Low FODMAP diet
Does cramping, bloating and constipation sound familiar? These are just some symptoms associated with IBS and coeliac disease.
This is where a low FODMAP diet can help, writes nutritional counsellor Nikki Heyder.
According to specialist dietitian and author Dr Jaci Barrett of Diet Solutions, gastrointestinal issues are symptoms that many people choose to ignore or consider as a normal part of their bodily functions. Along with this normalising attitude, there are also many people who feel embarrassed to talk about their symptoms and therefore put off resolving them.
“I genuinely thought that everyone suffered from these types of issues,” says Julie Thomas, who has now been diagnosed with coeliac disease. “IBS was something that I had read about but thought it was a bit silly to book a whole medical check-up based on it.”
Getting checked out
The good news is, these symptoms don’t need to be tolerated and they certainly aren’t normal. The importance of having symptoms checked and figuring out the triggers can not only lead to resolving the discomfort in a simple and effective method, but, as reiterated by leading dietitian and member of the Monash University team that developed the Low FODMAP Diet, Dr Sue Shepherd, it is “essential that people with abdominal symptoms described above are also investigated for coeliac disease by their doctor”.
This is because the two symptoms are very similar. Although IBS and coeliac disease are two very different issues, the repercussions from ignoring coeliac disease are much more severe than that of IBS and can lead to an increased risk of osteoporosis, cancer, infertility and even certain auto-immune diseases such as diabetes. It is important to note that coeliac disease “…can only be investigated if gluten is still being consumed in the diet,” Dr Shepherd says. “So, it is important that people don’t trial a gluten-free diet to ‘self-diagnose’ the disease.”
According to Dr Shepherd, you are definitely not alone if you suffer from digestive issues, with one in seven Australians being affected by IBS and one in 70 being affected by coeliac disease. She suggests that the increase in numbers diagnosed with these diseases is due to an increase in people taking action to see health practitioners regarding their symptoms and because “it is likely that food processing and the hygiene hypothesis could be contributing to the elevated prevalence in adverse reactions to food that we see today.”
The human digestive system is an intricate and complex one at the best of times, but when we suffer from gastrointestinal issues, the journey to recovery can be extremely confusing without the right specialist information and treatment. Asking Google why we feel bloated can bring up a whole host of answers with many of them contradicting one other. On top of this, each individual is exactly that – individual. What triggers certain symptoms for one person may not be the same thing that triggers the same reaction in another. If coeliac disease is the diagnosed cause, a lifelong elimination of gluten is prescribed. If it is IBS, however, the elimination process can be a little more involved.
What does FODMAP stand for?
As explained by Dr Shepherd, FODMAP is an acronym for a collection of short carbohydrate molecules that naturally occur in foods – they are the triggers for symptoms of IBS. The reason that they trigger these symptoms is because these molecules are potentially poorly absorbed in the small intestine and as they continue their journey through the digestive tract, they arrive at the large intestine unabsorbed. Here, the naturally occurring bacteria of the large intestine uses the sugars as a ‘food source’, and when the bacteria digests (or ferments) these molecules, the process releases gas as well as an increased delivery of water into the bowel. The effects lead to excess wind, bloating, abdominal pain and changes in bowel habits.
As explained by fodmap.com, FODMAP is an acronym that stands for:
Fermentable – meaning molecules are broken down (fermented) by bacteria in the large bowel.
Oligosaccharides – ‘oligo’ means few and ‘saccharide’ means sugar. These molecules are made up of individual sugars joined together in a chain.
Disaccharides – ‘di’ means two. This is a double sugar molecule.
Monosaccharides – ‘mono’ means single. This is a single sugar molecule.
And
Polyols – these are sugar alcohols (however, don’t lead to intoxication!).
An example of each category and its related foods can be found in the table below:
For an extensive list of the different foods that fall into each category, there are books that can be purchased via the Monash University website or at shepherdworks.com.au.
Alternatively, a specialist dietitian or nutritionist will be able to provide more information.
How do you get tested?
The process involved with a low FODMAP diagnosis and diet usually consists of an initial consultation with a GP where blood and stool samples are taken. After this, a hydrogen or methane breath test can be organised, which will detect malabsorption of some of the FODMAPs including lactose, fructose and sorbitol, and then a consultation with a specialist dietitian or nutritionist will see the patient embarking on a two-part low FODMAP diet.
Firstly, a six to eight week diet trial occurs – where the specialist will advise the strict removal of foods as well as provide expert nutritional advice on alternative food sources in order to ensure that nutritional adequacy and a balanced diet are maintained. This part of the process can be the most frustrating and difficult for the patient.
“It was close to impossible to find low FODMAP foods on the shelves of the grocery store” says 26-year-old patient Elizabeth Smith. “You really have to take the time to prepare all the food from scratch yourself, which was difficult for me as I was unwell and working full time. I knew my health was my priority so I stuck to it and it paid off.”
Fortunately, after six to eight weeks, the diet becomes a lot easier to manage. If symptoms have cleared or improved, the dietitian/nutritionist will trial both the type and the amount of FODMAPs that can be tolerated by that particular client. Slowly, certain foods will be reintroduced according to their specific reactions, with the ultimate goal being to ensure that the patient is able to obtain maximum variety in their diet without the irritability of IBS. “People generally start to see results in only a few weeks,” says Dr Shepherd. “It does not necessarily take the entire six weeks of phase one to see results; it is seen very quickly…but not overnight.”
Dr Barrett says that the diet has been successful with approximately 75 per cent of IBS patients, but there will be some who do not benefit completely from this approach due to the fact that their symptoms might be a different issue altogether. “For them, we look at alternative dietary triggers or work with other health professionals to help them achieve symptoms of relief,” she says.
Patient Elizabeth Smith, who was initially diagnosed with IBS, underwent a whole host of tests including a colonoscopy, breath tests, blood and stool samples, a pelvic ultrasound and then an MRI. It wasn’t until the MRI results came through that what she and her doctor thought was simply IBS turned out to be diverticulitis – an inflammation and infection within small pouches that develop within the intestine, leading to surgery. Elizabeth stressed the importance of going to the doctor to assess your symptoms as it could be something much more serious than you imagine.
Ignoring IBS does not have any negative long-term health repercussions like that of coeliac disease or diverticulitis, but it is extremely uncomfortable and unpleasant. By understanding what triggers the symptoms, that sense of discomfort can easily be managed and eliminated. An important point to reiterate here is that people should never self-diagnose coeliac disease or any other gastrointestinal problem. Dr Barrett says that, “high FODMAP foods are actually good for us, so unless you suffer from gastrointestinal symptoms, they should be enjoyed as part of a healthy diet.”
Is there a pro in probiotics?
Perth-based Naturopath Tess Doig suggests that in conjunction with a low FODMAP diet, patients could also incorporate the correct strain of probiotics for their symptoms depending on if they have constipation or diarrhoea. “Herbs such as chamomile and meadowsweet can reduce inflammation in the gut to help with bloating and pain, glutamine powder helps to heal the gut lining, apple cider vinegar can help in breaking down foods, and nutritional deficiencies will need to be looked at and addressed individually as most people would have not been absorbing their nutrients properly,” she says.
Dr Barrett states that even though there is poor evidence to suggest positive results from using probiotics, she nonetheless encourages her clients to try them. “If my patients are keen to try (a strain of probiotics), I suggest they do. But if they have not had relief of symptoms within six weeks, it’s probably not going to help.
“Other patients try alternative therapies such as hypnotherapy and cognitive behavioural therapy, both of which have been shown to provide improvement in gut symptoms when conducted with a specialist psychologist. This impacts on the gut-brain axis and is receiving much attention due to some successful research trials,” Dr Barrett explains.
According to Liz Campbell, a chronic IBS sufferer, the FODMAP diet was definitely effective in relieving her symptoms. However, she found it very difficult to maintain a “strict regime” while preparing food for herself and her children. She has now permanently eliminated lactose, apples, pears and gluten from her diet, but finds it difficult to be any stricter. “Perhaps it would be easier for single people who only have to prepare meals for themselves,” she says.
So what is out there that can help make this diet more manageable? Many people experience trouble in knowing what to cook, what to buy and, most importantly, how to make certain meals taste flavoursome when key ingredients such as onions or garlic are eliminated. This additional frustration, alongside an already restrictive food list, could discourage many people from maintaining their low FODMAP diet and consequently increase their chances of relapsing into a state of discomfort and bloating. Excitingly, Dr Shepherd has just released a world-first range of seven different meal solutions designed specifically for those following a low FODMAP diet. “All products are not only low FODMAP, but they are also gluten free, lactose free, four of the seven are vegetarian, and there are no artificial colours, flavours, or preservatives and no added MSG,” she says. “I wanted to help make people’s lives easier…the meals all taste like they are homemade and feedback has been fabulous”. The meals can be bought from Coles supermarkets. For more information check out: sueshepherdfoods.com.
Know your gut
For people who do not have a keen interest or knowledge in food, the team at Monash University have produced a FODMAP information booklet as well as a smartphone app as tools for consumers to ensure the whole process is as easy as possible. You can find more information on the Monash University website: med.monash.edu/cecs/gastro/fodmap/education.html.
Can we prevent IBS completely? Unfortunately the answer is no, but Dr Barrett suggests that having a healthy gut flora may help. This means eating a nourishing, high fibre diet with lots of fruit, vegetables, grains and legumes. Eliminating high-processed foods, fast foods and high sugar foods, including sweet drinks and sodas, can improve our gut health; and sticking to ‘whole foods’ rich in essential nutrients is the best thing for a healthy and happy body.
