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When FODMAPs doesn’t work

“I’m contemplating doing the RPAH elimination diet after little success with low FODMAPs” wrote a woman in her mid 50s with a 13 year history of IBS. 

FODMAPs vs the RPAH Elimination Diet

A dietitian who specializes in IBS tells us that she usually finds that food chemicals are the main issue in IBS, and the RPAH diet is the one she uses most.

If your only symptoms are IBS (e.g. bloating, reflux, stomach cramps, wind and diarrhoea) your dietitian may recommend a trial of the FODMAPs diet but if there are any other food intolerance symptoms – in you or your family - then it may be best to do the 3 week strict RPAH Elimination diet, perhaps with gluten and dairy free options - and no mistakes.

My GP said “… most people would react if eliminating and then introducing a dose of something” and she’s concerned I will make myself more sensitive.

I am disappointed that your GP didn't refer you to an RPAH trained dietitian (see our list below). We recommend the diet with a dietitian’s supervision because there are 3 important stages:

  • elimination (no more than 3 weeks)
  • challenges (exactly as written down by RPAH)
  • reintroduction

That way you will find out exactly what affects you, and reintroduce everything else in a timely manner - as recommended by dietitian Joy Anderson in the letter below:

Why see a dietitian? - an answer for your GP
 
A letter from Joy Anderson (a retired WA dietitian from our list who was made a Member of the Order of Australia for her significant contribution to community health especially through the Australian Breastfeeding Association)

"As a dietitian who uses the RPAH Allergy Unit Elimination Diet in my everyday practice, I can assure you that it does work brilliantly in the majority of cases, in infants (via mother's breastmilk), in children and in adults as well. However, it needs to be done properly ... The diet should be supervised by an Accredited Practising Dietitian with experience in food-chemical intolerances and conducted as a test diet, for a limited period of time - usually only 3-4 weeks in duration. Occasionally it may go longer, but the dietitian ensures that nutrients are adequately compensated for. The challenges are then performed in a timely manner and the diet refined to be liberalised as much as possible, while only avoiding the problem foods long term. I have many, many satisfied clients who were fobbed off by other health professionals in the past, because they didn't 'believe' in food-chemical intolerance” – Joy’s  letter appeared in the June 2013 issue of the Medical Journal of Australia InSight

Have you seen much success treating IBS?

Absolutely!!!!  There are reports from people like you for whom FODMAPs didn't work or made them worse, who then did well on the RPAH diet. Or some people need to combine both.

"I was diagnosed with IBS about 2 years ago and told to follow the FODMAP diet to reduce symptoms. The last few months my symptoms flared right up again … and  have now been told to cut out salicylates and amines (at least initially) as that is likely to be my problem. After one week on the elimination diet I have noticed a huge improvement, apart from the fact I am missing all my usual fare like spinach, coconut, berries, tomato and the list goes on! I am so grateful though for the relief, I actually feel normal again. Thanks!" –  Lisa, story [1214]

“I was on the Fodmap diet and it wasn't working - now I am going low Salicylate foods and I'm improving a lot “– Karen, story [1465]

“I have been suffering from various IBS-like symptoms for several years… A couple of months ago I saw a dietitian and tried a FODMAP elimination diet for a month. Although there was improvement in some areas there was a decline in others. I became VERY forgetful and suffered stomach cramps when eating what turned out to be foods high in salicylates“ – Sharon, story [1122]

See more stories in our new story collections about IBS and FODMAPs

More information

IBS factsheet

Introduction to food intolerance

List of experienced and supportive dietitians

Support - people say our facebook group is friendly and supportive

 

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Food intolerance

Some of the many symptoms of food intolerance that can be helped by diet:

Airways: Asthma, Stuffy blocked or runny nose/ nasal polyps, Frequent nose bleeds, Catarrh, chronic throat-clearing, Sinusitis, Frequent ear infections, Frequent tonsillitis, Frequent colds and flu, symptoms of Samter's Triad, hayfever, allergic rhinitis Skin: Eczema, Urticaria (hives), Cradlecap, Other skin rashes, Angioedema (swollen lips, eyes, tongue), Geographic tongue, Pruritis (itching), Rosaceae, Allergic shiners (dark circles under eyes), Pallor (pale skin), Flushing, Excessive sweating, Body odour, Sore vagina in children, Alopecia (patchy baldness) Digestive system: Irritable bowel symptoms (IBS), Recurrent mouth ulcers, Indigestion, Nausea, Bad breath, Vomiting, Diarrhea, Stomach ache, Bloating, Reflux in babies, adults, Constipation, Colic in babies, adults, Sluggish bowel syndrome (feeling of "more to come"), Encopresis, Soiling (sneaky poos), Dairy intolerance, Gluten and wheat intolerance, Eating disorders (ed), anorexia nervosa, bulimia nervosa, binge eating disorder (BED)  Bladder: Bedwetting, Daytime incontinence, Urinary urgency, Recurrent inflammation (cystitis) Skeletal: Growing pains, Gout, Arthritis, joint pain, arthralgia Eyes: Nystagmus (involuntary movement), Blurred vision Muscles: Low muscle tone, Myalgia (muscle pain), Tics (involuntary movement), Tremor, Leg 'jiggling', Heart: Rapid heart beat, Heart palpitations, Cardiac arrhythmias, Pseudo heart attack (feeling of impending doom, chest pressure, pain down arm), Tachycardia (fast heart beat), Angina-type pain, HHT Central nervous system: Headaches or migraines, unexplained tiredness, Chronic fatigue, Feeling 'hung-over', Confusion, Dizziness, Agitation, Tinnitus (noises in ear), HyperacusisAuditory sensory processing disorder (ASPD), Paraesthesia (pins and needles), Dysaesthesia (numbness), Hypoglycemia, Salicylate-induced hypoglycemia, Epileptic seizures, Fits, Sensory symptoms of multiple sclerosis, Scents and perfume sensitivity, Symptoms of lupus Anxiety: Panic attacks, Depression, Obsessive ruminations (repetitively focusing on bad feelings and experiences from the past), Self harm, Suicidal thoughts, actions, teeth grinding (bruxism) Impaired memory: Vague or forgetful, Unable to concentrate, Won't persevere, Unmotivated, Disorganised, Easily distracted, Difficulty reading and writing Speech: Loud voice (no volume control), Speech hard to understand, Speech delay, Selective mutism, Stuttering, Repetitive noises, Talks too much (empty chatter) Coordination: Poor handwriting, Poor coordination, Frequent accidents, Vertigo Sleep: Difficulty falling asleep, Restless legs syndrome (RLS), Persistent night waking, Insomnia, Nightmares/night terrors/sleepwalking, Sleepless babies, Sleep apnoea Mood: Brain snaps, Mood swings, Premenstrual tension, Grizzly or unhappy, Cries easily or often, Irritable, Uncooperative Oppositional defiance: ODD, Loses temper, Argumentative, Refuses requests, Defies rules, Deliberately annoys others, Blames others for own mistakes, Touchy, easily annoyed, Angry, resentful Other behaviour: ADHD, ADD, Autism, Aspergers, Inattentive, easily bored, unmotivated, 'Unable to entertain himself', Restless, fidgety or overactive, Head banging, Hyperactivity, Fights with siblings, Difficulty making friends, Destructive, aggressive, Unreasonable, Tantrums, Demanding, never satisfied, Disruptive, Discipline is ineffective, Pervasive Development Disorder

Some causes of food intolerance:

Food additives: Artificial colours: (food dyes, artificial colors) tartrazine 102 (E102, FD&C Yellow No.5), quinoline yellow 104 (E104), sunset yellow 110 (E110, FD&C Yellow No.6), azorubine, carmoisine 122 (E122), amaranth 123 (E123), ponceau, brilliant scarlet 124 (E124), erythrosine 127 (E127, FD&C Red No.3), allura red 129 (E129, FD&C Red No.40), indigotine, indigo carmine 132 (E132, FD&C Blue No.2), brilliant blue 133 (E133, FD&C Blue No.1), green S, food green, acid brilliant green 142 (E142), fast green FCF 143 (E143, FD&C Green No.3), brilliant black 151 (E151), brown, chocolate brown 155 (E155)  Natural colours: (colors) Annatto (annatto extracts, bixin, norbixin, 160b, E160b) Preservatives: Sorbates: (sorbic acid 200, E200, sodium sorbate 201, E201, potassium sorbate 202, E202, calcium sorbate 203, E203) Benzoates, hydroxybenzoates, parabens: (including benzoic acid 210, E210, sodium benzoate 211, E211, potassium benzoate 212, E212, calcium benzoate 213, E213, ethyl para-hydroxybenzoate 214, E214, sodium ethyl para-hydroxybenzoate 215, E215, propylparaben 216, E216, propyl 4 hydroxybenzoate 217, E217, methylparaben 218, E218) Sulfites, bisulfites, metabisulfites: (200-228, sulphites, sulphur dioxide, sulfur dioxide 220, E220, sodium sulphite 221, E221, sodium bisulphite 222, E222, sodium metabisulphite 223, E223, potassium metabisulphite 224, E224, potassium sulphite 225, E225, calcium sulphite 226, E226, calcium bisulfite 227, E227, potassium bisulphite 228, E228) Nitrates & nitrites: (249-252, potassium nitrite 249, E249, sodium nitrite 250, E250, sodium nitrate 251, E251, potassium nitrate 252, E252 Propionates: (bread preservative, mould inhibitor 280-283: propionic acid 280, E280, sodium propionate 281, E281, calcium propionate 282, E282, potassium propionate 283, E283, 'natural' preservatives in bread, cultured wheat, cultured dextrose, cultured whey) Synthetic antioxidants: Gallates 310, 311, 312 (E310, E311, E312), tBHQ 319, E319, BHA 320, E320, BHT 321, E321 Flavour enhancers: (flavor enhancers) glutamic acid and all glutamates, MSG monosodium glutamate 620-625, yeast extract, hydrolysed vegetable protein HVP, disodium guanylate 627 (E627, DSG, GMP), disodium inosinate 631 (E631, DSI, IMP), ribonucleotides 635 (E635, I&G, nucleotides)  Flavours: (flavors)  Natural food chemicals: Salicylates: salicylic acid, sodium salicylate, acetylsalicylic acid Biogenic amines: vasoactive amines (tyramine, phenylethylamine, histamine and others) Glutamates:  Natural foods: Dairy: milk, yoghurt, cheese, butter, lactose-free milks Wheat or Gluten: (wheat, rye, barley, oats) Soy: Sugar free sweeteners:Sugar free sweeteners: polyols, sorbitol, mannitol

On this website, failsafe refers to foods that are Free of Additives and Low in Salicylates, Amines and Flavour Enhancers. Note that copyright applies to the commercial use of the term "failsafe" in the food and health context so as to control inappropriate use by the food and health industries.