42 yo F unresolved digestive issues on a FODMAP diet

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Welcome! Forums 42 yo F unresolved digestive issues on a FODMAP diet

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    • #1021
      Paula Needham

      Female, age 42, history of digestive issues. Used to be mainly constipated and had diagnosis of chronic IBS 3 years ago after colonoscopy showed all was clear. also has frequent episodes of thrush. She also showed negative result after lactose intolerance breath test 3 years ago, and had an ASI test showing normal results apart from a very high morning cortisol and low afternoon DHEA (none of which may be relevant now), although the client is fairly stressed.

      She came to see me with a ‘fermenting’ feeling in her intestines – bloating, gurgling, burping and flatulence, with extreme watery diarrhoea (pale and floaty) and frequent vaginal thrush. She avoided processed foods and cannot tolerate pulses. She ate bread, alcohol and sugar fairly regularly but stated that they did not agree with her. Her blood sugar balancing was poor and she had signs of adrenal fatigue (exhausted in mornings, overwhelmed). She craves coffee and sugar. She had mucus in stools, watery eyes and a frequent sore throat.

      I put her on a blood balancing programme and we discussed ways of dealing with stress and I suggested a calming supplement for the adrenals but she never took it. She did a 14 day elimination diet of wheat and dairy and found sensitivity, especially bad to dairy. She still had diarrhoea though so I put her on a low FODMAP diet as she was reacting to so many foods. I followed the advice given on the cookery day held by Christine and Antony and told her to take ADP alternated monthly with berberine and grapefruit extract. She took ADP for the odd week, one per day. She kept up the berberine for one month at a higher dose.

      Symptoms improved but returned whenever she tried to reintroduce the foods at each stage, even a small spoonful of avocado for example to test for mannitol. We did a CDSA and found no bifidobacteria or lactobacillus, not surprisingly after 3 months of low FODMAPS, low SIgA (she didn’t take the Sacc boulardii or enzymes I had recommended last time), presence of dysbiotic bacteria (Citrobacter freundii) and parasite Dientamoeba, no yeast, SCFA in range but at the lower end. She took more Berberine as this was recommended for these pathogens, and took ADP for a week (9per day) in December. I am concerned that she is still on a low FODMAP diet after 5 months but she says that although the diarrhoea is much less extreme, it still occurs when she tries reintroducing foods in small amounts, following the order that Christine gave. What am I missing? The client is convinced she has a yeast problem – none was found in the stool test, but I advised her to take ADP in a large enough dose to hopefully get rid of any if it existed. I am wondering if by not following the supplement programme I gave her, and only taking small amounts of ADP periodically, that this is causing some kind of resistance? She can now tolerate a small amount of GOS (Bimuno powder) which i was keen for her to take as it increases bifidobacteria . Could stress be an issue?

      Posted By Paula Needham 13/01/2018




    • #1022
      Antony Haynes

      Hello Paula

      Many thanks for posting this case and providing the detail of the case. Well done on what you have recommended for this woman thus far, and it is noted that she does not follow your instructions completely. It is not likely at all that there is some resistance to the ADP Oregano. It is not possible for the yeast to become resistant to this oregano extract.

      To my mind, if SIBO had been the only issue then the low FODMAPs diet and the supplements you describe would have resolved this woman’s symptoms. As I know you are aware, the low FODMAPs diet is not intended for longer term use than 8 weeks, and as you point out this is likely to lead to insufficiency of commensal bacteria as was identified in the CDSA. There was also low SIgA which may or may not have been due to having followed the low FODMAPs diet.

      A key comment and observation is that whenever a food is reintroduced it elicits gut symptoms, in particular diarrhoea. It does not appear likely that the symptoms are caused by the presence of Citrobacter freundii nor Dientamoeba fragilis, although they may be having some contribution to her overall state of gut health. Rather, it appears to me that there is a situation of maldigestion going on here. With the inability to digest food, it can lead to diarrhea and effectively to food intolerance, as in lactose intolerance, which leads to diarrhoea. In this way, a low FODMAPs diet does not challenge the compromised digestive function and symptoms abate but when she introduces a food which she cannot digest, lo and behold there is a predictable state of loose stools.

      I have found a significant minority of patients with formally diagnosed SIBO who do not respond to the anti-microbial programme in the sense that whilst the anti-microbials may reduce the symptoms at the time of taking them alongside a low FODMAPs diet, the symptoms return as soon as a wider diet is consumed. This leads to reverting to the low FODMAPs diet which in itself can readily compromise the gut bacteria, short chain fatty acid production, and possibly SIgA as well. My intention is to write up some of these cases in detail and share with Nutri-Link practitioners in our eNewsletter.

      It is the inability to digest food properly that is at the core of the matter. This may involve lack of pancreatic enzymes and poor bile function or bile flow or bile production. There may be a need for gut lining support too. I have found that the use of probiotics is not appropriate. The route to resolution is the taking of digestive enzymes and bile support, and sometimes HCl acid supplements. However, herbal bitters may be useful too. Some patients fare well on longer-term anti-microbials alongside the digestive support. In my experience, I have found that some digestive enzymes are more effective than others, but it can take trial and error; it is not simply a case of using any old digestive enzyme and seeing what happens. I make suggestions below and give the specific names of the specific products that I find effective.

      The underling causes may be linked to stress, to answer your question about that. Sympathetic dominance switches off digestive juices and in the long term this can lead to digestive disorders as you describe in this case. Not everyone is affected in the same way, of course, by stress or being perpetually in the fight and flight mode, but this can certainly be involved in unmasking such dispositions. Simply de-stressing or making a sudden shift to being more calm and mindful and in the here and now is not going to resolve what is often a chronic digestive insufficiency.

      The taking of digestive enzymes and bile most certainly does NOT switch off the body’s own production of these invaluable digestive juices. On the contrary, they help the body to make more of their own. Taking enzymes and bile, after the start of a meal, can be the single most important means by which to correct the digestive symptoms you describe.

      You need to be aware that a return to a wider diet can be a slow process. In addition to correcting a long term digestive insufficiency, which may not show up in the markers in the CDSA, there may have developed food sensitivities (IgG mediated reactions), which further complicates things. However, the symptoms that are based on maldigestion should be distinct and rapid and predictable, in the early days.

      A habit of relaxing before eating and engaging the parasympathetic system is vital. Chewing food thoroughly is a must.

      The use of probiotics needs to wait and sometimes I do not ever have patients take a probiotic supplement but rather aim to support their microbiota with foods.

      In this particular case, there may be a need to address those unwelcome guests of Citrobacter freundii and Dientamoeba fragilis, if they have not been successful addressed already, but this does not strike me as being significant to her symptoms as you describe them.

      Lastly, I would say that it is not readily possible to determine which client / patient is gong to be in need of this digestive support programme when they have a positive SIBO result. In my experience, it has become apparent over time when the low FODMAPs diet and the anti-microbials simply don’t resolve matters.

      I have yet to read or find any meaningful research papers or studies on this, the chronically suffering patient who had or has SIBO.


      The following supplements are suggested for you to consider in light of your relevant expertise and intimate understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.

      Digestive enzymes

      Pancreas (pork) (ARG) – 1-2 with each meal


      Full Spectrum Digest (ARG) (veg) – 1-2 with each meal


      Bio-6-Plus (BRC) (porcine) – 1-2 with each meal – http://tinyurl.com/yb5fcozz

      Bile support

      Beta Plus (BRC) – 1 with breakfast, 2 with lunch & dinner – http://tinyurl.com/hskrbum


      Ox Bile (ARG) – 1 with breakfast, 1 with lunch & dinner – http://tinyurl.com/ybcmzlp2

      Consider this fat emulsifier

      Phosphatidylcholine (BRC) – 1-2 with each meal – http://tinyurl.com/jq7923l

      Herbal Bitters tincture (available from health food store) – 20-15 mins before each meal

      Some patients benefit from gut lining support

      IPS Caps (BRC) – 2 at start of each meal – http://tinyurl.com/y9vbpxl6

      Please consider these suggestions in light of the other clinical information pertaining to this individual.  If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered.  I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.

      I hope this helps your client.



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