Living with chronic abdominal pain, gas, bloat-ing, 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, Aus-tralia.1 Monash University researchers call this approach the low-FODMAP diet, known as fermentable oligo-, di-, and mono-saccharides 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 follow-ing 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 health-ful food choices while dining out.

Research Behind FODMAPsFODMAPs 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

By Kate Scarlata, RD, LDN

Experts Discuss

Meal-Planning

Strategies to

Help IBS Clients

Better Control

GI Distress

Low-FODMAPLiving

36 today’s dietitian march 2012

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 intes-tine 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 con-tent 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 dis-ease is in remission but who have enduring IBS symptoms.4 In patients with strictures, however, a low FODMAP diet is con-traindicated, as the osmotic effects of the FODMAPs are likely to be beneficial in preventing intestinal obstruction.

Balance Good Nutrition With Symptom ControlWhen counseling clients about menu planning, factor-

ing in their food preferences and lifestyle behaviors likely will help them adhere to the low FODMAP diet. The diet is some-what restrictive but can provide adequate nutrients with careful planning. For those with lactose intolerance, meeting calcium and vitamin D requirements can be more challenging. Encour-age consuming lactose-free milk; acceptable cheeses such as Swiss, cheddar, feta, and mozzarella; enriched rice milk; spin-ach; 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 on page 38.

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

FODMAP-Friendly Menu PlanningWhen 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 vegeta-ble 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

Low FODMAP Vegan MenuBreakfastQuinoa flakesEnriched rice milk3⁄4 cup strawberries1 T sliced almonds

LunchRice cakes with nut butterFruit salad with 1 cup (total) low FODMAP fruits (eg, kiwifruit, strawberries, blueberries)Spinach salad with lemon dressing and cherry tomatoes

SnackCarrots and red peppers dipped in tahiniRice milkHandful of almonds

DinnerTofu and vegetable stir-fry (red peppers, zucchini, summer squash, carrots)Quinoa and millet sauté with pine nutsKiwifruit or orange

Low FODMAP MenuBreakfastErewhon Corn FlakesEnriched rice milk (organic Rice Dream)Banana1 T sliced almonds

LunchUdi’s white breadSliced turkeyLettuce or spinach leavesTomatoSliced cheddar cheeseGreen Valley lactose-free vanilla yogurt1⁄2 cup blueberriesBaby carrots

DinnerGrilled chicken or salmonBaked 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 oilKiwifruit

march 2012 www.todaysdietitian.com 37

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 FOD-MAPs, 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 on page 37 feature a typical low FODMAP vegan and nonvegan menu for breakfast, lunch, and dinner that you can share with patients.

Safe SnackingOnce 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 FODMAPsClients 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 asafoe-tida 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 WayOnce clients plan their menus, they’ll need to shop for

ingredients. Maintaining a low FODMAP pantry is key to sus-taining a low FODMAP diet. Here are some tips to help clients get started:

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

•Select vegetables such as spinach, carrots, red bell pep-pers, 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 StrategiesAs clients shop for low-FODMAP foods, they must learn

how to read labels. Many people assume a gluten-free prod-uct 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 chic-ory root extract and fructo-oligosaccharides. Both are sources of fructans and can trigger symptoms.

The sidebar on page 39 presents ingredients lists to illus-trate a low and high FODMAP product. The bolded items are considered FODMAP sources.

Table 1: Fiber Without FODMAPsFood 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

38 today’s dietitian march 2012

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 assort-ment 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, sweet-ened, 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 table-spoon 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, tor-tilla 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 ComeThe 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 con-sumption 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.

Low FODMAP vs. High FODMAP LabelLow FODMAP Bread: Filtered water, tapioca starch, brown rice flour, potato starch, sunflower oil or canola oil, egg whites, evaporated cane juice or sugar, tapi-oca syrup or brown rice syrup, yeast, xanthan gum, salt, baking powder (sodium bicarbonate, cornstarch, cal-cium sulfate, monocalcium phosphate), mold inhibi-tor (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.

For references, view this article on our website at www.TodaysDietitian.com.

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