Tuesday, 30 August 2016

RESEARCH UPDATE: How important is diagnosis of Fructose malabsorption in the FODMAP approach?

By Lyndal McNamara and Dr Jaci Barrett

New research regarding breath testing and its use to diagnose fructose malabsorption in IBS has just been published. Researchers examined existing data from several prospective clinical trials involving two groups of IBS patients to see if fructose breath test results were the same when repeated over time.1  The studies also investigated reporting of gastrointestinal symptoms during fructose breath testing and the relationship between test outcome (‘positive’ or ‘negative’ for fructose malabsorption) and the experience of symptoms.1

Study 1 - 41 IBS patients - two fructose breath tests performed, with the second test completed ≥2 weeks after the first

Study 2 - 36 IBS patients - completed a single fructose breath test and kept gastrointestinal symptom diaries the day before and the day of the test

Patients in both studies followed a diet low in fibre and FODMAPs for 24 hours and were required to fast overnight prior to each breath test. Participants consumed a drink containing 35g of fructose in 200ml of water for each test and breath samples were collected every 15 or 20 minutes for up to four hours.

Study 1 – is a fructose breath test result reproducible?

Major findings
  • 30% of participants, positive for fructose malabsorption in their first breath test, tested negative on the subsequent test ≥2 weeks later
  • The was no relationship between the amount of breath hydrogen produced in the first and second fructose breath tests

Study limitations-
  • Some study 1 participants had their second breath test performed >19 weeks after the first. This relatively long period of time between tests means that changes in diet or medications may have affected gut bacterial populations and therefore influenced the results.
  • This study included a small number of participants and retrospectively analysed data from existing studies. A larger, prospective study that collects data over a longer test period would be useful to further validate these findings.

Study 2 – are symptoms on a breath test related to breath hydrogen response?

Major findings
  • Those who tested ‘positive’ for fructose malabsorption were more likely to report symptoms during a fructose breath test than those who tested ‘negative’
  • This was NOT significant when test day symptom scores were adjusted to account for the participants’ usual level of symptoms (pre-test day symptom scores)

Study limitations-
  • Gastrointestinal symptom data from study 2 was only collected during the breath-testing period and not the remainder of the day, so may not have captured participants who had a delayed symptom response.

Further data-
In 2013, a group of researchers in the UK conducted a study looking at the effects of fructose in the gut.2 They were examining the osmotic effect of fructose (how much water fructose moves through the gut) and did this using superior MRI technology. They demonstrated some very interesting findings:
  • Fructose has an osmotic effect, delivering water through the small intestine
  • Fructose has this effect regardless of whether the person has a positive or negative fructose breath test
  • The authors conclude – fructose has an osmotic effect and this does not depend on breath test outcomes
  • Clinical significance – a fructose breath test is not helpful in identifying fructose as a trigger.

This figure demonstrates the increase in small bowel water content (SBWC) seen on consumption of fructose in individuals with a positive fructose breath test (blue) and a negative fructose breath test (red).2 You can see there is no difference. Fructose increases SBWC regardless of breath test outcomes.

Take home messages-
  • Fructose breath test results are not reproducible, i.e. you can have a positive breath test one day, and can have a negative breath test just weeks later
  • There seems to be a poor correlation between fructose breath test outcome (i.e. a ‘positive’ or ‘negative’ result for malabsorption) and the experience of symptoms in individuals with IBS
  • Fructose can contribute to symptoms regardless of whether a breath test is positive or negative
  • The results of this and previous research DO NOT support the use of routine fructose breath tests for the diagnosis of fructose malabsorption or to guide management in people with IBS.

  1. Yao CK, Tuck C, Barrett J, Canale K, Philpott H, Gibson P. Reproducibility of lactulose and fructose breath hydrogen testing and impact on clinical utility. Journal of Nutrition & Intermediary Metabolism. 4:29.
  2. Murray K, Wilkinson-Smith V, Hoad C, Costigan C, Cox E, Lam C, et al. Differential effects of FODMAPs (fermentable oligo-, di-, mono-saccharides and polyols) on small and large intestinal contents in healthy subjects shown by MRI. The American journal of gastroenterology. 2014;109(1):110-9.

Tuesday, 23 August 2016

Being vegan on a low FODMAP diet

By Dr Jane Varney

Are you vegan and following a low FODMAP diet? The combination of these dietary restrictions can make finding nutritious food choices difficult, but as you’ll discover, not impossible. 

A vegan diet excludes all animal-derived products, meaning meat, poultry, fish, seafood, dairy, eggs, animal fats, and honey are all off limits. Vegans instead must rely on plant-based foods to meet their nutritional needs, such as fruit, vegetables, breads, cereals, grains, legumes, lentils, soy products, nuts and seeds. As you can see from this list, many of the foods suitable on a vegan diet are naturally high in FODMAPs, which is why balancing the two dietary restrictions is difficult. 

It is also where the expertise of a dietitian comes in. Unless a low FODMAP, vegan diet is carefully planned, the diet will be deplete of essential nutrients including protein, iron, zinc, calcium, vitamin B12, vitamin D, omega 3 fatty acids and fibre.

So what foods are suitable to eat on a low FODMAP, vegan diet? Below is a brief list. Just remember to check the Monash app for serving sizes and consult with an experienced dietitian about balancing your diet and managing your symptoms.

  •          Milk alternatives: coconut milk, almond milk, hemp milk, rice milk and soy milk (made from protein)
  •          Soy products: Firm tofu, tempeh
  •          Grains: polenta, buckwheat, quinoa, oats, amaranth, bourghul, millet, rice and sorghum flour
  •          Nuts: brazil nuts, peanuts, macadamias, pecans, almonds (1/2 serve), walnuts
  •          Seeds: sunflower seeds, pumpkin seeds, chia seeds, tahini paste (1/2 serve) and sesame seeds
  •          Fruit: bananas, strawberries, orange, kiwi, grapes, mandarins
  •          Vegetables: carrots, broccoli, eggplant, green beans, capsicum, kale, potato, tomato and zucchini
  •          Pulses: canned lentils, butter beans (1/2 serve), canned chickpeas (1/2 serve), red/green lentils (1/2 serve)

Friday, 19 August 2016

Low FODMAP Kartoffelknödel - Potato Dumplings

By Shirley Webber


  • 10 large potatoes
  • 1 cup gluten free flour (any flour you wish to use)
  • 3 eggs lightly beaten
  • ⅔ cup of gluten free bread crumbs (quinoa flakes also work well)
  • 1 tsp salt
  • ½ tsp ground nutmeg
  • 12 cups water
Butter sauce
  • ½ cup butter
  • 2 rashers of bacon, diced
  • ¼ cup bread crumbs or quinoa flakes


  • 10 große geschält und geviertelt Kartoffeln
  • 1 Tasse glutenfreies Mehl (alle Mehl Sie verwenden möchten)
  • 3 Eier leicht geschlagen
  • ⅔ Tasse glutenfreie Paniermehl
    (oder Quinoaflocken ist auch gut)
  • 1 TL salt
  • ½ TL gemahlener Muskatnuss
  • 12 Tasse Wasser
  • ½ Tasse Butter
  • 2 Speckscheiben , gewürfelt
  • ¼ Tasse glutenfreie Paniermehl oder Quinoaflocken 

Serves: 8

Portionen: 8

  1. Place potatoes in a large pot and add salty water until potatoes are all covered. Bring to the boil. Once boiled reduce the heat and cook uncovered for another 20 minutes or until tender. Drain the water off and peel the potatoes.
  2. Mash the potatoes until smooth. Stir through the flour, eggs, bread crumbs, salt and nutmeg. Roll the mixture into approximately 8 balls.
  3. In the large pot bring 12 cups of water to the boil. Carefully spoon the dumplings into the water. Once the water is boiling reduce the heat and leave to simmer uncovered for 15-20 minutes or until the dumplings are cooked. 
  4. Meanwhile, in a small saucepan, heat the butter and the cubed bacon on medium heat. Heat until the butter is golden brown and bacon is cooked. Stir constantly. Remove from heat and stir in breadcrumbs (or quinoa flakes).
  5. Place dumplings in a serving dish and pour over the butter and bacon sauce.

  1. Kartoffeln waschen und in einem Topf mit kaltem Salzwasser bedecken. Zugedeckt aufkochen lassen und bei mittlerer Hitze 20-25 Min. weich garen. Wasser abgießen und die Kartoffeln auf der ausgeschalteten Herdplatte im Topf ausdampfen lassen. Kartoffeln pellen. 
  2. Noch heiß Kartoffeln durch die Kartoffelpresse drücken oder mit einem Kartoffelstampfer sehr fein zerstampfen. Vollständig abkühlen lassen.
  3. Die Kartoffelmasse mit Mehl, Eier, Salz und etwas Muskat würzen. Mischen mit den Händen. Kartoffelteig mit Stärke bemehlten Händen zu 8 Knödeln formen, dabei mit glutenfreie Paniermehl füllen. 12 Tasse Gesalzenes Wasser zum Kochen bringen, die Knödel behutsam hinein geben und nun im leise kochenden Wasser etwa 15-20 Minuten garen. Knödel gut abtropfen lassen.
  4. In einem kleinen Topf erhitzen Butter und den gewürfelten Speck auf mittlerer Hitze. Hitze bis die Butter goldbraun und Speck gekocht. Ständig rühren. Vom Herd nehmen und untermischen Paniermehl. 
  5. Legen Knödel in eine Schüssel und gießen über die Buttersoße.


Tuesday, 16 August 2016

Grain-based foods on a low FODMAP diet

By Jane Varney 

Grain-based foods have been demonised by a number of dietary trends in recent years (think paleolithic diets, low carbohydrate diets and gluten free diets). However, this reputation is ill-earned, with robust scientific evidence to suggest that diets rich in whole grains confer protection against a range of diseases, including type 2 diabetes, obesity, cancer, and cardiovascular disease.

If you’re following a low FODMAP diet, you might feel it’s easier to restrict your intake of grain-based foods as many of them are high in FODMAPs and off limits anyway. Well this is far from true, as there are an abundance of healthy, tasty, low FODMAP grains to choose from. If you’re willing to expand your repertoire and try less traditional varieties, this will provide more choice, as will choosing grains that may be rated red/amber at a full serve, but green (low FODMAP) at a half serve.

Grain-based foods include those made from wheat, oats, rice, corn (maize), barley, sorghum, rye, millet, farro (emmer), freekeh, kamut, spelt, triticale, amaranth, buckwheat and quinoa. Processing greatly affects the nutrient composition of the grain-food end product, with whole grains being nutritionally superior to refined grains. Whole grains are those left intact after food processing and thus contain all three layers of the grain (the bran, endosperm, and germ). By contrast, refined grains are those that have had one or more parts of the grain removed during food processing, e.g. the bran. From a nutrition perspective, choosing foods rich in whole grains in preference to refined grains is preferable as they are more nutrient dense: rich in carbohydrates, protein, fibre, iron, magnesium, iodine, folate, and thiamine.

So which grains are low in FODMAPs? The following is a list of whole grain foods that Monash has tested and found to be low FODMAP at either a full or half serve: 

  • Amaranth (puffed)
  • Bourghul
  • Buckwheat (kernals, flour
  •  Corn (cob, polenta, tortilla, popcorn)
  •  Millet (grain, flour)
  • Oats (whole, quick, oatmeal)
  • Quinoa (grain, flakes, flour, pasta)
  •  Rice (brown)
  • Sorgham (flour)
  •  Wheat (wholemeal bread)

In future blogs, we’ll discover how to identify whether a processed food is likely to contain whole or refined grains and discuss uses of some of the less traditional grains. Stay tuned!

Friday, 12 August 2016

Rote Grütze – Red fruit pudding

By Shirley Webber


  • 200g Strawberries
  • 100g Raspberries
  • 30g Blueberries
  • 20g Cherries
  • 1 Vanilla bean pod
  • 350ml Cranberry juice or red grape juice
  • 2 Tbsp. Corn starch
  • 30g Sugar


  • 200 Gramm Erdbeere
  • 100 Gramm Himbeere
  • 30 Gramm Heidelbeere
  • 20 Gramm Kirsche
  • 1 Vanilleschoten
  • 0,35 Liter roter Fruchtsaft (Cranberry-Saft oder Traubensaft)
  • 2 EL Speisestärke
  • 30 Gramm Zucker

Serves: 4

25 minutes
Portionen: 4

25 Minuten

  1. Wash berry mix, dry and halve the large berries and remove stones from the cherries.
  2. Halve the vanilla pods lengthways and scrape out the seeds.
  3. Stir the corn starch in with 2 Tbsp. of water until smooth and add to the boiling fruit juice.
  4. Stir while the mixture is boiling and add the prepared fruits.
  5. Remove from heat and add sugar to taste. Stir the mixture. Leave to cool.
  6. Remove vanilla bean just before serving.
  7. Fill the red fruit mixture in glasses and serve with lactose free yoghurt and garnish with dark chocolate.

  1. Gemischte Beeren putzen, kurz waschen und große Beeren evtl. halbieren und entsteinen Kirschen.
  2. Die Vanilleschoten längs halbieren und das Mark herauskratzen. Vanilleschoten und –mark und den Fruchtensaft aufkochen.
  3. Stärke und 2 EL Wasser glatt rühren und in den kochenden Fruchtsaft gießen.
  4. Unter Rühren aufkochen und die vorbereiteten Früchte dazugeben.
  5. Vom Herd nehmen und mit Zucker abschmecken. Rühren Mischung. Grütze abkühlen lassen.
  6. Vanilleschote kurz vorm Servieren entfernen.
  7. Die Rote Grütze in Gläser füllen, laktosefreie Joghurt dazugeben und mit dunkle Scokolade garnieren.

Tuesday, 9 August 2016

Alleviating Symptoms Part 4

Stress/Anxiety Related Symptoms
By Shirley Webber

A major contributor to IBS symptoms in some individuals is stress. Many of you will have experienced an increase in symptoms prior to a job interview or a public presentation… We wrap up our series on alleviating symptoms with some tips to help manage this potential contributor:

Stress/Anxiety related symptoms

·         Find stress management strategies to help you through the situation.

·         You might find it helpful to talk to someone – someone close to you, a colleague or a professional counsellor.

·         Exercise can be a great stress reliever for many people and can help relieve your symptoms. Again this doesn’t have to be strenuous - just getting moving can help. 

·         If the stress that you are experiencing is high level and is continuing for an extended period of time then we recommend discussing this stress with your regular GP for extra support strategies.

·         You might also benefit from gut directed psychological therapies such as hypnotherapy and cognitive behavioural therapy.

Friday, 5 August 2016

Potato Pancakes / Kartoffelpfannkuchen

  • 1 kg Potatoes peeled and grated
  • 6 eggs, lightly beaten
  • 6 Tbsp Gluten free flour or your choice
  • 2 tsp Salt
  • 1½ Pepper
  • ¾ cup cooking oil (of your choice)

  • 1 kg Kartoffeln, geschält und gerieben
  • 6 Eier, leicht geschlagen
  • 6 EL. Glutenfreies Mehl (Mehl Ihrer Wahl)
  • 2 TL Salz
  • 1½ TL Pfeffer
  • ¾ Tasse Speiseöl (nach Wahl)

Nutritional information:
Energy: 763kJ or 182 cal
Fat: 12g
Protein: 3g
Fibre: 1g
Nährwert Information:
Energie: 763kJ oder 182 cal
Fett: 12g
Eiweiß: 3g
Kohlenhydrate: 16g
Ballaststoffe: 1g
Peel and grate 1 kg of potatoes. You can use the fine side of a handheld grater or a food processor.

Combine the potato mixture with the eggs, gluten free flour, salt and pepper. Mix well.

Heat 2 Tbsp. of oil in a large non-stick pan over a medium heat.

Using a large serving spoon divide the mixture into 4 potato cakes and place in the pan. Press the potato cakes down to flatten a little.

Cook the potato cakes on a medium heat until the potato cakes are golden brown.

Flip the potato cakes to finish frying the over side until golden brown.

Drain on paper towel and serve warm.
Schälen 1 kg Kartoffeln und raspeln mit der feinen Seite der Haushaltsreibe oder mit der Küchenmaschine reiben.

Die Eier, Mehl, Salz und Pfeffer unterrühren mit der Kartoffelmasse mischen.

2 El Öl in einer beschichteten großen Pfanne erhitzen.
Jeweils 1 größen El Kartoffelteig nebeneinander in die Pfanne geben und etwas flach drücken.

Die Kartoffelpfannkuchen bei mittlerer Hitze braten, bis die Unterseite goldbraun ist.

Die Kartoffelpfannkuchen wenden und goldbraun fertigbraten.

Lassen die Kartoffelpfannkuchen auf einem Papiertuch und dienen warm.

Tuesday, 2 August 2016

Alleviating Symptoms Part 3

Abdominal Pain and Bloating
By Shirley Webber

This week we are highlighting some strategies to manage abdominal pain and bloating that generally occur due to a build up of gas in the intestinal tract. These are the most common IBS symptoms.

·       Often a heat pack placed on the area of pain can help to loosen up the muscles and alleviate some of the pain and discomfort with cramping. A heat pack also allows more blood to flow to the area where the heat is placed and can assist in relieving the cramping.

·       Over the counter medication such as Buscopan or Mintec may help with managing symptoms. Ask your pharmacist what they would recommend.

·       Stretch it out – sometimes a bit of Pilates or yoga stretching can help with relieving some of the gas that is built up in the gastrointestinal tract reducing the pressure on the gut and therefore reducing the pain.

·       Better out than in. If you do have gas then it is okay to let it out. If you’re in a closed environment and feeling uncomfortable to deflate, go for a walk outside or move away from others. Remember gas is a sign of a healthy gut – see a previous blog post on this http://fodmapmonash.blogspot.com.au/2016/02/a-bit-of-bloating-is-beneficial.html