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:NEW US RESEARCH: The Low FODMAP diet superior for the relief of abdominal pain and bloating

The Low FODMAP Diet & mNICE Diet Compared

By Dr Jane Varney

 

An interesting study was published by our colleagues at the University of Michigan this week (1). The US study compared the effect of two dietary interventions on IBS symptoms in people with diarrhoea predominant IBS (IBS-D). The interventions in question were the low FODMAP diet and a more traditional dietary approach, known as mNICE (modified guidance from the National Institute for Health and Care Excellence).

Ninety-two eligible subjects were recruited into the study, all of whom had IBS-D and most of whom were female (71%). Participants were randomised to either a low FODMAP diet or the mNICE diet for 4 weeks. Because this was also not a feeding study, a dietitian taught participants how to follow their respective diets, but participants were required to put this advice into practice and prepare their own meals. Resources developed at Monash and Michigan Universities were used to teach participants how to follow the low FODMAP diet. Guidance given to the mNICE group included to eat small frequent meals, to avoid trigger foods and to avoid excess alcohol and caffeine. This guidance was considered ‘modified’, because high FODMAP foods were not specifically excluded as would typically be the case on this diet.

 

 The study revealed a number of interesting findings:

·         The diets were equally effective at providing ‘adequate relief’ of overall IBS symptoms, with improvements experienced in 41% of participants in the mNICE group and 52% of participants in the low FODMAP group.

·         More participants in the low FODMAP group experienced an improvement in abdominal pain, 51% versus 23%, p=0.008.

·         The greatest benefit of the low FODMAP diet was for relief of abdominal pain and bloating, with improvements in stool consistency, stool frequency and urgency also observed in this group.

Take home messages:

·         The low FODMAP and mNICE diets improve symptom control in roughly half of all people with IBS-D.

·         The low FODMAP diet may be a superior choice for the relief of some symptoms, namely abdominal pain and bloating

 

1. Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K. A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. Am J Gastroenterol. 2016.

Link to full research article: http://www.nature.com/ajg/journal/vaop/ncurrent/full/ajg2016434a.html 

 

Diet Tips:Adding glucose to high FODMAP foods – does it really help?

By Marina Iacovou (PhD Candidate and Accredited Practising Dietitian)

In an earlier blog post this year (http://bit.ly/1WvWU5Y) we speculated that although early studies suggested adding glucose to fructose may improve tolerance, the strategy was not looking promising – instead all it was doing was adding more sugar to the overall diet.  There was confusion around this strategy with individuals adding glucose to all FODMAPs, not just fructose, which is the only FODMAP that could benefit from glucose addition. Consuming glucose tablets became common practice for many people when eating onion and garlic, foods rich in fructans, not fructose, which scientifically will not improve symptoms.

We can now confidently tell you that adding glucose to foods to help with the absorption of FODMAPs, even fructose, does not work.

One of our PhD candidates, Caroline Tuck, has published work on this very topic. If you want to read the full publication, please click here.

A brief summary of the study and its findings:

• Patients with a positive fructose breath test (“fructose malabsorption”) and functional bowel disorders such as IBS, were recruited. Healthy participants were recruited as a reference/control group
• Participants were provided with 6 different sugar solutions (PART A) – some acted as control solutions (glucose only) and others were combinations of fructose and glucose, and fructans and glucose which were compared to fructose alone and fructan alone
• Additional studies (PART B) were undertaken. where glucose was added to whole foods high in excess fructose
• It was a series of two randomised controlled, double or single-blinded crossover trials – this means that the participants (and in part A the researchers) were not aware what solutions were being consumed and the solutions were given in a random order. As such the results are more reliable
• Overall, breath hydrogen scores and patient symptoms did not improve with the addition of glucose to fructose or fructan solutions, or to whole foods
• Breath hydrogen responses in healthy participants were similar to patients with functional bowel disorders – showing that “fructose malabsorption” is normal
• The results of the study, question the reliability of breath hydrogen tests in a clinical setting. 

So we can conclude that: 1) breath hydrogen tests, particularly to fructose, are unreliable – this is consistent with a previous study we posted about http://bit.ly/2fSaVcn and 2) Overall, the strategy of adding glucose to drinks or foods to lessen the effects of dietary FODMAPs on functional gastrointestinal symptoms, has no evidence.

Some of you may have been doing this already – taking glucose tablets with high fructose foods. If you really feel it helps, you can continue, but remember these points:

• Your total sugar intake will increase significantly
• Your tolerance to FODMAPs, including fructose, can fluctuate over time, so maybe this strategy is working because your tolerance to fructose has improved and you can drop the glucose without significant symptoms

Something to consider…

Tuck CJ, Ross LA, Gibson PR, Barrett JS, Muir JG. Adding glucose to food and solutions to enhance fructose absorption is not effective in preventing fructose-induced functional gastrointestinal symptoms: Randomised controlled trials in patients with fructose malabsorption. J Hum Nutr Diet. 2016.