Monday, 27 April 2015

Low FODMAP diet – not a ‘lifetime’ diet

Dr Jane Varney



A common misunderstanding concerning the low FODMAP diet is that it is lifetime diet (similar to the strict gluten-free diet that individuals with coeliac disease must adhere to for life).   

Well, this is far from true. A strict low FODMAP diet should be trialed under the guidance of a dietitian, for a period of only 2-6 weeks. People who experience symptomatic improvement during this strict phase (our research suggests that around 75% will) should then enter a re-challenge phase, during which a dietitian assists the reintroduction of FODMAP containing foods, in a systematic manner, to determine your individual level of tolerance to the various FODMAP subgroups. 


The type and quantity of food that you are re-challenged with is usually agreed upon between yourself and the dietitian. It might be that you begin by re-introducing the foods that you miss the most or that you re-challenge with foods rich in a particular FODMAP, for example, mango if you wanted to assess tolerance to fructose.

Although individual FODMAP tolerance varies, most people find that they are able to liberalise their FODMAP intake, whilst maintaining reasonable symptom control. Ultimately, the goal is to achieve a balance between the restriction of some high FODMAP foods (to a level that provides symptomatic relief) and the reintroduction of FODMAP-rich foods which are better tolerated. Often people are able to reintroduce many high FODMAP foods back into their diet, but may not be able to eat them as often or in the same quantity as they did before.

Why do we advise you not to remain on a low FODMAP diet for life? 


There are a few reasons. Firstly, we know that some FODMAP rich foods promote the growth of good bacteria in your bowel. This is known as a ‘prebiotic effect’ and we think it is not ideal to restrict prebiotic fibres over the long-term. It is also a restrictive diet that can compromise your intake of fibre, calcium and B-vitamins. 

Finally, a low FODMAP diet can be inconvenient and socially difficult to follow, as foods previously consumed on auto-pilot become off-limits; recipes require adjustment, and eating out becomes challenging.

So the take home message: if you have diagnosed IBS, see a dietitian about trialing a strict low FODMAP diet, but ensure you follow-up with him/her 2-6 weeks later to discuss the re-challenge phase. In the long run, you only need to limit your FODMAP intake as strictly as your symptoms require! 


Other suggested readings:
Click here to read another blog post that explains the re-introduction phase in more depth.e Low FOMAP diet being not a 'lifetime' diet.



17 comments:

  1. I have been on the diet for 1 year, my health has improved dramatically, I have put on weight (I was underweight) and have energy I didn't have before. I don't see the problem with staying on the diet. I don't miss many foods and I still get problems even with low fodmap food if I eat too much in one time. So it is an individual thing and I don't see how a dietician can help.

    ReplyDelete
    Replies
    1. Hi Linda,
      This advice is all assuming your IBS has been properly diagnosed by a doctor.
      There are a few reasons to reintroduce FODMAPs.
      -Low fodmap diet can compromise fibre and calcium intake
      -Low fodmap diet may adversely affect gut microbiome if followed long-term.
      -Some people miss higher FODMAP foods and are keen to rechallenge with these
      -individual tolerance to FODMAPs varies. Eg some people will be intolerant to polyols, while others won't.

      If done systematically, rechallenge phase (directed by a dietitian) can identify which FODMAPs you tolerate and how much, enabling you to include a greater variety of foods in your diet.

      Remember though, portion control is important. Even 'green' foods may trigger symptoms if eaten in sufficiently high quantity.

      Kindly,
      Dr. Jane Varney
      Monash FODMAP

      Delete
  2. My husband has been on a strict FODMAP diet, (initially guided by a dietician recommended by his gastroenterologist) for 2 years (lactose tolerated). His health and symptoms improved immediately and dramatically. He has periodically eaten small amounts of foods normally restricted but symptoms reappear. So he remains permanently on his FODMAP friendly diet

    ReplyDelete
    Replies
    1. Hi LW,

      It is recommended that you try the re-introduction phase again with the guidance of a dietitian to assess which foods are less problematic and suitable in small amounts.

      Kind regards,

      The Monash University Low FODMAP team

      Delete
  3. I have been on the diet for a few weeks and the bloating had mostly disappeared. So I tried reincorporating wheat back into my diet by eating a plate of noodles (wheat was the only thing high in FODMAP) and the bloating came back. Does that mean I will not be able to enjoy noodles and bread for the rest of my life?

    ReplyDelete
    Replies
    1. Hi Yu Yang,

      Fortunately, it does not mean this. What you may need to do is trial different types of noodles/breads, but more importantly trial the portion sizes you consume in one sitting but also trial how much you have across the day. This is why we recommend you see a dietitian who can specifically gauge your specific tolerance levels. You can find one who specialises in this area by visiting http://daa.asn.au/

      Kind regards,

      The Monash University Low FODMAP team

      Delete
  4. It took awhile for me to feel comfortable reintroducing foods but I slowly did and it has been worth it. I have a more balanced and healthy diet. I still need to play with amounts and types of foods but it has been easier for me to catch when I ate too much of something that can be irritating.

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  5. I've been on the low FODMAP diet for about 2 1/2 months. I've found that it has really improved my symptoms. My problem is that even following it strictly for 2 months I've found my symptoms have gone up and down a lot. For this reason I'm not sure about re-introducing foods. + I lack a bit of confidence as it has sucked so bad and is finally feeling better so I don't want to compromise it.

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  6. Hi Direct Skate,

    Completely fair enough that you’re not
    feeling confident challenging The Low FODMAP Diet restrictions when you’re
    symptoms continue to fluctuate and you do not have a clear base.

    Have you seen a dietitian?

    If not, I suggest
    this would be a great idea. The Low FODMAP Diet is most effective when your
    diet is balanced (i.e. no too much or too little of any one food group) with
    adequate fibre from Low FODMAP vegetables, fruit, wholegrains, nuts and seeds.
    A dietitian is the best person to assist you to achieve this.

    ReplyDelete
  7. I have been on Low fodmap diet for over one year, I do not have a dietician locally who knows anything about fodmaps so have had to trial things myself. I am still juggling what I can eat and what I can't, even though I have had great success on the low fodmap diet it still seems impossible to introduce food back though I keep trying.

    ReplyDelete
  8. Hi Linda,

    It is great to hear you have had some success. We would suggest you contact a dietitian that is experienced in this area even if they are not local because often a Skype or phone consultation is offered. Visit www.daa.asn.au and when searching under ‘find an accredited practicing dietitian’ go to ‘area of practice’ and select ‘irritable bowel syndrome’ under ‘gastrointestinal disorders’. All the best.

    ReplyDelete
  9. I was on the FODMAP diet for 6 months before I found some amount of stability in my symptoms. Even though things weren't completely resolved, I tried to do a very controlled reintroduction - http://www.alittlebityummy.com/re-introducingfodmaps/ - and had a major relapse in my IBS. After that I went back on a very strict FODMAP-SCD combo diet, including not eating anything that has any amount of FODMAPs, e.g. no peas even though 1/4 c is allowed because 1/2c exceed limits. I still couldn't get back to a stable place after 2 months. Two rounds of Rifaximin+Neomycin and I only got 4-6 weeks of reprieve from each round before relapsing. The thing that seemed to finally get my IBS under control is the MiraLAX purge that I had to do for my colonoscopy. After completely emptying my bowels and then sticking to the strict FODMAP-SCD diet for 5 weeks, I was able to start doing a controlled introduction again. I found that only oligosaccharides cause problems. So now I am trying to challenge myself with very small amounts to get to a place where I can hopefully eat onion, garlic, and beans again.

    Monash Team - I so very much appreciate all the work you put into this. I couldn't have done it without the guidance provided by your app. However I think what you're hearing from the commenters here is that there isn't a set, defined path for everyone. It only makes sense to try to reintroduce foods if you can achieve a stable baseline in your symptoms. What good is it to reintroduce after 2-6 weeks on the FODMAP diet if your symptoms are still raging? Do you recommend abandoning the FODMAP diet if you do not get relief of your symptoms within the 2-6 week period?

    ReplyDelete
  10. Hi Sean,

    Thanks for your comments. We are happy to hear you have found some relief. This is why we recommend people see a specialist (Gastroenterologist). Procedures such as these have been beneficial to rule out any other medical conditions but also because diet alone may not be effective for everyone. All the best.

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  11. I do not understand why someone is able to process/digest fermentable sugars following several weeks on the FODMAP restriction diet (guided by dietician) when previously unable to do so. Can you please explain the physiology?

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    Replies
    1. Hi LW,
      The low FODMAP diet excludes all FODMAPs, even though not all people with IBS will be intolerant to all FODMAPs. The purpose of the rechallenge phase is to determine which of the FODMAPs you are actually intolerant to. Therefore, it is not that your tolerance changes, rather, eliminating all FODMAPs and systematically reintroducing individual FODMAPs provides an opportunity to identify individual symptom triggers. Doing the rechallenge phase of the diet ensures that in the long run, you follow a less restrictive diet.
      Hope that answers your query.

      Kindly, Jane Varney
      The Monash University low FODMAP team

      Delete
  12. Hi, my IBS symptoms resulted from medication that I will be on for life and unfortunately it appears that the FODMAP Diet and I will be together for a long time. I am currently taking B-12 and calcium supplements and am wondering if there is more I should be doing seeing as this diet is not short term.

    ReplyDelete
  13. After experiencing relieved symptoms from a gluten free diet it would be nice to try this out to see if there are any foods I can bring back into my life. Unfortunately I am but a poor college student with no way of hiring a specialist, but it is nice to have a greater understanding of this diet. If I use a food journal I can at least get a better feel of exactly how my body reacts to these various molecules.

    ReplyDelete