icacy is not restricted to patients with diarrhea-predominant IBS, but applies equally to any bowel habit. Thus, the evidence base for efficacy of the diet is now substantial. The ability of those instructed in the low FODMAP diet to adhere to it is remarkably good. More than 75% of patients were judged to be completely or mostly compliant with the diet in a retrospective review median 14 months (range 2–40 months) after implementation of the diet. In patients with inflammatory bowel disease, dietary compliance and efficacy of the diet were associated with more time availability, higher education status, and the use of specific cookbooks. These findings suggested that an understanding of the dietary principles and allocation of time to work on applying the diet were important to ensure success. These findings are not surprising. Limitations of tables of the FODMAP content of foods There are limitations in developing tables of FODMAP-rich and FODMAP-poor foods. This review paper provides a summary that is incomplete and is useful as a guide only. • 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.25, 26 • 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 FODMAPs) at any one meal is a major factor in determining whether symptoms will be induced or not. In the original description of the diet,39 cut-off values were based on careful clinical observation, which included obtaining feedback from patients regarding foods that they identified as triggers for symptoms. The foods reported by patients as being troublesome were examined for trends in the pooled food composition table. Foods and beverages containing > 0.5 g fructose in excess of glucose per 100 g, > 3 g fructose in an average serving quantity regardless of glucose intake (termed a ‘high fructose load’), and > 0.2 g of fructans per serve were considered at-risk of inducing symptoms. The concept of a ‘high fructose load’ has not been evaluated in terms of its importance in the success of the diet. The low FODMAP dietary strategy The pre-dietary workup is important and is outlined in Figure 1. Breath hydrogen testing, to define who can completely absorb a load of fructose and/or lactose is very useful as it can reduce the breadth of dietary restriction that is necessary. It is not strictly necessary—the fully restricted diet can be initiated—but altering diet carries the risk of nutritional compromise and it is a good principle not to restrict foods if not necessary. Details are in the caption following the image Figure 1 Open in figure viewer PowerPoint A bi-disciplinary approach to the patient with functional gastrointestinal disorder (FGID), especially irritable bowel syndrome or functional bloating. Breath hydrogen tests determine the degree of dietary restriction necessary by defining who can completely absorb fructose and/or lactose. Other FODMAP (oligosaccharides and polyols) are malabsorbed by all. The low FODMAP diet has only been evaluated as a dietitian-delivered diet.39, 42 This has mostly been achieved in a one-to-one setting, but group education sessions have also been used with apparent success. The ability of written literature only to achieve efficacy has not been studied and clinicians should be cautious in undertaking such an approach. Patients often only select the parts of any diet that appeal to them and ignore the rest. This defeats the goals the diet is designed to achieve. The strategy used at the first consultation is as follows: • Define qualitatively the typical eating practices and style of the patient. It is important to understand the likely FODMAPs to which the patient has daily exposure. Pre-completed food recording diaries and direct questioning of the patient during the consultation can be useful methods to obtain such information. This enables individualized dietary advice to be given. For example, if a patient already omits lactose-containing foods from their diet, then this potential FODMAP would not be contributing to ongoing symptoms. • The physiological framework for the dietary approach (i.e. the scientific basis of FODMAPs and their malabsorption and subsequent fermentation) is explained to the patient. This is pertinent as it provides the basis for a better understanding of food choice and may increase the likelihood of durable adherence (although this has not been evaluated).