Diet Tips:Low FODMAP diet provides both short- and long-term relief of gut symptoms

By Dr Jane Varney

Good news for people following a low FODMAP diet! A recent study conducted by researchers at Kings College London measured the long-term effectiveness of a low FODMAP diet. The study followed 100 participants with IBS from baseline (pre-FODMAP restriction), through the elimination and rechallenge phases and for 1 year thereafter. Participants reported their gastrointestinal symptoms at baseline (before FODMAP restriction), at 4-8 weeks (after FODMAP restriction) and at 1 year (following a rechallenge phase). Dietitians taught participants how to implement the elimination and rechallenge phases, but participants made their own food selections (meals were not provided in this study).

Sixty-two percent of participants reported satisfactory relief of symptoms after the initial elimination phase and the majority of these participants (71%) continued to experience satisfactory symptom relief at 1 year. Almost all of the participants who responded to the diet at 1 year continued to avoid high FODMAP foods at least half of the time.

So what are the take home messages from this study? Reassuringly, the study shows that a low FODMAP diet improves IBS symptoms in both the short, and long-term. The study also suggests that some degree of FODMAP restriction may be necessary to maintain adequate symptom control in the long-term. It is here that we issue a note of caution. Given the adverse changes in gut microbial populations associated with long-term adherence to a low FODMAP diet, we always encourage people to enter a re-challenge phase and under the guidance of a dietitian, find an acceptable balance between the occasional inclusion of moderate and high FODMAP foods (naturally rich in healthy prebiotics) and adequate symptom control.  In the long-term, we advocate people follow the least restrictive diet necessary. Further research into the rechallenge and long-term maintenance phases of the diet is warranted.

Reference:

Martin, L., van Vuuren, C., Seamark, L. (2015) Long term effectiveness of short chain Fermentable carbohydrate (FODMAP) restriction in patients with irritable bowel syndrome. Gut, 64: A51-A52.

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Diet Tips:The super sensitive in IBS

By Caroline Tuck (APD, PhD Candidate)

Irritable Bowel Syndrome (IBS) can express itself in many different ways, resulting in different symptoms that may change over time. Therefore, IBS is not a straightforward condition to treat and the IBS management does not suit a ‘one-size-fits-all’ approach.

There are many IBS treatments available, including medications, dietary change, hypnotherapy and herbal remedies, with varying levels of evidence supporting their use. 

Therefore, two people (even with the same type of IBS – constipation predominant, diarrhoea predominant or mixed) may not respond to the same treatment.

At Monash University, we focus on diet therapies because this is our area of research expertise. We recommend people follow a low FODMAP diet for a short period of time followed by a period of rechallenges, during which higher FODMAP foods are reintroduced enabling people to assess their tolerance to the various FODMAP subgroups. Most people should not need to stay on a strict low FODMAP diet for life. The reason we suggest rechallenging with higher FODMAP foods is discussed in previous blog posts: 

http://fodmapmonash.blogspot.com.au/2015/06/just-2-6-weeks-it-is-not-diet-for-life_8.html and http://fodmapmonash.blogspot.com.au/2015/04/low-fodmap-diet-not-lifetime-diet.html

But for some people, reintroducing foods is not easy or straightforward. In fact, in more sensitive individuals, reintroducing higher FODMAP foods can be very hard. Some people find that symptoms return even if they reintroduce very small quantities of higher FODMAP foods. This may require the person to follow a strict low FODMAP diet for longer to maintain symptom control.

The complexities of treating IBS mean that consultation with a Dietitian is very important, especially in people very sensitive to dietary factors such as FODMAPs. 

How a Dietitian can help:

•          They can suggest other strategies (both dietary and non-dietary) to help improve food tolerance.
•          They can ensure your diet remains nutritionally adequate if you need to remain on a low FODMAP diet for longer periods.
•          They can recommend other dietary and non-dietary therapies that may improve symptoms further.
•          They can identify food triggers other than FODMAPs
•          They can work with your doctor/gastroenterologist to find the best treatment for you.

You may also find this blog post helpful: http://fodmapmonash.blogspot.com.au/2015/05/top-5-reasons-why-you-should-see_22.html

In the long term, we advise that a strict low FODMAP diet is not continued, even in super sensitive individuals. We also recommend you repeat unsuccessful food challenges because IBS symptoms and tolerance to different foods changes over time. Reintroducing foods very gradually can also improve your tolerance.

Diet Tips:What is IBS and how is it diagnosed?

By Caroline Tuck (PhD Candidate and APD)

Irritable Bowel Syndrome (IBS) is a condition of the gastrointestinal tract. IBS causes symptoms such as abdominal pain, bloating, wind, constipation and diarrhoea. However, these symptoms can be caused by other more sinister conditions, so it is important to get the correct diagnosis. IBS cannot be diagnosed via a test e.g. blood test, scan or bowel biopsy (tissue sample which is sent to a laboratory for analysis). Instead, it is diagnosed based on symptom criteria after the exclusion of all other gastrointestinal disorders.

How do you know if you have it?

Firstly, we recommend you speak with your GP. Your GP may recommend some investigations or that you see a Gastroenterologist. This is to ensure that other gastrointestinal disorders are ruled out, for instance coeliac disease and inflammatory bowel disease (i.e. Crohn’s disease or ulcerative colitis). These diseases cause inflammation of the gut wall and left untreated, can lead to other serious problems including nutritional deficiencies and some cancers, so it is important they are excluded. If you have had other conditions ruled out, a diagnosis of IBS might be made.

Your doctor should use “Rome III” criteria to diagnose your IBS. These criteria provide specific guidelines on the type and frequency of symptoms that should be present for a diagnosis of IBS to be made. Your doctor will compare your symptoms to the criteria to determine if you have IBS.

What is IBS and what causes it?

The cause of IBS is not known. While many factors are likely to contribute to disease onset, one specific cause has not been identified and it is likely that multiple factors are involved. Factors thought to cause IBS include visceral hypersensitivity (i.e. a more sensitive gut); changes in the way the gut moves food through the gut; changes in gut bacteria populations, and disturbances in the way the brain processes information from the gut. We also know that lifestyle factors, such as diet, stress and exercise can affect IBS symptoms.

There are many IBS treatments available, including the low FODMAP diet, which was developed by our team at Monash University. The low FODMAP diet has been shown to improve symptoms in around 70% of patients, but it is not the only therapy for IBS. Because each person may respond to therapies differently, it is important to talk to your doctor about the treatment options available.

What do I do if I suspect I have IBS?

First things first – see your GP! It is especially important not to make any changes to your diet before undergoing any tests, because changing your diet may interfere with the results. If you or your GP think diet may have affect your condition, then see your local Dietitian who has experience in this area (see also our related blog post: Top 5 reasons why you should see a dietitian before initiating a low FODMAP diet).

To find a gut-specialist dietitian in Australia, visit www.daa.asn.au - Find an Accredited Practising Dietitian page and select "Gastrointestinal (Bowel) disorders" in the area of practice dropdown box.

For all other countries, visit the webpage and search under "gastrointestinal" or "digestive disorders"

Canada: http://www.dietitians.ca/Find-a-Dietitian.aspx

New Zealand http://dietitians.org.nz/find-a-dietitian/

UK https://www.bda.uk.com/improvinghealth/yourhealth/finddietitian

USA  http://www.eatright.org/programs/rdnfinder

Diet Tips:The FODMAP Grand Tour Down Under: IBS relief

Animation artists are helping to visualise and communicate complex scientific findings. The Monash FODMAP Team has worked with the animation artist, Christopher Hammang (from the Garvan Institute in Sydney) to produce a short video that explains how FODMAPs trigger symptoms associated with IBS. 

We have found that when patients have a good understanding of the mechanisms by which FODMAPs trigger IBS symptoms, they find it easier to follow a low FODMAP diet.

The new animation video brings to life the physiological effects of FODMAPs; explains how FODMAPs trigger IBS symptoms, and shows the dramatic effects of a low FODMAP diet in this population. The animation visualises and communicates the findings of research, conducted over several decades, which has quantified the FODMAP composition of hundreds of different foods; described the mechanism by which the diet works, and shown that a low FODMAP diet improves symptom control in approximately three out of every four people with IBS.

The animation has so far received a very welcome response on social media and we hope it continues to be a valuable tool for clinicians and patients alike.

Here are some of the thoughts of our audience so far:

·        ‘Excellent video to explain the effect of FODMAPS on IBS sufferers.’

·        ‘This a great explanation thankyou!! I'm also so grateful for the low fodmap diet!!’

·        ‘This is exactly what I needed to explain to friends/family what the heck is going on in my gut! Thanks Monash team’

·         ‘Great work guys. This is going to be really useful to use in the clinic.’

·         ‘Such a great little piece of sci comms...well done!’

·         ‘This explains my tummy a bit better than I can’

We hope you like it too.

The Monash FODMAP Team

Diet Tips:Preventing festive flare-ups of IBS

By Peta Hill (Paedeatric dietitian)

This Christmas, many of us with IBS will suffer bloating, wind, abdominal discomfort and/or disturbances in bowel habits - even those us who normally have good symptom control. The combination of high stress levels with excessive consumption of rich foods and alcohol at this time of year can be a recipe for tummy trouble. Here are 5 tips for minimising festive flare-ups of IBS:

1.      Continue to eat balanced meals and snacks



Cocktail party food tends to be high in fat – a gut irritant – and contain hidden FODMAPs in marinades, dips, sauces and fillings. The more you consume, the more likely you are to experience symptoms of IBS. Therefore, continue to eat regular meals and snacks, including something before you go to the event - ideally a balanced low FODMAP light meal with protein, salad/vegetables and starch. This way you won’t arrive starving and be tempted to eat every canapé in sight!

2.      Fill up on low FODMAP wholefoods

Whether it’s drinks and nibbles or a sit-down meal, there will be foods you identify immediately as low or high FODMAP and others that you’re unsure of.  Try to fill-up on those you know you tolerate and simply sample those you’re unsure of. 

Party foods to enjoy - peanuts, hard yellow cheeses, olives, rice crackers, sushi, rice paper rolls, cold meats, smoked salmon, fresh seafood, plain barbequed or roast meats, roast vegetables and greens, onion free salads and fresh berries. 

3.      Enjoy alcohol at alternate events with low FODMAP foods

Alcohol is a gut irritant. Try to indulge in alcohol at alternate events, enjoying alcoholic beverages at one event and drinking sparkling water with lemon or lime at the next. If possible, enjoy alcohol at events where you know there will be low FODMAP food options available and choose sparkling at events with limited low FODMAP options.

4.      Plan recovery phases

Stress and anxiety can trigger IBS symptoms. Don’t over commit yourself this festive season and do schedule some early nights at home. On these nights, eat a well balanced low FODMAP meal, drink lots of water, have no alcohol and limit screen time to promote a good night’s sleep.

5.      When you can bring something, bring a low FODMAP option

When you need to bring a plate, bring something you enjoy and tolerate well. Here are some yummy low FODMAP variations to traditional festive favourites:

Appetiser

Smoked salmon makes a delicious appetiser but is often served on bagels or bread. For a low FODMAP twist on a smoked salmon appetiser try:

·         Smoked Salmon & Cucumber Appetizer and replace Greek yoghurt with lactose-free yoghurt or sour cream if lactose is an issue for you

·         Smoked Salmon Fingerling Potatoes and use lactose-free sour cream if lactose is an issue for you

·         Gluten-free blinis with smoked salmon and again, use lactose-free sour cream if lactose in an issue for you

Entrée

Platters make for fabulous entrees. Try:

·        Italian style antipasti plate but omit garlic and opt for spelt sourdough rather than regular bread

·         Fresh seafood platter

Main

Modify traditional stuffing recipes by:

·         Infusing oil or butter with chunks of garlic and onion, then removing chunks.

·         Using gluten free bread or bread-crumbs instead of regular. I recommend, using toasted cubes of gluten free bread.

 

Diet Tips:IBS-Constipation - Sometimes you need to do more than just eat low FODMAP!

By Peta Hill (Paedeatric dietitian)

Adults and children with IBS that tend towards constipation often find a low FODMAP diet alone does not sufficiently alleviate symptoms. Here are some extra tips to prevent constipation:

1.       Eat a variety of fibres

Dietary fibre comes from plant foods.

Insoluble fibre is found in the skins of vegetables and fruit as well as in the bran portion of whole grain cereals. Insoluble fibre promotes regularity by adding bulk to the stool.

Soluble fibre is found in some vegetables and fruit, oats, legumes, nuts and seeds as well as the fibre supplements psyllium and Metamucil. When water is added to soluble fibre it thickens and becomes gel like, helping to soften the stool by adding a gelatinous bulk.

Resistant starch rich foods include legumes, cold cooked potatoes and firm bananas. Resistant starch may improve gut health by feeding good bacteria in the large bowel.

Including a variety of fibres in your diet will ensure you get the health benefits of all of them. Here are tips to assist you with this:

Food	Goals
Vegetables	·         Where possible, consume with the skin on ·         Include a variety of colours each day ·         Eat at least 3 different vegetables per day ·         Spread vegetable intake over at least 2 meals/snacks More tips on improving your intake of vegetables here
Fruit	·         Where possible, consume with the skin on ·         Eat a variety of colours ·         Eat two serves per day (a serve is roughly the size of your fist)
Wholegrains	·         Choose cereal products (breakfast cereal, cracker, bread, pasta, etc.) based on a variety of wholegrains (for example, sorghum or oat breakfast cereal, spelt sourdough bread, brown rice cracker and quinoa pasta ·         Read the ingredients to determine which grain is in the product (remember, ingredients are always listed in quantity from most to least)
Nuts and seeds	·         Eat daily via whole nuts and seeds, 100% nut spreads and ground nuts/seeds (e.g. LSA)
Legumes	·         While many legumes are high FODMAP and best avoided during the initial strict phase of the low FODMAP diet, there are some low FODMAP options including firm tofu, ¼ cup tinned chickpeas and ½ cup tinned lentils are low FODMAP. Aim to include legumes at least 1/week in your diet

More tips on improving your fibre intake here.

2.       If your doctor recommends laxative, take them as prescribed

Laxatives contain chemicals that help increase stool motility, bulk, or frequency and are usually recommended for short-term use. When misused or overused, they can cause problems, including chronic constipation. It is important to understand how laxatives work and use them as specified by your doctor: take the specified dose, at the specified time for the specified period of time and avoid self-medicating.

3.       Drink plenty of water

Drinking plenty of water will assist to keep the stool soft and pass easily.

	Approximate fluid* requirements
Pre-schoolers	4-5 cups
Primary school aged children	5-6 cups
Adolescence	6-8 cups
Adults	8 cups

*Fluid includes plain water, milk and other drinks. The majority of your fluid intake should consist of water.

An adequate fluid intake is particularly important in people taking osmotic laxatives and soluble fibre supplements. An adequate fluid intake helps the laxative and fibre to be effective and decreases the possibility of side-effects.

Handy hints for improving a child’s intake of water: ·         Encourage them to finish a small glass of water with all family meals and snacks ·         Provide them with a water bottle in the car and encourage them to drink to-and-from activities

4.       Be active every day

Exercise is essential for regular bowel movements. Aim to be active every day. For children, encourage active play by limiting screen time and encouraging them to get outdoors. For adults, pedometers can provide self-motivation through tracking steps and setting a target of at least 10000 steps per day.

5.       Try to open your bowels regularly

If you have the urge to open your bowels, GO - even if it means using a public toilet or the toilet at work or school. If your child suffers from constipation and their school has a strict toilet policy (e.g. only one child can use the toilet at a time or “you should have gone at recess”), talk to the school and explain the situation and if necessary, get supporting documents from your child’s health professional(s). With very young children, encourage them to sit on the toilet after each meal for 5-minutes and try to use their bowels. Use a special toy or book to positively reinforce this behaviour.

 

           

Diet Tips:A dietitian’s day on a plate - week 2 of 2

By Shirley Webber (Research dietitian)

If you've ever wondered what a day in the life of a dietitian on a low FODMAP diet looks like, here is a snapshot. 

My general week day

6.00 Cup of tea

7.30 Greek yoghurt with ½ cup muesli (I slowly built up my tolerance to yoghurt)

9.00 Sourdough spelt toast with Marmalade and a cup of tea

10.30 ½ banana and hand full of nuts

12.00 Chicken stir fry (homemade) with rice or Jaffle with mince meat and vegetables (sourdough spelt bread)

** I always have a lots of vegetables with a variety of low to moderate FODMAP rating Occasionally I would throw in some high FODMAP vegetables eg. snow peas, but I’ll only eat about 4-5

3.00 Muesli bar or baby bell cheese and a tea

4.00 Glass of water

6.30 ½ Raw carrot while I’m cooking to stop myself from snacking on the food that I’m preparing and thus overeating

Dinner – Shephard’s pie with lots of vegetables. I make mine with a tomato sauce and check that there is no garlic or onion in the sauce base. Vegetables include carrots, capsicum, and the green tops of spring onion. I always top mine off with a thin layer of cheddar cheese baked in the oven, so it’s nice a crunchy on the top

Another frequently made meal in my house is roasted chicken with roasted vegetables: sweet potato, radishes, carrots, a couple of slices of beetroot and pumpkin

8.00 Peppermint tea or water

My weekends are never the same

Generally, I like to sleep in and have breakfast at 8.30 am. One of my weekend favourite breakfasts is bruschetta and poached eggs. I make this with sourdough spelt toast, topped with a variety of tomatoes, black olives, olive oil, salt and a poached egg on top.

If I’m out exercising, hiking or at the gym, I’ll snack on a banana and a Greek yoghurt in between breakfast and lunch, while drinking plenty of water.

12.30 pm Lunch is usually a meat (chicken or deli ham) and salad sandwich with tomatoes, ice berg lettuce and avocado. If I’m feeling adventurous I might add a teaspoon of chutney or mustard

4.00pm I usually drink tea in the afternoon

6.30pm Dinner is a big family affair which usually involves a barbeque. Salmon with a bit of lemon, butter and salad is popular in warm weather or roasted vegetables if it’s cold out

Eating out

I still enjoy eating out. I tend to choose Japanese as it is freshly cooked and I can ask for onion and garlic to be left out (those two ingredients are my main concern). If I eat other cuisines I tend to order non-marinated chicken or meat with mixed vegetables. I always run my dietary requirements passed restaurant staff and have found chefs are generally willing to alter meals for me. An advantage of living in Melbourne is that the low FODMAP diet was developed here by Monash University. Therefore, I find that there is good awareness of food intolerances compared to other countries. This said, awareness of the low FODMAP diet is growing worldwide, so this is a positive sign. 

I think that even though I struggle with IBS it is important to still have a diet that includes a wide variety of foods to ensure that I get all the nutrients that my body needs. Food is meant to be enjoyed, so go ahead, try new things and get creative!

What’s on your plate?