Successful Low-FODMAP Living — Experts Discuss Meal-Planning Strategies to Help IBS Clients Better Control GI Distress

March 2012 Issue

Successful Low-FODMAP Living — Experts Discuss Meal-Planning Strategies to Help IBS Clients Better Control GI Distress
By Kate Scarlata, RD, LDN
Today’s Dietitian
Vol. 14 No. 3 P. 36

Living with chronic abdominal pain, gas, bloating, diarrhea, or constipation is no walk in the park. For clients suffering from irritable bowel syndrome (IBS), these symptoms can greatly impact their quality of life. And yet 76% of those who suffer from IBS can better manage them by following a novel dietary approach that originated in Melbourne, Australia.1 Monash University researchers call this approach the low-FODMAP diet, known as fermentable oligo-, di-, and monosaccharides and polyols, a group of short-chain carbohydrates.

These carbohydrates can exert luminal distention via osmotic effects and rapid fermentation, resulting in gas, pain, and diarrhea in sensitive individuals. Since the majority of IBS sufferers acknowledge symptom improvement when following the low FODMAP diet, it’s important for RDs to be proficient in providing dietary guidelines and strategies to clients to help them plan menus, grocery shop, read labels, and make healthful food choices while dining out.

Research Behind FODMAPs
FODMAPs are found in everyday foods, including milk and ice cream (lactose); apples, pears, honey, and watermelon (free fructose); wheat, onions, garlic, and inulin (fructans); legumes (galacto-oligosaccharides [GOS]); and prunes, sugar-free gum, and mints (polyols). FODMAPs have a cumulative impact on gastrointestinal symptoms. Individuals may tolerate small amounts, but symptoms can develop if they consume quantities that surpass their threshold.

Studies have shown that ingesting FODMAPs exacerbates symptoms in most people with IBS, while dietary restriction of FODMAPs improves symptom control. Ong and colleagues2 from Monash University found that in those with IBS, dietary FODMAPs induce prolonged hydrogen production in the intestine to a greater degree. More recently, researchers at King’s College London found that the low FODMAP diet, in contrast to standard diet therapy for IBS management, showed improved overall symptom response in 86% of participants compared with 49% in the standard diet group.1 Halmos and colleagues3 found that enteral formula with the highest FODMAP content created a greater risk of diarrhea, a common concern with enteral tube feeding. Research supports the use of the low FODMAP diet in patients whose inflammatory bowel disease is in remission but who have enduring IBS symptoms.4 In patients with strictures, however, a low FODMAP diet is contraindicated, as the osmotic effects of the FODMAPs are likely to be beneficial in preventing intestinal obstruction.

Balance Good Nutrition With Symptom Control
When counseling clients about menu planning, factoring in their food preferences and lifestyle behaviors likely will help them adhere to the low FODMAP diet. The diet is somewhat restrictive but can provide adequate nutrients with careful planning. For those with lactose intolerance, meeting calcium and vitamin D requirements can be more challenging. Encourage consuming lactose-free milk; acceptable cheeses such as Swiss, cheddar, feta, and mozzarella; enriched rice milk; spinach; and canned salmon for low FODMAP calcium sources. You can suggest vitamin supplements as needed and choose those free of FODMAP ingredients such as sorbitol and mannitol.

Fiber intake can decrease when clients follow the low FODMAP diet so discuss low FODMAP fiber sources such as oatmeal and rice bran as shown in Table 1.

If clients need fiber supplements, suggest a nonfermentable fiber choice such as Citrucel.

FODMAP-Friendly Menu Planning
When helping clients plan menus, it’s a good idea to encourage them to develop a strategy and plan ahead. For example, since most commercial meat and vegetable broths are rich in FODMAP ingredients, suggest clients make a homemade broth by boiling water containing chicken breasts, celery leaves, parsnips, carrots, salt, and pepper. Save the broth and chicken for meals and side dishes during the week. They can make risotto, chicken pot pie, chicken salad, or chicken and rice soup. Recommend they make large batches of grains such as quinoa and rice and use them throughout the week to top salads, add to soups, or make a pudding. Since meats and oils are free of FODMAPs, clients can include them in recipes as desired. Using gluten-free pasta, pizza crusts, and bread instead of wheat-based products is a simple way clients can reduce fructans in their diet.

Clients who have functional gut disorders such as IBS or functional bloating often self-limit their diet beyond the low FODMAP guidelines. It may be necessary then to create menus that include other dietary restrictions in addition to the low FODMAP diet. The sidebars feature a typical low FODMAP vegan and nonvegan menu for breakfast, lunch, and dinner that you can share with patients.

Safe Snacking
Once clients are armed with menu ideas, encourage them to keep low FODMAP snacks on hand since they’re not always available while on the go. Here are a few ideas:

• Glutino pretzels and a mozzarella cheese stick

• Two rice cakes spread with a layer of peanut butter

• One banana and a handful of almonds

• Blue Diamond Almond Nut thins and Swiss cheese

• Lactose-free yogurt (Green Valley) with 1 cup of blueberries and 1 T of almonds

• Half of a sandwich using Udi’s white bread filled with sliced chicken, lettuce, and tomato slices

• One celery stick filled with peanut butter. Suggest clients eat just one, as celery contains mannitol, a polyol source.

Add Flavor Not FODMAPs
Clients who like to cook often use onions and garlic to flavor their food. But these pungent flavor enhancers aren’t suitable for those following the low FODMAP diet.

For onion flavor, substitute low FODMAP choices such as chives, scallions (green part only), and/or a dash of asafoetida powder. Found in Indian markets, asafoetida powder may contain small amounts of wheat, so advise clients with celiac disease to buy a wheat-free brand. For garlic lovers, suggest they sauté large garlic chunks in oil over medium heat until the flavor permeates the oil. Remove the garlic pieces before using the oil as a flavoring to ensure the dish remains tasty but low in FODMAPs. Warn clients not to add chunks of garlic to a water-based recipe and remove them because the fructans in the garlic are water soluble and may seep into the water.

Grocery Shopping the Low FODMAP Way
Once clients plan their menus, they’ll need to shop for ingredients. Maintaining a low FODMAP pantry is key to sustaining a low FODMAP diet. Here are some tips to help clients get started:

• Choose colorful fruits low in FODMAPs such as strawberries, bananas, blueberries, grapes, cantaloupe, pineapple, oranges, and kiwifruit.

• Select vegetables such as spinach, carrots, red bell peppers, eggplant, bok choy, tomatoes, zucchini, and potatoes.

• Purchase gluten-free, all-purpose flour blends that are free of soy. Bean flours such as Namaste Foods Perfect Flour Blend (www.namastefoods.com) or King Arthur Gluten-Free Multi-Purpose Flour (www.kingarthurflour.com) also are good choices.

• Select lactose-free dairy foods such as hard cheeses, including Parmesan, cheddar, and Swiss, and Green Valley Lactose-Free Yogurt and Lactose-Free Kefir Milk.

• Select a variety of meats, fish, and poultry and heart-healthy oils, which are all FODMAP free.

• Choose nuts and seeds low in FODMAPs such as walnuts, almonds, peanuts, pecans, pine nuts, macadamia nuts, and sesame seeds. Avoid FODMAP-rich pistachios.

Label Reading Strategies
As clients shop for low-FODMAP foods, they must learn how to read labels. Many people assume a gluten-free product is low in FODMAPs, but that’s not always the case. In fact, many gluten-free products contain honey, pear juice, onions, and garlic, so they aren’t appropriate for those following a low FODMAP diet. Tell clients that ingredients are listed with the most predominant ingredient first. So if honey is the last ingredient in the list (an indication it’s not used to sweeten the product), it’s likely a low-FODMAP food. Suggest clients avoid products in which FODMAPs are more abundant or if multiple FODMAPs are present. Furthermore, clients should take note of added fiber ingredients such as inulin, often labeled as chicory root extract and fructo-oligosaccharides. Both are sources of fructans and can trigger symptoms.

The sidebar below presents ingredients lists to illustrate a low and high FODMAP product. The bolded items are considered FODMAP sources.

Dining Out Without Consequence
Restaurants that serve gluten-free foods may be a good choice for clients on a low-FODMAP diet. Although the low FODMAP diet isn’t a gluten-free diet, both restrict wheat, which is a big source of FODMAPs. Since onions and garlic added to dishes may pose a problem, instruct patients to order foods without these ingredients. Hidden sources of onions and garlic include salad dressings and broth-based dishes such as risotto and marinades.

Suggest clients follow these tips for dining out:

• Bring a low-FODMAP roll, wrap, or bread to the restaurant and order a burger, grilled fish, chicken, or beef.

• Fill a thermos with lactose-free milk or rice or almond milk to add to your cereal, oats, or coffee when dining away from home.

• Order a salad and dress it with vinegar or lemon wedges and olive oil.

• Choose brown rice or gluten-free pasta with butter and Parmesan cheese, or a baked potato for a side dish.

Patsy Catsos, MS, RD, a Maine-based dietitian and FODMAP diet expert, says, “Many world cuisines are rice based, such as Thai, Chinese, Japanese, and Indian. Have a look at the menu and choose grilled or roasted beef, chicken, shrimp, or fish with traditional seasonings. Add rice or rice noodles with an assortment of steamed or stir-fried vegetables and ask to hold the onions. The sauces are likely to contain most of the FODMAPs in these meals, so either find out what they’re seasoned, sweetened, and thickened with or ask for them on the side so you can use just a little.”

In a pinch, clients can go to some fast-food restaurants that have low FODMAP options. For instance, clients can eat oatmeal from Starbucks or McDonalds. “Just use 1 tablespoon of dried cranberries or raisins,” Catsos suggests. Other low FODMAP options include Wendy’s baked potato, sushi, a banana, a small fresh fruit cup, a handful of roasted nuts, tortilla chips, sliced deli meat, chicken or tuna salad, a chef salad, hard-boiled eggs, cheese sticks, pumpkin or sunflower seeds, and even pickles, Catsos says.

More to Come
The low FODMAP diet will continue to undergo additional modifications as food samples are evaluated. Staying abreast of the research is essential to provide clients with the most up-to-date information. Recently, researchers have developed consumption cut-off levels for foods containing FODMAPs for those suffering from FODMAP-induced GI distress (less than 0.5 g per sitting as long as individuals meet FODMAP guidelines). Monash University researchers have provided the following recommended limits:

• Excess fructose limit is less than 0.2 g per serving.

• GOS and fructans limit is less than 0.2 g (less than 0.3 g for breads/cereals) per serving.

• Sugar polyol limit is less than 0.3 g per individual polyol or less than 0.5 g per total polyols per serving.

Australian researchers are preparing a food composition booklet called FODMAP Food Facts. This booklet should serve as a great tool to help clients and dietitians understand the FODMAP content of foods, make safe food choices, and stick to limits to avoid triggering symptoms.

IBS is a common condition, and dietitians are best suited to teach and translate the science to clients. Peter Gibson, a professor of medicine at Monash University and leading FODMAPs researcher, emphasizes the importance of the RD’s role: “Dietary restriction of FODMAPs is an effective therapy in the majority of patients with functional bowel symptoms. It’s a diet that should be taught by a dietitian, and it should be first-line therapy provided the dietitian is trained in the technique.”

— Kate Scarlata, RD, LDN, is a Boston-based dietitian in private practice who specializes in digestive health and the author of The Complete Idiot’s Guide to Eating Well With IBS.

References
1. Staudacher HM, Whelan K, Irving PM, Lomer MC. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011;24(5);487-495.

2. Ong DK, Mitchell SB, Barrett JS, et al. Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. J Gastroenterol Hepatol. 2010;25(8):1366-1373.

3. Halmos EP, Muir JG, Barrett JS, Deng M, Shepherd SJ, Gibson PR. Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP) content of the formula. Aliment Pharmacol Ther. 2010;32(7):925-933.

4. Gearry RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR. Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease—a pilot study. J Crohns Colitis. 2009;3(1):8-14.

Table 1: Fiber Without FODMAPs

Food	Portion Size	Grams of Fiber
Oatmeal	1/2 cup, dry	4.1
Oat bran	1/2 cup, dry	7.2
Rice bran	1/4 cup, dry	6.2
Strawberries	1 cup, halves	3
Blueberries	1 cup	3.6
Orange	1 medium	3.1
Spinach	1/2 cup, cooked	2.2
Baked potato, with skin	1 medium Russet	4
Quinoa	1 cup, cooked	5.2

— Source: USDA National Nutrient Database for Standard Reference

Low FODMAP Menu

Breakfast
Erewhon Corn Flakes
Enriched rice milk (organic Rice Dream)
Banana
1 T sliced almonds

Lunch
Udi’s white bread
Sliced turkey
Lettuce or spinach leaves
Tomato
Sliced cheddar cheese
Green Valley lactose-free vanilla yogurt
1/2 cup blueberries
Baby carrots

Dinner
Grilled chicken or salmon
Baked potato with skin (butter optional)
Sautéed spinach and red peppers seasoned with green part of spring onion, salt, pepper, handful of pine nuts, and olive oil
Kiwifruit

Low FODMAP Vegan Menu

Breakfast
Quinoa flakes
Enriched rice milk
3/4 cup strawberries
1 T sliced almonds

Lunch
Rice cakes with nut butter
Fruit salad with 1 cup (total) low FODMAP fruits (eg, kiwifruit, strawberries, blueberries)
Spinach salad with lemon dressing and cherry tomatoes

Snack
Carrots and red peppers dipped in tahini
Rice milk
Handful of almonds

Dinner
Tofu and vegetable stir-fry (red peppers, zucchini, summer squash, carrots)
Quinoa and millet sauté with pine nuts
Kiwifruit or orange

Low FODMAP vs. High FODMAP Label
Low FODMAP Bread: Filtered water, tapioca starch, brown rice flour, potato starch, sunflower oil or canola oil, egg whites, evaporated cane juice or sugar, tapioca syrup or brown rice syrup, yeast, xanthan gum, salt, baking powder (sodium bicarbonate, cornstarch, calcium sulfate, monocalcium phosphate), mold inhibitor (cultured corn syrup, ascorbic acid), ascorbic acid (microcrystalline cellulose, corn starch), enzymes.

High FODMAP Bread: Water, potato extract, rice starch, rice flour, sorghum flour, organic high oleic sunflower/safflower oil, organic evaporated cane juice, organic honey, egg whites, organic inulin, yeast, sea salt, organic molasses, xanthan gum.

Honey and molasses are sources of excess fructose and inulin is a fructan, making this bread a poor choice for followers of a low FODMAP diet.