due to atrophy of the villi in the mucosal layer of the small intestine. This condition is associated with coeliac disease. The dietary treatment is the same as for coeliac disease and often it may also be necessary to eliminate milk and milk products.
Inflammatory gastrointestinal diseases (ulcerative colitis and Crohn’s disease)
Several theories exist regarding the causes of these diseases, including genetic as well as infective and immunological factors. In some people the distinction between the two conditions is slight.
When one or more segments of the small or large intestine are inflamed, then the condition is called Crohn’s disease. The symptoms include fatigue, poor appetite, joint pains, pain in the lower-right quadrant of the body, cramps, diarrhoea and fever.
When the inflammation starts in the rectum and extends to the colon, without affecting the ascending or right side of the colon or the connection with the small intestine, the condition is called ulcerative colitis. The symptoms include discomfort in the lower bowel, cramps, chronic diarrhoea, depression, irritability and emotional instability.
Initially, the same dietary principles are applied to both conditions. As lactase-enzyme activity is reduced in people with these conditions, milk and milk sugar (lactose) are restricted in the diet. Some people do well on a milk- and gluten-restricted diet. It is very important to consult a dietitian with the planning of this diet to improve the health of the gastrointestinal tract and to provide the necessary nutrients to the body in the long term.
Increased intestinal permeability and intestinal dysbiosis
A healthy gastrointestinal tract provides an effective barrier or filter to prevent the invasion of harmful substances into the bloodstream via the intestines. This barrier may become less effective due to diseases, resulting in substances such as bacteria, allergens and large protein molecules passing into the bloodstream.
Increased intestinal permeability may contribute to an increased incidence of food allergy and food intolerance. The excessive intake of antibiotics is also thought to have an effect on the incidence of the condition.
Intestinal dysbiosis can briefly be described as the inability of the gastrointestinal tract to absorb nutrients effectively, thereby impairing the immunity of the body.
In the medical and academic world there is no consensus on dysbiosis or increased intestinal permeability. Despite differences of opinion, many people suffering from these conditions experience relief when following a balanced elimination diet, which could include the avoidance of milk, milk products, wheat, gluten-containing grains, yeast, moulds and sugar.
Note that it is important to carefully consider the avoidance of any nutrients and to ensure that an elimination diet complies with the basic nutritional needs of a person. A dietitian will be able to provide sound advice in this regard.
Lactose intolerance
Lactose is milk sugar and is present in all forms of animal milk. Hard types of cheese contain little or no lactose. Soya milk, rice milk, coconut milk and nut milk, such as almond milk, contain no lactose. A lactose intolerance may be the result of a lactase-enzyme deficiency, which is responsible for the digestion of lactose. This enzyme deficiency may be the result of damage to the membranes of the gastrointestinal tract due to long-standing use of antibiotics, diarrhoea, malnutrition, or inflammation in the gastrointestinal tract due to Crohn’s disease or ulcerative colitis.
Sucrose intolerance
Sucrose is present in many products, of which cane sugar and sugar from beet are the most familiar. A sucrose-enzyme deficiency hampers the digestion of sucrose to glucose and fructose, the forms in which sugar is absorbed and consumed by the body. Sucrose intolerance may contribute to diarrhoea and a bloated abdomen due to fermentation and gas production in the gastrointestinal tract. Note, however, that sucrose intolerance is not the same as diabetes mellitus.
Lactose intolerance and sucrose intolerance may be present in the same person, possibly because the respective enzymes are produced and excreted in the same region of the gastrointestinal tract.
Irritable bowel syndrome (IBS)
Irritable bowel syndrome (IBS) is one of the diseases that keep dietitians and doctors very busy because it is a common problem in our rushed daily lives. Ongoing stress and poor eating habits weaken the immune system and may aggravate the symptoms of IBS.
The typical symptoms of irritable bowel syndrome include abdominal pain, a bloated abdomen, winds, and altered stool habits, which may include diarrhoea and constipation.
Several studies have been done regarding the causes of IBS symptoms. In summary, the following:
1.Studies suggest the possibility that some people with IBS could be suffering from a clinical condition known as non-coeliac gluten sensitivity (NCGS), resulting in a sensitivity to gluten and more specific products prepared from wheat flour such as bread, pasta and pizzas, which also contain stabilisers such as fructans to improve the texture and stability of the products. Despite the presence of gluten in rye, it seems as if pure rye products are tolerated relatively well.
2.In recent studies the influence of FODMAP (an acronym for fermentable oligosaccharides, disaccharides, monosaccharides and polyols) in people with irritable bowel syndrome has been documented. We will discuss FODMAP more in the next topic.
3.When comparing people without IBS to people suffering from IBS, the latter have less of the “good” bacteria, lactobacillus and bifidobacterium, in their intestinal flora. These good bacteria cling to the epithelial cells of the gastrointestinal tract and this reinforces the buffer or filter function of the intestinal wall and prevents pathogenic bacteria from clinging to the epithelial cells or passing into the bloodstream. These bacteria do not produce gas when carbohydrates are digested and will also suppress the overgrowth of the clostridium species (people who are troubled with an overgrowth of this bacteria will detect the smell of methane gas when passing wind). The tolerance for FODMAP, as well as fibre in general, will improve when supplementing a person’s existing intestinal flora with the lactobacillus and bifidobacterium species.
4.Inulin and FOS (fructo-oligosaccharides) are important foods for maintaining good bacteria. Keep this in mind if you decide to follow the FODMAP guidelines, especially when you consider eliminating water-soluble fibre (including oats, barley, cooked legumes, vegetables and fruit) from your diet.
The low FODMAP diet
As mentioned earlier, FODMAP is an acronym for fermentable oligosaccharides, disaccharides, monosaccharides and polyols.
Although the principles of the low FODMAP diet are commonly recommended by medical practitioners in some countries, in Australia especially, the low FODMAP diet is still a relatively new concept in South Africa. Read the following information together with the information above regarding irritable bowel syndrome. Keep an accurate record of your food intake and determine if it is necessary to eliminate all the food items below. Remember that unnecessary exclusion may lead to an unbalanced diet with a poor intake of nutrients. It is also valuable to note your state of mind every day as food is often blamed for symptoms, when in fact stress is to blame. Consult a dietitian to assist you in creating a balanced meal plan.
Food items and ingredients which are eliminated in the low FODMAP diet:
•Oligofructose, inulin and FOS (fructo-oligosaccharides). These serve as prebiotics (food) for the “good” bacteria (lactobacillus and bifidobacterium) in the gastrointestinal tract and are often added as functional ingredients (fructans) in products such as meal-replacement formulas. However, inulin and FOS may worsen the symptoms of IBS in some people. Although IBS symptoms can be relieved by avoiding inulin and FOS, keep in mind that in the long term this elimination may hamper the growth and survival of good bacteria.
•Processed and convenience foods such as breads, pizzas, pastas, instant breakfast cereals, cakes, biscuits and crackers to which fructans have been added to improve the quality and shelf life of the products. On the food label fructans will be indicated as “flour enhancer” or “stabiliser”.
•Polyols such as lactose (milk sugar), fructose