IBS: The Myths, The Facts, and How You Can Fix It Today

Do you have IBS? If you are feeling discomfort, or undergoing tests in hopes of finding an explanation to your digestive symptoms, there could be an easy answer.

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Is Small Intestinal Bacterial Overgrowth (SIBO) Real?

In a recent article about SIBO, I cited evidence which proved that hydrogen and methane breath tests do not measure SIBO activity. I noted that diets and treatments that strive to reduce bacterial counts are less effective than placebo treatments.

The hypothesis that an overgrowth of bacteria in the small intestine is the cause for digestive symptoms in some people. And, that by reducing these bacteria we can improve their symptoms, is a failed hypothesis. In short, SIBO is not real.

The natural follow up question becomes: what to do for a SIBO diagnosis or ongoing digestive symptoms?

If you were diagnosed with SIBO but do not have digestive symptoms, you do not need to do anything. You can safely disregard the diagnosis, since up to 40% of healthy people will falsely test positive for SIBO.

Researchers made the SIBO hypothesis because they were trying to find a cause behind symptoms like:

• Gas
• Bloating
• Abdominal pain
• Irregular stools

In the absence of an explanation, we call these symptoms Irritable Bowel Syndrome (IBS). If we move past SIBO, we can start to identify exactly what constitutes IBS and how you can effectively treat it.

What is IBS?

IBS is a combination of abdominal pain, abnormal stools, and bloating. Syndrome, implies that this condition is a collection of symptoms lacking a singular cause.

The first established pattern of symptoms to define IBS was the “Manning criteria,” codified in 1978. It included:

• Pain relief with defecation (often)
• Loose stool at pain onset (often)
• More frequent stools at pain onset (often)
• Visible abdominal distention
• Mucus per rectum
• Feeling of incomplete evacuation

The current symptom pattern used to diagnose IBS is the “Rome criteria.” Four consecutive panels of researchers and gastroenterologists have met to review evidence and update these criteria.

The latest was the Rome IV meeting in May 2016 from which we have the Rome IV criteria. This includes:

• Recurring abdominal pain. On average equal to or greater than or one day per week in the last three months, and related to two or more of pain related to:
  • Defecation
  • Change in stool frequency
  • Change in stool form

Based on the frequency of hard stools and loose stools, the Rome IV criteria defines the following versions of IBS:

• C – Predominantly constipation
• D – Predominately diarrhea
• M – Mixed constipation and diarrhea
• U – Unsubtyped. This pattern does have symptoms but neither constipation or diarrhea greater than 25% of the time.

How common is IBS?

The rates of IBS vary greatly, based on geography.

In some parts of the world, only 1.1% of the population has it.

That said, in other areas it can often be as high a 45%. In the United States and Europe, rates range from 5%–10%.²

Who Gets IBS?

Both genders get it, but the condition is more common in women than men. Those who have had early life trauma are also more at risk.

IBS is more common with age, but it is rare for it to first appear after 50 years. ⁴

What Causes IBS?

There is no clear cause.

Until recently, IBS was categorized as a functional disorder. Unrelated to the term “functional medicine,” functional disorders are defined as conditions in which there is altered function – something does not work right, but there is no apparent change in structure or chemistry.

Functional disorders are often stigmatized as being made up or psychosomatic. In 2016 researchers revised IBS from functional disorder to disorder of gut-brain interaction (DGBI.)

Once this problematic view is generally embraced, it seems that one of two paths follow:

1. Those with an internal sense of control may feel that this idea is silly. Of course, it’s a real condition because they have real symptoms. They lose respect for those who purport this view, and seek solutions that make intuitive sense (like a change in diet). They also become opposed to treatment approaches like cognitive behavioral therapy or hypnotherapy because they affirm what seems to them to be a self-deprecating idea.
2. Those with an external sense of control may believe that the idea is true, and it reaffirms their self-doubts. They may lose any remaining hope and deepen any existing negative views about themselves.

The Mind-Body Approach

Mind-body approaches work not because one is naive or uneducated, but because the brain and the gut connect in powerful ways we are just beginning to understand.

Those who have IBS have higher rates of other functional disorders, also called somatic disorders since they relate to the somatic nervous system – brain and conscious activity. ⁶

Apart from the Rome IV patterns, another version of IBS is known as post-infectious IBS (PI-IBS). This lasting response happens to about 10% of patients after infectious gastroenteritis.

It seems that inflammation and changes in the nerve activity in the bowels disrupt the flora in ways that lead to lasting symptoms.

The specific flora changes associated with PI-IBS include:

• Overgrowth of bad bacteria (such as enterobacteriaceae, veillonella, streptococcus, dorea, blautia, roseburia, ruminococcus, methanobrevibacter)
• Deficiency of protective bacteria (such as bifidobacterium, collinsella, faecalibacterium, christensenellaceae (yay! I’m so glad it is a good bug!), clostridiales, methanobrevibacter)

The changes in flora inhibit the production of short-chain fatty acids. This lack of protective short chain fats, like butyrate, is harmful to the intestines as well as to the whole body.

In PI-IBS the nerves that carry pain signals from the gut to the brain are more active than typical. PI-IBS is also distinct in that it is a structural disease with measurable changes in the intestinal tract. ⁸

How is IBS diagnosed?

First, one must rule out other causes of digestive symptoms and evaluate for Inflammatory Bowel Disease (IBD) like ulcerative colitis and Crohn’s disease.

Do you happen to have any of these “alarm symptoms”? These include:

• Unexplained weight loss
• Waking at night with abdominal pain
• Fever
• Blood in stool

History is also a vital component. As it pertains to these symptoms, have you noticed that?

• New symptoms that are getting worse
• Symptoms have started after age 50
• Symptoms have begun after recent antibiotic use
• You have a family history of colon cancer before age 50 or IBS
• You have physical findings (like an abdominal mass, hidden blood in the stool, or swollen lymph nodes)

Can You Test Without Symptoms?

If you do not have any alarm symptoms there are no specific tests for IBS, although many are in development.

In other cases, routine testing is appropriate to rule out immune diseases, hidden inflammation, thyroid disease, celiac disease, imbalances in the bowel flora, and food allergies.

It is also worth screening for celiac disease because about 1% of the general population has celiac disease. In those that have IBS, the rate is higher, closer to 3%.⁹

A suggested minimal panel of tests for those who have IBS would include:

• CBC
• CRP
• Thyroid Panel
• Celiac Antibodies
• Stool Microbiology
• Food Intolerances

If you do have IBS-D or PI-IBS, it is worth having stool cultures to rule out clostridium infections. In the case of IBS-C, it is also important to rule out dyssynergic defecation.

Many people have abnormal nerve responses that tighten their rectum when they attempt to have bowel movements.

This response can lead to many IBS symptoms, but is distinct from IBS.¹⁰ If you suspect this condition, most gastroenterologists can diagnose it with a simple physical exam.

What Are Treatments For IBS

For decades, researchers saw an unusual pattern with IBS treatments. Many would work for brief periods of time and then stop.

The more often the participant visited the clinician, the better the treatment worked.

Also, treatments and diets that were based on opposing mechanisms seemed to work equally well.

Placebos and IBS

Placebo means ‘I please’ and can be a medication, diet, or treatment that has no biological effect, but results in improving symptoms.

As soon as placebo-controlled studies became routine, it seemed that IBS responded to placebos about 50-70% of the time.

In the recent 10-15 years, the rate has dropped off. It seems that participants in studies often connect via social media and are able to figure out before the study is over who is on the placebo and who is not.

Surprisingly placebo treatments also work nearly as well in Inflammatory Bowel Disease as they do in IBS. When it comes to digestive symptoms, placebos do not work better on one gender than another.

There is also no clear pattern with age. Intelligence and educational levels do not predict placebo responses either way.

There is at least one genetic link. Those with catecholamine – o – methyltransferase variations (COMPT) do tend to respond better to placebos.

Nocebo and Digestive Symptoms

Something that I feel is understudied is the role of nocebo on digestive symptoms. Nocebo means ‘I harm.’ It seems that those with IBS are more apt to have side effects (nocebo reactions) to placebos than others.¹²

The interplay between placebos and nocebos can be bizarre. In one study, people with known food allergies were told that they were given an infusion of a low-dose version of the food which causes them to react.

Truthfully, they were given harmless saline, but many had allergic symptoms. During a follow-up procedure, they were given another infusion told that it was an antihistamine and it would block their symptoms. They got better despite the fact that the second infusion was also saline.

It is easy to think of people as gullible, but real changes happen. In another study, those with IBS were given antispasmodic medication which normally acts as a sedative. One group was falsely told that the antispasmodic was a stimulant. Not only did this group have stimulant side effects like anxiety and a racing heart, they had lower blood levels of the medication than those who were told what it really was.

A Personal Case Study

I remember one of my first forays into natural medicine. It was a book that claimed that combining carbohydrates and proteins in one meal would lead to digestive distress and eventual poor health.

Once I was enlightened about this effect, I noticed that I felt genuinely unwell when I did not heed the advice. I experienced a nocebo reaction. I now understand how digestion works and know that there is no truth behind this claim.

This first step put me on a path of fear and unease. I read countless books and the more possible reactions I learned about, the more I seemed to suffer from.

Often the diets I followed were far too restrictive in calories and nutrients for a physically active young man.

As my health declined I went into a spiral of fatigue, depression, and paranoia about food. It was only years later that I realized that these symptoms were not present until I expected them to be.

At the low point of that journey, I contorted my life to abide by numerous, contradictory rules in hopes of feeling better I.

• Ate only once daily
• Only ate raw vegetables
• Carefully balanced the ‘yin and yang’ of my foods
• Never ate past 3 pm
• Avoided ‘low-water-content’ foods
• Adjusted my food choices based on the pH of my urine

The Extenuating Factors

During this process I attended college on a full-time basis, studying pre-medical sciences and worked over 30 hours per week to pay for my school and expenses.

The irony is that the best paying job I could find was that as a waiter in a pizza restaurant. I spent each moment of every shift in constant loathing of the ‘bad’ food around me and in judgment of the ignorant souls who ate it.

If that’s not enough of a perfect storm, I was also running about 5-10 miles each day outdoors in Northern Minnesota.

In case you didn’t know, raw salads do not help you adapt to -40 temperatures. My weight kept dropping, I was miserable, and my food cravings were off the charts.

The books I read convinced me that I was clearly toxic. I must have been losing weight because my gut was toxic, and I wasn’t absorbing nutrients. The cravings were clear signs that something I was eating was setting me off. If only I could clean myself out better, then everything would fall into place.

I’ve seen far too many people fall into the same trap. I think that at some point the dietary restriction leads to a real compromise in the capacity of the digestive tract. One can go from fear of foods and an exaggerated experience of symptoms to a place where malnourishment leads to damage.

Diets and IBS

There are those with undiagnosed celiac disease, or food allergies. Those are different stories. For those without clear food reactions – many people who change their diets do feel that their digestion improves.

It seems that diets help and for many, they do – at least for a while.

To date, no diet has helped IBS better than placebos.¹³

• Gluten free
• Low fodmap
• Specific Carbohydrate Diet
• Paleo diet (Read: Is the paleo diet really paleo?)
• Autoimmune paleo diet
• Vegan diet

It seems so intuitive that if you have digestive symptoms, it must be caused by what you ate. Especially when symptoms often come on in short periods of time after meals and are often much better long periods of time after eating.

Let’s think about a car analogy for a moment.

There are scenarios in which poor quality gas that makes the car run badly. Yet there are also nearly limitless ways the car can go wrong that have nothing to do with the quality of the gas.

If a car has a problem with its electrical system, it would seem to only be a problem when the car was running. You’d never notice any issues when it was shut off. So too it is with the digestive system. If something is wrong, you would be less likely to notice anything when it was not busy digesting food even if the food were not the culprit.

If you are lucky enough to have found that one of these diets has given you lasting relief from IBS. Please don’t change. The question I’m trying to answer is – for those who have not yet found relief, what is most likely to work with the least trial and error.

Food Choices To Help IBS

Here are some of the food choices that I recommend, which may consistently help with IBS:

• Avoid foods that trigger immediate symptoms. It is worth questioning reactions that seem to come and go, since IBS symptoms are known to fluctuate without a clear pattern. This can often make it maddening to try to tie them to the last meal. Many who assume that a recent food caused their symptoms end up frustrated, and confused, because there is no clear pattern as to which foods did it.
• Eat meals at consistent times. IBS is a disease of gut peristalsis, and one’s eating schedule is one of the factors that regulate peristalsis. That’s why we think about food at similar times each day, even when we aren’t particularly hungry. If your intestinal nerves can predict when food will arrive, they’ll be less apt to make the errors that lead to IBS.
• Stay clear of high-fat diets. It seems that the more fat in the intestinal tract, the more nerves are prone to overreport pain signals to the brain. Polyunsaturated fats may be a special case since they are less easily converted into the types of prostaglandins that produce inflammatory pain signals.¹⁴ Since high-fat diets are usually low in fiber, it is also worth considering whether too much fat is to blame or too little fiber.

Specific Liquids to Avoid

• Prevent excessive caffeine. Caffeine is an acid and it also has a direct effect stimulating the nerves of the intestinal tract. Many notice that they have a full bowel movement soon after coffee intake because of this effect. Those with IBS may find that the nerve stimulation leads to more gas and bloating, even many hours later. The best way to see if caffeine is a culprit is to avoid it for a block of two weeks and see if symptoms reduce.
• Keep away from high amounts of carbonated water. I love fizzy water and sparkling water but many with IBS do not effectively burp up the carbonation. The extra gas creates pressure in the intestines and can trigger a cycle of bloating and discomfort.

Strategies to Help IBS

• Stay hydrated. Those who are even a few percent below ideal on their fluid levels have impairments in many facets of digestive function. The stomach and small intestines cannot secrete their contents as well, the gut lining has less of a protective mucous barrier, and the small intestinal lining is exposed to food by-products at dangerously high concentration only for a lack of fluid to dilute it.
• Consume a high-fiber diet. Fiber is a special case. In the long run, the more fiber and the more fiber diversity you have, the better your intestines work. However, if you are in a situation where your flora is lacking protective strains, increases in fiber are often met with short-term symptoms, even if they could be helpful over time. If you are fiber-sensitive, the solution is increased intake, but to take it slowly. This principle can be especially true for cruciferous vegetables such as: cabbage, broccoli, and cauliflower; beans, and other high RS foods.¹⁵
• Studies have shown that most who are fiber sensitive can consume 1-2 tablespoons of fiber-rich foods for two weeks and afterward can tolerate them much more effectively.

Other Common Treatments

Here are other things you might want to consider for IBS treatment:

• Antispasmodics. These are used to relieve spasms and involuntary movement of muscles, and can have a soothing effect on those with IBS. The two most worth considering are perilla and peppermint oil. One particular study showed that women, between the ages of 42 and 64, who received perilla extract were relieved of their gastrointestinal discomfort.¹⁶ Peppermint has also been used for centuries to treat these same type of symptoms. The main ingredient of menthol may also improve neuromotor function and visceral sensation. There is also a high degree of safety with this method, which is why it is certainly worth considering.¹⁷
• Probiotics. There is a tremendous variation in efficacy when it comes to these, many are not helpful (and some might even be counterproductive), there are risks to the elderly and those whose immune systems are compromised. The risks are small, but so too are the benefits, to the point where they nearly cancel each other out. The one notable exception is that of saccharomyces cervisae (a good yeast, but not a good bacteria). In its most prominent study, it helped improve abdominal pain and regulated bowel frequency.¹⁸
• Prebiotics. Many researchers feel that prebiotics have a great deal of promise for IBS (since they work to improve the existing flora in the body). Probiotics, on the other hand, are limited in that they cannot contain anaerobic organisms, despite the fact that anaerobes make up 99% of the more important bowel flora. Prebiotics can improve counts and types of anaerobic bacteria. Most seem to help by supplying substrates that good anaerobic bacteria make into short chain fatty acids like butyrate. These fats improve bowel motility, nerve conduction, reduce inflammation, and regulate the bowel borders.

According to one particular study, butyric acid was shown to have powerful anti-inflammatory effects on the body. This means that butyrate can provide benefit when it comes to hypersensitivity on intestinal receptors, as is the case with IBS.²⁰

Butter typically consists of 3 – 4% butyrate by weight.²¹ If you had a teaspoon of butter, weighing about 5 grams, you would have roughly 150 mg of butyrate.

Butyrate is powerful when the bacteria in your colon makes it, but much less when you take it. This is because it changes on the way down, and loses nearly all of its potency. Studies using this method found that 8000 mg was needed to show a clinical change in the colon flora.²²

That means that if you were to use butter to try and change your flora, you would need about 1.1 cups of butter, several times each day – which amounts to about 5300 calories!

Butyrate and Resistant Starch

A much more efficient way of raising your butyrate levels is with resistant starch (RS) (Read: Don’t resist this starch). In a recent human study, just seven days of a diet high in RS was shown to improve butyrate levels and increase many strains of protective bacteria. These results kept increasing for a full week after the RS was stopped.

There are distinct types of resistant starch, which you can see illustrated in the chart below:

Other Treatments for IBS

Now let’s get back to considering some of the other treatments for IBS…

• Exercise. Whether it’s walking or yoga, exercise can have a powerful effect on your IBS symptoms. One such study found that, amongst 273 patients, yoga can help with symptoms, severity, and anxiety surrounding IBS.²³
• Stress management. A little meditation can go a long way, especially as it relates to the overall concept of mindfulness. This is a promotion of the sensory versus the emotional processing of interoceptive signals and can help reduce the severity of IBS in women.²⁴
• Cognitive Behavioral Therapy (CBT). One study in particular trumpeted the benefits of CBT when it came to treating IBS symptoms. These psychological treatments proved to be effective ways of helping patients deal with the mental stress of IBS and its accompanying symptoms.²⁵
• Hypnotherapy. This approach relies on what we know as gut-directed hypnosis (GDH). One study focused on how GDH was being used on those with both IBS and IBD²⁶, to ease their symptoms and to encourage a therapeutic effect in patients. While the evidence is not necessarily all there, it is continuing to grow in popularity.
• Fiber supplements. These kinds of supplements happen to work differently than dietary fiber. The studies are mixed, but soluble versions may help (with the main version being psyllium). Insoluble, on the other hand, does not help – and you can see these versions in most bran supplements.

Are There Medications For IBS?

There are certain medications which may be useful when it comes to the treatment of IBS. You have…

• Antidepressants – Like SSRIs, TCAs, with the former being safer but less effective, and the latter being more effective with greater risk of seizures, palpitations, and sedation
• loperamide – This is particularly effective for IBS-D, and is anti-diarrheal, but is overall not effective at lowering symptoms²⁷
• Osmotic Laxatives – These are best for IBS-C, and are considered safer than stimulant laxative (magnesium citrate, polyethylene glycol, and lactulose)
• Rifaximin (nnt 11) – Consider this one not effective (even less than a placebo)²⁸
• Lubiprostone (NNT 13) – This is a newer gastrointestinal chloride-channel activator
• Linaclotide for IBS-C (NNT 8)

The Reality of IBS

IBS is certainly real, painful, and can be a key disruptor in your everyday life – and currently is for millions of people across the country.

The most effective treatments include natural compounds like resistant starch, peppermint oil, and s. cervasie, and perilla, mind-body approaches like hypnotherapy, CBT, and yoga are also of value.

Fiber is useful on a long-term basis, but must be adjusted slowly.

I hope you have learned a little bit more about IBS today, and how you can use this important information moving forward.

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Dr. Alan Glen Christianson (Dr. C) is a Naturopathic Endocrinologist and the author of The NY Times bestselling Adrenal Reset Diet, The Metabolism Reset Diet and The Thyroid Reset Diet.

Dr. C’s gift for figuring out what really works has helped hundreds of thousands of people reverse thyroid disease, lose weight, diabetes, and regain energy. Learn more about the surprising story that started his quest.