10 things I wish I had known when starting the low FODMAP diet

I am one of those that suffered for two years with IBS and didn’t have a clue what it was.  I thought my abdominal cramping was due to chemo, but like clockwork, by about 4 pm most afternoons, I was doubled over in pain and had to lie down.  On most of those days, I never got back up again.  I was certain the severity of the pain meant my cancer was coming back.  Then I’d get a scan and there was no cancer.  It was hard to believe pain that bad was not life threatening.  I’ve canceled more plans (lost fun) and work appointments (lost funds) from IBS than from chemo sickness.  I’ve been less productive and less able to concentrate due to IBS pain than from chemobrain.  No wonder some people with IBS say they would give up 25% of their remaining lives to be cured..

1. Visceral hypersensitivity means some people are more sensitive to normal amounts of gut stretching. To understand the low FODMAP diet, you must understand what Monash University researchers discovered:  There are certain small carbohydrate molecules found in some foods that cause intestinal stretching either by drawing water into the intestines (making a kind of water balloon effect) or causing gas (making a kind of air balloon effect), thus activating pain receptors.  People with IBS don’t necessarily draw in more water or have more gas than normal people, but they do have visceral hypersensitivity meaning they are more sensitive than normal folks to even small amounts of stretching.  Monash University researchers developed the low FODMAP diet by systematically testing foods to identify the ones most likely to cause this stretch effect.  There are other theories emerging such as a baseline gut microbiome problem, but the FODMAP research has been based on the stretch effect and visceral hypersensitivity.

2. The low FODMAP diet is a diet of food intolerance.  But it’s not dairy free, gluten free, sugar free, or low carb, all of which I’d already tried with little success.  I was so cynical about trying one more diet, especially with its dumb name, that I put off getting serious about the low FODMAP until I was desperate.  It just seemed like another fad diet.  There have been miraculous claims about every specialized diet-keto, paleo, Mediterranean, low carb, vegan, vegetarian, and carnivore, and I’ve never once been the miracle.    

 I wouldn’t have been so skeptical except that I was already eating healthier than most anyone I knew and was more miserable than most of them.  I was eating a larger variety of plants and fermented foods than a lot of people to restore a healthy gut microbiome.  Still, abdominal pain disabled me. 

3.The FODMAP diet is highly researched and highly specific, meaning you need to know what to eat, and not base your eating just on what you think is healthy.

Consider the little quiz below.  In each pair, only one food is considered low FODMAP although both foods could be considered equally healthy. I was eating everything on that list aiming to eat a lot of plants and fermented foods.  I did not realize how much I needed to discriminate even among healthy foods and even parts of foods in the case of green onions and broccoli.    

 Quiz:  Which is low FODMAP?  Only one is correct in each pair. Answers at the end of this post.

• 1.      Cabbage or beets

• 2.      Blueberries or blackberries

• 3.      Citrus fruit or apples/pears 

• 4.      Garlic or ginger

• 5.      Potatoes or peas

• 6.      Which part of the green onion is low FODMAP?  The green part or the white part

• 7.      Broccoli or cauliflower

• 8.      Which fermented food is low FODMAP? Kimchi or Sauerkraut from red cabbage

 Within about three days of starting the diet, I was pain free.  This was ridiculous.  I kept thinking my mind is playing tricks on me.  But it’s been two years now, and I can pretty much (not always) control my symptoms.  Yes, I still have flares, but they don’t control my life, and it’s usually because I have overconsumed something that I still can’t handle in large quantities, like two plates of rigatoni with Italian garlic bread and a garlicky, oniony salad.  Constipation can also trigger a flare, so now I know to take something for constipation if I haven’t gone for 2 days. For the most part, I am able to do those little things that give the most quality to my life: exercise in nature, travel by car, train or plane, sit at my computer and create, do yardwork,  go to the university and take classes, go out with friends, and keep up with family.  My life has been restored.  

 Clearly, a large part of mastering the diet is just getting familiar with what to eat.  The website Katescarlata.com provides these above lists in their resources section.  That’s where I’d start if I knew then what I know now.  At first, the low FODMAP looks scarily complex.  It’s not.  It grows on you and becomes automatic much like being in Weight Watchers and knowing the acceptable foods.  

 4: Researchers at Monash University are the pioneers and have a great app.  When I began trying to follow the low-FODMAP diet, I didn’t know that Monash University pioneered the FODMAP research and remains a leader in the field.  I didn’t know their information was the gold standard.  Instead, I was scattered all over the web finding a disconcerting amount of conflicting information and not knowing who to trust. 

Just this week, for example, I listened to a podcast on the FODMAP diet given by two well-known health commentators.  The host began by saying how he’d been on the low FODMAP diet, and it was so restrictive that he was eating mostly chicken and white rice.  THIS IS SO WRONG. If that had been the first piece of information I’d encountered, I might have been too discouraged to delve deeper not realizing that was a completely false depiction of the low FODMAP diet.

 If you use apps, I’d recommend the Monash University FODMAP app for a

one-time $10 fee.  Monash updates the app as new research comes available and puts the fee back into research.  Reference 2 at 13:25 shows the main features of the Monash app. 

 There are nearly 50 apps that pop up if you search on FODMAP in the app store.  It’s easier to find the Monash app by searching on Monash.  Their app with a blue and black logo will be one of the top three to pop up.  

The app color codes foods on a traffic light system of green (low), yellow (moderate), and red (high), so at a glance, you can see what’s low vs high. 

When you open the app, you will see that there are more than 100 low FODMAP vegetables and almost 50 low FODMAP fruits.  You will see that all meat and fish are low FODMAP, just broil or bake and leave off breading or gravy as that’s where the FODMAPS will be hiding.  Eggs, butter, and aged hard cheeses like Swiss, provolone, cheddar and parmesan are also low FODMAP.  Hardly the restrictive chicken-and-rice diet that podcast host depicted.

Because FODMAPS are dose-dependent, the app shows how even a high FODMAP food can have a serving size that makes it low. 

 I’d also start with Monash lectures on Youtube and Monash-trained dietitians on Podcasts or Youtube (References 1-4 at the end of this post).  My favorite Monash-trained dietitian is Kate Scarlata because she makes things clear enough that I can understand her even with my chemobrain.  The first time I understood FODMAPS was when I watched her in Reference 1.  Her website and blog, Katescarlata.com answers questions you didn’t even know you had.  The resources section is especially helpful with its low/high FODMAP checklists and grocery list which contains brand names. Also, there are tons of recipes.  Plus, it jives with Monash University’s data.   Once I would have had the fundamentals correct from Monash, I would feel more confident browsing out all over the web knowing if someone gave contradictory information to Monash, I’d refer to Monash.   

In Reference 2, Kate Scarlata presents the concept of a Nourish Bowl (below), as an easy way to eat a balanced low FODMAP diet. 

Additions to the Nourish Bowl:

·         Select a protein can include eggs or lactose free cottage cheese.

·         Pick a base is picking a starch and can include sweet potatoes or white potatoes

·         Add colorful vegetables can include olives, sprouts, chives, green part of green onions or leeks.   Every color has different nutrients that feed the gut microbiome.  That’s why it’s important to eat a rainbow.

·         Finish with a healthy fat can include flax see or chia seeds, both good sources of omega-3’s, good for the gut microbiome, and easy to put in oatmeal.

·         Top with fruit can also include bananas and all citrus.

·         Remember to also add fermented foods as these are extremely good for the gut microbiome.  Low-FODMAP fermented foods include miso, lactose-free yogurt, lactose-free kefir, lactose-free cottage cheese with live cultures (Goodbelly and Green Valley brands have this) sauerkraut found in the refrigerated section and labeled with live cultures.  (Sauerkraut in the condiments section contains vinegar and has no live cultures).

 5: The FODMAP-gentle approach is a simpler approach that doesn't involve completely eliminating all high FODMAP foods.  The standard, well-researched FODMAP diet has three distinct and detailed stages.  Reference 2 at 32:42 does a great job explaining these:

(1) Substitution, sometimes called Elimination. This is where you eliminate all high FODMAP foods. The easiest way to do it is simply to substitute a low FODMAP food for a high one. Like eating an orange instead of an apple.

(2) Reintroduction.  You begin to add back high FODMAP foods and see how you are.

(3) Personalization.   You know what you can eat and not eat.

In the FODMAP-gentle approach, you look over the high FODMAPS list and get a sense of where the troubles probably are for you and just eliminate those foods.  You don’t eliminate all high FODMAP foods. 

Reference 2 at 53:23 gives the best explanation FODMAP-gentle approach including a short list of the highest FODMAP foods to avoid.  Reference 3 at 39:40 takes more time to explain about the FODMAP-gentle approach.  Some people are too overwhelmed to do the whole three-stage approach but will do the gentler way.  

 6:  FODMAPS are water soluble.  This is HUGE.  This one fact boosted my understanding of FODMAPS the most.  I’d seen things that made zero sense like use canned beans instead of dry beans.  Why??  I always thought fresh of everything was better.   Why canned beans?  Because as the beans sit in the water in the can over time, the FODMAPS are drawn out of the beans into the water, making the beans themselves lower in FODMAPS.  Throw out the water; don’t use it for anything like soup stock.  Rinse the beans thoroughly before using.   Lentils and chickpeas (1/4 cup) done this way can be used as low FODMAP.

 You cannot use garlic or onions in Stage 1 – the substitution/elimination stage because in almost all cooking, as soon as garlic mixes with water, the water draws the FODMAPS into the food.  However, because oil is not water soluble, you can soak garlic in oil and just remove the garlic before you cook with the oil. Oil will not draw out the FODMAPS.  FODMAPS are not fat soluble.  So, the oil gives you the garlic taste without the FODMAPS. You can also buy garlic-infused oil. Shallots can be marinated the same way to give an onion-flavored oil.

Because FODMAPS are water soluble, silky tofu that is more porous and hence holds more water will hold more FODMAPS than firm or extra firm tofu.  This goes for cheeses, too.  Hardened, aged cheeses are low FODMAP, but cheeses with more moisture (whey), such as ricotta or cottage cheese are not.

Ref 2 at 40:08 shows ways to swap out those water-soluble FODMAPS for other foods.

 7:  FODMAP stacking means FODMAPS add up.  I picture a bucket with water, with the water level representing the FODMAP level. When the water spills over, you get symptoms.  When you are eating only low-FODMAP foods in stage 1, you keep the water level low and don’t need to worry about raising the water level high enough to cause symptoms.  But as you re-introduce high FODMAPS, you may need to pay attention.  Reference 2 at 15:25 presents more on stacking.

 In retrospect, I believe the reason why I used to hit a wall around 4 pm was that I had been FODMAP stacking all day until I spilled over around 4 pm.  I might have started my day with oatmeal (ok) and soy milk (high FODMAP).  At lunch, I might have rice (OK) and beans (high FODMAP) or soup loaded with high FODMAP ingredients like beans, celery, garlic onions with wheat crackers.  A snack might be yogurt (high if not lactose free) or cauliflower (high) with ranch dip (high due to onions and garlic seasoning).

 When I started the low FODMAP diet, I got relief and felt not the least bit deprived by swapping low FODMAP foods in place of high ones.  For breakfast I had oats with blueberries or a spinach, green onion (green part only), and cheese omelet.  For lunch, I had grilled cheese on sourdough bread with miso soup and a salad made from any of these: spring mix, radishes, carrots, red cabbage or red cabbage sauerkraut, sprouts, olives, and cucumbers.  My favorite snacks became lactose-free cottage free with cut kiwi or/and mandarins, or roasted broccoli and sweet potatoes.  Dinner could be a stir fry using garlic-infused oil, vegetables, and firm tofu.

 Ref 2 at 40:08 shows ways to make these and other swaps.

You can use FODMAP stacking to plan ahead. When I was  putting higher FODMAP foods back in my diet, that’s when I started using the info on FODMAP stacking to avoid a ton of higher FODMAP foods.  If I’m going to travel, I go back on the low FODMAP diet a day or two prior to traveling just to be sure I’m not stuck somewhere with an IBS attack.  If I’m going out to eat, I might eat all low FODMAPS earlier in the day before that restaurant meal, so I have more leeway to have FODMAPS during that meal and worry less about hidden ingredients.  It’s kind of like saving your calories for the restaurant meal if you’ve ever done Weight Watchers.  I also often use gas-x before a restaurant meal to be safe.

 8:  The FODMAP diet is not a dairy-free or sugar-free diet.  Milk sugar (lactose) is high FODMAP, so yogurt, milk, and cottage cheese is ok only if it is lactose free.  However, all hard cheeses like Swiss, parm, or provolone are low FODMAP naturally.   When you do the reintroduction stage, you may find a few foods that still trigger symptoms.  For me, that is lactose.  So, even though I can consume a large bowl of watermelon now, I still have to buy lactose-free milk and lactose-free cottage cheese. 

Sweeteners are completely counterintuitive.  Sucrose (common white table sugar) is not high FODMAP, so a person following a low FODMAP diet can have white sugar.  If you are avoiding sugar for other reasons, that’s fine, but there is no need to avoid it based on FODMAPS.  Pure maple syrup is also low FODMAP and can be used to sweeten oatmeal, pancakes, plain Greek yogurt, and salad dressing; whereas, honey is high FODMAP.  High fructose corn syrup is just plain bad news.  It’s high FODMAP and terrible on the gut microbiome.  It has no redeemable reason to exist.

 9:  The FODMAP diet is not a gluten-free diet.  FODMAP info will sometimes erroneously tell you to avoid gluten.  However, gluten is a protein, and FODMAPS are only found in the carbs, so gluten is technically not the problem.  It just so happens that the same three grains with high-FODMAP carbs (wheat, rye, barley) also have gluten, so sometimes it’s easier to just shop for gluten-free labels.  It's important to know gluten is not a FODMAP problem because many are using gluten to boost their protein intake.  So, read the label.  If something contains “wheat gluten” but no other wheat part such as bran or germ, it is low FODMAP.  It means the gluten (protein) has been separated out from the carbohydrate part of the wheat.  Gluten is only a problem if you have a true gluten intolerance or Celiac disease. It has nothing to do with FODMAPS.

 10:  Sourdough bread is OK even though it’s made from wheat flour.  This is because the fermentation process substantially reduces the amount of FODMAPS.  I’m not one that likes gluten-free breads, but I love buttered sourdough toast with blueberry jam in the morning with coffee.   Being able to start my day off with toast is one of life’s little pleasures.

 When I travel, I always throw a loaf of sourdough bread and peanut butter in my carry on.  That way, I always know I have breakfast ready for the next day. 

 So, what happens if someone doesn’t respond well to the low FODMAP diet?  What else can be going on?  Reference 2 at 50:26 reviews other conditions and surprisingly does not completely overlap Reference 3 at 27:33 which thoroughly reviews other conditions.  So, listen to both.

 Low FODMAP Answers from Quiz:  cabbage, blueberries, citrus, ginger, potatoes, green part of green onion, broccoli, sauerkraut with red cabbage

 Reference 1

1.      Low FODMAP Diet Basics and Tips for Success.  This is an easy 20-minute introduction to FODMAPS by Kate Scarlata.

2.      Reference 2 Low Fodmap in Real Life: "How To" The Low FODMAP diet | Epicured | Partners In Health | Webinar  (60 minutes).  This summarizes the research, is geared to dietitians while still giving extremely practical information to patients.  The slides carry most of the info, so plan to watch instead of just listen.  The most practical advice for patients begins at 30:10 with Kate Scarlata.

3.      Reference 3 Kate Scarlata, MPH, RDN on The Low Fodmap Diet, IBS, Bloating, Constipation, and More (50 Minutes starts out with her personal story and then goes into IBS theory and research, then the  three stages) There are no slides so you can listen to the Podcast: The One Thing Podcast with Dr. Adam Rinde, episode 10/25/2019 or  Youtube

4.      Reference 4 The IBS Toolbox: Diet, Lifestyle, and Gut Health with Kate Scarlata, MPH, RDN There are no slides, so you can listen to the Podcast: The Good Clean Nutrition Podcast, Episode 40, 5/21/2024) or Youtube.