The Gut Experts: ‘Women with gut problems used to be told by doctors it was all in their head. We want to change that’
Professor Barbara Ryan and Elaine McGowan — aka The Gut Experts — are on a mission to help women find a healthier, happier gut. Here, they talk about the secrets of separating fads from facts, the problem with ‘clean’ diets and why IBS sufferers are being let down by the health system
‘There’s a lot of talk about gut health at the moment,” says Professor Barbara Ryan, “and everywhere you turn, people are saying, ‘Eat loads of fibre!’ and, ‘Feed your gut with good bacteria!’ That’s all fine and dandy; it’s good for most of us and reduces the risk of lots of diseases, but if you have a gut problem like IBS or Crohn’s or colitis, you cannot just feed your gut bacteria in a blind way by eating loads of fibre and kimchi — you have to be more specific.”
During their collective five decades of professional experience, consultant gastroenterologist Professor Ryan and her colleague, clinical dietitian Elaine McGowan — who have worked together at the Hermitage Clinic for 14 years — have treated over 60,000 patients. They reckon there has never been more misinformation and confusion around diet than there is now.
“I should be redundant,” says McGowan. “Ten years ago, I would have thought I would be out of a job by now and I’d have nobody attending my clinic, because that’s the way it should be with the advent of Google and so much information available. But I think what we’ve seen is the exact opposite. We are seeing more patients than ever, and more confusion than ever before.
“So many people are embracing vegan diets and, while we have nothing against veganism per se, we think this is contributing to the rise in functional problems such as bloating, as these diets are inherently very high in fibre and fermentable foods that produce gas in your gut. We are not major fans of a vegan diet, or becoming too ‘clean’ for that reason, and also because it’s very hard to meet all your nutritional needs on a vegan diet.”
Whatever about nutritional claptrap having reached an all-time high, what’s undisputed is that between 10 and 11pc of the world’s adult population has IBS, and 70pc of those are women. A common sister condition of IBS, functional dyspepsia, affects 15-20pc of all adults, and is more common in people who have IBS. And while IBS is not life-threatening, it can be life-altering — making people anxious around eating, and leading to them eat a very restricted diet, restricting social outings and travel, planning shopping trips around the location of the nearest lavatories, and worrying about needing to run to the loo in the middle of a meeting.
Ryan and McGowan’s belief that women with digestive problems such as IBS are particularly badly served by medical services brought them together to write their first book, What Every Woman Needs to Know About Her Gut, The FLAT GUT Diet Plan: Solutions for Bloating, IBS and Digestive Symptoms. They believe that with the right, individualised approach, people with IBS and other digestive problems can transform their lives and regain their quality of life.
The Gut Experts' FLAT GUT Diet Plan for healthy digestion
“I work in both the public and private systems,” explains Professor Ryan, “and I think that conditions such as irritable bowel syndrome — which are really common, and much more common in women — are badly served. With any of these ‘functional’ conditions where there is no hard abnormality, the response from healthcare professionals is often, ‘You don’t have cancer, you don’t have Crohn’s, there’s nothing serious or life-threatening; you’re grand really...’ The system is so clogged up with all the life-threatening diseases that a lot of people with these very debilitating conditions have a few tests, are told everything is fine, that this isn’t going to kill you, and you should get on with things, but actually have an incredibly poor quality of life.
“They are frustrated and distressed because they feel dismissed, and paradoxically take up a lot of time with GPs and hospital services, as they feel they are being fobbed off, their questions are not being answered, and their problems are not being solved — so they keep coming back and back and still aren’t dealt with very satisfactorily.”
IBS presents differently in women to the way it does in men. “Women get more constipation and bloating,” explains Ryan, “while men tend to get more diarrhoea. While 30 years ago, you might be told you had a spastic colon or abdominal migraine, now IBS is fairly commonly recognised. Women who suffer with IBS often notice a pattern in bowel habits over the course of their menstrual cycle — maybe they get a bit constipated in the week before their period, and once they get their period, their bowel motions get a bit looser again.
“Hormonal factors may be one of the reasons why IBS is more common in women; it’s an evolving science and we don’t really have all the answers yet. Pregnancy has a huge effect on the gut, because pregnancy hormones slow everything down, and women get more constipation and reflux, because the stomach doesn’t empty as quickly as it should, plus there is the impact of the baby sitting in their abdomen.
“We also see a huge number of women who develop gut problems perimenopausally and post-menopausally, because hormone changes mean the bowel may become either more sluggish, which is most common, or a bit looser. A woman who had a difficult delivery 30 years ago may have weakened muscles in her pelvic floor, leading to difficulty holding on to wind and loose bowel motions. We want to increase awareness of these issues, encourage discussion, and encourage women to seek help.
“Traditionally these sorts of problems would have been categorised as hysterical — thankfully not a phrase used anymore — and the women with IBS told it’s in her head, but it’s really very much not in her head. Yes, psychological factors play a role and if you’ve been fobbed off by people for years, you’re going to get anxious and stressed, but it is not an imagined condition. People end up going to alternative practitioners and while we are supportive of that and embrace many aspects of complementary medicine, there are all sorts of unusual practices that are not proven, which people end up resorting to because we [the health service] are not giving them the help that they need.”
With waiting lists at record levels, people in the public system could be waiting years to see a gastroenterologist. “I work in Tallaght University Hospital,” says Ryan, “where we get 800 referrals a month to our gastroenterology clinics. We are constantly trying to sift through those referrals to see if somebody might have cancer, on the basis of what the GP is telling us. So where people have very worrying symptoms, they are absolutely prioritised, and people who sound like they have IBS are routine, unfortunately, and they will be waiting a long time. That said, things have improved and a lot of hospitals such as Tallaght have dietitian-led clinics where patients can be triaged and put on the correct pathway. If it sounds like IBS, we can do some preliminary tests and get them very quickly to a dietitian.”
The delays many IBS sufferers experience while waiting for help, and the huge amount of misinformation in circulation, is a source of frustration for Ryan. “About two years ago,” she says, “I was on a walk with my brother, giving out about all the quackery and the bad information people were getting, the wrong things they were doing with their diet. He told me to stop giving out and do something about it. So I called Elaine and said, ‘I think we need to put our combined experience and the dietary approach we have developed down on paper.’ Ours is based on established practices but slightly different, and we’ve used it to help a lot of people. That was just before the pandemic — and let’s just say we didn’t get to watch a lot of Netflix.”
“We are passionate about sharing our information,” adds McGowan. “We are conscious that we can’t see everyone, and not everyone can come to see us, and we have a lot of experience and feel it’s important to share what we’ve learned to impact more women’s lives and help them.”
So how does The Gut Experts’ FLAT GUT Diet Plan differ from other dietary approaches to IBS, most notably the low FODMAP diet, which has helped many people with IBS but can be restrictive and hard to stick to in the long term?
“It is depressing to be on a very restricted diet,” notes Ryan, “and adds to the stress and anxiety of dealing with the condition, because you think you can’t go out to restaurants and you end up avoiding situations that involve going out for meals because you are so anxious about what’s in the food. We are trying to get people to realise that you don’t need to cut out everything but you do need to look at how much of particular things you eat.”
“Our diet has many similar principles to the low FODMAP diet and has evolved in a similar way,” explains McGowan. “But a key difference is that most people who follow that diet are gluten- and dairy-free from the outset. We’ve found many people don’t reintroduce these things and that’s not good for your overall health. Low FODMAP is supposed to be dairy-free only if you have had a specific breath test to determine lactose intolerance, but it’s often misinterpreted and very few people get the test done and just eliminate dairy.
“Ours is very much an inclusive diet, so it includes all food components that are possible triggers for the gut,” she continues, “but we have developed a unique points-based system which starts you off on a certain number of these components. So you limit rather than eliminate the main triggers — the three ‘F’s (fibre, fructans, fructose), lactose, and alliums — and the system allows you to identify which food triggers you are more sensitive to. The approach includes ‘T’ — Total Mind and Body Health — as an integral part of gut health is your mind-and-body connection.
“We see a lot of people with digestive issues exacerbated by ‘clean’ eating and rigid rules, so while there are still rules in this diet around portion control, not everyone has to look at every aspect of the diet — maybe they just need to look at fructose and have two pieces of fruit a day rather than six, which might be too much for them.”
Fibre, which many people with IBS avoid, is also an integral part of the FLAT GUT Diet Plan. “We see people who either eat too much fibre, say 50g per day, or too little, say 10g,” says McGowan. “As we know, in Ireland, 80pc of the population eat too little fibre. We help each individual find their own fibre tolerance — is it 20g? 25g? All IBS sufferers have a different tolerance level. One size does not fit all, and a core component of good gut health is to find your own individual tolerance of fibre.”
Most importantly, Ryan and McGowan do not believe most IBS sufferers need to eliminate wheat and dairy from their diet. “Wheat is very important to feed your gut microbiome, for gut motility and for general gut health,” explains McGowan. “So we like people to eat wheat, but maybe not large volumes of wheat. In the last decade, we have seen a huge increase in wheat consumption — people might eat six slices of bread a day, big bowls of pasta, a whole pizza plus garlic bread, and a lot of the wheat is very processed, or reheated, and contains a lot of resistant starch, which can cause digestive issues.”
“A lot of people who suffer with gut problems latch on to things they read and say, ‘I’m going to give up wheat!’” says Ryan. “So apart from people eating way too much wheat, we’ve also got a lot of people who go wheat- and gluten-free for no good reason. Then they are on this non-wheat and gluten track but they are still bloated and they say, ‘Now I’m going to give up dairy!’ We actually want people to gain confidence and reintroduce all these things — our approach is all about going back to basics. Unfortunately, onions and garlic remain a problem for some people, but many can reintroduce them successfully.”
In their book, Ryan and McGowan provide women with digestive symptoms with a simple framework of steps they can take, in conjunction with their GP, including a test for coeliac disease and routine blood and stool analysis, to help determine what their particular issue is and whether further investigations are needed. Not everyone needs to see a specialist.
“If you are 20 or 25 and there is nothing else alarming going on, then, yes, you more than likely have IBS and you can embark on that line,” says Ryan, “but you shouldn’t assume you have IBS when you have digestive symptoms. You need to see someone interested in helping you. If you have a colonoscopy and you’re told it’s normal and you’re grand, that’s reassuring but it doesn’t solve the problem.
“I particularly wanted to help older women, who tend to be very stoical and put up with a lot. I’ve seen several women over the past few years who all came to me because they wanted to travel to Australia to meet a grandchild and were worried about how they would cope on the flight. With changes in diet, and in some cases with medication, most people can be helped — but not everyone can be fixed, because IBS is a mish-mash of things. There are lots of pieces in the IBS jigsaw.”
Ryan and McGowan’s book is a practical guide that will help many women educate themselves about their IBS and other digestive issues, and empower them to seek solutions to improve their quality of life without resorting to poor-quality advice from non-professionals that risks damaging their overall health.
‘What Every Woman Needs to Know About Her Gut’ is out now. Follow The Gut Experts on Instagram @thegutexperts
