Aidan:

Hello and welcome to the ideal nutrition podcast I am Aidan Muir and I’m here with my co-hosts Leah Heigl and this is now episode 9 and today we’re going to be talking about what to do if FODMAPs don’t work. pointing out the obvious or what to do if the low FODMAP diet doesn’t work. So to point out the obvious on that is that we said in a previous episode low FODMAP diet seems to work for about 50 to 80% of people with IBS. The obvious point there there is a percentage of people, 30 to 50%, that it doesn’t work for. So what is the next step if you have tried some of those frontline treatments, maybe not all the way, but then have gone on, the low FODMAP diet and you still experience symptoms? What is the next step? So starting with you, Leah, what are some of the things you’d look at first?

Leah:

Well, first things first, because low FODMAP diet is kind of considered the gold standard for IBS treatment, I would also be considering like, what was that person’s compliance to a low FODMAP diet? Cause that can be really important as to why it may not work for some people. The low FODMAP diet is something that is really difficult to do. And generally people do need a fair bit of guidance and help through that process. So it is hard. So, you know, what was their compliance like to the low FODMAP diet during that elimination phase? And were they doing it in a way that actually would reduce symptoms? So that would be definitely the number one thing I would look at.

Aidan:

It’s very zero to 100 as well. Like I said this on previous podcasts as well, but it’s kind of like, took me like two years to be comfortable with identifying most foods in terms of being that’s high FODMAP, that’s low FODMAP, and then kind of guessing amounts and stuff like that. If you have just learned about the low FODMAP diet, and have tried to implement it from the moment you’ve learnt about it, it’s very unlikely that you’ve nailed things right off the bat. There is a solid chance that something has been messed up. That’s not to say that’s what’s happened. It’s just like, statistically speaking, that’s a good chance to happen unless you’ve spent a long time learning about FODMAPS first.

Leah:

Yeah, that’s a good point because it’s not even compliance from the point of, I just didn’t feel like doing it this day. It’s like accidental in many circumstances. So even when it comes down to, you have a really great understanding of what is a low and high FODMAP food, which takes a really long time, firstly. But then you’ve also got the serving sizes that you need to worry about. So some foods are low FODMAP at lower serving sizes and they’re high FODMAP at higher serving sizes. And all that nuance can be really hard to understand. So for a lot of people in practice, I do put them on like meal plans because for a lot of people, that is easier when they know exactly what they need to eat as opposed to going it alone. So I would definitely be looking at compliance to that plan.

I think something that fits into that well is this social life aspect of being on low FODMAP diet. So you’re just not able to dine out for the most part. So it really does take away your ability to be social because food is such a big part of how we interact as humans. So there’s definitely that and that feeds back into compliance. Another thing I would be looking at specifically in my own practice, working with a lot of plant-based people, is that maybe they followed the low FODMAP diet quite well in terms that they’re eating all low FODMAP foods in the right serving sizes but they still have these symptoms.

So if they’re just eating a really high amount of plant-based foods, even though they’re low FODMAP, that can build up with their total daily intake and therefore not reduce their symptoms to the point of being non-existent almost.

Aidan:

For sure, and something you touched on previously as well podcast was you can go too high fibre. Like if you have a lot of fibre, gas and bloating are not uncommon. They’re often going to go hand in hand with really high fibre diets. And there’s a line I heard from Lane Norton very early on before I learned about what FODMAPs are and stuff like that. We were talking about like, it’s about bodybuilders, but like classic chicken, broccoli, brown rice kind of meal, trying to get really high calorie intakes on those kinds of foods.

And then replacing some of that with pizza as an example, just something that’s really calorie dense and low fiber. So taking the broccoli, which is really high fibre and a ton of food volume and just taking it away for something like that. And it’s like, maybe someone that can position could get caught up looking at FODMAPs and stuff like that when maybe it’s simpler than that. Like maybe it is just overly high food volume and high fibre at the same time as well.

Leah:

Totally.

Aidan:

The next point I want to talk about if FODMAPS hasn’t worked is another kind of obvious one, but stress and anxiety and mood and how it all links into this kind of topic. So there is a gut brain connection. Our brain and our gut communicate with each other. Our brain communicates to our gut, obviously, but our gut also communicates to our brain. So that is something to be aware of. And if you’re constantly stressed out, there’s a few ways to think about it.

Even just think about in terms of that like fight or flight mode and blood being diverted away from the gut, of course food is going to be more poorly digested in those kind of conditions versus that quote unquote rest and digest kind of state. That’s another thing to think about. Another area that to make this even more clear cut actually is that a pretty high percentage of people with IBS also have depression or anxiety.

About 40% of people with anxiety have IBS or diagnosed IBS from what I understand. And for people with depression, there’s about twice the rate of IBS in that population versus people without depression. So there’s a clear, statistically speaking, clear connection between the two. Something that’s even deeper than that though, is there are some antidepressants, so SSRIs, so serotonin re-uptake inhibitors, or selective serotonin re-uptake inhibitors, that can be used for IBS-C, so constipation because these SSRIs may stimulate nerve activity and restore normal nerve function between the brain and the intestines.

So sometimes even medications do help with that. And I’ve had clients in that position where they’ve seen their GP and their GP has given them a medication to kind of help out with that. And at the other end spectrum, using a little bit of common sense, it seems like the SSRIs are more common for constipation. But if you use a bit of common sense, it’s understanding that serotonin plays a role as well.

This can also work for diarrhoea at the other end of spectrum with kind of drugs that block serotonin receptors as well, because that’s one of the things that goes on. There’s too much kind of exposure with this. So like it goes both ways, like diarrhoea is the opposite of constipation and that kind of thing. And digging deeper down that rabbit hole of stress, anxiety, mood, all of those kinds of things. There’s a 2014 meta analysis. Obviously there’s more recent data than this, but this just was like the study that I’m most aware of that showed 50% of IBS patients benefit from CBT, cognitive behaviour therapy.

That’s an interesting one to start off with because not many people with IBS are going down that route for that purpose. Not many people even make the connection. I’ve also long been aware of research showing yoga and stuff like that being really good for IBS and like, honestly having similarly good kind of statistics in comparison to the low FODMAP diet as well. And then the next thing that I’ve been on the hype train for the past year or so, but like I was aware of for ages, I just didn’t have a practical way of doing it, is gut directed hypnotherapy. Around 70 % of people who undertake gut directed hypnotherapy notice significant improvements. Let’s go back to that FODMAP statistic, 50 to 80%.

What’s easier minutes a day of gut directed hypnotherapy or the low FODMAP diet? I don’t know. And like it’s a complicated topic as well because there’s even been studies where they’ve tried to do both treatments as in the low FODMAP diet and gut directed hypnotherapy. And it hasn’t really improved outcomes any more than just doing one or the other. Like it’s a very nuanced topic. Like seems to me like putting both together would work even more effectively. But it’s still early days in research perspective.

And what I mean about I didn’t have a practical way of doing it is it’s very expensive to see a professional for gut directed hypnotherapy and doing, because it’s going to take a lot of sessions most likely. It’s not just going to be a one-off and you’re done. It’s going to take multiple sessions. The way around that I’ve found now is Nerva. It’s an app called Nerva and it basically involves there’s six sessions of gut directed hypnotherapy, around 15 minutes.

And those sessions go on repeat for six weeks. So it’s a six week program, but because repetition is a key component of hypnotherapy, you just do that. It’s kind of like guided meditation with a little bit of gut directed stuff in the middle of it. I’ve got no affiliation with them. I get nothing out of it. It’s just the easiest way I’ve found of getting people to actually do it. I think it’s still pretty expensive. Still like $100. But compare that to seeing a practitioner, even compare that to changing your whole diet, it’s cheaper. If you’re somebody with IBS and stressed, at minimum it’s 15 minutes of your day where you’re not stressed, where you’re not focusing on anything that makes you stressed. At best, you’re one of the 70% who get significant improvements from that.

Leah:

Yeah, I just say it it makes sense with Nerva. If you are a pretty stressed out or anxious person and you do suffer from IBS, I feel like the buy in process for using an app like Nerva is a lot more simple, a lot easier than buying into the low FODMAP diet, which is like, especially if you’re working with a dietitian can be really expensive if you’re seeing them every couple of weeks, as opposed to $100 for like a six week course on Nerva. So I have kind of gone down that rabbit hole as well. And I’d say for many people, it makes sense to just to try that before the low FODMAP diet and before you kind of go dabbling in something so aggressive.

But moving on to gut health. So your overall gut health and the quality of your gut microbiome as a whole could be playing a factor in your symptoms. So outside of low FODMAP diets, it could be that you do have poor gut health for whatever reason. That could be because you’ve maybe had a poor diet up until now, or you’ve taken long courses of antibiotics, or there’s many reasons that your gut microbiome may not be at the highest quality that it could be. And that could potentially be causing symptoms like constipation, diarrhoea, bloating, et cetera.

And so we don’t actually know what the gold standard gut microbiome looks like. So that does make it a little bit confusing in being able to, you know, if we don’t know what a great gut microbiome looks like or what the gold standard is, you know, what are we aiming for? And so that can be a little bit hard, but we do know that the variety of the gut microbiota is pretty important. And also increasing the variety and of those healthy bacteria within the gut. So there are several ways that you can do that and you can improve your gut microbiome variety.

And the biggest way is to eat more than 30 different plant-based foods a week. So there’s pretty good research to say that the people that do have over 30 different plant-based foods every week do have a more diverse gut microbiome. So if you’re someone who’s tried the low FODMAP diet and that’s not worked for you, but you know, in the past you’ve had a diet that’s a bit lacking and not that diverse in plant-based foods. It’s definitely worth a try. And even outside of people that do have symptoms, it’s something I recommend to everybody. Cause I think everybody can benefit from having a really diverse amount of plant-based foods in their diet. So it’s definitely something that you could try.

Aidan:

And for me to add onto that as well, this Hates to Angosulka, I remember probably like two or three years ago, I saw a certain dietician on TV with people with IBS, she was getting them to increase garlic and onion intake, even though very clearly they were intolerant to it, as in like they were having issues related to that. Just to slowly build up the tolerance to it, because that’s one thing that can work. then building on that, like, honestly, that’s not an approach I’m going to use with clients, because I’m like, I’m not going to give you something that causes you symptoms. But it is a valid way of thinking about from the overall gut microbiota kind of perspective because those are great prebiotic foods and can help build this better overall gut health.

And to dig deeper on that as well, to be more specific, one of the things that we know that is good in terms of IBS management is certain short chain fatty acids. So butyrate is one of those ones that comes to my mind. butyrate is produced by certain healthy gut bacteria. And you look at the foods that produce butyrate and a lot of them are high FODMAP. You’re hard pressed finding low FODMAP ones. They exist, but you’re hard pressed to find them. And that’s a really interesting angle, because it’s like, if the low FODMAP diet hasn’t worked, we already know that FODMAPs aren’t your issue. Like you might even want to double down and actually increase some of these foods. That can increase butyrate production, and that might help overall. And you can’t really just take a butyrate supplement, because it just doesn’t get absorbed well. It doesn’t actually make that much of a difference. But if you eat these foods that are prebiotic foods that are food for the bacteria that produce these short chain fatty acids. Overall, that could help as well.

Leah:

Yeah, and definitely looking at just your fibre intake in general to nourish the gut is a good idea. So on top of having foods that are prebiotic rich and having a variety of foods, just hitting that basic recommendation of having your 30 grams of fibre daily and potentially even a little bit more than that. It can be a little different for everybody, but 25 to 30 grams of fibro day is the recommendation. So if that’s something you’re not already doing, it’s something you could absolutely start doing to further nourish your gut microbiome.

Aidan:

For sure. And the next thing we’ll touch on is like severe food restriction and how that impacts IBS. So there’s two things I’m going to touch on. The first one I’m going to touch on there is going to be eating disorders. Actually, no, I’ll leave eating disorders for you. I’ll let you do that one. I want to touch on the competition prep for bodybuilders. I want to touch on that aspect. So it’s a space I’m actually working in quite a bit, mostly female bikini athletes post show about six months post show. Tunnel them with constipation. Super, super common. What I want to touch on with that is there’s this thing called, well, there’s two aspects. One is relative energy deficiency.

Going back to all that stuff I talked about, like diverting blood away from the the gut and stuff like that. Similar kind of concept to a certain degree. If you’re going through competition prep to get stage lean, you get exceptionally lean, and you are on low amounts of calories in relation to the amount of training that you’re doing and all these kinds of things, the body starts shutting down certain processes because it’s trying to conserve energy in some way. It’s either shutting them down or down regulating stuff. Think of it as battery saver mode. And one of the things that goes on is there’s a reduced amount of calories spent on digestion.

That’s part of what goes on there. Another aspect is competition prep diets are usually quite restrictive. You’re usually minimising your food intake. You’re usually eating the same stuff over and over and over. You don’t have this great diversity of plant-based foods, particularly if you track macros. It’s like most people do in competition prep either on a meal plan that’s relatively strict or they’re tracking macros. If you’re tracking macros, it doesn’t exactly encourage diversity of intake because that makes it harder.

It’s easier to track stuff if you just have the same stuff over and over and over and over. So there’s this nice, neat combination of this relative energy deficiency kind of syndrome kind of thing, or you could just call it getting too lean, whatever you’d want to go with, doesn’t really matter, still the same kind of symptoms, or the combination of that and the restriction that goes on. And then post-show, there is a lot of reintroduction of foods that haven’t been had in anywhere near those amounts and stuff like that and digestion is already poorer. So a lot of people have stuff going on there.

And in some cases, FODMAPS doesn’t work there. Some of these people are stressed individuals as well and anxious and there’s a whole bunch of stuff that factors into it. 12 months post-show, no symptoms at all. It’s literally just a waiting game, just getting calories back higher, reintroducing foods, doing all those things and just taking far longer than you’d expect to take to get the job done.

Leah:

So we do see a very similar thing in restrictive eating disorders. So we know a very high amount of people that have eating disorders do have IBS. So one of the papers that we did find said that around 50 % of people that do have a diagnosed eating disorder also have IBS going along with that. like a range of reasons very similar to what we see in comp prep athletes but potentially also there, there may be the issue of a low fibre intake as well. So with a lot of comp prep athletes, they typically, like they tend to eat enough fruits and vegetables to get adequate fibre intake, but that’s not always the case with an eating disorder. So, you you might also have that there at play as well.

Another study that we found is, this is kind of a crazy statistic and I actually didn’t know this previously, but 98% of people that are admitted to an eating disorder unit have functional, a functional gastrointestinal disorder. So they are experiencing these symptoms of IBS at such a high rate that we know that this restrictive eating pattern is kind of going hand in hand with these IBS symptoms. And I’m not really sure too much about the background of this study and the exact participants but I’d say if you’re using any compensatory mechanisms, like if you’re purging and if you’re taking laxatives and doing things that go along with some eating disorders, that would absolutely play a role in gut health.

Aidan:

For sure. And like I was thinking about this as well in terms of like we’re often thinking about eating disorders in terms of like anorexia nervosa and stuff like that. But what about just binge eating? Not even binge and purge, just binge eating. There’s periods of times where there’s this massive calorie intake and then there’s probably periods of time where there’s much lower calorie intake. It’s inconsistent. Even just using constipation as an example, people having a very consistent intake seems to help with that.

Using one example, the 5-2 diet. Not really talked about, but a lot of people on the 5-2 diet get constipation because there’s these days where there’s not much food coming in and the lack of routine and stuff like that plays a role in all of this. So same kind of concept for binge eating as well. You have a massive amount of food, probably going to get bloated. Even if you don’t have issues with normal amounts of foods and normal amounts of FODMAPs and stuff like that there is often such a large amount in one hit that some of these foods that are poorly digested anyway will be poorly digested. So it makes a lot of sense and it’s food for thought as to why the low FODMAP diet is contraindicated for those with disordered eating habits.

Because it’s like the disordered eating habits alone could be explaining the symptoms. And then you’re just doubling down on it by restricting fervour. So that’s food for thought as well. Personally, I have seen people who have been in that kind of space who had tried the low FODMAP diet before seeing me and still get symptoms and it’s very hard to get them off of it because it’s the attraction to restriction as well.

Anything else you want to touch on before I go to my hot take?

Leah:

Go to your hot take, I’m excited.

Aidan:

So the hot take I’ve got is vitamin D. This is not really talked about much in the IBS space at all, but it’s something that I’ve always been quite curious about because the number I’ve given for many years is that about 80% of people with IBS are deficient in vitamin D. And I’ve never really gone out on a limb and been like, probably should supplement. Like I’ve never been like, it’s just supplement and it’s gonna address your symptoms. It’s just that it’s always been such a strong overlap that I’m like, we know that vitamin D supplementation, particularly if you’re deficient, it’s not harmful. if you are nowhere near the top end of the healthy range, getting more sunlight or supplementing vitamin D is gonna be good for other stuff anyway. It’s gonna be good for other stuff.

There’s other benefits. So I’ve always been saying for ages, it’s worthwhile at least checking it and seeing. Doubling down on that though, in preparation for this podcast, I did look through all the research on it. Surprisingly little considering how positive all the research has been done has been. 2015 study from Saudi Arabia identified that 82 % of people with IBS were deficient in vitamin D compared to 31% of control participants. I’m stoked with those statistics because it’s actually lined up with what I’ve said previously. That podcast a while ago, a few episodes back, I 30% of people had.

Vitamin D deficiency, I just said about 80% of people will deficient in vitamin D if they have IBS. So firstly, stoked about that. Next one though. That basically, well firstly with that study just doubling down, it’s obviously there’s a clear linkage that is going on. But there’s so many other factors with vitamin D. People with low vitamin D see the sun less. Do you have IBS or anything mental health related as we said there’s a linkage between two, do you go out in the sun as much?

Like that is another variable. Like I don’t know the answer, but like it probably shapes it in some way. Another study from 2016, so a year later, put that to the test basically. And they got 90 people with IBS and they got them supplement with 50,000 international units of vitamin D every fortnight for six months. So that’s a relatively high dosage, but like when you bring it out over the fortnight, it’s not super high. It’s just kinda high in comparison to like relatively low dosages that people normally use.

There was a significant improvement in almost all symptoms, but it did not completely resolve the IBS symptoms on average. Keep in mind in that study, they didn’t measure deficiency. They didn’t measure the levels to start off with. We make the assumption that like 80% are deficient, but they didn’t actually measure it. What happens from my perspective, if you exclude the people who were not deficient, that improves the study odds even further, like it makes it look even more positive, just the same as like there’s this research on calcium supplementation and fractures risk, where they just do a population level and the people who take their supplements do have a slight reduction in risk of fractures. What if you just got a bunch of people that really low calcium intake and put them in like, it makes it, it looks even more positive. So it’s food for thought, it’s worth testing that. That’s our take because there’s not that much research on it, but what we have so far is incredibly promising as well. Next topic for you.

Leah:

Okay, so this is something I don’t tend to use a lot in practice, but our next topic is going to be probiotics. So it’s absolutely not something that I tend to use as like a first line approach when someone comes to see me with IBS issues. And that’s because the research on it is so mixed. So we do have some research to say that particular strains of probiotics can be useful for specific symptoms. But there are a ton of studies that show no significant changes in symptoms when supplementing with a probiotic. But I think at a certain point, it’s worth considering.

So we know that particular kinds of probiotics such as bifidobacteria and lactobacilli seem to be the most effective in reducing some IBS symptoms. So, you know, if you’ve tried a few things and you’re really kind of grasping at straws, it makes sense to just try it. There’s no harm in trying a probiotic at some point. So these bacteria populations are typically lower in people with IBS. There’s no real clear-cut recommendations on how much you should be taking and exactly the kinds of strains or combination of strains. But if you are going for a probiotic, it makes sense to go for something that contains at least one of those strains.

So we do have a review by the British Dietetic Association that had 29 studies in total, and only 14 of those studies actually showed a positive result from probiotic supplementation using over 10 different kinds of probiotics. So I’d say like 14 out of 29 studies showing a positive result. Like I’d say that’s very, very mixed. I wouldn’t say it’s like a clear cut thing where, know, probiotics are definitely gonna help with IBS, not at all. But I think it’s worth mentioning and it’s worth a try for some people in some circumstances.

Aidan:

For sure. And the moment I’ve got a client who’s interested in trying that and they have IBS, I’m going to say yes every time. But it’s also as we were saying, if we widen the net, so to speak, in terms of like our recommendations, what supplements we’d recommend, if we include that in our net, we’re including a lot of other supplements as well. And then suddenly it’s taking a lot of things. When going back to a previous episode, it’s kind of like, we are food first people where possible. Like, I don’t know, we don’t want to end up taking a whole bunch of supplements. like, that’s what I’m saying, like if somebody’s interested in it, there’s nothing really harmful about taking it. Only the time to do it. It’s not much time involved in that. And the dollars, the money, and it’s not that expensive. So it can be worth a try, but we’re not like super passionate about it either.

Leah:

Yeah, 100%. And if it is something that you do want to try, I’d suggest taking it for at least three to four weeks consistently to really give it a good hot go. But if you don’t see any changes in your symptoms, say after four weeks, then it’s likely not going to be beneficial for you. And maybe you want to kind of branch out and try other strains of probiotics. But I think at that point, you know, it’s not going to work for you. So it’s best to move on to the next thing to try.

Aidan:

Yeah, I see people who’ve got symptoms for long, long periods of time taking the same probiotic for a long period of time as well. And they’ve noticed no difference. I don’t know.

Leah:

Why would you continue taking it then? Yeah. So something else that you might want to try that tends to be even a little bit more effective in some cases than probiotics would be taking a peppermint oil supplement. So we do know that menthol in peppermint oil can cause the muscles of the large intestine to relax. So this can have a pretty significant impact on abdominal pain. So if you’re experiencing high amounts of abdominal pain after eating and that’s part of your your IBS symptoms, it could make sense to try something like a peppermint oil supplement. The only thing is with this is you do need to take it a few times a day. So that can be difficult for a lot of people. So taking a supplement once a day is one thing. Doing it multiple times a day is again a whole different ball game.

Though there is some research to say that it can also help in bloating by allowing the trapped gas to pass through the intestine. So you know if you are struggling with either bloating or abdominal pain or maybe the combo of the two it could be well worth a try particularly if you’ve gone and tried quite a number of other things and you’re still struggling with these symptoms. The most extensive review of peppermint oil that we do have included several studies with over 800 patients I think it was 12 clinical trials in total. And the review showed that IBS symptoms were 44% less common in the people that took peppermint oil than the people that didn’t. So I’d say that’s a pretty good statistic in terms of like, it’s worth a try at that point. Like if you have tried other things, kind of like probiotics, it’s like, might work, it might not, but again, it’s worth a try.

Aidan:

Yeah and the standard dosage, so 0.2 to 0.4 mLs three times per day before meals, probably like half an hour before meals or like just before, it doesn’t really matter too much, like I wouldn’t be overly precise with that. Two things to touch on with that, one, you can just buy it off of something like iHerb online, like just type in iHerb and it will come up and like, you don’t have to like, the dosages are going to line up with that most likely, obviously double check, but most likely to line up with that. And another, once again, hot take, but something to add on to that is like, I don’t think you need to take it three times a day. As in, we had this conversation where we were like, I don’t know, I personally wouldn’t want to take a supplement three times per day.

If I bad enough symptoms, yes, of course, no brainer. But like if they just kind of mild symptoms, but they were annoying, like I probably wouldn’t take it three times a day. But like there’s no reason you couldn’t buy it and take it haphazardly. Like there’s no downside to taking it. If it was so effective that 44 % less common for symptoms in these patients in those groups, that’s a big enough effect. It’s like, I don’t know, like you could take it and take it suboptimally. Like you can still get benefits from it.

Wrapping things up now as well though, there’s two things I want to touch on. One of them is that I want to go through some conservation specific nutrition stuff in a future episode. Like we’ve already drawn this out pretty far. I want to leave that for a future episode because there is a lot to go through with that and there’s some stuff that actually really does move the needle that isn’t really kind of common advice.

There’s heaps to talk about on that. And another thing that we haven’t touched on that is a massive topic in itself is the RPAH elimination diet also known as the failsafe diet. I don’t know when we’ll do an episode on that, probably pretty far down the line, but it deserves a podcast on its own because that can explain a lot of these symptoms as well and that can be another option for if the low FODMAP diet doesn’t work. So basically wrapping things up, thank you for listening to this. This is episode nine and I hope you have all enjoyed it.