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Gut feeling

Stress and anxiety can play havoc on gut health, initiating the onset or worsening of digestive symptoms but pharmacy teams can help customers get back on their feet

Most people feel anxious or stressed from time to time, experiencing not only emotional symptoms but physical symptoms too. They may notice nausea, an upset stomach or ‘butterflies in the tummy’ when they’re worried. Everyone reacts differently when life’s demands get too much, but stress and anxiety can lead to a change in bowel movements or symptoms such as bloating. 

“Stress usually has an emotional reaction, but sometimes it can cause physical symptoms as well, due to stimulation of the autonomic nervous system,” says Dr Anton Emmanuel, medical director at the charity Core. “In some people, these symptoms are barely noticeable. But in others, stress can trigger a more exaggerated or prolonged response. Loose bowel motions can lead to persistent diarrhoea, while butterflies in the tummy can lead to pain. Irritable bowel syndrome (IBS) is influenced by the autonomic nervous system as well. Many people with irritable bowel syndrome IBS have background sensitivity levels set to high, and this is often associated with changes in gut bacteria.”

The stress effect

There’s evidence that stressful modern lifestyles are contributing to the rise in many digestive problems. During a ‘fight or flight’ stress response, the brain releases the hormones adrenaline and cortisol, which impair the body’s ability to digest food. Chronic stress can alter the secretion of digestive enzymes and stomach acid, decrease the blood flow to the gut and have a negative effect on gut microflora or microbiota – the bacteria, yeasts, protozoa and other micro-organisms that live in the gut. 

In a survey by Asda Pharmacy to coincide with April’s IBS Awareness Month, 75 per cent of IBS sufferers said that stress and anxiety exacerbate their symptoms. This was backed up by a survey by Alflorex in April 2017, which revealed that 72.4 per cent of IBS sufferers report that stress is a major cause of their IBS flare-ups. Then in October 2017, research on mice at Brigham Young University, published in Nature Scientific Reports, revealed that stress may be as harmful to the body as a high-fat diet, due to its effects on gut bacteria. The researchers believe that the situation is the same in humans too. “We sometimes think of stress as a purely psychological phenomenon, but it causes distinct physical changes,” says Laura Bridgewater, Brigham Young University professor of microbiology and molecular biology.

Gut-brain axis

Dr Ashton Harper, head of medical affairs for Protexin, says an intriguing area of research is the “brain-gut-bacteria axis”, which explores the two-way communication pathways between our brains and our guts. “The smooth running of this system may be compromised by a host of factors, such as bad diet, antibiotics, stress and even ageing, which have all been shown to disrupt the bacterial populations in our intestines,” he says.

The gut is a highly sophisticated organ that is involved in the health of the whole body. The gut walls contain millions of neurons (often called a second brain), and research shows that these can influence our mood and wellbeing. 

“The second brain’s main job is transmitting information from the microbiota to the brain and the other way round,” says Professor Ted Dinan, professor of psychiatry and a principal investigator at the APC Microbiome Institute at University College Cork. “Stress can alter the connections between the gut and brain. The gut microbiota regulates our stress responses and can be linked to anxiety disorders and even depression.”

Scientists are now treating the gut microbiota as an organ in its own right. Research shows that the make-up of our gut microbiota is individual to us, and may have a major influence on our physical and mental health, as well as affecting our skin, weight, immune function, metabolism and appetite.

“Extensive evidence from both animals and humans has shown that our diets have a significant impact on the populations of bacteria that we harbour in our intestines,” says Dr Harper. “If we harbour ‘damaging populations’ then this may compromise our intestinal barrier and cause a ‘leaky gut’ where bacteria and toxins gain access to our blood (metabolic endotoxaemia) and then on to our brains where they result in inflammation (release of inflammatory cytokines), which has been linked to alterations in mood and mental health.”

Stress management

Dealing with stress is an important way of keeping the digestive system in good health. Dr Emmanuel suggests relaxation, meditation and exercise for stress-induced digestive symptoms. According to NICE guidance on IBS in adults, which was updated in April 2017, if patients find that medicines for IBS aren’t working, they can be referred for hypnotherapy, cognitive behavioural therapy (CBT) or counselling on the NHS. 

“Hypnotherapy has been proven to reduce stress, especially in IBS, as well as breathing exercises in their own right, not just as part of hypnotherapy,” says Dr Emmanuel. “Increased stress leads to more pain and other digestive symptoms, which in turn leads to further stress. So it’s important to break this cycle.” 

Professor Dinan agrees that the IBS and stress cycle can be difficult to manage. He recommends exercising three to four times a week, practising a relaxation technique, getting plenty of sleep, speaking to friends and family and looking after the digestive tract. A balanced life is important, allowing time to rest and relax as well as work. Customers also need to cut out anything that can have a negative effect on their digestive system, including alcohol, caffeine, and smoking. Some people find that foods high in fat can stimulate nausea, indigestion, diarrhoea and gut spasms, and that low-fat varieties may reduce their symptoms. Choosing healthy foods is essential, including five portions of fruit and vegetables a day, as well as eating regular meals and taking time to eat rather than eating in a rush. NICE guidance on IBS in adults recommends drinking at least eight cups of fluid every day, especially water or other decaffeinated drinks, such as herbal teas. Caffeinated tea and coffee should be restricted to three cups a day and fresh fruit to three portions a day. 

Symptom relief

According to research for Love Your Gut Week, the most common gut problems include constipation, diarrhoea, bloating and persistent stomach pains. “This research shows that significant numbers of people experience problems with their gut and it can have a huge impact on people’s lives,” says Dr Joan Ransley, nutritionist for the Love Your Gut campaign. “Digestive health is something we all need to take seriously. Listening to your gut can really make a difference to your overall wellbeing, from understanding the steps you can take to keep your gut healthy, to being aware of when you should see a doctor.”

Alison Reid, CEO of The IBS Network, says pharmacies play a key role in signposting people with IBS symptoms to see their GP for a diagnosis. “Our members have reported that talking openly about their condition with people who understand really helps them break this cycle, supporting them in taking control of their IBS,” she says. 

If customers think they have IBS, they should visit their GP to make sure there’s no underlying cause for their symptoms. Most IBS cases can be managed with dietary and lifestyle changes. Some people find avoiding certain types of carbohydrates called FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) can help – these can be found in some fruits and vegetables, wheat products and beans. Customers can also buy specific IBS medicines over the counter, such as antispasmodic medicines and peppermint oil capsules.

If customers are experiencing an acute bout of diarrhoea, they don’t need any specific treatment, as long as they drink plenty of water-based drinks and eat light, carbohydrate-rich foods such as rice or crackers. Anti-diarrhoeal medicines, such as loperamide, aren’t usually necessary, but these can be taken to reduce bowel movements before a special occasion. Oral rehydration therapy should be recommended for older people, young children and babies to prevent dehydration. 

Customers with constipation should increase their intake of fibre-rich foods, drink plenty of fluids and take more exercise. Laxatives should generally be avoided – if they do wish to try them, customers should try a bulk-forming laxative first. 

Wind and bloating are usually nothing serious, but persistent symptoms should be checked out by a GP. Certain foods can cause wind and bloating or make it worse. These include beans, onions, broccoli, cabbage, cauliflower and chewing gum. Over-the-counter remedies for wind often contain simeticone. Antispasmodic medicines may help if the symptoms are associated with IBS.

Gender wars

Increasingly, research is revealing that women and men may have different digestive needs. This may be related to the gut-brain axis, which links the digestive system and nervous system, and also the gut microbiota – the bacteria and other organisms that live in the gut. In October 2017, Brigham Young University research found that stress causes changes in gut microbiota of female mice, rather than male mice, and the researchers believe these findings can be extrapolated easily to humans. 

“In society, women tend to have higher rates of depression and anxiety, which are linked to stress,” says Laura Bridgewater, Brigham Young University professor of microbiology and molecular biology. “This study suggests that a possible source of the gender discrepancy may be the different ways gut microbiota responds to stress in males versus females.”

Around twice as many women as men have been diagnosed with IBS. This may partly be because women have more sensitive guts to certain foods and lifestyle factors. But doctors believe there are other important reasons for this as well. “Women are more prone to seeking help from secondary care for IBS,” says Dr Anton Emmanuel, medical director of the charity Core. “This may reflect that men are less likely to present to a GP, and women are more likely to report stress-related symptoms. But it could also be the effects of female hormones, as some women are affected by fluctuations in their menstrual cycle, with more pronounced symptoms just before, and in the early days, of their menstrual period. There are other differences in digestive disorders between the genders. Peptic ulcers tend to affect more men, whereas dyspepsia (indigestion) tends to affect more women.”

At present, the treatment for different digestive disorders is the same for men and women. But as research reveals more about the gut-brain axis and the gut microbiota, it is possible that gender-specific treatments could be in the pipeline in the future.

Probiotic supplements

Probiotics are becoming increasingly popular, and not just within digestive health. These live cultures of bacterial strains have been shown to restore a healthy balance of bacteria in the gut microbiota, if it has been depleted by diarrhoea, antibiotics or stress. Probiotics feed on prebiotics, which are complex carbohydrates. Research shows that probiotic and prebiotic supplements may help certain digestive symptoms, such as diarrhoea, constipation and bloating. Ongoing studies are also looking at whether probiotics could help a range of other health problems, including depression and anxiety. Gut bacteria seem to modulate the balance of neurotransmitters in the brain, with some strains producing neurotransmitters, including serotonin, which can have a positive effect on mood and emotion.

The clinical evidence for probiotic supplements in IBS management is still limited. NICE guidance recommends that anyone who wishes to try probiotics should take them for at least four weeks (at the recommended dose) and monitor their symptoms. 

“It’s only been in the last five years that probiotics have received individual study and more focused research,” says Dr Emmanuel. “There are many different dietary supplements out there; some are effective for IBS-type symptoms but they don’t help everyone. It is very much a case of trial and error. Most yoghurts sold in supermarkets don’t contain enough density of the bacteria so aren’t especially effective.”

During a ‘fight or flight’ stress response, the brain releases the hormones adrenaline and cortisol, which impair the body’s ability to digest food

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