The FODMAP Elimination Diet:  What to Consider Before You Start

For those who suffer from irritable bowel syndrome (IBS), a low FODMAP diet can be a game changer.  The greatest benefit of a low FODMAP diet is symptom relief, but there are some major downsides too. Read on for the things you should consider before starting a FODMAP elimination diet. Be sure to discuss with your healthcare provider to help determine if it is right for you!

What are FODMAPs?

FODMAPS: Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols

The acronym FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols.  I know what you are thinking…  fermentable what?  These are fancy words for certain short chain carbohydrates. 

Now you can go ahead and forget what the acronym means, because what you really need to know is that FODMAPs are carbohydrates that are poorly absorbed and may trigger uncomfortable symptoms in people with IBS (and perhaps other functional gut disorders). 

These poorly absorbed carbohydrates make their way through the intestines and attract water along the way. This causes the intestines to stretch and stimulate overactive nerves that can cause abdominal pain and discomfort. 

In addition to drawing in water, these carbohydrates make their way to the colon. Even though we humans do not break down FODMAPs very well, our gut microbes (bacteria) do!  These microbes ferment the leftover carbohydrates, using them for energy.

This process of fermentation creates gas, which is completely normal.  However, people with IBS have what is often referred to as visceral hypersensitivity. This means that the increased pressure in the intestines that normally causes little discomfort, triggers pain in someone with IBS.  Now, it is important to know that not everyone with IBS is sensitive to FODMAPs (more on this to come).

Are FODMAPs Bad For You?

Simply put – No!  In fact, many foods that are high in FODMAPs are very healthy. And FODMAPs do NOT cause IBS.  People should include as many FODMAP rich foods in their diet as they can tolerate.

High FODMAP foods include many fruits, vegetables, beans, legumes, nuts, seeds, and dairy.

So what’s left? Meat and eggs? There are still many healthy foods that are low FODMAP (check out this Low FODMAP Grocery List). 

But not everyone is sensitive to all types of FODMAPs. The goal of a low FODMAP diet is to help determine which specific categories of FODMAPs are triggers for you. 

The FODMAP Elimination Diet

The low FODMAP diet was originally developed by the folks at Monash University.  Thanks Monash!  It is an elimination diet involving three phases, and it can be one complicated beast! Unfortunately, many doctors will prescribe a FODMAP elimination diet without giving adequate direction on how to carry it out.

I like to think of the low FODMAP diet as more of a process than an actual diet, because all phases are important to complete.  The best way to make sure you appropriately implement the protocol is by working with a FODMAP trained dietitian who can teach you the diet, troubleshoot your symptoms, and walk you through each phase.

3 Phases of a FODMAP Elimination Diet: Elimination, Reintroduction, Personalization

Phase 1:  Elimination

The first phase of a low FODMAP diet includes eliminating all sources of high FODMAP foods. This phase usually lasts 2-6 weeks. If you have an acceptable amount of symptom relief in phase one, then you move on to phase two.

Phase 2:  Reintroduction

In the second phase, foods are systematically re-introduced, one FODMAP category at a time. A challenge food is chosen for each category of FODMAPs, and a small portion is consumed. If that food does not trigger symptoms, then a larger portion may be attempted.

If symptoms are triggered, it is usually recommended to go back to a low FODMAP diet until symptoms resolve before trying your next category of FODMAPs. 

Phase two can vary in length depending on tolerance to each FODMAP category but can take six weeks or more to complete.

Phase 3:  Personalization

In the third phase it is all about adding back the foods that you are not sensitive to. And it often includes finding your threshold for tolerance of the FODMAPs that you are sensitive to. The goal is to have as varied a diet as possible (Read also The Importance of Food Diversity in Gut Health).

This is your long-term diet, though you can (and should) continue trying to add foods back as long as your symptoms are controlled.  Tolerance to FODMAPs can change over time, so it is encouraged to continue to challenge small portions of FODMAPs that previously triggered symptoms.

Many people who are sensitive to FODMAPs find that they can tolerate a certain amount in their diet.  For example, you may find that you are sensitive to fructans in onions. However, you may do fine with a small amount of onions in your meals occasionally.

So, if a recipe calls for “one large onion”, you may be able to add ¼ cup of onions without getting bloated, feeling pain, or running for the nearest bathroom.

The reintroduction and personalization phases are very important and give back some of the freedom that a strict FODMAP elimination diet takes away.

FODMAP Examples

There are five main categories of FODMAPs: lactose, fructose, fructans, galacto-oligosaccharides, and polyols. Sometimes fructans and galacto-oligosaccharides are grouped together under the term oligosaccharides.

Lactose

Lactose is a naturally occurring sugar found in dairy products.  Lactose intolerance is very common and occurs when an individual does not have enough of the enzyme lactase that breaks down lactose to allow for absorption.

Examples of foods high in lactose: cow’s milk, yogurt, ice cream, custard.  Of note, yogurt with live and active cultures is often well tolerated because the bacteria in the yogurt break down the lactose that his present.

Fructose

Fructose is a type of sugar found in fruits, some vegetables, and certain sweeteners.  Fructose is often found in foods with glucose (another type of sugar). The presence of glucose helps with the absorption of fructose. Fructose is not absorbed well in some people, but only causes problems if there is more fructose in a food than glucose.

Examples of foods high in fructose:  mango, orange juice, honey, asparagus, sugar snap peas.

Fructans

Fructans are chains of sugars that humans do not have the enzymes to digest. Although nobody can digest them, they usually do not cause discomfort in people with a healthy gut. They are fermented by gut bacteria, which is very healthy for the gut, but can cause gas, bloating, pain, and alterations in bowel habits in people with IBS.

Examples of foods high in fructans:  garlic, onions, wheat, rye, dates, artichokes, brussels sprouts.

Galacto-Oligosaccharides (GOS)

GOS are longer chains of sugars that humans cannot digest. People respond similarly to GOS as to fructans, which is why they are often grouped together when talking about FODMAPs.

Examples of foods high in GOS:  pistachios, wheat, lentils, black beans.

Polyols

Polyols are sugar alcohols that are found naturally in some fruits and vegetables. They are also sometimes used as food additives or sweeteners. The most common polyols are sorbitol and mannitol.

Polyols that are present naturally in foods are poorly absorbed in some people. Polyols that are used as sweeteners are poorly absorbed in most people if consumed in large amounts.

Examples of foods containing sorbitol: sweet corn, avocado, blackberry, peaches.

Examples of foods containing mannitol: cauliflower, mushrooms, celery.

Examples of High FODMAP Foods: milk, yogurt, ice cream, asparagus, mangos, garlic, onion, artichoke, wheat, black beans, lentils, mushrooms, avocado, blackberries

Who Might Benefit from a FODMAP Elimination Diet?

The low FODMAP diet is backed by science to reduce symptoms and improve quality of life in those with IBS.1  In fact studies suggest that 50-87% of people with IBS find relief following a low FODMAP diet.2

There may be a benefit in other functional gut disorders as well, such as functional dyspepsia,3 functional constipation, etc. A FODMAP elimination diet is also commonly used in people with small intestine bacterial overgrowth (SIBO).

There is some evidence to support its use in inflammatory bowel diseases, like Crohn’s disease or Ulcerative Colitis.  However, it is known that a certain subset of people with inflammatory bowel disease also have IBS.

So, the thought is that a low FODMAP diet doesn’t do anything to help get inflammatory bowel disease in remission. However, it might help people who are already in remission but have lingering gut symptoms (ie, they may also have undiagnosed IBS).

A low FODMAP diet may also have some promise for women with endometriosis who experience gut symptoms. In fact, in one small study, women with endometriosis and IBS had better symptom relief than in women with IBS alone.4

A FODMAP Elimination Diet Does Not Work for Everyone

If you are any good at math, you may have come to your own conclusion that if a low FODMAP diet is effective in 50-87% of people with IBS, that means up to 50% of people might not respond to a low FODMAP diet.

FODMAPs are not the only triggers for IBS. Some people do fine with FODMAPs but do not tolerate fat, spicy foods, alcohol, or caffeine (learn about coffee here).

Plus, there are factors other than foods that can trigger symptoms, such as stress or anxiety. Sometimes it can be easier to address other potential triggers before trying out a complicated elimination diet. 

And it is worth pointing out that when a FODMAP elimination diet does not work, it is possible that there was a misdiagnosis of IBS.  If you have followed the elimination protocol and your symptoms did not improve it might be worth exploring your diagnosis some more. 

Consider:  Were other conditions with overlapping symptoms adequately ruled out?  Could there be more than one condition affecting your gut? 

Talk to your doctor to determine if you need further evaluation.

Who Should Think Twice About A FODMAP Elimination Diet?

FODMAP Elimination Diet: Who should think twice?

There are some groups of people who should be cautious when considering a low FODMAP diet, or any other elimination diet.

If you fall into one of the following groups, you should work with your healthcare provider to determine if a low FODMAP diet is still worth pursuing. Continue to the section on Alternatives to a Low FODMAP Diet to learn about other strategies to get your symptoms under control.

Undiagnosed Gut Problems

Because of the symptom overlap between functional gut disorders and many other conditions it is important to get an accurate diagnosis before trying to treat your gut dysfunction. 

Inflammatory bowel disease, endometriosis, celiac disease, and cancer are a few of the conditions with IBS-like symptoms. An accurate diagnosis can help get you the right treatment and prevent complications down the road.

Self-diagnosing and starting on a treatment for the wrong condition can delay appropriate care. This can be important in inflammatory bowel and celiac disease, because left untreated these conditions can actually damage your bowel. And if cancer is what is causing your bowel symptoms, you definitely do not want to delay the right treatment.

Pregnant Women

It is usually not recommended start an elimination diet while pregnant due to increased nutrient demands. Doing so can increase the risk of nutrient deficiencies for both the mother and baby.  Wait until after your bundle of joy has arrived, then discuss the possibility of a low FODMAP diet with your doctor or dietitian.

If you are pregnant and already on a low FODMAP diet, include as much variety in your diet as you possibly can. If you find that you are restricting many foods to keep your gut symptoms under control, work with a dietitian to make sure your diet is nutritionally complete. And don’t forget to take that prenatal multivitamin!

Children

While a low FODMAP diet can be safely implemented in children, there are some special considerations to keep in mind.  The low FODMAP diet is not as well studied in children and may be higher risk.

Children need adequate nutrients for proper growth and development. If there are already concerns regarding your child’s growth you should discuss other treatments for your kid’s tummy troubles with a doctor.

If your child has some eating difficulties, a low FODMAP diet may be too limiting for your little one. For example, if your child is a picky eater, will he or she accept foods that are low in FODMAPs?  Does your child already have to limit certain foods due to allergies? How might a low FODMAP diet affect your child’s quality of life?

In older children, how might an elimination diet affect their relationship with food? Is your child or teen self-conscious of his or her weight? Could eliminating foods increase the risk of disordered eating?

As you can see, starting a child on a low FODMAP diet is a decision that shouldn’t be taken lightly. If this is the route you choose to go, make sure to do so under the supervision of a doctor. Also seek the help of a FODMAP trained pediatric dietitian who can assure your child is able to meet his or her nutrition needs.

The Elderly

Special considerations must be made when thinking about a low FODMAP diet in the elderly population, usually defined as over the age of 65 years.

The low FODMAP diet has not been well studies in older adults. That does not mean it might not help, however the reason it is not well studied in an older population is because the elderly are considered a higher risk group.

The one study we do have is small and is a lower quality study design.  This study does suggest that a low FODMAP diet in older adults with chronic diarrhea can be helpful. Participants had improvements in diarrhea, pain, and reflux symptoms.5

There were no significant changes in nutrient intake in the above study.  However, it is worth noting that calcium intake decreased (not significantly) while baseline intake of calcium was already low.  A dietitian worked with the subjects in this study, which we know is associated with higher rates of success. 

If you are over the age of 65, it is important to consider your nutrition before starting a FODMAP elimination diet.  Has your weight been stable? Is your appetite good?  Do you eat regular meals and snacks? A dietitian can help you determine if you are at risk for malnutrition.

Are you able to prepare your own meals?  Do you live independently, or do you live in a residential facility? A low FODMAP diet can be especially challenging to implement in a long-term care setting, as meals are usually prepared in bulk and dietary staff are often not trained on how to provide a low FODMAP diet.

If you are over the age of 65, it might be that much more important to work with a dietitian to make sure you are meeting your nutrient needs.  You might also consider doing a modified version of a low FODMAP diet that is less restrictive (see below for information on a “FODMAP light” approach).

Eating Disorders

Eating disorders are common among those with gut issues. If you have been diagnosed with an eating disorder or suspect that you do not have a healthy relationship with food, an elimination diet is not recommended.

Even if you have a history of an eating disorder that you feel is under control, starting an elimination diet might be dangerous.

Check out this article from the National Eating Disorders Association to learn about common signs of eating disorders.

Other Significant Diet Restrictions

OK, so not everyone with other dietary restrictions needs to take the option of a low FODMAP diet off the table. For example, if you have diabetes or follow a low sodium diet, a low FODMAP diet can likely be implemented safely with the help of a dietitian.

A gluten free diet can pair nicely with a low FODMAP diet as well. In fact, in people with treated celiac disease, a low FODMAP diet might help when gut symptoms persist even when their celiac disease is considered “in remission”.6

However, a FODMAP elimination diet might not be appropriate if you have big dietary restrictions – like if you are on a renal diet (for kidney failure) that already has you down to a very limited variety of foods. Also, if you have multiple food allergies and going through a FODMAP elimination would further restrict your already limited diet.

High Anxiety

If you have anxiety that is not well controlled, that might be your best place to start.  Because IBS and other functional gut disorders are conditions of the gut and the brain, getting your anxiety under control might be enough to reduce your gut symptoms.

An elimination diet can add to your anxiety. So, if just the thought of a restrictive diet makes your stomach ache, consider alternative approaches to getting your IBS under control.

A Low FODMAP Protocol is Complicated

If you read through the section on the phases of the low FODMAP diet, you may have noticed that the full protocol takes months to complete. 

The list of foods that are limited are long and hard to memorize. Therefore, meal planning and grocery shopping can be tricky. It also takes time to learn how to read ingredient lists to determine whether an untested food might be a problem.

Some people simply don’t have the time or energy to deal with that type of diet commitment. And that’s ok! However, working with a FODMAP trained dietitian can make the process SO. MUCH. EASIER.

FODMAPs and The Gut Microbiome

FODMAP Elimination can Affect the Microbiome

Since many higher FODMAP foods are high in fiber and prebiotics that help gut bacteria flourish, there is concern that following a low FODMAP diet long term may be harmful to your gut microbiome.

Food diversity, especially plant-based foods, is an important factor in a healthy microbiome. This is one of the reasons that it is so important to go through the re-introduction and personalization phases of the low FODMAP diet. Again, the goal is to expand the diet to include as large a variety of foods as possible.

Currently, the impact of a low FODMAP diet on the gut microbiome is a little fuzzy. The research that has been done suggests that it may decrease the overall number of bacteria in our gut. However, it seems that a low FODMAP diet might not be as bad for our gut microbes as we once thought. 

It is hard to study because there is no agreed upon definition of a “normal” or “healthy” microbiome. As microbiome research improves, we should get answers to this and many other questions.

FODMAP Elimination May Affect Diet Quality

As with other restrictive diets, there tends to be a decrease in quality when following a low FODMAP diet. However, diet quality also tends to be low in people with IBS in general7, likely due to avoidance of certain foods that are perceived as triggers. The consequence of the diet quality on a low FODMAP diet is debatable.

Most studies have not found lower intakes of micronutrients (vitamins and minerals) in people on a low FODMAP diet versus a regular diet. However, there have been some studies that have identified small decreases in intake of riboflavin, calcium, iron, and thiamine.1 Following a highly restrictive low FODMAP diet long term may increase the risk of nutrient deficiencies.

A FODMAP trained dietitian can help you achieve a healthy balanced diet while completing a FODMAP elimination protocol. In fact, most of the studies on nutritional adequacy used a dietitian to instruct patients, which may be why nutrient intake was not significantly compromised. It is unclear whether following a low FODMAP diet without the help of a dietitian would lead to nutritional deficiencies.1

A FODMAP Elimination Diet May Affect Quality of Life

Most studies on a low FODMAP diet talk about improvements in quality of life.  However, for some people a FODMAP elimination diet could decrease your quality of life.

Consider your current lifestyle.  Are you someone who likes to go grocery shopping and prepare your own meals?  Or do you prefer to eat in a restaurant, order out, or use convenience products for most of your meals?

If you do not cook a lot of meals at home, a low FODMAP diet gets a little trickier, though not impossible. Some tips for sticking with a low FODMAP diet when you eat out include reviewing menus ahead of time, asking your server questions about the way foods are prepared, avoiding dishes that are heavily seasoned or sauced, and making your needs known.

Another option if you do no like to cook or do not have time is to use a meal delivery service. Modify Health provides certified low FODMAP meals. Meals are fully prepared and shipping is free! By clicking my affiliate link I recieve a small commision at no cost to you.

If you don’t adhere perfectly to the diet, don’t stress about it.  That might only make your symptoms worse.  It can be helpful to keep a food and symptom diary as you go through the FODMAP elimination diet. That way if you eat something you “weren’t supposed to have” you may be able to learn from it.

Consider a FODMAP Light Approach

FODMAP light approach

If the full blown FODMAP elimination diet sounds like too much, a simpler approach can be attempted. This is often referred to as a FODMAP “light” or “gentle” approach. 

This approach typically limits sources of highly concentrated FODMAPs rather than limiting all sources of FODMAPs.2  The following are foods that might be restricted on a FODMAP gentle diet.

Grains: wheat, barley, rye

Dairy:  milk, yogurt, ice cream

Fruits:  pears, apples, stone fruit like peaches and nectarines, dried fruit, watermelon

Vegetables:  onions, leeks (white part), cauliflower, mushrooms

Protein: most beans and lentils (canned chickpeas and canned lentils are ok)

Like the full FODMAP protocol, these foods should only be eliminated for a specified period of time.  Then they should be re-introduced one at a time to determine tolerance.

A FODMAP light approach is far less restrictive, easier to adhere to, and may result in fewer nutritional concerns than the full FODMAP elimination approach.  However, there is less evidence available on the success of light approach.

Tools for Your Low FODMAP Journey

Fortunately, there are many tools and resources available to help get you through the FODMAP elimination diet. 

Low FODMAP Apps

There are several low FODMAP phone apps available. And while I have not tried them all, the Monash University FODMAP diet app is the one that I recommend most. 

The main feature of the Monash app is of course the list of foods and their FODMAP content.  Additionally, there are a number of recipes, a symptom journal, and a ton of information on IBS and the low FODMAP diet in general. 

You can also access Monash’s database of FODMAP trained dietitians using the app. At the time I downloaded the Monash app it was $10 (US).

Another helpful app is FODMAP Friendly.  FODMAP Friendly, like Monash, tests foods for FODMAP content.  Both companies also certify food products as being low FODMAP. 

Different brands pair with Monash vs FODMAP Friendly to get their certifications, so products that show up on one app might not show up on the other.  That’s why I like to use both apps. 

Food and Symptom Journals

Journaling can be a great way to help determine your sensitivity to certain foods.  You do not need to keep a food journal forever, but it can be a helpful tool at each stage of the FODMAP elimination protocol.

It can be helpful to start tracking before you make any changes to your diet or lifestyle, to establish your baseline.  This way it is easier to figure out if these changes are making a difference.

Journaling can help determine your overall response to removing FODMAPs, your sensitivity to certain FODMAPs, and your personal threshold for tolerance.  It can also help you and your provider troubleshoot if it seems like the low FODMAP diet is not working. 

Plus, a journal can help you figure out other food triggers (like fat, caffeine, alcohol, large portions) and even non-food triggers. You can do this by keeping tabs on your level of stress, your sleep, medication use, supplements, activity level, or perhaps even the phase of your menstrual cycle.

Food and Symptom Journal

If you choose to keep a journal, be sure to share it with your dietitian or healthcare provider who might be able to see patterns that you may not notice yourself. 

Blogs and Websites

The internet is full of blogs that contain useful information and delicious low FODMAP recipes.  Just be careful on who you trust for this information. 

Look for blogs written by credentialed healthcare practitioners – registered dietitians should be at the top of your list of professionals you trust for food and nutrition information.  Believe it or not registered dietitians have way more nutrition training than most doctors. 

It is also a good idea to make sure the articles on the website are evidence based, citing legitimate research when available.

Cookbooks

When I typed in “Low FODMAP Cookbook” in Amazon, it came up with 585 results!  That’s a lot of recipes!  There are some great cookbooks out there to help you with your low FODMAP journey.  But once again, make sure the cookbooks you use come from a trusted source.

Alternatives to a Low FODMAP Diet

If you are thinking that a low FODMAP diet might not be for you, no worries… There are a lot of other strategies you can try to get your gut symptoms under control!  In fact, it is often well-advised to start with a less restrictive approach first.  Then, consider a low FODMAP diet if your symptoms persist.

Implementing one new strategy at a time can help determine whether it is working for you. If you do not feel any improvement after a few weeks on any intervention, try something different.  If you do notice a difference but you would like to see if your symptoms can be further improved, wait until you are at your new baseline before adding other interventions.

The following list of interventions for IBS is not all inclusive.  Your healthcare provide may have other ideas to target your specific symptoms.

NICE Guidelines / Traditional Diet Advice

If you have newly diagnosed IBS and have not tried any interventions yet, the guidelines from the National Institute for Health and Care Excellence (NICE) can be a good place to start.  These guidelines are less restrictive than a FODMAP elimination diet.  However, it can still be helpful to implement them under the guidance of a dietitian. NICE guidelines consist of diet and lifestyle strategies which include:

  • Find time to relax.
  • Increase activity levels.
  • Eat regular meals and take your time.
  • Avoid skipping meals.
  • Drink at least 8 cups of fluid per day.
  • Restrict caffeinated coffee or tea to 3 cups per day.
  • Limit intake of alcohol and carbonated beverages.
  • Limit fresh fruit to 3 portions per day.
  • Avoid sorbitol if you have diarrhea (a sugar alcohol found in many sugar-free or “diet” foods and beverages).
  • Include oats and flaxseed in your diet if you have gas and bloating.
  • Limit intake of high fiber foods (insoluble fiber).
  • Limit intake of resistant starch.
  • Gradually increase intake of soluble fiber.

Other “traditional” diet advice includes eating smaller more frequent meals, limiting fat intake, and avoiding spicy foods if they trigger symptoms.

Gut Directed Hypnotherapy

Gut directed hypnotherapy has been around since the 1980’s,8 but has been gaining traction in recent years as a therapy for IBS.  Gut directed hypnotherapy has been found to be as effective in relieving symptoms of IBS as a FODMAP elimination diet9

Gut Directed Hypnotherapy: As effective as a low fodmap diet

During a session of hypnotherapy, a trained therapist puts their patient into a state of heightened awareness and deep relaxation.  The therapist may then invite their patient to imagine that their digestive tract is working smoothly and free from pain. Guided imagery is a common technique used in gut directed hypnotherapy.

There have been many studies suggesting that gut directed hypnotherapy is an effective method of treating IBS.  This is likely related to the complex relationship between the gut and the brain, usually referred to as the gut-brain axis. 

A recent review of the evidence for gut directed hypnotherapy indicated that it is most effective when used in high volume8. So, the more sessions and the longer the duration of the sessions, the better. This may be a barrier for some people as many protocols involve 6-12 one-hour sessions.

Another barrier may be finding someone who is trained in gut directed hypnotherapy.  However, virtual treatment is an option that might be easier to access and has been shown to be effective.  More recently there have been phone apps emerging as an at-home alternative, perhaps the most well-known being Nerva. 

Cognitive Behavioral Therapy and Psychotherapy

Cognitive behavioral therapy (CBT) for gut disorders focuses on changing negative and fear-based thinking patterns. It also helps individuals “unlearn” negative behaviors or coping methods that may be problematic for your health and wellbeing. 

CBT often involves education on the stress response and techniques for stress management, relaxation, and mindfulness.

CBT has been well studied in functional gut disorders and is among the most effective treatments for IBS. It has been shown to be effective in many different forms, including one-on-one, group therapy, phone visits, and online or digital.10 Look for a therapist who is knowledgeable about gut disorders.

Psychotherapy usually involves a longer timeframe for treatment than CBT.  Psychotherapy establishes a trusting relationship between a patient and therapist.  It can be especially helpful in the presence of deeper emotional issues, mental illness, and trauma, all of which may have an affect on gut function.

Mindfulness, Meditation, and Deep Breathing

Mindfulness and meditation are other practices that can help disorders of the gut-brain axis.  The great thing about these practices is they don’t have to cost you a dime!  Though if you are not familiar with these practices it might help to invest in some classes to learn the techniques. 

Breathwork is often a big part of a meditation practice.  Diaphragmatic breathing or “belly breathing” can help induce relaxation, slow down your heart rate, and reduce blood pressure.

There is also some evidence that deep breathing exercises can also help with rumination (regurgitation or spitting up food you just ate), abdominal distention, indigestion, fullness, and fear of eating.10

Meditation to calm the mind and calm the belly

Spiritual teachers, therapists, and yoga instructors are some of the people who can teach you mindfulness, meditation, and breathing techniques.  Online courses are also available. 

In addition, there are now countless meditation apps available for your phone – some paid and others free.  Some of the popular apps include Calm, Headspace, Insight Timer, Ten Percent Happier, Exhale, and Sattva.

An important thing to note in the subject is that it takes time!  Don’t expect immediate results.  They call it a “practice” for a reason.  Meditation is not as easy as it sounds.

It can help to set aside a few minutes at the same time every day to get you into the habit.  Attach it to another behavior you already routinely do.  For example, I might say I am going to meditate for 3 minutes every day after my cup of coffee.  Then work on increasing toward 10 minutes or more for a daily practice.

Exercise

While the research on exercise and IBS is could be improved upon, it is generally thought that exercise, or even regular gentle movement, can be helpful. 

There are both physical and mental benefits that go along with regular exercise. Exercise is known to boost mood while reducing levels of stress, anxiety, and depression.  Given the gut-brain connection, it is likely that the psychological effects of exercise can also help with gut function. 

There are also some more direct effects of exercise on the gut, including improvements in gas and bloating. Exercise can help stimulate the bowels to move, which can be helpful in IBS-C, but challenging in IBS-D.  However, most people with IBS-D can tolerate some form of exercise. 

It can be helpful to start slow.  Then, increase the duration and intensity as tolerated. Here are a few other tips to succeed with exercise: listen to your body, stop if it feels too intense, know where the nearest bathroom is at, wear loose fitting clothing, and consider starting your routine in a safe space.  

Yoga in particular receives a lot of attention in relieving gut symptoms. When it comes to yoga, traditional styles of yoga might be more helpful than that calorie burning, super intense, make-you-sweat power yoga class at the local gym.

The benefits of traditional yoga for IBS likely comes from the combination of physical movement, mindfulness, and relaxation.  In fact, in one study regular yoga was comparable to a low FODMAP diet in reducing symptoms11. The yoga classes in this study focused on relaxation, breathwork, meditation, and poses traditionally believed to affect digestion.

So, exercise is generally good! But as you’ve probably heard a million times before… discuss any plans for a new exercise routine with your doctor to make sure it is safe for you.

Medications and Herbal Supplements

There are many medications out there to help control symptoms of IBS.  None of these are a cure for IBS.  Many people will use a combination of over the counter and prescribed medications. Your IBS subtype (IBS-C vs -D or -M) may determine which medications are recommended for you.

Here are the common categories of medications you may want to discuss with your doctor:

Antispasmodics can reduce abdominal pain and cramping.

Laxatives and stool softeners can help with constipation.  Some types of fiber supplements fall under this category as well.

Prokinetics can help stimulate muscle contractions of the gastrointestinal tract to get things moving.

Guanylate cyclase C agonsits (Linzess, Trulance) are newer medications for IBS-C that increase fluid secretions in the intestines and help stimulate a bowel movement.

Antidiarrheals can reduce the frequency of bowel movements and help firm up watery or loose stools.

Antibiotics may be helpful when small bowel bacterial overgrowth is suspected.

Antidepressants have also been shown to help reduce the symptoms of IBS, especially in IBS-D.12

Pain medications may be useful for abdominal pain. Over the counter pian medications may a good place to start. Discuss use of all pain medications with your doctor. Some prescription pain meds can make constipation worse but can be helpful for diarrhea.

Antiemetics can be useful if you have nausea or vomiting.

Ginger is an herbal supplement that can help with nausea.

Peppermint oil is another commonly used herbal supplement for IBS, which acts as an antispasmodic.   This should be in the form of enteric coated capsules.

Probiotics

Probiotics for IBS

Probiotics are often taken for IBS under the assumption that dysbiosis, or a disruption of the body’s natural balance of gut bacteria, is the cause of symptoms.

While the gut microbiome is thought to play a role in IBS, we still have a lot to learn about it.  What a “normal” microbiome looks like is still debatable.  And even more unclear, is what bugs we need to add back or take away to get the gut functioning smoothly again.

Plus, taking probiotics only temporarily impacts the microbiome. Generally, when the supplement stops, the make-up of the microbiome goes back to what it was before. But that does not mean probiotics don’t do anything.

There is some evidence to support that probiotics can help with IBS symptoms.  If you choose to use probiotics, the NICE Guidelines suggest taking them for at least 4 weeks to determine if they are working. This is a good time to bust out that journal again and track your symptoms.

The best probiotic supplement for IBS has not been determined and may vary based on IBS subtype and symptoms.  The US Probiotic Guide can be a good place to start.  It summarizes which products have evidence for various conditions. 

Probiotics may also be helpful for anxiety, which in turn might help the gut. There’s that gut-brain connection again! Check out this excellent blog post by Angela Lago for more on probiotics for anxiety.

Look at the full ingredients of any probiotic supplement you are considering.  Check if there are also prebiotics present.  Some prebiotics are considered high FODMAP (inulin, chicory root) and might not be well tolerated in IBS.

Summary

A FODMAP elimination approach gets a lot of attention in the management of IBS symptoms, and for good reason.  However, the full elimination protocol can be challenging, time consuming, and in some cases risky.  It is not the best fit for everyone. 

If the thought of starting a low FODMAP diet is overwhelming, consider one of many other approaches.  This might include other diet and lifestyle changes that might be easier to implement.  It might also include medications, supplements, or focusing on therapies that are directed toward the gut-brain connection.

Discuss the options with your healthcare provider, weigh the pros and cons, and when you are ready to start, track your progress. 

Feel free to comment below on which strategies have worked for you! 

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References

1.         van Lanen AS, de Bree A, Greyling A. Efficacy of a low-FODMAP diet in adult irritable bowel syndrome: a systematic review and meta-analysis. Eur J Nutr. 2021;60(6):3505-3522. doi:10.1007/s00394-020-02473-0

2.         Halmos EP, Gibson PR. Controversies and reality of the FODMAP diet for patients with irritable bowel syndrome. J Gastroenterol Hepatol. 2019;34(7):1134-1142. doi:10.1111/jgh.14650

3.         Staudacher HM, Nevin AN, Duff C, Kendall BJ, Holtmann GJ. Epigastric symptom response to low FODMAP dietary advice compared with standard dietetic advice in individuals with functional dyspepsia. Neurogastroenterol Motil. 2021;33(11):1-8. doi:10.1111/nmo.14148

4.         Moore JS, Gibson PR, Perry RE, Burgell RE. Endometriosis in patients with irritable bowel syndrome: Specific symptomatic and demographic profile, and response to the low FODMAP diet. Aust New Zeal J Obstet Gynaecol. 2017;57(2):201-205. doi:10.1111/ajo.12594

5.         O’brien L, Skidmore P, Wall C, et al. A low fodmap diet is nutritionally adequate and therapeutically efficacious in community dwelling older adults with chronic diarrhoea. Nutrients. 2020;12(10):1-12. doi:10.3390/nu12103002

6.         van Megen F, Skodje GI, Lergenmuller S, et al. A low FODMAP diet reduces symptoms in treated celiac patients with ongoing symptoms – a randomized controlled trial. Clin Gastroenterol Hepatol. Published online 2022. doi:10.1016/j.cgh.2022.01.011

7.         Staudacher HM, Ralph FSE, Irving PM, Whelan K, Lomer MCE. Nutrient Intake, Diet Quality, and Diet Diversity in Irritable Bowel Syndrome and the Impact of the Low FODMAP Diet. J Acad Nutr Diet. 2020;120(4):535-547. doi:10.1016/j.jand.2019.01.017

8.         Krouwel M, Farley A, Greenfield S, Ismail T, Jolly K. Systematic review, meta-analysis with subgroup analysis of hypnotherapy for irritable bowel syndrome, effect of intervention characteristics. Complement Ther Med. 2021;57:102672. doi:10.1016/j.ctim.2021.102672

9.         Peters SL, Yao CK, Philpott H, Yelland GW, Muir JG, Gibson PR. Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2016;44(5):447-459. doi:10.1111/apt.13706

10.       Keefer L, Ballou SK, Drossman DA, Ringstrom G, Elsenbruch S, Ljótsson B. A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction. Gastroenterology. 2022;162(1):300-315. doi:10.1053/j.gastro.2021.09.015

11.       Schumann D, Langhorst J, Dobos G, Cramer H. Randomised clinical trial: yoga vs a low-FODMAP diet in patients with irritable bowel syndrome. Aliment Pharmacol Ther. 2018;47(2):203-211. doi:10.1111/apt.14400

12.       Kułak-Bejda A, Bejda G, Waszkiewicz N. Antidepressants for irritable bowel syndrome—A systematic review. Pharmacol Reports. 2017;69(6):1366-1379. doi:10.1016/j.pharep.2017.05.014

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

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