These days, people are better informed about health matters than at any other time in history. Many people know the risks and benefits of medications and have opinions on the usefulness of specialized tests, and nearly everyone knows about the importance of diet and exercise. Physicians, as well as family members, coworkers, and friends will commonly recommend exercise and lifestyle modifications to each other for a variety of medical conditions. These modifications (losing weight, decreasing fat intake, increasing dietary intake of fresh fruits and vegetables, cutting back on red meat intake) are known to improve a variety of disease symptoms, positively influence mood and emotional health, and prolong life. Certainly, they have benefits for people who have diabetes, hypertension, arthritis, and heart disease. Do similar recommendations apply to people who have irritable bowel syndrome? Are there data to support the use of exercise and lifestyle modifications for people who have IBS?
The role of lifestyle modifications in the treatment of IBS has not been well studied, for reasons that are easy to appreciate. First of all, patients and physicians all have different definitions of “lifestyle modifications.” You can’t test the effect of something that is undefined. For example, if we were designing a study to test whether adopting a less stressful lifestyle improved the health of people who have IBS with diarrhea, how would we define “less stressful lifestyle”? It would be different for each participant. How would we measure responses to lifestyle modifications? Should we use only objective measures, such as the number of days with constipation or the number of days with diarrhea, or should we try to quantify subjective measures, such as sensations of abdominal pain or bloating after changes in diet or medication? If we used these subjective measures of symptoms, what rating scale would help us tabulate the results?
There is little information in the scientific literature about the effects of lifestyle modifications on people who have IBS. One well-designed scientific study described a small group of patients who were enrolled in a structured program that included lectures on diet, exercise, and different approaches to tackling the symptoms of IBS in a positive, constructive manner. According to the report, patients who completed the course felt that their abdominal pain lessened overall, but no significant improvements were observed with other symptoms.
Despite the lack of scientific data, physicians treating people who have IBS have learned from their patients about some lifestyle factors that can worsen IBS symptoms and some elements of daily life that, if addressed proactively, can improve IBS symptoms. These components include exercise, sleep, and stress reduction.
Because a routine exercise program has been shown to positively influence the natural history of diabetes, hypertension, and cardiovascular disease, the benefits of exercise automatically apply to other diseases, such as IBS. Although little data in the past supported the role of exercise in the treatment of IBS, now three small research studies are worth mentioning.
A survey study that gathered information from a group of women, some of whom had IBS, found that the women who had IBS were generally less likely to be physically active than other women. However, the women who had IBS and were physically active were less likely to be bothered by some of their IBS symptoms than were women who had IBS but were less active. Another small study performed at the Mayo Clinic evaluated the effects of exercise as part of a multicomponent IBS treatment program. Patients who had IBS were enrolled in exercise classes and other classes that covered diet and stress reduction. Six months after completing the treatment program, some of these patients noted an improvement in their level of abdominal pain.
Although both of these studies lend some support to the notion that exercise may improve IBS symptoms, it is hard to know how much benefit patients can expect and whether all patients will improve if they embark on an exercise program. In an attempt to address some of these shortcomings, in a recently published study, researchers randomly assigned men and women who had IBS to either a treatment group, in which physical activity was encouraged during a 12-week period, or to a control group, in which patients were asked to maintain their typical lifestyle (not very active). The people who had IBS in the physical activity group were given advice by a physiotherapist to try to slowly increase their activity so that they were eventually participating in 3 to 5 sessions per week (of a variety of exercises) that would last 20 to 60 minutes per session. A variety of measurements and questionnaires were performed at the beginning and at the end of the study, and the groups were evenly matched with regard to age, sex, race, educational level, employment status, type of IBS, and severity of IBS. The researchers reported that patients who participated in the 12-week exercise program had a significant reduction in the severity of their IBS symptoms. Individuals in the exercise group also noted some improvement in their overall quality of life (through a validated scoring system). This study provides good evidence that physical activity improves IBS symptoms.
Although the precise mechanism by which physical activity improves IBS symptoms is unknown, it may be related to a reduction in stress, an improvement in constipation symptoms, or an improvement in the transit of intestinal gas, which may lead to an improvement in bloating. Further research is needed to confirm these results, but exercise is now something I routinely recommend to my patients who have IBS.
Sleep disturbances (often referred to as disordered sleep) are common in the general population. Disordered sleep includes not being able to fall asleep, awakening too early and not being able to go back to sleep, having fragmented sleep (a pattern of falling asleep and then awakening that occurs repeatedly throughout the night), waking up not feeling refreshed, and having very shallow (or light) sleep. Other than the obvious problems of feeling exhausted and having difficulty concentrating or performing tasks the day after a poor night’s sleep, disordered sleep can contribute to other health problems, such as cardiovascular disease, obesity, and mood disorders. Some researchers estimate that nearly 50 percent of the general population experiences some symptoms of insomnia each week.
Although more research needs to be done regarding sleep and IBS, disordered sleep may worsen IBS symptoms in some people. Nearly 25 years ago, a study showed that 30 percent of people who had IBS experienced poor sleep, compared to just 5 percent of a control group who did not have IBS (note that this number is much lower than the 50 percent mentioned above because the researchers from the earlier study used a very strict definition of poor sleep). Several years later, a small prospective study showed that 74 percent of people who had IBS characterized themselves as being “poor sleepers.” These people also reported that more severe IBS symptoms in the morning correlated with poor sleep the night before (a finding that was confirmed several years later in a study of women who had IBS).
Symptoms of IBS undoubtedly reduce a person’s quality of life. The term “quality of life” refers to a general measure of a patient’s daily well-being and is meant to include physical and mental (psychological) symptoms. Multiple studies have clearly demonstrated that IBS symptoms detract from the daily home, professional, and social life of a patient. One IBS research study determined that poor sleep was another independent factor that contributes to the reduced quality of life for people who have IBS. This finding emphasizes that treatment for IBS can’t rely on just one component (such as only treating bloating). Rather, an effective treatment plan needs to address the many different factors that contribute to the development of IBS symptoms, and disordered sleep is one of those factors.
Because such a large number of people who have IBS also experience disordered sleep, researchers have logically questioned whether IBS causes poor sleep or whether poor sleep causes IBS. The answer is probably a combination of both. Symptoms of bloating, intestinal gas, and abdominal pain could definitely prevent falling asleep or cause disrupted sleep. The following day, poor sleep may worsen IBS symptoms, creating a vicious cycle. Although not yet studied in individuals who have IBS, there is evidence from sleep studies that poor sleep decreases a person’s pain thresholds. This means that pain is more easily sensed after a night of poor sleep than after a night of good sleep. Many people feel a little bit more irritable or “edgy” after a poor night’s sleep. For a person who has IBS and is already more sensitive to gut stimulation than other individuals, a night of disrupted sleep is likely to worsen IBS symptoms.
The treatment for disordered sleep is very individualized. Similar to the treatment for IBS, one size does not fit all. I usually recommend these simple steps:
• Routine bedtime and routine awakening time is helpful. Don’t allow your sleep schedule to change every day. The body generally likes routines, so try to go to bed at approximately the same time each night and get up at the same time each morning (this includes weekends and holidays).
• Your bedroom should be cool and dark. An overly hot bedroom disrupts sleep.
• Get into a routine before going to bed. This may mean a warm shower or bath 30 to 60 minutes before bedtime (but not overly hot), reading for 30 minutes, or watching a little bit of TV.
• Consider having “background” noise in the bedroom. This can mean a fan on low speed, “white noise,” or soft, soothing music.
• Think of your bedroom as your “retreat.” Don’t use your bedroom as your TV room, playroom, or office. The idea is to trick your brain into thinking that once in the bedroom, it’s time for sleep.
• Naps can backfire. If necessary, a brief nap after lunch or in the very early afternoon is okay, but nothing longer than 20 to 30 minutes.
• Don’t go to bed overly hungry or overly full. If you missed dinner, consider having a light snack one to two hours before bed (for example, a piece of fruit and a few crackers). Don’t eat a large meal and go right to bed—you might have severe acid reflux, which will keep you up. Also, monitor the volume of fluids that you drink in the evening. You don’t want to have an overly full bladder that awakens you.
• Avoid caffeine after lunch (or at least no caffeine-containing product of any kind six hours before bedtime).
• Try to exercise each day to reduce IBS symptoms and to improve sleep. But don’t exercise three to four hours before bed, because this may make falling asleep more difficult.
• Don’t use alcohol as a method of falling asleep. It is okay to have a glass of wine or a drink with dinner; however, three to four drinks right before bed may make you fall asleep faster but will disrupt your sleep overall, making you more tired and edgy (and, of course, drinking so much alcohol will ultimately injure your liver).
• If you awaken and cannot fall back asleep within 15 to 20 minutes, don’t stay in bed for hours tossing and turning. Get up, leave the bedroom, and sit in another room to read, knit, or watch TV until you are sleepy. Then, return to bed.
If these suggestions do not work after a trial period of two to three weeks, then you should talk to your doctor about over-the-counter or prescription sleep medications. Keep in mind that some sleep medications can become habit-forming, meaning that you will constantly require them to get any sleep, you may have more sleep problems if you stop them, and you may need ever-increasing doses to get some sleep. In addition, although sleep medications may help you sleep, they may cause grogginess the next morning or a feeling of being “hung over.”
Melatonin. A natural hormone, it is found in the body and is involved in the normal sleep-wake cycle. Melatonin is commonly used to prevent or minimize jet lag. It is sold at most pharmacies and health food stores and is reasonably priced. Melatonin is generally considered quite safe, although some people report feeling a little dizzy or fatigued the day after taking it. It has the potential to interfere or interact with blood-thinning medications (such as Coumadin) and oral contraceptives, so you should check with your doctor before taking it. A good starting dose is 1 mg taken approximately 1 hour before bedtime. If your sleep does not improve after 1 week, then increase to 2 mg each night (again, 1 hour before bedtime). If it still isn’t helping with your sleep problem, add an additional 1 mg dose every 7 to 10 days, until you are taking 8 mg a night total. At that point, if you are still having sleep problems, then melatonin is probably not the medication for you, and you should slowly cut back on the dose (decrease by 1 mg every 3 to 4 days) until you are completely off the medication. Stopping melatonin all at once isn’t thought to be dangerous, but you may notice a temporary worsening of your insomnia. Long-term trials evaluating melatonin’s safety and efficacy are not available; for that reason, most physicians recommend that it only be used for short-term relief (two months or less).
Valerian. A plant supplement available at most health food stores, valerian has not been well tested. Although it is unknown exactly how valerian helps people with their sleep problems, many people who prefer to use alternative medications believe it is helpful. Some people report that it causes mild abdominal distress or a feeling of irritability. Doses vary based on how it was manufactured—you will want to speak to the owner of the health food store to get reliable information about its use.
Diphenhydramine (Benadryl). An antihistamine, diphenhydramine is traditionally used to treat mild seasonal allergies or allergic reactions. A side effect of this medication is that it causes fatigue and sleepiness in some individuals. It is generally considered safe, but it can cause a dry mouth, fatigue the following day, and a feeling of grogginess. In the rare patient it can cause blurry vision, memory problems, or urinary retention (difficulty emptying the bladder). You should not take diphenhydramine if you have glaucoma or if you drink alcohol. It is sold in different doses and forms; usually 12.5 mg taken 1 hour before bedtime is a good place to start (some people require 25 mg each night).
Doxylamine. This is another antihistamine with the same potential side effects as diphenhydramine (Benadryl).
Other agents. A variety of other over-the-counter (OTC) agents are available. One example is “I Sleep Soundly.” Keep in mind that many of these OTC agents are sold as supplements and thus are not regulated or tested by the FDA.
Many sleep medications are now available by prescription. The number of choices available highlights how common sleep disorders are in the general population and also points out that no single medication is right for all people with disordered sleep. Currently available medications include eszopiclone (Lunesta), zolpidem (Ambien), ramelteon (Rozerem), and zaleplon (Sonata). All of these medications have side effects, and all require a careful discussion with your health care provider to review risks and benefits of the medication, especially if you are taking other prescription or over-the-counter medications, to prevent dangerous drug interactions.
We live in a stressful world, and most of us encounter stress every day. Stress is different for different people. For some people, stress may be due to work or relationships. For others, stress may be related to health issues or financial issues. Some people are able to deal with stress at work but have a very difficult time dealing with financial stress. Others find that dealing with stress from difficult family situations is easy, but dealing with stress from a chronic medical or psychological illness is nearly insurmountable. Because stress comes in so many forms, a “one-size-fits-all” treatment program won’t work. Here is a list of suggestions on how to reduce stress that you may want to think about incorporating into your daily routine:
• Exercise. In addition to helping with sleep, daily exercise has been shown to reduce stress. This does not mean that you have to spend thousands of dollars on work-out equipment or a gym membership. Daily exercise can easily be incorporated into your routine by taking a walk at lunch, biking on weekends or in the evenings, and climbing extra stairs.
• Make a list. Stress can develop from a sense of being overwhelmed by life’s multiple daily activities. Sit down every night after dinner and make a list of things to accomplish the next day. Make sure that the list is reasonable—don’t set out such a massive agenda that you fail, which will only worsen your stress.
• Meditation. Finding time to sit quietly and relax and reflect on the day, or the day yet to come, can help relieve stress.
• Deep breathing. As simple as it seems, standing or sitting quietly and taking several long deep breaths (and holding them) during a 3- to 5-minute period can greatly reduce stress and provide an immediate sense of calm. Doing this in a quiet, dark area is even better.
• Laugh. Many medical studies have shown that people who have fun, laugh, and play are less likely to suffer from stress, high blood pressure, and heart disease than those who do not. So, have fun with your friends, tell a joke, and laugh about old times.
• Socialize with friends. Work can consume people and create stress. Make sure that you take time each week to socialize with friends, family, and neighbors. Do not be a loner. Make the extra effort, if necessary, to connect with someone at work, at church, or in your neighborhood.
• Get a pet. The health benefits of having a pet are well known. Pets reduce stress, improve mood, and help reduce blood pressure.
• Volunteer. If you are feeling overwhelmed and stressed due to demands at home and at work, it can be hard to imagine finding time to donate to others. However, volunteering at a food bank, shelter, church, local school, or civic center can greatly improve your stress level. Giving to others will improve your negative feelings and may help put the chaos of everyday life into perspective.
• Although we have limited data about the effects of lifestyle changes on IBS symptoms, routine exercise appears to improve IBS symptoms.
• Poor sleep is common in people who have IBS and may change pain thresholds. Improving sleep will usually improve IBS symptoms.
• People can reduce their stress in a variety of ways. If one approach does not work, don’t give up—just try another.
• Most physicians who specialize in treating people who have IBS believe that routines are important. The GI tract in individuals who have IBS seems to function better on a set schedule. Meals, exercise time, sleep, and trips to the bathroom should fit into a schedule that is maintained throughout the week, including weekends.