Nutrition Essentials | How To Manage IBS with Christine Lee, MD

Podcast Transcript

John Horton:

Welcome to another episode of Nutrition Essentials, an extension of our long-running Health Essentials Podcast. I'm John Horton, your co-host with registered dietitian Julia Zumpano. How are you doing today, Julia?

Julia Zumpano:

I'm doing great, John, and I'm so excited to talk about this topic. We're talking about irritable bowel syndrome.

John Horton:

Now, Julia, I know your experience with IBS goes beyond just working with patients to help them live with it. You live with it, too, and I've heard you talk about the difficulties and frustrations that can come from having IBS.

Julia Zumpano:

Yes, unfortunately, I have had IBS most of my life, and it's very frustrating, and I've spent most of my life trying to figure it out. And you know what? Sometimes, I realize this might be something that is going to ebb and flow and all I can do is help manage and mitigate some of my symptoms. So, that's really where it comes down to. Our goal is to help people understand that — to help minimize their symptoms, help them feel better, help them recover better from a flare-up. So, it's just really knowledge is power, and that's our goal here today.

John Horton:

Yeah. And we brought in somebody really special to kind of help with that discussion.

Julia Zumpano:

Yes. We have Dr. Christine Lee, who's a gastroenterologist with the Cleveland Clinic's Digestive Disease Institute.

John Horton:

All right. Well, as you said, knowledge is power, so let's give people some of that power. Welcome back to the podcast, Dr. Lee. If my memory was right, you were the first guest we had on Nutrition Essentials and got to say, we're really happy to have you back.

Dr. Christine Lee:

Well, thanks for having me back, John. I enjoyed being here.

John Horton:

Well, we always enjoy having you, and you're here today so we can talk about IBS. And when I looked into this and did a little research, IBS is not exactly uncommon when you look at the statistics. But it seems that there are way more people living with the condition than what the numbers show. Do you find that a lot of folks just kind of wave off ongoing GI issues that point to IBS instead of just getting answers?

Dr. Christine Lee:

Yeah, I think you are right on. The irritable bowel syndrome is a diagnosis, and the reported prevalence is, I think, grossly underestimated. A lot of people are hardworking and they have very busy schedules; they just don't simply have the time to go see their medical provider and get that official diagnosis. But basically, the irritable bowel syndrome are those who have GI ailments or discomforts that flare up or pop up from time to time that does compromise their quality of life, or at least their scheduling of their life. And when identified and treated, their quality of life can be greatly improved.

Julia Zumpano:

Dr. Lee, we know it's common, but how prevalent is it?

Dr. Christine Lee:

The reported prevalence in the United States is about … 10% to 15% of the U.S. population are officially diagnosed with this irritable bowel syndrome. But in our estimation, I do think that number is grossly underestimated.

Julia Zumpano:

Yeah, I would agree. I see patients with symptoms that classify as a typical IBS and I would say it's probably closer to 40% of my patients, I would say.

Dr. Christine Lee:

I think you're right on. It's just a lot of us live extremely busy lives and complicated lives and it's just difficult to get ourselves seen and get the official diagnosis and thereby, the prevalence being grossly underestimated.

Julia Zumpano:

I find, too, commonly, people just kind of slough it off as being a symptom of maybe eating a bad meal or stress or not enough sleep. They usually make an excuse for some of the symptoms and then it just continues to go on. So, I think not understanding that there really is a syndrome that's associated with coupled with all these different gastrointestinal symptoms.

Dr. Christine Lee:

Unlike diseases, irritable bowel syndrome kind of has waxing and waning features. So, it could just kind of pop its head, cause a lot of discomfort and grief, and then it kind of abates and disappears for a while. So, it's oftentimes easy to think about, maybe I should see a doctor. And then, the symptoms get better and then they just kind of forget about it, and then it flares up again. So, for all of that, the nature of the syndrome itself makes that diagnosis a little bit more difficult or delayed.

John Horton:

Dr. Lee, one of the things you talked about before with us was just kind of the unpredictability of IBS and with those symptoms, and they can just kind of strike it at any time. Can you walk us through a little bit what some of those symptoms are, like what people might be experiencing, and then how that really has a big effect on their quality of life?

Dr. Christine Lee:

Yeah. The complexity of irritable bowel syndrome is just that. The symptoms that people present can vary widely from people to people. So, some people may just have abdominal distension, gas, bloating, mostly all pain, discomfort-oriented. And another patient with irritable bowel syndrome may not have the pain component, but they have the unpredictability of getting hit with diarrhea with urgency or explosiveness or difficult to control and increased frequency. And then, you have a third subset where they may have both. They may have the pain and the discomfort and the irregularity and unpredictability of the bowel movements.

So, some people can have some of those and some people can have all of those, and that's what makes the diagnosis a little bit more tricky in these populations.

John Horton:

And I know one of the things we talked about, this is where you get into the difference between a syndrome and a disease, like when you talk about IBS and what it is and how it's addressed. Can you briefly just tell us what the difference is between those and how it kind of relates to IBS?

Dr. Christine Lee:

So, in general, when you have a medical diagnosis of a disease, it's an ongoing process that's always there. So, they tend to not disappear for weeks or even a month at a time and then come back. You either have the disease, which is progressive and escalating in symptoms; whereas in syndrome, it's not an organic disease itself. It's just how your intestinal tract works with each other. So, it may be a motility problem and not a structural, anatomical problem.

So, the things have to be stacked up — the stress, lack of sleep, the poor diet — they all have to kind of line up in a perfect line, and then you can get that syndrome show its rear ugly head, and then you might get horrible abdominal pain, discomfort, distension, nausea, unpredictability of bowel movements. You can have a little bit of it or a whole gamut of things. So, it's the unpredictable nature of the symptoms and the presentation that makes it a little bit challenging because it's so different from people to people.

John Horton:

Dr. Lee, with everything you just said, it kind of makes sense that people kind of wave off some of these issues if they kind of disappear from time to time and just think it's kind of random instead of going, "I have a condition that needs to get some attention."

Dr. Christine Lee:

That's right. It's easy to blow it off as, "Oh, I must have eaten something bad," and then just kind of ignore it until it hits again. And then, they're racking their brain to see what they ate bad this time. So, it's important to recognize the syndrome so that you don't mislabel foods as allergies, and then make sure that you are getting treated appropriately.

Julia Zumpano:

Dr. Lee, correct me if I'm wrong, but I believe that even flare-up to flare-up, symptoms can vary as well. So, it can present itself in different forms, which can even lead to more confusion or excuses in your head as to why maybe you're feeling these symptoms because they're different from the last time. And to your point, I think it can lead to this almost obsession around what you're eating and how your body's reacting to it and you're just trying to be a detective and figure it out and trying to just remove foods, so you don't feel the uncomfortable symptoms. And I think it can lead to just unnecessary restriction, dietary restriction.

Dr. Christine Lee:

You're absolutely right. Not only unnecessary dietary restrictions, but it really builds up anxiety in patients. They're almost like a PTSD response like, "Oh, I can't eat that because last time I had that I had X, Y, and Z occur." So, it brings up a lot of fear and some anxiety. And then, I also noticed that some of those patients have decreasing quality of life because they stop doing the things that they enjoy. They don't like hiking because they're afraid they don't know where the bathrooms are or they're afraid to go on plane rides or boat ride or go on long car rides with their friends, and they kind of avoid certain scenarios because of fear.

So, it's important to just kind of dispel that fear and then have a better approach as to managing the symptoms.

John Horton:

That makes a lot of sense. And I know when we talked earlier, both of you mentioned that you talk with a lot of patients who try to self-treat. They look some things up online and just kind of start randomly doing things to try to address the IBS issues that they're seeing. But it is way more complicated than that. And so, we're going to try to break it down a little for folks so they get a better understanding of what's happening and maybe what kind of steps can be taken. And sounds like, a lot of that starts with nutrition. Julia, I know you said when you talk with people, there is one thing that you start with every single time to try to get things calmed down.

Julia Zumpano:

Yeah. So, I always take a diet history to see what someone's eating, and I try to really limit those processed foods. So, we know that processed foods can increase inflammation. Fatty foods take longer to digest, so they kind of slow things down. Oftentimes, process foods are inadequate in fiber, vitamins and minerals. So, the inadequate fiber can definitely exacerbate symptoms. So, I think just really looking at, just basic, the cutting out processed foods, cutting out fatty foods, processed meats, fast foods, eating out is a big one, too, because you don't know what kind of ingredients they're using. So, oftentimes, I'll see more symptoms associated with eating meals away from the home. So, that would be a big one. I mean, it's a simple step.

John Horton:

It makes a lot of sense. And when we say, “processed food,” because I know that's a term that gets thrown out there a lot — I mean, we're talking really the kind of sugar ... I hate to say bad stuff.

Julia Zumpano:

I'm speaking more toward ultra-processed foods. So, sugary beverages, bakery items, commercially baked items, fast foods, deep-fried or breaded foods. So, some of those really highly ultra — chips, snacky foods, candy bars, candy — some of those really highly processed foods. So, the sugar, the lack of fiber, the high fat, those are all contributors to some of those symptoms.

John Horton:

It's not like all the convenience foods where we see the wrappers and the bags in the backseat. So, those would be where you under control.

Julia Zumpano:

Some convenience foods are OK. We all do need convenience. So, as long as you're educated and understand what you're buying, what the ingredients are and how your body reacts to them, some convenience foods are OK, like maybe a protein bar or protein shake. Some of those are convenience and still can be safe. But we want to look toward, really, those ultra-processed high-fat, high-sugar, low-fiber foods are the ones we really want to focus on cutting back on as much as possible.

Dr. Christine Lee:

Especially in this day and age, there's an old adage where you use food as your medicine and medicine is your food. Nowadays, it's not just the food itself, but a lot of places use certain preservatives so that their ingredients last longer. In small amounts, may be OK, but when they're accumulated because they're in the lining of the to-go boxes that you're carrying it in or on the lining of your hot beverage cups, they can all kind of add up. And then, MSGs or variants of MSGs that people use to make sure that their foods last longer so they don't spoil.

And then, even foods that we think are healthy, like salads pre-washed, some of those are processed with chlorinated washes so that the lettuce won't wilt and they stay fresher longer. So, anything that has an expiration date that's really prolonged, you have to think twice about. And so, all of those again are additive and then cause problems for patients in varying degrees depending on your sensitivity to those ingredients.

John Horton:

Yeah. And I think what we're getting into here is we're starting to talk about triggers. And I know that is an extremely complicated thing to figure out because it could be just about anything. I know Julia, you had mentioned folks have to kind of be a food detective to kind of figure things out. But I know there's kind of a map for that when people are kind of looking at it, and it's literally called a FODMAP. I kept messing up the word. Did I say it right this time?

Julia Zumpano:

Correct. Yeah. So, it's called a low FODMAP diet. It's designed to be a temporary plan. So, FODMAP stands for fermentable oleo di monosaccharides and polyols.

John Horton:

I understand why they go with FODMAP.

Julia Zumpano:

Right, exactly. Exactly. And that isn't even abbreviated version of the long name. These are carbohydrates that are poorly absorbed in your small intestine. So, it leads to more fermentation by bacteria and water in flux in your gut. So, it can really heighten these symptoms for sensitive individuals with IBS. So, the low FODMAP diet takes a group of these foods, these foods that are ... it does include healthy foods. So, these high FODMAP foods do include fruits and vegetables and some dairy and some grains. And what it does is it eliminates these high FODMAP foods for a short period of time, on average, about a month, three to four weeks.

And then, each group is added back in slowly, and symptoms are monitored the whole time. A food diary is highly recommended, and you see if there are a combination or one or two of these groups that could be triggering your symptoms. And if that's the case, then we then investigate further within those groups how much of that you can have, what foods are better tolerated than others. And so, we try to create more of a personalized plan to minimize symptoms. But oftentimes, people will see this low FODMAP diet and just follow it without an end. And it is an elimination diet. It is designed to be followed for a short period of time.

And then, it's essential that the foods are added back in, because as I mentioned, the foods that are high in FODMAPs are very nutrient-dense and most of the time, all of the foods are not triggers. It's usually maybe one or two categories and maybe even just a handful of foods within that category. So, I think it's very important that if you choose to follow an elimination diet, you follow it properly, very strategically, and ideally, if you have the opportunity to do it with a registered dietitian.

John Horton:

So, it sounds like what you're saying … so, the FODMAP diet … basically, you have six food groups there. You eliminate them all, you bring them back one at a time, and when those IBS symptoms kind of flare up, then all right, stuff you just introduced is kind of what's triggering it. And then, within that group, it sounds like you even have to break it down and do a little work and figure out what within that group is causing you the issues.

Julia Zumpano:

Yeah. Most people know because most of the time, by the time you get to a low FODMAP diet, you've played around with so many foods and played around with eliminating so many things, at that point, I would say even to my patients, I'm like, "Let's look at this list. Is there anything on this list that you know is a trigger for you?" And I'll take that group and say, "OK, let's just work on this group then. We know that this is a trigger. Let's eliminate this group." And they may add groups back in that they know they have no problem with.

I usually do encourage they take the full elimination first, but then we add in the groups that they know historically they haven't had an issue with, and then we may experiment further in the groups that they do have triggers with. So, it is a little fine dance that you really have to be very diligent on. But in the end, it does give you more of a strategic plan on how to manage IBS.

And then another big thing is this is symptom-based. So, there are periods of time where maybe you can have some of those foods, and then maybe you're having too much of them, and there's a flare up. And then, these symptoms start to exacerbate even more. So, then you have to just back off.

So, you have to be open-minded and understand that at certain times of your life, you may be able to consume less or more of these foods just based on your gut's reaction.

John Horton:

Dr. Lee, do you find a lot of your patients come in, and maybe they've been struggling with IBS or with these symptoms and they've looked up FODMAP on their own, they just start cutting stuff, and now, they just don't know what's going on and they're really frustrated?

Dr. Christine Lee:

Yeah. When they present, they usually come with them a lot of emotional turmoil, anxiety, frustration to no end, just because they've been battling it for so long. And the reason for all of that frustration is exactly what Julie had said. Some of the food triggers at some point in your life may be triggers and then others, it's not. And the best example I can come up with is it's like exercise. You wouldn't run a marathon when you are suffering with the worst influenza of your life. There's a timing issue where you could run the best marathon or best 10K, 15K under the right circumstances, but under the wrong scenario, let's say, you didn't sleep at all and you are fighting the cold, you can't breathe because your nose is all stuffed up, that's really a poor time for you to run the best marathon of your life. So, situational awareness that's important.

For irritable bowel syndrome, because there's so many moving parts, it really takes a multidisciplinary approach. A partnership with someone with a dietitian, in this case Julia, is key to success because you are what you eat. So, the nutrition part is a huge role in managing IBS, but not the only role.

The other components that we need to kind of weigh in, and that multidisciplinary approach, is a careful interview on what medicines are you on, what antihypertensive or blood pressure medicines or allergy medicines could be contributing to your IBS and people don't realize there's a carryover. They're like, "Oh, I didn't know my allergy medicines had X, Y, Z effect." But almost all prescriptions have some side effects. So, whether it's a pain pill because you just had a left hip replacement and you're on opioids or you're on an antihistamine because your allergies are flaring up or even some simple blood pressure medicines that may have constipating effects that you're not aware of.

So, a lot of the prescriptions have side effects. It's really important to make sure that we don't ignore that and we go over your entire medicine list, including over-the-counter medications. So, a lot of over-the-counter medications also have side effects. So, it is important that we go through all of those because that plays a key role in how you improve or manage your IBS symptoms.

And then, the other approaches are their lifestyle. Are you sleeping well? What kind of quality sleep are you having? Or do you sleep a lot, but the quality is poor because you have undiagnosed sleep apnea. Also, your anatomy.

This is where it's so important not to take your neighbor's treatment and just copy it because no two people are alike. So, what works for your neighbor may not work for you because you might've had a hysterectomy or you might had a gallbladder removal or you might had a hernia repair. So, you got to look at the anatomy that you're working with that's specific to you.

Julia Zumpano:

IBS presents itself in so many different symptoms. To your point, someone may have chronic constipation, some have chronic diarrhea, some have more gas and bloating and indigestion and cramping. So, there is no one-size-fits-all. That's what makes this so complicated is that there's so many factors into play. That's why I completely agree with you. Oftentimes, we'll Google search or look up a treatment, but we don't really fully understand that there are so many different ways to treat IBS, and we really try to treat the symptoms really more than anything.

Dr. Christine Lee:

Right. And your comorbidities are important. Do you have underlying Parkinson's or MS, or do you have scleroderma, or all of those play a role in how to approach your IBS differently. So, it's important to just kind of do a full medical evaluation, a deep dive in your medical conditions, your anatomy. If you've had surgeries, as we alluded to, your physical activity. So, some people who are more physically active will be treated very differently than someone who have a sit down job, a nine-to-five job that they have to sit or they're in the board office all day, boardroom all day, or they have a lot of traveling involved in their job where they're flying or long car rides every day.

So, all of those play a role in how we treat or approach that IBS patient.

John Horton:

Dr. Lee, this seems to kind of go to that “30, 30, 30 concept” that you were talking about with us earlier. And you got nutrition is kind of one of the big ones, but then there's those other things. You mentioned stress, sleep, exercise, other health issues. Yeah. All of that factor into whether IBS is going to flare up and what it's going to do. And it sounds like they all need to be addressed in tandem.

Dr. Christine Lee:

Yeah, absolutely. That's where the multidisciplinary approach shows the biggest success. So, a close partnership with the dietitian, even maybe a physical therapist and your primary care doctor is really key to success.

Julia Zumpano:

One thing, John, that you mentioned was stress, and we can't go without addressing the gut-brain interaction here when it comes to IBS. So, we do know that the gut is considered the second brain. There's over a hundred million neurons that are housed in their brain that they communicate. Your gut talks to your brain and your brain talks to your gut and they interface. So, when you are stressed, when you're anxious, when you haven't slept and you're irritable, that actually does lead to an increased trigger of symptoms. So, we have to address the fact that they are associated so significantly.

So, you can't necessarily reduce symptoms of IBS without really looking at the gut-brain connection and the mental status of patients.

Dr. Christine Lee:

That's an excellent point. Stress is a perfect example. People react to stress differently. And some people, when faced with stress, they might get really hyper and hyper-agitated and hypervigilant, and they tend to be more activated. And the other subset of people, when dealt with stress, they shut down. They just crawl up in a ball and they just can't. Everything slows down. So, that same effect happens to your gut because of the brain, gut access or close interactions. When faced with stress, some IBS patients, they get hypermotility of their bowels and they have frequent diarrhea, lots of spasms, a lot of bloating and a lot of pain.

And then, you also have a different set of people who when faced with stress, everything slows down. They get gastroparetic symptoms where the stomach just sits there and doesn't move or the colon just relaxes and the world just slows down. They just don't want to function. So, then they have the other extreme of constipation and inability to pass gas or defecate properly. So, it's very interesting, stress, how it affects IBS patients. It can be from one extreme to the other.

Julia Zumpano:

And oftentimes, people deal with their stress with eating. So, it also can trigger more emotional-based eating, which can trigger symptoms, too. So, it's just also how you deal with stress.

John Horton:

Well, and when you were talking about the foods that can trigger problems, I mean, most of the time, if you're stress eating — I know when I stress eat, I usually don't go for a banana or an apple or something healthy.

Julia Zumpano:

Yeah, we're not eating celery if we're stressed.

John Horton:

That's usually not what I'm hitting. It's usually something that isn't too great for you and then-

Julia Zumpano:

…yeah, you're looking for the immediate gratification, that immediate satisfaction from an outside stimulus is what people are constantly looking for. It's understandable, but it can worsen symptoms, unfortunately. So, it's really important, I think, from a multidisciplinary team, to really even consider meeting with a therapist — cognitive behavior therapy has been shown to be very beneficial for the treatment of IBS to help us with the associated symptoms.

Dr. Christine Lee:

And exercise is key. Exercise is the other medicines that's just vital for IBS patients. So, whether you're well-versed and you can do this on your own, or if you actually need to elicit the help of a professional as a trainer to put you on a good exercise regimen, or if you're just the beginner, just going for a long walk or a hike, or even just choosing to take the stairs instead of the elevator at work, all of those kind of play a role and help address your IBS symptoms slowly, but they do build up. So, exercise can't be emphasized enough.

John Horton:

Dr. Lee, I was going to ask, how does exercise tame IBS a little bit? Is it just that it kind of gets your gut on a more regular pattern or something like that?

Dr. Christine Lee:

Yes, for sure. In so many ways, it helps IBS. Number one is that any kind of exercise improves circulation. So, you're going to get blood flow, better circulation to the intestines, to the colon, to the stomach, all the vital organs. So, from increased circulation, you get one benefit. The other, second benefit is any bit of exercise increases your metabolism. So, anytime your metabolism is increased, your motility kind of starts to wake up. So, that's helpful in that aspect.

A third aspect is muscles. Your intestines is an organ and it's lined by muscularis, mucosa layer, and those muscles have to squeeze well. They can't squeeze lightly. They got to squeeze pretty well to have that effective higher-quality peristalsis moving the things forward. It's kind of like if you had a tube of toothpaste and you had a weak hand and you can only squeeze a little bit, toothpaste will come out, but your tube's not empty. But if your hand's strong and powerful and you squeeze that tube of toothpaste from the bottom up, you're more efficient and more effective at moving that tube of toothpaste down the tube.

John Horton:

I am not going to look at my tube of toothpaste the same when I go to brush my teeth tonight. I got to tell you, but that is a great explanation as to how exercise can kind of, I guess, muscle up your gut and help the pooping process.

Dr. Christine Lee:

Yeah. So far, we've talked about increased motility, circulation, muscle strength. There's more: endorphins. When you exercise, it's a scientific fact that you release the happy endorphins. So, it just makes you feel good and makes your gut feel good. You're able to tolerate more. So, there's so many benefits to exercise.

John Horton:

And one of the other side things that we haven't talked about is sleep. So, Dr. Lee, how does just making sure you're getting that seven to nine hours of good snooze at night, how will that help with IBS?

Dr. Christine Lee:

Oh, sleep is so vital. That's where our body is able to do repair. Cell damage repair. So, sleep is so important and it's not about the exact quantity either. It's the quality. So, make sure if you are getting six to seven hours of sleep, make sure the quality is good. So, if you have undiagnosed sleep apnea, you want to get that addressed. Or if your spouse has sleep apnea, you want to get that addressed because you want to make sure your sleep is the high-quality sleep that you need. When you do that, you set your circadian rhythm correctly. With your circadian rhythm driving your metabolism and your motility is so important that all of that line up in a healthy fashion.

So, sleep is very important, not just in the circadian rhythm and motility, but also allows your body to repair cell damage.

Julia Zumpano:

I will say, coupled with that, the importance of sleep in the circadian rhythm, but even with meal timing. So, timing your meals around that circadian cycle, so your sleep-wake cycle. So, making sure you're eating within the first couple hours you're waking up, eating every four to five hours. So, timing your meals appropriately, not eating too close to bed. So, those things are really important just from a basic symptom management. People tend to tolerate more small frequent meals, too. So, those are just some little tactics you can start to take to see if your symptoms improve.

John Horton:

Yeah, I was going to say, I would think meal sizes would be maybe a big issue with IBS flaring up. So, I take it, Thanksgiving is probably not a good day if you-

Julia Zumpano:

…no. And also not eating all day just from a regular standpoint. Just snacking all day and then consuming a large dinner right before bed is also not a good thing. So, just being able to balance your meals appropriately, spread out your intake. I do usually say when you're active, your stomach can… it's working. So, try to get more food in through the daylight hours and try to lighten up through the evening. You're starting to tell your body to slow down, to start resting. And it's important that we not have a very large meal before bed because it can lead to symptoms.

John Horton:

We've covered a lot of ground here, and we started off with food, and we're in the FODMAP diet and all that, and we went into all these other issues. I want to kind of do a U-turn and kind of go back to nutrition. I mean, we are Nutrition Essentials after all, and kind of talk about supplements. I know both of you were really emphatic about how sometimes supplements can help people with IBS to make sure they're kind of meeting their nutrient needs while also addressing their symptoms. So, what should we be looking at with that? What are the kind of the go-to things?

Julia Zumpano:

Great question. So, I will start with magnesium. Magnesium is a mineral that is responsible for 300-plus enzymatic reactions in our body. It's extremely important, and most people, it's projected — we don't have really good solid data — but it's projected that 50% to 60% of Americans are deficient in magnesium. And it's just because the food that we eat, we're not consuming large amounts of magnesium. We're not absorbing it well. There's a lot of theories as to why that's the case, but magnesium is very beneficial from a stress reduction standpoint. So, we know we've talked about stress and IBS.

It's helpful from a motility standpoint so it can help keep your bowels moving. And it can be more gentle or aggressive depending on the type of magnesium you take. And then, it can also help sleep. So, it helps all of the three main factors we are addressing here. And in some cases, I find that most minerals can also help, like muscle recovery. So, we're really hitting it in every aspect here. So, I think magnesium … I recommend glycinate because it is the best absorbed. Now, if you are dealing with constipation, chronic constipation, magnesium citrate might help you resolve that constipation better. So, you may want to try to start with that magnesium. And then, once you have your bowels moving more regular, we can transition to glycinate. But I do recommend magnesium at bedtime. That's a big one.

Second one I recommend is fiber. Now, this can be through the diet or through a supplement. It just depends. It's case by case. So, fiber is very important for the management of IBS symptoms. So, that's something that you would discuss with your healthcare provider or registered dietitian. But if you're going to do supplemental fiber, I recommend something very natural, like a ground flax seeds or chia seeds, psyllium husks, something of that sort.

There's also IBS-specific fibers that do not have a lot of those fermentable carbohydrates that tend to be tolerated the best. So, those are the types of fibers I would recommend. Again, fiber can exacerbate symptoms if not taken properly.

John Horton:

Yeah. It sounds like you got to be careful.

Julia Zumpano:

You do, you do.

John Horton:

Too much fibers isn't a good thing. You got to find that right balance.

Julia Zumpano:

Exactly. And the right kind.

So then, we have vitamin D. Vitamin D is very important. Again, very commonly deficient in America, specifically in those colder climates, colder states like Ohio, most of our patients are deficient in vitamin D. So, I think that's important … well, what I will say is instead of just starting a vitamin D supplement, I will encourage people to get their vitamin D tested because then you can dose properly. So, you may be completely fine. You may be one of those people who absorb vitamin D great and your level is perfectly normal because we don't want it too high or too low. But if it is low, that's when you can treat.

So, if it's very low, your primary care physician or your healthcare provider may actually prescribe a prescription dose of vitamin D to get it up quickly. If you're just moderately lower on the lower end of normal, an over-the-counter supplement will do, but it's really important to know where your value is before you supplement.

And then, I have one last one, and that's omega-3 fatty acids. And that's because omega-3s play such a great role in reducing inflammation. They can help kind of build that gut lining, that gut barrier, so that can help relieve symptoms.

And omega-3 fatty acids are very often very commonly inadequate in the standard American diet, and they're found mainly in fatty fish, and we just don't consume enough as Americans to give us the amount that we really need.

The other piece is that there's something called an omega-3, omega-6 ratio, which is also important. So, Americans also eat a lot of omega-6, which can kind of offset that ratio. So, it's also very important to provide more omega-3, but also decrease the omega-6 consumption to help that balance. And the reason that balance is important is because it can help reduce inflammation and IBS is an inflammatory syndrome.

John Horton:

Dr. Lee, I know when we talked the last time, and we had our little pre-podcast meeting, you actually had the bottles of supplements there as like props to show us. I mean, you believe really strongly, it sounds like, in people with IBS using those to make sure they're addressing all those nutritional needs.

Dr. Christine Lee:

Yes, John, times have changed. The foods, I feel, is very different than the foods that our parents or grandparents were raised in. We live a very fast, techie lifestyle. So, most of us do not have the opportunity. In an ideal state, we have our great garden in our backyard and we grow our vegetables and go fishing and eat a lot of omega-3-rich foods. But when we live a very busy life on the go, most of us do not have the opportunity to have sardines or our coworkers would not be happy. So, most of our diets are very lacking in the vital nutrients that Julia so well explained that we need.

So, omega is so important in our gut lining and our gut health. It really helps our IBS patients with their symptoms.

But unless you have a full-time job where you can dedicate yourself to make sure you're hitting all the boxes right, it's just easier to just make sure you're getting your requirements with a supplement. Now, I'm not a big supplement fan. That being said, I do take omega-3s because it's so important for our gut health and it's so protective and helpful. I also take magnesium because it's also so great for all the things that she mentioned: high-quality sleep, muscle and bone health. Most of us are at risk for osteoporosis. It's really good for bone health as well. So, it is important to make sure that we are not deficient in magnesium because that's low-hanging fruit. It's such an easy thing for us to take care of ourselves.

And then, the vitamin D, especially in the Cleveland area, most of us are vitamin D-deficient. But as Julia pointed out, that I do think you need to be monitored because vitamin D is what we call a fat-soluble vitamin. So, you don't want it to be too low, but you certainly don't want it to be too high. There's a range that needs to be met. And again, most of us are low, but we want to make sure we're not overshooting either. So, check in once a year and get a vitamin D level. It's very simple, but it's so important. And now, there's data showing vitamin D deficiency increases your risk of IBD diseases and even some cancer.

So, these are things that are just readily available within our reach that we can do for ourselves. So, vitamin D, magnesium and omega-3s are very important, especially if your diet's not rich in fatty fish, like salmon and sardines.

Julia Zumpano:

One thing I do want to add is there may be additional supplements you may need with IBS based on if you're following a restricted diet or absorption is not key. So, that is really important, where you can meet with a dietitian and you can get your diet fully assessed, and some other supplements may be recommended just for a short period of time to get your stores back up. But it is important to look at the other nutrients that are important that are essential as well. I mean, I will say calcium is one that can be commonly inadequate because of the elimination of dairy due to symptoms.

John Horton:

The supplements are great, and we talk about them on this podcast often, but the reality is we also, I mean, we're going to fill up our plates multiple times a day. And this is where I kind of want to circle back to that FODMAP diet or that low FODMAP diet, which it seems like is where a lot of people go and where a lot of times kind of frustrations grow. And just want to reemphasize again that the way you've talked about it, that low FODMAP diet, it's a temporary reset.

Julia, when we were talking earlier, I know you explained it really well where when you're kind of finding those IBS triggers, the goal isn't just to restrict today, it's to learn what foods and what amounts you can kind of add in in the future to really be a happy diner at some point.

Julia Zumpano:

Absolutely. Yeah. So, the intent of any elimination diet, whether it's a low FODMAP diet or eliminating gluten or dairy, whatever the case might be, is to hopefully do it temporarily. Two reasons. Number one, we get relief of our symptoms and that's great. People love that, right? Hopefully, they show that the low FODMAP diet can eliminate up to 65% to 70% of IBS symptoms.

Now, oftentimes, though, we'll see that the symptoms come back. So, this is this yo-yo effect of the syndrome. So, yes, you'll get relief for a short period of time, and then maybe stress hits, you're not sleeping well, or your body just kind of gets tired with the foods you have and you have something new and your triggers relapse.

So, I think it's important to recognize the fact that these elimination diets are not lifestyle habits. They're not lifestyle diets to follow. They're short term. They're intended to help you figure out if there are dietary triggers and what they are and then to help you manage those triggers.

So, a lot of times you can play around with some of those. When you're feeling great and you're not in a flare up, dairy could be something you could have a little bit more frequently maybe than when you are in a flare-up.

And then, there's certain dairies that you know that you can have, and certain things — like I commonly hear ice cream — ice cream is a trigger for a lot of people. You have the fat. It tastes amazing. Some people love to deal with the trigger, but ice cream is a big one. So, maybe you don't go straight to ice cream if you're going to add back dairy, but you try some Greek yogurt or some lower-fat cheese. So, there's just a lot of flexibility. There's so many foods that you can play around with and add and that are so nutrient-dense that we hope to find this little balance of understanding what your triggers are and then what amount you can consume those foods in.

John Horton:

I love it. I think you referred to it as that fine little dance and balance that you kind of need to look to get if you have IBS. And here's everything we've been talking about and how difficult it is to find these triggers and the solutions and things like that, it sounds like it is possible.

And Dr. Lee, I know you had shared a story with us about a patient you were working with who scheduled an appointment to come back and see you just to share good news. So, if you could kind of recount that for us, because I think it's really one of those, if you're dealing with, it's a point of optimism.

Dr. Christine Lee:

Yeah. As I started saying, when I see IBS patients, they come with a lot of baggage of suffering, anxiety and whatnot. We had a particular patient who had a really great difficulty controlling her IBS symptoms for quite some time, a lot of struggles. We were able to sit down and kind of go through her medications, her over-the-counter meds that may be contributing to her symptoms, and then kind of had a good plan as far as making sure her sleep's good and making sure if she does travel, how to mitigate those symptoms that you can anticipate from long car rides or plane rides and travels.

We got to a point where she was really happy with her IBS management, and if she finally came to a place where she felt confident that she could travel and do the things with her friends. So, she made a follow-up appointment because she wanted to tell me in person, she didn't want to just send me a MyChart message saying, "I'm doing great." She wanted to come in person and tell me face-to-face that she's doing great. And I was so touched and so moved.

So, we have a huge opportunity to influence people's lives and improve their quality of care. So, it may not be a disease, but it is a syndrome that a lot of patients suffer greatly from.

So, it is important to get this message out that you don't have to suffer in silence and you're not alone, but your treatment is very different from your friend or your neighbors’ or your family member. It is important that you come in and sit down and just do a good deep dive in the diet and all the other contributing factors, whether it's because you had a gallbladder surgery or you've had a pelvic reconstruction surgery or what meds that you're on, all of those influence how we treat you and your success outcome.

Julia Zumpano:

Oh, I love that story. Thank you for sharing with us. I think one thing that's really important is giving yourself grace because oftentimes, people will say, "Oh, I shouldn't have eaten that. I knew I was going to feel horrible." And then, you almost blame yourself. And then, also patience is important. So, being very patient. It can be kind of a tedious and long process to get to the end, but it is worth it. And if you have that multidisciplinary team, it can really help you relieve symptoms significantly.

John Horton:

So, I guess as we prepare to kind of sign off here, I want, with both of you, if someone's listening to this and they're going, "Wow, I may be having IBS symptoms and maybe I should do something," what would you recommend is that first step they should do and to kind of get on that path to feeling better and eating better?

Dr. Christine Lee:

Well, I may be biased here, but I recommend seeing your GI doctor or your primary care doctor. I think that's a first step just to make sure that you don't have any of the classic alarm symptoms that may be masquerading as IBS. So, just make sure that colon cancer screening's up-to-date and you don't have a history of pancreatic cancer. You just want to make sure you get that checked off first, and then you start looking into treatment options.

And then, for treatment options, just the key is one size does not fit all. So, that is so important. I hear so many times, "Oh, my neighbor does this. My spouse has this." I understand that, but you're uniquely different. So, your treatment plan may be very different and that's important.

The third key is, whatever the treatment plan that we do come up with, understand it's not going to be static. You have to mitigate. And the best analogy I can provide for patients is it's like driving a car on an interstate highway...

Julia Zumpano:

Yeah. I'm going to be very biased as well. Just like Dr. Lee, my first recommendation would be, meet with a registered dietitian...

John Horton:

And from Dr. Lee's story with that one patient, and I'm sure there's many others like her, it is possible to kind of figure out what's driving these IBS problems and get a solution, so that way, you can just live your life.

Speaker 4:

Thank you for listening to Nutrition Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.