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Clinical Alimentary

Know your guts, love yourself.

Interested in home cooking? Do you want to take part in a new TV cooking competition?

Voltage TV are looking for people who are passionate about home cooking for a new BBC2 series to get in touch. This will be the next big TV cooking competition. Voltage TV are looking for Britain’s best home cooks and want to hear from people who are renowned for their home cooked dishes. Do you have family recipe’s that has been passed down for generations? Do you have a different outlook on cooking and eating? Then email food@voltage.tv

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The moorland wild bilberry

In the month of August the moors around Lancashire and Yorkshire provide an abundance of wimberry (more frequently called bilberry). These little berries are delicious but it takes some effort in gathering them, but it is certainly worth that effort. They are ready now to harvest and if you have a few hours to spare you can gather enough to make jam – not enough time? Then perhaps gather enough to serve on your breakfast (portion is 80g), these little fruits are also likely low fodmap according to Monash – so a free, low fodmap berry that you have to exercise to find the bushes and picking them is a mindful task, a win win all round! A tip to save time in gathering them is to look for the bright green new growth on the bushes as this seems to have the larger berries. This year seems to have a bumper growth of them there are plenty to pick but I always leave enough on the bush for the local wildlife. Also do ensure that you identify these bushes correctly before foraging the fruit – see the image below.

Winberry are high in acidity so this will produce a moderate set without necessarily any addition of extra acidity and not too much additional pectin for jam making. Nutritionally they contain anthocyanins, water soluble pigments that are proposed to have antioxidant properties. A anecdote often proposed for bilberry is that it enhances night vision and was used during the second world war by pilots to enhance their vision during bombing raids (a story proposed for the carotenoids in carrots too!) A review Canter PH & Ernst E (2004) Anthocyanosides of Vaccinium myrttilus (bilberry) for Night Vision – A systematic Review of Placebo Controlled Trials Survey of Ophthalmology Volume 49 issue 1 reported the hypothesis that bilberry enhances night vision has a lack of evidence from rigorous clinical studies. Also the fact that these fruits are not going to be consumed on a regular basis will also impact on the health benefits they do have – so let’s not get overly concerned about it, just eat them for the pleasure of gathering them in summer and a the reward for your hard earned efforts!

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Can you cook a cucumber? British cucumber week

The humble cucumber – stalwart of the afternoon tea finger sandwich has it’s own week, dedicated its summer fresh light green crispness. I find the cucumber a great salad vegetable and obviously it has been used in sandwiches for afternoon tea – a meal that has had a revival recently, but can you use it any other way?

Soup is a good start but what about roasting cucumbers or fried cucumber pasta? I think I might give it a try as the cucumber is a low fodmap vegetable – let’s see what happens!

Ingredients

2 inches of cucumber sliced thinly

1 roasted pepper (sliced)

10 olives

matchbox piece of Parmesan grated

150-200g dried gluten free pasta

1 teaspoon of garlic infused olive oil

Method

Boil the pasta as directed by the packet instructions

Using the oil fry the cucumber, pepper and olives till warmed through

Drain the pasta and combine with the vegetables

Sprinkle with grated Parmesan

Serves 2 – this was very tasty – despite first appearances!

pasta2

It’s Not ‘Just’ IBS campaign

Watch the presentation I gave for the IBS Networks event the patients perspective about the petition to recognise that it’s not ‘just’ IBS. The petition is still open and you can sign it here if you wish https://www.change.org/p/all-political-parties-and-the-national-medical-director-recognise-it-s-not-just-irritable-bowel-syndrome-ibs

Its Not Just IBS Campaign-YouTube from CVC Event Services on Vimeo.

Pecan, lime and blueberry bircher low fodmap

What a glorious way to start the day with a yoghurt and oat based creamy breakfast – this recipe contains ground flaxseed to add lots of soluble fibre to your breakfast, a real treat for sluggish bowels! Skyr yoghurt contains lactose – if you are lactose intolerant and are concerned about yoghurt add lactase liquid to the yoghurt. The dose recommended is 5 drops per pint – 4 drops to convert a large pot of yoghurt (450g) for the Biocare liquid lactase product,  it does contain glycerol, which is a polyol, but lactase enzymes should be included after the re-introduction phase of the fodmap diet and you will be aware of whether you need to exclude polyols, although lactase drops are used in very small amounts, usually. Another product available appears to be Colief but this is marketed as infant colic drops at a slightly higher price for 15ml with very similar ingredients. These were the only two brands available when I searched for UK products, do let me know if you use others. It is probably better to treat milk/yoghurt with lactase prior to drinking or using it in recipes, as this forgoes the complex vagaries of digestion – I would suggest digestion is certainly more complex with IBS – the effects other food components in the digestive tract or in recipes may reduce the effectiveness of the lactase. This prepared yogurt needs to be left for twenty four hours in the fridge for the lactase to take effect. However some people with lactose intolerance can manage yoghurt, as the manufacture means a lower level of lactose in yoghurt – go with what you tolerate, once you have completed your fodmap re-introductions you should know how much you can have without symptoms. The yoghurt can then be used to make up the bircher, this is usually left overnight.

Ingredients

200g of low fat low sugar Skyr or thick textured yoghurt

50 mls fluid

1 heaped tablespoon of ground flaxseed

1 teaspoon of lime curd (check labels for any fructose based syrups and avoid)

20g of pecan nuts

1 heaped tablespoon of oats

13g of dried blueberries or 80g of fresh.

Method

Add the flaxseed to 50ml of water, mix well.

Then add the yoghurt, oats, blueberries and lime curd to the mix.

Prepare this recipe the night before and it will be ready for you to eat the next day! Add the chopped pecans just prior to serving to retain the texture. Yum!

Drink a glass of fluid or cup of tea with this for additional fluid to help the flaxseed move through your bowel.

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All ingredients for this dish were purchased.

 

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!

http://bit.ly/1Unq3u7

http://bit.ly/1UzuYaW

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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The ‘ravelled sleeve of care; how sleep affects IBS — The Sensitive Gut

See here for a great post from Dr Nick Read about how sleep disturbance affects IBS

Sleep disturbance affects about a third of the American population, but is particularly common in patients diagnosed with IBS. As many as 74% of people with IBS characterise themselves as poor sleepers. People with IBS often report that their sleep has been disturbed and they do not feel rested when they get up in the […]

via The ‘ravelled sleeve of care; how sleep affects IBS — The Sensitive Gut

Quinoa deli filler

This deli filler can be used in gluten free wraps, sandwiches and on the top of jacket potatoes and is a really quick easy recipe to make. It has a very fresh taste and is a great option for summer al fresco dining. Just perfect if you want to go out for a picnic or need some alternative ideas for your lunchbox. I used Clearspring organic quinoa trio. Packet quinoa can be used hot or cold and is suitable for a low fodmap diet, just ensure you check the ingredients list before you buy. The recipe does contain egg in the small amount of mayo used to bind the ingredients together. The quinoa contains some oil but you could add a little dressing instead of the mayonnaise, if you are vegan, to bind the rest of the ingredients. You could also cook your own quinoa but this would defeat the point of making this dish as easy as possible so you can quickly make your sandwiches or wraps and get outside in the sunshine, for a picnic perhaps!

Ingredients

1 packet of Clearspring Quinoa

6 radishes

5 chives

3 tablespoons of pine nuts (these are expensive – leave them out if you wish)

150g of white cabbage

2 roasted peppers (use roasted from a jar to save time)

3 heaped teaspoons of extra light mayonnaise

Method

Wash the vegetables.

Slice the radishes thinly, chop the white cabbage, chives and the peppers

Empty the packet of quinoa into a dish

Add the rest of the ingredients and mix well.

Taste, then season if needed – the ready made quinoa already contains salt, I certainly didn’t need to add any extra.

Serve.

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(The quinoa was purchased by me, other makes of quinoa can also be used in this dish if needed.)

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