If you have Irritable Bowel Syndrome (IBS), you are certainly not alone – with a worldwide prevalence of between 9% and 23%, it is considered to affect around 1 in 5 people in the United Kingdom at some point in their lives.
With April being National IBS Awareness Month, we thought it would be useful to review this common condition and the natural and nutritional support that is frequently adopted in an attempt to relieve the symptoms.
What is IBS?
Irritable Bowel Syndrome (IBS) is a common condition, described as a functional disorder that affects a wide range of men and women, including young adults. It is considered to affect up to 1 in 5 people during their lifetime.
The exact cause is considered unknown, although onset can sometimes be traced to infections of the Gastroinstestinal (GI) tract. Many patients and practitioners also consider that the onset of symptoms can be linked to life events or periods of stress and anxiety.
The medical approach to the condition focusses on symptom relief, with prescription drugs to reduce pain and intestinal muscle spasms, anti-diarrhoea preparations, laxatives for constipation, and anti-depressants.
The latter is a controversial subject, however IBS sufferers often confirm that the symptoms of their condition lead to low mood and an increase in anxiety.
Please note that IBS should not be confused with IBD, which refers to inflammatory bowel disease – usually considered to cover the conditions of Ulcerative Colitis and Crohn’s Disease.
Ulcerative Colitis – In this condition, small ulcers and inflammation develop on the inside of the colon and sometimes the rectum, with symptoms of urgent and bloody diarrhoea, pain and continual tiredness. When symptoms are located only the rectum, this is referred to as proctitis.
Crohn’s Disease – Inflammation, deep ulcers and scarring to the wall of the intestine often occurs in patches, affecting anywhere along the GI tract from the mouth to the anus. The areas most commonly affected are the small intestine and colon. The main symptoms are abdominal pain, urgent diarrhoea, tiredness and weight loss.
Common Symptoms of IBS
Diarrhoea – One of the most common symptoms of IBS is diarrhoea, requiring frequent and urgent visits to the toilet. This may be more severe in the mornings after waking; eating or drinking can also trigger urgent diarrhoea, as can feelings of stress and anxiety.
Intermittent pain – Frequently described as ‘colicky’ or spasms of pain, intermittent pain may occur in different parts of the abdomen. This pain may ease after the passage of wind or a stool. Bloating and general discomfort in the abdomen are common, which can unfortunately be aggravated by some medications used during treatment. Nausea and loss of appetite may also be present.
Constipation – This presents a different side to IBS. A frequent sensation is one of needing the toilet, yet unable to pass a stool, or a sense of incompletion during a toilet visit.
Diagnosis is usually carried out from monitoring symptoms, or after other conditions have been excluded by tests and investigations. Blood samples are frequently taken to rule out conditions such as anaemia, inflammation and the presence of antibodies. It is possible that blood tests for IBS may be used in future diagnosis, as research reported in 2009 (which assessed serum bio-markers patterns) demonstrated a 70% accuracy for test results (AJ Lembo 2009).
Clinical approaches to treating IBS
An ideal start is for clients to record a diary of their food intake plus a detailed diary of symptoms and any lifestyle events that may occur during periods of symptom aggravation. This information may provide evidence for food or stress inciters and assist in establishing the most suitable support.
Unfortunately, there can be no one treatment for IBS as symptoms can vary greatly between patients. Over the years the medical recommendation for increased fibre in the diet in terms of helping with the symptoms of IBS has changed from ‘promoting’ to ‘avoiding’ to ‘may be suitable for some’.
Some people report having received medical advice to eat a ‘junk diet’ to combat symptoms, the lack of fibre in this diet may well improve some people’s symptoms in the short term, however long term implications for health of the digestive system and general health of the patient are a concern for this method.
Introducing large quantities of insoluble fibre to the diets of clients with IBS is likely to cause problems, particularly if the diet previously contained highly refined foods.
A gradual change to the diet is essential, introducing those foods which are easier to digest in the initial changes and in small portions. Clients frequently perceive bran as the only source of fibre and a health option, however it is important to note that bran can be an undesirable irritant on the bowel, and hence is not ideal.
Sugar, sweeteners, refined and processed foods and a lack of natural fibre may be responsible for symptoms of bloating, pain, flatulence, diarrhoea and constipation.
For those who do experience constipation, adequate fibre, fluids and regular exercise can often result in improved transit time, therefore reducing bloating, flatulence and pain. Inadequate hydration can also increase problems.
Soluble fibre is often the best fibre to introduce and is provided by fruit, vegetables, pulses and oats – although these also contain some insoluble fibre. Introducing these foods, cooked initially, may increase patient tolerance by providing them in an easier-to-digest form.
A gradual increase in both variety and quantity is likely to achieve more successful results. For those that seem unable to tolerate these foods look at and compare those that are excluded on the FODMAP diet (see below) as this may be relevant.
FODMAP carbohydrates are particular types of carbohydrates and fibres found in certain grains, fruits, vegetables, dried peas and beans, milk products and processed foods and drinks. FODMAP stands for Fermentable Oligo-Di-, Mono-saccharides and Polyols. Specifically some of the dietary carbohydrates described by the term FODMAP are lactose, fructose, fructans, polyols and galactans. FODMAPs have several things in common:
– They are all carbohydrates
– They are sometimes poorly absorbed
– They are all rapidly fermentable by gut bacteria
– They can all disrupt the fluid balance in yoru gut
In some people ingested FODMAP carbohydrates are not absorbed as they should be in the small intestine, instead they pass through the far end of the small intestine and into the large intestine.
FODMAPs act as fast food for the bacteria which give off a lot of gas as they ferment the food. The gas makes your large intestine swell and you experience bloating. Another problem is that FODMAPs can draw fluid into the intestine. Pain and watery urgent diarrhoea can result. In other cases changes to fluid and gas production are associated with constipation.
You may be able to tolerate some FODMAPs in your diet. It is the total load from all sources that causes a problem. This may be from a large quantity of a single food or smaller amounts of several different FODMAP foods added together over a period of time (e.g over a day or a few days).
Please note that a low FODMAP diet involves initially restricting a considerable number of foods which some may find very difficult; however it is not intended to be a long-term diet and because of the restrictive nature and complexity it is best done with the guidance of a practitioner.
Some examples of foods to be avoided on a low FODMAP diet include:
- Fructose found in fruits, honey, high fructose corn syrup etc
- Lactose found in milk products
- Fructans found in wheat, garlic, onion and chicory etc
- Galactans found in legumes; including beans, peas and lentils.
- Polyols found in sweeteners containing isomalt, mannitol, sorbitol, xylitol plus stone fruits such as avocado, apricots, cherries, nectarines, peaches and plums.
After excluding high FODMAP foods for a month, foods from each FODMAP group should be reintroduced, one at a time (e.g foods containing fructose, then foods containing lactose etc). During the reintroduction symptoms should be monitored and if a FODMAP group of foods causes problems then continue to eliminate this group.
Wheat is a FODMAP so this is eliminated on a low FODMAP diet – Gluten is also found in rye and barley (not FODMAPs) but these tend to be less frequently eaten foods – so FODMAP exclusion may, by happy coincidence, also result in gluten exclusion. Could the improvements seen be due to gluten elimination?
Gluten sensitivity and IBS
Animal studies have shown the potential for IBS symptoms to be linked to a gluten sensitivity. Laboratory tests demonstrated elevated IgG to wheat (as well beef, pork, lamb and soya bean) in IBS patients. IgE response is low and found only in a small number of patients.
Some patients who have been diagnosed with irritable bowel syndrome (IBS) report a lessening of symptoms when they follow a gluten-free diet. And although good quality studies are limited, the American College of Gastroenterology concludes that a gluten-free diet holds promise for IBS patients.
Intestinal permeability is considered an important factor in food intolerance and research has confirmed the presence of small intestinal permeability in diarrhoea-predominant IBS sufferers. In this research those whose IBS onset was not considered to be linked to infection, appeared to have an increased defect in permeability. It has been established that gluten increases intestinal permeability, even in healthy individuals, through increasing expression of the protein zonulin. A previous blog on leaky gut discusses this in more depth.
The 4-Step Plan to IBS
Functional medicine practitioners use a 4 step plan for IBS called the 4-R programme. This programme involves identifying and removing dietary and lifestyle factors that may be damaging the gut, replacing missing factors and adding in gut healing nutrients for repair.
Remove – Sugar, alcohol, processed foods plus any foods that are already known to cause a reaction. Other foods which often contribute to IBS include gluten, dairy and FODMAPs so eliminating perhaps gluten and dairy to start with (followed by FODMAPs if necessary) should be considered. Other factors to remove/reduce include stress, and non-steroidal anti-inflammatories (unless these have been prescribed by a medical practitioner). If there is an overgrowth of undesirable bacteria or yeast this will also need to be addressed using appropriate anti-microbials.
Replace – use digestive enzymes (and betaine hydrochloride if indicated) as natural production of digestive enzymes and stomach acid may be compromised in a leaky gut. Ensuring adequate digestion of food will help with absorption and prevent undesirable bacteria from using the food.
Repair – with digestive tract healing nutrients such as l-glutamine, aloe vera, curcumin, essential fatty acids and vitamins A and D. It is important this step is not overlooked – if the gut is not healed then further food sensitivities may develop and you may not see a full resolution of symptoms.
Rebalance – with live bacteria and additional nutritional support. Live bacteria are needed to rebalance the gut flora. In addition there may be a need for additional nutritional support – if digestion and absorption have been compromised for some time short-term additional nutrients will be needed to address any specific needs identified, along with a good quality multivitamin and mineral in both the short-term and for long-term maintenance.
Research has demonstrated the benefits of a certain bacterial species in IBS, and a large scale trial using Bifidobacterium infantis showed statistically significant beneficial results. Prebiotics, an indigestible polysaccharide which provides food for the gut bacteria, can be beneficial. Initial or high doses of prebiotics may initially aggravate some patients’ symptoms, with some bloating and flatulence: introduction should be gradual and monitored.
For those who have an imbalance of bacteria or Candida, the use of Saccharomyces boulardii may be suitable. This beneficial yeast has been subject to much research with positive outcomes for the treatment of Candida infections, bacterial infections and antibiotic-associated diarrhoea, and small trials have shown positive benefit in Crohn’s disease.
Native Friendly Bacterial products (formerly known as probiotics) include:
Acidophilus Plus – 9 strains of live native bacteria with activity throughout the whole GI tract. Most suited to people under the age of 40 and ideal for long term use in those susceptible to GI disturbances. Comes in two sizes of 30 and 60 capsules.
Fos-a-dophilus – Ideal for those over the age of 40, this live native bacteria supplement is high in bifidobacteria which colonise the large intestine and are most often less easily replenished in those over the age of 40. Helpful for IBS conditions and suitable for daily long term use. Comes in one size of 60 capsules.
Cyto-biotic Active – This is a 9 strain product with activity throughout the whole GI tract. Ideal for all ages and helpful against severe acute GI gastrointestinal upsets. Comes in two sizes of 50g and 100g of powder.
Aloe Vera Inner Leaf – The inner leaf gel of Aloe Vera is a product which may well be beneficial to IBS symptoms of both constipation and diarrhoea. The inner leaf fillet contains higher levels of salicylates, and a small amount of aloin, and is used for its anti-inflammatory action, assisting with the healing of the gut.
L-Glutamine – Glutamine assists in the regulation of the acid base balance of the body, and systems such as the immune system and gut also require glutamine for energy production. Glutamine has been found to have a positive impact on the intestinal barrier, reducing permeability and preserving mucosal integrity and encouraging turnover of the serous and endothelial lining to produce new healthy tissue.
Slippery Elm – A traditional remedy for digestive upsets, when mixed with water Slippery Elm produces a thick mucilage that coats the intestinal membranes and providing a soothing action on the digestive system.
If you have any questions regarding the health topics raised in this article then please do get in touch via phone (01684 310099) or e-mail ([email protected])
Amanda Williams & The Cytoplan Editorial Team: Joseph Forsyth, Clare Daley and Simon Holdcroft