The bane of our times is the intensification of the occurrence of chronic, recurring ailments, such as IBS – Irritable Bowell Syndrome. The number of people suffering from these ‘non-specific’ ailments, described by the mysterious term ‘idiopathic’, is increasing year on year. Stomachache, flatulence, discomfort, constipation and diarrhea are becoming the everyday nightmare of millions of people, profoundly impacting both the quality of life and productivity.
Jagoda Koniarek, DVM, dietetics and human nutrition specialist, LEAPprogram consultant
IBS – a worldwide problem
Irritable Bowel Syndrome affects 20% of the population on all continents. Twice as many women suffer from IBS and the majority of the ill are younger than 45 years of age. Data does not fully reflect reality, because only some people suffering from this illness are diagnosed or treated. The IBS population comprises people suffering chronically who more frequently take their physicians’ advice, are subjected to a greater number of diagnostic examinations, are prescribed more medicines, are more frequently hospitalized, more often take leave, are less efficient at work, and generate higher costs for basic and specialist medical care than patients without IBS. They constitute a common problem for family doctors, and 20-50% of gastrological advice is given to patients with this disorder.
People live with IBS for many years before a proper diagnosis is established. They report that they tried to relieve suffering using over 300 drugs available with prescription and without. Diagnostics are difficult and costly because there is no specific marker allowing for fast diagnosis. Recommendations of the gastroenterologists’ organization outline only standard diagnostic and therapeutic procedures indicating the necessity of revising nutritional behavior and the manner of nutrition and lifestyle. On the other hand, treatment of patients with IBS is difficult, owing to the fact that nutritional standards among such a large group of patients do not yield satisfactory improvement. Ineffective elimination diets and the use of contemporaneous note-taking diaries only cause frustration and the abandonment of any nutrition regime. As a result, people with this syndrome often seek solution to their health problems single-handedly, searching through many internet forums. Irritable Bowel Syndrome is a chronic, recurring disorder of the bowels without detectable organic causes. The establishment of a diagnosis rests on criteria developed on the basis of the symptoms and the exclusion of ailments of an inflammatory nature. IBS causes chronic or recurring, paroxysmal symptoms.
Symptoms are varied and may depend on the meals eaten. Ailments appear in many patients after severe gastrointestinal infections, important life events, or as the result of a exposure to significant stress. Symptoms aren’t characteristic and might occur periodically in anyone. In order to distinguish IBS from transient intestinal ailments, an additional criterium of chronicity and recurrence was introduced. IBS may coexist together with other functional diseases of the digestive tract or lead to them (dyspepsia, gastrointestinal reflux, functional constipation). However, its codependence with the occurrence of inflammatory diseases or digestive tract tumors has not been established. Celiac disease occurs in people with IBS more frequently than in others, mainly in a latent form.
Discover the causes
Considering the variety of symptoms and the extremes appearing in different forms of IBS, it might be assumed that the etiological factors which trigger splanchnic hypersensitivity and disorders of intestinal motility may also be different. Many factors may have an impact on IBS: genetic predisposition, environment, stress, allergies, infections and inflammatory states, bacteria outgrowth, hormones, and neurotransmitter disorders. Along with IBS, anxiety, panic attacks, mood disturbances, and somatization occur. Factors disturbing communication on the brain-intestine axis participate in the development of the disorder; however, the mechanics are not fully explained. Intestines are an enormous cluster of tissues of the nervous and immune systems. Examination gives more and more evidence of a marked participation of changes in the immune system in IBS pathogenesis. In the first place, it was observed in patients with PI-IBS (Post-infectious IBS). Although the participation of the immune system in IBS seems to be incontestable, very little is known about the manner and the strength of immunological response changes on the functioning of the nervous system.
Therole of microbiota
The digestive tract is inhabited by a few million bacteria. The microbiota consists of beneficial and harmful divisions; maintaining the balance between them is extremely important. The dependence between the host and the microbiota is complex. The strongest fermentation processes (with participation of gram-negative anaerobes), as well as organic acid and gas production, take place in the colon. Both bacterium and fermentation products (methane, hydrogen sulphide) modulate the activity of the sensory nerves of the lower part of the digestive tract. Such proper modulation is necessary for the physiological work of the intestines. In patients with IBS it was shown that photogenic bacteria prevail in the microbiota. Attributing only a mechanical role to probiotics while omitting the importance of immune-modulating is controversial in IBS treatment.
Intestinal protective barrier
A number of research studies indicate that the intestinal protective barrier is altered in IBS and increased permeability of the intestines occurs. Examination of the epithelial barrier of the intestines points to changed expression and decomposition of the proteins forming tight junctions in patients with IBS. The increased permeability of the intestines is not a direct cause of pain and other ailments but only increases access to the wall of the intestine for the lumen content of the digestive tract, triggering an inflammatory response.
Immune system disorders
The mostexamined population of cells of the innate immune system are mastocytes. Activated mast cells release a mixture of pro-inflammatory mediators including proteases, prostaglandins, histamine, and cytokines, many of which modulate splanchnic nerve activity. As scavenger cells, macrophages (monocytes) also have the capacity to present antigens and release various types of cytokines activating nerve endings. An increased level of autoantibodies against neuron channels has been confirmed in a segment of patients with IBS. The occurrence of neurological dysfunction of the digestive tract triggered by autoantibodies is possible, therefore, in some cases of IBS.
Inflammatory state mediators, whose level increases in patients with IBS, activate nerves of the large intestine and are the main culprit of motor and pain symptoms. A high concentration of cytokines was reported in the peripheral blood of patients with IBS-D (diarrhea type) correlating with the severity of symptoms including the frequency and exacerbation of pain attacks as well as symptoms of intestinal motility. There is a lack of clear evidence as to whether changes in the immune system are mediated centrally or peripherally, and whether the change in mental nature and psychic disorders (fear, depression) are a result or the cause of the increased activity of the immunological system. There also is no certainty regarding the peripheral mechanisms activating the immunological system. Allergies and hypersensitivities to foods, chemical food additives, microbiota disorders, and bacterial, viral and parasitic infections are suspected of being the cause of such activity. Genetic predisposition might also be the reason for IBS occurrence.
Easing IBS symptoms through diet is a challenge. There is a lack of adequate knowledge about the efficiency of treatment via diet. Physicians do not usually give patients any dietary recommendations or they are very general and do not refer patients to dietitians. Nonetheless, dietitians think that food and nutritional habits have a significant impact on the intensity and the frequency of the occurrence of symptoms. Some foods may trigger a pro-inflammatory immunological response, while others may induce flatulence or change intestinal motility because of their composition. The regularity of meals and the culinary techniques employed may also influence digestion and the intestinal tract. Deciding on the proper diet must be preceded by a precise tracking of nutritional history and symptoms in order to evaluate the organism’s reactions to particular foods.
The foundation of diet therapy for IBS is that there is not one ‘IBS’ diet. Each diet should be completely customized. People have unique symptoms and exposure to stress and different levels of physical activity, which is an important triggering factor. Moreover, everyone has different triggers and individual interactions with food. The objective is to find a path to healthy, balanced nutrition that brings his diet close to a base diet. Patients frequently visit a dietitian after years of fighting with symptoms of the illness, having tried the elimination of various products and following numerous IBS diets found on the internet. Their menus often consist of only a few products consumed in small quantities, because the fear of exacerbating symptoms is greater than the feeling of hunger.
There are no universal recommendations for IBS which might be advised for all patients. Diet has a very individualized character with this disorder.
To find the culprits
The greatest number of problems involves determining which foods cause the occurrence or exacerbation of symptoms. The majority of sufferers follow an elimination diet in accordance with general recommendations, eliminating the most suspicious foods. However, better effects are achieved by implementation of an individually customized diet based on the results of the Mediator Release Test — the MRT.
This test’s objective is to define the reaction of white blood cells in the peripheral blood to contact with food antigens through measurement of the volume change of leukocytes. The greater the volume change, the stronger is the pro-inflammatory action of food. Hypersensitivity to food might be identified as a non-infectious pro-inflammatory reaction caused by a food factor, in which antibodies of the IgE class do not participate. Activation of immune system cells triggers the release of pro-inflammatory and pro-pain factors, which causes numerous symptoms and ailments. A significant group of them constitute digestive tract disorders including IBS, as well as emotional disorders, e.g. depression. Immunological reactions are initiated by immune system cells including leukocytes circulating in the bloodstream. The starting point of each inflammatory reaction will always be a reaction of cell elements of the immune system and the release of cytoplasmic and chemical mediators. On the basis of the MRT test results, a multistage, customized elimination diet is developed – the nutrition program LEAP (Lifestyle, Eating and Performance). The first stage of the program, which lasts a few days during which the patient’s diet is based on a dozen foods that are safest for him, allows a significant weakening of the symptoms of the illness to be achieved. Additional safe products are gradually introduced over the next four stages. Such a gradual expansion of the menu facilitates the detection of undesirable reactions in which other mechanisms may take part, e.g. enzymatic deficiencies. The last stage of the program is a new nutritional model – a three-day rotation diet and gradual expansion of the menu with untested foods from biologically safe families. The patient should maintain a two-day break in the consumption of foods belonging to the same biological family. The objective of the rotation is to limit the increased concentration of antigens of particular foods in the organism, maintaining the immune system’s reaction at a low, safe level. In the case of patients with gastrointestinal disorders, it is important that the consultant in charge of the LEAP Program oversees the expansion of the diet. It very often happens that patients, afraid of the recurrence of the ailment, do not want to move beyond products from the first phase. However, eating only a dozen foods may, after some time, lead to their change in status from safe to highly unsafe and trigger an inflammatory defensive reaction.