Amy Jones, MS, RD, LD, chief clinical dietitian for Mary Rutan Hospital talks about FODMAPs, the low-FODMAP diet and how they can potentially help with stomach discomfort.
FODMAPs and the low-FODMAP diet are fairly new to the gluten-free world. When people with celiac disease or non-celiac gluten sensitivity ‘(gluten sensitivity’) continue to have symptoms and it has been determined that gluten ingestion is not the issue, it may be beneficial to explore a low-FODMAP diet with an experienced professional.
To get some insight into FODMAPs and how the low-FODMAP diet could help people with gluten-related disorders, the National Foundation for Celiac Awareness (NFCA) talked to Amy Jones, MS, RD, LD, chief clinical dietitian for Mary Rutan Hospital.
Q. What does FODMAPs stand for?
A. The term FODMAPs is an acronym for:
Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols
FODMAPs are short chain carbohydrates that may be poorly absorbed in the small intestine. This can cause more water to be pulled into the colon and can also rapidly ferment, or be broken down, by bacteria in the bowel. This can cause symptoms like increased gas, bloating, constipation/diarrhea and pain. These symptoms are part of the diagnosis of Irritable Bowel Syndrome (IBS) and also overlap with celiac disease symptoms.
|
FODMAPs |
Examples of high FODMAPs* |
Examples of low FODMAPs |
|
Oligosaccharides |
Kidney beans, baked beans, garlic, onion, prunes, watermelon, rye, wheat, barley, inulin, chicory root, pistachios, cashews |
Gluten-free breads, corn/rice pasta, rice cakes, corn tortillas, almonds, peanuts, walnuts, pumpkin seeds, carrots, zucchini, lettuce, cucumber, spinach, green beans, potatoes, oats (limit to ½ cup gluten-free oats cooked for people with celiac disease)** |
|
Disaccharides |
Ricotta cheese, cottage cheese, milk, evaporated milk, ice cream, yogurt, custard |
Brie, lactose-free cottage cheese/yogurt/ice cream, sorbet, almond milk, lactose-free milk, Swiss/cheddar/mozzarella cheese |
|
Monosaccharides |
Apples, sugar snap peas, agave, honey, high fructose corn syrup (HFCS), tomato paste, asparagus |
Banana, strawberries, blueberries, cantaloupe, raspberries, pineapple, orange, lemon/limes, grapes, rhubarb, kiwi, (limit fruit to 1 serving per meal or less) pure maple syrup, table sugar, brown sugar |
|
Polyols |
Cauliflower, mushrooms, snow peas, apples, pears, watermelon, prunes, sugar alcohols (found in sugar free gum/mints, some medications, and cough drops |
Banana, Oranges, strawberries, blueberries, cantaloupe, grapes, kiwi, pineapple, lemons/limes, rhubarb, raspberries, Sweeteners: table sugar, aspartame, stevia, |
*The FODMAP content of every food and brand may not have yet been measured. Consult a registered dietitian nutritionist (RDN) for the most updated information.
** Oats are not considered high in FODMAPs. However, if you have celiac disease or non-celiac gluten sensitivity (‘gluten sensitivity’), you should purchase oats that are labeled gluten-free.
Q. What’s the relationship between celiac disease and FODMAPs? For some celiac disease patients who have persistent symptoms after adopting a gluten-free diet, how could a low-FODMAPs diet possibly help?
A. Celiac disease is caused by a reaction to gluten (the proteinfound in wheat, rye, barley, and Brewer’s yeast). Someone who is sensitive to FODMAPs is reacting to the type of carbohydrate(fructans to be specific) in wheat, barley, and rye. Those who have celiac disease or gluten sensitivity may also have issues with FODMAP carbohydrates. While they are both present in many of the same foods, it’s important to note that gluten is NOT a FODMAP.
Studies show that those with celiac disease who continue to have gastrointestinal symptoms after adopting the gluten-free diet may benefit from a trial of a low-FODMAP diet. In fact, many people who are newly diagnosed with celiac disease have some degree of lactose intolerance (a disaccharide), which usually resolves as the intestine heals.
For those with gluten sensitivity, the picture gets a bit more complicated. There are some studies that show that those with gluten sensitivity may actually be reacting to the FODMAP carbohydrate found in wheat, instead of gluten. Because there is no test to diagnose gluten sensitivity, it can be difficult to tell what a person is reacting to as symptoms of gluten sensitivity and IBS can be very similar.
Q. Can a person be more sensitive to one FODMAP over another?
A. Absolutely. While the FODMAP elimination diet removes all high FODMAP foods from the diet for a few weeks, the “challenge” phase is actually where you learn the most about what foods affect you. For example, when it is time to test your tolerance to lactose-containing foods, you might find that those are what bother you the most, or you might do just fine with milk products and find you have the most issues with onion and garlic. Everyone is different.
The most important thing to remember is that you shouldn’t stay on the low FODMAP diet forever. It’s meant to be a learning diet, not a diet you stay on for life – which is very different from the medically necessary strict lifelong gluten-free diet required for people with celiac disease. The goal is to find out which and how many high FODMAP carbohydrate foods you can tolerate.
Q. Does the consumption of FODMAPs cause any unique symptoms, or are they strictly gastrointestinal and similar to IBS?
A. FODMAPs affect everyone differently. In individuals with IBS, eating a diet high in FODMAPS can make them more fatigued and make digestive distress worse.
Q. How well does the FODMAP diet work, meaning, do most people have an improvement in symptoms?
A. A 2013 study of 90 patients with IBS who were followed for almost a year and a half showed that 75% felt improvement with those symptoms. Again, the goal is not to stay on a very low-FODMAP diet forever; rather, the goals are to figure out which foods create the most problems, and have the most balanced diet possible.
Q. Please explain the two phases of the diet.
A. The first phase is a strict elimination diet, which removes foods high in FODMAP for a period of 2-6 weeks. If you feel significantly better during that time, then some FODMAP carbohydrates may indeed affect you.
The second phase of the diet involves re-challenging foods by type. For example, the lactose challenge involves adding back in milk, cottage cheese, and/or ice cream. If those don’t seem to cause symptoms, then you can try another challenge group. These challenges should be done one FODMAP group at a time.
Like celiac disease and the gluten-free diet, it’s a really good idea to work with a registered dietitian nutritionist (RDN) who has experience in working with patients in this area.
Q. Is reintroduction of FODMAPs successful in most patients? Are people eventually able to return to a regular diet (gluten-free if required) where the amount of FODMAPs ingested no longer has to be limited or carefully monitored?
A. The goal of the low-FODMAP diet is to figure out which foods give you the most issues, and how much of those you can tolerate. Unlike food allergies or celiac disease, food intolerances don’t always behave predictably. Often it depends on how many other FODMAP carbohydrates you consume in a day. For example, some patients may tolerate a small amount of onion in a recipe, but have problems with large slices of onion on a sandwich.
Q. How do physicians and/or registered dietitians tell if someone has a problem with FODMAPs? Is there a test or a specific process involved?
A. There is no lab or medical tests available to see if you are sensitive to FODMAP carbohydrates. The best way to see if this is a problem for you is to eliminate high FODMAP carbohydrates from your diet (under the careful supervision of an experienced healthcare provider) for a few weeks to see if symptoms improve.
Hydrogen breath testing isn’t recommended routinely, as many people malabsorb fructose on testing but have no symptoms. Conversely, others may not malabsorb fructose on testing but still have symptoms when eating high FODMAP foods.
Q. What are some of the similarities and differences between the gluten-free diet and the low-FODMAPs diet?
A. Wheat, barley and rye contain both gluten and FODMAPs. The gluten-free diet restricts the protein in these grains, while the low FODMAP diet reduces the carbohydrates in these grains. Interestingly, some who thought they were reacting to the gluten in their cereal were actually reacting to the milk!
The good news is that these diets work very well together. If you have celiac disease, when it comes time to reintroduce wheat, rye or barley, you just won’t do that challenge.
As always, don’t start the gluten-free diet without being tested for celiac disease first. Because the symptoms of can be very similar, you don’t want to self-diagnose celiac disease. Learn more about getting tested for celiac disease here.
Q. Is there anything else you’d like to add?
A.There are symptoms that are NOT symptoms of IBS that should never be ignored. For example, if you have rectal bleeding, fever, weight loss, anemia, or a sudden increase in diarrhea that doesn’t get better, you should see you healthcare provider as soon as you can.
Those who don’t purchase or prepare their own foods (like someone living in a nursing home), those who are at risk for an eating disorder, children who are already anxious, or people who are underweight and at risk for malnutrition may not be a good fit for the low-FODMAP diet. Again, working with a registered dietitian nutritionist (RDN) who has experience in this area will increase your likelihood of success.
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