The gut-brain axis is a topic of interest in fields from neurology and gastroenterology to psychology and integrative and functional medicine. While most available evidence on the gut-brain axis comes from animal studies, emerging human research is providing valuable insights into the complex integration of psychology and physiology of the human body.

The gut is a busy place. Not only does it house the influential microbiome, it also includes immune cells, neuropeptides, microbial metabolites and enteroendocrine cells, which secrete hormones. The vagus nerve is a key connection point linking the brain and gut, while nerves along the gut allow for direct communication with contents of the stomach and intestine.

The digestive tract is one of the major entry points for external substances, from food and supplements to drugs and bacteria. These substances all have the potential to impact the gut-brain axis.

Intestinal permeability refers to the physical gaps between intestinal cells, which is thought to be partly regulated by the microbiome. The term “leaky gut” was coined to describe when those gaps are enlarged and external substances and waste products are allowed to pass into the bloodstream. This has been associated with changes in mood, immune function and inflammation. Intestinal permeability may be associated with numerous conditions including inflammatory bowel disease and autoimmune disorders such as Type 1 diabetes and celiac disease.

“RDNs can play an integral role in preventing and repairing intestinal permeability,” says Mary Purdy, MS, RDN, the 2017- 2018 chair of the Academy’s Dietitians in Integrative and Functional Medicine dietetic practice group. According to Purdy, consuming adequate amounts of vitamins A and D, with plentiful dietary fiber, prebiotics and probiotics to keep the gut microbiota healthy, can maintain and improve the integrity of the gut.

It also is becoming clear that the microbiome can influence its host’s appetite and eating behavior. Animal and human research has found a link between specific species of microbes and increased host intake of nutrients that the microbes prefer. “Cravings and feelings of hunger we experience may not be just our own,” says April N. Winslow, MS, RDN, CEDRD, who is working toward her doctorate in food science and human nutrition with an emphasis in nutritional neuropsychology.

The metabolites microbes produce and the neurochemicals they influence impact secretion of satiety-promoting hormones; researchers suspect the microbiome also can influence taste, smell, thoughts, impulsivity and compulsivity about food. Short-chain fatty acids, a major metabolite of gut microbes, and their possible link to obesity and metabolic syndrome are an active area of research. In fact, administering the short-chain fatty acid proprionate to the colon of adults who are overweight led to greater satiety hormone release and reduced calorie intake and weight gain.

Disrupting the gut-brain axis already is used as a treatment for obesity through Roux-en-Y gastric bypass surgery, a restrictive and malabsorptive intervention that in 2015 accounted for an estimated 23 percent of bariatric surgeries. This surgery is unique compared to purely gastric restrictive bariatric surgeries, such as laparoscopic adjustable gastric banding, because part of the stomach is stapled off and attached to the middle part of the small intestine, bypassing the lower portion of the stomach and parts of the small intestine. This may affect not only the absorption of certain micronutrients, but also hunger and satiety hormones.

People who undergo gastric bypass surgery tend not to experience the same increase in the hunger hormone ghrelin as people who achieve non-surgical weight loss through diet and exercise alone. Bariatric experts suspect this is a major contributor to the success of the surgery. In addition, sometimes the vagus nerve is severed during gastric bypass surgery, which could affect hunger hormones and innervation of the gut, therefore impacting appetite.

Nina Crowley, PhD, RDN, LD, metabolic and bariatric surgery program coordinator at the Medical University of South Carolina, says it is imperative to counsel bariatric candidates on the mechanisms at work in various bariatric surgeries, how they differ and how this impacts metabolism. “I like to discuss how the change in gut hormones may be what is required for them to see a metabolic change, and keep a focus on biology, rather than blaming the person for their eating habits or behavior,” Crowley says.

When the body is underfed, such as with bariatric surgery recovery and anorexia nervosa, gut microbiota composition and diversity changes. This has been correlated with depression and anxiety in people with anorexia nervosa and may be related to the fact that 95 percent of the neurotransmitter serotonin, which plays a role in depression, is produced in the gut.

Research is examining what happens when fecal samples from people with anorexia nervosa are transplanted into mice born in a germ-free environment, compared to what happens when fecal samples from healthy people are transplanted into germ-free mice. This science serves as a foundation for potential new treatments for anorexia nervosa as well as furthering the understanding of the underlying mechanisms of this complex disease.

There is not enough evidence to explain the role of the gut-brain axis in binge-eating disorder, although some researchers suspect the gut microbiome’s impact on impulsivity and compulsivity may play a role.

While research on the gut microbiome is booming, human research is needed on other parts of the gut-brain axis, especially as it pertains to risk and development of psychological and chronic disease. As more human evidence becomes available, novel intervention strategies involving food and nutrition likely will come to light.

“Registered dietitian nutritionists are the ideal medical professionals to lead research in this area because they have the training and skills to obtain nutritional data from human participants and conduct motivational interviewing,” Winslow says.

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Then, TV personality Elisabeth Hasselbeck published The G-free Diet (Center Street 2011), President Bill Clinton promoted his post-heart-surgery gluten-free diet on “The Ellen DeGeneres Show,” Paleo and Wheat Belly (Rodale Books 2014) hit the scene, and a billion-dollar industry was born.

At the time, the scientific community accepted celiac disease as the only adverse reaction to gluten — despite that individuals who tested negative for the autoimmune disease were reporting celiac-like symptoms (“foggy mind,” depression, ADHD-like behavior, abdominal pain, bloating, diarrhea, constipation, headaches, bone or joint pain and chronic fatigue). Eventually new research suggested a spectrum of non-celiac gluten-related disorders that improve when gluten is removed from the diet — now known as non-celiac gluten sensitivity or non-celiac wheat sensitivity.

Today, adults in the U.S. are increasingly self-reporting food allergies without a diagnosis from a doctor. Consumers around the globe are experimenting with elimination diets as a means to identify causal association with symptoms ranging from gut distress to joint pain, lethargy or depression.

Most health practitioners, and registered dietitian nutritionists in particular, do not advocate unnecessary restrictive dieting. Nonetheless, many consumers are finding relief through elimination diets — and the scientific community isn’t sure why.

Confusion over what causes certain responses to foods is a culmination of heated debate among medical researchers, vague terminology with conflicting definitions, gaps in research and, arguably, the inherent discomfort of “the unknown.”

Let’s Start with the Known

A food allergy exists when exposure to a specific food results in an adverse response in the immune system. Because a one-time reaction is not definitive, a criterion for a food allergy is that the immune response be reproducible.

Symptoms range from mild itching and hives to severe anaphylaxis, which can cause difficulty breathing, dizziness, loss of consciousness or death.

Most food allergies are IgEmediated, meaning the immune system identifies an allergen as an “invader” and overreacts by producing antibodies called immunoglobulin E. However, some food allergies — such as eosinophilic GI disease and protein-induced enterocolitis — are not IgE-mediated.

A food intolerance refers to malabsorption in the digestive tract and does not involve the immune system. The inability to break down certain foods may be the result of enzyme deficiencies or reactions to naturally occurring chemicals in foods. Unlike food allergies (in which even a microscopic morsel of an allergen can cause an adverse reaction), food intolerances are dose dependent: the more one eats of the offensive food, the worse the symptoms — usually along the lines of nausea, stomach pains, vomiting and diarrhea.

Here is Where it Gets Tricky

There also appear to be adverse food reactions that do not fit current diagnostic criteria for food allergies or food intolerances. Some practitioners refer to these as food sensitivities; however, food sensitivity has no universally accepted definition — and to compound confusion, the term has different meanings, depending on who you ask.

For example, the American Academy of Allergy, Asthma and Immunology uses “food sensitivity” interchangeably with intolerance. According to the Guidelines for the Diagnosis and Management of Food Allergy in the United States, the term “food hypersensitivity” often is used to describe food allergies, while other groups use “food sensitivity” as an umbrella term that includes both allergies and intolerances. And a 2012 study in the Canadian Medical Association Journal defines “food sensitivity” as “a nonspecific term that can include any symptom perceived to be related to food and thus may be subject to a wide range of usage and interpretation.”

These mysterious non-allergic adverse food reactions have many practitioners perplexed.

For example, take sulfite sensitivity, which is more common in people with asthma, especially those taking steroid medications. Reported symptoms include respiratory reactions and asthma, hypotension, GI reactions, dizziness and hives. Currently there are no validated lab tests to diagnose a sulfite sensitivity and the mechanism is yet to be determined. Medical history, symptom diaries and controlled exposure to test for reactions (known as an oral challenge) are used to make the diagnosis.

Other reports of triggers for adverse food reactions run the gamut, including various fruits and vegetables, grains, protein foods and dairy. Often these cases have already gone through allergy testing, excluded GI health conditions and exhausted diagnostic processes by physicians, including general practitioners, endocrinologists, gastroenterologists and allergists.

Debra Indorato, RDN, LDN, CLT, a nutrition and food management consultant in Tampa, Fla., has specialized in food allergies for nearly 30 years. It was early in her career when some of her referrals experienced persistent symptoms, even after testing negative for food allergies, and she began researching food sensitivities and immunology. Her personal working definition for food sensitivity is “a nonallergic inflammatory reaction that can affect any area of the body.” But identifying such a broad, enigmatic occurrence of inconsistent, overlapping symptoms is a challenge.

Food allergy assessment tools — skin pricks or the double-blind, placebo-controlled food challenge — are not applicable for these cases since allergic reactions are immediate and often dramatic, while “food sensitivities” are delayed and hit-or-miss. Carbohydrate intolerances, such as lactose intolerance, can be diagnosed with a hydrogen breath test or fecal test, while blood tests, endoscopies or biopsies may be used to rule out other conditions.

In an attempt to identify specific foods to which individuals are sensitive, medical testing companies have developed various proprietary blood panels. Some measure antibodies in the blood, such as the “IgG test” (which, since IgG is a “memory antibody,” actually only confirms exposure to a food, not a reaction to it). Others are centered on studying white blood cells as an indication of an inflammatory response — including the Alcat test and the enzyme-linked immunosorbent assay, or ELISA.

Recently, the mediator release test, or MRT, has gained favor among some practitioners, including a segment of registered dietitian nutritionists who then implement the Lifestyle Eating and Performance, or LEAP, diet based on the assay results. The MRT measures levels of cytokines, histamine, leukotrienes, prostaglandins and other mediators released from white blood cells after exposure to 150 foods and food chemical profiles. MRT supporters cite evidence indicating correlations between the immune system mediators, ensuing inflammation and risk of chronic disease such as osteoporosis and cardiovascular disease, as well as other conditions including GERD and cognitive decline. But while there is plenty of anecdotal vouching for MRT’s effectiveness in identifying potential sensitivities, there are no peer-reviewed, published studies validating the test.

Laura Matarese, PhD, RDN, LDN, CNSC, professor at the Brody School of Medicine at East Carolina University and co-editor of The Health Professional’s Guide to Gastrointestinal Nutrition (Healthy Nutrition Academy 2013), says that in addition to the lack of research, there also is no consensus or endorsement of food sensitivity panels by any allergy or immunology organizations, noting that most insurance companies will not cover them.

Janice Vickerstaff Joneja, professor at the School of Family and Nutritional Sciences at the University of British Columbia and author of The Health Professional’s Guide to Food Allergies and Intolerances (Healthy Nutrition Academy 2014), also is an MRT skeptic. However, she says the elimination and challenge components of LEAP therapy are useful.

Los Angeles-based consultant Christine Bou Sleiman, MS, RDN, CLT, has been a certified LEAP therapist since 2016 and experienced significant improvements in her own digestive health and inflammatory skin disorder since following the immune-calm LEAP protocol. “The MRT gives us a starting point, rather than taking a stab in the dark,” she says, “especially when many of these referrals are already on some form of elimination diet.” Bou Sleiman adds that she sees profound symptom relief in her clients and often helps increase the variety of foods in their diets.

Still, Emily Fonnesbeck, RD, CD, CLT, says that practitioners need to understand clients’ underlying issues, such as disordered eating, that may be exacerbated by an elimination diet. Before she suggests food sensitivity testing, Fonnesbeck works with new clients to identify potential causes of the symptoms and address primary issues, such as the stress caused by not being able to pinpoint why they don’t feel well.

“Even for clients who feel better on the elimination diet, it is difficult to know exactly why they are seeing benefits,” Fonnesbeck says. After all, the virtue of being more mindful about eating may in itself help ease physical symptoms.

A study in the journal Social Science and Medicine explored the perspectives of British general practitioners when confronted with patients who believe they are experiencing adverse reactions to certain foods. Although working with the patients’ beliefs was seen as important to preserving the doctor-patient relationship, skepticism among the physicians was strong.

However, it was “tempered by an element of self-awareness and an awareness of the limitation of modern medicine,” wrote the authors. “With the transitional nature and constant evolution of medical knowledge, several of the participants entertained the idea that this condition might be recognized and understood in the future.”

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There is no concrete evidence to support the use of activated charcoal to lower cholesterol, decrease flatulence, remedy hangovers or help the body “detox.” It can bind nutrients in the digestive tract, prevent absorption of prescribed medicines, lead to constipation and is not advisable for consumption without instruction from a medical provider.

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According to National Health and Nutrition Examination Survey data, obesity in adults more than doubled over half a century — from 13.4 percent in 1962 to 38.2 percent in 2014 — and the National Bureau of Economic Research reports the estimated annual health care costs of obesity-related illness to be nearly 21 percent of annual medical spending in the United States.

With links between higher body mass index and increased risk for disease, including Type 2 diabetes, cardiovascular disease and certain cancers, public health messaging to the masses and patient advice from medical practitioners have centered on weight loss as both prevention and treatment for many chronic diseases. However, there isn’t a single therapy (dietary, surgical, pharmaceutical or otherwise) that has been shown to sustain long-term weight-loss maintenance in a significant number of people.

Researchers are only just beginning to understand the myriad factors that affect body weight and body fat, including genetics, hormones, medications, diseases, age, sleep, stress, environmental pollutants, sex, ethnicity, socioeconomic status, dietary quality and physical activity. And some epidemiological studies actually support conflicting theories on body weight and health.

For example, the “Obesity Paradox” refers to the anomaly of some people with BMIs in the overweight and obese categories, especially older adults and even with chronic disease, outliving people with normal BMIs.

“In general, there is a strong relationship between BMI and health outcomes,” says Hollie Raynor, PhD, RD, LDN, obesity researcher and co-author of the Academy’s 2016 position paper on interventions for the treatment of overweight and obesity in adults, “but there are individual differences.” Among limitations inherent to epidemiological research, according to Raynor, is that studies correlating body weight and morbidity and mortality may not control for moderating factors affecting disease risk, such as high intake of calorie-rich, low nutrient-dense foods, low intakes of nutrient-dense foods, physical inactivity and smoking.

Other concepts — including “metabolically healthy obesity” (individuals with BMIs of 30 or higher who have normal blood lipids, blood sugar and insulin levels) and “metabolically obese normal weight” (people with normal BMIs and negative health outcomes) — are countered by a much higher proportion of people with obese BMIs who are not metabolically healthy.

However, it is well recognized in behavioral health research that weight stigma (stereotyping and bias based on one’s size) is associated with increased calorie consumption and binge eating, negative body image, depression, greater likelihood of becoming obese, and reduced desire to engage in healthy behaviors.

Other studies suggest that a focus on weight in health care settings may increase false positives and negatives. For instance, if physicians look for certain diseases in patients with overweight or obese BMIs but not in individuals with normal BMIs, some conditions may be overdiagnosed in larger people or underdiagnosed in smaller people.

According to a 2014 review of unintended harm associated with public health interventions, weight loss messaging is not only ineffective, but actually can promote body dissatisfaction and disordered eating. Campaigns centered on healthy behaviors without mention of weight are better received and are more likely to result in healthy behaviors among targets, wrote the authors.

Enter the “weight-neutral” movement: a therapeutic approach to improving the health of individuals by focusing less on BMI, and more on lifestyle behaviors.

“In light of having no validated methods to help more than a small number of people lose weight and keep it off,” says Marci Evans, RD, CEDRD, CPT, who specializes in body image issues and emotional eating, “we need to use tools that will enhance clients’ health at their current weight without causing more harm — remembering to consider long-term harm as well.”

Some evidence suggests dietary restriction and a history of weight loss are associated with eating disorders. In addition, a key concern cited by weight-neutral proponents is that dietary restriction often leads to weight cycling — repeated gain and loss of weight — rather than sustained weight loss. Some research associates weight cycling with loss of lean body mass, reduced metabolic energy expenditure, increased inflammation, hypertension, insulin resistance, dyslipidemia, osteoporotic fracture, some types of cancer, cardiovascular risk, mortality risk and emotional distress. Other studies suggest weight cycling is more strongly linked with certain adverse health outcomes than is having an obese BMI.

But many obesity researchers do not agree with these conclusions, citing studies that show losing even 3 percent to 5 percent of body weight reduces some health risks in people with elevated BMIs.

“Lifestyle interventions that include dietary, physical activity and behavior components typically do not lead to eating disorders,” says Raynor, adding that structured eating can even help with bulimia nervosa and binge-eating disorder — although robust, multidisciplinary intervention programs designed by researchers may not be accessible for many people or covered by insurance.

On the other hand, there is limited research on the efficacy of weight-neutral interventions; although some studies have found significantly better physiological, behavioral and psychological outcomes compared to weight-centric models and dieting, including low dropout rates and no adverse events, those study samples were small and did not include individuals classified as morbidly obese. Other criticisms include that a weight-neutral approach gives people a “free pass” to engage in unhealthy lifestyle behaviors — and that weight loss should be pursued as soon as possible for people with obese BMIs.

But weight neutrality is not in conflict with, and actually helps support, the Nutrition Care Process, according to Jennifer McGurk, RDN, CDN, CDE, CEDRD, who advocates for the inclusion of weight-neutral concepts in continuing professional education for registered dietitian nutritionists.

“Many weight management trainings do not address binge-eating disorder,” says McGurk of a behavior that is prevalent in up to 30 percent of people seeking weight loss treatment. “Behavioral health is a critical component of health care, yet many weight management approaches address food and diet only — without taking into consideration individuals’ genetic predispositions, preferences and feelings surrounding food.”

Evans agrees, adding that while dietetics is grounded in compassion and individualized care, there is tremendous pressure as practitioners to focus on weight loss. “As registered dietitian nutritionists, we need to self-assess,” says Evans, “And determine whether an intervention will truly improve a client’s health, or if it comes from a desire to make them smaller.”

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Physicians David Jenkins and Thomas Wolever invented the glycemic index in 1981 by first plotting curves to show how a specific amount of glucose raised study participants’ blood sugar over two hours. Then they had participants consume the same amount of carbohydrate via foods and plotted the resulting rise in blood sugar. A food’s glycemic index is the percent by which it raises blood sugar compared to glucose and is expressed on a scale of 0 to 100. 

During the next several years, Jenkins and Wolever published additional studies with participants from various populations, including healthy adults and people with hyperlipidemia and diabetes. Glycemic index seemed to be a useful tool for people with diabetes to control blood sugar, as well as a way to lower cholesterol and triglycerides in people with high blood lipids. Additionally, Wolever found when healthy adults consumed low-glycemic index meals for dinner, they tended to experience lower glycemic responses to carbohydrates at breakfast the next day than they did when they had high-glycemic index meals at dinner. 

A main criticism of the glycemic index is that people usually consume a variety of foods in a single meal. Since a balanced meal typically contains a blend of foods with different glycemic indices, the glycemic index of an individual food in a total meal may be insignificant. Jenkins and Wolever addressed these concerns in a 1986 study showing how a meal’s glycemic index may be calculated. Research participants experienced expected rises in blood sugar based on calculated glycemic indices of the meals they ate. 

More recently, studies have addressed glycemic index in a variety of populations with differing results. In 2002, Jenkins authored a review paper promoting a low-glycemic index diet for people with diabetes and for reducing cardiovascular disease risk. For individuals with diabetes, the American Diabetes Association says the glycemic index may be used to help fine-tune blood sugar, but the amount of carbohydrate a food contains is more important than its glycemic index. The Healthy Nutrition Academy’ Nutrition Care Manual includes information on glycemic index as an alternative to the ketogenic diet for people with epilepsy.  

Emerging evidence suggests a low-glycemic diet may help improve insulin sensitivity in children with obesity and elevated insulin. The 2013 International Carbohydrate Quality Consortium, convened by the Glycemic Index Foundation, asserts glycemic index is a valid strategy for controlling blood sugar in healthy adults and it can be used to prevent diabetes, heart disease and obesity. However, the Natural Medicines Database says there is insufficient evidence to rate claims for the glycemic index. Additionally, the 2015-2020 Dietary Guidelines for Americans do not mention glycemic index, leading one to reason it is not of concern for the average, healthy American. 

Using the glycemic index as a weight-loss strategy lacks strong evidence. When used in addition to caloric restriction, a low-glycemic index diet can produce weight loss. However, one of the diet’s modern selling points is users don’t have to count calories and can still lose weight, which is a claim yet to be supported. A 2015 study of 91 adults with obesity found a low-glycemic index diet had no effect on weight loss, fat mass, lean mass nor metabolic adaptation during a 17-week weight-loss period compared to an isocaloric high-glycemic index diet. But a small 2013 study found when participants consumed high-glycemic index meals, they experienced increased hunger and cravings. 

Skepticism about using the glycemic index as a dietary tool exists for several reasons. The glycemic index of a food tells nothing about its nutritional qualities. For instance, watermelon has a higher glycemic index than ice cream, but most would say watermelon is a more nutritious option and may be eaten by people with diabetes, without need for concern, in accordance with their carbohydrate patterns. Academy spokesperson Jim White, RDN, ACSMEP- C, says he sees clients who are afraid to eat nutritious high-glycemic index foods such as potatoes, melon or pineapple, but these foods should not be avoided. When it comes to healthy eating, following the key recommendations of the Dietary Guidelines while using a total diet approach and MyPlate are more realistic and applicable strategies for most people. 

Academy spokesperson Marina Chaparro, MPH, RDN, LD, CDE, finds the glycemic index to be too variable and impractical to recommend to her clients with diabetes. Both Chaparro and White suggest clients use glycemic load, rather than glycemic index, to take portion size into account. “I teach my clients to focus on wholesome food, learn how to count carbs and focus on the right portion size,” Chaparro says. 

Although the glycemic index is not perfect, it can be a useful tool in addition to evidence-based strategies for controlling blood sugar in people with or at risk for diabetes, as long as they are not unnecessarily restricting foods. Prediabetes and diabetes are not caused by eating high-glycemic foods; they are complex diseases with a variety of risk factors, including other dietary variables, activity level, age, race, sex and family history. A wellness plan including assessment of all these factors helps health care professionals develop individualized strategies for patients and clients. 

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As it turns out, these claims are backed by little science and likely surfaced due to spirulina’s impressive nutrient profile. One ounce, or approximately 4 tablespoons, of dried spirulina contains 81 calories, 16 grams of protein, 60 percent of the daily value of riboflavin, 44 percent of the daily value of iron and thiamin, 14 percent of the daily value of magnesium and 11 percent of the daily value of potassium.

The Natural Medicines Comprehensive Database lists all health claims associated with spirulina as having insufficient evidence to rate, and warns that women who are pregnant or breast-feeding should avoid it. There also is some evidence that spirulina could interact with anticoagulant, antiplatelet and immunosuppressant drugs. Due to its high protein content, people with phenylketonuria, or PKU, should not consume spirulina.

After the Natural Medicines monograph was updated in 2015, a double-blind, placebo-controlled, randomized trial of 40 individuals with hypertension was published in 2016. It found that consuming 2 grams of spirulina for three months led to improved BMI, body weight and blood pressure in this small sample. While spirulina is very protein-dense and these results seem promising, there is not enough information at this time to recommend it as a supplement for specific health conditions.

Due to its growing popularity, spirulina is cultivated in ponds and mass-produced all over the world, including Hawaii and China. Spirulina’s distinctive and strong seaweed flavor leads many people to consume it via capsule, while others mix the powder form into water, juice or smoothies. Contamination by toxins and heavy metals is a serious concern, so it is important to choose a spirulina supplement with reliable third-party testing and quality assurance. 

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While diet does not cause IBS, individualized nutrition therapy can significantly lessen symptoms through identification and restriction of trigger foods. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols, or FODMAPs, have been identified as a group of short-chain carbohydrates that are rapidly digested and poorly absorbed in the gut, thus provoking excess fluid and gas in the bowels of many people with IBS. FODMAPs are naturally occurring carbohydrates found in foods such as apples, watermelon, asparagus, broccoli, milk and beans and are sometimes added to food as sweeteners.

Although some carbohydrates under the FODMAP umbrella, such as lactose and fructose, have been targeted in IBS therapy in the past, research on diet therapy addressing all FODMAPs as a group only began within the last decade. Research started in Australia in 2006, and subsequent studies have occurred elsewhere, including the United Kingdom, New Zealand, Scandinavia and the U.S. The results have been clear: When people with IBS consumed high amounts of FODMAPs, their symptoms got worse; when they restricted FODMAPS, their symptoms improved.

Now with enough evidence to support its use, a low-FODMAP diet is recommended as a nutrition prescription for patients with IBS in the Academy of Nutrition and Dietitics' Nutrition Care Manual. Client education materials for a low-FODMAP diet will be available in the NCM later this year.

Nonetheless, doctors caution that low-FODMAP diet therapy is not a cure for patients with IBS. Individual response to the diet varies, and some people with IBS experience little relief from following a low-FODMAP diet. And while a low-

FODMAP diet produces significant results in most IBS patients, it doesn't always eliminate all symptoms. For instance, some patients may experience relief from gas and bloating, but their irregular bowel patterns remain.

FODMAP expert Patsy Catsos, MS, RDN, LD, began using low-FODMAP diet therapy in her private practice almost a decade ago. To date, she has helped thousands of patients through the diet and says that "the FODMAP elimination diet is more than just a list of foods — it's a process. To get the best outcomes, patients need a strategic plan, and that's where the dietitian comes in."

One concern about following a low-FODMAP diet is the effect it may have on a patient's gut microbiota. Evidence shows IBS patients have different gut microbiomes compared to the healthy population. Preliminary research suggests taking a probiotic supplement during low-FODMAP diet therapy can prevent the washout of beneficial gut bacteria, leading some FODMAP experts to recommend this type of supplement to people with IBS on the diet.

In addition to IBS, limited evidence shows promise of a low-FODMAP diet for people with inflammatory bowel disease, which is a separate medical condition (an autoimmune disease characterized by chronic inflammation; includes Crohn's disease and ulcerative colitis). Some researchers suspect a low-FODMAP diet may help alleviate digestive symptoms in people with non-celiac wheat sensitivity, but the diet has not been validated in this population.

Not all FODMAP-containing foods worsen IBS symptoms for all patients, which is why the diet therapy is conducted in two phases. To identify specific foods that trigger symptoms in a patient, phase 1 restricts all high-FODMAP foods and phase 2 gradually reintroduces them.

Phase 1 typically lasts up to eight weeks and is when patients feel most challenged by the restrictiveness of the diet. Elimination and reintroduction of FODMAP-containing foods is the only effective strategy to identify trigger foods in patients with IBS. Reliable assessment methods such as hydrogen breath tests are available to detect some, but not all, FODMAP malabsorption, but these tests are capable of false positives and are not perfect. Because long-term evidence is not available and there is a risk of nutritional inadequacy if the diet is poorly planned, restricting high-FODMAP foods should be temporary and reintroduction should be as quick as possible in accordance with the patient's symptoms.

Patients and physicians should work with an RDN who is trained in administering a low-FODMAP diet to ensure the success of the nutritional therapy. According to low-FODMAP diet educator Kate Scarlata, RDN, LDN, "The low-FODMAP diet has many nuances, and online resources are often outdated, making the IBS patient confused and frustrated. The role of the dietitian is to be well-prepared with the latest and most accurate low-FODMAP diet research to successfully guide the patient with this effective nutrition intervention." While research shows good patient compliance of about 75 percent following the diet, it is restrictive by nature.

Barriers include expense of low-FODMAP specialty foods, dislike for the taste, unwillingness to follow the diet and the challenge of identifying and selecting low-FODMAP foods when eating away from home. Additional challenges are the lack of defined cutoff values for high- and low-FODMAP foods and shortage of FODMAP content on food packaging.

Two voluntary certifications for low-FODMAP food products are available, one from Monash University and the other from FODMAP Friendly, both of which have access to FODMAP laboratories to conduct food testing. These seals are on few products in grocery stores today, but likely will increase as the diet gains popularity. Dietitians interested in learning more about FODMAP diet therapy are encouraged to read books by reputable FODMAP experts, seek continuing education opportunities such as workshops and trainings led by FODMAP experts and use the Monash University low-FODMAP diet app.

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Not only are there many other nutrients involved in developing and maintaining bone, but also exercise is imperative. People who exercise more have higher peak bone mass, and research suggests exercise plays just as important a role in bone health as nutrition.

Like muscles, bones are living tissue, and they require stress to stimulate growth and maintain integrity. Just as consuming extra protein without exercising will not result in strong muscles, consuming calcium without exercising will not result in optimal bone mass. Consider astronauts floating around in a spacecraft with little to no gravity — they experience significant bone mineral loss. But when astronauts participate in heavy resistance exercise, bone loss is reduced.

Exercise positively affects bone health in a number of ways. High-impact exercise has a site-specific effect on bones, meaning the area of the body worked in the exercise is where the most benefit is seen.

Stress in the form of a load stimulates calcium uptake and new bone formation, especially in children. Exercise also promotes stronger muscles and enhances coordination and balance, thus reducing the risk of falling and possibly fracturing a bone.

According to the National Osteoporosis Foundation's 2016 position statement on peak bone mass development and lifestyle factors, lifestyle behaviors affect 20 percent to 40 percent of adult peak bone mass, and only calcium intake and exercise received evidence with a grade A. All other lifestyle factors — including intakes of vitamin D, dairy and protein, and smoking — received lower grades, suggesting they do not have as significant an impact on bone health as calcium and exercise.

It's important to note that all forms of exercise are not equal when it comes to bone health. Weight-bearing exercise provides the stress load that bones need to stimulate mineral uptake. While this does occur in both children and adults, weight-bearing exercise is particularly important early in life as the most significant gains in bone mass are made during puberty. A 2014 meta-analysis found that weight-bearing activities in conjunction with high calcium intake resulted in optimal bone mineral content among prepubertal children.

Exercise is important for maintaining healthy mature bones, too. The impact of weight-bearing exercise on bone mineral density of premenopausal women is significant, and in healthy young men, even short-term exercise can boost bone mineral density. Analyses of National Health and Nutrition Examination Survey data found that the impact of physical activity on bone density and risk of osteoporosis is significant even when controlling for factors such as age, sex, race and ethnicity, body mass index, calcium and vitamin D intake, tobacco use and socioeconomic status.

Even postmenopausal women, who are at a particularly increased risk for osteoporosis, experience an increase in bone density from performing resistance exercises. Additionally, studies of osteopenia rehabilitation programs demonstrate feasibility and effectiveness of exercise on bone mineral density.

According to the National Institutes of Health, children between 6 and 17 should get 60 minutes of activity per day with bone-strengthening activities three days a week. Bone-strengthening activities for children include walking, jogging or running; playing tennis, racquetball, soccer, basketball or hockey; climbing stairs; jumping rope or other types of jumping; dancing; hiking; and lifting weights. While there are no specific recommendations for children younger than 6, the NIH recommends they play actively several times a day.

The National Osteoporosis Foundation recommends adults engage in weight-bearing exercise for 30 minutes most days of the week, with muscle-strengthening activities two to three days per week and balance, posture and functional exercises every day. Similarly, the surgeon general recommends daily physical activity with strength-building and balance-enhancing activities at least twice per week. Regarding type and duration, the surgeon general notes that five to 10 minutes of high-impact, load-bearing exercises may be sufficient, while 30 to 45 minutes of lower-impact exercises are needed to effectively impact bone health.

When discussing bone health with patients and clients, registered dietitian nutritionists should assess physical activity behaviors and reinforce physical activity recommendations to promote bone health. RDNs may find explaining cardiovascular and musculoskeletal benefits of exercise to clients while de-emphasizing weight and image-related motivations for exercising may increase clients' motivation and adherence.

While RDNs are qualified to communicate physical activity guidelines, clients interested in learning advanced exercises or starting new exercise regimens should consider working with a certified fitness professional, such as an American College of Sports Medicine-certified personal trainer or certified exercise physiologist. For specific guidance on balance, posture and functional exercises, a physical therapist should be consulted.

The post Built to the Bone: Why Weight-Bearing Exercise Is Key to Strong Bones appeared first on HealthStylz.

The public health push to reduce sodium intake is not exactly new. The first Dietary Guidelines for Americans, published in 1980, encouraged Americans to “avoid too much sodium,” and every edition since has included a key recommendation on limiting sodium in the diet.

The 2015 Dietary Guidelines recommends consuming less than 2,300 milligrams of sodium per day, and no more than 1,500 milligrams per day for individuals with prehypertension and hypertension. The Institute of Medicine agrees that limiting sodium improves high blood pressure but states there is insufficient evidence to recommend the entire population go low-sodium — pointing to a link to adverse health outcomes in some individuals. And currently, the American Heart Association recommends everyone consume no more than 1,500 milligrams of sodium per day.

The History Behind Dietary Sodium Research

To understand the evolution of these recommendations requires a brief summary of dietary sodium research. In the middle of the 20th century, strong evidence first emerged in favor of restricting sodium to combat hypertension. A series of studies from the 1980s and 1990s, called Trials of Hypertension Prevention (or TOHP) provided additional data in favor of limiting sodium in prehypertensive populations. A TOHP follow-up study in the early 2000s found a significant correlation between sodium intake and cardiovascular disease, suggesting a 17-percent increased risk for every 1,000 milligrams of sodium consumed daily. The TOHP researchers concluded there were “overall health benefits of reducing sodium to 1,500 to 2,300 milligrams per day in the majority of the population,” consistent with Dietary Guidelines at that time. TOHP data also suggest the ratio of sodium-to-potassium intake has a significant impact on cardiovascular outcomes.

A limitation of the TOHP data is there were no controls for energy intake. Individuals who consume fewer calories naturally will consume less sodium, and that won’t necessarily put them at a lower disease risk (and vice versa). In addition, how individuals respond to sodium can depend on their baseline blood pressure. TOHP participants already had elevated blood pressure, and when blood pressure is high, eating less sodium has a profound blood pressure-lowering effect. However, when blood pressure is normal, lowering sodium intake has little to no effect on blood pressure.

Fast-forward to 2014, a big year in dietary sodium research. A systematic literature review concluded there is limited evidence that daily sodium intakes greater than 3,400 milligrams and less than 2,900 milligrams increased incidence of cardiovascular disease events, all-cause mortality and hospitalization in the general population. Also that year, authors of a meta-analysis found that individuals with daily sodium intakes of 2,645 milligrams to 4,945 milligrams have the lowest cardiovascular disease and mortality risks — and that plotting sodium and mortality creates a U-shaped curve with significantly increased risks at the highest and lowest intake levels. Some of the more compelling and controversial findings came from a large-scale epidemiologic study following more than 150,000 individuals in 17 countries.

Participants with the lowest mortality and cardiovascular risk consumed between 3,000 milligrams and 6,000 milligrams of sodium per day, and greater than 1,500 milligrams of potassium per day. High sodium intake was only linked with increased risk of death and cardiovascular events when blood pressure was high, while people with normal blood pressure who consumed more than 6,000 milligrams of sodium daily did not experience increased risk of death and cardiovascular events. Additionally, those who consumed less than 3,000 milligrams experienced increased risk when blood pressure was normal.

Skeptics of these studies cite a lack of intervention trials, questionable sodium assessment tools and statistical analysis prone to random and systematic error. There also is a question of reverse causality: When people are sick, they tend to eat less, therefore consuming less sodium — and epidemiological studies cannot determine whether less sodium causes poor health, or poor health causes less sodium.

Both Sides Make Their Cases

In 2015 during the American Heart Association’s Scientific Sessions, prominent researchers on either side debated the complexities of this issue. Low-sodium proponents asserted that to protect their health, Americans must limit sodium intake — and that given the majority of Americans’ sodium intake comes from processed food, this effort should focus on industry-wide interventions. The opposing side maintained that for people without elevated blood pressure, there is no benefit to consuming less than 2,500 milligrams of sodium per day, that it actually may be harmful in some cases, and that to base general guidelines on extrapolations of data is unsound.

Currently, the perfect study to settle the sodium controversy does not exist. Large randomized controlled trials with long follow-up periods are difficult and expensive, and an ideal sodium intake assessment tool is yet to be discovered. In the meantime, the DASH diet — which places more emphasis on fruits and vegetables than sodium (DASH trials averaged around 3,000 milligrams of sodium per day) — is the most effective dietary intervention for hypertension.

And for patients and clients with normal blood pressure, practitioners should continue to develop individualized eating patterns based on clinical judgment, guideline recommendations and scientific evidence.

The post Is Dietary Sodium Really Harmful? A Complex Debate Heats Up appeared first on HealthStylz.

"In searching through catalogues of nutrition education materials, I found they depicted foods, people and settings that these [overseas communities] have never seen," says Dixie Havlak, RD, who has worked in rural Nicaragua and Honduras. "It takes months to put together information, and that makes people think twice about going overseas and doing work."

In countries where people may not have a very sophisticated understanding of science and most local community nutrition workers have little training or poor access to education materials, health practitioners must go back to basics. Visual aids that meet the needs of minimally literate people are especially important, Havlak stresses.

"In the U.S., most people know we get nutrients from food. But some cultures may not even have a word for that," she says. "We have to go back to the very fundamentals of nutrition, health care and how the body works."

Culturally appropriate and effective education aids not only support volunteers, but also the efforts of practitioners whose careers are with government agencies, NGOs or military services. "Before and after my journeys in Central America, I often met other people going down there — dietitians, nurses and medical teams who commonly teach about nutrition and health issues — who had to throw together health education materials at the last minute," Havlak says. "That seems really inefficient."

To help close the gap and support international nutrition education, the Healthy Nutrition Academy has launched a pilot project to develop a collection of free resources for health practitioners working in developing countries. Made possible through funding from the Academy Foundation through the Wimpfheimer-Guggenheim Fund for International Exchange in Nutrition, Dietetics and Management, the first phase of the collection will focus on Central America.

All RDNs, registered nurses, pediatricians, family practitioners, physician assistants and other public health workers with field experience in this region are invited to take an online survey to assess needs for materials and tools that could aid in international medical missions and humanitarian assistance efforts. Respondents also can submit examples of materials (handouts, posters, visual aids) they have developed or used in nutrition education efforts.

"When we can share materials, we improve our ability to serve the developing world and make it easier for more practitioners to volunteer," Havlak says. "Many people on the ground are desperate for material, and we can help them facilitate understanding of health issues and improve the ability to communicate that with the people they serve."

To share your ideas and experiences, visit sm..org/intsurvey or email IRproject@eatright.org. Resources will be available mid-2016 on eatrightPRO.org.

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