October 18, 2023 • 24 mins
The GI Research Foundation was able to produce this podcast with a sponsorship from AbbVie.
Featuring Lori Rowell Welstead, MS, RD, LDN and Courtney Schuchmann, MS, RD, LDN
Registered Dietitians with the University of Chicago Digestive Diseases Center
"People might think that a registered dietitian is going to say, 'cut this out, cut that out,' where in reality, we focus on adding food back into to your diet to really optimize your nutritional status."
In this episode, patients with digestive diseases learn what they should eat, why they should eat it, how they should manage their diet, and how to make sure that they’re maximizing their nutrition so they get all of the optimal benefits of the food they are eating. Registered dietitians with the University of Chicago Digestive Diseases Center, Lori Rowell Welstead and Courtney Schuchmann share their expertise on nutrition and its relationship to IBS, Celiac disease, Crohn's, ulcerative colitis, gastroparesis, fatty liver disease, and more.
Written and produced by Anna Gomberg. Edited and mixed by Mike Collins-Dowden. To access other podcast episodes and learn more about research to treat, prevent, and cure digestive diseases, please visit www.giresearchfoundation.org.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
This podcast, Visceral, is a production of the GI Research Foundation.
(00:03):
The GI Research Foundation was able to produce this podcast
with the sponsorship from AbbVie.
I think a lot of people might initially think a registered dietitian
might be cut this out, cut that out, right?
Where we really try to focus on add more things back in, right?
Not take away.
It's like, what else can we tuck into your regular intake
to really optimize your diet and optimize your nutrition status?
(00:31):
Welcome to Visceral, the podcast by the GI Research Foundation.
My name is Anna Gomberg, and today I am here with Lori Wellsted
and Courtney Schuchman, who are the registered dietitians
who work with the Digestive Diseases Center at the University of Chicago Medicine.
And we are so fortunate to have them with us to tell us
all we need to know about nutrition and digestive diseases.
(00:52):
Lori has been working at the Digestive Diseases Center for a very long time.
Lori, how long have you been working here?
18 years.
18 years. And Courtney, you started shortly after I started.
So when did you begin working at the Digestive Diseases Center?
I just hit the six-year mark.
Oh, my goodness. So 20, almost 25 years of combined
(01:14):
digestive diseases, nutrition experience in this room right now.
And I'm so glad that you guys are here to share.
Most of the conversations I've had with either one of you,
I have wished that I could push record on because there's so much knowledge
that you have to share. And all of our patients with digestive diseases,
of course, want to know what they should eat, why they should eat it,
(01:35):
how they should manage their diet and how to make sure that they're
maximizing their nutrition so that they have all of the optimal
benefits of the food that they're eating.
So to begin with, could you tell us a little bit about your specific areas
of expertise? Laurie, why don't we start with you?
OK, so, yeah, over the past, like I said, 18 years,
I've been seeing a variety of patients.
(01:56):
I've seen a lot of IBD, so Crohn's and colitis, a lot of IBS,
irritable bowel syndrome.
I also specialize in celiac disease, gastroparesis, upper GI disorders
like EOE or eosinophilic esophagitis.
And we just hired a new dietician that's really doing more of the fatty liver
disease because we've seen a really big uptick in that.
(02:17):
And then I do some weight management as well to kind of round it out.
That's pretty much all of it, I think.
And Courtney, how about you?
What's where do you specialize?
So I do specialize more in inflammatory bowel diseases.
So Crohn's and ulcerative colitis.
And then Laurie and I split a lot of the other gastrointestinal overlaps.
So IBS as well as pancreatic insufficiency, a lot of the upper and lower
(02:42):
GI symptom or symptom management, and then a lot of functional.
Symptom control as well.
What are some of the things that patients who have some of these
digestive diseases need to look out for with regard to diet, nutrition?
Maybe we should start with celiac, Laurie.
Yes.
So celiac disease, really the only thing they have to avoid is gluten.
(03:02):
So that's wheat, rye and barley, but otherwise they could have a varied diet.
And what does meeting with a dietician look like for a
patient with celiac disease?
What kind of help can you give them?
Yeah.
So, you know, really we do a nutritional assessment, have the patient sit down
with us, whether it's virtual in person and really kind of go through what their
(03:24):
typical intake is, seeing what their current digestive symptoms are.
Again, are they complaining of diarrhea, constipation, heartburn, you know, to see,
again, what are those kinds of markers that we're going to look at to see if
your symptoms improve, making some dietary and behavioral modifications.
So we go through those things, kind of a 24 hour recall.
And then really at the end is coming up with some goals that it's kind of like
(03:47):
patient centered goals and having them come up with their ideas of what they
want to work on.
And again, for celiac disease, again, we're going over the strict gluten free
diet because there is no medication for it.
So they have to adhere to a strict gluten free diet, but again, there's no
medications for it.
So these patients might meet with us, you know, they have an initial visit and
depends on, again, insurance coverage or patient interests of how often they want
(04:09):
to follow up as well.
It's wonderful.
And then same thing for IBD patients.
What's your first meeting with an IBD patient like, and what kind of
nutritional needs do they typically have?
So IBD looks really different from one patient to the next.
So again, like Lori said, a nutritional assessment, one of the first things I
ask is what are you experiencing?
Cause a lot of people assume that IBD means lots of frequent diarrhea, blood
(04:32):
in your stool, but for some of our patients, it may not present with any
symptoms or maybe just like discomfort or abdominal pain.
Some patients experience more constipation.
It also depends on where their disease is located.
So if a patient has colitis or ulcerative colitis or Crohn's that's
specifically in the colon, their symptoms might look very different than someone
that has small bowel involvement.
(04:54):
That also affects what kind of nutritional deficiencies that we're
typically monitoring for since the small intestine main job is to absorb a lot of
those vitamins and minerals.
So those individuals with disease in the small intestine, specifically the
ilium, tend to have more of the vitamin and mineral deficiencies versus
patients with colitis, whether that's Crohn's colitis or ulcerative colitis
(05:16):
might have more, more of those functional symptoms like the
diarrhea or constipation.
They often tend to have more electrolyte abnormalities if they're having frequent
loose bowel movements and less frequently present with some of those
micronutrient deficiencies.
It sounds like we're really talking about a really personal issue.
We're talking about a really personal approach to the way that people eat and
(05:41):
what they're eating and then also doing the evaluations to make sure that they
are not having those deficiencies that you mentioned.
Is it very common for people to have deficiencies and nutritional issues
with any digestive disease?
Yeah.
So Laurie was speaking to celiac and we do frequently see vitamin B12 and
(06:01):
vitamin D deficiencies, as well as iron deficiency in that patient population.
We also see that with patients that present with ulcerative colitis
and Crohn's as well.
So if a patient does have some of these nutrient deficiencies, it doesn't
indicate what type of digestive disorder we're working with.
Further evaluation with their gastroenterologist is really important to
pinpoint what specific disease we're managing.
(06:23):
It is more common, like I said, with Crohn's to see a full gamut of vitamin
deficiencies or mineral deficiencies.
So anywhere from vitamin A, E, D, B12, B6, folate, zinc, iron, selenium.
So there are a lot of different nutrients we're monitoring for.
When a patient is in a state of active disease, we tend to see more of these
(06:45):
nutrient deficiencies and we want to monitor them more closely than when
someone's in remission.
However, I always stress to my patients, be your own patient advocate and make
sure that you're still getting those labs checked at least once a year.
Because sometimes it flies under the radar and we don't check labs for
multiple years and you could still have some of these underlying deficiencies.
Like vitamin D is extremely common, especially for those who live in the
(07:07):
Midwest, just because we don't have as much exposure to sunlight.
And then some of the other vitamin and mineral deficiencies we do see commonly
too, just because of diet quality with a Westernized diet.
Totally.
So outside of nutritional deficiencies, what else does a dietitian help with?
Maybe Lori, what kinds of things you mentioned, some of the functional bowel
(07:30):
stuff that can really be a problem for patients because it's really
disruptive to their lives.
How does diet factor into that?
Well, I think our goal too, is really to try to vary people's
diet and try to add things in.
I mean, every week I have multiple patients that are eating such a
self-limited diet, right?
Like they're cutting out X, Y, and Z because someone might have told them.
(07:53):
And next thing you know, they're eating a very limited diet and then they're
undernourished just because of their lack of variety in their diet.
So like Courtney said, sometimes people are not even getting enough vitamin C
and a lot of the common things that could be quite easy to get enough in.
So really kind of going over the whole diet, making sure people are eating
adequate protein, making sure they're eating, again, I always say all the
colors of the rainbow, right?
(08:15):
So kind of seeing what else they can kind of add in versus, again, I think a
lot of people might initially think a registered dietitian might be cut this
out, cut that out, right?
Where we really try to focus on add more things back in, right?
Not take away.
It's like, what else can we tuck into your regular intake to really optimize
your diet and optimize your nutrition status and help energy and quality of
(08:36):
life? I think that's our big thing too, is really kind of like re-educating
people to not feel that they need to avoid so many things because there's
really not enough evidence for a lot of that on necessary restrictions.
Well, and food is energy.
That is why we eat food, right?
And so the idea that like people are saying like, and I think we see this in
our, the support group that I run all the time that people really do in an
(08:59):
effort to get a handle on their pain and an effort to get a handle on their,
their symptoms, their frequency, their urgency, they really say like, okay,
I'm just not going to eat because eating is the root of this.
And of course we know that you can't live like that.
Like that's a terrible way to live.
So it's like very helpful to think about, but like, what about patients?
(09:20):
So, so, so patients come with that limiting perspective.
How do you, is it like, where does that come from?
Why do people self restrict? Why do they over, over restrict?
What kind of information is out there about that?
And why, why does that happen?
I believe a lot of it's an adaptive response.
So when you eat and you experience a symptom immediately after eating,
(09:43):
you correlate those symptoms with the specific food that you just ingested.
So it's kind of like Pavlov's theory that we learned in school,
where you bring a bell, the dogs start to salivate. It's a trained response.
So it's an adaptive response that if we eat things that don't feel good,
that we might want to eliminate those foods.
But what patients tend to see is they eliminate one food, they still have
(10:03):
symptoms, they eliminate the next food.
So especially in patients with an inflammatory condition like IBD,
during a state of active disease,
all things might not feel so great in the body.
So even sometimes sipping water doesn't feel good.
So if you start to eliminate everything that causes symptoms,
you might be left with very limited items that provide nutrition for you.
(10:24):
So a lot of, I think what Lori and I do is educating on foods that are
generally well tolerated. It doesn't mean that it works for everyone,
but we provide the education on why those specific foods do tend to sit
better in the digestive tract.
So whether that's the types of fibers or how we prepare them or manipulate
the fibers to help just ease digestion,
(10:46):
making sure that we're using swaps for foods that might cause more functional
symptoms like gas and bloating.
A lot of what we do is rather than focusing on eliminating,
we talk about what foods can we swap that might provide a similar nutritional
value and enjoyment with eating without completely having to restrict entire
food groups.
What kind of manipulation do you recommend?
(11:07):
For patients, you mentioned the fibers that you can,
that you can change how the fibers are received by the,
by the digestive system. What does that mean?
So we talk a lot about particle size when it comes to IBD.
So this doesn't translate to all patients with digestive disorders.
So if you have something like celiac disease or IBS or acid reflux,
(11:29):
you might not have to go to some of these measures to manipulate the foods
that you're eating. But with some of our patients with IBD,
if you have inflammation in parts of the digestive tract,
or if you have an ostomy where there might be an increased risk for things
getting stuck or blocked, or if you have structuring,
which is the narrowing in the intestines,
foods can potentially cause blockages or obstructions for those individuals.
(11:52):
So manipulating the fiber, and this is,
this could just be as simple as peeling it.
So eating a peeled sliced up apple or apple sauce,
it's the same nutritional value as eating an apple,
but the fiber is softer and easier to digest.
Some of my patients, we do more of like the roast a bunch of vegetables,
throw them in a blender and make like a vegetable puree.
You can use this for pastas.
(12:13):
You can use it as a spread on sandwiches and wraps.
You can use it as a sauce to put over protein like chicken or fish.
And this is a way to really break down those fibers so that they're gentler
and easier to move through the digestive tract.
It actually makes some of the nutrients more bioavailable.
Too, because the foods are pulverized and the nutrients are easier
(12:34):
to absorb by an already inflamed intestinal tract.
But it also makes these foods frequently safer for a lot of our patients
that are worried about things like blockages.
And for patients that have their disease managed with medicine,
how do you treat, I mean, and maybe they get a handle on all this.
Maybe they see you and they say, I've got a vitamin D deficiency.
I have a vitamin B12 deficiency.
(12:55):
I'm going to make some corrections to get there.
But for people who are in remission or who are living pretty well with celiac
or with any digestive disease like IBD, Crohn's disease, all sort of colitis,
like how does the nutritional evaluation shift for them?
Can they eat more food?
Can they eat more and better food than vegetable puree, which sounds wonderful?
(13:17):
It sounds like a great hack.
Does it change over time?
Yeah, absolutely.
And again, it kind of depends on the patient.
If they're in a flare, like Courtney said, if they have stricturing,
they do really have to watch some of those fibers.
But for some individuals, they might have to lower it
and be able to ramp up a little bit more of the fiber.
But again, we look at kind of the matrix in some of those individuals.
They might not be able to eat a salad the size of their head,
(13:39):
but maybe a small salad with very soft ingredients, right?
Like Courtney said, even doing like roasted vegetables or grilled vegetables.
And you could also have them like cold later with like dips and things.
A lot of catering companies do that.
So I'll even recommend that to patients to kind of ramp it up.
Versus like, OK, you start with maybe pureed, then roasted vegetables, right?
(13:59):
Now, some people might not be able to eat raw carrots and raw celery
because of the disease, whereas others, again, if they are in remission,
they don't have stricturing, they could eat a quite varied diet.
So we do recommend still getting in that fiber.
And like Courtney said, some people have to manipulate that matrix of the fiber
and some individuals can handle more fiber.
So yeah, it has to be very individualized.
(14:20):
And again, Courtney and I both have seen so many people
have seen so many patients that have said, oh, I was diagnosed, you know,
20, 30 years ago, I was told to eat no fiber, no fruits or vegetables.
Right. And then they're having a lot of other issues with blood sugars,
weight and just energy and right there, diets very poor.
Well, and I think it's important to note that, especially when it comes to IBD,
(14:43):
research does show and support that high intake of fruits and vegetables
reduces your risk for flair.
So a high fiber, more of this plant based dietary pattern is shown to be protective.
So trying to make patients where they're at and determining how we can incorporate
these foods. So maybe like Lori said, if they can incorporate more of the roughage,
the raw fruits and vegetables, great.
(15:04):
If they can't, maybe we try something like bean and lentil pastas where you're
getting some of the nutritional value or like hummus.
But it's not like everything's a pureed diet.
So and retrying a lot of these foods too, when you are in remission.
So I think that's the biggest thing I can stress is something that didn't sit
you well when you were in a flair is likely to be a very different experience
(15:25):
when you're in remission.
So you might have some hesitation about adding those foods back in, but trying
one for a few days at a time, one by one can create that exposure therapy that
makes you a little bit more comfortable and it can really help you get a better
sense of what you're able to tolerate in remission.
Well, before I did this call, I Googled very quickly, what should I eat for
(15:47):
digestive diseases? And the internet thinks that I should eat things like
apple cider vinegar and lemon juice and cayenne pepper and various cleanses and
take a whole lot of different supplements that seem to be very expensive.
What do you say to the internet at large?
(16:10):
Are they a great registered dietitian or what kind of information would you say
patients can get from those kind of searches?
Yeah, I mean, I guess I'll start.
I think that, yeah, you have to take it with a grain of salt.
Everyone's going to always have these kind of quick fixes and these hacks,
but unfortunately, like they don't really do the trick, right?
You can spend a lot of money on supplements.
(16:31):
Unfortunately, they're not regulated by the FDA.
So you don't really know what you're getting for the end product.
We have things like our liver and our kidneys and things that should be able to
detoxify our body naturally.
And they do.
So again, making sure people are getting adequate sleep, enough water,
even things like getting enough protein.
I'll explain to patients like if you don't have enough protein in your diet,
(16:52):
that could affect the integrity of your gut, right?
The integrity of all your tissues and your organs throughout the body,
not just your muscle and your hair.
So I think versus saying, oh my gosh, I'm going to go take all these supplements.
I think what we also see a lot is patients are taking a lot of supplements.
They might come in with a big bag of supplements and they'll say, gosh,
I have a stomach ache.
I feel like I'm so full.
I have no appetite.
Well, yeah, you're taking 30 pills a day, right?
(17:12):
So I think it's again, I just had a patient this morning, messaged me back.
I'm so happy I cut down on all those supplements, right?
Because people have really good intentions.
And like you said, they are really trying to help some of their symptoms,
but then they're sometimes self-tab,
attaching with some of these things that are unnecessary.
Well, in the supplement industry is a multi-billion dollar industry for a reason.
And it's one of the leading causes for ER visits each year.
(17:36):
So that's something I always stress to patients is that
there are side effects with a lot of these.
Too much of a good thing is not a good thing.
There was a publication last year about a patient who died from a vitamin D overdose,
which prior to this, we didn't know that the upper limit could be exceeded
and cause such a detrimental side effect.
So that's just one example.
(17:57):
Liver toxicity is a big one.
We see patients that end up with liver damage that's irreversible
from taking too many supplements.
So making sure that you're just taking the ones that are absolutely necessary.
So this is typically just if you have vitamin or mineral deficiencies,
or if you have a part like a digestive disorder that affects absorption,
or you're on a restrictive diet, like a gluten-free diet,
(18:18):
you might need something like a daily multivitamin
to fill in some of those nutrient gaps.
But also making sure that you're choosing third-party tested products.
I stress this every single day in my practice is the USP and then NSF
are two of the organizations you can look for that are labeled on bottles.
And these are third-party organizations that go in and test the product
(18:40):
and look to ensure that it contains what it says it contains
in the doses it says it does.
Some supplements sometimes report a certain amount
and it's a lot more that's actually in the product.
So you can end up with an overdose of a certain nutrient
and didn't even know you were taking that because like Lori said,
the FDA does not regulate these supplements.
Yeah, so maybe easier to get from the garden or the grocery store
(19:03):
than from a bottle.
Though a bottle would be wonderful.
What would you say if you could really tell your patients
one thing about diet nutrition?
What's like the one big takeaway you'd like them to know from you,
from your combined almost 25 years of expertise?
If there was one message you wanted to share, what would it be?
Yeah, I mean, I think that food and your diet is very like interrelated
(19:28):
with so much of your life, right?
So social, all of that.
So I think that the goal is really to help increase quality of life
and not feel overly restricted because a lot of these different diseases
or things could be restricting.
So I always try to look on the bright side a lot of times.
Mine kind of boils down to quality of life as well.
So I think if you are restricting your diet so much as a means
(19:51):
to control your symptoms, but it's impaired your mental health,
your ability to socialize, interact with others,
you're feeling depressed or anxious about your eating behaviors,
that tends to mean that the diet is not the appropriate approach for you.
And despite the fact that Lori and I very frequently preach
all the things we can do with diet and nutrition,
sometimes diet is not the answer, especially in the realm of digestive disorders.
(20:15):
We have other approaches.
We have GI psychologists where maybe diet isn't appropriate
and working with a GI psychologist would be more beneficial for those individuals.
There's also medications that can frequently help improve your diet.
Help improve symptom control without having to overly manipulate your diet
where it's greatly impacting your quality of life.
So even though diet should be used as an adjunct, it's not our only approach.
(20:38):
Well, unfortunately, my advice is that people need to see Lori and Courtney
and our other RDs because I think that's the biggest takeaway for me
is I want every patient with a digestive disease to talk to one of you
and just get at least that assessment, that conversation,
begin that process because I know how vital it is.
And we all have to eat every day, right?
(20:58):
You have to eat so many times a day.
My children think they need to eat a lot more than they do.
Certainly snacks and candies and cookies and cakes.
This is like bonus for myself.
What kind of diets do you guys have?
I'm always curious to know what dieticians eat.
I think everybody is.
What kind of diet do you eat?
Courtney, I follow you on Instagram.
(21:19):
I know you're kind of a foodie.
What's your personal philosophy about food?
All foods fit, anything and everything can fit within a balanced diet.
So I think we all as dieticians frequently preach,
try to incorporate more whole foods.
So things that don't have a laundry list of ingredients.
This is going to be fruits and vegetables, legumes,
lean proteins, unprocessed proteins,
(21:42):
but also that food is a social part of our lives as well.
So being able to go out to eat, indulge in things without a restrictive mindset,
I also think is my personal philosophy is I like dining out.
That's probably a highlight of my week is going out with my significant other
and eating out and enjoying new cuisine.
But then also majority of the week we're focusing on preparing foods at home
(22:06):
with simplistic ingredients that provide a good variety of that rainbow,
the fruits and vegetables and lots of color.
I wish I had your life, your life, the dining out life
that at least you share on the gram is very inspiring.
Lori, how about you?
She's pre-kids too, so that's another.
I know she's pre-kids.
Pre-kids.
Now I have to look to forever.
Wow, you know, like kid menus are right.
(22:28):
So it's a challenge.
I think that, yeah.
But yeah, and again, I have celiac disease, fortunately, unfortunately.
I've been diagnosed about eight years ago.
So I just follow a gluten-free diet, but I eat all the other things, right?
So I eat, I don't risk anything else besides that.
I love food and like I'm always like, oh my gosh, where am I going to go to eat next?
So my friends always make fun of me because I'm always on a mission to try
(22:50):
different gluten-free things.
Whether it's fried foods that are gluten-free,
because that's another thing I'm very restricted on.
I can't eat out of fried regular fryers.
So that's something I like get excited about.
And yeah, I agree with Courtney.
I eat like all foods.
I have a sweet tooth.
So again, I always, I think a lot of my recommendations of patients
are things that I also have experienced.
(23:12):
And again, we say like making sure that, yeah, you're satisfied.
Are you eating things that are making you feeling satiated, right?
Otherwise you're just going to say, forget it.
I'm just going to eat whatever, right?
So I think it's all about.
Oh, yeah.
Well, I have had such a great time knowing you and eating with you guys
and going to have our events with you.
(23:33):
And I know that you speak the truth.
You live that truth and it's really inspiring.
And it helps remind us that like the people who really know this treat food
the way that it should be part of your life
as something that really brings joy and brings a lot of fulfillment and happiness
as well as doesn't make you sick.
So that's very helpful to hear.
(23:55):
I want to just want to say thank you guys so much for being here today.
This is, I know that you are so busy all the time and just taking the time to talk to us
and share some of your wisdom is just such a gift.
And we will have more, I'm sure more conversations in the future
because everybody likes to talk about food.
And you guys really know everything that we need to share.
(24:18):
Thank you guys so much.
Thank you.
Thank you for listening to this episode of the podcast,
Fisero from the GI Research Foundation.
This episode was written and produced by me, Anna Gomberg,
and edited and mixed by the incredible Mike Collins-Dowden,
who also composed our theme music.
We hope you will join us next time.
Until then, to access other podcasts and learn more about research to treat, prevent,
(24:38):
and cure digestive diseases, as well as access to our online course
as well as access additional educational materials,
please visit the website at giresearchfoundation.org
and follow us on Facebook, Twitter, and LinkedIn.
Thank you again to Abbvie for making this podcast possible.
This podcast, Visceral, is a production of the GI Research Foundation.
(00:03):
The GI Research Foundation was able to produce this podcast
with the sponsorship from AbbVie.
I think a lot of people might initially think a registered dietitian
might be cut this out, cut that out, right?
Where we really try to focus on add more things back in, right?
Not take away.
It's like, what else can we tuck into your regular intake
to really optimize your diet and optimize your nutrition status?
(00:31):
Welcome to Visceral, the podcast by the GI Research Foundation.
My name is Anna Gomberg, and today I am here with Lori Wellsted
and Courtney Schuchman, who are the registered dietitians
who work with the Digestive Diseases Center at the University of Chicago Medicine.
And we are so fortunate to have them with us to tell us
all we need to know about nutrition and digestive diseases.
(00:52):
Lori has been working at the Digestive Diseases Center for a very long time.
Lori, how long have you been working here?
18 years.
18 years. And Courtney, you started shortly after I started.
So when did you begin working at the Digestive Diseases Center?
I just hit the six-year mark.
Oh, my goodness. So 20, almost 25 years of combined
(01:14):
digestive diseases, nutrition experience in this room right now.
And I'm so glad that you guys are here to share.
Most of the conversations I've had with either one of you,
I have wished that I could push record on because there's so much knowledge
that you have to share. And all of our patients with digestive diseases,
of course, want to know what they should eat, why they should eat it,
(01:35):
how they should manage their diet and how to make sure that they're
maximizing their nutrition so that they have all of the optimal
benefits of the food that they're eating.
So to begin with, could you tell us a little bit about your specific areas
of expertise? Laurie, why don't we start with you?
OK, so, yeah, over the past, like I said, 18 years,
I've been seeing a variety of patients.
(01:56):
I've seen a lot of IBD, so Crohn's and colitis, a lot of IBS,
irritable bowel syndrome.
I also specialize in celiac disease, gastroparesis, upper GI disorders
like EOE or eosinophilic esophagitis.
And we just hired a new dietician that's really doing more of the fatty liver
disease because we've seen a really big uptick in that.
(02:17):
And then I do some weight management as well to kind of round it out.
That's pretty much all of it, I think.
And Courtney, how about you?
What's where do you specialize?
So I do specialize more in inflammatory bowel diseases.
So Crohn's and ulcerative colitis.
And then Laurie and I split a lot of the other gastrointestinal overlaps.
So IBS as well as pancreatic insufficiency, a lot of the upper and lower
(02:42):
GI symptom or symptom management, and then a lot of functional.
Symptom control as well.
What are some of the things that patients who have some of these
digestive diseases need to look out for with regard to diet, nutrition?
Maybe we should start with celiac, Laurie.
Yes.
So celiac disease, really the only thing they have to avoid is gluten.
(03:02):
So that's wheat, rye and barley, but otherwise they could have a varied diet.
And what does meeting with a dietician look like for a
patient with celiac disease?
What kind of help can you give them?
Yeah.
So, you know, really we do a nutritional assessment, have the patient sit down
with us, whether it's virtual in person and really kind of go through what their
(03:24):
typical intake is, seeing what their current digestive symptoms are.
Again, are they complaining of diarrhea, constipation, heartburn, you know, to see,
again, what are those kinds of markers that we're going to look at to see if
your symptoms improve, making some dietary and behavioral modifications.
So we go through those things, kind of a 24 hour recall.
And then really at the end is coming up with some goals that it's kind of like
(03:47):
patient centered goals and having them come up with their ideas of what they
want to work on.
And again, for celiac disease, again, we're going over the strict gluten free
diet because there is no medication for it.
So they have to adhere to a strict gluten free diet, but again, there's no
medications for it.
So these patients might meet with us, you know, they have an initial visit and
depends on, again, insurance coverage or patient interests of how often they want
(04:09):
to follow up as well.
It's wonderful.
And then same thing for IBD patients.
What's your first meeting with an IBD patient like, and what kind of
nutritional needs do they typically have?
So IBD looks really different from one patient to the next.
So again, like Lori said, a nutritional assessment, one of the first things I
ask is what are you experiencing?
Cause a lot of people assume that IBD means lots of frequent diarrhea, blood
(04:32):
in your stool, but for some of our patients, it may not present with any
symptoms or maybe just like discomfort or abdominal pain.
Some patients experience more constipation.
It also depends on where their disease is located.
So if a patient has colitis or ulcerative colitis or Crohn's that's
specifically in the colon, their symptoms might look very different than someone
that has small bowel involvement.
(04:54):
That also affects what kind of nutritional deficiencies that we're
typically monitoring for since the small intestine main job is to absorb a lot of
those vitamins and minerals.
So those individuals with disease in the small intestine, specifically the
ilium, tend to have more of the vitamin and mineral deficiencies versus
patients with colitis, whether that's Crohn's colitis or ulcerative colitis
(05:16):
might have more, more of those functional symptoms like the
diarrhea or constipation.
They often tend to have more electrolyte abnormalities if they're having frequent
loose bowel movements and less frequently present with some of those
micronutrient deficiencies.
It sounds like we're really talking about a really personal issue.
We're talking about a really personal approach to the way that people eat and
(05:41):
what they're eating and then also doing the evaluations to make sure that they
are not having those deficiencies that you mentioned.
Is it very common for people to have deficiencies and nutritional issues
with any digestive disease?
Yeah.
So Laurie was speaking to celiac and we do frequently see vitamin B12 and
(06:01):
vitamin D deficiencies, as well as iron deficiency in that patient population.
We also see that with patients that present with ulcerative colitis
and Crohn's as well.
So if a patient does have some of these nutrient deficiencies, it doesn't
indicate what type of digestive disorder we're working with.
Further evaluation with their gastroenterologist is really important to
pinpoint what specific disease we're managing.
(06:23):
It is more common, like I said, with Crohn's to see a full gamut of vitamin
deficiencies or mineral deficiencies.
So anywhere from vitamin A, E, D, B12, B6, folate, zinc, iron, selenium.
So there are a lot of different nutrients we're monitoring for.
When a patient is in a state of active disease, we tend to see more of these
(06:45):
nutrient deficiencies and we want to monitor them more closely than when
someone's in remission.
However, I always stress to my patients, be your own patient advocate and make
sure that you're still getting those labs checked at least once a year.
Because sometimes it flies under the radar and we don't check labs for
multiple years and you could still have some of these underlying deficiencies.
Like vitamin D is extremely common, especially for those who live in the
(07:07):
Midwest, just because we don't have as much exposure to sunlight.
And then some of the other vitamin and mineral deficiencies we do see commonly
too, just because of diet quality with a Westernized diet.
Totally.
So outside of nutritional deficiencies, what else does a dietitian help with?
Maybe Lori, what kinds of things you mentioned, some of the functional bowel
(07:30):
stuff that can really be a problem for patients because it's really
disruptive to their lives.
How does diet factor into that?
Well, I think our goal too, is really to try to vary people's
diet and try to add things in.
I mean, every week I have multiple patients that are eating such a
self-limited diet, right?
Like they're cutting out X, Y, and Z because someone might have told them.
(07:53):
And next thing you know, they're eating a very limited diet and then they're
undernourished just because of their lack of variety in their diet.
So like Courtney said, sometimes people are not even getting enough vitamin C
and a lot of the common things that could be quite easy to get enough in.
So really kind of going over the whole diet, making sure people are eating
adequate protein, making sure they're eating, again, I always say all the
colors of the rainbow, right?
(08:15):
So kind of seeing what else they can kind of add in versus, again, I think a
lot of people might initially think a registered dietitian might be cut this
out, cut that out, right?
Where we really try to focus on add more things back in, right?
Not take away.
It's like, what else can we tuck into your regular intake to really optimize
your diet and optimize your nutrition status and help energy and quality of
(08:36):
life? I think that's our big thing too, is really kind of like re-educating
people to not feel that they need to avoid so many things because there's
really not enough evidence for a lot of that on necessary restrictions.
Well, and food is energy.
That is why we eat food, right?
And so the idea that like people are saying like, and I think we see this in
our, the support group that I run all the time that people really do in an
(08:59):
effort to get a handle on their pain and an effort to get a handle on their,
their symptoms, their frequency, their urgency, they really say like, okay,
I'm just not going to eat because eating is the root of this.
And of course we know that you can't live like that.
Like that's a terrible way to live.
So it's like very helpful to think about, but like, what about patients?
(09:20):
So, so, so patients come with that limiting perspective.
How do you, is it like, where does that come from?
Why do people self restrict? Why do they over, over restrict?
What kind of information is out there about that?
And why, why does that happen?
I believe a lot of it's an adaptive response.
So when you eat and you experience a symptom immediately after eating,
(09:43):
you correlate those symptoms with the specific food that you just ingested.
So it's kind of like Pavlov's theory that we learned in school,
where you bring a bell, the dogs start to salivate. It's a trained response.
So it's an adaptive response that if we eat things that don't feel good,
that we might want to eliminate those foods.
But what patients tend to see is they eliminate one food, they still have
(10:03):
symptoms, they eliminate the next food.
So especially in patients with an inflammatory condition like IBD,
during a state of active disease,
all things might not feel so great in the body.
So even sometimes sipping water doesn't feel good.
So if you start to eliminate everything that causes symptoms,
you might be left with very limited items that provide nutrition for you.
(10:24):
So a lot of, I think what Lori and I do is educating on foods that are
generally well tolerated. It doesn't mean that it works for everyone,
but we provide the education on why those specific foods do tend to sit
better in the digestive tract.
So whether that's the types of fibers or how we prepare them or manipulate
the fibers to help just ease digestion,
(10:46):
making sure that we're using swaps for foods that might cause more functional
symptoms like gas and bloating.
A lot of what we do is rather than focusing on eliminating,
we talk about what foods can we swap that might provide a similar nutritional
value and enjoyment with eating without completely having to restrict entire
food groups.
What kind of manipulation do you recommend?
(11:07):
For patients, you mentioned the fibers that you can,
that you can change how the fibers are received by the,
by the digestive system. What does that mean?
So we talk a lot about particle size when it comes to IBD.
So this doesn't translate to all patients with digestive disorders.
So if you have something like celiac disease or IBS or acid reflux,
(11:29):
you might not have to go to some of these measures to manipulate the foods
that you're eating. But with some of our patients with IBD,
if you have inflammation in parts of the digestive tract,
or if you have an ostomy where there might be an increased risk for things
getting stuck or blocked, or if you have structuring,
which is the narrowing in the intestines,
foods can potentially cause blockages or obstructions for those individuals.
(11:52):
So manipulating the fiber, and this is,
this could just be as simple as peeling it.
So eating a peeled sliced up apple or apple sauce,
it's the same nutritional value as eating an apple,
but the fiber is softer and easier to digest.
Some of my patients, we do more of like the roast a bunch of vegetables,
throw them in a blender and make like a vegetable puree.
You can use this for pastas.
(12:13):
You can use it as a spread on sandwiches and wraps.
You can use it as a sauce to put over protein like chicken or fish.
And this is a way to really break down those fibers so that they're gentler
and easier to move through the digestive tract.
It actually makes some of the nutrients more bioavailable.
Too, because the foods are pulverized and the nutrients are easier
(12:34):
to absorb by an already inflamed intestinal tract.
But it also makes these foods frequently safer for a lot of our patients
that are worried about things like blockages.
And for patients that have their disease managed with medicine,
how do you treat, I mean, and maybe they get a handle on all this.
Maybe they see you and they say, I've got a vitamin D deficiency.
I have a vitamin B12 deficiency.
(12:55):
I'm going to make some corrections to get there.
But for people who are in remission or who are living pretty well with celiac
or with any digestive disease like IBD, Crohn's disease, all sort of colitis,
like how does the nutritional evaluation shift for them?
Can they eat more food?
Can they eat more and better food than vegetable puree, which sounds wonderful?
(13:17):
It sounds like a great hack.
Does it change over time?
Yeah, absolutely.
And again, it kind of depends on the patient.
If they're in a flare, like Courtney said, if they have stricturing,
they do really have to watch some of those fibers.
But for some individuals, they might have to lower it
and be able to ramp up a little bit more of the fiber.
But again, we look at kind of the matrix in some of those individuals.
They might not be able to eat a salad the size of their head,
(13:39):
but maybe a small salad with very soft ingredients, right?
Like Courtney said, even doing like roasted vegetables or grilled vegetables.
And you could also have them like cold later with like dips and things.
A lot of catering companies do that.
So I'll even recommend that to patients to kind of ramp it up.
Versus like, OK, you start with maybe pureed, then roasted vegetables, right?
(13:59):
Now, some people might not be able to eat raw carrots and raw celery
because of the disease, whereas others, again, if they are in remission,
they don't have stricturing, they could eat a quite varied diet.
So we do recommend still getting in that fiber.
And like Courtney said, some people have to manipulate that matrix of the fiber
and some individuals can handle more fiber.
So yeah, it has to be very individualized.
(14:20):
And again, Courtney and I both have seen so many people
have seen so many patients that have said, oh, I was diagnosed, you know,
20, 30 years ago, I was told to eat no fiber, no fruits or vegetables.
Right. And then they're having a lot of other issues with blood sugars,
weight and just energy and right there, diets very poor.
Well, and I think it's important to note that, especially when it comes to IBD,
(14:43):
research does show and support that high intake of fruits and vegetables
reduces your risk for flair.
So a high fiber, more of this plant based dietary pattern is shown to be protective.
So trying to make patients where they're at and determining how we can incorporate
these foods. So maybe like Lori said, if they can incorporate more of the roughage,
the raw fruits and vegetables, great.
(15:04):
If they can't, maybe we try something like bean and lentil pastas where you're
getting some of the nutritional value or like hummus.
But it's not like everything's a pureed diet.
So and retrying a lot of these foods too, when you are in remission.
So I think that's the biggest thing I can stress is something that didn't sit
you well when you were in a flair is likely to be a very different experience
(15:25):
when you're in remission.
So you might have some hesitation about adding those foods back in, but trying
one for a few days at a time, one by one can create that exposure therapy that
makes you a little bit more comfortable and it can really help you get a better
sense of what you're able to tolerate in remission.
Well, before I did this call, I Googled very quickly, what should I eat for
(15:47):
digestive diseases? And the internet thinks that I should eat things like
apple cider vinegar and lemon juice and cayenne pepper and various cleanses and
take a whole lot of different supplements that seem to be very expensive.
What do you say to the internet at large?
(16:10):
Are they a great registered dietitian or what kind of information would you say
patients can get from those kind of searches?
Yeah, I mean, I guess I'll start.
I think that, yeah, you have to take it with a grain of salt.
Everyone's going to always have these kind of quick fixes and these hacks,
but unfortunately, like they don't really do the trick, right?
You can spend a lot of money on supplements.
(16:31):
Unfortunately, they're not regulated by the FDA.
So you don't really know what you're getting for the end product.
We have things like our liver and our kidneys and things that should be able to
detoxify our body naturally.
And they do.
So again, making sure people are getting adequate sleep, enough water,
even things like getting enough protein.
I'll explain to patients like if you don't have enough protein in your diet,
(16:52):
that could affect the integrity of your gut, right?
The integrity of all your tissues and your organs throughout the body,
not just your muscle and your hair.
So I think versus saying, oh my gosh, I'm going to go take all these supplements.
I think what we also see a lot is patients are taking a lot of supplements.
They might come in with a big bag of supplements and they'll say, gosh,
I have a stomach ache.
I feel like I'm so full.
I have no appetite.
Well, yeah, you're taking 30 pills a day, right?
(17:12):
So I think it's again, I just had a patient this morning, messaged me back.
I'm so happy I cut down on all those supplements, right?
Because people have really good intentions.
And like you said, they are really trying to help some of their symptoms,
but then they're sometimes self-tab,
attaching with some of these things that are unnecessary.
Well, in the supplement industry is a multi-billion dollar industry for a reason.
And it's one of the leading causes for ER visits each year.
(17:36):
So that's something I always stress to patients is that
there are side effects with a lot of these.
Too much of a good thing is not a good thing.
There was a publication last year about a patient who died from a vitamin D overdose,
which prior to this, we didn't know that the upper limit could be exceeded
and cause such a detrimental side effect.
So that's just one example.
(17:57):
Liver toxicity is a big one.
We see patients that end up with liver damage that's irreversible
from taking too many supplements.
So making sure that you're just taking the ones that are absolutely necessary.
So this is typically just if you have vitamin or mineral deficiencies,
or if you have a part like a digestive disorder that affects absorption,
or you're on a restrictive diet, like a gluten-free diet,
(18:18):
you might need something like a daily multivitamin
to fill in some of those nutrient gaps.
But also making sure that you're choosing third-party tested products.
I stress this every single day in my practice is the USP and then NSF
are two of the organizations you can look for that are labeled on bottles.
And these are third-party organizations that go in and test the product
(18:40):
and look to ensure that it contains what it says it contains
in the doses it says it does.
Some supplements sometimes report a certain amount
and it's a lot more that's actually in the product.
So you can end up with an overdose of a certain nutrient
and didn't even know you were taking that because like Lori said,
the FDA does not regulate these supplements.
Yeah, so maybe easier to get from the garden or the grocery store
(19:03):
than from a bottle.
Though a bottle would be wonderful.
What would you say if you could really tell your patients
one thing about diet nutrition?
What's like the one big takeaway you'd like them to know from you,
from your combined almost 25 years of expertise?
If there was one message you wanted to share, what would it be?
Yeah, I mean, I think that food and your diet is very like interrelated
(19:28):
with so much of your life, right?
So social, all of that.
So I think that the goal is really to help increase quality of life
and not feel overly restricted because a lot of these different diseases
or things could be restricting.
So I always try to look on the bright side a lot of times.
Mine kind of boils down to quality of life as well.
So I think if you are restricting your diet so much as a means
(19:51):
to control your symptoms, but it's impaired your mental health,
your ability to socialize, interact with others,
you're feeling depressed or anxious about your eating behaviors,
that tends to mean that the diet is not the appropriate approach for you.
And despite the fact that Lori and I very frequently preach
all the things we can do with diet and nutrition,
sometimes diet is not the answer, especially in the realm of digestive disorders.
(20:15):
We have other approaches.
We have GI psychologists where maybe diet isn't appropriate
and working with a GI psychologist would be more beneficial for those individuals.
There's also medications that can frequently help improve your diet.
Help improve symptom control without having to overly manipulate your diet
where it's greatly impacting your quality of life.
So even though diet should be used as an adjunct, it's not our only approach.
(20:38):
Well, unfortunately, my advice is that people need to see Lori and Courtney
and our other RDs because I think that's the biggest takeaway for me
is I want every patient with a digestive disease to talk to one of you
and just get at least that assessment, that conversation,
begin that process because I know how vital it is.
And we all have to eat every day, right?
(20:58):
You have to eat so many times a day.
My children think they need to eat a lot more than they do.
Certainly snacks and candies and cookies and cakes.
This is like bonus for myself.
What kind of diets do you guys have?
I'm always curious to know what dieticians eat.
I think everybody is.
What kind of diet do you eat?
Courtney, I follow you on Instagram.
(21:19):
I know you're kind of a foodie.
What's your personal philosophy about food?
All foods fit, anything and everything can fit within a balanced diet.
So I think we all as dieticians frequently preach,
try to incorporate more whole foods.
So things that don't have a laundry list of ingredients.
This is going to be fruits and vegetables, legumes,
lean proteins, unprocessed proteins,
(21:42):
but also that food is a social part of our lives as well.
So being able to go out to eat, indulge in things without a restrictive mindset,
I also think is my personal philosophy is I like dining out.
That's probably a highlight of my week is going out with my significant other
and eating out and enjoying new cuisine.
But then also majority of the week we're focusing on preparing foods at home
(22:06):
with simplistic ingredients that provide a good variety of that rainbow,
the fruits and vegetables and lots of color.
I wish I had your life, your life, the dining out life
that at least you share on the gram is very inspiring.
Lori, how about you?
She's pre-kids too, so that's another.
I know she's pre-kids.
Pre-kids.
Now I have to look to forever.
Wow, you know, like kid menus are right.
(22:28):
So it's a challenge.
I think that, yeah.
But yeah, and again, I have celiac disease, fortunately, unfortunately.
I've been diagnosed about eight years ago.
So I just follow a gluten-free diet, but I eat all the other things, right?
So I eat, I don't risk anything else besides that.
I love food and like I'm always like, oh my gosh, where am I going to go to eat next?
So my friends always make fun of me because I'm always on a mission to try
(22:50):
different gluten-free things.
Whether it's fried foods that are gluten-free,
because that's another thing I'm very restricted on.
I can't eat out of fried regular fryers.
So that's something I like get excited about.
And yeah, I agree with Courtney.
I eat like all foods.
I have a sweet tooth.
So again, I always, I think a lot of my recommendations of patients
are things that I also have experienced.
(23:12):
And again, we say like making sure that, yeah, you're satisfied.
Are you eating things that are making you feeling satiated, right?
Otherwise you're just going to say, forget it.
I'm just going to eat whatever, right?
So I think it's all about.
Oh, yeah.
Well, I have had such a great time knowing you and eating with you guys
and going to have our events with you.
(23:33):
And I know that you speak the truth.
You live that truth and it's really inspiring.
And it helps remind us that like the people who really know this treat food
the way that it should be part of your life
as something that really brings joy and brings a lot of fulfillment and happiness
as well as doesn't make you sick.
So that's very helpful to hear.
(23:55):
I want to just want to say thank you guys so much for being here today.
This is, I know that you are so busy all the time and just taking the time to talk to us
and share some of your wisdom is just such a gift.
And we will have more, I'm sure more conversations in the future
because everybody likes to talk about food.
And you guys really know everything that we need to share.
(24:18):
Thank you guys so much.
Thank you.
Thank you for listening to this episode of the podcast,
Fisero from the GI Research Foundation.
This episode was written and produced by me, Anna Gomberg,
and edited and mixed by the incredible Mike Collins-Dowden,
who also composed our theme music.
We hope you will join us next time.
Until then, to access other podcasts and learn more about research to treat, prevent,
(24:38):
and cure digestive diseases, as well as access to our online course
as well as access additional educational materials,
please visit the website at giresearchfoundation.org
and follow us on Facebook, Twitter, and LinkedIn.
Thank you again to Abbvie for making this podcast possible.
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