Produced by

Department of Gastroenterology
&
Department of Nutrition & Dietetics
Guy's and St Thomas' NHS
Foundation Trust
London UK

Nutritional Sciences Division

King's College London
London UK

Acknowledgements:
Department of Medicine, Eastern Health Clinical School, Monash untvcrsttv,
Box Hill, Victoria 3128, Australia www.med.monash.edu.au/eh

Copyright of Guy's and St Thomas' NHS Foundation Trust and

King's College London October 2010.
All rights reserved. For further information or permission for reproduction or
further use of the copyright, please contact terry.parlett@gstt.nhs.uk

Introduction

Eating is an essential part of living and the gut

(gastrointestinal tract) prays a vital rote in delivering
nutrients to the body and maintaining health. Whi'le the
normal functions of the gut are not impaired, many people
experience symptoms such as diarrhoea, constipation,
bloating, abdominal pain and wind.
These symptoms are often described as irritable bowel
syndrome or 'IBS' and affect up to 15% of the UK population.
These symptoms can also occur in people who have other
conditions such as inflammatory bowel d.isease (Crohn's
disease and ulcerative cotltls), coeliac disease and bowel
cancer. If you have IBS it is important to rule out other
causes for your symptoms, so please see your GP for medical
advice.

Irritable

bowel syndrome (IBS)

The cause of IBS is not fully understood. Symptoms can

affect your quality of life and they can come and go
without explanation. In particular, a hectic lifestyle,
anxiety and stress can all affect the gut which in turn may
increase symptoms. IBS can be difficult to treat but diet
and lifestyle changes can be very helpful to improve
symptoms.

Other gut disorders

Why do FODMAPs contribute to symptoms?

Food is made of many components, such as proteins, fats
and carbohydrates (including sugars). Some of the food
we eat does not get absorbed in the small intestine. This
food residu.e passes a.long the gut to the larqe intestine
where there are billions of bacteria. The bacteria ferment
the food residue which may result in gas-producing
symptoms such as wind and bloating and sometimes
alters stool consistency. The food residue can also
contribute to diarrhoea due to an osmotic effect which
increases the amount of water in the large intestine,
making stools loose or liquid.

Sometimes individuals with other gut disorders (e.g.

inflammatory bowel disease) can have IBS-like symptoms.
They may benefit from similar diet and lifestyle changes.

lal'.ge :intes.tine

Does diet affect symptoms?

Sma'l:l

FOOMAPsl

It is difficult to perform research into diet for IBS. In the

past, various dietary factors have been proposed to be
important triggers for IBS symptoms, such as alcohol,
caffeine and fatty foods. Dietary triggers are difficult to
identify particularly when you have a flare up of IBS as
your gut may be more sensitive to some foods. Recent
research has shown that some carbohydrates may
contribute to IBS symptoms. These carbohydrates are
called Fermentable, Oligo-saccharides, Di-saccharides,
Mono-saccharides And Polyols or FODMAPs.

il~testiine
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Deliverl' of ~'{atel' thl'Gugh

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b.G\~el

Gas preduction

[)ial'rnooea

Bloa~ing. dlstensicn, flatulence.

ab.dominal pain, constipation

FODMAPsare dietary carbohydrates which are poorly

absorbed in the small intestine and fermented in the large
intestine triggering symptoms in sensitive individuals.
Reducing the intake of FODMAPshas been shown to
improve gut symptoms in most individuals with IBS-like
symptoms.
3

How long do I need to follow the diet?

FODMAPs

Usually 8 weeks is long enough to. 'identify if symptoms wiH

respond to a low FOD-MAPdiet .. Reintroduction of FODMAP
containing foods after this ttme is often well tolerated. Ask
your dietitian for 'further advice.

What about the long term?

IBS refers to a gut hypersensitivity and ev:en though some

FODMAPs are poorly absorbed In everyone, they only need
to be restricted i,f they cause symptoms.

After the initial 8 weeks it is important for you to reintroduce

FODMAP containing foods to identify which carbohydrates are
a problem. Different individuals wi:11be more sensitive to
certain FODMAPs. Working' out what you are most sensitive to
helps to Increase variety in your diet and widen food choices.
This is especially helpful' when eating: out.

Individuals with lBS-I:ike symptoms appear to be sensitive

1tothe gases produced and water chances in the large
Intestine that occur when the diet contains lots of
FOD'MAPs.

For the majority of individuals with IBS-Hke symptoms the

diet does not need: to be too restrictive for the Iung term. It is
important to seek advice from your dietitian to help you
reintroduce FODM,AP-containing foods.

Does everyone need to restrict FODMAPs?

How strict do I need to be?

Is the diet balanced?
Try to fo:llow the low FODMAP diet for 8 weeks as strictly
as possible to improve your symptoms. There wi:ll be
times where vou cannot avoid some or the problem
foods. Eating problem foods is not known to cause
damag.e to. your qut, but ,it may cause symptoms. Clmlcal
experience shows. that lndlvlduats who foHow the diet
more strictly experience better symptom improvement.

Yes, a diet that is low .in FODM'APscan be nutritionally

adequate. Often individuals w.ith lBS-like symptoms severely
restrict their diet in order to help improve their symptoms. It
is not recommended that you follow any diet without
appropriate advice. It ls advised that you see a dietitian who
is experienced in thi-s area. This wil'i ensure that your diet is
healthy and as varied as possible.

Some individuals do not need to restrict all the FODMAPs

because they absorb lactose and/or fructose well. Breath
testing :js useful to help determine if you can absorb
these carbohydrates or not, Ask your doctor or dietitian if
these tests are available.

Types of FODMAPs

Galacto-oligosaccharides

Fructans and ga:lacto-oligos-accha.rides are poorly

absorbed carbohydrates in an people. We do not have the
abilltv to break them down in the small intestine. Dietary
restriction of these FOD:MAPsis helpful in most individuals
with ISS.

(GOS)

Galacto-oliqosaccharides
(GOS) are chains of the sugar
galactose of varying length.
The main dietary S(H;JrCeS
are 'beans and pulses.

Polyo.ls are poorly absorbed carbohydrates in most people

and are likely to trigger IBS-'like symptoms.
Fructose and Jactose are FODNAPs that may be poorlv
absorbed (i,e. rnalabsorbed) in some tndlvidoals and do not
need to be restricted in everyone with IBS-like symptoms
(see pages 17-20). Speak to your doctor or dietrttan to see
if you need to restrict fructose and/or lactose.

Fructans

Fructans are also known as fructo-oliqosaccharides (FOS)

and are chains of the sugar fructose of varying length.
The main dietary sources include wheat products (bread/
breakfast cereal/pasta), some veg.etables (e.g. onion,
artichoke) and FOS added to some processed foods as a
prebiotic (e.'9'. FOS, oliqofructose or rnulin).

PoIYOlsare sugar alcohols such as sorbitol and xylltol.

They occur naturally in some fruit, particularly stone fru,i,t,
and some vegetables.
They are atso used as artltlcial sweeteners in suqar-free
chewing' gum., sugar-free mints, sugar-free chocolate and
some other low-calorie or sugar-free products. Polyols are
also sometimes used. to keep foods moist.

Savoury biscuits
Water biscuits, crispbreads,
crackers, cream crackers

Cereal grains
Wheat (including bulghur wheat,
couscous, semolina)
Rye

Sweet biscuits
All biscuits made with wheat flour
(digestives, shortbread, rich tea,
custard creams)

Bread
All wheat bread and rolls (white,
wholemeal, multigrain,
sourdough, rye bread)
Pitta bread, ciabatta, focaccia,
panini, naan bread, chapatti,
croissants, muffins, brioche,
pastries
Garlic bread, pizza

Cakes
All cakes made with wheat flour
(fruit cake, fairy cakes, Victoria
sponge, chocolate cake)
Pastry
All pastry made with wheat flour
(shortcrust, puff, flaky, filo)
Shop bought pastry and pastry
goods (pies, quiche, pasties)

Flour
All wheat flour (white, wholemeal,
plain, self-raising)
Rye flour
Pasta and noodles
All fresh and dried pasta (white,
wholemeal)
Egg noodles, Hokkein, Udon
Pot noodles, supernoodles,
Ramen

Breadcrumbs and batter

Crumbed fish and poultry,
fishfingers, fish in batter, tempura
batter, Scotch eggs
Minor wheat ingredients do
not need to be avoided
(thickeners, starches and
flavourings)

Breakfast cereals
Wheat or bran based cereals
(Weetabix, Shredded Wheat, bran
flakes, All-bran, Cheerios, muesli)
Wheat bran, wheat germ

Starchy foods should make up about a third of the total amount of

food we eat. Spread them throughout the day and have them at each
meal. The 'free from' section in the supermarket stocks many suitable
low FODMAPoptions. Gluten free starchy foods are usually wheat free
so are also suitable,
Cereal grains & starchy foods
Rice, potato, sweet potato, oats,
buckwheat, polenta, barley,
millet, sorghum, amaranth, quinoa
Bread
Wheat free or gluten free bread
and rolls (white and fibre)
Bread made from oat, rice, corn,
barley, potato flours
Wheat free or gluten free pizza
bases, wheat free or gluten free
pitta bread, wheat free or gluten
free ciabatta, wheat free or gluten
free naan bread
Homemade wheat free bread
using a breadmaker is a good
option for fresh bread every day
Flour and raising agents
Wheat free or gluten free flour,
arrowroot, buckwheat, cornflour,
millet flour, maize flour, polenta,
potato flour, rice flour
Baking powder, bicarbonate of
soda, cream of tartar, yeast
Pasta and noodles
Wheat free or gluten free pasta,
buckwheat pasta
Rice noodles, buckwheat noodles

Breakfast cereals
Porridge and oat based cereals
(Oatabix), cornflakes, rice
krispies, some wheat free or
gluten free muesli and cereals
Check ingredients label for
problem fruit, FOS, inulin,
oligofructose
Savoury biscuits
Rice crackers (Kallo), corncakes,
oatcakes (Nairns), wheat free or
gluten free crackers
Sweet biscuits
Some Florentines, macaroons,
oat based biscuits (Oatland Biscuit
Co.), flapjacks. Most 'free from'
varieties are wheat free
Cakes
Flourless cakes, meringues,
cornflour sponge. Most 'free from'
varieties are wheat free
Pastry
Wheat free or gluten free varieties
and mixes
Breadcrumbs
Polenta, oats, cornflake crumbs,
gluten free breadcrumbs
10

Foods to avoid high in fructans, GOS or polyols

Fruit (fresh, dried and juice)
Apple
Apricot
Blackberry
Cherry
Lychee
Nectarine

Peach
Pear
Plum/prune
Watermelon
Tinned fruit in apple/pear juice

Vegetables
Artichoke (globe & Jerusalem)
Asparagus
Avocado
Beans & pulses (chick peas,
broad beans, soy beans, black
eyed peas, butter beans, lentils,
baked beans, kidney beans)
Beetroot
Broccoli
Brussels sprouts
Cabbage
Cauliflower

Chicory root
Fennel (bulb/leaves)
Garlic
Leek
Mange tout
Mushroom
Okra
Onion (red, white, Spanish,
shallots)
Peas
Spring onion (white part)

11

Suitable foods
Fruit
Try to have at least 3 portions spread throughout the day. One
portion is 80g fresh fruit. Approximate portion sizes are given in
brackets below, 100mi fruit juice accounts for one portion.
Banana (one)
Blueberry (small bowl)
Canteloupe melon (one slice)
Clementine (two)
Date (two)
Galia melon (one slice)
Grapes (ten)
Grapefruit (half) .
Honeydew melon (one slice)
Kiwifruit (two)

Lemon (juice of one)

Lime (juice of one)
Mandarin (one-two)
Orange (one)
Passion fruit (one)
Papaya (one slice)
Pineapple (one slice)
Raspberry (small bowl)
Strawberry (small bowl)

Vegetables
Try to have at least 2 portions per day. One portion is 80g (2-3 tbs).
There is no upper limit to the amount you can have at once.
Alfalfa
Aubergine
Bamboo shoot
Beansprouts
Butternut squash
Bok Choy
Carrot
Celery
Courgette
Chilli
Chive

Lettuce (endive, iceberg)

Olive
Parsnip
Pepper (green, orange, yellow, red)
Plantain
Potato
Pumpkin
Spinach
Spring onion (green part)
Sweet potato
Sweetcorn
Tomato

12

Foods to avoid high in fructans, GOS or polvols

Suitable foods

Added garlic or onion

Soups, stocks, gravy, sauces, dressings & ready
meals often contain garlic, dried garlic, garlic
extract, garlic powder, garlic puree, or onion,
dried onion, onion extract, onion powder or
onion puree
Check ingredients labels. Products with the term
'flavouring' listed as an ingredient may contain
onion or garlic

Soups, stocks, gravy, sauces, dressings & ready meals

Homemade alternatives using dried herbs and spices or chives
Asafoetida powder can be used to provide onion flavour
~'"'-\

!~

Herbs, spices, savouries & flavourings

Salt, pepper, vinegar, herbs, spices, chilli, ginger, lemon, green part of
spring onion, garlic infused oil, mono-sodium-glutamate
Marmite, Bovril

Added polyols
Sugar-free mints, sugar-free chewing gum, sugar-free lollies,
sugar-free chocolate, some 'diet/low calorie' products, protein
powders and supplement drinks. They are also added as a
humectant to help retain moisture in foods
Check ingredients labels for sorbitol, mannitol, lactitol, maltitol,
xylitol, erythritol or isomalt
Added fructans
Foods or tablets with added fibre or prebiotics e.g. some yoghurt,
some fermented milk drinks, some snack bars, some breakfast cereals
Check ingredients labels for FOS, inulin, oligofructose
Nuts & seeds
Pistachio nuts
.Drinks
Chicory (Camp)
Dandelion tea
Check fruit & herbal teas for unsuitable fruit (apple)
13

Sugars, preserves & confectionery

Most people in the UK eat too much sugar. For a healthy
diet you should try eating less foods containing added
sugars. High sugar foods contain more than 15g sugars
per 100g and low sugar foods contain up to 5g sugars
per 100g.
Golden syrup, maple syrup, treacle, jam and marmalade
Check ingredients of low sugar or reduced sugar jam and
marmalade for polyols
Honey (not suitable if you have fructose malabsorption,
see pages 17-18)
Some artificial sweeteners: aspartame, acesulfame K,
saccharin, Canderel, Silver spoon, Splenda, Hermesetas
Nuts & seeds
Most are suitable in moderation (small handful)
Cashews, hazelnuts, macadamia nuts, peanuts, pecans,
pine nuts, pumpkin seeds, sesame seeds, sunflower seeds,
walnuts
Almonds (maximum 10)
Drinks
Have at least 6-8 glasses or 1.5-2.0 litres of fluids per day. Choose
water or non-caffeinated drinks and limit fizzy drinks.
Alcohol
Discuss with your dietitian
14

Suitable foods

Choose from the following meal ideas

Meat, poultry, fish, eggs or vegetarian protein foods

Eat 1-2 portions per day. One portion is 75-100g or 2 eggs.

Breakfast
Porridge with milk or wheat free cereal with milk
Wheat/rye free toast with cheese/jam/other spread
2 eggs on wheat/rye free toast
Smoothie made with suitable fruit

Fresh and frozen without sauce or coating: beef, chicken, duck, lamb,
pork (including bacon and ham), turkey
Fresh or frozen shellfish, white fish, oily fish
Tinned fish in brine or oil
Eggs (boiled, fried, poached, scrambled)
Tofu
Quorn check ingredients: some varieties contain onion and/or garlic
Textured vegetable protein (soya mince)

Fats, oils & spreads

Most people in the UK eat too much fat. For a healthy diet you should
try eating less foods containing lots of fat. Fats are high in calories so
use sparingly. Choose polyunsaturated or monounsaturated where
possible.
Cooking oils, margarines, low fat spreads, butter, ghee, lard, suet
Milk & milk products
Eat 2-3 portions per day. One portion is 200ml milk (one glass),
125-150g yogurt (one small pot), 30g cheese (one small matchbox).
Fresh milk, dried skimmed milk, some soya milk, rice milk
Buttermilk, cream, creme fraiche, sour cream, butter
Cheese e.q, Cheddar, cottage, blue, brie, cream cheese, goat's
Yoghurt and some fermented milk drinks
Check ingredients label for problem fruit (see page 11), FOS, inulin,
oligofructose
See page 19-20 if you have lactose malabsorption

Lunch
Wheat/rye free sandwich/pitta/wrap or wheat/rye free crispbread
with tuna/sardines/salmon/egg/cheese/cold
meat/poultry/ham with
salad
Homemade soup with suitable vegetables
Baked potato/rice with tuna/cheese or homemade filling (e.g. chilli)
Salad/rice salad/potato salad/gluten free pasta salad with cold
meat/tuna/egg/cheese

Sushi/sashirni

Suitable fruit/yoghurt

Dinner
Meat/fish/poultry/eggs/tofu/Quorn
with suitable vegetables and
rice/rice noodles/wheat free pasta/gluten free pasta/potato/sweet
potato/ polenta
Risotto with salad or omelette with salad
Gluten free pasta/spaghetti Bolognese (no onion/garlic) with salad
Suitable fruit/fruit salad/rice pudding/ice cream/yoghurt/custard
Beverages

Snacks

Water +/- lemon

Semi-skimmed milk
Tea/coffee
(up to 3 cups per day)
1/3 glass (100ml) fruit
julce/srnoothie made
with suitable fruit
Tip: add water to fruit
juice to make a longer
drink

Suitable fruit
Low fat yoghurt check ingredients
Vegetable sticks & dips check for
onion
Cheese/tomato on rice crackers/
corn cakes
Occasionally: potato crisps,
chocolate, sweets, wheat free or
gluten free cakes, wheat free or
gluten free biscuits

If lactose and/or fructose is a problem for you, your dietitian will

advise you about suitable alternatives.
15

16

Additional foods to avoid in fructose malabsorption

Fructose malabsorption
Fructose is a sinqle unit sugar (mono-saccharide). Not a.lI
individuals with IBS-like symptoms have fructose
malabserption. A fructose breath test may be helpful to identify
if it is a problem for you. Ask your doctor or dietitian if this test
is available.
Glucose and sucrose are sugars that are easily absorbed and
are suitable for indivlduals with IBS-l:ike symptoms.
Fructose and glucose are often present in the same food.
Glucose 'helps the absorption of fructose. If you rnalabsorb
fructose, foods that contain more fructose than glucose may
cause symptoms.

Fruit &fruit juice

Mango
Vegetables
Sugar snaps
e

Other foods
Honey
Agave nectar
Fructose-based sweeteners (granulated, powder, syrup)

The followinq advice is for individuals with fructose

malabsorption.

Added fructose
Some jams and marmalades, some yoghurts, some
breakfast cereals, some sweet and savoury sauces, some
snack bars
Check ingredients labels for:
lNGREDIENTS: MAlT VINEGAR IFROM
Fructose, fructose syrup,
glucose-fructose syrup,
fructose-glucose syrup,
STARCH, RYE FLOUR, TAMARIND
high fructose corn syrup and
EXTRACT,SPICES,
ONION EXTRAO:
high fructose corn syrup solids

Handy tips

See pages 12 & 14 for suitable alternatives

Fructose is found i.n large amounts in many different foods,

especially in some fruit (see pages 11 and 18) and honey. It
is also added to many food products as a sweetener or to
enhance flavour, appearance or texture.

:AR. AfOS~;+uaOSfSjR~ .
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T

To avoid a high fructose load, limit your intake of suitable

fruit to no more than one portion per meal or snack. For
example

.,

One banana (80g)

A slice of pineapple (80g)
A small bowl of fruit salad (80g)
Half a qlass of suitable fruit juice (lOOml)
One tomato (80g)

17

18

" .....

Lactose ma.labsorption

Suitable foods

Lactose is a di-saccharide found jln animal rnilk (cow's, sheep,

goat's). It is malabsorbed in some people and often depends on
your ethnic origi.n. Not aH tndfviduals with IBS-Hke symptoms have
lactose malabsorption and a lactose breath test may be helpful to
identify if it is a problem for you. Ask your doctor or dletlttan if
this test is available.

Additional foods to avoid in lactose malabsorption

Milk*
Whole, skimmed, semi-skimmed
milk, goat, sheep, buttermilk,
milk powder, evaporated milk,
condensed milk
Yoghurt*
Whole milk, low fat, drinking
yoghurt
Fromage frais

Custard*
Ice cream*
Added lactose
Check ingredients labels for
lactose, buttermilk, milk solids,
skimmed milk powder, whey

Cheese*
Processed cheese, cheese slices
Reduced fat cheddar
Cottage cheese, ricotta, quark,
low fat soft cheese
*These foods are tolerated in small amounts (see page 20)

Calcium
Calcium is essential for healthy bones and teeth. A daily intake of
700mg calcium is recommended for adults. Dairy foods are good
sources of calcium, alternatively choose soya, rice or oat based
milks enriched with calcium.

Milk
Lactose free milk (Lactofree)
Soya milk (Alpro - unsweetened
long life or Original chilled, So
Good - all products)
Rice milk (Rice Dream, Alpro)
Oat milk (Oatly Oat Drink)
Ensure soya/rice/oat milks are
calcium enriched
Check ingredients for apple juice,
fructose and inulin

Cheese
Cheddar, feta, mozzarella, brie,
camembert, blue, cream cheese,
edam, goat's
Soft and hard cheeses are low
lactose
3tbs maximum cottage cheese,
ricotta, quark, low fat soft cheese

Custard
Soya
custard (Alpro)
!4 cup (SOml) maximum of whole,
Custard
desserts (Alpro - all
skimmed or semi-skimmed milk
flavours)
as a drink, part of a meal or snack
e.g. milk in tea and coffee or as
2 tbs maximum of normal
an ingredient in white sauces or
custard. Add to suitable pudding
wheat free bread
or fruit. If making from powder
use lactose-free milk

Yoghurt
Lactose free yoghurt (Lactofree
strawberry, raspberry)
Soya yoghurt (Alpro plain)
Check ingredients for problem
fruit, FOS, inulin, oligofructose
If fructose is a problem check
ingredients for fruit juice
concentrate, fructose
2 tbs maximum (check for other
FODMAPs)as part of a meal or
snack. Add natural yoghurt to
breakfast cereal or suitable fruit

Ice cream
Soya ice cream (Swedish Glace)
1 scoop maximum of normal ice
cream. Check for other FODMAPs
Chocolate
Dark chocolate
SOgmaximum of milk or white
chocolate.
Other dairy
Butter, cream, sour cream, creme
fraiche are low lactose

Aim for at least 3 portions of dairy or alternative foods per day. One
portion: 2.o0ml milk or 12Sg yoghurt or 30g cheese.
Other good sources of calcium are tinned fish with edible bones,
calcium fortified wheat free breakfast cereal, some g'luten free
bread, some drinking water.
19

20

What if m,y symptoms do not improve?

Eating out .
Eating out can be challenqinq on a low FODMAPdiet. You
may need to adjust some of the types of foods you would
usua'llyeat.
Suitable chorces for main meals:
Plain fish, poultry or meat with salad or veqetables
(avoid or limit sauces with onion or qarllc)
Risotto (request no onion) with suitable veqetables
(no artichoke, mushroom, asparagus)
Baked potato, with salad
Frittata (no 'Onion if possible)
Asian style rice or rice noodle dishes (check veg.etables)
Tips
A void eating coatings, batter, sauce and qravy
(where possible scrape them ott)
Ask for seuce or gravy to be served in a separate dish.
Choose options that are without a seuce (e.q. steak, stir
fry, risotto)
Gluten free options avoid wheat but check for other
ingredients e.g. leek in a gluten free pie
Enjoy eating. out! Some people get symptoms when eating
out because it is difficult to avoid al'l problem :ingredients.
However, most people find that eating' out is a pleasurable
experience and' the benefits outweigh the symptoms,

The low FODMAPdiet is beneficial for many individuals with

IBS-like symptoms. If your symptoms have not improved
after 8 weeks please see your dietitian for further advice.

What about foods not listed?

A low FODMAPdiet is an emerging dietary treatment and
information on the FODMAP content of some foods is not yet
known. Ask your dietitian about the suitability of foods not
listed in this booklet,

If you have any questions or concerns about the information

covered in this leaflet, please contact your dietitian below:

Dietitian

Telephone

Email.

Address

21

22