Taming tummy troubles

There's nothing worse than stomach pain whether it be constipation, bloating, diarrhea, or gas. People are quick to blame what they eat, but how often is it food related and how do you solve about solving the mystery? ​Read on for more. 

Digestion is a complicated (and often embarrassing) conversation for most people. The digestive process operates head to toe - from our mouth down to our bum. ​For more about the digestion, click here .  For most people complaining of tummy troubles, they are referring to feelings of discomfort that occur after eating - usually meaning the lower GI system or the small and large intestines (GI = gastro-intestinal). 

Symptoms associated with the lower GI system are typically gas, bloating, diarrhea, and/or constipation. When these symptoms are chronic and cannot be attributed to disease or physical abnormality, they often get labeled as IBS (irritable bowel syndrome).  For the sake of simplicity, this post focuses on the lower GI system. And in particular, calming bowel patterns that are not related to a disease. 

NOTE: Ultimately, it's best to work with your health care team (primary care doctor, gastrointestinal doctor) to rule out any major medical conditions that might affect digestion such as reduced motility, Crohn's, Colitis, gallbladder issues, reproductive issues, and celiac disease to name a few.

A dietitian that specializes in GI can be helpful in exploring food, behaviors, triggering foods, and intolerances, but please keep in mind that dietitians cannot diagnose a medical condition.

​A dietitian's work navigating GI upset is best supported when you either have a diagnosis AND/OR have ruled major medical conditions. 

What is "normal?"

"Normal" bowel patterns change day to day and person to person. Some days our GI system is like a well oiled machine and other days it seems fickle and frustrating.  Gas, bloating, and even stool changes are not always a cause for concern. However, if the issue seems chronic, is associated with bleeding, contains a lot of mucous, and/or interfering with your quality of life, it may be worth exploring to make sure all systems are operational. 

The Bristol Stool Chart (see right) is one way to categorize bowel movements in an objective way. But bear in mind that it's perfectly normal for stool to change AND there can be pretty big variation person to person based on interpretation. 

Additionally, it's hard to define a normal frequency for bowel movements. Bowel movements may happen every 1-3 days. And for some people they may happen multiple times a day. 

In helping people explore GI symptoms and food, there are many questions to consider. It's easy to blame the food because symptoms tend to happen after eating. But just because there's a correlation, doesn't mean there's a causation.

Food intolerance are absolutely real and increasingly common! But they are less common than programs like Whole 30 would have you believe.  I find many clients haphazardly eliminating foods based on what they read online or following elimination diets that have no scientific evidence. Often food gets blamed before looking at the bigger picture.

Questions to consider...

Before I start an elimination diet with a client, here are some common questions and scenarios I explore ...

Any recent changes to your life? 

Did the symptoms come on sudden or gradual? Did they start after a major life and/or health event such as ...​

​surgery | medication changes | intense treatments such as chemo / radiation | travel | major life events (death, divorce, marriage, birth) | rapid weight loss / gain | eating disorder recovery ​

Any one of these events can change the way our bodies metabolize and/or interact with food that have little to do with the food itself.

How often are you eating?

I often hear complaints about GI symptoms in the afternoon and evening hours. This also tends to be the time period that people are not eating / drinking and / or experiencing more stress - commutes, family obligations, work meetings.

Going too long without eating and/or getting excessively hungry is a great way to induce bloating and discomfort regardless of what you eat. Combine that with higher levels of stress and it's a great recipe for stomach upset. 
​

Are your symptoms clustered or erratic? 

When I'm talking with clients I'm looking for patterns - are there certain times of day the symptoms are more present than another and what's happening around those times? 

Common patterns clinic include...

• Hydration / fueling / stress before, during, or after exercise
• Lifestyle changes of week days vs weekends
• Morning vs afternoon vs evening eating patterns
• Hormonal changes due to menstruation

​These patterns are often situation specific and have less to do with the body not tolerating food and more to do with the situation itself. 

What's your stress level?

They often refer to our GI system as our second brain (click here for more details). Our emotions are closely linked to the nerves and hormones in our GI system which in turn impacts the speed and comfort of digestion.

Increased stress / anxiety can speed up or slow down peristalsis which result in constipation or diarrhea. If you have a history of anxiety around food or disordered eating, you may experience IBS symptoms that are related to a malnourished / heightened emotional state. 

Also, stressful times often equate to sudden changes in diet and lifestyle - skipped meals, smaller / bigger portions, different food choices - making some tummies upset. 

Interestingly enough, research demonstrates that is just as good (if not better) than dietary restriction in IBS. 
Long term effects hyponosis and IBS
Hyponosis vs low fodmap diet

Any common behavior / food triggers? 

How much air you ingest is a big consideration in bloating. After all, if air goes in, it has to go out! Eating fast, chewing gum, drinking out of a bottle (instead of a cup), and/or using a straw are all behaviors that increase the amount of air you swallow while eating / drinking and therefore can increase bloating and gas. 

There are also some chemistries in the diet that commonly cause GI upset like bloating and diarrhea. Thing to consider are...

• artificial sweeteners (splenda, aspartame, equal, sweet n low)
• sugar alcohols (xylitol, mannitol, sorbitol, isomalt)
• carbonated beverages (seltzer, soda)
• excessive caffeine (coffee, tea)

• alcohol abuse
• tobacco use
• weight loss pills
• exercise supplements
• synthetic fibers in large doses

Have you made any recent changes to your diet?

While our society categorizes food as "good" and "bad" our GI system sees food as a variety of chemistries that it has to break into smaller pieces using the tools it has - churning, digestive enzymes (bile, lipase, protease, amylase etc), peristalsis (movement), bacteria (microbiome) to name a few. Our bodies adjust these tools based upon what we eat. When the tools don't match the chemistry, it can result in increased production of gas and/or more water gets pulled into the intestine causing diarrhea.  

Here are some common examples I see in clinic: 

• "I'm eating healthier" - to many people, this means eating more plant based food (vegetables, beans, fruits, whole grains) which also have more fiber. While high fiber  foods have a lot of health properties, they require unique tools compared to lower fiber options.  If you make sudden changes, it takes a while for our GI system to "catch up" if you will. Additionally, eating more fiber without getting enough fiber can cause constipation. Ideally fiber is added gradually with sufficient water to keep stool moving. 

• "I'm cutting down on sugar" - to many, this means eating more "sugar free" products (eg, sugar alcohols, artificial sweeteners, "sugar free" candy, gum, and ice cream).  While these products taste sweet, they can be really challenging for some bodies to digest resulting in bloating and diarrhea - especially when eaten in large quantities. 

• "I'm traveling more" - Travel often means eating out more often and erratically. Between heavier meals, long durations between meals, varying meal sizes, irregular sleep, and the stress of traveling, not all bodies adjust easily and sometimes it's evident in the bathroom. 

​Some bodies adjust easily to dietary change and others take more time and still others don't have the capacity for change. That doesn't mean it's impossible! But consider the intensity with which you're changing and if you have introduced any triggering foods. 

What if none of these apply to me?

If none of the above circumstances apply AND all major medical conditions have been ruled out, that's when I may begin exploring an elimination diet such as the low FODMAP diet with clients. But honestly, I find more often than not, by improving hydration, managing stress, and eating regularly, most symptoms improve without an elimination diet. 

Elimination diets are a process - not a diet. It's a systematic way of identifying food chemistry that may cause IBS symptoms. You start by carefully identifying a problematic chemistry, removing it for a period of time, and then reintroducing to see if symptoms re-occur. If you find a consistent connection, you may have a trigger! The final list of triggering foods is often quite small so that only a few foods are identified - not entire food groups. Additionally, the foods are often "dose response" - meaning that most people can tolerate a little, but the more they have, the more symptoms they have. 

With the exception of Celiac disease, there are few (if any) reliable tests to identify food intolerances (NOT ALLERGIES). Blood tests are often inaccurate (CLICK HERE for a helpful article). Breath tests can give a clue about where to start, but they too are variable and not always available or covered by insurance. So when there's no test, it's about experimentation with food chemistry. 

When experimenting with elimination diets, it's important to work with a nutrition expert (aka, registered dietitian or RD) -  particularly someone who specializes in the GI system because food chemistry is not intuitive...AND it has nothing to do with "healthy" or "unhealthy" food. 

There's a lot to food that common knowledge doesn't know - it's best to hire an expert to help guide you and keep you safe. Trying to sort through food without a chemistry degree is like trying to scale Everest without a map, having never walked a mile. You're better off training and hiring a sherpa to get you there safely. ​

Some amazing RD resources who specialize in irritable bowel syndrome: 
​Kate Scarlata & Lauren Dear
​FODMAP dietitians ​

Moral of the story...

Our gastrointestinal system is an incredibly complicated connection of our physical AND our emotional life. Food intolerance are absolutely real but not necessarily the only reason we experience bloating, constipation, and diarrhea. Before blaming food and entire food groups...

1. Check in with your doctor
2. Find a local dietitian who specializes in GI (list below) and
3. Consider factors that might be causing distress that aren't about the food

Stay nourished friends!