Erika Pathó analyses the challenges related to the adoption of a Western-designed dietary measure to manage IBS symptoms in India, focusing on patients’ accounts of their experiences of dietary change.
Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract with no known biomedical cure. It manifests as a “variable combination of chronic or recurrent symptoms such as abdominal pain, bloating, constipation and diarrhoea that have no structural or biochemical abnormalities detectable by conventional laboratory methods” (Gwee 2005, 317). While IBS long puzzled researchers, recent biomedical studies have recognised it as a disorder of gut-brain interaction, in which alterations in microbiota composition, dietary patterns, lifestyle, immunological responses and the ways of coping with stress play a collective role (Ghoshal 2017; Sperber et al. 2021).
Dietary management as a tool to control IBS symptoms has been subject to many reviews (El-Salhy and Gundersen 2015; Staudacher et al. 2017) as it is accepted that diet plays an important role in the pathophysiology of IBS. Nutrition-based therapies are often recommended as a treatment approach. One of the most common dietary measures is the internationally recognised low-FODMAP diet, developed originally by researchers at Monash University, Australia. The term “FODMAP” refers to foods containing fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs), which have been investigated for their poor absorption and resulting effects on the gastrointestinal tract (Barrett 2017, 7). The most common foods containing these sugars include milk and dairy products, legumes, cruciferous vegetables, some fruits, and grains, especially wheat and rye (Gibson 2017, 5).
Although numerous studies have been conducted with IBS patients in Western settings (Halmos et al. 2014; Staudacher et al. 2017), the diet is a relatively novel concept in Asia (Goyal et al. 2021). During my time conducting ethnographic research at the Gastroenterology Department at Surya Hospital, a renowned tertiary care institution in North India, the low-FODMAP diet was being trialled as a dietary approach for patients suffering from diarrhoea-predominant IBS and related digestive conditions.
Prior to implementing the diet, a trained dietitian conducted a FODMAP meal challenge test (FMCT) to assess patients’ reactions to foods containing high and low-FODMAP constituents. The test took place on two full days and patients were required to come to the hospital on an empty stomach. On day one, following the establishment of a baseline hydrogen level in the breath, patients consumed a low-FODMAP meal. Subsequently, breath hydrogen was measured every fifteen minutes over an eight-hour period. The procedure was repeated with a high-FODMAP meal on day two. Patients who reacted strongly to high-FODMAP foods in the FMCT, were advised to follow the low-FODMAP diet for a period of three months.
Guidelines in the Indian context
Although the diet was based on Western-derived standards, it was tailored to the needs of Indian patients and adjusted to the local cultural and culinary settings. Vegetables such as cucumber, tomato, lettuce, carrots, certain fruits such as grapes, orange, lemon, banana, as well as rice, fish, margarine, and black tea without milk were advised to be taken as low-FODMAP foods. In contrast, high-FODMAP foods, such as wheat, milk and dairy products, fruits such as mango, all kinds of legumes, vegetables such as cabbage, cauliflower, green peas, mushrooms, okra, bitter gourd, and condiments such as onion and garlic were restricted. Local guidelines similarly called for a limitation of chilli, masala (spice powders) as well as the regulation of the quantity and quality of oils used in meals.
Given the fact that many high-FODMAP foods, such as milk, legumes and wheat, are staples in the Indian diet and constitute the backbone of protein intake for vegetarians, avoiding these completely was challenging. To alleviate complexities and ensure compliance, local specifications permitted their limited use. The consumption of milk was allowed in very small quantities, such as 1-2 tablespoons in tea. Similarly, small quantities of fermented products such as dahi (yoghurt) and chaach (buttermilk) were allowed daily. Although legumes were banned from the diet, particular sorts, such as yellow lentils were allowed in small quantities only if tolerated. To make the diet more palatable for patients, further recommendations included switching to other, locally available substitutes. For instance, wheat-based roti (flatbread) was to be replaced with rice, or with roti prepared from other types of flours, such as corn, millet or buckwheat flour. Dairy products in large quantities were to be substituted with soy, rice or almond milk. However, the lack of access to substitutes, their cost, poor social acceptance, questions of satiety and nutrition and the high prevalence of vegetarianism meant that patients found the diet even despite the local easing measures burdensome and onerous to implement.
Cultural and nutritional challenges
I talked to 46 patients and their families over a period of 11 months concerning their experience with the diet. I found that challenges of implementing it were closely intertwined with beliefs about the cultural and nutritional importance of certain high-FODMAP foods, which were heralded as fundamentals to nourishment in the Indian vegetarian diet. Given the long-standing religious and cultural traditions surrounding milk and its culturally embedded meanings, e.g. the sanctity of the cow symbolising endless bounty and blessings (Wiley 2014, 57), many patients found it impossible to avoid or find acceptable substitutes for milk. Since many patients considered milk as essential nutrition for the body, they believed they would suffer from “weakness” if they avoided drinking it.
The replacement of wheat-based roti posed further challenges due to cultural and nutritional issues. Wheat has been an essential staple in India, constituting an important source of nutrition particularly in the Northern Indian diet (Gandhi, Zhou and Mullen 2004, 4745).
Many patients considered roti made from wheat more satiating and nutritious compared to rice.
Moreover, given the association of rice consumption with least affluent social backgrounds and the beliefs that “rice-eaters” belonged to the most deprived strata of society, some patients considered eating wheat-based roti as “more prestigious,” reflecting positively on their status and identity.
In the absence of spices and condiments, a further challenge to the diet was its lack of taste. Having to reduce onion, garlic, chilli and different masalas in their dietary regimen, patients reported that their meals had become “boring, not appetizing and not palatable.” Moreover, the reduction of oil intake also meant that beloved Indian snacks, such as samosa and khasta, frequently consumed with chai (tea), as well as all street and fast foods under the umbrella term bahar ka khaana (outside food) were banned from the diet. All the above restrictions caused immense distress to patients and their families, since with all these measures, the possibility of maintaining a traditional diet became severely impaired.
Social challenges
Although dietary change was one of the prerequisites for improving one’s symptoms, from the patients’ perspective, complying with the diet presented a plethora of hurdles which proved to be difficult to manage in their own social contexts. When talking with IBS patients about their diet, the first question the dietitian raised was about their preference for vegetarian or non-vegetarian foods. Diet-related conversations were sometimes controversial because of the underlying caste-, class- and hierarchy-based associations they connoted. Food in India can signify class and caste-based boundaries, gender roles, occupations and mobility, and it can be a “site for articulating ethnic and national identities” (Sengupta and Sen 2022, 169). In the wider society, deeply embedded ideologies existed around traditional food consumption practices and their importance in the affirmation of one’s identity and belonging.
The “social concept,” which implied the practices and habits of consuming food together in familial or social surroundings, equally shaped positions regarding the acceptance of dietary meals.
The challenge of implementing the diet was also intertwined with gender and gender-based roles and the quality or lack of familial support. Many of the IBS patients whom I interviewed were men, who were used to being served food by their wives and female members of their households. If these patients did not receive family support with the preparation of their meals, to ensure that they contained low-FODMAP ingredients, it was impossible for them to implement the diet.
In addition to the above challenges, for quite a few patients, the matter of compliance with the diet was also closely related to financial matters. Patients from less affluent backgrounds could not afford to purchase adequate quantities of fruits and vegetables and had to rely on the heavy consumption of the more satiating types of high-FODMAP foods, such as wheat-based roti and lentils.
Conclusion
As evident from patients’ accounts, adopting the Western-derived low-FODMAP diet in the Indian context required that patients constantly navigate the incorporation of favourable and the avoidance of unfavourable foods in their diet. This was subject to a process of continuous negotiation in both public and private domains. Effectuating change was influenced and shaped by the need of persistently affirming one’s identity, was intertwined with the performance of social and familial roles, one’s preferences for taste, affordability, beliefs about adequate nutrition, as well as the simultaneous objective of achieving favourable health outcomes. These competing priorities often did not sit well together, neither in patients’ heads nor in their stomachs.
About the author
Erika Pathó is a PhD candidate at the Department of Anthropology, Durham University, UK, funded by the Economic and Social Research Council (ESRC). Her research interests include health-seeking behaviour across cultures, biomedicine and traditional healing systems, and themes at the intersections of health, society and culture in the context of India and South Asia.
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