The Role Of Diet And Nutrition In Managing IBS (Irritable Bowel Syndrome)

Another characteristic and defining feature of IBS as per Rome iv criteria is recurrent abdominal pain more than four times per month for two months associated with defecation, change in stool frequency, and change in stool colour.

The IBS Diet plays a vital role in irritable bowel syndrome. Research Studies have shown a change in the gut mechanism when nutrients stimulate the receptors present in the gut. Several abnormalities are associated with the disease’s prognosis in irritable bowel syndrome. These include gut dysmotility, hypersensitivity in the gut, altered microbiota, increased intestinal permeability, and low-grade mucosa inflammation.

Inflammatory Bowel Syndrome Diet management is the driving force for regulating irritable bowel syndrome. Broadly, dietary management is split into two parts based on the approach or steps for improving the condition. The first line of approach is  IBS Diet management, and the second line of approach is the LOW FODMAP Diet.  

Dietary factors influencing irritable bowel syndrome include:

• Food intolerance.
• Food allergy.
• Poor absorption of some carbohydrates and fibres.
• Comorbidities of obesity with irritable bowel syndrome. 

As said, the approach for controlling the IBS through the IBS diet is divided into the first line & second line of approach. The first line of approach is managing diet and lifestyle as per guideline consensus. When the role of Food Allergy & Intolerance in IBS was studied, it showed IgE-mediated food allergy. This IgE-mediated reaction is missing in IBS. 

Research and studies have no evidence for this IgE-mediated reaction. Food intolerance is characterised as a non-toxic, non-immune mediated reaction to bioactive chemicals like Monosodium glutamate and sulphites, and the symptoms are extra-gastrointestinal. None of these kinds of symptoms is seen in IBS.

Typical recommendations for IBS are regular food intake patterns and limiting foods that may trigger IBS, like alcohol, spicy foods, caffeine and fat. Other lifestyle-related recommendations are physical exercises and staying hydrated. 

The primary or first line of approach for managing IBS 

1. Eating Habits

IBS Diet habits influence colonic motility and hence, its effect on IBS.

The recommendation as per scientific dietary guidelines and literature for eating habits in IBS are 

1. Establish a regular pattern for food consumption like breakfast, lunch and dinner, with snacks between meals. Avoid long gaps between eating, eating late at night and skipping meals.
2. IBS patients should give sufficient time for eating, eat slowly, chew thoroughly and avoid large meals.

2. Alcohol intake 

Alcohol influences gut motility, absorption and permeability. Concerning IBS, There are self-reported instances of alcohol consumption on IBS. So the recommendations as per scientific dietary guidelines and literature for alcohol consumption in IBS Diet is 

1. Alcohol intake levels should be assessed to see if the alteration in consumption level can alleviate the symptoms. 
2. Two alcohol-free days are recommended, and limited alcohol consumption is recommended.
3. The typical alcohol limits are one drink per day for women and two drinks per day for women. The drink can be defined as 12 oz of regular beer, 5 oz of wine, and 1.5 oz of 80-proof distilled spirit. 

3. Caffeine intake 

Coffee with low to medium concentrations of caffeine affects gastric acid secretion and colon motor activity in healthy individuals. The recommendation per scientific dietary guidelines and literature for caffeine consumption in IBS is 

1. The role of coffee in IBS patients has to be assessed first; then, coffee consumption should be controlled, i.e. 400 mg per day in all adults.
2. Limit the intake of products like tea, coffee, energy drinks, soft drinks, dark chocolates, and a few over-the-counter analgesics.

Read more- Does Coffee and Caffeine Cause Anxiety?

4. Spicy food consumption 

Several IBS patients have reported the relationship between spicy food and IBS symptoms(Spicy foods are IBS trigger foods). Spicy food influences Gastroesophageal reflux and abdominal pain. The recommendations per scientific dietary guidelines and literature for spicy food consumption in IBS Diet is

1. The role of spicy food should be assessed, and the intake of such food items should be controlled. 
2. The role of foods other than spicy hot foods like garlic should be appropriately assessed. 

5. Fat Intake

Many people have reported a significant role of fat in the IBS Diet. Avoiding fat-rich foods has shown a positive outcome on IBS. The duodenum lipid(fats) restricts the motility of the bowel (gut) motility, resulting in no gas clearance from the gut, bloating, and gas retention. The recommendation as per scientific dietary guidelines and literature for spicy food consumption in IBS are

1. According to FAO/WHO Recommendations, the total fat intake should range from 3o- 35% of total energy. 
2. The amount of fat intake should not be more than 40g/d. 

6. Dietary fibre intake 

The role of dietary fibre in IBS has changed with time. Earlier, it was believed that dietary fibre helps improve the symptoms of IBS. But later, the dietary fibre may exacerbate the IBS by increasing abdominal gas and motility, pain and cause distention. Hence, the recommendation as per scientific dietary guidelines and literature for dietary fibre consumption in IBS Diet is

1. A gradual increase of dietary fibre can be done to 20-30g/day. The intake of wheat bran should remain the same while managing IBS. 
2. Patients with a particular type of IBS can try consuming two tablespoons of linseed daily for a three months trial.
3. The linseed supplementation benefits, like GI improvements, may take up to 6 months. 

7. Milk and dietary products 

The symptoms of lactose intolerance are close to IBS. Lactose intolerance is due to indigestion of milk and related products. The gastrointestinal tract complaints include abdominal discomfort, bloating and loose stools. The recommendation as per scientific dietary guidelines and literature for milk and related dairy products consumption in the IBS diet is 

1. The patient’s positive lactogen breath test should only be advised of a low lactose diet, 
2. Patients with IBS should be informed of a lactose diet’s benefits/ risk ratio. 
3. In case of the absence of a positive lactogen breath test, a trial period of a lactose-less diet should be done to assess the effect of lactose on a diet in the case of IBS. 

8. Fluids intake 

The role of fluids in IBS is established unconventionally. Upon intake of water, up to 1.5 to 3 litres will increase the stool frequency and reduce the use of laxatives in a particular type of IBS. The recommendation as per scientific dietary guidelines and literature for liquids consumption in IBS is

1. Take 1.5 to 3 litres of water or any caffeine-free beverages 

9. Physical activity 

The recommendation as per scientific dietary guidelines and literature for physical activity in IBS are

1. Moderate physical activity, like yoga, walking, cycling, and swimming, for 30 minutes daily, five days a week or more, is recommended for IBS. 
2. Physical activity should be recommended based on the risk-to-benefit ratio influenced by the patient’s lifestyle. 

The secondary or second line of approach for managing IBS –  LOW FODMAP Diet 

The second line of approach is meant when the first line of approach does not meet the required levels of management in irritable bowel syndrome. The LOW FODMAP diet is primarily done to alleviate the IBS symptoms. 

LOW FODMAP Diet for IBS 

The low (fermentable oligosaccharides, disaccharides monosaccharides and polyols diet) FODMAP diet consists of a slow or poor absorbing set of short-chain fermentable carbohydrates. The foods rich in FODMAP are dairy products, apples, and stone fruits. The LOW FODMAP passes unabsorbed in the colon, draws water into the intestine and leads to gas production. It causes enlargement and GI symptoms, as seen in irritable bowel syndrome. It also affects the endocrine cells of the gut, there are odd numbers of endocrine cells in the gut, and the endocrine cells play an essential role in local immune defence, motility, absorption and appetite. Abnormalities in endocrine cells lead to symptoms which are similar to IBS. Such symptoms include visceral hypersensitivity, abnormal intestinal secretion, and dysmotility. 

LOW FODMAP is good in improving the overall symptoms of irritable bowel syndrome. The foods included in LOW FODMAP are wheat-free grains, wheat-free flour and products made from them, like bread and pasta. Spelt and spelt products like oats, quinoa, and rice. Legumes like canned chickpeas. Vegetables rich in LOW FODMAP are carrot, cucumber, potato, eggplant, lettuce, pumpkin, spring onion, tomato, zucchini, bamboo shoots, bok choy, choko, and choy sum. Milk-free products like almond milk, rice milk, lactose-free milk, hard cheeses, butter, ice cream substitutes, Fruits like banana, blueberry, grapefruit, honeydew melon, kiwi, lemon, lime, mandarin, orange, tangelo, raspberry, strawberry, pawpaw, star fruit, passion fruit, rockmelon, carambola, honey is substituted for maple syrup—sweeteners- sugars which do not end with ‘ol’, sugar, or glucose. Implementing a LOW FODMAP diet has helped nearly two-thirds of people suffering from IBS. 

The recommendations per scientific dietary guidelines and literature for physical activity in IBS Diet are

1. The LOW FODMAP IBS diet has to be tailored by a specialised dietician. 
2. This diet should not be followed for a long-term period. 
3. Three to four weeks are sufficient to elicit a response for IBS. 
4. If the four weeks are crossed, and no desired response is obtained from LOW FODMAP, then the therapy has to be discontinued, and a different therapeutic option has to be chosen. 

Gluten / Wheat intake in IBS 

When patients without any celiac disease or wheat allergy show response symptoms related to irritable bowel syndrome on ingestion of gluten. A new nomenclature is coined as non-celiac gluten sensitivity (NCGS). The recommendations per scientific dietary guidelines and literature for NCGS in IBS Diet are

1. When the patients are voluntarily willing to follow the NCGS diet, they should be informed about the conflicting use.
2. Patients should be warned of the detrimental effects of the NCGS diet. 

Read more- Gluten-Free Diet and its Benefits

Probiotics supplementation in Irritable bowel syndrome 

The recommendation as per scientific dietary guidelines and literature for probiotics in IBS are

1. Though few benefits of probiotics for IBS are known, the optimum dose, organism and other characteristics of probiotics should be decided well before indicating it in IBS.
2. One probiotic should be chosen at one time; only then should the other probiotic be given.
3. Probiotic supplements should not be taken until four weeks after the first one since the effect won’t be seen until then.

Conclusion

IBS Diet management is an essential tool for managing irritable bowel syndrome. Its success lies in systematic and scientific evidence for following these guidelines for framing the first line and second line of approach. The concepts and literature on the irritable food pyramid are another source & guide to managing irritable bowel syndrome. 

References 

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467063/
• https://www.gastrojournal.org/article/S0016-5085(21)04084-1/fulltext
• https://nutritionj.biomedcentral.com/articles/10.1186/s12937-015-0022-3