Article by Chloe Adams RD – Freelance Dietitian Specialising in Digestive Health

If you experience regular digestive discomfort associated with an irregular bowel habit (diarrhoea and/or constipation), you may be experiencing Irritable Bowel Syndrome (IBS). If you are reading this article thinking, “yes, that sounds like me” – first things first – pop along to your GP and let them know. Before you can be sure it is IBS, your GP needs to do a few simple tests to make sure there isn’t anything more going on that could be causing your symptoms. Once your GP has completed these tests, and all is okay, it can be confirmed you are experiencing IBS.

What is IBS?

IBS is an increased sensitivity of the large bowel (colon) – a.k.a. the gut. This sensitivity can present for different people for different reasons. Here are a few factors that can contribute to a sensitive gut:

• Stomach bug or food poisoning
• Use of antibiotics
• Hormonal fluctuations
• Surgery on the digestive system
• Some gynaecological conditions (e.g. fibroids, endometriosis)
• Long term pain conditions (e.g. fibromyalgia)
• The body’s stress response

Yes, I did say stress. When the body is under stress, it sends out stress hormones and signals to help you cope. Whilst this does help you cope to a degree, these hormones and signals make your gut a lot more sensitive, especially if there is a prolonged release.

For this reason, if you are experiencing IBS, it is important to consider treatment from two angles. Anything you can do to support yourself in respect of well-being, will help to dampen down the stress response making your gut less sensitive; although this is much easier said than done. Any sensitivity left can be treated through dietary management, and adapting to a diet that is more comfortable for the gut.

Dietary factors that influence digestive comfort^[1]

Regular Meals – Eating regularly allows a steady flow of nutrition to move through our digestive system. This can prevent the sudden stop and start of digestion. For this reason, consuming regular meals is a great start to allowing your digestive system to feel more comfortable.

Fruit & Veg – Fruit and vegetables contain soluble fibre. This sort of fibre helps to keep your stools soft; it helps to wash the stools through your gut and out of your body in a comfortable way. This is the digestive reason for the 5-a-day recommendation. A portion of fruit and veg is roughly a handful. To help you achieve this, it is best to include some sort of fruit, vegetables or salad with every meal.

Wholegrain Foods – The other type of fibre is insoluble fibre and is found in whole grain foods. This includes wholemeal bread, brown rice/pasta, oats, nuts, seeds and the skins and pips of fruit and vegetables. Insoluble fibre helps to bulk your stools out, and it helps to push poo through your gut. Simply swap your carbohydrate choices to wholegrain versions to help you get enough of these sorts of foods.

Fluid – It is vital to stay well-hydrated for all sorts of reasons one of which is to keep the gut hydrated. Fluid helps the fibre we eat to work in supporting our gut motility, preventing constipation. To promote digestive comfort, 1.5 to 2 litres of fluid per day minimum is recommended. We can meet our fluid requirement by including water, squash and hot drinks too. Keeping a water bottle handy to sip on throughout the day can remind us to drink plenty.

Caffeine & Alcohol – These both stimulate the bowel. So, quite simply, the more we drink, the more we will stimulate our gut. Including high levels of caffeine and/or alcohol can worsen symptoms such as frequent loose bowel motions, abdominal pain and bloating. For this reason it is recommended to include caffeine and alcohol in moderation. Three to four caffeinated drinks a day shouldn’t influence digestive comfort too significantly, though any more than this could. Caffeine is found mainly in tea, coffee, cola and energy drinks. There are decaf versions of all of these, so look out for them if you think reducing your caffeine intake could be useful. Keeping to the national recommendation for alcohol will support your digestive comfort. This is 14 units per week, and spread these out to allow for alcohol-free days. 14 units is the equivalent to 6 x 175ml glasses of wine, 6 pints of cider/beer or 14 x 25ml shots of spirits.

What more can I do?

You may be thinking, “yes, I’m doing all of that and I still get symptoms”. If this is the case, you may benefit from seeing a FODMAP-trained dietitian. Many hospitals now offer the Low FODMAP Diet to support the management of IBS. Alternatively, you may be able to access a local dietitian privately. The Low FODMAP Diet is quite complicated and information available online can be variable and conflicting. A dietitian with the relevant experience will support you in making the diet much more achievable by tailoring the Low FODMAP Diet to your lifestyle, ensuring you still achieve a well-balanced nutritionally complete diet^[2]. Clinical trials demonstrate the Low FODMAP Diet can improve symptoms of IBS by up to 70%, in 70% of the people that use it^[3]. The Low FODMAP Diet is a very effective way to manage IBS in addition to getting the above basics right and focusing on your wellbeing.

What are FODMAPs?

FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. Simply put, FODMAPs are short-chain carbohydrates that don’t get digested. Therefore, when we eat them, they move all the way through our digestive system, straight through our small intestine (where most of the absorption of nutrients happens) and into the colon. When FODMAPs reach our colon, they become food for the good bacteria that reside there. When the bacteria feed on the FODMAPs causing a fermentation process, this releases gas and causes water to be drawn into the gut. This is a completely normal and natural process that happens in everyone. However, those with heightened gut sensitivity (IBS), are more likely to feel this process happening. In turn, this can worsen abdominal pain, bloating, wind and diarrhoea, as a consequence.

Where are FODMAPs found?

There are five main types of FODMAPs in the diet:

Fructans – These are short chains of fructose which are poorly absorbed by most people. This means that a lot of what we eat will move straight into the colon and add to the gas build-up. This FODMAP is a real contributor to pain, bloating and wind. Fructans are found in wheat, rye and barley along with a few other grains. They are also found in garlic, onions and various fruits and vegetables.

Galacto-oligosaccharides (GOS) – No human actually has the enzyme to digest this FODMAP; it is for this reason GOS moves all the way through the digestive system reaching the colon undigested. This FODMAP causes gas buildup and water to be drawn back into the lower bowel, so in addition to affecting pain, bloating and wind, they can alter stool consistency. GOS are found in beans and pulses.

Polyols – These FODMAPs are passively absorbed in the digestive system. This means only 20% of what we eat is absorbed into the body^[4]; therefore, the remaining 80% moves through into the colon undigested. Polyols cause a lot of water to be drawn back into the bowel, so often contribute towards diarrhoea in those with IBS. They also contribute to a gas build-up in the bowel. Polyols are found in many artificial sweeteners, e.g. sorbitol which is used in sugar-free gum, mints and sweets. They are also naturally occurring and found in various different fruits and vegetables.

Fructose – This is fruit sugar and is actively absorbed in the small intestine when taken in equal measure to glucose. The glucose helps the fructose get out of the digestive tract into the body to be used as energy. When fructose is taken in, in excess of glucose, it cannot be absorbed properly. The fructose that is not absorbed then moves into the colon and behaves like a FODMAP. Fructose is in all fruit, even low FODMAP fruit, so it is not completely avoided as part of the Low FODMAP Diet. It is recommended to just have one portion (80g) at a time, and spread your intake of fruit over the day. Fructose is also found in natural products such as honey and agave nectar.

Lactose – Approximately 65 percent of the human population has a reduced ability to digest lactose after infancy^[5]. This is when we don’t have enough of the enzyme lactase that helps us break down lactose for it to be absorbed in the body. When this breakdown process isn’t happening, the lactose moves through into the colon undigested and behaves like a FODMAP. After childhood, an individual’s ability to produce sufficient lactase slowly reduces and is why lactose intolerance is common. Lactose avoidance forms a part of the Low FODMAP Diet as a means of screening for lactose intolerance. Lactose is found in dairy products in particular milk and yoghurt. Cheese, butter and cream are actually naturally low in lactose, due to the fact most of the lactose is removed in the process of making them.

The Low FODMAP Diet

The Low FODMAP Diet is a four- to eight-week reduction of FODMAPs. The exclusion part of the diet involves swapping around your diet to eliminate FODMAPs. During this phase of the diet symptoms often improve and completely subside in some. Once this has been achieved, and you have had a little time to enjoy improved symptoms, this is followed up by a reintroduction process. This part of the diet is just as important as the first part. The reintroduction phase is when you learn how each FODMAP interacts with your body. Your dietitian will talk you through how to introduce one FODMAP at a time, systematically, so you can test each FODMAP to understand how they influence your symptoms. Once you have completed this, you are in the driver’s seat! No longer do your symptoms control you: you control the symptoms. You can then decide how you want to bring FODMAPs back into your diet, dependent on the level of symptom control you require. By the end of the Low FODMAP Diet process, you will have learned how to settle symptoms down when you need to, and how FODMAPs affect you personally. With this knowledge, awareness and skill-set, you can manage symptoms independently long term.

Huel & FODMAPs

Huel Powder v3.0 and Black Edition Huel are low FODMAP and for this reason they can be used alongside the Low FODMAP Diet and as part of your dietary routine if you have IBS. I experience IBS myself, and trialled Huel Powder for a week, replacing both breakfast and lunch with a shake. I was comfortable and can vouch for this practically, in addition to noting there are no FODMAPs on the ingredients list. If you have IBS and an extremely busy lifestyle where convenience is a top priority, Huel could form a part of your eating routine to ensure you are achieving a regular meal pattern and optimal nutrition.

Please note: Huel Hot & Savoury, Huel Ready-to-drink and Huel Bars are not low FODMAP.

References:

1. McKenzie YA, et al. British Dietetic Association: systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update). J Human Nut & Diet. 2016; 29(5): 549-75.
2. O’Keeffe M & Lomer MC. Who should deliver the Low FODMAP diet and what educational methods are optimal: a review. J Gastroenterol & Hepatol. 2017; 32(S1): 23-26.
3. Staudacher HM, et al. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Human Nut & Diet. 2011; 24(5): 487-95.
4. Beaugerie L, et al. Digestion and absorption in the human intestine of three sugar alcohols. Gastroenterol 1990; 99: 717-723.
5. Harrington LK, et al. A re-appraisal of lactose intolerance. International journal of clinical practice. 2008; 62(10):1541-6.