Low FOD MAP DieT
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Contents 3 Introduction 4 Identifying my symptoms 4 What is a low FODMAP diet? 5 How do I know if I need to
follow a low FODMAP diet?
6 My current diet 9 High FODMAP food tables 11 Low FODMAP food tables 12 Identifying the FODMAP’s in my diet 13 My low FODMAP diet plan 15 Low FODMAP 3-day meal plan 15 Achieving a balanced diet 17 Challenging my tolerance of the FODMAP’s 19 Label reading 20 Low FODMAP diet recommended resources
Introduction The low FODMAP diet was developed in 1999 by Advanced Accredited Practicing Dietitian Dr Sue Shepherd. It is recognised as the gold standard for the nutritional management of Irritable Bowel Syndrome and is also used to assist individuals who mal-absorb sugars such as fructose and sorbitol. The low FODMAP diet consists of two stages: Stage one – 6-8 weeks of dietary restriction to alleviate symptoms Stage two – A series of food challenges to determine tolerance levels and a suitable long-term diet This handbook provides support material to guide you through stage one of the low FODMAP diet. Stage two is not covered in detail in this handbook as it is very complex with many dietary changes that may vary on an individual basis. It is recommended that you consult with one of our experienced Accredited Practicing Dietitians during both stages of the diet to ensure you achieve optimal results without compromising your nutritional intake. Our dietitians will also help you to develop a long-term diet that relieves you of your symptoms, meets your nutritional needs and fits with your lifestyle. Our dietitians are available for face-to-face consults in Melbourne, Skype or phone consultations Australia wide.
Identifying my symptoms
What is a low FODMAP diet?
What is Irritable Bowel Syndrome?
FODMAP is an acronym for different groups of short chain carbohydrates. It stands for:
Irritable Bowel Syndrome (IBS) is a condition that is characterised by some or all of the following symptoms: ) Bloating
Oligosaccharides - Fructans and Galactooligosaccharides (GOS)
) Excessive wind
Disaccharides - Lactose
) Abdominal pain
Monosaccharides - Excess Fructose
) Distension of the abdomen
And
) Nausea
Polyols – Sorbitol, Mannitol, Maltitol, Xylitol and Isomalt
) Reflux ) Fatigue ) Diarrhoea ) Constipation List three symptoms that you experience and are of most concern to you: 1.
2.
3.
4
Fermentable
These carbohydrates are a collection of molecules that can be found in a variety of foods we eat everyday. Some individuals have difficulty absorbing these molecules during digestion meaning they freely pass through the small intestine (where they would typically be absorbed) and into the large intestine. Once in the large intestine these molecules are fermented by natural bacteria, in turn producing IBS symptoms.
How do I know if I need to follow a low FODMAP diet? Before commencing a low FODMAP diet we recommend talking with one of our experienced dietitians and consulting with your GP. What to discuss with your dietitian
Testing
It is not uncommon for dietary change to make no difference to symptoms of IBS in some individuals. Environmental factors and emotions can also be a trigger for IBS symptoms. If you are unsure of what your triggers are, our dietitians can help you to determine if a low FODMAP diet may be helpful to you.
Breath testing is available to diagnose sensitivity to three individual FODMAP’s: fructose, lactose and sorbitol. If you mal-absorb the FODMAP being tested, the gas produced in the large intestine during digestion will be present in your breath.
What to discuss with your GP Symptoms of IBS are similar to disorders such as coeliac disease, inflammatory bowel disease and bowel cancers. Ensure you have seen your GP and had tests to rule out these more serious conditions prior to trialling a low FODMAP diet. Although the symptoms of IBS are uncomfortable, the condition does not have long-term negative effects on health.
Unfortunately there is no test for the remaining FODMAP’s: fructans, galactans and mannitol. While breath testing is a handy tool and can make your diet less restrictive, it is not essential as tolerance of all FODMAP’s can be investigated through diet. We recommend breath testing at Stream Diagnostics. They are located around Melbourne in Box Hill, Ringwood and Brighton. If you cannot make it into a Stream Diagnostics branch, breath tests are available to order via their website and you can complete the test in your home. Contact Stream Diagnostics Web: www.breathtest.com.au Phone: 1300 837 863
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MY current
diet
Task: Complete the 7-day food diary, recording everything you eat over one week. Be sure to list as many ingredients as you can, including specific fruits and vegetables. You will benefit most from this process if you aim to eat a ‘typical week’ for this time. You are also required to record your symptoms on a daily basis. Please note you are not to restrict your intake at this stage rather eat and record your normal diet.
FOOD & SYMPTOMS DIARY BREAKFAST
SNACK
LUNCH
SNACK
DINNER
SNACK
SYMPTOMS
M T W T F S S
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Please list any foods that you have already identified to cause symptoms
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High FODMAP
food tables
High FODMAP
food tables
The following table provides a list of foods containing the individual FODMAP’s. Some foods have more than one FODMAP so will be listed in more than one column. Some foods contain only small quantities of FODMAP’s and therefore can be tolerated in the quantities specified. Stage one of the low FODMAP diet typically requires avoidance of all foods in the table however this may not be necessary in every case. Your dietitian will advise which individual FODMAP’s you need avoid.
Fructans
Safe serve size
GOS
Safe serve size
Coconut water Carob powder Corn thins Rye biscuits Rye bread Multigrain bread Multigrain gluten free bread White bread Raisin toast Corn flakes Rice bubbles Oats Barley Cous cous Noodles Gnocchi Spelt pasta Wheat pasta Apricot Grapefruit Nectarines Persimmon Plum Pomegranate Watermelon Cashews Hazelnuts Pistachios Baked beans Butter beans Four bean mix Lentils, boiled Kidney beans Artichoke Beetroot Garlic Onion Leek Mushrooms Snow peas Hommus dip Tahini Tzatziki dip
100ml 1 tsp 1 biscuit 1 slice
Rye bread Multigrain bread White bread Oats Barley Custard Apple Almonds Cashews Hazelnuts Pistachios Baked beans Butter beans Chickpeas Four bean mix Lentils, boiled Kidney beans Beetroot Corn Snow peas Peas (thawed) Butternut pumpkin Hommus dip
1 slice 1 slice ½ cup 10 nuts 10 nuts ¼ cup ¼ cup ¼ cup 2 slices ½ cob 5 pods ¼ cup ¼ cup -
Lactose
Safe serve size
Milk Ice-cream Dairy desserts Custard Condensed milk Evaporated milk Milk powder Yoghurt Soft cheeses (i.e. ricotta, cream cheese, cottage cheese) Sour cream Buttermilk Milk chocolate White chocolate
-
Mannitol
Safe serve size
Mushrooms
-
Snow peas Cauliflower Sweet potato
5 pods ½ cup
Butternut pumpkin
¼ cup
1 slice ½ cup ½ cup ¼ cup ¼ cup cooked ½ cup cooked ½ cup cooked 1 whole ½ small ¼ cup seeds 10 nuts ¼ cup ¼ cup 2 slices ½ cup 1 tb -
15g 15g
Fructose
Safe serve size
Honey Apple Mango Pear Nashi pear Boysenberries Cherries Figs Tamarillo Tinned fruit in natural juice Watermelon Sugar snap peas High fructose corn syrup Sweet wines Rye bread Raisin toast Noodles Baked beans Broad beans Four bean mix Asparagus Sun-dried tomatoes Tzatziki dip Balsamic vinegar
½ medium -
Sorbitol
Safe serve size
Apple
-
Peach Nectarine Avocado Plum Blackberries Apricot Cherries Longon Lychees Nectarines Peach Watermelon Plum Coconut water
1/8 avocado 3 cherries 5 longons ¼ slice -
Shredded coconut Corn
¼ cup ½ cob
(in excess of glucose)
¼ cup -
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LOW FODMAP
food tables
LOW FODMAP
food tables
The following table provides a list of foods that are low in FODMAP’s and safe to eat in unlimited quantities. Vegetables
Breads and Cereals
Condiments/Herbs
Capsicum Cucumber Eggplant Olives Spinach Rocket Silverbeet Kale Bok Choy Witlof Butter lettuce Radicchio Broccoli Zucchini Jap Pumpkin Butternut pumpkin (1/4 cup only) Sweet potato (1/2 cup only) Potato Alfalfa Green beans Bean sprouts Beetroot Green peas Tomato Turnip Squash Spring onion (green part only) Canned lentils Quorn mince
Gluten Free (i.e. Country life) 100% Spelt breads Oat breads Porridge (<1/4 cup raw oats) Gluten free cereals Rice flakes Quinoa Amaranth Polenta Buckwheat Gluten free biscuits (savoury and sweet) (i.e. Freedom foods) Rice cakes Rice crackers Wheat free/buckwheat noodles Gluten free pasta (i.e. San Remo) Vermicelli noodles Quinoa pasta
All fresh herbs Chutney Mustard Barbecue sauce Fish sauce Oyster sauce Soy sauce Sweet and sour sauce Balsamic vinegar (1 tb limit) Rice wine vinegar Worcestershire sauce Marmalade Strawberry jam Peanut butter Vegemite
Plain tofu
Fruit Blueberry Boysenberry Blackcurrent Banana Grapefruit Grapes Kiwi fruit Mandarin Orange Passionfruit Pineapple Raspberry Rockmelon Strawberry Sugar banana
Fats and Oils Coconut oil Olive oil Walnut oil Sesame oil
Dairy Soy milk made from soy protein (i.e. SoGood) Lactose free milk Hard cheeses Feta cheese Ricotta (2 tb limit) Haloumi (50g limit) Lactose free yoghurt
Nuts and Seeds Macadamia Peanuts Pine nuts Pecans Hazelnuts (10 nut limit) Walnuts LSA Chia Pumpkin Sesame Sunflower
Sugars & Artificial Sweeteners Brown Castor Icing or raw sugar Equal Sucralose Aspartame Saccharine Stevia
Tea and Coffee Herbal teas Peppermint tea Regular tea and coffee Decaf
Confectionary Minties Mentos Tic Tacs
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1
stage
one Identifying the FODMAPâ&#x20AC;&#x2122;s in my diet Task: With a highlighter and using the food diary that you have completed over the past week, highlight the foods that appear in the high FODMAP table.
My low FODMAP diet BREAKFAST
SNACK
LUNCH
SNACK
DINNER
SNACK
M T W T F S S
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
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LOW FODMAP
MEAL PLAN
Task: Complete the meal plan using your food diary as a guide. Replace all of the high FODMAP foods you have highlighted with an alternative from the low FODMAP table. If you need any assistance with this task our dietitians are happy to help you. Once completed, this will be your diet for up to 8 weeks or until you are symptom free and complete stage one. It is recommended that you touch base with one of our dietitians at this point to ensure your diet is nutritionally balanced and for assistance with moving onto stage two. NOTE: If you have no improvement in symptoms after following a restricted FODMAP diet for 8 weeks, resume normal eating and seek advice from your GP.
Low FODMAP 3-day meal plan DAY 1
DAY 2
DAY 3
½ cup Traditional Rolled Oats cooked on the stove with 250ml lactose free or soy milk and topped with 1 tsp of maple syrup and cinnamon
2 poached eggs on 2 slices of gluten free toast served with sautéed spinach and 1 roasted tomato
1 cup of gluten free, fruit free cereal with 1 cup of lactose free milk
1 medium banana + 10 walnuts
Berry smoothie made with 1 cup berries, 1 cup of soy milk (made from soy protein) and 1 tsp brown sugar or golden syrup
200g lactose free yoghurt + 2 mandarines
Gluten free wrap with grilled chicken, iceburg lettuce, cucumber, grated carrot, spring onions (green part only), coriander and wholegrain mustard
Spinach, avocado (<1/8), cherry tomato, cucumber, carrot and fresh basil salad topped with 1 can of tuna and finished off with a light drizzle of olive oil and white balsamic vinegar
Sandwich made with gluten free or spelt sourdough bread filled with ham, tomato, grated carrot, cucumber, iceburg lettuce and chutney
SNACK
2 kiwi fruit + gluten free and fruit free homemade muffin
1 medium orange + 200g lactose free yoghurt
Gluten free dry biscuits with 40g reduced fat cheddar cheese + 1 cup grapes
DINNER
Stir fried beef, carrot, bok choy, green beans and red capsicum with soy sauce served with 1 cup of steamed basmati rice
150g fish served with ½ cup steamed sweet potato and a spinach, cucumber, cherry tomato and celery salad. Dress with olive oil and lemon juice
Pumpkin soup made with ½ Jap pumpkin, 2 carrots, 1 tsp nutmeg and 1L salt reduced stock, (add a pinch of salt for flavour and boiling water if needed), garnish with 1 tbsp fresh chives and a dollop of lactose free sour cream
200g lactose free yoghurt + herbal tea
2 gluten free and fruit free homemade sweet biscuits + green tea
Chai tea + 30g dark chocolate
BREAKFAST
SNACK
LUNCH
SNACK
Achieving a balanced diet
In many cases, progressing though the stages of a low FODMAP diet can take several months. It is therefore important to ensure you are meeting your nutritional requirements to prevent any nutrient deficiencies and long-term negative health affects. A balanced diet is one that includes a variety of foods from each of the core food groups every day. The 5 core food groups are: ) Fruit
) Breads and Cereals/Grains
) Vegetables
) Meat and Alternatives
The recommended intake from each group differs for individuals depending on age, gender, activity level and life stage. For tailored information on the quantity you require, contact our Accredited Practicing Dietitians. You can also access free information about eating a balanced diet and the core food groups at the Eat For Health website www.eatforhealth.gov.au.
) Dairy
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2
stage
two
Challenging my tolerance of the FODMAP’s The challenging stage of a low FODMAP diet allows you to test your tolerance level of each of the individual FODMAP’s. This process will help to form your long term eating plan and potentially allow you to eat some of the high FODMAP foods more freely without experiencing any symptoms. You may begin challenges once you have completed stage one hence when you have been symptom free for at least 2 weeks. It is recommended that you consult with one of our experienced dietitians for additional resources and guidance that will help you to complete this stage effectively. Outline of the challenging process It is recommended that you take at least one week to complete each challenge (the process will take five weeks in total; one week per FODMAP) and keep a food and symptom diary for the duration of this stage of the diet.
IMPORTANT: Wait until you are symptom free before re-commencing a challenge. To become symptom free, resume the diet you were eating in stage one. Continue this diet for as long as it takes to alleviate your symptoms for two consecutive days. At this point, you may resume challenging again. b. If symptoms do not occur: Great! You are not intolerant to this FODMAP group. Note this in your food diary and proceed to test the next FODMAP group the following week. 2. Continue using the process in step one until you complete the five weeks of challenges. How to interpret the symptom free weeks
Week 3 – test tolerance of Fructose
The week/s (if any) that you do not experience any symptoms will correlate with the FODMAP’s you are not intolerant to. You may resume eating all foods from this FODMAP group freely.
Week 4 – test tolerance of Fructans
How to interpret symptom containing weeks
Week 1 – test tolerance of Sorbitol and Manitol Week 2 – test tolerance of Lactose
Week 5 – test tolerance of GOS Task: For each of the five challenge weeks, complete the following steps: 1. Start by consuming one serve of a challenge food from the specified FODMAP group twice during a week and monitor for symptom response. a. If symptoms occur: Ensure you have taken other factors into consideration such as stress, anxiety, menstrual cycle, tight clothes etc. If you are unsure if variables have had an impact on your tolerance then challenge the same group for an additional week.
The week/s (if any) that you experience symptoms will correlate with the FODMAP’s you do have an intolerance to and will need to limit in your diet. You may wish to gain further insight into your tolerance level of these FODMAP’s by challenging the same foods at an increased frequency. For example, consume one serve of the challenge food four times in the week rather than only twice.
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LABEL
READING
Label reading When label reading for FODMAP’s in foods, the ingredients list will be your best friend! By law there must be a nutrition information panel and ingredients list on every packaged food label. The ingredients will be listed from highest to lowest by weight. Check the ingredients list for hidden FODMAP’s such as apple juice concentrate (often used as a sweetener), fructose, high FODMAP fruit pieces such as apple, milk concentrate, garlic and onion. Complete the following activity to practice label reading for FODMAP’s and gain confidence in knowing what you are looking for on the supermarket shelves.
Activity
Label reading tips
1. Which of the following product labels are low FODMAP (if any)?
Look for the FODMAP Friendly logo for certified low FODMAP foods. Manufacturers with low FODMAP approved products include:
2. Circle the FODMAP containing ingredients in each product (if any) Product #1 Low fat strawberry yoghurt INGREDIENTS: Cultured grade A non-fat milk, strawberry, sugar, fructose, natural flavour, carrageenan, carmine and black carrot juice concentrate (for colour), sodium citrate, potassium sorbate (to maintain freshness), malic acid, vitamin D3 Product #2 Wheat free muesli bars INGREDIENTS: rolled oats (64%), glucose, diced apricot (6%), apple juice concentrate, canola oil, inulin, natural apricot flavour (0.4%), soy lecithin Product #3 Dip
) Sue Shepherd low FODMAP ) Kez’s Free ) Naturally Good ) Well & Good ) Bayview ) Rick Grant’s Allergen-Friendly Food Low FODMAP diet recommended resources Monash University Webpage med.monash.edu/cecs/gastro/fodmap Monash University low FODMAP diet app Available from the App Store Shepherd Works factsheets and cookbooks Shepherdworks.com.au
INGREDIENTS: spinach, salt, cornstarch, onion powder, yeast extract (barley), caramel colour, partially hydrogenated soybean oil, monosodium glutamate, corn syrup, sulphur dioxide (to protect quality) Find the answers on the back page of this handbook.
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Label reading activity Answers Question 1
None of the products are low FODMAP Question 2
Product 1: Milk and fructose Product 2: Rolled oats, apricot, apple juice concentrate, inulin, apricot flavour Product 3: Onion powder and yeast extract
References Gibson PR, Shepherd SJ. Food choice as a key management strategy for functional gastrointestinal symptoms. Am J Gastroenterol. 2012 May;107(5):657 66. Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010 Feb;25(2):252-8. Monash University FODMAPs Research Team, 2014, The Monash University Low FODMAP Diet App (updated June, 2014) SA Gastro Dietitians Interest Group 2012 Treating Food Intolerance: A Dietitian’s Guide to the low FODMAP and low Food Chemical Dietary Approaches Shepherd, S 2014 The FODMAP Friendly Food Program, www.fodmap.com
be well.
be you.
If you need any additional assistance with a low FODMAP diet, we are never far away. You can contact our dietitians directly on 1300 303 807 or at admin@jakhealth.com.au.
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