Pumpkin gnocchi and sage butter

I have been thinking about Halloween recipes this weekend – this is likely to be the last one I post this year. I adore gnocchi but I do find it very filling. It is a dish for a day where you need something satisfying and tasty. The day has been nothing but grey sky and drizzle so it is very apt to make a starchy dish and pumpkin is a seasonal alternative to potato. Enjoy!

Ingredients

  • 1 Medium pumpkin – mine gave 600g flesh
  • Spray oil
  • 300g maize or cornflour
  • 1 Egg
  • Seasoning
  • 25g butter
  • 10-12 sage leaves
  • 30g Grated parmesan

Method

  • Slice the pumpkin and spray with oil and roast in the oven till soft.
  • Leave the slices till cooled.
  • Remove the skin from the flesh, season.
  • Add to a blender with the egg and enough flour to bind the mix.
  • The mix is slightly soft but can be weighed into 10g portions and rolled, then flattened with a fork.
  • Heat a large pan with boiling water add seasoning and drop in the gnocchi – don’t add to many at once – they will float (Halloween reference to IT here) when ready.
  • You might have to change the water if it becomes too starchy.
  • Dry well on kitchen paper.
  • Chop the sage, melt the butter in a pan and add the gnocchi.
  • Serve and sprinkle with parmesan cheese.
  • Serves 6.

Autumn jacket potatoes

It’s Autumn, I love this time of year but as the dark nights role in thoughts of wholesome, warm filling meals arrive. What could be more sustaining than a jacket potato for people following the low fodmap diet? This is also married with carrot and celeriac, oregano and thyme and of course mixed with cheese – not so much – but enough to provide ample calcium.

However food means more than sustenance – it is family, experience, love – in fact food ripples throughout life and our lived experiences. Many of us have stories to tell about food – both negative and positive. There are two considerations for people who wish to follow a low fodmap diet, what benefits might there be? Much longed for reduction in symptoms? The benefits are often the driving consideration. But what about negatives – how is changing the way that I eat going to affect my quality of life? You might be somewhat surprised at this suggestion – negatives in quality of life? But this diet is supposed to improve my situation, surely?

Consider cooking for the family, going out for a meal with a treasured friend, traveling on holiday and having a suitable option for lunch at work. How much additional planning and work is it going to take to follow this diet – can I afford to have additional work when I already have a very busy schedule to follow? These are all considerations that should be taken into account when deciding to follow an elimination diet – these are considerations that the dietitian can help you with and are what your dietitian will be contemplating as part of the assessment process. This is also another reason that the reduction phase of the diet should be as short as possible. The re-introduction phase will provide some freedom and release from some of the restrictions the low fodmap diet instills.

There are options for people who may not wish to follow a complete exclusion and would find that following the low fodmap diet too much to plan – because planning is what you will need to do, to be successful. There is a shorter low FODMAP version that the dietitian may consider if the full diet is too challenging and a wheat free or lactose free diet if these food types are considered to be the main issue from a diet history.

It hasn’t gone unnoticed by me how people with IBS try hard with regards to treatments – sometimes unfortunately too hard and continue far too long when diet treatments are not working. People then should explore other treatments and often need help or a nudge to move onto other options. To some extent this hard effort is why I work in the area of digestive illness, because I know my patients will often try their upmost to make changes, more than in other areas of dietetics and when this works, it is satisfying – although, truly, it is their hard work that has produced dividends. Symptoms of IBS really are the great motivator, I would suggest that their may be no greater drive towards change than these symptoms provide – imagine what could be achieved with such an instigator, if it was a positive driver rather than a negative one?

But, enough of the musings and lets get back to the recipe…

Ingredients

  • 3 jacket potatoes
  • 3 carrots
  • 2cm of celeriac (tip here: keep some blanched celeriac ready cut in your freezer for any recipes that ask for celery)
  • 150g grated cheese
  • 1 teaspoon oil
  • 1/2 tablespoon of chopped fresh oregano or 1 teaspoon of dried
  • 3 sprigs if thyme or 1 teaspoon of dried
  • Seasoning

Method

  • Warm the oven to 200 degrees C and then wash and prick the three jacket potatoes, place them on a baking tray and add to the oven. Depending on the size cook for 1 hour to 1 hour 20 minutes.
  • Whilst the potatoes are cooking add the oil to a pan and add the herbs and cook for 2-3 minutes.
  • Slice the carrots and celeriac and boil in a pan of hot water till soft. Mash and add the herbs and seasoning.
  • Grate the cheese.
  • When the potatoes are cooked scrape out the potato leaving the skins intact. Mash the filling with the carrot mix and add 100g of the grated cheese and mix. Add back to the potato skin shells and top with the remaining cheese.
  • Grill till the cheese has melted and then serve (serves 3)

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

Lemon – Low FODMAP

http://www.compoundchem.com

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.


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!

Ingredients

1 aubergine

1 tablespoon of olive oil

100g carrots

1 tin of tomato

1 teaspoon of cinnamon

1 teaspoon of paprika

1/2 teaspoon of nutmeg

150g walnuts

150g of sharply flavoured cheese (if vegan you can use alternative vegan cheese here) but I used Manchego.

Method

Chop the vegetables and walnuts

Fry the spices in the oil to release their flavour.

Add the vegetables to a casserole dish with the tomatoes and mix in the spices and salt to taste

Cook for 1 hour at gas mark 6, 200 degrees C

Crumble the cheese, sprinkle on the top of the casserole and grill to melt

Serve with crusty bread (gluten free or otherwise for those following a low fodmap or gluten free diet.)

IBS digestive distress – is there a problem with bread?

Many people with IBS state that bread is a real issue in provoking symptoms. Is this true? What is it about bread that is the problem? This post aims to discuss the provocateurs of digestive distress in IBS (Irritable Bowel Syndrome).

Cited as sustenance – for example, the line ‘give us this day our daily bread’ in the Lord’s prayer – having access to bread was life for the poor in the past and bread is a staple food in the United Kingdom. The first piece of toast dripping in butter and a cup of tea after a period of fasting through having surgery is one time I recall, and bread was all the food I desired. How wonderful it tasted. The mouthfeel of gluten is undeniable and can be identified by those who do need to follow gluten, wheat or fructans free diet. I have identified it when I have infrequently made a mistake, as in ‘wow, this gluten-free bread tastes GREAT’ only to later realise my mistake at a cost and in fact it was the standard wheat based bread I had consumed!

The-Chemistry-of-Bread-MakingIn the past bread was made locally and bakers were part of the local community. When industrialisation arrived, bread, needed in large quantities as a staple food, soon was produced in factories, one of the possible reasons was because it was terrible work – bakers had to rise early and work hard to provide the daily loaf for their community. Is industrialisation the cause of bread symptoms? Many blame the Chorleywood bread making process and fast fermentation – but harking back to the bread of the past does not always leave a rosy glow. Adulterating food with cheap ingredients was commonplace in Victorian history, alum (aluminium salt) was added to the dough to improve it’s colour and was thought to be one cause of Rickets, by reducing the availability of phosphorus, leading to decreasing its absorption from the diet.

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So, let’s take a look at bread more closely. There are possibly a few protagonists for digestive discomfort after eating bread, and the reason may be different for individuals – we will now discuss some of those possible causes:

Resistant starch content

‘Resistant’ starch does what its name suggests – it resists digestion and is a component of fibre.  Produced by heating/cooling treatment, these resistant carbohydrates are based on wheat (and other) grains. Now for a little bit of chemistry, not too complicated, I promise. Starch is a crystalline polymer (think of a chain of a necklace containing many small beads, each small bead representing a sugar molecule, the necklace representing a polymer chain – a starch). Chains of the starch molecules closely line up on cooling, forming crystals within the bread matrix, links (imagine two or more necklace strings joined together) or bridges between the starch chains makes the structure a tightly packed area, where our digestive enzymes (amylases) can’t penetrate. The speed and repetition in cooling and heating will affect the amount of the resistance formed. Exposed to up to 20g of resistant starch per day from our diet some of the bacteria (amylolytic) in our large intestine may be able to ferment these crystalline resistant areas more successfully . IBS has alterations in the gut microbes, meaning that gut fermentation is a possible consequence and symptoms likely, in those people with IBS.

Research has shown that only certain types of bacteria are capable of digesting resistant starch of the form Bifidobacterium spp. and Clostridium butyricum but these types of study are limited. Consumption of these starches enriches the gut microbial populations with more of the microbes capable of breaking down the starch. We know that people with IBS have different populations of gut bacteria than the general public – a changing diet to improve symptoms is a possible cause of this difference.

Similar mechanism to the mechanism that causes issues from resistant starch – in other words poorly absorbed starch components causes these starches to be fermented in the large bowel resulting in symptoms when the colon is overly sensitive in IBS.

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Gluten

Gluten is a different component, and it is a protein, not a starch. Different mechanisms occur with proteins. During bread mixing initially, the gluten is softened by adding water to the flour, then kneading the bread with the salt that is added strengthens the gluten bonds gives a stretchy mixture, which traps air giving a better rise. Proteins tend to solidify when heated during baking, producing the tight structure or links between the protein molecules. Some research has found by blinding during trials that it does appear to be the fructans in wheat that result in the majority of problems for people with IBS. However is it still possible for individuals to have an issue with gluten? It does make you wonder, for those people who can tolerate all other fodmaps except wheat, whether this is, in fact, a non-coeliac gluten sensitivity. In my experience, most people following a low fodmap diet will go utterly gluten-free despite the fact that small amounts of wheat are tolerated well. Or perhaps the problem is a non-IgE wheat allergic reaction, or maybe natural toxins developed by the wheat is the problem…

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Wheat ATIs

Wheat amylase-trypsin inhibitors are proteins that are found naturally in wheat and are resistant to digestion and were developed by the plant to act as a defence against parasites and insects. They are activators of innate immunity and are suggested to lead to digestive symptoms by activating an immune reaction in the gut mucosa resulting in low levels of inflammation. Bioactivity of these proteins was found to be lower in spelt flour – often stated to be tolerated better for digestion. Is it possible that these ATI’s or gluten activate an immune response that then sensitises the colon leading to reactions to fodmaps?

The processing of wheat to produce bread, however, reduced ATI’s bioactivity up to 30-50%. But some people state bread is explicitly a problem so we should look at the manufacturing process specifically.

Chorleywood bread making process – the case for fructans?

All the above are commonly found in all wheat-based food, but bread is processed, what effects does this have? The Chorleywood process was developed in 1961 and improves production time reducing costs of bread production. This production method can also use a lower protein content flour, which was the type of flour available in the UK, to reduce costs of having to import flour with higher protein. The protein content in UK wheat has increased since this development, but this process is still used and widely disparaged as a cause of digestive distress.

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One fascinating study looked at the differences in symptoms between the general population and those with IBS and whether a longer fermentation would lead to lower gut fermentation and gas (1). Now, this study was tiny and was completed in vitro (it was not a controlled trial in human subjects, although human stool from volunteers was used) so, the conclusions would need further study. The Chorleywood process produced more gas more quickly, after simulated digestion. The more prolonged fermentation process also led to a higher level of bifidobacteria in the stool, the levels of these microbes are reduced in IBS. Bifidobacteria also produce less fermentation in the gut, suggesting increasing numbers compared with others may help reduce symptoms.

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So, the combination of less gas delivered more slowly and increasing commensal bacteria that produce less gas anyway, was suggested to equal better tolerance, which is perhaps a leap of faith to suggest that this reduction will reduce symptoms without it being tested in humans. Voila, testing in humans has been done (2)! A more extensive study in humans also looked at Chorleywood process compared with sourdough and showed that a more extended fermentation leads to the breakdown of ATI components and reduced fodmap levels BUT NO DIFFERENCE IN SYMPTOMS OF IBS. Both studies used constipated volunteers, so no difference there, the symptom production in the second study was reported to possibly be a nocebo effect – expecting symptoms due to previous experience. Which is possible, six slices per day is a considerable amount to consume for people who have an intolerance to wheat. Diet was excluded as a confounding factor but what is not clear is how the bread was eaten and whether this was different in the two groups – toasted, fresh, or frozen, perhaps taking us back to resistant starches? Also, about a third of people with constipation based IBS will have pelvic floor dyssynergia, which in theory could elicit symptoms that might not necessarily be helped by changes in the diet, if symptoms are severe. Both these studies were pilot studies and need further investigation on a broader population of people with IBS.

Yeast

For many people with IBS yeast is anecdotally reported to result in symptoms. We do not have any evidence that this is a problem and this has been dismissed by the medical establishment as a cause. No evidence means precisely that, we don’t know, so would it be an issue? Saccharomyces cerevisiae, a yeast, has been studied in improving IBS symptoms, so we have another situation of modulating the gut microbiota to improve symptoms. While we have absolutely no evidence that a low yeast diet is useful, in IBS treatment, it might lead to altering the microbiome and should not be advised, but this is an area indeed worthy of further study.

I think in conclusion, symptom inducement in IBS with bread is complicated and needs further study – with this detail of research required for one food item – is it any wonder that we have not got a cure for this medical condition?

  1. Adele Costabile, Sara Santarelli, Sandrine P. Claus, Jeremy Sanderson, Barry N. Hudspith, Jonathan Brostoff Alison Lovegrove, P R. Shewry, Hannah E. Jones, Andrew M. Whitley, Glenn R. Gibson (2014) Effect of Breadmaking Process on In Vitro Gut Microbiota Parameters in Irritable Bowel Syndrome PLOS one Volume 9 Issue 10 e111225
  2. Laatikainen R, Koskenpato J, Hongisto SM, Loponen J, Poussa T, Huang X, Sontag-Strohm T, Salmenkari H, Korpela R (2017) Pilot Study: Comparison of Sourdough Wheat Bread and Yeast-Fermented Wheat Bread in Individuals with Wheat Sensitivity and Irritable Bowel Syndrome. Nutrients. 2017 Nov 4;9(11). pii: E1215. doi: 10.3390/nu9111215.