Case Study 1: Importance of Dietary Expansion After GI Treatment

Patient Summary: 

• Overview Context: 
  • 38 year old female with pleasant demeanor who has “hit a roadblock” working with her local functional medicine provider. Although she has seen significant improvements, she is hoping to completely resolve her remaining GI symptoms.

Visit 1 – Clinical Analysis:

Initial Impression: 75/100. 

Symptoms and Concerns

• Chief Complaints:

  • Diarrhea
    • Few times per week (previously up to 10x/day) 
  • Abdominal pain
    • Few times per week
  • Bloating
    • Related to menstrual cycle
  • Gas pain

• Onset/Timeline
  • 2021
    • Symptoms began during a high period of stress, including a COVID-19 diagnosis. 
    • Daughter had a ‘stomach bug’ the same week as the patient’s symptoms began. 
    • IBS was diagnosed. 
  • 2023
    • Patient has been on a low FODMAP diet for a few months. Despite no improvement in symptoms from it, she is afraid to stop it.

Past Medical History

• Prior Diagnosis:
  • Rosacea (2022)
  • IBS (2021)
• Medications:
  • N/A
• Pertinent Labs: 
  • Stool Test 2021: Normal
    • Normal calprotectin 
    • Negative for Giardia, Cryptosporidium, Lactoferrin, Salmonella/Shigella, Campylobacter, Shiga Toxin, Clostridium Difficile

Prior Testing and Treatment History

• Previous Treatments:
  • Helpful
    • Herbal antimicrobials 
    • Rifaximin 
      • Helpful for symptom resolution, but symptoms returned. 
    • Digestive enzymes 
    • Hydrochloric acid (betaine HCl) 
  • Negative
    • Immunoglobulins
    • Probiotics
• Previous Diets
  • No change
    • Low FODMAP diet 
      • Although she continues to follow this diet

Initial Impression

• Clinical Commentary:
  • This patient’s symptoms began during a period of high stress and possibly after a gastrointestinal infection. I suspect dysbiosis is contributing to her symptoms, primarily because of her positive response to both herbal antimicrobials and rifaximin. 
  • Due to her previous diagnosis of IBS, she was under the impression that she may have to follow a restricted diet long term.

Visit 2 – Initial Recommendations:

• Initial Treatment Recommendations
  • Diet:
    • Begin a relaxed Paleo diet. Stop low FODMAP diet. 
      • Reintroduce foods you have been avoiding 
    • Intermittent fasting 14-18 hours, 1-2 days per week
  • Lifestyle:
    • Meditation or breathwork daily
    • Continue Heartmath
    • Continue current exercise program
  • Supplements:
    • Elemental diet 3-4 day reset, then replace 1-2 meals on most days until the next appointment
    • Add in Saccharomyces Boulardii, Soil Based probiotics, Lactobacillus and Bifidobacteria probiotics 
  • Followup:
    • 5 weeks

• Clinical Commentary:
  • Although the low FODMAP diet hadn’t made an impact on her symptoms, the patient was worried she wouldn’t heal if she stopped following it. She was taking detailed notes about how foods immediately affected symptoms, and reported a lot of stress around food choice.
  • Given her neutral response to the low FODMAP diet, plus the fact that it was leading to negative emotions, we decided to relax her diet. This can be one of the most important treatment recommendations given to patients who are on unnecessarily restrictive diets. 
  • Although the patient noted a negative reaction to probiotics in the past, we have found that patients can tolerate some foods and supplements better after an elemental reset.

Visit 3 – Follow-up Visit and Treatment Evaluation

• Subjective Assessment 
  • 98/100 Mostly better
• Current Symptoms:
  • Improved: 
    • Gas
      • Resolved
    • Abdominal pain
      • Resolved
    • Diarrhea
  • Same: 
    • Bloating
  • Worse: 
    • Moodiness
    • Headaches
• Response to Treatment 
  • Diet: 
    • Helpful:
      • Elemental diet
  • Lifestyle:
    • Helpful:
      • Meditation 
  • Supplements:
    • Helpful
      • Probiotics

• Updated Treatment Recommendations
  • New Treatment:
    • Herbal antimicrobials x 1 month
  • Continue:
    • Probiotics
    • Elemental diet daily meal replacement as needed
  • Followup: 5 weeks

• Clinical Commentary:
  • It was exciting to see her gas and diarrhea resolve and her bowel movements normalize. Bloating was still significantly impacting her quality of life. 
  • The next best logical step was pivoting to herbal antimicrobials, primarily because she had responded well with her previous provider. We often find patients do better with herbal antimicrobials when probiotics are concurrently being used.

Visit 4 – Follow-up Visit and Treatment Evaluation

• Subjective Assessment 
  • 95/100, 20% better
• Current Symptoms:
  • Improved: 
    • Bloating
      • Resolved
  • Same: 
    • Headaches
  • Worse: 
    • Diarrhea 
      • Once weekly
• Response to Treatment
  • Supplements:
    • Helpful
      • Herbal antimicrobials were helpful for bloating, slight worsening of diarrhea.
• Updated Treatment Recommendations
  • Continue:
    • Continue with the second month of herbal antimicrobials
  • Followup: 8 weeks
• Clinical Commentary:
  • She was starting to feel more relaxed about food choices based on her symptom improvement, and reported that she was able to consume foods she had been avoiding for months. 
  • Her trials of new foods at home helped to build confidence that she would be able to continue expanding her diet as her symptoms improved.

Visit 5 – Follow-up Visit and Treatment Evaluation

• Subjective Assessment 
  • 100/100, 25% better from her last appointment. 
• Current Symptoms:
  • Improved: 
    • Diarrhea
    • Abdominal pain
  • Same: 
    • None
  • Worse: 
    • None
• Response to Treatment 
  • Supplements: 
    • Better
      • Herbal antimicrobials have led to continued and sustained symptomatic improvement, even after having finished the 2 month protocol. 
• Updated Treatment Recommendations
  • Continue: 
    • Use elemental diet as needed if a diarrhea episode occurs.
    • Probiotics as needed or consider half dose daily. 
  • Followup: As needed only!

Closing Thoughts

• This patient was excited that she was feeling better symptomatically and feeling more empowered. She now understands the tools she can use for improving her digestive health if she experiences any future setbacks, as opposed to further restricting her diet. 
• We frequently see patients come to the clinic who are on strict diets, despite still experiencing digestive symptoms and seeing minimal to no change on their current diet. If a patient isn’t seeing symptomatic improvement on a diet after a few weeks, they can likely stop that diet. 
• With a few exceptions, like celiac disease, patients shouldn’t be on any particular diet because they have a certain diagnosis. This patient was led to believe that because she had IBS, she “needed” to be on a low FODMAP diet. This kind of thinking leads to unnecessary dietary restrictions. When selecting a diet for a patient, we should instead focus on symptomatic response.
• If they have been on a diet for a long period of time, empowering them to reintroduce foods is crucial for long-term health and overall quality of life.

Can restrictive diets for improving gut health lead to psychological harm?

Study Purpose 

• What is the prevalence of orthorexia in women following various restrictive diets? 

Orthorexia Definition: 

• “Orthorexia nervosa is a relatively new form of obsessive–compulsive eating that is described as a pathological obsession with healthy eating. The consequences of this disorder are nutritional deficiencies, malnutrition, underweight, and a variety of health-related consequences”

Study Design

• 420 women were categorized by current restrictive diet, including: 
  • Traditional diet
  • Vegetarian diet
  • Low FODMAP diet
• All participants filled out the ORTO-15 questionnaire, which is designed to identify orthorexia

Main Results:

• Orthorexia, based on the ORTO-15 questionnaire, was present in: 
  • 47% on a low FODMAP diet
  • 33% on a vegetarian diet
  • 24% on a traditional diet
• “In our study, the presence of orthorexia symptoms was observed in almost half of the subjects following a low FODMAP diet, which was the highest percentage among all the women studied.”

Authors Conclusion: 

• “Due to the possible recurrence or worsening of eating disorders during an elimination diet, in patients who have suffered from eating disorders, diet therapy with functional foods or brain and gut psychotherapy is suggested instead of following a restrictive dietary regimen.”
• “The low FODMAP diet was most often used on the recommendation of a dietician or doctor, so it seems important to screen for eating disorders before recommending diet therapy in order to individually adjust the dietary regimen and refer patients to appropriate specialists.”

Clinician’s Comments

• We at the clinic frequently see patients who have been on restrictive diets for months to years, usually for digestive symptoms or food reactivity. Unfortunately, long-term restriction can lead to both physical harm (weight loss, nutrient deficiencies, fatigue, poor sleep) and emotional harm (social isolation, depression, anxiety). 
• Elimination diets can be very helpful for improving symptoms, but it’s important to know if your patient is a good fit for this treatment approach. Do they have a history of an eating disorder? Do they have a fear of food? Are they already on a restrictive diet? If yes to any of these, an elimination diet will likely do more harm than good, and instead it’s best to focus on identifying and treating the root cause of why they are reacting to certain food.

How to Recommend a Dietary Intervention 

• When recommending various elimination diets, we like to frame it in 2 ways:  
• First, the diet is used as a short-term trial (generally 3-4 weeks) to see if they experience any symptomatic improvement. If they don’t, we either have them go back to their previous diet or trial another dietary intervention. If they see benefits from the diet, then we have them stick with it until symptoms are stable, while simultaneously addressing the underlying cause of symptoms, and then start to reintroduce food.
• Second, we don’t tell patients they need to be 100% compliant with the diet to see benefits. We have found at least 80% compliance is good enough for most patients. Trying to be 100% can be stressful, and we find it isn’t necessary to see improvement in symptoms.

Can a cognitive behavioral therapy app improve GI symptoms and reduce fear of food?

Study purpose

• Can a cognitive behavioral therapy (CBT) mobile app called Zemedy improve IBS symptoms, reduce fear of food, and improve overall quality of life?

What is the Zemedy app?

• Zemedy is a self-guided mobile app that delivers CBT specifically for improving IBS symptoms. It is available for both Apple and Android. 
• It consists of 6 modules that provide both education and hands-on tools to improve GI symptoms and quality of life. The CBT tools used to mitigate the impact of IBS on daily life include relaxation training, exercise, cognitive restructuring and de-catastrophizing, exposure exercises to reduce avoidance, and behavioral experiments. 
• The app also includes a “flare module,” which users can access at any point to address immediate GI pain and anxiety. Flare mode includes a variety of exercises, such as deep breathing, hypnotherapy, guided imagery, and progressive muscle relaxation. 
• Monthly subscription costs $19.49 per month, and there are a variety of other payment options. Can also do $57/month for the app + personalized coaching.

Intervention: 

• 121 participants who believed they had IBS were randomly assigned to: 
  • Control (no treatment) 
  • Zemedy

Main Results:

• After 2 months, the Zemedy app led to significant improvements in:
  • IBS quality of life 
  • GI symptoms
  • Visceral hypersensitivity 
    • Heightened awareness and sensitivity to gut symptoms
  • Fear of food
  • Catastrophizing
    • Imagining worst possible outcome
  • Anxiety regarding symptoms
  • Depression
  • Stress response
• Number needed to treat = 2
  • For every 2 people treated with Zemedy, 1 will see meaningful improvement
• Most benefits were maintained at 3 month follow-up

Compliance & Drop Out

• The majority of participants completed less than 50% of modules, which suggests one doesn’t need to complete all modules to see significant improvement in symptoms and quality of life.
• “Participants who dropped out during the initial treatment phase had significantly higher rates of visceral anxiety and fear of food at baseline. This might represent a population requiring more personal guidance, encouragement, and support from in-person therapy.”

Authors Conclusion: 

• “This 8-week intervention appears to have substantially reduced the burden of illness compared to that of waitlist controls… Zemedy is an effective modality to deliver CBT for individuals with IBS, and could increase accessibility of this evidence-based treatment.”

Clinician’s Comments

• For many patients, our goal is to help them expand their diet. However, due to prolonged dietary restriction and fear of food worsening their symptoms, they may have a challenging time expanding. 
• According to this 2020 study, about 93% of patients with ARFID avoid certain foods due to their fear of triggering digestive symptoms. This is another area where cognitive behavioral therapy is helpful. When patients have been experiencing digestive imbalances for years, they can “catastrophize” their symptoms. Catastrophizing is a cognitive process in which people believe their symptoms and impact on their lives are worse than they truly are. 
• As this study showed, Zemedy is able to help patients reduce both catastrophizing thoughts and fear of food. 
• However, it’s important to note in this study, those with a high fear of food will likely require more personal support from a cognitive behavioral therapist.

How can I help my patients expand their diet?

Listener asks:

Some of my patients are having a hard time expanding their diet due to their reactivity to food. They eat such a limited diet right now. How can I help them expand their diet?

Encouraging reintroduction of food can positively impact patients’ quality of life and symptoms such as low mood, fatigue, and poor sleep. However, some patients may have a difficult time with dietary expansion for a few reasons, such as high food reactivity and/or fear of food. Let’s discuss key steps to improve their tolerance to food and expand their diets. 

Gastrointestinal Supports

• • Correct dysbiosis
    • Gastrointestinal dysbiosis can lead to food reactivity due to excessive fiber fermentation, increased intestinal inflammation, heightened visceral sensitivity, and reduced ability to metabolize histamine. 
    • We find that correcting dysbiosis with probiotics, herbal antimicrobials, and elemental dieting often improves food tolerance by correcting the aforementioned underlying mechanisms. 

• • Reduce GI-immune reactivity 
    • If a patient has thoroughly implemented a dysbiosis protocol and still hasn’t seen improvements in food reactivity, they may benefit from more direct gut-immune support. 
    • We find serum-derived bovine immunoglobulin therapy works well for food reactivity, especially in patients who haven’t seen improvements with direct dysbiosis support. 
    • Immunoglobulins work by binding various pro-inflammatory toxins in the gut produced by various bacteria and fungi, such as LPS, cytolethal distending toxin, clostridium difficile toxins, candida toxins, and more [1]. Immunoglobulins help reduce immune reactivity in the gut, and therefore lead to better tolerance to food.

Psychological & Nervous System Supports

• • Cognitive behavioral therapy
    • We have seen clinically how a fear of food and catastrophizing thoughts about symptoms can make it more challenging to expand someone’s diet. It’s important to be in a relaxed state when eating, as this improves the ability to properly digest and tolerate food. However, if a patient is trying to eat a food they are particularly afraid of, this increases the chance of experiencing symptoms. 
    • CBT is primarily indicated for those with a fear of food and negative thoughts about their symptoms. For mild to moderate fear of food, consider an app like Zemedy. If this fear of food is very strong, then 1:1 therapy is more indicated.
  • Limbic retraining 
    • There is a subgroup of patients who benefit from limbic retraining for improving their reactivity to food. The limbic system is part of our brain that is designed to keep us safe from threats. When our brain feels under attack, it initiates the appropriate defense responses to help us survive. Once the threat is over, our brain can then relax and “turn off” the defenses. However, in some people, this defensive response can become “stuck” in fight or flight, so the brain detects threats more unnecessarily, which can contribute to immune overreactivity and subsequent food reactivity. Patients with limbic imbalance are also usually reactive to supplements, medications, odors, mold and more. 
    • Limbic retraining programs, such as Gupta or DNRS, can be helpful for reducing food reactivity by rewiring the brain to be in a more relaxed, parasympathetic state. 
    • Check out the February FFHR edition for more information on who benefits from limbic retraining.