Following the Low-FODMAP Diet
FODMAP carbohydrates are found across a wide spectrum of foods and can trigger digestive issues like bloating, gas and abdominal pain. Dietitian Stacy Cavagnaro discusses which foods to avoid and recommended substitutes for following the Low-FODMAP diet.
Following the Low-FODMAP Diet
Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.
So welcome back to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Very pleased to have today, Stacy Cavagnaro, a registered dietician in Cleveland Clinic's Digestive Disease & Surgery Institute. Stacy, thanks for joining us on Butts & Guts.
Stacy Cavagnaro: Thank you for having me.
Scott Steele: So we're going to talk a little bit about diets today, something that is near and dear to everybody's heart. Everybody likes to eat and we're going to talk about a specific diet today. But before we delve into that, tell us a little bit about yourself, where you're from, and how did it come to the point that you're at the Cleveland Clinic.
Stacy Cavagnaro: So I'm a registered dietician originally from Buffalo, New York. I went to Penn State for undergrad and then the University of Buffalo for my masters. And then I was matched to the Cleveland Clinic to do my intern year. I left for a year and went to Pittsburgh, worked primarily in intensive care, missed this place. They got me back, so I came and worked with the Center for Gut Rehab and Intestinal Transplant for a few years before I met Dr. Regueiro and learned about the IBD Medical Home and he brought me over there about a year ago.
Scott Steele: Wonderful. We're very glad to have you here. And so for the frequent listeners to Butts & Guts, we've had a couple of dietitians on, so you can look for those other episodes out there. But as a dietician, let's first kind of go to the very basic, what's your role in working with patients to achieve their optimal health and how do you work with them to say this is the right nutrition plan for you?
Stacy Cavagnaro: The important thing about GI nutrition is that it's completely individualized, so you can't go online and google what's the best diet for Crohn's or colitis or IBS because there's a lot of factors. So when I'm assessing a patient, I am looking for malnutrition. If they've had any surgeries, what their anatomy is, any specific food intolerances, allergies, cultural preferences. There's a lot that goes into it. There could be a couple different GI etiologies working at once, whether someone has celiac disease and Crohn's disease that we may need to combine things if they're going to surgery, if they just had surgery.
So GI nutrition is definitely very individualized and it's important, I think, to involve the dietician early on to catch malnutrition early on because we know that that can increase a lot of complications with various GI diseases and also so that they can get that individual diet instruction based on what's going on at that point in time.
Scott Steele: So Stacy, you're a little bit unusual in the fact that you have just this unique aspect of this Medical Home care and working very closely with the chairman of our gastroenterology department. But for the person out there who just is like, "God, this sounds awesome. I want to meet with a nutritionist. I want to meet with a dietician." How do they get to see you?
Stacy Cavagnaro: And you're right in that I am referred because I'm within the Medical Home. So I am very unique in that I see my patients right in the same room with the physician at the same time. But that's not necessarily how it has to go. Here at the Cleveland Clinic, we have probably close to a hundred dieticians throughout the region, in Akron, in Florida. And so your physician can place a referral or you can just call to schedule an appointment with a dietician to talk about any questions that you have related to diet.
Scott Steele: That's fantastic. And again, I encourage all of our listeners out there to take advantage of this wonderful type of a process that can occur. So today we're going to really focus on the low FODMAP, F-O-D-M-A-P diet. So let's give our listeners the big overview in terms of what that is and what type of foods are we talking about.
Stacy Cavagnaro: So the low FODMAP diet is actually an acronym for fructo oligo- and di-saccharides and polyols, which you don't need to remember. That's why we have an acronym for it. But basically these are small chain carbohydrates or sugars that are found in our foods that aren't digested very well. And so when we eat them, they draw water into the small intestine. So that can cause symptoms like bloating and diarrhea and discomfort. And when they reach the large intestine undigested, it's basically a field day for the bugs that live in your colon. And so they feed on those and they produce air which causes more gas and bloating and pain and diarrhea and in certain types of, or certain people, they have a really hard time digesting these types of foods.
Stacy Cavagnaro: So the idea with the low FODMAP diet is we take out all of these types of indigestible carbohydrates that can cause GI discomfort for about four weeks, four to six weeks or so, kind of let things settle down. A lot of patients come back and they say, "I feel so good. I don't want to touch any of these foods again. Don't make me add things back in." But then what we do after that initial elimination phase is we add in one group at a time. We can talk a little bit more about what those foods would be and we test it in a very step-wise fashion to identify triggers. Seems like a very strict diet at first. But once we test these triggers, it's usually only one or two groups that a person responds to, and then that kind of gives them their maintenance diet. Then going forward, they know what to avoid. So it's kind of a lot of work and a big commitment upfront for a lot of reward on the backend long-term.
Scott Steele: So Stacy, I got to tell you, these symptoms that you are talking about in terms of bloating and maybe a little bit of gassy, a little constipation, a little of diarrhea, it sounds pretty common. What type of disease processes would patients have if a disease at all to cause these types of symptoms? And can you tell us a little bit more? What specific foods are you talking about in terms of this FODMAP?
Stacy Cavagnaro: So I would say this is the best researched and studied diet for irritable bowel syndrome. Some evidence for IBS with constipation. Definitely good evidence for IBS and diarrhea, but primarily even if you don't have an IBS diagnosis, when someone comes to me and they say, "I'm bloated all the time, I eat something and my gut's out to here," or, "I have tons of gas and I've tried every over-the-counter gas medication and nothing gets better," that keys me into someone that's really going to benefit from this diet.
Scott Steele: So Stacy, one of the things we had talked about earlier and I just want to make sure that our listeners are clear on this, you work with more IBD patients and what you're talking now is IBS. Can you tell the listeners a little bit of the difference between the two?
Stacy Cavagnaro: Mm-hmm (affirmative). So IBD is inflammatory bowel disease and that encompasses primarily two conditions. That's Crohn's disease and ulcerative colitis. These are conditions that cause inflammation throughout the GI tract that would show up on various testing and imaging. Irritable bowel syndrome, it can present in multiple different ways, but that is primarily symptoms of constipation, diarrhea, bloating, gas, a lot of burping, belching with no inflammatory process. So there's no kind of one medication that can take care of that inflammation. There's no underlying inflammatory process. It's irritable bowel syndrome, so it's more of just a collection of symptoms.
And so that's where really treating the whole patient comes into play with involving a dietician for diet along with the physician. And oftentimes, also we have a GI psychologist who helps deal with stress management and sleep because we know that that plays a role, too, in this kind of syndrome of symptoms.
Scott Steele: So let's go into the details a little bit more about the condition and about this diet, and then how long is a person typically on this diet. So foods that are included in the low FODMAP diet, again, meaning limiting these type of FODMAP carbs, what are they and how long does it typically take to show an effect or not show an effect? And isn't this just telling people to just eat healthier?
Stacy Cavagnaro: Great question. And so a lot of times when people come to me they say, I don't understand why I feel so bad because I'm eating so healthy. All I'm eating is broccoli and salad and fruit and I am getting worse and worse. And unfortunately, with the low FODMAP diet, a lot of the biggest culprits of our bloating and gas and pain are fruits and vegetables and whole grains and the foods that we think are healthy.
So the categories that we eliminate, one is lactose and that tends to be a trigger that maybe at this point when people come to see me, probably have already tried to eliminate lactose or dairy. So you can still do things like Greek yogurt and hard cheeses, but really cutting out the milk and the ice cream. The next category is fructose, so that's found in certain high fructose fruits such as watermelon and mangoes. It's also found in honey. It's also found in high fructose corn syrup, which is in everything. So check in your ketchup, your barbecue sauce, your salad dressing, your Sprite because high fructose corn syrup is very widespread.
There's also fructans. Those are found primarily in onions and garlic. And we do a full elimination, meaning you can't have the pasta sauce with onion and garlic. You can't have the barbecue sauce that has onion in there. We do a full overhaul. Foods like broccoli, beans, foods that we normally think are healthy, unfortunately, are a lot of the ones that can cause these symptoms. So a lot of the vegetables are eliminated. Your starchy beans, peas, corn. In addition, this diet ends up being gluten-free because while we don't intend to make it a gluten-free diet, fructans, one of these types of undigestible compounds, are found in wheat, rye, and barley. So inherently this makes it gluten-free. And when we think about gluten sensitivity actually, in people that do not have a celiac diagnosis but come off of gluten and then we do a challenge and they feel so much better, and we kind of call it gluten sensitivity, we actually wonder if they're responding to removing the fructans from the diet, by removing the gluten.
Scott Steele: It sounds a little bit onerous. And so let's go through some good substitutes for these FODMAP rich foods that someone on this diet would basically want to go with. So you talked a little bit about this before. So lactose, what can they take and what should they avoid?
Stacy Cavagnaro: Absolutely. So you can still do things that are naturally low in lactose, like Greek yogurt or kefir, which is like a drinkable yogurt. But you can also do just lactose-free milk, lactose-free cottage cheese. You can do dairy free milks like almond milk and coconut milk. You can do hard cheeses still. So you can have a slice of cheddar cheese, you can have a string cheese or sprinkle some feta cheese. Those are all still allowed. You can do a little bit of butter still.
Scott Steele: So butter is available in this one or do you have to substitute olive oil?
Stacy Cavagnaro: Olive oil is usually the recommendation. It's a little bit more heart-healthy, but you could still do small amounts of butter.
Scott Steele: How about the fruits?
Stacy Cavagnaro: So fruits, basically what we do when you come to see me is instead of focusing on all the ones you can't do, we go through the list of all the ones you can do and figure out the ones that you like. So you can still do bananas, and strawberries, and blueberries, and pineapple, and oranges, and grapes and you still have a good number of options. So if Apple was your go-to, well for the next three or four weeks we're packing a banana or we're packing grapes. It sounds overwhelming, but it does come down to sometimes just tweaking what you normally do. If your go-to for dinner was always broccoli and cauliflower, now we can do carrots and green beans and zucchini and other low-FODMAP vegetables in place.
Scott Steele: Yeah, that's interesting that you said that the vegetables were on this now. So what vegetables can you have?
Stacy Cavagnaro: So the big ones, carrots, zucchini, summer squash, green beans. You can do winter squashes, like acorn squash. You can do still do, although these are starch versus vegetable, potatoes and sweet potatoes. You can do spinach, you can do tomatoes. So you do have still a good number of options
Scott Steele: What about for the people out there who like beans and things like that?
Stacy Cavagnaro: Those are one of the toughest ones besides the green beans. All starchy beans are eliminated. So no black beans, no kidney beans. You can't even do a little bit of hummus. No edamames, so no soy beans in this diet. That tends to be one of the bigger triggers I find when we add things back in, unfortunately.
Scott Steele: And then what about alcohol? Is that involved in this process?
Stacy Cavagnaro: So there are some low FODMAP alcohols that one you just kind of have to do your research so it's not totally eliminated. And now we do have to look at the whole patient wondering what else is going on? And maybe alcohol isn't a good idea because it could be triggering them in other ways. But there are some types of alcohol that fall within that. A lot of the high sugar wines and things like that are not allowed. But some of the drier wines are allowed. Of course, we want them to avoid things like fruity drinks where you might find fructose looming. But there are some that do fit.
Scott Steele: So Stacy, a lot of our listeners will be hearing this at various points in the year. And so let's say I'm going on a vacation or the holidays are coming up or something like this, can I take a little break from this low FODMAP diet and just kind of cheat a little bit and then just go back on it? Or how's a person going to feel if they do this?
Stacy Cavagnaro: So I actually tell people, wait till after the holidays, wait until that vacation, wait till that wedding. Because if you do it halfway, we actually don't have any benefit. And basically you just suffer by restricting yourself unnecessarily. So it really needs to be done for at least three, preferably four weeks, where it's a total elimination. So at the end of the four weeks, if you don't feel any better, we don't do the reintroduction phase. We say, this didn't work, go ahead, we'll try something else.
But if at the end of the four weeks you really feel better, that step-wise approach of adding one group back at a time is so crucial. So even people will follow it perfectly, but don't come back and don't follow up and just kind of eat whatever at the end of the four weeks and then they aren't able to figure out what it was that was their triggers, which is really important in the long-term. So I say find three to four weeks of your life where you can really, really be dedicated to this because otherwise you are restricting yourself and you're causing a lot of stress doing this tough diet and then you don't get any of the benefits from it. So if people are a little hesitant, I say don't do it then until you're ready.
Scott Steele: And so how do you reintroduce these foods? Is it one a week and while they're in the second week and they keep this stuff from the first week, or how do you go about that?
Stacy Cavagnaro: Great question. So everyone, the intricacies are a little different depending on the center and the preferences. But the big idea is the same, is that for me at least, I say, "What did you miss the most?" If it's onions and garlic, we start there. If it's watermelon, we start with the fructose. And so what we do is we try one food in that group that doesn't have other groups mixed in, if that makes sense. Because some foods may be fructose and polyol and we don't want that kind of confusion. So, for example, fructose, we use either honey or mango that's really high in fructose. So we might start on day one, week one with a teaspoon of honey. Day two, nothing new. Day three, you might do a tablespoon of honey. Day four, nothing new. And day five, I want you to do two tablespoons of honey.
And what we might find is there may be a group where on day one, just a little bit of honey or two tablespoons of onion really caused you to be bloated, gassy, diarrhea. And we know, okay, we're going to table that for a while. Maybe months down the line we can re-challenge but that might be a major trigger for you. More times than not, we find a couple categories where day one they did good but it was day three or day five when they increased the amount that they really had problems, which for like the onion and garlic category would tell me I can do some pasta sauce with onion and garlic but I probably shouldn't overdo it or I probably shouldn't go have fajitas and eat a bunch of onion because then I really might start to have some problems.
So while it sounds really restrictive upfront, what I find is it actually gives people more freedom to make decisions because it's not going to hurt you if you decide, "Hey, I love black beans and I know they're a major trigger and so today I'm home, I'm going to eat black beans." Just like someone who is lactose intolerant can make that decision. And so it's actually, while it seems restrictive up front, ends up being kind of freeing because it takes back control.
Scott Steele: That's fascinating stuff. And as we finish up here, we always like to end with our guests a couple of quick hitters. So what's your favorite sport?
Stacy Cavagnaro: My favorite sport, football.
Scott Steele: What is your favorite meal, being a dietician and all?
Stacy Cavagnaro: Grilled cheese.
Scott Steele: What is your favorite place that you've traveled?
Stacy Cavagnaro: Peru.
Scott Steele: And what is the last nonmedical book that you've read?
Stacy Cavagnaro: Reread all the Harry Potter books this summer.
Scott Steele: Fantastic. And so tell our listeners one thing you like about being here in Cleveland.
Stacy Cavagnaro: I really like that Cleveland is an incredibly welcoming city. I think I was here for less than a year before it really started to feel like home and people really are nicer here.
Scott Steele: Oh, that's fantastic. So give us some final take home messages for our listeners.
Stacy Cavagnaro: So I would recommend really anybody suffering with GI problems to ask their doctor of how they can get in touch with a dietician or do your own research. You can go to eatright.org which is a database with dieticians and just search dietician GI to find some in your area if you aren't local to Cleveland and getting them involved in your care early because diet can make a huge impact. In terms of the low FODMAP diet, it is one of the more studied, better established diets in helping irritable bowel or other conditions that have similar type symptoms. So do some research. If you think that this would benefit you, then talk to your doctor about it.
Scott Steele: That's fantastic, and so for more information on nutrition therapy and support programs at the Cleveland Clinic, please visit clevelandclinic.org/nutrition. That's clevelandclinic.org/nutrition. N-U-T-R-I-T-I-O-N. And to speak with a specialist in the Center for Human Nutrition, please call (216) 444-5957. That's (216) 444-5957. Stacy, thanks for joining us on Butts & Guts.
Stacy Cavagnaro: Thank you for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.