Finding Relief from IBS with Functional Medicine: A Story about the Food we Eat, the Good Bugs, & the Bad

10 Mar Finding Relief from IBS with Functional Medicine: A Story about the Food we Eat, the Good Bugs, & the Bad

Irritable Bowel Syndrome, otherwise known as IBS, is an exceedingly common chronic condition throughout the world, since the term came into use in 1944. It affects anywhere from 10–45% of the population globally, depending on the country (10–15% in the developed world), and is characterized by symptoms such as abdominal pain, bloating, and changes in the form, consistency, and frequency of bowel movements.

Referred to as a disorder of gut-brain interaction, it arises most commonly before the age of 45, is more common amongst women than men in the western world, and is typically diagnosed by excluding other possibilities, including celiac disease, inflammatory bowel disease, colon cancer, microscopic colitis, bile acid malabsorption and giardiasis.

Although referred to as a solitary condition, it can vary greatly in how it arose and the contributing factors that lead to it developing, as well as to its severity and difficulty in treating, managing and resolving.

Following are three separate stories of IBS to illustrate the number of potential contributing factors, and how it is commonly assessed and treated by a functional or naturopathic physician.

Sally has had IBS for the past 8 months. It seemed to arise as she started highschool, and worsened with periods of intensive studying for exams. Prior to high school she did not recall having had many stomach aches or troubles with abnormal bowel movements. But as the year progressed, she felt she would often wake feeling fine, but then quickly become bloated as the day progressed, along with uncomfortable gas, abdominal cramping and frequent urgent loose bowel movements. Her family doctor ruled out celiac disease with a blood test for TTG (tissue transglutaminase), and a stool test came back negative for any bacterial cause. She was left without any recommendations from her family doctor, aside from trying the probiotic Align, which did little to help.

Dale’s IBS seemed to develop after backpacking throughout Central America 2 years ago. He felt he always had a cast iron stomach, but developed a case of traveller’s diarrhea while there, which was treated with antibiotics and cleared up, only to return shortly thereafter. His family doctor had run a stool test only to find that nothing showed up, and no answer for why his bowels were now inconsistent, often loose, occasionally urgent, and combined with considerable gas and discomfort.

Dale has tried to help improve his situation by eliminating certain foods from his diet, and while it helped initially, and he’s continued avoiding them, his symptoms are now little improved from where they were previously.

Irene feels she’s had chronic constipation ever since childhood. She has a bowel movement every 3 or 4 days, feels chronically bloated, and frequently gets stomach aches. She’s recently started getting episodes of heartburn as well to make matters worse. Her doctor has had her on any number of laxatives including peg, restoralax and now on Constella, a common prescription for chronic constipation. She has tried increasing fiber in her diet, as well as adding in different kinds of fiber supplementation to her diet, with little improvement. Psyllium in fact, gave her considerable discomfort and pain.

All three of these individuals went to go see the same functional medicine physician who took them through the same phases of assessment and treatment.

The functional physician explained that the potential contributing factors for IBS can be categorized as including 1) dietary reactions; 2) flora imbalances (bacterial, parasite or yeast); and 3) stress (gut brain dysfunction).

He elaborated that dietary reactions as a whole, can be broken down into 5 types in lessening order of severity: 1) celiac disease; 2) food allergy; 3) food sensitivity; 4) dietary lectins, and 5) dietary intolerances. And that when it came to IBS, dietary intolerances and sensitivities are common factors, while celiac disease should be differentiated or ruled out, and allergies typically manifest with easily distinguished (different) symptoms.

Celiac disease is described as an abnormal IgA immune reaction upon exposure to gluten, in which the lining of the small intestine becomes inflamed, leading to malabsorption, bleeding and anemia. Food allergies in turn, occur rapidly if not immediately after exposure, and typically lead to hives, swelling and potentially more severe symptoms such as anaphylaxis, and are related to IgE antibodies.

Food sensitivities on the other hand, are non-life threatening inflammatory reactions , that occur anywhere from several hours after exposure or in a delayed manner, taking several days to clear. Referred to as type III delayed hypersensitivity reactions, they occur when circulating IgG antibodies form immune complexes with food antigens, and are not able to be cleared as they commonly are by macrophages (white blood cells that engulf microorganisms and dead cells), due to an excess exposure of a particular food antigen. The formation of the complexes with the first three subclasses of IgG antibodies (IgG1, IgG2, and IgG3), activates the part of the immune system referred to as the complement pathway, and an inflammatory cascade ensues.

While these are not widely recognized by allergists as a type of food reaction, as the 4th subclass (IgG4) has been related to exposure, (and possibly tolerance to food), numerous studies have found that elimination or avoidance of foods found to have high total levels of all IgG antibody subclasses, to be effective in improving symptoms of IBS-D, migraines, and eczema, amongst others.

It should also be pointed out that it is common knowledge amongst allergists that there do exist inflammatory reactions to foods not identified via traditional skin prick allergy testing, and these are referred to as simply, ‘non-IgE mediated’ reactions. Whether referred to as IgG reactions or non-IgE reactions seems like semantics. The point is, there are different kinds of potential reactions to foods, and when it comes to IBS, it’s those specifically that aren’t IgA (celiac) or IgE (allergy) that may play a significant role. It’s for this reason that allergists consider the gold standard test to be the elimination re-introduction diet, when skin prick allergy testing seems to have missed some dietary triggers for related symptoms.

Dietary lectins are carbohydrate-binding proteins found predominantly in certain plant based foods (legumes, beans, soybeans, peanuts, and nightshade family vegetables), that can be resistant to cooking or digestive enzymes and lead to inflammatory reactions.

And finally, dietary intolerances are defined as an inability by the body to properly digest certain carbohydrates due to a lack of particular enzymes needed to digest those type of foods, resulting in gas and bloating as the main symptoms. Intolerances are categorized by the complex sugar that is not being digested properly and the related foods. Examples include: Fructose and Fructans (fruits such as apples, pears, peaches; vegetables such as artichokes, asparagus, brussel sprouts, broccoli, cabbage, garlic, onions; cereal grains (wheat), and nuts such as cashews or pistachios), Galactans (legumes), Lactose (dairy products), and Polyols (certain fruits, vegetables (cauliflower, celery, mushrooms, sweet potatoes, snow peas), and sweeteners such as alcohol sugars (sorbitol, mannitol, xylitol, maltitol, and isomalt). These foods are referred to as High FODMAP foods, which stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols.

So five types of possible food reactions. Where to start?

The first is to rule out celiac disease and allergies, which is typically done by inquiring as to the nature of the symptoms, severity, and the effect of any dietary changes the person may have attempted on their own. In many cases no further testing is needed, just a thorough clinical history. In other cases, when celiac disease isn’t easily dismissed, testing is warranted.

The next step is to differentiate between symptoms and their relationship to consuming meals; whether gas and bloating are the predominant issue (following certain meals), or if it’s included urgent loose diarrhea following certain meals.

If symptoms are of the latter type (gas and bloating predominant), dietary intolerances are likely, and a warm and cooked Low FODMAP diet is indicated.

If the symptoms also include abdominal cramping, pain and urgent bowel movements, dietary sensitivities are possible, and can be identified with either an elimination and re-introduction diet or through IgG food sensitivity testing (measuring serum levels of all four IgG subclasses in regards to food antigens).

It should be noted that dietary sensitivities are often a further development of dietary intolerances; having frequent exposure to dietary intolerances, leads to a greater exposure to dietary antigens as the food is poorly digested.

Lectins overlap considerably with High FODMAP foods and common IgG food sensitivities (which likewise tend to include High FODMAP foods), and thus don’t need to be explored individually. Rather, a low lectin diet (which is likewise Low FODMAP), can be used as a basic dietary approach to try in the absence of other more specific symptoms as described above.

In short, a change in one’s diet ought to be the first therapeutic step in most cases of IBS, if the underlying cause is as yet not evident. It is a means to assess contributing factors or causes.

The effect (benefit or lack thereof), should be evident within days in the case of avoiding dietary intolerances, to 1–2 weeks, in the case of sensitivities and lectins, and the resulting reduction in inflammation.

Now back to our story…

In the case of Sally, following a warm and cooked Low FODMAP diet made a night and day difference for her IBS. Her bloating and gas simply went away, along with her urgent bowel movements. On re-introducing dairy and wheat she found her abdominal cramps and urgency returning, which lead her to the conclusion that she must be lactose intolerant and either gluten intolerant or sensitive. The functional physician explained that digestion is not static and unchanging, and although she may be genetically prone to some of her dietary intolerances (such as lactose), there may be some variability according to stress and lifestyle, which can impact the variable degree of stomach acid and pancreatic enzyme production. In other words, the stress of school may have impacted her digestion, and once life was more balanced, matters might improve on their own.

For now, she was to follow the warm and cooked Low FODMAP diet (as cooking helps to break food down making it easier for assimilation), and to use either digestive enzymes or digestive bitters (a herbal tincture of herbs that aid digestive function), if she were having some of the higher FODMAP food options. She could test occasionally how her digestion was doing, and re-introduce foods accordingly.

In Dale’s case, he was already on a very restricted diet, already having found improvement initially in avoiding High FODMAP foods and some of the common dietary sensitivities. Likewise, he used digestive enzymes with meals, and had even added in a high dose, broad spectrum probiotic the year before, which likewise had had some benefit initially.

Dale’s case was a good example of having thoroughly investigated diet and finding that the issue lay beyond it. It appeared that Dale’s issue likely involved his microbiome or flora balance. A decision was made to redo his stool test using a more comprehensive diagnostic stool test focused on parasitology, with the knowledge that is not uncommon for certain parasites to evade detection in single sample stool tests. Three separate samples from three separate days were taken, sent off to the lab, and the report returned with a positive finding of a relatively common parasite called Blastocystic Hominis.

Blastocystis is a single-celled parasite that can live in your intestines. Many people have no symptoms, while others do develop gastrointestinal symptoms. The fact that many individuals are asymptomatic carriers of it lead to Blastocystis being considered commensal bacteria (common, not necessarily bad or good), versus pathological up until a decade ago or so. What is known, is that of those who do develop symptoms, antibiotic medications usually resolve symptoms.

Dale started on a course of metronidazole, followed by several months on two probiotics; a multi strain broad spectrum probiotic, along with Sacchromyces Boulardii, a particular probiotic yeast strain, found to be effective in eradicating Blastocystic Hominis.

Symptoms improved, but returned after the antibiotic, prompting him to continue for a couple months on a combination of berberine (a broad spectrum herbal antimicrobial) and Allisyn (a garlic concentrate). By his 4th week of treatment he was feeling 95% improved, reaching full recovery at the end of the second month.

Irene’s chronic constipation that was immune to dietary change and fiber supplementation, suggested to her functional physician that there likely was an issue with the motility of her gastrointestinal tract. One common reason for this could be Small Intestinal Bacterial Overgrowth, or SIBO for short. Unlike the colon, which is rich in bacteria, the small intestine has a considerably low population of bacteria. Individuals with bacterial overgrowth can develop IBS symptoms that may include nausea, bloating, vomiting, malabsorption, diarrhea, or constipation; depending on the bacterial culprit. The bacteria feed on the fermentable high FODMAP starches, adding to one’s bloating, and the altered microbiome in turn, influences the migrating motor complex (MMC), which consists of the waves of smooth muscle contractions in the GI tract that occur between meals and contribute to bowel movements occurring. As a result, SIBO can be the underlying cause for both types of IBS-D and IBS-C.

A SIBO breath test was performed, and it was found that as expected Irene was positive for the presence of SIBO. She was placed on a Low FODMAP diet, a SIBO specific probiotic, and an alternating schedule of anti-microbial herbs. She improved leaps and bounds over the next three months, and did not need to take any further measures, such as the often prescribed antibiotics for SIBO.

This concludes our exploration of IBS from a functional medicine perspective.

Of course, we were not able to cover every particular facet of IBS assessment or treatment, and one ought not to interpret the three stories as encompassing all possibilities, nor should any of the information be construed as medical advice or direction. If the stories provided some understanding of the potential avenues for investigation under the medical guidance of one’s family doctor, functional physician or naturopathic doctor, then this blog has served its purpose.