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If you’re one of the more than 25 million people in the U.S. with irritable bowel syndrome, chances are your symptoms have worsened at some point in the past two years. Or you may have developed symptoms for the first time.
“We found reports of increased constipation, diarrhea and abdominal pain,” said Kendra Kamp, a researcher at the University of Washington School of Medicine. She surveyed IBS patients with anxiety or depression about their experiences at the start of the pandemic. Over 90% reported increased stress and 81% reported increased anxiety. Another study sponsored by a pharmaceutical company found that half of IBS patients say their symptoms have been more difficult to manage, and many reported an initial onset of IBS during the pandemic.
“The pandemic created an environment of uncertainty, isolation, and less access to supportive resources that people depended on for their well-being,” said Suzanne Smith, a nursing specialist with UCLA’s Integrative Digestive Health and Wellness program. The center combines diet and stress management treatments, and Smith helps patients understand the brain-gut connection in IBS.
IBS was once thought of as a gut problem, but scientists now know that disruptions in the way the nervous system, brain, and gut interact can cause changes that lead to IBS symptoms, including stomach pain, gas, bloating, and abnormal bowel movements. “There’s a continuous feedback loop between the brain and gut,” explains Smith. Information flows along the vagus nerve, which connects the brain to the gut, so what happens in the mind affects the gastrointestinal system.
Finding the triggers
Stress is one factor that can trigger symptoms or make them more difficult to manage. Diet, sleep, exercise and socializing are also important. “All of these things play a role in digestion,” says Smith.
Doctors also look for triggers like an infection or bacterial overgrowth that may require antibiotics, but the goal, Smith says, is to package all the elements into a holistic treatment approach.
Smith teaches a mindfulness course that can help patients reduce the anxiety associated with their symptoms. In 2020, a study of patients enrolled in the 8-week course, called Mindfulness Based Stress Reduction, found that 71% of patients had robust improvements in their gastrointestinal symptoms. “There was a significant improvement in quality of life and overall well-being,” says Smith. The participants learned a series of techniques to promote present-moment awareness, mitigate anticipatory anxiety, and stop the feedback loop that can amplify the unpleasant feelings and sensations associated with IBS symptoms.
“It was life-changing for me,” said Vicki Mayer, 52, who took part in the study. She first noticed stomach problems, intermittently, in college, but in recent years her symptoms have worsened. “Every time I went out for dinner, lunch or coffee, I was riddled with a lot of anxiety and fear,” she recalls, anticipating that she might need to urgently find a toilet or leave the restaurant. She started avoiding going out.
When her doctor recommended the mindfulness class, she hesitated. “I was probably the most skeptical person in the room,” she recalls. “I thought, ‘Oh, I’m going to have to lie down for an hour. I can’t keep my mind completely still.'”
But when class started, she was hooked. “We practiced different types of meditation, whether it was a body scan, a three-minute breathing exercise, or a walking meditation,” says Mayer, going on to explain that each of these techniques instilled a sense of calm and a new way to tune into her body.
Meditation didn’t change her symptoms overnight, but she did begin to gain control over her emotional responses. She realized that much of her anxiety was caused by worst-case thinking, such as anticipating an embarrassing restaurant incident. But if she stayed in the moment, the situation really wasn’t that dire. And instead of letting her mind weave a story about what might happen, she learned to reframe her thoughts.
“It’ll be fine, there’s always a bathroom available,” she told herself when she went out to dinner, realizing it wouldn’t hurt to excuse herself from the table. “Once I changed my mindset, I had much less anxiety and was able to get through the meal with little to no problem.”
Studies show that mindfulness can increase both attention and emotional regulation. “If you have a better ability to regulate your attention, then you can focus your attention on something more useful,” says Smith, just as Mayer learned.
Mayer says she feels much better these days. “It’s incredibly powerful to know how to change your mindset and see the physical results of doing so in a positive way,” she says. And she continues the meditation practice: “You can do a one or two minute breathing exercise while standing in line at the grocery store.”
The power of the right nutrition
Changing what’s on the menu is another important tool for people to manage IBS. “We’ve developed dietary strategies that can be quite effective,” said William Chey, a gastroenterologist at the University of Michigan who has documented the benefits of integrative care.
Michigan has had a special GI nutrition program since 2007. “When I started talking about nutrition as an important part of treating patients with IBS at the time, people literally laughed at me,” says Chey. “But now almost every gastroenterologist accepts that nutrition is an important part of the solution.”
Over the past 15 years, many studies have shown that dietary strategies can control symptoms.
The FODMAP diet has received the most attention from researchers. Studies show that anywhere from 52% to 86% of participants report significant improvement in their symptoms after following the diet, including less gas and bloating. The FODMAP diet requires the elimination or reduction of certain foods, including gluten, lactose, excess fructose (found in some fruits and corn syrup), as well as certain nuts, beans, and starchy vegetables. Researchers at Monash University in Australia explain that the FODMAP diet is based on the understanding that certain compounds in our diet cannot be fully digested or absorbed, so they can pass into the large intestine where they are fermented by gut bacteria. This leads to gas and bloating.
“I saw the benefits almost within the first week,” says Karen Beningo of Northville, Michigan, who was treated at the University of Michigan. She started the FODMAP diet last October and noticed that her energy levels improved significantly. “The dilation and bloating went away very quickly,” she says. After following the diet strictly, she has now added some food to her diet again. She knows gluten is a trigger, so she stays gluten-free.
“I discovered other things, and most of them were things I was already suspicious about anyway,” she says. She realized that onions, broccoli and Brussels sprouts, as well as some nuts, make her windy. And it was only by calming down my system and then re-entering it [them] which I pretty much confirmed, yes, I have a problem with those things,” she explains.
Where to get help
Beningo was lucky enough to live near a major academic center. The University of Michigan has registered dietitians in their GI program who can support patients through dietary changes, which can be somewhat frustrating and confusing to follow. But what can people do if they don’t have access to this kind of integrative care?
Most gastroenterology practices do not employ a registered dietitian, psychologist, or stress management professional. “Most physicians don’t have the tools or the training to effectively implement emerging science into their practices,” says Chey.
To fill in the gaps, there is a shift to virtual support to help people access behavioral health care, stress management tools, and nutritional strategies. “Digital tools coming online will help scale these integrated strategies to a more national level,” says Chey. He points to three examples. Mahana is an FDA-authorized digital cognitive behavioral therapy app that doctors can prescribe for IBS patients to manage stress. Zemedy is another CBT based digital app. There’s also Nerva, a mobile app that delivers gut-directed hypnotherapy to help manage symptoms.
“Those three are all evidence-based, meaning they’ve all done at least observational clinical studies to show efficacy,” says Chey. And many more digital products are in development, he says, adding that he is involved with a number of companies as a researcher. Chey says large-scale clinical trials of some of the tools are planned to better understand how to use them effectively. “This is a very fast-growing space,” he says.