Low FODMAPs Guideline 7.2012

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7/2012 Minnesota Gastroenterology, PA. (612) 871-1145

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Low FODMAPs Guideline

CATEGORY: Clinical Practice

PURPOSE: To assist MNGI Physicians and NPPAs in the use of the FODMAPs diet inpatients with irritable bowel syndrome.

RESPONSIBLE PARTIES: All MNGI Physicians, nurse practitioners and physician assistants

GUIDELINE:

Introduction

Symptoms related to functional gastrointestinal symptoms may, at times, improve based uponwhat a person eats. Limited data has shown that avoiding certain carbohydrates may improvesymptoms. These carbohydrates, known as FODMAPs include Fermentable:

Oligosaccharides

Disaccharides

MonosaccharidesPolyols

It is believed that the ingestion of FODMAPs increases the delivery of fermentable substrateand water to the distal small intestine and proximal colon, which may induce luminal distention.While diets low in FODMAPS have not definitively been shown to be of benefit, it is reasonableto complete a trial.

The central focus of the FODMAPs diet is to reduce the intake of all poorly absorbed short chaincarbohydrates to be more effective in reducing luminal distension. The global approach torestricting carbohydrates should optimize symptom control in patients with functionalgastrointestinal disorders, such as irritable bowel syndrome and functional bloating. The

avoidance of short chain carbohydrates may reduce symptoms if the patients underlying bowelresponse is exaggerated or abnormal.

Approach to initiating the FODMAPs Diet

1. Identify patients with a diagnosis of a functional gastrointestinal disorder (i.e. irritable bowelsyndrome, functional bloating)2. Consider completion of fructose and lactose breath tests

Assists in determination of degree of dietary restriction necessary by defining whocan completely absorb fructose and/or lactose

Oligosaccharides and polyols are malabsorbed by everyone

3. Referral to a dietitian for instruction on the FODMAPs dietA dietitian-delivered diet has been shown to have higher levels of compliance.

The use of written literature alone for the direction of the FODMAPs diet has notbeen studied and caution should be used when undertaking that approach.

4. Consider follow up 6-8 weeks after the patient has started the FODMAPs diet


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Low FODMAP FoodsFruit Vegetables Grain Foods Milk Products Other

Banana,

blueberry,

boysenberry,

cantaloupe,

cranberry,

grape,

grapefruit,

honeydew

melon, kiwi,

lemon, lime,

mandarin

oranges, orange,

passion fruit,

raspberry,

rhubarb,strawberry

* Eat dried fruit in

small quantities

Alfalfa, bamboo

shoots, bean

shoots, bok

choy, carrot,

celery, endive,

green beans,

potatoes,

pumpkin,

spinach, summer

squash, sweet

potato, tomato,

yam, zucchini

Glutenfree

bread or cereal ,

100% spelt

bread, rice, oats,

polenta,

arrowroot,

millet, psyllium,

quinoa, sorgum,

tapioca

Milk

Lactose-free milk

and yogurt, oat

milk*, rice milk,

soy milk**Check for additives

Cheese

Hard cheeses,

brie and

camembert

Yogurt

Lactose-free

varieties

Ice Cream

Substitutes

Gelato or sorbet

Butter

Olive oil

Sweeteners

Sugar* (sucrose)

glucose, artificial

sweeteners not

ending in -ol

Honey

Substitutes

Maple syrup*,

molasses

*small quantities

High FODMAP FoodsFruit Vegetables Grain Foods Milk Products Other

Apples, apricots,blackberries,

canned fruit,

cherries, mango,

nectarines,

peaches, pears,

plums, prunes,

watermelon, large

amounts of dried

fruit or fruit juice

Artichokes,

asparagus, beets,

broccoli, Brussels

sprouts,

cabbage,

cauliflower,

eggplant, fennel,

garlic, green bell

pepper, leek,

mushroom,

onion, snow

peas, sugar snap

peas, sweet corn

Wheat and rye,

in large amounts

(i.e. bread,

crackers,

cookies, pasta)

Milk from cows,

goats or sheep,

custard, ice

cream and

yogurt, soft

cheeses such as

cottage cheese,

cream cheese

and ricotta

Sweeteners

Fructose, high

fructose corn

syrup, honey,

isomalt, maltitol

mannitol,

sorbitol, xylitol

Legumes

Baked beans,

chickpeas,

kidney beans,

lentils


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REFERENCES/RELATED DOCUMENTS:

1. MNGI Irritable Bowel Syndrome Guideline2. Marion, DW. Treatment of irritable bowel syndrome. In: UpToDate, Basow, DS (Ed),

UpToDate, Waltham, MA, 2012.3. Gibson, PR, Sheperd, SJ. Evidence-based dietary management of functional

gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010;

25(2):252-84. Choi YK, Johlin FC, Summers RW, et al. Fructose intolerance: an under-recognized

problem. Am J Gastroenterol. 2003;98(6):1348.5. Ong DK, et al. Manipulation of dietary short chain carbohydrates alters the pattern of gas

production and genesis of symptoms in irritable bowel syndrome. J GastroenterolHepatol. 2010;25(8): 1366.

6. Sheperd SJ, Parker FC, Muir JG, Gibson PR. Dietary triggers of abdominal symptoms inpatients with irritable bowel syndrome: randomized placebo-controlled evidence. ClinGastroenterol Hepatol. 2008;6(7):765.

Person initiating original guideline or revision: _Kadee Watkins, PA-C__________

Original Date of guideline: ___July 2012_________________Date of Revisions: ______________________________Date of Review: ________________________________

APPROVAL:

______________________________ _______________________Chair, Clinical Practice Committee Date

Douglas Nelson, MD

Low FODMAPs Guideline 7.2012

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