Sausage and watercress conchiglie pasta – gluten free and low fodmap

This dish is really easy to make and can be incorporated into your low fodmap recipes for working week nights, plus you don’t need to use fresh herbs – dried are just as good but maybe use a little less as the flavour is more concentrated in dried herbs. I don’t eat sausages often, and I do find gluten free ones generally have a higher level of meat so you tend to get what you pay for. Pricking and grilling them does remove some of the fat but they are still relatively high in fat – although 1 1/4 sausages for each serving is not too much! Check the sausages are gluten free but also free of onion – sometimes local butchers are the best option to buy.

Ingredients

300g of dried gluten free pasta

1 pack of watercress

6 gluten free sausages

1 sprig of fresh rosemary

2 sprigs of fresh oregano

drizzle of oil

Seasoning

2.5cm block of grated parmesan

fresh oregano flowers to decorate

Method

Prick the sausages with a fork and grill for 15 minutes till cooked

Put a pan of water to boil add a small amount of seasoning and add the dried pasta

In a pan add a small drizzle of oil and add the herbs and fry to release the flavour, then add the watercress and heat till wilted

Slice the sausage, drain the pasta

Add all the ingredients to the pasta and stir well

Serve

Add a sprinkle of parmesan to each dish

Decorate

Serves 4 with a green salad!

Tomato, pepper and spaghetti squash soup

This is a lovely flavoured soup and has a very vibrant colour. A great winter soup to warm you up on cold days!

Ingredients

800g of plum tomatoes

1 large spaghetti squash

400g tin of roasted red pepper

1 teaspoon of ginger

1 teaspoon of cinnamon

500ml water

2 teaspoons of oil

season to taste and sprinkle with poppy seeds

Method

This couldn’t be easier, fry the tomatoes and spices in oil then add the squash, water and red pepper. Cook for 15 minutes and blend using a hand blender. Serve sprinkled with poppy seeds.

Serves 6-8

Herding cats – the challenges of probiotic research in IBS.

The dietary guidelines for IBS have been published. It has taken considerable work to produce these guidelines over the last 2 years at least and I was very pleased to be part of the development process with some very experienced dietitians. The paper on probiotics I was involved in was a really great way of learning about this subject area and also the complexities of developing probiotic products. The perhaps unsurprising result of the systematic review means that the evidence base for these products is not strong enough to allow us to advocate one probiotic product for IBS. However the Ford (2014) review with meta analysis (a calculation used to show whether combining controlled treatment trials are effective) showed that overall probiotics are effective. Wow – conflicting!

The variety of formulation possibilities of a probiotic product means that it would be unusual for a new product to be the same as one that has been previously developed. Heterogeneity of these products is a big problem, imagine you are a manufacturer, you don’t necessarily want to go over old ground as the expense of development and research is high and you want to fund research to showcase your new product. Research in industry is about marketing and the product, you want to recoup your investment.

But repetition is exactly what is needed to strengthen the evidence – more papers showing effectiveness for one product. A generic medication, where choice of how to produce the medication formulation is likely limited by the chemical nature of the active ingredient, perhaps meaning the tablet excipients do not vary overly much. The result is you can have many published papers for one medication, a position of strength. Probiotics, on the other hand, can be added to a food, and should be classed as a functional food, which is chemically complex and varied. Not that I lay the blame solely at the door of the manufacturers, the choices they have when considering new developments are enormous – to include one or many probiotic species, to have a tablet, yoghurt of fruit juice drink? What is the likely shelf life, when do you take it – with food, after or before? Does it survive to the digestive tract? Does it need too? (Enck 2008 denatured their probiotic before its use) What dose to include? (This was tested by Whorwell in 2006 – three doses and only one proved to be marginally effective.)

Are we looking at a food or a medication? As I have stated above probiotics should be classed as a functional food. Randomized controlled trials are a very good method of researching medications, but not necessarily diets, which are overly complex and difficult to randomise. However, this is the best method we have and is a requirement for a good evidence base, so clearly needs to be used.

Confounding variables (a factor that is not under study that can vary and influence the final result) are vital to be considered and ruled out. In probiotic research, when we a researching a food item, we should ensure participants diets do not change and influence the final result. The more understanding we have in how our diets influence our own microbiota, which has improved over the past few years, the more important this variable is becoming to the methodology. So it needs to be considered a part of the methodology and shown not to change throughout the duration of the study.

We have a varying medical condition – IBS, IBS-C, IBD-D, IBS-M and IBS post infection – could these possibly be distinct groups? Treatment for one type of IBS also might result in swinging symptoms to another type – changing bowel function for sure, but the patient feels no better. Quality of life is very important and certainly should be part of the measures used, testing has used a variety of different validated tools to assess this important factor. Also, measuring tools for IBS are often not standardised, all of these factors make for poor results.  We also have Rome IV, which has removed the term ‘discomfort’ from it’s diagnostic criteria, reducing prevalence of IBS overnight – it is going to be very interesting to see what effect this has on future treatment research.

Numbers of participants in studies are often low, meaning that the studies should be defined as pilot studies – this results in a positive effect being overly positive (p values will be likely closer to 0.05 for higher numbers of included participants, if you have a p value of 0.001 check out the number of participants – if you have over a hundred this is a good result! If you have 10, maybe not so great.) We do need over 100 patients to make good research in IBS.

We also have a situation where some probiotics that have two RCTs – often with conflicting results, how is this possible? We are likely comparing two ‘moving targets’ both with high heterogeneity – my personal view is that research in probiotics and IBS is a little bit like herding cats – a very big challenge. When herding cats, the method used is vital to the success of the job and probiotic research is no different in this. The methodology, whilst has improved over the last twenty years, needs to be further tightened up, I’m afraid.

One topic that is often mentioned in IBS research, is placebo effect, this is reported to be high, anywhere from 30-50%. So, to know if the product is actually effective you need to test whether the result gives an improvement of over this percentage, from baseline. Not many are. But is this an issue? Maybe not if the patient feels better that is a result, we need to consider the patient in our assessment of the evidence too.

This is where we are, considering the patient. Perhaps the fact we have any studies showing a positive effect is nothing short of a miracle considering how difficult this research is to undertake. Standardizing the process will produce better results and should certainly be considered. Drivers for the probiotic industry are the ability of using a health claim on their product, EFSA have still declined to confer this privilege to any probiotic product. The one manufacturer that does achieve this status is likely to be a market leader, using good methodology is key to this process, in my humble opinion. However we have a duty here to people with IBS and perhaps taking a pragmatic approach is best, as overall the evidence by meta-analysis suggests that probiotics are effective. We should publish where the evidence is best to help patients to choose the best option, if they want to try these products. It might not help all symptoms, but the patient should choose the symptom they wish to reduce and go with the product where the evidence is weak.

My own toe dip into herding the evidence of RCTs into a systematic review proved how much of a challenge this is, numerous hours (immeasurable) pouring over data proved to be a interesting way to learn about these products. Hopefully this effort will result in some improved data and improved results in the future.

If you wish to look at the papers yourself the links are below, and if you are a healthcare professional the probiotics paper contains a really good chart that can be used in a clinic situation. Download your copy today!

 

It’s national picnic week – low fodmap picnic loaf

It’s national picnic week – although the weather isn’t that fantastic, but you can use the ideas from this event all through the summer. Here’s hoping for better weather. This recipe used a Warburton’s gluten free seeded sourdough artisan boule (purchased.) You could just as easily use a sourdough spelt loaf – this is available from artisan bakers or make your own if you have time to spare. See the link to the Sustain website search facility for artisan breads. There are three types of sourdough and for the low fodmap diet you should choose 100% spelt flour based bread – only sourdough type one and two use a fermentation process that will reduce the fructans levels in the bread see link.

Ingredients

1 sourdough boule

1 lemon

a few sprigs of lemon thyme

1 skinless chicken breast

1 roasted red pepper

1 teaspoon of grained mustard

2 teaspoons of extra light mayonnaise

100g of Brunswick ham

young kale leaves (or rocket or green lettuce)

2 tablespoons of pine nuts

1 tablespoon of oil

Method

Cut a circular lid in the top of the cob

Mix the mustard and mayonnaise together

Remove the centre of the cob and crumb

Spread the mayo/mustard on the bottom of the cob

Layer the Brunswick ham on the top of the mustard

Layer the roasted pepper on the ham.

Layer the leaves on the top of this.

Layer sliced chicken on the top

Grate the lemon to produce zest

Add half the oil to the breadcrumbs, lemon zest, lemon thyme, pine nuts and roast at the top of a hot oven – watch this carefully as it can burn very easily.

Cool the breadcrumbs

Pack this in the top of the cob use the rest of the oil on the bottom of the lid.

Place the lid on the cob, wrap tightly in clingfilm and refrigerate overnight.

Serves 6

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Allergy + Free From Show talk on IBS

Are you going to the Allergy + Free From Show in July? Don’t forget to get your free tickets here http://bit.ly/1Pga0N5 and come and see my talk for the IBS Network on Diet and Constipation – is it just about fibre and fluid?

This is on Sunday 10th July in the Learning Centre at 11:00am – come early as seats do fill up fast! If you want to see some of my talks given at previous shows check out my LinkedIn account http://bit.ly/1X8Vgav

I look forward to seeing you there!

Why your wind smells of roses – The Life of Poo book review

Well now, a book all about poo, why would anyone want to read this you may ask, surely the grim subject of poo is not something to read about – certainly not in public or polite company, I imagine you thinking. This thought briefly entered my head as I picked up the book in the bookstore and I do confess, even as a professional working in the area of digestion and more than happy to talk about poo in clinic, I purchased it online – it came in a brown package. If you are wondering whether to read on – this is not a post for those with a ‘delicate’ disposition (who perhaps belong in the eighteenth century) or one to read on your tablet at the breakfast table. You have been warned.

It might surprise you to know, you really ought to read this book. How can I persuade you to take a quick peek? How about the post title? Have you ever said, with an air of superiority, ‘my wind smells of roses, that smell cannot possibly be down to me’? You are correct it seems, at least in very small doses anyway. The ‘flower’ odour usually appears at much lower doses than is produced by a ‘silent but deadly’ however, but I’d bet you didn’t expect that did you? Adam writes that skatole and indole, the gases found in malodorous wind, smell of flowers in small concentrations.

A very surprising incident happened whilst out walking yesterday, my hubby stated this very fact when smelling hawthorn blossom. Wow, I thought, how does he know that? I really couldn’t believe it, I had only read this fact in Adams book the day before.  Well the story behind his knowledge is a bit more grim than Adam’s fascinating publication. So now I have told you about my husbands experience you want to know about it, don’t you? My husband is a chemist, he worked in a company making pharmaceutical products, one of which utilised the chemicals indole and skatole – “oh, good grief”  I exclaimed, “what sort of pharmaceutical product uses those?” “dog trainer liquid” was the response – the mind boggles. My husband had the unfortunate experience of contaminating his lab coat with these very chemicals and not only that, then proceeded to wander down to the restaurant in said lab coat, at lunch time. Chaos ensued, this had the effect of teaching him the very good lesson of removing his lab coat before dining, which one should always do, to prevent ingestion of nasty chemicals and nauseating diners. He showed absolutely no sense of embarrassment though, surprisingly enough and regaled the story with a good degree of relish.

Now, back to the topic in hand. This book is factually correct, very amusing in places and does have a small reference to irritable bowel syndrome and inflammatory bowel disease in it’s chapters – something for everyone then! It discusses the microbiota, antibiotics, prebiotics, probiotics and the microbiota’s relationship with health and disease. Very topical and containing everything of interest to me. I really like the examples used in the book to describe some complex concepts in simple easy to read form. If you want to know more about poo – yes you really do, think of it this way, it’s like looking in the bowl before flushing, you know you really should (but DO put the lid down before the flush, read a lot more about that in the book) – then I can’t think of a better book to buy.

 

This book was purchased by myself.