This article is intended to give out general advice for IBS (irritable bowl syndrome). I have had clients, friends and family members ask advice about IBS after having been to the doctor and been told they may have IBS but feel they have not been given appropriate advice on how to deal with the issue. I had a family member told just to go and find out and do her own research about FODMAP by her GP after been told she has IBS and that was all the advice she received.
I wrote this article for general advice on the subject from research I have done, it is not intended to help treat or diagnose. It is always recommended to seek medical advice if you have any of the symptoms and if applying low FODMAP use an appropriately qualified dietitian who has knowledge of FODMAP.
Irritable bowl syndrome (IBS)
Is a chronic, relapsing and often life long disorder. People will experience abdominal pain or discomfort, which is often associated with change in bowel habit. They may experience either constipation or diarrhoea and bloating. Symptoms may overlap with other gastrointestinal disorders such as coeliac disease or non ulcer dyspepsia.
Despite the limited evidence for a beneficial role, general advice on healthy eating and lifestyle is recommended as the first-line approach in the dietary management of IBS. Standard recommendations include adhering to a regular meal pattern, reducing intake of insoluble fibres, alcohol, caffeine, spicy foods, and fat, as well as performing regular physical activity and ensuring a good hydration.
Second-line dietary approach should be considered where IBS symptoms persist and recommendations include following a low FODMAP diet, to be delivered only by a healthcare professional with expertise in dietary management.
1st Line Approach to IBS symptoms
There is currently no widely recognized standard for dietary advice for patients with IBS. However, the National Institute for Health and Care Excellence (NICE) from the United Kingdom has published dietary guidelines that cover a variety of aspects, including style of eating and food choice,
National Institute For Health Care and Excellence (NICE)
Irritable Bowl Syndrome In Adults: Diagnosis and management
It is therefore generally recommended that patients with IBS should be advised to establish a regular meal pattern (breakfast, lunch, dinner with snacks as appropriate) and to avoid skipping meals, leaving long gaps between eating or eating late at night. Recommendations are to avoid large meals as well as to take time to eat and chew food thoroughly.
IBS FOOD PYRAMID
The IBS food pyramid was built upon the current dietary guidelines and the existing literature on diet and lifestyle recommendations in IBS ) Cozma-Petruţ et al 2017).
The pyramid consists of nine levels. At the base of the pyramid, it is emphasized the importance of regular physical activity, good hydration and healthy eating habits.
Then, foods are arranged on the basis of recommended intake frequency in ascending order, from the most to the least frequent. Each food level also contains examples of what the patient can consume within a low FODMAP diet.
A pictogram on the left side of the pyramid highlights the importance of seeking specialized dietary advice in case considering the low FODMAP dietary approach.
The other pictograms on the left side are accompanied by recommendations on the intake of dietary fibre and administration of probiotics in IBS.
Recommendations have associated superscript letters symbolizing the level of scientific evidence that supports them. IBS: Irritable bowel syndrome.
(Use common sense and discretion with cereals and cereal derivatives. Smaller measurements if smaller, less active etc.)
What Is Low FODMAP?
Oligosaccharides, disaccharides, monosaccharides and polyols are names for molecules that are in a variety of foods (for example, wheat, some fruit and vegetables, pulses, artificial sweeteners and some processed foods). FODMAPs can be poorly absorbed in the small bowel and pass into the large bowel, where bacteria ferment them.
This can produces gas that can cause bloating, wind and discomfort or pain. FODMAPs can also draw water into the bowel, causing diarrhoea. Following a diet that is low in FODMAPs could help with these symptoms in people with irritable bowel syndrome.
People can gradually re‑introduce foods again to find out which specific FODMAPs cause problems for them (NICE).
There are 3 stages to the low FODMAP diet: (from Kings College)
Low FODMAP and High FODMAP Food List
Below is a list of food types which are either high or low FODMAPs.
Instead of focusing just on foods to eliminate it would be wise to focus on all the foods you can still have in a low FODMAP diet. Many people feel there is little choice in the diet and complain of feeling hungry or frustrated with lack of choice. (this is one of the many reasons to see a suitably qualified dietitian if considering low FODMAP).
What is dietary fibre and how it may affect symptoms?
There are two types of fibre which work differently in the body.
Insoluble and Insoluble fibre
Reducing insoluble fibre may help with symptoms
But if an increase in fibre is necessary, this should be from soluble fibre.
This type of fibre does not dissolve in water and is not readily broken down, so it passes through the digestive system mostly intact.
It absorbs water,
Adds bulk to stools (faeces)
And allows waste to be passed through bowels more quickly.
Reducing this type of fibre may help to improve symptoms of diarrhoea.
Foods to reduce or avoid:
Skin, pith and pips of fruit and vegetables.
Wheat and bran. Corn (maize).
Nuts and whole grains
This type of fibre dissolves in water and is broken down by the natural bacteria in the bowels.
It softens stools and makes them larger.
Increasing this type of fibre may help to improve symptoms of constipation.
Foods to include are:
Oats, Barely Psyllium and ispaghula.
Nuts and seeds.
Fruit and vegetables.
Beans and pulses.
Whole grains (for example, wholemeal bread, brown rice and whole-wheat pasta) may also help with constipation.
Although increasing fibre may help to improve symptoms, it may also generate gas and cause pain and bloating. Monitoring is important to help identify this and to adjust your fibre intake according to your symptoms. If fibre intake is suddenly increased, this can cause symptoms of wind and bloating.
Introduce high-fibre foods gradually to allow the gut to become used to the extra fibre. Introduce one new food over a two- to three-day period and monitor any symptoms.
For example, have porridge for breakfast on the first day; then perhaps add beans or extra vegetables to a casserole two days later; then maybe have an extra piece of fruit two to three days later.
Please be aware IBS is an expression of symptoms to which there is no ‘one size fit all’ approach. Symptoms should be dealt with individually, this is why it is important to seek advice from your GP or a trained dietitian.
Lifestyle and dietary approaches are recommended. If following a Low FODMAP approach using an experienced specialized dietitian can provide a detailed dietary plan that will ensure the low FODMAP diet is nutritionally adequate.
Additionally, after good response is achieved, the dietitian can help gradually reintroduce FODMAPs using a systematic food-challenge process to determine personal tolerance thresholds to individual foods
References & Good resources
Jamie Miller Personal Trainer
UK Fitness Personal Training
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