IBS – The world’s most common disease?

This column is written by Stig Bengmark – professor emeritus, researcher, lecturer and author. Read more of Stig’s columns here.

Irritable bowel syndrome (IBS), to a large extent, is a disease of middle age. It is estimated that one in four working age persons in the Western world suffers from IBS – two thirds are women and one third men – and it is more severe in women than men. Of those afflicted with the disease, about 40% have a milder form of IBS, 35% suffer from a more moderate/relatively tolerable form of IBS, but 25% – one in four adults – suffer from a severe and extremely debilitating form of the disease. In the US, no less than about 12 per cent of primary care patients are reported to suffer from symptoms related to IBS, which is estimated to result in between 2.5 and 3.5 million doctor visits in the US alone. The overarching problem is that no doctor should make the diagnosis without first having ruled out other, more serious diagnoses such as cancer in any of the many abdominal organs.

IBS results in tremendous costs to society and widespread individual suffering.

IBS patients should be able to get a diagnosis immediately, but this is unfortunately not the case – it has been reported that, on average, a patient makes five doctor visits before IBS is diagnosed. Those who suffer from IBS use twice as many sick days compared to the average person who takes sick leave. Add to that the fact that many people with IBS have such severe symptoms that they are forced to work part-time more often than the average worker. It has been estimated that IBS costs the American economy no less than 21 billion dollars, and this only from work absences.

Women are also hit particularly hard because they are too often subjected to unnecessary surgical procedures, such as removal of the uterus and ovaries, but also removal of the appendix, in an effort to control these disorders. And IBS sufferers are often subjected to completely unnecessary courses of antibiotic treatment, all in the hope of at least temporarily gaining control over the symptoms and – oddly enough – it occasionally seems to have helped.

Symptoms of IBS can vary widely among individuals

Characteristic symptoms experienced with IBS are, of course, abdominal pain, symptoms that often get worse after eating and often improve for a while after bowel movements. Constipation and/or diarrhoea are extremely common, and IBS sufferers often alternate between these two conditions. Bowel movements do not follow a discernible schedule but are extremely irregular. The symptoms come and go and often disappear for a while. Distension, gas, gurgling and upset stomach are also characteristic symptoms. The consistency of the stool alternates from day to day between hard and loose; often a hard lump comes first followed by diarrhoea-like stool – and you often feel that you are never “really done” and end up visiting the toilet repeatedly as well as wiping and wiping repeatedly.

What to do?

IBS often goes hand in hand with other conditions such as lactose intolerance and gluten intolerance. Historically, lactose-free and/or gluten-free diets have therefore frequently brought some relief. In recent years, however, a link has been found between a decreased ability to digest an especially hard-to-digest group of fibre called fructans, a collective term for a variety of dietary fibres that are monosaccharide, oligosaccharide or polysaccharide in nature. Based on this discovery, a list has now been developed with hundreds of foods that should be avoided – a list called the FODMAP list. Unfortunately, strictly following a FODMAP-reduced diet does not provide relief for everyone – in fact, about 25% of IBS sufferers show continued symptoms.

High FODMAP foods

  • Fructose: Apple, pear, peach, mango, watermelon, canned fruit, dried fruit, honey, juice.
  • Fructans and/or galactans: Wheat and rye in larger quantities (bread, pasta, biscuits). Broccoli, Brussels sprouts, cabbage, onions, garlic, peas, legumes.
  • Polyols (sugar alcohols): Apples, apricots, cherries, nectarines, plums, avocado, mushrooms, cauliflower. Sweeteners, e.g.: sorbitol, mannitol, xylitol.
  • Lactose: Milk, yoghurt, cream cheese.

Many of the “forbidden” fruits and vegetables are those that have been considered to be especially nutritious over the years – this includes the most fructan-rich fruits and vegetables such as bananas (especially unripe), onions, garlic and also Jerusalem artichokes. Bananas are a wonderful source of a variety of healthy fibre, nutrients and minerals, quickly makes you feel full and satiated and is reported to contribute to weight loss and the control of a variety of chronic diseases. The same experience is reported with frequent consumption of, e.g. Jerusalem artichokes, which have been proven to help keep a variety of chronic diseases at bay in a number of studies.

The solution can be summed up in one word – Synbiotics

There are only a handful of gut bacteria strains that can manage to break down fructans, and many argue that modern Westerners have never been colonised by these “specialists” or that they have lost them at an earlier stage because the Western diet has rendered them “unemployed/starved out” – we simply have not eaten fructan-rich diets – as bad as our diets often are.

The solution was presented way back in 1994 by researchers at an agricultural research institute in Braunschweig, Germany by Marina Müller and Dorothee Lier. They were involved in research related to silage (fermented animal feed). Lack of fructan degradation/decomposition is also a concern in the long-term storage of animal feed, something I was not aware of. Müller and Lier tested no less than 712 strains of lactobacilli, all recovered from plants, mostly grass.

Read and be amazed: Only 16 of these lactobacilli strains were able to break down phlein, a fructan with no less than 5 bonds, and only 8 could break down inulin – perhaps the most well-known and widely-used prebiotic today.  These 16 lactic acid bacteria were identified as Lactobacillus paracasei subsp. paracasei, Lactobacillus plantarum, Lactobacillus brevis and Pediococcus pentosaceus – three of these, though not the same strains, are included in my Synbiotic 2000. All strains of Lactobacillus paracasei subsp. paracasei that were tested, proved to be capable of digesting fructans. Other lactic acid bacteria strains did not fare so well. Most of the others that were tested, with the exception of two strains of Lactobacillus plantarum, had greater difficulty digesting inulin compared to phlein.

Currently missing in action across much of humanity

Our gut flora has been slowly thinning out, and the dwindling numbers continue to decline today. We have known that this is the case for almost forty years without really doing anything about it. This trend had already been demonstrated back in 1983 by a very prominent American microbiology researcher, Steven Finegold, and was later confirmed by my colleagues in the team which would later become Probi, which we started in the late 1990s.

It was clear at a very early stage that it was precisely the fructan fermenting lactobacilli: Lb plantarum and Lp paracasei, that were hardest hit by the depletion of the “bacterial organ”. It was no accident that it was a lab plantarum strain that became Probi’s feature bacterial strain; it still is today and became the strain around which the ProViva health drink was built.

But I wanted to go further, which was not possible with the structure of Probi at the time. Above all, I wanted to look for new lactobacilli, not in the depleted gut of the modern human, but in nature, just as Müller and Lier did. It was through this new approach that we would eventually find several lactobacilli with unexpectedly strong immune functions, three of which became part of my research composition: Synbiotic 2000.

I was also driven by another ambition, namely to add beneficial fibre to the selected lactobacilli – prebiotics – to serve as a “packed lunch” for the bacteria on the trip down to the final “worksite” – the large intestine. We decided to add four kinds of fibre that were known in the scientific literature for their magical effects, one of which would be a fructan – inulin.  Today, the combination of probiotics and probiotics – now called synbiotics – is widely known for its strong health-promoting effects.

Some final thoughts

I was hesitant to write this column. I feel discouraged that I have not succeeded in anchoring the knowledge and research that I have been engaged in for so many years. This is partly due to the fact that I have mostly focused on severely ill patients in intensive care – patients associated with my profession – surgery. And while we have succeeded in demonstrating the dramatic effects of Synbiotics, we have failed to anchor that knowledge in a medical world that is almost entirely focused on chemical cures – not whole plants and certainly not bacteria.

Now we are starting to hear that we need to avoid certain plants – FODMAPs – to feel healthy – but we are still hardly seeing the phrase “eat lots pf plants” enter into the vocabulary of the modern medical community.

My advice is this: “Throw the FODMAP list in the trash” – that is where it belongs. Search high and low for the fructan bacteria you have lost – they are all around you on living plants – they are there to protect and nourish the plant that hold them.

I would like to add something:

Obese people are almost completely lacking in fructan-fermenting paracasei and plantarum – can that be a coincidence? We need fructan-containing foods – does it help us eat less? Fructan-containing foods are less likely to lead to fat storage? Obesity often occurs in parallel with IBS. And – IBS affects women more often than men. I do not know the answer – but at least it is worth thinking about.

In any case, I have drawn a lot of inspiration from two women, Marina Müller and Dorothee Lier, I think they are worthy of A LITTLE NOBEL PRIZE – they discovered something that might be the key to one of the true scourges of the planet – IBS.


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