FLAT TUMS and FODMAPs

FLAT TUMS and FODMAPs

Flat tums? Well, now that we have your attention!…

Today’s chat is about Irritable Bowel Syndrome (IBS) and a group of foods called the FODMAPs that – when reduced or eliminated- have been proven to help with symptoms such as bloating.

IBS is a condition that affects around 15% of the population and the usual symptoms are bloating, distension, abdominal pain, wind, diarrhoea and/or constipation. It’s a very common condition encountered in General Practice. Note- IBS should be diagnosed by a medical practitioner- other serious bowel and gynaecological conditions need to be excluded.  Several aspects need to be addressed in the management of IBS ( diet, IgG intolerances, stress, gut bacteria etc). Today’s discussion however, is on one very important topic that is sometimes not considered – and hence wanted to bring to your attention.
The FODMAPs

This is an acronym for Fermentable Oligosaccharide, Disaccharide, Monosaccharide And Polyols (!!!)
Research on FODMAPs has been led by Prof Peter Gibson (Dept of Gastroenterology) and Dr Jane Muir (Head of Nutritional Sciences) at Monash University in Melbourne. It has been shown that avoiding or cutting down on these foods can benefit people with IBS.

Dr Muir, at the Nutrition Conference in Melbourne 2012, stated
–a diet low in FODMAPs reduces symptoms in 74% of IBS sufferers
-should be first line treatment for IBS
-and interestingly, the fermentable component of wheat may be causing a non gluten IBS

Indeed, A LOW FODMAP DIET IS NOW WRITTEN IN THE THERAPEUTIC GUIDELINES AS THE PREFERRED DIETARY THERAPY FOR SYMPTOMS IN AUSTRALIA.
What are FODMAPs?

They are short chain carbohydrates, some of which are poorly absorbed in the small intestine of some people. They then pass through the large intestine where the resident gut bacteria ferment them, causing some of the common symptoms – gas (methane, hydrogen and carbon dioxide) , diarrhoea (small molecules so they have an osmotic effect which draws water into the bowel), distension and pain.
Nobody can absorb the oligosaccharides (fructans, galactans) and the others (lactose, fructose, polyols) are only partially absorbed. Those with IBS are more sensitive to these FODMAPs (possibly due to damage of the gut lining e.g alcohol, non- steroidal medications, viral/bacterial/yeast/protozoal infection , small intestinal bacterial overgrowth-SIBO)
Which foods?
Below is a practical list of some of the culprit foods that are high in FODMAPs. If they are eaten on a regular basis/large amounts, they can often bring about symptoms. (Don’t get put off by the long list!- there’s still lots of other food that can be eaten- there’s a nice little handout link at the end of this article which lists all the low FODMAP foods that are OK).
Fruits / fruit products and drinks
Apples, apricots, cherries, mango, peaches, plums, watermelon, nashi pear, lychee, persimmon, guava, nashi fruit (Asian pear), papaya, quince, starfruit (carambola), nectarines Coconut milk and cream

Dried fruit, Fruit juice/drinks, carbonated drinks, Fruit juice concentrate, Canned juice, Dried fruit bars, , Fructose sweetener, High fructose corn syrup, ,pancake syrups, Jams,Jellies,Pickle,relish,

Alcohol (esp wine,rum) , beer, dandelion tea
Dairy products (lactose) – Cow’s milk, ice cream, yoghurt, custard, soft cheeses (cottage, ricotta,mascarpone).
Note- Asians have lower lactase levels
Many people with IBS and about a third of other individuals, malabsorb excess fructose.
Vegetables
Onion –common cause of IBS; onion also in many processed foods inc sauces,stocks and gravies.
Leek, Asparagus, Artichokes, Cabbage, Brussel sprouts, celery
Chicory based coffee substitute Beverages (caro,ecco)

Grains and legumes

Wheat -breads, pastas, noodles, breakfast cereals, cookies, crackers cakes
Rye, barley
Chickpeas, Lentils, Beans: Borlotti, Baked, Kidney, Butter

Sauces and sweeteners
Honey, Artificial sweeteners – sorbitol (420) mannitol (421), isomalt (953), maltilol (965) xylitol (967).
Most people with IBS would benefit from restriction of sorbitol; some with mannitol.

Tomato paste chutney relish sauces- sweet&sour ,plum, barbecue
Nuts
Pistachios, cashews
Improving IBS symptoms
A trial of eliminating or at least cutting down on these for 2-6 weeks is useful to see if there is any change in symptoms. It is advisable to see a dietician or other health professional with an interest in nutrition and FODMAPs- as one still needs to be able to maintain a healthy nutritionally balanced diet with appropriate supplementation. The elimination of certain foods is not necessarily life-long; some foods may be able to be re-introduced into the diet.
So, FODMAPs should be considered in the management of IBS.
And of course, cutting out some of them could help reduce that tum!
Further reading and references:
Monash University website- great info and links from the home of FODMAPS! – includes diet plans, phone apps and books:  http://med.monash.edu.au/cecs/gastro/fodmap/

Excellent article from the Gastroenterological Society of Australia:  http://www.gesa.org.au/files/editor_upload/File/Consumer%20Brochures/A4_Low_FODMAP_Diet.pdf

Useful practical chart of high and low FODMAP foods:  http://www.ibsgroup.org/brochures/fodmap-intolerances.pdf

Food intolerance and the irritable bowel syndrome
Gut 1989;30:1099-1104  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1434180/pdf/gut00221-0081.pdf

Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach
Journal of Gastroenterology and Hepatology 25 (2010) 252-258  http://www.ncbi.nlm.nih.gov/pubmed/20136989

Dietary Triggers of Abdominal Symptoms in Patients With Irritable Bowel Syndrome: Randomized Placebo-Controlled Evidence
Clinical Gastroenterology and Hepatology, 2008:6 (7) 765-771  http://www.ncbi.nlm.nih.gov/pubmed/18456565

Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management
Journal of the American Dietetic Association;2006;106:1631-1639  http://www.ncbi.nlm.nih.gov/pubmed/17000196