Updated: Oct 3, 2021
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Updated: Oct 3, 2021
The low FODMAP diet provides symptom relief for 75% of people with IBS. But unfortunately, that means that 25% of people don’t get the results they were hoping for and are left wondering what to do next.
If you are one of these people, read on to find out what your next steps may be…
Check you followed the low FODMAP diet correctly
The truth is that the low FODMAP diet is a pretty complicated one to follow and most people find that even with the proper guidance, they are likely to make mistakes, particularly in the beginning.
There are often FODMAPs hidden in foods which we may not have considered and unfortunately even small amounts of FODMAP can trigger symptoms in some people.
The low FODMAP diet should only be attempted with the support of a registered dietitian who can support you with following it correctly and ensure that you achieve a well-balanced diet whilst doing so.
Did you get a confirmed IBS diagnosis?
IBS can be a complicated condition to diagnose as there is no specific test to confirm it.
A diagnosis of IBS should be considered only if there is abdominal pain or discomfort that is either relieved by defaecation or associated with a change in bowel habit. This should be accompanied by at least two of the following four symptoms:
· altered stool passage (straining, urgency, incomplete evacuation)
· abdominal bloating (more common in women than men), distension, tension or hardness
· symptoms made worse by eating
· passage of mucus.
All people presenting with IBS symptoms should be clinically assessed for ‘red flags’ including signs and symptoms of cancer, inflammatory bowel disease (crohns and ulcerative colitis) and coeliac disease. A blood test and stool sample are usually required to exclude these diagnoses. Although best practice guidelines state that further testing is usually not required, some practitioners will arrange further testing such as a colonoscopy or endoscopy if they consider it appropriate.
If your GP or consultant has given you a diagnosis of IBS and you have trialled dietary modification including the low FODMAP diet with no improvement, then your GP may refer you to a gastroenterologist to explore other causes. Other possible causes include small intestinal bacterial overgrowth (SIBO), gastroparesis and diverticular disease.
Tip: If you are not sure about your diagnosis go back to your GP.
Consider Taking Probiotics
A Probiotic is defined as a micro-organism that when introduced into the host (human body) it should have beneficial qualities.
The use of probiotics in people with IBS may help to change the gut microbiota and improve the number of beneficial bacteria in the gut and reduce the number of unfavourable strains. Although probiotics have been researched considerably for their role in the treatment of IBS, there remains enough strong evidence to confirm which specific strains of bacteria or doses may be the most beneficial. This may in part be because everyone’s gut bacteria are different and therefore the required strain and dose of probiotic may vary between individuals.
It may be worth trying a probiotic, ideally one with multiple strains of different bacteria. You should take it for at least 4 weeks before deciding whether it has worked or not. If you see no improvement in symptoms after 12 weeks, then you should stop taking it.
Most people who see an improvement in their symptoms find that they must take the probiotic continuously or their symptoms return.
Although the elimination phase of the low FODMAP diet should not usually be followed for longer than 8 weeks, I often see people who haven’t had any guidance and may have been following it for much longer. Unfortunately, studies in recent years have shown that this can lead to unfavourable changes to the gut microbiota which can cause increased gut sensitivity. Researchers at Kings College in London found that taking a probiotic may help to offset these changes.
Tip: Trial a probiotic for at least 4 weeks before deciding if it has worked. If you notice no improvement after 12 weeks, then stop taking it.
Balance Your Fibre Intake
Fibre is an important component of the diet, it helps to keep our guts healthy and promotes regular bowel movements. Foods high in fibre include fruits and vegetables, beans, pulses, nuts, seeds and wholegrains.
Fibre can be a complicated topic when it comes to the management of IBS. A common mistake is to try introducing fibre into your diet too quickly. In practice I often see clients who set out to improve their diet to optimise their health or transition on to a plant-based diet and as a result their fibre intake doubles or even triples overnight.
As a starting point, if your symptoms are diarrhoea predominant then try reducing your fibre intake and then gradually increasing it again. If your symptoms are constipation predominant try gradually increasing your intake of fibre.
Tip: Increasing your fibre intake should always be done gradually to give your gut time to adjust.
Limit your intake of caffeine, alcohol, spicy and fatty foods
The above are potential gut irritants and are likely to contribute towards IBS symptoms. If you are currently consuming caffeinated drinks such as tea and coffee regularly, try and limit them to a maximum of 2-3 caffeinated drinks per day.
Alcohol is a potential gut stimulant, if you notice your symptoms are worse when drinking alcohol try and limit your intake to a maximum of 2 units per day. This is equivalent to approx. 1x 175ml glass of wine, a pint of beer or 2 single spirits. You should also try to only consume alcohol with food rather than on an empty stomach.
Although the mechanism is not clear, fatty foods have been shown to exacerbate symptoms in some people with IBS. If you have tried following the low FODMAP diet but your symptoms persist, be aware of whether fatty foods such as takeaways, cakes, pastries, butter, and cooking oils may be making you feel worse.
The ingredient capsaicin in chilli has been shown to worsen symptoms in people with IBS, particularly women. Again, if you notice your symptoms are worse following consumption of spicy foods then try removing spicy foods from your diet.
Tip: Try alternating your tea and coffee with decaffeinated options.
Practice Intuitive Eating
In some cases, IBS symptoms are exacerbated when you are not eating according to what your body needs. You may be swinging between going for long periods without eating, to eating large portions in one sitting. In doing so you may be putting your digestive system under strain.
Eating intuitively means that you are paying attention to your body’s hunger and satiety signals and therefore eating when you are hungry and stopping eating when you are no longer hungry. By eating intuitively, you are more likely to be following a little and often approach to eating which may be better tolerated by your gut.
Tip: Take your time when eating to be able to recognise when you have had enough. It takes approximately 20 minutes for your stomach to signal to your brain to tell you when you are full. If you eat very quickly you could easily eat quite a lot in one sitting before realising you have had enough.
Stress, Anxiety and Mood
Stress, anxiety and low mood have been shown to be significant contributors to IBS symptoms. Research has shown that people who have IBS are more likely to suffer with depression.
We have all heard of the phrase a “nervous tummy” and this may be explained by the “gut-brain axis” which consists of communication between the emotional and cognitive centres of the brain and the intestines.
Managing stress can be a difficult thing to master, particularly when most of us tend to lead busy lifestyles. Taking time out to relax, taking part in regular exercise and cognitive behaviour therapy are all useful tools.
If you suffer from depression and/or anxiety then your GP may recommend a mild dose of anti-depressants which have been shown to improve IBS symptoms in some cases.
More recently, gut hypnotherapy has been studied as a method to help “fix” the miscommunication between the gut and the brain. A study at Monash University in Australia compared the benefits of using gut directed hypnotherapy with the benefits of doing the low FODMAP diet and found it to be equally as beneficial for providing symptom relief. As a starting point I recommend a trial of the gut hypnotherapy app Nerva to my clients. If they start to see signs of improvement, then this suggests they may benefit further from 1:1 gut hypnotherapy.
Tip: Consider exercising regularly, taking time to relax, meditation or gut hypnotherapy.
Eat lots of plant-based foods
An imbalance in gut bacteria may be a contributing factor to your IBS symptoms. Bacteria in the gut are critical for normal gut development and health. A key factor supporting this is that IBS often develops after an episode of gastroenteritis (“stomach upset”) which has been shown to alter the number of bacteria in our gut. Additionally, multiple studies have shown that people with IBS have fewer strains of gut bacteria present compared with healthy controls.
By eating a well-balanced diet and in-particular focussing on consuming a large variety of different plant foods can help to optimise your gut health and repair any imbalance in gut bacteria. It is recommended that we should try to eat 30+ different plant-based food sources per week. This is likely to explain why in practice I often see clients who transition to a plant-based diet see an improvement in their IBS symptoms.
Tip: Aim to include 30+ different plant-based sources in your diet each week.
Summary:
Whilst the low FODMAP diet has high success rates in the management of IBS, 25% of people unfortunately do not see any benefit from following it.
Considering taking probiotics, limiting intake of caffeine, alcohol, spicy and fatty foods, adjusting dietary fibre and managing mood are all suggested methods which may help.
Sources:
Gralnek IM, Hays RD, Kilbourne A, et al. : The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology. 2000;119(3):654–60. 10.1053/gast.2000.16484 [PubMed] [CrossRef] [Google Scholar]
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Updated: Oct 3, 2021
A vegan diet consists of only foods made from plants such as fruits and vegetables, grains, nuts and seeds.
Research has shown that a vegan diet can provide us with all the nutrients we need for a well-balanced diet at any stage of life. As with any diet however, understanding and planning is key.
Are you thinking about transitioning to a vegan diet but not sure how to start? or perhaps you are already vegan and want to ensure that you are getting the balance right? Read on to find out more about how to eat for optimum health on a vegan diet…
Think about your protein options
Protein is an important macronutrient for tissue growth and repair. It is also involved in transporting oxygen around our bodies and fighting infections. Furthermore, protein can help to regulate our blood sugar control and keep us feeling fuller for longer making it an important macronutrient in the prevention of obesity.
As most of us are aware animal products such as meat, fish, eggs and dairy products are rich sources of protein. A common mistake on a vegan diet is to forget about substituting these for plant-based protein alternatives. Not having enough protein can lead to lethargy, increased hunger, reduced immune function, dry skin, brittle nails and hair loss. Good plant-based sources of protein include beans, chickpeas, lentils, nuts, seeds, and soy products such as tofu and tempeh.
Tip: As a starting point aim to include a plant-based protein source in at least 2 meals per day.
Eat a variety of different fruit and vegetables
Fruit and vegetables are an exceptionally good source of vitamins, minerals and antioxidants. They are also high in fibre which helps to keep our digestive systems healthy, and low in calories which helps with maintaining a healthy weight. We should all aim to eat at least 5 portions of fruits and vegetables per day. Variety is also important as different fruit and vegetables contain different vitamins and minerals. Click here to learn more about what counts as a portion of fruit and vegetables.
Tip: Aim to eat a rainbow of different coloured fruits and vegetables.
Base your meals on starchy carbohydrate
Carbohydrates are the body’s primary energy source. Starch is broken down into glucose which is then used by the body as fuel. Consequently, without them you would find yourself feeling quite lethargic and potentially very hungry.
Starchy foods should make up about a third of all the food we eat. Aim to base your meals on a source of starchy carbohydrate such as potato, rice, pasta, or bread.
Think about your fats
The good news is that a vegan diet is typically rich in heart healthy unsaturated fats which can help to lower your cholesterol and reduce the risk of heart attack and strokes. Omega 3 fatty acids are particularly important. On a non-vegan diet these are primarily found in oily fish. On a vegan diet the best sources include rapeseed oil, flaxseed, avocado, soy-based products, such as tofu and walnuts.
Although plant-based fats are an important part of the diet, be careful with portion control, especially if you are trying to lose weight. As with any type of fat, plant-based fats are high in calories so consuming too many of them will make it harder to lose weight or lead to unwanted weight gain.
Include dairy substitutes
Dairy products are a rich source of calcium, B12 and iodine, all of which are important components of a healthy diet. Not substituting your dairy products is likely to lead to insufficient calcium intake which may lead to poor bone health. A lack of B12 can lead to anaemia, and Iodine deficiency is associated with poor thyroid function. The good news is that most plant-based dairy substitutes are fortified with calcium and sometimes B12 and iodine. If you are trying to increase your protein intake, then opt for soya or pea based dairy substitutes.
Tip: Choose dairy substitutes that are fortified with calcium, iodine and B12. Suitable options include Oatly original oat drink, Alpro Soya drink or Mighty pea original milk.
Consider whether you are getting enough selenium
Selenium is an important antioxidant involved in the normal function of the immune system and sperm production. On a non-vegan diet rich sources include fish, meats (especially organ meats) and dairy products. Vegan sources include Brazil nuts, whole oats, and wholegrains options such as brown bread, rice or pasta.
Tips: 1. You can achieve your daily selenium requirement by eating just 5 Brazil nuts per day 2. Choose wholegrain starch options when possible.
Do vegans need to take supplements?
Vitamin D - Regardless of whether you are following a vegan diet or not I recommend that you take a daily vitamin D supplement containing at least 10mcg or 400IU of vitamin D. It is very difficult to consume enough vitamin D through diet alone. Vitamin D is produced in the body when our skin is exposed to sunlight. Unfortunately, in the UK most of us don’t get enough sunlight exposure. Vitamin D is especially important for helping the body to absorb calcium and optimise bone health. A vitamin D deficiency can also lead to tiredness and general aches and pains.
Vitamin B12 - For most people following a vegan diet I recommend supplementing with vitamin B12. Unless you are consuming B12 fortified products such as cereals, milks, nutritional yeast, marmite or vegan spreads at least twice a day, it is very difficult to achieve enough. Make sure your B12 supplement contains at least 10mcg.
Iodine - If you are unlikely to be able to consume at least 2 portions (~400ml) of iodine fortified dairy substitutes per day, then I recommend taking a 140mcg daily supplement.
Selenium – If you don’t like Brazil nuts, and you struggle with wholegrains then you are unlikely to be able to get enough selenium in your diet. If this is the case, then a daily supplement of 65mcg for women and 70mcg for men is recommended.
Tip: If you need to supplement with all the above then The Vegan Society markets a supplement providing reliable intakes of vitamins D, B12, iodine and selenium.
Thanks for reading 😊 For further information and personalised advice, consider booking my plant-based diet package.
Sources:
1. EFSA. EU Register on Nutrition and Health Claims [Internet]. 2016 [cited 9/9/2021]. Available from: http://ec.europa.eu/food/safety/labelling_nutrition/claims/register/public/?event=search
2. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom: Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy, Volume 41 of Department of Health Report on Health and Social Subjects, Issue 41 of Reports on health and social subjects, ISSN 0300-8045
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