Why a GI Dietitian Adds Value to a GI Practice
Difficult to treat gastrointestinal conditions such as irritable bowel syndrome can be cumbersome for the patient and health care practitioner alike. Food induced symptoms are common in IBS patients with poorly absorbed carbohydrates reported as the most common group of food triggers. Symptom severity correlates with the number of food triggers.
A recent survey study of 1,562 gastroenterologists published in 2018 in the Journal of Neurogastroenterology and Motility revealed that 90% of GI doctors felt diet was as effective – if not more effective – than medications for IBS. Yet, only 21% of GIs routinely referred their patients to a registered dietitian. Lack of insurance coverage, limited access to dietitians with GI nutrition expertise and the perceived complexity of dietary interventions are potential obstacles. Insurance coverage, however, varies state by state with many insurance providers covering nutritional counseling for GI disorders. Also, training programs are emerging to address the need for more GI specialized dietitians, such as the annual University of Michigan’s GI nutrition conference.
The Beneficial Role of a GI Dietitian
GI dietitians provide tailored nutrition interventions that incorporate the patient’s clinical data, nutritional intake, socio-economics and lifestyle to ensure a feasible and nutritionally adequate plan to manage GI symptoms. Unfortunately, self-guided elimination diets can result in severe food restriction and in some cases, malnutrition as observed in patients in clinical practice.
Dietitians can help assess suitable candidates for the low FODMAP diet. For example, dietitians screen patients for overt eating disorders such as anorexia nervosa and bulimia, as these patients frequently report GI symptoms and fulfill the criteria for functional gut disorders. Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis in the DSM-5. Unlike individuals with anorexia, those who experience ARFID do not have concern about body shape or size. ARFID results in insufficient caloric and nutrient intake due to concern about troublesome symptoms as a consequence of eating. In patients with severe GI symptoms, ARFID should be evaluated and addressed with psychological and nutritional interventions. Elimination diets are not indicated for individuals that fulfill eating disorder criteria as a restrictive eating pattern many trigger disordered eating behaviors leading to deleterious health outcomes.
A collaborative care process in treating patients with GI disorders, allows the dietitian to fulfill gaps in the patient’s medical history that may or may not have been divulged or missed in the GI visit. Together, providers can piece together the patient’s full clinical picture to provide a better assessment and multi-faceted approach to care. In my clinical experience, this collaborative care process leads to improved patient satisfaction and outcomes.
Patients desire nutritional and holistic treatments. In a novel pilot project presented at DDW 2017, researchers from the Netherlands evaluated a shared decision model of IBS management. Patients were presented with 10 different treatment modalities with the goal to choose their top three choices. The overwhelming majority of patients favored holistic approaches, with 51% selecting a probiotic intervention, 49% the low FODMAP diet, 36% hypnotherapy and 27% elimination diet. By providing patients with a shared decision treatment model, per patient contact time with gastroenterologists was reduced from an average of 45 minutes to just 10 minutes.
Application of the Low FODMAP Diet
The low FODMAP diet is gaining traction globally as an evidenced-based nutritional approach to managing symptoms in IBS patients; in part, it has validated the role of the dietitian in IBS treatment. Previous diet therapies such as maximizing fiber or trial of a lactose-free diet offered little net gain in symptom management.
Although often touted as a highly restrictive diet, a dietitian-guided low FODMAP diet is not cumbersome for the patient. One study showed that 60% of patients found the low FODMAP diet easy to follow, 65% could easily find suitable products to eat and 43% were able to incorporate the diet easily into their life. In the initial session, dietitians provide lifestyle tips such as label reading, menu and grocery store planning to enhance application and understanding of this nuanced diet intervention.
Dietitians review and monitor in detail the patient’s dietary intake to ensure nutrients such as calcium and fiber are provided adequately. The low FODMAP diet can be nutritionally adequate when applied properly. For instance, calcium rich foods such as lactose-free milk, hard cheeses and even chia seed can help meet the patient’s calcium needs. At the same time, low FODMAP foods such as oatmeal, quinoa, blueberries, and strawberries help to maintain gut health by providing adequate amounts and diverse types of fiber. As a clinician with more than 30 years’ experience, I find the uptick in food fears in the current culture astounding. The internet provides a plethora of unsubstantiated sites geared toward gut health, leaving patients more confused and fearful of food and at increased risk for maladaptive eating. Dietitians are well suited to help patients separate the hype from the science. Dietitians know when to apply a less restrictive or modified nutritional approach. In clinical practice, some IBS patients fair well with a modified low FODMAP approach, where an individual may trial removal of one FODMAP subtype rather than engaging in the full elimination diet.
Reliable FODMAP Resources
IBS patients benefit from a variety of up-to-date and accurate educational resources such as My GI Nutrition, an interactive video that showcases the low FODMAP diet (http://www.myginutrition.com); simple low- and high-FODMAP checklists (http://www.katescarlata.com); as well as books that provide menu planning and recipes such as The Low FODMAP Diet Step by Step by myself and Dede Wilson and The IBS Elimination Diet and Cookbook by Patsy Catsos. The Monash University low FODMAP diet app is also helpful to navigate the latest low FODMAP food composition data.
- Bohn L, et al. Am J Gastroenterol. 2013;doi:10.1038/ajg.2013.105.
- Boyd C, et al. Scand J Gastroenterol. 2005;40(8):929-935.
- Lenhart A, et al. J Neurogastroenterol Motil. E-pub ahead of print June 8, 2018.
- Otten MH, et al. Abstract 164. Presented at: Digestive Disease Week; May 2017; Chicago, IL.
- Roest RH, et al. Int J Clin Pract. 2013;doi:10.1111/ijcp.12128.
- For more information:
- Kate Scarlata, RDN, is a Boston-based registered dietitian and New York Times best-selling author known worldwide for her expertise. She can be reached on Twitter at @katescarlata_RD.