FODMAP is not a single entity, but a group of an acronym that stands for fermented, oligo, di, monosaccharides and polyols. FODMAPs are found in a variety of fruits, vegetables, milk and wheat.

HOW FODMAP WORKS;

FODMAP may exacerbate IBS symptoms through a various mechanism such as ;

OSMOTIC OVERLOAD; Poor absorption of FODMAP causes osmotic overload and distention of small intestine and abdominal symptoms.

BACTERIAL FERMENTATION; FODMAPs are rapidly absorbed by colonic bacteria and produce colonic distention due to gas production associated with abdominal pain and bloating.

FODMAPs are not bad for everyone, in normal healthy individuals they have important physiological effects like; they increase stool bulk, enhance calcium absorption and modulate immune function. They selectively stimulate the growth of Bifidobacterium a species of good bacteria.

FODMAPs and the irritable bowel syndrome (IBS)

IBS is a chronic functional disorder of the intestine, the most common symptoms are abdominal pain, bloating and altered bowel movements.The global prevalence of IBS is around 12% and is more common in women.

Treatment of IBS consist of pharmacological and non pharmacological measures. Among the non pharmacological options; stress reduction, dietary modifications ( restriction of certain food (FODMAP) and cognitive behaviour therapy are the most important.

LOW FODMAP DIET

In recent years, there is a growing body of research which support low FODMAP diet for the management of IBS, studies have shown that it can help up to 70-85% of patients with IBS achieve relief of their symptoms. it is now included in NICE guidelines as a second line intervention for IBS.

Following a low fodmap diet may helpful in alleviating symptoms of IBS like

• Abdominal pain
• Bloating
• Altered bowel movement
• Gas

There is no evidence that low FODMAP diet works for non digestive symptoms that are associated with IBS, such as headache and skin or joint problems.

Phases of low FODMAP diet

It is three phased elimination diet, first phase is the restriction phase in which high FODMAP food should be completely avoided. This phase lasts for 2-6 weeks. Second phase is reintroduction in which food with high FODMAP reintroduced but one at a time. This will enable you to identify which FODMAP you are sensitive too. This stage can take several months to complete and ideally should be completed under the guidance of a dietitian. Personalized stage the third phase is a combination of phase 1 and phase 2 and involves the long term, modified FODMAP diet. For more information regarding a high FODMAP food list https://www.monashfodmap.com/about-fodmap-and-ibs/high-and-low-fodmap-foods/

WHAT IS DOWNSIDES OF LOW FODMAP.

There is short term risk associated with insufficient protein, dietary fibre, B group vitamins and calcium intake.

Low levels of prebiotics;

Prebiotics are indigestible carbohydrates that are resistant to gastric acid and fermented by bacteria present in the large intestine. Prebiotics predominately found in food containing Fructans and Galacto-oligosaccharides.The low FODMAP diet restricts the intake of many high prebiotic (high FODMAP) foods and prolong restriction of high FODMAP can alter gut microbiome diversity. Studies have shown low levels of total bacterial abundance and reduced level of bifidobacterium following a low FODMAP diet. This is why re-introduction phase is very important as it allows you to have more variety in your diet but also maintain a healthy gut.

Calcium in low FODMAP diet;

The restriction of lactose containing dairy products may enhance the tendency to poor calcium availability since these items are primary source of calcium and promoting effect of lactose on calcium absorption is lost.

Lactose or dairy free calcium sources are; Kale, lactose free plant based milk fortified with calcium, hard cheese, firm tofu.

TAKE HOME MESSAGE

Low fodmap diet is considered as a second line treatment option for patients with IBS as recommended by NICE guidelines. This diet should not be used without specialized dietary advice from a registered professional. Vegan or vegetarian are at increased risk of protein deficiency due to limited plant protein sources however well constructed meal plans by registered dietitians may reduce possible nutritional deficiencies.

We know that obesity is a risk factor for several non communicable diseases, it can lead to diabetes and other metabolic conditions, but there is less awareness that obesity can lead to serious liver disease.It is estimated up to 1 in every 3 people in the UK has early stages of NAFLD, where there are small amounts of fat in their liver.

Non-alcoholic fatty liver disease is the accumulation of triglycerides in the liver cell and this buildup is independent of alcohol consumption. It is a spectrum of disorder ranging from less severe steatosis (fatty liver) to more severe non-alcoholic steatohepatitis (NASH), where the liver has become inflamed; this is estimated to affect up to 5% of the UK population. Fibrosis and cirrhosis develop at later stages and lead to liver failure and sometimes liver carcinoma.

what causes NAFLD

• The exact cause of NAFLD remains unclear, however, it is linked with genetic and environmental factors like
• 1.Obesity
• 2.Diabetes
• 3.Hyperlipidemia
• 4.Women with PCOS5.
• 5.Sedentary lifestyle

Treatment and prevention

There is no specific pharmacological treatment for NFALD. However, various medicines can be useful in managing the problems associated with the condition like;medications for high cholesterol, high blood pressure and Insulin sanitizers.

Life style modifications;

There is a strong consensus that lifestyle interventions such as diet, physical activity and weight reduction can help in preventing and reduces the progression of the disease. A metanalysis of 23 trials shows that lifestyle modification including weight loss and physically activity consistently reduced liver fat and improved histopathology.

WELL BALANCED DIET; Diet consists of vegetables and fruits with less processed carbohydrates. Low Glycemic index carbohydrates with more fibre content also reduce insulin resistance which is directly linked with NAFLD. Low caloric diet intake ( 3-6 months) either low carbohydrates or low fat diet results in weight loss and improved lipid profile.

Intake of polyunsaturated fats especially omega 3 fatty acids reduces the risk of NAFLD. Mediterianean diet is a best source of mono unsaturated fatty acids( MUFA) like n– oleic acid (olives, nuts, avocado), which play an important role in the metabolic profile of human metabolism. MUFA has been demonstrated a beneficial effect on lipid profile bt decreasing  plasma triacylglycerol and very low density lipoprotein (VLDL) cholesterol concentrations and modestly increasing high density lipoprotein (HDL) cholesterol without adversely affecting low density lipoprotein (LDL) cholesterol concentrations. 

Soft drinks are leading cause of added sugars in the world and different observational studies report a positive association between soft drink consumption and NAFLD. Soft drinks like cola drinks contain caramel coloring, which is rich in advanced glycation end products (AGEs) that may increase insulin resistance and inflammation.

Observational studies have demonstrated a favourable impact of coffee intake on health and in particular a protective effect from the metabolic syndrome. Coffee contain polyphenols chlorogenic acid which acts as antoxidants, anti inflammatory and reduces the risks of developing NAFLD and cardiovascular diseases.

Regular physical activity: There is a dose-response relationship between NAFLD and physical activity (both prevalence and disease severity,  therefore, the more physical activity performed throughout the day, the better! Aim to do at least 150 minutes/week of physical activity like walking or cycling. Increasing daily walking has also been shown to improve fat oxidation and is a way of increasing physical activity levels at no cost and without additional equipment. Aerobic and resistance exercises both improves NAFLD. A systematic review (24 exercise-only studies) revealed that exercise produced a 20–30% relative reduction in hepatic steatosis, independent of weight loss in NAFLD patients.

weight reduction: Based on available data, patients should optimally achieve a 5%-10% weight reduction. A prospective study with 7 years of follow up emphasized that even a modest weight change of 3–5 kg is an independent predictor for the development and remission of NAFLD, regardless of baseline body mass index (BMI).

TAKE-HOME MESSAGE

Lifestyle interventions can be highly effective in treating NAFLD across the disease spectrum and offer a holistic way of managing not only liver health, but also cardiovascular and metabolic health. Patients often feel difficult to achieve and implement these modifications, however with proper and individualized support suffient long term changes can be possible.

always set Smart, Meaurable, Achievable, Relevant, Timely goals

Irritable bowel syndrome (IBS) is not as simple as just having an unhappy gut, its not all in our head either. IBS not only manifest as painful gut but it also affects patients confidence, body image and mental health.

Irritable bowel syndrome (IBS) is the most common chronic functional disease of the digestive system. Around 20% of the world population is affected by this order. Women are around 2 to 3 times more likely to be diagnosed with IBS and 4 to 5 times more likely to seek specialty care for it than men.

A variety of gastrointestinal and extraintestinal factors are likely to influence the manifestation of IBS. Dysregulation of the brain-gut axis, gastrointestinal infection, low-grade infiltration and activation of mast cells in the intestinal mucosa with consequent release of bioactive substances, and altered serotonin metabolism are the emerging factors of IBS pathogenesis.

sex hormones like estrogen and progesterone affect motor and sensory function of GIT and triggfer IBS symptoms in women before or during mensturation.

SYMPTOMS OF IBS

The most common symptoms of IBS are abdominal pain, bloating, altered bowel movements diarrhea or constipation. Some people may experience both constipationa and diarrhea at different time. IBS is also associated with psychological disorders like anxiety and depression, gastroesophageal reflux and genitourinary infections. women with IBS may be at risk of developing endometriosis or having a hystercetomy.

TREATMENT

Only symptomatic treatment is available for IBS, the choice of drug treatment depends on the nature and severity of the symptoms. Many drug treatment options for IBS are available over-the-counter. According to NICE guidelines, Antispasmodic drugs (such as alverine citrate, mebeverine hydrochloride and peppermint oil) can be taken in addition to dietary and lifestyle changes. A laxative (excluding lactulose as it may cause bloating) can be used to treat constipation.

Antidepressants like amitriptyline and citalopram can be used as a second line of treatment  in patients who have not responded to antispasmodics, anti-motility drugs, or laxatives. A selective serotonin reuptake inhibitor may be considered in those who do not respond to a tricyclic antidepressant [unlicensed indication]

LIFESTYLE INTERVENTIONS

DIET

Diet plays an important role in IBS management as it controls symptoms, but it does not necessarily target the underlying cause. so if you eliminate the foods that trigger your symptoms it improves your IBS symptoms but, when trigger foods are reintroduced, often symptoms also return. In IBS management, the way you eat and what you eat both have an important impact on gut symptoms.

• Reduce caffiene intake;limit tea and coffee to not more than three cups a day.
• limit alcohol and fizzy drinks
• Reduce intake of resistant starch, fatty foods
• Drink plenty of water
• Try Probiotics;Yoghurt and some drinkss and supplemets such as tablets, capsules or sachets.

Fibre in IBS; Fibre is double edge sword in IBS as for some it is a blessing and for other IBS patients, it can worsen their symptoms. When considering fibre, it is important to look at both the quantity and the type of fibre (insoluble or soluble), as too little or too much fibre can trigger IBS symptoms.

Quality of fibre also matters. soluble fibre and insoluble fibre behave very differently when they reach the digestive system. If an increase in dietary fibre is required always to prefer soluble fibre as they dissolve in water and remove excess fluid and that how they are good in IBS with diarrhea.

 Intake of insoluble fibre (e.g. bran) and ‘resistant starch’ should be reduced or discouraged as they may exacerbate symptoms.

• Psyllium; It is a unique soluble fibre that has a dual function, it softens the hard stools and also helps in IBS with diarrhea by thickening up loose stool.it may also improve bloating and incomplete evacuation.

• Flaxseed; Flaxseed is good for IBS with constipation. aways start with low quantity like half tablespoon (6g) per day and then gradually increase up to 2 tablespoons. The seeds are either swallowed whole with water or soft food such as yogurt, or they are ground up and sprinkled on food

• Peppermint oil /tea; There is a growing body of evidence that supports the efficacy of peppermint oil in IBS. It is a natural solution for IBS with minimal side effects. Peppermint oil is antispasmodic and relax intense intestine and reduce abdominal pain.

FODMAP

There is a group of carbohydrates found in different foods which causes IBS symptoms as they are poorly absorbed in the small intestine. FODMAP is a term used for these foods. f=fermented,o=oligosaccharide,d= disaccharides, m=monosacchrides,p= polyols. these are present in the stonefruits, legumes, lactose-containing foods, and artificial sweeteners might exacerbate symptoms in a subgroup of patients due to their fermentation and osmotic
effects.

• BACTERIAL FERMENTATION; Gut bacteria in the large intestine ferment this indigestible fodmap and gives off-gas. This gas distends the stomach, causing bloating, wind, constipation and explosive stool.
• OSMOTIC OVERLOAD; FODMAP can draw water in from the body into the small bowel and increasing the pressure over the intestinal wall causing diarrhea or some experience hard stool followed by watery stools.

Low FODMAP diet ; Low fodmap diet is a sceond line approach for IBS patients. It improves IBS symptoms in around 70% of patients however, this diet is not for a lifetime and should be introduced under the supervision of qualified professionals. For more about low fodmap diet, which food are included, phases of this diet, visit this website. https://www.monashfodmap.com/

NON DIET APRROACH

Move YOUR BODY;

Physical activities boost mood and also good for the gut muscles. Low-intensity exercises like walking, swimming, cycling, light jogging can help reduce stress and control IBS symptoms.

STRESS MANAGEMENT

IBS is considered a disorder of gut and brain and any kind of stress, physical or psychological have a direct effect on the symptoms of IBS as evident by data. Relaxation and other stress-reduction techniques could bring a sense of wellbeing and have an impact on the severity of IBS symptoms.

COGNITIVE BEHAVIOURAL THERAPY (CBT); There is increasing evidence for the efficacy of CBT in alleviating the physical and psychological symptoms of IBS.

SLEEP HYGIENE;

Sleep disturbance is very common among IBS patients. studies show positive association between sleep deprivation and worse gut symptoms. Poor bad night sleep results in bad IBS day symptoms. Sleep quality and duration equally important, but one in three adult do not get quality sleep.

take home message;

IBS is a chronic disorder ofthe digestive system but for the majority of patient, it is frustrating and its effect on the quality of life make it a disease with high cost. Current medical tratment for IBS, only targets the symptoms of this disorder. IBS can be managed by identifying what triggers the symptoms, which food is good for IBS. Non diet approach like physical activity, relaxing tecniques all show promising results in alleviating IBS sypmtoms.IBS symptoms varies from person to person so personalized interventions are important.

The shoe that fits one person pinches another; there is no recepie for living that suits all