Therapeutic Elimination Diets Orientation

Culinary Nutrition ImmersionKathie Madonna Swift MS RDN LDN FAND

Co-Founder, IFN Academywww.IFNAcademy.com

Therapeutic Elimination Diets• Six Food Elimination Diet (SFED):

• Eosinophilic Esophagitis (EoE)

• Fermentable Oligosaccharides Disaccharides Monosaccharides Polyols (FODMAP) Diet: • IBS, IBD, SIBO

• Specific Carbohydrate Diet (SCD): • IBD, SIBO

• Ketogenic Diet: • Epilepsy, Neurodegenerative Conditions, Weight Loss…

EoE and Diet

• EoE: chronic inflammatory GI disease

• Symptoms: Trouble swallowing, food impaction, reflux, N/V, abdominal pain

• Currently available food allergy tests do not adequately predict food triggers for EoE especially in adults

• Elemental diet & Six food elimination diet (SFED) consistently have shown best cure rates (72% histologic remission meta-analysis)

EoE, Genetics & Endotypes

• EoE: complex interplay genetics, environmental risk factors, allergic sensitization and esophageal-specific pathways

• Genes identified with 3 EoE Endotypes: EoEe1, EoEe2, and EoEe3

• Framework for developing distinct predictive medicine and future therapeutic strategies (food elimination diets, PPIs, topical steroids)

Six Food Elimination Diet (SFED)

• Eliminates the most prevalent dietary allergens:• Cow’s milk• Soy• Wheat• Egg• Peanuts/tree nuts• Seafood and fish

Refer to T4M1 Clinical Toolkit for further resources

SFED GuidelinesFoods to Include:

Protein: chicken, beef, game meats, turkey, lamb, pork, beans, lentils, amino acid based formulas

Fruits & vegetables

Grains: rice, quinoa, millet, amaranth, buckwheat, GF oats, sorghum, teff

Oils: olive, sunflower, coconut, etc.

Most coffee and tea, non-dairy beverages

Step Up Approach• High level of restriction of SFED often a deterrent for

patients

• Novel step up strategy (1-2-4-6) enhance patient adherence and identify responders to diets with few food triggers

• Less restrictive approaches: • One food (milk)• Two food (milk, gluten)• Four food (milk, gluten, egg, legumes)

EoE app:

FODMAP• Fermentable (key word!)• Oligosaccharides

• Fructans• Galactans

• Di-saccharide: Lactose• Mono-saccharide: Fructose • And• Polyols (sugar alcohols)

• Sorbitol• Mannitol• Xylitol• Maltitol

FODMAP pathophysiology

Chumpitazi BP & Shulman RJ. Ann Nutr Metab. 2016;68(suppl 1):8-17 .

FODMAP & GI disorders

• Irritable bowel syndrome (IBS) – Strongest evidence

• Other emerging evidence:• Inflammatory bowel disease (IBD) • Small intestinal bacterial overgrowth (SIBO)• Exercise-induced GI symptoms• Diverticulitis prevention• Childhood functional abdominal pain

Gibson PR. Use of FODMAP diet in inflammatory bowel disease. J Gastroenterol Hepatol. 2017;32 (Suppl.1) 40-42.

Clinical Considerations• Subtypes: different effects in the gut

• Tailor diet based on subtypes and symptoms• IBS-D: Lactose, excess fructose & polyols, osmotic

effects• IBS-C: Fructans & GOS, fermentative effects

• When in doubt, do full FODMAP elimination diet IBS-M (alternating diarrhea and constipation)

FODMAP Phases• Restrict

• Temporarily restrict high FODMAP foods as part of comprehensive medical nutrition therapy

• Time period 2-6 weeks (may have results in few days)• Choose low FODMAP foods (In’s), Avoid high FODMAP foods (Outs)

• Re-challenge• Conduct systematic re-introduction following elimination to

determine individual response to:• Specific foods• Quantity of food (dose effect)

• Reintegrate: adapted low FODMAP diet for at least 2 months

www.drjockers.com

Monash University Low FODMAP App

• Guide: Food categories ( Fruit, Vegs, Dairy, etc.)

• Stop-light motif:• Green = low FODMAP• Yellow = moderate FODMAP• Red = High FODMAP

• Ratings consider portion size• Ex: large portion of Green food will be

listed as Yellow

• Filter for personal sensitivities

• Includes recipes, shopping list, weekly journal, updates, blog

www.monashfodmap.com

Swift SwapsFood Item Delete EatMilk Cow’s milk Hemp milk

Wheat flour All purpose wheat flour Gluten free flour blends

Soybean Soymilk, soft or silken tofu

Extra-firm tofu,tempeh, edamame

Legumes Broad beans Canned & drained lentils or chickpeas

Onion & garlic Garlic, onion, garlic and onion powders and salts

Green part of scallionsor leeks; onion/garlic infused oils; asafetida powder

How do I get enough fiber? • Fiber nourishes the gut microbes!

• Resistant starch has low osmotic activity, fermented slowly by gut bacteria (ex. cooked/cooled potato, rice)

• Many low FODMAP foods contain fiber: (portion sense) • Vegetables: Brussels sprouts, eggplant, broccoli, carrots

• Fruit: Banana, orange, blueberries, raspberry, strawberry, grapes, kiwi• Legumes: Lentils, firm tofu, chickpeas (soak, rinse, drain, soak, rinse,

drain)• Grains: Oat bran, buckwheat groats, millet, quinoa, rice• Nuts & Seeds: Most nuts and seeds in small portions are ok• Other: Psyllium (soluble fiber source)

How do I get more flavor in my low FODMAP diet?• Fresh herbs and spices (ginger,

peppermint, oregano, cinnamon, cumin, cilantro parsley, basil, rosemary, etc.)

• Apple cider vinegar, rice vinegar

• Miso

• Tamari

• Capers

• Mustards

• Worcestershire sauce

• Citrus zest

• FODMAP friendly salsas, tomato sauce, Tabasco sauce

• Vanilla bean

• Peanut butter

• Wasabi

• Oils: Sautee garlic and onions in oil for 1-2 minutes, remove and discard the garlic and onions –use the oil to flavor food

FODMAP Foods in the Marketplace

• Must read food labels of packaged foods

• Low FODMAP junk is still junk!

• Packaged low FODMAP foods now available

SIBO Update• SIBO is characterized by presence of excessive bacteria in the

small intestine and presence of particular species of bacteria in atypical locations in the small bowel

• No gold standard for the diagnosis of SIBO; clinical presentation + breath test

• Risk factors: reduced gastric acid production, deranged small bowel motility, altered bowel anatomy, impaired systemic and/or local immunity

• Important to identify and treat the underlying disorder causing SIBO

Adike A & DiBaiseJK. Small intestinal bacterial overgrowth: nutritional implications, diagnosis and management.Gastroenterol Clin N Am 47 (2018) 193–208.

Diet Therapy SIBO• Diet in management of SIBO poorly understood!

• Carbohydrate intolerance is common in SIBO, thus carbohydrate restriction may help• Lactose or Fructose intolerance/malabsorption• FODMAP diet has merit in patients with IBS with

SIBO• SCD diet and variations have been used

• Fat restriction if fat malabsorption evident

Specific Carbohydrate Diet (SCD)

• Designed to address inflammatory digestive disorders:• Ulcerative Colitis • Crohn’s Disease• Diverticulitis• Celiac Disease

• Allows certain carbohydrates (CHOs), monosaccharides, or simple sugars

• Excludes larger carbohydrate molecules such as di-, oligo-, and polysaccharides as they require extra digestion steps to break down

SCD GuidelinesFoods to Exclude:• All grains

• Sugars: lactose, sucrose, high-fructose corn syrup, fructose, molasses, maltose, isomaltose, fructooligosaccharides

• Certain vegetables: starchy vegetables such as potatoes, yams,; pickled vegetables (if they have added sugar or preservatives), canned vegetables

• Dried & canned fruits: if they contain added sugar or preservatives

• High lactose dairy: milk, processed cheeses, fresh cheeses (mozzarella, ricotta), ice cream, margarine, buttermilk

• Processed meats, poultry & fish: hot dogs, cold cuts, smoked meat/fish, canned meat

• Some legumes: soy, chickpeas, bean sprouts, black eyes beans, fava, garbanzo, pinto, canned beans

SCD Guidelines

Vegetables (except those listed to exclude)

Fresh & dried fruits (no added sugar or preservatives)

Unprocessed meat, poultry, fish, eggs

Homemade yogurt fermented at least 24 hours & low lactose cheeses

Oils: olive, coconut, grapeseed, etc.

Nuts: tree nuts, peanuts (no preservatives or added starches)

Some legumes: lima beans, white beans, lentils, split peas

Foods to Include

SIBO Specific Diet• Combination of SCD and FODMAP diet

• Created by Dr. Allison Siebecker (Naturopath)

• No RCTs on this dietary therapy

• Downloadable SIBO Specific Food Guide that is color coded• Green: least fermentable /SCD legal/low FODMAP• Light yellow: SCD legal/moderate FODMAP• Darker yellow: SCD legal/high FODMAP• Red: SCD illegal/more fermentable

Reference: siboinfo.com

Reference: siboinfo.com

Reference: siboinfo.com

Ketogenic Diet (KD): Timeline

• 1920’s: Treatment of epilepsy, then fell out of favor with advent of anticonvulsant pharmaceuticals

• 1970’s: Increase in popularity of VLCDs in numerous conditions due to Atkins diet

• Recent years: Standard of care for refractory epilepsy

• Growing interest in many conditions beyond epilepsy

Paoli A. et al. Eur J Clin Nutr 2013;67: 789-796

KD Description

• Very low carbohydrate, high fat, moderate protein• Reduction in carbohydrates (usually to < 50

grams/day) • Relative increase in fat and protein to meet

needs

Ketone Bodies• Fuel for brain when carbohydrate availability is limited

Keto Macronutrient BreakdownFAT 70-90%

PROTEIN To meet needs(.8-1.4 g/kg)

CARBOHYDRATE MinimizedNet carbs (Total Carb minus Fiber)Limited fruitLimited root veggies & tubersNo sugars, refined carbs

Low Carb Veggies• Asparagus

• Broccoli, broccoli rabe

• Brussels sprouts

• Celery

• Cauliflower

• Cabbage

• Cucumber

• Eggplant

• Fennel

• Green Beans

• Onions

• Mushrooms

• Peppers-red, green yellow, orange

• Spinach & other leafy greens

• Squash: yellow, zucchini

• Tomato

Ketodietapp.com

Keto Diet Recipes Galore!

www.Charliefoundation.org