Contraindications for the Low FODMAP Diet

Applying simplified FODMAP approaches with patients

The low FODMAP diet is an effective tool to learn and manage FODMAP intolerances, but can be very restrictive and burdensome. Increasingly, clinicians are recognizing the negative impact of restrictive diets and how they are not appropriate or feasible for many types of patients.

Poor candidates for a restrictive diet like low FODMAP include:

• Those with or or at risk for disordered eating or an eating disorder
• Children
• Patients who are at risk for malnutrition, are underweight or are malnourished
• The elderly
• Those who are already following a restrictive diet, possibly for another condition
• Patients with a comorbidity where diet change or excessive restriction presents risk, such as pregnancy
• Those who have trouble with food prep or reading labels
• Anyone unwilling or with a poor ability to apply dietary change

While the low FODMAP diet is generally effective for symptom control in roughly 70% of adults with IBS, its restrictions have consequences.

Risks of excessive diet restriction

Even in the absence of a contraindication, a low FODMAP diet puts everyone at risk for nutritional deficiencies, disordered eating, increased anxiety and decreased health-related quality of life.

Specific nutritional, microbiological and quality of life concerns of the low FODMAP diet include:

• Inadequate micro and macro- nutrient intake, such as decreased dietary carbohydrate and calcium 
• Negative microbiota changes, in part due to reduced fiber intake 
• Social isolation and anxiety, due to the burden of following a restrictive and complex diet
• Food fears, which make increase risk for disordered eating behaviors
• Increased food costs, as low-FODMAP and specialty foods can be as much as 2-3x times as expensive as their regular counterparts

Simplified FODMAP Approaches

In 2019, researchers at Monash University started publishing recommendations for a simplified FODMAP approach for patients who are contraindicated or poor candidates for a full three-phased low FODMAP diet. 

This targeted approach eliminates the most common FODMAP triggers without having patients go through the full restriction of the traditional low FODMAP diet. This simplified diet uses a "bottom up" approach to identify trigger foods, rather than the traditional "top down" approach used in the low FODMAP diet.

Top down vs. bottom up

While simplified FODMAP approaches are less restrictive and generally suitable for those who necessitate less diet restriction, though is still complex and should only be implemented under the guidance of an RD.

The "bottom up" approach starts with restriction of just known triggers and continues to exclude FODMAP categories as needed to improve symptoms. It begins by restricting the most common FODMAP triggers, oligosaccharides and lactose, reducing intake of foods high in fructans, GOS, and lactose. Patients then monitor response, and if relief isn't achieved, restrict more FODMAP groups as needed to identify triggers.

Foods Restricted on the "Bottom Up" FODMAP Approach

The "bottom up" approach to FODMAP restriction just eliminates the most common FODMAP triggers, which include milk, wheat, legumes, garlic and onion, cauliflower, mushrooms, and some of the less tolerated fruits, like stone fruits and fruits high in excess fructose.

Since this list was published in 2019, additional research has compared the efficacy of a traditional low FODMAP restriction phase with a simplified approach to conclude that eliminating solely fructans and galactooligosaccharides (the most common FODMAP triggers) can be equally effective as full restriction in controlling symptoms in many patients with IBS.

Head to our FODZYME Trainings & Resources to learn more about applying simplified FODMAP approaches.

Non-Diet strategies to control symptoms

Once patients have identified FODMAP triggers, digestive enzymes can help with reintroduction of FODMAP triggers.

Especially for those contraindicated for the low FODMAP diet, non-diet interventions can offer symptom control without increasing risk for negative side effects of dietary restriction.

Using FODZYME digestive enzymes

Enzymes can be used with or without dietary change based on a patient’s indications and awareness of FODMAP triggers. 

For example, digestive enzymes would be used prior to or in lieu of diet change when patients can identify high FODMAP foods as known or suspected triggers, such as garlic, onion, wheat and beans. In these instances, digestive enzymes can be used with these foods to validate a FODMAP intolerance and learn if and how FODMAP-targeting digestive enzymes can provide symptomatic relief. With these populations, there's little need for a highly restrictive and burdensome diet and enzymes can likely provide immediate relief, often without needs for significant diet change.

Alternatively, if enzymes are used with dietary change, it would be with known FODMAP triggers during the personalization phase and for long-term maintenance. In these cases enzymes can help further liberalize a patient's diet and allow them to enjoy more high FODMAP foods. 

Additional clinical resources

Our library of free CEU webinars includes trainings on applying FODMAP approaches in complex patient populations. Learn from expert dietitians through webinars such as Disordered Eating and GI: Screening, Assessment, and Intervention, Alternative Interventions for the Low-FODMAP Diet for Patients with IBS and more.