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THE DIGESTIVE HEALTH SOLUTION

Your personalized five-step plan for inside-out digestive wellness

BENJAMIN I. BROWN, ND

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TESTIMONIALS

‘There is an old naturopathic adage that “ill health begins in the bowel” and modern research has shown that digestive dysfunction results in nutritional deficiencies and excessive toxins — the basic causes of many health problems. To improve your health, read — and use — the excellent guidance provided in The Digestive Health Solution.’

— Dr Joseph Pizzorno, ND, editor-in-chief of Integrative Medicine, A Clinician’s Journal, author of Encyclopedia of Natural Medicine

The Digestive Health Solution offers a proven, practical, step-by-step approach to understanding, controlling and reversing irritable bowel syndrome. Ben Brown has combined all the best natural approaches into a logical, easy-to-follow program.’

— Leo Galland, MD, FACP, FACN, author of The Fat Resistance Diet, director of The Foundation for Integrated Medicine

The Digestive Health Solution is an outstanding synthesis of cutting-edge research, a timely book that stands apart from the hype and pop nutritional fads. Ben Brown has established himself as a trusted authority, a researcher and clinician dedicated to sound nutritional approaches in complex cases. Ben captures the reader immediately with raw honesty as he describes his own experiences; he then proceeds to expertly navigate difficult discussions in a beautifully written, crystal-clear manner — a reader-friendly resource, providing guidance that matters.’

— Alan C. Logan, ND, co-author of Your Brain on Nature

‘One of the biggest issues in the world today is poor gut health — it’s at the root of just about every chronic health condition. The talented Ben Brown has taken the reader through the trenches of the digestive terrain in a way that is multi-faceted, personalized, and most of all, solves the problem! A must read for all.’

— Deanna Minich, PhD, functional nutritionist, author, and founder of Food & Spirit

‘Ben Brown has assimilated personal experience, peerreview research and his knowledge base as a naturopathic practitioner to create a practical guide for those with IBS. This easy-to-read book offers an up-to-date view of IBS and a sensible stepped program for a return to good gastrointestinal health. The Digestive Health Solution is highly recommended for anyone trying to cope with an irritable bowel.’

— Megan Arroll, PhD, FHEA, C.Psychol., C.Sci., AFBPsS, director of Simply Research Ltd, author of Chronic Fatigue Syndrome: What You Need to Know

‘This book is for anyone wishing to resolve their digestive health issues for good. With an ideal combination of scientific evidence and practical tips to follow, you’ll find this book a fabulous resource to refer to time and time again.’

— Christine Bailey, MSc, nutritionist and author

Disclaimer

This book is a general guide only and should never be a substitute for the skill, knowledge and experience of a qualified medical professional dealing with the facts, circumstances and symptoms of a particular case. The nutritional, medical and health information presented in this book is based on the research, training and professional experience of the author, and is true and complete to the best of their knowledge. However, this book is intended only as an informative guide; it is not intended to replace or countermand the advice given by the reader’s personal physician. Because each person and situation is unique, the author and the publisher urge the reader to check with a qualified healthcare professional before using any procedure where there is a question as to its appropriateness. A physician should be consulted before beginning any exercise program. The author, publisher and their distributors are not responsible for any adverse effects or consequences resulting from the use of the information in this book. It is the responsibility of the reader to consult a physician or other qualified healthcare professional regarding their personal care. This book contains references to products that may not be available everywhere. The intent of the information provided is to be helpful; however, there is no guarantee of results associated with the information provided.

 

 

 

 

 

This book is for you, for asking questions, seeking answers and empowering yourself to improve your own health; we are all the authors of our own health and wellbeing.

And this book is also dedicated to the clinicians, educators and scientists who are selflessly championing a shift in medicine towards a more compassionate, natural and personalized approach, grounded in the connection to our food, lifestyle and environment.

CONTENTS

Introduction

Part 1: Understanding digestive troubles

The digestive illness epidemic

Do you have IBS?

What’s going on in your gut?

Part 2: How to achieve great gut health

Banish bad bugs and balance your bacteria

Boost your digestion for better health

Clear constipation and reboot your system

Uncover secret problem foods

Put your bacteria on a low-carbohydrate diet

Rewire the nerves of your gut–brain axis

Reset your digestive clock

Get on a digestive fitness program

Part 3: The Five Steps to Great Gut Health

The five-step plan for digestive health

Acknowledgments

Resources

References

Index

INTRODUCTION

I recently spoke at an international conference with the world-leading researcher and gastroenterologist Alessio Fasano, MD, who exclaimed, ‘The microbiome, well I didn’t see that coming!’ And no one did. In the last few years ground-breaking discoveries have transformed the way we think about our digestive system. Ancient healing cultures have known for millenia that digestive health is the keystone of a healthy mind and body, and modern science has rediscovered the digestive health connection in ways that nobody would have dreamed possible just a decade ago.

The ‘microbiome’ Dr Fasano spoke of refers to the ecosystem of bacteria that lives in our digestive system, and only a decade ago we had no idea of its complexity and importance to our health. Thanks to huge advances in scientific research we now have a clearer picture. Today we know that the human digestive tract is home to a remarkable abundance of bacteria — at least tenfold more micro-organisms than cells that make up the human body — and that they influence not only our digestive health but the health of our whole body, including our immune system, cardiovascular system, metabolism, skin health and even our brain.

Disturbances in our gut bacteria have been linked to anxiety, depression, dementia, heart disease, allergies, autoimmune disease and weight gain, among many other illnesses. This is not to say it is the only cause, but it is an important part of the picture and helps us understand not only why these diseases occur, but how we could be better at treating them. The view that our overall health hangs so much on our digestive health is quite literally revolutionizing medicine. And, perhaps most importantly, we also have a better understanding of how we could influence our gut bacteria to improve our health and wellbeing and prevent illness before it even occurs, so there are important implications for wellness, healthy ageing and longevity, too.

So how do you know if your gut bacteria are out of balance? Digestive symptoms such as bloating, distension, pain, constipation and/or diarrhoea, discomfort and other niggling symptoms are strong indications. Research has shown that there are very robust correlations between these symptoms and the health of your gut bacteria. In general, if you have one or more of these symptoms regularly (which can be medically referred to as irritable bowel syndrome, or IBS) it is likely you are low in good bacteria, have more of the types linked to disease, and have lower overall diversity in your gut ecosystem. And just as low environmental diversity is an indicator of poor planetary health, low bacterial diversity in your gut is a signature of poor digestive health and ultimately bad news for the health of your whole body.

The good news is that scientists all over the world are working out why our digestive systems have become so unhealthy, and it has a lot to do with things we can do something about. It turns out that many of the things we have known are bad for us are probably bad for us because they are bad for our gut bacteria. Modern diets, too much sugar, excess alcohol, environmental toxins, stress, lack of sleep, and too little exercise have all been linked to important changes in the microbiome. And the function of your body is also important: whether or not you have impaired digestion, inflammation in your digestive system, or your immune system is sensitive to certain foods, could all be important, for example. But there are also many other surprising reasons, and they are different for everyone.

The Digestive Health Solution is my modest answer for the millions of people who want to improve their digestive health and need a place to start. The internet, popular press and self-help books are awash with dubious information, but I have kept this book evidence-based so you know it is factual and really works. It is also highly personalized because there is no magic diet, drug or supplement. We are all unique, and therefore should have equally unique care.

A new view of health also permeates this book, the view that your body is a web of interconnected systems and that your health is dependent on your diet, lifestyle and environment. This may sound logical, but conventional medicine has for too long been concerned with dysfunction in one system (ignoring how digestive dysfunction could cause anxiety, for example) and with giving symptoms a name (such as IBS), then prescribing a corresponding drug (such as a pain medication); while this works well for acute, life-threatening illness it does not work well for chronic diet and lifestyle related disease, such as chronic digestive issues. This approach often fails to appreciate the underlying cause of the illness, the interconnection between systems and the role of nutritional and lifestyle changes as powerful therapeutic options that could eliminate your symptoms. The aim of this book is to emphasize these connections, explore why problems might occur and empower you with the tools you need to improve your health by addressing the underlying causes.

This second edition of The Digestive Health Solution has been updated to include important recent discoveries and is also shaped by the experiences of the thousands of people already using the book. Having given countless talks across many countries and spoken to hundreds of people using the book, I have learnt a lot from everyone and have distilled this into the new edition. You will find this an even better resource for helping transform your health and helping others do the same. After all, this book is for you.

PART 1

UNDERSTANDING DIGESTIVE TROUBLES

1

THE DIGESTIVE ILLNESS EPIDEMIC

Abdominal pain, bloating, discomfort and erratic bowel movements are the classic symptoms that define irritable bowel syndrome; however, symptoms of IBS are not just limited to your digestive system and can extend out to a host of related complaints ranging from muscle pain and fatigue to anxiety. If you suffer from these symptoms you are not alone. The number of people who suffer from these symptoms is extremely high and tends to range from at least 5 to 10 per cent of the general population, which makes IBS the most common gastrointestinal problem in the world.

For many years the symptoms of IBS have been dismissed as being ‘all in the mind’ (and were even historically named ‘nervous colitis’) or were linked to an unhealthy diet. However, we now know that both these assumptions are wrong, yet, even today, digestive complaints remain a source of great confusion. Subsequently, people who suffer from these symptoms also suffer from a great deal of frustration due to the lack of understanding about their illness.

Importantly, the conventional medical diagnosis of IBS is based only on a cluster of common symptoms, so by its very definition there are no functional causes. In other words, if you get labelled with IBS you have the symptoms but little attention is paid to what’s actually going on in your digestive system to cause your discomfort. The lack of an objective diagnosis, such as a blood test, makes things even more challenging. And the complex nature of these digestive symptoms means that the disease frequently baffles not only the people who suffer from it but also health professionals who may misdiagnose or mismanage the disease.

There is no simple cure for the symptoms of IBS. Medications don’t work very well for most people and none offer any hope of complete relief. Sadly, the most frequently used medications are painkillers or self-medication with dangerous narcotics, which provide modest symptom relief at best and are fraught with serious side effects. Perhaps not surprisingly, most people have been suffering for a very long time.

The majority of people affected with digestive complaints experience symptoms daily and for many years. A large survey of people with IBS revealed that 50 per cent had had symptoms for more than ten years and a remarkable 16 per cent had suffered for up to 30 years. Alarmingly, 57 per cent of people had symptoms daily, 25 per cent weekly, and 14 per cent monthly.1 Living with a digestive illness can be life crippling.

The toll that digestive complaints can take on quality of life is frightening. Dietary restrictions, mood disturbances and symptoms such as pain, bloating, constipation and diarrhoea interfere profoundly with the ability to lead a normal life. On average, the symptoms of IBS restrict daily activities for about ten weeks out of each year, and can be so bad that when asked in a survey, people said that, given a choice, they would rather give up 25 per cent of their remaining life (an average of 15 years) than continue to live with their symptoms.2

The reason these symptoms remain a medical enigma is that underlying them is a complex process that is the result of multiple environmental factors influencing genetically susceptible people.3 In other words, your digestive system is your weak spot and there could be a number of factors to blame for your symptoms. So, there is no single cause but rather multiple reasons why people develop poor gastrointestinal health. For this reason, identifying the cause is no simple task, and there is often more than one cause to blame.

Recent environmental and lifestyle changes help to explain why digestive complaints have become so common. It has been suggested that the symptoms of IBS, like other chronic diseases such as heart disease and obesity, are a disease of modern civilization. Indeed, as societies modernize, the prevalence of IBS becomes much higher.4 With modernization comes dramatic lifestyle changes: increased psychological stress, sleep deprivation, dietary upheaval, decreased physical activity, social isolation, and exposure to drugs and pollutants — all typical features of modern life that can have adverse effects on digestive health.

Although a family history of IBS is not unusual and some genes have been identified that may increase susceptibility to digestive illness, it is generally accepted that genes only make a minor contribution to the disease. Rather, it is an array of environmental factors working in concert with a subtle genetic predisposition that is thought to be the underlying cause of IBS. In other words, for some people their gut is their weakness and this weakness may manifest as chronic, life-crippling symptoms given the right pressures.

While IBS continues to be dismissed as a set of symptoms with no known cause, this view has been seriously challenged by recent evidence that there are several clear causes of IBS that, when addressed, can result in significant improvement and even complete resolution of symptoms.

Further, the notion that IBS is not related to any underlying disturbance in the gastrointestinal system has also been proven to be wrong. Research has identified changes in the gastrointestinal system that help to explain many of the symptoms. The type of dysfunction may vary from person to person but there are commonalities that can nonetheless be identified with testing, and treated with remarkable results.

These discoveries offer a new view of poor digestive health as a complex problem that has tangible and very real underlying causes. This view also opens up the door for new hope because identifying and addressing the underlying cause of an illness is a powerful way to pave the road to recovery.

This book will take you on a journey through the latest research, helping you understand what is going on in your gut and why the health of your digestive system is linked to the health of your whole body. This book will also explore the reasons for your symptoms and empower you with the knowledge you need to get to the root cause of your illness, to reclaim your digestive health and total wellbeing.

NINE COMMON MEDICAL MYTHS ABOUT DIGESTIVE ILLNESS

Myth 1: It is all in your head

For a long time the symptoms of IBS have been thought to be purely psychological and people with chronic digestive complaints are sometimes still told that it’s all in their head. Well, it is in your head, but not how you think! Several studies have found an increased incidence of stress, anxiety and even functional changes in the brains of people with IBS, but this is only half the picture.

Your head is part of your gastrointestinal system. This may sound like a crazy suggestion but your brain and gut are in constant communication via what is referred to scientifically as the gut–brain axis. The gut–brain axis is basically a network of nerves and hormones that closely link your digestive system and brain, sending messages so that your gut can tell your brain if you are hungry or full, and your brain can tell your gut if you are stressed or anxious. The interesting thing is that your gut can change your emotions, but more on that later.

So the truth is that your brain and gut are intimately interconnected, and dysfunction in one area can affect the other. Just as stress can cause digestive problems, digestive problems can cause stress. So if someone tells you it’s all in your head, let them know politely that scientific research has proven that their brains are in their bowels. Stress, depression and anxiety are very common complaints in people suffering from digestive illness, but these afflictions are far more often a symptom rather than a cause.

Myth 2: There is no known cause

As you will find in this book, there are a lot of very different potential causes of your digestive complaints, and the symptoms are remarkably diverse, so understanding what’s going on requires a big-picture view. This is why people with digestive complaints are frequently misdiagnosed and wrongly treated. Drug treatments for the symptoms of IBS rarely work well because of the narrow way they act.

The problem is that while a diagnosis (the classification of an illness based on symptoms or testing) can be useful, identifying the underlying cause is much more meaningful. Rather than being labelled with IBS, wouldn’t you rather someone investigated every possible cause and helped you get to the reason for your symptoms?

The purpose of this book is to help you explore a wide range of possible causes of your symptoms and for you to achieve long-term relief by identifying and dealing with the reason for your problems in the first place, rather than being labelled with IBS and given little hope for recovery. Actually, there are many different reasons why people suffer from digestive symptoms and there is a lot you can do about it.

Myth 3: Your symptoms will go away with time

For some people, digestive troubles are intermittent and may even disappear with time but, unfortunately, most people constantly suffer and may have symptoms for the whole of their lives. Furthermore, there is evidence to suggest that having the symptoms of IBS increases your risk for Inflammatory Bowel Disease (IBD), a severe and crippling autoimmune condition. Some researchers believe that IBS is actually a mild precursor to IBD; in fact, the two diseases share many similarities and people with IBS are far more likely (up to fifteen times) to develop IBD.5 Researchers also think that IBS may be linked to the development of conditions such as obesity, heart disease and type-2 diabetes because of poor digestion, nutrient absorption or changes in gut bacteria.6

The good news is that it is highly likely your symptoms will go away with time if you get to the underlying cause.

Putting up with symptoms in the hope that the condition will improve is not going to get you anywhere if you don’t deal with the root cause of your problem. For example, if it turns out you have a food intolerance and something in your diet is aggravating your symptoms, you are unlikely to mysteriously get better with time, or with medication for that matter, if you keep eating the problem food.

While this book does not claim to be a miracle cure, it will empower you with the information and tools you need to take control of your health rather than live in the hope that things will just get better. If you do take action your symptoms may improve with time, and in some cases very fast.

Myth 4: Probiotic supplements are useless

The media loves an attention-grabbing headline and often misrepresents scientific research, and this is true for probiotic supplements. It’s not that the people in the media are wrong or mischievous, it’s that we need to be smarter when it comes to science reporting and believing media headlines.

When looking at the effect of dietary supplements like probiotics, it is important to review the research in its entirety. Unfortunately, isolated studies can be misleading and these are generally what are reported on. A headline might read ‘Probiotic supplements are useless’ but what do the thousands of other studies suggest?

Some probiotics have been shown to be tremendously effective for common digestive complaints such as bloating, pain and diarrhoea, but not all of them (even the ones that have shown some benefit) are effective for everybody. So the truth is, certain probiotics can be very helpful for some people. In fact, there is evidence to suggest that probiotics can not only relieve symptoms, they can also help improve the balance of your gut bacteria, which may well be a reason why people develop digestive problems in the first place.

Myth 5: Diet has nothing to do with it

Many people with digestive complaints identify diet as a trigger of their symptoms. Unfortunately, some dietary recommendations for IBS don’t take into account newer research in this area and fall short of the mark by making simplistic, general healthy-eating guidelines that often don’t help at all.

Following the popular recommendation to simply eat a healthy, balanced diet could spell disaster for a lot of people with digestive problems. There are many seemingly healthy foods that can aggravate symptoms and, although touted as being beneficial, may actually be the root cause of the problem.

As the old adage suggests, ‘One person’s food is another person’s poison’ and there really is no one-size-fits-all dietary approach. This book will help you identify common but perhaps surprising foods that may be a problem for you, and enable you to personalize your diet for optimal digestive health.

While dietary change is not the solution for everyone, for some people diet has everything to do with their symptoms. Diet does play a very important role when it comes to digestive illness, but perhaps not in the way you have been led to believe.

Myth 6: You need to eat more fibre

Early studies claimed that dietary fibre might be able to help people with symptoms such as bloating, pain, constipation or diarrhoea, and since then increasing fibre intake has been a popular recommendation. But these early studies had important flaws in the way they were conducted and we now know that for some people, fibre can make things a lot worse.

In fact, pioneering research into the dietary treatment of digestive illness has found that reducing specific dietary fibres can result in dramatic improvements in symptoms, which flies in the face of the ‘eat more fibre’ mantra. It also appears that the type of fibre you eat matters, with some able to aggravate symptoms while others can be used to provide relief.

So, if you have tried eating more fibre and found that it doesn’t help much, or makes things worse, don’t worry, you are not alone. Understanding how certain fibres can aggravate symptoms and why, as detailed in this book, will help you make dietary changes that don’t send you into a symptom attack. You will also learn which types of fibre can really help get your digestive system back on track.

Myth 7: The symptoms are only in your gut

One of the biggest misunderstandings about digestive illness, and perhaps the human body in general, is that dysfunction in one area is not connected to another. Everything in the body is interconnected and works in synchrony. So ill health in the gut is linked to ill health throughout the rest of your body.

People with digestive problems commonly experience symptoms that affect their mental function, feelings, sleep, muscles, joints, pain sensitivity, physical energy, urination and sexual function. This is not due to random chance, it is because many of the disturbances in the gut are connected to, or are creating disturbances in, the rest of the body.

Instead of looking at your digestive symptoms as a problem affecting your gut, it is better to think of it as a complex issue that can affect many different areas of your body and result in an alarmingly wide range of symptoms beyond digestion.

Myth 8: Medications will fix the problem

Unfortunately, there are no medications that cure the symptoms of IBS and it is unlikely that a wonder drug will ever exist. There are some medications that are used to help control certain symptoms, such as severe diarrhoea, but the effectiveness of these for the most troubling symptoms, mainly abdominal pain and bloating, is disappointing.

The reason medications are unlikely to offer a cure for your digestive issues is that they have targeted effects, like on a cell receptor or biochemical pathway. For most people, their gut problems are the result of several widespread factors involving the gut, brain, immune and nervous systems, so a single medication is limited in addressing the wide variety of issues that are going on. And the symptoms themselves can be caused by a variety of different issues such as diet or changes in your gut bacteria. Logically then, identifying and dealing with the actual cause is going to be far more effective than treating the symptoms with a drug. Even if medications could and do provide relief, they may not be dealing with why the problem is there in the first place.

Myth 9: There is no cure

There is a cure for the various symptoms of IBS, but not in the traditional sense of a one-size-fits-all magic bullet. The cure varies from person to person and in most cases requires addressing multiple dietary, behavioural and lifestyle factors.

By addressing the personal and unique causes of your symptoms, you will be able to experience dramatic improvements in your symptoms and perhaps even cure your disease, but this will take some learning, personal exploration, trial and error and ongoing life-long preventative care.

This may seem like a lot to ask in today’s quick-fix, pill-for-an-ill society, but the idea of an instant cure, as you already know, is often an illusion. Modern medicine does not have all the answers and it is important to understand that digestive illness can be a complex problem with many aggravating factors. You could ignore your symptoms and continue to suffer, or take your health into your own hands, adopt a proactive approach and enjoy the freedom of being symptom free.

2

DO YOU HAVE IBS?

Very simply, if you have abdominal pain, bloating, discomfort and erratic bowel movements, there is a good chance you have irritable bowel syndrome, or IBS. But there is a lot more to it than that, so let’s look at IBS in more detail.

If you have the symptoms listed above, you are not alone. Up to one in five people suffer from IBS, making it the most common digestive problem that anyone experiences.1 But despite how widespread the problem is, the medical diagnosis of IBS is grossly lacking and many people are misdiagnosed and sometimes incorrectly treated.2 To make things worse, some medical professionals still hold on to the old and incorrect idea that it is all in people’s heads, and dismiss the problem as a psychological disorder.

There is no single laboratory test that can identify whether or not you have IBS, so the way of identifying whether you have it is by using the Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. The Rome III criteria were developed to help assess various gastrointestinal problems by the Rome Foundation, a non-profit, independent expert committee who met in Rome, hence the name. The Rome III criteria is simply:

Recurrent abdominal pain or discomfort* at least three days a month over the last three months associated with two or more of the following:

1. Improvement with defecation.

2. Onset associated with a change in frequency of stool.

3. Onset associated with a change in form (appearance) of stool.

*Discomfort being an uncomfortable sensation and not pain.

In short, if you have occasional abdominal pain or discomfort and altered bowel movements over a period of at least three months, you have IBS. If you suffer from IBS I am sure you can quickly see that this is, well, a rather inadequate description, as the symptoms of IBS are in reality far more varied and often much more frequent. We will explore the symptoms in a lot more detail later.

The Rome III criteria also has three subtypes of IBS depending on whether you tend toward constipation, diarrhoea, or a combination of both:

Type 1: IBS with diarrhoea (IBS-D): Loose stools more than 25 per cent of the time and hard stools less than 25 per cent of the time.

Type 2: IBS with constipation (IBS-C): Hard stools more than 25 per cent of the time and loose stools less than 25 per cent of the time.

Type 3: IBS with mixed bowel habits or cyclic pattern (IBS-M): Both hard and soft stools more than 25 per cent of the time.

The problem with this classification is that many people will switch between each of these subtypes. Your predominant subtype may, however, be used to direct your treatment. For example, if you have IBS-D you might receive a drug to help stop the diarrhoea.

It is important to know that the Rome III criteria is more of an ‘expert opinion’ than it is based on the range of symptoms that people with IBS actually suffer from, and is more for research purposes than it is for working out if you actually have IBS. In fact, an expert review concluded that the accuracy of the Rome III criteria has not been established. In other words, it is not something you want to solely rely on.3

So what are the symptoms of IBS? Well, beyond the simple Rome III definitions there are a host of other symptoms that people with IBS are known to suffer from. Answer the following questionnaire to see if you are experiencing some of the more common symptoms.

THE IBS SYMPTOM QUESTIONNAIRE

Tick ‘yes’ if you typically have experienced these symptoms more than three days a week over the last month.

 

1. Do you suffer from abdominal pain or discomfort?

image No image Yes

2. Do you feel relief of pain or discomfort upon defecation?

image No image Yes

3. Does the pain or discomfort change with bowel movements?

image No image Yes

4. Do you feel bloated or distended?

image No image Yes

5. Do you have visible abdominal distention?

image No image Yes

6. Do you experience constipation (hard, pellet-like stools)?

image No image Yes

7. Do you experience diarrhoea (loose and runny stools)?

image No image Yes

8. Do you experience a combination of constipation and diarrhoea?

image No image Yes

9. Do you get abdominal pain and cramps?

image No image Yes

10. Do you suffer from excessive flatulence?

image No image Yes

11. Do you get a sense of urgency to rush to the bathroom?

image No image Yes

12. Do you strain upon defecation?

image No image Yes

13. Do you get more frequent stools at the onset of pain?

image No image Yes

14. Do you get looser stools at the onset of pain?

image No image Yes

15. Do you feel a sense of incomplete evacuation?

image No image Yes

16. Do you notice mucus in your stools?

image No image Yes

17. Do you experience reflux or heartburn?

image No image Yes

18. Are your symptoms worse after eating?

image No image Yes

19. Are your symptoms worse as the day progresses?

image No image Yes

20. Are your symptoms related to stress?

image No image Yes

21. Do you suffer from depression and/or anxiety?

image No image Yes

22. Do you experience chronic fatigue and tiredness?

image No image Yes

23. Do you suffer from muscle aches and pains?

image No image Yes

If you answered ‘yes’ to questions 1, 2 or 3, you have IBS by the textbook definition. However, in reality there are a lot of other common symptoms and there is a good chance you have a lot more going on.

As you can see, there are many varied symptoms of IBS. Although you may not have all of these, you will have quite a few. It is important to understand that IBS is more than just the Rome III ‘textbook’ definition; it is actually a constellation of diverse symptoms ranging from digestive symptoms to problems that are not limited to your digestive system, such as chronic fatigue, anxiety or muscle pain.

UNDERSTANDING COMMON DIGESTIVE SYMPTOMS

Constipation

Constipation is very common; in fact, a large survey of over 10,000 people in the United States found that 14.7 per cent suffered from constipation and almost half of these people said they had been constipated for over five years.4 Many of these people also met the criteria for IBS.

One of the difficulties with defining constipation is that no one seems to agree on what the definition is exactly. The opinion of medical professionals varies but one of the most popular is based on frequency, defining constipation as less than three bowel movements per week, although this is not a strictly accurate definition. And if you ask the average person what constipation is, they will tend not to focus on frequency at all and tell you constipation is related to symptoms such as straining, hard lumpy stools, bloating, abdominal discomfort, unproductive urges, inability to defecate at will, an excessive amount of time spent on the toilet or a feeling of incomplete evacuation.5,6

To further complicate things, what constitutes a ‘normal’ bowel movement seems to vary quite widely from person to person. When surveyed, most people (98 per cent) tend to report that they normally have between three bowel movements per day and three bowel movements per week. So you can see, a definition based solely on how frequently you move your bowels is not going to be very helpful.7

To help clarify things again, the Rome III criteria also has a definition of constipation:

Presence of two or more of the following symptoms over the last month:

1. straining during at least 25 per cent of defecations

2. lumpy or hard stools in at least 25 per cent of defecations

3. sensation of incomplete evacuation for at least 25 per cent of defecations

4. sensation of obstruction/blockage for at least 25 per cent of defecations

5. manual manoeuvres (that is, using your fingers, or pushing against your pelvic floor) to facilitate at least 25 per cent of defecations

6. fewer than three bowel movements per week.

Also, loose stools are rarely present without the use of laxatives.

You are forgiven if you lost interest after the word ‘Presence’. Many people find this definition hard to grasp. Fortunately, a much easier to understand and perhaps more revealing definition of constipation was developed by a group from the University of Bristol in England which, incidentally, is known as the Bristol Stool Scale.8 The great thing about the Bristol Stool Scale is that it is an easy visual reference guide that gives you an idea of whole-gut transit time, that is, the time it takes your food to pass from your mouth, through your digestive system and out the other end.

The average transit time is around 30 to 40 hours, with 70 hours (three days) at the upper range of normal.9 Transit time in people with IBS may vary from just seven hours with diarrhoea, up to 96 hours with constipation.10 A slow transit time based on the Bristol Stool Scale is an excellent indicator of constipation and is a more accurate indicator than how frequently you go.11

Simply, if you have a slow intestinal transit time you will have hard lumpy stools (Types 1 and 2 on the scale), which cause straining, difficulty and discomfort. Types 1 and 2 on the scale are a sign of constipation. If your stool is slow, it sits in your colon longer and tends to dry out because you reabsorb the water, hence the dry, compact shape.

Ideally your stools should be a Type 3, or even better a Type 4, which is soft and easy to pass. Higher numbers up the scale (5, 6 and 7) are the realm of rapid transit and watery diarrhoea.

image

Diarrhoea

Like constipation, diarrhoea is a surprisingly common problem in the general population. A survey of more than 1000 people in the United States found that as many as one in four people reported suffering from chronic diarrhoea.12 It is estimated that about 70 per cent of people with IBS suffer from diarrhoea, and half of these people will have diarrhoea most of the time while the other half alternate between constipation and diarrhoea.13

Chronic diarrhoea is an incredibly stressful and troubling symptom to live with. Not knowing when you might have an episode, having to plan ahead and risking embarrassment, has a huge impact on a person’s quality of life and psychological wellbeing and may cause fear, anxiety and panic. In fact, a survey at South Manchester University Hospital revealed that feelings of hopelessness because of the relentless and often poorly treated symptoms of IBS cause a lot of sufferers to go so far as contemplating suicide.14

And, in a vicious circle, stress and anxiety are known to decrease gut transit time and thus cause diarrhoea because your digestive system is under the control of your nervous system.15 So in a catch-22, diarrhoea can cause stress that can trigger diarrhoea.

The general definition of IBS-related diarrhoea is loose (mushy) or watery stools more than 25 per cent of the time for at least three months. On the Bristol Stool Scale, diarrhoea would be a Type 6 or 7, indicating rapid transit.

If your diarrhoea is with every bowel motion, is watery, associated with excessive gas, weight loss and relatively recent (less than two weeks) you should seek immediate medical care as you can become severely dehydrated and need to be investigated for something more serious, like a parasitic infection or an underlying illness, that may be causing your symptoms.16 In any case, if diarrhoea is your predominant symptom you should seek medical advice for the same reasons.

If you have had diarrhoea for a number of months and have been tested and nothing has been found, or it is intermittent with normal bowel movements, it is likely you have IBS. A number of experiments have found that people with IBS-related diarrhoea have subtle changes in gut function including increases in muscle contractions and a fast transit time.17 This helps explain why diarrhoea may occur in IBS in the absence of common causes, and why after your tests come back negative you might be diagnosed with IBS.

It is also worth noting that another subtype of IBS called postinfectious IBS (PI-IBS) usually has diarrhoea as a predominant symptom.18 As the name suggests, PI-IBS develops after gastrointestinal infection with a bacteria or parasite, such as traveller’s diarrhoea. Sometimes infections like this can develop into IBS months or even years after the infectious organism is treated or your initial symptoms have passed.

Bloating

Abdominal bloating is one of the most troubling symptoms of IBS. In a survey where people with IBS were asked to rate their most bothersome symptoms, the vast majority said bloating was a far more significant symptom than physical pain.19