Irritable Bowel Syndrome—Where Does Bread Fit?

Andrea Hardy, RD

Irritable bowel syndrome (IBS) is a common digestive disorder, affecting up to 1 in 10 Canadians.¹ Symptoms not only impact quality of life, but also what foods people tolerate eating. In this post, registered dietitian Andrea Hardy explains what IBS is, how good nutrition can help manage IBS symptoms, and how high fibre, low FODMAP bread can be part of your IBS management toolkit.

In this article:

• What is IBS?
• IBS Subtypes
• How is IBS Treated?
• Will IBS Ever ‘Go Away’? Triggers, Flare-ups and Long-Term Symptom Management
• Which Foods Contribute to IBS Symptoms?
• What are FODMAPs?
• The Bucket Effect: Understanding Your Personal FODMAP Tolerance
• Is Gluten the Cause of IBS Symptoms?
• What About Fibre? 
• How Much Fibre do you Need?
• Alternatives to Wheat

What is IBS?

IBS is a functional gut disorder―meaning everything in the digestive system is structurally normal, however its function is off―and for some people, it can be very off! It is also classified as a disorder of gut―brain interaction. Our brain and our gut are highly connected through our nervous system, sending important messages back and forth all day on this ‘information superhighway’. In IBS, this communication is altered, interpreting digestion as signals of pain or discomfort.

There is no specific test for diagnosing IBS. When structural causes are ruled out, IBS is diagnosed through assessing symptoms―with abdominal pain being the predominant symptom. While this can feel frustrating for people, it’s important to know that IBS is a very real condition, with real options for management.

While the exact cause of IBS is unknown, there are many factors that appear to contribute to its development, including illness, infection, or stress. These events can alter our gut microbiota (the makeup of bacteria, viruses and fungi in the gut), alter how our nervous system in the gut functions, and in turn, result in IBS symptoms.

IBS Subtypes

Did you know there are four IBS subtypes? Knowing your subtype can help you determine the best strategies for management with your health care team.

The four subtypes include:

• IBS-D, predominantly with diarrhea, or very loose bowel movements accompanying symptoms
• IBS-C, presenting with constipation, or very hard or infrequent bowel movements accompanying symptoms
• IBS-M, where a mixture of diarrhea and constipation fluctuate among symptoms
• IBS-Unclassified, where the change in bowel movements is minimal but meets the diagnostic criteria for other symptoms

While pain is the predominant symptom in IBS, patients also can experience:

• Bloating and distension
• Gas
• Fluctuations in constipation and diarrhea
• Nausea

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How is IBS Treated?

Unfortunately, there is no cure for IBS. However, there are many strategies that can improve IBS symptoms enormously. IBS management isn’t one size fits all, which is actually kind of nice! Having so many options, you can try many different strategies to see which works best for you.

Strategies include:

• Nutrition and diet
• Stress management
• Sleep hygiene
• Physical activity
• Over the counter medications
• Prescription medications
• Psychological interventions, like cognitive behavioural therapy (CBT) and gut-directed hypnotherapy to improve how the gut and brain interact

Will IBS Ever ‘Go Away’?
Triggers, Flare-ups, and Long-Term Symptom Management 

As someone that struggles with IBS, there are periods in my life where I no longer meet the diagnostic criteria. Inevitably, something eventually happens to have my symptoms pop back up; when this happens, my IBS requires more awareness and diligence in managing. This is a common situation reflected in both the research and with my patients.

For IBS that developed during a period of stress or after an illness, IBS does seem to improve over the long term. However, things can happen that cause your IBS symptoms to flare, including:

• A round of antibiotics
• Illness―including COVID or a foodborne illness
• Periods of high stress
• Hormonal changes
• And so much more

Knowing how to manage your IBS flare-ups and what triggers them can help improve your quality of life and how you cope with chronic disease over the long term. Diet is one key strategy I work with patients on to improve their IBS symptoms.

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Which Foods Contribute to IBS Symptoms?

It might not surprise you, but diet quality is highly tied to overall IBS symptoms. A diet low in fibre and high in fat can worsen IBS symptoms. However, if you struggle with IBS, you might have noticed that even nutritious foods can make symptoms worse.

This is in part due to how our body senses normal digestion. Beyond dietary basics, researchers have found that when the digestive tract is stretched, this can lead to the sensation of pain. This stretch can occur due to excess gas, or fluid in the intestines. Certain foods called FODMAPs can contribute to this.

What are FODMAPs?

It’s a mouthful!

They are a group of carbohydrates that either pull water into the bowel or rapidly ferment, leading to gas, bloating, distention, abnormal bowel movements, and other IBS-related symptoms.

While many high FODMAP foods are highly nutritious, eating too many FODMAPs can worsen IBS symptoms.

Remember: if a product does not contain the certification logo, it doesn’t always mean it is high in FODMAPS—the logo simply takes the guesswork out of determining what is low FODMAP. Reading ingredient lists and using the Monash app to check if your food choices are low, moderate, or high in FODMAP containing foods can be helpful when following the low FODMAP diet. 

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The Bucket Effect:
Understanding Your Personal FODMAP Tolerance

You can think of your FODMAP tolerance like a bucket. When that bucket overflows with FODMAPs, that’s when you experience symptoms. With IBS, your bucket can be quite small, meaning you have to be mindful of how much high FODMAP foods you consume.

High FODMAP foods include certain grains, fruits, vegetables, legumes and lactose-containing dairy products, among others.

It might not surprise you to learn that wheat is high in FODMAPs in the portions most people would consume in one sitting. Wheat is frequently identified as a trigger in those with irritable bowel syndrome due to the high levels of fructans.

Is Gluten the Cause of IBS Symptoms?

Before exploring this, first we need to understand what gluten actually is! Gluten is the protein found in wheat, barley, and some other grains. It helps bring the elastic quality, structure, and keep moisture in baked goods.

Many gluten-containing foods, such as wheat products, also contain high levels of FODMAPs, such as fructans and galacto-oligosaccharides. Although wheat products contain both gluten proteins and FODMAP carbohydrates, they are not the same thing.

Interestingly, a recent study² explored whether gluten (the protein) or FODMAPs (the carbohydrates) in wheat that contributed to symptoms in individuals with IBS by administering the components individually, rather than together as they naturally occur. This study was able to show that in patients with irritable bowel syndrome, symptoms resulted from the presence of FODMAPs specifically, and did not occur when they were only exposed to gluten on its own.

It’s important to note that gluten-free does not always mean low FODMAP! Although gluten exists in high FODMAP foods like wheat or barley, not all gluten-free products are suitable for a low FODMAP diet. Given high FODMAPs foods exist beyond those that contain gluten, a gluten-free product is not always suitable for an individual following a low FODMAP diet.

For example, where a decadent gluten-free fettuccine alfredo may be suitable for someone with celiac disease requiring a strict gluten-free diet, the other ingredients such as milk or garlic are high in FODMAPs and may lead to symptoms in individuals struggling with IBS.

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What About Fibre?

One difficulty of following a low FODMAP diet? It can be hard to hit fibre targets. Why? Many high FODMAP foods are important sources of fibre.

Fibre doesn’t just play a role in good digestion, it is also important in helping to keep us full, preventing certain types of cancer, lowering cholesterol, and preventing the development of many chronic diseases like type 2 diabetes.³

How Much Fibre Do You Need?

Men need 38 grams of fibre per day and women should aim for 25 grams of fibre each day.⁴ This can be hard to do on a low FODMAP diet. I recommend patients get very intentional about hitting their fibre targets. You can do this by tracking how much fibre you eat in a day using an app, like Cronometer.

Whole grain wheat is a significant source of fibre in many people’s everyday diet. Unfortunately, many wheat-free and gluten-free alternative products don’t deliver on fibre the same way that whole wheat and whole grain products do!

Alternatives to Wheat

Reducing wheat intake on a low FODMAP diet can be difficult. Luckily there are alternatives available to help fill the void of the wheat-containing products that you may have loved. For example, many noodles have wheat-free alternatives that are suitable in a low FODMAP setting, such as rice noodles, gluten-free pasta, or even using corn tortillas instead of flour tortillas in your favourite Mexican dish. These can be easier to find and label read for on a low FODMAP diet, as corn tortillas and gluten-free pasta contain just a few ingredients.

Oftentimes, people get stuck on which bread is going to meet their needs. Most gluten-free breads that are friendly for a low FODMAP diet significantly lack fibre, an essential part of many people’s IBS management toolkit, or they contain high FODMAP ingredients, like chicory.

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About Andrea hardy

Nutrition communicator and knowledge translator, Andrea Hardy is a registered dietitian from Calgary, Canada, where she runs Ignite Nutrition, a multi-disciplinary digestive health practice. She specializes in gut health and gastrointestinal diseases and is recognized in the media as Canada’s Gut Health Expert. Passionate about translating science into easy to digest information to support a healthy gut, Andrea Hardy has spoken on the TEDx stage, as well as internationally about digestive health. Follow her on Instagram at @andreahardyrd or tune into her gut health podcast Let’s Gut Real which is all about making nutrition science easy to digest!

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footnotes

1. Guo, H., & Turbide, C., Diagnosis and management of irritable bowel syndrome: A practical overview for primary care providers. Canadian Primary Care Today, volume 1(2), 18–22. 2023 June 14. Available from: https://canadianprimarycaretoday.com/article/view/1-2-guo_et_al/pdf_en ↩︎
2. Nordin, E., Brunius, C., Landberg, R., Hellström, P.M., Fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs), but not gluten, elicit modest symptoms of irritable bowel syndrome: a double-blind, placebo-controlled, randomized three-way crossover trial. The American Journal of Clinical Nutrition, volume 115(2), 344–352. 2022 Feb 9. PMID: 34617561; PMCID: PMC8827068. Available from: https://pubmed.ncbi.nlm.nih.gov/34617561/ ↩︎
3. Reynolds, A., Mann, J., Cummings, J., Winter, N., Mete, E., Te Morenga, L., Carbohydrate Quality and Human Health: A Series of Systematic Reviews and Meta-Analyses. The Lancet, Volume 393(10170), 434–445. 2019 January 10. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31809-9/fulltext ↩︎
4. Health Canada. Fibre – Canada. 2019. Updated 2019 01 22. Available from: https://www.canada.ca/en/health-canada/services/nutrients/fibre.html ↩︎

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