FODMAPs represent a group of indigestible carbohydrates known as Fermentable Oligo-, Di-, Mono-saccharides, And Polyols.1 FODMAPs can be found in fruit, vegetables, dairy products, legumes, honey, sweeteners and cereals.1 The low-FODMAP diet is a series of phases, beginning with total elimination of all FODMAPs for 4-8 weeks.1 After the elimination phase, there is a reintroduction of certain FODMAPs to determine which foods are causing discomfort. The goal is for the diet to be personalized for each individual, however without a nutrition professional such as a dietitian, the diet can be misinterpreted.
Which healthcare professional should oversee the use of the low-FODMAP diet?
The low-FODMAP diet (LFD) is usually discussed with patients experiencing IBS as a nutrition intervention to attempt to alleviate their gastrointestinal symptoms. Considering the LFD is an elimination diet, there are potential risks including but not limited to nutritional deficiencies, errors in execution, expense, and possible disordered eating habits. Due to these risks, it can be concluded that a registered dietitian should be in charge of monitoring this particular dietary approach.
Reasons why dietitians should monitor & recommend the low-FODMAP diet
Reason #1: Dietitians have the education and training to review previous dietary history, evaluate potential causes of a GI disease or disorder, monitor dietary intake for potential deficiencies, and provide nutrition education regarding the process of the low-FODMAP diet.
Considering GI-related conditions and symptoms have become a major focus online, many people turn to the internet or self-help books for advice on the low-FODMAP diet, and then use the diet as a self-prescribed nutrition intervention. The issue is the low-FODMAP diet is complex and requires the training of a nutrition professional such as a dietitian. Additionally, online resources can contain outdated or misinformed information. A dietitian understands the relationship between the body and food, as well as the process of what an elimination diet includes.4 The dietitian will take time to review your symptoms, diet history, and how often you are eating foods containing high amounts of FODMAPs.3 The dietitian will then start to figure out what foods may be triggering your symptoms, while also making sure you continue consuming the nutrients you need.
Reason #2: Gastroenterologists and other medical providers have limited knowledge on the low-FODMAP diet and do not have the time to explain the complexities of the process to patients.
A 2018 clinical research study found that physicians were spending an average of 29 minutes with patients in the room, which is most likely is not enough time to assess the patient as well as include adequate nutrition education.8 Therefore, even with additional training or education on the complexities of the low-FODMAP diet, your provider will most likely not have the necessary time to explain the process to you without confusion or concerns coming to mind. Most gastroenterologists will recommend the LFD, but only utilize educational handouts rather than refer to a dietitian.2
Reason #3: Dietitians are able to address social or economic barriers, and incorporate aspects of the patient’s cultural background into the LFD to increase the patient’s possibility of success.
Unfortunately, if recommended without the supervision of a dietitian, you can be left feeling the LFD is complicated, potentially expensive, and deprives you of some of your favorite foods. A dietitian has the education and experience to be able to help you utilize the LFD within your budget and create meal ideas to incorporate cultural foods, as well as substitutions for some preferred foods that may be removed in the elimination phase. Additionally, the dietitian can also help you learn how to read labels, understand what you are looking for when avoiding FODMAPs, and provide strategies for navigating social situations when utilizing the LFD.
Reason #4: Dietitians are able to assess a patient’s risk for disordered eating behaviors and adapt their approach without further increasing food restriction tendencies through either a FODMAP-gentle diet or other methods.
Dietitians understand that studies have shown a connection between digestive disorders and using elimination diets linked with an increased risk of disordered eating.5 A 2019 study found increased adherence to the LFD resulted in increased eating disorder behaviors, therefore showing it is important for dietitians to proceed with caution recommending this diet to someone with previous disordered eating habits.5 Other alternative methods to the LFD if disordered eating habits are present include a “FODMAP-gentle” diet which only limits foods particularly high in FODMAPs to reduce overall restriction.2 It is important to work with a licensed nutrition professional if you have experience with disordered eating habits, in order to ensure you receive the individualized care you require.
Insurance: a potential barrier to accessing dietetic services
There is a significant need to advocate for nutrition services, delivered by dietitians, to be more substantially covered by insurance companies. A 2021 study reported one of the most common perceived barriers to having registered dietitians in their practice, reported by family medicine practitioners, included concerns about the cost of referring patients to dietitians.6 Currently, most insurance companies will not cover visits with a dietitian to discuss the LFD.7 This lack of coverage results in the patient relying on information provided by their general practitioner or gastroenterologist, along with supplementation from online sources that may contain misinformation.
How can we advocate for the registered dietitian to be the lead provider of the LFD?
The plan of action to signify the dietitian as the primary provider in the implementation of the low-FODMAP diet includes:
● Educating other healthcare professionals on the role of a dietitian
● Increasing access to a dietitian through increased healthcare coverage for nutrition services
● Advocating as well as emphasizing the importance of evidenced-based nutrition therapy in the use of the LFD in order to discourage the spread of misinformation
Regarding healthcare coverage, utilizing the form of group education intervention to reduce costs for patients may be a proposed solution for lack of insurance coverage for GI-related dietitian visits.
REFERENCES:
- Bellini M, Tonarelli S, Nagy AG, et al. Low FODMAP Diet: Evidence, Doubts,
and Hopes. Nutrients. 2020;12(1):148. Published 2020 Jan 4.
doi:10.3390/nu12010148 - Halmos EP, Gibson PR. Controversies and reality of the FODMAP diet for
patients with irritable bowel syndrome. J Gastroenterol Hepatol.
2019;34(7):1134-1142. doi:10.1111/jgh.14650 - Barrett JS. How to institute the low-FODMAP diet. J Gastroenterol Hepatol.
2017;32 Suppl 1:8-10. doi:10.1111/jgh.13686 - O’Keeffe M, Lomer MC. Who should deliver the low FODMAP diet and what
educational methods are optimal: a review. J Gastroenterol Hepatol. 2017;32
Suppl 1:23-26. doi:10.1111/jgh.13690 - Mari A, Hosadurg D, Martin L, Zarate-Lopez N, Passananti V, Emmanuel A.
Adherence with a low-FODMAP diet in irritable bowel syndrome: are eating
disorders the missing link?. Eur J Gastroenterol Hepatol. 2019;31(2):178-182.
doi:10.1097/MEG.0000000000001317 - Sastre LR, Van Horn LT. Family medicine physicians’ report strong support,
barriers and preferences for Registered Dietitian Nutritionist care in the primary
care setting. Fam Pract. 2021;38(1):25-31. doi:10.1093/fampra/cmaa099 - Werlang ME, Palmer WC, Lacy BE. Irritable Bowel Syndrome and Dietary
Interventions. Gastroenterol Hepatol (N Y). 2019;15(1):16-26. - Butler R, Monsalve M, Thomas GW, et al. Estimating Time Physicians and Other
Health Care Workers Spend with Patients in an Intensive Care Unit Using a
Sensor Network. Am J Med. 2018;131(8):972.e9-972.e15.
doi:10.1016/j.amjmed.2018.03.015
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