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

Welcome to The Perfect Stool: Understanding and Healing the Gut Microbiome. This is your host, Lindsey Parsons, and today in this podcast sponsored by Casa de Sante, I will be speaking with Onyekpe Adegbola, MD, who goes by Onyx, who is the founder of Casa de Sante, a virtual gut health clinic that provides low FODMAP coaching and products and comprehensive gut healthcare plans to patients online. As a lifestyle medicine physician with a passion for helping others improve their health and well-being, she has a deep understanding of the role that lifestyle factors play in managing IBS, or irritable bowel syndrome, and other chronic conditions. Casa de Santa takes a holistic approach to IBS care, which is why their team includes not just medical professionals but also registered dietitians and health coaches. But before our conversation, if you haven't yet followed or subscribed to the show, be sure to do so. If you want to get transcripts of the podcast, pop over to my website, HighDesertHealthCoaching.com, and sign up for my newsletter. You'll also get free ebooklet, Finding Your Root Cause Through Stool and Organic Acids Testing, when you sign up. And if you haven't yet done my quiz on which stool test would help you get to your root cause, you can find a link in the show notes and take that. Now on to the show. Welcome to the podcast, Onyx. Hi.

Hi. Thanks for having me here. It's a, it's a real pleasure.

Yeah. I'm glad you could come on. So let's start by just the basics about what IBS is and what causes it.

Sure, sure. IBS is a functional gut disorder. Cause of IBS is not exactly known, but it's thought to be a function of the disturbance in the sensation of the 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, 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, the other things have to be excluded as well.

Like inflammatory bowel disease and—

Exactly. Exactly.

Right. Okay.

Colon cancer, things like that. Yeah.

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

Yeah. So it's been shown that a lot of people with SIBO have IBS-like symptoms as well. The SIBO is is overgrowth of bacteria in the small intestine that can occur in certain conditions or following surgery in some people. And, and so, so 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. Okay.

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

Yeah, so the low FODMAP diet is a diet whereby you decrease the amount of fermentable carbohydrates in your 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 you get when you're making beer or bread, for example. So you're going to get a whole bunch of gas and that's going to cause, cause symptoms like abdominal pain and constipation, diarrhea, and bloating when it draws in, when you draw in 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 amount of IBS symptoms. A lot of studies have shown that about, I would say, 75, 70 to 75% of people with IBS get symptom relief from the low FODMAP diet.

And what kinds of foods are FODMAPs?

Yeah, that's an interesting question. It's, 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 to do, or even something that is lactose-free, right? You just remove milk and dairy products. So, so there's a wide range of foods that are FODMAP, and I would urge anybody who is trying this diet to not wing it for sure and use the Monash app to go through, uh, to find the levels of FODMAPs in various foods. So Monash and FODMAP Friendly are the two organizations that test for the amount of FODMAPs in food and tell you what serving is okay on the low FODMAP diet. Because for a lot of foods, there is, even though there 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, even if it's quote unquote low FODMAP or moderate FODMAP food.

Yeah.

But basically, if you want to do like a simplified diet in a very simplified manner, you would say that things like dairy, for example, lactose, things that have lactose are high FODMAP. Foods that have onion, onion and garlic is high FODMAP because just even a little bit of that is 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, I don't have IBS, but I react to inulin. And so that's something that a lot of people with IBS react to. Sweeteners ending in -ol, all.

Yeah, all the sugar alcohols.

Exactly, sugar alcohols. They are high FODMAP, even though the simplest sugar alcohol, which is erythritol, can be low FODMAP, but it still causes, it's still been shown to cause symptoms on its own. So I would definitely avoid it as well. And so, and then you also have beans, which I guess nobody's surprised about, high FODMAP, fruits like apples. Apples and which have high fructose content are high FODMAP. There's a long list of things, 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 fruits, they have problems. A lot of fruits, you have diarrhea sometimes. So I think people, some people would know that as well.

So yeah, onion and garlic are definitely the hardest ones to eliminate because they're kind of in everything, even, and then the powders as well, which salad dressing, it's, it's hard to, I think I, what I was doing doing that low FODMAP diet, I went outside, I would take my own salad dressing with me to restaurants because otherwise it was just oil and vinegar, which is kind of boring.

Yeah, exactly, because it's everywhere. It's really easy. I mean, even when you're not told that onion and garlic is there, it could be there.

I mean, right, it's the base of every recipe, practically.

Exactly, right, right, right. And that's actually why we— one of the reasons why we started off with the low FODMAP seasonings, because with WOW seasonings, don't have any onion or garlic. So, so for people on the low FODMAP diet, that's, that's That's very, very useful. But, you know, we have people like, I mean, why would he have a seasonings that have no onion or garlic? That's strange, right?

So you sell those seasonings?

Yeah, we do.

Oh, okay, cool.

Low FODMAP certified. Yeah.

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

Yeah, sure, sure. So the process, uh, it generally takes about 6 to 8 weeks to go through the low FODMAP diet, and there are 3 stages. So in the first stage, you would eliminate FODMAPs from your diet. So that's where apps like the Monash app and the FODMAP-friendly app, you know, can be very useful because they help, they help to tell you what serving size is normal. And I think that that's a low FODMAP and normal for you in that situation. But so I think that for a lot of people, those are, that's the most 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 then even if you, but you, people should understand, like, you know, even if you make a mistake or something goes wrong during that, during that time, you can always start again. You shouldn't be down on yourself. So, so you start off with that. That part of the diet usually takes 6 to 8 weeks. And then once you, 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 out of all these fermentable carbohydrates out of my diet. Which one is causing my problem. So let's use a sort of a reverse elimination process to figure it out. So you'll test each FODMAP group one by one over a couple of weeks or so. There's a lot of resources. We have some resources to help you, free resources to help you through the part of that, that part of the diet, which is called reintroduction and which can be tricky for some people. Monash also has some resources on their app to help you go through that. And then once you figure out, okay, Okay, well, this is what I'm reacting to in the diet, whether it's fructose or oligosaccharides or monosaccharides 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, which you can follow every day with and get rid of IBS symptoms. So that's pretty much, pretty much it. And the whole process, you know, probably takes a couple of months and if you have a dietitian 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, and while it might not work for 25% of people, you wanna make sure that it's not working for you because you're not, because it's actually not working for you, not because you're not doing it properly.

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?

Yeah, absolutely. And that's why it's, it's meant to be a short-term diet, even though unfortunately some people find 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 probiotic can help with modulating the levels of Bifidobacterium from the low FODMAP diet. But then there are other changes with the microbiome that 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 deficiencies over the long term, nutrition 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 your problem is, you can move on to a more normal diet.

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

Yeah, once you figure out your sensitivities, I would, I would advise people to just figure that out as their base diet, yeah.

Okay. And can you discuss the other treatment options for IBS besides the low FODMAP diet? I assume you use some adjuncts to that.

Yeah. So there's definitely medications, good adjunct to the low FODMAP diet for people who respond to them. So you're talking about medications like Linzess, Imodium, 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 having, I'm not depressed. And so this is not really useful for me, but they're actually working on the gut and not, this has nothing to do with depression. So they can be useful for people with IBS. And also things like yoga, exercise, and mind-body meditation. And even so, some people, hypnosis can be helpful. Cognitive behavioral therapy can also be helpful. And so what is very useful is for you to find out the combination of things that work for you. Personalized, you could call that personalized medicine because everybody's different with IBS, as I guess a lot of people with IBS know, because if you are ever in an IBS forum and people talking about their triggers, but there's such a wide range of triggers. If 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, 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.

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, or, or IBS, I should say?

So, yeah, so it's, it's more used in different forms of IBS. And so it, it acts on the gut. It helps with pain, for example, people who have abdominal pain, uh, in IBS.

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

Uh, for patients with SIBO. Yeah, rifaximin is definitely helpful. So expensive in the US and not always covered with insurance.

Yeah.

Yeah. But helpful. Sometimes you can use it. Also metronidazole flagyl, which is metronidazole, can also be used because, and it's cheaper than rifaximin. So that can also be used for patients who can't get, who find the cost of rifaximin too expensive or Who can get it from Canada, some people get it from Canada where it's cheaper, but, um, can definitely be used for SIBO.

Okay.

And then also for SIBO, people have also looked at antibiotics, herbal antibiotics like oregano and, and whatnot, and shown that it can be effective as well.

Mm-hmm. So what kind of testing do you do to determine what patients have?

So you, IBS is mostly, it's 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 a 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 and with age and whatnot, you might have to do some testing just to rule out celiac disease, rule out IBD, rule out colon cancer as well.

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

Yeah. Yes. Yes. In that case, yes, we would. Although we do prefer patients who have symptoms their gastroenterologist already, because we don't, we're not a gastroenterologist, we're not aiming to be their primary care or their gastroenterologist. We're more an extension, a help, because people with IBS often have, you have all those symptoms and it takes time to, and trial and error to resolve them. And so they don't, the time that they spend at the doctor's of 15 minutes or 20 minutes in a typical appointment is just not enough, which is often rushed for them. And also So 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, nobody will— they can't get anybody to talk to them. We're that stopgap where you have somebody you can always talk to. You can always— and 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. Give you a shorthand out with two sentences and with So we go in depth and really help you to get a hold of your IBS symptoms and take them, take control of your symptoms with personalized plans.

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

Yeah, sure, 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 with the, people on the low FODMAP diet or with some food intolerances have the confidence that they're, what they're eating is not going to give them problems later on.

Is that under the name Casa de Sante?

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 or customers and we, We got a lot of inquiries. Well, we try to help them even though we always have 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. Cause a lot of people are just going to Facebook groups at this point and, you know, asking questions from people who, it's always good to get information from your peers and learn from people's experiences. I think that can be very useful, but it's also helpful to get, and it might also sometimes be more helpful to get help that could help you in the long term rather than just ad hoc recommendations as you have problems. So, so we started this service as a personalized, virtual personalized service that is integrative care. So you have not just a doctor or a clinician, a GI clinician, you have a GI clinician that is specialized in IBS as well as a dietitian who is specialized in IBS as, and a health coach to help you resolve your, your IBS problems. So we have a whole, we have a holistic and personalized approach. And you 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're having issues with IBS. So we offer a whole approach, which is both the consultation and the visits with the clinicians, and also low FODMAP products if someone needs it.

Okay. And 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 have difficulty following the low FODMAP diet just because it's, can be so, it can be very restrictive. Actually, it is very restrictive. So, and 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, to be exact, right? So, so it can be challenging from that perspective. And so for people who have, who can't, or 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, which I just want to mention that wheat is a FODMAP and 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, those type of gluten-containing grains. And so you could 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 FODMAP or low FODMAP diet. And so we tailor it to our patients based on what they can do. To 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 benefits from the low FODMAP diet, even with IBS. Yeah.

So if the low FODMAP diet doesn't help What are the likely causes of, say, bloating and gas is one of the big symptoms.

Yes. Trying an elimination diet could be helpful because even if you don't react to FODMAPs, you could react to other foods. So definitely having a dairy and doing an elimination diet will be a good first step. And then for bloating, now bloating is a whole interesting subject by itself, but you want kind of start off by saying, okay, well, when is the patient bloating? When is the client bloating? How soon after eating does the client bloat? And then you can, you can then sort of divide up what the possible causes are. And there's a wide range of causes depending on when the bloating occurs, how soon after eating, and also understanding what is— 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 a 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 testing. In for the testing to figure out what is going on. I recommend some general approaches that would help anybody that has bloating, such as, you know, don't drink some— don't drink heavily carbonated 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.

Are you using like the functional medicine stool tests?

Yeah, we use different various depending on what the patient's symptoms and history is. So.

Which test do you like?

I, yeah, so that's, I wouldn't say we like a particular test. It just, it's very, again, we go through this very personalized approach. It really depends on what the patient's history is. And I, you know, various practitioners do have their favorite tests. We have a few practitioners, there are a few practitioners in our practice, different practitioners, and they do have their favorite tests. We try to individualize it for each patient. Patient.

Yeah. There's a little, little different offering on each test of what's included.

Yeah, exactly.

So this is true. Okay. So can you talk a little bit about the research on the effectiveness of the low FODMAPs diet for IBS?

Yeah. So research has shown that it is effective in about 70 to 75% of patients with IBS. Uh, general, generally the, the FODMAP gentle approach has also been found to have high effectiveness. So 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, has also been shown to be helpful. So just eliminating wheat and milk 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 fairly effective for many people with IBS, but not all. Mm-hmm.

And so you, we talked a little bit about the low FODMAP diet and the impact on the gut microbiome, but what can you, I don't know if you wanna elaborate anymore on what else it does to the gut microbiome, but what steps can you take to ensure that you still have a healthy microbiome?

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

Like lactobifidotype probiotics?

Yeah. Biofido, biofido, Biotics as well, Lactobacilli, yeah, that, those are also helpful. We, 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, is low FODMAP certified.

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

I can't think of any particular strains that you avoid. The thing is that so many studies, different studies on probiotics that have different varying results. So the data on probiotics is not always very clear. So oftentimes you need more studies. And so that's why the type of probiotic and 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 it's making your symptoms worse, symptoms worse, then you stop it. But probiotics are also very individual as well.

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

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

It's always tricky to decide whether or not to recommend them.

Yeah, exactly. The data is definitely conflicting with probiotics. And so if you could, again, it's, you try it. I just recommend people who want to try, they try a shot trial and see if it works for them or not.

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

Diet? 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 sort of avoid high FODMAP foods and supplements. And so there was a study that came out recently, maybe a year or so, over a year ago now, that showed that a lot of people just did not realize that, and which a lot of people did not realize is that a lot of medications and supplements have things gluten, they have lactose, and they could actually be a source of problems for people who are trying, who have food intolerances or allergies. In general, there's probably a little, 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 your supplements. They could, they could possibly have FODMAPs in them and they could be the source of your symptoms. Symptoms. I think I remember someone having inulin, for example, 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.

And it's also a big additive to like, exactly, those bars.

Yeah, exactly.

The commercial ones because it's a lot of added fiber at low cost, I guess.

Yep, exactly. Exactly. So I would, I, using a low FODMAP certified product, low FODMAP brand is probably probably the way to go at the, while you're in the elimination phase of the low FODMAP diet.

Yeah, no, I sometimes see now a brand in stores too called FODi. Yeah.

Yeah.

Yeah.

Yeah. They have a number of low FODMAP products as well.

Okay. Well, we'll share all those links in the show notes. So tell people where they can find you and I'll also include all the links in the show notes.

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

Okay. And any final thoughts before we finish up?

Well, I just want to, you know, thank you for having me here. Happy, 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, I guess.

Okay, great. Well, thank you so much.

Thank you.

Onyx gave me lots of resources for the show notes, like links to low FODMAP recipes and a video course and a link to a free discovery session. So do check that out. And of course, if you're struggling with any type of gut health issue, you can set up a free 30-minute breakthrough session with me from a link in the show notes. And if you'd like to connect with me online, you can follow my High Desert Health Facebook page, join my Gut Healing Facebook group, or join my newsletter list at highdeserthealthcoaching.com, as well as Twitter, Instagram, and Pinterest. Links for all those are in the show notes. Thanks for joining me today, and here's wishing you all the perfect stool.