Irritable bowel syndrome

Part 1: Overview and Pathophysiology

Irritable bowel syndrome (IBS) is a disorder of the gastrointestinal system characterized by changes in bowel habits and abdominal pain or discomfort with no detectable biochemical and structural abnormalities. Patients fall into three subtypes as per the predominant bowel pattern. The subtypes are IBS with constipation, diarrhea, and mixed-stool-pattern IBS (Holtmann, Ford & Talley, 2016). The condition’s pathophysiology is not fully understood. Additionally, there are no specific diagnostic tests or effective treatments for IBS (El-Salhy, 2015). As a result, patients with IBS visit physicians more frequently, undergo more diagnostic tests, consume more medication, and get hospitalized more frequently than those without the condition.

IBS Prevalence estimates significantly vary worldwide, within, and between countries. Findings from the surveys indicate that within communities, the prevalence of IBS is between 10% and 15% (Canavan, West & Card, 2014). At the international level, estimates place the prevalence rate at 11.2%, with a variation by geographic region. The prevalence is estimated to be highest in South America at 21.0% and lowest in South Asia at 7% (Canavan, West & Card, 2014). IBS occurs across all age groups, but women, compared to men, tend to report the symptoms more frequently.

Many patients who have developed IBS report dietary triggers. Most patients link their symptoms to the intake of specific food items such as milk and dairy products, wheat products, hot spices, onions, cabbage, and smoked foodstuffs (El-Salhy, Patcharatrakul & Gonlachanvit, 2021). Reports indicate that “fermentable oligosaccharides, monosaccharides, and disaccharides and polyols (FODMAPs)” may exacerbate symptoms of IBS in a section of patients (Holtmann, Ford & Talley 2016, p.134). FODMAPs include lactose, fructose, sugar sources, galactans, and fructans.

FODMAPS occur in various foods, including legumes, wheat, vegetables, rye, and fruits. They contain poorly absorbed and indigestible short-chain carbohydrates (Aziz, Tornblom & Simrén, 2019). After ingestion of FODMAPs, the unabsorbed carbohydrates go into the distal small intestine and the colon. They increase osmotic pressure within the luminal cavity and provide a substrate for bacterial fermentation (El-Salhy, 2015). The bacterial fermentation results in gas production, and its accumulation brings about abdominal distension and pain (El-Salhy, 2015). Diets rich in FODMAPs are reported to trigger gastrointestinal symptoms in IBS (Cozma-Petruţ et al., 2017). However, a diet low in FODMAPs reduces symptoms and improves patients’ quality of life.

Part 2: Food Plan and Therapeutics Foods

Given the critical role that diet plays in the pathophysiology of IBS, dietary interventions may help manage and treat the conditions. One such intervention is the Low FODMAP diet, which is currently viewed as second-line dietary therapy for the disorder (Aziz, Tornblom & Simrén, 2019). The plan entails a three-step elimination diet that starts with the elimination phase. In the first step, all high FODMAP-containing foods are restricted for between 4 and 8 weeks (Aziz, Tornblom & Simrén, 2019). The second phase involves the gradual reintroduction of FODMAPs to identify the foods the patient can tolerate and those they cannot tolerate. The final step is the personalization phase, in which the intolerable foods are eliminated or limited, and the patient is taken into long-term follow-up (Aziz, Tornblom & Simrén, 2019). The diet must be implemented under the guidance of a qualified dietician.

Several studies have supported the efficacy of the Low FODMAP diet in managing IBS. In one study, de Roest et al. (2013) reported a significant improvement in most symptoms, such as diarrhea, bloating, and abdominal pain, among IBS patients, placed on the diet over 15.7 months. In another study conducted in Australia, Peters et al. (2016) report that a low FODMAP diet reduced overall gastrointestinal symptoms over six months. These findings support the potential usefulness of the diet for patients with IBS.

A Low FODMAP diet includes dairy products such as rice milk, almond milk, and lactose-free milk. It also includes fruits such as bananas, and oranges and vegetables such as potatoes, lettuce, and carrots (Liu et al., 2020). Proteins in the diet include beef, pork, fish, and chicken, while grains include gluten-free pasta, rice bran, and oat bran (Liu et al., 2020). Whole grain and bran cereals such as rice and oat bran are excellent sources of insoluble fiber. Consuming them daily will help promote regular laxation (Cozma-Petruţ et al., 2017). Their consumption also ensures that patients have enough energy throughout the day.

There are several negative aspects of the low FODMAP diet. The elimination of galactans and fructans could result in the alteration in the composition of gut microbiota and the reduction of beneficial bacteria (Zanetti et al., 2018). The dietary restriction could also result in weight loss among patients. The concerns can be overcome by educating patients about the importance of involving a qualified dietician in planning and implementing the diet. A qualified dietician will ensure that the diet is adequately balanced and with enough proteins to prevent possible weight loss. Involving a qualified dietician will also ensure that patients incorporate the right probiotics needed to maintain the suitable composition of gut microbiota.

Part 3: Dietary Supplements

Several dietary supplements are effective in the management of IBS. They include guar gum and glutamine. Guar gum is a water-soluble fiber extracted from the guar plant’s seeds (Niv et al., 2016). This plant is native to India and Pakistan. Guar gum’s primary component is a galactomannan. Niv et al. (2016) conducted a study to establish its efficacy in IBS. They report that administering 6 grams per day of partially hydrolyzed guar gum (PHGG) helps with bloating and gas in IBS patients. Contraindications for Guar gum include hypoglycemia, hypotension, and gastrointestinal obstruction (Rxlist, 2022). The dietary supplement should be avoided at least two weeks before surgery.

Figure 1: Guar gum seeds ( Retrieved from https://www.therealgoodnutrition.com/therealgoodblog/2018/10/18/the-good-gut-part-i-guar-gum)

The second dietary supplement, glutamine, is an essential amino acid. It is a preferred energy source for cells with a fast turnover, such as enterocytes and lymphocytes. It promotes the proliferation of enterocytes, controls tight junction proteins, and inhibits pro-inflammatory signaling pathways (Rastgoo et al., 2021). Zhou et al. (2019) conducted a two-month clinical study to evaluate the efficacy of taking a glutamine supplement in IBS with diarrhea. Their findings show that a 5-gram dose of glutamine supplement taken three times daily helps reduce symptoms’ severity and daily stool frequency. In addition, the supplement improved stool consistency and intestinal permeability compared to a placebo (Zhou et al., 2019). Contraindications for glutamine include liver disease and kidney disease (Drugs, 2022). The supplement is available in powder and tablet forms.

Part 4: Educating Clients in Self-Management

Self-management can be quite effective in relieving the significant symptoms of IBS. As part of self-management, patients should change the types of food they eat. They should be on the lookout for foods that worsen the symptoms and avoid them. Patients should be educated about foods rich in FODMAP and how they contribute to the exacerbation of IBS symptoms. They should be taught about the low FODMAP diets and some foods that can be incorporated into the diet. Clients should also be informed about the importance of regular exercise, relaxation, and avoiding stress in managing IBS.

Part 5: Collaboration with Healthcare Professionals

Among the many factors that contribute to IBS is stress. Stress can be managed through many approaches, yoga being one of them. D’Silva et al. (2020) report that yoga is safe and effective and may target several mechanisms involved in IBS treatments. Findings from their study indicate that yoga is equally as effective as dietary interventions in managing the disorder. This implies that a dietician can collaborate with a psychotherapist to ensure effective treatment of IBS.

Part 6: Conclusion

IBS is a manageable condition. Numerous factors trigger the condition, but diet is a significant factor. Available evidence supports the efficacy of a low FODMAP diet in managing the condition. However, this should be implemented with other interventions for optimum patient outcomes. Exercising regularly, yoga, and other practices that help promote mental well-being are some additional approaches patients should consider. One can download a simple guide to low FODMAP here.

References

Canavan, C., West, J., & Card, T. (2014). The epidemiology of irritable bowel syndrome. Clinical epidemiology, 6, 71–80. https://doi.org/10.2147/CLEP.S40245

Cozma-Petruţ, A., Loghin, F., Miere, D., & Dumitraşcu, D. L. (2017). Diet in irritable bowel syndrome: What to recommend, not what to forbid to patients! World journal of gastroenterology, 23(21), 3771–3783. https://doi.org/10.3748/wjg.v23.i21.3771

de Roest RH, Dobbs BR, Chapman BA, Batman B, O’Brien LA, Leeper JA, Hebblethwaite CR, Gearry RB. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract. 2013 Sep;67(9):895-903. DOI: 10.1111/ijcp.12128. Epub 2013 May 23. PMID: 23701141.

Drugs. (2022). Glutamine. Retrieved from https://www.drugs.com/mtm/glutamine.html

D’Silva, A., MacQueen, G., Nasser, Y., Taylor, L. M., Vallance, J. K., & Raman, M. (2020). Yoga as a Therapy for Irritable Bowel Syndrome. Digestive diseases and sciences, 65(9), 2503–2514. https://doi.org/10.1007/s10620-019-05989-6

El-Salhy M. (2015). Recent developments in the pathophysiology of irritable bowel syndrome. World journal of gastroenterology, 21(25), 7621–7636. https://doi.org/10.3748/wjg.v21.i25.7621

El-Salhy, M., Patcharatrakul, T., & Gonlachanvit, S. (2021). The role of diet in the pathophysiology and management of irritable bowel syndrome. Indian Journal of Gastroenterology, 40(2), 111-119. https://link.springer.com/article/10.1007/s12664-020-01144-6

Holtmann, G. J., Ford, A. C., & Talley, N. J. (2016). Pathophysiology of irritable bowel syndrome. The Lancet Gastroenterology & hepatology, 1(2), 133-146. https://doi.org/10.1016/S2468-1253(16)30023-1

Liu J, Chey WD, Haller E, Eswaran S. Low-FODMAP Diet for Irritable Bowel Syndrome: What We Know and What We Have Yet to Learn. Annu Rev Med. 2020 Jan 27;71:303-314. doi: 10.1146/annurev-med-050218-013625. PMID: 31986083.

Niv, E., Halak, A., Tiommny, E., Yanai, H., Strul, H., Naftali, T., & Vaisman, N. (2016). Randomized clinical study: Partially hydrolyzed guar gum (PHGG) versus placebo in the treatment of patients with irritable bowel syndrome. Nutrition & metabolism, 13(1), 1–7. https://doi.org/10.1186/s12986-016-0070-5

Peters, S. L., Yao, C. K., Philpott, H., Yelland, G. W., Muir, J. G., & Gibson, P. R. (2016). Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Alimentary pharmacology & therapeutics, 44(5), 447–459. https://doi.org/10.1111/apt.13706

Rastgoo, S., Ebrahimi-Daryani, N., Agah, S., Karimi, S., Taher, M., Rashidkhani, B., Hejazi, E., Mohseni, F., Ahmadzadeh, M., Sadeghi, A., & Hekmatdoost, A. (2021). Glutamine Supplementation Enhances the Effects of a Low FODMAP Diet in Irritable Bowel Syndrome Management. Frontiers in nutrition, 8, 746703. https://doi.org/10.3389/fnut.2021.746703

Rej, A., Aziz, I., Tornblom, H., Sanders, D. S., & Simrén, M. (2019). The role of diet in irritable bowel syndrome: implications for dietary advice. Journal of internal medicine, 286(5), 490-502. https://doi.org/10.1111/joim.12966

Rxlist. (2022). Guar Gum. Retrieved from https://www.rxlist.com/guar_gum/supplements.htm

Zanetti, A. J. A., Rogero, M. M., & Von Atzingen, M. C. B. C. (2018). Low-FODMAP diet in the management of irritable bowel syndrome. Nutrire, 43(1), 1-5. https://doi.org/10.1186/s41110-018-0076-z

Zhou, Q., Verne, M. L., Fields, J. Z., Lefante, J. J., Basra, S., Salameh, H., & Verne, G. N. (2019). Randomised placebo-controlled trial of dietary glutamine supplements for postinfectious irritable bowel syndrome. Gut, 68(6), 996–1002. https://doi.org/10.1136/gutjnl-2017-315136