Ep.49 – Case study – Fear of hunger & restriction
19 Jun, 2024

Episode Intro

Are you listening to too many different sets of voices in terms of what to do for your IBS? In this episode, I'm going to go through another case study of a previous client I worked with who was listening to so many voices in the nutrition space about what is good for gut health. But she had created a set of rules that were actually inadvertently contributing to her IBS symptoms. She was suffering with constipation, bloating, and constant gurgling, a really noisy digestion. This episode will explain how I worked with Fran to improve her digestion and her trust in her body.

Podcast transcript

Welcome to episode 49 of the Inside Knowledge podcast for people with IBS. I’m Anna Mapson. This week is another case study. I would like to introduce you to my previous client, Fran.

Fran’s IBS symptoms

Fran was completely overwhelmed when we started working together. She had researched a lot of information and was very knowledgeable in nutrition and dieting and foods. And had created herself a diet which was really trying to maximize growing the good beneficial gut bacteria. Really working on improving her diversity and really had a lot of information to hand about how to improve gut health. The reason she was doing all of this research is that she had very erratic bowel habits.

Mostly constipation with a lot of bloating and a very noisy, gurgling digestion.

Constantly feeling hungry

She felt hungry all the time and described to me having to eat almost constantly throughout the day because she always felt hungry. One of the things she was really keen to avoid was an elimination diet. Because she’d struggled in the past with a strict Elimination diet. Like a FODMAP diet and restricting foods and how that made her feel.

She had previously tried a low histamine diet, a SIBO elimination diet and an anti inflammatory diet. These were all things she’d researched in order to try to resolve her gut symptoms.

Managing stress

Fran was a mum of two and was working part time and had, I would say, fairly high stress levels in terms of managing her children, her relationship with parenting and also just general house management.

So she had kind of constant state of mild anxiety, I would say, and also had ways to manage it, like very experienced in yoga and so had a lot of tools that she knew about as well. Because a lot of you out there might be the same.

You’ve done a lot of research. You understand the connection between the gut and the brain and how working with anxiety and your emotions is really important if you want to get good gut health. It’s not just about the food.

Choosing the right IBS nutritionist

One of the reasons she chose working with me was the fact that it’s a three month program and you get a lot of the one to one calls. She really wanted to be able to discuss some of the technicalities, I suppose, around gut health. Really verify if what she’d been researching and understanding was correct.

Needing to feel supported

And also just to feel supported. Like I said, when you’ve got a high degree of worry and like an ongoing low level anxiety, it can be really helpful to have a sounding board. And to have someone who is confident to say, no, don’t do that. Or yes, pick this first and give you some direction.

Fran’s diet was very high FODMAP

When I was looking at Fran’s existing diet, I noticed that there was a lot of high FODMAP foods which could have been adding to her bloating.

She was quite worried about going on a low FODMAP diet though. We came to a bit of a compromise, which is sometimes called the gentle low FODMAP. Or a kind of semi low FODMAP diet.

What is the gentle low FODMAP diet?

Working with someone who knows the low FODMAP diet quite carefully, you just go through your diet. You don’t have to follow the complete low FODMAP plan.

But what you do is you cut out the highest FODMAP foods for you. So we were able to do that in initially. Just go through her diet and think about what would make the biggest amount of difference.

Managing the non-negotiables

One of the things that was really important to her was to still have two biscuits every afternoon.

This was part of her not feeling like she was restricting. She felt if I asked her to give up eating these biscuits in the afternoon she would feel in a restricted mindset. So I said, let’s carry on with the biscuits then. That’s absolutely no problem. We will reduce down some of the highest FODMAP meals.

And I gave her some simple swaps and some ideas to change things up, to just reduce down the amount of FODMAPs in other meals.

Relying on an afternoon snack

But the thing that was going to be non negotiable was to have these specific biscuits every afternoon. She felt if she didn’t eat those biscuits, she got really bad cravings.

And also she felt excessively hungry. So that was a non negotiable and that was completely fine with me. I’m really happy to work around people’s need to keep some things consistent.

Taking your time to implement change

And actually, she took around two to three weeks to even decide whether she could cope with the gentle low FODMAP diet before we got started.

In that time, we talked about lots of other things, particularly around her sensations of hunger and appetite.

Understanding your appetite can improve IBS

Something I think I’ve mentioned before is the appetite pendulum that I use, where I ask people to engage with how much hunger they’re feeling throughout the day. Before and after meals, particularly, by rating it on a scale of minus 5 to plus 5 before and after meals.

This helps you get in touch with your hunger patterns throughout the day, to know whether you’ve eaten enough food, or whether you’ve eaten too much food. And how that’s affecting your enjoyment of the next meal and how long you’re able to go in between meals.

How to measure your appetite

All you need to do is to write down if minus five is absolutely starving and plus five is really full, where you are on that pendulum that’s swinging backwards and forwards throughout the day. From minus five to plus five before and after every meal.

Now this was really interesting for her, and she spent a lot of time really thinking about it, and this is one of the things I loved about working with Fran. She really threw herself into it, even the difficult aspects of changing your diet and changing your attitudes to foods.

Avoiding diet culture

What she found is that she had a desire to eat intuitively. She was really keen on not being on a diet, not restricting due to the diet culture that is so pervasive. Everyone’s always told be in a smaller body, eat less, take up less space. So I really could connect a lot with this desire to knock all of that on the head.

But what I wanted her to do was to think more instead of having those as rules, actually just use your body as a guide for how much to eat, or when to eat.

Allowing a busy schedule to rule mealtimes, rather than appetite

She realised sometimes she was going for long periods of time without eating in order to fit around the kids schedules, clubs after school, rushing around. Sometimes she was not eating. So she would get super, super hungry and then snack on foods. And then when it came to the main meal, she wasn’t actually hungry for that.

And then other days she would eat more to a routine. And eat sitting down at a meal table, but other times it was all over the place. This was just helpful for her by mapping it out and just thinking about what symptoms correlated with what eating patterns.

Once she had committed to doing this low FODMAP gentle approach with some non negotiables.

Increasing vegetarian protein with IBS

Then what she realized is she probably wasn’t eating that much protein. She was on a vegetarian diet for ethical reasons. And so we talked a lot about vegetarian protein, how to increase tofu, eggs, nuts and seeds, and also meat replacement products.  Because she was open to eating veggie sausages and veggie burgers, that sort of thing.

It’s harder with vegetarians to get enough protein to keep you fuller, and the more protein you can eat, you tend to be fuller for longer.

Fran’s fear of hunger

One really interesting thing that came out from this work was talking about her fear of hunger. So, What we uncovered as we got further and further into getting to know each other and having deeper conversations about where relationship to food had stemmed from. Is that Fran was a really fussy eater as a child.

She literally only had a few meals that felt safe to her. She couldn’t bear to eat anything else. And so she had quite a lot of panic about feeling hungry. To her, feeling hungry meant feeling very unsafe and very dangerous.

Fear of hunger driving today’s eating habits

I’ve had another client who had a similar experience where her parent was massively over restricting with family meals. The children weren’t given enough food. Not because they couldn’t afford it, but because the mother was very controlling.

And so, in the same way, my other client had this fear of hunger. This need to have immediate food all around you. Sometimes really unpicking how you feel about food and where this has come from can be absolutely transformative.

She hadn’t really connected that her fear of hunger was driving a lot of her behaviours. And this fear of hunger had stemmed right back to childhood. Where she worried a lot about what she could eat.

Maintaining unhelpful habits

And so this had, in some way, carried on into her adulthood. Even though she was the adult, she was the one buying all the food. Also she’d done so much research into what is good and what is healthy. That she’d put a lot of expectation on herself to go the complete opposite of her childhood. Which was very restricted in terms of what was acceptable to her. Right up to a very broad diet where she was eating probably too much fibre.

Quietening a noisy digestion

The next really interesting thing that came out of this work was, once she’d got a couple of weeks into doing the low FODMAP diet, she found that her digestion really quietened down. So when we eat fibre, foods that are rapidly fermentable. Often they’re drawing water into the small intestine and that can cause noises as food is moving through your digestion.

It’s not necessarily anything to be worried about, but if you suddenly get a noisy digestion and it won’t go away, it is worth getting it checked out with your doctor. But most of the time it’s just noise. It’s just the gas, food and digestive juices moving through you. She’d had this noisy digestion for a long, long time.

Is it hunger noises, or digestive noises?

She wasn’t particularly concerned about it, but in her mind it was really connected to hunger. And again, this fear of being hungry, this fear of being without safe foods was, a mental trigger for her as well. So really triggering her anxiety. What she said within a few weeks was,

I didn’t know my digestion could be this quiet.

So when we do the low FODMAP diet, we’re cutting out a lot of that food that’s rapidly fermentable and it just quietened down. And what she thought was hunger was actually this sort of unsettled feeling in her gut, partly down to the high amounts of gas traveling through the gut.

Getting to know your digestive process

Fran realized that she was potentially eating in order to settle her stomach. She didn’t need as many snacks.

So remember when we started out, she said the things that were non negotiable were to have these certain brand of biscuits, to have at least two every afternoon? As she got more into the low FODMAP diet, she found she didn’t even need them. She didn’t have this noisy digestion.

She didn’t have the rumbling that was ongoing that she thought was hunger.  Partly down to eating more protein, partly down to taking some of those fermentable fibres out, she just didn’t need to snack as much and her energy levels were fine.

Taking stock in the gut reset

Once we’d got to this point, she was feeling relieved, I knew what I was talking about, that I had given her some advice that had worked and she felt a little reassured by that.

I was comfortable that this was a good new baseline and then we were going to push on through the FODMAP reintroductions to try and get her back to eating a more normal diet.

Chaotic FODMAP reintroduction

Her FODMAP reintroduction phase was a little bit chaotic, partly because there were times when she was going away for the weekend or she had a family party. She would just eat a meal that had mixed FODMAPs in it. A normal meal that might have had some spices in it, some onions. Some other things that could have been high FODMAP, and then she would get a reaction.

She wouldn’t know what that was connected to. This is quite normal, I would say, with a lot of people I work with.

The FODMAP reintroduction process takes around another two to three months, and after doing the FODMAP restriction phase for a couple of weeks. People are just keen to get off it. And there’s often social events, which means that you don’t stick to the diet as clearly.

So what we found is that she could do the trials, but it got a little bit muddled at times. And to be honest, that is realistic. So if you’re someone who struggled with the FODMAP reintroduction process, Do not think that you are alone.

Take a break from the reintroduction if you need

A lot of people do it even when I am telling them this is exactly how you should do it throughout the week.

Because you know, things come up normally, I would say take a little break, have the meal out, or go for your weekend away, whatever.

Don’t try and do any reintroductions during that. Take a break, then come back to it, reset, and then go to do the next reintroduction. And if you want more advice on that. I’ve got episode 17 and 18 where I go through the low FODMAP diet and the reintroduction process.

Does the low FODMAP diet lead to weight loss?

Now, something else that happened. The third really interesting point was talking about intuitive eating, and diet culture. She was very keen that that was not a part of our work, didn’t want to weigh herself, talk about body measurements, and actually it wasn’t really relevant.

Her weight wasn’t relevant to her digestive symptoms. However, partway through this process, she weighed herself and, She thought that she would have lost weight because she was restricting FODMAPs.

FODMAP restriction doesn’t mean weight loss

However, she was not restricting her calorie intake because this is not part of the FODMAP diet. The low FODMAP diet is not there to help people lose weight. And so this was actually more of a challenge than she realized. She thought that she would have lost weight doing the low FODMAP diet. And she felt disappointed that she’d actually put on one or two pounds.

She wanted to give herself a little ego boost, she said, by weighing herself to think, Oh, I’m working really hard here. I’m losing weight and I’m getting my digestion back on track. Actually, putting on a few pounds and improving your digestion have got no correlation really.

Restricting your food intake can lead to weight loss

It’s partly back to that restrictive mindset, that sense that I am restricting, therefore it must be helping me lose weight. Whereas in actual fact, there’s no reason why you should lose weight on the low FODMAP diet.

However, I will just say some people do lose weight on the diet because they are restricting foods that they tend to eat a lot of. Like if you’re someone who snacks on lots of bread, or you’re often eating lots of biscuits and cakes and you cut them out, then maybe your energy levels will go down.

In this case, that was not her goal. That was not anything that she was working towards. It was just a side note, but that’s, what’s really interesting is to think about. Our expectations of going on a restrictive diet where energy is not part of the equation. But because we’re on a diet we might feel like okay Therefore we should be losing some weight.

Sometimes sorting out your diet helps you realise what else needs work

The final point I want to make about working with Fran was She, as I said, really reflected on everything to do with this process. Like she went deep into how food affects her and her relationship with food.

One of the things she realized is that when her stress and worry went up in her life, her symptoms were worse. But because they were up and down all over the place before working with me, she automatically assumed it was because of something she’d eaten.

Stress affects your digestion

As she realized that food wasn’t always the trigger for her flare ups, she realized there were other things. That were actually harder to tackle that were causing her flare ups. And what I meant by that is that there were life stresses, you know relationship stresses, parenting problems, problems with running a business.

These all are stresses that can impact on your digestion But they’re much harder than just eliminating onions, for example It’s easy to blame the food cut the food out and then If that doesn’t work, cut more food out and think about more and need more research, more, more, more about your digestion.

Creating a new baseline gives you clarity

And actually, once you’ve unpicked that and almost like crossed the food off the list, then you have to turn your attention to other things in your life that might be driving these symptoms. This level of worry and anxiety that could be triggering your digestive symptoms. It is much harder. To face that and I was so proud of her for realizing ‘there are some things in my life that I actually need to deal with and I’ve been spending all my mental energy focusing in on food.’

Blaming food can be easier

Because in a way that was easier and it’s not to say wrong because there probably were things that we changed in her diet that were making an impact. But she was also able to see that there was potential for other problems and other ways of living that would make her life a little bit easier.

Creating your new digestive baseline

At the end of working together, she realized that she’d reset her digestive system so that she could notice a change. She had a good new baseline. And then if things went wrong, things started to go haywire again. She knew how to reset.

So she had all the FODMAP meals she knew worked really well for her. She also had got back to a really good level of diversity.

Aim for 30 plants a week

So sometimes at the end of working with people, when they’re feeling good, I try to encourage people to get to 30 different types of fiber.

A week and she was pretty much meeting that consistently so she was doing so well But without the symptoms and that is the ultimate goal from all people I work with is to eat as wide a variety as possible with reduced symptoms.

Taking your time in the Gut Reset programme

Fran was a client who as I said, I really enjoyed working with. She took a long time to think about things.

For example, she contacted me about working together and then I didn’t really hear from her for about four months. But during that time, she sent me a few emails. She was thinking it over before she made the commitment to invest in working with me. She was someone who needed time.

You get 3 months with me in the Gut Reset

And because I work with my clients for at least three months, we get that time to discuss, to change things and to work together.

And I think this also felt like. Well, from my perspective, anyway, it felt like a really good partnership where I was able to provide her with guidance and my input. But a lot of the work, as always, with all my clients is she did it herself. She did all the work and the transformation, especially around connecting her eating history to her current symptoms.

I can help with your IBS

If you’re someone who would like some help with your digestion, then please do get in touch. My three month gut reset is open and I welcome in people from all over the world. So wherever you are you can just set up a call to speak to me, first of all, to see if it’s a good fit for us to work together.

Do you want to work with me? And do I think I’ll be able to help you with your digestive issues?

I will leave it there though for this episode. So, thanks very much for listening to the Inside Knowledge.

Better digestion for everyone.

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