Written By Krystal Karalli, PNW Intern, Summer 2022
So far, in our Vegan Low FODMAP diet series (here’s part 1 and part 2, if you missed them), we have covered what the low FODMAP diet is, who the low FODMAP diet is for, how FODMAPs cause gastrointestinal stress, where FODMAPs are found, and how to make a low FODMAP diet vegan-friendly. In this post, we will wrap things up by discussing our favorite resources and recommendations for successfully following a vegan low FODMAP diet and alternative options if the diet fails.
Our Favorite Resources
The following resources provided in this post are those that have been helpful for past clients on their own low FODMAP journey. If you need general guidance on how to navigate low and high FODMAP foods, this app has got you covered. Stanford University created this printout that offers a really good breakdown of the low FODMAP diet, regardless of what diet you follow (please note that meat is included in this list). For a low FODMAP and high FODMAP checklist, Kate Scarlata, RD created two printouts that showcase both low and high FODMAP foods (again, meat is included on these lists as they are not specific to vegan or plant-based diets). Although the resources created by Stanford University and Kate Scarlata are based on both vegan and non-vegan foods, they are still very helpful. If you’d like a 100% vegan printout version, use this list created by Virginia Messina, MPH, RD. Finally, for more plant-based recipes that are low in FODMAPs, check out this website.
Alternative Options if the Diet Fails
Unfortunately, a low FODMAP diet works for most (it has about an 80% success rate), but not all individuals that are diagnosed with irritable bowel syndrome (IBS). There are many reasons why someone may not be responsive to a low FODMAP diet, including an inability to sufficiently reduce FODMAP intake as a result of unknowingly eating high FODMAP foods. On the other hand, some have trouble adhering to the diet as a whole. This is why working with a registered dietitian is crucial, as he or she can help you with troubleshooting when issues arise. Further, not all people diagnosed with IBS are sensitive to FODMAPs, which means the diet may not help in improving IBS symptoms. Another possibility is that you don’t actually have IBS. Conditions other than IBS may produce IBS-like symptoms, including inflammatory bowel disease (IBD), endometriosis, or celiac disease. This is why screening tests are important for ruling these other conditions out before you start any kind of diet-related therapy.
Luckily, if you do have IBS, have worked with a qualified health professional, and haven’t seen success with a low FODMAP diet tailored specifically for your needs, there are a few evidence-based, diet and non-diet approaches that have been shown to help improve IBS-related symptoms.
Other Dietary Approaches
As mentioned in part one of this series, common GI symptoms associated with IBS include lower abdominal pain, diarrhea or constipation (or a combination of both), bloating, and excessive gas. Either increasing or decreasing fiber intake may be helpful in those who are not responsive to a low FODMAP diet. For individuals with a low fiber intake, hard, dry stools, or infrequent bowel movements, incremental increases in slowly or minimally fermentable soluble fiber may be of benefit. Examples of those foods include oats and psyllium husk. In contrast, if your fiber intake is relatively high, a reduction in fiber may be beneficial. There are many different types of fiber out there, with each having its own effect on IBS. Note it would be most beneficial to work with a registered dietitian to make these adjustments.
Fiber supplementation is another option. MONASH University (which is where the low FODMAP diet was first developed) provides specific fiber supplement recommendations for specific types of IBS. Partially hydrogenated guar gum (PHGG), for example, may be well-tolerated and helpful in people with irritable bowel syndrome with diarrhea (IBS-D), although more studies are needed to make a strong recommendation for it. Psyllium husk supplements may be helpful in relieving constipation in people living with IBS-C, although they may not be tolerated by everyone. Again, the use of fiber supplementation should be guided by a qualified registered dietitian or a gastroenterologist because it requires starting at a recommended dose, then making adjustments in dosage.
Stress Reduction
Many times in individuals who have IBS, there is a deep connection between GI symptoms and chronic stress and or anxiety. Psychological stress activates the sympathetic nervous system (SNS), which is commonly referred to as our fight or flight system. When this system is activated, it “borrows” energy from our gut, resulting in changes in the way our gut functions. Activation of the SNS can cause reduced blood flow, reduce movement of food throughout the gut, and heightened gut sensitivity. These changes can cause gastrointestinal symptoms that individuals with IBS often experience, including abdominal pain, bloating, and changes in stool consistency. If someone diagnosed with IBS is chronically stressed, IBS-related symptoms will continue to persist.
There are several evidence-based stress reduction techniques that experts from MONASH University recommend incorporating into your daily routine, including diaphragmatic breathing (also known as belly breathing). This no-cost stress reduction method involves the expansion of the abdomen rather than the chest when breathing. Diaphragmatic breathing does the opposite of what stress does - it activates the parasympathetic nervous system (also known as the rest and digest system), a part of your brain that controls the body’s ability to relax and normalize gut function. Here you will find a short instructive video showing the techniques used for diaphragmatic breathing. There are other stress-reduction techniques recommended by researchers at MONASH University that have shown some benefit in IBS, including progressive muscular relaxation, mindfulness meditation, and biofeedback therapy, with the choice of the stress management technique being dependent on patient preference, therapist availability, cost, and time restraints.
Gut-directed hypnotherapy:
The gut-brain axis is the flow of information that occurs between the gastrointestinal tract and the brain. Experts believe that, in individuals with IBS, there is dysregulation in the gut-brain axis, which is what plays a role in contributing to IBS-related symptoms. This is often referred to as a “miscommunication” issue between the brain and the gut that may be healed through a method known as gut-directed hypnotherapy. With this form of therapy, a qualified therapist uses suggestions, imagery, and relaxation techniques to improve symptoms. Believe it or not, there is strong evidence that suggests this alternative approach is as effective in reducing IBS-related symptoms as using some of the newest medications used to treat IBS and can be equally as effective as using a low FODMAP diet.
Cognitive-behavioral therapy (CBT)
CBT is a type of psychotherapy that has been proven to be effective (with response rates ranging between 25-80%) for a range of problems including depression, anxiety, and alcohol abuse, and is now increasingly being applied to patients with IBS. Think of CBT as another form of psychological treatment, but in its own unique way. It usually involves efforts to change thought and behavioral patterns with a range of diverse strategies and with the guidance and support of a qualified psychologist. There are various forms of CBT and it may be combined with other stress management techniques, such as mindfulness.
.Probiotics
Probiotics are defined as ‘live microorganisms that, when administered in adequate amounts, confer a health benefit to the host”. Basically, they are the “good bacteria” that naturally live in the body but can also be consumed as a supplement. Recent evidence shows that the gut microbiome (which is basically the trillions of bacteria that live within your gut) may actually play a role in the development of IBS. In fact, the microorganisms living within our gut may influence IBS symptoms, with lower numbers of specific bacteria being associated with higher pain scores in IBS.
As far as the use of probiotic supplements in the treatment of IBS-related symptoms (and without co-existing diseases or conditions), most evidence suggests that probiotics are safe, but are they effective? Different health organizations have different views on the use of probiotics in IBS. The American College of Gastroenterologists, in a recent conditional statement, recommended against the use of probiotics in individuals diagnosed with IBS. Yet, a systematic review and meta-analysis (two gold standard methods of scientific analysis) of fourteen randomized controlled trials testing the use of probiotics in patients with IBS found a modest improvement in overall symptoms.
Further, a 2021 report made by the British Dietetic Association states that the use of probiotics can be used as the first line of therapy for IBS. There have been studies to show that probiotics can be safe and effective, but there just isn’t enough scientific data to recommend a specific strain at this time. They advise that, if probiotics are to be used, one does so for a minimum of four weeks and only as long as 12 weeks. It may take time to see benefits, however, at least 3-4 weeks. If symptoms do not improve, then supplement use should be discontinued. Here are the recommendations made by MONASH university when it comes to probiotic us:
Trial 1 probiotic product at a time
Probiotic supplements should be taken regularly – benefits are not permanent and are lost within days if you stop taking a probiotic
Consider other ingredients in probiotic products – synbiotics (mixtures of prebiotics and probiotics) often contain FODMAPs, such as inulin or FOS. These may be poorly tolerated in people with IBS
If you have tried the low FODMAP diet and you are not seeing results within 2-6 weeks, taking a probiotic is an option. If you are interested in taking a probiotic, it’s best that you work with a gastroenterologist or a registered dietitian to find one that suits you. If you are curious, the Alliance for Education on Probiotics created a clinical guideline for Products Available in the U.S., which summarizes the latest research on probiotics available in the U.S., with specifics on probiotics that can be applied to IBS symptoms.
Wrapping Up
As you can see, there are diet and non-diet approaches to improving IBS symptoms with alternative options if either form of therapy fails. Note that there is also a wide range of pharmaceutical drugs used for specific subsets of IBS. A gastroenterologist and registered dietitian can work collaboratively to determine the best treatment option(s) that work best for you.
We sincerely hope that we have provided enough information to make you feel more confident in your healing journey. Please feel free to reach out if you have any additional questions. Till next time!
