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iiAbout the Author

Beth Rosen, MS, RD, CDN is a weight-inclusive registered dietitian specializing in gastrointestinal (GI) nutrition and disordered eating, who has been working in the field of nutrition for 30 years. In her private practice, Beth helps clients find relief from digestive disorders such as irritable bowel disease (IBS), small intestinal bacterial overgrowth (SIBO), gastroparesis, gastroesophageal reflux disease, and celiac disease. Beth herself suffered from gut issues for years before she fought for a diagnosis of post-infectious IBS by advocating for herself and educating herself on GI issues. She lives on Long Island with her husband, who has microscopic colitis, her daughter, who has lactose intolerance, and their two dogs with food intolerances. Miraculously, her son manages to tolerate all foods to this day.

iiiOvercoming Common Problems

Gut Goals

A Practical Plan for Managing IBS

Beth Rosen, MS, RD, CDN

www.sheldonpress.co.uk

vFor Eli and Amelia

11

Introduction

My IBS Story and Philosophy on Care

If you are reading this page then most likely you a) have irritable bowel syndrome (IBS), b) know someone who does, or c) are having some gastrointestinal (GI) issues that are troubling you and you are looking for help. Well then, this book is for you. IBS is no joke, and it’s not something you can self-diagnose, nor is it a diagnosis of “we don’t know what this is so let’s just call it irritable bowel syndrome.” It’s important that before you treat any GI symptom on your own, you seek care from a physician (ideally a gastroenterologist) and get a proper diagnosis, or at the very least rule out diseases that need specific specialized care (more on this in Chapter 4).

As a registered dietitian (RD) for over 30 years, I have worked with many clients to improve their symptoms and quality of life through both dietary and non-diet interventions. My ultimate goal is that these pages provide you with a framework to seek care, advocate for yourself, and find the same digestive peace that I and so many of my clients have found.

Yes, you read that right, I said “I.”

Not only am I a registered dietitian, I’m a patient, too.

Everybody Poops

Before I tell you my IBS story though, I want to talk about one of my favorite subjects—poop. In fact, I am going to be talking a lot about bowel movements, stool, number twos, dropping the kids off at the pool, or whatever you call it, throughout the pages in this book. You might say I talk a shit-ton about shit—its size, shape, color, and consistency. Your poop can tell you a lot about your gut health and it can offer your healthcare providers a clue as to what might be causing your symptoms (more on this in Chapter 3).

2Many people are embarrassed when asked to talk about their poop and avoid alerting their healthcare providers about what they see in the bowl or on the paper when they wipe because they think it is uncouth. Omitting your poop story from the information you share with your doctors may lead to a delay in diagnosis and care, or misdiagnosis and ineffective care. If you are among these people, I have a secret to share with you: Everybody poops! There are even children’s books about it.

Getting comfortable with bodily functions and deciphering dysfunctions is an integral part of understanding your body and how it works so that you can get care when you need it. In fact, you know your body best, so we rely on you to share your crap chronicles with us, along with all of your GI symptom details. Doctors, dietitians, and other healthcare providers have tools like blood tests, scans, and nutrition plans, but we won’t know if we are helping you heal, recover, or manage your symptoms and diagnoses without your complete input and feedback. After all, you live in your body, so you know it best, and you are the keeper of your IBS story.

My IBS Story

In 2010, after a recent move to Connecticut, my then six-year-old daughter was hospitalized with pneumonia after having swine flu. She and I spent two nights in the hospital—she in the bed, me in a chair. At the time, I was on a course of antibiotics for a minor infection and thought nothing of the potential impact they might have on my microbiome. In fact, I don’t think I ever considered my microbiome prior to my IBS diagnosis (more on the microbiome in Chapter 2).

A few weeks later, I came down with a “stomach bug” that began with abdominal cramping, pain, and urgent diarrhea. I assumed it was something I ate (as many people do) and began cutting things out of my diet to rid my body of the culprit. My symptoms continued: excruciating gut pain, urgent diarrhea that woke me up in the early morning and persisted all day, and spasming throughout my lower abdomen. So I removed more and more foods and food groups from my diet.

3At the recommendation of a family member, I took a food sensitivity test (more on these in Chapter 4) and eliminated 40 foods based on the results. My diet was now made up of the flesh of baked potatoes, pita chips, and plain grilled chicken. My energy was low, I was unintentionally losing weight, and my symptoms persisted uncontrollably. I was urgently moving my bowels more frequently each day until one day the pain was so severe, and the diarrhea seemed so endless, that I needed to go to the emergency room. While there, they just rehydrated me, gave me something for the pain, and referred me to a gastroenterologist, who was able to see me the next day.

After a stool test, I was diagnosed with Clostridioides difficile, an infection known as C.diff, which causes diarrhea and inflammation of the colon. I was put on antibiotics and told that I would be back to normal within two weeks.

After two weeks, my symptoms weren’t as intense, but they persisted. The gastroenterologist suggested that I eliminate gluten, dairy, and eggs to alleviate my symptoms. This proved to be difficult and impacted my ability to eat socially and prepare meals and snacks for my family without becoming a short-order cook. While these changes did not help, I did not return these foods to my eating pattern for fear that they might still be part of the problem.

Then I received a phone call from the Centers for Disease Control and Prevention (CDC). Apparently, they keep track of C. diff diagnoses and asked me a series of questions to ascertain where I might have contracted it. Lo and behold, the CDC said without hesitation that my two-night stay in the hospital while on antibiotics was the impetus. C. diff is extremely contagious and can easily be passed from patient to patient (or mom) in hospitals via healthcare staff, shared bathrooms, and even the privacy curtains that hang in patient rooms. The best way to avoid contracting it is proper handwashing and cleaning surfaces with antimicrobial products.

I returned to the gastroenterologist and he suggested I have an endoscopy to look for what else might be causing my pain and discomfort. When I awoke, he told me that he did not see anything (nor did he biopsy anything which would have definitively 4ruled out celiac disease), and he offered me toast with butter (uh, what about no gluten or dairy?). Confused and sad, I had no more answers or solutions than I did before the endoscopy, nor ways to manage my symptoms. When I pressed him for more help, he told me that I had post-infectious IBS (PI-IBS) and my symptoms would clear within two years. I was devastated that I would have to live with pain and urgent diarrhea for that long.

After 18 months, I switched doctors to see if perhaps another practitioner might have solutions. The new gastroenterologist sent me for stool testing, a blood test to rule out celiac disease, and a colonoscopy. While the colonoscopy revealed nothing other than inflammation, the blood test indicated that I had non-celiac gluten sensitivity (NCGS) and the stool test indicated that I still had C. diff. No wonder my symptoms were not improving! I was treated again with antibiotics, and again my symptoms improved slightly, but I certainly did not feel better. I had a hard time believing that I had NCGS. After initially eliminating gluten, I had added it back after my endoscopy the year before, so I went home and made pasta for dinner. Big mistake! My belly swelled and ached for the rest of the night and into the morning. Since that day, I have avoided eating gluten-containing foods.

I visited the gastroenterologist every six weeks for the recommended follow-ups, but there was nothing they could do for me. My parents begged me to switch providers, this time to one in New York City. That doctor sent me for lactose intolerance testing and small intestinal bowel syndrome (SIBO) breath testing, and I tested positive for both (more on this in Chapter 4). I went on another round of antibiotics and avoided dairy as recommended. While we were discussing my treatment plan, the gastroenterologist took not one but two phone calls. I sat in her office, listening to her talk about other patients with a colleague. Instead of apologizing for the disruption of our time, she said their cases were more serious and urgent than mine.

Time to find yet another doctor.

While on the hunt, I began to have bladder pain in addition to the PI-IBS and SIBO-related discomfort. I was referred to a urologist who diagnosed me with interstitial cystitis (IC). IC is a 5chronic, painful condition where the bladder is overly sensitive to being filled with urine.

I continued my search for a doctor who might listen to my issues and teach me how to manage them. A friend recommended one that she worked with (she was a nurse and worked in the research department at Yale). I didn’t want a repeat of all of the testing and recommendations that I had received from my previous doctors, so I wrote a detailed history of what I had been through over the past two years.

I went for my first visit and met the kindest, most attentive physician I have ever encountered. He sat and reviewed my history with me, asking me questions and validating my frustration and perpetual discomfort with and within my body. Then he told me something that I wasn’t ready to hear: I had irritable bowel syndrome and it was never going to go away. I knew that there were worse diagnoses I could have received in my lifetime, but I couldn’t believe it. C. diff had triggered a chronic illness in my gastrointestinal system that I was now going to have to learn how to live with for the rest of my life. I cried right there in the office. The doctor assured me that although there was no cure, he had plenty of ways to bring my pain and discomfort levels from a seven or eight out of ten to a two or a three. I trusted him. He validated my experiences and gave me tools to manage each symptom I shared with him.

If you were keeping count, I saw four gastroenterologists over the course of two years before having an appropriate diagnosis and someone to guide me through evidence-based management tools for my symptoms. I started to find relief from my IBS, but it took a lot of time and trial and error to reach my “new normal” of living with a chronic illness. I spent two years blaming food for my symptoms when restriction might have been exacerbating them. I lived with pain, bloating, lack of trust in my body, and urgent loose stools for years until my doctor partnered with me to find what eased my symptoms. IBS has not been an easy ride. I still have flares where my symptoms return, but now I have tools to help me manage my symptoms and reduce their frequency, severity, and duration.

6Why You Won’t Find Weight Loss Prescribed in This Book or in My Practice

Weight loss is often touted as a panacea for various health conditions, including GI diseases like gastroesophageal reflux disease (GERD) and metabolic dysfunction-associated steatotic liver disease (MASLD, aka fatty liver disease). Many medical professionals are quick to prescribe it as a remedy by telling clients to “just lose weight and exercise.” However, when we look at the research, we see a different, and potentially dangerous, picture. Some studies may correlate weight with health outcomes, but they often fail to see that the underlying health behaviors are what truly drive improvements in health.

Think of it this way: You are told to lose weight and exercise to improve your cholesterol numbers. So, you begin a walking regimen, add in a salad with your dinner, grab some fruit for a snack after lunch, and change your white bread to whole wheat. At your next doctor visit, you’ve indeed lost a few pounds and your cholesterol has dropped a few points. You are praised for the weight loss because it “worked” and are encouraged to keep up the good work.

But who is to say that the decrease in cholesterol was due to the weight loss and not to the added fiber from fruits, veggies, and whole grains? Unless studies specifically control for calorie restriction on its own for weight loss versus adding health behaviors, like increasing fiber-rich foods and movement, the lower cholesterol is only correlated with weight loss and it cannot definitively be proven that it was caused by weight loss. Correlation is a connection between two things while causation is a cause and effect between two things.

Here’s an example of the difference between correlation and causation. A man with yellow teeth develops lung cancer, and there seems to be a growing trend of people having yellow teeth and being diagnosed with lung cancer. So, people start doing everything they can to reduce their risk of lung cancer by getting their teeth whitened and avoiding foods like berries and coffee that can stain the teeth. The yellow teeth and lung cancer connection is a correlation. When research is done on this relationship 7to see what other factors may be present that might correlate with or cause lung cancer, they find that those with yellow teeth also smoke cigarettes, and for those who smoke, their risk for cancer is increased. For those with yellow teeth who smoke and make efforts to whiten their teeth, a decrease in cancer risk is not seen. The researchers also find that there are study participants with yellow teeth that don’t smoke and don’t develop lung cancer at the rates at which the smokers with yellow teeth and white teeth do. They conclude that smoking causes cancer and that yellow teeth is one correlation with lung cancer, but because smokers who whiten their teeth are still at an increased risk of cancer, yellow teeth is only a correlation with cancer and with smoking.

Behaviors such as regular exercise, incorporating fiber-rich foods into your diet, smoking cessation, and managing stress levels can all lead to positive health outcomes. These behaviors, referred to as “health-promoting behaviors,” can be the catalyst for changes in health independent of weight loss, meaning that you can partake in these behaviors to improve your health without losing weight and you will still benefit from those behaviors … to a degree.

What is often overlooked is the impact that genetics and the social determinants of health (for example, access to healthcare, socioeconomic status, race) play in the determination of who develops reflux, fatty liver disease, diabetes, etc. These factors influence our health far beyond what diet and exercise alone can do. In fact, the amount of control we have over our health is about 29 percent—that means that approximately 71 percent of our health is in the hands of our genes, how much money we have, and if we live near places that have lots of skilled healthcare providers. I tell you this not to dissuade you from participating in health-promoting behaviors but to inform you so that you are aware that your IBS and many other chronic illnesses are not within your total control. Changing your weight or living in a thin body is not a guarantee that you will be disease-free. There is not one disease—not cancer, diabetes, or reflux—that is only diagnosed in people living in larger bodies.

Let’s say that you believe (as many do) that living in a smaller body is the key to health. How would you go about being and staying smaller? Research tells us that the pursuit of weight 8loss through restrictive diets or intense exercise regimens is frequently unsustainable in the long term; the vast majority—anywhere from 88 percent to 95 percent—of individuals who embark on a diet will ultimately regain the weight they lost within three to five years. Of those people who regain the weight, two thirds will gain more than they initially lost (Tylka et al., 2014). This phenomenon, known as weight cycling or yo-yo dieting, not only fails to deliver lasting weight loss but also comes with a host of negative consequences.

Weight cycling has been linked to increased inflammation, which subsequently increases the risk of developing various chronic diseases. It’s important to note that the emotional toll of repeatedly losing and regaining weight can be profound, contributing to heightened levels of stress and leaving people vulnerable to disordered eating patterns and eating disorder diagnoses. Assigning blame to one’s body size for health concerns perpetuates harmful stereotypes and biases. It is important that healthcare providers prioritize addressing symptoms and improving overall well-being rather than fixating on weight. It is downright wrong to diagnose one’s fatness as the cause of their disease in one person while offering a thin person medical interventions to manage or treat the same disease. Your healthcare professionals should emphasize the adoption of sustainable, health-promoting behaviors that can yield significant improvements in health outcomes without the detrimental effects associated with weight-focused interventions. Look for these providers—they exist.

A Note on Language

You may have noticed that while I was talking about bodies, I didn’t use the words “overweight” or “obese,” and that was intentional. These words are based on the Body Mass Index (BMI), which many experts consider to be flawed. The BMI doesn’t accurately measure health risks for populations or individuals and is based on height versus weight without any consideration for conditioned muscles, age, gender, or race.

9Sticks and Stones May Break Bones, But Words Can Lead to Weight Bias

Language plays a crucial role here—simply by their definitions, these terms can reinforce biases against people with bigger bodies. For instance, “obesity” comes from a Latin phrase meaning “eaten itself fat,” implying that everyone with a larger body is that way due to lacking willpower, overeating, laziness, or neglecting their health. Similarly, “overweight” suggests that there’s an ideal weight for every height and exceeding it carries the same stereotypes as “obesity.” I and many of my colleagues in the fat liberation movement have embraced the term “fat” as a neutral descriptor, akin to “tall” or “muscular.” Other preferred terms include “in a larger/bigger body” or “at a higher weight.” To reduce the risk of contributing to or reinforcing weight stigma or bias, I will not use the “o” words when referring to bodies and I hope you will consider doing the same in your everyday life.

My Care Philosophy

My experience was the catalyst for the pivot in my career as a registered dietitian and in my resolve: to support and guide my clients with GI issues by helping them seek out skilled practitioners, share their symptoms, and advocate for equitable and appropriate care so that they can improve their quality of life and once again have digestive peace. You might say that these are my gut goals.

Now, you’ve gotten to know a little about me and my weight-inclusive approach to treating my clients, but I don’t know you (though I would very much like to!). You may have IBS or think you do, but you may also have heart disease, thyroid issues, autoimmune diseases, or an eating disorder. Because I cannot begin to know you through the pages of this book, I cannot be your personal registered dietitian merely by what I provide in these pages. What I will share with you will help you manage your symptoms, reduce the duration, intensity, and frequency of your flares, and offer you hope that while living with IBS you can still enjoy all that life has to offer. None of my advice will focus on losing weight because this isn’t the best way to improve 10health. Instead, by thinking about the larger picture of health and focusing on health-promoting habits, we can safely work toward feeling better and being flare-free.

However, this does not replace working with your gastroenterologist or any other healthcare practitioners in real life. I state this so that you are aware that my goal is to avoid harming you or exacerbating your co-occurring illnesses. When you decide to apply my recommendations, please first look at the big picture of your health and collaborate with your healthcare team to ensure that solving your digestive issues won’t trigger a hiccup with your other health issues.

Let’s get started!