<#L#> HEALTHY FOOD GUIDE November 2012 November 2012 HEALTHY FOOD GUIDE <#R#>

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Coffee is often viewed as an IbS culprit, but new research pinpoints other, unexpected food triggers

Eat welll

The new soluTion for

Big news for sufferers of irritable bowel syndrome: a new treatment from Australia looks set to become the gold standard over here. Dietitian Jennifer Low explains how an elimination-based diet, focusing on a set of ingredients called FODMAPs, could transform your health

It’S oNe of the UK’S moSt CommoN gaStroINteStINal dISorderS, thought to affect 10 to 20% of the population at some point in their lives. We know twice as many women are affected as men, diet and socioeconomic status are thought to be contributory factors and it’s closely linked to stress, but beyond that, its cause remains unknown. and because the type, number and severity of the symptoms and triggers can vary greatly from one person to another, it can be tricky to diagnose and – until now – treat.

These days it’s so common, many people wrongly use IBS as an umbrella term to describe any sort of ongoing digestive upset. But officially it’s defined as a condition where there is abdominal pain alongside altered bowel habits. There are many symptoms (see Your At-A-Glance Guide, right), but if you think you may have the condition, it’s really important to see your GP for further investigations. Not only will they be able to offer valuable advice and treatment, but they’ll also want to rule out a number of other, more serious, gastrointestinal disorders, such as Crohn’s disease, ulcerative colitis and coeliac disease – which share many of the symptoms.

The link with dietResearch in recent years has built on the idea that diet can play a vital role in alleviating the embarrassing and often painful symptoms associated with IBS, so once diagnosed, your doctor is likely to offer you some dietary and lifestyle advice along with any medication. Current guidelines from the UK’s National Institute for Health and Clinical Excellence (NICE), which advises health care professionals on best practice, include eating regularly, taking time to eat, not skipping meals or leaving long hours between eating, drinking plenty of fluid each day, but restricting tea and coffee to three cups daily and drinking fewer alcoholic and fizzy drinks. Depending on your symptoms, you may also be advised to vary your fibre intake.

These are all useful interventions – indeed, if you have bowel symptoms and are not already eating regular, healthy, balanced meals and taking time out to de-stress, you’ll find this a good, first-line treatment. But the most promising recent finding has been that a group of ingredients, given the name FODMAPs, may be a major trigger.

YouR at-a-gLancE guidE to common iBS SYmptomS• abdominal pain

and discomfort• bloating• changes in bowel

habits (constipation and/or diarrhoea)

• heartburn• nausea• excessive wind• a noisy abdomen• pain in the rectum

ThaT works …through diet, not drugs

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what is this group of ingredients?FODMAPs (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides And Polyols – see panel, left) are sugars (simple carbohydrates) found in foods that provide ‘fast food’ for the bacteria in the digestive system.

FODMAPs aren’t absorbed in the small intestine but instead pass into the colon, where the gut bacteria try to break them down. They cause the bowel to distend by drawing in more fluid and rapidly generate gas when the bacteria start to ferment them. Diarrhoea can occur due to an osmotic effect that increases the amount of water in the colon. Interestingly, most FODMAPs are poorly absorbed by everyone, but only some people go on to develop the symptoms of IBS.

The concept of the low-FODMAP diet, whereby foods containing the offending ingredients are virtually eliminated, was developed at Monash University in Australia. It has been found to all but eliminate symptoms in some sufferers and is now in such widespread use Down Under that many dietitians across the globe are starting to recommend a low-FODMAP diet as their new treatment of choice.

POLYOLS

FERMENTABLE

OLIGOSACCHARIDES

DISACCHARIDES

MONOSACCHARIDES

Examples are fructans and galacto-oligosaccharides (GOS), which are found in wheat products, some vegetables, and beans and pulses

In this context, this means lactose, found in dairy products

In this context, this means fructose, found mainly in fruit, honey and some processed cakes

These occur naturally in some fruits and vegetables, and are also used as artificial sweeteners in foods such as sugar-free sweets and chewing gum

so what foods are excluded?the table opposite offers a guide to the more common foods that are best avoided on a low-fodmaP diet – as well as those you can safely replace them with. the list is only a starting point – a dietitian will be able to provide you with a more comprehensive list.

Fodmap StandS FoR:

food Type avoid These… sTick wiTh These…

Flours and Grains

Legume products, including barley, bulgur, chickpea flour*, couscous, durum, lentil flour*, multigrain flour, pea flour*, rye, semolina, soya flour*, wheat bran, wheaten cornflour, wheat flour, wheatgerm

Arrowroot, buckwheat flour, cornflour and cornmeal (maize), custard powder, ground rice, malt, oats, oat bran, oatmeal, polenta, potato flour, quinoa, rice (brown or white), rice bran, rice flour, sago, tapioca, wild rice

Cereals Wheat-based and mixed-grain breakfast cereals, muesli

Rice-based or corn-based breakfast cereals, rolled oats (porridge), wheat-free muesli (with minimal amounts of suitable dried fruit)

Fruits Apples, nectarines, pears, peaches, plums Bananas, blueberries, grapes, grapefruit,kiwi fruit, lemons, limes, mandarins, melon, oranges, passionfruit, paw paw, raspberries, strawberries, tomatoes

VeGetables Broccoli, brussels sprouts, cabbage, garlic, mushrooms, onions

Alfalfa, aubergines, bamboo shoots, bean shoots, carrots, celery, chard, cucumber, green beans, lettuce, marrow, olives, pak choi, peppers, parsnips, potatoes, pumpkin, spinach, spring onion (green part only), squash, swede, sweetcorn, sweet potatoes, turnips, yams

Pasta and noodles

Egg noodles, pasta, gnocchi Gluten-free pasta, rice noodles, rice vermicelli, soba noodles

breads, bisCuits and Cakes

All biscuits, bread, breadcrumbs, cakes, croissants, crumpets, muffins and pastries containing wheat and rye, ready-made sourdough breads

Gluten-free biscuits, bread, cakes and pastries, maize tortillas, plain rice cakes and crackers, taco shells

dairy Foods and alternatiVes

Milk, ice cream, soft cheeses (in large quantities), yogurt

Hard cheeses, lactose-free milk, ice cream and most yogurts, soya milk (calcium-fortified)**, tofu

Meat, FisH and eGGs

sausages and other processed meats (check for onion and dehydrated vegetable powders)

Bacon, eggs, fish, poultry, red meat

nuts and seeds

Pistachios All nuts except pistachios, all seeds

sPreads, CondiMents and FlaVourinGs

Honey, shop-bought chutneys, dressings, gravies (containing onion), relishes and sauces, stock cubes

Jam, golden syrup, herbs, maple syrup, marmalade, peanut butter, soy sauce, spices, tamari, vinegar

drinks Fruit juices made with FodMaP fruits (see above)

Cocoa (made with lactose-free milk or water), coffee***, tea***, rice milk, soft drinks, juice made with ‘safe’ fruits (see above, but no more than 125ml per serving)

Fats and oils

Dairy spreads and margarine (in large quantities)

Butter, cream (in small quantities), ghee, vegetable oils

this table should be followed only under the guidance of a registered dietitian specialising in IbS management.*these contain the oligosaccharides goS and fructans, but in small amounts as part of a recipe do not cause IbS symptoms in most people. You should assess your tolerance under the supervision of a registered dietitian. **Soya milk is usually well-tolerated. ***NICe advises limiting consumption to three cups a day.

This covers all the IBS food culprits – basically, it’s anything rapidly broken down by bacteria in the bowel

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• rice• Quinoa• rice milk• lactose-free milk• bananas• Plain meat, fish, chicken• Spinach• Carrots• Peppermint• olive oil

DON’T self-diagnose or ignore your symptoms – they could point to something else. Make an appointment with your GP.DO see a registered dietitian for expert advice on what foods to limit and what to replace them with. DON’T skip meals. Establish a regular eating pattern and limit fat, alcohol and caffeine-rich foods and beverages.DO ensure adequate fibre intake – 18g a day is recommended for adults, although your GP or a dietitian may advise differently,

depending on your symptoms.DO take part in stress-reducing activities such as meditating, reading, exercising and listening to music, and ensure you get enough sleep.DON’T forget to drink plenty of water – aim for six to eight glasses a day.DO Pass wind! Holding on can make symptoms worse.

l Jennifer Low is a registered dietitian with a masters degree in nutrition and a postgraduate diploma in dietetics from King’s College London. She first came across the low-

FODMAP diet while working in New Zealand. Recent UK research confirms a low-FODMAP diet appears to be more effective than standard dietary advice for symptom control in IBS.

do i have to avoid these foods for ever?No, and from a nutrition point of view, it’s essential that you don’t avoid foods unnecessarily – the goal is for you to reintroduce the fodmaPs one by one to identify your own tolerance to different foods. Many people are actually reluctant to start eating more types of foods again because the diet makes such a life-changing difference that they’re wary of symptoms returning. But it’s important to persevere with the re-introduction stage – the diet can be restrictive and difficult to manage socially, so it’s worth taking the time to identify those FODMAPs you can tolerate in small amounts or without any symptoms at all.

Your dietitian will be able to provide you with further advice on re-introducing FODMAPs to help you with this process. You’ll start with one and ‘challenge’ that food by consuming a certain quantity. For example, you may challenge fructose using honey. If you get symptoms on day one, you’re unlikely to be able to tolerate that FODMAP. If, however, you get no symptoms on day one, on day two you’ll challenge the same food with double the quantity. If you get no symptoms, you’ll re-challenge the following day with three times the original quantity. If you have no symptoms on day three, it means you’re able to tolerate that particular FODMAP. If you get symptoms returning on days two or three, you’re able to tolerate a certain amount of it.

This can be a lengthy process, but if the result is the ability to eat a varied, healthy diet – with those painful and uncomfortable symptoms either reduced or eliminated – most people agree your patience will be paid off.

how do i cut out fodMaps?Since they’re found in a wide variety of foods, including many healthy ones, it’s important not to embark on an elimination diet on your own, but to seek the guidance of a registered dietitian. Your GP will be able to refer you to a dietitian experienced in the use of low-FODMAP diets, or find one privately at freelancedietitians.org.

To start with, most people will be advised to avoid all FODMAPs. However, in some people, fructose and lactose aren’t poorly absorbed and don’t cause symptoms, so they can carry on eating them. It’s possible to determine whether or not this is the case for you by taking a breath test, so ask your GP or dietitian if this can be done before your diet begins. Fruit and low-fat dairy products are healthy foods containing important nutrients, so they should not be cut out unnecessarily.

Experts recommend you follow the diet for at least eight weeks, during which time your symptoms should lessen dramatically or even disappear. If they don’t, it may be that FODMAPs aren’t the issue and you may need to discuss other options, such as medication, with your GP or dietitian.

Top 10 iBs-friendly foods

tHE doS and don’tS oF iBS

‘Joanna’S SYmptomS aRE now FEw and FaR BEtwEEn’Jennifer talks us through the case notes of her client Joanna, 21, who visited her clinic in tunbridge wells (jlnutritionclinic.com) earlier this year.

‘Joanna had been experiencing tummy aches every day for a number of months. They were characterised by bloating and frequent bowel movement, followed by occasional constipation. Her doctor diagnosed IBS and she’d tried a low dose of citalopram (a type of antidepressant called a selective serotonin reuptake inhibitor, or SSRI, which can help in IBS), but her symptoms hadn’t improved.

She had also been losing weight and continued to do so throughout January as she was scared to eat too often in case it made her tummy aches worse. But her BMI was below the recommended level for good health. She’d cut out all dairy products to see if that helped, yet she hadn’t replaced the calcium in her diet. Joanna was in her final year of university and really couldn’t afford to be losing weight or feeling ill.

Our goal was to stop Joanna

losing any more weight, get her eating more regularly and up her calcium intake – as well as addressing her IBS symptoms, of course. She managed to stick to a low-FODMAP diet on and off for a couple of months – no mean feat while at university and under stress from exams!

We decided to delay reintroducing the FODMAPs until after she had finished her final exams and started work. So far, Joanna has tried reintroducing wheat, a fructan (which comes under oligosaccharides). She challenged wheat on three consecutive days and got tummy aches on the third day. So she now sticks mainly to wheat-free products, but knows she can tolerate a small amount if she needs or wants to, without making her symptoms worse.

Today, Joanna’s BMI is back within the healthy range and her symptoms are few and far between. When she does experience them, it tends to be related to stressful situations, such as starting her new job. We’ll continue to work together to reintroduce the FODMAPs. The next one she’s going to try will be fructose, as she misses being able to eat honey!’

give your system time to relax – get a good night’s sleep