Irritable bowel syndrome is one of the most common conditions seen by primary care doctors. While IBS is not life threatening, this condition can be a source of significant discomfort, embarrassment, and worry for patients who experience symptoms. IBS is associated with a wide variety of symptoms including abdominal pain, constipation, diarrhea, gas, nausea, and mood disturbances like anxiety or depression. The causes of IBS are not completely clear, but microbial, physiological, psychological and dietary factors have all been linked to this condition.
In this series, I’ll be discussing important causes of of irritable bowel syndrome and ways that our physicians at Full Circle Care help to identify causes and relieve the symptoms of IBS.
It’s important to note that many other conditions may mimic the symptoms of IBS and should be ruled out with the help of a medical professional.
7 IBS Treatment and Diagnostic Considerations
- Dietary Fiber - The Fiber Paradox
- SIBO - Small Intestinal Bacterial Overgrowth
- Sugar Malabsorption Syndromes
- Allergies and Intolerances
- Psychological Components
- Diet Recommendations
- Probiotics - Should You Be Taking Them?
1. Dietary Fiber - The Fiber Paradox
Dietary fiber plays an essential role in our overall health and in treating IBS. Eating higher amounts of dietary fiber can help improve metabolic health, cholesterol levels, blood sugar levels, and improve the frequency and quality of bowel movements.
The best types of fiber to include in the diet are water-soluble fibers found in vegetables, fruits, oat bran, guar, chia and flax seeds, legumes (beans and peas), and psyllium seed powder.
The general recommendation for an adult is to eat between 25 and 30g of dietary fiber daily. The standard American diet is typically sorely lacking in this nutrient.
Many grains are considered excellent forms of fiber but are frequently implicated in malabsorptive and allergic conditions. With the new fads of paleo and ketogenic diets, we see a significant movement away from grains, and this is also reflected in a common diet used for IBS, called the low FODMAP diet.
This presents us with our fiber paradox. For some people, fibers can become a fermentable food source for a small intestinal bacterial overgrowth, and for others, it becomes an excellent addition to the gut environment, promoting diversity and growth of healthy microorganisms, as well as improving stool consistency and regularity. This is why an individualized regimen is so critical for treating IBS, as the same product that works for one patient will have the opposite effect for others.
2. SIBO - Small Intestinal Bacterial Overgrowth
Many of my IBS patients come in to the office with complaints about bloating: “I feel so bloated after I eat a meal. It’s like I wake up with a flat stomach, and then I eat and I puff up like a marshmallow.”
This is a common complaint that I hear from my IBS patients. Gas, bloating, and constipation or diarrhea paired together with uncomfortable pressing, aching pains in the abdomen.
There is a growing body of evidence suggesting that an overgrowth of intestinal bacteria may contribute to Irritable Bowel Syndrome. This condition is called Small Intestinal Bacterial Overgrowth, or SIBO. In clinical practice here at Full Circle Care, we see a strong connection between IBS and the results of laboratory breath tests measuring gas produced by intestinal bacteria. These breath tests - which involve drinking a sugar solution and then breathing into tubes - measure the amount of gases produced by the bacteria as they feed on the sugar. This gas production can lead to inflammation, changes in the intestinal lining due to toxic byproducts, constipation, diarrhea, and anxiousness.
When treating this condition, we have to consider the amount and timing of meals, the sugar and fiber content of the foods we eat, what medicines we will prescribe to reduce bacterial populations and gas production, and what brought the problem on in the first place (as well as how to prevent the problem from coming back).
Huge portions are a huge problem in our society, and our bacteria are eating like kings because of the size of our meals. Pair that with carb and sugar heavy meals, and we’ve served up a bacterial buffet.
Occasionally, breath tests all return normal, and at this point we’ll typically consider running a stool test or a urine organic acid test to determine if an overgrowth of fungi (candida) may be present, or if a patient has contracted an intestinal parasite of some sort (especially in our patient population, with a significant number of missionaries who are traveling abroad and eating exotic foods for one to two years, this can be a common occurrence). We work with some excellent stool tests that not only assess for bacteria, fungi, and parasites, but also tell us how much inflammation is present in the intestinal system, how much digestive juice the pancreas is releasing, and the amount if sIgA produced, which tells us how well the gut immune system is working.
3. Sugar Malabsorption Syndromes
Sugar malabsorption syndromes like lactose intolerance and GSID (Genetic Sucrase Isomaltase Deficiency) are their own separate conditions, but they frequently mimic the symptoms of IBS.
These conditions are caused by improper breakdown and absorption of dietary sugars. Some patients are born with lower levels of enzymes that break down these sugars, and experience abdominal pain, bloating, gas and diarrhea as a result. Because foods like dairy and table sugar are very common in the diet, sometimes people are unaware of the cause of their symptoms until they remove the offending foods.
The physicians at Full Circle Care use breath tests to help identify whether sugar absorption issues are the cause of digestive symptoms. Treatment of these conditions typically include removal of the offending food and/or replacement with the missing digestive enzymes that break down these sugars.
4. Allergies and Intolerances
Research shows that patients with IBS frequently point to food related sensitivities as a cause. A large number of patients who present with bowel symptoms test positive for food allergy or sensitivity in tests of their food specific immune cells called Immunoglobulins (IgE, IgG4 or IgG). With the help of food sensitivity testing and the elimination of offending foods, patients frequently see improvements in IBS symptoms.
There are a number of other popular tests including ALCAT, MRT testing (both ALCAT and MRT assess white blood cell reactivity to foods), EAV (electrodermal testing), the Carroll test, and more. In our clinic, we prefer immunoglobulin (IgG, IgE) and ALCAT testing as more reliable blood testing methods of evaluation for food sensitivity and allergy. We do not perform skin patch testing, which is typically performed at an allergist/dermatologist’s office.
The gold standard and most reliable food sensitivity screen is still an elimination diet. Patients use a 30 day elimination diet, during which time a hypoallergenic diet is followed, and many common allergens are removed. After that 30 days, foods are reintroduced one at a time every 3-7 days. If symptoms worsen or return, that newly reintroduced food should be considered a sensitivity or trigger and should be avoided. This systematic removal and reintroduction of foods allows for an accurate determination of food triggers (at least those more immediate food triggers). Since some sensitivities are of delayed type, they may take more than just several minutes or hours to cause symptoms. Because of this, a gradual, stepwise reintroduction is used to avoid inaccurately identifying food triggers.
One advantage in using food antigen blood tests like IgG/IgE or ALCAT is they provide a guide for what to eliminate, so we aren’t left guessing and removing huge portions of our diet for a month or more.
5. Psychological Components
Many patients with IBS report depression, fatigue, and anxiety. Increased research and knowledge regarding a gut-brain axis has emerged in recent years, and we can use this knowledge to our advantage. Through treating the gut, we see big improvements in our IBS patients’ mood and energy levels.
Additionally, increased stress levels are associated with worsening of IBS symptoms. This is likely due to the role our sympathetic nervous system (stress response) plays in our digestive system. Stress reduction, mindfulness practices, biofeedback, acupuncture, massage, and physical exercise all play a key role in helping to reduce stress and improve mood and IBS symptoms.
Mood symptoms pose a challenge for our patients with IBS. Naturopathic Physicians such as those at Full Circle Care frequently work with alternatives to antidepressants including amino acids, bioidentical hormone replacement, botanical medicines, vitamin and nutrient support, and IV therapies to help improve nutrient status and correct deficiencies. We find that these strategies can be an important alternative to the standard pharmaceutical approach to depression.
6. Dietary Recommendations
The low FODMAP diet is commonly prescribed for patients with bacterial overgrowth or IBS. This diet drastically limits the fermentable fiber and sugar content that is consumed. Some patients who begin eating a ketogenic diet, paleo diet, or low carb/low sugar diet report improvement, but frequently it feels incomplete. The missing link here is that even some vegetables are fermentable and contain natural compounds that bacteria love. While a paleo diet limits sugar and carbs, some other fermentable vegetables and fruits might still be causing symptoms.
Our physicians at Full Circle Care can help determine whether bacteria, sugar malabsorption, or food sensitivities are contributing to symptoms, and then design a dietary regimen to fit individual patients’ needs. We fully believe that a “one size fits all” approach doesn’t work, and we guide our approach with this understanding.
Strict medical diets like low FODMAP are important to do safely, and with the help of a medical practitioner, nutritionist or dietitian. Strict limitation of foods can lead to rapid weight loss, nutrient deficiencies, and can make normal day to day functions like work and exercise difficult. I do not routinely recommend attempting major dietary changes without the supervision of a licensed professional.
7. Probiotics - Should You Be Taking Them?
Similar to dietary fiber, some IBS patients tolerate probiotics well, and others experience worsening of symptoms after taking them. Taking a probiotic introduces bacteria and other fibers and colonizing agents like inulin to the small intestine, which can be problematic for patients with bacterial overgrowths, where arguably too many bacterial are already present. Additionally, if patients take probiotics based in dairy products, they can also flare a lactose intolerance issue.
It’s important to know that different strains of probiotics and different additives can make these products more or less tolerable. Probiotic strains also have variations in their medical uses, so not all probiotics have the same function in the body.
We’ll consider probiotics in a future blog entry, but if you’ve got IBS, it’s important to work with your physician to determine if a probiotic regimen is right for you, and which specific bacteria or formulation would be most helpful.
All information contained within this article is for educational purposes only, and is not intended as treatment advice from myself or our clinic. Beginning any treatment protocol without the advice of your physician may be unsafe, and you should check with your provider before beginning any medicine, supplement or therapeutic diet.
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