New Science, New Thinking on IBS
Irritable Bowel Syndrome (IBS)
IBS is often a multi-year, remitting-relapsing functional bowel disorder with no known organic cause, characterized by symptoms of abdominal pain or discomfort, often associated with disturbed defecation, bloating, urgency of bowel movement, pain during defecation, gas and excessive mucus.
The Recent Thinking in IBS
The older thinking in the healthcare community was that IBS was primarily a psychosomatic condition. Later, this thinking evolved to the belief that the site of the disturbance in IBS was primarily in the colon. This understanding was based on the colon’s association with disrupted bowel movements and visceral sensitivity.
Recent thinking in IBS has been enabled by new tools such as confocal laser endomicroscopy1,2, staining of immune cells3, targeted biopsies4 and genotypic/phenotypic correlations. With the use of these new tools, it has been shown that, in addition to complex psychological and pain- perception cascades in IBS, gut barrier disruption and reversible, localized, often temporary, low-grade immune activation and gut microbiota dysbiosis – all occurring in the small intestine - are now also clearly associated with IBS.
In patients reporting bloating, it has been found that the small intestine is the region responsible for ineffective gas propulsion.5 Finally, in the last decade, it has been clarified that gut microbiota dysfunction in the small intestine adds to bloating because unwelcome bacteria give off gases (mainly hydrogen and methane) as they intercept nutrients and consume them before these nutrients can get to the intestinal wall.
The Distinctive Nutritional Requirements for People with IBS
Nutrient intake in IBS is disturbed because, due to distressful IBS symptoms, patients typically circumnavigate their regular diet. According to the American College of Gastroenterology IBS 2018 Monograph, 90% of IBS patients already exclude certain foods – thus setting up an altered nutritional intake.6
From a nutritional uptake point of view, the digestion and absorption of food nutrients is often disrupted in IBS in three ways. First, food moves too fast (diarrhea) or too slow (constipation) through the digestive tract – thus disturbing the normal residence time for uptake of nutrients. Second, the gut-mucosal barrier is disrupted and IBS-related intestinal malabsorption occurs. And third, invading, unwelcome bacteria in the small intestine (SIBO) compete with intestinal cells for nutrients. As these unwelcome bacteria consume nutrients, they also give off gases (especially hydrogen and methane) which add to IBS-related bloating. This SIBO also adds to IBS-related gut mucosal barrier disruption.
The possibility of nutritional deficiencies/imbalances can be reduced by building equilibrium (homeostasis) in the gut and by avoiding or reducing future IBS disruptions.
The degree and type of maldigestion and malabsorption of food nutrients depend on the individual, the type of IBS and the severity and the persistence of the condition. In IBS-related diarrhea, for instance, electrolyte loss can occur.
Regarding managing IBS with dietary modification alone, fiber is often recommended as first-line therapy but is not known to work reliably.6 As mentioned in an earlier answer, IBS-exclusionary diets are frequently resorted to but, long-term, they can lead to nutrient imbalances. They can also have a relatively low level of patient adherence.6 In 2015, a large study done on a common exclusionary diet did not separate from the control arm.7
The American College of Gastroenterology IBS 2018 Monograph6 was clear in its concerns about long-term dietary modification alone being sufficient to manage IBS.
IBS often manifests in patients not being able to absorb fructose, other food nutrients,8,9 and bile acid. IBS-related excess mucus and/or gas in the gut can interfere with nutrient absorption. Inappropriate activation of mast cells and T lymphocytes in the lamina propria10 part of the intestinal lining impair mucosal defense mechanisms.11
IBgard has anti-inflammatory12, antispasmodic13, visceral analgesic14, carminative (anti-gas)15 and antibacterial16,17 properties. The basis for each of these properties is well understood. For its antispasmodic property, for instance, peppermint oil, and especially its main constituent, l-Menthol show Ca2+ channel antagonism (calcium channel blocking) to enable intestinal smooth muscle relaxation. IBgard’s antispasmodic property may help with bile duct spasms, which affect bile flow for digestion purposes.18
Vitamin D is a nutritional deficiency that often occurs in IBS patients. According to one source, this deficiency was found in 8 out of 10 IBS patients versus 1 out of 4 in the general population.19 The importance of vitamin D has caused it to be a highlighted ingredient within “Nutrition Facts” in food labels.20 Vitamin D supplementation was evaluated in a trial with a vitamin D-deficient IBS population. The supplementation did not show a statistical separation in the symptoms in the two arms.21 In another study, megadoses (50,000 IU) of vitamin D every 2 weeks in an IBS population, showed favorable effects in some IBS symptoms, but not bowel symptoms.22
As mentioned earlier, the best way to manage IBS is to normalize the gut (gain homeostasis). This means a daily and proactive biopsychosocial approach that combines lifestyle improvements with daily and proactive gut calming agents. This approach would first calm the angry gut and then, with daily and proactive management, go on to fortify the gut so that equilibrium (homeostasis) is maintained.
As mentioned earlier, the intestinal disruption and malabsorption that results from IBS- related dysfunction manifests itself as activated IBS symptoms. Any intervention that reduces or eliminates these symptoms also helps with the reduction or even elimination of these dysfunctional cascades. Once the symptom comes close to or at equilibrium (homeostasis), then maintenance measures such as good biopsychosocial practices, along with the daily and proactive use of a gut calming agent such as IBgard, can help fortify the gut against the severity or frequency of future IBS flares.
IBgard’s good anti-inflammatory12, antispasmodic13, visceral analgesic14, carminative (anti-gas)15 and antibacterial16,17 properties all help support the transition to equilibrium (homeostasis) and then help maintain that equilibrium. Additionally, IBgard’s fiber and amino acids content, as well as its more distal delivery in the small intestine, also help toward achieving this equilibrium (homeostasis).
1Fritscher-Ravens A, Schuppan D, Ellrichmann M, et al. Confocal endomicroscopy shows food-associated changes in the intestinal mucosa of patients with irritable bowel syndrome. Gastroenterology. 2014;147(5):1012-1020.e3. doi:10.1053/j.gastro.2014.07.046.
2Holtmann GJ, Ford AC, Talley NJ. Pathophysiology of irritable bowel syndrome. Lancet Gastroenterol Hepatol. 2016;1(2):133-146. doi:10.1016/S2468-1253(16)30023-1.
3Vanheel H, Vicario M, Vanuytsel T, et al. Impaired duodenal mucosal integrity and low-grade inflammation in functional dyspepsia. Gut. 2014;63(2):262-271. doi:10.1136/gutjnl-2012-303857.
4Yantiss RK, Odze RD. Optimal approach to obtaining mucosal biopsies for assessment of inflammatory disorders of the gastrointestinal tract. Am J Gastroenterol. 2009;104(3):774-783. doi:10.1038/ajg.2008.108.
5Salvioli B, Serra J, Azpiroz F, et al. Origin of gas retention and symptoms in patients with bloating. Gastroenterology. 2005;128(3):574-579. doi:10.1053/j.gastro.2004.12.047.
6Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation. Am J Gastroenterol. 2018:S2-S26. doi:10.1038/ajg.2014.187.
7Böhn L, Störsrud S, Liljebo T, et al. Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome as Well as Traditional Dietary Advice: A Randomized Controlled Trial. Gastroenterology. 2015;149(6):1399-1407. doi:10.1053/j.gastro.2015.07.054.
8Niaz SK, Sandrasegaran K, Renny FH, Jones BJ. Postinfective diarrhoea and bile acid malabsorption. J R Coll Physicians Lond. 1997;31(1):53-56.
9Shepherd SJ, Gibson PR. Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management. J Am Diet Assoc. 2006;106(10):1631-1639. doi:10.1016/j.jada.2006.07.010.
10Drossman DA. Functional gastrointestinal disorders: History, pathophysiology, clinical features, and Rome IV. Gastroenterology. 2016;150(6):1262-1279e2. doi:10.1053/j.gastro.2016.02.032.
11Martínez C, González-Castro A, Vicario M, Santos J. Cellular and molecular basis of intestinal barrier dysfunction in the irritable bowel syndrome. Gut Liver. 2012;6(3):305-315. doi:10.5009/gnl.2012.6.3.305.
12Juergens U, Stober M, Vetter H. The anti-inflammatory activity of L-menthol compared to mint oil in human monocytes in vitro: a novel perspective for its therapeutic use in inflammatory diseases. Eur J Med Res. 1998;3(12):539-545.
13Hawthorn M, Ferrante J, Luchowski E, Rutledge A, Wei X, Triggle D. The actions of peppermint oil and menthol on calcium channel dependent processes in intestinal, neuronal and cardiac preparations. Aliment Pharmacol Ther. 1988;2:101-118.
14Liu B, Fan L, Balakrishna S, Sui A, Moris JB, Jordt S-E. TRPM8 is the Principal Mediator of Menthol-induced Analgesia of Acute and Inflammatory Pain. Pain. 2013;154(10):2169-2177. doi:10.1016/j.pain.2013.06.043.TRPM8.
15Harries N, James KC, Pugh WK. Antifoaming and carminative (anti-gas) actions of volatile oils. J Clin Pharm Ther. 1977;2(3):171-177.
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17Jeyakumar E, Lawrence R, Pal T. Comparative evaluation in the efficacy of peppermint (Mentha piperita) oil with standard antibiotics against selected bacterial pathogens. Asian Pac J Trop Biomed. 2011;1(SUPPL. 2). doi:10.1016/S2221-1691(11)60165-2.
18Blumenthal M, Busse W, Goldberg A, et al. Peppermint oil - Menthae piperitae aetheroleum. In: The Complete German Commision E Monogrpahs - Therapeutic Guide to Herbal Medicines. ; 1998:181.
19Locke T. IBS Linked to Low Vitamin D. https://www.webmd.com/ibs/news/20151222/ibs-low-vitamin-d. Published 2015.
20Levings J. The New Food Label: What RDs Need to Know. https://www.todaysdietitian.com/enewsletter/enews_0516_03.shtml.
21Tazzyman S, Richards N, Trueman AR, et al. Vitamin D associates with improved quality of life in participants with irritable bowel syndrome: outcomes from a pilot trial. BMJ open Gastroenterol. 2015;2:1-8. doi:10.1136/bmjgast-2015-000052.
22Abbasnezhad A, Amani R, Hajiani E, et al. Effect of vitamin D on gastrointestinal symptoms and health-related quality of life in irritable bowel syndrome patients: a randomized double-blind clinical trial Neurogastroenterology & Motility. Neurogastroenterol Motil. 2016;28:1533-1544. doi:10.1111/nmo.12851.