IBS

Let’s Talk About Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic disorder that has been estimated to affect as many as 22 million people.


The symptoms of IBS include diarrhea, constipation, excessive gas, abdominal pain and bloating. Sometimes the pain is relieved by defecation, or there is a feeling of incomplete evacuation of the bowels. After other disorders have been excluded, treatment is usually directed at the predominant symptoms and gauged to their severity. “A careful balance between a thoughtful investigation and the expense and dangers of overtesting must always be considered. Most patients continue to have persistent symptoms several years after the original diagnosis” {Bonis and Norton 1996}.

Professor Wingate, in his foreword to the book Treating IBS {Backhouse and Dancey 1995} succinctly summarizes the medical status of IBS: “…the disorder is a constellation of symptoms lacking an agreed and objective pathophysiology.” “A doctor examining a patient with IBS will find no consistent physical changes. There are no accepted diagnostic tests. Finally, there is no therapy that is accepted as effective in even the majority of cases.” He goes on to point out that “..IBS is the source of much frustration between patients and doctors. The patient describes the symptoms to the physician and awaits a response; often, there is virtually none, because, while the physician agrees with the diagnosis (which is often already known to the patient), there seems nothing more to be done. Patients are frustrated by what seems to be the inertia or even indifference of physicians, while physicians are irritated by the reiteration of complaints that sometimes sound trivial”.

Lamentably, as Christensen {1994} points out, “After more than fifty years of study, the only agreement about the irritable bowel syndrome is the idea that it occurs in the absence of demonstrable organic disease of the colon.” Even more disconcerting for both patient and health care provider {Bonis and Norton 1996} is that “the challenge of irritable bowel syndrome is treating a symptom complex without having a clear understanding of the cause”. An added confounding factor in the treatment of IBS is that the placebo response seems inordinately high: It has been estimated that improvement can be due to the placebo response in as much as 71 percent of cases {Drossman and Thompson 1992}. This inescapably leads many physicians to suspect that psychological factors predominate in patients presenting with symptoms of IBS.

Patients with IBS appear to have more somatic complaints than people without IBS. Fatigue, headache, backache, pelvic pain and psychosocial factors leading to psychiatric illness such as anxiety and depression, especially with a history of abuse in childhood and adulthood, often accompany symptoms of IBS. Additional costs accrue from alcohol abuse, use of sedatives and oral narcotics, which appear to be more frequent in persons experiencing IBS {Lonstreth 1995}. In women, IBS symptoms frequently worsen during menstruation and overlap of IBS with gynecological disorders leads to increased numbers of visits to gynecologists. Because of the frequent association with other organ systems and psychological factors, the severity of IBS waxes and wanes within the population, which determines the numbers of patients who seek medical help and undergo costly gastrointestinal investigations at any given time {Longstreth 1995}. Because IBS remains a diagnosis of exclusion, these expensive investigations are often prerequisites for a final diagnosis of IBS.


The Role of Diet

greeksaladSufferers from chronic irritable bowel syndrome and its associated distress tend to blame food for their problems. Since eating causes them to feel ill, presumably not eating will make them feel well. However, everyone knows that without food they will starve to death. The alternative is choosing the right food. So often, food is the only factor in a person’s life over which they have complete control. I have frequently been requested to supply the magic diet that will make the patient “feel good”. Unfortunately, many popular books and magazine articles have promised this unattainable prize, and our patients frequently blame themselves for “not having enough willpower to stick to my diet”, or worse, blame their previous health care providers for not supplying them with the right formula, because, of course, such a thing does exist, if only someone would tell them what it is!

Even more worrying are the many patients who have “given up on food”. They have read every available treatise on herbal, homeopathic, and naturopathic remedies and supplements. While all of these have their place, without professional guidance in their use some rather worrying scenarios result. On a number of occasions I have read through an “exposure diary” (the food and symptom record that each patient completes before a consultation) and have failed to find more than five or six foods hidden within long lists of supplements and “remedies”. Again, the patient is looking for the right combination of elements to feel well, while avoiding the food that makes them sick. When told that food is not the cause of their symptoms, most patients at best express disbelief, at worst hostility, unless prior validation of their experiences has provided a forum for discussion of the key to recovery. The most important fact that a person must recognize is that it is the body’s response to the food that is making them ill, not the food itself. As the patient grasps this concept, their attitude shifts perceptibly from the hostile, “Food is a poison and my body is a helpless victim”, to the nurturing, “Food is nourishment, but my body has been injured and needs care”. It is at this point that healing can start.


Although the appropriate diet will reduce exacerbation of the insult or insults that initiated the dysfunctions that underlie IBS, no diet will help the condition if the underlying cause(s) of the condition have not been addressed. Thus, if an infection remains untreated, the gastrointestinal symptoms will persist until it is. Likewise, if neuropeptides released in the stress response are mediating inflammation in the gastrointestinal tract, the cause of the stress will need to be addressed before the inflammation can resolve. A combination of therapeutic measures, including appropriate medications where indicated, will often lead to a successful outcome when any one approach alone achieves little improvement.


Many studies have attempted to prove or disprove the concept that an allergic reaction to food is a cause of, or contributes to IBS. All of these studies have approached the problem from the standpoint that elimination of the culprit food will lead to remission of symptoms, while eating the food must cause their recurrence {Gertner and Powell-Tuck 1994; Zwetchkenbaum and Burakoff 1988; Bentley et al 1983; Alun Jones et al 1982; 1983}. However, with IBS we are not dealing with a causal effect as in an allergic reaction where an antigen triggers a devastating response of the immune system. Instead we have a situation where a previous insult is being prolonged and often exacerbated by the exposure of damaged cells in the gastrointestinal tract to a variety of factors in foods that make the situation worse. Whatever the underlying causes of IBS, it is irrefutable that since the symptoms are confined to the digestive tract, and the function of the digestive tract is the processing of food, food components will impact on the condition. When the way in which each food component might exacerbate or ameliorate each of the of the events suggested to contribute to IBS is considered, it is possible to develop an eating plan that provides some degree of symptomatic relief of the condition by dietary manipulation.

How Food Interacts with the Damaged Digestive Tract

The mechanisms underlying the food/gut interaction may be immunological, physiological, pharmacological or psychogenic in origin, but food is inevitably involved in any event in the gastrointestinal tract. Delivering food components in the form in which the least amount of irritation to the tissues ensues, will help in relieving some of the distress of the condition in the majority of cases. The IBS management program is a practical approach to dietary management of IBS based on many years of scientific research and clinical practice in applying the science of food chemistry to determining how individual food components might impact on the irritated bowel (Joneja 2004). The strategies we use have provided relief for more than a two thousand patients with IBS who have consulted the Allergy Nutrition Clinic at Vancouver Hospital and Health Sciences Centre since its inception in 1991.


Advantages of Dietary Management of IBS

Management of IBS by dietary manipulation has many advantages. It provides the sufferer with the means to control their own symptoms by voluntary selection of the least irritating form of each food they consume. Even if the improvement is suspected to be due to “placebo effect”, the relief of the pain and distress of IBS is real, and improvement of the sufferer’s quality of life will override the often negative connotations attached to this explanation for their recovery. Sometimes this degree of control and taking responsibility for their own choices has positive benefits in certain psychologically-mediated situations, particularly when the patient has previously felt powerless. A frequent psychological benefit seems to be that when an individual feels more in control, they are less fearful of entering social and work situations in which their symptoms may cause embarrassment, discomfort, or distress.

When the IBS patient has experienced obvious and consistent improvement as a result of dietary manipulations, the fear that the condition is intractable, incurable, or even life-threatening is often ameliorated and their quality of life improves significantly. Recurrence of symptoms can often be explained on accidental or knowing deviation from the prescribed diet, and patients are often willing to accept the discomfort when they feel that it will be temporary and under their power to control in the future. When the patient feels capable of managing their own condition, repeated visits to physicians’ offices and outpatient clinics are decreased, resulting in reduced health care costs. Since dietary management frequently decreases the need for prescription and over-the-counter medications, the cost of treatment of IBS symptoms is often significantly reduced, and the risk of adverse side-effects of drugs is lessened.

An initial trial period of about four weeks on the IBS diet should be adequate to determine whether this approach is appropriate. If the symptoms have not improved significantly during this time, it is unlikely that food is contributing to the problem, and manipulation of the diet will be of little benefit. If symptoms have improved, sequential incremental dose challenge (SIDC) of each restricted food component will determine the degree to which foods are contributing to the symptoms and suggest whether dietary management will be the treatment of choice for long-term management of the IBS. If the condition can be managed principally, or even partially by dietary manipulation, the benefits to the sufferer and their families are undeniable.

A complete description of IBS and details of IBS management programs can be found in Dr. J’s book Digestion, Diet and Disease


References

Alun Jones V, McLaughlan P, Shorthouse M, Workman E, Hunter JO. Food intolerance: A major factor in the pathogenesis of irritable bowel syndrome. Lancet 1982 ii:1115-1117

Alun Jones V, Shorthouse M, Workman E, and Hunter JO. Food intolerance and the irritable bowel. Lancet September 10 1983 633-634

Backhouse S and Dancey CP. (eds) Treating IBS. Grune and Stratton 1995 London

Bentley SJ, Pearson DJ, Rix KJB. Food hypersensitivity in irritable bowel syndrome. Lancet 1983 ii:295-297

Bi-zhen W and Qi-Ying P. Functional bowel disorders in apparently healthy Chinese people. Chinese J Epidemiol 1988 9:345-349

Bonis PAL and Norton RA. The challenge of irritable bowel syndrome. Amer Fam Phys Mar 1996 53(4):1229-1236

Bueno L and Fioramonti J. Effects of inflammatory mediators on gut sensitivity. Canadian Journal of Gastroenterology 1999 13(Suppl A): 42A-46A

Burns DG. The risk of abdominal surgery in irritable bowel syndrome. S Afric Med J 1986 70:91

Camilleri M. Management of the irritable bowel syndrome. Gastroeneterology 2001 120: 652-668

Christensen J. Defining the irritable bowel syndrome. Perspectives in Biology and Medicine 1994 38(1):21-35

Drossman DA and Thompson WG. The irritable bowel syndrome: Review and a graduated multicomponent treatment approach. Annals of Internal Medicine 1992 116(12 Part 1):1009-1016

Evangelista S. Involvement of tachykinins in intestinal inflammation. Curr Pharm Des 2001 7(1):19-30

Gertner,D, Powell-Tuck J. Irritable bowel syndrome and food intolerance. The Practitioner 1994 238:499-504

Harvey RF, Salih SY and Read AE. Organic and functional disorders in 2000 gastroenterology outpatients. Lancet 1983 1:632-634

Jamieson DJ and Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain and irritable bowel syndrome in primary care patients. Obstet Gynecol 1996 87(1):55-58

Joneja, JMV. Digestion, Diet and Disease: Irritable Bowel Syndrome and Gastrointestinal Function. Rutgers University Press. August 2004 ISBN 0-8135-3387-2

Jones R., Lydeard S. Irritable bowel syndrome in the general population. Br Med J 1992 304:87-90

Longsreth GF. Irritable bowel syndrome and chronic pelvic pain. Obstet Gynecol Rev. 1994 49:505-507

Longstreth GF. Irritable bowel syndrome: A multibillion-dollar problem. Gastroenetrol. 1995 109:2029-2031 (Editorial)

Martinez-Augustin O, Sanchez de Medina F, Sanchez de Medina F. Effect of psychogenic stress on gastrointestinal function. J Physiol Biochem 2000 56(3):259-274

Mertz HR. New concepts of irritable bowel syndrome. Current Gastroeneterology Reports 1999 Oct. 1(5):433-440

O’Sullivan M, Clayton N, Breslin NP, Harman I, Bountra C, McLaren A, OP’Morain CA. Increased mast cells in the irritable bowel syndrome. Neurogastroenterology Motility 2000 12:449-457

Sandler RS. Epidemiology of irritable bowel syndorme in the United States. Gastroenterology 1990 99:409-415

Sonnenberg A and Everhart JE. Socio-economic determinants of digestive diseases. Gastroenterol 1993 6:100-114

Talley NJ, Gabriel SE, Harmsen WS, Zinsmeister AR and Evans RW. Medical costs in community subjects with irritable bowel syndrome. Gastroenterology 1995 109:1736-1741

Thompson WG and Heaton KW. Functional bowel disorders in apparently healthy people. Gastroenterology 1980 79:283-288

Whitehead W. Psychotherapy and biofeedback in the treatment of irritable bowel syndrome. In: Irritable Bowel Syndrome 1985 245-

Zwetchkenbaum J and Burakoff R. The irritable bowel syndrome and food hypersensitivity. Ann.Allergy 1988 61(1):47-49