• Change the texture of the diet based on the
patient symptoms. Ex: IBS-D
- Cook all vegetables, no salads
- Have nut butters over nuts
- Lower fat overall
- No fruits on an empty stomach
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Low FODMAP Diet-Best approaches
• Work with a dietitian familiar with the diet
• Step 1: Elimination Phase. A global restriction
will have better outcomes versus choosing 1-2
categories to limit.
• A temporary diet: 2-6 weeks max
• Step 2: Reintroduction Phase. Intro of one
category at a time to test intolerance and
volume limits
7
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Low FODMAPs
• Lactose: Aged cheese, LF dairy, Brie, Mozzarella, kefir, LF yogurtplain, rice milk, coconut milk
• Fructose: (1 serving per meal) bananas, blueberries, strawberries,
grapes, honeydew, cantaloupe, maple syrup, table sugar
• Fructans/GOS: bok choy, bell peppers, Swiss chard, carrots,
spinach, zucchini, GF breads, GF pasta, potatoes, quinoa, oats, polenta,
10-15 nuts: almonds, macadamia, peanuts, pine nuts, pumpkin seeds, flax
and chia seeds. Firm tofu, tempeh
• Polyols: banana, blueberry, cantaloupe, coconut, lemon, limes,
papaya, rhubarb, table sugar, maple syrup, aspartame, stevia
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Moderate FODMAPs
• Fructans: (limited to 1 choice per meal) beet root4 slices, broccoli-1/2 cup, butternut squash-1/4 cup, peas -1/3 cup,
pomegranate-1/2 small, sweet corn-1/2 cob, canned pumpkin -1/4 cup,
canned chickpeas-1/4 cup, canned lentils-1/2 cup
• Polyols: (limited to 1 choice per meal) avocado-1/8,
celery-1/4 stalk, sweet potato-1/2 cup
• Beverages: espresso, tea: black/white/green/mint,
• Alcohol: (limited to 1 drink per day) most wine
and beer, vodka, gin and whisky
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Proficient Label Reading!
• A label may contain a high FODMAP
ingredient, but look where it falls on the list
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There’s an APP for that
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What about Fats and Proteins?
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All fats are fine- no carb in them
The following proteins are acceptable:
Poultry, beef, lamb, pork, eggs and fish
Nuts, limited to a handful. Nut butters, 2 TBS
Firm tofu, tempeh, seitan
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Elimination phase- Sample diet
Breakfast:
1 cup corn flakes
1 cup lactose free milk
½ ripe banana
1 cup coffee with lactose free milk and
1 tsp sugar
Snack
Handful of almonds
Lunch
2 slices spelt sourdough bread
2 ounces of turkey
1 tablespoon real mayo
Lettuce and tomato
½ cup fresh blueberries
½ cup baby carrots
Snack
½ cup lactose free cottage cheese
8 cherry tomatoes
Dinner
3 ounces baked salmon
1 cup cooked zucchini
Medium baked potato
1.5 tbsp sour cream
2 cups raw spinach
½ cup sliced bell pepper
1 tsp evoo
1 tbsp balsamic vinegar
Drinks: water, allowable tea
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Adding Flavor
• Garlic infused oils- cook garlic in oil and
remove
• Herbs: (keep ‘em fresh) basil, cilantro,
coriander, rosemary, parsley, tarragon, thyme
• Stock- made without garlic and onions
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Eating out
• Review menus ahead of time on line and have
a plan of action
• Give instruction about how you would like
food to be cooked- baked, broiled, lemon and
herbs.
• Bring snacks, avoid being un-prepared when
starving
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Possible Negative Implications
• Avoid eliminating whole food groups
• May be low fiber content
- Work in chia seeds, psyllium husk, ground flax and allowable whole grains
• Limited intake of Prebiotics may not be
beneficial for extended periods of time,
decreasing concentrations of bifidiobacteria.
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Staudacher, et al. J Nutr, 2012.
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Reintroduction Phase
1. As soon as the person starts to feel like their
symptoms have significantly lessened, start
introducing foods back into to the diet- one
category at a time
2. Do not use foods that cross over categories
3. Introduce a small amount, once a day for three
days
4. Check in to see if there is any reoccurrence if
no, return to Low FODMAP diet and start the next
category!
5. Keep a log of symptoms as you go
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Sample Re-Intro
Fructans
wheat, garlic and onions should be tested
separately
Monday, Tuesday, Wednesday- add 1 teaspoon
of chopped garlic to one meal ONCE a day. If ok,
resume Low FODMAP diet and go to next
category
Fructose
Thursday, Friday, Saturday- add 1-2 tsp of honey
once a day.
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Re-Intro
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Lactose- drink ½ cup of milk
Polyols- test Sorbitol and Mannitol separately
Sorbitol, have 1 peach
Mannitol, have ½ cup mushrooms once a day
GOS- have ½ cup of kidney beans
* If person failed a challenge, resume low FODMAP
diet and wait three days without symptoms.
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Diet Of Info!
• Person walks away with information on how
to manage their condition and can choose to
alter their diet as needed.
* Gives a sense of empowerment!
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Important movers and shakers in the
Low FODMAP method:
• Patsy Catsos, MS, RDN, LD
• Kate Scarlatta, RD
• Monash University,
Aurtralia:http://www.med.monash.edu/cecs/
gastro/fodmap/
• Mark Pimentel, MD The New IBS Solution
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Quote From A Friend
What did we ever do before FODMAPs?
- Tamara Duker Freuman
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Published reviews (small sample)
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Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach - Journal of Gastroenterology
and Hepatology 25 (2010) 252-258
Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management – Journal of the
American Dietetic Association;2006;106:pp1631-1639.
Dietary Triggers of Abdominal Symptoms in Patients With Irritable Bowel Syndrome: Randomized Placebo-Controlled Evidence –
Randomized Placebo-Controlled Evidence – Clinical Gastroenterology and Hepatology, 2008:6 (7) pp765-771.
Coeliac Disease and A Gluten Free Diet – Healthy and Heartwise Magazine.
Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with
inflammatory bowel disease – a pilot study – Journal of Crohn’s and Colitis 2008:3(1), pp8-14.
Understanding the Gluten-free Diet For Teaching in Australia – Nutrition and Dietetics. 2006:63: pp155-165.
Food for thought: Western Lifestyle and Susceptibility to Crohn’s Disease – The FODMAP Hypothesis – Alimentary Pharmacology &
Therapeutics; 2005:21: 1399-1409.
Review article: Fructose Malabsorption and The Bigger Picture – Alimentary Pharmacology. & Therapeutics. 2007;25(4) pp349-363.
For Celiac Disease, Diagnosis Is Not Enough- Clin. Gastroenterol. Hepatol. 2012;8:900-901.
Nutritional inadequacies of the gluten‐free diet in both recently‐diagnosed and long‐term patients with coeliac disease- J. Human. Nutr.
2012 DOI: 10.1111/jhn.12018.
Food Choice as a Key Management Strategy for Functional Gastrointestinal Symptoms- Am. J. Gastroenterol. 2012; 107:657–666.
Manipulation of dietary short chain carbohydrates alters the pattern of hydrogen and methane gas production and genesis of
symptoms in patients with irritable bowel syndrome- J Gastroenterol. Hepatol. 2010 Aug ;25(8):1366-73.
Dietary FODMAPs increase delivery of water and fermentable substrates to the proximal colon - Aliment. Pharmacol. Therapeutics.
2010;31(8):874-882.
Comparison of the prevalence of fructose and lactose malabsorption across chronic intestinal disorders - Aliment. Pharmacol.
Therapeutics 2009;30(2):165-74.
A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome.- Gastroenterology 2014;146(1)67-75.
Characterization of Adults With a Self-Diagnosis of Non-celiac Gluten Sensitivity. Nutrition in Clinical Practice- Nutr. Clin. Pract. 2014.
Short-Chain Carbohydrates and Functional Gastrointestinal Disorders- Am. J. Gastroenterol. 2013;108:707-717.
Design of Clinical Trials Evaluating Dietary Interventions in Patients With Functional Gastrointestinal Disorders- Am. J. Gastroenterol.
2013;108: 748-758.
Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with
inflammatory bowel disease—a pilot study - J. Crohn’s Colitis 2009;3(1):8-14.
Pilot study on the effect of reducing dietary FODMAP intake on bowel function in patients without a colon. - Inflamm. Bowel Dis.
2007;13(12):1522-8 .
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THANK YOU!
Laura Manning
Laura.manning@mountsinai.org
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