Fodmaps & Gaps in the Management of IBS

With the continued increase in the cost of functional testing and supplements in South Africa, practitioners are once again reminded of the importance of dietary intervention when it comes to managing chronic disease and functional imbalances.

Irritable bowel syndrome (IBS) is the most common gastrointestinal condition worldwide. It can be a debilitating functional disorder, which includes widely varied symptoms including abdominal pain, bloating, and constipation and/or diarrhoea.

IBS treatment often includes dietary and lifestyle modifications, fibre supplements, probiotics, and medications (antispasmodics, laxatives, antidepressants). While the mainstay of most integrative practitioners has been to remove wheat and dairy from the diet, it has now become increasingly clear that there is no one food or food group proven to trigger IBS symptoms. Dietary interventions that tend to have the most success address functional imbalances, inflammation or both.

THE WAY FORWARD

So where does that leave us? In the past few years, two dietary interventions have shown positive results in IBS management. One is used solely for the dietary management of IBS while the other is used to manage a range of inflammatory conditions ranging from IBS to neurologic disorders. Historically, the problem with both has been the effort and time required to implement them. Yet, we now find ourselves in a position where dietary and lifestyle modifications need to take precedent over supplements, prescription and OTC medications.

LOW FODMAP DIET

The low FODMAP diet was developed by researchers at Monash University in Melbourne, Australia. The premise of the diet is that IBS symptoms are triggered by certain types of carbohydrates called FODMAPs – Fermentable Oligo- (e.g. fructans, galactans), Di- (e.g. lactose), and Mono-saccharides (e.g. glucose, fructose), and Polyols (e.g. sorbitol, mannitol, maltitol, xylitol and isomalt).

Most carbohydrates, once broken down, can be absorbed through pumps on the surface of cells in the gut. However, FODMAPs (rapidly fermentable short-chain carbohydrates) can’t be absorbed. The presence of these FODMAPs causes water to be dragged into the small intestine. Additionally, because they aren’t absorbed, FODMAPs travel through the gut to the large intestine. When bacteria in the large intestine get access to FODMAPs they use them for energy to survive. The bacteria rapidly ferment FODMAPs and produce gas as a result. Excess gas production and water retention cause the intestines to expand. When the intestinal wall stretches, the highly connected nerves around the intestines send signals to the brain. People with IBS have very sensitive intestines so these signals contribute to the pain they experience.

Monash University developed the low FODMAP diet to reduce FODMAP intake and to alleviate the distention, bloating and other symptoms associated with IBS.

Process of elimination

The low FODMAP diet begins with the elimination of all FODMAPs for 6 to 12 weeks. Ideally, IBS symptoms will improve during the restriction period and this improvement will be maintained as FODMAP foods are slowly reintroduced. If symptoms do not improve during the elimination period, it is assumed that FODMAPs are not a contributory factor and the diet is terminated.

The downside to a low FODMAP diet is that many of the foods that are high in FODMAPs are highly nutritious foods which have a beneficial impact on gastrointestinal health including that of proliferating beneficial flora. As such, it is extremely important to try and reintroduce as many of the high FODMAP foods as possible in the long term – specifically foods such as onion, garlic, avocado, broccoli and apple.

GAPS

The GAPS diet was derived from the Specific Carbohydrate Diet (SCD) to naturally treat chronic inflammatory conditions in the digestive tract as a result of a damaged gut lining (or ‘leaky gut’). Dr Natasha Campbell McBride adapted the SCD to found GAPS (Gut and Psychology Syndrome) to fit the needs of her patients suffering from a range of intestinal and neurological conditions believed to be as a result of an imbalanced gut microbiome. While GAPS is not typically used for IBS, it can be extremely effective if the cause of IBS is dysbiosis coupled with an underlying inflammatory response.

The GAPS Protocol is broken into three parts specifically designed to heal the gut lining, rebalance the immune system, and restore the optimal microbial balance within the gastrointestinal tract. The nutritional protocol restricts all grains, commercial dairy, starchy vegetables and all processed/refi ned carbohydrates while focusing on easily digestible and nutrient-dense foods. The supplementation protocol and detoxification protocol, which can be used alongside the nutritional protocol, have been purposefully excluded from this article.

The GAPS diet (nutritional protocol) is divided into two parts: the Introduction Diet and the Full GAPS Diet.

The Introduction Diet

The Introduction Diet is divided into six stages. It generally takes three to six weeks to complete all the stages. However, this is very individual and in many cases may take longer. Initially, it is common to experience an increase in symptoms and many feel unwell in the initial stages of this diet.

Home-made bone broths (which can include certain well-cooked vegetables) and probiotic foods are the mainstay of the introduction diet. Boiled meats can be added to the broth as well as a few teaspoons of the liquid from fermented vegetables or fermented dairy products. As one progresses through the six stages, eggs yolks, different meats, kefir, avocado, fats like ghee, fresh juices, fermented vegetables and nut flours are added.

Full GAPS Diet

Once the first six stages of the Introduction Diet have been completed successfully, one can move onto the Full GAPS Diet. It is recommended to stay on this for 18 to 24 months. The majority of the diet should consist of fresh meats (hormone free and grass fed if possible), animal fats, fish, shellfish, organic farm-fresh eggs, fermented foods and vegetables. While nut flours can be used for baking, overindulging in baked good can be detrimental to the healing process so these types of foods should only be eaten in moderation.

HIGH FODMAPS AVOID / REDUCE

• Grains: Any made with gluten – wheat, barley, rye, spelt.
• Dairy: High lactose dairy: buttermilk, chocolate, creamy/cheesy sauces, custard, ice-cream, cow’s milk, goat’s milk, soft cheese, sour cream.
• Vegetables and legumes: Onions – avoid entirely: artichoke; asparagus; beetroot; butterbeans; cauliflower; celery – greater than 5 cm stalk; kidney beans; leeks; mange tout; mushrooms; peas; spring onions; shallots.
• Fruit: Apples; apricots; avocado – no more than ½ per day; cherries; dates; figs; grapefruit; litchi; mango; nectarines; peaches; pears; prunes; raisins; watermelon.
• Nuts: Cashews; pistachios.
• Sweeteners: Agave; fructose; honey (limit); sorbitol; xylitol.
• Prebiotic foods: FOS – fructooligosaccharides; inulin; oligofructose.
• Drinks: Any fruit/herbal tea with apple; fruit juice; sports drinks; fennel tea; chamomile tea; oolong tea; wine – limit to 1 glass.

(This list is by no means comprehensive).

LOW FODMAPS – ENJOY

• Grains: Gluten-free (made with gluten-free oats, quinoa, rice, tapioca, corn).
• Dairy: Lactose-free dairy, lactose-free yoghurt.
• Vegetables and legumes: Bean sprouts; bok choy; broccoli – avoid large servings; brussel sprouts – limit; butternut squash – ¼ cup; cabbage – 1 cup; carrots; corn – organic; courgettes; chickpeas (¼ cup); chilli; cucumber; eggplant; fennel; green beans; green pepper; ginger; kale; lettuce; olives; parsnip; radish; red pepper; potato; pumpkin; baby spinach; sweet potato – ½ cup; tomato – limit cherry tomatoes.
• Fruit: Bananas; blueberries; cantaloupe; cranberry; clementine; grapes; honeydew; kiwifruit; lemon; lime; orange; pawpaw; papaya; pineapple; raspberry; rhubarb; strawberry.
• Nuts: Brazil; coconut; hazelnut; pecans; pine nuts; pumpkin seeds; sesame seeds; sunflower seeds; walnuts.
• Sweeteners: Maple syrup; stevia.
• Drinks: Coffee; nut milks; black weak tea; herbal weak tea; peppermint tea; water

(This list is by no means comprehensive).

SOME OF THE GAPS FOODS TO AVOID

Agave syrup; flour, made from grains; aloe; FOS; arrowroot; all grains (gluten and gluten-free); baked beans; lactose; baking powder and raising agents of all kinds; margarine and butter replacements; balsamic vinegar; meats, processed, preserved, smoked and salted (e.g. bacon and ham); buttermilk; milk from animal, soy, rice; canned coconut milk; carob; molasses; processed cheeses and spreads; parsnips; chewing gum; pasta, any kind; chicory root; white and sweet potato; chocolate; soy coffee, instant and substitutes; sugar or sucrose of any kind; cooking oils; tapioca; cordials; wheat germ; corn; powder or liquid whey; corn syrup; commercial yoghurt; corn-starch; flour made from grains. (This list is by no means comprehensive).

SOME OF THE RECOMMENDED FOODS FOR THE FULL GAPS DIET

Avocado, including avo oil; lentils; bananas (ripe only with brown spots on skin); meat, fresh or frozen; butter; nut flour or ground nuts (usually ground blanched almonds); coconut (fresh, milk, dried – without any additives); virgin cold-pressed olive oil; coconut oil; dried split and fresh green peas; coffee, weak and freshly made, not instant; fresh or frozen poultry; fresh eggs; fresh or frozen shellfish; fresh or frozen fish; spices, single and pure without any additives; fruit; tea, weak, freshly made, not instant; fresh or frozen game; uncreamed cottage cheese (dry curd); garlic; vegetables (most apart from potatoes, sweet potatoes and parsnips); homemade ghee; vinegar (cider or white); raw honey; homemade yoghurt; juices (freshly pressed from permitted fruit and vegetables). This list is by no means comprehensive.

CONCLUSION

While dietary changes may be the most difficult to make and implement, the benefit is that they may ultimately offer a long-term solution to a very difficult and debilitating condition. Neither GAPS nor low FODMAP are intended as life-long diets. Once healing has taken place and there has been a resolution in symptoms, the hope is to move onto a less restrictive and nutrient-dense diet. If implemented correctly, they certainly won’t cause any harm and may offer a sustainable solution in a difficult economic climate.

Further reading

1. Campbell-McBride N. Gut and Psychology Syndrome: Natural Treatment for Autism, Dyspraxia, ADD, Dyslexia, ADHD, Depression, Schizophrenia. Medinform Publishing; 2004.
2. Shepherd S Gibson P. The Complete Low-FODMAP Diet. Us Imports; 2013.