From burning reflux, debilitating gas or bloating to urgent diarrhea or unrelenting constipation, digestive health distress impacts millions of Americans. These symptoms can truly stop people in their tracks and can disrupt their quality of life.
What I have learned from working with patients with functional gut disorders is that diet often plays an important part in symptom control but it may be only part of the treatment plan. Thinking of a pie chart, diet might only take up one-quarter of the pie for some individuals or maybe one-sixth for another. In essence, each person has their own digestive symptom pie!
Don’t get me wrong, many individuals with digestive symptoms will respond to diet changes alone….but not all! For those with functional gut disorders such as irritable bowel syndrome, constipation, bloating, diarrhea and gastroparesis, a more comprehensive strategy and treatment plan is likely.
My friend and colleague, Dr. William Chey, MD, a Professor of Medicine, Director of the GI Physiology Laboratory, and Co-Director of the Michigan Bowel Control Program at the University of Michigan and leading US gastroenterologist in functional gut disorders eloquently notes , “Food is the great enabler. In healthy people, food can turn an otherwise mundane event into a highly pleasureable, even memorable experience. On the other hand, for people with gastrointestinal problems like gastroesophageal reflux disease, irritable bowel syndrome, diarrhea, constipation, or fecal incontinence, food can serve as an important trigger for symptoms that lead to embarrassment and misery. Most often, food isn’t is THE cause of a problem as much as it unmasks a problem in function or sensation that is already there.”
Sensitivity to foods can be related to the types of microbes in our intestine, where they reside and how much gas they produce, the way the intestine handles the gas and fluid present in the intestine, how the intestine moves—too slow or too fast or the degree of sensitivity of the intestine.
Patients with functional gut disorders require diligent detective work and a collaborative treatment plan that involves the patient, the gastroenterologist and the dietitian. I firmly believe a collaborative team effort can lead to better outcomes for the patient. As in most facets of work, a team effort results in a more comprehensive outcome than work done individually. Collectively, a team can offer the patient much more than each provider could do for the patient on their own. And of course, we all learn from each other.
When I educate someone on the low FODMAP diet, I often tell them, that the diet will pull out some of the trees from the forest. What I mean by this, is the low FODMAP diet often settles down some of the primary symptoms …i.e. “clears some trees”…and then I will be able to identify better what else might be contributing to their remaining digestive distress. Janine Clifford-Murphy, MS, RD, a dietitian that specializes in the low FODMAP diet and works with me in my Medway practice finds, “Sometimes, patients overlook the role of fat in their diets as they focus on the low FODMAP foods. Once they realize cheese and butter are very low in lactose, they might be tempted to overdue it. Subsequent discomfort is often misinterpreted as FODMAP or dairy related, when it might be just too much fat at one time.”
After the initial low FODMAP diet trial, I will call the patient’s gastroenterologist to discuss the possibility of other testing or perhaps try alternative dietary modifications (modify fat intake, trial of low histamine or gluten free, adjust fiber intake) in an effort to manage any persistent symptoms. Most dietary trials should be undertaken with a dietitian to help ensure nutrient intake is adequate. Overly restrictive diets can backfire and set up the stage for weight loss and malnutrition which ultimately can impact the health of the individual and their GI tract!
Many of my clients have presented with overlapping digestive health issues such as small intestinal bacterial overgrowth (SIBO), pelvic floor dysfunction, alteration in stomach emptying such as fast emptying called dumping syndrome or delay in emptying called gastroparesis. These overlapping issues alongside IBS require additional therapies often beyond diet. According to Mark Pimentel, Director of the Gastrointestinal Motility Program and Laboratory at Cedars-Sinai Medical Center and leading SIBO researcher, “Classically, SIBO is characterized by bloating and distention after meals. Up to 70% of IBS patients may have SIBO. This is now based on small bowel culture studies. ” If you find the low FODMAP diet is not providing adequate relief, you and your team (I hope you can find one!), can work on figuring out what other over-lapping issues might be a piece of your pie. If bloating or fullness after eating is a primary issue for you perhaps SIBO is present. SIBO symptoms mimic those found in IBS. Testing is typically done via glucose or lactulose breath testing.
According the the Mayo Clinic, “Up to 50% of patients with chronic constipation have pelvic floor dysfunction (PFD, or dyssynergia). This condition is characterized by impaired coordination between pelvic floor (e.g., puborectalis) relaxation and abdominal wall motion, which is necessary for normal defecation. However, PFD is not widely recognized as a possible cause of chronic constipation. As a result, many patients with medically refractory constipation do not receive optimal therapies that enable them to recover normal bowel habits.” If chronic constipation is part of your GI picture, discuss whether you should be evaluated for PFD with your GI doctor.
Work closely with your dietitian and gastroenterologist to find ALL potential pieces of your health care puzzle…so you can feel your very best!