Patsy Catsos, MS, RDN, LD began using the FODMAP approach with her Portland, Maine, patients in 2007. The 8-step program in her book, The IBS Elimination Diet and Cookbook, introduced consumers and health care providers around the globe to the power of the FODMAP elimination diet. Patsy happily divides her time between caring for her own patients, developing new recipes, keeping tabs on the latest digestive health research, and teaching other health care providers how to get great results for their IBS patients.
Mathea Ford: [00:00:27] Hey there! It’s Mathea. Welcome back to the Nutrition Experts Podcast. The podcast featuring nutrition experts who are leading the way using food starts today right now with our next guest. It’s great to have Patsy Catsos on the show today. She is an author of an excellent book called The IBS Elimination Diet and Cookbook available wherever books are sold. And Patsy I want to welcome you to Nutrition Experts.
Patsy Catsos: [00:00:54] Well, thank you for having me on the show.
Mathea Ford: [00:00:56] I’m excited to have you on the show I want to talk about this IBS. We’ve gotten into it and a couple other episodes of my podcast with with other guests. And I really want to get into some more detail with you. So, tell my listeners a little more about you and what you do.
Patsy Catsos: [00:01:13] Okay. Well, I’m a Registered Dietitian in private practice in Portland, Maine where I see patients three days a week and at the beginning of my time in private practice I was mostly helping patients with more general nutrition problems like helping them reduce their cholesterol or manage their high blood pressure. But about 10 years ago I learned about a special diet that can really help people with irritable bowel syndrome. And when I found out how effective that was, I was really excited and that led me to eventually write my book. But also I’ve been helping patients ever since with gastrointestinal problems. So, that’s really become the focus of my practice over the years.
Mathea Ford: [00:01:58] So, Patsy what is the biggest issue that you would say that you help your patients work on?
Patsy Catsos: [00:02:04] You know there’s lots of general advice for people out on the Internet. Many books many websites and so on, lots of Facebook groups but helping people find a really individualized diet or you know selection of foods that work for them specifically is what I help the most with.
Mathea Ford: [00:02:26] What sorts of symptoms are they experiencing? What is it about their condition that they come to you to talk about?
Patsy Catsos: [00:02:32] So, gastrointestinal symptoms can include abdominal pain. I would say that right up there as the primary complaint that most of my patients have. They can also experience excess gas and bloating. They may have diarrhea or constipation or both. And those symptoms can be very general. They can be related to a number of different problems.
Mathea Ford: [00:02:58] So, how do you help people figure out if it’s something more than just the stress they’re experiencing you know eating too much fast food, having too much weight all those things can cause those types of symptoms that you talked about. How do you help people to figure out if there’s a deeper cause to that?
Mathea Ford: [00:03:18] Well, hopefully they’re working with their primary care provider or a gastroenterologist to evaluate those symptoms. Dietitians don’t diagnose people with medical problems right? We diagnose them with nutrition problems. But if a patient were to approach me first for help with their GI complaints and told me about any alarming symptoms like passing blood in their stool for example or having a fever in conjunction with their bouts of GI symptoms if they reported to me and the abnormal lab values they had that I thought might suggest a problem with absorption of nutrients. Those kinds of things would cause me to refer the patient back to their doctor to get a really good evaluation and diagnosis. So, the ideal scenario for me as a dietitian working with the patient if they’ve already been through that process.
Mathea Ford: [00:04:15] Can you talk a little bit about what is an elimination diet and how it’s used with IBS or other gastrointestinal issues?
Patsy Catsos: [00:04:22] There are a number of different elimination diet out there. They should have a really pretty clear theme or plan and they typically have three steps. First of all, the patient or the client eliminates all the foods that might be suspected of causing the problem. And then the second step they reintroduce the foods in a logical way to try to narrow the problem down to only the foods that can be proven to trigger the problem again. And then third, moving on from there to a modified diet that the person can live with over the long term that will both support good nutrition and help them manage their symptoms and feel great. That’s my goal for my patients.
Mathea Ford: [00:05:13] What are the different things that people might call whatever they have or how they’re picking their elimination diet? Does that matter based on what they’re diagnosed with?
Patsy Catsos: [00:05:24] Well a lot of the patients that I see irritable bowel syndrome that is considered a functional disorder. Which means that your guts aren’t functioning right. Even though you don’t seem to have an actual medical problem that would explain it. Many of the patients that I work with have that as a diagnosis but people who have other G.I. problems like inflammatory bowel disease. In other words Crohn’s or colitis have very much the same symptoms and we can often use diet to help them manage their symptoms which is awesome even if they have another diagnosis. I also work with patients who have celiac disease and who have been on a gluten free diet for a long time but they still have some of those symptoms that I mentioned. Patients with other GI complaints like reflux or GERD or diverticulitis or there’s quite a long list of potential problems. I can often help them with those as well.
Mathea Ford: [00:06:25] So, let’s talk about foods because I think obviously it’s dietitians we talk a lot about guts and stuff but sometimes we forget that where it all comes from is the food we put in our mouth. So, what are some of the top foods that seem to create this bloating feeling or diarrhea or even constipation?
Patsy Catsos: [00:06:45] Okay. This was a big surprise to me. You know when I first started learning about FODMAPs. Some of the foods I’m going to mention are really healthy foods. And so I just want to say that I’m not suggesting they are bad foods in any way shape or form but some of the foods that we actually try to eat to improve our diets can actually increase G.I. symptoms. And I’m thinking of things like milk products, fruit on certain fruits like apples and watermelon are especially problematic. But just large servings of fruit in general are difficult for some people to handle. You know some vegetables like cauliflower and broccoli and mushrooms and they are very healthy but if you eat a whole plateful of them for dinner you might regret it later on or even the next morning. Certain whole grains that would normally be healthy choices could be really troublesome for people with irritable bowel syndrome for that particular wheat richh products and even things like nuts and seeds that are really healthy for us now, in a small portion like a handful at a time could cause GI distress if you overdo it.
Mathea Ford: [00:08:02] You mentioned the word fried map and I mentioned it earlier too. So, tell us what does that mean? What is it that if fad map diet is and what does it do?
Patsy Catsos: [00:08:12] Okay. So, the theme that ties all those foods I just mentioned together is the fact that they have a lot of FODMAPs in them. And FODMAP is an acronym and I usually tell people it stands for a bunch of jargon that is referring basically to a group of certain sugars and certain fibers in food that can cause GI distress and they can do that because they have a few things in common. FODMAPs are the favorite foods of the normal gut bacteria that we all have. And so if they’re too much of them available for the gut bacteria they will ferment them too rapidly or too much and fermentation. It sounds like a little bit of a scary word but it’s actually a really normal part of human physiology so we don’t want to get rid of it altogether. But again if it’s too rapid or too much it can cause your intestines to you know I guess blow up a little bit like a balloon and that can be a very painful sensation. The other thing that these FODMAPs have in common is that they can sometimes pull too much extra water into the gut and that can promote loose stools or diarrhea and sometimes some pretty significant urgency to get to the toilet. A couple other interesting things about FODMAPs, they have a cumulative effect. That means that it’s the FODMAPs from all the different foods that we eat that can kind of add up to affect us if we eat too much of them in too short a time like in a single meal. That is one reason that we learn more if we take kind of a big picture overview and use a process like an elimination diet to stop eating all the high FODMAP foods for a few weeks. That can often be a more effective way to learn than if we tried eliminating just one suspect food at a time. That’s really the main reason for using the process.
Mathea Ford: [00:10:16] So, how do you do that? So, basically you give them a list of all the FODMAP food once you’ve determined that or you’ve been referred because they have IBS not necessarily Crohn’s or colitis or anything like that? What are your steps that you do with patients?
Patsy Catsos: [00:10:35] I’m glad you brought that up. There is a little bit of a determination process there at the beginning. The first thing I do actually is to make sure the person’s a good candidate for this type of approach. Not everybody can do an elimination diet safely or easily. So, I like to make sure the person does an appropriate diagnosis and that it looks like they actually are consuming FODMAPs on somewhat of a regular basis because if they’re already eating nothing but chicken and rice and they’re still symptomatic there’s really nowhere, no room for improvement. But if they seem to be a good candidate for the diet, I first do give them a list of low FODMAP foods and I ask them to stick as closely as they can to that list for a few weeks or until our next visit. If they seem to be a good candidate for the diet, I ask them to eat only low FODMAP foods for a few weeks and ideally they’re going to feel much better and that improvement can start almost immediately but usually within two or three weeks they’re going to know the answer to the question. Our FODMAPs part of my problem. And then they come back for a second visit typically. And at that point I asked them to begin reintroducing FOD MAPs so that we can find out more specifically what the triggers are for them. Because some people are more sensitive to some FODMAPs than others. We don’t want to have to limit anything that isn’t really making a difference.
Mathea Ford: [00:12:11] What is kind of the research behind or the data behind where they found out about FODMAPs?
Patsy Catsos: [00:12:19] The individual parts of this map idea have been known for a long time. For example, lactose intolerance is an old idea right and everybody knows what happens if you eat too many beans you’re going to be gassy and have a little GI distress. So, what was really new here was around 2000 a group of researchers at Monash University in Australia realised that some of these foods that cause GI distress probably have some things in common. They decided to create this acronym to describe them FODMAP and really it’s looking more at the forest than the trees. Looking at at the big picture here. And that’s where the idea came from. And when they began to try this in the research setting with patients they found that up to 80 or even 85 percent of patients with IBS who were good candidates for the diet experienced significant improvement of their G.I. symptoms. And there have since been many many other studies that have been performed in various places all around the world that back that up. Of course, the results are always best and are really controlled setting like in a clinical research centre. But even in people that are free living as they say but who are just taught the diet and asked to carry it out on their own. The vast majority of IBS patients get significant improvement with this approach.
Mathea Ford: [00:13:52] Yeah! I imagine there’s a lot of motivation to try it and then especially once you start to experience some of the effects. What foods you typically add back first because you mentioned everything from apples to milk to whole grains? So, where do you start adding foods back?
Patsy Catsos: [00:14:10] I’m going to list the FODMAP categories real briefly and I’m going to do that because I add foods back one category at a time rather than food by food. Sometimes you know sometimes the food by food reintroduction comes later.
Mathea Ford: [00:14:26] If you’re trying to narrow down?
Patsy Catsos: [00:14:28] Exactly! But the map categories that I work with our number one lactose. Which is also known as milk sugar and there’s a lot more of it and some milk products than others. So, things like regular old glass of milk is high in lactose. Yogurt is medium but aged cheeses are low in lactose. The next FODMAP is fructose and that’s found in sugars that are added to our food for example honey, high fructose corn syrup, agave but it’s also naturally present in all fruits. Of the next category of FODMAP is called sugar alcohols and these are easy to spot when they’ve been added to foods like sugar free gum and candy because they usually end with OL so things like xylitol, sorbitol, maltitol, mannitol. Those are easy to spot but I mentioned earlier they’re also naturally found in certain fruits and vegetables. So, those three I just mentioned are the sugar type FODMAPs and then moving on to the fiber type FODMAPs. They go by the umbrella term of oligosaccharrides which is the O in FODMAP and they are contributed to our diet by whole grains, nuts, seeds, beans and also by fibers that are added to boost up the fiber content of our food such as inulin and chicory root. So, those are the big categories. That’s the theme that I follow during the reintroduction process. It’s one category at a time.
Mathea Ford: [00:16:11] Yeah. I think that once people start seeing the results they probably are happy to follow this. Is there any part of the diet that ends up being too restrictive over the long term?
Patsy Catsos: [00:16:25] Yes. As a you know we discussed at the very beginning when you first asked me about individual foods we know these are healthy foods right? Especially the whole foods that are good sources of fiber and that’s probably the nutrient that deserves the most special attention ongoing is to make sure that you’re eating enough fiber. Even if you have to cut back somewhat on high FODMAP fiber. There are plenty of good options and I encourage people to continue eating a wide variety of fruits and vegetables and beans and nuts and seeds right up to the limit of what they can tolerate so that they can get the benefits of those foods without distress.
Mathea Ford: [00:17:12] So, we’ve been talking about FODMAP but you also mentioned at the beginning that Gerd was something that you help people with or reflux type things. So, what types of things do you do with people to help them with reflux or GERD?
Patsy Catsos: [00:17:26] This low FODMAP diet is not I guess not intended directly to help people with GERD but if people have IBS and GERD, I can tell you that their reflux symptoms often improved quite a bit with this low FODMAP at the same time. If they have GERD only no IBS, I would probably review some of the basics that have actually been known about for quite a long time for managing that problem. Things like eating smaller more frequent meals perhaps, not eating too close to bedtime, elevating the head of the bed makes a big difference because gravity can then help the contents of the stomach remain in the stomach instead of refluxing up into the esophagus. And then there are a few food choices that they might want to consider. There are certain foods that have a bit of a reputation for making GERD worse although I do find that’s pretty individual as well. And so I encourage people to try eliminating these foods from their diet but if it doesn’t make a difference they don’t necessarily have to stick with it but some of those foods would be things like chocolate, coffee, tea. Things that are real peppermint based high fat foods are often a trigger for GERD. Acidic foods. But again you know give it a try but if it doesn’t make a real difference for you you can move on.
Mathea Ford: [00:18:58] I’ve heard recently that GERD or reflux is not necessarily because you have too much acid in your stomach it’s because maybe you don’t have enough. So, is there any research you’ve seen about that or any comments about that?
Patsy Catsos: [00:19:12] I would say it’s pretty anecdotal and a lot of functional providers I think rely a lot more on their own experience with patients than necessarily the clinical research foundation. They’re you know they’re willing to try to implement some things without an evidence base. That’s not how I practice. So, I don’t really initiate that kind of treatment with people that would be based on that idea. But if they are doing it on their own or they’re also working with a functional provider that wants them to try to increase acidity by taking a supplement for example, I probably wouldn’t interfere with it or ask them to stop.
Mathea Ford: [00:19:51] Well, that’s a good point though. It’s just something that’s recently been in the news that I’ve heard and it is very intriguing thought. So with IBS and G.I. issues how are these handled in our current health care system? Because you mentioned you know that people typically come to you with the diagnosis from their doctor but I know a lot of times people suffer for a while before they either put their foot down with their doctor and say “you’ve got to figure this out” or are just some of the symptoms too general or too hard to recognize by doctors or how do you see it coming through the system?
Patsy Catsos: [00:20:27] So, years ago, it was quite a difficult and even expensive process to arrive at an IBS diagnosis. It used to be considered a diagnosis of exclusion. And people would have to go through the process of having a colonoscopy and multiple other tests that could be invasive and difficult and expensive before they would get the diagnosis. But these days we have some clinical guidelines that suggest that really it can be a diagnosis that’s made with out all of that. If the patient has a particular pattern of symptoms, these are called the Rome IV Criteria for irritable bowel syndrome. If they have a particular pattern of pain and altered bowel habits and the absence of those alarm symptoms I talked about earlier, then they can be diagnosed with irritable bowel syndrome right in the doctor’s office and that can pave the way for them to be treated more effectively.
Mathea Ford: [00:21:30] So, doctors are basically a little bit have a little bit more guidelines to say these are some of the typical patterns for that?
Patsy Catsos: [00:21:38] Absolutely! Absolutely! And so more people are being diagnosed with IBS right with their primary care provider instead of having to go through the referral process to see a gastroenterologist.
Mathea Ford: [00:21:51] How do you think this information can be used by our listeners in their day to day life? So, our listeners are dietitians doctors nurses and just regular individuals.
Patsy Catsos: [00:22:01] Okay. So, first of all if you’re suffering from abdominal pain, excess gas, bloating, bowel habits that are not satisfactory to you. Bring it up with your physician. Absolutely do not have to suffer in silence. It’s not something you should just have to put up with. Have your doctor evaluate you and if necessary you know maybe you do need to be seen by a gastroenterologist. But don’t just live with this situation. Then if you do get diagnosed with irritable bowel syndrome ask your doctor whether he or she can refer you to a registered dietitian who’s skilled in this area and see if they can help you work through whether food is contributing to your symptoms or not.
Mathea Ford: [00:22:48] So, if you’re a dietitian you work with just regular you know like you mentioned cholesterol, heart disease that type of stuff. What types of things are people going to be saying to you that help you to recognize “Okay, I need to mention to them that they should possibly follow up with their doctor about these things?”.
Patsy Catsos: [00:23:06] Okay. So about 20 percent of your patient population is going to have irritable bowel syndrome. So, whether you’re seeing people for diabetes or cholesterol or or anything else you could be listening for for signs and symptoms that might suggest IBS. And if you’re hearing patients complain about you know not only abdominal pain, diarrhea and constipation, excess gas and bloating. You know you can make that referral back to their doctor. Most patients that you’re going to be able to help with a FODMAP elimination diet for example are going to be aware that food has something to do with their symptoms. In fact they’ve probably been trying to manipulate their diet on their own long before they ever met you or heard of FODMAPs. Some patients will say you know “bread really really bothers me when I or when I was following the Atkins diet or paleo diet or some other variation of a low carb diet that they were feeling better.” Patients might say “the healthier I try to eat the worse I feel.” A lot of patients that have done programs that really promote the fruits and vegetables and skim milk and all that. For example Weight Watchers, patients can feel more symptomatic because they’re eating a lot more FODMAPs in those foods. So, those are some of the clues I would be listening for if I were in a more general practice.
Mathea Ford: [00:24:35] I think that’s great especially that is surprising to me to say that 20 percent of people have IBS because I did not realize it was that prevalent.
Patsy Catsos: [00:24:44] The statistics of course vary a little bit depending on who produces them. But that is pretty consistent around the world.
Mathea Ford: [00:24:51] So, Patsywe’ve been talking a lot about food and I’m going to ask you the question I ask everybody is what is your favorite food?
Patsy Catsos: [00:24:59] Well, I think that salmon is probably my favorite food both because I like it myself but also because I when I’m a hostess I feel like it checks almost all the boxes as dietitians we’re all is kind of aware of the dietary needs of our guests. Righ?. So I feel like I served salmon. I’m doing a good job for my guests who have irritable bowel syndrome or celiac disease. We’re eating the low carb diet and also most vegetarians seem to be willing to enjoy fish once in a while. So, all in all it’s a great food, very nutritious and delicious.
Mathea Ford: [00:25:44] So, how do you like to cook it?
Patsy Catsos: [00:25:46] My favorite recipe is a baked salmon which is kind of a crumb crust made of walnuts and olive oil and a little Parmesan cheese. Some something like bread crumbs or crushed potato chips or something to give it a little crunchiness. It’s really delicious and we usually have that on holidays.
Mathea Ford: [00:26:06] Oh that sounds delicious. So Patsy, thank you so much for being on the podcast today. It was a pleasure to have you on the show. I know my listeners have learned a lot about IBS and FODMAPs and I appreciate you going into such detail about those. So, if listeners want to connect with you what’s the best way to do that?
Patsy Catsos: [00:26:24] I think the best way to connect with me is to visit my website which is IBSfree.net and from there you’ll find plenty of links to everything from my book to my social media. So, I look forward to connecting with you.
Mathea Ford: [00:26:42] All right! Well guys this has been another great episode of the Nutrition Experts Podcast. The podcast that is all about learning more so you can do more with nutrition in your life.
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