clinical alimentary

Know your guts, love yourself.

French toast for breakfast? – gluten free, low fodmap

This is a great Sunday morning treat and is very easy to prepare and to relax and enjoy! French toast is not sweet but when combined with fresh fruit and a drizzle of maple or golden syrup the sweetness is added – you only need a drizzle and the breakfast is complete. Posted just in time for you to enjoy tomorrow morning.


2 eggs

70 mls lactose free milk

4 drops of vanilla essence

4 drops of orange essence

spray oil

2-3 slices of gluten-free bread (depending on the size of eggs used)

Maple syrup for drizzling

Strawberries, blueberries and raspberries – a small handful.

Crack the eggs into a bowl and mix with the milk, vanilla and orange.

Slice the bread and soak in to the egg mix until it is soaked through ( a minute or two)

Spray oil into a frying pan and fry the bread for 1 minute each side or until golden.

Serve warm with fruit and a drizzle of syrup – or you can use sweetener if you don’t want to use syrup – aspartame, stevia or sucralose is suitable.




Which probiotic could I try for IBS?


Photo Credit: Christiann MacAuley

A systematic review last year by Ford and his collegues (2014) looked at probiotics and their effectiveness for IBS, the conclusion the authors made after applying some statistical analysis was that probiotics in general were effective to treat IBS. However they also stated that recommendations for individual products were difficult to make because the studies were so different from each other and the products were also different (different strains, doses, and carrier food or tablet etc) this means that the evidence for a particular product is unclear. We have guidelines that suggest probiotics can be tried by people with IBS and they should be tried for one month at the dose the manufacturer recommends, but which one? This research by Ford and collegues is good evidence of the fact that they are effective, but the information is not really that useful for people wishing to try a product. So what do you do when faced with the fact these products are recommended by guidelines but researchers are unable to specify a particular product? It is worth perhaps looking at which symptom of IBS bothers you the most and taking the pragmatic approach that it might be better to try products that have some level of effectiveness – even if this is limited. As such I have listed the products and the symptoms where some level of effectiveness has been found

Global symptoms Activia* (natural yoghurt), Alflorex, Align, Prosynbioflor 2, Pro-Viva, Synprove

Diarrhoea              Alflorex, Align

Constipation         Activia* (natural yoghurt)

IBS mixed              No papers (perhaps it would be best to choose the products in the global                                                     symptom list)

Abdominal Pain    Activia* (natural yoghurt), Alflorex, Align, Prosymbioflor 2 (may give side effects), Pro-viva Synprove

Discomfort (lower degree of abdominal pain) Yakult (this was only viewed as an abstract but data looked promising)

Flatulence               Alflorex, Align, Lab 4, Pro-Viva, #VSL 3, Synprove, Yakult (this was only viewed as an abstract but data looked promising)

Bloating                  Alflorex, Align, #VSL 3,

Satisfaction with bowel habit   Synprove

Quality of life           Bioflor

*for people with more severe symptoms of IBS

It might be worth considering checking the product for fodmap content if you are following the low fodmap diet or have particular food intolerances, This data has come from the published data on these products – I will try to update this list as new developments occur.

Ford A, et al (2014) Efficacy of prebiotics, probiotics and synbiotics in irritable bowel syndrome and Chronic Idiopathic constipation: systematic review and meta analysis Am J Gastroenterol. 2014 Oct;109(10):1547-61


Potato and smoked mackerel soup – Low Fodmap

This is a really tasty soup that is made from basic ingredients and I hope you like it!


800g of potato

1 carrot

sprinkling of asafoetida

1 tablespoon of garlic infused oil

1 1/2 smoked mackerel

300 ml of lactose free milk

Salt and pepper

grating of nutmeg


1 litre of water (or more depending on how thick you like your soup! Just add more as needed)

wash and peel the potatoes and carrot and chop

add oil to the pan and add asafoetida and fry

add vegetables

add flaked mackerel

add milk and water, bring to the boil and simmer till vegetables are soft

add salt and pepper to taste

blend or mash soup – depending on your preference

add grated nutmeg.

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This dish serves 3-4 (depending on how much water you add!)

Monash advises on the suitability of ‘superfoods’ for the Low Fodmap diet and de-bunks the myth

If you have followed my blog for some time you are probably aware of my views on super foods – if not check out one of my previous posts on the superfood called carrots – yes really! The blog has an old reference to David Cameron’s pasty saga though, which you might not be aware of, as the post was written some time ago!

The carrot has the added advantage that it is low fodmap too, so don’t believe all the superfood hype. The best fact is though that carrots are cheap – superfoods attract a super high price, the best tip however is to have a good variety of foods in your diet. You don’t need to include these super foods to be healthy. But what if you want to include coconut water, kale and chia seeds in your Low Fodmap Diet? The Monash blog has a really good post about de-bunking the myth behind super foods and gives advice on the fodmap content of those foods. You should check out this blog.

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Purple sage & parsnip gnocchi

Today the weather has been grim again so I am stuck in the house being creative, or perhaps you should decide if I am! I adore parsnips, they are a tasty root vegetable that is not too hard on the digestive system. It is getting towards autumn now so a nice recipe using parsnips in place of potato sounds an interesting idea. Not that I have anything against potatoes or I not that I reckon parsnips are some kind of ‘super root’ – if you have been following my blog for some time you will know my views on this ;-)

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500g of parsnips

80g of gluten free flour

20g of Parmesan cheese

2g purple sage leaves (you can use ordinary sage if you wish)

Salt and pepper

1 tablespoon of garlic infused olive oil

a sprinkling of asafoetida


wash, peel and boil the parsnips until they are quite soft in salted water

mash them well

whilst still warm add the gluten free flour and mix well

empty the mix on to a floured surface, split into four equal amounts

roll each into a sausage shape and cut into disks evenly

roll each disk into a ball then squash flat with a fork

Boil a pan of water and add a few gnocchi at a time they will float when they are cooked

remove them from the water and drain.

using the olive oil fry the sage and asafoetida and mix with the gnocchi

add grated Parmesan to serve

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the gnocchi can be served as they are if you are vegetarian or they will taste great with meat, chicken or fish too!

If you follow a vegan diet then you should use a dairy free Parmesan alternative.

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I hope you like them – the recipe serves two for a main dish, it is also possible to use them as a side dish serving 4. If you are following the Low Fodmap Diet parsnips are low fodmap – have a small portion. I am seriously wishing the weather to improve a little – it is much to early for wintry weather to be a feature but of course being situated in the middle of the Pennines this is a distinct possibility. Although I don’t want to end on a negative note so enjoy the recipe and I will blog again soon from happy valley!

Gluten free, low lactose rosemary and olive bread

The seat in the wood has intrigued me since I stumbled across it, looks home made, old – it has certainly seen its fare share of winters, I guess. It doesn’t overlook a repose worthy view and the valley’s features are obscured by the wall when seated, but is certainly a welcome resting place from the steep climb of the valley side. A haunting melancholy spot in an old oak forest – to come home to a meal of rosemary and olive bread is certainly what’s needed to cheer up the spirit after today’s walk! Check out the recipe below.

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450g gluten free self raising flour

1 teaspoon of xanthan gum

3 tablespoons of olive oil

15 green olives


350 mls of lactose free milk

5g of rosemary leaves

Spray olive oil

2 eggs

50g of Parmesan cheese

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Wash your hands

Measure out the lactose free milk, add eggs and olive oil mix well, add salt to season.

Weigh out the gluten free flour and add the xanthan gum, and mix well.

Grate the Parmesan cheese and add 2/3 to the flour leaving the remainder to sprinkle on the finished bread.

Chop the rosemary finely and add to the flour.

Slice the olives and add 2/3 to the flour leaving the remainder to decorate the top of the bread mix before cooking.

Mix the Parmesan and olives into the flour, make a well in the centre of the flour mix and add the liquid ingredients.

Incorporate the liquid into the flour till everything is blended in.

The finished mix has a slightly sticky texture.

Oil a tray well and add the mix, wet your hands and smooth the surface and add a thumb print in lines down the bread as a decoration.

Spray the surface of the mix with olive oil

Add the remaining olives and cheese.

Cook for 40 minutes or until a skewer inserted into the bread comes out clean at gas mark 6 or 220 degree centigrade.

Serves 8-10

For a low fodmap diet xanthan gum is possibly fermentable but is in the bread in very low levels (less than 0.5%) so most people should be OK to have a portion.

Prunes – natures laxative.

“I hope my tongue in prune juice smothers, If I belittle dogs and mothers”

Ogden Nash

Ogden Nash was an American poet who suffered from crohn’s disease according to Wikipedia, his unfortunate demise was after a lactobacillus infection after eating poorly prepared coleslaw as the Wikipedia site states. Interesting quote about prune juice, do you get the feeling he detested prunes? Prunes might have resulted in symptoms for him – depending on his crohn’s disease. I can only speculate, but what do these dried fruits do for us? Should we in fact include them in our diet? The following post by Compound Interest explains the chemistry behind the prune – or dried plum.

Prunes do in fact improve constipation – but for some people at a cost – the reason they do is down, in part to the large amount of sorbitol and fructans they contain, these FODMAPs or fermentable sugars draw fluid into the small bowel and rapidly ferments in the large bowel. Sorbitol is also found in sugar free mints and gum – often a warning is given on these to avoid eating too much as a laxative effect may be the result. Not great if you have IBS and bloating and are intolerant to sorbitol. Prunes could also result in symptoms for people with active crohn’s disease too – perhaps that is the reason they are suggested by Nash to be a treatment to instill an avoidance of denigrating your mother! Or alternatively it might be just down to taste or personal preference. But to help constipation if you don’t suffer from IBS, bloating and excessive wind – they are worth a try – introduce them in your diet slowly so your bowel adjusts to the extra fibre they contain. These sugars can also have a pre-biotic (food for bacteria) action, so it is worth including some in your diet if you tolerate their effects!


Sprouts – love them or hate them?

What do you think of Brussel sprouts? Like them or loath them? According to Compound interest website they are a real marmite vegetable, a gassy fodmap food but some people really love them! Check out the link below to learn more about the chemistry of the much maligned vegetable from the excellent chemistry website Compound Interest.

Sprouts also contain fructans which is responsible for the propensity of Brussel sprouts to be fermented by the gut microbiota, small amounts can be tolerated but don’t go over the top with your portion if you suffer from IBS and are following the low fodmap diet or are intolerant of fructans!

Our amazing gut microbiome – what is it and what happens when it goes awry?

Courtesy of MetaHit website
Courtesy of MetaHit website

Our microbiome is the name for the microbes that live on our body and some people think that the microbiome is our forgotten organ. Over the last few years our knowledge of what our microbiome is has increased through the Human Microbiome Project (USA) and the Metagenomics of the Human Intestinal Tract (metaHIT) project (Europe) specifically researching the digestive system microflora. Research has also been instigated to look at the way these microbes interact with our immune system and the implications that alterations to our microbiome has our health and well-being. This also has implications of how you think of yourself – do you consider at all that you are a home for microbes that do provide tangible benefits, some of which are still possibly to be discovered? We live in a synergistic way with our microbiota so both them & us gain benefit from this relationship, so it is worthwhile considering this aspect of ourselves when we choose our lifestyle and diet.

The microbes that live with us have over 400-1000 species depending on which research is viewed. As this blog is all about the digestive system we will focus on this area – we have approximately 100 trillion microbes in our large bowel, that number is very difficult to comprehend, but it is 10 times the number of cells we have in our bodies. For an average man of 70 Kg, 2kg (or 3 percent) of his body weight will be due to his microbiota. Throughout the digestive tract the numbers are as follows, in our mouth anywhere between 20 – 100 billion this is a difficult area to measure the population level, because it does tend to vary with levels of mouth hygiene. Our stomach has a much reduced level of 10-1000 per ml, this is as a result of the acid produced by the stomach, it is a more difficult environment, some microbes have developed complex strategies to make the stomach a home, H Pylori is one such bacteria and this is a pathogenic bacteria causing ulcers. Our small intestine is a more favourable environment, due to its neutral pH, but again numbers are small 10,000 – 10 million. The large bowel is where all the action takes place, 70% of the bodies microbes are found within the large bowel.

Our gut microbes provide us with vitamins examples such as vitamin K, B vitamins biotin & folate, through the bacterial fermentation of the fibre sources in our diet. This process also produces substances such as short chain fatty acids (SCFA) such as butyrate, the cells lining the digestive tract use SCFA as an energy source and butyrate is a beneficial SCFA, which has been implicated in helping to have a good gut barrier function and also protective against colon cancer for example. Chemicals produced by our commensal gut bacteria act to kill off pathogenic bacteria and our ‘good’ bacteria compete for nutrition, through competitive exclusion, so there is definitely benefits to having safety in numbers of our ‘good’ bacteria. Our microbes have a role to play in our developing immune system and the barrier function of the digestive tract.


A new born baby is exposed to the microbiome of it’s mother during birth and it has been found that vaginal birth compared with c-section changes the types of digestive system microbes – c-section babies have higher numbers of the microbes that are found on the skin. Exclusive breast feeding also populates the digestive system, it is known that breast feeding protects the infant, lowering the risk of diarrhoea & vomiting, constipation, developing obesity, type 2 diabetes, allergy and atopy. It is not always possible for women to breast feed but as a society we should be promoting breastfeeding and making it easier for women who can, to be able to do so. The microbiome then changes around the time of weaning to the first three years of life so what we eat also changes the population too. Infancy is also an important time for the developing immune system and also new exposures to our environment and this has lead to the ‘old friends’ theory.

The ‘old friends’ theory has overtaken the hygiene hypothesis as a concept for the changes in our microbiome in early years and the implications this has for our future risk of disease development. It hypothesizes that regular exposures to human, environmental and animal microbiota during the development of the immune system is essential, as these microbes interact and regulate the immune system, keeping it in balance. In recent years changes to our lifestyles and exposures to our environment have inadvertently reduced our exposure to our microbial ‘friends’. Lack of exposure to the right kinds, doses and diversity of microbes is implicated in affecting long term health – it is known that children who live on farms have a lower level of allergic disease for example, but more research is needed.

Schematic representation of theories behind IBD development (2)

Changes to the microbiota have been implicated in obesity, malnutrition, cardiovascular disease, diabetes and the digestive conditions such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). For Crohn’s and colitis it is hypothesized that it is a genetic variability in the innate immune response that predisposes the risk of developing these diseases. For IBS it is known that a lower number of lactobacillus and bifidobacteria and generally a reduction in number of species of the microbiome is present. Previous acute gastrointestinal inflammation has been established as a major risk factor for the development of post-infectious IBS (IBS-PI) and a significant body of evidence has emerged in support of microscopic inflammation as a primary factor in the pathophysiology of IBS without necessarily a clinical history of infection. Therefore is an altered gut microbiome a subgroup of patients with IBS? However we also know that people do change their diet in an effort to ameliorate symptoms – so is it changes to gut function in IBS or changes in the diet resulting in microbiota changes in the large bowel? There is still some uncertainty needing further research with this complex area. More also needs to be researched with respect of our dietary choices and how this changes our commensal populations. With particular respect to alterations in macro-nutrient components in our diet and the possible implications that malnutrition and obesity states have an associated alteration in the microbiome and what effect this has on health & disease.

What is certain however is much more is likely to be discovered about our interactions with our microbiota and how those interactions protect us from long term medical conditions, plus this information may lead to new treatment possibilities for the diseases implicated in an altered microbiome. It is a really exciting time for the understanding of the microbiota and I for one will keep looking at the published studies to see what new developments arise in this fascinating area – will you join me?

The most downloaded papers of 2014


It’s great to know clinical guidelines for dietary management of crohn’s disease in adults was one of the most downloaded papers in JHND!

Originally posted on Journal of Human Nutrition and Dietetics Notes:

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