Gastrointestinal disorders are often stress-related and present with co-morbidities, including pain, fatigue, anxiety, and stress.
The evaluation and treatment of GI disorders must go well beyond an objective inventory of symptoms.
An effective approach considers the whole person behind the symptoms. This whole person approach evaluates behavioral, social, environmental, psychological, and biological factors and incorporates nutrition and mind-body interventions into a personalized care plan.
The integration of complementary and integrative health and whole person health
Psychological approaches
Psychological approaches relevant to GI disorders include brain-gut behavior therapies, such as cognitive-behavioral therapy, gut-directed hypnotherapy, and related mind-body practices (e.g., meditation and mindfulness) and spiritual practices (e.g., prayer or religious-based experiences).
Biological factors
- Brain-gut behavior therapies target stress sensitivity and alterations in CNS-ENS processing. They also address brain-gut dysregulation and the brain-gut microbiota axis.
- Eastern approaches, such as meditation and mindfulness, are regularly incorporated into brain-gut behavior therapies.
- Mindfulness is paying attention to the present moment with curiosity and non-judgment.
- Mindfulness-based stress-reduction programs show a reduction in irritable bowel syndrome (IBS) symptom severity and improve stress-related outcomes.
- Research also demonstrates the benefit of mindfulness-based interventions in improving stress, mood, and quality of life in patients with IBD.
- A study examining psychosocial-spiritual factors in patients with functional dyspepsia (FD) found that symptomatic patients had more stressful life events, less belief in religion, and increased somatization compared to their asymptomatic counterparts.
Behavioral factors
- Mindfulness allows for freedom of intentional choice and behavior
- The ability to act with awareness is associated with improvements in GI symptoms and visceral sensitivity and decreased covert behavior of GI symptom-specific anxiety among individuals with IBS.
- Among patients with IBD, acting with awareness has been identified as a potential protective factor, given its influence on quality of life, perceived stress, and fatigue.
Social factors
- Research demonstrates that IBS can be influenced by learned illness behaviors, as well as early GI symptoms, socioeconomic status, and trauma.
- Some patients develop social anxiety in the context of dining with others, especially when their GI symptoms are exacerbated.
- Day-to-day social phenomena can also contribute to GI symptomatology.
- This is often addressed with brain-gut behavior therapies, such as cognitive behavioral therapy,
- Socio-cultural background can also influence one’s experiences and presentation of physical health symptoms.
Environmental factors
- Nature-based therapy aims to promote relaxation and improve resistance to disease and stress.
- Nature therapy includes gardening, exercising or socializing in nature, and shinrin-yoku.
- Shinrin-yoku (forest bathing) is a Japanese practice of mindful immersion in nature with the intent to harmonize an individual with their environment, often a forest. Shinrin-yoku usually includes several complementary and integrative health (CIH) techniques that engage all senses, such as breathing, yoga, meditation, and walking to enhance relaxation and to promote the feeling of bathing in one’s environment
- The benefits of nature-based interventions and shinrin-yoku, including parasympathetic system activation, reduced blood pressure and feelings of stress, improved well-being, improved immune function, reduced inflammation, including interleukin (IL)-6, and fewer symptoms of anxiety and depression
- Nature-based therapies can include being around plants, watching videos of nature scenes, and visiting local parks, all of which can benefit health.
Nutritional approaches
Nutrition is vital for GI and overall health. CIH offers various nutritional approaches, including herbs, probiotics, mindful eating, and food as medicine.
Biological factors
- Nutritional approaches can directly influence biological processes, including GI motility and inflammation.
- Natural products, some of which have been utilized for thousands of years, have a growing evidence base for use among patients with GI disorders.
- Ginger positively affects GI motility and reduces nausea and vomiting via anticholinergic and anti-serotonergic pathways.
- Peppermint and caraway reduce symptoms of functional dyspepsia by inhibiting smooth muscle contraction, antiemetic properties, and spasmolytic effects.
- Psyllium fiber acts as an osmotic bulking agent, decreasing bowel transit time and improving bowel function in those with IBS.
- Soluble fiber can improve global IBS symptoms by possibly acting as a prebiotic.
Behavioral factors
- Patients with chronic GI conditions often have complicated relationships with food, including avoidance and distrust.
- Aversive consequences can occur, including conditioned food sensitivity, malnutrition, and eating disorders (e.g., avoidant restrictive food intake disorder)
- Mindful eating may be a behavior-based way to improve patients’ relationship to food and thus improve health and psychosocial outcomes.
- Mindful eating is consuming food with an intentional, non-judgmental, moment-to-moment, and curious approach. Mindful eating includes awareness of the five senses while preparing and eating food and noticing the cognitive, physical, and emotional responses to eating.
- It can increase awareness of hunger and satiety cues, and it has the potential to improve digestive processes by attenuating stress responses.
- A randomized control trial of mindfulness training, including mindful eating, among women with IBS found significant improvements in IBS symptom severity, quality of life, and visceral anxiety at 3-month follow-up
- Online mindfulness intervention for patients with IBD that included mindful eating found several psychological benefits, including improved symptoms of depression, stress, and anxiety.
Social factors
- Natural products, such as medicinal plants and herbal products, have been recognized and relied on for disease prevention and health promotion for millennia and across cultures, including traditional Chinese medicine and Ayurveda.
- Triphala is a revered polyherbal preparation made from the dried fruit of three plants: Emblica officinalis (Amalaki), Terminalia bellerica (Bibhitaki), and Terminalia chebula (Haritaki).
- A 2017 review of Triphala's benefits identified several GI benefits, including improved constipation, abdominal pain, and flatulence, as well as benefits to the microbiome.
Environmental factors
- “Let thy food by thy medicine and medicine be thy food”, a phrase often credited to Hippocrates, captures the idea of nutrition as foundational for disease management.
- An individual’s environment determines the availability of foods that can promote health or increase disease risk.
- There is increasing evidence that the Western diet of processed foods, refined foods, and red meat can increase the risk for GI disorders, specifically.
- Food as medicine centers on nutrition-based interventions, such as medically tailored meals and groceries, and on producing prescriptions to prevent and manage chronic health conditions.
- Dietary interventions, like low FODMAP, gluten-free, lactose-free, and Mediterranean diets, are often a first-line approach for GI disorders with varying degrees of benefit.
- One’s food environment, including access to nutritional options, cultural beliefs, and preferences, influences a patient’s ability to adhere to and benefit from certain diets, regardless of disease state.
Mind-body approaches
Mind-body practices can profoundly impact biological processes among patients with GI disorders.
Biological factors
- Yoga is a type of meditative movement that incorporates asanas (physical postures), pranayama (breathwork), and dhyana (meditation).
- Yoga research among patients with IBS suggests that this mind-body practice may be a beneficial, feasible, and safe treatment approach.
- Yoga reduces stress by correcting parasympathetic underactivity and modulating immune responses. Psychophysiological mechanisms also impact positive affect, self-compassion, inhibition of the posterior hypothalamus, and reduction of salivary cortisol.
- Massage may also be helpful because it increases digestive movement by manipulating soft tissues.
- Ultimately, a combination of stimulation, relaxation, and stress reduction may underlie the changes associated with massage.
Behavioral factors
- Acupuncture may be a good way to enhance adaptive behaviors among GI patients. It is considered to be generally low-risk and well-tolerated.
- Acupuncture has been studied in both disorders of the gut-brain axis (DGBIs) and IBD with promising results, including benefits in mood, pain, nausea, vomiting, inflammation, and disease activity.
- Research findings suggest that acupuncture's benefits derive from its modulation of the nervous system, including brain regions associated with behavior, attention, and pain perception, such as the prefrontal cortex, default mode network, and homeostatic afferent processing network.
- Acupuncture also appears to be beneficial for emotional health.
- Acupuncture may regulate GI motility, the GI barrier, visceral sensitivity, and the brain-gut axis and have dual regulatory effects by promoting gastric peristalsis in individuals with low gastric motility and suppressing peristalsis in individuals with active initial motility
- Among patients with mild to moderate active Crohn’s Disease (CD), acupuncture has been associated with improved symptoms of anxiety and depression.
- A 2022 meta-analysis of 31 randomized-control trials using acupuncture needling and/or moxibustion among subjects with IBS also found benefits for abdominal pain, symptom severity, and quality of life.
- Acupuncture can be performed individually or in a communal setting
Social factors
- Several CIH mind-body approaches, which originated in ancient medical systems, have been adopted globally and are often practiced in social settings.
- For example, Tai Chi, a Chinese meditative martial art that involves postures and gentle movements alongside breathing, relaxation, and a focused mental state, is traditionally performed in a social group setting.
- Tai chi may be particularly relevant for older adults with GI disorders. Research has demonstrated that group tai chi interventions may increase social support and have added health benefits for this age group.
Environmental factors
- Light stimulation or light exposure is a CIH mind-body practice with increasing interest, especially as knowledge of the influence of vitamin D and circadian rhythms grows.
- Given the association between UV light exposure and IBD, light exposure and vitamin D have been identified as possible beneficial CIH therapies. One clinical trial found that oral vitamin D3 treatment significantly reduced the risk of relapse among 108 patients with Crohn’s.
- Light exposure has also been suggested as a treatment for chronodisruption, a chronic disruption of the circadian rhythm driven by discordance between light exposure, behaviors, and the environment.
- Chronodisruption is associated with altered intestinal permeability and IBD.
Optimal Takeaways
- Complementary and integrative health approaches align with a whole-person approach to gastrointestinal disorders and are associated with improved outcomes, healthier lifestyles, and enhanced well-being.
- The whole person model considers four domains: Biology, behavioral, social, and environmental.
- The whole person approach integrates various modalities, including mindfulness, yoga, cognitive behavioral therapy, nutrition intervention, group activities, and nature therapy.
- For example, mindfulness can improve the biopsychosocial mechanisms of IBS, acupuncture is associated with decreased GI symptom severity, and nutritional products have the potential to enhance quality of life.
Reference
Craven, Meredith R, and Elyse R Thakur. “The integration of complementary and integrative health and whole person health in gastrointestinal disorders: a narrative review.” Translational gastroenterology and hepatology vol. 9 75. 6 Aug. 2024, doi:10.21037/tgh-23-121 This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0)