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doi:10.1111/jgh.13687

REVIEW ARTICLE

Re-challenging FODMAPs: the low FODMAP diet phase two

Caroline Tuck and Jacqueline Barrett
*
Department of Gastroenterology, Monash University, Melbourne, Victoria, Australia

Key words
diet therapy, FODMAPs, functional bowel
disorders, irritable bowel syndrome.
Accepted for publication 14 November 2016.
Correspondence
Caroline Tuck, Department of Gastroenterology
Central Clinical School, Monash University,
Level 6, The Alfred Centre 99 Commercial
Road, Prahran, Melbourne, Vic 3004, Australia.
Email: caroline.tuck@monash.edu
Disclosures: C Tuck was supported by an
Australian Postgraduate Award Scholarship.
The authors have no conflicts of interest to
declare.
Abstract
The low fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols
(FODMAP) diet has good evidence for use in the treatment of patients with irritable bowel
syndrome. Importantly, patients are encouraged not to remain on a strict low FODMAP
diet long-term, and many patients maintain symptom improvement with a relaxed,
moderate FODMAP restriction. The re-challenge phase is crucial to assist patients in
identifying specific dietary triggers, reduce the level of dietary restriction required, and
increase prebiotic intake. Limited evidence is available to guide best practice, but, in
practice, beneficial outcomes can be seen through strategic food reintroductions. Here,
we set out some practical recommendations based on clinical experience. Dietitians
should tailor the challenge process to the individual patient and their needs. Food
challenges should aim to improve dietary variety and nutritional adequacy while consid-
ering specific food preferences and usual dietary habits. Identifying FODMAP subgroups
that are well tolerated is helpful, allowing the reintroduction of some moderate to high
FODMAP foods back into the diet without symptom induction. FODMAP subtypes that
are less well tolerated may also be reintroduced, but dosage and frequency of consump-
tion need to be individualized.
Additional challenges that face dietitians include consideration of patients with multiple
dietary restrictions such as in vegetarians or patients with diabetes who are simultaneously
following a low FODMAP diet. Ensuring nutritional adequacy is essential. The outcome of
the re-challenge process aims to find a balance between good symptom control and
expansion of the diet.

Introduction Reasons for re-challenging foods with higher

FODMAP content. There are a number of reasons for the
Symptoms of functional bowel disorders (FBD) including irritable
importance of the re-challenge process.
bowel syndrome (IBS) can be treated with a diet low in ferment-
able carbohydrates, named FODMAPs (fermentable, oligosaccha-
rides, disaccharides, monosaccharides, and polyols). The low
FODMAP diet is now included as first-line therapy and has been
shown to provide symptom improvement in approximately
68–76% of individuals.1 Symptom improvement generally occurs
following 3–4 weeks on the restrictive phase of the diet,2 although
the length of time required and degree of symptom improvement
can vary between patients. Following the restrictive phase, patients
are encouraged to reintroduce high FODMAP foods to assess their
tolerance to the individual FODMAP subgroups. The aim of this
re-challenge phase is to find a balance between good symptom
control and expansion of the diet. Patients requiring the diet
long-term then follow a “modified FODMAP diet” based on their
dietary tolerance found while challenging.2 Although this re-
challenge phase is conducted worldwide, and anecdotally has
success in relaxing the approach and maintaining symptomatic
improvement, limited data exist to define the re-challenge process.
What is clear is that working with a dietitian experienced in the
area is crucial for the success of the diet and the re-challenge
process.
• High FODMAP foods, specifically those containing fructans
and galacto-oligosaccharides (GOS), are known to be prebi-
otic, and 3–4 weeks of a low FODMAP diet has been shown
to lead to marked alterations in the colonic microbiota.3,4
However, the clinical significance of these changes is not
known.2 Reintroduction of some prebiotic high FODMAP
foods, even if in small quantity, may attenuate potential
long-term impact of dietary alteration on the microbiota.
However, this has not been investigated.
• Although the low FODMAP diet does not restrict entire food
groups, reintroduction of high FODMAP foods will assist in
improving food variety and nutritional adequacy. There is
risk of nutritional inadequacy with implementation of any
exclusion diet or dietary restriction.5 Indeed, recent data
demonstrate that more than half of patients following a low
FODMAP diet did not meet their recommended intakes of
calcium and iron, although values were not dissimilar to the
healthy population on a habitual diet. Interestingly, this study
did not see any change in the proportion of those meeting
fiber recommendations from baseline to follow-up.6 Further

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© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd
Re-challenging FODMAPs
data including comprehensive analysis of micronutrient
intake are needed to fully understand what effect the low
FODMAP diet and re-challenge phase has on nutritional
adequacy.
• Patients often report difficulty with complying with the low
FODMAP diet when eating away from the home through,
for example, fear of inadvertently consuming high FODMAP
foods, possibly affecting social inclusion and quality of life
(QOL). Expansion of the diet through re-challenge would
increase flexibility of food choices and thereby hope to reduce
any potential negative effects on QOL. One study assessing
IBS-specific QOL found 19 patients with diarrhea-
predominant IBS had improved QOL during a 6-week trial
of the low FODMAP diet. However, this study showed no
improvement of QOL in those with constipation predominant
or alternating IBS subtypes.7 The improved QOL in the
diarrhea-predominant patients may have been related to
enhanced symptom control. It is encouraging that the dietary
restrictions themselves did not result in a reduction in QOL
in any of the IBS subtypes. However, more data are needed
to understand the balance of improved symptom control
versus the potential negative impact on QOL due to the dietary
restrictions imposed.
• Importantly, once a patient has completed the re-challenges,
their improved understanding of their own food tolerance
can assist them to establish their own modified FODMAP
diet to be used in the long-term.
Evidence for the re-challenge phase. Owing to the rel-
atively recent emergence of the low FODMAP diet, most studies
to date have focused on confirming the efficacy of the restrictive
phase. Preliminary data regarding symptom control and total
dietary intake are now emerging for the reintroduction phase and
the use of the diet in the long-term. One study has specifically
assessed long-term dietary intake and level of FODMAP reintro-
duction in patients with IBS. Follow-up questionnaires provided
to 100 patients at 6–18 months following initial education showed
that 62% had satisfactory relief on the low FODMAP diet. Of
those, 71% continued to have satisfactory relief at 1 year post-
reintroduction, and 68% continued to avoid high FODMAP foods
at least 50% of the time.8 Another study providing a follow-up
questionnaire at 6 months post-treatment found that those who
had remained on a strict or attenuated diet at 6 months had a
significantly greater symptomatic improvement at 6 weeks com-
pared with those who had abandoned the diet, although information
on the level of reintroduction was not assessed.9 Those who had
abandoned the diet were likely to have been unresponsive within
the initial 6-week strict elimination phase.9 It is key that those
who do not respond to the low FODMAP diet should not be
encouraged to continue on the dietary restrictions. Further, long-
term data on the re-challenge phase are needed regarding how
challenges are carried out, amount of high FODMAP foods patients
are able to reintroduce back into the diet, and the effects this has on
nutritional adequacy, microbiota composition, and QOL.
Undertaking the re-challenge process. Despite limited
evidence, re-challenge protocols have been established based on
12
© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd
C Tuck and J Barrett
clinical experience. The re-challenge phase is usually commenced
following 2–6 weeks on the restrictive phase of the low FODMAP
diet. The length of time on the restrictive phase can be adapted
depending on the time required for an adequate symptom response
to occur as well as constraints related to, for example, clinic
waiting times. The degree of symptom improvement provided by
the restrictive phase is variable between patients and should be
discussed with the patient prior to commencing the re-challenge
process in order to establish level of baseline symptom control.
Figure 1 provides a flowchart of steps of the re-challenge phase.
The dietitian plays a key role in assisting the patient to complete
the challenge process in a strategic way to ensure patients are able
to identify specific dietary triggers for their symptoms. The re-
challenge phase can finally provide patients with some certainty
around their dietary intolerances, of which patients have often
struggled for many years.
Patients are encouraged to remain on the strict low FODMAP
diet while completing the challenges. One challenge is completed
at a time, often over a 3-day period. Owing to differing physiolog-
ical effects of FODMAPs in the gastrointestinal tract,10 it is impor-
tant that each FODMAP subgroup be challenged individually as
tolerance to each may vary. Table 1 provides example challenge
foods and doses for each FODMAP subgroup. The suggested
foods only contain significant amounts of one FODMAP sub-
group; for example, milk is high in lactose and does not contain
any other FODMAP subgroup. Small doses are listed in Table 1
and can be used as a guide, but the dosage used in practice should
be adapted to the patient. As outlined in Table 1, some challenges
may be better tolerated if consumed every second day rather than
in consecutive days; hence, the food can be challenged second
daily first and, if well tolerated, challenged again across consecu-
tive days. Patients are encouraged to monitor and record their
symptom types and severity throughout the challenges. If a partic-
ular challenge causes a significant increase in symptoms, it is rec-
ommended the patient stops challenging this particular food. If
symptoms continue to be controlled, then patients can increase
the dosage of the challenge food toward their preferred serving
size. Between challenges, patients are encouraged to have a 2- to
3-day “washout” to ensure no additive and/or crossover effects
occur. Once tolerance to each subgroup is established, patients
are encouraged to assess their tolerance to larger doses, increased
frequency, and combinations of high FODMAP foods. At this
point in the re-challenge process, challenges should be adapted to
suit the specific dietary needs of the patient and to assist the patient
to return toward their pre-morbid diet.
As an example, a patient may choose to challenge with honey to
determine their tolerance to excess fructose (Table 1). Honey is
chosen as it is a food that contains excess fructose but is not high
in other FODMAP subgroups. One teaspoon of honey is con-
sumed per day, for 3 days. If symptoms worsen, the patient should
be encouraged to stop the challenge. Alternatively, if good symp-
tom control persists, on the third day, they may increase the dosage
to two teaspoons and monitor their response for a further 1–2 days
or as long as the dietitian and patient feel is required to adequately
assess symptom response. Following the excess fructose chal-
lenge, the patient should be advised to undertake a 2- to 3-day
break remaining on the low FODMAP diet, prior to commencing
the next challenge in order to ensure no additive or crossover
effect occurs. If they have had good symptom control during the
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C Tuck and J Barrett Re-challenging FODMAPs

Figure 1 Flowchart of the re-challenge process.

honey challenge, future challenges to evaluate FODMAP combi- The order and nature of the challenges completed should be
nations and higher total FODMAP doses could include trialing adapted to suit the patients’ needs. Foods that were previously
honey on wheat bread (or other alternatives depending on the consumed more frequently may be those that the patient would
patient’s preferences and tolerance). prefer to challenge earlier. Foods that the patient suspects to be a
trigger may be best to be challenged later. The quantity of foods
Table 1 Examples of re-challenge foods for each FODMAP subgroup trialed and the specific food chosen to represent each FODMAP
subgroup should be adapted to the patients’ preferences and usual
FODMAP Suggested food Quantity Frequency dietary intake. For example, challenging their intake of yoghurt
Excess fructose Honey 1 tsp Daily for 3 days with one cup provides irrelevant information if the most yoghurt
Mango ½ mango they would ever consume is two tablespoons in one sitting.
The dietitian has a key role in helping the patient understand and
Lactose Milk ½ cup Daily for 3 days interpret the response to each challenge. Those challenges in which
Yoghurt 200 g no symptoms occur are likely foods that the patient can reintroduce
Sorbitol Avocado ⅓–½ avocado Daily for 3 days back into their diet freely. Foods that cause a mild response may be
Apricot 1 small reintroduced at times when the patient is able, such as when the pa-
tient is at home, or smaller doses at a lower frequency could be
Mannitol Mushroom ½ cup Daily for 3 days
trialed. Those foods that cause more severe symptoms should be
Cauliflower ½ cup
avoided in the long-term for optimal symptom control. However,
Fructose + sorbitol Apple ½ apple Daily for 3 days symptoms of FBD can vary over time within the individual, and
Pear ½ pear foods that are not tolerated should be re-challenged at another time,
with the long-term aim of increasing intake of prebiotics, including
Fructan (wheat) Wholemeal 1 slice Second daily for
preferred foods and optimizing dietary adequacy.
bread 3 days
An alternative to completing the re-challenge phase in this way
Pasta 1 cup
is to utilize the Monash University, Low FODMAP diet
Fructan (onion/garlic) Onion 1 ring Second daily for smartphone application.11 Information within the app is provided
Garlic ¼–½ clove 3 days using a traffic light rating of “green,” “amber,” and “red” serves
representing low, moderate, and high FODMAP content, respec-
GOS (galacto- Lentils ½ cup Daily or second
oligosaccharides) Chickpeas 2 tbs daily for 3 days
tively.11–14 “Green” and “amber” foods represent foods containing
low and moderate quantities of FODMAPs and are designated as

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Re-challenging FODMAPs
suitable during the restrictive phase of the diet. To assist with
reintroductions, patients may gradually increase intake of “amber”
serves and assess tolerance. Subsequently, they may increase
intake of “red” serves as tolerated to gradually increase total
FODMAP intake. This particular approach is more suitable for
patients who may struggle to complete more structured challenges
for reasons such as time constraints or unpredictable and un-
planned meal patterns.
Re-challenging in special populations. Care should be
taken when working with patients who have additional dietary
requirements such as vegetarians, patients with diabetes, or those
with additional food intolerances. The dietitian can assist these
patients to preferentially reintroduce foods of highest nutritional
concern. For example, protein sources can be limited during the
restrictive phase for patients following a vegetarian diet owing to
the high FODMAP content of legumes. Therefore, the dietitian
may encourage vegetarians to challenge legumes early in the chal-
lenge process and may suggest more strategic legume challenges
(e.g. assessing tolerance to multiple different types of legumes)
in an effort to increase the likelihood of meeting protein require-
ments. Patients with diabetes may need to consider carbohydrate
sources to assist in blood glucose control, and therefore, the choice
of challenge foods in particular for the fructan challenge should be
chosen carefully.
Finally, anxiety is common in patients with FBD, and hence, the
patients’ level of anxiety toward completing food challenges is
important to consider. Those patients who report more anxiety or
reluctance to challenge may benefit from a modified re-challenge
approach. This may include challenging with smaller serving sizes
or at reduced frequency. These patients may prefer to use the alter-
native method of challenging by gradually increasing FODMAP
intake using the traffic light rating system in the smartphone
application as discussed previously. It is important to note, the
stress surrounding the FODMAP challenge process may in itself
induce symptoms in anxious patients due to the interaction of the
brain–gut axis.15 The dietitian should adapt the challenge process
accordingly with the aim of reducing these effects and utilize his
or her important counseling skills.
The dose effect. Data are available from sugar solution
studies to show the effect of different FODMAP doses on gastro-
intestinal symptoms. One study comparing symptom response
found that symptoms were more frequent at higher dose of
fructose, with 71% experiencing symptoms at 50 g fructose dose
compared with 48% at a 25 g dose.16 Another study comparing
symptoms with fructose, fructan, and combined solutions also
found that the presence of symptoms occurred more frequently
with increasing dose.17 The data are more limited for the additive
effect when FODMAPs are ingested in combination, which com-
monly occurs in foods such as an apple that contains both excess
fructose and sorbitol. The fructan/fructose combined solution in
the aforementioned study showed increased symptoms compared
with fructose alone but not fructan alone.17 Despite data from
sugar solutions studies, limited data are available on how varied
doses of individual FODMAPs or FODMAPs in combination in
every day foods and fluids may affect symptoms owing to the
difficulty in conducting well-controlled studies using whole food,
14
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C Tuck and J Barrett
because of the complexities of the food matrix. Hence, a strategic
and individualized re-challenge phase that includes varying doses
of individual FODMAPs and combinations of FODMAPs specific
for each patient is vital to assist the patient in assessing their own
tolerance thresholds.
Long-term concepts. Once the re-challenges are completed,
the patient is encouraged to then follow their own individual
modified version of the low FODMAP diet in the longer term,
ensuring that their diet is only as restrictive as their symptoms
require. Strategies to assist the patient in the long-term should be
discussed; for example, limiting intake of higher FODMAP foods
prior to eating out may assist the patient to better tolerate meals
eaten away from the home. Advice regarding the prebiotic effect
of higher FODMAP foods may help to motivate the patient to
reintroduce well-tolerated foods. Patients should also be advised
that a certain degree of symptoms is normal (for example, some
flatulence or bloating after a large meal are common); that the
patient may find symptoms worsen in times of heightened stress;
and that functional gastrointestinal symptoms may change over
time, hence food tolerance may not remain stagnant.
Limitations of the current literature. Despite the chal-
lenges faced with implementing dietary studies, some data are now
emerging regarding the long-term use of the low FODMAP diet
and the implementation of the re-challenge phase. However, sig-
nificant gaps exist in the current literature including the level of
FODMAP reintroduction tolerated by patients, whether tolerance
to FODMAPs changes over time, and if reintroduction leads to
changes in the microbiota and nutritional adequacy. Further data
on the degree of dietary FODMAP restriction required for individ-
ual patients would be beneficial to help tailor the diet more specif-
ically to the individual patients’ needs. This may only be possible
with the identification of biomarkers or clinical features that could
predict an individual’s sensitivity to specific FODMAP subgroups.
Conclusions
While evidence is limited regarding the re-challenge phase, it is an
integral part in the dietary management of patients who undergo
the low FODMAP diet. A suggested re-challenge protocol based
on clinical experience has been set out here. Re-challenging high
FODMAP foods is critical to reduce the burden of dietary restric-
tions and to avoid potential negative effects on the microbiota, nu-
tritional adequacy, and QOL. The principle aim of the re-challenge
phase is to identify specific dietary triggers and reintroduce foods
that are well tolerated. The dietitian has a key role in supporting
patients in correctly identifying dietary triggers and to ensure
long-term nutritional adequacy. Further data to provide best prac-
tice guidelines for re-challenging FODMAPs are required.
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