Marnie Nitschke, APD
Marnie is an experienced FODMAP-trained dietitian consulting at Everyday Nutrition
If you’re reading this, you’ve no doubt heard of the Low FODMAP diet. More and more people are doing it, and plenty of doctors, nutritionists and dietitians are recommending it. These days it’s the first line of dietary therapy recommended for people with IBS. We now have apps, websites, books and online courses dedicated to the diet, but you may be surprised that back in 2001 when I graduated as a dietitian, our Masters of Dietetics class hadn’t even heard the word FODMAP. The diet was yet to be perceived!
When confronted with an IBS patient, doctors and dietitians alike inwardly cringed. What advice could we give them? Eat more fibre? Eat less fibre? A vague recommendation to avoid ‘windy foods’ and questions about their bowel habits. And why did so many people find bread and pasta problematic? The IBS client was the one that made our heart sink, because we just didn’t know what to tell them. But behind the scenes, exciting things were happening in the realm of nutrition research.
During this time, Melbourne dietitian Sue Shepherd was seeing great results with irritable bowel syndrome (IBS) patients in her private practice, using what was called at the time the ‘fructose malabsorption’ diet. Fructose (the monosaccharide or single sugar) and fructans (oligosaccharides, or chain-length form of fructose) were the main culprits targeted, and in simple terms, it looked something like this:
Back then, information about the fermentable sugar content of foods was hard to come by. Lists were devised using the scarce data available, but also anecdotal evidence (ie. commonly reported trigger foods). Mesclun lettuce mixes, green beans and cabbage were out. Mushrooms and rye bread were in. Hydrogen breath testing was frequently recommended, and depending on the results, avoidance of lactose was another strategy applied.
By the early 2000’s, research was underway and being published by Sue Shepherd and the researchers at the Monash University team. Foods began being tested using new techniques and equipment, and our knowledge of fermentable sugars was growing. As the research progressed, we learned that polyols and galactooligosaccharides were also part of the puzzle, and this was built into the dietary advice given to patients.
Polyols are sugar-free sweeteners, and include things like erythritol, hydrogenated starch hydrolysates, isomalt, lactitol, maltitol, mannitol, sorbitol and xylitol. Galactooligosaccharides belong to the group of prebiotics and are found in foods such as legumes, certain nuts and soy milk, among others. The role of these in gut health was now being recognised.
By this time, the research team at Monash had developed a well-structured and defined diet specifically for patients with symptoms of irritable bowel syndrome. Sue Shepherd released the first of many cookbooks dedicated to the diet, titled “Irresistibles for the Irritable”, and the word was spreading. The low FODMAP diet soon had a name, and by 2006, research was being published that proved its efficacy as a dietary treatment for the trigger symptoms of IBS.
The FODMAP diet was the first to recognise that short-chain carbs known as fermentable oligo-, di-, mono-saccharides and polyols are resistant to digestion. Instead of being absorbed into the bloodstream, they reach the far end of the intestine where most of our gut bacteria reside. Gut bacteria use these carbs for fuel, producing hydrogen gas and causing digestive symptoms, abdominal pain bloating and diarrhea in sensitive individuals. This finding would revolutionise our approach to gut health, and enhance our understanding of the small intestine and large intestine.
Being fortunate enough to work alongside Dr Shepherd and the team at Shepherd Works for nearly 10 years, I’ve seen the low FODMAP diet develop and change over time. Since the launch of the Monash University smartphone app in 2012, the information available to consumers and practitioners has expanded exponentially. These days, instead of just ‘high fodmap foods’ or ‘low’, we now have ‘moderate’ categories, and detailed information about the serving sizes and various FODMAPs present. Instead of ‘yes’ or ‘no’, we need to distinguish between different varieties of berries, pumpkin and mushrooms before deciding on their suitability.
Following clients through their food intolerance journey, I’ve seen that the low FODMAP diet works for a great many, which is fantastic! But what strikes me and other dietitians in this specialised field is that there is still so much left to learn. And given it’s a constant learning process for trained dietitians and nutritionists, it’s easy to see just how overwhelming today’s low FODMAP diet can be to the newcomer.
Do you know the most common advice I hear myself telling clients in private practice of late? Let’s just relax a bit and stop sweating the small stuff. And that they don’t need to get the diet 100% right to see results. Big picture changes will often get great results – as did the clunky old ‘fructose malabsorption diet’ we were working with 15 years ago!
There is no doubt that becoming too focused on lists and minute details can stress people out and backfire monumentally. If you are feeling bamboozled about your intolerance symptoms, and starting to feel like food is your worst enemy, I’d strongly encourage you to consult a dietitian or nutritionist for help. Our training and experience means we can guide you through the minefield of dietary information out there. We’re not the food police – we actually love food!
Marnie & Joanna are gut health expert dietitians with the knowledge and skills to support you with personalised advice and gut health solutions. We consult privately in Melbourne’s inner South East and via Skype. To make an appointment or seek advice, you can call any of the consulting rooms directly or email us at firstname.lastname@example.org