176 | Who Actually Needs a Low FODMAP Diet?

If you were taking your boards and a question asked you what FODMAP stands for, would you know the answer? Okay, no judgment if you wouldn't. It's a mouthful. FODMAP stands for fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols. And if those words haven't crossed your mind since nutrition class, don't worry, I'm gonna break it all down. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and dietitian, and today we're talking about irritable bowel syndrome and the low-FODMAP diet with Samina Kureshi, a registered dietitian who specializes in digestive disorders and disordered eating. Now, IBS is a disorder of gut-brain interaction characterized by abdominal pain and changes in bowel habits. Some patients struggle mostly with diarrhea, while others constipation, and some alternate between the two. Add bloating, gas, urgency, and unpredictable symptoms, and you can understand why patients start feeling like food is the enemy. So where do FODMAPs come in? Well, they're a group of short-chain carbohydrates that aren't completely absorbed in the small intestine. They draw water into the intestines, and when they reach the colon, gut bacteria ferment them, producing gas. Now, this happens to all of us, but for someone with IBS whose gut may be more sensitive, that extra water and gas can lead to pain, bloating, and changes in bowel habits. And these carbohydrates are found in some pretty common foods. So let's go through the acronym FODMAPS. The F stands for fermentable. This refers to the process through which gut bacteria ferment undigested carbohydrates to produce gases. The O stands for oligosaccharides, which are fructins and galacto oligosaccharides. These are found in things like wheat, rye, onions, garlic, and legumes or pulses. The D is disaccharides, which is lactose found in dairy products like milk, cheese, and yogurts. The M is monosaccharides, which is found in fructose, typically in honey, apples, and high fructose corn syrups. The A actually stands for and, and the P is polyols, this is sorbitol and manitol, which is found in some fruits and vegetables and is used as artificial sweeteners. Now, according to research from the Monash University, about three out of four people with IBS experience symptom improvement on a low FODMAP diet. But the low FODMAP diet isn't meant to be a permanent elimination diet. It's actually a three-step process, which is exactly what I'm discussing in today's episode. We talk about who benefits from a low FODMAP diet, why the reintroduction phase is so important, and how to recognize when managing digestive symptoms is starting to turn into fear of food. All right, now that you've got your crash course on what FODMAPs are, let's get into the episode. Grab your coffee or drive safe and enjoy my conversation with Sabina. Sabina, I am so excited to have you on the podcast. I love this topic. So thank you so much for being here today. Thanks for having me. I'm excited to chat. Something that's super common that I hear patients tell us is I feel like everything I eat bothers my stomach. And I kind of cringe when my patients tell me this because it's such a broad statement. And sometimes in your mind, you're like, I don't even know where to go with this. So can you help us tease this out and explain where do we even start with a concern like that?

Yeah, absolutely. So obviously, we need to get more information. We need to better understand the clinical picture. So I'm asking questions, right? What are your symptoms? What are you specifically experiencing when you feel like everything bothers your stomach? When did you start to notice that you started having these types of symptoms? Then I really want to get into the nitty-gritty of their bowel movements. I want to know how often they're having a bowel movement, what they're like. We talk about the Bristol stool chart. And are symptoms associated with eating? Are they occurring throughout the day? And what other things are going on, right? Do you have food anxiety and fear? Are you even eating enough consistently throughout the day? So before even looking at an elimination style diet, I really want to get a better idea of what's going on.

Love that. And, you know, it's been like the theme of my podcast. And it just shows that this is how dieticians think is to get curious first. And I love information gathering. I really think before we can even give advice, we need to get more information from the patients so we really know exactly like what they mean and maybe what their triggers are. Because it sometimes feels like everything bothers your stomach, but really when you get down to it, it might be only a handful of things. And that brings us into the topic of the day, which is a low FODMAP diet. And that gets recommended pretty quickly for patients with IBS. So I would love to start with understanding who is a good candidate for this diet and then who might be served better by like a different approach.

Yeah, absolutely. So the low FODMAP diet can be effective for people with IBS. Monash has reported it to show improvements in IBS symptoms for roughly three out of four patients who follow the diet, but evidence-based doesn't necessarily mean appropriate for everyone, right? A good candidate is going to be someone who has a confirmed IBS diagnosis, symptoms that may be responsive to dietary modification, is nutritionally stable, and I think that one's key, isn't already severely restricted, understands that this is a temporary therapeutic dietary intervention, and is willing and able to complete the reintroduction and personalization phases. So I become much more cautious when someone has significant disordered eating, significant food fear, malnutrition, and other things.

You mentioned something really important, and that's that this, you know, diet kind of experiment is quote, temporary. And I think a lot of people and even clinicians don't really understand that. And what I've seen in practice, you know, they're diagnosed with IBS and then they're told eat low FODMAP foods, avoid these high FODMAP foods, and then they're given like a one-page handout and a list of all these foods that they think they could never eat again. And based on what you just said, because you had also mentioned that there are different phases and we need to add certain things back in. I would love if you could walk us through what this low FODMAP diet is actually supposed to look like. What are the phases looking like, just so we can really help our patients?

Yeah, absolutely. So the low FODMAP diet is actually a three-phase type diet, right? The first phase is called the elimination phase, which usually lasts around two to six weeks. Okay, so keep that in mind. Um, you're swapping, you know, the higher FODMAP foods that they consume regularly with lower FODMAP alternatives. And the goal here is to have symptom improvement. The second phase after they have eliminated or reduced total FODMAPs in their diet is a strategic reintroduction. And this can be a long process. It is where you, as the dietician, work with the patient to strategically reintroduce each FODMAP group into their diet to better understand what this patient tolerates and what they do not. And the third step is this personalization phase where you're really helping the person expand their diet to as much as they can tolerate and eat as much variety of foods as possible while still managing their symptoms. And so the low FODMAP diet, you're right. People get that handout where, okay, they just see this as an elimination phase, but you're not done just at the elimination phase. The goal isn't just to have your diet shrink as much as possible and avoid symptoms. It's to really identify those food triggers as well, which FODMAPs you don't tolerate and then understand how much you can tolerate moving forward.

Yeah, let's talk a little bit about the phases because you're not just sitting in one phase forever. So how long is each one? And sort of like what are you looking for in order for the patient to progress to the next one?

Yes. So, like I said, the elimination phase, you can reduce the high FODMAP foods in their diet for about two to six weeks. And I think a big key point here is if after two to six weeks they have not found any symptom relief, there's no need to continue pushing the low FODMAP diet. We need to find an alternative route for them. But let's say that they do respond well and they're like, wow, I feel so much better after this low FODMAP diet. Great. Then we would say, okay, now it's time for us to strategically reintroduce these FODMAPs. And so there's no like real set way for you to reintroduce the FODMAPs. My favorite way of doing it is to ask my patients which foods they miss most and go from there. Because really, my goal with all of my patients is for them to eat as much variety as possible. Because what do we know about gut health, right? The more variety we have, the better our microbiome is thriving. Um, and we just we want to expand that diet as much as possible. And so reintroduction phase, it can last anywhere from like six to eight weeks because uh with the reintroduction, we're actually strategically reintroducing the foods. While they are on the reintroduction phase, they're actually continuing on the low FODMAP diet and only adding in that FODMAP group's food, right? And so we are going to add these FODMAP foods for three days in a week. So let's say Monday, Tuesday, Wednesday, we're adding in fructons and a small portion, maybe half a cup of something the first day, three-fourths of a cup the second day, and one cup the third day. We're having a wash period for Thursday, Friday, Saturday to see if how their symptoms are. Along the way, we are hopefully having the client do a food and symptom journal where they're logging, you know, what they're adding to their diet as well as any symptoms that they experience. And then you're coming back and following up with them to say, okay, what do you think? How do you feel that reintroduction went? What were your symptoms like, and where do you want to go from here? If they passed the food reintroduction, then you would uh reintroduce the next FODMAP group strategically for three days on, three days off, and assess symptoms and hopefully identify their personal tolerance from there. In the reintroduction phase, you're going through all of the FODMAP groups that they had eliminated, and you can see how this can be a very drawn-out process. We identified which ones they tolerate and don't. Awesome. The third phase is personalization. And this is kind of an ongoing thing where you help put the client's diet back together. You talk about what foods they can tolerate and their trigger foods, if they've identified, we really want to help them modify the portion, maybe the frequency or the combination in which they are adding that food to their diet. Always tell people if they have failed a reintroduction, it's not necessarily an off-limits food that they need to avoid forever. We really do need to look at that portion and how much they can tolerate.

So I have a couple follow-up questions based on what you had said. The first one is you had mentioned like a three-day washout after you introduced a few of those FODMAPs from a group. Can you elaborate?

Does that mean you're going, you're back to like eliminating them? That's correct. So as you're doing the reintroduction phase, the client should be on a pretty strict low FODMAP diet. The only thing changing are those foods we are testing. During the washout period, they will go back to the regular low FODMAP diet they were following before. Even if they feel like, oh, I did really well with it, we don't want them to continue eating that tested low FODMAP food. So because FODMAPs can kind of compound, they can stack, right? And oftentimes the symptoms are not going to be immediate. They need some time for them to reach the digestive system and um show up with symptoms if they are going to have any.

Okay. Yeah, that's helpful. Do you find there are certain foods that are more common to be triggers amongst the patients that you've worked with, or is it kind of like very random?

Yeah, yeah. I will say beans, lentils, onion, garlic, and lactose-based foods are going to be the ones that my clients are most regularly sensitive to.

I want to talk more a little bit about what you had mentioned earlier, when patients can sort of become a little bit too restrictive, almost like obsessive a little bit about avoiding certain foods. And from your perspective, what are some of the signs that we should be looking into that maybe this symptom management has turned into fear of food or maybe some disordered eating?

Yeah, yeah. So rigidity around reintroduction. If someone's like, no, I've been doing a low FODMAP diet for three years and I'm fine, and somehow that low FODMAP diet is getting smaller and smaller. They won't introduce sourdough bread, which is known to be low FODMAP. They won't have um white rice, which is known to be low FODMAP. These are trigger, not triggers, but signs, warning signs for us to say this person is intentionally restricting their already very restrictive diet and is not willing to enter the reintroduction phase. And so we really want to make sure that if that is happening, to partner with an eating disorder therapist, partner with an eating disorder dietitian who can really help you navigate expanding their diet.

Okay, so you gave us some kind of warning signs to look out for, but what about a patient who already has a history of an eating disorder? How would you approach someone like that if you are trying to start them on a low-phod map diet?

So if someone already has a significant food fear, history of an eating disorder, chronic dieting, or restriction, right? We don't want to reinforce the exact behaviors that we're trying to get them to move away from. So if you look at the guidelines for nutrition therapy for IBS, um, in the UK, they use something known as the NICE guidelines. And so it really revolves around adequate nutrition, establishing a routine and regular meal pattern. So making sure they're not skipping meals or leaving long gaps in between eating, making sure that you're offering some non-diet approaches to easing digestive symptoms, right? Like how fast are they eating, really slowing down, chewing your food to applesauce consistency, making sure that they are adequately hydrated, implementing mealtime stress management. If they experience a lot of this anxiety and fear around food, naturally mealtimes are going to trigger that. And so, what are some grounding practices that you can implement before and after meals that will help the digestive process just be a little smoother? Something called diaphragmatic breathing is something that I practice with my clients, as well as different grounding exercises and even mindful eating if you find that to be applicable. Um, and then we'll also talk about different types of fibers and which ones may benefit bowel regularity and ones that they tolerate better. And of course, with this, um, there are GI-specific behavioral therapies done by a GI psychologist. So gut-directed hypnotherapy, as well as GI CBT and different mindfulness-based approaches. And um, they can be a really, really great tool to have a resource for patients alongside the work you're doing as a dietitian, especially among patients who may um really struggle with their relationship with food.

Yeah, Semina, you mentioned psychology and it makes me think about stress and anxiety. And we know the gut and the brain are connected. And so I'm curious how much can stress and anxiety actually affect someone's IBS symptoms? And then help us explain maybe that connection without making the patient feel like we're telling them, oh, it's just all in your head, or maybe being too dismissive.

Yeah, so IBS is considered a disorder of gut brain interaction or a DGBI, formerly called a functional GI disorder. And so the gut brain axis is how our brain and our gut communicate, and that there's actually this bidirectional pathway via the vagus nerve. And so not only is the brain communicating with the gut, the gut is also communicating with the brain. And with IDS, there's a miscommunication that can lead to hypersensitivity and increased symptoms. What I tell patients is that it makes sense that when you are stressed or in a heightened stress state, you may experience symptoms. That doesn't mean that everything is all in your head. Stress can absolutely impact your GI symptoms and how they show up. And so I do think that behavioral health and managing stress in general needs to be a part of the treatment plan for IBS.

Now I want to go back to something you mentioned earlier, and you mentioned the word fiber, which is my favorite nutrient ever. But it gets really tricky and honestly confusing for individuals with IBS because traditionally, for someone with constipation, we usually tell them to eat more fiber. But we know that adding a ton of fiber can sometimes worsen their bloating or their stomach pain or you know, changes in their bowel movements, and they end up feeling worse. So, how do you think about fiber in your patients with IBS?

Yes. So, first I want to do an intake. I want to know where is the fiber coming from in their diet? What supplements are they taking? And by supplements, I even mean protein powder, um, bars, convenience foods, drinks, because now we know that there are drinks fortified with fiber. And many of the fortified fiber-rich foods are fortified with chicory root or inulin fiber, which are known high FODMAP ingredients. And so if that is happening, you know, and they are struggling with constipation, they may already have tried these on-the-market ways to add fiber to their diet. So if reducing that type of fiber actually helps with symptom management of bloating, excess gas, um feeling too full, et cetera, um, awesome. From there we talk about the right types of fiber for someone with IBS. And I think we should lean more towards the soluble fiber sources. And my favorite two are gonna be psyllium husk fiber and partially hydrolyzed guargum, which is PHGG or sun fiber. These are the two that are going to be least fermentable. They're not gonna cause the excess gas, abdominal pain, cramping, bloating, which is accompanied by constipation. Um, however, if my patient is coming to me saying they are constipated, I'm actually not going to throw fiber at them. I want them to talk with their physician and see if they have a constipation relief plan. Are they on medication? Do they have a laxative? Do they have something on hand that they know is going to work for their body? And what does that regimen look like? If they find relief from constipation, then the name of the game is prevention. How can we prevent constipation long term? We need to look at not only, yes, eating fiber, but making sure they're eating enough consistently throughout the day, adding enough hydration with the increased fiber, getting some movement and of course stress management, as well as bowel hygiene and positioning. So there's a lot to talk about when it comes to constipation, but those are those are my highlights.

I really love that you mentioned bowel hygiene and positioning. Can you uh linger there and tell us what do you mean by those two things?

Yes. So bowel hygiene to me means making sure that your patient is able to use the restroom when they initially feel the urge. So go into the restroom when they feel the urge. And if they have the opportunity, making sure that they are sitting in the appropriate bowel movement position, which can include raising the legs to about a little above hip level. So this can be simply turning this trash can in their bathroom on its side and placing the feet on them and leaning forward a little bit. It can be a potty stool. I'm sure you guys have heard of squatty potty, or it could be what I use in my bathroom, my child's toddler stool to reach the sink. So a variety of different things. And I think with that bowel positioning or toilet positioning, what ends up happening is it really helps your pelvic floor relax, which helps the bowel movement pass more easily. And the stool in proper positioning can help reduce straining, which is often accompanied by constipation.

This is something that is not talked about enough. Like most of my patients, when I mention this, and I talk about this with kids because their little legs dangle on the toilet, right? And they're in a horrible position to stool. People don't even think about that. So I think this should be absolutely part of your education for anybody who's constipated, not just with patients with IBS. So thank you for giving us those examples. All right, I have to talk about supplements because they're just widespread in this population. And honestly, probably thanks to like online marketing and the quote gut health professionals and the protocol. Calls that are out there. We see everything from like food sensitivity testing, enzymes, peptides now. It's just all over the place. So it's a big topic, I know, but in general, do you recommend these for patients? What are some things that you really think that they should avoid or are just unnecessary due to cost?

Yes. So I say if you're on a probiotic, um, what is the reason? How long have you been taking it? And who told you to take it? If you're taking something because an influencer said it helped them, but it wasn't recommended by a health professional, I'd say we need to reassess. If it sounds too good to be true, it likely is. And I say that to my patients. I'm very upfront and I say, I know that you have been trying to find solutions. That's why you're here today. We need to make sure that we are being as effective as possible and reviewing all of the things that you're doing currently so that many of these supplements aren't contributing to the symptoms you're experiencing. So going back to that on the market these days, there are a lot of products with both prebiotics and probiotics and symbiotics and postbiotics and all the things, right? I think when someone is trying to figure out why their digestive symptoms are happening, these types of supplements can cloud what's going on. And so in my practice, I say if we, if you are comfortable with it, we are going to take a pause while we are addressing these things. If we deem them appropriate moving forward, we can implement them. But again, it's going to be done strategically so that we can identify whether or not it's harmful or helpful. Some products that I think are helpful specifically for IBS is uh peppermint capsules. Um, the L menthol in peppermint has been shown to help with abdominal cramping, pain, pretty much global IBS symptoms of alternating bowel patterns, conservation urgency and bloating. So that can be a really great tool taken before a meal, as well as gas X. Naturally, if your patient is experiencing excess gas, I do think that that can be a welcome support. There are digestive enzymes out there. However, we need to know whether or not they are appropriate for you. So if our work during our work together, we've identified that yes, you're um sensitive to FODMAPs, a FODMAP directed type of enzyme can be helpful. Let's say you want to enjoy the holidays. You go to someone's house, you aren't sure what they have. It can be a tool that can help you have have more fun, enjoy life, and improve that quality of life as well.

Can I ask your opinion on all of the different food sensitivity sensitivity testing? Is this something that is evidence-based or is it another kind of ploy just for a company to make money?

You know, this is so funny. I am uh I've been on many podcasts and done many things, and I always say that I believe that IgG food sensitivity testing is a scam. There has been one research study that recently just came out on food sensitivity testing, and I just got a notification from it, but sorry, I haven't read it. So I can't speak on it. Um, but IgG food sensitivity testing has been shown to uh identify foods that are already in your diet, not necessarily tell you whether or not they're harmful or causing symptoms. So the best way for you to figure out food sensitivities is this long drawn-out process with a dietitian. And so people are always quick to look for these solutions because they are fast. But unfortunately, I think they're a money-grabbing scam.

Share your sentiment too, but like I don't have any like science to stand on. So I don't go on social media debating this topic. But I agree with you. And I think this is the perfect place to end because my last question was going to be sort of a leading question: whether you think patients can do this on their own, or do you really think they need a dietitian's guidance?

I think that from all of my patients, they have tried it on their owns up to five to 10 years on the low FADMAP diet. I'm not even kidding you. And they come to me looking for help because what they have tried has not worked, or they have reduced their diet so much that now the rest of their health is suffering. So if you have the opportunity, please reach out to a dietitian who can support you that is trained in the low FODMAP diet, that understands just because you have a diagnosis doesn't mean you have to restrict foods, really understands the um benefit of nourishing your body with a variety of foods.

Yeah, and you mentioned something really, really important. And that's that the dietitian has experience in low FODMAP diets. This is a very specialized niche. Don't just refer to any dietitian. Granted, that's better than not referring, but you want to make sure the dietitian you're working with is a gut health dietitian, has GI training. You want to make sure there's additional certification and that they are low FODMAP, you know, trained and have a deep understanding of that. I think that's really important.

Yes. And there is a new um Academy and Nutrition and Dietetics certification for digestive health dietitians. It's CSDH. So if you they have that, which I have, um it is a board certified specialist in digestive health.

Cool.

That would give you more of an understanding of hey, who really is a GI dietician and who's just kind of calling them a gut health expert.

Yeah, like a lot of people online. All right, Samina, this has been amazing. I know you are online and on social media. So if uh people want to connect with you, maybe they have patients who can work with you. Where can people find you online?

Yes, on Instagram and TikTok. I am at inclusive IBS Dietician. And if you um want to refer a patient to me or just chat, you can always schedule a free discovery call with me on my website, www.wholesomestart.com.

Perfect. Thank you so much for sharing. This was a really fun conversation and a great refresher for me on the low FODMAP diet. So I appreciate your time, Sabina. Thank you so much for having me. And if you want to learn more about FODMAPs, I'll link to the Monash University's resources in the show notes. They're a fantastic resource for you to learn more. And thank you guys for carving out some time for nutrition today. I will see you next week.