Read on for the full transcript of my interview with Larah from episode 2 of the Low FODMAP Diet and IBS podcast.
Hi and welcome to the low FODMAP diet and IBS podcast. My guest today is Joanna Baker. She is an accredited practicing dietitian from Melbourne. Joanna has been working in health care for twenty years. In addition to being an accredited practicing dietician, she is also an accredited nutritionist and a registered nurse. Joanna is also the founder of the everyday nutrition website, where she has an active role in helping her patients to prevent diseases, improving and maintain good health, primarily by adopting a healthy lifestyle. And here she is: Joanna.
Larah: Hi Joanna…
Joanna: Hi, Larah. Thanks for having me.
Larah: I’m so excited to have you here today. You have so much knowledge on the low FODMAP diet and it will be great to share some of your knowledge with the listeners of the podcast.
Joanna: Sure. I’m excited to be here.
Larah: So the first question is, just if you could tell the listener a little bit more about yourself and how did you get interested in nutrition and the low FODMAP diet in general.
Joanna: Sure. I’ve always loved food and enjoyed cooking, eating and experimenting with different ingredients, but it was when I started studying dietetics and I discovered the low FODMAP diet, it was then that I realised that abdominal symptoms that I’ve had my whole life, that I thought it was just me and I thought it was normal, where actually it was not normal after all. So it was soon after this, that I began investigating what was going on, and I was diagnosed with IBS. From there I began to implement the low FODMAP diet to manage it.
The FODMAPs were a real game changer for me; for the first time in my life, I got to two o’clock in the afternoon and I wasn’t bloated and uncomfortable. And the result of that was, I was also sleeping better, I was less irritable and I could eat a meal and be full and satisfied after the meal without feeling bloated and unwell. Nowadays, obviously for me, it has improved my life and my quality of life and I do really enjoy working with other people, and helping them discover what a difference the low FODMAP diet can make to their everyday life.
Larah: That’s great. A little bit the same for me when I discovered FODMAP, I felt so much better afterwards. So if we have to just explain the basic of what is the low FODMAP diet?
Joanna: Yep! So, FODMAP it’s actually an acronym and it comes from the names where the small carbohydrates of sugars that are found in a variety of fruits, vegetables, grains and legumes, so the sorts of beans and nuts and things. And what we know is that when FODMAPs are consumed in food or drinks, they are not fully absorbed. We can’t fully absorb these molecules in the small bowel and what this means that they continue their path along the digestive tract to the colon, and then there is one of two processes that happens that triggers the symptoms of IBS in certain people. And it might be symptoms like bloating, cramping, wind, constipation, diarrhea or even a combination of the two.
The first thing that happens is that some FODMAPs, fructose and lactose particularly, are highly osmotic; and what this means is that as they travel through the bowel they draw water into the bowel and then that effects how the bowel moves, so speeding up gut motility and drawing water in, is going to result in diarrhea. The other thing that happens is that when FODMAPs reach the colon, so this may be any of the FODMAPs, we’ve got natural bacteria that live in our colon, and FODMAPs are fermented by these bacteria that are essentially designed to keep us healthy, but when they ferment these molecules, it’s kind of like it they aren’t going to ferment there, we produce gas and bubbles and when the healthy bacteria digests FODMAPs in our bowel we get gas and we get bubbles. So for individuals who have IBS this causes bloating, it causes distention, it causes cramping and the nerves that supply sensation to the bowel, they can get quite irritated by this instead of sending messages to the brain and then the brain talks back and nobody is very happy as a result.
The FODMAP diet was one that was designed and it’s now actually been scientifically proven that three in four people that have IBS, by limiting the foods that contain these molecules or FODMAPs, they are able to prevent and minimise their IBS symptoms.
A really important part of this diet though, is that FODMAPs don’t cause physical harm, so the low FODMAP diet is not one where there are foods or drinks that have to be strictly avoided. It is based around symptoms and symptoms are directly related to a threshold effect, and as we consume these foods, they build up and they compound each other until we hit a threshold and once this threshold is reached, that’s when the symptoms occur. So the low FODMAP diet is one where the foods only needs to be limited or restricted as far as somebody’s individual symptoms would dictate. This means though, that it’s actually a really individual diet and that different people have different thresholds and different tolerances and different sensitivities to the different FODMAP groups. And on top of this, to make it even a little more complex, is that most people’s symptom threshold is not fixed and their threshold often would vary day to day, week to week and even over a lifetime, depending on the other things that are going on in a person’s life.
Larah: Yeah, that make sense. It’s not just about “Okay, now I know what food I can and cannot have,” because that keeps on changing. Sometimes I can see with myself I can tolerate a little bit more of something else and then a few weeks later on, “Oh no, maybe I had too much.” It just keeps on adjusting every time.
Joanna: It’s a constant sort of levelling between your threshold is here and your FODMAPs are here and keeping that balance, so that you can prevent and minimise your symptoms, but have as much variety in your diet at the same time. It’s a constant balancing act.
Larah: Yeah absolutely. So now let’s talk about FODMAP as an acronym. It sounds a bit like a mouthful to say, but you can do that really well, I’m sure.
Joanna: Absolutely, so FODMAP, it’s a bit of a funny word, but when we break it down, the ‘F’ is for fermentable. So this is talking about the molecules that don’t get digested. They pass through the digestive tract to the colon and they are fermented, and it’s this that causes the IBS symptoms.
So the ‘O’ then is oligosaccharides, and these are types of sugars. They include fructans and galactans and they come in chains. So it’s a chain of fructose molecules with the glucose on the end, while galactans are chains of galactose molecules. So these are found usually in foods like onions, garlic, wheat, barley, rye, inulin and some dried fruits and they’re also the ones that are found in kidney beans, the lentils, the chick peas, baked beans, that sort of thing.
Now, the ‘D’, that stands for disaccharides and ‘di’ meaning two. It’s two sugar that are joined together and that’s lactose, which is found in milk. We’ve known for a long time that some people don’t tolerate lactose very well and they got abdominal symptoms because of it. And that’s what makes lactose part of the FODMAP diet. So of course, lactose is found in milk, yogurt, some soft cheeses, ice creams, custards, those sorts of foods.
Now the ‘M’ of the FODMAP, that’s mono-saccharide. These are the simplest sugars, and this is fructose. Fructose is just one single molecule. Now the thing with fructose, is it’s about how we absorb fructose. So, we know that if a food has got equal levels of fructose and glucose, we can absorb fructose quite easily. But if the fructose is present on its own or there is more fructose than there is glucose, then it can be difficult for some people to absorb it. So, monosaccharides or FODMAPs fructose are an excess of glucose. This can be found in foods like asparagus, apples, mango, honey, cherries, some dried fruits, pears, some juices and, of course, high fructose corn syrup has got a lot of fructose in it.
‘A’ is the easy word. ‘A’ is for ‘And’. I don’t think I need to explain that one.
Larah: Easy enough…
Joanna: The last one is ‘P’ for polyols, and these are sugar alcohols. Now these aren’t referring to alcohols like beer and wine that we drink, it’s a type of sugar molecule and they include things like sorbitol and mannitol. These are often found in foods like cauliflower, mushrooms and snow peas, and we know that nobody absorbs these sugar alcohols very well. They have a sweet flavor, but because they do not absorb, they do not contain calories so they are often used to sweeten things like sugar-free chewing gum. They provide a sweet taste, but we won’t absorb them, so they become calorie-free.
Larah: That’s a good point.
Joanna: So, then of course, because they are not absorbed, they travel to the colon where some people can be more sensitive to them.
Larah: Good. Perfect explanation and I think it has been clear for our listeners as well.
Joanna: Thank You.
Larah: Now, if you could please also explain about high and low FODMAP food and when some foods are considered high and when some are considered low?
Joanna: I guess one of the easier ways to look at it is that FODMAPs, they are not really black and white, they’re a continuum. So some foods contain a high percentage of the troublesome molecules and low FODMAP foods either contain none of them or they contain a very small percentage of these molecules. So onion, for example, has a lot of oligosaccharides for the amount of food that you are eating. So you only need to eat a little bit of onion to have a large dose of fructans or oligosaccharides, so this makes it quite a high FODMAP food. In most people, it will be enough to push them over their symptom threshold and create the IBS symptoms.
So something like butternut pumpkin however, that’s more of an average FODMAP food and most people need to eat quite a bit of it to get enough FODMAPs to push them over their threshold. And then there is foods like meats and oils that don’t contain any carbohydrates so they don’t contain any FODMAPs and they’re not going to contribute to pushing you over your FODMAP threshold. So, because of this as well, it’s a good time to mention that with portion size and with high and low FODMAP, it’s sometimes easy to sort of think of it like a bucket. So everybody has a bucket and during your day, during your week, you’re throwing things into your bucket, and when the bucket overflows, is when your FODMAPs symptoms occur.
So bucket sizes can change. Some days you may be highly stressed and it might only take you a small amount of food to overflow your bucket and get symptoms. But on other days, for some people buckets are huge and they can take a lot of FODMAP triggers before they break their threshold and get FODMAP symptoms.
Larah: It makes absolutely perfect sense and I think in the past, before being on a low FODMAP diet, my bucket would be spilling all the time. That’s why I was sick, and maybe the same for you, but now it’s usually only halfway full, so I can tolerate some bits more.
Joanna: Absolutely, and I think that’s one of the things about implementing a low FODMAP diet, is reducing the amount of triggers that are in your bucket and that gives you more room to move with a variety of food before it does overflow. So keeping that baseline bucket sort of half empty, is a good way to be long term.
Larah: Yeah, I agree with that. So could you please also explain what happens when we eat FODMAP food as IBS sufferers and what’s the difference if FODMAP food is consumed by a healthy individual, who doesn’t suffer from IBS?
Joanna: I can, sure. This varies depending on the type of FODMAP. So, when we breakdown the FODMAP acronym I talked about: oligosaccharides, disaccharides, monosaccharides and polyols. and those are the four groups of FODMAPs. So the lactose and the monosaccharides, this is directly related to absorption of the molecules. So some people absorb these molecules very easily and there’s no problem for them. Some people have low amounts of the enzymes, that are involved in the absorption of these molecules and they don’t absorb them properly in the small bowel. This means that people who don’t absorb them fully, they make it to the colon where they can cause IBS symptoms, whereas people that do absorb them fully, they never make it to the colon so they’re never going to get IBS symptoms from these molecules.
So people who do have low numbers of the enzymes that are involved in the absorption, they won’t absorb lactose or fructose properly, and they might have an osmotic effect. They’re drawing water into the bowel there and then becoming fermented. Diarrhea is often quite common in these people, as well as bloating and distension. Now the polyols and the oligosaccharides on the other hand, they’re a little different because we know that nobody fully absorbs these molecules, so it doesn’t matter whether you have IBS or not, nobody absorbs them. We have known for a long time that if you eat too many baked beans, people are likely to get a little bit gassy and you’ll want to have the doors open and have some earplugs.
Joanna: So, these molecules, because they’re never absorbed, they will always go to the colon and they will always get fermented. Now these actually do have a beneficial effect on keeping the bacteria in the colon healthy. In some people, the nerve ending that are around their gut, are more sensitive than they are in other people or they may be sort of more irritable; they may be more alert and more aware, so they’ll respond more quickly sending messages to the brain saying, “Hey, there is something a bit odd going on here and I’m not quite sure about it.” And then the brain sort of responds with pain which is often a result of that so they get the bloating. Everybody may get a bit bloating and a bit of distention, but some people will be bothered more by this than other people, depending on the nerves around the gut.
Larah: It’s perfect. I think it should be clear for the listener. So you covered this already a little bit, but can you just go into in more detail about how FODMAP food affects also non-IBS sufferers?
Joanna: I talked earlier about how FODMAPs symptoms are related to a threshold. So everybody does have a threshold somewhere, and some people would tolerate a lot more FODMAP food before
they do reach their threshold. This really comes back to the bucket analogy again, where everyone’s bucket is a different size.
My husband, for example, he’s got a cast-iron stomach. He can eat pretty much whatever he wants, but the thing is, if he eats a whole cauliflower, he’s still going to get a stomach ache from that. So for me, it might be one little piece of cauliflower is enough to give me a stomach ache, but he can eat a whole one, but he’ll still get stomach ache eventually when he eats enough of it. His stomach ache might be a bit of a niggling annoyance, but for someone with IBS, the stomach ache is going to their nerve endings, which are going to be a lot more upset by this effect.
Larah: That makes perfect sense, but sometimes I talk to friends and they don’t have IBS, but they say, “I can’t eat this,” or “I can’t eat that,” so that kinds of explain why, even for non-IBS sufferers, some of the high FODMAP food could give some slight discomfort.
Joanna: Excellent. If you eat enough of anything, then it’s probably not going to be particularly good for you.
Larah: What do you think in terms of which individuals should really follow a low FODMAP diet?
Joanna: The low FODMAP diet isn’t for everyone and there are other things that can cause abdominal symptoms. There’s things like other food intolerances that can cause IBS type symptoms, but they’re not related to FODMAPs. And there are also medical concerns like celiac disease, Crohn’s, colitis, those sorts of things. So anybody who has abdominal symptoms, it’s really important to investigate those medical causes first because if they’re not managed well, they can cause physical harm and injury.
So, we know that eating FODMAPs doesn’t cause physical harm; it’s more related to how the gut functions. So, by ruling out those medical concerns like celiac disease like Crohn’s, like colitis, first of all, that will ensure that the treatment suits what’s going on for the person. So, we’re always going to be getting better health and better symptom relief if we’re treating the right cause. Once all these things that have been ruled out, by first going to see a doctor and rule out these medical symptoms. If you investigate all of those and there is nothing else wrong, the doctor may diagnose you with a food intolerance or some sort of IBS. Once you’ve determined that there is nothing medically wrong, it’s then important to see a dietician, because a dietician is the one that can determine whether its FODMAPs that are causing your problem or if it’s a different food intolerance that are causing your problems. So this step is really important for optimal symptom relief.
I see a lot of people who started a low FODMAP diet and have been following it for quite a long time and they come to me and say, “I’ve been doing FODMAPs for 4 to 5 years even, but I’m still have symptoms or it’s not working.” And what I find once I actually assess them properly, it turns out that there’s a different food intolerance that’s causing their problems, and once I place them on the correct plan, they actually get symptom relief. So again, medical diagnoses, a proper nutrition assessment and a proper nutrition diagnosis is really important.
The other things that I also consider, whether a low FODMAP diagnosis suits, is that sometimes there’s non-related medical or lifestyle things that are important to consider, and placing some people on a restrictive diet, there may be nutritional deficiencies so I want to take that into account as well. Not everybody is nutritionally able to restrict their diet and stay healthy at the same time. So, if I can’t replace the things that we’re removing to keep them healthy, then we may consider whether this is the best course of action for them.
Larah: Absolutely. I agree 100% with you that you should not attempt to self-diagnose and do not attempt to do a low FODMAP diet on your own. If you want to be successful, just go to a specialised dietitian because not all dietitians are specialised on a low FODMAP diet.
Joanna: Yes. True. It’s a new diet, Larah, so we are learning about it every day and a lot of dietitians are still learning about it. In some parts of the world, some dietitians have never heard of it still because it’s so new.
Larah: Yeah, that’s good. So in terms of guidelines, are there any guidelines that help us identify how much low FODMAP food we can consume in one meal or in one day before it becomes too high in FODMAPs?
Joanna: Absolutely, and this is part of, when I do see a patient, it’s part of how we implement the diet. How much a person can consume in a meal or a day, it really varies a lot from person to person. And like we talked about earlier, FODMAPs is a constant balancing act between what and how much you want to it, where your symptoms occur and how many symptoms that you’re personally willing to put up with. So essentially, the patient is the only one that can decide where that balance is.
What I do as a dietician is that I use a structured and systematic approach to help the person identify and pinpoint what exactly is going on for them. So what I have in my tool box is that foods are often tested for FODMAP content, and they’ll be tested based on their serving size, and then they can be related comparably to when most people with IBS experience symptoms. Some people find that they’re more sensitive to certain foods and they can tolerate more of other foods. So going through a process where we eliminate all possible triggers and then systematically reintroduce these foods or reintroduce these triggers one by one, we are then able to identify which foods the person is most sensitive to and how much of them they can tolerate, before they reach their symptom threshold. So these things gives us the information that we need to personalise the diet and at the same time allow variety and keep the symptoms under control or keep the symptoms managed.
Larah: Perfect! That kind of makes me that it’s something that the listeners may need to know, then what is the best approach for them to follow a low FODMAP diet?
Joanna: Well, I’m always going to recommend seeing a dietician that’s got expertise in the diet. Even if you go and see a dietician just once to determine whether it’s the right diet. If that’s the only thing you can afford then really, that step is vital. What I would do with a patient is that we go through elimination, then reintroduction, and then a maintenance phase. So this is really structured and it’s really systematic. A lot of people to come to me with food diaries. Now the food diaries do have their pros and cons and in regards to FODMAPs, there’s two reasons for that.
So personal FODMAPs, because it’s a threshold, because they compound each other, there’s often a delayed reaction, so people can get symptoms anywhere from 30 minutes to even a day or two later, and this is because the food that you’re eating actually takes time to get from your mouth to your stomach to your small bowel and to your colon where the symptoms occur. So, what this means is that it’s unlikely to be the food that you’ve just eaten that are causing your symptoms. It’s more likely to be the something that you’ve eaten at breakfast, and then you eat something else again at lunch, and it’s the two together that will push you over your symptom threshold, not just what you ate at lunch. So, we need to look at the whole diet for that reason.
And again, like I said, the other one is that FODMAPs compound each other, so there’s usually a variety of foods that can contribute to reaching the threshold, not just one food in particular.
When we’re going to implement the diet, the elimination phase is the first step and at this point, we remove all possible FODMAP triggers and we bring a person as far away from their symptom threshold as we possibly can. So once somebody has been away… We do that usually for about 3 to 4 weeks and once they’ve found out that they’ve got good symptom relief for a little while. So, I usually like 3 weeks because that’s gives us a really good baseline far away from the symptom threshold that we can start from.
Then we are looking at the reintroduction phase. At this point, we are going to choose the test foods and we are going to start introducing them, and we are going to introduce them one by one over a few days and we are going to slowly increase the amount of that food over a few days as well. So the reason that we’re going to choose foods very carefully is that if we’re going to choose fructose, for example, we can’t use an apple to do this, because an apple has got fructose and sorbitol in it, which means that if you react to an apple, it is impossible to know whether it’s the fructose or the sorbitol that’s causing your reaction. So we do need to be particularly careful about the food that we’re choosing.
And then, obviously, once we’ve selected our food, we reintroduce it on day one and then slowly increase the amount over a few days and that will give us a good indication of how much you can tolerate, before you reach your symptom threshold.
Then, if we’re looking at the long-term maintenance phase of the diet, we want to consider which FODMAPs. By then, we’re going to know which FODMAPs are specifically triggering you and we’re looking at anything that we remove from your diet, we need to consider the nutrients that that provides to your diet. So we need to find alternative ways to getting those into your diet or ensuring that we can space them in your day or in your week, so that you are getting the nutrients that you need.
Larah: Perfect! It’s understandable that someone cannot do all this by themselves. They should really be followed throughout just to make sure that it is successfully done, really.
Joanna: Well it’s just such a complex and individual diet. I think what works for one person is not necessarily going to work for another. I’m constantly, with all my patients, adapting on how I reintroduce foods and what foods that I’m choosing and I make that decision on a very individual basis, so I don’t have one rule that I apply for everybody.
Larah: That’s good, yeah. In terms of help for any other health issues, has a low FODMAP diet been helpful for other issues apart from IBS?
Joanna: That’s a really interesting topic, Larah. There’s not a huge amount of research around this at the moment, so I’m a little wary about how much I do say about it. There is some initial research that’s coming out, though. It’s very early stages and it’s very preliminary that there is possibly some indication that it may benefit other inflammatory bowel diseases like Crohn’s and colitis. At this point, it’s such early research that it is impossible for me to say empirically yes or no on this topic, but I would say watch this space. I think that we might find out a lot more about it and a lot more benefits of the low FODMAP diet in the future, so it’s going to be interesting to see where it goes in that respect.
Larah: Yeah. I would say the same. Watch this space. If more research gets done, we’ll be covering it in the future.
Joanna: Yes. I’m really excited about it.
Larah: Yes. We’re quite lucky in Australia because most dietitians, I think they have a knowledge at least, even though they might not be expert in the low FODMAP diet, they at least have a knowledge of the low FODMAP diet.
Joanna: Yeah, for the FODMAP diet, we developed it here in Melbourne so it’s the place to be if you’re looking at FODMAPs.
Larah: Yeah, absolutely. I think I’m really lucky that when I got IBS I was in Australia and not in Europe, especially not in Italy.
Larah: So what do you think about other countries? I know that you’re doing Skype sessions as well with people from abroad?
Joanna: Yeah. I’ve got patients in New York; I’ve got patients in other parts of Australia; I’ve even got a couple in Scandinavia, as well. So sometimes, it’s a little tricky getting the timing right, but we usually manage it with Skype.
Larah: Yeah, that’s fantastic. And yes, so other countries are not as advanced in their knowledge and obviously, most of the research is done in Australia. Are there any other countries that are a kind of following our path here?
Joanna: Yeah, I have been doing a lot of research all around the world in other countries, particularly in the UK. I know Kings College in London has done a lot of research into the low FODMAP diet and I believe that the British Dietetic Association has recently changed their recommendations and included the low FODMAP diet as part of their first line management for IBS. I know that in other parts of the world… I think in California there is some research going on at the moment, and in some parts of Europe, they’re also looking at it as well. In Australia, we all know about it and it’s certainly growing and spreading, but there is the other consideration that dieticians do tend to have their own specific areas of interest, and that means that they have their own specific areas of expertise. Looking for a dietician who has been trained or has experience on the low FODMAP diet is a really good idea.
Larah: That’s perfect. Thank you, Joanna. I would say, yes, we are really fortunate in Australia. We do have a lot of knowledge of the low FODMAP diet and I hope that all the work we are doing, even with this podcast, it can spread the word on the low FODMAP diet just a bit more and get people more and more aware that there is another thing that they can try.
Joanna: I know in traditional treatments for IBS, the low FODMAP in research is far outweighing other treatments, so it’s nice that people can finally have a positive outlook on managing their symptoms and not just have to put up with them as a part of life.
Larah: Yeah, absolutely. And both you and I can testify that it has worked for us.
Joanna: Excellent. It’s changed my life.
Larah: Yeah, I agree.
Joanna: I have so many patients that come to me and I start them on the elimination phase and when they come back after four weeks, they came back and say, “Oh my gosh! I can’t believe the difference.” They’re blown away by it. It’s wonderful to see.
Larah: Yeah, I can imagine.
Thank you so much for being on the podcast. I think there’s a lot of great content here that should definitely help our listeners. If people want to get in touch with you, Joanna, where can they can find you?
Joanna: Sure. So I’ve got my website. It’s www.everydaynutrition.com.au. My Facebook page is called Everyday Nutrition. And you can also find me on Twitter and on Instagram. My handle is @joannabakerAPD.
Larah: Perfect. If you haven’t caught it you guys, don’t worry because I will be putting all these details in the show notes for this episode.
Joanna: Brilliant. Thanks for having me, Larah.
Larah: Thank you for participating. That was great. See you next time.
Joanna: See you next time, Larah. Thanks.
Thank you for listening to this episode of the Low FODMAP Diet and IBS podcast with my guest Joanna Baker, an accredited practising dietitian from Melbourne, Australia. Joanna has a wealth of knowledge on the low FODMAP diet, and during this interview, she has explained to us what the low FODMAP diet is, what the acronym FODMAP stands for. She gives us an explanation of what FODMAP food is and explained high and low FODMAP food and also what we need to know before starting a low FODMAP diet.
Please join me next time for a new episode of the Low FODMAP Diet and IBS podcast. Until then, I wish you all the very best. Bye for now.
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