Lifestyle plays an important role in reducing symptoms
By David Dunaief, M.D.
According to estimates, 10 to 15 percent of the population suffers from irritable bowel syndrome (IBS) symptoms, although only five to seven percent have been diagnosed (1). The general perception is that IBS symptoms are somewhat vague. They include cramping, abdominal pain, bloating, constipation and diarrhea.
Physicians use the Rome III criteria, an international effort to create scientific data to help diagnose and treat functional gastrointestinal disorders, plus a careful history and physical exam for diagnosis.
What epitomizes IBS is the colonoscopy study, where IBS patients who underwent colonoscopy had diagnostic findings of nil. This tended to frustrate patients more, not reduce their worrying, as the study authors had hoped (2).
Rather, it plays into that idea that patients don’t have diagnostic signs, like in inflammatory bowel disease, yet their morbidity (sickness) has a profound effect on their quality of life. Socially, it is difficult and embarrassing to admit having IBS. Plus, with a potential psychosomatic component, it leaves patients wondering if it’s “all in their heads.”
So, what can be done to improve IBS? There are a number of possibilities to consider.
Mental state’s effect
The “brain-gut” connection is real. It refers to the direct connection between mental state, such as nervousness or anxiety, to gastrointestinal issues, and vice versa.
Mindfulness-based stress reduction was used in a small, but randomized, eight-week clinical trial with IBS (3). Those in the mindfulness group (treatment group) showed statistically significant results in decreased severity of symptoms compared to the control group, both immediately after training and three months post-therapy.
Those in the treatment group were instructed to do meditation, gentle yoga and “body scanning” — focusing on one area of the body for muscle tension detection. The control group attended an IBS support group once a week.
A preliminary study has suggested there may be a link between IBS and migraine and tension-type headaches. The study of 320 participants, 107 with migraine, 107 with IBS, 53 with episodic tension-type headaches (ETTH), and 53 healthy individuals, identified significant occurrence crossover among those with migraine, IBS and ETTH. Researchers also found that these three groups had at least one gene that was different from that of healthy participants. Their hope is that this information will lead to more robust studies that could result in new treatment options (4).
The role of gluten
In a small randomized clinical trial, patients who were given gluten were more likely to complain of uncontrolled symptoms than those who were given a placebo (68 percent vs. 40 percent, respectively).
These results were highly statistically significant (5). The authors concluded that nonceliac gluten intolerance may exist. Gluten sensitivity may be an important factor in the pathogenesis of a portion of IBS patients (6).
I suggest to my patients that they might want to start avoiding gluten and then add it back into their diets to see the results.
Some IBS patients may suffer from fructose intolerance. In a prospective (forward-looking) study, IBS patients were tested for this with a breath test. The results showed a dose-dependent response. When patients were given a 10 percent fructose solution, only 39 percent tested positive for fructose intolerance, but when they were given a 33 percent solution, 88 percent of patients tested positive.
The symptoms of fructose intolerance included flatus, abdominal pain, bloating, belching and alternating bowel habits. The authors concluded that avoidance of fructose may reduce symptoms in IBS patients (7).
According to another study, about one-third of IBS patients are fructose intolerant. When on a fructose-restricted diet, symptoms appeared to improve (8). Foods with high levels of fructose include certain fruits, like apples and pears, but not bananas.
What is the role of lactose?
Another small study found that about one-quarter of patients with IBS also have lactose intolerance. Two things are at play here. One, it is very difficult to differentiate the symptoms of lactose intolerance from IBS. The other is that most IBS trials are small and there is a need for larger trials.
Of the IBS patients who were also lactose intolerant, there was a marked improvement in symptomatology at both six weeks and five years when placed on a lactose-restrictive diet (9).
Though small, the trial results were statistical significant, which is impressive. Both the durability and the compliance were excellent, and visits to outpatient clinics were reduced by 75 percent. This demonstrates that it is most probably worthwhile to test patients for lactose intolerance who have IBS.
Do probiotics help?
Treatment with probiotics from a study that reviewed 42 trials shows that there may be a benefit to probiotics, although the endpoints were different in each trial. The good news is that most of the trials reached one of their endpoints (10).
Probiotics do show promise, including the two most common strains, Lactobacilli and Bifidobacteri, which were covered in the review.
All of the above gives IBS patients a sense of hope that there are options for treatments that involve modest lifestyle changes. I believe there needs to be a strong patient-doctor connection in order to choose the appropriate options that result in the greatest symptom reduction.
(1) American College of Gastroenteroloy [GI.org]. (2) Gastrointest Endosc. 2005 Dec;62(6):892-899. (3) Am J Gastroenterol. 2011 Sep;106(9):1678-1688. (4) American Academy of Neurology 2016, Abstract 3367. (5) Am J Gastroenterol. 2011 Mar;106(3):508-514. (6) Am J Gastroenterol. 2011 Mar;106(3):516-518. (7) Am J Gastroenterol. 2003 June;98(6):1348-1353. (8) J Clin Gastroenterol. 2008 Mar;42(3):233-238. (9) Eur J Gastroenterol Hepatol. 2001 Aug;13(8):941-944. (10) Aliment Pharmacol Ther. 2012 Feb;35(4):403-413.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com.