Excerpt
The IBS Elimination Diet and Cookbook
A Revolution in IBS TreatmentWhat do apples, multi-grain bread, cauliflower, yogurt, high-fiber breakfast cereals, and hummus have in common? These “healthy” foods all contain fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs), and they can trigger symptoms of irritable bowel syndrome (IBS). Ironically, for many years it was thought that foods like these would help everyone with IBS. And even today, many health-care providers still have not moved beyond traditional one-size-fits-all “fiber” therapy for IBS—if they give any dietary advice at all. If you are reading this book, it may not come as a surprise that high-fiber IBS therapy, beloved by doctors everywhere, doesn’t always (or even usually) work! If thirty-three IBS patients are told to eat more bran, only one of them is likely to report improvement of his or her symptoms over the next month. Clearly, we need to do better.
There is now proof that changing the types of sugars and fibers in your diet can help you achieve lasting relief from IBS symptoms. The FODMAP approach, developed in Australia and now used around the world, is increasingly recognized as the most effective way to manage IBS with diet. Up to 85 percent of patients report significant improvement of their IBS symptoms when they have followed a low-FODMAP diet. The 35 million Americans with IBS (about 11 percent of the population) are no longer left to their own devices, desperately looking for help with their symptoms. There is no longer any reason for doctors to stand by helplessly, to give the same old “high-fiber diet” advice or, worse yet, to tell patients that diet doesn’t matter.
When I wrote the first edition of IBS—Free at Last! in 2008, almost no one knew about FODMAPs outside of Australia; the challenge was to get the information to the IBS sufferers who needed it. Its publication coincided with exploding consumer interest in nutrition and non-drug therapies for IBS. Connected by social media and with ready access to published medical literature, people began to learn self-help strategies directly from each other, without regard to international boundaries and without the filter of what their health-care providers knew or chose to share with them. This meant that patients often learned about FODMAPs from the Internet, or from my book, before their doctors or dietitians did. We are witnessing a revolution, with nutrition emerging as first-line therapy for IBS, and it has been a patient-driven phenomenon.
Today, the challenge for many IBS sufferers is actually dealing with too much information (and misinformation!). Word spreads fast on the Internet, sometimes presented by people with a thin grasp of nutritional science. Pretty recipe pictures on Pinterest and lists of high- and low-FODMAP foods are not enough. To get the best outcome from a FODMAP elimination diet, you need a strategy and a plan. You need help in cutting through the confusion about FODMAPs and IBS, and in getting down to work. You deserve trustworthy guidance, and you can find it here. With this book, you can conduct a dietary experiment to learn how FODMAPs affect you by eating only low-FODMAP foods for a few weeks, then reintroducing high-FODMAP foods and monitoring your symptoms. You will learn which FODMAPs affect you and which ones don’t.
That’s what this book is. This revised and expanded version of IBS—Free at Last! is your guide to understanding the science of FODMAPs and finding your unique FODMAP fingerprint. And it offers fifty-six delicious recipes to get you started on your new pain-free lifestyle, as well as tips and plans for eating when you don’t have the time and resources to cook every meal from scratch.
You may wonder: Why are FODMAPs so complex? and Why do I need to learn so much in order to follow this diet? It’s because of where the FODMAP data come from; how they are affected by the natural variability of food; what the difference is between FODMAP data and FODMAP teaching tools, such as are included in this book; and how these different tools can be used, depending on where you are in the elimination phase of the program. There’s a lot of conflicting information online, so it’s good for you to have a little backstory before you embark on this journey.
FODMAP BackgroundThe FODMAP concept was created by researchers at Monash University in Australia, and this group continues to publish most of the available FODMAP food composition data—these published data tables are the primary sources for the program. An example of FODMAP data is: “There are 1.2 grams of sorbitol in 100 grams of an apple.” We can’t get too attached to such data, though. Different varieties of apples, different growing conditions, and different degrees of ripeness make each apple unique, and the same holds true for each type of fruit or vegetable, as well as for every batch of grain or loaf of bread.
Most people do not have the time, interest, or know-how to plan a low-FODMAP diet directly from the data tables published in the medical journals. So health-care professionals and educators create tools to communicate this information to patients and readers. At the heart of each tool is a list of low-FODMAP foods. For example, I developed the tools in this book—the Low-FODMAP Pantry (page 81) and the label reading tips on pages 91–97—based on the available data about the FODMAP content of foods at the time of publication. I built my unique approach to the data on the way people actually eat and live—a methodology that has made it possible for my patients to stick with the diet and reap its benefits.
Tool creators make decisions about which foods to include on a low-FODMAP diet based on cut-offs they have determined for what is considered a “high-FODMAP” food. There are no scientifically proven rules for determining these cut-offs or deciding what the food portions should be. Each tool creator or project team decides these things independently. They filter the FODMAP data through their different lenses; that’s okay, because different tools can help different people. That’s also why you can expect some minor variations in the FODMAP tools and corresponding recipes. Don’t worry; these few minor discrepancies won’t diminish the overall impact of lowering the FODMAP load of your diet.
In this book, I’ve determined whether a food is low in FODMAPs based on standard serving sizes, such as 1/2 cup of vegetables. I made this decision, which admittedly errs on the side of oversimplification, so this complex and technical diet is easier to learn and easier for you to remember. Another developer’s FODMAP tool might shrink the vegetable servings to as small as necessary to give those foods a green light. For example, in my program, Brussels sprouts are not suitable for the elimination phase of the program because 1/2 cup contains too many FODMAPs. However, in the Monash University Low FODMAP Diet app, which uses a traffic light system, a serving of two Brussels sprouts gets that green light.
Conflicts can also arise when the context is fuzzy. For example, if you searched the Internet to answer the question “Can I eat Greek yogurt on a low-FODMAP diet?,” you would get a variety of answers. So, you need to be clear whether you are following a strict elimination/reintroduction program or are eating a relatively low-lactose diet after completing the reintroduction phase. Now, let’s answer your question: No, Greek yogurt is not recommended during the elimination phase of this program because it contains several grams of lactose per serving. Yes, it is a good choice for a relatively low-FODMAP diet because it is lower in lactose than other yogurts. So, as you see, both responses are true. Greek yogurt may be a perfectly good choice after the reintroduction phase—if you’ve found you can tolerate several grams of lactose at once. You will need to remind yourself of where you are in your program as you review such confusing or seemingly contradictory information.
Likewise, if you are comparing two tools created by the same person, keep in mind that the food lists with later publication dates are likely the more accurate ones. As more primary data is published, the FODMAP status or recommended portion sizes may change. For instance, the food lists in this book are more up to date than those in my previous books.
As you can see, learning about FODMAPs means also learning to live with some uncertainty about the suitability of the foods for your diet. The inevitable discrepancies can cause a little anxiety about whether you are “doing it right.” Don’t let those worries distract you from the big picture. Even with some uncertainty, substantially lowering your overall FODMAP intake will help you decide whether FODMAPs are impacting your IBS symptoms, and if that’s the case, you will be able to manage these symptoms more effectively.
