IBS—Free at Last!

Is it IBS?

Are you one of the many people affected by uncomfortable or debilitating symptoms such as diarrhea, constipation, gas, bloating or abdominal pain? Could it be irritable bowel syndrome (IBS)? IBS is defined as abdominal pain and discomfort with altered bowel habits in the absence of any other mechanical, inflammatory, or biochemical explanation for these symptoms.  In other words, your gastrointestinal system just doesn’t work right, even though there doesn’t seem to be an obvious reason for it.

Some day-to-day variations in your bowel habits are within the normal range. It isn’t necessary for good health to have one and only one bowel movement every single day.  Likewise, some gas production and flatulence is normal. Everyone has it! According to the National  Digestive Diseases Information Clearinghouse, many people think they have too much gas when they really have normal amounts. Most people produce about 1 to 4 pints a day and pass gas about 14 times a day. However, if you are in pain due to your bowel habits or if they interfere with your work, exercise or social life, you might have IBS. You should not diagnose yourself. If you experience symptoms suggestive of IBS, seek a thorough medical evaluation to rule out other potentially serious conditions, especially if you are experiencing any of the following:

• Passing blood from the rectum
• Fevers or night sweats
• Aching joints or inflammatory arthritis
• Anemia or other abnormal lab results
• Unplanned weight loss greater than 10 pounds
• Change in bowel habits after age 50
• Poor growth or failure to thrive (in children)
• Itchy rash
• Family history of Crohn’s disease, ulcerative colitis, celiac disease, ovarian or colon cancer
• Foul-smelling or greasy stools
• Incontinence or soiling
• Urge to move bowels waking you from sleep

Your health care provider will consider the pattern of your symptoms and compare them to established diagnostic criteria. He or she will take your medical and family history, physical examination, and test results into account. In younger patients without “alarm symptoms,” an office visit may be sufficient to diagnose IBS. In patients with alarm symptoms such as those listed above, a more extensive workup may be needed. If you are a female, especially over the age of 40, be sure that your workup includes a visit to a gynecologist. Bloating and abdominal pain are not always related to the digestive system, even if they occur between periods or after menopause; diseases and disorders of the reproductive and urinary systems should also be ruled out.

After your IBS diagnosis, you will want to begin exploring the role of diet in managing  IBS symptoms. To learn more about the FODMAP approach to diet for IBS, please explore this site, www.IBSFree.net, or read my book, IBS--Free at Last! Second Edition, Change Your Carbs, Change Your Life.

How do FODMAPs cause constipation?

Question: I can understand how FODMAPs might cause diarrhea, but how do they cause constipation?

Short answer: I don't know. Skip the rest of this post if you're not keen on rambling speculation about  FODMAPs and the gut microbiome.

Long answer:

In so-called simple constipation, as opposed to IBS, fiber/FODMAPs sometimes will actually improve symptoms. But let's talk about IBS-constipation predominant (IBS-C), which rarely responds to increasing fiber in the diet, and which we might be attempting to treat with a low FODMAP diet.

There is no final answer to the puzzling question: "how do FODMAPs cause IBS-C?" In fact, it isn't likely that food or food components cause IBS, rather there are underlying problems such as disordered immune function, dysbiosis, visceral hypersensitivity, slow or rapid transit time, etc. Still, reducing the FODMAPs in the diet can help manage symptoms.

Here are a few things to think about. The Merck Manual says "Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation."

One way FODMAPs affect bowel function is via osmotic activity; in other words FODMAPs have the ability to attract and hold fluid in the gut. If anything, we might expect this to soften stool and perhaps cause urgent, watery diarrhea. That seems to suggest that the osmotic activity of FODMAPs is not the main problem in IBS-C, although it clearly plays a role in people with diarrhea-predominant IBS. (We can't rule out that colonic distention due to increased fluid load in the gut causes constipation through some sort of broken feedback loop in fluid balance physiology, though.)

The other way FODMAPs affect bowel function is via their rapid fermentability and how that interacts with the type, amount, and placement of the resident gut bacteria in people with IBS-C.

Every single one of us is colonized by a unique set of microbes, as unique as our fingerprints. There is some preliminary work now showing that people with IBS may tend toward different populations of microbes than people without IBS, and that people with IBS-C tend to be colonized by more methane-producing bacteria. Limiting FODMAPs in the diet changes the food supply available and affects the microbiome in unknown ways. Using probiotics or antibiotics also affects the type and amount of gut microbes, and can sometimes improve symptoms. How these observations relate to "difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation" only time will tell.

Diarrhea: Still a Problem?

Have you been following the FODMAP Elimination Phase yet are still experiencing diarrhea? In my book, I purposely focused very narrowly on FODMAPs. The protocol is specifically meant to help you find out whether FODMAPs are contributing to your symptoms. Although the FODMAP approach is very effective for many IBS sufferers, the fact remains that FODMAPs are far from the only cause of diarrhea. Perhaps this would be a good time to review other possible causes. As you know, my philosophy is that the causes below will NOT apply to everyone, but each one should be considered in turn to see how it might apply to you.

• Caffeine can stimulate a bowel movement. Try going "de-caf" if this is unwelcome.
• Smoking, especially the first cigarette of the morning, can trigger a bowel movement.
• Alcohol can be a GI irritant. We are talking the alcohol itself, not the beverage it is in. Try abstaining from all forms of alcohol. Or, to assess the affects of alcohol in isolation, next time you indulge try a small serving of vodka, which is essentially pure ethanol and water, and see if you notice any ill effects.
• Supplements and medications. Magnesium supplements can cause diarrhea, in fact are often used as laxatives. If you have diarrhea, don't take a magnesium supplement unless it has been prescribed by your physician for a specific reason. Discuss your prescription medications with your pharmacist to find out whether any of your medication might be contributing to your diarrhea or might contain hidden FODMAPs. For example, lactose is often used as a filler, binder, or coating on tablets. Sorbitol is often used to sweeten liquid medications. Really study your pharmacy records or medical records to see if your symptoms began soon after beginning a new medication.
• Fatty foods can cause bouts of diarrhea. Many people can tolerate a teaspoon of olive oil on salad or in cooking but not fried food or greasy meats. Try forgoing the chicken wings and barbecued ribs but don't give up the essential fatty acids in small servings of healthy fats.
• Complete lack of fiber in the diet can leave some people with "unformed" stools. Try some FODMAP-friendly forms of fiber such as oat bran, rice bran, ground flax or chia seeds. These may gel the stool into a more formed state.
• Dysbiosis--the wrong balance of microbes in your gut--may be a factor. This may be especially likely if your IBS developed after a bout of gastoentiritis or antibiotic use. Now that you've reduced the fermentable carbs in your diet, introduce a probiotic. Try one for a month. If it doesn't help, try another. Good candidates: Lp229V (Jarrow, Goodbelly or TuZen (Canada)), B. infantis (Align), LGG (Culturelle), VSL#3, or S. boulardii (Jarrow or Florastor).
• Stress and/or anxiety. "Bowels turning to water" is more than a literary phrase to describe that response to anxiety or fear that many of us have experienced. The gut-brain connection is very real. A stress management practice of some kind can help, whether it be deep breathing, yoga, meditation, prayer or whatever interests you. "Practice" is the key word, so that you will be well-prepared to calm yourself when stress inevitably comes along.
• Hormones. Discuss your symptoms with your gynecologist. It is common for women to experience bouts of diarrhea at the beginning of the menstrual period. Endometriosis can play a potential role. Hormone replacement therapy can occasionally cause diarrhea.
• Food allergies. Classic food allergies can include a GI component such as diarrhea. If you have ever had symptoms such as hives, facial or oral swelling, or shortness of breath related to a bout of diarrhea, consult an allergist for a proper evaluation.
• Food (or food chemical) sensitivities. There are a number of of types of bad reactions to food that do involve your immune system but are not considered classic food allergies. You can still experience diarrhea when eating particular foods (or food chemicals) that your immune system over-reacts to, even if you are not "allergic" to them. There is growing evidence in the scientific literature that inflammatory changes in the gut are present at the cellular level in many cases of IBS. Examples of food chemicals that one could be sensitive to are amines, salicylates, solanine, benzoates, nitrates, food dyes and more. Many of them occur naturally in food, so cannot be spotted on the food label.
• Diseases of the gastrointestinal tract. Don't diagnose yourself with IBS. Discuss your symptoms with your healthcare provider so that diseases or disorders such as ulcerative colitis, Crohn's disease, celiac disease, diverticulitis, bile salt or fat malabsorption, pancreatic enzyme deficiencies, and cancer can be ruled out.
• Oh my gosh, lets not forget parasites, either current infections or past infections that have left residual damage to the small intestine...polluted or unprotected well water, drinking water while camping or backpacking, or eating unsafe food at certain travel destinations are common sources of parasitic infection.
• Or...

I will stop here for now, but may add to this already overwhelming list as I think of more.

You just can't possible take on all these "maybes" at one time without affecting your life beyond reason, which is why I cut the project down to size to just FODMAPs in my book. Still, reviewing this list with the health care provider who knows you best might shed some new light on your symptoms if FODMAP elimination hasn't done the trick.