Recently I welcomed my colleague and world-renown expert in GI- nutrition,
Kate Scarlata, MPH, RDN onto my podcast . Kate has been a great contributor to the field of gastroenterology nutrition and with Irritable Bowel Syndrome patients. I encourage you to listen to the episode . Below are my show notes from the episode. But first a little more about our guest.
Kate Scarlata, MPH, RDN, LDN is a registered, licensed dietitian with a nutrition consultation business in Medway, Massachusetts. She has 30 years experience providing nutrition consultation to patients with irritable bowel syndrome, celiac disease and inflammatory bowel disease. Ms. Scarlata is considered a global expert in the low FODMAP diet and an invited speaker to numerous conferences in the US and abroad. Kate is a New York Times Best Selling author for her co-authored book, 21 Day Tummy Diet and author of The Complete Idiot’s Guide to Eating Well with IBS and co-author of The low FODMAP Diet Step by Step. Ms. Scarlata earned her B.S. in Nutrition from Simmons College in Boston, Massachusetts and her MPH at the University of Massachusetts. She was awarded the Outstanding Dietitian of the Year by the Massachusetts Dietetic Association and voted Boston’s Best Dietitian award by Boston Magazine.
show notes below by Adam Rinde, ND
Kate Scarlata's Background
Kate's Career started as a dietitian helping underweight and malnourished
When pregnant with middle child had strangulated intestine requiring 6 feet of intestine to be removed. Surgery involved ileum which is responsible for bile acid absorption, B12, and fat absorption. Subsequently she developed SIBO and went on a quest to figure out how to help herself.
This led her to Monash University in Australia where she traveled to and learned about The Low Fodmap Diet through Dr. Jane Muir. She helped herself and soon after her practice filled up with patients with IBS and other conditions needing help with the low fodmap diet.
Low Fodmap Diet overview
The Most researched diet for Irritable Bowel Syndrome
Acronym Fermentable Oligosaccharides (fructans and galacto oligosaccharides), Disaccharide (lactose), Monosaccharides (Fructose) AND Polyols (sugar alcohols)
Fermentable means that it is producing gas.
Oligosaccharides consist of Fructans which mainly consists of garlic, onions, and wheat and Galacto oligosaccharides which mainly consists of the legume group
Disaccharides is lactose which is sugar from dairy products .
Monosaccharides: consists of fruits that have a high fructose: glucose ratio.
Polyols (stone fruits, cauliflower, celery. Large amounts of sweet potato, sugar alcohols in gums,mints, and medications)
How Fodmaps trigger symptoms
Fodmaps are small carbohydrates and fast food for bacteria
Highly osmotic . Pulls water into intestine
The water and gas production trigger stretch and stretch receptors into the gut
Fodmaps lead to production of metabolites from bacteria such as histamine and Lipopolysaccharides (LPS) which may increase pain and visceral hypersensitivity in the gut.
Who is likely to benefit from Low Fodmap Diet
70% of patients with IBS subtypes respond to low fodmap diet according to studies
Most studied group is IBS-D patients.
Kate feels all patients she sees with gas and bloating will respond
SIBO patients. A little evidence but not clean evidence yet.
Work up needed and screening needed before embarking on a low fodmap diet.
Has Inflammatory Bowel Disease been ruled out?
Has Celiac Disease been ruled out ?
Has Ovarian Cancer been ruled out?
Have eating disorders been screened for? We don’t want to trigger eating disordered behavior.
Can a person afford changing their diet?
Phases of the Low fodmap diet
Elimination phase 2-6 weeks pending response. Emma Halmos, PhD study at Monash found that symptom control maximized by day 7 after being provided all low fodmap meals. At University of Michigan study which was a slower ramp up most patients maximize the benefit at 4 weeks.
Reintroduction phase: adding fodmaps back in small increments to see what can be tolerated and it might tolerated. Must be pure challenges like onion , garlic, milk vs. apple . Apple has multiple types of fodmaps within it.
Personalization phase: moving forward with your own customized low fodmap diet. The goal is to have a liberal diet without triggering symptoms. A wide variety of foods!
Steps summarized here: https://www.monashfodmap.com/blog/3-phases-low-fodmap-diet/
Risks and Deficiencies on a Low Fodmap Diet
Kate integrates Prebiotics like OATS and Oat energy bites gradually and later on . Especially if patients are having problems with garlic, onion, and wheat. Oats are rich in resistant starch which is a great prebiotic. It is not a fodmap and is long chain carbohydrate.
The only reason to supplement is if the patient has additional restrictions on top of the low fodmap diet.
All food groups are covered on the low fodmap diet.
Response to prebiotics is individualized because you need certain bacteria that would consume the prebiotic innately. For example you need bifidobacterium to consume some prebiotics . The result of prebiotic consumption is the production of Butyrate
Non-responders to the Low Fodmap Diet, what else could be causing these symptoms?
Constipation patients likely have Dyssynergic Defecation . 95% of her patients have physical therapy and 70% respond to pelvic floor physical therapy. Kate has blogged on this. Jenna Leader, PT, DPT in Boston is a resources.
Kate’s Trifecta for constipation: Treat SIBO, Treat Dyssynergic Defecation, and Give Low Fodmap Diet
Dairy intolerance . May be A1 beta casein intolerance . A1 beta casein or A2 beta casein. A2 milk
Mast Cell Activation Syndrome. Many systemic symptoms. GI symptoms that is often diarrhea, Hives , rapid heart beat, POTS, SIBO and many other symptoms. These patients generally respond to a low histamine diet. Not common. Kate has a 3 part interview on Mast Cell Activation Syndrome with Dr. Hamilton at Harvard.
Congenital Sucrase Isomaltase Deficiency. (CSID). Emerging condition in adults. Studies at University Michigan not responding to low fodmap diet had genetic snps related to Sucrase Isomaltase Deficiency. People with this have troubles with some sugars and starches.
Bile Acid Diarrhea. Treated with a sequestrant of bile salts.
Emerging directions and future of low fodmap and IBS diet research
Big emphasis on preventing food fear. Monash University released a fodmap gentle approach that is helping people be more flexible on the Low fodmap diet . Restriction is not a diet for life.
Carefully finding the balance between wrongly labeling someone with an eating disorder and honoring that food can cause discomfort and food avoidance because of pain .
Kates updates on her career
Just completed a Masters in Public Health at the University of Massachusetts
Blogging . Soon on hypnosis, and on the MAST program from Cedar Sinai Hospital.
Speaking All Over
Doing two research projects
Trying to regain some balance with her chocolate lab and walks on the beach
Jane Muir,PhD https://research.monash.edu/en/persons/jane-muir
Emma Halmos, PhD https://research.monash.edu/en/persons/emma-halmos
Shanti Lynn Eswaran, MD https://www.uofmhealth.org/profile/254/shanti-lynne-eswaran-md
2016. Eswaran, SL; Chey, WD; Han-Markey T; Ball, S: Jackson K: ARandomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. American Journal of Gastroenterology. Dec;111(12):1824-1832. Link