1.13 Digestive issues and IBS

"Our gut is the most amazing giant forest ever, populated by the weirdest of creatures."

Giulia Enders, Gut: The Inside Story of our Body's Most Underrated Organ

The gut is one of the most under-rated and ignored organs in the body. It is 30ft long and the whole of the tube that starts at your lips and ends at your bottom is enveloped in a layer of nerve cells. These specialized cells, known as neurones, are just the same as the ones found in your brain and throughout your nervous system.

In total, there are something like 100 million neurones throughout the gut. That’s more than the combined total you will find in the whole of the spinal cord and the peripheral nerves that wind around your body. The gut is not just about grinding up and absorbing all the nutrients you need and disposing of the junk. Your gut has enormous power to influence your mood, your emotions, and even how you think. It has easily earned its nickname as the 'second brain.’

All of this means there is a complex interaction between you and your gut. We've all experienced tummy problems related to stress or anxiety. It might have been an examination at school, a driving test, an important interview for a job, or speaking in public. Chances are that the symptoms you describe will involve the gut. It might be symptoms from the upper end of the gastrointestinal tract like nausea or indigestion. Or it could be lower down with stomach gurgling, wind, or even full-on diarrhea.

"Anyone who suffers from anxiety or depression should remember that an unhappy gut can be the cause of an unhappy mind. Sometimes, the gut has a perfect right to be unhappy, if it is dealing with an undetected food intolerance, for example. We should not always blame depression on the brain or on our life circumstances – there is much more to us than that."

Giulia Enders, Gut: The Inside Story of our Body's Most Underrated Organ

Constipation

The sedentary nature of writing can be a factor and being physically inactive can reduce your bowels to glacial speeds. It’s not the most glamorous of topics, but it is not just a minor inconvenience; it can be genuinely unpleasant and that’s not usually appreciated by people until it is experienced. As well as being plain painful it can be difficult to think of anything else, and it can leave you feeling fatigued as well.

Some medications are notorious. Opiates are a common cause and even the small amounts of codeine found in relatively simple painkillers that can be bought in the pharmacist will often wreak havoc on bowels.

The prevention of constipation is, as most people know, best achieved by keeping up with healthy levels of fruit and vegetables in your diet. Ensuring you get active will help. You also need to pay attention to your hydration, as this can worsen constipation.

If it gets out of hand then you’ll probably need to pay a visit to the local pharmacist to get something to help.

"When I finished my first novel and received the first round of heavy feedback from my editor, it threw me for a loop. I thought I was prepared for harsh criticism; I thought I had braced myself for critique. Instead, it hit me like concrete and I went down – hard. I've always been a picky eater and experience digestive issues related to stress, but this kicked it up to a whole new level."

Robin C. Farrell, The Healthy Writer survey

Irritable bowel syndrome (IBS)

There is a risk that IBS becomes a diagnosis of exclusion, left over after all the investigations have been exhausted. And medicine has a lot of investigations that can have nasty side effects.

There are some important tests that need to be done in the initial investigation but you don’t necessarily need to have had every test under the sun to make a diagnosis of IBS. You will need to discuss it with a healthcare professional to find a sensible path that balances appropriate assessment while avoiding over-investigation. With that in mind here are some key features of IBS:

Cramping and abdominal pains. These can be very variable and they may be associated with food.

Bloating. People with IBS will often feel swollen and uncomfortable.

Diarrhea/constipation. You might have one or another of these. Some people with IBS will oscillate between the two. There might be mucus in your poo as well. There shouldn’t be blood with IBS, but if you do see it then don’t panic. It should definitely be checked out but the most common cause of blood is hemorrhoids. Most people will not have cancer or any other significant bowel disease.

General symptoms. These can be hugely wide-ranging but feeling tired, fatigued or lacking energy is common as well.

Options for managing your IBS

With IBS you need to be careful about the advice you are given as your gut and your IBS will not be the same as the next person. IBS presents in an enormous range of ways and the right way to manage it can be very different from person to person. Here is some general advice that applies to most people:

Make sure you are well-hydrated. It’s important for the gut to have enough water to form the stool or constipation can result.

Caffeine can be a trigger for many people. I’ve seen startling improvements in some patients who have cut back or cut out caffeine and their bowel symptoms have resolved.

Often a ‘treat the symptoms’ approach is taken. These could be medications that help reduce spasm in the gut, it could be laxatives that ease constipation, it could be anti-diarrheal medications. These are hugely dependent on your symptoms and your immediate discomfort. Your pharmacist will have lots of medications to try.

A holistic approach with IBS can be useful. Think about the stress and possible anxiety in your lifestyle and how this can be addressed.

Think about your diet

Most people who have IBS relate their problem to the food they eat, but specific individual triggers are often hard to find. If you have lactose or gluten intolerance then you will need to eat with these in mind. Establishing food intolerances can be tricky and you may need the help of a dietician to manage exclusion diets. Many different diets have been tried with limited success in IBS but there are broad dietary principles that can help some people.

Reduce your ‘resistant starches’

Some foods are not as easy to digest as others. If those foods manage to get all the way to your colon then they can cause problems. Gases can lead to wind and to bloating. Foods that can be particularly problematic include:

Increase your fiber

The Western diet is notoriously poor when it comes to fiber. Most of us don’t take enough of any kind. It gets a little more complicated with IBS as it can be helped by fiber, but the trick here is to get the right kind of fiber.

What? There is more than one kind of fiber?

‘Fraid so. The fiber that seems to be of benefit to people with IBS is the soluble kind. Insoluble fiber can make IBS worse. Normally insoluble fiber is good to have. It doesn’t get broken down in the gut so pulls in water that helps to bulk out stool and that helps the poo get through your gut. That’s unhelpful in IBS. Sources of insoluble fiber are the skin and pith of fruit and vegetables, wheat and bran, and whole grains. Examples of soluble fiber (the good stuff in IBS) include oat, barley, nuts and seeds, fruit and vegetables.

The challenge with fiber is that increasing it at all can cause wind and bloating. A cautious approach is usually necessary to test changes.

The FODMAP diet

Joanna gives a lot more information in the next chapter on her personal experience with FODMAP and it is a remarkable success story. She gives details on the specific components of the FODMAP diet.

There is increasing evidence that this can be helpful for many people but one of the biggest barriers is that it is quite a challenging diet. You need to have a decent understanding of the different building blocks that make up food and some of these are quite subtle.

You will need to commit.

That could be really tough if you are eating with your partner (who may have their own dietary needs) and with your family or anyone else. But if you're motivated to reduce your pain, it could be worth trying.

Joanna gives a lot more information in the next chapter on her personal experience with FODMAP and it is a remarkable success story. It is possible that you will need the specialist advice of a dietician to get FODMAP to work for you but it can absolutely be followed by anyone.

Probiotics

There is some evidence of improvement in IBS symptoms with probiotics, but it remains difficult to recommend specific regimes. The research suggests a single probiotic in a low dose for a short period is most likely to be effective.

Other medications

There is evidence that anti-depressant medications can improve symptoms in some people. The ones looked at most carefully are medications like selective serotonin re-uptake inhibitors (SSRIs) and the best known one is fluoxetine (Prozac®).

Some people rail against taking SSRIs for their digestive problems. They suspect the implication is the doctor thinks it's 'all in their head' somehow. That’s not the case. Well, it’s certainly not what I’m thinking.

There is unquestionably an important link between anxiety and gut symptoms, and we know SSRIs can treat anxiety disorders. In addition, thinking about the gut as a ‘second brain’ throws the rationale for these drugs into clearer focus. The gut releases chemicals, known as neurotransmitters, in the same way as the brain. Influencing the amount of serotonin in that network of gut neurones helps reduce IBS symptoms in some people in just the same way as it can help the anxiety and depression in the brains in our head.

Hypnotherapy

There's actually some decent evidence that hypnotherapy can be useful for some people with IBS. The biggest challenge might be finding someone that can do it effectively, so look for specific testimonials around IBS for a practitioner.

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