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Endometriosis and the FODMAPs Diet

June 9, 2018
endometriosis and FODMAPs, toronto naturopath, naturopathic doctor toronto

Women who live with endometriosis often report symptoms of abdominal bloating, diarrhea, constipation and of course pain. It’s been suggested that IBS (irritable bowel syndrome) may happen in about 90% (!!!) of women with endometriosis. Since almost all women are affected, it seems obvious that diet can play a huge role in pain and overall health, highlighting the need for an endometriosis diet. 

The above symptoms may happen because of the location of endometriosis (ie. near the sigmoid colon or rectovaginal space). Moreover, endo may affect nervous system function and lead to changes in sensitivity and movement in the GI space.

How is IBS Diagnosed?

IBS is often a diagnosis of exclusion –  aka. many conditions need to be ruled out before IBS can be ruled in. Nevertheless, IBS is diagnosed by the the Rome IV criteria. 

You may have IBS if you have recurrent abdominal pain on average at least one day/week in the last three months, associated with two or more of the following criteria:

  • related to defecation

  • associated with a change in frequency of stool

  • associated with a change in form (appearance) of stool

Endometriosis and FODMAPs

Because IBS is so common in women with endometriosis, focusing on nutrition and diet makes total sense. Ultimately, we want to see if certain foods are causing pain and bloating, and changes in stool formation. 

The FODMAP diet has a lot of research with respect to improving symptoms of IBS. Therefore, it should be considered for women with endometriosis as it may provide therapeutic benefit. 

FODMAP Diet for IBS and Endometriosis

If you’ve never heard of a FODMAP – that’s okay! It’s an acronym that refers to carbohydrates (ie. sugars) commonly found in food. Here’s what the letters mean:

  • Fermentable

  • Oligosaccharides

  • Disaccharides

  • Monosaccharides

  • And

  • Polyphenols

The Pathway of Food and Gut Bacteria

When we eat, food travels from our mouth down the esophagus, and enters the stomach where the carbs, protein and fats are digested. As it moves through the small intestine, the food will continue to break down into smaller nutrients which will end up being absorbed into the bloodstream. The leftovers will pass through the large intestine, which will remove fluid through absorption. The bacteria in the large intestine will digest any leftover bits of carbs and proteins.

If someone has IBS, then the above carbs (O, D and M) will NOT be properly digested and will move into the large intestine, where the gut bacteria will begin to ferment them. This may cause painful gas, bloating, diarrhea, and other undesirable symptoms.

Therefore when someone chooses to follow a FODMAP diet, they’re choosing foods that are low in fodmaps – PREVENTING fermentation by the bacteria. 

Understanding FODMAPs

Let’s talk about the FODMAPs acronym again – oligo, mono and di are saccharides (which is another name for sugar).

  • Oligo means a FEW sugars linked together – like cellulose and starch

  • Di means TWO sugars linked together – like lactose which is made up of glucose and galactose sugars (monosaccharides)

  • Mono which means ONE sugar like fructose/glucose/galactose

A note about fructose: fructose is only an issue if there’s NOT enough glucose to help with absorption. Which means that anything with high fructose corn syrup or foods that have excess fructose (ie. apples) should be AVOIDED if you’re on a FODMAPs diet.

Lastly, polyphenols are sugar alcohols – basically any sugar that has –ol at the endo of it, such as xylitol, mannitol, etc.

How does the diet work?

This diet is similar to an elimination diet, with 3 phases: 

Phase 1: Low FODMAP

Eating a low-FODMAP diet. You would accomplish this by going through the FODMAP list and designing your meals around foods that you can eat, and foods you should avoid. For instance, if you’re used to eating an apple at 11am (to obviously keep the doctor away), you’ll want to switch it up for an orange. 

To make sure you get all the FODMAPs out of your system, you’ll want to follow this for about 2-6 weeks.  

Phase 2: Challenge

This is where you introduce FODMAP rich foods back into your diet (although not all at once!) to determine which foods trigger symptoms. If you do experience symptoms once you re-introduce a particular food into your diet, it’s best to avoid introducing another for a few days to let your gut get back to baseline. 

Based on how many foods you’re introducing and which symptoms keep popping up, this may take about 6-8 weeks. It’s best to go through this phase with a Naturopathic Doctor’s help.  

Phase 3: Adaptation

Now that you’ve gone through re-introducing all the foods that may cause unwelcome symptoms, you’ll know which foods you can safely eat and which you should avoid. In the adaptation phase, you can also re-challenge foods that previously cause you pain to again determine if they’re safe or should be avoided – this is because tolerance may change as time progresses. 

Final Thoughts of the Endometriosis Diet & Additional Resources

Monash University has an easy to use app highlighting FODMAP foods, as well as a great blog that provides additional information and FODMAP-friendly recipes. One particular article that I like is eating out on a FODMAP diet – because it’s always a huge limitation for everyone 

If you found this information helpful, I would encourage you to download my FREE EndoDiet meal guide and plan. It goes through everything we discussed: foods that are safe and that should be avoided, and a 7 day meal plan and preparation guide!

A Guide to the Endometriosis Diet

June 12, 2018
endometriosis diet

As we well know, endometriosis is a condition that cannot (yet!) be cured. When I see patients in my private practice, diet plays a huge role in terms of treatment plan, as it can often be easier to maintain than simply taking supplements. In this article, I’ve outlined what the latest research (2010 – present) has to say about food and its relationship to endometriosis. 

FODMAPs and Endometriosis

A 2017 study looked at the association between the FODMAP diet and endometriosis, because many people with endometriosis experience symptoms similar to those of IBS. They found that women who follow the FODMAP diet, experience an alleviation in their gut symptoms and endometriosis-related pain. Check out this post to learn more about the FODMAP diet (and get a free meal plan!). 

Fruit and Endometriosis

A 2018 prospective study looked at the association of fruit intake and endometriosis. Researchers observed a non-linear inverse association between higher fruit consumption and risk of laparoscopically-confirmed endometriosis. In particular, they discovered that citrus fruits conferred a 22% lower risk of endometriosis, when women consumed over 1 serving of citrus fruits per week. 

When purchasing fruit, it’s best to choose organic if the particular fruit you’re interested in is on the Dirty Dozen list. For example, if purchasing strawberries – be sure to purchase the organic version as strawberries are highly sprayed with pesticides. Some pesticides can act as endocrine disruptors, and affect estrogen levels within the body. As of 2018, no citrus fruits appear on the Dirty Dozen list, so purchasing the non-organic version is fine. 

Vegetables and Endometriosis

The same 2018 study assessed the relationship between vegetables and endometriosis. Surprisingly, no association was observed between total vegetable intake and endometriosis risk. However, researchers did notice that women consuming over 1 serving of cruciferous vegetables (broccoli, kale, Brussels sprouts, cabbage, etc.) per day, had a 13% increased endometriosis risk.

But before you swear off these veggies for good, this might have been related to the FODMAPs symptoms as mentioned above. If you don’t experience any negative gut symptoms when eating cruciferous veggies – keep eating them! They contain a wide array of important nutrients including DIM, which helps to metabolize estrogen. Obviously this is important as estrogen is one of the theorized causes of endometriosis. 

Fish and Endometriosis

The Nurses Study examined the association between fish intake and endometriosis. They observed that consumption of poultry, fish, shellfish, and eggs were unrelated to endometriosis risk.

The Nurses Health Study II also looked at fish consumption (polyunsaturated fatty acids, PUFA) and observed women in the highest fifth of long-chain omega-3 PUFA consumption were 22% less likely to be diagnosed with endometriosis. Another study did not observe this association. 

Omega-3 PUFA help in the regulation of prostaglandin and cytokine physiology, especially when it involves inflammation. 

Eggs and Endometriosis

The Nurses Study examined the association between egg intake and endometriosis. They observed that consumption of eggs were unrelated to endometriosis risk. Choose organic and cage-free (chickens that are able to roam around in their environment) if possible. 

endometriosis diet, toronto naturopath, naturopathic doctor toronto

Chicken and Endometriosis

The Nurses Study examined the association between poultry intake and endometriosis. They observed that consumption of poultry was unrelated to endometriosis risk. Nevertheless, choosing antibiotic-free chicken products may be the best choice to keep ‘extras’ out of the diet. 

Red Meat and Endometriosis

The same Nurses Study assessed the relationship between meat and endometriosis. They observed that women consuming  more than 2 servings/day of red meat/day had a 56% higher risk in endometriosis, compared to women eating 1 serving or less. This was highly noted in non-processed red meats (ie. beef, lamb, pork, hamburger) especially in women who had not reported fertility troubles. Women in the highest category of processed red meat intake (ie. bacon, hot dogs) also had a higher risk of endometriosis. The study did not mention if the women consumed grass-fed, antibiotic and hormone-free meat.

A 2013 review assessed the results from three studies assessing endometriosis risk and meat intake. Unfortunately no definitive conclusion was made. 

Meat eaters may want to choose grass-fed, antibiotic and hormone-free meat may be the preferred choice. While it’s true that cows inherently have hormones (just like humans), you may want to avoid any ‘extras.’

Soy and Endometriosis

Soy is a highly contentious food as some of its compounds act as phytoestrogens. Phytoestrogens are all structurally similar and have estrogenic activity and include both isoflavones (found in soy and soy products) and lignan metabolites (found in flax seeds, nuts, grains, and cruciferous vegetables). They can bind to estrogen receptors, and may elicit both estrogenic and anti-estrogenic effects. 

A 2017 study assessed the relationship of phytoestrogens and endometriosis, and found no evidence that urinary phytoestrogen concentrations were associated with a higher risk of an endometriosis diagnosis in both a general population and operative sample (women scheduled for a laparoscopy). That said, the women studied were not told to consume more soy products for the purpose of this study. Their regular diet was simply followed. 

A 2015 study looked at endometriosis risk and early life factors such as prenatal exposure to diethylstilbestrol (DES), cigarette smoking, and soy-formula ingestion. They observed an association between exposure to regular soy formula feeding during infancy and increased risk of endometriosis (especially in women born after 1965). In animal models, the early exposure to genistein and daidzien many change the uterus and hypothalamic-pituitary-ovarian axis (which continue to develop rapidly after birth, and may be susceptible to hormonal disruption). This study did not have detailed infant feeding data including information on the timing of initiation, duration, and exclusiveness of soy formula feeding as well as information on other sources of infant nutrition such as non-soy formulas and breastfeeding.

Soy does not have to be the enemy, and in fact can be rather helpful – especially when it comes to estrogen metabolism. Be sure to choose products that are organic and non-GMO.

Coffee and Endometriosis

The 2013 looked at four studies involving coffee and endometriosis risk. Two studies showed an increase risk of endometriosis in women who reported coffee consumption. It’s thought that concentrations of early follicular phase estrogens and concentrations of estrone were found to be higher in women with high caffeine intake. Nevertheless more data is needed. 

An interesting note about coffee is that it can act as a laxative. It helps to stimulate the movement of the colonic muscles, and promote a bowel movement. This is great because estrogen is able to leave the body, and does not recirculate leading to a relative excess. 

Gluten Free Diet and Endometriosis

A small 2015 study demonstrated the relationship between gluten and endometriosis. Results showed that a gluten-free diet could improve pelvic pain, and may in fact improve the management of deep-infiltrating endometriosis. 

Final Thoughts

It’s certainly difficult to avoid some of the above foods

Have any of the foods in this article surprised you? Let me know in the comments below. 

References

Moore J, Gibson P, Perry R, Burgell R. Endometriosis in patients with irritable bowel syndrome: Specific symptomatic and demographic profile, and response to the low FODMAP diet. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017;57(2):201-205. doi:10.1111/ajo.12594.

Harris H, Eke A, Chavarro J, Missmer S. Fruit and vegetable consumption and risk of endometriosis. Human Reproduction. 2018;33(4):715-727. doi:10.1093/humrep/dey014.

Yamamoto A, Harris H, Vitonis A, Chavarro J, Missmer S. A prospective cohort study of meat and fish consumption and endometriosis risk. Am J Obstet Gynecol. 2018. doi:10.1016/j.ajog.2018.05.034.

Mumford S, Weck J, Kannan K, Buck Louis G. Urinary Phytoestrogen Concentrations Are Not Associated with Incident Endometriosis in Premenopausal Women. J Nutr. 2016;147(2):227-234. doi:10.3945/jn.116.238840.

Upson K, Sathyanarayana S, Scholes D, Holt V. Early-life factors and endometriosis risk. Fertil Steril. 2015;104(4):964-971.e5. doi:10.1016/j.fertnstert.2015.06.040.

Parazzini F, Viganò P, Candiani M, Fedele L. Diet and endometriosis risk: A literature review. Reprod Biomed Online. 2013;26(4):323-336. doi:10.1016/j.rbmo.2012.12.011.

Missmer S, Chavarro J, Malspeis S et al. A prospective study of dietary fat consumption and endometriosis risk. Human Reproduction. 2010;25(6):1528-1535. doi:10.1093/humrep/deq044.

Marziali M, Capozzolo T. Role of Gluten-Free Diet in the Management of Chronic Pelvic Pain of Deep Infiltranting Endometriosis. J Minim Invasive Gynecol. 2015;22(6):S51-S52. doi:10.1016/j.jmig.2015.08.142.

Iron: the most common nutritional deficiency in women

December 4, 2017
iron deficiency

The most common nutritional deficiency in women is iron, as most women and people who menstruate lose blood each month. In fact, iron deficiency is the most common cause of heavy periods. Iron is a necessary part of our body as it transports oxygen throughout the body, and helps with thyroid production.

As mentioned, you’re at risk for this deficiency if you experience heavy periods. If you use a cup to track blood loss, anything over 80mL is considered a risk. Similarly if you are changing pads or tampons every 2 hours or less, you are at risk for deficiency. 

Signs & Symptoms of an iron deficiency

An iron deficiency can lead to many symptoms including:

  • Mental and physical exhaustion

  • Hair loss

  • Brittle nails

  • Mouth ulcers and oral tongue 

  • Headaches

  • Paleness

  • Shortness of breath

  • Cold hands and feet

Testing your iron status

Finding out your iron levels is very simple. A doctor will run your serum ferritin levels (the storage form of iron), and ensure that they are optimal. Depending on if you choose to supplement or increase dietary sources of iron, your ferritin levels may take more than 3-6 months to improve. 

Food sources of iron

There are two types of iron – heme and non heme. Heme iron is found in animal products, such as meat – and is generally better absorbed. While non-heme is found in plant-based products like lentils and leafy greens. Iron is best absorbed with vitamin C. So if you’re going to make yourself a kale salad, squeeze some lemon on top! Dairy can actually inhibit iron absorption, so try to avoid pairing these two. 

Moreover, if your iron levels are quite low, it’s usually best to supplement with a quality iron product. Iron bisglycinate is a highly absorbable and is quite gentle on the stomach.

Final Thoughts

If you are experiencing heavy periods and are noticing any signs and symptoms of iron deficiency, getting your iron tested and ensuring that it’s optimal (not normal!) – it would be a great idea to get your ferritin levels tested! 

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