Irritable bowel syndrome (IBS) is still largely a mystery—what causes it, who gets it and what eases symptoms are all questions that have not yet been fully answered. Given that a gut microbiome imbalance sometimes is to blame, you might think that taking probiotics for IBS could be the answer. Bottom Line Personal asked gastroenterologist Suneeta Krishnareddy, MD, if that is true and what is the best probiotic for gut health?
What We Know About IBS
IBS is a syndrome characterized by specific symptoms, not a disease like Crohn’s or ulcerative colitis, the two most prevalent forms of inflammatory bowel disease (IBD).
IBS’s hallmarks are painful stomach cramps, bloating and stool issues. There are three major types of IBS defined by the type of bowel movement most often experienced…
IBS-C, in which constipation occurs most frequently,
IBS-D, in which diarrhea occurs most frequently, and
IBS-M, with alternating diarrhea and constipation.
IBS is frustrating for several reasons…
The cause is unknown. Some explanations for IBS are that it is a miscommunication between the brain and the gut…caused by intestinal sensitivities to certain foods…or results from disruptions to the gut microbiome. With IBS-D specifically, people sometimes have an overlapping small intestine bacterial overgrowth (SIBO).
Symptoms may not have any discernable pattern. They may occur daily…or sporadically a few days per month…or a few days in a row with periods of relief.
There are no medications that target the condition itself. Treatments focus on managing symptoms and avoiding any identifiable triggers, such as specific foods or stress.
IBS does not cause physical changes to the intestines, as IBD does. A diagnosis of IBS often is made only after other conditions have been ruled out.
First Step in IBS Treatment
Changes in diet can have a huge impact on IBS symptoms. These include…
Increasing intake of foods rich in probiotics, such as fermented foods, to promote a healthy gut microbiome.
Increasing fiber intake.
Going gluten-free.
Trying an elimination diet to determine which foods worsen symptoms.
Trying the low-FODMAP diet, which limits foods with fermentable oligo-, di-, and monosaccharides and polyols. FODMAPs are in a variety of foods across many food groups. Some of the most common high-FODMAP foods are onions, garlic, tomatoes, wheat, dairy, apples and watermelon.
Because changing your diet can seem complicated at first, especially for an elimination or low-FODMAP diet, it is best to work with a registered dietitian who has experience in guiding people with IBS.
A gastroenterologist likely will recommend foods with probiotics as part of an overall healthy diet—foods that are fermented and sour such as yogurt, kefir, sauerkraut and pickles offer the best probiotics because they contain live cultures that your body will process in the way that you need them. One serving a day should be enough.
He/she will also recommend fiber because good bacteria thrive on it. Avoid very highly processed foods and foods high in sugar.
What About Probiotic Supplements?
A few, very small studies have shown that taking packaged probiotics such as Align can help, but research hasn’t yet found which strain-specific ones are the most effective at easing IBS symptoms. Some people do anecdotally report symptom relief from packaged probiotic supplements. These products are safe though pricey, and results vary from person to person. Packaged probiotics are one-size-fits-all, but the ratio of good bacteria to bad bacteria within each person’s microbiome is different. So taking Lactobacillus, the most commonly available probiotic, at a standard dose may not work the same for everyone. There is some trial and error involved in determining if a probiotic supplement will work for you.
Another reason for unpredictable results: Probiotics on pharmacy shelves aren’t refrigerated, so their bacteria aren’t live. It’s possible that capsules or gummies retain some amount of good bacteria, but there’s no way to know exactly how much is getting into your system.
If you have celiac disease: Be careful about choosing gluten-free packaged probiotics. Probiotics are not regulated as medications are, so there could still be traces of gluten even in a product labeled “gluten-free”—and that might make your symptoms worse than if you took nothing at all.
Also keep in mind that if you have symptoms just once or twice a month rather than two or three days a week, packaged probiotics may not be the right way to go because they are a daily treatment for something that’s not occurring very frequently. Packaged probiotics, however, should not be taken only intermittently…they must be taken regularly to work, and there is no risk associated with taking them everyday.
Caution: Don’t take probiotics while you are taking antibiotics—they will work against one another, and neither will work to its full potential. When there’s a problem with bad bacteria in your system, as in the case of SIBO, it’s unlikely that you can change your microbiome for the better until you get rid of the problem bacteria through antibiotics.
How to tell if probiotics are working: Whether by increasing probiotic foods or taking over-the-counter products, the most important sign of effectiveness is a normalization of your bowel movements. If your symptoms decrease, you have fewer episodes of flares and bowel movements become more regular, whatever regular means for you—maybe every third day, three times a day and anything in between—those are indications that the probiotics are working. Results should happen within two or three weeks of starting the probiotics. If you don’t notice improvement, stop taking them to avoid wasting money.
Other Ways to Ease IBS Symptoms
Testing
We now can test people during procedures such as endoscopies for enzyme deficiencies (lactase, fructose and sucrose, to name a few) that cause digestive issues and often correlate with IBS. These deficiencies can lead to diarrhea and abdominal pain because your body isn’t producing enough of the enzymes needed to properly digest certain foods.
Reduce stress
IBS often is triggered by stress. Patients often say that when they feel stressed at work or become anxious, they get more diarrhea or abdominal pain. Using an app like Nerva can help you keep track of symptoms and manage them with mindfulness, meditation and exercise. Many people minimize the number of symptom days they experience by practicing some of these activities.
Medication
When symptoms are severe, medications may help.
For IBS-D, eluxadoline (Viberzi) works on the opioid receptors in the gut, so it re-regulates your motility and decreases bowel movements as well as pain in the intestines.
For IBS-C, linaclotide (Linzess) promotes normal colonic motility to reduce constipation, which causes a vicious cycle of abdominal pain. Sometimes a low-dose anti-anxiety and depression medication in the selective serotonin reuptake inhibitor (SSRI) classification works on the nervous system of the gut.
Get reevaluated
A lot of people, especially women, are diagnosed—and labeled—with IBS when they’re young, and then they and even their doctors relate other health problems to that. But that means they may not get a full evaluation for other issues. Don’t accept an IBS diagnosis without a full medical workup that rules out conditions such as food intolerances, celiac disease, medication side effects, pancreatic insufficiency and any illnesses that run in your family. If it’s been years since you were told you had IBS, it may be time for a reevaluation from a different gastrointestinal doctor. Keep in mind, too, that treatments change. So just having a fresh set of eyes review your medications and possibly suggest a new one may help.
