Some of us feel our stress in our stomachs, regularly experiencing digestive issues such as heartburn, bloating, constipation and diarrhoea.
The 2024 Profmed graduate professionals stress index, released earlier this year, found that more of us in SA are struggling with these symptoms. Digestive issues emerged as a new stress-related symptom, with 23% of respondents reporting an increase in digestive issues. The index also flagged higher levels of fatigue and poor sleep, which are often related to an inadequate diet and poor digestion.
From what she sees in her Johannesburg practice, registered dietitian Ria Catsicas blames too little fibre for the rise in digestive issues. She says her patients with digestive problems fall into three categories: those who consume high-protein diets (these are often image-conscious gym-goers); those who eat a traditional diet consisting mostly of meat and pap; and those who live mainly on junk food. All three diets provide insufficient nutrients for good health, and contain inadequate fibre.
“Current research is beginning to illuminate the important role of a healthy gut in decreasing inflammation and risk for chronic diseases such as type-2 diabetes, cardiovascular disease and hypertension,” she says.
Excessive stress can activate the stomach to produce too much acid. “This causes the lower oesophageal sphincter to slip, causing heartburn. The movement of the large and small intestines is regulated by our autoimmune nervous system and where there is stress, this system gets overactive, causing irregular bowel movements such as diarrhoea and constipation, and bloating.”
This highlights the importance of stress management techniques such as meditation and massage, and getting enough exercise.
The Profmed study showed that only 35.7% of respondents reported exercising an optimal three to four times a week, whereas 12.62% said they never exercised. In addition, 35.55% of respondents reported eating more than usual, and 16.70% report drinking more than usual; alcohol can irritate the gut.
Intake of ‘bad food’ leads to a ‘bad gut’, which can contribute to overweight or obesity.
— Ria Catsicas
It is not how much and what we eat. It is also important to make time for proper meals rather than eat at your desk or on the run. Eating while distracted inevitably leads to eating too fast and too much.
High-fat diets have become popular but these often aggravate inflammation in the gut, which is the core problem associated with the development of many chronic diseases.
“Intake of ‘bad food’ leads to a ‘bad gut’, which can contribute to overweight or obesity. It sounds simple, but a study was done on mice where gut flora was extracted from two sisters and inserted into the gut of mice. The normal weight sister’s gut flora yielded normal weight mice and the obese sister’s gut flora yielded obese mice. The two main factors that influence gut health are the fibre content of the diet and the metabolic products that are produced by the flora in the gut,” says Catsicas.
Digestive issues often begin with bloating and many of Catsicas’ patients consult her for this reason. “This is mainly due to gut dysbiosis — when the gut microbiodata are disturbed and the bad gut bacteria, such as yeast and candida, dominate the good bacteria, such as acidophilus, lactobacillus and bifido flora. This can lead to symptoms such as diarrhoea, constipation and bloating, as well as irritable bowel syndrome, diverticular disease and, in some cases, inflammatory bowel disease, Crohn’s disease and ulcerative colitis.”
Food intolerances play a role in food digestion. “The main food intolerance I see is lactose intolerance, with a reference from a gastroenterologist.”
Good-quality complex carbohydrates such as whole grains, fruit, vegetables, legumes, seeds and nuts aid digestion. “People need an adequate amount of fibre in their diet, both soluble and non-soluble,” says Catsicas.
“Many are following high-protein diets, cutting out carbohydrates. It is good to cut out pizza and white bread, but living on chicken, veggies and fruit does not give you the 25g of fibre you need daily. We need whole grains: rolled oats, quinoa, brown rice. Fibre is the food that the good bacteria need to live and to multiply. They produce a magic substance we call short-chain fatty acids that boost serotonin levels and increase immunity because 60% of your immune cells are located in the gut.
People need an adequate amount of fibre in their diet, both soluble and non-soluble.
— Ria Catsicas
“Fibre enhances peristaltic movement so it solves the problems of diarrhoea and constipation, it helps the liver to produce less cholesterol and it helps with mood.”
To treat diarrhoea, she also tells patients to avoid caffeine. “Coffee is a stimulant and can in some cases cause diarrhoea. It depends on the number of cups you drink a day, and the strength, but it can have a laxative effect.”
Adequate hydration is key and she recommends drinking 1.5l of water a day.
When symptoms are acute, it helps to eliminate lactose-containing foods. The FODMAP diet is also recommended, restricting carbohydrates that are fermentable; oligosaccharides, which include fructans (found in wheat, rye, onions, garlic) and galacto-oligosaccharides found in beans and legumes; disaccharides or lactose, found in dairy products; monosaccharides, the fructose found in fruits, honey, and high-fructose corn syrup; and polyols, found in sugar alcohols such as sorbitol and mannitol, some fruits and vegetables and artificial sweeteners.
FODMAPs are poorly absorbed in the small intestine and can be fermented by bacteria in the large intestine, leading to gas, bloating, and other symptoms of dysbiosis. These should be eliminated for a while and then can be reintroduced when the symptoms have gone, says Catsicas.
Inflammation: contributor to disease
Inflammation in the body is a major contributor to disease and there is a fibre connection, she says. “Atherosclerosis — where plaque, made up of cholesterol, fat and other substances, builds up inside the arteries, narrowing them and restricting blood flow — underlies many chronic diseases. This is first and foremost, an inflammatory process. The cluster of metabolic abnormalities (insulin resistance or pre-diabetes, type-2 diabetes dyslipidemia, hypertension) that result from abdominal obesity, are also associated with low-grade inflammation.
“Adequate research now supports that high-calorie, high-fat diets alter gut microflora composition and numbers to such an extent that it causes an increased potential for pathogens to penetrate through the gut and this contributes to increased inflammatory processes in the gut. The mechanism for this is that high-calorie, high-fat diets appear to cause a decrease in gut permeability and therefore lead to an overall increase in the uptake of non-beneficial bacteria. This results in activation of the immune system and the release of a variety of pro-inflammatory substances that contribute to insulin resistance (pre-diabetes) and dysfunction in the arteries, which contributes to heart disease.”
Filling up on healthy natural foods that are high in fibre is the solution: “The American Heart Association and the European Society for Atherosclerosis suggest an intake of on average 25g of fibre per day. This translates to a minimum of five portions of fresh fruit and vegetables and three portions of whole grains to be consumed daily. The benefits of whole grains extend beyond their fibre content. They are packed with healthy nutrients, and the synergistic effect of B vitamins, vitamin E, iron, phosphorus, phytoestrogens and phenolic compounds all together protect us from chronic disease.”
Overweight individuals at risk for disease are frequently advised to follow a high-protein, high-fat, very low-carbohydrate diet (low in fibre), but Catsicas believes this may be inappropriate for treating obesity, metabolic syndrome, type-2 diabetes and dyslipidemia. “Instead, it is imperative that an individualised eating plan and nutrition education is undertaken. The resultant overall energy intake will be based on a moderate distribution of macronutrients (carbohydrates 40%-45%, protein 15%-20% and fat 25%-35% of total energy intake) to ensure adequate and optimal intake of fibre.”
Supplementation is a last resort, she believes. “The benefits of deliberately manipulating the host gut flora through supplementation are debatable. However, increasing the levels of probiotics, bifidobacterium and lactobacillus has been shown to have positive health outcomes, especially in patients with compromised gut function. Supplementation can be useful in stabilising bacterial gut communities that have ‘come under attack’ by the use of certain medication, antibiotics and anaesthesia. Supplementation, a nutritionally balanced, calorie-controlled eating plan and physical activity should all be considered as intervention to optimise gut health.”
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