[EN] Good Gut - part 2

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What do the numbers say?

In the Netherlands, about 10% of the population is diagnosed with an irritable bowel. Although the actual number is probably higher, because not everyone with complaints visits a GP. The number is comparable to other countries in what we call the “western world”. And so a couple of questions rise:

1. Is this condition less common in non-European countries?

2. If so, is this condition associated with a “modern” / western lifestyle?

3. Is the condition different in other parts of the world?

The answer to all three of these questions is: yes! IBS is less common in non-Western countries. In a country like India, IBS occurs in just over 4% of the population [3]! That is quite remarkable, especially considering the - sometimes extreme, almost sterile - hygiene standards that countries with a western lifestyle maintain. Nonetheless, it can generally be concluded that IBS occurs frequently in South Asian countries [4].

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Figure 1: Global distribution of IBS. From Canavan C et al. (2014) [12]

But pay attention! Because despite the fact there is a wide geographic variation in disease prevalence (i.e. how often a disease occurs), it has to be noted that proper health care is not nearly as accessible everywhere else as it is here in the Netherlands. This has become quite evident, during the current corona pandemic. And although we don't seem to bother talking about poo and pee, certain cultures have other values and ways of (not) expressing themselves with respect to this topic. The conclusion that IBS is a condition of “the west” may seem a bit premature, although there are certainly some interesting associations that I'd like to share with you.

Cultural adaptation: the west isn't always the best

Now let's suppose that IBS is indeed less common in non-western countries, as previously suggested by scientists [5], the main question arises: what makes people elsewhere less susceptible to developing IBS?

A very peculiar observation is that countries that rapidly “westernise” show an increase in the incidence of intestinal disorders like IBS [6, 7]. This may also explain their high prevalence in the South American countries (see figure 1) [4]. Singapore also clearly shows such a trend: after a decade of continuous industrial growth, the number of people with IBS has almost quadrupled [5]!

Neither genetics nor a reduced intestinal sensitivity in non-western countries, but behaviour seems to play a role in this whole issue. Westernised behaviour. Reason enough to take a closer look at the situation. What seems to be the case here is that important factors associated with an increase in the incidence of IBS in so-called westernised countries are a) improved hygiene, b) overcrowding, c) stress and d) a changed diet.

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Photography: Jeroen Jorissen

Causes of irritability

Digging even deeper shows us that three of those four factors are related to currently believed underlying causes of IBS.

Hygiene and infections

An intestinal infection during adolescence or the early adult years can be a risk factor for developing IBS. When I was still working a the medical-university centre, I often saw patients with IBS-like symptoms after a holiday in South Asia or Egypt, for instance. Not that holiday itself, but the persisting diarrhoea that they developed out there, turned out to be a trigger for the persistence of complaints and their evolution to IBS, the so-called post-infectious IBS.

Research has now shown that children in non-western countries can contract a bacterial intestinal infection up to 8 times a year in their first years of life. That is much less compared to countries such as Australia, Germany, Japan or the US, for example [8]. It is precisely this early exposure to bacteria that seems to build up some kind of immunological resistance, which makes the body more resistant to developing intestinal infections and subsequent post-infectious IBS in later life. Later-in-life exposure (the holiday story) can lead to severe immune reactions in the intestine. Eventually, these can fade out, but to a certain extent they maintain a low-grade level of inflammation and irritation that can lead to the aforementioned post-infectious irritable bowel.

Modern man is teased by high-performance requirements at work, we have to be turned 'on' 24/7 and on top we have high social demands (new house, better job, renovation, car, children) and there you have it: our stress center is working overtime.

Stress and the brain-gut axis, a white-collar thing

Although our gut can function independently of our brain, they are closely related. Think of how acute stress can lead to acute intestinal complaints (you have an important test and you get acute diarrhoea). Persistent stress also, can lead to overactivity of the so-Modern man is teased by high-performance requirements at work, we have to be turned 'on' 24/7 and on top we have high social demands (new house, better job, renovation, car, children) and there you have it: our stress center is working overtime. It may become quite evident why many people in a stressful job suffer from bloating, abdominal pain and a disturbed stool pattern [9].

Know what you eat

It may not sound strange that foods and drinks we consume can also play a role in the development of intestinal complaints. Monotonous, processed food, lots of fat and simple sugars: they affect our gut health. Mostly because they simplify the composition of our intestinal microbiota: our gut bacteria. On top, once abdominal complaints have become reality, eating itself can also worsen them. Processed foods high in fat and sugars, including both FODMAPs and spicy foods, are known to trigger bloating, abdominal pain and flatulence [10,11].

The gut is the gateway to good health

A comparison at a cultural level does yields interesting findings. Findings that are also of bio-scientific importance. By looking at the bigger picture and studying a condition like IBS holistically, we can come to new insights that make treatment possible in the future. The low-FODMAP diet is one of the approaches that achieves good results in FODMAP-sensitive patients, but one size fits none and in most cases a personalised approach is highly desirable. And of course: prevention is always better than cure.

Summer vacation is just around the corner, time for reflection after the tumult of the first six months, perhaps? Make a plan and create space for new ambitions, but also spend some time resting and relaxing. Recharge for the second half. Eat tasty, but also healthy and varied. And don't forget to properly “listen to your gut feeling” because in the end it is the gut that is the gateway to good health!

Enjoy health!

The doc.

- Samefko

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*DISCLAIMER - If you are suffering form intestinal complaints, like the ones described above, please consult a doctor to get to a valid diagnosis. Never draw conclusions based on the info you read here, because there might be a different cause for your complaints!


1. Rome III criteria for the Irritable Bowel Syndorm at http://www.romecriteria.org/assets/pdf/19_RomeIII_apA_885-898.pdf

2. Thijssen A, Jonkers D, et al. Dysfunctional cognitions, anxiety and depression in irritable bowel syndrome. J Clin Gastroenterol. 2010; 44 (10)

3. Ghoshal U, Abraham P et al. Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force. Indian J Gastroenterol 2008; 27: 22–8

4. Lovell R, Ford A. Global prevalence of and risk factors for Irritable Bowel Syndrome: A meta-analysis. Clinical Gastorenteorlogy and Hepatology, 2012; 10: 712-721

5. Spiller R, Garshed K. Infection, inflammation and the irritable bowel syndrome. Digestive and Liver Disease, 2009; 41: 844-849

6. Gwee KA, Wee S, Wong ML, et al. The prevalence, symptom characteristics, and impact of irritable bowel syndrome in an asian urban community. Am J Gastroenterol 2004; 99: 924–31

7. Ho KY, Kang JY, Seow A. Prevalence of gastrointestinal symptoms in a multiracial Asian population, with particular reference to reflux-type symptoms. Am J Gastroenterol 1998; 93: 1816–22

8. O'Ryan M, Prado V, Pickering LK. A millennium update on pediatric diarrheal illness in the developing world. Semin Pediatr Infect Dis 2005; 16: 125–36

9. Grodzinsky E, Hallert C et al. Could gastrointestinal disorders differ in two close but divergent social environments? Int J Health Geogr. 2012; 11: 5.

10. Ludidi S, Conchillo J et al. Does meal ingestion enhance sensitivity or visceroperception assessment in IBS? Neurogastroenterol Motil, 2012; 24 (1): 47-53

11. Ludidi S, Conchillo J et al. Rectal sensitivity as hallmark for IBS: defining the optimal cut off]. Neurogastroenterol Motil, 2012; 24 (8): 729-733

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