How is irritable bowel syndrome (IBS) treated?
Treating irritable bowel syndrome (IBS) can be difficult as there are a number of different factors (diet, lifestyle, mental health) to consider. People with IBS often have to try a number of therapies, techniques or lifestyle changes in order to determine what works best for them.
Treatment can include the following:
1. Traditional medical therapies
Traditional therapies that treat IBS symptoms include:
• Bulking agents for constipation (i.e. Normacol)
• Antidiarrhoeals (such as Loperamide) for diarrhoea
• Antispasmodics (i.e. Brevispas, Colofac) for pain
2. Serotonergic drugs
Serotonergic drugs like prucalopride seem to be effective in IBS patients with constipation, and may become an important therapy in the near future.
3. Drugs that increase fluid secretion in the gut
Two new drugs in this category await approval in the USA. They’re therefore not yet available in South Africa. Linaclotide and lubiprostone stimulate the secretion of fluids, improve the ease of stool passage and thus improve colon transit time.
The most promising of the emerging drugs is rifaximin, an antibiotic that isn’t absorbed from the gut. Studies have found that it improves all the symptoms of IBS and that the improvement is sustained for up to three months after stopping the medication. The antibiotic is, however, currently unavailable in South Africa.
Probiotics, defined as microorganisms with potential therapeutic benefits, are becoming increasingly popular and could be of value to certain people with IBS. A combination of two or more organisms seems to be more effective than preparations that contain only one organism. Lactobacillus on its own seems to do nothing for people with IBS, whereas a combination with Bifidobacterium is quite effective.
Unfortunately, there aren’t any clear-cut guidelines on exactly the right dose for each probiotic strain, and long-term safety data still lacks.
Probiotics could work via three mechanisms:
• Secretion of small molecules that have antimicrobial activities against other bacteria (direct antagonism).
• Stimulation of immune cells to kill off bad bacteria (immunomodulation).
• Making the gastrointestinal environment inhospitable to certain bacteria (exclusion).
Around the globe, popular sources of natural probiotics include yoghurt, kefir, sauerkraut, pickles, kombucha, tempeh and miso.
The bacteria in the gut make up a significant component of any healthy person’s gastrointestinal tract. They’re responsible for fermenting food as it passes through the gut, particularly in the intestines. Fermentation perpetuates the growth of beneficial microbes called probiotics. These live microbes beneficially affect the host by improving its intestinal microbial balance.
Probiotic foods in African cultures
Of course, not all fermentation happens inside the body. It’s also the oldest food-preservation technique on record. Africans have long consumed fermented foods. The continent is the cradle of humankind, so this ancient technology may very likely have originated in Africa as cavemen started collecting and storing food.
People in Africa usually ferment mainly cereal-based foods (like sorghum, millet and maize), roots such as cassava, fruits, vegetables (though less commonly), and meat and fish (to a lesser extent).
Two of southern Africa’s most popular fermented products are amasi, or sour milk, and amahewu, a non-alcoholic fermented maize drink. Amasi is mainly produced by spontaneous fermentation of milk. Amahewu is produced by spontaneous fermentation of cooked maize or sorghum meal. There’s also incwancwa, a sour porridge made from maize or sorghum gruel. This is allowed to spontaneously ferment to improve and develop palatability, flavour and nutrition. It’s then cooked.
Other popular fermented products from this region include umqombothi, or sorghum beer, that’s made from cooked maize or sorghum by wild yeast fermentation, a Zimbabwean traditional sorghum beer called chibuku, and a trio of traditional Zambian non-alcoholic beverages called mabisi, munkoyo and chibwantu.
In Nigeria and elsewhere in West Africa, ogi, iru and gari are three traditional fermented foods that are still produced in households today. Ogi is a fermented product of cooked maize, or sorghum or millet grains. Iru is a fermented product of African locust bean, and gari is a fermented cassava product. Gari is made by peeling fresh roots and grating them into mash before putting them into sacks for fermentation. Borde and shamita are two of Ethiopia’s important traditional fermented beverages. They’re produced through overnight fermentation of certain cooked cereals.
These foods and drinks are treasured: both for nutritional purposes and cultural practices. African families still provide amahewu and umqombothi during ceremonies like traditional weddings as a treat for their guests. The non-alcoholic foods and beverages are used for weaning children and to refresh adults.
But there’s far more to these fermented foods than a good meal. They offer scientists some important insights into just how such foods encourage the growth of probiotics and how this keeps people healthy. Our African ancestors were onto something – and the continent’s increasingly urban populations should follow their example.
The probiotic microbes associated with fermented foods are hugely beneficial. They degrade anti-nutritional substances like mycotoxins and phytic acid. The abundant probiotics in fermented food also improve digestion and the production of nutrients, like vitamins. Probiotic microbes inhibit the growth of food spoilers and can both prevent and treat diarrhoea. They inhibit tooth decay, can help to manage some types of diabetes, and some have been proved to reduce “bad” cholesterol.
It stands to reason that all of these benefits helped African communities who didn’t have access to antibiotics. Just because we now live in a world where antibiotics are increasingly available doesn’t mean the old ways are irrelevant.
6. Other natural therapies
Peppermint oil can provide substantial relief for IBS and has been extensively used by medical practitioners, while turmeric is also believed to give reasonable relief of symptoms.
A review published in the American Journal of Gastroenterology found that, in some trials, acupuncture seemed to work better than certain medications for IBS. But, in others, acupuncture was no better than a sham procedure. As acupuncture is expensive, it might be best to wait for more evidence before putting it to the test.
St. John's Wort doesn’t appear to relieve the pain and discomfort that accompanies IBS. And, unfortunately, many products such as Slippery Elm haven’t been medically tested.
7. Changes in lifestyle
Exercise: Experts recommend doing 30 minutes of exercise most days of the week, or a total of 150 minutes of exercise per week. Exercise assists the stool to move forward via peristalsis and can therefore improve symptoms (especially constipation). Not only does exercise physically affect your bowel movements, it’s also a great way to relieve stress.
Research backs this up: a study done in 2011 showed that people with IBS who did 20 - 30 minutes of exercise 3 - 5 days a week saw a dramatic improvement in abdominal pain, stool problems, and other symptoms.
Diet: Most people with IBS mistakenly believe that specific foods play a significant role in their symptoms and that avoiding these foods will reduce their symptoms. Although certain foods may exacerbate symptoms, they don’t cause the symptoms in most people with IBS. Following a gut-healthy diet can help you to manage IBS symptoms and promote general health.
Research has shown that 12% of people with IBS have very restricted diets that are unbalanced and inadequate in terms of the nutrients required for general health. Restricting your diet isn’t recommended and could lead to deficiencies. Work with a dietitian to ascertain your food triggers and to ensure that your diet is nutritionally adequate.
For adults, the recommended amount of fibre intake from foods is 30g per day. This includes both soluble and insoluble fibre. Reaching the recommended daily fibre intake is important for gut health, as fibre-rich foods are beneficial for our healthy gut bacteria. When fibre ferments, it forms a short-chain fatty acid known as butyrate – an important fuel source for the cells in your gut.
Most fibre-rich foods contain both types of fibre. Therefore, concentrating on foods that are good fibre sources is important for overall gut health. But some people with IBS feel that they react to wheat and legumes – two good sources of both insoluble and soluble fibre.
Working with a dietitian can help you tease out which foods are indeed triggers for your IBS symptoms, and he or she can assist you to reach your recommended amount of fibre intake per day. Whole-wheat products and legumes are very good sources of fibre, and cutting them out unnecessarily can make it difficult to reach your 30g per day allowance for optimal gut health.
Fibre supplementation is the most widely studied dietary treatment for IBS. However, increasing the amount of insoluble fibre in the diet, especially if you have constipation, may actually worsen IBS symptoms. For some people with IBS, especially those with constipation, increasing the intake of soluble fibre by 10 - 20g per day in the form of supplements such as ispaghula and psyllium, and foods high in soluble fibre, can improve symptoms.
Most foods increase the amount of gas formed in the colon. However, certain foods are thought to produce larger amounts of gas (due to their fermentation in the colon). These include beans, Brussels sprouts, onions, celery, cabbage, legumes, cauliflower, broccoli and raisins.
There’s no clear evidence that people with IBS generate more gas than normal individuals, but they may be more bothered by intestinal gas because of greater sensitivity or abnormal handling of gas.
People with IBS seem to have increased intestinal sensitivity to fat. High intakes of fat can also slow down the manner in which the intestinal content (stool) moves through the gut as well as reduce the movement of gas in your gut. This can make bloating much worse.
Some people also report that rich or fatty foods are trigger foods that can cause IBS symptoms. However, there are no controlled studies investigating the effect of a low-fat diet for the treatment of IBS.
Coffee, with or without caffeine, stimulates gastrointestinal motility and can cause diarrhoea in normal individuals. Studies with IBS patients have shown an improvement when caffeine was excluded, and recurrence of symptoms when caffeine was reintroduced. Up to 26% of individuals with IBS report limiting or avoiding use of coffee due to adverse reactions.
Up to 21% of people with IBS report intolerance to various alcoholic beverages, and up to 12% limit or avoid them. It’s best to work together with a dietitian to ascertain your own specific trigger foods. However, for general health, it must be noted that the alcohol guidelines would still apply, i.e. one standard drink for women or two standard drinks for men per day.
Highly fermentable carbohydrates (FODMAPs)
The low-FODMAP diet has been in the IBS limelight of late due to promising results with symptom management. In an Australian study, 75% of people with IBS showed improvements in their symptoms on this diet.
The acronym FODMAPs stands for “fermentable oligo-, di-, and monosaccharides and polyols”. FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine. These carbohydrates are fermented by gut bacteria, which produce gas and draw water into the gut. This, in turn, causes bloating, pain and diarrhoea.
On the one hand, fermentation produces short-chain fatty acids that have, in recent years, been identified as beneficial to health. These fatty acids potentially protect against gastrointestinal disorders, cancer and cardiovascular disease.
On the other hand, the fermentation produces considerable quantities of various gases such as hydrogen, carbon dioxide and methane. This is the reason why people with IBS tend to suffer bloating that increases over the course of the day until some people complain that they look as if they’re nine months pregnant by suppertime. These gases, particularly methane and hydrogen sulphide, are also particularly noxious – another aspect of IBS that causes great distress.
FODMAPs are found in a wide range of foods. It’s therefore important to work with a registered dietitian who has a special interest in IBS and FODMAPs to assess if you’re a good candidate for the low-FODMAP diet and to ensure that your diet is nutritionally adequate.
Highly fermentable carbohydrates include:
Lactose is a disaccharide (short-chain carbohydrate) that some people struggle to digest and absorb. Individuals with or without IBS may report increased symptoms such as bloating, flatulence, abdominal discomfort, nausea and loose stools following the intake of lactose-containing foods.
Note that lactose (which consists of a glucose and a galactose molecule) is only classified as a FODMAP, and only causes fermentation, if the individual in question suffers from lactose intolerance. This person doesn’t produce sufficient lactase enzyme in the intestine. This is important to remember. It’s simply not a good idea to eliminate milk and dairy products without good reason.
Lactose malabsorption isn’t the sole cause of IBS symptoms either, nor is it more prevalent in people with IBS than in the general population. If you do have a lactase deficiency, then avoiding milk and all products that contain milk will probably help a great deal to relieve your symptoms. Check food labels carefully and remember to take a calcium supplement to make up for the lack of calcium in your diet. Also note that some dairy sources (e.g. cheese) contain small amounts of lactose and may be perfectly acceptable to consume.
Be aware that eliminating one source of fermentation (lactose, in this case) doesn’t mean that all your IBS symptoms will be cured. You may still be sensitive to one or more of the other FODMAPS and need to identify them, preferably with the help of a registered dietitian with a special interest in IBS and the FODMAP concept.
Fructose is naturally found in honey, certain fruits, dried fruit and fruit juices. Most adults, with or without IBS, usually struggle to absorb fructose when consumed in high amounts. People with IBS may feel the effects of fructose malabsorption to a greater degree as they have visceral hypersensitivity.
Therefore, fruits that contain higher amounts of fructose compared to glucose should be restricted. Fruits such as bananas and strawberries, where glucose is present in equal or greater amounts, are preferable. Mangoes, apples and pears contain more fructose and should be avoided.
Galacto-oligosaccharides are found in pulses and legumes as well as in cashew and pistachio nuts. As legumes are a good source of soluble fibre, it must be stressed that the low-FODMAP diet shouldn’t be continued for long periods of time.
The low-FODMAP diet should only be implemented for a period of 4 - 6 weeks under the supervision of a registered dietitian. After the elimination period, it’s essential that you slowly re-introduce the FODMAP sources to your diet. This must be done in a controlled manner in order to ascertain which of the FODMAPs may be triggering your symptoms.
Fructans are found particularly in wheat-based products as well as in onions, leeks, rye and certain fruits. Inulin, a type of fructan, is found in chicory root and Jerusalem artichokes (the root-version of artichokes). Fructo-oligosaccharides and inulin are also found in peach, watermelon, Brussels sprouts, fennel, garlic, leek, onion, wheat, rye, barley, legumes, lentils and chickpeas.
Sugar alcohols (polyols)
Sugar alcohols include sorbitol, mannitol, xylitol, and isomalt, and are digested and absorbed poorly. Certain fruits and vegetables (see table below) naturally contain sugar alcohols. They’re also used in many sugar-free products (e.g. chewing gum) and other sweetened products. This is because polyols are difficult to absorb.
For many years, polyols have also been used as sweeteners in diabetic and slimming products. If you chew sugar-free gum that contains polyols as a sweetener, you may set yourself up for bloatedness and flatulence. Abdominal gas will form as a result of the fermentation of the polyols in your chewing gum as well as from swallowing air when you chew. Try cutting out chewing gum for a week or so to see if it relieves the flatulence.
FODMAP tools and resources
Remembering which foods are high in fermentable carbohydrates can be exhausting. To make life easier, the Gastroenterology Team at Monash University have put together a low-FODMAP diet app that houses the latest research related to foods high in fermentable carbohydrates.
The app is available on the iOS App Store as well as Google Play. There’s a charge for the app, but all proceeds go back into funding IBS research.
There are also great blogs and websites you can follow to learn more about the FODMAP concept. These include:
• The FODMAP blog
• For a Digestive Peace of Mind blog
Refer to the table below for a more detailed list of foods containing FODMAPs:
As mentioned before, the low-FODMAP diet should only be implemented for a few weeks under the supervision of a registered dietitian who has experience in implementing the low-FODMAP diet.
The low-FODMAP diet isn’t nutritionally adequate over long periods of time as it eliminates various fruits and vegetables. This may result in a lower fibre intake.
There’s also evidence to suggest that the low-FODMAP diet negatively affects levels of healthy gut bacteria (bifidobacteria) due to the restriction of foods that naturally ferment and provide nutrients to the gut bacteria. Additionally, there’s a concern if dairy products (especially milk) are eliminated, as they’re the best sources of calcium in the diet.
During the elimination period, it’s important to restrict the FODMAPs globally (with the exception of lactose), and not individually, as a reduced intake of all FODMAPs is more effective in reducing luminal distention. Once the 4 - 6 week period is over, work with your registered dietitian to achieve symptom control by introducing the FODMAPs back into your diet.
Your dietitian will help you to reintroduce the high-FODMAP foods in a graded manner, and assist you with assessing your tolerance levels for the higher-FODMAP foods. It’s important to note that FODMAPs don’t cause IBS symptoms. Following the FODMAP approach (including the reintroduction phase) only provides an opportunity to better manage your symptoms and to become more aware of your trigger foods and tolerance levels.
There’s now a condition termed “non-coeliac gluten intolerance”. This refers to IBS patients that don’t have coeliac disease when tested, but who respond very well to a gluten-free diet. However, further research is needed in this field.
Other strategies to manage IBS:
• Avoid large meals – eat small meals and snacks
• Don’t skip meals
• Ensure adequate water intake
• Sit down to eat and chew food well
• Don’t smoke, especially on an empty stomach
• Don’t self-medicate
• Get at least 7 - 8 hours of sleep every night
There’s evidence to suggest that undesirable reactions to food exacerbate the symptoms in some people with IBS, especially those with diarrhoea. But evidence suggests that dietary restrictions will help only about a quarter of people with IBS. It’s also important to remember that the diet and way of life that improves IBS symptoms is different for each person.
Keep a diary of the foods you eat and the symptoms you experience (a so-called food-symptom diary), and track the amount of sleep you get and how much exercise you do. Take note of foods that seem to be followed by increased symptoms, paying particular attention to the above-mentioned possible triggers (e.g. alcohol, lactose, fructose, sorbitol, gas-forming foods, wheat, fat, coffee). The elimination of these foods (except alcohol and coffee) should only be done with the guidance of a dietitian.
8. Looking after your mental health
Doctors have long known that psychological therapies such as relaxation, cognitive behavioural therapy (CBT), other psychological therapies and hypnosis can temporarily ease the symptoms of IBS. But new research suggests they could also offer long-term benefits.
Lynn Walker, a professor of paediatrics at Vanderbilt University Medical Centre in Nashville, conducted a study looking at the long-term benefits of psychological therapies. The team found that the moderate benefit that psychological therapies confer in the short term continue over the long term. This is significant, because IBS is a chronic, intermittent condition for which there’s no cure.
The researchers analysed results of 41 clinical trials involving more than 2,200 IBS patients. They found that several different psychological therapies, including relaxation, hypnosis and cognitive behavioural therapy, were equally beneficial in helping people change the way they think.
Psychological treatment is important, as gastrointestinal symptoms can increase stress and anxiety. This, in turn, can increase the severity of symptoms. This is a vicious cycle that psychological treatment can help break.
You don't need a PhD in physiology to know that stress can be hard on the stomach. We've all done our own experiments on the subject, intentionally or not. Remember how you felt the last time you spoke in public? Those butterflies weren't in your head.
The impact of stress on the stomach goes far beyond indigestion. In recent years, doctors have uncovered a remarkably complex connection between the brain and the digestive system, noting that the entire system is extremely sensitive to our moods.
In fact, experts now see stress as a major factor in a wide range of digestive problems, including IBS, indigestion and heartburn. Most experts agree that by understanding how stress affects our bodies, we can open up new avenues for prevention and treatment of conditions such as IBS.
We all talk about "gut feelings", but few of us really appreciate the amazingly strong connections between the brain and the digestive system. The stomach and intestines actually have more nerve cells than the entire spinal cord, leading some experts to call the digestive system a "mini-brain". A highway of nerves runs directly from the real brain to the digestive system, and messages flow in two directions. Consider this: 95% of the body's serotonin – a hormone that helps to control mood – is found in the digestive system, not in the brain.
When the brain feels severely stressed, it unleashes a cascade of hormones that can put the whole digestive system in an uproar. The hormones have different and sometimes contradictory jobs. For example, the hormone CRH (short for corticotropin-releasing hormone) is one of the body's main alarm bells. In stressful situations, the brain pumps out CRH to tell the adrenal gland to start making steroids and adrenaline, chemicals that can give you the strength and energy to run or fight your way out of trouble.
CRH also turns off appetite, which explains why some people can't eat anything when they're stressed. At the same time, the steroids triggered by CRH can make a person hungry, which is why some people fight stress with ice cream, chocolate or potato chips.
Clearly, different people have different responses to stress, and there's no way to say for sure how specific situations will affect digestion. But there are some general rules of thumb. Over the short term, stress can cause stomach aches, nausea and diarrhoea. In the long term, prolonged stress can aggravate chronic diseases such as IBS.
Stress is especially troubling for people who have digestive problems without any clear physical cause – the "functional gastrointestinal disorders", in medical speak. In these instances, every part of the system looks healthy and normal, but they still don't work as they should.
Not only does stress mess with your hormones, it also affects the way your colon contracts. This makes the contractions uncoordinated and unproductive, which could lead to stomach pain. Stress can also make the mind more aware of sensations in the colon. And since people with IBS may feel more discomfort due to extra-sensitive pain receptors in the gastrointestinal tract, even normal contractions can feel unpleasant.
Stress, for most people, is difficult to manage and can be a trigger for an IBS flare-up. Ask your doctor if you would be a good candidate for cognitive behavioural therapy, interpersonal therapy, relaxation therapy, or another form of counselling.
The American National Digestive Diseases Information Clearinghouse (NDDIC) suggests these methods to manage stress:
• Use relaxation therapies, such as meditation.
• Seek private counselling or support groups.
• Get regular exercise, such as walking or yoga.
• Change a stressful situation in your life.
• Get adequate sleep.
Hypnotherapy for IBS involves progressive relaxation and suggestions of soothing imagery and sensations focused on the individual’s symptoms. Some clinical trials have shown that hypnosis is an effective treatment for people with IBS and that it can improve overall well-being, quality of life, abdominal pain, constipation, diarrhoea and bloating.
Gut-directed hypnotherapy therefore seems to have beneficial short-term effects in improving gastrointestinal symptoms of people with IBS, and studies indicate that the results are maintained after one year in half of people.
Cognitive behavioural therapy (CBT)
The best-studied form of psychological treatment is cognitive behavioural therapy. This is focused on replacing maladaptive coping strategies with more positive cognitions and behaviours. Several studies showed that cognitive behavioural therapy is effective in reducing bowel symptoms in IBS, both post-treatment and after short-term follow-up.
A therapy that combines mindfulness meditation and gentle yoga may help soothe symptoms of IBS, a small clinical trial suggests. In a study of 75 women with the digestive disorder, researchers found that those assigned to mindfulness training saw a bigger improvement in their symptoms over three months than women who were assigned to a support group. The findings, they say, suggest that the mindfulness technique should be an option for treating the condition.
A doctor not involved in the study agreed. "I think people with IBS should learn mindfulness skills," said Dr Delia Chiaramonte, director of education for the University of Maryland's Centre for Integrative Medicine in Baltimore.
Learning such skills, she said in an interview, is 100% safe and could offer people a way to help manage IBS symptoms on their own, long term.
In another study, Susan A. Gaylord and colleagues at the University of North Carolina, Chapel Hill looked at managing the "brain-gut" connection through mindfulness-based stress reduction. The researchers randomly assigned 75 women with IBS to either undergo the mindfulness training or attend an IBS support group once a week for eight weeks. The training included lessons on meditation, gentle yoga postures and "body scanning”, in which participants had to focus their attention on one body area at a time to detect muscle tension and other sensations.
Gaylord's team found that three months after the therapy ended, women who'd undergone mindfulness training were faring better than the support group. On average, their scores on a standard 500-point IBS symptom questionnaire fell by more than 100 points, with a 50-point drop considered a "clinically significant" improvement. In contrast, women in the support group averaged a 30-point decline, according to results published in the American Journal of Gastroenterology.
Chiaramonte said the trial was "tremendously well-designed", and set up to address the common criticisms of studies of mind-body therapies. Testing mindfulness training against a support group, for example, helps control for the fact that people involved in any form of therapy may simply expect to get better – and, therefore, do. In surveys, the researchers found that women in the support group were as likely to expect benefits as those in the mindfulness group.
"And still, the mindfulness group did better," Chiaramonte said. "So it's not just the contact with another human being, or not just that they expected to get better."
It also makes sense that mindfulness training would help people with IBS, according to Chiaramonte. "Part of the problem in IBS," she explained, "is the attention people give to the physical discomfort, and what the mind then does with that." With mindfulness training, the goal is to help people become aware of what they’re feeling, but then to "let it go" instead of ruminating and potentially making the physical symptoms worse.
There are still questions about the role of mindfulness in managing IBS, though. Larger trials, including ones that recruit men as well, are needed, according to Chiaramonte. There's also the fact that "mindfulness" can be learned in many different ways – at your local yoga or meditation centre, or through a book or CD, for example. If you’re interested, buying a CD or taking a meditation class would be a low-cost, low-commitment way to give mindfulness a go.
Reviewed by Kim Hofmann, registered dietitian, BSc Medical (Honours) Nutrition and Dietetics, BSc (Honours) Psychology.