FODMAPs: The Latest In Health And The Irritable Bowel

By Dr Jaci Barrett

Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder. Symptoms of bloating, abdominal pain and diarrhoea or constipation (or alternating) are frequent. These impact daily life, mental wellbeing, increase absenteeism from work/school and affect social activities.

How Is IBS Managed?

There was little help for people with IBS 10 years ago.  It was often considered ‘stress related’ and not much could be done to provide relief. As graduate dietitians in the early 00’s we were instructed to advise our patients that they just needed to eat more fibre – with no relief of symptoms as a result. It was frustrating for both patient and clinician. 
 
Over my career in dietetics I have been lucky enough to be heavily involved in research into IBS and diet. Both patients and dietitians knew that diet was a factor in IBS symptom induction. We found that foods that were naturally high in specific carbohydrates that were not well absorbed and could be fermented by intestinal bacteria demonstrated a worsening of IBS symptoms. And so, at Monash University in Box Hill Hospital, the Low FODMAP Diet was born.
 

What Are FODMAPs?

FODMAPs are different types of carbohydrates including lactose, fructose, fructo-oligosaccharides, galacto-oligosaccharides and polyols. Foods with richest FODMAP content are listed below (Note: the list is not exhaustive, but gives an idea of the most common symptom triggers).
 
Table 1. Common IBS trigger foods rich in FODMAPs
Fruit Apples, pears, watermelon, mango
Vegetables
Sugar snap peas, asparagus, artichokes, garlic, onion, leek, spring onion
Legumes/nuts Baked beans, red kidney beans, cannellini beans, cashews, pistachios
Dairy Milk, condensed milk, ice cream, custard, ricotta cheese, cottage cheese
Grains Rye bread, white bread, wholemeal bread, multigrain bread, wheat-based cereals, pasta
 
A diet low in FODMAPs is now recognised as the most successful therapy for IBS, as long as it is followed under the direction of an experienced dietitian, with FODMAP exclusion, reintroduction and long term diet planning. 
 
FODMAPs actually have effects on the gut that suggest they are very good for us; they promote the growth of beneficial bacteria. For that reason, a strict low FODMAP diet for life is not recommended. The dietitian guided reintroduction of FODMAPs is essential in order to establish a long term diet that manages symptoms, whilst also promoting gut health. 
 

What’s The Latest In This Space?

Low FODMAP diet research continues around the world to test out the efficacy of the diet in different populations of people with IBS. Success is always seen in 50-85%, with dietitian involvement increasing the benefit. 
 
Alongside symptoms, recent studies have demonstrated an improvement in quality of life for IBS patients following a low FODMAP diet. For those that don’t respond with adequate symptom relief, there are other dietary therapies to trial.
 

What About Breath Testing?

Breath tests were initially used to detect poor absorption of individual FODMAPs so that the diet could be tailored to each person and made less restrictive. However, research has demonstrated that breath test results do not determine whether a particular carbohydrate is a symptom trigger or not (with the exception of lactose).  Given this research, we do not recommend referring for breath testing as it is costly and not as beneficial as previously thought.
 

Team Approach To IBS Management

We will often work with other health professionals to optimise results, including GP’s, Gastroenterologists, gut directed Psychologists, and Pelvic Floor Physiotherapists.  A Pelvic Floor Physiotherapist can help when a patient has bowel incontinence, difficulty emptying their bowels, or painful bowel emptying.  The pelvic floor muscles play an important role in bowel emptying and bowel control, and normalising function of these muscles is vital.
 
Our team at Diet Solutions are experts in IBS management, all with exceptional knowledge to assess, educate and individualise diet. We will consider usual diet, symptom type/frequency/severity and medical history in order to establish an individualised nutrition plan for patients. Our aim is to provide sound advice to limit dietary restrictions whilst ensuring patients eat comfortably, without symptoms and include foods to optimise their overall health.
 
Dr Jaci Barrett is an accredited practicing Dietitian specialising in gastrointestinal disorders and food sensitivities.  She is the director of Diet Solutions and also an affiliate member of the Monash University FODMAP Research Team where she has previously undertaken her PhD and post-doctoral student supervision. Most recently, Jaci has had a role as Lead Dietitian and Co-Founder of the new food intolerance/allergy smartphone application due for release in early 2020, TLRT (pronounced Tolerate), which aims to help people with dietary restrictions dine out safely.