Food intolerances and allergies are becoming a more common and complex trend in clinical practice. Unfortunately for many patients, the only solution is a restrictive diet. While avoiding dietary triggers can offer relief, an overly restrictive diet can produce further complications to digestive health long-term. Many of the commonly eliminated foods in these kinds of diets are important to maintain healthy diversity of the gut microbiome.¹ Therefore, long term dietary restrictions can end up worsening gut health for the patient. Elimination should only be the first step to a broader treatment for food allergies, and this case demonstrates the benefits of gradually improving gut health to reduce symptoms and increase tolerance.

Initial presentation and case history

A 42-year-old female presented with multiple food intolerances which were producing marked digestive symptoms of chronic bloating, digestive cramps and constipation. 4 years earlier she had contracted gastroenteritis after a social function, for which she received antibiotics. A month later she had another episode of gastroenteritis and a subsequent course of antibiotics. Following the second round of antibiotics, she started experiencing symptoms of bloating and loose stools which continued for several months and gradually worsened, and she begun to experience cramping after eating.

Over the course of the next year, symptoms continued to increase in severity and loose stools shifted to constipation. Her GP diagnosed IBS and prescribed the FODMAP diet. Introduction of the diet produced significant symptomatic relief of digestive symptoms initially and garlic, onion, apples, wheat and dairy were identified as highly reactive foods and were eliminated from the diet.

Despite mostly adhering to the FODMAP diet over the following year, symptoms re-emerged and worsened. Likewise, more foods were triggering digestive symptoms and it was becoming difficult to identify associated foods.   

Upon initial presentation to the clinic, symptoms were: severe bloating, cramping, constipation (incomplete bowel movement every 3-5 days), flatulence and fatigue (Figure 1). Likewise, the unpredictability and severity of symptoms was now causing anxiety around eating out and she was finding it all very stressful.

Treatment aims

• Identify and remove dietary triggers.
• Reduce gastric inflammation and mediate allergic response.
• Facilitate regular bowel movements.
• Gentle digestive enzymatic support.

Prescription

• Elimination stage of FODMAP diet.
• Probiotic to reduce intestinal inflammation, containing Bifidobacterium bifidum W23, Bifidobacterium lactis W51, Lactobacillus acidophilus W37, Lactobacillus brevis
  • Dose: 1 sachet daily.
• Liquid herbal formula containing; Baical skullcap (Scutellaria baicalensis), Chamomile (Matricaria chamomilla), Lemon balm (Melissa officinalis), Marshmallow (Althaea officinalis), Licorice (Glycyrrhiza glabra), Cramp bark (Viburnum opulus), Gentian (Gentiana lutea) and Ginger (Zingiber officinale).
  • Dose: 5 mls TDS.
• Herbal tablet formulation; Cascara (Frangula purshiana), Yellow dock (Rumex crispus), Dandelion root (Taraxacum officinale).
  • Dose: 2 tablets before bed.
• Slippery elm (Ulmus rubra)
  • Dose 2 capsules BD.

Follow up (2 weeks)

Symptoms improved markedly with significant reduction in bloating, cramping and constipation (Figure 1). Bowel movements were easier and she was experiencing complete evacuation on some days.  There was only a slight improvement in fatigue

Prescription

• Moved to reintroduction phase of FODMAP diet. Started with reintroduction of polyols as deemed the least likely reactive group.
• Remained on liquid herbal formula, herbal laxative formulation, slippery elm powder and probiotic at the same dosing.

Follow up (6 weeks)

After challenging reintroduction of foods from each group of FODMAPs, it was found that polyols were well tolerated and small amounts of galactans and fructose could be handled without producing symptoms. Bloating and mild cramping was induced after trialling fructans and lactose, however these resolved after 3 or 4 days, when previously it would have taken at least a week and symptoms would have been far more severe. Bowels were now moving daily with full evacuation, despite having run out of the herbal laxative formula a week earlier. She had experienced a mark improvement in fatigue in the past 2 weeks and even family had noticed her increased energy levels.

Now that the patient’s symptoms had been largely resolved, it was time for the second part of the treatment. This involved addressing the microbial disturbance and suspected small intestinal bacterial overgrowth (SIBO), and correcting digestive function of enzyme secretion and migratory motor complex to restore microbiome and gut health. While the patient could have started this phase of treatment at this point, it was decided to take another 4 weeks supporting gut healing and to allow the patient to enjoy reduced symptoms before beginning antimicrobial treatment.

Prescription

• Advised to continue new broader diet with the inclusion of recently established ‘safe’ foods.
• Slippery elm powder was swapped to a formula for supporting gut healing containing; glutamine, Acacia, Licorice (Glycyrrhiza glabra), zinc carnosine.
  • Dose: 2 teaspoons BD.
• Liquid herbal formula and probiotic continued at same dosing.

Follow up (10 weeks)

Symptoms continued to improve to the point that she was noticing increased tolerance to reactive foods. Despite accidentally eating pasta sauce containing garlic at a restaurant, it only produced moderate bloating which resolved the next day. Previously this would have caused marked cramping, pain and bloating for several days. Bowel movements were consistently regular and easy, and energy levels remained high.  

Prescription

• Liquid formula was changed to a herbal digestive support formula containing; Mandarin peel (Citrus reticulata), Gentian (Gentiana lutea), Ginger (Zingiber officinale), Wormwood (Artemisia absinthium).
  • Dose: 1 tablet TDS.
• Garlic (Allium sativum)
  • Dose: 1 tablet twice daily.
• Herbal antimicrobial tablet containing; Phellodendron (Phellodendron amurense), Andrographis (Andrographis paniculata), Anise oil (Pimpinella anisum).
  • Dose: Start at 1 capsule daily, increase by 1 capsule every 3 days.

Follow up (14 weeks)

Could only tolerate 2 capsules a day of herbal antimicrobial formulation, as higher doses produced cramping pain. Borborygmus had appeared in the past 2 weeks but it “felt as if digestion was functioning better” and improvements in appetite were noticeable. Stools had become easier to pass and were consistently achieving full evacuation.

Prescription

• Maintain herbal digestive support at same dose.
• Continue with gut healing powder.
  • Dose: Reduced dose to 2 teaspoons daily.
• Slowly try to reintroduce small amounts of known reactive foods.

Follow up (18 weeks)

All symptoms remained low or completely resolved. She was now able to eat small, infrequent amounts of previously reactive foods. So long as they were not eaten consistently or in high amounts, she was able to include these foods as ‘treats’. Furthermore, she no longer had to be concerned when eating out as she knew she was far less reactive, which had a marked improvement on her quality of life.

Avoidance is not the answer

Chronic adherence to restrictive diets has been shown to deplete keystone species in the microbiome and negatively impact digestive health.1 While such diets are beneficial to produce therapeutic gains in the short-term, they should be viewed as acute interventions and not lifelong diets. Unfortunately, many patients do not understand this and persist with such diets for too long, which negatively affects microbiome health and gut function.  When treatments for food intolerance move beyond avoidance and address the underlying functional disturbance within the gut (specifically enzymatic insufficiency, intestinal mucosa inflammation, gut microbial imbalance and immune regulation), long-term improvements can be seen.

Figure 1: Symptom scores throughout treatment.

References

1) Haskey N, Gibson DL. An Examination of Diet for the Maintenance of Remission in Inflammatory Bowel Disease. Nutrients. 2017 Mar 10;9(3).