#023 Gastroenterologist Dr. O’Brien Helps Her IBS Patients To Return To Their “True Self”

Dr. Miechelle O’Brien believes that a low FODMAP diet is currently the most successful way to help her patients who suffer from Irritable Bowel Syndrome.

In this week’s episode, I have the pleasure to interview Dr. Miechelle O’Brien, my first gastroenterologist guest. Dr O’Brien explains IBS and other GI issues while sharing her knowledge and passion with us. Also you can find out how she got the fantastic idea of creating the TrueSelf™ Foods products to help many IBS sufferers with convenient, yet healthy and delicious snack bars that won’t trigger their symptoms.

 In this episode, you’ll learn:

    • What is a gastroenterologist?
    • How important is to see a gastroenterologist for someone suffering from digestive issues?
    • What is the difference between syndrome, disorder and disease?
    • What does “brain in our gut” means?
    • What causes IBS?
    • How common is IBS around the world?
    • What is post-infectious IBS?
    • Are women more prone to IBS than men?
    • What is the best way to find out if you have IBS?
    • What is Rome IV criteria all about?
    • How is IBS different from IBD (Inflammatory Bowel Disease)?
    • How to treat IBS symptoms?
    • How Dr. O’Brien found out about the low FODMAP diet?
    • How knowledgeable are other GI specialists about the low FODMAP diet?
    • How Dr. O’Brien came up with the idea of creating low FODMAP food products?


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Can’t listen to this episode right now? Read the transcript below!

 LARAH: Hi and welcome to the low FODMAP diet and IBS podcast. My guest, Dr. Miechelle O’Brien, is a board-certified practicing gastroenterologist in the US with specialised expertise in functional gastrointestinal disorders such as Irritable Bowel Syndrome. Dr. O’Brien received her medical degree from New York Medical College and her PhD in pharmacology from the University of Pennsylvania.

Dr. O’Brien found treating her patients with functional gastrointestinal disorders very frustrating because of limited therapeutic options. She was excited to learn through research on how diet impacts symptoms and specifically how the foods which are high in fermentable sugar known as FODMAPs can trigger the symptoms associated with digestive discomfort.  The use of the low FODMAP diet proved to be a very powerful tool in Dr. O’Brien’s clinical practice, but this success also led to a new problem. The low FODMAP diet can be challenging because FODMAPs are present in so many foods and are used as ingredients in many processed foods. Dr. O’Brien kept waiting for food companies to develop products for these patients, but there weren’t any. The lack of convenient low FODMAP foods in the marketplace, inspired Dr. O’Brien to start TrueSelf™ Foods to make low FODMAP foods that are easy to incorporate into one’s diet. And we’ll be talking about those foods a little bit later on, but for now, I have the great pleasure of welcoming Dr. Miechelle O’Brien to my podcast.

LARAH: Hello Dr. O’Brien.

Dr. O’BRIEN: Hi Larah, thank you so much. This is so exciting. I’m honoured to be a guest on your podcast and I’m just really excited to have a fun discussion today about a subject that I’m very passionate about which is Irritable Bowel Syndrome and what we can do for our patients to help them feel better.

LARAH: Well the pleasure is all mine. You cannot imagine how privileged I feel to have a doctor here on the podcast. This is just incredible.  And you are, of course, my first doctor and my first gastroenterologist on the podcast so there are all these questions that I’m just dying to ask you. Maybe we’ll start with the very basic. What is a gastroenterologist and why people with IBS may be interested in seeing a gastroenterologist?

Dr. O’BRIEN: Well, a gastroenterologist is a physician who specialises in disorders of the gut, meaning the oesophagus, the stomach, the small intestine, the large intestine, the liver and the pancreas — basically our gut. So in order to become a gastroenterologist you go to medical school, then you do your internship and residency in internal medicine. So you’re a general doctor first, and then you go on to specialise to do a fellowship training to zero in on the organ systems that you’ve chosen. And I have to tell you, it’s been a tremendous amount of fun, this specialty, and it’s just so funny how life works. If you’d have told me when I was twenty-five years old that I would be a gastroenterologist, I probably would have laughed. But, you know, you just have to follow your interests, and here I am, and every day is a lot of fun. I learn so much from my patients and am so excited to do my work and to be there every day and to help make a difference for these people.

What puts somebody in my office? Typically, they’ve seen their general practitioner maybe a few times for their symptoms, for not feeling well. They may have tried a few things at their suggestion — either it’s not working or the general practitioner is worried that there’s something more going on that needs a little deeper digging, so they’ll send them my way. But to be honest, Larah, a lot of referrals, at least in my country, for gastroenterologists, are for Irritable Bowel Syndrome. It’s estimated that about twenty-five to fifty percent of all referrals to see a gastroenterologist are for Irritable Bowel Syndrome. So it’s very prevalent, obviously, and it’s a big part of who we see.

LARAH: Yeah, thank you, Dr. O’ Brien. It’s very interesting because when I had my diagnosis from my GP, he never referred me to a gastroenterologist. When he was satisfied that I did, indeed, suffer from IBS, he suggested I see a dietitian. But I do hear from a lot of other IBS sufferers that they have been asked to see a gastroenterologist instead, so I wonder why some doctors bypass that step.

Dr. O’BRIEN: Yeah, I think it’s just a matter of sort of a cultural thing. And in the States, really, we use our specialists maybe sooner, or in that way. And I will also say that in the States, we don’t really, at least in my experience, make really good, effective use of dietitians. I think they’re very underutilised, unfortunately.  And I think that a lot of good can come in, and it probably will ultimately save a lot of money for the health care dollar, if we did make better use of our dietitians, but that just seems to be the path that people follow in the States.

LARAH: Yes, understood, and I also agree that dietitians are not consulted as often as they should be. Sometimes we probably choose to go and just get some tablets for this or that rather than looking at our diet, which is, in a lot of cases, responsible for how we feel.

Dr. O’BRIEN: I think you’re absolutely right. I think people learn, or are sort of starting to realise that. I think people are ready to embrace that concept that what they eat affects how they feel — what they eat affects their health overall.  So I think we’re sort of in a unique time where people are open to these ideas.  I think all you have to do is look at the whole gluten-free movement and craze that’s been going on around the world and in the States to know that people are now really in tune to the fact that what they put in their mouth affects how they feel, and they want to be in better control of that.  And they also want to seek therapeutic options apart from pharmaceutical. People are more conscious about what they’re putting in their body, potential side effects, all sorts of things. So I applaud the efforts that they’re making now to more closely examine their diet and tying their symptoms to their health overall.  So it’s an exciting time, really, to be on the sidelines and watching medicine and how diet is really, really on the minds of our patients now.

LARAH: Yeah, thank you for that. Yes, I do agree with you. It’s an exciting time and knowledge is getting bigger and the word is spreading more and more, so that is great.  So I just wanted now to ask you all those IBS questions that I’ve always wanted to ask a doctor.

Dr. O’BRIEN:  Oh, I hope I know the answers, Larah.

LARAH: I’m sure you will. So, Irritable Bowel Syndrome is considered a syndrome. Could you explain what a syndrome is and also what the differences are between a syndrome, a disorder, and a disease?

Dr. O’BRIEN: Yes, sure. Let’s start with a disease. A disease is really a pathophysiologic response to an external or internal factors. It’s specific. Let’s take, for example, Parkinson’s disease. If you lose certain neurons in the brain then you develop Parkinson’s disease. We know the cause; we know the affects. A syndrome, on the other hand, really is not so precisely known. It’s, rather, a collection or set of signs or symptoms that characterise a syndrome, meaning we probably don’t know as much about what the underlying pathology is — what is actually going on. We don’t really know what the disease is, or what the disorder is in the normal function, but we see this set of symptoms that result, and they cluster. So, if you have abdominal pain; if you have nausea; if you have bloating; if you have discomfort; if you have altered bowel habits with constipation or diarrhea, these are all symptoms that, when they cluster together in that way, are the syndrome of Irritable Bowel Syndrome.

LARAH: All right. That was a great explanation and thank you for explaining it in such great detail. Hopefully it is clear for everyone listening. We also hear that our second brain is in our gut, and this may seem strange to those who have never heard this expression. It was strange to me as well. Could you explain what this means exactly,  and how this affects IBS symptoms?

Dr. O’BRIEN: Yeah, I think this is just absolutely fascinating. So, you know, listen, we have three nervous systems. We have our central nervous system which is our brain, our mind, our thoughts. We have our peripheral nervous system which is, “I think that I decide to move my arm, and my arm raises.” And then, we have this third nervous system, the enteric nervous system, and that’s the nervous system that regulates and controls action in the gut. And there are constant signals going back and forth at all times from our gut to our brain; from our brain to our gut; from gut to gut, and it’s always happening behind the scenes. We’re completely unaware of it. And to a large extent, the enteric nervous system governs motility which means how fast things move through us, or how slowly things move through us. And the gut is constantly sending signals: “Move faster, move slower,” especially in Irritable Bowel Syndrome. And this is mediated through a neurotransmitter cluster. And we know that when we intervene, or when we block certain neurotransmitters in the gut, we can influence the motility in the gut.  But we also know if we give certain drugs or pharmaceuticals that mimic a neurotransmitter, we will, thus, mimic the response and we might increase motility, or decrease motility or what have you. So it really is fascinating and we’re starting to learn more and more about this — to really drill down to those details of what exactly is going on in there.  There’s always more to learn, but our tools get better and better so we’re able to look at it more closely, and we do take advantage of this for our pharmaceuticals, especially for Irritable Bowel Syndrome, and exploit these features.

So it is a lot of fun. It’s exciting to watch new drugs emerge, and the mechanism of action, which gets me very excited, in case you can’t tell. I was, first and foremost, trained as a pharmacologist for my PhD which is drug mechanism of action — how drugs work. So I always find it very fascinating that we are able to target these molecules and the receptors that they get so precisely so as to have the influence that we can have. And that’s very exciting. But I will say this: the more we learn about this, I think the more we realise how much there is to learn about this, and we’re getting better and better. But I’m always in wonder of the amazing human body and how eloquent it is and how things are always such a delicate dance.

So the answer was the brain that is the gut. And every person knows this, and everyone realises intuitively that their gut has its own brain. Many of my patients will tell me that, “I’ve always had a nervous gut or a nervous belly, and any time I was growing up and I had an exam, or I was anxious or nervous, I had to run to the bathroom.” Well, the reason that happens is because when you’re nervous — when you’re amped up and you’re anxious and all those neurotransmitters are sort of firing — you feel it in your mind; you feel that anxiety. They’re also amped up and revved up in your body — in your periphery — and so they’re exerting an effect there as well. We all, I think, are aware of this brain in our gut even though we never really maybe took the time to think about it.

LARAH: Yes, and I think that a lot of people, especially in the past, that had the IBS symptoms and would have gone to some form of health professional — and maybe because the health professional could not pinpoint what it was, a lot of them might have been told “It’s all in your brain.”

Dr. O’BRIEN: Yeah, I hear that a lot from my patients that come in and they are so frustrated. They are so just exhausted and frustrated by their disease, and maybe by their experience in the health care system, and it’s always disheartening to have a patient tell me that they’re told that this is in their head. And when I do take the time —  which I almost always do, because it’s so very important for this person who’s sitting in front of me. When you take the time to say to them, “Listen, in the last five years we have learned so much more about this and we’re starting to learn now what is going on in the gut. We don’t have all the answers yet, but day-by-day we’re learning more and more. And we’re learning about how this is potentially an autoimmune disorder, or some dysfunction in the immune system or dysbiosis in the gut, in the microbiome. But this is not in your head!” And I think patients are so relieved to have a physician say to them, “This is not in my head,” because I refuse to believe that this is in the head of these patients. I think we, as physicians, have done a real disservice to our patients by saying that, and I think it’s always very healing for a patient to hear that, “No, this disorder is not in your head. You didn’t make it up; you didn’t dream it up, and this is actually something going on in your body.”  And I think that provides them great comfort, and now they’re ready to say, “All right, now I have a better understanding of what’s going on. How do we go about a remedy? How do we go about dealing with this, managing it?” And I think sometimes, just telling them what it is and why it is, even if you can’t necessarily offer them a great treatment, I think that is very reassuring and that goes a very long way, in my book, to helping patients cope with this.

LARAH: Thank you. That’s absolutely great what you said. I know that some of the guests I had on the podcast were actually prescribed antidepressants when they couldn’t find an answer for their symptoms. So I know that for some practitioners, there is still that tendency of thinking that. But, hopefully, the more the knowledge is spread and the more research is done, the more they’re going to find alternatives to those.

Dr. O’BRIEN: Yeah, absolutely. And it is true that a lot of our patients with Irritable Bowel Syndrome do have anxiety, but, to me, it’s the chicken and the egg. I don’t know what comes first. Are they anxious and then they develop Irritable Bowel Syndrome? I happen to think they probably have Irritable Bowel Syndrome, and because they have to memorise every gas station as they drive to work, or to their children’s school, and they have to plan their outings meticulously, and they have to worry, “Am I not going to feel well? Should I not go out with my friends tonight? Should I not go out out for dinner?”  I think that would make somebody very anxious. So, to me, it’s the chicken and the egg. What came first? Being sick all the time and then being anxious, or vice versa? I think that there is a component of anxiety, but I think it’s justifiable when you have a disorder like this.

LARAH: Yeah, and a lot of specialists that mentioned exactly the same thing as you said, “Which one came first…?” And they all seem to be thinking that, in the majority of the cases, it’s the fact that they have IBS that their stress increases, and that anxiety increases. Yeah, it’s an interesting topic. We could probably talk about that just for an hour, but…

Dr. O’BRIEN: Once a patient has better control and management over their symptoms, a lot of their anxiety just melts away. So that speaks to the disorder as a big player and a factor in the anxiety.

LARAH: Yes. So now I would like to talk percentage if you have an idea. In your studies, in your research, have you come across on how common IBS is in the world? Is there a difference in sufferers, as a percentage. in the western world compared to other parts of the world with a different diet? And is that, in fact, due to the diet or to the lifestyle, or to a combination of things?

Dr. O’BRIEN: Yeah, this is really interesting because it seems like there should be a difference in different regions owing to those factors that you’ve said. But to be honest, there really is not. There are some variances, but it’s actually pretty uniform from continent to continent, and it’s amasing. Studies basically show between five and fifteen or five and twenty percent, maybe an average of ten to fifteen percent incidence of Irritable Bowel Syndrome. And this is in the States, in North America, in Europe, in Australia, in Asia, in Africa. So it’s really striking that this disorder affects almost everybody equally. And same thing across socio economic lives as well. It’s not a disorder of the poor or the rich. It really spares nobody. It gets everybody about the same way, which is about fifteen percent of the population.

LARAH: Yeah, that’s very interesting because, not having read those studies, I would have thought that some populations… were not spared from it, but because of their diet and their different lifestyles, would not have as many sufferers as in places like Australia or the US or the Western world in general, and because of our diet as well.  So that’s very interesting that it is actually the same, pretty much, for everyone in the world.

Dr. O’BRIEN: It is interesting. It really is.

LARAH: So do we know what can cause IBS? We talked about how stress could be a cause or an effect, but could it be, as well, the diet that causes it? Or could it be that someone has taken too many, let’s say, antibiotics for a long period of time and that has interfered with their bacteria? Or maybe they suffer from some type of gastrointestinal infections?  Do we know at all what can cause it?

Dr. O’BRIEN: Well, we really are starting to learn more and more about this. Unfortunately, we don’t have all the answers yet, but we’re certainly getting closer. And one thing we’re learning is that much of IBS is rooted in an infectious illness at some point. So we know that if you have an acute gastroenteritis infection, a food poisoning event, that you have a much higher chance of developing Irritable Bowel Syndrome down the road — about ten percent for men and about twenty percent for women. Patients come in all the time and they tell me, “You know, I got this episode of food poisoning. I got better and then a few weeks later it’s like it happened all over again and diarrhea started again. I didn’t have the fever this time, or the vomiting, just diarrhea, and I just can’t seem to shake it.”

So that’s what we call a post-infectious Irritable Bowel Syndrome, and we think a lot of Irritable Bowel Syndrome comes from some kind of an infection. Now it may have happened early on in life, and I certainly have patients who say, “You know, listen, this has been my pattern since as far as I can remember, since I was a little kid.” And then other people can almost pinpoint when their symptoms began, and those are the folks who really, with the more recent memory of events, who will say, “Yes, you know, I did. I had an infection and I got better, and then symptoms just returned.” And they try to wait it out for a while thinking that it will get better. And a lot of times, and in time, it does get better, but, unfortunately, it can persist and turn into an Irritable Bowel Syndrome type of event.

So infection, certainly, is a big reason. The other thing is diet. Now I don’t think diet causes Irritable Bowel Syndrome, but I think we can certainly influence Irritable Bowel Syndrome with diet. We can certainly influence symptoms with diet, and I’m sure we’ll spend a lot of time talking about that. And likewise, with stress, I don’t think that stress causes Irritable Bowel Syndrome. But I think if you have Irritable Bowel Syndrome, stress certainly exacerbates your symptoms and it’s probably a trigger for symptoms, but I don’t think it’s absolutely the cause for Irritable Bowel Syndrome.

The other one you mentioned, antibiotics, is interesting. Now I can’t speak to any science or literature studies that have shown the effects are a causal relationship from antibiotics, but, also — this is sort of off the record in that way — but I will say that I have had a fair amount of patients who come in and tell me that they were on this antibiotic for a sinus infection, or some kind of a prolonged infection, or perhaps Lyme disease. I live in the northeast of the United States where Lyme disease is quite common, and the treatment for that is often a month-long antibiotic. And patients will tell me that prior to these treatments they had no issues with their bowel or with their gut, but following antibiotic exposure, they do. They say, “You know, since I took that antibiotic, I’ve just never been right. I’ve just never been the same.” With a lot of these patients, I think, in time, that resolves itself, but some of them need a lot of help along the way.

So could antibiotics be a cause? You could theoretically make a case for why that could happen, but I can’t say that I can speak to any evidence at this point. You know, maybe in a few years that’ll be a different story.

LARAH: Yeah, sure. There has not been enough research done to see if that could be the case.

Dr. O’BRIEN:  If there has been, I’m not aware.

LARAH: Yeah, well watch this space.  So now, it’s a question I’ve asked a few of my podcast guests, and we came up with some sort of answer, but I was wondering if you know more about it. Is it true, or is it a myth, that there are more women than men suffering from IBS?

Dr. O’BRIEN: There are more females diagnosed with Irritable Bowel Syndrome than men. That’s a fact. But why is that? We certainly don’t know. It could be that there is something specific to females that makes them more susceptible to developing Irritable Bowel Syndrome. Irritable Bowel Syndrome is, at its core, an autoimmune disorder which we, as of yet, do not know. But, if it is, then we know that women, in general, are more susceptible to autoimmune disorders, so that might explain it. We also know that women are more likely to go to the physician and talk about these things or seek treatment. They use the medical system more than males do, so could that explain why this disorder is diagnosed more often in females? It’s possible. I’m really interested to follow how the science is going to evolve with this whole autoimmune disorder theory, and I think, eventually, we might come to learn that that’s the case. If that is the case, then it does make sense why women might be more susceptible.  And, you know, could it be from hormones? I have no idea, but it is interesting.

LARAH: Yeah, it is interesting. And what you said about women seeking doctors advice more often than men, that’s probably the case. You know, we do go to the doctor; we do ask for advice and ask for help more than men usually tend to do.  So, yeah, it will be really good if there was some research done in the future about it.

Now, if you want to just clarify for people, how can they get their IBS diagnosed? If they think that they have the symptoms, how would they know that they have IBS? How is their doctor, their specialist, going to find out that they have IBS? One of the things that I’ve come across in my research is the Rome III criteria?  Is that one still one of the best ways to diagnose IBS? And, if yes, could you just explain what it is?

Dr. O’BRIEN: Sure, sure. So what you’re referring to is the Rome Criteria. Actually, now, we have Rome IV.

LARAH: Oh, okay.

Dr. O’BRIEN: It was just announced, released, in May 2016, and there’s been some small modifications from Rome III — nothing earth-shattering, but small changes. And this is a criteria meant to help physicians make a diagnosis when there is no need to do so much invasive testing, to help really make this diagnosis based on clinical grounds. So Rome IV states the following, in order to make a diagnosis of Irritable Bowel Syndrome: that you must have abdominal pain at least one day a week in the past three months, which is associated with two or more of the following — so abdominal pain plus two of the next three things — which is that the pain is related to defecation; the pain is related to change in the frequency of the stool — how often you’re going to the bathroom — as well as a change in the form of the stool — i.e. is it loose; is it hard? That kind of thing. And these symptoms must have been ongoing for at least six months. So they’re not brand new symptoms; they have to have been going on for six months. And you have to have symptoms of abdominal pain at least one day a week with associated defecation frequency or change in the form of the stool.

So this is great. The one drawback to these sort of clinical criteria is that a lot of people with different diseases would fit into these criteria. So you can’t look at it just as one criterion. You really have to take into account the whole patient in front of you. For instance, if I have a twenty-five year old or a twenty-two year old who comes in and tells me, “I’ve had these symptoms for a long time,” and they’re not telling me any sort of alarming features that go with this; like blood in their stool or weight loss, and the sort of things that will raise my antenna to think that there could be something else going on,  I’m more inclined to diagnose them with Irritable Bowel Syndrome after that. Now, if somebody is seventy-five who comes into my office and has the exact same symptoms, but has never had them a day before in their lives, then I am really going to be more cautious about looking for other underlying disorders that can happen in a seventy-five year old. So while the criteria certainly provide us with guidance, you do still have to look at the whole patient in front of you and take into account the whole picture.

LARAH: Yes, thank you. Because, yes, it is so individual. It’s almost too generic just using one criterion, I guess. If you had to have to have a set of questions once you see a patient that complains about IBS symptoms, what would be the questions that you would ask your patient?

Dr. O’BRIEN: Yes, I think one of the best things a physician can do to get the diagnosis of the patient is to just let them speak.  So, what I usually will do when a new patient comes to me is I will just simply say, “What brings you here today? What’s going on?  What’s brought you to my office? Tell me your story,” and I leave the question open ended. And I always find that if you give the patient an opportunity to talk, they will tell you just about everything you need to know to make a diagnosis. Here are the details I’m looking for, and if they don’t provide them then I’ll probe them a little further with questions. One of the things I want to know, obviously, first off, is there pain? If there is pain, where is it felt? How strong is it? Does it come and go, or is it there constantly? Is the pain worse after eating? How long after? Do your symptoms began while you’re still sitting at the table or does it take a few hours until you feel it,  and where do you feel it? I also ask them if they make an association — if they notice that the pain is associated with bowel movements. Is the pain better after they have a bowel movement or what are the bowel movements like? Do they tend to alternate between normal and diarrhoea or normal and constipation, or are they swinging like a pendulum all over the place? And another thing I ask about, or they actually offer up, and this is not in the Rome criteria — if there’s nausea and bloating with the bowel distension. Often they’ll tell me that after eating they feel nausea or they’re bloated. Their bellies are sticking out. Patients often tell me that they wake up fine in the morning, but by the evening time they look pregnant. Even men tell me that they look pregnant. Sort of a common theme that I see in my Irritable Bowel Syndrome patient.

As I alluded to before, of course I want to know if there are any of what we call alarm features such as bleeding or weight loss. If they haven’t been trying to lose weight and they’ve dropped, you know, ten pounds or so in the last month or two months, then that’s alarming. You have to take into account their age, as well as how long the symptoms have been going on. I often ask, or wait for them to tell me, if they can recall any inciting events. Maybe there was a gastroenteritis that tore through the whole family; or a course, or two of antibiotics that were given for either a sinus infection, or if they were travelling; or maybe they’ve interacted with a pet turtle or with their cousin who has a pet turtle. These are all clues that help us decipher the etiology of a patient’s symptom.

LARAH: Sorry, could you just explain the pet turtle thing?

Dr. O’BRIEN: Turtles and reptiles can harbor salmonella on their skin, so if you handle these pets and then you don’t wash your hands, you can get salmonella. You know, one thing is always in my differential diagnosis is infectious etiology, so it’s one thing I look for. I have to say, fortunately, many people don’t tell me that they have been handling turtles.

LARAH: That’s funny.

Dr. O’BRIEN: Lastly, if I’m pretty convinced that this is Irritable Bowel Syndrome, I ask them if they’re any foods that they typically shy away from or that they avoid because they think that they make their symptoms worse.  And you’d be surprised how many IBS sufferers are really intuitive about this.  And they say, “Oh. my gosh, yeah. I don’t eat onions. This is horrible,” so they sort of already intuitively put themselves on a low FODMAP diet, even though they’ve never heard the word before.

LARAH: Yeah, that’s good. Just going back to one of the characteristics or the symptoms, it’s mucous in the stools also a characteristic of IBS?

Dr. O’BRIEN: Well, it’s certainly something I hear about often.  It’s not in the Rome criteria, but it certainly is something that you hear often. I’m not sure why that is.  Is it because mucous is secreted naturally? Normally, it’s a sort of lubricant in the GI tract. And, yes, we do hear this from patients, that they often see more mucous, and you’re right. Yeah, absolutely.

LARAH: Yeah, that was one of my symptoms as well. I found it really strange in the beginning when it happened, but then I thought, “Okay, it must be all part of the package.”

Dr. O’BRIEN: Yeah, you’re right. It’s part of that package.

LARAH: All right.  Another question I had in my mind is how IBS differs from IBD (Inflammatory Bowel Disease).  Obviously, IBD is a much more serious disease. It’s not a disorder, so it’s much more serious, but how are they different from each other? Could the symptoms be confused between IBS and IBD?

Dr. O’BRIEN:  Well, absolutely. If we went back to the Rome criteria I read to you about — abdominal pain one day a week for the last three months where the associated comes with defecation — either diarrhea or constipation or frequency of stool — that’s very much a part of IBD because Inflammatory Bowel Disease, it’s either Ulcerative Colitis or Crohn’s Disease, is an inflammatory. Those are both inflammatory diseases. Ulcerative Colitis is inflammation. That is in the large intestine only, and Crohn’s disease can be inflammation that occurs anywhere in the GI tract, and often, it is in the small bowel and the large intestine.

So when a patient comes to me and they have these symptoms and I’m suspicious for Inflammatory Bowel Disease, it’s typically a younger person and they will say that they have abdominal cramping pain. They will also typically say that they have diarrhoea, though not always; and they will also typically say that they see blood, though not always. So there certainly is some overlap there, and part of the reason why we have to do our due diligence disposition is to make sure this isn’t Inflammatory Bowel Disease.  This does need to be treated sort of more aggressively, with medication, to control the inflammation, so that there’s no sort of sequelae from this constant long-term inflammation.

There is also a difference when we look into the colon of these patients. In Inflammatory Bowel Disease we’ll typically see ulcers; we’ll see inflammation.  It’s red, it’s inflamed.  We see ulcers in there, and we may see some areas where it’s bleeding. And in Irritable Bowel Syndrome, on the other hand, all we see is an absolutely normal looking colon.  Sometimes, when we suspect Inflammatory Bowel Disease and we don’t see it visually to the naked eye, we can see evidence of it under the microscope, so it’s important, I think, to biopsy and look for those changes that occur under the microscope. In Inflammatory Bowel Disease it may represent sort of a milder presentation, or just maybe the beginnings of it. So that is also distinguished from Irritable Bowel Syndrome which typically shows normal mucosa under the microscope.

But it’s interesting you ask, are there similarities, because some people are starting to say that there are similarities. We are starting to see the earliest hint of just maybe the two disorders — Inflammatory Bowel Disease and Irritable Bowel Syndrome — maybe somehow they are both on the same spectrum, though one more severe than the other.  So I think it’s sort of premature to talk about that, but it’s a rather interesting area of research.

LARAH: Yeah, thank you for the explanation.  And, yes, it sounds like there is a lot of research still happening in all this space so you just have to wait and see what  comes up.

Okay. When you have a patient that you are quite comfortable that has IBS, what would be the main treatments that you would suggest to your patient to manage their IBS symptoms?

Dr. O’BRIEN:  Well, I have to say, five years ago if you’d asked me this question, I would have said that the main treatment would be really to target the symptoms that the patient is experiencing.  So we know that Irritable Bowel Syndrome, typically, either is a mixed picture where it’s constipation and diarrhoea that sort of goes back and forth like a pendulum. Or it might stay more to one side and be more diarrhoea predominant, or more to the other side and more constipation predominant.  So you first sort of stratify this patient as diarrhoea predominant and constipation or are they kind of in the middle fifty-fifty?

So if they are constipation predominant, you target those symptoms; you give them something for constipation — either Miralax or a soluble fibre — and then you hope that that solves the pain. But to be honest, it really didn’t.  A lot of patients will report that, “Okay, now I’m going to the bathroom better, but, you know, I still have this same pain.”  So then you would target the pain with another drug, i.e. an antispasmodic. So you try to do your best to sort of take it as it comes, but not a lot you could really do in terms of preventing episodes to begin with.

On the other hand, diarrhoea predominant Irritable Bowel Syndrome will do the opposite. We’ll try to give them something to slow the gut motility; slow the bowel motility. If it’s a really bad case, just sort of target those diarrhoea symptoms.  And I have to say, for the past several years since I’ve been using diets, I really don’t have to go to drugs as often as I used to, which is great. I would say that the vast majority of patients, in my experience, really do respond to dietary changes. And when I think someone’s going to do well or they’ve given me a story where they say, “Oh, there’s no way I eat A,B,C,D because I know I feel horrible if I do…”  Or if they come into my office and they say, ”You know, I tried dairy free, and that helped a little bit,” or “…and then I tried gluten-free, and that helped a little bit,”  but it wasn’t the whole puzzle. They’ll often say they got a partial response then I’m pretty sure that they were just missing those other pieces of the puzzle.  And when you really take the time to explain to them how diet influences their symptoms, and really point them in that direction, I find that they really do well.trueself low fodmap foods logo

So I use the low FODMAP diet quite a bit in my practice. It’s really been a game-changer for these patients and I am a firm believer. And I really try to emphasise to my patients that the low FODMAP diet is a learning diet; it is not a forever diet. And I take the time to put the application on their phone and say, “All right, just for two weeks and two weeks only, I want you to be really mindful of everything you put in your mouth.  I want you to look it up, and if it’s not okay, then don’t eat it. If you’re not sure, don’t eat it…and for two weeks — that’s all I ask, two weeks. And then we will start to liberalise it and add some foods back and see how you do. And that’s the only way that you can pinpoint which specific foods are triggers for you because, of course, everybody is different.”

So that really has changed my practice tremendously and is really sort of the first thing I go to nowadays, and it’s been amazing. Often people who have seen other gastroenterologist or bounced around the system for a long time and were taking various drugs for years and years will come back and say, “You know what? I don’t need to have the antispasmodic anymore. I don’t need the Imodium anymore.”  So, they’re happy to get off of their meds, or need to reach for them much less frequently.

LARAH: That’s good. Yeah, it’s just incredible, isn’t it, that there is so much more knowledge now on the diet’s effect on IBS symptoms. But when did you specifically find out about the low FODMAP diet and how did that happen?

Dr. O’BRIEN: I probably started about four years ago or so with the low FODMAP diet. And like I said, first and foremost, I trained as a pharmacologist and so that’s a drug-designed mechanism of action, so I really drank the Kool-Aid there. And I really believed that drugs are fabulous tools. They’re tools to use, but I just felt so very frustrated with my Irritable Bowel Syndrome patients that these tools that I had to offer just weren’t that great. They just didn’t work that well, or they are costly, and it was very frustrating. And sort of out of frustration, I started to hear a little bit about this diet, but hadn’t really paid close attention. And I finally decided that, you know what, I’m going to try it. Why not? Let’s see how this works. And honestly — I’m being completely honest — to my surprise, patient after patient came back and said, “Oh, my God. I have not felt this good in years.” I mean to have a patient break down crying in your office because they are so grateful, they’re so thankful, that they forgot what it feels like to feel good. And that’s when I really opened my eyes and said, “Wow! This is amazing, and more people need to know about this.” And that’s when I really took the time to educate myself as much as I could about this so that I could give the best information to my patients and have them have the best success that they could have. But it really, like I said, has been an amazing tool in our tool box. I think it’s done a lot for the IBS community.

I’m very grateful to those people who have done all the work, really — the folks at Monash University who really did the research and have been such proponents of this, as well as stateside where we have the wonderful Patsy Catsos who’s done so much to teach our dietitians and the physicians about this diet. And we’re starting to see it go a little bit viral. It’s still in the early stages, but certainly more people have awareness than they did five years ago, and I think that’s only going to increase as time goes on.

LARAH: Yes, that is fantastic that we now have the low FODMAP diet because I know that it has completely changed my life.  And, yeah, Patsy Catsos, a great credit to her for pretty much bringing the low FODMAP diet to America. And I had the great pleasure to interview Patsy on my podcast, so if you missed episode three — that’s with Patsy Catsos — you can find it on my website or on iTunes.

Dr. O’BRIEN: And really, there have been so many dietitians now who have done just fabulous work — Kate Scarlata amongst them as well. They have cookbooks for these patients; they have blogs; they have recipes, and are really just a wealth of fabulous information.  And I will tell you that when I start my patients on this diet and it’s clear that they do well when they start to discern their trigger foods, I make sure they’re set up with all that information before they leave the office.

LARAH: Uh-huh.

Dr. O’BRIEN: It’s also important, I think, to offer patients a dietitian. Really, for patients to do well with this, and once they demonstrate to me that they respond, then I really think they should see a dietitian to help supervise the reintroduction phase of the diet so that they do it right; so that they can get it done as efficiently and expeditiously as possible and ultimately get to their goal of where they want to be in a shorter time. So I really do try to encourage dietitians, and I think they really are a very powerful ally with us physicians on this. I think we physicians need to realise that.  We need to learn that we need to partner with dietitians on this and that that’s the best chance that our patients have for feeling better.

LARAH: Yes. So you will give your patient the initial guidance for the elimination and what food that they should have in which quantities, but then, to be properly followed through with their reintroduction, you would suggest going and seeing a dietitian.

Dr. O’BRIEN: Absolutely. So when I see a patient, I never discuss diet in our first visit, to be honest. I think it’s important to establish a rapport with the patient, especially Irritable Bowel Syndrome patients. I think there’s a lot of value in building a trust relationship there, and it also gives me an opportunity to sort of do a little work on the side. Are there some labs we need to obtain or a little digging deeper to make sure there’s nothing else going on? But when they come back to see me in my office and I think a diet treatment is appropriate, I explain the diet to them and then have them come back in a few weeks and report back how they’re doing. And the large majority really do say that they are feeling a lot better and their IBS symptoms have really quieted. And that’s when I have them see a dietitian; and that’s also a time when I say, “Okay, now that we’ve removed the influence of diet of what was going on, we have ‘helter skelter’  going on inside your guts, let’s see where you are now.” For instance, someone who might have been a mixed constipation — they were diarrhea, then they were constipation or they were diarrhea normal and now they have sort of settle to where they really are — I call this their true selves — now they sort of settle to where they really are. Then you can deal with any remaining symptoms. So, for instance if they come back and they say, “Well, listen. The good news is I’m no longer running to the bathroom constantly. I’m no longer having diarrhea and I’m not calling out sick from work anymore. I’m going out with my kids for dinner. I’m enjoying my life, but the problem is that I find myself now to be more constipated than I was.  Quite frankly, I don’t know how to deal with it.” That’s when I’ll say, “All right. Let’s try this for the constipation.”  So you can kind of work on those peripheral symptoms, if you will — those secondary symptoms — after they’ve sort of settled into being what they actually are.  So that follow up visit is very important for those reasons.

LARAH: Yes, thank you. And would there be any cases in which your IBS patients would be asked to do like a colonoscopy or any exam like that?

Dr. O’BRIEN: Well, again, this goes back to our initial consultation. If they do have any features like blood in their stool, or if they have lost a significant amount of weight, then, yes, I do a colonoscopy because I want to make sure there is no underlying Inflammatory Bowel Disease or malignancy. Something like that that needs to be known sooner rather than later so that it can go away.

LARAH: All right, that’s good, thank you. In terms of your colleague gastroenterologists, do you think they are as open-minded as you, and as knowledgeable as you on the low FODMAP diet? And are they prepared to think that it is as helpful for IBS symptoms as well?

Dr. O’BRIEN: Well, I think certainly awareness is growing. I see evidence of that at the most recent meeting on this this past May in San Diego, which was called Digestive Disease Week, and FODMAP diet, those sessions were really well attended. So you see that physicians are hearing about it, either from other physicians, or maybe even from their patients. So they are making an effort to educate themselves on it, and I think it is being used more. I don’t know if I agree that it’s always being done well. To be honest, I think, given the time limitations we physicians have with our patients, we simply don’t have the time to take a half an hour to explain the diet to people. Quite frankly, I think that’s the best chance they’re going to have a success. Rather, I think, oftentimes, unfortunately, they’re handed a piece of paper — you know, the one you can print out from the web that’s red on the top and green on the bottoms that says, “These are the foods to avoid, and these are the foods to eat..” type of thing. But I think as education improves, more and more GI’s will know about the diet and how to do it properly.  It’ll   filter down. I just expect that will take some time.

LARAH: Yes, well that’s good that it is already starting and they are talking about it    are seeking more information. So that’s great compared to a few years ago.

So, as I mentioned in your introduction, you have a created a range of FODMAP friendly products and they’re called TrueSelf™ Foods and they include different types of snack bars. Can you explain how the idea came about to create these FODMAP friendly products and what these snack bars have that is different from all the other snack bars that are available in the shops.

TrueSelf food snack bars for GI discomfortDr. O’BRIEN
: Well, really, the idea came because of my patients. I would see patient after patient after patient come back to my office so excited that they have found a way to manage their symptom and they feel great. But it really presented another problem, which was, if you’re into the diet, it can be difficult, as you well know, and you have to be a pretty sophisticated shopper. You have to know how to read labels; you have to be able to translate labels and know what ingredients actually mean what. And not only that, but you have to be able, often, to cook from scratch all of your meals, all of your snacks. You really have to have tight control over what you’re putting into your body, and that’s very difficult for my patients. It’s difficult for me… “You know, listen. I’m a busy lady. I’ve got four kids; I’ve got a job. I have a lot to do and I don’t honestly have time to cook in that way, so I need something quick and on the go.” My patients needed something that they could grab, that they could put in their backpack or they can put in their purse or their car, and they know that this is safe for them — that if they reach for this, they’re not going to be grabbing their tummy in a few hours in pain or they’re not going to be having to say, “Where are the bathrooms on the route that I’m going today?”  So, really, it was to make compliance convenient for patients. And I am not a food scientist, and, quite frankly, I don’t really know how to cook all that well. For me to venture into starting a food company was really uncharted territory for me; so I was sort of hesitant to do it. I knew that somebody had to do it, and I kept saying to my husband over and over, “Somebody has got to start making products for these people.  Somebody has got to start making products for these people. When is it going to happen?” And one day he just said out of frustration, “You need to stop talking about this. Either do it or stop talking about it.”  I think he was so tired of hearing me.

And so I said, “All right, fine. I’m going to do it.” So I partnered with a good friend of mine, and she has quite an expertise in marketing, and we said, “All right, we’re going to do this.” So we hired a food scientist to help us develop some formulas and went back and forth to the drawing board a few times — came up with some flavours. It was important, I thought, to make it convenient, so I did want to start with a snack bar, although I hope that we will go on and on and add more and more products. But we had to start somewhere, so we started with the snack bar. And once we actually said, “All right, we’re pleased with this,” I sent it to Australia and had it tested to make sure that it’s low FODMAP because the last thing I would ever want is for patients to believe that they’re eating something that is safe, and then, God forbid, they react to it. So it was very important to me that in its final form we have it tested, which fortunately it did pass and we could put a FODMAP Friendly seal on that so that our consumers know that they can eat with confidence. So the bars are the first of hopefully many products to come.

LARAH: Yeah, that’s fantastic.  And first of all, congratulations for doing this venture. If you think about it, you’re a busy doctor, you’re a busy mum, and now you’ve started something as big as starting food products. But it’s such a worthy cause because there’s not enough products that we can just go in and buy from the supermarkets. On the shelves of, let’s say, the healthy section in the supermarket, they would have lots of gluten-free products, and now, in Australia, we’ve started to see quite a few FODMAP friendly products. But in America, probably, there’s not even as many so there’s not much choice, so it’s absolutely fantastic that you’ve done that. And, hopefully you will increase the variety and the range of the products you offer, and people in America will be very happy about it.

Dr. O’BRIEN: Well, the goal is, first I wanted to make sure that people were ready for this. And like I said earlier, I think they are. I think that people are ready.  I think people do make the connection between what they’re eating and how they feel, and that the timing is right for this. And all along, this was meant to help patients who have IBS, so hopefully they like it and that will allow us to expand.

LARAH: So now, could you tell the listeners, please, where can they find the products? Are they online or at the supermarket or specific shops?

Dr. O’BRIEN: Absolutely. Well, right now, we are online at our website as well as Amazon.com. We will ship anywhere in the world. And online, you can find us at www.trueselffoods.com and Amazon. Amazon may be the easiest for most because they’re accustomed to using Amazon.  And like I said, we’ll ship anywhere.

LARAH: Yeah, that’s great. So in terms of people wanting to be able to contact you again, they can probably reach you on the website you’ve just given. What about anything else? Is there any other way  to contact you?

Dr. O’BRIEN: This has also been an education for me — social media.  I’m a little bit older than the millennial generation so I am learning how to tweet and I’m learning about Facebook and Instagram. So, yes, we do have a presence on social media. You can look for us on Twitter @trueselffoods or at our Facebook trueselffoods.com. Look for the yellow sunshine. And, absolutely, our website is probably the easiest at  www.trueselffoods.com — and any questions you have, never hesitate to reach out via our email. And I tell my patients all the time I might not know the answer, but I’ll do my best to try to find it for you to help you get to it as well.  So, absolutely, we welcome that.

LARAH: Thank you, Dr. O’Brien, and I will have all the links posted as usual on the show notes on my website so that it will be easy for people to just click and get to your website that way as well. And what can I say? This has been a fantastic and a very long episode. This is the longest one I have done so far, but I just had to take the opportunity to ask you these really good questions and I can’t thank you enough for answering all the questions and to be such a wonderful guest on the podcast and for all your knowledge and for all you do.

Dr. O’BRIEN: Larah, it has been an absolute pleasure. So fun to have this discussion with you and I must thank you as well, really, for all you do for our patients in providing information and valuable resources. So, a lot of fun, thank you.

LARAH: Thank you so much. Goodbye.

LARAH: Well, that was another great episode with Dr. O’Brien. I hope you have enjoyed it and that you’ve got some answers to those important questions on IBS. It is such a great comfort that more and more doctors are now considering dietary changes, such as the low FODMAP diet in addition to or instead of pharmaceutical products. As we have heard from Dr O’Brien, she has started to see the most positive results on her patients after they were introduced to the low FODMAP diet. It is absolutely fantastic that we are seeing this happening.

As discussed Dr. O’Brien has recently created the TrueSelf™ Snack bars, which are delicious snack bars certified FODMAP Friendly.

I was fortunate enough to have been sent a sample of the snack bars and I truly enjoyed them. There are four different flavours that contain excellent ingredients such as pumpkin seeds, quinoa, poppy seeds, chia seeds, some dried fruits and even turmeric and other spices. They are such a   convenient snack when you don’t have the chance to cook your own food. When you’re out and about, you can just keep one in your bag. At least you will know that you can consume the snack bar safely  because it has been certified low FODMAP.

If you want to know more, I’ll put the link to TrueSelf™ Foods on the show notes for this episode, which is episode 23, so you can just go to www.lowfodmapdiets/23 to find the transcript and all the links.

Links and resources mentioned in this episode:





About Larah

I have been suffering from Irritable Bowel Syndrome for many years, but it took a longtime to get a diagnosis, since then I have been following a low FODMAP diet, which has changed my life for the better. This is my story and experience with IBS and the low FODMAP diet.