These poorly absorbed sugars are fermented by bacteria in the large intestine (bowel).Irritable bowel syndrome (IBS) is a condition that affects approximately 15 percent of the population. It affects males and females of all ages. Symptoms include excess flatulence; abdominal bloating, distension, pain, or discomfort; and altered bowel habits (diarrhea, constipation, or a combination of both). These symptoms fluctuate in their severity from day to day and week to week.
Because the diagnosis of IBS is based on the pattern of the symptoms, it is important to rule out other conditions that have the same symptoms, such as celiac disease and inflammatory bowel disease (IBD), both of which can mimic IBS. Anyone with symptoms of IBS should be examined for these disorders before going on a low-FODMAP or gluten-free diet, so speak with your doctor about being tested if you haven’t already (see page 5 for more information). However, bear in mind that is possible to have both IBS and another digestive disorder.
I developed the low-FODMAP diet in 1999, and it has been shown to help at least three out of four people with IBS, a condition that has been difficult to manage in the past. It also shows promise for treating persistent symptoms associated with celiac disease, Crohn’s disease, and ulcerative colitis.
I have included a summary of the diet’s principles below, but more in-depth information is available in The Complete Low-FODMAP Diet, which I coauthored. Please also consult with a doctor and registered dietitian before embarking on a low-FODMAP diet.
FODMAPs are a group of naturally occurring sugars that are not absorbed in the small intestine; instead, they travel down the rest of the digestive tract and arrive into the large intestine, where bacteria are present (which is normal and healthy). These bacteria use the unabsorbed sugars (FODMAPs) as a food source. When the bacteria munch on the FODMAPs, they ferment them, and this results in the release of gas, which can lead to excessive flatulence, gassiness, bloating, and abdominal distension and pain. The FODMAPs can also change how quickly the bowels work, so can lead to constipation or diarrhea (or a combination of both) in susceptible people. So it is very clear how FODMAPs trigger symptoms of IBS.
All the recipes in this book use ingredients that are low in FODMAPs—that is, they exclude the ingredients known to be high in FODMAPs (see table on facing page).
These poorly absorbed sugars are fermented by bacteria in the large intestine (bowel).
Oligo means few, and saccharide means sugar. So these are individual sugars, joined together to make a chain.
The two main oligosaccharides that are FODMAPs are:
Fructans, made up of fructose sugars joined together to make a chain (with glucose at the very end).
Galacto-oligosaccharides (GOS), made up of galactose sugars joined together, with a fructose and glucose at the very end.
Di means two, and saccharide means sugar. So these are two individual sugars, joined together to make a double sugar.
The important FODMAP disaccharide is lactose, made up of an individual glucose sugar joined to an individual galactose sugar.
Mono means one, and saccharide means sugar. So these are individual sugars.
The important FODMAP monosaccharide is excess fructose. Not all fructose needs to be avoided. Only foods that contain more fructose than glucose (or “excess fructose” foods) need to be avoided on the low-FODMAP diet.
If a food contains more glucose than fructose, or if glucose and fructose are present in equal (“balanced”) amounts, then it is suitable on the low-FODMAP diet.
If a food (for example, a piece of fruit) contains more glucose than fructose, or equal amounts of fructose and glucose, it is suitable to eat; however, only one piece of suitable fruit should be consumed at a time. This doesn’t mean you can only have one piece of fruit per day! You can have several, but spread them out so that you only have one per sitting.
A polyol is made up of a sugar molecule with an alcohol side-chain. Polyols are also known as sugar alcohols, but I promise they won’t make you feel intoxicated!
The two polyols most commonly occurring in foods are sorbitol and mannitol.
Though all FODMAPs may trigger symptoms of IBS, there are breath hydrogen (or methane) tests available to determine individual sensitivity to certain sugars, especially fructose, lactose, and sorbitol. Breath tests are not a prerequisite for following the low-FODMAP diet but can be helpful in planning it. Ask your doctor if you are interested in having these tests run.
The tests work on the basis that bacteria in the large intestine produce hydrogen and/or methane gas by fermenting carbohydrates. Although some of the gas produced in the large intestine is passed out as flatulence, most of it is transferred across the lining of the large intestine into the bloodstream. The gases then dissolve into the blood, and the blood carries it to the lungs, where it is breathed out and can be measured.
Different testing centers have different guidelines for breath tests; however, you generally need to follow a low-FODMAP diet the day before the test to ensure that there is no hydrogen or methane already in your breath on the day of your test. A sample of your breath is collected into a special airtight bag and is then tested for the presence of hydrogen and/or methane, measured in parts per million. This is considered your baseline breath test. You then drink a solution containing a specific sugar (e.g., fructose, lactose, or sorbitol). Only one sugar can be tested at a time, and each sugar must be tested on a different day within the span of a month. Once you have drunk the solution, you breathe into a new airtight bag at regular intervals over a period of around three hours. Each testing center has different criteria for defining malabsorption of sugars tested. It is also helpful to keep a record of any symptoms you experienced at the time of the test.
For more information on breath hydrogen testing, see www.thelowfodmapdiet.com.
Lactose is a naturally occurring sugar that is found in cow’s, goat’s, and sheep’s milk. Typically in people with lactose intolerance, the body stops making enough lactase, the enzyme that breaks down the sugar lactose. However, people can differ in the severity of their intolerance. Most people are able to tolerate small amounts of lactose (up to 4 grams) in their diet.
Lactose intolerance can cause symptoms of IBS. Additionally, many people with celiac disease have a secondary lactose intolerance, meaning an intolerance caused by the damage to their small intestine. Secondary lactose intolerance is generally but not always temporary.
Lactose is present in large amounts in milk, ice cream, and pudding. It is present in small to moderate amounts in products such as yogurt, cream, crème fraîche, and soft or unripened cheeses (e.g., cottage, ricotta, and cream cheese). Hard and ripened cheeses (cheddar, Parmesan, Camembert, Edam, Gouda, blue, mozzarella, etc.) and butter are virtually free of lactose.
The majority of recipes in this book are lactose-free or contain only minimal amounts of lactose. Recipes that require modification provide suggestions.
Fructose malabsorption is a condition in which the small intestine is impaired in its ability to absorb fructose (a naturally occurring sugar). Fructose malabsorption is different from hereditary fructose intolerance (HFI), a condition usually diagnosed in children in which the complete inability to digest fructose may result in symptoms such as vomiting, low blood sugar, and jaundice, and can lead to death.
Fortunately, in people who have fructose malabsorption, there still exists a pathway through which fructose can be absorbed in the small intestine. If glucose is present at the same time, the glucose “piggybacks” the fructose across the intestine into the bloodstream.
This is good news for fructose malabsorbers. It means that fructose and foods that contain it do not need to be avoided altogether (as is the case with HFI).
As mentioned previously, only foods that contain more fructose than glucose (excess fructose foods) need to be avoided on the low-FODMAP diet.
If a food contains more glucose than fructose, or if glucose and fructose are present in equal amounts, then it is suitable on the low-FODMAP diet. However, fructose malabsorbers do need to be aware of serving sizes. Only consume one serving of suitable food (such as fruit) at a time. Spread them out through the day so you only have one per meal or sitting.
Although all the recipes have been formulated with ingredients that are suitable for fructose malabsorption, ensure that you limit the serving size of any fruit-based dish to the quantity indicated in the recipe. Consuming large quantities of even “safe” fruits can cause symptoms.
Both a gluten-free diet and a low-FODMAP diet restrict wheat. On a low-FODMAP diet, this is due to wheat’s fructan content rather than its gluten content. The good news is that although wheat is a source of both fructans and gluten, not every wheat ingredient contains both (see the table on the opposite page).
You will notice that some ingredients in the recipes are specified as “gluten-free.” Gluten must be avoided by those with celiac disease, and is present in wheat, rye, and barley. Some people on a gluten-free diet also react to oats. Every recipe in this book is gluten-free, which also ensures that fructans from wheat, rye, and barley are restricted.
If you do not need to follow a gluten-free diet, you need not seek out gluten-free-labeled versions of some ingredients, such as sauces, which are unlikely to contain enough fructans to trigger a reaction.
SUITABILITY OF WHEAT PRODUCTS
|
Ingredient |
Suitable for gluten-free diet |
Suitable for low-FODMAP diet |
|---|---|---|
|
White wheat flour |
× |
× |
|
Whole wheat flour |
× |
× |
|
Wheat starch |
× |
✓ |
|
Modified food starch (wheat) |
× |
✓ |
|
Wheat thickener |
× |
✓ |
|
Wheat maltodextrin |
× |
✓ |
|
Wheat dextrin |
× |
✓ |
|
Wheat dextrose |
✓ |
✓ |
|
Wheat glucose |
✓ |
✓ |
|
Wheat glucose syrup |
✓ |
✓ |
|
Caramel color (rarely from wheat in North America) |
✓ |
✓ |
Celiac disease is an autoimmune disease in which the immune system’s response to gluten severely injures the body. Gluten is the main protein component of wheat, rye, and barley (and some people with celiac disease also react to avenin, a protein in oats). In people with celiac disease, the immune response to gluten causes damage to the lining of the small intestine, particularly the villi, fingerlike structures that help absorb nutrients. As a result of dramatically decreased nutrient absorption and ongoing inflammation, people with celiac disease may become very ill. Typical symptoms can include bloating, gas, pain, diarrhea or constipation or a combination of both, fatigue, iron deficiency, anemia, and infertility. People with untreated celiac disease are also at greater risk for certain cancers and other maladies.
Celiac disease is diagnosed by antibody blood tests and a confirming endoscopic biopsy of the small intestine if the tests are positive. People being tested for celiac disease need to be eating gluten for the tests to be useful; otherwise, false negatives are common.
Celiac disease is a lifelong condition treated by a diet free from all gluten. This prevents further damage to the villi and allows them to return to normal so that nutrients can be properly absorbed.
The gluten-free diet permits fruits, vegetables, meat, fish, chicken, legumes (including lentils), most dairy foods, oils and margarines, and many grains. Breads, pasta, and cereals can be made from alternative sources, including corn, rice, soy, buckwheat, sorghum, nuts, and legumes, to name a few. These days, there are many specialty gluten-free products available, and many of those are also low-FODMAP. Look for them in the health food section of supermarkets and in health food stores.
For people prescribed a gluten-free diet, the change in lifestyle is often overwhelming. Learning which foods are suitable and which foods are no longer permitted in the diet is time-consuming at first, and the diet can seem very restrictive. I hope that this book will help you enjoy the great tastes of a gluten-free and low-FODMAP diet with confidence.
While every effort has been made to indicate and ensure gluten-free and low-FODMAP ingredients, it is essential to read the ingredients list of all food products to determine whether they are suitable for inclusion in your diet. The recipes in this book comply with the FDA’s gluten-free labeling standards at the time of printing and exclude foods known at the time of printing to be high in FODMAPs. However, the gluten-free status of individual brands may change, the process of testing foods for their FODMAP content is ongoing, and the finished recipes have not been laboratory tested for FODMAP levels. Gluten-free labeling standards in other countries may also be different from the FDA’s, so I stress again the importance of reading all food labels. Always assess your own level of tolerance when it comes to specific FODMAPs and recommended serving sizes.
For more information, see www.shepherdworks.com.au.
IBD includes Crohn’s disease and ulcerative colitis, illnesses in which the bowel becomes chronically inflamed. Symptoms include diarrhea (sometimes bloody), abdominal pain, bloating, gas, and fatigue. As for celiac disease, the “gold standard” for diagnosing IBD is an intestinal endoscopy with biopsies, though blood tests, stool samples, colonoscopies, and other medical procedures may also be considered.
The causes of IBD are not known, and treatment is directed toward controlling the inflammation and preventing it from returning. Those whose bowel inflammation is well controlled but whose gastrointestinal symptoms continue may find the low-FODMAP diet a useful tool.
FOODS KNOWN TO BE HIGH IN FODMAPS THAT SHOULD THEREFORE BE RESTRICTED*
Additives (sweeteners and added fiber): fructo-oligosaccharides, high-fructose corn syrup, honey, inulin, isomalt, mannitol, maltitol, polydextrose, sorbitol, xylitol
Cereal and grain foods: bran (from wheat, rye, or barley); bread (from wheat, rye, or barley); breakfast cereals, granolas, and muesli (from wheat, rye, or barley); crackers (from wheat or rye); pasta, including couscous and gnocchi (from wheat); wheat noodles (chow mein, udon, etc.)
Drinks: chamomile and fennel tea, chicory-based coffee substitutes, juices made from unsuitable fruits (below)
Fruits: apples, apricots, Asian pears, blackberries, boysenberries, cherries, figs, mangoes, nectarines, peaches, pears, persimmons, plums, prunes, tamarillos, watermelon, white peaches
Legumes: beans (all kinds, including certain forms of soy, such as textured vegetable protein/TVP), chickpeas, lentils
Milk and milk products: custard, ice cream, milk (cow’s, goat’s, and sheep’s, including whole, low-fat, skim, evaporated, and condensed), pudding, soft cheeses, yogurt (cow’s, sheep’s, or goat’s)
Nuts: cashews, pistachios
Vegetables: artichokes (globe and Jerusalem), asparagus, cauliflower, garlic (and garlic powder in large amounts), leeks, mushrooms, onions (red, white, yellow, and onion powder), scallions (white part), shallots, snow peas, sugar snap peas
FOODS KNOWN TO BE MODERATE IN FODMAPS THAT SHOULD THEREFORE BE EATEN IN MODERATION
Fruits: cherries, longans, lychee, pomegranate, rambutan
Milk and milk products: cottage cheese, cream, cream cheese, crème fraîche, mascarpone, ricotta
Nuts: almonds, hazelnuts
Vegetables: avocado, beets, broccoli, Brussels sprouts, butternut squash, celery, corn, fennel, green peas, savoy cabbage, sweet potato
Note: Courtesy Monash University, Department of Gastroenterology