The Low FODMAP Diet for Beginners - a Resource Package

Happy new year everyone! I feel like this is a timely topic to write about, as many people might have either jumped completely off the low FODMAP bandwagon during the holiday season or have been putting off beginning the diet until now, so as not to overwhelm themselves over Christmas. No judgement here, I was also tempted over the last few weeks.

So, for those who are new to this medically prescribed diet, and the not-so-new who might need a refresher course in what it’s all about and a list of resources that are just a click away, read on. The purpose of this resource package is not to tell you everything about the diet – as I have other links that do that, as do the bloggers and professionals that I list below, it is to provide all the resources that a beginner or ex-FODMAPer might need to get a handle of the diet again, by assisting you to understand the science and get inspired to create delicious low FODMAP meals.

To everyone else, I’ll be back to recipes in February – feel free to subscribe to receive emails about new posts in the top of the right hand side-bar.

What IS the low FODMAP Diet?

A much more in-depth description about FODMAPs and how they cause symptoms of irritable bowel syndrome (IBS) can be found here – please read it for full information – but the abridged version is this:

FODMAPs are a group of carbohydrates that are especially fermentable by the flora (bacteria) that live in your colon – this fermentation leads to gassy by-products and an osmotic effect that cause symptoms of abdominal pain, bloating, flatulence and altered bowel movements, to name a few. The low FODMAP diet is a medically prescribed diet that should be undertaken with the supervision of a trained dietitian, if at all possible. It aims to allow you to pin point your specific triggers by eliminating the foods with high levels of FODMAPs for a period of anywhere from 4-12 weeks (depending on who advises you and the severity of your situation) to allow your gut to settle, followed by a structured reintroduction period in which you individually test a variety of foods that are high in the different FODMAPs to learn your particular intolerances.

After completing the elimination and food trial phases, there is no need to remain completely low FODMAP, unless every food you test has caused you to react. See the “should I see a dietitian” section for more information.

The low FODMAP diet is also no longer purely for IBS sufferers. It has been found to help alleviate symptoms in those with carbohydrate malabsorption disorders (like fructose malabsorption), as well as Inflammatory Bowel Diseases, such as Crohn’s Disease and Colitis.

It is important to note that, while gluten is a gut irritant for those with Coeliac disease, non-coeliac gluten sensitivity (NCGS) or certain autoimmune disorders, gluten it is not a FODMAP. Gluten is a plant-based protein that occurs in all varieties of wheat, barley and rye, whereas FODMAPs, as mentioned earlier, are carbohydrates. A low FODMAP diet is not a gluten free diet; however, they can be used in conjunction to achieve full control of IBS (and other) symptoms.

Diagnosis

Hopefully you were diagnosed by your dietitian, GP or gastroenterologist after having a set of tests run to rule out anything more serious that can disguise itself as IBS, such as coeliac disease or colon cancer. For obvious reasons, it is important to rule out autoimmune diseases and cancer early on, to limit damage done and improve prognosis – read more here. In addition to the more sinister causes of digestive distress, there are many disorders, diseases and food intolerances that can cause similar symptoms and muddy the diagnostic waters, so to speak.

These differential diagnoses include, but are certainly not limited to, the following conditions:

Testing should be carried out for as many conditions as is deemed relevant for your individual case, until an answer is reached. The gold standard testing method for FODMAP specific malabsorptions (fructose, lactose, sorbitol) is a hydrogen/methane breath test. If your small intestine malabsorbs the carbohydrate, the concentrated solution you drink will, to varying extents, pass through into the colon, where the resident bacteria feed on it, leading to either (or both) hydrogen or methane gas production, which is measured by breathing into a bag or a meter.

Testing for coeliac disease includes an antibody blood test, as well as endoscopic procedures to check for visible signs of damage. Inflammatory bowel disease testing can include stool tests, blood tests, endoscopic procedures and imaging.

Unfortunately, not everyone will receive a standard diagnosis, and after this point “IBS” is typically diagnosed, if the case matches the Rome Criteria for IBS diagnosis.

Should I see a dietitian?

The short answer is yes, if you can. In addition to assisting with diagnosis of FODMAP specific issues, they can help with weeding out any other potential causes of your IBS. For some, FODMAPs aren’t the complete picture, or even part of their answer. For the 25% of people out there whose IBS is not related to FODMAP consumption, a dietitian will be able to help guide you to different possibilities, such as food chemical intolerances or perhaps allergies.

The low FODMAP diet is not meant to be followed forever. Many healthy foods, that are full of fibre and nutrients, are restricted during the full low FODMAP elimination phase, so it is best to get these back into your diet, if you can. Obviously, some people are unable to reintroduce some or any higher FODMAP foods; these people especially would benefit from a dietitian’s supervision, as the dietitian will be able to help them tailor an eating plan that is both low FODMAP and nutritionally balanced. The more foods you can reintroduce successfully, the more balanced your diet can be with less effort.

In which foods do FODMAPs occur?

For complete and up-to-date lists of the foods to avoid while in the elimination phase (with serving size recommendations), please check out one of the phone applications I have listed below (Monash University, FODMAP Friendly, or Baliza), as they regularly conduct research to test new foods and products for FODMAP content.

Resources

Phone Applications

Low FODMAP Professionals Online

  • The Well Balanced FODMAPer – Kate Scarlata, RD | Delicious recipes, fantastic up-to-date low FODMAP resources and an easy-to-understand food list.
  • IBS: Free at Last! – Patsy Catsos, RD | Easy to make recipes, reliable low FODMAP resources for both dietitians and FODMAPers, as well as free downloads to help beginners.
  • Shepherd Works and FODMAP Friendly – Sue Shepherd, RD PhD | Dr. Sue Shepherd, one of the low FODMAP diet pioneers, runs both a clinic in Melbourne, Australia and a company that has a low FODMAP app and low FODMAP food products.
  • A Less Irritable Life – Glenda Bishop, PhD | Glenda is a registered nutritionist, wellness coach, neuroscientist and educator. She uses her insider experience of irritable bowel syndrome and food intolerances, alongside her expertise in nutrition, health and medical science, to develop easy to use strategies that help fellow suffers rediscover the joys of delicious food.
  • R & M Dietetics – Lee Martin, RD and Mel Rendall, RD | Two dietitians who follow the low FODMAP diet, create delicious recipes, provide information about eating out and communicate important research to IBS sufferers.
  • FODMAP Life – Colleen Franciolo, certified nutritionist consultant | balanced, nutritious recipes for FODMAPers and those suffering from other health conditions, such as Hashimoto’s and IBD.
  • Lauren Renlund – Lauren Renlund, RD is a registered dietitian and nutrition coach from Canada | Lauren has firsthand experience following the low FODMAP diet and sees clients in person and over the phone/Skype.

Reliable Low FODMAP Websites

  • The Friendly Gourmand – Nataliya Friend, B.Physio | Low FODMAP and gluten free recipes from scratch for all tastes, science-based resources and guides to travelling with food intolerances.
  • Calm Belly Kitchen – Julie O’Hara | A recipe developer who works for a magazine and, in her spare time, has created a digestive wellness resource for women with IBS, offering low-FODMAP recipes and meal planning tips.
  • The FODMAP Friendly Vegan – Sharon Rosenrauch, BPsyc MNut Candt. | A solid option for those eating a plant-based diet, Sharon provides healthy whole food meals that are delicious and FODMAP friendly.
  • Friendly Little Kitchen – Stephanie Papillo | Delicious, inspired low FODMAP and gluten free meals from an obviously talented cook.
  • Fructopia – Deniz Ficicioglu | Fructose friendly, processed sugar free and wheat free recipes that are delicious and healthy. Bonus – gorgeous food photography.
  • The Fructose Friendly Chef – Melissa | A qualified chef who creates delicious fructose friendly meals, and takes gorgeous photographs to go with them. Say no more.
  • Life and Thymez – Zlata Thoughtz | Quick, delicious and nourishing low FODMAP and gluten free meals – great for the new mums and busy parents out there!
  • A Little Bit Yummy – Alana Scott | Low FODMAP and gluten free recipes, with additional dairy and nut free options and reliable low FODMAP diet information posts.
  • My Gut Feeling – Joana | Healthy low FODMAP and gluten free recipes from a passionate (and well-travelled) foodie.
  • Strands of My Life – Suzanne Perazzini | Beautiful FODMAP friendly recipes, reliable resources and a low FODMAP coaching programme for those struggling to understand the diet.

Books for those following a low FODMAP diet

Low FODMAP coaching courses for IBS sufferers

Facebook Support Groups

I hope you have found this resource page useful! If there is anything you feel should be added, please leave a comment below, or email me at thefriendlygourmand@gmail.com.

The Guide to FODMAP Friendly Sugars and Sweeteners

Updated on 18.03.17

This list of safe sugars and sweeteners is suitable for those following the low FODMAP/fructose friendly diet for fructose malabsorption, which is also known as dietary fructose intolerance. If you have hereditary fructose intolerance (HFI), please do not use this list, as it is not strict enough for your fructose free requirements. If you have an infant/young child that is failing to thrive, has an aversion to sweet foods or continuously reacts poorly to sucrose/fructose/sorbitol containing foods, please ask your doctor about getting them checked for HFI.

There is a lot of confusion regarding the terms "sugar" and "sweetener" with regards to the low FODMAP diet. Either due to miscommunication with their dietitian - or not seeing a dietitian at all - fodmappers can unnecessarily over-restrict themselves. Given that the full low FODMAP diet is restrictive enough as it is, and perhaps taking into account other allergies or intolerances, I'm assuming that most of us would like to keep our diets as open as possible.

To begin with, let's clarify something; this is what a low FODMAP diet is not:

  • FODMAP free - there's no such thing, unless you're eating an unseasoned cut of meat or pure oil. Every plant food has FODMAPs in them, it's the amount that makes the difference. I don't want to say, "it's the dose that makes the poison," as FODMAPs are not poison.
  • Sugar free - FODMAPs include a range of sugars (saccharides) and other carbohydrates. Some sugars, such as fructose and lactose, are FODMAPs while others, such as glucose and maltose, are not.
  • Fructose free - unless you have hereditary fructose intolerance, fructose does not need to be completely eliminated from your diet, just reduced. Given their similar structures, as long as glucose is consumed in equal or greater amounts than fructose, the co-transport system will help with fructose absorption in the small intestine (up to a point, it can be overwhelmed).
  • Low carbohydrate - FODMAPs are a group of carbohydrates that are readily fermentable. Many carbohydrates, however, are not, so are safe. Starch, for example, is an example of a non-FODMAP complex carbohydrate. A low carb diet is not necessarily a low FODMAP diet.
  • Organic/non-GMO - whether a food is grown using organic, non-GMO, non-organic or GMO farming products or methods holds no bearing over its FODMAP content.
  • A forever diet - the low FODMAP diet is designed to allow you, with professional guidance, to work out your individual IBS triggers (including amounts/thresholds). There is no point in completely eliminating all potentially high FODMAP foods when, you only malabsorb one or two of the individual FODMAPs. The food trial phase is an important part of the diet that should not be avoided, unless your health practitioner has advised you otherwise.

So rest easy, guys - if you are following only the low FODMAP diet, then you can still consume moderate amounts of your favourite sweet or starchy foods, as long as they are not otherwise high FODMAP.

Now that we have that sorted, let's discuss a variety of commonly used sugars and sweeteners and their FODMAP content. This is a long article but hopefully it will be a great resource for confused FODMAPpers out there!

Sugars/Saccharides

  • "Saccharide" is the scientific term for the word "sugar." There are different types, including monosaccharides (single sugar molecules), disaccharides (double sugar molecules) and polysaccharides (multiple sugar molecules joint together).
  • Sugars form part of the carbohydrate macro-nutrient group, along with fibres and starches.
  • Not all sugars are considered FODMAPs.
  • Aside from potentially causing IBS flare ups, all sugar consumption should be limited for general health reasons.
  • If even modest servings of "safe" sugars continue to cause your fructose malabsorption/IBS to react, please consider getting tested for SIBO.
  • If you are diabetic, please consult your doctor or dietitian before using any concentrated glucose syrup

Agave Syrup/Nectar

FODMAP rating: unsafe.

Made from either the leaf or the root of several species of the agave plant, including Agave tequilana and Agave salmiana, agave syrup has become a popular "healthy" sugar choice over the last few years. It is approximately 90% fructose, thus some people claim that it doesn't spike blood glucose and is a better choice for diabetics and those wishing to lose weight. This research, however, is only suggestive and is countered by studies that suggest the opposite - that too much fructose, while it won't spike blood glucose, is still not good for you metabolically. The American Diabetes Association recommends that agave consumption should be limited, just like all the other sugars in the list.

Whichever side of this you choose to believe, the facts stand that agave syrup is just about the worst sugar a fructose malabsorber could choose, given it's extremely high ratio of excess fructose.

Beet Sugar

FODMAP rating: safe.

Beets are one of the two most common sources of common table sugar production, the other being cane sugar (listed below). Beet sugar contains 99.95% sucrose, which is a disaccharide comprising one molecule each of glucose and fructose. Given that the fructose ratio is 1.0, beet sugar (and any other sucrose-based sugar) can be consumed in moderate amounts, relying on the glucose co-transport method of fructose absorption.

Brown Sugar

FODMAP rating: safe in 1 tbsp. servings.

Brown sugar is common table sugar (sucrose) that has either had a little molasses left in during the refinement process, or alternatively, some molasses was added back in later on. Monash University lists the safe serving of brown sugar at 1 tbsp.

Molasses (listed below) is generally considered unsafe as there is a fructose ratio greater than 1.0 however, the ratio is small at approx 1.075 (according to Nutrition Data) and not a lot of molasses is added into the brown sugar. For this reason, a little bit of brown sugar in a baked good every now and then should be tolerated by most. More molasses is added into dark brown sugar than the light brown sugar, so I'd stick to the latter.

As with everything to do with FODMAPs, if you are extra sensitive and find that you react to brown sugar, just leave it out. Alternatively, use a combination of brown sugar and dextrose and the dextrose (glucose) will bring the fructose ratio back to well under 1.0, while allowing you to take advantage of the rich, caramel-like flavours that brown sugar can bring to your food.

Cane Sugar/Syrup

FODMAP rating: safe.

Cane sugar is made from sucrose, which has a fructose ratio of 1.0 and is considered safe in terms of FODMAPs.

Monash University suggests that the amount found in a glass of diluted cordial mix, or a small handful of lollies, should be well tolerated by most but that those who are more sensitive should limit large doses. Given that lollies are mostly sucrose, the amount of sucrose found in a slice of otherwise low FODMAP cake should be within those limits.

Coconut Sugar

FODMAP rating: safe but watch your serving size.

Coconut sugar, which is produced by dehydrating the sap of coconut palms, is rated by FODMAP Friendly as safe in 1 tsp. (4.0 g) serves.

Monash rates a similar product, coconut treacle, as safe in 1/2 tbsp. (14 g) serves, more becoming higher in FOS.

This information matches with my previous research that stated that coconut sugar contains inulin, which is a type of fructan (FOS) that is mildly sweet and can reduce the rate of glucose absorption in the gut, which is one of the reasons why coconut sugar is touted as a healthier, lower GI option.

Given the above and, knowing that FODMAP reactions are dosage dependent, I'd make sure that you do not over-consume coconut sugar during your elimination phase, though please discuss this with your dietitian/nutritionist.

Corn Syrup

FODMAP rating: safe.

Corn syrup is made by extracting glucose from corn starch, using a multi-step enzymatic approach. It is anywhere from 93-96% glucose (as maltose, a disaccharide of two glucose molecules), so is one of the safest sweeteners available, in terms of FODMAPs. For more information on FODMAPs, corn syrup and other corn products, read this article.

Please note that high fructose corn syrup is different to corn syrup and has been listed separately below.

Fructose (isolate)

FODMAP rating: unsafe.

Isolated fructose is anywhere from 90-100% fructose and, as such, is unsuitable for consumption by symptomatic fructose malabsorbers.

Fruit Sugar

FODMAP rating: unsafe.

Refers almost only to fructose; avoid it like the plague if you are a symptomatic fructose malabsorber.

Glucose Syrup

FODMAP rating: safe.

Depending on the country you live in, glucose syrup can be produced from corn, wheat, rice, potatoes or tapioca. In the USA, corn syrup is used synonymously with glucose syrup and, in Australia, it's typically produced from wheat glucose. The starch from the base ingredient is isolated and, via a multistep enzymatic process, is converted to a concentrated glucose solution.

Given that glucose is the safest form of sugar for fructose malabsorbers to consume, glucose syrup is a good choice of sugar to use during the elimination phase of the low FODMAP diet. It is less sweet than sucrose, due to the absence of fructose, and you will find that the flavour lacks a little volume but this can be corrected by using either a combination of glucose syrup and a sucrose-based sugar or adding low FODMAP spices to your food.

If you have coeliac disease, please confirm with the product manufacturers that the glucose syrup produced from wheat (or any other gluten containing grain) is considered gluten free. 

Golden Syrup

FODMAP rating: safe at 1/2 tbsp, unsafe at 1 tbsp.

Golden syrup, also known as light treacle, is a sucrose-based inverted syrup produced during the process of refining the juice of either sugar cane or sugar beets into common table sugar. It has been rated as low FODMAP in serves of 1/2 tbsp. (7 g) and high in FOS in larger amounts, so make sure that you monitor serving size if using it in baked goods or drizzling it on your porridge or toast.

In terms of cooking and baking, it is a great substitute for honey and molasses, which should be restricted due to excess fructose levels, and also for maple syrup, which can be outrageously expensive in certain places, like all of Australia. It lends a rich, distinctive flavour to dishes that is milder than molasses, which can be quite bitter.

High Fructose Corn Syrup

FODMAP rating: unsafe.

Once corn syrup (which is mostly maltose/glucose) has been produced, the reaction is taken a step further and the corn syrup is processed with the enzyme glucose isomerase, to convert some of the glucose into fructose. This produces HFCS-42. Liquid chromatography is used to further convert glucose into fructose, to create HFCS-90, which can be blended with HFCS-42 to create HFCS-55.

Regardless of your opinion of the health dangers of HFCS, it is NOT low FODMAP. As the varieties (42%, 55% and 90% fructose) are not labelled differently, it’s best to stay clear of it completely.

Other names include: isoglucose, glucose-fructose syrup, fructose-glucose syrup, isolated fructose and fructose syrup (the latter two refer to HFCS-90).

Honey

FODMAP rating: unsafe.

Honey is produced from the nectar that honey bees collect from flowers. For this reason, it is not vegan. Different varieties of honey contain vastly different fructose ratios, with a rare few possibly being as low as 1.0, which would be considered safe in terms of FODMAP consumption. However, unless honey is specifically labelled as FODMAP friendly, it would be safer to assume that is has a high fructose ratio and should therefore be avoided until such a time that you and your dietitian decide it should be tested.

Monash University lists 1 tbsp. of honey as high in excess fructose and thus unsafe for those with fructose malabsorption.

Invert Sugar

FODMAP rating: tentatively safe but potentially problematic for some.

Invert sugar is a tricky beast. The term refers to sugars that have been converted to syrups using heat and an acid-based chemical reaction. You can mimic this by creating golden syrup at home by melting table sugar with a slice of lemon (the acid). Honey is another invert syrup, though obviously bees don't have stoves and lemon slices on hand to create it.

The problem is that when "invert syrup" or "invert sugar" is listed, it is impossible to tell which invert syrup is being referred to and thus it has an unknown fructose ratio. Many people in the fructose malabsorption groups online state that invert syrup is a trigger for them. As invert syrup hasn't officially been tested yet, I can't say for sure but Patsy Catsos, a well-known dietitian and a FODMAP expert, says that invert syrup is "tentatively okay." I understand this to be that if the fructose ratio is safe, the invert syrup would be safe. If you are unsure and don't want to risk a reaction, simply avoid it.

Maple Sugar/Syrup

FODMAP rating: safe.

Maple syrup is produced by boiling and dehydrating the sap from sugar maple trees, until a viscous, delicious syrup has formed. Luckily for fructose malabsorbers, it is a sucrose-based syrup, with a fructose ratio of 1.0, so is safe in moderation on the low FODMAP diet.

It lends a rich, distinctive flavour to foods that only gets better when you buy grade B, rather than grade A maple syrup. Please ensure that you are buying pure maple syrup and not a "table syrup" or "pancake syrup," which could contain higher FODMAP ingredients.

Molasses

FODMAP rating: unsafe.

While Monash University has not tested molasses just yet, other reliable sources suggest that it has a fructose ratio slightly greater than 1.0 (1.073 to be exact), so it seems to be unsafe for those with fructose malabsorption. However, we will have to wait for Monash University's independent lab tests and food trials to be sure.

Raw Sugar (Turbinado/Rapidura/Demerara)

FODMAP rating: safe.

Raw sugar is a partially refined version of crystallised table sugar. Each variety has varying degrees of molasses left in from a shortened refinement process. Typically found in coarser grains, they provide similar caramel notes to brown sugar. Also like brown sugar, they are safe in moderation. I would stick to the 1 tbsp. serving size of brown sugar, or combine the raw sugar with glucose or dextrose powder to achieve the rich flavour with a more favourable fructose ratio.

Rice Malt/Brown Rice Syrup

FODMAP rating: safe.

Rice malt syrup is glucose/maltose syrup that has been produced from (typically brown) rice. In the modern/industrial method of rice malt syrup production, the brown rice is fermented in the presence of enzymes, to separate the starch from the other components, after which it is strained and heated to achieve the concentrated glucose/maltose syrup that we can buy in most health food stores or online. In the traditional method, barley sprouts are used in the first step, so please make sure you complete further research on traditionally made rice syrups and gluten content if you have coeliac disease.

As rice malt syrup contains approximately 3% glucose and 45% maltose (a disaccharide of two glucose molecules), it is considered safe to use by those with fructose malabsorption and is lower GI than sucrose and pure glucose. If you are diabetic, please use caution and consult your doctor or dietitian before using any alternative syrup for the first time.

Sucrose

FODMAP rating: safe.

Sucrose is the scientific name for any disaccharide (double sugar molecule) that contains a molecule of fructose and a molecule of glucose (see image above). As fructose and glucose are present in equal amounts, the fructose ratio is 1.0, so sucrose is considered safe for fructose malabsorbers to consume in moderation, because the glucose co-transport method of fructose absorption will take care of the fructose present, up to a point. Be careful, as this method can be overwhelmed, so symptoms would resume if you over-consume sucrose-based products.

Table/Castor/White/Icing/Baker’s (etc) Sugar

FODMAP rating: safe.

Common table/white sugar is the product of completely refining sugar cane of sugar beet juice. They resulting product is entirely sucrose, so the fructose ration is 1.0 and they are considered safe for FODMAPpers to consume in moderation, according to Monash University.

The varying names refer to the different grain sizes and uses that the refined sugar product has been ground into. For example, White/table sugar is coarse (though not as coarse as most raw sugars), followed by baker's sugar, castor sugar and then finally icing/powdered sugar. Icing/powdered sugar can often be found cut with corn starch to prevent clumping - this is not a FODMAP issue but it is something to keep in mind if you have additional intolerances to corn.

Sweeteners

This section covers both artificial and naturally occurring sweeteners, which are commonly used instead of different sugars to provide sweetness in foods without the calories. No comment or judgement is being made about an individual's choice to use artificial/zero calorie sweeteners, as we must fuel our bodies as we see fit.

Aspartame

FODMAP rating: safe.

Aspartame is a methyl ester of two amino acids: aspartic acid and phenylalanine, to which form it is returned during digestion in the human body. Also known as NutraSweet and Equal, and coded as E951 in Europe, aspartame is a zero calorie, non-saccharide sweetener that is approximately 200 times sweeter than sugar.

It was approved for use by the FDA in 1981 and since then has been the source of many health debates - I won't go into them here, as it is not within the scope of a low FODMAP/gluten free blog and I am not a food scientist. Regardless of your opinion on whether aspartame is carcinogenic or suitable to consume, it is low in FODMAPs, so is safe to use on the low FODMAP diet. 

Phenylketonurics should avoid aspartame.

Polyols

FODMAP rating: unsafe.

Polyols refers to the P in FODMAPs, consisting of sugar alcohols that are commonly used as "sugar free" low calorie sweeteners. They can be naturally occurring or man-made, and include (but are not limited to) erythritolisomaltmaltitolmannitolsorbitol and xylitol. It is well-known that polyols can have a laxative effect (you've all seen the warnings about the side effects of over consumption on the back of sugar-free gum), so it shouldn't surprise you to learn that polyols can be malabsorbed in the human small intestine, just like fructose and lactose.

The size of the sugar alcohol will determine the extent to which it is likely to be absorbed in most people; erythritol, a four carbon polyol, is generally well absorbed, where as those that are six carbon or greater in size are unable to be absorbed via simple diffusion. In addition to being malabsorbed themselves, polyols, when consumed in combination with fructose, will bind to and block GLUT-5 fructose channels, thus increasing fructose malabsorption and worsening symptoms. For this reason, you should watch your intake of polyols, regardless of whether you malabsorb them specifically, as well as your fructose load.

Saccharin

FODMAP rating: safe.

Also known as Sweet 'n Low, and coming in at approximately 300-400 times sweeter than regular sugar, saccharin is considered to be low FODMAP. It is unstable when heated but doesn't interact chemically with other ingredients, so is otherwise shelf stable. A couple of studies suggest that the sweet taste can trigger an insulin response under fasting conditions, even though there is no glucose present.

Stevia

FODMAP rating: safe.

Derived from the leaves of the plant Stevia rebaudiana, pure stevia, whether produced from the whole leaf or extracted, is around 100-300 times sweeter than table sugar. The active ingredients in stevia leaf extract are steviol glycosides, which are heat stable and are not fermentable, making them FODMAP friendly

The two main components that provide sweetness are stevioside and rebaudioside. Rebaudioside A has the least bitterness of the two, and is preferentially extracted in commercially produced Stevia products, such as those listed above. The whole leaf version of stevia can impart a slightly more bitter flavour to drinks and bakes goods, etc but some people prefer it, as they can grow the plant easily and then dry and grind the leaves themselves.

Due to the strange flavour of pure stevia, many products contain a blend of the extract and another sweetener, which is usually a polyol (erythritol is common). Please make sure you always check the ingredients of the stevia  liquid or powder that you purchase, to make sure it only contains low FODMAP ingredients. As of the most recent edit, Pure Via is the only product I am aware of that contains only stevia and a FODMAP friendly sugar (dextrose).

Sucralose

FODMAP rating: safe in terms of FODMAPs but potentially problematic in terms of influence on gut bacteria.

Also known as Splenda, sucralose is low in FODMAPsOne study, however, suggests that extended sucralose use might reduce colonies of beneficial gut bacteria, as well as increasing foecal pH and reducing the bioavailability of certain orally administered drugs. This is not something that someone who is already prone to functional gut disorders would want to play with, so please discuss the use of sucralose with your health practitioner, to determine the right course of action for you.

Disclaimer: Although I come from a health science background, I am not a dietitian or a medical doctor; I have just researched this topic myself. If your health professional has advised you to avoid certain or all sugar-based products or sweeteners, please do so, as it might not be for a FODMAP-related reason.

Title photo credit goes to: Unsplash.

Travel Series - Flying with Fructose Malabsorption or IBS

I’m not a huge fan of flying. I’m not scared of it but I don’t find it enjoyable, either; long hours (15 hours between Melbourne and LAX) in cramped seating, recirculated air, mostly unsuitable foods and the bathrooms, if you can call them that, all add up to me not having a good time. I stress about connections until we make them and about whether our luggage will make it when we do.

We have had enough mishaps with changed departure gates, delayed planes and missing luggage (LAX is a disorganised hellhole) that Ev and I have become very adept at travelling light. The last time we went home to Australia, we got everything we needed for two weeks, including things for other people, in two carry on bags… and by “carry on” I mean the real carry on bags, not the giant suitcases that American based airlines let people take on and try in vain to cram into the overhead compartments, taking up space meant for everyone. Yes, that annoys me. If I’ve been responsible and packed my belongings into a small suitcase intended for overhead bins, perhaps with valuables in there, I am not impressed when I am told it HAS to be checked, because a 3/4 full plane has already run out of overhead storage. But I digress.

Some people truly do enjoy flying but for the rest of us, here’s how I manage eating with FM and dealing with potential symptoms while flying. It’s pretty appropriate timing, because Ev and I are going to spend the next week in Cabo, Mexico! We’ve been waiting for this holiday since we got back from Cabo last summer. As much as I prefer road trips and exploring different towns, not staying in the one place for too long, sometimes it’s nice to just go and veg out somewhere that is completely relaxing and not have to worry (so much) about the food. As I have said previously, for me, Mexico/Mexican food seems to be a safe bet if I eat plainly and avoid tropical fruits.

The other posts in the travel series can be found here.

I’m sure I’ll be posting photos of tropical paradise on my Instagram account, if you’d like to follow along.

Step 1: Plan ahead, Stress less

Most people don’t need to be told that stress can increase their IBS symptoms; I know I don’t. It’s not all in our heads, though. Research also demonstrates that the two coexist (see here and here), as the autonomic nervous system and certain hormones, which are triggered during times of stress, also act upon the gut.

To avoid stress related IBS and ensure as smooth a travel/flight experience as possible, plan ahead. Some things to consider are:

  • Book your flights as early as possible – cheaper flights means more money in your pocket and less concern about finances during your trip. It’s only a small matter but everything helps.
  • Have all your home-affairs in order well before you go, so you’re not panicking about getting emergency cash out for the house/dog-sitter or paying a last minute bill.
  • Pack early. This is something I can’t help but do, as it all adds to my excitement of going on holiday. It also means you won’t be up until 3 am the morning of your 8 am flight to finish packing your bags.
  • Check in online 24 hours before your flight, if you are able. This means that your seat is reserved on the flight, all you need to do is collect your boarding pass and check in your luggage.
  • Call the airline to ask what their menu will be and decide whether it will be safe for you. This is more important for long haul flights, as I’m pretty sure that standard fare on every flight under 3 hours is a bag of pretzels/mixed nuts and a soft drink/water. Actually, mixed nuts and water sounds fine, thanks. I’ll take that. Just make sure they’re unseasoned.
  • A few days before you fly, call the airline again and re-check your meal preference. I normally go for the gluten free meal and pick what I can from it, supplementing with food I’ve brought from home. The last time I flew between Melbourne and LAX I didn’t do this; my gluten free meal was a normal meal and my husband’s normal meal was vegan. No idea how that happened. What was worse – they don’t carry spares and everyone who had successfully ordered a gluten free meal had shown up for the flight. Which is why I was glad I’d also packed snacks…
  • Pack some non-perishable FODMAP friendly snacks; more on this later, just make sure you call the airline(s) and ask what you are able to take in carry on and what must be in checked baggage.

Step 2: Make some safe food flash cards

If you don’t speak the language, flash cards listing the ingredients you can and cannot consume in the language spoken by the airline/at the airport will help prevent a lot of confusion, if you decide to brave the food.

In fact, even if you do speak the local language, flash cards might still be a good idea as the idea of fructose malabsorption is still so novel that the apparently random list of ingredients that you cannot consume might overwhelm the staff and create an unwanted fuss.

Make sure the lists are clear and concise as to what you can and absolutely cannot consume.

Step 3: Eat plain before the plane

Each time I fly, I will eat plainly in the preceding week, for a few reasons:

  • I know that additional stress seems to set me off with foods I can normally tolerate, so why push boundaries?
  • I want to give my gut the week to calm down, as some foods cause delayed reactions that can last a few days. This way, if I do happen to react to something at the end of the second-to-last week before flying, I have seven days for it to pass.
  • If I am starting from a better place, in terms of my gut, then a small slip up won’t end up with such severe results as it would if my gut wasn’t terribly happy to begin with.
  • Do you want to have diarrhoea on a plane? Exactly.

Step 4: Pack your own food

This will not always be possible, due to customs regulations and such but if you are able, I highly recommend taking FODMAP friendly snack foods to tide you over during flights and layovers while you’re away.

Some ideas include:

  • A variety of foods for different meal times – who wants tuna for breakfast?
  • Non-perishable foods (or at least foods that will keep for a few days outside the fridge) are best.
  • Easily digestible foods that won’t tax your gut too much.
  • Pack the food in a freezer bag and take what you are allowed to inside your carry on luggage. Some carry on restrictions might prevent this, so put it on your list of questions to ask when you call ahead.

Examples of what I might pack:

  • FODMAP friendly veggies of your choice, such as carrot sticks, celery (if you can tolerate polyols), cucumber etc.
  • FODMAP friendly fruits, to a lesser extent, such as bananas and berries. These will need to be kept in a hard case, as they’ll bruise easily while travelling, so I generally wouldn’t bring them on a flight as they’re more likely to get squashed than on a road trip.
  • Muesli bars, like my strawberry pepita or fruit free bars. pictured below. Muffins are delicious but I find that they squash too easily.
  • Pre-packaged snacks, such as corn chips or rice cakes.

Step 5: Be prepared for the worst

Sometimes, despite our best efforts, shit happens. Literally. While it’s not ideal, you can lessen its impact on your travel by planning for it. If you have an FM-ergency kit, your life will be a lot easier. (See what I did there? You can use it). Keep this in your carry on, you may need it on your flight as well as at your destination.

  • Analgesics to help with cramps – ibuprofen is a known gastric irritant, so I personally don’t use it but if it works for you then don’t stop. I prefer paracetamol (acetaminophen) to help ease cramps, which are not fun to have on a plane.
  • Dextrose/glucose tablets – to help offset any excess fructose that you may accidentally consume, using the co-transport method of absorption.
  • Any supplements that you take, such as a probiotic, digestive enzyme or multivitamin. It’s best not to disrupt your schedule, if possible.
  • Stay hydrated.
  • Wet wipes/baby wipes, in case of an emergency cleaning situation.
  • Any other methods that you know work, such as Buscopan (I’m not saying it does work, it’s just an example). I would advise against using something you haven’t tried before, especially on a plane. It’s best to try those things out at home, beforehand, where you can crawl into a ball and feel sorry for yourself without upsetting the rest of the flight and your holiday.

I hope these guidelines help you fly and travel successfully, as they have me. If you think of anything that I should add, please let me know.

The Difference Between Fructose Malabsorption and Hereditary Fructose Intolerance

Updated April 2017

The following piece of writing is intended to be informational only. If you have any concerns regarding FM or HFI, please see your healthcare practitioner. Unless you have HFI or FM/IBS, there is generally no need to follow the fructose free or fructose friendly diets. Before starting a low fructose diet for the other health issues mentioned below, I highly recommend seeing a doctor or dietitian to check if it is the right course of action for you.

glucose-fructose-sucrose-fodmap-hfi

Fructose Malabsorption (FM) and Hereditary Fructose Intolerance (HFI) are two different disorders with such similar names and the same sweet culprit – no wonder people get confused. So much so that FM was actually renamed from Dietary Fructose Intolerance, to prevent mix ups.

If you have been following any health websites over the last few years, you will have heard that excessive consumption of dietary fructose – a 6 carbon monosaccharide (sugar) common to fruits and vegetables, with the chemical formula C6H12O6, the same as glucose – has been labelled as the cause of many health issues, such as non-alcoholic fatty liver disease, the obesity epidemic, changes in your blood-lipid profile, increased risk of cardiovascular disease and atherosclerosis. 1,2,3 And this is just in people without any problems absorbing or metabolising fructose. I mention this because, even removing FM and HFI from your search, fructose is plastered everywhere, just adding to the confusion. So far we have the:

  • Fructose Free diet for HFI
  • Fructose Friendly diet (which falls under the FODMAPs umbrella) for FM
  • Low Fructose diet being publicised by books like I Quit Sugar or Sweet Poison

Please note I am not disagreeing with any of these, I am just highlighting how the tiny differences in nomenclature can lead to confusion for the uninitiated. Which diet should you follow, if any?

Once you have decided that you are having issues with fructose, it is time to start the search for answers. The rest of this post will discuss FM and HFI, about which I aim to outline the aetiology, signs/symptoms, diagnosis, treatment and prognosis, so you can see the similarities and differences between the two disorders.

Fructose Malabsorption

Aetiology

An inability to absorb fructose from the small intestine, due to malfunctioning GLUT-5 protein channels, leads to dietary fructose consumed in excess of glucose remaining in the intestine and reaching the colon. Your colon is full of multiple colonies of bacterium, which are necessary for our health,4 that then proceed to feed on the fructose; their method of choice is fermentation, which results in carbon dioxide and hydrogen and/or methane gas, as well as short chain fatty acid production and increased water content due to osmosis. The products of fermentation lead to IBS (irritable bowel syndrome) like symptoms, which are generally what drives a person to seek a diagnosis.

Those with FM are also generally more sensitive to fructans (or “fructooligosaccharides”/FOS), which are indigestible fibres for all mammals, even non-FMers. Your gut microbiota will also ferment the FOS, leading to the same resulting by-products as fructose fermentation. For a more complete description, read my earlier post, entitled, “What is Fructose Malabsorption?

Signs/Symptoms

Ingesting excess free fructose can result in a variety of symptoms, not all of which are related to irritable bowel syndrome. An example of symptoms could include (but are definitely not limited to):

  • Abdominal pain.
  • Altered bowel movements – constipation or diarrhoea.
  • Bags under your eyes.
  • Bloating.
  • Confusion, also known as “brain fog.”
  • Dizziness.
  • Fatigue.
  • Flatulence/gas.
  • Gastro-oesophageal reflux disease (GORD) style symptoms, such as heartburn.
  • Mental depression. 12
  • Nausea.
  • Night sweats.
  • Poor absorption of vitamins and minerals, which can lead to secondary health issues.
  • Skin issues – puffy skin, pimples etc.
  • Stomach ache.
  • Vomiting.

The non-digestive symptoms are harder to pinpoint as being related to fructose but, with a detailed food and symptom diary, it can be done. For instance, it took me a while but I realised that a trigger for my sinus issues is eating wheat, which also causes me to get little pimples on my chin and hairline and night sweats. As my digestive symptoms after eating wheat weren’t too severe (mild bloating and discomfort), I was ignoring them and still occasionally eating wheat-based treats, which eventually led me to discover links between wheat and the other, apparently more random, symptoms.

Diagnosis

The current diagnostic tool for FM is the hydrogen/methane breath test. Breath test protocol is as follows:

  • No antibiotics, colonoscopies or barium enemas or probiotic supplements in the month leading up to the test. 5
  • Restricted carbohydrates and no laxatives or high fibre foods in the 24 hours before the test. 5,6
    • Your testing clinic will give you more specific instructions for the lead up to the test.
  • Fast completely for 12 hours before the test. 5
  • You will then take a baseline breath reading before drinking a fructose solution, which is typically 35 g fructose dissolved in 300 ml of water. 5 After this, you will record breaths every half hour for approximately three hours. 5,6

Results are generally sent to your referring health practitioner for interpretation, however FM is generally diagnosed with an increase of more than 20 ppm of hydrogen (or more than 10 ppm of methane) levels over your baseline reading twice in succession. 6

An elimination diet can also be undertaken, to discover which foods stir up symptoms; then you can work out what the common factor between all your trigger foods may be. The basic method of an elimination diet would be to cut out all foods that contain known gut irritants, such as FODMAPs, gluten and casein (etc) for a period of six to eight weeks (generally speaking) and then slowly introduce new foods (one per week) to see if you react. A nutritionist, dietitian, doctor or a naturopath would be best to help you structure an elimination diet specific for your situation – a food/symptom diary would also be very helpful.

Management

FM symptoms are managed primarily through a change in diet:

  • Limit free fructose intake to less than an excess of 100.5 g fructose for every 100 g of glucose.
  • Limit your total fructose load per meal, regardless of a higher glucose intake.
  • Limit your intake of FOS, eating less than 0.5 g per sitting.
  • Other FODMAPs might be causing you issues, an elimination diet or further breath testing may help you to discover which.

In addition to following a “fructose friendly” diet, the following methods might be employed for symptom management:

  • Glucose/dextrose might be useful as a supplement to even out the f:g ratio, though this only works for fructose and not FOS, and even then works best when the glucose is actually IN the food. Please note that this is generally used as an emergency action only and does not work for everyone. I would personally not sprinkle glucose on an apple and see if I could eat it.
  • Probiotics (tablets or lacto-fermented foods) can help to re-balance your gut microbiota, which should hypothetically improve your gut health and reduce your sensitivity to foods high in excess fructose/FOS. 7 It is not as easy as just popping a daily probiotic for some, though, as it depends on which bacterial strains you may be deficient in and whether you have a confounding disorder, such as SIBO, which would be exacerbated by taking probiotics.
  • Multivitamins can help to maintain your nutrients and thus your body’s ability to properly digest foods – carbohydrates, fats and proteins alike. This would mean that there are less substances in your colon that shouldn’t be there, so the chance of an irritation is reduced. Vitamins to concentrate on would include the B group, C and D, as well as zinc, calcium and magnesium. 8 Once again, this might not work for everyone and should be done with the help of a health practitioner.
  • Ginger can calm upset stomachs and is low FODMAP. 9
  • L-Glutamine is a supplement that supports intestinal health and may assist some people with absorption of nutrients. 7
  • A product like Buscopan or Beano may help to manage flare ups (I am not endorsing any of these or saying they are safe, just listing them as examples).
  • Xylose isomerase is an enzyme that catalyses fructose metabolism and has demonstrated an ability to assist with symptom control. 10
  • Water to maintain hydration.
  • Other methods, such as meditation and yoga for stress reduction and gentle physical activity to help reduce cramps.

Prognosis

As of the time of writing, there is no currently known or accepted method by which FM can be cured, symptom management is achieved through diet control. 10 There are instances where sensitivity can come and go over time – I experienced this once myself – however the FM remains, the IBS lying dormant.

There are subjective reports of people having found that, once they have been following a strict low FODMAP (and often gluten free) diet, they have been able to slowly re-introduce foods that they were previously unable to eat, though this takes time, often years – for example, I was able to introduce garlic and onion after 3 years. The hypothesis is that because the gut is not as distressed (inflammation etc), it is able to tolerate moderate loads of FODMAPs.

I have even heard of a very new procedure in Germany that claims to heal FM by correcting the autonomic nervous system’s control of digestion. The hypothesis is that the ANS insufficiently activates the GLUT-5 transport proteins that are responsible for fructose absorption, thus leading to free excess fructose remaining in the intestine and passing into the colon. By addressing this issue, the ANS is able to correctly pair instructions to the GLUT-5 transport proteins with fructose ingestion.11 However exciting this may sound, I was only able to find the one link and no peer reviewed, blinded trials have been published to date – so I would not say that this is a definite/reliable cure. Hopefully this will change in the future!

Hereditary Fructose Intolerance

Aetiology

HFI is an autosomal recessive disorder of the ALDOB gene, 17 characterised by a deficiency of the liver (and kidney/intestinal) enzyme, aldolase B, which is responsible for metabolising fructose and gluconeogenesis (generating glucose from non-carbohydrate substrates). 13

Other names for HFI include: ALDOB deficiency, aldolase B deficiency, fructose-1-phosphate aldolase deficiency, fructose intolerance or fructosaemia, to name a few. 17

In healthy subjects, the aldolase B catalyses the reversible cleavage of fructose-1-phosphate (F1P) into glyceraldehyde and dihydroxyacetone phosphate (DHAP); this is demonstrated in the image below. In those with HFI, this does not occur and the F1P accumulates in the liver to potentially toxic levels, leading to hyperphosphataemia, as well associated hypoglycaemia, due to the competitive inhibition of the phosphorylase enzyme by F1P, thus impairing glucose homeostasis. 13,14

liver-metabolism-fructose-aldolase-b-enzyme-hfi

Signs/Symptoms

Signs and symptoms of HFI are caused by the interruption to the metabolic pathway of F1P and include:

  • An aversion to sweet tasting foods,
  • Abdominal discomfort,
  • Bloating,
  • Coma,
  • Death,
  • Failure to thrive in infants,
  • Growth retardation,
  • Hypoglycaemia (low blood glucose),
  • Jaundice,
  • Kidney faliure,
  • Liver failure – hepatomegaly and/or cyrrhosis,
  • Nausea,
  • Renal tubular dysfunction,
  • Seizures,
  • Vomiting. 13,14,15,17

Diagnosis

There are (currently) two tests that can be used to determine if an individual has HFI, which are:

  • An enzymatic assay – an invasive liver biopsy is performed, after which the sample’s enzyme activity is assessed.
  • A fructose tolerance test – a fructose solution is injected into the circulatory system and glucose, fructose and phosphate levels are closely monitored. 16

A third test exists, which involves a blood draw and subsequent genetic screen for mutations of the aldolase B gene, three of which apparently account for more than 75% of HFI mutations in Europeans and Americans. However, this test is not considered diagnostic, as less than 5% of possible aldolase B mutations are known to researchers. This means that the genetic screen is used more as a guideline in aiding diagnosis, as a negative result does not automatically rule out HFI if the individual carries mutations that have not yet been discovered. 18

The hydrogen breath test used to diagnose FM will not diagnose HFI; however, it is possible that individuals with HFI may test positive to FM. 16

Treatment/Management

HFI is treated through management of your diet, including the elimination of sugars that are metabolised through the F1P pathway, including fructose, sucrose (a fructose-glucose disaccharide) and sorbitol, to less than 40 mg/kg of body weight/day. This fructose free diet should completely resolve most symptoms and result in a normal life span. 14 Unlike the fructose or FODMAP friendly diets, the use of glucose to “balance out” the fructose will not make a difference to those with HFI, as the problem is with how the fructose is processed once it’s inside the body, not with absorption.

Prognosis

Infants are most at risk of toxicity and liver failure due to undiagnosed HFI, which, for them, is potentially lethal. If an older child/adult complies with a fructose free diet, HFI symptoms should resolve and a normal life span is expected. If the HFI goes undiagnosed, or the patient continues to consume fructose in excess of 40 mg/kg body weight per day, then symptoms and comorbidities listed above will continue. 13

References

  1. Bray, GA (2007). How Bad is Fructose? http://ajcn.nutrition.org/content/86/4/895.full.pdf+html
  2. Bray, GA, Nielson SJ, Popkin, BM (2004). Consumption of HFCS in Beverages May Play a Role in the Epidemic of Obesity. http://ajcn.nutrition.org/content/79/4/537.full.pdf+html
  3. Bray, GA (2005). Adverse Effects of Dietary Fructosehttp://www.ncbi.nlm.nih.gov/pubmed/16366738
  4. Cummings, JH, Macfarlane, GT (1997). Role of intestinal bacteria in nutrient metabolismhttp://www.clinicalnutritionjournal.com/article/S0261-5614(97)80252-X/abstract
  5. GastrolabTV. Gastrolab – Hydrogen and Methane Breath Testing for Sugar Malabsorption Explainedhttp://www.gastrolab.com.au/patient-information/video-hydrogen-methane-breath-testing-explained.html
  6. Wilder-Smith, CH, Materna, A, Wermelinger, C, Schuler, J (2013). Fructose and lactose intolerance and malabsorption testing: the relationship with symptoms in functional gastrointestinal disordershttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3672687/pdf/apt0037-1074.pdf
  7. WebMD. 8 Digestive Health Supplementshttp://www.webmd.com/vitamins-and-supplements/lifestyle-guide-11/slideshow-digestive-health
  8. http://www.livestrong.com/article/371412-vitamins-that-aid-digestion/
  9. Not From A Packet Mix (2013). Chocolate and ginger root… No, don’t pull a facehttp://wp.me/p3g4oZ-BS
  10. Komericki P, Akkilic-Materna M, Strimitzer T, Weyermair K, Hammer HF, Aberer W. Oral xylose isomerase decreases breath hydrogen excretion and improves gastrointestinal symptoms in fructose malabsorption – a double-blind, placebo-controlled study. http://www.ncbi.nlm.nih.gov/pubmed/23002720
  11. Systematic elimination of fructose malabsorption within three days.https://docs.google.com/file/d/0BxIq6H_bnmx7eHZKaW0xS2NtQ3M/edit
  12. Ledochowski M, Widner B, Murr C, Sperner-Unterweger B, Fulchs D. Fructose Malabsorption is Associated with Decreased Plasma Tryptophanhttp://www.fructose.at/pdf/works/11336160.pdf
  13. Tolan Laboratory at Boston University. Aldolase. http://www.bu.edu/aldolase/lab/research.html#AldB
  14. HFI Laboratory at Boston University. Specifics of HFI and its Diagnosishttp://www.bu.edu/aldolase/HFI/hfiinfo/detail.html
  15. HFI Laboratory at Boston University. What is HFI? http://www.bu.edu/aldolase/HFI/hfiinfo/index.html
  16. HFI Laboratory at Boston University. How is HFI diagnosed? http://www.bu.edu/aldolase/HFI/diagnosis/index.html
  17. Genetics Home Reference. Hereditary Fructose Intolerance. http://ghr.nlm.nih.gov/condition/hereditary-fructose-intolerance
  18. HFI Laboratory at Boston University. Our HFI Genetic Test. http://www.bu.edu/aldolase/HFI/hfitest/hfitest.html

Travel Series - Managing Fructose Malabsorption/IBS while staying at a Resort

As the warm weather and summer holidays are just around the corner, I thought I’d write a post about managing resort-based holidays while following a FODMAP friendly diet.

Last summer, Ev and I, along with a few friends, flew down to Cabo San Lucas in Mexico for the 4th of July long weekend. It was pure bliss, even if we did get a little bored on the second last day (thanks for the rain, weather man!). We spent four days relaxing and exploring downtown Cabo, not having to worry about cash at the resort, as everything was included.

I was initially concerned about what I would eat but, given that corn and avocados (I’m okay with polyols) are staples in every Mexican restaurant I’ve ever been to, I thought it shouldn’t be too bad. Luckily, I was right.

The following will outline how to successfully manage a resort-based holiday with fructose malabsorption.

Step 1: Can the resort cater for your dietary requirements?

From the beginning, when you’re browsing websites, many will state specifically whether they can cater for certain diets and will ask you to list dietary requirements when you book your stay. If they don’t, you can always call or email and double check.

However, as FODMAPs and fructose malabsorption are still such unknowns, you might choose to contact the resort and ask anyway. If the resort cannot cater for you, it’s up to you to decide whether you will go and supply your own foods (if possible) or you will find somewhere else.

Step 2: Make some safe food flash cards

If you don’t speak the language, flash cards listing the ingredients you can and cannot consume in the language spoken at the resort will help prevent a lot of confusion.

In fact, even if you do speak the local language, flash cards might still be a good idea as the idea of fructose malabsorption is still so novel that the apparently random list of ingredients that you cannot consume might overwhelm the staff and create an unwanted fuss.

Make sure the lists are clear and concise as to what you can and absolutely cannot consume – perhaps even just handing them the “Can Eat” list might be easier.

Step 3: Plan ahead

If at all possible, pack an emergency food supply (for transit and when you’re out on the town exploring) and bring a stash of fructose-remedies, just in case. This won’t be possible everywhere you go, due to customs regulations and the like – it’s one extra point to research before you go.

Pack any dietary supplements and take them with you if customs regulations allow it. This may include:

  • A good probiotic.
  • A multivitamin.
  • Digestive enzymes.
  • Apple cider vinegar (apparently FODMAP friendly in 1-2 tbsp. servings).
  • bicarb soda etc.

Good emergency foods include:

  • Non-perishable foods, or at least foods that will keep well for a few days in warm weather in a freezer bag (so no yoghurts or cheeses).
  • Foods that won’t tax your gut too much, especially if you plan on being tempted by local delicacies that you haven’t tried before – give yourself the best chance for success.
  • A variety of foods for different meal times.
  • See Road Tripping with Fructose Malabsorption (step 3) for a complete list of foods that may be suitable.

Handy fructose remedies could be:

  • Paracetamol (acetaminophen in the USA) – ibuprofen is a known gastric irritant, so I personally don’t take it. I’m not recommending that you do take paracetamol but it’s my preferred method of choice for helping to ease intense cramps, which aren’t fun even when you’re not on holiday. At home I might try another method first (such as water or tea) but when I’m away from home I’ll go straight to the Panadol.
  • Dextrose – to help offset any excess fructose that you may have ingested, swallowing dextrose (glucose-glucose) ASAP will help to even out the glucose/fructose ratio and potentially prevent a reaction. This all depends on how much fructose you consumed, how much glucose you followed it with and your gut’s own behaviour.
  • Water and lots of it. Not only is it healthier for your gut and body to remain hydrated but if you have to take a tablet, it’s a lot easier to take it with water than dry. Water is also useful for washing things… and on that note,
  • Wet wipes/baby wipes, in case of an emergency cleaning situation.
  • Any other methods that you can take with you that is feasibly going to be useful in case of a reaction. Something along the lines of Buscopan or Beano might be suitable but I do not recommend relying on a product you haven’t tested before to stop a reaction unless you have no other choice.
    • Buscopan contains sucrose, so is listed as inappropriate for those with “fructose intolerance.” I am assuming that they mean HFI here (as we know sucrose is safe for FM) but use your discretion when deciding whether or not to try it – it might help some with IBS but it might not help at all or even worsen your symptoms.

Step 4: Make use of the staff (and the buffet)

At the Riu Santa Fe in Cabo, if worst came to worst, I could have lived off potatoes, avocado, eggs and corn chips. The buffet was amazing. Secrets Puerto Los Cabos was even better - at each restaurant they asked if anyone had any dietary requirements and the food was to die for. 

Using your flash cards (or a friend who happens to speak the language fluently), double check the ingredients with the staff for anything that could potentially hide some FODMAP bombs and decide what is safe for you. For example, the guacamole: is it just avocado, salt, olive oil and lemon juice or did they throw in some garlic, too?

Stay AWAY from the doughnuts at the breakfast bar, no matter how tempting they look – they’re just not worth it. The scrambled eggs and omelette will probably be seasoned and use normal milk (but it doesn't hurt to ask). Instead, I opted for a healthier breakfast of hard-boiled eggs, avocado slices, sauteed veggies (if safe/unseasoned), baked potatoes and plantains in maple syrup for the sweet note. Plantains are like a cross between a banana and a potato and have a low FODMAP serve (check the Monash app)! The juice bar luckily had fresh squeezed OJ, so I could drink a bit of one of the pre-poured glasses (do not over do it, or try it if you haven't since elimination). All the other juices looked phenomenal, including a really healthy (and delicious, according to Ev) green juice but of course it contained apple.

Step 5: Relax!

Research (and experience) shows that stress is a major trigger for many with IBS style symptoms. Do yourself a favour and take a break from the stress while you’re on holiday and it could go a long way towards reducing reactions. In fact, many people report that they are able to tolerate foods on vacation that they normally could not eat back home – though I’m not sure whether this is due to lack of stress or the quality of foods they’re eating, or maybe a combination of the two.

All the steps above, especially planning ahead (and not just for the eating side of things), will help you to relax while you’re actually away and make the most of your well-earnt break.

If you have any new suggestions for managing resort travel with dietary restrictions, please let me know in the comments section below.

Cheers and happy holidaying.

Travel Series - Road Tripping with Fructose Malabsorption/IBS

Road trips are possibly my favourite way to travel; you get to see so much more of the landscape than if you fly everywhere and I find that cities tend to look the same after a while. To be able to drive down the west coast of the USA and see lush greenery and snow-capped mountains turning first into farm land and then into a more arid landscape complete with mesas is pretty awesome. Also, California is full of eucalyptus trees, which reminds us of home and smell amazing, as well.

In my opinion, road trips are also the easiest type of holiday to take while on a low FODMAP diet, as you can really be in control of your food if you plan ahead and pack an Eski (cooler) with sufficient supplies.

I will outline below how I manage my meals on a road trip:

Step 1: Make an itinerary and food list

I am a list maker, so is my sister. It’s something we’ve always done, as we’re OCD control freaks who can’t bear to be disorganised. Plus, it’s fun. Luckily for me, Ev is the same… although he hates packing his own bag. But he’s not the one with FM, so that’s not such a big deal.

Being a list maker means that I like to plan each leg of the road trip with hours and distances and town names. This is good, as it will help you with step 2. Another way to make step 2 easier (well, the act of eating at the restaurants that you’ve researched) is to call ahead or go armed with a list of foods that you CAN EAT (make sure it’s labelled clearly, so you don’t get a plate of onions sauteed with apples on whole wheat toast) to make both your life and those of the wait staff and cooks much easier.

Step 2: Research local restaurants and eateries

Before you go out to dinner, you would find online menus or call the restaurant you’re thinking about going to and see if they can provide a meal for you; travelling is no different. The key to a relaxed holiday (and gut!) is planning. I know lots of people who like to wing it – I have never been one of them – but a “we’ll find something, don’t worry” attitude is more likely to lead you to either an irritated or hungry gut later on if you are following a FODMAP friendly diet.

Either before you leave home, or each day of your trip (if you have internet connectivity), scout out a few potential cafes, restaurants and supermarkets, and note their locations with regards to your itinerary. What town will you be driving through at lunch time? Does the town you plan to spend the night at have a restaurant or supermarket from which you can source meals?

Some tips:

  • To reiterate – PLAN AHEAD.
  • Restaurants that already cater to other dietary requirements (gluten free, vegan, nut free etc) will generally be more likely to be able to create a meal for you.
  • Fast food chains can still provide salads – just request no dressing or croutons etc – and hot chips/fries will do in a pinch, as long as they’re unseasoned and suited to other non-FODMAP issues you might have (i.e. if you have coeliac disease, they must be made in a dedicated GF fryer).
  • Choose simple meals that require minimal alterations to be suitable – it’s both ridiculous and rude to think a restaurant will be able to make you an onion free lasagne but to whip up a salad with a plain protein sans onion and dressing is much easier - and many restaurants make their salads when ordered, anyway.
  • Don’t forget about supermarkets, as you can always find gluten free breads/crackers, cheese and suitable veggies etc to fill your stomach.
  • Busier restaurants will find it harder to tailor a meal to you, so eat at quiet times, even if that does mean sitting down to dinner before 6 pm.

Breakfast – a safe omelette with potatoes and green capsicum.

Lunch - Eggs Benedict on polenta (that little bit of sauce is okay for me but you can order the hollandaise on the side if you haven't tested it yet/aren't sure), with potatoes seasoned with salt and pepper and garnished with the green tips of spring onions.

Dinner – a chicken salad sans croutons and dressing on the side.

Dessert - a GF chocolate chip cookie (luckily I don't have lactose intolerance).

Step 3: Pack emergency foods

If you’re driving down a deserted highway and you can’t find anywhere to eat, things can get ugly; this is true even if you don’t have a food intolerance. I tend to become very irritable when I’m hungry (more like a 6 year old than a 26 year old) and I’m sure I’m not pleasant to be around when I’m like that. In fact, even when we’re not road tripping, Ev will tell me to eat something if I’m beginning to get grumpy.

I think packing an emergency food supply is a good thing to do for road trips, regardless of FM. Things to consider when packing a food kit include:

  • A variety of foods for different meal times – I know I wouldn’t want a tin of tuna for breakfast but would be happy to eat it any time after lunch.
  • Non-perishable foods (or at least foods that will keep for a few days outside the fridge) are best.
  • Easily digestible foods that won’t tax your gut too much.
  • Pack the food in an Eski/cooler/freezer bag/car fridge (whatever you’d like to call it) to prevent any mishaps of food left in a car on a hot day. Besides going hungry if your food has gone off, it’s also a waste of money.

Examples of what I might pack:

  • FODMAP friendly veggies of your choice, such as carrot sticks, celery (if you can tolerate polyols), cucumber etc.
  • FODMAP friendly fruits, to a lesser extent, such as bananas and berries. These will need to be kept in a hard case, as they’ll bruise easily while travelling.
  • Muffins, as sometimes a piece of fruit or a carrot stick just isn’t enough. Some good options include my banana nut or pumpkin and chive muffins.
  • Pre-packaged snacks, such as corn chips, rice cakes or gluten free pretzels.
  • Suitable GF or sourdough bread and sandwich fillings, such as ham, cheese, lettuce and tomato, or even just jam and Vegemite (though never together!).

Step 4: Be prepared for the worst

Even the most diligent planning can’t prevent a slip up here or there. A waiter might not take your request seriously, or simply misunderstand you; or you might sneak a food in and hope that your FM has gone on holiday elsewhere. Go prepared with a kit containing methods you know will help to alleviate your symptoms.

My FM-emergency kit would include some or all of the following but yours may be different:

  • Paracetamol (acetaminophen in the USA) – ibuprofen is a known gastric irritant, so I personally don’t take it. I’m not recommending that you do take paracetamol but it’s my preferred method of choice for helping to ease intense cramps, which aren’t fun even when you’re not on holiday. At home I might try another method first (such as water or tea) but when I’m away from home I’ll go straight to the Panadol.
  • Dextrose – to help offset any excess fructose that you may have ingested, swallowing dextrose (glucose-glucose) ASAP will help to even out the glucose/fructose ratio and potentially prevent a reaction. This all depends on how much fructose you consumed, how much glucose you followed it with and your gut’s own behaviour.
  • Any supplements that you take, so for me this would include my probiotic and multivitamin. For you it may include digestive enzymes, ACV, bicarb soda etc.
  • Any other methods that you can take with you that is feasibly going to be useful in case of a reaction. For example, I will often drink tea with ginger, lemon and mint to help settle my gut but am I always going to have access to a kettle? Something along the lines of Buscopan or Beano would be more suitable for a road trip but I do not recommend relying on a product you haven’t tested before to stop a reaction unless you have no other choice. Buscopan (etc) might help some with IBS but it might not help at all or even worsen your symptoms.
  • Water and lots of it. Not only is it healthier for your gut and body to remain hydrated but if you have to take a tablet, it’s a lot easier to take it with water than dry. You could crush up some ginger, mint leaves and lemon slices and leave them sitting in your water bottle (remember to change them daily) to infuse the water and help keep your gut happy. Water is also useful for washing things… and on that note,
  • Wet wipes/baby wipes, in case of an emergency cleaning situation.

This sounds like a lot and if it overwhelms you, I’m sorry. Just please remember that you can still enjoy a road trip while on the low FODMAP diet with some extra planning; just like road tripping with kids or dogs… but we still do that!

If you have any other tips that I have forgotten, please let me know in the comments section below. Happy road tripping!