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:Research update: long-term improvement in symptoms of IBS and IBD patients treated with a low FODMAP diet- A retrospective Study

By Lyndal McNamara (APD)

Background

New research about the long-term effectiveness of a low-FODMAP diet to reduce the symptoms of irritable bowel syndrome (IBS) has just been published! This retrospective study provides data regarding the longest follow up to date of patients with IBS (some of which also had IBD) using the low FODMAP diet approach. One hundred and eighty patients were included in the study. All patients had been assessed by a gastroenterologist and previously received dietary education from a dietitian regarding a low FODMAP diet. Participants were surveyed to collect information about the effectiveness of the diet, symptoms, adherence to the diet, their satisfaction with dietary treatment, disease activity, changes in stool type and quality of life over an average follow-up time of 16 months.

Results

Symptoms:

The study found that 86% of patients had a significant improvement in their IBS symptoms on a low-FODMAP diet, with the greatest relief in symptoms of bloating and abdominal pain. Overall, stool form normalised with a low FODMAP diet in the majority of patients.

Adherence and satisfaction with the diet:

Eighty four percent of patients had expanded their low FODMAP diet at follow up, where some higher FODMAP foods had been re-introduced after the identification of trigger FODMAP foods. The most common foods not reintroduced by participants were wheat, onion and lactose containing products. Despite the fact that the vast majority were following a very relaxed version of the low FODMAP diet, they still reported satisfaction with the treatment and good symptom control.

IBS severity and quality of life:

Most patients reported good quality of life and only mild-moderate IBS severity at follow up. Furthermore, 37% of IBS patients who started the trial with more severe IBS (type B, C or D in graphs below) tended towards a milder IBS (type A) at follow-up. A similar effect was noted in the group with IBS in the setting of IBD.

Study Limitations:

A major limitation of this study was that it was conducted retrospectively, meaning that the results rely on the patients’ memory and recall of events, which introduces a potential source of error. A large percentage of patients (48%) invited to take part in the study also declined to participate. This introduces a type of bias known as selection bias, meaning that those who agreed to participate may be more likely to have had a positive experience with the diet being tested. Additionally, the researchers used tools that were not validated, such as the IBS severity graphs shown in the above figures. As these are not validated, they have not been tested for their accuracy and cannot be relied upon to form firm conclusions.

Take home messages:

·         This is the first study to demonstrate the long-term effectiveness of a low-FODMAP diet for improved symptom management in IBS (alone or with coexisting IBD) patients

·         This study also supports the importance of the reintroduction phase of the diet and demonstrates that for most patients, symptom management remains satisfactory on a modified low FODMAP diet in the long-term (where some high FODMAP foods have been successfully reintroduced)

·         When looking at research studies, the tools used should be validated, and if not, outcomes should be read with caution

·         This type of retrospective study has several important limitations that need to be considered

Larger, prospective trails are now required to further investigate the long-term effectiveness and determine other effects of a low FODMAP diet in IBS and IBD patients, particularly any negative effect on the gut microbiota

1.    Maagaard L, Ankersen DV, Végh Z, Burisch J, Jensen L, Pedersen N, et al. Follow-up of patients with functional bowel symptoms treated with a low FODMAP diet. World Journal of Gastroenterology. 2016 Apr 21;22(15):4009-19.