FODMAPs and Meal Sequencing

Before I was a PA, I worked as a full-time RD and I worked with several patients who were newly diagnosed with celiac disease. These were their most common questions:

• What can I eat?
• What can’t I eat?
• Do I have to eat at like this forever?
• Do I have to buy a different toaster for my house?
• Should I take any vitamins?

As a trained nutrition-professional, I knew how to answer these specific questions.

But these detailed questions can make most medical provider’s head spin. 

"Oh, By The Way ..."

You end the visit (or so you thought) and your patient catches you as you stand up to leave and says, "Oh, by the way..." Rather than ignoring them or telling them to Google It, let's walk through how a dietitian would answer this in 1 minute.

Let's answer this week's question: "Oh, by the way, he doesn't eat meat. Should I be worried?"

“If you’re concerned about his protein intake, don’t worry. He can get enough protein from milk, cheese, cereal, chicken nuggets and pasta, which are foods most kids like. Children need less protein than adults – between 13-19 grams daily for age 1-8. For example, 1 cup of milk has 8 grams and 1 egg offers 6 grams. Meat can be very a tricky texture for kids to enjoy, so try to offer non-meat options like beans, tofu, edamame, spinach and whole grains. These are also great sources of iron!”

What "Oh, by the way..." questions do your patients ask you? Email me at Colleen@examroomnutrition.com and I'll feature it next week!

Disease Spotlight | Irritable Bowel Syndrome

1 in 20 Americans suffer from IBS, according to the American College of Gastroenterology.  IBS is a chronic, often debilitating, and highly prevalent disorder of gut-brain interaction characterized by 4 distinct subtypes: IBS-D, IBS-C, IBS-M, and those without a significant pattern of abnormal stool (IBS-U).  

Common symptoms include abdominal pain at least once weekly, in association with a change in stool frequency, a change in stool form, and/or relief or worsening of abdominal pain related to defecation. Although bloating is a commonly reported symptom, its presence is not mandatory to accurately diagnose IBS. 

Work-Up: 

ACG Clinical Guidelines suggest:

• Serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms
• fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease
• food allergy/sensitivity testing is not recommended unless there are reproducible symptoms concerning for a food allergy
• soluble, but not insoluble, fiber be used to treat global IBS symptoms
• a limited trial of a low FODMAP diet in patients with IBS to improve global symptoms. 

Since this is a nutrition newsletter, let’s Review the Low FODMAP diet.

What’s a FODMAP? The acronym stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Simply put, they are types of sugars that are naturally found in various foods and people with IBS are unable to digest and absorb large amounts of them, though small amounts may be tolerated. FODMAPs are found in a wide variety of foods, including fruit and vegetables, grains and cereals, nuts, legumes, lentils, dairy foods and manufactured foods. You cannot simply guess which foods will be high or low in FODMAPs. Fermentable means that the bacteria in the intestines feed on FODMAPs and produce gas which leads to bloating and constipation. The elimination of dietary FODMAPs can be considered as a treatment for patients with IBS.  

What’s the low FODMAP diet? The worst thing you can do for your patient is hand them a list of low and high FODMAP foods and tell them to avoid all foods that contain FODMAPs. For many people they can tolerate a small portion of a high FODMAP food and as a result, enjoy more variety in their diet. This is why the low FODMAP diet is a short-term, 3-phase trial designed to identify foods that cause symptoms. The first stage is an elimination of high FODMAP foods for low FODMAP choices; the second stage is a gradual, systematic reintroduction of foods from each FODMAP group into the diet while assessing symptoms; the third stage is personalization of the diet to avoid foods that trigger symptoms. Each phase lasts between 2-8 weeks with the goal of liberalizing their diet as much as possible.   

Sound complex? It is. That’s why the ACG, recommends patient’s complete the 3-phase trial under the close supervision of a GI-trained Registered Dietitian. 

References: Monash University FODMAP diet 

ACG Clinical Guideline: Management of Irritable Bowel Syndrome

Your Questions, Answered

“Does the order I eat my food matter?"

Meal sequencing, or the order in which you eat different foods during a meal, shows promise as a practical dietary treatment for diabetes and obesity. Research indicates it can help with blood sugar control, nutrient intake, and satiety. Different studies have looked at consumption of protein and/or fat or fiber before carbohydrate, resulting in promising results of glucagon-like peptide-1 (GLP-1) secretion, delayed gastric emptying, decreased postprandial hyperglycemia, and weight loss. 

The exact mechanisms are still unclear, yet currently available reports strongly support that meal sequence dietary therapy is beneficial in controlling postprandial glucose excursion and bodyweight to better prevent and manage diabetes and obesity. I believe this strategy is both safe and potentially beneficial for your patients to explore. Additionally, it promotes mindful eating, a practice supported by numerous studies for its positive effects. If your patient asks, here’s one method to sequence meals:

1. Begin with fiber: Start with non-starchy veggies.  
2. Eat protein: Include lean meat, fish, tofu, or plant-based protein. 
3. Add healthy fats: Incorporate sources like avocados, nuts, seeds, or olive oil. 
4. Finish with carbohydrates: Consume whole grains or starchy veggies last. 

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551485/

https://www.mdpi.com/2072-6643/14/14/2865

 Submit your question HERE

I'll leave you with a quote and friendly reminder from Nicole Kidman to never give up, "Sometimes your mistakes are you biggest virtues. You learn so much from the mistake. Those things that you think are the worst thing that's happening to you can somehow turn around and be the greatest opportunity."

Thanks for being here and for loving your patients.

Have a great week!