Managing IBS and Training Through Flare-Ups

In recognition of Irritable Bowel Syndrome (IBS) Awareness Month in April, I've decided to share my story and the insights I've gained to support those facing similar challenges. By sharing my journey, I aim to demystify IBS and encourage open conversations about managing its impact on daily life and training.

*Please note that I am not a healthcare professional, and seeking advice from a qualified medical expert is essential. My goal is to offer some foundational knowledge to guide your journey!

My IBS Journey

I've probably had IBS symptoms for around ten years, but these were generally mild enough not to raise alarm. Occasional upset stomachs seemed no big deal, especially when they coincided with nerve-wracking moments, like before fitness competitions or races. I rationalised this as normal - everyone gets butterflies, right? 

Every so often, I'd eat something which would cause my (usually flat) stomach to blow up like a balloon, forcing me into huge, baggy clothes. Identifying beans, plums, and pistachios as culprits, I eliminated them from my diet, hoping for a simple fix. Unfortunately, I was still getting flare-ups, so there had to be something else causing them, too - but what? With the rise in popularity of gluten-free diets for digestive issues, I decided to cut out gluten as well. It provided a slight improvement initially, but my symptoms soon returned to full force. The situation escalated to a point where eliminating more and more foods seemed like the only option. You reach a stage where food itself can become a source of anxiety, given the uncertainty of what's causing the symptoms.

Three years ago, my symptoms intensified significantly, prompting urgent medical attention. My stomach was so distended it was causing me back pain - to the point where even walking and driving were uncomfortable, not to mention I had to wear my boyfriend's T-shirts from where I could no longer fit into my own! I permanently looked about ten months pregnant! None of this is ideal when you work as a strength and fitness coach! 

Despite a hospital admission and multiple GP visits, it was a considerable time before the NHS offered all the tests I needed, and wait times were long. The wait time for a colonoscopy was approximately 14 months. During this waiting period, I dedicated my time to researching ways to manage my symptoms and maintain my training regimen, as well as developing a more profound knowledge of IBS and its symptoms.

After nearly a decade of suffering, I would later go on to find that many of my IBS symptoms were actually due to endometriosis (tissue resembling that of the uterus lining growing in places where it shouldn't be) present next to my bowel. Surgery to remove this drastically reduced many of my IBS symptoms.

Understanding IBS: Symptoms and Prevalence

Irritable Bowel Syndrome (IBS) is a common gastrointestinal disorder that impacts the lower sections of the digestive system, specifically the small and large intestines. It affects people of all ages, but it is more commonly diagnosed in young adults and is often found more frequently in women than in men. It is characterised by a variety of symptoms, which can vary in intensity from mild to severe, such as abdominal pain, bloating or distension, and altered bowel habits. Surprisingly, IBS affects 1 in 7 adults, making it even more common than asthma! This high prevalence suggests that you know someone within your circle of friends who also struggles with this condition.

Other common symptoms include abdominal cramping, painful or trapped wind and nausea. For some people, these symptoms are mildly irritating; for others, they are debilitating and can last days or even weeks. It is often common for sufferers experiencing a flare-up to feel low, partly because of the discomfort experienced but also because over 85% of serotonin, the body's primary 'feel-good' hormone, is produced in the gut, not the brain. If production decreases during a flare-up, it can diminish feelings of positivity.

Triggers such as stress, hormonal fluctuations, certain medications, and consuming foods not well tolerated can lead to a flare-up. There is no known cause for the symptoms of IBS and no cure for the condition. Treatment focuses on managing symptoms, which can be challenging as some strategies may work for some individuals but not others. The psychological toll of IBS, stemming from its unpredictable flare-ups, further underscores the need for comprehensive management strategies.

What is normal when it comes to our bathroom habits?

Let's explore healthy bathroom habits to provide contrast and offer reassurance about what is considered usual.

• You should expect to have bowel movements anywhere from three times a day to three times a week.

• Bowel movements shouldn't be painful.

• You should feel confident you can make it to the bathroom in time.

• It's not unusual for stool consistency and colour to vary sometimes due to diet, hydration, exercise, hormones, and other factors. (However, seeing blood in your stool should prompt a medical check-up.)

• It is not uncommon for older adults to experience dryer stools due to their bowel and stomach muscles weakening and slowed intestinal motility. 

• Bloating is normal and is experienced by 10-30% of the population, especially after a large meal. A 'normal' amount of bloating should subside within a few hours. It differs from distension, which significantly increases the circumference of the gut.

• You may experience more wind than usual after eating certain foods (like beans or cabbage), but this is still entirely normal. People with IBS produce a similar amount of gas to those without it, but IBS sufferers often have an increased awareness of it because it causes pain or becomes trapped.

• Stomach noises, or borborygmi (bawr-buh-rig-mai), are a normal part of digestion. They occur as food is moved through the gut and tend to be louder when you're hungry because there is less material in the stomach to muffle the sounds. Releasing the hunger hormone ghrelin may cause these contractions to become more pronounced. While these sounds can sometimes be embarrassing, they are a sign that your digestive system is functioning correctly!

Why a Proper IBS Diagnosis Matters

It is important not to self-diagnose IBS because its symptoms can mimic those of several other conditions, including Coeliac disease, bowel cancer, and Inflammatory Bowel Disease (IBD)—which includes Crohn's disease and ulcerative colitis. For women, these symptoms might also coincide with gynaecological conditions like endometriosis.

Additionally, if your symptoms worsen (like mine did), an existing diagnosis of IBS can facilitate quicker access to further testing. Diagnosing IBS involves the Rome IV criteria, which suggest IBS is probable when a patient has experienced recurrent abdominal pain at least one day a week for the last three months, accompanied by at least two of the following: pain associated with bowel movements, changes in the frequency of bowel movements, or changes in stool appearance. If these criteria are met, further tests, such as blood tests, stool samples, and colonoscopies, are conducted to rule out other conditions. After ruling out other conditions, a doctor can then diagnose IBS.

*Important: Before getting tests like a blood test for coeliac disease (an autoimmune response to gluten), don't change your diet, as removing gluten too soon can lead to incorrect test results since your body needs to react to gluten to show if you have the disease.

** It is worth noting that eliminating endometriosis as the cause is tricky. Often an NHS scan only checks the reproductive organs, so any endometriosis on or near the bowel will not be seen. This can sometimes be identified on a private scan done by somebody specially trained in detecting endometriosis. However, sometimes, if it's superficial it can only be definitively diagnosed through surgery. If you notice your IBS symptoms are cyclical, or you have other symptoms of endometriosis, it is important to advocate for yourself and push to have this properly ruled out.

With a proper diagnosis in hand, the next step is to identify your specific IBS subtype, which is essential for tailored treatment.

Determining Your IBS Sub-Type

IBS can be classified into three main subtypes based on the predominant symptoms: IBS-C (constipation-predominant), IBS-D (diarrhoea-predominant), and IBS-M (mixed, where patients experience both constipation and diarrhoea). ​

Identifying your subtype is crucial as it influences the treatment strategy. Typically, you can determine your subtype by maintaining a stool diary over a few weeks to identify patterns in bowel movements. The Bristol Stool Chart is a valuable tool in this process. Please see the attached cartoon version! Type 4 on the chart represents the ideal stool consistency, with types 3 to 5 within the normal range. Types 1 and 2 indicate constipation, while 6 and 7 indicate diarrhoea. Professional guidance in diagnosing and understanding your subtype can be essential to prevent self-misdiagnosis and ensure accurate treatment strategies.

Determining IBS-D is relatively straightforward since the stool consistency predominantly ranges from normal to watery (diarrhoea), with constipation rare.

Identifying IBS-C can be more complex, and a detailed stool diary is essential. Symptomatic days will primarily show hard or lumpy stools (type 1 or 2) or no bowel movement; however, sometimes, diarrhoea can be present too. Individuals with chronic constipation may experience overflow diarrhoea, where watery stool leaks around a hard stool blockage; this can mistakenly lead some to believe they have IBS-M. Typically, IBS-C is characterised by a pattern of mainly types 1 and 2, with occasional occurrences of types 6 and 7 from overflow diarrhoea before returning to hard or lumpy stools.

For IBS-M sufferers, bowel habits alternate between constipation and diarrhoea. On days when symptoms are present, they experience constipation at least 25% of the time and diarrhoea at least 25%, indicating a true mixed pattern of bowel movements.

It's important to remember that your IBS subtype may change over time. If you observe any changes in your symptoms, periodically maintaining a stool diary can be beneficial in tracking these shifts.

Among the various symptoms of IBS, constipation often tends to be misunderstood, meriting a closer look.

Constipation Explained

Understanding constipation involves recognising it as more than just experiencing infrequent bowel movements or being unable to go to the toilet. You can go to the bathroom every day and still be constipated if you don't completely empty your bowels. For instance, if you only empty 80% of the waste each time, the remaining 20% stays and builds up. 

Common signs of constipation include dry, hard, or lumpy stools that are difficult or painful to pass, often requiring straining. It's not uncommon for individuals with constipation to experience bleeding or develop haemorrhoids as a result. (If you see blood in your stool or the toilet bowl, you should see a doctor as soon as possible.)

Other symptoms of constipation can vary but often include bloating, nausea, cramping, and abdominal pain. Understanding constipation's role in IBS highlights the importance of managing symptoms based on your specific subtype.

Managing IBS Based on Your Sub-Type

Individuals with IBS-M face challenges due to their fluctuating condition, which requires adaptability to current symptom trends. In contrast, those with IBS-C or IBS-D can adopt specific strategies regarding fibre intake, meal frequency, and dietary choices to manage their symptoms more effectively.

Let's start with fibre. Fibre is crucial in digestive health and is categorised into two main types: soluble and insoluble. Soluble fibre forms a gel-like substance when mixed with water, slowing digestion and increasing water content in the gut, which softens stools and allows them to be passed more easily. Foods rich in soluble fibre include oats, apples, and citrus fruits. Insoluble fibre, by contrast, does not dissolve in water. It adds bulk to stools and accelerates movement through the digestive system, with nuts, seeds, and whole grains being excellent examples.

Incorporating soluble and insoluble fibre into the diet is beneficial for IBS-C sufferers. Starting with soluble fibre can soften hard stools (essential if you're currently constipated), while gradually introducing insoluble fibre will help promote regular bowel movements. Foods like kiwifruit and flaxseed, which contain a mix of fibre types, can be particularly effective additions to the daily diet (assuming there are no allergies to either of these foods).

Those with IBS-D should focus more on soluble fibre to absorb excess water and improve stool consistency. They should be wary about consuming too much insoluble fibre, which may worsen their diarrhoea by quickening food transit through the intestines. Once symptoms are under control, insoluble fibre can be cautiously increased alongside soluble fibre.

Regardless of the IBS subtype, increasing fibre intake gradually and ensuring adequate hydration is essential. Soluble fibre draws water into the bowel, making it crucial to drink plenty of fluids to prevent dehydration.

Next, let's examine meal frequencies. Sometimes, adjusting meal size and frequency can help control symptoms, mainly due to the gastrocolic reflex; this is the natural bodily response to eating that triggers the intestines to move, making space for incoming food by clearing out the old.

Eating smaller, more frequent meals or snacks may benefit those with IBS-C. This regular eating pattern stimulates the gastrocolic reflex, encouraging consistent bowel movements. In contrast, individuals with IBS-D might find having fewer but larger meals helpful in reducing bowel stimulation and decreasing the chance of diarrhoea. However, it's crucial to spread eating across at least three meals daily to avoid overly stimulating the gastrocolic reflex with huge meals. A food and symptom diary can