Adventures in Holistic Adult and Child Psychiatry Follow @JudyTsafrirMD
"One only sees what one looks for, one only looks for what one knows." - Goethe
"I did then what I knew how to do. Now that I know better, I do better." - Maya Angelou
FODMAPs + GAPS = ?
Necessity is the mother of invention, or in this case, it was the urgent distress of my patient and her family, which drove me to seek a supplementary approach to the GAPS treatment protocol.
Keiko is an adorable, very bright, not yet 7 year old girl in treatment with me for constipation and encopresis.
The drawing above is Keiko’s rendition of the game CandyLand, which she drew during one of her very early play therapy sessions with me. Study it for a moment. What comes to mind? It reminds me of an illustration of the large intestine. At the distal end it looks like something is being explosively expelled. She informed me that the black squares found intermittently through the path are places where the pieces get stuck.
Keiko is suffering from life long IBS, primarily constipated type, which began in infancy. As a neonate she was treated with broad spectrum antibiotics for a urinary tract infection, and kept in the hospital for 10 days. At the age of 2 months, she began to go 4-5 days between bowel movements. The pediatrician reassured her worried parents that this was just a normal variant, and no cause for concern. Dr. Campbell-McBride links broad spectrum antibiotic treatment with disruption of the ecological balance of the microflora of the gut, resulting in GAPS conditions.
Keiko went on to be chronically constipated and never completely toilet trained. As is the case with so many severely constipated children, stool builds up in their bowel, and then soiling accidents occur, as liquid stool leaks around the hard, dry impacted feces. Her belly was often swollen and distended. She would become impacted and lose interest in food.
Keiko was seen at a clinic specializing in pediatric incontinence, and was prescribed laxatives and stool softeners, which worked initially, but then her body habituated to the treatment, and it was no longer effective. At one point supplementary fiber in the form of bars and gummie bears was prescribed, which only made her condition worse. The necessity of monthly clean outs resulted in vomiting and made her feel very sick. Eventually her parents, uncomfortable with the idea of their daughter being dependent on daily laxatives, decided to seek a more holistic approach, and came to see me.
I recommended the GAPS treatment protocol to treat her constipation, and play therapy to help Keiko integrate all of the difficult experiences she has endured as a result of having this chronic troubling medical condition.
Keiko is a talented highly productive artist, and spends her hours with me drawing and creating stories about chickens laying eggs, cows being milked, and farmers having accidents. Her work is a clear representation of her attempts to make sense of the mystery of anatomy, and all the miraculous processes that go on inside the body, as well as what goes in and what comes out.
This is the way young children communicate and process what is on their mind. They do it through play and drawing. This is technically called displacement. It can be very healing for them to express themselves in this way. It is not necessary for them to put their thoughts and feelings into words, in order for it to be very helpful to them. Keiko does not need to say to me, “I am so confused and in such despair about all I am going through with my pooping.” She can tell me about it with her play. It is as important to heal her physical digestive symptoms, as to help her psychologically metabolize all of the trauma that she has been through, and continues to endure, because of this condition.
Despite strict adherence to the GAPS protocol, with Mother tirelessly preparing all the labor intensive homemade GAPS broths, ferments, and grain free foods, Keiko’s situation has recently deteriorated significantly. Over the February school vacation her constipation became mixed with diarrhea, and she began to have frequent daily soiling accidents. With the advent of school beginning again, something needed to be done quickly.
In the context of this distressing situation, yesterday a reader wrote to me that her IBS has been much improved with a mixture of GAPS and FODMAPs. FODMAPs had been on the periphery of my awareness, but my worry about Keiko’s worsening condition prompted me to investigate it.
FODMAPs is a dietary treatment for IBS. Evidence suggests that up to 75% of patients with IBS will experience relief from symptoms following the FODMAPs diet. The list of foods which are permissible and prohibited are not the same as GAPS.
FODMAPs is an acronym for Fermentable, Oligo-, Di- and Mono-saccharides and Polyols, used to describe a group of fermentable short-chain carbohydrates. FODMAPs are prevalent in the diet and are composed of oligosaccharides (fructans, galactans), disaccharides (lactose), monosaccharides (fructose), and polyols (sugar alcohols). The total amount of fermentable sugars consumed is considered significant, rather than looking at each sugar individually. There is a threshold for the amount of global FODMAPs an individual can tolerate at one time. The fermentation of these short chain sugars produce an osmotic effect, which increases fluid delivery to the large bowel, resulting in gas, pain, diarrhea and/or constipation. Pathogenic microflora in the gut thrive on the malabsorbed sugars and create gas, resulting in abdominal bloating.
Here are some of the foods that contain FODMAPs:
Fructose: Most commonly known as fruit sugar, is also found in honey, high-fructose corn syrup (HFCS), agave, sucrose (table sugar) bound to glucose, and fructans. Fructose-containing foods with a 1:1 ratio of fructose to glucose are generally well tolerated on the FODMAPs diet. Conversely, foods with excess fructose compared with glucose, such as apples, pears, and mangoes, will likely trigger abdominal symptoms.
Fructans: These are oligosaccharides made of fructose molecule chains that are malabsorbed because the small intestine lacks hydrolases to break their fructose-fructose bond. For this reason, fructans can contribute to bloating, gas, and pain. Inulin and FOS, sources of fructans, are added to many foods to enhance their fiber content. Patsy Catsos, MS, RD, author of IBS-Free at Last wrote, “Inulin and FOS are added to foods and supplements precisely because they are fermentable fibers, meant to encourage the growth of friendly gut bacteria. While this makes sense in general, these food additives are sometimes poorly tolerated by people with IBS.”
Galactans: Oligosaccharides which contain chains of the sugar galactose are called Galactans. They can be poorly absorbed by people who lack the enzymes to hydrolyze them into digestible components. Thus galactans often contribute to gas and GI distress. Dietary sources of galactans include lentils, chickpeas, kidney beans, black-eyed peas, broccoli, and soy-based products.
Polyols: These are the sugar alcohols, which have a laxative effect on the GI tract. They are found naturally in some fruits and vegetables and added as sweeteners to sugar-free gums, mints, cough drops, and medications. Polyols produce osmotic diarrhea when consumed in amounts above an individual’s personal limit or when combined with other FODMAPs foods.
I am recommending that Keiko only consume foods which are permissible on both the GAPS as well as the FODMAPs plan. Apparently with FODMAPs, improvement should be seen in 1-2 weeks. If improvement is noted, then Keiko will continue with it for another 4 weeks, and then we can try introducing previously eliminated foods systematically, in order to determine which she can tolerate, and which effect her adversely. I am also going to try it, as I am still suffering from digestive symptoms, which have not fully responded to the GAPS approach.
In my research on FODMAPs, I found a blog by Cassandra Forsythe, which listed foods that are permissible and those to avoid on the FODMAPs plan. There are many allowed carbohydrates on the FODMAPs list, such a certain grains, starchy tubers and sugar which are not permissible on GAPS. Ms. Forsythe sensibly notes that this is not a one size fits all situation, and that each individual will need to customize their own list.
Here is the list:
It is titled Complete Food List for a Happy Gut
FRUITS TO AVOID:
Excess Fructose fruit:
Excess Fructan fruit:
Excess Polyol fruit:
Blueberries – buy organic
Boysenberry – buy organic
Cranberry – buy organic
Grapes – buy organic
Raspberry – buy organic
Strawberry – buy organic
Suitable dried fruits (some people are ok with dried fruits, others are not):
Cranberries (often are coated in sugar – only eat if not sweetened)
Pineapple (often are coated in sugar – only eat if not sweetened)
Raisins (may not be suitable for everyone…)
Special notes on fruit:
Limit intake of suitable fruits to one serve per meal.
e.g. One whole banana or orange.
Third to half a glass of suitable juice.
Small handful of berries or grapes.
Small amount of suitable dried fruit (e.g. 10 sultanas).
VEGETABLES TO AVOID:
Excess Fructose vegetables:
Sugar snap peas
Excess Fructan vegetables:
Artichokes (Globe & Jerusalem)
Onion (brown, white, & Spanish)
Spring onion (white section).
Excess Polyol vegetables:
Broccoli (may not be suitable for everyone…)
Corn (raw corn may bother some people)
Eggplant (this may be troublesome for some; asses individual tolerance)
Lettuce (may be ok or not)
Spring onion (green section)
Squash (this may be troublesome for some; asses individual tolerance)
Tomato (cherry tomatoes often are moldy – try to avoid)
Zucchini (this may be troublesome for some; asses individual tolerance)
Special notes on vegetables:
Onion is one of the greatest contributors to IBS. Strict avoidance is recommended.
• Onion (brown, white & Spanish), Onion powder, White section of spring onion.
• Leeks, Shallots, Garlic.
There is undeclared onion hidden in many processed foods including, chicken salt, vegetable salt, vegetable powder, dehydrated vegetables, stocks, gravies, soups, marinades, & sauces.
• Green part of spring onion
• Asafoetida powder (* contains gluten).
• Fresh & dried ginger, coriander, basil, lemongrass, chili, mint, parsley, marjoram, oregano, thyme, rosemary & others.
PROBLEM WHEAT & Rye products:
Bread (white, wholemeal, multigrain, sourdough, pita, & many rye)
Pasta & noodles (regular, two minute, spelt, egg noodles, hokkien & udon)
Breakfast cereals (containing wheat, excess dried fruit &/or fruit juice).
Savoury biscuits (wheat based)
Cakes & baked goods (wheat based)
Sweet biscuits (wheat based)
Pastry & breadcrumbs (wheat flour made)
Others (semolina, couscous, bulger)
ALTERNATIVES to WHEAT Grains:
Corn (may bother some people)
ALTERNATIVES to WHEAT Products:
Gluten free bread, 100% spelt bread, wheat free rye.
Gluten free pasta, rice noodles, wheat free buckwheat noodles.
Porridge, wheat free muesli, rice bubbles, corn flakes, & gluten free cereals.
Corn thins, rice cakes & crackers, gluten free crackers, ryvitas, & rye cruskits.
Gluten free cakes, flourless cakes.
Gluten free biscuits.
Gluten free pastry mixes, & bread crumbs, polenta, cornflake crumbs.
Buckwheat, polenta, millet, sorghum, sago, tapioca, rice, & corn flours.
Special notes on Wheat:
• Wheat free Rye is tolerable for most (assess individually).
• Small amounts of wheat, such as breadcrumbs, may be tolerable (assess individually).
• Those with diagnosed Coeliac disease should eliminate gluten from their diet.
• Gluten free foods do not contain wheat, rye oats & barley.
o A low FODMAP diet allows oats & barley.
• Trace amounts of wheat ingredients such as soy sauce should not be a problem.
• Many wheat derived products such as wheat starch, wheat thickeners, wheat maltodextrin, wheat dextrin, wheat dextrose, wheat glucose, & wheat color caramel are fructan free glucose chains & should be safe to eat.
OTHER FODMAPs FOODS (containing, FRUCTOSE &/or Fructans) to AVOID:
• Corn syrups
• Corn syrup solids
• Dandelion tea
• Artificial sweeteners (see GOS)
• Sugar free or low carb sweets, mints, gums, & dairy desserts.
• Baked beans, lentils, & chick peas
• Golden syrup
• Maple syrup
• White, brown, raw & castor sugar (sucrose) eaten in moderation.
• Tea, coffee, & herbal teas
• Nuts & seeds (moderation)
• Oat bran
• Barley bran.
• Rice bran.
• Suitable sweeteners (nutrasweet, sucralose, aspartame, stevia, saccharine, tic tacs, minties, regular gum).
• Limit alcohol intake.
• Avoid alcohol which is high in indigestible carbohydrate, such as beer.
• Clear spirits such as Vodka & Gin with water/soda flavored with fresh suitable fruit in moderation is preferable.
• Drink plenty of water.
• Eat in moderation.
• Chew your food well.
• Limit processed foods (hidden FODMAPs & irritants).
• Limit or avoid processed meats ((hidden FODMAPs & irritants).
• Fresh fruit, vegetables, & whole meats/fish are best.
I would be grateful to any readers who would be willing to leave comments about their experience with FODMAPs in combination with GAPS, so that all of us can learn more about how we might make use of these two approaches to heal the debilitating condition of IBS.