IBS, alongside Functional Medicine & Nutrition

Irritable Bowel Syndrome, also known as IBS, is a common condition affecting the digestive system. IBS is usually a lifelong problem, affecting daily life. Flare-ups can last weeks or months if managed inadequately, causing symptoms such as stomach cramps, bloating, diarrhoea and constipation. 

This IBS awareness month, we wanted to discuss the ins and outs of the gut, what may be triggering IBS and how functional medicine can be used alongside it, to manage symptoms and prevent frequent flare ups. 

In conversation with Gut Health Specialist & Nutritional Therapist

We spoke to Libby Linford, our Founder and Angie, another of our Functional Medicine Practitioners & Registered Nutritionists that works closely with Gut Health.

According to Functional Medicine, what are the possible root causes of Irritable Bowel Syndrome (IBS)?

IBS or irritable bowel syndrome is simply a collection of non-specific gastrointestinal symptoms, and although many people are diagnosed with IBS as a condition in itself, it is in fact not a single condition, but the result of numerous different gastrointestinal imbalances. These will be different for each person living with IBS.

The causes of IBS are multifactorial and can be caused by;

• intestinal barrier malfunction or leaky gut

• gut flora imbalance - An imbalance in gut flora can also trigger IBS. These may lead to food intolerances and sensitivities which further exacerbate symptoms, increase both gut and systemic inflammation

• Pathogenic overgrowth of bacteria, yeast or parasites

• Food reactivity

• Coeliac disease and non coeliac gluten sensitivity

• stress damaging the gut/brain axis 

• increased visceral hypersensitivity 

• gut motility dysfunction - Poor motility in the gut which can be caused by thyroid issues or brain/spine injuries such as whiplash and landing on your coccyx which damage the signalling to the gut.

• Hypermobility which may result in loose guts and lead to slow and sluggish motility again  leading to an imbalance in gut flora.

• Childhood traumas or PTSD

• Reduced or insufficient levels of digestive enzymes - leading to poor food breakdown. Such as Exocrine Pancreatic Insufficiency (EPI) which is a condition where the pancreas does not make enough digestive enzymes. Without adequate levels of digestive enzymes it is a struggle to break down the foods you eat and to absorb the nutrients they contain properly. The food that passes through your intestines therefore is not fully digested and can lead to the symptoms of IBS and also bacterial imbalance or pathogenic overgrowth

• SIBO - Staggeringly, 70% of people diagnosed with IBS test positive for SIBO. The root causes of SIBO are stress, structural issues in the digestive system, as well as faulty valves such as the ileocecal valve.

• Damage caused by abdominal surgeries - (even keyhole can cause significant damage)

• Gastrointestinal adhesions - which may result from endometriosis etc. may result in structural abnormalities of the digestive system which leads to slow motility and bacteria overgrowth.

• Post infectious IBS - There can also be an autoimmune aspect to IBS which can occur after food poisoning outbreaks. Anti vinculin antibodies are produced which damages nerve cells in the gut which may to a damaged gut motility which can trigger PI-IBS (post infectious IBS). This can occur sometime after the original food poisoning making it difficult to pinpoint the original trigger.

• COVID infection - We are now also seeing a significant increase in IBS symptoms post COVID infection and post - overall gastrointestinal disorders may be 35% more likely in those who have been infected with COVID 19 than those who have not. One study showed;

  • 62% increase in stomach ulcers

  • 35% risk of GERD - (reflux)

  • 46% increase in gastritis

  • 54% increase in IBS

  • 47% increase in the incidence of inflammation of the stomach lining and

  • 54% increased prevalence of constipation, diarrhoea, bloating, vomiting and abdominal pain

What are the most common dietary and environmental triggers of IBS? 

Depending on the reason or underlying causative factors for a clients IBS, there may be no food reactivity present at all. However, many people will suffer with reactivity to foods due to one or more of the factors listed above which may result in improper breakdown of the components of the foods, or due to the action of gastrointestinal bacteria on certain foods, or if inflammation of the lining of the stomach such as gastritis is present then certain foods such as acidic foods may trigger symptoms.

Here we have listed some of the most common foods to trigger IBS symptoms;

• Gluten and Dairy

• Sugar and refined carbohydrates such as white bread

• Alcohol and coffee

• Foods high in FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) - this is a great resource for FODMAP food listings; https://www.monashfodmap.com/

• Acidic foods such as oranges and other citrus, tomatoes, pineapples to name a few

• Fried and fatty foods

• Spicy foods

• Carbonated or fizzy drinks

There are also lifestyle or environmental factors which may exacerbate or trigger IBS and these may include;

• Stress and emotional upset

• Eating whilst on the go

• Insufficient chewing or eating too fast

• Not embracing the cephalic phase of digestion
  (The cephalic phase occurs before food is eaten and also before it enters the stomach. It can also occur whilst food is being eaten. It results from the sight, smell, thought, or taste of food. It is a stimulatory process. The purpose of the cephalic phase is to prepare the body to recieve food and begin to breakdown the foods by releasing stomach acid and other digestive enzymes. Getting involved in the prep of food or watching someone prepare food is a great way to begin this very important part of digestion. So the grab and go mentality to food that we now see prevalent in our busy societies causes disassociation from food and reduced digestive function.

What does IBS feel like -what are the symptoms? 

The symptoms of IBS vary widely and are dependant on the underlying causative factors, and IBS can typically be divided into two subtypes of IBS-D (diarrhoea) and IBS-C (constipation). Some of the most common IBS symptoms are;

• Constipation

• Diarrhoea

• Inability to empty bowels (or feels incomplete)

• Indigestion or reflux

• Nausea

• Passing excessive amounts of gas

• Urgency to pass stool (the need to rush to the toilet)

• Abdominal cramping, pain or discomfort

• Anxiety - this can result from the problems associated with living with the conditions such as always feeling the need to be near a toilet or feeling unable to be in social situations due to wind, but may also result from nutrient insufficiency that may result from poor digestive function

• Fatigue

• Depression

What dietary and lifestyle changes are typically recommended for those with IBS? 

The conventional medical system will often recommend the FODMAP diet to those with IBS, and whilst for some this may relieve some of the symptoms of the IBS, it will not get to the root cause of the condition and so will not address what is underlying the IBS symptoms in the long term and as soon as you consume FODMAP foods again the symptoms return. This is neither a sustainable way to eat longterm nor a healthy way as you are actually reducing the availability of healthy fibres to the beneficial bacteria that reside in the gut, which may in turn result in further imbalance of the commensal bacteria present, and can leave you open to greater susceptibility for pathogenic growth and other more serious gastrointestinal health concerns.

Having said all that, the FODMAP diet is a tool that may be recommended by a functional medicine practitioner or nutritional therapist in the short term whilst the underlying causative factors are being identified and targeted through very specific and personalised dietary, lifestyle and often supplement protocols.

The exact dietary changes required to address a clients IBS symptoms will be dependent on the underlying causative factors and trimmest identified. Through very detailed nutritional therapy and functional medicine case work and often functional and diagnostic testing the causative factors can be identified and then specific dietary changes implemented. These may include restriction of certain food types such as gluten, dairy or foods to which we have identified reactivity.

It is our goal to only ever use restrictive dietary protocols when absolutely necessary and for as short a time as is possible. Our ultimate aim is for our clients to leave our care with the ability to eat as varied a diet as possible.

With stress being such a large part of the experience or a client with IBS, your focus is always to support using lifestyle factors as far as possible the client’s ability to cope with stressors. We cannot always remove the stressor itself but we can learn how to respond to life stresses without it harming our health. Examples of recommendations may be, sleep, meditation, mindfulness, affirmations, exercise, time in nature, trauma release therapies, counselling, psychotherapy etc.

How does functional medicine work with IBS compared to conventional medicine treatment?

Functional medicine works to understand the underlying imbalances or causative factors through thorough investigation using functional casework and testing where necessary. This is a person centred root cause approach not a symptoms approach. The functional medicine approach therefore is not simply to target the symptoms and as such is not what I would call a sticking plaster approach, but is a really deep dive approach to understanding where these symptoms are coming from, what is causing them and not just in terms of gastrointestinal imbalances but also from environmental factors which may be impacting a clients mental wellbeing, in turn having knock on effects on gut health.

Whereas, conventional medicine may look to identify underlying issues through colonoscopy or endoscopy, maybe some bloodwork and possibly stool testing for example which are frequently recommended for those with IBS symptoms, functional medicine applies testing approaches which look for a plethora of factors that cannot be seen using conventional testing approaches. Tests that we commonly run for those clients with IBS type symptoms include;

• Comprehensive diagnostic stool testing

• SIBO breath testing

• Food reactivity screening

• Screening for Coeliac disease

• Thyroid testing

The approach via conventional medicine is also different from a functional approach. This is to say that often set protocols are applied to those with IBS symptoms such as medications to reduce reflux symptoms and FODMAP dietary approaches, regardless of a lack of understanding of the true underlying factors, and without attention to the person themselves, their mind and mood etc. The conventional approach is more a one size fits all approach that cannot be personalised because the underlying factors have often not been determined.

What role does the immune system play in IBS?

There are several mechanisms by which the immune system may be be involved in IBS, and therefore IBS may result from an immunological aetiology such as infectious gastroenteritis, various forms of inflammatory bowel diseases, including autoimmune disease such as Ulcerative Colitis or Crohn’s or Coeliac disease, Autoimmune Gastritis.

Symptoms of pain associated with IBS may in part result from mast cells and the impact that immune mediators released from mast cells may sensitise pain receptors

Conversely having IBS may result in increased levels of cytokines (inflammatory immune mediators) in systemic circulation, which therefore in turn may result in systemic inflammation which can have impacts across the body, for some people we see that this may result in conditions such as joint inflammation, inflammatory skin disorders such as eczema, or neurological inflammation resulting in brain fog, fatigue, depression, anxiety etc or. Neurological inflammation activated via the gut-brain axis may also result in neurodegenerative diseases such as Alzheimers and Parkinson’s.

When leaky gut or intestinal permeability is part of the picture of IBS, and when this is accompanied by an overgrowth of pathogenic bacteria, we see inflammatory response in tissues, often at the sight of old injury but not always. This may be as a response to what is called LPS (lipopolysaccharides) which are the most abundant antigen on the cell surface of most Gram-negative bacteria, which may reside in the gut, entering systemic circulation and triggering inflammatory immune response.

Similarly when leaky gut is present this can result in an immune response being triggered to non invading antigens (any molecule that can cause your immune system to react and produce antibodies to it) such as larger than normal particles of food which may have passed through the hyper permeable intestine into systemic circulation. This reactivity to food can result in a multitude of systemic disease states or conditions, and it can be found that the removal of these foods brings symptomatic relief.

For more on this topic, head to the following articles:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228974/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4930555/#:~:text=LPS%20activates%20cells%20of%20the,dramatic%20secondary%20inflammation%20in%20tissues
https://www.nature.com/articles/s41577-022-00700-9
https://www.nature.com/articles/s41531-016-0002-0

What role does inflammation play in IBS? 

Low grade inflammation is part of the symptom picture of IBS. When you look at the various root causes, all of them will cause low grade inflammation. Whilst addressing the inflammation while supporting the client’s symptoms is important, addressing the cause of the inflammation is the key to real improvement of IBS outcomes. 

There is likely a timeline in the aforementioned multifactorial causes of IBS for example gut flora imbalances lead to low grade inflammation which leads to poor intestinal barrier health which increases the likelihood ofgastro infections, resulting in IBS.

For more on this topic, read this article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159811/#:~:text=Inflammation%20may%20play%20a%20pathogenic,disease%20have%20also%20been%20reported.

I’ve heard of the mind-body connection - How does a functional medicine practitioner view this in relation to IBS?

The mind-body connection is also known as the gut-brain axis and is a bi-directional communication pathway between the gut and the brain that confers some change in biochemical or physiological activity in each of these. Not only this but the brain is communicating not just with the gut itself but with the bacteria that reside in the gut (the microbiota), this is known as the microbiota-gut-brain-axis. They do this primarily through immune, hormonal, and nervous system signalling. 

The gut houses its very own nervous system called the Enteric Nervous System (ENS) which like the Central Nervous System (CNS) is regulated by a complex balance of chemicals and cells which balance digestive function but can also communicate with the brain to tell it when something is wrong. The ENS is sometimes knows as our second brain!. https://hms.harvard.edu/news-events/publications-archive/brain/gut-brain#:~:text=The%20enteric%20nervous%20system%20that,brain%20when%20something%20is%20amiss

Brain to gut:

Some clients come to us saying that after many rounds of investigation and consultation that their gastrointestinal/IBS symptoms are all in their mind…… and whilst it is not fair to say that a client is imagining their symptoms in some sort of a psychosomatic manner, there is much truth in the fact that what occurs in your brain in terms of mood changes, stress, anxiety, trauma and depression can result in very real biochemical or even physical changes in the health of the gut.

You see the brain is communicating with the gut, and when we experience a certain feeling such as anxiety this will be communicated to the gut via vagus nerve signalling, and may for example alter the motility of the gut. People often notice that when they are nervous or anxious that the need to rush to the toilet and may have loose stool. Emotional distress is known to exacerbate symptoms in those with IBS. In one article they refer to IBS as being a combination of irritable bowel and irritable brain because of how intrinsically linked the health of our brain is with the development of IBS.

Gut to brain:

The bacteria that reside in our gastrointestinal systems are symbiotic in that we confer benefit to them as their host and they confer benefit to us also. However when there becomes an imbalance in the normal commensal bacteria that reside in the gut this can alter the way we feel emotionally. We may experience depression, low mood, anxiety and stress to a greater degree. The bacteria do this by producing neurotransmitters such as serotonin, GABA and melatonin. 

Any aspect of imbalance in gut health may result in alterations in brain health, such imbalance may relate to multiple different factors of gut health but include; the bacterial ecology of the gut but also to inflammation within the gut, poor digestions and absorption of nutrients required by the brain for proper functioning such as essential fatty acids and b-vitamins.

For more information, follow these links:

https://hms.harvard.edu/news-events/publications-archive/brain/gut brain#:~:text=The%20enteric%20nervous%20system%20that,brain%20when%20something%20is%20amiss
https://www.nature.com/articles/s41579-020-00460-0#:~:text=The%20'gut%E2%80%93microbiota%E2%80%93brain,systems%20of%20animals1%2C6. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202343/#:~:text=Stress%2Dinduced%20alterations%20in%20neuro,stress%20and%20stress%2Dinduced%20responses.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5193306/

How do we work with Gut Health issues?

When we work with clients with gut health complaints, the first part of the process is to unpick through a number of nutritional therapy and functional medicine questionnaires and identify any possible underlying imbalances in the various aspects of gastrointestinal functioning. We will also look in detail at the progression of the disorder of gastrointestinal health over time and the health of the gut over the client’s lifetime. This will help us to understand possible triggers and mediators of the client’s symptoms. The next phase of the process is to undertake comprehensive diagnostic testing which may involve stool testing, food reactivity testing, and gastrointestinal autoimmunity screening example.

Once we have collected all this data we can be much more targeted in the approaches and protocols that we apply to address the client’s health complaints. People often ask if food exclusion or elimination diets are necessary and the answer is sometimes yes, but our approach is to limit exclusion as far as possible and when necessary only apply exclusion diets for the shortest possible period of time. The truth is the unnecessary exclusion of foods can be counterproductive to overall gut health and can result in further complications for example.

Are you struggling with symptoms of IBS? 

Book a FREE discovery call with us at the Surrey Centre for Nutrition to opt for a natural and holistic approach to your condition. We integrate Nutritional Therapy with Functional Medicine to ensure that you have a treatment plan completely suited to you and your needs.