Hello FODMAPs--Nice to Meet You!

Have you been diagnosed with irritable bowel syndrome? Not sure what to eat? In the past, your doctor might have automatically recommended a high fiber diet. A high fiber diet is certainly worth a try considering fiber’s many well-known health benefits; increasing fiber intake with high fiber foods and fiber supplements can resolve some cases of IBS. However, if a high fiber diet made your symptoms worse, instead of better, it’s time to learn about FODMAPs, a promising new nutrition approach for IBS.

If you’ve never heard the term FODMAP before you are not alone! The term FODMAPs was coined by Australian researchers Susan J. Shepherd and Peter R. Gibson; they found that a low FODMAP diet helped up to 75% of their IBS patients. A low FODMAP diet avoids foods containing certain sugars and fibers capable of causing diarrhea, constipation, gas, bloating and abdominal pain in people with IBS. 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, mannitol, and other “-ol” sweeteners (found in certain fruits and vegetables as well as some types of sugar-free gums and candies)
• Fructans (a type of fiber found in wheat, onions, garlic and chicory root)
• GOS (a type of fiber found in beans, hummus and soy milk)

These five types of FODMAPs have several things in common: They can be poorly absorbed during the digestive process. They are rapidly fermented by the bacteria that live in your gut. They can alter the fluid balance in your gut. Together, these effects can lead to bouts of IBS symptoms within hours of eating a high FODMAP meal or snack. By reducing the overall dietary load of these carbohydrates, you can often reduce your troublesome GI symptoms.

Ironically, many high-FODMAP foods are otherwise healthy choices, and are often recommended by health care providers. For those who can tolerate them, high FODMAP fruits, vegetables, milk products, legumes and whole grains may be wonderful foods!  But people with IBS often have to limit their portions of these foods or suffer the consequences.

Click here for a downloadable PDF of this chart. This is not an complete list of high or low FODMAP foods, but hits many of the highlights in the diets of people with IBS.

Common high FODMAP foods or ingredients	Low FODMAP alternatives
Soy milk; cow’s or goat’s milk, yogurt, ice cream	Lactose-free cow’s milk, yogurt, ice cream; rice, coconut or almond milk
Beverages, syrups or condiments sweetened with high-fructose corn syrup, honey, agave	Beverages, syrups or condiments sweetened with granulated sugar, evaporated cane juice, brown sugar, 100% pure maple syrup
Dried fruit, fruit juice, trail mix, fruit bars	Fresh or frozen fruit
Apples, pears, stone fruits (cherries, peaches, plums/prunes, apricots, avocados, mango), watermelon, blackberries	Small portions (1/2 cup) of strawberries, blueberries, cranberries, grapes, pineapple, cantaloupe, honeydew melon, kiwi, ripe bananas, oranges, lemons, limes, grapefruit
Garlic, onions, broccoli, cauliflower, cabbage, mushrooms, sweet corn	Garlic-infused oil, chives, spinach, lettuce, fresh tomatoes, cucumber, carrots, zucchini, bell peppers, white potatoes, small portions (1/2 cup) of green beans, peas, sweet potato
Wheat, barley or rye; breads, cereals, pastas or baked goods made of wheat, barley or rye; high-fiber bars or cereals	Oats, rice, cornmeal or quinoa; breads, cereals, pastas or baked goods made of oats, rice, cornmeal or quinoa
Sugar-free candy sweetened with sorbitol, mannitol, maltitol	Small portions (1-2 ounces) of sugar-sweetened candy
Beans, baked or refried beans, hummus	Firm tofu
Pistachios, cashews	Small portions (1 handful) of other nuts, nut butters or seeds

© 2012 Patsy Catsos, www.ibsfree.net

A FODMAP elimination diet may be recommended by your doctor or dietitian. An elimination diet is a “learning diet” with a strategy and a plan; close monitoring of your symptoms will help you learn how the food you eat affects you. At the beginning, you may limit all of the FODMAPs in your diet. Soon, it will be time to reintroduce FODMAPs one type at a time. You may find that only one or two FODMAPs are responsible for most of your symptoms. In the end, most people find they can still have their favorite high-FODMAP foods in moderation. For example, if you discover high-FODMAP grains are a problem area but pizza is your favorite food, your new knowledge can help you to decide how to handle it: choose pizza with a thinner crust; have fewer pieces; use a wheat-free crust; eat less other FODMAPs at that meal, eat it less often, or go for the gusto and endure the resulting belly-ache. The ultimate goal is for each person to eat the most varied diet that he or she can tolerate, not to restrict the diet with a one-size-fits-all rules.

There are a few things you can do to get your low-FODMAP diet off to a good start:

• Consult your doctor to rule out other causes of your symptoms; celiac disease in particular should be ruled out before trying this wheat-free diet, since going wheat-free will interfere with the accuracy of future celiac testing.
• Choose a trial period when you have a little extra time for label reading and home food preparation.
• Eat mostly whole foods, simply prepared, during the low-FODMAP trial. No labels, no label reading—easy!
• If eating out, choose simply prepared foods with easily recognizable ingredients, such as grilled steak or fish, a baked potato and a green salad (hold the onions) with olive oil and balsamic vinegar.
• Get some guidance from a registered dietitian, especially if you have other health conditions that affect your diet. Word is now getting out in the health care community about FODMAPs, but some doctors and dietitians may not yet be “in the know”. Mention your interest in FODMAPs as you schedule your appointment, so that your dietitian can be well-prepared for your visit.

Don’t just learn to live with your IBS symptoms. Instead, learn about FODMAPs! Try an elimination diet, and find out if a low FODMAP diet is right for you!

Comments

[Farida]

Thank you so much for this info, they are very helpful

[kim worth]

Hi there. i just purchased your book and a copy for my sister. I had a few quick questions and then i plan to arrange the hour with you for 198. first, the vitamins i take have grape seed extract, acai extract and pomegranit so I assume i need to not take these? the other parts with mag, calcium and so on dont seem to have anything in them.
can you recommend a good vitamin to take and also a good alternative ketchup to use? thanks very much

[Patsy]

I know there is a really good discussion about this in my book on page 120. Have a look at that and "comment" back if you still have questions.

[Amy Jones]

Hi Patsy--from a client of mine--

"I had a question about sweetener. I'm a little confused because on page 50 of Patsy's book it says that a maxiumum of 40 grams of total sugar per serving is allowed on the Elimination Phase of the diet, but 1 1/2 T of sugar is less than 20 g of sugar so how come only 1 1/2 T is allowed? Just curious."

Thanks! Amy Jones, M.S., R.D., L.D.

[Patsy]

I see what you mean...maybe I could have gone with a bigger serving so as to max out at 40 grams of sugar, but it just doesn't seem proper as a dietitian to recommend a portion size of 3 or 4 Tb. of added sugar. So that was a call that I made for the purpose of the food lists. In recipes or on food labels, the 40 grams of sugar I still think is a good rule of thumb and might include not only added sugars but sugars from milk products, fruits, vegetables, etc.

[Amy Jones]

One more question from this same client--if carrots are ok on the elimination diet, what about carrot juice?

Thanks!
Amy

[Patsy]

I would think that a 1/3 cup serving of pure carrot juice would be OK.

[Amy Jones]

Couple of more questions...my client is vegetarian and so getting protein is a challenge right now. She is asking about almond dream ice cream. Would this be allowed?

http://www.tastethedream.com/products/product/5073/745.php

Additionally, she is asking about Coconut Milk based ice cream, like the one below.

http://www.thatssomichelle.com/2011/06/so-good-trader-joes-strawberry-coconut.html

Nutritional Yeast

http://www.bobsredmill.com/nutritional-yeast.html

Thank you!
Amy

[Patsy]

Just compare the list of ingredients on the labels one by one with the allowed food lists and the label reading tips in the book or RD kit. If all the ingredients are allowed, then the product is probably OK. If in doubt, leave it out during the elimination phase, you can be more "liberal" after the challenge phase or if the client is just doing a "Lower FODMAP" diet. As far as I know, nutritional yeast has not been analyzed, so I don't know the answer to that one.

[jonathan]

Hi Patsy,

My doc has recommended that I take 3000-4000 mg a day of fish oil. Do you see any problem with that?

Thanks! Jonathan.

[jonathan]

Oh, I forgot. He also recommends 500 mg of turmeric, 3x a day. What do you think?

Thanks again, Jonathan

[Mary H]

Dear Patsy,
Thank you!!! I have been reading your blog and using the 2nd edition of your book -- and many of my IBS symptoms are gone! It is so nice to be able to go to bed at night without feeling poorly - or make it through the middle of the day without cramps... can't thank you enough!
My question is about dairy and gluten/wheat products: I have been off them for a couple of years in an effort to help IBS. Is it true (from leaky gut proponents) that eating a little wheat/gluten or dairy would upset bowels for months? Should I do the challenges for these food groups? Last year I did try some low/no lactose cheeses but didn't think I did well with them (of course, now I know it could have been accompanying food).
Thank you again,
Mary H.

[Patsy]

Jonathan, I am confident that the fish oil does not have FODMAPs. The turmeric I am less sure of. It has not been specifically analyzed that I know of, but if I had to guess I would say it is probably OK. Turmeric powder is derived of the rhizomes of a plant in the ginger family. Ginger HAS been analyzed, and appears to be low FODMAP.

[Patsy]

Mary, great to hear you are feeling better! You have asked a tough question. I think you should seek personal advice from the health care provider who knows you best about the wisdom of reintroducing dairy and gluten, but I have some general opinions. I understand the reality that people can have increased intestinal permeability (technical term for "leaky gut")but my bias is against dogmatic or permanent prohibitions of any food or food component without a proven reason specific to the individual, such as the presence of celiac disease. I could go on and on about this, but only you can weigh the risks and benefits of reintroducing these foods. I don't think I would "challenge" with them so much as cautiously re-introduce them, a very little bit at a time, and monitor your symptoms closely for days to months. It would be ideal to have a local dietitian to help you with this project.

[Karen]

Hi Patsy,I have been on the elimination diet for 3 days and from the beginning things have been a lot worse!I was wondering if this ever happens before improvement.I've been careful following the diet,even though peanut butter is allowed I'm going to try switching to other nuts and see if that helps.Thanks! Karen

[Patsy]

Hi Karen, getting worse before improvement is not the "usual" with this protocol, although some people have a history of a rough time to any change in diet. More common would be certain constipated patients who have to wait a week or two before beginning to feel better, but they don't usually report to me that they felt worse at the beginning. Some questions to ask yourself...were you eating so little fiber before that even the modest fiber on the elimination phase was a sharp increase? Could you be eating something new that doesn't agree with you, like the peanuts you mentioned? Could you be eating larger portions than recommended of the items in bold face? Is a stomach bug going around your neighborhood? Have you stopped taking any meds or supplements that might have been helping you before, or added any new ones? If you had IBS-constipation dominant could you be one of those people that actually benefits from more whole grain fiber and polyols (apples, prunes, etc.) in the diet and you are suffering without them? Hope you can learn something from the experience, even if you find out that a low FODMAP diet is not for you.

[Karen]

Hi Patsy, I actually went from having a lot of fiber from all the fruit veggies,etc to much less now. I expected I might become constipated(usually problems are lots of gas and urgent stool) but instead I've been having diareah several times a day since the first day! I had taken Immodium a week ago(5 days before starting the elimination diet) which slowed things down a bit for 4 days. Could that have caused FODMAP's that I already consumed to linger and cause problems now? I haven't eaten anything new,even peanut butter isn't new for me.I have been eating quinoa,which I've had before with no problem,but just read it can help digestion to soak it(I just rinsed) I won't be having quinoa or peanut butter the next few days and see what happens.Thanks so much for your response!

[Karen]

Hi Patsy,one more thought.Maybe since I
am eating quite a bit less fiber I need more to firm things up? I've noticed in the past that things are a bit better on weekends,when I sleep late and only end up eating 2 meals plus snacks.So I'm eating less FODMAPS than other days,but still more fiber than now.

[Patsy]

Sometimes fiber can firm things up--gel, basically. Perhaps some oat bran cooked cereal or some ground flax seed would help?

[Olivia]

Hi there. Does anyone know if Aloe Vera contains fodmaps? I take it for my IBS but it's not mentioned in the book and I can't find out if it's suitable for the diet or not. Thanks!

[Patsy]

Sorry, no specific info on aloe vera is available, but since it is "known" as a laxative probably not a good idea for the elimination phase.

[erin]

Hi Patsy,

For the most part the FODMAP diet followed pretty closely has improved my symptoms a lot. It did take a few weeks though (I am a IBS-C) individual. Right now I am taking up to three servings of fiber a day and miralax. Do you think miralax would have any ill effect on my gut? I wish I didn't need to take it but I find it helps and otherwise my stool gets hard and irritates a fissure I have. If you have any other suggestions let me know.

[erin]

Hi Patsy,

The first time I tried the FODMAP diet I went through a serious obsession with cashews (clearly a mistake) as I see it is now listed as a fodmap. Although that time has passed, and i've cut out cashews, I am curious from a scientific point of view, what makes cashews a fodmap and not peanuts? Also, is there evidence that peanuts are gut irritants in any way?

[Eric in Seattle]

I thought that Aloe Vera was not recommended for oral consumption?

http://en.wikipedia.org/wiki/Aloe_vera#Dietary_supplement

http://nccam.nih.gov/health/aloevera

[Megan]

Hello Patsy, thank you for your book... I'm looking forward to trying the Elimination Diet. I have a question about goat's milk... I'm coming from a couple of years on GAPS and I'm dairy free at the moment other than ghee and lactose free whey, and was hoping to try raw goat's milk which I would ferment myself with kefir grains or yogurt culture. Will this be okay for FODMAPs? I read your explanation about goat's milk. I'm assuming it would be okay with raw cow's milk?
Also, is there any data yet on sea vegetables?
Thank you for your time, Megan.

[Patsy]

Erin--Miralax is supposed to be relatively safe for extended use and if you need it, you need it. Peanuts--funny, I know, you would think they would have more FODMAPs since they are a legume, but when they are actually analyzed in the lab it appears they are just very low in FODMAPs. No evidence that I know of would suggest peanuts are a gut irritant anyway, in the sense that caffeine or alcohol might be. Can a person have an individual sensitivity to peanuts or any other food? Sure. It could be that.

[Patsy]

Eric, the way you put it is overstating it a bit, as there are plenty of people who recommend it for human consumption to treat a variety of ailments. I personally would not recommend it for IBS patients because of potential laxative effects, and I think it is fair to say there are some other potential safety concerns as well.

[Patsy]

Megan, nothing yet on sea vegetables. As long as you ferment it long enough, kefir or yogurt made from either cow's or goat's milk should be virtually lactose free. Wish there was a way to know how long is "long enough" but 24-hour fermented yogurt seems to be well tolerated. I shouldn't think this would be affected by whether the milk was raw or not. Let us know how your kefir turns out!

[Megan]

Thank you Patsy!

[Amy Jones]

Quick question--have a client in the Fructose A challenge, and she is having issues finding a ketchup or BBQ sauce that has HFCS but is also free of garlic and onion (since those are in a different challenge). Do you have a recommended challenge brand?

Also,she is wondering about tomato paste and what challenge that would be in.
Thanks!
Amy

[Patsy]

I don't know of a ketchup or BBQ sauce that does not have onion or garlic; if anyone finds one, let me know!Tomato paste would be in the fructose challenge.

[Amy Jones]

So does that mean that she shouldn't try ketchup or BBQ sauce as part of the Fructose A challenge (because of the garlic and onion)? Or is the amount small enough that she could try?
Amy

[Patsy Catsos]

That's right. Unless a ketchup or a BBQ sauce without onions can be found, don't use during the fructose challenge.

[Jennifer MacWilliams]

My daughter is in the fructans challenge, can you recommend the best fiber bar to use? what about the high-fiber cereal?

[Patsy Catsos]

Trader Joe Fiber Bars and Fiber One Bars and most of the Fiber One cereals have lots of chicory root, chicory root extract or inulin. Some instant oatmeals marketed for weight control or heart health have inulin added. They may have minor amounts of other FODMAPs but they will be overshadowed by the large amount of inulin in them.

[Beth]

Is coconut yogurt or almond yogurt okay?

[Patsy Catsos]

Coconut and almond yogurt might be OK or not, depending on the other ingredients. The coconut milk and the almond milk part are fine.

[DeB]

My husband just started the FODmaps diet last week. He was diagnosed with IBS, but his main symptom was always extreme nausea. We went to the emergency room a couple times, before he was diagnosed because of extreme pain, tightness and tremors. After a lot of experimenting we changed his diet after he was diagnosed to food he could handle including plain potatoes and chicken breast baked, special k protein plus, corn chex, lactose free milk, apples and twizzlers red licorice. This helped, but the nausea was always there just more manageable. So after starting FODmaps we cut out the apples, twizzlers, special k and we have been trying to add other foods so he can get enough protein, vitamins and minerals and he is actually having other symptoms of IBS now. Mainly diarrhea everytime he eats his corn chex and lactose free milk. He is very frustrated, and I was wondering if we are missing something. Is it supposed to get better before it gets worse. Since he had IBS my husband has a hard time maintaining his weight, he put 15 lbs back on after he started eating special k protein plus, and I am worried that he is going to lose weight again. Help please!

[Patsy Catsos]

I can't give you personal medical advice in this venue, so I hope you are working with a dietitian locally. Check out my directory in the sidebar or ask your gastroenterologist for the name of someone knowledgeable about GI nutrition. I will comment generally that FODMAP intolerance is not one of those things that seems to get worse before it gets better. IF (capital IF) FODMAPs are the cause of symptoms, one should only feel better after removing them from the diet. Sometimes the improvement is faster, sometimes slower. Feeling worse suggests that FODMAPs are not the answer for that person.

[Beth]

Hi Patsy, I know fennel bulb, the vegetable is not allowed on this diet, but what about fennel tea which discards the seeds? I heard, from someone who has researched the diet, that fennel tea is okay. I trust you more, though. I drink fennel tea everyday for bloating. Thanks so much.

[Patsy Catsos]

I'm not sure about fennel seeds, I don't believe they've been analyzed. Fructans and GOS are water soluble, so IF they are in the seeds, and I'm not sure whether they are or not, they will end up in the tea water. Other seeds that have been analyzed tend to be OK in small amounts such as a tablespoon or two.