Gluten Free Alphabet Soup!

Transcription

1 Gluten Free Alphabet Soup! Kate Scarlata, RDN, LDN Owner, For a Digestive Peace of Mind Digestive Health Nutrition Consulting Medway, MA

2 DISCLOSERS Advisor and consultant Nestle Health Science, FODY foods, Gastro Girl, Casa de Sante foods. Published book and e-books

3 OBJECTIVES Detail the physiologic effects of FODMAPs in the intestine. Describe the low FODMAP elimination diet and reintroduction phase. List foods high and low in FODDMAPs.

4 IBS: Functional Gut Disorder Disorder due to function vs. physical abnormality Altered motility and visceral hypersensitivity are key presentations. Alterations in gut flora likely plays key role. Is IBS an infectious disease? How does the gut microbiome factor in to this condition?

5 IBS Epidemiology IBS impacts about 11% of the population globally w/ range from 10-25% Only 30% will consult with a physician about their sx. Female predominance; 1.5 to 3 fold higher compared to men IBS occurs in all age groups, including children. IBS is twice as high in individuals with biological relative with IBS. Clin Epidemiology 2014:

6 IBS & Celiac Connection 20 to 23 percent of treated celiac patients fulfill the diagnostic criteria for IBS. For these individuals, a low FODMAP gluten free diet may offer improved symptom management. El-Salhy, M, Hatlebakk, JG, Gilja, OD, and Hausken, T. The relation between celiac disease, nonceliac gluten sensitivity, and irritable bowel syndrome. Nutrition Journal (2015);14:92

7 Low FODMAP diet Low FODMAP is a dietary approach developed by dietitian, Sue Shepherd, Peter Gibson & colleagues, at Monash Univ. (Australia) to manage IBS/FGD symptoms. Elimination diet, FODMAP intake is reduced significantly; then individual FODMAPs are re-introduced methodically to help patient identify their personal triggers.

8 FODMAP acronym stands for:

9 FODMAPs effects

10 Osmotic Effects Spencer M, et al. Cur Tx Opt GI Cognitive and Emotional Factors

11 Why are FODMAPs malabsorbed? Lactose: Up to 70% of the world population has lactase non persistence, also secondary LI observed in post-infectious IBS & SIBO Fructose: poor absorption due to it s slow, low-capacity transport mechanism across the epithelium & SIBO; FM occurs in 1in 3 ppl Fructans/ GOS: humans lack digestive enzymes Polyols: too large for passive diffusion; absorbed in pores in small intestine.

12 FODMAPs & IBS FODMAPs DO NOT cause IBS but reduction of FODMAPs in the diet may reduce symptoms. Symptoms are triggered due to response of the enteric nervous system to the luminal distention in IBS, likely due to: - Nature of gut flora - Dysmotility impacting fluid and gas clearance - Visceral hypersensitivity - Possibly, mast cell degranulation - Bacterial metabolites as by-product of fermentation of FODMAPs may likely play a role

13 FODMAPs beyond the gut Depression/anxiety: r/t fructose malabsorption; FM significantly lower plasma tryptophan concentrations and significantly higher scores in the Beck depression inventory compared to those with normal fructose absorption. (Ledochowski M, Scand J Gastroenterol. 2001) Fatigue: IBS patients experience greater fatigue/lethargy with high FODMAP diet compared to controls. (Ong,D et al J Gastroenterol Hepatol. 2010)

14 SAMPLE OF HIGH FODMAP SOURCES

15 FODMAPs effects are cumulative - Each individual fills their personal bucket differently

16 Learning Diet NOT long term!

17 3 Phase Nutritional Approach 1 st phase: Remove high FODMAP containing foods for 2-6 weeks on elimination phase 2 nd phase: Re-introduce FODMAPs or challenge phase of the diet. 3 rd phase: Integrate to patient s tolerance

18 Current and accurate resource! Updated by Monash University s latest FODMAP food analysis research Traffic light system: Red: avoid High FODMAP Amber/yellow: caution moderate FODMAP Green: Go/ eat! Low FODMAP Filters can be added Funds to purchase support further research!

19 Up to date: Low FODMAP resources Many free downloadables: katescarlata.com

20 Balanced nutrition is key for GI health Include nutrient rich whole food carbohydrates to feed Healthy beneficial gut microbes Healthy fats more omega 3 vs 6 at each meal. Too much can delay stomach emptying & lead to distention Fiber should be included per personal tolerance; slows stomach emptying but adds bulk to stool Protein rich foods should be ¼ of plate

21 Great FODMAP swaps Food Choose Lose Garlic Garlic infuse oil; Boyajian brand Garlic flesh, garlic powder or salts Onion Shallot or onion infused oil or use chives, asafetida powder or green part of leeks or scallions Onion, shallot, leek (Fructan in the bulb); onion powder or salts Legumes ¼ cup canned: rinsed and drained chickpeas or ½ cup canned lentils Kidney beans or dried beans Wheat flour King Arthur GF flour blend, Trader s Joes GF flour, Bob s Red mill 1 for 1 cup GF Wheat flour Soybean Firm tofu, edamame Soymilk made w/ whole soybean Milk alternatives Lactose free milk, hemp, almond, canned coconut milk, rice milk Cow s milk Cheese Most hard/aged cheese Ricotta/ Cottage

22 Global FODMAP Research Trials in IBS Studies conducted in Australia, Norway, Denmark, New Zealand, Switzerland, Sweden, Canada, Hong Kong, Ireland, Spain, UK, USA Small numbers of subjects (<100) Dietary advice given from trained dietitians Overall easy to adhere. Efficacy in symptom management ~50-75% of patients.

23 Low FODMAP vs. Typical Australian Diet This trial compared GI symptoms over 3 weeks of low FODMAP diet with the moderate FODMAP intake on a typical Australian diet in unselected patients with IBS who had not previously received advice from a dietitian. Randomized, controlled, cross-over trial Halmos, E et al Gastroenterology (2014)

24 Research Methods 38 participants: 30 IBS & 8 healthy controls Inclusion of healthy controls was to ensure the typical Australian diet utilized did not induce symptoms in the general population. Almost all food, comprising 3 main meals & 3 snacks daily provided. GI symptoms were measured daily during the baseline week and interventional diet periods using a 100 mm visual analogue scale (VAS)

25 Results: FODMAP vs. Traditional Diet Subjects with IBS had lower overall gastrointestinal symptoms scores while on a diet low in FODMAPs, compared with typical Australian diet Sx reduced by 50% in 70% of IBS pts. (Noted as good sx control) Symptoms were minimal and unaltered by either diet among controls. Of the 70% of subjects who felt better on the low FODMAP diet, this encompassed subjects across all four subtypes of IBS.

26 VAS (0-100 mm) Low-FODMAP vs Typical Australian Diet Mean overall GI symptoms improved with low-fodmap diet in IBS patients ( 0.5 g of FODMAPs per meal) 60 IBS Baseline Typical Australian diet Low-FODMAP diet 60 Healthy Controls 40 P< Day Day Halmos et al. Gastroenterology 2014

27 First US, RCT: Low FODMAP vs. Modified NICE Diets for IBS-D 60% 50% 40% 30% 20% 10% 41% p= % 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 Eswaran, Chey et al Am J Gastroenterol Dec;111(12): Slide courtesy of U. Michigan; W. Chey N=38 N=45

28 Average Daily Abdominal Pain Scores (0-10) Average Daily Abdominal Bloating Score (0-10) Weekly Abdominal Pain & Bloating Scores 6 6 Urgency # Baseline Week 1 Week 2 Week 3 Week 4 m-nice Low FODMAP m-nice Low FODMAP * = p.05 = p.01 # = p.001 = p.0001 P values refer to the change WITHIN group comparing to baseline score Eswaran, Chey et al. AJG 2016

29 LFD vs. mnice Diet: IBS-QOL Scores Mean Score p=.03 p < p< Baseline Week 4 Baseline Week 4 m-nice Low FODMAP Eswaran, Chey et al. Am J Gastroenterol Dec;111(12):

30 LFD and the Metabolome Eight-fold reduction of urinary histamine in the low vs. high FODMAP group McIntosh K. Gut Mar 14.

31 LFD & Metabolome Do FODMAPs modulate visceral sensitivity due to changes in gut microbiome and gut permeability? N=12 ; 6 IBS and 6 HC Fecal samples obtained before & after LFD Fecal LPS was 2 fold higher in IBS-D patients compared to HC 4 week treatment of LFD resulted in significant improvement of IBS symptoms and normalized fecal LPS to level similar of HC DDW 2016 Zhou, SY et al; U. Michigan

32 Visceral Hypersensitivity In separate study, fecal supernatant from IBS-D patients and HC were administered intra-colonically to naïve rats & visceral hypersensitivity to colonic distention was evaluated 3 hours later. Behavioral pain studies showed fecal supernatant from IBS-D patients given in colon caused a 3-4 increase in visceral motor response to colonic distention while no visceral motor response occurred in rats receiving fecal supernatant from HC. DDW 2016 Zhou, SY et al; U. Michigan 2016 Kate Scarlata, RDN

33 Low FODMAP diet Prior to start: Patient should be screened for celiac Patient diagnosed with IBS by GI doctor? Assess for any alarm features: bloody stool, weight loss, night sweats etc. If so, refer back to GI. Assess appropriateness for full elimination diet and level of instruction Eating disorder? Willingness to change diet?

34 Low FODMAP Diet Maintain low FODMAP diet 2-6 weeks-until good symptom control. Most patients will experience symptom benefit from the diet by day 7 (Halmos, Gastroenterology 2014) other research report sx. improvement by 4 weeks of diet (Eswaran Am J Gastroenterol 2016) Begin re-challenge phase when symptoms are controlled. Do reintroduction phase systematically.

35 Why Reintroduce FODMAPs? Research has shown that the low FODMAP diet reduces bifidobacteria and other probiotic gut bacteria (butyrateproducing Clostridium cluster XIVa and mucus-associated Akkermansia muciniphila (Halmos, Gut 2015; Staudacher HM, J Nutr 2012) Stool ph increases slightly on the low FODMAP diet---this may allow pathogenic microbes to grow. (Halmos, Gut 2015) The low FODMAP has been shown in 2 studies to increase gut microbial diversity a good thing. (Halmos Gut 2015, McIntosh Gut 2016)

36 Why Reintroduce FODMAPs Overly restrictive diets reduce QOL. Although one can consume a well-balanced low FODMAP diet, fiber & calcium can take a hit. It s important to identify what FODMAPs are tolerated in large amounts, moderate amounts and what to leave off the plate. Tolerance to FODMAPs can change over time!

37 The Rechallenge Details Reintroduce challenge foods in setting of low FODMAP diet. Day #1, add in challenge food. Day #2, if no symptoms, double challenge food portion. Day #3, keep portion the same or triple the Day#1 portion depending on patients normal intake of that food and assess tolerance. Abort challenge if undesirable* symptoms occur.

38 Sample Challenge foods Lactose: ½-1 cup milk Fructose: 1-2 tsp. honey or ½ mango Fructans: 1 TB onion, 1 garlic clove GOS: ½ cup beans Polyols: ½ cup mushrooms, 1/3 cup cauliflower (mannitol) or 1 peach, 5 blackberries (sorbitol)

39 What is a failed challenge? A failed challenge should be a noticeable & significant change in your symptoms. Symptoms may resemble an IBS flare: diarrhea, cramping, return of constipation, bloating. = Undesirable outcome. If you are unsure, it likely is a passed challenge.

40 Tips while reintroducing a FODMAP - Reintroduce at a meal vs. on its own. - Select a FODMAP subtype to challenge that you think you may pass! - A successful challenge will provide positive momentum to trying other challenges.

41 Breaking it down

42 SIBO: small intestinal bacterial overgrowth What: SIBO is defined as a bacterial population in the small intestine exceeding organisms/ml. Normally, less than 10 3 organisms/ml are found in the upper small intestine, and the majority of these are G+/ Gram positive organisms. Where: Small bowel Why: small bowel inflammation, motility disorders i.e. IBS, diabetes, scleroderma, hypothyroidism, small bowel diverticula, pancreatic insufficiency, food borne illness

43 Celiac and SIBO - The prevalence of SIBO diagnosed by quantitative culture of intestinal aspirate study was 9.3% in patients with CD - Another study using breath test, lactulose H2-BT as diagnostic tool suggested that SIBO was present in 66% of patients with CD and persistent GI symptoms after gluten withdrawal. - Small bowel inflammation may predispose SIBO. Rubio-Tapia A et al. Prevalence of Small Intestine Bacterial Overgrowth Diagnosed by Quantitative Culture of Intestinal Aspirate in Celiac Disease. Journal of clinical gastroenterology. 2009;43(2): ; Tursi A,et al. High prevalence of small intestinal bacterial overgrowth in celiac patients with persistence of gastrointestinal symptoms after gluten withdrawal. Am J Gastroenterol. 2003;98:

44 SIBO clinical presentation Abdominal bloating Post prandial fullness Nausea Gas Often diarrhea, but may present with constipation particularly linked with microbes that produce methane gas. Fat malabsorption Elevated folate, depressed B12

45 Breath test

46 Methane flora Methane production is associated with constipation Reduction of methane by therapeutic manipulation improves constipation Chatterjee, S et al Am J Gastro 2007;102: ;Ghoshal, UC et al J Neurogastroenterol Motil 2011;17:

47 SIBO Treatments Most commonly: 550 mg rifaximin TID with hydrogen + test Dual therapy is proposed for methane+ testing: 550 mg rifaximin TID with 500 mg neomycin BID Rifaximin reduces methane and improves gut transit but combo: neomycin and rifaxmin tx is more effective (Low K, et al J Clin Gastro 2010;44:547-50)? Role of prokinetic medications/supplements Low dose erythromycin 50 mg per night Iberogast Prucalopride

48 Food & Microbial Interactions Colonic microbiota is largely driven by efficient breakdown of complex indigestible carbs (fibers, RS) while the sm. intestine is shaped by capacity for the fast import and conversion of small carbs (FODMAPs, sucrose). Machesi, JR Gut. 2016;65(2):

49 SIBO diet and prevention There is NO evidenced based dietary intervention for SIBO Proposed nutritional interventions: SCD (specific carb. diet) + low FODMAP (restrictive!) GAPs (no science) Low FODMAP (evidence base for IBS) Cedar Sinai/ M. Pimentel s low fermentation diet (not studied)

50 IBS (&SIBO) Awareness Campaign

51 RESOURCES: KATE SCARLATA BLOG AND WEBSITE RECIPES, FREE DOWNLOADS, DIGESTIVE TIPS CHECK OUT MY CHANNEL FOR A DIGESTIVE PEACE OF MIND