He followed a diet low in FODMAPs and it didn't work...I wonder why?

While there must be few people who don't know what FODMAPs are or at least have heard of the ben(mal)said gas-forming and water-retentive ones, here's a definition before I move on with any further comment.

Fodmap stands for:
Fermentable carbohydrates (these carbohydrates present in many foods and some food additives are not easily absorbed and are at the mercy of our bacteria to produce gas and retain water, which causes so many symptoms(pain, diarrhoea, constipation...) in certain cases.
Oligosaccharides - Fructans and Galacto-oligosaccharides - Wheat, rye, onion, garlic, pulses, etc.
Disaccharides - Lactose - dairy products.
Monosaccharides - fructose - honey, apples, grapes, vegetables,...
Polyols - sorbitol and mannitol - artificial sweeteners but naturally present in some fruits and vegetables.

In a completely healthy gut fermentation also takes place, but to an extent that causes no discomfort or symptoms.

Monash University in Australia has a vast research on the subject and therefore, nowadays, the treatment of many intestinal alterations (mainly in cases of irritable bowel syndrome) by implementing a diet low in these carbohydrates. It is always a good way to start, if the process is well monitored, as the elimination phase is followed by the reintroduction and personalisation phase. Discovering which foods and how much you can eat can be time consuming but also effective. 

We also very often use this approach which is well basedbut, "there's no beauty without a catch" and a diet low in FODMAPs can easily become an inflammatory diet or poorly balanced if it is poorly monitored. Suffice it to say that table sugar is low in FODMAP and crisps too. Well done can even decrease inflammatory markers. But, that's not where we're going today.... I will be happy to write about the diet in another post, because carried out correctly it has many benefits yes.

Although there is much success, a low FODMAP diet does not always help eliminate intestinal disc omfort or the symptoms return some time later and the causes can be diverse:

• One has not yet begun to deal with the stress (I am not saying that the illness is in the patient's head, but that the stress is effectively (and with no way back) a point to be worked on; 

• There are unrealistic expectations and it was not expected that some symptoms would not disappear completely (it can happen). Some symptoms appear from time to time, they may vary with the menstrual cycle or with the level of stress at a certain time, for example;

• Feeding was started when there was already a state of systemic inflammation and the diet is not being enough to reduce that inflammation;  

- The restriction phase was done too long, which caused an overgrowth of bacteria undesirable bacteria in the large intestine, which led to the return of the same or different symptoms. 

- Patient heard of FODMAP but found it too complicated and did only gluten and dairy withdrawal; 

- The existing bacterial overgrowth is in the small bowel (SIBO - Small intestinal bacterial overgrowth) and not in the large intestine, so a diet low in FODMAPS may only be one part of the treatment; 

- There is some enzyme deficiency that was not being taken into account, which causes the digestive process to remain inefficient even on a low FODMAP diet;

- There is a parasite, virus or bacteria that must be eradicated from the gut;
- You have not been "feeding the bacteria" with prebiotic foods or a probiotic is needed;
- The bacteria that are unbalancing the intestinal flora are in biofilms that are difficult to eradicate,...

This is where the wonder of personalised nutrition comes in and in these cases you can rarely avoid doing some analyses (if we were transparent everything would be simpler). A good, detailed assessment of the stools and beyond will help us to discover:

• Which beneficial bacteria are in short supply?

• Which bacteria/parasites/viruses should not be in the gut or not in large quantities?

• Is there an intestinal candida or other fungus?

• Which short chain fatty acids are being produced or are in short supply?

• Are there carbohydrates/proteins/fats in the stool?

• Is IgA being produced in adequate quantities?

• Is there SIBO or not?

• Is SIBO more methane or hydrogen forming?

• How is the elastase level?

• Is there already altered intestinal permeability and high levels of zonulin?
  

  
  An assessment of some vitamins and minerals also helps to better target your diet and/or supplementation. Are you eating vegan, vegetarian, paleo, eating meat, eating fish?

  These are all points in addition to FODMAPS that make a difference to your gut health/recovery.

The answers to these questions and many others, make nutritional and/or medical monitoring truly personalised and help guide treatment beyond FODMAPs.

Each patient is effectively unique.

Written by Dr. Helena Santos. You can read more information about her approach here.