The elim­i­na­tion diet, sugars & the low-FODMAP diet, Ir­ri­ta­ble Bowel Syn­drome

Great Health Guide - - CONTENTS - Dr he­len Dodd

In the pre­vi­ous is­sue of Great Health GuideTM, Food In­tol­er­ance Part 1 de­scribed the dif­fer­ence be­tween Food Al­lergy and Food In­tol­er­ance. Many peo­ple suf­fer from food in­tol­er­ance af­ter eat­ing cer­tain foods. These symp­toms can be sim­i­lar but are more mod­er­ate than with a food al­lergy. Food in­tol­er­ance is harder to di­ag­nose as there is no spe­cific test for this con­di­tion. Food in­tol­er­ance is the most com­mon cause of un­di­ag­nosed Gas­troin­testi­nal (GI) tract prob­lems. Many fac­tors cause in­tol­er­ance to foods that were pre­vi­ously well ab­sorbed. Cells along the lin­ing of the bow­els are al­tered, dam­aged and de­stroyed by var­i­ous in­fec­tions and med­i­ca­tions. Al­ter­ation in the gut flora, from in­fec­tions, use of an­tibi­otics, stress and age are some other fac­tors in food in­tol­er­ance. Lac­tose in­tol­er­ance is the

only food in­tol­er­ance that can be di­ag­nosed with the Hy­dro­gen Breath Test.

Food In­tol­er­ance is a hy­per­sen­si­tiv­ity to cer­tain foods and there are no spe­cific tests for this con­di­tion. Symp­toms in­clude di­ar­rhoea, con­sti­pa­tion, flat­u­lence, bloat­ing of stom­ach and bow­els, nau­sea, vomiting, re­flux (GERD), fa­tigue, dizzi­ness, rashes, brain fog to list a few. Thus the sim­plest way to deal with food in­tol­er­ance is to use an Elim­i­na­tion Diet. If food in­tol­er­ance is left un­di­ag­nosed and un­treated, it can be­come chronic Ir­ri­ta­ble Bowel Syn­drome (IBS).

Food In­tol­er­ance is di­ag­nosed us­ing an Elim­i­na­tion Diet, with Two Phases:

Dur­ing the ini­tial Ex­clu­sion Phase, many known in­tol­er­ant foods are ex­cluded from the diet. It is nec­es­sary to keep an ac­cu­rate and de­tailed di­ary of all foods con­sumed, when they were eaten and the time if symp­toms oc­cur. It is then pos­si­ble to de­ter­mine a pat­tern of which foods may be caus­ing the prob­lem. A pat­tern is some­times dif­fi­cult to see as symp­toms may not ap­pear for 24 hours. The GI tract should be­come less sen­si­tive af­ter 2-3 weeks of the ex­clu­sion phase.

The Rein­tro­duc­tion Phase is where a sin­gle food is in­tro­duced into the diet for 3-4 days and symp­toms are noted in the di­ary. Since the symp­toms may take up to 48 hours to ap­pear af­ter the prob­lem food is in­gested, 3-4 days test­ing of a sin­gle food is nec­es­sary. If upon rein­tro­duc­ing the sus­pected food, the symp­toms re­turn, then this is a re­li­able di­ag­no­sis of in­tol­er­ance to that food. If asymp­to­matic, a sec­ond food is rein­tro­duced and checked in the same man­ner. This is re­peated with other ex­cluded foods be­ing slowly added and pres­ence or ab­sence of symp­toms noted. A very sim­ple de­scrip­tion of an Elim­i­na­tion Diet with a sug­gested choice of foods to elim­i­nate is found here.


This is a com­mon dis­or­der of the GI tract. The un­der­ly­ing cause is not known but cer­tain fac­tors are re­lated to the con­di­tion. This hy­per­sen­si­tive bowel may be trig­gered af­ter a se­vere bout of gas­troen­teri­tis or the pro­longed use of strong an­tibi­otics. Symp­toms do vary but in gen­eral IBS has symp­toms of ab­dom­i­nal pain, ex­ces­sive wind, bloat­ing, di­ar­rhoea, con­sti­pa­tion, heart­burn, nau­sea and some­times vomiting. With IBS, mi­croflora that nor­mally in­habit the bowel are al­tered with an over­growth of bac­te­ria or a new bac­te­rial species be­com­ing dom­i­nant. Foods that are not tol­er­ated with IBS in­clude choco­late, al­co­hol, fatty foods, dairy prod­ucts & sugars.

In the Ex­clu­sion Phase, one Food or sev­eral Foods will be re­moved over time.

Over­con­sump­tion of sugars may re­sult In change In Mi­croflora lead­ing to Ibs.

SUGARS are ma­jor prob­lems in IBS. A de­tailed Elim­i­na­tion Diet for IBS, was pi­o­neered by Dr Sue Shep­herd, an Aus­tralian di­eti­cian. This diet is called The Low-FODMAP diet, and lists in de­tail, foods con­tain­ing sugars and re­lated com­pounds that will cause IBS.

Sugar such as lac­tose: ‘milk sugar’ is one of the main trig­gers for IBS. It com­prises two sim­ple sugars, glu­cose & galac­tose. In­tol­er­ance to lac­tose is due to the lack of the en­zyme lac­tase, which breaks down lac­tose into the two sim­ple sugars. Lac­tose in­tol­er­ance can be read­ily di­ag­nosed by re­plac­ing reg­u­lar milk with lac­tose free milk. Thus milk, yo­ghurt, cream, ice cream and deserts made with reg­u­lar milk, will cause IBS. But­ter and older, ma­tured cheese do not con­tain lac­tose, so can be in­cluded in a lac­tose-free diet.

Other sugars, with the acro­nym FODMAP: Fer­mentable, Oligosac­cha­rides, Disac­cha­rides, Monosac­cha­raides And Poly­ols, are not ab­sorbed in the small in­tes­tine. They pass into the large in­tes­tine where bac­te­ria use them as a food source, caus­ing IBS symp­toms. These nat­u­ral sugars are present in freshly grown fruits & veg­eta­bles, nuts, grains and nat­u­ral sweet­en­ers such as honey and maple syrup. These foods with high quan­ti­ties of FODMAP sugars are listed in FODMAPs. Many other sweet­en­ers added to pro­cessed foods trig­ger IBS, in­clud­ing High Fruc­tose Corn Syrup (HFCS), sor­bitol and man­ni­tol.

The Low-FODMAP Diet, us­ing Elim­i­na­tion and Rein­tro­duc­tion Phases, will iden­tify the prob­lem foods and their re­lated sugars. The

diet plan is fol­lowed over these two phases and any prob­lem foods are to­tally re­moved from diet.

Avoid FODMAP’s:

• Pre­pare you own food, then you know ex­actly what is in it.

• Do not pur­chase pro­cessed or prepack­aged food as all the in­gre­di­ents may not be listed or if listed, un­der a dif­fer­ent name or a coded num­ber.

• The in­gre­di­ents in the pro­cessed food may not spec­ify the word ‘sugar’ and there are many ways to hide the fact that cer­tain sugars are present.

Al­ways seek ad­vice from your GP rather than at­tempt­ing to di­ag­nose or treat these prob­lems your­self. It is very im­por­tant that your doc­tor take nu­mer­ous tests ini­tially to ex­clude other pos­si­ble con­di­tions. It is im­por­tant that a GP or di­eti­cian man­age an elim­i­na­tion diet to bal­ance nu­tri­tional re­quire­ments.

Food in­tol­er­ance is treat­able. Many peo­ple have symp­toms for years and only when symp­toms be­come a chronic diges­tive dis­or­der, are food in­tol­er­ance and IBS recog­nised. By elim­i­nat­ing the of­fend­ing foods, life be­comes so much more pleas­ant.

He­len Dodd BSc. BPharm. PhD, is a re­tired phar­ma­cist, con­tin­u­ing to pro­vide in­for­ma­tion and ed­u­ca­tion on nutri­tion and dis­eases that af­fect mod­ern so­ci­ety. Con­tact He­len by email.

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