I recently completed a course covering Irritable Bowel Syndrome (IBS) and the low FODMAP approach to working with IBS through Monash University.
The course, designed for dietitians, was a wealth of information. Having recently acquired my Level 5 diploma in advanced nutrition through Mac-Nutrition University, I was granted access to the Monash course.
One point of distinction is that, since I am not (nor do I aim to be) a registered dietitian, I cannot claim to be “certified” in the course, only that I passed and completed it.
Since IBS is something that comes up with a fair amount of frequency in my conversations with clients, I wanted to break down the course in as close to layman’s terms as I could for my readers and, hopefully, as a reference for those who suffer with IBS and may be looking for treatment options.
If you believe you need help with this approach, consider speaking with an RD or gastroenterologist for more in-depth care and guidance.
To offer a framework of functional bowel disorders, there are 3 potentially overlapping characteristics: abdominal pain, constipation and diarrhea. Within those characteristics, patients can present with symptoms of bloating and distension.
IBS currently affects somewhere between 3.8 and 9.2% of the worldwide population and there are three factors which may contribute to an increase in seeing the diagnosis: a leaning towards a more “western” diet, the increase of anxiety and depression (which affects how the brain and gut communicate) and more people seeking out treatment for their concerns.
IBS affects 1.5 times more women than men, it does appear more common in people with a lower socio-economic status and appears to be more prevalent in people under the age of 50.
I should mention that symptoms of IBS can improve and then get worse, new symptoms can develop over time and sometimes symptoms can be mild or more severe, all of which can have a direct effect on the quality of life of the patient since there can be periods of more urgency to go and this influencing the social life of each individual struggling with it.
It was noted in the coursework that IBS can affect the desire to travel and attend work events. It can also have a negative effect on sleep, diet and intimacy.
While it’s unclear what causes IBS, proposed mechanisms are: visceral hypersensitivity, changes in gut microbiota, changes in gut motility, anxiety/stress related symptoms, inflammation, immune system response, and intestinal permeability. There may also be a hereditary factor but this may have more to do with exposure and learned behaviors rather than a genetic link.
The most common symptoms of IBS are: bloating, abdominal distension, constipation, diarrhea, lower abdominal pain, excessive flatulence, and alternating bowel habits.
Practitioners who are diagnosing IBS will likely use some combination of the Rome criteria test to look at frequency of conditions and the Bristol stool chart to assess the consistency of bowel movements.
There are a series of red flags which may also contribute to diagnosis or point to something else happening with the body: unexplained weight loss, age of onset greater than 50 years, family history of bowel disease, rectal bleeding/anemia, nocturnal bowel motions, persistent daily diarrhea, recurrent vomiting, fever and progressive/severe symptoms.
Where circumstances can be further complicated is when IBS presents with symptoms similar to other conditions such as: inflammatory bowel disease, celiac disease, intestinal cancers, pelvic floor disorders, bile salt malabsorption, endocrine disorders, pancreatic exocrine insufficiency, endometriosis and diverticular disease. Generally, a family physician or gastroenterologist can administer a series of tests to rule out something more serious or to come closer to a diagnosis of IBS.
As of this writing, the diagnoses of candidiasis and non-celiac gluten/wheat sensitivity are controversial and not backed by high quality evidence. Also, fecal microbiota testing, fecal short-chain fatty acid testing, IgG food intolerance testing, salivary IgA, and intestinal permeability testing is not recommended in routine clinical practice.
Some practitioners may advise breath testing to diagnose conditions but currently the only breath test which appears to have clinical significance is the lactose breath test.
At this time, the therapies available to help with IBS include: certain medications such as anti-diarrheals, laxatives and antidepressants, dietary interventions (more on low FODMAP below), exercise, certain probiotics, psychotherapy (CBT and gut-directed hypnotherapy) and biofeedback therapy.
Anecdotally, some people associate an increase of IBS symptoms with fatty foods (fried foods, pizza, cream, etc.) In addition, certain proteins may also be problematic including β-casein (found in milk), rubisco (found in spinach), wheat-germ lectin, α-amylase/trypsin inhibitors (ATIs), and gluten. While some people may simply try to remove gluten from the diet, it’s unclear whether gluten is totally at fault or if the ATIs or fructans are the issue.
As for carbohydrates, the ones which appear to be implicated in an increase of IBS symptoms include: fiber, prebiotics, and short-chain carbohydrates (lactose, sorbitol, mannitol, fructose and oligosaccharides). Monash University pioneered the low FODMAP approach for IBS symptoms. FODMAP is the acronym for: Fermentable Oligo- Di- Mono-saccharides And Polyols.
For those who want a deeper dive into this approach, Monash has created an app which allows you to see and tailor which foods and servings of foods are most problematic for each individual and helps you tailor a plan specific to your needs. Search for “Monash University FODMAP diet” on your smart device to download.
In Phase 1 of the approach, it’s suggested that you trial for 2-6 weeks and swap “high” and “moderate” FODMAP foods for “low” foods. In Phase 2 (6-8 weeks) you’ll have a reintroduction period to determine what the body can tolerate. In Phase 3, you should have enough data to personalize a plan for yourself.
While this is not a comprehensive list and more options can be found within the app, I’ve given examples of foods which could be excluded in efforts to improve IBS symptoms:
Fructans: grapefruit, dates, onion, garlic, wheat/rye based bread, and falafels
GOS: green peas, black beans, navy beans, kidney beans, cashews, and pistachios
Sorbitol: apple, pear, avocado, apricot, blackberries, and plums
Mannitol: mushrooms, cauliflower, celery, and sweet potatoes
Fructose (in excess of glucose): mango, boysenberry, grapes, watermelon, asparagus, honey and fruit juice
Lactose: cow’s milk, yogurt, and custard
It should be noted again that just because you are temporarily removing a food to test against your symptoms, it does not mean that you can never have the food again. Rather, you may find that in the reintroduction phase, that you can tolerate smaller amounts of a given food and can learn your personal threshold for inclusion back into the diet.
As a reference, certain medications/supplements may present with GI symptoms and this may affect how your body reacts to a dietary intervention. Examples would be: antibiotics, codeine, iron, metformin and magnesium. If you’re currently taking any of these, work with your doctor to see if other options are available to minimize conflicting results.
In some cases, caffeine and alcohol may need to be eliminated to determine if the removal improves IBS symptoms. Since there is a correlation with stress and how stress can effect the digestive system, it should be recognized that exercise can be both a stress reliever and help with gut motility. Bear in mind that intense exercise can worsen symptoms so you may need to reduce intensity to gauge effectiveness of exercise in your regimen.
Also on the topic of stress, cognitive behavioral therapy, gut-directed hypnosis and having a meditation practice can all help improve feelings of stress and may have a correlation to improved IBS symptoms.
I’ll add in closing that due to the restrictive nature of the low FODMAP approach, working with an RD or gastroenterologist is recommended to make sure that you don’t develop micronutrient deficiencies along the way.
This course was of great interest to me due to changes we saw in my wife and her dietary needs over the last couple of years. There was a link to IBS and we frequently heard about the low FODMAP approach while she was seeking help. I’ll recommend again that you download the Monash app to see if it’s helpful for you and reiterate that the information in this post is not meant to replace the guidance of a doctor or dietitian.
Disclaimer: I receive no incentives for the app recommendation.
(Photo courtesy of Maddi Bazzocco)
