Holistic approach to managing IBS and food sensitivities.

What is IBS?

IBS affects about 5% to 20% of people worldwide. Diagnosis is based on symptoms of chronic abdominal pain, discomfort, bloating, and alteration of bowel habits, in the absence of overt organic disease. Diarrhoea or constipation may predominate, or they may alternate.

In routine clinical practice, IBS is diagnosed based on typical symptoms. The use of investigations is often restricted to a selected panel of tests that help to exclude known organic diseases that present with similar symptoms, such as inflammatory bowel disease or coeliac disease.

IBS is very poorly understood by conventional medicine. It is seen as a group of symptoms without a clear cause. As a result, the treatment of IBS is very much focused on symptom management. Unfortunately, in most cases, this only provides limited relief as it doesn’t address why the IBS is happening. IBS symptoms are sometimes exacerbated by stress and can be associated with psychological co-morbidities such as anxiety, depression, hypochondriasis and phobic disorders.

In the past, patients with IBS were treated by giving medicines targeting individual symptoms of IBS, such as bloating, abdominal pain, diarrhoea, and constipation. The IBS population is diverse, with a wide range of complaints and varying degrees of symptom severity. According to the National Institute for Health and Care Excellence (NICE), Loperamide and antispasmodic are the first choice of antimotility agents for IBS-D and linaclotide and laxatives are for IBS-C if dietary and lifestyle changes have not helped. For the second line of treatment for IBS, tricyclic antidepressants (TCAs) are recommended if laxatives, loperamide or antispasmodics have not helped. NICE advised considering selective serotonin reuptake inhibitors (SSRIs) for people with IBS only if TCAs are ineffective. Psychological interventions such as cognitive behavioural therapy (CBT) are considered for people with IBS who do not respond to pharmacological treatments after 12 months and develop a continuing symptom profile. (NICE,2017).

Why do we have IBS?

There is no single model or hypothesis can explain all aspects of the pathophysiology mechanism and cause of IBS. Traditionally, IBS has been conceptualised as a condition of visceral hypersensitivity (leading to abdominal discomfort or pain) and gastrointestinal motor disturbances (leading to diarrhoea or constipation), with no known underlying structural or biochemical explanation, but this concept is likely to be outdated, so, by definition, it is a heterogeneous disorder.

There are several different underlying disease mechanisms underlying these subtypes.

  • Small Intestinal Bacterial Overgrowth (SIBO)
  • Food Intolerance
  • Low-grade Mucosal Inflammation, Immune activation, and Altered Intestinal Permeability
  • Post Infection (PI-IBS)
  • Serotonin Dysregulation
  • Gut-Brain Dysfunction
  • Altered Intestinal Microbiota
  • Disordered Bile Salt Metabolism
IBS is a complex and multifaceted condition, and the naturopathic approach reflects this in supporting the person and not the symptoms. The treatment of IBS should be individualised with an emphasis on mind and body connection and clinical support.

FODMAP Diet for IBS

Varjú et al.'s (2017) meta-analysis confirms that a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) significantly improves general symptoms and quality of life in patients with irritable bowel syndrome. FODMAP diet is a 2-phased intervention, with strict reduction of all slowly absorbed or indigestible short-chain carbohydrates (i.e., FODMAPs) followed by reintroducing specific FODMAPs according to tolerance. The efficacy of the elimination phase of the FODMAP diet is well established, but the success of maintaining this diet has been shown in only a few observational studies.

As a restrictive diet, the low-FODMAP diet carries a risk of nutritional inadequacy. According to Hill et al. (2017), a strict FODMAP restriction induces a potentially unfavourable gut microbiota, and the impact of this consequence on health is unknown.

Ref : Hill, P. Muir, J.G. Gibson, P.R. (2017). ‘Controversies and Recent Developments of the Low-FODMAP Diet.’ Gastroenterology & Hepatology, 13(1), pp.36-45.

Varjú, P. Farkas, N. Hegyi,P. et al. (2017).'Low Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAP) Diet Improves Symptoms in Adults Suffering from Irritable Bowel Syndrome (IBS) : A Meta-Analysis of Clinical Studies.’ PLOS ONE, 12(8), p. e0182942.

5R Programme Protocol for IBS

The 5R gut healing protocol is designed to restore the gastrointestinal tract's natural balance, including Remove, Replace, Reinoculate, Repair, Rebalance.

Step 1. Remove

Trigger Food – Remove any type of gut irritant such as alcohol, caffeine, processed food and food additives, and specific type of carbohydrates. Gut Pathogens such as pathogenic bacteria, parasites, candida, and yeast. Botanical anti-microbials such as berberine, oregano, and neem allicin can be used at this stage.

Step 2. Replace

Supplements to replace the missing elements such as betaine HCL, bile salts, and enzymes that help digest fat, lactose, carbohydrates and protein. Digestive conditions can affect the absorption of nutrients such as B12, iron, calcium, magnesium and zinc: high-potency multivitamins and mineral formulas or food to correct nutrient insufficiency.

Step 3. Reinoculate

The focus of the third step is to normalise the balance of gastrointestinal bacteria. Probiotic foods such as sauerkraut, kimchi and kombucha and prebiotic foods such as onions, garlic, leeks, asparagus, apples and bananas, and pro/prebiotic supplements can be administered.

Step 4. Repair

At this stage, we want to create an environment that supports gut healing and improves intestinal permeability (leaky gut syndrome). Reversing leaky gut can improve IBS symptoms. Foods high in vitamins A, C, D, E, and zinc and foods rich in amino acids, such as bone broth, are recommended. Supplements such as L-glutamine, collagen, aloe vera, marshmallow or slippery elm can be used.

Step 5. Rebalance

The one that most healthcare practitioners often overlook. This last step is focused on lifestyle choices, such as sleep, stress and exercise and how they impact the gut. A holistic approach, such as practising yoga, meditation, breathing exercises, and getting enough sleep, is the way to improve inner peace. Movement and exercise are vital in maintaining good health but within moderation. Strenuous exercise can sometimes have the opposite effect and trigger a leaky gut.