Irritable Bowel Syndrome (IBS)

Summary - 

IBS (irritable bowel syndrome) affects the large intestine and is characterized by chronic abdominal pain and abnormal or altered bowel habits. It is sometimes referred to as colitis or spastic colon. Although symptoms vary depending on the person, the most common symptoms include abdominal pain and cramps, bloating, constipation, diarrhea, and gassiness. There are several “triggers” for IBS patients that vary considerably. While the cause of IBS is unknown, there are theories suggesting an exaggerated response to stimuli (the triggers) creating an intolerance or hypersensitivity among those affected with IBS. There are different forms of IBS depending on symptoms:

  • IBS-D (diarrhea)
  • IBS-C (constipation)
  • IBS-A (alternating diarrhea and constipation)
  • IBS-M (mixed symptoms)
  • IBS-U (unclassified)

Diagnosis - 

The Rome diagnostic criteria is a common tool to diagnose functional GI disorders (FGID). Please see their latest diagnostic criteria for IBS at irritablebowelsyndrome.net.

Treatment - 

A Registered Dietitian helps a patient with IBS to create an individualized plan to diet and lifestyle that will help manage GI symptoms, prevent malnutrition, and help the GI tract to function properly again. With IBS, there are certain triggers that affect people differently. For instance, although stress is a common trigger among IBS patients, it is not a trigger for all. Other common triggers include eating large meals, high fat foods, or other foods (see list below). Food and dietary habits are key to managing IBS symptoms.

Common recommendations include:*

  1. Normalize eating patterns, eat at a relaxed pace at consistent times, with small frequent meals, and ensure adequacy of nutrients.
  2. Adjust diet for food allergies and intolerances; common problem foods include wheat, yeast, and eggs.
  3. Reduced lactose (if lactose intolerant or experiencing symptoms upon the ingestion of certain dairy).
  4. Low-FODMAP diet (avoid foods high in fructose, sorbitol, xylitol and mannitol, and gas producing foods).
  5. Use of pre- and probiotics.
  6. Progress slowly to a diet adequate in fiber (25-35 g/day).
  7. Ensure adequate fluid intake of 2-3 quarts of water daily.
  8. Foods to avoid: alcohol, black pepper, caffeine, chili powder, cocoa/chocolate, coffee, colas, garlic, red pepper, spicy foods, and sugars.
  9. Avoid high-fat intake.
  10. Supplement with B-complex vitamins, calcium, vitamin D, and riboflavin (if lactose is not tolerated).
  11. Supplement with 1 tbsp daily of bulking agent, such a Metamucil, which may be helpful meeting fiber needs; avoid bran supplements as it may be irritating.

More elaborate explanation of some recommendations:

  • Eat small, nutrient dense, meals at regular and consistent times. Large meals may exacerbate symptoms, so eating small meals (perhaps more frequently throughout the day) may help. Having a routine will help regulate bowels, hormones, and metabolism. All meals should be nutrient dense to enhance wellness and promote proper nutrition for the body, especially for a patient with IBS-D (diarrhea – where the risk of malnutrition is higher). It is ideal to chew foods thoroughly and slowly to aid digestion and prevent overeating (as large meals may cause problems).
  • Eat a high fiber diet. Fiber is essential for good health and also helps to regulate bowels and prevent constipation. Please contact me when upping your fiber intake, as the process should occur slowly to prevent IBS complications from getting worse. Note: whenever fiber is increased in the diet, water should also be increased as well to help your body adjust. On that note, regardless of fiber intake, water is also essential for good health for many different reasons, one reason being preventing constipation (a common symptom for IBS).
  • Avoid gas-producing foods. Certain foods are prone to cause gas (but remember everyone is different!): cruciferous vegetables like broccoli, Brussels sprouts, cabbage, cauliflower, and beans, peas, cucumber, corn, leeks, and onions. It is wise to keep track of IBS symptoms along with dietary intake in order to identify which foods give you complications. A food journal comes in handy.
  • Often times food intolerance may cause IBS symptoms. Although IBS does not directly damage the intestinal tract, the complications of IBS and the resulting malnutrition can indirectly affect gut health. In addition, there are certain factors that might cause IBS in the first place, such as infections or antibiotic use, which impact gut health directly. Repeated exposure to trigger foods can possibly damage the gut lining even further (a change gut permeability, or also known as leaky gut). It is recommended to follow a FODMAP diet to eliminate common triggers, help identify the foods that cause problems, as well as give the bowel some rest and promote healing. Main idea: you’ll need to manage your personal food intolerances.
  • Avoid other substances that cause symptoms. The foods listed here are common triggers for IBS, but triggers vary wildly. Alcoholic drinks, caffeine, sugar alcohol, and sometimes the sugar in fruit may effect IBS patients. The main idea is to identify what causes symptoms for YOU so you can avoid them. If you are interested in following a low FODMAP diet, feel free to contact me for guidance.
    • See information below on a low FODMAP diet!
  • Practice stress management. Stress and anxiety effect bowel health tremendously, and stress is a common trigger for IBS patients. It is vital to practice stress management techniques.
  • Certain medications and supplements might affect the GI tract. See a doctor or dietitian if you are taking medications, as certain ones can make symptoms worse (such as antacids) or affect bowel movements (like some herbal supplements). 
  • Pre- and probiotics. Depending on your health and personal IBS symptoms, probiotics might be recommended to promote healthy gut bacteria.

FODMAPs - 

(Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) – certain carbohydrates which may be poorly absorbed in the small intestine and pass through to the large intestine largely undigested. As a result, fermentation in the large intestine occurs, which may cause increased gas, abdominal distention, bloating, cramping, and diarrhea. Here is a common list of FODMAPs:

  • Fructans: garlic, inulin, onion, wheat
  • Fructose: fruit, high fructose corn syrup, honey
  • Galactans: legumes, like beans, lentils, and soybeans
  • Lactose: dairy
  • Polyols: apricots, avocados, cherries, peaches, and plums and sugar alcohols like mannitol, sorbitol, and xylitol
  • Please see this link for a complete list

o   A low FODMAP diet might be difficult to follow because there are so many different foods included in this list. It is best to work with a healthcare professional who specializes in a low FODMAP diet in order to make sure you are meeting your nutritional needs. It is recommended to follow the diet for 6-8 weeks in order to see if the diet is effectively easing symptoms, and regular follow ups are essential during the process to keep you on track and make sure you are meeting your needs. After ~6 weeks, you can slowly reintroduce foods in order to determine if certain foods trigger your symptoms. 

Bottom line - 

IBS is a multifaceted condition that can be exacerbated by various factors including stress and poor diet. There is no one-dietary strategy for IBS as one solution might work for one client but not another. It is best to work with a Dietitian in order to identify trigger foods and follow a personalized plan created just for you.

Resources - 

 Visit  Kate Scarlata, RDN/FODMAP + IBS exper t for more resources

Visit Kate Scarlata, RDN/FODMAP + IBS expert for more resources

Ulcers

Summary - 

Location: occur in the stomach and upper duodenum

Ulcerations of the gastric or duodenal mucosa that penetrate the submucosa. Usually occur in the antrum of the stomach or in the first few cm of the duodenum. Erosion may proceed to other levels of tissue and can eventually perforate. Breakdown in the tissue allows for continued damage by the highly acidic environment of the stomach as well as damage from other secretions of the stomach, such as pepsin. 

Helicobacter pylori (H. pylori) is a common cause of ulcers. H. pylori lives under the mucous layer of the stomach and attaches to mucus-secreting cells lining the stomach. 

The etiology of PUD also involves factors that may decrease mucosal integrity, such as a reduction of protective prostaglandins (a group of lipids made at sites of tissue damage or infection that are involved in dealing with injury or stress) through the use of NSAIDs or alcohol, excessive glucocorticoid secretion or steroid medication, and factors that decrease the blood supply, such as smoking, stress, or shock. Factors that increase acid secretions including certain foods, rapid gastric emptying, or increased gastrin secretions, also contribute to the development of PUD. 

The most common symptom related to ulcers is epigastric pain(upperabdominal pain). Patients may complain of abdominal pain and a burning sensation, which may be precipitated by certain types of foods or accentuated by food intake. For others, epigastric pain may be relieved by food intake due to its ability to dilute any irritants. For a duodenal ulcer, pain may occur 90 minutes to 3 hours after eating, and is usually relieved within minutes either by eating or by the use of antacids. *Unfortunately, partial neutralization of gastric acid is followed by a rebound of gastrin release, causing additional stimulation of HCL and probably more pain.

The presence of blood in stool or vomit + changes in hemoglobin or hematocrit may be indicative of active bleeding from the ulcer + changes in WBC will be consistent with an active infection.

Treatment - 

Antibiotics: If the cause of ulcers are due to H. pylori, therapy includes medications (such as PPIs) with antibiotics

Medication: Other treatment focuses on the use of medication to suppress acid secretion, which will ultimately promote healing of the ulceration. Such medications include antacids, PPIs, histamine blocking agents (H2 blockers), prokinetic agents, and mucosal protectants. 

o  Because salicylates (aspirin) and NSAIDs are linked to increased gastric irritation, these medications should not be taken by someone with PUD.

Surgery: For those unresponsive to treatment or supper from complications like bleeding, perforation, or obstruction, surgical resection may be necessary. 

Nutrition intervention: goals include supporting medical treatment, maintaining or improving nutritional status, and providing a diet that minimizes symptoms of PUD.

Restricting foods that may increase acid secretion or cause direct irritation to gastric mucosa: these foods include black and red pepper, caffeine, coffee (including decaffeinated), and alcohol.  Restricting acidic juices or other foods is not consistently warranted unless the patient identifies intolerance to them.

o  Patients should not lie down after eating and avoid eating large meals close to bedtime. Smaller, more frequent meals may be better tolerated. 

o  Foods not recommended if symptomatic: cola, coffee, tea, cocoa, alcohol, 2% or whole milk, cream, high fat yogurt, chocolate milk, fried meats, bacon, sausage, pepperoni, salami, bologna, hotdogs, and desserts high in fat or fried, such as pastries and doughnuts. 

Factors that decrease mucosal integrity (cause gastric irritation): NSAIDs, alcohol, glucocorticoid secretion, or steroid medications

Factors that decrease blood supply: smoking, stress, shock

Factors that increase acid secretions: Certain foods, rapid gastric emptying, increased gastric secretions

GERD

Summary

Location: esophagus and upper stomach

GERD, also known as Gastroesophageal Reflux Disease, is the chronic condition where acid from the stomach refluxes into the esophagus, causing inflammation and the resulting painful symptoms like heartburn, chest pain, and difficulty swallowing. These symptoms are the result of the inflammation within the esophagus (called esophagitis). In a normal situation, food travels through the mouth, down the esophagus and into the first part of the stomach. Then the lower esophageal sphincter (LES) keeps food and stomach components like acid in the stomach, as opposed to leaching backwards into the esophagus. This occurs by the amount of pressure being exerted on the LES.

Occasional reflux and heartburn (acute esophagitis) is not a sign of any serious condition. Certain medications or foods can cause acute esophagitis. Chronic reflux, however, is technically termed GERD (the disease state, rather than just experiencing occasional reflux symptoms). GERD and constant reflux increases ones risk for Barret's esophagus (see definition below), a precancerous condition that occurs due to the repeated inflammation and destruction of the esophagus tissue.

As previously mentioned, a properly functioning LES works to allow food to enter the stomach and keep food and other components (like acid) in the stomach once it passes. However, there are many factors that influence the LES:

Foods that stimulate gastric acid production: black and red pepper, coffee, alcohol, meals of larger size, rapid gastric emptying, increased gastric secretions, and smoking.

Foods and behaviors that decrease LES pressure (a decrease in LES pressure causes the LES to open and acid from the stomach leaches back into the esophagus):

  • peppermint/spearmint (and mint oils)
  • chocolate
  • fried foods (high fat)
  • alcohol
  • smoking
  • coffee, and caffeine
  • raw onions
  • cucumber
  • radishes
  • peppers
  • overeating (causes high pressure on the stomach)
  • drinking during meals (also causes high pressure on the stomach)
  • certain medications

Hormones that influence the LES ability:

  • Progesterone (pregnancy, late phase of menstrual cycle)

Medications that influence the LES:

  • Anticholinergics and Bronchodilators 

Two general reasons LES may also fail to function properly include 1) structural damage from constipation and 2) temporary weakening (due to a secondary health condition or foods). A common cause of GERD is hiatal hernias.

Treatment & Nutrition Intervention - 

Alternatives:

  • Do not lie down after eating (wait a few hours! Another reason why we should not eat too close to bed time!)
  • Elevate the head of the bed
  • Limit or avoid smoking
  • Use medications such as antacids, H2 receptor antagonists, and PPIs. See note. 
  • Weight loss (overweight contributes to reflux and hiatal hernias)
  • Wear loose-fitting clothing (avoid tight)

Diet to prevent reflux:

  • Eat small, frequent meals
  • Avoid large meals
  • Avoid single high-fat meals
  • Eat low-fat, higher protein meals
  • Limit alcohol
  • Avoid certain foods that effect you: common foods include chocolate, coffee, mints, garlic, onions, cinnamon
  • Avoid drinking liquids with meals - drink in between meals instead

During acute esophagitis:

  • Avoid acidic foods like citrus fruits and tomatoes)
  • Avoid spicy foods
  • Follow a bland and soft diet
  • Eat small, frequent meals

All factors listed above will be different for everyone. Some people are very sensitive to raw onions while others sensitive to alcohol instead. These factors are simply the most common due to their effect on the LES. Find out your sensitivities and determine what works best for you.  

Note: Chronic use of acid-reducing medications may interfere with the absorption and metabolism of several nutrients such as folate, B12, iron, calcium, zinc, and magnesium. Always try dietary and lifestyles changes before relying on supplements or medications. When the above listed treatment methods have failed, surgery may need to be considered.

Resources:

Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

Medline Plus: https://medlineplus.gov/gerd.html

National Institutes of Health: https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults

International Foundation for Functional Gastrointestinal Disorders: https://www.aboutgerd.org/what-is-gerd.html

Barret's Esophagus:

The tissue of the esophagus is replaced by tissue similar to the intestinal lining; abnormal cell growth of the esophagus marked by a dramatic discoloration of the tissue; considered to be premalignant – esophageal adenocarcinoma: cancer of the lower esophagus. More on Barret's Esophagus here: https://www.niddk.nih.gov/health-information/digestive-diseases/barretts-esophagus 

Rheumatoid Arthritis

Summary - 

Rheumatoid Arthritis (RA) is a chronic inflammatory disease affecting primarily the joints and causes symptoms of swelling, stiffness, pain, joint deformity, disability, and limited range of motion. RA is considered an autoimmune disease because the immune system mistakenly regards the body's issues as foreign, producing antibodies (autoantibodies) which then damage the healthy tissues. Other musculoskeletal conditions that are considered autoimmune include systemic lupus erythematosus and scleroderma. Some research suggests that this autoimmune response is due to an infection in a genetically susceptible person.(1)

The pathophysiology of RA is characterized by periods of exacerbation and remission and the most common affected joints include the hands, wrists, knees, and feet. Some people with RA have mild to moderate symptoms lasting only a few days whereas others may progress to irreversible joint deformity and destruction with debilitating pain. As inflammation progresses, the growth and destruction of cells in the synovial membrane of the joint cause abnormal thickening known as pannus. A gradual build-up of pannus release enzymes that digest the adjacent bone and cartilage, causing further problems like joint deformity, severe pain, and immobility of the joint which is known as ankylosis. Unfortunately many of these physiological changes in the joint are irreversible. 

Treatment - 

The primary goals for RA are to reduce inflammation and pain and slow the progression of the disease. Some evidence suggests that lower intakes of vegetables, fruits, and vitamin C are associated with an increased risk for developing RA.3 This further illustrates the importance of consuming a nutrient dense diet for the treatment and prevention of several different health conditions. Further evidence shows the importance of omega-3 rich diets through foods like fatty fish (like salmon and sardines), fish oil, walnuts, chia seeds and flaxseeds.

An overall anti-inflammatory diet may be beneficial for those with inflammatory health conditions such as RA. Furthermore, many patients have reported improved RA symptoms after eliminating meat (especially red), dairy products, cereals, and wheat gluten.(2) Research on these benefits have been inconclusive due to the difficult nature for conducting research related to so many different food components. For example, eliminating meat from one's diet may mean increasing one's intake of more healthful foods like fruits and vegetables. In essence, it is difficult to determine the cause and effect nature. Regardless of the amount of research conducted between RA and certain foods, an anti-inflammatory diet will be beneficial, and that includes increasing ones intake of fruits, vegetables, nuts and seeds and decreasing pro-inflammatory foods like processed meats, alcohol, dairy, and other refined foods.

Resources - 

Citations - 

  1. Rizzo DB. Disorders of musculoskeletal function: rheumatic disorders. In Porth CM, Matfin G (eds) Pathophysiology: Concepts of Altered Health States. 8th ed. Philadelphia (PA): Lippincott Williams & Wilkins, 2009m 1519-43.
  2. Nelms, M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology. Brooks/Cole Cengage Learning. 2011. p 791-793.