Beyond FODMAP - When You're Still Feeling the Bloat

By Dr. Vince Ziccarelli PhD. MSc. RD ND FICN

Many of my clients often ask why they continue to still have troubling digestive symptoms even though they have tried the FODMAP diet for a significant period of time. Often they become very frustrated, very overwhelmed, and many times throw in the towel with their FODMAP elimination diet. This is totally understandable, especially when trying their best to comply with a fairly restrictive dietary regime, to no avail.

What I usually suggest is to re-center, hit the refresh button, and take a closer look at what might be going on. Perhaps there may be some outliers that are being overlooked. The gold standard to working with food reactions is to undertake a comprehensive food symptom diary, which, when followed diligently for a 2-3 week period, will provide some very valuable insight, as to unique food triggers that may be the main culprits for adverse food reactions. In many cases, foods that are not necessarily listed in the FODMAP category, may likely be the primary triggers to adverse reactions.

Although a food symptom diary may appear daunting at first, with diligent mind-fullness you will soon become aware of the foods that are likely causing your reactions, which are usually unique to the individual. The latter is especially the case when a skilled dietitian evaluates the food symptom diary along with other dietary patterns, labs, and medical history. A skilled registered dietitian, experienced with food intolerances, is able to navigate the dietary intake patterns, and food symptom diary to pinpoint both immediate and delayed food triggers for most people with considerable accuracy.

You may have noticed that when you eliminate common FODMAPS such as gluten, lentils, legumes, garlic, milk and onions - you experience some improvement, but not enough to appreciably improve your quality of life. With the careful implementation of the food symptom diary, under the direction of a skilled dietitian, you may find out that you are still sensitive to dairy proteins, or eggs, or certain nuts, or even possibly an unexpected fruit such as Mangos. Most times when it comes to food reactions, there are cross overs in both delayed allergies, immediate allergy and or even histamine intolerance.

For instance, histamine intolerance is another area of food reactions that are surfacing for many people. In this case, individuals are sensitive to the naturally occurring histamine levels in many fermented foods including the many obvious forms namely cheese, yogurt, sauerkraut, processed meats, pickles, anchovies, chocolate, and wine. Further, leftover meals, and select fruit such as strawberries may also give rise to elevating intake of naturally occurring histamine levels. Histamine, whether from food or immune mediated response, is an inflammatory mediator, so when it reaches a threshold level in the body - it elicits an inflammatory response similar to that of an allergic reaction. Common classic symptoms of this include migraines, anxiety, itching, rashes, panic attacks, vomiting, and abdominal cramps. What predisposes individuals to histamine intolerance may commonly be some other sensitivity.

Usually these individuals may have environmental allergies that they may or may not be aware of, which tends to increase the circulating histamines in their bodies so that when they eat foods rich in naturally occurring histamines - it pushes things over the baseline threshold, thereby causing a sort of histamine reaction in the body affecting various organs, in many cases, also targeting the digestive tract. Alternatively, these individuals may be genetically low in endogenous diamine oxidase activity, which simply means they are unable to produce enough of an internal enzyme that helps break down the histamine so it does not accumulate to excessive levels.

Preliminary studies in Europe have found benefit to supplementing histamine intolerant people with Daosin (oral diamine oxidase enzyme substitution) with improved biomarkers and better overall histamine tolerance reflected by improved symptom profile. Daosin is sold throughout Europe and the UK to help people with Histamine intolerance. Daosin is taken just before meals, as a capsule orally with water, which increases the amount of DAO in the small intestine so that histamine may be processed in the digestive tract, thus re-balancing the threshold to prevent symptoms. In terms of dietary treatment - elimination and or limiting dietary intake of histamine producing foods are the cornerstone to dietary therapies for those suffering with this form of intolerance.

So getting back to FODMAP diets. Yes there are absolutely those times for certain individuals that present with IBS symptoms - the FODMAP diet therapy does the job very well, with almost 90-99% effectiveness with symptom relief. For many others, other dietary reactions are usually crossing over or it may be something altogether different than the foods found in the FODMAP category. So the take home message is to not give up. With diligence and careful investigation, under the guidance of a skilled dietitian practitioner, there is hope for better digestive and food symptom relief, take heart and hit the restart button and you may finally figure things out.