Sheila E. Crowe, MD, FACG

The Low FODMAP Diet What Does it Do and Who is it For? Sheila E. Crowe, MD, FACG Department of Medicine University of California, San Diego

At the end of this presentation the participant  will be able to: 1. Recognize the various foods that may impact symptoms associated with IBS; 2. Understand how different foods can contribute to abdominal pain, bloating and altered bowel function; 3. Develop a dietary approach in management of patients with IBS and other FGID

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Sheila E. Crowe, MD, FACG

A Food Intolerant Patient • A 58 yr old woman with abdominal bloating and discomfort after eating various foods, abdominal cramping and loose stools ranging from 2 to 3 per day without blood for the past few years. Symptoms are relieved by passage of stool. She attends a Celiac Support Association meeting and comes to my clinic concerned she has celiac disease. No family or personal history of atopic disorders or autoimmune disease. • She went on a gluten free diet two months ago. She feels better but reports that she is allergic to onions and peppers since these cause bloating, pain and loose stools. She wants to know what she should eat and what not to eat.

How do you answer the patient’s question?

Cause of IBS: Patients’ Beliefs % of Patients

100 80 60 40 20 0 od Fo Al

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Lacy, BE et al, Aliment Pharmacol Ther, 2007;25:1329

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Sheila E. Crowe, MD, FACG

Why the Fixation with Food? • The average human ingests a large amount of food in their lifetime ~ 60,000 pounds = 27,273 kilograms = 30 tons

• Historically humans did not get sufficient food • Overeating behavior is common for many reasons • Comfort foods are typically preferred in illnesses and times of stress • As a consequence many patients with IBS do not select the best diet

Association of Diet, GI Symptoms & IBS • Romanian study of 193 subjects assessed for eating habits and diet – 19.1% met criteria for IBS by Rome III – IBS subjects ate more canned food, processed meat, legumes, whole cereals, sweets, fruit compotes

• Swedish study of 197 IBS patients completed questionnaires for food, depression, anxiety, QoL, etc – 84% reported symptoms associated with ≥1 food • 70% carbs – dairy, legumes, apple, flour, plums • Histamine-releasing foods – milk, wine/beer, pork Chirila, I. et al, J Gastrointestin Liver Dis, 2012, 21; 357. • Fried or fatty foods Bohn, L, et al, Am J Gastroenterol, 2013, 108: 634.

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Sheila E. Crowe, MD, FACG

So What do We Know about Dietary Treatments for IBS and Other FGID? Diet

Evidence for use

Low fat

Limited

Gluten-free

Limited

Low FODMAP

Increasing data

Histamine-free diet

Little to none

Paleolithic

Minimal

Candida

None

Elimination

Little to none

Limited evidence overall but for low FODMAP diet studies there are 6 randomized and 7 observational studies1 Only 3 of 17 elimination diets met eligibility criteria2 1‐Nanayakkara, WS et al. Clin Exp  Gastroenterol. 2016;9:131 2‐Moayyedi, P, et al, Clin Trans Gastroenterol, 2015; 6, e107

Mechanisms By Which Food  Components Cause IBS Symptoms • Components of food that cause altered pathophysiology and  can lead to symptoms: – Fiber, fat, histamine, starches/sugars 

• • • •

Stimulation of mechano‐ and chemoreceptors Release of hormones/peptides Alteration of the innate immune system   In some genetically susceptible individuals food stimulates  the adaptive immune system  Chey, WD, Am J Gastroenterol, 2016, 111, 366. 

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Sheila E. Crowe, MD, FACG

Physiological Food Reactions • Large volume meals (overeating) cause distension, promote regurgitation • Fatty foods delay gastric emptying, alter motility • Legumes, cruciferous vegetables, garlic, onions, etc., may lead to flatus (farts) • Non-absorbable or poorly absorbed sugars and carbohydrates can cause diarrhea, bloating, flatulence, etc. • However, intestinal gas is NORMAL (up to 20/day) MD Levitt, et al, A. J. Gastroenterol., 1998: 93:2276

What are FODMAPs Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols • Fructose and fructans • Sorbitol • Sucrose • Lactose Many foods (grains, starches, fruits, vegetables, lactose, sweeteners) contain FODMAPs Shepherd SJ, et al. Clin Gastro Hep. 2008;6:765  Shepherd SJ, Gibson PR. J Am Diet Assoc. 2006;106:1631

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Sheila E. Crowe, MD, FACG

Pathophysiology of FODMAPs • • • • • • •

Poor absorption in the small intestine Osmotic effects in the colon, increased water Fermentation with gas production Luminal distension Effects on microbiota Immune modulation Alteration of intestinal barrier Chey, WD, Am J Gastroenterol, 2016, 111, 366

Effect of FODMAPs on Breath Hydrogen Breath hydrogen (ppm)

40

35

N=29

30

IBS on High FODMAPs

25

20

Controls on High FODMAPs

15

10

Low  FODMAP 5

0

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Hours

Ong DK et al. J Gastroenterol Hepatol. 2010;25:1366

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Sheila E. Crowe, MD, FACG

Gluten Causes Symptoms in IBS Patients Without Celiac Disease

No Effect of Gluten after Reduced FODMAP Diet in IBS Patients • 37 subjects with IBS (Rome III) reporting NCGS (celiac disease meticulously excluded) underwent double-blind cross-over study • 2 wks low FODMAP diet resulted in significant improvement of GI symptoms and fatigue • Challenge with gluten (high, low or control) did not result in symptomatic or biological changes • Suggests sensitivity may not be due to gluten J. Biesiekierski, et al, Gastroenterol, 145:320, 2013

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Sheila E. Crowe, MD, FACG

No Effect of Gluten after Reduced FODMAP Diet in IBS Patients

J. Biesiekierski, et al, Gastroenterol, 145:320, 2013

A Diet Low in FODMAPs Reduces Symptoms of IBS

Halmos, EP, et al, Gastroenterol: 2014, 146; 67.

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Sheila E. Crowe, MD, FACG

Intervention Diets A) Low‐FODMAP Diet • Foods to avoid (apple,  beans, white bread, milk) • Foods to eat (orange,  blueberries, lactose‐free  milk, 100% spelt bread) • Avoid foods rich in  fructans, galacto‐ oligosaccharides, lactose,  free fructose, etc.

B) Traditional IBS Diet • 3 meals per day • 3 snacks per day • Reduce fatty, spicy foods,  coffee, alcohol, onions,  cabbage, beans • Avoid soft drinks,  carbonated beverages,  sweeteners (‐ols) Bohn, L, et al, Gastroenterol: 2015, 149; 1399.

Low FODMAP vs Traditional IBS Diet

Bohn, L, et al, Gastroenterol: 2015, 149; 1399.

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Sheila E. Crowe, MD, FACG

Study Results & Conclusions • 67 patients completed dietary intervention • 33 low FODMAP, 34 traditional IBS diet

• Significant reduction of severity of IBS symptoms (IBSSSS) before and after the 4 week interventions in both the groups (p50 compared with baseline vs 17 (46%) of group B (p=0.62) had IBS severity scores >50 compared with baseline • Food diaries showed good adherence to dietary advice • The authors suggest that combining elements from these two dietary regimens may have further benefit IBS symptoms

Recent Study Suggests Benefits of Low FODMAP Diet • 40 patients IBS Rome III controlled single blinded study for 3 weeks • 19/20 on low FODMAP, 18/20 high FODMAP diet completed

• Significant reduction of IBS symptoms (IBS-SSS) • Significantly altered metabolic profile in urine (histamine,  p‐hydroxybenzoic acid, azelaic acid major determinants) and an 8-fold decrease of histamine levels in urine • Increased Acetinobacteria in the microbiome • This study suggests a benefit but more studies in different populations with larger numbers are needed to determine the true value of the low FODMAP diet McIntosh, K, et al, Gut: 2016, ePub.

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Sheila E. Crowe, MD, FACG

Back to the Food Intolerant Patient • Reviewed prior records - she had a normal EGD and colonoscopy a few years ago. Duodenal biopsies, no evidence of celiac disease. • I reassured her history was not consistent with food allergy • Referred to a RD with expertise with GI disorders • After a year she returned to my clinic to let me know how much I had improved her life after starting a strict low FODMAP diet and re-introducing foods back in to her diet. She had lost weight, greatly improved symptoms and her whole outlook. • She had 6 visits with the RD.

Who Benefits From a Low FODMAP  Diet?

• Motivated, compliant, educated patients with IBS-D, M, C • Other functional GI diseases may benefit from a low FODMAP diet • NCGS and celiac disease patients on a GF diet (eliminates wheat starch with gluten, also some have increased FODMAPs in their diet) • Low FODMAP diet reported to work better in IBD than IBS patients in one report1 • • • •

The downsides and unknowns of the diet Long term effects are not known Very stringent restrictions may have adverse effects Impact on the individual’s microbiome 1- Maagaard, L, et al, World J. Gastroenterol: 2016, 22; 4009

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Sheila E. Crowe, MD, FACG

Take Home Messages • Food ingestion is a significant factor in causing symptoms in  patients with IBS and other FGID • Culprits are often comfort foods (sweets/starches, fatty foods,  histamine containing foods)  • Lactose in lactase deficient patients  • Non‐celiac gluten sensitivity in some but may be due to  coexisting dietary wheat starch  • Bacterial overgrowth, dysbiosis • The low FODMAP diet does provide some benefit but difficult  to adhere to long‐term • A minority will have food allergy or celiac disease – an overlap  of common diseases (IBS affects 15% of the US population, 1%  with celiac disease and 2‐4 % of adults have food allergy)

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