Interview with Jessica Biesiekierski, Nutritionist at Diet Solutions & PhD Researcher at Monash University (Australia)
Jessica Biesiekierski is preparing her thesis on IBS and diet. The research team Jessica belongs to is the worldwide leader in terms of FODMAP diet and gluten in the context of irritable bowel syndrome.
Jessica visited Finland in June 2011, and gave a guest lecture for dietitians and staff at the University of Eastern Finland. She kindly answered some questions regarding FODMAP diet from the perspective of a nutritionist and researcher.
1. Could you first describe shortly what is the low FODMAP diet?
FODMAPs are rapidly fermentable, poorly absorbed short chain carbohydrates (in the gut) found in a range of foods. They have an osmotic effect in the small intestine and increase gas production in the large intestine. Together, these can trigger symptoms to people with a more sensitive gut (irritable bowel syndrome). FODMAP is an acronym for Fermentable Oligo-, Di-, Monosaccharides And Polyols. In this diet, you reduce FODMAP intake (and thus also reduce fermentation in colon) by choosing low FODMAP carbohydrate containing foods.
2. How do FODMAP carbohydrates differ from soluble fiber?
Fibre are long chain carbohydrates that resist digestion in the small intestine. Fibre and resistant starch are important for stool formation and normal functioning of the bowel. FODMAPs are short chain carbohydrates which can be poorly absorbed. In our studies, we always control the amount of fiber and resistant starch in control and active groups.
3. Which bacteria in colon is mostly responsible for the fermentation processs?
Bifidobacteria and lactobacillus are mostly taking care of fermentation process. Up until now, we have not analysed the colonic bacteria in our research. There is a large study nearing completion from Melbourne, Australia and also another one from London looking at the effects of the low FODMAP diet on gut bacteria.
4. How do your patients perceive FODMAP diet after your introduced it. What is normal reaction?
Most patients are frustrated after years of trying different treatments and numerous diets to improve their gut symptoms that they willingly accept any help. In my opinion, it’s rarely a shock.
For some patients, the low FODMAP diet changes their life. Patients are setting up online forums for themselves and others alike. They continually ask us for more research and updates in food analyses . In Melbourne , there is a lot of trust towards the FODMAP diet.
Some patients might be a bit reluctant in the beginning. Especially as garlic and onion avoidance can seem to be challenging. We teach patients to implement diet flexibility, and not become too strict after the initial 6 week period. Foods should be reintroduced and patients should work out their individual tolerance level. Occasional intake of FODMAPs may not induce symptoms when the overall load of FODMAPs is reduced. We always recommend seeking the guidance from a dietitian with experience in the low FODMAP diet to ensure the patient’s diet remains balanced and nutritionally adequate.
5. Do you have any sub sequential reintroduction process of FODMAP foods after 6-weeks’ initial period?
After 6 weeks FODMAP diet the patients come for a review appointment with their dietitian. In some outpatient centers we do breath testing to identify what FODMAP is or is not malabsorbed and therefore most likely to trigger or not trigger symptoms. Breath testing can be decided by the patient as it can be a time consuming and expensive test.
Typically, you introduce one sugar per week, and test it during 2-3 days that week. For example if you want to test fructose you take one teaspoon honey once on Monday, twice on Wednesday and maybe three times on Friday. If the patient didn’t get symptoms, you may reintroduce fructose containing foods into the diet. This protocol can vary and should be tailored to meet each persons needs. For challenging sorbitol we recommend using an apricot or blackberries; for lactose use ½ cup of milk; for mannitol use mushrooms.
6. How much broader is a FODMAP diet after a year from introduction?
Patients can push their tolerance gradually, ie. start with moderate FODMAP containing foods and slowly increasing amounts eaten. We don’t advocate the low FODMAP diet as a life long diet, or even long term diet plan. Patients should not feel restrictive for rest of their life. The main aim of the low FODMAP diet is to achieve good symptoms control. Most patients may only have to avoid high FODMAP foods in large amounts.
7. What is a typical patient like? Age, symptoms, gender.
Middle aged, female. Nowadays younger and younger.
Many have struggled with symptoms for many years. Once they have spoken with a friend or someone with IBS, they only then realise how severe their symptoms are and that these are not normal. Once they get rid of the symptoms they feel well and energetic – perhaps for the first time in a long time.
8. Do you use FODMAP diet for patients without clinical IBS?
Yes, after IBD and celiac diseases are cleared, we do consult patients who have disturbing symptoms without clinical IBS. In these cases, we are not likely to introduce a full scale FODMAP diet but partial one and only focus on the really high FODMAP containing foods.
9. Where do patients come from? Via word of mouth, GPs, nurses or other dietitians?
GPs and gastroenterologists refer to us. Breath testing clinics are quite a common channel for patients as well. But the reputation of the team is also good, so word of mouth does a lot too.
10. What about gluten? You have shown in a recent trial that gluten really can cause gastrointestinal symptoms in IBS when FODMAP levels are controlled.
Definitely. We originally thought that fructans (FODMAPs) were the only ingredients in grains to trigger IBS symptoms in non-celiac patients. We were surprised that gluten really induced gut symptoms and fatigue seen in our double blinded, randomised, placebo controlled study. Now we are going to do even to re-examine this phenomenon with a new feeding trial (we provided all of the food for patients). We are analysing more specific and sensitive biomarkers to try and understand how these symptoms are being induced. I hope we can have the results early next year.
11. You have mentioned that FODMAP diet is well known and widely implemented in Melbourne. How about the other parts of Australia?
Not all dietitians fully understand the low FODMAP diet yet. However, word is spreading across the country. It’s a popular discussion subject on our national online discussion boards for dietitians. Education of the low FODMAP diet is not well covered in the training programme of dietitians. Teaching has started only recently and our research deparment conducts regular seminars aimed towards teaching the approach to dietitians.
Australian gastroenterologists are now advocating the low FODMAP diet in national therapeutic guidelines for IBS.
12. What would you like to say to dietitians who are interested in the FODMAP diet?
I guess you might not believe its efficacy without testing it. Give it a go. Results usually speak for themselves. But, please study the research in order to give the correct information.
Jessica Biesiekierski, thank you very much for your time and answers. You do wonderful work for IBS sufferers all around the globe!
More on FODMAPs and Jessica Biesiekierski, click here.