Nutrition Matters - Cleveland Clinic€¦ · Gluten Sensitivity . Wheat Allergy : Exposure to...

DOS CME Course 2011 1 Oxtober 2010 1 Confidential

Nutrition Matters: An update on Human Nutrition

Lynda N. Newman, MSN, RN, ACNS-BC, CNN

Clinical Nurse Specialist Center for Human Nutrition Digestive Diseases Institute Cleveland Clinic

© Cleveland Clinic 2014 DOS CME Course 2014 1

• After attending this presentation, the participant will be able to:

1) Distinguish between food allergy and food intolerance 2) List two dietary interventions to recommend to symptomatic

patients

Objectives

DOS CME Course 2014 2

Presenter

Presentation Notes

Definitions of:-Food Allergy-Food Intolerance Review of Symptoms with which patients with food allergy present Review of Symptoms with which patients with food intolerance present Review of Celiac Disease and how it is diagnosed Review of the elements of a generally healthy diet vs: Gluten Free diet FODMAPS diet Brief overview of some nutrition fads: Paleo- Diet Specific Carbohydrate Diet

Chief Complaint:

http://advancedallergytreatment.com


Presenter

Presentation Notes

The complaint is: “My tummy hurts!” This could be anything from mild indigestion to a burst appendix. We are going to need to take a careful history. What are the issues that might make us think food allergy or intolerance?

5 Minute Consult- © Wolters Kluwer Health Lippincott Williams & Wilkins


Adverse Food Reaction

Immune Non-immune

IgE (Oral Allergy Syn.

Hives Anaphylaxis)

Non-IgE (Food-Protein

induced Enterocolitis Syn.,

Celiac)

Mixed (Eosinophilic Esophagitis)

Cell

(Allergic contact Dermatitis)

Pharmacological (Tyramine)

Metabolic (Lactose

Intolerance)

Other (Mechanical, physiological)

Toxic (e.g.Scromboid Clostidium, etc.)

Modified from Boyce JA, et al. JACI 2010;126:1105


Presenter

Presentation Notes

OAS = Oral Allergy Syndrome, FPIES = Food Protein-Induced Enterocolitis Syndrome

• Affects all people alike

• Seafood – Scromboid poisoning (fresh tuna & mackerel) – Ciguatera poising (grouper, snapper) – Saxitoxin (shellfish)

• Other food poisoning – Clostridium botulinum (improperly canned foods) – Staphylococcus aureus (pre-cooked and processed foods) – Salmonella (poultry)

• Fungal toxins: – Aflatoxin (peanut butter, cooking oils) – Trichothecanes (cereals) – Ergot (rye and other grains)

Definitions: Toxic Reactions


• Non-toxic – Unique reactions – Only some people are affected

• Food Allergy – Adverse health effect – Specific immune response – Reproducible on exposure to a given food

• Food intolerance – Adverse health effect – NOT immune mediated – Example: Lactose intolerance

– Ingestion causes cramps, diarrhea and gas

Definitions


• Immune response – Immune OVER-REACTION to offending protein – Antibody response as if to HOSTILE invader

• Physical response – Swelling of face, eyes and tongue or throat – Difficulty breathing – Skin irritation

–Eczema or Hives – Nausea and vomiting

True Food Allergy


Worst Case: Anaphylaxis

http://stefanwirawan1.hubpages.com/


Think EpiPen

Or

Auvi-Q

• Some children outgrow food allergies – But allergies to peanuts and nuts seldom go away!

Severe Food Allergy Reaction


• Rate of perceived food allergy = 20%

• True food allergy – By double-blind, placebo-controlled food challenge = 1.4%

• Industrialized nations – 1 in 20 young children – 1 in 50 adults

• More common in infants and children – Most outgrow their hypersensitivity

Food Allergy Facts


• Can vary from acute uticaria to FATAL ANAPHYLAXIS

• Most food allergies are caused by just a few major food allergens*

– Milk - Eggs – Soy - Wheat – Fish - Peanuts (legume, not a true nut) – Shellfish - Tree nuts (Walnuts, etc)

– *New law will require these allergens to be clearly labeled to have

any of these and clear guidelines for labeling foods as “Gluten-free”

Food Allergy Symptoms


• Generalized reaction – Anaphylaxis

• Respiratory reaction – Asthma – Rhinoconjunctivitis – Laryngeal edema

• Cutaneous reactions – Dermatitis herpetiformis – Urticarial angioedema – Atopic dermatitis

Disorders Related to Food Allergy • Specific GI Syndromes

– Oral allergy syndrome – GI anaphylaxis – Allergic eosinophilic gastroenteritis – Food-protein induced – Proctocolitis – Enteropathy – Enterocolitis syndrome – Celiac disease


• 65% of children lose reactivity to wheat by age 12

• Can affect up to 1% children

• Systemic: Anaphylaxis – Wheat-dependent exercise-induce anaphylaxis (WDEIA) – IgE to omega-5-gliadin

Wheat Allergy and Anaphylaxis

Keet CA et al. Ann Allergy Asthma Immunol 2009;102:410 Inomata N. Curr Opin Allergy Clin Immunol 2009;9:238


• Lactose is hydrolyzed by – Intestinal lactase to glucose and galactose – Microvillus membrane of the intestinal adsorptive cells

• Lactase production can be reduced by – Mucosal injury – Reduced genetic expression of the enzyme lactase-phlorizin

hydrolase

Lactose Intolerance


• Lactose progresses to the colon

• Converts to – Short-chain fatty acids (SCFA) – Hydrogen gas – By bacterial flora – Producing acetate, butyrate, and propionate – SCFAs are absorbed for energy

What Happens When Lactose Is Not Absorbed In The Small Intestines?


• Hydrogen gas!!! – Cramps – Bloating – Pain – Flatulence

• Basis of Hydrogen Breath Test

What’s Left?


• Developmental

• Congenital

• Secondary: – Celiac disease – Bacterial overgrowth – Possibly Crohn’s disease

Causes of Lactose Intolerance


Common multi-system autoimmune disorder – Genetic – Environmental – Immunologic components

What is Celiac Disease?

Wikipedia.com/celiac


• What types of people? – Adults > Children – Females > Males – Caucasians 1:133 people

–Blacks and Asians can develop Celiac disease

• Age – Any from children to elderly

• People with immune disorders

• Family members of Celiacs

• NOT just a kid’s disease anymore!

Who Gets Celiac Disease?


• Autoimmune

• Genetically susceptible individuals – DQ2 and/or DQ8 positive Human Leukocyte Antigen (HLA)

haplotype is necessary – But not sufficient

• Unique because – Both the environmental trigger (gluten) and the auto-antigen

(tissue Transglutaminase) are known – Elimination of environmental trigger leads to a complete resolution

of the disease

Celiac Defined


The Celiac Iceberg

Genetic susceptibility:

DQ2, DQ8

Healthy individual

Latent Celiac Disease

Silent Celiac

Atypical

Classic Celiac Disease Histologic Changes

Normal Mucosa

Abnormal Serology


Presenter

Presentation Notes

I made this slide Few people present with the CLASSIC SYNDROME of GI Symptoms Diagnostic small bowel biopsy Positive anti-endomysial antibody

Pathogenesis

= +

Cleveland Clinic Medical Art & Photography


Gluten

Gluten-free diet

Normal Small Bowel Celiac Disease



• Confirm diagnosis before treating – Celiac Disease diagnosis mandates a strict gluten-free diet for life

–Following the diet is not easy – Quality of life (QOL) implications

• Failure to treat – Potential long term adverse health consequences – Morbidity and mortality

Diagnosic Principles


Presenter

Presentation Notes

A diagnosis of celiac disease means the individual must stay on a strict gluten free diet for life. Following such a diet strictly is not always easy as there are many hidden sources of "gluten". A gluten free diet may also involve added cost to the individual and impact their quality of life. Therefore it is essential that the physician first confirm the diagnosis before recommending life long adherence to the diet. On the other hand it is equally important to not miss the diagnosis of celiac disease. Failure to treat an individual with celiac disease carries potential adverse long term health consequences involving both increased morbidity and mortality.

Serum Tests for Diagnosis of Celiac Disease

Test Sensitivity

(Range) Risk of False Pos

Specificity (Range)

Risk of False Neg Comments

IgA anti tTG ATB

>95.0 (73.9-100)

>95.0 (77.8-100) First level screen

IgG anti-tTG ATB

Widely variable (12.6-99.3)

Widely variable (86.3-100)

Useful with IgA deficiency

IgA anti-endomysial ATB

>90 .0 (82.6-100)

>90 .0 (94.7-100)

Useful when Dx is uncertain

IgG DGP >90.0 (80.1-98.6)

>90.0 (806.0-96.9)

Useful with IgA deficiency and young children

HLA- DQ2 or HLA- DQ8

91.0 (81.6-97)

54.0 (12.0-68.0)

Highly negatively predictive

adapted from: Fasano A, Catassi C. N Engl J Med 2012;367:2419-2426


Presenter

Presentation Notes

Will not talk about these in the interest of time– just point out that they are in the handout

Clinical and Pathogenic Differences Among Celiac Disease, Gluten Sensitivity and Wheat Allergy

Variable Celiac Disease Gluten Sensitivity Wheat Allergy

Exposure to symptom interval Weeks to Years Hours to Days Minutes to Hours

Pathogenesis Autoimmunity (innate and adaptive)

Possibly innate immunity

Allergic immune response

HLA Restricted to HLA-DQ2 or HLA DQ8

(pos. in 97%)

Could be pos . HLA-DQ2 and HLA

DQ8 positive (50% have both)

Similar to gen. population. Could be neither, one or

both 35-40%

Auto-antibodies Almost always present Always absent Always absent



Presenter

Presentation Notes

Clinical and Pathogenic Differences Among Celiac Disease, Gluten Sensitivity and Wheat Allergy

Variable Celiac Disease Gluten Sensitivity Wheat Allergy

Enteropathy Almost always present Always absent Always absent

Symptoms

Intestinal and extra-intestinal:

Symptoms same as gluten sensitivity

and Wheat allergy

Intestinal and extra-intestinal:

Symptoms same as Celiac disease and

Wheat allergy

Intestinal & extra-intestinal:

Symptoms same as Celiac disease and

gluten sensitivity

Complications

Co-existing conditions Long term

complications

Absence of co-existing conditions

Long term complications

Absence of co-existing conditions

Short term complications

e.g. Anaphylaxis



Presenter

Presentation Notes

• Gluten sensitivity due to Celiac Disease (CD) – Genetically pre-disposed person – Chronic small intestinal immune mediated enteropathy – Precipitated by exposure to dietary gluten

• Non-Celiac Gluten Sensitivity (NCGS) – Celiac disease has been ruled out – One or more immunological, morphological and/or symptomatic

alterations triggered by gluten ingestion

What is Gluten Sensitivity?


Proposed Algorithm for the Differential Diagnosis of Gluten-Related Disorders.

Fasano A, Catassi C. N Engl J Med 2012;367:2419-2426 DOS CME Course 2014 30

Presenter

Presentation Notes

Figure 1 Proposed Algorithm for the Differential Diagnosis of Gluten-Related Disorders. AGA denotes antigliadin peptide antibodies, EGD esophagogastroduodenoscopy, EMA antiendomysial antibodies, and tTG tissue transglutaminase. Adapted from Sapone et al.45

Based on : Alaedini A, Green PHR. Ann Intern Med 2005;142:289-298

• Endocrine – Autoimmune thyroid disorders – Type I Diabetes – Addison’s disease – Alopecia areata – Reproductive disorders

• Cardiac – Autoimmune myocarditis – Idiopathic dilated cardiomyopathy

• Hepatic – Autoimmune cholangitis – Autoimmune hepatitis – Primary biliary cirrhosis

Disorders Associated with Celiac Disease • Neurologic

– Epilepsy – Cerebellar ataxia – Migraine – Neuropathy

• Other – Anemia – Dental enamel defects – Down syndrome – Juvenile chronic arthritis – Osteoporosis – Selective IgA deficiency – Sjogren’s syndrome


• Affects 10-20% of Celiac pts.

• Pruritic, chronic skin disease characterized by – Symmetrical papulo-vesicular lesions – Presence of granular deposits of IgA

in dermal papillae

• Rx – Gluten-free diet – With / without Dapsone

Dermatitis Herpetiformis

dermatology atlas online


• Endoscopic features of villous atrophy

• Reduced number of folds

• Scalloping of folds

• Mucosal grooves

• Mosaic appearance

• Atrophic appearance – Biopsy is the “gold standard”

GI Endoscopy

Donald Kirby, MD Cleveland Clinic


• Confocal endomicroscopy – Permits in vivo magnification up to 1000 fold – Sensitivity 94% – Specificity 92% – Also sensitive in seeing changes with GFD

• Video capsule – Has shown 1/3rd of Celiac patients have mucosal changes

beyond the duodenum – Compared to biopsy – Sensitivity 88% (true positives) – Specificity 91% (true negatives) – positive predictive value 97% – negative predictive value 71%

GI Methods of Diagnosis


Presenter

Presentation Notes

Discuss briefly

Murray J, et al. Clin Gastroenterol Hepatol 2008;6:186-193

Distribution of Villous Atrophy seen in Wireless Capsule Endoscopy


Untreated Celiac Disease Gluten Free Diet x6 Months

Biopsies Are Important!



• Therapy of choice – Vitamin deficiencies resolve – Risk of autoimmune mediated diseases and Celiac Disease – Associated malignancies is reduced

• Even fully compliant 7-30% may not go into full remission – ~5% refractory disease

Gluten Free Diet


Gluten-free

≠

Wheat-free DOS CME Course 2014 38

• Several meanings misinformation

• Bakers think gluten is “sticky” part of ANY grain

• Includes corn and rice – These are safe for people with celiac disease

• Better to inquire whether food is Gluten Free or has any ingredients derived from wheat, barley, rye

Gluten


• High fat diet

• Low fiber diet

• Low carbohydrate diet

• Diet low in – Iron, folate, niacin, vitamin B12, calcium, phosphorus, zinc

• Lactose intolerance

Potential Nutritional Issues


• Wheat flour is fortified with vitamins, minerals and iron

• Gluten Free grains are made from refined flours/starches – That are not enriched

• Deficiencies – Calcium, vitamin B complex, iron, vitamin D

• Low fiber intake

Potential Deficiencies


• Provided by registered dietitian is strongly recommended

• Consultation with a registered dietitian – Part of a team-based approach – Results in improved self-management

ADA Pocket Guide to Gluten-Free Strategies

Medical Nutrition Therapy


• Essential to effectively determine nutrition diagnoses and plan the intervention – Food and nutrition intake – Medication and supplement use – Readiness to change – Behavior (social network)

ADA Pocket Guide to Gluten-Free Strategies

Nutrition Assessment


• Choose GF whole grains and products made from them – Brown rice, millet, buckwheat, whole corn

• When choosing refined grain foods, (breads, cereals, pastas) select products that are in enriched or fortified

Nutrition Recommendations


• Grain foods = > 2 g fiber/serving

• Avoid products with Trans fat

• Choose products with least amount of total and saturated fat when comparing similar products

Nutrition Recommendations


Cross Contamination


– In the field prior to harvesting – During transportation off grains and plant foods to be processed – At the grain-processing plant – At the food manufacturing plant – In the home, restaurant…..

Cross Contamination


• Use separate jars of peanut butter, jelly, butter, mayo to avoid crumbs in jar

• Clean utensils thoroughly before cutting gluten free foods

• Use separate fryers or clean oil

• Separate toaster and dishes

Avoid Cross-Contamination


• Research on individuals with celiac disease found including oats

– Not contaminated with wheat, barley, or rye – At intake levels of ~50 grams of dry oats per day – Is generally safe and – Improves compliance with the GF diet

Oats


• All foods that are GF are not necessarily “healthy”

• Manufacturers make it very easy for shoppers to find GF foods and market them as such

• Usually found in “health food” section

• Ever read the food labels?

Gluten-Free Stamp


• Labeling of allergens is not mandatory – Estimated 80-90% voluntary compliance

• If product label has “Contains” statement or other allergen labeling – Manufacturer is voluntarily complying with allergen labeling

Label Reading


• USDA mandates that all foods are to be listed by their common/usual name – Malt, starch, modified food starch, dextrin

• Protein ingredients must be listed by common/usual name and cannot be hidden under collective names – Natural flavorings – “May contain” statements are also voluntary

Ingredient Labels


• Long ingredient lists of names you do not recognize – Not a good sign

• Look at sugar content

• Look at sodium content

• Highly processed = added fat, added sugar – High calorie

Label Reading


• Dextrin – Unless GF ingredient listed

• Modified food starch – Unless GF grain is listed

• Starch – Unless GF grain is listed

Questionable Ingredients


• Avoid the following unless GF can be confirmed – Brown rice syrup – Hydrolyzed Vegetable Protein (HVP) – Hydrolyzed Textured Protein (HTP) – Textured Vegetable Protein (TVP) – Rice malt – Seasonings – Soy sauce – Modified food starch

Questionable Ingredients


Hidden Gluten Sources

• Broth

• Energy bars

• Imitation bacon

• Vitamins/minerals, meds

• Communion wafers

• Processed meats – Deli, bolgona – Hot dogs – Lunch meat

• Nutritional supplements

• Sauces, gravies

• Pastas

• Marinades

• Roux, thickeners

• Stuffing, dressing

• Imitation seafood

• Breading


• “If in doubt, leave it out!”

• Just Say NO to: –Bites –Licks –Tastes

Better To Be Safe Than Sorry


• Call / write manufacturer directly

• Request written info re: OTC and Rx

• Ask about fillers, tablet coatings or capsules

• Brand name vs generic equivalents – Same ingredients? – Still GF?

• Glutenfreedrugs.com

Medications


• Most likely – Starch (unspecified) – Dusting powder – Pregelatinized starch – Flour (unspecified)

• Less likely – Sodium starch glycolate (corn) – Caramel coloring

• Least likely – Maltodextrin (corn)

Inactive Ingredients in Medications


Alcohol

• Allowed – Wines – Distilled beverages

–Gin, rum, vodka, whiskey – Pure liqueurs – GF beer

• Avoid – Beer – Ales – Lagers – Wine coolers


Restaurants


• Choose restaurants with wide variety of choices

• Options: Mexican, Indian, Thai, Japanese

• Check ahead of time for restaurants indicating a GF menu

Dining Out


• Fried foods need to be in different oil

• Hamburgers = no fillers / never touched the bun

• Request grill be wiped down/washed – Before food is cooked

• Emphasize importance of keeping utensils clean and separate from other foods

• Suggest contacting restaurant ahead of time

Tips to Keep in Mind


• Healthy options for all!

• Milk

• Cheese

• Fruit

• Vegetables

• Fresh meats

• Fish

• Poultry

• Nuts

• Rice

Naturally Gluten Free


• Portion Control

– Used to eating larger portions to maintain weight

– With healing intestines the larger amounts are unnecessary

Weight Management Considerations


• GF diet education – Must include discussions related to weight gain

• These patients used to eat whatever they wanted and did not gain weight

• Patients should be made aware of this and provided information as to why this is healthy

• Goals – Want CD patients to follow GF diet – Not be “afraid” of weight gain

Weight Management Considerations


Gluten Free Craze


• Promotes weight loss – ONLY if person has been overeating Carbohydrates

• Promotes weight gain – Easily

• Gluten Free diet healthy vs Gluten Free diet made up of Gluten Free processed high Carb -type foods

• Some with gluten intolerance benefit from decreasing or avoiding gluten – Case by case basis

Bottom Line


• Placebo response in Irritable Bowel Syndrome (IBS) up to 70% – Gluten (increased prolamines) is hard to digest – Increases stool volume

• GFD often eliminates other dietary factors – Potentially other mechanisms explain the benefit – Sensitivity to factors other than gluten or even grains

Is Dietary Response to A Gluten Free Diet (GFD) Diagnostic of Celiac Disease?


• Positive Predictive Value of symptom improvement after gluten withdrawal for Celiac Disease – only 36% in one study (1)

• Celiac Disease patients have Increased Irritable Bowel Syndrome (IBS) -type symptoms compared with controls (2)

• Irritable Bowel Syndrome (IBS) patients are more likely to demonstrate Non-Celiac gluten sensitivity than controls (2)

Is Dietary Response to A Gluten Free Diet (GFD) Diagnostic of Celiac Disease?

1-Campanella J, et al. Scand J Gastroenterol 2008;43:1311 2-Sainsburg A , et al. Clin Gastroenterol Hepatol 2013:11:359


• RCT in 45 subjects with IBS-D comparing – 4 weeks of Gluten Free Diet (GFD) against – 4 weeks of Gluten Containing Diet (GCD)

• Stratified by HLA DQ 2/8 status

• Assessed: – BMs – Gut transit – Permeability – Histology

Controlled Trial of Gluten Free Diet in Irritable Bowel Syndrome with Diarrhea (IBS-D)

Vazquez-Roque MI, et al. Gastroenterology 2013;144:903


• Results – More BMs in GCD,

–Especially if HLA DQ2/8+ – GFD benefitted IBS-D patients

–Stool frequency, permeability –Especially if HLA DQ2/8+

• No effect on transit or histology

Controlled Trial of Gluten Free Diet in Irritable Bowel Syndrome with Diarrhea (IBS-D)

Vazquez-Roque MI, et al. Gastroenterology 2013;144:903


• Type 1 – Normal intraepithelial lymphocyte phenotype – Rx – steroids, et al.

• Type 2 – Clonal expansion of aberrant intraepithelial lymphocyte population – Bad prognosis – steroid refractory – Increased risk of lymphoma

Refractory Celiac Disease


Therapeutic Agent Mechanism of action

Genetically modified gluten

Decreases gluten exposure by transamidation of gliadin

Zonulin inhibitor Decreases zonulin secretion and inhibits intestinal permeability - Phase III trials

Therapeutic vaccine

Creates immune tolerance to gluten fragments and desensitizes celiac disease patients to the toxic effects of gluten DQ-2 positive patients only -

Probiotics Detoxify gliadin, promote intestinal healing

Tissue transglutaminase

inhibitors

Stop tissue transglutaminases from modifying gluten fragments, a process that otherwise triggers the immune response

Bakshi A, et al. Gastroenterology & Hepatology. 2012;8:582-588


• Gluten-free diet

• Tincture of time

“Thy food shall be thy medicine” - Hippocrates

Celiac Disease Treatment


Cases


• 54 yo man with known Dermatitis Herpetiformis (DH) – HLA DQ8 positive – On a strict Gluten Free Diet that has put him

–In remission for his Celiac Disease – In remission DH

• He asks you how best to see if his 18 year old college- bound daughter should be Gluten free at college 1. Tell her best to be Gluten Free – no testing 2. Obtain endoscopy as soon as possible 3. Obtain HLA testing 4. Obtain IgA and Tissue Transglutaminase IgA and IgG

Case 1


• Obtain HLA testing will have the best NEGATIVE predictive value

• Daughter WAS Negative for HLA DQ2 and DQ8

Case 1


Unidentified GI Symptoms: FODMAP Diet

Fermentable, Oligo-Di, Mono-saccharides and Polyols


• Fermentable

• Oligo-

• Di- and

• Mono-saccharides And

• Polyols

• Three common properties – Poorly absorbed by the small intestine – Small, osmotically active molecules – Rapidly fermented by bacteria

FODMAPS


• Branched fructose polymers – Oligosaccharide and polysaccharide (FOS)

• Inulin – Subgroup of fructans

• Polyols – Sorbitol – Xylitol – Mannitol – Malitol

Fructans


• Small intestines do not have enzyme to break up fructose-fructose bonds

• Cannot be broken down to monosaccharides

• Cannot be transported across epithelium leading to malabsorption

• = Laxative effect

• Major sources of fructans – Wheat – Artichokes

Fructans


• Sorbitol = most common

• Polyol effects worsen when consumed with fructose

• Foods containing polyols: apples, pears, apricots, peaches, plums, cherries, nectarins

• Sugar-free foods w/ artificial sweeteners

Polyols


• Bloating, abdominal distention, discomfort, pain, altered bowel habits are categorized as “functional” gut symptoms

• Related to the enteric nervous system and the gut – Usually not abnormality in structure

Functional Gut Symptoms

Above is the image at: lostcheese.teacherarnold.com/.../upset-stomach


Carbohydrates Considered FODMAPS

www.GInutrition.virginia.edu

Fructans and Galactans Polyols

Fructose Sorbitol

Lactose Mannitol

Fructooligosaccharides Xylitol

Galactooligosaccharides Malitol


• All FODMAPS = Osmotic and fermentative

• Minimize distention – Small bowel and proximal large bowel

• Studies have shown that those provided with low FODMAP diet instruction adhere to it extremely well

Principles of Low FODMAP Diet


Suggested Theory For Relationship Between Functional Gut Symptoms and FODMAPS

Practical Gastroenterology • August 2007


• Identify typical eating practices of the patient to distinguish types of FODMAPS consumed regularly – Food records – Direct questioning – FODMAP checklist –

• Explain the scientific basis of FODMAPS – Malabsorption and fermentation

Key to Success


• Avoid foods containing free fructose or lactose – Unless negative breath tests)

• Fructose : Glucose ratio balanced

• Consume glucose-containing foods to balance

• Limit dietary fructose load at one meal

• Avoid foods high in fructans and galactans

Low FODMAP Diet Strategies


Sample (Fruits)

Intestine Friendly Food to Avoid if FODMAP Intolerant

Questionable Foods/Foods to

Limit

Bananas, blackberries, blueberry, grape, grapefruit, honeydew, kiwifruit, lemons,

limes, mandarin orange, melons, oranges, papaya, passion fruit, pineapples,

raspberries, rhubarb, strawberries, tangelos

Apples, apple cider, apple juice, applesauce, apricots,

cherries, dates, grapes, lychee, mango, peaches, pears, pear juice, plums,

prunes, watermelon

Other fruit juices or drinks, sugar-free jam/jelly, dried fruit, canned fruit in heavy

syrup, other fruits



Sample (Vegetables)



Limit

Bamboo shoots, bok choy, carrots, cauliflower, celery, cucumber, eggplant, green beans, green peppers, leafy greens, parsnip, pumpkin, spinach, sweet potatoes, white potatoes, other root

vegetables

Artichokes, asparagus, some beans (baked beans, chickpeas, kidney beans, lentils) beetroot, broccoli,

brussels sprouts, cabbage, cauliflower, fennel, garlic,

sugar snap peas, leeks, soy products, okra, onions, peas,

shallots

Avocado, corn, mushrooms, tomatoes, other beans



Sample (misc.)



Limit • All meats

• All fats

• Yogurt and hard cheeses

• All eggs

• Aspartame(Equal®; Nutrasweet®)

• Saccharin (Sweet `n Low®)

• Sucrose (table sugar)

• Glucose

• Honey

• Flavorings with fructose or sorbitol

• Desserts (icecream, candy, cookies, bars, popsicles with fructose or sorbitol)

• Cereal or other processed foods containing fructose

• Sherry and port wine

• Sorbitol, mannitol, xylitol, maltitol, and isomalt used in sugar-free gum/candies/mints

• Limit products with HFCS if symptoms still continue

• If you experience symptoms with lactose, try limiting milk, cottage cheese, and other lactose-containing foods

• (see lactose intolerant diet ed mat)



• Strict low FODMAP diet for 6-8 weeks

• Keep food diary/symptom diary

• Examining accumulated intake over several days is essential to gauge how strict the patient will need to be

Recommendations


• Diet compliance

• Correct deficiencies

• Modify intake of resistant starch and soluble and insoluble fiber

• Food chemicals

• Caffeine

• Fat intake

• Meal size

• Regularity

Symptoms Still Present…


• Not a cure

• Restriction of foods with prebiotic effects – Unfavorable for large bowel health

• Decrease in fiber intake

• Watch out for medications

Limitations to Diet


• Paleolithic Diet – Stone age or Hunter-gatherer diet

• Centered on – Fish – Grass-fed pasture raised meats – Eggs – Vegetables – Fruit – Fungi – Roots

Other Interesting Diets

• Excludes – Grains – Legumes – Dairy products – Potatoes – Refined salt – Refined sugar – Processed oils


• Advantages – Largely free of diseases of affluence

• Disadvantages – Questionable science – May be low in fiber and calcium

Paleolithic Diet Stone age or Hunter-gatherer diet


• Purports to reduce the symptoms of – Irritable Bowel Syndrome – Inflammatory Bowel Disease

–Crohn’s Disease –Ulcerative Colitis

– Celiac Disease – “Leaky Gut” – Autism

Specific Carbohydrate Diet (SCD)


• Allowed – Meats Lean meats, game meats, eggs, poultry – Vegetables Most fresh or frozen – Fruits Most fresh or frozen – Dairy Yogurt, aged cow or goat cheese – Nuts and Legumes

• Not Allowed – Any cereals or grains – Meats Processed or cured – Any canned fruits or vegetables – Starchy vegetables and legumes

Specific Carbohydrate Diet (SCD)


Cases


• 28 year old woman

• Bloating, diarrhea, gas, feeling of fullness

• Fructose breath hydrogen test – negative

• Negative for Celiac Disease

• Requesting Gluten Free diet education

• Also interested in weight loss

Case 1


• Newly diagnosed Celiac Disease

• No weight issues –

• Diet recall per patient – I can eat whatever looks good

• I don’t feel any worse when I eat Gluten Free – Do I have to do this diet forever?

Case 2


DOS CME Course 2011 105 DOS CME Course 2014 105

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