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.


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)


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:

  1. Detox your body – your liver, kidneys and lungs are all you need for this.
  2. Reduce ‘inflammation’ we don’t have enough information that broccoli has any effect for this unspecific term.
  3. 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/

An alternative low fodmap Christmas cake

If you have fructose malabsorption and/or fructans malabsorption and you are really missing a Christmas celebration cake – look no further. Christmas cake is exceptional – like the Wedding cake, but in recent years the heavy fruit cake has gone out of favour somewhat. It is also not really suitable for the low fodmap diet despite only a small slice being recommended, being packed with dried fruit and made using wheat flour. This alternative has ingredients that provide a Christmas taste and is packed full of flavour.

This is a spiced whiskey ginger and chestnut cake

Ingredients

225g Dairy free margarine

340g Dark muscovado sugar

2 eggs (or 40g egg alternative if you have an egg allergy)

240g Self-raising gluten free flour

100g Chestnut flour

1/2 teaspoon of salt

1 1/2 Teaspoons of nutmeg

1 1/2 Teaspoons of ground cloves

2 Teaspoons of ground cinnamon

2 Teaspoons of ginger

100g of crystallised ginger pieces

Method

Weigh out the dry ingredients and sieve them well into a bowl.

Cream the butter and sugar in another bowl. Add the eggs to a measuring jug and beat them with a fork, then slowly add the egg to the wet mix while beating.

If the mix looks slightly curdled (grainy) than add a tablespoon of flour to the wet ingredients and continue to mix it well.

Add the dry ingredients to the wet mix and stir them in using a metal spoon and a cutting and folding action, to not lose the air you have already added.

Chop up the ginger pieces finely and add to the mix. 

Place the mix into a greased 18cm cake tin.

Cook in an oven for 2 hours at gas mark 4 or 180 degrees C or until a cake skewer comes out of the mix clean (the surface of the cake was dry, and this might give a false  reading with the skewer, ensure you pierce the surface with a wider hole to allow wet mix to come out.)

I soaked the cake with whiskey to give it an added depth of flavour!

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!

🎆Bonfire bangers and mash low fodmap

Gravy, mmm, this is what most low fodmapers miss the most. I have found a ready-made beef stock from Atkins & Potts  https://www.atkinsandpotts.co.uk/products/stocks-gravies/17-stocks-and-gravies/P2724-beef-stock it does contain lemon juice concentrate, but as the stock ingredients consist of only 5% of the end product, this is unlikely to prove problematic. Not all of their products are suitable for the low fodmap diet, but this beef stock is handy and not too expensive compared with other specific low fodmap products. Some of you may notice there are only five sausages in the picture – hubby couldn’t wait and ate one of then during the preparation!

Ingredients

Gravy

1 pack of Atkins and Potts beef stock

2 teaspoons of gluten-free flour

Sausages

6 Gluten-free sausages (check other ingredients for fodmaps such as onion)

Vegetables

80g carrots

80g swede

80g celeriac

Spray oil

1 teaspoon of Italian mixed herbs

Salt to season

Potatoes

300g potatoes

salt to season

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Method

Prick and grill the sausages for 20-25 minutes until cooked

Peel, season and boil the potatoes in salted water for 20 minutes and mash

Mix the 2 teaspoons of gluten-free flour with water to make a paste and add this to the beef stock in a pan, keep stirring and cook until thickened to your preferred thickness, add hot water if it is too thick for your taste.

Peel and chop the vegetables and spray in oil. Add the peppercorns and herbs and roast in the oven – gas mark 6, 200 degrees C until soft.

Combine and enjoy before venturing out into the cold for bonfire night!