DR. PHILIP K. BLUSTEIN M.D. F.R.C.P.(C) TH ST. NW. CALGARY AB T2N2A1 STRATEGY TO MANAGE IRRITABLE BOWEL SYNDROME

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1 DR. PHILIP K. BLUSTEIN M.D. F.R.C.P.(C) TH ST. NW. CALGARY AB T2N2A1 PHONE (403) FAX (403) STRATEGY TO MANAGE IRRITABLE BOWEL SYNDROME IRRITABLE BOWEL SYNDROME (IBS): This is a very common problem of the colon or large bowel that may also overlap with problems in other parts of the gastrointestinal tract such as the esophagus or food pipe, stomach and small bowel. Individuals often experience an irregular bowel pattern with either diarrhea, constipation or alternating diarrhea and constipation. There may be associated pain, gas and bloating. This a problem of function, in other words how the bowel works. If one looks at the colon with a scope, x- rays or does blood tests everything is normal. The problem is motility or how the bowel works or squeezes. Normally the colon squeezes in a peristaltic fashion. That means it squeezes in an orderly fashion with a squeeze moving from one end of the colon to the next. In the irritable bowel syndrome the squeezes may not be normal. They may be too hard, too soft or not in an orderly fashion. The other problem is that there is a difference in sensitivity. If a balloon is blown up in someone with the irritable bowel they may feel pain when the balloon is small while another individual may feel pain when the balloon is a lot bigger. This reflects a problem in how the brain interprets different stimuli that come to the brain. Our brains work pretty effectively in screening all the sensations that come in and ignoring what is not important. Unfortunately in patients with the irritable bowel syndrome the brain s filters are not as good and one feels sensations as painful where someone else would not even know there is a sensation. There may also be a change in the complicated bacterial makeup of our bowels that can influence gut motility and sensitivity. The irritable bowel can be diagnosed just by the symptoms alone. Further investigations with lab tests, scope or x- ray may not be necessary. The IBS can be present for a long time. It can fluctuate and be worse at some times and better at other times. Some patients are worried that they have their problem for years. This is actually REASSURING. If something bad was going on such as cancer one would have died years ago!

2 You are not alone. 1 in 4 people may experience symptoms of the irritable bowel. That is a lot of people! The irritable bowel can certainly interfere with how you enjoy life. The good news is that this does not progress to anything serious such as cancer. There are strategies that can be helpful! The symptoms may never go away completely but it is possible to feel better. Please continue to read further so that you can hopefully learn what you can do to help yourself. BOWEL BOWEL stands for the strategy that one can use to deal with the IBS. B - Before O - Observe W - Way the bowel works E - Eat L - Lifestyle In following this program it is always important to do one thing at a time. If you do more than one thing and you get better or worse you won t know what it was that helped or not. BEFORE: It is rare for the IBS to start with out a reason. There can be multiple factors that can lead to the IBS. In identifying what may have caused your IBS this may help you understand how you got this problem and perhaps accept and deal with it easier. I would like you to search and see if any of these factors happened before your symptoms started. The IBS often can follow an INFECTION such as food poisoning, traveller s diarrhea or infectious diarrhea. The bug that caused the initial infection disappears but the infection can disturb how the bowel works. Individuals can be left with the IBS that can last for a long time. Sometimes it can slowly improve over time. Don t worry that the parasite or bug is still inside of you. This would be a very rare occurrence. The bug is gone but the bowel unfortunately just doesn t work as well. Did you have an infection before your problem started? New MEDICATIONS can affect the way the bowel works. This can also include vitamins and nutritional supplements. Antibiotics in particular can sometimes cause

3 an infection with a bacteria called Clostridium difficile that can then lead to the IBS. Was there any new medication that you started before your symptoms started? If so discuss with your family doctor about an alternate choice. Certain SURGERIES can also influence how your bowel works. In particular a CHOLECYSTECTOMY or gallbladder surgery can lead to diarrhea as the bile salts that are normally stored in the gallbladder get dumped into the bowel and lead to diarrhea. If you had a cholecystectomy before your problem started discuss with your family doctor about using a medication that can bind the bile and control the diarrhea. Was there surgery before your problem started? Changes in DIET can influence the way the bowel works. If someone goes on a reducing diet to lose weight they may develop constipation as they are consuming less calories. If they go on a high fibre diet this can sometimes create gas, bloating and loose stools. Consuming more milk could unmask lactose intolerance. Everyone is different but the common foods that can be a problem include caffeine, lactose, gluten, fructose, beans and certain vegetables. This will be discussed further later. Was there any change in your diet prior to the onset of your problem? STRESS is a definite factor that can lead to or aggravate an already existing problem. What we experience in our mind is definitely reflected in our bodies. Some people with stress may have headaches, jaw pain, their shoulders jump up to their ears, they may hold their breath, there can be abdominal pain, butterflies in their bellies, diarrhea or constipation. Patients come to see a gastroenterologist because they may have abdominal pain, diarrhea or constipation. However one of the commonest reasons they are experiencing their physical problem is that there is underlying stress! Was there any significant stress that occurred before your problem started? Identifying the factor that may have led to your problem can be helpful in understanding what is happening. This makes it less frightening! SUMMARY: Look to see if there was something different that could have caused your problem: *INFECTION *NEW MEDICATION *SURGERY *DIET CHANGE *STRESS OBSERVE: If your symptoms wax and wane there may be something that is acting to aggravate your problem. Keeping a DIARY can be very helpful in trying to identify what is making your problem worse.

4 I would suggest that you keep a diary for 2-4 weeks. First you want to identify what really is happening with your symptoms, what are they really like, how often due they come. Write down on a daily basis: *How often you have a bowel movement? *What is the bowel movement like ie. hard, soft, diarrhea? *Is there a lot of gas or bloating? *Is there pain, where is it located primarily, where does it spread to? *Are you passing mucus from your bowel? *Is there any bleeding from your bowel? Next you are interested in identifying if there is anything specific that makes your problem worse. You are keen to look for such factors as: *What are you eating the day of your problem? *What are you doing physically? *Was there any more stress? *Do your symptoms get worse at the time of your periods? It is very common to see a relationship between one s periods and bowel function that can cause diarrhea or constipation. The hormones can affect bowel function. Hopefully in keeping an accurate DIARY you may be able to identify something that aggravates your problem. This will give you a clue to help you in dealing with the problem. SUMMARY: Keep a DIARY for 2-4 weeks to: *CHART YOUR SYMPTOMS *IDENTIFY AN AGGRAVATING FACTOR On the Canadian Digestive Health Foundation website there is a free app that will allow you to track the factors mentioned above. It is called gi body guard. WAY THE BOWELS WORK: Once you have finished keeping your diary you can proceed to treat your irregular bowel pattern. Is it normal to have a bowel movement every day and if I don t is that a problem? Studies have shown that a normal bowel frequency can vary from 3 bowel movements a day to 3 bowel movements a week. However there are people who have one bowel movement a week and don t have a problem and some people have one bowel movement a day and complain. If you are ok with your bowel pattern and

5 it is not causing a problem then that is perfectly fine! You don t need to have a bowel movement every day! You are not more likely to have bowel cancer if you are constipated. The constipated stool is not going to create toxins that can harm you. In the IBS one can have predominant constipation, predominant diarrhea or alternating diarrhea and constipation. Let us first look at constipation predominant IBS. CONSTIPATION: Symptoms of constipation can include: *Infrequent bowel movements (<3 bowel movements a week) *Straining to pass a stool *Passing hard stools *Sensation of incomplete emptying *Sense of blockage in the opening or lower bowel When treating constipation one wants to start initially with dietary steps and then progressively take a more potent laxative. It is ok to take laxatives on a long term basis provided you have started with the first step and then progress. If one is suffering with significant constipation that is causing major problems and interfering with your life then it is better and safe to take a laxative to move the bowel. One doesn t have to worry that one will become dependent on the laxative. One could try the following strategies as outlined starting with number one and moving to number 5. Try each step consistently for 2 weeks and then move on to the next if it doesn t help. The following laxatives have been demonstrated to be effective in clinical studies. However other laxatives may also be of value. You can ask your pharmacist to help find the laxatives listed below. 1) DIET: *HEALTHY DIET: Life is so hectic! How many of us truly eat HEALTHY? Are you buying processed and prepared meals? Do you eat out a lot? How much junk food do you have? The first step in treating the IBS is to start eating healthy. The CANADA FOOD GUIDE is an excellent way to get your diet back on track. The basic plan is that there are four food groups and ideally we should have a certain amount of servings from each group each day. A healthier diet will help your IBS.

6 Depending on your age and sex one should aim for 7-10 servings of vegetables and fruits, 6-8 grain products, 2-3 milk and alternatives and 2-3 meat and alternatives a day. The Canada Food Guide will help point out what to eat. It is also important to know what to avoid. One should try and stay away from processed food, fast foods, ready- to- eat foods and foods and liquids high in calories, fat, sugar or salt. One needs to plan to be able to start making more of your meals at home using fresh products. Click on the link below to learn about the Canada Food Guide. How can you improve your diet to help your irritable bowel? sc.gc.ca/fn- an/food- guide- aliment/index- eng.php *HIGH FIBRE DIET: Part of eating a healthy diet is getting enough fibre. This is important if one is experience constipation of the IBS. Fibre comes from plants and is the indigestible portion of food. The goal is to have grams of fibre a day. Many people only take grams of fibre a day that is inadequate for having a proper bowel movement. It is important when introducing fibre to do this gradually. If you introduce it too quickly this can lead to gas, bloating and discomfort. Seeing a dietician can be helpful for some people in better understanding what a high fibre diet is. Below is a listing of foods that are high in fibre. GRAINS: whole grain breads and cereals, wheat bran FRUITS: raspberries, blackberries, strawberries, raisin, prunes, pears, mangos, apples LEGUMES (BEANS): navy beans, split peas, pinto beans, lentils, black beans, lima beans, kidney beans, baked beans NUTS AND SEEDS: almonds, pistachios, pecans, peanuts, walnuts VEGETABLES: sweet potatoes, green peas, potatoes, spinach, broccoli All- Bran Buds 1/3 cup a day is an easy way to increase one s fibre intake. Look at these sites for more info concerning a healthy and high fibre diet. sc.gc.ca/fn- an/food- guide- aliment/index- eng.php

7 FLUID: When the digested food moves too slowly thru the colon water is increasingly removed from the stool. Therefore it is important to have 6-8 full glasses of liquid in a day. Liquids consist of water, juices, soups etc. Buy a 1 litre container and this will make it easier to see how much you are drinking. 2) BULKING AGENT: Psyllium increases the bulk of the stool by combining with water to help move it thru the intestines. One can choose psyllium husks or seeds. PSYLLIUM HUSKS: 2 teaspoons (5 grams) once a day increasing to 2 teaspoons (5 grams) twice a day if needed. Dissolve each dose in an 8 oz. glass of water. PSYLLIUM SEEDS: ½ teaspoon to one cup of water increasing to 2 teaspoons in two cups (8 oz.) glasses of water if needed. Psyllium can cause gas and bloating. Start low and build the dose as needed. Allow 2-3 days to see if there is an effect. Psyllium can reduce or delay the absorption of certain medications. Take psyllium 1 hour before or 2-4 hours after taking other medications. Psyllium absorbs fluid from the bowel. Therefore it is important that you take enough water to prevent any problems. Natural psyllium husks or seeds can be obtained in your grocery or health food store. METAMUCIL 1 serving a day (depending on the product use) is a bulking agent that contains psyllium seed husks. It comes as a powdered mixture, capsule or wafer. It is an effective bulking agent. CITRUCEL is an alternate bulking agent that contains methylcellulose. Try these options for 2 weeks to see if they work. 3) OSMOTIC LAXATIVE: When diet and bulking agents fail one moves to using an osmotic laxative. They work by drawing fluid into the bowel to help soften the stool. Try then for two weeks. Laxatives that contain PEG 3350 (POLYETHYLENE GLYCOL) are our first choice and have been demonstrated to be effective. They are taken initially at 17 grams or one capful once a day. They can be increased to a twice a day dose. Some commercial preparations include LAXADAY and RESTORALAX.

8 Some other non PEG osmotic laxatives include LACTULOSE or a magnesium containing laxative such as MILK OF MAGNESIA. 4) STIMULANT LAXATIVES: They work by stimulating or making the bowel work stronger. It normally causes a bowel movement within 6 to 12 hours. Therefore it is often taken at bedtime to promote a bowel movement in the morning. It is a strong laxative and is often used as an on needed basis rather than taken regularly. However there are some people who have significant constipation in spite of gentler laxatives and require a stimulant laxative on a regular basis. If you need this laxative regularly that is ok. Just check with your family doctor. Try them for 2 weeks to see if they work. Try BISACODYL LAXATIVE (DULCOLAX) 1-2 tablets a day initially. Some other stimulant laxatives include laxatives containing senna (SENOKOT, PRODIEM AND EX- LAX). 5) PROKINETICS: These are medications that stimulate the bowel to squeeze more effectively. They may be of value when over the counter laxatives are not working. PRUCALAPRIDE (RESOTRAN): This can be of value in difficult to treat constipation in woman. This requires a prescription from your doctor. LINACLOTIDE (CONSTELLA): This is a medication that works by increasing fluid in the gastrointestinal tract and helps treat constipation and abdominal pain of the IBS. This requires a prescription from your doctor. SUMMARY: To treat constipation start with diet and then every 2 weeks progress to more potent laxatives if needed. The order is: *HEALTHY AND HIGH FIBRE DIET (All- Bran Buds) *BULKING AGENTS CONTAINING PSYLLIUM(Metamucil) *OSMOTIC AGENT PEG 3350 (Laxaday, Restoralax) *STIMULANT AGENT (Bisacodyl, Senna) *PROKINETIC (Prucalapride, Linaclotide) OTHER LAXATIVES: LUBRICANT LAXATIVES: These laxatives make the stool greasy. They include MINERAL OIL or LANSOYL. STOOL SOFTENERS: They include a wetting agent that helps to make the stool softer. They include docusate sodium or COLACE.

9 ENEMAS AND SUPPOSITORIES: They stimulate the rectum to expel its contents. They can be helpful when there is a hard stool blocking the rectum. They are used on as an on needed basis. FLEET ENEMA and GLYCERINE SUPPOSITORIES are examples of these products. If one needs to take a laxative on a daily basis this is ok. It is better to take laxatives more consistently then swing back and forth from normal to constipation if this is occurring frequently. Otherwise if possible one should take the lowest dose of laxatives that is effective. Herbal laxatives often contain a stimulant laxative such as senna or bisacodyl. Again it is always better if one can start with diet and the less potent laxatives first. There is no value in going for a bowel cleanse. What is more important is what you do on a daily basis to keep your bowels moving such as diet and exercise. ALTERNATE TECHNIQUES FOR CONSTIPATION: There are some other non laxative techniques that may also be of value. They include: *ALLOW TIME: Don t rush to have a bowel movement. Set aside enough time. *SET A SCHEDULE: The normal time for the colon to be most active is upon awakening. Therefore it makes sense to take advantage of this timing. One should try and schedule the time to have a bowel movement in the morning. However if your bowel has a different rhythm then follow it. *MORNING MEAL: The bowel becomes active after a meal. The bowel is naturally most active in the morning. One can try and optimize this with the breakfast meal. First it is important to have a meal in the morning. A meal that also has a higher fat content is more stimulating. Caffeine and fibre also help to move the bowel. *RESPECT THE URGE: When you have an urge to have a bowel movement, follow the urge. If you put it off the urge may not come again for a while. *FOOTSTOOL: Using a footstool or a few books to put your feet on when sitting on the toilet can help change the angle your bowel works to make it easier to pass a bowel movement. You are trying to raise your feet.

10 *YOGA POSES FOR CONSTIPATION: TWIST: From a seated position extend your left leg so that it is straight on the floor. Then bend your right leg so the knee is coming to the chest. Then place the right foot to the outside of the left thigh. Turn to the right and look behind you. Grab the outside of the right bent knee with the left hand. The right arm is straight to the floor just behind your back. Breathe for 5-10 breaths in this position. Then change to the other side. Doing this practice in the morning before having a bowel movement may help. *AVOID PAINKILLERS: Painkillers such as codeine, oxycodone and morphine will constipate you. Avoid them if possible. *PROBIOTICS: Our intestine has a vast array of bacteria that in some circumstances lead to gastrointestinal problems. Probiotics are microorganisms that can potentially provide beneficial bowel effects. They are most developed from food sources. Recent studies have suggested that there may be a benefit in some symptoms of the irritable bowel syndrome. However not all probiotics have a similar benefit. It appears that the benefits are specific to certain strains. The problem is that there is no standardization between the probiotics. In other words it is difficult to compare one probiotic to another as they may contain totally different organisms. *ALIGN 1 CAPSULE a day (BIFIDOBACTERIUM INFANTIS) May decrease gas and bloating of the Irritable Bowel Syndrome. *ACTIVIA (BIFADOBACTERIUM LACTIS DN) May be of value in constipation dominant Irritable Bowel Syndrome. *VSL#3 May be helpful in patients who have inflammation of a pouch after surgery for ulcerative colitis. *TUZEN May relieve pain and bloating in the Irritable Bowel Syndrome. *FLORASTOR May help diarrhea. DIARRHEA: Let us now look at diarrhea predominant IBS. 1) If diarrhea is the main complaint and occurs intermittently then keeping a DIARY may help identify the offending food agent or stressful factor. 2) If the diarrhea occurs on a regular basis then initially the DIETARY ELIMINATION TRIALS as discussed in the next section can be very helpful. 3) If one is still having problems then a trial with a BULKING AGENT such as psyllium may be helpful. The bulking agents help hold water in the stool and add bulk to it. The bulkier stools may slow the bowel movements down. When one reads the label on bulking agents such as Metamucil it states that they are for constipation. However don t be confused. These products can be helpful in both diarrhea and constipation.

11 However if one is experiencing significant persistent or new onset diarrhea it is important to see one s doctor to ensure that there is no other major medical problem going on. Your doctor may recommend a medicine that slows diarrhea down such as Imodium or Lomotil which requires a prescription. One could use these antidiarrheal drugs on certain occasions when one wants to have more control such as going out for dinner, on a plane ride or a long car trip. Some individuals may need them on a more regular basis. EAT: Once you have finished treating your irregular bowel pattern you can explore the role that diet plays in your problem. Gas or air in the gastrointestinal tract can be a problem. This is caused by swallowing air or by the breakdown of certain foods by the bacteria in the colon. One can help decrease swallowed air by AVOIDING: *Drinking carbonated drinks *Using a straw *Eating fast *Smoking *Chewing gum *Sucking on a candy *Having poorly fitting dentures FOOD INTOLERANCES: Individuals with IBS do not digest their foods any different than people without IBS. What we eat plays a big role in causing bowel symptoms such as gas and bloating. However one has to recognize that what we are talking about mostly is FOOD INTOLERANCES. Food ALLERGIES in adults is rare. We certainly recognize that allergies can exist to shellfish and nuts. Food intolerances are due to the fact that the enzymes that help to digest the food in the small bowel may be lacking. Therefore more intact sugar molecules reach the large bowel or colon where the bacteria live. These bacteria now break down the undigested food and create a lot of gas that can lead to bloating and loose stools. There are some foods that we eat that don t have enzymes normally present in the small bowel to break them down. We recognize that IBS patients may have visceral hypersensitivity. This means they are more sensitive to whatever stimuli such as gas, bloating and bowel squeezing they may experience from their gut. If we can decrease the gas and bloating there will be less stimuli coming to our brains that can over respond. Allergy testing is not helpful in identifying the foods that can cause a problem.

12 You may have already identified certain foods that cause a problem when you kept your diary initially for one month. DIETARY ELIMINATON TRIALS: Following your attempts to deal with your constipation or diarrhea one can then proceed to DIETARY ELIMINATION TRIALS. This is a simple strategy to identify what foods one may be intolerant to. Every two weeks you would stop one food product completely. If you are better at the end of two weeks then this would indicate that the particular food is causing a problem. This may not be an all or none phenomena. In other words there may be a certain level of the food that one can tolerate. One would then reintroduce the food in a small amount and slowly increase it until you reach a level where you have a problem. One would then go on to the next food in the list. Below is a list of the common foods that one can be intolerant to. I would suggest that you eliminate one food from the list every 2 weeks to see if you can find a food that may be causing a problem. *DAIRY PRODUCTS (LACTOSE): Lactose is a sugar that is normally part of milk products. Some people may not have enough of the small bowel enzyme called lactase to break down the lactose. Avoid milk, buttermilk, condensed, evaporated and powdered milk, cheeses (especially soft and processed cheeses such as cottage, cream, mascarpone and ricotta), yogurt, ice cream, butter, cream, margarine with butter or milk *WHOLE GRAINS (GLUTEN): Gluten is a protein found in grains such as wheat, barley, rye and triticale. Avoid breads, beer, cakes, cereals, cookies, candies, crackers, pastas, french fries, processed luncheon meats, snack foods, sauces, salad dressings. *ARTIFICAL SWEETENERS (SORBITOL and MANNITOL): These are products that are used as low- calories sweeteners in sugar- free and diet products. They can include sorbitol, mannitol, xylitol, maltitol and isomalt. Avoid sugar free gum, mints and candies. This includes products containing Aspartame, Equal or Splenda. *FRUITS (FRUCTOSE): Fructose is a natural sugar found in most fruits, fruit juices, honey and some vegetables. However now a days a large portion of fructose comes from the processed sweetener high fructose corn syrup (HFCS) made from cornstarch. Avoid such fruits as apples, cherries, mangoes, watermelon and pears.

13 Avoid all types of fruit juices, dried fruit and canned fruits. Avoid asparagus, artichoke and sugar snap peas. Avoid honey and sweeteners high in high- fructose corn syrup and agave syrup. Avoid HFCS that can be present in baking and cooking ingredients, beverages, breads, breakfast cereals, cookies and cakes, dairy, vegetables, fruits, ice cream, jams, jellies, snacks. ONE NEEDS TO CHECK THE LABELS. *VEGETABLES: Brassica containing vegetables, onions and fructose containing vegetables can be a problem in causing gas. Avoid cabbage, cauliflower, broccoli, Brussels sprouts, asparagus, artichoke, sugar snaps, onions and garlic. *BEANS (LEGUMES): Legumes are plants that have the edible fruit in a shell or pod. They include lentils, peas, beans and peanuts. They contain a particular sugar (oligosaccharide) that the body cannot break down. Avoid navy beans, split peas, pinto beans, lentils, black beans, lima beans, kidney beans and baked beans. *CAFFEINE: Caffeine maybe an intestinal irritant and aggravate IBS symptoms. Avoid coffee, tea, chocolate. AGENTS TO PREVENT AND TREAT GAS: The following products may be of some value in preventing and treating gas. BEANO: Beano contains the enzyme alpha- galactosidase that breaks down the sugar oligosaccharide found in beans. They should not be used by diabetics as they can cause an increase in the blood sugar level. GAS- X: Gas X contains simethicone that helps to break up gas bubbles in the gut. LACTAID: Lactaid contains lactase enzyme supplements that help digest dairy (lactose) products.

14 FODMAP DIET: If the sequential dietary elimination trials are unsuccessful one can look into trying a FODMAP diet. A FODMAP diet has been demonstrated to be helpful in the IBS. FODMAP s are a group of carbohydrates or sugar molecules that are not well absorbed from the small bowel. They reach the colon or large bowel where the bacteria there break down the FODMAP s that can cause gas and bloating. FODMAP stands for: *FERMENTABLE carbohydrates *OLIGOSACCHARIDES such as certain vegetables, grains (galactans) and beans (fructans). Humans do not have the enzyme to break these products down. Therefore they are not absorbed in the small bowel and reach the colon intact. *DISACCHARIDES such as dairy products (lactose). When the enzyme lactase is missing to break down the two sugars of lactose then problems develop. *MONOSACCHARIDES such as fruits (fructose). 30% of people will not absorb excess fructose. *POLYOLS such as artificial sweeteners (sorbitol and mannitol). Only one third of what is consumed is absorbed. To learn more about the FODMAP diet visit the APP store to download the app: THE MONASH UNIVERSITY LOW FODMAP DIET. SUMMARY: Initially try 2 week SEQUENTIAL DIETARY ELIMINATION TRIALS: *DAIRY PRODUCTS (LACTOSE) *WHOLE GRAINS (GLUTEN) *ARTIFICIAL SWEETENERS (SORTBITOL AND MANNITOL) *FRUITS (FRUCTOSE) *VEGETABLES (BRASSICA) *BEANS (LEGUMES) *CAFFEINE If this fails try a FODMAP DIET

15 LIFESTYLE: There are definite lifestyle factors that influence the irritable bowel syndrome. 1) EXERCISE: Exercise has multiple positive effects. It can lower the risk or improve outcomes of stroke, diabetes, depression, obesity, colon cancer, cataracts, age related macular degeneration, osteoporosis and dementia. It also has positive gastrointestinal benefits. It can increase how the colon squeezes that helps moves gas along. Exercising with moderate intensity aerobic activity 5 days a week for a minimum of 30 minutes at a time is what one is aiming for. You don t have to do all 30 minutes at once. You can do three 10 minute blocks in a day. Simply walking at a fast pace for 30 minutes 5 days a week is an excellent start. Do you exercise consistently? Watch the youtube segment 23 ½ hours to learn more about the value of exercise. 2) SLEEP: Sleep is very important not only for our gastrointestinal health but our overall benefit. Individuals who are sleep deprived, having less than 6 hours of sleep a night, have an increased risk of obesity, diabetes, stroke, cardiac disease, memory loss, depression, flare of Crohn s disease, fatigue, colon cancer and polyps! Sleep allows our bodies and brain to regenerate and repair and do the necessary functions for better health. For individuals over 18 the approximate sleep requirements are 7-9 hours. However this can vary according to the needs of the individual. Are you getting enough sleep? 3) STRESS MANAGEMENT: STRESS is a definite factor that can lead to or aggravate an already existing problem. What we experience in our mind is definitely reflected in our bodies. Some people with stress may have headaches, jaw pain, their shoulders jump up to their ears, they may hold their breath, they sweat, their heart beats faster, there can be abdominal pain, butterflies in their bellies, diarrhea or constipation. How do you experience stress in your body when you are anxious? Patients come to see a gastroenterologist because they may have abdominal pain, diarrhea or constipation. However one of the commonest reasons they are experiencing their physical problem is that there is underlying stress! There is a recognized connection between our minds and our bodies. When we are psychologically relaxed our bodies are more relaxed. When we have more anxiety our bodies feel more tense. And the reverse happens in that the physical tension we have in our bodies can influence our psychological tension. Therefore in trying to

16 relax our mind and or body can have a direct beneficial effect on the symptoms of IBS. Not all patients with IBS have psychological issues. However we do recognize that some patients may have increased problems of anxiety and depression that can aggravate IBS. Some patients are hypervigilent. They pay very close attention to whatever they physically feel that leads to an exaggeration of that sensation and thinking the worse. Realizing that there is this connection of stress and body can be very helpful in understanding how your problem started and what makes it worse. Take a moment to examine if you have stress in your life and if it plays a role in aggravating your IBS symptoms. There are several techniques that deal with psychological issues that have been proven to benefit patients with IBS. They include: *COGNITIVE BEHAVIORAL THERAPY (CBT): One examines one s thoughts and then uses some strategies to change these distorted views. Free online course to learn CBT *HYPNOTHERAPY *RELAXATION TECHNIQUES: MEDITATION YOGA BREATHING FOR RELAXATION MBSR (Mindfulness Based Stress Reduction) This is a 6-8 week course that teaches people how to deal with stress in a nondrug fashion using mindfulness, meditation and body exercises. To learn more about effective relaxation techniques visit To join an MBSR course you have the following options in Calgary: *University of Calgary Continuing Education, Dr. Michael Speca Mindfulness Meditation *Shirley McMillan mcmillsj@telus.net *Doug Maclean doug@practicalwellbeing.ca

17 *Tom Baker Center for cancer patients and their family For psychological counseling: then search for Access Mental Health We all lead very busy lives and these important lifestyle issues are what we do when we have done everything else. The problem is we never get to them because we have run out of time. The real problem is that we are going to run out of time for living if we don t take the time to take care of ourselves. One needs to look at the day and start with making enough time for sleep, exercise and stress management. What time is left over is what we then do with all the rest of the stuff we do in a day. I hope this program will be helpful to you and give you the tools to deal with your IBS! GOOD LUCK. Dr. Phil Blustein To learn more about IBS visit the websites listed below: Canadian Digestive Health Foundation ibs.org

18 SUMMARY: BOWEL BEFORE: Look to see if there was something different that could have caused your problem: *INFECTION *NEW MEDICATION *SURGERY *DIET CHANGE *STRESS OBSERVE: Keep a DIARY for one month to: *CHART YOUR SYMPTOMS *IDENTIFY AN AGGRAVATING FACTOR WAY THE BOWELS WORK: To treat constipation start with diet and then every 2 weeks progress to more potent laxatives. The order is: *HEALTHY AND HIGH FIBRE DIET (All- Bran Buds) *BULKING AGENTS CONTAINING PSYLLIUM (Metamucil) *OSMOTIC AGENT PEG 3350 (Laxaday, Restoralax) *STIMULANT AGENT (Dulcolax, Senokot) *PROKINETIC (Resotran, Constella) EAT: Initially try 2 week SEQUENTIAL DIETARY ELIMINATION TRIALS: *DAIRY PRODUCTS (LACTOSE) *WHOLE GRAINS (GLUTEN) *ARTIFICIAL SWEETENERS (SORBITOL, MANNITOL) *FRUITS (FRUCTOSE) *VEGETABLES (BRASSICA) *BEANS (LEGUMES) *CAFFEINE If this fails try a FODMAP DIET LIFESTYLE: *EXERCISE (30 minutes 5 days a week) *SLEEP (7-9 hours) *STRESS MANAGEMENT (Cognitive Behavioral Therapy Hypnotherapy Relaxation techniques MBSR)

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