The IBS Elimination Diet and Cookbook: The Proven Low-FODMAP Plan for Eating Well and Feeling Great - Couverture souple

A Revolution in IBS Treatment

What 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 Background

The 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.

Before moving on, let me tell you a little about myself and what I do. I regularly advise consumers to “consider the source” when evaluating any information about IBS and FODMAPs, so it is only fair that I invite you into my point of view. To begin, know that I share your history of miserable gastrointestinal (GI) symptoms. I have been in your shoes, trying to practice what I know about the science of nutrition in my grocery cart, in my kitchen, and for my body. When we’re not feeling well, we don’t have the time or the energy to read dozens of research papers and figure everything out from scratch. I’ve found out that it is all well and good to know what not to eat, but in our everyday lives we need to know what we can eat.

I am a registered dietitian nutritionist with two degrees in nutrition, from Cornell University and Boston University, and have experience as a research dietitian and nutrient database manager at Tufts New England Medical Center. As a medical nutrition therapist with a focus on digestive health, I see patients three days a week in Portland, Maine. I spend the rest of my work time teaching or attending scientific events, as well as reading and writing about FODMAPs. I rely on peer-reviewed, published primary sources for my data, but I use my own ideas to create tools such as menus, label reading tips, recipes, and shopping lists for my patients. I wrote this book to share these tools with you.

My own interest in digestive health goes back to when I was a 22-year-old dietetic intern at Beth Israel Hospital in Boston. I presented my first case study on a patient, whose name and face I still recall, with ulcerative colitis. As I studied and wrote about the diagnosis and treatment of bowel disorders, little did I know that I, too, was about to be diagnosed with ulcerative colitis. As a patient, I have had both good years and bad. Indeed, I have had enough bad years to deeply empathize with my patients who suffer from painful and disabling GI symptoms. These symptoms take a huge emotional toll.

I feel hesitant, even now, to talk briefly about my own challenges and health problems. How will readers react? Will my symptoms and special dietary needs be taken seriously? Will people think it is all in my head? After all, I look healthy enough. It can be hard to get past the stereotypes and judgment that IBS sufferers endure every day. People with gastrointestinal problems all too often suffer in silence because of social stigma or because they’ve been told they just have to learn to live with their symptoms.

Many of my patients tell me they have felt isolated by their IBS. I hope this book will offer you the comfort of knowing that you do not have to face your problems alone. I understand how embarrassing it can be to discuss your symptoms, even with a physician, family members, or close friends. I have experienced many of those same awkward moments and difficult social situations, so I can appreciate why reading a book like this about diet and IBS is a discreet way to get some help.

Since 2009, when IBS--Free at Last! first appeared, I have interacted with thousands of patients and readers. One thing is clear: citizens of today’s world are passionate about their food. People identify strongly with their food philosophies. In the past, with limited interaction and travel outside the local community, people had little choice but to eat like their neighbors. Today, with food and health information streaming to and from almost every corner of the world, food trends emerge quickly and circulate widely within days.

I want to make sure you understand my point of view, so you can decide whether this is the right book for you. I believe that humans are biologically omnivores and that anything edible is fair game as food. At this time in history, many of us choose to limit our intake of certain foods for social, ethical, health, environmental, or religious reasons, and I respect that. Some of my clients prefer to eat gluten-free, vegan, paleo, non-GMO, or organic, while others are more interested in eating affordable, convenient food. My job as a dietitian is to encourage each person to work within his or her own preferences so as to eat a wide variety of nutritious, well-tolerated foods. I hesitate to call a low-FODMAP diet a “lifestyle,” since it does not come attached to any particular set of values, except that it should be approached experimentally--to see what works and what doesn’t work for you. All this is to say that the recipes in this book are all low in FODMAPs, and they are made from a wide variety of whole, real foods. The rest of your food philosophy is up to you.

How to Use This Book

The IBS Elimination Diet and Cookbook is written primarily for lay people, although it is also a resource for medical practitioners. I have done my best to translate the latest research into terms that anyone can understand. Most readers will benefit from reading the next few pages to get acquainted with the vocabulary and the ideas behind the diet.

Part 1 (“IBS and FODMAP Basics”) provides a description of IBS symptoms, describes the FODMAP elimination phase, and gives some useful general information on the program. Part 2 (“The Two-Phase Program”) is an eight-step program of the two phases--elimination and reintroduction--with the latter offering three approaches to that reintroduction of FODMAP foods, ranging from the most aggressive to the gentlest. You can pick and choose, depending on your personality and the severity of your symptoms. You should first work your way through Part 1, so as to learn about the diet and determine if it’s right for you; but if time is short and you already have a firm diagnosis of IBS, it is possible to skip that and jump directly into Part 2. Steps 1 through 5 will help you begin eliminating FODMAPs from your diet; that’s the elimination phase. It is here you will find menus, shopping tips, and lists of suitable foods. There are also tips on monitoring your symptoms. Then, in Steps 6 through 8, you are led through the process of reintroducing FODMAPs, a very important part of the program. Please don’t miss this important point: the FODMAP elimination phase is a temporary learning diet; it is not meant to be a permanent lifestyle. At its completion, you need to reintroduce nutritious, high-FODMAP foods and eat as much of them as you can tolerate for your long-term diet. Finally, the program offers a way to evaluate your results, and it addresses many common questions about the program.