Irritable bowel syndrome is an extremely common functional digestive disorder that can be difficult to treat. Drugs are often ineffective and can have uncomfortable side effects. These five strategies can help address the root causes of a patient’s symptoms so you can treat IBS safely and effectively.
Irritable bowel syndrome (IBS) is a widely diagnosed, often misunderstood condition that affects a huge chunk of the population, with some estimates as high as 28 percent. (1) IBS is characterized by abdominal pain, discomfort, and changes in bowel habits and is diagnosed when other conditions with structural or biochemical diagnostic criteria (such as IBD or celiac disease) have been ruled out. In other words, IBS is a “diagnosis of exclusion.” The range of symptoms, poorly defined pathogenesis, and functional nature of IBS make it a notoriously difficult disorder to treat.
Because there is no widely recognized cause of IBS in the mainstream medical community, standard treatment is based primarily on symptom suppression and management. This may include antidiarrheal medications, anticholinergic or antispasmodic medications, laxatives, SSRIs, or 5-HT3 antagonists. These drugs primarily target intestinal motility and pain relief as a way to address a patient’s most problematic symptoms.
There are several problems with this approach. The most glaring issue is that these treatments are often ineffective, with high rates of patient dissatisfaction and many seeking alternative treatments. (2, 3) Further, many of these drugs can cause side effects such as bloating or constipation that may be just as problematic as the patient’s initial IBS symptoms. Some of the drugs, such as alosetron, have more severe (even life-threatening) complications. But the core issue is that none of these drugs actually address the underlying causes of IBS and therefore aren’t really improving the health of the patient.
Successful non-drug options for IBS
Fortunately, our understanding of the causes of IBS is rapidly improving, allowing us to develop safer and more targeted treatments for IBS. I discussed several potential causes of IBS in depth in another article, focusing mainly on disrupted intestinal microbiota and food intolerances, but there can be other contributing factors as well. In this article, I’ll discuss five options for treating IBS that address the root causes of IBS and are safer and often more effective than the standard drug treatments.
#1: Probiotics and Prebiotics
One emerging factor in the pathogenesis of IBS is disrupted intestinal microbiota. Several studies have identified differences in the intestinal flora of IBS patients compared with healthy controls, including decreased microbial diversity, a higher degree of temporal instability, and decreased levels of bacteria that are believed to be beneficial, such as Bifidobacterium and Lactobacillus species. (4)
With this in mind, it’s unsurprising that probiotics are being increasingly investigated as a treatment option for IBS. Aside from their potential role in reshaping the gut microbiome, there are several mechanisms by which probiotics may improve IBS symptoms: changing intestinal motility, reducing visceral hypersensitivity, improving intestinal barrier function, and calming intestinal inflammation and immune activation, to name a few. (4)
Clinical trials evaluating the effectiveness of probiotics for treating IBS are promising but still limited with respect to specific treatment protocols. Because there are so many probiotic strains and combinations of strains on the market, the number of studies on any one formulation is too small to base any strong conclusions on. Variables like dosage, frequency, method of delivery, symptoms measured, and trial duration make the body of research even more heterogenous.
That said, the overwhelming trend is that probiotics have a beneficial impact on IBS patients, and there’s more than enough evidence to support their incorporation into a treatment protocol. (4, 5, 6, 7) Some of the probiotics that have had positive results in placebo-controlled trials include various Lactobacillus species like L. rhamnosus GG and L. acidophilus, various Bifidobacterium species like B. infantis and B. longum, and mixtures of strains. Table 3 in this review paper summarizes the results of randomized controlled trials testing various probiotics in IBS patients.
The most appropriate probiotic will depend on the patient’s specific issues. For instance, patients with SIBO-associated IBS often don’t tolerate probiotics containing lactic acid bacteria but do well with a soil-based probiotic. Unsurprisingly, research indicates that the best results with probiotics are seen in patients whose IBS was initially triggered by infectious gastroenteritis or a round of antibiotics. (5)
Prebiotics are another tool that can be extremely useful for rebalancing the intestinal microbiota, but as of yet, there’s little research on using prebiotics to treat IBS. A couple of studies have shown improvement in IBS symptoms in response to prebiotic administration, (8, 9) and others have shown benefit when used in combination with other therapies, (10, 11) while others have resulted in worsening symptoms or no effect. (12, 13)
Really, it isn’t surprising that the results are so mixed. On the one hand, it is well understood that prebiotics promote the growth of beneficial bacteria in the gut and are typically far more effective at modulating the intestinal microbiota than probiotics are. On the other hand, prebiotics promote bacterial fermentation, which can exacerbate bloating and other IBS symptoms. The key is balancing short-term goals, such as symptom alleviation, with the long-term goal of restoring healthy intestinal flora. Prebiotics are an important tool for achieving that goal but will likely be most useful in combination with probiotics, antimicrobials, and other strategies.
#2: Low-FODMAP Diet
Another approach that is gaining traction in the scientific community as a treatment for IBS is the low-FODMAP diet. FODMAP stands for fermentable oligo-, di-, mono-saccharides, and polyols and is a class of short-chain carbohydrates that are poorly absorbed by humans but are readily fermented by our intestinal bacteria. Foods that are generally considered to be high in FODMAPs include things like onions, beans, wheat, apples, and most dairy products. Many prebiotic supplements are also FODMAPs, including inulin, galactooligosaccharides (GOS), and fructooligosaccharides (FOS).
FODMAPs can cause problems in IBS patients for a couple of reasons. First, unabsorbed FODMAPs prompt increased secretion of fluid into the intestines, which can contribute to abdominal discomfort and diarrhea. Second, these unabsorbed FODMAPs are fermented by intestinal bacteria, resulting in gas, bloating, and abdominal distention. This is a problem, particularly when SIBO is present and excessive fermentation occurs in the small intestine, but many IBS patients also experience heightened sensitivity and discomfort in response to normal gas production in the colon.
Clinical trials have consistently shown that adopting a diet low in FODMAPs can significantly reduce the severity of IBS symptoms and improve quality of life. Several reviews published within the past year summarize the available evidence and conclude that a low-FODMAP diet is effective for treating IBS compared to control diets and other dietary interventions. (14, 15, 16)
However, it’s important to realize that a low-FODMAP diet is primarily a way to manage symptoms in the short term and is not the best choice as a long-term solution for IBS. If the patient’s IBS is caused by SIBO, a low-FODMAP diet will provide relief but will not address the underlying problem of bacterial overgrowth. Additionally, removing FODMAPs means removing many of the best food sources of prebiotics. Maintained long term, this can lead to reduced microbial diversity, which can actually contribute to IBS. (17, 18, 19)
So while a low-FODMAP diet can provide safe and immediate relief to patients with IBS, it’s important to also address the underlying causes of the IBS and avoid staying on a low-FODMAP diet long term.
#3: Identify Food Intolerances
Other food sensitivities are also extremely common among IBS patients and are often responsible for causing or exacerbating symptoms. We know that certain food proteins (gluten, for instance) can lead to inflammation in sensitive individuals, especially where increased intestinal permeability is already present, and studies show that at least two-thirds of IBS patients exhibit chronic low-grade inflammation. (20, 21)
I’ve written before about non-celiac gluten sensitivity (NCGS), and I maintain that it’s a significant clinical problem that is still not taken seriously enough by most healthcare providers. IBS-like symptoms occur in most patients with NCGS, making the two conditions nearly indistinguishable in many cases, and one study estimated that about one-third of IBS patients have NCGS. (20)
Proteins in dairy, yeast, soy, eggs, and other foods may also contribute to IBS, whether as IgG-mediated food sensitivities or true IgE-mediated allergies. (21) Lab testing for food intolerances still has a long way to go, but we often use Cyrex Arrays 3 and 4 for testing for wheat protein sensitivity and gluten-associated cross-reactive foods.
The gold standard for identifying food intolerances is an elimination diet. It takes more work for the patient, but it’s cheap and effective, and there are lots of resources available to guide patients through both the elimination phase and the slow reintroduction of foods. (My book The Paleo Cure is a good place to start.)
It’s worth noting that in many cases, food intolerances themselves are caused by a deeper problem like SIBO, gut infections, or increased intestinal permeability. So while identifying and removing food intolerances is often an important component of treating IBS, it’s still wise to investigate whether other issues could be at the root of the problem.
#4: Digestive Support
Another avenue I like to explore when treating IBS patients is supporting strong digestion with HCl and digestive enzymes. Stomach acid is vital for protecting against infectious agents and digesting food but also for preventing bacterial overgrowth in the small intestine, so having enough stomach acid is especially important when addressing SIBO-related IBS.
I’ve also found digestive enzyme supplements to be helpful for many IBS patients. A good approach is often to have the patient do a trial of HCl and/or digestive enzymes, where they take the supplement for a period of time and note whether their symptoms improve. The supplements I typically recommend are Thorne Research Betaine HCL/Pepsin and Now Super Enzymes.
#5: Mind–Body Approaches
One myth about IBS that can cause a lot of distress for patients is that “it’s all in their head.” Patients with IBS are often led to believe that because nothing is structurally wrong with their digestive system, their symptoms are simply a result of stress—or worse, their symptoms aren’t real.
It’s very clear that many, if not most, cases of IBS involve physical causes. However, that’s not to say that stress and cognitive function have no bearing on IBS. On the contrary, extensive research on the gut–brain axis shows how dramatically mental function can affect digestion.
The digestive system is connected to the brain directly via nerve pathways and also indirectly via the endocrine and immune systems. Stress-induced signaling in these pathways can cause changes in intestinal motility and secretion, increased visceral sensitivity and intestinal permeability, and even disruptions of the intestinal microbiota. (22) You may notice that these changes sound a lot like IBS.
Several approaches targeting the brain–gut connection have been studied and found to be effective for treating IBS patients. For example, studies have shown that mindfulness techniques, including mindfulness-based stress reduction (MBSR) and meditation, reduce IBS symptom severity and improve patient quality of life. (23) Additionally, results suggest that mindfulness interventions create lasting and even continued improvement for patients. This is at odds with most drug interventions, where any improvement disappears as soon as treatment ceases.
Research also supports the use of hypnotherapy for treating IBS. At present, IBS hypnotherapy trials have uniformly shown significant improvement in symptom severity and/or quality of life, with the majority showing improvement compared to control groups. (24, 25, 26) Cognitive behavioral therapy can also be effective for reducing symptoms and improving daily functioning in IBS patients. (27, 28, 29, 30)
Another interesting area of IBS research is the placebo response. IBS patients have a notoriously large placebo response in clinical trials (between 30 and 60 percent (2)), and several studies have now been conducted to investigate placebo as a treatment in itself. One trial from 2008 used placebo acupuncture along with a strong patient–practitioner relationship to treat IBS patients, and 60 percent of the participants experienced a significant improvement in symptoms and quality of life. (31)
Another interesting study found that 59 percent of patients taking open-label placebo pills reported “adequate relief” at the end of the study. (32) The researchers compared this result to that of the IBS drug alosetron, which provided adequate relief to 51 percent of patients on average. In other words, patients taking a sugar pill who knew they were taking a sugar pill showed more improvement than patients taking a specifically formulated and extensively researched IBS drug (a drug that also happens to be quite dangerous).
It’s pretty obvious that stress reduction and other “mind–body” techniques have an important role to play in treating IBS, and it’s vital for patients to have some way of managing mental stress in order for other treatments to be maximally effective.
To sum up, there are many non-drug strategies that can be effective for treating IBS, especially when used together in a multi-pronged approach. To be clear, I’m not against drugs as a rule. As always, I’m interested in the treatment that is most effective while doing the least amount of harm, and sometimes drugs are the best choice. (For instance, rifaximin is quickly becoming one of the most useful IBS treatments and deserves a post of its own.) But the five non-drug strategies described here are low risk and often high reward and thus deserve consideration when treating IBS.