This article was written by one of contributors; doctor with a bachelors degree in medical science – Laura Elliot
We met for the first time on a Tuesday afternoon. Emma*, a 24 year-old admin worker, had been thinking about seeing a doctor about her symptoms for a while, but because they seemed to come and go, she kept putting it off. She was struggling predominantly with symptoms of bloating, telling me she often looked “six months pregnant”, but also of fluctuating between very loose and very hard bowel motions. This had been happening for nearly a year and she couldn’t figure out what she was doing wrong. Was it something she was eating? She wasn’t sure. She admitted she’d been under quite a lot of pressure at work recently and had been quite stressed and not sleeping well. It was important to conduct a thorough history and examination so that we could exclude symptoms and signs of any more serious conditions such weight loss, loss of appetite or any palpable lumps in the abdomen. We also did some blood tests, looking for any sign of infection, anaemia, gynaecological causes, inflammatory bowel disease or difficulty absorbing nutrients, as in coeliac disease. Everything came back negative: now what?
I explained that her symptoms were in keeping with irritable bowel syndrome or IBS, a very common condition thought to affect between 10 and 20 percent of the population (1). Unfortunately, there’s no positive test for IBS and can only be diagnosed after all other causes have been excluded. It typically gives symptoms of abdominal pain, bloating and changes in bowel habit and there are certain criteria to fulfil before the diagnosis can be made. It is also more common in women than men and most prevalent in those aged 20-30 years old, although doctors are starting to see an increase in the numbers of older people with IBS-symptoms (1). Emma was keen to know what could be done to help with her troubling symptoms.
General lifestyle advice
IBS is a chronic condition felt to be the result of many different genetic, lifestyle, physiological and psychological factors, with new evidence coming out all the time. As its cause is poorly understood, the management of IBS can be challenging. We discussed how, because of its myriad causes, there are general lifestyle changes that can help.
Firstly, we discussed how Emma might be able to alleviate stress at work and together we identified other sources of anxiety in her life which could be potentially alleviated . I asked Emma about her diet, explaining that having regular, balanced and healthy meals can be helpful in people with IBS. It can be helpful to pay particular attention to fibre and water intake too, and for Emma to see how these affect her bowel movements. On the subject of diet, we talked about limiting caffeine, alcohol and spicy and fatty foods which are reported as triggers in up to 90% of IBS sufferers (2).
Emma, told me she didn’t exercise regularly but after discussing how exercise can help with reducing both stress and gas retention, she agreed to give it a go. I explained that we can use medications if we need to which can be targeted at reducing constipation, diarrhoea or abdominal pain. She told me she’d tried some anti-spasmodic medication she bought over the counter and it had helped in the past.
I saw Emma around one month later. She told me she had found that lack of sleep and stress at work both seemed to affect her bowels, and that exercise generally helped with issues of constipation. Keeping a diary had helped her to identify that food was a big trigger for her symptoms and although she had noticed some changes to her bowels after altering her fibre intake, her predominant symptom of bloating was still ongoing. I took this opportunity to mention the FODMAP diet.
What is the low FODMAP diet?
You may have heard of the low FODMAP diet (or maybe you’ve just heard people trying to pronounce it). It’s a diet which can be used in the management of IBS, or irritable bowel syndrome. Out of 10 people with IBS, 7 or 8 could see their symptoms improve with this diet (3). I’d read online about patients’ dissatisfying first encounters with the diet: doctors simply thrusting a list of ‘do’ and ‘don’t’ foods at them and sending them on their way. The word FODMAP itself is an acronym:
Oligosaccharides (Fructo- and galacto-oligosaccharides, FOS and GOS)
Polyols (sorbitol and mannitol)
Oligo-, di- and mono-saccharides and polyols are different chain length carbohydrates- that is, groups of sugar (glucose) molecules. These are of particular importance because they are poorly absorbed in the small intestine, instead passing through to the large intestine to be processed. The F of FODMAP refers to the fermentation of these carbohydrates in this part of the gut. Similarly to how yeast ferments sugar to make alcohol, these carbohydrates are fermented in the gut. And just like for alcohol, this produces gas as by-product. This can lead to IBS symptoms of bloating and excessive wind. These sugars are found in a variety of foods (see here for a list of high and low FODMAP foods) and reducing your intake of these foods can therefore reduce these symptoms for people with IBS.
The way it works is in three stages: Elimination, Re-introduction and Personalisation. In the first stage you don’t eat foods that are high in FODMAPs. To give it the best possible chance of success, I referred her to a registered dietitian for support (find a list here).
Emma and I then chatted through the three stages of the diet that the dietitian would guide her through. I explained that stage one, Elimination, is about reducing those foods which are high in FODMAPs for around 6-8 weeks with the hope that by the end you will feel your symptoms have improved. So, Emma said, looking down the list of high-FODMAP, “black-listed” foods, this means no onion… no garlic… no normal bread!? Yes, I said, but only for stage one! I felt it was important to re-emphasise the fact that the diet is about symptom control; it doesn’t focus on solving the source of the problem. It can be frustrating, I warned, because we don’t really know what causes IBS, but that it’s likely a combination of physiological and psychological factors. As such, I advised she continue to keep a diary of her symptoms throughout the trial of the diet, including aspects of her mood, exercise, sleep and menstrual cycle, as well as of her diet. It’s important to do this stage with guidance, I explained, because cutting out food groups can put you at risk of nutrient deficiencies. We discussed how she should focus on not cutting out whole food groups, and being mindful to keep a balanced and colourful plate even when avoiding certain ingredients.
The next stage would then be focussed on reintroducing high-FODMAP foods back into the diet with the guidance of the dietitian to identify any flare up of symptoms that correlate with various food challenges. For example, the dietitian at this stage might start off reintroducing lactose-containing foods over a few days and you would note whether you get any symptoms from these, before moving onto the next group. It’s a bit like running a science experiment at school where you make sure you are only testing one variable at one time, I explained. By working through the different food groups- fructans, polyols, fructose, lactose, GOS- you may start to identify what your triggers are. That will lead you nicely onto the third stage of Personalisation where you use what you’ve learnt to create a diet that works for you and your body.
I saw her at the end of her trial with the dietitian. She told me how it had been difficult at first trying to find suitable swaps for common ingredients that had suddenly been placed off-limits, but gradually she had found her way, swapping in garlic oil for garlic, the green part of spring onions for white onions, and replacing her usual couscous lunches with brown rice or quinoa. She had seen a slight improvement in her symptoms, finding after the first two weeks that her bowel habits had become more regular and noticed less bloating after the first month. After the stage two period of trial-and-error with different food groups, Emma had learnt which food groups she could tolerate better than others and which worsened her symptoms. She explained to me how her experiences had taught her that it was not only individual high FODMAP foods which were triggers, but also combinations of them. We discussed how eating large quantities of high FODMAP foods can contribute to an overall high load of FODMAPs in the system. She was surprised that often she could eat high FODMAP foods and be well, but other times she would eat low FODMAP foods and still experience some symptoms. I explained that this is likely because of the many other factors at play in IBS; she herself had found that periods of poor sleep or stress often exacerbated her symptoms, but she could manage these better by following a low-FODMAP diet during these times. She understood that although the diet won’t always be foolproof or failsafe, it worked for the vast majority of the time, and this was already a significant improvement. She was still learning, still exploring her own tolerances and boundaries. I reiterated the fact that she may find her tolerances change over time and that if she needed to in the future we could always re-refer her to a dietitian again to make a few adjustments.
The diet provided Emma another tool in the toolbox for managing her symptoms, alongisde those key basics of good sleep, regular exercise, mindfulness and stress reduction. We can’t always adjust for all the variables in our lives, but can we do our best to try. It might not always be plausible, easy or achievable, but we know we can fall back on a diet with our personalised low FODMAP foods to help us along our symptom-free way.
feature image: Lukas Budimaier via Unsplash