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.
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/