Clinical Alimentary

A nice cup of tea

There is nothing more quintessentially English than a nice cup of tea. We debate the nuances of how to make it properly – milk before the tea or after, warm the pot before adding the hot water and tea or not, or how much tea to add to the pot. Tea also has lots of reported health benefits but does it help people with IBS? If you are interested, please read on…

Tea is culture, it’s refreshing, herbal tea is reported to be calming, relaxing – we all could do with a little of that, surely? Well perhaps all is not as it first appears.

Standard tea (black, white, green, yellow and oolong) are the true teas

Tea contains caffeine, a stimulant, not as much as coffee but certainly enough to have a systemic effect if sufficient is consumed. It is worth changing to decaffeinated if you have IBS, caffeine can not only stimulate the gut causing diarrhoea type symptoms it also disrupts sleeping patterns and poor sleep can be a symptom of IBS for some people. Some individuals with IBS also have overactive bladders, symptoms which can be influenced negatively by caffeine intake. Tea has lower levels of caffeine than coffee and certainly less than energy drinks, but do consider reducing or slowly swapping to decaffeinated if you drink caffeinated versions.

Oolong tea is high fodmap so will need to be avoided for the low FODMAP diet and tested as part of a re-introduction protocol, if you wish to drink it.

One study reported hard stools for tea in people with IBS (Simren et al 2001) but this was a prospective self reported study and has not been tested directly by a true randomized controlled study. This probably should be investigated but there are fewer studies in people with IBS with constipation for all treatments, unfortunately.

Rooibos

Rooibos is not a true tea and as such does not contain any caffeine and lower levels of tannin’s than true teas. It does however contain some of the poly-phenol compounds found in true tea. For the Monash version of the low fodmap diet it is categorized as low in FODMAP.

Herbal teas

Peppermint

Peppermint has been widely investigated for IBS symptoms. It acts as a smooth muscle relaxant so it can reduce those lower digestive tract spasms. Many people use the tea for the same effect. A number of people with IBS will also experience reflux, or upper gastrointestinal symptoms. Peppermint may also relax the sphincter (a ring of muscle) that prevents stomach acid from traveling up the food pipe (oesophagus). If someone has reflux it is probably not a good idea to drink peppermint tea. However it is good to help with lower abdominal pain so feel free to try it for that. If you want to read more about peppermint and IBS see my other blog post here:

https://clinicalalimentary.blog/2018/01/21/peppermint-and-ibs/

Camomile

Camomile is often stated as a treatment for IBS and ‘helps’ abdominal pain and induces sleep. Camomile acts as a neuroendocrine modulator so it has been suggested as a possible treatment to help with anxiety, insomnia and stress. This does suggest that it could be helpful for IBS type symptoms however Camomile contains FODMAP sugars therefore for those people with fodmap intolerance it is probably best avoided. Camomile also interacts with some drugs – please discuss this with you doctor or pharmacist before trying camomile tea. Common interactions are suggested with sedatives, blood thinners, anti-platelet drugs, aspirin, NSAID painkillers like ibuprofen and naproxen, but also others too (source: WebMD)

Fennel

Fennel is another herbal tea that is suggested to be a good option for those people with IBS. It again, also contains FODMAPs so if you are following the diet, perhaps this is one to avoid.

Dandelion tea

This tea has lot’s of anecdotal suggestions that it helps digestive symptoms, from increasing appetite, soothing minor digestive ailments and relieving constipation. There is no evidence that any of these symptoms are improved. Dandelion tea is another tea that it high in FODMAP so this might be the reason for the anecdotal reports of improving constipation, as lots of FODMAP containing foods are prebiotic (food for gut bacteria) and can help increase bowel function. Dandelion tea has also implications for drug interactions so it is best avoided for people taking diuretic medications, lithium and ciprofloxacin (an antibiotic.) Discuss this with your doctor or pharmacist before considering dandelion tea.

Fruit teas

Many people love fruit teas – they are naturally low in caffeine, however for me, they always promise more than they give. The odour of them is very tempting and I always feel disappointed that they are not more highly flavoured when drunk. If you like them though fruit teas should be fine to use. Use flavours suitable for the low FODMAP diet, if you are following it.

Testing tolerance to teas

For people following the low fodmap diet if you want to test the tea’s above which are high in FODMAP, to see if you can tolerate them, you can. Everyone has an individual tolerance to teas high in fodmap. Once your symptoms are reduced to a good level you could re-introduce the teas above and see how you get on. Use a standard cup as a portion and increase to three over three days, monitoring your symptoms as you go.

Following a Low FODMAP diet and adding milk to tea?

If you are following the low FODMAP diet then lactose is a problem for some people and if you need to exclude lactose then you can use lactose free cows milk – this is suitable for the low fodmap diet and the calcium it contains is slightly better absorbed than from milk alternatives. If you have been tested for lactose intolerance and you are not intolerant, you can use standard milk. Lactose free cows milk also marries with tea very well and you will not notice a difference in taste. This also means that Chai tea (milky tea with spices also added) is not suitable for people following the Low FODMAP diet, as it will contain lactose. You could make your own Chai tea with lactose free milk, if you wish.

Needing a milk free diet and have milk in tea? Which is the best option?

Well, for tea without sugar the best option is cashew milk, and for those who have sugar in their tea then coconut or almond milk are the better choices, according to people who have to follow milk free diets. I can attest to the cashew milk being suitable for tea without sugar, I tried it and really couldn’t taste a difference. Please ensure that your milk alternative is fortified with calcium, as cow’s milk forms a very good source of calcium in the diet and changing to milk alternatives may reduce your calcium intake. You could choose ones that are also fortified with B12 if you are following a vegan diet.

Image by Pexels from Pixabay

Image by congerdesign from Pixabay

August 11, 2019

Jules_GastroRD2 Comments

Orecchiette con Cima de rape – Low FODMAP

This recipe was in a newspaper supplement but wasn’t really Low FODMAP friendly so I decided to give it an update and make it suitable for those with food intolerances. It is a traditional Puglian recipe using broccoli tops (Cima de Rape), which is a winter vegetable in Italy but is a really refreshing recipe for spring in the UK using broccoli tops makes it a suitable low FODMAP version.

The other problem is that there is no suitable gluten free Orecchiette pasta that is available in the UK, so fresh gluten free pasta has to be made if you want an authentic dish. The other point to note is that only if you find cooking relaxing should you attempt to made home made gluten free pasta. An important factor is not making more work for yourself if you don’t find cooking relaxing and dried pasta is suitable for this dish.

I have decided to make a longer recipe today as it is Bank Holiday weekend and the forecast suggested that it was going to rain although it hasn’t done yet. I have also posted some bluebell images from this weekend – bluebells are everywhere at the moment and are quite a spectacle.

Ingredients

Pasta (wheat free)

250g Pure maize flour (wheat contamination free if you are coeliac)

50g Gluten free bread flour

2 Eggs

Salt

1/2 Teaspoon xanthan gum

Enough water to bring the dough together

Stock

1 Ladle of pasta cooking water – top up to 500ml with water

20g Carrot chopped

30g Celeriac

1 Bay leaf

Small amount of salt and 6 peppercorns

Sauce

1 Head of broccoli (250g) stalks removed

1 Anchovy

1 Lemon

20g Parsley

20 Bay leaves

20g Rocket

30g Parmesan

3 Tablespoons of garlic infused olive oil

25g Butter

100ml White wine

Salt to taste

Method

Pasta

Weigh the flours into a bowl and add salt and xanthan gum. Mix the dry ingredients well before adding any liquid to the mix. Add the eggs and start to mix the flour, then add water to bring the flour together into a dough. Add just enough to ensure a soft mix – it is not possible to give a volume as this will depend on the fineness the flour mix you use. Once the dough is formed work it well to incorporate it together and make a smooth mix. This will take time, don’t worry about over working – this is not the same as making standard pasta. Roll out logs of the dough to the thickness of you thumb and then slice finely. To make the orecchiette shape press your finger into the centre of the disc. Bring a pan of water to boil and add salt and the pasta. Cook till the pasta rises in the pan remove and drain.

Zest the lemon and juice.

Chop the broccoli tops, celeriac, carrot, anchovy finely and add to separate bowls.

Then chop the basil, rocket and parsley and add to a bowl with the rest of the lemon juice.

Make the stock adding the pasta cooking liquor, carrot, celeriac, bay leaves and pepper to a pan and cook for 10 minutes, drain and save the stock. You could add the carrot and celeriac to the main dish but remove the bay leaf and peppercorns.

Add the olive oil to a pan and add the broccoli, anchovy and the zest of 1/2 the lemon and cook for four minutes then add the stock, wine, 1/2 the parmesan and butter and simmer for 10 minutes until the broccoli is soft.

Add the herbs and the rest of the lemon zest to the pan and then gently mix in the pasta to warm through. Serve and finish with a tablespoon of the lemon juice and the rest of the parmesan.

Serves two

May 6, 2019

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Lemon – Low FODMAP

The words of the song the Lemon Tree, the words are undeniable “Lemon tree very pretty, and the lemon flower is sweet, but the fruit of the poor lemon is impossible to eat.” Many people with gastro-oesophageal reflux (GORD) and IBS avoid all citrus fruit due to reporting of them making symptoms of reflux worse. Yet, citrus fruits are allowed on the low FODMAP diet. I actually love lemon, the flavour is sharp and strong but has to be handled carefully in recipes to prevent is tasting like a popular cold remedy.

One point to mention here is that the National Institute of Health and Clinical Excellence (NICE) guidance on reflux does not specify a reduction of citrus fruit consumption as part of lifestyle GORD treatment. The reduction of coffee, chocolate, alcohol and fatty foods are the main focus of dietary lifestyle factors. Although the date of the review of this lifestyle advice is 2004 – so somewhat old data, but this is fine if no new developments have come to light. It is also worth noting that the measure of acidity, pH, is very low for stomach acid (2-3), for lemon Juice, it is 2, so not much different than the pH of gastric juices anyway. But people do report problems, so we do treat everyone as an individual and they can be reduced to a tolerable level, when needed.

Reduction of acidic foods also can reduce the amount of vitamin C in the diet, as ascorbic acid is found in higher levels in citrus fruits. Vitamin C full deficiency is rare in the UK, although arguably becoming more common due to fad diets, such as complete carnivore diets. Our bodies cannot make it, unlike other animals. Not much data is available on low vitamin C intake and GORD, but the effects of deficiency include damage to skin and likely the GI tract, which has a fast turnover of cells, not that helpful for those who have sensitive guts. The requirement for vitamin C might be increased in people who have diarrhoea – although caution is advised as vitamin C supplements above 3g/day (three times the amount of a standard over the counter supplement) will increase symptoms of abdominal pain and diarrhoea. As ever, it is better to get your nutrition from food, so once your symptoms have reduced, re-introduce those low FODMAP foods you have stopped eating, try them again, you might find that you can eat them after all.

Lemon butter drops

These little biscuits are only a mouthful – just a bite – but are a divine melt in the mouth treat. Especially nice for this time of year, Spring and Easter, (when Easter does arrive in April).

Ingredients

100g butter

200g rice flour

1/2g zanthan gum

Grated rind of 2 unwaxed lemons

1 egg

50g of gluten free self-raising flour plus extra for rolling out.

Filling (lemon curd)

4 wax free lemons – juice and rind

350g castor sugar

200g butter

1 1/2 tablespoons of corn flour

4 eggs

Method

Add the butter and sugar and cream (mix) together well.

Then add the grated lemon rind and egg, mix well

Add the flour and bring together into a dough, if it doesn’t bind together add a little more flour till it does.

Roll thinly and cut out small rounds (I made 40 with the mix)

Cook for 10 minutes at gas mark 6.

cool

Make the curd

Whisk together 4 eggs

Juice and grate the lemons and weigh out the other ingredients

Warm the eggs whilst adding the other ingredients and cook till thickened

Cool and add to the jars

(This is based on a Delia Smith recipe but with additional cornflour to make the curd thick enough to sandwich between the biscuits.)

Recipe makes enough for 20 small sandwich biscuits and enough curd to add to a litre and a half volume – more than enough to add to sterilized jam jars and they will keep for a few weeks.It does go a long way so you don’t need to use much for a sweet and sharp lemon flavour.

March 7, 2019

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Spinach, a superfood – fable, fact or just wartime propaganda?

If I had a pound every time a patient says spinach is high in iron in the clinic, I reckon I would be relatively wealthy. Also, if I knew what I was about to find out about this story whilst researching it, I would have looked into this much earlier. Thanks to Andy Brunning at compoundchem.com for the story background and links, a story of the importance of evidence and good referencing.

Although spinach is a green vegetable, which is particularly versatile and useful to include in a healthy balanced diet, the above infographic from Compound Chem shows the availability of iron from spinach is poor, unfortunately. So, what does it contain that is great for nutrition? Spinach is a good source of manganese, folate, vitamin A, vitamin K and fibre, which is excellent, as the fibre at least is an essential part of the diet if you are following a low fodmap diet. It is the content of polyphenols in spinach that bind with the iron rendering it insoluble, not the fact that it is a non-heam source, which is usually able to be absorbed, if a source of vitamin C is consumed at the same time.

The type of polyphenol compounds found in spinach varies but the example below accounts for the majority of polyphenol compound at 37.37 mg/100g FW. What no-one seems to have considered here is what effect microbial interaction in the bowel has on these polyphenols. Whether microbial digestion of these polyphenols affects their structure and whether this process helps the availability of iron to digestion. Interesting, Huh? Needs investigating – Yes!

Many people assuming that spinach is high in iron is probably due in part to social history. Popeye, a cartoon character developed in 1931, ate spinach to give himself ‘strength’ – “I’m strong to the finish cause I eats mi spinach”. But an original report of the iron content of spinach was stated to have contained a decimal point error, that gave the iron content as 10 times more than the actual amount. This is what I was told, as a student from 2003-2007, although others report that this was an error of reporting the iron content of dried spinach as fresh spinach. But whatever the cause, the erroneous reporting of the content of iron from spinach being higher exists to this day and has consequences. This is a particularly pervasive nutritional myth that has been investigated and reviewed by Sutton and published in the Internet Journal of Criminology, see the link below, it is a fasinating read of failings to attribute data with references and looking for clues from original sources.

Spinach does have the same iron content as some meat, but the important point to note is the availability of the iron from both foods. Spinach is a poor source, and as I have stated before in this blog, micronutrients need to be absorbed for them to be useful to us, it is no good just looking at the bare numbers. Also, Sutton states it was, in fact, the vitamin A content that Popeye was eating spinach for. This may be true, as spinach is a good source of vitamin A, from carotenoids. But also reminds me of another UK wartime ‘fable’ of eating plenty of carrots to improve eyesight. Improved eyesight only occurs if someone has a severe vitamin A deficit and night blindness, no improvement is gained with those who have adequate vitamin A stores. I wonder if spinach was the USA wartime equivalent of the UK carrot propaganda? How ironic that would be!

Why are these stories essential to debunk? Wikipedia states that during the first world war spinach was given to soldiers who had suffered haemorrhage, presumably to ‘replace’ iron. It was delivered in red wine – presumably to ‘help’ absorption, by chemical conversion to increase the solubility, by the acidity of the red wine. Red wine also contains iron – but also contains polyphenols, which will also inhibit the absorption of iron – likely a double error occurred in this case, then. Another point to make here is that diet alone currently cannot be used to treat anaemia. Usually, iron sulphate supplements are the chosen option, containing 65mg per dose, (which can, by the way, have devastating effects on digestive symptoms for those with IBS. Iron federate is perhaps a better choice and if you have low iron/anaemia and IBS ensure your doctor has investigated the cause.) Although less of a ‘tonic’ than it was supposed to be, a ration of wine during World War 1 was probably welcomed by the soldiers.

What does this have to do with IBS you might ask? Well actually, rather a lot, particularly for those people who are vegans. The Low FODMAP diet is low in iron as many foods such as pulses and dried fruit – good sources of iron for vegans are limited on the diet. This shows the importance of proper knowledge and the impact of following such a diet has on nutrition and health. The importance of seeing a registered dietitian cannot be underestimated. Other sources are watercress, kale and include allowed portions of pulses with a source of vitamin C – although to what degree the overall polyphenol content of the vegan diet might affect absorption is not established and unlikely to be so. Digestion is complicated, this is a fact.

Spinach does have some really great other nutritional benefits, but it is no more a superfood concerning vitamin A content than the cheaply available carrot, (spinach has marginally more vitamin A content) or a good source of iron. It is, however, a source of vitamin K that can prevent blood clotting problems. The recipe below can be made for those who respond to a low fodmap diet and others who are just interested in tasty recipes!

Cream of spinach soup

100g Broccoli tops
35g carrots
70g celeriac
200g spinach (fresh or frozen)
1/4 teaspoon nutmeg
1/4 teaspoon cumin
1/4 teaspoon cinnamon
2 tablespoons of lactose-free mascarpone cheese
600ml water

Method

Chop the vegetables finely
Add them to a pan with 600ml water and spices
Cook till soft
Blend with a hand blender
Add the mascarpone cheese just prior to serving
Serves 4

https://www5.in.tum.de/~huckle/Sutton_Spinach_Iron_and_Popeye_March_2010.pdf

Neveu V, Perez-Jiménez J, Vos F, Crespy V, du Chaffaut L, Mennen L, Knox C, Eisner R, Cruz J, Wishart D, Scalbert A. (2010) Phenol-Explorer: an online comprehensive database on polyphenol contents in foods. Database, doi: 10.1093/database/bap024. Full text (free access)
Rothwell JA, Urpi-Sarda M, Boto-Ordoñez M, Knox C, Llorach R, Eisner R, Cruz J, Neveu V, Wishart D, Manach C, Andres-Lacueva C, Scalbert A. (2012) Phenol-Explorer 2.0: a major update of the Phenol-Explorer database integrating data on polyphenol metabolism and pharmacokinetics in humans and experimental animals. Database, doi: 10.1093/database/bas031. Full text (free access)
Rothwell JA, Pérez-Jiménez J, Neveu V, Medina-Ramon A, M’Hiri N, Garcia Lobato P, Manach C, Knox K, Eisner R, Wishart D, Scalbert A. (2013) Phenol-Explorer 3.0: a major update of the Phenol-Explorer database to incorporate data on the effects of food processing on polyphenol content. Database, 10.1093/database/bat070. Full text (free access)

January 29, 2019

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Broccoli

Broccoli is a newer addition to the low fodmap family – although particular attention needs to be made concerning which parts are low fodmap. Growing conditions and plant storage of FODMAPs affects the fodmap content of foods. A good example here is the ability to use the green parts of leeks and spring onions and not the bulb (the storage part of the plant.) The same is true for broccoli, the leaves and a small amount of stalk (less than 50g) are low fodmap – the stems alone above 50g per portion are not suitable. Testing individual components of food gives us more information about its fodmap content, and we are continuing to learn more about the diet with the valuable testing of the fodmap content of foods. It is thanks to the continued work by Kings College Nutrition department that has led to more information. Increased testing increases available foods and this makes the diet more varied, which is nutritionally more sound, but can add to the complexity of the diet making access to up to date information more critical. The best sources of information are dietitians who are fodmap trained, which is why it is recommended not to complete this diet alone.

What are the benefits of broccoli?

Nutritionally broccoli is suggested to be a powerhouse vegetable, although so are most others in their own way! The infographic above indicates that it has some good cancer-preventing properties via the content of sulforaphane – content of this chemical is affected by cooking time, and its benefits are debatable, as much of the evidence comes from studies in mouse models and cells in Petri dishes, one or two small studies in humans have been done, but certainly more information is needed. Broccoli provides dietary fibre content, which is always important for people with IBS. It contains good levels of vitamin A (more in the tops than the stalks), Vitamin C (but this will depend on how long the broccoli is cooked) and vitamin K.

What are the effects on the colonic microbiome? Well, in a small study broccoli consumption altered the variety of Firmicutes (reduced) and Bacteroides (increased) although it is really too early to say if this is beneficial in IBS or for those following the low fodmap diet. Interestingly Firmicutes have been found to be increased in people with IBS and reduction in the numbers of Bacteroides – perhaps this just represents people with IBS reducing consumption of those foods that are suggested widely on social media to increase symptoms, such as cruciferous vegetables. It would be interesting to know if including broccoli amounts recommended in the low fodmap diet improves these bacteria numbers and whether this is clinically significant.

What broccoli is unlikely to do:

Detox your body – your liver, kidneys and lungs are all you need for this.
Reduce ‘inflammation’ we don’t have enough information that broccoli has any effect for this unspecific term.
Reduce pain in fibromyalgia

I suggest cutting off the stem of the broccoli as close to the head as possible and discarding (or using for other members of the family or feeding to rabbits), then trimming the stalks contained within the base of the head – you can then weight the stems and calculate how much to add to the dish per portion.

What other cruciferous Brassicaceae vegetables are good to include in the low fodmap diet? Pak Choy, choy sum, kale, white cabbage and red cabbage – so do include these as well as other low fodmap vegetables – remember variety in the diet is best!

Now for the recipe:

Vegan broccoli and pine nut pasta – Low FODMAP

Ingredients

300g Gluten free pasta

40g Pine nuts

1 head of broccoli

2.5 cm square of Vegusto Prosociano

1 Tablespoon of garlic infused oil

A few basil leaves

Seasoning to taste

Method

Chop the broccoli close to the head and then into small ‘trees’

Cook the pasta in boiling water using the packet directions adding seasoning

Add 1 tablespoon of garlic infused oil to a pan and roast the pine nuts.

Add the basil, cooked pasta and broccoli to the pan with a tablespoon of water the pasta was cooked in.

Combine and serve with a sprinkling of the cheese for each portion

Serves 4

https://www.nhs.uk/news/cancer/broccoli-and-breast-cancer/

https://modalitypartnership.nhs.uk/self-help/livewell/topics/superfoods/is-broccoli-a-superfood ,

https://www.ncbi.nlm.nih.gov/pubmed/30317146

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4317767/

January 13, 2019

Jules_GastroRD2 Comments

The Aubergine

Aubergines have to be my favourite vegetable. I love that they marry well with other vegetables such as tomato and potato. They have a velvety texture and a creamy taste and more than earn their title as the vegetarian steak.

Although in some quarters they are suggested to produce intolerance, as along with potato, peppers and tomato, the aubergine is a member of ‘the nightshade family’ or Solanaceae, a deadly associated name for a wonderful group of vegetables (and fruit, if you count the tomato, which is technically a fruit). We have little evidence for the problems of the ‘nightshade family’, concerning the above group of four as a whole, and why would you want to exclude these versatile vegetables from your diet? Some are however known as histamine producing – the aubergine and tomato – but histamine intolerance is a rare occurrence and can be identified by knowledgeable practitioners, plus aubergine is only classed as a moderate inducer. Another possible consideration for reactions to the Solanaceae group is the alkaloid solanine, which is found in green potatoes, so store your potatoes well, covered in the dark to avoid sprouting and this should not be a problem.

I have not had experience of the bitter flavour with aubergine so wouldn’t usually resort to salting them, but the above infographic is useful as once salted they will not absorb as much oil, so it might be worth taking the time to do it. Segnit’s flavour thesaurus matches the aubergine with walnut and tomato and a sprinkling of nutmeg. So, here is my recipe for you – please tell me how you like it!