The FODMAP Gentle Approach

Kathryn Adel May 30, 2023 FODMAP, IBS Irritable Bowel Syndrome

The low FODMAP diet* has been shown to be effective in reducing the severity of gastrointestinal symptoms and improving quality of life of IBS sufferers and in about 70% of cases. However, in some cases, this diet may be contraindicated, which is why the gentle FODMAP approach has been developed.

In 2019, researchers at Monash University began publishing recommendations for a gentle FODMAP approach. This approach is less restrictive and is generally suitable for people with contraindications to the standard FODMAP approach.

The low FODMAP diet is not recommended in the following cases, as it can lead to harmful consequences such as nutritional deficiencies, eating disorders, and increased anxiety:

• Children
• The elderly
• Pregnant women
• People with an eating disorder (e.g. anorexia, bulimia, etc.)
• People at risk of malnutrition, (i.e. who are underweight, have recently lost a significant amount of weight involuntarily or are already struggling to meet their nutritional needs through food only)
• People who already have many other dietary restrictions (e.g. multiple allergies, other major health problems, etc.)

A gentle FODMAP approach may also be a better choice for people who find the standard low FODMAP diet too difficult to follow, such as those who have to travel regularly for work, or for those whom the diet causes too much stress. Also, depending on one’s eating habits as well as the frequency and severity of the symptoms, it is not always necessary to restrict all the high FODMAP foods.

The standard low FODMAP diet and the gentle approach follow the same three-phased protocol to identify foods that are causing symptoms. However, with the gentle approach, only foods that are very high in FODMAP, frequently consumed, and suspected to be triggers of major symptoms, are eliminated. This allows to eliminate many less foods and offers much more food flexibility. A personalized list of foods to avoid should be provided to patients. Garlic and onions are generally excluded if they are the main ingredients, but included if they are minor ingredients in processed foods.

Patients using a simplified approach in phase 1 can also follow a simplified approach in phase 2, testing only the FODMAP families that they have eliminated. Reintroduction trials should be conducted in the same way as with the standard low FODMAP diet. If you have to use a different test food than those recommended, you can adjust the portions as follows:

• Day 1: 1/3 of your usual serving size
• Day 2: 2/3 of your usual serving size
• Day 3: your usual serving size

A major disadvantage of the gentle approach is that it can be more difficult to identify whether a person is sensitive to FODMAPs. If by following the gentle approach, the improvement of symptoms is insufficient, it is difficult to know if the person is insensitive to FODMAPs or if a higher degree of restriction is necessary. Thus, the standard low FODMAP diet should generally be prioritized, and the gentle approach should only be used when necessary. Since the gentle approach should be personalized, it is highly recommended to obtain the help of a Registered Dietitian who is specialized with the low FODMAP diet.

*FODMAPs are fermentable carbohydrates that are partly responsible for causing symptoms in people with irritable bowel syndrome (IBS). For more info, read this article.

References

Halmos et Gibson (2019) Controversies and reality of the FODMAP diet for patients with irritable bowel syndrome. J Gastroenterol Hepatol; 34(7):1134-1142.

Gibson (2017). The evidence base for efficacy of the low FODMAP diet in irritable bowel syndrome: is it ready for prime time as a first-line therapy? Journal off Gastroenterology and Hepatology; 32 Suppl 1:32-35.

Simons et al. (2022) Narrative review: Risk of eating disorders and nutritional deficiencies with dietary therapies for irritable bowel syndrome. Neurogastroenterol Motil; 34(1):e14188.

Author

Kathryn Adel

Kathryn holds a Bachelor Degree in Nutrition as well as a Bachelor and a Master Degree in Kinesiology, all from Laval University. She is a Registered Dietitian and active member of the Ordre professionnel des Diététistes Nutritionnistes du Québec (ODNQ) and of the American Academy of Nutrition and Dietetics. She holds the Monash University's certification for the FODMAP diet and IBS, and has considerable clinical experience in that area. She is also an accomplished athlete, having ran track and cross-country at a national level. Kathryn specializes in sports nutrition, weight loss, diabetes, as well as heart and gastrointestinal health.