Stop putting my clients on restrictive diets for GI stuff

One of the less discussed but very difficult things about being a healthcare practitioner is “staying in your lane” when your client’s presenting concerns have roots or branches that extend outside of your scope. I’m a Licensed Professional Counselor (OR) and Licensed Mental Health Counselor (WA) and especially when I treat folks with OCD, health anxiety, body dysmorphia, and skin picking/hair pulling, what I’m treating often intersects with medical concerns. I want to be careful with what I say here, but not so careful that my message gets lost so let’s start with stating the obvious:

"I’m not a doctor and nothing I say here constitutes medical advice or is a substitute for your medical team advising you, through their expertise, on your personal health.” - Katie

I see a lot of folks with digestive issues. I talk a lot about gas, bloating, poop, and vomit in my practice. I treat emetophobia (fear of vomiting) and because the gut-brain axis is tightly connected, a lot of folks with OCD and other anxiety have GI issues.

Medical rule out is vital

First, before you think I’m dogging on all medical practitioners, I am not. Medical rule out is a vital part of treatment anytime body symptoms are associated with distress. We’ve been talking about the rising incidence of colorectal cancer in younger people for years. No amount of psychotherapy I do will treat colon cancer, ulcerative colitis, Crohn’s disease, etc. I do not EVER want to be the person who urged a client to think of their gas as “just anxiety,” and for them to die. I’m a BIG FAN of primary care doctors and gastroenterologists ruling out things they can treat or cure. In fact, I require it for clients who have objective symptoms and who have not recently seen a physician. We NEVER EVER treat GI distress as “just anxiety” without substantial medical evidence to support that hypothesis.

What happens from here concerns me

Once we’ve ruled out really scary stuff, many clients, especially those anxious about their gut behavior, turn to alternative practitioners to treat their bothersome GI tract. Before you think I’m going to dog on alternative health practitioners, let me emphasize my love of what my acupuncturist did for my migraines (I’m still sad you retired, Kate). But I do think that some alternative practitioners are quick to jump to evidence-poor diagnoses and treatments of various GI complaints without considering a risk/benefit calculation of how these treatments may impact a patient’s mental health.

Feeling so upset about diet culture and the intersection with OCD.

It’s true - there is definitely evidence that there is a gut-brain connection and I often tell clients “I wish I could fast forward 100 years and find out what we’re going to know about how to treat mental health concerns through the gut!” But we’re not there yet. We don’t have clear dietary interventions for mental health stuff and there is a lot of debate about how to treat even GI symptoms themselves with diet. Take small intestinal bacterial overgrowth, for example. There is some solid evidence that it happens. The truth about testing and appropriate interventions is EXTREMELY murky and does not justify the number of clients who present to my practice with SIBO diagnoses by naturopaths. I cannot see any evidence, when looking at peer-reviewed studies, that highly restrictive diets make a huge difference for most people with SIBO but everybody I see in my practice with that diagnosis is highly anxious about food and their responsibility to stay on their SIBO diet.

Evidence of harm

I’ve recently become an extreme fangirl of Christy Harrison and her FoodPsych podcast. As a registered dietitian, she illustrates through her website, podcast, and program the harm that comes from using loosely evidence-based interventions that involve prescribing restrictive diets - elimination diets, etc. Christy features folks on her podcast who developed eating disorders secondary to medically prescribed restrictive diets. It’s horrifying. While I love her podcast, it’s also made me so, so angry at my colleagues who don’t consider mental health impacts of their prescribed treatments.

In my practice, I see folks with health anxiety who are desperately trying to control symptoms of sensation in their guts, increasingly restricting what they consume. I see folks with orthorexia, trying to attain the perfect “healthy” diet and blaming and shaming themselves anytime they eat a “BAD” food. I see people who carry their stress in their guts and who have had tons of scopes to ensure nothing is wrong, spend THOUSANDS of dollars chasing dubious diagnoses and treatments for their gassy, overly motile guts, which in the end, seem to resolve a bit with acceptance and anxiety treatment.

Medical professionals, please…

• Only prescribe dietary changes to patients when you have a clear evidence-based reason to do so. Food can be medicine but it’s also fuel, comfort, love, culture, art, and so many things beyond medicine. Your advice has impacts beyond GI health.

• Screen your patients for OCD, body dysmorphia, eating disorders, and other mental health diagnoses before assuming the benefit of your diet outweighs the risk to the whole person.

• Consult with your patients’ mental health providers on whether this client is a good candidate for major dietary changes, based on their mental health. Some folks have life and death risks here.

• Highlight the psychological and medical risks of dietary restriction and warn your patient that even a person with NO HISTORY of eating disorders can develop an eating disorder from a single restrictive diet.

• Remember to question everything about diet culture and how it has impacted you as a health practitioner. The “wellness diet” is a diet. The “hunger and fullness diet” is a diet. Review Health at Every Size literature. Unless you have GREAT evidence of benefit, don’t disregard the harms to the client that can occur with restrictive eating of any type. The risks are real but difficult to measure.