If not low FODMAP, what diet should I follow for my IBS?

Let's go beyond low FODMAP to what dietary strategies help with IBS

As I wrote about a few weeks ago—there are many risks with the low FODMAP diet. Due to these pitfalls, I do not believe this diet should be the go-to diet for IBS. But, what should? What other diets have been successful in the research? What have I seen be successful with my patients?

Let’s first dive into the research. What are other dietary options for IBS vs Low FODMAP?

I want to highlight one of my favorite studies on low FODMAP. This study compared the effects of three diets on IBS symptoms—low FODMAP, gluten free and a balanced diet (Mediterranean style diet).

28 IBS patients completed each diet for 30 days. While this study was small, I really liked that each patient did each diet vs other randomized controlled trials where each patient is selected for one of the diets. Having each patient do all the diets gives unique insights about how the diets compare for that one individual.

Questionnaires were completed after each diet to assess effectiveness of the diet to reduce IBS symptoms. These diets were administered under the guidance of a dietitian.

Since the balanced diet may be a bit confusing as it seems broad—this description may provide a bit more idea of what the participants focused on while they were eating the balanced diet: “The balanced diet is mostly focused on increased fiber intake, improving food habits in patients who are used to skipping breakfast and snacks, and also, on redistributing meals, calories and FODMAPs over the 24 hr period.” The participants were instructed to eat 3 meals a day and a snack for each diet.

The previous dietary habits of the participants are also important to note as skipping meals/snacks seems to be common in this population. Of the 42 IBS patients that initially enrolled in the study, 26% did not normally eat breakfast, 38% did not normally eat snacks and all of them ate most of their daily calories at their evening meal.

These meal patterns are super interesting to me. Skipping meals/snacks only to play catch up later could certainly lead to undereating, blood sugar instability, hormonal changes that can lead to gut brain axis issues.

All the diets reduced bloating and pain in the IBS patients. Although the Low FODMAP diet was superior in normalizing stool in this study compared to the both the gluten free and balanced diet. The balanced diet was easier for participants to adhere to and showed better quality of life improvements compared to the GF diet and the FODMAP diet. Participants preferred the more relaxed balanced approach than the low FODMAP approach.

The authors concluded:

“Considering the results obtained and patients’ dietary habits, it is probably more appropriate to recommend a diet that contains FODMAPs, but adequately distributed in different meals throughout the day, avoiding their overload, and with a correct distribution of calories. This investigation highlighted that patients often avoid breakfast and intermediate meals in the morning and afternoon, and they concentrate most of the caloric needs at dinner (evening meal). A balanced Mediterranean diet, while guaranteeing an adequate daily supply of carbohydrates, proteins, lipids and fibers, prevents patients from excessive FODMAP overload by dividing the total intake into five meals. In this way, it avoids the excessive load of FODMAPs at lunch and dinner, which is often responsible for the exacerbation of symptoms, and it subdivides FODMAP intake, in smaller quantities, into the five daily meals. It also avoids an excessive economic burden, is well accepted by patients and is easier to follow compared to the other two proposed diets, in the short-term period of four weeks”

Basically, the key takeaway is balanced diet plan will reduce symptoms of IBS and is preferred by patients as it increased quality of life more than the other diets. Starting with a balanced diet plan that has virtually zero risk, but lots of upside may be your best initial dietary option for IBS.

Another randomized controlled trial, looked at 3 different diets for IBS—TDA (traditional dietary advice), gluten free and low FODMAP and their ability to reduce symptoms. 99 patients were randomly assigned to one of the 3 diets. The study also looked at non-constipated IBS, so it may be less relevant to IBS-C patients.

The researchers main goal was to assess if these dietary interventions lead to symptom reduction, but they also looked at acceptability and food-related quality of life with dietary therapy, changes in nutritional intake, alterations in stool dysbiosis index, and baseline factors associated with clinical response.

All the diets were effective at improving symptoms. The participants found that the TDA was cheaper, easier to eat out and easier to incorporate in daily life compared to GF or Low FODMAP diets. Nutritional intakes and dysbiosis markers were not significantly different between the 3 groups.

The big takeaway by the researchers was: “We recommend TDA as the first-choice dietary therapy in non-constipated IBS, with LFD and GFD reserved according to specific patient preferences and specialist dietetic input.”

This study provides additional evidence that FODMAP may not be necessary in many IBS cases. In my opinion and clinical experience, it is better to start with a diet as broad as possible and only restrict what you need to. Low FODMAP unnecessarily restricts for many IBS sufferers and comes with risks.

Focusing on eating a diverse healthy balanced Mediterranean diet is a good starting point for most IBS sufferers. You can always restrict later, but start with a diet with the greatest potential health benefits with the lowest risk.

How do I take this “balanced Mediterranean diet” framework to the next level in my practice with IBS patients?

If I was working with a patient, I would also want to explore their nutrition more deeply than just following the general advice of eating a Mediterranean diet or Traditional Dietary Advice that were used in both the studies discussed above.

I would want to ensure my patients were optimally nourished. Your gut brain axis needs fuel, balanced macros and lots of micronutrients to run effectively. Filling gaps in my patients nutrition can have profound gut benefits as well as overall health benefits.

In my 8 years of practice, long term success RELIES on my patients abilities to nourish the gut brain axis. That means eating a diet that is meeting all your nutritional needs. The study confirming a balanced diet helps symptoms is a great start—but taking it to the next level by ensuring nutrition is optimized can lead to even more gut (and overall health) improvements.

In addition, diet is only one piece of your puzzle. Instead of jumping straight to restrictions, I would want to explore what other levers would help support the gut brain axis and reduce symptoms BEFORE moving onto restriction.

Checking in on sleep, movement, circadian rhythms, stress management and connection are all crucial too. In fact, lifestyle habits like yoga and hypnosis have been shown to be as effective as low FODMAP (more on this in future posts) for reducing IBS symptoms. Don’t put all your eggs in the diet basket—diversify your gut investments increases your symptom improvements.

Lets say you have optimized your nutrition and lifestyle habits, but you are still symptomatic—is this the time for the low FODMAP diet?

Before trialing diet restriction, I would assess whether other interventions may be helpful based on patients labs, history, symptoms and past experiences using supplements. Supplemental tools I employ regularly are prokinetics, probiotics, postbiotics, prebiotics, digestive aids, nervine herbs, vitamin/mineral supplements and herbs that help with hypersensitivity. And most people only need a few supplements—more is not better!!

And like diet change, these supplemental tools are meant to be used short term for symptom management while you work on fortifying your gut brain axis. While they can be helpful, they are not magic bullets. So, don’t skimp on the fundamentals.

While there is an expense for using supplements, I usually find the cons are less risky than the low FODMAP diet. You can achieve good symptom relief without the risk of disordered eating, stress and negative microbiome shifts that come with low FODMAP.

My one caveat is that blindly using supplements can backfire. Working with a provider who can help you understand what supplements are best for your case can make a big difference in how effective supplements are for you. There are also supplements that are not a good fit for certain individuals and can make things worse.

When you take a supplement it is important to understand:

• Why are you taking the supplement?

• How long are you supposed to take it?

• When will benefits likely occur (is it immediate relief or something that may take a few months)?

• Are their any side effects to it?

• Do you stop abruptly or wean off?

What if I am working on optimizing my diet and lifestyle, have added in some targeted supplements and still have symptoms?

I may suggest a modified low FODMAP diet at this point. This is a diet that removes the biggest FODMAP offenders in your diet vs removing all of the FODMAPs. It is a more liberal version of Low FODMAP.

One study showed that the modified low FODMAP diet was just as effective at reducing IBS symptoms as the strict low FODMAP diet. In both groups, 84% of participants had “satisfactory relief of gut symptoms”. The diets were both equally effective at normalizing stool quality as well.

The modified low FODMAP focused on removing the biggest FODMAP sources in the participants diets. Basically these were wheat, onions, garlic and lactose for most of the participants. While avoiding this narrower category of foods may still be tough, it is way easier than avoiding all of FODMAP categories in the stricter version. And in my experience, risk of food fears, stress and microbiome imbalances are less than full blown FODMAP.

It is still important to view modified low FODMAP as a short term tool. This change will hopefully calm down the gut in the short term so that you are more tolerant to foods later on.

What if you have optimized your nutrition and lifestyle, tried a few supplements and trialed modified low FODMAP with no luck?

I have rarely seen this. I can count on one hand when I have recommended full low FODMAP to my patients in my practice. Usually with the right diet, lifestyle and supplemental support—my patients symptoms improve and they can enjoy more diversity in their diets.

But if my patient has explored other less risky options—it may make sense to do full blown FODMAP for 4-8 weeks as a means to settle down the gut. I would view it as a gut reset. I would continue to try to isolate disruptions in their gut brain connection and target these with diet, lifestyle and supplemental strategies while the patient was eating low FODMAP.

I also want to avoid painting the picture that low FODMAP is dangerous. Yes, it has risks and more than other strategies. But, when done correctly and WITH GUIDANCE, you minimize many of the risks associated with this diet. It still has more risks than other strategies, but I don’t want my patients to be scared of the diet either. I do think low FODMAP can be dangerous when it is used inappropriately and indefinitely without re-introing.

Working with a Registered Dietitian or at minimum taking a MONASH course is recommended if you do go full low FODMAP.

So to sum up—here is a graphic that can guide you through a FRAMEWORK about when it makes sense to trial the low FODMAP diet

I will be covering other lifestyle strategies that you can trial as an alternative to low FODMAP in the next few weeks too.

If you need support finding relief from your IBS, schedule a discovery call with me to see if we make a good fit. Just click this link and “request an appt”—then select the free call option and find a time that fits into your schedule.

Do you have any questions? Please leave them below.