IBS—Free at Last!

Nutrition Facts Panel and FODMAPs (U.S. only)

You can sometimes use the Nutrition Facts panel on a food package to figure out whether something has FODMAPs in it or not. Let's use Kikkoman Soy Sauce as an example.

First place to check is the list of ingredients at the bottom of the panel. If the product has added sugars, fibers, or polyols, or food ingredients that contain them, you will see them listed in the ingredients. This sauce contains water, wheat, soybeans, salt and sodium benzoate. Hmm. Suspicion is raised because it contains soy and wheat. But does it really contain FODMAPS?

Next place to check is total carbohydrates per serving of the food. All FODMAPs, by definition, are carbohydrates. "Total carbohydrates" on the Nutrition Facts Panel is the sum of the sugars, fibers, sugar alcohols and "other" carbohydrates (usually starches). If the total carbohydrates are zero, then one serving of the product is likely to be fine to eat on the FODMAPs elimination diet.

• Lactose and fructose would show up on the nutrition facts as "sugars".
• Fructans and galactans would show up on the nutrition facts as "fiber".
• Polyols (sugar alcohols) are harder to spot. If the product makes a claim on the label about sugar, and sugar alcohols are present in the food, they must be listed on a separate line. If not, they are lumped in with "other carbohydrates" which are often not listed on the food label at all.

In our example, the total carbohydrates listed on the food label are "zero". One serving of this food contains little or no FODMAPs, less than .5 grams of total carbohydrate according the FDA Rounding Rules. Is that low enough? It's low enough to slip under the guidelines for everything but polyols. If the food really did have .49 grams of polyols per serving it might be enough to trigger symptoms for some people. 

How can we make an educated guess whether or not this food might contain polyols? Polyols enter our diet as natural components of certain fruits and vegetables, and sweeteners added to food. Let's have one more look at the ingredients. There are no added sweeteners and no fruit or vegetable ingredients.

I conclude it is a very safe bet that this brand of soy sauce can be eaten during the elimination phase of the FODMAPs diet. You can use the same reasoning for other foods. Please comment if you have any brand name foods you can recommend to the rest of us!

FODMAPs - Dos and Don'ts for Vegetarians

Guest post by: Jillian Smith, Nutrition Student at the University of New Hampshire and Intern 

The FODMAPS elimination diet may seem difficult for vegetarians. Foods commonly consumed by many vegetarians, such as soy products, milk, and legumes are not allowed during the primary phase of the diet. Not only do these foods make up a large portion of the vegetarian diet, but they are also typically high in protein. Vegetarians may wonder how to consume enough protein. However, there are many foods included in the FODMAPS elimination diet that are allowed and provide plenty of protein to the diet. Don't let confusion or worry slow you down. The following list of do's and don'ts will help navigate vegetarians embarking on this diet. 

Do:

• Choose vegetarian high protein, low FODMAPs foods: quinoa, green peas, spinach, nuts, nut butters, seeds, seed butters.
• Make a large batch of seitan and add it to any meal. It works in casseroles, stir fries, or on the grill. It freezes well, too. (Note: seitan contains wheat gluten--in fact it IS wheat gluten.)
• Use lactose-free dairy products instead of other dairy substitutes. Lactose-free milk contains about 8 grams of protein per 8 oz. serving. Lactose-free cottage cheese is another great source of protein containing about 12 grams of protein per half cup serving. 
• Eat breakfast for dinner. Cook up your favorite egg dishes and serve them for dinner. Its a fun way to incorporate this high protein food into your diet. 
• Read labels! Get familiar with food labels of your favorite foods. Find higher protein alternatives. 
• Get creative! Try new and different combinations. Adding new flavorings to dishes will help you forget the absent foods.  

Don't:

• Rely on almond or rice milk for protein. They have only a 1-2 grams of protein per 8 fluid ounce serving.
• Stay on the elimination phase for more than two weeks. You need to liberalize your diet sooner than meat-eaters in order to get adequate nutrients.
• Don't over think it. The FODMAPS elimination diet will be easier with a clear and relaxed mind.

Update to Herbs and Spices

Herbs and spices can be used to make your FODMAPS elimination diet more interesting! Which ones are OK to use? The following is a list of suggestions for herbs, spice, and flavoring agents that are unlikely to cause IBS symptoms due to FODMAPs*:

• salt
• pepper
• vinegars of most kinds (check ingredients)
• lemon and lime juice
• granulated sugar
• maple syrup
• vanilla extract, real or imitation
• ginger root and turmeric
• green leafy herbs, either fresh or dried: parsley, oregano, cilantro, dill, marjoram, thyme, rosemary, mint
• chives and green (spring) onions--green part only
• paprika and ground chili powder
• seed spices such as: coriander, mustard, cumin, caraway, dill seed, celery seed, sesame seed, poppy seed, nutmeg
• cinnamon

Use caution with herbs and spices that tend to be used by the teaspoon or tablespoon in recipes, such as ground chili powder, cumin, and cinnamon. In such amounts they could contain enough FODMAPs to cause symptoms. Use caution with nutmeg, as it can cause nausea and vomiting in large amounts.

Expert opinion now suggests that cooking garlic and onions in water or broth probably releases fructans and is not recommended during the elimination phase of the diet, as fructans are water-soluble. However, garlic-infused cooking oil can add flavor to your food. Garlic and onion powder do contain FODMAPs and should not be used on the elimination diet.

*Remember that even though not containing significant amounts of FODMAPs, it is possible for people to have a unique food sensitivity to almost any food; avoid herbs and spices that are known IBS triggers for you.

Revised 9/11/2011

Peanut Butter Fudge Recipe

This peanut butter fudge was easy, delicious, and FODMAPS-friendly. I would post a picture of it, but there is none left to photograph. It was that good. We brought most of it to a Thanksgiving Day party and enjoyed the rest ourselves. It's nice to bring a dessert to a party that you are sure you will be able to eat and enjoy.

Peanut Butter Fudge

1 cup butter
1 pound natural peanut butter, unsalted (I used Trader Joe's--very smooth texture)
1 teaspoon vanilla
1 pound powdered sugar

1. Line an 8 x 8" baking pan with waxed paper.

2. Microwave butter and peanut butter together in large microwave safe mixing bowl until melted. Stir and check every two minutes until melted and smooth.

3. Add vanilla and powdered sugar to peanut butter mixture and stir to combine. Mixture should resemble a thick cookie dough. Add more powdered sugar if necessary to achieve the desired consistency.

4. Spoon the fudge into the baking pan and spread out to the edges with a knife.

5. Cover and chill. Cut into 1" square pieces and store in an airtight container for up to a week.

Servings: 64

We're Jammin'

When you need a little something sweet, what jams or jellies are FODMAPS-friendly? There are three things to consider: the fruit, the sweetener, and the total grams of sugar. Check the ingredients.

The fruit should be tart: blueberries, raspberries, strawberries, lemon.

The sweetener should be sugar or regular corn syrup (not high-fructose corn syrup).

The total grams of sugar per serving should not exceed 40 grams.

Make your own, or look for upscale or imported brands such as Stonewall Kitchen, Hero or Bonne Maman; there are many varieties that might work for you! Cheaper brands tend to be sweetened with high-fructose corn syrup. As usual, read the ingredients on the label before you buy, in case the manufacturer has made last minute changes.

For more information about the FODMAPS elimination diet, see IBS--Free at Last!, by Patsy Catsos, MS, RD, LD.

Does (Portion) Size Matter?

On a FODMAPS- (or fructose-intolerance-) friendly diet, does portion size matter? You bet. But only for foods that contain FODMAPS. Foods that do not contain FODMAPS can be eaten in the portions that are appropriate for your calorie needs and appetite, for example:

• allowed grains and starches
• allowed vegetables
• oils
• meat, fish, poultry, eggs
• lactose-free milk products

There are some foods allowed on the elimination phase of a FODMAPS elimination diet that do contain small amounts of FODMAPS. For these foods, portion size does matter. Examples include:

• allowed fruits
• sour cream or half-n-half or whipped cream
• sugar-sweetened foods
• nuts

In my book, IBS--Free at Last! you can recognize these foods because they are in bold-face type. I recommend limiting these foods to one serving per sitting. The servings are small. For example, blueberries are allowed, and the portion is 3/4 cup (corrected 4/22/10).

What would be the harm in having a whole cup of blueberries in one meal? Or adding a serving of whipped cream to the blueberries? Simply, you might not be able to absorb that much fructose fast enough to avoid "overflowing"--some fructose might end up unabsorbed, and might continue on to the large intestine where it could cause gas, bloating, and diarrhea.

For fruits and milk products, see the portion sizes listed in the book for a guideline. For sugar-sweetened foods, the rule of thumb is that your portion should contain less than 40 grams of sugar according to the Nutrition Facts on the food label.

Update to What about Vinegar?

Sprinkling your own oil and vinegar on salad is the FODMAPS-friendly way to dress it, since most commercial salad dressings have one or more ingredients that are not allowed during the elimination phase of the diet. I am often asked which vinegars are OK to use? The answer is that any filtered vinegar will do, in a 1 tablespoon portion. Filtered vinegars include white vinegar, white or red wine vinegar, champagne vinegar, rice or rice wine vinegar, and most flavored vinegars.

Unfiltered cider vinegar does retain some sugar in it, and it has an excess of fructose, so it is probably not appropriate during the elimination phase unless it is a minuscule portion. You can recognize unfiltered cider vinegar because it is cloudy in appearance, not transparent, like filtered or distilled vinegars are.

Balsamic vinegar has a 2 grams of sugar in a 1 Tb. portion, but luckily for us balsamic lovers, there is more glucose than fructose in it, so it is allowed on the elimination phase. For more information about the role of the fructose to glucose ratio, click here.

Update on 1/20/2010: Remember, even if a person has a verified problem with FODMAPS, other kinds of adverse food reactions can occur. Please read my post entitled: One of My Problem Foods is Allowed on the Elimination Diet. Vinegar is complicated. A person could be sensitive to the food the vinegar was made from. Vinegars vary in their degree of acidity. Aged vinegars like balsamic may contain phenylethylamine. Flavored vinegars may have additives; for example some commercially seasoned sushi vinegars contain high fructose corn syrup. Some stray yeasts can be present in raw vinegars. Malt vinegar contains gluten. And so on. All of these factors might influence a body's experience with consuming vinegar.

Sucrose, By Any Other Name...

Sucrose--good old table sugar--is one of the few allowed sweeteners on the elimination phase of the FODMAPS diet. In an effort to be more specific, more exotic or healthier-sounding, manufacturers use a great many different words on the food label that all mean essentially the same thing: sucrose. Here is a list of allowed sugar names you might see in recipes or the ingredients section of a food label:

• sugar
• brown sugar
• cane sugar
• confectioner's sugar
• granulated sugar
• superfine sugar
• naturally milled organic sugar
• sugar syrup
• cane syrup
• evaporated milled cane juice
• organic cane syrup
• organic sugar
• beet sugar
• bar sugar
• berry sugar
• castor sugar
• icing sugar
• refined sugar
• cane juice crystals
• invert sugar
• corn syrup (not high-fructose)

Remember, even if sweetened with sucrose, your treat shouldn't have more than 40 grams of sugar per serving during the elimination phase of the diet.

To learn more about the sweeteners named above, start with one of my favorite sites, Cook's Thesaurus.

Fructose 101

Fructose is known as "fruit sugar". It is present in fruits, some vegetables, honey, granulated sugar, agave syrup and high-fructose corn syrup. In the past, the human diet was lower in fructose than it is today--think of how hard it was to get honey in the wild, for example, or what a treat it would have been in the past to have fruit out of season, much less a never-ending supply of ketchup, cookies, candy and other sweets. Now it seems as though fructose is everywhere in our food supply.

Our capacity to absorb fructose is easily overwhelmed; it is almost considered normal to experience abdominal pain, flatulence, bloating or diarrhea when we overdo the amount of fruit or fruit juice we consume--many people have experienced this phenomenon. But some of us experience symptoms with much smaller intakes of fructose. And most of us overlook the impact that large portions of sugary sweets, baked goods and soft drinks can have. And what about those honey or fruit juice concentrate-sweetened energy bars? Interestingly, apples are part of the traditional BRAT diet sometimes recommended to fight diarrhea. Umm...maybe apples and apple juice aren't such a good idea for some people with diarrhea.

Diagnostic dietary fructose intolerance tests are available, but are not ordered as frequently in the US as they are elsewhere. If you suspect you don't tolerate fructose very well, try cutting back on soft drink and other sweets. Limit tomato paste. Choose small portions of fruits that are lower in fructose, such as kiwi, berries, citrus fruits, and bananas. Read labels, and avoid or limit portion sizes of foods sweetened with honey, fructose, high-fructose corn syrup, agave syrup and fruit juice concentrates.  See if you feel better!

Fructose malabsorption can occur on its own, or it can be part of the larger IBS picture.The FODMAPS elimination diet in IBS--Free at Last! can help you figure out how fructose fits into your IBS scenario.

It is important to distinguish dietary fructose intolerance, described in this posting, from hereditary fructose intolerance, which is a serious, hereditary disorder requiring a truly fructose-free diet.

Click here for more details about dietary fructose intolerance and how it causes GI symptoms.

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Agave

Agave nectar and agave syrup are the hot new sweeteners of the day. How do they fit into the FODMAPS elimination diet? Are they capable of causing IBS symptoms?

In my opinion, agave nectar and syrup products are sources of FODMAPS carbohydrates. I would not recommend using them during the elimination phase of a FODMAPS elimination diet.

According to the USDA, cooked agave plant has far more fructose than glucose in it. This is a set-up for fructose malabsorption and may cause symptoms for people with IBS. Also, cooked agave is about 10% dietary fiber. The type of fiber in agave is mostly inulin, which is defined a FODMAPS carb in the “fructans” category, and could also cause IBS symptoms.

The USDA nutrient database doesn't include agave nectar or syrup, so we don't have an authoritative source for nutrition information on these items. From what I gather, agave nactar and syrup are not standard products. Depending on how they are processed, the type and amount of sugars they contain can vary a great deal. The information I have seen on agave industry web sites indicates that agave nectars and syrups are high in fructose and osmotically active; these are described as selling points for the product.

I suggest holding off on agave sweetened products until the challenge phase of the diet; you could include during your fructose challenge.

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