Peppermint tea is one of my favourite refreshers, so I was interested to read a paper(1) published in the latest issue of the British Medical Journal linking peppermint in the treatment of IBS (irritable bowel syndrome).  Back in August I wrote three lengthy pieces investigating IBS and this paper provides a nice update. 

The key to IBS is to try and find a cause to treat, this is very individual and may be linked to stress, emotions, food intolerances and more.  Any sort of diagnosis needs to be done in conjunction with a health professional.  However, it is always good to have some idea of the natural remedies that can help reduce symptoms.  The research in the British Medical Journal was a review of randomised controlled trials looking into the effect of fibre, antispasmodics (prescribed medication) and peppermint oil in the treatment of IBS.

Fibre
Traditionally, people with irritable bowel syndrome were instructed to increase their daily intake of dietary fibre, because of its potentially beneficial effects on bulking stools and moving them through the intestine more quickly (speeding up intestinal transit time).  However, many individuals with IBS found this advice unhelpful and some people reported that it made the condition worse.  The study looked at types of fibre and their usefulness in IBS treatment.  The investigators found that bran fibre (usually from wheat) had no effect on IBS symptoms.  However, ispaghula fibre, a soluble fibre derived from plaintain, did have a beneficial effect and reduced persistent symptoms of IBS.  The authors of the study indicate that ispaghula may be particularly beneficial to individuals who suffer constipation as one of their major IBS characteristics.

Ispaghula husk is readily available to buy from health-food stores and pharmacies as well as online. 

Antispasmodics
Antispasmodic medications attempt to reduce spasms in the digestive system.  Doctors frequently prescribe these types of medication for IBS symptoms, particularly when an individual is suffering from bloating and pain.  In the study 12 drugs were assessed.  Only 5 of these were shown to bring about a relief for IBS symptoms.  Some of the drugs, which are specifically licensed for use in IBS e.g. mebeverine, dicycloverine and alverine actually seemed to have very little evidence behind them.  The best evidence seemed to be for a drug called hyoscine.  The most common side effects for this type of medication are dry mouth, dizziness, and blurred vision, but none of the trials reported any serious adverse events.

It is not really known why antispasmodics are helpful for IBS sufferers.  The authors of this study note that “The biological rationale for the efficacy of antispasmodics is unclear.....antispasmodics may act by reducing colonic contraction and transit time and therefore pain and stool frequency”.  In light of the evidence discussed in this medical journal I would think that further studies are necessary to investigate the use of these drugs in patients with IBS to see if they really are helpful.

Peppermint oil
There were fewer available studies to analyse for the use of peppermint oil.  However, the studies that have taken place with this remedy show consistently positive results for use in IBS patients.  In fact peppermint oil appeared to be the most effective treatment for IBS when assessed via a measure called NNT, or number needed to treat, a measure of the number of individuals that need to be treated for one to get significant benefit.  Peppermint appears to have natural antispasmodic properties and is widely available over the counter in capsule form.  Larger trials of this traditional remedy would be welcome.

The authors conclude their paper by talking about the current guidelines for the management of IBS, they discuss the fact that these guidelines have been set around previous studies that have potential methodological flaws.  In the UK “Antispasmodics are recommended as first line treatment, particularly when pain and bloating are the predominant symptoms, although which of these drugs should be preferred is not stated”(1).  They also suggest that the current clinical guidelines be updated to take into account their findings.

(1) Ford AC et al.  2008.  Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ.  337:a2313

Written by Ani Kowal

On the 16th July I wrote about artichoke leaf extract (ALE) supplements for cholesterol lowering.  Evidence is also mounting for the usefulness of this plant supplement in the reduction of IBS symptoms (1,2).  In one study (2) 208 adults with IBS were given ALE for a two month period.  The individuals had a significant improvement whilst taking the supplement with a normalising of bowel pattern away from alternating constipation/diarrhoea toward normal.  The IBS sufferers also had a significant improvement in their total health-related quality of life scores.  The trials were small and provide preliminary evidence but it certainly seems that artichoke leaf extract is useful for an array of digestive complaints.  If you decide to try ALE supplements for the management of your IBS symptoms please follow the manufacturers dosage advice, taken in excess it may cause digestive upset.

When discussing IBS it is difficult not to mention the issue of food sensitivities or intolerances.  Some studies indicate that a large proportion of people afflicted with IBS have food sensitivities, very few have true food allergies, and that gas production and other IBS symptoms diminish when the sensitivities are discovered and the offending food(s) eliminated (3,4,5,6).  Assessing sensitivities can be quite subjective and therefore difficult to assess properly in a clinical-trial setting. 

Research suggests that some people with IBS may malabsorb the sugars lactose (found in milk), fructose (found in high concentrations in fruit juice and dried fruit) and sorbitol (found in diabetic and sugar-free products) (7).   Research shows that in a large majority of IBS patients with lactose malabsorption, a lactose-restricted diet can improve symptoms markedly both in the short term and the long term (8).  Fructose- and sorbitol-reduced diets in subjects with fructose malabsorption reduce gastrointestinal symptoms such as bloating, cramps, osmotic diarrhoea and other IBS symptoms (9).  Hence, individuals with IBS attempting to uncover food sensitivities should consider the possibility that milk, fruit juice, dried fruit and products containing sorbitol might cause worsening of their symptoms.

A note of caution – please do not attempt elimination diets without supervision from your GP or a fully qualified professional.  Many ‘food sensitivity tests’ are advertised at very high cost and, in my opinion, can often be unhelpful.  Working with a professional and keeping food diaries and symptom scores may uncover specific triggers for your personal symptoms.  Stress, emotions and psychology may also be playing a major role in your IBS symptoms so assessing how you feel could also prove helpful.  Foods may be triggering symptoms in conjunction with stressful/emotional periods but less-so at other times.

Finally I would like to briefly mention aloe vera juice.  Many individuals with digestive complaints report that their symptoms diminish greatly with the regular ingestion of an aloe vera juice drink or supplemental aloe capsules.  Most of the evidence so far is anecdotal (but that does not lessen personal experiences).  A few animal studies have started to provide weight to the evidence but very few human studies have occurred to date.  A test tube study(10) using human colon cells has shown that aloe vera did appear to work as a potent anti-inflammatory.  You may find it useful to try the juice yourself to see if it is helpful in reducing your personal symptoms.  Remember to follow the dosage guidance and try and keep note of your symptoms for about a week.  If the juice works for you then it is worth continuing with. 

That ends my posts on IBS, I do hope that the information presented over the last few days has been of help?!

(1)Walker AF et al.  2001.  Artichoke leaf extract reduces symptoms of irritable bowel syndrome in post-marketing surveillance study.  Phytotherapy Research.  15:58-61
(2)Bundy R et al.  Artichoke leaf extract reduces symptoms of irritable bowel syndrome and improves quality of life in otherwise healthy volunteers suffering from concomitant dyspepsia: a subset analysis.  J Altern Complement Med.  10:667-669
(3) King TS et al.  1998.  Abnormal colonic fermentation in irritable bowel syndrome.  Lancet.  352:1187-1189
(4) Jones AV et al.  1982.  Food intolerance: a major factor in the pathogenesis of irritable bowel syndrome.  Lancet.  ii:1115-1117
(5) Smith MA et al.  1985.  Food intolerance, atopy, and irritable bowel syndrome.  Lancet.  ii:1064
(6) Parker TJ et al.  1995.  Management of patients with food intolerance in irritable bowel syndrome: the development and use of an exclusion diet.  J Human Nutr Diet.  8:159-166
(7) Fernandez-Banares F et al.  1993.  Sugar malabsorption in functional bowel disease: clinical implications.  Am J Gastroenterol.  88:2044-2050.
(8) Bohmer CJ, Tuynman HA.  2001.  The effect of a lactose-restricted diet in patients with a positive lactose tolerance test, earlier diagnosed as irritable bowel syndrome: a 5-year follow-up study.  Eur J Gastroenterol Hepatol.  13(8):941-944
(9)Ledochowski M et al.  2000.  Fructose- and sorbitol-reduced diet improves mood and gastrointestinal disturbances in fructose malabsorbers.  Scand J Gastroenterol.  35(10):1048-52
(10)Langmead L et al.  2004.  Anti-inflammatory effects of aloe vera gel in human colorectal mucosa in vitro.  Aliment Pharmacol Ther.  19:521-527

Written by Ani Kowal

Both of the review studies(1,2) that I mentioned yesterday discuss the growing evidence that probiotics, supplemental beneficial bacteria, seem helpful in managing IBS.  Probiotics may help by reducing the level of inflammatory chemicals (cytokines), implicated in IBS.  Imbalances in gut bacteria can lead to chronic low-level inflammation in the intestines and the measurable presence of inflammatory markers in the bloodstream.   There are complications with the scientific studies that have taken place to date as it seems that the type of bacterial probiotic supplement used may be responsible for the degree of improvement noted in IBS sufferers.  Supplements containing Bifidobacteria seem to be especially effective.

(For definitions of probiotic, prebiotic and symbiotic please read Part I)

The problem with probiotic only supplements is the survival of the bacteria through our digestive system before they arrive at the large intestine.  It is often impossible to know how many, and which, live organisms are present in the supplements.  It is important to look for brands that are enteric-coated, so that the bacteria are not destroyed/digested by the stomach.  It is thought that probiotics work only as long as they are being taken, i.e. as the probiotic is no longer consumed, the added bacteria are rapidly washed out of the colon.  Hence prebiotic or a symbiotic supplements are probably the most beneficial in the long-term.  Another useful point to remember is that the bacteria are killed by heat so try not to take your probiotic supplement whilst drinking your morning cup of tea! 

Recently there have been some trials using symbiotics(3,4,5), supplements containing both probiotics and prebiotics, in the treatment of IBS and they have shown encouragingly positive results.  Two studies(3,4) found that the prebiotic-probiotic treatment significantly reduced feelings of general ill health, nausea, indigestion and flatulence.  Another study (5) found that a prebiotic-probiotic preparation was particularly helpful for sufferers of constipation-type IBS.  The supplement reduced general IBS symptoms, bloating and abdominal pain and increased stool frequency.

Larger trials are needed but a symbiotic supplement containing both probiotics and prebiotics may well be worth a try if you are suffering with the discomfort of IBS.  Look for supplements containing bifidobacteria and lactobacilli as these seem to be most beneficial.  After an initial period of a month or so you may wish to switch to a prebiotic (FOS) only supplement to maintain consistently high levels of gut friendly bacteria.  As I mentioned in an earlier post, I take a daily FOS supplement out of habit now and feel good on it!  Bacterial balance has been implicated in many conditions (not just those related to the digestive system) and may be important for keeping our immune system healthy.

Tomorrow I will be continuing the IBS theme so please check back for some more helpful ideas

(1)Wald A & Rakel D.  2008.  Behavioural and complementary approaches for the treatment of irritable bowel syndrome.  Nutrition in Clinical Practice.  23:284-292
(2)Heitkemper MM & Jarrett ME.  2008.  Update on irritable bowel syndrome and gender differences.  Nutrition in Clinical Practice.  23:275-283
(3)Bittner AC et al.  2005.  Prescript-Assist probiotic-prebiotic treatment for irritable bowel syndrome:a methodologically orientated, 2-week, randomized, placebo-controlled, double-blind clinical study.  Clin Ther.  27:755-761
(4)Bittner AC et al.  2007.  Prescript-Assist probiotic-prebiotic treatment for irritable bowel syndrome:an open-label, partially controlled, 1 year extension of a previously published controlled clinical trial.  Clin Ther.  29:1153-1160
(5)Colecchia A et al.  2006.  Effect of a symbiotic preparation on the clinical manifestations of irritable bowel syndrome, constipation-variant.  Results of an open, uncontrolled multicentre study.  Minerva Gastroenterol Dietol.  52:349-358

Written by Ani Kowal

Two review papers(1,2) have recently been published in the journal ‘Nutrition in Clinical Practice’ which look at the therapeutic approaches to dealing with irritable bowel syndrome (IBS).  They cover everything from cognitive behaviour therapy and hypnosis to diet and nutrition.  The papers are timely, this is a topic I am often asked about and have decided to spend the next few posts covering various nutritional aspects of IBS. 

IBS describes a combination of symptoms including constipation, diarrhoea, abdominal pain/discomfort, nausea and vomiting, feelings of fullness, gas and bloating.  Sufferers are often embarrassed by the condition which generally develops in individuals between the ages of 20 and 30 and affects around 20% of the population.  IBS also appears to be more common in women than men.

The causes of this uncomfortable condition are unclear.  However, an imbalance in intestinal bacteria is frequently implicated.  Often IBS develops after a bout of gasteroenteritis or repeat courses of antibiotics (which kill off the vast majority of intestinal bacteria).  The bacteria in the digestive system of individuals suffering from IBS seems to be different to healthy people with fewer ‘beneficial/friendly’ bacteria such as Bifidobacteria and Lactobacilli being present in those with IBS. 

Up to about 30 years ago it was a common misperception that the major functions of the large intestine (colon) was simply water re-absorption and storage of waste matter.  The colon is now recognised as an important organ due to the number of bacteria present (well over 10million bacteria are present in the colon per g of contents!).  These bacteria produce compounds, which can have beneficial/positive, neutral or damaging influences on the body.  Age, stress, antibiotics, the environment and diet can all affect the type of bacteria present in our digestive system.  A healthy diet may help boost the number of the friendly bacteria and hence decrease the incidence of infective disorders of the gastrointestinal tract and boost natural resistance against them.

The knowledge that specific species of bacteria may be of benefit to our health, especially Lactobacilli and Bifidobacteria, led to the development of probiotics, prebiotics and synbiotics which are designed to beneficially alter the bacteria present in our gut.  Most people will have a predominance of Bacteriodes bacteria in their digestive systems, these have both pathological and neutral effects.  For optimal health it would be better for us to have a gut dominated by Bifidobacteria and Lactobacilli.  The health promoting effects of these bacteria include prevention of the growth of harmful bacteria, improvement of immune functions, reducing gas/bloating problems, improved digestion and better absorption of essential nutrients and vitamin synthesis.  A probiotic, prebiotic or symbiotic supplement may be a way of beneficially altering the bacterial status of our colon. 

A probiotic is a supplement containing live friendly bacteria which aim to improve intestinal bacteria balance.  Probiotics are available as yoghurts, fermented milks, fortified fruit juices and freeze dried capsules/powders.   

A prebiotic is a food that stimulates the growth of the beneficial bacteria already present in the colon.  Fructooligosaccharides (FOS) which can be bought as powders are the most common prebiotics available.  Natural prebiotics can be found in asparagus, onion, chicory and garlic. 

Synbiotics are a mixture of probiotics and prebiotics. 

Tomorrow I will look further into these supplements and their use in the alleviation of IBS specific symptoms.

(1)Wald A & Rakel D.  2008.  Behavioural and complementary approaches for the treatment of irritable bowel syndrome.  Nutrition in Clinical Practice.  23:284-292
(2)Heitkemper MM & Jarrett ME.  2008.  Update on irritable bowel syndrome and gender differences.  Nutrition in Clinical Practice.  23:275-283

Written by Ani Kowal