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How changes in diet can help Irritable Bowel Syndrome
IRRITABLE bowel syndrome (IBS) is one of the most common presentations to gastroenterologists, with its symptoms varying from gas and bloating, abdominal cramping to irregular bowel habits. It is a type of functional bowel disorder in which even with the presence of symptoms, all investigations such as blood tests or endoscopy are expected to turn out normal. There are multiple factors which can contribute to this condition, among them are alteration in the gut microbiota, stress, anxiety and the food factor.
It is not uncommon to experience abdominal discomfort or diarrhoea after having a feast. People will normally blame the symptoms on the contaminated food resulting in food poisoning. However, it is more likely that the condition is related to triggers in food that irritate the gut.
In fact, food is commonly cited by IBS patients to be the trigger of their symptoms. Recent studies show that diets which contain high amounts of fermentable short-chain carbohydrates can worsen IBS symptoms. These are collectively labelled FODMAPs, an acronym for "fermentable oligo-, di-, and mono-saccharides and polyols". FODMAPs are indigestible and poorly absorbed in the small intestine which are subsequently passed into the large bowel.
As they are osmotically active, more water is attracted into the lumen of the bowel. Once reaching the large bowel, they are readily fermented by bacteria and contribute to the production of gases (hydrogen, carbon dioxide, and methane). The consequent water and gases in the large bowel cause luminal distension, leading to bloating, flatulence and other abdominal symptoms in persons who have sensitive bowels.
Avoidance of foods which are high in FODMAPs can alleviate the symptoms of IBS. FODMAPs are naturally found in a wide range of foods, from comfort foods such as mee pok/ yellow noodles, bread, pasta (wheat-based products) to soya beans, mung beans (legumes), cauliflower, cabbage, mushroom (vegetables), apple, mango, watermelon (fruits) and milk, yogurt and ice cream (dairy products). If you start to have a feeling of impending doom and are not sure what to eat, fret not, there are other low FODMAP foods in the same food groups which can be used as substitutes. A search for "FODMAP" on the Internet will help you to understand more about the different types of food and their FODMAP contents. The general strategy is to avoid foods high in FODMAPs and replace them with foods low in FODMAPs. Sometimes, a visit to the dietitian can be useful, as they can educate you on the food types, teach you about interpreting food labels as well as give you suggestions on new recipe ideas.
Singaporeans love good food. Our cuisines are diverse and have the influence of different cultures - blending different ingredients, spices and herbs, and having a variety of cooking styles, very much reflecting our multi-ethnic cultures.
Tips and tricks
A typical serving of fried noodles comprises noodles with generous portions of meats, prawns, bean sprouts, spring onions, all pan-fried in a mixture of oil, soya sauce, salt, minced garlic and sambal chilli, before garnishing with some fried shallots on top. While this tantalising mix gives oodles of pleasure to those slurping it up, their bowels may not necessarily agree. In fact, high FODMAP food ingredients make up a considerable proportion of our cuisines.
Since it is not possible to avoid FODMAPs altogether, here are some tips on the dietary modifications which can help those with sensitive bowels:
- Onion and garlic are major high FODMAP sources, they are commonly used in daily food preparation. Instead of using them, you can use spices, herbs, the green part of spring onions and whole chives to add flavour to your foods;
- Rice is a staple in our society. It is probably the best source of carbohydrates, as it has almost complete absorption in the small bowel and has low gas production;
Apart from wheat-based noodles (yellow noodles, ramen, mee pok,mee kia) and bean-based noodles (dong fen) which have high FODMAPs, you can choose rice-based noodles (bee hoon, kway teow, laksa noodles) and buckwheat noodles (soba) which are friendlier to your intestines.
- Most breads are made of wheat flour, so limit your consumption to a small portion a day or ideally choose potato or corn breads over wheat breads;
- Sauces, marinades and seasonings are often added to dishes. They can pose a real hazard to your bowels as they often contain high FODMAP ingredients such as garlic, shallots, soya beans and others. Instead, prepare your food by grilling, steaming or stir-frying with little to no oil;
Condiments are also commonly consumed in our society, accompanying most dishes. Spices such as chilli, basil, coriander and curry leaves have a low FODMAP content, while condiments are always made from other ingredients which have high FODMAPs such as onion, garlic, shallots and wheat flour;
Always request for the sauces or condiments to be placed separately on the side of the dishes, so that you can control the amount to be consumed and only dip slightly if needed;
For the meat eaters, there is a reason to cheer. You can continue to enjoy your meats, fish and seafoods as they generally have low FODMAPs.
Vegetables such as kailan, bean sprouts, green beans, egg plant, cucumber, lettuce, radish and fruits such as dragonfruit, grapes, honeydew, papaya have low FODMAPs.
Try and limit fruit to one portion per meal. You may even get away with something that you don't think is good for your bowels if you only eat just a little. The next time when you order a drink from the hawker centre, ask for "kopi-o" instead of the usual "kopi", which has sweetened condensed milk. Avoid excessive dairy products or if possible use lactose-free milk.
Keep a food diary
As you may know now, it is quite tedious and difficult to avoid FODMAPs altogether as they are present in a broad range of foods. It is also not an easy task to change our food consumption patterns as it is closely linked to the traditional dietary patterns of our cultures.
However, you can start with keeping a food diary in order to track your food intake and identify the potential food triggers. Meanwhile, also eat high FODMAP foods less often or in smaller quantities, avoid sauces and heavily flavoured, rich and spicy foods and choose plain meat, fish, and rice-based dishes.
FODMAP tolerances also vary between individuals. Some can tolerate FODMAPs more than others. Consume small serving sizes of FODMAPs over a day until a balance between tolerated doses and control of your bowel symptoms is achieved.
It is not advisable to be so restrictive in your diet that it impacts on the nutritional value. Foods taken out of the diet should be replaced by alternative low FODMAP foods. This will ensure the diet is balanced, nutritionally adequate and will help to improve gut compliance in the long-term.
This series is produced on alternate Saturdays in collaboration with Singapore Medical Specialists Centre.