Re-introduction of FODMAPs: is there an easier way?
Ever since the Low FODMAP diet was introduced for IBS in 2006, most papers have shown that elimination of FODMAP foods from the diet causes a reduction of symptoms of bloating, abdominal pain and diarrhoea. But there is a problem; FODMAPs are found in many different foods including, vegetables, fruit, milk and wheat, so exclusion of those foods risks vitamin and mineral deficiency if the diet is continued for more than a few weeks. This risk is increased if other foods notably fats and meat, which may also trigger symptoms in a sensitive gut, are also excluded. Moreover recent studies have shown that a low FODMAP diet may also deplete the colon of beneficial bifidobacteria spp, which some commercial probiotics supply as a treatment for IBS1.
This is the reason why the team from Monash University, Melbourne, who developed the low FODMAP diet, have stressed that ‘a low FODMAP diet is not for life’. Once symptoms have been controlled, then the intention is to reintroduce the various FODMAP groups one by one to determine which components are most troublesome. To my knowledge only one paper has shown a long term positive result for the whole exclusion, reintroduction protocol2.
The Reintroduction Protocol.
Reintroduction follows a standard food challenge protocol and is supported by one double blind controlled study that clearly demonstrated a return of symptoms when fructose or fructans were introduced without the patients knowledge3. Nevertheless, when reintroduction is conducted in a clinical setting, it is a somewhat cumbersome procedure. There are four FODMAP groups, fructans, galactans, fructose and polyols and each needs to be tested, with, in the case of fructans, several different components. During this prolonged process, subjects are, of course, aware of what foods are being reintroduced and may well experience anxieties about those foods or other worries that may alter the sensitivity of the gut and skew the results.
Until recently, the protocol was considered too difficult for patients to do themselves. Instead they were advised to consult one of the 600 or so dietitians specially trained at King’s College, London, to supervise the low FODMAP diet
But within the last six months, King’s have introduced Food Maestro, their mobile app that takes people, who register, through a modified reintroduction protocol, while Lee Martin, their peripatetic low FODMAP dietitian, last heard of (by me) in Central America, has published ‘Rechallenging and Reintroducing FODMAPs, a self help guide to the entire reintroduction phase of the low FODMAP diet’. Both the app and the book describe a three stage process. In the first stage, people rechallenge their tolerance levels to the main groups of FODMAPs avoided during the elimination phase in order to discover which FODMAPs trigger symptoms and what portion size can be tolerated. This takes a week for each FODMAP food (galactans, fructans x3, fructose, lactose, sorbitol and mannitol) and includes a three day washout period between each different FODMAP group when people return to their low FODMAP diet. Next, people are encouraged to reintroduce the individual FODMAPS they can tolerate into their diet in order to work out what combination and overall load of FODMAPs they can eat in a day without triggering IBS symptoms. After that, people are encouraged to conduct their own modified low FODMAP diet.
Adding up the times for each stage, the whole protocol including the exclusion period takes no less than about 4 months, and during that time not only must you follow the protocol strictly, but other factors that may irritate a sensitive gut, including coffee, fat and stress levels need to be kept stable. This is not for the faint hearted, and it can be all too readily compromised by the fact that emotional tension changes the sensitivity of the gut, fluctuates from day to day in all of us and is probably heightened by going on a diet. So while this reintroduction protocol may seem scientifically robust, it assumes a stable baseline which seems to me unrealistic. Also, such a pervasively strict diet may isolate a person from their family and their friends, which might again raise emotional tension. Finally, it has been shown that as soon as you exclude or restrict a certain component ingredient from the diet, it can increase the sensitivity to that food or ingredient. So trying to find out which level of FODMAP a person can tolerate is like trying to hit a moving target. No wonder so many fail during the reintroduction phase.
So is there an easier way?
Diets only really work if you can adapt them and incorporate them into your life so they become part of who you are rather than something that is imposed upon you. The low FODMAP diet is about intolerance rather than allergy. You do not need to eliminate any food, but you do need to know which foods can be gassy and which foods retain fluid in the gut and can make your stools loose and sloppy. Then if you make a note of the foods that you tend to eat, you will soon be able to see if your gut symptoms might be related to eating a lot of fruit or onions or beans/lentils. People tend to learn best by experience; trying things out. All you need is a little guidance as to what foods might cause gas and diarrhoea so you can reduce those when your gut is particularly sensitive. Your ‘diet’ need only be as severe as your symptoms. As Peter Gibson once commented ‘sometimes all that is needed is judicious reduction of pulses and onions’. So know your food and the way it affects you use your judgement. If you have diarrhoea, you could be eating too much fruit or drinking too much fruit juice. Or could you be intolerant of lactose and need to cut down on milk and cream. If you suffer a lot from gas and bloating, think beans and onions. This is more about getting to know yourself and acquiring your own confidence than the strict application of a dietary protocol.
You will get to know your food and how it affects you much more if you cook it yourself, rather than leaving things to the vagaries of restaurants and ready meals. It is important to be guided by a recipe when you are cooking something new but after a few attempts, you can adapt it and make it yours. So why not adopt a pragmatic approach. Keep a diary of your food and your symptoms. Use it to decide whether your bloating or diarrhoea might be related to eating too much of a certain components. Then cut back and see if it makes a difference. Often that is all that is needed. But if you get confused, you could start with a regime that reduces (but does not eliminate) the main culprits: onions, pulses, wheat, milk, fruits and fruit juices. Then if you feel better, you can experiment with increasing the portion sizes to tolerable levels. In this way, you will soon get a feel for what suits you and when stress levels increase and your gut becomes more sensitive, you can always cut them back until you feel better. This approach puts you in charge instead of having to be the victim of either your illness or your diet. Living with IBS is so much a matter of finding your own way with the help of appropriate information and guidance. And of course, your FODMAP dietitian will be an excellent source of information about food and dieting, but ultimately you will need to adapt it to suit you.
In our book, Cooking for the Sensitive diet, published by Pavilion in January 2016, Joan Ransley described a hundred delicious and healthy recipes, each low in fat, FODMAPs, insoluble fibre and hot spices, that you can prepare for yourself and adapt for your family. These serve as a pragmatic and safe baseline for IBS. Then, when you relax and gain confidence with those dishes, you can be more flexible and adjust the ingredients or invent your own dishes.
With gut symptoms and diet, everybody is different. So know yourself. Let the food that you eat be an enjoyable part of you, not some burden that you have to bear forever. Only you can relax your gut and get your life back.
References
- Staudacher HM, Lomer MCE Anderson JS et al. Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome. Nutr. 2012. 142. 1510-1518
- Martin L, van Vuuren, C, Seamark L et al (2015) Long term effectiveness of short chain fermentable carbohydrate (FODMAP) restriction in patients with irritable bowel syndrome. Gut 2015;64:A51-A52
- Shepherd SJ , Parker FC , Muir JG et al. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence . Clin Gastroenterol Hepatol 2008 ; 6 : 765 – 71.
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Very nice bloog you have here
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