Episode 104 Transcript – Nutrition for Endometriosis

Leah:

Hello, and welcome to the Ideal Nutrition Podcast. I am Leah Higl and I’m here with my co-host Aidan Muir, and today we will be chatting about nutrition recommendations for endometriosis. So a little bit of background before we get into the nutrition stuff on endo itself. It is a condition where tissue that is similar to the tissue that typically lines the inside of the uterus, which is called the endometrium, grows outside of the uterus. This condition affects one in 10 women of childbearing age, which really is quite a lot of people, and it is often painful and comes with a whole host of symptoms. Like the symptoms can really be quite broad, but it can really affect someone’s quality of life. I know so many people with endo and it really does impact their day-to-day life quite dramatically.

And the issue with having endometriosis is there’s technically no cure for it, although it can be or is often medically managed with things like hormonal birth control or different kinds of surgery, maybe even particularly like hysterectomies in some cases there is no actual cure for it outside of that. So nutrition should not be viewed as something that can cure endometriosis or is a whole solution to even managing it, but it can be one of the things you can look at in order to ease symptoms and manage the condition as a whole.

Aidan:

So I always like to start with pitching how nutrition can help with endometriosis because it is a bit of a situation where there are kind of two camps. On one camp there’s people who view nutrition as the solution for everything and this is not a cure for endo, but on the other hand, there is a camp that is kind of like, “It’s nothing you can do with nutrition for endo, like it’s just got to be medically managed.” And the answer is somewhere in the middle as with most things, but starting with pitching with some places where it could help. The clearest one that it can definitely help with is IBS symptoms, so constipation, diarrhoea, bloating etc..

While nutrition won’t solve symptoms in every situation, it is super clear there can play a role there and we’ll talk more about that as we go. The next few things are a bit more debatable, there’s less clear evidence and everything like that, but let’s look at the mechanisms through which nutrition could help endometriosis. One could be reducing inflammation, the next one could be potentially managing oestrogen levels, and the third one could be reducing the production of harmful tissue. That’s a very tricky area to navigate, but there is a bit of evidence of benefit in all three of those areas. It’s just how far that extends, which is the bigger question, and what strategies would be the most effective.

Leah:

So starting in the clearest space when it comes to nutrition and endo is that IBS-specific stuff, and we are starting here because it is the clearest link. So many people with endo do experience some kind of IBS-type symptoms due to their condition. One study highlighted that 72% of women with both IBS and endo who undertook the low-FODMAP diet for four weeks showed an over 50% improvement in symptoms. So clearly, with this endo-related IBS, there is stuff that we can do from a nutrition perspective, particularly something like the low-FODMAP diet that can help most other concepts of IBS management also apply here.

So we have plenty of content on the ideal nutrition blog post about managing different IBS-like symptoms outside of just going for straight to the low-FODMAP diet. Again, that’s not something that everyone with endo needs, but it is something that if you do have quite severe IBS symptoms, it could be quite helpful obviously given that study. But yeah, we have plenty of content on there for managing things specifically bloating, constipation, diarrhoea, and there are things that we can do nutritionally, the nutrition strategies to help each individual, one of those symptoms, and that would apply in all IBS kind of cases and endo related IBS is also falling under that umbrella.

Aidan:

Yeah, I view that FODMAP study as a good example, as a proof of concept just being like if somebody did claim there’s nothing you can do with nutrition that could help with any endometriosis a symptom, you’d be like literally one approach, one strategy.

70% of women notice the greater future and improvement. So it’s like, okay, there is stuff you can do, but yeah, we wouldn’t necessarily jump straight to a low-FODMAP diet. There’s so many options, there are heaps of options.

Leah:

So many options, but it’s just like obviously we can do some pretty awesome stuff with nutrition when it comes to that IBS stuff.

Aidan:

Now moving on to the next area where it’s a bit broader, a bit less clear anti-inflammatory style diet, super broad, but general principles of a healthy diet also apply to endometriosis. For example, dietary approaches such as the Mediterranean diet fit into this category and there is some early promising evidence of benefit between the Mediterranean diet and endometriosis. Another specific area of research within this category is omega-3 intake, and this is where it starts to get a bit more mixed. I see some people overhyping it. I see some people under hyping it and animal research, which I don’t normally like to start with animal research, but animal research has indicated that omega-3s can help reduce the formation of those cystic lesions. So it’s like that’s really promising if that translates to humans. But once again, don’t like to read too much into animal research.

When we look at human research, which we have less of, we have research indicating that people with higher-than-average omega-3 intakes are 22% less likely to develop endo. This is another interesting area of endometriosis research being like we actually have a lot of factors that are linked with reducing or increasing the risk of endometriosis. How much does that translate to the management of endometriosis is a bit of a different question, but we know that reducing the risk of endometriosis, there’s a lot of things that we do have far more clear research on. And if you’re questioning say the omega-3 aspect, you’re not fully sold on that. We can look at the flip side and be like, “Okay, let’s look at other forms of dietary fat and see if this plays role.” One example is that there’s research on people with high trans-fat intakes that have found a 48% increased risk of endo.

So it’s like theoretically for a decrease in trans fats and an increase omega-3s, there’d be some pretty clear benefits, specifically looking at people who already have endo because that’s a bit more interesting to me right now is one study found that omega-3 supplements reduce pain in those with endo. That’s a good sign, but I would still caution against fully buying into that without more research because a few things, one, omega-3 research can often be mixed in many fields. I wouldn’t just make big decisions based on one study, but two, if this is relevant, it would likely be far more relevant for people with low baseline intakes of omega-3. Like if you’ve got somebody who had very low omega-3 dietary intake and get them something I said probably get more benefit than somebody with a higher intake. The other aspect of the anti-inflammatory kind of approach is antioxidant-rich foods.

I think it’s a good idea to increase intake of antioxidant-rich foods in general, but looking from a research perspective, there is some very promising research looking at antioxidant supplementation in the form of vitamin C and vitamin E in relatively high dosages that has found significant reductions in pelvic pain and mild improvements in period pain and cramps. Once again, super promising. Does that mean I go out and recommend vitamin C and vitamin E to every single person who comes with endo? Not necessarily, but it’s like if we are looking for angles where nutrition can play a role, that’s some of the more promising stuff from that kind of angle of looking at it.

Leah:

Getting onto the next topic, we’re going to talk a little bit about red meat, and I hate being the plant-based person, the vegan banging on about red meat, but I just happened to kind of fall on this topic. But research on red meat is… I mean it’s always difficult to interpret, but looking at the research, higher red meat intake is somewhat linked with the development of endometriosis and there are some proposed mechanisms around this involving heme iron, but the reason it could be difficult to interpret is because how much of this link is due to the combination of things like saturated fat, low fibre, high-calorie intake, lower intake of antioxidants, it’s really hard to say and have this clear link between red meat intake and the development of endometriosis when there’s so many other factors that can be playing a role that need to be considered regardless.

At a minimum, we would be cautious of having a really high red meat intake. I mean I tend to just generally for everyone try to follow the World Health Organization recommendations that it does recommend that your intake of red meat should be less than 500 grams of raw red meat weekly. So I tend to just throw that out to most clients, but particularly ones with endometriosis or ones that are worried about developing certain conditions and I think that’s just a good place to draw a line in the sand basically. But realistically, I think what matters more is the dietary context of where that red meat is. If you have a high or even moderate red meat intake and the rest of your diet looks really low in plant foods, low in omega-3s, low in fibre, I think that’s going to be obviously a lot more detrimental than someone who has red meat intake that is moderate but is eating a ton of plant foods, high fibre, high antioxidant intake, and everything. So I think that dietary context matters a lot more than looking at red meat specifically as the problem.

Aidan:

And in previous podcasts, or at least in one podcast, I’ve given my spiel about this whole healthy user bias thing with red meat research and how it’s hard to interpret, how the wider context matters, all those things as well. But this is still something that I care about a little bit with endo being, I don’t know how much this matters, but it’s enough to factor into my decisions using an example, I got a client recently who was in the bodybuilding world who was having red meat every single day and my recommendation to her was to limit to less than 500 grams and still just reach her protein targets using other options because there’ll be no downside of her doing that. One of the pieces of pushback I got from her was that she has a history of iron deficiency, but that’s when I’m like, “I do understand that, but can we address that in other ways.”

Leah:

Other places to get your iron that maybe don’t have those kind of negative drawbacks?

Aidan:

Yeah, just because it’s like, I don’t want to say it’s playing with fire, but it’s kind of like if this is one thing that I’m like, “Oh, I don’t know how much this matters or everything like that.” I’m still not super comfortable doing seven days a week of red meat intake just from the iron perspective, so to speak.

So the next one is looking at gluten, and this is another nuanced area that I definitely don’t like talking about in shorter form content, but on podcasts where on a podcast where I can talk a bit more in detail. I think this is the place where, whether I’m right or wrong, I believe that listeners of this podcast are very intelligent people, and they can read between the lines of some of the stuff that I’m about to say and not take what I’m about to say too literally before hearing the context after.

So technically the research is surprisingly positive with going gluten-free and having endometriosis. So one study with 207 participants showed that 75% of people with endometriosis had a decrease in pain after going gluten-free for 12 months. That is absurdly positive. I always think it’s worthwhile being sceptical. If I just saw that study in isolation, it’s interesting.

Leah:

Yeah. But it’s only one study.

Aidan:

But it’s one study. This study was repeated on similar circumstances with similarly impressive results. In the repeated study they did over three-month period and people had an average drop in pain of around 50%. Once again, that is very, very promising. You’ve heard me reaching around with maybe omega-3s for a small reduction in pain, maybe some vitamin C, vitamin E, all those kinds of things. None of them were like this impressive, but here’s where the intelligent listener aspect comes into play.

Don’t take that as a recommendation of me being like, “Go gluten-free, listen to the next section.” So I am personally not at a point where I’m recommending gluten-free diet to those endometriosis. I think it would take a fair bit more than even though those two promising studies, I think it would take a fair bit more to convince me of that. And then the next bit where it gets more interesting is it the gluten or is its other components using one example, fructans are also in wheat and fructans are a FODMAP. We know very clearly that that can contribute to IBS symptoms in certain individuals. Reducing gluten or eliminating gluten also reduces intake or fructan that would lead to significant improvements in IBS symptoms. Would that translate to pain or anything like that? Not necessarily, but I’m using that example to highlight that in the IBS space up until, I don’t know, around the 2010s or a little bit after, there was a big concept of non-celiac gluten sensitivity these days, the consensus mostly is that’s not really about gluten, it’s actually about fractions in that example.

The point I’m getting at is when these people went gluten-free, what did they cut out? They cut out wheat and maybe a few other gluten-containing foods. Could there be other components in weight that are causing this? Could there be other dietary changes that occur when you go gluten-free using an example, if you go gluten-free, do you now have to eat less packaged foods on average? Do you now not have the luxury of eating out at restaurants and choosing as many things off the menu? There’s hundreds of different components that can go on into this. That’s one angle. As I said, I wouldn’t necessarily go gluten-free based on this, but at the other perspective, I also like to think about, well, if somebody’s like, “Hey, I want to try everything, I want to try everything.” Looking at the other perspective, it is possible to have an incredibly healthy diet without gluten as well. So even though this is not a recommendation or anything like that, or me thinking that gluten is actually the link here, it’s another thing to consider.

Leah:

And it’s not necessarily something that’s going to impact your health negatively by doing it.

The next topic to a similar vein is looking at dairy. Of course, I, the vegan gets both of the animal product topics.

Aidan:

You were the one that chose which sections. 

Leah:

I know, it just kind of happened that way and I was like, “Should I change these because I don’t want to seem like I’m coming up against the animal products.”

Aidan:

I thought it was intentional.

Leah:

Not at all but looking at this. So dairy is not inflammatory, and neither is gluten in the absence of celiac disease, of course. So realistically there’s not going to be an issue specifically with dairy and endometriosis. But where we could find those two things interacting is since IBS and endo haven’t overlap, there is it’s worthwhile considering the possibility of lactose intolerance. If you are experiencing symptoms after consuming dairy products, we obviously know if you have lactose intolerance and you eat high-lactose dairy products, you’re probably going to experience symptoms. And we know there is an overlap between endo and IBS. And I think realistically that is where the link is the strongest. Although there is some research that has actually linked dairy consumption with a lower risk of developing endometriosis, which I also think is relevant to mention in that we know it’s not going to be one of those things where dairy is causing or significantly increasing the risk of endometriosis or making the condition worse outside of the IBS related stuff.

Aidan:

And another thing, I wish I got some stats up on this, but a large percentage of the population is lactose intolerant. And the reason why there’s such a broad range of stats. I’ve seen things ranging from within certain populations anywhere as low as 15 up to 90% of certain populations having lactose intolerance. And the reason why there’s often such broad range is because it depends on your definition, how much lactose you have to consume to get symptoms or whatever. But this could be a more complex topic, but say you have multiple things that are potentially triggers for IBS symptoms and say you are one of those people that would fit the criteria for lactose sometimes, but you’ve never really made the link yourself because it’s never been serious enough or anything like that. Say you have another trigger or another two or three or four triggers of your IBS symptoms and consuming lactose contributes to that, you might cross the threshold where you get symptoms and potentially going lactose-free could be a thing, super easy thing to test though.

Leah:

That’s super easy.

Aidan:

Just have a lot of lactose in a single sitting. If you get symptoms, probably lactose intolerance. Easy way to check this and rule out any other form of dairy being the cause would just be to have lactose-free milk the next day and see what happens.

Leah:

Yeah, and I think with this, it’s good to point out that it’s just you having to go, if you get these symptoms from lactose, you just have to go low lactose or no lactose, but you can still consume dairy products that are either naturally low on lactose or lactose-free.

Aidan:

Yeah. Another topic which is once again complex but it’s worth touching on is oestrogen. So elevated levels of oestrogen are often seen of endometriosis for a variety of reasons. And this can affect symptoms such as fatigue, heavy periods, and aggravated PMS. It also potentially contributes to growth of tissue outside the uterus. Once again, it’s a very complex topic because it’s like the endo can cause the increase in oestrogen as well. And I am very much not being like, “Follow this diet, it cures oestrogen etc.”. But yeah, a bit of a less clear role for how diet can play a role. But there are some examples. For example, a higher fibre diet reduces excess oestrogen resorption in the large intestines, theoretically lowering oestrogen levels, which theoretically could carry over to a reduction in all of those other symptoms. We do not have clear research on strategies looking at this specifically in endo, but it is another option. And we also do see medical options around this approach as well. So it could be an area that diet can also play a role too.

Leah:

So to summarise the key points from this discussion, it is likely best with endometriosis to follow an overall anti-inflammatory style diet that is just generally “healthy” but rich in plant foods, fibre, antioxidants, and omega-3. It’s probably beneficial to limit or at least moderate red meat intake and obviously manage IBS symptoms appropriately based on the symptoms that you have, which may include going through a FODMAP elimination diet process. But it might also just be general IBS recommendations regarding specific symptoms.

Aidan:

This has been episode 104 of the Ideal Nutrition Podcast. I was looking at Spotify yesterday and I saw that we’ve got 4.9 stars on average. So shout out to the people who’ve given us some negative, but it makes it look a lot more legit. If you could leave a positive review, I would greatly appreciate that.