Gluten-Free IBS FODMAP Diet with Patsy Catsos, RD
This week’s Gluten Free School Podcast episode talks about the gluten-free IBS FODMAP diet with Patsy Catsos, RD for those who still aren’t feeling better.
Here’s the breakdown of topics:
00:20 – Introducing Patsy Catsos, registered dietitian, medical nutrition therapist and author of IBS: Free at Last! Change Your Carbs, Change Your Life.
01:43 – Patsy’s diagnosis of ulcerative colitis led her to studying nutrition for GI problems. Because there was so little FODMAP information available in the US, she developed materials to use in her own practice and turned them into a book.
03:55 – FODMAPs explained in plain English and how they affect people with GI troubles.
05:30 – Five different kinds of FODMAP foods, and the one most likely to overlap with the gluten-free diet.
07:51 – How FODMAP foods trigger GI symptoms.
09:10 – Two types of people who would benefit from the FODMAP approach, and why eliminating them 100% is not always necessary.
11:47 – Irritable bowel syndrome (IBS) versus celiac disease symptoms, and what other systems a low FODMAP diet can effect.
14:28 – High FODMAP ingredients that find themselves in packaged and processed gluten-free products (aka Standard American Gluten-Free Diet).
15:56 – The importance of fiber, and non-FODMAP or low-FODMAP fiber options.
17:26 – How foods are analyzed for FODMAP content and where testing is done.
18:41 – Is there a FODMAP elimination diet? Questions to answer to determine if FODMAPs are an issue and how to proceed.
20:49 – Who would benefit from assistance in following a low-FODMAP diet?
21:33 – Is this a lifelong restrictive diet?
22:42 – Will a low FODMAP diet “flip the switch” on underlying GI issues? What is a typical outcome on this regimen?
23:45 – How difficult is it to make a FODMAP diet gluten-free.
24:12 – Resources available to learn more about the FODMAP Diet.
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Jennifer: Welcome back to the Gluten Free School podcast. I’m your host, Jennifer Fugo. Today, we’re going to talk about the FODMAP diet.
So I am very blessed to have Patsy Catsos joining me. She’s a registered dietitian, medical nutrition therapist and author of IBS: Free at Last! Change Your Carbs, Change Your Life. She has a practice up in Portland, Maine. She helps patients with IBS, celiac disease and other gastrointestinal problems manage their symptoms and experience a better quality of life.
Now Patsy is an expert at this and she actually speaks at a number of different community and professional events. She is really active on social media and we’ll give you all of the information to connect with her there. You can also find her in her website, ibsfree.net where she blogs about low FODMAP living.
She completed her undergraduate studies at Cornell and earned a master’s degree in nutrition at Boston University, then interning at Boston’s Beth Israel Hospital.
She’s a professional member of the Crohn’s and Colitis Foundation of America and the Academy of Nutrition and Dietetics.
Thank you so much for joining us, Patsy. We really appreciate your presence here.
Patsy: The pleasure is all mine. Thank you so much for inviting me.
Jennifer: So let’s dive into this. A lot of people don’t entirely understand. People actually can’t really explain things. This topic of FODMAPs is complicated. I know you have a lot of experience. Your book is incredible! How did you end up here, becoming an expert in Low FODMAP diets.
Patsy: Well, my interest in digestive health goes way back to my mid-20s when I was diagnosed with ulcerative colitis. Ever since then, I’ve followed all the developments in nutrition therapy for gastrointestinal problems very closely.
About seven years ago maybe, I heard this brand new term, FODMAPs at a Crohn’s and Colitis Foundation of America event. When I tried to dig into it a little bit, I found that it was such a new topic that there was really absolutely nothing available here in the U.S. for health care consumers or even medical professionals to implement a FODMAP approach type of diet.
It was a new area of research that emerged from Monash University in Australia where researchers Susan Shepherd and Peter Gibson developed the concept. So as soon as I could, I developed some materials to use in my own practice. When I realized how effective they were at helping my patients, I turned them into a book.
Jennifer: Nice! And so really you’re getting sick in a sense. Was that part of the inspiration in wanting to help others deal with their health issues as well?
Patsy: It was. No one can understand what it’s like to have these GI issues like someone else who’s been there. So when my patients tell me about their troubles and the urgent diarrhea and all that kind of thing, I can really relate to it on both a personal and a professional level.
Jennifer: So tell us a little bit about what FODMAPs are from the perspective of someone who may never have heard of it and they’re like, “What is that word? FOD-what?!” What is a FODMAP?
Patsy: Okay. Well, first of all, it’s an acronym. It’s spelled F-O-D-M-A-P and it stands for a bunch of jargon that a lot of people don’t really have an appetite for, but just for the record, it stands for fermentable oligo-, di- and monosaccharides and polyols. That’s kind of a mouthful.
Jennifer: It is. I can see why they use FODMAPs for short.
Patsy: It’s not really important to know what the acronym stands for to give the FODMAP approach a try. It’s more important to know that FODMAPs are a group of certain sugars and fibers in the diet that are capable of causing abdominal and gastrointestinal symptoms such as gas (excess gas really), bloating, abdominal pain, diarrhea and/or constipation.
Jennifer: And that can show up as someone who may appear to have IBS or any other number of intestinal issues and digestive issues.
Patsy: That’s right. Those symptoms are common to a number of different issues including Celiac disease and other gluten-related disorders.
Jennifer: Now, just real quick, did you notice because you said about the celiac disease (and we have a lot of people here who are listening to this who are diagnosed with celiac) that they’re starting to wonder as far as gluten-sensitivity is concerned whether it could actually be a FODMAP issue or is gluten-sensitivity real. I hope that we’ll be able to uncover some information today that will help people out there that maybe gluten is an issue. I don’t know, you’ve got so much information. I’m really curious to learn from you exactly how all these pieces fit together.
So as far as food is concerned, what would be considered a FODMAP?
Patsy: So there are five different kinds of FODMAPs. They include lactose, which also known as milk sugar so it’s clearly going to be in milk and milk products; fructose, which is also known as fruit sugar. That’s going to be found of course in fruit, but there’s also a lot of fructose in sweeteners like honey, agave, high-fructose corn syrup;
The next kind of FODMAP is called fructans and this is where the overlap with the gluten-free diet comes in because the number one source of fructans in the diets of Americans are the gluten grains. But other foods that contain fructans include certain vegetables, especially onions and garlic, as well as certain added fibers in our food;
Then the next category is called sugar alcohols. Sugar alcohols are sometimes seen as a sweeteners in certain sugar-free gums and candies, but they’re also naturally found in some fruits and vegetables;
And then the last category is the type of fiber found in beans and peas. This one really isn’t too much of a surprise. I think most of us are aware of the gassy reputation of beans or eating too much beans.
So that’s an overview of where FODMAPS are in our food.
Jennifer: And say we have a bean-y, onion-y, garlic-y mixture of food and you’re not feeling so well, how does the food cause the GI symptoms that result?
Patsy: Good question. So what happens when we eat these FODMAPs is that they’re poorly absorbed in our small intestine. When that happens, they keep moving on down the line to your large intestine and when they get there, they are seen as the favorite foods of the normal gut bacteria that live in our colons. They seize upon them, they rapidly ferment them and they put out a lot of gas as part of their fermentation process and that gives you gas. It also distends the colon and that’s experienced as a painful sensation by people at have irritable bowel syndrome. So that’s one aspect of it.
The other aspect is these FODMAPs when they hit the large intestine can sometimes pull a whoosh of fluid into the gut and that can cause a bout of watery, explosive diarrhea that some people might be familiar with unfortunately.
Jennifer: Yeah, and that’s the hard thing with IBS, we don’t really know all the time what’s going on. This is an important thing to consider because if you go gluten-free and you still don’t feel better – this is what I always tell people, “If you went gluten-free and you’re still not feeling better, you got to keep digging” and this should be one thing to consider.
So why might this explain after you’ve given us this information, if they’re not Celiac, why might they not feel better even though they don’t necessarily need to be gluten-free because of Celiac or gluten-sensitivity? Why would taking FODMAPs out help?
Patsy: Good question. There are definitely two types of people in your audience that could benefit from this FODMAP approach. First of all would be the people that actually do have Celiac disease, but also have some IBS-like symptoms. There’s a big study down that looked at over 3,000 patients who had Celiac disease and about 38% of them also have IBS. So there’s that whole group.
But then there’s the group that you just asked about who actually do feel better on a gluten-free diet even though they don’t have Celiac disease. Perhaps some of them have benefited because they have a non-Celiac gluten-sensitivity, but there may be a subset of them that are feeling better because a gluten-free diet is a lower FODMAP diet. The gluten grains (wheat, barley and rye) are huge contributors of FODMAPs to our diet.
One key concept when it comes to FODMAPs is that it’s the total load of FODMAPs in the entire diet or in the entire meal that count. So if you’ve lowered your FODMAP load a lot by being on a gluten-free diet, then you probably have more capacity to handle a lot of those other FODMAP contributing foods. You’ll probably do a better job of tolerating lactose, you’ll be able to eat more fruit and more nuts and beans and so on if you’ve gotten a big load out of your diet by eliminating glutenous grains.
Does that make sense?
Jennifer: It does. It does. I’m just curious because we hear these phrases, we all know what Celiac disease is and everybody’s familiar with what Irritable Bowel Syndrome or IBS is. But real quick before we talk about – can you have both? How would you define IBS?
Patsy: Well, a person with IBS has a functional bowel problem. Something is not working right. The symptoms that I referred to before (gas, bloating, diarrhea, constipation, abdominal pain) are present, but there doesn’t seem to be any medical reason for it.
Jennifer: Those are also symptoms of someone who has Celiac disease, for example. Could you have both or in essence would your IBS really be Celiac disease if say you had Celiac?
Patsy: You can definitely have both.
Jennifer: Would you differentiate between them?
Patsy: I certainly would. They’re very distinct. If I had a patient who was adhering to a gluten-free diet, 100% gluten-free who has Celiac disease and they’ve been on that diet for an extended period of time and I would expect their GI symptoms to have resolved and they haven’t, then I would go on and consider adding a Low FODMAP aspect to their diet to see if we could get any additional improvement.
Jennifer: That is really interesting. So for you, that’s really the next step. It’s FODMAP.
Patsy: In fact, even when I’m working with someone with IBS, I’d like to have Celiac disease ruled out at least with a blood test if not more extensively before I implement the Low FODMAP diet.
Jennifer: And aside from GI issues, are there other things that going on a Low FODMAP diet could help as far as the body is concerned?
Patsy: At this time, it looks as though most of the effects of the Low FODMAP diet are really local to the gastrointestinal tract. So I wouldn’t expect a lot of other changes. I wouldn’t expect it to affect migraine, headaches, rashes or joint pains or any of those more systemic sorts of symptoms.
Although there are a few clues that it might affect mood and fatigue. So I think we have a lot more to learn about it, but right now, it’s really gastrointestinal focus.
Jennifer: Okay. And so as far as the gluten-free diet is concerned, I can just guess what some of the problems might be as far as why you might have to take that next step, but what are some of the High FODMAP pitfalls that one might find in what I like to call the Standard American Gluten-Free Diet?
Patsy: Okay. There are a few that are unique to the gluten-free diet. I think one of them is the fact that a lot of the gluten-free food manufacturers are aware that many of the products that have been developed tend to be lower in fiber. A lot of the gluten-free grains can be low in fiber, grains and starches. So there’s now a bit of a movement towards fortifying those products with added fibers. Sometimes we see inulin or chicory root or chicory root extract or fiber from all kinds of novel sources added to the breads, to the pretzels, all the different gluten-free products. Those are introducing FODMAPs where there were none before.
Jennifer: So all of those are FODMAP foods?
Patsy: Most of the isolated added food fibers that they put in to boost up fiber are either definitely or probably high in FODMAPs.
Jennifer: Wow! But then here’s the thing, we’ve been trained to learn that we need fiber in our diet. It’s important for our bowel and all sorts of stuff. We need fiber. It’s good for you… is it? Do you think it is?
Patsy: I do. I do. I mean, fiber has so many well-known benefits that it is an essential nutrient. It’s an essential part of our diet, but only up to the point that you can tolerate it. There’s no particular benefit to consuming at a level that’s going to cause you pain.
Jennifer: So what would be some non-FODMAP or low FODMAP fiber options for people out there?
Patsy: Quinoa is a great fiber source that is both gluten-free and low in FODMAPs. Ground chia seeds are a low FODMAP fiber source – oat bran, rice bran, all of the lower FODMAP fruit and vegetables. Those would be good starts.
One issue that we have in this FODMAP world is that only a few hundred foods have really been tested to see if they contain FODMAPs or not. So we’re on a learning curve and we’ll stay on that learning curve for a long time, but those are some I can feel pretty confident are low in FODMAPs and gluten-free.
Jennifer: I’m just curious. Do you know how they test? Is this like a laboratory test that they do on foods to see the FODMAP?
Patsy: Yeah, yeah. I was lucky enough to actually visit their lab in Australia in May. I traveled there to meet the researchers that are generating all these information. It was a really awesome trip. I went to the lab where they analyzed for FODMAPs and it’s a high-performance liquid chromatography process. They take multiple samples of the food, they dry it, grind it, hydrate it with water and then run this solution through this machine and it spits up the information about how many grams of FODMAPs are in the test food.
Jennifer: Wow! So is it just more accepted in Australia because it sounds like if they’re doing it there, it must’ve originated in Australia?
Patsy: Absolutely did. Yeah, they originated there. They’ve produced so far four papers sharing the actual FODMAP data with the world.
Jennifer: Wow! That is really cool.
Patsy: Yeah, it is.
Jennifer: So if someone wanted to give this a try, is there such a thing as a FODMAP elimination diet and who would be ideal to do something like that?
Patsy: So if you think you might have some IBS in addition to your Celiac disease or gluten-intolerance, first you should ask yourself, “Have I taken care of all the basics? Am I eating three or four regular meals a day? Am I drinking enough water? Am I getting enough exercise?” – just some of the basic health questions.
If you’re really working to have a sensible diet and lifestyle and you’re still having trouble, then you could give this approach a try. Some people if they really don’t have a complicated situation might be able to do it on their own with the help of my book, which is called IBS: Free at Last! The book lays out a strategy and a plan for eliminating FODMAPs temporarily and then reintroducing them so that the reader can learn which FODMAPs are contributing the most to the problem and how they can get their favorite foods back in their diet without the pain. So that’s one possibility.
For people that have a more complicated medical situation (maybe have other medical conditions on top of their Celiac disease or gluten-intolerance), it really may be necessary to have some help from a dietitian to implement this program. At the top of my website, www.ibsfree.net, I have a link called Find a FODMAP Dietitian. I have a couple hundred dietitians now that have identified themselves to me and said, “Yes, I can help people with a FODMAP diet and I’m taking new patients.” So that could be a really great resource for people if they feel like they need someone to guide them through the process.
Jennifer: And would someone in that situation have Crohn’s, Colitis, or an IBD-type situation?
Patsy: Certainly those would be some scenarios that might require a little extra help, but even people that have GERD, gastroesophageal reflux or diabetes or unrelated conditions that have a dietary component to them, even those people might be able to benefit from a dietitian’s help with this.
It’s one thing to look up on the Internet and find list of high and low FODMAP foods and it’s another thing to figure out what to do with that information.
Jennifer: That’s for sure.
Patsy: I like to make sure that people understand that a FODMAP elimination diet is a learning diet. It’s meant to be temporary, not like a permanent restriction of these foods?
Jennifer: So most people, even if they did the elimination diet, they wouldn’t necessarily need to stay on it for the rest of their life?
Patsy: That’s right! Because a lot of these FODMAPs are part of high-nutrient value foods, we wouldn’t want people to have to stay away from all the good, healthy foods that have FODMAPs unless they absolutely have to. Some of them, not so much. I don’t really think it’s a big loss if somebody never has high-fructose corn syrup again, for example.
Jennifer: I agree with you on that.
Patsy: But the yoghurt, the nuts and seeds, the fruits and vegetables that have to be temporarily limited during the process, we want to get those back into people’s diets as soon as we can and right up to the point of tolerance.
Jennifer: And so by doing the elimination diet, the goal eventually is to sort of flip the switch so that you could then go back to eating those foods?
Patsy: I think “flip the switch” would be a little overly optimistic. It’s not really going to change the underlying IBS, but it will help manage symptoms.
A typical outcome might be somebody realizes after they’ve been through this elimination and challenge process that garlic and onions really are a problem. Now, that doesn’t mean never having them again, but it might mean making some accommodations like maybe using the minimal amount possible. Or if you know you’re going to have fajitas with a big plate of fried onions that night, you take it especially easy on all the other FODMAPs earlier in the day and that kind of thing.
Jennifer: So you’re sort of picking and choosing.
Jennifer: You’ve got to pick your battles in a sense.
Jennifer: So as far as doing a gluten-free version of this diet, do you think it’s very tricky to manage that?
Patsy: It’s actually very easy because for most people, the hardest part of a FODMAP elimination diet is giving up those gluten grains and your tribe who are already on a gluten-free diet have done the hardest part already.
Jennifer: Nice! So they just have to figure out the rest of it.
So on your website, you have some really great resources for people if they want to know more about how to do this. Aside from the book, just immediately, they can go and check out your – you have like a shopping list and some handouts and such?
Patsy: Yeah, I have some free handouts that are available also at the top of the page on one of the gray boxes. There’s a search function on the upper right-hand corner of the blog. That is a great way to just look up an answer to a particular question on the site if it’s already been addressed. There’s a link to the book there and a lot of other helpful links as well.
Jennifer: Great. Great! Well, thank you so much for joining us. I have loved learning about this. Every time I learn more and more about gluten-free living – I mean, FODMAPs are something I’ve never tried to do, a low FODMAP elimination. I love onions and garlic. I just think this is a really great space for people to be able to learn more about these types of – as you say, it’s like the next step. Beyond gluten-free, if it’s not working then you’ve got to look someplace else. Your book is an excellent resource.
Patsy, where can everybody find you online?
Patsy: Well, of course, the website. But also I have a really active Pinterest boards. My little handle there is pcatsos. I’ve got lots of boards with pictures of groceries that match the FODMAP elimination diet. And then I’m on Facebook as well.
Jennifer: Nice! And they can find you on Facebook at IBSFree.
Patsy: That’s right! And don’t forget to follow me on Twitter. I always post on Twitter when I’ve put up a new blog post. So that’s one way you can keep track of what’s new.
Jennifer: Well, thank you so much for joining us. And again, everybody please go check out her resources. Get Patsy’s book. And if you want to ask questions or continue this conversation, leave questions and comments below this podcast so we can continue to talk about this and perhaps we can get Patsy to come back and share more on this really fascinating topic on the future.
Patsy: Thanks for having me, Jen.
Jennifer: Absolutely! Thank you for joining me. And remember, go check out Patsy’s book. Alright, everybody! Remember to subscribe, rate and review this podcast and then head over to Gluten Free School and leave your questions and comments. I want to hear from what did you learn from Patsy. I think this topic is incredibly important. Are you one of those people where the gluten-free diet just doesn’t seem enough? Would you be willing to do this? I think it’s definitely worth a try.
Alright! Thanks for joining me. I’ll see you guys the next time. Bye bye.
The links referred to in this episode are:
Patsy Catsos, RD’s Website — www.ibsfree.net/
Follow Patsy on: