With a worldwide prevalence of 10-20%, irritable bowel syndrome (IBS) is an exceedingly common bowel disorder that often occurs with a variety of other conditions. Join the AANMC and Dr. Thor Conner to learn why naturopathic doctors view gut health as core to good patient care, and what NDs can offer those living with intestinal conditions.
Dr. Conner will cover:
– How IBS is diagnosed and treated
– How gastrointestinal (GI) function contributes to other aspects of overall health
– Nutrition and lifestyle approaches to improve gut health
– A patient case study
To view the archive of past webinar recordings, please click here.
About the Presenter
Wm. Thor Conner, ND,CNS,LMT received his naturopathic medical degree from National University of Health Sciences and his massage certificate from the Connecticut Center for Massage Therapy. Dr. Conner operates a private practice – WorldTree Natural Medicine in Oakbrook Terrace, IL. Combining physical medicine, counseling, and knowledge of natural therapies, Dr. Conner is dedicated to educating and improving the health of his patients and the planet through the healing power of nature.
One of the most common complaints that naturopathic doctors encounter revolves around digestion and digestive health. It is estimated that roughly 70 million Americans are affected by some type of digestive disorder, which includes everything from gas and bloating, constipation or diarrhea, to an actual named disease such as Crohn’s disease or ulcerative colitis. 1
Why is digestive health so important and why do NDs focus on it?
As the Hippocrates quote heading this article indicates, “All disease begins in the gut.” This idea is echoed in naturopathic medical practice, as gastrointestinal (GI) function contributes to many other aspects of overall health.
A newer concept in mental and emotion health is the “gut/brain axis.” It is acknowledged that there is an intricate communication mechanism between the digestive system and the brain. In fact, the gut is so highly innervated that it has its own dedicated nervous system, the enteric nervous system (ENS). The parasympathetic nervous system (PSNS) and ENS provide a feedback system to each other via the vagus nerve (a cranial nerve that innervates the heart, lungs, and almost the entire GI tract). 2 They are also connected through the limbic system (hypothalamus and amygdala), the area of the brain involved in memory and emotional response. 3
The vagus nerve begins in the brain stem and travels through the neck, down through the thoracic and abdominal regions, and particularly affects the organs of the digestive system. During times of stress, anxiety, or depression for example, signals from the vagus nerve travel to the GI tract and can cause symptoms such as abdominal pain, constipation, and diarrhea. The feedback mechanism is such that these messages travel back up to the brain via the vagus nerve, possibly creating even more mental and emotional registration of symptoms. A similar effect occurs between the gut and limbic system in that signals from the brain impact digestive health and vice versa. 4 Additionally, many neurotransmitters directly act via the gut-brain axis, such as dopamine, epinephrine and norepinephrine. Large amounts of serotonin are actually produced in the gut. 5
The microbiome, which is a collection of micro-organisms found primarily in the large intestine, is critically important in optimal gut function, and overall health as well. The microbiome is an enormous population of bacteria that had previously been thought to outnumber our own body’s cells by as many as 10:1, though a recent study reports that the ratio is closer to 1:1 in most people. 6 That’s still a lot of bugs! The microbiome has been connected to several health conditions including depression and anxiety (7), lung conditions such as asthma and cystic fibrosis (8), impaired immune function (including autoimmunity and allergy) (9) , obesity (10), type 2 diabetes (11), Alzheimer’s Disease (12), Autistic Spectrum Disorders (13), and epilepsy.14
Finally, digestive health is tied to immune function, as nearly 70% of our entire immune system resides in the gut! 15 This intricate immune system consists of gut-associated lymphoid tissue (GALT) and is part of the larger mucosal-associated lymphoid tissue (MALT) which includes immune cells in the respiratory tract, oral passage, and genitourinary tract. These GALT areas of tissue, referred to as Peyer’s Patches, are found prominently throughout the intestinal tract and are critical in protecting us from pathogenic or opportunistic microbes (bacteria, fungi, protozoa, and viruses) and toxic material that may be in our food and water supply.
I often talk with my patients about how they can be good stewards of their digestive tract. It’s pretty straight forward (though not always easy) – eat plenty of plants (the brighter and more polyphenol rich, the better!), drink enough water (filtered, please), get daily de-stressing time and restful sleep, and avoid excessive snacking between meals and give your gut that nice long nighttime fast (it works hard, and needs breaks just like you!). If doing these things are difficult for you to implement or you have symptoms regardless, find a physician that can help you navigate appropriate testing and treatment. This is what we naturopathic physicians do best!
Because NDs practice medicine by identifying the root cause of any condition, testing is usually required to determine underlying pathology responsible for issues in a patient’s health. If someone is suffering from digestive complaints, blood testing for food sensitivities and allergies, bacterial or yeast overgrowth via a stool test or even a breath test can be utilized to determine if there are organisms living in the small intestine (where there should not be) or other imbalances implicated in symptom expression. Treatment is then individualized based on the results of the testing. The following are digestive issues that are commonly treated by naturopathic doctors.
As described above, the microbiome is a collection of bacteria that resides in the large intestine of the digestive tract. Unbalanced gut flora is one of the primary drivers of many digestive disorders. The problem can be either an overgrowth of unhealthy bacteria, or an undergrowth of beneficial bugs. Frequently, an overgrowth of yeast is to blame, and the most common symptoms produced are gas, bloating, and diarrhea. Dysbiosis can be diagnosed via a stool test (large intestine imbalance) or a breath test for the small intestine. The naturopathic approach for treatment is a “weed and feed” process. Either herbal or prescription antimicrobials (sometimes alternating with both) are given to kill the bad bacteria (the weeding), and then a probiotic is prescribed to re-populate the gut with good bacteria (the feeding). In this way, the good bacteria are able to crowd out the harmful microbes and proper digestive functioning can be re-established. Prebiotics may also be prescribed. These are substrates that the beneficial bacteria use to grow.
An example of dysbiosis (microbiome imbalance) which has become better understood in recent years is small intestinal bacterial overgrowth (SIBO). SIBO occurs when bacteria inappropriately colonize the small intestine. Because of defective motility of the gut, the bacteria migrate upward rather than staying in the colon where they belong. As with other forms of dysbiosis, the symptoms are abdominal pain, gas, bloating, constipation, and/or diarrhea. The treatment is also comprised of a weed and feed approach (remove offending bacteria and then replace with beneficial ones), with the addition of motility agents that prevent the bacteria from moving upward.
Dietary Considerations for Dysbiosis
Dietary considerations must be taken into account when balancing the microbiome to prevent and treat dysbiosis. Highly processed foods are associated with a less healthy microbiome, particularly a diet high in refined carbohydrates and low-quality fats. These foods have been shown to reduce the biodiversity of the microbiome, resulting in a host of health issues that may be related to the above conditions. A diet high in legumes, fruits, and vegetables are associated with a more diverse microbiome which keeps inflammation at bay and ensures a more properly functioning immune system. 16
Intestinal permeability, or leaky gut as it is commonly known, is a condition that affects the lining of the small intestine. When the intestinal wall comes into contact with inflammatory foods, toxins from food and water, or even metabolites from the above-mentioned bacteria and fungi, this can result in damage to the cells that line the gut. Connections between the cells are referred to as “tight junctions,” because its job is to create a sufficient barrier between the gut and the bloodstream. 17 This is necessary to prevent larger proteins from food and toxins from escaping out of the GI tract and entering the system. If these tight junctions are affected, and become “leaky” and proteins do escape, the immune system identifies them as outside invaders and will launch an immune response, resulting in food sensitivities, allergies, and autoimmunity. 18
Leaky gut is typically addressed by identifying and eliminating food sensitivities, healing the gut lining with supplements such as L-glutamine, and adding anti-inflammatory herbs and a whole foods diet low in processed fats and carbohydrates.
Inflammatory Bowel Disease
Inflammatory bowel disease (IBD), as its name suggests, is chronic inflammation of the gut. Generally speaking, the two most common forms of IBD are Crohn’s and ulcerative colitis UC) and are characterized by symptoms such as abdominal pain, diarrhea, rectal bleeding, and weight loss. 19
While the cause of IBD is not entirely known, research suggests that a genetic component may be present, combined with environmental factors, such as stress and lack of exercise, and of course, the state of the microbiome. 20 Research shows that a diet high in low quality fats, frequent meals of fast foods, high refined carbohydrate intake, and low fiber diets result in a dysbiosis that may exacerbate symptoms of IBS. Dietary recommendations include a low fat, high fiber, diet that excludes potential triggers such as dairy and refined grains. Foods high in vitamins A, D, E, folate, and beta carotene, as well as minerals zinc, selenium, manganese, and iron appear to be particularly helpful. 21
Gastroesophageal Reflux Disease (GERD)
Heartburn, and acid reflux are other names for GERD, which is an extremely common condition affecting approximately 20% of people in the United States. 22 GERD occurs when stomach acid moves upward from the stomach into the esophagus and results in symptoms of chest pain/burning, sour taste in the mouth, sore throat, chronic cough, and difficulty swallowing, and is usually worse at night when lying down. 23 GERD is caused by a laxity of the lower esophageal sphincter (LES), which allows the gastric juices to “reflux” up into the esophagus rather than remaining in the stomach where they belong. GERD is typically diagnosed by symptoms; however, an endoscopy may be ordered to assess for damage to the esophagus or to rule out more serious conditions. 24
Naturopathic treatments include finding and eliminating food sensitives, body work to tonify the LES, and supplements/ herbs that are soothing and healing to the upper digestive tract (see below).
Naturopathic doctors focus on making the delicately balanced system work the way it should – removing reactionary and irritating foods from the diet, balancing the flora, and encouraging digestion and motility. Just as importantly, we teach the patient to take charge of the process of healing and to alter lifestyle factors. We do not suppress the symptom to manage a disease. We will use drugs and surgery if it is necessary for the case, but as a last option.
Because digestive complaints are so incredibly prevalent in our society, naturopathic doctors have lots of treatment options to help re-establish gut health! Here are a few of our favorites:
L-Glutamine – this amino acid acts as a primary fuel source for the cells of the GI tract and can heal leaky gut.
Digestive Enzymes – taken orally, digestive enzymes help breakdown our meals to ensure proper digestive function and takes stress off of the pancreas and gall bladder.
De-glycyrrhizinated Licorice (DGL) – is made from licorice root (not the candy!) and is used to sooth inflamed tissues from GERD and to treat gastric and intestinal ulcers.
Slippery Elm – another soothing herb, as its name implies, the bark of this tree develops a “slippery” consistency when brewed into a tea. Useful in treating GERD and ulcers.
Peppermint – made as a tea, tincture or soft gel to swallow, this common herb is great for dispelling gas and reducing abdominal bloating – too much can lead to GERD – so it is best monitored by an ND.
Chamomile – not only is chamomile very relaxing to the nervous system, but it acts as a gentle bitter herb to stimulate digestive enzyme production. Very helpful for indigestion and constipation.
Curcumin – the active component of turmeric, this compound is a powerful anti-inflammatory that can effectively treat IBD and leaky gut.
Berberine – this chemical constituent of Goldenseal and Oregon Grape root is a broad spectrum, antimicrobial used to kill harmful bacteria and yeast.
Naturopathic doctors are specifically and thoroughly trained to assess and treat a wide range of digestive disorders in cases where conventional medicine often fails.
Hear from a few naturopathic doctors about how they help patients with GI complaints
Naturopathic physicians view the health of the gastrointestinal tract as foundational for overall health and wellness. We often have many more tools that our conventional colleagues for approaching functional gastrointestinal disorders (IBS, dyspepsia, abdominal pain, constipation, etc.), and are a perfect complement providing adjunctive care for many of the pathologic diagnoses, including inflammatory bowel disease, hepatic and biliary conditions, and malignancies of the GI tract. As with naturopathic medicine as a whole, we think about the “whole person” and provide strategies guided by this perspective, as opposed to a singular focus of GI-based interventions for GI conditions, as can happen more so in conventional medicine. I think this is our greatest strength and is why patients keep seeking us out for care.
Growing up, my aunt battled ulcerative colitis. I didn’t need to understand pathophysiology to see chronic GI illness play a mental, emotional and physical toll on patients and families that cannot be addressed by surgeries and medications alone. I enjoy treating every patient as unique and utilizing all of my tools as a naturopathic doctor to find an individual treatment to address all of parts of health.
I truly believe that the greatest wealth is gut health. Our gut is where life begins, it is where we take in the outside world and use it for our inside world. It is how we digest, absorb, and eliminate – the three most vital functions to living well. We must be able to take in nutrients and use them to survive. It is ALWAYS the first thing I focus on when patients come to me because without a healthy gut, nothing in the body will get the nutrients it needs to function optimally.
Gut health is so important because what is happening in the digestive system can have a large effect on all other systems; from skin to mood. I feel that gut health is the basis for overall health. An example of this is the fact that significant amounts of neurotransmitters such as serotonin are also made in the gut (in addition to the brain) which may help explain the gut-brain connection.
I often use specific probiotics that have been studied to treat particular GI conditions, control symptoms, and reset the gut balance. Additionally, I frequently emphasize fermented foods, such as sauerkraut, kimchi, pickled foods, etc., to promote gut health with my patients, in order to create an environment that facilitates and sustains the optimal health of the microbiome.
Pre-digesting the food is important. That sounds gross, but it’s just cooking, cutting and fermenting to make it ready to be absorbed quicker and more efficiently when it gets to the gut. For example, lightly steamed broccoli is easier to digest than raw, yogurt is easier to digest than milk, and think about the difference cooking makes to a potato or chicken. Fermented foods like sauerkraut are great to add to a healthy diet. The fermentation process unlocks a lot of extra nutrients and confer a decent dose of probiotic bacteria and prebiotic food for the bacteria. A good amount of mixed fiber from food sources and supplements will keep things moving, and don’t forget to drink enough water.
Dr. JoAnn Yanez, AANMC executive director, joins KCAA’s NBC LA affiliate On the Brink to discuss Irritable Bowel Syndrome (IBS).
Full Transcript of Interview Below.
IBS as a diagnosis of exclusion
IBS prevalence and the impact on quality of life
Mind-body holistic approach to IBS treatment
Erin Brinker: Welcome back. I’m Erin Brinker.
Tobin Brinker: And I’m Tobin Brinker.
Erin Brinker: And we are On the Brink, the morning show on KCAA, AM 1050, FM 106.5, and FM 102.3. We are so excited to welcome back to the show Dr. JoAnn Yanez. She is the executive director for the Association of Accredited Naturopathic Medical Colleges, and the chair of the Academic Collaborative for Integrative Health. She also serves on the Integrative Health Policy Consortium Education Committee. Weaving a passion for illness prevention into her professional life, Dr. Yanez’ career has spanned advocacy, academia, patient care, and public health. As AANMC executive director, Dr. Yanez oversees research, advocacy effort, and the joint academic endeavors of the accredited colleges of naturopathic medicine. Additionally, she helps spread awareness of naturopathic medicine as a viable and satisfying career path. Dr. JoAnn Yanez, welcome back to the show.
Dr. Yanez: Good morning, folks. How are you doing?
Erin Brinker: Doing great. The weather is warming up and it’s beautiful outside, so life is good.
Dr. Yanez: I know. I know. Some of the joys of southern California living, especially right now.
Erin Brinker: What is new and exciting at the AANMC before we get to our topic?
Dr. Yanez: Oh gosh, there’s so much going on. We actually have a webinar coming up tomorrow on how to apply to Naturopathic Medical Schools. So, folks are welcome to join that and hear about the steps you need to take as a student. We always have our webinars every month. Coming up, we’ve got ones on cancer. We have a naturopathic doctor and veteran presenting on PTSD in June. So, there are a lot of really great webinars that we have coming up, so I encourage people to check out our events and register if they’re interested.
Dr. Yanez: Oh no, we record all of the webinars. They’re on our YouTube station, as well as on the website. So, they’re all archived. If there are past ones that people want to take a look at, they can go to the prior event as well and see all of the other webinars we’ve done over the years.
Erin Brinker: Wonderful. Now there’s an issue that is kind of embarrassing, but effects a lot of people. That’s irritable bowel syndrome. I don’t know that … I know people who have gone for treatment and that is with some mixed results. Sometimes it works and sometimes it doesn’t through traditional medicine. Does naturopathic medicine have anything to offer people who are suffering?
Dr. Yanez: You know, it is one of those issues that, like you said, is very embarrassing. People don’t like to talk about problems with the bathroom, but one of the things that is core to naturopathic medicine, as we’ve talked over the years now with coming on your show, is the ND’s ability to get to the root of an issue. We talk about diet and we talk about elimination. I know one of the running jokes when I was in medical school was we talked a lot about poop. It was just one of those things that when you go to a naturopathic doctor, be prepared to talk about poop. They are going to ask you, how many times do you poop? Do you have trouble pooping? What does it look like? What does it smell like? Do you have any other digestive issues, like gas, bloating or indigestion? We’ll make light of it and we’ll make a joke out of it, but your elimination really is a sign, and can be a sign of underlying imbalance in the body. And that is one of the reasons why we ask about it. I know we’ve talked about libido before as well, and energy and sleep. All of those things, when they’re working well, are signs that our body is in balance, and when they’re not, can give us hints about other things that may be wrong. So, IBS Worldwide has a prevalence of about 10% to 20%. The thing that we’ve recognized is the costs for IBS are upwards of $20 billion annually.
Erin Brinker: Oh my gosh. Wow.
Dr. Yanez: Yes, wow. So, when we’re thinking about the prevalence of this, and not to even mention the quality of life issues, this is a pressing concern for so many. If you are uncomfortable or you don’t know when you’re going to need a bathroom, how do you go out? Years ago when the HIV meds first started to be used, there were horrible GI symptoms. I had patients who got to the point where they were almost incontinent, where they could not control their bowels. How do you leave the house? How do you go out and hang out with friends if you don’t know if you’re going to have an accident? And an accident like that, like you said, can be extremely embarrassing for people. So, that is the sort of thing that if you’re having excessive flatulence or diarrhea or problems with constipation and bloating, you don’t feel good. That is a huge impact on quality of life.
So, with Irritable Bowel Syndrome, it is a diagnosis of exclusion, which means that you have to rule out everything else. So, it’s one of those, ‘well if it’s nothing else, then it’s this’ diagnosis, which isn’t a great. It’s not like that simple, oh we’ve got a blood test for it, we test for it, and oh boom this is what you have. You have to rule out a whole lot of other things. So, many patients will come to naturopathic doctors having long time symptoms of gas, bloating, irregularity with their poop, and really just not feeling right, but not knowing what’s wrong. NDs will dig down. We’ll look at stress, because anxiety can play a role. How many times have you heard, “Oh I’ve got butterflies in my stomach.” Well, that is the connection between your brain and your gastrointestinal symptoms. So, there is a connection between our emotions and our gut. Oftentimes with kids who are experiencing anxiety, they’ll just say their tummy hurts. They won’t have the words or the connection to say, “I’m nervous about this.” They’ll just complain of tummy pain. So, it really is incumbent upon us to flesh this out further and to find the root cause. Is there a mental emotional component? Is there a food allergy component? Are the foods that you’re eating exacerbating a symptom? Is there an imbalance in the gut flora? So is probiotics something that needs to be taken? Are we not digesting our foods? Do we need to have an old timey naturopathic treatment that’s called digestive bitters? In many cultures, we see that folks will have greens. There’s a reason why we eat salads at the start of a meal, and it’s to … Normally without all of the sweet syrupy salad dressings, salad greens on their own are bitter. That bitterness can stimulate digestive juices. So, there’s a reason why-
Erin Brinker: Interesting.
Dr. Yanez: Oftentimes there’s that green at the beginning of a meal. It was really intended as an appetite stimulant and to stimulate the digestive juices. So, NDs incorporate a lot of different components into assessing and treating patients, not only the mind and the body, but supplementation as well. There’s really a lot that NDs can do for folks that haven’t seen benefit otherwise.
Erin Brinker: Like so many other things, and we’ve talked about this, your standard family physician or general practitioner is so busy that they don’t … You get a pat on the head and say, they say take something over the counter and then you’re on your way. So, the naturopathic doctor really has the time to be able to sit down with the patient and do that history, and really look into what’s bothering the patient.
Dr. Yanez: Yes. Again, it’s a mind-body approach. It’s a holistic approach. The six principles, which I have talked about before, first, do no harm, physician as teacher, treating the cause, treating the whole person and prevention are inherent in how we address each patient, as is the therapeutic order. We start with the basics. Before we go to recommending drugs or surgery or something more invasive, we start with diet. We start with sleep. We start with stress. We start with your environmental factors, your social support, your exercise, all of the basic things that people need to be healthy, and then we go up the ladder in intensity from there. I think it’s a really important approach that addresses things in a gentle way, but also helps patients take responsibility and understand, hey, maybe let’s not just throw a pill at this. Let’s look at the real reason why you’re having this. Now in very serious situations or situations that are more life threatening or really impacting, of course there’s medication, and NDs aren’t going to shy away from that, but in the situations like this, IBS, where there are very strong environmental factors, food factors that help, let’s go there first.
Erin Brinker: Yeah, because that’s Occam’s razor, right. Usually it’s the most obvious solution that is the right one.
Dr. Yanez: Yes. I always like to think of my math teacher. Back in the day when we did long form math, there are a lot of different ways to teach math, and I know Tobin, you teach in the school settings. But my math teacher, and I always remember this phrase, “Find the most elegant solution for that problem.” That was his way of pointing and saying, “Hey sure there are a lot of ways to solve this, but what’s the simplest, easiest and quickest way to get you there?”
Erin Brinker: What a good math teacher. So, this is also the time of year when people graduating from college are really thinking about what they want to do after they graduate from college. Where can they find out more information about naturopathic medical careers?
Dr. Yanez: Well again, our website is a great resource. Tomorrow we have a webinar on finding your way in applying to ND School. That would be a great resource as well. But we’ve got all the different ways that NDs are using their careers. On our website, we’ve got a great video that also explains the different types of career options you can take as an ND. So, lots of good information on our website. Hope that folks check it out.
Erin Brinker: Well, Dr. JoAnn Yanez, it’s always a treat to have you on the air with us. Thank you so much for joining us today.
Dr. Yanez: Thanks. Talk soon!
Erin Brinker: Talk soon. And the website is AANMC.org for the Association of Accredited Naturopathic Medical Colleges.
Dr. Yanez: Thank you, Erin.
Erin Brinker: Thank you so much. It’s now time for a break. I’m Erin Brinker.
Tobin Brinker: And I’m Tobin Brinker.
Erin Brinker: And we are On the Brink, the morning show on KCAA. We will be right back.
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