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The Diet Is Tremendously Helpful. The Rest of the Book, Not So Much.
on March 18, 2014
"The Complete Low-FODMAP Diet: A Revolutionary Plan for Managing IBS and Other Digestive Disorders" lays out the principles for a diet to control the symptoms of irritable bowel syndrome as well as help for non-responsive celiacs and those with IBD whose symptoms may be aggravated by sensitivity to FODMAPs. The book is written by Sue Shepherd, PhD, an Australian nutritionist who was instrumental in developing the low-FODMAP diet, and by Peter Gibson, MD, a gastroenterologist at Monash University in Australia, which continues to do a lot of research on IBS and the low-FODMAP diet. FODMAP is an acronym for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which are all poorly absorbed short-chain carbohydrates. Indigestible sugars, in other words. Lactose, fructose, and polyols are poorly absorbed in many people, while fructans and galato-oligosaccharides are not absorbed by anyone. When they are not absorbed, the sugars are easily fermented by intestinal bacteria, which produces symptoms.
The first part of the book explains the principles behind the low-FODMAP diet. The second part of the book is recipes. There are about 60 pages of substance, followed by 190 pages of recipes and menus that I did not find at all useful. The good news is that the substance of the book is short and easy to digest (no pun intended, ahem). The authors begin by explaining the differences between food allergies, hypersensitivities, and intolerance. IBS symptoms are largely caused by intolerance. They briefly discuss the Rome III diagnostic criteria for IBS before getting into theories about causes and descriptions of common symptoms. Oddly, the authors are dismissive of small intestinal bacteria overgrowth (SIBO) as a cause, though there is now a large body of research on it. The attitude toward SIBO seems obtuse after a while, as the authors claim that the symptoms of IBS are caused by fermentation, by bacteria, of indigestible sugars but dismiss the idea that there are problematic bacteria there.
The meat of the book is the tables of what foods you can and cannot eat, depending on which sugars you're not tolerating. There is a comprehensive table of low, moderate, and high-FODMAP foods on pages 44-45, which is the most handy reference (note that there is an error: broccoli is a moderate fructan food, not low). It is recommended that people with IBS follow the low-FODMAP diet strictly for 2 months, then introduce some other foods one at a time to test tolerance. The authors offer advice on how to do this, examples of what you might eat for snacks, drinks, and which alcoholic beverages are acceptable, baking tips, and substitutions for wheat flour. There is advice specifically for vegans, vegetarians, diabetics, celiacs, and children. I should warn you that the diet is very restrictive in that there are very few vegetables you can eat and fruit is also limited, more in quantity but less in variety than vegetables. To give you an idea, I have 60 vegetable soups in my repertoire, and only 14 are low-FODMAP -and that isn't even considering onions and garlic, for which I substitute oils.
But the low-FODMAP diet relieves symptoms in 75% of those with IBS. It worked wonders for me, so I highly recommend trying it. I have some criticisms of this book, however. One, as I mentioned, is its indifference to finding and treating the causes of IBS. No one would want to stay on this diet forever, as it is difficult to get adequate vitamins and minerals due to the restrictions on fruits and vegetables. Unlike most medical diets, low-FODMAP restricts foods that are your primary sources of nutrition, not only filler foods like grains, sugar, and dairy products. There is no mention that fungal overgrowths can also cause IBS. There is no mention of IBS symptoms that are not confined to the GI tract, namely neurological and inflammatory symptoms. For me, it was the neurological symptoms associated with fructose malabsorption that led me to seek and find this dietary solution. Also no mention that all of this fermentation of non-absorbed saccharides increases the permeability of the intestinal wall, causing some nasty systemic symptoms that are more alarming than IBS.
In any case, the diet is very helpful -or the principles of it are. The sample diets are too low in vegetables and absurdly high in carbohydrates. Very bad if you have an intestinal overgrowth. But I've been on the low-FODMAP diet for 4 months now, so I offer some tips: (1) They are not kidding when they say that minute amounts of onion can cause trouble. Don't eat anything that has onion or garlic powder or unidentified "spices" in it, even in the smallest amount. You don't want one onion molecule. It took me months to identify and eliminate all onion contaminants. (2) You can cook with onion and garlic oils for flavor. Fructans are not soluble in oil. The botulism scare concerning garlic oil is from uncooked oil. If you cook garlic in oil, that will kill any and all nasty organisms. I substitute ½ teaspoon garlic oil for 1 clove garlic and 2 tablespoons onion oil for 1 large onion. (3) Remember that it is the total FODMAP load for each meal or sitting that matters. Even low-FODMAP foods can cause symptoms if ingested in huge quantity. Don't eat two moderate-fructan or moderate-polyol foods together. (4) You may want to eliminate moderate-fructan and moderate-polyol foods entirely until you are symptom-free, as you may not tolerate them as well as the authors suppose. (5) You can eat the green tops of onions, leeks, and related plants. The book mentions scallion tops, but I contacted the Department of Gastroenterology at Monash University to make sure that this was true of leeks as well. They said up to 1.5 cups of leek greens could be eaten. I use leek greens in place of onions to flavor vegetable and chicken broths for soup. (6) You will find that many fruits and vegetables are not mentioned in this book. You can sometimes find fructose/glucose numbers in online nutrition databases, so you can determine for yourself if a food is suitable. But there is no resource for fructan content. Monash University has a FODMAP smartphone app that may be helpful. I don't know how often they update it. (7) Don't bother with hydrogen breath tests for fructose or lactose malabsorption. The question isn't whether you have fructose or lactose malabsorption. You probably do. Most people do. The question is whether they are causing your symptoms. (8) If you don't tolerate heavy cream or half & half, or if you want to make your own lactose-free milk, a company called Seeking Health makes lactase drops. Let them sit in your dairy product for 24 hours to break down 70% of the lactose or 48 hours to break down 96%. There is a downloadable data sheet on Seeking Health's web site. (9) The book is not clear on what spelt bread products are suitable. It's sourdough spelt bread that has been proofed overnight so that the yeast has consumed all of the fructans.