Welcome to episode 70 of the Inside Knowledge podcast for people with IBS, I’m Anna Mapson.
Send me your podcast questions
This week’s podcast is in response to a question I had from a lovely listener who said, I don’t think you’ve ever covered IBS-M subtype, and please would you do a podcast episode about it? So here I am. And if you have got questions that you would like me to further explore in future podcast episodes, please, please drop me a line.
I’m always happy to hear from my lovely listeners. So let me know if there’s something you want to hear me talk about and explain in more detail in a 20 minute episode, you can get hold of me at my email address, which is info@goodnessme-nutrition.Com. Or you can find me on Instagram where I am @goodnessme_nutrition
What is IBS-Mixed type
To answer the question about IBS M, this week I’m going to be talking about how many people have this mixed type of IBS and what you can do about it. And also, in order to understand what you can do about it, we need to think about why your symptoms might be alternating from slow transit time to fast transit time. All those things we can think about to try and improve your, overall digestive capacity.
Firstly, when we are thinking about IBS, there is something called the Rome 4 criteria by which we categorize IBS. Everybody who has IBS has some set of symptoms that are the same and some things that are different depending on the mini subtypes.
Defining IBS symptoms
So everyone who’s got IBS has got problems associated with having a poo. And they have been a problem for at least one day a week for the last three months. Normally you’re getting change in frequency of your stool and also maybe a change in the appearance of it, so perhaps it’s much runnier, a different color, all of those things.
Then the subtype elements are that you have really hard pebbly type poos. If you look at the Bristol stool chart, you’re going to have very hard, small pebbles or very large, difficult to pass stools. That’s type one and type two for about a quarter of the times that you go to the toilet. And then Another quarter of the time, you might have loose, like, watery diarrhoea type symptoms.
Type 7 is loose, watery, urgent stools, and type 6 would just be very mushy, but liquidy type stools. But obviously with some substance there, not just complete liquid.
IBS-M – mixed symptoms
Now, IBS-M type patients alternate between very constipated and very loose.
But also will have problems with probably straining, feeling like you haven’t been able to empty your bowels properly, and maybe even needing to use your finger to extract the poo out. That is common with people who get constipation predominant symptoms. But at the same time, you might also get a load of urgency when you’re getting the loose stools, the watery stools.
Worst of both worlds
In some ways, you’ve got the worst of both worlds because you’re getting sometimes when it’s loose, you don’t know whether you might have an accident and it’s very urgent. And other times you might not go for days and then when you do, it’s painful. You’re straining to get it out. You just feel a lot of the time like it’s just a real struggle to fully evacuate your bowels.
The other things that we see from the research is that potentially people who have this mixed type of IBS might have a trend for a higher frequency of nausea, so that feeling of sickness particularly in the morning. I see this more often in line with people who have constipation anyway.
Morning nausea may be a symptom
People who tend to be feeling nauseous in the morning as often if you can’t go and you just feel very full. But also people who have IBS-M may have a higher tendency to have anxiety or low mood and depression. Again like maybe it’s because the symptoms are so bad and also they’re alternating.
It’s more common than you may think
In terms of how common it is, in the research it seems to be between about 19 percent and I think the highest I saw was around 60 percent of people who are classified as having IBS fall into that subtype of IBS M. So you can see it’s actually pretty common. It’s not as rare as you might think. Even though we tend to focus on solutions and the problems of people who have constipation or diarrhea.
And we don’t focus so much on the people who are alternating. You may also see it written down as IBS A, which means like alternating IBS, or IBS M, which is mixed.
They’re the same, it’s just different ways of saying it. There is two particular reasons that I want to explain a bit about around why people may be alternating between these two types of very hard to very loose stools and then back again.
IBS-M to constipation
And actually, interestingly, people seem to transition more between IBSM and constipation than IBSD and constipation. So more veering to the harder stool side.
Now one of the reasons this can happen is you might have heard me talk in episode 33 and episode 34 when I talk about common causes of constipation and what to eat when you have constipation. You might have heard me mention in those episodes something called overflow diarrhea. And this can happen when you are constipated so you have hard stool that is stuck in your colon. As you start eating, you get more and more food that’s coming through, and maybe it’s It’s a bit softer above the build up of the hard stool, which is there.
Overflow diarrhoea – potential IBS-M cause
As this more softer stool comes down, it kind of causes the bowel to stretch. You might feel very bloated, quite painful, quite hard to press your stomach. Then this softer stool that’s behind the blockage can overflow around the blockage and come out as diarrhoea. And then you still don’t feel like you’ve properly emptied your bowels.
You still feel blocked and hard and uncomfortable because that blockage is still there. It’s just that you’ve had a release of some of the liquid that’s been building up behind this hard blockage. This can sometimes come out as leakage or incontinence, which obviously can be embarrassing and worrying. It may mean you feel like you don’t want to leave the house. Like you’re afraid to go out in case you get another one of these attacks.
The other thing is, it’s not like people who get constant diarrhoea, who are always feeling like everything’s been emptied out of them, like they’re just drained and empty. Everything’s gone.
People who get this kind of overflow diarrhoea are often still incredibly bloated and hard and feel heavy and all of those normal symptoms of constipation, despite the fact you’ve just had diarrhea, it hasn’t released everything. So that is one potential cause for having a mixed presentation, is that actually it’s constipation underlying it.
Switching between laxatives and anti-diarrhoea meds
Another potential cause is that you are. going too hard on your medication or supplements that you take to deal with your symptoms. So what I mean by this is that you overshoot in terms of things that get your bowels looser because you’re constipated.
So maybe you take too much magnesium oxide. You take a little bit too many laxatives, and then you veer into very loose and soft stools. And then you think, Oh, now maybe I better take some anti diarrhoea medication because I’m getting a diarrhoea attack. So then you take one or two of those for a couple of days.
Over supplementing
Then your stools go very hard and it takes you another few days to go soft again. And the whole time that you’re bouncing around between very loose stools and very hard stools. Constantly trying to readjust supplements and over the counter medication. You don’t know what to eat. You don’t know what to do.
Feeling lost with IBS-M
And you feel pretty lousy. You’re still getting straining. You’re still getting periods of pain and bloating and the bowel habits are irregular. You don’t know how to deal with them. This has actually been shown in some studies to account for up to one third of people who are classified as having a mixed type of IBS.
So when we look at that Rome criteria for diagnosing people with IBS, out of a whole range of people, I think it was 350 people.
What they found, is that, 32 percent of these people, one, were actually overshooting their medication by taking too many products to loosen their stools or to firm them up and that was actually the cause of their IBS.
Eating erraticly
Other things that I see my clients doing that may be contributing to this pattern of erratic bowel habits would be eating a very low fibre diet. Then suddenly eating more fibre or not eating enough food and then eating very large meals.
So erratic eating habits, but also a low fibre diet. Let’s explain a bit about those two.
A low fibre diet
So a low fibre diet will mean that you are struggling to form a good bowel movement. Then you might have days when it’s slightly better depending on what you’ve eaten. Other days where you’re not eating enough fibre it really slows down and you become a bit constipated.
Then maybe you eat another day where you are having quite high fibre, maybe a bit more fruit. And you’re really trying to make an effort and trying to be healthy. That might then, because they’re higher FODMAP foods, draw water into the small and large intestine. And that can cause diarrhea and really cause things to speed up.
That might be one of the causes to it. So your, your erratic fibre intake.
Erratic eating pattern
And then also I mentioned erratic eating, which means sometimes you skip meals, sometimes you eat very large meals, then you might go for a day. All you eat is dinner and you just have a few snacks at lunchtime and you only eat one main meal a day.
The most common way I see this is people who are skipping breakfast. That is not going to get your bowels moving in the morning. And that’s one of the best times to open them before you leave the house in the morning after you’ve had breakfast. That’s the ideal time you want to go get it done for the day and then it might happen again later but it’s not necessarily going to be a problem because you have got some of it out for the day.
Anyway. That is also a problem when you are eating erratically. Your body doesn’t know what’s coming, when your meal’s going to arrive. Sometimes then you don’t eat for a while, so you become very hungry. That in itself can then lead you to overeat or eat very quickly. Perhaps this means you’re not chewing your food very well and you’re eating it pretty quick.
Get your fibre levels right
So those things are you will have heard me talk about it lots of times. Whoever you are, with whatever kind of IBS you’ve got, you should be eating fibre. And I know it can be tricky, and I know people say that high fibre foods do bloat them. That is why we can start with some low FODMAP fibres, and some different ways of eating that are not going to bloat you, very gradually increasing your food.
So that you actually tolerate fibre better. It’s almost like you need to train your bowels up to receive fibre. And we can do that in a really careful way. This is what I do when I work with people in my 3 month gut reset. Is working to pinpoint your issues. And working to understand how to improve your experience of eating.
And for everyone it will be slightly different. Now let’s think about what you can actually do about it.
How to help IBS-M
Check for overflow diarrhoea
Firstly, I want you to think about whether you potentially could have that overflow diarrhoea and you’re actually constipated. One of the hardest challenges with overflow diarrhoea is convincing people that they need to take laxatives when what they are experiencing is diarrhoea.
So if you feel like you’re getting leakage and very loose stools that are very watery, you’re still very bloated, you’re not going to necessarily come up with the idea of taking more laxatives. Because it feels like that’s going to exacerbate the problem. So we do have to be sure that that is really what you are having. Rather than you do actually have diarrhoea, because if you have another type of diarrhoea, for example, and you take a laxative, it could actually significantly make things worse.
Clear the blockage
The reason you need to clear out the blockage is so that you can reset your bowel almost, like you can clear the blockage and then start to input the fibre.
If you go straight back to your old diet, which is very low fibre, Hardly eating any foods. It’s just gonna happen again, and it will maybe feel better for a little while, but it’s gonna come back.
So we need to get rid of that impacted stool through laxative use. You may even have some support from your doctor to clear blockages. It depends really how bad it is and how stuck it is. I know some people also are prescribed an enema kit to do at home where you can kind of wash water up your bum but it does need to be done under strict instructions and I don’t recommend anyone just starts doing this at home. You may also see people suggesting you put coffee up your bum as well as a coffee enema. But I definitely don’t suggest that.
Diet for IBS-M
Thinking about what you can do other than that, would be Food, changing your diet. So when you clear the blockage, however, you’re going to do that through laxative use or through disimpaction protocol from your doctor or hospital.
Then you need to start gradually feeding the gut with fibres that are going to keep things moving. We need a variety in fibres because, some fibre is bulk forming, it forms the need to stimulate the bowel to want to go.
Keep things varied
Other types of fibre, pull the water in and kind of keep it soft and jelly like and loose so that it can be formed into a nice squishy stool that just comes out in one go and isn’t going to leave you feeling uncomfortable.
That is the reason you need to normalize and stabilize your fibre intake and it will be done gradually over time. It’s not going to happen immediately. But I do suggest starting with some low FODMAP foods that are going to increase your fibre very slowly. If you want a list of things that you can eat on the low FODMAP diet, you need to listen to episode 37, which covers What can you eat on the low FODMAP diet?
And in there, I go through some specific fruits, vegetables, grains, and different kinds of things that you definitely can eat.
Start very slowly
Now, when you’re introducing anything to your diet for the first time, I do suggest doing it very slowly, very carefully. There’s this nice phrase like start low and slow. And I always suggest that for supplements, but definitely also with food, particularly if you haven’t eaten it for a while.
For example, broccoli, people are a little bit surprised that this is low FODMAP. This is different to cauliflower, which is very high FODMAP. This is why the diet is really not very intuitive. And I do have a self study guide to following the low FODMAP diet, which you can buy off my website, which includes loads of videos, handouts, checklists, and everything you need to make it super simple.
But, like I said, listen to episode 37 first, make sure you understand what foods you can eat, and then think about how to increase them. If you do that route, maybe you’ll just build it up on your own. But maybe you need to actually go and follow the low FODMAP diet. And this is as effective for IBS M as it is for the other subtypes of IBS.
Try the low FODMAP diet
If you’ve been struggling with your IBS for a while and you fall into this category of having mixed symptoms, then I do suggest giving the low FODMAP diet a go. One of the problems with following it for too long though is that you can end up restricting your fibre intake long term. When you’re following the low FODMAP diet you’re cutting out a lot of fermentable carbohydrates. Which over time might reduce your fibre intake.
You have to focus a lot on fibre and making sure you’re getting enough when you’re in that restricted phase and then through the reintroduction part of the process. The FODMAP diet is only meant to be followed as a dietary intervention to identify foods that might be triggering your symptoms. I do think it’s worth doing if you haven’t approached it yet and you’ve been struggling with IBS for a while.
And that’s why I put the guide together. You can pay for it on my website, and you can then download meal plans, it shows you recipes, and it’s got a lot of information in there about how to manage the FODMAP diet. Critically, it’s how to get off it, and that is one of the key things that I really feel like I specialize in with my clients.
Expanding your IBS diet
Helping people get back to a broader diet. I want you to be eating foods that you enjoy. I want you to get back to eating normal amounts of foods as well that really interest you. Not just plain boring foods with no flavor that you’ve been eating on repeat for weeks and weeks on end or even months on end.
The other things you could do would be to go back to your IBS basic checks to run through those things and see if there’s anything that you’re doing that could be exacerbating your symptoms. So when I say the IBS basics, I mean things like getting enough sleep, making sure you’re doing some exercise regularly each week.
Checking your IBS basics
Are you eating three meals a day? Are you, you know, just looking after your stress levels? All of those things which are general good health advice. They’re not specifically meant for IBS and yet they are very important. I bet you’re not doing all of those things because Who is. And again, this is the kind of thing I can pinpoint with you when I work with people one to one.
So I can look at all the lifestyle things you’re doing. I ask you lots of questions about your sleep and about your exercise routines and about how and when you eat. Because then we can work out where things might be able to change. And sometimes some of the tweaks are not as massive as you might think.
So if you’re worried about the effort that’s going to be required to get on top of your IBS diet. When you work with me over three months, I can assure you that it is piece by piece, step by step. There’s no expectation that you do everything all in one go. And that’s why I meet with my clients weekly to begin with for the first couple of weeks.
When people say their symptoms are fluctuating between one to the other is also really helpful to track your food intake and track your symptoms where you feel like there’s no pattern.
When you feel like there’s nothing you’re doing that’s causing these symptoms, it just comes out of nowhere, what’s really helpful is to start writing it down and start measuring how often you do actually have a bowel movement and where is it on the Bristol Stool Chart? If you haven’t yet downloaded my tracker, you can do that for free.
And that’s the same one I use with my clients to track their food intake and also to look at lifestyle things. So, feel free to have a play around with that first. Then, If you still don’t find anything and you can’t identify anything yourself, then get in touch about working with me one to one in my three month gut reset.
I will also put a link in the show notes to my low FODMAP diet beginner’s guide, because that is a great place to start. If you haven’t yet tackled the low FODMAP diet, as I said, it’s not an easy thing to do on your own. So it’s definitely worth having some good guidance, and if you can’t work with a trained nutritionist who knows a lot about the FODMAP diet, then this guide can help you do it and manage it by yourself at home through videos, instructions, and checklists.
Work with me
For more guidance, check out my 3-month Gut Reset programme, where I help clients pinpoint their triggers and improve their digestion step by step. And if you have any questions or topics you’d like me to cover on the podcast, feel free to reach out at info@goodnessme-nutrition.com or find me on Instagram @goodnessme_nutrition.
Listen to Episode 70 of the Inside Knowledge Podcast for more insights on IBS-M!
If you have any questions about this week’s episode, as ever, please send me an email or, like I said at the beginning, send me any suggestions for topics you’d like me to cover. And I will be back next week. Thank you for listening to this episode of The Inside Knowledge.
Better digestion for everyone.