What should I eat? Patient Questions Bethany Doerfler MS, RD, LDN

Answering Your Questions

• Someone who I know that had scleroderma said that she is feeling much better on gluten free diet. Is there any scientific basis to it?

• Besides sugar, white carbs and saturated fats, what are foods to avoid and reduce inflammation?

• What supplements help gain energy? What are the best juices to fight inflammation? How does dairy effect digestive tract?

• Benefits of vegan and gluten free diet Implications of low iron ferritin level • Wondering why my child does not gain weight even if she eats whatever?• What is the best way to obtain calcium if you are lactose intolerant? • What is the best way for someone with scleroderma to lose weight?• What are anti-inflammatory foods?

How Do I Lose Weight?

Average daily per capita calories from the US food availability, adjusted for spoilage and other waste

ERS Food Availability (Per Capita) Data System http://www.ers.usda.gov/Data/FoodConsumption/

Portion Controlled Mediterranean Diet

Structured Meal Plans UNLIMITE

D Vegetable

Fruit Protein Whole Grain/

Starchy Veggies

Green beans sauté

Pear (1 medium)

Chicken breast (3 oz)

Instant brown rice (3/4 cup, cooked)

Fresh tomato slices and green beans

Strawberries (1 cup)

Baked Tofu or tempeh, diced (3 oz)

Whole wheat pasta (3/4 cup cooked)

Spinach salad Pineapple (1 cup juice removed)

Turkey meatloaf (3 oz)

Baked sweet potato (small; size of soap bar)

Spinach salad Peach (1 medium)

Three bean salad (¾ cup)

Whole wheat couscous (3/4 cup)

Romaine lettuce, and tomatoes & raw veggies 

Plums (2 small)

Turkey breast (3 oz)Hummus (2 Tbsp.)

Whole grain bun (1 small)

Tomato slices, romaine lettuce, and pickle slices

Orange (1 medium or 2 “cutie” mandarins)

Lean ground beef/turkey patty (3 oz)

Whole wheat pita (1)

Sautéed spinach and mushrooms

Banana (½ of medium),

Eggs ( 2) scrambled

Whole grain tortilla (1)

Is Butter Back?

What Foods Are Anti-Inflammatory?

Healthy FatsType of Fat is More Important than the Amount

Is a Mediterranean Diet Anti-Inflammatory?

Fruits &VegetablesWhole GrainsHealthy FatsLean ProteinsREDUCE Inflammation

Refined sugarsRefined starchesSaturated fats &trans fatsINCREASE inflammatory markers

Esposito K. Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. JAMA 2004; 292: 1440– 6.

Mediterranean Diet

How do I eat Healthy on Lower Fiber Diet?

Breakfast: cooked oatmeal sliced bananas or berries & lactose free milk

Lunch: Chicken & vegetable soup, Reduced fat Greek Yogurt & ¼ cup crushed cheerios for crunch

Snack: banana & creamy nut or seed butter

Dinner: Baked chicken, roasted sweet potato & cooked string beans or peas

Dessert: 1 oz dark chocolate or ½ cup sorbet or 1 all fruit popsicle

GI Symptoms: Gastroparesis & GERD & Bloating

Diet Therapy for GERD: Conventional Wisdom

ACG Guidelines: Weight loss HOB elevation Cessation of eating 2-3 hours before bed Smoking cessation Routine and global elimination of foods is not

recommended

Katz PO et al. Am J Gastroenterol 2013;108:308-328

Small Particle Size Improves Symptoms of GP

RCT 20 weeks, each subject got 7

visits with RD Nutrient Composition Same

across groups 25%-30% fat calories 6 mini meals

All symptoms of GP improved No difference in changes in

body weight or blood sugars

Large Particle vs. Small Particle Size Foods:Improved GP symptoms DM

Eggs Pureed cabbage

Rye Crisp Fruit Sauce

Eggs cabbage

Fresh bread Fresh fruit

Olausson EA. Am J Gastroenterol. March 2014

Consequences Malabsorbed Fructose

Consequences Excess

Substrate

Osmotic Load

FermentationGI

Motility

• Fructose Osmotic effect →water to distal small Intestine & colon → Speeds motility

• Fructose and fructans rapidly fermented by bacteria in distal small bowel & proximal colon

• Luminal distention

Gibson PR. Aliment Pharmacol Ther 25,349-363.

What are FODMAPs?

Lentils, cabbage, brussel sprouts, legumes

Sorbitol

Raffinose

Honey, apples, pears, peaches, mangos, fruit juice, dried fruit

Apricots, peaches, artificial sweeteners, artificially sweetened gums

Wheat (large amounts), rye (large amounts), onions, leeks

Excess Fructose

Fructans

Fermentable oligo-, di-, monosaccharides and polyols

1. Shepherd SJ, et al. Clin Gastroenterol Hepatol. 2008;6:765-771; 2. Shepherd SJ, Gibson PR. J Am Diet Assoc. 2006;106:1631-1639.

High FODMAP Diets Induce Increased Breath Hydrogen and Symptoms in IBS Patients

• Design- Single-blind crossover study in 15 healthy and

15 IBS patients- 2-day consumption of high-FODMAP diet (50

g/d) or low-FODMAP diet (9 g/d)

• Results- Higher levels of breath hydrogen produced with

high FODMAP diet- Gastrointestinal symptoms and lethargy

induced by high FODMAP diet in IBS but not control patients

Breath hydrogen production40

35

30

25

20

15

10

5

0

Health-HFD Healthy-LFDIBS-HFD IBS-LFD

N=29

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Hours

Bre

ath

hydr

ogen

(ppm

)

HFD=high-FODMAP diet; LFD=low-FODMAP dietOng DK et al. J Gastroenteorl Hepatol. 2010;25:1366-1373.

Non-Celiac Gluten Sensitivity (NCGS)

• Defined by panel of experts from 14 countries in 2011

• “Non-allergic and non-autoimmune condition in which the consumption of gluten can lead to symptoms similar to those seen in Celiac Disease”

• Negative antibodies (except IgG)• Grossly normal histology• Clinical improvement on a GFD in the absence of

antibodies and intestinal mucosal abnormalities

Sapone et al. BMC Medicine 2012 10:13

Non-Celiac Gluten Sensitivity (NCGS)

Also known as:Gluten sensitivity (GS) Gluten intolerance

Verdu EF, et al. Am J Gastroenterol 2009; 104:1587–1594

”

Summary

• Global limitation of acidic foods not necessary• Weight loss• Technique driven weight loss aids patients

GERD

• Utilize texture modifications• 5-6 small meals• Avoid excessive weight loss• Assess and treat malnutrition

Gastroparesis & Nausea

• Modify Textures• Low FODMAP diet

Gas, Bloating & Diarrhea

Seeking Information on Supplements & Complementary Therapies

• National Institute of Health Office of Dietary Supplements:- http://dietary-supplements.info.nih.gov/

• Look up your supplement:- http://ods.od.nih.gov/health_information/health_information.aspx

• Complementary and Alternative Medicine- http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm

• Institute of Medicine- http://www.iom.edu/?ID=4829

• Department of Health and Human Services Agency for Healthcare Research and Quality- http://www.ahrq.gov/

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What do I tell my patients?

• Eat real food• Limit refined sugars

- Sugar Sweetened Beverages and excess carbohydrates• Balance dietary fats

- Plant based is best• Include more plant based foods: cooking peeling help improve tolerance• Balanced animal protein

- Nitrate Free• Multivitamin, Calcium & Vitamin D, B12 and sometimes iron