Re‐challenging FODMAPs: the low FODMAP diet phase two

Abstract

The low fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet has good evidence for use in the treatment of patients with irritable bowel syndrome. Importantly, patients are encouraged not to remain on a strict low FODMAP diet long-term, and many patients maintain symptom improvement with a relaxed, moderate FODMAP restriction. The re-challenge phase is crucial to assist patients in identifying specific dietary triggers, reduce the level of dietary restriction required, and increase prebiotic intake. Limited evidence is available to guide best practice, but, in practice, beneficial outcomes can be seen through strategic food reintroductions. Here, we set out some practical recommendations based on clinical experience. Dietitians should tailor the challenge process to the individual patient and their needs. Food challenges should aim to improve dietary variety and nutritional adequacy while considering specific food preferences and usual dietary habits. Identifying FODMAP subgroups that are well tolerated is helpful, allowing the reintroduction of some moderate to high FODMAP foods back into the diet without symptom induction. FODMAP subtypes that are less well tolerated may also be reintroduced, but dosage and frequency of consumption need to be individualized. Additional challenges that face dietitians include consideration of patients with multiple dietary restrictions such as in vegetarians or patients with diabetes who are simultaneously following a low FODMAP diet. Ensuring nutritional adequacy is essential. The outcome of the re-challenge process aims to find a balance between good symptom control and expansion of the diet.

Fermentable short chain carbohydrate (FODMAP) content of common plant‐based foods and processed foods suitable for vegetarian‐ and vegan‐based eating patterns

“…Other food processing techniques, such as pickling, provide additional ways of improving patient tolerance of high FODMAP foods. The variation in FODMAP content found in the present study, depending on product, food processing and cooking methods, highlights the importance of individual tolerance testing in patients with IBS . Reductions in FODMAP content via food processing and cooking techniques, even if only modest, may improve patient tolerance.…”

“…Dietitians should target foods containing nutrients of concern, such as tempeh in an individual with low iron intake. Foods not meeting the low FODMAP cut‐off criteria at a standard serving size could then be trialled in small quantity during the re‐challenge phase with a gradual increase in serving size to assess individual patient tolerance . For example, first by commencing the patient on 100 mL of Quinoa milk, which did meet the low FODMAP cut‐off, and gradually increasing the serving size as tolerated toward a standard serving size of 250 mL, which did not meet the low FODMAP criteria.…”

Controversies and reality of the FODMAP diet for patients with irritable bowel syndrome

“…Since then, knowledge of its possible negative associations and the observation that tolerances to foods differed across individuals led to the current three‐step FODMAP diet. This protocol details how to initially restrict, then reintroduce foods, and finally personalize a diet for long‐term IBS management and has been described in detail elsewhere . This protocol has not been formally assessed in randomized controlled trials, but several studies of the longer‐term efficacy when individualization of the diet is achieved have now been published.…”

Low-FODMAP diet in the management of irritable bowel syndrome

“…Given the reestablishment of tolerance to each group, the patient should be encouraged to increase the doses, the frequency and the combination of high-FODMAP food. In this context, it is possible to improve the diet from the nutritional point of view [21].…”

“…This fragmentation happens due to the different effects FODMAPs cause in the gastrointestinal tract. Regarding the quantities, it is recommended to start reinsertion with reduced portions for approximately 3 days, thereby checking the patient's acceptance to a particular category [7,21].…”