Welcome to episode 32 of the Inside Knowledge. I’m Anna Mapson.
My IBS Case Study
I’d like to introduce you to Tony.
Tony, I worked with this year, and his big problem when we started working together was severe pain every single night that was coming from a bile acid build up during the night. He had bile acid reflux, so that’s where the bile that we produce to help us emulsify fats was backing up into his stomach and causing him a lot of pain.
The reason it was dripping out is he didn’t have a gallbladder. He’d had it removed about 30 years prior. And it was really affecting his sleep, really bad pain he was getting, and he also had issues around constipation. So he was passing one bowel movement every day, but he was really struggling.
He also felt that he had some problems with gastric dumping. So this is where your stomach is emptying too quickly into the small intestine.
Restrictive diet for IBS
All of these problems together had led him to have a really, really restrictive diet. So not only was he waking up several times throughout the night, He was also on such a small selection of foods, so his energy levels were really low, he’d lost a lot of weight.
He was extremely low in mood and just felt like things had hit a real crisis point. He was only eating eight different foods, and actually one of those foods was and fruit juice. So it was a really reduced amount of different things and eating those on repeat every day.
Losing hope
But with a sense of hopelessness, there was a sense that he was not going to survive this health condition.
He really felt like things had got so bad that he was just wasting away, and he didn’t know where to turn to. Obviously, he’d been to his doctors lots of times. He’d really been back and forth, to his different healthcare providers, and they had run lots of different tests, they had given him some medication to help excrete the bile out of the body, and that was helping to an extent, but not really.
How Tony chose me as his IBS nutritionist
The reason that Tony said he wanted to work with me is that he knew from our first discovery call where we went through his issues that I had a good understanding of his health conditions, Of diet and food and what things can do. And by that I just understood what the medication was I knew a lot about the different medical terms that he was using. I was able to challenge him a little bit on different diet things that he may have heard online. Or read about that actually, I thought weren’t helpful.
So he knew that we were gonna have a good working relationship and that we would be able to be on the same page about things. So I think that’s what really helped him is that discovery call, just feeling like actually I can learn from you and I want to work with you.
And I have to say he is one of the most committed people I’ve ever worked with in terms of taking everything on and really going for it.
How Tony reintroduced foods to his IBS diet
So as an example of that, one of the first things I wanted to do is try and get him eating. a variety of different foods. I wanted to increase the amount of fibre that he was getting to help increase bowel movements. And ease that sense of constipation that he was getting. I also really wanted him to eat more protein because I was really concerned that he was not able to sustain his muscle mass and would eventually start to lose even more weight if he couldn’t increase his amount of calories.
I started off by suggesting to him that he would introduce green beans. Little thin green beans, and at such a gentle way we would start off with one bean on one day. The next day we would increase it to two beans, and the next day to three beans.
Starting with green beans
So that was my first suggestion, and I said you don’t need to do anything, just the first step is to go out, buy the beans, and we will chat in a few days and see how it’s gone.
One of the examples of how I think he was so committed is by the time I’d spoken to him, he had already bought the beans and he’d already done day one and day two. He was just on it. He was so keen to make some changes.
And even though these were tiny changes, he was really prepared to give it a go. Despite the anxiety and the worry that this would not work for him, that there would be a further problem by following my advice.
Finding the right nutritionist for your gut issues
This is a really crucial part of working with someone. So if you have a call with me or someone else, another nutritionist. And you don’t really get the sense that they know what they’re talking about. That they have got examples of having done this before. And that you just don’t believe what they’re suggesting is going to be helpful.
It’s not going to work. You have to buy in to the process and you have to buy in to the thought that this person is the right one for you. And it might not be the right one. Like, you can shop around and find different nutritional therapists all over the world. People who are doing a similar job to me but in a different style.
You’ve got to find the right person for you.
Increasing protein to help gain weight – a case study
The next thing that I really wanted him to focus on was increasing his protein and this was where it didn’t go so well. I asked him to start taking some whey powder because when people are sensitive to FODMAPs, that’s the carbohydrate element of lots of foods, lactose can be something that people react to.
It can make you bloated, it can give you gas, it can cause diarrhoea, all kinds of things that people don’t always get on well with in terms of drinking cow’s milk. However, I have had some really good results with people taking whey protein., That’s the protein from dairy and adding it to their food, or adding it to a smoothie or something. The problem was, is that he wasn’t having anything that he could mix it with, so it was really difficult.
Early reintroduction of milk – a bad choice!
So what he decided to do was buy some milk and mix the whey protein with milk.
This was terrible, and he started getting a lot of gas, and even within one day, he just decided this was not going to work.
So, what we did instead was move back towards focusing on other types of protein.
He kept the whey protein because it keeps for a long time, won’t go off, and we started thinking about how he could eat more eggs. Eggs were another protein he was prepared to try. So starting off with just one, then having maybe two scrambled eggs, and then maybe moving on to an omelette.
Adding more vegetables
The next vegetable that he increased was butternut squash. So once he’d got to three green beans, I said keep it at that level for a few days. We’re going to start to aim for 80 grams, which is one portion of vegetables. So I wanted him to aim for 80 grams. But once he’d got to say about 40 grams, we started to reintroduce another vegetable, which in this case was butternut squash.
And again, starting with really small amounts, little cubes of mashed up soft boiled vegetables. Really easy to digest and just helped him to get a bit more confidence.
That was just in the first sort of two weeks, we just introduced those things. So green beans, the whey, which went terribly, and then butternut squash and eggs.
In this way, he’s starting to increase his fiber, starting to increase some protein containing foods. Now alongside all of this, there was education really around Digestion and how long things take to move through you, so I asked him to do a stool transit time to check how long food was taking for him to eat, uh, and then how long he would see it in the toilet.
This was really important because he was feeling that some foods were giving him an immediate sense of constipation or bad bowel movement.
Learning about gut transit time in IBS
And I talked a lot about how long food takes to move through us. If you want some details on that, go and listen to episode one about normal digestion. But, effectively, you’re looking for like 24 hours, 36 hours for food to start coming out.
That’s normal. So something you literally just eat is not going to cause you constipation or a hard stool the next time that you go to the toilet.
It’s kind of uncoupling that sense of what you’re eating, giving you an immediate problem. We also had a lot of conversations about what is constipated, what does that actually mean.
Sense of incomplete evacuation
If you’re going to the toilet every day and the stools are relatively soft, and you’re having sufficient amount of stool come out of you, that’s not constipated. And yet, some people feel that they haven’t got rid of everything, and there’s this sense of incomplete evacuation. That is really common. Now it doesn’t necessarily mean that you’re constipated and that you need laxatives or that you need to change your diet.
Sometimes more food is the answer to constipation
It could just be needing to eat more food because sometimes we need more bulk to move along. A lot of things are getting absorbed through the gut and so sometimes you need to add more fibre in, in order to get a more bulky stool. And that is actually what happened in this case. So the more food he ate by the time he got through a month. Or a month and a half that actually he was getting a really good stool. It was happening because he was eating more fibre, more bulk that could be passed through the gut.
Tony also introduced potatoes. These were good foods for him because we could cook them in a variety of ways and led him to eat a bit more of an interesting diet. Also kiwi fruit because I stressed about how it was a good way, low FODMAP way, to increase stools and move away from constipation. But he also introduced a whole range of proteins including beef, salmon, chicken and even nuts as well.
Normalising the diet – adding flavour
And some days he ended up going two to three times a day. This was in about a month into our journey of working together. I also really wanted him to focus on flavour giving food. So things like green herbs, like parsley, coriander, mint. These are really great additions to boost the flavour profile of your meals and make them a bit more desirable.
When you’ve had a history of eating the same food again and again, it just gets so boring. And so naturally you don’t. Really feel much of an appetite. So in order to stimulate your appetite to be able to eat more It’s good to increase flavours things like ginger, citrus fruits These can all be really helpful in small doses to begin with till you feel confident with the flavour And then you can just go wild with those things like green leafy herbs. Because they’re actually really good for you as well and can contain things like iron and magnesium.
Slow digestion from eating protein
Going back to the protein, Tony really had a sense that when he ate too much protein, his stomach just shut down.
He felt like things did not move through his gut for a really long time. He felt too full eating a small amount of protein. So when we’ve introduced these things like beef and the salmon, at first he was just eating a really small amount once a day. Obviously, I knew that this is not enough protein to keep him going.
However, he was prepared to keep going with it and just stay at, for example, three days, eating one amount of beef for three days in a row, just at lunchtime. After that period, once he felt like that was being okay and tolerated, he was able to eat. Protein twice a day, for example, having eggs in the morning, having the chicken at lunch and then even moving on to having three amounts of protein throughout the day.
Gradually increasing the food volume
As his confidence grew, we also introduced snacks in between meals, and these were additional ways to eat foods that he just quite fancied eating. That he actually just ate for enjoyment, but also to try to up the nutrient content. And up the calorie content because he really didn’t want to lose any more weight.
So this feeling that protein was bad for him that was closing down his system and shutting things down was actually really key to address because without that level of protein I didn’t feel like he was going to get enough energy and enough strength to start and start feeling better overall. We need a lot of fats, proteins, carbs.
Like we need the balance of all of these things to have a good, healthy response and be able to create neurotransmitters that help us feel happier. And just feeling like we’ve got energy to want to go out for a walk. We need nutrients for all of these things. Basically feeling like you’re having a good life rather than just existing.
Case study learning – Eating more can lead to a better appetite
And so trying to get all of those different. Balance of nutrients in was really important in order to make it feel like life isn’t just about this condition or the problems. Actually, he felt like the more he ate, his appetite came back.
So, he ended up saying, I’ve got a huge appetite this week. About two months into working together, and he had not felt hungry for so long.
One of the best points for me in this was that he said he once had a normal bowel movement. It was the first he’d had in four years.
And he was really happy and we had a little mini celebration about that. Because this is a real turning point. And it felt… to him like a normal bowel movement. I really attribute this to eating more food and eating a bigger variety of foods. Because it was enabling him to have a better bowel movement. But also enabling him to feel more energy, feel a bit more positive.
Lastly – bringing back the FODMAPs
One of the final areas he introduced was the really high FODMAP foods, including onions, garlic, and also wheat.
I talked a lot about the prebiotic qualities of these foods, like they are really good for your gut bacteria. How grains as well, like whole grains, including wheat, rice, these can be very beneficial foods for supporting your gut bacteria.
Starting supplements for IBS
With this client, I didn’t use many supplements. One of the things I suggested that he would do would be start taking some magnesium powder. And this was specifically at the beginning when I had really understood that he was feeling constipated. He also had a high degree of anxiety. So we used magnesium citrate powder.
The reason I like using a powder with people is because you can titrate it up and down. You can increase the dose, and you can make very small doses if you prefer. So powder is really good in that sense, particularly when people are nervous about taking different supplements.
Butyrate – the gut bacteria’s creation
I also suggested that he start taking butyrate, which is a short chain fatty acid produced by your gut bacteria.
But if you don’t have many good bacteria in the gut, then sometimes taking it can be a way to accelerate progress. Changing the environment of the gut by actually putting this short chain fatty acid in. There’s three types of short chain fatty acids that our good gut bacteria make. Butyrate is one of them.
Benefits of short chain fatty acids
The other ones are acetate and propionate. These are anti Inflammatory. They are fuel for the colon cells and they can actually move around the body and have an anti inflammatory effect. But specifically in the gut, they really help to change the environment of the gut. So sometimes taking a butyrate supplement may be helpful.
It’s not important for everybody and the best way to get that is through food and fibre. But at the beginning when he wasn’t really eating much fibre, I thought that this might help accelerate his changes. And towards the end of working together, we talked about introducing some probiotics as well. He was keen to do that, but I wouldn’t have thought it was essential.
It was just another like additional future proofing to try and really keep, keep things working as they were.
Client’s feedback on this case
One of the really nice things that we ended on was him saying this is better than I ever thought it could be for myself. Like, I can really see myself getting better now and that sense of hope was really moving for me.
I have to say, I really enjoyed working with this person because he was so engaged in the suggestions that I gave him.
Toning the throat muscles
Another thing that was slightly different that I hadn’t done before was encouraged him to use an iQuoro device. This is like a little plastic device you put in your mouth and bite down on it. It tries to help you tone the muscles in your throat and your neck and can be quite helpful for people with various issues around swallowing. Sometimes like if dysphagia where you can’t swallow very well or you have silent reflux. It’s just about helping coordinate the muscles of your throat, your esophagus and, and the tongue as well, and strengthening those up.
The thing about this device is that it only really works if you continue to do it. It’s a bit like weight training. It’s not like a once and done and you’ve done it. You have to keep going and keep those muscles working. But if it allows you to eat better and get the sense that your diet is improving, I think it’s worth doing some of those things sometimes in order to sustain the improvements.
And that’s the other thing about when I say people are really motivated. When you are in such a bad place and you can see some signs of improvement, of course you’re going to be more motivated. There are other people who I’ve worked with who, it takes a long while for them to start to see changes and they don’t feel as motivated, and I really get that.
If you’re not seeing progress, it feels just all like an uphill struggle, whereas in this case… It was pretty quick, I have to say, and rapidly saw some improvements in the way that he was feeling. So, I hope there’s been something from that that you can take that’s useful for your situation, your digestion.
Join the Gut Reset
If you’re interested in working with me, I work with people specifically over three months in my gut reset. Check out the show notes for links to my website where you can find out a bit more about how I work. I work with you wherever you are in the world, as long as the time differences work and we can align our schedules to talk during my working hours, then I’m happy to work with you wherever you are.
And I also have a whole range of education. That is given as part of the Gut Reset in videos and things that are pre recorded that you can do in your own time. So you can learn about gut health, about diet and healthy nutrition, as well as getting the regular coaching calls. Because I speak to people each week and I think for me that’s a big part of why I see this transformation or why I see this Process being effective is that I really get to know people and what will work.
And I think that’s where people make the biggest improvements is because if things aren’t working it’s only another few days until we speak again and we can really problem solve and work out what would be better for you. What could you start, stop, change to actually get the improvements that you need.
Right, I will leave it there for next week.