Maintenance Phase of the Low FODMAP Diet
To refresh your memory
FODMAPs are poorly absorbed short-chain carbohydrates including fructans, galacto-oligosaccharides (GOS), lactose, fructose (in excess of glucose), polyols. Science based evidence has suggested that a diet low in FODMAPs can alleviate symptoms of Irritable Bowel Syndrome (IBS) in up to 70% of patients.
In the last 3 weeks, we have explored what IBS is, how it is diagnosed, and Phase 1 & 2 of the Low FODMAP Diet.
The 3 phases of the Low FODMAP Diet
The Low FODMAP Diet consists of three phases including:
Phase 1: Elimination
This phase involves a complete elimination of high FODMAP foods for 2-6 weeks until IBS symptoms settle.
Phase 2: Challenge & Reintroduction
During this phase, patients remain on a low FODMAP diet, whilst re-introducing one FODMAP subgroup at a time. This enables patients and the Dietitian to identify what subgroups and quantities of FODMAPS can be tolerated in order to develop an individualised, modified low FODMAP diet for symptom control.
Degree of tolerance to each FODMAP subgroups varies. Some people can tolerate a lot of one subgroup and a small amount of the other subgroups. Some can only tolerate one subgroup with minimal symptoms but none of the other subgroups.
Foods of the FODMAP subgroups that are tested to be well tolerated without any symptoms can be completely reintroduced into the diet. Foods that cause a mild reaction can be reintroduced in smaller servings to be consumed occasionally. Foods that trigger severe symptoms should be avoided.
Keep in mind that mild bloating and flatulence are part of normal digestion and should not be confused with severe IBS symptoms.
Phase 3: Maintenance
In this blog, we’ll discuss Phase 3: Maintenance – how to maintain a reasonable control of IBS symptoms by balancing between the restriction of some high FODMAP foods and individual’s food desires as well as nutritional needs.
It is highly recommended that Phase 1 to 3 of the Low FODMAP Diet are delivered and monitored by an Accredited Practising Dietitian to ensure nutritional adequacy and long-term gut health.
Here is a great infographic to show what the FODMAP subgroups are and what foods are they found in:
So what happens in Phase 3: Maintenance?
The Maintenance Phase is to determine what combinations and overall load of FODMAPs IBS patients can consume without triggering symptoms in order to develop an individualised, modified Low FODMAP Diet for long-term adherence.
During Phase 3, tolerance of combined FODMAPs will be tested by challenging foods containing multiple FODMAPs (that have passed Phase 2). This further helps determine your combined and overall FODMAP threshold. Examples of foods that contain more than one FODMAP subgroups include: apple (which contains fructose and sorbitol) and sultanas (which contains fructans and fructose).
Similar to Phase 2, if symptoms occur during challenges, you will be recommended to go back to the strict Low FODMAP Diet for a few days until symptoms settle, before resuming the Phase 3 challenges.
Based on your results of Phase 2 & 3, your Dietitian will then help create an individual, modified Low FODMAP Diet based on your individual tolerances. To begin with, it might be a good idea to keep one to two meals per day Low FODMAP and gradually add high FODMAP foods into your meals.
Tolerance to FODMAPs can vary overtime. It is important to consider consulting the Dietitian to re-challenge foods at a later time to further increase the variety of the diet, especially the foods that contain prebiotics which are great for gut health such as garlic and onions.
What are the other therapies and recommendations?
Apart from the Low FODMAP Diet, general dietary recommendations for IBS patients include:
- Adhere to a regular meal pattern and avoid skipping meals
- Drink at least 8 cups of fluid per day, especially water or non-caffeinated drinks
- Reduce intake of alcohol, fizzy drinks, tea and coffee
- Limit intake of high-insoluble fibre food (such as bran)
- Limit fresh fruit to 3 portions per day (a portion should be approximately 80 g) and the portions should be spread out over the day
- Limit fatty and spicy food if found to be triggers
- People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar free sweets (including chewing gum) and drinks, and in some diabetic and slimming products
- People with wind and bloating may find it helpful to eat oats (such as oat based breakfast cereals or porridge) and linseeds (up to 1 tablespoon per day)
There are a number of medications that can help reduce symptom severity. To find out more about these pharmacological approaches to IBS you can have a read of one of our previous blogs ‘Pharmacology Approaches to IBS’ . Consult your GP for more.
Cognitive behavioural therapy (CBT), hypnotherapy or psychological therapy, which may help control gastrointestinal pain and discomfort, could be considered for people with IBS who do not respond to pharmacological treatments alone.
Managing stress levels regularly can help with reducing symptoms. Although more research is required in this area, some data has suggested that meditation and mindfulness training may help with symptom control and improve health-related quality of life in people with IBS. A simple way to start is to join a yoga class, or a mindfulness training available on many Apps and websites online.
Thanks for reading! I hope the blogs this IBS Awareness Month have been useful in helping you understand IBS and the Low FODMAP Diet!
Until next time,
Written by: Flora Cheung (APD, AN)
Edited By: Atlanta Miall-Shorten (APD,AN, AccSD)
Erin Peisach. The Modified FODMAP Diet: Your Guide After Reintroduction [Internet]. Place of publication unknown: DietVsDisease; year of publication unknown [cited 2018 Apr 23]. Available from: https://www.dietvsdisease.org/modified-fodmap-diet-maintenance/
Nanayakkara, W.S., et al., Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date. Clin Exp Gastroenterol, 2016. 9: p. 131-42.
NICE, Irritable bowel syndrome in adults: diagnosis and management. 2015.
Tuck C, Barrett J. Re-challenging FODMAPs: the low FODMAP diet phase two. Journal of Gastroenterology and Hepatology 2017 32(1):11-15.