Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome (IBS) poses something of a dilemma: Physicians readily recognize when a person has it but describing a consistent pattern of symptoms is nearly impossible. People with an irritable bowel may complain of cramping pain in any part of the abdomen, feeling bloated, gas, constipation, as well as diarrhea and excessive mucus in the stool. Often, the same person may complain of either constipation or diarrhea, later experience another symptom, and then alternate again. The symptom(s) that occurs most frequently also will vary from individual to individual.
Worldwide, IBS affects about one in seven to 10 people. Over 22 million Americans suffer from this condition, which is second only to the common cold as a cause of absenteeism from work. Reports indicate that three times as many women as men are afflicted with irritable bowel syndrome. Researchers speculate that the fluctuation of reproductive hormones during menstrual cycles may increase the occurrence of these symptoms. The truth is that the cause or causes of IBS are not well understood at all. It is very likely that multiple factors are involved.
You can guess at the number of disorders that researchers thought produced IBS by ticking off the names given to this problem over the years. Irritable bowel syndrome has been called psychogenic colitis, mucous colitis, or just plain colitis – suggesting that there is inflammation (or “-itis”) of the lining of the colon. This is a misnomer because no inflammation is present.
Perhaps, as some have suggested, if there is an inflammation it is due to a bowel infection. Nowadays, most physicians do not believe infection is a factor, though they do think that some irritation of the small or large intestine is involved. At one time intolerance to certain foods and food allergies were considered major factors in IBS. While we know that this is a cause, it is unlikely to be the only cause.
Irritable bowel syndrome has also been called psychogenic colitis, or the nervous gut, in the belief that psychologic distress – nerves, depression, or anxiety – causes the onset of symptoms.
Another name for IBS was spastic colitis or spastic colon. This referred to the painful contractions a sufferer would feel inside his or her lower gut. These abnormal, uncoordinated contractions, or dysmotility, may be linked to a change in the firing of electrical signals that control muscular activity. This pacemaker mechanism is similar to the system controlling the contraction of heart muscle. And as with the heart, an abnormal pattern or rhythm—a dysrhythmia—may develop.
Recent research has strongly suggested a central role for abnormal gut sensitivity. According to this view, motility in the gut is normal. However, the nerve endings in the lining of the small and large intestines are unusually sensitive and will react abnormally to even ordinary events such as eating. For example, when ingested food reaches the bowel, the gut wall expands (or distends), causing the nerves to trigger exaggerated patterns of muscular activity. As a result, sometimes, a meal may be followed almost immediately by cramps, and soon after by a bowel movement. Other stimuli that can cause this over-reacting include stressful events, taking certain medications, drinking milk or swallowing too much air.
In any person with irritable bowel syndrome, it is difficult to pin down the cause because each time, the underlying disorder, or combination of contributing disorders, will probably be different. Thus, there is no specific test you can take that will tell whether or not you have IBS — and no procedure that will allow the physician to see what is wrong. In technical language, that means IBS is a functional disorder.
Nevertheless, your physician will frequently order tests because your symptoms might suggest the presence of another, more serious disease. He or she will be particularly alert to this possibility if you have rectal bleeding, weight loss, or severe and/or persistent pain. After analyzing the results of appropriate tests, the physician will be able to reassure you, for example, that you do not have cancer.
What to Do About It
Even though we do not fully understand the causes of irritable bowel syndrome, dietary recommendations and techniques for reducing stress, along with the use of medications for specific symptoms have been shown to work for a substantial number of people. Both diet and stress can be managed quite well. For example, adding more fiber, drinking lots of water, and following a moderate exercise program may do the trick for some. Others may need to keep a food diary for a few days to target problem foods, or learn to deal with stress situations through counseling.
Fat seems to be a major offender in exacerbating IBS, because in any form it is a strong stimulus of colonic contractions. So, foods such as cream, cheese, vegetable oils, shortening of any kind, avocados, whipped toppings and meat will need a reevaluation. It’s not necessary to eliminate any of them altogether. However, it is helpful to know exactly how much of each item you’re eating. With that information in hand, you can begin to make some small modifications. Start by reducing portion sizes, using less rich sauces with main dishes and having more high-fiber foods at meals and as snacks.
Chocolate, caffeine, alcohol and milk products are also frequent offenders. Yogurt and other cultured products may not give any distress at all.
For a while, you’ll have to keep a journal noting the foods that seem to cause the most problems. The latest research indicates that fructose (a sugar found in fruit) and sorbitol (an artificial sweetener) may aggravate IBS symptoms. That may be why apple, grape and pear juices are linked with diarrhea and abdominal pain. Excessive intake of magnesium-containing antacids also can cause diarrhea.
In many people with IBS who predominantly have constipation, dietary fiber seems to offer relief. Increase your fiber intake gradually and eat just enough so that you have a soft and easily passed bowel movement. Fruits, vegetables, whole-grain cereals and breads, lentils and beans all are good sources of dietary fiber. Six to 11 servings of breads, cereals and grains; three to five servings of vegetables; and two to four servings of fruits are the recommendations in the Dietary Guidelines for Americans and the Food Guide Pyramid. In addition, you might want to include about three tablespoons of bran each day with meals. Start with one tablespoon of bran once or twice a day and work your way up from there.
Reduce or eliminate any foods that you already know cause distress for you. Beans, for instance, are usually not well tolerated by people with IBS. Other gas-producing foods such as cabbage or grapes may also be a problem.
Strange as it may seem, high-fiber diets can also help when diarrhea is the major symptom. The basic water-holding ability of fiber helps to absorb excess fluids and also to increase the bulk of the stool. Those two actions are beneficial in regulating colonic motility. That regulation, or adjustment, means a stabilizing effect for both constipation and diarrhea.
On the other hand, there are a few individuals in whom fiber may intensify constipation or diarrhea. For them, high-fiber foods should be eliminated from the diet. It’s a good idea to talk to your doctor or dietitian first. Even if you’re not one of these individuals, it’s possible you may have added too much fiber too soon; your system may not have yet had the opportunity to adjust to the presence of extra fiber.
Cramping and diarrhea can be brought on by large meals. Try to eat smaller meals throughout the day or reduce the total amount you eat. In addition, select foods that are low in fat and high in fiber. While you’re at it, chew your food thoroughly and allow enough time to eat your meals slowly and in a relaxed way.
Make sure to drink plenty of water as you begin to increase your fiber intake. Six to eight glasses of water a day should be the goal. The extra fluid will also keep you well hydrated and feeling better throughout the day. You’ll want to avoid carbonated water (or other drinks), especially with meals. These can produce gas and lead to discomfort.
In fact, you may even want to avoid sipping plain water during meals because it facilitates the swallowing of air which can increase gas. Make a habit of drinking water in the early and mid-morning and afternoon.
You may want to identify foods that you suspect you’re allergic to or don’t tolerate well. In some people, citrus fruits, gluten, eggs, or chocolate may produce reactions. Note, lactose is less often an offender than is commonly believed. A person with true intolerance can readily find low-lactose dairy products, as well as lactase supplements which will facilitate the digestion of lactose in food.
Stress, whether it be related to business, career, marriage, family, or friends, seems to increase colonic spasms; especially in people with IBS. A true cause-and-effect relationship has yet to be demonstrated, but the evidence in support of a connection is strong. Certainly, irritable bowel symptoms increase during periods of anxiety, depression or panic. Fortunately, stress-reducing techniques are available. The bonus is that these methods also can help enhance your daily life.
Biofeedback, hypnosis, meditation and psychological counseling are the most common stress-reducing techniques to help you cope with IBS. The first is a system that trains patients to monitor and improve their health by learning to recognize signals from their own bodies. It is also quite helpful in teaching people how to relax. Initially, biofeedback involves the use of equipment that picks up electrical signals in the muscles. It also requires the services of a certified biofeedback therapist who may also be a physician or a psychotherapist.
Hypnosis is a centuries-old practice that is receiving new attention. The American Medical Association has approved hypnosis training since 1958 and today many health care professionals use this approach to help people with weight problems, cigarette smoking and chronic stress. Because hypnosis is a state of heightened suggestibility brought on by increased relaxation, people can learn a variety of ways to deal with stress-related behavioral patterns.
Hypnosis seems to hold great potential for those suffering from IBS. One study showed a clinical improvement in 85 percent of patients under 50 years of age. Be sure you’re working with a well-trained, licensed hypnotherapist. Again, he or she may be a physician, a psychologist, or a nurse-practitioner. Most important of all, have a positive attitude. Self-motivation is helpful in changing any behavior.
Daily exercise is a great way to reduce stress, and it makes people feel better psychologically as well as physically. Allow enough time for regular bowel movements. Trying to postpone a movement rather than rushing it, which will only cause more anxiety and aggravate your symptoms. Relaxation is an important key to the successful management of irritable bowel syndrome.
Sometimes drugs can help provide symptomatic relief. However, know that no one medication will be effective in everyone with IBS. If an individual mostly has diarrhea, his or her physician may recommend loperamide (Imodium), or, on rare occasions cholestyramine (Questran). If severe constipation is the primary problem, consider taking natural vegetable fiber like bran or psyllium. Try food sources of fiber before buying an over-the-counter fiber supplement.
To treat debilitating pain, the physician may consider a tricyclic antidepressant (Elavil). For chronic abdominal pain that presents after meals, part of the treatment may be administration beforehand of an anticholinergic agent (e.g. Levsin) – a drug that inhibits the nerves regulating intestinal contractions.
Some women with constipation predominate IBS may be a candidate for tegaserod (Zelnorm) which can relieve painful bloating and increase frequency of bowel movements.
Finally, bear in mind that treatments for irritable bowel syndrome are personal and depend entirely on the individual. Spend some time identifying what is irritating your individual system. Then develop an approach that can effect lifestyle changes – diet, exercise, and stress reduction – on a gradual basis. Modifications that can be adopted step by step in a comfortable manner are the ones that are most effective and long-lasting.
It is helpful to know a few quick tricks that can help keep fat out of your meal while maintaining good flavor:
- Choose low-fat cuts of meat and chicken in the supermarket.
- Try to roast, broil, poach, stir-fry, or microwave when cooking at home. Look for some terms like roasted or broiled in restaurants instead of ordering foods that are sautéed or fried.
- Use broths, juices, water, and/or wine to steam vegetables, poultry, and fish instead of sautéing in oil.
- In restaurants, ask the server whether the fish or meat is marinated in oil before it is grilled. If it is, request that it be cooked with little or no oil.
- Select low and nonfat dairy products. Use the higher fat cheeses like gorgonzola, or an aged cheddar in small quantities to perk up the flavor in a grain or pasta dish.
- Invest in a new microwave oven, high quality pressure cooker, or nonstick wok. All of these devices cook food fast and with little fat and oil.
- Cook quantities of rice, beans, and grains; then freeze in small portions (use zip-lock bags or plastic bowls). These foods defrost quickly or they can be tossed (while still frozen) into soups and sauces.
- Puree leftover beans or vegetables with a bit of salt and your favorite herb (basil, perhaps) to use as a tasty replacement for butter or cream cheese.
- Read labels. The new food label format makes it easier than ever to know exactly how much fat is in one portion of that food. Consider how may portions you’ll really be eating. However, don’t automatically pass up an item if it appears to have a large percentage of fat calories. Consider what else you’re eating throughout the day. Balance is the key.
How Much Fat?
The recommendations of the U.S. Dietary Guidelines for Americans and a number of other health organizations are quite consistent. Fat should represent 30 percent, or less, of your total daily calories. For most people that concept doesn’t mean too much. However, if you consider that most adults consume between 1,500 and 2,400 calories a day, the range for fat should be 50 to 80 grams for the day. Once you choose your number of total fat grams, then try to keep the amount of saturated fat, the kind that comes from animal products, to a third or less of the total amount. For example, if 60 grams is your total fat allowance, keep saturated fat to 20 grams or less per day.
You can be the judge of how many total grams to have each day. Part of that may depend on how severe your IBS is, and what your weight goals are. A registered dietitian can help you plan a menu that is best suited to your lifestyle and personal needs. There is also some flexibility here. Most dietitians today will have you look at a weekly pattern, rather than one day or one meal. In other words, unless you are suffering intense distress, a little more fat on one day can be balanced out with less the next. This is another situation in which a food diary can come in handy. Keeping a record of several days of normal eating will give a clearer picture of how much fat you’re currently eating. That makes it easier to make any adjustments if they’re necessary.
Food labels are quite clear about the number of grams contained in one serving. Just be sure to calculate properly if you’re actually eating several servings. There are also a number of nifty little fat-counter books around. They list a wide variety of all the food categories with the amounts of fat in specific items; frequently they include calorie and cholesterol information as well. They’re a good way to start getting acquainted with the amount of fat that’s in your favorite foods.
Intestinal Gas and Flatulence
People with irritable bowel syndrome are particularly bothered by the pain, discomfort and embarrassment of gas. Whether that gas is coming from above the belt or below, it’s still a nuisance. Knowing more about gas can help make its management easier. In most cases it should be possible to reduce its occurrence considerably.
There are three sources of intestinal gas. Every day each one of us produces about 10 liters of gas. Normally, most of the gas is absorbed through the bowel wall into the bloodstream. People with irritable bowel syndrome don’t produce more gas than others, the discomfort may make it feel the way, but actually the amount of gas produced in people doesn’t vary considerably. It probably feels more painful to someone with IBS because that person is more sensitive to normal degrees of abdominal distention and because there may be abnormal intestinal motility.
Room air is another source of gas. Most of the time, too much air is swallowed (“aerophagia”) while eating or drinking. Aerophagia may be a nervous habit related to anxiety. Gulping food, chewing gum, chewing with your mouth open and drinking carbonated beverages are other means by which too much air gets into the stomach. The result is belching, the most common symptom of gas. Excess air can cause further discomfort if you wear tight clothes or lie down soon after a meal. If the air isn’t released through belching, then bloating and abdominal discomfort result.
Gas expelled through the rectum (flatulence) is usually caused by fermentation of food by friendly bacteria normally present in the intestine. These bacteria frequently act on indigestible carbohydrates like those found in beans, dried peas and lentils. Fruits and grains, which are also high in fiber, can have the same effect. Other food sources that may cause flatulence include milk and other dairy products; fructose, a fruit sugar which is used as a sweetener in foods and beverages and which may be incompletely digested; and sorbitol and mannitol, two artificial sweeteners. Flatulence also can be caused by certain medicines like colestipol (Colestid), which is used to lower blood cholesterol levels.
Avoid gas-producing foods. Once again, the food diary becomes a handy tool for identifying offending foods. Remember, what bothers one person may not bother another. The quantity of food or beverage ingested may be a factor. For instance, someone may experience pain after eating two cups of beans yet be fine with a half-cup serving.
For nutrition’s sake, don’t just randomly eliminate foods from your diet. Take some care to find alternative solutions as well. For instance, if beans are irritating, consider using Beano, a nonprescription product containing alpha-galactosidase, an enzyme which breaks down the carbohydrates in beans that most people find bothersome. Note: this is added to foods as well as swallowed or chewed. Another possible solution for reducing intestinal gas is to soak the beans overnight and discard the soaking water before cooking. Adding fiber slowly to the diet and drinking plenty of water along the way are the best means of avoiding excess flatulence. Though not systematically studied, regular exercise has been reported to aid in relieving or preventing gas.
Relaxation techniques may be helpful in reducing the amount of air swallowed if the problem is related to stress. Other remedies include eating fewer hard candies, reducing the amount of carbonated beverages you drink, and even talking less when you eat. Finally, over-the-counter products like simethicone (Mylicon) and simethicone-containing antacid preparations may be effective in breaking-up trapped gas.
Possible Gas Producing Foods
The real list of problem foods is potentially endless because everyone’s body responds to food differently. Here’s a list of the foods that most commonly cause distress.
- Apples (raw)
- Apple juice
- Hard candy
- Beans (kidney, lima, navy)
- Split peas
- Brussels sprouts
- Peppers, green
Cereals and Grains:
- Bran Cereals
- Excessive quantities of wheat products
- Carbonated beverages
- Chewing gum
- Mannitol and Sorbitol
- Fats and high fat foods
- Rich sauces and gravies