The Low FODMAP Diet Approach & Managing IBS Symptoms

Irritable Bowel Syndrome (IBS) & the Low FODMAP Diet Approach for Managing Symptoms

Emily Haller, RDN Senior GI Dietitian Division of Gastroenterology [email protected]

@ea_haller IBS: Prevalence & Burden of Illness

Prevalence 5%-10% in North America1

Resource Utilization • 3 million ambulatory care visits in 20042 • >$20 billion in direct and indirect costs3 • 14 hours of lost productivity per 40-hour work week1

1. ACG Task Force on IBS. Am J Gastroenterol. 2009;104(suppl 1):S1-S35. 2. National Institutes of Health. The burden of digestive diseases in the United States. NIH Publication 09-6443; January 2010. 3. American Gastroenterological Association. The burden of gastrointestinal diseases. 2001:1-89. IBS and Comorbidities

• Increased prevalence of psychiatric disorders in patients with IBS compared with controls1,2  Major depression  Anxiety  Somatoform disorders

• Non-gastrointestinal, non-psychiatric disorders commonly associated with IBS include1  Fibromyalgia  Temporomandibular joint disorder  Chronic fatigue syndrome  Chronic pelvic pain  Painful bladder syndrome/interstitial cystitis

1. Whitehead WE, et al. Gastroenterology. 2002;122:1140-1156. 2. Levy RL, et al. Gastroenterology. 2006;130:1447-1458. Evolving Pathophysiology of IBS Genetics Microbiome Immune Activation Permeability

Brain-gut interaction

Visceral hypersensitivity

Abnormal motor function

Psychological disorder

1950 1960 1970 1980 1990 2000 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

5 Microenvironment and FGIDs

Brain-Gut Axis

Genetic polymorphisms Increased mucosal (IL-10, TGF-β, TNF-α, IL-6, SERT) permeability (ZO-1) Gene expression

Altered enteroendocrine metabolism Mucosal immune (serotonin) activation

Neuroplasticity (SP, NGF) Food hypersensitivity / Intolerance

Bile Acid Metabolism Transient infection Altered and unstable microbiota Diagnosing IBS: Rome IV Criteria*

Recurrent abdominal pain or discomfort at least 3 days/month 1 day per week associated with two or more of the following: • xImprovement with Related to defecation • Onset associated with a change in the frequency of stool • Onset associated with a change in the form of stool

Fermín Mearin et al. Gastroenterology. May 2016 T7 IBS Subtypes Are Still Based on Stool Consistency 100

* Bristol Stool Form Scale 1-2 † Bristol Stool Form Scale 6-7 75 IBS-M = IBS-mixed IBS-U = unclassified IBS IBS-C* IBS-M Subtyping based only on when stools 50 are abnormal in the absence of therapy

† 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 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

Nojkov B, et al DDW 2014 Hello FODMAPs!

• The low FODMAP diet is a nutritional concept developed by Sue Shepard & Peter Gibson at Monash University to manage IBS/IBD symptoms.

• Done in 2 phases: 1) Elimination phase 2) Challenge phase What are FODMAPs?

Fermentable Oligosaccharides – few simple sugars linked together (fructans, galactans) Disaccharides – double sugar (lactose) Monosaccharides – single sugar (fructose) And Polyols – sugar alcohols (sorbitol, mannitol, isomalt, xylitol, glycerol) What do FODMAPs Have in Common?

• Short chain carbohydrates • Poorly absorbed in the small intestine & delivered to the colon • Rapidly fermentable by gut bacteria resulting in gas and SCFA • Small, osmotically active molecules increasing water load to the colon Monash University Cumulative effect of FODMAPs produces symptoms in IBS patients Why are FODMAPs malabsorbed?

Lactose: with reduced activity of brush border enzyme lactase • Lactase splits lactose into glucose + galactose which can then be absorbed • 25% of IBS patients malabsorb

Fructose: with slow, low-capacity transport mechanism across epithelium • Absorbed via two mechanisms: cotransport with glucose GLUT-2 or GLUT 5 (low saturation levels) • Glucose facilitates absorption across the transporter • 1:1 ratio of fructose to glucose is considered FODMAP friendly • Fructose load: recommend to limit to 1 serving of ripe FODMAP friendly fruit per sitting

Barrett J.S. et al (2009) and Yao C.K., et al (2014) Why are FODMAPs malabsorbed?

Fructans/Galactans: humans lack digestive enzyme • Therefore not broken down and 100% of people malabsorb, fermented by intestinal microflora

Polyols: too large for passive diffusion • Has a laxative effect (prunes) • Increased absorption in IBS patients, along with increased GI symptoms. Symptoms appear to be independent of malabsorption - ? Fluid distension due to osmotic effect

Barrett J.S. et al (2009) and Yao C.K., et al (2014) Who is the low FODMAP diet indicated for?

• IBS: ~50-74% of IBS patients have partial or full relief of GI symptoms • Benefit for IBD (in remission), ileostomy, ileorectal anastomosis • Celiac disease (commonly overlapped with IBS; negative serologies/biopsy)* • Gastroparesis/IBS overlap* • SIBO • GERD*

*along with other dietary modifications

IBS: Bohn (2015), Piacentino (2015), Halmos (2014), Staudacher (2011), Gibson (2010) IBD: Prince (2016), Pederson (2014), Barrett (2010); Gearry (2009), Croagh (2007) Irritable Bowel Syndrome & FODMAPS

• Altered motility, gut microbiota & visceral hypersensitivity are key presentations • FODMAPs do not cause the underlying functional GI disorder, but they can exacerbate the symptoms • Symptoms are triggered due to response of the enteric nervous system to the luminal distention in those with IBS likely due to the nature of the gut flora and dysmotility Research Role of FODMAP in Patients with IBS: A Review

Mansueto et al. Nutrition in Clinical Practice. 2015 665-682. . Included: Six RCTs and 16 non-randomized interventions

. There was a significant decrease in IBS SSS scores for those individuals on a low FODMAP diet in both the RCTs (OR 0.44, 95 % CI 0.25– 0.76, p = 0.00) and non-randomized interventions (OR 0.03, 95 % CI 0.01–0.2, p = 0.02)

. Significant improvement in the IBS-QOL score for RCTs (OR 1.84, 95 % CI 1.12–3.03, p = 0.39) and for non-randomized interventions (OR 3.18, 95 % CI 1.60–6.31, p = 0.89).

. Following a low FODMAP diet was found to significantly reduce symptom severity for abdominal pain (OR 1.81, 95 % CI 1.13–2.88, p = 0.56), bloating (OR 1.75, 95 % CI 1.07– 2.87, p = 0.45) and overall symptoms (OR 1.81, 95 % CI 1.11–2.95, p = 0.4) in the RCTs. FODMAPs exert osmotic & fermentation related effects which trigger symptoms in IBS

• Fructose but not inulin distends the small bowel with water. • Adding glucose to fructose reduces the effect of fructose on SBWC and breath hydrogen. • Inulin distends the colon with gas more than fructose, but causes few symptoms in healthy volunteers.

Murray et al. Am J Gastroeterol 2014;109:110 US RCT Comparing the Low FODMAP Diet vs m-NICE Guidelines in IBS-D

• Aim: Compare the efficacy of the low-FODMAP diet to a diet based upon modified guidance from the National Institute for Health and Care Excellence (mNICE) in US adults with IBS-D • Single center trial

• Dietitian guided mNICE recommendations: • Small frequent meals • Caffeine and alcohol in moderation • Avoidance of trigger foods

Eswaran, Chey, et al. 2016 Inclusion Criteria

• Rome III criteria for IBS-D • Normal lower endoscopy with biopsy • Negative workup for celiac disease • Normal baseline labs • Stable dose of antidepressant medications permitted Exclusion Criteria

• IBS-M/IBS-C • Major co-morbidities affecting the GI tract • Abdominal surgery except appendectomy or cholecystectomy (>6mo) • Probiotics, antibiotics, narcotics • Active participation in another dietary therapy • Previous low FODMAP diet Screening visit Randomization Criteria 14 day Average daily abdominal pain score Screening phase of 4 or higher on an 11- point numerical rating Day 0 scale (NRS) Randomization AND Teaching with RD Average daily stool consistency of ≥5, assessed by Bristol Stool Form Scale (BSFS) mNICE Low FODMAP

4 weeks Symptoms assessed daily Adequate relief assessed weekly Day 28 Final Visit Endpoints

Primary endpoint: Adequate relief of overall IBS symptoms during 50% or more of the last 2 weeks of study period (weeks 3-4) Secondary Endpoints A decrease in mean daily Bristol Stool Form Scale value of ≥1 compared to baseline for 2/4 weeks

≥30% reduction in mean daily abdominal pain score for 2/4 weeks

≥30% reduction in mean daily bloating score for 2/4 weeks Baseline Symptom Severity

Symptom Low mNICE p-value Baseline CharacteristicsFODMAP N = 50 N = 42

Abd Pain Score 5.10 ± 1.5 5.06 ± 1.34 p = .9051

Bloating Score 4.87 ± 1.83 5.01 ± 2.07 p = .7195

Urgency Score 4.98 ± 1.93 5.39 ± 2.1 p = .3347

Bristol Stool Form 5.21 ± .60 5.25 ± .70 p = .7710

Stool Frequency 3.45 ± 1.66 3.37 ± 1.76 p = .8204 Nutrient Intake

Low Nutrient FODMAP m-NICE p-value p-value p-value between Baseline Week 4 within Baseline Week 4 within groups: (n=43) (n=41) group (n= 39) (n = 37) group BASELINE Kilocalories/d 2020±661 2006±502.5 p=.9166 Average Number of 5.43±1.7 5.52±1.7 p=.8070 Daily Meals Protein (g/d) 76.53±28.6 74.14±21.9 p=.6743 Fat (g/d) 79.26±32.9 80.97±25.6 p=.7954 Alcohol (g/d) 8.60±16.4 5.74±9.3 p=.3311 Carbohydrates (g/d) 244.59 ± 87 244.07±70 p=.9767 Monosaccharides (g/d) 43.59±33 39.47±28 p=.5457 Fructose (g/d) 20.97±17.2 19.62±14.6 p=.7051 Lactose (g/d) 9.95±9.9 9.30±8.8 p=.7543 Polyols (g/d) .98±1.3 .57±.6 p=.0746 Total Dietary Fiber (g/d) 18.67±8.4 19.14±8.1 p=.7992 Nutrient Intake

Low Nutrient FODMAP m-NICE p-value p-value p-value between Baseline Week 4 within Baseline Week 4 within groups: (n=43) (n=41) group (n= 39) (n = 37) group BASELINE Kilocalories/d 2020±661 1691±600.7 p=.0023 2006±502.5 1835±714.1 p=.0416 p=.9166 Average Number of 5.43±1.7 4.92±1.5 p=.0119 5.52±1.7 4.80±1.4 p=.0040 p=.8070 Daily Meals Protein (g/d) 76.53±28.6 72.7±36.7 p=.3959 74.14±21.9 77.27±36.1 p=.4959 p=.6743 Fat (g/d) 79.26±32.9 75.05±37.9 p=.3580 80.97±25.6 69.90±36.3 p=.0116 p=.7954 Alcohol (g/d) 8.60±16.4 5.91±12.4 p=.3580 5.74±9.3 7.14±13.5 p=.6179 p=.3311 Carbohydrates (g/d) 244.59 ± 87 180.31 ± 55.5 p<.0001 244.07±70 219.39 ± 84 p=.0450 p=.9767 Monosaccharides (g/d) 43.59±33 25.96±14.1 p=.0013 39.47±28 37.3±30.5 p=.6686 p=.5457 Fructose (g/d) 20.97±17.2 10.44±7.1 p=.0004 19.62±14.6 17.79±14.3 p=.4920 p=.7051 Lactose (g/d) 9.95±9.9 2.10±2.7 p<.0001 9.30±8.8 7.32±6.9 p=.1927 p=.7543 Polyols (g/d) .98±1.3 .68±1.4 p=.3173 .57±.6 .84±1.1 p=.0872 p=.0746 Total Dietary Fiber (g/d) 18.67±8.4 17.76±7.2 p=.4336 19.14±8.1 18.68±9.1 p=.8972 p=.7992 Nutrient Intake Low Nutrient FODMAP m-NICE p-value p-value p-value between p-value Baseline Week 4 within Baseline Week 4 within groups: between groups: (n=43) (n=41) group (n= 39) (n = 37) group BASELINE WEEK 4 Kilocalories/d 2020±661 1691±600.7 p=.0023 2006±502.5 1835±714.1 p=.0416 p=.9166 p=.3370 Average Number of 5.43±1.7 4.92±1.5 p=.0119 5.52±1.7 4.80±1.4 p=.0040 p=.8070 p=.7259 Daily Meals Protein (g/d) 76.53±28.6 72.7±36.7 p=.3959 74.14±21.9 77.27±36.1 p=.4959 p=.6743 p=.5790 Fat (g/d) 79.26±32.9 75.05±37.9 p=.3580 80.97±25.6 69.90±36.3 p=.0116 p=.7954 p=.5425 Alcohol (g/d) 8.60±16.4 5.91±12.4 p=.3580 5.74±9.3 7.14±13.5 p=.6179 p=.3311 p=.6754 Carbohydrates (g/d) 244.59 ± 87 180.31 ± 55.5 p<.0001 244.07±70 219.39 ± 84 p=.0450 p=.9767 p=.0220 Monosaccharides (g/d) 43.59±33 25.96±14.1 p=.0013 39.47±28 37.3±30.5 p=.6686 p=.5457 p=.0448 Fructose (g/d) 20.97±17.2 10.44±7.1 p=.0004 19.62±14.6 17.79±14.3 p=.4920 p=.7051 p=.0075 Lactose (g/d) 9.95±9.9 2.10±2.7 p<.0001 9.30±8.8 7.32±6.9 p=.1927 p=.7543 p=.0001 Polyols (g/d) .98±1.3 .68±1.4 p=.3173 .57±.6 .84±1.1 p=.0872 p=.0746 p=.5901 Total Dietary Fiber (g/d) 18.67±8.4 17.76±7.2 p=.4336 19.14±8.1 18.68±9.1 p=.8972 p=.7992 p=.6173 Adequate Relief p= .3055 60% 52% 50% 41% 40%

30%

20%

10%

0% m-NICE Low FODMAP “In the last week, have you had adequate relief of your GI symptoms?” Proportion of patients that answered “Yes” for ≥50% of weeks 3 and 4 Stool Consistency

60% p=.1812 50% 42% 40%

30% 28%

20%

10%

0% m-NICE Low FODMAP

A decrease in mean daily Bristol Stool Form value of ≥1 compared to baseline for 2/4 weeks Figure 4. Comparison of daily scores averaged by week for abdominal pain score, bloating score, BSFS, stool frequency, and urgency score to baseline for each treatment group. P values refer to the change within group comparing specified week to baseline score.

Abdominal Pain Bloating

Consistency/Bristol Stool Form Scale Stool Frequency

Weekly Abdominal Symptom Scores

6 6

m-NICE Low FODMAP m-NICE Low FODMAP 10)

5 10) 5 Urgency - ○ # 4 § 4 § § § 3 § 3 §

2 2

Average Daily Bloating Score (0 Score Bloating Daily Average Average Daily Abdominal Pain Scores (0 Scores Pain Abdominal Daily Average 1 1 Baseline Week 1 Week 2 Week 3 Week 4 Baseline Week 1 Week 2 Week 3 Week 4 Abdominal Pain Bloating

* = p ≤.05 ◦ = p ≤.01 P values refer to the change WITHIN group # = p ≤.001 comparing to baseline score § = p ≤.0001 Overall IBS- QOL Scores p < .0015

p<.0001 80 p=.03 69.3 70 59.4 60 Mean 54.3 53.4 Value 50

10 Baseline Week 4 Baseline Week 4

m-NICE Low FODMAP IBS- QOL Scores Proportion with Improvement from Baseline ≥ 14

60% p =.0105 52%

50% Meaningful Clinical Response: 40% > 14 point increase in IBS-QOL score from 30% baseline % 21% 20%

10%

0% m-NICE Low FODMAP Meaningful Clinical Response Conclusions

• Both dietitian-taught interventions improved IBS symptoms • The low FODMAP diet led to significantly greater improvements in abdominal symptoms • Abdominal pain • Bloating • Modest improvements in stool consistency • Benefits extend beyond GI symptoms • This study supports a role for low FODMAP diet in the treatment of IBS-D patients Indications to try the FODMAP diet

• “The more fiber (food/supplements) I eat, the more bloated and constipated I get.”

• “I take prune juice for constipation, but it makes me feel even more bloated”

• “I’m a vegetarian and eat a very healthy diet. I eat tons of soy, beans, nuts, fruit and vegetables-- I don’t get it!”

• “I get more and more bloated as the day goes on. I feel 9 months pregnant at night.” More indications….

• “I tried a gluten-free diet and only had partial improvement in my symptoms.”

• “I am lactose intolerant so I switched to soy milk but it made me even sicker.”

• “My symptoms are totally random. I record my intake to try to see which food makes me sick. Sometimes I can eat an apple and feel fine and other times I get very bloated after eating the same food.” FODMAP dietary approaches

• Full elimination (minimum 2 weeks; max ~6 weeks if compliant) followed by challenge/reintroduction phase • Shorter for diarrhea/bloating/gas; longer for constipation (slower transit) and high anxiety pts (gut-brain connection)

• Hope to identify trigger foods

• Goal is to increase variety as much as possible for long-term

• Usually 3 visits with RD FODMAP diet approaches

• Reduced FODMAP intake/selective ‘swaps’ • Elderly; underweight/malnourished; 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 meals • Obese patient…very poor eating habits/meal patterns: address main issues first and make a couple ‘swaps’ Which foods are high in FODMAPs?

• Lactose: milk, yogurt, pudding, custard, cottage/ricotta/cream cheese, ice cream, evaporated milk, large amounts of milk chocolate • Fructose: apple, pear, mango, honey, agave, HFCS • Fructans: onion, garlic, wheat, rye, barley, inulin/chicory root, artichoke, grapefruit, pistachios, cashews • Galactans: all legume beans (soy beans/soy milk, black beans, baked beans, lentils, hummus...) • Polyols: stone fruits (peach, plum, prune, cherry, nectarine), watermelon, mushrooms, cauliflower, sugar-free gums, cough drops, and candy (can also be in vitamins/meds) Which foods are low in FODMAPs?

• Fruit: Banana, blueberries, strawberries, raspberries, orange, pineapple, grapes, cantaloupe, honeydew • Vegetables: Tomato, lettuce, kale, spinach, cucumber, carrots, green beans, bell peppers, zucchini, squash, eggplant, moderate portions of several other vegetables • Grains/Starches: Rice, quinoa, potato, oats/oatmeal, corn tortillas, gluten free bread/pasta/crackers/cookies, cereals (including Cheerios, Rice Chex, Corn Flakes) • Dairy: Lactose-free milk/yogurt/cottage cheese/ice cream, hard or aged cheeses, butter, cream • Proteins: Chicken, fish, turkey, beef, pork, eggs, firm tofu, peanut or almond butter, nuts , small amounts of canned chickpeas and lentils Elimination phase: Lactose free, NOT dairy free • High lactose: milk, yogurt, cottage/ricotta cheese, pudding, custard, ice cream, evaporated milk, large amounts of milk chocolate • Low lactose / lactose free: lactose free milk (NOT soy), almond or rice milk (vegan options), hard/ripened cheese, lactose free yogurt/ice cream, lactose free cottage cheese • Lactase enzyme added to these LF dairy products • Lactase pill: not as effective, but can use when away from home/dining out or for small amts of lactose (sweets, mixed dishes, hard/ripened cheese if needed)

**Lactose intolerance varies in severity: many people cannot tolerate milk but can do yogurt (15g vs 6g) Initial Nutrition Assessment

• Discuss specific GI symptoms • Frequency, consistency, time of day • May document use of meds for GI symptoms to use as a marker for improvement at follow up • GI workup: breath testing, celiac serologies/EGD biopsies, pelvic floor dysfunction • Any suspected food triggers? 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, zinc, vit C...) • Fiber supplements, probiotics (helpful or not? FODMAP prebiotic additives?) • Spend first 20-25 min in clinic on the above FODMAP Counseling Approach

Prepping the Patient:

. 2 part diet: elimination phase, challenge phase . 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

Hidden Sources of Onion/Garlic

• Sauces and tomato products • Soups, broths, bouillon • Salad dressings, marinades • Seasoning packets/blends • Seasoned GF snack foods • Condiments • Deli meats • Frozen dinners • Prepared foods Label Reading for Onion & Garlic

• According to the FDA, food manufactures in the US cannot list onion and garlic as ‘spices’ in the ingredient list because they are regarded as food items • However, ‘natural flavors’ or ‘flavoring’ can include onion and garlic • Avoid savory foods with these ingredients or call manufacturer to get more info • Broth, stock, bouillon • GF crackers • Meat products Coping Strategies • Garlic infused olive oil • Chives and green part of scallion for onion flavor • If they must have soda: choose one made with sucrose- Pepsi or Mountain Dew throwback or coca-cola products from Mexico (international aisle) or diet • Gum: regular sugar gum instead of sugar free (small amts) • Sweeteners: stevia, splenda, aspartame; and regular sugar/brown sugar, pure maple syrup in small amts • When reintroducing beans: canned, rinsed, drained, cooked will be lowest in galactans (water soluble) • Suggest making vinegar + oil salad dressing Low FODMAP Fiber Sources

• Brown rice • Quinoa • Potato with skin • Oatmeal • Nuts and nut butters (not pistachio or cashew) • Flax, chia, hemp seeds • Fresh fruit/vegetables from low FODMAP list Vegan/Vegetarian

• Typically consume a high FODMAP diet • Legumes, soy milk (GOS); whole wheat, garlic, onions (fructans) • Assist pt in picking out good sources of protein/products • Provide sample menu • Oatmeal with ½-1 cup fresh berries, chopped walnuts or almonds, almond or hemp milk • Firm tofu sautéed in garlic infused olive oil with bok choy, carrots, red bell pepper, broccoli bits, green part of scallion, rice, soy sauce • Tossed salad with spinach, ¼ cup chickpeas, cucumber, tomato, shredded carrots, quinoa, olive oil/balsamic vinegar dressing, gluten free pretzels or rice crackers Low FODMAP vegan protein & products

• Firm tofu (not silken) • ¼ cup canned chickpeas • ½ cup canned lentils • Tempeh (check label) • Seitan • Quinoa • Nuts and seeds, nut- and seed butters • Brown rice protein powder • 1 cup edamame Dining Out

• Look online at restaurant menu for potential options • Call restaurant ahead of time during off hours • Ask how menu items are prepared and if items can be modified • i.e. Grilled chicken salad: onion/garlic seasoning on grilled chicken? Is plain chicken an option? • Choose simple entrees • Prioritize avoiding onion and garlic • Good choices: • Seafood restaurants • Sushi (avoid: teriyaki sauce) • Steak house • Salads with plain grilled protein • Omelets • Gluten free menu: i.e. hamburger (no seasoning), GF bun, lettuce/tomato, 1 tbsp ketchup and French fries Traveling

• 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 • Lactase enzyme pills if needed • Other medications: imodium, etc Other Considerations • Due to complexity it is best if patient waits to start the diet until appt with RD • Brief intro FODMAP handout in clinic- MD will give to patients so they know what to expect at visit with RD • If pt does not want a nutrition visit, the brief intro handout is not comprehensive enough to follow the diet.

Directed to good resources:

1) MyGINutrition.com 2) UM GI Dietitians on Pinterest 3) The Complete Low FODMAP Diet book by Sue Shepard 4) Kate Scarlata website: www.katescarlata.com 5) Patsy Catsos’s website: www.ibsfree.net/ 6) Monash University

Yes, there is an App for that! Portion sizes matter

Challenge 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 Thank you!

Questions