Q&A With Registered Dietitian Tamara Duker Freuman, MS, RD, CDN
Author Of “REGULAR, The Ultimate Guide to Taming Unruly Bowels and Achieving Inner Peace”
America’s Trusted Digestive Nutrition Expert joined us for an in-depth interview to discuss the many causes of bowel irregularity, with tailored solutions for a dozen common— and some lesser-known— digestive issues.
Rather than focusing on a single one-size-fits-all approach to restoring bowel regularity, REGULAR aims to help readers identify the likely cause of their irregular bowel patterns and offers a wide variety of personalized solutions.
Belly bloat, diarrhea, constipation, and irritable bowels may not seem like the sexiest topics— but they still affect millions of Americans every year.
We delve into all this and more in our recent interview with Tamara, including diarrhea and constipation symptoms, the various causes of bowel irregularity, and tailored solutions for common as well as lesser-known digestive issues. Tamara also provides insights into managing irritable bowel syndrome (IBS) and offers personalized strategies for achieving digestive wellbeing.
Let’s get into it.
Congratulations on the new book and all the incredibly well-deserved praise it’s already gained. We’re so glad you could join us to share your expertise. To get started, could you share your background and expertise?
Sure thing! I’m a registered dietitian who’s worked in NYC-based gastroenterology practices for the past 13 years, treating patients with all manner of digestive symptoms and conditions. Over the years, I’ve seen it all– from garden variety acid reflux and IBS to very complex medical conditions and unusual food intolerances. I earned my master’s degree in clinical nutrition from New York University and completed my clinical training at Mt. Sinai Hospital in New York.
What prompted you to write this book? What are the most common conditions you see in your practice? What conditions are covered in the book? Who is the book designed to help?
Anytime I find myself repeating the same mantras to patients over and over or correcting the same misconceptions about digestive regularity again and again… I know it’s time to write a book. Working in a gastroenterology practice for so long, I’ve developed a really effective method of assessing peoples’ symptoms and connecting the dots to uncover the patterns that lead to effective nutrition interventions–or in some cases, even to assist my physician colleagues in the medical diagnosis.
But I am one person and not particularly scalable; not everyone has access to an expert GI dietitian like me. Writing a book is my way of giving tens of thousands of people–or more, hopefully– access to expert, evidence based, clear and practical information that they can use to improve their digestive wellbeing.
REGULAR covers the top 10 most common causes for diarrhea that I encounter in my clinical practice, and the three main causes of constipation. These include everything from Irritable Bowel Syndrome (IBS), celiac disease and inflammatory bowel disease to “IBS mimickers” like SIBO, bile acid malabsorption, sucrose intolerance and histamine intolerance. I also get into various causes of constipation, including pelvic floor dysfunction, which affects an estimated 40% of people who suffer from chronic constipation.
With such broad reach and a diagnostic quiz to help readers find themselves in one of the chapters, this book truly is for everyone who suffers from chronic bowel irregularity, whether diarrhea, constipation or a very un-fun mix of the two.
Can you tell us a little more about what it means to have a regular bowel pattern? What is an irregular bowel pattern? How do other symptoms, like pain, bloating and gas, fit into the picture?
Regularity can be defined by both subjective and objective measurements. By the “book,” a normal range would entail anything from 3 bowel movements per week to four bowel movements per day. But honestly these stats tell me very little about how regular you are, because they ignore the subjective experience of how you feel that is what most people care about.
You could be “normal” on paper based on having two bowel movements per day, but each time you go the stools are hard, require straining to pass and never feel complete; you still wind up constantly feeling a need to go more but you can’t and are constantly bloated as a result. Or maybe you go twice daily but the stools are crampy and urgent and you’re always worried about when the urge will strike and if you can make it to a bathroom in time. Conversely, I’ve had patients who only moved their bowels about twice per week, but they actually had zero complaints…. Each time they went, they’d have a very large, satisfying stool that was easy to pass and there was no pain, bloating or excess gas on the inbetween days.
Regularity is in the eye (or abdomen?) of the beholder. You’ll know you’re there when your bowel patterns no longer occupy more than a fleeting thought or tiny percentage of your mindshare because your bathroom patterns are not problematic enough to intrude on your life.
You’re known for your diagnostic algorithms that help patients (and providers) understand symptoms and what might be driving them. Can you tell us more about the quiz you’ve developed for this book? How does it work? Who can it help?
Both of my books start off with a short, symptoms-based quiz that attempts to recreate the type of differentiating questions I’d ask a patient in my care as I work to make an educated guess about the likeliest cause of their irregularity. The answers you give get tallied up and provide a cluster of data points that should point to one or two conditions that are characterized by those specific types of symptoms. This helps readers flip directly to the chapters in my book that may be most relevant for them, read about those conditions, and determine whether it seems like a possible fit. If so, there are dietary suggestions readers can try implementing as well as suggestions for talking with their own doctors about their symptoms or possibly even diagnostic tests or medications that could be relevant.
“For people who do have a diagnosis but do not feel their diagnosis ‘fits’”
The quiz is primarily for people who do not yet have a medical diagnosis, or for people who do have a diagnosis but do not feel their diagnosis “fits,” perhaps on the basis of not responding to any of the treatments they’ve already been offered. The quiz does not actually provide a definitive medical diagnosis, but it can be used to facilitate the types of dietary trials and conversations that can help facilitate obtaining a medical diagnosis from a physician.
Many of our readers are interested in learning more about FODMAPs and their relationship to symptoms.
Can you tell us about some of the FODMAP related conditions you cover in it? What should readers know about FODMAPs?
REGULAR has chapters on diarrhea-predominant IBS (IBS-D) and Small Intestinal Bacterial Overgrowth (SIBO), both of which are “FODMAP related conditions,” so to speak. I also have a chapter on osmotic diarrhea from carbohydrate intolerances, which I lovingly call “the sugar runs,” which discusses fructose and polyol malabsorption, with lists of foods that contain each of these FODMAPs. There is a chapter on constipation predominant IBS (IB-C), though truthfully I don’t find FODMAPs to be as central an issue in this condition.
We also know many GI symptoms can be driven by non-FODMAP causes. Could you share about some of those conditions? What advice can you share with readers about how to tell if these might be contributing to symptoms?
FODMAP avoidance has become somewhat overused in the GI field, I think, and people with all manner of symptoms are being offered this diet as a solution whether or not they are good candidates for it.
“If you have been following a low FODMAP diet for two weeks and you are not notably better, my best advice is to move on”
If you have been following a low FODMAP diet for two weeks and you are not notably better, my best advice is to move on… it’s not the FODMAPs, and the longer you stay on the strictest elimination phase, the more fearful you may become of liberalizing your diet. There is no point in getting stuck on a diet that is not helping you.
By far the number one reason I see for people not improving on a low FODMAP diet is that they are extremely backed up with stool. A high stool burden produces bloating and abdominal pain regardless of what you eat, and while extremely high FODMAP meals could make you feel worse, eliminating all FODMAPs rarely makes you feel much better.
Other “IBS mimickers,” like sucrose intolerance or bile acid diarrhea, can also create gas, bloating and diarrhea that would not respond to a low FODMAP diet. People who feel WORSE on a low FODMAP diet should especially consider sucrose intolerance as a possibility, since often sucrose intake is HIGHER on a low FODMAP diet. There’s no easy way to tell if bile acid diarrhea is causing your symptoms of urgent, loose, sticky or frequent stools– though sometimes very high fat meals will make things worse for you the following day. We often land on this diagnosis after you have failed to respond to multiple diets and treatments and diagnostic tests have turned up empty. Rumor has it there will soon be widely available diagnostic tests for bile acid diarrhea here in the US, so hopefully this will become a much easier diagnosis to come by in the near future!
Is there any other advice you can share on how to tell if FODMAPs are causing symptoms? Are there clues that can tell you when FODMAPs are likely not the culprit?
If you are symptomatic 24/7, fasted or fed, it’s not the FODMAPs.
If you follow a strict FODMAP elimination for 2 weeks and your symptoms are not better, it’s not the FODMAPs. (You can’t blame your symptoms on foods you are not eating, after all!)
If you don’t have the wherewithal to do the elimination diet, then you can try tracking whether symptoms onset in the aftermath of consuming a higher FODMAP food.
“expect to start feeling symptoms of a FODMAP intolerance 4-8 hours after consuming a food”
For people with normal digestive transit times, you should expect to start feeling symptoms of a FODMAP intolerance 4-8 hours after consuming a food– and certainly no sooner than 2 hours. This is how long it takes for undigested FODMAPs to make their way to your colon, where the symptoms generally originate. The exception to this rule is for people who have SIBO, who will experience symptoms much sooner, since the symptoms originate further upstream in the digestive process (the small intestine). In these cases, you may start feeling symptomatic within an hour of consuming higher FODMAP foods. These types of FODMAP reactions are often temporary, since they are secondary to SIBO. If SIBO can be successfully eradicated, you may find yourself able to tolerate these foods again.
We were honored to be mentioned in the book. Can you share a little more on how digestive enzymes, like FODZYME, can help those with FODMAP intolerances?
Enzymes are proteins that facilitate specific chemical reactions, and digestive enzymes are proteins that facilitate the breakdown of components in our food into smaller, absorbable molecules. For a digestive enzyme to work, it needs to be matched to the specific food component that it is designed for. A protein-digesting enzyme cannot help you break down fat, and a fat-digesting enzyme cannot help you break down lactose (milk sugar), for example.
Historically, digestive enzymes have been minimally helpful for many of the patients I worked with, because the commercially available digestive enzyme cocktails being marketed did not actually contain enzymes specific to the food components that gave my patients the most trouble– especially the fructans in onions and garlic. Even when they did have some helpful enzymes–like lactase for lactose (milk sugar) and alpha galactosidase for the type of gassy carbs in beans, chickpeas, brussels sprouts, cashews and more– the doses were typically really low because the products needed to make room for a dozen other enzymes that were, frankly, pretty redundant and useless for the typical person whose pancreas was functioning well and producing adequate levels of the ‘basic’ enzymes.
“more targeted than the first generation digestive enzyme products”
When FODZYME came to market it really was a game-changer for my practice and my patients, because it contained just the three enzymes specific to the foods that give my IBS patients the most trouble, and it actually contained these enzymes at therapeutic levels. A product like this can mean the difference between being stuck on a strict low FODMAP diet indefinitely in order to be able to feel functional, and being able to eat with minimal restriction, dine out and travel without worry. It’s so much more targeted than the first generation digestive enzyme products that contain a bunch of different enzymes that people with IBS usually don’t need and not enough–or any–of the enzymes they do.
Here at FODZYME, we often talk about how important it is to develop the most liberal diet possible (ideally full of fruits, vegetables and whole grains), while still controlling symptoms.
We know this is important for gut health, as well as for enjoying the social experience of eating. Can you share a little on the role of fiber in promoting bowel regularity? Without getting too much into the weeds, what are the different types of fiber and what are their benefits?
Dietary diversity of fiber promotes microbiome diversity, and microbiome diversity is a key indicator of your gut microbiome’s resilience– in terms of resisting infection by pathogenic (disease causing) bacteria and bouncing back after an insult, like a norovirus, food poisoning or antibiotics.
Different types of fiber also have different physical properties in the gut. Soluble fiber dissolves in water, forming a viscous gel that helps keep stools soft and hydrated through the long journey in the colon. It’s often the ‘glue’ that holds poop together and can prevent both diarrhea/looser stools as well as constipation and hard/dried out stools. It’s found in grains (especially oats and barley), fruits, root veggies and squashes.
Insoluble fiber is the coarse, ‘roughage’ type of fiber that does not dissolve in water– it retains its bulkiness and can stimulate the bowel walls to contract and keep motility chugging along. It’s found in leafy greens, nuts, seeds and berries. Diarrhea prone people may find too much insoluble fiber to be excessively stimulating and cause looser, more urgent or frequent stools. In some cases, too much insoluble fiber can also be constipating– if transit time through the colon is prolonged, insoluble fiber can contribute to stools that are hard and dried out, since it does a lousy job holding on the moisture.
Dietary variety helps people find a natural balance between these two types of fiber that compliment one another and help promote regularity. Extreme elimination diets– especially very low carb or keto diets– often distort fiber intake heavily to insoluble fiber. Some people find this can make them unexpectedly diarrhea OR constipation prone.
Is there any other advice you’d like to share with readers on how to tame their unruly bowels?
You really need to get to the bottom of what’s causing your unruly bowels if you want to tame them, and that’s what REGULAR was written to help you do. There are literally dozens of reasons why your bowels may be misbehaving. Therefore, diet for regularity is NOT one-size-fits-all, and most of the ‘gut health protocols’ or Instagram infographics that offer a single approach to managing constipation or irregularity will have no relevance to you as an individual. Read my book!
How can readers order your book and find you on the world wide web?
REGULAR is available everywhere books are sold in the US, Canada, the UK and Australia/New Zealand. Look for it on Amazon, Barnes & Noble, or your local indie bookstore!
You can find me at www.thebloatedbellywhisperer.com, on Twitter @tamaraduker and on Instagram @bloatedbellywhisperer
And that's a wrap!
Thank you, Tamara, for sharing your expertise on the causes and treatments for bowel irregularity. From diarrhea and constipation symptoms to how to develop a personalized approach to relieve digestive distress, there is truly so much to cover when it comes to achieving relief for those who experience chronic constipation, diarrhea and digestive trouble. Tamara’s expertise in managing irritable bowel syndrome (IBS) and her comprehensive coverage of digestive health conditions and interventions makes her book "REGULAR" a truly insightful and actionable guide for anyone seeking relief from irregular or infrequent bowel movements. Whether you're experiencing belly bloat, diarrhea, constipation, or a mix of symptoms, Tamara's evidence-based strategies and personalized solutions offer a path towards achieving inner peace and digestive wellbeing. Don't miss the opportunity to learn from her years of experience helping patients transform their digestive health and achieve relief from digestive symptoms.
In addition to her impactful work in the field of digestive health and her insightful book "REGULAR," Tamara Duker Freuman showcased her expertise and commitment to advancing digestive wellbeing at Digestive Disease Week 2023. At the event, FODZYME had the honor of having Tamara represent FODZYME at our booth, where she engaged with fellow registered dietitians and gastrointestinal doctors.
The attendees were eager to discuss her book and gain valuable insights into her evidence-based approach for managing various digestive issues. Tamara's discussions extended beyond her book's content to include the innovative use of FODZYME as part of her treatment strategies for patients. This dynamic exchange highlighted the significant impact she and FODZYME are making in the field of digestive health, providing a platform for healthcare professionals to explore new avenues for helping individuals achieve optimal digestive wellbeing.
Images: Tamara Duker Freuman and "REGULAR" at the FODZYME booth at the Digestive Disease Week 2023.