Sunday, 29 April 2012

Outpatients, interpreters and FODMAPS

Building with clean white lines and blue sky beyond
Leamington Spa's 'Justice Centre' Jan 2011
I am starting to enjoy my outpatient clinics. One of the main reasons for this is that I am no longer scared of them, no longer worried that I won't know the answer, or won't know what to say. They are still difficult and tiring: three and a half hours on a Tuesday morning, with slots for up to three new and eight follow-up appointments. I would be very surprised if any Dietitian has actually managed to see eleven patients, though, because usually fewer are booked in, or at least one patient doesn't turn up. This is actually the only thing that makes a clinic manageable - I don't quite know how I could possibly cope if all the scheduled patients did turn up. Last week one of my colleagues had ten patients, and she had a student with her. She deserves a medal.

I have also had an unusual number of patients who require interpreters. Neither of the other junior Dietitians have needed any interpreters at all, but so far, in about ten clinics, I have needed interpreters for Punjabi (twice), Persian, Kurdish, French (North African), and English (Sign Language for a deaf patient).

Up to now the system has worked in that nobody has turned up without an interpreter, and I have been given extra time for a consultation that includes an interpreter - except last week when I had only fifteen minutes for what was effectively a first appointment, which should have been allocated thirty minutes, even without the need for interpretation. Luckily, the patient didn't turn up. Unluckily, the interpreter did.

Using an interpreter is slow and difficult, especially when there is something complicated or sensitive to discuss, such the foods that do or don't contain gluten (how do you say 'rye' or 'buckwheat'?) or the workings of the bowels. Talking about the consistency of poo with a stranger is difficult enough without having someone else you've never met and who has no health qualification involved in the conversation as well.

Irritable Bowel Syndrome, or IBS, is one of the most frequent conditions that I see in my outpatient clinic. It's not really a disease, it's what's left when all the other likely diseases have been eliminated. If you have chronic bloating, wind, diarrhoea or constipation and you don't have a malignancy or tumour, or coeliac disease, or inflammatory bowel diseases like Crohn's Disease or Ulcerative Colitis, then IBS is what's left.

Treatment: well, there isn't really any treatment other than trying to identify what's causing the symptoms and eliminating that. It could be stress rather than anything physiological, or an intolerance to a food or ingredient, or not enough fluid or fibre, or the wrong type of fibre. A recent innovation is the FODMAP diet, where foods are eliminated that contain Fermentable Oligo-, Di-, Mono-saccharides and Polyols. These are short and medium chain length carbohydrates (compared with the long chain polysaccharides that comprise starch and cellulose), and it is thought that trying to digest them may cause some of the symptoms of IBS for some people.

Digestion takes place mostly in the small intestine, where transit time is relatively brief and enzymes excreted by the pancreas, liver, gall bladder and the gut chop up the food into its constituent parts so they can be absorbed through the wall of the intestine into the bloodstream or lymphatic system. A lot of fluid is needed for this task, so when the undigested remainder of our meals passes into the large intestine, the main job is to recover all that fluid so we don't dehydrate (which is the main problem with diarrhoeal diseases like dysentery and cholera).

But quite a lot of potentially digestible material still remains, such as these FODMAPs. The huge number of bacteria that colonise the lower intestines can perform this function on our behalf, chopping up the FODMAPs, allowing us to absorb potentially useful molecules, but generating gas as they do so. Eliminating FODMAPs from the diet might bring relief to someone who suffers with wind, bloating or diarrhoea.

Unfortunately, it's no easy thing to eliminate FODMAPs, which are present in many different foods. It takes a lot of effort and creativity as well as time to remember lists of foods, read food labels and avoid many social situations that include eating, for six to eight weeks. If there is no relief, then either FODMAPs are not to blame, or else the task of achieving their exclusion is too hard. If excluding FODMAPs is of benefit, then there is a protracted period of re-introduction, to try and ensure that foods are not unnecessarily excluded from the diet.

If all this doesn't work, then there is the Exclusion diet, where you cut down to a very few foods and gradually reintroduce things one at a time. This is almost as hard as the low FODMAP option, and takes just as long. In the end, IBS is not like Crohn's or coeliac disease, because eating foods that cause symptoms does no underlying damage to the body, it's just a matter of deciding how much effort you're prepared to put in to identify troublesome foods compared with the pain or discomfort of the symptoms.

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