Low-FODMAP

Living

Experts Discuss
Meal-Planning
Strategies to
Help IBS Clients
Better Control
GI Distress

By Kate Scarlata, RD, LDN

iving 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,

36 todays dietitian march 2012

and diarrhea in sensitive individuals. Since the majority of IBS

sufferers acknowledge symptom improvement when following the low FODMAP diet, its 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

Low FODMAP Menu

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 Kings
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.

Breakfast
Erewhon Corn Flakes
Enriched rice milk (organic Rice Dream)
Banana
1 T sliced almonds
Lunch
Udis 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)
Sauted spinach and red peppers seasoned with green
part of spring onion, salt, pepper, handful of pine nuts,
and olive oil
Kiwifruit

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 on page 38.
If clients need fiber supplements, suggest a nonfermentable
fiber choice such as Citrucel.

FODMAP-Friendly Menu Planning

When helping clients plan menus, its 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

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 saut with pine nuts
Kiwifruit or orange

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

Table 1: Fiber Without FODMAPs

Food

Portion Size

Grams of Fiber

Oatmeal

4.1

Oat bran

7.2

Rice bran

6.2

Strawberries

1 cup, halves

Blueberries

1 cup

3.6

Orange

1 medium

3.1

Spinach

2 cup, cooked

2.2

Baked potato, with skin

1 medium Russet

Quinoa

1 cup, cooked

5.2

2 cup, dry
4 cup, dry

Source: USDA National Nutrient Database for Standard Reference

Safe Snacking
Once clients are armed with menu ideas, encourage them
to keep low FODMAP snacks on hand since theyre 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 Udis 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 arent 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 saut 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 waterbased 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, theyll 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:

38 todays dietitian march 2012

2 cup, dry

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 hearthealthy 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 thats not always the case. In fact,
many gluten-free products contain honey, pear juice, onions,
and garlic, so they arent 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 its not used to sweeten the
product), its 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 on page 39 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 isnt 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 theyre 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 Wendys 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-todate 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.

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.

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 RDs
role: Dietary restriction of FODMAPs is an effective therapy in
the majority of patients with functional bowel symptoms. Its a
diet that should be taught by a dietitian, and it should be firstline 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 Idiots Guide to Eating Well With IBS.

For references, view this article on our website

at www.TodaysDietitian.com.

march 2012 www.todaysdietitian.com 39