When the Full FODMAP Protocol Is Too Much: A Grand Rounds Case on IBS-D
When I brought Christine’s case to Grand Rounds, I wasn’t presenting a finished protocol—I was asking for help.
If you’re new to the Clinician’s Incubator community, Grand Rounds is one of our core learning experiences. Everyone in the program is welcome, and we offer sessions throughout the month. Some focus on specific themes like lab interpretation or behavior change, while others—like this one—are open-ended.
In each session, a supervisor or CNS candidate presents a case where they’re feeling stuck, need feedback, or want help planning next steps. Then, as a group, we work through it—sharing ideas, clinical reasoning, and practical strategies in real time.
That day, I shared Christine’s story. She’s a 52-year-old woman with IBS-D, a long history of chronic dieting, and significant early life trauma. Her nervous system was already working overtime, and she told me clearly: “I can’t do the full low FODMAP diet. It’s too much.”
So I brought that dilemma to the group: How do we make evidence-based recommendations without overwhelming a client who already feels maxed out?
I asked the group to help me brainstorm ways to reduce CD’s FODMAP load without asking her to do the full protocol. But before we got into the weeds, I askedl: “Did anyone learn how to modify the low FODMAP diet in school?”
Nearly every head was shaking “no.”
That’s exactly why supervised practice matters. School gives you the framework; we help you learn how to use it with real people.
Here is the list we came up with (not organized in any particular order):
Eliminating specific trigger foods (garlic, onion, or apples, etc.)
Replace any known trigger foods with low FODMAP versions (garlic oil for garlic, like FODY or Garlic Gold)
Crowd out FODMAPs, focusing on foods that are naturally low FODMAP
Eliminating a single FODMAP (fructose)
Identifying biggest FODMAP foods and replacing or reducing
Explore a FODMAP digestive enzyme like FODZYME or FODMATE
Get low FODMAP meal delivery (Modify Health, Epicured)
Try cooked foods instead of raw to see if that changes the symptoms
Make sure your diet is diverse - so no single food is making up the majority of her intake
Changing the macronutrient ratio so she’s getting less carbohydrates, aka less FODMAPs.
“Light” low FODMAP (eliminate only two most reactive FODMAPS)
After we built the list, I asked everyone to take it a step further: “How would you rank these strategies from easiest to hardest for you personally to implement?”
What followed was a thoughtful and eye-opening conversation about just how personal nutrition really is. Some people said ordering low FODMAP meal delivery would be the easiest change to make—but others felt it would get boring fast or disrupt their social life. A few thought shifting the macronutrient ratio to include more protein and fat was a smart strategy, while others raised concerns about potential side effects, like fat malabsorption.
The most striking part? No two lists were the same. Everyone had a different idea of what felt manageable, which highlighted exactly why a one-size-fits-all approach just doesn’t work.
This is what personalized nutrition actually looks like—not just tailoring macronutrients or swapping ingredients, but learning how to meet each client’s physiology, psychology, and capacity with flexibility. And this is what makes Grand Rounds so valuable. It’s not about showing up with perfect answers. It’s about bringing all our brains together, and leaning on each other’s strengths.
I left that session with more options and renewed clarity on how to help Christine feel supported. I’ll be bringing those insights back to her, along with a protocol that feels doable, not depleting.
Thanks to everyone who contributed. See you at the next round.
—Meg