This case is a composite drawn from clinical encounters over many years. Names, timelines, occupations, and identifying circumstances have been changed. No individual patient is depicted. The clinical pattern has been preserved.
She said it once while describing the abdominal pain.
“I kept going.”
She said it again when I asked how long she had followed the diet.
Eight months.
No garlic. No onions. No wheat. No beans. No restaurant meals unless she had chosen the menu first.
She had started a low-FODMAP diet after years of bloating and unpredictable bowel symptoms. At first, it helped. Her abdomen felt quieter. The improvement was real.
Then the temporary restriction became the permanent plan.
She had never been taken through systematic reintroduction. Nobody had asked which foods actually caused symptoms. Nobody had helped her find the broadest diet her body could tolerate.
Instead, she became better at restriction.
She carried food to family gatherings. She declined dinner invitations. She read labels until eating required more vigilance than hunger.
“I kept going,” she said again.
I asked what happened when she tried a food outside the plan.
She did not describe the symptom first. She described the fear.
That changed the visit.
The diet was not wrong. The sequence had stopped halfway.
The American Gastroenterological Association describes the low-FODMAP approach in three phases: restriction for no more than four to six weeks, reintroduction, and personalization. The American College of Gastroenterology recommends only a limited trial, and grades the evidence as very low quality.
Restriction had given her useful information. It was never meant to become her identity.
The diet was not wrong. The sequence had stopped halfway.
We did not tell her to eat everything. We did not dismiss the symptoms as anxiety. We treated the fear and the bowel symptoms as different information.
She began with one food, one amount, on one ordinary day. Then she watched what happened.
Not what she feared would happen. What happened.
The goal was not perfect digestion. The goal was a life in which digestion did not make every decision.
At the next visit, she had added several foods back. Some still caused symptoms. Others did not. The list was smaller now.
So was the fear.
Near the end, she said it once more.
“I kept going.”
This time, she meant something different.
This case note is the companion to Tuesday’s essay, The Day Discipline Became a Symptom.
Case Notes are short stories from the exam room, the moments that change a visit. Subscribing is free, and it's how the next one finds you.
If someone you love has been on a “temporary” diet for months, send this to them.
Have you ever kept going with a plan long after it stopped helping? Tell me in the comments. I read them.
Dr Shiv Kumar Goel is an internal medicine and functional medicine physician, founder of Prime Vitality Care in San Antonio. Across 25 years in hospitals, intensive care, and functional medicine, he has studied the gap between what medicine can measure and what patients actually live through. He writes Healing the Split and is the author of the forthcoming book Healing the Split: When Your Biology Is Fighting Your Biography.