IBS: symptoms, triggers, diagnosis and fasting in Ramadan

Irritable bowel syndrome (IBS) is a common condition that affects the digestive system. The UK's National Health Service (NHS) describes symptoms such as stomach cramps, bloating, diarrhoea and constipation, which tend to come and go and can last for days, weeks or months at a time. It is usually lifelong, and it can have a big impact on everyday life.

The British Dietetic Association (BDA) puts it at around one in five adults. In the United States, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) cites studies suggesting that about 12% of people have IBS. Women are up to two times more likely than men to develop it, and it is more common before the age of 50.

Below: what IBS is, how it is diagnosed, common triggers, and what to think about if you plan to fast in Ramadan.

What is IBS?

NIDDK describes IBS as a group of symptoms that occur together: repeated pain in the tummy and changes in bowel habits, which may be diarrhoea, constipation or both. With IBS, there are no visible signs of damage or disease in the digestive tract.

Doctors now call IBS a disorder of gut-brain interaction. Problems with how the brain and the gut work together can make the gut more sensitive and change how the bowel muscles contract. A more sensitive gut can mean more pain and bloating; changes in the muscle contractions lead to diarrhoea, constipation or both. NIDDK adds that some people with IBS feel pain from a normal amount of gas or stool in the gut.

The exact cause is unknown. The NHS says IBS has been linked to food passing through the gut too quickly or too slowly, a past bout of gastroenteritis, an oversensitive gut, stress, and a family history of IBS. IBS can be painful, but NIDDK notes that it does not lead to other health problems or damage the digestive tract.

Doctors describe three types, depending on the main change in bowel habits: IBS with constipation, IBS with diarrhoea, and IBS with mixed bowel habits.

What are the symptoms?

The main symptoms, according to the NHS, are:

• Stomach pain or cramps, usually worse after eating and better after doing a poo.
• Bloating: your tummy may feel uncomfortably full and swollen.
• Diarrhoea: watery poo, sometimes with a sudden need to go.
• Constipation: straining, and feeling that you cannot empty your bowels fully.

IBS can also cause wind, passing mucus, tiredness and a lack of energy, feeling sick, backache, problems peeing, and pelvic pain. There may be days when symptoms are better and days when they flare up. NIDDK notes that women with IBS often have more symptoms during their periods.

How is IBS diagnosed?

There is no test for IBS itself, the NHS explains, but you may need tests to rule out other causes of your symptoms. Your GP will ask what your symptoms are, whether they come and go, how often and when you get them (for example, after certain foods), and how long you have had them. They may also feel your tummy for lumps or swelling.

NIDDK describes the pattern doctors look for: tummy pain at least once a week over the last 3 months, together with at least two of these:

• the pain is related to bowel movements, getting better or worse afterwards;
• a change in how often you have a bowel movement;
• a change in how your stools look.

To rule out other conditions, the NHS says your GP may arrange a blood test to check for problems such as coeliac disease, and a test on a sample of your poo to check for infections and inflammatory bowel disease. Depending on your symptoms, NIDDK lists other tests a doctor may use, such as a hydrogen breath test for problems digesting certain carbohydrates, including lactose intolerance.

The BDA stresses that it is important to have a diagnosis of IBS confirmed and other conditions ruled out.

What can trigger symptoms?

Flare-ups can happen for no obvious reason. Sometimes, the NHS says, they have a trigger, such as:

• alcohol;
• caffeine;
• certain foods, such as spicy or fatty food;
• stress and anxiety;
• regular antibiotic use.

The NHS and the BDA suggest some everyday habits that may help:

• Eat regular meals, and do not delay or skip them.
• Eat slowly, relax while you eat, and chew well.
• Cut down on rich, fatty, fried and processed foods.
• Have no more than 3 portions of fresh fruit a day (a portion is 80g).
• Have no more than 3 cups of tea, coffee or other caffeinated drinks a day, and go easy on alcohol and fizzy drinks.
• Drink plenty of fluid, especially water or other non-caffeinated drinks.
• Find ways to relax, and get plenty of exercise.

If bloating and wind are a problem, the BDA suggests limiting gas-producing foods such as beans and pulses, Brussels sprouts and cauliflower, as well as sugar-free mints and gum; our guide to gas and bloating explains why. The NHS also suggests avoiding products with the sweetener sorbitol. NIDDK notes that some people with IBS have more symptoms after eating gluten, even though they do not have coeliac disease, and that a doctor may suggest trying the low FODMAP approach, often with a dietitian's help.

How can a food diary help?

The NHS suggests keeping a diary of what you eat and any symptoms you get, so you can try to avoid the things that trigger your IBS. The BDA adds two tips: make one change at a time, so you can see what has helped, and try simple changes first, because major changes may not be needed.

If symptoms continue, the BDA suggests asking your doctor to refer you to a dietitian, who can make sure your diet stays nutritionally adequate. Your doctor, pharmacist or a registered dietitian can advise on options. Do not cut out lots of foods on your own: the NHS advises seeing a GP if you find you need to avoid many different foods to control your symptoms.

Can you fast in Ramadan if you have IBS?

Talk to your doctor before fasting if you have IBS or another condition. The BDA advises that medical advice should be discussed with your healthcare team before Ramadan begins. It summarises guidance from the British Islamic Medical Association, which places stable IBS among the gut conditions with a low to moderate risk during fasting.

Fasting changes the usual pattern of eating, and the BDA's general IBS advice includes eating 3 regular meals a day and not eating late at night. That is one more reason to plan ahead with your doctor or a dietitian. With their advice, these practical patterns from the BDA's Ramadan guidance and its IBS advice may help:

• Break your fast gently. Many people start iftar with dates and a glass of water. Rather than one large meal, the BDA suggests splitting iftar into two or three smaller meals; its IBS advice notes that smaller meals may ease symptoms.
• Eat slowly and pay attention to how full you feel.
• Spread your fluids. Share your drinks evenly between iftar and suhoor. Drinking a lot at once can fill you up and take away your appetite.
• Plan for caffeine. The BDA suggests cutting down on caffeine in the week before Ramadan, which can help with headaches in the first days of fasting.
• Go easy on fried, fatty and salty foods. The BDA suggests grilling or baking instead of deep-frying, and limiting salt and processed foods, which can make you thirstier.
• Keep fibre in, but know your triggers. The BDA notes that fibre from fruit, vegetables and whole grains lowers the risk of constipation. If pulses or certain vegetables bring on bloating, your food diary can show it.
• Keep your diary going. Meal times and food choices change in Ramadan, so note what suits you.

If your symptoms flare during Ramadan, or you notice any of the warning signs below, contact your doctor.

When to see a doctor

The NHS advises seeing a GP if:

• you think you might have IBS and have had symptoms for over 4 weeks;
• changes to your diet, and options a pharmacist has suggested, are not helping;
• you need to avoid lots of different foods to control your symptoms.

The BDA advises seeing your doctor if you think you have IBS and also have:

• weight loss that you cannot explain;
• bleeding from your bottom;
• a family history of bowel or ovarian cancer;
• looser or more frequent poo for more than 6 weeks, if you are over 60.

Get medical advice urgently, the same day, the NHS advises, if:

• you have lost a lot of weight for no reason;
• you are bleeding from your bottom or have bloody diarrhoea;
• you find a hard lump or swelling in your tummy;
• you have shortness of breath, noticeable heartbeats (palpitations) and skin that is paler than usual.