Laura Schoenfeld: OK, so that’s kind of a two-fold question. Again, that does kind of go along with what we just talked about as far as what kinds of foods you can start reintroducing if you want to be doing a bacteria-feeding diet during any sort of SIBO treatment or if you just want to get people off a really restricted diet. Usually what I like to do is start with the low-FODMAP carbs that do contain resistant starch. A lot of my clients that are very low carb to control SIBO symptoms or IBS symptoms, I like to try adding things like white rice or white potatoes or plantains, something that’s not high FODMAP that we can start with, because a lot of times carbs on their own are not the issue for these people. It’s more the FODMAP-containing carbohydrates like sweet potato or squash or wheat products, those kinds of things that have a lot of FODMAP content in them. Those are the carbs that they don’t do well with.
Now, I don’t usually go from a zero-carb diet to a higher, moderate-carb diet immediately. I like to try to bring things in slowly, maybe start with a quarter-cup to a half-cup portion at each meal while they’re trying to reintroduce things, like I said, starting with the ones that are low-FODMAP, and then if they tolerate those, you can experiment a little bit with the higher FODMAP starches likes sweet potato or squash. One that I’ve see do really well with a lot of people is buckwheat, which is not technically a grain. It’s actually a fruit, and I believe buckwheat is low FODMAP. For whatever reason, buckwheat seems to be super-well tolerated by my clients, even the ones that don’t tolerate things like rice or potatoes in large quantities. That’s a great one to start with if somebody is afraid about moving into more of a carb intake. Then there are some fruits that are lower FODMAP that you can try reintroducing. Maybe do some berries. Maybe do a little bit of banana, green banana. You don’t want to do a whole banana at once, but maybe do a quarter of a banana at a time to see how they tolerate that. A lot of times people don’t tolerate an immediate shift super-well just because of the changes in your gut flora that happen when you change your diet from a very-low-carb diet to even a lower carb, but still carb-containing diet. So do remind them that there could potentially be some gut issues. Usually there will be some gut discomfort or gut changes. Maybe their stool frequency will change. Maybe they’ll have a day or two where they’re having loose stools. You don’t want to be seeing really bad diarrhea or anything like that, but a little bit of loose stools or a little bit of constipation when you’re making these changes is totally normal.
OK, so that’s the first part of the question, how to start doing just specific types of carbs for these clients because, again, the low-FODMAP carbs tend to be a better tolerated carb to add in for people that have SIBO or IBS.
Now, the second part that actually is far more complicated, in my opinion, is the psychosomatic and the kind of disordered eating side of things because I work with a lot of clients that are afraid to add foods back in because of really bad experiences with the foods. Maybe they got really sick or they have a really bad reaction to a food in the past and they’re afraid to try it again. That’s almost like a post-traumatic stress disorder kind of situation where the person really is afraid of eating that food again because they had such a bad reaction to it.
I’ve also worked with clients with severe gut issues that did have some level of body image dysmorphia, so they were restricting carbohydrates both for the gut reasons—they had gut symptoms, so they were trying to avoid having those symptoms—but then there was also a layer of eating disorder, like anorexia nervosa, in the restrictions. Some of those clients will feel like if they’re adding carbs back in, they’re going to gain weight. They get bloated. They really feel like, oh, I’m so fat today because I ate carbs. I see it pretty frequently, and I don’t know if that’s just because I market to people with disordered eating tendencies, but I see a lot of clients that have been on long-term restricted diets to deal with IBS and SIBO that also have a concurrent eating disorder, whether or not it’s been diagnosed. There’s a lot of functional gut disorders are connected with eating disorders. Now, whether or not the gut disorder comes first and then the eating disorder develops or if they had the eating disorder and then that caused the gut disorder because of maybe some bingeing-and-restricting cycling that they were going through. That can be a real barrier to people reintroducing carbohydrates into their diet if they’re dealing with SIBO or IBS.
I can’t necessarily give you a ton of guidelines on how to deal with that kind of client because you really need to take a team approach and make sure they’re seeing a psychologist or a psychiatrist and that they have a primary care physician that they’re working with and really addressing the reason that they’re afraid to reintroduce a food. Is it because they’re afraid they’re going to have symptoms? Or are they afraid they’re going to get fat if they eat those foods? Are there any sorts of body image or disordered eating tendencies that are coming up? Or is it simply just that they’ve had so many bad experiences with eating foods that they’re afraid to add the food back in? A lot of my clients that are in this situation, it takes a lot of counseling. This is where the counseling side of things is really important and really just trying to make sure people don’t have fear around the food that they’re eating, because if they are afraid while they’re eating the food, that can definitely affect their digestion. It can cause some psychosomatic symptoms. It can cause a placebo effect where they end up getting gut issues because they were afraid, not because the food did anything, but because they had so many emotions around eating that food.
It’s really, really complicated, and again, it really depends on if the person is simply nervous because of the gut symptoms they’ve had in the past from eating those foods or if they’re actually getting into eating disorder territory. You’re going to have to approach those two differently. I’ve had a client that had severe aversion to carbs, but it was just because she had had such bad bloating and such bad gut reactions that she was just afraid that she was going to do more damage. And then I’ve had, on the other end of the spectrum, clients that said they didn’t want to be having gut symptoms, but then when we really got deep into it, they actually just didn’t want to gain weight and they wanted to stay at their low weight because that was a way for them to control their appearance. It was scary for them to think about possibly gaining weight by adding carbs back in. So try to dig into the reason they’re afraid, and once you realize why they’re afraid, then you can approach treating them with either counseling methods or sticking to certain types of carbs that are going to be less problematic with the symptoms.