Food & Nutrition

Why This Registered Dietitian Tells (Some of) Her Patients to Avoid Kale Salads

I’ve worked as a dietitian in a gastroenterology practice long enough to have seen many food trends come and go.

When I first started practicing, an austere, sugar-free regimen called the “candida diet” was popular among patients of mine who had gone the alternative health route before consulting with me, so I practically got whiplash when just a few years later, the juicing craze hit and suddenly everyone seemed to be consuming nothing but sugar. After all, juicing just means creating a cocktail of concentrated sugars from the fruits and vegetables they derive from. Soon after, my patients ushered me through the paleo craze (what I call the neo-Paleolithic era of 2013-2014), and I’ve watched as increasing numbers of them have gone gluten-free since then as paleo and paleo-esque diets like Whole30 mandate cutting out gluten-containing foods. Starting in 2015, I’ve been called upon by patients figuring out how to eat “normally” again after so-called clean diets scared them into thinking that dairy, sugar, grains, and legumes were basically poison. Soon after, I watched helplessly as the ketogenic diet claimed almost everything that was healthy and good from some of my patients’ diets in favor of bacon, beef, and cheese. Most recently, I’ve been helping patients make sense of the overwhelming dietary dictates emerging from personalized food sensitivity and gut microbiome tests.

The particulars of each new diet sensation vary, but the scenario I encounter with my patients on these programs has been remarkably consistent. People arrive at my office having recently adopted a new regimen for which they drastically change their usual eating habits—eliminating certain foods and wholeheartedly embracing others—all in a quest for better health, better energy, and better living. Sometimes, at least initially, weight seems to be coming off, much to their delight. They’re excited about this new-found way of eating that promises to help them achieve their goals for health and weight. But diets based in eliminating and/or restricting foods and food groups rarely lead to longterm, sustained change. As SELF has reported, the ketogenic diet, for example, doesn’t seem to be any more or less effective for short term weight loss than any other way of restricting calories (and long term weight loss by way of keto is thought to be unlikely). Not only are elimination-based diets not necessarily helpful for weight loss, cultivating a relationship with food that’s based on restriction and avoidance is just unhealthy.

But there’s another, slightly sneakier culprit lurking in these fad diets. They may bring exciting changes after a few days or weeks, sure. But digestive system bliss? Not so much. Sometimes, after pivoting hard to a brand new healthy eating habit, people make an unexpected discovery: the foods they think of as good can sometimes make you feel bad.

I’ve seen newly minted vegans struggle with incessant gas and bloating on their new plant-based diets. I’ve seen people embrace giant salads for lunch every day, only to be rewarded with the telltale lower intestinal churning that requires a graceful but urgent exit from afternoon meetings.

This is but a small sampling of all the healthy-eating deeds that haven’t gone unpunished in my years of counseling patients with digestive disorders.

There are countless reasons why objectively nutrient-dense, health-promoting foods might not agree digestively with a given individual.

One common issue I see pertains to foods high in insoluble fiber, or what we commonly think of as “roughage.” It’s the crunchy, tough stuff found in leafy greens, fruits and veggies with thick skins or lots of seeds, popcorn kernels and bran, tough-coated seeds and crunchy nuts, stringy celery, or woody asparagus stalks. These coarse, highly textured types of fiber can remain surprisingly intact even after chewing, which leaves quite a job for the digestive system organs to break down into passable particle sizes. For some susceptible people, this means that large portions of such foods will spend a prolonged time being churned around in the stomach, provoking acid indigestion and upper stomach bloating.

Insoluble fiber is also unable to absorb or retain water in the digestive tract, which can result in irregular bowel movements of varying types. People with speedy digestive systems or whose intestines are hypersensitive to stimuli—such as those with Irritable Bowel Syndrome (IBS)—can find that eating a load of bulky foods high in insoluble fiber triggers urgent, crampy and unformed stools, often within an hour of consumption. Conversely, some people with slower gut transit may find that diets very high in roughage leave them feeling totally backed up, able only to pass hard, dried out stools that come out in incomplete pebbles. As these people learn the hard way, adopting a low-carb diet that excludes grains, root veggies, and fruits—all foods that contain the moisture-holding, formed-stool-promoting soluble fiber—may change your bowel patterns in unanticipated and unwelcome ways.

Gas can be another side effect of healthy diets, owing to high intake of certain types of carbohydrates that our gut bacteria find particularly delicious. Beans and lentils, soy protein-based meatless foods, Brussels sprouts, broccoli, beets, and cashews are all highly nutritious staples of a plant-based diet—and all of them share a type of fiber called galacto-oligosachardies (GOS). As is the case for all fiber, we humans lack digestive enzymes to break GOS down and extract energy (calories) from it. (That’s what makes it fiber!) But the microorganisms inhabiting our intestines have no such problems. They can ferment this fiber particularly well, and ferment it they do. Fortunately for us, feeding bacteria with lots of fiber seems to promote good gut health. But unfortunately for us, a key byproduct of bacterial fermentation is gas, and the more such fibers we feed them, the more gas they produce. Different people make different amounts of gas based on what kind of bacteria they harbor. While having lots of intestinal gas can be a badge of pride bestowed on you by a healthy diet, some people find too much of it to be, well, too much, either for their physical or social comfort.

Similarly, we humans can’t digest a type of naturally occurring, highly fermentable sugar alcohol called mannitol which happens to be found in #cauliflower (1,000,000 Instagram posts and counting!). This may explain why some folks looking to reduce intake of carbs (in general) and highly processed grains (in particular) can find themselves battling a sharp uptick in gas and gas pain when embracing novel dishes like cauliflower “rice,” cauliflower crackers, cauliflower gnocchi and cauliflower pizza in lieu of their grain-based alternatives. To be clear, getting gassy from too much cauliflower doesn’t mean you have some underlying digestive disease that needs to be fixed; gas is only a problem if its, well…a problem.

Then there’s the diarrhea that some people experience as the result of too much fructose or sorbitol—two naturally occurring sugars found in many unrefined sugars and fruits. While you may have heard of lactose intolerance, there’s a lesser-known condition called fructose intolerance, in which an individual may not be able to absorb the natural sugar, fructose, particularly well. This predisposes them to diarrhea several hours after consuming fructose-rich foods. So if you find yourself clutching your belly as you race to the bathroom several hours after downing a green-apple-based cold-pressed juice, an agave-sweetened protein drink, or a mango and granola topped smoothie bowl, there’s a perfectly logical explanation.

The knee-jerk reaction most of my patients have when I explain why their healthy diet may not be agreeing with them is incredulous, “But I thought I was being so good!”

This is when I find myself explaining that healthfulness and tolerability are two separate issues.

Whether a food agrees with you digestively (or otherwise) says nothing about whether it is a “good” food, nor is it a referendum on your character. Contrary to the popular aphorism, you are not what you eat.

Consider the following: there are hundreds of objectively healthy foods out there for us to choose from: veggies rich in all manner of powerful antioxidants, fruits rich in potassium and vitamins, nuts and seeds rich in magnesium, fish and plant-based foods loaded with heart-healthy monounsaturated fats and omega-3’s, leafy greens and beans rich in folate, and herbs, spices and teas with known anti-inflammatory compounds.

Now, let’s say you have a friend who has an allergy to one of these healthy foods; we’ll choose nuts for the sake of this example. Does the fact of your friend’s nut allergy mean that nuts aren’t still an objectively healthy food for human beings in general? Should you encourage your friend to experience an allergic reaction because the nuts are a “superfood?” Are nuts a healthy food choice for your friend? Of course not. Can your friend obtain similar—if not the same—nutritional benefits from other foods that won’t endanger their life?

Most people considering the example of food allergy above would conclude that nuts can be both a nutritious food AND a food that happens to make this particular person feel “bad.” These two things can be true at once. We take it as a given that a person with a nut allergy should avoid nuts and replace them with something comparable but tolerable—like sunflower seed butter or roasted pumpkin seeds perhaps. It wouldn’t occur to us that the person should feel guilty for their allergy, as if the nut allergy were some sort of personal moral failing.

But I’m amazed by the guilt that seems to drive my patients to force down foods that make them feel digestively awful because they feel they “should.”

There’s something amiss in our wellness culture when people feel so guilty about the fact that eating a bagel may feel infinitely better than eating a giant kale salad that they wind up in a clinician’s office essentially seeking “permission” to stop eating the kale salad.

I attribute this largely to a public dialogue about food and health that has appropriated such virtuosic language that it’s easy to see how feeling bloated, gassy, and miserable after eating a kale salad could seem like a moral failing to someone on a quest for better health. If kale salads are part of a “clean” diet and wheat flour is deemed “toxic” or “inflammatory,” then it’s not hard to imagine the impulse to seek a dispensation from a doctor or dietitian to eat a so-called ‘bad’ food that feels—well, good.

Social media messaging within the healthy eating and wellness community—particularly on Instagram—seems to fuel feelings of guilt associated with “failing” to tolerate the staples of “clean living,” like kale salads, smoothie bowls, raw date cacao energy balls, avocado chocolate “mousse” and entire heads of roasted cauliflower. (Not to mention those of us who are able to tolerate them digestively but simply dislike them.) One small study published in the European journal Eating and Weight Disorders surveyed hundreds of social media users who followed healthy-food-focused accounts. The researchers found that higher use of Instagram was associated with a person exhibiting more symptoms of an eating disorder called orthorexia nervosa. Orthorexia describes a fixation with “pure” or “clean” eating to the point of becoming unhealthily restricted. It can express itself in terms of extreme psychological preoccupation with the provenance of the food one eats; guilt over perceived dietary indiscretions; social isolation due to rigid, inflexible eating habits; and/or malnutrition from excessive restriction.

The increasingly narrow portrayal of what’s “healthy” as defined by fad diet books or social media influencers is often at odds with the wide variety of dietary patterns that actual scientific research tells us are healthy. And it can really do a number on your emotional wellbeing.

“Let’s find the healthiest diet you can comfortably tolerate.”

The first step in liberating yourself from unhealthfully-limiting beliefs about what you should be eating is to broaden your mindset around what constitutes a healthy diet. In the U.S. we are fortunate enough to live in a country where a dizzying variety of foods is available all year round (although food deserts and food swamps mean that we don’t all have equal access to all foods). Because of this, no single food in our diets needs to carry the weight of delivering the entire supply of a single nutrient, nor is there any single, essential “superfood” we all must eat… or else. Since many different foods provide similar nutrients, I try to help my patients identify nutritious foods they love—and that love them back—to replace others they feel obliged to eat but don’t actually feel so good.

Green leafy roughage make you feel rough? I absolve you from the 11th commandment, “Thou Shall Eat Kale,” and suggest you get your folate from cooked beets, avocados or peanut butter, and your Vitamin A from cantaloupe, roasted butternut squash, or a carrot ginger soup.

Those large lunch salads not tasting as good on their way back up? Swap out raw veggies for cooked ones—whether steamed, sautéed, roasted or souped. (As I tell all my patients: soup is liquid salad.) Sometimes, taming the texture of a vegetable can make all the difference in how your digestive system handles it.

Looking to eat less animal protein, but beans produce too much gas for your comfort? Try cultured forms of legumes, like firm tofu or tempeh, instead. Or test your tolerance for small portions of less-gassy legumes like lentils and chickpeas with the aid of a bean-fiber-busting enzyme supplement called alpha galactosidase.

Cold pressed juices or smoothie bowls at breakfast giving you the afternoon runs? Skip apples, dried fruit and mangoes and opt instead for fruits lower in fructose or sorbitol, like blueberries, strawberries, raspberries, kiwi, banana, cantaloupe, pineapple and oranges.

You have permission to eat foods that feel good to eat.

You don’t need my permission—or anyone’s—to stop eating foods that ‘everyone’ says are healthy but that make you feel perfectly miserable. (But if you’d feel better having it, then consider it granted.) Achieving good health is a worthwhile goal, but know that there are many different dietary paths to that goal. The signposts to guide you on your journey toward the healthiest diet for you exist within yourself—and how your body feels in response to eating certain foods. They’re not to be found on Instagram, nor on dubious lab test results, nor from the diet your best friend or co-worker swears by, not from people trying to sell you on their one-size-fits-all proprietary diet program.

Just because a food is “good for you,” that doesn’t mean it’s good for you.

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