Seemingly every week, a new food makes headlines for its disease-fighting properties. Unfortunately, many of these so-called "superfoods," including broccoli, kale, tomatoes, garlic and berries, can be problematic for people who have certain diseases. FODMAPs, oxalates, and nightshades are examples of food categories that may trigger inflammation or digestive issues in susceptible individuals.
Understanding FODMAPs
FODMAPs, or Fermentable Oligo-, Di-, and Monosaccharides and Polyols, are short-chain carbohydrates that ferment in the gut and feed the bacteria in the small intestine, and they can be especially problematic for people who have digestive troubles, such as irritable bowel syndrome (IBS), small bowel intestinal overgrowth (SIBO) and inflammatory bowel disease (IBD). These carbohydrates are osmotically active. Some of these are slowly or minimally absorbed in the small intestine (fructans, galacto‐oligosaccharides, polyols) and others are not absorbed in certain conditions (i.e., fructose when fructose intake exceeds GLUT5 capacity, lactose in lactase deficiency). Upon reaching the colon, the unabsorbed carbohydrates undergo rapid fermentation by bacteria, leading to the production of short‐chain fatty acids, carbon dioxide, hydrogen and methane. These gases are associated with gastrointestinal (GI) symptom provocation in individuals with irritable bowel syndrome (IBS).
FODMAPs and Gut Health
Evidence from a recent network meta‐analysis ranked the low FODMAP diet first against several other comparator diets for global symptoms, abdominal pain severity and bloating. Studies show that three out of four IBS patients experience fewer symptoms, such as gas, bloating, constipation and diarrhea, while eating a low-FODMAP diet. High FODMAP foods include dairy, wheat, onions, garlic, brussels sprouts, cauliflower, legumes (including beans, lentils and soybeans) and fructose (including fruits, honey and high-fructose corn syrup).
Considerations and Recommendations
Eating a huge amount of high-FODMAP foods could cause digestive problems for almost anyone, but most people don’t have trouble digesting the amount of FODMAPs in a typical diet. In fact, high-FODMAP foods are loaded with critical nutrients, including prebiotics, which promote the growth of healthy gut bacteria. If you need to restrict FODMAPs because of IBS, IBD or some other digestive issue, don’t do it alone.
Oxalates: A Closer Look
Oxalates occur naturally in all sorts of fruits and vegetables, and there’s a lot of overlap between foods that are high in FODMAPs and those laden with oxalates. Our bodies also make oxalates during the digestive process. If you have underlying kidney issues, the salts produced by oxalates can crystallize in the urine and act as a trigger for kidney stones. Oxalates also can bind to minerals, such as calcium and magnesium, and reduce their absorption. High-oxalate foods include green leafy vegetables, soy, almonds, potatoes, tea, beets and some legumes.
Read also: Weight Loss with Low-FODMAP
Oxalates and the Body
For most people, oxalates are not a problem food. Bacteria in the gut breaks them down so they can be used for energy (and won’t interfere with nutrient absorption). Unfortunately, people who have low levels of oxalate-degrading gut bacteria-and those with certain digestive disorders-may accumulate oxalates, which can lead to kidney stones. Most urinary oxalates are produced by the body naturally, as a waste product. They don’t come from the diet. But reducing your intake of high-oxalate foods could still help limit the among of oxalates circulating in the kidneys. Drinking sufficient water can also help dilute the urine and prevent oxalates from building up on kidney walls.
Recommendations for Oxalate Intake
If you have a family history of kidney stones or have digestive disorders that inhibit your ability to absorb nutrients, talk to your doctor about whether you should consider limiting your oxalate intake.
Nightshades: Understanding the Controversy
Nightshade is a family of plants that contain small amounts of a chemical called alkaloids. One particular alkaloid in nightshade fruits and vegetables, solanine, acts almost like a pesticide while the plant is growing. Through fighting off insects, parasites, microbes and bacteria, nightshade fruits and vegetables develop complex chemicals, some of which may be inflammatory for some individuals. Nightshade-containing foods include tomatoes, potatoes, bell peppers and eggplant.
Nightshades and Inflammation
There’s no solid evidence that nightshades are unhealthy. However, people who have certain inflammatory conditions, including IBD and rheumatoid arthritis, may notice that eating nightshades amplifies existing inflammation-and if you have digestive issues, the acidic profile of peppers or tomatoes may exacerbate your symptoms.
Considerations for Nightshade Consumption
If you have a propensity for inflammation, or you have an inflammatory condition like IBD, autoimmune disease or arthritis, eliminating nightshades may improve your symptoms.
Read also: Delicious low-FODMAP vegan recipes
The Low-FODMAP Diet and IBD
Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, affects approximately 3.1 million people (1.3%) in the USA and 2.5-3 million people (0.4%) in Europe. Beyond healthcare costs, IBD impacts activities of daily living, is associated with social stigma and impacts food‐related quality of life for patients. While research has predominantly focused on the impact of FODMAPs in IBS, there is also some evidence that FODMAPs exacerbate GI symptoms in individuals with IBD, and manipulation of dietary FODMAPs is recommended in several global clinical guidelines for patients with IBD to treat functional symptoms.
Research on Low-FODMAP Diets and IBD
A systematic review aimed to synthesise high‐quality evidence on the potential impact of a low FODMAP diet on IBD disease activity, inflammatory markers, GI symptoms, quality of life, diet quality and the microbiome in adults living with IBD. Additionally, it aimed to evaluate the experiences and perspectives of individuals implementing a low FODMAP diet.
Study Details
The review included RCTs investigating the low FODMAP diet compared with a control group in adults (≥ 18 years) with a diagnosis of IBD (ulcerative colitis, Crohn's disease or unspecified IBD). Interventions that were implemented through counselling and/or controlled feeding strategies were included. Eligible control groups included groups that continued habitual diet or undertook a control or comparator diet (e.g., sham diet, high FODMAP diet).
Key Findings
Compared with controls, there was no effect of a low FODMAP diet on disease activity (Crohn's disease: SMD −0.33; −0.77, 0.11; ulcerative colitis: SMD −0.31; −0.78, 0.15) or faecal calprotectin (SMD −0.20; −0.49, 0.09), but lower severity of global IBS symptoms (SMD −0.56; −0.90, 0.23) and higher QoL scores (SMD 0.43; 0.05, 0.81) at end of intervention. Patients with IBS described implementation as burdensome (Severity, Barriers), inadequate professional support (Susceptibility) and found it difficult to interpret information (Susceptibility, Barriers).
Implications for IBD Management
A low FODMAP diet does not impact IBD disease activity and inflammation markers, but leads to improved gastrointestinal symptoms compared with controls. The diet should be considered for improving functional gastrointestinal symptoms, but not an IBD treatment. There are minimal studies about patient experiences implementing the low FODMAP diet, all in IBS.
Read also: Delicious Low FODMAP Chicken
Anti-Inflammatory Diet and IBS
Research suggests that chronic inflammation in the body exacerbates symptoms of IBS. Lowering inflammation in the body allows the good bacteria in our guts to thrive and flourish, and promote a healthy gut environment.
Key Components of an Anti-Inflammatory Diet
An anti-inflammatory diet prioritizes several key components including minimizing processed foods, increasing dietary fiber intake, incorporating omega-3 heart healthy fatty acids, and including various lean proteins from plant and animal based sources while also implementing various spices. This diet ultimately works to minimize intake of trans and saturated fats that can contribute to inflammation in the body and a pro-inflammatory state.
The Role of Dietary Fiber
One key nutrient of the anti-inflammatory diet is dietary fiber. Dietary fiber is found in a wide range of plant-based food choices, including fruits, vegetables, whole grains, legumes, nuts, and seeds. The bacteria and microorganisms that reside in the gut go through a process known as fermentation, which essentially breaks down the dietary fiber that was consumed. Research has shown that production of SCFAs from increased dietary fiber intake can demonstrate anti-inflammatory properties as well as assist in chronic disease prevention in a number of chronic diseases, including obesity, cardiovascular disease, diabetes, inflammatory bowel disease, and liver disease, to name a few.
Combining Low-FODMAP and Anti-Inflammatory Diets
Integrating a low FODMAP or anti-inflammatory diet can be done separately or in combination for maximum benefits. By identifying food-related triggers with the low FODMAP diet and then incorporating anti-inflammatory foods, individuals may achieve significant relief from their digestive discomfort and IBS.
Sample Menu
The following foods can be implemented at any stage of these two diets. For more exact serving sizes that are low in FODMAP, please refer to the Monash App for additional suggestions on portion sizing. Yes, low glycemic index foods are anti-inflammatory food choices, given that lower glycemic index foods contain higher amounts of dietary fiber, which means that blood sugar levels are less likely to be elevated after a meal or snack choice.
Other Dietary Considerations in IBD
Diet seems to play a role in both the occurrence and the course of IBD. Many studies focus on finding a connection between food groups or nutrients and the progression of the development of IBD. On the other hand, the course of the disease may affect the nutritional status of patients. In patients with IBD, malnutrition may manifest as low body weight and reduced body mass index (BMI), reflecting an imbalance in energy and nutrient intake. This can result in protein-energy malnutrition as well as deficiencies in essential micronutrients. It is vital to note that malnutrition is common among patients with IBD, affecting up to 60% of individuals and significantly impairing quality of life. Moreover, malnutrition is also diagnosed in patients in remission.
Fats and Fatty Acids
The impact of fat and fatty acids on the development and course of IBD is still being studied. However, it has been observed that fatty acids can exhibit both pro-inflammatory and anti-inflammatory effects and can play a regulatory role in immunity by affecting intestinal barrier permeability. For example, a high-fat diet rich in saturated fatty acids (SFA) shows pro-inflammatory effects. This is supported by a study which demonstrated that a high intake of fat, especially cholesterol and animal fat, increases the risk of UC. Additionally, a high-fat diet affects gut immunity by influencing intercellular tight junctions, mucin 2 secretion, and antimicrobial peptide production. According to the guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN), a diet high in omega-3 fatty acids and low in omega-6 fatty acids reduces the risk of developing IBD. Moreover, the American Gastroenterology Association (AGA) recommends a Mediterranean diet, rich in fats (about 40% of energy is driven from fat), mainly monounsaturated fats, for all IBD patients.
Protein
In a systematic review by Potcovar et al., the incidence of sarcopenia in patients with IBD ranged from 36.7 to 65%. Scientific studies have shown that supplementation with both whey and soy protein can increase skeletal muscle mass, hemoglobin and iron levels, creatinine levels, and albumin levels in patients with IBD. Parenteral glutamine is thought to have anti-inflammatory effects, which may potentially improve clinical outcomes in Crohn’s disease.
Fiber and Carbohydrates
In a systematic review conducted by Hou et al. in 2011, the authors focused on the type of food consumed and the risk of IBD, finding that high intake of fruit and dietary fiber correlated with a low risk of developing IBD.
Vitamins and Minerals
Beyond the general problem of malnutrition, patients with IBD have an increased risk of nutritional deficiencies, including vitamins, such as vitamin D, folic acid, vitamin B12 and minerals, with most common iron deficiency. In the case of vitamin D, ESPEN experts suggest monitoring its concentration in both adults and children with an active form of the disease, treated with corticosteroids, and suspected 25(OH) vitamin D deficiency; if the result indicates deficiency, it is recommended to include vitamin D/calcium supplementation. One of the more serious deficiencies is anemia, which occurs in 60-80% of patients with Crohn’s disease. In the case of patients with UC, the occurrence of anemia (66%) is due to iron deficiency, which constitutes a significant majority compared to patients in the CD group. Furthermore, in patients with nonspecific IBD, common problem is also folic acid deficiency caused by low intake. Scientific studies have noted that patients with CD are particularly susceptible to folate deficiency-the location of the disease and the use of sulfasalazine. The 2020 European Crohn’s and Colitis Organization (ECCO)-ESPGHAN guidelines suggest that patients taking methotrexate should receive 5 mg of folate once a week (24-72 h after methotrexate administration) or 1 mg daily for 5 days a week-these data apply to both adults and children.
Navigating the Low-FODMAP Diet: A Phased Approach
The low-FODMAP diet is meant to be undertaken in three phases. In the first phase, all high-FODMAP foods are eliminated from the diet for an extended period of time, often four to six weeks. In phase two, you systematically reintroduce restricted foods, noting how well you tolerate increasing quantities of the foods you're reintroducing. This multiphase process can be complex and confusing, and requires substantial food knowledge.
Potential Risks and Considerations
There is also concern that long-term restriction of high-FODMAP foods changes the makeup of bacterial colonies in the gut, which may negatively impact intestinal health and possibly worsen digestive issues over time. The low-FODMAP diet is not intended for individuals without IBS, nor is it appropriate for everyone with the condition. It should be avoided by anyone with an eating disorder, as it may worsen food fears and diet restrictions. In addition, people with already restricted diets, such as vegans or those with food allergies, may be unable to meet their nutritional needs on the diet.
Alternative Diets for Arthritis
The research is clear: No diet can cure arthritis - but can a diet ease arthritis symptoms? Research gives the popular Mediterranean diet high marks for its anti-inflammatory benefits and varied food choices. While vegetarian and vegan diets are more restrictive, studies also show anti-inflammatory benefits. Some people with arthritis may consider trying lesser known diets that they’ve heard about online.
Autoimmune Protocol (AIP) Diet
The AIP diet relies on the theory that autoimmune conditions stem from a “leaky gut,” the concept that substances permeating the intestinal lining and entering the bloodstream trigger inflammation. “Done in a structured and monitored way, with testing periods and reintroduction of foods, the AIP diet may help patients identify foods that trigger [rheumatoid and other forms of inflammatory arthritis] symptoms,” says Alicia Romano, clinical registered dietitian at the Frances Stern Nutrition Center at Tufts Medical Center. It’s restrictive. In addition to nixing the same foods as the paleo diet, including dairy, grains and legumes, AIP bans nuts, seeds and alternative sweeteners. Following the AIP long-term can result in nutrient deficiencies and resulting complications. AIP may be a last-line approach when less restrictive nutritional therapies have failed. People who are underweight, malnourished or pregnant should avoid AIP.
Lectin-Free Diet
Former cardiac surgeon Steven Gundry, author of the book The Plant Paradox, which promotes this diet, claims naturally occurring proteins called lectins are a key culprit in Americans’ health problems. According to the theory, a high intake of lectins, found in some dairy and plant foods, may damage the intestinal lining, affecting the way nutrients are absorbed and eliciting an immune response and autoimmunity in certain people, Romano explains. It’s hard to stick with because it’s restrictive, and it eliminates many foods with inflammation-fighting properties. The diet rejects grains, legumes and most dairy products, along with nightshade vegetables, cucumbers, nuts and seeds. If you have a lot of gut issues, going lectin-free may offer some relief.
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