Gas-producing food with high fiber content
Less gas-producing food with high fiber content
Vegetable
Fruit
Vegetable
Fruit
Broccoli
Apple
Apricot
Carrots
Brussels sprout
Grape
Pineapple
Corn
Cauliflower
Banana
Berries
Green
Cabbage
Raisin
Orange
Tomato
Cucumber
Prunes
Peach
Spinach
A new trend in diet in IBS patients is reduced consumption of fermentable oligosaccharides, disaccharides, monosaccharides, and polyol (FODMAP) [42]. FODMAP food include products with high amount of fructose (pears, apples), oligosaccharides including fructans (wheat and onion), galacto-oligosaccharides (legumes: kidney beans and chickpeas) and sugar polyols such as sorbitol, xylitol or mannitol (artificial sweeteners) [43, 44]. Almost all of the highly processed food (main dishes, fast food and sauces) contain FODMAP.
FODMAPs are present in grains, some dairy products – milk, sour cream (with lower content of fat), kefir, yogurt, butter, some cheeses. Onions, garlic, asparagus, beets, leeks, broccoli, cauliflower, Brussels sprouts, chicory, fennel are rich in FODMAPs. Peaches, avocados, nectarines, plums, cherries, watermelon, melon, blackberries, lychee, mango, guava, papaya, avocado contain FODMAPs in high concentrations. Moreover, honey and liqueur wines also include FODMAPs.
Lethargy, increased GI symptoms (bloating, abdominal pain, passage of wind and dissatisfaction with stool consistency) and higher levels of breath hydrogen are produced on high FODMAP diet [45].
A low FODMAP diet could help decrease the distention caused by both the osmotic effect of FODMAPs and gas production resulting from its fermentation in the colon [46]. Moreover, lowering FODMAP consumption clearly reduced the relative abundance of all intestinal bacteria [27]. Of course, it is impossible to rule out FODMAPs from diet, but all these benefits indicate that it should be under consideration of IBS patients to minimize the FODMAPs consumption. Citrus fruit (oranges, lemons, limes, grapes) and forest fruit (cranberries, blueberries, raspberries and strawberries) are suitable for IBS patients on low FODMAPs diet. Vegetables which can be consumed are potatoes, peppers, carrots, cucumbers, zucchini, tomatoes, radishes, sweet potatoes, bamboo sprouts, olives, Chinese cabbage, and lettuce. Thyme, rosemary, basil, ginger, mint and oregano are herbs and spices which should enrich main dishes. Fruit and vegetables with high and low FODMAP content are listed in Table 5.2.
Table 5.2
Fruit and vegetables with high and low FODMAP content
High FODMAP content | Low FODMAP content | ||
|---|---|---|---|
Vegetable | Fruit | Vegetable | Fruit |
Asparagus | Apple | Carrot | Banana |
Garlic | Pear | Celery | Raspberry |
Cabbage | Mango | Lettuce | Strawberry |
Onion | Watermelon | Corn | Orange |
Pea | Nashi pear | Tomato | Grape |
Gluten-free food should be introduced to the diet instead of wheat products. Wheat could be successfully replaced by spelt, which is known to contain fewer galactans and fructans than wheat and therefore not to produce frequent IBS symptoms [47]. It was evidenced that gluten-free diet improved IBS symptoms [48]. Patients with IBS-D, who received gluten-free diet (bread and muffin without gluten) reported a significant improvement in the following symptoms: pain, bloating, stool consistency, and tiredness as compared to IBS-D patients who ingested gluten (bread and muffin, 16 g gluten per day) [49].
IBS patients often complain due to lactase deficiency. Lactase is an enzyme involved in digestion of lactose—sugar in milk. The most common symptoms of this ailment include cramping abdominal pain, bloating, flatulence, diarrhea and nausea. IBS patients with lactase intolerance should avoid high-lactose food: dairy products: milk, sour cream, cheese (also cottage cheese, ricotta, spread cheese) and ice cream. However, they should remember that dairy products are a big source of calcium, potassium, magnesium, vitamin A, vitamin B2, vitamin B12 and other microelements and therefore they risk the development of these nutrient deficiencies. Vitamins and microelements should be replaced in other food products or supplemented [50].
Fructose malabsorption should be considered in the handling of patients with IBS complaints. Fructose reduced diet should result in lower fructose intake (less than 2 g per meal) and allow IBS symptoms improvement [51].
Box 5.1 Diet recommendations
What to avoid:
overeating
high-fiber food
high-FODMAP food
dairy products
artificial sweeteners
fried and processed food
chocolate
carbonated beverages
alcohol
caffeine
white bread
red meat
spicy food
onion
Recommendations:
increase fluid intake
drink warm or hot drinks
drink small amounts of alcohol (only during dinner)
drink a lot of herbal tea
eat slowly and regularly
eat low-FODMAP food
eat low- to medium-fiber food
forget about processed food
eat dinner 3 h before sleep
5.2.2 Obesity
The correlation between IBS development and obesity is not clear and not confirmed in big scale clinical trials. Data are conflicting—in one study an association between low body mass index and IBS has been found [52], while in another study it was evidenced that most IBS patients are normal-weight or overweight [53]. High-fat diet has been shown to have an impact on the intestinal microbiota and thus may contribute to more severe IBS symptoms in obese patients.
5.2.3 Alcohol Consumption
The consumption of alcohol, mainly wine and beer, was also described as a factor involved in the exacerbation of disease symptoms, and therefore it should be avoided [54]. Finally, alcohol drinks with carbonated beverages (sweetened with mannitol or sorbitol) should also be excluded from diet, because they facilitate gas production [33].
5.2.4 Social Life
IBS is a chronic and relapsing disorder and its symptoms decrease patients’ quality of life. Disease symptoms often complicate outgoing lifestyle of patients; patients often avoid friend appointments—especially in the restaurants. This uncertainty of when and where disease symptoms may occur can cause fear when patient is away from home. Moreover, they feel psychical discomfort because of lack of easy access to toilet during friend meetings [55].
5.2.5 Physical Activity
Active lifestyle and physical activity should be pivotal from early years to adult. People who practice sports are more conscientious as compared to inactive ones. Moreover, systemic trainings can help to maintain regular life style. There is an increased risk of IBS development in physically inactive people. It was noted that physically active IBS patients reported not so severe disease symptoms as compared with physically inactive patients [56]. For example, active women were less likely to report a feeling of incomplete evacuation than inactive ones. Moreover, daily exercise can help to maintain good intestinal function, prevent bloating and are effective in relieving constipation [57]. Finally, daily exercise can improve mood and symptoms of fatigue, which are also more frequently noted in IBS patients [58].
Yoga is recommended in IBS patients, because it combines physical postures, breathing exercises and meditation or relaxation. Yoga can have beneficial effects on the emotional and the physical symptoms of IBS, thus can help to cope with stress. However, yoga is safe only when practiced appropriately.
Not all the patients are satisfied after training—in some IBS patients strenuous exercise may act on the intestines as a stressor. Therefore it should be taken into consideration whether increased physical activity will help to alleviate or exacerbate IBS symptoms [59].
5.2.6 Sleep Disturbances
Sleep is a time needed for regeneration after day full of work; sleep and dream disturbances influence IBS symptoms [60]. For example, the history of being psychologically abused and less than 6 h of sleep are combined with more severe disease course and fear of symptoms exacerbation. The time of sleep for IBS patients should be longer than 6 h. Patients should also take care about quality of their dream, for example last caffeine beverage should be drunk 4 h before bed time. Moreover, an important issue is the maintenance of bed time frame (both in the evening and in the morning). Bed should be used only for sleeping or sexual activity, not for eating, watching TV or book reading. One of the possible solutions to improve quality of sleep is relaxation exercise or yoga. In IBS patients regular napping periods during the afternoon should be avoided since lethargy further aggravates IBS symptoms.
In conclusion, regular exercise, smoking cessation, abstinence from alcohol, and maintenance of regular eating habits can be easily achieved by IBS patients in daily life without their doctor’s assistance and should be the first approach in IBS management.
5.3 Psychological Aspects and Treatment
The term “brain-gut axis” refers to the bi-directional communication between the gut (enteric nervous system) and the central nervous system. Brain-gut axis plays a crucial role in gut function modulation in health and disease (Fig. 5.1). The human psyche is affected by many factors, including personality features, altered health beliefs, coping skills and psychological factors. They all have impact on the motor, sensory, secretory and immune functions of the GI tract through the brain-gut axis [61].
Fig.5.1
Brain-gut axis
Anger proneness and expression style may be associated with pro-inflammatory processes and visceral hypersensitivity that contribute to IBS signs and symptoms [62]. Patients with IBS had significantly higher levels of trait anger than healthy subjects [63]. The trait anger represents a stable dispositional feature and includes a general predisposition to become angry.
IBS symptoms have impact on daily function, thoughts, feelings and behaviors because of the impression that disease symptoms can be aggravated anytime. Moreover, IBS patients indicate that they lost sense of freedom, social contacts, but gained feelings of fearfulness and embarrassment due to frequent visits in the toilet [62].
Patients with IBS are more likely to be psychiatrically ill (panic, anxiety, mood disorders, depression and post-traumatic stress disorder) than the general population [35]. On the contrary, people who are more prone to fear, anxiety and affective disorders more frequently suffer from IBS symptoms [64]. Depression constitutes risk factor for the development of IBS and is the most common psychiatric disorder diagnosed in IBS patients [65].
Social problems, tiredness, dizziness, excitedness, and excessive use of health care services (including alternative medicine) occur more frequently in IBS patients as compared to healthy individuals [66]. Moreover, worrisome and stressful life events have been reported to be associated with more severe IBS symptoms [67]. The major life events (divorce, unemployment, death of a relative) or social events (social changes, revolution) influence IBS [61]. There is apparent correlation between stress loading and exacerbation of GI symptoms in IBS patients [68]: when psychosocial stress was loaded on IBS patients in an examination room, GI transit was accelerated, as determined by measurement of colonic manometry [69].
Currently available therapeutics used in IBS therapy that target psychological disturbances include anxiolytic agents and antidepressants [70]. The mechanism of antidepressants action involves their participation in pain modulation (peripheral analgesic effect), improved quality of sleep, and regulation of GI motility [71].
Non-pharmacological forms of psychological treatments used in IBS therapy include psychotherapy (cognitive-behavioral therapy), relaxation therapy and hypnotherapy [72]. Gut-directed hypnotherapy improves IBS symptoms, mainly abdominal pain, and quality of life [73]. The mechanism through which hypnotherapy alleviates IBS symptoms is still unclear, but it was postulated that rectal sensitivity to distension is decreased. The major limitation of hypnotherapy is low number of qualified therapists and high costs of visits [74].
The choice of treatment depends on the patient requirements, available resources, and the experience of the doctor.
5.4 Co-operation Between the Doctor and the Patient
Only one third of IBS patients search for advice from a family physician or an internist. Most of IBS patients do not consider their symptoms serious enough to consult the doctor and try to lead own control of the disease and therapy. They often receive medical information from the Internet, brochures and books and from a nurse. Only when IBS symptoms are exacerbated, they look for help from the gastroenterologist.
Patients with IBS often think that they are insufficiently informed in relation to risk of serious GI diseases and the role of diet in the course of IBS [75]. They have a feeling that doctors do not listen to them or do not understand their illness experience. Moreover, IBS patients feel only partially satisfied with their information about disease as compared to patients with diabetes mellitus, hypertension or heart disease [76]. Consequently, a detailed and comprehensive explanation of the disease should be the first step in communication with IBS patient. Education is a very important part of IBS treatment—for example, it was evidenced that IBS patients who participated in psychoeducational program reported improvement in symptoms severity and quality of life [77].
After diagnosis, IBS patients should realize that IBS is a chronic incurable disorder and being under continuous control of the doctor is extremely important (even in relapsing periods of IBS), not only when they have symptoms exacerbations and need a quick help.
Doctor consultation should be the first line of choice in the management of IBS, mainly because of health professional’s knowledge, experience and ability to notice other characteristics that IBS patient exhibit, e.g. anxiety or depression. Regular appointments with a doctor is a key to effective therapy in IBS. The information obtained during examination is on both sides—patient’s and doctor’s [78]. The patient should ask the doctor about all deliberations according to proper lifestyle without any embarrassment. The doctor should ask about disease symptoms and their severity, including frequency of defecations, relief after defecation, abnormal stool, blood in stool and presence of nausea or flatulence (Table 5.3).
Table 5.3
Questions which need to be answered during the visit
Issues addressed during appointment | |
|---|---|
Doctor’s side | Patient’s side |
Do you feel satisfied with current drugs and treatment or you want to discuss it? | Could I have other GI disorders? |
Were there any stressful situations since your last visit? | Do I lead a proper life style? Do you recommend any changes? |
What about severity of symptoms? Improvement of exacerbation? | Can physical activity help in symptoms improvement? |
Brief dietary history | Are there any other possible therapies? |
Do you have problems with sleep? | What about traditional medicine? |
Psychological aspects of IBS | Do I need psychiatric consultation? |
Do you use regularly any other drugs? | Which food should I avoid? |
Doctor can ask about a brief dietary history, any associated factors (like daily obligations, stressors, sleep disturbances, used drugs). It can help to identify dietary and/or other factors that may have an impact on disease course.
Doctor should be focused on patient concerns and expectations of therapy. Doctor should observe or ask about warning symptoms, such as unexplained weight loss, progressive or unrelenting pain, GI bleeding, longitudinal diarrhea during consultation. In particular, any patient older than 50 years of age should undergo a detailed examination to confirm the absence of a colon cancer.
The preservation of warmth and empathy between doctors and their patients will make an important contribution to improved quality of life of patients instead of a brief doctor visit (only for prescription). It has been also demonstrated that patients who see the same doctor during consecutive consultations are less anxious and simultaneously more satisfied with their treatment process.
Patient knows everything about his/her body, therefore can determine if the current therapy brings satisfying benefits. If they do not feel any improvement in health, possibilities of alternative treatments should be broadly discussed—including changing lifestyle, conventional treatments (e.g. suppositories, creams, heat pad) and alternative modalities (e.g. hypnotherapy, acupuncture, homeopathy).
Doctors should remind their patients that they should not forget to lead a normal social life and try not to think negatively about the disease. The doctor should ask about daily life—sport activities, sleep quality, stressful events. Moreover, the doctor should ensure the patient that social contacts are pivotal—patients should benefit from being with family and friends—not staying at home. Finally, IBS patients should take short holidays few times a year. Being outgoing and active seems to bring a lot of benefits for them.
As mentioned above, IBS is combined with brain-gut disturbances, and psychiatric diseases are more frequently noted in IBS patients. The doctor should observe IBS patient and react when any additional help from a psychiatrist is needed. Many doctors refer IBS patients to psychological and psychiatric clinics, but they sometimes do not realize that it may paradoxically further escalate patient’s confusion and frustration. Sometimes it is better to just listen to the patient’s needs.
In conclusion, most IBS patients benefit from a therapeutic relationship with the doctors. An experimentally applied supportive patient-doctor relationship significantly improved symptoms and quality of life in IBS [79]. The establishment of a positive patient-doctor relationship reduces the number of appointments (which should stay regular) and improves long-term therapy, although it has not been confirmed in any clinical trials, mainly because of the nature of the intervention [80, 81].
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