Diet Tips:Testing your tolerance to untested foods

By Dr Jaci Barrett

For those of you who have been following a low FODMAP diet for some time, we hope that you have been testing out some moderate to high FODMAP foods using our app. As you know this is an essential part of the approach, working toward the goal of the diet - to relax the diet to your level of tolerance whilst still controlling your symptoms. Find out why here.

Due to the number of foods that make up our diet, particularly when we include packaged foods, there will come a time when a food you would like to include in your diet is not in the app.

Don’t panic. This means we haven’t tested it.

Again, don’t panic. There is a reasonable chance it will be well tolerated.

Don’t avoid it just because it isn’t in the app. Instead, when your symptoms are well controlled, try a small quantity, once a day over 2-3 consecutive days. If you do not get troublesome symptoms, then it is OK to include it in your diet. You can decide how often and what quantity you can manage. Remember, your low FODMAP diet only needs to be as strict as your symptoms require.

Also remember our food testing continues. You can even send us suggestions on which foods you would like tested by contacting us directly through the app.    

Diet Tips:A bit of bloating is beneficial

By Dr Jaci Barrett

Bloating is one of the most common gastrointestinal symptoms. It can occur as a sensation of gas stretching the gut, with or without actual distension, when the abdomen is visually swollen. Bloating often results in significant discomfort and/or pain and is a major complaint in many patients with irritable bowel syndrome.

One of the major aims of the low FODMAP diet is to reduce bloating by restricting short chain carbohydrates from the diet that are fermented by gut bacteria. The fermentation process is responsible for the gas release and distension of the gut that leads to bloating. 
As we have pointed out previously, the low FODMAP diet should only be followed strictly short term. 

The diet should be relaxed long term to ease the burden of following the diet, but more importantly to reintroduce some FODMAPs back into the diet for their potential benefits. This benefit arises from the fermentation of FODMAPs by gut bacteria – the reason we restrict FODMAPs in the first place – but small amounts of FODMAPs are fuel for good bacteria and is likely to be important in long term gut health.

Many people try the reintroduction or rechallenge phase and state they have failed - their symptoms returned on reintroduction of the foods and they went back to a strict low FODMAP diet. This will be necessary for symptom control only in the minority of extremely sensitive individuals. For everyone else, it may be that smaller amounts of FODMAPs need to be trialed, and in fact, the return of symptoms needs to be looked at in a different way.


When you experience symptoms, it is vital that you are tuned in to the severity. Pain and significant discomfort are not OK and you can discuss these outcomes with your treating dietitian who can advise further on future challenges and food trials you may better tolerate. But for many people, the reintroduction of FODMAPs, or FODMAP ingestion when eating, results in gas production and a little bloating. The initial thought is that there has been a reaction and the food should again be removed from the diet, but we ask you to think about it in a different light.

Fermentation and gas production after eating high FODMAP foods is beneficial to the gut. If you experience some gas related symptoms that are tolerable and perhaps just include some mild bloating and flatus, this could be a good sign that you are providing fuel that encourages good bacteria in your gut. Everyone experiences some bloating and flatus and it is important not to immediately consider these as ‘symptoms’ of IBS, rather they should be considered a normal part of healthy digestion (as long as there is no significant discomfort or pain!).

So remember, a little gas is a good thing.

           

Diet Tips:Food Allergy or Food Intolerance?

By Lyndal McNamara (APD)

The terms food allergy and food intolerance are often confused as they can have similar symptoms, but they actually refer to two very different conditions. Whilst both ‘food allergy’ and ‘food intolerance’ broadly describe an adverse reaction that occurs in response to exposure to a particular food, there are a number of important differences between the two conditions.

Food Allergy

A food allergy results when the body’s immune system has an abnormal reaction after exposure to a particular food protein. Exposure may be via eating the food. However, in severe cases it may also be triggered by simply touching the food. In allergic individuals, the body’s immune system responds by releasing various chemicals into the blood stream, which can affect many different parts of the body. 

These chemicals are responsible for the often-severe symptoms associated with a food allergy including an itchy skin rash (hives), swelling of the lips, mouth and tongue, vomiting, diarrhoea, abdominal cramping and even breathing difficulties. Extremely severe allergic reactions to food, known as anaphylaxis, can even be life threatening and require urgent medical attention. 

Onset of symptoms in someone with a food allergy can be extremely rapid (within minutes), however, delayed reactions are also known to occur (taking several hours). Exposure to even trace amounts of the responsible food protein is often enough to trigger activation of the immune system and result in symptoms. 

For this reason, strict avoidance of the food protein is necessary and being able to confidently read and understand food labels is key to avoiding unintentional exposure. Food allergies are typically first recognised and diagnosed in infancy or early childhood and new diagnosis as an adult is rare. True food allergies are diagnosed by an allergist, who uses a detailed medical and symptom history in combination with skin prick testing. 

Food Intolerance

Food intolerances on the other hand have many different causes, with the key difference being that they DO NOT involve activation of the body’s immune system. The symptoms of food intolerance predominately affect one system. Gut symptoms due to food intolerance typically result due to components within a food (such as FODMAPs) not being digested and/or absorbed well. This in turn can result in higher levels of gas production by bacteria that live in the large intestine or cause excess water to be drawn into the bowel, leading to symptoms such as bloating, abdominal pain and changes in bowel habit (i.e. diarrhoea or constipation). 

The skin can be affected by certain chemicals found naturally in or added to food, for example the natural chemical group, amines in beef, tomato and cheese can trigger eczema in sensitive individuals. Despite the symptoms of food intolerance being unpleasant, they are not life threatening. Onset of symptoms is also usually quite delayed (several hours to several days) and may not occur every time the offending food is consumed. 

The symptoms of food intolerance are therefore ‘dose responsive’, meaning that symptoms will not be experienced until a certain amount or ‘threshold dose’ of the food has been eaten. This ‘threshold dose’ can vary significantly between individuals. First onset of a food intolerance can occur at any age, but unlike food allergies, food intolerances cannot be diagnosed using any specific test. 

Elimination and food rechallenge dietary approaches, such as the low FODMAP diet, are therefore often necessary to pinpoint particular foods that may be triggers of food intolerance symptoms. As these diets can be overly restrictive, it is highly recommended that individuals with suspected food intolerance consult with a dietitian before attempting to modify their diet. A dietitian will help ensure that these diets are implemented in such a way that they are effective but also provide adequate amounts of essential nutrients.

Summary – Food Allergy vs Food Intolerance

Food Allergy	Food Intolerance
An adverse reaction to food that involves activation of the immune system	An adverse reaction to food that DOES NOT involve activation of the immune system
Symptoms occur rapidly (within several minutes to hours) after exposure to even minute quantities of the food allergen            Symptoms will always occur when exposed to the food allergen	Symptoms may not occur unless exposure to the trigger food exceeds the individual's ‘threshold dose’            Symptoms can occur several hours or even days after exposure to the trigger food
The food allergen must be strictly avoided to prevent an allergic reaction	The trigger food does not need to be strictly avoided as consumption of small amounts may not cause any symptoms
Symptoms are often severe and potentially life threatening	Although symptoms may be unpleasant, they are not life threatening
Able to be diagnosed using immunological testing (blood test or skin prick testing)	Unable to be accurately diagnosed using any specific test            Diagnosis relies on food elimination and rechallenges
Diagnosis usually occurs in infants and young children            New diagnosis in adults is rare	Diagnosis is common at any age

References:

Turnbull JL, Adams HN, Gorard DA. Review article: the diagnosis and management of food allergy and food intolerances. Alimentary pharmacology & therapeutics. 2015;41(1):3-25.

 

 

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:Zucchini Pasta with Cabbage and Parmesan salad

By Dr Jaci Barrett

A few weeks ago we shared with you some information about FODMAP stacking, explaining that green foods are safe, some foods have an upper limit, and how this impacts when you combine foods. See here to read this blog again.

We wanted to show you how to “FODMAP stack” in a recipe and tempted you by mentioning a zucchini pasta and cabbage and parmesan salad…. Here it is.

This recipe contains a greenserve of zucchini and a green serve of common cabbage. Both of these foods become amberor red if eaten in larger quantities. If you eat more than 1 cup of common cabbage it will take you to a red serve. Try this as a challenge if you are at the stage of testing your tolerance to FODMAPs. We want you to try to step up your FODMAP intake and relax the diet over time. If you are not ready for that, you can swap common cabbage for red cabbage which is greenuntil even larger servings of 1 ²/₃ cups.

Ingredients:

Zucchini pasta – serves 1

• 1 small zucchini, cut into strips like spaghetti (<100g)
• 2 teaspoons olive oil
• ½ clove garlic, sliced
• 2 anchovies, sliced
• Chilli flakes, ~¹/₄ teaspoon or as desired
• 1 tablespoon grated Parmesan

Cabbage and Parmesan salad – serves 1

• 1 cup thinly sliced cabbage (common or red cabbage – see note above)
• ¹/₃ cup grated carrot
• 10g Parmesan, shaved with vegetable peeler
• 2 teaspoons olive oil
• 1 teaspoon apple cider vinegar
• Salt and pepper to taste

Method:

Zucchini pasta

1. Heat oil in small fry pan
2. Add sliced garlic and heat for 1 minute to add flavour into the oil
3. Remove garlic slices from pan and discard
4. Add anchovies and chilli and heat for 2 minutes, stir
5. Add zucchini and heat for 2 minutes, stir
6. Transfer to a plate and stir through parmesan

Cabbage and parmesan salad

1. Add cabbage, carrot and parmesan to a bowl and combine
2. Add olive oil, vinegar and salt and pepper

Nutrition Information/serve:

Energy	1509kJ
Protein	16g
Carbohydrates	8g
Fat	28g
Saturated fat	8g
Fibre	7g
Sodium	870mg
Calcium	379mg