Case study: When a diet isn’t the answer – Managing a complex patient

Case study overview

• A complex patient in distress presented with multiple complaints including reflux, frequent loose bowel movements, and lower abdominal pain.
• The patient's anxiety and negative mindset were significant concerns. Considering her history of disordered eating and self-imposed diet restrictions, it was decided that commencing with a low FODMAP diet wasn't the appropriate initial step in the treatment plan.
• The patient responded swiftly to gut-directed hypnotherapy and reported lower anxiety within a few days.

Managing desperate patients

For gut health and IBS specialists like Keren, aiding a distressed patient population and guiding them toward a positive outcome is a fundamental aspect of their daily practice.

“The people who come to me are all like Lily and often in a state of desperation,” Keren acknowledged. “They've typically sought medical help multiple times for their gastrointestinal issues, such as diarrhea or constipation, and they may have been ignored or endured a battery of tests resulting in an IBS diagnosis.”

​​Adding to the complexity of Keren’s role is the prevalence of patients resorting to Google to comprehend their symptoms or, like Lily, cobbling together DIY diets hoping something will improve.

“Their doctor might have briefly mentioned something about FODMAPs to them, prompting them to go online to learn more. They usually try to follow some version of the diet and find themselves bewildered and lost along the way. However, what they have in common is they’re all suffering and struggling to manage their gastrointestinal health.”

Deciphering the symptom puzzle

Lily turned to Keren for help with her “unusual, defensive diet.”

She was hoping Keren could help alleviate her digestion problems and broaden her dietary choices. “She hadn’t consulted a dietitian yet, so her restrictions were all self-led at this stage,” Keren said. 

Her predominant concerns encompassed reflux, frequent loose bowel movements, and lower abdominal pain. Lily disclosed a celiac disease diagnosis from 20 years ago, managed through a stringent gluten-free diet. Additionally, she grappled with food intolerances, arthritis, and GERD.

Certain fruits triggered mouth itching, nuts caused throat irritation (except when cooked), and rice and beans led to stomach discomfort. Despite a preference for a vegetarian diet, Lily reluctantly included chicken for protein, noting challenges with both protein and carb digestion.

By the time Lily met with Keren, she had grown increasingly pessimistic and distressed about her health. “She felt helpless, like there was no solution for her.” This anxiety pushed her to consult with a GI about her indigestion in November 2021.

Given her reflux history, the GI prescribed proton pump inhibitor (PPI) medication, resulting in adverse reactions and heightened anxiety without relieving her acid reflux. Over the following 18 months, Lily underwent several diagnostic procedures, including two endoscopies, a colonoscopy, and an abdominal ultrasound, all showing no abnormalities. 

Despite clear results, Lily's distress drove her to seek further guidance. Her aim was not centered on being led through a low FODMAP diet, but rather a quest for understanding her dietary options and an overall approach to her health. “She didn’t want dietary advice exactly from me, it was more that she didn’t know what to eat or what to do,” Keren said. 

Tailoring a non-dietary intervention

‘What am I going to do with her?’ was Keren’s initial reaction to Lily’s complex presentation. “She had a terrible mindset, this horrible acid reflux, and she wasn’t on any medication and didn’t want to go down that path.” 

To best navigate Lily's case, Keren took the time to reflect and organize her observations in a case study format. “I don’t do this for every patient, but when I get a challenging client like Lily, I like to collate my notes into this format and run it by another dietitian for their perspective to check if there’s something I’m missing.” 

Adding to Lily's complexity was her unintentional, rapid weight loss that intensified her presentation to Keren, along with her multiple food sensitivities and restrictions.

Lily had primarily developed her restrictive diet on her own, shaped by her celiac disease diagnosis two decades ago. She was gluten-free initially and then went dairy-free too, which exacerbated her arthritis. 

“She was also avoiding onions and garlic for her reflux, but she didn’t want to take medication for it. Otherwise, she had a high intake of FODMAP-rich foods and fiber. While I could see that she could benefit from a low FODMAP diet, I knew it would cause her so much stress and anxiety and possibly contribute further to her disordered eating.”

When a stopgap transforms into the solution

Keren’s treatment plan for Lily began with a 24-hour diet recall and an in-depth exploration of Lily's dietary history. "I honed in on her altered GI function, unintentional weight loss, and reflux disease."

Recognizing the intricacies of Lily's symptoms, Keren then suggested gut-directed hypnotherapy as a first step, considering Lily's already low weight and deeming a dietary approach unsuitable at this point. “My plan was to put her in a holding pattern with Nerva, like a stopgap.”

Keren also recommended FODZYME, an enzyme blend facilitating the digestion of high-FODMAP foods. This recommendation stemmed from suspicions regarding fructans, GOS, and lactose being problematic for Lily, aiming to avoid unnecessary dietary restrictions.

To enhance understanding, Keren encouraged Lily to document her food intake, facilitating a more comprehensive analysis. She equipped Lily with a meal planner containing low FODMAP recipes. “I told her she didn’t need to follow it strictly, but I thought this approach might help liberalize her diet.”

Despite Keren’s initial uncertainty – “I almost felt like I was leaving her hanging as I wasn’t fully sure what to do with her at first” – she structured her recommendations strategically, aiming to ease Lily into testing the suitability of these interventions, providing room to adapt based on what proves effective.

“Offering Nerva, FODZYME, and a digital meal planner was my way of testing the right approach for her and seeing what sticks.”

An unexpected breakthrough

Lily was apprehensive about the new approach and had many questions for Keren. However, she did have a swift breakthrough. 

“When I first suggested Nerva she was a bit hesitant. She said, ‘Oh…okay’ and wasn’t convinced. But after trying the program, she told me it really calmed her anxiety within the first week and she noticed a significant difference.”

Keren emphasizes a patient-centered approach in her practice, providing information and options rather than imposing recommendations. 

“I don’t like to push things on people. So, when I refer Nerva, I give my patients a handout and my Nerva referral code and let them know they can try it for free for seven days. I never promote one product over another and ensure they know they have options.”

Considering her initial reservations, Keren was surprised by Lily's decision to try Nerva. “I was actually a bit shocked she went ahead with Nerva – I didn’t think she was going to follow through. She also tried some of the recipes I offered, and even though she was hyper-focused on food, they were less successful.”

Sharing her positive progress 

Lily scheduled a follow-up appointment with Keren after completing the program, eager to share the significant improvement in her well-being, which she attributed to Nerva.

“She told me that listening to gut-directed hypnotherapy helped her feel calmer and much less anxious. She managed to complete the entire six-week program and saw significant improvement in her reflux, bowel movements, lower abdominal pain, and was happier in general with her diet. 

“She actually told me she was upset that her doctor didn't bring Nerva up with her sooner and that they didn't know about it!

“Talking to her in this follow-up appointment was like night and day – before she was so miserable and had a terrible mindset. Then, when I met her again, she was blooming and so happy. I thought to myself, ‘Okay, did I give her fairy dust?’ Just so different!

“Though I still wonder if medically there’s something else going on – am I missing something? And while Nerva has been great for calming her anxiety, I’d still like her to feel like she can liberalize her diet. She wasn’t as keen to try the FODZYME because she has reacted poorly to supplements in the past, so there’s some anxiety there around trying something new. But I will encourage her to try it in small quantities next time.  

“As a dietitian, Nerva and FODZYME have both been so good for the times when I don't think a diet is going to help a patient, so it's really opened up my toolbox.” 

Guiding complex patients

“My advice for other dietitians trying to manage complex patients like Lily is to pay attention to dietary red flags that indicate a low FODMAP diet may not be the ideal starting point. Look for signs of disordered eating, an eating disorder, malnutrition, food avoidance or restriction, and heightened anxiety focused on GI health – these are indicators that clients might benefit from starting with something like Nerva before implementing a dietary intervention.

“I always give my clients options, but if someone presents with any of these red flags and is hesitant to try Nerva, I still won’t recommend a full low FODMAP diet. Instead, I might opt for a gentler approach to FODMAPs or trial-and-error methods before considering the full diet. Dealing with complex cases often requires several appointments to tailor the best approach.

“Reflecting on my initial consultation with Lily, I wouldn't change my approach. With experience in handling similar cases, I am now more confident in recognizing when a dietary intervention may not be the most effective strategy."

Keren Reiser is a registered dietitian and nutritionist working in a private practice in Ottawa, Canada. She specializes in digestive health, food intolerances, FODMAP, DNA, nutrigenomics, weight, and mind and body health.  

*Name changed. As we share real stories from real people, stock images have been used to ensure we protect the privacy of our patients.

‍