HiPhi Patient Guide (EN)

Patient advice sheet Irritable bowel syndrome (IBS) guide What is IBS? IBS is irritable bowel syndrome, symptoms of which can include constipation or diarrhoea, bloating and abdominal pain. IBS is diagnosed once other conditions have been excluded. It is sometimes triggered by the foods we eat. For this reason we suggest considering how you can change your diet to address the most troubling symptom you experience. In this guide you will find advice on changes to your diet which can help you reduce each of the main symptoms noted above. You may find it helpful to complete the symptom evaluation questionnaire before you begin.

We strongly encourage you to carry out this advice at home for about 3-4 weeks. After making changes, complete the symptom questionnaire again. This should help you to evaluate if this guidance has helped. If your symptoms persist despite changing your diet, you may wish to trial the low FODMAP diet. ‘FODMAP’ is an anagram for different fermentable fibres found within many foods, which might cause IBS symptoms in some people. For more details on a low FODMAP diet, please watch webinars 3 and 4 at the following link https://patientwebinars.co.uk/condition/ibs/webinars/ or discuss this with your dietitian.

It’s also important to note that if you notice a food is triggering your IBS symptoms, for example if you are experiencing stomach cramps after a particular food, you are not causing any physical harm to your gut by continuing to eat that food. This is your choice and the symptoms will pass. If you have been diagnosed with IBS but develop any new symptoms, such as unexplained weight loss or blood in the stool, please see your GP to discuss this. General tips Regular meals: Your digestion can become overwhelmed by large meals or eating most of our daily intake over only a few hours. Try to spread out your meals over the day aiming for 3 meals and 2 snacks. Increasing fluids :

Fluids are important to help pass a soft stool if constipated and to replenish fluid lost through loose stools. Aim for at least 2 litres or 4 pints a day of fluids, including water, squash, juice, tea and coffee or milk based drinks. Probiotics: You may wish to consider trying a probiotic. These come in many different types and concentrations. We advise a trial of 4 weeks. If you have not noticed an improvement by then, it is unlikely that continuing will provide a benefit. See further information under ‘constipation’ and ‘diarrhoea’ for guidance on which probiotics to choose. Alcohol: You may find that alcohol is a trigger for your symptoms.

There is no safe amount of alcohol to take, and any reduction may be beneficial for IBS, but also for your overall health. 1/6 Issue date: February 2024 Review date: February 2026 Aut Ver hor: Nutrition and Dietetics sion: 1.0

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Make changes one by one , alongside keeping a food diary to help track your progress. See our separate food and mood diary template to help get started. You may find that symptoms worsen or improve for no apparent reason, and keeping a food diary is usually the best way to pinpoint potential triggers. Also consider non dietary triggers, such as stress (page 2). Dietary exclusions: If you feel that, after tracking your symptoms, a particular food group such as lactose products or wheat are causing your issues, you may wish to try a short elimination (perhaps for a few weeks). It is important that you replace these foods with appropriate alternatives.

For example, you could choose a lactose free or plant based milk instead of cow’s milk, if you are excluding lactose. Make sure this is calcium enriched. It is also important that, if you find no benefit, you promptly reintroduce these foods at the end of the trial. IBS can be a frustrating and often isolating experience. If you feel you would benefit from support, or would like further trusted information on IBS, please see the ‘other useful resources/websites’ on page 6.

The following 4 sections cover the symptoms that you may have with IBS and actions that you may try to relieve these symptoms 1 Stress and mental health There are definite connections between the gut and the brain (called the gut-brain axis). IBS has recently been classified as a disorder of gut-brain interaction, which is why you may have been suggested to take a low dose anti-depressant by your Doctor, to help reduce your IBS symptoms. Mental health can play a significant part in IBS symptoms. Addressing stress in your life can complement changes made to your diet, and stress may even be the main cause of your symptoms.

The following holistic treatments may be useful for helping to manage IBS: Gut directed hypnotherapy Yoga (2 hours per week of hatha yoga) Deep breathing Meditation IBS specific cognitive behavioural therapy (CBT) Movement or exercise is also recommended to help manage IBS, which may be linked to it’s mental health benefits. Try to find some form of movement that you enjoy, it all counts! If you are interested in gut directed hypnotherapy or CBT, speak with your GP or consultant about the services which are available in your area. If you do start any of the above interventions, jotting this down in your food diary may help you identify what works to help manage your symptoms.

For more advice on stress relief you can contact Be Healthy Bucks ( https://bhb.maximusuk.co.uk/ ) by self-referring online or by calling 03332 300177 2/6 Issue date: February 2024 Review date: February 2026 Autho Versi r: Nutrition and Dietetics on: 1.0

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2 Constipation In addition to the general tips, you may find these tips useful: Activity Movement is important to help get things moving internally, try to bear this in mind and remember that everything counts, even if it’s not classed as conventional exercise! Fibre Both having too much and too little fibre can cause bowel symptoms. If you do not eat many wholegrain options or fruits and vegetables, you may benefit from increasing these in your diet. However, try to avoid adding additional wheat bran into your diet (e.g. bran flakes, Weetabix), as this is high in insoluble fibre, which may worsen any accompanying symptoms of abdominal pain or bloating.

See the ‘quick fibre guide’ for more information. Soluble fibre Instead, try to focus on increasing your intake of soft fruits, vegetables, oats and linseeds to help boost your intake of soluble fibre . Soluble fibre forms a gel in the gut, which helps to soften hard stools, and also helps to manage loose stools. Increasing your intake of soluble fibre can help with abdominal pain and bloating, and it’s also a prebiotic. This provides food for the good bacteria in the colon, which could help in IBS. Soluble fibre supplements such as psyllium/ispaghula husk are available from most health food shops or online and you could also try products such as Optifibre or Fybogel.

Start with a small dose (for example, 1 tsp/day) and increase this gradually. Linseeds For constipation you can try adding up to 2 tablespoons of linseeds a day to cereal or yogurt, salads or soups. Start with 1 tsp and increase gradually, making sure you have at least 150ml of fluids at the same meal as the linseeds. Respond to your body’s cues Where possible, try to respond to the urge to open your bowels when it occurs. Holding it in will cause more water to be absorbed and make the stool harder to pass. How you position yourself on the toilet is also important and this will help make it as easy as possible for you to pass a stool—see the diagram.

Probiotics for constipation You might find Activia yoghurts (Danone) helpful in the following portion: 125g pot x 2 per day (trial for 1 month). Alflorex capsules are a lactose free option, and are available at some UK pharmacies or online (trial period 4-12 weeks) from https://precisionbiotics.ie 3/6 Issue date: February 2024 Review date: February 2026 Autho Versi r: Nutrition and Dietetics on: 1.0

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3 Diarrhoea Caffeinated drinks: (Tea, coffee, energy drinks). We recommend you limit these to 2-3 cups a day, as caffeine is a bowel stimulant which can worsen loose stools. Decaffeinated versions can be consumed freely instead. If you want to switch to decaff, try to do this gradually to avoid caffeine withdrawal symptoms such as headaches. High fat foods: Large or frequent amounts of high fat foods (such as fried foods, full fat dairy products, chocolate), can lead to loose stools. Consider opting for lower fat options to see if this has any effect. Soluble fibre:

This type of fibre, found in oats, some seeds and fruits/vegetables forms a gel in the gut, which helps to soften hard stools, and also helps to manage loose stools. Increasing intake of soluble fibre can help with abdominal pain and bloating, and it’s also a prebiotic. This provides food for the good bacteria in the colon, which could help in IBS. Soluble fibre supplements such as psyllium/ispaghula husk are available from most health food shops or online and you could also try products such as Optifibre or Fybogel. Start with a small dose (for example, 1 tsp/day) and increase this gradually. Insoluble fibre:

Whilst keeping some soluble fibre in your diet, you may wish to decrease intake of insoluble fibre, which is found in skins of fruits and veg and wholemeal cereals, particularly wheat bran (e.g. bran flakes, Weetabix). This may worsen loose stools, pain or bloating. To decrease total/insoluble fibre intake whilst keeping soluble fibre in your diet, see the ‘quick fibre guide’ to help. Probiotics for diarrhoea: Alflorex capsules can be effective in managing diarrhoea and are available from most UK pharmacies or online ( https://precisionbiotics.ie ), the recommended trial period is 4-12 weeks.

Symprove is another option and has shown benefit after 12 weeks and is available from https://www.symprove.com . The company sometimes offers a free trial. Both of these options are lactose free. Bile acid malabsorption (BAM): The British Society of Gastroenterology suggests that up to 1/3 of people diagnosed with diarrhoea predominant IBS, could have BAM, which isn’t routinely tested for. Bile, produced by our liver and stored in our gallbladder, helps us to digest fat. This is released into the gut when we eat and should be reabsorbed by the gut further down.

But in some people, this reabsorption does not occur, and can lead to frequent loose stools (sometimes at night) which may be yellow/green or oily and associated with wind and bloating. This can happen in anyone but is more likely in patients who have had a cholecystectomy (gallbladder removal surgery) or who have had part of their small bowel removed. If you feel this could be a cause of your symptoms, please see your GP or gastroenterologist to discuss this. They may wish to send you for a test, or trial a medication that can help with BAM. 4/6 Issue date: February 2024 Review date: February 2026 Autho Versi r: Nutrition and Dietetics on: 1.0

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