Food Blog

Our latest articles on food allergies & intolerances, low FODMAP diet, free-from recipes, health & wellness, dietitian blogs, reviews & lots more...

Beyond the low FODMAP diet By Dr Megan Rossi

Beyond the low FODMAP diet By Dr Megan Rossi

by FoodMaestro | 22 August 2016

Beyond the low FODMAP diet -  By Dr Megan Rossi 

Welcome to blog number four in the irritable bowel syndrome (IBS) series. By now I hope you feel a little more confident in your understanding of IBS and the low FODMAP diet - so how about we test your knowledge with a quiz?

Okay, don’t panic not quite a quiz, just one simple question…

What is the most common dietary intervention for IBS?  Is it (A) altering food components like caffeine, alcohol, fat, dietary fibre etc. or (B) the low FODMAP diet?

If you went with (B) then you’d be in the majority (and not just because it’s been the focus of my blogs…although slightly misleading I realise ;)) but because over the past few years, the low FODMAP diet has received a lot of attention in both the media and research arenas.  So then you may be quite surprised when I tell you that in real world clinical practice option (A) is in fact the most common dietary intervention for IBS.

WHAT?! So you’re saying I don’t necessarily have to follow a low FODMAP diet?

Yes, that’s right. Although arguably less “sexy”, option (A), which is known as first line dietary advice for IBS, has been shown to improve gastrointestinal symptoms in nearly 50% of IBS suffers.1 What’s more, this diet is not only a whole lot easier to follow but the British Dietetic Association’s new guidelines for dietary management of IBS suggest people should only embark on a low FODMAP journey if their symptoms aren’t adequately controlled with first line dietary advice.2

So what exactly does first line advice entail?

There are eight components to first line dietary advice detailed in Table 1. It is important to note that the evidence supporting most of these recommendations is based on how these food components effect the general population (particularly gastrointestinal motility, stress hormones and gut bacteria). Meaning a lot of the mechanisms have been extrapolated from the way the general population react to them, effects which are thought to be heightened in the IBS population because of their underlying issues across these three domains (gastrointestinal motility, stress hormones and gut bacteria). So clearly more studies in people with IBS are needed, although let’s not forget clinical trials are expensive and no easy feat (trust me!…as I embark on a program of research to tease out the role of dietary fibre in the management of IBS with Prof Whelan at King’s College London).

Okay so the research behind first line dietary advice isn't great BUT IBS experts with decades of hands on clinical experience recommend trialling these strategies as a first step…so why not give them a try?

Table 1: First Line dietary advice in IBS

Dietary component

Recommendation2

Alcohol

If related to symptoms assess intake and trial restriction

Caffeine

If related to symptoms assess intake and trial restriction. Behavioural changes (eg. irritability, nervousness or anxiety) have been reported with higher caffeine intakes

Spicy food

If related to symptoms assess spicy food intake and trial restriction. Also note it maybe the FODMAPs in onion and garlic!

Fat

If related to symptoms during or after eating, assess fat intake and ensure it is not excessive

Fluid

Aim for a total intake between 1.5-3L/day (preferably water)

Dietary habits

Chew your food well, don’t eat too fast, smaller portions, avoid eating a big meal before bed

Milk and Dairy products

If you suspect you’re sensitive to milk trial a low lactose diet (lactose being the fermentable carbohydrate found in many dairy products)

Dietary fibre

Avoid wheat bran supplements. If constipation predominant IBS, linseeds may help (up to 2 tablespoons/day for a 3 month trial)
Caution: consume with plenty of fluid and gradually introduce ie. 1 teaspoon/wk

What about probiotics?

There is growing interest in the use of probiotics in IBS. The rationale behind this is based on research that suggests some people with IBS have lower levels of “healthy” bacteria living in their large bowel (termed a dysbiotic gut microbiota).3 Unfortunately, the evidence for probiotics in IBS (considering both different strains and doses) is inconclusive at this time, with most studies showing  notable risks of bias.4 Nonetheless probiotics are considered safe in IBS and the guidelines suggest if individuals chose to try a probiotic they should do so for a minimum of 4 weeks at a dose recommended by the manufacture.  

Well that’s it for blog number four. Hopefully this has increased your awareness of the different dietary strategies for controlling IBS symptoms… because remember no one “size” fits all. Up next we take a look at why a low FODMAP diet might not be working for you.

Related articles by Dr Megan Rossi in the irritable bowel syndrome (IBS) series:

  1. Introduction to a low FODMAP diet - By Dr Megan Rossi 
  2. The research behind the low FODMAP diet -  By Dr Megan Rossi 
  3. Lactose guidelines for the FODMAP diet by Dr Megan Rossi
  4. Beyond the low FODMAP diet By Dr Megan Rossi
  5. Why the low FODMAP diet may not be working for you

By Dr Megan Rossi 

Instagram: Dr_Megan
Twitter: @DrMegan_RD

1. Bohn, L, et al.: Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology, 149: 1399-407.e2, 2015.

2. McKenzie, YA, et al.: British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update). J Hum Nutr Diet, 2016.

3. Rajilic-Stojanovic, M, et al.: Intestinal microbiota and diet in IBS: causes, consequences, or epiphenomena? Am J Gastroenterol, 110: 278-87, 2015.

4. McKenzie, YA, et al.: British Dietetic Association systematic review of systematic reviews and evidence-based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). J Hum Nutr Diet, 2016.

-