A written Guide for how to manage your symptoms
Written by Holly Baxter APD, BS, MS
April 13, 2021
What is IBS / What are the causes and How to manage your symptoms?
IBS is the abbreviation for Irritable Bowel Syndrome, which is a fairly common disorder or dysfunction which affects the large intestine.
The signs and symptoms of IBS can vary in severity and will also differ between people. The most common symptoms of IBS include things like cramping, abdominal pain, bloating, gas, diarrhea or constipation, or sometimes both. IBS is considered a chronic condition, so by definition this means it has been present for more than 1 year, so if you experience these types of symptoms but only on very rare occasions, then it’s unlikely that you have a true case of IBS as the infrequency doesn’t meet the prerequisites for a formal diagnosis.
What causes IBS?
The exact cause of IBS isn’t known. There are however a number of factors that appear to play a role including:
Increased gut motility.The walls of the intestines are lined with layers of muscle that contract as they move food through your digestive tract. Contractions that are stronger and last longer than normal (also known as a hyperactive gut) can cause excess gas, bloating as well as diarrhea. On the flip side, weak intestinal contractions (I call this a sluggish GI which is what I have) means the passage of food is significantly reduced and this can lead to hard, or often dry stools.
Dysfunction of the Nervous system. Dysfunction or sensitivity of the nerves in your digestive system may cause you to experience greater than normal discomfort when your abdomen stretches from either gas or large amounts of food. Poorly coordinated signals between the brain and the intestines can also cause your body to overreact to changes that occur as a normal part of the digestive process, and this results in pain, diarrhea or constipation. We often hear people referred to the gut brain axis, so people with IBS can be hypersensitive to these small changes due to the neurological connection between the brain and the gut.
Have you had a severe infection? IBS can also develop after a severe infections or even a bad case of diarrhea (gastroenteritis) caused by bacteria or a virus. IBS may also be associated with a bacterial overgrowth in the intestines which is why it is often recommended to have a stool sample during the investigation phase of IBS.
Changes in gut microbes. Who has recently taken an antibiotic? While highly effective for reducing pathogenic bacteria, antibiotics can also wipe out many of the good microbes in our gut. Sudden changes to our bacteria, fungi and viruses naturally present in our GI may be linked to IBS. Even the way we were delivered at birth might be a potential cause for the development of IBS in later life due to its influence on our gut microbiome. Interestingly research has shown there to be significant differences in the gut microflora of people who are delivered by vaginal birth and those who are delivered by cesarean birth. We also know that the gut microbes in people with IBS often differ from those in healthy people.
Early life stress. People who have been exposed to stressful events, especially in childhood, also tend to report more symptoms of IBS.
What are the IBS Subtypes?
There are 4 different subtypes of IBS, and these include IBS-C, IBS-D, IBS-M, IBS-U. IBS C is predominately constipation. IBS D is predominantly diarrhea or very loose stools. IBS M is mixed, meaning both constipation and diarrhea might be present. IBS-U means undiagnosed, which is typically only diagnosed if someone presents as having IBS but the subtype is not formally diagnosed.
Who can help you diagnose IBS?
A dietitian or gastroenterologist are the two best medical professionals who can help you determine which of these subtypes best describes your symptoms and provide you with a formal diagnosis. Something you can do prior to your appointment with your health care professional is to monitor and record your daily bowel movements, and you can do this with a bristol stool chart.
What should my stools look like?
The type of stool depends on the time it spends in the colon. After you go to the bathroom, what you see is basically a result of your diet, fluid, medication and lifestyle. This chart shows seven categories of stools. Every person will have different bowel habits, however a normal stool should be soft and easy to pass like types 3 and 4 shown on the chart. Type 1 and 2 indicate constipation while types 5-7 may indicate diarrhoea. Once we know what subtype we are dealing with, it becomes much easier to manage your symptoms.
How frequently should I be going to the bathroom ?
We often hear the expression ‘eat this or drink that and it will keep you regular’, but what is regular? And how do we define normal?. It’s common for people to empty their bowl once a day, although it’s still normal if you are more or less frequent. What’s most important is the type and ease in which your stool passes, and this can happen anywhere from 1-3 times per day or as infrequently as 3 times per week. To be given a formal diagnosis of IBS-C, which is constipation predominant, by definition you would be averaging less than 3 stools per week. For a diagnosis of IBS-D subtype, you would be experiencing a bathroom trip frequency of greater than 3 times per day.
What are some signs of a healthy bowel?
Being regular is one thing, (great work if you are!) but some other signs your have a healthy GI are:
- You can hold on for a short time after you feel the first urge to go to the toilet. You should also be able to pass within about a minute of sitting down on the toilet.
- You should be able to pass a bowel motion easily without pain, you shouldn’t be straining or struggling to pass anything that is hard and dry.
- You should also be able to completely empty your bowel when you pass a motion. You shouldn’t be running back to the toilet soon after to go again.
So how do we treat IBS?
I like to think of this as a 2 tiered approach where we have a first line advice and a second line advice.
First line advice
There are a number of food and beverages as well as eating behaviours that can cause IBS symptoms to be more exaggerated.
- Daily Fluid Consumption
- Speed of Eating & Meal Timing
How is your Daily Fluid intake? Drinking a sufficient amount of water each day is not only important for reducing the risk of chronic disease, for example, having a high fluid intake is associated with a reduced risk of chronic kidney disease, but can also help relieve constipation. Water not only acts as a lubricant for the intestines so they remain soft and flexible, but to help the food we eat travel through your GI tract. Low fluid intake or irregular fluid intake, such as going without fluid for large periods of time, can lead to hard stools and eventually this becomes constipation. If you are someone with IBS-C, make sure you are drinking a sufficient amount of water and regularly throughout the day. If you are wondering how much? The recommended amount of fluid is 35ml / kg body weight, however if you sweat a lot throughout the day, or maybe you work outdoors or you train in high temperatures, you may need to consume significantly more than this.
Alcohol can be another problem for IBS sufferers and can rather be unfavorable for both IBS-D and IBS-C subtypes. Like caffeine, alcohol also increases gut motility. This gut hyperactivity causes foods to move through the GI too quickly and this often results in diarrhea. Large amounts of alcohol can also kill the natural gut microflora present in our GI, which can cause a bacterial overgrowth which can also lead to loose stools. Consuming too much alcohol can also cause constipation if you aren’t also consuming a good amount of fluid when you’re drinking. Alcohol reduces the secretion of ADH, a hormone that signals the body to retain water. Low levels of ADH leads to increased urine production, so if the fluid excreted isn’t replaced, it can contribute to constipation as the body needs water for stool to move normally through our GI.
Eating slowly and eating regularly may seem like very simple words of advice, however studies have shown that people with IBS report more exaggerated GI symptoms when a meal is consumed too quickly or when their meal timing is irregular. If you know you eat too fast or skip meals, try slowing down when you eat and try to evenly time your meals to avoid large volumes of food being consumed in one sitting, these simple changes may drastically improve your symptoms.
Second Line Advice
Beyond these simple strategies, we can now look to other potential approaches to reduce frequency and severity of symptom flare ups.
- Diet (Fodmaps & Fiber)
- Medication and counselling
Fiber is another highly important part of the dietary approach used to help manage IBS. Fiber might just be one of the missing puzzle pieces in the case of someone with IBS-D, as it can help to provide bulk to your stool, however, for someone with IBS-C, too much fiber or the wrong type of dietary fiber may actually worsen symptoms. This is why it’s so important to know your subtype, to help best manage your symptoms.
Fiber is typically found in plant based foods, specifically fruits, vegetables, nuts and seeds as well as whole grains and legumes. It is recommended that we consume on average 25-30g per day (3).
Dietary fibers are a specific type of carbohydrate known as oligosaccharides and non starch polysaccharides which are unable to be broken down in the small intestine, so instead, they travel undigested to the large colon. There are two types of dietary fiber, soluble fiber and insoluble fiber, and they each have an important role to play for our digestive health.
Soluble fibers include things like pectins, gums, inulin type fructans and some hemicelluloses, you’ll often see these listen on the labels of packaged foods, and these fibers are able to absorb large amounts of water which form a thick viscous gel. Since they are unabsorbed in the small intestine, soluble fiber is more easily fermented by our gut microflora which is one of the reasons we produce gas, as well as short chain fatty acids called acetic, propionic and butyric acid which can be reabsorbed and ultimately used for energy (4).
Insoluble fibers do not absorb water and include things like lignin, cellulose and some hemicelluloses. Most of the foods we consume are about a third soluble and two thirds insoluble (4). Both types of fiber are important for a healthy digestions as insoluble adds bulk to our stool and soluble draws in water and makes it easy for us to go to the bathroom.
How can fiber help those with IBS
For those who have IBS-C subtype, including more soluble fiber in the diet will increase the amount of water in the GI which can help speed up your transit time, and allow you to go to the bathroom more regularly. Something to consider is that different types and amounts of fiber can affect people differently, so for this reason, I recommend increasing your fiber very gradually ~3-5g every few days until you find an amount that helps you become more regular. For someone with IBS-D, they may require more insoluble fiber to help provide bulk to their stool and can help to slow down digestion and reduce the frequency of loose stools and diarrhea.
Diet & Fodmaps
Fodmaps is an acronym that stands for fermentable oligosaccharide, disaccharides, monosaccharides and polyols. Eliminating certain Fodmaps from the diet can be another effective management option for people suffering from IBS (5). This is huge topic and worthy of an entire series of its own, so if you want to learn more about fodmaps, there is a link to an article on my website as well as a video on my youtube channel which covers this topic in more detail.
Why is exercise important in the management of IBS? Low activity levels have frequently been reported to worsen IBS symptoms. The reason for this is thought to be due exercises’ effect on gut motility and transit time. A clinical trial in patients with IBS found that 12-weeks of regular moderate activity significantly improved gastrointestinal symptoms and quality of life (6). Other studies have found that participation in regular exercise has been shown to help to relieve pain and bloating caused by gas and may encourage more frequent bowel movements (7).
Lastly, exercise has also been linked to reducing stress which is a huge trigger for IBS as I mentioned earlier. Things like yoga & meditation, as well as getting outdoors and being in nature have also been reported to help with stress relief and in turn reduce IBS symptoms (8), so the moral of this story is if you suffer from IBS and you aren’t exercising regularly or if you are under alot of stress or you spend a significant amount of time indoors and you’re seated for long periods of time (like me), it may be a good idea to get up, get outside and move more!
The final option is medication, and this is typically only considered once all these strategies Ive talked about today have been trialled for several months with limited success are medications. The most common medication used to manage IBS symptoms are laxatives, and these can either help to stimulate the gut or help draw water into the GI and soften the stool. For IBS-D antispasmodics may be prescribed and these can help relieve cramps and relax the smooth muscles of the gut. Another medication is the use of a low dose antidepressant. Like I spoke about before, the gut has lots of nerve endings and are in constant communication with our brain, so if you suffer from anxiety or are under alot of stress, this can affect the messages your brain sends to your gut. Antidepressants have been shown to help reduce that messaging and can provide some relief of symptoms. Additionally, hypnotherapy has also been used in clinical trials for helping reduce symptoms of IBS. Now I do want to reiterate that medications should only be considered if you have tried all of the previous first line and second line approaches, for several months with minimal improvement.
As you’ve come to learn, there is no cure or treatment and there is no one magic solution that helps everyone manage the symptoms of IBS. How we address this is very much an individualised approach, and as we’ve discussed today, there are several strategies you can use that have been shown to help improve your symptoms for different IBS subtypes.
As someone who personally suffers from IBS, for me, learning my subtype and understanding what areas needed to change, have made a huge impact on my overall quality of life. I now know what causes my symptoms, so IBS is at large, under my control. This doesn’t mean I’m completely pain free or that there aren’t times where I’ve eaten too quickly, or have ordered a meal at a restaurant that contains one of my known fodmaps, but for the most part, I know what makes my symptoms worse, and now it’s a choice to avoid them.
I hope this was helpful for you, and if you know someone who would benefit from this information, please share it with them or check out my Youtube Video on this topic! No one has to live in pain and by simply investing some time into monitoring your symptoms, learning your subtype, and committing to a few small changes, can drastically improve your quality of life.