Irritable bowel syndrome (IBS) is a complex condition and is an umbrella term given to this functional disorder of digestion. One of the problems in getting a diagnosis is that there are other conditions that can mimic IBS. Often people assume they have IBS but there could be other issues lurking. This is why a trip to your family doctor can be helpful in ruling out other possible conditions. In fact conditions that mimic IBS can range from cancer to diverticular disease to coeliac disease. Metabolic disorders such a hypo and hyperthyroidism also impact bowel health. If you are experiencing abdominal distension, pain with bowel movements and relief afterwards or more frequent loose stools or find that you go between constipation and looser stools, a visit to the doctor can be useful to rule out other culprits. In IBS, the colon may either be squeezing too hard in the case of diarrhoea or not hard enough as is the case with constipation, neither of which are issues we should ignore long term.
IBS is thought to affect between 10 and 15 percent of the population and accounts for around 30 to 50% of referrals to gastroenterologists. However the true figure may be much higher as many just live with the symptoms and never seek help. It is also thought to be a leading cause of missed work days behind the common cold.
One thing’s for sure, the prevalence of IBS has increased in recent decades which begs the question, what has changed? What factors could be behind the increased issues with bowel and digestive function? Well when you are steeped in the research as I am, you can’t help but notice the increased evidence for changes to our gut flora which have impacted our digestive health. The reasons for this are many and complex but all sets us up for the perfect conditions for conditions like IBS. Here are just a few examples….
So, you have your diagnosis, what next? Well fortunately there is much that can be done, but often that involves further investigations. Because of biochemical individuality there isn’t a one size fits all approach here. We need to identify our individual triggers and go from there. The most common approaches involve the following.
Increase dietary fibre.
Although this can be an obvious starting point particularly if someone has constipation, we have to be careful about which fibres we choose. Keeping a food diary becomes useful here to note any individual difference in response to foods. In the past people have used wheat bran as a high fibre food. However due to the link between wheat and food allergy and intolerances this is perhaps better replaced with dietary sources of fibre from fruits and vegetables. Psyllium seed husks are a useful and popular way to supplement the diet and can relieve constipation. We also need to be mindful that certain high fibre foods can be a trigger for some people and we need to find our own balance here while we are healing our digestive system. For example, you may see it recommended that you should eat more soluble fibre with prebiotic benefits such as artichokes, leaks, onions and garlic which are ideal for many but if you are one of those who is affected by foods high in fodmaps, this is not going to be the best strategy! It’s also why an appointment with a Nutritional Therapist is invaluable to help you identify some of those challenges and also find out the WHY! We can find ourselves going in ever decreasing circles if we don’t find out the WHY and it can be very frustrating.
Simple tip to do at home to support constipation
Soaked linseeds or chia seeds to relieve constipation. Soak 1-2 tsp of cracked linseeds in half a pint of warm water and soak overnight. Drink on rising and follow with another glass of warm water. Delay breakfast for about half an hour.
It may surprise you to find out that the relevance of food allergies in IBS has been known about since the early 1900’s! Recent studies have shown that around two thirds of patients with IBS have at least one and often several food intolerances. As a result many people find marked improvement following elimination diets. In practice I find elimination diets to be the most helpful in eradicating or reducing symptoms and go from there to identify other triggers. It is quite clear that for some, certain foods provoke an inflammatory response which is thought to be behind IBS symptoms in practice an elimination of common culprits such as gluten and dairy can bring significant relief. Studies have indicated that the most common triggers are dairy and grains. But what if stress is also a component which needs to be addressed or what if there are other inflammatory aspects of foods which are contributing to symptoms? The nightshade foods are an example of this and are also common triggers for many. These include potatoes, tomatoes, aubergine and peppers. When I see people in clinic, the most helpful starting place from experience is the elimination diet. At this point some people also choose to take up the opportunity of food intolerance testing. However, we build a programme over time addressing all possible triggers. This means we are not just looking at foods but also our digestion, whether we eat quickly or slowly, how we prepare foods, our stomach acid levels, digestive enzymes and also whether other medications might be contributing to our symptoms. Sometimes a stool test is done to identify any signs of infection, inflammation and to get a full picture of digestive function. Although food diaries can be helpful at identifying trigger foods, if food intolerance as opposed to food allergy is the issue, testing can be more effective as IgG food intolerance reactions can be from 2 up to 72 hours following consumption. More info on the differences here.
Dietary FODMAPs (Fermentable oligo-di and monosaccharides and Polyols.)
For some people reducing foods that are high in FODMAPs can be the way forward. These are foods with short chain carbohydrates which are poorly absorbed and therefore find themselves being fermented by intestinal bacteria. This fermentation can produce gas and and lead to abdominal bloating. One example of FODMAPs are oligosaccharides called fructans and include wheat based foods, onions and artichokes. Similar to fructans are galactans which are composed of chains of fructose with a galactose molecule on the end. These include legumes e.g. chickpeas, lentils, dried beans, cabbage and sprouts. A well known disaccharide that is implicated in IBS is lactose in dairy products but which also finds its way into other foods such as soups and sweets. Open studies have suggested that one in four patients will see a reduction in symptoms following a low FODMAP diet. This kind of approach can be particularly helpful in cases of SIBO. It doesn't mean eating low FODMAP's forever, as after a period of healing, gradual inclusion of previous trigger foods can be achieved with a very individualised approach.
When IBS appears out of the blue…
If you’ve never had bowel issues before and have suddenly experienced a shift, many questions need to be asked. Obviously a change a living circumstances, different water, perhaps moving abroad or students living away from home for the first time whose diets have changed, all of these issues are going to cause some inevitable changes. However, often changes can follow on from a high stress period or trauma, sudden death, divorce, accident. In practice I’ve also come across clients who suddenly developed a shift in bowel function following a period on non steroidal anti-inflammatories (NSAIDs). Perhaps they were involved in an accident or recently developed arthritis which was followed by a time on NSAID’s. Equally, repeated infections such as UTI’s, sinusitis, tonsillitis and chest infection etc can compromise our gut as a result of repeated rounds of antibiotics and we can find ourselves with IBS type symptoms. Therefore when I’m going through a very lengthy patient history I’m looking for these sorts of patterns which can trigger changes in both digestive and bowel function. Interestingly, autoimmune disease including Inflammatory Bowel Disease (Crohn’s and Ulcerative Colitis) and also increasingly common, underactive thyroid, can follow these kinds of long term use of particular medications due to gut/immune system compromise. If you are experiencing blood in the stool, we would recommend you attend your family doctor to rule out a potential IBD or anything sinister. When we do stool testing we can also see if there are any raised inflammatory markers such as calprotectin which would warrant further investigation via your GP and a secondary care referral.
Multiple rounds of antibiotics can also result in SIBO or small intestinal bacterial overgrowth, which basically means that there is an overgrowth of the number and types of bacteria in the small bowel which would normally reside in the colon. SIBO can also be a part of the IBS story with IBS and low stomach acid as part of the risk factors for this.
Natural approach and supplements
Primarily the Nutritional or Functional medicine approach involves identifying root cause and also triggers, be they food related, drug induced, infection or stress or a combination of factors. We then address the need for some gut healing including reinoculation with good bacteria or probiotics to redress current imbalance. Studies have shown that for some patients a 6 month supplementation with probiotic can reduce symptoms significantly. We use different probiotics which are each researched and appropriate in different situations according to patient history. It is essential to incorporate a gut healing approach so that at least some of the current food triggers or intolerances can be reintroduced back into the diet after a few months of healing and in a controlled manner. This is very much an individual approach and supports each case as we find it. We also offer symptomatic relief while we get to the bottom of individual triggers which can include peppermint oil for its antispasmodic benefits. However, the functional protocol which offers the most comprehensive approach to triggers and drivers in gastrointestinal challenges is as follows and what we call the 5R approach.
Remove: This can apply to eliminating pathogenic bacteria, viruses, fungi, parasites. Also foods that have become triggers. We also remove foods/drinks that are unhelpful to changing the ecosystem in our guts and make choices that support a healthier environment for the good bacteria.
Replace: This involves identifying anything that is missing which could be contributing to a picture of compromise. Digestive enzymes are very relevant here and stomach acid. A lack of the necessary enzymes to break down and digest foods can lead to nutrient deficiencies and a range of symptoms and conditions can result.
Reinoculate: This refers to the reintroduction of good bacteria or probiotics into the intestine to reestablish the microflora balance. This can incorporate food form and supplements as appropriate.
Repair: The Gastrointestinal mucosa represents the largest mass of rapidly proliferating cells and repair is needed whenever there has been a loss of integrity of structure or function or both. Damage can result from chronic nutritional insufficiency, food allergen, dysbiosis, xenobiotic exposure (toiletries etc), pathological intestinal infection and chronic inflammation. Nutrients required include glutamine , essential fats, and zinc.
Relax: You may have heard of the gut brain connection and personal experience will indicate the impact of stress on gut health! However, when it comes to finding a comprehensive approach to creating a healing environment in the gut it is essential to address this aspect. That means recognising and finding approaches to rebalance the mental, spiritual and emotional aspects of our lives so as to support a move away from sympathetic dominance to parasympathetic in digestive function.
Whatever your story and range of symptoms, it's important that you get to the bottom (if you'll pardon the pun!) of this one. Living with compromised bowel and digestive function can compromise our immune health, mental health and long term leave us vulnerable to a range of conditions. If we are not absorbing nutrients properly, this can lead to low energy levels and often we find ourselves with a range of unexplained symptoms further down the line if we continue to ignore the condition. To give an example of where IBS can cause nuisance, there are many out there who have experienced repeated iron deficiency over the years. Often with the right support for gut healing this kind of problem can be prevented.
Further information on what's involved in a Nutritional Therapy consultation here
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