Why Low-FODMAP Diet Doesn’t Treat IBS
It was really a coincidence that I got diagnosed with irritable bowel syndrome. But let’s rewind a couple of years first.
I had been having episodes of stomach pain and diarrhea for years. Way more than normal. To the point where it interfered with my daily life too much. Sometimes I’d have to visit the toilet every second hour during work hours. This didn’t seem sustainable to me.
So I went to see my GP who referred me to some specialists. After a few tests, they told me I have celiac disease. It basically means I can’t eat gluten. The pastries, pasta, pizza, etc — they all had to go.
For about two years I stayed away from gluten. Tbh, it was pretty difficult — it was hard to find food that didn’t have ANY gluten in it. Even if you avoid the typical culprits, you still might discover that, for example, the sauce on your steak is made with flour.
It also didn’t help that I lived next to one of the best Neapolitan pizza places in North Europe — the temptation was always there.
However, two years after I changed my diet, the symptoms didn’t improve at all. I got suspicious.
I happened to be in the small town I was born in and decided to go see a doctor there at the local hospital. He specializes in gut and stomach problems. He went over the tests and ran some additional ones. I went back to his office the next day for results.
He said that I definitely do not have celiac disease. This should have been clear already with past tests. Instead, I have IBS.
What Is Irritable Bowel Syndrome?
More than one in ten people has irritable bowel syndrome (IBS) on average. Women (in the Western World) are twice as likely to have it as men. And you’re also more likely to have it when you’re under 50.
I suspect that in the startup community (where I work) the likelihood is even greater than in the average population. It’s a fast-paced high-stress environment.
However, there is very little talk about IBS in the society. “Irritable bowel syndrome” appeared in only 48 articles on CNN.com compared to 697 that mentioned “clinical depression” although IBS is twice as prevalent in society. That’s over a 20-fold difference. Perhaps it’s because it has to do with diarrhea, so, it’s kind of a taboo topic.
So, what is it exactly?
Irritable bowel syndrome (IBS) is a “disorder of gut-brain interaction” characterized by a group of symptoms that commonly include abdominal pain, abdominal bloating, and changes in the consistency of bowel movements.
However, there is no known cause. So, there isn’t a reliable test either that can tell you that you have IBS.
Instead, the diagnosis is given by elimination. Basically, if nothing else fits when you have symptoms of abdominal pain and abnormal bowel movements, then it’s gotta be IBS.
What Is Recommended As Treatment?
My doctor recommended two things.
First, keep on taking loperamide. It’s a drug for treating diarrhea (similar to activated charcoal).
I had been taking it cautiously for years almost daily and it really helped to reduce the symptoms. Although pharmacists often tell you to not take it for more than a couple of days, I couldn’t actually find any studies on serious long-term effects. It could increase bloating though, so, it might make one symptom worse on the account of improving others.
Secondly, try out the low-FODMAP diet.
FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols, which are short-chain carbohydrates (sugars) that the small intestine absorbs poorly. Some people experience digestive distress after eating them.
The idea is to limit sugars that might cause or worsen the symptoms.
I don’t have the original picture my doctor gave me anymore but it listed various foods that contained different types of sugars: fructose (fruits), fructans (asparagus, cabbage etc.), lactose (milk etc.) etc.
So, I went through the list and eliminated a certain type of sugar for a couple of weeks each time. No change in symptoms.
Why Low-FODMAP Diet Doesn’t Work for IBS
I was curious though. Why didn’t the low-FODMAP diet help? Once I started seriously thinking about it, it’s quite simple really.
IBS isn’t caused by diet. If it were, everyone with similar nutrition would get it. But they don’t. So, IBS can’t be cured by nutrition.
It’s no wonder then that the meta-studies on low-FODMAP diet have found no conclusive evidence that it actually helps.
There is very low quality evidence that a low FODMAP diet is effective in reducing symptoms in IBS patients.
Source: PubMed
It’s pretty obvious that if you don’t know the cause, you usually can’t treat the symptoms properly either. Not to mention curing it.
The low-FODMAP diet might even do more harm than good. Changes in your nutrition and gut microbiome are not something you’d want to experiment with too much.
[…] its [low-FODMAP diet] long-term use can have negative effects because it causes a detrimental impact on the gut microbiota and metabolome. It should only be used for short periods of time and under the advice of a specialist.
Source: Wikipedia
Short-term dietary experiments might be beneficial for another reason though. They might help identify something else — celiac disease or food allergies, for example.
So, it’s pretty clear that low-FODMAP diet is not a proper treatment for IBS. Those, who keep on studying it are missing the point.
Trust Your Gut, Stupid
I like to read and research different topics. Psychology especially. So, I’ve been reading up on various topics, especially related to mental health.
At some point, I came upon the book “When the Body Says No: Exploring the Stress-Disease Connection” by Gabor Maté. In it, Dr. Maté argues for a more holistic approach for many chronic conditions. Although the symptoms are physical (they manifest in your body in one way or another), their source might be outside your body or in your past experiences.
This is something that I was already aware of thanks to having studied psychology. Even the very definition of health (at least by WHO) emphasis that:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Source: WHO
A person as an individual doesn’t exist in a vacuum. Your mental and physical health both depend on your environment and other people.
This is very obvious yet in both psychology and medicine it’s somehow often forgotten. When was the last time your GP asked about your life instead of just prescribing you some pills?
But back to the book. In it, dr Maté writes:
The brain relays to the gut data from sensory organs such as the eyes, the skin or the ears — or more correctly, relayed to the gut is the interpretation of such data by the brain’s emotional centres. The resulting physiological events in the gut then reinforce that emotional interpretation. The signals sent back to the brain give rise to gut feelings that we can apprehend consciously. If we lose touch with gut feelings, the world becomes less safe.
…
When there are too many “gut-wrenching” experiences, the neurological apparatus can become oversensitized. Thus, in the spinal cord the conduction of pain from gut to brain is adjusted as a result of psychological trauma. The nerves involved are set off by weaker stimuli. The greater the trauma, the lower becomes the sensory threshold. A normal amount of gas in the intestinal lumen and a normal level of tension in the intestinal wall will trigger pain in the sensitized person.
Pages 189–190
Basically, your (early) traumatic experiences might make your gut too sensitive. So, a normal event might trigger a disproportionate reaction — either through pain or diarrhea.
So, it’s not surprising to read then that:
Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.
Source: Wikipedia
And also the very definition of IBS says that it’s a “disorder of gut-brain interaction”.
Your gut is trying to tell you something. It’s trying so hard, it attacks itself. Perhaps it’s better to listen, I thought.
I started suspecting that it might be true that people with IBS have lost touch with their intuition and don’t know how to interpret (or maybe even describe their emotions properly).
I too sometimes find myself making decisions against my gut feeling and regretting them instantly. How does one start listening to one’s gut again though?
What Actually Helped Me With IBS
If the core reason why people develop IBS is trauma, then probably the only way to deal with it is to get better at dealing with traumas and life in general. This means examining both past traumas and dealing with your current environment (including the relationships and people in it).
I first wanted to test though, whether what Dr. Maté wrote about might be true. Is there a psychological reason behind the triggers?
My method was simple:
- Write down what happened just before the onset of symptoms
- Dig deeper behind the triggers
- Search for patterns
Already a week in I started noticing pretty obvious patterns. One of the main triggers was uncertainty in its various forms. Whether I got overwhelmed by a task or just felt unsure about something, it was related to uncertainty. Uncertainty about a relationship, for example. Or even uncertainty about where I was going to live the next week (I was travelling at the time).
I also noticed that as soon as I had identified the actual trigger, it already made me feel better. Often I’d get up to go to the toilet but somehow the symptoms disappeared as soon as I started thinking about the trigger.
But it’s not magic. One doesn’t develop IBS just magically. So, it won’t also go away magically. It requires work but it is possible to at least reduce the symptoms consistently. It helped a lot that I already knew a lot of the coping mechanisms from studying psychology.
So, I started coming up with coping mechanisms for either getting rid of triggers or at least minimizing their effect. And it helped. I wouldn’t say IBS has disappeared completely but the symptoms have reduced to a point where I’m comfortable dealing with it and I’ve stopped taking loperamide.
Turning The Solution Into An App
I didn’t have any plan to work on something that would help treat IBS. I had actually already begun working on another product when it occurred to me what maybe I should focus on IBS instead.
The more I used my method the more I realised it actually made perfect sense as an app for several reasons:
- You need to log the symptoms in order to start seeing patterns
- You need statistics in order to see whether you improve or not
- You need help with coming up with coping strategies to deal with the triggers
The first two would have been easy to solve even 10 years ago. But the third one would have been very difficult to do back then. You’d have to somehow connect the person to real doctors and psychologists. This would have driven up the cost and reduced the availability.
This has changed dramatically during the past couple of months with generative AI.
AI can now perform even medical exams better than most doctors. So, you can ask for health advice from AI on most topics knowing that on average the answers will be more accurate than from a random doctor.
“In medical student board examinations, among 12 question categories, GPT-4 significantly outperformed users in each.”
See the article or source study
This is a quote from an article that references OpenAI-is GPT-4 product.
Google has lately shown similar results with their Med-PaLM 2 model where the AI would easily pass a medical exam:
Using AI has several advantages — it’s always available, it knows many languages, and it drives down costs. Not everyone has access to the best doctors and psychologists. AI can help with that.
So, I started working on an app. I called it GutBound — cause everything major that you experience is bound to go through your gut, one way or the other.
The app has three parts:
- Symptom and trigger tracking
- AI consultation
- Statistics
When you log a symptom, you’re also prompted to describe the trigger. What you were doing and thinking/feeling at the time.
The AI consultant will then help you make sure that you’re equipped with the right mental tools to help you deal with the trigger the next time it occurs. Or help you avoid it in the first place.
And of course, the statistics are there so you can see whether you actually improve or not.
It has worked for me. I hope it will for you as well.
The waitlist for GutBound is now open. The public release will happen in the coming weeks.
Edit: Is IBS Even One Disease?
As I mentioned above, IBS is diagnosed mostly through elimination. There are no good biomarkers as far as I’m aware. All we have is a list of symptoms.
This might mean that what we call IBS is really not one but many different diseases. This would explain why there is no single treatment or cure for IBS.
It wouldn’t be the first time when something like that happened. Many mental illnesses used to be lumped together until we bothered to look deeper.
Similarly, heart failure and cancer were both originally classified as one disease. We’ve since learned that cancers have many different types and so has heart failure.
Update 1: A Case For Nutrition
I said above that nutrition can’t be the cause because otherwise, everyone with the same nutrition would get it. It’s maybe not quite that simple.
It could be that nutrition and another factor play a role. We just don’t know what the exact combination is.
One hypothesis is that maybe the diets of the majority of people are wrong. It is definitely true that nutrition has gone through some major changes during the last 100–150 years and at the same time we’ve had rises in a lot of conditions: obesity, IBS etc.
One big change is that we consume way less meat and animal fats than we used to. Plus meat and vegetables don’t have the same quality (nutrition). If you’ve ever compared the smell and taste of a tomato grown in your own garden vs the one in a supermarket, you know what I’m talking about.
We’ve also replaced animal-based fats (butter, lard, tallow) with plant-based fats (margarine, vegetable oils).
So, instead of the Low-FODMAP diet, it could be interesting to test out the carnivore diet and also eliminate vegetable oils.
See, for example, this study where adults self-reported major improvements across the board for various health conditions (including gastrointestinal health).
As far as the other factor — I still believe (based on research and my own anecdotal evidence) that psychological stress/trauma is something to look into more deeply.
Update 2 (11-Apr-2024): A Case For Lifestyle Changes
A new study confirms my initial hypothesis — healthy lifestyle lowers the risk of IBS by up to 42%.
The authors followed over 64k people who weren’t initially diagnosed with IBS. They were enrolled between 2006 and 2010 and followed until 2022.
The five healthy lifestyle behaviors studied were:
- never smoking,
- optimal sleep (7–9 hours per night),
- high level of vigorous physical activity,
- high dietary quality (balanced meals),
- moderate alcohol intake (between 5–15 grams daily).
Adopting even one healthy habit lowered the risk significantly:
- One healthy habit — 21% lower risk
- Two healthy habits — 36% lower risk
- Three healthy habits — 42% lower risk
You can read an overview of the study in CNN.
Update 3 (26-Jun-2024): There’s A Gene For That?
There’s some progress in understanding IBD (some forms of it include Crohn’s disease and ulcerative colitis).
However, while IBD includes chronic inflammation and swelling, IBS doesn’t. So, it’s not the same thing most likely. I’m just referencing the news here to illustrate a larger point about “explaining” disease through genes.
“Scientists at the Francis Crick Institute in London have identified a genetic mechanism underpinning the development of inflammatory bowel disease (IBD) and other autoimmune or inflammatory conditions and identified existing drugs that could target this pathway.”
There’s no drug that deals with this specifically. However, they do want to push MEK inhibitors which are also used for cancer treatment.
This alone should make one extremely suspicious. It seems to be one of those “the cure is the worse than the disease” type of situations. The list of side effects for MEK inhibitors is pretty long.
Another problem with this is that just because a gene has been identified, doesn’t mean that it is the cause. Genes are turned on and off (in simplified terms) by the environment and experiences. A renegade gene is very unlikely to be the root cause of anything that’s common (genetic diseases are very rare while in the US roughly 1 in 100 people has IBD).
So, a step forward in understanding the physiological mechanisms of IBD but no cure or core understanding yet.
PS: I’d love to hear your feedback — especially if you have experimented with different methods of treating IBS and what the results were.
