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Gut Reactions: Do You Have IBS?

Though it's not a topic for cocktail-party conversation, at any given gathering, a handful of smiling, drink-in-hand guests are likely suffering from irritable bowel syndrome -- which may have led even more people to send their regrets and stay home.

To the 30 million Americans afflicted with IBS, those bowels can seem not just irritable but downright cranky. With symptoms such as chronic diarrhea, constipation, and bloating, the condition is painful, embarrassing, and often debilitating. In a given workweek, a person with IBS may lose 14 hours of productivity. 

Women -- lucky us -- suffer from it disproportionately, making up some 60 to 65 percent of reported cases.

If it seems half your friends have IBS, you may not be that far off; experts estimate that up to 20 percent of the population is actually suffering from the condition. Whether the actual incidence of IBS has increased in recent years is unknown, however. 

It may be that "there's more awareness of it," says Christine Frissora, M.D., a gastroenterologist at Weill Cornell Medical College in New York City. IBS is still considered a syndrome (as opposed to a disease), so as with other syndromes -- think chronic fatigue -- there's no single known cause, definitive test, or official cure; it's defined by the long-term presence of certain symptoms and the absence of more serious conditions. 

Research has been homing in on underlying causes, though, including what and how we eat (often poorly and mindlessly), our stress levels (high for many), food-borne illness (on the rise), and the use of certain medications (commonly overprescribed). 

"Restoring balance is key to IBS," explains Gerard Mullin, M.D., director of Integrative Gastroenterology Nutrition Services at Johns Hopkins Hospital in Baltimore, "and we're out of balance."

Like most complex conditions, IBS doesn't lend itself to a quick fix. But a holistic approach -- looking deeper and treating root causes -- can bring health to far more than your gut.

Fire in the Belly
The calling cards of IBS are abdominal pain, bloating, constipation, cramping, and diarrhea, Frissora says. We all get these on occasion, of course; to merit an IBS diagnosis, you need to have some combination of the symptoms for a total of 12 (not necessarily consecutive) weeks within 12 months -- and not have a more serious intestinal condition, such as an inflammatory bowel disease. 

While pain is a common denominator, "if you have 10 different patients, you'll have 10 different sets of symptoms," notes Dave Rakel, M.D., director of the Integrative Medicine program at the University of Wisconsin.

What gives rise to these symptoms? Keeping in mind that IBS manifests differently in different people, imagine a GI cam that zooms in on one particular woman with the condition. 

Deep down in her body, the normal processes that keep her digestion running smoothly have broken down, including the balance of healthy bacteria. "We're learning that the gut has its own ecosystem, and there's a very dynamic balance between the different flora," Rakel notes. 

She may have low-grade chronic inflammation in her digestive tract and intestinal permeability, in which toxins and pathogens penetrate the normally protective intestinal wall. The causes of that breakdown of normal digestion can be everything from chronic stress to infection, certain medications, food allergies, or all of the above. Once set in motion, this cascade of reactions becomes self-perpetuating -- not to mention misery-making.

Common Culprits
A number of forces can set the stage for, trigger, and exacerbate IBS, and it's often impossible to tease those factors apart. The dismal standard American diet and sedentary way of life "is a root cause of most digestive disorders," including IBS, Mullin says. Food sensitivities (like to dairy or wheat) and allergies (such as to shellfish or nuts) can also play a role.

Infections, such as those from bacteria like salmonella or E. coli, are yet another frequent trigger. And certain medications can actually lead to IBS, including antibiotics, some birth-control pills, and, ironically, commonly prescribed drugs for another digestive complaint. According to Rakel, long-term use of proton-pump inhibitors, which are used to treat heartburn and acid reflux, "can reduce stomach acid and disrupt the balance of the GI ecosystem," exacerbating symptoms of IBS.

According to both Rakel and Mullin, stress is nearly always a factor in IBS -- not occasional stress, but the kind that lingers for months or years and wears you down. The connection between emotions and digestion isn't new, of course; the notion of a "nervous stomach" has been around forever. But the mechanisms behind the connection -- and, moreover, mind-body-related treatments -- are one of the hottest areas of research in digestive disorders such as IBS. 

"The GI tract is often called a 'second brain,' " Mullin notes. The same neurotransmitters present in the brain, like serotonin, are abundant in the intestinal tract and in the vagus nerve, which directly connects the mind and the digestive system. Think of it as an information superhighway running straight from the gut to the brain. 

"When you get nervous, stress hormones shut down [the functioning of] your gut," Mullin says. "Your blood and digestive hormones stop mobilizing. Essentially, your gut freezes." 

In this classic fight-or-flight response, resources get routed to the extremities. When this happens on occasion (at, say, a public-speaking event), it might give you a stomachache but doesn't do long-term damage. However, unrelenting stress causes a shift in GI bacteria -- from the friendly to the unfriendly bugs -- and can even weaken the gut's ability to defend itself against harmful molecules and toxins, Mullin notes. "The brick wall of defenses [that normally keeps your gut functioning properly] breaks down under chronic stress."

Given that most of these are equal-opportunity triggers, why do women bear the brunt of IBS? Biologically, we have more developed limbic systems (the brain area that governs emotion), Rakel says. This may impart laudable qualities -- compassion, sensitivity, intuition -- but it also makes us more vulnerable to stress. In other words, the same forces that make our shoulders such comfortable crying posts also make our intestines more sensitive and prone to dysfunction.

Treatment Essentials
If you have symptoms that sound like IBS, the first step is to get a doctor to rule out what you don't have. It's important to find a practitioner who's willing to investigate symptoms and tailor a treatment to you rather than jump to an IBS diagnosis. Many patients walk around for years thinking they have IBS, and lo and behold, a condition like celiac disease (severe gluten allergy) or inflammatory bowel disease (Crohn's disease) eventually "unmasks itself," Mullin notes. The problem, he says, is that many doctors "only look for serious dysfunctions when there are red-flag symptoms," like rectal bleeding.

Given the complexity of IBS, it's not surprising that researchers haven't found a magic pill to make it go away. 

"Many drugs have been approved and many taken off the market due to side effects," Rakel says. And while there are FDA-approved medications for certain symptoms, like constipation, the cost-benefit ratio is often high, he says. "They're very expensive and only work so-so." Granted, we live in a society that doesn't encourage the balance and harmony that are required for IBS treatments, but at some point, Mullin says, "We sort of have to forget about society and rebalance ourselves."

Tummy Tamers
The conventional notion is that there's no cure for IBS, but Rakel has seen evidence to the contrary. "You can learn from your symptoms -- why they're there and what you can do to manage them -- and reduce your gut's sensitivity to reactivity," he says. "So in essence, it is curable." While everyone's treatment will vary based on their history and symptoms, work with a holistic practitioner, and keep these principles in mind.

1. Refine your diet. Following a plant-based, whole-foods diet is a given. But once the IBS process has begun, even healthy foods can trigger reactions. Choose cooked vegetables rather than raw, Frissora says, since they're easier to digest. And while soluble fiber (found in oatmeal, berries, carrots, and legumes) can help your digestion, insoluble fiber (potato and other vegetable skins) may worsen symptoms, she adds. It's also a good idea to reduce or eliminate caffeine and alcohol. Ferret out any food sensitivities or allergies by slowly eliminating common allergens and irritants like wheat, dairy, shellfish, nuts, and beef from your diet and see how you feel.

2. Rebalance your gut. Cutting-edge research on IBS points to the importance of maintaining a healthy balance of flora in your GI tract. Improving your diet will help restore this equilibrium, particularly if you include fermented foods like organic yogurt or miso; managing stress also helps. A probiotic supplement may be in order, too. Bifidum bacterium has shown some promise in studies, but you and your practitioner may need to do some trial and error to find what works. More strains will become commercially available as the research develops. "We only know a few, but there are thousands," Rakel says.

3. Exercise in moderation. Depending on your symptoms, your exercise habits may need an adjustment, Rakel says. Gentle exercise, such as walking and yoga, can help nearly everyone with IBS: It relieves stress and reduces inflammation. Those with constipation-dominant IBS may benefit from turning up their fitness routine, and diarrhea-prone patients should limit aerobic activity to less than 45 minutes, Mullin adds.

4. Master your mind-body connection. Rakel advises his patients to think of IBS as a metaphor: What's tying you up in knots? Answering that question can help to ease your mind and, by extension, your gut. "Use a mindful approach to become more aware of what's happening in your day, what your stressors are," he says. Simple stress-busting techniques like deep breathing stimulate the vagus nerve, that gut-brain superhighway. There's also solid data to support the benefits of hypnosis, meditation, biofeedback, and yoga for IBS, Mullin says. "It's really about finding what you're willing to do and what you enjoy."

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