IBS

Is a Low FODMAP Diet a Healthy Diet?

This is a question I get a low from my clients, worried that this may be just another fad diet. The low FODMAP diet was created by the researchers at Monash University in Australia to alleviate symptoms in people with Irritable Bowel Syndrome (IBS). It is currently considered the best dietary approach for this condition and several research studies have shown it is successful in 50-80-% of people with IBS. 

The answer to the question “is the low FODMAP diet healthy” depends on how it is implemented. Let me digress for a moment to a better-known diet concept, that of a vegan diet. Most people would think that the vegan diet is very healthy as it brings to mind pictures of environmentally friendly, animal-loving people feasting on salads, nuts, and tofu.

However, the definition of vegan diet verges on what it excludes – all animal products – rather than what it includes – plant-based foods. You could, in principle, be eating French fries, cookies made without eggs or butter and drink sodas and you would be considered a vegan. Although I have exaggerated with this example (at least I hope so!), you get the idea: having a bagel with jam for breakfast, a vegan burger on a white bun with lots of ketchup for lunch and a big plate of pasta with tomato sauce for dinner may be closer to what uninformed vegans may be eating and hardly be called a nutritious diet.

Going back to the low FODMAP diet, whether it is healthy or not depends more on what you include than what you exclude. The low FODMAP protocol teaches you to avoid high FODMAP foods (at least during the elimination phase) or minimize them according to tolerance once you have figured out your own personalized FODMAP diet. Many people, however, end up avoiding all high FODMAP foods long term either because they are afraid of re-challenging them or they don’t know that the low FODMAP diet is not supposed to be a life-long diet. And, especially during the elimination phase, they may get into a routine of eating the same few types of vegetables and fruit, or avoiding some foods, like legumes and dairy altogether.

The message I am trying to bring home here is that a poorly planned low FODMAP diet can lacking in important nutrients like calcium and B vitamins, and in fiber. Working with a dietitian who is an expert in the low FODMAP diet can help you avoid this common mistake. Here are a few questions you may ask yourself to get an idea about how healthy your low FODMAP diet is:

1. Am I eating enough fiber?

You don’t need a nutrition software to know whether you are eating enough fiber. Write down what you eat for a few days or a week and look back at your diary: are you eating vegetables at your main meals and at least one snack? Are you occasionally eating low FODMAP servings of canned lentils or chickpeas? Are you including some nuts and seeds? See my 5 Tips to Eat More Fiber on a Low FODMAP Diet for more ideas. 

2. Am I eating enough calcium?

Contrary to common belief, the low FODMAP diet is not a lactose-free diet. It is a low lactose diet and can include small portions of some hard cheese and cream cheese. Small amounts of lactose can be tolerated even by lactose-intolerant people. It is not a dairy-free diet either and you can eat plain lactose-free dairy freely. If you are avoiding dairy for other reasons (allergy to milk protein, ethical reasons, or you just don’t like them), there are many alternative calcium sources. And, yes, even vegans can eat enough calcium if they plan their diet well.

3. Am I eating the colors of the rainbow?

Is your diet white and red (gluten-free pasta and tomatoes) or do you choose vegetables and fruit with all the colors of the rainbow? This is an easy way to ensure you get the bounty of vitamins, minerals, and phytochemicals that vegetables and fruit have to offer. Chard, kale, spinach, carrots, red peppers, eggplant, kabocha and summer squash are just some of the vegetables that have either negligible or small amounts of FODMAPs and can be eaten freely or in fairly large portions. Fruit can be usually enjoyed in half-cup portions per meal or snack. In the spring and summer, strawberries, raspberries, blueberries and cantaloupe or honeydew are great low FODMAP choices, whereas in the fall/winter look for the citrus fruits and kiwi just to name a few.

If you answered yes to all these questions – great job! If you answered no to at least one of these questions, try some of the suggestions above and look at the Monash University Low FODMAP Diet App for guidance on foods and serving sizes.

Probiotics for IBS: To Use or Not to Use? That is The Question

Probiotics are a hot topic these days. Articles in magazines highlight them, supplements are growing in greater numbers, and certain foods are supplemented with them.

Why do probiotics get so much attention? Probiotics are microorganisms that can live in our gut and might improve gut health. The scientific definition is: “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host”. Some of these potential gut benefits include fighting off bad bacteria, protecting the lining of our intestinal tract and minimizing intestinal permeability (also known as “leaky gut”). Studies in people with IBS are suggesting that they may also improve some symptoms.

It would seem natural for someone with IBS to think about trying one, but should you? It’s a big question without an easy or straightforward answer. Here are a few key points from the emerging literature:

1.   After only 3-4 weeks of a low FODMAP elimination diet, gut bacteria decrease in numbers and variety and probiotics may be useful in restoring them.

2.   A lot of research has been done to study the effects of probiotic supplementation in people with IBS but we don’t yet have all the answers and there isn’t enough consensus to give firm recommendations.

3.   Nonetheless, probiotics seem generally safe to use and if you’d like to try one, the researchers at Monash University recommends that you:

  • Don’t’ expect miracles, the improvement in symptoms may be mild at best
  • Take them consistently for 4 weeks as it may take that long to see any benefits
  • Make sure there aren’t any prebiotic fibers mixed with the probiotic supplement (such as inulin or fructo-oligosaccharides) as these may be poorly tolerated in people with IBS.
  • Those who are most likely to benefit from are IBS patients with mild symptoms and those with compromised microbiome, such as in post-infectious IBS.
  • Test only one management strategy at a time: try the low FODMAP diet first, then consider probiotics
  • Ask your doctor or gastroenterologist to recommend a product that has been researched for IBS and is most suitable for your symptom profile
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Last but not least, probiotics may be naturally present in some foods. You may want to consider including some low-FODMAP prebiotic foods in your diet:

  • Lactose-free yogurt and kefir
  • Some types of low-FODMAP cheese (mozzarella, cheddar, cottage cheese)
  • Miso
  • Tempeh
  • Sourdough spelt bread (unless you have celiac disease are gluten intolerant)

After you have completed the re-challenge phase of the low FODMAP diet, you may expand the range of probiotic-rich foods. If you tolerate the mannitol (a sugar alcohol), you may be able to eat small portions of sauerkraut or kimchi (beware that some may also contain garlic). If you tolerate oligosaccharides, you may be able to drink some kombucha. If you’d like to learn more about probiotics for IBS, read this great article from Monash University.

6 Tips for Eating Out on a Low FODMAP Diet

Preparing all your meals at home would be ideal while following a low FODMAP diet, as you have more control on what and how much you are eating. Still, it’s hard to avoid eating out completely. Whether you have a dinner date at a restaurant, are invited to a wedding, or need to travel, here are a few tips on how to navigate restaurants without getting GI symptoms.

1. Choose your restaurant wisely

This is key when you eat out. You will find blogs on how to choose meals at various ethnic restaurants (Chinese, Indian, Italian) but it will make your life simpler at this point to avoid certain restaurants altogether. For example, Indian dishes almost always include garlic and/or onions and mostly feature high-FODMAP vegetables and legumes. Chinese and Thai restaurant may be better as most of their dishes are rice-based but they rely a lot on garlic and onions when cooking vegetables or meat/poultry. Even if you find a gluten-free pizza place, the tomato sauce is almost always made with garlic and/or onions, and there is usually is way too much cheese. You will be able to eat in a variety of restaurants after you have learned what your trigger foods are but for now, keep it simple.

2. Keep it simple

Restaurants that will more likely have low FODMAP choices are those where you can order a chicken/meat/fish entree with a choice of side dishes. You can look up the menu for options such as rice and potatoes and a low FODMAP vegetable (kale, carrots, bell peppers, etc.). Look up the list of vegetables in the Monash App for more choices and appropriate serving sizes. If you are a vegetarian you can ask for firm tofu as a substitute for animal protein. Or have a protein-rich snack before your leave the house, and eat the starch and vegetables at the restaurant.

3. Beware of hidden FODMAPs

Stay away from menu items that may have hidden FODMAP ingredients: soups, stews and risotto (garlic and onion in the broth); marinated meats/fish or hamburgers (may have garlic or onion powder); sauces and salad dressings; creamed-based soups or pasta sauces.

4. Keep the portions small

Keep in mind that most restaurants serve portions that are larger than those most of us prepare at home, and any large meal may trigger symptoms in people with IBS. Have a low-FODMAP snack before going out so you don't get too hungry and take some of the restaurant food home to keep your meal size moderate. 

5. Don’t be afraid to ask

Do your homework before you head out or choose the restaurant and peruse the menu to see whether you have a few low FODMAP choices. Call ahead and ask the staff whether they allow substitutions (they may have ingredients they don’t feature on the menu that you can have in place of high-FODMAP items). Explain you can’t have even a trace of garlic and/or onions. Whereas pretty much everyone today is familiar with the term gluten-free, waiting staff or even chefs may not know what a FODMAP is and you will need to ask precise questions.

6. Avoid potential FODMAP overloading

If you plan to eat out ahead of time, make sure you are as strict as you can with your other meals and snacks. If you eat as low FODMAP as possible during the rest of the day, you will avoid the build-up effect of adding too many FODMAPs in the same day. And, if you end up eating a high-FODMAP ingredient accidentally, the effect will hopefully not be as bad, as your overall FODMAP load will be lower.

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Timing of IBS Symptoms

IBS symptoms are life-disrupting at the very least and it is understandable that people afflicted by this condition wonder why they happen when they happen.

For example, you have breakfast and, within minutes, you need to run to the bathroom and experience abdominal cramps and diarrhea. You conclude the symptoms were triggered by one or more of the foods in your breakfast. Correct? Not exactly.

Let's take a closer look at how the GI system works. After you eat, it may take (according to research studies) from 12 to 48 hours for the food to move all the way to the end of the GI tract (mouth to colon). When you are trying to figure out which food(s) may have triggered your symptoms, you need to look further back to the meals in that time period.

You may then wonder: why do you sometimes experience symptoms right after eating? This is more likely due to the effect of hormones and nerve regulators that are stimulated after a meal. For example, there are hormones that stimulate the production of digestive enzymes. Also, when the food enters the GI tract, it stretches the intestinal walls and triggers nerves that stimulate muscles which push food through the GI tract.

As digestion may take hours to days to be complete, there are always food particles (and possibly FODMAPs) in your GI tract from a meal you ate earlier that day or even the day before. The symptoms you experience, therefore, are delayed symptoms: they have nothing to do with the meal you just ate but are likely due to foods in a previous meal.

The bottom line? It is quite tricky for anyone to interpret the origin of their symptoms. The best way to track them is to keep a food and symptom diary, where you write down what you eat and the timing of your symptoms. As you do this day in and day out, you may notice some interesting patterns. If you are still confused, write a detailed list of foods (including the timing of your symptoms) for at least 2 days and ask an expert dietitian to help you figure out what foods may trigger them.

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