Understanding FODMAPs
Last month I traveled to Washington, DC for the Digestive Health Alliance Advocacy Day, as well as the UNC Patient Symposium on Functional Gastrointestinal Disorders. Separately each of these events was worth the trip, but the together they made for an especially informative and empowering three days.
The first day of the Symposium consisted of a series of short lectures and Q&As sessions covering a wide range of Functional GI Disorders, including gastroparesis. (Recap on that coming soon!)
On the second day, participants were able to choose two two-hour workshops to attend. My first workshop was with Kate Scarlata, RD and FODMAP expert. I'm a big fan of Kate and her work, so it was great to finally meet her in person and to fine-tune my own understanding of the low-FODMAP diet.
My second workshop was about clinical hypnosis and its benefits for GI disorders like gastroparesis. Read more about that here.
Briefly, FODMAPs are highly fermentable carbohydrates that are often poorly digested and absorbed, particularly by those with functional gastrointestinal disorders. In Kate's terms, "FODMAPs are fast food for gut bacteria." For those of us who have an imbalance of bacteria in our gut, have bacteria growing in the wrong places (SIBO), or have an increased sensitivity to sensations in the gut (visceral hypersensitivity), feeding those bacteria causes gas, bloating, pain, and bowel disturbances.
Eliminating high-FODMAP foods, including wheat, most dairy products, certain sweeteners, sugar substitutes, and specific fruits and veggies, often helps to alleviate the symptoms mentioned above. While the diet has only been studied for IBS, I've found personally and in my coaching programs that it seems to be quite effective for many people with gastroparesis, as well. And it's no wonder, really. The typical "gastroparesis-friendly" diet (not the kind I recommend) is based mostly on high-FODMAP foods: bread, cereal, cookies, crackers, yogurt, ice cream, applesauce, canned pears and peaches, and ginger ale, as well as things like canned/boxed chicken broth and soups.
While I can't rehash Kate's entire talk, one thing that I did want to highlight is that the low-FODMAP diet is meant to be a short-term elimination diet followed by a series of reintroduction challenges. I think there are many of us with gastroparesis (including me!) who simply removed high-FODMAP foods from our GP-friendly diets and stopped there, never moving on to the reintroduction phase of the program.
There are several reasons why following a low-FODMAP diet indefinitely could be problematic in the context of gastroparesis. First, it further limits the variety in the diet. This can make it more difficult (and more stressful) to figure out what to eat, especially away from home. Restricting variety also further restricts nutrition, something that those with gastroparesis cannot afford to do. Many high-FODMAP foods, particularly the fruits and veggies, have nutrients that we may not get from other sources. What's more, higher-FODMAP whole foods may help to properly balance our gut bacteria, which plays a vital role in everything from our mood to our immune system (not to mention our digestion).
When followed properly, the elimination phase of the diet removes all high-FODMAP foods for 2-8 weeks. Once symptoms have improved, a specific food from each FODMAP group is re-introduced one at a time to determine whether or not there is a reaction. Those FODMAP groups that do not provoke symptoms can be added back into the diet, while those that do will continue to be off-limits for the time being. The length of the re-introduction phase, which is best supervised by an educated nutrition professional, will vary depending on how many groups of FODMAPs a person reacts to. It's necessary to be symptom-free for 3 days before trying the next group.
Of course, the idea of being "symptom-free" is a little tricky for many people with GP. Whereas the low-FODMAP diet often significantly and very noticeably reduces symptoms for those with IBS, the effect on those with gastroparesis may less easy to tease apart from the general ebb and flow of GP symptoms. My guess is that's part of the reason why people tend to stay "low-FODMAP." I think the key is being really purposeful about eliminating FODMAPs in the first place and paying close attention to any changes you may notice in the weeks after, primarily as they relate to pain, gas, bloating, and bowel habits.
I also think it's important to implement the low-FODMAP diet, or any other dietary protocol, in the context of gastroparesis. That usually means avoiding raw veggies, whole nuts and seeds, excessive amount of fat, and too much total fiber. Just as important, in my view, is to implement the diet as part of a comprehensive management plan. I'm not convinced that any diet, or drug for that matter, is likely to significantly reduce symptoms and improve quality of life without supportive lifestyle practices, stress reduction, and possibly complementary therapies
Lastly, I'd make a few tweaks to the low-FODMAP recommendations just based on my slant toward an ancestral way of eating. For example, I believe that a lot of us with gastroparesis would do better without as many grains, especially processed ones. While I think many people might benefit from eliminating gluten, I'm not a big fan of gluten-free products, such as bread, crackers, cereals, and cookies. I also think that most dairy products, even those that are lactose-free and especially those that are not organic, are best avoided. While it may fly in the face of everything you've been told, I've found that many people with gastroparesis do better with whole foods, carefully chosen and prepared with gastroparesis (and FODMAPs!) in mind.
My own diet follows these general guidelines and I've noticed a definite improvement over the past year or so, even in the context of my well-established comprehensive wellness plan. (More to come about that in the future.) In the meantime, if you're struggling with constipation, diarrhea, pain, bloating, and/or gas in addition to gastroparesis symptoms, I highly recommend trying a combo of a nutrient-rich GP-friendly diet and the low-FODMAP approach.
As I mentioned above, it really is best to approach this kind of elimination/reintroduction diet with a qualified practitioner. There are many nuances to a low-FODMAP diet, which are easy to overlook or misunderstand. Here is a list of FODMAP-knowledgeable dietitians. These dietitians may not have experience with gastroparesis, of course, so continue to be your own advocate and proceed carefully to determine what works best for you.
Check out an audio Q&A I did with Kate here and visit her website for more information: www.KateScarlata.com.