Amy Bernhard, MS, ACSM-CES Dietetic Intern Morrison Chartwell s Dietetic Internship

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1 Amy Bernhard, MS, ACSM-CES Dietetic Intern Morrison Chartwell s Dietetic Internship 1

2 Objectives Discuss Lactose Intolerance MNT Lactose Intolerance Low-FODMAP Diet Discussion 2

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4 Statistics/Risk Factors 70% of the American population Higher prevalence: Adulthood, highest incidence in elderly Ethnicity: Including African, Hispanic, and Asian Americans, and American Indians. Least common among Americans of northern European descent. Infants born prematurely infant's lactase levels do not increase until the third trimester of pregnancy (2) 4

Lactose Intolerance Lactose: short-chain carbohydrate Requires enzyme, lactase Enzyme deficiency lactose travels to large intestine Gut flora cleave lactose into SCFA and

5 Lactose Intolerance Lactose: short-chain carbohydrate Requires enzyme, lactase Enzyme deficiency lactose travels to large intestine Gut flora cleave lactose into SCFA and excess gas Can cause osmotic diarrhea Symptoms Diarrhea Nausea Bloating Borborygmi (growl) Abdominal Pain Long-term Impacts Inflammation Malnutrition Perianal skin breakdown (1,3) 5

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7 Medical Nutrition Therapy Goals: Alleviate symptoms of lactose intolerance Patient to be knowledgeable of non-dairy calcium sources and lactose content of food Instruct patient on usage of lactase supplements Restrict lactose to 12g/day, if tolerable Other Relevant Goals: Prevent any further weight-loss r/t lactose intolerance (1,4) 7

8 Medical Nutrition Therapy Interventions Education: Lactose content of food Lactose-Free diet Non-dairy Ca+ Sources Begin with complete elimination of lactose for at least 2 weeks. If symptoms relieved, try reintroducing low lactose foods. DRI s Calcium (mg/day) Infants Ages Ages Ages Ages F 1200 Ages M 1000 Ages Pregnant Pregnant Lactating Same as Pregnant 8

9 What if Symptoms Persist? 9

10 The low FODMAP diet improves GI symptoms in patients with irritable bowel syndrome: a prospective study 10

11 Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice patients with irritable bowel syndrome N= 82 Adult patients diagnosed with IBS 9 Month evaluation ½ Low-FODMAP diet, ½ instructed on NICE diet Follow up RD appointments Significant improvement noted in low-fodmap group for diarrhea when compared to NICE group. Greater improvement in nausea and abdominal pain for low-fodmap vs. Nice (8) 11

12 Fermentable Oligo-, Di-, Mono-saccharides and Polyols (FODMAPs) FODMAP Short-chain carbohydrates Highly fermentable and poorly absorbed Increase the osmotic load of the intestine Increases luminal distention Symptoms Diarrhea, nausea, bloating, borborygmi, and abdominal Pain (1,4) 12

13 MNT Low-FODMAP Diet Assess patient for receptiveness of diet. Food diaries Previous to and during diet restriction Explain Physiological relevance of diet Educate FODMAP & non-fodmap foods. Provide examples of FODMAP/nutrient substitutes (3,5) 13

14 FODMAP Content of Foods 14

15 Re-Introducing Foods After a complete elimination 2-3 weeks vs. 6-8 weeks (5,7 ) Re-introduce low-fodmap foods in stages Introduce one group at a time No clear indication of which to re-introduce first Identify tolerable levels of FODMAP foods Assessed by the presence/change of symptoms FODMAPs distributed throughout the day High FODMAP meals balanced with low-fodmap meals (3,6,7,8 ) 15

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17 References 1. Misselwitz B, Pohl D, Fruhauf H, et al. Lactose malabsorption and intelerance: patogenesis, diagnosis and treatment. [published June 11, 2013]. United European Gastroenterology Journal Accessed November 1, Lactose Intolerance. National Digestive Diseases Information Clearinghouse. Available at: Published June Page last updated April 23, Accessed October 31, Shepherd SJ, Lomer MC, Gibson PR. Short-chain carbohydrates and functional gastrointestinal disorders. Am J Gastroenterol. 2013; 108: Lactose Intolerance:Goals. The Academy Nutrition Care Manual Website. Available at: nutritioncaremanual.org. Accessed October 29, Roest RH, Dobbs BR, Chapman BA, et al. The low FODMAP diet improves the gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract. 2013;67(9): Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: the FODMAP approach. J Gastroenterol Hepatol. 2010;25: Lomangino, K. The low-fodmap diet: a new treatment approach for irritable bowel syndrome. Clinical Nutrition Insight. 2012; 38: Staudacher HM, Whelan K, Irving PM, et al. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011; 24: Shepherd SJ, Parker FC, Muir JG, et al. Dietary Triggers of abdominal symptoms in patients with irritable syndrome: randomized placebo-controlled evidence. Clin Gastroenterol Hepatol. 2008;6:

The long-term impact of the low-fodmap diet for management of irritable bowel syndrome. Dr Miranda Lomer RD.

The long-term impact of the low-fodmap diet for management of irritable bowel syndrome Dr Miranda Lomer RD Email: miranda.lomer@kcl.ac.uk What is IBS - ROME IV Criteria A functional bowel disorder in which