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Mia*, a young student in her early 20s with a vegetarian diet high in FODMAPs, turned to dietitian Chloe Madigan for help with her irregular bowel. With 35 years of dietetic practice to draw from, Chloe was able to guide Mia towards a better quality of life thanks to a combination of gut-directed hypnotherapy and dietary therapy that supported her lifestyle.
Here’s Chloe’s approach.
Seeing the stress signals
“Mia is a college student who fits in part-time work as well, so she had a lot going on when she first came to see me.
“As soon as she walked into my consultation room, I thought of Nerva almost from the onset. She had a high anxiety level; you could just see it. She spoke very quickly and tried to tell me everything all at once, almost sounding panicked. I picked up on her stress right away.
“Her bowel pattern was irregular, and she was opening her bowel about two to three times a day, and she said it was often loose stool.
“We all know stress is a huge exacerbator of IBS. And I know it’s a sign of the times, but I’ve been seeing more and more patients like Mia who take on so many stressors in their life. Sometimes they don’t realize the impact this has on their gut health.
Mia, however, could already see that stress was exacerbating her bowel.
“She was also a vegan when she was a teenager, and then became more of a vegetarian. In addition to her IBS, what concerned me was she had low iron (but regular periods).”
DIY digestion
Like most patients, Mia had already tried a few things on her own like Metamucil, Movicol, and probiotics.
“She tried lots and lots and lots of different things before seeking professional support, but she just couldn’t get her bowel under control.
“Her diet was good and she was eating reasonably well. But as a vegetarian, she was relying heavily on high FODMAP vegetables, legumes, and whole grains.”
Before her first consultation with Chloe, she’d already met with GI and had a colonoscopy.
“She did this test as she was experiencing stomach cramps, excess wind, and bloating. So, it could have been either IBS or IBD. But the results from the colonoscopy were all fine.”
First steps to the full picture
With Mia, and all of her patients, Chloe always begins with a comprehensive assessment.
“I talk about their symptoms and ask how long it’s all been going on for. I like to determine what it’s not to confirm it is IBS. And then I look at their dietary intake.
“So often FODMAPs aren’t the problem – they’re just exacerbating the existing condition.
“But, having said that, I didn’t automatically put Mia on a low FODMAP diet – I don’t do this with any of my patients.
“I’ve been referring the low FODMAP diet since about 2008, so I’ve been dabbling in it for a long time! And obviously it’s evolved and been refined, but now I approach IBS very differently.
“In the past, I’d probably say that we all got a bit excited about the low FODMAP diet – finally we had a solution to offer people with IBS! And we were more willing to put people on the diet without too much consideration. Now, my approach is entirely different.
“What I find nine times out of 10 is if we improve people's dietary fiber intake, their fluid, and activity, we can often regulate the bowel, and then FODMAPs are better absorbed.
“However, I do refer Nerva and gut-directed hypnotherapy quite a bit. What I see happening all the time with patients like Mia is they all have this huge preoccupation with their gut and their symptoms and we need to quieten that down – this is when Nerva comes in for me.”
Merging the mind and gut
While Nerva and the low FODMAP diet are effective standalone options for IBS management, both Chloe and Mia believe teaming the two approaches together was what led to Mia’s life-changing improvements.
“I thought to myself at the time, ‘It’s probably not a bad time to trial the low FODMAP diet to start’. But I still talked to her about Nerva on that first visit too.
“The first roadblock was she told me she couldn’t afford it. But I reached out to Nerva Clinical Specialist, Eloise, who was able to offer Mia a compassionate access account, which was incredible. She was so, so grateful. For me, it was just great to see a patient who I knew would really benefit from gut-directed hypnotherapy be given the opportunity to access the program.
“She started the low FODMAP diet and Nerva at the same time, and she’s currently up to the reintroduction phase. She did have a few setbacks with the diet and was slightly less compliant. She started strictly, but it was the end of her university year, and heading into the Christmas holidays made it challenging to follow closely, so her improvements were more gradual.
“I also had her on partially hydrolyzed guar gum, which is a prebiotic to increase gut mobility and can reduce small bacterial overgrowth – it’s actually as effective as the antibiotics for this.
“I also recommended psyllium husk and Movicol to keep her bowel regulated if required. One of the problems for patients like Mia is if their bowel isn’t regulated, they’ll continue to get bloating. And when they’re hypersensitive like she is, it becomes even more complicated. So, I wanted to work on her physical symptoms, as well as her emotions and anxiety with Nerva.”
Moving from meditation to hypnotherapy
Mia says her meditation practice helped her embrace the Nerva program fully from the beginning.
“Before she came to me, she was already doing daily meditation and yoga. So, when I introduced her to gut-directed hypnotherapy, she was really excited by the idea as she could already see the benefits of meditation and yoga and liked the idea of expanding on this practice.
“After that first appointment, she went home and looked into Nerva for herself and said she found it to be a genuine, trustworthy resource, and the app felt honest and transparent to her.
“She called it ‘slow education’, meaning she liked how the in-app psychoeducation progressed and built on topics at a good pace.”
Mia was happy to share she experienced very few setbacks moving through the six-week program.
“She’s a very diligent, conscientious person, but also overly anxious and a perfectionist. So, she listened every day, no problem, and started on the maintenance plan right away.
“Something she did experience, however, is if she was having a significant flare-up, sitting down to actively listen and concentrate on a gut-directed hypnotherapy session made it worse. She couldn’t do yoga either and often got a sharp, growing pain on her left side.
“However, I have referred many patients to Nerva and most are textbook: they listen, they feel fantastic, and it helps them desensitize. Mia was an exception in this way.”
Score improvements before and after the intervention
Mia saw huge improvements in her scores at the end of Nerva.
“I think the bloating and wind were huge successes for Mia – moving from 70 to 21 for bloating and from 72 down to 21 is incredible for her. Though I’m sure these significant improvements were supported by her dietary changes as she wasn’t fermenting as much in her gut.
“But it was great to see her anxiety and depression PHQ-4 score halve! It was a really positive outcome.
"Both Mia and I feel like it was the combination of Nerva paired with the low FODMAP diet that really worked for her and made an impact – it was a balancing act for her.”
Reviewing the outcome
Chloe met with Mia recently to review her progress.
Mia said she’d had a few flare-ups and was experiencing stress that was mostly due to her university studies. “We’re going to do reintroductions in her diet once her bowel has stabilized a bit.
“She has noticed she can tolerate some FODMAPs, but she does experience a flare-up if she eats a lot. It was more challenging because she’s a vegetarian and reliant on particular foods like legumes, but I gave her options and meal plans.
“What I always emphasize to all of my IBS patients is they can not stay on the low FODMAP diet long term. It’s like injurying your leg and being in a cast for six weeks – you’ve got to learn to walk again.
“Reintroductions are important, especially for prebiotics, and it’s one of the reasons why I don’t generally put people on the low FODMAP diet unless I genuinely believe that a patient’s diet is high in FODMAPs, or I can see there’s a strong correlation between certain foods and their symptoms.
“Generally speaking, my first approach with gut health patients like Mia is to regulate their bowel, and around 90% of these patients will have issues with stress exacerbation, and that’s why Nerva is in the mix straight away.
“I’ve found that the combination of regulating the bowel and adding Nerva is what gives you the best results.”
Referring gut-directed hypnotherapy
Chloe is a strong advocate for using gut-directed hypnotherapy for IBS management for her clients.
“I’ve only worked for 3 days so far this week and I’ve prescribed GDH five times this week already! So, I do recommend it a lot, and this week I haven’t prescribed the low FODMAP diet once.
“For me, Nerva is this additional tool I use in conjunction with regulating someone’s bowel. Because once their bowel is out of whack and they’re getting all of this bloating, they become hyperfocused on it. And once they get more stressed, they get more bowel symptoms, and they’re on the roller coaster. A big part of my work with Mia was helping her become less fixated on her symptoms.
“I’m always careful suggesting Nerva and don’t want to offend anyone. How I approach a patient is I start by asking, ‘Do you feel that your bowel is worse when you’re under a lot of stress? Does it misbehave?’ And then this leads to, ‘Well, there’s a tool that can help with that and it involves a 15-minute commitment...’”
Chloe Madigan is an accredited practicing dietitian at Ochre Medical Centre in Wollongong, Australia.
*Name changed
