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 individuals that Dietitians encounter.

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

The three phases of the low FODMAP diet involve the initial low FODMAP phase, followed by the re-introduction phase and then the longer term personalisation phase. 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.

The Initial Low FODMAP phase:
The trial phase of the low FODMAP diet that swaps the high FODMAP foods for low FODMAP foods, even if the individual thinks that they are well tolerated. The purpose of this phase is to determine whether removing FODMAPs make a significant difference to symptoms. This step usually lasts around two to six weeks.

The Re-introduction Phase:
Commenced if symptoms have improved significantly upon completion of the initial phase. The re-introduction 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 re-introduction phase is structured and systematic – similar to running an experiment.

Longer term personalisation:
May include well tolerated higher FODMAP foods in the diet. It aims to give individuals the knowledge of which foods may give them symptoms but allows them to work to balance symptoms with food desires.

This three-phased structure seems to work effectively for majority of those with IBS. We would call this a ‘top down’ approach to treatment – where someone uses big picture thinking to reduce all FODMAPs, re-introduction them individually, identify the triggers and refine their diet accordingly. However, this approach is not suitable for all individuals, particularly if other aspects of health or nutritional status are contradictory to implementing a restrictive diet.

What is the gentle approach to the low FODMAP diet?

This is the ‘bottom up’, gentle approach to the low FODMAP diet. Instead of initially swapping all high FODMAP foods for low FODMAP foods, as is the case in the three-phase structure, the gentle approach first identifies a few high FODMAP foods and/or targeted FODMAPs that may be causing symptoms in someone. Then, the individual may reduce these FODMAPs for a period of time, and then ‘increase the accelerator’ with further dietary restriction if necessary. Symptom response is monitored throughout.

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 an individual. The commitment may mean that those trying the regular three-phased approach may give up halfway due to the rigidity of the initial and re-introduction phases. Additionally, individuals present themselves with varying degrees of IBS symptoms. At the milder end of the spectrum, a gentle approach may be all an individual needs to reduce digestive discomfort.

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

A gentle approach should be considered in individuals with:

• Existing dietary restrictions such as vegetarianism. Although having dietary restrictions does not automatically mean the FODMAP gentle approach should be followed, practitioners need to assess if individuals are capable of taking on more restrictions before prescribing the traditional low FODMAP diet.
• Older Adults or Children, where the focus must be to meet nutritional adequacy and/or establish healthy eating habits to carry across the lifespan.
• Known food intolerances or even tolerances if it is known that lactose is tolerated after having a hydrogen breath test.
• Comorbidity with existing dietary restrictions g. individuals with Inflammatory Bowel Disease, Heart disease, Coeliac 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?

Firstly under Dietitian guidance.  Some practical steps to consider:

• Reduce common high FODMAP foods from each food group such as wheat bread, onion, garlic, mushrooms, apples, pears, cow’s milk, chickpeas, cashews, apricots.
• Reduce diet specific FODMAPs. This approach requires individuals 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, it may be ok to just reduce fructose and lactose.

Questions to ask when analysing individuals’ food diaries

A well-trained Dietitian can target attention to the changes to each individual’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 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 lot of one particular FODMAP group being eaten?
• Are symptoms particularly worse after a meal high in a certain FODMAP?
• Is the individual already avoiding a certain type of food?
• Does the individual already have a good idea of what types of foods triggers symptoms?
• Is there a certain time of the day that symptoms may appear?
• Was there a stressful life event that triggered the onset of symptoms? If so, the practitioner may be able to identify that the individual’s IBS may be 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 an individual 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 peoples. A comprehensive diet history can aid in working with individuals to reduce diet specific FODMAPs. Overall, seek advice from an IBS and FODMAP trained Dietitian for support and guidance on the low FODMAP diet and discern the best approach.

Written by Charlotte Barber (Student Nutritionist)
Reviewed by Kiarra Martindale (Accredited Practising Dietitian)