Analysis

Supporting patients with IBS: how dietary advice and holistic care can improve quality of life

What you need to know to help reduce the impact of this chronic, often debilitating condition

What you need to know to help reduce the impact of this chronic, often debilitating condition

Up to one in five of the UK population are thought to be affected at some point in their lives by irritable bowel syndrome (IBS), a chronic and often debilitating condition.

Stomach pain and cramps, abdominal distension (bloating), diarrhoea and constipation are common symptoms of this relapsing, potentially life-long disorder.

Prevalence among different groups

IBS incidence peaks among people in their 20s and 30s, and is twice as common in women, according to the British Society of Gastroenterology .

But people can be affected at any age, and National Institute for

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What you need to know to help reduce the impact of this chronic, often debilitating condition

Picture: iStock

Up to one in five of the UK population are thought to be affected at some point in their lives by irritable bowel syndrome (IBS), a chronic and often debilitating condition.

Stomach pain and cramps, abdominal distension (bloating), diarrhoea and constipation are common symptoms of this relapsing, potentially life-long disorder.

Prevalence among different groups

IBS incidence peaks among people in their 20s and 30s, and is twice as common in women, according to the British Society of Gastroenterology.

But people can be affected at any age, and National Institute for Health and Care Excellence (NICE) guidance says there is significant prevalence in older people.

Here, we give an overview of the condition and specialist nurses explain how to help patients who present with symptoms.

The symptoms and impact of IBS

Up to 1 in 5

people will be affected by IBS at some point in their lifetime

Source: NICE

For those affected, IBS can have a huge impact on every aspect of life.

NICE says it can lead to lack of sleep, anxiety and lethargy, which may result in time off work, avoidance of stressful or social situations and a significant reduction in quality of life.

Those with IBS may choose not to travel or go far from home, as they do not want to be too far from a toilet.

The IBS guidance from NICE, first published in 2008 and updated in 2017, says establishing a diagnosis is an essential part of the care people should receive.

As IBS is a functional problem, it is not something that shows up through any test or procedure. Instead it is a clinical diagnosis often based on excluding other causes.

People often present with varying symptom profiles, most commonly ‘diarrhoea predominant’, ‘constipation predominant’ or a combination of these.

What causes IBS?

Its cause is not fully understood, although gut hypersensitivity, disturbed colonic motility, bowel dysfunction after an infection, microbial imbalance in the gut, low-grade inflammation or a defective antinociceptive (anti-pain) system are possible causes, according to NICE.

There is no cure, but nurses and support groups say there is still a lot that can be done to improve symptoms and quality of life.

‘IBS is embarrassing, debilitating and unpleasant, but it isn’t going to kill you, so people may just be told to eat more fibre, and that’s it… Those affected will often have a history of not being heard’

Alison Coutts, senior lecturer in nursing, City, University of London

NICE recommends that healthcare professionals consider assessment for IBS if a patient reports having had abdominal pain or discomfort, bloating or a change in bowel habit for at least six months.

Hydration is crucial – ideally with non-caffeinated drinks Picture: iStock

This means looking out for red flag symptoms that could suggest bowel cancer or other cancers, and inflammatory markers that could indicate inflammatory bowel disease.

When other conditions, including coeliac disease, are ruled out, and based on the symptoms (see box below), a diagnosis can be made.

The NICE 2016 quality standard on IBS, which sets out the priorities to improve care, says a positive diagnosis is important to reduce unnecessary anxiety in people with symptoms of the syndrome.

Identifying IBS: what are the symptoms?

A diagnosis of irritable bowel syndrome (IBS) should be considered only if the person has abdominal pain or discomfort that is either relieved by defecation or associated with altered bowel frequency or stool form.

This should be accompanied by at least two of the following symptoms:

  • Altered stool passage (straining, urgency, incomplete evacuation)
  • Abdominal bloating (more common in women than men), distension, tension or hardness
  • Symptoms made worse by eating
  • Passage of mucus

Other features such as lethargy, nausea, backache and bladder symptoms are common in people with IBS, and may be used to support the diagnosis.

Source: NICE guidance

Taking the time people need to discuss their symptoms

Most of the care for people with IBS will be carried out in primary care.

Community clinical nurse specialist for IBS Ellie Bradshaw

While the condition can be well managed in these settings, the most difficult issue can be giving people enough time to investigate their needs properly.

Community clinical nurse specialist for IBS Ellie Bradshaw says that in secondary and primary care, gastroenterologists and other professionals with expertise in this area are primarily occupied with identifying and caring for those with cancer or inflammatory bowel disease.

Ms Bradshaw, who works at the Royal Free London NHS Foundation Trust and is the only community IBS nurse in England, says: ‘Doctors are very busy looking for life-shortening pathology, and I understand that, but it does mean that a life-limiting pathology is not really catered for. Often there just isn’t time.’

‘Remember that bowels are still a taboo subject for some. A lot of people are not comfortable discussing it, so give them the space to do it’

Ellie Bradshaw, community IBS nurse specialist

She says that nurses are ideally placed to provide the care that people need, as they are good at listening, providing a holistic assessment, supporting patient education and encouraging self-management, which are all at the core of good IBS care.

Talking about bowel problems

Some people find it hard to talk about bowel problems, and the conversation needs to be taken forward carefully and individuals given plenty of time.

20s and 30s

are the ages when symptoms of IBS are most common

Source: NICE

‘Be very gentle with the conversation, giving patients a safe space, and remembering that bowels are still a taboo subject for some,’ says Ms Bradshaw. ‘A lot of people are not comfortable discussing it, so give them the space to do it. Often as we talk, they will make connections themselves. It is about asking the right questions.

‘I often find repeating the language and words that they do, and letting them guide the conversation by asking open-ended questions, can help.’

Alison Coutts, senior lecturer in nursing at City, University of London, agrees that people need time to be heard.

‘People need to be taken seriously, as what often happens is they are slightly dismissed,’ she says.

‘IBS is embarrassing, debilitating and unpleasant, but it isn’t going to kill you, so they can just be told to eat more fibre, and that’s it. People need to be given the chance to really talk about the impact it has on them, as those affected will often have a history of not being heard. The assessment, and the management, needs to be holistic.’

Supporting self-management can include dietary advice (see box below), including reducing insoluble fibre, which can aggravate symptoms, and increasing soluble fibre (found in fruit and oats).

Dietary advice for people with IBS: what to eat and what to avoid

Advise patients to drink at least eight cups of fluid a day Picture: iStock
  • Have regular meals and take time to eat
  • Avoid missing meals or leaving long gaps between eating
  • Drink at least eight cups of fluid per day, especially water and other non-caffeinated drinks (for example herbal teas)
  • Restrict tea and coffee to three cups per day, and reduce intake of alcohol and fizzy drinks
  • It may be helpful to limit intake of high-fibre food (such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
  • Reduce intake of resistant starch (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re-cooked foods
  • Limit fresh fruit to three portions per day (one portion = approximately 80g)
  • People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free products including chewing gum and drinks, and in some diabetic and slimming products
  • People with wind and bloating may find it helpful to eat oats (such as oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day)

Source: NICE guidance

Anxiety, stress and IBS

People with IBS need to be properly hydrated, and should not start exclusion diets without the support of a healthcare professional.

Encouraging activity and exercise, and finding time and techniques to help people relax, are also recommended by NICE.

Pharmacological care includes antispasmodics, laxatives for those who are constipated, but not lactulose.

Oats may help with wind and bloating Picture: iStock

Loperamide should be the first choice of antimotility agent for diarrhoea in people with IBS.

There is also a strong link between anxiety and stress and IBS.

NICE says that stress can play an important role in aggravating IBS, and the British Society of Gastroenterology guidelines say that at least half of IBS patients can be described as depressed, anxious or hypochondriacal.

Among the pharmacological treatments suggested by NICE are antidepressants and selective serotonin reuptake inhibitors (SSRIs).

Life events when the patient’s symptoms started

Ms Bradshaw says that when talking to patients, asking about their mental well-being and exploring whether they have experienced adverse life events is important.

‘We know there is such a strong gut/brain connection,’ she says. ‘I talk to patients about when their symptoms started and what else happened in their life at that time.

‘Nurses should be sensitive with the terms we use when asking about adverse life events, and let patients speak openly. Patients will generally make connections themselves, about how they are feeling mentally, and the impact of stress and anxiety levels, during the conversation.

‘I have found that cognitive behavioural therapy, hypnotherapy and counselling can all really help. Exercise is important because it helps use up the adrenaline and cortisol produced by anxiety that otherwise finds its way to the gut.’

Advice and help for IBS: ‘what is offered still seems like pot luck’

Bronwen Barber has been experiencing IBS symptoms for more than four decades, since first experiencing digestion problems as a teenager.

Bronwen Barber received a diagnosis of IBS after decades of experiencing symptoms

Ms Barber realised it was a condition that she was going to have to learn to manage and live with, as restrictive diets and other treatments had little impact.

During more acute phases of symptoms, including severe bloating, stomach aches and diarrhoea, it has had a major impact on her life.

It became very difficult when she was living abroad in her 20s, she says.

‘I had a busy social life, I wanted to go out a lot, go out for meals and on dates, and it was having a real impact on that,’ says Ms Barber, who is retired and lives near Barnsley, South Yorkshire. ‘I was often in a lot of discomfort and it can be very isolating.’

She once visited an emergency department as she was in so much pain that she thought she had appendicitis.

‘I have found what works for me, through trial and error’

When symptoms worsened again about a decade ago, she visited her GP, who referred her for tests to rule out conditions such as bowel cancer. At this point she got her IBS diagnosis for the first time.

She says the treatment she was given didn’t help, and an NHS dietician did not provide any helpful or individual advice.

‘I was just told to follow a healthy, balanced diet, which was really not useful,’ she says. ‘It still seems like pot luck as to the help someone with IBS is offered.’

In the years since, she has found an approach that works her for and her IBS is well managed.

‘Now I have found what works for me, through trial and error. I know what food triggers it, and I’ve found that if I am going to eat something that can make it worse, such as lentils, kale or cabbage, if I take digestive enzymes that I buy from a health food shop just before, it is normally fine. Stress can make it worse, but I do my best to manage that.’

Ms Barber has trained as a support group leader through charity the IBS Network, and runs a monthly IBS support group. She says some people find their IBS extremely distressing.

‘It can be absolutely devastating,’ she says. ‘Some people don’t want to travel anywhere as they worry about being able to get to a toilet quickly. It has such an effect on their lives.’

Reviews based on self-management

Patients should have a regular review of their treatment and management, says the NICE quality standard.

2 times

IBS is twice as common in women as in men

Source: NICE

This should ensure that people are supported to manage their condition and to improve or maintain their quality of life.

‘However, because self-management is the best approach for many people, the patients themselves should play a key role in determining when they need the review,’ the guidance says.

With the right support to self-manage, almost everyone improves and, importantly, no-one gets worse with support, Ms Bradshaw says.

She says that for almost every one of the 150 people with IBS that she has worked with in the community, there has been a significant reduction in symptoms.

‘There is so much that can be done, and with the right support, and a holistic approach, I have found it almost always helps,’ she adds.


Further information

British Society of Gastroenterology: Guidelines on the irritable bowel syndrome: mechanisms and practical management

The IBS Network

NICE quality standard: Irritable bowel syndrome in adults

NICE: Irritable bowel syndrome in adults: diagnosis and management


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