Diet Tips:Grain-based foods on a low FODMAP diet

By Jane Varney 

Grain-based foods have been demonised by a number of dietary trends in recent years (think paleolithic diets, low carbohydrate diets and gluten free diets). However, this reputation is ill-earned, with robust scientific evidence to suggest that diets rich in whole grains confer protection against a range of diseases, including type 2 diabetes, obesity, cancer, and cardiovascular disease.

If you’re following a low FODMAP diet, you might feel it’s easier to restrict your intake of grain-based foods as many of them are high in FODMAPs and off limits anyway. Well this is far from true, as there are an abundance of healthy, tasty, low FODMAP grains to choose from. If you’re willing to expand your repertoire and try less traditional varieties, this will provide more choice, as will choosing grains that may be rated red/amber at a full serve, but green (low FODMAP) at a half serve.

Grain-based foods include those made from wheat, oats, rice, corn (maize), barley, sorghum, rye, millet, farro (emmer), freekeh, kamut, spelt, triticale, amaranth, buckwheat and quinoa. Processing greatly affects the nutrient composition of the grain-food end product, with whole grains being nutritionally superior to refined grains. Whole grains are those left intact after food processing and thus contain all three layers of the grain (the bran, endosperm, and germ). By contrast, refined grains are those that have had one or more parts of the grain removed during food processing, e.g. the bran. From a nutrition perspective, choosing foods rich in whole grains in preference to refined grains is preferable as they are more nutrient dense: rich in carbohydrates, protein, fibre, iron, magnesium, iodine, folate, and thiamine.

So which grains are low in FODMAPs? The following is a list of whole grain foods that Monash has tested and found to be low FODMAP at either a full or half serve: 

• Amaranth (puffed)
• Bourghul
• Buckwheat (kernals, flour
•  Corn (cob, polenta, tortilla, popcorn)
•  Millet (grain, flour)
• Oats (whole, quick, oatmeal)
• Quinoa (grain, flakes, flour, pasta)
•  Rice (brown)
• Sorgham (flour)
•  Wheat (wholemeal bread)

In future blogs, we’ll discover how to identify whether a processed food is likely to contain whole or refined grains and discuss uses of some of the less traditional grains. Stay tuned!

           

Diet Tips:#FODMAPchat Twitter Forum- Summary of Responses

Thank you to all who participated in our September 2016 Twitter chat. For all those that wanted to participate but couldn’t make it for the chat, here is a summary of the conversation:

Q1. Is there a standard re-challenge protocol to use with all patients on a low FODMAP diet?

We wish it was that simple, but unfortunately there is no standard protocol for re-challenging FODMAPs. It is so important to seek the assistance of an experienced dietitian to individualise the FODMAP challenge process to the needs and symptoms of each patient. The length of the re-challenge, foods chosen and the portion sizes used may also vary between each individual. Dietitians may find it useful to ask their patient which foods they miss the most from their regular diet and consider introducing those foods first when getting them started on re-challenging.

The re-challenge phase is an important part of the low FODMAP diet, but research studies on this specific area are lacking. Unfortunately, a rechallenge research trial is very difficult to design and conduct.

Q2. Should all FODMAP subtypes be challenged in every patient?

It is important that all FODMAP subtypes that have been restricted are re-challenged. For some patients lactose may remain in the diet, even during the initial elimination phase, if lactose intolerance is not evident. We always recommend re-challenging fructose due to unreliability with the fructose breath testing.  

A key point to note is that often just because an individual didn’t tolerate one particular food within a subtype of FODMAPs doesn’t mean that this person won’t tolerate any other foods within that subtype. The portion sizes of these foods may need to be adjusted. Seeking the assistance of a dietitian to tailor the diet to an individual is essential.

As each person’s FODMAP tolerance and their FODMAP threshold varies, a dietitian may need to be more cautious with one person who is extremely sensitive compared to another person who may have reasonable FODMAP tolerance. No two patients are alike and personalising the diet will assist patients with expanding the diet long term, which is very important.

Starting with a subtype of FODMAPs that the patient may tolerate better can ease the patient into the rechallenge process.

Q3. How long should each FODMAP challenge go for?

The answer varies depending on the patient and their symptoms and their level of anxiety about doing the re-challenge. For those who need a cautious approach, slowing down the challenge to testing a food every second day over the course of a week may be appropriate. For others, a typical challenge of a new food is to introduce a small portion and increase the amount every day for 3-4 days.

Q4. What sort of doses of foods should be used for FODMAP challenges?

There are no set portion sizes that suits each person. How much should be used depends on the individual, their symptom severity and tolerance level. As a general rule, half of a normal serving of a particular FODMAP containing food would be consumed on day 1, then increase the serving size on the second and third day.

Q5. What do you do with a patient who has severe reactions to all challenges?

For highly sensitive patients it may be necessary to slow down the re-challenges to small serves of a particular food consumed every second day. Alternatively try using different foods to the previous challenges in small amounts. If the patient continues to react to even small amounts, alternative therapies may need to be considered or they should be referred back to their GP for further investigations.

Small intestinal bacterial overgrowth (SIBO) may be a contributing factor in those with ongoing symptoms, however SIBO is very difficult to diagnose. A glucose breath test can be undertaken, but this is not a perfect science and will not diagnose SIBO in all cases.

Assess the patient’s stress levels as stress is one factor that can further exacerbate symptoms with challenges increasing stress and anxiety.  Continue to provide support and encouragement during the re-challenge phase.

Q6. What are some helpful tips to increase fibre intake on low FODMAP diet?

Some handy hints for increasing fiber while on a low FODMAP diet:

·         Try and include a vegetable with breakfast, such as tomato or spinach,

·         Add small amounts of low FODMAP legumes or pulses to soups, stews and salads - You may want to start by adding canned legumes and pulses as they tend to be lower in FODMAPs than fresh options

·         Aim to include fiber at each meal and snack, this may include oats, baked potatoes with the skin, oranges, quinoa and chia seeds

·         Also making food swaps such as using brown rice rather than white rice will help increase fiber

Q7. What are some of the key hidden FODMAPs that can be found in US commercial products?
Hidden ingredients aren’t always so hidden so do encourage your patients to check the ingredient label for foods and supplements high in FODMAPs particularly looking at sweeteners and added fibres such as inulin, fructose, high fructose corn syrup, crystalline fructose, lactose, and apple/pear juice concentrate. Also check liquid medications, chewable vitamins, powdered protein supplements or shakes for sweeteners that are often high in polyols or fructose.

Please remember to check the Monash University low FODMAP app for more information on US products that we have tested for FODMAP levels that includes sauces, gluten free breads and jams containing fructans and HFCS.

 Q8. Are fermented foods suitable on a low FODMAP diet?

There is a huge interest in this area and yes there are some fermentable foods that are low in FODMAPs, however not all low FODMAP foods remain low in FODMAPs when fermented.  Tempeh is low in FODMAPs and a good vegan option for a low FODMAP fermented option. We have also found spelt sourdough bread to be low in FODMAPs.

Sauerkraut has recently been tested and found an interesting result. 1 Tablespoon of Sauerkraut is low in FODMAPs however becomes moderate to high in the Polyol (mannitol) in a larger serve despite common cabbage being low in FODMAPs. We also tested fermented red cabbage and found that when red cabbage was fermented it was low in FODMAPs when consuming only ½ a cup but contained moderate Oligosaccharides (Fructans) at 1 cup, whereas fresh is still low in FODMAPs at these portion sizes.
Kefir is only high in lactose so another suitable option for those who are not lactose intolerant.
We can’t always predict what is going to happen to low FODMAP foods once they have been processed in some way or another and therefore these foods need to be tested. We will share this knowledge via our Monash University low FODMAP app as the foods are tested.

Q9. What next if the low FODMAP diet does not improve symptoms?
When the low FODMAP diet is unsuccessful for a particular patient then look further into their diet history to see if excess fats, sugar and caffeine, or an inadequate intake of fibre are contributing to their symptoms. Further investigate if other dietary factors may be relevant for each individual patient such as histamine, Type IV hypersensitivity or IgE- mediated food allergy.

The low FODMAP diet doesn’t always work for everyone. If it does not work it is very important that FODMAPs are reintroduced into the diet. A dietitian can continue to provide support and assistance to a patient in achieving a healthy balanced diet, consider other dietary factors that may be playing a role, as well as working with other health professionals to investigate other factors contributing to symptoms.

Q10. What are some handy hints for travelling on a low FODMAP diet?

Travelling while trying to follow a low FODMAP diet can be difficult. Monash University are testing more international foods and will continue to add these to the Monash University low FODMAP diet app under specific country flags.

Plan ahead. Pack low FODMAP snacks to avoid getting hungry and therefore grabbing something that may flare up symptoms. If lactose is an issue then carrying Lactaid / Lacteeze and/or Beano + Dairy defence could assist with managing symptoms if you are limited with food choice. For the very organised traveler, take a soft side lunch bag or cooler in your luggage to carry low FODMAP snacks purchased at your destination. Request a hotel room with a mini fridge to store low FODMAP options.

For domestic trips you may want to take your own fruit, cheese, nuts, snack bars or nutritional drinks.

Note that patients may actually tolerate foods better whilst travelling due to having less stress and anxiety to contribute to symptoms and being in a relaxing state may help relieve some symptoms.

Thank you to all who participated in the fodmapchat and for those who missed this twitter chat feel free to check out the hashtag #fodmapchat for the discussion and follow us on Facebook and twitter to stay in the loop for when the next one will be happening.

Remember to encourage patients to download the Monash University low FODMAP diet app to further fund research and food testing as well as to get all the latest food testing information.

           

Diet Tips:FODMAP Stacking – can I overeat “green” foods??

By Dr Jaci Barrett (Dietitian)

 

With the increasing amount of detail we share with you via our Monash University low FODMAP diet app, we are getting more and more questions about FODMAP stacking. Green foods on the app are low FODMAP and are therefore suitable on a low FODMAP diet, but more detail is provided in the app for some low FODMAP foods, where we reveal an upper limit serving size when the food then becomes red and therefore high FODMAP.

Broccoli and zucchini are good examples of this:

 

 

A standard serve of broccoli is ½ cup, which is low FODMAP and suitable for a low FODMAP diet. But you can see further details are given, revealing that large servings, >1 cup, contain high levels of the oligosaccharides and sorbitol.

For zucchini, a standard serve is ½ cup, also low in FODMAPs, with large servings >100g, high in fructans.

The important thing to know is that not all greenfoods have upper limit serving sizes. Most greenfoods are low FODMAP, even in very large serves. If there is no upper limit noted in the app, then you can safely eat a large amount. This is the case for vegetables such as carrot. Eggplant is green, but when you click on it you will see that very large quantities are amberdue to a moderate amount of sorbitol.

 

The questions that come with this information are around FODMAP stacking. Can I eat ½ cup broccoli, ½ cup zucchini and 1 cup of eggplant all of which are green in these quantities? Are they still green if consumed together in the one sitting? Is there an additive effect?

For the vast majority of IBS patients following a low FODMAP diet, this sort of example will be tolerated. Even if the total FODMAP content goes above the green limit, most people manage to eat amber and even the lower limit of red serves of foods. Should you FODMAP stack during the initial 4 week strict low FODMAP dietary trial? You should feel comfortable eating reasonable portions of greenfoods in one sitting, but don’t be disheartened if you eat a larger amount. It will not undo all your good work. Most people won’t get symptoms from these type of foods. It’s the really high FODMAP foods that create the most havoc, such as onions, dried legumes and pears.

 

For foods with upper limit serving sizes, you can modify your meals to ensure your serving size is controlled. Broccoli soup is unlikely to be well tolerated if it is made purely out of broccoli and you eat 2 cups of it. But a modification of the recipe to bulk the broccoli out with parsnip, potato and carrot (all of which are green regardless of how much you eat), the end result will be a low FODMAP broccoli soup. Similarly, if you consider using zucchini strips as a pasta replacement, you just might want to watch how much you use. Keep it to a small zucchini (<100g), add your low FODMAP pasta sauce and serve it with a low FODMAP red cabbage (amber but OK if you don’t eat too much) and parmesan salad – YUM! Recipe coming in the following weeks!

In the end, we want you to remember that a low FODMAP diet should include green and amberfoods (and for some people even some redfoods). So, you can consume larger servings of foods that may bring them into moderate or high FODMAP levels as long as you don’t experience any nasty symptoms. The diet should be relaxed over time and we hope that the detailed information we share with you through the app will help you to achieve this.

We are more than happy to provide some guidance with further FODMAP stacking questions. What sort of food combinations have you been concerned about? Post them on facebook and we will provide some guidance on whether they are OK, and how you could modify your meal to lower the FODMAP content.

Diet Tips:Including Legumes on a Low FODMAP Diet

By Lyndal McNamara (Dietitian)
 

 

Legumes (otherwise known as pulses) include all types of beans, peas and lupins. The health benefits of regular consumption of legumes are well known (see table 1), predominately because they are low in saturated fat, have a low GI, are an excellent source of dietary fibre and contain a variety of phytochemicals (natural plant chemicals with health promoting effects).

Table 1: Health Benefits of Legumes

Nutritional characteristic	Associated health benefits
High in dietary fibre	-          Can assist with weight management by promoting a feeling of fullness after eating -          Contain insoluble fibre, which adds bulk to stools and assists with preventing constipation -          Contain soluble fibre, which assists in maintaining healthy blood glucose and cholesterol levels -          Contain prebiotic fibre, which is fermented by colonic bacteria to short chain fatty acids and promotes overall digestive health
High in phytochemicals	-          Contain antioxidants and other bioactive compounds, which help to protect the body against disease
Low glycaemic index (GI)	-          Contain slowly digested carbohydrates, that improve blood glucose control and insulin response in those with diabetes and reduce risk of diabetes in healthy people
High in protein	-          Legumes are a great non-animal source of protein for vegetarians and vegans
Low in saturated fat	-          Assist with maintaining healthy cholesterol levels and reducing risk of cardiovascular disease

References: please see an extensive list of references on the Grains & Legumes Nutrition Council (GLNC) website http://www.glnc.org.au/legumes/legume-references/

Legumes on a Low FODMAP diet

For those following a low FODMAP diet, legumes can be a troublesome food because they are naturally high in oligos; including galacto-oligosaccharides (GOS) and fructans.

The good news is that legumes do not need to be strictly avoided by people following a low FODMAP diet, with suitable ‘green’ serve information available for many legumes on the Monash app.

Because oligos dissolve in water, cooking and processing methods can affect the FODMAP content of legumes. For example, canned legumes or those that have been boiled and drained tend to be lower in FODMAPs as some oligos ‘leach’ out into the canning/cooking water and are removed when they are drained and rinsed. Read more here 

Dietary Recommendations for Legumes

The GLNC recommends enjoying legumes 2-3 times per week for maximum health benefits. Here are some suggestions for how to easily incorporate more legumes into a low FODMAP diet:

- Add a small can (125g) of chickpeas to stir-fries or curries – try this ‘low FODMAP Vegan Coconut & Pumpkin Curry’

- Substitute half of the meat in bolognaise sauce/casseroles for canned lentils- try this ‘low FODMAP slow cooked Lamb Casserole’:

- Sprinkle ¼ cup (53g) of cooked mung beans (boiled & drained) over salads  

- Add canned butter beans to homemade soups or stews

- Mix ¼ cup (42g) canned chickpeas with a small tin of tuna for a protein and fibre rich snack

- Add legumes to homemade dips- try this ‘Roasted Red Pepper & Pumpkin Hummus’

- Top an egg on toast for breakfast with homemade baked beans (using ¼ cup (35g) canned butter beans per person)

- Substitute meat in Asian style dishes for firm tofu or tempeh- try this low FODMAP ‘Marinated Tofu with Asian Greens and Rice’ or ‘Hot & Sour Asian Soup’:
 

Enjoy!