Irritable Bowel Syndrome (IBS) is a disorder that affects the nerves and muscles of the bowel. It’s the least understood, but most common gastrointestinal disorder – affecting one in five Australians.
IBS isn’t a disease itself, but a label given to symptoms that are not related to other conditions like coeliac disease and Inflammatory Bowel Disease. Therefore it’s very important to speak with your GP about your symptoms as soon as possible to rule out more serious gut conditions.
Symptoms can vary in severity and come and go, lasting for hours, days, weeks or months. For most people, it’s a chronic condition, while for others it can improve and even disappear completely. Some of the most common IBS symptoms include:
• Abdominal pain or cramping – often relieved by passing wind or bowel motion
• Altered bowel motions such as constipation or diarrhoea (or alternating between both)
• A feeling of incomplete emptying of the bowel or sudden urgency
• Mucus in the bowel motion
• A feeling of fullness, or bloating of the abdomen (due to wind or increased water volume drawn into the gut buy certain sugars and fibres)
What causes IBS?
IBS can occur at any age. For many people with this condition, the bowel appears to be over-sensitive. Unfortunately, the cause isn’t always known, but a variety of factors can play a role:
• Foods: The role of food intolerance in IBS isn’t clearly understood, but many people have symptoms after eating certain foods. For some people, too much fibre, fat or spices, can be the culprit, but for others, it can be trickier to identify.
Our best option for testing more sensitive people is through the process of dietary elimination and then food challenges. Depending on symptoms, the Low FODMAP diet or RPAH Elimination diet have been helpful for many people. See below for more details.
• Enzyme deficiencies: Some people are born with or develop with age, insufficient enzymes to digest, absorb or deal with some foods. For example, a deficiency of the enzyme lactase results in lactose intolerance. Some people also benefit from supplementing the enzymes needed for fat, protein and carbohydrate breakdown.
• Stress: Most people with IBS find that their symptoms worsen or are more frequent at times of increased anxiety or stress. Such strong emotions can affect the nerves in the bowel for susceptible people. Chronic stress can also divert blood supply away from the digestive system, resulting in less effective function.
• Hormones: Because women are twice as likely to have IBS, researchers believe that hormonal changes play a role in this condition. Many women find that signs and symptoms are worse during or around their menstrual periods.
• Medications: Some medications (e.g. antibiotics, antacids, painkillers) and supplements (e.g. iron) can cause gut irritations and lead to constipation or diarrhoea.
• Other factors: For example, an acute episode of gastroenteritis or food poisoning; bacterial infections or parasites; dysbiosis (an altered balance of good and bad microbes in the large bowel) or too many bacteria in the small intestines (bacterial overgrowth e.g. SIBO), can cause the gut to become more sensitive and trigger IBS.
How to manage your symptoms:
Your dietitian’s first priority will be to get you feeling better. Most people can improve their IBS symptoms with changes to diet, improving stress management and prescribed medications (if required).
Some of the dietary changes that can help improve symptoms include reducing high-fat foods, spicy foods, foods high in insoluble fibres, dairy proteins, coffee and alcohol, and reducing meal sizes.
Beyond those simple changes, you can also consider the following strategies.
Low FODMAP Diet for IBS
Many people find relief in symptoms from following a low FODMAP diet. FODMAPS (Fermentable Oligosaccharides, Disaccharides, Mono-saccharides, and Polyols) are sugars that are poorly absorbed in the gut. They travel to the large bowel where they can be food for gut bacteria or draw water into the gut through osmosis. For people with gut sensitivity, this can cause symptoms.
The low FODMAP diet is a short-term investigative diet, followed by a systematic food challenge process, to identify problematic foods.
Common high FODMAP foods include avocado, onion, garlic, kidney beans, bread, pasta, milk, apples, pears and mushroom (along with a whole lot of other things!).
Management of IBS through the elimination of high FODMAP foods, then reintroduction is the best way of determining trigger without unnecessarily restricting your diet.
It is important that you seek guidance from your dietitian through this process to ensure you are following the most appropriate guidelines and have the diet tailored to your needs.
Why not just stay low FODMAP?
Most people do not react to all the high FODMAP groups of foods. Identifying these means that we can include the groups of foods that weren’t a problem, then determine tolerance levels of those that were. This is recommended because:
• Most people with IBS can maintain suitable symptom control with the reintroduction of some high FODMAP foods. This makes it easier to make informed choices when not in control of food choices, and better management of symptoms on a daily basis.
• Avoiding unnecessary restrictions helps to ensure a nutritionally adequate diet.
• Many high FODMAP foods are also high in prebiotics. These fibres provide food for the healthy bacteria that are found in your gut. Research indicates that long-term avoidance of these may affect the health of your gut microbiome.
Food Chemical Elimination Diet
If your symptoms don’t subside through the dietary changes suggested above, other issues including food chemical intolerance may be considered, depending on symptoms.
Typically having other symptoms such as rashes, sore joints and chronic fatigue in combination with gastrointestinal issues (GI) is going to be a more clear cut case for the food chemical elimination diet.
However, food chemicals can cause just GI issues in some people and this elimination diet may be worth a try for the management of IBS.
The gold standard to investigate food chemical intolerance in Australia is following the RPAH Elimination diet.
I would say that this elimination diet is even a little more complicated than the low FODMAP diet. So having professional help to guide you through the process is likely a good idea. Although the RPAH Elimination Diet Handbook is a great tool to have.
Probiotics & IBS
Taking probiotics can help to reduce the symptoms of IBS by nourishing the gut microbiome.
Probiotics are bacteria that assist with diversifying and increasing the colonies of microbiota in the gut.
Probiotic supplements can be made up of a single strain of bacteria or include several strains.
Different types of bacteria are helpful for different things. The most common and well-researched are species of Lactobacilli and Bifidobacteria.
IBS patients appear to have lower levels of both species compared to non-IBS sufferers. So it may make sense to take probiotics that include one or both of these strains.
The research of probiotic use is mixed and it is hard for researchers to pinpoint their effectiveness for different conditions.
So whilst, probiotics may be useful it isn’t clear how effective they are in the management of IBS.
If you do trial probiotics, it is best to try them for at least four weeks and independent of other IBS management strategies. If you see no improvement within that month either try another brand (strain), a high strength version or move onto something else.
Gut Directed Hypnotherapy
Gut-directed hypnotherapy is a fairly new approach to the management of IBS but an extremely promising one.
This type of therapy can be done with a qualified therapist or even using an app such as Nerva.
Multiple well-controlled studies have shown that gut-directed hypnotherapy improves gastrointestinal symptoms in people with IBS by 70-80%. The best thing is that these improvements are maintained in the long term.
It can even be effective for diarrhea and constipation. Which is just mind-blowing when you think about it.
During gut-directed hypnotherapy, the focus is on the normalization of gastrointestinal function to the subconscious part of the mind. This differs from typical psychological therapies that are often aimed at the conscious mind.
It is not understood how this type of therapy actually works in regards to its impact on IBS symptoms. But we do know that the brain-gut axis is a powerful thing.
Gut Directed Hypnotherapy As a Front-line Approach For IBS?
The gut-brain axis is a bidirectional link between the central nervous system and the enteric nervous system. Meaning that gut health can impact mood and neurological functions and mood can affect gut health and gastrointestinal function.
For example, gut-directed hypnotherapy has been shown to reduce gastrointestinal symptoms by improving motility and reducing sensitivity through mood regulation.
With gut-directed hypnotherapy being just as and if not more effective than the low FODMAP diet, it may even be worth making it a more front-line approach. Apps like Nerva make it affordable and better yet, you don’t have to make any changes to your dietary habits.
Enzyme supplements can assist with IBS symptom management when an enzyme deficiency is the cause of symptoms.
The most common enzyme insufficiency is lactase. Lactase is used to break down the sugar molecule lactose which is found in dairy products. Lactose intolerance is a spectrum and the amount of dairy a person is able to tolerate it directly correlated to how severe their lactase insufficiency is.
Lactase tablets are easily accessible and can be taken with dairy products to help a lactose intolerant person digest the lactose. Alternatively, they can opt for lactose-free products or low lactose dairy such as hard cheeses.
A far less common condition is sucrase-isomaltase insufficiency or other known as GSID/CSID. This condition is genetic and a person will often be born with GSID. Although surgery on the pancreas can cause this condition later in life.
In GSID, the body lacks sufficient levels of sucrase and maltase which is needed to break down sucrose (found in some fruit, vegetables and table sugar) and maltose (found in starches and grains).
Many people with GSID can also be lactose intolerant and have to follow a low disaccharide diet.
Whilst there is no enzyme supplement for maltase, there is a supplement called Sucraid which can be taken with high sucrose foods to help with breakdown and digestion.
In conditions such as chronic pancreatitis, cystic fibrosis, cancer of the pancreas, post-pancreatectomy, post-gastrointestinal bypass surgery, the pancreas may not be able to produce enough pancreatic enzymes. This can lead to the malabsorption of food and result in diarrhea, steatorrhoea (foul-smelling, fatty stools which float in the toilet), bloating, and weight loss.
For pancreatic enzyme deficiency, you can take Creon tablets with your food to help break down fats, proteins, and carbohydrates. However, Creons require a prescription and should only be used when medically advised by your doctor.
Other FODMAP Enzymes
There are also enzyme supplements to help with the breakdown of other FODMAPs. Lactose is a FODMAP and lactase enzymes are available. But there is also glucose isomerase enzyme to assist with fructose breakdown and alpha-galactosidase to assist with the breakdown of oligosaccharides (found in legumes).
Peppermint Oil & IBS
Peppermint oil is a naturally occurring herb containing L-menthol.
L-menthol has been shown to be able to blocks calcium channels in smooth muscle, thus producing antispasmodic effects on the gastrointestinal tract.
Peppermint oil also possesses several other properties relevant to the management of IBS including:
- Being Antimicrobial & anti-inflammatory,
- And have anesthetic activities
Overall research shows that peppermint oil can be effective in relieving symptoms of IBS in some people, especially in regards to abdominal pain.
The most extensive review of peppermint oil included data from over 800 patients from twelve clinical trials. The review showed IBS symptoms were 44% less common in patients who took the peppermint oil group compared to those who took a placebo.
It should be noted that peppermint tea has not been shown to have the same effects as peppermint oil. This is likely due to the discrepancy in dosage between tea leaves and extracted peppermint oil.
For adults, a dosage of 0.2ml to 0.4ml of peppermint oil 3 times a day taken in the form of coated capsules works best.
Where To Start?
IBS management can be a deep rabbit hole to go down. That is because so many things can result in IBS-like symptoms.
It could be as simple as reducing stress, being more active, and being well hydrated too as complex as requiring an elimination diet or specific enzyme supplementation.
If you have gastrointestinal symptoms that you would like to manage better, these are the steps I would take:
- See your doctor about your symptoms to eliminate the possibility of more serious conditions such as coeliac disease and inflammatory bowel disease.
- Make sure you are covering the 3 FFF’s. Fibre, fluids and fitness. This means having enough fibre (>25g per day), being well hydrated and exercising regularly. Note that if you are plant-based, you may be having too much fibre and need to reduce it to 25-40g per day.
- Take steps to manage stress if this is something that is an issue for you. Particularly if you find that your symptoms are worse during periods of high stress.
- If you are still experiencing symptoms, this is where I might suggest trying something like probiotics or peppermint oil. As they are simple things to trial before moving on to more complicated management strategies.
- Next, I would recommend gut-directed hypnotherapy. This is a great thing to trial before an elimination diet. As you don’t have to change anything about your diet and it has been shown to be surprisingly effective.
- Now before trialling a restrictive elimination diet, you may want to keep a food and symptom diary for a couple of weeks to see if you can spot any patterns. This may be where you pick on things like potential lactose intolerance.
- Still, have no idea and nothing has worked? Depending on your symptoms you may want to trial a low FODMAP diet, a food chemical elimination diet or have further investigation with a gastroenterologist.
In the management of IBS symptoms, it is likely that you will have to trial and error your way through it. The course of action you take should be based on your symptoms, what your current diet looks like, and if stress plays a role in your life.
That is why it can be useful to have a health professional guiding you through the process and assisting with the best course of action for you as an individual.
But if you do try a few things on your own, just make sure to trial one thing at a time. Shotgunning a whole heap of management strategies at once can just leave you more confused than when you started.