IBS and the Low FODMAP Diet with Onikepe Adegbola, MD of Casa de Sante

Adapted from episode 91 of The Perfect Stool podcast with Onikepe Adegbola, MD, sponsored by Casa de Sante and edited for readability.

Lindsey: 

So let’s start by just the basics about what IBS is and what causes it.

Onikepe Adegbola, MD: 

Sure, IBS is a functional gut disorder. The cause of IBS is not exactly known, but it’s thought to be a function of the disturbance in the sensation of intestine for the patients. Some people get IBS after infections. But for most people, the cause of IBS is unknown. There are a few criteria for diagnosing IBS called the Rome Criteria, and doctors follow that criteria. There’s a lot of items in the criteria, such as abdominal pain and other GI symptoms over a certain period of time. And of course, if the patient has what we call alarm symptoms, like blood in the stool, and things like that, though, a lot of things have to be excluded as well.

Lindsey: 

Like inflammatory bowel disease

Onikepe Adegbola, MD: 

Exactly. Colon cancer, things like that.

Lindsey: 

Yeah. And do you want to mention SIBO at all, and the distinction between IBS and SIBO?

Onikepe Adegbola, MD: 

Yeah, so it’s mentioned that a lot of people with SIBO have IBS-like symptoms as well. SIBO is overgrowth of bacteria in the small intestine that can recall in certain conditions or following surgery in some people, and and so once a while, you can use the low FODMAP diet for both conditions; the therapy is not exactly the same. So there’s a difference between the two. People with SIBO often have IBS like symptoms as well.

Lindsey: 

Okay, and so tell me about the low FODMAP diet and how it manages IBS symptoms.

Onikepe Adegbola, MD: 

Yeah, so the low FODMAP diet is a diet, whereby you decrease the amount of fermentable carbohydrates diet, sort of a mouthful of an acronym, right? It stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. So it’s a little bit of a mouthful, but quite simply, they’re all fermentable carbohydrates, that some people don’t digest properly in the intestine, and it gets broken down by bacteria, which results in gas. You know, think about fermentation, like when you’re making beer or, or bread, for example. So you’re going to get a whole bunch of gas. And that’s going to cause, because of symptoms like abdominal pain, constipation, diarrhea, and bloating, when it draws water into the intestine as well. So people with IBS generally have a problem with those type of carbohydrates. So using the low FODMAP diet, you can decrease the amount of those carbohydrates in your diet, and thereby prevent flare ups, reduce the the amount of IBS symptoms. A lot of studies have shown that about 70 to 75% of people with IBS get symptom relief from the low FODMAP diet.

Lindsey: 

And what kinds of foods are FODMAPs?

Onikepe Adegbola, MD: 

Yeah, that’s an interesting question. And that’s what makes the diet sometimes difficult for people to follow, because first you have a whole bunch of carbohydrates, right? And secondly, it’s not like gluten, where you just remove maybe things that have gluten like wheat, for example, you know, that’s straightforward. Or even somebody that is lactose-free, right? You just remove milk and dairy products. So there’s a wide range of foods that are FODMAPs. And I would urge anybody who is trying this diet to not wing it for sure. And there’s the Monash App to go through to find the levels of FODMAPs in various foods. So Monash and FODMAP Friendly are the two organizations that tests for the amount of FODMAPs in food and tell you what servings is okay on the low FODMAP diet, because for a lot of foods even though they may be low FODMAP in low quantities, they could easily get high FODMAP in high quantities. And so so you have to watch the amount of of each food that you take in even if you quote unquote follow FODMAP or moderate FODMAP food. But basically if you want to do a simplified diet in a very simplified manner, you would say that things like dairy for example, lactose, things that have lactose or high FODMAP foods that have onion and garlic. Garlic is high FODMAP because even a a little bit of that, it’s a problem for people who react to FODMAPs Inulin is high FODMAP; you see it in a lot of foods and even in small quantities. That can be a problem. I mean for inulin for example, I don’t even have IBS, but I react to inulin, so that’s something that a lot of people with IBS react to. Sweeteners ending in -ol . . .  . . . all the sugar alcohols . . .  exactly, sugar alcohols. They are high FODMAP. Even the simplest sugar alcohol, which is erythritol, can be low FODMAP. But it still causes, it’s still mentioned  because it causes symptoms all on its own. So I would definitely avoid it as well. And then you also have beans, which I guess we won’t be surprised about, high-FODMAP fruits like apples, which have high fructose content, are high FODMAP. There’s a long list of foods that are high FODMAP. But I think some of the more common culprits, except for maybe onion and garlic, are not a surprise. A lot of people they eat foods, they have problems, a lot of foods, you know, dairy, sometimes I think people, some people would know that as well.

Lindsey: 

Yeah, onion and garlic are definitely the hardest ones to eliminate. Because they’re kind of in everything. And then the powders as well, which are in salad dressing. When I was doing the low FODMAP diet and I went out, I would take my own salad dressing with me to restaurants because otherwise, it was just oil and vinegar, which is kind of boring.

Onikepe Adegbola, MD: 

Yeah, exactly. Because it’s everywhere. Even when you’re not told that onion and garlic is there, it could be there.

Lindsey: 

Right! It’s the base of every recipe practically.

Onikepe Adegbola, MD: 

Exactly. Right. And that’s actually why one of the reasons why we started off with the low FODMAP seasonings, because our seasonings don’t have onion or garlic. So for people on the low FODMAP diet, that’s very, very useful. But you know, we have people who are like “Why would you have a seasoning that has no onion? No, garlic. That’s strange, right?”

Lindsey: 

So you sell those seasonings?

Onikepe Adegbola, MD: 

Yeah, we do. Low FODMAP certified.

Lindsey: 

Okay. And so can you walk us through the process of starting a low FODMAP diet?

Onikepe Adegbola, MD: 

Yeah, sure. So the process, it generally takes about six to eight weeks to go through the low FODMAP diet. And there are three stages. So in the first stage, you would eliminate FODMAPs from your diet. So that’s where the apps like the Monash app, and the FODMAP friendly app, can be very useful, because they help to tell you what serving size is normal. And I think that that’s a low FODMAP normal in that situation. But I think that for a lot of people, that’s probably the toughest part of the diet, just eliminating all those foods. And it can be very confusing for people. It can be easy to make a mistake. And even if you make a mistake, or something goes wrong during that time, you can always start again, you shouldn’t be down on yourself. So you start off with that, that part of the diet usually takes six to eight weeks. And then hopefully by that time, your symptoms will subside, and you’ll get some relief. And now then you get to the second part where you’re trying to figure out, okay, well, so I’ve taken all this stuff, all these fermentable carbohydrates out of my diet, which one is causing my problem? So let’s use a sort of reverse elimination process to figure it out. So you test each FODMAP group, one by one over a couple of weeks or so. There’s a lot of resources, we have some free resources to help you with that part of the diet, which is called reintroduction and which can be tricky for some people, and Monash also has some resources on the app to help you go through that. And then once you figure out, okay, well, this is what I’m reacting to in the diet, whether it’s fructose or oligosaccharides, disaccharides, or polyols, then going forward, you can go into the third phase of the diet, which is the maintenance phase, where you just you have a diet that eliminates what you react to. And hopefully a diet which you can follow everyday and get rid of IBS symptoms. So that’s pretty much it. And the whole process, you know, probably takes a couple of months. And if you have a dietitian helping you, that’s very helpful because it can be confusing for some people. And if you don’t do it properly, then you might not get the relief. Or you might think it doesn’t work. Well, while it might not work for 25% of people, you want to make sure that it’s not working for you because it’s actually not working for you not because you’re not doing it properly.

Lindsey: 

And so I imagine that if you stay on a diet like low FODMAPs for an extended period of time that there could be some risks or downsides. What might those be?

Onikepe Adegbola, MD: 

Yeah, absolutely. And that’s why it’s it’s meant to be a short term diet, even though unfortunately, some people claim that they can’t really ever go back to eating stuff, and they sort of have to keep being on a completely low FODMAP diet for a while, but it’s been shown to change the microbiome. Studies have shown that taking probiotics can help with that, relating to the levels of Bifidobacterium from the low FODMAP diet, but then the other changes with the microbiome have been shown with the low FODMAP diet. And you could, by restricting some foods in your diet, such as dairy and other foods, you could end up with some nutritional deficiencies over the long term. So that’s why it’s not supposed to be a forever diet. It’s ideally a diet which is short-term and targeted. And once you figure out what the problem is, you can move on to a more normal diet.

Lindsey: 

And do you advise people like maybe to use it just when they’re flaring or once they figure out their sensitivities just to stick with that as their base diet?

Onikepe Adegbola, MD: 

Yeah, once you figure out your sensitivities, I would advise people to just figure that out. That’s the best idea.

Lindsey: 

Okay, and can you discuss the other treatment options for IBS? Besides the low FODMAP diet? I assume you use some adjuncts to that?

Onikepe Adegbola, MD: 

Yeah, so there’s definitely medications, good adjunct to the low FODMAP diet for people who want to them. So you’re talking about medications like Linzess, Immodium, antidepressants, all depending on what the symptoms are. So for example, antidepressants, even though people hear antidepressants and they think, oh, well I’m not depressed and so this is not really useful for me, but they’re actually working on the garden. Now, this has nothing to do with depression; so they can be useful in for people with IBS. And also things like yoga, exercise, mind-body meditation. And so even some people have noticed, hypnosis can be helpful. Cognitive behavioral therapy can also be helpful. And so what is very useful is for you to find the combination of things that work for you personalized. You could call that personalized medicine, because everybody’s different with ideas, as I guess a lot of people with IBS know. Because if you are ever in an IBS forum, and people are talking about their triggers, there’s such a wide range of triggers. You talk to 10 people, you get 20 different triggers. So there’s definitely a wide variety of triggers. And what works for everybody is different. So yeah, it’s important to work with somebody if the low FODMAP diet is not helping you. Or maybe if you want to supplement it with something, it’s helpful if you work with somebody who can personalize the diet, personalize your interventions and come up with a plan, a personalized plan that can help you to get your symptoms under control.

Lindsey: 

And so is the mechanism of action with the antidepressants is that these are SSRIs that are increasing your serotonin, such that you have more motility in the gut, like for more constipation SIBO? Or is this also for more diarrhea type SIBO? Or IBS I should say.

Onikepe Adegbola, MD: 

So yeah, so it’s more use it in different forms of IBS. And so it acts on the gut, it helps with pain, for example, people have abdominal pain and IBS.

Lindsey: 

Okay. And do you use Rifaximin at all with your patients?

Onikepe Adegbola, MD: 

For patients with SIBO, Rifaximin is definitely helpful. It’s so expensive in the US and not always covered with insurance. But helpful sometimes you can use it. Also metronidazole, Flagyl, which is metronidazole can also be used because and is cheaper than Rifaximin. So that can also be used for patients who can’t get or find the cost of Rifaximin too expensive or who can’t get it from Canada. So if you get it from Canada where it is cheaper, it can definitely be used, it’s possible. And then also, placebo. People have also looked at antibiotics, herbal antibiotics like oregano on and whatnot can be effective as well.

Lindsey: 

So what kind of testing do you do to determine what patients have?

Onikepe Adegbola, MD: 

It’s mostly a diagnosis that you can make from symptoms and mostly from symptoms. But if the patient is having what we call alarm symptoms, like blood in the stool, change in bowel habits and things of that nature, you might want to do tests to rule out something that could be sinister. So you want to rule out colon cancer, for example. And IBD is also differential, a possible diagnosis. So you want to rule that out as well. So while IBS is a diagnosis you can make through history, if a patient has alarm symptoms, and in certain situations with age or whatnot, you might have to do some testing just to rule out celiac disease, rule out IBD, rule out colon cancer.

Lindsey: 

So would you send people to their local gastroenterologist in that case for a colonoscopy?

Onikepe Adegbola, MD: 

Yes, in that case, yes, we will. Although we do prefer patients who have seen their gastroenterologist already because we’re not aiming to be their primary care, or their primary gastroenterologist, we’re more an extension, a help, because people with IBS often have, you have all those symptoms and it takes time and trial and error to resolve them. And so the time that they spend, the doctors have 15 minutes or 20 minutes in a typical appointment, which is just not enough, and is often rushed for them. And also they have to make appointments to see the doctor, which could be weeks, days or whatever, in the future when they’re having symptoms like right now. And you know, they can’t get anybody to talk to them. We’re that stop gap where you have somebody you can always talk to. We have the time, we have long appointments, and we focus solely on IBS. So it’s not a situation where you know, you go to your doctor and they say, okay, well try the low FODMAP diet. And you’re like, Well, how do I do it? And oh, well Google it, they give you a short handout with two sentences. And we so we go in depth and really help you to get a hold of your IBS symptoms and take control of your symptoms with personalized plans.

Lindsey: 

Okay, and so can you tell me a little bit more about your virtual IBS clinic and how you help people manage their symptoms?

Onikepe Adegbola, MD: 

Yeah, sure. So we actually started off as a low FODMAP brand. So for the last few years, we’ve been selling low FODMAP products, foods like the seasonings, like I talked about salad dressings, protein powders, as well as gut health supplements, which are low FODMAP certified, so that people on the low FODMAP diet or with some food intolerances have the confidence that what they’re eating is not going to give them problems later on.

Lindsey: 

Is that under the name Casa de Sante?

Onikepe Adegbola, MD: 

Yeah, that is correct. Yeah. So that is under the name Casa de Sante. And in the process of doing that, we’re very in tune with clients and customers. And we would get a lot of inquiries while we tried to help them, even though we always had the disclaimer that this is not medical advice. So we saw the need interacting in groups talking to our customers for this type of service, because a lot of people are just going to Facebook groups at this point and asking questions of people. It’s always good to get information from your peers and learn from people’s experiences, I think that is very useful, but it’s also helpful to get it right also sometimes more helpful to get help that could help you in the long term rather than just ad hoc recommendations as you have problems. So we started this service as a virtual personalized service. That is integrative care. So you have not just a doctor or a GI clinician, you have a GI clinician that is specialized in IBS, as well as a dietitian who is specialized in IBS, as well as a health coach to help you resolve your your IBS problem. So we have a holistic and personalized approach. And we have you set up appointments, providers, and you have long appointments, you have access to resources, you have a community, you have meal plans that can help you, you have testing; we do advanced testing. So if you have to do food sensitivity tests, we can help you. And based on all the data we get from the testing, as well as from your symptoms, we can come up with a personalized plan for you. And if you have questions, you have an app where you can log your symptoms and then reach out to us if you have questions or if you have any issues with IBS. So we have a whole approach, which is both the consultation and the the visits with the clinicians, and also the low FODMAP products if someone needs it. Okay, so how do you work with your patients to tailor the low FODMAP diet to their individual needs and preferences? Yeah, so a lot of people who have difficulty following the low FODMAP diet, just because it can be very restrictive. Actually, it is restrictive. So it can be difficult to understand and it’s not a lot of people that go about the whole place carrying a scale to weigh their food and to be exact, right? So it can be challenging from that perspective. And so for people who can’t, or are having difficulty following the low FODMAP diet, we can do a simple or gentle low FODMAP approach, whereby we eliminate the most common common offenders such as milk, onion and garlic wheat, wheat containing products. And I just want to mention that wheat is a FODMAP so it gives people problems, not because it contains gluten but it contains fructans. So some people who think they’re reacting to gluten might actually be reacting to the fructans in wheat and those types of gluten-containing grains. And so you could you do a gentle approach and start off with eliminating those and see if it helps the patient. And if not, then you can go into the full bore low FODMAP diet. And so we tailor it to our patients based on what they can do and what we understand from their previous experience. And some people already know what they react to, to some extent, and some people don’t. So everything’s personalized. And for some people, it just doesn’t work for them. They’ve tried it before, and it doesn’t work. And so that’s not necessarily the answer. And we know that 25% of people do not get any benefit from the low FODMAP diet, even with IBS.

Lindsey: 

So if the low FODMAP diet doesn’t help at all, what are the likely causes if say bloating and gas is one of the big symptoms?

Onikepe Adegbola, MD: 

Yes, trying an elimination diet can be helpful, because even if you don’t react to FODMAPs, you could react to other foods. So definitely having a diary and doing an elimination diet will be a good first step. And then for bloating, bloating is a whole interesting, subject by itself. But you want to start off by saying, okay, well, when is the patient blaated? When is the client bloating? Or how soon after eating does the client bloat? And then you can divide up the possible causes. And there’s a wide range of causes depending on when the bloating occurs, how soon after eating, and, and also understanding people have a very different description of what bloating is. For some people, bloating could be distension of the abdomen, of the stomach. Also for some people it’s the sensation of fullness. So you also have to understand what the client means by bloating. So that’s where understanding what the symptoms are, when they occur and taking a good history from the patient and understanding what is really happening helps. And then based on that we can do further tests to figure out what is going on. And we recommend some general approaches that would help anybody that has boating such as, don’t drink heavily caffeinated drinks fast, things like that are just helpful for people in general that have bloating, while you figure out what exactly is causing the bloating.

Lindsey: 

Are you using the functional medicine stool tests?

Onikepe Adegbola, MD: 

Well, yeah, we use different various tests, depending on what the patient’s symptoms and history are.

Lindsey: 

So which tests do you like?

Onikepe Adegbola, MD: 

I wouldn’t say we like a particular test. Again we go through this very personalized approach. It really depends on what the patient’s history is. And various practitioners do have their favorite tests. We have a few different practitioners in our practice and they do have their favorite tests. We try to individualize it for each patient.

Lindsey: 

Yeah, there’s a little different offering on each test of what’s included. So this is true. Okay, so can you talk a little bit about the research on the effectiveness of the low FODMAP diet for IBS?

Onikepe Adegbola, MD: 

Yeah, so research has shown that it is effective in about 70 to 75% of patients with IBS general, generally. The FODMAP gentle approach has also been found to have high effectiveness. Even if you don’t go through the whole low FODMAP approach, it can be helpful. And even having eliminated some of the common triggers that we know about has also been, which is also more simple than the low FODMAP diet. It has also been shown to be helpful. So just eliminating wheat and milk and and high fructose foods, high fructose corn syrup, and that sort of stuff can also be helpful. So yeah, so the low FODMAP diet is clearly effective for many people with IBS, but not all.

Lindsey: 

And so we talked a little bit about the low FODMAP diet and the impact on the gut microbiome, but what can you, and if you want to elaborate any more on what else it does to the gut microbiome, but what steps can you take to ensure that you still have a healthy microbiome?

Onikepe Adegbola, MD: 

So it’s been shown that taking probiotics can be helpful with that.

Lindsey: 

Like lacto-bifido type probiotics?

Onikepe Adegbola, MD: 

Yeah, bifidobacterium varieties as well as lactobacilli, yeah, that’s also helpful. And that’s why we have a low FODMAP certified probiotic that has a number of probiotic strains that are helpful bacterial strains that are helpful for IBS. It’s low FODMAP certified.

Lindsey: 

Are there are strains you should avoid when you have IBS?

Onikepe Adegbola, MD: 

I can’t think of any particular strains that you should avoid. The thing is that so many different stories on probiotics that have different varying results. So the data on probiotics is not always very clear, as oftentimes, you need more stories. And so that’s why the type of probiotic and the the administration of the probiotics is just very individual to people. And so we recommend that. Okay, when you try a strain, you try it for a short period of time. See if it’s working for you, make sure it’s not making your symptoms worse. And if it’s not working, or is making your symptoms worse, then you stop it. But probiotics are also very individual as well.

Lindsey: 

Yeah, I have heard the suggestion that people with SIBO, the probiotics can be overgrown themselves, that you can be essentially implanting strains that will overgrow.

Onikepe Adegbola, MD: 

Yeah, I have I heard that too. And then there are also studies that show that probiotics can be helpful.

Lindsey: 

I know. It’s always tricky to decide whether or not to recommend them.

Onikepe Adegbola, MD:  

Yeah, exactly. The data is definitely conflicting with probiotics. And so if you could get it, you’ll try it. I just recommend that if people want to try, they try a short trial and see if it works for them or not.

Lindsey: 

And so how do you recommend including low FODMAPs food and supplements into an overall healthy diet?

Onikepe Adegbola, MD: 

So I think if you’re on the low FODMAP diet, and while you’re in the elimination phase, the first phase, you want to avoid high FODMAP foods and supplements. And so there was a study that came out recently, maybe a year or so ago now, that showed that a lot of people just did not realize that a lot of medications and supplements have things that are gluten, they have lactose, and they could actually be a cause of problems for people who have food intolerances or allergies. In general, there’s probably just a little bit in those in of the FODMAPs, in those supplements and medications. But some people could react to that. So you probably just want to make sure that if you’re still having symptoms, check your medications, check supplements, they could possibly have FODMAPs in them, and they could be the source of your symptoms. I think I remember someone having inulin, for example, that could be in a lot of medications. And that’s a huge, even for me in small amounts, that’s a huge trigger for bloating and gas.

Lindsey: 

And it’s also a big additive to those [granola] bars.

Onikepe Adegbola, MD: 

Exactly.

Lindsey: 

The commercial ones because it’s a lot of added fiber. Low cost, I guess.

Onikepe Adegbola, MD: 

Yeah, exactly. Exactly. So I would I use a low FODMAP certified product, low FODMAP brand is probably the way to go while you’re doing the elimination phase of the low FODMAP diet.

Lindsey: 

You know, I sometimes see now the brand in stores called Fody.

Onikepe Adegbola, MD: 

Yeah, they have a number of low FODMAP products as well.

Lindsey: 

So tell people where they can find you.

Onikepe Adegbola, MD: 

We are at Casadesante.com. We have a lot of resources for people, not just on the low FODMAP diet, but also on IBS and gut health in general. We’re also on Instagram, Facebook, and Twitter, all the major social media platforms. And you can also email us or contact us through our website as well.

Lindsey: 

Okay, and any final thoughts before we finish up?

Onikepe Adegbola, MD: 

Well, I just want to thank you for having me here. Always happy to answer any questions anyone has about gut health, IBS or the low FODMAP diet and you know, here’s to your health and healthy poops!

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