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Non-pharmacological interventions in Irritable bowel syndrome Baron, Leigh-Ann 2018-04

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Running head: NON-PHARMACOLOGICAL INTERVENTIONS   1 NON-PHARMACOLOGICAL INTERVENTIONS IN IRRITABLE BOWEL SYNDROME by Leigh-Ann Baron BSc Nursing, British Columbia Institute of Technology, 2010   A CULMINATING PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF NURSING – NURSE PRACTITIONER  in  THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (School of Nursing) THE UNIVERSITY OF BRITISH COLUMBIA   Vancouver  April 2018  Leigh-Ann Baron, 2018  NON-PHARMACOLOGICAL INTERVENTIONS  2 Table of Contents Abstract .............................................................................................................................. 3 Research Problem ............................................................................................................. 5 Literature Review ............................................................................................................. 8 Search Process ............................................................................................................................ 8 Dietary Interventions ................................................................................................................. 8 Exercise and IBS....................................................................................................................... 16 Psychological Therapies ........................................................................................................... 17 Project Description ......................................................................................................... 20 Challenges, Strengths and Limitations................................................................................... 22 Impact on Practice ................................................................................................................... 23 Conclusion ....................................................................................................................... 24 References ........................................................................................................................ 27 Appendix: One Page Primer .......................................................................................... 34  NON-PHARMACOLOGICAL INTERVENTIONS  3 Abstract The aim of this project is to support Nurse Practitioners in navigating the complex world of non-pharmacological interventions for irritable bowel syndrome (IBS) by creating a one-page clinical information sheet for use in practice. IBS is a chronic functional gastrointestinal disorder commonly seen in primary care and the pathophysiology of IBS is largely unknown, leading to a wide variety of interventions.  Non-pharmacological interventions are suggested first-line therapies for IBS. A literature review was conducted to assess the state of the evidence for fiber supplementation, traditional IBS dietary advice, the low-FODMAP diet, exercise and psychological therapies.  All of these interventions have some part to play in an IBS management plan, with traditional IBS dietary advice and the low-FODMAP diet having the strongest evidence for efficacy in treating IBS.                       NON-PHARMACOLOGICAL INTERVENTIONS  4 Non-Pharmacological Interventions in Irritable Bowel Syndrome Irritable bowel syndrome (IBS) is a chronic condition commonly seen in primary care.  With an estimated prevalence of up to 15% in the worldwide population (Altobelli, Del Negro, Angeletti & Latella, 2017) and 12% of the Canadian population (Thompson, Irvine, Pare, Ferrazzi & Rance, 2002) IBS is a condition primary care providers should expect to encounter in their practice.  IBS has a negative impact on quality of life and imposes a significant burden on the healthcare system (Altobelli et al., 2017) with IBS sufferers using a disproportionate number of healthcare resources (Brandt et al., 2009).  Direct medical costs traceable to IBS is estimated at $1.5 billion in Canada (Canadian Digestive Health Foundation, 2009).  Due to the heterogeneous nature of IBS symptoms and the unclear pathophysiology, one treatment option does not fit all.  Both pharmacological and non-pharmacological treatment options are used.  First-line therapies are lifestyle and dietary interventions, with dietary adjustments being the main treatment modality (Wald, 2016).   While it is the primary care provider’s role to provide the most effective options, given the wide variety of treatments and ever-changing pharmaceuticals available, it is unreasonable to expect the practitioner to be well-versed in all modalities. The aim of this project is to identify relevant clinical information on the non-pharmacological treatment options for IBS and collate this information into a one-page primer for use by the Nurse Practitioner (NP) to aid in the management of patients with IBS.  In the following paper, I will further elaborate on the problem of managing IBS as an NP.  I will also review literature to inform evidence-based practice and help identify key information for the one-page primer.   NON-PHARMACOLOGICAL INTERVENTIONS  5 Research Problem Nursing itself is not a new profession, however, NPs are a relatively new addition to the healthcare team in British Columbia.  First regulated in 2005, NPs are nursing professionals who have completed advanced requirements through a master’s program to become primary care providers.  As independent primary care providers, NPs provide comprehensive clinical care and can diagnose and manage disease and illness; prescribe medications; order and interpret diagnostic tests and refer to specialists (British Columbia Nurse Practitioner Association [BCNPA], 2018).  The NP brings a holistic view to health with a focus on teaching, counseling and support, which adds to the treatment they provide (BCNPA, 2018; College of Registered Nurses of British Columbia, 2018).  The unique background and perspective of the NP is valuable in treating and supporting individuals with IBS as this disease process is multifactorial, challenging to treat, and requires continued follow-up and support by healthcare providers. NPs may have varying degrees of prior knowledge about IBS.  The amount of information available on IBS management can be overwhelming for any practitioner, especially for NPs who are unfamiliar with the topic and even more so for the novice NP.  Transitioning into the role of NP is stressful, especially for novice NPs who are still building confidence in their abilities, while also continuing to develop, integrate and apply knowledge (Hill & Sawatsky, 2011).  Both the novice or experienced NP may have little or no experience in managing a patient with IBS.  Compounding this problem is the lack of teaching on dietary approaches in medical and nursing education (Adams, Kohlmeier, Powell & Zeisel, 2010; Kris-Etherton et al., 2014).  NPs may find researching appropriate treatment modalities time-consuming and potentially stress-inducing if there is a patient waiting.  However, a quick, easy to use, printable one-page primer on the treatment of IBS could help inform the NP of current non-NON-PHARMACOLOGICAL INTERVENTIONS  6 pharmacological treatment practices.  The goal of this project is to create this clinical primer on non-pharmacological IBS treatments (see Appendix).  The project focuses on non-pharmacological treatments as these are first-line interventions for patients with IBS, and potentially modalities about which the NP has the least amount of knowledge.  IBS is a chronic functional gastrointestinal disorder characterized by abdominal pain or discomfort, associated with changes in bowel function, usually diarrhea, constipation or both. Other common symptoms include bloating and flatulence. IBS is a common condition with high prevalence worldwide, with estimates between 7-15% (Altobelli et al., 2017; Cozma-Petrut, Loghin, Miere & Dumitrascu, 2017). There are four subtypes of IBS: IBS with prominent constipation, IBS with prominent diarrhea, IBS with mixed bowel habits and IBS unclassified.    Patients with IBS frequently visit the primary care provider’s office, consuming more healthcare resources, such as diagnostic testing and more frequent hospitalization than those without IBS (Brandt et al., 2009; El-Salhy, Ostgaard, Gunderson, Hatlebakk & Hausken, 2012; Harvie et al., 2017).  NPs, as primary healthcare providers, can expect to encounter patients with IBS in practice. Unfortunately, the pathophysiology of IBS is not fully understood and is multifactorial therefore, development of a management plan may be challenging for the NP.  Gastrointestinal motility changes, visceral hypersensitivity, altered brain-gut axis, inflammation, psychological distress, altered gut microbiota and impaired immune function are all thought to be a factor (Altobelli et al., 2017; Harvie et al., 2017).  Specific diagnostic testing is therefore not available for IBS and diagnosis is made clinically and by ruling out other disease states and illnesses.  The heterogeneity of IBS creates difficulties in managing this disorder.  Both pharmacological and non-pharmacological modalities can be applied.   NON-PHARMACOLOGICAL INTERVENTIONS  7 Pharmacological methods vary widely and often treat only one symptom (Harvie et al., 2017).  Since IBS symptoms fluctuate over time, targeting one symptom will not adequately treat IBS (Altobelli et al., 2017) and should only be used in conjunction with dietary measures.  Additionally, while effective in the short term, the benefits of long-term use of IBS medications is unclear, and the risk of developing side-effects increases with prolonged use (El-Salhy, 2012).  Therefore, non-pharmacological treatments with dietary and lifestyle changes are considered first-line treatments for IBS. Up to 70% of patients with IBS report food as being a major contributor to their symptoms (Altobelli et al., 2017).  Consequently, IBS sufferers avoid certain foods they feel exacerbate their symptoms.  However, differences between patients with IBS and healthy controls are not evident (El-Salhy, 2012).  Understandably, a majority of patients want and need information regarding dietary interventions that could help relieve IBS symptoms.   Considerable interest in dietary interventions exists in the medical community (Altobelli et al., 2017; Cozma-Petrut et al., 2017; Eswaran et al., 2016; Harvie et al., 2017).  Current dietary advice for IBS includes regular meal patterns, avoidance of dietary triggers and avoidance of fats, caffeine, alcohol and spicy foods (Cozma-Petrut et al., 2017).   Another option is a novel dietary approach: the low-FODMAP diet (Altobelli et al., 2017; Marsh et al., 2016). FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are short-chain carbohydrates that have been shown to contribute to the worsening of IBS symptoms.  FODMAPs are poorly absorbed, osmotically active, and rapidly ferment in the gut, leading to classic IBS symptoms of abdominal pain, bloating, diarrhea and flatulence (Barret, 2013; Marsh et al., 2016).  Some examples of sources rich in FODMAPs include cauliflower, legumes, garlic, onions, wheat and sugar alcohols (Barret, 2013).  These carbohydrates were NON-PHARMACOLOGICAL INTERVENTIONS  8 individually identified as contributing to gastrointestinal symptoms as early as the 1950s; however, these were not grouped into the FODMAP theory until the early 2000s by researchers at Monash University in Australia (Gibson, 2017).  Since then, interest in the effect of FODMAPs on functional gastrointestinal disorders, particularly IBS, has soared. This interest has led to a surge of studies on the low-FODMAP diet in recent years, some of which will be reviewed in this paper.  In addition to dietary measures, other non-pharmacological options show some promise in the treatment of IBS and include exercise and psychological therapies (Harvie et al., 2017; Wald, 2016).   Literature Review  A thorough literature review was conducted on the non-pharmacological management of IBS.  The following topics were reviewed: dietary interventions, including the low-FODMAP diet and fiber supplementation; exercise; and psychological therapies.  As dietary interventions are the main treatment modality for IBS, the focus of the review is on these interventions, specifically the low-FODMAP diet.  Search Process A systematic search for relevant literature was performed using the electronic databases PubMed, Google Scholar and CINAHL.  Various combinations of the search terms diet and IBS, low-FODMAP diet, fiber and IBS were used to find articles pertaining to the dietary interventions of IBS treatment.  Terms used to search for literature on exercise and psychological therapies included exercise or activity and IBS, therapy and IBS, Cognitive Behavioural Therapy and IBS, and mindfulness and IBS, respectively.  To narrow the search, only articles from the last 10 years in the adult population were considered.   NON-PHARMACOLOGICAL INTERVENTIONS  9 All studies considered had to involve patients with IBS and the above discussed interventions. Titles and abstracts were scanned for suitability; those not examining the required interventions were excluded.  For greater depth, reference lists from the chosen articles were also researched for additional articles.  A total of 18 articles were chosen for review, of those 18 articles, 12 were on dietary intervention, two on exercise and four on psychological therapies.  All studies examined the effects of a non-pharmacological intervention on IBS symptoms.   Dietary Interventions Dietary interventions are the first-line treatment for IBS symptoms (Cozma-Petrut et al., 2017; Wald, 2016) and as such there is considerable interest in exploring these interventions.  The 12 chosen studies on dietary interventions in IBS management, excluding fiber supplementation, included two meta-analyses (Altobelli et al., 2017; Marsh, Eslick & Eslick, 2016), five randomized control trials (RCT) (Bohn et al., 2015; Eswaran, Chey, Han-Markey, Ball & Jackson, 2016; Halmos, Power, Shepherd, Gibson & Muir, 2014; Harvie et al, 2017; McIntosh et al, 2017), and two cohort studies (Mazzawi, Hausken, Gundersen & El-Salhy, 2013; Staudacher, Whelan, Irving & Lomer, 2011).  Three studies were chosen on fiber supplementation and IBS, two were meta-analyses (Moayyedi et al., 2014; Nagarajan et al., 2015) and one was a review (El-Salhy, Otterasen Ystad, Mazzawi & Gundersen, 2017).   Dietary fiber supplementation has been a mainstay of treatment for functional gastrointestinal disorders, including IBS, and is often recommended as an initial treatment for IBS by primary care providers (El-Salhy et al., 2017).  However, fiber supplementation use in IBS has been questioned.  Certain types of fiber can, in fact, exacerbate IBS symptoms (Moayyedi et al., 2014). There are two types of fiber, soluble and insoluble, and within those categories differences in physical and chemical properties.  Soluble fiber (i.e. can dissolve in NON-PHARMACOLOGICAL INTERVENTIONS  10 water) can be either viscous or non-viscous, fermentable or non-fermentable, and comprised of short-chain or long-chain carbohydrates.  The soluble short-chain carbohydrates are rapidly fermentable and lead to gas production in the gut.  This gas formation can lead to pain, bloating and flatulence experienced by people with IBS.  Conversely, soluble, long-chain carbohydrates are moderately fermentable, thus causing low gas production and no symptoms related to excessive gas.  Therefore, one cannot simply recommend any fiber as treatment for IBS (El-Salhy et al., 2017).   Nagarajan et al. (2015) conducted a systematic review and meta-analysis on the role of fiber supplementation in the treatment of IBS.  The analysis covered studies investigating both types of fibers, soluble and insoluble.  The review found that only soluble fiber may have some effect on improving IBS symptoms. Global Assessment of IBS symptoms (GAS) was the primary outcome measure.  GAS, a tool using a Likert Scale, is used to measure the overall change in IBS symptoms and can evaluate multiple symptoms, or be dichotomous, indicating improved or not improved symptoms (Moayyedi et al., 2014; Nagarajan et al, 2015).   Nagarajan et al. (2015) found that soluble fiber supplementation demonstrated a statistically significant improvement in the intervention group compared to the placebo group.  These results are echoed by the review and analysis by Moayyedi et al. (2014).  Studies that used the IBS symptom severity score (IBS-SSS) or the IBS quality of life index (IBS-QOL) demonstrated no statistical significance, so these results were not included in the meta-analysis.  The IBS-SSS is a tool used to measure the severity of IBS symptoms and the IBS-QOL tool measures aspects of quality of life in relation to IBS symptoms.  Both these tools are administered in the form of a questionnaire (Drossman et al., 2000; Francis, Morris & Whorwell, 1997). No adverse effects were reported in any of the studies.  NON-PHARMACOLOGICAL INTERVENTIONS  11 There were limitations to analysis by Nagarajan et al. (2015). The studies reviewed were moderately heterogeneous.  There were large variations in types of fiber, doses and duration of study. There was also high risk of incomplete data and some studies were methodologically challenged, which contributed to bias in the analysis.  Furthermore, the majority of the studies reviewed did not use validated diagnostic criteria for IBS.  Moayyedi et al. (2014) reported similar results with statistical significance in the soluble fiber supplementation groups compared with placebo on GAS.  Insoluble fiber was not effective in reducing IBS symptoms. The types of fibers also varied but were more homogenous than the previous review.  Bran was found to have no statistically significant effect on IBS symptoms, whereas Ispaghula was effective.  This review also included studies that did not use validated diagnostic criteria for IBS. Some studies also did not provide data on the content of the fiber supplement, and there were variations in duration of therapy, as well as in definitions of IBS.   The current evidence for use of fiber in IBS treatment is of relatively low-quality due to limitations such as the heterogeneity of the studies and inadequate sample sizes. Soluble fiber supplementation, particularly psyllium, is the only fiber to result in some improvement of IBS symptoms (El-Salhy et al., 2017).  In fact, it is the only fiber recommended by the American College of Gastroenterologists (2009).  As fiber supplements are inexpensive and safe to use, soluble fiber (i.e. psyllium) can be suggested as a potential treatment for IBS. In addition to fiber supplementation, traditional dietary recommendations for treatment of IBS symptoms include: regular meal patterns; reduced fat, alcohol and caffeine intake; no insoluble fiber; and avoidance of large meals, spicy foods, and gas-inducing foods like cabbage, beans and onions (Bohn et al., 2015; Cozma-Petrut et al., 2017).  These guidelines are recommended as first-line treatment for IBS (Wald, 2016; Cozma-Petrut et al., 2017).  However, NON-PHARMACOLOGICAL INTERVENTIONS  12 evidence for the validity of these suggestions varies widely, with almost all evidence being of poor or low quality (McKenzie et al., 2016; Ford et al., 2014).  Only fiber supplementation received a moderate rating in one guideline (Ford et al., 2014).   The dietary intervention with the best evidence is the low-FODMAP diet.  This diet is currently suggested as a second-line treatment for IBS in patients for whom traditional dietary advice has failed (Cozma-Petrut et al., 2017; McKenzie et al., 2016).  Many studies have investigated the effectiveness of the low-FODMAP diet compared to traditional dietary advice for IBS management.  Two RCTs (Bohn et al., 2015; Eswaran et al., 2016) and one cohort study (Staudacher et al., 2011) that compared these diets were examined for this review. All three studies compared the low-FODMAP diet with traditional dietary advice for IBS using the National Institute of Health and Clinical Excellence (NICE) guidelines based out of the United Kingdom (National Institute of Health and Clinical Excellence, 2008).   All studies reported an improvement in overall IBS symptoms in the low-FODMAP diet group; however, Staudacher et al. (2011) was the only study to find the low-FODMAP diet was superior to standard dietary advice.  Although improvement in IBS symptoms was higher in low-FODMAP groups in all three studies, statistical significance was not achieved in two of them (Bohn et al., 2015; Eswaran et al., 2016).  Individual outcomes such as abdominal pain, bloating, flatulence, stool frequency, consistency and urgency were improved in low-FODMAP groups compared with NICE groups (Eswaran et al., 2016; Staudacher et al., 2011).  Some limitations of the studies include: inadequate sample size in Eswaran et al. (2016) which suggests an incorrect interpretation of the results; each study used a different tool to measure IBS symptoms, although all were validated tools; and food was not provided, so adherence to the specified diets is questionable.  Eswaran et al. (2016) and Bohn et al. (2015) NON-PHARMACOLOGICAL INTERVENTIONS  13 used food diaries in attempt to monitor adherence, whereas Staudacher et al. (2011) did not record any information on what or how much participants were eating, or if any medications were taken during the study.  Overall, the evidence suggests that both, or a combination of, the low-FODMAP diet and NICE guidelines can be used in the treatment of IBS symptoms.    Other studies have compared the efficacy of the low-FODMAP diet with a normal unaltered western diet (Halmos et al., 2014) and a high-FODMAP diet (McIntosh et al., 2017).  Both of these RCTs reported that a diet low in FODMAPs results in significant improvement of IBS symptoms.  Halmos et al. (2014) reported 70% of IBS group participants feeling better on the low-FODMAP diet.  Total IBS symptom score and abdominal pain reduction was statistically significant in the low-FODMAP groups with symptoms reduced by more than half in one study (Halmos et al, 2014).  Conversely, a standard diet high in FODMAPs resulted in an increase in IBS symptoms.  However, one study did not obtain baseline dietary measurements, which may lessen the impact of the interventions (McIntosh et al., 2017).  A unique strength of the Halmos et al. (2014) study not seen in any other reviewed study was the provision of meals for each dietary intervention.  This helped control for any confounding variables from other dietary elements.  The McIntosh et al. (2017) article also had a unique aspect.  In addition to IBS symptoms they also studied the effects of FODMAPs on the microbiome.  The low-FODMAP diet altered gut flora in such a way as to allow for potential invasion of opportunistic bacteria.  This alteration of gut flora brings into question the safety of a long-term low-FODMAP diet.   Further apprehensions regarding the long-term effects of the low-FODMAP diet concern nutritional adequacy.  This diet is quite restrictive and could lead to deficiencies in known nutritious elements such as fiber, vitamins, and minerals, particularly calcium (Cozma-Petrut et al., 2017; Mazzawi et al., 2014).  Harvie et al. (2017) conducted an RCT investigating the long-NON-PHARMACOLOGICAL INTERVENTIONS  14 term effects of education on FODMAPs, nutritional adequacy, quality of life and symptom severity.  A secondary outcome was to investigate the effect of the low-FODMAP diet on the microbiome.   In the parallel study design by Harvie et al. 2017, participants were given dietary education on low-FODMAPs, followed by how to reintroduce FODMAPs into their diet after three months of low-FODMAP.  IBS-SSS was lower in the group that received the intervention first compared with the group waiting for the intervention.  The improvement in symptoms was maintained at the six-month follow-up even after reintroduction of FODMAPs.  Results were replicated in the second group during their intervention period.  Quality of life measures were significantly better in both groups during the intervention and at follow-up.  Nutritional deficiencies were not significant during the study.  Calcium levels were always within normal ranges.  Fiber intake did decrease below recommended levels during the low-FODMAP phase but came back up to baseline values after reintroduction of FODMAPs.  Unfortunately, the authors were not able to demonstrate the effects of the low-FODMAP diet on the microbiome due to loss of stool samples during a power failure.   Due to the nature of the study design, the placebo effect cannot be ruled out.  In fact, participants in the comparator group who were waiting for the intervention demonstrated some improvement in IBS symptoms.  No blinding to treatment was done.  The risk of response bias is also present, as the same researcher who provided the education also collected the data (Harvie et al., 2017). Overall, this study demonstrates that a low-FODMAP diet and reintroduction of FODMAPs, administered by a healthcare professional, is effective in treatment of IBS symptoms.  Concerns about nutritional deficiencies can be allayed, but more studies on the long-term effects of the low-FODMAP diet are needed to enhance the evidence.   NON-PHARMACOLOGICAL INTERVENTIONS  15 Patients with IBS have been shown to avoid certain food items high in FODMAPs but unknowingly continue to eat other sources of FODMAPs.  Guidance on appropriate implementation of the low-FODMAP diet is needed (Mazzawi et al., 2013) and this guidance should be provided by a healthcare professional (Cozma-Petrut et al., 2017; McKenzie et al., 2016).  A cohort study investigated the effects of nurse-led dietary guidance on IBS symptoms, quality of life and nutritional intake in patients with IBS (Mazzawi et al., 2013).  The dietary guidance resulted in a decrease in IBS symptoms and an increase in quality of life. The only significant changes in nutritional intake were an increase in vitamin B12 and cholesterol.  However, this study suffered from a large attrition rate with only 17 of 46 participants completing the study.   Dietary guidance may improve IBS symptoms and quality of life and should be considered part of a management plan for IBS.   The current evidence for the efficacy of the low-FODMAP diet in treatment of IBS is becoming increasingly robust (Altobelli et al., 2017; Marsh et al., 2016).  Although Altobelli et al. 2017 found statistical significance in favour of the low-FODMAP diet over the traditional IBS diet, the superiority of this diet over traditional IBS dietary recommendations in decreasing IBS symptoms is not certain. The lack of a significant difference between the two diets could be attributed to the traditional guidelines excluding some known FODMAPs.  The current research is widely varied in terms of how the studies were conducted.  For example, there were various controls and outcome measurements among the studies discussed above and reviewed in the meta-analyses (Marsh et al., 2016; Altobelli et al., 2017).  Additional limitations in the current research include responder bias, lack of appropriate blinding, and inadequate treatment duration.  Furthermore, the placebo effect is known to be high in IBS research (Harvie et al., 2017).  Future research needs to be conducted to address the long-term effects of the low-FODMAP diet and NON-PHARMACOLOGICAL INTERVENTIONS  16 establish whether it is indeed superior to traditional IBS treatment recommendations (Altobelli et al., 2017; Marsh et al., 2016).  Other approaches to non-pharmacological IBS treatments were also explored.  Exercise and IBS Two RCTs (Daley et al., 2008; Johannesson, Simren, Strid, Bajor & Sadik, 2011) on the effects of exercise on IBS symptoms where reviewed.  Exercise has been shown to improve gastrointestinal function in healthy adults. Therefore, using exercise to treat IBS is an appealing strategy (Daley et al., 2008; Johannesson et al., 2010).  Exercise has also been shown to improve symptoms in those with chronic constipation (Johannesson et al., 2010).  Unfortunately, very few studies have been conducted to investigate this intervention in IBS.  Two RCTs (Daley et al., 2008; Johannesson et al., 2010) studied the effects of exercise on IBS symptoms and quality of life.  Johannesson et al. (2010) reported a significant decrease in IBS symptom severity and an improvement in certain quality of life measures among the physical activity group compared to the control group.  The physical activity group demonstrated a significant improvement in physical function and physical role. No other significant differences between these groups were reported.  Daley et al. (2008) did not find any significant differences in quality of life, nor an improvement in total IBS symptom score.  The only significant symptom change was in constipation.  No other IBS symptoms (i.e. pain, diarrhea) were significantly improved.  Some limitations to these studies include self-reporting and no supervision of exercise, which may lead to response bias and overestimation of exercise. There was also a lack of blinding, but this is not a reasonable expectation with this type of intervention.  Both studies experienced issues with their samples.  Daley et al. (2008) had difficulties with recruitment, which affected the generalizability of the results, and Johannesson et al. (2010) experienced a NON-PHARMACOLOGICAL INTERVENTIONS  17 high rate of dropouts. However, dropout rate was comparable between groups. Overall, the evidence for exercise as an intervention for IBS is not strong.  Nonetheless, an increase in physical activity is inexpensive and beneficial to health overall and should be part of a management plan for patients with IBS.  Further studies in this area are needed to enhance the state of the evidence.  Psychological Therapies Psychological therapies are another non-pharmacological treatment option for IBS. Two meta-analyses and two RCTs, one of each type on Cognitive Behaviour therapies (Labus et al., 2013; Li, Xiong, Zhang, Yu & Chen, 2014) and on Mindfulness-Based therapies (Aucoin, Lalonde-Parsi & Cooley, 2014; Zernicke et al., 2013) were reviewed.  External stressors and cognitive distress can affect the gastrointestinal tract, increasing motility, sensation and secretion, thus contributing to IBS symptoms.  Subsequently, increased pain further increases psychological distress (Zernicke et al., 2013). Patients with IBS are also more likely to suffer from a mood disorder, depression, and anxiety compared to healthy controls (Li et al., 2014).  Both cognitive behavioural therapy (CBT) and mindfulness-based therapies have been studied for use in IBS.  Labus et al. (2012) studied the effect of cognitive behaviour therapy with relaxation techniques on symptoms of IBS and quality of life. This RCT provided five weekly educational sessions on the connection between mood, stress and IBS with CBT approaches and relaxation techniques.  A significant reduction of IBS symptoms post-intervention and at the three-month follow-up was reported.  Quality of life was significantly improved as well.  However, those participants who had a high baseline quality of life did not experience a reduction in their IBS symptoms. Some limitations of this study include: significant baseline sample differences of NON-PHARMACOLOGICAL INTERVENTIONS  18 symptom severity and anxiety, although the authors did control for this during analysis; expectation bias from the waitlist control group; lack of blinding and small sample size.  These limitations were also found in the studies analysed by Li et al. (2014).  Overall, the evidence suggests that CBT may be effective in treating IBS symptoms.  However, the diversity and heterogeneity of current CBT studies does not lend strong support for recommendation of this treatment modality.  Mindfulness-based therapies may also be effective in IBS management.  Zernicke et al. (2013) conducted a randomized wait-list control trial on the effect of mindfulness-based stress reduction (MBSR) on IBS symptoms.  MBSR practices are hypothesized to help patients with IBS better cope with their disorder via monitoring and regulating their arousal to their symptoms, leading to better problem evaluation and emotional stability. Participants were given eight weekly MSBR sessions, which were followed up six months post intervention.  The authors reported a decrease in IBS-SSS at eight weeks and at follow-up.  The wait-list group only had improvement at the six-month follow-up and this did not reach statistical significance (Zernicke et al., 2013). Limitations of this study include unclear adherence, lack of blinding, and small sample size.  There was also a high rate of attrition, although this was accounted for statistically. The remaining participants may have been more interested in trying psychological therapies, thereby decreasing the generalizability of this intervention.  Aucoin et al. (2014) report similar challenges in the current literature on mindfulness-based therapies.  Although the results show that this style of therapy may be effective in treating IBS, the overall weaknesses and deficiencies found in the research does not allow for conclusive recommendation for use in practice (Aucoin et al., 2014). NON-PHARMACOLOGICAL INTERVENTIONS  19 Both CBT and mindfulness-based therapies are potential adjunct modalities to other IBS treatments and may be useful in those who are experiencing psychological distress in particular, or who are open to trying psychological therapies.  Major limitations of these therapies in general are the cost, time requirements, effort and availability of appropriate therapists (Labus et al., 2012).   Overall, all the above-mentioned non-pharmacological therapies have a place in developing a management plan for IBS.  However, not all interventions are useful or equally effective for all patients, with some interventions having stronger evidence for use than others.  Current consensus is that dietary interventions and lifestyle modifications are first-line treatments for IBS.  Regular physical activity and traditional dietary advice of regular meal patterns, avoidance of large meals, reduction of caffeine, spicy foods, alcohol, fats, gas-inducing foods and insoluble fiber are the first steps in managing IBS (Bohn et al., 2015; Cozma-Petrut et al., 2017).  Although these interventions are suggested as first-line, the strength of the evidence for these suggestions is widely varied (McKenzie et al., 2016; Ford et al., 2014).  The evidence for increased physical activity as an IBS treatment is not strong; however, exercise should be a part of any IBS management plan as some benefits have been demonstrated and overall health is improved (Daley et al., 2008; Johannesson et al., 2010).  Soluble fiber supplementation has some use in IBS management and has the best evidence among fibers tested (Brandt et al., 2009; El-Salhy et al., 2017).  The low-FODMAP diet is suggested as second-line therapy if traditional IBS interventions have failed (Cozma-Petrut, 2017; McKenzie et al., 2016).   Evidence for efficacy of the low-FODMAP diet in treatment of IBS is becoming increasingly robust (Altobelli et al., 2017; Marsh et al., 2016); however, the evidence has shown that neither the low-FODMAP diet nor traditional dietary advice is better than the other in NON-PHARMACOLOGICAL INTERVENTIONS  20 reducing IBS symptoms (Altobelli et al., Marsh, 2016).  Traditional dietary interventions are simple to follow and should be a first step in IBS management plans. The low-FODMAP diet needs to be monitored by a health care professional and the learning curve is steeper for both patients and care providers.  For these reasons, this diet should be used as a second-line therapy or in combination with traditional dietary advice (Cozma-Petrut, 2017; Barrett, 2013).  Psychological therapies can also be used in an IBS treatment plan. The evidence for use of psychological therapies, such as CBT or mindfulness-based therapies, in IBS is not strong but may be beneficial in those open to psychological therapies. These interventions should be reserved for those who are resistant to other treatments, both pharmacological and non-pharmacological or those who are seeking this type of treatment (McKenzie et al., 2016). Project Description The literature review allowed for in-depth exploration of non-pharmacological treatment and management modalities for IBS.  Based on the current evidence for treating IBS, a printable double sided one-page primer on the non-pharmacological treatment modalities for IBS was created (see Appendix).  The evidenced-based interventions included on the primer are general or traditional IBS dietary advice, the low-FODMAP diet, fiber supplementation, exercise and psychological therapies.  The majority of the primer focuses on dietary interventions using traditional IBS advice and the low-FODMAP diet.  General or traditional IBS dietary interventions are presented as the first approach used in the management of IBS, with the low-FODMAP diet as a secondary approach if initial interventions fail to adequately treat symptoms.  Also noted are the potential benefits of combining the traditional guidelines with elements from the low-FOMAP diet to enhance symptom relief.  NON-PHARMACOLOGICAL INTERVENTIONS  21 Fiber supplementation is presented as a potential addition to help treat symptoms.  Specific fiber types and dose guidelines are provided.  Finally, the other non-pharmacological, non-dietary interventions are presented.  Increased physical activity and psychological therapies are suggested as interventions to incorporate in addition to the dietary measures.  The primer addresses when these adjunct interventions would be best implemented.  The psychological therapies include CBT and mindfulness-based therapies.  Appropriate referrals to other healthcare providers—dieticians, psychologists or therapists—is indicated. References and resources for the NP and patient are given if additional information is desired by either.  A mobile app on the low-FODMAP diet is suggested as a tool for use by patients when implementing this diet.   Canadian national and local guidelines for management of IBS reflect those of the primer.  The Canadian Digestive Health Association (CDHA) (2018), The Canadian Society of Intestinal Research (2018) and HealthLink BC (2017) include management plans which cover all non-pharmacological treatments mentioned in the primer. The primer lists dietary interventions as first line, including traditional dietary advice and the low-FODMAP diet.  Fiber supplementation, exercise and stress reduction—which is addressed through psychotherapies on the primer—are also included as interventions.  However, the use of fiber in IBS management differs slightly among the HealthLink BC (2017) and Canadian Society of Intestinal Research (2018) guidelines.  Soluble fiber is recommended in both the primer and by CDHA (2018) with insoluble fiber to be avoided, whereas the other guidelines make no suggestion between the fiber types and suggest a general increase in dietary fiber (Canadian Society of Intestinal Research, 2018; HealthLink BC, 2017).  This suggestion to increase general fiber intake does not correspond with current research NON-PHARMACOLOGICAL INTERVENTIONS  22 as discussed in the literature review.  How to implement the one-page primer in practice will be discussed next.   Challenges, Strengths and Limitations I can foresee some potential challenges to implementing the primer.  For instance, where would the document be stored, how would NPs know this primer exists, and how would this information be disseminated?  In addition, how might the content of the primer be kept up to date?  Potential solutions could be to provide the primer to my current NP classmates and encourage them to distribute to other NPs for use and feedback.  A digital copy of the printable primer is the best method for easy distribution.  I could also contact the British Columbia Nurse Practitioner Association and ask if they would consider posting the primer in the clinical resources section or other appropriate section on their website.  In order to keep the information in the primer current and relevant possible solutions include, periodic review and alterations of the content or I could allow for open editing of the document by other NPs and primary care providers.   As there is a large amount of information on the treatment of IBS, a one-page primer will not provide all the details of each intervention, particularly the dietary interventions.  If the practitioner wants to provide a more detailed dietary management plan, more information will need to be researched and reviewed.  However, the intention of this project is to provide NPs with the main points of how to manage IBS non-pharmacologically, and to provide sources to more detailed information if needed.  The condensed and concise nature of the one-page primer could be seen as both a limitation and a strength of the project.  The most salient points of treatment, as well as the resources to expand on these points, are provided to facilitate development of a management plan.  In the fast-paced environment of most primary care clinics, NON-PHARMACOLOGICAL INTERVENTIONS  23 anything that will enhance workflow—like having the main points of treatment readily available in a one-page primer—is desirable.  The current evidence for non-pharmacological treatments of IBS provides no definitive rules for how to manage IBS.  No one intervention provides instant or full remission of symptoms.  The heterogeneous nature of IBS and lack of understanding of the etiology results in difficulties developing treatments.  While we do know that dietary and lifestyle interventions will have an effect on IBS symptoms, results will vary as individuals may respond differently to certain interventions.  The most promising interventions are related to diet changes, with the low-FODMAP diet potentially being the most effective. In my own practice I would not hesitate to suggest any of the non-pharmacological interventions included on the primer.  All of the interventions have a place in a management plan, with traditional and low-FODMAP dietary advice being the first choice, and adding fiber supplementation, exercise and psychotherapies as appropriate.  Impact on Practice Assessing the actual impact of this project on NP practice is beyond the scope of this culminating project.  However, potential impacts can be hypothesized.  IBS, as discussed previously, is a common condition that NPs would encounter in their practice.  Due to the heterogeneous nature of IBS, treatments are widely varied, and each patient may present with a unique combination of symptoms.  How to manage these patients may be challenging for the NP.  Popular interest in naturopathy and alternative medicine has grown, and many patients want more information on non-pharmacological treatments.  I have witnessed this surge in popularity in my own practice and personal experiences. Therefore, having an accessible one-page primer on the most salient evidence-based non-pharmacological treatment recommendations would be a NON-PHARMACOLOGICAL INTERVENTIONS  24 helpful launching point in developing a management plan.  I surmise that the primer would enhance NP practice by providing guidance and resources for managing patients with IBS.  The primer would allow NPs to use their time more efficiently in creating a management plan, rather than having to research evidence-based treatment recommendations while a patient is waiting.  The main information and resources will be easily accessible and ready to put into a management plan.  Hopefully this primer facilitates an efficient and informative appointment for both patient and provider.  Patients will also benefit from the evidence-based primer, as it will be referred to by their primary care provider when developing a management plan.  Conclusion IBS is a chronic, relapsing and remitting functional gastrointestinal disorder characterized by symptoms of abdominal pain, bloating, gas, constipation and diarrhea.  IBS prevalence is estimated at 15% in the world population and 12% of the Canadian population (Marsh et al., 2016; Thompson et al., 2002).  IBS sufferers experience a decreased quality of life and utilize a disproportionate amount of healthcare resources (Brandt et al., 2009; El-Salhy et al., 2012).  The mechanisms behind IBS are not fully understood and are thought to involve gastrointestinal motility changes, visceral hypersensitivity, changes in gut microbiota and inflammation (Altobelli et al., 2017; Marsh et al., 2016).  Due to the heterogeneous nature of IBS, treatments are varied.  Both pharmacological and non-pharmacological interventions are utilized, with non-pharmacological dietary and lifestyle changes being the first-line approach.  Since pharmacological interventions only target specific symptoms, they are not effective in managing the variety of symptoms that affect patients with IBS.   Up to 70% of patients with IBS associated food with development and worsening of symptoms (Altobelli et al., 2017).  Much research has been done on dietary interventions in IBS NON-PHARMACOLOGICAL INTERVENTIONS  25 (Altobelli et al., 2017; Bohn et al., 2015; El-Salhy et al., 2017; Eswaran et al., 2016; Halmos et al., 2014; Harvie et al, 2017; Marsh et al., 2016; Mazzawi et al., 2013; McIntosh et al, 2017; Moayyedi et al., 2014; Nagarajan et al., 2015; Staudacher et al., 2011).  Fiber supplementation, regular meal patterns and avoidance of certain food items have been the traditional dietary guidelines for IBS (Cozma-Petrut et al., 2017; NICE, 2008).  A novel dietary approach, the low-FODMAP diet, has piqued the interest of researchers due to the growing evidence for the efficacy of this diet in treating IBS symptoms (Altobelli et al., 2017; Marsh et al., 2016).  Current research has demonstrated the efficacy of the low-FODMAP diet in treating IBS with reports of significant improvements in symptom severity and quality of life (Altobelli et al., 2017; Marsh et al., 2016).  However, significant improvements were also observed using traditional IBS dietary interventions, so the superiority of the low-FODMAP diet to traditional interventions is not clear.   Fiber supplementation, a mainstay of IBS treatment, has been reviewed in recent years with the efficacy of fiber use being questioned. The consensus is that fiber supplementation can be used in treating IBS, but recommendation is weak (McKenzie et al., 2016; Ford et al., 2014).  Other suggested non-pharmacological methods include exercise and psychological therapies (i.e. CBT and mindfulness-based therapies).  Although evidence for both these treatment options is weak (Aucoin et al., 2014; Li et al., 2014), they may still be useful as an adjunct to other interventions.    Considering the amount of information regarding IBS treatment, primary care practitioners—including the NP—may be at a loss when developing a management plan for patients with IBS. This project aims to aid both the experienced and novice NP in managing patients with IBS by creating a one-page primer on the non-pharmacological treatments for IBS NON-PHARMACOLOGICAL INTERVENTIONS  26 (see Appendix).  I hope this clinical information sheet will be a resource for all NPs as they continue to stay current and acquire knowledge throughout their careers. There are limitations to this project.  The nature of the primer only allows for a small amount of information on the non-pharmacological interventions for IBS and is by no means exhaustive.  Also, the impact of the primer on NP practice cannot be demonstrated with certainty, as this goes beyond the scope of this project.  I can only hypothesize as to the potential impacts and success of the project in practice.  Going forward, more research is needed to solidify the evidence for the current recommended dietary and other non-pharmacological treatment modalities.  In particular, the long-term effects of specialized diets, such as the low-FODMAP diet.  Diet is such a fundamental component of IBS and more dietary education in nursing and medical education is recommended.  Dietary advice is often sought in primary care (Adams et al., 2010) and not all communities may have access to a dietician.  IBS is a complicated and multifactorial disorder and treatment approaches are dynamic.  As with many other disease states, each patient must be assessed and an individual management plan must be developed. The availability of a primer on non-pharmacological treatments for IBS can provide guidance on how best to share complex information in a succinct and easily digestible manner.  The primer will help streamline the NP’s work in ensuring best care and outcomes for patients.  Access to a summary of evidence-based IBS treatment recommendations will help novice and expert NPs alike navigate the ever-changing landscape of IBS treatment.      NON-PHARMACOLOGICAL INTERVENTIONS  27 References Adams, K. M., Kohlmeier, M., Powell, M., & Zeisel, S. H. (2010). Nutrition in Medicine: Nutrition Education for Medical Students and Residents. Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition, 25(5), 471–480. http://doi.org/10.1177/0884533610379606 Altobelli, E., Del Negro, V., Angeletti, P., & Latella, G. (2017). Low-FODMAP diet improves irritable bowel syndrome symptoms: A meta-analysis. Nutrients, 9(9), 940. https://doi.org/10.3390/nu9090940 Aucoin, M., Lalonde-Parsi, M., & Cooley, K. (2014). Mindfulness-based therapies in the  treatment of functional gastrointestinal disorders: A meta-analysis. Evidence-Based Complementary and Alternative Medicine, 2014. doi:10.1155/2014/140724 Barrett, J. S. (2013). Extending our knowledge of fermentable, short-chain carbohydrates for managing gastrointestinal symptoms. Nutrition in Clinical Practice, 28(3), 300-306. https://doi.org/10.1177/0884533613485790 Brandt, L. J., Chey, W. D., Foxx-Orenstein, A. E., Schiller, L. R., Schoenfeld, P. S., Spiegel, B.  M., . . . American College of Gastroenterology Task Force on Irritable Bowel Syndrome. (2009). An evidence-based position statement on the management of irritable bowel syndrome. American Journal of Gastroenterology, 104(Suppl 1), S1-S35. doi:10.1038/ajg.2008.122 British Columbia Nurse Practitioner Association, 2018. NPs in BC. Retrieved from https://bcnpa.org/npsinbc/ Böhn, L., Störsrud, S., Liljebo, T., Collin, L., Lindfors, P., Törnblom, H., & Simrén, M. (2015).  NON-PHARMACOLOGICAL INTERVENTIONS  28 Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: A randomized controlled trial. Gastroenterology, 149(6), 1399–1407. https://doi.org/10.1053/j.gastro.2015.07.054 Canadian Digestive Health Association (2009). Establishing digestive health as a priority  for Canadians: The Canadian Digestive Health Foundation national digestive disorders prevalence & impact study report. Retrieved from http://cdhf.ca/bank/document_en/25 establishing-digestive-health-as-a-priority-for-canadians.pdf#zoom=100 Canadian Digestive Health Association (2018). Understanding irritable bowel syndrome (IBS).  Retrieved from http://cdhf.ca/bank/document_en/15understanding-irritable-bowel-syndrome-ibs-.pdf#zoom=100 Canadian Society of Intestinal Research (2018). Irritable Bowel Syndrome (IBS). Retrieved  from https://www.badgut.org/information-centre/a-z-digestive-topics/ibs/ College of Registered Nurses of British Columbia, 2018. Nurse Practitioner. Retrieved from  https://www.crnbc.ca/WhatNursesDo/TypesOfNurses/Pages/NursePractitioner.aspx Cozma-Petrut, A., Loghin, F., Miere, D., & Dumitrascu, D. L. (2017). Diet in irritable bowel  syndrome: What to recommend, not what to forbid patients! World Journal of Gastroenterology, 23(21), 3771–3783. https://doi.org/10.3748/wjg.v23.i21.3771 Daley, A., Grimmett, C., Roberts, L., Wilson, S., Fatek, M., Roalfe, A., & Singh, S. (2008). The  effects of exercise upon symptoms and quality of life in patients diagnosed with irritable bowel syndrome: A randomised controlled trial. International Journal of Sports Medicine, 29(9), 778-782. doi:10.1055/s-2008-1038600 Drossman, D. A., Patrick, D. L., Whitehead, W. E., Toner, B. B., Diamant, N. E., Hu, Y., . . .  NON-PHARMACOLOGICAL INTERVENTIONS  29 Bangdiwala, S. I. (2000). Further validation of the IBS-QOL: A disease-specific quality-of-life questionnaire. The American Journal of Gastroenterology, 95(4), 999-1007. doi:10.1016/S0002-9270(00)00733-4 El-Salhy, M., Østgaard, H., Gundersen, D., Hatlebakk, J. G., & Hausken, T. (2012). The role of  diet in the pathogenesis and management of irritable bowel syndrome (review). International Journal of Molecular Medicine, 29(5), 723–731. doi: 10.3892/ijmm.2012.926 El-Salhy, M., Ystad, S.O., Mazzawi, T., & Gundersen, D. (2017). Dietary fiber in irritable bowel  syndrome (Review). International Journal of Molecular Medicine, 40(3), 607-613. https://doi.org/10.3892/ijmm.2017.3072 Eswaran, S. L., Chey, W. D., Han-Markey, T., Ball, S., & Jackson, K. (2016). A randomized  controlled trial comparing the low FODMAP diet vs. modified NICE guidelines in US adults with IBS-D. The American Journal of Gastroenterology, 111(12), 1824-1832. doi:10.1038/ajg.2016.434 Ford, A. C., Moayyedi, P., Lacy, B. E., Lembo, A. J., Saito, Y. A., Schiller, L. R., . . . Task Force  on the Management of Functional Bowel Disorders. (2014). American college of gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. The American Journal of Gastroenterology, 109 (Suppl 1), S2-S26. doi:10.1038/ajg.2014.187 Francis, C.Y., Morris, J., & Whorwell, P. J. (1997). The irritable bowel severity  scoring system: A simple method of monitoring irritable bowel syndrome and its progress. Alimentary Pharmacology & Therapeutics, 11(2), 395-402. doi:10.1046/j.1365-2036.1997.142318000.x NON-PHARMACOLOGICAL INTERVENTIONS  30 Gibson, P. R. (2017) History of the low FODMAP diet. Journal of Gastroenterology and  Hepatology, 32(Suppl. 1), 5–7. doi: 10.1111/jgh.13685. Halmos, E. P., Power, V. A., Shepherd, S. J., Gibson, P. R., & Muir, J. G. (2017). A diet low in  FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology, 146(1), 67–75. https://doi.org/10.1053/j.gastro.2013.09.046 Harvie, R. M., Chisholm, A. W., Bisanz, J. E., Burton, J. P., Herbison, P., Schultz, K., & Schultz,  M. (2017). Long-term irritable bowel syndrome symptom control with reintroduction of selected FODMAPs. World Journal of Gastroenterology, 23(25), 4632–4643. https://doi.org/10.3748/wjg.v23.i25.4632 HealthLink BC (2017). Irritable bowel syndrome (IBS). Retrieved from https://www.healthlink bc.ca/health-topics/hw117851#hw117980 Hill, L. A., & Sawatzky, J. V. (2011). Transitioning into the nurse practitioner role through  mentorship. Journal of Professional Nursing, 27(3), 161-167. doi:10.1016/j.profnurs.2011.02.004 Johannesson, E., Simrén, M., Strid, H., Bajor, A., & Sadik, R. (2011). Physical activity improves symptoms in irritable bowel syndrome: A randomized controlled trial. The American Journal of Gastroenterology, 106(5), 915–922. doi: 10.1038/ajg.2010.480 Kris-Etherton, P. M., Akabas, S. R., Bales, C. W., Bistrian, B., Braun, L., Edwards, M. S., . . . Van Horn, L. (2014). The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. The American Journal of Clinical Nutrition, 99(5 Suppl), 1153S-1166S. doi:10.3945/ajcn.113.073502 NON-PHARMACOLOGICAL INTERVENTIONS  31 Labus, J., Gupta, A., Gill, H. K., Posserud, I., Mayer, M., Raeen, H., … Mayer, E. A. (2013). Randomised clinical trial: Symptoms of the irritable bowel syndrome are improved by a psycho-education group intervention. Alimentary Pharmacology and Therapeutics, 37(3), 304–315. https://doi.org/10.1111/apt.12171 Li, L., Xiong, L., Zhang, S., Yu, Q., & Chen, M. (2014). Cognitive-behavioral therapy for  irritable bowel syndrome: A meta-analysis. Journal of Psychosomatic Research, 77(1), 1-12. doi:10.1016/j.jpsychores.2014.03.006 Mazzawi, T., Hausken, T., Gunderson, D., & El-Salhy, M. (2013). Effects of dietary guidance on the symptoms, quality of life and habitual dietary intake of patients with irritable bowel syndrome. Molecular Medicine Reports, 8(3), 845–852. doi: 10.3892/mmr.2013.1565 Marsh, A., Eslick, E. M., & Eslick, G. D. (2016;2015;). Does a diet low in FODMAPs reduce  symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. European Journal of Nutrition, 55(3), 897-906. doi:10.1007/s00394-015-0922-1 Mcintosh, K., Reed, D. E., Schneider, T., Dang, F., Keshteli, A. H., Palma, G. De, … Vanner, S.  (2017). FODMAPs alter symptoms and the metabolome of patients with IBS: a randomised controlled trial. Gut, 66(7), 1241–1251. https://doi.org/10.1136/gutjnl-2015-311339 McKenzie, Y. A., Bowyer, R. K., Leach, H., Gulia, P., Horobin, J., O'Sullivan, N. A., . . . IBS  Dietetic Guideline Review Group on behalf of Gastroenterology Specialist Group of the British Dietetic Association. (2016). British dietetic association systematic review and evidence‐based practice guidelines for the dietary management of irritable bowel NON-PHARMACOLOGICAL INTERVENTIONS  32 syndrome in adults (2016 update). Journal of Human Nutrition and Dietetics, 29(5), 549-575. doi:10.1111/jhn.12385 Moayyedi, P., Quigley, E. M. M., Lacy, B. E., Lembo, A. J., Saito, Y. A., Schiller, L. R., . . .  Ford, A. C. (2014). The effect of fiber supplementation on irritable bowel syndrome: A systematic review and meta-analysis. The American Journal of Gastroenterology, 109(9), 1367-1374. doi:10.1038/ajg.2014.195  Nagarajan, N., Morden, A., Bischof, D., King, E. A., Kosztowski, M., Wick, E. C., & Stein, E.  M. (2015). The role of fiber supplementation in the treatment of irritable bowel syndrome: A systematic review and meta-analysis. European Journal of Gastroenterology & Hepatology, 27(9), 1002-1010. doi:10.1097/MEG.0000000000000425  National Institute for Health and Clinical Excellence (2017). Irritable bowel syndrome in adults:  diagnosis and management. Retrieved November 19, 2017 from https://www.nice.org.uk/guidance/cg61/chapter/1-Recommendations.  Staudacher, H. M., Whelan, K., Irving, P. M., & Lomer, M. C. E. (2011). Comparison of  symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome, Journal of Human Nutrition and Dietetics 24(5)487–495. doi: 10.1111/j.1365-277X.2011.01162.x Thompson, W. G., Irvine, E. J., Pare, P., Ferrazzi, S., & Rance, L. (2002). Functional  Gastrointestinal Disorders in Canada: First Population-Based Survey Using Rome II Criteria with Suggestions for Improving the Questionnaire. Digestive Diseases and Sciences, 47(1), 225–235. https://doi.org/10.1023/A:1013208713670 Wald, A. (2016). Treatment of irritable bowel syndrome in adults. In S. Grover (Ed.), UpToDate.  NON-PHARMACOLOGICAL INTERVENTIONS  33 Retrieved August 29, 2017, from https://www.uptodate.com/contents/treatment-of- irritable-bowel-syndrome-in-adults?source=search_result&search=IBS&selected Title=1~150 Zernicke, K. A., Campbell, T. S., Blustein, P. K., Fung, T. S., Johnson, J. A., Bacon, S. L., &  Carlson, L. E. (2013). Mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: A randomized wait-list controlled trial. International Journal of Behavioral Medicine, 20(3), 385-396. doi:10.1007/s12529-012-9241-6                             NON-PHARMACOLOGICAL INTERVENTIONS  34 Appendix: One Page Primer   NON-PHARMACOLOGICAL MANAGEMENT OF IRRITABLE BOWEL SYNDROME (IBS)  1st Line approaches Dietary and Lifestyle Modifications General Advice  • Regular meal patterns • Avoid large meals • Reduce fat intake • No insoluble fibre (e.g. wheat bran)  • Decrease caffeine, insoluble fiber, spicy food, fat, alcohol consumption  • Gas-producing foods (e.g. onions, beans, legumes, cabbage) • Adequate fluid intake May reintroduce food items as tolerated once symptoms stabilized *Trial lactose-free diet in patients who experience no change in symptoms after reducing gas producing foods  Physical Activity • Improves IBS symptoms and overall health • Advise moderate physical activity, may increase activity as tolerated  Fiber supplementation • Soluble fiber (e.g. psyllium) may benefit some patients with IBS, particularly those with IBS-C (constipation predominant) subtype  • Start slowly and gradually increase upwards; doses should be determined by patient tolerance. Total daily fiber intake goals: 25g for women and 38g for men. https://www.canada.ca/en/health-canada/services/nutrients/fibre.html • Oats and rice bran also tolerated • Avoid insoluble fiber (e.g. wheat bran)  If general advice not effective,  2nd line approach Low-FODMAP Diet • a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) these carbohydrates are poorly digested and absorbed, osmotically active and fermentable causing IBS symptoms Examples of FODMAPs Please see http://cdhf.ca/bank/document_en/32understanding-fodmaps-.pdf#zoom=100  Timeline: Trial of 4 weeks then reassess and begin gradual reintroduction of FODMAPs to levels tolerable to patient. Low-FODMAP diet is a strict exclusion diet and is not meant for long-term use NON-PHARMACOLOGICAL INTERVENTIONS  35  Referral:  Dietician for close monitoring and development of individualized diet plan and to ensure nutritional adequacy of diet Resources: Monash University low-FODMAP App https://www.monashfodmap.com/ Canadian Digestive Health Association http://cdhf.ca/en/  *Aspects of both 1st line approaches and the low-FODMAP diet may be combined for enhanced symptom relief*  Psychological Therapies • Cognitive behavioural therapies and mindfulness-based therapies may be useful in those patients with refractory symptoms  • Useful in patients seeking psychological therapies and/or open to participating in these therapies • Referral to psychologists, psychiatrists, therapists   References • Cozma-Petrut, A., Loghin, F., Miere, D., & Dumitrascu, D. L. (2017). Diet in irritable bowel  syndrome: What to recommend, not what to forbid patients! World Journal of Gastroenterology, 23(21), 3771–3783.  • Barrett, J. S. (2013). Extending our knowledge of fermentable, short-chain carbohydrates for managing gastrointestinal symptoms. Nutrition in Clinical Practice, 28(3), 300-306.  • Wald, A. (2016). Treatment of irritable bowel syndrome in adults. In S. Grover (Ed.), UpToDate.  https://www.uptodate.com/contents/treatment-of-irritable-bowel-syndrome-in-adults?source= search_result&search=IBS&selectedTitle=1~150 

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