Did you know that Irritable Bowel Syndrome (IBS) is the most common cause of employee absenteeism next to the common cold? I had no idea until I started doing this work. The reality is, IBS affects 10-20% of U.S. adults and is one of the most common reasons patients visit a doctor. Why is this so underappreciated? Because people don’t talk about it because IBS symptoms are embarrassing. Interestingly, many people find when they do open up to others about their struggles with IBS, other people admit to having similar problems!
Once of the biggest frustrations many of my patients encounter when they have been living with IBS, or have just received an IBS diagnosis, is that there are not any great medical solutions for IBS. This is because there are many factors that can contribute to IBS, and symptoms can be so inconsistent, it leaves the medical system scratching its head. In fact, the GI task force of the American Gastroenterological Association considers IBS an area of great failure because there are not medications that do much more than moderately alleviate local symptoms, and even these medications do little to address the global symptoms of IBS.
Symptoms of IBS can include:
IBS is considered a functional disorder, which means its symptoms exist but no problems can be identified with the organs. This leads to confusion when, after testing or scoping, a patient is told nothing was found to be wrong, but the patient knows they are far from feeling well. Often IBS gets worse over time, until you become more and more of a shut –in, and have more and more trouble tolerating foods, specifically fiber. IBS often leads to a very poor quality of life and a restricted lifestyle, and difficulty carrying out the normal activities of work and social life.
I have heard patient after patient describe the stress of leaving the house, the diligence required to locate every bathroom from their home to their destination, and tales of mortifying accidents that only further worsen the anxiety they have surrounding this condition. Some patients have certain times of day when they know they can’t schedule meetings, or know they will need to be home, as they begin to structure their life around their IBS.
Although the relationship between diet and IBS has been largely denied or ignored by the medical system, it is my experience that symptoms can be completely resolved or significantly improved through modification of diet alone. In some cases, dietary change must be combined with various other interventions, and when my recommendations have been followed, I have never seen an IBS patient not significantly improve.
Diagnosis of IBS
In the past, IBS has been considered a diagnosis of exclusion – when blood testing and scoping revealed no sign of cancer, bowel disease, gallbladder problems, or any other reason to explain symptoms, IBS was diagnosed. Now it’s acceptable for doctors to diagnose IBS if the Rome II criteria are met and there are no alarm symptoms to indicate potential disease – this is nice because it means absent alarm symptoms, you don’t have to endure a colonoscopy! More than half of people with IBS are not diagnosed as they never go to see a doctor, and just learn to live with their symptoms. Often even if they go to a doctor, they are told they have to live with the disease and that not much can be done.
Standard Treatment Options for IBS
The treatment options for IBS are limited and only modestly effective for most people. Treatments may serve to temporarily alleviate symptoms in target organs of gastrointestinal symptoms.
- Anti-diarrheals – can decrease frequency and improve stool consistency
- Anti-spasmotics – can reduce cramping and diarrhea
- Antidepressants/Antianxiety – can be helpful, but did anxiety cause your IBS or are you anxious because you don’t know where the next bathroom is going to be located?
- Fiber – can help but is often not well tolerated and worsens bloating and discomfort
- Avoid spicy foods, cruciferous vegetables, beans, alcohol, caffeine, lactose, chocolate, fructose, sorbitol
None of these med classifications address the global, systemic symptoms of IBS. They really just serve to mask local symptoms, and many come with unwanted side effects. In my opinion, these medications can be helpful short-term to manage symptoms as we work to restore your gastrointestinal health by addressing the underlying imbalances causing your gastrointestinal dysfunction.
Managing IBS from a Functional Perspective
As mentioned earlier, IBS is a result of a complex relationship between various factors. The degree to which these factors contribute to IBS varies from patient to patient. Here is a diagram displaying the components of IBS from a functional perspective:
The Gut-Brain Connection: your brain and your gut are physically connected via nerves such as the Vagus nerve, and communicate via neurotransmitters. If you’ve ever felt queasy or had butterflies in your stomach as a result of nervousness or anticipation over an event in your life, you’ve seen how this connection can manifest. So is the case with IBS – what you are thinking and feeling is communicated to and can directly affect the sensation, motility, and secretion in your GI tract.
I find it interesting that almost every patient I have with IBS can tell me about something that was occurring in their lives around the time their symptoms began, that classifies as either physical or emotional stress. They may have had food poisoning (in fact, 25% of cases of IBS were triggered by an infection). Or, they were going through grad school and working full time, had a traumatic event occur, had a surgery, were in a car accident, had a baby, had a miscarriage, took lots of antibiotics or steroid medication, or were just under more stress than usual for a period of time.
I have found that in most cases, once the physical components of IBS are properly addressed, and the patient becomes more confident in his or her ability to control and prevent symptoms, the anxiety component is relieved. In some cases, where anxiety has become more severe, or if anxiety was there before the IBS, this may require further professional evaluation.
Healthy intestines are lined with a single layer of cells that are connected by tightly sealed junctions. You might think of the cells as bricks and the tight junctions in between the as mortar. This layer of cells serves to sample the contents of the space inside your intestines, and selectively decide what it will allow to pass through into your bloodstream, and which potentially harmful substances or organisms it will not allow to pass into the blood. Various factors can compromise the integrity of this layer of cells, opening those tight junctions and allowing components in the gut that normally would not be allowed into the bloodstream to enter. This how food sensitivities and food allergies can develop.
When the lining of the GI tract is healthy, food is broken down into its building blocks before those individual components are absorbed. When the tight junctions are compromised, food particles that are still intact get into the blood stream. Because these are seen as foreign by the immune system, your immune system may decide they are invaders, and start releasing arsenal (immunologic mediators) every time you eat that food. Since 80% of your immune cells are in your gut, you can imagine the degree to which this problem would cause GI upset and gastrointestinal symptoms!
Food Sensitivities and Food Allergies, and the Role of Inflammation in IBS
For a long time, it was not believed that inflammation played a role in IBS, because no inflammation is visible when the patient is scoped, as it is with inflammatory bowel disease such as colitis or Crohn’s. Now studies are starting to indicate a relationship between inflammation and IBS, such as with one study which showed the number of inflammatory mediators in the small intestine increased when test subjects ate foods they were sensitive to. Many studies and clinical observations have shown a relationship between food sensitivity and IBS, and resolution of symptoms was seen through avoidance of problematic foods. In addition, studies have shown the number of mast cells (a type of immune cell that releases mediators) in a biopsy of subjects’ intestines were significantly greater in patients with IBS than control. This demonstrates a relationship between IBS and inflammation – maybe not to the degree that it would cause tissue damage in a way that would be visible via scoping, but it certainly leads to significant functional symptoms.
As mentioned earlier, the immune system may decide certain foods are invaders and begin to fight them off, releasing inflammatory mediators such as histamine, prostaglandins, leukotrienes, cytokines, and others. Think of mediators as bullets, and the branches of the immune system as armed forces. Mediators are directly responsible for local inflammation causing smooth muscle contraction resulting in diarrhea, cramping, and increase in pain sensitivity of the nerves lining the intestine. This inflammation can affect other parts of the body due to change in blood flow resulting in vasoconstriction or vasodilation, or pain receptor activation which can lead to headaches. Many of the global symptoms of IBS such as fatigue, muscle aches, and joint aches, have inflammation as their basis.
Many of the studies on this have been European and until recently have been overlooked by the U.S. Also, for many doctors, there is just not a good way to handle the food component of IBS. Even if the patient believes food is playing a role in their symptoms, there has not been a way to reliably identify what those foods are. You can keep a food journal, but because food reactions can be delayed, dose-dependent, and have a combined effect, it can be very complicated to try to identify all the sources of food reactions, and looking for patterns between foods and symptoms becomes a complex puzzle. Much of this “trial and error” approach leads to poor acceptance and compliance by the patient, frustration to the patient and doctor, and poor outcomes.
Food sensitivity are far more likely to be associated with IBS symptoms than food allergies, although some patients with IBS have both food sensitivities and food allergies. Read this for a description on the difference between food sensitivity, food allergy, and food intolerance. Testing for food sensitivities has been around awhile, but has not been viewed as clinically valid because for so long, there was not a reliable test to measure inflammation caused by foods. IgG testing has been announced as an unreliable way to test for food sensitivities, yet it’s still the most commonly used test by naturopaths and functional medicine doctors because it can take a decade or two to change the standard of practice once a new technology or treatment comes available. Because of the unreliability of IgG testing, many doctors dismiss food sensitivity testing altogether.
However, we now have a blood test that directly measures total volume of mediator release which equates to the degree of inflammation produced when various foods are eaten! This is a revolutionary way to help manage the dietary component of IBS, which up until now has been confounding the medical community.
The test is called the Mediator Release Test, or MRT, which I have used with hundreds of patients and seen consistently amazing outcomes, which one patient recently described as “magic.” Using MRT to help guide the care plan, I consistently see long-suffering IBS patients experience dramatic turn-around in their condition, and return to wellness and much improved quality of life.
Read here about Mediator Release Testing, which includes a detailed comparison of MRT and other food sensitivity tests.
Malabsorption and Food Intolerance
When intestinal function is compromised due to the issues discussed above, there are various mechanisms by which food components can be poorly digested and absorbed. One important way this can occur is through food intolerance, which is characterized by a lack or deficiency in a component necessary to digest a particular food item. Examples include lactose intolerance, which occurs when there is inadequate production of the lactase enzyme to digest the lactose in milk, or bile salt deficiency which occurs when there is inadequate production or secretion of bile salts to digest fat. It can be important to distinguish between foods that are poorly tolerated as a result of intolerance, and foods that directly trigger an inflammatory response.
When a food is not well digested or absorbed due to intolerance, this can result in symptoms such as bloating and gas due to the fermentation of that food in the gut, or diarrhea due to the drawing of fluid into the intestine. Common food intolerances include: lactose, fructose, fructan, galactan, and polyol intolerance. In most cases, I find that by managing food sensitivities and restoring the health of the gut, the patient resumes normal digestive function and intolerances resolve. In some cases, it is necessary address food sensitivities and intolerances until this can be achieved. Some intolerances may improve but never resolve, which I commonly see with lactose.
Dysbiosis is a word that is at first unfamiliar to most of my patients, but it just refers to an imbalance in the “good” and “bad” microorganisms that live in your gut. Did you know you have trillions of probiotic bacteria in your gut that help your body stay healthy? They are like good guys that are on your side, helping you stay healthy so they have a place to live and prosper as well. Read more about your gut bacteria, or “good guys,” here. One of the important functions these good guys serve is to help fight off and keep the “bad guys” at bay. By “bad guys,” I’m referring to pathogenic (or disease-causing) microoranisms such as certain strains of bacteria, yeast, or parasitic organisms. Interestingly, we all have some “bad guys” that live in our bodies in small numbers and don’t cause us harm. However when our immune system is tied up fighting food due to food sensitivities, this decreases its available resources to fight off these “bad guys,” and they can overgrow. In addition, environmental factors such as antibiotics we take or that are found in our food supply, toxins in our air, pesticides on our food, chemical exposure, and others can kill off our “good guy” probiotics, decreasing their ability to help us out by fighting on our side against the “bad guys.”
Dysbiosis is often overlooked in the treatment of IBS, and patients with dysbiosis can suffer for years, sometimes cyclically, without understanding the cause. It is estimated, for example, that 50% of IBS patients have Small Intestinal Bacterial Overgrowth (SIBO). Thankfully, more and more gastroenterologists are testing for SIBO these days using a hydrogen breath test. Parasites are also far more common than we realize now that the world has become smaller with world-wide travel and trade. We used to think parasites were only contracted when traveling abroad, but these days one can come into contact with parasites without ever leaving the U.S. One study showed 18% of participants with IBS had parasitic infections, another study found giardia in 9% and parasites in 15%.
For simplicity, I would classify dysbiosis into 3 categories:
- Parasites – such as Giardia, benign pinworms, Blastocystis Hominis, and many others
- Candida overgrowth – many possible strains of yeast
- Bacterial – such as SIBO, H. Pylori, and others
While there are tests that can check for candida and parasites, they are not widely used in conventional medical practice, and therefore can be very expensive to purchase out of pocket. When working with a patient with IBS, I usually address their diet first. For patients who do not have significant dysbiosis, this is enough to get them well and on the road to healing. Even if dysbiosis is present, giving the immune system a rest by removing foods it is constantly fighting, and repopulating the beneficial probiotics, is often enough to restore the body’s ability to bring the gut microbes into proper balance naturally. In some cases, it is necessary to add supportive components to assist the immune system in balancing gut flora.
So often patients will address one issue but not realize they are neglecting to address other factors contributing to their IBS, and will see only moderate results, and the results they do see may be temporary. For example, a patient may be treated with antibiotics for SIBO but not realize they also have food sensitivities. They will feel better for awhile but symptoms may return, and even the SIBO can return. Now that you understand the different factors involved in IBS and how they affect each other, you can see why it’s important to address all of these components at once to really allow the gut to heal and see lasting results. If the gut does not heal and intestinal cell integrity is not restored, new food sensitivities can develop and pathogenic microorganisms can continue to overgrow.
Diet for IBS
One of the most challenging aspects of the diet for IBS is that it very different from person to person. There are general recommendations which, although helpful for many, offer little to no relief for many others.
If you haven’t already, it’s worth adopting the general diet recommendations for IBS to see how much and if they are going to help you:I find that for many patients, these general recommendations are not enough because they have food sensitivities or intolerances they are not aware of, many times accompanied by dysbiosis. Patients often have difficulty identifying what their food sensitivities are without testing. Often, my patients are convinced they don’t tolerate a food, only to learn it’s actually something they always eat with that food that is the problem. For example, you may think you do not tolerate pork, but you might always consume pork seasoned with black pepper, and through MRT testing you discover it is actually the black pepper you are reacting to.
To effectively manage IBS and achieve and maintain symptom relief, it is necessary to address all components so your GI system can resume normal functioning. We can do this using the 6 R’s:
I hope this information has convinced you that you don’t have to live with the miserable symptoms of IBS, and empowered you to take steps toward your own path to healing and recovery. I would love to help you along that journey! Together we will create a diet individualized to you that will lead you back to the state of wellness that is natural for you.