Irritable Bowel Syndrome and Vitamin D: Is There a Connection?
Common symptoms of IBS are constipation, diarrhea, or alternating diarrhea and constipation with or without abdominal pain.
Is There a Correlation Between Low Vitamin D Levels and IBS?
Studies suggest a correlation between IBS and an inflammatory response in the gut. The gut microbiota is an area of increased interest and research mostly because of the effect the gut microbiota has on the gastrointestinal tract than can lead to chronic gastrointestinal diseases.22 Inflammation, gut motility, and brain-gut axis disturbances may explain triggering and continuation of bowel symptoms along with visceral sensitivity due to bowel sensation and afferent nerve signaling.23 Histologic examination in individuals with IBS suggests an increase in mast cells, lymphocytes, and other cell types in parts of the colon and small intestine leading to increased sensitivity in the nervous system and visceral hypersensitivity along with altered perception of abdominal pain.24 This suggests that inflammation in the gut triggers an increase in sensitivity and pain perception.
The relationship between a patient's perception of symptoms has also been an interesting area of relevance. Studies note that individuals with IBS show a lower tolerance to balloon distension in the large and small bowel compared with healthy subjects.9 In one study, magnetic resonance imaging was performed on male patients with IBS and healthy male controls at the rectal balloon distension threshold. The investigators noted an increase in activation of common neural regions in the brain with rectal balloon distension in the male patient with IBS.25
Two specific changes in gut motility noted in the patient with IBS — changes in gut transit and increased motility — may be associated with specific stimuli such as psychological stress and meals.9 The stress that occurs due to a patient's thought process may lead to worsening of the patient's symptoms. Research suggests that low vitamin D levels may be a cause or effect of mental illness such as depression.26 If this is the case, then is it possible that low vitamin D has a larger role in thought processes and can lead to IBS symptoms?
Vitamin D has been known to inhibit T-cell proliferation, thereby decreasing the potential for an immune response.27 Interestingly, 70% to 80% of vitamin D absorption in the gut occurs in the ileum with most vitamin D receptors (VDRs) and regulatory mechanisms in the cecum and large intestine.27 VDR is a protein that regulates physiologic processes and in present in most tissues of the body.28 The presence of VDRs in the gut suggests that vitamin D is needed to maintain normal function. The effects of vitamin D on gut function may be due to VDR expression in the gut and the neurologic system that regulate the epithelium barrier, neurotransmitters, and serotonin synthesis, causing a decrease in visceral hypersensitivity and abdominal pain.24
A study in 2016 recognized a benefit of vitamin D 50,000 IU every 2 weeks on IBS symptoms, severity, and quality of life.24 In an article published in 2015, VDRs were found to play an important protective role in the mucosal barrier, and an increased risk of dysfunctional mucosal barrier and inflammation was identified with a reduction in VDR.29 The same article reported that increasing the epithelial VDR level with vitamin D therapy will result in a decrease in inflammation and a decrease in the risk of colitis and inflammation in the colon.29 In an article by Klampfer, decreased levels of VDR in the intestinal epithelium were correlated with low levels of vitamin D and inflammation in the gut.30 Diet may also have an effect on the enteric microbial community in the gut, resulting in an alteration in composition and function.31
Studies have explored the possible correlation of IBS and vitamin D with results favoring further research. In a study conducted by Khayyat and Attar, 49 out of 60 participants with IBS were found to have low vitamin D levels compared with 31 of 100 healthy individuals having low vitamin D levels.27 A separate case study reported on cessation of symptoms in a patient with IBS taking vitamin D 3000 IU daily; the patient's symptoms returned upon discontinuation of the vitamin D supplementation.2 An analysis of blogs of 37 patients with IBS noted 70% improvement with vitamin D supplementation in those with low vitamin D levels.32 In a recent randomized control trial, 112 individuals aged 14 to 18 years who met the Rome III [RA1] criteria for IBS with vitamin D levels <20 ng/mL were followed from April 2015 to April 2017.33 Out of the 112 study participants, 56 received vitamin D supplementation and 56 received a placebo; results showed improvement in symptom severity and quality of life in the patients who received vitamin D supplementation.33
Research into the correlation between vitamin D and IBS is certainly compelling, and the need for further investigation is recommended by previous studies. The diagnosis of IBS is based strictly on the Rome IV criteria, and treatment can be frustrating for both the patient and the healthcare provider. Due to the increase in direct and indirect healthcare costs associated with IBS and the impact that IBS has on an individual's daily life and psychiatric health, improving a patient's outcome is certainly a goal for healthcare providers who provide direct care to these patients. Knowledge of the Rome IV criteria is essential for appropriate diagnosis and can help to determine whether further testing is warranted. Vitamin D deficiency has been recognized as a possible cause of some cancers and other diseases. With the identification of VDRs in the gut and a possible inflammatory response from lack of vitamin D, the correlation between IBS and vitamin D is plausible. However, there is currently no evidence-based practice recommendations for ordering vitamin D levels for patients with IBS. Further research into vitamin D insufficiency and IBS is necessary to prove a correlation between the 2 conditions and ultimately improve patient outcomes.
- Functional GI disorders. International Foundation for Functional Gastrointestinal Disorders website. Available at: https://www.iffgd.org/functional-gi-disorders.html. Updated November 9, 2016. Accessed December 12, 2018.
- Tazzyman S, Richards N, Trueman AR, et al. Vitamin D associates with improved quality of life in participants with irritable bowel syndrome: outcomes from a pilot trial. BMJ Open Gastroenterol. 2015;2(1):e000052.
- Lembo A. The clinical and economic burden of irritable bowel syndrome. Practical Gastroenterology website. Available at: https://www.practicalgastro.com/pdf/September07/02LemboArticle.pdf. September 2007. Accessed December 12, 2018.
- Zhang R, Naughton D. Vitamin D in health and disease: current perspectives. Nutr J. 2010;9:65.
- Occhipinti K, Smith JW. Irritable bowel syndrome: a review and update. Clin Colon Rectal Surg. 2012;25:46-52.
- Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features, and ROME IV. Gastroenterology. 2016;150:1262-1279.
- Simren M, Palsson OS, Whitehead, WE. Update on ROME IV criteria for colorectal disorders: implication for clinical practice. Curr Gastroenterol Rep. 2017;19(4):15.
- Heidelbaugh JJ. These 3 tools can help streamline management of IBS. J Fam Pract. 2017;66(6):346-353.
- Freeman K. Irritable Bowel Syndrome. Cleveland Clinic Center for Continuing Education website. Available at: www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/irritable-bowel-syndrome/.
- Ferreira NB, Eugenicos MP, Morris PG, Gillanders D. Using acceptance and commitment therapy to understand and improve outcomes in irritable bowel syndrome. Gastrointest Nurs. 2011;9(9):28-35.
- Wilkins T, Pepitone C, Alex B, Schade RR. Diagnosis and management of IBS in adults. Am Fam Physician. 2012;86(5):419-426.
- Nair R, Maseeh A. (2012). Vitamin D: the “sunshine” vitamin. J Pharmacol Pharmacother. 2012;3(2):118-126.
- Ross AC, Taylor CL, Yatkin AL, Del Valle HB. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC; National Academies Press: 2011.
- Grasso D, Rafferty M. Vitamin D: implications of the Institute of Medicine report for clinical practice. Am J Nurse Pract. 2012;16:35-40.
- Holick MF, Binkley NC, Bischoff-Ferrari HA; for the Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911-1930.
- Stevenson C, Blaauw R, Fredricks E, Visser J, Roux S. Food avoidance in irritable bowel syndrome leads to a nutrition-deficient diet. South Afr J Clin Nutr. 2013;27:25-30.
- Ultraviolet radiation (UV). World Health Organization website. Available at: https://www.who.int/uv/en/. Accessed December 12, 2018.
- Colidron B. American Academy of Dermatology statement on Journal of Internal Medicine study on sun exposure, vitamin D levels and mortality. American Academy of Dermatology website. Available at: https://www.newswise.com/articles/american-academy-of-dermatology-statement-on-journal-of-internal-medicine-study-on-sun-exposure-vitamin-d-levels-and-mortality. Accessed December 12, 2018.
- Droste L, Hernandez J, Holmes C, Mahdjoubi M. Diagnosis and management of vitamin D deficiency in adults. Am J Nurse Pract. 2010;14: 25-32.
- Vitamin D Deficiency: Screening. US Preventive Services Task Force website. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/vitamin-d-deficiency-screening. November 2014. Accessed December 12, 2018.
- Pepper K, Judd SE, Nanes MS, Tangpricha V. Evaluation of vitamin D repletion regimens to correct vitamin d status in adults. Endocr Pract. 2009;15,95-103.
- Guinane CM, Cotter D. Role of gut microbiota in health and chronic gastrointestinal diseases: understanding a hidden metabolic organ. Ther Adv Gastroenterol. 2013;6(4):295-308.
- Sayuk GS, Gyawali CP. Irritable bowel syndrome: modern concepts and management options. Am J Med. 2015;128:817-827.
- Abbasnezhad, A., Amani R, Hajiani E, Alavinejad P, Cheraghian B, Ghadiri A. Effect of vitamin D on Gastrointestinal symptoms and health-related quality of life in irritable bowel syndrome patients: a randomized double-blind clinical trial. Neurogastroenterol Motil. 2016;28(10):1533-1544.
- Ghoshal UC, Shukla R, Ghoshal U, Gwee KA, NG SC, Quigley EM. The gut microbiota and irritable bowel syndrome: friend or foe? Int J Inflamm. 2012;2012:151085.
- Bhati MS, Kaur J, Rathi A, Srivastava S. Vitamin D deficiency among psychiatric outpatients. Delhi Psychiatry J. 2014;17(1):113-116.
- Khayyat Y, Attar S. Vitamin D deficiency in patients with irritable bowel syndrome: does it exist? Oman Med J. 2015;30:115-118.
- Adachi R., Shulman AI, Yamamoto K, et al. Structural determinants for vitamin D receptor response to endocrine and xenobiotic signals. Mol Endocrinol. 2004;18(1):43-52.
- Li YC, Chen Y, Du J. Critical roles of intestinal epithelial vitamin D receptor signaling in controlling gut mucosal inflammation. J Steroid Biochem Mol Biol. 2015;148:179-183.
- Klampfer L. Vitamin D and colon cancer. World J Gastrointest Oncol. 2014;6:420-437.
- Ferguson LR, Laing B, Marlow G, Bishop K. The role of vitamin d in reducing gastrointestinal disease risk and assessment of individual dietary intake needs: focus on genetic and genomic technologies. Mol Nutr Food Res. 2015;60(1):119-133.
- Sprake E, Grant VA, Corfe BM. Vitamin D3 as a novel treatment for irritable bowel syndrome: single case leads to critical analysis of patient-centered data. BMJ Case Rep. 2012;2012: pii: bcr-2012-007223.
- El Amrousy D, Hassan S, El Ashry H, Yousef M, Hodeib H. Vitamin D supplementation in adolescents with irritable bowel syndrome: is it useful? A randomized control trial. Saudi J Gastroenterol. 2018;24(2):109-114.