Beyond the Gluten-Free Diet: What Foods Are Right for Me?

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Laurie A. Higgins, MS, RD, LDN, CDEPediatric Nutrition & Diabetes Educator

Joslin Diabetes Center

Karen Y. Warman M.S.R.D.Pediatric Nutrition Educator

Boston Children’s Hospital

Disclosures

Laurie A. Higgins, MS, RD, LDN, CDE- No disclosures

Karen Y. Warman M.S.R.D.- No disclosures

Objectives

• Understand the nutrition pitfalls of the gluten-free diet.

• Discuss additional intolerance if you are symptomatic on the gluten-free diet

• Identify when you need to seek additional help from a dietitian.

Common Nutritional Deficiencies in Newly Diagnosed Celiac Disease

• Anemia– Iron, Folate, Vitamin B12– 12 to 69% patients at anemic at diagnoses– 78 to 98% adults will respond to the GFD

• Fat Soluble Vitamins – A,D,E, and K• Calcium, Phosphorus & Vitamin D

– Lactose Intolerance– Diet low in calcium, and vitamin D

• GDF diet is low in fiber and enriched foods

Women (n = 39)• Fiber (46%)• Grain foods servings (21%)• Iron (44%)• Calcium (31%)

Men (n = 8)• Fiber (88%)• Grain foods servings (63%)• Iron (100%)• Calcium (63%)Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK. Gluten-free diet survey: are Americans with coeliac disease consuming recommended amounts of

fibre, iron, calcium and grain foods? Journal of Human Nutrition and Dietetics. 2005;18(3):163-9.

Results of 2005 GF Diet Survey: % of people with celiac disease meeting

recommended amounts of nutrients

• 47 volunteers who provided a 3-day food record • Records were assessed for daily intakes of calories, %of

calories from carbohydrates, dietary fiber, iron, calcium,

and grain food servings.• Recommended amounts of fiber, iron, calcium and grain

servings are as follows:

• More emphasis is needed on the nutritional quality of the GF diet (especially for women) as it concerns fiber, iron and calcium

• Eat 6-11 servings (depending on calories) of GF grain foods daily, choose whole or enriched

• Increase non-grain food sources of Iron & B vitamins• Consume 3 servings/day* of lowfat or nonfat GF dairy

foods, or calcium-rich and vitamin D fortified, non-dairy foods

• Consider GF vitamin/mineral, calcium and vitamin D supplements, as recommended.

*depending on individual needsThompson et al, JHND 2005;18:163-169

Conclusions of GF Diet Survey Study

USDA 2010 Dietary Guidelines

• Build a Healthy Plate – Make half your plate fruit & vegetables

• Eat red, orange, and dark green vegetables – Choose skim or 1% (lowfat) milk – Make a least half your grains whole – Vary your protein choices

• Choose seafood twice a week• Add beans (legumes) for a natural source of fiber and

protein • Keep your meat & protein portions small

http://www.choosemyplate.gov/downloads/MyPlate/DG2010Brochure.pdf

USDA 2010 Dietary Guidelines

• Cut back of foods high in solid fats, added sugars, and salt– Choose foods & drinks with little or no added

sugars – Look out for salt (sodium) in processed or

prepared foods – Eat fewer foods that are high in solid fats

http://www.choosemyplate.gov/downloads/MyPlate/DG2010Brochure.pdf

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• Undigested, unabsorbed part of plants, found in grains, legumes, fruits, vegetables, nuts and seeds

• Deficient in most American diets• Helps normalize blood sugar and insulin levels• Helps with bowel motility – diverticular disease, certain

cancers• Decrease risk of heart disease with a high fiber diet• Helps fill you up on fewer calories – satiety• Soluble: helps lower total cholesterol & LDL• Insoluble: may help prevent constipation & diverticulosis• Increasing fiber should be gradual and drink plenty of

fluids

Facts on Fiber

General Fiber RecommendationsAge Fiber (grams/day)

Women < 50 25

Women > 50 21

Men < 50 38

Men > 50 30

Dietary Reference Intakes Released for Carbohydrates, Fats, Protein, Fiber and Physical Activity. Dietetics in Practice, American Dietetic Association, Fall 2002.

• 14 grams Fiber/1000 calories • 1800 calories = 25.2 grams fiber per day• 2400 calories = 34 grams fiber per day

General Fiber RecommendationsAge Fiber (grams/day)

Less than 12 months Not determined

Children 1-3y 19

Children 4-8y 25

Males 9-13y 31

Males 14-18y 38

Females 9-13y 26

Females 14-18y 26Institute of Medicine of the National Academies. Dietary Carbohydrates: Sugars and Starches. Dietary Reference Intakes: The essential guide to nutrient requirements. Washington D.C.: 2006: 536.

How to get 25-30 grams Fiber in a Day! Breakfast Calories Fiber (g)1 cup GF oatmeal 166 41 cup lowfat milk 120 01 tbsp Ground Flax seed 37 1.9Raisins (0.5 oz small box) 42 0.5

Am Snack medium apple (3" diameter) 95 4.4

Lunch 2 slices Glutino Bread w/fiber 180 43 oz turkey 83 01 tsp mustard 3 0lettuce & 2 slice tomato 36 0.4Corn Chips 1 oz 141 1.51 Kiwi 42 2.11 cup low fat milk 120 0

Afternoon Snack1 serving lentil crackers (5) 110 1Vegetable Sticks (carrots & celery) 1 cup 13 1.11/2 cup hummus 100 3.6

Dinner1 serving of Quinoa Pasta (2 oz dry) 205 41/3 cup tomato sauce 74 2.21/2 cup broccoli 27 2.64oz salmon 206 01.5 cups salad (let, tom, carrot) 30 1.8Balsamic Vinegeratte (2 Tbsp) 20 0.1

1850 35.2

• Choose GF grains whole grain• Add 2-3 servings of fruit to daily diet• Add 2-3 servings of vegetables to your

day

Go Slow Increase Gradually

• Fermentation by bacteria• Potential binding with minerals• Increase gradually to enhance tolerance• Increase water intake• Limit intake to appropriate age group• Too much fiber can cause, gas, diarrhea, and or

constipation

Fiber Content:Gluten Free Grains & Flours

Tapioca Flour

White Rice Flour

Millet, flour

Brown Rice, flour

Enriched Corn Flour

Montina All Purpose Flour

Sorghum Flour

Chix Pea Flour

Quinoa, uncooked

Buckwheat Flour (whole groats)

Amaranth, uncooked

Teff, incooked

Oats, uncooked

Millet, raw

Whole Wheat, flour

02468

1012141618

• Most GF cereals, pasta and bread are not enriched and are low in:– Dietary fiber– Thiamin (B1)– Riboflavin

• WHAT ARE THEY MADE FROM?• Reformulation of products by some GF food companies

are higher in fiber and nutrients.• Try to purchase enriched products.

• Niacin• Iron• Folate

Fiber & Vitamin Fortification in GF Foods

Sources of B Vitamins• Thiamine (B1)*

– Best: enriched GF grains and flours, pork– Good: soy milk, peanuts, orange juice, legumes and watermelon– GFD: legumes (peanuts, beans, soy) products

• Riboflavin (B2)*– Best: enriched grains, eggs and meat– Good: liver, mushrooms, spinach and green leafy vegetables, broccoli,

asparagus, milk, and cottage cheese– GFD: eggs, meats, green leafy vegetables, broccoli, milk and milk products

• Niacin (B3)*– Best: enriched grains, beef, chicken, turkey, fish (tuna, halibut, salmon)– Good: peanuts, asparagus– GFD: animal proteins, peanuts and asparagus

*Main source in the American diet is in the enriched flours, breads, crackers, and breakfast cereals

Sources of B Vitamins • B6

– Best: meat, fish and poultry– Good: banana, avocado, potatoes, sunflower seeds– GDF: meat, fish, poultry, banana, avocado, and sunflower seeds

• Folate* – Best: fortified breakfast cereals and other grain products, legumes, and

vegetables (spinach and leafy greens, sprouts, romaine lettuce, cabbage, etc.

– Good: liver, broccoli, beets, sunflower seeds, legumes, orange juice– GFD: vegetables, and leafy greens, legumes (lentils)

• B12 – Best: animal products (meat, poultry, seafood, and eggs)– Good: milk and milk products– 10-20% of older adults are at risk of B12 deficiency because they lose

the ability to absorb (decrease intrinsic factor) the vitamin – Vegans – need a reliable source

Flours B1 B2 B3 B6 FolateAmaranth 0.11 0.28 1.7 0.30 66

Buckwheat 0.50 0.23 7.4 0.70 65

Millet 0.76 0.48 2.8 ---- ----

Quinoa 0.22 0.44 3.3 0.25 55

Sorghum 0.46 0.27 5.6 1.13 38

Teff 0.51 0.14 1.9 ---- 97

Wheat whole-grain

0.54 0.26 7.6 0.41 53

Wheat, white, enriched

0.91 0.62 7.4 0.06 229

B Vitamin Content in GF Flours (1C)

USDA National Nutrient Database -http://www.nal.usda.gov/fnic/foodcomp/search/index.html

Bone Disease

• At celiac disease diagnosis:– ~10-30% have osteoporosis– ~40% have osteopenia

• Vitamin D and Calcium deficiency result in greater risk of bone loss, fractures, falls, and perhaps infections, autoimmune diseases and cancer

Meyer D, AJG 2001; McFarlane et al., Gut 1996; West et al., Gastroenterology 2003

Key Points: Celiac Disease & Bone Metabolism

• Vitamin D and calcium deficiency are common across the United States – ½ of Americans have suboptimal levels

• Vitamin D and Calcium absorption may not completely normalize with GFD

• Patients with celiac should have adequacy of the Vitamin D and Calcium regimen checked after 6 months of GFD

Recommended Dietary Allowance (RDA’s) for Vitamin D (IU’s)

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.

Age Male Female Pregnant Lactation

0-12 months 400 400

1-13 years 600 600

14-18 years 600 600 600 600

19 - 50 years 600 600 600 600

51- 70 years 600 600

> 70 years 800 800

National Osteoporosis Foundation: March 2011 Recommendations

Calcium and Vitamin D Recommendations

Children & Adolescents Calcium (Daily) Vitamin D (Daily)

1 through 3 years 500 mg 400 IU*

4 through 8 years 800 mg 400 IU*

9 through 18 years 1,300 mg 400 IU*

Adult Women & Men Calcium (Daily) Vitamin D (Daily)

19 through 49 years 1,000 mg 400-800 IU

50 years and over 1,200 mg 800-1000 IU

Pregnant & Breastfeeding Women

Calcium (Daily) Vitamin D (Daily)

18 years and under 1,300 mg 400-800 IU

19 years and over 1,000 mg 400-800 IU

* These are the recommendations of the American Academy of Pediatrics.

Food Sources Serving Size Vitamin D (IU)

Sunshine 5-15 mins Varies; see your doctor for advice on sun exposure

Cod liver oil 1 T 1360

Wild-caught salmon, Sockeye 4 oz 739

Wild-caught salmon, Chinook 4 oz 411

Mackerel 3 ½ oz 345

Sardines 1 ¾ oz 250

Tuna fish 3 oz 200

Soy Milk 1 cup 120

Milk, nonfat/reduced fat/whole/vitamin D fortified

1 cup 98

Margarine, fortified 1 T 60

Ready-to-eat cereals fortified with 10% of the DV for vitamin D

¾ to 1 cup (depending on the brand)

40

Egg 1 whole 20

Liver, beef, cooked 3 ½ oz 15

Cheese, Swiss 1 oz 12

Food Sources of Vitamin D

http://ods.od.nih.gov/factsheets/vitamind

Food Serving Size Calcium (mg)

Yogurt, plain low fat 1 cup 415

Orange juice, calcium fortified 6 fluid oz 378

Mozzarella Cheese, part skim 1.5 oz 333

Sardines, canned in oil, with bones 3 oz 32

Cheddar Cheese 1.5 oz 306

Yogurt, fruit low fat 1 cup 313 - 384

Milk (nonfat, low fat 1%, reduced fat 2%, whole 3.25%) 1 cup 272 – 296

Tofu, firm made with calcium sulfate ½ cup 253

Tofu, soft made with calcium sulfate ½ cup 138

Salmon, pink, canned, solids with bones 3 oz 181

Cottage cheese, 1% milk fat 1 cup 138

Turnips greens, boiled ½ cup 99

Kale, raw/cooked 1 cup 90/94

Soy beverages, calcium fortified 1 cup 80 - 500

Ice cream, vanilla ½ cup 84

Chinese Cabbage, raw 1 cup 74

Tortilla, corn, ready-to-bake 1 medium 46

Broccoli, raw ½ cup 21

Food Sources of Calcium

http://ods.od.nih.gov/factsheets/calcium

Calcium Supplementation • Calcium supplements should not be taken at the same time as

iron supplements. • Medications that need to be taken on an empty stomach should

not be taken at the same time as a calcium supplement.• Calcium is absorbed best when taken in amounts of 500 – 600

mg or less.• Calcium comes in four forms calcium carbonate, calcium citrate,

calcium phosphate and calcium lactate. – Each have different amounts of elemental calcium – always

check label – Calcium citrate more easily absorbed– Calcium carbonate better absorbed on an empty stomach

• Calcium can interfere with absorption and action of other medications – always check with your health care provider

http://www.nof.org/aboutosteoporosis/prevention/calcium & http://ods.od.nih.gov/factsheets/calcium

Choosing a Multivitamin • A must - Be sure it contains:

– B1 (thiamin)– B2 (riboflavin)– B3 (niacin) folic acid– Vitamin D

• Ideal– Zinc and iron

• If you are not taking the recommended number of servings of Calcium– Calcium supplement as the multivitamin with mineral will

never have enough calcium if you are taking < 75% of the recommended number of servings

• Check the percentages. – Greater than 100% of any vitamin or mineral should be

checked by your health care provider

Continued GI Symptoms

• Inadequate fiber Intake• Carbonated beverages• FODMAPS and other fermentable

carbohydrates• Food Allergens

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FODMAPS

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What are FODMAPs

Characteristics of a FODMAP

FODMAPs- small chain sugars/carbohydrates and fiber

- poorly absorbed in small intestine - delivered to the large intestine- small osmotically active molecules- food for bacteria – when eaten gas is produced –

fermentation

Poorly absorbed, rapidly fermentable, osmotically active dietary carbohydrates (FODMAPs)

What does FODMAPs stand for ??

• F is for Fermentable - Carbohydrates that are fermented by bacteria in the large intestine instead of being broken down by our digestive enzymes. - Fermentation results in gas, bloating and pain.

• O is for Oligosaccharides - Oligosaccharides are short-chain carbohydrates- Fructans- Fructooligosaccharides (FOS)- Oligo-galactans. - Xylo-oligosaccharides

What does FODMAPs stand for ?• D is for Disaccharides - These are pairs of sugar

molecules. - Lactose, maltose

• M is for Monosaccharides - This describes a single sugar molecule. - Fructose, glucose, galatose, xylose

• A is for And - Every list needs a good conjunction.

• P is for Polyols - Polyols include sugar alcohols like xylitol, sorbitol, or maltitol.

Carbohydrate Why they might cause an issue

Disaccharide Found in milk. Lactose intolerance is caused by partial or complete lack of the enzyme lactase..

Monosaccharide Found in fruit. Fructose intolerance is is due to incomplete digestion in the GI track. The absorption of fructose is dependent on glucose. Monosaccharaides are poorly absorbed due to their low capacity transport across the epithelium. Low expression of GLUT5.

FructansOligosaccharide

Fructans are completely malabsorbed because the intestine lacks an enzyme to break their fructose-fructose bond. Wheat accounts for the majority of peoples fructan intake.

GalactansOligosaccharide

Found mostly in beans and lentils. Galactans are malabsorbed as the intestine does not have the enzyme needed to break down galactans.

Polyols Found naturally in some fruits and vegetables and added as sweeteners to candy, gum and meds. Polyols are too large for passive diffusion.

Shepherd S et al. Short-Chain Carbohydrates and Functional Gastrointestinal Disorders. Am J Gastroenterology. 2013;108:707-717

A: Poorly absorbed CHO arrives in colon populated with microbiotia

B: Osmotic activity leads to increase water retention in lumen of the small and large bowel

C: CHO is a substrate for bacterial fermentation, resulting in the rapid product of gas and luminal distention

Fructans &(FOS) Fructooligosaccharides

Galactans (GOS) (oligosaccharides)

Lactose (disaccharide)

Fructose (monosaccharide)

Food Fructose (gms)(per 100 g food)

Glucose (gms)(per 100 g food)

Excess Free Fructose

Verdict

Honey 40 30 10 Problem

Kiwi 4 4 0 Suitable

Pineapple 5 5 0 Suitable

Mango 3 1 2 Problem

Watermelon 4 2 2 Problem

Asparagus 1 .65 .35 Problem?

www.nutritiondata.com

Polyols• Sorbitol- more common in fruits • Mannitol-more common in vegetables • Added as a sweetener in many “low-calorie foods”

especially sugar free gum and toothpaste”

SorbitolItem Portion size Sorbitol content

(gms)

Prunes .25 cup 9

Dried Apricot .5 cup 4.1

Dried Pear 6 pieces 2.2

Sugar-free gum 2 pieces 4

Plum 1 1.6

Apricot 1 1.3

Apple Juice 1 cup 1.1

Dried Apple .5 cup .9

Wasabi 1 teaspoon .6

Cherries 5 .3

Coconut Milk 1 cup .3

Dried coconut .5 cup .2J Hum Nutr Diet. 2014 apr;27 Suppl 2:263-75

Mannitol content of foods

Item Portion size Mannitol (gms)

Cauliflower 1 cup 3.4

Celery 1 cup 1.9

Mushrooms 1 cup 1.9

Snow Peas 10 pods .4

Sweet Potato 1 cup .3

Pomegranate 1 fruit .2

Evidenced Based?

Candidate for Low FODMAP

• Symptoms– Bloating– Belching– Distention– Gas– Abdominal pain– Nausea– Diarrhea

Implementing the diet

• Complete elimination is the most efficient method of assessing responsiveness.– 2 week MINIMUM to determine whether it will be

helpful– 6 to 8 week of strict avoidance prior to FODMAP

challenge• Candidates for partial reduction

– Very picky eater, unwilling to eat low FODMAP foods– Dietitian has identified foods/beverages that are

contributing significant FODMAPs

FODMAPs Foods High in FODMAPs Suitable Alternatives (limit to ½ cup serving per meal/snack)

Excess fructose and polyols

Apples (Juice)Apple Sauce Cherries (Juice)Pears (Juice)Fruits packed in Juice

Firm bananasBlueberriesCantaloupeClementinesGrapesHoneydew melonKiwi fruitLemon juiceMandarin oranges Navel oranges PineappleRaspberriesRhubarbStrawberries

Excess fructose Ripe bananasMango

Polyols BlackberriesPeaches

Oligosaccharides Dried cranberriesDried datesDried pineapple Grapefruit (Juice)PersimmonPomegranateRaisins

Oligosaccharides and Polyols

Nectarines

Oligosaccharides, Fructose, and Polyols

Watermelon

Vegetables

FODMAPs Foods High in FODMAPs Suitable Alternatives

Excess fructose Asparagus ArugulaBean sproutsBok choyBroccoliBrussel sprouts (small serving)CarrotCommon cabbage (not Savoy cabbage)CucumberEggplantFennel bulb and leavesGreen beansGreen pepperKaleLettuce OkraParsnipsRadish Red pepperSpinachSpring onion tops TomatoTurnipWhite potato Yellow summer squashZucchini

Polyols CauliflowerCeleryCornMushroomsSnow peasSweet potato

Oligosaccharides ArtichokesBeetGarlic (as a flavoring)Leek bulbOnions (as a flavoring) Shallots

Oligosaccharidesand polyols

Butternut squash (moderately high)

FODMAP Foods High in FODMAPs Suitable Alternatives

Oligosaccharides (fructans) Barley RyeRye-based breadRye-based cerealsWheatWheat-based breadWheat-based cerealsWheat-based pastaWhite Bread (made from wheat)

BuckwheatCorn MilletOatsQuinoaRice Rice breadRice or corn-based pasta

FODMAP Foods High in FODMAPs

Lactose (gm) Suitable Alternatives Lactose (gm)

Lactose Milk (1 cup)Evaporated milkSweetened condensed milk Yogurt

9-1424-2831-504-17

Lactaid milk (1 cup)Yoplait lactose-free vanilla yogurt Green Valley lactose-free yogurt

0

Cottage cheese (1/2 cup)

0.7-4 Lactaid cottage cheese 0

American cheese (1 oz)

0.5-4 Cheddar cheese (1 oz) 0.4-0.6

Ricotta cheese (1/2 cup)

0.3-6 Mozzarella, part-skim (1 oz) 0.08-0.9

Ice cream (1/2 cup) 2-6 Lactaid Ice cream 0

Butter (1 pat) 0.04-0.5

Cream cheese 0.1-0.8

FODMAPs Foods High in FODMAPs

Oligosaccharides –galactooligosaccharides (GOS)

Dried split peasBaked Beans Black BeansKidney BeansCannellini BeansGreat Northern Beans Pinto beansNavy beansLima beansVeggie-burgers soy,Edamame Soy milk if made from whole bean PistachiosCashews

Nuts: (limit to small handful per sitting) almonds, peanuts, pecans, walnuts, sunflower seeds TofuTempeh Canned and Drained:< ½ cup Chickpeas < ½ cup Lentils During Reintroduction phase use of Beano is recommended Soy milk made from Soy protein

Other items to considerFODMAPs Foods High in FODMAPs Sorbitol Sugar free chewing gum

Pepsi, Coke, other regular sodas

Sugared Chewing gum (chewing gum can add to gas) Pepsi Throwback (caution with carbonation as that can add to gas)

Reading Food Labels – Shopping tips• Look out for Inulin – this is added to many yogurts, cream cheese,

organic valley vanilla milk, rice milks• Organic Inulin exists

• Look out for High Fructose Corn Syrup: this is added to as a sweetner in beverages and as a browning agent in baked products.

• There is currently no organic sources of HFCS • Metamucil is 100% inulin. An alternative would be psyllium husk.

GF Is a good starting point as they are wheat free but make sure they don’t have apple, pear, honey or molasses

• Apple juice and pear juice are often added to GF products to sweeten them. Beware as apples and pears are high in sorbitol.

• Low polyol sweeteners are aspartame, stevia (some have added inulin), sugar (sucrose) and maple syrup. Onion powder and garlic powder – often added to salad dressings and broths. “Natural Flavoring” is often onion and garlic.

Ingredients to Avoid

Agave syrupApple juiceBrown rice syrup Bulgar wheat Chicory root extractCrystalline fructoseDry milk solidsFructo-oligosaccharides (FOS)FructoseFructose solidsFruit juice concentratesGarlicGlycerinHigh-fructose corn syrup HoneyHydrogenated starch hydrolysatesInulinIsomaltLactatolLactitolLactulose

MaltitolMannitol MisoMolassesOnionPear juicePolydextroseSorbitolTomato pasteWhey protein concentrate (unless lactose-free)Xylitol

Pointers during Elimination phase • Gluten-free is not always FODMAP friendly look for the inulin and High

Fructose corn syrup and honey , molasses and fruit juice sweetened. ? Guar gum.

• Unless the client has Celiac Disease the diet DOES NOT NEED TO BE GLUTEN FREE

• Green tops of leeks and green onion adds flavor without significant FODMAP

• There is no evidenced that FODMAP ingestion results in damage to the intestine

• Fiber is very important and often missing, If the have IBD-C be sure to add flaxseed, Chia and Citracel

• Even though Fat is not a FODMAP it can be a trigger• Even though Caffeine and carbonation are not FODMAP, they can be a

trigger.

Some suitable milk substitutes

Ingredients:Fat Free Soymilk (Water, Soy Protein)

Ingredients: water Osmosis reverse, soybeans(s) organic

Water Filtered, soybeans whole

Challenge Phase • 3 week trial of Strict Low-FODMAP• Continue for 6 to 8 weeks if significant symptom improvement• Map out a challenge that works for each client.

– If they don’t care• Trial of Lactose first, as lactaide can be used• Trial of GOS (raffinose) as Beano can help• Trial of fructose as glucose can be used to facilitate

absorption• Fructans are the hardest and in my personal experience

the least well tolerated.

IN MY OPINION: Biggest offenders

• Lactose: only if you are lactase deficient• Fructans: large amount so wheat, onion and garlic

avoiding wheat is probably why the SCD, Paleolithic and wheat belly are popular

• Fructose: High Fructose Corn Syrup, honey, mango, • Polyols: Sorbitol in sugar free gum and toothpaste,

apple and pears and products packed with apple and pear juice

Unanswered Questions• Long-term safety

– Nutritional adequacy of the diet– Effect on Microbiota (reduction of natural prebiotics)– Effect on colorectal carcinogenesis

• Effect on physiology of the bowel– Does it change visceral hypersensitivity

• Mechanisms of action in– Induction of fatigue– Increasing gastro-esophageal reflux

Final Thoughts The FODMAP diet is now viewed as evidence-based

first-line treatment strategy for patients with IBS.

- scientifically proven

- provides all the nutrients needed

- reduces symptoms of IBS in ¾ of IBS suffers

- won’t cure IBS but it does help to prevent trigger symptoms

- should be prescribed by a dietitian who is an expert

- there is high compliance to the diet – if diet is delivered well

When you need to seek additional Help

• Concerns about weight and or growth• Continued GI symptoms on a strict GFD• Persistently elevated celiac blood work

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Questions??

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Thank you