Carbohydrates break down in the gut into tryptofan and then to serotonin and serotonin is a real problem in IBS.
You can also have a problem with wheat and not have full blown celiac.
also did you see this by any chance?
IBS
Bette Bischoff
Background
Prior to medical school when I was a practicing dietician, I had the privilege of
working with many patients who had irritable bowel syndrome (IBS). I found
the subject of nutritional intervention related to IBS to be very rewarding and
often challenging because there is no "perfect" diet for this syndrome. In light
of the different etiologies potentially at work in each patient with IBS, nutrition
therapy should be carefully and thoughtfully tailored to each person. This can
be likened to times past when a cobbler hand-made each person's shoes. Since
each IBS patient can differ dramatically, careful documentation of exacerbating
factors listed in the IBS diary maintained by patients may yield important clues
to an effective approach to diet and nutrition.
One of the issues is that patients with IBS may have a lower threshold to stressors
compared to people without IBS. An example of this is patients with carbohydrate
intolerances as well as a diagnosis of IBS, who experience an even greater
response to problematic carbohydrates such as lactose or fructose as compared
to someone who does not have IBS. Another important issue is being alert to
unnecessary food aversions. Individuals may experience abdominal discomfort
and associate this with eating a certain food, so they decide to avoid eating that
particular item, even for life. This may lead to excessive food restriction and the
potential for a full-blown eating disorder. What must be kept in mind is that IBS
is characterized by increased gut and central nervous system (CNS) reactivity
to stressors, and that these stressors can include any dietary excesses as well as chain fatty acids. Good sources of soluble fiber
include oats, psyllium seed, pectin, and guar gum.
Insoluble fibers consist of the outer husk of the
grain and generally tend to decrease transit time.
The national nutrition guidelines recommend an
intake of 20-30 grams of fiber per day, yet the
typical American consumes less than 10 grams of
fiber per day. Fiber intake should be increased
gradually in IBS patients with constipation,
with an emphasis on including adequate water
consumption (5).
The overall fiber picture can become a bit more
confusing than a simple recommendation to
increase fiber intake. Insoluble fiber may have a
high content of cereal bran, which is the outer husk
of the grain. A recent paper investigated the effects
of adding or omitting bran and found conflicting
results. It appears the primary care provider may
see a greater benefit from patients adding fiber
to their diet than the gastroenterologist, possibly
because primary care physicians see mostly
milder forms of IBS and gastroenterologists see
patients with more severe IBS. Whorwell studied
100 patients in a primary care setting that were
encouraged to increase cereal bran. The results
in the primary care provider scenario produced
a "mixed" picture -- 22% reported worsening
of IBS symptoms while 27% who showed
improvement. This may be the result of visceral
hypersensitivity triggered by bran consumption.
Whorwell recommends that patients identified
with IBS and visceral hypersensitivity should be
counseled to exclude cereal (insoluble) fibers
for a brief period to see if symptoms improve,
especially if this is within the care of a specialty
clinic. Another study found that cereal fibers were
associated with a 55% worsening of symptoms (6,
7). Thus, if the goal is to increase transit rate and
increase the frequency of bowel movements (for
IBS-C), one could add insoluble fiber to the diet;
however, since IBS is also associated with visceral
hypersensitivity, if discomfort/pain or bloating
occurs, the patient may need to switch solely to
soluble fiber.
Caffeine is a gastrointestinal stimulant. For IBS
patients with diarrhea, a period of caffeine
sensitivities to particular foods that are unique to
the individual rather than to the IBS condition.
This article reviews some of the literature in this
area and then presents some treatment options
to be considered in the nutritional management
of IBS. It should be noted that the research and
peer-reviewed published literature regarding IBS
and diet is still very limited and, therefore, some
of the resources cited in this article will date back
several years.
Nutritional Factors Influencing Motility:
Fiber, Fat and Caffeine
IBS is the most common of the functional GI
disorder, affecting approximately 10-15% of the
US population (1). IBS is a multifactorial illness with
several different emerging pathophysiologies,
including disorders of motility, visceral
hypersensitivity, central processing dysfunctions,
psychological factors, and post-infectious
inflammation.
Fiber: A recent survey reported that close to
95% of general practitioners believe that fiber
deficiency is the main cause of IBS. In fact, the
most common dietary advice offered to patients
with IBS is for them to increase their intake of
fiber, primarily to address the constipation that
may be associated with IBS. However, since IBS
is also associated with visceral hypersensitivity,
luminal distension -- as might be caused by the
bacterial fermentation of insoluble fiber -- can
also produce discomfort (2).
Dietary fiber is a non- starch polysaccharide
derived from plant foods that are poorly digested
by human enzymes. A fiber-enriched diet can
relieve constipation, accelerate intestinal transit
time, and may reduce intracolonic pressure.
Furthermore, the intake of fiber is associated
with a reduction in the intraluminal concentration
of bile acids, which may reduce the contractile
activity of the colon (3, 4).
There are two types of fiber -- soluble and
insoluble. Soluble fiber is derived from fruits and
grains, and is fermented in the colon to form short
exclusion may prove beneficial. The total intake
of caffeine-containing beverages by many adults
and children often reaches levels that can induce
pharmacological effects. Evidence associating
caffeine with GI symptoms suffered by patients
with IBS is limited in the current literature, but one
study revealed that caffeinated coffee stimulated
colonic motor activity in a magnitude similar to
that of an entire meal and had a 60% stronger
effect than ingesting water (.
Dietary fat is also a potent modulator of gut
motor function. This macronutrient delays gastric
emptying time and accelerates small bowel
transit rates. Symptoms of bloating are commonly
reported after consuming a high-fat meal. Serra
et al. found that after an infusion of enteral fat,
the volume of retained gas increased from 298
to 505 ml (9, 10). For patients who need to limit
their fat intake, counting actual fat grams in the
diet can be an excellent way to identify high-fat
food sources. In general, IBS patients should aim
for only 40-50 grams of fat per day. If weight loss
becomes an issue with fat restriction, medium
chain triglycerides (MCT) are an excellent source
of calories. Unfortunately, MCT oils are expensive
and, due to taste issues, are generally not wellreceived
by patients.
Food Allergy, Hypersensitivity and
Intolerance
Although up to 45% of the population reports
adverse reactions to food, the actual prevalence
of immune-mediated food allergy is unknown.
Symptoms are more common in atopic individuals
who often have allergies to non-food antigens
as well, such as pollens, and in young children
who tend to outgrow an allergy. The role of food
allergy in IBS has not been studied well. Surveys
indicate that 40-70% of food-allergic patients
report GI symptoms including nausea, vomiting,
abdominal pain, bloating, and diarrhea. Stefanini
et al. conducted a 4-week multi-center study
comparing the efficacy of the mast cell stabilizing
agent sodium cromoglycate at 1500 mg per day
with an elimination diet, and 67% of the patients
reported improvement in their symptoms (11).
Attempts to "test" for food hypersensitivity in
IBS have largely focused on the classic food
allergy, which is based on the presence of IgE --
immunoglobulins of the "immediate type". These
antibodies attach to certain cells in the body
that release chemicals that cause anaphylaxis.
Present speculation in the literature suggests
that adverse reactions to food in patients with
IBS might be due to forms of immunological
mechanisms other than a dietary allergy, namely
IgG antibodies. These tend to have a delayed
response following exposure to a particular
antigen and have been implicated in some cases
of food hypersensitivity. IgG studies surfacing in
the IBS literature are promising, but the issue of
the validation of serum IgG testing is often raised.
Atkinson et al. observed significant improvement
in IBS symptoms in elimination diets using Elisa
IgG antibody testing. Their results suggest
that IgG antibodies may have a role in helping
patients identify candidate foods for elimination
(12). Collins et al. also found significant change
in patients receiving the IgG exclusion diet. The
foods that were most frequently associated with
elevated IgG levels were yeast, milk, eggs, wheat,
cashew nuts, peas, almonds, and barley. The
mechanism by which the IgG antibodies have a
detrimental effect is unclear, but most likely is
associated with low-grade inflammation (12,13).
For the most part, most patients with IBS do not
have immune-mediated allergies to food and,
more likely, have increased sensitivity to the direct
effects of food on digestive function including
increased food volume ingestion and the addition
of fats, caffeine, carbohydrates, alcohol, etc.
Food Intolerance and Exclusion Diets
Niec recently summarized the literature on clinical
trials using food elimination diets followed by
rechallenge. Of the seven studies included in their
review, positive response rates varied from 15 to 75
percent. A higher rate of response was correlated
with diarrhea-predominant IBS. Milk, wheat and
eggs were the most frequently implicated foods
(14). Although the principle of food elimination
or exclusion appears straightforward, it can be
very demanding for the patient. If the patient
appears hesitant or confused about food choices,
physician referral to a registered dietitian may be
helpful. With the exclusion of entire food groups,
such as dairy products, the risk of developing a
nutritional deficiency must be considered.
Carbohydrate Malabsorption
Carbohydrate intolerance can be seen in many
patients with IBS. Fructose, lactose and sorbitol
malabsorption are common among patients who
have IBS, and dietary restriction of these sugars
may improve symptoms (15,16). One study found
that 42% of IBS patients developed symptoms
from sorbitol-fructose mixtures compared to 3.5
% in the control group (1. This could be an
important factor when patients are consuming
large amounts of weight-loss products or have
diarrhea-predominant IBS.
Lactose malabsorption occurs when lactose, the
primary sugar in dairy products, is not completely
digested and absorbed in the small bowel. Lactase,
the enzyme required to hydrolyze lactose for
intestinal absorption, is found primarily in the tips
of the jejunum. When unabsorbed lactose reaches
the colon, colonic bacteria uses this substrate
for fermentation, producing gas and short chain
fatty acids. The unabsorbed lactose also affects
osmolality, causing water to be drawn into the
bowel and accelerating the intestinal transit
time. If lactose intolerance is suspected, it can be
confirmed with a hydrogen breath test. Lactose
intolerance appears to be dose dependant. This
means that many patients can tolerate small
amounts of dairy products throughout the day,
such as ½ cup of milk, but not larger amounts.
Although it may seem obvious which foods
contain lactose, some sources may be difficult to
discern. Patients should look for hidden sources
in baked goods, salad dressings, and powdered
mixes. Labels with the following words contain
lactose: nonfat dry milk, milk powder, dry milk
solids, whey curds, and caseinate milk sugar.
Contrary to popular belief, acidophilus milk
does not have the lactose sugar digested and
is, therefore, a poor substitute for regular milk.
Soymilk and rice milk do not contain lactose and
are, therefore, good dairy substitutes. However,
these products are often low in calcium and
vitamin D. Hard cheeses and cultured yogurt
are usually acceptable alternatives. For patients
who do not tolerate lactose but want to consume
dairy products, supplemental lactase enzymes
are available. Several studies have shown that
patients with lactose intolerance have significantly
less calcium intake than those who tolerate
lactose. In one study, patients who were lactose
intolerant had a calcium intake of approximately
300 mg per day (1, which is only 20-40% of the
recommended calcium intake for adults. Patients
with lactose intolerance have also exhibited
decreased bone mass density (19). In light of the
potential for compromised calcium and vitamin D
intake, it would be prudent to evaluate all patients
with lactose intolerance for a calcium supplement
if needed.
Fructose is a hexose sugar that is highly utilized
in the western diet. In the past 20 years, there
has been a 10-fold increase due to its use in
highly processed food products. It is often used
as high fructose corn syrup in soda, fruit juices,
cookies, baked goods, jellies, and candy. Unlike
glucose, which is completely absorbed, fructose
absorption capacity is limited. Therefore, when
ingested in small quantities, dietary fructose
will probably not be an issue. However, when
consumed in larger amounts, fructose may serve
to osmotically draw fluid into the intestinal lumen.
This may cause distension of the small intestine
and produce symptoms such as abdominal pain,
bloating and discomfort. Furthermore, after
reaching the colon, unabsorbed fructose may
be fermented by colonic bacteria, producing
excessive gas (20).
Probiotics
Several studies now exist defining the potential
role of probiotics in IBS. These papers have
exhibited a great degree of variability, possibly
due to the use of different probiotic strains, their
ability to adhere and colonize in the GI tract,
and the number of colony-forming units actually
ingested by the individual. The probiotics most
often studied are lactobacillus, bidifobacterium,
and some non-pathogenic forms of e-coli. In a
recent study, bifidobacterium 35624 significantly
alleviated symptoms of abdominal pain and
discomfort, bloating, and distension. There was
also a normalization of IL-10/IL-12 ratios (this
skewed cytokine ratio may be indicative of a
proinflammatory Th-1 state). The bifidobacterium
used in this study is currently unavailable in the
US marketplace in the concentrations used in this
study (21,22).
Food products that are high in probiotics include
fermented milk, pourable yogurt, and yogurt with
live active cultures. Currently, there is no federal
agency in the US that routinely tests or "polices"
the market to ensure standardization and quality
of probiotic products. Independent tests have
revealed that up to 30% of probiotics on the
market are "laced" with reasonably adequate
live bacteria. One study used DNA extraction to
test five probiotic products at a local health food
store. The PCR analysis revealed that 2 of the 5
products did not contain the bifidobacterium
claimed on the label (23). I called a well-known
dairy in the Midwest several years ago. The
technician responsible for mixing the probiotic in
the yogurt explained that the bacteria are added
to a very large vat of product. The yogurt is then
packaged in individual cartons and there is no
final definitive measurement to ensure that the
amount of probiotic stated on the label is actually
in each individual container.
Putting It All Together
Due to the complex underlying pathophysiologies
in patients with IBS, nutritional intervention will
vary with each patient. The following general IBS
categories attempt to help "map" an approach
for dietary manipulation in the patient with IBS.
For individuals with diarrhea predominant IBS,
consider limiting nutrients that exacerbate GI
motility or intestinal secretion -- caffeine, fat
and some carbohydrates (fructose, lactose and
alcohol sugars). Probiotics can also be of benefit,
especially if post-infectious IBS or bacterial
overgrowth is suspected, or the patient has had
numerous antibiotic therapies in the past. If
constipation is the main issue, make sure the
patient has had an adequate trial of increased
insoluble fiber. This usually means that the
patient needs to count fiber grams and seek to
attain 20 grams of fiber per day. When visceral
hypersensitivity is suspected, ask the patient
to limit the amount of food eaten in one session
and instead to eat three small meals per day with
snacks. A low-fat diet and avoidance of insoluble
fiber may also be helpful for these patients.
Targeting nutritional intervention in the patient
with IBS can be challenging due to the many
different etiologies of this syndrome and the fact
that some patients have heightened responses to
different foods. A food diary kept by IBS patients
can be a particularly helpful way to ascertain which
foods may be problematic. It is recommended that
the clinician look for food "trends" in the journal,
with the goal of steering the patient away from
excessive food restriction behaviors.
References
Drossman DA, Camilleri M, Mayer EA, et al. AGA Technical Review on
Irritable Bowel Syndrome. Gastroenterology 2002;123(6):2108-2131.
Bijkerk CJ, de Wit NJ, Stalman WA, et al. Irritable Bowel Syndrome in
Primary Care: the Patient and Doctors Views on Symptoms, Etiology,
and Management. Can J Gastroenterology 2003;17(6):363-368.
Muller-Lissner SA. Effect of Wheat Bran on Weight of Stool and
Gastrointestinal Transit Time: A Meta Analysis. Br Med J 1988;296:615-
617.
Villaneva A, Dominguez-Munoz J, Mearin F. Update in the Therapeutic
Management of Irritable Bowel Syndrome. Dig Dis 2001;19:244-250.
Floch MH, Narayan R. Diet in Irritable Bowel Syndrome. J Clin
Gastroenterol 2002;35:S48.
Francis CY, Whorwell P. Bran and Irritable Bowel Syndrome: Time for
Reappraisal. Lancet 1994;344(8914):39-40.
Lea R, M Bch B, Whorwell P. The Role of Food Intolerance in Irritable
Bowel Syndrome. Gastroenterol Clin N Am 2005;34:247-255.
Rao S, Welcher K, Zimmerman B, et al. Is Coffee a Colonic Stimulant?
Eur J Gastroenterol Hepatol 1998;10:113-118.
Serra J, Salvioli B, Azpiroz F, et al. Lipid Induced Intestinal Gas Retention
in Irritable Bowel Syndrome. Gastroenterology 2002;123(3):700-706.
Jones VA, McLaughlin P, Shorthouse M, et al. Food Intolerance: a
Major Factor in the Pathogenesis of Irritable Bowel Syndrome. Lancet
1982;2(8308):1115-1117.
Stefanini GF, Saggioro A, Alvisi V, et al. Oral Cromolyn Sodium in
Comparison with Elimination Diet in Irritable Bowel Syndrome,
Diarrheic Type. Muti Center Study of 428 patients. Scand J Gastroenterol
1995;30(6):535-541.
Atkinson W, Sheldon T, Shaath N, et al. IgG Antibodies to Food: a Role in
Irritable Bowel syndrome. Gut 2004;53: 1459-1464.
Collins SM, Vallance B, Barabra G, et al. Putative Inflammatory and
Immunological Mechanisms in Functional Bowel Disorders. Bailleres
Best Pract Res Clin Gastroenterol 1999;13(3):429-436.
Niec AM, Frankum B, Talley NJ. Are Adverse Food Reactions Linked to
Irritable Bowel Syndrome? Am J Gastroenterol 1998;93(11):2184-2190.
Fernadez-Banares F, Esteve-Pardo M, de Leon R, et al. Sugar
Malabsorption in Functional Bowel Disease: Clinical Implications. Am J
Gastroenterol 1993;88(12): 2044-2050.
Nelis GF, Vermeeren MA, Jansen W. Role of Fructose-sorbitol
Malabsorption in the Irritable Bowel Syndrome. Gastroenterology 1990;
99(4):1016-1020.
Symons P, Jones MP, Kellow J. Symptom Provocation in Irritable Bowel
Syndrome. Effects of Differing Doses of Fructose-sorbitol. Scand J
Gastroenterol 1992;27:940-944.
Carroccio A, Montalto G, Cavera G, et al. Lactose Intolerance and Selfreported
Milk Intolerance: Relationship with Lactose Maldigestion
and Nutrient Intake. Lactase Deficiency Study Group J Am Coll Nutr
1998;17:631-636.
Di Stefano MD, Veneto G, Malservis S, et al. Lactose Malabsorption and
Intolerance and Peak Bone Mass. Gastroenterology 2002;122:1793-
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Choi YK, Johlin F, Summers R, et al. Fructose Intolerance: An Underrecognized
Problem. Am J Gastroenterol 2003;98:1348-1353.
O'Sullivan MA, O'Morain CA. Bacterial Supplementation in the Irritable
Bowel Syndrome. A Randomized Double-blind Placebo Controlled
Crossover Study. Dig Liver Dis 2000;32(4):294-301.
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in Irritable Bowel Syndrome: Symptom Responses and Relationship to
Cytokine Profiles. Gastroenterology 2005; 128(3):541-551.
Drisko J, Bischoff B, Giles C, et al. Evaluation of Five Probiotic Products
for Label Claims by DNA Extraction and Polymerase Chain Reaction
Analysis. Digestive Disease and Sciences 2005;50: 1113-1117.
http://www.med.unc.edu/wrkunits/2depts/medicine/fgidc/collateral/digest/fall_2005_digest.pdf
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My website on IBS is www.ibshealth.com
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