An Introduction To The FODMAP Gentle Approach – How To Implement This More Relaxed Version Of The Low FODMAP Diet

A common misconception of the low FODMAP diet is that there is only one way to prescribe it – when, like all dietary modifications, there are many nuances. The FODMAP gentle approach is an emerging concept that stems from practitioners implementing the traditional phases of the low FODMAP diet and finding that this stringent method isn’t for everyone. It’s an evolving amalgamation of ideas on how to implement the diet in a more relaxed way to suit the different types of patients that dietitians encounter.

What are the three typical phases of the low FODMAP diet?

The three phases of the low FODMAP diet involve strict elimination, challenge/reintroduction and long-term modification/individualisation. The overall goal of these steps is to identify which FODMAP groups are involved in triggering or exacerbating IBS symptoms, and subsequently use this information to develop a personalised eating plan that ensures as much variety and as little symptoms as possible.

Elimination is the trial phase of the low FODMAP diet that removes all FODMAP groups, even if the patient thinks that they are well tolerated. The purpose of this phase is to determine whether removing FODMAPs makes a significant difference to symptoms. This step usually lasts around two to four weeks.

The challenge phase is commenced if symptoms have improved significantly upon completion of the elimination phase. The challenge phase aims to identify which FODMAP groups are well tolerated and which ones are problematic. This reduces the need for an over-restrictive elimination-style diet, which can limit foods high in prebiotics and plant variety. The challenge phase is structured and systematic – similar to running an experiment.

Long term modification includes well tolerated high FODMAP foods in the diet. It aims to give patients the knowledge of which foods may give them symptoms but allows them to work to balance symptoms with food desires.

What is the gentle approach to the low FODMAP diet?

The structured protocol seems to work effectively for majority of IBS sufferers. We would call this a ‘top down’ approach to treatment – where a patient uses big picture thinking to restrict all FODMAPs, challenge them individually, identify the triggers and refine their diet accordingly. However, this approach is not suitable for all patients, particularly if other aspects of health or nutritional status are contradictory to implementing a restrictive diet.

There is a ‘bottom up’, gentle approach to the low FODMAP diet. Instead of initially eliminating all FODMAPs, as is the case in the three-step protocol, this approach first identifies a few high FODMAP foods and/or targeted FODMAPs that may be causing symptoms in a patient. The patient will eliminate these for a period of time, and then ‘increase the accelerator’ with further dietary restriction if necessary. Symptom response is monitored throughout.¹

Why is the FODMAP gentle approach better in some scenarios?

The three FODMAP phases can take a long time to execute, and a high degree of patience and commitment to the cause is required in a patient. The commitment may mean that patients give up halfway due to the rigidity of the elimination and challenge phases. Additionally, patients present themselves with varying degrees of IBS symptoms. At the milder end of the spectrum, a gentle approach may be all a patient needs to reduce digestive discomfort.

Which types of patients are known to be better suited to the FODMAP gentle approach?

A gentle approach should be considered in patients with:

• Active eating disorders or a history of disordered eating who are already experiencing detriment to their psychological health and nutritional status. For any patient who presents a tendency to give themselves ‘food rules’, a strict approach to the low FODMAP diet may not be advisable.
• Malnutrition where nutritional status is already compromised.

• Existing dietary restrictions such as vegetarianism or Coeliac disease. Although having dietary restrictions does not automatically mean the patient should follow the FODMAP gentle approach, practitioners need to assess if their patients are capable of taking on more restrictions before prescribing the traditional low FODMAP diet.
• Children, where the focus must be to meet nutritional adequacy and establish healthy eating habits to carry across the lifespan.
• Comorbidity with existing dietary restrictions e.g. patients with Inflammatory Bowel Disease, Heart disease or Cardiovascular disease. 
• An unwillingness to apply the diet or poor capability to understand and/or apply the diet in its traditional sense – as the three-step approach will likely result in non-adherence.

How is the FODMAP gentle approach implemented?

There are currently no specific guidelines to implementing the FODMAP gentle approach. However, using the best available evidence, there are some practical steps that practitioners can consider discussing with patients:

• Reduce common high FODMAP foods from each food group such as wheat and rye in grains, onion, garlic, leek, cauliflower and mushrooms in vegetables, apple, dried fruit and stone fruit in fruits, milk and yoghurt in dairy and legumes in meat/alternatives.
• Reduce diet specific FODMAPs. This approach requires the patient completing a comprehensive dietary history so you can work together to identify the foods highest in FODMAPs most frequently eaten. For example, if a vegetarian adult eats fruits and dairy products four times per day, but doesn’t eat as many vegetables and grains, you might recommend reducing just fructose and lactose.

Questions to ask when analysing a patient’s food diary

A well-trained dietitian can target attention to the changes to each patient’s current intake and make allowances for dietary flexibility. They can also extrapolate which FODMAP group is likely to be causing the most issues.

For example, they would instinctively know that vegetarians may need to have a greater allowance for legumes, or someone with many work commitments may need to eat out more freely. Here are some key questions to consider:

• Is a patient eating a lot of one particular FODMAP group?
• Are symptoms particularly worse after a meal high in a certain FODMAP? E.g. a banana smoothie leaves the patient in pain, a piece of wholegrain toast not so much.
• Is the patient already avoiding a certain type of food?
• Does the patient already have a good idea of what types of foods trigger them? E.g. if a banana smoothie sends the patient to the bathroom, fructose may be restricted first.
• Is there a certain time of the day that the patient gets symptoms?
• Was there a stressful life event that triggered the onset of symptoms? If so, the practitioner may be able to identify that the patient’s IBS is most likely stress related, so implementing de-stressing techniques would be appropriate to word alongside the gentle approach.

Asking such questions stresses the important of taking the entire history of a patient into account and not blindly prescribing the three-phase low FODMAP approach. Diet history, medical history and lifestyle factors are important pieces of the puzzle to consider.

In summary
There is more than one way to implement the low FODMAP diet, and a ‘bottom up’, FODMAP gentle approach has great potential for a number of patients. Although there are no prescribed guidelines to implementing this approach, a comprehensive diet history can aid in working with your patient to reduce diet specific FODMAPs. Overall, a FODMAP trained practitioner should be able to take into account the number of factors that may affect a patient’s ability to adhere to the low FODMAP diet and discern the best approach. 

References:

1. Halmos, E. P., and Gibson, P. R. (2019) Controversies and reality of the FODMAP diet for patients with irritable bowel syndrome. Journal of Gastroenterology and Hepatology, 34: 1134– 1142.

Written by: Charlotte Barber (Student Nutritionist)

Reviewed by: Rebecca Ponsford (Dietitian)