IBS can get out of control, take over your day and hijack your mind in such a short time. I did a radio spot on RTHK national radio here in Hong Kong, where we introduced how IBS can affect people.
To explain the context of how it affects people, I asked the following question:
Can you imagine feeling progressively more unwell with every meal you eat, every day, for months or years?
It seems like an exaggerated question, but to put it in context, for people living with IBS, three meals a day over three hundred and sixty-five days can equal over nine hundred independent episodes that can worsen their gut issues.
Now, this can seem a little hyperbolic, but I’ve had many patients over the years who have experienced worsening IBS symptoms with every meal.
Some people have been dealing with IBS for over a decade!
Whilst there isn’t a raft of information about the prevalence of IBS in Hong Kong, one survey from 2002 had around six per cent of the population affected.[1]
Calculated out just over four hundred and fifty thousand people based on the city’s current population in 2022 may be living with IBS and gut issues.
This number could double depending on the age group, with over 12 per cent of Chinese university students found to have IBS based on the Rome III criteria.[2]
Globally, this number is similar. A 2020 study brought together fifty-three studies done in thirty-eight countries with just under four hundred thousand participants, placing the global prevalence at just under ten per cent of the world’s population.[3]
Once again, calculated out an estimated seven hundred and ninety-eight million people are living with some form of IBS!
How do you know what you are experiencing is irritable bowel syndrome?
Identifying IBS is in its fourth iteration, called the Rome IV criteria. This criterion helps to bring together the various ways IBS can present.
One of the main features of IBS is visceral abdominal pain. If you are wondering if this is you, the best way to define this is discomfort where you can’t quite pinpoint the location.
I’ve had some patients mention that “it just feels like it’s everywhere.”
The other defining feature for most people I see with IBS is dysfunctional or altered bowel habits. Altered bowel habits can mean you either lean towards loose or challenging bowels or, in some cases, diarrhoea or constipation. Some people can experience a mixture of both of these.[4]
Depending on your bowel habits, IBS subtypes exist to help with a specific diagnosis. For example, if your bowel patterns are more diarrhoea dominant, then you have IBS-D, constipation dominant, IBS-C or mixed, IBS-M.[5]
Aside from these main symptoms, bloating, feeling full or distension, change in pain location, and symptoms worsening from eating/food are widespread.[6]
No matter how you experience your IBS symptoms, if they are out of control, the first step is to try what seventy per cent of people with IBS don’t.
It’s the simplest thing.
The first thing to do when your IBS is out of control is to ask a professional healthcare practitioner for help.
Estimates from another study suggest that only thirty per cent of people who experience IBS symptoms seek medical help.[7]
This same study went on to suggest that even though the symptom picture between the people who do and don’t seek help are similar, those who don’t have more significant anxiety and lower quality of life.[8]
An interesting study deconstructed a survey conducted by the American Gastroenterological Association (AGA) of over three thousand people with IBS and their satisfaction with different forms of treatment.
The results were very similar to what I see in the clinic.
Seventy-seven per cent of those surveyed reported that they had tried over-the-counter treatments for their IBS symptoms. The product varied depending on the subtype of IBS, either IBS-D or IBS-C. Less than twenty per cent of the IBS-D and fifteen per cent of respondents in the IBS-C group said they were very satisfied with their over-the-counter choice.[9]
Have you been or are you in this position now?
One recent patient mentioned that she had tried every possible option on iHerb before booking her first appointment. At least, the good news for her is that it took four weeks for her symptoms to turn around after initiating the next step.
Ask your healthcare practitioner to help choose the proper functional medicine test to investigate the origin of your IBS symptoms.
Often IBS can feel like it’s coming from so many places that its origins can be hard to pin down. For example, one minute you’re bloated; the next minute, your bowels are urgent or unsatisfactory; finally, you have a sensation of pain and discomfort that doesn’t have an easy-to-pinpoint location.
A famous natural and functional medicine adage is “test, don’t guess.”
In the case of out-of-control IBS, there are two testing options. A comprehensive stool test such as the GI-Map, GI-360 or GI-Effects test looks at the lower abdomen, specifically the large intestine, bowel and colon.
These tests can also give us insights into some of the deeper origins of gut issues like IBS. For example, we can see certain species of bacteria that drive imbalances in the microbiome associated with leaky gut and other immune system markers.
Another key indicator that all stool tests cover helps people determine why food worsens their IBS symptoms. One of the first articles on this website explored what I call function over food. Whilst you can read it in your own time, how it relates to stool testing is that we can determine how you absorb your protein, carbohydrates and fat.
These are vital gateways to developing IBS symptoms but can also explain how small intestinal bacterial overgrowth (SIBO) can occur.
I’ve written another detailed article about the connection between IBS and SIBO. Still, if you are one of the many people who develop bloating that feels worse around the belly button, then SIBO might be a factor to consider.
If you are new to SIBO, its definition is an excessive presence of colonic bacteria in the small intestine.[10]Whilst some bacteria are present in the small intestine, these levels should not increase over a certain point. If they do, then this can generally cause symptoms such as bloating and flatulence.
Estimates vary when it comes to SIBO’s prevalence in IBS.
For example, some studies have it up to seventy per cent of people with IBS have SIBO. A more recent meta-analysis bringing together over three thousand people living with IBS found SIBO in thirty per cent of cases.[11]
I would say that in the clinic, I see slightly higher numbers than thirty per cent, but the severity of SIBO varies widely.
The good news is that you can use a breath test to see if you have SIBO and find out if this is the cause of your out-of-control IBS.
A lactulose breath test investigates small intestinal bacterial overgrowth or SIBO for bloating around the belly button.
When bacteria overgrow in the small intestine, depending on the species, different gases can increase in volume because of the bacteria’s presence. When you drink a lactulose or glucose syrup, these gases, predominantly hydrogen, methane and hydrogen sulphide, can significantly increase.
By exhaling into a tube at various time intervals over three hours, we can then track the increases in these gases as the lactulose or glucose syrup travels through the small intestine to the large intestine.
If the gas levels increase beyond a particular amount above baseline, then SIBO is considered present.
Some SIBO can be hydrogen-dominant, methane-dominant, hydrogen sulphide dominant or a combination of the three. Depending on these subtypes, your practitioner can formulate a combination of a dietary and herbal medicine intervention to help you clear the overgrowth and begin controlling your IBS symptoms.
The connection between the diet and your IBS symptoms may be the next step in taming your gut issues.
Dietary change can seem attractive for people with IBS who feel like food is the problem.
But what changes do you make?
Most begin the process by restricting animal products. But, unfortunately, these changes don’t help. This lack of results doesn’t mean the diet can’t be the key.
This key lies within the removal of foods high in what’s called dietary FODMAPs.
FODMAP stands for fermentable, oligo, di- and monosaccharides and polyols.[12] An easy way to think of these is as simple carbohydrates that occur in a wide variety of foods.
FODMAPs are in fruits and vegetables, grains and cereals, nuts, legumes, dairy and manufactured, processed foods.
Because of the wide variety of foods and the different levels of FODMAPs in each, it is often better to use a guide to help. Monash University, out of Melbourne, Australia, is the world leader in FODMAPs. Their direction is best used by following this link:
https://www.monashfodmap.com/about-fodmap-and-ibs/high-and-low-fodmap-foods/
A review published in 2020 showed that overall, fifty to eighty-five per cent of people report significant improvement in their IBS symptoms with the elimination of dietary FODMAPs.[13]
If it helps, from more of a clinical point of view, I see the removal of FODMAPs show more success in people who have diarrhoea-dominant IBS or IBS-D. Still, in combination with removing starches in the SIBO Bi-phasic diet, those with IBS-C or constipation-dominant IBS have also found relief.
There is an important note if you haven’t tried to remove FODMAPs from your diet before.
As with other prescriptive diets, any dietary change done for therapy should have a start and an end date. Removing foods high in FODMAPs for longer than four to six weeks maximum can hurt your microbiome, vitamin, mineral and fibre status.[14]
Furthermore, slowly reintroducing FODMAP foods can assist in restoring important probiotic and prebiotic bacteria into the gut, allowing for a better outcome![15]
The reason why this is so important?
For a large number of people who feel better, reintroducing FODMAPs can be a daunting experience. Especially if removing those foods has ended years of feeling unwell.
Still, I’m here to tell you that it’s not only necessary but part of the journey towards gaining power over your out-of-control IBS.
So what do you think?
Maybe you’ve already tried these steps; perhaps they’re new to you. Regardless, I hope this article has offered a reassuring sense that you don’t have to tolerate your IBS and gut issues.
Especially if you are one of the seventy per cent living with IBS symptoms yet to reach out and ask for help, be brave and step out; you might find it opens a gateway to feeling better and breaking the seemingly never-ending daily pattern of IBS.
Hope this helps xx
References!
[1] Kwan AC, Hu WH, Chan YK, Yeung YW, Lai TS, Yuen H. Prevalence of irritable bowel syndrome in Hong Kong. J Gastroenterol Hepatol. 2002;17(11):1180-1186. doi:10.1046/j.1440-1746.2002.02871.x
[2] Yang W, Yang X, Cai X, et al. The Prevalence of Irritable Bowel Syndrome Among Chinese University Students: A Systematic Review and Meta-Analysis. Front Public Health. 2022;10:864721. Published 2022 Apr 15. doi:10.3389/fpubh.2022.864721
[3] Oka P, Parr H, Barberio B, Black CJ, Savarino EV, Ford AC. Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: a systematic review and meta-analysis [published correction appears in Lancet Gastroenterol Hepatol. 2020 Dec;5(12):e8]. Lancet Gastroenterol Hepatol. 2020;5(10):908-917. doi:10.1016/S2468-1253(20)30217-X
[4] Patel N, Shackelford K. Irritable Bowel Syndrome. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534810/
[5] Patel N, Shackelford K. Irritable Bowel Syndrome. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534810/
[6] Chey WD, Kurlander J, Eswaran S. Irritable bowel syndrome: a clinical review. JAMA. 2015;313(9):949-958. doi:10.1001/jama.2015.0954
More references!
[7] Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol. 2014;6:71-80. Published 2014 Feb 4. doi:10.2147/CLEP.S40245
[8] Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol. 2014;6:71-80. Published 2014 Feb 4. doi:10.2147/CLEP.S40245
[9] Rangan V, Ballou S, Shin A, Camilleri M; Beth Israel Deaconess Medical Center GI Motility Working Group, Lembo A. Use of Treatments for Irritable Bowel Syndrome and Patient Satisfaction Based on the IBS in America Survey. Gastroenterology. 2020;158(3):786-788.e1. doi:10.1053/j.gastro.2019.10.036
[10] Sorathia SJ, Chippa V, Rivas JM. Small Intestinal Bacterial Overgrowth. [Updated 2022 May 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546634/
[11] Takakura W, Pimentel M. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome – An Update. Front Psychiatry. 2020;11:664. Published 2020 Jul 10. doi:10.3389/fpsyt.2020.00664
[12] Syed K, Iswara K. Low-FODMAP Diet. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562224/
[13] 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;71:303-314. doi:10.1146/annurev-med-050218-013625
[14] Syed K, Iswara K. Low-FODMAP Diet. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562224/
[15] Davani-Davari D, Negahdaripour M, Karimzadeh I, et al. Prebiotics: Definition, Types, Sources, Mechanisms, and Clinical Applications. Foods. 2019;8(3):92. Published 2019 Mar 9. doi:10.3390/foods8030092
