I spend a lot of time discussing the PKU diet but have not yet discussed my own dietary restrictions. I follow the low FODMAP diet, and as you can see, have tagged certain recipes as ‘FODMAP friendly’. I began following this diet after being diagnosed with Fructose Malabsoption, Lactose Intolerance and Gluten Sensitivity following a hydrogen breath test performed through consultations with a Naturopath. Many people have asked me what the low FODMAP diet is, so I have given a basic explanation below but would really recommend to do some research or better yet, discuss it with your Naturopath or Nutritionalist. I have provided a list of further readings below.
Due to the level of my intolerance and symptoms, I actually follow quite a strict version of the low FODMAP diet where I eliminate much more fructose than is typically allowed on this diet. I also strictly avoid all or most forms of lactose. I have also found that I am very sensitive to sugar alternatives due to the high level of fructose found in most. That alone would warrant another post about sugar alternatives which I plan to write; especially after 5 months of strictly avoiding sugar and fructose. Cutting sugar is very popular and seems to be all the rage at the moment so I won’t delve too much into that topic at the moment. So then back to the discussion of FODMAPs….
WHAT IS THE LOW FODMAP DIET?
FODMAPs are found in the foods we eat. FODMAPs is an acronym for:
Oligosaccharides (eg. Fructans and Galacto-oligosaccharides (GOS))
Disaccharides (eg. Lactose)
Monosaccharides (eg. excess Fructose)
Polyols (eg. Sorbitol, Mannitol, Maltitol, Xylitol and Isomalt)
These are complex names for a collection of molecules found in food, that can be poorly absorbed by some people. When the molecules are poorly absorbed in the small intestine of the digestive tract, these molecules then continue along their journey along the digestive tract, arriving at the large intestine, where they act as a food source to the bacteria that live there normally. The bacteria then digest/ferment these FODMAPs and can cause symptoms of Irritable Bowel Syndrome (IBS). Symptoms of Irritable Bowel Syndrome include abdominal bloating and distension, excess wind (flatulence), abdominal pain, nausea, changes in bowel habits (diarrhoea, constipation, or a combination of both), and other gastro-intestinal symptoms.¹
So what food should be avoided? I have included a long list below but simply put, that means a diet that eliminates:
- Lactose – the milk found in cow, sheep and goat milk
- Fructose – the sugar found in fruit
- Fructans – a form of fructose found in wheat and vegetables. The most common vegetables are onions, and garlic. Other common fructans are inulin and fructooligosacharride (FOS). These are found in many probiotics and “nutrient fortified” foods.
- Galactans – a carbohydrate found in beans and lentils
- Polyols – a sugar alcohol. The most common are the artificial sweeteners sorbitol, xylitol and mannitol.
MY OWN STRUGGLES WITH FOOD
My struggles with food intolerance began at birth. Although my family and I didn’t come to realize it until I was 21. It was like a slow coming epiphany that followed a grilled cheese sandwich and banana milkshake. Suddenly I was curled over in excruciating pain accompanied by bloating and wind. Then a light bulb went off as we all realized that I was lactose intolerant. My poor mother sadly remembered that when I was 2 1/2 she had taken me to the doctor after I complained of stomach aches and several rounds of x-rays were performed yet showed nothing. Years later when we were looking at my baby book, we saw she had written about this visit to the doctor and his recommendation to stop feeding me dairy products, which “seemed to work”. This diagnosis was quickly forgotten until I was 21. In that time, I suffered a lot of stomach pain and moods swings (normal for my age of course, but possibly exacerbated by my intolerance).
So lactose intolerance was the first (and I dare say easiest) problem to decipher, but the pain and symptoms did not stop there. In fact, I spent all of my 20’s dealing with food related discomfort or out right pain and struggled to find out what was the cause of this pain. I had times where the bloating would last for a couple of weeks and be beyond uncomfortable. It definitely affected my mood and I truly experienced bouts of depression associated with the food intolerances. As part of my desperation, I searched out many different health practitioners. All the general medical practitioners were absolutely useless and either could not help me at all or ran countless exams; all of which left me thinking that I was crazy. At best, I was diagnosed as having Irritable Bowel Syndrome (IBS) which gave me a name to my issues but no real solutions.
Then in my early 30’s, I visited a Naturopath for fertility reasons and finally found answers to my IBS. My Naturopath recommended that I perform a series of Hydrogen Breath Tests used to detect high levels of fructose, lactose, sorbitol, lactulose and glucose. My results showed that I not only suffered from lactose intolerance, but also fructose malabsorption. My Naturopath also explained that my fructose malabsorption was most likely a result from having gluten sensitivity. We did not perform a Coeliac test as I had already been following a gluten free diet for several years on my own based primarily on how I felt when I ate gluten.
The symptoms between each sensitivity can be very similar or even mimic each other. That is why the Hydrogen Breath Tests are so important in determining which sensitivity one has. Some symptoms that I experience include:
- Diarrhea and/or constipation
- Stomach pain and spasms
- Mood swings
- Headaches or migraines
- Low blood pressure and fainting
So I finally had an answer to over 20 years of painful symptoms brought on by food, but the solution is never easy. Some days or months I’m stricter than others and when I ‘fall off the wagon’ it takes a long time of detoxing to get back to a comfortable place, both mentally and physically. It will be a life long journey, but with knowledge comes choice. I know what makes me feel good and I know what doesn’t. It’s about finding a balance but also finding what works for me. I also know that all my intolerances are interrelated. If I slip in one food type, the other sensitivities will act up. So best to stay as close to my allowed foods as possible.
FOOD SOURCES OF FODMAPS
I have seen many lists outlining the foods to avoid on a low FODMAP diet; some are stricter than others. The list compiled below is from the Journal of Gastroenterology and Hepatology in the article “Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach” written by Peter R Gibson and Susan J Shepherd (the authors of the FODMAP diet). Everyone who follows this diet will respond to trigger foods differently and tolerances will undoubtedly change over time depending on how strict one is. For me, certain foods listed as possible alternatives are never an appropriate food; I will always have a reaction. For example, I cannot have any lactose in any form and corn is not an option either. If you do want to follow this diet, I would recommend discussing it with your Naturopath or Nutritionalist; otherwise, do some research for additional recommended food sources of FODMAPs.
Food sources of FODMAPs (where FODMAPs are problematic based on standard serving size) and suitable alternatives. ²
Problem high FODMAP food source:
- Fruits: apples, pears, nashi pears, clingstone peaches, mango, sugar snap peas, watermelon, tinned fruit in natural juice
- Sweeteners: fructose, high fructose corn syrup
- Large total fructose dose: concentrated fruit sources; large serves of fruit, dried fruit, fruit juice
- Milk: cow, goat and sheep (regular & low-fat), Ice cream
- Yoghurt (regular & low-fat)
- Cheeses: soft & fresh (e.g. ricotta, cottage)
Oligosaccharides (fructans and/or galactans)
- Vegetables: artichokes, asparagus, beetroot, Brussels sprout, broccoli, cabbage, fennel, garlic, leeks, okra, onions, peas, shallots.
- Cereals: wheat & rye when eaten in large amounts (e.g. bread, pasta, couscous, crackers, biscuits)
- Legumes: chickpeas, lentils, red kidney beans, baked beans
- Fruits: watermelon, custard apple, white peaches, rambutan, persimmon
- Fruits: apples, apricots, cherries, longon, lychee, nashi pears, nectarine, pears, peaches, plums, prunes, watermelon
- Vegetables: avocado, cauliflower, mushrooms, snow peas
- Sweeteners: sorbitol(420), mannitol(421), xylitol(967), maltitol (965), isomalt (953) & others ending in ‘-ol’
Suitable alternative low-FODMAP food source
- Fruit: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, paw paw, raspberry, rockmelon, strawberry, tangelo.
- Honey substitutes: maple syrup, golden syrup
- Sweeteners: any except polyols
- Milk: lactose-free, rice milk
- Cheese: ‘hard’ cheeses including brie, camembert
- Yoghurt: lactose-free
- Ice cream substitutes: gelati, sorbet
Oligosaccharides (fructans and/or galactans)
- Vegetables: bamboo shoots, bok choy, carrot, celery, capsicum, choko, choy sum, corn, eggplant, green beans, lettuce, chives, parsnip, pumpkin, silverbeet, spring onion (green only), tomato
- Onion/garlic substitutes: garlic-infused oil
- Cereals: gluten-free & spelt bread/cereal products
- Fruits: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, paw paw, raspberry, rockmelon
- Sweeteners: sugar (sucrose), glucose, other artificial sweeteners not ending in ‘ol’
ADDITIONAL FOOD SOURCES IN FRUCTOSE MALABSORPTION
In addition to the foods listed in the low FODMAP diet, I have found other food sources to be quite problematic with Fructose Malabsorption. There are extensive lists for FM online if you wish to search. However, the following substances, listed on food (and supplements) nutrition facts labels, are worth listing:
· Corn syrup solids
· Fructooligosaccharides (FOS)
· Fructose-glucose syrup
· Fruit juice concentrate
· Galactoologosaccharides (GOS)
· High fructose corn syrup (HFCS)
· Hydrogenated starch hydrolysates (HSH)
· Invert sugar, saccharin, sucanat
· Sugar alcohols
The list above is probably not complete (some polyols ending with -tol are missing), but the point is that not just any “food additive” or “sweetener” is problematic in FM.
I hope that helps clarify a bit about the low FODMAP diet. I decided to list foods on this blog as ‘FODMAP friendly‘ instead of Fructose, Lactose or Gluten friendly because it covers all three of these sensitivities; although as mentioned the typical low FODMAP diet is not as strict as the one I follow. Even though my lists look very bleak and you may wonder ‘what can I eat?’, I do not think following this type of diet is restrictive. It is all about finding a balance and being creative with what you can eat. So I sincerely hope some of the recipes I work on and put out on this blog can help a bit with finding a way for you to be creative and healthy. XX
1. Shepherd, Sue. “LOW FODMAP DIET.” http://shepherdworks.com.au/disease-information/low-fodmap-diet
2. Gibson, Peter R and Susan J Shepherd. “ADVANCES IN CLINICAL PRACTICE, Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach.” Journal of Gastroenterology and Hepatology. Monash University Department of Medicine, Box Hill Hospital, Box Hill, Victoria, Australia