FODMAP

Source: Peter R Gibson and Susan J Shepherd. Journal of Gastroenterology and Hepatology. 2009.

Functional gastrointestinal symptoms are common and their management is often a difficult clinical problem. The link between food intake and symptom induction is recognized.

The low FODMAP diet provides an effective approach to the management of patients with functional gut symptoms. The evidence base is now sufficiently strong to recommend its widespread application.The restriction of their intake globally (as opposed to individually) reduces functional gut symptoms, an effect that is durable and can be reversed by their reintroduction into the diet.

The acronym, "FODMAP" for Fermentable Oligo, Di and Mono saccharides And Polyols was coined to describe a previously  unrelated group of short-chain carbohydrates and sugar alcohols (polyols).

They comprise fructose, lactose, fructo and galacto oligosaccharides (fructans, and galactans), and polyols (such as sorbitol, mannitol, xylitol and maltitol) all of which putatively have three common functional properties:

• Poorly absorbed in the small intestine: Poor absorption occurs by virtue of slow, low-capacity transport mechanisms across the epithelium (fructose), reduced activity of brush border hydro- lases (lactose), lack of hydrolases (fructans, galactans), or molecules being too large for simple diffusion (polyols). 
• Small and therefore osmotically-active molecules: This effect has been demonstrated with, for example, a synthetic FODMAP, lactulose, which exerts a laxative effect when given in sufficient dose by increasing the liquidity of luminal contents and subse-quently affecting gut motility.  
• Rapidly fermented by bacteria: The rapidity of fermentation by bacteria is dictated by the chain length of the carbohydrate; oligosaccharides and sugars are very rapidly fermented compared with polysaccharides such as soluble dietary fibre.

Food sources of FODMAPs (where FODMAPs are problematic based on standard serving size) and suitable alternatives:



Excess fructose:

• Problem high FODMAP food source

Fruits: apples, pears, nashi pears, clingstone peaches, mango, sugar snap peas, watermelon, tinned fruit in natural juice.
Honey
Sweeteners:  Sweeteners: fructose, high fructose corn syrup
Large total fructose dose: concentrated fruit sources; large serves of fruit, dried fruit, fruit juice

• Suitable alternative low-FODMAP food source:

Fruits: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, paw paw, raspberry, rockmelon, strawberry, tangelo.
Honey substitutes: maple syrup, golden syrup
Sweeteners: any except polyols



Lactose:

• Problem high FODMAP food source 

Milk: cow, goat and sheep (regular & low-fat), Ice cream 
Yoghurt (regularand low-fat)
Cheeses: soft and fresh (e.g. ricotta, cottage)

• Suitable alternative low-FODMAP food source

Milk: lactose-free, rice milk
Cheese: "hard" cheeses including brie, camembert
Yoghurt: lactose-free
Ice cream substitutes: gelati, sorbet
Butter 



Oligosaccharides(fructans and/or galactans)

• Problem high FODMAP food source

Vegetables: artichokes, asparagus, beetroot, Brussels sprout, broccoli, cabbage, fennel, garlic, leeks, okra, onions, peas, shallots.
Cereals: wheat and rye when eaten in large amounts (e.g. bread, pasta, couscous, crackers, biscuits)
Legumes : chickpeas, lentils, red kidney beans, baked beans
Fruits: watermelon, custard apple, white peaches, rambutan, persimmon

• Suitable alternative low-FODMAP food source

Vegetables: bamboo shoots, bok choy, carrot, celery, capsicum, choko, choy sum, corn, eggplant, green beans, lettuce, chives, parsnip, pumpkin, silverbeet, spring onion (green only), tomato
Onion/garlic substitutes: garlic-infused oil
Cereals: gluten-free and spelt bread/cereal products






Polyols

• Problem high FODMAP food source

Fruits: apples, apricots, cherries, longon, lychee, nashi pears, nectarine, pears, peaches, plums, prunes, watermelon
Vegetables: avocado, cauliflower, mushrooms, snow peas
Sweeteners: sorbitol (420), mannitol (421), xylitol (967), maltitol (965), isomalt (953) and others ending in "ol"

• Suitable alternative low-FODMAP food source

Fruits: banana, blueberry, carambola, durian, grapefruit, grape, honeydew melon, kiwifruit, lemon, lime, mandarin, orange, passionfruit, paw paw, raspberry, rockmelon
Sweeteners: sugar (sucrose), glucose, other artificial sweeteners not ending in "ol"