Bringing the Low FODMAP Diet into your Nutrition Practice

Bringing the Low FODMAP Diet into your Nutrition Practice An online practical course for nutrition professionals by Dr Glenda Bishop, R.Nutr. Copyright Information These slides are provided by Glenda Bishop and A Less Irritable Life to nutrition professionals and students enrolled in Bringing the Low FODMAP Diet into Your Nutrition Practice. They are provided solely for educational purposes and you may not copy, share or distribute any images or text, in whole or in part. You may not distribute them to other nutrition professionals or students, to clients, or share them on the Internet, social media or in any other way. Violations of Copyrights and/or Intellectual Property rights will be reported and handled under the law. 2 Course Overview Session 1: Foundations of the low FODMAP diet Week 1: Foundations of the low FODMAP diet Week 2: Tools and strategies for your practice Week 3: Progression through the low FODMAP diet Week 4: Additional considerations and troubleshooting What are FODMAPs and why do they matter? The low FODMAP diet and how its 3 phases work FODMAP food lists and how to use them 3 4

What are FODMAPs? [1] What are FODMAPs and why do they matter? F O D M A P fermentable oligosaccharides disaccharides monosaccharides and polyols Small carbohydrate molecules + sugars. Not all sugars and carbohydrates are FODMAPs. Must be fermentable. FODMAPs include: Excess fructose {M} Lactose {D} Fructans {O} Galacto oligosaccharides (GOS)/galactans {O} Polyols/sugar alcohols (e.g. sorbitol, mannitol, and most other ols ) {P} 5 6 Where are FODMAPs found? Absorption and metabolism of FODMAPs Naturally occurring and found in many foods. All 5 core food groups. Most discretionary foods. Processed foods: enhance flavour, cut back on sugar, or make foods seem healthier. Most commonly eaten foods: wheat, onions, garlic, legumes, apples, honey and stone fruits. Fructose Poorly absorbed by only some people. Fructose uptake is more efficient in the presence of glucose. Problem when in excess of glucose. 1 in 3 people have sensitivity. Lactose Poorly absorbed by only some people. Requires lactase for metabolism. Problem if lactase is deficient. Polyols Only partly absorb by everyone. About 50% is absorbed (passive process). Excess polyols have laxative effects in everyone. Oligosaccharides Poorly absorbed by everyone. Humans can t hydrolyse oligosaccharides (bacteria can). 7 8

Mechanism of FODMAP action Onset of symptoms: Faster reactions (30 minutes to a few hours): Normally due to water being pulled into the intestine. Most likely due to excess fructose and polyols; sometimes lactose. Often presents as bowel urgency and diarrhoea. Slower reactions (3 5 hours to 24 hours or more): Doesn t happen until the digested food reaches the colon where fermentation happens. Also takes time for excess water to reach the colon. Mostly caused by oligosaccharides. Fermentation continues over time and builds up. From: Tuck et al 2014 Expert Rev Gastroenterol Hepatol 8(7):819 34 9 10 Who has a problem with FODMAPs? Irritable Bowel Syndrome (IBS) Most people don t digest FODMAPs well and can experience some gas and water build up. But only people with IBS experience digestive discomfort. Due to visceral hypersensitivity (nerves in gut are more sensitive). E.g. for the same degree of distention in the colon, people with IBS report feeling more pain or discomfort. Functional gut disorder. Affects 15 20% of adults. 2X women as men. Most common reason for referral to a gastroenterologist. Cause is unknown, no cure. Symptoms vary between individuals. Abdominal pain (often relieved by a bowel motion). Changes in bowel habits frequency or form. Bloating and gas are common, but not essential for diagnosis. Nausea, reflux, back pain, hip pain, general malaise, low energy. 11 12

IBS must be medically diagnosed The low FODMAP diet is a management strategy, not a cure No specific test for IBS: symptoms + exclusion. The GI symptoms of IBS are not specific to IBS: occur in many other conditions. FODMAPs do not cause IBS A low FODMAP diet doesn t cure IBS The low FODMAP diet is the most effective strategy Could indicate a more severe condition, e.g. IBD, colon cancer or ovarian cancer. Also need to check for the presence of coeliac disease. FODMAPs trigger IBS symptoms. It decreases the onset of symptoms. Helps ~70% of people with IBS. 13 14 Important take home points: FODMAPs are naturally occurring carbohydrates, present in many foods, across all food groups. Most people don t digest FODMAPs well, but it s only people with IBS who experience digestive discomfort from them. [2] The low FODMAP diet and how its 3 phases work A low FODMAP diet is effective in 70% of IBS sufferers, but it s a management strategy, not a cure. 15 16

The low FODMAP diet Who should or shouldn t consider following a low FODMAP diet? is: is NOT: A medical therapeutic diet. A learning diet. A temporary diet. A no FODMAP diet. A fad diet. A weight loss diet. A gluten free diet. A dairy free diet. Should Anyone who has IBS that is affecting their quality of life. Note: not always the best option for people with very mild IBS. Must be prepared to commit to major change. Shouldn t People who don t have IBS (or IBD with functional gut symptoms). People who won t commit to major change in their diet for an extended period. Maybe, with caution Anyone with a history of an eating disorder. Pregnant women who are new to the diet (lack of safety data). Children can benefit, but not sure if the adult requirements are appropriate. 17 18 The low FODMAP diet has 3 phases Phase 1: The restriction (elimination) phase. Purpose What does it involve? What results are expected? How long does it take? Phase 1: Restriction (elimination) Lowers all FODMAPs across the diet. Tests whether FODMAPs may be an IBS symptom trigger. Phase 2: Tolerance Testing (reintroductions) Returns FODMAPs to the diet systematically. Also tests tolerance thresholds. Phase 3: Maintenance (modification) FODMAPs that are tolerated can be returned to the diet. Diet is adjusted to suit individual needs. To determine whether decreasing FODMAPs improves IBS symptoms. Complete dietary overhaul to switch high FODMAP foods to low FODMAP options. Ideally, symptoms will be no more than an irritation. Most people get improvements but not a complete clearing up. As short a time as possible. Normally at least 6 8 weeks. May need 10 12 weeks if additional adjustments are needed. 19 20

Phase 1 must be completed successfully before moving on You can t start FODMAP tolerance testing until the IBS symptoms have stabilised. Don t allow clients to jump ahead. Need to develop a stable baseline for testing; minimum 1 week without symptoms. If a client continually makes mistakes and is getting FODMAPped, needs to be coached for better control. Client Example: Can t move past phase 1 Female, 20s, single mother, studying full time. IBS since a teenager. Asking to try a low FODMAP diet. Good results for 1 st week, but not so good after that. Fortnightly coaching for 2 months, but unable to stick to the diet strictly enough to get stable symptom relief. Stopped sessions and diet. 21 22 Phase 1 shouldn t continue indefinitely Important take home points: Long term health effects aren t known. We do know Gut microbiota changes. FODMAPs are prebiotics and necessary for gut bacteria to survive. Not known if these changes are good or bad. Highly restrictive for food choices. Many people over restrict, causing nutrient issues. Creates a fear of food and may cause eating disorders. If someone can t complete phase 1, they should return to regular food choices. The low FODMAP diet is a medical therapeutic diet designed to teach people which foods trigger their IBS symptoms. The low FODMAP diet should only be followed if medically indicated and with caution in certain individuals. Successful completion of phase 1 is needed before tolerance testing, but a client shouldn t stay on the low FODMAP diet indefinitely. 23 24

[3] FODMAP food lists and how to use them 25 26 Using the food lists Some general FODMAP rules During the initial restriction phase: High FODMAP foods should be avoided. Low FODMAP foods can be eaten. Things to note: There are more low FODMAP foods than high FODMAP foods. There are high FODMAP foods in every food group There are low FODMAP foods in every food group. Portion size matters anything in orange needs to be limited to the portions indicated. High FODMAP Foods If it belongs to the allium family and it s not green, it s got fructans. A stone normally means sorbitol. Drying fruits increases FODMAPs. All legumes have GOS. If it s got gluten, it s got fructans. Most processed foods have FODMAPs onions, garlic and more. Sweeteners can make the tamest foods high FODMAP. Low FODMAP Foods Veggies more low FODMAP options. Nuts + seeds have oligos, but most can be tolerated in small amounts. Most plant based proteins can only be eaten in small amounts. Lactose free makes most dairy okay; cheese is naturally lower in lactose. Meats, fish + eggs have no FODMAPs. Oils have no FODMAPs. 27 28

ACTIVITY: Spot the high FODMAP foods Sample menu plans for women and men, from www.eatforhealth.gov.au Designed to provide nutrition and energy requirements for people aged 19 50 years of average height, healthy weight and light activity. Only one meal is (potentially) low FODMAP can you spot it? Eat for Health: sample meal plan for women 29 30 Eat for Health: sample meal plan for women Eat for Health: sample meal plan for men 31 32

Eat for Health: sample meal plan for men High FODMAP food additives to avoid Polyols E420 sorbitol E421 mannitol E953 isomalt E965 maltitol E966 lactitol E967 xylitol E968 erythritol (becomes high FODMAP when combined with fructose) E1200 polydextrose (mostly dextrose but contains ~10% sorbitol) Fructans Inulin extract from chicory root Chicory root FOS Fructooligosaccharides Oligofructose Prebiotic fibre Dietary fibre (may be one of the above fructans) 33 34 Sneaky FODMAPs Effect of food processing: Fermentation Honey Stock/broth (onion and/or garlic). Added fibre sources (see additive list fructans). Agave syrup Spices, natural flavours, flavours in savoury foods = garlic High FODMAP glutenfree flours (besan/chickpea, soy, lupin, amaranth) Fruit juices, purees or concentrates Dehydrated vegetables = onion Milk derivatives, milk solids, lactose Polyols hide as e numbers Salts and seasoning mixes (garlic and/or onion) Less FODMAPs Bread: natural sourdough process breaks down some of the fructans in spelt and wheat. Worcestershire sauce: contains garlic and onions, but fermentation breaks down the fructans. More FODMAPs Sauerkraut: cabbage is low FODMAP, but fermentation creates FODMAPs only small portions are safe. Green cabbage sauerkraut is very high in mannitol. Red cabbage sauerkraut is moderately high in fructans. 35 36

Effect of food processing: FODMAP solubility issues Effect of food processing: Soy products Not soluble in oil You can infuse oils with high FODMAP ingredients without the transferring the FODMAPs, e.g. garlic, onion. Useful for flavouring food without FODMAPs must ensure no pieces of high FODMAP ingredients remain. Soluble in water You can t infuse water with high FODMAP ingredients because they transfer to the water, e.g. stocks and soup. Canning decreases FODMAPs because they leach into the canning liquid, e.g. canned legumes and canned mushrooms (in brine). High FODMAP soy Soya beans, boiled Soy flour Soymilk made from whole soybeans Silken tofu Low FODMAP soy Edamame (frozen soybeans) Soymilk made from soy protein isolate Firm tofu Tempeh Soy sauce Soy lecithin (most likely) 37 38 Also need to consider potential gut irritants Important take home points: Known gut irritants include: Alcohol all types Caffeine coffee, tea, coke, energy drinks Carbonated drinks Fatty foods Chilli Oranges and tomatoes reflux Chocolate Encourage removal of gut irritants: Should be removed or at least minimised during phases 1 and 2 the low FODMAP diet. But, most people won t remove them unless the diet is failing. FODMAPs are present in all 5 core food groups and many processed foods. Avoiding high FODMAP foods means making changes across the whole diet. There are many more low FODMAP foods to choose from than high FODMAP foods to avoid. While not FODMAPs, gut irritants must also be considered to increase success of the diet. 39 40

Practical Activity: Assess a regular diet for FODMAPs. Objectives: To understand how common high FODMAP foods are in a regular diet. To start you thinking about what it takes to make a diet low FODMAP. What you need to do: Record your normal food intake for at least 2 days (or do a recall of the last 48 hours). Assess your food intake to see which foods/meals are high in FODMAPs and which are low in FODMAPs. Can you think of any easy ways to change the foods that are high FODMAP? Estimated time: 30 45 minutes 41 42 Practical Activity: Getting started with label reading. Objective: To understand how common FODMAPs are in processed foods (even simple ones). To appreciate how carefully you need to read a label to detect hidden FODMAPs. What you need to do: Look through your pantry, fridge and freezer for foods that have ingredient labels. Read the labels to see if you can detect FODMAPs in the ingredient lists. Write a list of the foods (and brands) that were low FODMAP. Write a list of the foods (and brands) that were high FODMAP. Estimated time: 1 1.5 hours 43 44