Diet Tips:Research article: Group or One-on-one FODMAP education?

By Caroline Tuck (APD, PhD Candidate)

King’s College in London has recently published a research article comparing group vs. one-on-one low FODMAP diet education in patients with Irritable Bowel Syndrome. This has never been researched before.

The study compared 263 patients receiving Dietitian-led group education (no more than 12 people in each group) to 101 patients receiving the more traditional approach of one-on-one sessions with a Dietitian. Before being enrolled in the study, each patient was assessed to check suitability to either group or one-on-one education. They asked each patient to rate their symptoms before and after intervention.

Overall, the study found that more participants were satisfied with their symptom control after education than before, suggesting that the low FODMAP diet was working. However, participants were equally satisfied after group versus one-on-one education, showing that the different types of education were equally beneficial; 54% were satisfied with symptom control after group education and 60% were satisfied with symptom control after one-on-one education.

There are a few things to keep in mind here. In some cases, seeing a Dietitian on an individual basis is important. This is especially the case if you have any additional food intolerances / allergies / preferences. It is also important to keep in mind that the low FODMAP diet is not always a one-size-fits-all approach, therefore you may benefit from seeing a Dietitian who is able to adapt the diet to closely suit your needs and symptoms.

We always recommend you consult with your Doctor first, before attempting any dietary change.

Thanks King’s College for a very interesting research article investigating something that has never been looked at before!

Whigham, L., Joyce, T., Harper, G., Irving, P. M., Staudacher, H. M., Whelan, K., & Lomer, M. C. E. (2015). Clinical effectiveness and economic costs of group versus one‐to‐one education for short‐chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome. Journal of Human Nutrition and Dietetics.

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:A dietitian’s day on a plate - Week 1 of 2

By Shirley Webber (Research dietitian)

As someone who has struggled with IBS for many years, I was relieved when I found out about the low FODMAP diet. Throughout my high schooling, I thought that having an upset stomach was “normal” and constantly feeling tired and like my head was in a giant cloud was just me being a typical teen. It wasn’t until I went to University that firstly, I realised these symptoms were not normal and secondly, I began to suspect that the symptoms may have been triggered by dietary factors.

I subsequently underwent testing to rule out serious illnesses, including coeliac disease, all of which came back negative. As a last resort, my GP suggested I have a breath tests to check my tolerance of lactose and fructose. When I found that I malabsorbed both sugars, my GP then gave me a list of all fructose and lactose containing foods that he found on the internet and told me to “never eat these foods”. That was the problem solved as far as my GP was concerned. Having seen this doctor for most of my schooling life, I trusted his every word and followed a very restricted diet for three years. I felt anxious when I ate out and found growing up in a family where food was at our core very difficult.  Increasingly, I felt that my highly restricted diet was difficult to follow and just not good enough for me.

This all changed when I read a magazine article about research into diet and gut health. This article sparked my interest in dietary research and health. At a similar time, my dad discovered that he had the same food intolerances as I did and after consultation with a dietitian, we became aware of the low FODMAP diet. Importantly, we discovered that foods should not be restricted for life, but rather reintroduced slowly to identify tolerance to specific FODMAPs. Over the next two years, I gradually tested my tolerance to new foods, reintroducing foods I was previously “not allowed”. This saw me find a much healthier diet that I could happily live with.

My personal interest in nutrition and food intolerances grew to the point that I decided to do further post graduate studies in Dietetics to better understand the complexities of food intolerances.

So now you have my personal IBS story. Next week I will give you an idea of what I eat to keep myself healthy and my symptoms at bay…a dietitian’s ‘day on a plate’.

 

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?

Diet Tips:The Low FODMAP Diet For IBS – It does not need to be difficult!

By Marina Iacovou (PhD candidate and Accredited Practising Dietitian)

There is no reason why a low FODMAP diet cannot be a nutritionally balanced diet. There is a variety of foods to choose from in each of the five core food groups which are outlined in the Australian Guide to Healthy Eating:

1) Grain foods

2) Vegetables and legumes/pulses

3) Dairy and dairy alternatives – milk, yoghurt, cheese

4) Fruit

5) Meats and meat alternatives - lean meats, poultry, fish, eggs, tofu, nuts and seeds and legumes/pulses

Our app breaks down each of the 5 core food groups for you, making it easier for you to find suitable foods in each group while trialling the low FODMAP diet. So if anyone has recently been diagnosed with IBS and is about to trial the low FODMAP diet, or you are simply trying to explain this diet to friends and family – it is not a fructose-free, dairy-free, nut-free, wheat-free, gluten-free diet or a diet that excludes a particular food group.  

The first step is to see a dietitian to help you. This is something we always recommend to people and something we have written about before http://bit.ly/1BfAYNL and http://bit.ly/1HSJhRi.  It is also important to remember it is not a ‘lifetime’ diet http://bit.ly/2ccWi4b and once your symptoms are well-controlled, the next step is to work with your dietitian to re-introduce foods back into your diet.

Also, if your symptoms are well-controlled and there are foods you want to eat but we are yet to test or you are unsure of, we recommend you try them in small amounts to begin with and then monitor your symptoms as you go. This is something we have also written about http://bit.ly/1Upsw8K, which your dietitian can help you with as well.  

If you have a family, are entertaining at home, or have children with IBS there is no reason why everyone has to eat a low FODMAP meal, or for anyone to feel different/left-out.  This can be done by creating meals where everyone can choose what they eat. This can be fun especially for children and a way of re-introducing moderate-high FODMAP containing foods back into your diet. Here are some ideas to get you thinking: 

- Antipasto platters http://bit.ly/1KXVI1S

      -  Baked potatoes http://bit.ly/1SzdxH2

The low FODMAP diet does not need to be plain and boring – we have that covered for you as well. Here is how to add some flavour without adding symptoms http://bit.ly/1EwLRy3 and some tips on adding the taste of onion and garlic http://bit.ly/1MnpAG7into your meals.

If you are travelling or dining out this may need a bit more planning. For instance, when dining out you may want to source a menu from the restaurant beforehand or call ahead and ask what can be arranged for you. You may like to try some Asian cuisine, http://bit.ly/208AS8qor Greek cuisine http://bit.ly/1E2qSSh - whatever you prefer there will always be an option for you. When travelling you may need to organise a special meal on a flight or take some suitable snacks with you just in case. There are several tips and ideas to get you through while travelling, which you can read all about here http://bit.ly/1RnI7IM and http://bit.ly/1YqHvRL. 

If you want to learn more about our team, our history, our resources, what research we are doing and more, here it all is http://www.med.monash.edu/cecs/gastro/fodmap/

           

Diet Tips:#FODMAPchat Twitter Forum- Summary of Responses

Thank you to all who participated in our September 2016 Twitter chat. For all those that wanted to participate but couldn’t make it for the chat, here is a summary of the conversation:

Q1. Is there a standard re-challenge protocol to use with all patients on a low FODMAP diet?

We wish it was that simple, but unfortunately there is no standard protocol for re-challenging FODMAPs. It is so important to seek the assistance of an experienced dietitian to individualise the FODMAP challenge process to the needs and symptoms of each patient. The length of the re-challenge, foods chosen and the portion sizes used may also vary between each individual. Dietitians may find it useful to ask their patient which foods they miss the most from their regular diet and consider introducing those foods first when getting them started on re-challenging.

The re-challenge phase is an important part of the low FODMAP diet, but research studies on this specific area are lacking. Unfortunately, a rechallenge research trial is very difficult to design and conduct.

Q2. Should all FODMAP subtypes be challenged in every patient?

It is important that all FODMAP subtypes that have been restricted are re-challenged. For some patients lactose may remain in the diet, even during the initial elimination phase, if lactose intolerance is not evident. We always recommend re-challenging fructose due to unreliability with the fructose breath testing.  

A key point to note is that often just because an individual didn’t tolerate one particular food within a subtype of FODMAPs doesn’t mean that this person won’t tolerate any other foods within that subtype. The portion sizes of these foods may need to be adjusted. Seeking the assistance of a dietitian to tailor the diet to an individual is essential.

As each person’s FODMAP tolerance and their FODMAP threshold varies, a dietitian may need to be more cautious with one person who is extremely sensitive compared to another person who may have reasonable FODMAP tolerance. No two patients are alike and personalising the diet will assist patients with expanding the diet long term, which is very important.

Starting with a subtype of FODMAPs that the patient may tolerate better can ease the patient into the rechallenge process.

Q3. How long should each FODMAP challenge go for?

The answer varies depending on the patient and their symptoms and their level of anxiety about doing the re-challenge. For those who need a cautious approach, slowing down the challenge to testing a food every second day over the course of a week may be appropriate. For others, a typical challenge of a new food is to introduce a small portion and increase the amount every day for 3-4 days.

Q4. What sort of doses of foods should be used for FODMAP challenges?

There are no set portion sizes that suits each person. How much should be used depends on the individual, their symptom severity and tolerance level. As a general rule, half of a normal serving of a particular FODMAP containing food would be consumed on day 1, then increase the serving size on the second and third day.

Q5. What do you do with a patient who has severe reactions to all challenges?

For highly sensitive patients it may be necessary to slow down the re-challenges to small serves of a particular food consumed every second day. Alternatively try using different foods to the previous challenges in small amounts. If the patient continues to react to even small amounts, alternative therapies may need to be considered or they should be referred back to their GP for further investigations.

Small intestinal bacterial overgrowth (SIBO) may be a contributing factor in those with ongoing symptoms, however SIBO is very difficult to diagnose. A glucose breath test can be undertaken, but this is not a perfect science and will not diagnose SIBO in all cases.

Assess the patient’s stress levels as stress is one factor that can further exacerbate symptoms with challenges increasing stress and anxiety.  Continue to provide support and encouragement during the re-challenge phase.

Q6. What are some helpful tips to increase fibre intake on low FODMAP diet?

Some handy hints for increasing fiber while on a low FODMAP diet:

·         Try and include a vegetable with breakfast, such as tomato or spinach,

·         Add small amounts of low FODMAP legumes or pulses to soups, stews and salads - You may want to start by adding canned legumes and pulses as they tend to be lower in FODMAPs than fresh options

·         Aim to include fiber at each meal and snack, this may include oats, baked potatoes with the skin, oranges, quinoa and chia seeds

·         Also making food swaps such as using brown rice rather than white rice will help increase fiber

Q7. What are some of the key hidden FODMAPs that can be found in US commercial products?
Hidden ingredients aren’t always so hidden so do encourage your patients to check the ingredient label for foods and supplements high in FODMAPs particularly looking at sweeteners and added fibres such as inulin, fructose, high fructose corn syrup, crystalline fructose, lactose, and apple/pear juice concentrate. Also check liquid medications, chewable vitamins, powdered protein supplements or shakes for sweeteners that are often high in polyols or fructose.

Please remember to check the Monash University low FODMAP app for more information on US products that we have tested for FODMAP levels that includes sauces, gluten free breads and jams containing fructans and HFCS.

 Q8. Are fermented foods suitable on a low FODMAP diet?

There is a huge interest in this area and yes there are some fermentable foods that are low in FODMAPs, however not all low FODMAP foods remain low in FODMAPs when fermented.  Tempeh is low in FODMAPs and a good vegan option for a low FODMAP fermented option. We have also found spelt sourdough bread to be low in FODMAPs.

Sauerkraut has recently been tested and found an interesting result. 1 Tablespoon of Sauerkraut is low in FODMAPs however becomes moderate to high in the Polyol (mannitol) in a larger serve despite common cabbage being low in FODMAPs. We also tested fermented red cabbage and found that when red cabbage was fermented it was low in FODMAPs when consuming only ½ a cup but contained moderate Oligosaccharides (Fructans) at 1 cup, whereas fresh is still low in FODMAPs at these portion sizes.
Kefir is only high in lactose so another suitable option for those who are not lactose intolerant.
We can’t always predict what is going to happen to low FODMAP foods once they have been processed in some way or another and therefore these foods need to be tested. We will share this knowledge via our Monash University low FODMAP app as the foods are tested.

Q9. What next if the low FODMAP diet does not improve symptoms?
When the low FODMAP diet is unsuccessful for a particular patient then look further into their diet history to see if excess fats, sugar and caffeine, or an inadequate intake of fibre are contributing to their symptoms. Further investigate if other dietary factors may be relevant for each individual patient such as histamine, Type IV hypersensitivity or IgE- mediated food allergy.

The low FODMAP diet doesn’t always work for everyone. If it does not work it is very important that FODMAPs are reintroduced into the diet. A dietitian can continue to provide support and assistance to a patient in achieving a healthy balanced diet, consider other dietary factors that may be playing a role, as well as working with other health professionals to investigate other factors contributing to symptoms.

Q10. What are some handy hints for travelling on a low FODMAP diet?

Travelling while trying to follow a low FODMAP diet can be difficult. Monash University are testing more international foods and will continue to add these to the Monash University low FODMAP diet app under specific country flags.

Plan ahead. Pack low FODMAP snacks to avoid getting hungry and therefore grabbing something that may flare up symptoms. If lactose is an issue then carrying Lactaid / Lacteeze and/or Beano + Dairy defence could assist with managing symptoms if you are limited with food choice. For the very organised traveler, take a soft side lunch bag or cooler in your luggage to carry low FODMAP snacks purchased at your destination. Request a hotel room with a mini fridge to store low FODMAP options.

For domestic trips you may want to take your own fruit, cheese, nuts, snack bars or nutritional drinks.

Note that patients may actually tolerate foods better whilst travelling due to having less stress and anxiety to contribute to symptoms and being in a relaxing state may help relieve some symptoms.

Thank you to all who participated in the fodmapchat and for those who missed this twitter chat feel free to check out the hashtag #fodmapchat for the discussion and follow us on Facebook and twitter to stay in the loop for when the next one will be happening.

Remember to encourage patients to download the Monash University low FODMAP diet app to further fund research and food testing as well as to get all the latest food testing information.

           

Diet Tips:A Guide to Low FODMAP Meal Planning

By Lyndal McNamara (Dietitian) 

Meal planning is a great skill to have, not only for those with special dietary needs, but anyone who leads a busy lifestyle (let’s be honest, that’s most of us!).

As a dietitian with IBS, planning my meals in advance not only saves precious time during the week but also helps ensure that my low FODMAP diet is nutritionally balanced and well thought out (helping me avoid uncomfortable mistakes!).

Here is an example of what my typical day looks like. I like to use the Australian Guide to Healthy Eating (AGHE) to help plan out my day according to the number of serves I need of different foods from the five food groups. As a 23 year old female, the AGHE recommends that each day I aim for:

-          5 serves vegetables/legumes/beans

-          2 serves of fruit

-          6 serves of grain/cereal foods

-          2 ½ serves meat/alternatives

-          2 ½ serves dairy foods

Check out the AGHE website for more information about the 5 food groups and how much you need each day (this varies depending on your age, gender and activity level)

https://www.eatforhealth.gov.au/food-essentials

Sample Meal Plan:

Breakfast	Porridge with yoghurt, cinnamon & banana ½ cup cooked rolled oats (120g) 1 tsp. chia seeds (5g) 1 tbs. low-fat milk (25g)* low-fat natural yoghurt (100g)* 1 medium banana (100g)  Sprinkle of cinnamon
Snack	Small handful mixed nuts (30g)
Lunch	Moroccan chicken & roast vegetable salad: chicken tenderloins (40g) ¼ cup roasted sweet potato (35g) ¼ cup roasted red capsicum (26g) ½ cup baby spinach leaves (19g) ¼ cup canned chickpeas (42g) 1 tbs. garlic infused oil (to cook chicken and vegetables) 1 tbs. Moroccan spice mix (cumin, coriander, cinnamon & ginger  ½ cup cooked quinoa
Afternoon Tea	2 x wholemeal crackers (18g)  2 slices low-fat cheese (40g)
Dinner	Beef stir-fry  Beef stir-fry strips (65g)  ¼ cup red capsicum (26g) ¼ cup carrot (30g) ¼ cup green beans (43g)   ¼ cup bok choy (22g) 1 tsp grated ginger (3g)  ½ red chilli (14g) 2 tsp oyster sauce (10g) 2 tsp soy sauce (10g) 1 cup steamed brown rice
Supper/dessert	Tub of low-fat yoghurt (200g)*  1 cup strawberries (140g)

*I am not lactose intolerant so use regular dairy products. Please substitute for a lactose free alternative if you malabsorb lactose.

	Total/day
Energy	7223kJ
Protein	103.5g
Carbohydrates	170.7g
-          Sugar	68.0g
Fat	63.6g
-          Saturated fat	14.8g
Dietary fibre	31.4g
Iron	12.8mg
Calcium	1075mg
Sodium	2059mg
Total FODMAPs (excluding lactose)	LOW

Meal Planning tips: 

• Set aside a few hours each weekend to think about the coming week and plan your meals using the Monash App. Decide what you will have for dinner each night (at a bare minimum) and use this plan to write a shopping list. 

• Busy week ahead? Why not spend a few hours each Sunday afternoon cooking 1-2 healthy low FODMAP meals to set aside or freeze for those hectic weeknights! 

• Pre-prepare and stock your fridge with healthy low FODMAP snacks such as tubs of low-fat yoghurt (lactose free if needed), small zip-lock bags of low FODMAP nuts, cut up vegetable sticks (carrot, cucumber, capsicum) with Roasted Red Pepper & Pumpkin Hummus or Low FODMAP Tzatziki Dip, low FODMAP fruit, cheese and plain crackers etc.