One such example is irritable bowel syndrome (IBS),  a chronic gastrointestinal disorder that affects the large intestine and impacts approximately 15% of adults in the U.S.  Women are twice as likely as men to have IBS and the most common age for onset is between 20 and 30 years.  

Signs/symptoms of IBS include:

1. Pain & cramps
2. Excessive gassiness 
3. Bloating
4. Diarrhea
5. Constipation 

The Rome IV Criteria defines markers which allows medical professionals to diagnose IBS. But because the symptoms of IBS share the symptoms of so many other intestinal illnesses, diagnosis relies heavily on exclusion or the ruling out of other conditions first. Generally speaking, abdominal pain and other symptoms that recur at least 1 day per week for a period of 12 weeks or longer, with no other identifiable cause, tend to be IBS related.   IBS can be divided into three subtypes, based on symptoms: constipation-predominant (IBS-C), diarrhea-predominant (IBS-D) or mixed.

While there is no cure, there are effective ways to manage IBS:

Avoid Foods That Trigger Your Symptoms
Avoiding items such as carbonated beverages, caffeine, alcohol, raw fruit, and cruciferous vegetables, such as cabbage, broccoli and cauliflower has been shown to help alleviate bloating and gassiness in some individuals. Other research shows that some people with IBS report improvement in diarrhea symptoms if they stop eating gluten (wheat, barley and rye) even if they don't have celiac disease.

The bottom line: It is important to remember food triggers are highly individualized, so pay attention to repeat food offenders. This can be done by keeping a food journal—but make sure to include notes on physical and mental symptoms and stool form and frequency. This can be extremely useful for identifying the culprits or patterns that lead to flare ups.

Try the FODMAP Diet 
Research indicates the dietary restriction of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is an effective method for managing the functional gastrointestinal symptoms in about 75% of IBS patients. FODMAPs are a collection of short-chain carbohydrates found in certain grains, vegetables, fruits and dairy products. For some, FODMAPs result in increased volume of liquid and gas in the intestines that contribute to symptoms such as abdominal pain, gas, and bloating, and the motility problems of diarrhea and constipation. 

However, there appears to be a dose-related effect of these foods on symptoms. In other words, eating more high-FODMAP foods (quantity or variety) at a given meal may result in symptoms that you might not experience if you ate the food in isolation or smaller amounts.

The diet consists of three stages: FODMAP restriction; FODMAP reintroduction; and FODMAP personalization.  The strict low-FODMAP stage should only be followed for a period of 4 to 6 weeks, under the supervision of a registered dietitian or doctor. This recommendation stems from data suggesting that a strict long-term, low-FODMAP diet may negatively impact the intestinal microbiome. 

The bottom line:  For many, IBS symptoms ease when following a strict low-FODMAP diet and then reintroducing foods one at a time, in order to test for tolerance--ultimately resulting in a personalized FODMAP diet. 

Mend Your Microbiome and Manage Your Stress
IBS is also considered a stress-related disorder. A growing body of research now supports the concept of IBS as a microbiome-gut-brain axis disorder responsible for the main features of IBS.  For instance, study findings show a lower diversity of gut microbes in those with IBS compared to healthy controls.  Diet, sleep habits and stress, along with other factors, play major roles in shaping the gut microbiome.  Additionally, it is well established that anxiety and depression increase the risk of developing IBS—evidenced by research that evaluated the waxing and waning of IBS symptoms in response to stress reactivity.  There is also a correlation between early life adverse experiences and the risk of developing IBS.

Thus, a maladaptive stress response may be fundamental to the initiation, persistence and severity of symptoms in IBS and the co-existent stress-related psychiatric comorbidities, namely anxiety and depression. The good news is accumulating evidence suggests abnormal stress responses can be mediated via the balancing of gut microbiota. But the bidirectional relationship must also be acknowledged. Meaning, while the gut microbiota can act as a regulator of the stress response, anxiety and depression---bouts of acute and chronic stress can disturb the composition of the gut microbiota, which can tip the scale back in the direction of undesired gut and psychological symptoms. This builds a strong case for the integration of stress management techniques as part of an IBS treatment plan. In fact, meditation has als been shown to help regulate the stress response via the microbiome’s regulation of neurotransmitters. 

Other studies investigating multi-strain probiotic supplements and fermented foods, such as sauerkraut and fermented milk products, have been found to improve both GI symptoms and mood for some IBS sufferers.  Although probiotics are increasingly recognized for their antidepressant and anxiety-inhibiting effects, it still remains unclear what microorganism strains and what combination of strains are most effective. Further (and larger) investigations are needed.  It should also be noted that probiotic supplements often have a delayed effect in relation to the improvement of symptoms. It can take 8 weeks or longer to begin experiencing noticeable benefits.

The bottom line:  The synergistic effects of engaging in regular stress management practices (meditation, exercise, music, relaxation techniques, behavioral therapy, or whatever works for you) along with taking a multi-strain probiotic (if tolerated and doctor approved), may have beneficial effects far greater than the sum of these parts.

Exercise…But Don’t Overdo it
Daily exercise can boost mood and reduce symptoms such as flatulence, bloating and constipation by positively influencing gut motility and function.  But for some with IBS, strenuous exercise can induce or worsen symptoms.  

During exercise, there is a redistribution of blood flow to the working muscles and a reduction of blood flow and activity in the gut. If the intestines experience a significantly lower amount of blood, especially during endurance exercise or training, it can lead to inflammation, the impairment of the gut lining, reduced motility and malabsorption.  Running appears to exacerbate the gut disturbances more than other forms of exercise, such as cycling, as does exercising in hot temperatures (≥86°F). Findings from a recent study showed that low to moderate activity may be beneficial for symptom management and improving quality of life in IBS patients. Walking programs over 10 -12 weeks and running three times per week did not exacerbate symptoms and were associated with improvements in general well-being. For those with IBS engaging in strenuous or endurance activities, emerging evidence suggests following a low FODMAP diet leading up to heavy training sessions or running events may reduce gut related symptoms.

Strenuous exercise poses can compromise gut integrity and function, at least temporarily, in all individuals—but it may be more severe for those with IBS. Several prevention and management strategies can help address compromised gut function.
These include: 

  • regulating exercise duration and intensity
  • practicing optimal hydration before, during and after exercise
  • identifying individual tolerance levels for pre and post feedings
  • watching for signs of exercise-induced malabsorption
  • avoiding non-steroidal anti-inflammatory drugs (aspirin and ibuprofen) around training schedules
  • exercising in cooler temperatures or times of the day.

The bottom line:  Tolerance to exercise intensity and duration is individualized.  Some may feel best with lower intensity forms of activity like walking and yoga, whereas others may tolerate more intense forms of movement. Pay attention to signs and symptoms and adjust accordingly.


Barrett, J. S. (2017). How to institute the low-FODMAP diet. Journal of Gastroenterology and Hepatology, 32, 8–10. doi: 10.1111/jgh.13686

Costa, R. J. S. (2017). Systematic review: exercise-induced gastrointestinal syndrome-implications for health and intestinal disease. Alimentary Pharmacology & Therapeutics, 46(3), 246–265. doi: 10.1111/apt.14157 

Dale, H. F., et al. (2019). Probiotics in Irritable Bowel Syndrome: An Up-to-Date Systematic Review. Nutrients, 11(9), 2048. doi: 10.3390/nu11092048 

Househam, A. M., et al. (2017). The Effects of Stress and Meditation on the Immune System, Human Microbiota, and Epigenetics. Advances in mind-body medicine, 31(4), 10–25.

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Kennedy, P. J. (2014). Irritable bowel syndrome: A microbiome-gut-brain axis disorder? World Journal of Gastroenterology, 20(39), 14105. doi: 10.3748/wjg.v20.i39.14105

Liu, R. T., et al. (2019). Prebiotics and probiotics for depression and anxiety: A systematic review and meta-analysis of controlled clinical trials. Neuroscience & Biobehavioral Reviews, 102, 13–23. doi: 10.1016/j.neubiorev.2019.03.023

Nielsen, E. S., et al. (2018). Lacto-fermented sauerkraut improves symptoms in IBS patients independent of product pasteurisation – a pilot study. Food & Function, 9(10), 5323–5335. doi: 10.1039/c8fo00968f

Whelan, K., et al. (2018). The low FODMAP diet in the management of irritable bowel syndrome: an evidence-based review of FODMAP restriction, reintroduction and personalisation in clinical practice. Journal of Human Nutrition and Dietetics, 31(2), 239–255. doi: 10.1111/jhn.12530 


These materials are provided to you by Blythedale Children’s Hospital and Kohl’s
Eat Well, Be Well Nutrition Outreach Program.
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