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

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!

http://phenol-explorer.eu

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

  1. 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)
  2. 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)
  3. 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)


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.)

Meat free Sausages – Low fodmap

This recipe was devised as a result of trying to find low fodmap meat-free sausages and failing to find a suitable option easily. They are very tasty – although they do not taste the same as standard sausages – perhaps they are better as a result, give them a try and see! Just in time for meat-free Monday.

Ingredients

100g walnuts

2 slices of vegan gluten free bread

90g celeriac

190g roasted peppers

1/4 teaspoon of asafoetida

1/4 teaspoon of paprika

salt & pepper to taste

Method

Add all the ingredients into a food processor and blitz till fine. This should be a thick paste texture, but it will depend on the size of the slice of bread, just add more bread if it is too thin. Dust gluten-free flour on your hands then roll handfuls of this mix into a sausage shape, or they can also be rolled into balls if preferred. Shallow fry in vegetable oil and serve. It couldn’t be easier really!

This recipe was made at the end of a day out at The Piece Hall at Halifax – as the pictures show below, we had a great day out, but it was freezing!

Italian meatballs with Fodmapped sauce – a review.

I have purchased some Fodmapped sauces and soups to try, so I thought I would give you the low down. I bought them through the IBS Network website so that they would benefit from the purchase – were you aware that if you buy a starter pack you get membership covered for 1 year? The sauce was really tasty and gave an added advantage to tomato pasta sauces as you could really pick out the flavour of the aubergine – one of my favourite vegetables. Shortlisted for the Free From Food Awards I would say they are a great contender and tremendous to see a low fodmap product being reviewed. Any drawbacks? Yes, the price – the sauces are expensive compared to other sauces but they are onion and garlic free, which most ready made sauces (except plain passata and some pure tomato based pasta sauces) are not. Sometimes following the low fodmap diet can mean dry food unless you make your own stocks and sauces, you could argue that this needs to be done, but not everyone has the time. You could make a very simple roasted vegetable sauce yourself, however if time pushed these products are certainly a consideration. Putting additional pressures on busy lifestyles by making everything from scratch is sometimes unhelpful to symptoms. The packet gave a serving for 2 people. I have made an Italian dish, a comforting winter recipe, and in the process increased the portion size to 4!

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Ingredients

500g lean minced beef

1 egg

100g gluten free breadcrumbs

10g of basil leaves

10g oregano

1 packet of Fodmap Easy roasted vegetable pasta sauce

200g of dry polenta

60g parmesan

Seasoning

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Method

Place the mince in a bowl and add chopped herbs, egg and breadcrumbs and some seasoning, mix well. Roll into even sized meatballs – I made about 14 from the full mix. Set them aside.

Fry the meatballs in a dry non stick frying pan till browned.

Add the meatballs to a casserole dish with the sauce mix and 300mls of water. Place in an oven at gas mark 5 or 190 degrees C. Cook for 1 hour.

Using the directions on the packet for 200g of polenta add water to a pan and bring to the boil and pour in the polenta whilst stirring. Add extra liquid if needed to form a thick sauce, add parmesan (retain a small amount for serving) and seasoning (not much salt needed here!) to taste.

Serve

Serves 4 for a main meal.

Peppermint and IBS

Peppermint has a history of being used as a treatment for IBS. It is even used as a medication in a capsule that ensures it reaches the digestive tract where it is most useful. Peppermint, or more precisely menthol, relaxes smooth muscle and as our bowel is composed of layers of muscle fibres, peppermint can help relax the spasms that are a common symptom of IBS. Menthol activates cold-sensitive TRPM8 receptors in the mucosal tissues of the digestive tract, it is the primary source of the cooling sensation that follows the topical application of peppermint oil, this sensation is what is proposed to have an antispasmodic effect in IBS (Camilleri & Ford 2017)

Peppermint as a herb and food ingredient

So what about peppermint tea? There is no good systematic reviews or studies for this use of peppermint in IBS, but as a natural product it is less likely to have evidence, but some people do report that it does help them and they find it a useful to have means of including peppermint in the diet.

Peppermint is a suitable herb to use for the low fodmap diet. It can be used in low fodmap suitable recipes, such as the one below. According to Niki Segnit’s flavour thesaurus mint marries well with low fodmap foods such as peanut (particularly peanut butter – I am not convinced about this – but I am intrigued enough to give it a try) potato, beef, ginger, goats cheese, lamb, lime, melon (honeydew and cantaloupe), mackerel (and other oily fish), raspberry and strawberry. Not forgetting the ubiquitous marrying of dark chocolate and mint see a recipe here https://clinicalalimentary.blog/2017/11/24/chocolate-coated-peppermint-snow-peaks-low-fodmap-christmas-recipes/.

Warm feta and mint salad

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Ingredients

100g feta cheese

2 tablespoons pine nuts

200g cooked rice

25g finely chopped mint

1 tablespoon of olive oil

1 pack of small courgettes (or 2 large courgettes -works just as well!)

Caper flowers and a tablespoon of pomegranate are used here to decorate

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Method

Add the oil to a frying pan then add the pine nuts, chopped mint and finely cut courgette

Fry till toasted then add the cooked rice and blend well

Add chopped feta at the end of cooking and mix to warm through

Note the lack of salt added – feta is quite a salty so it is more than enough seasoning for the dish.

Serve warm or cold – marries well with grilled meat or just as it is!

Peppermint in medications

I am a dietitian and any medications should really be discussed with your doctor but as peppermint is a common food ingredient I don’t necessarily see a problem in looking at the evidence of peppermints use as an antispasmodic agent.

Peppermint is more effective than placebo for treating IBS (number needed to treat 2.5 – Ford et al 2008) with small numbers of adverse events with this medication but not all the reviewed studies reported on these. (Khanna R, Macdonald JK & Levesque BG 2014) completed a more recent review of the use of peppermint in IBS and again a moderate level of evidence of effectiveness was the reviews result which included a combination of data from 726 patients with IBS. With more side effects in the peppermint group of patients reported by these reviewers, although no data was given in the abstract, the effects were reported to be transient and heartburn was reported as the most experienced side effect. A more recent review (Camilleri and Ford 2017) suggested effectiveness of peppermint as an antispasmodic, with moderate evidence but also gave safety concerns for peppermint of reflux, heartburn, dry mouth and belching – and peppermint taste – presumably through reflux? Plus smell (not sure how this would be adverse though – it is in fact quite a pleasant smell on the breath) (Camilleri and Ford 2017.)

Why am I not surprised that heartburn is a side effect for some people with IBS? It is quite common for people with IBS to experience some upper gastrointestinal symptoms. As such, reflux and heartburn are included as symptoms checked for when using the Kings College validated symptom checklist, which I use in clinic. Again peppermint is a smooth muscle relaxant – so would it not relax the ring of muscle at the bottom of the oesophagus, leading to reflux symptoms?

All studies reviewed the short term effectiveness and suggested that more studies in the long term use is needed. Should you try a peppermint based medication? Certainly do if your GP/gastroenterologist suggests it, and the evidence based from systematic reviews suggest it is effective. But if you do suffer from IBS and reflux, another antispasmodic option might be a better choice, discuss with your GP or pharmacist, who can advise on use of peppermint and suitable alternatives.

Does peppermint ever cause any problems with allergy/intolerances?

One case review reported on an anaphylaxis reaction due to an IgE mediated allergic reaction to peppermint (Bayat R, Borici-Mazi R 2014) – this is extremely rare. It is quite possible that other reactions may be causing symptoms for a very small number of people. Peppermint is a natural source of salicylate. Aspirin, as a form of salicylate, can occasionally cause allergic reactions, and people with aspirin allergy, asthma and nasal polyps can occasionally have a food hypersensitivity to foods naturally containing salicylate. This type of food reaction again is quite rare but symptoms could be mistaken for IBS. Do seek the help of a dietitian if you suspect this kind of food hypersensitivity, as often information about salicylate containing foods on the internet is often far too restrictive for any low salicylate diet to be implemented safely. Also it is often quite tricky to identify these reactions to foods so an experienced practitioner is important to seek advice from.

Chemistry-Salicylic-Acid
www.compoundchem.com

Alexander C Ford, Nicholas J Talley, Brennan M R Spiegel, Amy E Foxx-Orenstein, Lawrence Schiller, Eamonn M M Quigley, Paul Moayyedi, (2008) Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis BMJ. 2008; 337: a2313.

Khanna R, MacDonald JK, Levesque BG. (2014) Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014 Jul;48(6):505-12.

Michael Camilleri and Alexander C. Ford (2017) Pharmacotherapy for Irritable Bowel Syndrome J. Clin. Med. 2017, 6(11), 101; doi:10.3390/jcm6110101

Bayat R, Borici-Mazi R. (2014) A case of anaphylaxis to peppermint. Allergy Asthma Clin Immunol. 2014 Jan 28;10(1):6. doi: 10.1186/1710-1492-10-6.