Irritable bowel syndrome (IBS) is often difficult to resolve; once given a diagnosis, patients are often left to figure it out by themselves. But there are plenty of ways nutritional therapists can support people with gut issues, writes Hatty Willmoth.

Irritable bowel syndrome (IBS) is described on the NHS website as a singular condition with no obvious cause, that is “usually a lifelong problem”.

IBS symptoms may include constipation, diarrhoea, bloating and stomach cramps; there’s no cure, and the exact cause is “unknown” – according to the NHS.

Those who have been diagnosed with IBS by a GP are likely to have gone through a process of elimination first to rule out anything more serious, such as Crohn’s disease, ulcerative colitis and bowel cancer.

In practice, IBS is a label doctors give to those with otherwise unexplained gut symptoms, often with an apologetic shrug.

But for nutritional therapists, the story doesn’t end there; gut issues are their bread and butter.

Armed with an arsenal of tests and protocols, there is plenty they can recommend to support a client’s gut health, alleviate their IBS symptoms, and stop the diagnosis from becoming a life sentence.

ION lecturer Dr Kirstie Lawton is a nutritional therapist with decades of experience helping clients resolve their gut issues.

Alex Manos is Director of Functional Medicine at Healthpath, a functional medicine clinic with a “gut-first” approach.

Both have provided case studies which together demonstrate how clients with similar gut symptoms can have completely different paths to recovery.

The clients’ names have been replaced with aliases to preserve their anonymity.

Client one: Annie, 26

Annie, 26, came to Lawton after eight years of gut symptoms and a recent IBS diagnosis. Annie continually had an upset stomach, was bloated daily, and regularly experienced diarrhoea and flatulence.

Horrible already, Annie added that her symptoms seemed to get worse with exercise, which got in the way of her active lifestyle.

She wanted to train for a triathlon, but that was impossible when it was likely she would suddenly need to find a loo.

Lawton found out that Annie thought her digestive issues had become worse after taking a series of antibiotics, aged 17.

And, from a food diary, Lawton learnt that Annie’s diet included high amounts of gluten, dairy and sugar.

“There was a reasonable intake of grains and vegetables, and some fruit,” says Lawton, “and she mentioned that her and her husband generally cooked from scratch at breakfast and dinner.

“Lunch tended to be shop-bought sandwiches from a bakery or a meal from the canteen at her work.”

Could this be dairy intolerance?

After a lengthy conversation, Lawton recommended that Annie try removing dairy from her diet for three weeks, and then see what happened when she reintroduced it to test whether she might be intolerant.

There were a number of other small dietary changes that Lawton advised, such as the addition of anti-inflammatory foods to help calm down inflammation in Annie’s gut.

Lawton also recommended a few foods high in prebiotic fibre, to feed Annie’s gut bacteria; probiotic foods, to introduce some live cultures of helpful microbes into her gut; and polyphenol-rich foods, which contain beneficial plant compounds.

One step closer to solving Annie's IBS

Lawton says: “At the second consultation, I was delighted when [Annie] told me that removal of dairy had fully resolved all her gut symptoms, and that she now felt comfortable starting her training for a triathlon.

“We decided to continue without lactose at this time, while continuing to support her gut through diet and supplementation as it continued to heal.”

There were three supplements that Lawton suggested: one prebiotic, one probiotic, and one that was anti-inflammatory and would support the immune system, among other things.

At the same time, Lawton suggested that Annie could try some lactose-free products to try to work out whether it was lactose or casein which prompted her symptoms. Lactose and casein are proteins in dairy which are usually the root of dairy intolerances.

Resolving Annie's IBS for good

Annie’s third consultation rolled around, and it seemed that, yes, lactose was definitely the problem.

Lactose-free dairy products hadn’t seemed to have an adverse effect, but when Annie tried a hot chocolate and some dairy-containing desserts at a party, she had subsequently suffered with severe diarrhoea, bloating and tummy pain.

For the foreseeable future, Annie decided to continue without dairy for the most part, opting for lactose-free dairy products only occasionally.

And, for situations in which Annie couldn’t easily avoid dairy, Lawton recommended a lactase enzyme to help her digest lactose and avoid unpleasant symptoms.

There were also a few foods that Lawton mentioned to Annie which contained nutrients that she might miss from cutting out dairy, such as calcium, riboflavin, iodine, protein and fats.

They agreed that Annie would continue with her supplements and supportive nutrients for three more months, to repair any damage caused by inflammation, and they would catch up at another consultation three months later.

Case two: Jacob, 32

So, Annie’s IBS ended up being fairly straightforward; she had a dairy intolerance, specifically to lactose, and her symptoms went away when she went dairy-free.

But some cases are more complicated than that. Take Jacob, for instance.

Jacob, 32, came to Lawton with self-diagnosed IBS. He had extreme bloating in his upper gastrointestinal region, daily flatulence and abdominal discomfort, severe constipation, and occasional diarrhoea.

Since his teens, Jacob had also experienced severe sporadic incidents of debilitating fatigue that could last for weeks.

Jacob reported a number of stressful life events: family breakdown, an unwell child, and the collapse of a business during the pandemic.

He had also had severe food poisoning and a bout of glandular fever as a child.

Jacob had already tried to get rid of his symptoms in a plethora of ways. He had excluded dairy and gluten from his diet – and then processed foods, red meat, and fat too.

He had taken probiotic supplements, fibre supplements, peppermint oil capsules, and regularly took Buscopan – an IBS medication commonly taken to relieve cramping pains.

He had eaten more natural probiotics, such as sauerkraut, kimchi and kefir.

Jacob had even tried to follow a low-FODMAP diet: an elimination diet that excludes certain carbohydrates identified to exacerbate IBS symptoms in some people.

The acronym stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols, but they’re just sugars which aren’t easily broken down in the small intestine, and so can spend a while fermenting in the large intestine, which can result in uncomfortable gas.

People on low-FODMAP diets choose to avoid or reduce foods such as onions, garlic, mushrooms, apples, lentils, rye, milk, and more. It can be very restrictive.

But even this diet hadn’t helped Jacob. Nothing seemed to be working.

Lawton says: “He felt that he wasn’t getting anywhere, and that this was having a negative impact on his life. He was feeling more and more fatigued, and his usually very high energy levels had declined significantly.”

Moving forward with a stool test

Lawton ran a stool test for Jacob, and this revealed active inflammation and an imbalanced gut microbiome, with too much of some microbes and low levels of others.

Lawton also asked Jacob to fill in a template giving her a few more details, including “the time he ate, what he ate, how much he ate, the time of the onset of his symptoms, and the severity of symptoms”.

She recommended that Jacob began taking some supplements to support his energy levels, including vitamins A, C, D and E, selenium and zinc.

The second stage for Jacob

At their second consultation, Jacob said he already felt less fatigued, and they decided to continue supporting his immune health with the supplements and a diet rich in polyphenols and anti-inflammatory foods.

Taking a look at Jacob’s food diary confirmed to Lawton that he had an issue with a number of high-FODMAP foods, in particular oligosaccharides. This meant gluten, garlic, onion and chickpeas could be problematic for Jacob and worsen his symptoms.

So, oligosaccharides would be off the cards for now, and the first step to rebalancing Jacob’s gut would be introducing some antimicrobial foods to calm down the overgrown microbes; these included oregano, clove, grapeseed extract and wormwood, which he would take for eight to ten weeks.

Alongside this, he would take a low-dose Saccharomyces boulaardi supplement, to encourage the growth of some of his struggling gut microbes.

A resolution for Jacob's symptoms

At their third consultation, Jacob told Lawton that his gut symptoms were now minimal. He was no longer constipated or bloated, and his energy levels were back to normal.

They decided to phase out the antimicrobials he was taking over the course of two weeks, and Lawton recommended a few other probiotic, prebiotic and gut-supporting supplements to help Jacob’s gut fully recover. He continued taking the immune support supplement too.

Lawton says: “I’m pleased to report that [Jacob] no longer experiences GI issues and comes in for checks once annually.”

A third client at his wits' end

When Leo came to seek help from Alex Manos, he was experiencing much the same symptoms as Annie and Jacob: diarrhoea, bloating and stomach cramps.

Like Jacob, Leo had tried a variety of gut healing techniques already and had even seen a few practitioners over a two- to three-year period.

He had been on numerous diets, taken countless supplements, and tried “all the usual additional interventions”, says Manos, including time restricted feeding (a version of intermittent fasting), and vagus nerve exercises such as humming and gargling (intended to heal the nerve that connects the gut with brain). These therapies did help for a bit, but not much and not for long.

The practitioners Leo had previously been to see had already confirmed that he had a number of gut issues.

These included SIBO, which stands for small intestinal bacterial overgrowth, and refers to when certain strains of gut microbes grow so much in the small intestine that it throws the gut out of balance.

Leo also had a leaky gut, which is when the gut wall is compromised, so substances can travel in and out of the intestine; and dysbiosis in the large intestine, aka an unbalanced microbiome in his colon.

Leaky house: another piece to this puzzle

But during Leo’s first consultation with Manos, it became apparent that he also suffered with some sinus issues, fatigue and brain fog.

After further investigation, Manos found out that there had been a water leak in Leo’s home the year before his symptoms started.

Water damage can lead to hidden mould, which can allow spores and mould toxins – called mycotoxins – to proliferate and make those exposed to it unwell.

So, Manos and Leo decided to run a mycotoxin urine test to see whether the leak in Leo’s home had led him to come into contact with these harmful substances.

Leo's toxic environment

The results confirmed Manos’s suspicions: elevated levels of ochratoxin A. This particular mycotoxin has been linked to poor gut health through a number of different mechanisms.

Manos and Leo therefore put together a plan to get rid of it. They talked about how the mycotoxins could be removed from Leo’s home, by carefully removing the mould and fixing any remaining leaks.

They discussed how toxins work: the body eliminates them through our poo, pee and sweat, so all three have to be considered.

Air quality would need to be improved, so they talked about how mould grows and how Leo could prevent it in future, i.e. by controlling the temperature, humidity and ventilation of his home.

Manos recommended some supplements, including zinc, probiotics, liposomal glutathione, a broad-spectrum antimicrobial, and anti-inflammatory and antioxidant compounds such as quercetin, luteolin and resveratrol.

“Zinc can be very helpful for ochratoxin A,” says Manos. “In fact, zinc has been shown to help protect the gut lining from damage caused by ochratoxin A.”

No more mould!

Six weeks later, Leo was feeling much better and a mycotoxin test came back with a negative result.

“Interestingly, [Leo] had some incredible stressors during this time period,” says Manos, “but he noticed he was able to handle this much better than he previously would have been able to.”

Manos says that this case is “fairly typical” of what he sees in clinic these days.

“We can’t expect someone to have a healthy well-functioning digestive system if they have other health issues going on; it is a mutual relationship.

“I’ll admit, this case was made much easier by all the great work that previous practitioners had done, which resulted in us having to consider another strategy from the beginning of our work together.”

Gut health: the mystery of IBS

Part of what makes IBS so complicated, and so difficult for doctors to treat, is that there is no single cause; gut symptoms could be prompted by any number of factors, often in conjunction with each other.

While some combination of constipation, diarrhoea, bloating, abdominal pain and flatulence will be present each time, the answer will be different for each person.

For Annie, it was eliminating lactose; for Jacob, his gut microbes were out of balance; and for Leo, mould was at the root of his issues.

Gut symptoms can be difficult to resolve – but that’s where a nutritional therapist comes in handy.

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