Q. How do you navigate reintroduction of FODMAPs when patients have experienced relief and are afraid to reintroduce them?
A. In one word: gently. I would re-introduce small amounts of FODMAPs in the subtype (lactose, excess fructose, fructans etc.) that I would suspect would be the least problematic for a patient. If the patient had a tremendous amount of gas, for instance, I might not try fructans first—as these are know to create the MOST gas in the gut. Instead, I might, for instance, try introducing a food with excess fructose first.
Q. Regarding motility, can FODMAPs reduce or slow motility in the small intestine and colon?
A. It is possible that bacteria fermentation in the small intestine can slow motility in the small intestine—and in the colon, fermentation often but not always increases motility.
Q. I’m hearing a lot about gluten and FODMAPs and their effect on the body. Where does the discussion of sugar come in?
A. I believe the inflammatory and immune-response to sugar is under-represented in research and practice. Can you please speak to this? Sugar is typically well digested in most people, but may be poorly digested in the presence of small intestinal inflammation or small intestinal bacterial overgrowth. Diets high in sugar such as the Western diet are associated with inflammation and alterations in our gut microbes that are viewed as less favorable or less healthy. I encourage my digestively challenged patients (and really all of my clients) to use sugar as a treat, to their tolerance, but to not over-indulge. For instance, best to have a small piece of dark chocolate that contains a little sugar than a large piece of chocolate cake with a lot of sugar. I am not in favor of the notion we need to exclude food groups or forbid occasional treats, unless deemed medically necessary. (My opinion!)
Q. Does cooking lower the FODMAP content of foods?
A. If cooking in water, some of the FODMAPs in a food will leach out of the food and into the fluid. If you drain this fluid out, it is possible that you will reduce the FODMAP content. But, just cooking without water should not alter the FODMAP content though this needs to be studied in more detail in the research setting. Pickling foods reduces FODMAP content, soaking and draining does as well, and in some (but not all) fermenting foods can lower FODMAPs. But in cabbage, fermenting actually increases FODMAP content—so sauerkraut is actually higher in FODMAPs compared to cabbage. Because of all these nuances, I can’t stress enough to work with a dietitian with a solid and up to date understanding of the low FODMAP diet.