Cutting through the B.S. on I.B.S

I used to suffer from terrible “I.B.S or Irritable Bowel Syndrome”. I went to the doctors a couple of times, but was met with indifference and a lack of solutions: Drink peppermint tea or try some anti-spasmodic drugs were the responses.

I didn’t fancy the latter, and the former did nothing, so it appeared I would either have to live with it, or find a solution on my own.

To someone who’s never suffered from I.B.S (as likely the case with the doctors I visited), living with it might not sound so bad – It’s just a bit of gas and bloating, get over it…

For me, however, living with it wasn’t an option – it drove me crazy, and made me miserable. I decided I had to take matters into my own hands.

Though the doctors made no mention of this, it struck me that as it was an issue with my bowels, where something appeared to be going wrong with the digestion of my food, then possibly, the food I was eating may have some kind of effect on the problem – and thus started my journey into the world of nutrition.

At the time I was a lacto-ovo-pescatarian, eating no red meat or poultry, and lots of grains and legumes. Since then I’ve been through everything from strict ketogenic paleo, to carb cycling, to WAPF, to IF, and all the rest.

This journey into nutrition took me many places, I learned many things, made great improvements to my health and physique – but I still suffered from unruly digestion, bloating and constipation throughout.

I think finally though, I can safely say I have finally slain the beast – or at least got it securely caged. It may not be possible to “cure” IBS – I don’t think I’ll ever be able to eat any food indiscriminately with total impunity, but I can now happily eat a relatively unrestricted diet without suffering any symptoms.

I therefore thought it about time I did a post on the topic, in the hope I might be able to aid some others out there to soothe their bowels too!

Multiple Problems, with Multiple Causes

What is Irritable Bowel Syndrome? The truth is, you’re not really off to a good start, if your “diagnosis” is really little more than a vague description of symptoms:

Patient: “Doctor Doctor, my bowels are very irritable, what’s wrong with me?
Doctor: “Ah, you must have an irritable bowel.”

Hardly reads like an episode of House does it!

What this diagnosis really means, is that your doctor has absolutely no idea what is wrong with you, what is causing the issues, or how to treat the problem.

If you went to your doctor with a pain in your leg, you probably wouldn’t be satisfied with the diagnosis “Pain in the leg syndrome” – You’d want to know what was causing the pain, and a course of treatment specific to that cause.*

Perhaps one of the main reasons I.B.S. can be tricky for doctors to effectively diagnose and treat, is that really there are a number of different underlying pathologies which can lead to the same/similar symptoms, but which may have different root causes and treatments. These can include:

• Leaky Gut
• Dysbiosis
• Food intolerance/Allergies
• Nutrient Malabsorption
• Visceral Hypersensitivity

It’s possible, if you are suffering from IBS, that you have just one of these conditions, but most likely, you will be suffering from a combination of at least two or more, which is another factor which makes diagnosis and treatment a tricky task.

Introducing FODMAPs

I have talked at length before about leaky gut and dysbiosis in my 5 part series on gut flora and health, so rather than go through it all again, please go back and take a look at those posts.

What I will say here, however, is that if you suffer from irritable bowel syndrome, there is a very strong possibility that you are suffering from dysbiosis of the gut flora, which in turn could be a cause of leaky gut and nutrient malabsorption.

I think it highly likely that a significant contributory factor to my I.B.S. was a combination of poor diet (not just that I was veggie, but that I was eating cheap, processed junk vegetarian food), coupled with numerous courses of strong antibiotics to treat recurring bouts of tonsillitis.

Following the steps in post number 5 are likely to pay dividends.

Or possibly make things a lot worse… Well, I never said it was going to be easy or straightforward did I!

FODMAPs = Fermentable oligosaccharides, disaccharides, monosaccharides and polyols. The acronym and diet were developed by Peter Gibson and Susan Shepherd at Monash University in Melbourne.

The FODMAP carbohydrates are:

• Oligosaccharides = Fructans and Galactans
• Disaccharides = Lactose
• Monosaccharides = Fructose
• Polyols = Sugar Alcohols such as sorbitol, mannitol, xylitol and maltitol

Essentially, FODMAPs are carbohydrates which are often poorly absorbed by the small intestine, and as a result can end up getting fermented like crazy in your bowels in a big microflora party, resulting in excess gas and digestive distress.

Below is a list of high and low FODMAP foods, categorised both by carbohydrate type, and food groups.

As you can see, the list of high FODMAP foods is pretty extensive, more than likely containing many of the foods you eat on a daily basis, and many which would typically be considered as “good foods” on most conventional diets.

Don’t despair though, as:

1. It’s unlikely that you’ll have reactions to all categories
2. Even if you are sensitive to a FODMAP group, you can probably still tolerate it in small quantities
3. There’s a good chance you can improve your digestion and reintroduce groups in the future

Before I get onto how to implement the FODMAP diet as part of your escape from IBS, a quick note on prebiotics.

Prebiotics vs FODMAPs?

As mentioned previously, some form of dysbiosis of the gut flora is likely to be one of the underlying causes of IBS, and can also lead to many other problems, such as a weakened immune system, inflammation and possibly even emotional stress.

In my article on eating to restore healthy gut flora balance, I recommend the use of prebiotics – foods with fermentable carbohydrates on which our friendly bacteria can feed.

If we take a look at this list again, however, you’ll see that the majority of high prebiotic foods, are also high FODMAP foods (marked in red):

• Chicory Root
• Jerusalem Artichoke
• Dandelion Greens
• Garlic
• Leek
• Onion
• Asparagus
• Banana

This is of no surprise – prebiotics are fermentable carbohydrates intended to be fermented by friendly bacteria. In FODMAP sensitive individuals however, these carbohydrates end up being overly fermented either by too much friendly bacteria, friendly bacteria in the wrong area of the gut, or unfriendly bacteria that thrive on the same foods.

Restoring Gut Flora Balance with a FODMAP Intervention

The first step is to find which, if any, group or groups of FODMAPs you have an issue with.

The only way to do this, I’m afraid, is temporarily eliminate them from your diet. Personally I did this for 28 days.

The change was quite remarkable – my symptoms of gas and bloating pretty much disappeared, and that was without 100% compliance (unless you lock yourself in your house, it’s going to be pretty much impossible to avoid all FODMAPS, but I found providing I didn’t have more than one small portion of one food in a day I was OK).

After you’ve eliminated all the groups for 28 days, and hopefully experienced similar improvements, comes the fun part – testing one group at a time to see which FODMAPs specifically cause you a problem.

Personally, I’d just reintroduce one group at a time, start off small, and gradually build up the portions over the period of a week or two.

After the testing period, even if you found you could tolerate the food without issue, it’s important to then eliminate it again before testing the next group. The reason being that even if you don’t have an issue with one FODMAP food on its own, it could be the increased level of fermentable carbs from 2 or more groups combined which causes an issue.

Through conducting this experiment on myself, plus further retesting and tinkering, I’ve found that I can tolerate lactose (i.e. all dairy products), and certain fructans (wheat and rye products) with impunity. Galactans (legumes) are my public enemy number one, which I generally still avoid altogether whenever possible.

Vegetables are a little more nuanced. Cruciferous vegetables (broccoli, cauliflower, cabbage, sprouts, etc) are fairly problematic, and I no longer choose to eat them, but if someone cooks them for me I can eat the odd portion here and there without much issue. Alliums (onions, garlic, spring onions, shallots, etc) can also be an issue, particularly in high quantities or raw. (Perhaps Buddhists outlawed their consumption as the flatulence is disruptive to the practice of meditation?).

The high FODMAP fruits aren’t an issue if I just eat one piece, and it’s an isolated snack. If I have more than one piece or in close proximity to a meal, however, it can cause problems.

Indeed, this is why, particularly when testing for reactions, it’s important to just try one food at a time. While I can tolerate a small amount of any FODMAP food, the sum effects of a meal with small quantities of multiple FODMAP foods can still be a problem, and isn’t unusual. A stir fry with onions, garlic, shredded cabbage, chickpeas and mushrooms served with pita bread for example is not going to end well, particularly if followed by a fruit salad desert (the joys of being invited for dinner…).

A note on polyols

Polyols are used as artificial sweeteners, for the simple reason that they can’t be broken down and absorbed by anyone (therefore you can’t take in the calories). My personal advice would be to just cut them out, and never consume them again. If you’re active and have a good diet, there’s no reason you can’t enjoy better tasting treats, with real sugar, that aren’t going to play havoc with your insides!

Other problem foods

Whilst high FODMAP foods are prime candidates for disrupting your digestion, this doesn’t mean that it is the only possibility.

I’d strongly recommend keeping a food diary throughout the testing period and beyond, to try and identify correlations between IBS symptoms and foods.

Still on the starch front, not listed in the FODMAP lists, I’ve found I’m best avoiding reheated potatoes – somehow the cooling process affects the starch structure, and turns it into highly fermentable flora fodder. I’ve also found that many products can contain “modified potato/maize starches” which have similar effects.

Carbs aren’t the only potential problem foods however – eggs were a surprise one for me (particularly as I’ve always loved them and eaten them by the dozen (well half-dozen maybe). I now limit myself to two at a time maximum or suffer the consequences.

Too much fat in one meal can also be an issue. A fatty cut of meat, with fat roasted veg, perhaps a salad dressing, some cheese and a fatty desert could well leave me sprinting for the bathroom…

It’s no surprise that following a Paleo diet didn’t do my IBS any favours – I ended up cutting out two major food groups (cereal grains and dairy) which give me no issues whatsoever, and replaced them with extra veggies, fruits, fats and eggs, which all actually contributed to the condition!

I guess my digestive system was just too highly evolved?

Anyway, I think the take home message is that when it comes to your own personal digestion, there’s no one perfect diet. Everyone is different, and the only way to find out which foods agree with you, and which don’t, is a process of trial and error.

It’s not just what you eat, but how you eat

The composition of the diet has a huge effect on IBS symptoms, but so too do your eating habits – portion size control, meal frequency, and mindfulness can all have a dramatic impact on your digestion.

Your digestive system is an amazing piece of apparatus, but it has it’s limits – do what you can to take the strain off it. The following 5 strategies I have found very useful:

• Digestion Starts in the Kitchen

I’ve mentioned before Richard Wrangham’s book: Catching Fire, How Cooking Made Us Human, an excellent book, well worth a read. In it he argues convincingly that we have evolved to thrive on cooked/prepared food. Food preparation techniques such as cooking, soaking, fermenting etc, help to start break down foods before they’ve even entered our mouths, thus reducing the work our digestive system has to do.

Techniques such as slow cooking and fermenting in particular, help break down hard to digest elements in food, whilst preserving and making more available the essential nutrients within.

• Control Portion Sizes

The larger the volume of food you deliver to your stomach, the harder it is for it to deal with it. I was always taught to clean my plate, in order to not waste food. This is good advice, providing you don’t put too much food on your plate in the first place!

The better strategy is to serve yourself a small portion in the kitchen. Once you’ve cleared your plate, if you’re still actually hungry, go back and serve some more. If not, stick the rest in a container and save it for tomorrow. No waste, hopefully no bloated feeling either.

• Chew, and Eat Mindfully!

It’s all too easy to inhale your meals in our fast paced, no time to stop, consume everything in sight society. Many modern convenience foods are designed to be eaten on the move.

Set aside proper meal times. Sit down at a table, switch off all other distractions, and just eat. Chew each mouthful as much as you can, savour the taste, and enjoy the experience.

Proper chewing will help start the digestion process, through the mechanical breaking down of the food and the chemical effects of the saliva, plus, chewing properly and eating slowly have been shown to more effectively stimulate the feeling of satiety, assisting you with the previous point of not eating too large a portion. Double win.

• Rest and Digest

Controlling portion size is important for easing the strain on the digestive system, but equally as important is the frequency with which it is required to work.

“Little and often” was a popular piece of health advice for quite some time, and still persists in many circles. Advice, like much nutrition info out there, not backed by evidence. Just as dumping too much food into your guts causes a strain, so does making it work constantly, even at a low level.

I’ve talked about intermittent fasting before here and here, and while it might be too early to say just how real the benefits are to long term health and weight maintenance, giving your guts a break once in a while may at least help ease your IBS.

As I’ll come back to shortly, IBS is about a lot more than just excess gas. Dysfunctional intestinal motility plays a large roll. Giving your digestive system a break in-between meals could help restore better function.

The Princess and the Legume

Excessive gas production is no one’s idea of fun – but it may not necessarily be the major issue behind IBS.

A common symptom of I.B.S. is a feeling of a huge, bloated, distended stomach, full of gas to the point of bursting.

While it might seem sensible to attribute these symptoms to an excess production of gas, research has shown that this is often not the case.¹

It seems that in many cases, irritable bowel symptom sufferers actually produce similar quantities of gas as healthy individuals, but that they are either more sensitive to its presence, it gets trapped in the wrong areas, or most likely, a combination of the two.

I’ve talked before about chronic pain, and how in many cases it is not linked to actual structural damage, but more likely is a neurological issue, often linked to poor body mapping of the area, and factors such as stress and expectation.

It appears that just as people can experience crippling pain in limbs and joints in the absence of any actual physical damage, so people can experience phantom symptoms of gas, bloating, distension, constipation and extreme digestive distress – a condition known as “visceral hypersensitivity”.

As with chronic pain associated with a particular joint or movement pattern – i.e. back pain when bending over – this heightened perception of pain and discomfort in the digestive system is often linked with disrupted movement patterns within the intestines.

While IBS sufferers may not produce more gas than symptom free individuals, it is likely that this gas takes much longer to transit through the intestines, and ends up getting trapped along the way.

Just as with chronic back pain, it is hard to say which comes first – does the faulty movement pattern trigger the pain, or does the pain trigger the faulty movement pattern? Perhaps it could be either direction, other factors which trigger both, or most likely a combination of all these factors which feedback on one another, thus exacerbating the problem further.

The situation makes me think of the fable of the Princess and the Pea – the Princess suffers great discomfort due to the presence of a pea under the mattress, and therefore can’t sleep. Is the problem that there is a pea under the mattress, or that the Princess is overly sensitive?

The immediate solution for fast relief would of course be to simply remove the pea.

This can be likened to removing FODMAPs and/or any other problematic foods from the diet. (I vaguely recall that in the fable, the solution is to add more and more mattresses – perhaps this could be likened to some kind of pharmaceutical solution…)

Though this fix may be all well and good in the short-term, one can never be sure of having control over your external environment – you never know when or where you might encounter a pea under the mattress. If the Princess is happy to shut herself in her tower, no problem, but what if she wants to go out on quests and adventures where she might have to rough it a bit in the woods – this is 2014 after all!

A better long-term solution, therefore, would be to look to try to restore normal sensitivity, so that a pea under the mattress/a bit of gas in the guts, does not cause pain or discomfort. This is of course not quite so straightforward as removing legumes from under the mattress or off the menu.

Stress and the Stomach

Anyone who’s experienced butterflies in the stomach, or the need to dash to a toilet cubical prior to a major sporting event or public speaking appearance, has felt first hand the effects of acute stress on the digestive system.

Chronic low-level stress also impacts on the digestion, and is most likely a major contributory factor to IBS symptoms and Visceral Hypersensitivity.

Stress, its causes, effects, and how to deal with it, is a massive topic, which warrants a post all of its own, but here I hope to highlight some key points which can be implemented relatively easily, with huge returns.

For the purposes of this article I’m going to divide stress into 3 main categories:

• Direct stress to the digestive system

I’ve already touched on not overloading the digestive system – avoiding oversized portions and/or constant snacking, in favour of 2-3 normal sized meals, plus a maximum of 1-2 small snacks per day. Cutting out FODMAPs, and other potentially irritating foods.

Avoiding excess sugar, alcohol, fats and total calories is also probably a good idea. A vindaloo washed down with several pints might not seem like a stressful experience to your conscious brain at the time, but trust me, it is to your digestive system. If you don’t trust me, your digestive system and your brain will probably let you know in the morning.

• Physical Stress from Exercise, Activities and Physical Labour

All hard physical exertion is a stress on the body. In the right dose, a small amount of stress can be a good thing, creating the stimulus which drives the body to adapt and change by coming stronger and fitter.

It stands to reason that over-training can put a huge stress on the body, but even a moderate exercise program can be the straw which breaks the camels back for someone with lots of stresses from other areas.

Trying to follow the routine of a professional athlete who does nothing except eat, sleep and train, when you are juggling full-time work, problems at home, and a hectic social life, is not going to end well.

• Emotional Stress and Sleep

If you can’t sleep because there’s a pea under your mattress, you can fairly easily remove the pea, or sleep on the sofa.

If you can’t sleep because you owe the bank £100,000, you’ve just lost your job, and your house is being repossessed tomorrow, getting some zzz’s might be a little trickier.

The important thing to realise about emotional stress – i.e. stress from pressures at work, debts, relationship problems, and so on, is that all the negative physical effects of that stress are a product of your own brain, not the situation itself.

Unlike your diet and your physical activity, you may have relatively little control over many other aspects of your life. You can skip the baked beans, and cut your Sunday run from 30k to 5k easily enough, but you might have no control over that Monday morning deadline at work, or when your next mortgage payment is due.

What you can gain control over, however, is your emotional response to uncontrollable external events.

Some time ago, I came across this interesting little video clip of Andrew Bernstein, author of The Myth of Stress:

To summarise, in the video, Bernstein asks “Is having a tiger behind you a stressful experience?”

The answer depends on whether or not you are aware of the tiger’s presence. If you don’t know the tiger is there, you won’t experience the symptoms of stress. On the flip side, if you belive there is a tiger behind you, you will most certainly experience the symptoms of stress, even if there is no tiger actually there.

The point of this example, is to illustrate that the potential negative physical effects of stress, such as cortisol build up, inflammation, increased blood pressure etc, are actually a product of your own mind, and their reaction to/interpretation of external, uncontrollable events and situations, rather than the external situations themselves.

Having your house repossessed tomorrow does not prevent you from sleeping, or raise your blood pressure. It is thinking, and more specifically, worrying about your impending eviction, which causes you to toss and turn.

Equally important to realise and accept, is that laying awake, and re-running potential worst case scenarios through your mind, will not have any effect on the outcome of future events.

Of course “not worrying” is easier said than done… perhaps now you’re worrying about worrying… but at least making the connection that these feelings of stress and anxiety come from within is the first step.

As I said previously, the topic of stress deserves a post all of its own. What I’ll say now, is beginning a program of daily meditation is a great first step towards its mastery.

A couple of good starting places would be Meditation for Dummies Mini Edition or Andy Puddicome’s HeadSpace website and app.

Lack of sleep, for me at least, appeared to be another critical factor with the I.B.S. Often I’d spend nights lying awake, trying to get comfy with a painful, bloated, unruly digestive system. Did the I.B.S. keep me awake, did the lack of sleep affect my digestion, did stress cause both, or did they cause stress? Again, probably a mix of all of the above.

Like stress, I’ll devote a whole post to sleep in the future. In the short-term, I’ll direct you to the new book by Richard Wiseman “Night School” (he’s also got a lot of great tips on his youtube channel).

For me personally, I think it was addressing stress which had the biggest impact on battling the beast of IBS.

I’ve always had a very laid back personality, and neither I, nor I think any of my friends would ever have described me as a “stressed person”, at least not by the typical definitions.

Looking back, however, a combination of over working, over training, under sleeping, crazy diets and still never saying no to a party took its toll, perhaps manifesting itself in the form of IBS.

While of course, the foods you eat are still important, and I think the “removal of the pea” is an essential step in tackling irritable bowel syndrome, in my case at least, it appears that dealing with the emotional/psychological aspect was equally, if not more important.

Indeed, I stated earlier that there were still certain foods that I was best to avoid – legumes in particular, or combinations of different FODMAP foods in large doses.

While this is kind of the case, I find now all that happens if I do eat too much of any of these foods is excessive gas. Perhaps mildly annoying (or a source of great amusement depending on the situation), but certainly not IBS.

Conclusion

Though I think it’s unlikely I’ll ever be able to eat any quantity of any food with complete impunity (I can kiss goodbye to my dreams of winning the World Championship of Cabbage Eating), I think that I can safely say that I no longer suffer the symptoms of IBS, and can eat whatever foods may be put in front of me when out for dinner (though if you are planning on inviting my round, I’d still favour a grass-fed steak than a lentil stew please).

As per usual, I’ve rambled on a bit in this post, so below are the take home points:

• Irritable Bowel Syndrome is a description of the symptoms, not a diagnosis – there could be a number of underlying causes and treatments
• A good starting point is to try a FODMAP elimination diet to see if you have any specific carbohydrate absorption issues which exacerbate your problem.
• Keep a diary of your symptoms and your food intake, and look for correlations.
• Stick to 2-3 full meals per day, with 0-2 snacks. Avoid huge portions, try to eat mindfully, and stop eating when you’re satisfied, not full to bursting!
• Manage your stress, physical and emotional, and get your sleep in order. 10 minutes of meditation per day is a great starting point.

None of the above is going to be easy, nor will the effects be rapid or immediately evident, but for me it was most definitely worth the effort.

If you are currently suffering from any form of digestive disorder, I hope that this post brings you some relief!

*Ironically, in many cases, this kind of diagnosis may actually be a more appropriate and useful diagnosis than those typically given. ITBand syndrome, for example, is probably more likely to be a chronic pain syndrome, unconnected to any actual structural damage, or the ITBand, making a diagnosis of “Lateral Knee Pain Syndrome” far more accurate and useful. See my posts on Chronic Pain for more details!

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Understanding Intestinal Gas Fernando Azpiroz, MD, PhD

Image 1 courtesy of David Castillo Dominici at FreeDigitalPhotos.net

Adventure Time Image courtesy taken from ForWallPaper.com