FODMAP CHALLENGES
FODMAP CHALLENGES are best done using a food approach.
Breath tests for lactose and fructose have been popular in the past but recent research shows that fructose tests are inconsistent and unreliable, and while lactose tests are more reliable, the amount of lactose in the breath tests are far higher than exists naturally in foods so does not give information on the level in foods that can be safely eaten and at which point you start reacting.
Food trials end up giving you more practical information as everybody with lactose intolerance (with few exceptions ) can tolerate a degree of lactose in foods.
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Finding your personal threshold is the whole point of food trials.
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WHY DO FODMAP CHALLENGES?
Many people feel so relieved by the improvement of symptoms, especially if they have been suffering with intolerable symptoms for a long time with no answers in sight, that a desire to stay in the happy space of minimal symptoms is more than tempting. This is understandable.
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The next phase, though is pretty exciting, as you get to IDENTIFY your specific food triggers. Everybody likes this stage, and often the results are quite surprising and liberating. Maybe you can tolerate the dreaded onion, but garlic is ok for you in moderate amounts. Maybe fructose is ok after all but it is sorbitol that sends your gut into spasms.
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Until you do food trials, everything is just a 'best guess'. Food trials give a whole lot more clarity, and they are EASY trials.
The purpose of this diet is to only avoid in the diet what you really need to avoid, as having a restricted diet (especially if you don't need to) is not a good idea and could impact long term health and certainly affects the daily quality of life, making it so very hard to eat outside the home, which can lead to social isolation.
Which FODMAPS are you sensitive to?
Chances are that you are not sensitive to ALL the FODMAP foods- just SOME.
The challenges allow you to identify which of the FODMAPs are your personal triggers, how sensitive you are: mild, moderate or very sensitive and what foods you can get back into your diet without triggering gut issues.
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There are 8 -10 different challenges and the order of the challenges depends on your preferences (see below).
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The challenges are simple as they involve trialling out one food (per FODMAP sub-group) at increasing doses over 3 days.
These 3 days can be consecutive (at their fastest implementation), in the case of the smallest FODMAPs (lactose, excess fructose and the 2 polyols: sorbitol and mannitol) or with a rest day in between each dose for the larger FODMAPs (GOS in legumes, and the fructans in bread, fruits, onion and garlic).
The larger FODMAPs are best done with a day between doses as it takes longer for these FODMAPs to reach the large intestine where rapid fermentation occurs and symptoms are triggered so e need to monitor over this critical time period.
Then 2 days of rest (and settled symptoms) before embarking on a new food trial.
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At the end of the challenges- you will have a reaction profile and now can identify the high FODMAP foods causing you mild issues, moderate symptoms and more severe symptoms.
Of course, you will also be identifying the FODMAPs that you have gone through all the effort of avoiding but end up being fine for you!
The results never cease to surprise people who think they know what they are going to react to.
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FODMAP CHALLENGES
First up- these trials are really easy. Eat what you normally eat and just add the one food at one sitting into what you normally have. NO SPECIAL MEALS NEED TO BE MADE. In fact, best if this is not done as best not do anything too different to what you normally would do.
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For example, for the excess fructose trial, you start of day 1 adding moderate dose of honey into (for example) your normal breakfast or just eating it on a spoon. That is it!! Really simple.
Food trials (or challenges) are commenced in any preferred order although I personally think it is good to start with trials of foods that you are most likely going to be ok with.
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If the Simplified FODMAP elimination was undertaken then the challenges are around the 4 different FRUCTAN* groups (see below) and GOS*.
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If other sensitivities are suspected, such as salicylate sensitivity then most of the FODMAP trial foods suggested will not be suitable and alternative low salicylate foods need to be recommended (specialized Dietitan help here is extremely important).
EXCESS FRUCTOSE
Honey, Mango, normal serve of Strawberries or Grapes
MANNITOL
Cauliflower, Mushrooms
LACTOSE
Normal lactose containing milk eg low fat milk, skim milk, full fat milk
FRUCTANS*
Onion
Garlic
Wheat Fructans
Vegetable Fructans
(4 separate trials)
SORBITOL
Apricot, Avocado
GOS*
Legumes and other foods eg normal serve of Almonds
WHAT HAPPENS AFTER FOOD TRIALS?
Now is the time to get some FODMAP foods back into your diet - the best way to keep your gut as healthy as possible as FODMAPs are prebiotics that help optimise your gut biome or natural probiotics in your gut.
This last phase of the FODMAP elimination diet, reintroduction, is based on what you have identified through food trials - which FODMAPs are fine for you, and which ones you may need to manage.
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Foods that are fine can be reintroduced and check that you are actually fine with this, while the FODMAPs you react to can be reintroduced based on your individual level of sensitivity.
At this point, the FODMAP journey will be very individualised as to your FODMAP profile.
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It is useful to get help to see how you can expand your diet based on your personal profile of triggers as per your food challenge results. What fruits and vegetables can you now have? What does the challenge results mean in the real world?
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Do you have other non FODMAP food trials that are important to explore such as Wheat Gluten, Dairy Protein and how can you combine this with low FODMAP and still have a nutritionally adequate diet?
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Work with me so I can guide you through a safe and nutritionally sustainable diet, look for opportunities for expansion and suitable food replacements to prevent nutritional holes, and nutritional supplementation when this is not possible.
REFERENCES
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Yao, C. K., and Tuck, C. J. (2017) The clinical value of breath hydrogen testing. Journal of Gastroenterology and Hepatology, 32: 20–22. doi: 10.1111/jgh.13689.
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Gibson, P. R. (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 of Gastroenterology and Hepatology, 32: 32–35. doi: 10.1111/jgh.13693.
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Barrett, J. S. (2017) How to institute the low-FODMAP diet. Journal of Gastroenterology and Hepatology, 32: 8–10. doi:
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Tuck, C., and Barrett, J. (2017) Re-challenging FODMAPs: the low FODMAP diet phase two. Journal of Gastroenterology and Hepatology, 32: 11–15. doi: 10.1111/jgh.13687.