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Irritable Bowel Syndrome & The Low FODMAP

Emily Haller, MS, RDN Lead GI Division of Gastroenterology and Hepatology Michigan Medicine What is (IBS) ?

IBS is a chronic, often debilitating, and highly prevalent disorder of gut-brain interaction (previously called functional gastrointestinal [GI] disorders)

Characterized by symptoms of recurrent abdominal pain and disordered defecation without evidence of organic disease

The Rome IV criteria can be used (by a physician) to diagnose IBS Rome IV Diagnostic Criteria for IBS

Recurrent abdominal pain at least 1 day per week in the last 3 months, associated with two or more of the following: 1. Related to defecation 2. Associated with a change in the frequency of stool 3. Associated with a change in the form (appearance) of stool

Ford et al. N Eng J Med 2017;376:2566–78. Drossman and Hasler. Gastroenterology 2016;150:1257–61. Fermín Mearin et al. Gastroenterology. May 2016 IBS Subtypes Are Based on Stool Consistecy

100 * Bristol Stool Form Scale 1-2 † Bristol Stool Form Scale 6-7

IBS-M = IBS-mixed 75 IBS-U = unclassified IBS Subtyping based only on when stools are abnormal in the IBS-C* IBS-M absence of therapy 50

25

† IBS-U IBS-D

Percentage of hard or lumpy stools hard of lumpy or Percentage 0 25 50 75 100 Percentage of loose or watery stools

Adapted from Mearin et al. Gastroenterology. May 2016 IBS PATHOPHYSIOLOGY

• IBS symptoms have traditionally been linked to disturbed GI motility, visceral hypersensitivity, and psychological distress

• Growing evidence suggests that alterations in intestinal and colonic microenvironment play an important role in IBS  Infectious gastroenteritis significantly increases the risk of developing IBS  Quantitative and qualitative changes in gut flora have been noted in IBS patients  Alterations in permeability, mucosal immune activation, bile acid metabolism have been identified  Food, stress and medications are important triggers

Slide courtesy of Chey, W, Michigan Medicine IBS: Prevalence & Burden of Illness Prevalence 10-15% in North America Affects twice as many women Dx more often in individuals younger than 50

Resource Utilization • 3 million ambulatory care visits in 20041 • >$20 billion in direct and indirect costs2 • 14 hours of lost productivity per 40-hour work week3

1. National Institutes of Health. The burden of digestive diseases in the United States. NIH Publication 09-6443; January 2010. 2. American Gastroenterological Association. The burden of gastrointestinal diseases. 2001:1-89. 3. ACG Task Force on IBS. Am J Gastroenterol. 2009;104(suppl 1):S1-S35. Slide adapted courtesy of Chey, W, Michigan Medicine Evolving Pathophysiology of IBS Genetics Immune Activation Permeability

Brain-gut interaction

Visceral hypersensitivity

Abnormal motor function

Psychological disorder

1950 1960 1970 1980 1990 2000 2016

Slide credit: Chey, W Why Do We Care About Food in IBS Patients?

Proportion of UMHS patients (n=247) reporting at least moderate effects on the three IBS-QOL food related questions

Slide courtesy of Chey, W, Michigan Medicine Nojkov B, et al DDW 2014 FOOD FOR THOUGHT

/sensitives are frequently reported: Up to 84% of individuals with IBS associate their symptoms with food/eating1

 Individuals with IBS are interested in holistic approaches to treatment which include diet / therapy

 Food impacts health and quality of life

1) Böhn. Am J Gastroenterol. 2013;108:634-41 2) Scarlata. 2018. Why a GI Dietitian Adds Value to a GI Practice. [online] Healio.com. THE LOW FODMAP DIET

Personalization Elimination Reintroduction Phase • A dietary approach Phase Phase (Long-term developed by (2-6 weeks) (6-8 weeks) dietitian, Sue maintainence) Shepherd, Peter Gibson & colleagues, at Monash University to manage IBS symptoms. Improvement in Identify trigger Increase variety as GI symptoms foods much as possible Breaking Down the Acronym

Fermentable – few simple sugars linked together (, GOS) – double sugar () – single sugar () And – sugar alcohols (, , , , glycerol)

GOS, galacto-oligosaccharides. WHAT ARE ?

 Short-chain  Poorly absorbed in the & delivered to the colon  Rapidly fermentable by gut bacteria resulting in gas and SCFA  Small, osmotically active molecules increasing water load to the colon Mechanisms of Individual FODMAPs

• Lactose: with reduced activity of brush border enzyme lactase • Lactase splits lactose into glucose + galactose which can then be absorbed • Fructose: slow, low-capacity transport mechanism across epithelium • Glucose facilitates absorption across the transporter • 1:1 ratio of fructose to glucose is considered FODMAP friendly • >0.2g excess fructose compared to glucose per serving is high FODMAP • Fructans/GOS: humans lack digestive enzyme • Therefore not broken down and 100% of people malabsorb/partially malabsorb • Polyols: many too large for passive diffusion • Has a effect (i.e. ) Differential Effects of FODMAPs

500-mL drink containing 40 g of : 1) Glucose (placebo) 1,2 2) Fructose1,2 3) Inulin1,2 4) 1:1 mixture of glucose and fructose1

• Fructose but not distends the small bowel with water.1,2 • Adding glucose to fructose reduces the effect of fructose on SBWC and breath hydrogen.1 • Inulin distends the colon with gas more than fructose, but causes few symptoms in healthy volunteers.1 • Colonic hypersensitivity to distension, rather than excessive gas production, produces carbohydrate- related symptoms in patients with IBS.2

1) Murray et al. Am J Gastroeterol 2014;109:110 2) Major et al. Gastroenterology. 2017;152(1):124-133 What does the science say??? RCTS EVALUATING THE LOW‐FODMAP DIET FOR IBS

 7 RCTs compared a low FODMAP diet with various controls in 397 participants  A low FODMAP diet was associated with reduced overall symptoms compared to controls (RR 0.69; 95% CI 0.54, 0.88, I2 25%)  The 3 RCTs that compared low FODMAP diet with rigorous control diets had the least heterogeneity between studies but also the least magnitude of effect  The overall quality of the data was “very low” according to GRADE criteria  Most studies were high risk of bias  Heterogeneity between study designs  Imprecision in the estimate of effect

Slide courtesy of Chey, W., Michigan Medicine Dionne et al. Am J Gastroenterol 2018; 113:1290 EFFICACY OF LOW FODMAP DIET

 At least 5 systematic reviews of the low FODMAP diet report improvements in abdominal pain, & some integrated symptom scores  At least 10 RCT or randomized comparative trials of the low FODMAP diet, most of which demonstrate efficacy compared to a control, demonstrates a clinical response in 52–86% of IBS patients  Included in National Institute for Health and Clinical Excellence guidelines for IBS management in primary care in the UK and as ‘second line’ intervention by the British Dietetic Association guidelines  Included in the new ACG Clinical Guideline: Management of IBS

Whelan et al. J Hum Nutr Diet. 2018;31(2):239-255 Lacy et al. Am J Gastroenterol 2021;116:17–44. INTAKE ON THE LOW FODMAP DIET

 When well-planned, the LFD can meet a person’s nutrient, both macro- and micronutrient, needs.  Some studies have demonstrated decreased intakes of carbohydrate, , and energy. While others have found nutrient intakes to remain similar between a LFD intervention, habitual diet or control arm.  Dietitian led elimination phase enhanced micronutrient intake from baseline as was demonstrated by the increased intake of A, C, E, K, niacin, B-6, Cu, & Mg on a 4-week LFD, with significant increases in niacin (P<0.05) & vitamin B-6 (P<0.01).1  Patients educated on a LFD who continued some form of restriction, termed ‘FODMAP adapted’, were found to be consuming a nutritionally adequate diet up to 18 months after initial education.2

1. Eswaran et al. J Acad Nutr Diet. 2020;120(4):641-649. 2. O'Keeffe et al. Neurogastroenterology & Motility. 2017;30(1). IDENTIFYING THE APPROPRIATE CANDIDATE:

Scarlata K. Am J Gastroenterol. 2018 Oct 24. WILL THE REAL FODMAP EXPERTS PLEASE STAND UP

 FODMAP diet should be delivered by a knowledgeable RDN  Experience of FODMAP advice when given by GPs & Gastros to people with IBS:  Materials valued as a “trusted source”  Too simplistic (i.e. food lists)  Little personalization  Difficult to apply to real life  Small study, cannot be generalized to all ppl w/ IBS

Trott et al. . 2019;11(6) High FODMAP Low FODMAP Grains , , Corn tortillas/chips, Grits, free- pastas, crackers, and breads*, Oatmeal, Polenta, Potato, Popcorn, Rice, Slow-rise Sourdough bread, Quinoa Fruits / juice, , (unripe), Blueberry, Cantaloupe, Blackberry, , Dates, Fig, Clementine, Cranberry, Grapes, Honeydew, Grapefruit, Mango, Nectarine, , , , Kiwifruit, Lemon, Lime Mandarins, Orange, Papaya, Pineapple, Pomegranate, Raspberry, Rhubarb, Strawberry Vegetables , , Canned Corn, , Bamboo shoots, sprouts, Bok choy, , , (button, portabella), Broccoli, Carrot, Chives, Cucumber, /shallots, Eggplant, Kale, Lettuce, (oyster), Sugar snap peas Olives, Parsnip, Radish, Spinach, Swiss chard, Tomato, Turnip, Water chestnuts Protein Most /, Processed meats*, -silken Beans: edamame, Canned/rinsed: chickpeas, black beans, Beef, Chicken, Egg, Fish/ Seafood, Pork, Turkey, *, Tofu-firm Dairy / Plant-based Coconut milk (in the carton), Cottage cheese, Almond milk, Cheese, Coconut yogurt, Custard, Frozen yogurt, Ice cream, Milk, Hemp milk, Lactose free -ice cream, -milk alternatives Ricotta cheese, Soy milk, Yogurt -yogurt, & -cottage cheese, Rice milk* ELIMINATION PHASE: LACTOSE FREE, NOT DAIRY FREE

 High lactose: milk, yogurt, cottage/ricotta/cream cheese, pudding, custard, ice cream, evaporated milk  Low lactose (suitable): lactose-free milk, hard/ripened cheese, lactose-free yogurt/ice cream, lactose-free cottage cheese  Lactase pill: not always as effective, but can use when away from home/dining out or for small amounts of lactose (sweets, mixed dishes)  Vegan options: almond milk, rice milk, hemp milk, oat milk, macadamia milk

** varies in severity: many people cannot tolerate milk but can do yogurt (15g vs 6g) FODMAP GENTLE / FODMAP LITE

 Reduced FODMAP intake/selective ‘swaps’

 Elderly; underweight; low education level; unmotivated pt; very picky eaters or those who have multiple other diet restrictions; history of eating disorder

 This diet is complicated and requires a lot of label reading and additional time preparing

 Very poor eating habits/ patterns: address these issues first and potentially make a couple ‘swaps’ INITIAL NUTRITION ASSESSMENT

Discuss specific GI Document use of meds GI workup: breath Any suspected food symptoms for GI symptoms to use testing, celiac triggers? as a marker for serologies/EGD biopsies, improvement at follow pelvic floor dysfunction up Initial Nutrition Assessment

• Dietary recall: • Any foods currently excluded • Assess - smoothies, protein powders, fruit • Diet interventions already tried intake/portions, meal size; onion/garlic • Probe for FODMAP intake use; fiber intake in general, high fat diet?, • Frequency of dining out/cooking skills caffeine?

• Vit/min supplements (certain supplements can have GI side effects...calcium carbonate, Mg, K, , vit C...) • Fiber supplements, (helpful or not? FODMAP additives?) • Spend first 20-25 min in clinic on the above FODMAP Counseling Approach

• 3-part diet: elimination, challenge, personalization • Explain mechanisms of FODMAPs, bucket concept • Education emphasizes what they can eat vs focusing on what they cannot • Label reading and hidden sources of FODMAPs • Cooking and recipe modifications • Grocery shopping and dining out tips • Personalized plan based on patient likes/dislikes, cooking skills, lifestyle Foods with onion/garlic

• Broth • Soups • Sauces/gravies • Most tomato products: ketchup, marinara, tomato soup, salsa • Almost all frozen dinners/pre-seasoned convenience foods • Seasoning packets • Marinades/salad dressings • Some savory snack foods Coping Strategies • Garlic infused olive oil • Chives and green part of scallion for onion flavor • Soda: choose one made with sucrose- Pepsi or Mountain Dew throwback or coca-cola products from Mexico or diet soda • Gum: regular sugar gum instead of sugar free (small amounts) • Sweeteners: stevia, Splenda, aspartame; and regular sugar/brown sugar, pure maple syrup in small amounts • When reintroducing beans: canned, rinsed, drained, cooked will be lowest in (water soluble) • Suggest making vinegar + oil salad dressing Portion sizes matter Low FODMAP Certified Products LOW FODMAP MEAL DELIVERY SERVICES Low FODMAP vegan protein & products

• Firm tofu (not silken) • ¼ cup canned chickpeas • ½ cup canned lentils • ¼ cup red/green lentils • Tempeh (check label) • 1 cup edamame • Quinoa • Nuts and seeds, nut- and seed butters • Brown rice protein powder • powder Low FODMAP Fiber Sources

• Quinoa • Potato with skin • Oatmeal • Nuts (not pistachio or cashew) • Flax and chia seeds • Fruit/vegetables from low FODMAP list • Brown rice • Edamame, small amounts of lentils, chickpeas Traveling Tips (when that used to be a thing….) • Pack FODMAP friendly snacks in suitcase • Instant oatmeal packets • Single serve PB/almond butter packets • Pre-portioned or 100 calorie nut packs • GF crackers • Low FODMAP granola bars • Request mini fridge in hotel • Trip to local grocery store if needed • Research restaurants ahead of time • Choose simple entrees: salads, sushi, protein of choice + potato + veggies • Lactase enzyme pills if needed • Other medications: imodium, etc.  MyGINutrition.com  UM GI Pinterest Page www.pinterest.com/UMGIdietitians  Kate Scarlata website: www.katescarlata.com  Patsy Catsos’s website: www.ibsfree.net/  Monash University: http://fodmapmonash.blogspot.com  FODMAP Friendly fodmapfriendly.com Reintroduction Phase

• Reintroduce FODMAP groups/foods one at a time to identify triggers • Encourage patient to keep a food/symptom log • Cumulative effect versus specific type(s) of FODMAPs • Portion size matters

Example (sorbitol): Day 1: 2-3 slices yellow peach Day 2: 1/2 yellow peach Day 3: 1 yellow peach Maintenance /Personalization Phase:

• Review reintroduction phase results • Guide patients to other foods they are likely to tolerate • Retry failed challenge foods in the future in smaller portions • Revisit bucket concept for long-term management of symptoms • Goal is most varied, nutritionally balanced diet tolerated Personalization Phase:

• Coping strategies for reducing symptoms with trigger foods • Review alternative products, recipes • Limiting portion size/frequency • Enzyme pills may helpful: • Lactase supplement in those who are lactose intolerance • Alpha-galactosidase supplement in those who display GOS-sensitivity • Tuck et al. found 300 GALU vs 150 GALU provided a significant reduction in symptoms (IBS, GOS- sensitive pts) • Optimal timing

Tuck et al. Am J Gastroenterol. 2018 Jan;113(1):124-134. Questions

Thank you!!