{"id":128,"date":"2021-08-14T12:46:17","date_gmt":"2021-08-14T16:46:17","guid":{"rendered":"https:\/\/pressbooks.library.ryerson.ca\/dietmods\/?post_type=chapter&#038;p=128"},"modified":"2025-04-06T01:01:12","modified_gmt":"2025-04-06T05:01:12","slug":"gi_out-plan","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/","title":{"raw":"Plan","rendered":"Plan"},"content":{"raw":"<h1><img src=\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-1024x132.png\" alt=\"Step 2: Plan\" width=\"1024\" height=\"132\" class=\"alignnone wp-image-1368 size-large\" \/><\/h1>\r\n<header class=\"textbox__header\"><\/header>\r\n<h1>Common PES Statement Terminology<\/h1>\r\n<span>As you interpret the dietary data from the assessment, you can form Problem, Etiology, Symptoms (PES) statements or nutrition diagnoses that help identify nutrition concerns that need to be addressed in your plan. If you are not familiar with how to write a PES statement please review this<a href=\"https:\/\/www.ncpro.org\/pub\/file.cfm?item_type=xm_file&amp;id=93467\"> resource from the Academy of Nutrition and Dietetics<\/a>.<\/span>\r\n\r\nHere are some common nutrition problems that clients may experience:\r\n<ul>\r\n \t<li>Excessive energy intake<\/li>\r\n \t<li>Not ready for diet\/lifestyle change<\/li>\r\n \t<li>Inappropriate intake of types of carbohydrate<\/li>\r\n \t<li>Inappropriate intake of types of fats<\/li>\r\n \t<li>Limited food acceptance<\/li>\r\n \t<li>Inadequate vitamin\/mineral intake<\/li>\r\n \t<li>Inadequate fiber intake<\/li>\r\n \t<li>Food- and nutrition-related knowledge deficit<\/li>\r\n \t<li>Physical inactivity<\/li>\r\n \t<li>Unintended weight loss<\/li>\r\n \t<li>Altered nutrition-related laboratory values (specify)<\/li>\r\n \t<li>Disordered eating pattern<\/li>\r\n \t<li>Inability to manage self-care<\/li>\r\n \t<li>Impaired ability to prepare foods\/meals<\/li>\r\n \t<li>Limited adherence to recommendations<\/li>\r\n<\/ul>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\">PES Statements for Christian<\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<div>\r\n\r\nHere is a brief list of potential PES statements for Christian. At this stage, the problem is mostly related to a lack of nutrition education in the past and a willingness to make changes.\r\n\r\n<\/div>\r\n<ol>\r\n \t<li>Food and nutrition related knowledge deficit related to a lack of previous disease specific education from a dietitian as evidenced by client report and dietary\/lifestyle history.<\/li>\r\n \t<li>Not ready for diet changes related to a lack of desire to remove \u201ctrigger\u201d foods as evidenced by clients resistance to remove coffee and alcohol from diet to relieve IBS and GERD symptoms.<\/li>\r\n \t<li>Inappropriate food intake related to knowledge deficit as evidenced by the consistent consumption of traditional \u201ctrigger\u201d foods for GERD and IBS (tomatoes, onions, garlic, spices, caffeine, alcohol).<\/li>\r\n \t<li>Inadequate physical activity as evidenced by client report (under 150 minutes per week guideline).<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>\r\n<h1>Management of [pb_glossary id=\"1656\"]GERD[\/pb_glossary]<\/h1>\r\nCounsel the client on dietary and lifestyle triggers for GERD, and build a strategy to manage them closely for 2-4 weeks. Reintroduce foods as tolerated and depending on symptoms. Please note that triggers may vary, and restrictive diets may not be appropriate for all individuals.\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\">Christian's Medication and Laboratory Values<\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nAs previously mentioned in the Assess stage, Christian was experiencing heartburn, regurgitation, and hiccups before starting his medication. Christian hopes to reduce or remove the medication entirely, so it is important to provide him with education and strategies for the relief of symptoms.\r\n<div><\/div>\r\nWhen considering Christian\u2019s management for GERD, it is also important to consider the potential adverse effects of his medications.\r\n<div><\/div>\r\nWe know the following about Christian:\r\n<ul>\r\n \t<li><span style=\"font-size: 1em;text-align: initial\">He has been taking Nexium (a proton pump inhibitor) for his GERD for 4 weeks<\/span><\/li>\r\n \t<li><span style=\"font-size: 1em;text-align: initial\">He has <\/span><span style=\"font-size: 1em;text-align: initial\">low serum iron and ferritin and is on the low-normal range for vitamin B12. <\/span><\/li>\r\n \t<li><span style=\"font-size: 1em;text-align: initial\">He reports that he experiences extreme fatigue, headaches, and lightheadedness. Although these symptoms may be attributed in part to other lifestyle factors, you should consider his laboratory values in the context of these symptoms (as they are common).<\/span><\/li>\r\n<\/ul>\r\nAs <strong>vitamin B12 and iron are nutrients of concern when taking proton pump inhibitors (PPI's) for extended periods of time<\/strong>, it is important to consider that Christian already has low laboratory values.\r\n\r\n<span style=\"text-align: initial;font-size: 1em\">Consider the recommendation of an iron and vitamin B12 supplement, if it is appropriate and aligns with your clients needs. You may or may not consult with the interdisciplinary team regarding supplementation (it is not necessary, but you may want to in some cases depending on the client and care plan).<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n<h2>Dietary Strategies<\/h2>\r\nThese are dietary strategies to help individuals manage their GERD symptoms:\r\n<ul>\r\n \t<li><strong>Avoid foods that increase gastric pressure: <\/strong>e.g. anything carbonated.<\/li>\r\n \t<li><strong>Avoid foods that relax the Lower Esophageal Sphincter<\/strong> (LES): e.g. hot sauce, mints (spearmint, peppermint), fried foods, fatty foods, spicy foods, chocolate, caffeine, and alcohol.<\/li>\r\n \t<li><strong>Eat smaller meals throughout the day: <\/strong>5 \u2013 6 meals is ideal. Large meals take a longer time to empty from the stomach, exerting pressure on the LES.<\/li>\r\n \t<li><strong>Slow your eating and drinking:<\/strong> Eat and drink slowly, and chew foods well. Do not use straws or chew gum.<\/li>\r\n \t<li><strong>Avoid foods and beverages below pH 4<\/strong>: In some cases, symptoms can be managed through avoiding foods and beverages like pineapple, strawberries, coca cola, cognac, cranberry juice, and yellow mustard. You may obtain detailed lists for this.<\/li>\r\n \t<li><strong>Avoid other common triggers<\/strong>: e.g. citrus fruits and juices, tomatoes, chocolate, onions, garlic, and spicy foods.<\/li>\r\n<\/ul>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<h3 class=\"textbox__title\">Christian's Dietary Data: GERD Trigger Foods<\/h3>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nIn consideration of dietary recommendations for the management of GERD, it is important to highlight key foods that may be contributing to Christian\u2019s symptoms. In Christian\u2019s case, this is his first appointment with you. It is important not to overwhelm him with suggestions. Instead, focus on key \u201dtrigger foods\u201d and \u201csimple recommendations\u201d such as swapping apples, tomatoes, onions, garlic (spices or seasoning) for other types of vegetables, and reducing caffeine and alcohol intake. Reducing consumption of these foods aligns with dietary management strategies for GERD.\r\n<table class=\"grid\" style=\"width: 100%;height: 277px\"><caption>Christian's 24-hour diet recall\r\n<span style=\"background-color: #ffff00\">[*] indicates trigger foods for GERD<\/span><\/caption>\r\n<tbody>\r\n<tr style=\"height: 15px\">\r\n<th style=\"height: 15px\" scope=\"col\">Meal<\/th>\r\n<th style=\"height: 15px\" scope=\"col\">Christian's diet recall<\/th>\r\n<\/tr>\r\n<tr style=\"height: 70px\">\r\n<td style=\"height: 70px\">Breakfast 6 am<\/td>\r\n<td style=\"height: 70px\">Fruit smoothie (strawberries, <span style=\"background-color: #ffff00\"><strong>apple*<\/strong><\/span>, avocado, kale, cucumber, almond milk), 2 hard boiled egg or \u201degg muffins\u201d with spinach mixed in, and <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\r\n<\/tr>\r\n<tr style=\"height: 87px\">\r\n<td style=\"height: 87px\">Lunch\r\n12 pm<\/td>\r\n<td style=\"height: 87px\">Premade salad or rice bowl (spring mix or brown rice, marinated or spiced baked chicken, cucumber, tomato, green pepper, onion, chick peas or kidney beans, walnuts, and feta or goat cheese with an olive oil dressing or any \u201clight\u201d dressing available), <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\r\n<\/tr>\r\n<tr style=\"height: 70px\">\r\n<td style=\"height: 70px\">Dinner\r\n5 pm<\/td>\r\n<td style=\"height: 70px\">6 oz baked fish, chicken, or beef, with mixed roasted vegetables (broccoli, cauliflower, asparagus, potatoes cooked in olive oil with <span style=\"background-color: #ffff00\"><strong>garlic, paprika, and other spices*<\/strong><\/span>), and 1 cup of quinoa, rice, or whole grain pasta<\/td>\r\n<\/tr>\r\n<tr style=\"height: 35px\">\r\n<td style=\"height: 35px\">HS snack\r\n11 pm<\/td>\r\n<td style=\"height: 35px\"><span style=\"background-color: #ffff00\"><strong>1-2 glasses of red wine*<\/strong><\/span>, 1-2 cookies or 2 cups of popcorn or carrots with red pepper hummus<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<\/div>\r\n<h2>Lifestyle Strategies<\/h2>\r\nWhile it may not be a concern during an initial appointment, physical activity is an important lifestyle strategy and can be addressed at a follow-up.\r\n\r\nClients can be encouraged to complete:\r\n<ul>\r\n \t<li>150 minutes of moderate to vigorous aerobic exercise every week (e.g. 30 minutes, five days a week)<\/li>\r\n \t<li>Resistance exercises (like lifting weights) two to three times a week<\/li>\r\n<\/ul>\r\nIt some cases, it may be beneficial to refer clients to the physiotherapist to be:\r\n<ul>\r\n \t<li>Assessed for conditions that might place them at increased risk for an adverse event or injury during certain exercises<\/li>\r\n \t<li>Supervised by an exercise specialist for a certain period of time to ensure safety<\/li>\r\n<\/ul>\r\nIn addition to being physically active, here are more lifestyle strategies to help individuals manage their GERD symptoms:\r\n<ul>\r\n \t<li>Practice stress management<\/li>\r\n \t<li>Avoid alcohol or smoking<\/li>\r\n \t<li>Do not lie down for 2-3 hours after eating<\/li>\r\n \t<li>Try raising the head of your bed to avoid laying flat at night<\/li>\r\n \t<li>Avoid wearing tight clothing around your stomach and chest<\/li>\r\n \t<li>Maintain a healthy weight: Consider this strategy in the context of your client\u2019s history and goals. Many normal and underweight individuals experience GERD and it may not be the most crucial factor for your client. Always consider that weight is not a modifiable factor for everyone and may not be realistic for your client.<\/li>\r\n<\/ul>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<h3 class=\"textbox__title\">Christian's Lifestyle Habits<\/h3>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nIn addition to reviewing dietary data, lifestyle habits play an important role in managing GERD and IBS. After you discuss with Christian, he provides you with the information regarding his willingness to make changes to his lifestyle habits that may help relieve GERD symptoms.\r\n<div><\/div>\r\n<div>Christian's lifestyle habits are listed here:<\/div>\r\n<ul>\r\n \t<li>Christian reports eating quickly during meals, especially during breakfast and lunch as his workdays are busy. After discussion, Christian will try to eat his meals slowly.<\/li>\r\n \t<li>Christian does not have time to take a \u201csnack break\u201d during the workday. After discussion, Christian prefers to eat three meals a day and does not want to worry about snacks.<\/li>\r\n \t<li>Christian reports sleeping from 12:00am - 6:00am. After discussion, he recognizes that he should be sleeping more, which may help reduce his stress levels. He is willing to go to bed at 11:00pm.<\/li>\r\n \t<li>Christian reports wearing tight clothing (his business attire is a suit). After discussion, this is not negotiable.<\/li>\r\n \t<li>Christian exercises 2 times per week for 60 minutes, which does meet the guidelines (~150 minutes per week). He is not currently interested in engaging in more physical activity. Since dietary concerns are of greater importance at this stage of his nutrition care, there is no physical activity plan at this time.<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n<h1>Management of IBS<\/h1>\r\nElimination diets are often used for IBS. The [pb_glossary id=\"1410\"]FODMAP[\/pb_glossary] elimination diet (<em>which will be explained later on<\/em>) has a growing body of evidence but is still widely criticized. There are \u201ctraditional food triggers\u201d that can be explored before using a restrictive or elimination diet, such as FODMAP. Using a FODMAP diet requires commitment and dedication for it to be effective, which may not be necessary.\r\n\r\nIt is up to the dietitian and client to determine the need for an intensive strategy, but it may be best to explore \u201ctraditional triggers first\u201d using a food symptom journal.\r\n<h2>Food Symptom Journals<\/h2>\r\nKeeping a food and symptom journal is critical to improving digestive symptoms. By consistently tracking multiple factors that relate to your digestive system, you can identify what may be triggering symptoms and truly relieve digestive symptoms.\r\n\r\nDuring an initial appointment for IBS, it is important to provide a detailed explanation of the food symptom journal and the expectations for documenting. This will help the client understand and provide you with the best information for assessment, recommendations, and plans. Keeping a food symptom journal for 1-2 weeks before a follow-up appointment is often the first \u201cplan of action.\u201d\r\n\r\nA food symptom journal can be kept in a table format, and should include the following headings:\r\n<ul>\r\n \t<li><strong>Day and time:\u00a0<\/strong>what time of day you eat<\/li>\r\n \t<li><strong>Food and beverages: <\/strong>exactly what you eat and drink (including condiments, sauces, and seasonings)<\/li>\r\n \t<li><strong>Environment:\u00a0<\/strong>where you are eating (homemade or outside food) and what's going on that day (e.g. stress levels, people around you, events, eating behaviors, etc.)<\/li>\r\n \t<li><strong>Symptoms and severity:\u00a0<\/strong>indicate symptom severity on a scale of 1 to 5. Often the client will choose 2-3 symptoms that are affected by the most and focus on those when recording; they can denote symptoms with a letter for ease of recording<\/li>\r\n \t<li><strong>Bowel<\/strong> <strong>movements<\/strong>: indicate number and consistency according to the Bristol Stool Scale<\/li>\r\n<\/ul>\r\n<h3>Bristol Stool Scale<\/h3>\r\nThe Bristol stool scale is a diagnostic tool that you can provide clients for explaining the appearance of their stool. The scale classifies stool into seven types, listed and depicted in the table and image below.\r\n<table class=\"grid\" style=\"border-collapse: collapse;height: 136px;width: 100%\" border=\"0\"><caption>Bristol Stool Scale<\/caption>\r\n<tbody>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"col\">Type<\/th>\r\n<th style=\"width: 12.7749%;height: 17px\" scope=\"col\">Description<\/th>\r\n<th style=\"width: 14.8901%;height: 17px\" scope=\"col\">Indication<\/th>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 1<\/th>\r\n<td style=\"width: 12.7749%;height: 17px\">Separate hard lumps<\/td>\r\n<td style=\"width: 14.8901%;height: 17px\">Constipation (severe)<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 2<\/th>\r\n<td style=\"width: 12.7749%;height: 17px\">Lumpy and sausage like<\/td>\r\n<td style=\"width: 14.8901%;height: 17px\">Constipation (mild)<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 3<\/th>\r\n<td style=\"width: 12.7749%;height: 17px\">A sausage shape with cracks in the surface<\/td>\r\n<td style=\"width: 14.8901%;height: 17px\">Normal<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 4<\/th>\r\n<td style=\"width: 12.7749%;height: 17px\">Like a smooth, soft sausage or snake<\/td>\r\n<td style=\"width: 14.8901%;height: 17px\">Normal<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 5<\/th>\r\n<td style=\"width: 12.7749%;height: 17px\">Soft blobs with clear-cut edges<\/td>\r\n<td style=\"width: 14.8901%;height: 17px\">Lack of fibre<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 6<\/th>\r\n<td style=\"width: 12.7749%;height: 17px\">Mushy consistency with ragged edges<\/td>\r\n<td style=\"width: 14.8901%;height: 17px\">Diarrhea (mild)<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 7<\/th>\r\n<td style=\"width: 12.7749%;height: 17px\">Liquid consistency with no solid pieces<\/td>\r\n<td style=\"width: 14.8901%;height: 17px\">Diarrhea (severe)<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n[caption id=\"attachment_1345\" align=\"alignnone\" width=\"698\"]<img src=\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/BristolStoolChart.png\" alt=\"Chart of Bristol stool scale, outlining seven types of stool in order of consistency (solid to liquid) and indication (constipation to diarrhea)\" width=\"698\" height=\"420\" class=\"wp-image-1345 size-full\" \/> Bristol Stool scale, with illustrations<br \/>Source:Cabot Health, <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\">CC BY-SA 3.0<\/a>, via <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:BristolStoolChart.png\">Wikimedia Commons<\/a>[\/caption]\r\n<h3>Traditional Trigger Foods and Beverages<\/h3>\r\nThis list can serve as a reference point for you and the client to identify common \u201ctrigger foods\" and as a first step to resolve symptoms before consideration of an elimination diet (e.g. FODMAP).\r\n<ul>\r\n \t<li>Avoid or limit caffeine and chocolate<\/li>\r\n \t<li>Avoid all preservatives and artificial flavours<\/li>\r\n \t<li>Avoid most raw fruits and vegetables<\/li>\r\n \t<li>Avoid wheat<\/li>\r\n \t<li>No alcohol<\/li>\r\n \t<li>No cabbage in any form (e.g. cauliflower, cabbage, broccoli, brussels sprouts)<\/li>\r\n \t<li>No corn or popcorn<\/li>\r\n \t<li>No onion or garlic<\/li>\r\n \t<li>No red meat or deli meats<\/li>\r\n \t<li>No spices (e.g. cinnamon, curry, chili powder, black pepper cumin)<\/li>\r\n \t<li>No vinegars or anything fermented<\/li>\r\n \t<li>No whole seeds or nuts<\/li>\r\n<\/ul>\r\n<div>\r\n\r\nConsider using a more comprehensive list during your practice.\r\n\r\n<\/div>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<h3 class=\"textbox__title\">Christian's Dietary Data: IBS Trigger Foods<\/h3>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nThe plan for Christian\u2019s IBS is to start with him using a food symptom journal to track his patterns over the next 1-2 weeks. He will come back with a strong representation of his habits (both dietary and environment). Managing IBS is trial and error, with a combination of various strategies, so the more we know about the person, the better.\r\n\r\nIn the meantime you can start by identifying a few foods that are of concern from his dietary recall. The foods bolded in the chart are foods you may want to identify with Christian.\r\n<table class=\"grid\" style=\"width: 100%;height: 277px\"><caption>Christian's 24-hour diet recall\r\n<span style=\"background-color: #ffff00\">[*] indicates trigger foods for IBS<\/span><\/caption>\r\n<tbody>\r\n<tr style=\"height: 15px\">\r\n<th style=\"height: 15px\" scope=\"col\">Meal<\/th>\r\n<th style=\"height: 15px\" scope=\"col\">Christian's diet recall<\/th>\r\n<\/tr>\r\n<tr style=\"height: 70px\">\r\n<td style=\"height: 70px\">Breakfast 6 am<\/td>\r\n<td style=\"height: 70px\">Fruit smoothie (<span style=\"background-color: #ffff00\"><strong>strawberries*<\/strong><\/span>, <span style=\"background-color: #ffff00\"><strong>apple*<\/strong><\/span>, avocado, kale, cucumber, almond milk), 2 hard boiled egg or \u201degg muffins\u201d with spinach mixed in, and <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\r\n<\/tr>\r\n<tr style=\"height: 87px\">\r\n<td style=\"height: 87px\">Lunch\r\n12 pm<\/td>\r\n<td style=\"height: 87px\">Premade salad or rice bowl (spring mix or brown rice, <span style=\"background-color: #ffff00\"><strong>marinated or spiced*<\/strong><\/span> baked chicken, cucumber, <span style=\"background-color: #ffff00\"><strong>tomato*<\/strong><\/span>, green pepper, <span style=\"background-color: #ffff00\"><strong>onion*<\/strong><\/span>, chick peas or <span style=\"background-color: #ffff00\"><strong>kidney beans, walnuts*<\/strong><\/span>, and feta or goat cheese with an olive oil dressing or any \u201clight\u201d dressing available), <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\r\n<\/tr>\r\n<tr style=\"height: 70px\">\r\n<td style=\"height: 70px\">Dinner\r\n5 pm<\/td>\r\n<td style=\"height: 70px\">6 oz baked fish, chicken, or beef, with mixed roasted vegetables (<span style=\"background-color: #ffff00\"><strong>broccoli, cauliflower, asparagus*<\/strong><\/span>, potatoes cooked in olive oil with <span style=\"background-color: #ffff00\"><strong>garlic, paprika, and other spices*<\/strong><\/span>), and 1 cup of quinoa, rice, or whole grain pasta<\/td>\r\n<\/tr>\r\n<tr style=\"height: 35px\">\r\n<td style=\"height: 35px\">HS snack\r\n11 pm<\/td>\r\n<td style=\"height: 35px\"><span style=\"background-color: #ffff00\"><strong>1-2 glasses of red wine*<\/strong><\/span>, 1-2 cookies or <span style=\"background-color: #ffff00\"><strong>2 cups of popcorn*<\/strong><\/span> or carrots with <span style=\"background-color: #ffff00\"><strong>red pepper hummus*<\/strong><\/span><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nIn Christian's case:\r\n<ul>\r\n \t<li>You can create a plan together about foods he is willing to remove (even on a trial basis) to evaluate he symptoms.<\/li>\r\n \t<li>You can give him low-FODMAP alternatives (<em>which will be listed later on) <\/em>to replace these traditional trigger foods. Note that these recommendations are similar to the ones we created for GERD.<\/li>\r\n \t<li>It is reasonable to create nutrition recommendations for both GI concerns, as they compliment each other. But in other cases, too many changes or recommendations in an appointment may become overwhelming and may not be appropriate.<\/li>\r\n \t<li>You are not going to start a FODMAP diet immediately because this is the first appointment and you should gather more information and try eliminating traditional triggers first<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n<h2>FODMAP Diet<\/h2>\r\n<strong>FODMAP<\/strong> is an acronym for:\r\n<ul>\r\n \t<li><strong>F<\/strong>ermentable<\/li>\r\n \t<li><strong>O<\/strong>ligosaccharides (Fructans &amp; Galacto-oligosaccharides)<\/li>\r\n \t<li><strong>D<\/strong>isaccharides (Lactose)<\/li>\r\n \t<li><strong>M<\/strong>onosaccharides (Fructose)<\/li>\r\n \t<li><strong>A<\/strong>nd<\/li>\r\n \t<li><strong>P<\/strong>olyols (Mannitol and Sorbitol)<\/li>\r\n<\/ul>\r\nThese are short-chain carbohydrates that have been shown to increase water volume in the small intestine and be rapidly fermented in the large intestine. This leads to increased gas production and symptoms (i.e. pain, bloating, distension, flatulence, nausea and altered bowel motility). A low FODMAP diet restricts these short-chain carbohydrates.\r\n\r\nA low FODMAP diet is the only focused elimination-type diet that is appropriate for IBS. Even if an individual is not pursing a FODMAP diet, it is still important to understand FODMAPs and where they are found.\u00a0 You should seek further readings to review and become familiar with the common high FODMAP foods in each group.\r\n<h3>Caveats<\/h3>\r\nThe low FODMAP diet is considered to be a<strong> second-line dietary strategy that can pursued <em>after<\/em><\/strong>:\r\n<ul>\r\n \t<li>Assessment<\/li>\r\n \t<li>Management of dietary and lifestyle factors<\/li>\r\n \t<li>Elimination of \"traditional triggers\"<\/li>\r\n<\/ul>\r\n<strong>The long-term restriction of FODMAPs is not recommended<\/strong>. Briefly, recent research suggests that long term FODMAP restriction carries the risk of nutritional inadequacy, has the potential to foster disordered eating, and potentially unfavourable gut microbiota (although the impact is unknown).\r\n\r\nStructured reintroduction of FODMAPs is recommended after six weeks to identify which FODMAPs an individual is sensitive to, assess tolerance to individual high FODMAP foods, promote food variety and support long-term self-management.\r\n\r\nThe key is to find and emphasize substitutions for foods that are eliminated (as they are triggers). This is to help clients make realistic and positive changes and reduce the fear and anxiety around consuming foods.\r\n<h3>Phase 1: Elimination<\/h3>\r\nThe FODMAP diet involves a three-phase approach. The first phase is \u201cElimination\u201d focused on replacing foods high in FODMAPs with those lower in FODMAPs. It is very important to work with your client to ensure they are still eating a balanced diet.\r\n\r\nDietary strategies may include the following:\r\n<ol>\r\n \t<li>Avoiding foods that are substantial sources of fructans (e.g. wheat, rye, onions, garlic) and galactans (e.g. cabbage, certain vegetables, legumes such as chickpeas).<\/li>\r\n \t<li>Restricting lactose-containing foods (if lactose malabsorption intolerance is present).<\/li>\r\n \t<li>Avoiding naturally-occurring and artificial polyols (e.g. stone fruits, and mushrooms, sugar-free chewing gum).<\/li>\r\n<\/ol>\r\nThe following list acts as an example of information you may provide a client. This is not comprehensive, and if following a FODMAP diet, you will want to provide your client with a more detailed list.\r\n<table class=\"grid\" style=\"height: 380px\"><caption>Foods high and low in FODMAP, by food category<\/caption>\r\n<tbody>\r\n<tr style=\"height: 44px\">\r\n<th style=\"height: 44px;width: 88.7031px\" scope=\"col\">Food Category<\/th>\r\n<th style=\"height: 44px;width: 330.797px\" scope=\"col\">Avoid High FODMAP foods<\/th>\r\n<th style=\"height: 44px;width: 381.375px\" scope=\"col\">Choose Low FODMAP foods<\/th>\r\n<\/tr>\r\n<tr style=\"height: 73px\">\r\n<th style=\"height: 73px;width: 88.7031px\" scope=\"row\">Vegetables<\/th>\r\n<td style=\"height: 73px;width: 330.797px\">\r\n<ul>\r\n \t<li>Artichoke<\/li>\r\n \t<li>Asparagus<\/li>\r\n \t<li>Cauliflower<\/li>\r\n \t<li>Garlic<\/li>\r\n \t<li>Green peas<\/li>\r\n \t<li>Leek<\/li>\r\n \t<li>Mushrooms<\/li>\r\n \t<li>Onion<\/li>\r\n \t<li>Sugar snap peas<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 73px;width: 381.375px\">\r\n<ul>\r\n \t<li>Aubergine\/eggplant<\/li>\r\n \t<li>Bell pepper<\/li>\r\n \t<li>Bok Choy<\/li>\r\n \t<li>Broccoli<\/li>\r\n \t<li>Carrot<\/li>\r\n \t<li>Cucumber<\/li>\r\n \t<li>Green beans<\/li>\r\n \t<li>Kale<\/li>\r\n \t<li>Lettuce<\/li>\r\n \t<li>Potato<\/li>\r\n \t<li>Tomato<\/li>\r\n \t<li>Zucchini<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 58px\">\r\n<th style=\"height: 58px;width: 88.7031px\" scope=\"row\">Fruit<\/th>\r\n<td style=\"height: 58px;width: 330.797px\">\r\n<ul>\r\n \t<li>Apples, apple juice<\/li>\r\n \t<li>Cherries<\/li>\r\n \t<li>Dried fruit<\/li>\r\n \t<li>Mango<\/li>\r\n \t<li>Nectarines<\/li>\r\n \t<li>Peaches<\/li>\r\n \t<li>Pears<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 58px;width: 381.375px\">\r\n<ul>\r\n \t<li>Blueberries (\u00bc cup)<\/li>\r\n \t<li>Cantaloupe<\/li>\r\n \t<li>Grapes<\/li>\r\n \t<li>Kiwi<\/li>\r\n \t<li>Mandarin<\/li>\r\n \t<li>Orange<\/li>\r\n \t<li>Pineapple<\/li>\r\n \t<li>Raspberries (one-third cup)<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 88px\">\r\n<th style=\"height: 88px;width: 88.7031px\" scope=\"row\">Protein sources<\/th>\r\n<td style=\"height: 88px;width: 330.797px\">\r\n<ul>\r\n \t<li>Cow\u2019s milk<\/li>\r\n \t<li>Custard<\/li>\r\n \t<li>Evaporated milk<\/li>\r\n \t<li>Ice cream<\/li>\r\n \t<li>Sweetened condensed milk<\/li>\r\n \t<li>Soy beverage (made with soybeans)<\/li>\r\n \t<li>Yogurt<\/li>\r\n \t<li>Most legumes or pulses<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 88px;width: 381.375px\">\r\n<ul>\r\n \t<li>Almond milk<\/li>\r\n \t<li>Brie and camembert cheese<\/li>\r\n \t<li>Feta cheese<\/li>\r\n \t<li>Hard cheeses<\/li>\r\n \t<li>Lactose-free milk and yogurt<\/li>\r\n \t<li>Soy beverage (made with soy protein)<\/li>\r\n \t<li>Eggs<\/li>\r\n \t<li>Firm tofu<\/li>\r\n \t<li>Plain meats, poultry, seafood and fish<\/li>\r\n \t<li>Tempeh<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 59px\">\r\n<th style=\"height: 59px;width: 88.7031px\" scope=\"row\">Grain products<\/th>\r\n<td style=\"height: 59px;width: 330.797px\">Wheat, rye, and barley- based products, including:\r\n<ul>\r\n \t<li>breakfast cereals<\/li>\r\n \t<li>cookies<\/li>\r\n \t<li>crackers<\/li>\r\n \t<li>snack products.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 59px;width: 381.375px\">\r\n<ul>\r\n \t<li>Corn or quinoa flake<\/li>\r\n \t<li>Oats<\/li>\r\n \t<li>Quinoa or corn pasta<\/li>\r\n \t<li>Rice<\/li>\r\n \t<li>Rice noodles<\/li>\r\n \t<li>Rice cakes<\/li>\r\n \t<li>Sourdough spelt bread<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 58px\">\r\n<th style=\"height: 58px;width: 88.7031px\" scope=\"row\">Nuts and seeds<\/th>\r\n<td style=\"height: 58px;width: 330.797px\">\r\n<ul>\r\n \t<li>Cashews<\/li>\r\n \t<li>Pistachios<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"height: 58px;width: 381.375px\">\r\n<ul>\r\n \t<li>Almonds (10)<\/li>\r\n \t<li>Macadamia nuts<\/li>\r\n \t<li>Peanuts<\/li>\r\n \t<li>Pumpkin seeds<\/li>\r\n \t<li>Sunflower seeds<\/li>\r\n \t<li>Walnuts<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h3>Phase 2: Reintroduction<\/h3>\r\nThe goals of the reintroduction phase are to help:\r\n<ul>\r\n \t<li>Increase variety and re-introduction of foods quickly<\/li>\r\n \t<li>Identify foods that do and do not trigger symptoms.<\/li>\r\n<\/ul>\r\nClients can reintroduce each FODMAP category one at a time to determine which foods they can tolerate and in what amounts. This process may be done gradually, rather than following a strict challenge protocol, depending on the client\u2019s preference.<span style=\"font-family: Barlow, sans-serif;font-size: 1.602em\"><\/span>\r\n\r\nThe goal is to introduce a high FODMAP food from just one category at a time, increasing the serving size over a 24-hour period to monitor for symptoms. If no symptoms occur after this trial, the next food can be reintroduced after 48 hours, assuming the client is feeling well.<span style=\"font-family: Barlow, sans-serif;font-size: 1.602em\"><\/span>\r\n\r\nDuring the \u201cPersonalization\u201d phase, clients can begin adding foods back into their diet once they have identified which ones are tolerated without symptoms.\r\n\r\n<span style=\"font-family: Barlow, sans-serif;font-size: 1.602em\">Phase 3: Personalization<\/span>\r\n\r\nOnce the client has tested a variety of FODMAP categories and has a stronger clarity about individual trigger foods and\/or portion sizes that are tolerable, the last step involves bringing FODMAP foods back into the diet to increase variety and nutritional quality.\r\n\r\nAt this stage, it is a balancing act between symptom management and enjoyment of food (sometimes symptom management instead of resolution is the result). It is also important to remember other factors that influence IBS symptoms, such as stress and environment.\r\n\r\nThe process for this personalization phase can be broken down into the following steps:\r\n<ol>\r\n \t<li>Add one high FODMAP food per day<\/li>\r\n \t<li>Add another new FODMAP food the next day<\/li>\r\n \t<li>If these foods (and portion sizes) do not trigger symptoms, keep including them in your diet.<\/li>\r\n \t<li>If you experience symptoms, continue documenting in a food symptom journal to determine if this is a trigger food and return to regimen.<\/li>\r\n<\/ol>\r\n<h2>Probiotics and Other Supplements<\/h2>\r\nProbiotics are\u00a0 edible, living microorganisms that may be helpful in the management of IBS. There are many probiotic products available in different doses and variable bacterial strains. Many practitioners and clients have reported improvement of IBS symptoms with probiotic use.\r\n\r\nIn general, taking probiotics for IBS is considered safe. If an individual finds four weeks of use of a probiotic is beneficial, they can continue to take it. This is a decision to be made between the client and the dietitian, in consideration of a variety of factors (adherence, effectiveness, cost).\r\n\r\nIndividuals with IBS who choose to try probiotics should be aware that some products contain other ingredients that may increase IBS symptoms (e.g. dietary fibre: oats; FODMAPs: inulin, lactose, fructose, sorbitol and xylitol).\r\n\r\nThere is currently inadequate evidence to recommend any specific probiotic product independent of IBS-subtype (constipation or diarrhea or mixed predominant IBS)\r\n\r\nThe minimum concentration of bacteria typically recommended in probiotic supplements is 1 billion CFU per dose or higher. However, some research may demonstrate the effectiveness of a smaller dose for specific strains. Most probiotics range from 1 billion \u2013 10 billion (with some up to 50 billion).\r\n\r\nIn addition to probiotics, here is a list of other IBS management supplements that clients may ask you about:\r\n<ul>\r\n \t<li>Digestive Enzymes<\/li>\r\n \t<li>Prebiotics<\/li>\r\n \t<li>Apple Cider Vinegar<\/li>\r\n \t<li>IBGard (peppermint)<\/li>\r\n \t<li>Biocidin (herbal)<\/li>\r\n \t<li>Candibactin (herbal)<\/li>\r\n \t<li>Ginger<\/li>\r\n<\/ul>\r\nIt is worthwhile to explore the evidence surrounding these supplements as you may receive questions about them in practice.\r\n<h1>Management of Celiac Disease<\/h1>\r\n<div class=\"textbox shaded\"><strong>Note<\/strong>:<strong>\u00a0<\/strong>This section of the Plan stage does not concern our client Christian, and is meant to provide you with an introductory overview of education for celiac disease.<\/div>\r\nAlthough celiac disease cannot be \"cured\", it can be managed effectively by keeping a strict gluten-free diet.\r\n\r\nTo help manage a client's celiac disease:\r\n<ul>\r\n \t<li>Look out for nutrient deficiencies: iron (in 50% of diagnosed), vitamin D, folate, B12, B6, and zinc.<\/li>\r\n \t<li>Evaluate a client's diet for nutrients of concern (as a result of a gluten-free diet and their dietary behaviours)<\/li>\r\n \t<li>Develop strategies to provide a balanced and nutrient dense diet.<\/li>\r\n<\/ul>\r\nIt is important to overview the following with someone who is newly diagnosed with celiac disease:\r\n<ul>\r\n \t<li>Cross-Contamination: Individuals with celiac disease should have their own cooking supplies, utensils and condiments.<\/li>\r\n \t<li>A general list of foods to avoid and foods to include: This is a starting point to get individuals familiar with gluten-containing foods in various categories. May consider using a phone \u201capp\u201d for scanning barcodes or eating at restaurants as lists can be overwhelming.<\/li>\r\n \t<li>Reading food labels: even though many food companies are highlighting \u201cgluten-free\u201d on labels, it is important that individuals know common and \u201chidden\u201d ingredients to look for.<\/li>\r\n<\/ul>\r\nReview the list of gluten containing foods below\r\n\r\n[h5p id=\"44\"]\r\n<h1>Management of Diverticulitis<\/h1>\r\n<div class=\"textbox shaded\"><strong>Note<\/strong>:<strong>\u00a0<\/strong>This section of the Plan stage does not concern our client Christian, and is meant to provide you with an introductory overview of education for diverticulitis.<\/div>\r\n<h2>Preventing Diverticular Disease<\/h2>\r\nPractice-based Evidence in Nutrition (PEN) suggests that the overall recommendations for the prevention of diverticular disease and acute diverticulitis are based on small amounts of low-quality evidence. However, <strong>they provide the recommendations with caution as a result of limitations in evidence<\/strong>.\r\n\r\nHealthy lifestyle practices should be encouraged to prevent diverticular disease and acute diverticulitis. General recommendations include:\r\n<ul>\r\n \t<li>Consuming a high fibre diet through dietary sources with or without supplementation (e.g. up to 20 grams per day of supplementary fibre)<\/li>\r\n \t<li>A diet high in fruit, vegetables and whole grains<\/li>\r\n \t<li>Staying hydrated<\/li>\r\n \t<li>Being physically active<\/li>\r\n \t<li>Limiting intake of red meat<\/li>\r\n \t<li>Ensuring adequate vitamin D levels<\/li>\r\n \t<li>Limiting intake of alcohol consumption and not smoking (although no significant associations have been found)<\/li>\r\n \t<li>Avoiding nuts, corn, popcorn and fruit with small seeds (e.g. strawberries, blueberries)\u00a0<em>in some cases<\/em>.\r\n<ul>\r\n \t<li>This applies mostly to those who experience an occurrence of acute diverticulitis, if they have worsening symptoms that may be related to the consumption of these foods (common triggers)<\/li>\r\n \t<li>Assess this recommendation on a case-by-case basis<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\nA recommendation regarding probiotics cannot be made at this time. However, there is emerging data to suggest the beneficial use of probiotics for diverticulitis. Given there are no contradictions for probiotics, you and your client would decide whether probiotics may be a part of their nutrition care plan.\r\n<h2>Managing Acute Diverticulitis<\/h2>\r\nThe dietary management of acute diverticulitis is different than preventing it. It is important that clients understand the difference.\r\n\r\nIf a client\/patient is having a diverticular flare, they can:\r\n<ol>\r\n \t<li>Stick to a fluid-only diet for a few days until symptoms (i.e. pain) improve.<\/li>\r\n \t<li>Eat a low insoluble fibre diet while recovering. Once symptoms resolve, patients can return to a high-fibre diet.<\/li>\r\n \t<li>Receive antibiotics, as acute diverticulitis management is often accompanied by antibiotics<\/li>\r\n<\/ol>\r\n<h1>Simulation Activity: Christian<\/h1>\r\nTo practice what you\u2019ve learned about GERD and IBS management, complete the simulation activity below. After you complete the simulation, review a summary of Christian's nutrition care plan.\r\n\r\n&nbsp;\r\n\r\n[h5p id=\"62\"]\r\n<h1>Nutrition Care Plan Summary<\/h1>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\">Christian's Nutrition Care Plan<\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nBased on the details gathered prior to and during your initial appointment with Christian, here is a suggested nutrition care plan.\r\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%;height: 170px\" border=\"0\"><caption>Summary of recommendations for Christian's nutrition care plan<\/caption>\r\n<tbody>\r\n<tr style=\"height: 15px\">\r\n<th style=\"width: 15.6489%;height: 15px\" scope=\"col\">Area of Concern<\/th>\r\n<th style=\"width: 134.351%;height: 15px\" scope=\"col\">Recommendations<\/th>\r\n<\/tr>\r\n<tr style=\"height: 87px\">\r\n<td style=\"width: 15.6489%;height: 87px\">Medication and supplements<\/td>\r\n<td style=\"width: 134.351%;height: 87px\">\r\n<ul>\r\n \t<li>Continue taking Metamucil and vitamin D<\/li>\r\n \t<li>Continue taking PPI. The goal is to implement dietary and lifestyle strategies to remove or wean off PPI's<\/li>\r\n \t<li>Start taking iron and vitamin B12 supplements, as directed by RD. Start with B12 supplement and elimination diet. Add iron supplement 1-2 weeks after depending on clients preference. A \u201cstaggered\u201d approach is used in consideration of side effects of supplementation (especially iron).<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 15.6489%\">GERD &amp; IBS Management<\/td>\r\n<td style=\"width: 134.351%\">\r\n<ul>\r\n \t<li>Keep a food symptom journal for 1-2 weeks<\/li>\r\n \t<li>Follow-up in 2 weeks to evaluate journal results and determine next steps<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<td style=\"width: 15.6489%;height: 17px\">Dietary choices<\/td>\r\n<td style=\"width: 134.351%;height: 17px\">\r\n<ul>\r\n \t<li>Continue eating foods that are high in fibre<\/li>\r\n \t<li>Seek lactose-free alternatives to dairy milk<\/li>\r\n \t<li>Reduce consumption of caffeine (to 1 coffee per day) and alcohol (to 1 drink every other day), as client is not comfortable with removing these entirely<\/li>\r\n \t<li>Avoid other triggers in diet, including: tomatoes, onions, cabbages (incl. broccoli and cauliflower), garlic, and added spices<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 17px\">\r\n<td style=\"width: 15.6489%;height: 17px\">Lifestyle habits<\/td>\r\n<td style=\"width: 134.351%;height: 17px\">\r\n<ul>\r\n \t<li>Continue to exercise 2 times per week for 1 hour; no changes required at this time<\/li>\r\n \t<li>Go to sleep earlier (1 hour earlier than normal)<\/li>\r\n \t<li>Eat meals and beverages slowly<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<\/div>\r\n<div class=\"textbox shaded\">PART 2: PLAN COMPLETE. Please pause to reflect on the nutrition care plan we created for Christian. When you\u2019re ready, move on to Part 3: Implementation.<\/div>\r\n&nbsp;","rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 counter-hierarchy ez-toc-counter ez-toc-grey ez-toc-container-direction\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">Page Contents<\/p>\n<label for=\"ez-toc-cssicon-toggle-item-69d1428a566da\" class=\"ez-toc-cssicon-toggle-label\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/label><input type=\"checkbox\"  id=\"ez-toc-cssicon-toggle-item-69d1428a566da\" checked aria-label=\"Toggle\" \/><nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Common_PES_Statement_Terminology\" >Common PES Statement Terminology<\/a><ul class='ez-toc-list-level-2' ><li class='ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#PES_Statements_for_Christian\" >PES Statements for Christian<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Management_of_pb_glossary_id%221656%22GERDpb_glossary\" >Management of <button class=\"glossary-term\" aria-describedby=\"128-1656\">GERD<\/button><\/a><ul class='ez-toc-list-level-2' ><li class='ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Christians_Medication_and_Laboratory_Values\" >Christian&#8217;s Medication and Laboratory Values<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Dietary_Strategies\" >Dietary Strategies<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Christians_Dietary_Data_GERD_Trigger_Foods\" >Christian&#8217;s Dietary Data: GERD Trigger Foods<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Lifestyle_Strategies\" >Lifestyle Strategies<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Christians_Lifestyle_Habits\" >Christian&#8217;s Lifestyle Habits<\/a><\/li><\/ul><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Management_of_IBS\" >Management of IBS<\/a><ul class='ez-toc-list-level-2' ><li class='ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-10\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Food_Symptom_Journals\" >Food Symptom Journals<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-11\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Bristol_Stool_Scale\" >Bristol Stool Scale<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-12\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Traditional_Trigger_Foods_and_Beverages\" >Traditional Trigger Foods and Beverages<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-13\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Christians_Dietary_Data_IBS_Trigger_Foods\" >Christian&#8217;s Dietary Data: IBS Trigger Foods<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-14\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#FODMAP_Diet\" >FODMAP Diet<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-15\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Caveats\" >Caveats<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-16\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Phase_1_Elimination\" >Phase 1: Elimination<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-17\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Phase_2_Reintroduction\" >Phase 2: Reintroduction<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-18\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Probiotics_and_Other_Supplements\" >Probiotics and Other Supplements<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-19\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Management_of_Celiac_Disease\" >Management of Celiac Disease<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-20\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Management_of_Diverticulitis\" >Management of Diverticulitis<\/a><ul class='ez-toc-list-level-2' ><li class='ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-21\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Preventing_Diverticular_Disease\" >Preventing Diverticular Disease<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-22\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Managing_Acute_Diverticulitis\" >Managing Acute Diverticulitis<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-23\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Simulation_Activity_Christian\" >Simulation Activity: Christian<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-1'><a class=\"ez-toc-link ez-toc-heading-24\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Nutrition_Care_Plan_Summary\" >Nutrition Care Plan Summary<\/a><ul class='ez-toc-list-level-2' ><li class='ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-25\" href=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/chapter\/gi_out-plan\/#Christians_Nutrition_Care_Plan\" >Christian&#8217;s Nutrition Care Plan<\/a><\/li><\/ul><\/li><\/ul><\/nav><\/div>\n<h1><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-1024x132.png\" alt=\"Step 2: Plan\" width=\"1024\" height=\"132\" class=\"alignnone wp-image-1368 size-large\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-1024x132.png 1024w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-300x39.png 300w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-768x99.png 768w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-1536x198.png 1536w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-2048x264.png 2048w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-65x8.png 65w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-225x29.png 225w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-350x45.png 350w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/h1>\n<header class=\"textbox__header\"><\/header>\n<h1><span class=\"ez-toc-section\" id=\"Common_PES_Statement_Terminology\"><\/span>Common PES Statement Terminology<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<p><span>As you interpret the dietary data from the assessment, you can form Problem, Etiology, Symptoms (PES) statements or nutrition diagnoses that help identify nutrition concerns that need to be addressed in your plan. If you are not familiar with how to write a PES statement please review this<a href=\"https:\/\/www.ncpro.org\/pub\/file.cfm?item_type=xm_file&amp;id=93467\"> resource from the Academy of Nutrition and Dietetics<\/a>.<\/span><\/p>\n<p>Here are some common nutrition problems that clients may experience:<\/p>\n<ul>\n<li>Excessive energy intake<\/li>\n<li>Not ready for diet\/lifestyle change<\/li>\n<li>Inappropriate intake of types of carbohydrate<\/li>\n<li>Inappropriate intake of types of fats<\/li>\n<li>Limited food acceptance<\/li>\n<li>Inadequate vitamin\/mineral intake<\/li>\n<li>Inadequate fiber intake<\/li>\n<li>Food- and nutrition-related knowledge deficit<\/li>\n<li>Physical inactivity<\/li>\n<li>Unintended weight loss<\/li>\n<li>Altered nutrition-related laboratory values (specify)<\/li>\n<li>Disordered eating pattern<\/li>\n<li>Inability to manage self-care<\/li>\n<li>Impaired ability to prepare foods\/meals<\/li>\n<li>Limited adherence to recommendations<\/li>\n<\/ul>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"PES_Statements_for_Christian\"><\/span>PES Statements for Christian<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<div>\n<p>Here is a brief list of potential PES statements for Christian. At this stage, the problem is mostly related to a lack of nutrition education in the past and a willingness to make changes.<\/p>\n<\/div>\n<ol>\n<li>Food and nutrition related knowledge deficit related to a lack of previous disease specific education from a dietitian as evidenced by client report and dietary\/lifestyle history.<\/li>\n<li>Not ready for diet changes related to a lack of desire to remove \u201ctrigger\u201d foods as evidenced by clients resistance to remove coffee and alcohol from diet to relieve IBS and GERD symptoms.<\/li>\n<li>Inappropriate food intake related to knowledge deficit as evidenced by the consistent consumption of traditional \u201ctrigger\u201d foods for GERD and IBS (tomatoes, onions, garlic, spices, caffeine, alcohol).<\/li>\n<li>Inadequate physical activity as evidenced by client report (under 150 minutes per week guideline).<\/li>\n<\/ol>\n<\/div>\n<\/div>\n<h1>Management of <button class=\"glossary-term\" aria-describedby=\"128-1656\">GERD<\/button><\/h1>\n<p>Counsel the client on dietary and lifestyle triggers for GERD, and build a strategy to manage them closely for 2-4 weeks. Reintroduce foods as tolerated and depending on symptoms. Please note that triggers may vary, and restrictive diets may not be appropriate for all individuals.<\/p>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"Christians_Medication_and_Laboratory_Values\"><\/span>Christian&#8217;s Medication and Laboratory Values<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p>As previously mentioned in the Assess stage, Christian was experiencing heartburn, regurgitation, and hiccups before starting his medication. Christian hopes to reduce or remove the medication entirely, so it is important to provide him with education and strategies for the relief of symptoms.<\/p>\n<div><\/div>\n<p>When considering Christian\u2019s management for GERD, it is also important to consider the potential adverse effects of his medications.<\/p>\n<div><\/div>\n<p>We know the following about Christian:<\/p>\n<ul>\n<li><span style=\"font-size: 1em;text-align: initial\">He has been taking Nexium (a proton pump inhibitor) for his GERD for 4 weeks<\/span><\/li>\n<li><span style=\"font-size: 1em;text-align: initial\">He has <\/span><span style=\"font-size: 1em;text-align: initial\">low serum iron and ferritin and is on the low-normal range for vitamin B12. <\/span><\/li>\n<li><span style=\"font-size: 1em;text-align: initial\">He reports that he experiences extreme fatigue, headaches, and lightheadedness. Although these symptoms may be attributed in part to other lifestyle factors, you should consider his laboratory values in the context of these symptoms (as they are common).<\/span><\/li>\n<\/ul>\n<p>As <strong>vitamin B12 and iron are nutrients of concern when taking proton pump inhibitors (PPI&#8217;s) for extended periods of time<\/strong>, it is important to consider that Christian already has low laboratory values.<\/p>\n<p><span style=\"text-align: initial;font-size: 1em\">Consider the recommendation of an iron and vitamin B12 supplement, if it is appropriate and aligns with your clients needs. You may or may not consult with the interdisciplinary team regarding supplementation (it is not necessary, but you may want to in some cases depending on the client and care plan).<\/span><\/p>\n<\/div>\n<\/div>\n<h2><span class=\"ez-toc-section\" id=\"Dietary_Strategies\"><\/span>Dietary Strategies<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>These are dietary strategies to help individuals manage their GERD symptoms:<\/p>\n<ul>\n<li><strong>Avoid foods that increase gastric pressure: <\/strong>e.g. anything carbonated.<\/li>\n<li><strong>Avoid foods that relax the Lower Esophageal Sphincter<\/strong> (LES): e.g. hot sauce, mints (spearmint, peppermint), fried foods, fatty foods, spicy foods, chocolate, caffeine, and alcohol.<\/li>\n<li><strong>Eat smaller meals throughout the day: <\/strong>5 \u2013 6 meals is ideal. Large meals take a longer time to empty from the stomach, exerting pressure on the LES.<\/li>\n<li><strong>Slow your eating and drinking:<\/strong> Eat and drink slowly, and chew foods well. Do not use straws or chew gum.<\/li>\n<li><strong>Avoid foods and beverages below pH 4<\/strong>: In some cases, symptoms can be managed through avoiding foods and beverages like pineapple, strawberries, coca cola, cognac, cranberry juice, and yellow mustard. You may obtain detailed lists for this.<\/li>\n<li><strong>Avoid other common triggers<\/strong>: e.g. citrus fruits and juices, tomatoes, chocolate, onions, garlic, and spicy foods.<\/li>\n<\/ul>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<h3 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"Christians_Dietary_Data_GERD_Trigger_Foods\"><\/span>Christian&#8217;s Dietary Data: GERD Trigger Foods<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<\/header>\n<div class=\"textbox__content\">\n<p>In consideration of dietary recommendations for the management of GERD, it is important to highlight key foods that may be contributing to Christian\u2019s symptoms. In Christian\u2019s case, this is his first appointment with you. It is important not to overwhelm him with suggestions. Instead, focus on key \u201dtrigger foods\u201d and \u201csimple recommendations\u201d such as swapping apples, tomatoes, onions, garlic (spices or seasoning) for other types of vegetables, and reducing caffeine and alcohol intake. Reducing consumption of these foods aligns with dietary management strategies for GERD.<\/p>\n<table class=\"grid\" style=\"width: 100%;height: 277px\">\n<caption>Christian&#8217;s 24-hour diet recall<br \/>\n<span style=\"background-color: #ffff00\">[*] indicates trigger foods for GERD<\/span><\/caption>\n<tbody>\n<tr style=\"height: 15px\">\n<th style=\"height: 15px\" scope=\"col\">Meal<\/th>\n<th style=\"height: 15px\" scope=\"col\">Christian&#8217;s diet recall<\/th>\n<\/tr>\n<tr style=\"height: 70px\">\n<td style=\"height: 70px\">Breakfast 6 am<\/td>\n<td style=\"height: 70px\">Fruit smoothie (strawberries, <span style=\"background-color: #ffff00\"><strong>apple*<\/strong><\/span>, avocado, kale, cucumber, almond milk), 2 hard boiled egg or \u201degg muffins\u201d with spinach mixed in, and <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\n<\/tr>\n<tr style=\"height: 87px\">\n<td style=\"height: 87px\">Lunch<br \/>\n12 pm<\/td>\n<td style=\"height: 87px\">Premade salad or rice bowl (spring mix or brown rice, marinated or spiced baked chicken, cucumber, tomato, green pepper, onion, chick peas or kidney beans, walnuts, and feta or goat cheese with an olive oil dressing or any \u201clight\u201d dressing available), <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\n<\/tr>\n<tr style=\"height: 70px\">\n<td style=\"height: 70px\">Dinner<br \/>\n5 pm<\/td>\n<td style=\"height: 70px\">6 oz baked fish, chicken, or beef, with mixed roasted vegetables (broccoli, cauliflower, asparagus, potatoes cooked in olive oil with <span style=\"background-color: #ffff00\"><strong>garlic, paprika, and other spices*<\/strong><\/span>), and 1 cup of quinoa, rice, or whole grain pasta<\/td>\n<\/tr>\n<tr style=\"height: 35px\">\n<td style=\"height: 35px\">HS snack<br \/>\n11 pm<\/td>\n<td style=\"height: 35px\"><span style=\"background-color: #ffff00\"><strong>1-2 glasses of red wine*<\/strong><\/span>, 1-2 cookies or 2 cups of popcorn or carrots with red pepper hummus<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>\n<h2><span class=\"ez-toc-section\" id=\"Lifestyle_Strategies\"><\/span>Lifestyle Strategies<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>While it may not be a concern during an initial appointment, physical activity is an important lifestyle strategy and can be addressed at a follow-up.<\/p>\n<p>Clients can be encouraged to complete:<\/p>\n<ul>\n<li>150 minutes of moderate to vigorous aerobic exercise every week (e.g. 30 minutes, five days a week)<\/li>\n<li>Resistance exercises (like lifting weights) two to three times a week<\/li>\n<\/ul>\n<p>It some cases, it may be beneficial to refer clients to the physiotherapist to be:<\/p>\n<ul>\n<li>Assessed for conditions that might place them at increased risk for an adverse event or injury during certain exercises<\/li>\n<li>Supervised by an exercise specialist for a certain period of time to ensure safety<\/li>\n<\/ul>\n<p>In addition to being physically active, here are more lifestyle strategies to help individuals manage their GERD symptoms:<\/p>\n<ul>\n<li>Practice stress management<\/li>\n<li>Avoid alcohol or smoking<\/li>\n<li>Do not lie down for 2-3 hours after eating<\/li>\n<li>Try raising the head of your bed to avoid laying flat at night<\/li>\n<li>Avoid wearing tight clothing around your stomach and chest<\/li>\n<li>Maintain a healthy weight: Consider this strategy in the context of your client\u2019s history and goals. Many normal and underweight individuals experience GERD and it may not be the most crucial factor for your client. Always consider that weight is not a modifiable factor for everyone and may not be realistic for your client.<\/li>\n<\/ul>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<h3 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"Christians_Lifestyle_Habits\"><\/span>Christian&#8217;s Lifestyle Habits<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<\/header>\n<div class=\"textbox__content\">\n<p>In addition to reviewing dietary data, lifestyle habits play an important role in managing GERD and IBS. After you discuss with Christian, he provides you with the information regarding his willingness to make changes to his lifestyle habits that may help relieve GERD symptoms.<\/p>\n<div><\/div>\n<div>Christian&#8217;s lifestyle habits are listed here:<\/div>\n<ul>\n<li>Christian reports eating quickly during meals, especially during breakfast and lunch as his workdays are busy. After discussion, Christian will try to eat his meals slowly.<\/li>\n<li>Christian does not have time to take a \u201csnack break\u201d during the workday. After discussion, Christian prefers to eat three meals a day and does not want to worry about snacks.<\/li>\n<li>Christian reports sleeping from 12:00am &#8211; 6:00am. After discussion, he recognizes that he should be sleeping more, which may help reduce his stress levels. He is willing to go to bed at 11:00pm.<\/li>\n<li>Christian reports wearing tight clothing (his business attire is a suit). After discussion, this is not negotiable.<\/li>\n<li>Christian exercises 2 times per week for 60 minutes, which does meet the guidelines (~150 minutes per week). He is not currently interested in engaging in more physical activity. Since dietary concerns are of greater importance at this stage of his nutrition care, there is no physical activity plan at this time.<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<h1><span class=\"ez-toc-section\" id=\"Management_of_IBS\"><\/span>Management of IBS<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<p>Elimination diets are often used for IBS. The <button class=\"glossary-term\" aria-describedby=\"128-1410\">FODMAP<\/button> elimination diet (<em>which will be explained later on<\/em>) has a growing body of evidence but is still widely criticized. There are \u201ctraditional food triggers\u201d that can be explored before using a restrictive or elimination diet, such as FODMAP. Using a FODMAP diet requires commitment and dedication for it to be effective, which may not be necessary.<\/p>\n<p>It is up to the dietitian and client to determine the need for an intensive strategy, but it may be best to explore \u201ctraditional triggers first\u201d using a food symptom journal.<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Food_Symptom_Journals\"><\/span>Food Symptom Journals<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>Keeping a food and symptom journal is critical to improving digestive symptoms. By consistently tracking multiple factors that relate to your digestive system, you can identify what may be triggering symptoms and truly relieve digestive symptoms.<\/p>\n<p>During an initial appointment for IBS, it is important to provide a detailed explanation of the food symptom journal and the expectations for documenting. This will help the client understand and provide you with the best information for assessment, recommendations, and plans. Keeping a food symptom journal for 1-2 weeks before a follow-up appointment is often the first \u201cplan of action.\u201d<\/p>\n<p>A food symptom journal can be kept in a table format, and should include the following headings:<\/p>\n<ul>\n<li><strong>Day and time:\u00a0<\/strong>what time of day you eat<\/li>\n<li><strong>Food and beverages: <\/strong>exactly what you eat and drink (including condiments, sauces, and seasonings)<\/li>\n<li><strong>Environment:\u00a0<\/strong>where you are eating (homemade or outside food) and what&#8217;s going on that day (e.g. stress levels, people around you, events, eating behaviors, etc.)<\/li>\n<li><strong>Symptoms and severity:\u00a0<\/strong>indicate symptom severity on a scale of 1 to 5. Often the client will choose 2-3 symptoms that are affected by the most and focus on those when recording; they can denote symptoms with a letter for ease of recording<\/li>\n<li><strong>Bowel<\/strong> <strong>movements<\/strong>: indicate number and consistency according to the Bristol Stool Scale<\/li>\n<\/ul>\n<h3><span class=\"ez-toc-section\" id=\"Bristol_Stool_Scale\"><\/span>Bristol Stool Scale<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>The Bristol stool scale is a diagnostic tool that you can provide clients for explaining the appearance of their stool. The scale classifies stool into seven types, listed and depicted in the table and image below.<\/p>\n<table class=\"grid\" style=\"border-collapse: collapse;height: 136px;width: 100%\">\n<caption>Bristol Stool Scale<\/caption>\n<tbody>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"col\">Type<\/th>\n<th style=\"width: 12.7749%;height: 17px\" scope=\"col\">Description<\/th>\n<th style=\"width: 14.8901%;height: 17px\" scope=\"col\">Indication<\/th>\n<\/tr>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 1<\/th>\n<td style=\"width: 12.7749%;height: 17px\">Separate hard lumps<\/td>\n<td style=\"width: 14.8901%;height: 17px\">Constipation (severe)<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 2<\/th>\n<td style=\"width: 12.7749%;height: 17px\">Lumpy and sausage like<\/td>\n<td style=\"width: 14.8901%;height: 17px\">Constipation (mild)<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 3<\/th>\n<td style=\"width: 12.7749%;height: 17px\">A sausage shape with cracks in the surface<\/td>\n<td style=\"width: 14.8901%;height: 17px\">Normal<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 4<\/th>\n<td style=\"width: 12.7749%;height: 17px\">Like a smooth, soft sausage or snake<\/td>\n<td style=\"width: 14.8901%;height: 17px\">Normal<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 5<\/th>\n<td style=\"width: 12.7749%;height: 17px\">Soft blobs with clear-cut edges<\/td>\n<td style=\"width: 14.8901%;height: 17px\">Lack of fibre<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 6<\/th>\n<td style=\"width: 12.7749%;height: 17px\">Mushy consistency with ragged edges<\/td>\n<td style=\"width: 14.8901%;height: 17px\">Diarrhea (mild)<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<th style=\"width: 2.79188%;height: 17px\" scope=\"row\">Type 7<\/th>\n<td style=\"width: 12.7749%;height: 17px\">Liquid consistency with no solid pieces<\/td>\n<td style=\"width: 14.8901%;height: 17px\">Diarrhea (severe)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<figure id=\"attachment_1345\" aria-describedby=\"caption-attachment-1345\" style=\"width: 698px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/BristolStoolChart.png\" alt=\"Chart of Bristol stool scale, outlining seven types of stool in order of consistency (solid to liquid) and indication (constipation to diarrhea)\" width=\"698\" height=\"420\" class=\"wp-image-1345 size-full\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/BristolStoolChart.png 698w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/BristolStoolChart-300x181.png 300w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/BristolStoolChart-65x39.png 65w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/BristolStoolChart-225x135.png 225w, https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/BristolStoolChart-350x211.png 350w\" sizes=\"auto, (max-width: 698px) 100vw, 698px\" \/><figcaption id=\"caption-attachment-1345\" class=\"wp-caption-text\">Bristol Stool scale, with illustrations<br \/>Source:Cabot Health, <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\">CC BY-SA 3.0<\/a>, via <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:BristolStoolChart.png\">Wikimedia Commons<\/a><\/figcaption><\/figure>\n<h3><span class=\"ez-toc-section\" id=\"Traditional_Trigger_Foods_and_Beverages\"><\/span>Traditional Trigger Foods and Beverages<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>This list can serve as a reference point for you and the client to identify common \u201ctrigger foods&#8221; and as a first step to resolve symptoms before consideration of an elimination diet (e.g. FODMAP).<\/p>\n<ul>\n<li>Avoid or limit caffeine and chocolate<\/li>\n<li>Avoid all preservatives and artificial flavours<\/li>\n<li>Avoid most raw fruits and vegetables<\/li>\n<li>Avoid wheat<\/li>\n<li>No alcohol<\/li>\n<li>No cabbage in any form (e.g. cauliflower, cabbage, broccoli, brussels sprouts)<\/li>\n<li>No corn or popcorn<\/li>\n<li>No onion or garlic<\/li>\n<li>No red meat or deli meats<\/li>\n<li>No spices (e.g. cinnamon, curry, chili powder, black pepper cumin)<\/li>\n<li>No vinegars or anything fermented<\/li>\n<li>No whole seeds or nuts<\/li>\n<\/ul>\n<div>\n<p>Consider using a more comprehensive list during your practice.<\/p>\n<\/div>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<h3 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"Christians_Dietary_Data_IBS_Trigger_Foods\"><\/span>Christian&#8217;s Dietary Data: IBS Trigger Foods<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<\/header>\n<div class=\"textbox__content\">\n<p>The plan for Christian\u2019s IBS is to start with him using a food symptom journal to track his patterns over the next 1-2 weeks. He will come back with a strong representation of his habits (both dietary and environment). Managing IBS is trial and error, with a combination of various strategies, so the more we know about the person, the better.<\/p>\n<p>In the meantime you can start by identifying a few foods that are of concern from his dietary recall. The foods bolded in the chart are foods you may want to identify with Christian.<\/p>\n<table class=\"grid\" style=\"width: 100%;height: 277px\">\n<caption>Christian&#8217;s 24-hour diet recall<br \/>\n<span style=\"background-color: #ffff00\">[*] indicates trigger foods for IBS<\/span><\/caption>\n<tbody>\n<tr style=\"height: 15px\">\n<th style=\"height: 15px\" scope=\"col\">Meal<\/th>\n<th style=\"height: 15px\" scope=\"col\">Christian&#8217;s diet recall<\/th>\n<\/tr>\n<tr style=\"height: 70px\">\n<td style=\"height: 70px\">Breakfast 6 am<\/td>\n<td style=\"height: 70px\">Fruit smoothie (<span style=\"background-color: #ffff00\"><strong>strawberries*<\/strong><\/span>, <span style=\"background-color: #ffff00\"><strong>apple*<\/strong><\/span>, avocado, kale, cucumber, almond milk), 2 hard boiled egg or \u201degg muffins\u201d with spinach mixed in, and <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\n<\/tr>\n<tr style=\"height: 87px\">\n<td style=\"height: 87px\">Lunch<br \/>\n12 pm<\/td>\n<td style=\"height: 87px\">Premade salad or rice bowl (spring mix or brown rice, <span style=\"background-color: #ffff00\"><strong>marinated or spiced*<\/strong><\/span> baked chicken, cucumber, <span style=\"background-color: #ffff00\"><strong>tomato*<\/strong><\/span>, green pepper, <span style=\"background-color: #ffff00\"><strong>onion*<\/strong><\/span>, chick peas or <span style=\"background-color: #ffff00\"><strong>kidney beans, walnuts*<\/strong><\/span>, and feta or goat cheese with an olive oil dressing or any \u201clight\u201d dressing available), <span style=\"background-color: #ffff00\"><strong>1 large coffee with 2 cream (5%)*<\/strong><\/span><\/td>\n<\/tr>\n<tr style=\"height: 70px\">\n<td style=\"height: 70px\">Dinner<br \/>\n5 pm<\/td>\n<td style=\"height: 70px\">6 oz baked fish, chicken, or beef, with mixed roasted vegetables (<span style=\"background-color: #ffff00\"><strong>broccoli, cauliflower, asparagus*<\/strong><\/span>, potatoes cooked in olive oil with <span style=\"background-color: #ffff00\"><strong>garlic, paprika, and other spices*<\/strong><\/span>), and 1 cup of quinoa, rice, or whole grain pasta<\/td>\n<\/tr>\n<tr style=\"height: 35px\">\n<td style=\"height: 35px\">HS snack<br \/>\n11 pm<\/td>\n<td style=\"height: 35px\"><span style=\"background-color: #ffff00\"><strong>1-2 glasses of red wine*<\/strong><\/span>, 1-2 cookies or <span style=\"background-color: #ffff00\"><strong>2 cups of popcorn*<\/strong><\/span> or carrots with <span style=\"background-color: #ffff00\"><strong>red pepper hummus*<\/strong><\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>In Christian&#8217;s case:<\/p>\n<ul>\n<li>You can create a plan together about foods he is willing to remove (even on a trial basis) to evaluate he symptoms.<\/li>\n<li>You can give him low-FODMAP alternatives (<em>which will be listed later on) <\/em>to replace these traditional trigger foods. Note that these recommendations are similar to the ones we created for GERD.<\/li>\n<li>It is reasonable to create nutrition recommendations for both GI concerns, as they compliment each other. But in other cases, too many changes or recommendations in an appointment may become overwhelming and may not be appropriate.<\/li>\n<li>You are not going to start a FODMAP diet immediately because this is the first appointment and you should gather more information and try eliminating traditional triggers first<\/li>\n<\/ul>\n<\/div>\n<\/div>\n<h2><span class=\"ez-toc-section\" id=\"FODMAP_Diet\"><\/span>FODMAP Diet<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p><strong>FODMAP<\/strong> is an acronym for:<\/p>\n<ul>\n<li><strong>F<\/strong>ermentable<\/li>\n<li><strong>O<\/strong>ligosaccharides (Fructans &amp; Galacto-oligosaccharides)<\/li>\n<li><strong>D<\/strong>isaccharides (Lactose)<\/li>\n<li><strong>M<\/strong>onosaccharides (Fructose)<\/li>\n<li><strong>A<\/strong>nd<\/li>\n<li><strong>P<\/strong>olyols (Mannitol and Sorbitol)<\/li>\n<\/ul>\n<p>These are short-chain carbohydrates that have been shown to increase water volume in the small intestine and be rapidly fermented in the large intestine. This leads to increased gas production and symptoms (i.e. pain, bloating, distension, flatulence, nausea and altered bowel motility). A low FODMAP diet restricts these short-chain carbohydrates.<\/p>\n<p>A low FODMAP diet is the only focused elimination-type diet that is appropriate for IBS. Even if an individual is not pursing a FODMAP diet, it is still important to understand FODMAPs and where they are found.\u00a0 You should seek further readings to review and become familiar with the common high FODMAP foods in each group.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"Caveats\"><\/span>Caveats<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>The low FODMAP diet is considered to be a<strong> second-line dietary strategy that can pursued <em>after<\/em><\/strong>:<\/p>\n<ul>\n<li>Assessment<\/li>\n<li>Management of dietary and lifestyle factors<\/li>\n<li>Elimination of &#8220;traditional triggers&#8221;<\/li>\n<\/ul>\n<p><strong>The long-term restriction of FODMAPs is not recommended<\/strong>. Briefly, recent research suggests that long term FODMAP restriction carries the risk of nutritional inadequacy, has the potential to foster disordered eating, and potentially unfavourable gut microbiota (although the impact is unknown).<\/p>\n<p>Structured reintroduction of FODMAPs is recommended after six weeks to identify which FODMAPs an individual is sensitive to, assess tolerance to individual high FODMAP foods, promote food variety and support long-term self-management.<\/p>\n<p>The key is to find and emphasize substitutions for foods that are eliminated (as they are triggers). This is to help clients make realistic and positive changes and reduce the fear and anxiety around consuming foods.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"Phase_1_Elimination\"><\/span>Phase 1: Elimination<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>The FODMAP diet involves a three-phase approach. The first phase is \u201cElimination\u201d focused on replacing foods high in FODMAPs with those lower in FODMAPs. It is very important to work with your client to ensure they are still eating a balanced diet.<\/p>\n<p>Dietary strategies may include the following:<\/p>\n<ol>\n<li>Avoiding foods that are substantial sources of fructans (e.g. wheat, rye, onions, garlic) and galactans (e.g. cabbage, certain vegetables, legumes such as chickpeas).<\/li>\n<li>Restricting lactose-containing foods (if lactose malabsorption intolerance is present).<\/li>\n<li>Avoiding naturally-occurring and artificial polyols (e.g. stone fruits, and mushrooms, sugar-free chewing gum).<\/li>\n<\/ol>\n<p>The following list acts as an example of information you may provide a client. This is not comprehensive, and if following a FODMAP diet, you will want to provide your client with a more detailed list.<\/p>\n<table class=\"grid\" style=\"height: 380px\">\n<caption>Foods high and low in FODMAP, by food category<\/caption>\n<tbody>\n<tr style=\"height: 44px\">\n<th style=\"height: 44px;width: 88.7031px\" scope=\"col\">Food Category<\/th>\n<th style=\"height: 44px;width: 330.797px\" scope=\"col\">Avoid High FODMAP foods<\/th>\n<th style=\"height: 44px;width: 381.375px\" scope=\"col\">Choose Low FODMAP foods<\/th>\n<\/tr>\n<tr style=\"height: 73px\">\n<th style=\"height: 73px;width: 88.7031px\" scope=\"row\">Vegetables<\/th>\n<td style=\"height: 73px;width: 330.797px\">\n<ul>\n<li>Artichoke<\/li>\n<li>Asparagus<\/li>\n<li>Cauliflower<\/li>\n<li>Garlic<\/li>\n<li>Green peas<\/li>\n<li>Leek<\/li>\n<li>Mushrooms<\/li>\n<li>Onion<\/li>\n<li>Sugar snap peas<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 73px;width: 381.375px\">\n<ul>\n<li>Aubergine\/eggplant<\/li>\n<li>Bell pepper<\/li>\n<li>Bok Choy<\/li>\n<li>Broccoli<\/li>\n<li>Carrot<\/li>\n<li>Cucumber<\/li>\n<li>Green beans<\/li>\n<li>Kale<\/li>\n<li>Lettuce<\/li>\n<li>Potato<\/li>\n<li>Tomato<\/li>\n<li>Zucchini<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 58px\">\n<th style=\"height: 58px;width: 88.7031px\" scope=\"row\">Fruit<\/th>\n<td style=\"height: 58px;width: 330.797px\">\n<ul>\n<li>Apples, apple juice<\/li>\n<li>Cherries<\/li>\n<li>Dried fruit<\/li>\n<li>Mango<\/li>\n<li>Nectarines<\/li>\n<li>Peaches<\/li>\n<li>Pears<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 58px;width: 381.375px\">\n<ul>\n<li>Blueberries (\u00bc cup)<\/li>\n<li>Cantaloupe<\/li>\n<li>Grapes<\/li>\n<li>Kiwi<\/li>\n<li>Mandarin<\/li>\n<li>Orange<\/li>\n<li>Pineapple<\/li>\n<li>Raspberries (one-third cup)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 88px\">\n<th style=\"height: 88px;width: 88.7031px\" scope=\"row\">Protein sources<\/th>\n<td style=\"height: 88px;width: 330.797px\">\n<ul>\n<li>Cow\u2019s milk<\/li>\n<li>Custard<\/li>\n<li>Evaporated milk<\/li>\n<li>Ice cream<\/li>\n<li>Sweetened condensed milk<\/li>\n<li>Soy beverage (made with soybeans)<\/li>\n<li>Yogurt<\/li>\n<li>Most legumes or pulses<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 88px;width: 381.375px\">\n<ul>\n<li>Almond milk<\/li>\n<li>Brie and camembert cheese<\/li>\n<li>Feta cheese<\/li>\n<li>Hard cheeses<\/li>\n<li>Lactose-free milk and yogurt<\/li>\n<li>Soy beverage (made with soy protein)<\/li>\n<li>Eggs<\/li>\n<li>Firm tofu<\/li>\n<li>Plain meats, poultry, seafood and fish<\/li>\n<li>Tempeh<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 59px\">\n<th style=\"height: 59px;width: 88.7031px\" scope=\"row\">Grain products<\/th>\n<td style=\"height: 59px;width: 330.797px\">Wheat, rye, and barley- based products, including:<\/p>\n<ul>\n<li>breakfast cereals<\/li>\n<li>cookies<\/li>\n<li>crackers<\/li>\n<li>snack products.<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 59px;width: 381.375px\">\n<ul>\n<li>Corn or quinoa flake<\/li>\n<li>Oats<\/li>\n<li>Quinoa or corn pasta<\/li>\n<li>Rice<\/li>\n<li>Rice noodles<\/li>\n<li>Rice cakes<\/li>\n<li>Sourdough spelt bread<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 58px\">\n<th style=\"height: 58px;width: 88.7031px\" scope=\"row\">Nuts and seeds<\/th>\n<td style=\"height: 58px;width: 330.797px\">\n<ul>\n<li>Cashews<\/li>\n<li>Pistachios<\/li>\n<\/ul>\n<\/td>\n<td style=\"height: 58px;width: 381.375px\">\n<ul>\n<li>Almonds (10)<\/li>\n<li>Macadamia nuts<\/li>\n<li>Peanuts<\/li>\n<li>Pumpkin seeds<\/li>\n<li>Sunflower seeds<\/li>\n<li>Walnuts<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><span class=\"ez-toc-section\" id=\"Phase_2_Reintroduction\"><\/span>Phase 2: Reintroduction<span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>The goals of the reintroduction phase are to help:<\/p>\n<ul>\n<li>Increase variety and re-introduction of foods quickly<\/li>\n<li>Identify foods that do and do not trigger symptoms.<\/li>\n<\/ul>\n<p>Clients can reintroduce each FODMAP category one at a time to determine which foods they can tolerate and in what amounts. This process may be done gradually, rather than following a strict challenge protocol, depending on the client\u2019s preference.<span style=\"font-family: Barlow, sans-serif;font-size: 1.602em\"><\/span><\/p>\n<p>The goal is to introduce a high FODMAP food from just one category at a time, increasing the serving size over a 24-hour period to monitor for symptoms. If no symptoms occur after this trial, the next food can be reintroduced after 48 hours, assuming the client is feeling well.<span style=\"font-family: Barlow, sans-serif;font-size: 1.602em\"><\/span><\/p>\n<p>During the \u201cPersonalization\u201d phase, clients can begin adding foods back into their diet once they have identified which ones are tolerated without symptoms.<\/p>\n<p><span style=\"font-family: Barlow, sans-serif;font-size: 1.602em\">Phase 3: Personalization<\/span><\/p>\n<p>Once the client has tested a variety of FODMAP categories and has a stronger clarity about individual trigger foods and\/or portion sizes that are tolerable, the last step involves bringing FODMAP foods back into the diet to increase variety and nutritional quality.<\/p>\n<p>At this stage, it is a balancing act between symptom management and enjoyment of food (sometimes symptom management instead of resolution is the result). It is also important to remember other factors that influence IBS symptoms, such as stress and environment.<\/p>\n<p>The process for this personalization phase can be broken down into the following steps:<\/p>\n<ol>\n<li>Add one high FODMAP food per day<\/li>\n<li>Add another new FODMAP food the next day<\/li>\n<li>If these foods (and portion sizes) do not trigger symptoms, keep including them in your diet.<\/li>\n<li>If you experience symptoms, continue documenting in a food symptom journal to determine if this is a trigger food and return to regimen.<\/li>\n<\/ol>\n<h2><span class=\"ez-toc-section\" id=\"Probiotics_and_Other_Supplements\"><\/span>Probiotics and Other Supplements<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>Probiotics are\u00a0 edible, living microorganisms that may be helpful in the management of IBS. There are many probiotic products available in different doses and variable bacterial strains. Many practitioners and clients have reported improvement of IBS symptoms with probiotic use.<\/p>\n<p>In general, taking probiotics for IBS is considered safe. If an individual finds four weeks of use of a probiotic is beneficial, they can continue to take it. This is a decision to be made between the client and the dietitian, in consideration of a variety of factors (adherence, effectiveness, cost).<\/p>\n<p>Individuals with IBS who choose to try probiotics should be aware that some products contain other ingredients that may increase IBS symptoms (e.g. dietary fibre: oats; FODMAPs: inulin, lactose, fructose, sorbitol and xylitol).<\/p>\n<p>There is currently inadequate evidence to recommend any specific probiotic product independent of IBS-subtype (constipation or diarrhea or mixed predominant IBS)<\/p>\n<p>The minimum concentration of bacteria typically recommended in probiotic supplements is 1 billion CFU per dose or higher. However, some research may demonstrate the effectiveness of a smaller dose for specific strains. Most probiotics range from 1 billion \u2013 10 billion (with some up to 50 billion).<\/p>\n<p>In addition to probiotics, here is a list of other IBS management supplements that clients may ask you about:<\/p>\n<ul>\n<li>Digestive Enzymes<\/li>\n<li>Prebiotics<\/li>\n<li>Apple Cider Vinegar<\/li>\n<li>IBGard (peppermint)<\/li>\n<li>Biocidin (herbal)<\/li>\n<li>Candibactin (herbal)<\/li>\n<li>Ginger<\/li>\n<\/ul>\n<p>It is worthwhile to explore the evidence surrounding these supplements as you may receive questions about them in practice.<\/p>\n<h1><span class=\"ez-toc-section\" id=\"Management_of_Celiac_Disease\"><\/span>Management of Celiac Disease<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<div class=\"textbox shaded\"><strong>Note<\/strong>:<strong>\u00a0<\/strong>This section of the Plan stage does not concern our client Christian, and is meant to provide you with an introductory overview of education for celiac disease.<\/div>\n<p>Although celiac disease cannot be &#8220;cured&#8221;, it can be managed effectively by keeping a strict gluten-free diet.<\/p>\n<p>To help manage a client&#8217;s celiac disease:<\/p>\n<ul>\n<li>Look out for nutrient deficiencies: iron (in 50% of diagnosed), vitamin D, folate, B12, B6, and zinc.<\/li>\n<li>Evaluate a client&#8217;s diet for nutrients of concern (as a result of a gluten-free diet and their dietary behaviours)<\/li>\n<li>Develop strategies to provide a balanced and nutrient dense diet.<\/li>\n<\/ul>\n<p>It is important to overview the following with someone who is newly diagnosed with celiac disease:<\/p>\n<ul>\n<li>Cross-Contamination: Individuals with celiac disease should have their own cooking supplies, utensils and condiments.<\/li>\n<li>A general list of foods to avoid and foods to include: This is a starting point to get individuals familiar with gluten-containing foods in various categories. May consider using a phone \u201capp\u201d for scanning barcodes or eating at restaurants as lists can be overwhelming.<\/li>\n<li>Reading food labels: even though many food companies are highlighting \u201cgluten-free\u201d on labels, it is important that individuals know common and \u201chidden\u201d ingredients to look for.<\/li>\n<\/ul>\n<p>Review the list of gluten containing foods below<\/p>\n<div id=\"h5p-44\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-44\" class=\"h5p-iframe\" data-content-id=\"44\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"List of gluten-containing foods and ingredients\"><\/iframe><\/div>\n<\/div>\n<h1><span class=\"ez-toc-section\" id=\"Management_of_Diverticulitis\"><\/span>Management of Diverticulitis<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<div class=\"textbox shaded\"><strong>Note<\/strong>:<strong>\u00a0<\/strong>This section of the Plan stage does not concern our client Christian, and is meant to provide you with an introductory overview of education for diverticulitis.<\/div>\n<h2><span class=\"ez-toc-section\" id=\"Preventing_Diverticular_Disease\"><\/span>Preventing Diverticular Disease<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>Practice-based Evidence in Nutrition (PEN) suggests that the overall recommendations for the prevention of diverticular disease and acute diverticulitis are based on small amounts of low-quality evidence. However, <strong>they provide the recommendations with caution as a result of limitations in evidence<\/strong>.<\/p>\n<p>Healthy lifestyle practices should be encouraged to prevent diverticular disease and acute diverticulitis. General recommendations include:<\/p>\n<ul>\n<li>Consuming a high fibre diet through dietary sources with or without supplementation (e.g. up to 20 grams per day of supplementary fibre)<\/li>\n<li>A diet high in fruit, vegetables and whole grains<\/li>\n<li>Staying hydrated<\/li>\n<li>Being physically active<\/li>\n<li>Limiting intake of red meat<\/li>\n<li>Ensuring adequate vitamin D levels<\/li>\n<li>Limiting intake of alcohol consumption and not smoking (although no significant associations have been found)<\/li>\n<li>Avoiding nuts, corn, popcorn and fruit with small seeds (e.g. strawberries, blueberries)\u00a0<em>in some cases<\/em>.\n<ul>\n<li>This applies mostly to those who experience an occurrence of acute diverticulitis, if they have worsening symptoms that may be related to the consumption of these foods (common triggers)<\/li>\n<li>Assess this recommendation on a case-by-case basis<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>A recommendation regarding probiotics cannot be made at this time. However, there is emerging data to suggest the beneficial use of probiotics for diverticulitis. Given there are no contradictions for probiotics, you and your client would decide whether probiotics may be a part of their nutrition care plan.<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Managing_Acute_Diverticulitis\"><\/span>Managing Acute Diverticulitis<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>The dietary management of acute diverticulitis is different than preventing it. It is important that clients understand the difference.<\/p>\n<p>If a client\/patient is having a diverticular flare, they can:<\/p>\n<ol>\n<li>Stick to a fluid-only diet for a few days until symptoms (i.e. pain) improve.<\/li>\n<li>Eat a low insoluble fibre diet while recovering. Once symptoms resolve, patients can return to a high-fibre diet.<\/li>\n<li>Receive antibiotics, as acute diverticulitis management is often accompanied by antibiotics<\/li>\n<\/ol>\n<h1><span class=\"ez-toc-section\" id=\"Simulation_Activity_Christian\"><\/span>Simulation Activity: Christian<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<p>To practice what you\u2019ve learned about GERD and IBS management, complete the simulation activity below. After you complete the simulation, review a summary of Christian&#8217;s nutrition care plan.<\/p>\n<p>&nbsp;<\/p>\n<div id=\"h5p-62\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-62\" class=\"h5p-iframe\" data-content-id=\"62\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Simulation for Outpatient GI\"><\/iframe><\/div>\n<\/div>\n<h1><span class=\"ez-toc-section\" id=\"Nutrition_Care_Plan_Summary\"><\/span>Nutrition Care Plan Summary<span class=\"ez-toc-section-end\"><\/span><\/h1>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\"><span class=\"ez-toc-section\" id=\"Christians_Nutrition_Care_Plan\"><\/span>Christian&#8217;s Nutrition Care Plan<span class=\"ez-toc-section-end\"><\/span><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p>Based on the details gathered prior to and during your initial appointment with Christian, here is a suggested nutrition care plan.<\/p>\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%;height: 170px\">\n<caption>Summary of recommendations for Christian&#8217;s nutrition care plan<\/caption>\n<tbody>\n<tr style=\"height: 15px\">\n<th style=\"width: 15.6489%;height: 15px\" scope=\"col\">Area of Concern<\/th>\n<th style=\"width: 134.351%;height: 15px\" scope=\"col\">Recommendations<\/th>\n<\/tr>\n<tr style=\"height: 87px\">\n<td style=\"width: 15.6489%;height: 87px\">Medication and supplements<\/td>\n<td style=\"width: 134.351%;height: 87px\">\n<ul>\n<li>Continue taking Metamucil and vitamin D<\/li>\n<li>Continue taking PPI. The goal is to implement dietary and lifestyle strategies to remove or wean off PPI&#8217;s<\/li>\n<li>Start taking iron and vitamin B12 supplements, as directed by RD. Start with B12 supplement and elimination diet. Add iron supplement 1-2 weeks after depending on clients preference. A \u201cstaggered\u201d approach is used in consideration of side effects of supplementation (especially iron).<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 15.6489%\">GERD &amp; IBS Management<\/td>\n<td style=\"width: 134.351%\">\n<ul>\n<li>Keep a food symptom journal for 1-2 weeks<\/li>\n<li>Follow-up in 2 weeks to evaluate journal results and determine next steps<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<td style=\"width: 15.6489%;height: 17px\">Dietary choices<\/td>\n<td style=\"width: 134.351%;height: 17px\">\n<ul>\n<li>Continue eating foods that are high in fibre<\/li>\n<li>Seek lactose-free alternatives to dairy milk<\/li>\n<li>Reduce consumption of caffeine (to 1 coffee per day) and alcohol (to 1 drink every other day), as client is not comfortable with removing these entirely<\/li>\n<li>Avoid other triggers in diet, including: tomatoes, onions, cabbages (incl. broccoli and cauliflower), garlic, and added spices<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 17px\">\n<td style=\"width: 15.6489%;height: 17px\">Lifestyle habits<\/td>\n<td style=\"width: 134.351%;height: 17px\">\n<ul>\n<li>Continue to exercise 2 times per week for 1 hour; no changes required at this time<\/li>\n<li>Go to sleep earlier (1 hour earlier than normal)<\/li>\n<li>Eat meals and beverages slowly<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>\n<div class=\"textbox shaded\">PART 2: PLAN COMPLETE. Please pause to reflect on the nutrition care plan we created for Christian. When you\u2019re ready, move on to Part 3: Implementation.<\/div>\n<p>&nbsp;<\/p>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"128-1656\" hidden><p>Gastroesophageal Reflux Disease<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"128-1410\" hidden><p><strong>F<\/strong>ermentable <strong>O<\/strong>ligosaccharides, <strong>D<\/strong>isaccharides, <strong>M<\/strong>onosaccharides <strong>A<\/strong>nd <strong>P<\/strong>olyols (short-chain carbohydrates)<\/p>\n<\/div><\/div>","protected":false},"author":315,"menu_order":3,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-128","chapter","type-chapter","status-publish","hentry"],"part":106,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/128","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/users\/315"}],"version-history":[{"count":77,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/128\/revisions"}],"predecessor-version":[{"id":2421,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/128\/revisions\/2421"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/parts\/106"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapters\/128\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/media?parent=128"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/pressbooks\/v2\/chapter-type?post=128"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/contributor?post=128"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/dietmods\/wp-json\/wp\/v2\/license?post=128"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}