Modifying Paleo for FODMAP-Intolerance (a.k.a. Fructose Malabsorption)

August 7, 2012 in Categories: , by

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One of the many challenges that people face when adopting a paleo diet is dealing with the confounding factor of additional food sensitivities.  Sometimes these sensitivities are known (perhaps you had allergy testing done at some point or react so violently to certain foods that it was a no-brainer).  Sometimes these sensitivities are unknown and make it frustrating when we don’t experience the instant improvements to our health touted by so many paleo enthusiasts.  One such sensitivity is FODMAP-intolerance (also referred to as fructose malabsorption).  This isn’t a food sensitivity in the sense that there is any sort of immune reaction to these foods.  Instead, it is a case of a person who cannot properly digest the fructose (and longer sugar molecules containing fructose) in these foods.

The term FODMAP is an acronym, derived from “Fermentable, Oligo-, Di-, Mono-saccharides and Polyols”.  FODMAPs are short chain carbohydrates rich in fructose molecules which, even in healthy people are inefficiently absorbed in the small intestine.  I know you’ve heard the limerick “beans, beans, the magical fruit…”; the punchline refers to the large amount of FODMAP carbohydrates in beans (or any of other vegetable that has a reputation for being “gassy”) that are only partially absorbed in the small intestine.  When this excess fructose enters the large intestine, which is full of those wonderful beneficial bacteria we love so much, they feed the bacteria allowing for overgrowth of bacteria and excess production of gas.  The presence of FODMAPs in the large intestine can also decrease water absorption (one of the main jobs of the large intestine).  This causes a variety of digestive symptoms, most typically: bloating, gas, cramps, diarrhea, constipation, indigestion and sometimes excessive belching.  In individuals with FODMAP-intolerance, a far greater portion of these sugars enter the large intestine unabsorbed, causing exaggerated symptoms.  In fact, some researchers believe that Irritable Bowel Syndrome is purely a case of FODMAP-intolerance 1,2.

Carbohydrates, which are just chains of sugar molecules, are broken down into individual monosaccharides (a single sugar molecule) by digestive enzymes in the small intestine (actually, this sugar digestion process begins with the salivary amylase enzyme in the mouth when you chew, but it continues all the way through the small intestine).  Monosaccharides are then absorbed into the blood stream by first being transported through the cells that line the small intestine, the enterocytes.  Enterocytes have specialized transporters, or carriers, embedded into the membrane that faces the inside of the gut.  These carriers bind to specific sugar molecules and transport them into the cell (where the cell can either use those sugars for energy or transport those sugars to the other side of the cell where they can easily enter the blood stream).  FODMAP-intolerance may be due to lack of digestive enzymes required to break longer chains of carbohydrates down to their individual monosaccharides and/or due to an insufficient amount of these carbohydrate carriers, specifically the carrier called GLUT5, which is the specific carbohydrate carrier for fructose (why this is also called fructose malabsorption). 

FODMAP-intolerance means that large amounts of dietary fructose and longer carbohydrate chains that are rich in fructose are problematic.  These longer, fructose-rich carbohydrate chains are called fructans (inulin, which is a type of fiber, is also rich in fructose and problematic for those with FODMAP-intolerance).  Sugar alcohols, called polyols, (sorbitol is an example) are additionally problematic because these sugars have the ability to block GLUT5 carriers (and if you’re working with a deficiency, that’s really not helpful!).  Why do some people develop FODMAP-intolerance?  Researches don’t know yet.  It may be a reaction of the body to high fructose and fructan consumption with the Standard American Diet.  It may be a side effect of a very distressed and/or leaky gut.  There are also very likely to be genetic factors at play.  The good news is that, for many, as their gut and bodies heal, their ability to digest and absorb these sugars improves.

When it comes to modifying your diet to address a suspected FODMAP-intolerance, dose is the key.  The type of FODMAP may be important for some people.  Some people are more sensitive to the fructose and polyols (due to GLUT5 carrier deficiency) while some are more sensitive to fructans (due to digestive enzyme deficiency).  Some people are sensitive to both.  How much you can handle is very individual and is likely to change as your gut heals.  There are medical tests available to diagnose fructose malabsorption, however an elimination diet approach is more reliable.  Research has shown that the removal of FODMAPs from the diet is beneficial for sufferers of irritable bowel syndrome and other functional gut disorders 1.  

The following table was created by Aglaée the Paleo Dietitian, and is posted with her permission.  It breaks down common foods into three categories:  safe (very low to no FODMAP), be careful (low to moderate FODMAP), and avoid (high FODMAP).  It also contains which kind of FODMAP is richly present in each food in parentheses (helpful for those who are more sensitive to one versus the other). (Aglaée told me that this table is likely to be updated in the near future.  I will repost the edited version when it becomes available.  You can see the original table here: http://www.eat-real-food-paleodietitian.com/support-files/paleo-fodmap-food-list.pdf)  

 As you can see from this table, many of the moderate to high FODMAP foods are foods that we typically increase consumption of when adopting a paleo diet.  How frustrating for those who experience an increase in gastrointestinal symptoms when they adopt a paleo diet compared to so many who find instant alleviation of symptoms!  If you suspect (or know you have) FODMAP-intolerance, I recommend eliminating all food sources of FODMAPs from your diet for a couple of weeks.  If you are sensitive, you should notice a fairly dramatic effect on your digestive symptoms.  You can try reintroducing some of the lower FODMAP fruits and veggies and see if your symptoms return.  In many cases, following a gut-healing protocol (as outlined in this post, this post or in the book Practical Paleo) will improve digestion of FODMAPs and they can be reintroduced carefully but successfully. 

It is very important to note that the symptoms of FODMAP-intolerance are virtually identical to the symptoms of Small Intestinal Bacterial Overgrowth (SIBO).  The reason for this is that these two conditions are highly related.  The difference is simply a matter of location, larger versus small intestine.  Without testing it can be difficult to discern which of these paleo diet modifications to try first (for more information on SIBO, read this post and this post).  Even more confusing, FODMAP-intolerance may or may not be linked to Small Intestinal Bacterial Overgrowth.  In some cases, the unabsorbed sugars caused by FODMAP-intolerance will lead to an environment in the small intestine where bacteria will grow, thus causing SIBO.  So, you may have SIBO without FODMAP-intolerance, you may have FODMAP-intolerance without SIBO, or you may also have both.  If you have digestive symptoms and are unsure which condition is the problem, then, I’m sorry to say that you’ll need to either have some tests done or follow the diet restrictions for both.  After a period of a couple of weeks, you can try adding in either the starchy vegetables eliminated in the modification for SIBO or some of the FODMAP fruits and veggies (choose whichever food you miss the most).  It should be clear fairly quickly which foods are problematic.  Also note that both of these conditions are likely to resolve completely with continued elimination of these foods (although in some cases this will take 6-12 months or even longer), so you may find that you can add everything back in and your symptoms don’t return (fingers crossed!)

1 Gibson PR and Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010. 25(2):252-8.

2 Born P Carbohydrate malabsorption in patients with non-specific abdominal complaints World Journal of Gastroenterology, 2007, 13(43): 5687-5691

Comments

I read your post with interest because a friend was just mentioning her 2 1/2 year old twins probably have FODMAP issues. I’m a bit confused though – if the problem is fructose (as opposed to fructans) then what should people do about the fruits on the ‘safe’ list in the table? I’m very new to all this and still trying to wrap my head around it all… [I don’t have FODMAP intolerance, but I’m trying to break a VERY strong fructose addiction and am very sensitive to it so I know that nuts, all fruits, some veg (eg beets, sweet potato, tomato) and coconut products (apart from the oil) are a no-go for me. Just wondering why some of those things would be ok for someone who is fructose intolerant?

The fruits on the safe list are fruits that are either quite low in overall sugar (so you’d have to eat tons of them to have a big dose of fructose) or fruits that are much higher in glucose than fructose. With FODMAP-intolerance, a low dose of fructose is usually okay because a little can be absorbed. There are likely some people who are so sensitive that they can’t even handle these fruits, however.

Hi! I am 10 weeks pregnant and it has come up that I am deficient in the amino acid Tryptophan, and that is the reason for my constant nausea. My dr. suggested a supplement and said that it should help with the nausea but it hasn’t yet. Then, a friend told me she read in The Paleo Approach book that there is a link between FODMAPS and tryptophan absorption. It makes total sense because I’m even sicker on days where I eat apples and other fruit on the no list for FODMAPS. I can easily cut those fruits and other things out but here’s my concern: I’ve not been good AT ALL about eating paleo since I’ve become pregnant. I’ve been very food adverse and NOTHING sounds good except PB&J, and other things that have bread and junk I know I shouldn’t be eating. I’m wondering how those things are affecting the tryptophan absorption. Any ideas?

They could be. More importantly, they aren’t very nutrient-dense foods, so you’re probably not getting enough of a lot of things. The good news is that aversions are really normal this early and your body should have nutrient stores to burn though and it should be a whole lot easier to stick to paleo once you hit the second trimester. In the meantime, you can try things like spinach or bananas by themselves which can help. But, even better would be to try and get some organ meat (maybe hide it in a smoothie or something? or do the frozen liver pill thing?) or seafood into you if you can stomach it.

Great, great job! I was waiting for someone to write about this with clarity for a long time. By the way, I just found this website about chemical food intolerances called the “The Failsafe Diet Explained” (http://failsafediet.wordpress.com/). I find it interesting because people in the paleo community don’t seem to talk about this.

Did you konw about this? What do you think?

Thanks! Chemical intolerance is very much on my radar (maybe because my brother is allergic to chlorine and chloramine). I’m actually working on a post about salicylate sensitivity. :) and I will be expanding on issues with NSAIDS in an autoimmune protocol post. I’m trying to systematically write about as many extra issues that people may face that a regular paleo diet might not help as I can. :)

Great! I look forward to read that. I’m interested because the Paleo diet hasn’t addressed some of my issues so I’m looking for other things that might be important for my healing process.

This was really enlightening. And depressing. I have days when I experience painful bloating and gas. And there’s plenty on the avoid side of that chart that I do consume, some occasionally and some almost daily. Sigh….

I am very interested in the Paleo diet. I am gluten sensitive and have been trying to stay away from any foods that are not going to bring nourishment to my body. I was wondering why the Paleo diet doesn’t include legumes?

Legumes are rich in lectins, saponins and phytic acid (saponins probably being the biggest problem in legumes). I’ve addressed lectins and saponins in these posts:

http://www.thepaleomom.com/2012/03/how-do-grains-legumes-and-dairy-cause.html

http://www.thepaleomom.com/2012/03/how-do-grains-legumes-and-dairy-cause_29.html

Phytic acid binds to minerals in your food and makes them more difficult to absorb. I will hopefully have a post going into more detail about phytic acid sometime this fall.

However, many people do tolerate occasional consumption of legumes (not peanuts), especially when traditionally prepared (typically sprouted and fermented), which reduces the amount of lectins and saponins. I typically suggest trying some time without (3-4 weeks) then reintroducing and seeing how you feel.

Thanks for sharing this. I was just wondering if I had an increase in bloating and gas from cherries. Now I know I’m not crazy!

Is that probiotics on the avoid side? I thought probiotics were safe! Sigh… I think I might have some of this because I notice a negative gut reaction when I eat fruits (my tummy starts to rumble) and I get very bloated with sugar. And, if I eat a lot of sugar, even from fruit like watermelon, my body starts to give off a smell like when you’ve had too much alcohol. This whole what to eat/what to avoid gets demoralizing sometimes.

It’s more that probiotic supplements are often packaged with FODMAPs (like lactose) to help them survive the transit. This is highly dependent on the manufacturer, so just check out the ingredients list. Food sources of probiotics are still good (kombucha, fermented veggies, water kefir and even coconut milk kefir for some people). Well fermented veggies like sauerkraut are tolerated by man people who get symptoms from eating cabbage because all those good bacteria digest the FODMAPs for you before you eat it.

I’m the same with sugar. Doesn’t seem to be FODMAP for me so much as SIBO. But, I get very bloated when I eat too much sugar. It’s frustrating!

ok, this might be a dumb question, but what do the x’s mean? good or bad? little confused. But thank you for the great info!

Thank you for this great post! I’ve been operating under the assumption that I had SIBO, but I didn’t realize the symptoms were similar to FODMAP symptoms. I haven’t found any relief following protocol for SIBO, so I think I’ll give this a try. The chart you posted is very helpful!

Thanks so much for this post! I’ve come to the same conclusion after self-experimenting with the advice given in the old Dr. Atkins book. One day I looked up and realized I had ended up on a Paleo diet! Most people think I’m crazy for limiting my sugar as much as I do – because lots of fruit’s supposed to be GOOD for you! – but my body tells me time and again that it doesn’t like it. Now I have a name for it: Fructose malabsorption. Yup, sounds about right!

Now, I am in a dilemma, and I hope you can help me. I just got braces! Ouch. And I would love to make some protein-rich smoothies and blended soups but don’t know where to start. I want to avoid sugar as much as possible – not only because my body is better of without it, but also because sugar feeds bacteria and you really have to watch that with braces.

Any tips or ideas? I’d like to stay with real food (and preferably low-carb). I eat lots of kale already so I plan to blend that with my brand-new immersion blender and my homemade bone broth. Where I’m getting stumped is with the protein part. Creamed chicken? Creamed beef? Sounds so weird, but I’m hesitant to turn to protein powders.

Also, any tips for low-sugar (protein containing) fruit smoothies? How do people get their protein in fruit smoothies?

Sorry this post is so long! I really like how you delve into subjects and really try to understand and inform. Thanks in advance!!!

Maria

The stereotypical paleo protein powder is egg white protein powder (some people also use grass-fed whey protein, which you can get from Tropicial Traditions http://secure.ttpurchase.com/DAA28EEE-1E0B-90B3-0E8A77E197EA34C8 ).

What I do for my husband is to make shakes with whole raw eggs. I typically add 3 eggs for protein, half an avocado or some coconut milk for fat, green juice or orange juice or more coconut milk for liquid, and banana, mango or berries for sweetness. Sometimes I add spinach too. I’ve been thinking about trying them with bone broth for liquid because that would also add some good protein, but I’m not sure he’s game. :) Banana and avocado are an awesome combination as are mango and coconut milk. You could adjust the fruit to your needs (or even just go for a sweeter vegetable juice like carrot or beet). I hope this helps!

I seem to have a problem with Coconut Oil. Could this have something to do with Fodmap intolerance? I saw that on the chart it’s listed as safe. Or could it be perhaps that I just need to use a tiny bit to get used to it and build my body to get used to it?

I also am sensitive to coconut oil when I use it for cooking (tried it in my hot tea and it was like I’d poured in a laxative!). I take a capsule of virgin coconut oil from GNC and have had no problems, but would love to cook with it. I read on Mark’s Daily Apple that people who have this reaction have a gut that isn’t healed for other reasons (diet, etc). I plan to try this FODMAP plan and hope things improve enough overall that I can reintroduce coconut oil into my family’s diet.

This seems to be a common reaction (my husband has the same thing if he eats something with alot of coconut oil in it, although he’s okay with some). There’s also the possibility of an actual allergy to coconut, but I think an incompletely healed gut is a more likely possibility.

I too have issues with Coconut Oil. I began taking spoonfuls of it as I read it is anti-fungal (my naturopath diagnosed me with Candida) but after several weeks I began noticing extreme racing heartrates. I didn’t make the connection till I asked my naturopath about it and he told me Coconut oil changes your absorption of calcium (can’t remember if he said it increases it or decreases it, I’d have to ask him again) He said stop Coconut oil immediately but it took several weeks for the extreme heart racing to go away. I won’t ever use it again, and I’m even leery of making my own coconut milk, which I’d love to do since it’s so economical and I want to cut out using commercial soy milks. Guess it’s just almond milk for me!

I have very severe fructose malabsorbtion and have been trying to go paleo for the past year, thanks so much for this! From my research and experiences tomatoes are an absolute no-no, same with iceberg lettuce, eggplant and ginger. Strawberries and bell peppers are closer to “Be careful”. Papaya has more fructose than glucose too. thanks for this post :)

I have had indigestion all my life. Eating was a minefield. Finally, thyroid issues were discovered. Addressing that alleviated some of those symptoms. But there were more. Not too long ago I gave up gluten and dairy. While I don’t adhere to the Paleo diet, I do restrict grains. That initially helped a lot, especially with my arthritis. But recently the old gassy, bloating symptoms have returned. Eliminating FODMAP foods seems like a very logical direction to go, but at this point I am just tired. I’ve been taking proton pump inhibitors way too long, but when I try to stop, the pain is excruciating. I vacillate between the joy of discovering and addressing intolerances and the despair that my gut will just never get well.

Sounds really tough! I’m sorry you are so discouraged. As someone following a very restricted diet, I totally understand the mixed emotions.

Is there a way to slowly wean off the PPIs? Of all the paleo books out there, Practical Paleo has the most thorough protocol for healing the gut and digestive support (including supplements you can take to help get your gut healed which should help get off the PPIs). I hope this helps!

http://www.amazon.com/gp/product/1936608758/ref=as_li_tf_tl?ie=UTF8&camp=1789&creative=9325&creativeASIN=1936608758&linkCode=as2&tag=wwwthepaleomo-20

Thanks for such a wonderful post! I am just beginning the AIP from Practical Paleo. I didn’t eliminate FODMAPs right away because I was hoping I would do ok. Well, I made the AI friendly banana pucks and macaroons and I’ve been in trouble for two days now. I’m feeling a bit confused because there are many FODMAPs I can tolerate just fine, but a few from different categories that I react to and then there are the leafy greens which are not FODMAPs, yet they go right through me. How can I tell if it’s a stomach acid issue or fodmap issue? Thanks!

The issue with the leafy greens is insoluble fiber, which is a little different than FODMAP sensitivity. If they go right through you, I would definitely avoid eating them! You will probably digest them better after your gut has healed and you have better types/amounts/location of gut microorganisms.

As for reciting to some FODMAPs and not others, you might be differently sensitive to different types of FOMDAPS. I’m pretty good with fructose and polyols, but not so good with inulin fiber. But if I eat a lot of fuctose, then bad things happen too. This would make it harder to figure out which foods are okay for you and which aren’t because many of them will have different amounts of the different types of FODMAPs. And then add insoluble fiber to the mix, which then makes it even more complicated since many sources of FODMAPS also have some insoluble fiber. The only thing you can really do is systematically go through the diffrerent fruits and vegetables and keep notes on which ones agree with you and which ones don’t.

Also, many people with autoimmune disease are very sensitive to sugar. So that might actually be the issue with the banana pucks and the macaroons.

I’m sorry there isn’t an easier answer here. It can take a while to figure out where your individual tolerance is.

Thank you for your thoughtful reply. I do have hope that I am at least on the right path. Thank you for your insights. I have endometriosis and PCOS which being primal has done wonders for. But yes, it’s time to take it a step further with the AIP. I’ve lost most of the weight I need to and have the last 10 to go of course. That beloved set point/plateau. I can’t thank you enough for your posts. I’ve learned so much. And I keep meaning to comment regarding your podcast, so I’ll do it here. Science with Sarah is always my highlight. Blessings upon you and your family.

Hi Sarah, I’m easing into reducing FODMAPS in my diet. The first thing I did was fill up a big spice jar of asafoetida at my co-op. I noticed one blog mentioned that asafoetida contained gluten. I googled it and have found that come up again on other sites. I contacted my co-op. They should be able to tell me if it’s glutened. I’m wondering if this is why I’ve been having pain in my solar plexus area. It could very well be stress. Just thought it would be important that everyone knows that asafoetida can be glutened.

Hi. Great read. Very concise and easily explained. I was just wondering how up to date your list was as other sources put kale on the avoid list as it is related to cabbage, broccoli and the other cruciferous vegetables. I know they are constantly researching foods and sometimes they do move around on the list. Thanks.

Ditto that this list seems very helpful and that I’ve been finding lots of contradictory information out there on what’s safe at moderate levels and what should be entirely avoided during elimination phase for FODMAP. I see that the post date of this chart was August 2012. Has “PaleoMom” received the updated version from Aglaée?

I read your FODMAPS reminder on FB and applied it yesterday. A 7 day bout of nausea and loose digestion is ALL GONE in 24 hours. 7 months on AIP and I thought I knew it all. ;-)

Dear Sarah
You are amazing! I have been researching Candida, Leaky Gut, Autoimmune Diseases, Hashimotos, etc forever and your information is by far the BEST of the BEST! Thank you for all of your hard work and dedication to this cause. I await your new book, but cannot pre-order as I need the Kindle version, I live in Turkey and sending anything here for the states is painful. Will it come out in a Kindle version?

This blog was perfect for me. I have been eating for Candida elimination for the last 6 months and decided to start to add back some fruit since it is season now. I was shocked to become so sick from a few cherries. I had no idea that fruit was a problem for me. Then a week later I tried 1/4 of a green apple – not good! We have nice ripe bananas in our garden and I tried a small one – that didn’t seem to effect me- glad to have the list now to double check before I end of spending the night on the toilet instead of in my bed sleeping!!!

You are a life saver! Please keep of the GREAT work!
I wish you perfect health and prosperity .

HI! Thanks for the info. I am here because I ate a good amt of garlic they other night and thought I was dying! Bad pain, nasusea bloat gas and constipation. I started doing Whole30 in March, it helped my gut dramatically, and now follow Paleo since then. I still get the bloat and gas sometimes however still, tho much better then when I was on the “all american diet”. Anyway the pain the other night has me researching and I wonder if I have a sensitivity to fructans. I seem to be able to process avocado fine and most other foods that fall under the “polyol”. Should I cut out ALL Fodmaps then add back in the polyol’s gradually? Or just cut out the fructans? If I have a problem digesting them should I take a probiotic as well? I currently do not. I need a nondairy probiotic….
Thanks for all the info!

By far, far, far the highest fructan foods are from the allium family (onions, leeks, garlic). I would suggest just avoiding those for now but keep the other FODMAPs in mind if you notice any other symptoms. Oh, and the green part of alliums are okay, so you could buy green garlic (looks like a leek) and just use the green part, or use chives, or the greens of green onions, etc.

My favorite probiotic is Prescript-Assist: http://www.amazon.com/gp/product/B0049NRWHS?ie=UTF8&camp=1789&creativeASIN=B0049NRWHS&linkCode=xm2&tag=wwwthepaleomo-20

You said, “Some people are more sensitive to the fructose and polyols (due to GLUT5 carrier deficiency) while some are more sensitive to fructans (due to digestive enzyme deficiency). Some people are sensitive to both.”

I can eat polyols on a rotational basis. I have a lot of trouble with fructans and am wondering if there is a particular enzyme that is best to help digest them? Thanks!

Great article! Love all of your stuff!

I remember you suggesting these enzymes but didn’t realize you had previously had FODMAP sensitivity yourself, that’s helpful to hear! What FODMAPS were your most sensitive and how long did you remove them? Or did you go straight to the enzyme supplement? I’ve always been jealous of the beautiful plates of veggies you post when you take a pic of your meals, OH how i’d love to be able to do that again! Thanks for all your work/research/posts!

Thank you for answering about the palm shortening! I wanted to try out the paleo low fodmap diet. I printed out the food list. But I keep wondering if I should add in the SIBO recommendations as well and just do a great big elimination diet all at once. Is there a chart for that? Does it take out all carbs? I feel that I need some carbs. (I eat white rice, popcorn, and fruits and vegetables and tiny amounts of maple syrup or honey for my carbs.) I was going to cut out the honey, and popcorn. I have bloating that I cannot totally figure out. I have done lots of things with my doctor (antibiotics, h pylori protocol, many probiotics, l glutamine, aloe, etc.) and now wanted to try working on my diet more. I already eat a good amount of vegetables, healthy fats, and proteins, and am gluten and dairy free. I never really eat out or eat unhealthy oils or sugar. I have been diagnosed with pcos and other health issues (but really think the root may have been mercury issues, and I have already worked on that, and am doing much better.)

The SIBO recommendations aren’t validated by the scientific literature, so I would recommend starting out with FODMAPs (which are well studied). But I do think it’s a good idea to cut out rice and popcorn and try to stick with starchy vegetables and some fruit for your carbs (much more nutrient dense).

Okay, brain freeze. I’m on the AIP but am also pretty sure this might be an issue for me too. That doesn’t leave a whole lot of vegetation left to eat – especially at this time of year in the UK.

Hi Sarah! Does the way in which veggies/fruits are cooked/prepared change the sugar content and thus effect the way we react to it from a FODMAPS/SIBO point of view? Just wondering because I bloat up more readily eating roast starchy veggies such as sweet potato than the same veggies in say a blended soup.

Hi Sarah, I am thinking of starting the Paleo diet for an auto-immune condition. It all seems very overwhelming, but promising. Do you know of any person or organizations that I could contact that would be able to assist me in setting up an acceptable food list and just give me direction? Thanks so much for all your hard work! Your website is incredible!

I’m launching a consulting company next month. In the meantime, I would suggest contacting Mickey Trescott of autoimmune-paleo.com who is a certified nutritional therapy consultant. My book will also have complete food lists (and will be out just two weeks from tomorrow). You could also try the facebook group The Paleo Approach Community.

I had always thought my severe FODMAP was from potential SIBO…but…it would appear then that they can be separate entities? So perhaps why my repeated (four times) tx of perceived SIBO with strong antibiotics, has not eliminated my severe FODMAP intolerance? Hmmmm….I had “thought” adding back onions and garlic had been ok, but repeated consumption = not good at all. Cabbage is an absolute no go…as is any vinegar and any squash (even spaghetti squash). carrots, zucchini, and spinach remain my safe zone…still unsure about nightshades and inflammation in my neck. Hmmm….

What is the problem exactly with nuts?? It’s just that in the regular FODMAP diet it only says that you have to avoid pistachios, but the other nuts are ok. I usually have 20 or 30 grames of nuts every day, is this too much? Thank you

From my understanding, FODMAP diet says more than just avoiding pistachios. It also says to avoid cashews all together and to greatly limit all other nut intake (think general guideline is no more than ~2 tablespoons in a sitting).

Is soy lecithin isolated free of phithostrogen and allergens tha would be safe for people with leaky gut . I feel that if that the case would be helpful to have the soylent (food replacement ) to help the diet . Have you heard of it ? and what you think ?

My understanding is that soy lecithin does not have phytoestrogens or the more common allergens (although sensitivity to lecithin is still possible), however lecithin by itself can contribute to a leaky gut, so taking it in supplement form is not something I recommend (I have not heard of soylent).

Very interesting, and something I realize I have to try. (Bad pains/bloating most recently after foods with…garlic! jerusalem artichoke!) I’ve been avoiding legumes for some time, along with gluten, but still have occasional post-dinner experiences…and realize it could well be the FODMAPs.

I’m fond of making chicken soup…any suggestions for what one puts into it besides carrots and parsnips? Chives, perhaps? I’ve always been a fan of onions, but ready to try. Is cilantro ok? Parsley? I don’t feel great after dill–is this also a FODMAP?

Winter squash is just a maybe? Along with avocado?

Finally, why are tomatoes ok, but not tomato sauce? We use sauces without sweeteners. But, is there a problem with cooked tomatoes? (If that’s the case, is an omelet with tomatoes ok or not?)

Thank you so much! I appreciate it.

The green part of leeks would be really good in chicken soup. I believe parsley and cilantro are fine. I don’t know about dill. With many of these foods, it’s a concentration versus sensitivity formula, so cooked tomatoes concentrates and why there are so many maybe foods. Unfortunately, you have to experiment.

Thank you, @ThePaleoMom and @J.W. Gardiner! I actually had already made it last night before seeing these comments. I used carrots, celeriac (thinking that perhaps the root would be better than the green?), parsnips, rutabaga, cilantro, pepper, cayenne, and chives. It was good, and the first time I didn’t feel bloated after eating the soup (which I’d always attributed to it being lots of water!) I will try the green onions and leek greens at some point as well, and may use them for a crockpot recipe instead of onions for later this week.

Very informative post. I recently came to realize that I am on the FODMAP intolerant list. I was so confused why a good doze of onion, garlic, and fermented drinks make me sick in my stomach. I even looked up onion intolerance and the like to see if this was a known condition.
Just one comment about saurkrat, not sure if it is just me or not, but I tried half a cup of it almost a week ago hoping it will help, but it really did hurt me. I’ve been having constant diarrhea ever since with very slow healing. I’ve got into this type of traps before, but this one is taking a long time to get back on track for some reason…

This is a really great, clear, explanation of FODMAP’s. I’m interested by your suggestion that they could eventually be reintroduced. I find that I can have a FODMAP once – for example, a dinner with garlic in it – and not melt down. However, if I repeat for two or more days, its blimp city for me. Perhaps I haven’t taken long enough off. I do worry about not getting enough veggies, I mostly eat lettuce, and carrots in my soups.

Interestingly, my parents have told stories about when I was a breast-feeding infant – if my mom consumed onions, I would get gassy and fussy. I think that may be a suggestion that the FODMAP intolerance is pretty fundamental to my make-up and may be unlikely to resolve completely. Now that I have a pretty good understanding of what my body wants, I can at least keep it from self-destructing.

Hi! I just made the pumpkin (well, acorn squash) gingerbread muffins as a treat for my kids. I had one–they are very good! Then, I started wondering where blackstrap molasses falls on the FODMAP list. I didn’t see it on there; perhaps I missed it? It’s probably safest to stop with one muffin, just in case. If you have any information on molasses, I would appreciate it. Thank you!

I’ve been doing AIP for over three weeks now; the first two I started to feel better, and then symptoms started coming back, and looking at this list I am suspecting many of the foods on this list that I have been relying on for snacks. Hypoglycemic tendencies means I have to eat frequently, and without nuts, I’ve been turning to dried fruits. I’m also not feeling very well with all of the coconut-heavy snacks. Does anyone have any suggestions for what the heck I can snack on?? Half of this battle is mental, I think, but I am feeling really frustrated. AIP+FODMAP=SAD

Dried fruit and coconut flesh are high in sugar and inulin fiber respectively, both of which Sarah recommends avoiding or consuming only in moderation on the AIP. Sarah’s book, The Paleo Approach, has an excellent troubleshooting guide in the back that you may find helpful. Good snacks include small servings of protein (perhaps jerky or leftovers from the day before) or raw vegetables. – Christina, Sarah’s assistant

Hi Sarah! I know I have an issue with FODMAPs, especially onions or when I eat too much of them altogether. I just read the paleo approach, and I don’t find it too restricting as I love vegetables and meat. But if I have to cut FODMAPs, there’s not much left. I’m wondering if I have to cut out FODMAPs to heal my gut when I know I have an intolerance, or if it’s possible that FODMAP symptoms will subside eventually as I heal? Thanks! Amazing, theoretic as well as practical book you have written!!

I’ve been living a paleo lifestyle for a year, and have done AIP for a month. I feel great, but I also feel I have more weight to lose (maybe 5-8lbs), AND I have a small rash near my nose that I haven’t been able to get rid of (started a few months ago). I have no digestion issues whatsoever. Should I even bother removing FODMAP’s?

I would not remove them unless you have been diagnosed with or strongly suspect an intolerance to them. You might consider looking into infections, histamine, or thyroid issues re: the rash. – Christina, Sarah’s assistant

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