I normally share positive stories on this podcast. People I’ve helped whose symptoms have reduced and they feel better after they’ve been working with me. But what about when I didn’t help with IBS? If people still experience issues at the end of the three months. This can happen for a variety of reasons, and today I want to share some of those with you.
When an IBS nutritionist doesn’t help with IBS
It might be because their IBS wasn’t really being driven by food or lifestyle, or maybe it wasn’t even actually IBS. Sometimes there are other physical conditions, lifestyle constraints, or mental states that stop us getting to the bottom of their IBS symptoms, and I’m going to go through a few different examples with you today.
Welcome to episode 80 of the Inside Knowledge podcast for people with IBS. I’m Anna Mapson. This episode will give you a couple of examples of people I’ve worked with that haven’t got to the bottom of their issues. They’ve still finished their three month gut reset with a couple of problems, and I’ll explain to you what they are and what we tried and what we did about it.
What my clients did get
Everyone who works with me will come away with a better understanding of what foods work for them, and have a good understanding of how their digestion works. Those kind of things are almost guaranteed. You will understand a lot more about how your digestion is working. What you may not be able to do is reduce the symptoms, whatever they are.
I’ve got examples here ranging from diarrhoea, abdominal pain, constipation and acid reflux. And each of those people had a different reason why they didn’t get any progress. Sometimes they weren’t able to implement any of the things I was suggesting. Sometimes there was a physical reason why the diet and lifestyle changes wasn’t making any difference. And sometimes they needed something else that I wasn’t able to provide because I’m not a doctor.
Let’s have a look at some of these cases. Part of the reason for sharing this with you is to be honest and be really upfront. But I also would like whoever you work with, if you’re looking for a nutritionist for your IBS, That you have realistic expectations of what is achievable in a three month period. Whether you work with me or somebody else, because sometimes, you’ve had these conditions for years and years and it’s just not realistic that they will vanish in three months.
Knowing you have a good diet is a good first baseline
Also, you will go through a process working with me that will allow you to rule out food triggers, or allow you to rule out other things that might be contributing to your symptoms, so that you can take that knowledge and go back to your doctor. Knowing that you’ve properly done a dietary intervention such as the low FODMAP diet, for example, is really helpful.
You can go back and be 100 percent confident with your doctor, ‘I’ve done it, I did a reintroduction process, it didn’t make any difference, and I know that I’ve got a good diet’. I can look at your mix of macros like proteins, fats and carbs, for example, check that you’ve not really low in any key nutrients such as iron, B12, calcium. To make sure that there’s no nutritional intervention that could help you.
Case 1 – Reflux and bloating
Having a look at some of the clients, the first one I wanted to start with is somebody who had reflux and bloating. He had tried going on a proton pump inhibitor, and if you want more support for how to manage acid reflux, then do take a look at episode 62 and episode 63 about acid reflux and proton pump inhibitors. This client, he had tried being on a PPI, he didn’t get on well with that. And so, just before he started working with me, he’d just switched to a histamine blocker, and was getting on much better with that, but it was very early days.
Prior to working with me, he’d cut out a huge range of foods from his diet. He’d cut out anything that he’d read on the internet that could have histamine in it or be triggering histamine release. He’d also cut out a lot of common FODMAPs, things like onions and garlic and gluten and dairy. So he was on a very restrictive diet. He also had a huge cupboard full of supplements that he had tried and half used.
Through the process of working with me, I helped him reintroduce quite a few foods. So one of the main things that he learned was the proper reintroduction process. So how do you test whether a food is really giving you symptoms or not? We went through that in quite a careful way. He managed to bring back quite a few foods that he’d ruled out because he’d read these cause acid reflux, this can cause bloating, this can release histamine.
Diet change didn’t help with IBS
There was just a huge list of foods for a variety of reasons that he was not eating. So we brought that back in and really expanded out his diet. We did a proper test of the low FODMAP diet. So, being very strict for two weeks to see if that had any improvement on his symptoms.
Now, that didn’t really. Although, when we decided, okay, it’s not working. Let’s just go back to eating all the foods, which is a valid thing to do. If you don’t get any improvement on the low FODMAP diet, then there’s no point going through the reintroduction process. One thing he did was to start eating all the foods again.
I think he was having onions and cheese and he was eating, bread and all of those things that he brought back in again. But then his symptoms were worse, so he said he actually felt like he’d underestimated how much the diet was actually helping with the restriction. So then we did go through a more formal reintroduction process so we could probably test them.
So this is why it’s helpful to have someone to bounce ideas off, someone to talk this through with. Now, at the end of working together, over three months, he didn’t get to the point where his acid reflux had resolved. He was still getting pain at night, heartburn, and he was still using the H2 blocker for the symptoms.
IBS wins and benefits
But what he did get out of the process was that he’d really had a good understanding of the various diets that affect your digestion. He could go and take that information back to the doctor and say, ‘I have tried this. I know what I’m talking about and I know which foods are my triggers and which aren’t. And I’m still getting some problems.’
I suggested as well that he go to get some physical manipulation for reflux. So sometimes people have a hiatus hernia, which is where your stomach can slide up into the oesophagus. There are particular trained physical therapists who have a way of manipulating your stomach and your abdomen that can sometimes, in some cases, improve things.
The other thing that I managed to do with this client was really cut down on his supplement usage which saved him a lot of money. He was taking very expensive supplements which I didn’t really rate in terms of their efficacy, so they weren’t strong enough to have an effect, or there was things in them which weren’t particularly well researched and tested, and so I was able to show him which supplements had been well tested for both IBS and reflux, and which ones were not really probably worth taking.
So that saved him money, and also saved him a lot of time googling what to do for reflux.
Case 2: Stress and anxiety
The next client I was working with was feeling very nauseous all the time. She was incredibly stressed when I started working with her. She had two children who had additional needs, and she had relationship issues with her partner. She was feeling very down in herself, but she wanted to do something to support herself.
So, we started off very slowly. I knew she was very stressed and overwhelmed and we started off with some very small changes. Even those things that I suggested at the beginning were too overwhelming. I really had to strip it back to literally just one thing per week. One thing that she had to focus on, and sometimes even that was difficult.
Now, this client, in the end, halfway through the three months, she just said, I can’t continue because she needed to focus on her mental health. And this was where she was so overwhelmed and so, there was so much going on in her life, she was just not able to give working with me any time and any attention. She, was going to find a therapist, find some counselling support and also keep going back to her psychiatrist for medication changes.
More planning and actions didn’t help with IBS
So sometimes you have to be in the right place to be able to make changes and whilst she felt that she could do that at the beginning, in the end when it came down to it, She just didn’t have capacity to focus on diet changes. Now, of course, sometimes changing your diet can actually give you more energy, help you sleep better, help you face some of those challenges.
And, at the same time, there are just instances where it’s not possible to balance that level of distress, anxiety, with making change, because making change is hard.
Accountability and support helped
For this person, she gained a lot in that she knew that there were people out there to support her. She knew that there were things that she could do. She had a list of very simple things that she could try when she felt better, but during the three months, she wasn’t really able to access some of those activities.
Case 3: Constipation
Somebody else I worked with who had such bad constipation she was only going to the toilet once a week. She literally had no urges to go throughout the week. She would never feel an urge to go and had a very slow transit time. Despite eating a pretty good diet, she was very fit, very active and healthy in all kinds of ways, although her transit time was incredibly slow.
She’d been to the doctor multiple times, she’d had a lot of tests, colonoscopy and all of these things. She was eating a pretty good diet. We tried the low FODMAP diet, that didn’t really make any difference and I didn’t necessarily think that it would, but I wanted to try it because the bloating was pretty bad on some days.
If you imagine, if you are only going to the toilet once a week, you’ve got a lot of backlog in there. Food is sitting there for a long time and that fermentation can increase the gas and really make things very uncomfortable. She was worried about gas release when she was running. She liked exercising and she was just embarrassed to go for a run with people because she was basically farting as she was running and she found that really embarrassing.
So we went to a low FODMAP diet to see if we could get control of the gas. We were also trying a number of things to try and obviously get the bowels moving. Before she was working with me she was already taking laxatives. So we tried, various other mixes of laxatives just with the over the counter things you can get from a chemist.
More laxatives didn’t help with IBS
Trying things that both stimulate the bowel like senna as well as things that can soften the stool and make it easier to pass. I’ve also, helped her with some supplements, so things like magnesium oxide, which are also drawing the water in. Helping a little bit with stress management as well, where some of the magnesium does get absorbed.
So at the end of the three months, this person still had very slow transit time. She was not going to the bathroom more than three times a week. She might have gone a little bit more frequently, but it really wasn’t to the point where we think that’s a normal bowel regularity. So less than three times a week is definitely considered constipated, and she was still going like two to three times a week. It wasn’t good.
IBS wins – SIBO test and clear next steps
The things that she had got out of it though was that we had done a SIBO breath test and realized that she had intestinal methanogen overgrowth. So that’s an overgrowth microbes in her large and small intestine creating methane gas which work on the nerves to slow down the transit time.
So she was able to take that breath test to her doctor and get antibiotics to reduce these microbes. So that was one thing. I also suggested that she go to see a pelvic health physiotherapist to talk about the constipation because of the fact she wasn’t getting any urges.
And because her diet was good and she was using quite a lot of laxatives, it was less likely, I think, to be diet and lifestyle driven. You know, she was doing all the right things. I felt like there was some muscle problems. The muscles were not coordinating properly to work together to release the stool. But also that connection from the brain to the bowel wasn’t working as effectively because she was not receiving those messages to go.
I helped her look for the right kind of pelvic health physiotherapist in her local area, and she also then made an appointment to go and see somebody about that. In that case, she hadn’t got to normalise her bowel movements. But she’d been through the low FODMAP diet and looked at whether that would reduce the bloating.
It didn’t really, and I think that is because she was still so constipated. You can’t get rid of bloating when you’re only going to the toilet once a week. You know, you’re literally full of stool, but also there is fermenting fibres coming down that are going to be creating gas. What she had got is she had got this positive test for intestinal methanogen overgrowth that she took to her doctor. Her doctor never thought to test her for this, or referred her back to the gastro team to get this tested, but her GP hadn’t ever heard about intestinal methanogen overgrowth. So that was something she’d learned from working with me. She’d also learned about the possibility of doing the biofeedback for pelvic health strength and training
Case 4: Constipation and medication
Another case where there was somebody who had very bad constipation. Now she wasn’t quite as bad as that. She was going probably three to four times a week, but it was quite hard. She was straining to get it out every time. It was uncomfortable and she felt very bloated. This was somebody who was retired. She had been in the medical profession herself, so understood quite a lot about physiology.
She was very worried about being on medication and just didn’t want to be taking medication. She felt kind of shame with that and had always prided herself on being someone who didn’t need medication for the long term. And so she really wanted to do this through diet and lifestyle.
I helped her look at the variety of fibres that she was eating to optimize this to try and improve her bowel movement. I also talked to her about all the things that she could do in terms of calming the gut brain connection because there seemed to be a level of anxiety and worry about bowel movements and about her health.
So we talked a lot about how to calm that. Breathing that you can do to improve your digestion and the things like that help like going for a walk regularly. Now again, this person was doing a lot because she was quite well read and understood a lot about the body. So she had already ticked off a lot of the basics that I would say first of all.
I helped her with positioning on the toilet by suggesting she get a little step, put her knees up to get into that squatting position. Because that could really help. So that eased some of the straining. Once we’d gone through these various diet changes, we kind of had a point where I thought actually what’s the next step here? And I felt that it would be worth going back to the doctors. At the beginning of working together, she was feeling very overwhelmed, she was particularly worried or concerned.
Anxious about having to need medication and what that might mean, and so she’d always been putting it off.
Avoiding the doctor didn’t help IBS
Once she’d gone back to her doctor and had explained exactly what she’d been doing the doctor suggested taking Prucalipride, which is a motility agent. This worked almost instantaneously for her and really made a massive difference. Probably within about a week or two of taking this medication regularly, she could pretty much eat whatever she wanted to and not have to worry about the types of fibre or how she was eating, she just could relax.
And so having had the conversations with me about whether medication is worth it and what some of the drawbacks might be. I’m not obviously able to advise somebody on which particular medications they should be taking because I’m not a doctor, but I could talk to her about what some of the barriers might be mentally around going on medication or being a person who takes medication and what that means to you and your sense of self, your sense of ‘this is who I am, I’m not a person who takes medication’ to actually accepting. Maybe you do need it and maybe you do need some help.
And actually the change was fantastic to see. She just became so much happier, so much more relaxed once she’d kind of got over this hurdle in her own mind.
Sometimes there are cases when diet and lifestyle changes just aren’t enough, and we’re lucky enough to live in a society, in a culture where we do have access to medication that can help, and so I guess I wanted to bring this case study up as well because Sometimes I do see people who are fighting and fighting against using medication when actually it can be the thing that really gives you your life back.
Trying to do things naturally and without medication is a great first step and 100 percent support people to do that but at the same time when you’ve already done a lot of those things we’re lucky to have access to this medical care that can give you the right treatment. So, whilst I don’t suggest everyone just doses themselves up on medication all day long, diet and lifestyle are massively important for your health.
It’s okay to take it if you need to, and I think there’s a bit of shame sometimes, especially on social media about not being able to resolve your symptoms ‘naturally’.
Sometimes it’s okay to need medication.
Case 5: Abdominal pains and loose stools
And the last one, I’m going to do quickly because I’m running out of time here, was somebody who came to me and he had a pain in, around his belly button frequently when he ate, and then it would give him urgent diarrhoea.
He would get this really bad pain. We couldn’t really get to the bottom of it. He was avoiding eating because the pain was bad and he was experiencing headaches and dizziness and he would often skip breakfast and he was again a very active person, did a lot of sports and enjoyed running so he was kind of always busy, had a busy job as well and on the go.
We tried the low FODMAP diet. I know I keep saying this in this episode and it doesn’t always work for someone. If you listen to my FODMAP episodes, you will know that it works for 3 out of 4 people. These are some of the people where it has not worked. He did the low FODMAP diet.
He was very well read, this person. He knew he wanted to do a SIBO breath test, he wanted to do a stool test, so I helped him run both of those, and it found he was positive for hydrogen SIBO, slightly. It wasn’t massively high numbers, but he did have positive tests. He also had on the stool test a couple of things that were slightly out, like slightly low digestive enzymes, slightly raised bile acids, but nowhere near the level that would need investigation.
Low FODMAP diet didn’t help with IBS
Also, his bacterial diversity was quite low, and that was because he’d been probably restricted his vegetable intake and fruits for a number of years. A lot of the work that I did with him was reintroducing FODMAPs and trying to get him back off the diet, but also working on some supplements that might help the SIBO. Increasing antimicrobial supplements, as well as good gut bacteria feeders. Trying to increase fibre, trying to increase things that help the good gut bacteria grow.
I also wrote a letter to his doctor saying these are the symptoms that I’m worried about, these are the tests we’ve done. And this is what I’m still concerned about because the pain was quite significant for this person. You know it would require him to lie down for a couple of hours when it hit and it could happen in the middle of the day and this was partly why he was avoiding eating so that he would avoid the pain in the daytime whilst working.
So at the end of the three months he didn’t really have a full resolution of the pain although he did know that he had had a positive SIBO test, he’d had any bacterial infections ruled out through the stool test and we had fully reintroduced a lot of the higher FODMAP foods that he’d been avoiding for years so he was getting a better range of fibres to feed the good gut bacteria and also because he knew the diversity was low there was like an impetus to try and do that.
After working with him I didn’t hear from him for ages and then he wrote back to me probably about nine months later saying that he had eventually through the doctor, been tested for bile acid malabsorption, which is where your bile salts do not get reabsorbed and can trigger pain and diarrhoea.
And he’d also had a blood test and he was slightly low in vitamin B12, for example, and vitamin D, so he was making sure that his blood test, results were well managed through taking some supplements, but it was also, you know, continuing to eat well. Now, when the test came back from the bile acid malabsorption, that was a SeCAT test, it showed actually he did have severe bile acid malabsorption, so after doing the test, which he had to wait about four months for the test, then he had to wait nearly seven months back for the results and found that he had severe bile acid malabsorption.
So that is where he wasn’t seeing any results from just changing his diet and actually again needed some medication. Once he got that sorted, the pain was starting to resolve. So we’ve kept in touch and yeah, starting to feel a bit better.
But just goes to show that sometimes, you know, fiddling around with your diet and taking a few extra supplements is not really going to be the thing that resolves it and actually going back to the doctor, but with a letter stating these are the things that I was worried about, these are the things that we’ve tried and this is why I want him to have more investigations and that really helped and led to his diagnosis.
How does an IBS nutritionist help?
What you can get through working with me or any good nutritionist who specializes in IBS, is a better understanding of your digestion. A really clear process for trialling foods, reintroduction or food elimination, and a plan to get off an elimination diet, which is super important if that’s what you’re doing.
You can also have a review of your supplements, which ones are worth taking, which ones are a waste of money. You can get all your questions answered so that you feel confident and you feel like you know why you’re doing certain things or why you should stop doing certain things. And also you can have a review of your diet to make sure that you’re not low in key nutrients that could be contributing to some of your issues.
So whilst the people in this episode were not completely able to resolve their symptoms whilst they were working with me, there were things that they got out of it and that they benefited from. If this is something that you would like help with, if it hasn’t put you off, for me being really honest about how sometimes it doesn’t result in the perfect outcome, if that hasn’t put you off then please get in touch, I’d love to hear from you if you’re interested in working with me over three months.
I’ve been doing this job for over eight years and I really love helping people get rid of some of their unpredictable and painful gut symptoms. You can use the link in the show notes to get in touch and book a free call about what you want help with.
Thanks very much for listening to this episode of the Inside Knowledge. Better digestion for everyone.
