How To Eat Healthy To Manage Bloating On a FODMAP Diet

In Australia, this week in Smart Eating Week which aims to help increase awareness of health and nutrition within the community. We often talk about healthy eating for the general population, but what about those with specific medical conditions needing to follow a specific diet?

In this blog I will focus on irritable bowel syndrome (IBS) and the FODMAP diet. The FODMAP diet can be challenging to follow. I often get new clients, who have tried it own their own, saying that they struggle with limiting the different foods and have been restricting their diet more than they need too. In this blog I will share with you some simple smart eating tips to help you eat healthy and meet all your nutritional needs while on the FODMAP diet.

What are FODMAPs & What is The FODMAP Diet?

IBS is a common functional gastrointestinal disorder that affects 1 in 7 adults or 15% of the population worldwide. It is described by symptoms that are not explained by other conditions such as coeliac disease and inflammatory bowel disease. To learn more about IBS read my “Identify Your IBS Type To Manage Bloating & IBS)” blog here. Through changes to your diet and lifestyle, the nutritional management of IBS aims to improve your quality of life and decrease the frequency and severity of your symptoms.

The dietary cause of the symptoms associated with IBS is largely due to a group of carbohydrates called FODMAPs. This sounds like a really technical word, but it is just an acronym used to describe a group of carbohydrates, or sugars, which are found in a lot of everyday foods including fruit, vegetables, grains and dairy. It stands for;

Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols

Examples of FODMAPs include fructose, lactose, fructans and sorbitol. Although these carbohydrates are poorly absorbed in everyone, they are believed to affect and cause symptoms in people with conditions such as IBS as their guts are more sensitive. It’s important to remember that FODMAPs are not the cause of IBS, however limiting these in the diet can help control IBS symptoms.

The FODMAP diet is a therapeutic diet and is often recommended to those who have IBS. This means that it is actually used as part of the medical management or treatment for those with IBS. A low FODMAP diet can help improve gut symptoms in up to 75% of people with IBS. To learn more about FODMAPs and the FODMAP diet read my “The Journey Towards Managing Your Bloating (FODMAP Phase 1-3)” blog here.

Why is Healthy Eating on a FODMAP Diet Important?

When following a low FODMAP diet it is important to plan ahead as the diet can be quite restrictive and involves a number of changes to your diet. This means that you are more at risk of nutrient deficiencies. Therefore, it is recommended that the FODMAP diet be completed under the supervision of a specialised Accredited Practising Dietitian (APD), such as myself, as we are able to provide you with appropriate low FODMAP substitutes to your favourite foods while ensuring you are getting all the nutrition you need with a healthy, balanced diet and a wide variety of foods. Studies also show that those with IBS who follow the FODMAP diet with the assistance of an APD can get better relief from their symptoms.

For those with IBS, it can be difficult to eat enough fibre when following a low FODMAP diet because they are eating less of these carbohydrates that contain fibre and natural prebiotics. Prebiotics are known for promoting diversity and increase the number of bacteria in our gut which assists with improving our overall gut health. Prebiotics have
been scientifically shown to impact the gut microbiome in healthy people. So, a big consideration is the long-term consequences of a low FODMAP diet. And this is one of the reasons why it is only recommended for a short period of time of 2-6 weeks.

Healthy eating is also the key to feeling your best, both now and in the long-term. Nutrition plays an important role in the everyday functions of our bodies. Maintaining a healthy diet gives your body the energy and nutrients it requires to function. It also has numerous health benefits including lowering your risk of developing diabetes, heart disease, excessive weight gain and some cancers. A healthy diet can also improve your mental health by improving your mood, increasing your concentration and decreasing feelings of fatigue, anxiety and depression. The best way to get in all the nutrients you need is to eat a variety of low FODMAP foods from the five different groups every day. I will discuss these is detail below.

Healthy Eating on a Low FODMAP Diet – The 5 Food Groups

Vegetables and Legumes

Including these in your diet can provide a range of nutrients as they are a good source of vitamins, minerals and dietary fibre. Vegetables can help decrease the risk of developing some chronic diseases including heart disease and some cancers. They are low in energy/calories, so incorporating a high variety of these into your diet can help to maintain a healthy weight. All vegetables also provide vitamin C. Low FODMAP vegetables including capsicum, broccoli, bok choy and tomatoes are particularly high in vitamin C. Legumes and beans, such as canned lentils, are also a good source of protein, iron, zinc and carbohydrate.

How Much Should You Aim For?

Women 19 years old & above = 5 serves per day.
Men aged 19-50 years = 6 serves per day.
Men aged 51-70 years = 5½ serves per day.

What is a low FODMAP Serve?

½ cup cooked green or orange vegetables
- Whole broccoli, spinach, carrots or kent pumpkin.
½ cup canned lentils
1 cup green leafy or raw salad vegetables
- Most lettuce varieties and leafy greens are low FODMAP at this serving size.
½ cup or ½ cob sweet corn
½ medium potato or other starchy vegetables
- Sweet potato, taro or cassava are low FODMAP at a serving size of ½ cup.
1 medium common tomato

Fruit

Fruit are a good source of vitamins, including vitamin C, and folate and provide potassium, dietary fibre and carbohydrates in the form of natural sugars. As with vegetables, including fruit in your diet each day can help reduce the risk of some chronic diseases, including heart disease and some cancers. They are also low in energy, so including these in your diet can help maintain a healthy weight.

How Much Should You Aim For?

Men & Women 19 years old & over = 2 serves per day.

What is a low FODMAP Serve?

1 medium unripe banana or orange
2 small kiwi fruits or mandarins
1 cup diced fruit
- Cantaloupe, pineapple, strawberries, grapes
Or only occasionally: 125ml (½ cup) cranberry juice (with no added sugar)

Grains (Cereal)

Grain foods provide us with a range of different nutrients including carbohydrates, protein, dietary fibre and a wide range of vitamins and minerals including folate, thiamine, riboflavin, niacin, vitamin E and iron. Try and include a wide variety of wholegrain breads, cereals and pastas in your diet. These provide more dietary fibre, vitamins and minerals than refined or white versions of these foods. Eating wholegrain and/or high fibre cereal foods will not only keep your gut bacteria happy but can help reduce the risk of heart disease, type 2 diabetes, excessive weight gain, and some cancers. Low FODMAP options include spelt and gluten, wheat and rye free products.

How Much Should You Aim For?

Men aged 19-70 years & Women aged 19-50 years = 6 serves per day.
Women aged 51-70 years = 4 serves per day.

What is a low FODMAP Serve?

1 slice bread
- Keep in mind that although most breads are low FODMAP at 1 slice, they can become high FODMAP at 2 slices.
- Low FODMAP options at 2 slices include sourdough, spelt and gluten free white bread.
½ medium roll or flat bread
- As above regarding low FODMAP options.
½ cup cooked rice, gluten free pasta, gluten free noodles, quinoa
½ cup cooked porridge
2/3 cup low FODMAP cereal flakes
¼ cup fruit free muesli
3 low FODMAP crispbreads or crackers

Lean Meats & Alternatives

These are a good source of protein, iron, zinc and other minerals and B group vitamins. Great substitutes for lean meats are poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans. Just remember that vitamin B12 is only naturally found in animal-based foods, but can also be found in fortified plant-based products. The iron and zinc in animal-based foods is also more easily absorbed by the body than the iron and zinc from eggs and plant foods.

It is currently recommended that no more that 350g of cooked lean red meat is eaten per week as eating larger amounts can be linked with a higher risk of developing chronic diseases such as heart disease, diabetes and bowel cancer. Eating large amounts of protein from animal sources has also been shown to alter our gut microbiome. This can decrease the amount and diversity of the gut bacteria found in our gastrointestinal tract.

Fish and seafood are sources of long chain omega-3 polyunsaturated fatty acids. Eating fish regularly is linked with a lower risk of heart disease, stroke, dementia and age-related macular degeneration.

How Much Should You Aim For?

Women aged 19-50 years & Men aged 51 years & above = 2½ serves per day.
Men aged 19-50 years = 3 serves per day.
Women aged 51 years & above = 2 serves per day.

What is a low FODMAP Serve?

65g cooked lean meats such as beef, lamb, veal, pork, goat or kangaroo
80g cooked lean poultry such as chicken or turkey
100g cooked fish fillet or one small can of fish
2 large eggs
1 cup or canned legumes/beans such as lentils
170g firm tofu
30g low FODMAP nuts, seeds, peanut butter

Dairy & Alternatives

These are an excellent source of calcium and very few other foods in the Australian diet are as high in calcium as dairy foods. They are also a good source of other nutrients including protein, potassium, magnesium, iodine, riboflavin, zinc and vitamin B12. Eating dairy foods and alternatives also help lower the risk of high blood pressure, heart disease, stroke, type 2 diabetes and some cancers. The best choices for those with high cholesterol are low or reduced fat varieties. Many dairy products also contain prebiotics which means they help to increase the diversity of your gut bacteria and keep your gut microbiome healthy.

How Much Should You Aim For?

Men aged 19-70 years & Women aged 19-50 years = 2½ serves per day.
Women aged 51 years & over = 4 serves per day.

What is a low FODMAP Serve?

1 cup fresh lactose free milk
2 slices of hard cheese
¾ cup lactose free yoghurt
1 cup soy (made from soy protein) or rice milk with added calcium

15 Smart Eating Tips on a FODMAP Diet

Plan ahead and stock up on easy nutritious foods like;
- Low FODMAP wholegrain cereals and other grain foods.
- Lactose free milk
- Canned lentils
- Eggs
- Frozen or canned foods without added sugars or added salt
- This way you can eat at home more often and cook meals yourself by adding fresh ingredients that you know will be low FODMAP.
Choose a variety of different types and colours of fresh vegetables and fruits that are in season.
Try new ways of cooking with low FODMAP vegetables like roasting, baking, barbequing and stir-frying.
Add extra low FODMAP vegetables and legumes to your recipes.
Include at least 1-1.5 cups of low FODMAP vegetables with your lunch.
- Such as whole broccoli, spinach, potatoes, carrots, tomatoes, red capsicum, eggplant and bok choy.
Include at least 1.5-2 cups of low FODMAP vegetables with your dinner.
Try and eat at least 2 pieces of low FODMAP fruit each day.
- Such as strawberries, unripe bananas, grapes, cantaloupe, pineapple, oranges and kiwifruit.
Add fruit to your breakfast cereal, smoothies or yoghurt.
Keep edible skins on your fruit and vegetables.
Try having a small handful of nuts or seeds as snacks.
Use fruit for snacks and desserts.
Include 2 serves of fish or seafood into your diet per week.
Include at least 1 or 2 meat-free and plant-based meals each week.
- You can include eggs, legumes (like canned lentils) and firm tofu, nuts and seeds.
Include small amounts of foods rich in unsaturated fats such as;
- Oils, spreads, nut butters/pastes and avocado.
Limit your intake of packaged and processed foods as these can often be high in saturated fat, sodium and added sugar and also hidden FODMAPs.

If you’re newly diagnosed with IBS and bloating and told by your doctor to follow the FODMAP diet, but now you have no idea where to start, you’re not alone because 1 in 5 Australians have IBS. But you don’t have to be that person that lives with it for the rest of your life uncontrolled. You can manage it by following the FODMAP diet so that you can eliminate bloating and go out and enjoy the weekend with your friends, apply for coaching.

References

Brown K et al (2012). Diet-induced dysbiosis of the intestinal microbiota and the effects on immunity and disease. Nutrients. 4:1095– 119.
Collins SM (2014). A role for the gut microbiota in IBS. Nature Reviews Gastroenterology & Hepatology. 11: 497-505.
Gandy J & the British Dietetic Association. Manual of Dietetic Practice–Fifth Edition. 2014: 460-466.
Gibson PR & Shepherd SJ (2010). Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology. 25: 252–258.
Heart Foundation. Dairy and Heart Healthy Eating: Position Statement. National Heart Foundation of Australia; 2019.
Heart Foundation. Meat and Heart Healthy Eating: Position Statement. National Heart Foundation of Australia; 2019.
Hills RD et al (2019). Gut Microbiome: Profound Implications for Diet and Disease. Nutrients. 11:1613.
National Health and Medical Research Council. Eat for Health-Australian Dietary Guidelines. Canberra; 2013.
National Health and Medical Research Council. Eat for Health-Educator Guide. Canberra; 2013.
National Health and Medical Research Council. Nutrient Reference Values for Australia and New Zealand-Executive Summary. Canberra; 2006.
National Institute for Health and Care Excellence (NICE) (2008). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. CG61.

Manage Constipation in 4 Steps

Have you ever had trouble having a bowel movement or experienced constipation? If you answered yes, then you definitely know what it feels like when your gut is giving you the silent treatment!

Some quick facts about constipation;

It affects 1 in 10 children and is responsible for 3-5% of all visits to a paediatrician.
1 in 5 adults experience constipation.
It affects both men and women but is more of a common complaint in women.
The likelihood of experiencing constipation increases as we get older, particularly once we are over the age of 65 years.

What is Constipation?

Constipation is a common medical concern in both Australia and other developed countries. Constipation is defined as when a person is unable to empty their bowels, finding it more difficult to have a bowel movement or having more infrequent bowel movements than what is normal for them.

Constipation can be described as being either acute or chronic. So, what’s the difference?

Acute constipation: This usually lasts for a short period of time and occurs infrequently. It is likely related to changes to dietary habits, such as not eating enough fibre, changes to routine or short-term use of certain medications (I will talk more about this later!)

Chronic constipation: This means that you have been experiencing difficulty with having a bowel movement for a long period of time. Whilst this can also be related to dietary habits, particular medical conditions can also play a role (I will also talk more about this later!) If constipation has been experienced for a long period of time, it can sometimes be referred to as “functional”.

What is Functional Constipation?

What this means is that there is not a physical or physiological cause for your constipation. A person may be otherwise healthy, however despite this, is still having trouble with experiencing a normal bowel movement. This condition can often run in families and studies have shown that 1/3 of people with functional constipation will have family members with similar bowel issues.

Once other conditions have been ruled out a set of diagnostic criteria called the Rome IV Criteria for Diagnosing Functional Constipation will be used to confirm if you have this. This includes whether you have been experiencing 2 or more of the following, for the last 3 months with symptoms starting at least 6 months before diagnosis;

Straining during more than ¼ (25%) of bowel movements.
Lumpy or hard stools more than ¼ (25%) of bowel movements.
Sensation of incomplete evacuation more than ¼ (25%) of bowel movements.
Sensation of anal or rectal obstruction/blockage more than ¼ (25%) of bowel movements.
Manual manoeuvres to facilitate more than ¼ (25%) of bowel movements (such as digital evacuation, or support of the pelvic floor).
Fewer than 3 spontaneous bowel movements per week.

You must also have both of the following;

Loose stools rarely present without the use of laxatives.
Do not meet the ROME IV criteria for the diagnosis of irritable bowel syndrome (IBS) (to learn more about IBS you can read my “Identify Your IBS Type To Manage Bloating & IBS)” blog here).

How Often Should I Have a Bowel Movement?

This is a question that I get asked quiet frequently by my clients. What is considered normal can be different from person to person as everyone’s gut and lifestyles are different, but it can range from multiple times per day to three times per week.

What’s important to remember is that having less frequent bowel movements does not mean that you are constipated, as long as you are not experiencing any pain and are following your usual bowel habits. You only need to keep an on eye out for it if you start experiencing changes to your bowel habits. As I have mentioned, everyone is different, so if you have been having less than what’s “normal” for you, it may mean that you are constipated.

Tips to help determine if your bowel motions are regular enough;

Aim for a bowel movement every 1-2 days that is soft and easy to pass.
If you are not sure, you may find keeping a bowel diary helpful.
- You can record how often you are having a bowel movement.
- The type (for example, whether it is hard or soft).
- How easy it is to pass (did you need to strain excessively?)
- Have you been experiencing any other symptoms (such as wind, bloating or stomach pain).
Keep in mind, that if you are eating less than usual for any reason, you should still be having regular bowel movements.

Symptoms of Constipation

There are so many different symptoms that can be experienced with constipation and it’s important to remember that these will vary from person to person.

Some common signs and symptoms can include;

Stomach pain, bloating and discomfort
Wind
Feeling tired and fatigued
A decrease in appetite
Feeling full quickly after meals
Bowel obstruction or blockage
Excessive straining or difficulty having a bowel movement
A feeling of not being completely empty
Passing hard or lumpy stools
Infrequent bowel movements
Worsening of IBS symptoms, such as abdominal pain, excessive wind, bloating and/or distension.

Other symptoms can include;

Anal fissure. This is when trying to pass large, hard stools can cause a small tear in the lining of the anus. It can cause pain, stinging and bright red blood, which is often noticed in the toilet or on toilet paper.
Faecal overflow or incontinence. This occurs mainly in children and the elderly who have been experiencing chronic constipation. This leads to a loss of awareness of needing to have a bowel movement and unintentional soiling of underwear.

Causes of Constipation

As mentioned above, constipation may have no underlying cause, such as in those with functional constipation, or can be the result of another cause. This can sometimes be referred to as secondary constipation.

Medical causes of constipation include;

Pain relief medications
- Codeine
- Oxycodone
- Morphine
Anti-nausea medications
- Ondansetron
Other drugs or medications
- Anti-depressants
- Chemotherapy
Some nutritional supplements
- Iron supplements
- Calcium supplements
Excessive laxative use
Hormonal and metabolic conditions
- Underactive thyroid
- Diabetes
Some medical conditions
- Coeliac disease
- IBS
- Haemorrhoids
- Diverticulitis
Certain diseases
- Colorectal cancer
- Metastatic stomach cancer
Neurological disorders
- Parkinson’s disease
- Stroke
Cow’s milk allergy
- Studies have shown that this can cause severe constipation in some infants and children.
Pregnancy
Menstruation
- This may be due to changes in hormones that can affect bowel habits.
Slow gut motility

Lifestyle factors that can cause constipation;

Not drinking enough fluid or dehydration
Decreased mobility
Inadequate fibre intake
Physical inactivity
Ignoring the urge to have a bowel motion
Sedentary lifestyle
Stress
Changes to your daily routine

My Expert Tips to Help You Manage Constipation

1. Increase Your Intake of High Fibre Foods
Fibre helps to keep our stools soft by absorbing water throughout our gut. This assists with preventing constipation and keeping our bowel movements regular. So, high fibre foods help improve constipation by holding liquid in the stools and keeping them soft (to learn more fibre you can read my “10 Ways to Increase Fibre to Eliminate Bloating & Constipation” blog here). It also helps to keep us fuller for longer and supports keeping our gut microbiome happy and healthy.

In Australia, it is currently recommended we consume;

14-22g per day for children.
25g per day for women.
30g per day for men.

However, despite all the benefits of adequate fibre intakes, most Australians currently do not consume enough fibre.

The easiest way to make sure that you are getting enough fibre each day is by eating a healthy balanced diet with a wide variety of foods. This is easily achieved by ensuring that you eat foods from each of the 5 food groups. These are grains (cereals), meat and/or alternatives, fruit, vegetables and dairy and/or alternatives.

My expert tips for increasing your fibre intake are;

Include at least 1-1.5 cups of vegetables with your lunch.
Include at least 1.5-2 cups of vegetables with your dinner.
Include vegetables as snacks.
Choose wholegrain and/or high fibre breads, cereals, pastas and rice instead of refined or white versions of these foods.
Eat at least 2 pieces of fruit each day.
Use fruit for snacks and desserts.
Add fruit to your breakfast cereal, smoothies or yoghurt.
Keep edible skins on your fruit and vegetables.
Try having a small handful of nuts or seeds as snacks.
Add legumes such as beans or lentils to your meals.
Add high fibre foods slowly to your diet to avoid getting symptoms such as wind, bloating, cramps and diarrhoea.

2. Eat 2 Kiwifruit Each Day

Eating kiwifruit regularly has been shown to help relieve the symptoms on constipation. It is a simple, natural and budget friendly strategy to help with improving your bowel movements. Studies have shown it to be a safe alternative to other strategies as it seems to have very little, if any, side effects.

Eating 2 kiwifruit each day helps to increase how often you have a bowel movement and improves laxation, which means it makes it easier to have a bowel movement. However, keep in mind that improvements in your bowel movements will only be seen while you are regularly eating kiwifruit and will decrease if you stop eating them.

So how does the humble kiwifruit do all this?

This is thought to be because of the fibre content in kiwifruit as it helps with absorbing water throughout your gut, which bulks up your stools and improves laxation. It also contains an enzyme called actinase which is believed to also help with laxation by making it easier for the contents of your gut to move through it.

3. Increase Your Fluid Intake

When you increase your intake of fibre it is important that you also make sure that you are drinking enough water throughout the day. As mentioned above, fibre absorbs water in your gut to assist with keeping your stools soft and preventing constipation. Not drinking enough fluid can result in fluid not being absorbed from your gut into your stools. This can result in harder stools and cause stomach pain or discomfort and constipation.

You may have heard a lot about how much water we should drink, such as 8 cups or 2 litres per day, however as we are all different, there is no one amount that is recommended for everyone. The best way to judge if you are drinking enough water is by looking at the colour of your urine. This may sound strange, I know! Dark urine likely means that you may be dehydrated and have not had enough fluid, while clear urine means you may be drinking too much. Aim for a pale-yellow colour as this is likely to indicate you are well hydrated.

4. Increase Your Physical Activity

Being physically active every day and decreasing the amount of time you spend engaging in sedentary behaviour is not only important for improving constipation but is also vital for your overall health and wellbeing.

My expert tips for increasing your physical activity are;

Be sure to include regular activity in your day. Australia’s Physical Activity and Sedentary Behaviour Guidelines are a really good starting point.
Doing any type physical activity is better than not doing any.
- Find an activity that you enjoy doing and start with 5-10 minutes and gradually build up to the recommended amount.
Be active on most, preferably all, days of the week.
Add 2½ to 5 hours of moderate or 1¼ to 2½ minutes of vigorous intensity physical activity each week.
- This can be included as 30-60 minutes of moderate intensity activity (such as brisk walking or gardening) per day OR
- 75 to 150 minutes of vigorous intensity activity (such as swimming or running) each week.
Do muscle strengthening activities on at least 2 days each week.
Sit less, move more.
Limit the amount of time you spend sitting for long periods of time.
Break up long periods of sitting as often as you possibly can.
- This can include getting up from your desk once an hour and going for a short walk.

If you’re newly diagnosed with IBS and constipation and told by your doctor to follow the FODMAP diet, but now you have no idea where to start, you’re not alone because 1 in 5 Australians have IBS. But you don’t have to be that person that lives with it for the rest of your life uncontrolled. You can manage it by following the FODMAP diet so that you can eliminate bloating and constipation and live your best life, apply for coaching.

References

Australian Government: Department of Health. Australia’s Physical Activity and Sedentary Behaviour Guidelines [Internet]. Cited 2019 November 30. Available from:https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines#npa1864
Barbara G, Fukudo S, Drummond L, et al (2018). Tu1644 – Green Kiwifruit Compared to Psyllium for the Relief of Constipation and Improving Digestive Comfort in Patients with Functional Constipation and Constipation Predominant Irritable Bowel Syndrome — Analysis of Three International Trial Centres. Gastroenterology. 154:S-979-S-980.
Beck DE (2008). Evaluation and Management of Constipation. The Ochsner Journal. 8:25–31.
Bharucha AE (2007). Constipation. Best Practice & Research: Clinical Gastroenterology. 21:709-31.
Bijkerk CJ, Muris JWM, Knottnerus JA, et al (2004). Systematic review:the role of different types of ﬁbre in the treatment of irritable bowel syndrome. Alimentary Pharmacology & Therapeutics. 19:245–51.
Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoenfeld P & Talley NJ (2005). Systematic review on the management of chronic constipation in North America. The American Journal of Gastroenterology. 100(suppl 1):S5–S21.
Chan AO, Leung G, Tong T, et al (2007). Increasing dietary fiber intake in terms of kiwifruit improves constipation in Chinese patients. World Journal of Gastroenterology. 13:4771-5.
Chang CC, Lin YT, Lu YT, et al (2010). Kiwifruit improves bowel function in patients with irritable bowel syndrome with constipation. Asia Pacific Journal of Clinical Nutrition. 19:451-7.
Chey WD, Kurlander J & Eswaran S (2015). Irritable bowel syndrome: a clinical review. The Journal of the American Medical Association. 313:949-58.
Ford AC, Moayyedi P, Lacy BE, et al (2014). American college of gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. The American Journal of Gastroenterology. 109 Suppl 1:S2-S26.
Gastroenterological Society of Australia (GESA), Digestive Health Foundation. (2010). Constipation Information Sheet.
Klauser AG, Beck A, Schindlbeck NE, et al (1990). Low fluid intake lowers stool output in healthy male volunteers. Z Gastroenterol. 28:606-9.
Lacy BE, Mearin F, Chang L, et al (2016). Bowel Disorders. Gastroenterology. 150:1393-1407.e5.
Li YO & Komarek AR (2017). Dietary fibre basics: Health, nutrition, analysis, and applications. Food Quality and Safety. 1: 47–59.
National Health and Medical Research Council. Eat for Health-Educator Guide. Canberra; 2013:11-23.
National Health and Medical Research Council. Nutrient Reference Values for Australia and New Zealand-Executive Summary. Canberra; 2006.
Rush EC, Patel M, Plank LD, et al (2002) . Kiwifruit promotes laxation in the elderly. Asia Pacific Journal of Clinical Nutrition. 11:164-8.
Sanchez MI & Bercik P (2011). Epidemiology and burden of chronic constipation. Canadian Journal of Gastroenterology and Hepatology. 25: 11B-L 15B.
Suares NC & Ford AC (2011). Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and metaanalysis. American Journal of Gastroenterology. 106:1582–91.
Suares NC & Ford AC (2011). Systematic review: the effects of ﬁbre in the management of chronic idiopathic constipation. Alimentary Pharmacology & Therapeutics. 33:895–901.
Tack, J et al (2006). Functional gastroduodenal disorders. Gastroenterology. 130, 1466-1479.
Tucker DM, Sandstead HH, Logan GMJr, et al (1981). Dietary ﬁbre and personality factors as determinants of stool output. Gastroenterology. 81:879–83.
Voderholzer WA, Schatke W, Muhldorfer BE, et al (1997). Clinical response to dietary ﬁbre treatment of chronic constipation. American Journal of Gastroenterology. 92:95–8.
Vrees MD & Weiss EG (2005). The evaluation of constipation. Clinics in Colon and Rectal Surgery. 18:65–75.

What To Do When Your FODMAP Diet Hasn’t Eliminated Bloating in IBS

Before we get into natural food chemical intolerance, I think it is important to understand the difference between a food allergy and a food intolerance, as these are not the same.

A food allergy is due to our immune system reacting to a food protein that the body wrongly thinks is harmful, which causes a person to have a reaction and get symptoms. Whereas a food intolerance does not involve the immune system and reactions are rarely life-threatening. A food intolerance is when a person cannot properly digest or fully break down and absorb certain foods. If you would like to learn more about food allergies and food intolerance’s, you can read my “How to Eat More Foods With IBS (Food Allergy vs Intolerance)” blog here.

What are Natural Food Chemicals?

Food chemicals are found naturally in many everyday foods and there is a significant amount of variation in the make-up of natural chemicals in food. For most people these do not cause any issues or symptoms. However, in people who are more sensitive, such as those with irritable bowel syndrome (IBS), they can cause just as many symptoms as artificial food additives.

The most common natural chemicals found in foods are salicylates, amines, and glutamate. These are most likely to cause symptoms is sensitive people as they are found in a large number of many different common foods and are therefore eaten the most in people’s diets.

Salicylates

These are natural chemicals found in plants and are present in many fruits, vegetables, nuts, tea and coffee, honey, herbs and spices, flavourings, and most alcohols. The level of salicylates in food decreases as the food ripens and levels are highest in the skin. Salicylates are also found in some medications, such as aspirin and herbal remedies.

They are also found in many natural flavourings used in food, drinks and medications, such as mint and fruit flavours and are used to scent perfumes, washing powders, cleaning products, toiletries and botanical oils, particularly lavender, eucalyptus and tea tree.

Amines

These are a product of either protein breakdown or fermentation. They are found in meats, cheese, fish products, fruits, vegetables, and many alcoholic beverages. The level of amines found in fruit increases with ripening, such as in banana, tomatoes and avocado. Foods particularly high in amines include chocolate, jams and flavoured spreads, fruit juices, sauces and fermented products such as beer, wines and yeast extracts.

Glutamate

Glutamate is an amino acid present in most foods as it is a building block for proteins. Glutamate in used in the preparation of many meals as it enhances the flavours of foods. Foods containing natural glutamate include cheese, tomato, mushrooms, meat and yeast extracts, soy sauce and stock cubes. Monosodium glutamate (MSG) is also often used as an additive in soups, sauces and snack foods to increase the flavour and is commonly used in Asian cooking.

FUN FACT: Did you know that “organic” foods may actually not be better for those with a food intolerance?

Why you might ask…growing foods without pesticides and herbicides actually results in them significantly increasing the amount of salicylates and other chemicals that they naturally produce.

However, you can minimise and avoid the amount of pesticide residues and natural chemicals by peeling the skin off your fruit & vegetables and removing the outside leaves of lettuce & cabbage.

Natural Food Chemical Intolerance

Natural food chemical sensitivity or intolerance occurs when these natural chemicals (salicylates, amines, and glutamate) result in someone experiencing symptoms. When ingested these chemicals cause reactions by irritating nerve endings in different parts of the body which leads to symptoms. These symptoms can be different in each person and can include;

Bloating
Nausea
Stomach discomfort or pain
Diarrhoea
Headaches and migraines
Recurrent hives and swelling
Sinus trouble
Fatigue or feeling run down
Flu-like aches and pains

In children symptoms can include;

Irritability and restlessness
Exacerbation of behavioural problems such as ADHD.

In baby’s symptoms can include;

Colic
Irritability
Eczema
Loose stools
Nappy rash

The presence of symptoms after ingesting a food that you are intolerant to is dose dependent. A small amount of a food high in natural food chemicals may not be enough to cause a reaction straight away. However, eating a large amount that goes over your individual threshold can cause a reaction. Since these chemicals are found in many different foods they can accumulate in the body over time. Therefore, eating small amounts regularly can lead to symptoms occurring after a few days. The image below from the Royal Prince Alfred Hospital (RPAH) Allergy Unit is a great visual representation showing how these chemicals can gradually build-up until they exceed our threshold.

Dose Dependency Image

Management of Natural Food Chemical Intolerance

Management is dependent on your individual threshold to these natural food chemicals. Those with a low threshold are recommended to avoid large doses of these and are often required to follow a low chemical diet. However, those with a higher threshold may only need to avoid meals containing high levels of these chemicals but can still eat small amounts.

How an Elimination Diet Can Help

An elimination diet is important in the diagnosis of food intolerances as, unlike allergies, there are no skin tests or blood tests that can be used. Trying to eliminate foods or natural food chemicals one at a time can often lead to unclear results as to which foods or chemicals are actually triggering your symptoms.

Determining the dietary triggers to your food intolerance’s is incredibly important. This will allow you to know which foods you can and cannot eat safely and which foods are likely to trigger your symptoms. It will also allow you to avoid unnecessarily restricting foods from your diet.

The only reliable and effective way of determining which natural food chemicals are triggering your symptoms is to eliminate all of these at one time and wait for your symptoms to settle. This can be a big adjustment to your current diet and eating habits and may seem difficult and overwhelming at first. You may feel that meals times become more complicated or that eating out is no longer fun. However, you can take a deep breath and relax! There are so many easy strategies that an Accredited Practising Dietitian (APD) who specialises in food intolerances, such as myself, will be able to provide you with so that you can still enjoy your activities and have pleasure from eating.

It is very important to remember that an elimination diet should only be completed under the supervision on an APD and only for a short amount of time. This is due to the fact that people following a restrictive diet, such as an elimination diet, are more at risk of nutrient deficiencies. An APD will provide you with appropriate substitutes to your favourite foods while ensuring you are getting all the nutrition you need with a healthy, balanced diet and a wide variety of foods.

When Should You Consider an Elimination Diet?

Food chemicals are believed to exacerbate and cause gut symptoms in some people with IBS due to their guts being more sensitive.

A low chemical elimination diet is usually recommended to be trialled in those that have tried the low FODMAP diet and found that it did not give them a significant improvement in their symptoms. It also recommended for those who experience additional symptoms other than just in their gut.

The FODMAP diet is a therapeutic diet and is often used and recommended in the medical management of those with IBS. This diet helps to determine if these carbohydrates are responsible for triggering symptoms in those with IBS. To learn more about IBS & the FODMAP diet you can read my “Identify Your IBS Type To Manage Bloating & IBS)” & “The Journey Towards Managing Your Bloating & IBS (FODMAP Phase 1-3)” blogs.

Whereas an elimination diet aims to identify if a person’s symptoms are triggered by chemicals found in foods, rather than carbohydrates. So, they focus on quite different food components. Some foods low in natural food chemicals are also high in FODMAPs, so although FODMAPs and food chemicals can cause similar symptoms, it can sometimes be difficult to determine which elimination diet is the most suitable.

The low FODMAP diet is recommended to be trialled first as it is less restrictive and are more likely to trigger IBS symptoms. Studies have shown that a low FODMAP diet can improve gut symptoms in up to 75% of people with IBS. However, as mentioned above, if symptoms are still being experienced, then the low chemical elimination diet is recommended for IBS.

The RPAH Elimination Diet

The RPAH Allergy Unity have developed an elimination diet specifically used for the investigation and management of suspected food intolerances. There are 4 stages of the RPAH elimination diet protocol.

Stage 1: Elimination Diet

The elimination diet is followed for at least 2 weeks. However, symptoms may take up to 6-8 weeks to settle. This phase of the diet requires people to avoid any foods high in natural food chemicals and substitute these with low natural food chemical alternatives.

There are 3 possible approaches to this stage of the diet. These include a strict, moderate or simple approach and your dietitian will discuss which approach is most suitable for you.

Restricting high food chemical foods enables us to determine if someone is responding to the low food chemical diet and whether it is resulting in a decrease in their symptoms. Once someone has had at least 5 days in a row free of symptoms they can begin the food challenge stage of the diet.

Stage 2: Challenges

This stage involves the challenging or reintroduction of each of the food chemicals in a systematic way that is well planned to ensure that the results you get are clear and accurate. During this stage people continue to follow the low food chemical diet as their base diet, with each food chemical group being challenged one at a time. A dietitian will give advice and guidance on which food to use for challenging, the order to reintroduce them and also the amount. This stage helps to determine which food chemicals may be triggering a person’s symptoms.

Stage 3: Liberalisation

STEP 1 – Personalised Diet

This stage usually lasts at least 3-4 weeks and is where the food chemicals that a person did not react to are added back into their diet based on the results from their challenges. During this stage people continue to avoid food chemicals that they reacted to.

STEP 2 – Identifying Tolerance Thresholds

A person moves onto this step when they feel comfortable with their personalised diet. This step involves testing a person’s threshold for each of the food chemicals that they reacted to, to determine the amount of a food chemical that they can tolerate before getting symptoms.

This is a particularly important part of the diet as it will identify whether a person may be able to tolerate a low, moderate or high amount of a food chemical before getting symptoms.

Stage 4: Long-Term Management

This is where different food chemicals are added back into the diet based on person’s individual tolerance. This stage is a particularly important phase of the diet as it enables us to develop a long-term balanced diet to ensure people are able to maintain and improve their overall health and quality of life.

If you’re looking for support on how to follow the FODMAP diet or RPAH elimination diet so that you can eliminate your bloating and live your best life, apply for coaching.

References

Australasian Society of Clinical Immunology and Allergy (ASCIA). Food Allergy [Internet]. Cited 2019 May 28. Available from: https://www.allergy.org.au/patients/food-allergy/food-allergy
Australasian Society of Clinical Immunology and Allergy (ASCIA). Food Intolerance [Internet]. Cited 2019 May 28. Available from: https://www.allergy.org.au/patients/food-other-adverse-reactions/food-intolerance
Barrett JS & Gibson PR (2012). Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals? Therapeutic Advances in Gastroenterology. 5(4):261-8.
Perry CA, Dwyer J, Gelfand JA, Couris RR, McCloskey WW (1996). Health effects of salicylates in foods and drugs. Nutrition Review. 54(8):225-40.
Royal Prince Alfred Hospital, Allergy Unit (2011). RPAH Elimination Diet Handbook with Food & Shopping Guide.
Royal Prince Alfred Hospital, Allergy Unit (2016). Food Challenge Instructions Booklet.
Royal Prince Alfred Hospital, Allergy Unit. The Role of Natural Salicylates in Food Intolerance [Internet]. Cited 2019 October 12. Available from: https://www.slhd.nsw.gov.au/rpa/allergy/resources/foodintol/development.html
Skypala IJ, Williams M, Reeves L, Meyer R & Venter C (2015). Sensitivity to food additives, vaso-active amines and salicylates: a review of the evidence. Clinical and Translational Allergy. 5:34.

How The Gut Works With The Brain To Manage IBS

What is the Gut-Brain Axis?

Have you ever felt butterflies in your stomach when you’re nervous? Or ever felt the need to run to the bathroom right before you leave to go for a job interview? Thankfully there is an explanation for this! The link or communication pathway between your gut and your brain, also known as the gut-brain axis is what causes this to occur. This communication pathway is bidirectional, so it works in two directions. This means that your brain and how you are feeling can influence your gut activities (hence the nervous poos), and what is happening inside your gut can have an effect on your brain, generating particular feelings, emotions, thoughts and even behaviours.

How Does This Gut-Brain Axis Work?

Neurons or chemical transmitters are the main communicators and their role is to send information up and down the vagus nerve, which connects the gut to the brains limbic system (home of the emotions and stress in the brain). So, these neurons are regularly going back and forth sending these messages between the two systems, keeping them in contact.

The gut and brain are constantly in communication with one another and this line of communication is a rather convenient way for your gut to keep the brain up to date with your overall health. Research also suggests that your gut microbiome also plays an important role in the gut-brain axis.

The Gut Microbiome & the Gut-Brain Axis

Trillions of microbes or bacteria live throughout the body, all having various roles, with around 90% of these living all throughout the gut! Primarily, the gut microbiome plays important roles in digestion, production of hormones (to transmit messages!) and protection against pathogens, which are bacteria, viruses, or other microorganisms that can cause disease.

Each of our individual gut microbiome’s vary, with a large range of influencing factors, all starting from the moment we are born! For example, a vaginal birth means that you were exposed to the bacteria in your mother’s birth canal, immediately gaining exposure to a range of different species. Whereas a caesarean birth means you were exposed to bacteria located on the skin and less exposure to these varied species. Therefore, the diversity of gut bacteria is lower in infants born via caesarean section and the composition of their gut microbiome is different to those born vaginally. Fortunately, how you are born is not the only factor influencing the make up of your gut microbiome! There are so many more factors influencing the variety you have, including where you live, your work/home environments, who you are in contact with each day and most importantly, what you eat!

A wide variety of gut bacteria means a wide range of hormones being produced by the microbiome including serotonin (happy hormone) and dopamine (the hormone stimulating learning and memory). Once the microbiome releases these hormones, they are transported through the vagus nerve, stimulating the brain, which improves mood and memory. This helps to explain the link found between the diversity of the gut microbiome and its influence on anxiety and depression. Research suggests that a disturbance and reduced diversity of gut bacteria can have a link to increased feelings of anxiety and depression, with less of the serotonin and dopamine being produced.

Impact on Our Health & the Important Role of Nutrition

There are so many factors influencing the diversity, or the variety of different types of gut bacteria, in our gut microbiome. However, it is important to acknowledge that out of all these things, diet is the one factor that we can easily manipulate to help improve the diversity of our bacteria. Since a large portion of the microbiome is found in our gut, the types of foods we eat can influence their diversity.

The types of food that we eat and the nutrients that they contain can have a large influence on not only our gut bacteria, but the gut-brain axis overall, with studies linking our diet to our mental awareness, cognition, moral principles and our emotions. Variation is key! Research is still in its infancy, however studies involving dietary changes to positively influence the gut microbiome have shown many positive changes to mental health. So, in other words, the more variety in your gut microbiome, the happier you are!

The Gut-Brain Axis & Irritable Bowel Syndrome

As we now know, our gut and brain are constantly in communication with one another and when something goes wrong with one, the other reacts. Unfortunately, this is the case with people with irritable bowel syndrome (IBS) and is a perfect example of how the two systems communicate and influence each other. Research in this area is much more associated with animal studies rather than humans however, a significant link has been found between the gut microbiome, the gut-brain axis and in turn IBS symptoms, with significant links between stress and the gut microbiome response. Reality is, there is a link between IBS and stress/anxiety with stress reducing the diversity of the gut microbiome overall, increasing inflammation within the gut (with less production of those happy hormones).

How Can Food Help the Gut-Brain Axis?

Studies suggest that including probiotics and prebiotics in the diet can help in improving the diversity of gut bacteria with abnormal gut function improving when these foods are included in the diet.

Prebiotics are a form of fibre that passes through the digestive tract and into the large intestine where the good bacteria feed off the prebiotic, producing by-products that positively stimulate the gut-brain axis. Therefore, prebiotics have a large role in improving the diversity and the actions of the bacteria in the gut and in turn, the brain.

Probiotics, however, are the good gut bacteria already present in our body which have also been added into foods such as yogurt, kefir and even supplements. Currently the research available does suggest that there is a potential for health benefits with enough present in the gut, however we are currently unsure if probiotics consumed in the form of foods and supplements can survive the journey through the digestive system, suggesting they may not have extensive health benefits.

So overall, it is recommended a diet with a wide variety of high fibre foods (prebiotics), vegetables, fruit and grains with the inclusion of dairy products like yogurt and milk, can help to increase the diversity of the gut microbiome to stimulate positive activity in the gut and therefore the brain.

Why Should You Know About the Gut-Brain Axis?

The phrase “gut feeling” gets thrown around quite a bit, however, is an important concept. What you’re eating and how you’re feeling can often be interrelated, which most people are not aware of. If you do not have an overall varied and healthy diet, this may have an influence on the way you think or feel and can result in feeling fatigued, “cloudy” or emotional. This might be your gut-brain axis feeding back to you! If you think this might be the case, book in to see a dietitian, who can help you improve your overall diet and gut health.

Start Improving Your Gut Microbiome Now with These Simple Steps!

Choose a wide range of different fruits and vegetables daily! Remember to try to incorporate 2.5 cups of vegetables and 2 pieces of fruit daily.
Increase your intake of fibre by including more prebiotic foods into your diet! (See below for some suggestions).
Include a wide range of wholegrain foods into your diet! Remember, the more seeds and grains, the better.
Introduce omega 3 fats! Think about incorporating more oily fish into your diet and try to do so at least 2 times per week.
Don’t be afraid to try new foods! Perhaps a food you’re considering trying may have a positive effect on your gut microbiome or introduce a new strain!

Examples of Prebiotic Foods to Help Improve Your Gut Microbiome!

Garlic
Onion
Bananas
Soybeans
Red kidney beans and other legumes
Grapefruit
Rye
Bran Cereals
Oats
Cashews

If you’re struggling with bloating and aren’t sure what to eat, I show my clients step by step how to follow the FODMAP diet to eliminate bloating and live their best life. Being diagnosed with IBS doesn’t have to be a punishment when you know what to do, how to eat and how to live your best life and I’ll show you that when we work together, apply for coaching.

Written by Stephanie Monacella

Steph is a final year student dietitian completing her last two weeks of the Masters of Dietetics course at Deakin University. “I am very passionate about using my knowledge and skills that I have learnt to provide the public with nutrition related content from the most up to date scientific evidence-based research.”

References

Carabotti M, Scirocco A, Maselli MA & Severi C (2015). The gut-brain axis: interactions between enteric microbiota, central and enteric nervous systems. Annals of Gastroenterology. 28(2):203–209.
Clapp M, Aurora N, Herrera L, Bhatia M, Wilen E & Wakefield S (2017). Gut microbiota’s effect on mental health: the gut-brain axis. Clinics and Practice. 7(4).
Kennedy P (2014). Irritable bowel syndrome: A microbiome-gut-brain axis disorder? World Journal of Gastroenterology. 20(39):14105.
Martin C, Osadchiy V, Kalani A & Mayer E (2018). The Brain-Gut-Microbiome Axis. Cellular and Molecular Gastroenterology and Hepatology. 6(2):133-148.
Mohajeri M, La Fata G, Steinert R & Weber P (2018). Relationship between the gut microbiome and brain function. Nutrition Reviews. 76(7):481-496.
Monash University Department of Gastroenterology. Prebiotic Diet – FAQs [Internet]. Cited 2019 June 6. Available from: https://www.monash.edu/medicine/ccs/gastroenterology/prebiotic/faq#3
Oriach C, Robertson R, Stanton C, Cryan J & Dinan T (2016). Food for thought: The role of nutrition in the microbiota-gut–brain axis. Clinical Nutrition Experimental. 6:25-38.
Thursby E & Juge N (2017). Introduction to the human gut microbiota. Biochemical Journal. 474(11):1823-1836.
Umu Ö, Rudi K & Diep D (2017). Modulation of the gut microbiota by prebiotic fibres and bacteriocins. Microbial Ecology in Health and Disease. 28(1):1348886.

10 Ways To Increase Fibre to Eliminate Bloating & Constipation

What is Fibre?

Fibre is an important nutrient in improving our overall health. Fibre is the edible parts of plants that are unable to be digested, or broken down, and absorbed in our small intestine. These are then either partly or fully broken down by the bacteria in our large intestine.

In Australia, it is currently recommended that women consume 25g of fibre per day and men consume 30g of fibre per day. However, most Australians currently do not consume enough fibre.

Types of Fibre

There are three different types of fibre. As you will see below, they each affect the function of our gut in different ways and have numerous health benefits.

Soluble Fibre

Soluble fibre is mainly found in the cells of plants and includes pectins, gums and mucilage. This form of fibre assists with delaying or slowing down the speed that our stomach empties. This not only helps us feel fuller for longer, but also helps to keep our blood sugar levels stable and lower cholesterol. Soluble fibre is found in foods such as oats, barley, vegetables, fruit and legumes.

Insoluble Fibre

Insoluble fibre is the building block for plant cell walls and include cellulose, hemicelluloses and lignin. This type of fibre helps to keep our stools soft by absorbing water throughout our gut. This assists with preventing constipation and keeping our bowel movements regular. Insoluble fibre also helps to keep us fuller for longer and supports keeping our gut microbiome happy and healthy. It is found in foods such as the skins of fruit and vegetables, seeds, nuts and wholegrain cereals and breads.

Resistant Starch

Resistant starch is not digested or broken down in the small intestine. This means that when it gets to our large intestine it is fermented by the bacteria in our bowel to produce gas. This promotes good bacteria and forms short-chain fatty acids (SCFA). These play an important role in our gut health and maintaining a healthy microbiome. They may also help to protect against bowel cancer and assists with lowering cholesterol levels. Resistant starch is found in rice, under-cooked pasta, unripe bananas, cooked and cooled potato.

Health Benefits of Fibre

Adequate fibre intakes have been shown to decrease a person’s risk of developing chronic diseases such as bowel cancer, cardiovascular disease and diabetes. Fibre can also help with making us for fuller for longer after meals and plays a vital role in making sure our gut is working normally and keeping our gastrointestinal system healthy.

Eating enough fibre has been shown to;

Decrease cholesterol levels.
Lower blood pressure.
Control our blood glucose levels.
Improve and prevent constipation.
Decrease loose stools, manage diarrhoea and the symptoms associated with diarrhoea such as stomach pain, cramps and wind.
Increase the number of good bacteria in our gut.

My Expert Tips for Increasing Your Fibre Intake

The easiest way to make sure that we are getting enough fibre each day is by eating a healthy balanced diet with a wide variety of foods. This is easily achieved by ensuring that we eat foods from each of the 5 food groups. These are grains (cereals), meat and/or alternatives, fruit, vegetables and dairy and/or alternatives.

My expert tips for increasing your fibre intake are;

Include at least 1-1.5 cups of vegetables with your lunch.
Include at least 1.5-2 cups of vegetables with your dinner.
Include vegetables as snacks.
Choose wholegrain and/or high fibre breads, cereals, pastas and rice instead of refined or white versions of these foods.
Eat at least 2 pieces of fruit each day.
Use fruit for snacks and desserts.
Add fruit to your breakfast cereal, smoothies or yoghurt.
Keep edible skins on your fruit and vegetables.
Try having a small handful of nuts or seeds as snacks.
Add legumes such as beans or lentils to your meals.

When we increase our intake of fibre it is important that we also make sure that we are drinking enough water throughout the day. As mentioned above, fibre absorbs water in our gut to assist with keeping our stools soft and preventing constipation. Not drinking enough fluid can result in fluid not being absorbed from our gut into our stools. This can result in harder stools and cause stomach pain or discomfort and constipation.

References

Dhingra D, Michael M, Rajput, H & Patil RT (2012). Dietary fibre in foods: a review. Journal of Food Science and Technology. 49(3): 255–266.
Li YO & Komarek AR (2017). Dietary fibre basics: Health, nutrition, analysis, and applications. Food Quality and Safety. 1: 47–59.
Mohammadi AA, Jazayeri S, Khosravi-Darani K, Solati Z, Mohammadpour N, Asemi Z, et al (2016). The effects of probiotics on mental health and hypothalamic-pituitary-adrenal axis: a randomized, double-blind, placebo-controlled trial in petrochemical workers. Nutritional Neuroscience. 19(9):387-95.
National Health and Medical Research Council. Eat for Health-Educator Guide. Canberra; 2013:11-23.
National Health and Medical Research Council. Nutrient Reference Values for Australia and New Zealand-Executive Summary. Canberra; 2006.
Sekirov I, Russell SL, Antunes LCM, Finlay BB (2010). Gut microbiota in health and disease. Physiological Reviews. 90: 859-904.

The Journey Towards Managing Your Bloating & IBS (FODMAP Diet Phase 1-3)

What is the FODMAP Diet?

The FODMAP diet is a therapeutic diet and is often recommended to those who have Irritable Bowel Syndrome (IBS). IBS is a common gastrointestinal disorder that affects 1 in 7 adults and is characterised by symptoms that are not explained by other disorders such as coeliac disease and inflammatory bowel disease. The most common symptoms of IBS include; stomach pain, bloating, wind, diarrhoea, constipation and nausea.

These symptoms can lead to stress and anxiety and affect our quality of life. The exact cause of IBS is not completely understood, however there are a number of things that may trigger symptoms (to learn more about IBS read my “Identify Your IBS Type To Manage Bloating & IBS)” blog).

The dietary cause of the symptoms associated with IBS is largely due to a group of carbohydrates called FODMAPs. This is an acronym which stands for;

Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And Polyols

Examples of FODMAPs include fructose, lactose, fructans and sorbitol. These carbohydrates, or sugars, can be poorly absorbed in the small intestine and fermented or broken down in the large intestine. This produces gas which leads to the symptoms associated with IBS. FODMAPs are also small and increase the amount of water delivered throughout the gut. This is called an osmotic effect. The gas produced by the large intestine in combination with this osmotic effect can cause changes to our gut motility or it’s movement. This can result in the symptoms of constipation and/or diarrhoea.

FODMAPs are found in many common foods including fruit, vegetables, grains and dairy. Although these carbohydrates are poorly absorbed in everyone, they are believed to affect and cause symptoms in people with conditions such as IBS as their guts are more sensitive. It’s important to remember that FODMAPs are not the cause of IBS, however limiting these in the diet can help control IBS symptoms.

Did you know that a low FODMAP diet can help improve gut symptoms in up to 75% of people with IBS?

In order to follow a low FODMAP diet it is vital that you plan ahead as the diet can be quite restrictive and involves a number of changes to your diet. This means that you are more at risk of nutrient deficiencies. Therefore, it is recommended that the FODMAP diet be completed under the supervision on an Accredited Practising Dietitian (APD) as they are able to provide you with appropriate low FODMAP substitutes to your favourite foods while ensuring you are getting all the nutrition you need with a healthy, balanced diet and a wide variety of foods. Studies also show that those with IBS who follow the low FODMAP diet with the assistance of an APD can get better relief from their symptoms.

The 3 Phases of the FODMAP Diet

There are 3 phases to the FODMAP diet.

Phase 1 – Low FODMAP or Elimination Phase.

This usually occurs over 2-6 weeks. This phase of the diet requires people to avoid any high FODMAP foods and substitute these with low FODMAP alternatives. Restricting high FODMAP foods enables us to determine if someone is responding to the low FODMAP diet and whether it is resulting in a decrease in their IBS symptoms.

The low FODMAP diet can be restrictive and people often struggle with the amount of variety in their diet and also flavour. FODMAPs also contain fibre and are natural prebiotics, so those on a low FODMAP diet can struggle with meeting their fibre requirements which can lead to constipation. So, a big consideration is the long-term consequences of a low FODMAP diet. And this is one of the reasons why it is only recommended for a short period of time of 2-6 weeks.

Phase 2 – Reintroduction or Challenge Phase

This usually takes around 6-8 weeks to complete. This phase involves the challenging or reintroduction of each of the FODMAP groups in a systematic way that is well planned to ensure that the results you get are clear and accurate. During this phase people continue to follow the low FODMAP diet as their base diet, with each FODMAP group being challenged one at a time. A dietitian will give advice and guidance on which food to use for challenging, the order to reintroduce them and also the amount.

This phase helps to determine if FODMAPs may be triggering a person’s symptoms. It not only helps to identify which FODMAPs may be triggering a person’s symptoms, but also how much. This is a particularly important part of the diet as it will identify whether a person may be able to have a particular FODMAP or tolerate a small, medium or large amount of a FODMAP before getting symptoms.

Phase 3 – FODMAP Personalisation

This is where different FODMAP groups are added back into the diet based on the results from a person’s challenges. This phase is a particularly important phase of the FODMAP diet as it enables us to develop a long-term balanced diet to ensure people are able to maintain a healthy gut to improve their overall health and quality of life.

Expert Tips for Phase 1

My expert tips to follow during the elimination phase of the FODMAP diet are;

Find a low FODMAP substitute for any high FODMAP foods in the diet so that those following the diet can still enjoy all the meals they love.
Include foods from all 5 food groups to make sure that all nutritional requirements are met and to decrease the risk of developing a nutrient deficiency.

Strategies to add flavour without adding high FODMAP foods are also important. My expert tips are:

Use spices or herbs like basil, chili, cumin, ginger, pepper, rosemary or thyme on meat, fish, chicken, or vegetables.
Use maple syrup instead of honey to sweeten baked goods or cereal.
Avoid flavouring foods with onion or garlic powder.
Drink water, regular or decaffeinated coffee or black tea instead of herbal teas and fruit drinks or juices.

Expert Tips for Phase 2

The main thing that I hear clients struggle with and are concerned about during this phase of the FODMAP diet is managing a potential flare up of their symptoms during
the challenges. My expert tips to help with this are:

Take time to relax. This can include relaxation tapes, yoga, or massage as these may help improve gut symptoms.
Participate is regular exercise such as walking, cycling, swimming.
Take time when eating meals and make sure food is chewed well. Eating fast can result in us swallowing more air which can lead to symptoms such as bloating.
Keep a food and symptom diary during each of the FODMAP challenges to help identify which FODMAPs caused symptoms.
Using hot packs is also a great option to help improve gut symptoms.

Expert Tips for Phase 3

As the name suggests, this personalisation phase is individual for everyone. My expert tips to follow during the personalisation phase of the FODMAP diet are;

Let the results of the challenge phase guide the order in which each FODMAP is reintroduced back into the diet.
Reintroduce foods that were well tolerated first.
Try not to become disheartened if symptoms are experienced. Some gut symptoms from time to time are quite normal. We only need to become concerned if our symptoms are staring to impact on our ability to do our usual activities and quality of life.
Keep track of any symptoms that may be experienced. It can be helpful to rate symptoms on a scale of 1-10, with 1 being no symptoms and 10 being severe symptoms.

References

Gandy J & the British Dietetic Association. Manual of Dietetic Practice–Fifth Edition. 2014: 460-466.
Gibson PR, Shepherd SJ (2010). Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology. 25: 252–258.
Monash University. The 3 steps of the FODMAP diet [Internet]. Cited 2019 April 22. Available from: https://www.monashfodmap.com/blog/3-phases-low-fodmap-diet/
Monash University. Monash University Low FODMAP DietTM Application for Android. Cited 2019 April 22.
National Institute for Health and Care Excellence (NICE) (2008). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. CG61.
Tuck C & Barrett, J (2017). Re-challenging FODMAPs: the low FODMAP diet phase two. Journal of Gastroenterology and Hepatology. 32 (Suppl 1): 11–15.

Identify Your IBS Subtype To Manage Bloating & IBS

What is Irritable Bowel Syndrome (IBS)?

IBS is a common functional gastrointestinal disorder that affects 1 in 7 adults. It is characterised by symptoms that are not explained by other disorders such as coeliac disease and inflammatory bowel disease. The symptoms associated with IBS can vary from person to person. This includes the frequency severity and the types or number of symptoms experienced. The most common symptoms of IBS include;

Stomach pain or discomfort
Bloating
Wind
Diarrhoea
Constipation
Nausea

These symptoms can lead to stress and anxiety and affect our quality of life. The exact cause of IBS is not completely understood, however there are numerous factors that are believed to potentially trigger symptoms. The main cause is thought to be enteric nervous system dysfunction. This is the main and most important nervous system in our gastrointestinal tract (GIT). It is often referred to as our “second brain” and plays an important role in regulating the function of our GIT including motility or its movements and the transit of the contents within it. Others include low grade inflammation, gut hypersensitivity, delayed gastric emptying, acute gastroenteritis and lifestyle factors including psychological stress and life events.

How is IBS Diagnosed?

There are currently no medical tests available that can diagnose IBS. Your doctor is likely to take a detailed medical history and complete a physical exam to eliminate whether your symptoms may be caused by another medical condition. Your Dietitian will take a detailed medical, lifestyle and dietary history including the type and severity of symptoms you have been experiencing.

Once other conditions have been ruled out a set of diagnostic criteria called the Rome IV Criteria for Diagnosing IBS will be used to confirm if you have IBS. This includes whether you have been experiencing recurrent abdominal pain, on average, at least 1 day per week in the last 3 months, which is associated with 2 or more of the following;

Related to defecation (may be increased or unchanged by defecation)
Associated with a change in stool frequency
Associated with a change in stool form or appearance

What are IBS Subtypes?

IBS subtypes are determined on how often very loose or very hard stools occur. Percentages are used to assist with determining how frequently different stool types are occurring and are based on stool form on days with at least one irregular bowel movement.

There are three main subtypes of IBS;

IBS-C: constipation predominant
IBS-D: diarrhoea predominant
IBS-M: mixed bowel habits

There is also a fourth IBS subtype, IBS-U: unclassified. This is used when a person meets the diagnostic criteria for IBS, however their bowel habits cannot be accurately categorised into one of the 3 subtypes above.

It is important to remember that IBS subtypes are not separate conditions and that a subtype can be re-classified based on changes to a person’s bowel habits. Symptom quantity, intensity, and severity can also vary from person to person.

IBS subtypes

How Knowing Your IBS Subtype Can Manage Your IBS Symptoms

Knowing your IBS subtype is important as they each have different clinical signs and symptoms and management strategies vary between the different subtypes. Knowing your IBS subtype means that the management of your IBS can be individually tailored to your meet your specific needs which will assist with improving your symptoms.

Through changes to your diet and lifestyle, the nutritional management of IBS aims to improve your quality of life and decrease the frequency and severity of your symptoms. A dietitian will be able to work with you to develop a personalised management plan to ensure this occurs whilst you are getting all the nutrition you need with a healthy, balanced diet and a wide variety of foods.

The dietary cause of the symptoms associated with IBS is largely due to a group of carbohydrates called FODMAPs (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols). Examples of FODMAPs include fructose, lactose, fructans and sorbitol. These carbohydrates can be poorly absorbed in the bowel, which leads to the symptoms associated with IBS. Did you know that a low FODMAP diet can help improve gut symptoms in up to 75% of people with IBS? It’s important to remember that FODMAPs are not the cause of IBS, however limiting these in the diet can help control IBS symptoms. Studies also show that those with IBS who follow the low FODMAP diet with the assistance of an Accredited Practising Dietitian can get better relief from their symptoms.

References

Gandy J & the British Dietetic Association. Manual of Dietetic Practice–Fifth Edition. 2014: 460-466.
Gibson PR, Shepherd SJ (2010). Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology. 25: 252–258.
Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). Functional bowel disorders. Gastroenterology. 130: 1480–1491.
National Institute for Health and Care Excellence (NICE) (2008). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. CG61.
Schmulson MJ & Drossman DA (2017). What Is New in Rome IV. Journal of Neurogastroenterology and Motility. 23:151-163.