A131 MALNUTRITION FOLLOWING IMPLEMENTATION OF A STRICT LOW FODMAP DIET FOR IBS

Abstract Background Low fermentable oligosaccharides, disaccharides, monosaccharides and polysaccharides, polyols (FODMAP) diet is an elimination diet recommended for the symptom management of irritable bowel syndrome (IBS). It involves reducing the amount of unabsorbed and fermentable carbohydrates in attempt to decrease osmotic overload and gas production. This diet may be deficient in calcium and carbohydrates and alter the gut microbiota, however, its long-term nutritional implications are unknown. Thus, the 2019 CAG Guidelines for management of IBS suggest its short-term use with dietician supervision. To our knowledge, no previous cases of malnutrition secondary to a low FODMAP diet have been reported. Aims We report of case of severe weight loss and laboratory evidence of malnutrition following a low FODMAP diet in a patient with IBS. Methods Data was obtained by chart review, patient interview and review of relevant literature. Results A 40-year-old otherwise healthy female presented to the outpatient gastroenterology clinic for assessment of IBS in fall of 2018. At that time, she had been moderately restricting FODMAPs for several months to reduce abdominal pain and bloating. After her initial clinic visit, she followed a strict low FODMAP diet for 1 month, followed by slow and gradual re-introduction of high FODMAP containing foods. This was self-implemented without the supervision of a dietician, using on-line resources. From fall of 2018 to early 2019, she lost 12 percent of her body weight secondary to dietary restriction. While there was some improvement in bloating and pain, she developed significant fatigue. Blood work prior to implementation of low FODMAPs diet was normal, including INR of 1.2, albumin of 45 g/L, neutrophil count 2.2 x 10E9/L, and alkaline phosphatase 31 U/L (30–110 U/L). In spring of 2019, 5 months after starting a low FODMAP diet, her INR was elevated at 1.4, neutrophils low at 1.6 x 10^9/L, alkaline phosphatase low at 32 U/L (35 U/L – 120 U/L), with normal albumin of 45 g/L. After consulting a hematology specialist, she was advised to resume adequate dietary intake. She slowly returned to her baseline diet, but excluded lactose, beans, fruit, eggs, nuts and oats. While she restored her body weight by Fall 2019, her gut symptoms returned, although had improved overall. Her lab work showed normal neutrophils of 2.7 x 10^9/L, INR 1.3, with unchanged albumin at 45g/L. Conclusions While these are indirect markers of nutritional adequacy, the timeline and associated weight loss are highly suggestive of dietary inadequacy secondary to FODMAP restriction. Serum albumin remained normal as FODMAP restriction does not affect dietary protein intake. This case exemplifies the danger of initiating extreme dietary restriction in self-management manner and stresses the need of dietician supervision of such a restrictive diet. Funding Agencies None

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