The Low-FODMAP Diet Cookbook (4 page)

For more information on breath hydrogen testing, see
www.thelowfodmapdiet.com
.

Lactose is a naturally occurring sugar that is found in cow's, goat's, and sheep's milk. Typically in people with lactose intolerance, the body stops making enough lactase, the enzyme that breaks down the sugar lactose. However, people can differ in the severity of their intolerance. Most people are able to tolerate small amounts of lactose (up to 4 grams) in their diet.

Lactose intolerance can cause symptoms of IBS. Additionally, many people with celiac disease have a secondary lactose intolerance, meaning an intolerance caused by the damage to their small intestine. Secondary lactose intolerance is generally but not always temporary.

Lactose is present in large amounts in milk, ice cream, and pudding. It is present in small to moderate amounts in products such as yogurt, cream, crème fraîche, and soft or unripened cheeses (e.g., cottage, ricotta, and cream cheese). Hard and ripened cheeses (cheddar, Parmesan, Camembert, Edam, Gouda, blue, mozzarella, etc.) and butter are virtually free of lactose.

The majority of recipes in this book are lactose-free or contain only minimal amounts of lactose. Recipes that require modification provide suggestions.

Fructose malabsorption is a condition in which the small intestine is impaired in its ability to absorb fructose (a naturally occurring sugar). Fructose malabsorption is different from hereditary fructose intolerance (HFI), a condition usually diagnosed in children in which the complete inability to digest fructose may result in symptoms such as vomiting, low blood sugar, and jaundice, and can lead to death.

Fortunately, in people who have fructose malabsorption, there still exists a pathway through which fructose can be absorbed in the small intestine. If glucose is present at the same time, the glucose “piggybacks” the fructose across the intestine into the bloodstream.

This is good news for fructose malabsorbers. It means that fructose and foods that contain it do not need to be avoided altogether (as is the case with HFI).

As mentioned previously, only foods that contain more fructose than glucose (excess fructose foods) need to be avoided on the low-FODMAP diet.

If a food contains more glucose than fructose, or if glucose and fructose are present in equal amounts, then it is
suitable
on the low-FODMAP diet. However, fructose malabsorbers do need to be aware of serving sizes. Only consume one serving of suitable food (such as fruit) at a time. Spread them out through the day so you only have one per meal or sitting.

Although all the recipes have been formulated with ingredients that are suitable for fructose malabsorption, ensure that you limit the serving size of any fruit-based dish to the quantity indicated in the recipe. Consuming large quantities of even “safe” fruits can cause symptoms.

Both a gluten-free diet and a low-FODMAP diet restrict wheat. On a low-FODMAP diet, this is due to wheat's fructan content rather than its gluten content. The good news is that although wheat is a source of both fructans and gluten, not every wheat ingredient contains both (see the table on the opposite page).

You will notice that some ingredients in the recipes are specified as “gluten-free.” Gluten must be avoided by those with celiac disease, and is present in wheat, rye, and barley. Some people on a gluten-free diet also react to oats. Every recipe in this book is gluten-free, which also ensures that fructans from wheat, rye, and barley are restricted.

If you do not need to follow a gluten-free diet, you need not seek out gluten-free-labeled versions of some ingredients, such as sauces, which are unlikely to contain enough fructans to trigger a reaction.

SUITABILITY OF WHEAT PRODUCTS

Celiac disease is an autoimmune disease in which the immune system's response to gluten severely injures the body. Gluten is the main protein component of wheat, rye, and barley (and some people with celiac disease also react to avenin, a protein in oats). In people with celiac disease, the immune response to gluten causes damage to the lining of the small intestine, particularly the villi, fingerlike structures that help absorb nutrients. As a result of dramatically decreased nutrient absorption and ongoing inflammation, people with celiac disease may become very ill. Typical symptoms can include bloating, gas, pain, diarrhea or constipation or a combination of both, fatigue, iron deficiency, anemia, and infertility. People with untreated celiac disease are also at greater risk for certain cancers and other maladies.

Celiac disease is diagnosed by antibody blood tests and a confirming endoscopic biopsy of the small intestine if the tests are positive. People being tested for celiac disease need to be eating gluten for the tests to be useful; otherwise, false negatives are common.

Celiac disease is a lifelong condition treated by a diet free from
all
gluten. This prevents further damage to the villi and allows them to return to normal so that nutrients can be properly absorbed.

The gluten-free diet permits fruits, vegetables, meat, fish, chicken, legumes (including lentils), most dairy foods, oils and margarines, and many grains. Breads, pasta, and cereals can be made from alternative sources, including corn, rice, soy, buckwheat, sorghum, nuts, and legumes, to name a few. These days, there are many specialty gluten-free products available, and many of those are also low-FODMAP. Look for them in the health food section of supermarkets and in health food stores.

For people prescribed a gluten-free diet, the change in lifestyle is often overwhelming. Learning which foods are suitable and which foods are no longer permitted in the diet is time-consuming at first, and the diet can seem very restrictive. I hope that this book will help you enjoy the great tastes of a gluten-free
and
low-FODMAP diet with confidence.

While every effort has been made to indicate and ensure gluten-free and low-FODMAP ingredients, it is essential to read the ingredients list of all food products to determine whether they are suitable for inclusion in your diet. The recipes in this book comply with the FDA's gluten-free labeling standards at the time of printing and exclude foods known at the time of printing to be high in FODMAPs. However, the gluten-free status of individual brands may change, the process of testing foods for their FODMAP content is ongoing, and the finished recipes have not been laboratory tested for FODMAP levels. Gluten-free labeling standards in other countries may also be different from the FDA's, so I stress again the importance of reading
all
food labels. Always assess your own level of tolerance when it comes to specific FODMAPs and recommended serving sizes.

For more information, see
www.shepherdworks.com.au
.

IBD includes Crohn's disease and ulcerative colitis, illnesses in which the bowel becomes chronically inflamed. Symptoms include diarrhea (sometimes bloody), abdominal pain, bloating, gas, and fatigue. As for celiac disease, the “gold standard” for diagnosing IBD is an intestinal endoscopy with biopsies, though blood tests, stool samples, colonoscopies, and other medical procedures may also be considered.

The causes of IBD are not known, and treatment is directed toward controlling the inflammation and preventing it from returning. Those whose bowel inflammation is well controlled but whose gastrointestinal symptoms continue may find the low-FODMAP diet a useful tool.

The recipes in this book are intended to be easily adaptable to many different dietary needs, not just FODMAP intolerance. Read on for some substitution suggestions.

Vegetarians and vegans can eat well on a low-FODMAP diet, but it requires careful planning. A variety of plant-based proteins contain FODMAPs (such as whole wheat, barley, legumes, and certain nuts and soy foods). Vegetarians and vegans who do not tolerate these FODMAPs may be at risk of not meeting their daily protein needs. If you are vegetarian, you may eat eggs and dairy foods (lactose-free or low-lactose if necessary).

Otherwise, you can be sure of meeting your protein needs by consuming nuts and seeds, suitable soy products such as tofu and tempeh, cereal products based on high-protein, low-FODMAP grains and cereals, and protein-enriched milk alternatives. Provided you do not need to be gluten-free, you can also incorporate seitan (a vegan meat substitute made of vital wheat gluten) into your diet. Because it is made entirely of protein, it does not contain the problematic FODMAP carbohydrates.

To make recipes in this book vegetarian or vegan, follow specific instructions in the recipes or try these basic swaps:

For meat or seafood: firm or extra firm tofu (pressed, if desired, for at least 15 minutes between paper towels and plates with extra weight on top); cubed or crumbled tempeh (steamed, if desired, for 10 to 20 minutes); homemade or store-bought onion-free, garlic-free seitan (
not
gluten-free); Quorn™ chik'n tenders or grounds (
not
gluten-free or vegan)