Introduction to Low FODMAP Elimination & Reintroduction CASA DE SANTE Introduction This booklet is a brief introduction to the low FODMAP diet elimination and challenge (reintroduction) phases, produced by Casa de Sante, Inc. At Casa de Sante we make and sell all natural low FODMAP Certified Developed by a physician scientist, Casa de Sante quality low FODMAP products are all natural, vegan, gluten and diary free with no additives, preservatives or fillers. Casa de Sante products are lab tested and certified FODMAP friendly, so customers with IBS can eat with confidence. We offer delicious spice mixes, salad dressings, stock, granolas, drinks, sauces, salsa and more. Learn more or order at casadesante.com. Free Resources Shop Low FODMAP Products Low FODMAP Meal Plans Low FODMAP App (food diary, symptom tracker, meal plans & more) Low FODMAP Recipes Personalized Recipe Search (search by dietary restrictions, ingredients, meal type & more) Low FODMAP Elimination Diet Video Course Low FODMAP Tips & Tricks Low FODMAP Shopping List Meditation for IBS Facebook Group Video Recipes Cookbooks Connect with us on Facebook, Twitter, Pinterest & YouTube. Plans Plans What to eat Daily Guides meal plans to reviewed once Challenge phase is complete Before you start Challengeing What are FODMAPs FODMAP Challenenge Phase Whats out Gluten & FODMAPs Symptoms time frame Non FODMAP food triggers Dairy & FODMAPs Manageing symptoms Whats in Challenege schedules What to Eat What’s in: The following foods are low in FODMAPs. Consuming these will help you minimise the FODMAPs in your diet. The meal plans and recipes in the free Casa de Sante app are lowFODMAP, but may include a few medium FODMAP foods that can be enjoyed in small serve sizes (pay attention to serving limits) and watch for sensitivities as individual tolerance can vary. If you are going to modify or change the meal plans or recipes, make sure to select from these foods to stay on the low FODMAP diet. Low FODMAP vegetables: alfalfa, bean sprouts, bamboo shoots, Asian greens (bok choy, choy sum, gai lan, wombok), beetroot (up to 4 slices), broccoli, brussel sprouts (2- 4), cabbage (chinese, red & green), capsicum/bell pepper/pepper – red, green, yellow, carrot, celeriac & celery, chilli –red, green, choko (½ cup), corn (up to ½ cob), cucumber, edamame, eggplant/aubergine, fennel – bulb & leaves, galangal & ginger, green beans, kale, lettuce – all types, leek (green only), mushrooms: black fungi, shimeji, oyster, canned champignon, okra, potato, parsnip, pumpkin (kent, japanese, kabocha squash), radish, sauerkraut – red (3 tbsn.), white (1 tbsn.), seaweed (nori), silverbeet, snow Peas ( 5 pods), Spring onion/shallot (green only), squash, spinach, sweet potato (up to ½ cup), taro (up to ½ cup), tomatoes, turnip, water chestnut, yam, zucchini/courgette Low FODMAP fruits: avocado (1-2 tbsp.), banana (firm), blueberries, carambola (dragon fruit), clementine, coconut (up to 1 cup fresh, 4 tbsp. desiccated), cumquats, dates – dried & fresh (limit 1-2), figs (limit to 1-2), grapefruit (up to ½), grapes (red &, green), guava, honeydew melon (up to ½ cup), jackfruit, kiwifruit, lemon, lime, mandarin, orange, passion fruit, pineapple, pomegranate, prickly pear, rambutan (1-2), raspberries, rhubarb, rock melon/cantaloupe (up to ½ cup), star fruit, strawberries, tamarind Low FODMAP nuts, seeds & legumes: all nuts and seeds, excluding pistachios and cashews. Almonds and hazelnuts need to be limited to 10 or less per serve, canned chick peas (¼ cup drained), canned butter beans (¼ cup drained), canned lentils (½ cup drained), firm tofu Gluten free grains: quinoa, all rice, buckwheat, teff, millet, rice based pasta, buckwheat noodles, rolled oats (½ cup/60g serve), polenta Gluten containing foods: soy sauce (2 tbsp per serve), 1 slice wheat bread, ½ cup wheat pasta, 2 slices spelt or wheat sourdough bread, 2 dry crackers Meat, poultry & fish: fresh cuts of meat, poultry and fish are low FODMAP. Be sure to check seasonings or marinades for high FODMAP ingredients e.g. onion, garlic Eggs: all eggs are low FODMAP Dairy and dairy alternatives: Lactose free milk, yoghurt and ice cream (check for added high FODMAP ingredients e.g. fruit flavours, inulin), traditional Greek yoghurt, all set or firm cheese (cheddar, American, brie, blue, camembert), coconut milk (1/3 cup), pea milk, almond milk, rice milk, quinoa milk, hemp milk Oils & vinegars: apple cider vinegar, white, wine, red wine, balsamic vinegar, all oils are low FODMAP Herbs and spices: all herbs and spices are low FODMAP, avoid blends that include onion or garlic Sweeteners: pure maple syrup, table sugar, stevia, glucose syrup, dextrose, invert sugar, rice malt syrup Alcohol: red and white wine in small serves (avoid sticky or sweet wine), beer in small serves, spirits in small serves note: alcohol is a gut irritant in large serves Non-alcoholic drinks: Casa de Sante LemonAID, water, tea, coffee (in small serves), small serves of orange or cranberry juice ( ½ cup/4 oz) What’s out: Alcohol: rum, sticky or sweet wines, note: alcohol is a gut irritant in large serves Drinks: soft drinks, large serves of coffee & tea, most fruit juice, kombucha High FODMAP grains: Barley, rye, large serves of wheat bread, flour and pasta, cereals with high FODMAP ingredients e.g. dried fruit, honey, kamut, bran, farina, couscous, wheat flour Processed and packaged foods: Most contain high FODMAP ingredients. Unless a product is certified low FODMAP, you will need to check the ingredients list individually. High FODMAP vegetables: asparagus, artichoke – globe, Jerusalem, bitter melon, blackberries, cauliflower, garlic, karela, leek - white part, onion – shallots, brown, red, white, peas (frozen), mushrooms, spring onion – white part, yucca root High FODMAP fruit: Apple, apricot (fresh and dried), banana – ripe, blackberries & boysenberries, cherries, custard apple, feijoa, mango, nectarine, peach, pear, persimmon, sugar banana, tamarillo, watermelon Nuts, seeds & legumes: Cashews & pistachio nuts, baked beans, black beans, borlotti beans, broad beans, cannellini beans, fava beans, four bean mix, garbanzo beans, haricot beans, navy beans, soy beans, silken tofu Dairy & alternatives: cows, sheep & goat milk, soy milk made form soy beans, large serves of oat or coconut milk, kefir Sweeteners: high fructose corn syrup, agave, erythritol (e968), fruit juice concentrate, honey – all types, isomalt (e953), mannitol (e421), maltilol (e965), sorbitol (e420), treacle, xylitol (e967) Processed, packaged foods, sweet, candy, chocolate: many contain high FODMAP ingredients. Unless low FODMAP certified, Ingredients list will need to be assessed on an individual basis. Non-FODMAP trigger foods Even though they are low FODMAP, certain foods and drinks can be gut irritants. If you have IBS, it is best to limit these to small serves and eat/drink them slowly and mindfully. Non-FODMAP food triggers include: Alcohol Caffeine Spicy food Rich & fatty foods Large amounts of overly sweet foods Carbonated soft drinks Too much fibre, too little fibre or the wrong types of fibre Other Non- FODMAP triggers include: Stress & anxiety Eating too fast Certain medications or supplements Daily Guides To assess meal plans and recipes as soon as Challenge section is completed Before you Start 1. What are FODMAPs? FODMAP is an acronym for groups of short chain carbohydrate or “sugar” molecules that may be poorly digested in the small intestine. They continue their path along the digestive tract to the large intestine, or colon, where they become fast food for the healthy bacteria that live there. As FODMAP pass through the digestive tract, two events occur which may cause IBS type symptoms such as gas, bloating, abdominal pain or alter bowel habits (constipation and/or diarrhoea). 1. FODMAPs are osmotic – they attract water and draw water into the digestive tract. This extra fluid causes matter to move more quickly along the digestive tract and may also cause watery stool or diarrhoea 2. FODMAPs are fermented in the Large intestine by the healthy bacteria that live there. When these healthy bacteria consume FODMAPs, they create gas as a side effect. This results in gas which swells the large intestine creating a feeling of bloating and irritating the nerve endings around the bowel. Fermentable Oligosaccharides Di-saccharides Monosaccharides And Polyols Carbohydrate molecules that are fermented in the bowel creating gas as a side effect Short chains of sugar molecules found commonly in wheat, asparagus, barley, rye, onion, garlic, some nuts and legumes, watermelon, artichoke The double sugar - Lactose in milk and milk products Fructose in excess of glucose found in honey, apples, pears, agave, mango, high fructose corn syrup Sugar alcohols, sorbitol and mannitol, found in mushrooms, cauliflower, stone fruit, artificially sweetened gums and nutrition bars The low FODMAP diet is not a forever diet. It is instead designed to be used as a tool to identify the sorts of foods that trigger IBS symptoms in each individual. These trigger foods will vary from person to person, to know your individual triggers it is necessary to move though the three phases of the low FODMAP diet: Phase 1: The low FODMAP phase. All high FODMAP foods are removed from your diet for a period of 2-6 weeks. The aim of this phase is to determine if removing FODMAPs makes a consistent improvement in your IBS symptoms. Phase 2: The Re-Challenge (reintroduction phase). Each FODMAP group is challenge is a structured and systematic way to determine if it is problematic or not and what amount of the FODMAP can be tolerated at any one time. Phase 3: Adapted low FODMAP diet. This phase of the low FODMAP diet is where you use the information gathered during the Re-Challenge phase to expand your diet as much as possible while still keeping IBS symptoms well managed. 2. Gluten and FODMAPs Gluten is the protein in found in wheat, barley and rye. FODMAPs are the carbohydrate found in wheat, barley, rye, milk, sweeteners, certain fruits and vegetables, nuts and legumes. These are different molecules that are commonly found in the same foods. Celiac Disease, when they eat gluten containing foods an abnormal response occurs which results in damage to the lining of the small bowel. This has serious consequences and may result in serious long term health problems. People with celiac disease may have similar symptoms to those with IBS or no symptoms at all. Currently the only treatment for celiac disease is a strict gluten free diet for life including care with cross contamination. IBS does not cause damage to the bowel, although it can cause rather “unfriendly” symptoms that impact on a person’s quality of life. Since the bowel remains healthy, the treatment for IBS to avoid trigger foods only to the level necessary to keep symptoms settled at a tolerable level. In the case of IBS, it is most likely the FODMAPs (or carbohydrate) in wheat products that are the culprit. Not all gluten containing products are high FODMAP and some gluten is allowed on the low FODMAP diet. Similarly, not all gluten free products are low FODMAP and when choosing gluten free foods you will also need to check for the presence of high FODMAP ingredients. Low FODMAP foods that contain gluten: 1 slice serve of wheat bread ½ cup serve of wheat pasta 2 slice serve of wheat or spelt sourdough bread 2 tablespoon serve of soy sauce Gluten free foods that are high FODMAP: Besan/chick pea flour, coconut flour, lupin flour, soy flour Inulin/chicory root Certain fruits and vegetables including onion, garlic, apple Certain nuts and legumes Honey, agave Dried fruit 3. Dairy and FODMAPs Lactose is a di-saccharide” and the “D” in the FODMAP equation. It is a double sugar molecule made of glucose and galactose, found naturally in milk and milk products. When the glucose and the galactose are bound together, they form lactose. To digest lactose, the glucose and galactose must be separated to single sugar molecules by an enzyme, called Lactase, that lives in the lining of the digestive tract. Once they are separated, they are easily digested and absorbed. If an individual has got low numbers of the Lactose enzyme, they will not be able to separate the lactose, and it will remain in the digestive tract undigested. Like all FODMAPs, as lactose moves through the digestive tract it can cause IBS type symptoms such as pain, bloating, wind and altered bowel habits (constipation and/or diarrhoea) Lactase enzyme can be added to milk and milk products prior to eating or drinking (e.g. lactose free milk or ice cream). This can be done during manufacturer (i.e. in lactose free milk) or purchased from a drug store in tablet form and taken with a food that contains lactose. This is very effective, but be sure to check the ingredients, some lactase tablets can contain other high FODMAP ingredients e.g. mannitol. Dairy foods that are allowed on the low FODMAP diet include: Some dairy products e.g. cheese do not naturally contain lactose and can be consumed as normal on a low FODMAP diet. This includes all hard or set cheeses i.e. Cheddar, parmesan, harvati, swiss, tasty, edam, camembert, brie, all blue cheese, red leister, mozzarella, fetta, bocconcini Wet or fresh cheeses still contain small amounts of lactose and can be eaten in small serves i.e. ricotta, cottage cheese, cream cheese, haloumi Milk and white chocolate also contain some lactose, and is best limited to small serves on a low FODMAP diet. Greek yoghurt that has been made in the traditional way, is strained and most of the lactose is discarded. This means Greek yoghurt can be enjoyed in small amounts on a low FODMAP diet. Lactose free milk, sour cream custard, yoghurt, ice cream. Nb: be sure to check lactose free products such as yoghurts, ice creams, flavoured milks, for high FODMAP flavours or thickeners. These may include high FODMAP sweeteners (fruit juices, honey, polyols), high FODMAP fruit flavours (mango, pear) or high FODMAP thickeners (inulin, chicory root). Butter Lactase containing products that require the addition of lactase include: All mammalian milks e.g. cow, sheep, goat Regular yoghurt Regular ice cream Regular sour cream Regular custard Whey powder/whey concentrate Kefir Evaporated and condensed milk There are many alternative and plant based milks available in stores today. While these are lactose free, they may be high FODMAP for other reasons. If you choose to switch to a plant based milk, it is important to choose one that is nutritionally similar to cow’s milk so as to ensure you meet calcium and protein requirements. We suggest looking for an option with about 120mg/100ml or 30-35% calcium. Low FODMAP plant based milks include: Soy milk made with soy protein Almond milk Pea milk Rice milk Hemp milk Other nut milks High FODMAP plant based milks include: Coconut milk over ½ cup (4oz) Oat milk or over ½ cup (4oz) Soy milk made with soy beans Plant milk with high FODMAP ingredients e.g. high FODMAP fruit flavours, inulin, added fructose Lactose and medications: Lactose can sometimes be added as a filler in medications. This is only used in small amounts and well below the cut off for lactose, so not considered a concern on a low FODMAP diet. Challenging (Reintroduction) 1. FODMAP Rechallenge Phase Phase 2 of the low FODMAP diet involves Re-Challenging each FODMAP group to assess for personal tolerance. This will provide you with the information you need to Reintroduce FODMAPs into your diet into your diet and allow as much variety as possible while still maintaining good symptoms management. Similar to the elimination phase, you will continue to consume low FODMAP foods; however, each week you will “Re-Challenge” a different FODMAP group in increasing portion sizes to assess how your body responds. The portion size you tolerate, can then be used to guide your reintroduction. The following points are designed to help guide you through this phase: This process is meant to be done slowly and systematically. You will try a new FODMAP group each week, Re-Challenging a food item specific to a particular FODMAP group in increasing amounts (per tolerance). This phase is about testing your tolerance to each FODMAP group, so that you can use this information and apply it to a variety of different foods. Foods need to be chosen carefully to only include one FODMAP group. You can do challenges in any order, choosing one of the following to start with: Oligosaccharides (Fructans and GOS), Disaccharides (lactose), Monosaccharides (excess fructose), Polyols (sorbitol and mannitol) A key point to remember is that you want to only try one FODMAP type at a time. For example, if you are Challenging dairy (lactose), then you will want to try plain milk, not a milk product that contains other added FODMAP e.g. high-fructose corn syrup. Begin with a small portion and advance each day if you experience mild symptoms or no symptoms at all. Be sure to document which foods you have tried, how much, and associated symptoms (if any). If the symptoms you experience are severe, then wait until your symptoms resolve and try a different food item from the same FODMAP group or wait until the end of the washout period to try a different FODMAP group. If you experience symptoms, return to the baseline low FODMAP diet. You can also use other strategies that help to manage symptoms at this time, such as peppermint tablets, hot packs relaxation techniques and so on. Remember that you will want to continue to eat low FODMAP foods as you were doing in the elimination phase, and not try anything new at this time. 2. IBS Symptom time frame High FODMAP foods often cause symptoms in those with IBS within 6-24 hours. This is the amount of time it takes for food you’ve eaten to reach the large intestines where fermentation occurs. Symptoms occurring outside of this time frame may indicate a different mode of action and we suggest talking to a specialist registered dietitian. Common symptoms associated with high FODMAP food/beverage intake include: abdominal pain, distention, bloating, flatulence, cramping, diarrhea, and constipation. The length of time symptoms persist is variable. Some individuals experience resolution of symptoms within hours, some within 1-2 days. 3. Managing Symptoms At some point during the challenge phase, it’s likely that you will experience some sort of gut symptoms. There will also be times in the future that you overindulge or come into contact with one of your bigger FODMAP triggers. This is not something to feel bad about (no one can be strict all the time) and reactions to food can also be inconsistent. Having a plan to manage this makes it less daunting and helps symptoms to pass more quickly. Revert to the low FODMAP Elimination diet Stick with simple low FODMAP foods that you know are well tolerated. Avoid high fat foods, rich or spicy foods, coffee, soft drinks and alcohol Use behavioural techniques Rest, meditation and mindfulness are all great ways to help realign the gutbrain axis Fresh air & gentle exercise can help you feel better Hot packs, hot baths or a gentle tummy massage are great for bloating Treat your symptoms Your healthcare professional may recommend suitable counter medications like laxatives, anti-diarrhoea medications or anti-spasmodic Casa de Sante LemonAID is great for calming the gut Peppermint oil, peppermint tea & ginger may help with bloating and a queasy stomach Soluble fibre supplements (e.g. Metamucil® or Regular Girl® (PHGG) can improve stool form Stay hydrated by drinking plenty of water 4. Challenge Schedules Foods suitable for Challenging FODMAPs The food listed in the table below only contain one FODMAP group and are suitable to use for Challenging. Using these foods will tell you how you tolerate each FODMAP group and the information can be applied to other foods which contain multiple FODMAP groups Foods for Challenging Lactose Buttermilk Cow’s milk Evaporated milk, canned Goat milk Sheep milk Ice cream Regular yoghurt (no high FODMAP ingredients e.g. fruit, honey, inulin) Foods for Challenging Excess Fructose Mango Honey Artichoke hearts Sugar Snap peas Foods for Challenging Fructans (4 challenges needed) Wheat: Wheat bread Pasta Bran Couscous Fructan fruit: Leek (white part) Globe artichoke Grapefruit Persimmon Onion Garlic Foods for Challenging GOS Foods for Challenging Mannitol Foods for Challenging Sorbitol Butter Beans Chick Peas Black beans Almonds Pistachios Soy bean milk Mushrooms (Portobello, shitake, enoki or porcini) Cauliflower Sauerkraut Yellow Nectarine Lychees Sugar free mints Avocado Blackberries Green beans It is recommended that you follow the proceeding schedule when challenging a particular FODMAP group. Remember: You will only test ONE FODMAP group per week, followed by a three day washout. If you experience moderate/severe symptoms at any time you can discontinue Challenge and wait for your symptoms to resolve. When you feel well again you can challenge a different food from the same group or complete the washout period by returning to the Elimination diet prior to moving on to the next challenge. Day 1 Day 2 Re-Challenge Schedule Challenge Day #1 Symptoms are mild or no symptoms present: Proceed Small FODMAP to day #2 Portion Symptoms are moderate/severe: Do not advance to proceeding day. When symptoms resolve, try a different food from the same FODMAP group or commence the four day washout before moving on to the next FODMAP group. Challenge Day #2 Symptoms are mild or no symptoms present: Proceed Medium FODMAP to day #2 Portion Symptoms are moderate/severe: Do not advance to proceeding day. When symptoms resolve, try a different food from the same FODMAP group or commence the four day washout before moving on to the next FODMAP group. Day 3 Challenge Day #3 Large FODMAP Portion Day 4 Washout Period Low FODMAP diet Day 5 Washout Period Low FODMAP diet Day 6 Washout Period Low FODMAP diet Day 7 Low FODMAP Symptoms are mild or no symptoms present: Proceed to day #2 Symptoms are moderate/severe: Do not advance to proceeding day. When symptoms resolve, try a different food from the same FODMAP group or commence the four day washout before moving on to the next FODMAP group. Remove the challenge food and maintain low FODMAP intake for the duration of the washout period even if a FODMAP group was successfully Challenged Remove the challenge food and maintain low FODMAP intake for the duration of the washout period even if a FODMAP group was successfully Challenged Remove the challenge food and maintain low FODMAP intake for the duration of the washout period even if a FODMAP group was successfully Challenged Maintain low FODMAP diet in preparation for the next Challenge. Do not introduce high FODMAP foods even if they were successfully challenged previously. It is recommended that you Re-Challenge the following food items which represent a specific FODMAP group. You will also find various portion sizes that correspond to days 1-3. Day #1 of reintroduction will always be a small portion to assess overall tolerance of the FODMAP group being reintroduced. If Day #1 is tolerated well (mild or no symptoms), you are encouraged to proceed to day #2 (medium portion) and, if day #2 doesn’t cause moderate/severe symptoms, eventually to Day #3 (large portion). If you experience symptoms: You can stop the challenge at any time that you experience moderate or severe symptoms. Remove the test food from your diet and wait until the symptoms go away. If you do not experience symptoms: If you complete the full challenge without experiencing symptoms, congratulations! You still need to remove the test food form your diet and complete the washout phase prior to commencing the next challenge. Recommended FODMAP Foods to Challenge FODMAP Group Day (#) Portion Size Food Item Day #1 Small Milk Amount 125 mL Disaccharides (Lactose) Monosaccharides (Fructose) Oligos - Wheat Oligos - Onion Oligos - Garlic Oligos - fruit GOS Polyols - Sorbitol Polyols - Mannitol Day #2 Day #3 Day #1 Day #2 Day #3 Day #1 Medium Large Small Medium Large Small Day #2 Medium Day #3 Large Day #1 Day #2 Day #3 Day #1 Day #2 Day #3 Day #1 Day #2 Day #3 Day #1 Day #2 Day #3 Day #1 Day #2 Day #3 Day #1 Day #2 Day #3 Small Medium Large Small Medium Large Small Medium Large Small Medium Large Small Medium Large Small Medium Large Milk Milk Honey Honey Honey Bread (wheat) Bread (wheat) Bread (wheat) Onion Onion Onion Garlic Garlic Garlic Raisins Raisins Raisins Almonds Almonds Almonds Lychees Lychees Lychees Cauliflower Cauliflower Cauliflower 250 mL 375 mL 1 Tsp 1 Tbsp 2 Tbsp 1 Slice 2 Slices 3 Slices 1 tablespoon 2 tablespoons 3 tablespoons ½ teaspoon 1 teaspoon 1½ teaspoons 1 tablespoon 2 tablespoons 3 tablespoons 15 Pieces 20 Pieces 30 Pieces 5 pieces 10 pieces 15 pieces ¼ cup ½ cup 1 cup By taking your time to determine which FODMAP groups induce symptoms, and which do not, will enhance the variety of your diet tremendously. However, individual responses to FODMAP reintroductions vary widely. There are few that may be able to reintroduce all FODMAP groups in large serves, and there are some who may only tolerate small serves of most FODMAP groups. If you find that you do not tolerate any of the FODMAP groups upon Re-Challenging, consult with your healthcare professional to discuss other possible underlying causes for your intolerances.