A Revolution in IBS Treatment
W hat do apples, multi-grain bread, cauliflower, yogurt, high-fiber breakfast cereals, and hummus have in common? These “healthy” foods all contain fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs), and they can trigger symptoms of irritable bowel syndrome (IBS). Ironically, for many years it was thought that foods like these would help everyone with IBS. And even today, many health-care providers still have not moved beyond traditional one-size-fits-all “fiber” therapy for IBS—if they give any dietary advice at all. If you are reading this book, it may not come as a surprise that high-fiber IBS therapy, beloved by doctors everywhere, doesn’t always (or even usually) work! If thirty-three IBS patients are told to eat more bran, only one of them is likely to report improvement of his or her symptoms over the next month. Clearly, we need to do better.
There is now proof that changing the types of sugars and fibers in your diet can help you achieve lasting relief from IBS symptoms. The FODMAP approach, developed in Australia and now used around the world, is increasingly recognized as the most effective way to manage IBS with diet. Up to 85 percent of patients report significant improvement of their IBS symptoms when they have followed a low-FODMAP diet. The 35 million Americans with IBS (about 11 percent of the population) are no longer left to their own devices, desperately looking for help with their symptoms. There is no longer any reason for doctors to stand by helplessly, to give the same old “high-fiber diet” advice or, worse yet, to tell patients that diet doesn’t matter.
When I wrote the first edition of IBS—Free at Last! in 2008, almost no one knew about FODMAPs outside of Australia; the challenge was to get the information to the IBS sufferers who needed it. Its publication coincided with exploding consumer interest in nutrition and non-drug therapies for IBS. Connected by social media and with ready access to published medical literature, people began to learn self-help strategies directly from each other, without regard to international boundaries and without the filter of what their health-care providers knew or chose to share with them. This meant that patients often learned about FODMAPs from the Internet, or from my book, before their doctors or dietitians did. We are witnessing a revolution, with nutrition emerging as first-line therapy for IBS, and it has been a patient-driven phenomenon.
Today, the challenge for many IBS sufferers is actually dealing with too much information (and misinformation!). Word spreads fast on the Internet, sometimes presented by people with a thin grasp of nutritional science. Pretty recipe pictures on Pinterest and lists of high- and low-FODMAP foods are not enough. To get the best outcome from a FODMAP elimination diet, you need a strategy and a plan. You need help in cutting through the confusion about FODMAPs and IBS, and in getting down to work. You deserve trustworthy guidance, and you can find it here. With this book, you can conduct a dietary experiment to learn how FODMAPs affect you by eating only low-FODMAP foods for a few weeks, then reintroducing high-FODMAP foods and monitoring your symptoms. You will learn which FODMAPs affect you and which ones don’t.
That’s what this book is. This revised and expanded version of IBS—Free at Last! is your guide to understanding the science of FODMAPs and finding your unique FODMAP fingerprint. And it offers fifty-six delicious recipes to get you started on your new pain-free lifestyle, as well as tips and plans for eating when you don’t have the time and resources to cook every meal from scratch.
You may wonder: Why are FODMAPs so complex? and Why do I need to learn so much in order to follow this diet? It’s because of where the FODMAP data come from; how they are affected by the natural variability of food; what the difference is between FODMAP data and FODMAP teaching tools, such as are included in this book; and how these different tools can be used, depending on where you are in the elimination phase of the program. There’s a lot of conflicting information online, so it’s good for you to have a little backstory before you embark on this journey.
FODMAP BACKGROUND
The FODMAP concept was created by researchers at Monash University in Australia, and this group continues to publish most of the available FODMAP food composition data—these published data tables are the primary sources for the program. An example of FODMAP data is: “There are 1.2 grams of sorbitol in 100 grams of an apple.” We can’t get too attached to such data, though. Different varieties of apples, different growing conditions, and different degrees of ripeness make each apple unique, and the same holds true for each type of fruit or vegetable, as well as for every batch of grain or loaf of bread.
Most people do not have the time, interest, or know-how to plan a low-FODMAP diet directly from the data tables published in the medical journals. So health-care professionals and educators create tools to communicate this information to patients and readers. At the heart of each tool is a list of low-FODMAP foods. For example, I developed the tools in this book—the Low-FODMAP Pantry (this page ) and the label reading tips on this page —based on the available data about the FODMAP content of foods at the time of publication. I built my unique approach to the data on the way people actually eat and live—a methodology that has made it possible for my patients to stick with the diet and reap its benefits.
Tool creators make decisions about which foods to include on a low-FODMAP diet based on cut-offs they have determined for what is considered a “high-FODMAP” food. There are no scientifically proven rules for determining these cut-offs or deciding what the food portions should be. Each tool creator or project team decides these things independently. They filter the FODMAP data through their different lenses; that’s okay, because different tools can help different people. That’s also why you can expect some minor variations in the FODMAP tools and corresponding recipes. Don’t worry; these few minor discrepancies won’t diminish the overall impact of lowering the FODMAP load of your diet.
In this book, I’ve determined whether a food is low in FODMAPs based on standard serving sizes, such as ½ cup of vegetables. I made this decision, which admittedly errs on the side of oversimplification, so this complex and technical diet is easier to learn and easier for you to remember. Another developer’s FODMAP tool might shrink the vegetable servings to as small as necessary to give those foods a green light. For example, in my program, Brussels sprouts are not suitable for the elimination phase of the program because ½ cup contains too many FODMAPs. However, in the Monash University Low FODMAP Diet app, which uses a traffic light system, a serving of two Brussels sprouts gets that green light.
Conflicts can also arise when the context is fuzzy. For example, if you searched the Internet to answer the question “Can I eat Greek yogurt on a low-FODMAP diet?,” you would get a variety of answers. So, you need to be clear whether you are following a strict elimination/reintroduction program or are eating a relatively low-lactose diet after completing the reintroduction phase. Now, let’s answer your question: No, Greek yogurt is not recommended during the elimination phase of this program because it contains several grams of lactose per serving. Yes, it is a good choice for a relatively low-FODMAP diet because it is lower in lactose than other yogurts. So, as you see, both responses are true. Greek yogurt may be a perfectly good choice after the reintroduction phase—if you’ve found you can tolerate several grams of lactose at once. You will need to remind yourself of where you are in your program as you review such confusing or seemingly contradictory information.
Likewise, if you are comparing two tools created by the same person, keep in mind that the food lists with later publication dates are likely the more accurate ones. As more primary data is published, the FODMAP status or recommended portion sizes may change. For instance, the food lists in this book are more up to date than those in my previous books.
As you can see, learning about FODMAPs means also learning to live with some uncertainty about the suitability of the foods for your diet. The inevitable discrepancies can cause a little anxiety about whether you are “doing it right.” Don’t let those worries distract you from the big picture. Even with some uncertainty, substantially lowering your overall FODMAP intake will help you decide whether FODMAPs are impacting your IBS symptoms, and if that’s the case, you will be able to manage these symptoms more effectively.
Before moving on, let me tell you a little about myself and what I do. I regularly advise consumers to “consider the source” when evaluating any information about IBS and FODMAPs, so it is only fair that I invite you into my point of view. To begin, know that I share your history of miserable gastrointestinal (GI) symptoms. I have been in your shoes, trying to practice what I know about the science of nutrition in my grocery cart, in my kitchen, and for my body. When we’re not feeling well, we don’t have the time or the energy to read dozens of research papers and figure everything out from scratch. I’ve found out that it is all well and good to know what not to eat, but in our everyday lives we need to know what we can eat.
I am a registered dietitian nutritionist with two degrees in nutrition, from Cornell University and Boston University, and have experience as a research dietitian and nutrient database manager at Tufts New England Medical Center. As a medical nutrition therapist with a focus on digestive health, I see patients three days a week in Portland, Maine. I spend the rest of my work time teaching or attending scientific events, as well as reading and writing about FODMAPs. I rely on peer-reviewed, published primary sources for my data, but I use my own ideas to create tools such as menus, label reading tips, recipes, and shopping lists for my patients. I wrote this book to share these tools with you.
My own interest in digestive health goes back to when I was a 22-year-old dietetic intern at Beth Israel Hospital in Boston. I presented my first case study on a patient, whose name and face I still recall, with ulcerative colitis. As I studied and wrote about the diagnosis and treatment of bowel disorders, little did I know that I, too, was about to be diagnosed with ulcerative colitis. As a patient, I have had both good years and bad. Indeed, I have had enough bad years to deeply empathize with my patients who suffer from painful and disabling GI symptoms. These symptoms take a huge emotional toll.
I feel hesitant, even now, to talk briefly about my own challenges and health problems. How will readers react? Will my symptoms and special dietary needs be taken seriously? Will people think it is all in my head? After all, I look healthy enough. It can be hard to get past the stereotypes and judgment that IBS sufferers endure every day. People with gastrointestinal problems all too often suffer in silence because of social stigma or because they’ve been told they just have to learn to live with their symptoms.
Many of my patients tell me they have felt isolated by their IBS. I hope this book will offer you the comfort of knowing that you do not have to face your problems alone. I understand how embarrassing it can be to discuss your symptoms, even with a physician, family members, or close friends. I have experienced many of those same awkward moments and difficult social situations, so I can appreciate why reading a book like this about diet and IBS is a discreet way to get some help.
Since 2009, when IBS—Free at Last! first appeared, I have interacted with thousands of patients and readers. One thing is clear: citizens of today’s world are passionate about their food. People identify strongly with their food philosophies. In the past, with limited interaction and travel outside the local community, people had little choice but to eat like their neighbors. Today, with food and health information streaming to and from almost every corner of the world, food trends emerge quickly and circulate widely within days.
I want to make sure you understand my point of view, so you can decide whether this is the right book for you. I believe that humans are biologically omnivores and that anything edible is fair game as food. At this time in history, many of us choose to limit our intake of certain foods for social, ethical, health, environmental, or religious reasons, and I respect that. Some of my clients prefer to eat gluten-free, vegan, paleo, non-GMO, or organic, while others are more interested in eating affordable, convenient food. My job as a dietitian is to encourage each person to work within his or her own preferences so as to eat a wide variety of nutritious, well-tolerated foods. I hesitate to call a low-FODMAP diet a “lifestyle,” since it does not come attached to any particular set of values, except that it should be approached experimentally—to see what works and what doesn’t work for you. All this is to say that the recipes in this book are all low in FODMAPs, and they are made from a wide variety of whole, real foods. The rest of your food philosophy is up to you.
HOW TO USE THIS BOOK
The IBS Elimination Diet and Cookbook is written primarily for lay people, although it is also a resource for medical practitioners. I have done my best to translate the latest research into terms that anyone can understand. Most readers will benefit from reading the next few pages to get acquainted with the vocabulary and the ideas behind the diet.
Part 1 (“IBS and FODMAP Basics”) provides a description of IBS symptoms, describes the FODMAP elimination phase, and gives some useful general information on the program. Part 2 (“The Two-Phase Program”) is an eight-step program of the two phases—elimination and reintroduction—with the latter offering three approaches to that reintroduction of FODMAP foods, ranging from the most aggressive to the gentlest. You can pick and choose, depending on your personality and the severity of your symptoms. You should first work your way through Part 1 , so as to learn about the diet and determine if it’s right for you; but if time is short and you already have a firm diagnosis of IBS, it is possible to skip that and jump directly into Part 2 . Steps 1 through 5 will help you begin eliminating FODMAPs from your diet; that’s the elimination phase. It is here you will find menus, shopping tips, and lists of suitable foods. There are also tips on monitoring your symptoms. Then, in Steps 6 through 8, you are led through the process of reintroducing FODMAPs, a very important part of the program. Please don’t miss this important point: the FODMAP elimination phase is a temporary learning diet; it is not meant to be a permanent lifestyle. At its completion, you need to reintroduce nutritious, high-FODMAP foods and eat as much of them as you can tolerate for your long-term diet. Finally, the program offers a way to evaluate your results, and it addresses many common questions about the program.
I’ve collected some of my favorite recipes for you to enjoy in Part 3 (“The Recipes”). Although you aren’t required to do a great deal of elaborate cooking to follow the diet, I find my patients enjoy themselves more when their low-FODMAP food tastes great and when I’ve made it easy for them by modifying their favorite recipes. Each recipe in this book is suitable for the elimination phase, as well as for maintenance of a low-FODMAP diet, with an emphasis on homemade alternatives for commercially prepared foods that usually contain FODMAPs, such as salad dressings, sauces, and soups. You’ll be able to prepare low-FODMAP food that tastes so good, no one will know you are on a special diet.
You can think of Part 4 (“The Details”) of the book as the fine print. Those with an interest in understanding the science behind the program can learn even more about FODMAPs and IBS.
THE NUTSHELL VERSION OF THE PROGRAM
Here is a step-by-step method for liberating yourself from IBS symptoms triggered by certain dietary carbohydrates, known as FODMAPs. First, you eliminate all high-FODMAP foods. Indeed, if this diet is going to help you, you should start to feel better right away, typically within two weeks. Next, you add back one type of FODMAP at a time, in a systematic way. By paying attention to your symptoms, you will learn which foods were triggers for your IBS, so that you can limit or avoid them.
FODMAP is the acronym for F ermentable O ligo-, D i-, and M onosaccharides A nd P olyols. The FODMAP concept was originated by researchers at Box Hill Hospital and Monash University in Australia, including dietitians Susan J. Shepherd, Jacqueline S. Barrett, Peter R. Gibson, and Jane G. Muir. The Monash group continues to publish most of the emerging data on FODMAP food composition.
Don’t let this awkward term scare you, though! Here are the important parts: FODMAPs include certain natural sugars in foods such as milk, fruit, honey, and high-fructose corn syrup. FODMAPs also include certain fibers in foods such as wheat, onions, garlic, and beans.
All FODMAPs have a few things in common:
• They may be poorly absorbed in the small intestine. As the hours go by after a meal, these carbohydrates linger in the intestines.
• They are the favorite foods of the bacteria that live in your gut. When bacteria eat FODMAPs, they produce gas.
• FODMAPs can act like a sponge to draw and hold excess fluid in the intestines.
Imagine this combination of gas and fluid causing the intestines to swell up like a water balloon. For people with IBS, this can trigger a bout of IBS symptoms. This book presents a complete program for analyzing whether this scenario is contributing to your IBS symptoms and will help you relieve those symptoms. It involves the following eight steps:
1. Get ready: Educate yourself about FODMAPs and consult your physician and dietitian.
2. Record your baseline symptoms.
3. Plan your diet and go shopping.
4. Eliminate high-FODMAP foods from your diet.
5. Monitor your symptoms and compare them to your baseline.
6. Reintroduce FODMAPs and monitor your symptoms.
7. Evaluate your results.
8. Enjoy the most liberal and varied diet you can tolerate.
Given that so many foods contain FODMAPs, you may be a little worried about the elimination phase of the program—is there anything left to eat? Take a peek at the menus in Step 3 (this page ) and the Low-FODMAP Pantry in Step 4 (this page ). You may be pleasantly surprised to find there are plenty of tasty foods that you can eat during this phase. And remember—this is a short dietary experiment, not a permanent diet.
The biggest advantage of using this program is the dramatic effect it often has on IBS symptoms. My patients, understandably, want to feel better immediately. They have tried ineffective diet changes for years and are impatient for results. They want to know within a week or two whether the FODMAP approach will finally be the answer for them. And my patients aren’t alone. Studies show that, on average, IBS sufferers would be willing to sacrifice ten to fifteen years of their lives for an immediate cure. So, if you can give just a few weeks of careful attention to this program, you will learn how your body responds to the change in diet. How much better will you be feeling two weeks from today—50 percent better? 75 percent better? 100 percent better?
This program is not meant to be a substitute for appropriate medical nutrition care. Please share the information in the book with your physician or a registered dietitian, and ask for help, particularly if you have other health problems in addition to IBS. You and your dietitian may need to modify the food lists to make them medically appropriate for you.
IBS—DO YOU HAVE IT?
A person with IBS has a digestive system that does not function properly, even though nothing appears to be medically wrong. People with IBS may experience some of the following symptoms:
• Bloating (abdominal fullness, pressure, or a sensation of trapped gas—not to be confused with excess belly fat)
• Distention (bouts of measurable increase in girth—can be seen on the outside)
• Excess gas (wind)
• Diarrhea (loose, watery, or frequent bowel movements)
• Constipation (hard, dry, or infrequent bowel movements)
• Alternating diarrhea and constipation
IBS can be referred to as IBS-C (constipation predominant), IBS-D (diarrhea predominant), or IBS-M ( mixed bowel pattern).
It is normal to have some variation in the frequency and form of your stools, depending on what you have eaten. For example, people eating a plant-based diet will tend to have more frequent, softer stools than people eating meat. This is not a medical problem; it is normal human physiology. It is also normal to pass gas frequently—from seven to twenty-two times per day. The “numbers” don’t tell the whole story, obviously. The impact that IBS symptoms have on your social, work, and school lives matter far more.
For some people, IBS is merely a nuisance. For others, it’s not “just IBS,” especially if accompanied by depression, anxiety, fatigue, or poor sleep. At its worst, IBS can take over a person’s life, jeopardizing relationships, jobs, and quality of life. It’s expensive, too. In addition to missing an average of two days a month from work (and being affected by IBS on another nine days per month of work or school), people with IBS spend lots of money on doctor’s appointments, tests and procedures, emergency department visits, and medications. In fact, IBS is the seventh most common diagnosis in primary care, affecting 35 million Americans, and is the most common diagnosis made by gastroenterologists.
Although IBS research is an active area in medicine today, we still do not fully understand what causes it. Over the years, the scientific view of IBS has evolved, and it will probably continue to do so. At the present time, it seems likely that the symptoms can arise from various combinations of the following factors:
• Poor coordination or spasms of the intestinal muscles as they move food through the digestive system.
• Heightened pain when excess gas or fluid builds up in the intestines; we call this visceral hypersensitivity.
• Miscommunication between the gut and the brain; stress may play a role here in ways that are unclear at this time.
• Low-grade inflammation or auto-immunity.
• Imbalance in the gut microbiome, perhaps following a bout of food poisoning or a bad stomach bug. (“Gut microbiome” is the term used to refer to the community of microbes—bacteria, yeasts, and archaea—that live in the human digestive tract. Each person’s gut microbiome is as unique as a fingerprint.)
Thankfully, the low-FODMAP diet can help people with all kinds of IBS in a meaningful way. Do you have IBS because you’ve been eating the wrong diet? Not likely. However, finding the diet that’s right for you can help you enjoy food again, and can put you in control of your bathroom habits. Until scientists learn more about the root causes of IBS, those are important objectives.
Diagnosing IBS
If you experience symptoms suggestive of IBS, seek a thorough medical evaluation. Your health-care provider will consider the pattern of your symptoms and compare them to established criteria for digestive diseases and disorders. He or she will take your medical and family history, physical examination, and test results into account. In younger patients without any of the following so-called alarm symptoms, an office visit may be enough to diagnose IBS. If you do have one or more of these symptoms, which might indicate another potential diagnosis needs to be ruled out, your doctor might have to refer you to a gastroenterologist. If you are a female, especially over the age of 40, be sure that your workup includes a visit to a gynecologist. Bloating and abdominal pain are not always related to the digestive system; problems with your reproductive or urinary systems should also be ruled out. A pelvic floor evaluation might be in order for some patients as well, to uncover any issues with poor coordination of nerves and muscles affecting your bowels.
Here are the IBS alarm symptoms:
• An urge to move your bowels that wakes you from sleep
• Onset over the age 50
In addition, any of the following might influence your health-care provider’s evaluation:
• Anal or rectal problems such as abscesses, skin tags, fissures, or hemorrhoids
• Aching joints or inflammatory arthritis
• Poor growth (in children) or failure to thrive
• Family history of Crohn’s disease, ulcerative colitis, celiac disease, or ovarian cancer
Be sure to let your doctor know if you have a history of food poisoning, infectious gastroenteritis, intestinal surgery, gastroparesis, long-term opioid use, short bowel syndrome, small bowel obstruction, Crohn’s disease, liver disease, peripheral neuropathy, scleroderma, radiation enteropathy, hypothyroidism, pancreatitis or pancreatic insufficiency, celiac disease with poor response to gluten-free diet, or diverticulosis.
Even if you have suffered with gas, bloating, abdominal pain, diarrhea, or constipation for years, now is the time to put these symptoms back on the examination table; many new treatment approaches have been developed in the past few years, including probiotics and new medications in addition to special diets. No one should settle for living with IBS without having had a proper evaluation and a chance to try these new therapies.
Tips for Talking with Your Doctor
You might decide to make a special appointment for an IBS evaluation, especially if your symptoms are new, or you might want to bring them up at your next scheduled checkup. How can you make the most of your doctor’s appointment?
• When you schedule your appointment, don’t be shy about the reason for your visit. Clearly state your “primary complaint.” Your provider will put your primary complaint at the top of the list for discussion during your visit. If you aren’t sure how to communicate this to the scheduler without a lot of uncomfortable potty talk, you could try “change in bowel habits” or “abdominal pain.” Even “GI issues” is better than nothing.
• As good as you may be at Internet research, for your own sake, do not self-diagnose. You want your provider to evaluate your symptoms and your clinical history using all his or her diagnostic skills and experience, not just to note “history of IBS” in your chart.
• Use collaborative language. “I’d like to be more certain it isn’t celiac disease before I start changing my diet—how could we rule that out? I’m concerned about it because of my unexplained anemia and because it runs in my family.” This approach works better than either requesting tests with no context (especially by phone or email) or expressing worry that you might have this-or-that disease, which the doctor may dismiss as anxiety. The “rule out” idea is important in the practice of medicine, and your doctor will find that language easy to relate to.
• Make a list of your symptoms and bring it to your appointment. When did they start? Are they constant or do they occur in bouts? What seems to bring them on? What seems to relieve them? Are there any lab tests or procedure results you’ve had elsewhere that you can provide copies of, preferably ahead of time by mail or fax?
• It is perfectly okay for you to bring up the subject of a referral to a specialist. Try some of the following phrases: “Do my symptoms warrant referral to a gastroenterologist for evaluation? Why or why not?”; “I’ve been thinking I’d like to see a nutritionist for help with my IBS. Can you suggest a registered dietitian who works with IBS patients?” Depending on your insurance and local medical customs, you may be able to self-refer to a gastroenterologist or registered dietitian, but even then your specialist will probably request a clinical summary of some sort from your primary care doctor before seeing you. You can easily arrange this by calling your provider’s medical assistant or the medical records department of your primary care practice.
Change Your Carbs, Change Your Life
If you have been diagnosed with IBS, is it worth a few weeks of dietary experimentation to find a solution to the eternal stomachache and the bowel problems that prompted you to pick up this book? Only you can answer this question; I do know that many readers will find it life changing. For example,
I have battled IBS all my life. During my 30s the pain and bloating increased. I worked frantically with diet and exercise to combat my symptoms, but in my 40s, this problem took over my everyday existence. The more I learned about diet and colon health, the more FODMAPs I consumed. In fact, right before reading your book, I was up to eating five apples a day. I also ate tons of onions, garlic, and tomato sauces, never suspecting they could be causing problems. I would often start my day with fruit smoothies.
Today, my symptoms are 95 percent gone! (Most days 100 percent gone!) That remaining 5 percent is truly nothing, and only there when I cheat a little. This is a miracle! I can’t tell you how many prayers I prayed. I can’t tell you how many days and evenings I spent on the couch or bed with a heating pad on my tummy. I also can’t tell you the enormous amount of time, energy, and money I have spent trying to help myself. I have bought and tried every product that has crossed my path. I have bought so many books! I have tried many, many diets. My dear husband has endured years and years of all of this! I thank you for making my life IBS-FREE! —B. R.
I’ll be the first to admit that a FODMAP elimination diet isn’t easy. But if you are one of the three out of four people who get relief from IBS symptoms on this diet, I think you’ll agree with B. R. that it is absolutely worth it. Even people who have gotten less miraculous results from the program appreciate understanding more about how FODMAPs affect them, as this Amazon reviewer of IBS—Free at Last! , second edition, noted:
What I found was amazing! Foods that I thought were upsetting me were actually fine and other foods that I thought were okay were not. Also, I was relieved to discover that I was not as sensitive to as many foods as I had thought. In fact, after doing the elimination diet I was able to eat MORE things.
This program provides a game plan for changing your diet and, it is hoped, changing your life. I’ve translated the facts about FODMAPs into these tools that you can use to plan, shop for, and prepare meals so that you ultimately get the best possible outcome.
Shouldn’t I be having have malabsorption breath tests done?
Malabsorption breath tests (for lactose, fructose, mannitol, or sorbitol) will not help your doctor decide whether or not you have IBS. To some extent, malabsorption of sugars is quite normal, and many people who don’t completely absorb them do not have IBS or have IBS-like symptoms after ingesting them.
Early FODMAP-IBS studies looked only at study subjects who had a diagnosis of IBS and were fructose malabsorbers. One recent study in the U.K. found that fructose malabsorption as diagnosed with a breath test helped to predict which patients would do well on a low-FODMAP diet. However, at the same time there is trend in research telling us that symptoms of intolerance can occur for some people, even when sugars are completely absorbed. Since even patients who do not have fructose malabsorption can and do respond to a low-FODMAP diet, I almost always ask my patients to eliminate foods containing large amounts of fructose, along with lactose, mannitol, and sorbitol, during the FODMAP elimination phase regardless of whether they have had breath tests, and I rarely request malabsorption testing for patients before starting the diet.
My doctor says diet doesn’t matter with IBS and I can eat anything I want. Why would she say such a thing?
Patients often report hearing variations of this as they wake up, groggy, from their colonoscopies. To be fair, at this moment, the doctor is feeling pleased that he or she does not have to report any dire findings to you. She’s thinking, “Thank goodness it’s not cancer.” Knowing that a varied diet is important, your doctor may not want you to limit your diet unnecessarily or to follow a questionable fad diet. If you are underweight, she may just want you to eat, period. I like to think of it as a well-meaning but imprecise way to say, “There is no one-size-fits-all diet for IBS.”
As a nutritionist, of course, I strongly believe that what we eat does matter. It seems obvious that the gastrointestinal tract would be affected by the food that goes through it. Nutrients are not merely building blocks for body tissues; they also act as chemical messengers to every cell in our bodies. In addition to feeding us, they feed our commensal gut microbes. IBS patients rarely have to be convinced that what they eat matters; they have known this for a long time.
If I could put words in the doctor’s mouth, I would suggest something like this: “It’s important to eat the most varied diet possible. However, some people with IBS find that certain foods set off their symptoms. Your job is to work out which foods will nourish your body, yet keep your symptoms to a minimum.” While I am entertaining this little fantasy, let me go one step further. Next, the doctor will say, “I’d like to refer you to a registered dietitian to help you sort this out.” While a growing number of gastroenterologists are already working closely with dietitians to get the best IBS outcomes for their patients, you don’t have to wait for the doctor to suggest a referral. You can ask your primary care doctor or specialist to recommend someone, or you can just contact a registered dietitian directly to make an appointment.
Isn’t “ visceral hypersensitivity” just a fancy way of saying it’s all in your head?
Some people experience normal sensations arising from the digestive process as painful; this is known as “visceral hypersensitivity.” Differences in pain perception probably involve serotonin and other neurotransmitters, hormones, and substances produced by gut bacteria. Psychological factors such as anxiety, past trauma, and feedback we get from others about our pain play a role, too. At first this might sound like a variation of “It’s all in your head,” but the psychological factors interact with very real physical and biochemical differences.
To imagine how people might experience the exact same conditions in physically different ways, picture being inside on a cold winter day, with the heat on and the family gathered around for a holiday party. The temperature throughout the room is an even 68 degrees, yet the party-goers experience it differently. Most of them are comfortable in their party clothes, but Grandma is wearing her long underwear and a wool sweater, and she still wants to turn up the heat. Her fingers are white, her nail beds are turning blue, and she is shivering—she really is cold! Auntie has to step outside and strip off a couple of layers because she’s having a hot flash—she is visibly red-faced and perspiring; when she comes back inside she wants to crack a window for some fresh air. Meanwhile, the toddlers are running about happily in bare feet and nothing but diapers and undershirts. No one would deny that shivering Grandma is really feeling cold, or that Auntie is really feeling hot. And no one should argue that what IBS sufferers feel is not real, although their nervous systems are certainly involved.
I keep hearing about “ gut dysbiosis.” What is that?
Some people have an imbalance in the community of microbes that live in their guts; this is known as gut dysbiosis. The imbalance could be in the type, diversity, or amount of gut bacteria, yeast, or archaea. We are in the early stages of understanding how the gut microbiome affects every aspect of human health, including what a healthy gut microbiome looks like. In IBS, we are especially interested in how gut dysbiosis might affect intestinal inflammation, permeability, motility, pain perception, and more.
FODMAPS—THE BIG PICTURE
By now you know that FODMAP stands for fermentable olig-, di- and monosaccharides and polyols, and that FODMAPs have several things in common.
• They are carbohydrates (not all carbohydrates, only a subgroup of certain sugars and certain fibers in food).
• They can be poorly absorbed during the digestive process.
• They are rapidly fermented by the bacteria that live in your gut, a normal process that produces gas.
• They are capable of pulling fluid into the gut in a process called osmosis .
Specific examples of FODMAPs include:
• Lactose (also known as milk sugar; found in milk, yogurt, and ice cream)
• Fructose (also known as fruit sugar; found in fruit, high-fructose corn syrup, honey, and agave syrup)
• Sorbitol and mannitol (also known as sugar alcohols or polyols; found in certain fruits and vegetables, as well as some types of sugar-free foods and supplements)
• Oligosaccharides, including galacto-oligosaccharides (GOS) and fructans (types of fiber found in wheat, onions, garlic, chicory root, beans, hummus, and soy milk)
If you eat more FODMAPs than you can handle, the increased fluid load, the gas produced, or both can cause the intestines to expand (picture a water balloon), leading to bouts of symptoms in people with IBS.
High-FODMAP foods are not necessarily “bad foods”—in fact, many of them are excellent sources of nutrition, and they taste great, too. For people with IBS, they can be just too much of a good thing, while people with normally functioning guts can handle some extra fluid and gas in the intestines without blinking—in fact, malabsorption, fermentation, and osmosis are normal parts of human digestion. Fermentation actually produces some substances that are valuable to our health. The intention of the FODMAP elimination and challenge process is not to completely stamp out fermentation but, rather, to eat foods that are fermented at a slower rate, and keep it at a manageable level.
Seeing the Forest Instead of the Trees
When the term FODMAP was coined by the team of researchers at Monash University’s Department of Gastroenterology, they recognized this group of carbohydrates as having things in common and that they had a cumulative effect on IBS patients. Researchers found that by reducing the overall dietary load of high-FODMAP foods, troublesome GI symptoms could be dramatically minimized or eliminated.
Because all kinds of FODMAPs get tossed into the same “bucket”—your intestines—it can be difficult to figure out what is causing a problem without looking at the big picture and taking all the FODMAPs into account. In addition, the effects are “dose dependent”; that is, the more FODMAPs you eat in one meal or one day, the worse your symptoms are likely to be. The offending load of FODMAPs may be from a large quantity of one food or from smaller amounts of several different foods added together over the same period of time—all FODMAP-containing foods in the meal or day matter, not just foods in your most recent snack or meal. Readers tell me that the bucket analogy, which I’ve continued using since my first book in 2008, really helps them understand why the big picture is so important.
The delay between the time you eat FODMAPs and the time you experience symptoms also must be figured into your detective work. The lactose and fructose in your breakfast smoothie may just be hitting your large intestine around lunchtime, promoting gas and bloating throughout your abdominal cavity. The resulting pressure inside your abdomen might become painful as your stomach expands to contain your lunch. You might wonder what you ate for lunch that caused a stomachache, but you’d be looking for the problem in the wrong meal.
It also helps explain why you may be able to get away with eating something like ice cream one day but not another. On the “bad” day, you may have eaten a lot of other FODMAPs without recognizing it. For instance, you may have had a high-fiber breakfast cereal and milk at home; a latte on the way to work; an apple and a fiber bar for a snack; a sandwich, yogurt, and fruit for lunch; and garlic, mushroom, and onion pizza for dinner, with ice cream for dessert. That ice cream you had for dessert takes the rap, although it may have been merely the last straw before that bellyache really settled in.
For these reasons, food intolerances often do not always follow predictable cause-and-effect patterns. Many of my patients have tried for years to figure out what foods were bothering them, but simple food and symptom diaries aren’t helpful in such complex situations. It can be very difficult to identify trigger foods for IBS without a strategy and a plan, such as the one in this program, which will solve these problems when it is followed closely.
What Is the FODMAP Elimination Diet?
A FODMAP elimination diet is a process , not a list of high- and low-FODMAP foods. It is a “learning diet” with a strategy and a plan. Monitoring your symptoms throughout this multistage process will help you learn whether your symptoms are related to FODMAPs and to what degree they affect you. The ultimate goal is for you to eat the most varied and nutritious diet you can tolerate, not to restrict your diet with one-size-fits-all rules.
At the beginning, if you are a good candidate for the diet, you are advised to severely limit all the high-FODMAP foods in your diet. The elimination phase, described in Steps 3 and 4, is the most restrictive. This elimination phase typically produces fast, often dramatic results. If FODMAPs are triggers, then your IBS symptoms should improve quickly—usually within two weeks and sometimes almost immediately. You might feel so good that you aren’t in a hurry to reintroduce the foods. Or, in contrast, you may be eager to return to your usual way of eating. In either case, soon it will be time to reintroduce FODMAPs. In the reintroduction phase, you will reintroduce FODMAPs, one type at a time, in a controlled manner. In this way, you will learn which FODMAPs you can tolerate and in what amounts.
If you choose to, you can march through the reintroduction phase in six weeks or so. Alternatively, you can stretch it out over as much time as you and your health-care team feel you need, as long as you are regularly attempting to liberalize your diet. At the end of the reintroduction phase, you will have the information you need to choose the most nutritious and liberal diet you can tolerate.
Possible Outcomes of the Program
The most important outcome of this program is to learn how your body responds to the food you eat. You will discover whether your symptoms are related to consuming high-FODMAP foods and beverages—or not. (Most readers find that FODMAPs are indeed the triggers for their IBS symptoms.) You will also learn which FODMAPs bother you the most and how much of each FODMAP you can tolerate.
Consider a few typical results:
• You may find that only one or two FODMAPs are responsible for most of your symptoms. Lactose intolerance is the most common example of this. Many people are unaware that they are lactose intolerant; even some who know still seriously underestimate the effect even small amounts of lactose can have on their well-being. While it may be true that some people who are lactose intolerant can handle a latte or an ice cream now and then, others cannot. It’s harder than it might seem to figure out whether you are lactose intolerant, owing to delayed symptoms and “interference” from FODMAPs contributed by other foods. This program will help you isolate the variables to figure this out.
• You may find that you can tolerate any type of FODMAP as long as you don’t overdo it. Although it can be a challenge to learn how to budget your intake across all FODMAP groups, this is a great result, because it means you can continue to eat a varied diet in moderation. One of my patients said, “I choose the ‘FODMAP of the day,’ and take it easy on the others. I do fine as long as I don’t stack them on top of each other.”
• Most people can find ways to have priority high-FODMAP foods in moderation. For example, if you discover that fructose is a trigger for you, but apples are your favorite fruit, you can choose how to handle it: eat smaller apples, eat just a few slices, eat them less often, or avoid other FODMAPs at the same meal—or go for the gusto and endure the resulting bellyache.
• You might find out that you have a difficult time tolerating a large amount of any and all FODMAPs. If this is the case, you may choose to follow a low-FODMAP diet for a while or a moderately low-FODMAP diet for a longer period of time. While this situation is less than ideal, you can eat as wide a variety of low-FODMAP foods as possible, and consult a nutrition professional to address any potential nutrient shortcomings in your diet.
The Benefits and Risks of a Low-FODMAP Diet
The benefits of managing your gastrointestinal symptoms with a food-based system are many, indeed. Improved quality of life is at the top of that list. Understanding how FODMAPs affect your body gives you huge control over your symptoms—your life will no longer revolve around your IBS. As you gain confidence, you can dare to plan activities without immediate access to a toilet. The absence of bloating and abdominal pain will allow you to focus on your work and your relationships more fully. You’ll save lots of money on health-care bills, ineffective remedies, and even unnecessary surgeries. You’ll need fewer expensive prescription drugs. And you may well be able to improve the quality of your diet once you discover which healthy foods you can tolerate.
However, the FODMAP elimination phase has some potential risks. To begin, nutrient intake is affected by the diet. That isn’t always a bad thing, though; for example, people on low-FODMAP diets eat less sugar. But there is also the potential for a negative impact on nutrient intake. This is neither unique to a low-FODMAP diet nor inevitable; a well-planned and varied low-FODMAP diet can provide plenty of nutrients. Inadequate nutrient intake is more likely a problem when people have limited their diets in other ways, in other ways, such as being dairy-free or vegan, or having numerous food sensitivities. For example, calcium intake can suffer if someone chooses to reduce FODMAPs by cutting out milk products instead of switching to lactose-free milk products.
An important potential risk is that a low-FODMAP diet can affect prebiotic intake. Prebiotics are food for the good bacteria in our colons, and decreasing their food supply might reduce the bacterial production of substances believed to promote digestive health, such as short-chain fatty acids (SCFAs).
It is still unknown whether reducing one’s FODMAP intake has any persistent effects on the production of beneficial SCFAs or any long-term risks. If you and your health-care provider judge that these possible risks outweigh the benefits of the diet, you could certainly decide to hold off trying a low-FODMAP diet until these questions have been fully answered. But that may not be a satisfactory plan when you are feeling miserable today.
Here’s my advice to help minimize potential risks:
1. Carefully work through the section “Is a FODMAP Elimination Diet Right for You?” that follows. Don’t follow the diet if you do not have IBS or cannot follow a restricted diet safely.
2. Eat a wide variety of low-FODMAP foods to get a wide variety of nutrients.
3. Don’t follow the elimination phase of the diet for more than four weeks unless directed to do so by your health-care provider. If a low-FODMAP diet doesn’t help your IBS symptoms, stop following it. Don’t limit your diet any more than you have to.
4. Understand that it is normal to have some intestinal gas, and that it is okay for the form and timing of your stool to vary a little from day to day, depending on what you’ve eaten. These may be normal consequences of a varied diet and are a small price to pay for fully functioning, normal gut bacteria.
5. If you have any concerns about adequate nutrient or prebiotic intake, address them with the help of a qualified nutrition professional.
IS A FODMAP ELIMINATION DIET RIGHT FOR YOU?
There are no proven laboratory tests at this time to identify who will benefit from a low-FODMAP diet. Instead, you and your health-care provider can consider the following series of questions to determine if you are a good candidate for the program.
Do you have symptoms that can be managed with the FODMAP approach (abdominal pain, bloating, distention, excess gas, diarrhea, constipation, or fatigue)?
Yes. CONTINUE.
No. STOP. This program will not help you. People without these gastrointestinal symptoms should not cut FODMAPs out of their diets.
Have you tried to manage your symptoms with good health habits such as regular meals, managing stress, and getting adequate amounts of fiber, fluids, and exercise?
Yes, and they did not help, or fiber made my symptoms worse. CONTINUE.
No. STOP. Try gradually increasing your intake of fruits, vegetables, whole grains, beans, nuts, and seeds. Ask your doctor or dietitian for advice about trying a fiber supplement. A high-fiber diet has many well-known health benefits, and if it helps your IBS, that’s ideal. Eat meals on a regular schedule and drink plenty of fluids. Work at developing practices that will help you manage stress, such as regular exercise, yoga, or guided meditation. If these don’t help after a month or two, then continue.
Have you been properly evaluated by a qualified health-care provider?
Yes, and I have been diagnosed with IBS. CONTINUE. This diet is designed for people with IBS.
Yes, and I have been diagnosed with small intestinal bacterial overgrowth syndrome ( SIBO), Crohn’s disease, ulcerative colitis, celiac disease, non-celiac gluten sensitivity, chronic constipation, functional diarrhea, or GERD. Continue only with the input of your doctor or dietitian. The diet helps many people with IBS-like symptoms, even with another diagnosis, but depending on your condition, you may have more pressing nutrition priorities.
No. STOP. Present yourself for an evaluation by your primary-care provider or a gastroenterologist.
Do you consume high-FODMAP foods and beverages either regularly or sporadically? Have a look at The FODMAP Top 40 Foods ( this page ) as you think about this.
Yes. CONTINUE.
No. STOP. Discuss other treatments with your health-care provider. If your usual diet is already low in FODMAPs, it would be unrealistic to expect this program to further reduce your symptoms.
Maybe. If you’ve been trying a low-FODMAP diet on your own using outdated or questionable materials, or have not had proper guidance, it might be worth fine-tuning your diet with the tools in this book before deciding that the approach doesn’t work.
Do any elimination-phase red flags apply to you? Red flags include critical illness, major mental illness, cognitive impairment, malnutrition, eating disorder (past, present, or at-risk), anxiety, or perfectionism in children or adolescents.
No. CONTINUE.
Yes. STOP. Continue only with the input of your health-care provider, who will probably advise you against a restricted diet. Some people are poor candidates for elimination diets of any kind. These red flags are not specific to FODMAPs, but they suggest it might not be possible for you to restrict your diet safely. If one of these red flags applies to you, a trained dietitian can make specific diet suggestions informed by her knowledge of FODMAPs without putting you on a FODMAP elimination diet.
Are you willing and able to try a dietary experiment for two to ten weeks?
Yes. CONTINUE. Most people know within two to four weeks if a low-FODMAP diet helps; then it takes about six more weeks to learn how FODMAPs affect you when you start consuming them again.
No. STOP. Consider “FODMAP Lite,” described on this page .
Maybe. I am willing, but my living situation does not permit me to select, purchase, and buy my own food. If you eat most of your meals in restaurants, cafeterias, or the dining room of your residential community, you might not have enough control over your food to follow this program. Consider “FODMAP Lite,” described on this page .
Do you have any other medical conditions that require extra care with your meal planning, food, or beverage choices? Examples include (but are not limited to) food allergies, history of small bowel obstruction, eosinophilic esophagitis, gastroparesis, diverticulitis, inflammatory bowel disease, small intestinal bacterial overgrowth, GERD, hereditary fructose intolerance, celiac disease, gout, kidney stones, diabetes, high blood pressure, high cholesterol, or interstitial cystitis. If you aren’t sure, please consult your health-care provider. Or, do you take any medications that require extra care with your meal planning, food, or beverage choices? Examples include (but are not limited to) insulin, blood thinners, or psychiatric medications. If you aren’t sure, please consult your pharmacist or prescribing provider.
No. CONTINUE.
Yes. STOP. Continue only with the input of a medical nutrition professional, such as a registered dietitian. The food lists, menus, and recipes in this book may require modification.
Do you restrict your diet in any way? For example, are you an extremely picky eater? Do you eat a gluten-free or dairy-free diet, or are you a vegan?
No. CONTINUE.
Yes. Please proceed with caution. Although a varied low-FODMAP diet can provide plenty of nutrients, when additional restrictions are layered on top of a FODMAP-restricted diet, it takes extra planning to get enough nutrients such as protein, calcium, and fiber. Consider “FODMAP Lite” (this page ) if there are any concerns about getting adequate nutrition due to multiple dietary restrictions.
Congratulations! If your answers have brought you to this point, you are a great candidate for managing your IBS symptoms with a low-FODMAP diet. Go ahead and get your hopes up! In just a couple of weeks you’ll know whether FODMAPs are the key to managing your IBS.
The FODMAP Top 40 Foods
I’ve reviewed thousands of food records kept by IBS patients since 2008, when I started using FODMAPs in my practice. The list that follows includes the high-FODMAP foods I’ve seen occur over and over again in my patients’ diet histories. Your high-FODMAP foods might be different, particularly if you eat a traditional diet from another country or culture, so review the These Foods Contain FODMAPs list (this page ) for a more complete listing of high-FODMAP foods.
1. Milk (1 cup)
2. Milk in coffee drinks (lattes, frozen coffee drinks, etc.) or hot chocolate (1 cup)
3. Yogurt (6 fluid ounces, or ¾ cup)
4. Ice cream made from dairy milk or cream, soy, or coconut (⅔ cup)
5. Smoothie, shake mix, or protein powder (1 cup, 1 scoop or packet)
6. Cottage cheese or ricotta (½ cup)
7. Beans or lentils (½ cup)
8. Hummus (2 tablespoons)
9. Apple (1 small)
10. Pear (1 small)
11. Watermelon (½ cup)
12. Other fresh fruit (½ cup)
13. Fruit or vegetable juices (½ cup)
14. Trail mix (1 handful)
15. Onion (½ cup)
16. Garlic (1 teaspoon)
17. Cauliflower (½ cup)
18. Corn kernels (½ cup)
19. Mushrooms (½ cup)
20. Brussels sprouts (½ cup)
21. Frozen meals (1 portion)
22. Soup (1 cup)
23. Nuts (1 handful)
24. Bread or sandwich (2 slices or 1 roll)
25. Gluten-free bread (2 slices)
26. Cold or cooked breakfast cereal, including oatmeal (½ cup)
27. Fiber or protein bars (1 bar)
28. Pizza (1 slice)
29. Bagel (1 small)
30. Sweetened beverage such as soda, pop, bottled sweet tea, or lemonade (1 cup)
31. Herbal tea (1 cup)
32. Cocktail (1 drink)
33. Sweet syrup including honey, agave, pancake syrup, or yakon (1 tablespoon)
34. Seasoning blends or packets (1 teaspoon)
35. Ketchup or barbecue sauce (1 tablespoon)
36. Bottled salad dressing (2 tablespoons)
37. Sugar-free gum or candy (1 piece)
38. Milk or white chocolate (1 ounce)
39. Inulin fiber supplements (1 serving)
40. Chewable or gummy supplements (1 serving)
Here’s an exercise that might challenge some of your long-held beliefs about eating to control your IBS. You have been told that foods like bread and pasta are safe for IBS, for instance. Or, you may find it impossible to believe that milk could be causing a problem for you if you’ve been a milk drinker since childhood. And you may not suspect some particular foods that you’ve specifically included in your diet for their health benefits.
Circle the foods on the list that are either a regular part of your diet or that you eat sporadically—for example, fruit or vegetables in season. Use a highlighter to mark those foods you eat several times a day or in amounts larger than shown. Get out a set of measuring cups and spoons to remind yourself what 1 cup (8 fluid ounces) or what 1 tablespoon looks like. Remember that the foods you eat most often, and especially in bigger portions, have a greater influence on your health than foods you eat rarely or in small quantities. The more of these foods you eat, and the larger the portions, the more likely it is that the FODMAP elimination phase will make a big difference for you.
Now, don’t get me wrong. Very few of these are “bad” foods. But for some people, they can be too much of a good thing. In Steps 6 through 8, you’ll add the most nutritious foods on this list back into your diet. Or, you’ll learn more about low-FODMAP versions of some of these foods—for example, lactose-free milk, sourdough bread, and a variety of lower FODMAP teas.
Some Questions About Low-FODMAP Diets
Will a low-FODMAP diet cure my IBS?
Since the underlying causes of IBS are still unclear, and since it is probably a multiple-factor condition, it would be unrealistic to expect any single item, such as a change in diet, to cure the condition. The diet enables many people to manage their symptoms, and you might agree that this is quite welcome, even if not a cure.
How could the problem be wheat? I eat wheat products every day, and some days I feel fine!
Wheat is such a staple for most Americans that they may never suspect it could be contributing to their symptoms; indeed, this culprit is hiding in plain sight. When you aren’t eating much fruit, vegetables, milk, or beans, you may have greater capacity to tolerate bread, bagels, pasta, crackers, pizza, pastries, and so on. While eating that way may allow you to keep symptoms at a manageable level, it leaves a diet with a limited range of nutrients and a lot of empty calories.
How can I find a dietitian to help me with a low-FODMAP diet?
Ask your primary-care provider or gastroenterologist for a referral to an experienced gastroenterology dietitian. Like other health-care professionals, dietitians can be generalists or have expertise in helping patients with specific health conditions. It is probably not realistic to expect a general dietitian to know FODMAPs inside and out. You will get better care if you are specific and candid about the reason for your visit and if you mention any other significant medical or psychiatric conditions when you make your appointment, so the clinic can schedule you with the most appropriate nutritionist.
I have IBD. Can a low-FODMAP diet help me?
IBD stands for inflammatory bowel disease and should not be confused with IBS. Inflammatory bowel diseases include Crohn’s disease and ulcerative colitis. Unlike IBS, IBD causes visible inflammation, ulcers, and other damage to the gastrointestinal tract. To arrive at a diagnosis of irritable bowel syndrome, your physician will first try to make sure you do not have IBD, which requires different medical management.
So far, there is no convincing evidence that a low-FODMAP diet has an anti-inflammatory effect or can take the place of medicine for IBD patients. However, those patients put on low-FODMAP diets have less bloating, flatulence, and abdominal pain, as well as more normal stool form and frequency, compared to their previous diets. Certainly, it doesn’t make sense to replace fluids during bouts of IBD-related diarrhea with high-FODMAP beverages, such as fruit juice or regular milk. However, better symptom management could come at the cost of the loss of prebiotics from the diet (food for the good bacteria). Discuss the risks and benefits of the diet with your health-care provider before you start the program.
If you have IBD, be sure to work with a dietitian, particularly if you are considered at risk for small bowel obstructions; the food lists in this book may need to be edited to be appropriate for you. Also note that you will probably want to approach the reintroduction of FODMAPs with caution (Plan B) when you get to Step 8. You may find you can tolerate a more varied diet when you are in remission.
I have (or might have) celiac disease. Should I follow a low-FODMAP diet?
Celiac disease causes genetically vulnerable people to have a damaging autoimmune response to eating gluten. Gluten is a protein present in wheat, barley, and rye. On the other hand, during the FODMAP elimination phase, the focus is on the type of carbohydrate found in grains. Gluten is not a FODMAP. A low-FODMAP diet and a gluten-free diet are not the same thing. That being said, people with celiac disease are far more likely to have IBS or IBS-like symptoms than other people. If you have celiac disease, eat a 100 percent gluten-free diet with no exceptions, and still experience excess gas, abdominal pain, bloating, diarrhea, or constipation, FODMAPs could be to blame. Especially early in your diagnosis, before intestinal healing is complete on your gluten-free diet, you may be prone to poor absorption of lactose, fructose, and sorbitol. Once you have been gluten-free for a long time, your ability to tolerate foods containing these carbohydrates may improve a good deal. If you are still experiencing GI symptoms, ask an expert in gluten-free eating to review your diet for hidden sources of gluten. Then, consider trying a FODMAP-elimination diet.
If you have celiac disease, you should consider using this program with the support of a dietitian, particularly if you are a little shaky on which foods are gluten-free and which ones are not. The food lists in this book will have to be edited to be appropriate for you, since low-FODMAP foods are not necessarily gluten-free. Luckily, it is relatively easy to combine these two diets. If you have celiac disease, be sure to choose gluten-free versions of any food or ingredient listed in this book, and do not reintroduce gluten-containing foods during Step 6.
If you haven’t yet had celiac disease ruled out, the best time to do so is before starting a low-FODMAP diet. Following a low-FODMAP diet might (coincidentally) reduce your intake of gluten, which would interfere with the validity of your test results. Who should be tested? Recent guidelines published by the American College of Gastroenterology recommended that patients with symptoms, signs, or laboratory evidence of malabsorption should be tested for celiac disease, particularly patients with a father, mother, brother, sister, or child who has celiac disease. Evidence of malabsorption might include chronic diarrhea with or without weight loss, greasy stools, abdominal pain after eating, bloating, unexplained anemia, and premature osteoporosis. In children, growth failure sometimes occurs. Most adults with celiac disease don’t have the full range of these signs and symptoms. The most common sign of celiac disease in adults is iron-deficiency anemia.
I’ve been eating gluten-free for a while, but I’ve read that FODMAPs may be the real culprit. Can you help me understand this?
Many people with IBS find they feel better when they don’t eat wheat, and gluten-free eating is one of the most popular lifestyles today. People whose GI symptoms improve on a gluten-free diet usually don’t know which part of the wheat was causing their symptoms—wheat is more than just gluten. Wheat contains a complex assortment of proteins, carbohydrates, fats, and other components.
Sometimes people have bad reactions to one of the many proteins in wheat, such as the response to gluten in autoimmune disorders like celiac disease or dermatitis herpetiformis. Several different wheat proteins can cause classic food allergies or food sensitivities. Non-celiac gluten sensitivity (NCGS) is a newly recognized condition that occurs when a person has a bad reaction to gluten, even though celiac disease has been ruled out. Gluten is not a FODMAP. Coincidentally, some gluten-free foods work well on a low-FODMAP diet as long as other high-FODMAP ingredients aren’t added, but gluten-free does not equal FODMAP-free.
Wheat, barley, and rye also contain certain carbohydrates known as fructans, which can cause gastrointestinal symptoms. Fructans, a type of fiber, are FODMAPs. Because the U.S. diet revolves around wheat, it’s by far the biggest food source of fructans for Americans.
If you’ve been avoiding gluten even though you don’t have celiac disease or a wheat allergy, the FODMAP approach might help you enjoy a wider variety of foods. If you find through this program that fructans are your real problem, not gluten, you can worry less about consuming minor amounts of gluten. Cross-contamination is not a concern with fructans, and most people with IBS find in the end they can enjoy some wheat products—something that would be impossible on a 100 percent gluten-free diet.
I have (or might have) SIBO. Is a low-FODMAP diet suitable for treating SIBO?
SIBO stands for small intestinal bacterial overgrowth. While it is normal to have plenty of bacteria in the large intestine, there should be far fewer in the small intestine. If some underlying condition paves the way for SIBO to occur, the patient may experience disturbed digestion, with symptoms virtually the same as IBS, such as excess gas, bloating, distention, abdominal pain, and diarrhea or constipation. In addition, patients with SIBO may have some abnormal labs values or signs consistent with malabsorption, such as weight loss, anemia, steatorrhea (fat in the feces), low serum levels of vitamins, or low iron stores. The distinction is important because SIBO can be treated with antibiotics. The antibiotic rifaximin was recently FDA-approved for people with IBS-D, and part of its action may be to reduce bacterial overgrowth or reset microbial diversity. It is likely that a subset of people who have IBS actually have SIBO.
Health-care providers and researchers are still trying to figure out the best ways to diagnose and treat SIBO. Discuss the diagnostic process with your physician. Current practice is to treat the condition with either pharmaceutical or herbal antibiotics. In addition, common sense would suggest that a diet low in rapidly fermentable carbohydrates would discourage bacterial overgrowth. Though there is still little proof about the best dietary approach, the low-FODMAP diet is one of several diets in use for SIBO. If you are going to be treated for SIBO, arrange to start this program immediately after finishing the antibiotic treatment. During the reintroduction phase in Step 6, you will be directed to Plan B, which entails a cautious reintroduction of FODMAPs.
My child has fructose malabsorption. Will a low-FODMAP diet help?
Fructose is a FODMAP. Fructose malabsorption occurs when we consume more fructose at one sitting than we can absorb. Some people are slower fructose absorbers than others, but we all have a limit. In other words, fructose malabsorption can be considered normal to a large extent. If symptoms occur with fructose malabsorption, which is not always the case, they are better described as dietary fructose intolerance, rather than fructose malabsorption. If you or your child has dietary fructose intolerance, the low-FODMAP foods tools in this book might help, because people who have trouble with one FODMAP can find others are triggers as well. The foods suitable for the elimination phase of the diet are low in fructose; they are not necessarily fructose-free. That is appropriate because most people with dietary fructose intolerance find they can tolerate fructose in small amounts.
Please use great sensitivity and tact when restricting the diets of children. If your child has dietary fructose intolerance, consult a pediatric dietitian for strategies on changing the diet without increasing anxiety or introducing food fear. Consider leaving your child at home for this consultation, so you can discreetly alter the household food supply without making a big deal about it. It may be more appropriate to limit or avoid sources of fructose only, rather than put the child on a global FODMAP restriction. High-fructose foods are discussed in Step 6 of the program. The low-FODMAP fruits listed in the Low-FODMAP Pantry (this page ) may be well tolerated; however, portion sizes may have to be smaller than the ones shown, depending on the age and size of your child.
For more advice on the use of the low-FODMAP diet in a family with children, as well as more than a hundred original, kid-friendly low-FODMAP recipes, see my IBS-Free Recipes for the Whole Family , co-authored with mom and recipe developer Lisa Rothstein and pediatric dietitian Karen Warman of Boston Children’s Hospital.
Can the low-FODMAP diet help people with hereditary fructose intolerance?
The low-FODMAP diet is not for people with hereditary fructose intolerance (HFI), which is a serious, inherited metabolic disorder. Individuals with HFI should not consume any fructose at all, no matter how small the amount. Many individuals with HFI are diagnosed in infancy or childhood, when caregivers note the child is violently ill after ingesting anything containing fructose, such as table sugar, fruit, or honey. Rarely, adults have undiagnosed HFI; they have an absolute aversion to sweet food of any kind, going back to childhood. The “dislike” of sweets may run in the family. If you have HFI or suspect you may have HFI, there are some foods on a low FODMAP diet that you should not consume. Consult your health-care provider for an evaluation.
My naturopath says I have leaky gut. Will a low-FODMAP diet help?
There is, as yet, no direct evidence that the diet will reduce leaky gut in humans. The technical term for leaky gut is “increased intestinal permeability.” Recent scientific developments do suggest that the small intestine may play a bigger role than previously recognized in IBS, and that patients with IBS may have differences in small bowel permeability, activation of immune function, and release of histamines. Though this research is still preliminary, and it isn’t clear how these factors interact, it is likely intestinal permeability is linked to the intestinal microbiome and to dietary factors. That’s where FODMAPs might come in. Recently, researchers showed that IBS patients on high-FODMAP diets excrete more urinary histamines—an indicator of immune activation—than IBS patients on low-FODMAP diets. In a separate, very small study, researchers showed that a low-FODMAP diet in six people with IBS normalized fecal levels of lipopolysaccharides, which play a role in intestinal permeability.
Can vegetarians and vegans use this diet?
At first glance, it may seem difficult for vegetarians to get enough protein during the elimination phase of the program, but it can be done with careful attention to detail. Lacto-ovo vegetarians will have a relatively easy time getting enough protein on the elimination phase of the diet using lactose-free milk products and eggs to help meet their protein needs.
It will be more difficult for vegans, who do not eat any animal products. Many vegan staple foods are high in FODMAPs. The main problem for vegans is getting enough protein without consuming too many oligosaccharides (fibers found in vegan protein sources such as grains, beans, nuts, and seeds). It is only possible to get adequate protein on a vegan low-FODMAP diet if you are willing to eat a wide variety of the remaining low-FODMAP foods. In that case, it can be done if carefully planned, with good protein sources selected at every meal and snack. Unfortunately, I meet too many vegans who, for various reasons, have taken on additional dietary restrictions and do not eat soy products or corn products or potatoes or gluten or nuts or nightshades, and so on. When this is the case, I cannot support trying a low-FODMAP diet, as it will be all but impossible to get enough nutrients from food.
See the “Common Menu Variations” (this page ) for some vegetarian and vegan meal ideas. See the “Low-FODMAP Sources of Protein” (this page ) for details about low-FODMAP sources of protein.
Will a low-FODMAP diet help my GERD?
A low-FODMAP diet is not currently a first-line diet therapy for GERD, in the absence of IBS. GERD stands for gastroesophageal reflux disease. Reflux occurs when there is a temporary relaxation in the muscle tone of the lower esophageal sphincter, which allows the contents of the stomach to splash up into the esophagus. Heartburn may result, either from contact of stomach acid with the esophagus or from the resulting inflammation.
Many of my IBS patients also have GERD, and some do report that their reflux symptoms improve along with their IBS symptoms on the low-FODMAP diet. This effect has not been studied directly, so we can only speculate on possible explanations. The intestines fill most of the abdominal cavity and are close to the stomach in the upper abdomen (see illustration, this page ). If the intestines are distended with fluid and gas after eating FODMAPs, it could put some pressure on the stomach. The upward pressure might encourage reflux of the stomach contents into the esophagus, as it does during pregnancy. (We might guess this effect would be exaggerated in people with a lot of abdominal body fat or with short-waisted bodies.) Or perhaps the extra attention to healthy food choices and smaller portions during the low-FODMAP diet reduces reflux. Or, colonic fermentation could influence the muscle tone of the lower esophageal sphincter, as one small, pre-FODMAP study suggested. In any case, if your GERD improves, speak with your prescribing provider about reducing or discontinuing any anti-GERD medications you might be taking.
I need to lose some weight. Can I use the low-FODMAP diet for that?
Some people are used to hearing the word diet only in association with weight loss. I use the word simply to describe a set of available foods to choose from. This is not a weight-loss program. Still, it needn’t make it any harder to manage your weight. Some people who have found it difficult in the past to eat foods that would promote a healthy weight will be able to identify more fruits, vegetables, and whole grains they can tolerate. Following this program will probably mean eating less processed food and drinking fewer sweetened beverages, which may help if your food choices are in need of improvement.
If weight loss is one of your health-care goals, here are a few tips:
• Keep sweets and low-FODMAP baked goods, including breads, to a minimum.
• Use good nutritional common sense when it comes to fats and oils. Just because they are low in FODMAPs, that doesn’t mean you should overindulge in bacon, butter, or coconut oil.
• As usual, watch your portions. Tortilla chips and large bowls of rice might be low in FODMAPs but can still provide too many calories for your needs.
• Physical activity is a lot more fun when you don’t have to worry about being within a 20-yard dash of the toilet! As your symptoms improve, maybe you will decide it is time to start an outdoor exercise program. Walking, biking, kayaking, hiking—they all can be yours again!
My health-care provider wants me to gain weight. Can I use the low-FODMAP diet for that?
Some people with IBS are in the very difficult position of needing to gain weight, yet having to limit their food choices and portion sizes to avoid setting off their IBS symptoms. My underweight patients tell me they get plenty tired of wisecracks about how “lucky” they are. It can feel scary to be underweight, and it can be even harder to gain weight than it is for the rest of us to lose it.
There are plenty of good low-FODMAP foods with the protein and calories to help you work toward a healthy weight. Knowing which foods are less likely to trigger your IBS symptoms may help you find ways to eat more. If you are an underweight vegan with IBS, I respectfully suggest that you reconsider the reason for your vegan diet. If you are doing it for health reasons, it is time to recalculate the risks and benefits of veganism with the assistance of your health-care provider. Does correcting actual undernutrition take priority over the theoretical risk reduction for heart disease or the supposed benefits of eating a more “alkaline” diet? If you are a vegan for environmental reasons, consider other ways to reduce your environmental footprint, short of veganism: don’t eat animal products every day; choose chicken, turkey, or eggs, which require less feed and produce less methane than pork, cheese, beef, or lamb; buy only what you need, wasting nothing; and buy locally raised food from responsible farmers. If you are a vegan for ethical reasons, I respect that. Do think it over and see if there is any room to move (consider humanely raised eggs, for example), perhaps temporarily, until you are in better health. See the section “Weight-Gain Ideas” (this page ) for menu ideas.
Is a low-FODMAP diet good for treating anxiety or depression?
If your anxiety is related to unpredictable GI symptoms, and if those symptoms are well managed with a low-FODMAP diet, then it’s fair to say the diet can give you one less thing to be anxious about. But as far as having a direct treatment effect on a person diagnosed with anxiety or depression, it’s too soon to tell, though there are some early signs in the scientific literature that a low-FODMAP diet can reduce anxiety. One recent study at the University of Michigan demonstrated a trend toward reduced anxiety in a group of IBS-D patients on low-FODMAP diets compared to patients on a standard IBS diet, but it wasn’t significant. The same study did find that patients on a low-FODMAP diet had an improved overall quality of life, better sleep quality, and less interference of IBS on their activities.
Several very small studies have shown a link between carbohydrate malabsorption and depression, particularly in children. But the studies simply weren’t designed to prove that fructose and/or lactose malabsorption cause depression.
What is the take-away here? If you have IBS, there is a chance that removing excess amounts of FODMAPs from your diet might help you feel better mentally as well as physically, but a low-FODMAP diet is not recommended for treating anxiety and depression in the absence of IBS.