IBS—Free at Last!

Does IBS Get Worse with Age?

Although IBS can affect people of any age, some weeks it does seem as though I see more middle-aged and older patients in my practice than I might expect. What are the diet-related factors that might cause more gas, bloating, abdominal pain, diarrhea or constipation in older folks?

• Lactose intolerance is rare in young children, but common in older teens and adults. 
• Some patients are trying to be responsible adults and eat more healthfully. This might result in increased intake of FODMAP carbohydrates and result in symptoms. (Luckily you can use the IBSFree diet in my book to figure out which healthy foods you can tolerate well).
• Older adults are more likely to have diabetes, or have friends or family members with diabetes; sugar-free candies are popular with this crowd, and they often contain large amounts of sugar alcohols. Sugar alcohols such as sorbitol and maltitol are well known laxatives. Metformin, an oral diabetes medication, decreases sugar absorption, which can worsen IBS symptoms for some people.
• Conditions such as diverticulitis and c. difficile infection are more common in older individuals. The strong antibiotics that are prescribed for these conditions sometimes leave functional GI symptoms in their wake.

IBS related to most of the above age-related factors may respond well to changes in diet, including FODMAP elimination and, later, using probiotics to maintain gut health.

Spanish Translation of IBS--Free at Last! Launches

Exciting news for Spanish-language IBS-sufferers and the health care professionals who want to help them feel better fast, using food as medicine! This book project would not have been possible without the assistance of my two new European colleagues, Mario Bautista-Trigueros and Michela Mancarelli. They did a wonderful job combining their language skills with their professional backgrounds as scientists and nutritionists. 

The paperback book and the Kindle book are both available now on Amazon outlets worldwide. I will let some of Mario and Michela's Spanish-language colleagues tell you about their impressions of the book en español:

¡Por fin un libro sobre la Dieta FODMAP y el Síndrome del Intestino Irritable en español! Desde hace varios años muchas personas se están beneficiando de la dieta FODMAP para el SII y ahora, gracias a este libro, también lo podrán hacer todos aquellos que hablan español.

---Elvira Santamaría, Bióloga, Nutricionista y Blogger

El libro SII-¡Libre al Fin! es una herramienta muy interesante para cualquier nutricionista que quiera estar al día con los resultados más recientes de como ayudar a pacientes con el Síndrome de Intestino Irritable a través de la alimentación. En el libro se recogen las investigaciones de los últimos años sobre los FODMAPs y el SII, desde la explicación científica detrás de este enfoque hasta listas de alimentos con alto y bajo contenido en FODMAPs, recetas,  y lo que más he usado en mi consulta, una estrategia de eliminación y posterior reintroducción de los FODMAPs con el objetivo de conocer los carbohidratos FODMAP a los que cada persona es más sensible. Es una guía completa que me ha permitido establecer un plan de acción eficaz con cada paciente, ya que las fases de desafío con los diferentes grupos de FODMAPs permiten entender cuales son las necesidades específicas de cada persona a la hora de controlar el consumo de estos carbohidratos en la dieta. Es también de gran valor la última parte del libro, dedicada a responder a las preguntas que los lectores de la primera edición ya que ayudan a comprender en mayor profundidad el argumento y solucionan algunas dudas específicas que pueden surgir sobre qué productos pueden consumir las personas con SII.  En resumen, un gran libro que todo nutricionista que quiera estar actualizado respecto a los FODMAPs, el SII y la alimentación debe leer.

---Jorge Dorado Pérez, Nutricionista

Está muchas veces infravalorado el papel de la alimentación para manejar los síntomas de SII. Uno de los primeros pasos que recomiendo como médico gastroenterólogo es una dieta baja en FODMAPs. Es verdad que a veces recomendar que deben comer a mis pacientes se convierte en algo un poco difícil y ahí es dónde este libro se ha mostrado más valioso en mi experiencia, ya que explica que deben comer y que deben controlar o consumir en menor cantidad las personas con SII. La información está presentada al alcance de cualquier persona, no es necesario enredarse con terminología demasiado técnica e incomprensible. Debido a esto he recomendado el libro a algunos de mis pacientes, que querían profundizar sobre el tema. Este método, que ha demostrado su eficacia en los artículos científicos publicados en los últimos años, está respaldado por la investigación seria y no es otro libro más sobre dietas milagro con ninguna base científica. En mi opinión es una buena noticia la aparición de este libro en castellano sobre FODMAPs y SII  ya que existe un vacío en esta materia en lengua española y muchos pacientes y profesionales de la salud desconocen cuanto podemos ayudar a personas con SII a través de la dieta.

---Emilio Muñoz Regueiro, Médico Gastroenterólogo

Haz clic aquí para la versión en español por Hojas De Trabajo Y Listas De La Compra.

Haz clic aquí para Amazon.es

Haz clic aquí para Amazon.com

 

Boxes, Bags, Cans and FODMAPs

Oh, for the simplicity of whole foods! One glance at an orange or an onion tells you everything you need to know about what's inside. Not so for the many convenience foods that are part of our lives. When was the last time you made your own ketchup or yogurt? Many people have never served a salad dressing or spaghetti sauce that didn't come out of a bottle.

Where to begin? Well, you've got to have a look at the ingredients on the food label, and consider them one at a time. If any of them are high in FODMAPs, then that food is off limits for the elimination phase of the IBSFree diet unless or until the complete product is analyzed for FODMAPS and turns out to be low.

What are your resources for this task?

• Online, try the manufacturer's web site, your favorite large grocery store website, or my new favorite: Shopwell.com to review ingredients ahead of your shopping trip.
• The food label itself. Always double check the actual product; web sites can become out of date, and manufacturers can choose different ingredients in different regions.
• Your book, IBS--Free at Last! The book has pages and pages of label reading tips (the word "label" appears 43 times in the book, and I can't re-write the whole thing here!).

Let's use Enjoy Life Crunchy Sugar Cookies as an example. The manufacturer's web site lists the following ingredients, which you will consider one by one:

• Flour Mix (White Rice Flour, Millet Flour, Buckwheat Flour); these three flours are low in FODMAPs
• Evaporated Cane Juice; another name for sucrose--allowed as long as total sugar per serving does not get too high; two of these cookies have only 7 grams of sugar, far less than the limit of 40 grams of sugar suggested in the book
• Palm Oil; all oils are low in FODMAPs
• Brown Pure Cane Sugar; brown sugar is fine
• Natural Flavor; this one would be tricky if is was in a soup, but its a pretty safe guess there aren't any onions or garlic in a sugar cookie.
• Salt; fine
• Vanilla; fine
• Baking Soda; fine
• Sodium Acid Pyrophosphate; had to look this one up--together with the baking soda, this helps the cookies rise. Not a carbohydrate, therefore not a FODMAP. All FODMAPs are carbohydrates by definition
• Xanthan Gum; does not meet the definition of FODMAP
• Rosemary Extract; herbs and their extracts are fine

Conclusion: These cookies are allowed on the Elimination Phase of the IBSFree diet! To see products that I've reviewed and ideas for your grocery list, check out my new aStore on Amazon.com or my Pinterest boards. Enjoy your cookies!       

Click here to read a post about using the Nutrition Facts Panel to evaluate a trickier example, soy sauce.

How to Talk to your Doctor about IBS

If you’ve been suffering from gastrointestinal symptoms that interfere with your work or social life, you would be well advised to bring them to the attention of your primary care provider. You might decide to make a special appointment for this, especially if your symptoms are new, or to bring it up at your next scheduled check-up.  How can you make the most of your doctor’s appointment?

• Start with your primary care provider.
• For your own safety, do not self-diagnose. You want your provider to evaluate your symptoms using all of his or her diagnostic skills, not just note in your chart “history of IBS”.
• When you make your appointment, don’t be shy about the reason for your visit, what we call your “primary complaint”.  Your provider will put your primary complaint at the top of the list for discussion during your visit. If you aren’t sure how to communicate this to the scheduler without a lot of potty talk you could try “change in bowel habits” or “abdominal pain”; even “GI issues” is better than nothing.
• Make a list of your symptoms and bring it to your appointment. When did they start? What seems to bring them on? Review the alarm symptoms in Is it IBS so you can tell the doctor everything that he or she will need to know to plan your work-up or to make a diagnosis.
• It is perfectly OK for you to bring up the subject of a referral to a specialist. Try some of the following phrases: “Do my symptoms warrant referral to a gastroenterologist for evaluation? Why or why not?”; “I’ve been thinking I’d like to see a nutritionist for help with my IBS. Can you suggest a registered dietitian who works with GI patients?”; Depending on your insurance and local operating procedures, you may be able to self-refer to a gastroenterologist or registered dietitian, but your specialist will have more to work with if your primary care provider formally refers you and sends along your medical records.
• Be respectful of the doctor’s expertise and talk as though your two are on the same team when requesting lab tests. “I’d like to be more certain it isn’t celiac disease before I start changing my diet—how could we rule that out? I’m concerned about it because of my anemia and because it runs in the family.” This approach works better than either demanding tests or expressing worry that you might have this-or-that disease, which the doctor may dismiss as anxiety. The “rule out” idea is important in the diagnosis of IBS and your doctor will find it easy to relate to.

Even if you have suffered with gas, bloating, abdominal pain, diarrhea or constipation for years, now is the time to put these symptoms back on the examination table; many new treatment approaches have been developed in the past few years, including elimination diets, probiotics, and new medications. No one should settle for learning to live with IBS without a proper evaluation and a chance to try these new therapies.

Is it IBS?

Are you one of the many people affected by uncomfortable or debilitating symptoms such as diarrhea, constipation, gas, bloating or abdominal pain? Could it be irritable bowel syndrome (IBS)? IBS is defined as abdominal pain and discomfort with altered bowel habits in the absence of any other mechanical, inflammatory, or biochemical explanation for these symptoms.  In other words, your gastrointestinal system just doesn’t work right, even though there doesn’t seem to be an obvious reason for it.

Some day-to-day variations in your bowel habits are within the normal range. It isn’t necessary for good health to have one and only one bowel movement every single day.  Likewise, some gas production and flatulence is normal. Everyone has it! According to the National  Digestive Diseases Information Clearinghouse, many people think they have too much gas when they really have normal amounts. Most people produce about 1 to 4 pints a day and pass gas about 14 times a day. However, if you are in pain due to your bowel habits or if they interfere with your work, exercise or social life, you might have IBS. You should not diagnose yourself. If you experience symptoms suggestive of IBS, seek a thorough medical evaluation to rule out other potentially serious conditions, especially if you are experiencing any of the following:

• Passing blood from the rectum
• Fevers or night sweats
• Aching joints or inflammatory arthritis
• Anemia or other abnormal lab results
• Unplanned weight loss greater than 10 pounds
• Change in bowel habits after age 50
• Poor growth or failure to thrive (in children)
• Itchy rash
• Family history of Crohn’s disease, ulcerative colitis, celiac disease, ovarian or colon cancer
• Foul-smelling or greasy stools
• Incontinence or soiling
• Urge to move bowels waking you from sleep

Your health care provider will consider the pattern of your symptoms and compare them to established diagnostic criteria. He or she will take your medical and family history, physical examination, and test results into account. In younger patients without “alarm symptoms,” an office visit may be sufficient to diagnose IBS. In patients with alarm symptoms such as those listed above, a more extensive workup may be needed. If you are a female, especially over the age of 40, be sure that your workup includes a visit to a gynecologist. Bloating and abdominal pain are not always related to the digestive system, even if they occur between periods or after menopause; diseases and disorders of the reproductive and urinary systems should also be ruled out.

After your IBS diagnosis, you will want to begin exploring the role of diet in managing  IBS symptoms. To learn more about the FODMAP approach to diet for IBS, please explore this site, www.IBSFree.net, or read my book, IBS--Free at Last! Second Edition, Change Your Carbs, Change Your Life.

How do FODMAPs cause constipation?

Question: I can understand how FODMAPs might cause diarrhea, but how do they cause constipation?

Short answer: I don't know. Skip the rest of this post if you're not keen on rambling speculation about  FODMAPs and the gut microbiome.

Long answer:

In so-called simple constipation, as opposed to IBS, fiber/FODMAPs sometimes will actually improve symptoms. But let's talk about IBS-constipation predominant (IBS-C), which rarely responds to increasing fiber in the diet, and which we might be attempting to treat with a low FODMAP diet.

There is no final answer to the puzzling question: "how do FODMAPs cause IBS-C?" In fact, it isn't likely that food or food components cause IBS, rather there are underlying problems such as disordered immune function, dysbiosis, visceral hypersensitivity, slow or rapid transit time, etc. Still, reducing the FODMAPs in the diet can help manage symptoms.

Here are a few things to think about. The Merck Manual says "Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation."

One way FODMAPs affect bowel function is via osmotic activity; in other words FODMAPs have the ability to attract and hold fluid in the gut. If anything, we might expect this to soften stool and perhaps cause urgent, watery diarrhea. That seems to suggest that the osmotic activity of FODMAPs is not the main problem in IBS-C, although it clearly plays a role in people with diarrhea-predominant IBS. (We can't rule out that colonic distention due to increased fluid load in the gut causes constipation through some sort of broken feedback loop in fluid balance physiology, though.)

The other way FODMAPs affect bowel function is via their rapid fermentability and how that interacts with the type, amount, and placement of the resident gut bacteria in people with IBS-C.

Every single one of us is colonized by a unique set of microbes, as unique as our fingerprints. There is some preliminary work now showing that people with IBS may tend toward different populations of microbes than people without IBS, and that people with IBS-C tend to be colonized by more methane-producing bacteria. Limiting FODMAPs in the diet changes the food supply available and affects the microbiome in unknown ways. Using probiotics or antibiotics also affects the type and amount of gut microbes, and can sometimes improve symptoms. How these observations relate to "difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation" only time will tell.

Effects of Peeling or Cooking on FODMAPs in Fruits and Vegetables?

Does peeling, cooking or pureeing fruits and vegetables change the FODMAP content? Short version: this common questions does not have a good answer at this time.

Traditional nutrient database show little difference between cooked and raw fruits and vegetables. Published data from more complete FODMAP analysis has not yet explored many of these subtler variations in fruit and vegetable preparation.

It makes sense that peeling and cooking would affect certain FODMAPs in food, but there isn't enough info to be specific except in a couple of cases. We know that fructans in vegetables are water soluble and leach out into the cooking water, which is why onions and garlic in a soup or stew are potential problems even if you pick them out. We don't know specifically how many grams change, though. This effect could be useful for vegetables like broccoli and cabbage, I would think, suggesting that boiled and drained vegetables would have less fructans than raw or sauteed, but there is no data to prove it.

Peeled v. unpeeled apples and pears were analyzed in two studies by researchers at Monash University, Australia. Overall, peeled apples and pears by % weight actually had slightly more fructose than unpeeled (we might conclude fructose must be in the flesh of the fruit rather than the peel). Two varieties of apples were analyzed for polyols, peeled v. unpeeled . Peeled Granny Smith's had slightly more sorbitol than unpeeled. Peeled Pink Lady's had slightly less sorbitol than unpeeled. No generalization can be drawn, apparently. I have not seen any FODMAP data on cooked v. uncooked fruits.

It is hard to imagine any way that pureeing would change the fructose or polyol composition of fruits or vegetables. I am not aware of any specific data about whether pureeing can break down fructans in vegetables. My guess is that it can't break the molecular bonds of fructose links in fructans. Even if it could, would that be an advantage? Breaking down fructans, for example, would just mean the puree would be higher in fructose, which is also a FODMAP! (Might be helpful for someone without fructose malabsortion.)

What about food preparation methods that involve fermentation? Theoretically, the bacteria and/or yeast in fermented food could reduce the FODMAP content of the food before you eat it (instead of after you eat it, in your gut!). So far, we know that sourdough breads have less fructans than breads leavened with baker's yeast. The traditional two-day sourdough fermentation is what counts, not the word "sourdough" in the name or the flavor of the bread. These will usually be artisan breads from specialty bakeries. One clue to identifying a bread made by the sourdough process: there will be no baker's yeast in the list of ingredients.

Those are my thoughts on the subject, what about yours?

Updated 12/17/2012

Registration Open for May 4, 2012 Workshop: What Every RD Needs to Know About FODMAPs

Click here for a downloadable version of the registration form for the May 4, 2012 Workshop.

What Every RD Needs to Know about FODMAPs

A 5 CPEU, hands-on interactive workshop for dietitians.

Provided by: Kate Scarlata, RD, LDN and Patsy Catsos, MS, RD, LD

Friday, May 4, 9 am-3 pm, Great Bay Community College, Portsmouth, NH

REGISTER TODAY: LIMITED TO 70 PARTICIPANTS!

 Payment by credit card does not require a PayPal account. Click on "Don't have a PaypalAccount" during the transaction to use your credit card as a "guest." During your transaction, you will be asked to provide your ADA Member Number and your cell phone number for use. PayPal will email you a receipt, which will be your proof of registration. Your credit card statement will show a purchase from GI NUTRITION INC.

The FODMAPs concept, developed in Australia, is gaining momentum in the US as an emerging evidenced-based dietary approach that is effective in managing symptoms in 75% of those who suffer with IBS.

Each participant will receive the most up-to-date information about FODMAPs straight from Australia. Tools for patient education including a copy of IBS—Free at Last!, reproducible patient handouts, and a  low FODMAP recipe booklet.

Educational Objectives:

• Describe the common characteristics of FODMAPs carbohydrates and how they act in collective manner to trigger IBS symptoms.
• List prominent food sources of FODMAPs in the US diet.
• Create a FODMAPs nutrition care plan for an IBS patient.
• Instruct a patient on the details of a FODMAPs elimination diet, including the challenge phase, using tools provided at the workshop.

Schedule of Events:

8:30-9:00 AM Registration

9:00-9:45 FODMAPs: Efficacy, Food Composition and New Research

• What are FODMAPs and how do they cause symptoms of IBS?
• Do low FODMAPs diets work? What’s the evidence?
• What foods in the US diet contain measurable FODMAPs?
• What foods are low in FODMAPs?
• New cutoffs levels
• Fiber without FODMAPs

9:45 AM-11: 15 AM Advanced Medical Nutrition Therapy for IBS:  Using FODMAP Elimination Diet and Challenge Protocol

• Identify appropriate patients
• Three-visit nutrition care plan
• Use standardized language in patient medical records
• Teaching tools for the RD

 11:15-12:00 FODMAPs: Pearls for Practice 

• Menu planning, label reading, grocery shopping and recipe modification.
• Marketing your IBS practice and getting new referrals.

12:00 noon-1:00 PM Lunch break and networking

(Sharing marketing ideas: please bring business cards) 

1:00-3:00 PM FODMAPs Workshop in Small Groups

• Case studies and role playing
• Menu planning and label reading strategies
• Product sampling

Cost: $150.00

Cancellations will be refunded minus admin fee of $25.00 up to 1 week prior to event.

Registration deadline: April 25, 2012.

CPEUs approved: 5  Learning Codes: 5000 5220 3000

This conference is limited to 70 participants! Sign up early for this very hot topic in nutrition intervention.

 

Payment by credit card does not require a PayPal account. Click on "Don't have a PaypalAccount" during the transaction to use your credit card as a "guest." During your transaction, you will be asked to provide your ADA Member Number and your cell phone number for use. PayPal will email you a receipt, which will be your proof of registration. Your credit card statement will show a purchase from GI NUTRITION INC.

IBSDietplan.org Interviews Patsy Catsos About IBS and FODMAPs

IBSDietplan.org interviewed me on these questions:

• How to find a dietitian knowledgeable about FODMAPs
• Is  FODMAPs restriction accepted by the mainstream medical community?
• How to decide between FODMAPS, SCD and Heather Van Vorous/Help for IBS
• FODMAPs restriction v. elimination
• FM v. FODMAPs

Thanks to IBSDietplan.org for the opportunity to get the word out!

Breakfast Ideas for Vegetarians on the FODMAPs-Elimination Diet

Guest post by Jillian Smith, Nutrition Student at the University of New Hampshire and Intern

Breakfast is often said to be the most important meal of the day. There are many theories, such as "skipping breakfast increases your risk for overweight and obesity" or "skipping breakfast slows down your metabolism", that make headlines in the media. Whether or not you believe the trendy research, breakfast is a very significant meal. Breakfast gives your body fuel to perform requested activities. A good breakfast kick-starts the day allowing you to remain satisfied for several hours.

Breakfast should be a balanced meal. It should be composed of foods that are good sources of protein, carbohydrates, vitamins, and minerals. Vegetarians need to pay extra attention to the amount of protein consumed during breakfast to ensure an adequate intake of daily protein. A lack of protein in the first meal of the day makes it difficult to consume the proper amount of protein throughout the day. The following list of foods are great breakfast ideas to help vegetarians initiate their days with a burst of protein:

- 1 cup of cheerios with 1 cup of lactose-free milk. Top with almonds or chopped walnuts and your favorite allowed fruit.

- Eggs served any way! Make an omelet with cheddar cheese and vegetables for a surprising treat.

- Try seitan for breakfast. Add seasonings, salt and pepper and bake for a twist on traditional breakfast sausage. Serve with eggs!

- Make a batch of maple-syrup sweetened granola and serve on top of lactose-free yogurt with your favorite fruit. Add nuts to the granola to increase the quantity of protein!

- Serve up some good ole' fashion oatmeal. Top with a splash of lactose-free milk, nuts, and fruit. Add a teaspoon of maple syrup for a sweet concoction.

- Toast a piece of gluten-free bread such as Udi's white sandwich bread or FoodforLife's wheat and gluten-free English Muffins. Top with nut butter and banana. Make it a sandwich and eat it on the run.

- Relax with FODMAPs-friendly banana pancakes drizzled with real maple syrup or spread with a bit of sugar-sweetened blueberry preserves. These wonders will have you begging for more.

Get creative. Add new and different ingredients too keep you satisfied. Play with your food until you find something nutritious and enjoyable! Next post: Lunch Ideas for Vegetarians!