IBS with Obesity
Justin Wise, CA, BComm
Peter K. Raisanen, NMD, BSc
Student Scholarship – Second Place Case Study
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by chronic abdominal pain, bloating, and changes in bowel habit.1 IBS is categorized as IBS-C, D, or M, reflecting the symptoms expressed: constipation, diarrhea, or mixed symptomatology, respectively. IBS is a condition that strips people of their quality of life and is associated with high healthcare costs: in 2002, IBS was estimated to directly cost the US healthcare system $1.35 billion and incur productivity costs of up to $205 million.2 Therapies traditionally utilized include psychotherapy, nutritional intervention, medications, and natural substances. We present here a case of resolution of IBS-D and obesity following a 7-day water-only fast and a subsequent shift to a whole-food, plant-based diet, confirmed at a 7-month follow up.
A 62-year-old female patient presented to TrueNorth Health Center on March 5, 2017, with obesity and unremitting IBS-D since age 18. She described her life as being “toilet aware,” including a morning routine that required she be at home for the first 2 hours of the day to frequent the toilet numerous times. Her symptoms included diarrhea, cramping, bloating, and abdominal pain. Testing for celiac disease in 2007 was negative, colonoscopy was unremarkable, and parasites and infection were ruled out. She had long avoided dairy and caffeine, as they aggravated her symptoms. Cholestyramine and a selective serotonin reuptake inhibitor (SSRI) were both utilized without any noticeable effect except further weight gain while taking the SSRI. Alosetron was employed with some efficacy until it became unavailable. The only moderately successful interventions were overnight fasting and a commercial weight-loss program she had tried many years prior. Her highest adult weight was 257.6 lb, with 59.6% body fat. During the years that followed, she tried to lose weight by eating a vegan diet, but snacking on high-calorie refined foods prevented weight loss. She eventually gave up trying to lose weight and planned on shifting the focus to her IBS symptoms, with the future plan of wearing diapers for damage control. She reported having switched to a starch-based diet, which also excluded oils and animal products, for the few months prior to her arrival and 20-day stay at TrueNorth Health Center. This diet modification resulted in losing over 30 lb and reducing IBS symptoms from a daily occurrence to a few days per week.
The initial examination revealed the following findings: blood pressure 135/72 mm Hg; temperature 98.5°F; heart rate 72 bpm; weight 204 lb; height 5’ 1/2”; and a BMI of 38.5. A review of systems on admission was remarkable for loose stools, joint pain, knee pain, leg pain, and fatigue. Physical exam was unremarkable except for obesity and a grade-2 systolic murmur. She reported taking a daily probiotic (50 billion CFU) and no other supplements. During initial intake, an anxious tendency was noted. Food habits included eating in front of the television, also watching news while eating and holding strong political opinions. We discussed these matters and she was encouraged to notice how not eating in front of the television and observing less political jousting might affect her bowel positively.
Recommendations for Fast
Her treatment plan entailed 7 days of water-only fasting, followed by refeeding with a whole-food, plant-based diet and attention paid to mindful eating. She was instructed on how to proceed with her water fast, which included complete abstinence from food and beverages except for pure water, and daily monitoring of vitals and subjective feeling. Once we mutually agreed to break her fast, she would start on a protocol of soft-cooked, starchy foods while eliminating gluten, raw greens, fruits, and other cooked foods.
Introduction of Whole Foods & Follow-ups
Her fast was unremarkable in terms of daily vital signs, objective and subjective data collection. After 7 days of water fasting, she had lost 17 lb and decided that she wanted to initiate refeeding. She started on a refeeding plan, which included a slow introduction to food; the initial foods included zucchini and high-starch squash, quinoa, and very-well-steamed greens.
During the days that followed, she reported that she did not have the customary urgency or pain and was having 2-3 high-quality bowel movements that were well-formed and easy to pass. Additionally, she was instructed on how to eat mindfully. Every 72 hours she was to reintroduce 1 new food from the following, in sequence: 1) well-steamed vegetable, 2) well-cooked bean, 3) certified gluten-free oats, and 4) raw vegetable. The ultimate goal was reintroduction of whole plant foods with no added salt, sugar, or oil.
She regained some weight with the commencement of refeeding; however, she continued to eat for the remainder of her stay, with an average weight loss of 1.0 lb/day over the course of her stay. She left for home feeling elated at having resolved her IBS symptoms and at having lost roughly 20 lb over the 20 days at TrueNorth Health Center; she starting at 204 lb and ended up at 184 lb.
On June 25, 3 months after leaving TrueNorth Health Center, she weighed 160.2 lb, was free of IBS symptoms, and reported that she was feeling the best she had felt in her entire life. She had begun to ease herself into activities that required time away from restrooms. She had reintroduced quite a few varieties of whole vegetable and fruit, as well as a few starches, such as brown rice, quinoa, and sprouted corn tortillas. On this occasion, we further addressed mindfulness and its importance, especially around meals.
On September 30 (6 months later), her weight was 137.8 lb and her IBS was absent except on 1 occasion. Nutritional yeast had caused symptoms of irritability and loose stools. Since then, she was carefully adding back foods into her diet and had had no further recurrence of her IBS symptoms since the nutritional yeast.
On November 26 (7 months later), her weight was 127.7 lb and she was IBS-symptom-free. She reported that she was feeling fabulous about attaining her own desired goal of 120 lb for her height of 5’ 1/2.” We agreed that would be a suitable goal as long as she continued to feel good.
Of the 33 functional gastrointestinal disorders (FGID) that have been identified, IBS is the most prevalent, with a worldwide percentage estimated at 12%.3 IBS cases account for 40% of referrals to gastroenterologists.3 IBS is defined as a disorder of gut-brain interaction by the Rome IV criteria, which requires the presence of recurrent abdominal pain 1 day per week (average) within the last 3 months, with symptom onset at least 6 months before diagnosis, and associated with 2 or more of the following factors: a) related to defecation; b) associated with change in frequency of stool; and c) change in form or appearance of stool.3 The diagnosis of IBS relies on symptom-based criteria and investigation of concerning features with negative results, leading to the functional diagnosis. The investigation must cover the following to rule out red flags: onset after age 50 years, unexplained weight loss, family history of selected organic gastrointestinal (GI) diseases, evidence of GI blood loss, unexplained iron-deficiency anemia, and the performance of selected tests (CBC, C-reactive protein or fecal calprotectin, serologic testing for celiac disease, and age-appropriate colorectal cancer screening) to exclude organic diseases that can mimic IBS.4 Gross microscopic changes are often unremarkable, revealing normal mucosa in most cases. However, FGID diagnosis is not always straightforward, especially to the general practitioner; thus, a confident diagnosis is warranted.5 The various mechanisms proposed in the literature by which food may induce symptoms include immune and mast-cell activation, mechanoreceptor activation via luminal distension associated with visceral hypersensitivity and altered motility, and chemosensory activation by bioactive molecule activity.6
Nutritional intervention, as a justified therapeutic trial for patients, has been demonstrated extensively in the literature. Common nutritional interventions and exclusions regard gluten, dairy, and fermentable oligo- di- and monosaccharides, and polyols (FODMAPs) – exclusions that have garnered attention in recent years for their ability to reduce symptoms.7 Those who respond to gluten elimination and have tested negative serologically for celiac disease are considered non-celiac gluten-sensitive, which can include or exclude the need to restrict FODMAPs.8 However, exclusion of such a health-promoting domain of nutritional compounds may come at a significant cost to human health.9 FODMAPs have important physiological effects: they increase stool bulk, enhance calcium absorption and modulate immune function, and decrease the levels of serum cholesterol, triglycerides, and phospholipids.10 They also selectively stimulate the growth of some microbial groups such as Bifidobacteria, thereby exhibiting a prebiotic effect.10 FODMAP-rich foods include many of the most health-promoting vegetables and fruits. This restrictive approach should raise alarm in the clinical world, but instead the approach continues to band-aid symptoms related to poor gut health and lack of bacterial diversity.
Peppermint oil has long been utilized effectively as a natural therapy. Peppermint oil is a naturally occurring carminative that promotes relaxation of the GI smooth muscle through blockade of Ca2+ channels. Nine randomized, placebo-controlled studies have found peppermint oil to be a safe and effective treatment for IBS.11 Adverse events were recorded to be peppermint taste, peppermint smell, and a cooling sensation at the anus. In contrast, in some of the head-to-head peppermint vs drug studies, some of the drug side-effects were so intolerable that subjects had to drop out of the study.11 Loperamide is an opioid that also has demonstrated utility in IBS-D to decrease the frequency of diarrhea.12
Two newer medications – eluxadoline (a mu-opioid receptor agonist that targets the peripheral GI tract) and rifaximin (an antibiotic) – were both approved in May 2015 for the treatment of IBS-D.13 To address the pain often associated with IBS, patients are often prescribed benzodiazepines, tricyclic antidepressants, SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs), clonidine, gabapentin, and pregabalin, all with little likelihood of efficacy.14 SSRIs have been utilized as a first-line therapy; however, a meta-analysis by Ford et al concluded that of the studies comparing antidepressants to placebo, there were more adverse events among the patients taking antidepressants (31.3%, n=65) when compared to patients taking placebo (16.5%, n=33).7 This is significant and warrants a closer look at the recommendations in the medical community.
Water-only fasting has long been used as a reset for the human body, and new studies are showing its efficacy for a variety of conditions. The physiological adaptations that occur in the fasted state may produce various health improvements.15 Clinical evidence in humans suggests that fasting may improve hypertension, rheumatoid arthritis, cardiovascular disease, metabolic syndrome, osteoarthritis, fibromyalgia, chronic pain, chemotherapy side-effects, and quality of life.15 Water-only fasting is intended to promote the body’s self-healing mechanisms. Associations between IBS and consumption of processed meat, milk, canned food, high-carbohydrate vegetables, and confectionary goods have been demonstrated.16 Experience with numerous patients at TrueNorth highlights that in order to maintain the results obtained by water-only fasting, one must adhere to a health-promoting lifestyle.15
This case study demonstrates the need for further investigation into water-only fasting and a whole-plant-food diet, without refined ingredients such as salt, oil, and sugar, for IBS-D and obesity. The case we are presenting is most significant due to the complete resolution of symptoms of IBS-D and the elimination of obesity without medications, pharmaceutical or otherwise. The intervention is cost-effective, has minimal side-effects, and avoids long-term medication or supplement use. With a combination of simple, water-only fasting and whole-plant-food choices, we are optimistic that more sufferers of IBS could resume a life of freedom.
- Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome: mechanisms and practical management. Gut. 2007;56(12):1770-1798.
- Inadomi JM, Fennerty MB, Bjorkman D. Systematic review: the economic impact of irritable bowel syndrome. Aliment Pharmacol Ther. 2003;18(7):671-682.
- Lacy BE, Patel NK. Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome. Weber HC, ed. J Clin Med. 2017;6(11). pii: e99.
- Chey WD, Kurlander J, Eswaran S. Irritable bowel syndrome: a clinical review. JAMA. 2015;313(9):949-958.
- Andresen V, Whorwell P, Fortea J, Auzière S. An exploration of the barriers to the confident diagnosis of irritable bowel syndrome: A survey among general practitioners, gastroenterologists and experts in five European countries. United European Gastroenterol J. 2015;3(1):39-52.
- Gibson PR. Food intolerance in functional bowel disorders. J Gastroenterol Hepatol. 2011;26 Suppl 3:128-131.
- Ford AC, Quigley EM, Lacy BE, et al. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol. 2014;109(9):1350-1365.
- De Giorgio R, Volta U, Gibson PR. Sensitivity to wheat, gluten and FODMAPs in IBS: facts or fiction? 2015;65(1):169-178.
- Nanayakkara WS, Skidmore PM, O’Brien L, et al. Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date. Clin Exp Gastroenterol. 2016;9:131-142.
- Staudacher HM, Irving PM, Lomer MC, Whelan K. Mechanisms and efficacy of dietary FODMAP restriction in IBS. Nat Rev Gastroenterol Hepatol. 2014;11(4):256-266.
- Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014;48(6):505-512.
- Camilleri M, Ford AC. Pharmacotherapy for Irritable Bowel Syndrome. J Clin Med. 2017;6(11). pii: E101.
- Moayyedi P, Mearin F, Azpiroz F, et al. Irritable bowel syndrome diagnosis and management: A simplified algorithm for clinical practice. United European Gastroenterology J. 2017;5(6):773-788.
- Chen L, Ilham SJ, Feng B. Pharmacological Approach for Managing Pain in Irritable Bowel Syndrome: A Review Article. Anesth Pain Med. 2017;7(2):e42747.
- Myers T, Goldhamer A. Clinical Fasting. Sonoma Medicine. 2017;68(3):26-27. Available at: http://www.healthpromoting.com/sites/default/files/Clinical%20Fasting%20article.pdf. Accessed December 5, 2017.
- Chirila I, Petrariu FD, Ciortescu I, et al. Diet and irritable bowel syndrome. J Gastrointestin Liver Dis. 2012;21(4):357-362.
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Justin Wise, CA, BComm, is currently a 4th-year year student at Southwest College of Naturopathic Medicine (SCNM). He was inspired by fasting after completing an internship at TrueNorth Health Center in Santa Rosa, CA. Justin graduated from the University of Toronto and worked as a chartered accountant. He is eager to help patients achieve physical and financial wellness. He is counting on prolonged fasting to help him learn guitar faster.
Peter K. Raisanen, NMD, BSc, is the chief clinical care consultant at LifeDoc LLC, located in Deer Valley, Phoenix, AZ. An alumnus of Bastyr University and University of Arizona, he completed a 1-year residency at TrueNorth Health Center in Santa Rosa, CA. He is using his clinical expertise in nutritional medicine, water and intermittent fasting, hormone replacement, counseling and mind-body medicine, in addition to his experience in recovering from a severe TBI to address the needs of his VIPs (very important patients). He utilizes a concierge style of medicine and has a passion for permanent resolution of overweight and type II diabetes. He will be releasing a book called Rise Again, in December 2018.