Issue: September/October 1997
Author: Kristin Barendsen
THE MIND BOWEL CONNECTION
For those who suffer from IBS, here are tips to ease the pain-and embarrassment-of spastic bowels.By Kristin Barendsen
Irritable bowels are not exactly a topic of polite conversation, and I admit I feel a little funny discussing my own before a national audience. But the fact is, we all have bowels. TheyÕre nothing more than the small and large intestines, amazing organs that separate the wheat from the chaff, if you will. And their health greatly affects our well-being. So I'll put aside my modesty if you'll join me on a trip through the twisting tunnels of the colon.
It felt like something from the movie Alien-a creature inside my abdomen trying to get out. My belly squealed and popped with air painfully trapped inside, and I would stare at it in amazement as it visibly expanded and fell. I wasn't just bloated-I was inflated, like a blow-up doll. Cramps weakened my lower back, and sometimes a sharp pain made me double over without warning. Perhaps most inconvenient, my bowel habits were far from my grandmother's ideal of regularity-I stayed constipated for days, only to make a surprise dash to the bathroom in a sudden bout of diarrhea.
For weeks I looked for clues in my diet, but could discern no clear difference in symptoms between days I ate healthy foods (beans and rice, broccoli, tempeh) and days I didn't (pizza, chocolate, coffee with milk). Everything, in fact, seemed to irritate my gastrointestinal (GI) tract, and I began to approach meals with apprehension, dreading what symptoms they might provoke. Friends suggested the cause was stress-but I had been stressed before without these consequences. Then I remembered a weekend bout with intestinal flu that had seemed to start the whole thing off, and I began to wonder if I had a parasite or something equally sobering.
In fact I had irritable bowel syndrome (IBS), also known as spastic colon. IBS is a functional disorder, which means that there is no apparent damage to the intestinal tract; rather, the nerves and muscles react to stimulation in a dysfunctional way. My doctor, Linda Spangler, says that the nerve endings of the bowel appear to be more sensitive in those of us with IBS. She cites studies in which researchers introduced air into the bowels of subjects with and without IBS. "The people with IBS were in a lot more pain," she says, although their tolerance to pain in other parts of their bodies was the same as the control group. Spangler also notes that IBS causes the muscles of the intestinal wall to contract abnormally. "Instead of a uniform motion, the muscles tend to spasm and cramp much more easily than they do for other people," she says. "This can cause constipation, diarrhea, cramping, bloating, and abdominal pain." My body certainly exhibited the classic signs of IBS. People with IBS typically experience both constipation and diarrhea, though one of these tends to predominate. Other common symptoms include mucus in the stool, nausea, heartburn, gas, and varying degrees of anxiety and depression.
ALL IN THE MIND OR THE BELLY?
What causes the sensitivity and altered motility? Allopathic medicine maintains that the cause is unknown, possibly stemming from psychological disorders or a congenital difference in muscle and nerve function. Alternative medicine looks for an insult-past or present-to the intestinal wall, from factors such as dietary irritants (caffeine, sodas, sugar, spicy food), bacterial imbalance (recent bacterial infection, antibiotics, antacids, or candida overgrowth), or sensitivity to foods such as dairy and wheat. Both camps agree that whatever the cause, IBS symptoms are aggravated by stress and by certain foods.
Diagnosis of IBS is typically made on the basis of history and a simple physical exam. Some physicians may also perform bowel studies to rule out organic disease. These tests are indicated when the client has symptoms outside the normal pattern of IBS, such as significant weight loss without dieting, blood in the stool, or onset over the age of 60. (If you have any of these factors, contact your health care provider.)
IBS is very common. An estimated 20 to 30 percent of people worldwide have IBS, though many do not seek treatment. The incidence of reported cases is two and a half times higher in women than in men, with onset typically occurring between ages 20 and 40. Symptoms tend to wax and wane throughout life. For some people, IBS is a mild annoyance or inconvenience; for others, it is almost debilitating. One friend told me that some days she is afraid to leave the house for fear of being too far from the bathroom. However, IBS is not life-threatening, and the prognosis for controlling symptoms is quite good. As Andrew Weil, M.D., says in Natural Health, Natural Medicine, "It is easy to get rid of irritable bowel syndrome by making adjustments of lifestyle."
LIFESTYLE CHANGES ARE THE KEY
One year after this whole saga began, I feel I have proven Weil right. By paying attention to the food I eat and how it affects my body, as well as my behaviors and emotions surrounding food, I have determined what triggers my symptoms. Now I rarely experience digestive distress. When I do, I take beneficial herbs and supplements and tailor my yoga and relaxation practice to settle things down. Below I offer the practices that have helped me. Please note that the suggestions in this article are based on research and personal experience and are not intended as medical advice.
DIETARY FIBER. When Dr. Spangler gave me the diagnosis of IBS, she said that increasing dietary fiber and reducing trigger foods were keystones to improvement. Fiber adds bulk to the stool, which normalizes peristalsis. She said the best way to get fiber was through whole foods such as vegetables and grains. Supplements such as psyllium husk and wheat bran also work well, though wheat bran is problematic for those with a wheat intolerance or with very sensitive colons (its texture can be rough). Herbalist Mindy Green of the Herb Research Foundation in Boulder, Colorado, recommends flax seed as a source of fiber. A demulcent (a herb with mucilaginous, oily properties), flax seed is smooth, gentle, and very effective, Green says. With any of these supplements, and as a general guideline for those with IBS, it is important to drink lots of water.
TRIGGER FOODS. Increasing my fiber intake sounded easy, but when Dr. Spangler gave me the list of foods that may aggravate IBS, I balked-everything I ate was on it! Topping the list was dairy. Many adults-an estimated 15 percent of whites and 30 percent of other ethnic groups-are lactose intolerant, that is, they lack the enzyme necessary to digest milk sugar. Lactose intolerance produces symptoms identical to IBS-diarrhea, bloating, and abdominal pain. For this reason, many experts recommend eliminating dairy from the diet for a trial period; if the symptoms disappear, the problem is lactose intolerance and not true IBS.
Next on Dr. Spangler's list was caffeine, my favorite colleague. Caffeine stimulates the muscles of the bowel, causing diarrhea; the high acid content of coffee (even decaf) is also very irritating to the stomach. Next was sorbitol, which is used to sweeten some diet products and which occurs naturally in fruits such as apples, pears, and peaches. In one study, 43 percent of whites and 55 percent of people of color were sorbitol-intolerant. High amounts of fructose, found in fruit juices and baked goods sweetened with fruit juice, also cause gas and diarrhea for many people.
The next items surprised me: cruciferous vegetables (broccoli, cauliflower, cabbage, kale, and asparagus) and beans, including tofu and tempeh. Any third-grader would have been happy to tell me what those did in the intestines, but somehow I was blindsided by the fact that they're considered so healthy. What was a vegetarian to do, if even healthy foods were not safe for consumption?
I looked to Annemarie Colbin, author of Food and Healing, for further advice. To Dr. Spangler's list, Colbin adds alcohol, chocolate, and sugar-all GI irritants. She recommends avoiding white flour (very constipating); meat, eggs, and fats (acid-forming); and raw foods and salads, which require the most energy to digest. "People with IBS should concentrate on nicely cooked soups and stews, whole grains, and root vegetables such as carrots, potatoes, parsnips, turnips, rutabagas, and daikon." Winter and summer squashes are beneficial, she says, as are "greens, cooked the old-fashioned way, boiled for a while." Well-cooked cauliflower and cabbage may be tolerated as well, she says, along with red lentils and chickpeas.
FINDING THE CULPRITS
Of course, every bowel is unique, and trigger foods will differ from person to person. To help with this detective work, Colbin suggests keeping a food/symptoms diary. Other practitioners recommend an exclusion diet, in which you eat a very simple diet for a week (such as chicken, rice, and one vegetable). Then add one food for a day to see if it causes symptoms. If it does, eliminate it again, and a day or two later, try another new food. Though this sounds very efficient, I couldn't imagine being that disciplined, so I took a more informal approach.
I fasted for a day, then ate a basic diet of brown rice and cooked vegetables, with occasional forays onto the "possible triggers" list. I discovered that dairy, caffeine, and white flour were the worst offenders, so I needed to rethink my idea of breakfast. Bagels especially seemed to turn to concrete in my colon. Chocolate, popcorn, and peanut butter were certain to provoke symptoms, though curiously, whole peanuts in moderation were okay. The back spasms and occasional sprints to the bathroom I traced to cayenne and chili peppers.
As I began to link cause and effect, I automatically associated each food with how it felt in my body. For example, if I thought of drinking a cup of coffee, I would remember the acid stomach and cramping lower belly that it gave me, and I'd usually choose herb tea. I gravitated toward calming foods like steamed chard, rice, quinoa, and vegetable stew. A whole world of new vegetables and ways to prepare them opened up, and I no longer felt restricted. As my colon began to heal, I was able to reclaim a few shunned foods like beans and broccoli, which were fine in small amounts. Plain yogurt and parmesan cheese worked as occasional treats, and raw carrots and celery actually seemed helpful.Not just what I ate but how I ate it played an important role in my ability to digest. I could tolerate spicy food in a leisurely meal with a friend, but if I ate the same food on the run or in front of an unpleasant television program like the news, I would regret it later. Large meals provoked symptoms more readily than small ones, and food combining made a difference-for example, an apple by itself made an innocuous snack, but after a meal it would ferment with the other food and cause more gas.
HERBAL RELIEF
During a flare-up I would drink chamomile tea or take other beneficial herbs. Chamomile, an antispasmodic, eased the cramping I experienced along the bowel wall; crampbark, lemon balm, and peppermint do the same thing. Clinical trials have shown that essential oil of peppermint is a powerful antispasmodic. Only take peppermint oil internally in enteric-coated capsules, designed to pass through the stomach unaltered and disintegrate in the intestines. Without enteric coating, the oil can produce upper GI side effects such as heartburn. However, according to herbalist Green, the leaves of the peppermint plant contain little of the essential oil and make a soothing tea.
For people with diarrhea, Green recommends astringent herbs such as bayberry, strawberry, blackberry, and raspberry. These may be taken as teas when symptoms arise, she says, but no more than once a day, as "overdoing them might cause constipation."
Green emphasizes the importance of demulcent herbs in treating IBS. Thick and soothing, herbs like slippery elm and marshmallow cool irritation along the digestive tract. Demulcents work best when prepared as cold water infusions (like tea, but with cold water).
Other popular remedies include aloe vera, in juice form; bitter herbs such as gentian root; and herbs that contain digestive enzymes, like papaya. Ginger has a long history of use in digestive disorders, because it reduces nausea and gas. However, it is also stimulating to the GI tract, and for this reason Green hesitates to recommend it. "Ginger would not be my herb of choice-I would not stimulate something that's irritated." For me, it seems helpful for sluggish digestion.
Colbin also notes the healing properties of kudzu (kuzu) starch, her "preferred universal remedy for disorders of the digestive tract." In Food and Healing she gives a recipe for shoyu-kuzu: "Dissolve 1 tablespoon kuzu in 1 cup cold water and cook, stirring, until thick. Add 1 tablespoon natural soy sauce (shoyu or tamari), or enough so that it tastes wonderful." For apple juice-kuzu, she recommends dissolving 2 tablespoons kuzu starch in one cup apple juice, and adding 1 teaspoon vanilla extract (optional). Cook the mixture, stirring continually, until thickened. Swirl in 1 tablespoon tahini (sesame seed paste). Drink hot or cold. Take whichever remedy you choose once a day-the shoyu in the morning, for example, and the apple juice at night.
Because the balance of intestinal bacteria is often disturbed in people with IBS, many practitioners recommend taking acidophilus supplements, which contain "friendly" bacteria. Colbin advises a short course because, she believes, the body becomes habituated to these supplements if taken for more than two weeks at a time. Other good sources of "friendly" bacteria include yogurt (if tolerated) and miso soup.
STRESS-RELATED IBS
I realized, too, how closely tied for me were food, stress, and digestion. Stress creates a whole complex of GI symptoms in people both with and without IBS, including nausea, diarrhea, and even constipation. Compelling research has recently unraveled more reasons for the emotion/GI connection. According to Michael Gershon, Ph.D., a professor of anatomy at Columbia-Presbyterian Medical Center in New York City, the GI system actually has its own brain- the "gut brain," or enteric nervous system. This primitive nervous system consists of two networks of neurons, some of the same neurotransmitters found in the central brain (serotonin, dopamine, norepinephrine), a blood-brain barrier, and cells that nourish neurons and are involved in immune responses. The vagus nerve connects the gut brain and the central brain in the head, enabling both to send signals to each other and react to these signals. Researchers theorize that the central brain can either shut down the gut brain or overstimulate it.
Many questions remain, including why stress appears to cause more dramatic GI symptoms in people with IBS. Allopathic medicine used to view IBS as somatic symptoms imagined by patients with anxiety disorders, but that view has thankfully changed. Dr. Spangler says that her patients with IBS don't appear any more stressed than other patients. "I think it's just a different manifestation of stress. Some people have headaches, some have bowel problems."
The interaction of stress and IBS is complex, especially given our culture's attitudes about food and body image. We tend to use food as a stress reliever. We then feel guilty about eating, which in turn causes more stress. We might tense our abdominals in an effort to look thinner, and direct our anger at our bellies for not fitting our image of perfection. All of this, I believe, contributes to IBS.
HELPFUL PRACTICES
I can offer a few practices that helped me with my relationship to food and body image. Whenever possible I try to make eating into a meditation, fully tasting and appreciating each bite. Hypnotherapy helped me cultivate new ways to nourish myself. But the most important thing has been to let myself be imperfect.
Movement is another keystone in healing. When digestion is sluggish and blocked, movement can be either through visualization (such as imagining the free exchange of blood and lymph through the abdominal area) or physical exercise. Walking after a meal does wonders for digestion, and aerobic exercise several hours after a meal clears toxins and rejuvenates the body. Abdominal selfmassage-pressing gently into tender areas-helps to relieve gas pain. And then, of course, there is yoga.
Mark Horner, an Iyengar yoga teacher in Walnut Creek, California, notes the ways that yoga can help with digestive disorders. "First, the practice can bring awareness that something is out of balance. Then the asanas become specific tools to bring the system into balance." Horner, who leads occasional workshops on yoga and digestion, says that inverting the abdominal organs in poses such as Shoulderstand and Headstand "helps to break up the congestion of energy." Twisting variations on these poses (and other twisting asanas) are beneficial, he says, because they compress and release the organs,"flushing out the tissues like wringing out a sponge." This compression and release also occurs when forward bends are sequenced with backbends.
Breathing exercises can also bring awareness and softening to the abdominal organs, Horner says. Relaxing over a bolster in a supported Supta Baddha Konasana, the student can breathe into the belly, which "creates a natural massage on the abdominal organs, bringing more energy into the system and cultivating the life force." This pose creates a gentle back bend in the lumbar spine and relaxes the belly. More advanced techniques include uddiyana bandha, "a drawing of the entire abdominal wall up and back while holding the breath out," and agnisara, in which the breath is held out and the belly wall is pumped in and out several times. New students should practice them with a teacher, Horner says.
Although yoga helped Horner improve his own digestion, he cautions against narrowing your practice to focus on IBS. "I think it's a mistake to use yoga like an allopathic pill and perform only specific asanas for that problem. Irritable bowel syndrome is a sign that the body-mind is out of balance. Every asana can help.
"I think it's important not to get fixated on symptoms," Horner adds. "The practice should be based on respect for the body as a whole and a willingness to not have all the answers, to stay in the mystery."
Looking back over the past year, I see how IBS has been a door into respect for my body. When I stopped to listen, my body guided me toward eating the food it likes and reducing the stresses in my life. My diet isn't perfect, to be sure; I still make occasional forays into the "possible triggers" list. But even this I do consciously, knowing what symptoms to expect. I'm still very much "in the mystery," but if I can stay in the mystery with a more predictable colon, that's just fine with me.
Kristin Barendsen is a contributing editor of Yoga Journal.
RESOURCES
Food and Healing by Annemarie Colbin (Ballantine Books, 1986) Gastrointestinal Health by Stephen Peikin, M.D. (HarperCollins, 1991) The New Laurel's Kitchen by Laurel Robertson, et al. (Ten Speed Press, 1986)
Perfect Digestion by Deepak Chopra, M.D. (Harmony Books, 1995)
Search the Web using keyword "IBS."
FOODS AND IRRITABLE BOWEL SYNDROME
POSSIBLE TRIGGERS
>Dairy: all dairy is problematic, though yogurt, hard cheese, and cultured buttermilk may be tolerated in moderation
>Sweeteners: sugar, chocolate, fructose, sorbitol, aspartame
>Grains: wheat, corn, possibly all grains containing gluten
>Spices: cayenne, black pepper, chilies, mustard seed, cloves, curry, garlic
>Fats: oils, fried foods, meats, dairy, butter, nuts and seeds (especially peanuts)
>Gas-producing foods: beans, soy products, cruciferous vegetables (such as broccoli, cabbage, cauliflower, asparagus, kale), dairy, sorbitol, fruits (especially fruit juices and dried fruits), corn and popcorn, alcohol, carbonated drinks, nuts, raw foods, wheat
>Foods that irritate the esophagus: alcohol, chilies, peppers, tomatoes, citrus fruits
>Acid-forming foods: meat, eggs, fats, dairy, sodas, coffee (including decaf)
>Foods that cause constipation: white flour, meats, potatoes, protein powder
>Foods that cause diarrhea: dairy, caffeine, beans, fruits, cruciferous vegetables, some spices (especially hot spices like cayenne and chilies)
>Foods with harsh, rough texture: popcorn, dry fibrous crackers, raw fruits and vegetables, sometimes brown rice and millet, which can be difficult to digest
>Fermented foods: alcohol, yeasted bread, vinegar, miso soup,
tempeh, soy sauce
BENEFICIAL FOODS
>Grains: brown rice, barley, oats
>Vegetables: cooked greens, carrots, parsnips, turnips, daikon root, potatoes, winter and summer squashes, celery, all types of mushrooms
>Beans: well-cooked red lentils, chickpeas, aduki beans, mung beans, tofu
>Foods for acute diarrhea: rice cream, grated apple allowed to turn brown
>Foods to help constipation: fiber (vegetable or grain source), water, hot water
>Foods to rebalance intestinal bacteria: yogurt and cultured buttermilk (if tolerated), miso soup, garlic
>Meats: fresh fish, organic chicken
>Spices: ginger, cumin, coriander, fennel
THE AYURVEDIC APPROACH
According to Vasant Lad, an ayurvedic physician and director of the Ayurvedic Institute in Albuquerque, New Mexico, ayurveda sees IBS as an imbalance of vata (the principle of movement) and pitta (gastric juices) doshas. This imbalance causes agni, the digestive fire, to burn unsteadily. A sticky byproduct called ama then accumulates throughout the GI tract. The goal of treatment is to bring vata and pitta into balance, encourage a steady burning of agni, and reduce the accumulation of ama. Specific recommendations are based on the client's constitution, but some general guidelines are "safe for everyone," Lad says.
DIET: Lad recommends eating a pitta-soothing diet, which avoids sour, spicy, and salty tastes and favors sweet, bitter, and astringent tastes.
HERBAL MEDICINE: For vata types, 1/2 teaspoon of triphala may be soaked in 1 cup water overnight and consumed the next morning. Pitta types might try sat isab gol, a bulking agent like psyllium (1 teaspoon in a glass of warm water before bed). For kapha types, kutki and chitrak may help with constipation. As an antispasmodic tea after meals, Lad suggests mixing equal parts cumin, coriander, and fennel.
OTHER REMEDIES: For a delicious, soothing drink called lassi, blend 1 part plain yogurt with 4 parts water and 1/4 teaspoon cumin. Drinking plain hot water throughout the day is a purification technique to eliminate ama, Deepak Chopra says in his book Perfect Digestion. He recommends taking at least a few sips every hour.
STRESS REDUCTION: Try yoga, meditation, and abdominal breathing. "Breathe into the belly like a pregnant, happy Buddha," Lad says. "This is gorgeous."
CHINESE MEDICINE APPROACH
In classical terminology, traditional Chinese medicine describes IBS symptoms as "liver invading spleen" and "damp heat coming down into the lower burner," says Michael McCulloch, L.Ac., of the Pine Street Chinese Benevolent Association in Mill Valley, California. McCulloch translates this into modern clinical terms: "Dietary excess of sweets, alcohol, and fast food create a 'hot zone' in the colon," he says. Other causative factors include parasites and bacterial infection, antibiotics, and antacids. McCulloch says that unlike allopathic medicine, Chinese medicine sees IBS as an inflammatory condition and believes that, untreated, it can lead to more serious bowel disease.
DIET: McCulloch advocates a diet free of all grains and starches, as outlined by Elaine Gottschall in Breaking the Vicious Cycle.
HERBAL MEDICINE: Formulas may be based on the traditional ginseng and astragalus combination (Bu Zhong Yi Qi Tang). Antiinflammatories like oldenlandia (Bai Hua She She Cao) may be added if symptoms are severe. Two other effective herbs, particularly in a flare-up, are pseudo-ginseng (Tian Qi) and the patent medicine Yun Nan Bai Yao.
ACUPUNCTURE can be helpful in controlling symptoms, reducing inflammation, and providing "an example of what true relaxation is," says McCulloch.
STRESS REDUCTION can be done through meditation, biofeedback, or yoga.
COMPRESSES: Warming ginger compresses can help ease discomfort, says Misha Ruth Cohen in The Chinese Way to Healing (Perigee). Boil grated ginger root in water for 10 minutes, soak a cloth in the tea, and apply to your abdomen (but not directly after meals).
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