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Ep 70 - IBS-M - what do the mixed symptoms mean?
Episode 70 • 1st October 2024 • Inside Knowledge for people with IBS • Anna Mapson
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If your IBS symptoms leave you confused, and you switch between slow and fast transit, you could have the Mixed type of IBS.

IBS-M is when you alternate between constipation and diarrhoea, and still get the core symptoms like pain, bloating and straining on the toilet. This week I'm talking about

  • How common is IBS-M subtype of irritable bowel syndrome?
  • Potential causes of IBS-M
  • Suitable diets for IBS-M

Links

Low FODMAP Diet Guide - https://www.goodnessme-nutrition.com/ultimate-low-fodmap-diet-guide-find-your-ibs-triggers/

FREE IBS symptom tracker - https://mailchi.mp/goodnessme-nutrition/ibs-diet-tracker

Work with me

Ready for your gut reset? 🌍 I work with clients worldwide, providing remote consultations and a wealth of educational resources.

Instagram - @goodnessme_nutrition

The information in this podcast is not medical advice and is not designed to treat, diagnose or provide personalised health advice. This podcast content is information only and any changes you make are at the user's own risk. Please consult with your doctor or healthcare provider before implementing any new treatment.

Transcripts

Speaker:

Does your gut switch from being

constipated one week and then

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having loose stools the next week?

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You never know where you're at with it,

what to eat, what to drink, or what to

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take to reduce your digestive issues.

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We normally speak about diarrhoea

predominant or constipation predominant

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IBS, but there is a third type, IBS

mixed or sometimes called IBS M.

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This week's episode seeks to explain

a bit about what could be going on

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here, how to start making some changes

to support your digestion for the

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better, even if your symptoms seem

to be changing all the time and you

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don't know where you're going with it.

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Welcome to episode 70 of the

Inside Knowledge podcast.

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For People with IBS, I'm Anna Matson.

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This week's podcast is in response to

a question I had from a lovely listener

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who said, I don't think you've ever

covered IBS-M subtype, and please would

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you do a podcast episode about it?

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So here I am.

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And if you have got questions that

you would like me to further explore

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in future podcast episodes, please

Please, please drop me a line.

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I'm always happy to hear

from my lovely listeners.

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So let me know if there's something you

want to hear me talk about and explain

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in more detail in a 20 minute episode, you

can get hold of me at my email address,

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which is info@goodnessme-nutrition.Com.

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Or you can find me on Instagram

where I am @goodnessme_nutrition

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to answer the question about IBS M,

this week I'm going to be talking about

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how many people have this mixed type

of IBS and what you can do about it.

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And also, in order to understand what

you can do about it, we need to think

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about why your symptoms might be

alternating from slow transit time to

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fast transit time and all those things

we can think about to try and improve

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your, overall digestive capacity.

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Firstly, when we are thinking about

IBS, there is something called the Rome

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4 criteria by which we categorize IBS.

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And everybody who has IBS has some

set of symptoms that are the same

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and some things that are different

depending on the mini subtypes.

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So everyone who's got IBS has got

problems associated with having a poo,

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and they have been a problem for at

least one day a week for the last three

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months, and normally you're getting

change in frequency of your stool and

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also maybe a change in the appearance

of it, so perhaps it's much runnier, a

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different color, all of those things.

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Then the subtype elements are that

you have really hard pebbly type poos.

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So if you look at the Bristol

stool chart, you're going to have

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very hard, small pebbles or very

large, difficult to pass stools.

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That's type one and type two

for about a quarter of the

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times that you go to the toilet.

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And then Another quarter of the

time, you might have loose, like,

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watery diarrhoea type symptoms.

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So that's type 6 or type 7.

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Type 7 is loose, watery, urgent

stools, and type 6 would just be

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very mushy, but liquidy type stools,

but obviously with some substance

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there, not just complete liquid.

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Now, IBSM type patients have As well

as these, so alternating between

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very constipated and very loose.

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But also will have problems with

probably straining, feeling like you

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haven't been able to empty your bowels

properly, and maybe even needing to

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use your finger to extract the poo out.

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That is common with people who get

constipation predominant symptoms.

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But at the same time, you might also get

a load of urgency when you're getting

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the loose stools, the watery stools.

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So in some ways, you've got the

worst of both worlds because you're

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getting sometimes when it's loose,

you don't know whether you might have

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an accident and it's very urgent.

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And other times you might not go for days

and then when you do, it's painful, you're

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straining to get it out, and you just feel

a lot of the time like it's just a real

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struggle to fully evacuate your bowels.

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The other things that we see from the

research is that potentially people who

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have this mixed type of IBS might have a

trend for a higher frequency of nausea,

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so that feeling of sickness particularly

in the morning, and I see this more often.

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in line with people who have constipation

anyway, people who tend to be feeling

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nauseous in the morning as often if you

can't go and you just feel very full.

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but also people who have IBSM may have

a higher tendency to have anxiety or

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low mood and depression and again like

maybe it's because the symptoms are

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so bad and also they're alternating.

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In terms of how common it is, in the

research it seems to be between about

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19 percent and I think the highest I

saw was around 60 percent of people

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who are classified as having IBS.

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fall into that subtype of IBS M.

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So you can see it's

actually pretty common.

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It's not as rare as you might think,

even though we tend to focus on

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solutions and the problems of people

who have constipation or diarrhea.

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And we don't focus so much on

the people who are alternating.

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You may also see it written down as

IBS A, which means like alternating

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IBS, or IBS M, which is mixed.

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So, They're the same, it's just

different ways of saying it.

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There is two particular reasons that

I want to explain a bit about around

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why people may be alternating between

these two types of very hard to very

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loose stools and then back again.

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And actually, interestingly,

people seem to transition more

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between IBSM and constipation than

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IBSD and constipation.

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So more.

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veering to the harder stool side.

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Now one of the reasons this can happen

is you might have heard me talk in

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episode 33 and episode 34 when I talk

about common causes of constipation and

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what to eat when you have constipation.

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You might have heard me mention

in those episodes something

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called overflow diarrhea.

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And this can happen when you

are constipated so you have hard

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stool that is stuck in your colon.

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As you start eating, you get more and

more food that's coming through, and maybe

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it's It's a bit softer above the build

up of the hard stool, which is there.

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As this more softer stool comes down,

it kind of causes the bowel to stretch.

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You might feel very bloated, quite

painful, quite hard to press your stomach.

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And then this softer stool that's behind

the blockage can overflow around the

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blockage and come out as diarrhoea.

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And then you still don't feel like

you've properly emptied your bowels.

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You still feel blocked and

hard and uncomfortable because

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that blockage is still there.

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It's just that you've had a release

of some of the liquid that's been

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building up behind this hard blockage.

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This can sometimes come out as leakage

or incontinence, which obviously can be

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embarrassing and worrying, and May mean

you feel like you don't want to leave the

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house, like you're afraid to go out in

case you get another one of these attacks.

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The other thing is, it's not like

people who get constant diarrhea, who

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are always feeling like everything's

been emptied out of them, like

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they're just drained and empty.

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Everything's gone.

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People who get this kind of overflow

diarrhea are often still incredibly

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bloated and hard and feel heavy and all

of those normal symptoms of constipation,

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despite the fact you've just had

diarrhea, it hasn't released everything.

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So that is one potential cause for

having a mixed presentation, is that

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actually it's constipation underlying it.

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Another potential cause is that you are.

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going too hard on your medication

or supplements that you take

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to deal with your symptoms.

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So what I mean by this is that you

overshoot in terms of things that get your

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bowels looser because you're constipated.

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So maybe you take too much magnesium

oxide, you take a little bit too

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many laxatives, and then you veer

into very loose and soft stools.

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And then you have that

for a couple of days.

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So you think, Oh, now maybe I better

take some anti diarrhea medication

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because I'm getting a diarrhea attack.

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So then you take one or two

of those for a couple of days.

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Then your stools go very hard and it takes

you another few days to go soft again.

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And the whole time that you're bouncing

around between very loose stools and

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very hard stools and constantly trying to

readjust supplements and over the counter

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medication, You don't know what to eat.

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You don't know what to do.

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And you feel pretty lousy.

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You're still getting straining.

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You're still getting periods

of pain and bloating and the

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bowel habits are irregular.

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You don't know how to deal with them.

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This has actually been shown in some

studies to account for up to one

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third of people who are classified

as having a mixed type of IBS.

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So when we look at that Rome

criteria for diagnosing people with

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IBS, out of, um, A whole range of

people, I think it was 350 people.

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And I'll put the link for this in the

show notes if you want to go and have

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a look at the actual, research paper.

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What they found, is that, 32 percent

of these people, one, were actually,

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uh, overshooting their medication by

taking too many products to loosen

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their stools or to firm them up and that

was actually the cause of their IBS.

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Other things that I see my clients doing

that may be contributing to this pattern

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of erratic bowel habits would be eating

a very low fibre diet and then suddenly

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eating more fibre or not eating enough

food and then eating very large meals.

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So erratic eating habits,

but also a low fibre diet.

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Let's explain a bit about those two.

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So a low fibre diet will mean that you are

struggling to form a good bowel movement.

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Then you might have days when it's

slightly better depending on what you've

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eaten and other days where you're not

eating enough fibre so it really slows

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down and you become a bit constipated.

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Then maybe you eat another day where you

are having quite high fibre, maybe a bit

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more fruit and you're really trying to

make an effort and trying to be healthy.

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And that might then, because they're

higher FODMAP foods, draw water

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into the small and large intestine.

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And that can cause diarrhea and

really cause things to speed up.

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That might be one of the causes to it.

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So your, your erratic fibre intake.

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And then also I mentioned erratic

eating, which means sometimes you skip

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meals, sometimes you eat very large

meals, then you might go for a day

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and, All you eat is dinner and you

just have a few snacks at lunchtime

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and you only eat one main meal a day.

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The most common way I see this is

people who are skipping breakfast.

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Um, that is not going to get your

bowels moving in the morning.

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And that's one of the best times to

open them before you leave the house in

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the morning after you've had breakfast.

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That's the ideal time you want to go

get it done for the day and then it

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might happen again later but it's not

necessarily going to be a problem because

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you have got some of it out for the day.

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Anyway.

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That is also a problem when

you are eating erratically.

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Your body doesn't know what's coming,

when your meal's going to arrive.

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Sometimes then you don't eat for a

while, so you become very hungry.

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That in itself can then lead you to

overeat or eat very quickly, which maybe

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means you're not chewing your food very

well and you're eating it pretty quick.

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So those things are You will have

heard me talk about it lots of times.

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Whoever you are, with whatever kind of IBS

you've got, you should be eating fibre.

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And I know it can be tricky,

and I know people say that

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high fibre foods do bloat them.

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That is why we can start with some low

FODMAP fibres, and some different ways

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of eating that are not going to bloat

you, very gradually increasing your food.

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So that you actually

tolerate fibre better.

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It's almost like you need to train

your bowels up to receive fibre.

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And we can do that in

a really careful way.

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This is what I do when I work with

people in my 3 month gut reset.

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Is working to pinpoint your issues.

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And working to understand how to

improve your experience of eating.

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And for everyone it will

be slightly different.

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Now let's think about what

you can actually do about it.

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So if you're one of those people who

falls into this bracket, firstly, I

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want you to think about whether you

potentially could have that overflow

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diarrhea and you're actually constipated.

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One of the hardest challenges with

overflow diarrhea is convincing people

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that they need to take laxatives when

what they are experiencing is diarrhea.

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So if you feel like you're getting

leakage and very loose stools that

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are very watery, you're still very

bloated, you're not going to necessarily

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come up with the idea of taking more

laxatives because it feels like that's

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going to exacerbate the problem.

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So we do have to be sure that that is

really what you are having, um, rather

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than you do actually have diarrhoea,

because if you have another type

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of diarrhea, for example, and you

take a laxative, it could actually

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significantly make things worse.

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The reason you need to clear out the

blockage is so that you can reset

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your bowel almost, like you can

clear the blockage and then start

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to input the fib If you go straight

back to your old diet, which is very

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low fibre, Hardly eating any foods.

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It's just gonna happen again, and it

will maybe feel better for a little

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while, but it's gonna come back.

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So we need to get rid of that impacted

stall that can happen through laxative

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use You may even have some support

from your doctor to clear blockages.

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Um, it depends really how bad

it is and how stuck it is.

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I know some people also are prescribed

an enema kit to do at home where you

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can kind of wash water up your bum but

it does need to be done under strict

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instructions and I don't recommend

anyone just It starts doing this at home.

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You may also see people suggesting

you put coffee up your bum

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as well as a coffee enema.

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But I definitely don't suggest that.

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Thinking about what you can do other than

that, would be Food, changing your diet.

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So when you clear the blockage,

however, you're going to do that

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through laxative use or through

disimpaction protocol from your doctor

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or hospital, then you need to start

gradually feeding the gut with, fibres

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that are going to keep things moving.

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We need a variety in fibres because, some

fibre is bulk forming, it forms the need

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to stimulate the bowel to want to go.

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Other types of fibre, pull the water

in and kind of keep it soft and jelly

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like and loose so that it can be formed

into a nice squishy stool that just

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comes out in one go and isn't going

to leave you feeling uncomfortable.

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That is the reason you need to normalize

and stabilize your fibre intake and

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it will be done gradually over time.

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It's not going to happen immediately.

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But I do suggest starting with some

low FODMAP foods that are going to

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increase your fibre very slowly.

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If you want a list of things that you

can eat on the low FODMAP diet, you need

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to listen to episode 37, which covers

What can you eat on the low FODMAP diet?

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And in there, I go through some

specific fruits, vegetables,

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grains, and different kinds of

things that you definitely can eat.

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Now, when you're introducing anything to

your diet for the first time, I do suggest

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doing it very slowly, very carefully.

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There's this nice phrase

like start low and slow.

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And I always suggest that for

supplements, but definitely also

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with food, particularly if you

haven't eaten it for a while.

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For example, broccoli, people are a little

bit surprised that this is low FODMAP.

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This is different to cauliflower,

which is very high FODMAP.

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This is why the diet is

really not very intuitive.

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And I do have a self study guide

to following the low FODMAP diet,

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which you can buy off my website,

which includes loads of videos,

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handouts, checklists, and everything

you need to make it super simple.

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But, like I said, listen to episode

37 first, make sure you understand

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what foods you can eat, and then

think about how to increase them.

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If you do that route, maybe you'll

just build it up on your own.

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But maybe you need to actually go

and follow the low FODMAP diet.

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And this is as effective for IBS M as

it is for the other subtypes of IBS.

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If you've been struggling with

your IBS for a while and you

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fall into this category of having

mixed symptoms, then I do suggest

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giving the low FODMAP diet a go.

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One of the problems with following it

for too long though is that you can end

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up restricting your fibre intake long

term because when you're following the

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low FODMAP diet you're cutting out a lot

of fermentable carbohydrates which which

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over time might reduce your fibre intake.

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You have to focus a lot on fibre and

making sure you're getting enough

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when you're in that restricted

phase and then through the

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reintroduction part of the process.

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The FODMAP diet is only meant to be

followed as a dietary intervention

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to identify foods that might

be triggering your symptoms.

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I do think it's worth doing if you

haven't approached it yet and you've

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been struggling with IBS for a while.

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And that's why I put the guide together.

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You can pay for it on my website, and you

can then download meal plans, it shows you

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recipes, and it's got a lot of information

in there about how to manage the FODMAP

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diet, but critically, it's how to get

off it, and that is one of the key things

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that I really feel like I

specialize in with my clients.

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Helping people get back to a broader diet.

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I want you to be eating

foods that you enjoy.

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I want you to get back to eating

normal amounts of foods as

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well that really interest you.

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Not just plain boring foods with

no flavor that you've been eating

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on repeat for weeks and weeks

on end or even months on end.

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The other things you could do would

be to go back to your IBS basic checks

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to run through those things and see if

there's anything that you're doing that

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could be exacerbating your symptoms.

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So when I say the IBS basics, I

mean things like getting enough

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sleep, making sure you're doing

some exercise regularly each week.

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Are you eating three meals a day?

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Are you, you know, just looking

after your stress levels?

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All of those things which are

general good health advice.

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They're not specifically meant for

IBS and yet they are very important.

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I bet you're not doing all of

those things because Who is.

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And again, this is the kind of

thing I can pinpoint with you when

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I work with people one to one.

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So I can look at all the

lifestyle things you're doing.

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I ask you lots of questions about

your sleep and about your exercise

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routines and about how and when you eat.

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Because then we can work out where

things might be able to change.

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And sometimes some of the tweaks are

not as massive as you might think.

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So if you're worried about the

effort that's going to be required

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to get on top of your IBS diet.

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When you work with me over three

months, I can assure you that it

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is piece by piece, step by step.

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There's no expectation that you

do everything all in one go.

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And that's why I meet with my

clients weekly to begin with

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for the first couple of weeks.

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When people say their symptoms are

fluctuating between one to the other

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is also really helpful to track your

food intake and track your symptoms

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where you feel like there's no pattern.

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When you feel like there's nothing you're

doing that's causing these symptoms,

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it just comes out of nowhere, what's

really helpful is to start writing it

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down and start measuring how often you

do actually have a bowel movement and

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where is it on the Bristol Stool Chart?

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If you haven't yet downloaded my

tracker, you can do that for free.

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And that's the same one I use with

my clients to track their food intake

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and also to look at lifestyle things.

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So, feel free to have a

play around with that first.

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Then, If you still don't find anything

and you can't identify anything yourself,

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then get in touch about working with me

one to one in my three month gut reset.

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I will also put a link in the show notes

to my low FODMAP diet beginner's guide,

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because that is a great place to start.

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If you haven't yet tackled the low

FODMAP diet, as I said, it's not

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an easy thing to do on your own.

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So it's definitely worth having some

good guidance, and if you can't work

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with a trained nutritionist who knows

a lot about the FODMAP diet, then

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this guide can help you do it and

manage it by yourself at home through

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videos, instructions, and checklists.

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If you have any questions about this

week's episode, as ever, please send

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me an email or, like I said at the

beginning, send me any suggestions

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for topics you'd like me to cover.

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And I will be back next week.

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Thank you for listening to this

episode of The Inside Knowledge.

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Better digestion for everyone.

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