IBS--Free at Last!

Love garlic, hate FODMAPs?

It's easy to get the flavor of garlic into your favorite dishes without eating a load of FODMAPs.  Prepare this easy recipe for garlic oil, then use it as a cooking or seasoning oil in any FODMAPs-friendly recipe that would benefit from a shot of that incomparable garlic flavor:

Garlic Oil

1/2 cup olive oil
3 large cloves of garlic, wash, peeled and slightly crushed

Pour olive oil into a small, heavy saucepan. Add the slightly crushed garlic. Heat oil until small bubbles rise vigorously from the garlic. Remove from heat. Garlic will continue to cool. Allow the garlic and oil to cool for a few minutes, then pour them into a freshly washed glass jar with a lid. Store in the refrigerator for up to a week. Remove the garlic before using the oil. Olive oil will sometimes get a little cloudy or solidify when it is refrigerated, but it will quickly melt back to its familiar form when you remove a spoonful. Use this as a cooking or flavoring oil to modify any recipe in your collection that calls for garlic.

Note: To make sure your garlic oil is safe to eat, do not store it on the counter at room temperature, and do not eat it it if it has been in the fridge for a month! Garlic oil can go bad like any other fresh food.

Why not just used garlic powder, dried or dehydrated garlic? Although a small pinch of these certainly would not have as much fructans as would eating a few cloves of fresh or roasted garlic, they still have some. Garlic-infused oil is the better option.

Intolerance to a Single Food; Don't Overgeneralize.

This question comes up frequently: If you know you react to a food within a group (eg wheat/fructans) can you assume that you will react to all foods within that group.. in other words could you react to some fructans but not others?

Good question. Remember with FODMAPs we are trying to assess tolerance to a type of carb (ex. fructans) in our food rather than out tolerance to individual foods. If you do an organized challenge process, the outcome might be that you learn you do not tolerate fructans in general very well. But you cannot assume that just because you react to a single food in a group that you will react to others.

Here are a few reasons why: You might be allergic to that food; you might have celiac disease or non-celiac gluten intolerance(in the wheat example you gave); other foods in the same group might have much less fructans per serving than the one that bothers you; your portion size of other foods in that group might be much smaller, the specific type of fructans in the food might be more or less rapidly fermentable than others, etc.

It's important not to overgeneralize, because its a nutritional mistake to unecessarily restrict your diet.

Thoughts About Spelt and other Yeast Breads

A reader has asked for my latest thoughts about spelt, and whether it is allowed or not allowed. Love the stuff, but it is confusing! Here's what I know: Spelt is definitely an ancient variety of wheat. (It is not gluten free, which we don't care about so much for FODMAPs purposes.)

There has been a small flurry of new FODMAPs data on spelt coming out that is a little difficult to interpret. One Australian 2011 paper that you may have read reported that spelt bread was very low in fructans, lower than wheat; the bread that was analyzed appeared to be a sourdough spelt bread. A German 2007 paper found that spelt "wholemeal" and flour have MORE fructans than wheat . Meanwhile, we just saw a 2011 UK study published that found gluten free breads were about like wheat breads for fructan content (but did not analyze spelt breads). In reality the fructan content of these foods is on a spectrum, and it a matter of where we draw the line about how much fructans is too much. My interpretation on breads at the moment (and I would love to revise it as soon as I see more comprehensive data) in order:

rye bread (has the most fructans)
whole wheat, white, gluten-free of various types, spelt breads (all about the same)
white and wheat sourdough (guessing)
sourdough whole spelt (guessing)
sourdough refined/white spelt (has the least fructans)

I am inclined to keep spelt off the elimination diet for now--not allowed--until we see more complete data. However, after the challenge phase is over, sourdough spelt bread in particular might be especially well tolerated. I am guessing that maybe white wheat sourdough and even whole wheat sourdough would be the next best tolerated. Authentic sourdough breads are allowed to ferment over a much longer time period while rising than breads to which baker's yeast is added, and that may break down some of the fructans. (Must ask for specifics where the sourdough bread is made--sometimes baker's yeast is added even to sourdough to speed up the rise--not as good for our purposes.)

As always, there can be non-FODMAPs issues that influence a particular person's tolerance of these products, including celiac disease, non-celiac gluten intolerance, immune-mediated sensitivity to rye, wheat, spelt or baker's yeast, plain old wheat allergy, etc.

New note: Kate Scarlata, author of The Complete Idiot's Guide to Eating Will with IBS, recently returned from a FODMAPs educational event in Autralia. She learned that the FODMAPs content of grains can vary with growing conditions. Fructans, being the storage form of energy for the spelt or wheat plan, are lower in grains that have grown under drought conditions. Interesting.

What's the word on rye?

The sources I used to create the allowed food lists for the FODMAPS elimination diet suggest that in clinical practice rye seemed to be reasonably well tolerated and is not considered problematic, although it does contain fructans. A more recent publication by the same work group puts rye on the "problem" list (Gibson PR, Shepherd SJ, Evidence-based Dietary Management of Functional Gastrointestinal Symptoms: The FODMAP Approach. J Gastroenterol Hepatol 2010;25(2):252-258). This is creating some confusion, and a lot of questions from sharp-eyed readers and dietitians!

After doing some extra digging around, I conclude that this is an excellent example of the importance of cultural context in  In the US, for example, rye consumption is rare and in minor quantities. Even most rye breads in the US have more wheat flour in them than rye. This makes rye not "problematic" here, as in Australia.

In Scandanavian countries, on the other hand, rye may be eaten daily, and in larger amounts. According to a paper I recently read (Karppinen S, Dietary Fibre Components of Rye Bran and Their Fermentation In Vitro, VTT Technical Research Center of Finland, 2003) rye is the number one source of dietary fiber in the Finnish diet. That paper also reports that the fructan content of rye is significantly higher than that of wheat (typographical error corrected 8/18/10). Put those two facts together and you HAVE got a problematic food, at least in some parts of the world.

Looks like rye should be removed from the allowed food lists for the basic elimination diet, and added to the fructans challenge list. When all is said and done, most people will be able to eventually include rye in their diets in small quantities.

Remember, rye contains gluten. People with celiac disease shouldn't eat rye at all, even in small quantities.

Wheat Flour

Wheat is not allowed on the elimination phase of the FODMAPS elimination diet because wheat contains fructans. Sometimes, as I teach the diet to clients, it dawns on me they think I am referring only to whole wheat bread, or whole wheat flour when I say that wheat products are not to be consumed during the trial period.

This post aims to make clear that white bread and pasta are also made of wheat unless otherwise specified! You might see any one of the following "wheaty" ingredients listed on the food label or recipe (this list is not exclusive):

enriched flour or enriched wheat flour

all purpose flour

cake flour

pastry flour

self-rising flour

unbleached flour

stone-ground wheat flour

graham flour

semolina flour

durum wheat flour

whole wheat flour

white wheat flour

sprouted wheat

cracked wheat

Still in doubt after reading the ingredients list? In the United States, products containing have a statement on the nutrition facts panel to the effect of "Contains: wheat".

For more information about the FODMAPS elimination diet, see IBS--Free at Last!

Fructans 101

Fructans are a group of food fibers. As you might guess from the name, fructans are chains of ring-shaped fructose sugars. Humans don't have what it takes to break these chains apart, so the fructose in the chains is not absorbed in the small intestine where other sugars are absorbed. When these dietary fibers reach the large intestine, they are fermented by the bacteria that live there, producing gas. This is no problem for many people, and sometimes fructans are even deliberately added to foods or probiotic supplements for the specific purpose of feeding the "good" bacteria. But for some people with IBS, the gas causes painful bloating.

By far the largest source of fructans in the Western diet is wheat.It accounts for 70% of our fructans intake. The second biggest source is onions, followed by garlic and unripe bananas. You can recognize added fructans in your food or supplements by the names "inulin" or "FOS".

It is important to note that even though wheat happens to be the primary source of fructans in our diets, intolerance of this kind has nothing to do with the wheat protein, gluten, which those with celiac disease must avoid. For a more complete discussion of fructans intolerance versus gluten intolerance, please see my recent guest post on the Kitchen Therapy blog.

My Guest Post on Kitchen Therapy

My friend, Linda, invited me to write an article for her KitchenTherapy blog, and it was published today! The article is entitled "Wheat-Free, Gluten-Free, FODMAPS-Free" and explores the FODMAPS concept from the point of view of those who have a gluten-free lifestyle. Kitchen Therapy is one of my favorite blogs, with inspiring posts about gluten-free cooking, recipes, gardening, and more. Pop on over there, visit, and be sure to comment on my article for a chance to win one of my books, IBS--Free at Last!

Stevia

Stevia, also known as "candyleaf", is a bush native to Central and South America. Extracts from the stevia plant are rapidly appearing in our food supply since the FDA recently recognized the "Generally Recognized as Safe" (GRAS) status of the extract, Reb A. This has raised the question of whether stevia products are allowed on the FODMAPS elimination diet.

Reb-A, the stevia derivative used in most products, is up to 300 times sweeter than sugar. It is used in very minute quantities, and has zero calories. With no sugars or fibers to be malabsorbed or fermented, it cannot be a FODMAP, therefore it is allowed on the FODMAPS elimination diet.

Be aware of what fillers are used in the stevia product, however. Many of the products are designed to be substituted for sugar on an equal volume basis. For example, you are supposed to be able to substitute 1 cup of stevia product for 1 cup of sugar. If less than one percent (1/300th) of the product is stevia, you have to ask yourself, "What is the other 99% of the white fluffy stuff in the measuring cup or packet"? Some of those fillers are definitely fermentable by gut bacteria, and shouldn't be consumed on the elimination phase of your FODMAPS elimination diet. Some manufacturers consider this a plus, and are market the stevia product as "pre-biotic", which translates to "food for gut bacteria". Although this may be fine for most people, in my opinion, IBS sufferers who are sensitive to FODMAPS could potentially experience symptoms when consuming these fillers in large quantities. I'd suggest waiting to try them during the fructans challenge phase of the diet.

If you can locate a stevia product with no fillers, such as a SweetLeaf SteviaClear, you can use it during the elimination phase. You may be able to locate stevia products that are filled with "allowed ingredients". For example, Truvía, manufactured by Cargill, can be used during the elimination phase, as it is filled with erythritol, which is not fermentable by gut bacteria.

Finally, don't forget that foods sweetened with good old-fashioned table sugar and maple syrup are allowed on the elimination phase of the FODMAPS diet. While it isn't necessary to use non-nutritive sweeteners such as stevia on the diet, it is nice to have options.

Update 9/23/09 Sun Crystals with Stevia is another product you can use during the elimination phase of the diet. It's ingredients are pure cane sugar and stevia.

Buy IBS--Free at Last!

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.

Buy IBS--Free at Last!