Six Things That Might Help Your IBS

Irritable Bowel Syndrome is a common disorder, and causes a lot of grief. It's divided into three subtypes: IBS-D (diarrhea-predominant; >25% of stools are loose - Bristol 6-7); IBS-C (constipation-predominant; >25% of stools are hard - Bristol 1-2); and IBS-M (mixed; >25% are Bristol 1-2 and >25% are Bristol 6-7 - in other words, more than half the time the stools are either too loose or too hard). 

IBS is diagnosed using the Rome criteria, which were updated in 2016, (full article here) but diagnosis requires a careful assessment by your physician, as a key step is ruling out other conditions. In many cases this does not require extensive investigation, but the appropriate steps need to be assessed on an individual basis. Keep in mind it is also possible to have IBS in conjunction with another gastrointestinal disorder. IBS involves recurrent abdominal pain (at least 1 day/week in the past 3 months) that has 2 of these 3 criteria: related to defecation; associated with a change in the frequency of stool; associated with a change in the consistency of stool. This symptom set has to be present for at least six months to diagnose IBS.

IBS is a great example of a chronic condition that resists a "one size fits all" approach. It used to be that physicians felt that there was nothing much to offer folks with IBS, but that's not true, and has drastically changed recently with some exciting new evidence-based therapies. There are now a lot of tools in the IBS toolbox, so I'd like to review some of them here.

1) Start with this handout from the Canadian Digestive Health Foundation. I give it out to patients because it does a great job outlining what IBS is, what we think may cause it, and some of the first steps you can take. The CDHF website has lots of great resources, including an app called Gi Body Guard that you can use to track symptoms. 

2) If you suffer from IBS and enjoy detail, the book "Conquering Irritable Bowel Syndrome" by Nicholas J. Talley is well worth reading. It's up to date, evidence-based, and goes through all aspects of IBS including what it is, the latest research, and lots of therapy options.

3) The Low FODMAP diet. Developed in Australia, this diet is evidence-based to improve IBS symptoms in up to 70% of people in some studies. I highly recommend Stephanie Clairmont and Kate Scarlata's blogs for your low FODMAP-learning. Start with Kate Scarlata's FODMAPS 101 handout here. Monash University, who developed the Low FODMAP diet, also makes an app that you can use to track FODMAPs. It isn't meant to be followed forever, but for a short term followed by re-introduction. It can be difficult to follow, though.

4) A trial of a probiotic -- and it probably matters which one. There are many different probiotics supplements and foods out there, but only a handful have been studied or proven to help with IBS. Two that have evidence, are easily available in Canada and are relatively inexpensive are Align (B. infantis 35624) and TuZen (L. plantarum 299v). 

5) Peppermint oil. Peppermint oil reduces spasm in the gut, and has been shown in a recent meta-analysis (conducted in part here in London, Ontario) to reduce overall IBS symptoms and abdominal pain. The main side effect was heartburn, so keep that in mind if you also suffer from heartburn. Various doses have been tried, but in many studies the dose is 0.2-0.4 ml three times daily in capsule form. Like any medicine, herb, or vitamin, check with your doctor and/or pharmacist to make sure it's OK for you. 

6) A low dose antidepressant. For moderate to severe symptoms, this is worth considering. An excellent information sheet about this can be found here courtesy of the University of North Carolina's Center for Functional GI & Motility Disorders. They have excellent patient education videos on their website.

There are many other options I haven't covered here. Finding relief from your IBS can involve a lot of trial and error, and improvement can be very gradual - so be wary of anyone promising immediate or definite results. Hopefully with time you will find an approach that works to improve your symptoms and quality of life. 


Is it postpartum depression or anxiety?

Sometimes new moms aren't sure if they are suffering from pregnancy-related or postpartum depression or not. In my practice, I use the Edinburgh Postnatal Depression Scale, which is a validated screening tool.  You can review the questions here.  Screening is different than diagnosis, so if you are concerned in any way about the way you feel, then I urge you to discuss it with your health care provider.  Postpartum anxiety can also go unrecognized, and anxiety disorders appear to be more common in pregnancy and postpartum compared with other women of childbearing age. Sometimes women under-report feelings of anxiety because worrying is thought to be "normal" - but what matters is the degree of worrying, and how it's affecting you.  Although labels and diagnoses can be helpful, I also like to take a step back and simply look at whether someone feels they need help; you, the patient, are the best judge of this.  

The article "The Difference Between Postpartum Depression and Normal New Mom Stress" is a useful article. In it, Social Worker Kate Kripke provides a list of experiences that reflect "healthy" or "normal" adjustment, and those that suggest "postpartum distress that requires support". 

For example, the following experiences are common:

  • Fears about harm coming to your baby that come and go, that you know are not “realistic” but that do not cause lasting distress, and that decrease as your experience and comfort with motherhood grows.
  • Sleeplessness that occurs from caring for your baby at night, while still having the ability to sleep when your baby is sleeping or when given the option to rest.
  • Fatigue that comes from late night feedings and interrupted sleep.

While these may indicate the need for greater support:

  • Sleeplessness that occurs due to “monkey brain” –  anxious thoughts that will not go away.
  • A deep fatigue that is not alleviated with rest and/or a desire to remain in bed all day.
  • Unrelenting anxiety about having others help care for your baby and a deep fear and inability to let go of some of this control.

Recovery from pregnancy and birth and adjustment to life with a baby - whether your first or not - is challenging, and often new moms don't have a lot of support to draw upon. NEST-S is a way to remember the areas of self care that are important: nutrition, exercise, sleep and rest, time for yourself, and support. It's especially important to consider these areas if you have a history of depression or anxiety, Practical tips for all of these areas can be found in BC's excellent Self Management Guides for Perinatal Anxiety and Depression. Whatever the diagnosis you think you may have (or not), if you're feeling the need for more help, please do not hesitate to seek it.  Seek support not only from your health care provider but from your family, friends, and community.

Of course, if you are having thoughts of hurting yourself or your baby, think you are hearing or seeing things that aren't there, or feel you are in crisis, please get immediate help. In London, the HOPEline for postpartum support is 519-672-HOPE (4673).

Further reading:

Have a healthy Ramadan: tips for participants and health care providers.

Ramadan will soon be here - the month of fasting and worship observed by Muslims around the world. Here are my practical tips about fasting for those who will be observing, as well as information for health care providers whose patients who may be fasting. Ramadan advances in the Gregorian calendar about 10 days each year, so the fasting days this year will be especially long in Canada. 

  • On whether to fast with a health issue: If you have a health condition or take medications, talk to your doctor about whether you can safely fast.  Some people with chronic health conditions may be able to fast, others not at all, while others may fast every other day, or two days on, one day off, for example. And of course, there are many other spiritual, family and community activities in the month in addition to fasting. 
  • Type II Diabetes: Many times, adjustments in your activity and medication can be made to allow you to fast safely, but you need to plan for it, and find out if it's advisable. Make a visit to your health care provider in advance. In London, the Primary Care Diabetes Support Program has been offering specific consultations for Ramadan advice for the past few years. Referral information is here.
  • Pregnancy: I recommend that my pregnant patients abstain from fasting, especially when Ramadan falls in the summer as it does now. If you are a health care provider caring for pregnant women, ask whether they are intending to fast and be aware that they may be.  
  • Breastfeeding: In general, I advise my patients who are breastfeeding to abstain from fasting, especially if their baby is less than six months old, and especially when the fasting days are long as they are now. 

General Tips:

  • Be especially mindful to drink enough fluids during the evening. Get up and have suhoor (the pre-dawn meal), and I highly recommend including foods or fluids with electrolytes - such as kefir, banana, or yogurt. An electrolyte drink might be worth taking if you are especially prone to dehydration headaches. 
  • Include protein and fat in the suhoor meal as well, for nutrition and to keep you feeling fuller, longer. These egg muffins are easy to make ahead of time and would be ideal. 
  • Migraine sufferer, or tend toward headaches on the first day? You may want to try ibuprofen preventatively with your suhoor. Make sure it's safe for you to take, and be cautious especially if you are over 50. Check out my migraine post for more tips for migraine prevention.
  • Coffee or tea drinker? Taper off gradually in the week before. Or, if you wish, continue having a small cup at suhoor - it might allow you to get a productive hour or two in at the start of your day. Coffee as a dehydrating drink is actually a myth. 
  • Adjust your goals and simplify your schedule as much as possible.  Keep meals simple and healthy. Include salads and hydrating fruit at your iftar meal. 
  • Keep exercise mild. You will not likely be able to achieve an intense exercise regime for the month. Remember, though, that even one minute of exercise can be beneficial
  • Be especially careful if you work outdoors, in construction, or in any other "high risk" occupation that you need to remain alert for, like surgery or driving professionally. If you start to feel lightheaded or dizzy, rest, and break your fast if need be. Keep a sports drink at work in case this happens. 

Any comments or tips for managing Ramadan, as a participant or health care provider? 

Four Things That May Help Your Migraine

I find migraine headaches to be one of the most satisfying conditions to treat in family practice, because there are so many options for prevention, and treatment can be tailored to the patient's health conditions and preferences. For example, I have many patients who prefer to avoid a daily preventative medication, and instead I recommend one of the options below. 

I recommend keeping a headache diary, which may point to triggers.  In medicine we have historically advised people to avoid their triggers. On the surface this is intuitive, but this approach is being questioned, as avoiding certain things may lead to you becoming more sensitive to the trigger. An approach called "learning to cope with triggers" involves gradual exposure to certain triggers and has been shown in one randomized controlled trial to reduce headaches. It's yet to be seen how we should incorporate this into clinical practice. If you are interested in this approach, I recommend finding a therapist who does cognitive-behavioural therapy. 

I recommend a variety of options for preventative therapy and for treatment of migraine, including prescription medications. There are many prescription and non-prescription treatments that have some benefit. No one treatment is effective for everyone, but these non-prescription options may be worth a try. As always, speak with your health care provider to ensure any supplement you take doesn't interfere with your health conditions or current medications. 

Here are four non-prescription options that may help your migraines:

  1. A magnesium supplement. Magnesium 300-600 mg daily can reduce the frequency of migraine. Health Canada considers a dose of up to 350 mg of magnesium to be safe in pregnancy, so this is an ideal option for pregnant women who suffer from migraines. Some people (up to 40%) get bothersome diarrhea with it, but it might be helpful in people who suffer with chronic constipation. You might want to start with a low dose first, to see how it affects you. Food sources of magnesium can be found here.
  2. Coenzyme Q10 (CoQ10), 100 mg three times daily. In a small study, taking CoQ10 reduced migraine frequency, and it was well tolerated. 
  3. Acupuncture. There is good evidence that acupuncture provides similar effectiveness to preventative medication.  The main downside is the time and expense required to get treated. 
  4. Riboflavin (Vitamin B2) 400 mg daily. Food sources are listed here, but you can see that they contain very small amounts compared to the 400 mg dose studied for prevention of migraine. 

Have you tried any of these options for migraine? Are there other strategies that have helped you?

Welcoming students & learners to my clinic

As a community family medicine teacher, I have medical students and family medicine residents join me in the clinic at times. I respect my patient's choice as to whether they want to see a student that day, realizing that there may be various factors involved in their decision. There are, however, many positives to seeing a learner. Toronto family physician Dr. Sheila Wijayasinghe wrote a great article about the benefits of seeing a medical student. Her top five benefits to seeing a student are:

1. You get more time.
2. You’re getting the most up-to-date care.
3. You get two sets of eyes.
4. You may get seen earlier.
5. You can help shape a new doctor’s career.

I absolutely agree. I have had keen medical students and residents ask pertinent questions, or recommend a lifestyle change or practical tip that has stuck with patients. Students are enthusiastic and very grateful for the opportunity to be involved in a patient's care. Finally, I enjoy showing learners the diversity and joy of family medicine, in the hopes of continuing to attract capable, conscientious individuals to the field.