Introduction
The acronym ‘FODMAP' (Fermentable Oligo-, Diand Monosaccharides and Polyols) was created to describe a group of short-chain carbohydrates and sugar alcohols (polyols)(1). They comprise fructose, lactose, fructoand galactooligosaccharides (fructans, and galactans), and polyols (such as sorbitol, mannitol, xylitol and maltitol). These molecules are poorly absorbed in the small intestine, they are osmotically active and are rapidly fermented by bacteria producing gas(2). The additional gas and water inside the gut stretches the bowel wall and triggers symptoms such as abdominal pain, gas and bloating, distension, constipation and diarrhea in some situations and patients(3).
It was in 2005, when researchers in the Department of Gastroenterology at Monash University(3) identified this group of short-chain carbohydrates in food. The research team measured the FODMAP content of a wide range of foods, including fruit, vegetables, breads, cereals, nuts, legumes, dairy products and processed foods. This food composition information allowed the team to develop the first low FODMAP diet. The team used this low FODMAP diet in the first research studies which showed that a low FODMAP diet reduces symptoms in people with Irritable Bowel Syndrome (IBS)(3).
The FODMAP concept in the management of functional gut symptoms relies on a dietary approach that restricts FODMAP intake globally, not individually; and represents an opportunity for reducing symptoms(2). Restriction of individual FODMAP has been used with varying success in the management of functional gut symptoms for a long time. However, such approaches have not become widespread in their application, perhaps in part related to their limited success. Restricting one FODMAP in isolation ignores the likelihood that there is potentially a range of FODMAP in the diet, all of which have similar end-effects in the bowel(4). The innovation in the FODMAP concept is that global restriction should have a far greater and more consistent effect than limited restriction(2).
There is considerable evidence that FODMAP induce abdominal symptoms. Acute provocation tests with lactose(5), fructose(5,6), fructo-oligosaccharides (FOS)(7) or sorbitol(5,8) cause abdominal symptoms such as bloating, pain, nausea and disturbed bowel habit (diarrhoea and/or constipation) in many people, especially those with IBS.
All the research applying the low FODMAP diet indicates that up to 70% of the patients who follow a diet low in FODMAP present a significant improvement in symptoms, especially those related to abdominal pain and bloating(9-13). The symptom that least improves is constipation, which can be related to the low fiber intake of this dietary model(14). The low FODMAP diet has not only shown to have nutritional and symptomatic benefits in gastrointestinal diseases (e.g. IBS(15), non-celiac gluten sensitivity(16) or celiac disease(17)), but also in patients with fibromyalgia(18), sclerosis(19) and endometriosis(20).
A global approach to restricting carbohydrates that have similar actions (high osmotic effect and rapid fermentation) should optimize symptom control in patients. Nonetheless, the low FODMAP diet may not alleviate symptoms of every subject, being compliance a main factor (2). Because the diet is fairly complex, advice should be given by a specialized dietitian trained in the area with appropriate resources, along with a multidisciplinary team of other health professionals, and food intake should be monitored for nutritional adequacy(2). Since the first low FODMAP diets were described(21), there have been modifications to the food lists that have been prompted by new scientific data on food composition. Robust data now exist describing the FODMAP content of commonly consumed foods(22). However, not all studies provide the list of foods allowed in the low FODMAP diet or if they do, they differ between studies, as well as the quantities of FODMAP each food may have. Even some studies(23,24) allow foods (peeled apples, pears and milk) as part of the low FODMAP diet, which are not consistent with a low FODMAP diet as it was originally described. Inconsistency in the data provided has not only been found in relation to the FODMAP diet, but also in histamine content lists for histamine intolerance patients(25). Other limitations of the low FODMAP diet include lack of clear cutoff levels for FODMAP content in foods and non-availability of information on FODMAP content on food packages(2). All of the above make it difficult to standardize, homogenize and create a tool for clinical practice and research. It is also important to note that low FODMAP diets are very restrictive. Therefore they can produce a reduction in the intake of certain dietary components such as calcium, fiber, iron, zinc, folic acid and vitamin D(26). Thus, in order to ensure that the diet is not deficient despite the restrictions, it is necessary that the treatment is controlled by experienced dietitians(26). Generally, the strict low FODMAP diet is not recommended to be followed long term, as it may also result in reduced total bacterial abundance(27) and reduced concentration of bifidobacterial(9).
Despite the disadvantages of a low FODMAP diet, the diet has provided symptomatic relief in more patients with IBS compared to a standard dietary advice consisting of healthy eating principles, alteration of insoluble and soluble fibers, and limiting sugar-free foods and foods containing sorbitol (86% and 49%, respectively)(28). There are many studies carried out in the field of a low FODMAP diet, finding more than 350 results in some search databases, although many of them are retrospective(21,24) or prospective and uncontrolled(29-31) making the studies potentially subject to bias and confounding. However, in recent years well-designed clinical trials have been designed to support the efficacy of low FODMAP diet in patients with IBS; to date, two controlled trials(24,28) and six randomized controlled trials (9,11,12,29,32,33). However, more studies are needed to compare and establish more robust and specific food lists and quantities of FODMAP in foods. Further research is needed to standardize the information regarding the FODMAP diet and create reliable guidelines for clinical practice.
The lack of culturization and adaptation of the diet, through lists and gastronomic customs of countries where this diet is not very widespread, such as Latin American countries, can pose a problem in the treatment follow-up. Therefore, the aim of this research was to propose a FODMAP diet guide culturally adapted to different countries for Dietitians-Nutritionists and nutrition experts, to facilitate the management of patients who benefit from this diet.
Material and methods
A consortium of FODMAP diet experts was created among Spanish-speaking countries between June and August 2020. Dieticians from 11 Latin American countries (Argentina, Colombia, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, Peru, Uruguay and Venezuela) and Spain were enrolled in the project. Universidad de Belgrano (Argentina), Clínica Universitaria Colombia (Colombia), Consulta Adriana Pérez-Chávez (Ecuador), Nexa Resources Cajamarquilla S.A. (Peru), the Nutrition School at Universidad de la República (Uruguay), Centro de Medicina Deportiva y Rehabilitación MEDKAR (Venezuela), Centro de Hemodiálisis y de Salud Renal and Universidad Dr. Andrés Bello (El Salvador), the Nutrition department at Universidad del Valle de Guatemala (Guatemala), Universidad Tecnológica Centroamericana and Consulta María Regina Pacheco Blanco (Honduras), GenoVive (Mexico), Hospital Punta Pacífica and Instituto de Investigaciones Científicas y Servicios de Alta Tecnología INDICASAT-AIP (Panama) and Research Centers in Nutrition and Health CINUSA (Spain) participated in the elaboration of low FODMAP diets adjusted each to the culture of their own country.
At enrolment time, all participating institutions were asked to elaborate a low FODMAP balanced menu, adapted to the gastronomic culture of their own country (including typical recipes and ways of cooking and eating). Two examples of a menu were given to each participant as well as a unique list of foods rich (worst tolerated) and low (best tolerated) in FODMAP, to serve as a guide. In any case, participants were encouraged to use the Monash University FODMAP diet app(22) to access the library of low FODMAP foods, recommendations and recipes. Each diet had to be structured as a 7-day balanced healthy menu. Each intake must consist of carbohydrate + vegetable + protein or vegetable + protein, with an approximate distribution of 40-60% carbohydrates (no ultra-processing products, soft drinks, simple sugars, pastries or fast food), 15-30% protein (both animal and plant origin), and 20-35% fat (including blue fish, nuts, oleaginous fruits, and avoiding trans fats). The menus were revised by an experienced dietician on the FODMAP diet to ensure they all followed the same criteria.
All the collaborators were also asked for a list of foods, which are frequently consumed in their country, to be reintroduced in phase 2 (or reintroduction phase) of the FODMAP diet, along with typical recipes from the country where the reintroduction foods could be included.
Results
Low FODMAP diets
A total of 12 low FODMAP diets were designed, each adapted to the commonly consumed foods and recipes of each participating country (Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7, Table 8, Table 9, Table 10, Table 11 and 12).
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | - Almond drink - Rice cookies with homemade strawberry jam - Banana | - Quinoa drink or Infusion - Whole wheat bread (suitable) - Kiwi | - Almond drink - Rice cookies with homemade strawberry jam - Banana | - Quinoa drink or Infusion - Whole wheat bread (suitable) - Tangerine | - Almond drink - Whole wheat bread (suitable) - Kiwi | - Quinoa drink or Infusion - Quince muffins - Tangerine | - Almond drink - Rice cookies with homemade strawberry jam - Kiwi |
Lunch | - Goldfish with mashed potatoes - Carrot, tomato and cucumber salad - Tangerine | - Baked trout with lemon with pumpkin and eggplant wok and zucchini - Figs | - Meat, cheese and carrot cake - Baked quince | - Spinach pancakes with chicken - Pineapple or papaya slices | - Zucchini noodles - Baked salmon - Grapefruit | - Yamani rice risotto with chicken - Carrot and boiled beans - Kiwi | - Roast strip or vacío - Tomato, carrot, cucumber and quinoa salad - Grapefruit |
Afternoon snack | - Infusion - Chocolate chip cookies | - Almond drink - Rice cookie | - Infusion/ Mate - Chocolate chip cookies | - Almond drink - Rice cookie | - Infusion/ Mate - Chocolate chip cookies | - Almond drink - Rice cookie | - Infusion - Chocolate chip cookies |
Dinner | - Chicken and eggplant muffins - Baked pumpkin slices | - Carrot noodles - Meatballs | - Pork rib - Pumpkin puree | - Pizza with tuna dough, grated carrot and cucumber salad | - Pork croquettes stuffed with spinach | - Chorizo steak - Baked pumpkin slices | - Meatballs with rice - Tomato and grated carrot salad |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | ||||
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Breakfast | Beverage options: - Chocolate made with pure cocoa and lactose-free milk sweetened with stevia - Hot oatmeal made with lactose-free milk sweetened with stevia - Infusion, tea or coffee sweetened with stevia - Natural fruit juice (allowed fruits) Food options: - Rib broth with potato - Chicken broth with potato - Corn arepa with parrot eggs - Corn arepa with fresh lactose-free cheese - Corn arepa with fried egg in olive oil - Homemade tamale (without garlic and onion) - Gluten-free bread with fresh lactose-free cheese | |||||||||
Midday & Afternoon snack | One option: - Chocolate made with pure cocoa and lactose-free milk sweetened with stevia accompanied by fresh cheese without lactose - Fruit plate (allowed fruits) - Fruit salad (allowed fruits) with lactose-free yogurt - Fruit salad (allowed fruits) with grated lactose-free fresh cheese - Gluten-free bread with pure cocoa chocolate and lactose-free milk sweetened with Stevia - Homemade pandebono with fresh lactose-free cheese (no margarine / butter) - Homemade almojábana with fresh lactose-free cheese (no margarine / butter) | |||||||||
Lunch | - Rice with chicken and vegetables (carrot, tomato, green beans and celery) | - Beef stew with vegetables (carrot, zucchini, tomato) - Creole potato purée | - Baked mojarra with coconut rice - Tomato soup | - Chicken sancocho made with yucca and arracacha - Spinach, tomato and grated carrot salad | - Mixed grill of beef and pork loin with grilled cob - Ahuyama purée | - Seafood casserole with baked patacón - Cucumber, tomato and grated carrot salad | - Beef rib sancocho with mixed potatoes - Carrot and green beans stir fry | |||
Dinner | - Grilled white fish with lemon - Sautéed vegetables with spices (carrot, eggplant, zucchini) | - Egg omelette with vegetables (chard, zucchini and carrot) - Gluten-free bread | - Mondongo soup with vegetables (carrot, green beans, celery) - Radish, spinach and tomato salad | - Beef tenderloin in goulash with carrot and tomato - Ahuyama cream | - Chicken cream with vegetables (tomato, carrot, chard, zucchini) | - Pork chop with orange - Spinach, strawberry and grated carrot salad | - Chicken sudado - Baked aubergines au gratin with fresh lactosefree cheese |
*Lunches and meals can be accompanied by water, infusions or tea without added sugar, allowed fruit juices diluted in water and no added sugar.
*Spices and herbs to flavour preparations: oregano, salt, pepper, rosemary, turmeric, honey, thyme.
*Maximum 3 tablespoons a day of virgin olive oil to cook or consume raw.
*Salad vinaigrettes: White / balsamic vinegar with Dijon mustard. Stevia. Lemon juice. Natural lactose-free yogurt-based vinaigrette with lemon.
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | Beverage options: - Lactose-free yogurt - Infusion / tea / coffee / lactose-free milk with dark chocolate Food options: - Cassava omelette / bolón de verde with olive oil / oat pancakes with homemade strawberry/guava/pineapple/fig jam - Allowed fruit (banana, tangerine, papaya, kiwi, melon, strawberry, orange) - Eggs and fresh lactose-free cheese without lactose | ||||||
Midday & Afternoon snack | - Allowed fruit (banana, tangerine, papaya, kiwi, melon, strawberry, orange) - Lactose-free yogurt | ||||||
Lunch | - Rice with lentil stew - Grilled sea bass in Creole sauce (tomato, radish, cucumber, lemon and coriander) | - Rice with shredded chicken, carrots, turnips and green beans | - Fritada: baked pork loin, cooked corn and creole sauce (tomato, radish, cucumber, lemon and coriander) - Yapingacho (potato omelette stuffed with lactose-free cheese) | - Shrimp sango: green banana, shrimp, tomato, celery, parsley stir fry - Beans and carrot salad | - Balls broth: green banana dough filled with meat, chopped eggs and carrots | - Ceviche mixed with tilapia and shrimp - 1 cup of popcorn | - Hayaca stuffed with chicken: shredded chicken, sliced carrot, cornmeal, annatto, hard-boiled egg, olives |
Dinner | - Humita (corn dough stuffed with lactosefree cheese) with egg omelette - Carrot cream | - Tuna salad with potato, cucumber, tomato, olives, celery | - Pumpkin cream - Grilled chicken and tomato, beans and corn salad | - Beef stew: meat, potatoes, beans and carrots | - Chicken seco with rice - Chard, carrot and celery salad | - Cassava puree with hamburger - Swiss chard and spinach cream | - Green banana omelette with fried egg - Carrot and spinach cream |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | Beverage options: - Soy milk or drinkable quinoa Food options: - Gluten-free bread with tuna / lactose-free cheese / scrambled egg - Chopped fruit: pineapple, melon, papaya, strawberries, kiwi and orange | ||||||
Midday | - Whole fruit - Quince compote - Oatmeal pancakes - Lactose-free yogurt | ||||||
Lunch | - Pavita fillet with spinach puree - Radish salad - Passion fruit drink | - Pickled bonito (without onion) with boiled cassava - Orange soda | - Vegetable soup (allowed veg) - Chicken stew with spinach, cucumber and tomato salad - Lemonade with stevia | - Vegetable cream - Grilled pork chop with Italian zucchini salad, carrot, peas - Pineapple water | - Noodles in red sauce (tomato and carrot) with baked turkey fillet - Passion fruit drink | - Grilled trout with parboiled potato and cucumber salad - Fruit (allowed) | - Chicken ceviche with quinoa stew |
Afternoon snack | One option: - Tangerine or 100 g strawberries - Bread with frayed chicken without mayonnaise - 5 quail eggs - Passion fruit or fig Mazamorra | ||||||
Dinner | - Grilled hake fillet with tomato salad - Oatmeal with drinkable quince | - Quinoa burger with tuna - Soy milk | - Chicken thighs with orange - Boiled Italian zucchini - Quinoa with drinkable pineapple | - Baked pavita fillet with cooked vegetable salad - Soy milk | - Bonito fillet with fine herbs - Fresh salad - Oatmeal with passion fruit | - Rolled chicken breast with spinach, fig and ham - Cooked salad - Soy milk | - Rosemary chicken fillet with pineapple salad - Quinoa with quince |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | - Almond drink - Rice cookies with homemade strawberry jam - Banana | - Rice drink or Infusion - Sweet potato pancake - Kiwi | - Almond drink - Rice cookies with homemade strawberry jam - Banana | - Rice drink or Infusion - Sweet potato pancake - Tangerine | - Almond drink - Gluten-free bread with lactose-free cheese - Kiwi | - Rice drink or Infusion - Quince muffins - Tangerine | - Almond drink - Rice crackers with homemade strawberry jam - Kiwi |
Lunch | - Grilled steak - Carrot, tomato and cucumber salad - Mashed potatoes - Tangerine | - Baked hake - Baked zucchini and aubergines - Ioquat | - Broth - Pork ribs with applesauce - Baked quince | - Pumpkin soup - Quinoa pizza - Kiwi | - Salmon with tomato with oregano, carrot and peas - Grapefruit | - Polenta with tomato sauce - Carrot and boiled beans - Kiwi | - Chicken breast - Salad with grated carrot, radishes and quinoa - Orange |
Afternoon snack | - Infusion - Coconut cookies | - Almond drink - Quince muffins | - Infusion/ Mate - Coconut cookies | - Almond drink - Quince muffins | - Infusion - Coconut cookies | - Almond drink - Quince muffins | - Infusion - Coconut cookies |
Dinner | - Scrambled eggs with spinach and boiled potatoes | - Chicken with wok zucchini and aubergines | - Sole - Tomato, carrot, cucumber and red lentil salad | - Zucchini stuffed with quinoa with pumpkin puree | - Chicken curry with sweet potato and caramelized carrot | - Chard and spinach soup - Pumpkin, zucchini, carrot and tofu wok | - Pumpkin stuffed with meat - Quinoa paste |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast 7-8 am | - Roasted corn arepa with buffalo or goat ricotta cheese - Low fat margarine - Melon - Black coffee | - Gluten-free toast - Scrambled egg whites - Low fat margarine - Tangerine - Black coffee | - Corn cachapa (natural) - Buffalo or goat ricotta cheese - Low fat margarine - Papaya - Black coffee | - Gluten-free Andean arepas - Turkey ham - Buffalo or goat curd cheese - Low fat margarine - Cambur (banana) - Black coffee | - Ocumo (arrowleaf elephant ear) or sweet potato arepa - Ground beef - Low fat margarine - Orange - Black coffee | - Roasted corn patties with fish sauce - Cambur (banana) - Black coffee | - Cassava fritters stuffed with shredded chicken - Natural orange juice - Black coffee |
Midday 10 am | - Rice crackers - Turkey ham - Eggplant cream - Ginger and lemon infusion | - Casabe with guava jam with no sugar - Ginger with chamomile infusion | - Coconut yogurt | - Gelatine (no sugar) | - Melon | - Coconut yogurt | - Gluten-free cake |
Lunch 12-1 pm | - Vegetable cream - Grilled chicken milanesa - Green plantain toast - Rice with pods - Milk - Chamomile and lemon infusion | - Bone broth - Tuna croquettes - Steamed cassava - Sauteed zucchini - Parchita delicacy (cornstarch + passion fruit juice + stevia) - Lemon grass infusion | - Herb chicken - Rice with carrot - Steamed banana - Papaya - Lemon balm infusion | - Bone broth - Grilled steak - Steamed potatoes - Sautéed chayote - Melon - Linden tea | - Beef soup - Stuffed fish - Roasted aubergines - Boiled white rice - Churros - Natural infusion | - Chicken consommé - Gluten-free pasta with beef Bolognese - Green plantain tostón - Strawberries - Chamomile infusion | - Chicken rolls with vegetables (carrot, green dressings) - Steamed cassava - Papaya - Natural infusion |
Afernoon snack 3 pm | - Gluten-free pancakes - Strawberry jam with no sugar - Turkey ham - Water | - Gluten-free chocolate cake with vegetable milk - Chamomile tea | - Gluten-free zucchini cupcakes - Water | - Cocada (coconut drink) without milk | - Gluten-free cake - Natural infusion | - Hot chocolate (no milk, no sugar) | - Rice pudding with coconut milk |
Dinner 6-7 pm | - Zucchini canoes stuffed with chicken - Steamed ocumo - Linden tea infusion | - Baked chicken - Stewed quinoa - Sautéed pods - Cayenne infusion | - Mixed grill (chicken and meat) - Salad (potato, carrot and coriander) - Jamaica flower infusion | - Roasted corn arepa - Shredded meat - Linden tea | - Grilled steak - Stewed quinoa - Zucchini salad - Natural infusion | - Chicken croquettes - Sautéed vegetables - Steamed potatoes - Natural infusion | - Cassava arepa with fish sauce - Sautéed spinach - Jamaica infusion |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | - Sautéed bananas with strained ground beans (not fried) - Fresh cheese - Almond milk | - Scrambled eggs - Toast - Bread with jam - Apple juice | - Pancakes with honey - Rice drink | - Crepes (homemade bread flour) with strawberries - Skim milk - Banana with granola | - Rancher's eggs with fresh salsa, - Bread - Orange juice | -Fruit with Greek yogurt -Bread with mozzarella cheese and ham -Coffee with skim milk with Splenda | - Oatmeal with apple juice - Coffee with Splenda |
Midday | - Whole wheat bread - Mozarella cheese - Natural orange juice | - Granola bar - Greek yogurt | - Jam and seeds on bread | - Greek yogurt - Whole wheat bread with turkey - Chopped apple | - Banana smoothie with lactose-free milk | -Granola seed bar -Fruit nectar (your choice) | - Yogurt and mango smoothie sweetened with Splenda |
Lunch | - Roast chicken breast - Cooked rice with vegetables - Fresh salad - Natural soda | - Potato, steamed broccoli - Roast beef - Natural soda | - Caesar Salad: fresh salad (tomato, celery, cucumber, lettuce, carrot), shredded mozzarella cheese, avocado, grilled chicken breast, Italian or ranch dressing - Natural soda | - Meatballs - Pasta with fresh tomato sauce - Fresh salad - Natural soda | - Fresh vegetables - Grilled fish fillet - Toasted tortilla - Lemon soda sweetened with Splenda | - Rice with shrimp and vegetables: cooked rice, camores, vegetables. - Natural soda sweetened with Splenda | - Vegetables: corn, peas, carrot, broccoli - Mashed potatoes - Needle tenderloin - Toast with garlic and butter - Natural soda sweetened with Splenda |
Afernoon snack | - Chopped tropical fruit (pineapple, grape, tangerine and strawberries) | - Chopped fruit - Bread with cheese (mozzarella) | - Rice pudding (without sugar) - Whole wheat bread | - Tropical cup: green mango, cucumber, jicama on medium sticks | - Grapes and granola | - Peach and Greek yogurt ice cream | - Chopped fruit with seeds |
Dinner | - Chicken and apple salad - Hot or cold drink | - Green beans with egg - Bread with butter - Chopped fruit - Green tea infusion with Splenda | - Spinach with mushrooms and breaded chicken pieces, almond seeds - Toast - Natural drink sweetened with Splenda | - Sautéed vegetables (carrot, potato, green bean, peas) seasoned to taste - Mashed potatoes - Natural drink, sweetened with Splenda | - Sliced fresh tomatoes - Whole beans or pasta - Coriander - Bacon - Chopped lettuce, onion, bell peppers - Corn - Panela cheese - Natural drink, sweetened with Splenda | - Vegetable and beef skewers: beef, onion, bell peppers, eggplant, pineapple - Natural soda, sweetened with Splenda | - Vegetable muffin: Arab bread, turkey ham, lettuce, tomato, mozzarella cheese, dressings - Carrot juice sweetened with Splenda |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | ||
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Breakfast | Drink options: - Atoles: mosh with lactose-free milk, lactose-free rice puddin - Infusion / tea / coffee Food options: - Tortilla or corn toast - Breakfast cereals (puffed rice, corn flakes) - Allowed fruit (banana, tangerine, coconut, kiwi, papaya, melon - Egg: scrambled, starry, hard, with vegetables. You can use tomato, celery or natural tomato sauc - Low lactose cheese | |||||||
Midday & Afternoon snack | Options: - Corn toasts with tomato sauc - Lactose-free rice pudding or almond drin - Allowed fruit: papaya, melon, grapefruit, banana (plantain), tangerine, strawberries, orange, pineappl - Yucca pancakes | |||||||
Lunch | - Chicken stew: chicken broth, chicken piece, potato, sweet potato, zucchini, pumpkin and carrot | - Rice with vegetables: celery, carrot, tomato sauce - Stewed chard - Beef steak | - Rice soup or watered down rice: rice, potato, chili, red pepper, carrot, tomato sauce, chicken leg or breast | - Steamed potatoes - Sautéed spinach - Baked tilapia with vegetables (tomato slices, carrot) | - Hilachas: bolovique or shredded beef, carrot, green bean, potato, natural tomato sauce seasoned with pepper and coriander | - Cooked cassava - Radish mince - Pork Milanesa (ribbon loin) | - Corn baked toast - Vegetable soup - Shrimp ceviche (without onion) | |
Dinner | - Stewed potato with egg - Chicken broth with vegetables | - Tortilla soup: add lowlactose cheese - Green beans stewed with beef or pork | - Rice with vegetables - Stewed chard - Cheese Doblada (corn tortilla with low lactose cheese) | - Carrot and celery soup - Omelette with vegetables and mozzarella cheese | - Green beans wrapped in egg - Camote or sweet potato | - Vegetable soup (allowed) - Mashed potatoes (with water or lactosefree milk) | - Guicoyitos stuffed with chicken and low lactose cheese, tomato |
* Food could be accompanied by corn tortillas. You may also include a dessert (without lactose, sugar, fructose, etc.). At lunch, you could include Jamaica rose soda with cinnamon (without sugar), plain water, herbal infusions or tea
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | - Lactose-free rice pudding - ½ banana - 2 corn tortilla rolls with egg | - Chamomile tea without sugar - Fruit cocktail (melon, papaya, pineapple) | - Oatmeal with lactosefree milk + fig to sweeten - Baked corn toast with tuna |
- Chamomile tea without sugar - Corn tortilla - Egg with potato | - Soy drink - Gluten-free bread with margarine |
- Lactose-free rice pudding - ½ banana - 2 corn tortilla rolls with egg | - Lactose-free rice pudding - ½ banana - 2 corn tortilla rolls with egg |
Midday | - Lactose-free plain yogurt | - Melon with grated coconut | - Tangerine - Oatmeal cookie | - Guava - Oatmeal cookie | - Carrot and cucumber | - Soy yogurt - Oatmeal cookie | - Lactose-free plain yogurt |
Lunch | - Chicken breast - Natural mashed potatoes - Spinach salad with tomato | - Chicken broth with rice - Baked corn salmas - Radish with lemon |
- Aubergines stuffed with pork, vegetables (allowed), Parmesan cheese and olive oil | - White or blue fish fillet (allowed) with lemon | - Yucca with ground pork - Spinach, carrot and tomato salad |
- Fried corn cakes with chicken and Swiss chard - Natural tomato sauce and parmesan cheese | - Chicken breast - Natural mashed potatoes - Spinach salad with tomato |
Afternoon snack | - Lactose-free plain yogurt | - Melon with grated coconut | - Tangerine - Oatmeal cookie | - Guava - Oatmeal cookie | - Carrot and cucumber | - Soy yogurt - Oatmeal cookie | - Lactose-free plain yogurt |
Dinner | - Baked corn salmas with tuna - Tangerine | - Baked corn toast with tuna salad - Lactose-free yogurt | - Cooked potato wedges + comal chicken breast pieces - Chamomile tea | - Baked corn salmas with tuna - Tangerine | - Baked corn toast with sweet potato deep - Lactose-free yogurt | - Baked corn toast with tuna salad - Lactose-free yogurt | - Baked corn salmas with tuna - Tangerine |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | - Melon - Rancheros eggs | - Papaya - Pumpkin flower quesadillas | - Kiwi and strawberries - Chicken Enjitomatadas | - Pineapple - Eggs with nopales | - Orange or tangerine juice - Egg with dried meat | - Papaya, melon and pineapple fruit cocktail with orange juice - Chilaquiles with chicken in green sauce | - Inflated amaranth with lactose-free milk, banana and strawberries |
Lunch | - Nopales soup - Chicken in tinga with white rice or corn tortillas - Banana snow with strawberry - Lemon water with chia | - Zucchini soup with coriander - Shrimp aguachile toasts - Guava ate - Tangerine water | - Chayote salad with apple cider vinegar and olive oil - Beef cured meat tacos with corn tortilla - Dark chocolate - Jamaica water | - Radish salad with lemon and salt - Pork loin with fine herbs and mashed potatoes - Custard apple (seasonal) - Horchata water | - Spinach salad with cherry tomatoes - Chicken fajitas with corn tortilla and steamed purslane - Guavas with cinnamon - Guava water | - Leek and potato soup - Veracruz style fish with white rice - Chocolate amaranth wafers - Lemon water with chia | - Pozole with corn and pork or chicken - Kiwi snow with strawberries - Jamaica water |
Dinner | - Natural turkey breast rolls with rice cakes and figs | - Chicken broth with rice (without chickpeas) | - Fresh tuna toast with seedless cucumber and fried leek, olive oil and grain salt | - Inflated amaranth with skim lactose-free milk - Banana | - Fish cocktail with seedless cucumber and baked corn toast | - Roasted nopales and rice cake with dark chocolate and strawberries | - Corn tortillas with natural gluten-free turkey breast and pineapple slices |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
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Breakfast | - Roasted cassava omelette with scrambled patio egg - Strawberries | - Scrambled eggs with mushrooms and cherries tomatoes - Melon | - Roasted banana - Minced meat + mushrooms |
- Carimañola with chicken | - Roasted corn roasts with turkey sautéed with celery and peppers | - Spinach omelette with quinoa toast or brown rice - Primitive banana | - Roasted cassava dumplings stuffed with chicken |
Lunch | - Minced steak meat with zucchini and chayote - Banana | - Roast chicken with 1 roasted potato and carrot sautéed with olives and chayote | - Spring rice - Grilled sea bass fillet + carrot and mushrooms | - Pumpkin puree - Pork chop with zucchini + spinach | - Quinoa spaghetti with chicken or ground beef - Zucchini and coriander salad | - Baked chicken with potatoes sautéed with vegetables (carrot and beans) | - Grilled fish - Pumpkin puree - Arugula salad |
Dinner | - Vegetable soup with chicken | - Carimañolas with tuna | - Ripe banana balls with ground beef | - Chicken enyucado with zucchini and carrot | - Zucchini soup with balls of ground veal | - Grilled tuna with baby corn salad (preserves) and peppers | - Shrimp cocktail with celery and carrot sticks |
DAY 1 | DAY 2 | DAY 3 | DAY 4 | DAY 5 | DAY 6 | DAY 7 | |
---|---|---|---|---|---|---|---|
Breakfast, Midday & Afternoon snacks | Beverage options: - Vegetable drink of rice or coconut with pure cocoa with stevia - Infusion / tea / coffee Food options: - Gluten-free bread with olive oil with or without crushed tomato - Gluten-free bread with homemade blueberry / raspberry / strawberry jam - Mix of breakfast cereal flakes (puffed rice, quinoa flakes, buckwheat flakes, corn flakes) - Allowed fruit (banana, tangerine, coconut, kiwi, papaya, melon) - Lactose-free cold cuts - Fresh cheese without lactose | ||||||
Lunch | - Soupy rice with vegetables (green beans, carrots), clams, squid and turmeric | - Homemade chicken burger with oil-fried Swiss chard - Homemade mashed potato | - Red lentil paste with vegetables - Grilled emperor | - Stewed beef or stewed ribs with potato, beef broth, and zucchini, tomato, carrot sauce, seasoned with oregano, pepper, and rosemary | - Vegetable stew with zucchini, eggplant, tomato, carrot - Hake (with fish soup) | - Spanish potato omelette without onion - Baked or grilled chicken | - Galician octopus (with cooked potato, chard, oil and paprika) |
Dinner | - Baked turkey sirloin - Cream (puree) of zucchini and Swiss chard | - Green bean, carrot and hard-boiled egg salad | - Grilled zucchini - Baked chicken wings with spices | - Lamb's lettuce, pomegranate and vinegar salad - French omelette | - Salmorejo (cold tomato soup) with oil, vinegar, gluten-free breadcrumbs and pieces of hard-boiled egg and Serrano ham | - Grilled baby squid - Fish broth with allowed vegetables, soft fish and glutenfree noodles | - Eggplant stuffed with minced meat - Spinach, tomato and lactose-free fresh cheese salad |
* Non-wheat or non-rye bread and a dessert (without lactose, sugar, or fructose) may be added to lunch and dinner
Reintroduction of food
The FODMAP diet reintroduction phase involves reintroducing foods back into the diet in a methodical way to determine which foods and FODMAPs trigger symptoms and which do not. Each FODMAP subgroup should be reintroduced separately while the background diet remains low in FODMAPs. The reintroduction step is also best completed under the guidance of a dietitian, therefore, advise has been given by each country on when to reintroduce, which foods to reintroduce, the amount of the reintroduction food to have, and some recipes containing the reintroducing foods (Table 14, Table 15, Table 16, Table 17, Table 18, Table 19, Table 20, Table 21, Table 2, Table 23 y 24). A break of a few days between reintroduction of foods is taken to avoid any crossover effects. It takes around 6 to 12 weeks to complete the reintroduction step.
That step sometimes is complicated, unplanned and not guided by a fodmap diet nutrition expert. This, together with the lack of consensus, helps the result in practice to be frequently criticized by other professionals and scientists, who are partly right.
Starting from the low fodmap foods, the foods to be reintroduced are clearly and simply the opposite (Table 13). For what they have mostly and as an example, the following foods:
FODMAP | Food |
---|---|
Fructose | Fruits: apple, pear, melon, nashi pear, peach, mango, grape, cherry, watermelon Sweeteners: honey, fructose, jam with fructose Vegetables: asparagus, artichokes, peas. |
Lactose | Milk (cow, goat and sheep), yogurt Ice cream, cream Soft and fresh cheese (ricotta, cottage, mascarpone) |
Fructans | Cereals: wheat, rye, barley (bread, pasta, cookies) Vegetables: onion, shallot, garlic, beets, Brussels sprouts, cabbage, broccoli, fennel, leeks, endive Fruits: persimmon Nuts: walnuts, hazelnuts, pistachios |
Galactans | Legumes: beans, chickpeas, lentils, soy |
Polyols | Fruits: nectarine, apricot, plum, blackberries, avocado Vegetables: cauliflower, mushrooms, green bell pepper Sweeteners: sorbitol, mannitol, xylitol, maltitol, isomaltitol and others that end in "ol". |
Food | Recipes |
---|---|
cherry | Home made snowy cherry muffins |
Onion | Pancitos saborizados |
Cheese (lactose) and | Meatloaf with cheese and carrot |
Legumes: beans | Legume dumplings with beans |
Cauliflower | Cauliflower dough pizza |
Food | Recipes |
---|---|
Avocado | Bandeja paisa; soups. |
Cheese (lactose) | Arepa with cheese (queso doble crema) |
Garlic | Tamal |
Onion | Sancocho: beef rib, green plantains "viches", yucca, potatoes, corn on the cob, onions, coriander, tomatoes |
Peas | Ajiaco: chicken, dry guascas (colombian plant), papa criolla potato (yukon gold), papa sabanera (white potatoes), corn on the cob, chicken soup, green peas or peas (no onion or garlic) |
Food | Recipes |
---|---|
Mango | Mango juice or smoothie with lactose free yogurt / mango salad (lettuce, tomato, cucumber and mango) |
Ricotta cheese | Patacones with ricotta cheese / vegetable soup with ricotta cheese |
Curd | Patacones with curd / vegetable soup with curd |
Onion, garlic | Refrito / tigrillo / encebollado |
Chickpeas | Hummus |
Raisins | Caldo de bola with raisins/ cabbage and raisins salad |
Avocado | Ceviche with avocado / avocado, black beans, corn, tomato salad |
Food | Recipes |
---|---|
Pore | Leek cream: leek chunks, Italian zucchini, zapallo macre (pumpkin), pinch of salt |
Pear | Pear Mazamorra: peeled pears, cinnamon, chuño (thickener) |
Goldenberry | Goldenberry jam: goldenberry, Stevia, lemon |
Yellow Peper | Causa limeña |
Onion or green onion | Ceviche or Tacu Tacu |
Food | Recipes |
---|---|
Mango, Plum, Watermelon,.. | Jugo (common way of taking it) Alone, in compote or juice |
Avocado | Reina pepiada (Arepa) |
Mushrooms | Steamed or sautéed or cream soup |
Red and green peppers | Pabellón criollo (ajíes dulces verdes y rojos) |
Rye | Rye mixed with corn flour in arepa and cheese |
Beans (frijoles bayos /rojos) | Pique llanero |
Food | Recipes |
---|---|
Onion | Radish leaf stew cakes: radish leaves, 2 eggs, tomatoes, onion. |
Peppers | Tamales Salvadoreños (con chiles verdes) |
Letucce | Panes de gallina or “panes migueleños” |
Avocado | Enchiladas (with cheese) |
Beans | Empanadas made with a dough made from a ripe banana puree, with which rounded tortillas are made and stuffed with ground fríjoles, and fried. |
Food | Recipes |
---|---|
Yogurt and cheese | Combined with cereal, fruit smoothies with milk or yogurt, atoles such as mosh with milk, rice pudding |
Leek | Leek soup, cream |
Cabbage | Tortillas with loroco and cheese and cabbage |
Avocado | Natural, simple guacamole, guacamole combined with tomato |
Beet | Enchilada corn toast with minced meat, cheese, egg, cheese and beetroot |
Red Chili pepper | Chili stuffed with beef, chili pepper salad, add to traditional foods that carry chili pepper |
Food | Recipes |
---|---|
Black Beans | Baleadas (Tortillas with Beans and Cheese without lactose) |
Beans or kidney beans | Blended beans toast |
Onion or green onion | Montucas |
Avocado | Guacamole: 1 diced avocado, 2 boiled eggs in pieces, lemon and salt |
Skim milk | Skim milk with blended fruits (banana, strawberries, papaya) |
Food | Recipes |
---|---|
Avocado | Guacamole |
Pepper and onion | Frequent in enchilada, tamales, pozole… |
Beans, lentil, chickpeas | Beans with chicken tinga |
Wheat Bread | Bolillo |
Panela cheese, plain yogurt or cream | Grilled Panela cheese with roasted Tomatillo and Poblano Salsa |
Cheese (lactose) | Quesadilla |
Food | Recipes |
---|---|
Beans | Gallo Pinto (rice with frijoles) |
Onion | Mondongo |
Pepper, garlic | Tamal |
Cheese (lactose) | Boiled cassava with goat cream cheese Corn patty with roast beef, cheese egg and orange |
Chickpeas | Chickpeas stewed with Serrano ham, potato |
Peas |
Patacones + fish + tomato and cucumber salad Stewed shrimp with tomato, garnished with peas and sweet potatoes |
Discussion
Numerous studies in other countries have reported the use of the FODMAP diet(37). However, the information available in Spanish is scarce(38) and there are barely no local studies that have estimated the applicability and effectiveness of this strategy on the symptoms and the health-related quality of life in patients in the Hispanic setting.
The benefits of restricting dietary FODMAPs appears to be durable(34). The nature of the diets used, however, is generally poorly defined. While all FODMAP are potentially important in the genesis of symptoms, the relative contribution of different subgroups of FODMAP varies across ethnic and dietary groups due to the dose delivered in the diet(2). In Western European and Central and South American diets, fructose and fructans are by far the most widespread in the diet and therefore the ones to which nearly all patients with IBS are exposed in their everyday diet(2).
Using a well-defined diet, restriction of fructose and fructans, together with general avoidance of other FODMAP leads to impressive global symptoms response(35). There are limitations in developing tables of FODMAP-rich and FODMAP-poor foods. Published lists of foods are generally limited in the description of FODMAP content. This limitation has been assisted by the development of methodologies to measure FODMAP content, together with a systematic examination of fruits, vegetables and cereals(36). The cut-off levels of FODMAP content, which dictates whether it is classified as ‘high' or not, are not clearly defined. This is further complicated by the fact that the total of FODMAPs ingested (not the individual FODMAP) at any one meal is a major factor in determining whether symptoms will be induced or not.
More studies are needed on the use of the FODMAP diet. The current criticism towards the FODMAP diet and the lack of evidence and robustness for its clinical and dietary use seems to be justified. There is a great variation between the different lists of FODMAP content in foods. The intervention studies are mostly of short duration, usually less than 3-6 months. Besides, the necessary trained professionals are not always available in hospitals and primary care, therefore, the recommendation of the diet is limited.
In resume, defining qualitatively the typical eating practices and style of the patient and the subsequent adaptation of the diet to local gastronomy is pertinent, as it provides the basis for a better understanding of food choice and may increase the likelihood of durable adherence. An understanding of the dietary principles and allocation of time to work on applying the diet are also important to ensure success.
This publication is merely intended as a guide to help professionals manage the FODMAP diet.