Intuitive Eating and IBS: Part 1
Google what to eat for IBS and you’ll find most of the recommendations are all about eliminating certain foods or elimination diets. But these common recommendations for IBS can sometimes make things worse and not better, especially if you struggle with disordered eating. This post on intuitive eating and IBS shares how non-diet approaches can help manage your symptoms.
In the non-diet dietitian space, we often joke that you can’t specialize in disordered eating without also specializing in IBS, and visa versa. Most people with disordered eating also suffer from gastrointestinal issues, and many people with gastrointestinal issues then go on to develop disordered eating. When we work with clients who are struggling with disordered eating and IBS, it’s a bit of a chicken or the egg situation figuring out what came first!
If you’re someone who struggles with disordered eating and IBS, you might feel like the things you have to do to manage your IBS symptoms contradict what you need to do to heal your relationship with food. Intuitive eating can feel off limits for people with IBS, especially if you’ve been told to avoid lengthy lists of food, or if symptoms of IBS interfere with your ability to feel and respond to hunger and fullness cues. More than anything, when I work with clients who have disordered eating and IBS, they feel confused, overwhelmed, and a bit lost when it comes to knowing how to feed themselves!
Despite the fact that intuitive eating can feel off limits for people with IBS, it’s actually a really important tool, not just in helping people with IBS have a healthy relationship with food, but also for managing symptoms of IBS. This blog series will dive into intuitive eating and IBS, and hopefully provide you with some tools for navigating your tummy troubles from a non-diet approach. In this first blog post, I'm going to discuss what IBS is, symptoms and diagnosis, how intuitive eating can help, and touch on a few therapeutic diets for IBS. In part 2, I'm going to share nutrition, intuitive eating, and lifestyle tips for managing IBS symptoms, and part 3 will be a discussion of the relationship between IBS and disordered eating.*
* This blog post is a 2024 update of an article originally published August 2018, and parts 2 and 3 will be updated shortly.
What is IBS?
IBS, or irritable bowel syndrome, is a gastrointestinal condition that affects up to 16% of Americans. Symptoms may include gas, bloating, diarrhea, constipation, pain, and cramping that’s relieved with defecation (i.e. pooping). Diagnosis is based on the Rome Criteria, which essentially says that symptoms must be related to defecation, associated with a change in consistency and/or frequency of stool, and occurs at least 1 day/week for at least 3 months, and that symptoms started at least 6 months ago. This helps distinguish IBS from more acute, short term issues.
The other part of getting an IBS diagnosis is ruling out other potential causes, like celiac or inflammatory bowel disease. This typically involves blood tests and/or a colonoscopy. As I like to remind clients, IBS is a diagnosis of exclusion, based on symptoms that don’t have any other discernible cause, rather than a clear pathophysiology. There’s no blood test or X-ray that doctors can point to and say, “hey, looks like IBS!” If you have symptoms that match up to the Rome criteria that aren’t tied to anything that can be physically identified, then you will be diagnosed with IBS.
There are three main types of IBS. IBS-D is diagnosed when someone is diarrhea predominant while IBS-C is when someone is constipation predominant. You can also be diagnosed with IBS-M when symptoms are mixed.
What causes IBS?
You might be wondering what causes IBS. If so, you’re not alone! Researchers are still not sure what the exact cause of IBS is, but it has been linked to the following:
Overly sensitive nerves
People with IBS often have more sensitive nerves, especially the ones that lead to the gut. Their nervous system may perceive the contractions, movement of gas and fluids, and distention that occurs during digestion more severely and acutely. There’s a relationship with trauma and anxiety here that’s worth exploring if you have a history of either. As I explain it to my clients, trauma makes the nervous system more sensitive. Imagine a soldier returning from war and feeling jumpy and anxious when there are loud noises - that same hyperactivity happens all over your nervous system, including the nerves that connect your brain and gut! It’s another reason why people often experience more symptoms of IBS when they are stressed.
An overgrowth or imbalance of gut bacteria.
Gut microbiota, the mix of bacteria and other microorganisms in the gut, plays an essential role in not only digestion but immune function, metabolism, and hormone production. People with IBS have been shown to have less diversity in their gut microbiome, higher levels of potentially harmful bacteria, and have higher rates of overgrowth of bacteria in the gut, a condition called SIBO. The science here is in it’s infancy, and there is so much room for learning and scientific exploration!
Food intolerances.
A food intolerance occurs when your body has a difficult time breaking down and digesting certain foods. Lactose intolerance, caused by a deficiency of the enzyme that breaks down the lactose (a sugar found in milk) is a classic example. It differs from an allergy, which is caused by an immune system response to a specific food.
Serotonin levels
Serotonin is commonly thought of as the “happy hormone,” but it also plays a role in digestion too. People with IBS-C tend to have low levels of serotonin, while people with IBS-D tend to have high levels of serotonin.
Dietary patterns or fluid intake.
People with IBS may struggle with dietary imbalances, like eating too much or too little fiber, not eating enough food overall (we’ll get into the link between eating disorders and IBS later!), or not getting a balance of macronutrients, for example if someone is on a low carb diet or cutting out fat. Lack of fluids/dehydration can also contribute to constipation or cause alternating diarrhea and constipation. Another way dietary patterns can trigger IBS is with chaotic eating patterns, like a restrict-binge cycle. Think of what it might be like for the gut, which is designed to get food regularly throughout the day, to go a long period of time with nothing, then all of a sudden have to digest a large volume of food.
Endometriosis
OK, so technically this would be a misdiagnosis, but because SO many people with endometriosis are misdiagnosed as IBS, and because endometriosis can increase the risk for IBS I wanted to include it on here. Endometriosis is a condition where uterine tissue (the type that normally grows inside the uterus) grows outside the uterus. This tissue growth can happen around the gut, which can cause many of the same symptoms as IBS.
Phew, that’s a lot and I didn’t even get into gut motility, core strength/pelvic floor muscles, sleep and medications!
Personally, I don’t think there is one single thing that causes IBS. I like to think about each person with IBS having their own individual mix of causes/factors that contribute to their symptoms. I explain it to my clients using a pie chart, with each sliver representing a different cause, trigger, or factor behind their symptoms. Occasionally, you might run into someone with a really simple pie chart, like a college student I once worked with who had very low intake of fiber and didn’t drink much fluid. His IBS symptoms were completely resolved with a the addition of a few high fiber foods and a giant nalgene water bottle to take around campus! But for most people, their IBS is much more complex than that. Figuring out how to manage symptoms typically involves identifying what specific factors are at play and then coming up with an individualized plan for treatment/management.
This can be really frustrating, as it’s often hard to know exactly what’s leading to symptoms, and sometimes figuring out involves some trial and error! It makes so much sense to me why someone with IBS would be drawn to the one-size-fits all elimination plans and diets or expensive supplements, but these are rarely the solution, and often cause more harm in the long run. As we remind our clients with IBS, we’re here to partner with you and figure out a way of eating that helps manage your symptoms that’s realistic and as minimally restrictive as possible.
Intuitive Eating and IBS
Many people (and unfortunately practitioners!) assume that intuitive eating can’t be utilized if someone suffers from IBS. Because most of the common dietary recommendations for IBS involve avoiding specific foods or following an elimination diet, it can make intuitive eating feel off limits. Plus, symptoms of IBS can make it hard to read your body's cues, like hunger and fullness, so how are you supposed to eat according to your body’s cues? And if there are specific foods triggering symptoms, how can you make peace with all foods?
At the same time, it's been my observation that sometimes intuitive eating counselors can be dismissive to dietary approaches to treating IBS. There’s good reason behind it - IBS diets can do more harm than good, and are often prescribed irresponsibly, and by people who legally and ethically shouldn't be giving medical dietary advice. When it comes to IBS, there’s a TON of bogus information out there, which can make someone immediately skeptical about anything new that they hear. If you’ve worked in the non-diet space for any length of time, you’ve seen people who were harmed by well meaning advice for managing IBS. Even evidence-based advice, communicated in a rigid and fearmongering way, can contribute to disordered eating.
Thankfully, there are a lot of us non-diet practitioners spreading the word that intuitive eating can be a tool for managing IBS symptoms, especially when provided alongside Medical Nutrition Therapy (MNT). Not only that, but because disordered eating can be the main cause of IBS symptoms, sometimes intuitive eating is the solution for IBS. Here’s some ways that intuitive eating can support managing IBS symptoms:
Learning to honor hunger and feed your body consistently and adequately throughout the day, as chaotic/irregular eating patterns (like the restrict-binge cycle), undereating, and intense hunger or fullness can trigger IBS symptoms.
Making peace with foods helps decrease anxiety around specific foods, which itself can cause symptoms. Yes, simply thinking a food will cause symptoms can cause symptoms (read about the nocebo effect and gut-brain connection for more on that one!)
Incorporate pleasurable movement, as both excessive strenuous exercise and physical inactivity can contribute to symptoms.
Tuning into internal cues and noticing how food makes you feel (not what wellness culture tells you will cause symptoms), you may actually notice what specific foods (if any) or patterns of eating lead to or reduce symptoms.
Learn gentle nutrition strategies that may help you feel better.
Making peace with food can help increase overall variety in the diet, which is helpful for nurturing a diverse gut microbiota, which is helpful for healthy digestion.
When someone struggles with regular emotional eating or binge eating, the influx of food and big emotions at all one time can be a major contributor to IBS symptoms. Intuitive eating teaches you how to cope with emotions without food ,as well as how to mindfully emotionally eat, so you’re still connected to the experience and actually able to get some comfort from it.
Medical Nutrition Therapy for IBS
While intuitive eating for IBS can be helpful, many times other nutrition interventions are warranted. Some interventions are based on positive nutrition or gentle nutrition, which focuses on adding foods and nutrients rather than subtracting. A couple examples might be adding more fiber from foods like fruits, veggies, and whole grains or increasing intake of fluids. Other times, dietary recommendations may call for limiting or even eliminating certain foods, or following an elimination/reintroduction diet. This is where it can get a bit more complicated if you have a difficult relationship with food.
Most people with IBS have been told to eliminate a specific food or food group at some point. Sometimes this can reduce symptoms. Other times it’s unhelpful or even harmful. How I generally approach it with clients is if it’s a common trigger food that you can eliminate for a short period of time, and it’s not something that impacts your ability to feed yourself adequately, it may be worth experimenting to see if you feel better. A few examples of this include spicy food, lactose-containing dairy (lactose intolerance is relatively common!), alcohol, raw fruits/vegetables, foods with added fiber or sugar alcohols, and coffee/caffeine. Please note, these examples may not be pertinent to you!
Other times, recommendations to eliminate foods/food groups can be really broad, like going gluten free, dairy free, or sugar free, recommendations that are based more in diet culture than actual science. Sometimes these broad recommendations by proxy end up removing foods someone is reacting to, but also foods they are perfectly safe to eat too. While someone might feel better temporarily, more often than not, the reason why has little to do with the restriction. For example, clients who are cutting out all dairy are inherently cutting out lactose and may just be lactose intolerant. There can also be a bit of a placebo effect in the beginning too. For someone without disordered eating, these approaches usually just don’t work. For someone with disordered eating, or at risk for disordered eating, these recommendations can spiral into a life threatening eating disorder.
Another common recommendation for IBS is an elimination diet, which I remind people is really an elimination-reintroduction diet. These are plans that eliminate specific foods for a period of time then slowly add them back in to see what (if any) foods are triggering symptoms. There’s a few types of elimination diets you will commonly see recommended for IBS.
Low FODMAP Diet
The low FODMAP diet is an elimination-reintroduction diet that temporarily eliminates foods that contain specific types of carbohydrates that are highly fermentable (i.e. FODMAPs), meaning they produce a lot of gas when they’re broken down by bacteria in the gut. The gut distention that occurs from fermentation can cause pain, bloating, and diarrhea - people with IBS are thought to be more sensitive to typical amounts of distention, or experience more distention in response to these foods.
The low FODMAP diet is very effective as a short term relief of symptoms, with up to 86% of people finding some degree of reduction of their symptoms. The initial elimination phase of the diet is recommended only for about 2-6 weeks, as a low FODMAP diet is nutritionally inadequate, and long term avoidance of FODMAPs may make IBS worse by changing the gut microbiota. After the initial elimination phase, FODMAP containing foods are slowly added back in, testing for individual tolerance. It is strongly recommended to only do a low FODMAP diet under the guidance of a trained dietitian.
A low FODMAP diet is generally not recommended for people who have disordered eating or an active eating disorder, as it can make both symptoms of the eating disorder and digestion worse. When someone has an eating disorder and IBS, their gut needs more food and more variety, not less! People who attempt to do a low FODMAP diet who have disordered eating often have a very difficult time adding foods back in, and can stay stuck in the elimination phase, even when it’s no longer helping with symptoms. When we work with clients with disordered eating and IBS, we use the full low FODMAP as sort of a last resort. More often, we will do a targeted, personalized, “soft” low FODMAP diet or experiment with eliminating specific FODMAP containing foods for a short period of time.
Food Sensitivity Tests
There are many different food sensitivity tests that have become available over the past couple decades. They have become so ubiquitous that some are even available relatively inexpensively for home testing. Typically someone who does a food sensitivity test is instructed to eliminate foods they test as “sensitive” to, and certain tests will recommend gradual reintroduction of these foods to test for tolerance. While the premise sounds nice, unfortunately, the science behind all of these tests is iffy at best.
The most common food sensitivity test is an IgG test, which measures how much IgG (an immune molecule) is released when blood is exposed to specific foods. Most people who get this test done reply “oh my God no wonder I feel awful! I’m sensitive to all the foods I regularly eat!" Welp, that’s because IgG doesn’t actually measure sensitivity to a food. IgG simply indicates exposure to a food, and in fact higher levels seem to indicate tolerance of a food rather than intolerance! IgG testing, which is done via home testing through Everlywell and York, and is the most common one ordered in naturopathic practitioners offices, has been thoroughly debunked.
The Mediator Release Test (MRT) test is another common food sensitivity test that is offered by many dietitians, which measures inflammatory proteins (mediators) released in response to specific foods. In full disclosure, I used to provide MRT testing earlier in my career, as I was intrigued by studies looking at the role of mediators in IBS, and testimonials by other dietitians. While there is still some interesting research looking at mediators and IBS, it’s no longer a test I feel comfortable standing by for a few reasons. One is that I realized a test tube is not the same thing as a gut, and there is no research showing what happens in the test tube/centrifuge translates to digestion. I also learned a lot more about both the nocebo effect and the placbo effect in elimination diets. Second, after administering the test I saw how easily it could lead to disordered eating. While the same risks can occur with low FODMAP, there is much more research showing possible benefits, and I just don’t feel the risk is worth it with MRT testing. The final straw was when I saw their company sharing some pretty scary, conspiracy theory related stuff, which made me completely loose trust in any of their research and feel incredibly embarrassed to used their product. It’s not a test I recommend.
The bottom line on Intuitive Eating and IBS…
As you can see, when it comes to intuitive eating and IBS, it’s not a cut and dry thing - but neither is having an IBS diagnosis! Think of intuitive eating as one tool in the toolbox that can help support you in having a healthy relationship with food, and in managing your symptoms. You might need other tools, like medical nutrition therapy, alongside it.
If you struggle with disordered eating and IBS, it can be helpful to work with a dietitian who is trained in both, and can help you navigate and develop a personalized plan to help you feed yourself with confidence. We work with clients virtually throughout the US and my associate dietitian Kate sees clients in person in our Columbia, SC office. Feel free to reach out and we’re happy to see if we’re a good fit to work together, or can connect you with a dietitian in your area that might be a good fit.
If you’re a dietitian looking to learn more about the relationship between disordered eating and IBS, I highly recommend Marci Evan’s training on eating disorders and digestive disorders and there are also some fantastic webinars available through EDRD Pro. Samina Qureshi and Andrea Hardy are also dietitians who have some great resources for IBS (and you can listen to my podcast interview with Andrea here).
If this post on intuitive eating and IBS was helpful, you might also like:
Intuitive Eating & IBS Part 2: Non-Diet Strategies for IBS Management
Intuitive Eating and IBS Part 4: A Personal Narrative
Intuitive Eating and IBS Part 3: IBS & Disordered Eating
