By Dr Malcolm Mackay
Bloating, crampy pains and irregular bowel function are common symptoms and may lead to the diagnosis of irritable bowel syndrome or SIBO. It is important to exclude underlying medical conditions such as coeliac disease. Sufferers often attribute these symptoms to food allergies or parasites, but these are seldom the cause. Intolerance to salicylates, amines and glutamate are uncommon and are not discussed in this document.
We live in a symbiotic relationship with the microbes in our colon – the gut microbiome – and the health of the gut depends on the health of the microbiome. As individuals and as a community we have a depleted diversity of gut microbes due to good hygiene, antibiotics and lifelong exposure to animal products and fibre depleted refined grains and vegetable oils. Many of us will have a gut microbiome that is nearing a tipping point to a persistent state of dysbiosis – an unhealthy balance of microbes that does not support gut health. A severe bout of gastroenteritis or another course of antibiotics may be all it takes to tip someone over into long term gut problems.
Gut symptoms, such as pain and bloating, often lead to a downward spiral of food restriction and progressively more intolerance to fermentable carbohydrates. The low fibre, low FODMAP diet may relieve symptoms in the short term, but it starves the microbes that protect the gut barrier and support gut health by producing short chain fatty acids and other postbiotics. Long term gut symptoms ensue. The low FODMAP diet was never intended as a long-term strategy. The greater the degree and duration of restriction, the more difficult it becomes to reverse the dysbiosis and food intolerances.
The solution to gut dysbiosis and FODMAP intolerance is a reverse elimination diet. The first step is to eliminate foods that damage the gut or promote the growth of inflammatory microbes. These foods are replaced with increased quantities of low FODMAP starchy foods. Some individuals may need to use mindfulness techniques to reduce hypervigilance to visceral sensations. The next step is to reintroduce FODMAPs and other problem foods, in a graduated fashion over several months. If a particular food always brings back symptoms, then perhaps back off that item and work on others instead. Legumes are worth persevering with, even if that means starting with a teaspoon per day and freezing the remainder for subsequent days. Low stress days with no important events may be times to up the ante on reintroducing foods, while busy days with stressful events may be times to take a step backwards.
Stage one – eliminate non-health supporting food and additives
- All dairy foods from all species
- Meat, chicken, fish, eggs
- Vegetable oil
- Emulsifiers from processed foods
- Salt (including soy sauce and other high salt condiments)
Stage two – transition to a starch-based diet
(This is not a strict elimination diet – see our information on elimination diets)
- Potatoes, limited quantities of sweet potatoes
- Brown rice, millet, buckwheat (whole grains or pasta well cooked)
- Hold off on quinoa, bread and other yeast products
- Cooked rolled oats unless poorly tolerated
- Tofu may be used in small quantities
- Cooked vegetables (Lettuce may be eaten raw)
- Low FODMAP fruits including bananas
- Limit nuts and seeds to 1 tablespoon/ 10g per day
Stage three – reverse elimination
- Reintroduce whole wheat products – pasta, Freekah, Cous cous, homemade flour products
- Bread may be problematic due to salt and other ingredients
- Onion and other allium group foods
- High fructose foods may be tolerated when consumed with ‘starches’
- Legumes, well cooked and drained
- Lentils are often best tolerated
- Experiment with other beans
- Sprouting grains and legumes may increase tolerability
Stage four – maintenance and further diversity
- Continue increasing legumes and other FODMAP foods as tolerated
- Periodically re-challenge with “problematic foods” such as onion and garlic
- Stop all dairy foods.
- Minimise or eliminate other animal products
- Avoid emulsifiers and maltodextrins in processed food
- Add in more starchy foods – oats, brown rice, whole grain pasta, potatoes, and sweet potatoes
- Keep fat content low – limit nuts, seeds, and avocados. No oil!
- Limit salt
- Slowly increase beans and other high FODMAP foods
- Drink plenty of water
- Increase physical activity and reduce sedentary behaviour
Page created 28 June 2020
Page last updated 28 June 2020