#20 Lee Martin RD Explains The Re-challenge and Reintroduction Phase Of The Low FODMAP Diet

This episode’s guest, Lee Martin, is a specialised dietitian who became part of the low FODMAP diet research team at London King’s College, contributing to the research and development of the diet.

Currently, he works as a specialist gastroenterology dietitian at the University College London Hospital where he provides group education on the low FODMAP diet.

Lee has also published the book “Re-challenging and Reintroducing FODMAPs” which is the first book ever written that is completely dedicated to the reintroduction phase of the low FODMAP diet.

Lee has not been diagnosed with IBS, but suffers from functional gut symptoms and has followed the Low FODMAP diet, to understand more about the practicality of the diet and to improve his symptoms.

In this episode, you’ll learn:

  • Lee’s involvement with the low FODMAP diet research team at King’s College London.
  • Why Lee wanted to try the low FODMAP diet, even without IBS diagnosis.
  • What is Lee’s “Re-challenging and Reintroduction of FODMAPs” book all about?
  • What are the general guidelines and protocols for doing the re-challenging phase of the low FODMAP diet?
  • What is the difference between re-challenging and reintroduction?
  • What is meant by a three-day re-challenging and what is the best procedure?
  • What is a washout period all about?
  • Will it ever be possible to eat the foods that trigger your IBS symptoms again?
  • Do we need to stay on the low FODMAP diet forever?
  • What are some useful travelling tips for IBS sufferers on the low FODMAP diet?
  • What are some of the newest developments in the research of the low FODMAP diet?
  • and more….

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Can’t listen to this episode right now? Read the transcript below!

LARAH: Welcome to the Low FODMAP Diet and IBS Podcast. My guest, Lee Martin, is a low FODMAP diet specialised dietitian. Since completing a specialised training course at King’s College London, Lee has set up an IBS and FODMAP clinic. Lee has also worked with the FODMAP team at King’s College contributing to the research and development of the diet, and currently, he works as a specialist gastroenterology dietitian at the University College London Hospital where he provides group education on the low FODMAP diet. Lee has also published the book “Re-challenging and Reintroducing FODMAPs” which is the first book ever written that is completely dedicated to the reintroduction phase of the low FODMAP diet. I had the pleasure of meeting Lee here in the Gold Coast in March this year when I had the privilege to interview him for my upcoming documentary. And as you will hear from this interview, Lee is very knowledgeable about the low FODMAP diet and I’m very grateful for his participation in this podcast episode.  So, here we go…Lee Martin.

LARAH: Hi, Lee.

LEE: Hi, Larah, nice to speak you again.

LARAH: Thank you for being on my podcast. I think this will be a very useful episode for all the listeners, just to understand a lot more about the phases of the diet and, in particular, about the reintroduction phase of the low FODMAP diet.  Let’s start by, if you would like to explain a little bit more about yourself and when your interest in the low FODMAP diet started?

LEE: Sure, I’ve worked with the National Health Service here in the UK on and off for the last decade. I always saw people with IBS within clinics sort of settings. It was in 2012 when I did the low FODMAP training course at King’s College London where the university and hospital sort of pioneered the low FODMAP diet over here in the UK and Europe. So after completing that, I set up a specialist low FODMAP clinic, which was part of our IBS service, which was fantastic to do because the patients found it extremely useful; and it was great to see positive results. So, sort of after that, I completed a Master’s in Clinical Research which then led me, thankfully, to get a job in 2014 working for King’s College London with the FODMAP team where I was a research dietitian researching the low FODMAP diet. And while I was there, I was fortunate enough to lead on the first long-term study of the efficacy of the low FODMAP diet in the UK, as well as helping to train dietitians from around the world on the low FODMAP diet on their training course. I think it was about this time last year, after I left King’s, I travelled the world for about ten months, which was absolutely amazing. And if anyone gets a chance to do it, I suggest you do it. So I’ve been back in UK for a couple of months. Since I’ve been back, I’ve obtained a position, like you said, in the University College London Hospital, which is a really interesting position sort of specialised in gastroenterology and neurogastroenterology working with the consultants. I mainly see people, whatever their condition is, it’s related to their functional gut symptoms, and that’s what we’re trying to treat in the clinic.

LARAH: Thank you, Lee, for the information about yourself and, yes, you had a great experience, I’m sure, when you did your travelling around the world. So we are going to talk a little bit more about that later. And it’s a fantastic opportunity you had, as well, to work at King’s College London and be able to really help with the research of the diet because, apart from Monash University in Australia, King’s College London is the second best place for FODMAP research, if I’m not wrong?

LEE: Yeah, they are certainly the other source, behind Monash University, of people who are pioneering research on the low FODMAP diet. Thankfully now, there’s lots of the different centres around the world doing it in Europe and in America. And obviously, it’s become an extremely popular treatment because it does actually work in a lot of people. So I’m sure we’ll see more and more research into the low FODMAP diet and aspects related to it as we go forward.

LARAH: Yes, I’m sure of that, too. Even though you don’t suffer from IBS, you still wanted to try the diet yourself — probably to understand and increase your knowledge, and to experience what it means to be on the diet, and the practicalities of following the diet. Can you talk about this experience, please?

LEE: Yes, sure. So, I get functional gut symptoms. I wouldn’t have a clinical diagnosis of IBS. I don’t have any pain associated with my symptoms, and that’s sort of one of the clinical definitions that you need to be actually diagnosed with IBS. So I would have what would be diagnosed as like functional gut symptoms. And so after I completed the low FODMAP training course at King’s College London and started seeing patients, I decided that I would try the diet myself for eight weeks, as it was recommended back then. And I basically blogged on my experienced and created a website from that. And, really, like you said, I did it to not only understand the effects of the diet on symptoms, but also to learn the practical application of the diet, which is obviously what patients find the hardest thing to implement, is fitting the low FODMAP diet into a new sort of routine and a new dietary structure. And I, like everyone, found eating out on the diet was like one of the hardest things, trying to find low FODMAP foods when you’re on the go. First thing: I love cooking. It’s one of the things I like to do to relax, so creating low FODMAP meals was quite easy once you get used to it. What foods are sort of high and low in FODMAPs. And, for me, personally, I found that it was probably within a week after the first week that I had a reduction in symptoms. I don’t think those symptoms ever got any better, and I followed that for eight weeks… And, actually, what I found towards the end of eight weeks, I started to become bit more constipated, which can be like one of the common or unwanted side effects of going on the low FODMAP diet for too long. So, I then very much looked forward to reintroducing the high FODMAP foods back into the diet with FODMAPs that I could tolerate.

LARAH: All right, yeah, that’s interesting what you’ve said because I found it the same during the elimination. I very much found relief within a few days — less than a week I would say — and then, within a few weeks from being IBS-D, I then became IBS — sometimes they call it A for Alternate, and sometimes they call it M for mixed.

LEE: Yeah.

LARAH: So that’s what it became, and it has been like that ever since if I eat too much high FODMAP food. So generally, I try to stay about eighty-five percent on the low FODMAP diet so that I know I can keep my symptoms at bay. But on some occasions, I’ve just misjudged. So I had a little bit too much food, and then I noticed it’s either IBS-D or IBS-C that comes back; and before, I was only ever IBS-D.

LEE: Right, yeah, exactly. It is interesting. Obviously, the FODMAPs, apart from triggering these sort of symptoms, there are natural laxatives that contain, obviously, fibres as well, which is one of the reasons why it’s important to include high FODMAP foods in the diet, and certainly in clinical practice, with people who are constipation predominant, we might not even advise a low FODMAP diet to help with that. The low FODMAP diet is extremely effective in helping with symptoms of bloating, flatulence, diarrhea, pain, but not so much, perhaps, on the constipation side of things. But it still can be effective to help patients who are constipation predominant as well. So a dietitian can individualise the sort of advice which can be given on that side of things.

LARAH: Okay. So in the case of people that have IBS-C, do they need to have an increased intake of fibres or of liquid?

LEE: Yeah, exactly. It could be a combination of that and it might also mean that they go on the low FODMAP diet for a shorter period of time. Most people find the effects of the low FODMAP diet last, on average, two to three weeks. If FODMAPs are the things which are the main trigger of your symptoms, then usually, within the first week, you find a reduction of your symptoms. So for people with constipation, it might be that you try the low FODMAP diet for a very small period of time so that you can reduce those other symptoms that I mentioned, like bloating and flatulence which is quite common with constipation. And then, obviously, making sure you are having enough other fibre and fluid while on the low FODMAP diet to make sure you don’t become more constipated.  And then, hopefully, you see a reduction of your symptoms and then you can start reintroducing the FODMAPs back in so that, overall, you do get that balance between having enough high FODMAP foods so that you can relieve your constipation, but not having too many high FODMAP foods that increases other symptoms related to it.

LARAH: Yeah, that makes sense because they are completely the opposite, constipation and diarrhoea. And, yeah, thinking that you can adopt the same diet exactly the same probably doesn’t make much sense. So what you are saying is, yes, you’ll have to really balance it and readjust it.  Yeah, that’s great.

LEE: Yeah, I think the people with constipation, it’s a much more balancing act. It’s a lot trickier than diarrhea, which certainly, on the low FODMAP diet research side of things, is a lot more effective in.

LARAH: Uh-huh, yeah. Okay, thank you for that. So as I’ve already mentioned in your introduction, you have also written a very useful book which is called “The Re-challenging and Reintroduction of FODMAPs” and this is a guide to reintroducing high FODMAP food after the elimination phase. Could you please, first of all, explain the difference between re-challenging and reintroducing because sometimes, this term may be used interchangeably —  but, obviously, it is not — and then give an explanation on how the re-challenging phase works? And can you touch on things like how long does the phase last and which food should we try to reintroduce first, and so on?

LEE: Yes, so like you said, different words are used sort of interchangeably to describe the whole reintroduction phase. You have reintroduction; you have challenging and re-challenging; you have reintroducing. And so there’s no sort of general consensus yet, as to what the wording should be. But I think to help to explain the whole reintroduction phase more clearly, it’s quite useful to look at in two parts. And so the first part is the re-challenging phase. So this is where you test your tolerance levels to individual FODMAPs. And at the end of the re-challenging phase, hopefully you’ll have an understanding, then, of what individual FODMAPs trigger your symptoms and at what portion sizes trigger your symptoms. This phase usually last about ten weeks. And then, once you’ve completed the re-challenging phase, you then reintroduce the FODMAPs into your diet, and this really involves reintroducing all the tolerative FODMAPs back into your diet and discovering your threshold to multiple FODMAPs — your overall intake of FODMAPs before symptoms are triggered. And this is an ongoing process — as long as it lasts. But this can last years depending on how things change. But I realised that it helps define the overall level of FODMAPs you can consume before you trigger your symptoms. And what most people find is that, during this process, it leads them to consume a modified low FODMAP diet in the long-term to help control their symptoms. And like you mentioned, Larah, I think you said it’s like eighty-five percent of the food you eat is low FODMAP, whereas the other fifteen percent is sort of high FODMAP foods. Whereas for other people who are sort of more tolerant to FODMAPs, it might be that sixty percent of the food they eat is low FODMAP and forty percent of the food they eat is high FODMAP. And so, with the actual re-challenging phase, it’s certainly best to approach it in a sort of systematic way, following a defined protocol and guidelines because, hopefully, this will help achieve the most accurate results.  And it is very important for the re-challenging phase that you have the correct information available. Ideally, if you work with a dietitian, they can then help personalise the diet to you.

So just to give you some sort of general protocols and guidelines for how you do a re-challenging phase: Obviously, you are consuming the low FODMAP diet throughout this phase. The only thing that you are changing is your intake of FODMAPs. And the protocol which is most commonly recommended is a three-consecutive-day challenge protocol, where you gradually increase your portion size of FODMAPs being challenged over those three days. So like a Monday, Tuesday, Wednesday, for example, you have a small, medium then a large portion size of the FODMAPs over those three days and you would record your symptoms depending on how that portion size of that FODMAP triggered your symptoms. Now the portion sizes themselves will need to be adapted for the individual, and the dietitian can advise on that. And, also, there are general guidelines of portion sizes to follow; and that is fine to do, but if you can tailor it to yourself, then you’re much better off. Obviously, if you’re a little lady, then you’re going to eat a lot less than a big chap playing football, or something like that. That’s an important thing to think about.

The other thing which certainly needs to the individualised is the symptom response that you get, or the level of symptoms which you experience when you are challenging FODMAPs. So what I tend to advise people as they’re going through the three-day challenge is, if you get mild symptoms, then certainly try and push on and go for a larger FODMAP portion size to see what reaction you get to that, whereas if you get moderate symptoms, or if you get severe symptoms as you’re going through the challenges — say after even the first day, a small portion size you get severe symptoms — then you might as well stop at that point. There’s no point in trying higher portion sizes because, most likely, that FODMAP is something which does trigger your symptoms.  Whenever you do get severe symptoms, or after you’ve completed all three days of the challenges, then you need to complete a sort of three-day washout period where you just opt to continue with the low FODMAP diet and not re-challenging any other FODMAPs. And this is important for a couple of reasons: First of all, hopefully, during those three days you can get your symptoms back down to the baseline level that you were at when you were on the low FODMAP diet so that when you re-challenge the next FODMAP, you’ve not got any lingering symptoms effects. And also during those three days, hopefully, the FODMAP would have completely gone out of your system so, again, you’re not getting any potential lingering leftover effect from the previous FODMAPs for this new FODMAP which you will be re-challenging.

So there are several different FODMAPs, or foods that contain the high FODMAPs, which you can use to re-challenge the individual FODMAPs. And it is important you only use these foods that contain one individual FODMAP. There are, still, several sources on the internet which provide the advice on the wrong type of foods which you can use to re-challenge and this is either due to those foods containing more than one type of FODMAP, or, perhaps, the portion sizes they’ve recommended are slightly incorrect. So, for example, they might have advised to start with a too high portion size of FODMAP, and so, for your small portion size of FODMAP, actually you’re having a sort of medium or large portion size of FODMAP which is more likely to trigger symptoms. So this may mean you end up ruling out a whole group of FODMAPs just because you didn’t do the re-challenge as accurately as you could have done if you’d had more of a chance of increasing your symptoms.

The other thing I just wanted to say was if you follow the low FODMAP diet during the whole of re-challenging, it’s also quite important, I think, to make sure you keep other sort of variables in check like your caffeine intake, your alcohol intake, fats, certain foods, stress… All these sorts of things can also trigger IBS symptoms. So if you can try and keep them as consistent as possible, just like you would do if you usually have two cups of coffee, have two cups of coffee during re-challenging. Just keep your variables in check.

So you’ve got six FODMAPs to challenge. During re-challenging there are six FODMAPs, but you actually do up to ten re-challenges; and you don’t reintroduce any of the challenged FODMAPs until you have finished all the re-challenges. And so with these six FODMAPS — with five of the FODMAPs, you only need to do one challenge.  So, for lactose, you only need to do one challenge. The fructose, you only need to do one challenge. FOR GOS and the oligosaccharides, again, one challenge. For the polyols, mannitol and sorbitol, you only need to do one challenge each. Whereas for the fructans, which are found in a much wider variety of foods and also have a sort of different concentration of fructans within the food groups as well, doing an extra few challenges. So overall, you do five challenges for the fructans. The good way, I think, to do it is you do fructans which are found in your wheat, cereal and grains. You do two challenges for fructans which are found in vegetables like the onion and garlic, for example. So you would do the two challenges with the fructans containing vegetables and fruits where fructans are found a lot less in. And you need to do one challenge like you do for the other FODMAPs, and, hopefully, all that should give you a better awareness of what individual FODMAPs trigger your symptoms and what portion sizes you can eat of FODMAPS before they do trigger your symptoms.

LARAH: All right. That’s full on, isn’t it? That is not a simple diet.

LEE: No, this whole re-challenging phase is a complex phase of the diet and this is why it’s so important that you have the right information because it can be easy to make mistakes or not use the right sort of foods which will give the most accurate results. I mean, that is what you want to end of the day — is to have the most accurate results so that you have the most awareness of what foods are going to trigger your symptoms and what aren’t. So if you can see a dietitian, fantastic. If you can’t, then ensure that you do approach it in a systematic way and you have a defined way of controlling other things which could affect the result so that at the end of the day you get as accurate a result as possible.

LARAH: Yeah, thank you, Lee. And I’ve read your book and that explains it so well. So for people that are not able to go and see a dietitian for any reason, which is always the best option, but if you can’t see a dietitian, then pick up Lee’s book because it guides you step-by-step on what you should do to be able to reintroduce high FODMAP food at the level you can tolerate.  So, yeah, that’s really good work.

LEE: Yes, thank you very much, Larah. Yeah.

LARAH: Going back to the fructans group… So let’s say that someone has re-challenged the fructans group and they’ve chosen to, let’s say, reintroduce bread, like wheat bread. So should they just pick one type of fructan food for that first challenge and just increase the quantity? So making sure, like on Monday they go with a smaller quantity and on Wednesday they go with a bigger quantity, but still with wheat and not changing into something different like, let’s say, garlic?

LEE: Yes, that’s a very good point. Obviously, it is important when you’re re-challenging a FODMAP within a food, that you stick to the same food that you were challenging for the three days, particularly with the fructans, or with any of them, really. You’re then potentially changing the concentration of the amount of FODMAPs that you’re actually challenging. Fructans, as I kind of alluded, is kind of a more complex FODMAP to challenge. It’s found in a wider variety of foods. And even within — like you mentioned bread earlier as an example. If you are testing the fructans in wheat and grain-type products then, yes, you can use bread as one particular challenge. But I certainly would recommend within that group, you also challenge another sort of cereal or grain which contains fructans. So, for example, you challenge pasta just so you get an overall balance with how fructans affect your symptoms within the food groups which they’re contained within. And even, actually, like bread, for example, it does actually contain fructans and galacto-oligosaccharides, but we do still recommend bread as a useful re-challenge food, even though it does contain two FODMAPs, because it’s such a staple in people’s diets. This is another reason why it is so important then, for example, to challenge pasta which only contains fructans. And so if we find bread affects your symptoms, whereas pasta doesn’t, then that might actually be an indication that the fructans and galacto-oligosaccharides are in the bread, or it might actually be that there is some other element of the bread gluten, for example, or some other protein we haven’t quite figured out that triggers symptoms in people with IBS. So, yes, challenge pasta which only contains fructans, and then you get an overall clarity of the results for that particular group.

LARAH: All right. So that’s a very good point because my next question is, if a person reacts to the first fructans, or the first group that they challenge — so let’s say pasta in this case that only contains fructans — and they react to it even in a small dose, should they still try and re-challenge another fructans food that only contains fructan?

LEE: Yes, for the fructans, I think you definitely should, mostly because the different concentrations within the same food groups of the fructans whereas a lot of the other groups, say if you’re testing fructans, for example, and you may use honey or mango or some other sort of food which only contain fructose, then the results that you get from that, you can probably apply to all the other foods which contain fructose, of which there are only a limited amount of foods which only contain fructose. The same as lactose or sorbitol or mannitol, for example. There is only a limited amount of vegetables which can only contain mannitol. So when you re-challenge one of those, or the symptoms reaction that you get from the one food you challenge, you can apply it to the other foods which only contain mannitol, whereas with the fructans and the vegetables, and then the wheat-side of things and the grains-side of things, it’s certainly worth doing two challenges for those to get an overall indication.

LARAH: Okay, yeah that explains it well, that makes sense. So, for fructans that are a little bit different, you should challenge more than one food that contains fructans, but in some other foods, it may be okay. So if you want to re-challenge lactose, you don’t necessarily have to go through the ice cream; and the milk; or the custard and everything. If you are okay with milk, you may consider that maybe you are also okay with the custard — provided that it doesn’t contain other high FODMAP food.

LEE: Yes, indeed, another good point.

LARAH: Okay, yeah, that’s very good. So how long should people wait in reintroducing the different groups? So let’s say in one week — let’s say Monday, Wednesday and Friday — they will challenge one type of food belonging to one group, or the same group in the case of some of the groups. And then how long should they wait if nothing has happened — so if they’ve had no symptoms — to be able to re-challenge another group?

LEE: So, what’s generally recommended is a three-day washout period, or minimum, a three-day washout period anyway. So like I said, even if you get no symptoms after your three challenges, which is actually great, you should still leave the three-day washout period before you try your next re-challenge because let’s say, for example, you eat three slices of bread one day to test fructans and you didn’t get any symptoms, but then the next day you tested avocado, or like sorbitol levels, and you got symptoms straight away. It might have actually been the effects of the fructans from the day before, plus the sorbitol from the next day, that triggered your symptoms rather than the sorbitol alone. So it’s good to leave those three days just to make sure there’s no lingering effects from the food that’s FODMAP and that that FODMAP is out of your system so that you can get the best clarity from your re-challenges and the results which you obtain from it.

LARAH: Okay, so three full days. So let’s say that the last challenge was on a Friday, so they should leave Saturday, Sunday, Monday, and then start a new one on the Tuesday? Or is it okay to start on Monday?

LEE: They should probably start on the Tuesday just so you have the three full days. Obviously, it is going to be different for different people.

LARAH: Uh-huh.

LEE: If you haven’t reduced your symptoms to your typical baseline level that it was on the low FODMAP diet, then you might need an extra one or two days until your symptom levels are down to a base level. But for most people, they do find three days is long enough in between challenges. I mean, quite often, what a lot of people do is, if, for example, they do the three consecutive day challenge — say Monday, Tuesday and Wednesday they do the challenge, and then Thursday, Friday, Saturday, they have a washout period, they might actually, then, have Sunday off again as well so that in the next week, on Monday, they start that whole process again. So it ends up being like a week process, or most typical, sort of a six-day process. Of course, you can change it yourself. It needs to be individualised to the person. Don’t just run ahead and get on with doing the different re-challenges if you’ve still got symptoms occurring, because that’s obviously gonna be affecting your results.

LARAH: That was a really good explanation. And, yes, people can just understand how there really is a need for guidance to do this properly. And I often hear about people complaining, “Oh, no. I cannot have this anymore; I cannot have that anymore.” It’s like when I looked at the list that the dietitian gave me, I wanted to cry.  All the things I ate were in there. And, you know, a couple of my favourite things are avocado and mango. I looked at the list and said, “Why is it rhubarb there? I don’t care about rhubarb; I never eat that. Can I swap it with mango?“ Anyway, I can now tolerate some mango and some avocado and some hummus. I can have all of them in small quantities.  So for people who have tried to reintroduce a specific food before and reacted during the reintroduction phase, does it mean that they cannot have that food ever again? Or is there any hope to reintroduce that food?

LEE: Yeah, hopefully there is still hope. I think something which I’ve noticed from clinical practice, is that people are finding that they’re slightly more sensitive to FODMAPs straight after doing a low FODMAP diet. And for what reason this is, we don’t know; there’s no research on this. It could be that because people have seen a resolution of their symptoms from eliminating FODMAPs then, obviously, they know that these FODMAPs can trigger these symptoms. So even just the thought of them bringing that FODMAP back in and eating that FODMAP while knowing that eating that FODMAP could potentially lead to them having symptoms. Or it could be that in the low FODMAP diet, we know it reduces some beneficial bacteria in your gut. So when you bring these high FODMAP foods back in — which are prebiotics and are foods for the good bacteria in the gut — when they start digesting these FODMAPs and starting repopulating and re-colonising the gut with the healthy sort of bacteria, does that trigger more symptoms? We just don’t know. I’m just kind of speculating on that. But it is worth noting that you can be more sensitive to the FODMAP straight off the low FODMAP diet. As you reintroduce more FODMAPs back into your diet, then that tolerance level will probably decrease over time. And certainly, because IBS is a functional disorder. IBS changes over time; people’s tolerance to FODMAPs will change over time. So if you found a particular FODMAP did really trigger your symptoms at one point in time, there’s no reason why you couldn’t try a re-challenge of that food a few months down the line and you may obtain a complete different result. Another thing, of course, you could do is, if you found you were sensitive to a particular FODMAP, you could always start with an even lower portion size of that FODMAP and gradually increase it just to see whether it could help you build up any tolerance to that particular FODMAP.

LARAH: All right. That’s fantastic news. So for everyone who has done the reintroduction and had some symptoms occurring with some of the foods that were reintroduced, you can try later on again. So it doesn’t have to be the same forever; you can keep on re-challenging the food that is causing your symptoms.

LEE: Yeah, it’s not as clear as a black and white answer — “Yes, you can definitely never have that again.  Yes, yes you can have this again.”

LARAH: Yeah.

LEE: Things will change, and like you’ve said, always retest. It’s certainly worth doing. It’s always good to keep increasing the variety of your diet and check in how your symptoms react to different foods.

LARAH: Yes, okay, so that’s good. I’ve also heard about some people who, after having done the elimination diet, are just too worried and too scared to actually try to reintroduce any food. Any final tips for those who are so worried about having the symptoms reappear again that they just want to stay with a low FODMAP diet forever?

LEE: Oh, yeah. Well, I mean, I can certainly understand why people would want to continue with a diet which has factually reduced their symptoms. But what I will say is the research which I did it at King’s in which there was a paper which came up from the team over in Denmark, which is looking at the long-term effects of a low FODMAP diet. And what both of the studies have found is that about eighty percent of people — once they’ve done the low FODMAP diet and they have gone through the reintroduction phase — they then follow this modified low FODMAP diet, which I mentioned at the start, where you’re sort of consuming some high FODMAP foods within tolerance. And when we look at the symptoms of these people, in the long term, they still have control of their symptoms — the vast majority of them do. So even though people reintroduced high FODMAPs foods back into their diet, they still maintained adequate control of their symptoms, which obviously shows that in the long term, you can — or the vast majority of people can — reintroduce high FODMAP foods back into their diet and still have control of their IBS symptoms.

LARAH: Okay, that’s great news for everyone, so give it a go.

Let’s talk a little bit about your travelling. So you spent almost a year travelling around the world with your partner, Mel, who is also a dietitian. Would you be able to share with us in which countries you were able to find low FODMAP options? And any travelling tips for those that are on the diet?

LEE: Yeah, we spent six months in Asia and four months in Central and South America. Then, when we flew out of Mexico, we popped over to New York a few days — which is a great city to see — before we went back to London. And, I mean, everywhere we travelled around the world, you can find low FODMAP dishes. They’re quite similar in all the countries, to be honest. Omelettes, you can find — and like meat and potatoes or fish and rice. All are quite similar plain foods you can get a hold of as a low FODMAP diet. However, I certainly wouldn’t recommend that people, when they’re travelling or when they’re on holiday, they try to stick to a strict low FODMAP diet.  What me and Mel did as we were travelling, is we basically consumed like a modified low FODMAP diet. One of the best things of travelling is immersing yourself in other people’s cultures, and obviously, food is just such an important part of cultures. It would be a real shame to go these countries and not join in with those food cultures. And so, as we travelled in different countries for different dishes which we knew would be high FODMAP foods, we’d make sure that, throughout the day, we were having a sort of modified low FODMAP diet — so having some low FODMAP foods. And then when we came to having the foods which we knew were containing high FODMAPs, overall, throughout that day, we did have that modified intake. So overall, we didn’t really consume all the amount of FODMAP which would be triggering symptoms all the time. And certainly, actually, the low FODMAP diet came in quite handy when we were ill as well. You do pick up bacteria; you do get stomach problems when you’re travelling in these countries, and it’s nice to be able to help control some of the symptoms that you’re getting from that by having a low FODMAP diet to help slow everything down a little bit.

LARAH: Yeah, that is good. Probably the hardest part that I noticed when you travel, is the marinades, or the sauces, because anything else you can kind of pick out and say, “Okay, I can have this vegetable and not that.”

LEE: Yeah, yeah. The curry sauces are obviously going to be a problem and they normally always contain onion and garlic. But there’s an awful lot of low FODMAP fruits and vegetables all around the world, so there are plenty of options available that are out although you are going to limit yourself a lot if you are trying to stick to a strict low FODMAP diet. Funny enough, actually, when we were in Indonesia, Bali, there’s a religion which is quite strong there — I think it’s called Jain, and they actually don’t put onion and garlic in any of their foods. So, there were restaurants which all of the dishes didn’t contain onion and garlic which made it a lot easier to pick out options the low FODMAP options. That was very interesting.

LARAH: Yeah, that’s good. I’ve read your blog post about that restaurant that you found. Yeah, in Ubud, it’ss good.

LEE: Yeah, in Ubud, exactly. It’s lovely.

LARAH:  So, I guess, the fact is, if someone is doing the elimination while travelling,  well, that’s kind of tricky. But if you’ve done your elimination and then you re-challenge some food and you’ve seen at what level, let’s say, the way I am at the moment — I know what I can tolerate — then it is much easier; it’s much easier to go anywhere and it’s much easier to go to a restaurant as well.

LEE: Yeah, I think that’s the best tip I would give, actually, to people who are going travelling. In the country that you’re going to, obviously, know what sort of high  FODMAP food you are going to be coming across so at least re-challenge those particular foods so that you can have a much more variety of choice in the dishes that you’re going to have. And also, you know if you’re going to be having those foods, or those dishes with high FODMAP foods, then you know what sort of symptoms and reactions can be possible as well.

LARAH: Yes. Let’s talk a little bit about your book now — the “Re-challenging and Reintroducing FODMAPs” book that you wrote. Can you tell people where they can find it and any other information?

Re-challenging and Reintroducing FODMAPs Paperback by Lee MartinLEE: Yes, sure. It’s kind of exclusive with Amazon so you can get it on Kindle or you can order a paperback version that Amazon prints and posts out to you. It’s available in  most countries around the world. I wrote the book because it’s such a complex part of the diet — the re-challenging phase — and I felt there wasn’t enough accurate information for people out there, whether it’s dietitians or whether it’s people doing it on their own, so it must really help people and I’m quite passionate about making sure people do reintroduce the FODMAP foods and have high FODMAP foods in their diet because they’re all really healthy foods; they all taste fantastic, and I think it is much better for people’s food-related quality of life, and socialising and eating out, etc. That they have the option, obviously, to complete the low FODMAP diet because it is an integral part of the low FODMAP diet and don’t just do the restriction phase. That is not the low FODMAP diet; that it is just a tiny part of the low FODMAP diet. So hopefully, people have found it a really useful guide to help them liberalize their diet with foods and find out what foods actually are the main triggers of their symptoms.

LARAH: Yeah, thank you, Lee. And you’re absolutely right that there is not enough accurate information out there for people when they want to reintroduce food in the correct way. So I would suggest to anyone that, at that stage of the diet, who doesn’t have a dietitian, to follow that through and get a copy of Lee’s book.

LEE: I guess the only thing left to say is that thankfully now, there is some research that is coming out on the long-term effect of the low FODMAP diet and what happens to people once they’ve gone through the restriction phase, and then the reintroduction phase, and how they then manage their symptoms with a modified low FODMAP diet. And I think that’s a very interesting area of research. I think most of the research will be coming out of Europe on that side of things. So that will be an interesting thing to watch. and hopefully, who knows, in the future it might mean that actually we don’t need to put people on a restricted low FODMAP diet. It might be that we can put people on a modified low FODMAP diet and they can still achieve the same resolution of symptoms that they achieved on a restricted low FODMAP diet. And then, therefore, they wouldn’t have to go through this whole re-challenging and reintroduction phase. It would be a lot smaller aspect of the diet because they haven’t, obviously, been restricting as many foods. So, that would be, hopefully, a very interesting thing to watch develop.

LARAH: Yeah, absolutely. So watch this space; if there is more research coming out, we will be covering it and making sure that people can have a normal life as much as possible. It’s very much a trial and error in trying different things and pushing a little bit of the boundary to see if you can manage to reintroduce some more foods, some more variety, some larger quantities and…

LEE: Very, very true.

LARAH: Yeah. All right, well, thank you. Thank you so much for that. Last question is how can people get in touch with you?

LEE: Yup. So for those who specifically interested in the reintroduction phase, I set up a website: reintroducingfodmaps.com. So that is sort of dedicated to information on the reintroduction phase — on research, practical tips, links of the book and more about the book that I’ve written. Please do check that out. Whereas for information and everything to do about the low FODMAP diet and my experiences with following the diet as well, check out my business website which is RMdietitics.com, where also my girlfriend, Mel, who is also a dietitian writes blog posts about that and also details about travelling experience on the low FODMAP diet. And for social media, it’s @LeemartinRD and it’s mainly FODMAP tweets. So if you are interested, yeah, please do check out Twitter.

LARAH: Okay, great. All right, thank you so much, Lee. That was absolutely gold information that we have been able to share with the listeners today and I’m sure they would have found it really useful. And again, thank you so much for all you do and for all your research and for being able to provide such a good resource for people that want to reintroduce FODMAPs back to their diet which is the aim, I think, of everybody on the low FODMAP diet, to eventually reintroduce other food that they like and that they missed.

LEE: Yes, that’s the message I think we need to get out there a bit more. It’s not just restricting FODMAPs; it’s a whole dietary and long-term approach to managing symptoms.

LARAH: Yes, absolutely. Well, thank you again. Thank you, Lee.

LEE: Yeah, thank you. Thank you very much as well, Larah. It’s great to be part of your podcast and thanks for putting this sort of thing together. It’s great to have more and more information for the public out there. It’s really good.

LARAH: Thanks. I’ll talk to you soon. Bye.

LEE:  Okay, take care. Bye!

LARAH: There you go — another episode packed with information about the reintroduction phase of the low FODMAP diet which has been kindly provided by registered dietitian, Lee Martin. And as we’ve discussed, this phase is very complex and if you can, get expert help. If it is not possible, then go and check out Lee’s book on Amazon and I will put the link in the show notes on my website. Feel free to message me with your comments on the podcast, and if you also have any suggestions for future episodes, I’ll be very happy to hear those too. Until next time — and as usual, keep healthy and happy and look after yourself.  Goodbye.

Links and resources mentioned in this episode:

Lee’s website Re-challenging and Reintroducing FODMAPs
RM Dietetic Website
Lee’s Twitter
Two dietitians do the low FODMAP diet on Pinterest
Re-challenging and reintroducing FODMAPs (Paperback edition)
Re-challenging and reintroducing FODMAPs (Kindle edition)

About Larah Brook

I have been suffering from Irritable Bowel Syndrome for many years, but it took a longtime to get a diagnosis, since then I have been following a low FODMAP diet, which has changed my life for the better. This is my story and experience with IBS and the low FODMAP diet.