A low FODMAP diet can help with IBS and the gas, bloating, abdominal pain and bowel irregularity that occur in IBS. We have previously discussed how a low FODMAP diet can heal your intestines by normalizing intestinal cells, like intestinal serotonin cells. Today we speak with a researcher who has been publishing these findings. This is an extremely interesting episode which helps cover:
- understanding how the low FODMAP diet works
- when to use the low FODMAP diet
- who might want to avoid the low FODMAP diet
- special modifications to make if you have IBS with constipation
A must listen/read.
Dr. R’s Fast Facts
- He has been researching effects of the low FODMAP diet in IBS
Do you need to combined a Low FODMAP and Low fat diet in order to have results?
- No, but it may help some. Dr. Mazzawi’s research showed that FODMAP reduction was most important
Impact on serotonin
- Low FODMAP diet found to normalize enteroendocrine cells (serotonin) in those with IBS
- Serotonin helps with GI motility and dampening pain signaling
- Somatostatin and Peptide YY (PYY) also normalized – both involved in motility also
- Thus, a low FODMAP diet could repair/improve gut motility
Impact on the microbiota?
- Bifidobacteria (good bacteria) shown to reduce on a low FODMAP diet – a probiotic could prevent this
- Short chain fatty acids (SCFAs) may reduce also, but this might not be a bad thing
- R notes: many with IBS have high levels of SCFAs
- You can take probiotics while on the Low FODMAP diet
- The Low FODMAP diet is meant to be temporary (4 to 6 weeks) and used as a guide to add food back in
- Best to have someone guide you (physician or nutritionist)
Concerns about ‘diversity’?
- In our clinical newsletter we summarized a review paper that found insignificant impacts on diversity
Any other therapies that could achieve this?
- Fecal microbiota transplant appear to also, help with IBS
Who should not use a low FODMAP diet?
- Constipation might become worse on a low FODMAP diet
- Special modification for those with constipation
- Using a non fermentable fiber and/or a soluble fiber might offset this. Or using magnesium or vitamin C
Can testing indicate when to use low FODMAP diet? Breath testing?
- One paper showed a microbiota analysis could predict those who will respond to a low FODMAP diet (reference not available)
How to apply the Low FODMAP diet
- Find a physician who is willing to spend some time with you
- Find a nutritionist who you can met with on a consistent basis
- Be very specific with your doctor when answering questions
Where to find more about Dr. Mazzawi
You can find him on Facebook and find his studies online at Pubmed.com
Dr. Ruscio provides more information about Low FODMAP diets in his new book Healthy Gut, Healthy You which is available for purchase now.
In This Episode
Episode Intro … 00:00:41
About Low FODMAP Research … 00:02:10
Impact on Serotonin … 00:08:15
Impact on the Microbiota … 00:18:00
Concerns About ‘Diversity’ … 00:23:40
Any Other Therapies That Could Achieve This … 00:25:41
Who Should Not Use a Low FODMAP Diet? … 00:29:35
Testing … 00:36:10
How to Apply The Low FODMAP Diet … 00:39:51
Episode Wrap-Up … 00:48:31
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Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today, I am here with Dr. Tarek Mazzawi and he has published some research I find fascinating regarding the low-FODMAP diet and how it affects IBS and intestinal cells in IBS.
So I’m very excited to pick his brain. And, Tarek, just welcome to the show and glad to have you here.
Dr. Tarek Mazzawi: Thank you for having me on the show.
DrMR: Can you tell people a little bit about your background in training before we begin?
DrTM: Well, I am a medical doctor, graduated from Hungary. And then moved to Norway, started working in a hospital called Stord Hospital. And there, I started my internal medicine internship and fellowship in gastroenterology with my supervisor, Professor Magdy El-Salhy, where we started the Ph.D. research project and then moving forward to the university hospital in Haukeland, Bergen, Norway. There, I continued the research and did the dissertation for my Ph.D.
DrMR: Fantastic. Fantastic. So definitely, you’ve got an area of specialty that is very in alignment with our audience. And I believe the first of a few papers that you published that I read was entitled “Effect of diet and individual dietary guidance on gastrointestinal endocrine cells in patients with irritable bowel syndrome – a review.” And I found that just fantastic. And I definitely want to get into some of the details of your research.
About Low FODMAP Research
But before we get into the details, can you tell us a little bit about some of that research in IBS with low-FODMAP diet that you’ve been conducting?
DrTM: Yeah, absolutely. Well, you know that irritable bowel syndrome, which we shortened as IBS, is a very common chronic gastrointestinal disorder, which affects around 20% of the western population and it’s even a global problem now. And the people that complain mostly for what they eat and how short and how fast it can act into their bowel system. So there has been a new diet. Actually, it’s like some years ago that it has been developed, which is called low-FODMAP diet. And FODMAP is shortened for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols. And these are kind of carbohydrates which, in a way, fully absorbable after they have been fermented and they don’t get absorbed very well. They get stuck into the colon where the microbiota in the colon will eat them up. And as I usually joke with my patients, I tell them that the microbiota, which are the good bacteria in our colon, when they get these kind of carbohydrates, they get wild and fired up and they make a barbeque and they release lots of gases in the bowels. And this will give the distension and pain. And then they will change also the osmotic pressure in the bowels and that will cause the diarrhea or the influx of fluid into the colon.
So, it’s a new approach. And we try to do it on our patients and see how it affects their symptoms and how fast. And we follow them up for nine months with—a specialized dietary nurse follows the patient in different sessions—three sessions, actually—and see how it affects the patients. And then we went further on to see the mechanisms behind these effects, mainly the endocrine cells of the gut.
DrMR: Got you. Now, I want to get into the specifics on the mechanisms. But there was just one clarification I was hoping that you can make. Because in some of the papers, it appeared that you are also calling for a low-FODMAP and a low-fat diet. And I was just curious if you felt that a low-fat along with low-FODMAP diet was important to see some of these results or a low-FODMAP diet alone would suffice?
DrTM: The common issue here is that you have to tell the patient what they should eat. And our diet, it consists of carbohydrates, proteins, and fat. And not only the carbohydrates affect the symptoms of IBS, but also fat. Because fat, when it gets trapped into the intestinal system, it causes bloating because usually fat is totally absorbed in the small intestines. And this is the main thing that the hormones of the gut work on, for example, the peptide YY, it gives the breaking system of the small intestine so that all the fat is absorbed in the small intestine, nothing gets into the colon. So it’s very important to also say that fat is a factor in the diet and management of IBS. To reduce it or to reduce the amount of fat consumption also helps into the symptoms based on its mechanisms on the bowel.
In my research, we have given a general advice to the patients on consuming couple of days of high carbohydrates and then couple of days of low carbohydrates and then register their symptoms; and the same with the fat and protein amount in their diet. And what we registered was that the significant reduction in these dietary elements was registered for the carbohydrates, in my research. They did not have a significant reduction in the fat. That doesn’t mean that fat was not important, but my patients or the cohort of patients that we have used have not shown significant decrease in the fat amount in their diet. However, carbohydrate diet or the low-FODMAP or the—let me say in a better way, the FODMAP constituents of their diet was lowered after dietary guidance that resulted in the improvement on their symptoms. So fat is important as well.
DrMR: And I think that that probably resonates with many of the listeners, whether the listener be a clinician or a patient. And I’m just basing that on what I’ve observed in the clinic myself, where some patients are very, very carb sensitive. But they can eat high amounts of protein and fat and they feel okay, but it’s really the carbs that irritate them. There is a subset in my observation. I would say a smaller subset of patients that are fat sensitive and they do better on a lower fat, kind of higher carb diet. My personal experience seems to somewhat reflect that.
DrTM: IBS is very heterogeneous. It’s not a homogeneous group. You cannot find similarities between the patients. Everyone has somehow a little bit different profile than another patient. So you have to give advice based on the general idea that we have and then you go deeply as you know more your patient and you know what they relate to as a cofactor to their symptoms.
Impact on Serotonin
DrMR: Yeah. I think that’s very well said. So let’s talk now about some of the specific changes that you’ve noted. And the two that really struck me were—well, the one mostly was the normalization of serotonin cells after a low-FODMAP diet. So can you talk about some of the changes that happen in the intestinal cells and what that may mean for people with IBS?
DrTM: Well, let’s talk just a little bit about the enteroendocrine cells. These are specialized cells in the epithelium of the whole GI tract. It consists around 1% of the cells, epithelial cells. If you gather them all together, they can cover your thumb. That’s how much they are in the GI tract. And these cells are very specialized. They have microvilli, which sense the luminal contents in the GI tract like food and chemicals. And then they react upon this sensation and then they release their hormones, which affect and regulate the functions of the GI tract. So they are the little brain of the small intestine and the large intestine and the rest of the GI tract. And they release their hormones and these hormones will go to the enteric nervous system and then give the signals up to the brain and the brain reacts to it and it gives a feedback.
There are many cells according to the types of the hormones they release and the most important things in the ones that we have studied were the gastrin, ghrelin, secretin, cholecystokinin, gastric inhibitory peptide, oxyntomodulin, peptide YY, serotonin, and somatostatin. And serotonin, it stimulates the GI tract motility and it is involved also in the sensory motors, pain sensation in the GI tract. Each hormone has its own distinctive function. All of them, they relate to each other. They communicate with each other and they affect each other. Either the lower part of the GI tract or the upper part of the GI tract, they all talk to each other and communicate all the time.
And in case of serotonin, it covers the whole GI tract. Both serotonin and somatostatin, these are the two that covers the whole GI tract. Serotonin, the densities of these cells were found to be very low in the GI tract of IBS patients. And when we have conducted this research, first, my previous mentor, Professor Magdy El-Salhy, he was the one who first started with studying the endocrine cells in the population of IBS patients and he saw that the densities were low using immunohistochemistry. He proposed a hypothesis, is it true that irritable bowel syndrome could be an organic disease? And he published a paper about it. And then he’s listed many of these cells, which are abnormal in their densities, and then we thought that we should test this, should these cells’ densities change after these symptoms have been better in these patients of IBS after conducting a sort of treatment or management or not? And then we use the low-FODMAP because, these cells, they interact with the nutrients in the lumen of the GI tract. And then we saw that the densities of the serotonin in many parts of the GI tract changed after a patient has consumed a lower amount of FODMAP. These changes were changing towards the densities measured for the healthy individuals.
DrMR: So, essentially, the cells in the intestines in patients with IBS changed to be more like that of healthy controls after being on the low-FODMAP diet, is that correct?
DrTM: Correct. The density, so the amount of cells per like a cubic millimeter has changed after the diet.
DrMR: Now, do you feel that the changes are significant? And I guess I’m asking that both—was there shown to be a statistical significance and do you feel like there was a clinical significance to these changes?
DrTM: Well, yes. In many parts of the GI tract, these cells have had significant changes. For example, in the small intestines, the duodenum in the colon, these cells had a significant change. And you can translate it—this could be translated on the symptoms. In one of my papers, the first one, actually, that I have published in 2013, the effect of dietary guidance on the symptoms, quality of life, the habitual dietary intake of patients with irritable bowel syndrome, in that paper, which is published in the molecular and medicine report, it showed that the symptoms have changed. Specifically, the pain symptoms have significantly become less in these patients after receiving dietary guidance.
When we’re talking about serotonin, serotonin is involved in the pain sensation and also on the motility. And in this paper, we show that the symptoms of both diarrhea and the pain have significantly improved after executing the dietary guidance. So that gives us an idea that there was a relation between these two.
DrMR: Well said. That’s exactly what I was after. One of the remarks I have to make in the show is that it’s very important to tie a mechanism to a clinical outcome. And so, of course, it’s exactly what you just answered, where the mechanism also correlate with the clinical outcome and that kind of brings this full circle to something that I think is very important to then be brought into clinical practice and to act on. So, fantastic answer.
DrTM: Exactly. Unfortunately, we haven’t had any—we haven’t done the correlation statistics due to the amount of the patients. But, of course, we do tend to have like a bigger cohort of patients, a bigger amount, just to clarify this issue and to reproduce the results.
DrMR: So, you’ve already alluded to this. But I want to ask this question directly, just in case there’s anything you would add or elaborate on. Can these changes, and I think more specifically, the normalization or the increase in the density of the serotonin cells, could that lead to an improvement in gut motility? Because that’s a underlying factor that may be responsible for SIBO and I know our audience is very interested in that. So how do you think this may impact one another or connect?
DrTM: Well, the thing is that you cannot say that only one hormone was involved. That’s why we studied all the hormones. The other hormones, which are important, are somatostatin, an inhibitory for the motility. And the most important one was the peptide YY, because the peptide YY hormone is considered the ileal brake. It’s a hormone which is released when food comes to the intestines, for example, to the duodenum or to the jejunum, and then it will be released so that it gets it to slow down. Slow down the motility so that the system would have time to digest and absorb and consume all the nutrients, which are important for the body. In this case, having said that, so you have to look at all these hormones and see how the changes have happened to the different cells in this same patient to give the bigger picture of motility.
Yes, it could be that serotonin changes—and the densities of serotonin cells and PYY, together, have collaborated to improve the motility in these patients. And this could be seen on the improvement of their diarrhea and constipation.
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Impact on the Microbiota
Now, what about the impact on the microbiota? And this is something that, in the US, sometimes, unfortunately, patients are afraid to go on a low-FODMAP diet because they’ve heard that it may have a negative impact on your microbiota. And that’s not something I would fully agree with. But before I offer my thoughts on this, what are your thoughts on the impact of the microbiota and/or microbiota diversity?
DrTM: Right. Well, the microbiota now is the hot topic of the GI field, of gastroenterology. And we have had a research in Haukeland University Hospital by the research group that I’m working with, led by Professor Trygve Hausken and Professor Gülen Lied Arslan, where they have studied the effect of low-FODMAP on the microbiota. True, as it is known from before, that low-FODMAP affects the microbiota. It reduces the amount of the good microbiota, which are specifically the Bifidobacteria and the Actinobacteria, which is the bigger family of the Bifidobacteria.
And the Bifidobacteria, these are important for the energy and for the health of the colonocyte because these are the ones which eat up the carbohydrates and produce the short-chain fatty acids, the butyrates, for example, butyric acid. And butyric acid is very important for the energy and for the buildup of the colonocytes. Having said that, the new probiotics, the tablets, which are a combination of different gut bacteria, so the gut bacteria like the Lactobacillus, the Bifidobacteria in these tablets which the patient can’t consume while being on low-FODMAP.
The thing is that you should not look at low-FODMAP diet as a diet forever. It is considered lifestyle change. Meaning, the same way that you tell your patient don’t eat too much salt so that you don’t get hypertension. This is a way of management that you guide your patient to have an understanding that there are certain food elements that your system reacts to. So the first thing that you should do in this low-FODMAP diet is to consume less amount of it or eliminate it, for example, four to six weeks as we say here in Norway.
And then after that, you start to reintroduce these elements in small quantities. Because the patients of IBS are very different from each other, different people react to different amount of FODMAP and different types of FODMAP. Meaning, for example, when you eat onion, onions include different types of FODMAP, which are different in the types and the amounts than broccoli, than cauliflower, than wheat. So all of these has to be taken into consideration.
You tell the patient, “Okay, try to eat—when you reintroduce, try to eat one piece of white bread or loaf bread and see how it goes. If it goes well, then that’s good. Then after couple of days, you increase two pieces. If it goes well, then fine. If it doesn’t go well, then you know that your limit is one piece of bread that your bowels tolerate and that’s it.” That’s what I mean by a lifestyle change because you don’t have to starve and you don’t have to restrict yourself from eating things that you like. But you have to be cautious to the amount that could affect your symptoms and try to have an understanding, a general understanding of this diet, because we have shown in our research that using low-FODMAP over long time would affect the microbiota.
Okay, we have pills that cover these bacteria. But nothing is better than the natural sources, which are the prebiotics, which are food. The trick is to have a good understanding of how to use this diet and for how long and how to reintroduce to the amount that your system tolerates it. And, of course, a good persistent physician or a nutritionist who would follow-up the patient regularly so that the patient also would have a comfortable sense of belonging and a good follow-up from their healthcare practitioners.
DrMR: Absolutely reasonable. And probably the best way to use this diet, use it in a short-term more strictly and then try to reintroduce and identify where your boundaries are.
DrTM: Absolutely. That’s a good summary. In Norway, we say use it for four to six weeks and then you start reintroducing. But it’s best to have someone to monitor because the patient, alone, would most probably fail—or not fail, but the good word is adhere…Would fail to adhere to that diet because sometimes it could be difficult without guidance.
Concerns About ‘Diversity’
DrMR: Sure. What about diversity? There was recently a review paper that was published and we reviewed this in our clinical newsletter that essentially found inconsistent information regarding the impact on diversity. One paper showed no change in alpha nor beta diversity. Another paper found something very similar. One paper did show a decrease in diversity. One paper even showed an increase in diversity of healthy strains of bacteria.
So I, personally, am not overly concerned about impacts on diversity especially if you’re trying to only use a low-FODMAP diet to the degree to which you need to use it. What are your thoughts about diversity?
DrTM: Well, low-FODMAP does affect the microbiota even from the first weeks. We have seen that in that research that has been done here that within three weeks, the low-FODMAP diet led to a lower amount of Bifidobacteria and the general Actinobacteria. So the thing is that how long would this affect—what is the effect on the long run? Nobody knows. But, sure, the diversity in between the research articles could be related to how the research was conducted, the amount of patients, what are the methods that they have used, and which kit they have used between centers. This is something which is not really clarified yet, it’s a new field.
And, of course, everybody will have different results. But the general idea is there that low-FODMAP does affect the microbiota. You should either tell your patient to, if they would like to stay on it for a long time, then do consume the probiotic tablets, which include millions of these bacteria just to cover the lack that you are going to have from this diet.
Any Other Therapies That Could Achieve This
DrMR: Sure. So what about any other therapies that could achieve this reparative, if I can use that term, reparative impact on normalizing some of these intestinal cells? Have you seen any other diets or any other therapies that may lead to the same type of change?
DrTM: Well, yes. Currently, I am conducting another research, which is involving using fecal transplantation from healthy donors to patients and studying how would this affect the symptoms of the patients and the microbiota and the endocrine cells. And I could tell you from now that enteroendocrine cells just react to food but also do react to microbiota changes. And we have seen that the densities of these cells have changed towards the healthy donors in the patients who have received fecal transplantation.
DrMR: One of my general posits, albeit a bit broad, is that things that are healthy for the gut will probably help repair the intestinal cells and intestinal motility. Because one of the factors that prevents things like the interstitial cells of Cajal from repairing and regenerating is inflammation or irritation in the gut. And so it would stand to reason that if you undergo an intervention that reduces inflammation or irritation or, to use a more scientific term, oxidative stress in the gut, it would make sense that you would allow healing to occur. So it doesn’t surprise me that something like a fecal transplant that is usually accompanied by an improvement in symptoms would also lead to a normalization of some of these cells.
DrTM: Absolutely. But this is totally new. Nobody knows the mechanisms behind it yet. We are studying the mechanisms behind it. And, of course, the effect on the general symptoms is also being studied. And there are several papers now out that have shown that fecal transplantation does help in improving the symptoms of IBS, which is in a fast, in a rapid way. However, it doesn’t cover 100% of the patients. But a good amount percentage are having good effect with this, yes.
DrMR: What was the general response that you’ve seen? I’ve seen in some of the published papers between 30% and about 50%, roughly speaking.
DrTM: Yeah. In Norway, there are two research groups that have done it. One is my group like the group that I am working with. And another one, which is up in north middle Norway, and they had their paper published recently. And they had up to 65% response rate. In my group, we had up to 75% response rate in the beginning. But towards the end, after like seven-month follow-up, it was reduced to 65%. So this effect is not everlasting, it reduces with time. And this shows that these cells, these bacteria, they do regenerate, and they do change, and they do go back to their old habits. And then we have to think how we can reintroduce again and see the effects, if it is going to stay or if it’s going to be in a reducing fashion along with time.
Who Should NOT Use a Low FODMAP Diet?
DrMR: Sure. That’s great to see that your results are that high. What about prokinetic agents, have you done any research with these, found any maybe similar impacts?
DrTM: No, not yet. But we do use prokinetic agents in the clinic. In our university hospital, we do lots of motility studies. Starting from the stomach, we have the functional dyspepsia motility studies where we measure using ultrasound—and I have also submitted a paper about that—using the ultrasound, how we can use the ultrasound to measure the stomach after low or high caloric meal. And you can see how the motility of the stomach changes according to the colors of the meal and you can measure it. And it gives you an idea about the functional dyspepsia.
And also, we have another physician who is using another method, like using what we call the SmartPill, which goes through the intestine and it measures different parameters including the motility of the GI tract. And based on these results, we can introduce the patient to the prokinetic agents like metoclopramide or sometimes we use erythromycin if it is in the upper part of the GI tract. And if it is problem with, for example, constipation, then we use the agents which are specific for the constipation like—I don’t know if I’m allowed to say the generic name.
DrMR: Yeah, that’s fine.
DrTM: Like Constella or Resolor. These are the ones that we use for constipation. And for the diarrhea, we have the new one which is called Truberzi to be used for IBS diarrhea. I do not usually go to these three types of medications unless the patient had had no benefit of low-FODMAP for diarrhea type of IBS or basic drugs for constipation like lactulose and all these—yeah, correct. Because you have to start with the basic and then you have to add up to the treatment. And these, as I call it, three ones, are the big guns that we have that we reserve until the last.
DrMR: So shifting gears back to the low-FODMAP diet for a moment, in your observation, is there anyone who maybe you should not or at least be careful with the use of a low-FODMAP diet, for example, something I see sometimes is constipation will get worse. So if someone comes in with constipation type IBS, then we’re hoping that the low-FODMAP diet will help with bloating and abdominal pain, but they also have constipation. Sometimes they come back in and their bloating and abdominal pain are better or their constipation is a little bit worse from the low-FODMAP diet. Are you observing anything like this where people should be careful?
DrTM: Yes. We have the same kind of observation because low-FODMAP, you eliminate the reasons why you get bloated. And the reason why you get pain is because there’s too much gas in your bowels, which will stretch on the walls of the bowel. And this will fire too many serotonins as we have spoken and then will activate the pain sensors in the brain. And when you use low-FODMAP, then you reduce the gas in the bowels and then you would have less pain. But however, the osmotic pressure, the osmosis, usually when it is diarrhea, is the one that is most effective in low-FODMAP.
In case of constipation, then you have to take care of what kind of fibers are they using, because water-soluble fibers are the ones which are good for the constipated people. The water-insoluble fibers, these are the ones which can worsen the symptoms of IBS patients. So you have to cover the dietary management from all angles. So it’s not just the carbohydrates and the fats, but it’s also the fibers, which play a very important role in this.
Of course, sometimes the effect of low-FODMAP in the general population is up to 70%. So you have 30% who do not respond to it. And it’s not to all the types of IBS, so you cannot use it solely as a treatment, you have to have additional tablets to—laxatives to just help the patients with the constipation symptoms.
DrMR: Yeah. And sometimes we’ll use a fiber supplement along with a low-FODMAP diet if we’re working with IBS constipation type of patient or simply use some magnesium or some vitamin C. So it doesn’t have to be—
DrTM: Magnesium, yeah.
DrMR: It’s not necessarily the hardest thing to get around because there are a lot of good therapies there fortunately.
DrTM: Right. You just start with the simple ones and then you just build up upon it. You don’t have to go straight to the big guns, as we call it here, the Constella, the Resolor, the prucalopride and the other ones. So you start slow.
DrMR: Not using the top-down approach, exactly.
DrTM: Yeah. You start slow and then you go up with the management.
Dr. Ruscio Resources
Hey, everyone, this is Dr. Ruscio. I quickly wanted to fill you in on the three main resources that are available to you in case you need help or would like to learn more. Of course, I see patients both via telemedicine, via Skype, and also at my physical practice in Walnut Creek, California.
There is of course my book, Healthy Gut Healthy You, which gives you what I think is one of the best self-help protocols for optimizing you gut health and of course understanding why your gut is so important and so massively impactful on your overall health.
And then finally, if you are a clinician trying to learn more about my functional medicine approach, there is The Future of Functional Medicine Review, which is a monthly newsletter. Which is a training tool to help sharpen clinical skills. All of the information for all three of these is available at the URL drruscio.com/resources. That’s D-R-R-U-S-C-I-O. And in case you are on the go, that link is available in the description on all of your podcast players. Okay, back to the show.
So what about testing to indicate who might respond well to a low-FODMAP diet? Of course, breath testing is something that I’m curious if you’re doing and noticing any correlation between SIBO findings and breath testing or any other tests that might predictive?
DrTM: That’s a good question. But you caught me on a very sensitive issue here. Because last year, on the United European Gastroenterology Congress in Vienna, a Swedish researcher has received—I don’t remember his name unfortunately but we can look it up. He received an award because he has developed or he has written a paper about predicting who are the patients who are going to benefit from the low-FODMAP diet.
DrMR: Right. It was with the microbiota analysis that he was running to show a predictive pattern?
DrTM: Yes. This is something that you can use to predict who are the ones who could benefit from a low-FODMAP diet or not. And this is something which is new and we haven’t started with it yet but it’s a very good idea. Because we have the same company here in Norway that does these analysis and it’s very easy to read on everywhere.
DrMR: Is this the GA-map test?
DrTM: Yes. The GA analysis, yeah. It’s the same as the 16S rRNA sequencing. The sequencing stops a little bit before, I mean, how am I going to explain this? The 16S rRNA, this sequence is the whole rRNA of the microbiota. But the GA analysis they do the same sequence but they cover lesser probes. So they cover a good amount or a good spectrum of microbiota types and subtypes but it’s a little bit shorter than the original 16S rRNA sequencing.
So one can use the original 16S rRNA sequencing but this one takes time and I don’t know how about the expenses of it. But the GA analysis, they can produce the results in a couple of weeks and they are not so costly.
DrMR: It’s something that I’ve been thinking about using in the clinic is the GA-map. For the audience, this is different than a popular test that we are also actually use in the clinic called the GI-map. This is a different test. The GA-map, I believe, is out of Norway. And we’ve been thinking about using it, however, when I factored in what the shipping might cost and some of those logistics, I figured that it might be easier for a patient to do a two-week mini experiment on the low-FODMAP diet rather than going through—doing a sample, paying for international shipping and waiting for the results. But it’s definitely something that I find an interesting test and I’m hoping it’ll be more accessible here in the States soon.
DrTM: What is the GI-map that you have in the States?
DrMR: It’s by a completely different company, by a company called Diagnostic Solutions. And I mainly use them for pathogen detection, not a microbiota analysis. They do offer that. However, I don’t know that their—they don’t have the same validation as has been found in the GA-map test, and that’s what I’m really curious to start exploring.
How to Apply the Low FODMAP Diet
Just two more questions I want to ask you as we come to a close. I guess let me ask you what might be the longer one of the two first. I know you felt there were some important lessons for how to successfully apply the low-FODMAP diet. And I know that that question in and of itself might take a whole podcast to answer. But are there any kind of main takeaways for tips or for tricks for people to successfully apply the low-FODMAP diet?
DrTM: Well, the first important thing is that you find yourself a really nice physician who has good amount of time to spend on you or a nutritionist who is dedicated for that. Because the main trick for good adherence is to have good follow-up pattern. First, you have to have the introductory session where you get the general information about irritable bowel syndrome, what does it mean, and what’s the causes, and how can you generally manage it, and that it’s not a severe disorder that you’re going to have complications from, except that your quality of life and the symptoms that you’re suffering from are the main issues here. You’re never going to have cancer or die from it. When you cover this, then the patients usually calm down, relax, and can follow you until the end, because you eliminate the anxiety factor and the negative thoughts that they have.
And then you jump to the second session where you talk about—because you cannot give all the information at one point. The second session then you dedicate it for the low-FODMAP diet. You talk about it, you explain what does it mean and how long are we going to use it and the side effects that you’re going to have from it, what other things you can do to improve the symptoms. You give the patient the tools how to execute this diet, methods to use like dietary book that they can write their symptoms after each element that they have eaten. And then you can tell them that it’s important that you eat regularly and a small amount of food regularly every three hours, for example, to keep the bowels going and to go train and walk a lot so that the bowels can also move along with your body. And then you give them time to try this low-FODMAP. And then you should follow them up after couple of weeks to see how they are maintaining. Are they holding? Are there any questions that they are wondering about? What are the problems that they are facing?
In our hospital, we give them like papers about low-FODMAP that we have written ourselves in the hospital. We don’t refer them to buy any book from outside because we control the information and we are held responsible for the information that we give, so that the patient should follow what we give them. The recipes, we provide some recipes towards the end of this information file; what can they eat for breakfast, how can they make food for lunch and dessert and all that stuff to make their life a little bit easier. And we follow them up either from the nutritionist or the general practitioner or we do it ourselves depending on the time. But if you are a practitioner as yourself, then you can follow up your patient once a month or after they have—or every two weeks in the beginning and then once a month afterwards to see how it goes. And when they are fine, then you have succeeded. The important, key message here is follow-up because the patient is very reliable on the physician or the nutritionist to answer all the questions and any doubts executing this dietary management.
The other things that we have also, we have something which is called the IBS schools, which is like a group of people which meet, have the same symptoms and then they meet over a two-day course, where they get lecture about the IBS and the management of IBS; talking to the gastroenterologist, the nurse, nutritionist, either psychologist or psychiatrist where we cover all the elements of IBS. And this is another approach, which also has strong, good results, and we offer both of them to the patients. In the beginning, probably, the patient would like to have a head to head individual talk with the health personnel. But later on, it’s good if they see that others are suffering the same problem and that they could share their problems together with other patients and the different types of health personnel.
So this basically summarizes how you can manage these patients. It’s very good to be open. It’s very good to let them feel comfortable. Sometimes when I have my patients coming to me, we talk very open. I ask them flat out about the color, the smell, and the consistency of their stools and all that stuff. And then they feel embarrassed—they feel embarrassed and when they see that I am not embarrassed and I’m genuine, then they totally relax and then they just open up. Some people know the Bristol stool scale and I would like to comment on yours. I like it on your desk. I have it in my pocket, so I take it out and I tell them, show me, which one is your stool?
And this is the other thing. When I say diarrhea, you have to be careful, me and you, we are health personnel. When we say diarrhea, we know it is the consistency and the frequency. For them, the patients, sometimes they mix up. It could be the consistency, but not the frequency or vice versa. It could be the frequency but not the consistency. So the terminology does not always fit. So you should always be specific, a little bit more detailed.
Other things that’s very important, not to stigmatize all the patients with IBS, IBS should be the last diagnosis you give. You cover all the first ones like celiac disease and side work could be if they are operated upon or if you see differences in their blood test like low vitamin B12, high folic acid, and the serum, and the history of operation. You should cover if they have undergone cholecystectomy because bile acid diarrhea is very common after these patients and they become obese. They exhibit very similar symptoms to IBS and their treatment is very easy, which is just to give them cholestyramine and you’re done. It is very important thing that you should consider. You should consider IBD and you should consider cancer. If they have sudden change in their bowel motility and like a little bit of blood in their stools or if they can’t see it, then you take like a occult blood tests and you should cover all of this before reaching to the IBS diagnosis. Very important not to stigmatize each patient you see with IBS. And of course, you have to keep in mind the thyroid problems.
DrMR: Well, you just offered a lot right there. And I think it’s very sage advice to make sure, as I always recommend to my patients and on the podcasts, that if you’re working with a natural minded or a natural focused provider, don’t turn a blind eye to conventional medicine. And, yes, you may go to your gastroenterologist and they may not even have heard of the low-FODMAP diet. It doesn’t mean that you shouldn’t go back. You should have the standard evaluation to rule out some of these things.
And then if you’re looking for a feedback on using things like fiber, and low-FODMAP, and vitamin C, and some of these other therapies, you can have another provider that you work with, which was more natural minded. But, yes, it’s not intelligent to just focus on the natural. You’re hoping that that’s all you’ll need and then you never find anything with the conventional doctor. But certainly, don’t turn a blind eye, absolutely.
DrTM: Of course, you should keep the differential diagnosis in the back of your head as we say.
DrMR: Hundred percent. So, Tarek, any closing thoughts for people and also, where could the track you down? I don’t know if you have a website or a blog or anyway they could follow your work, so please share that.
DrTM: I do not have a personal website like I have my own page on Facebook and LinkedIn and we do have—unfortunately, it’s in Norwegian currently, which is IBS school it’s called Tarm Skole in Norway here in Bergen where we offer our patients the—we have like an internet service where our patients can login, and read, and have a conversation with the health personnel about their symptoms.
As for me, Facebook and LinkedIn, I have an account there as well. You can see my publications on researchgate.net. All my research are there with the original articles, download it for free. We try our best to publish all our articles that it is open access so that we can help all people all around the world for free.
DrMR: Awesome. Well, thank you very much for taking the time. I really appreciate it. I find the research you’re doing fascinating and very important. And maybe we’ll have you back sometime in the next several months to talk about your FMT findings.
DrTM: Absolutely. Thank you so much for having me. It was great pleasure.
DrMR: Same here. Thanks again.
DrTM: Thank you. Bye-bye.
➕ Resources & Links
- Dr. Mazzawi on Facebook and LinkedIn and Pubmed.com
- Tarm Skole in Norway
- Summary of a review paper that found insignificant impacts on diversity
- Mazzawi T, Hausken T, Gundersen D, El-Salhy M. Effects of dietary guidance on the symptoms, quality of life and habitual dietary intake of patients with irritable bowel syndrome. Mol Med Rep. 2013 Sep;8(3):845-52
- Mazzawi T, Gundersen D, Hausken T, El-Salhy M. Increased gastric chromogranin A cell density following changes to diets of patients with irritable bowel syndrome. Molecular medicine reports. 2014;10(5):2322-36
- Mazzawi T, Hausken T, Gundersen D, El-Salhy M. Effect of dietary management on the gastric endocrine cells in patients with irritable bowel syndrome. European journal of clinical nutrition. 2015;69(4):519-24
- Mazzawi T, Gundersen D, Hausken T, El-Salhy M. Increased chromogranin-A cell density in the large intestine of patients with irritable bowel syndrome after receiving dietary guidance. Gastroenterology research and practice. 2015;2015:823897
- Mazzawi T, Hausken T, Gundersen D, El-Salhy M. Dietary guidance normalizes large intestinal endocrine cells densities in patients with irritable bowel syndrome. European journal of clinical nutrition. 2016 ;70(2):175-81. doi:10.1038/ejcn.2015.191
- Mazzawi T, El-Salhy M. Changes in small intestinal chromogranin A-immunoreactive cell densities in patients with irritable bowel syndrome after receiving dietary guidance. Int J Mol Med. 2016 May;37(5):1247-53. doi: 10.3892/ijmm.2016.2523.
- Mazzawi T, El-Salhy M. Dietary guidance and ileal enteroendocrine cells in patients with irritable bowel syndrome. Exp Ther Med. 2016 Sep;12(3):1398-1404. doi: 10.3892/etm.2016.3491.
- Mazzawi T, El-Salhy M. Changes in duodenal enteroendocrine cells in patients with irritable bowel syndrome following dietary guidance. Experimental Biology and Medicine. Article first published online: March 17, 2017.
- Mazzawi T and El-Salhy M. The effect of diet and individual dietary guidance on the gastrointestinal endocrine cells in patients with irritable bowel syndrome (Review). International Journal of Molecular Medicine, 2017