April 2011 Issue

Cracking Myths — Experts Bust Digestive Health’s Top Misconceptions
By Sharon Palmer, RD
Today’s Dietitian
Vol. 13 No. 4 P. 24

Eating nuts increases risk of diverticulitis—it’s just one urban legend of the gut health world, according to our interviewees.

These days, it seems as though Americans are a little preoccupied with their gut. From battling the symptoms of irritable bowel syndrome (IBS) to choosing probiotics to nurture the body’s intestinal microflora, eating for digestive health has become a priority. According to New Nutrition Business, a global nutrition business researcher and publisher, digestive health tops the list of key trends in the functional food market. It reports that digestive health is a “mega-trend moving beyond the tipping point,” serving to popularize functional food ingredients such as prebiotics, probiotics, and fiber. In part, this rise in interest could be attributed to today’s many digestive disorders and conditions, including gastroesophageal reflux disease, celiac disease, Crohn’s disease, diverticular disease, constipation, ulcers, dumping syndrome, and IBS. On top of that, there is more interest in promoting a healthy intestinal microflora balance, which has been associated with inhibiting the growth of harmful bacteria, promoting good digestion, and boosting immune function.

Of course, when a nutrition topic becomes hot, a couple of things usually happen. First, industry cashes in and markets products promoting a benefit; second, people become very confused. Dietitians can easily see digestive health fitting into this scenario. The Internet is booming with dietary supplements, diet books, and websites that claim to possess the secrets for managing digestive health. Bookstores and natural and health food stores are benefiting from the digestive health craze, too. “One may only observe how many cures there are on the bookshelves for IBS alone,” notes Michal Hogan, RD, LD, CLT, a dietitian specializing in IBS and food sensitivities in her practice, Nutrition Results.

Jeannie Gazzaniga-Moloo, PhD, RD, a nutrition counselor, national spokesperson for the American Dietetic Association, and instructor at California State University, Sacramento, believes the confusion starts with a basic lack of understanding of the entire digestive system—a complicated bodily process that is often difficult for laypeople to comprehend.

Patsy Catsos, MS, RD, LD, a private practice dietitian, president of the Maine Dietetic Association, and author of IBS-Free at Last! The Revolutionary New Step-by-Step Method for Those Who Have Tried Everything, believes a big factor behind the confusion boils down to embarrassment. “Digestive health is a very delicate and potentially embarrassing subject, and many people do not discuss it with their doctors,” she explains. “For example, it is estimated that less than 25% of individuals having symptoms consistent with IBS seek medical attention for it. People rely on product advertisements, the popular press, and old wives’ tales for much of their information about gastrointestinal health.”

Kate Scarlata, RD, LDN, a nutrition consultant and author of The Complete Idiot’s Guide to Eating Well With IBS, says, “There is a great deal of confusion about digestive health and treatments because most people are thinking about the quick-fix solution.”
Given the current landscape of public misperception surrounding digestive health, Today’s Dietitian asked several experts to bust what they consider to be today’s top myths—once and for all.

The Deceptive Dozen

Myth 1: Excessive restrictions are necessary—and forever.
People with digestive health concerns frequently wind up on overly restrictive diets. Foods are often inappropriately scratched off the “OK” list, resulting in not only a joyless diet but also nutritional compromise. Scarlata believes overzealous diet restrictions can lead to health problems. For example, eliminating all dairy products in cases of lactose intolerance—even though many people can still tolerate hard cheeses and lactose-free yogurts—can reduce calcium intake, which can later lead to diminished bone health and hypertension.

“Dietitians need to do a scientifically sound, directed elimination diet to test each foodstuff so that they are not encouraging clients to unnecessarily eliminate foods from their diet. After the true culprits are exposed, then dietitians can adjust the diet and maximize ‘normalcy’ as much as possible,” Hogan says.

People tend to not only overrestrict foods but also think food restriction will last forever. According to Hogan, the goal of IBS therapy should be: “First we get you well, and then we get you ‘normal,’” which ultimately means adding more foods back into a nutritious, delicious diet.

Myth 2: Spicy foods cause ulcers.
This myth likely dates back to or even before your grandmother’s time, when spicy foods were considered too “exciting” for the system and the root of many health evils. “The more likely cause of ulcers is H pylori [Helicobacter pylori] and overuse of pain medications, which are tough on the stomach lining. Spicy foods may aggravate an ulcer but not cause it,” Scarlata says.

Indeed, the National Institutes of Health (NIH) reports that H pylori and anti-inflammatory drugs such as aspirin and ibuprofen—not spicy foods—are common causes of peptic ulcers.

Myth 3: Don’t eat nuts or seeds.
Leslie Bonci, MPH, RD, author of the American Dietetic Association Guide to Better Digestion, says this is a common myth among people with diverticular disease. Gazzaniga-Moloo adds that some people even believe eating nuts, seeds, corn, and popcorn will increase their risk of diverticulitis, probably because health practitioners used to caution patients with diverticular disease against consuming nuts and seeds on the premise that these foods might lodge and fester in the diverticula of the colon.

In her book, Bonci says that people do not need to eliminate nuts and seeds from their diet out of fear that these foods will get caught in the diverticula; however, they should chew foods well.

Myth 4: What works for one will work for all.
If people followed the advice of one IBS website, they’d eliminate all red meat from their diet. But who’s to say meat causes digestive problems for everyone?

“Since food sensitivities are so individual, different things work for different folks. Even identical twins being treated for IBS syndrome have different triggers and different symptoms,” says Hogan.

When counseling clients, remember to stress the importance of addressing individual food intolerances.

Myth 5: Consuming more fiber is always better.
Fiber is tricky territory, especially for individuals prone to IBS. “[Consuming more fiber] has been proven to be a very bad idea over and over. Yet the myth lives, even with diarrhea-predominant IBS,” says Hogan.

For years, health practitioners’ advice for treating IBS was to increase fiber intake, even in patients with diarrhea. But getting the gastrointestinal tract moving faster as a result of increased dietary fiber is hardly the goal for such patients. The type of fiber may matter more than the amount. While insoluble fiber found in wheat and bran may aggravate IBS symptoms, a 2009 study published in BMJ found that soluble fiber such as psyllium offers a significant reduction in IBS symptom severity.

Fiber can even be troublesome for people without IBS. “As dietitians, we all know the benefits of a high-fiber diet. However, some people just cannot tolerate it without significant discomfort from gas, bloating, constipation, or diarrhea. I prefer to recommend that people eat as much fiber as they can tolerate or up to 40 g a day—whichever comes first,” says Catsos, who reports having seen several clients who were eating 60 to 70 g of fiber a day, believing that they were following doctors’ orders to eat more fiber. No matter what, it’s very important to increase fiber intake gradually—2 to 5 g per day, according to Bonci’s book.

Myth 6: Avoiding FODMAPs is a cure for IBS.
The FODMAPs (Fermentable, Oligo-, Di-, and Mono-saccharides and Polyols) approach to managing functional gut disorders has certainly gained credence when it comes to caring for IBS. These carbohydrates are known to contribute to gas, bloating, and diarrhea in susceptible people, but sometimes they are not the root of the problem.

“Certain carbohydrates can … aggravate the condition of uncontrolled IBS. However, I have found that when you can quickly identify the immunological triggers, restriction of these carbohydrates proves unnecessary,” Hogan says.

Myth 7: You must detox to clean your gut.
This notion has gained a lot of traction thanks to celebrities proclaiming the benefits of “detox” or “cleanse” diet programs in popular magazines and on national TV.

“I think the whole idea of needing to detox has confounded and confused,” says Bonci.

Popular detox programs involving diets, fasts, supplements, and enemas claim that the body needs help detoxifying itself of its burden of toxins. But the human body is well equipped with its own detoxification system: the lungs, kidneys, colon, lymphatic system, and liver. According to Natural Standard, an organization that analyzes and validates scientific data on integrative medicine, there is insufficient evidence to support the validity of detox procedures and the idea that people can release toxins stored in organs and fatty tissues by changing their diet.

Myth 8: Weight loss and digestive problems always accompany celiac disease.
Scarlata, who calls this a common myth, says estimates suggest that “celiac disease with few or no gastrointestinal issues is the more prevalent form….”

Weight loss and digestive symptoms such as abdominal bloating and pain, chronic diarrhea, vomiting, constipation, and pale, foul-smelling, fatty stool may occur in patients with celiac disease. But the NIH reports that adults are less likely to have these symptoms and instead have symptoms such as unexplained iron-deficiency anemia, fatigue, bone or joint pain, arthritis, bone loss or osteoporosis, depression or anxiety, tingling or numbness in the hands and feet, seizures, missed menstrual periods, infertility or recurrent miscarriage, canker sores inside the mouth, and dermatitis herpetiformis.

Myth 9: Digestive health supplements are superior to whole foods.
Bonci reports a common assumption that supplements for gut health, such as fiber and probiotics, are superior to whole food sources of these functional food ingredients. Although fiber benefits may depend on an individual’s specific condition, the bulk of scientific research related to fiber’s overall colorectal benefits are related to fibers found in whole foods rather than isolated fibers. And whole food sources of fiber are packed with vitamins, minerals, and phytonutrients, which may also provide health benefits. Of course, that’s not to say fiber supplements are not helpful for many people with chronic constipation.

When it comes to probiotic supplements, there is concern that by the time consumers take them home from the store, they may not provide the same number of viable organisms listed on the label. ConsumberLab.com, an organization that provides independent testing and reviews for dietary supplements, found in a November 2009 survey of probiotic supplements that when a probiotic is purchased, it may contain as little as 10% to 58% of the amount of bacteria listed on the label. And regardless of whether the probiotic comes in a food or supplement form, some varieties do not have scientifically proven benefits.

Consumers should always keep the following three things in mind when selecting probiotics:

• They must be alive when consumed.

• They should have a documented health benefit.

• They must be taken at levels that will produce a health benefit.

Myth 10: Wait until there is a problem to increase fiber intake.

A common behavior that Catsos observes among her clients, particularly older adults, is waiting until they are constipated before increasing fiber intake or using over-the-counter (OTC) medications such as fiber supplements, stool softeners, or laxatives recommended by their physician.

“Too often, people overtreat constipation when it occurs, cause themselves diarrhea, respond to that by dropping the constipation preventatives, end up with another bout of constipation, and so on. I encourage these patients to work toward a consistent routine of constipation prevention. They may need very specific, written instructions for how to titrate their intake of fiber, fluids, and OTC medications. Sometimes one half, or even one fourth, of the labeled dose of OTC medications daily will do the trick, along with sound diet, adequate fluids, and regular activity,” she explains.

Myth 11: There are no consequences to taking medications long-term.
Scarlata believes that people are often attracted to quick-fix solutions for digestive problems, failing to look at the long-term ramifications of medication use. “As a result, people may trade one digestive problem for another,” she says. “For example, taking over-the-counter medications for heartburn appears to be linked with changes in microflora that may increase the risk of bacterial overgrowth.”

According to a study published in the December 2010 issue of the Canadian Medical Association Journal, there is a significant association between the use of gastric acid suppressive medications such as proton pump inhibitors (eg, Prevacid, Prilosec) and histamine 2-receptor antagonists (eg, Tagamet, Zantac) and pneumonia. Scientists believe gastric acid suppressives may lead to bacterial overgrowth in the upper gastrointestinal tract that may travel to the lungs as well as inhibit immune cells’ ability to fight off bacteria and infection.

Myth 12: A gluten allergy is the cause of all my troubles.
Perhaps the most common urban legend of late is that gluten is to blame for just about every health woe. “An allergy to gluten would explain all the aggravating aches, pains, fatigue, etc experienced by a person, hence the gluten-free diet craze,” says Gazzaniga-Moloo.

Supermarkets and restaurants are offering more gluten-free foods to feed the nation’s growing appetite for gluten-free products. Going gluten free is a necessity for people diagnosed with celiac disease. Other legitimate gluten avoiders include people with non-celiac gluten sensitivity and wheat allergy. But people are increasingly eliminating gluten without a proper diagnosis for one of these conditions. Thus, they may be unnecessarily missing out on an opportunity to eat healthful, tasty whole grains.

What’s a Dietitian to Do?
Sure, many misperceptions surround digestive health, but that’s all the more reason to be part of the solution. Dietitians are perfectly positioned to bust these myths and provide support and solutions for their clients’ digestive health problems.

“RDs can continue to provide a better understanding of digestive health and dispel the misinformation for people by keeping messages simple, clear, and concise,” says Gazzaniga-Moloo. “Don’t hesitate to explain the basics of digestion to dispel a myth. It takes vigilance by dietitians. Many people are convinced their beliefs about digestive health are indeed accurate, often because they say they’ve felt relief of symptoms after eating their restrictive diet. This makes dispelling a myth that much more challenging. To the individual, the connection they’ve made between their digestive health and dietary practice is very real.”

People with digestive conditions are often desperate for help. “We need to ask the questions and provide the answers the [other healthcare professionals] don’t,” says Bonci. Think beyond the “foods-to-avoid” lists and help people bring the challenge of their diets home to supermarket aisles, restaurant tables, and kitchens.

Catsos believes it’s important for dietitians to allow their clients—no matter what their original reason for seeking counsel—a chance to fully confide their digestive problems. “When working one on one, give clients, especially elderly clients, a chance to discuss concerns about their bowels. Many people resign themselves to living with uncomfortable gastrointestinal symptoms. They may initially come to see you because they have diabetes or hyperlipidemia, but they will be eternally grateful to you if you can help them with their gastrointestinal problems as well,” she says.

One big challenge for dietitians is staying on top of the latest science on the complex and evolving field of digestive health. “Dietitians should review the literature and continue to offer evidence-based medical nutrition therapy when working with clients with digestive health problems,” says Scarlata. “We continue to learn more and more about intestinal microflora and its impact on digestive health. Stay abreast of this research, which truly is in its infancy, as I feel this is an area that will likely direct many of our nutritional interventions in the near future.”

If you don’t feel confident counseling a client with digestive health problems, seek help from professionals who specialize in this area. “Refer to folks who dedicate time, interest, and literature review to intensive study of these things if you are not an expert in this area. Check out evidences posted in websites friendly to dietitians working with digestive and immunological disorders like NutritionResults.com,” advises Hogan.

Dietitians can truly make a difference in the lives of people with digestive health conditions. “I think we need to bring digestive health to the dinner table. It is truly underappreciated and underemphasized. We have heart month, breast cancer awareness—how about the good gut club?” says Bonci.

— Sharon Palmer, RD, is a contributing editor at Today’s Dietitian and a freelance food and nutrition writer based in southern California.

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