Heal Your Gut – A Crucial Link for Successful IBS Management

Irritable Bowel Syndrome (IBS) affects around a third of the UK population as some point in their lives, with twice as many women suffering compared to men. Symptoms can included abdominal pain and discomfort, diarrhoea and constipation along with abdominal bloating, which can have a big impact on everyday life. 

One of the main contributory factors in IBS is a dysfunctional intestinal barrier known as ‘intestinal permeability’ or ‘Leaky Gut Syndrome’.[1] This is where the delicate lining of the gut and tight junctions that ensure the contents of the gut does not directly enter the blood stream, is damaged.

The intestinal barrier covers a surface of about 30-40 m² (the size of half a badminton court!) and requires approximately 40% of the body’s energy expenditure.[2] The barrier prevents against loss of water and electrolytes, as well as entry of immune stimulating molecules (antigens) and microorganisms into the body, whilst still allowing absorption of nutrients from the diet and exchange of molecules between host and the environment. It is a complex multilayer system, now known to consist of an external “physical” barrier and an inner “functional” immunological barrier.[3]

Causes of Leaky Gut Syndrome

Damage to the intestinal barrier can be triggered by changes in the microbiota (gut flora)[4], insults from foods such as gluten (a protein found in wheat and other grains)[5], casein (from animal milk), toxins, viruses, infections[6], past antibiotic use and certain medications including Proton Pump Inhibitors (PPIs), commonly prescribed to for acid reflux, and Non Steroidal Anti-inflammatory Drugs (NSAIDs) like aspirin.[7] Lifestyle factors such as stress can also play a role in altering the permeability of the intestinal barrier through different mechanisms; e.g. increasing levels of stress related chemical mediators (corticotrophin-releasing hormone), reduction of secretory IgA (an antibody produced in mucus sections found in the intestinal epithelium as a first line defence against enteric toxins and pathogenic microorganisms)[8] and altering microbiota levels.

The role of intestinal permeability is now recognised to be prevalent in common disorders such as infections with intestinal pathogens, inflammatory bowel disease (IBD), obesity, coeliac disease, non-coeliac gluten sensitivity, and food allergies, as well as IBS.[9]

Healing the Gut – the 5Rs

So what can be done to repair the gut barrier and restore optimal digestion?

Reinforcement of the intestinal barrier and management of the bacterial colonies represent current and evolving strategies. A programme known as the 5Rs of gut healing has been shown to optimise and support healthy gut function.

1. REMOVE

This means removing foods and medications that exacerbate damage to the gut lining including gluten and NSAIDs such as aspirin, known to increase gastric damage. It’s worth noting that food intolerances and food sensitivities are not the same thing. Symptoms of food intolerance(s) are exclusively gastrointestinal and mostly occur after sugar fermentation by the intestinal microbiota, leading to the production of gas, which causes abdominal distension, abdominal pain, and irregular bowel movements.[10] Common examples include lactose intolerance, or intolerance to excess fermentable oligo, disaccharides, monosaccharides and polyols (FODMAPs), or to lactulose.

Food sensitivities, on the other hand, are individualistic adverse reactions to foods and adverse food reactions can include IgE and non-IgE-mediated primary immunological sensitivities.[11] This may seem confusing so we suggest seeking the advice of practitioner trained in functional nutrition to help you navigate the ever-evolving path through nutrition and formulate a personalised nutrition programmes with your specific requirements. 

2. REPLACE

Digestive secretions of the pancreas are necessary for appropriate breakdown of food substances into the smaller molecules, which our body is able to utilise. Some of the enzymes that are produced by the pancreas include lipase, which breaks down lipids (fats) and peptidases, which break down peptides (proteins). The enzyme lactase, which breaks down lactose, a milk sugar, is not something made by the pancreas but by the cells lining the small intestine.  There are many reasons why the body at times may not have adequate digestive enzyme levels, whether it be genetics, a recent gut bug, or other chronic conditions like coeliac or pancreatic disease. Even stress can negatively impact our body’s production of digestive enzymes! For this reason, taking a supplement known as a digestive enzyme including lipase, proteases and even specialist enzymes that help break down plant sugars, which may precipitate bloating and gas, may help many individuals with digestion.[12]

3. REPOPULATE

Increasing levels of beneficial gut through careful choice of dietary fibres: IBS symptoms are notoriously exacerbated by certain types of carbohydrates found in different vegetables, grains, legumes and pulses so it may mean at the beginning of a nutrition programme careful choices of whole plant foods such as following a mucosal tolerance programme or FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. These interventions are best done with professional support and are considered a transitional intervention co-administered with other interventions to ensure a return to broader food choice as soon as possible.[13] Eating a balanced diet that includes adequate fibre, water, and nutrients including fats all are things that support the body to have proper digestive function.  Although water is important, consuming the bulk of liquids away from meals is better to support digestion, as if liquids are with meals they may dilute and lessen the concentration of digestive secretions.

Other repopulation interventions may include a good quality probiotic supplement including Lactobacilli, Lactococci and Bifido bacteria species[14], as well as Saccharomyces boulardii capsules to support mucosal sIgA production and reduction of diarrhoea.[15],[16] Other interventions are outlined in the rest of the 5R programme below.

4. REPAIR

A combination of the interventions in the 5R strategy helps to repair the gut lining. These include foods that are rich in anti-inflammatory, gut supporting nutrients such as turmeric and ginger, peppermint and papaya.[17]

There are also specific supplements than can be used in conjunction with the diet to help support the integrity of the gut barrier:

• High potency phosphatidyl choline lecithin powder known to support repair of damage gastrointestinal cells.
• L-Glutamine (in combination with gut supporting botanicals) and essential amino acid in IBS and the preferred fuel soured for rapidly proliferating gastrointestinal epithelial cells – the ones that form the gut barrier.
• Whole leaf aloe vera juice to reduce gut inflammation, support beneficial gut bacteria and stimulate collagen synthesis in newly forming gut cells.

5. REBALANCE

This area acknowledges the complex link between the gut-brain axis, i.e. the direct nervous system link between the gut and brain via the vagal nerve and other complex pathways.[18] Stress and psychological pressure can directly affect gut function through a number of mechanisms and contribute to many digestive disturbance symptoms, including those people living with IBS. Addressing lifestyle and stress management techniques, such as the practices of meditation and mindfulness, can play an integral role in a holistic approach to healing the gut.[19]

The manner in which meals are consumed also affects digestion. Eating on the run has a negative effect on the “rest-and-digest” state that the body requires for proper digestion. Many people probably can remember work lunches at the desk, or grabbing a bite between work and evening activities while driving, and the sensation of “gut rot” or abdominal pain that followed. Although the types of food one consumes can lead to this, not giving the body time for digestion also can! So sit and take some time to eat your meals! Your body will thank you!

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References

1. König J, et al (2016) Human Intestinal Barrier Function in Health and Disease. Clin Transl Gastroenterol. 2016 Oct 20;7(10):e196 Full Paper
2. Helander (2014) Surface area of the digestive tract – revisited. Scand J Gastroenterol. 2014 Jun;49(6):681-9.
3. Holtmann G, Shah A, Morrison M. Pathophysiology of Functional Gastrointestinal Disorders: A Holistic Overview. Dig Dis. 2018 Feb 8;35 Suppl 1:5-13 View Full Paper
4. Ivanov II, & Littman DR (2010). Segmented filamentous bacteria take the stage. Mucosal immunology, 3 (3), 209-12
5. Ménard S, Cerf-Bensussan N, & Heyman M (2010). Multiple facets of intestinal permeability and epithelial handling of dietary antigens. Mucosal immunology, 3 (3), 247-59 
6. Rook GA, Brunet LR.  Microbes, immunoregulation, and the gut. Gut. 2005 Mar;54(3):317-20. Review. View Full Paper
7. T.T. Macdonald and G. Monteleone. Immunity, inflammation, and allergy in the gut. Science 307: 1920–1925, 2005
8. Mantis et al (2011) Secretory IgA’s Complex Roles in Immunity and Mucosal Homeostasis in the Gut. Mucosal Immunol. 2011 November ; 4(6): 603–611. doi:10.1038/mi.2011.41 Full paper
9. König J, et al (2016) Human Intestinal Barrier Function in Health and Disease. Clin Transl Gastroenterol. 2016 Oct 20;7(10):e196 Full Paper
10. Fasano A, Sapone A, Zevallos V, Schuppan D. Nonceliac gluten sensitivity. Gastroenterology. 2015 May;148(6):1195-204 PMID: 25583468
11. Taylor S & Hefle S. Food allergies and other food sensitivities: A publication of the Institute of Food Technologists’ Expert Panel on Food Safety and Nutrition. Scientific Status Summary. Food Tech 2011;55:9
12. https://www.clinicaleducation.org/news/digestive-enzymes/
13. Does a low FODMAP diet help IBS? [No authors listed] Drug Ther Bull. 2015 Aug;53(8):93-6
14. Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol. 2000;95(12):3503
15. Favre, L., Spertini, F. & Corthesy, B. Secretory IgA possesses intrinsic modulatory properties stimulating mucosal and systemic immune responses. J. Immunol. 175, 2793–2800 (2005).
16. Kelesidis et al (2012) Efficacy and safety of the probiotic Saccharomyces boulardii for the prevention and therapy of gastrointestinal disorders. The Adv Gastroenterol 5:111-125 Full paper
17. Langmead L, Dawson C, Hawkins C, Banna N, Loo S, Rampton DS. Antioxidant effects of herbal therapies used by patients with inflammatory bowel disease: an in vitro study. Aliment Pharmacol Ther. 2002 Feb;16(2):197-205
18. Galland (2014) The Gut Microbiome and the Brain. J Med Food 17:1261-1272
19. Dinan et a; (2015) Collective unconscious: How gut microbes shape human behavior. J Psych Res 63:1-9