Treating the Root Cause for IBS: Removing Gut Irritants

Following a Whole Foods, Plant-Based Diet

The first step in removing irritants that cause or exacerbate IBS is implementing a whole-plant-based diet. Processed, refined foods can cause intestinal permeability, feed pathogenic bacteria and promote inflammation. Pro-inflammatory foods include those high in sugar, processed starches, refined vegetable oils and trans fats, and foods with artificial sweeteners, chemicals and preservatives. Alcohol, caffeine and NSAIDs should also be removed. 

In patients with IBS, also consider the potential presence of a food allergy, sensitivity or intolerance. Food allergies are an immediate response to a food (in any amount) that causes an immune response; food sensitivities are also an immune response that leads to symptoms but may not be triggered until a certain amount of food is ingested. In contrast, a food intolerance is a digestion-related reaction to a food due to a potential lack of enzymes or other imbalance in the digestive process. For example, those with lactose intolerance lack the enzyme lactase to break down the carbohydrate in lactose. Common food allergies, intolerances, and sensitivities include gluten, wheat, dairy, soy, corn, nuts and eggs. Other eliminations to consider include nightshades (such as peppers, eggplant, potato), cruciferous vegetables (such as broccoli, cauliflower and cabbage), legumes, high-FODMAP foods and histamine-rich or histamine-releasing foods [1,2,3].

Removal of dietary triggers aims to control symptoms while allowing for the most liberal diet possible. Some patients may present with pre-existing hypotheses about trigger foods, while others may have little sense of what dietary factors are contributing to symptoms. Allow conversations with patients, along with any food sensitivity or allergy tests, to guide the choice of whether to implement a full elimination diet or to take a more targeted approach and eliminate only common triggers or patient-suspected trigger foods. A full elimination diet may exclude gluten, dairy, egg, soy, corn and nuts,and in many cases, high-FODMAP foods. However, individual triggers should always be assessed and not all eliminations may be appropriate for every patient. Guide patients towards options such as, lean meat, chicken and fish, vegetables such as zucchini, carrots, green beans and spinach, olive and avocado oil, low-FODMAP fruits, coconut products and rice or sweet potatoes. In contrast, the FODMAP Gentle approach may be warranted in those with contraindications for a full elimination diet. 

Once symptoms are under control, patients can begin to add back whole foods one by one to assess tolerance. Remember that patients with food intolerances may have a sensitivity threshold to some foods, so start by introducing small amounts of each. Use accidental exposures or “slip-ups” as a learning opportunity to assess and learn tolerances. For patients who are chronically non-compliant, explanation of why and how foods cause inflammation, contribute to leaky gut, and feed pathogenic bacteria can help them understand the importance of dietary changes in promoting digestive healing and controlling symptoms.

A focus on what patients can eat, versus those they cannot can help frame the conversation in a positive direction. While highly-processed products, sugar, refined oils, and alcohol should be avoided long-term, minimally processed alternatives can be considered, such as olive oil, maple syrup, plant-based milks that are free from added sugars and gums, and alternative flours, like almond, coconut, or chickpea. Work with patients to develop a long-term, whole foods diet that fits within their lifestyle and promotes pleasure and satisfaction. 

Introducing Antimicrobial Supplements to Target Pathogens

After implementing dietary and lifestyle changes, supplements may be considered. Antimicrobial supplements may be used to remove pathogenic bacteria in patients with suspected bacterial overgrowth. These include herbal supplements that use a therapeutic (not a food dose) of active compounds to kill microbes. They are different from prescription medications, such as antibiotics, which kill bacteria, and antifungals, which kill yeast. Instead, antimicrobials create a gut environment where beneficial bacteria can flourish. Examples include allicin (from garlic), caprylic acid (from coconut), oregano, thyme, peppermint oil, turmeric, clove and others delivered in large doses to kill unwanted gut bacteria [4,5].

There is no universally recommended antimicrobial supplement; choosing those to trial will depend on a patient’s symptom profile and/or suspected root cause(s) of IBS. Both single-ingredient formulas and broad-spectrum antimicrobials are available. Effective broad-spectrum options include GI MicrobX, Para-Gard, Broad Spectrum Complex and Biocidin. Each should be taken approximately 1-hour before meals and separate from a probiotic. 

When recommending supplements and enzymes, consider a patient’s general sensitivity to foods. Some products contain walnuts, coconut, dairy and gluten, while others may be derived from animal sources. Combination and broad-spectrum products can be impactful because they have many active ingredients that target a host of pathogenic bacteria, yet they also increase the risk for an adverse reaction and make it harder to identify triggering ingredients. Another important question to ask is whether patients are on a blood thinner, as many herbal blends such as berberine, garlic, clove, ginger, ginkgo, garlic, ginseng, oregano, resveratrol and turmeric, slow blood clotting.

In Practice

Dietary changes play an important role in removal of irritants that contribute to the trifecta of dysbiosis, inflammation and intestinal permeability, while supplements may also support overall healing. The aim of dietary changes and supplement use is always to use as few supplements and promote the most liberal diet possible while effectively reducing symptoms. Food eliminations and supplement recommendations require an ongoing iterative process and must be driven by an individual’s response to each food or product, as well as the quantity or dose at which they’re ingested. A patient’s microbiome, genetics, lifestyle and enzyme levels all contribute to response so it’s important to maintain frequent contact, sometimes between individual counseling sessions. Extra caution should be considered when recommending supplements for pregnant or breastfeeding women. Ensure patients purchase supplements from a trusted source, as supplements, enzymes, probiotics, and medical foods are not regulated by the FDA. Always check a trusted database of prescription drug food-nutrient interactions.