WHAT’S EATING YOU?

It’s a very real scenario for anyone who’s ever tried the LOWFODMAP diet. But while it has improved the lives of IBS sufferers the world over, it can have a darker side, too

The diet that’s changed the lives of some, but led to a whole new struggle for others

Dr Peter Gibson isn’t your typical trendsetter. A professor of gastroenterology at Monash University in Melbourne, Australia, he spent some 20 years researching intestinal disease before coining a term to more simply describe a group of short-chain carbohydrates that would change the course of his career – and the thinking behind eating for digestive health worldwide. ‘My team and I started talking about our research into fermentable oligosaccharides, disaccharides, monosaccharides and polyols,’ he explains. ‘But by the time you’ve said all that about 20 times in a talk, you’ve lost most of your time – and your audience. So we had to come up with a collective term for them.’ And while no one’s debating the efficacy of the digestive diet plan that transpired, there are now questions about whether it’s leading to a larger emotional fallout. In the years since, the LOW-FODMAP diet has experienced an ascent comparable with cryptocurrency and contactless, with study after study suggesting it’s the best thing to happen to IBS sufferers since gluten-free sliced bread. ‘FODMAPS are either absorbed slowly from the small intestine or not absorbed at all,’ explains Dr Gibson. ‘We all get symptoms from them – if you eat a can of baked beans, you’ll probably get a bit of wind.’ But it isn’t the FODMAPS themselves that trigger a reaction, it’s the impact they have on the gut. ‘When the FODMAPS move into the bowel, where they are fermented by bacteria, this produces gas and can also cause water to move into the bowel. This stretches the bowel wall, which stimulates the gut.’ That’s science-speak for the urge for a post-lunch toilet dash. This is where the LOW-FODMAP diet comes in. ‘We found that when you remove FODMAPS from the diet altogether, the impact on symptoms was greater than if you just removed fructose or lactose by themselves,’ Dr Gibson continues. Today, dietitians are overt in recommending an elimination phase of four to six weeks before a reintroduction phase. But a small section of research points to a rather more troubling trend: that beyond the physical impact of this diet, the mental toll is going unnoticed. A recent article published in the Journal Of Gastroenterology & Hepatology explored the latest developments in the LOW-FODMAP diet. And, amid the head-spinning science jargon, there are two words you’re bound to know: disordered eating. Could it be that solving one health issue is causing another?

THE ELIMINATION GAME

The theory goes that Fodmap-tolerance varies from person to person, and reintroducing foods one FODMAP at a time will help you discern the ones you can tolerate from the ones you can’t. The evidence in its favour is stacking up fast. ‘When the FODMAP approach was used in London, Norway and New Zealand, people were having great results,’ says Dr Gibson. He’s being modest. Proving that a specific way of eating improves health is hard – it takes decades of research to prove that what you think is happening is happening for the reason you think. But the latest review of observational studies and clinical trials concluded that the evidence for the LOW-FODMAP diet is now so strong, it’s ready to be rolled out as first-line therapy for IBS patients. So what’s the problem? Well, the sheer number of Fodmap-containing foods makes this diet trickier than most. The list of things you can’t eat reads like an everyday shopping list. There’s the home-cooking staples like onions and garlic; the snacks you probably munch on without thinking, like apples and cashews; the but-i-thought-they-were-healthy kombucha and camomile tea; and that’s before you throw in the likes of muffins, wine and cream cheese. While there is, of course, a list of foods you can eat, the result can be launching yourself into a restrictive diet with a good food/bad food mentality. Sacha Walsh, a 38-year-old co-founder of a legal tech company in Brisbane, Australia, started experiencing gut symptoms in her early twenties, but it was around five years ago that the pain became unmanageable. Her GP referred her to a dietitian, who suggested she follow the LOW-FODMAP diet.

She thought it would be the fix she’d been waiting for; instead, it marked the start of another struggle altogether. ‘Because of the nature of the diet – I had to write down everything I was eating, including quantities – I became quite obsessive,’ she recalls. ‘I’d take Fodmapfriendly food with me everywhere so I was in control of my eating, and I’d be forensic about it. But then, if I slipped up, I’d think “sod it” and I’d eat all the food that was off limits, which resulted in pain for days. It was a binge-eating cycle of sorts.’ With hindsight, Sacha recognises the pattern as disordered eating. After being on the diet for a year, she visited her GP with symptoms of anxiety and depression and began counselling. Her experience could, of course, be a one-off. Eating disorders are complex psychological conditions with myriad causes and triggers. But, according to Dr Joanna Silver, lead therapist for eating disorders at The Nightingale Hospital, London, any kind of elimination diet could be triggering if you have a history of – or you’re vulnerable to – disordered eating. ‘There is never one risk factor, it’s often a combination of the psychological, biological and social,’ she explains. ‘From a social perspective, if you’re in a situation where there’s a lot of talk about diets and food, that can be really difficult; and when you start categorising food as good and bad, you can enter really dangerous territory.’ Some personality types are more vulnerable than others. ‘A perfectionist personality is certainly a risk factor,’ she adds. ‘They will constantly want to achieve, to be the best at something, and that can feed into dietary choices, too. Other risk factors include difficulty expressing emotions and impulsive or obsessive behaviours.’ For Sacha, it all makes sense now. Perfectionist, check; high-achiever, check. But research suggests that her history of gut problems alone is a red flag. In a 2015 study published in the journal Appetite, researchers concluded that disordered eating was more common in those who had GI disorders than it was in healthy control groups. It’s a chicken-and-egg situation, and researchers don’t yet know why this link exists, but Dr Silver confirms it’s a thing. ‘Often, what starts as a physical problem can develop into an eating disorder. For example, if you’ve eaten a certain food and had a very bad reaction to it, then that food can come to feel scary, and it can lead to a desire to stay away from it.’ Whatever the reason, it does suggest that the very people who are looking to the LOW-FODMAP diet for a solution are also likely to be predisposed to having a problematic relationship with food.

FAKE NEWS

But it isn’t just those with existing issues with food who are at risk. With wellmeaning proponents shouting from the supermarket aisles and social media providing fertile ground for success stories, awareness of the LOW-FODMAP diet is growing globally with a momentum that the medical profession can’t match. Try googling the term and, among the 11 million results, you’ll find hundreds of guides detailing how to do it. The result is a problem that’s best described as FODMAP fake news. While a website might be able to give you a list of high- and LOW-FODMAP foods, it can’t tell you the ins and outs of this diet. ‘The data collected on the amount of FODMAPS in certain foods is protected,’ explains Dr Megan Rossi (@theguthealthdoctor), a research associate at King’s College London who also runs a gut clinic on Harley Street. ‘Decide to measure your macros and that data is readily available online – how many grams of protein there are in a handful of nuts, for example – but there are only a few places in the world that measure FODMAP data and they don’t publish it widely. It is protected in this way for a reason – because it’s such a restrictive diet. If you’re working off wrong information, you could be cutting out the wrong things or restricting too much.’ One of those places is Monash University, where Dr Gibson teaches, and this is an issue he is well aware of. ‘What’s happening right now is what I call the paper-plane method,’ he says. ‘Doctors will google the diet, throw a piece of paper at the patient and it’s up to them to work out how to do it. That’s not how the diet has ever been studied and it shouldn’t be administered by someone who isn’t trained.’ According to Dr Rossi, this isn’t something that’s just happening in Australia, but in the UK, too. ‘There have been a number of cases where GPS have said, “You’ve got IBS, go on a LOW-FODMAP diet,”’ she adds. ‘The only support they give is a printout with a limited explanation of the diet from the internet. I’ve had clients coming to my practice who’ve been given a list of 10 “friendly” foods to survive on, which is nutritionally dangerous.’ It’s an experience 30-year-old Sarah Taylor from Edinburgh recalls all too well. ‘I first heard about the LOW-FODMAP diet from my doctor around three years ago,’ she says. ‘She mentioned it in passing and handed me a piece of paper. I’d already been suffering from IBS for years by this point,

‘BECAUSE OF THE NATURE OF THE DIET, I BECAME QUITE OBSESSIVE’

and I was desperate for something that would work. But this long list of foods was completely overwhelming. I couldn’t face the thought of cutting out things like garlic and onions, so I just ignored it. It was only when my friend, a dietitian, suggested that I see someone who is trained to deliver the diet that I did.’ With the right support, Sarah followed the elimination part of the diet for eight weeks and she now blogs about her experience at theweefoddie.com. ‘Some people contact me via my blog to say they’re surprised to hear that the elimination phase is short-term; others tell me they’re scared to reintroduce foods so end up putting it off. I’m trying to get the message out there that you have to see a trained professional.’ While a doctor should always be your first port of call with a health problem, the advice from the UK government is that you should see a dietitian if you want to follow the LOW-FODMAP diet. It is yet another reason to apply the same level of scrutiny to your choice of nutrition professional that you would your dentist. In the UK, the gold standard is a registered dietitian. This is a legally protected title for nutrition professionals who are registered with the Health And Care Professions Council and accredited by the British Dietetic Association. FYI, Monash University has struck a data-sharing arrangement with King’s College London and, as a result, King’s has produced a LOW-FODMAP booklet, which is being distributed to healthcare professionals throughout the NHS and to registered dietitians.

ALT-MEDICINE

If you present symptoms of digestive issues and you’re worried about how you’ll react to the diet, it’s worth talking it out with your GP or a registered dietitian to see if there is a way that you can make it work. Sacha credits counselling with helping her to reshape her relationship with food and follow the diet in a way that worked for her physical and mental health. ‘It gave me that extra support I needed to find a more balanced way of looking at the diet,’ she says. ‘For me, that means an 80:20 approach. For the most part, I eat LOW-FODMAP foods, but if I fancy eating a beautiful nectarine, then I will eat it and I will enjoy it. I might experience symptoms, but I don’t have the accumulative effect, which is what made it so unbearable before.’ If, on the other hand, you feel the FODMAP approach isn’t for you, there are, increasingly, other options. Researchers are actively working towards building an evidence base for other approaches to IBS treatment, from hypnotherapy to yoga. ‘Let me be clear that this diet has changed my life for the better,’ adds Sacha. ‘To be able to go through a day without being in excruciating pain is truly amazing – but it comes with a caveat. I’ve witnessed people close to me go through eating disorders and it’s absolutely horrendous. I feel really fortunate that I was able to catch mine before it progressed any further.’ In health, as in life, knowledge is power.