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

You said in your post that you may not know the difference between SIBO or FODMAP sensitivities unless you get tested. What tests would you need to get done? Thanks!

Thank you for getting back to me! I have read that post but it doesn’t actually say what tests are needed to differentiate between the two.

I started the AIP diet a few months ago. I noticed while reading up on the diet that I had intolerances to some vegetables in the FODMAP group. So I eliminated high FODMAP foods. Since then I’ve had so many gastrointestinal issues every time I’ve tried eating the smallest amount of anything on the FODMAP list. It’s gotten to the point where I’m seriously considering going a step back to the Paleo diet because I never had such issues before. Anyone else gone through that?

I feel the same Melanie – it’s so depressing. I never had such bad issues eating SAD food. Makes you wonder whether there’s any point in doing this at all?! I can’t eat a regular Paleo diet because of the reactions to various FODMAP vegetables. I never have the issue when eating SAD food, but appreciate that’s because I’m permanently inflamed and bloated… Bleugh. No real advice, but you’re not alone :)

Hi there. Do FODMAPs do anything to ferritin levels? I’ve changed a lot in my diet, and no matter how I supplement iron, or how much meat I eat, the ferritin won’t budge. Could FODMAPs be to blame? An apple a day keeps everyone away :-P

Do you cook in cast iron pans and eat liver? Any kind of poor gut health can make it difficult for your body to absorb the nutrients you eat or supplement. If it’s chronically low, you will need to work with a practitioner to find some way to get it up to a healthy level. – Christina, Sarah’s assistant

I have tested positive for SIBO and am on the Elemental diet. I reacted to the vitamins and large doses of honey. I don’t eat many carbohydrates, including honey so my body was not used to it. I almost always get nauseated from B vitamins. My doc has switched me to the higher fat mixture, which I somehow lost track of – brain fog! So the idea now is to take less of the multivitamin, supplement with a good mineral combination, extra electrolytes – a homemade version without sweeteners, and switch out half the honey with coconut oil for energy.
Just in case anyone else needs to get rid of SIBO and does not want to go the antibiotic route. Regardless of the initial treatment, it has to be followed with a very strict diet that is very similar to the FODMAP plan. Everyone reacts differently and sometimes a little wise tweaking is necessary.
For comparison, here is the link for the post treatment SIBO food list.
http://www.siboinfo.com/uploads/5/4/8/4/5484269/sibo_food_guide_jan_13_2014.pdf

Can you clarify for me what was the initial treatment for you. How did you know you were ready to change to a maintenance diet? What is your maintenance diet? Thanks!

Sorry I wasn’t clear. I am in the midst of the Elemental diet. It is severe. For two weeks I can only ingest (not eat! Bleh) a mixture of vitamins, fat, honey and pure and complete protein powder. It is meant to starve the little beasties to death. Because the bacteria feed on a specific type of carbohydrate regular food is limited to items on the safe list, gradually adding food from the cautionary list. (Link above) several months on the very limited list. I eat Paleo with occasional cheats with gluten-free and am already following (largely) the auto-immune protocol so the additional limitations won’t be that different.

Ok thanks for clarifying. What was the test you did for SIBO and where can I find out exactly what the Elemental diet is in case I need to try it out (ingredients you “ingest”)? I’m following the AIP, but am having issues with some some veg and fruit that are high in FODMAP. So I’m not sure if it’s FODMAPs or SIBO for me.

My doc told me about SIBO. I read a little about it here but she has had several people test and treat for it.
She gave me a kit that measures gases. You breathe into the tube and there are little glass vials attached (one at a time). Then when all the samples are collected – every 20 minutes for 3 hours – and labeled, you send the box off to the lab. In about a week the doc gets the results and you decide which course to take.
My doc suggested I try the Elemental diet because I am somewhat used to fasting and the antibiotics are harsh. There is another option that takes a month of strict food list, high dosage garlic and oregano oil or goldenseal. The garlic and goldenseal kill the bacteria and the strict diet keep it dead. I did not do this because I just wanted to get it over with. Also, I work with the public and don’t want to stink of garlic!
The link for the “homemade” version is here: http://www.siboinfo.com/elemental-formula.html
I ordered the amino acid powder online and have a coupon I think you can use if you decide to go that route. I ordered it from Jo-Labs. I bought the vitamins and minerals from my doc, they have to be pure and in capsules because you have to open the capsule to put the contents in the “smoothie”. It is kinda yucky but there are ways to make it better.
The non-homemade version is Vivonex and it is very expensive.
I go to a naturopath but the research and treatment was done by an Allopath (M.D.).
The Elemental diet or Vivonex is used to treat IBS and Crohns as well as people like me, with auto-immune diseases.

Curious to know if anyone else has experienced this- I’ve been on FODMAP for 2 days (so far with a great reaction by my GI issues)- there’s just one massive problem: I now can’t sleep.
Everything about my sleep patterns is the same and I allot myself 9 hours to get sleep. Except I can’t sleep. I didn’t have any sleeping issues before FODMAP. Ideas?

Thanks for the list/link! Many of these things I already do, others I’m not so good at or don’t do at all.
I’m still in the process of trying to find out what might have gone suddenly wrong with my GI tract through medical tests, etc. I decided to try FODMAP on my own and after a few days, many of my more minor symptoms have lessened. And then began insomnia at the exact same time. That’s about as far as I’ve gotten. :)

I’ve been on the auto-immune protocol for 6 weeks now. Intially, I felt better and my fatigue lessened but the last week I’ve had terrible abdominal pain, gas and indigestion. I haven’t tried digestive aids as I didn’t have the finances but now I can try them. I was wondering if it was a FODMAP problem. I honestly can’t see a way forward with cutting out the foods that are keeping me going at the moment and many of them fall into this list. Should I try the digestive supplement first before I do FODMAP? I used to be normal paleo before this AIP and never felt as hungry all the time as I do now. I eat a lot of vegetables but still feel so hungry. I can’t imagine cutting out a large part of my current diet. I can’t afford to lose weight. Is it possible I just need to try the digestive aids first?

It’s possible. Sarah recommends speaking to your healthcare provider before making any additional dietary changes — you may not need a low-FODMAP diet if you have not been diagnosed with FODMAP intolerance or SIBO. – Christina, Sarah’s assistant

Kathleen, are you drinking a lot of water and/or herb tea? That does help. Are you getting enough fat? I have made up coconut oil/honey/lemon juice and frozen it in ice cube trays. I pop a couple from time to time as a supplement and a little snack treat. I like the flavor of the lemon but you could use something else. When I was on the elemental fast I used natural peppermint and orange flavoring to make it more palatable. Your gut needs to heal and the coconut oil helps, as does gelatin. We make a gelatin using Tulsi tea, honey and pure beef gelatin but you could use almost any liquid to make it. We even tried coconut milk once.

I eat a lot of coconut oil and gelatin. I drink lots of water and a fair amount of rooibos tea. I thought coconut wasn’t allowed on FODMAP. And honey. I also have concerns about orthorexia. Doing the AIP and FODMAP together limits a person so much that isn’t it close to an eating disorder? I’ve had anorexia years ago and definitely don’t want to go that route again where I barely eat anything.

Kathleen, I am on a very restricted diet due to SIBO. Coconut oil is not restricted. Coconut flakes are limited to a quantity as is coconut milk. I eat every four to five hours to make sure my digestive tract has at least one clean flush cycle (doctor’s orders). You can eat as much as you like during those meals and if you cannot make five hours, you do four. Last night I had a company dinner and used Gather Paleo Entertaining cookbook and a recipe from the celiac site. There was plenty of food and I could eat most of it. I only changed a couple of items. I posted the link for the SIBO/FODMAP food list in an earlier comment, above.

I’ve been AIP + FODMAP for almost six months; the first month was just AIP, and I didn’t begin finding relief from symptoms until I omitted FODMAPs. I started reintroductions about two months ago, on a very slow schedule, beginning with FODMAPs as Sarah suggested, which seemed to go fine. The only thing I’ve successfully reintroduced in that time is eggs. The last week and a half I’ve been very unwell, and I finally figured out that it’s due to FODMAPs (damn delicious cherry season!!)

Here’s my question: If FODMAPs are causing trouble (AGAIN!), it is indicative of a gut in need of healing (I do suspect fructose malabsorption; I’ve tested negative for SIBO), so I feel like I need to go back to the beginning for a few weeks until I feel better. I am so skeptical about reintroductions at this point though; I plan to skip FODMAPs and just avoid them going forward, but I’ve been unsuccessful with the nuts and most seeds I’ve tried (and haven’t even considered testing dairy or grains!), so there’s not much else to even reintroduce. FODMAPs are supposed to be a first-tier challenge, so if those are problematic, is it even possible to go on to the “harder” challenges? I’m just concerned that living on meat, carrots, and plantains might not be super healthy for a long-longterm plan. :(

Same problem here Kelli! I’m getting depressed by the diet challenges and having to cook for a husband on a Paleo diet and two boys under 7 years old that are rebelling against my attempts at moving their diet away from grains and refined sugars. I’ve begun slipping on the diet lately as a form of rebellion against myself – self-sabotage! Trying to get back on the wagon again, however I am struggling a lot :(

Yes, having to cook for other people not doing AIP is extra challenging. There are six in my family (everyone with separate intolerances and allergies), so we often have four dinners to make. It’s a lot of food prep for zero satisfaction. I never cheat, so it’s really frustrating to still be sick after six months of this. :/ I’m glad to commiserate with you, Melanie.

I have been diagnosed with Celiac for 2 years now. My doctor has been trying to put me on statins since then too, but I refuse. Says my cholesterol is way too high. I want to control everything natural by diet. I have cut out dairy now too and am trying to limit meats to possibly once a day if that. He said I should incorporate beans into my diet for the protein, but I know that legumes are usually not tolerated well for celiacs. I know you are not a Dr but what is your opinion on this? I know I can’t survive on just fruits and veggies alone.

Teresa, all of my counts are better since going Paleo. I didn’t think I would like eating meat as my main source of protein but my body is so much happier. My doc even had to lower my prescription thyroid dosage.
Once you are off all grains and using coconut oil, bone broth and whole foods your gut will feel so much better, you will probably find that your body’s weight will even out (I lost weight), and you will have so much more energy.
I urge you to get tested for SIBO too. It is a drag to treat and follow up on but healing is the goal.

I feel much the same as Kelli. I’ve been on the FODMAPs diet for 3 years now and am concerned about the limited whole foods that I am eating. During this period I have been addressing SIBO, gut healing, digestive enzymes, stomach acid, and colon bacterial undergrowth. Confusions I have relate to some veg that are listed as safe on some FODMAPs lists , but not safe in others. I can tolerate some “moderate” foods and not tolerate many “safe” foods. Of course I am now supersensitive to small amount of these foods, and rechallenging foods, even after all of the above, has not proven benefitial. HELP PLEASE !!

I’m curious.. I have a particularly strong intolerance to fructans but not so much polyols. Are there any digestive enzymes in particular you would recommend? Or just a general wide spectrum blend? Thank you so much!

I’ve been on AIP for about three months now. I’m still having problems and my attempt at reintroductions didn’t go too well. I’m considering FODMAPs. The above list is different to the one in “The Paleo Approach.” Is this a more updated list? It seems more manageable than the one in the book. I have limited finances and can’t eat a lot of meat to fill me up. Also, I’m losing weight and don’t particularly want to lose more. Could I possibly introduce things like white rice to keep my carbohydrates up – being hypothyroid, I don’t want to limit carbohydrates too much and with cutting out starchy vegetables and quite a few fruits, it’s going to be a struggle. We also don’t get plantains here. I’m also often hungry on AIP – get lots of blood sugar dips.

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