One year on – Still living Fat Free!

It’s exactly one year since I posted my first blog about my ‘tummy troubles’. My ramblings about my digestive dysfunctions have had nearly 9000 views over the last 12 months which is just astonishing to me! Hopefully I’ve provided some answers or given a new perspective to people looking for help with their own digestive problems.

I’ve found out so much more about what could be causing my symptoms (fat intolerance, eggy burps) over the last year. I’ve had a few theories, tried out a few different experiments – some worked, others not so much (My Trial with Symprove). In general life I am fitter than I’ve been in a long time – maybe ever. Exercise helps a huge amount with my symptoms. Here’s a Tara Stiles yoga video which is great for easing that over-full feeling.

I’ve discovered over the last year that coca-cola can be a medicine for helping to move stuck food through your stomach. The first instinct when you feel sick is to take antacids but if you have bile reflux the problem may be that your stomach is not acidic enough because bile is neutralising the natural stomach acid required for normal digestion. A small drink of cola may be all you need to feel fine – antacids could be making things worse! I still occasionally get acid reflux as well and take an antacid but only the burn in my throat is particularly uncomfortable.

In the last year I’ve also learned more about the ‘second brain’ we have hiding away in our digestive system. Our Enteric Nervous System controls all the different aspects of digestion and is almost entirely independent of our ‘first’ brain. This is why it is so very difficult to diagnose stomach disorders. Any number of things can be wrong yet because our stomach and our brain do not talk to each very well our only indicators of a problem are nausea or pain. There’s a lot of research about how our food intolerances can effect our mood. It is so common for people to blame digestive disorders on depression or stress but what if it is the digestive disorder that is causing the feelings of depression or stress? I’m reading up even more and planning to post about our second brain soon.

My diet is still very low in fat and that continues to keep the particularly bad episodes at bay. My last one was in February the day after stealing a pizza crust from my husbands dinner plate. The pizza crust was delicious but definitely not worth the result. Times like that renew my resolve to fight to be healthy and live a good, happy life not chained to the bathroom! I still get waves of nausea, bloating, sensation of fullness and ‘traditional’ IBS-D symptoms on a daily basis but they are eased by keeping portion sizes small and avoiding those foods which I know trigger my symptoms. Everyday I discover something new and everyday I get closer to finding that perfect balance to keep my digestive system calm and functional permanently. Thank you for reading!

IBS or Functional Gastrointestinal Disorder – What’s in a name?

I find it difficult to discuss my ‘tummy troubles’. Which is part of why I started writing this blog. It’s hard to judge how much detail a person wants when they ask ‘so what exactly is wrong with your stomach?’. Do people want to hear about vomit and faeces or do they just want a nice ‘medically’ sounding disease name? I usually begin with saying my stomach just doesn’t work properly. If I say I have irritable bowel syndrome (IBS), which is true, most people associate that with pro-biotic yoghurt adverts with middle-aged women discussing ‘digestive discomfort’ rather than staying up all night on or over the toilet emptying your entire body contents because you unknowingly ate something containing a spoonful of oil. If I mention fat intolerance quite often I get the response ‘ooh that’s good – I wish I had that’. I can understand the response being jokey and meant harmlessly but depending on how ill I’m feeling that day I can take it quite badly (though I have to admit I laughed hard when someone thought it meant I really couldn’t stand fat people).

I was recently asked to fill in a health questionnaire as part of registration to a fitness centre. Most of it was straight forward as these things are but I was stumped by the last question – ‘are there any health concerns your instructor should know about?’. What do I put? IBS as everyone ‘knows’ is just a bit of bloating isn’t it so why list that as health concern? Unfortunately an over-sensitive spasmodic stomach and bowel can be a whole lot more than that. Should I put Functional Gastrointestinal Disorder which is perhaps a more accurate description of my collection of symptoms? The owner of the fitness centre said ‘basically what we need to know is what we would need to tell a paramedic if you passed out’. So I immediately decided to leave the section blank – why would there be any reason that I should pass out so why agonise over the details of the form. I have wondered after the event why I had such trouble with the question? Am I embarrassed to be associated with having IBS even though it so obviously affects my life and is thus one of the things everyone knows about me – I have ‘tummy troubles’. Is it a pride thing? To admit I have a weakness is difficult for me especially one of no known cause that some (not me) believe is entirely psychosomatic.

The Rome III criteria definition for irritable bowel syndrome (IBS) is as follows:

Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated with two or more of the following:
1. Improvement with defecation
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form (appearance) of stool

So according to the Rome III criteria IBS doesn’t cover stomach symptoms. I would need to include functional dyspepsia:

Functional Dyspepsia
Diagnostic criteria* Must include:
1.One or more of the following:
a. Bothersome postprandial fullness
b. Early satiation
c. Epigastric pain
d. Epigastric burning

and

2. No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms
* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

and to cover the fat intolerance symptoms I would need to include functional gallbladder and/or sphincter of Oddi disorders:

Functional Gallbladder and Sphincter of Oddi Disorders
Diagnostic criteria
Must include episodes of pain located in the epigastrium and/or right upper quadrant and all of the following:
1. Episodes lasting 30 minutes or longer
2. Recurrent symptoms occurring at different intervals (not daily)
3. The pain builds up to a steady level
4. The pain is moderate to severe enough to interrupt the patient’s daily activities or lead to an emergency department visit
5. The pain is not relieved by bowel movements
6. The pain is not relieved by postural change
7. The pain is not relieved by antacids
8. Exclusion of other structural disease that would explain the symptoms

Supportive criteria
The pain may present with one or more of the following:
1. Associated with nausea and vomiting
2. Radiates to the back and/or right infra subscapular region
3. Awakens from sleep in the middle of the night

So perhaps just to say I have Functional Gastrointestinal Disorder is easier! However as each of these conditions can be explained by erratic bowel spasms then it seems bizarre to give them separate names. My bowel is erratic and unpredictable – irritable in fact!

What causes Eggy Burps?

When I have a really bad episode coming the first sign is eggy, sulphurous burps. For me these eggy burps are always followed within minutes or hours (each episode varies) by excruciating upper abdominal pain then sometimes by vomiting and always by diarrhoea. I have mentioned eggy burps to every doctor I’ve seen over the years and never had an explanation of why these occur or how to stop them. Even the more verbose doctors who, quite frankly, loved the sound of their voice were more keen to explain to me the technicalities of bowel innervation than why I was belching pure rotten egg stench. I’ve had various theories and none seemed to fit completely. I have repeatedly searched the Internet – never the most reliable source for symptom analysis – and found various herbal remedies and personal accounts which do little to shed light on the physiological processes involved.

Bacterial infection is the most common cause of eggy burps but the effects are short term, gone after the immune system or antibiotics evict the bad bacteria. Having an extremely high protein diet (bodybuilders beware) is frequently associated with eggy burps. Infection with the Giardia parasite is another increasingly common cause. There are a lot of people that believe these repeated symptoms of eggy burps, stomach pain and diarrhoea are as a result of one initial Giardia infection (giardasis) that somehow recurs or left damage in the digestive system in its wake.

I know the awful egg smell comes from hydrogen sulphide being produced somewhere in the digestive system and bubbling it’s way up and out through your mouth. Hydrogen sulphide (or sulfide) can be produced by the bacterial breakdown of organic matter in the absence of oxygen – anaerobic digestion. So what causes an environment in your gut where anaerobic digestion takes over the usual digestive process?

It seems to me that anaerobic digestion could be encouraged in a stomach that does not empty properly. I have found that my symptoms are worst if I eat food that contains too much fat. In a previous post I discussed how eating fatty foods could cause biliary colic type symptoms due to irregular spasms of the bowel. If these irregular spasms also cause the stomach to have delayed emptying or even completely prevents emptying at times then this could explain the bad smells as well. Fat is difficult to digest and has a slow transit time through your digestive system. If you had a digestive dysfunction (gastroparesis, gastric stasis) where food passes more slowly than usual through your gut then food that passes even slower would effectively get stuck and begin to stagnate. If you have ever collected up your food waste for separate disposal to your other household waste (think green) then you’re aware certain foods begin to smell very strongly quite quickly and others just decompose without much fuss. Imagine this process occurring in your stomach. It’s a big bag we’re pouring food and drink into regularly throughout the day – if that food gets stuck it’s going to start to smell and smell bad. This theory for me explains the ‘delayed reaction’, why if I sneak a bit of my husbands pizza crust one evening after dinner then I don’t get the eggy burps until the following afternoon. The pizza crust is still there along with a rancid soup of partially digested foods. The stomach reacts to evict this noxious concoction as quickly as possible – if it can’t go down then it comes up! If some does make it’s way down into your intestine then in those with an already sensitive, ‘irritable’ bowel it passes out extremely quickly. So slow stomach transit time is followed by extremely rapid exit time!

In a normal functioning digestive system the stomach emptying process begins within about 20-30 minutes of eating a normal meal and the stomach is mostly emptied after about 3 hours. The higher the fat content the longer the emptying time, if the meal is less solid (i.e. soup) then transit time will be faster. So is the solution simply to eat less – or just soup? I’ve found from my experimentations with food that only eating soup does not help as much as would be hoped. A lot of soups you can buy in the shops or restaurants are very high in fats, plus the liquid state does not stimulate the stomach enough to begin emptying. Smoothies also tend to include hard to digest fruit skins and other indigestible fibres plus fruit acids. Small snacks are not large enough to stimulate the stomach to begin emptying. Large fatty meals are too much for the stomach to process efficiently resulting in stinky ‘leftovers’. I’ve also experimented with probiotics in the hope that introducing ‘good’ bacteria’ would prevent the proliferation of ‘bad’ bacteria which could create the environment where hydrogen sulphide is produced. Unfortunately my experiments did not produce definitively positive results for but it may work for others!

The best ways I’ve found to prevent eggy burps are:

• to eat regular small meals (i.e. risotto)
• avoid hard to digest foods (e.g. fats, insoluble fibres, fruit skins, any meat except chicken and turkey)
• try not to eat any later than 4 hours before bedtime
• exercise regularly to physically assist movement through the bowel

Why Does Eating Fat Make Me Sick?

I asked this question to various doctors while my symptoms were being investigated and I never got a clear reply. So if you are experiencing pain, sickness, diarrhoea or even just foul breath and eggy burps after eating fatty food then hopefully I can help you to understand why.

Firstly how is fat digestion supposed to work? The majority of fat digestion occurs in the small intestine. When the fat reaches the start of the small intestine (duodenum) it triggers the release of hormones which in turn initiate the release of enzymes from the pancreas and bile from the liver (via the gall bladder and bile duct, see here for an excellent diagram of the digestive system). The healthy stomach is very acidic mainly to assist in protein digestion and to break down or damage any pathogens (germs) that may have found their way into the stomach. However our digestive enzymes are proteins too so they do not work as well in an acidic environment. One function of bile, along with sodium bicarbonate released from the pancreas, is to restore an almost neutral pH to the bowel so the digestive enzymes can function properly. Bile is also essential to fat digestion by making the fat molecules water soluble (emulsification) which makes the digestive enzymes job much easier. The most important enzyme for fat digestion is pancreatic lipase, it completes the digestion process and allows the small intestine wall to absorb the fat molecules.

So this is how the fully functional fat digestion process works but why and how does this process end up causing pain and sickness in some people? If you have had all the tests and scans showing no ulcers, inflammation, gallstones, pancreatitis or other disease then the fault will possibly lie with irritable bowel syndrome (IBS).

The main symptoms of IBS are caused by erratic bowel spasms. If one or more of these spasms occurs in the duodenum it can result in the stomach not being able to drain properly (sometimes known as gastroparesis) leaving an uncomfortable full sensation, bloating, bad breath, nausea, stomach cramps and feelings of ‘indigestion’ (dyspepsia). I have found eating smaller meals more frequently helps with all of these symptoms and low dose (10mg) amitriptyline helps with the discomfort and pain.

Why are these symptoms worse when fat is present? This could be the result of ‘bile reflux’. Bile is only released in the presence of fat in the duodenum and bowel spasms may push this bile into stomach. Bile is not normally present in the stomach so this upsets the normal digestive process. There are some reports that bile can damage the stomach lining resulting in symptoms of gastroenteritis (gastritis) or worse lasting damage but I do not believe these have been scientifically verified and should not be something to worry about. Bile acid sequestrant medication can help with these symptoms. Bile acid sequestrants include: Cholestyramine (Questran) , Colesevelam (Cholestagel in Europe, Welchol in the USA) and Colestipol (Colestid, Colestipid).

The worst symptoms I get after eating fatty foods are extreme stomach pain (usually occurring in the night or very early morning), vomiting and diarrhoea match closely those of biliary colic. Biliary colic is the pain resulting from gallstones blocking one or more of the ducts leading from or to the gallbladder causing it to distend. So it is possible that the bowel spasms somehow prevent draining of bile from the gallbladder into duodenum causing the gallbladder to painfully distend. In a similar way bowel spasms could mimic pancreatitis as bowel spasms could prevent draining of the pancreas via the pancreatic duct into the duodenum. Both amitriptyline and bile acid sequestrants help to control the diarrhoea but the best treatment I have found to prevent these extreme episodes is to eat a very low fat diet. I have not found any medication that helps, even powerful painkillers do not control the pain it is simply a matter of waiting it out. Unfortunately there is no ‘cheat day’ on this diet even one sneaky chocolate bar would result in a really bad night. For more information on my diet see here.

Recipe for Fat-Free Risotto

Half a leek, chopped

White wine

Half a lean chicken breast chopped

A handful of chopped mushrooms,

Half a carrot, grated

75g rice (I prefer basmati or arborio risotto rice)

Half a pint of stock

Warm a saucepan then add the chopped leek and a splash of the wine. Cook over a medium heat until the leek softens then add the chicken and continue to stir until the chicken is white through (add a splash more wine if necessary). Then stir in the mushrooms, carrot and rice. Stir for a couple of minutes then pour over enough stock to cover the contents of the pan. Do not cover and leave simmering until the rice is cooked (about 20mins). Serve and enjoy!

 

Seasoning: Add a little salt and pepper to taste. I like to add a little celery salt. Sometimes using this basic recipe I make a biriyani by adding some of my favourite curry spices.

Alternatives: You can buy packets of low fat cooked chicken in most supermarkets or use some of the breast meat from a roast chicken (recipe to follow soon) for an even quicker cook. I also like this recipe with some chopped wafer thin lean ham or quorn. The vegetables are entirely up to you, add whatever’s your favourite or what you tolerate best. Vary the quantity of rice according to your appetite. If you don’t have fresh stock available to cook with I use powdered organic vegetable bouillon as it’s best to avoid monosodium glutamate which is found in most stock cubes.

Stress and IBS

Stress is often implicated as a cause of IBS. Is stress the cause or is it a result of the condition? Or both? Physiologically stress or anxiety has proven bowel effects. As the body gets ready to fight or run away the blood drains from the bowel to provide ready supply for the muscles. This is the reason you get a ‘sinking’ feeling or ‘butterflies’ in your stomach when faced with a stressful situation. A common response to extreme nerves is to vomit or have diarrhoea as the body tries to relieve itself of excess weight in order to make escape or defence easier. Is it simply that lower levels of stress cause the same symptoms in people with IBS? I don’t believe this is the whole story as there are times when I am under no stress or pressure and I experience a bad IBS day. I’ve read a recommendation that alongside a food diary people who experience IBS symptoms should keep a stress diary. This sounds completely ridiculous to me. Analysing each minute how stressed you are feeling seems to me like a perfect way to increase stress.

I’ve written before about my experience with doctors in diagnosing the reason for my stomach pain and vomiting. I was given four different diagnoses before IBS was mentioned: Crohn’s disease, umbilical hernia, gallstones and pancreatitis. All of these are very serious conditions in most cases requiring abdominal surgery. Being told you have even one of these conditions is stressful especially when I first went to the GP I was expecting to be given a dose antibiotics and that would be that. As each condition was ruled out (chronic pancreatitis has not yet been entirely ruled out although at the moment there are no indicators that there is any disease my blood is regularly checked to ensure no signs of disease appear) I would increasingly get the impression from doctors that I was making it all up or it was all psychosomatic. This impression in fact could have been imagined but it was difficult not to feel patronised. So if IBS is stress related and getting treatment for it is stressful what do we do?

My approach is to maintain a positive mental attitude (PMA). This sounds new agey and pretentious but in general we tend to get ‘stressed’ about so many things that really shouldn’t. Just because a doctor gives the worst case scenario does not mean that it will turn out that way.

Stress makes bowel conditions worse, this is undeniable but is it a cause? Maybe. The only thing we can do is try to remain calm in the face of a hysterical world and listen to our body. I’ve said it before and I’ll say it again everyone is different, your symptoms are unique to you and if something works then go for it. Forcing yourself into a particular diet you hate or an exercise regime you can’t keep up with because you read somewhere it’s a cure for IBS will inevitably increase your stress. Balance is key, balance between symptoms, medicines, exercise and food to find a way of life you are happy with and can thrive.

Controlling IBS with diet changes

When you type IBS into a search engine there are thousands of sites listed and most, if not all, say “here are the facts about IBS” and go on to list a whole load of foods you ‘should’ eat and ‘shouldn’t’ eat. To my knowledge there has been no study which has found an exclusionary diet that benefits a statistically significant proportion of people with symptoms of IBS. Every person is different. IBS is a label used to group together people with bowel complaints of no known cause, if there was one simple cure it wouldn’t be such big business! So here I’m going to write about some of the changes I’ve made to my diet that I’ve found to help my symptoms and hopefully you’ll get some ideas of things you can try for yourself. I’m not making up some kind of IBS diet book – there are thousands out there already to choose from – there are no rules (at the moment) just whatever works for you.

I’ve found caffeine, citrus fruits, dried fruits and very cold food or drink all make me nauseous and wholemeal foods trigger diarrhoea so I avoid them completely. Alcohol and dairy can trigger both nausea and diarrhoea so I avoid them almost completely – a splash of milk (skimmed or non-fat) in my tea (decaf) or a glug of wine in cooking is fine. Fat is the trigger of my worst symptoms of severe night time stomach pain, vomiting and diarrhoea, however cutting fat from your diet is a very difficult thing to achieve. In the beginning, it took a long time of trial and error to discover exactly what foods had too much fat for me to tolerate. As a rule of thumb now I will eat a food only if it contains less than 1g of fat per serving. If I stick to this rule then I get to eat a reasonable amount of food in a day. Importantly this way I don’t have to stress over food diaries to monitor how much fat I’ve eaten so far in a day, though it does lead to a lot of label checking in the supermarket. In many ways I eat very much like I always have except without the junk food that I should have done without anyway!

Cooking without oil isn’t as hard as you might think. I use a splash of wine in the pan with the onions or leeks (I often use leeks as a substitute where you would usually use onions as I can be sensitive to them but not enough to cut them out completely). They may not crisp up as they would with oil but a lot of recipes call for softened onions and they taste delicious. This can then be a base for soups, bolognaise, risotto even curry. I don’t miss cooking with oil at all! I do miss the obvious things like chocolate, but my favourite cheat there is CocoPops! They are admittedly quite high in sugar so I try not to eat a huge amount but are very low in fat so they are my breakfast of choice, without milk – but I prefer the crunch anyway.

The food I miss the most is cake so to finish this post I thought I’d let you in on my secret fat and dairy free cake recipe (not so secret now): Spiced Fruity Tea Cake

My Experience with Irritable Bowel Syndrome (IBS)

This month is IBS Awareness month and because of this so I have been inspired to write about my experiences.

I was first diagnosed with Irritable Bowel Syndrome (IBS) when I was about 11. IBS is a condition where erratic bowel spasms cause many different gastrointestinal symptoms. My particular brand of IBS is known as IBS-D as my main symptom was diarrhoea, along with painful bowel spasms. Stress is definitely a trigger, but I also just had good days and bad days that seemed to me to be unrelated to stress and became just one of those things I dealt with in life. Diet changes and medicines didn’t really seem to make much difference in any significant way. In December 2009 (aged 31) I woke in the night with severe stomach pain and the most awful sulphurous (eggy) burps followed by vomiting and diarrhoea. This persisted for a few days then went away so I dismissed it as a stomach bug. Then at Christmas I experienced the same symptoms again, then a month later again, then two weeks later and so on and so on. Various visits to doctors, referrals and scans later I got no help, advice or support just doctors with concerned expressions suggesting another scan they could try. Meanwhile I just kept losing weight and was getting desperate so I turned to the Internet for help. I found out, unhelpfully, that my symptoms matched several conditions which is what you get when you search medical conditions on the Internet! Though I came away with the novel concept of fat intolerance – something I’d never heard of before. I immediately became more aware of the fat content of what little food I was able to eat and cut it down as much as possible. I found I didn’t get the night time pain and vomiting though the daily diarrhoea, stomach cramps, bloating and discomfort were persisting so my weight was still dropping – although more gradually. Finally after all scans showed no abnormality or disease a doctor suggested that all of my symptoms may be a part of IBS. This at first seemed ridiculous to me, but I have since read this:

“The erratic intestinal spasms associated with irritable bowel syndrome, or IBS, may delay the emptying of food from your stomach (sometimes known as gastric stasis or gastroparesis). In gastroparesis, food sits undigested in the stomach for extended periods of time rather than passing directly into the small intestine. Increased random movement in the small intestine after eating may cause the stomach to empty too slowly. This interruption in the normal passage of food and fluids from your stomach may result in upper abdominal pain, heartburn, nausea, vomiting or an abnormal sense of fullness after having eaten only a small amount. The intestinal spasms that contribute to gastroparesis may also cause diarrhoea, nausea, abdominal cramps and bloating in some people who suffer from IBS.

Changes in your diet may help you manage gastroparesis and control the altered digestion and bowel patterns associated with IBS. Eating six small meals each day rather than three large meals may help food pass more easily through your stomach. By avoiding fatty foods, which slow digestion, and high-fibre foods, which are more difficult for the stomach to process, you may digest foods more efficiently.“

I found when I searched online for anything to help that there are so many people out there with the same symptoms I have. For as many people feeling these symptoms there are as many different diagnoses. The human gastrointestinal system is as individual as a fingerprint, hugely complicated and poorly understood. So until medical science catches up with IBS I take daily medication (anything between 1-10 tablets a day) exercise regularly and carefully control my diet to minimise my symptoms. My intention with this blog is share my experiences, fat free recipes, exercise ideas and anything I’ve found over the years that helps my symptoms with the hope that it’ll help someone else too.