Fodmaps are found in many everyday foods. Don’t let the word put you off. These foods are not necessarily unhealthy. In fact, foods such as chickpeas, butterbeans and cashew nuts and certain fresh foods (avocado, beetroot and apple) are both nutritious and high in Fodmaps.
Fodmaps stands for Fermentable, Oligosaccharides, Disaccharides, Monosaccharides and Polyols. These are small constituents of foods that are poorly absorbed in people who have irritable bowel syndrome (IBS) and other functional gut disorders.
When these food components fail to be absorbed from the small intestine, they continue along the gut into the large intestine. Here gut bacteria ferment the Fodmaps and cause a range of symptoms including excessive wind, abdominal bloating, distension and changes in bowel habits (diarrhoea, constipation, or a combination of both).
An Australian research team from Monash University was the first to investigate the benefits of restricting Fodmaps in IBS patients. As they manipulated the Fodmap content of the diet, they saw a significant change in the pattern of gas production and other gut symptoms. Since then they have established a precise method of analysing the Fodmap content of a wide variety of Australian and international foods. This means we can now access a comprehensive and accurate database of Fodmap containing foods.
It is estimated that bowel conditions affect as many as one in five people and IBS is particularly common in young women in their 20s and 30s. Gut symptoms can make people feel wretched and consistently interfere with the enjoyment of food and the ability to live a normal life. Thanks to the Monash scientists we understand the mechanism by which the Low Fodmap diet works and we have the evidence that symptoms either improve or are resolved in three out of four people with IBS.
The nerve endings around the intestine are very sensitive in people who suffer with IBS. They are thought to have hypersensitive guts. There are many permutations of the disorder. Everyone experiences IBS a little differently.
The diagnosis of IBS is not verified by a specific test or biomarker. It is made using criteria* based on clinical symptoms. A detailed medical history is taken. It is essential to exclude organic disease such as IBD, coeliac disease and colon cancer. Symptoms and possible associations with medications, a recent history of travel and GI infections will be noted.
Rome III Criteria* for Irritable Bowel Syndrome (symptoms usually present for six months before diagnosis)
Recurrent abdominal pain or discomfort for at least three days per month in the last three months and associated with two or more of the following:
- Improvement with defecation
- Onset associated with a change in frequency of stool
- Onset associated with a change in appearance of stool
Once the diagnosis is made a patient can ask the gastroenterologist or GP for a referral to a dietitian specifically trained in the low Fodmaps diet.
Stage 1 of the low Fodmap diet is the elimination phase. This restricts all Fodmaps to rest the gut.
It is best to focus on the fairly impressive list of foods you can eat during Stage 1. Simple and relevant substitutions for the foods you have to remove are provided in Gut Feeling. Several suitable herbs and spices to flavour food (when garlic and onions are excluded) feature in the book such as;
“ Garlic-infused oil is widely available in supermarkets. If you don’t want to buy it off the shelf and you have the time, cut a few peeled garlic cloves into slices and sauté in oil for 1-2 minutes, until a garlic flavour develops. Then the tricky bit. You must fish out and discard every single garlic slice, even the tiniest pieces. You can see why buying the clear garlic infused oil instead is simply hassle free.
– Asafoetida powder (also known as hing) is an interesting spice found in Asian and health food shops. Be warned it has a dreadful pungent smell, but when heated in oil it gives it an onion flavour. You only need a tiny pinch to get the effect and this works well in curries, soups and stocks.
– Spring onion, the green part only. Discard the white parts or throw them on someone else’s plate. Anything that looks like an onion is omitted during the elimination weeks.
– Chilli and Paprika are tolerated by most patients in moderation.
– Chives and fresh herbs (parsley, thyme, rosemary, basil, coriander)
– Spices (cumin, turmeric, coriander, cinnamon) and Mustard
– Fresh lemons and limes
– Maple syrup (but not honey)
– Vinegar (red or white). You can use balsamic, but not more than 1 tablespoon.
– Salt and fresh black pepper
Stage 2 begins after the four to eight weeks of the exclusion stage and a review of symptoms. Reintroductions of Fodmaps are made in a particular order. Small amounts of the excluded foods are reintroduced in each three-day period with the amount of the food being tested increased to find a tolerance level. Written records of symptoms are kept for specific food challenges.
Most people enjoy this stage, as it allows them to test certain favourite foods (eg onion, garlic and avocado) that they have missed. Stage 2 can take up to eight weeks depending on how many food challenges are necessary.
Stage 3 allows you to an IBS management plan for the long term. Many people return to their normal diet with perhaps a few high FODMAP foods to avoid or consume in smaller amounts.
If there are many foods to avoid, a dietitian will ensure you will not be nutritionally compromised following a modified diet in the long term.
Cutting out Fodmaps can often leave people at a loss as to how to eat well when they can’t use staples like pasta, cow’s milk, onion and garlic. Trying to read ingredients in tiny print on food labels is a hassle. Briefing a waiter on the need to avoid honey but not maple syrup in your dessert can be challenging. Collating appropriate recipes a chore.
Ideally Gut Feeling is an adjunct to help patients avoid their trigger foods, tailor their cooking skills and follow low Fodmap recipes. All recipes are analysed for their nutrition content and allergens. Symbols are used to help quickly identify meals relevant to the IBS patient; "high in fibre", "low in calories", "spicy" etc.
The book also provides food swap ideas, eating out tips and information on how best to eat with specific symptom. For example, it is best to avoid supplementing your diet with wheat bran if you have constipation. Ground linseeds (6-24g per day) can help relieve abdominal discomfort and bloating if you have constipation.
With 100 versatile recipes, including dinners that include Beef and Bok Choy Stir-Fry and Chicken Skewers with Corn and Rice Salad, those who suffer with a sensitive gut can find real relief and still enjoy their food.
Always consult with your doctor and ideally a dietitian specifically trained in the Low FODMAPs diet (www.indi.ie) before you alter your diet.
Paula Mee is a Dietitian and member of the INDI. Gut Feeling by Lorraine Maher and Paula Mee will be published by Gill Books on March 10th. €19.99 @paula_mee
