Low-FODMAP diet for IBS ‘not intuitive,’ must be taught by a GI dietitian
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Irritable bowel syndrome is a dysfunction in the communication pathway between the gut and the brain, which contributes to symptoms such as gas, bloating, abdominal pain, diarrhea, constipation and mixed bowel habits.
It is a functional disorder, which means there is no change to the structure of the digestive tract — no ulcers, strictures or blockages — but instead, a change in how the gut functions.
People with IBS may have visceral hypersensitivity, which is best explained as a big reaction to a small amount of stimuli. When two people, one with IBS and one without, eat the same thing, they both may experience the same fermentation by gut microbes. But while the person without IBS does not have a GI reaction, the person with IBS may feel bloating, distention and experience gas, diarrhea and/or constipation.
Low-FODMAP Diet, Other Interventions
The most researched dietary intervention for IBS is the low-FODMAP diet. FODMAP is an acronym that represents fermentable carbohydrates (Fermentable, Oligo-, Di-, and Monosaccharides and Polyols). The intervention has three phases.
The first and shortest phase is the elimination phase, in which high-FODMAP foods are removed from the diet. This is not intuitive and needs to be taught by a GI registered dietitian as there is more misinformation than accurate information in the ether. The elimination phase is followed for 2 weeks and as long as 6 weeks.
If symptoms are markedly better, the second phase — known as reintroduction — can begin. If there is not a change in symptoms, then it is determined that food is not exacerbating or causing symptoms and the diet is abandoned. If there is some change, the elimination diet can be followed for up to 6 weeks to see whether symptoms continue to improve before moving on to reintroduction and eventually to the final phase.
The final phase is the personalization phase, which includes all low-FODMAP foods plus all high-FODMAP foods that were successfully reintroduced in the second phase. This food list can be expanded by continuing to reintroduce high-FODMAP foods that might not have been successfully reintroduced initially every few months.
The low-FODMAP diet can be complicated and is bound to come with concerns and questions from patients, the most common of which include: “Will this ever go away?”, “Is this food low-FODMAP or high-FODMAP?”, “Should I be taking a probiotic?” and “How do I eat on vacation/while traveling/at a catered event and still stick to the low-FODMAP phase I’m in?” All of these can be answered by a GI registered dietitian.
It is important to note that not everyone who is diagnosed with IBS is a good candidate for the low-FODMAP diet. In those cases, there are some variations to this diet and other non-diet options that can improve symptoms without a change in the food repertoire.
And while the low-FODMAP diet does not differ between subclasses of IBS, like constipation (IBS-C) and diarrhea (IBS-D), the use of non-diet interventions can differ and includes the type of fiber supplementation, toileting position, antispasmodic supplements and motility supplements.
Advice From a GI Registered Dietitian
My first piece of advice to providers caring for these patients is to not work in a bubble — create an integrated team for your patient by communicating with their other providers, which may include the gastroenterologist, GI psychologist and pelvic floor therapist, among others. This way we can focus what we have expertise in, share that information with the team and ask for support from other practitioners, so the patient gets the best care possible.
If you work with people with functional GI issues, then you work with people with disordered eating and eating disorders. My second piece of advice is to screen everyone you see for disordered eating. There are many questions you can ask and some screening tools available, including EAT-26, ecSI 2.0, NIAS and SCOFF, although there is only one validated screening tool for eating disorders with concurrent GI disorders and that is for people with celiac disease. If you come across someone with maladaptive eating patterns, disordered eating or a suspected eating disorder, refer them to a therapist before treating their IBS.
My last piece of advice is to hold space for your patients. They may have been through a lot just to be diagnosed. Their quality of life may have declined due to their symptoms and they may be experiencing added stress, anxiety and/or depressive symptoms.
Letting them know that you are listening, that you believe them and that you are honored to be on their team goes a long way to building trust and a strong relationship with a patient.
- For more information:
- Beth Rosen, MS, RD, CDN, is a registered dietitian and owner of Beth Rosen Nutrition, a virtual private practice based in Kings Park, New York. She can be contacted at beth@bethrosenrd.com.
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