Efficacy of a Low-FODMAP Diet in

Reducing Diarrhea for Irritable

Bowel Syndrome and Beyond
TAYLOR PALM
SODEXO DIETETIC INTERN
URI GRADUATE STUDENT
TOPICS TO COVER
Diarrhea
FODMAPs
Low-FODMAP Diet
Mechanism of FODMAPs and how it relates to diarrhea
IBS
IBD
Reduced Intestinal Length
Enteral Nutrition
Directions For Future Research
Registered Dietitians
Objectives
1. Discuss the Low-FODMAP diet, its components and the phases
of elimination and reintroduction
2. Understand the mechanism of FODMAPs and their effect on
diarrhea
3. Provide a thorough evaluation of the efficacy of a Low-
FODMAP diet on a variety of diseases and conditions involving
diarrhea
Introduction
The Low-FODMAP diet and
what it means to me

Aglabe, J. Paleo Low-FODMAP diet food list.

Radicata Medicine. https://s-media-cache-
ak0.pinimg.com/originals/9e/13/57/9e135750
9288e6992eaa683730938159.jpg. Accessed
April 7, 2017.
ICE BREAKER

TAKE OUT A PENCIL AND PAPER!

THE RULES
1. You have 2 minutes
2. Write as many high-FODMAP foods as you can
think of
3. After we go through the diet, I will hand out a list
of foods and their FODMAP content to see how many
you got right!
Diarrhea
Common symptom associated with a variety of gastrointestinal
(GI) disorders, infections and conditions1
Can lead to dehydration, electrolyte imbalance, weight loss,
malabsorption, nutrient deficiency, and/or malnutrition 1
Difficult to pinpoint treatment as the causes can be
multifactorial
Low-FODMAP diet has been suggested as a treatment2,3,4
What are FODMAPs?
Fermentable Oligosaccharides, Disaccharides, Monosaccharides,
and Polyols5
Highly osmotic, short-chain carbohydrates5
Poorly absorbed5
Oligosaccharides
Fructo-oligosaccharides (Fructans)5
Chains of fructose
Examples5
Wheat
Onion
Garlic
Artichokes
Inulin

Galacto-oligosaccharides5
Lactose
Glucose and Galactose5
Malabsorption3
Healthy Caucasians- 16%
Functional GI Diseases- 23%
IBD- 38%
Examples5
Milk
Ice cream
Yogurt
Cottage cheese
Fructose
Monosaccharide5
Malabsorption3
Healthy individuals- 34%
Functional GI disorders- 45%
Ileal Crohns disease- 78%
Examples5
Apples
Pears
Mango
Honey
High fructose corn syrup
Polyols
Sugar alcohols5
Malabsorption3
Healthy individuals- 60%
Examples5
Sorbitol
Mannitol
Mushrooms
Apples
Low-FODMAP diet
Two Phases5
1. Elimination
2. Reintroduction
Low-FODMAP v No FODMAP
Low-FODMAP Diet
Why it can be tricky6
Restrictive
Eating multiple servings of low-FODMAP foods may still cause
symptoms due to additive effects of FODMAPs
Everyones sensitivities will vary, low-FODMAP foods could still
cause symptoms
Not all foods have been analyzed to determine their FODMAP
content yet
Mechanism
How the Mechanism has been studied:
Ileostomy Model3
FODMAPs in effluent
Breath Hydrogen and Methane Testing3
Fermentation by microflora in the intestines
Mechanism
What has been found3,7
FODMAPs draw water into the small intestine
Fermentation in the large bowel
The Research
Does a Low-FODMAP diet reduce diarrhea for patients with
IBS?
Does a Low-FODMAP diet have applicability for improving
diarrhea for other conditions and disease states?
The Research
What we know2,3
Improvement of overall symptoms for those with IBS
Up to 86% of patients experience relief of overall GI
symptoms
It has been suggested that FODMAPs may improve other
disease states with diarrhea
Why is it important?
Management of diarrhea
Quality of life
Methods
Literature search from October 2016-January 2017
Databases including: PubMed, Rutgers Libraries, University
of Rhode Island Libraries, and Google Scholar
Key terms: FODMAPs, low FODMAP diet, diarrhea, Irritable
Bowel Syndrome, and Irritable Bowel Disease
Methods
Inclusion Criteria
Dietary intervention with a Low-FODMAP diet
Diarrhea as a dependent variable
Any condition associated with diarrhea managed with a Low-
FODMAP diet
Published within the last ten years
All study designs
15 articles in total
IBS
Up to 20% of people worldwide suffer from IBS2
Symptoms: diarrhea, constipation, nausea, abdominal pain,
bloating, flatulence2
IBS is subdivided by stool form2
Causes2
Treatment2
Up to 84% of IBS patients believe that at least one food in
particular triggers their symptoms8
 IBS
Low-FODMAP Diet v. Standard/Baseline Diet
Adherence
Improves diarrhea (P=0.007)9
Stool consistency
Kings Stool Chart10
One randomized controlled trial found score improvement for IBS-D (P=.034)
Bristol Scale
One retrospective study found normal stools increased by 41%(P<0.001) 11
One prospective study found no significant change in stool form 12
No separation by subtype.11,12
IBS-D v. other subtypes10-12
More significant changes in diarrhea for IBS-D
IBS
Low-FODMAP Diet v. Traditional Dietary Advice
Elimination of foods high in fat, spicy, high fiber, high in caffeine,
carbonated13
Recommendations such as not overeating13
 IBS
Low-FODMAP Diet v. Traditional Dietary Advice
Stool frequency13
One randomized controlled trial found overall symptom improvement for
both interventions (P<.0001)
No change in stool consistency, reduction in stool frequency in the Low-
FODMAP group (P<.001)
Improvement v Satisfaction4
A prospective study found a trend for improvement (P=0.052), more
satisfaction on Low-FODMAP diet (P=0.038)
IBS-D14
One randomized controlled trial found Improvement in stool consistency
(P=0.0092), frequency (P=0.0003), and urgency (P=0.0419) in the Low-
IBS
Overall findings4,9-14
IBS-D
Future Directions for research
Conclusion
IBD
Inflammatory Bowel Diseases11,15
Crohns and Ulcerative Colitis

Inflammatory Bowel Disease.

http://cdn2.hubspot.net/hub/472716/file-
2666356798-jpg/IBD.jpg Accessed April 6, 2017.
IBD
Symptoms such as diarrhea, constipation, vomiting, and
abdominal pain11,15
Causes15
Treatment11,15
Low-FODMAP diet suggested for IBD symptom
management8,11,15
IBD
One retrospective pilot study found improvements in diarrhea 15
Crohns patients-46%
Ulcerative Colitis patients-58%
After 3-6 months on a Low-FODMAP diet, diarrhea was improved
for all IBD patients (P<.001)
Significant improvements for all GI symptoms except constipation
One retrospective study evaluating stool using the Bristol Scale
found:11
66% of IBD patients reported more normal stools (P<0.001)
IBD
Significant correlations11,15
More high quality randomized controlled trials are needed
Promising that a Low-FODMAP diet may result in more normal
stools and improve overall diarrhea for patients with IBD 11,15
Reduced Intestinal Length

Ileostomy. Ostomy Help Web site. Colectomy. Mayo Foundation.

https://www.exmed.net/blog/ostomyhelp/post http://www.mayoclinic.org/-/media/kcms/gbs/patient-
/2016/04/13/ostomy-diet-for-ileostomy-and- consumer/images/2013/08/26/10/38/my00141_im00232_c7_left_hemi
colostomy.aspx Accessed April 6, 2017. colectomythu_jpg.jpg. Accessed April 6, 2017.
Reduced Intestinal Length
One crossover study looking at effluent found:16
Mean weight (P=0.01) and water content (P=0.013) were
lower on a Low-FODMAP diet compared to a high-FODMAP diet
Perceived effluent to have a thicker consistency on the Low-
FODMAP diet (P=0.005)
FODMAP content of the effluent was significantly and
positively correlated to water volume (P=0.035)
One retrospective study evaluating those with an ileal pouch
without a colon found:17
Stool frequency was reduced from a median of 8 to 4 stools
per day (P=0.02).
Reduced Intestinal Length
Randomized controlled trials are needed
These studies suggest a Low-FODMAP diet could be beneficial in
reducing diarrhea and frequency of stools for those with reduced
intestinal length16,17
Enteral Nutrition
Indicated in patients who cannot eat by mouth or are not
meeting their needs orally, yet still have a GI system that is
functional18,19
Diarrhea is common18
Significant factors include:
Medications like antibiotics (P=0.026) or PPIs (P=0.050)
Hospital length of stay >21 days (P<0.001)
Enteral nutrition for >11 days (P=<0.001)
Enteral Nutrition
Retrospective study18
Risk for diarrhea was reduced five-fold when patients were on
an enteral formula 47-71% lower in FODMAPs (P=0.029)18
Randomized Controlled Trial19
Compared to those on moderate and high FODMAP EN
formulas, diarrhea was improved in patients on low-FODMAP
EN (P<0.05)
Kings Stool Chart scores were better for those on low-FODMAP
EN indicating improved stool consistency, frequency and
weight (P<0.05)
Enteral Nutrition
Low-FODMAP formula could reduce diarrhea in tube-fed
patients18,19
Larger body of research is needed to confirm results
Limitations
Distinct lack of randomized controlled trials
Small body of research
Low-FODMAP diet itself6
Elimination v reintroduction
Implications For Future Research
Exclusive studies on IBS-D
Long term effects of a Low-FODMAP diet2
Summary
Low-FODMAP diet limits highly osmotic, poorly absorbed short-
chain carbohydrates5
Two phases: Elimination and reintroduction5
Summary
IBS
Low-FODMAP diet has already been adopted around the world as
a tool for overall symptom management6,7
Stool frequency, consistency, and weight are significantly
improved on a Low-FODMAP diet for those with IBS-D10,14
Compared to baseline or standard diets as well as traditional
IBS dietary advice, it appears to more positively affect those
with IBS-D compared to IBS-C or IBS-M4,9-14
Low-FODMAP diet is an effective strategy for managing diarrhea
in at least IBS-D patients2,3,9-14
Summary
Research supporting a Low-FODMAP diet for management of
diarrhea in patient populations beyond IBS is not quite as
strong11,15-19
Limited number of studies
Few randomized controlled trials
Results are favorable and demonstrate a positive effect of a
Low-FODMAP diet on diarrhea11,15-19
Summary
The Low-FODMAP diet is not intended to be lifelong5
Future research is needed to evaluate long-term changes in
stool, overall GI symptoms, and patient satisfaction after
FODMAPs have been reintroduced and individual tolerances
have been determined
Registered Dietitians
The Low-FODMAP diet is growing in popularity5
RDs are in the best position to educate patients on how to meet
their nutritional needs while following a Low-FODMAP diet 20
Aide as patients reintroduce FODMAPs to determine individual
thresholds3,5
Registered Dietitians
RD Education
More trainings, seminars, and workshops
Future research should address the effectiveness of these
trainings, workshops and seminars on patient outcomes like
diarrhea
Conclusion
Evidence supports the efficacy of a Low-FODMAP diet for
reducing diarrhea in at least IBS-D patients2-19
Research is promising for other patient populations such as
those with IBD, reduced intestinal length and those on enteral
nutrition4,11-19
RDs have the potential to make a substantial impact on the
management of diarrhea and quality of life for these patients
 References
1. World Health Organization(WHO). The treatment of diarrhoea: a manual for physicians and other senior health workers. 4th rev ed.
Geneva, CH: WHO Press;2005.
2. Nanayakkara WS, Skidmore PM, OBrien L, Wilkinson TJ, Gearry RB. Efficacy of the low FODMAP diet for treating irritable bowel syndrome:
the evidence to date.Clin Exp Gastroenterol. 2016;9:131-142.
3. Barret JS. Extending Our Knowledge of Fermentable, Short-Chain Carbohydrates for Managing Gastrointestinal Symptoms. Nutr Clin
Pract.2013;28(3):300-306.
4. Staudacher HM, Whelan K, Irving PM, Lomer MCE. 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(5):487-495.
5. Shepard, S. Low FODMAP Diet. Shepherd Works Web site. http://shepherdworks.com.au/disease-information/low-fodmap-diet/. Accessed
January 11, 2017.
6. Catsos B. RD FODMAP Practice Kit. IBS-Free at Last Web site. http://www.ibsfree.net/. Published 2012. Accessed August, 2015.
7. Murray K, Wilkinson-Smith V, Hoad C, et al. Differential Effects of FODMAPs (Fermentable Oligo-, Di-, Mono-Saccharides and Polyols) on
Small and Large Intestinal Contents in Healthy Subjects Shown by MRI. Am J Gastroenterol. 2014;109(1):110-119.
8. Bhn L, Strsrud S, Trnblom H, Bengtsson U, Simrn M. Self-reported food related gastrointestinal symptoms in IBS are common and
associated with more severe symptoms and reduced quality of life. Am J Gastroenterol.2013;108(5):634-41.
9. de Roest RH, Dobbs BR, Chapman BA, et al. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel
syndrome: a prospective study. Int J Clin Pract. 2013;67:895-903.
10. Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome.
Gastroenterol. 2014;146:67-75.
 References (cont.)
11. Maagaard L, Ankersen DV, Vegh Z, et al. Follow-up of patients with functional bowel symptoms treated with a low FODMAP diet.
World J Gastroenterol. 2016; 22(15):4009-4019.
12. Perez N, Torres-Lopez E, Zamarripa-Dorsey F. Mexican clinical response in patients with irritable bowel syndrome treated with diet
low in fermentable carbohydrates (FODMAP). Rev Gastroenterol Mex. 2015; 80(3):180-185.
13. Bhn L, Strsrud S, Liljebo T, et al. Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome as Well as Traditional
Dietary Advice: A Randomized Controlled Trial. Gastroenterol. 2015;149(6):1399-1407e1392.
14. Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A Randomized Controlled Trial Comparing the Low FODMAP Diet vs.
Modified NICE Guidelines in US Adults with IBS-D. Am J Gastroenterol.2016;111:1824-1832.
15. Gearry RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR. Reduction of dietary poorly absorbed short-chain
carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease-a pilot study. J Crohns
Colitis. 2009;3(1):8-14.
16. Barrett JS, Gearry RB, Muir JG, et al. Dietary poorly absorbed, short-chain carbohydrates increase delivery of water and
fermentable substrates to the proximal colon. Aliment Pharmacol Ther. 2010;31(8):874-82.
17. Croagh C, Shepherd SJ, Berryman M, Muir JG, Gibson PR. Pilot study on the effect of reducing dietary FODMAP intake on bowel
function in patients without a colon. Inflamm Bowel Dis. 2007;13(12):1522-1528.
18. Halmos EP, Muir JG, Barrett JS, Shepherd SJ, Gibson PR. Diarrhoea during enteral nutrition is predicted by the poorly absorbed
short-chain carbohydrate (FODMAP) content of the formula. Aliment Pharmacol Ther. 2010;32(7):925-933.
19. Yoon SR, Lee JH, Lee JH, Na GY, Lee K, Lee Y, Jung G, Kim OY. Low-FODMAP formula improves diarrhea and nutritional status in
hospitalized patients receiving enteral nutrition: a randomized, multicenter, double-blind clinical trial. Nutr J. 2015;14(1):116.
20. Monash University Low FODMAP Diet booklet. Monash University Web site. http://www.med.monash.edu/cecs/gastro/index.html.
Published 2013. Accessed January 13, 2017