Friday, April 1, 2011

The FODMAP diet




"Functional gut" symptoms (bloating, wind, abdominal distension, discomfort, pain, altered bowel habits) can be controlled by diet, but most theories of how exactly food components are linked to symptoms are lacking consistency. In 2005, Peter Gibson and Susan Shepard gave us food for thought by defining highly fermentable but poorly absorbed short-chain carbohydrates and polyols as an important dietary factor contributing to these symptoms ( see their original article that coined the term FODMAPs - Fermentable Oligo-, Di- and Mono-saccharides And Polyols).

Their studies of different patient groups (Irritable Bowel Syndrome, Irritable Bowel Disease, celiac disease, fructose malabsorption, patients who underwent colectomy, etc) showed that reduction of the intake of FODMAPs may help to reduce symptoms, depending on other things these people usually eat.

FODMAPs are types of sugars and fiber, found in wheat-based and other foods:

Fructans and Galactins Polyols
Fructose
Lactose
Fructooligosaccharides
Galactooligosaccharides
Sorbitol
Mannitol
Xylitol
Maltitol

There is a cumulative effect of these foods, of their osmotic (water moving) and fermentative (bacteria feeding) actions, on IBS symptoms such as  abdominal pain, bloating, gas, altered bowel movements and lethargy. Irritable Bowel Syndrome symptoms could result from many different (and independent) reasons including  low absorptive capacity of the small intestinal epithelium, increased sensitivity of the bowel, rapid transit through the small bowel, and bacterial overgrowth in the distal small bowel.

This means that you may eat some of the problem foods listed in the tables and still fill fine. It's not about the foods eaten in isolation, it's about hundreds of food components that are adding up. To follow the right diet, you need to identify your individual sensitivities and dietary combinations.


For informational purposes only, we are listing candidate dietary components contributing to osmotic load and rapid fermentation thus increasing luminal pressure and distension, along with common high and low FODMAP foods - as listed in scientific publications. Red and green tables were compiled by a FODMAP-sensitive IBS sufferer based on his own experiences - check his post: "Printable FODMAP Diet Chart for your Convenience".  Another FODMAP list compiled by trial and error can be found here.



Fruits: 
•  Serving size is ½ cup 
•  Limit to 1 to 2 servings per day.  
•  Fresh or fresh frozen fruit may be better tolerated than canned fruit. 
•  Keep in mind tolerance may depend on the amount you eat at one time.  
•  Limit concentrated sources of fruit--such as dried fruit and fruit juices  
•  Avoid eating large amounts of any fruit. 

Intestine Friendly Avoid if
FODMAP Intolerant
Questionable
May Need to Limit
Bananas (could be gas forming), blackberries, blueberry, grapes (if half a serving or less than 10), grapefruit, honeydew, kiwifruit, lemons, limes, mandarin orange, melons, oranges, papaya, passion fruit, pineapples, raspberries, rhubarb, strawberries, tangelos
Apples, apple cider, apple
juice, applesauce, apricots,
cherries, dates, grapes,
lychee, mango, peaches,
pears, pear juice, plums,
prunes, watermelon
Other fruit juices or
drinks, sugar-free
jam/jelly, dried fruit,
canned fruit in heavy
syrup, other fruits


                                                     Vegetables:
•  Serving size is ½ cup (most vegetables) or 1 cup of leafy green vegetables
•  Limit to 1 ½ to 3 servings per day.
•  Cooked vegetables may be tolerated best as cooking causes a loss of free sugars.
•  Keep in mind tolerance may depend on the amount you eat at one time.

Intestine Friendly Avoid if
FODMAP Intolerant
Questionable
Bamboo shoots, bok choy, carrots, cauliflower (gas forming), celery, cucumber (gas forming), eggplant (gas forming), green beans (gas forming), green peppers (could be gas forming), leafy greens, parsnip, pumpkin, spinach, sweet potatoes, white potatoes, other root vegetables Artichokes, asparagus,
some beans (baked beans,
chickpeas, kidney beans,
lentils) beetroot, broccoli,
Brussels sprouts, cabbage,
cauliflower, fennel, garlic,
sugar snap peas, leeks, soy
products, okra, onions,
peas, shallots


Avocado, corn, mushrooms, tomatoes,
other beans

Other
Intestine Friendly Avoid if
FODMAP Intolerant
Questionable
Meat, Fat, Yogurt and hard cheeses, Eggs, Aspartame (Equal®
and Nutrasweet®),
Saccharin (Sweet ‘n Low®),
Sucrose (table sugar), Glucose, Maple syrup
Honey, Flavorings with fructose or sorbitol,
Desserts (ice cream, candy, cookies, bars, popsicles) sweetened with fructose or sorbitol,
Cereal or other processed foods with sorbitol or fructose on the label, Wheat,
Sherry and port wine, Sweeteners such as sorbitol, mannitol, xylitol, maltitol, and isomalt used in sugar-free gum, candies and mints

High-fructose corn syrup,
Lactose


And here are two more tables with foods already listed above, just to show why they are problematic for FODMAP-sensitive people.

Note that some of the foods listed as intestine friendly may be less friendly for some people inducing functional gut symptoms. Inulins - often included in prebiotic supplements - are longer chain fructans thus are expected to be more intestine-friendlier than fructans with low degree of polymerization.  Yet inulins often lead to increased wind.




    Scientific publications:

    Gibson PR, Shepherd SJ. Personal view: food for thought--western lifestyle and susceptibility to Crohn's disease. The FODMAP hypothesis. Aliment Pharmacol Ther. 2005 Jun 15;21(12):1399-409. Review.  


    Barrett, J.S., Gibson, P.R.  Nutrition issues in Gastroenterology, Series # 52  Clinical Ramifications of Malabsorption of Fructose and Other Short-chain Carbohydrates.  Practical Gastroenterology 2007 XXXI:51-65


    Gibson PR, Newnham E, Barrett JS, Shepherd SJ, Muir JG. Review article: fructose malabsorption and the bigger picture. Aliment Pharmacol Ther. 2007 Feb 15;25(4):349-63. Epub 2007 Jan 8.


    Gibson, P. & Shepherd, S. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology 2010 25:252-258.

    Biesiekierski JR, Newnham ED, Irving PM, Barrett JS, Haines M, Doecke JD, Shepherd SJ, Muir JG, Gibson PR. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011 Mar;106(3):508-14. Epub 2011 Jan 11

    Rangnekar AS, Chey WD. The FODMAP diet for irritable bowel syndrome: food fad or roadmap to a new treatment paradigm? Gastroenterology. 2009 Jul;137(1):383-6. Epub 2009 May 29. 


    Other links:

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