A BEGINNER’S GUIDE TO FODMAPS
Everything you wanted to know…and more!
WORDS: CARA BOATSWAIN
If you’re among the 14 percent of Australians suspected to be suffering from irritable bowel syndrome (IBS), then you’re likely to be all too familiar with the bloating, tummy pain, flatulence, constipation and diarrhoea associated with the condition. When our bowels misbehave it can be uncomfortable and embarrassing.
“IBS is a very common problem in our Australian community,” says Dr Jane Muir, Head of Translational Nutrition Science at Monash University. “This condition is chronic and relapsing in nature and can greatly affect the quality of life of sufferers.”
Dr Muir explains that IBS is a large and complex disorder and, while post-infectious IBS (developed after a bout of gastro) can be cured, it is the exception. “The causes of other types of IBS are largely unknown but seem to involve gut hypersensitivity, abnormal motility and altered gut bacteria. Stress and anxiety also appear to have a role for some people,” she says. “Many individuals have good resolution of symptoms, while others may need to continue to avoid certain triggers.”
Advancement in treatment for IBS
While there is no easy or quick treatment for IBS, there are ways symptoms can be managed, especially when triggers (such as food or stress) are known. Researchers from Monash University in Melbourne, including Dr Jane Muir, have found that by restricting certain types of short chain dietary carbohydrates (that they’ve called FODMAPs), they are able to control the symptoms associated with IBS in most patients. The low-FODMAP diet discovered by the team at Monash is now providing relief to IBS sufferers around the world.
What are FODMAPs anyway?
FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) are a group of short-chain carbohydrates and sugar alcohols commonly found in the foods we eat. Milk, yoghurt, onions and honey are just some of the everyday ingredients you would need to review on the diet.
“These carbohydrates are poorly absorbed in the intestine due to a range of reasons,” explains Joel Feren, an accredited practising dietitian (APD) from Hearty Nutrition in Melbourne. “As a result of poor absorption, FODMAPs pass through to the large intestine undigested. The bacteria in the large intestine digest and ferment the undigested carbohydrates and produce gas.”
Consult an expert
As with the self-diagnosis of coeliac disease, it’s really important to see your GP should you suffer any of the symptoms associated with IBS. “There are quite serious bowel diseases (such as inflammatory bowel disease, coeliac disease and colorectal cancer) that produce similar types of symptoms,” says Dr Muir. “This is why it is very important to have these types of symptoms checked out by your GP and not to ‘self-diagnose’.”
How is IBS diagnosed?
While there is no diagnostic test for IBS, your GP will be able to positively diagnose the condition based on the characteristic symptoms of IBS. “The diagnosis is based on how often you experience the abdominal pain or discomfort, together with the presence of other bowel symptoms and changes in bowel habits,” explains Dr Muir.
Why do I need to follow the FODMAP diet?
“The FODMAP diet will allow you to identify which group/s of carbohydrates may be responsible for your symptoms,” says Feren. “FODMAP digestion or lack thereof differs between individuals, as do the symptoms. Further, while FODMAPs are mostly poorly absorbed in all people, it is particularly problematic for those with a sensitive gut.”
To discover which FODMAPs are causing your IBS symptoms you will need to follow the low-FODMAP diet in consultation with a trained dietitian. “The elimination stage is typically followed for 2-6 weeks, or until good symptom relief is achieved,” explains Lyndal McNamara, research dietitian from the Department of Gastroenterology at Monash University. “It is always recommended that you consult with a dietitian before commencing the diet. As a low-FODMAP diet restricts foods from multiple food groups, it is important that a dietitian oversees the entire process to ensure your diet remains nutritionally balanced.”
Is the diet for life?
One of the challenges of the low-FODMAP diet is that it can be restrictive because so many foods contain FODMAPs. The good news is that, unlike the gluten-free diet for coeliac disease, IBS does not require strict avoidance of FODMAPS.
“It is a low FODMAP diet, not a no FODMAP diet,” says Dr Muir. “The diet helps you learn which foods and FODMAP sugars may trigger your symptoms and the levels at which you can tolerate them. The diet has to be personalised and this is where a dietitian has a vital role.”
During the re-introduction phase, your dietitian will begin to identify the FODMAPs that are a problem for you. “The next phase of the diet involves a series of challenges with each FODMAP to identify which one/s are the cause of the discomfort,” says Feren. “Based on the findings, a diet only limiting the problematic carbohydrate can be formulated by an Accredited Practicing Dietitian (APD).”
Dr Muir also stresses that the low-FODMAP diet is specifically designed for those with bowel disorders such as IBS. “The low-FODMAP diet is a diet therapy for a medically diagnosed bowel disorder,” she says. “It is not suitable for the general healthy population.”
Is the low-FODMAP diet a sugar-free diet?
When it comes to eating low-FODMAP, it’s only the fermentable sugars that need to be avoided. “Ordinary table sugar (sucrose) is low in FODMAPs, so suitable to include on a low-FODMAP diet,” explains McNamara. “Although fruit contains natural sugars (which can include glucose, fructose, sorbitol and fructans), only fruits containing these sugars in large amounts need to be limited on a low-FODMAP diet.”
Do all foods contain FODMAPs?
“FODMAPs by definition are types of dietary carbohydrates,” explains McNamara. “Meat proteins, for example, do not contain carbohydrates, and are naturally low in FODMAPs.” McNamara also highlights eggs, cooking fats and oils as foods that are naturally low in FODMAPs.
“Many vegetables, fruits and grains are also low in FODMAPs, so just because a food contains natural sugars or carbohydrates does not necessarily mean it will be high in FODMAPs,” she says.
What is the difference between low- FODMAP and fructose friendly?
Fructose is a sugar found naturally in plants, fruits and honey. It has also been used commercially as a
sweetener in soft drinks and processed foods. As a result of the increased consumption of fast food and soft drinks, we are consuming more fructose than ever before.
Fructose is normally absorbed into the wall of the small intestine. Fructose malabsorption occurs when the body is unable to break down and absorb the fructose in the usual manner. If the fructose remains undigested and travels to the large intestine, it reacts with the naturally occurring bacteria and can cause gas, bloating, abdominal pain and diarrhoea.
“Around 30 percent of the population (including healthy people as well as people with IBS) malabsorb excess fructose. So fructose malabsorption is quite normal,” explains Dr Muir. “The problem is the presence of the gut disorder (IBS) which can result in the undesirable symptoms associated with malabsorbing fructose and other FODMAPs.”
“Fructose friendly” has become a popular claim on supermarket shelves, but it doesn’t necessarily mean the product is low-FODMAP. “Fructose is just one of the six main FODMAP sugars,” says McNamara. “Products that are ‘fructose friendly’ might be low in fructose, but they may contain other types of FODMAP sugars (such as lactose, sorbitol, mannitol, fructans or GOS).”
Can I eat oats on the low-FODMAP diet?
Oats have been the source of much debate within the gluten-free community, particularly in Australia. Oats contain a protein called avenin which has been found to produce a gluten-like reaction in some, but not all, people with coeliac disease. There are also concerns regarding cross-contamination risks from the way that oats are grown and harvested.
“The good news is that oats have been tested to be low-FODMAP,” explains holistic nutritionist Sarah Leung from Healthy Energy. “So as long as you don’t suffer from coeliac disease, you can enjoy oats as part of your low- FODMAP diet.”
What happens if I break the diet?
The low-FODMAP diet is designed to help you achieve control of your IBS symptoms. You may even find that, after following the diet and reducing the overall load of FODMAPs on your intestine, an occasional intake of FODMAPs may not produce symptoms.
If you do experience gastrointestinal symptoms, the researchers at Monash University recommend returning to a strict low FODMAP diet, with symptoms usually improving within one to three days. “It is best to stick to the low-FODMAP diet as best as you can,” says Feren. “However, if you do break the diet, just be sure to return to a stringent form of the diet as soon as you can.”
How can I meet my nutrient requirements while following the low-FODMAP diet?
“It is important to ensure that you still follow a healthy, balanced diet while following the low-FODMAP eating plan,” says Feren. “That means including foods from all five food groups.”
1. Vegetables – aim for 5-7 serves a day
2. Breads, cereals, rice and pasta and noodles – aim for at least 4 serves a day
3. Fruit – at least 2 serves a day
4. Meat and alternatives – 1-2 serves a day
5. Dairy – 3-4 serves a day
6. Limit your intake of fatty foods, caffeine and alcohol, as these are known triggers for IBS-type symptoms.
Can I still eat out at restaurants?
“Eating out can prove challenging, however, you don’t necessarily have to go without,” says Feren. “Choosing plain foods such as meat and fish with vegetables and potatoes or rice is a safe bet. Japanese is one cuisine with many low-FODMAP options. Alternatively, there are a number of Italian restaurants that will offer gluten-free pasta and pizza – just be mindful of sauces and toppings.”
Low-FODMAP sounds hard. Are there other effective treatment options?
There have been some studies that have found evidence of probiotics helping with IBS symptoms, although results vary depending on the strain of probiotic taken. The Monash University team recommends trying one IBS management strategy at a time. If you haven’t found relieve from your symptoms after two to six weeks on the diet, discuss alternate management strategies with your dietitian.
While researchers have found the low-FODMAP diet to be effective in managing IBS symptoms in most cases, there are some patients who don’t respond to the diet. “It is important to be aware of other dietary and non-dietary therapies that may assist in controlling IBS symptoms,” say the researchers. “These include the gluten-free diet in non-coeliac gluten sensitivity, the low-food chemical diet and gut directed hypnotherapy as a sole or complimentary therapy for managing gut symptoms.”
This article first appeared in Issue 1 of FODMAPPER magazine. For more information about the low FODMAP diet and dietitian approved recipes pick up an issue today.