What Every Woman Needs to Know About Her Gut

Introducing the new FLAT Gut Diet™ for IBS from The Gut Experts

Professor Barbara Ryan, MB, BAO, BCh, MD, MSc, FRCPI, Consultant Gastroenterologist and Clinical Professor of Gastroenterology, Trinity College Dublin
&
Elaine McGowan, M.Sc., B.Sc. (Human Nutrition and Dietetics), Dip. Diet., RD, Clinical Dietitian

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To my daughter Meghan, a ray of sunshine.

– Elaine

For Hugo and Owen, and my parents Terry and Tom.

– Barbara

About the authors

Barbara Ryan

Elaine McGowan

Professor Barbara Ryan, MB, BAO, BCh, MD, MSc, FRCPI

Professor Barbara Ryan is a Consultant Gastroenterologist in a Dublin University Hospital and a Clinical Professor of Gastroenterology with Trinity College, Dublin. She studied medicine in Trinity College, Dublin, gaining a coveted Trinity Scholarship and a plethora of awards during her time in university. She completed a doctoral thesis on colorectal cancer and has a Masters in molecular medicine as well as healthcare management. She completed her training in gastro-enterology and internal medicine in Ireland and then spent a number of years working in Germany, The Netherlands and the UK, before returning to Ireland.

Barbara has been working as a consultant gastroenterologist in a university hospital and in private practice for almost 20 years. She has been on a number of advisory boards in Ireland, Europe and the UK. She has a strong research pedigree, with over 100 publications in scientific journals. She has also won a number of research grants to fund ongoing research in a number of areas of gastroenterology including inflammatory bowel disease (Crohn’s disease and ulcerative colitis), pancreatic diseases, bone health in patients with digestive disorders and irritable bowel syndrome, to name but a few areas of her expertise.

Barbara has treated tens of thousands of patients over the course of her career and during this time she has gained a real insight into the plight, frustration and poor quality of life of people with many digestive diseases. Given her own background in clinical research, she strongly believes in an evidence-based approach to treating medical conditions, but also believes that this must go hand-in–hand with a holistic approach. The gut and the brain are intimately linked, and one can’t be treated without considering the other. She believes that there are not enough experienced medical experts informing and empowering the public regarding their own digestive problems, and that too much information in the public arena is coming from unreliable sources.

Digestive complaints are often embarrassing and people (particularly the older generations) often suffer in silence for years. She would like to help remove the stigma around discussing these important health issues.

Over the past 13 years she has developed a close working relationship with Elaine and they now work together as The Gut Experts. Their mission is the promotion of gut health through education and empowerment of people with digestive disorders, and encouraging eating for health and wellbeing. In 2019, while walking part of the Camino de Santiago, she realized that rather than just complaining about the poor information that patients were being given, she wanted to do something about it! This is her motivation for writing her first book, along with her colleague Elaine, on IBS and the Digestive Health of Women.

Elaine McGowan M.Sc., B.Sc. (Human Nutrition and Dietetics), Dip. Diet., RD, MINDI

Elaine McGowan is one of Ireland’s leading private healthcare dietitians and clinical nutritionists. Elaine has been at the forefront of training in dietary solutions for her cohort of IBS patients. She has over 30 years of experience, specializing in diet and gastrointestinal conditions including irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), coeliac disease, diverticular disease and, in more recent years, both small intestinal bacterial overgrowth (SIBO) and functional dyspepsia. Elaine also has a specialist interest in polycystic ovary syndrome (PCOS), underactive thyroid, difficult weight loss and functional gut symptoms associated with these conditions.

In 2010 Elaine travelled to Melbourne, Australia, to meet with one of the main researchers of the low FODMAP diet and was one of the first dietitians in Ireland to train in, and embrace the low FODMAP diet as part of her dietary solutions for IBS. Her dietary philosophy has evolved since her early career and she continually strives to find the most effective dietary solutions for her IBS patients.

Elaine has extensive experience in sports nutrition and has a Masters in sports nutrition: ‘A nutritional evaluation of elite Irish athletes’. She worked as a sports nutritionist with the Olympic Council of Ireland for the 1992 and 1996 Olympic Games, and with the sailing and rowing squads for the 2000 Olympic Games. In the past she has worked with the Irish National Rugby Squad, the National Training and Coaching Centre, and notably set up the sports nutrition component of the National Athlete Player Support Programme.

Elaine has provided dietetic consultancy to a wide range of industries. She has designed, piloted, implemented and coordinated workplace wellbeing programmes for several prominent organizations in Ireland.

Like Barbara, Elaine also has a strong interest in the whole person, where she focuses on psychological and emotional wellbeing as part of her holistic approach.

Elaine established her first practice clinic in Ireland in 1992, and since then has successfully used dietary strategies to help over 30,000 patients in her clinics. She also has a wealth of experience working with people to find dietary solutions for optimum health.

Introduction

As a gastroenterologist and a dietitian/clinical nutritionist with a special interest in digestive conditions, we have been working with patients with digestive problems for many years. Between us, we have treated over 60,000 patients with every type of digestive condition, ranging from IBS and functional dyspepsia to severe Crohn’s disease, ulcerative colitis, cancers of the digestive system and a range of liver conditions. The overriding concern of all the patients we see, regardless of their condition, is to learn what is wrong with them and how they can get healthy. With this book, we want to give readers the confidence to take control of their gut health and empower them to enjoy life to the fullest.

We find that people get the best results when there is a clear plan or roadmap in place. Uncertainty is undermining and overwhelming. Some conditions can be treated relatively easily. Other conditions, such as Crohn’s disease, require quite intensive medical treatment but, thankfully, there have been huge advances in treatment over the past two decades. A condition such as IBS, while not life-threatening, can be life-altering. While there is often no quick fix, which can be disheartening and frustrating for anyone who has been diagnosed with IBS, there have been major advances in our understanding of this condition. We now know that the right, individualized approach for people with IBS can transform their lives and give them back their quality of life.

Some patients who have been diagnosed with IBS have been suffering distressing symptoms for years, soldiering on, often feeling dismissed or unaided by the medical profession. By helping people to correctly identify their main symptoms, the triggers for these symptoms, and the impact of diet and lifestyle, we aim to empower them to make the changes that will get their IBS and other gut problems under control.

The female gut

The digestive systems of men and women are different. This is hardly surprising given how different we are in many other ways – physically, psychologically, emotionally and hormonally. The female body goes through a very complex and extraordinary journey during a woman’s lifetime. Like boys, girls undergo significant hormonal changes around puberty. Unlike men, however, a woman’s body is then influenced by significant monthly hormonal fluctuations with the menstrual cycle. Any woman who suffers with digestive symptoms, in particular IBS or functional dyspepsia, will know first-hand that the menstrual cycle can have a significant impact on her symptoms. We will explain why this happens and how it can be helped.

Many women become pregnant and give birth, and a woman’s body is never quite the same after pregnancy and labour as it was beforehand. This can have knock-on effects on the digestive system.

Women go through menopause, and ultimately enter a post-menopausal phase where the hormones that have played such a huge role all their life, are now at an extremely low level. Many women who have gone through menopause will have noticed a change in their bowel pattern and digestive function around that time. We will explain why this happens and what can be done to help.

The impact of gender identity on gut function and IBS, including genetic males identifying as female and vice versa, is not at all understood at this point, and for that reason is not something that we have discussed in this book. However, it is an important area and one that we will be watching keenly in the future.

Irritable bowel syndrome and functional dyspepsia

Between ten and 11 per cent of the world’s adult population has IBS, and 70 per cent of those are women. This equates to about 500 million adults and almost 350 million women worldwide. This is an astounding number of people, and women in particular.

There is another relatively unknown but extremely common sister condition of IBS, called functional dyspepsia (FD). Functional dyspepsia affects even more people than IBS (15–20 per cent of adults) AND is more common in people who have IBS. In this book we explain exactly what IBS and functional dyspepsia are, how and why they develop, what investigations should be done, and, in the light of the results, how these conditions can be treated. Most importantly, we describe how treatment must be tailored to the individual.

For some people, the symptoms of IBS or FD are simply an inconvenience and they can manage to live a normal life. Provided that they don’t eat certain trigger foods, they are generally fine. For other people, the symptoms can be utterly debilitating and restrictive, preventing them from living a normal life. IBS can affect every aspect of one’s life, both personal and professional: it can have an impact on mental and emotional wellbeing, energy levels, sexuality, social interactions and even the ability to exercise.

Many women with these conditions feel that they have been poorly served by traditional Western medicine. They undergo some tests, all of which reveal nothing abnormal. They are given reassurances that there is nothing seriously wrong and that they ‘just’ have IBS. This simply is not good enough. Women can be embarrassed to discuss their symptoms, and they often feel dismissed and cast adrift to find solutions for themselves. We hope that this book will arm women with the information and confidence they need to advocate for themselves regarding their digestive health, help ensure that they are appropriately (but not exhaustively) investigated and give them evidence-based solutions to help manage their condition.

The interconnectedness of body and mind

Functional disorders such as IBS and functional dyspepsia involve a complex interplay of the body and mind. In our field, we talk about the ‘gut–brain axis’, which is the intricate and complex two-way flow of information between the brain and the digestive system. Indeed, the gut has been called the ‘second brain’ because it contains even more serotonin (the ‘happy hormone’) than the brain itself. Today, researchers have expanded the term to the ‘gut–brain–microbiota axis’, encompassing the complex role of gut bacteria in this incredible network – a role we explore throughout the book.

Diet

Approximately two-thirds of people with IBS-type symptoms feel that their diet plays a large part. Understandably, this has led many people to try to identify what foods might be causing problems, and to try different exclusion diets in an attempt to control their symptoms. Studies have shown that almost one third of patients with IBS have excluded so many things from their diet, that their diet is nutritionally deficient (too low in fibre, calcium, iron, vitamin D or vitamin B12) and this can lead to serious health problems in the long term. We have diagnosed early onset osteoporosis developing in a young woman who has excluded dairy from her diet since her early twenties.

A number of dietary regimes, such as the low FODMAP diet, have helped many people with IBS. Sometimes patients can find this a little restrictive and difficult to adhere to in the long term and many patients end up falling back into old habits. For decades, doctors and dietitians have long recognized that certain foods are problematic for patients with IBS. These include fibre, wheat, fructose (fruit sugar), lactose (dairy sugar), the onion and garlic family (known as alliums), sweeteners and a few other items such as caffeine and alcohol.

The role of fibre in gut and overall health and in triggering digestive symptoms has been a little forgotten in recent years, but thankfully fibre is enjoying a renaissance; something we are very happy about. We think of fibre as being a super-food as it is vital for feeding your gut bacteria and maintaining healthy bowel function. In our practices we find that people are often eating far too much or far too little and, like Goldilocks, it is important to get this just right!

The Gut Experts’ FLAT Gut Diet

We have been using a particular dietary approach in clinical practice for a number of years to help manage problematic symptoms, such as bloating, abdominal pain and irregular bowel habit, all of which are particularly common in IBS and functional dyspepsia. This diet has evolved through our work with tens of thousands of patients, through our combined 50 years’ experience. We call this the FLAT Gut Diet, and we are excited to present this to you for the first time in this book.

The FLAT Gut Diet recognizes that a healthy gut needs plenty of variety in the diet. Variety in the diet leads to diversity of the gut bacteria, and this has been shown to be associated with good gut and overall health. More importantly, variety keeps things interesting, and if something is interesting, we are more likely to adhere to it.

The FLAT Gut Diet is based on a Mediterranean-style diet and looks at ‘how much’ of particular foods we eat, rather than excluding foods altogether. Unless you have a food allergy, most foods do not need to be excluded completely but we do need to look closely at how much, or ‘the load’ that we are eating.

As we will explain in Section 5 of this book, the FLAT Gut Diet focuses on the most important dietary components that tend to trigger digestive symptoms in patients with IBS. We call these the FLAT Gut Factors.

FLAT Gut Factors
F | Fibre
| Fructans
| Fructose
L | Lactose
A | Alliums
T | Total mind and body health

More than just a diet

We will also explain over the course of this book how diet alone is often not enough to successfully manage IBS and other gut conditions. The ‘T’ in FLAT stands for ‘Total mind and body health’. Given the particularly intimate relationship between the brain and the gut, it is not surprising that things that affect our mental health also have an impact on our gut health. Research has shown how other factors play a crucial role in either controlling or worsening symptoms of many digestive conditions, including IBS and FD. We call these the TEAMS factors and these are:

T | Total mind and body health
E | Exercise
| Regular exercise can help reduce symptoms of IBS
A | Alcohol
| Alcohol can worsen many digestive conditions, including IBS and FD, and intake should be kept to a minimum
M | Mental health
| Mental health needs to be actively nurtured, as stress is often a factor in triggering symptoms
S | Sleep
| It is important to get adequate, quality sleep

We will be asking you to record these factors and to assess their effect on your gut symptoms and overall health and wellbeing. We talk a lot more about the TEAMS factors throughout the book.

For some people, optimizing all these factors may still not be enough to control their symptoms. Certain medications can also have a vital role in managing IBS. While these are never the first-line therapy, they are an important add-on for some people who have particularly problematic symptoms. We look at prescription and over-the-counter medicines as well as natural and herbal remedies, and show how a holistic approach is key to managing IBS and FD.

Our ‘mission’: to improve quality of life through better gut health

We’re both passionate about gut health and digestive conditions. Through our considerable experience, having treated over 60,000 patients between us, we understand from first-hand experience, the frustration and poor quality of life experienced by people with various digestive diseases. We believe strongly in an evidence-based approach to treating medical conditions, but also that this must go hand in hand with a holistic approach.

Our ‘mission’ is to help you improve your quality of life through better gut health. We will help you do this in a number of ways, which we call ‘The Three Es’:

Education. We want you to understand how your gut works, so that you can understand what’s going on if you have been diagnosed with a digestive condition. In this book we will be focusing on a number of areas, which are particularly common in women. These are IBS, functional dyspepsia and the effects of female hormones and menopause on gut function.

Empowerment. By helping you to understand your condition, and removing any uncertainty regarding your diagnosis, you will be empowered to take the correct steps to restore your gut health and equilibrium. Knowledge is power. We want to challenge some of the common myths so that you do not waste your time, energy and money on pursuing treatments and tests that have no proven value.

Eating for health and wellbeing. By using the FLAT Gut Programme we will help you minimize your symptoms, while eating an interesting, varied and nutritionally balanced diet. But we also want you to understand that sometimes diet alone is not enough and that there are many other things which can help you. You should be confident that your dietary roadmap is the correct one towards better gut health and a better quality of life.

Why are you reading yet another book about your gut?

This might be the first book that you have picked up about digestive problems or perhaps it’s the fortieth. But if you are about to read this book, it’s probably because all the things you have tried already have not worked for you, or have not worked well enough. If the statements in the box below ring a bell, then this is the book for you.

Fear | You are afraid that there is something serious causing your symptoms that may have been missed or not investigated.
Pain/discomfort | You are experiencing very unpleasant symptoms that are having a negative effect on your quality of life. You want the pain and discomfort to stop.
Hope | You have lost hope or are feeling helpless about your symptoms and wondering if your quality of life will ever improve.
Pleasure | When every food you eat seems to cause you problems, where is the enjoyment? Family meals, eating out and holidays abroad all become something to dread rather than something to look forward to. You need to rediscover some pleasure in life.

How will this book help you?

If you are experiencing frustrating and debilitating gut symptoms, you may want to jump straight to the chapters dealing with dietary solutions in Sections 4 and 5 of this book. We want to empower you to find the solutions to your gut problems, and it will be a lot easier for you and make more sense if you have a good understanding of your gut: how it functions, how your hormones affect it, the importance of the gut–brain axis and ensuring that you have had appropriate investigations. For this reason, we have gone into some detail (hopefully not too much!) about these things in Sections 1, 2, 3 and 6. You may wish to skip around a bit as each chapter is stand-alone.

After reading this book, you should understand how your digestive system works. If you have been diagnosed with a functional digestive condition such as IBS or functional dyspepsia, we want you to have the knowledge to ensure that you have had the correct investigations and, as far as possible, ensure that you have the correct diagnosis. Every patient does not need every investigation, but there are some baseline tests that should be done in all patients before a diagnosis of IBS is made. Your digestive system and symptoms will no longer be a mystery to you, and you’ll have a good understanding of the role played by diet, bacteria, emotional factors, mental health, sleep and exercise in triggering and perpetuating these symptoms. Ultimately this will help you to get these symptoms under control so that you can get on with your life.

Remember, managing any digestive condition is a marathon and not a sprint, so you have to be prepared to make changes and to stick with them to reap the benefits. We are confident that this book will be your roadmap to better gut health and wellbeing.

Barbara and Elaine