Nerd Out: Irritable Bowel Syndrome

My latest assignment for my Master’s in Holistic Nutrition was to write a paper about a gastrointestinal disorder. I chose Irritable Bowel Syndrome, as it ranks up there as one of the most prevalent chronic disorders people experience. If you’d like to nerd out with me, continue reading:

Irritable Bowel Syndrome, or IBS, is defined as chronic inflammation of the large intestine and presents itself through a cluster of symptoms, including abdominal pain, spasms, bloating, gas, and abnormal bowel movements (Lipski, 2012, p.286). Because there is a spectrum within the symptoms (mild to severe), and because the symptoms fluctuate over time, it is often challenging to differentiate between IBS and normal variations of the gastrointestinal tract (Rakel, 2018, p.423). Stress has proven to play an integral part in the flare-up of IBS, providing a psychosocial perspective to treatment (Rakel, 2018, p.423), although some experts prefer to categorize it as a disorder of the gut-brain axis rather than as a psychiatric disorder (Kohlstadt, 2012, 261). A diagnosis is made due to its chronic nature (at least 6 months’ duration) (Kohlstadt, 2012, p.261), by excluding pathology, and including some or all of the symptoms of abdominal pain/discomfort, bloating, and diarrhea/constipation (Rakel, 2018, p.423).

Specifically, the Rome III Criteria for Irritable Bowel Syndrome defines IBS as at symptoms lasting at least three months, with onset at least six months previously of recurrent abdominal pain or discomfort associated with two or more of the following: Improvement with defecation; Onset associated with a change in frequency of stool; And/or onset associated with a change in form (appearance) of stool (Kohlstadt, 2012, p.262). This, with the absence of weight loss, anemia, and rectal bleeding, support the diagnosis of IBS (Kohlstadt, 2012, p.261).

Also prevalent amidst the cluster of symptoms may be nausea, anorexia, hypersecretion of colonic mucus, restless leg syndrome, migraine headaches, chronic fatigue, irritable bladder, and dyspareunia (Pizzorno & Murray, 2013, p.1557). IBS is often seen in patients with a history of sexual abuse and/or sexual dysfunction, fibromyalgia, urinary frequency and urgency, poor sleep, menstrual difficulties, lower back pain, and insomnia (Pizzorno & Murray, 2013, p.1557).

IBS is cited as the most common GI disorder seen in general practice, representing 30%-50% of all referrals to gastroenterologists (Pizzorno & Murray, 2013, p.1557). Women are diagnosed twice as often as men, which might be due to men under-reporting symptoms (Pizzorno & Murray, 2013, p.1557), and is more prevalent in Caucasian persons than others. Early studies demonstrate that IBS patients tend to have an enhanced stress responsiveness that presents higher morning cortisol levels and an inability to turn off the stress response, both which have been shown to increase intestinal permeability and inflammation (Rakel, 2018, p.429).  

There are three subgroups of IBS under which patients are categorized: constipation predominant (IBS-C), diarrhea predominant (IBS-D), or mixed (IBS-M) (Kohlstadt, 2012, p.261).  Risk factors may be environmental, genetic, or both (Kohlstadt, 2012, p.262). Several conditions, including food allergies, infections, poor diet, and metabolic disorders mimic the symptoms of IBS and must be ruled out in order to make the diagnosis.

The etiology of IBS is unclear, although it frequently occurs in concert with Small Intestinal Bacterial Overgrowth (SIBO) and Leaky Gut Syndrome (Lipski, 2012, p.287). IBS can also be caused by stressors to the gut as mentioned above, leading to an over-active inflammatory response in the mucosal tissue of the large intestine (Lipski, 2012, p.288). Parasites and candida overgrowth may also play a role in IBS, and women may experience increased symptoms around their menstrual periods (Lipski, 2012, p.288). Chronic stress, dysregulated immune response, dysbiosis, overconsumption of alcoholic beverages, certain medications such as NSAIDs and birth control pills, and even lectins have been implicated in the chronic inflammation characteristic of IBS (Lipski, 2012, p. 46-47) (Rakel, 2018, p.423).

Allopathic approaches to IBS focus on three main therapies: increasing fiber in diet, probiotics, and antibiotic therapy (Rifaxamin), especially if SIBO is indicated (Lipski, 2012, p.287) (Rakel, 2018, p.430). Another pharmaceutical, oral Cromolyn (brand name Gastrocrom), is used to control the release of GI-irritating substances from mast cells in the GI tract (https://www.mayoclinic.org/drugs-supplements/cromolyn-oral-route/description/drg-20063181).  And with the mind-body connection to IBS, tricyclic antidepressants and selective serotonin reuptake inhibitors are an option for patients with IBS-D (Rakel, 2018, p.430).

For IBS-C, a diet high in fiber (25-30 grams per day, preferably insoluble fiber such as in oats and psyllium), and low in fat help with stool bulking and intestinal motility (Kohlstadt, 2012, p.272).  Pharmaceuticals such as 5-hydroxytryptophan (5-HTP), Lubiprostone, Tegaserod, and Renzapride may be indicated soften the stool and relax the gut. (Kohlstadt, 2012, p.265) (Pizzorno & Murray, 2013, p.1560).

Anticholinergic agents are used to reduce abdominal cramping and smooth muscle spasms (Kohlstadt, 2012, p.266). Peppermint oil is gaining traction in the allopathic medical community as another option for relaxation of the smooth muscle in the GI tract as well as for mediation of other symptoms (Kohlstadt, 2012, p.266) (Pizzorno & Murray, 2013, p.1560).

Broad-spectrum probiotics are recommended to repopulate the intestinal microbiome with optimal rather than pathogenic gut microflora, decrease fermentation, and stimulate proper immune function (Rakel, 2018, p.427) (Pizzorno & Murray, 2013, p.1559).

Antibiotic therapy, specifically Rifaxamin, has been found to significantly improve IBS symptoms, especially in IBS-D patients and those with comorbid SIBO (Rakel, 2018, p.430).

All types of IBS may benefit from Cognitive Behavioral Therapy and/or hypnotherapy to help with accompanying anxiety and depression (Kohlstadt, 2012, p.271).

The above-mentioned approaches are based on an extensive medical history, including frequency of abdominal pains, gas, bloating, constipation, and/or diarrhea. Lab tests may include a comprehensive stool analysis, complete blood count, erythrocyte sedimentation rate, free thyroid T3 hormone levels, and antiendomysial antibody testing for celiac disease (Pizzorno & Murray, 2013, p.1557).  The enzyme-linked immunosorbent assay (ELISA) allergen challenge test or the ELISA IgE/IgG4 test are sometimes used to detect food allergies (Pizzorno & Murray, 2013, p.1558).

IBS-D type symptoms may indicate a panendoscopy with duodena, colonic, and terminal ileal biopsies to rule out celiac disease, inflammatory bowel disease, and colitis (Pizzorno & Murray, 2013, p.1557). Additional stool testing for eosinophilic cationic proteins may be indicated if food allergy is suspected (Pizzorno & Murray, 2013, p.1557). Finally, screening for occult fecal blood, flexible sigmoidoscopy/colonoscopy are also options to rule out other causes (Pizzorno & Murray, 2013, p.1557).

Integrative approaches take a broader approach to diagnosis and treatment. Assessments such as a health history questionnaire are combined with a comprehensive discussion and/or physical assessment, and include all of the inclusions and exclusions as a diagnostic tool as listed previously. Family medical history is noted, as there may be a genetic link (Rakel, 2018, p.423). A food journal and dietary history is collected to detect possible food sensitivities, intolerances, and allergies (Lipski, 2012, p.288-289), as well as helps determine detrimental dietary choices and eating patterns.

Breath tests, including the SIBO breath test (or the Hydrogen-Methane test), the Lactose-Intolerance/Lactose Malabsorption test, the Fructose Intolerance/Fructose Malabsorption test, and/or the Sucrose Intolerance/Sucrose Malabsorption test are utilized to detect gut sensitivities to sugars, and are especially indicated if leaky gut or SIBO are suspected (What is Irritable Bowel Syndrome, 2019, https://www.commdx.com/)  (Lipski, 2012, p.289) (Kohlstadt, 2012, p.272). Organic acid testing is also a possibility, providing an evaluation of intestinal yeast and bacteria (Lipski, 2012, p.289), and an HCl challenge test can detect decreased gastric acid production (Rakel, 2018, p.430).

Permeability, or leaky gut issues can also be assessed using a lactulose-mannitol urine test or with positive IgG food antibody testing (Rakel, 2018, p.423).

A comprehensive digestive stool analysis including parasitology is recommended, as candida overgrowth and parasites are often overlooked causes of IBS (Lipski, 2012, p.288).

An elimination diet and subsequent food challenge helps identify triggering foods (Rakel, 2018, p.426). Introducing therapeutic dietary systems (FODMaPs/fermentable carbohydrates avoidance, GAPS, Paleo, low-sugar, dairy-free, gluten-free, lectin-free, caffeine-free, alcohol-free, etc.), based on individual needs often provides symptomatic relief (Pizzorno & Murray, 2013, p.1558, 1559) (Lipski, 2012, p.289) (Rakel, 2018, p.426) (Kohlstadt, 2012, p.269). It is important to note that artificial sweeteners such as sorbitol, maltitol, or xylitol may worsen bloating and diarrhea in IBS patients so should be avoided (Kohlstadt, 2012, p.270-271).

Increasing fiber with psyllium seeds, flaxseed, or hemp seed is recommended, as well as adding a broad-spectrum probiotic that includes lactobacilli and bifidobacteria (Lipski, 2012, p.290). Eliminating dairy foods, sugar, fruit, honey, and maple syrup may ease symptoms (Lipski, 2012, p.289, 290). Prebiotic-rich foods (bananas, artichokes, garlic, onions, etc.) as well as probiotic foods (sauerkraut, kimchee, and kvass, etc.) stimulate and feed healthy GI flora (Rakel, 2018, p.428) (Axe, 2018, https://draxe.com/leaky-gut-diet-treatment/).

Other dietary supplements include pancreatic enzymes, ginger, aloe, Chinese herbs such as Padma Lax and STW-5, glutamine, EPA/DHA fish oil, peppermint oil, chamomile, rosemary, Melissa (balm), valerian, betaine hydrochloride, and calcium-magnesium citrate (Rakel, 2018, p.428- 430) (Lipski, 2012, p.290-291).

Bone broth soothes the gut and provides the nutrients collagen, glycine, proline, and glutamine, as well as easily absorbable minerals and natural anti-inflammatories like chondroitin sulfate and glucosamine (Kresser, 2019, https://chriskresser.com/the-bountiful-benefits-of-bone-broth-a-comprehensive-guide/).

Decreasing the chemical load by eating organic produce, and pastured eggs and meat, allows for optimal healing of the gut. Other nutrient-rich foods include healthy fats like coconut oil, avocado, and the omega-3 fats in fatty fish. Sprouted seeds, fermented vegetables, and adequate hydration round out the list (Axe, 2018, https://draxe.com/leaky-gut-diet-treatment/)

Finally, lifestyle modifications that include more self-care to decrease stress, anxiety, and depression have been shown to decrease IBS symptoms. Mind-body therapies include stress management, relaxation therapy, meditation, hypnosis, journaling, biofeedback, art therapy, acupuncture, and gentle exercise such as yoga, and walking (Rakel, 2018, p.429). Often more effective than medical therapy (Rakel, 2018, p.429), stress reduction strategies tap into the mind-body and gut-brain connection that affects both sickness and wellness. An entire paper could be written on this topic as well, but suffice it to say, a holistic approach to Irritable Bowel Syndrome, including diet, supplementation, exercise, and stress reduction, offers promise to provide not just physical but emotional relief as well.   

References

Axe, J. (2018, July 30). Leaky Gut Diet and Treatment Plan, Including Top Gut Foods. Retrieved May 30, 2019, from https://draxe.com/leaky-gut-diet-treatment/

Cromolyn (Oral Route) Description and Brand Names. (2019, February 01). Retrieved May 30, 2019, from https://www.mayoclinic.org/drugs-supplements/cromolyn-oral-route/description/drg-20063181

Kohlstadt, I. (Ed.). (2012). Advancing medicine with food and nutrients. Boca Raton: CRC Press.

Kresser, C. (2019, May 28). Bone Broth Benefits: Everything You Need to Know. Retrieved May 30, 2019, from https://chriskresser.com/the-bountiful-benefits-of-bone-broth-a-comprehensive-guide/

Lipski, E. (2012). Digestive wellness: Strengthen the immune system and prevent disease through healthy digestion. New York, NY: McGraw-Hill.

Pizzorno, J., & Murray, M. T. (2013). Textbook of natural medicine. St. Louis, MO: Elsevier.

Rakel, D. (2018). Integrative medicine. Philadelphia, PA: Elsevier.

What is Irritable Bowel Syndrome? (2019). Retrieved May 31, 2019, from https://www.commdx.com/

Nerd-Out: Vitamin D Report

(For those of you who like to nerd-out on the science behind nutrition, I will be sharing portions of my writings for my Master's of Science in Holistic Nutrition.)

Here's the first one: Vitamin D

Photo by pepifoto/iStock / Getty Images

Photo by pepifoto/iStock / Getty Images

          Vitamin D is something I’d taken for granted until my breast cancer diagnosis four years ago. Growing up in San Diego, California, I mistakenly believed that my long days at the beach, poolside, and soccer fields would provide me enough of that essential vitamin. Moving to Colorado as an adult didn’t change my mindset about it. Living closer to the sun and hiking, camping, skiing, snowboarding, and simply sitting outside on my beautiful backyard deck supplied ample exposure to the sun’s vitamin D-rich rays, or so I thought. It wasn’t until my breast cancer diagnosis four years ago and the subsequent battery of labs, blood tests, and scans, that I discovered I was vitamin D deficient. Thus began this heightened interest in this “sunny” vitamin and a subsequent “dance” of treatments with my traditional oncologist and my naturopathic physician.  

            Known chemically as (cholecalciferol), vitamin D3 can be synthesized on human skin when exposed to ultraviolet B (UVB) radiation from the sun (Higdon & Drake, 2012, p.83). It can also be ingested in food or supplement form in the diet (Higdon & Drake, 2012, p.83). Although not prevalent in many foods, it can be found in liver, salmon, mackerel, sardines, cod-liver oil, and egg yolks, and vitamin D fortified cereals and milk (Smolin & Grosvenor, 2013, p382).  Vitamin D acts like a hormone in that several organs are affected in its metabolism, including the skin, intestine, bone, and kidneys (Smolin & Grosvenor, 2013, p.382).

            Activated in the liver and then dumped into the blood stream, vitamin D circulates and travels to the intestines, bones, and kidneys where it helps increase calcium levels in the blood (Smolin & Grosvenor, 2013, p.383). The maintenance of normal blood calcium levels is crucial to maintain the growth, density, and strength of bones and prevent their breakdown (Higdon & Drake, 2012, p.83). Vitamin D also helps regulate cell differentiation, immunity, insulin secretion, and blood pressure regulation (Higdon & Drake, 2012, p.84).  Proposed but yet unproven actions of this vitamin include cancer prevention, protection from certain autoimmune diseases such as type 1 diabetes and multiple sclerosis, and protection from cardiovascular disease and type 2 diabetes (Smolin & Grosvenor, 2013, p.384).

            Without proper levels of vitamin D consumption or absorption, only about 10-15% of calcium in the diet can be utilized, affecting bone mineralization, strength, and growth (Smolin & Grosvenor, 2013, p.384). And without access to dietary calcium, the body resorts to leaching existing calcium from the bones, leaving them at risk for bone pain, muscle aches, and fractures (Smolin & Grosvenor, 2013, p.385). In a child’s growing frame, this deficiency causes rickets, characterized by bowed legs, weak bones, and short stature (Smolin & Grosvenor, 2013, p.384). In adults, vitamin D deficiency results in osteomalacia, or soft bones (Higdon & Drake, 2012, p.85).

            Too much vitamin D (toxicity) raises blood calcium levels too high, which can result in deposits of calcium in blood vessels, kidneys, and the heart, hardening them, resulting in damage (Smolin & Grosvenor, 2013, p.386). Most vitamin D toxicity results from over-supplementation or consuming too much of fortified foods. Sunlight and unfortified foods do not pose a risk for overconsumption (Smolin & Grosvenor, 2013, p.386).

            Lack of sun exposure is the primary way people become vitamin D deficient. Living in big cities with tall buildings blocking the sun, wearing sunscreen, spending all daylight hours indoors, and living at latitudes greater than 40 degrees north or south, increase decrease the skin’s exposure to the sun (Smolin & Grosvenor, 2013, p.384-385). Dark skin, which prevents much of vitamin D synthesis in the skin, and concealing clothing worn by certain cultural and religious groups, are also risk factors for deficiency, even in sunny climates (Smolin & Grosvenor, 2013, p.385). Elderly people, those with fat malabsorption syndromes, kidney disease, and inflammatory bowel disease are also at risk for deficiency, as these conditions prevent optimal absorption of vitamin D (Higdon & Drake, 2012, p.86). Finally, exclusively breastfed infants may be at risk, particularly if they have dark skin and/or receive little sun exposure (Higdon & Drake, 2012, p. 85).

            Foods rich in vitamin D, as mentioned above, are fatty fish such as salmon, mackerel, and sardines. Organ meats, particularly liver, are high in this vitamin. Egg yolks are dense sources of vitamin D as well. Sunlight, although not a food source, is by far the best provider of vitamin D.

            Using the iProfile Food, Liquid, and Activity Form, I tracked my food intake for a day to take a peek at my nutritional habits and get a feel for how much vitamin D I eat on an average day (Smolin & Grosvenor, 2010, iProfile). According to the dietary analysis, the eggs I consumed for dinner provided 82% of my Dietary Reference Intake (DRI), while the cheddar cheese provided 11%, the goat cheese 4%, and the Shiitake mushrooms 4%. I nearly reached 100% of my DRI with these food items. With 8ug the goal, I reached 7.8ug.

            The Suggested Optimal Nutritional Allowances (SONA) for vitamin D are slightly different. 24ug is the goal in this case, and here, with my 7.8ug, I fall desperately short. Since it is difficult to meet the requirements for vitamin D through diet alone without consuming fortified milk, which I don’t drink, I need to get mine from other sources. It’s winter in Colorado, and so the days when I can expose my arms, hands, and face to the sun are limited. Even with spending long hours in the sun all summer, my vitamin D levels have faltered, for whatever reason. However, I can supplement with vitamin D capsules to make up for the lack in my diet and sun exposure. I currently take 10,000iu of vitamin D3 daily, which translates to 250ug, which exceeds both the RDA (300iu/7.5ug) and the SONA (960iu/24ug). I do this under the care of a qualified naturopathic physician to avoid toxicity. Because I’m a breast cancer survivor, we’re taking special care of my vitamin D levels to prevent recurrence.

            If it weren’t for my breast cancer diagnosis, I may still be in the dark to the important role vitamin D plays in the prevention and treatment of disease. Though sun exposure is the optimal route to satisfy requirements, some foods, including fortified foods, and supplementation, provide necessary levels to keep the body systems operating optimally.

**UPDATE: I have since started taking fermented cod liver oil daily to provide more whole food supplementation of vitamin D. I plan on discontinuing my vitamin D capsules and consume only the fermented cod liver oil. Blood tests will determine if this is sufficient-- I'll keep you posted. xoxo, SF

References

Higdon, J., & Drake, V. J. (2012). An evidence-based approach to vitamins and minerals: health benefits and intake recommendations. Stuttgart: Thieme.

Smolin, L. A., & Grosvenor, M. B. (2013). Nutrition: science and applications(3rd ed.). Hoboken, NJ: Wiley.

Smolin, L. A., & Grosvenor, M. B. (2010). IProfile: assessing your diet and energy balance. Hoboken, NJ: Wiley. Retrieved January 25, 2018.

The Suggested Optimal Daily Nutritional Allowances (SONA)[Online reading material for
MSHN 515, Hawthorn University]. (2017).