Irritable Bowel Syndrome – what is it and how can I manage it?

By Mairead Keegan

Senior Specialist Dietitian, NHS Lanarkshire

With spring in bloom and April being the month for awareness of irritable bowel syndrome (IBS), it would be a shame to miss out on an opportunity to raise awareness of this condition and its treatment.

For many health professionals, they have a love/hate relationship with treating IBS. You could compare it to ‘marmite’: you either love it or hate it. I love it! Patients often think that Dietitians will ‘judge’ them on what they eat, or don’t eat; or suggest they make some radical changes to their diets, and whilst some do need a good overhaul we generally don’t do this. We’re here to offer advice to help patients take control and self-manage their condition.  Patients with IBS are sometimes so desperate to get symptom improvement, that they self-impose nutritionally inadequate diets, follow the latest ‘fad’ diet or buy the latest ‘superfood’ (no such thing!) for the treatment of IBS.

What I’ve decided to focus on, is the simple changes people can make that can have a significantly positive impact on their symptoms. But, before we look at dietary changes, let’s get some background on what IBS is.

IBS is a chronic, for some, life-long, debilitating, functional, gastrointestinal disorder. It affects twice as many women as men. Symptoms vary from individual to individual and can include bloating, abdominal pain, wind, altered bowel habit (diarrhoea, constipation or both), urgency to open bowels, nausea and lethargy.

In order to diagnose IBS, it’s important to note that one does not need to undergo invasive investigations, which is often a fear people have. I too would be dreading the thought of a colonoscopy or sigmoidoscopy! IBS, however, should be considered if a patient suffers from abdominal pain, discomfort, bloating or change in bowel habit, for at least six months. The National Institute for Health and Care Excellence (NICE) state: ‘diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation or associated with altered bowel frequency or stool form. This should be accompanied by at least two of the following four symptoms:

• altered stool passage (straining, urgency, incomplete evacuation)
• abdominal bloating (more common in women than men), distension, tension or hardness
• symptoms made worse by eating
• passage of mucus.’ ⁽¹⁾

In addition to these, you will be asked to give a blood sample. This is to ensure you do not have coeliac disease or inflammatory bowel disease both of which require different treatments to IBS. If you present to your GP with what’s called ‘red flag’ indicators (see table below) then you should be referred to your local hospital for further investigation as appropriate.

Examples of red flag indicators

• Unexplained and unintentional weight loss
• Rectal Bleeding
• Anaemia
• Abdominal or rectal masses
• Family hisotry of bowel or ovarian cancer
• A change in bowel habit to looser more frequent stools for more than six weeks in someone over 60

Once you have a diagnosis of IBS, you can then set about making simple but effective dietary and lifestyle changes to promote symptom resolution. Although everyone is talking about the low FODMAP diet as an effective treatment for patients with IBS, we need to remember it is not suitable for everyone. Don’t get me wrong; it is effective and probably one of the most successful approaches for the management of symptoms of IBS.

However, for some patients restrictive diets are not required, nor appropriate, but establishing a regular meal pattern and avoiding long gaps between meals, for example, can help.

My top ten tips for dietary and lifestyle management of IBS are:

1. Eat three regular meals per day.
2. Avoid eating on the go: take time to sit and eat in a relaxed environment, remember to chew your food well (I know I sound like your mum, but it works!).
3. Avoid long gaps between meals, skipping meals or eating late at night.
4. Reduce the amount of carbonated (fizzy) drinks and those containing caffeine and replace with non-caffeinated varieties, herbal teas or water.
5. Aim to drink eight cups of fluid (as above) per day.
6. Reduce the amount of alcohol consumed and limit to two units per day and have at least two alcohol free days per week.
7. Reduce your intake of processed foods and cook from scratch, where possible.
8. Reduce your intake of rich/fatty foods e.g. chips, fast food snacks, pies, creamy sauces, cakes, biscuits, crisps, burgers and sausages.
9. Limit fresh fruit to three portions per day (one portion is 80g).
10. Enjoy regular exercise e.g. swimming, walking, yoga ⁽²⁾

Outlined above are suggested changes patients with IBS should be attempting to improve their symptoms. Although I have outlined many changes which people can make, it is important to remember to make one change at a time. Trying to alter too many things at once is a real challenge and often patients fail to maintain changes because of it. Therefore, make changes one at a time. Also, completing a food diary may be helpful for some, as it can help you to identify what changes were of benefit and which ones weren’t.

In those where stress is a key trigger; firstly identifying this as a trigger is a start, as people often overlook it or perhaps haven’t yet realised the effect stress has on their symptoms of IBS. Therefore, discussing strategies to help with relaxation can be effective.

If you suffer from diarrhoea predominant IBS, in addition to the above, avoid sugar-free sweets, mints, chewing gum and drinks which contain sorbitol, mannitol and xylitol as foods containing these ingredients can exacerbate diarrhoea. Remember to drink plenty of fluid to replace your losses so you don’t become dehydrated!

If constipation is your predominant symptom, try slowly increasing the amount of fibre in your diet e.g. change to wholegrains, oats, vegetables, fruit. You could also try adding one tablespoon of brown or golden linseeds (ground or whole) to breakfast cereals, yoghurts, soup, or salads. With each tablespoon of linseeds consumed, remember to take a small glass/teacup (150ml) of fluid. It’s important to remember to avoid eating extra wheat bran.

Lastly, but by no means least, if bloating and wind cause you difficulties then try having oats in your diet e.g. porridge for breakfast. You can also try linseeds, as suggested above. Reducing your intake of gas producing foods e.g. beans, pulses, brussel sprouts and sugar-free items may be of benefit.

If you have tried the above advice but your symptoms persist, ask your GP to refer you to see a Dietitian who can provide you with further dietary information whilst ensuring your diet remains nutritionally adequate. Your Dietitian may suggest, if appropriate, a low FODMAP diet. Please, do not try this dietary approach without the guidance and support of a Dietitian who works in this field.

Remember dietary changes are effective and sometimes it’s the little changes that make the difference, so don’t think you need to follow a restrictive diet for life, seek help, and your local Dietitian will be happy to help you!

References

1. NICE Clinical Guideline 61 (February 2015): Irritable Bowel Syndrome in Adults: Diagnosis and management of irritable bowel syndrome in primary care
2. BDA Food Fact Sheet (2016): Irritable bowel syndrome and diet.

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