Mia’s thoughts- My family has a serious long history of cancer, bowel and stomach and in the females cervical and utrine and several relatives both male and female with breast cancer. So from the moment I turned fortyish she who must be obeyed my beautiful Ella, has had me at every specialist that is expert in the field of any cancer that has affected my family. You have no modesty left when you have as many invasive tests done as I have, but dead people don’t need modesty so the tests are worth it. I have had more doctors put more objects in me than I care to talk about. guys there is nothing unmacho about colonoscopies stay alive and get yourself checked.
Even though I am a devout vegan, as the old maxim says you can have too much of a good thing, a healthy body is all about balance and finally Dr rosen my gastroentrologist pointed out what no other hack has that there is a great food system to help prevent all ailments of the gut It’s called the Fodmap diet. Fodmap was invented by an Australian dr shepherd from monash university, so I think it is the duty of this blog to help get the word out that you not only need to eat vegan or vegetarian to live healthily and one with the earth but balanced as well thankyou dr shepherd.
Low FODMAP Diet
*Dr Sue Shepherd developed the low FODMAP diet in 1999. She has proven, through her pioneering PhD research, that limiting dietary FODMAPs is an effective treatment for people with symptoms of IBS. The low FODMAP diet has been published in international medical journals and is now accepted and recommended as one of the most effective dietary therapies for IBS. Abstracts of these articles are available in our GP/Specialist Section.
FODMAPs are found in the foods we eat. FODMAPs is an acronym (abbreviation) referring to Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols*. These are complex names for a collection of molecules found in food, that can be poorly absorbed by some people. When the molecules are poorly absorbed in the small intestine of the digestive tract, these molecules then continue along their journey along the digestive tract, arriving at the large intestine, where they act as a food source to the bacteria that live there normally. The bacteria then digest/ferment these FODMAPs and can cause symptoms of Irritable Bowel Syndrome (IBS). Symptoms of Irritable Bowel Syndrome include abdominal bloating and distension, excess wind (flatulence), abdominal pain, nausea, changes in bowel habits (diarrhoea, constipation, or a combination of both), and other gastro-intestinal symptoms.
What are the FODMAPs?
FODMAPs are found in the foods we eat. FODMAPs is an acronym for
Oligosaccharides (eg. Fructans and Galactans)
Disaccharides (eg. Lactose)Monosaccharides (eg. excess Fructose)
Polyols (eg. Sorbitol, Mannitol, Maltitol, Xylitol and Isomalt)
Where are FODMAPs found?
A few examples of food sources for each of the FODMAPs are listed below. The list is not complete. New data has been obtained through Monash University Department of Gastroenterology regarding the FODMAP content of foods. As a result, there have been some changes from previous food lists. Below is a list containing up-to-date information. The dietitians at Shepherd Works can provide you with an up to date list of the full list of foods during a consultation.
Excess Fructose: Honey, Apples, Mango, Pear, Watermelon, High Fructose Corn Syrup,
Fructans: Artichokes (Globe), Artichokes(Jerusalem), Garlic (in large amounts), Leek, Onion (brown, white, Spanish, onion powder), Spring Onion (white part), Shallots, Wheat (in large amounts), Rye (in large amounts), Barley (in large amounts), Inulin, Fructo-oligosaccharides.
Lactose: Milk, icecream, custard, dairy desserts, condensed and evaporated milk, milk powder, yoghurt, soft unripened cheeses (eg. ricotta, cottage, cream, marscarpone).
Galacto-Oligosaccharides (GOS): Legume beans (eg. baked beans, kidney beans, bortolotti beans), Lentils, Chickpeas
Polyols: Apples, Apricots, Avocado, Cherries, Nectarines, Pears , Plums, Prunes, Mushrooms, Sorbitol (420), mannitol (421), xylitol (967), maltitol (965) and Isomalt (953).
What can I eat on a low FODMAP diet?
The Low FODMAP diet involves many dietary changes that are best described to you in consultation with a dietitian. For expert dietitian advice, please book to make an appointment with one of the Shepherd Works dietitians on 03 9890 4911. Day time and early evening appointments are available. For people who live interstate, overseas or are unable to make it to one of our many practice locations, Shepherd Works offers a phone consultation service, please phone 03 9890 4911 to discuss.
Coeliac disease is a medically diagnosed condition of an intolerance to gluten in the diet. Gluten is the protein component of wheat, rye, barley and oats. In people with coeliac disease, after consuming gluten, the small intestinal lining (villi) becomes inflamed and the normal appearance changes so that it has a flattened appearance. A strict gluten-free diet can reverse these abnormalities, and is the only recognised treatment for coeliac disease.
Prevalence of coeliac disease is likely to be underestimated in Australia, and is probably in the order of 1 in 100, with diagnosis rates increasing. Coeliac disease also occurs in 10% of first-degree relatives. More than 99% of people with coeliac disease have the genetic profile of HLA DQ2 or DQ8.
It is becoming increasingly evident that there is indeed a broad spectrum of presentations of coeliac disease. Increasing numbers of adults are being diagnosed, whereas years ago it was considered a disease that was only diagnosed in children. Coeliac disease can present at any age and the variability and often vagueness of symptoms can present a diagnostic challenge to many medical practitioners. Presentation can include:
Gastrointestinal symptoms such as:
Loose stools/diarrhoea, or constipation (or a combination of both)
These can often be labelled as irritable bowel syndrome. It is strongly recommended all people experiencing symptoms of irritable bowel syndrome be investigated for coeliac disease.
Alternatively, it may present with no gastrointestinal symptoms at all.
Other symptoms can include:
Lethargy and fatigue
Poor weight and growth gain in children
Iron, folate, zinc, Vitamin D deficiency.
Osteopaenia and osteoporosis. Approximately 5% of patients being investigated for reduced bone mineral density have undiagnosed coeliac disease as a cause.
Delayed menarche or recurrent miscarriages in women
Infertility (in males and females)
Recurrent mouth ulceration
Dental enamel defects
The gold standard for diagnosis is a small bowel biopsy (the doctors will look for histological evidence of villous atrophy +/- infiltration of lymphocytes). This involves a special camera being passed down the oesophagus, past the stomach, and into the first part of the small bowel. There, small samples of the lining of the small bowel are taken and investigated under the microscope. If the biopsy samples show flattening of the lining, then it confirms coeliac disease.
There are some blood tests that can be performed to help screen for coeliac disease in “at risk” populations (eg. family members, people with diabetes, etc). However these are generally not ideal for diagnosing coeliac disease, as there can be false positives and false negatives. Blood tests including IgA tissue transglutaminase antibody tests and IgG Deamidated Gliadin Peptide can be ordered (“coeliac serology”). Total IgA antibody test should also be performed to help validate tissue transglutaminase results. The small bowel biopsy is still considered the best method for diagnosing coeliac disease.
There is no role for a trial of Gluten-Free diet without a preceeding biopsy.
It is important that people being checked for coeliac disease need to still be eating gluten in their diet. If they cut gluten out of their diet (eg. trial a gluten free diet) before being properly diagnosed, they can reduce their chances of being diagnosed, as the villi/lining can start to repair. If the camera is then inserted to take the samples for biopsy, but the person has already started the diet, the biopsies might show to be normal – but this may not be an accurate result – it could be false as it may be repaired. Therefore, all people who look suspicious for coeliac disease (eg. have symptoms, etc) should still be eating gluten whilst being investigated by their doctor(s).
Coeliac disease is a life-long condition and there is no cure. The only treatment available is a diet free from all gluten. This prevents further damage to the villi and allows them to return to normal, so that nutrients can be properly absorbed. People need to follow the diet even if they are not unwell with symptoms. It must be strict and life long – people cannot take a break every now and then and have a bowl of regular pasta, or a slice of regular bread.
If left untreated, people with coeliac disease can be at an increased risk of bowel cancer, osteoporosis, infertility, miscarriages and chronic ill health. The risk of all of these returns to normal on a gluten free diet.
Once the diagnosis of coeliac disease has been made, the following tests are recommended if not already completed: full blood examination, iron studies, folate, vitamin B12, zinc, vitamin D levels and bone mineral density. They can also have lactose intolerance, fructose malabsorption, problems with their thyroid gland (underactive, overactive), diabetes, etc. These should all be checked in people with coeliac disease.
Ongoing monitoring is important. People’s villi usually grow back and return to normal, but time for this to occur can range from months to years. People need to remain on their diet for life – even if the villi grow back. In this sense, people are only treated, they are not cured. The diet is for life (until a cure is found!! – and the doctors are working on it!)
A gluten-free diet for coeliac disease prevents further damage to the intestinal lining, allowing villi to heal so that nutrients from food can be properly absorbed. The gluten-free diet is a life-long diet, and strict dietary compliance is essential, even in the absence of symptoms. A gluten free diet involves a lot more than just avoiding regular bread and wheat-based pasta. It is very involved. Despite this, there are plenty of foods you can enjoy! As the diet must be strict and life-long, but to also to help ensure you are enjoying your diet safely, it is recommended you see a dietitian with experience in coeliac disease. The Dietitians Association of Australia and the Coeliac Societies can provide details of experienced dietitians.
All people diagnosed with coeliac disease are encouraged to join the Coeliac Society – there are Societies for each State. They are a valuable source of support and new food product information. Members receive a quarterly magazine, handbook and ingredients book. Events such as cooking demonstrations, group dietitian sessions, children’s camps, and social evenings are regularly offered. As information about the gluten-free diet can change over time, maintaining membership of the Coeliac Society should be for the long-term, to ensure ongoing access to up-to-date information. The Coeliac Society of Australia has branches in all states of Australia, and details can be found at http://www.coeliacsociety.com.au.
The gluten-free diet can be challenging and difficult, especially for the first few months following diagnosis, but it progressively becomes easier with familiarity with the diet and the foods available grows over time. There are many great tastes, gluten free, and the number of foods is increasing every day.
Gluten Free Diet
A gluten free diet involves choosing foods that do not contain gluten from the following:
Wheat (all varieties, including spelt, durum, kumut and dinkel)
Derivitives of these products, eg. malt.
Food products that are sources of gluten:
Breads and cereals made from these grains
Most breakfast cereals
Wheat flour (including wheaten cornflour, dinkle, kumut, spelt)
Wheat pasta, noodles
Semolina, couscous, burghul, stuffing
Wheat biscuits, cakes, pastry, scones, communion hosts
Wheat crumbed and battered foods
Wheat pastry foods e.g. pies, pizza
Fortunately there are a great range of alternative gluten free products now available. This will enable you to make the transition from a wheat-based diet to gluten free easily without sacrificing good nutrition or enjoyment of food. Specialty gluten free products include gluten free pasta, breakfast cereals, breads, crispbreads, sweet biscuits and many others. The health food section of the supermarket, health food stores and other specialty outlets will stock a variable range of gluten free foods.
Gluten-free grains and starches:
Rice (all forms, even glutinous)
Lentil/pea (besan, urid, gram flour)
A gluten free diet involves a lot more than just avoiding regular bread and wheat based pasta. It is very involved. Despite this, there are plenty of foods you can still enjoy! For example, many food groups are gluten free already. The gluten free diet permits fruits, vegetables, plain meat, fish and chicken, legumes and lentils, most dairy foods, oils and margarines.
Gluten may also be present in other foods such as confectionery, sausages and smallgoods, sauces, dressings and other condiments, canned soups, stock cubes, malted and cereal drinks, yeast extract spreads, soy milk, custard powder, icing sugar mixture, baking powder, beer, medications, etc.
People with coeliac disease can buy two types of gluten free foods;
1.those that are clearly labelled on the packet as being gluten free
2.those that are determined to be gluten free by reading the ingredients of a packaged food, and confirming that each individual ingredient is gluten free, to then know that the whole product is safe.
Identifying “type 2″ foods above can be an overwhelming task! Understanding ingredients is a necessary skill and must be taught properly. To help ensure you are enjoying your diet safely and you are educated about making the correct choices and enjoying a good variety of foods,, it is recommended you see a dietitian with experience in coeliac disease. Also, it is important to have access to ongoing information and support.
Publications through organisations such as the Coeliac Society allow you to keep up to date. The Coeliac Society of Australia has branches in all states of Australia, and details can be found at http://www.coeliac.org.au. The Coeliac Societies will also be able to provide you with details of dietitians with experience in coeliac disease.
This table is general in nature. People requiring a gluten free diet should check the ingredients of every food they consume to ensure suitability. * = check
FOODS TO INCLUDE AND FOODS TO AVOID WITH A GLUTEN FREE DIET
Foods to Avoid Foods to Include
Flours Wheat flour, wheaten cornflour, bakers flour, spelt flour, rye flour, custard powder made from wheat, oat flour, barley meal, gluten flour. Rice flour, pure cornflour (maize flour), cornmeal, soya flour, potato flour, arrowroot, buckwheat, sago, sorghum, millet, tapioca, besan flour, urid flour, lentil flour, amaranth, lupin, baby rice cereal
Bread All bread including rye, and commercial soya bread, flat bread, wuppertaler, pumpernickel, sourdough bread, biscuits, buns, pastries, muffins, crumpets, pikelets, croissants, breadcrumbs Rice cakes, corn cakes, some rice crackers *Gluten free bread, breadcrumbs, biscuits, rolls, cakes, pastries and desserts from allowed flours.
Gluten free bread, biscuit and cake mixes. Cornmeal, polenta.
Cereals Breakfast cereals containing wheat, oats, semolina, barley, rye, malt, malt extract, wheatgerm, wheatbran, oatbran, bulgur Rice and corn breakfast cereals (check for malt and malt extract)Homemade muesli using allowed ingredients.
Pasta Spaghetti, noodles, pasta, instant pasta meals (unless labelled gluten-free), couscous, gnocchi, Rice, tapioca, buckwheat, gluten free pastas, rice vermicelli, rice noodles
Fruit Commercial thickened fruit pie filling*, fritters, choc coated sultanas and nuts*. Fresh, frozen, canned, preserved, stewed or dried fruit, fruit juices
Vegetables Canned or frozen vegetables in sauce, commercially prepared vegetable and potato salads*, commercial hot chips/wedges* Fresh, frozen, dehydrated, or canned vegetables without sauces, vegetable juices
Meat, Fish, Poultry Foods prepared or thickened with flour, battered or crumbed, sausages, processed meats* and fish*. Meat pies, frozen dinners, corned beef* Fresh, smoked, corned, frozen without sauces, crumbs or batters. Canned meat or fish without sauce or cereal. Ham off the boneBacon, gluten free sausages
Dairy Products Malted milksIcecream with cone or crumbs Block or processed cheese, cream or cottage cheeseUHT, evaporated, powdered or condensed milk, buttermilk,
Yoghurt (check), dairy desserts*
Plain or flavoured icecream
Fresh or canned cream
Legumes, nuts Textured vegetable protein products, gluten steaksSome baked beans* Dried, canned or fresh beans, nuts and seeds, peanut butterGluten free canned baked beans
Takeaway food Hamburgers, pizza, souvlaki, sausages, battered food (e.g. fried fish), crumbed food (e.g. crumbed chicken), stuffed roast chickens Steamed rice, grilled fish (check no flour), chicken (no stuffing), steak, steamed vegetables, baked potato, some chips*
Snacks Packet savoury snacks*, many sweets and filled chocolates, licorice, many frozen desserts, flavoured potato crisps and corn chips* Plain chocolate, popcorn, jelly, meringue, plain potato crisps, plain corn chips, rice crackers*, most yoghurts*
Beverages Cereal-based coffee substitutesCereal-based cocoa beverages
(e.g. Milo®, Ovaltine®, Aktavite®)
Beer, ale, stout and lager
Alcoholic soft drinks containing malt vinegar
Water, tea, coffee, cocoa, milk, cordials, soft drinks, soda water, mineral water, fruit and vegetable juicesWine (including sparkling and fortified wines), most spirits and liqueurs, cider
Miscellaneous Malt vinegar, soy sauce containing wheat, baking powders containing wheat flour, mixed seasonings, beef, vegetable and yeast extracts (e.g. Vegemite®, Marmite®, Promite®), Many sauces, pickles, relish, chutney, salad dressing, stock cubes*, chicken salt. Tomato sauce, most vinegars, honey, jam, peanut butter, salad dressings not thickened, gelatine, gluten free baking powder, gluten free custard powder, gluten-free soy sauce, sugar, golden syrup, Mighty Mite®, Vege Spread®, Aussie Mite®Some stock cubes, gravies, sauces
Irritable Bowel Syndrome (IBS)
the lactose intolerance use of fodmap
You have been diagnosed with Irritable Bowel Syndrome (IBS), and you are probably wondering whether food plays a role.
The answer is yes and no!
For some people, a change in the food they eat may help their IBS, whilst for others it will make no difference. The key things to keep in mind are:
With any change in your eating, you need to make sure that you have a balanced diet, and
If the change in eating makes no change to the IBS, add those foods back into your diet. There is no point avoiding foods unnecessarily.
I have trialled eliminating some foods from my diet, what do I do now?
If you have tried the food changes and pin-pointed the problem foods, you are now ready to add the other foods back into the diet. There is no point avoiding foods unnecessarily.
If you have tried the changes and know that there is some improvement but you find it difficult to follow or are unsure which foods cut out really made the difference, then a dietitian may be able to help.
If these changes made no difference at all, then you can confidently reintroduce foods, and start to look at other things that may be upsetting your bowel eg stress, work, and family. Your doctor will be able to point you in the right direction for help.
Which foods may cause symptoms in IBS?
FODMAPS are often dietary causes for symptoms of IBS.
FODMAP is an acronym refering to:
Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols
Excess fructose, lactose, fructans, polyols (e.g. sorbitol and mannitol) and galacto-oligosaccharides are all examples of FODMAPS.
There can also be other dietary triggers for symptoms of IBS. Therefore, it is recommended you consult with a dietitian with experience in gastrointestinal nutrition. One of the team of Accredited Practising Dietitians at Shepherd Works can assess your diet and your symptoms and advise you about a dietary therapy that may assist your symptoms of IBS.
Find out information about a dietitian appointment, and hydrogen breath testing.
What Is Lactose?
Lactose is the sugar that is found in milk products from any mammal. It is a double-sugar made up of two smaller sugars (glucose and galactose).
What is Lactose-Intolerance?
Normally, lactose is broken down to these two smaller sugars by the enzyme, lactase. Lactase is produced by the villi that line our small intestine, however the production of lactase can be temporarily decreased by damage to the small intestine, such as the result of a gastro infection. Our production of lactase can also gradually decrease as we get older. In this situation, such people have a lactase insufficiency and therefore permanent lactose intolerance. Most people still produce a small amount of lactase.
Without enough lactase enzyme, the lactose sugar is not digested normally in the small intestine. Instead, it passes to the large intestine where it is fermented by bacteria. This fermentation can cause the common symptoms include diarrhoea or loose motions, wind and abdominal bloating and discomfort.
What Can I Eat on a Lactose-Free Diet?
The degree and severity of symptoms depends on the level of lactase insufficiency. If you are still producing some lactase enzyme, you can still continue to include lactose in small amounts in the diet as tolerated. For example, milk in tea and coffee throughout the day may be tolerated; however to drink a full glass of milk would cause symptoms. This is because the body can often be producing very small amounts of the lactase enzyme, however not enough to cope with a large load of lactose at once.
Avoiding dairy products is not the answer to lactose intolerance. Dietary therapy includes:
1.Choose lactose-free varieties where possible.
2.Lactose intolerance is often dose-related. Therefore having smaller quantities more often over the day may be better tolerated
For a full description of all of the foods that can be enjoyed on a lactose-free diet, you should consult an Accredited Practising Dietitian who specialises in gastrointestinal nutrition. Find out more about making an appointment to see a dietitian.
Find out more about hydrogen breath testing.