IBS, FODMAPs & Intuitive Eating with Kate Scarlata, RDN

May 28, 2019

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On today’s episode, I’m talking to Kate Scarlata, a Boston-based IBS and FODMAP Dietitian. Her 30 years of experience is mostly in gastrointestinal disorders and food intolerance, with a particular focus on the low FODMAP diet for functional gut disorders. I’ve had a lot of people come to me who  struggle with IBS, gastrointestinal problems, and SIBO, so if you’re struggling too, you’re in the right place!

In this episode, Kate and I talk about:

  • How anti-diet and medical nutrition therapy intersect
  • What happens if you have IBS and an eating disorder
  • How to treat IBS without restrictive diets
  • Emotions and the gut
  • Why food isn’t the only answer to IBS issues
  • What Kate recommends for her clients

Before we get into the episode, I want to get everyone up to speed on these abbreviations:

  • IBS: Irritable Bowel Syndrome
  • SIBO: Small Intestinal Bacterial Overgrowth
  • FODMAP: fermentable oligo-, di-, mono-saccharides and polyols
  • GI: gastrointesinal

How Anti-Diet & Medical Nutrition Therapy Intersect

Something I’ve talked about in earlier episodes is the disconnect in the RD community between Health At Every Size/anti-diet dietitians and weight-centric dietitians.

If you’re not specifically working in a Health At Every Size paradigm, not going out of your way to educate yourself about it, or if you’re not working with a weight-neutral approach to health, you might misunderstand the anti-diet movement as being:

  • Against medical nutrition therapy
  • Against dieting
  • Or against modifying your diet for a condition.

That is absolutely not true! Part of Intuitive Eating is respecting, supporting, and honoring your body. It’s understanding that if you have a condition and you get extremely bloated every time you eat garlic and onions, you probably shouldn’t eat them just for the sake of being ‘anti-diet.’ That’s not the point- the point is being against intentional weight loss and prescribing intentional weight loss for clients.

There are many GI doctors who, if you’ve been diagnosed with IBS, will tell you to never eat these things called FODMAPS and leave it at that. That’s never how this should be. Restrictive diets should NEVER be given outright to a person with a history of disordered eating- they are a huge potential trigger and there are other ways to go about treating IBS, which we will get into with Kate.

Kate’s Story & Why She’s Passionate About Gut Health, FODMAPs and IBS

Kate has been a Registered Dietitian for 30 years. Although she’s currently educating other dietitians about elimination diets, she was raised in Intuitive Eating and has followed Evelyn (a co-creator of Intuitive Eating) from the beginning. She’s always embraced food freedom. When she started her career, she didn’t love the education around highly restrictive medical nutrition diets such as with kidney disease or diabetes because they promote the food culture that exists today.

About 24 years ago when Kate was pregnant with her son, she developed a strangulated bowel and lost 1/3 of her small intestine. Since this is the area of your intestine where you digest nutrients, missing that much of it led her to develop new food intolerances. About 10 years after that surgery, she developed Small Intestinal Bacterial Overgrowth (SIBO), which escalated her food intolerances. It seemed like with anything she ate, she felt extraordinarily full. She was losing weight and felt like she was melting away.

After this diagnosis, Kate learned about the low FODMAP diet and discovered how modifying her diet could change her life for the better. This completely transformed her career, since a lot of her audience was also experiencing gut issues, food intolerances and was extremely interested to hear her break down the low FODMAP diet. 

Since then, she’s worked with IBS patients to help them eat a balanced, slightly modified low FODMAP diet, which she says is the most rewarding work that she could ever imagine.

Teaching FODMAP Diets Without Being Too Restrictive

Every IBS diet needs to be personalized. IBS itself is a very heterogeneous disorder- some people have constipation, some have diarrhea, some have severe debilitating pain, and others are just dealing with low-grade IBS that doesn’t impact their every breath.

The low FODMAP diet isn’t appropriate for everyone with IBS. When we look at IBS, we have to look at these individuals as having food fear. Naturally, if food causes pain, you’re going to have fear. For some patients, that fear is pathological. As health care providers, we have to be perceptive in determining where the patient’s mindset is- we need to screen for eating disorders.

If you look at IBS patients, 90% of them don’t have eating disorders, but 90% of patients with eating disorders have gut symptoms. We just need to pay attention and approach this as unbiased as possible so we can give patients appropriate, personalized treatment. Putting a person with an eating disorder on an elimination diet is very high risk, but for other people it’s not. It’s all about understanding where the patient is coming from and adjusting the plan to meet their needs.

Kate’s message to Dietitians is to remember your own personal bias. If you’ve experienced an eating disorder and are working with eating disorder patients, that’s your bias. If you solely work with GI patients and no eating disorder patients, that’s your bias. Ask yourself: how can you develop a better understanding of it all so you can best provide care to your patients?

 

Disordered Eating & Gut Symptoms

If patients have a history of disordered eating and have gut symptoms, dietitians should:

  • Look at their nutrition and diet
  • Look for balanced meals
  • See if they’re honoring their hunger
  • Figure out their food rules
  • Find out what stresses them out

As a Dietitian, Kate says to look for general Intuitive Eating messages. Make sure they’re listening to their body, honoring their health, and doing all those magical principles of Intuitive Eating that will help them with their gut symptoms.

Kate also recommends that these people work with a gut psychologist, who is specifically trained in this area. They can offer therapies that are non-diet related, including gut directed hypnotherapy (which is just as effective as the low FODMAP diet!), cognitive behavioral therapy, diaphragmatic breathing, and a number of other psychological approaches that can really work well. Gut psychologists understand the gut and how the symptoms are interrelated, and the role that diets and restriction play in overall stress and anxiety.

People with gut symptoms also need to understand that diet is only a part of the puzzle– it’s not the full-blown solution. A low FODMAP elimination approach isn’t the only thing that Kate implements with her clients. If you put all your eggs in the diet basket, you’re often going to be left short-handed. Diet is not the only thing that’s going to make a difference!

Navigating Food Fears & Treating Gut Symptoms

Kate mostly works with clients who have tried everything and can’t find a solution to their IBS symptoms. In other words, she works with the most severe cases. If someone came to her with mild or moderate symptoms such as gas and bloating, she would say that the low FODMAP diet is not for them.

Instead, she will often focus on the symptoms they’re having and how they can be managed first. For example, she might reduce oligosaccharides such as onions and garlic, since they’re often the most gas inducing out of all the FODMAPs. She notes that oligosaccharides are really good for the gut microbiome so she wouldn’t restrict them forever, but having a little less of them can help with symptoms.

So often, people are given a handout from a doctor and end up at the dietitian in a dark spiral because it has triggered fear and anxiety. There are 2 things in the GI community that we need to talk more about:

  1. Screening for eating disorders first
  2. Creating stronger relationships between dietitians and doctors so the situation can be addressed better 

It’s very possible to cherry pick FODMAPs for certain people. But for someone with high anxiety and food fears, she wouldn’t ever talk about FODMAPs. They’ll just go home, look it up and start cutting things out. She also tells doctors not to tell patients about the low FODMAP diet until they see her, so she can determine whether or not it’s suitable. Otherwise, it can do more harm than good.

Eliminating Foods In Intuitive Eating Without Falling Back Into Disordered Eating

This process is really about listening to your body and honoring your health. It takes a bit of work as well as honesty about recognizing your food fears and looking at them in a different way. You’re not trying to avoid the food because of the fear; you’re looking to avoid them because they can cause an issue. It comes down to intention. Ask yourself:

  • What is the intention of the restriction?
  • Are you doing this because someone told you this food could cause GI distress?
  • Or are you doing it because you can clearly define a symptom every time you eat it?

Sometimes, we don’t realize when we start believing things and taking arbitrary nutrition advice just because we heard them through the grapevine or read them online. We’ve gotten so used to accepting these things that we don’t question them as much as we should. If there’s an account on social media that promotes fear-based messaging around food, unfollow them. They might sound real- they might even be a doctor! But just because something is ‘life changing’ for them doesn’t mean it will be for you too. These convoluted messages, even if they’re well intended, often do more harm than good. 

Emotions & Gut Health

Intuitive Eating with a gut condition comes down to intuitively listening to your body and respecting its messages. With this in mind, remember that food is still only a part of the puzzle– your emotions are important to keep in mind as well.

To drive this point home, Kate explains her gut experiences with public speaking. Although she loves it, whenever she gives a talk, she swears her gut just stops working properly. When she’s done, she’s bloated and in pain. That has nothing to do with what she ate before! It’s related to stress. Shut down those messages you get from well meaning people about what you ate, and know your body enough to tell them it’s not about the food, it’s your emotions. It’s about the big picture; it’s not just about what you ate.

Implementing Elimination Diets

For people at risk of an eating disorder or extreme food fears, we’re not talking about low FODMAP diets. It’s important that the patients are really honest with themselves when talking about food fears so they can be honest with us when advising them. But in the hands of the right patient, elimination diets can be extraordinarily validating.

The elimination diet consists of 3 phases:

  1. The Elimination Phase– this is often 2-6 weeks, usually 4 in Kate’s practice.
  2. Reintroduction Phase– clients are reintroducing foods and personalizing it the diet.
  3. Adjustment Phase– this phase is continually checking in and adjusting as necessary, since FODMAP intolerance can change over time.

Throughout this process, patients become really intuitive to what works and what doesn’t for their body, and they learn to know when to scale back and when to go forward. It’s empowering in the right hands, but it’s not for every patient out there. Just because someone has an eating disorder doesn’t necessarily mean it’s not for them- it just means we need to use it responsibly and know that there are different ways of doing things for different patients. 

Kate’s goal as a GI Dietitian is to not restrict patients further, but to add more food back to a more liberalized diet so they can have less anxiety and more symptom management while enjoying as many foods as possible.

Kate’s Thoughts On Whole30

In short, Kate is not a fan of this diet or anything similar. Anything that puts food in terms of a moral issue or labels food as safe/unsafe is inherently problematic. Especially since it’s promoted as an elimination diet that’s supposed to help with gut health, people tend to try it when doctors aren’t listening to them.

It comes down to whether it’s evidence-based or not. Is Whole30 evidence-based? No. Is the low FODMAP diet? Yes, it is. It is a medical nutrition therapy that has been researched with at least 7 randomized control trials. Is it appropriate for everyone? No, but can it be life changing? Definitely.

Although Kate doesn’t agree with Whole30, she mentions there are some good messages associated with it- such as eating more plants and more fiber, and eating food in its natural state. It goes back to Intuitive Eating, gentle nutrition, honouring your health, and respecting your body. The food guilt needs to go!
 

Squatty Potties

To finish off the interview, I asked Kate about a product that can help everyone, but especially people with IBS. Kate has done giveaways with Squatty Potty, and is a huge fan of them. If you have ever struggled with constipation, you know how bloated you can feel. By essentially altering the shape of your anal canal and rectum, it helps you have a proper elimination so you get rid of that bloated feeling. Most of Kate’s patients have them! Even if you don’t have IBS or bowel issues, it’s a great tool that can help anyone with having regular elimination patterns.

 

#IBelieveInYourStory

As we close out, Kate wants to mention a passion project of hers- I Believe In Your Story. It’s an IBS and SIBO campaign that raises awareness as well as funds for research. These conditions have minimal funding- since people can live with it and it won’t kill you, they fly under the radar. For this reason, we need a lot of voices out there so that people with IBS and SIBO feel supported. That’s the goal of her mission- to change the story of people who have been suffering for far too long.


If you’re a patient, don’t just follow the handouts you get from your doctor. See a dietitian to get support- a low FODMAP diet is best in the hands of an expert who knows what you need. Remember too that it’s the big picture that has to be looked at holistically- food is never the only answer.
 

About Kate

Kate Scarlata, RDN, LDN is a Boston-based dietitian with 30 years of experience. Kate’s expertise is in gastrointestinal disorders and food intolerance, with a particular focus on the application of the low FODMAP diet for functional gut disorders. She was awarded the Outstanding Massachusetts Dietitian Award and recognized as Boston’s Best Dietitian by Boston Magazine. Kate is the author of numerous books and articles on digestive health topics including the New York Times Best Seller, The 21 Day Tummy Diet and her latest book, The Low FODMAP Diet Step by Step. Kate completed her postgraduate training at Brigham and Women’s Hospital, a Harvard Medical School teaching affiliate. She is currently enrolled in a Master’s of Public Health program at the University of Massachusetts. Kate has been an invited speaker to various scientific meetings nationally as well as internationally.

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This post was transcribed and edited by Brittany Allison, Intuitive Eating Counselor. You can find her on Instagram @brittybfit.

Xo, Whitney