Using Apps to Reduce Irritable Bowel Syndrome

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From NPR News

The science behind the integrative approach

A miswiring of the brain-gut connection

Let’s start with the basic re-set in thinking about IBS. It’s not just a problem of the gut. Scientists now know that disturbances in the way the nervous system, brain and gut interact can cause changes that trigger or worsen IBS symptoms, including stomach pain, bloating, diarrhea and constipation.

“There’s a continuous feedback loop between the brain and the gut,” explains Suzanne Smith, a nurse practitioner at UCLA’s Integrative Digestive Health and Wellness program. Information flows along the vagus nerve, which connects brain to gut, so what’s happening in the mind affects the gastrointestinal system.

Smith says stress and anxiety can increase sensations of pain in the body and disrupt the GI system. When you feel an unpleasant sensation in the body, “it’s registered as a threat, and the stress response is mounted,” she says. “That gets that negative feedback loop going.”

IBS symptoms include stomach pain, bloating and gas and sometimes urgent bowel movements or constipation. A new treatment approach helps patients learn how stress may make symptoms worse.

In a crisis – if your arm is broken – this amped up pain response is useful. It signals you should get help. But if there’s nothing structural to be treated, which can be the case with IBS, the heightened stress response is a problem, and can keep us stuck in the nervous system’s fight-or-flight mode. Every cramp or stomach sensation can register as a threat. The brain and the gut are talking, but it’s almost as if the brain is misinterpreting the signal.

Quiet the nervous system with mindfulness and relaxation techniques

A pillar of the integrative approach and many of the apps is to help patients limit anticipatory anxiety, and halt the feedback loop that can amplify the unpleasant feelings and sensations associated with IBS symptoms.

Mindfulness techniques can help patients tamp down the anxiety linked to their symptoms by learning to foster awareness of the present moment. In 2020, a study of patients who participated in an 8-week Mindfulness Based Stress Reduction course found that 71% of the patients had robust improvements in their GI symptoms.

“There was a significant improvement in quality of life and overall well-being,” Smith says.

The program includes various tools to help get patients to cultivate awareness and calm, including body scans, breathing exercises, or walking meditation.

It may raise eyebrows but hypnosis is another technique shown to help quiet the nervous system. New apps deliver specifically gut-directed hypnotherapy, including Meta Me (which requires a prescription) and Nerva, which people can purchase and download without a prescription. One small study found that about 70% of patients using Nerva had significant improvement in symptoms.

It’s not at all like what you’d see in the movies. There’s no pendulum swinging in front of your face. Gut-directed hypnotherapy combines relaxation techniques with suggestions and guided imagery to help reset communication between the gut and the brain.

When John Mastro, 38, of Melbourne, Australia, first heard about gut-directed hypnotherapy he was experiencing frequent bouts of GI distress that made him hesitant to join in normal day-to-day activities. “There was this sort of anxiety around the idea of leaving home, you know, the symptoms would just suddenly appear,” Mastro recalls.

Doctors had ruled out serious conditions and suggested stress could be a factor, but Mastro wasn’t convinced.

“I just sort of refused to believe that, hey, this could be some form of anxiety that’s triggering,” he recalls, though he was under a lot of stress running a business. He says using the Nerva app helped him understand the connection.

How hypnosis can calm IBS symptoms

Hypnosis can address “the hypervigilance and hypersensitivity that happens in patients that have irritable bowel syndrome,” explains Megan Riehl, a GI clinical psychologist at the University of Michigan who has been offering patients gut-directed hypnotherapy for several years.

“Our brain and our gut are communicating all the time. And if you’re somebody that has a digestive problem, it’s like the communication is turned up way too high,” she says. Hypnosis “helps calm that conversation down.”

The technique usually starts with taking some long, slow breaths, to activate the parasympathetic nervous system, followed by a type of body scan.

“You visualize, say, your chest relaxing or your stomach relaxing, your intestines relaxing,” says Ron Berli, 75, one of Riehl’s patients who lives in Grosse Pointe Park, Michigan. “You’re not into a deep sleep. I would call it just a deep relaxation. It’s almost like sitting in a hot tub.”

What distinguishes hypnotherapy from meditation alone is that after you’ve started to relax, a psychologist will talk you through a script. On the Nerva app, it’s a calming, mellifluous voice actor reading the script.

“Powerful changes are happening inside your body. Imagine the sensations of abdominal pain are becoming a thing of the past,” the soothing voice intones.

The voice tells you to imagine that you’ve been welcomed into an apothecary, where smells of herbs and concoctions fill the air. A pharmacist has made an imaginary special medicine just for you. You’re told it will create comfort and that it will soothe the line of communication between your mind and your gut.

“You’re put into a very calm state,” Mastro says. And the changes or “suggestions” articulated in the 15-minute sessions start to feel real, he says.

The app also includes short readings that distill the science of the gut-brain connection into easy-to-understand bits. Mastro says he came to understand how he was changing his physiology, activating the parasympathetic nervous system, which slows down the heart rate, lowers blood pressure and improves the digestive process.

“It’s been nothing but transformative,” Mastro says. He rarely has symptoms now, and when he does, he says he feels equipped to dial them back using the techniques he’s learned.

 

Cognitive tools to redirect anxious thoughts

There’s a lot of overlap between hypnosis, meditation, mindfulness based stress reduction and CBT, or cognitive behavioral therapy, which has a deep body of scientific research behind it. The basic gist of CBT is that it helps people identify the connection between their patterns of thinking, their emotions and their actions. And the goal is to recognize and alter their patterns of negative thinking.

CBT has been shown to help people overcome insomnia and poor sleep, and researchers are studying its effect on IBS too.

The idea is to help patients learn to “re-train” their thought processes to develop a more positive way of thinking, less likely to trigger stress.

For instance, if you’re hesitant to go out to eat because you’re worried about having a bathroom emergency, CBT can help break the cycle of catastrophic, negative thoughts. A more realistic assessment of the situation is to realize that if you did sense an urgent need to have a bowel movement, you could excuse yourself to the restroom.

There are now apps to deliver IBS-tailored CBT. Mahana is authorized by the FDA for the condition and requires a doctor’s prescription. Depending where you live, you can get a consult and prescription from within the app for a fee. Zemedy from Bold Health is another CBT-based digital app that has been shown to be effective in a small trial.

The benefit of the technique goes well beyond controlling symptoms of CBT. By developing more positive thoughts, CBT has been shown to improve overall mental health.

 

Foods to avoid to manage IBS symptoms

Changing what’s on the menu is another key tool for people to manage IBS.

The University of Michigan has had a dedicated GI nutrition program since 2007. “When I started to talk about diet as an important part of treating patients with IBS at that time, people literally laughed at me,” Chey says. “But now almost every gastroenterologist accepts that diet is an important part of the solution.”

 

The FODMAP diet has gained the most attention from researchers. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols — and the diet requires elimination or reduction of certain foods known to commonly cause gut distress, including gluten, lactose, excess fructose (found in some fruits and corn syrup) as well as certain nuts, beans and starchy vegetables.

Studies show somewhere between 52% to 86% of participants report significant improvement in their symptoms after following the diet, including reduced gas and bloating.

Researchers at Monash University in Australia explain that the FODMAP diet is based on the understanding that certain compounds in our diet can’t be completely digested or absorbed, so they can end up in the large intestine where they’re fermented by gut bacteria. This leads to gas and bloating.

“I saw the benefits almost within the first week,” says Karen Beningo of Northville, Mich., who was treated at the University of Michigan. After she started the FODMAP diet she found her energy level improved significantly. “The distension and the bloating went away very quick,” she says.

After following the diet strictly, she’s now added some foods back to her diet. She knows gluten is a trigger, so she remains gluten-free and avoids onions, broccoli and Brussels sprouts, as well as some nuts. The diet helped her learn what her triggers were.

“It was only through calming down my system and then reintroducing [them] that I pretty much confirmed, yeah, I’ve got a problem with those things,” she explains.

Following a rigorous diet takes a lot of awareness – luckily there’s an app for this one. Monash University has this FODMAP app that can help people follow the diet, detailing which foods, in which amounts, are ok, and which ones should be avoided.

 

Medical Myths About Water Consumption

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From NPR News

Myth #1: You need to drink at least eight glasses of water a day.

Photograph of eight glasses of water in clear glasses that are stacked into a pyramid. They are against a cobalt blue background and water is being poured into the top glass.

Is the advice of drinking eight, 8-ounce glasses of water a day to stay hydrated true? Researchers in 2002 tried to pin down studies that might support the claim by looking through multiple scientific databases — but were unable to find rigorous evidence behind it.

What we do know, says Hew-Butler, is that water is essential for our bodies. It makes up a majority of our cells and blood, flushes out waste through our urine and helps cool our bodies through sweat. Too little water, and our cells shrivel up from dehydration. Too much water, and our cells swell up from hyponatremia.

So how much water should we be drinking on a daily basis? It depends, says Hew-Butler, on your body size, your activity level, the temperature and how much you’re sweating.

Because of these factors, there’s no hard and fast rule for how much water you should consume. “The best advice is to listen to your body,” she says. “If you get thirsty, drink water. If you’re not thirsty, you don’t need to drink water.”

“This will protect you against the dangers of both drinking too much and drinking too little,” she adds. “And this recommendation applies to [people of] all shapes and sizes in all temperature conditions.”

Hew-Butler says hydration is also about the balance of water to salt. Sodium is necessary for our nerves and muscles to function. And it’s what our body uses to regulate the amount of fluid it needs to stay hydrated.

Thirst plays a central role in fine-tuning that balance, she explains. “There are sensors located in your brain and they are constantly tasting your blood to see if [there’s] just the right [amount of] salt. If it’s too salty, then [those sensors are] like, ‘Oh my God, I need more water.’ When that happens, it makes you thirsty.”

Then, if you drink too much water and the sensors in your brain detect that your blood is too watery, they release a hormone that tells your kidneys to pee out the extra water, she says.

In short: you don’t need an app to tell you how much water to drink or guzzle a gallon

There are, however, a few exceptions. Some research suggests that older people may have a reduced sensitivity to thirst and a decreased amount of water in their bodies — and are therefore at higher risk of dehydration. So they may need to be more intentional about their water intake. And other research has demonstrated that drinking more water can help with certain medical conditions, including kidney disease, kidney stones and urinary tract infections.

Myth #2: Caffeine makes you dehydrated.

Another persistent myth about hydration states that caffeine is a diuretic that makes you pee, and therefore caffeinated drinks like coffee and tea don’t hydrate your body. The idea is based on the findings of a study from 1928 that looked at three people. Not only is that sample incredibly small by today’s standards, but the finding has not held up to more recent experiments. So consider this myth busted.

According to multiple studies, ranging from a 2003 review of research dating back to 1966 to a 2014 clinical trial that compared coffee to water ingestion in 50 men, caffeine can be a mild diuretic in large amounts for people who aren’t accustomed to it. But caffeinated drinks consumed in moderation provide the same hydration as non-caffeinated drinks.

“Those studies have shown that drinking caffeinated and some low alcohol-content beverages [such as beer] are not much different than drinking water,” says Millard-Stafford of Georgia Tech.

Essentially, with the exception of higher alcohol-content beverages like hard liquor, all liquids count towards hydration. As does food. The experts we spoke to say about 20% of your fluid intake comes from the food you eat, from fruits and vegetables to pasta.

 

Myth #3: We need sports drinks to replace salt and other electrolytes.

You might hear that you need sports drinks to replace salt and other minerals known as electrolytes (like potassium and chloride, which are also essential for our bodies) when you’re active.

If you’re exercising for more than an hour or so, it’s likely you will need to replace the salt you’re sweating out along with water, say the experts. But you don’t have to do that by drinking sports drinks like Gatorade. While they can be one effective way to replace the body’s salt, you can get that salt from other foods and drinks. And like thirst, you can trust your body to tell you how much you need.

Researchers have found that along with a thirst for water, humans have evolved a thirst for salt and other minerals too. “The brain monitors [how much you lose], then triggers a precise appetite” for something salty, says Oka, the professor of biology at Caltech. That might be sports drinks — or a salty snack like peanuts.

Hew-Butler and a team of colleagues conducted a study to find out just how well the body’s thirst mechanism for salt works. They analyzed five years of research on ultra-marathon runners in northern California. Organizers at the races set out tables with salty snacks such as peanuts, pickles, salted watermelon and even salt packets in addition to water, soda and sports drinks and encouraged the runners to consume only what they craved. The researchers found that the runners were able to keep their salt-balance levels in check just by following their thirst and appetite.

Bottom line? Your body will tell you when it’s got a hankering for salt — so let your cravings be your guide.

 

Myth #4: Drinking water can help you lose weight.

Some small studies have found that drinking water before meals can help certain groups of people lose weight. The idea is that water makes your stomach feel full, and therefore, you eat less.

However, there are many conflicting studies on this topic. For example, one paper found that drinking up to 500 mL of water 30 minutes before a meal led to weight loss in a group of young men, but another paper found that the tactic did not work for younger people in the study — only the older ones.

And when scientists looked at papers on this subject in a systematic review, they concluded that there’s just not enough evidence for the general public. In a 2013 study published in the American Journal of Clinical Nutrition, researchers surveyed four electronic databases and found that only three studies suggested that increased water consumption could lead to weight loss if it’s part of a diet program. But the results were inconsistent for people who were not dieting. Ultimately, the researchers concluded, “The evidence for this association is still low, mostly because of the lack of good-quality studies.”

Studies have shown that drinking water can help with weight loss if it’s replacing sugary beverages like soda, sweet juices and sports drinks. In a study published in the American Journal of Clinical Nutrition, researchers asked a group of more than 300 overweight and obese individuals to replace such beverages with water for 6 months and found it helped reduce the subjects’ weight by an average of 2 to 2.5%.

 

Myth #5: Dark-colored pee means you’re dehydrated.

Scientists commonly measure dehydration by looking at the concentration of sodium and other solids in urine, which is what makes pee darker in color. But that isn’t the most precise way to tell whether someone needs more water, says Hew-Butler.

In 2017, she conducted a study published in the journal BMJ Open Sport & Exercise Medicine to see if measuring the salt concentration of urine was an accurate reflection of the salt concentration in blood. She asked 318 athletes to “pee in a cup, then we drew their blood,” she says. More than half of the athletes showed up as dehydrated when she measured their urine — but when she looked at their blood, none of them showed up as dehydrated.

Just because your urine is dark gold, says Hew-Butler, it doesn’t mean your body is dehydrated. It just means your kidneys aren’t releasing as much water in order to keep your blood’s water-sodium level balanced. It would be more accurate to look at the concentration of sodium in our blood, she says, because our brain’s sensors use that to decide how much water our bodies need.

That said, if you’re not great at paying attention to your thirst, some hydration experts recommend drinking enough water to keep your urine a light, straw-yellow color — a simple way to assess hydration.

Hydration, like so many things, comes down to balance.

“It’s a happy medium, right?” says Millard-Stafford. “Not too much. Not too little. Just right – the Goldilocks sort of approach.”

 

 

Breath Training May Reduce Blood Pressure

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From The New York Times

A normal blood pressure reading is less than about 120/80 mmHg, according to the Centers for Disease Control and Prevention. These days, some health care professionals diagnose patients with high blood pressure if their average reading is consistently 130/80 mmHg or higher, the CDC notes.

 

The impact of a sustained 9 mmHg reduction in systolic blood pressure (the first number in the ratio) is significant, says Michael Joyner, a physician at the Mayo Clinic who studies how the nervous system regulates blood pressure. “That’s the type of reduction you see with a blood pressure drug,” Joyner says. Research has shown many common blood pressure medications lead to about a 9 mmHg reduction. The reductions are higher when people combine multiple medications, but a 10 mmHg reduction correlates with a 35% drop in the risk of stroke and a 25% drop in the risk of heart disease.

 

The training helps prevent high blood pressure too

“I think it’s promising,” Joyner says about the prospects of integrating strength training for the respiratory muscles into preventive care. It could be beneficial for people who are unable to do traditional aerobic exercise, he says, and the simplicity is appealing, too, given people can easily use the device at home.

 

“Taking a deep, resisted, breath offers a new and unconventional way to generate the benefits of exercise and physical activity,” Joyner concluded in an editorial that was published alongside a prior study in the Journal of the American Heart Association.

 

So, how exactly does breath training lower blood pressure? Craighead points to the role of endothelial cells, which line our blood vessels and promote the production of nitric oxide — a key compound that protects the heart. Nitric oxide helps widen our blood vessels, promoting good blood flow, which prevents the buildup of plaque in arteries. “What we found was that six weeks of IMST [inspiratory-muscle strength training] will increase endothelial function by about 45%,” Craighead explains.

It has long been known that deep diaphragmatic breathing — often used during meditation or mindfulness practices — can help lower blood pressure too. Muscle training with the PowerBreathe device works in a similar way, engaging the breathing muscles and promoting the production of nitric oxide. The particular helpfulness of the IMST device, Craighead says, is that it requires less time to get the benefit because the small machine adds the resistance that gives the muscles a good workout. His research is funded by the National Institutes of Health.

 

The new study builds on the prior study and adds to the evidence that IMST — which is essentially strength training for the respiratory muscles — is beneficial for adults of all ages. “We were surprised to see how ubiquitously effective IMST is at lowering blood pressure,” Craighead says. Before the results came in, he’d suspected that young, healthy adults might not benefit as much. “But we saw robust effects,” he says, pointing to a significant decline in blood pressure for participants of all ages. He says the finding suggests IMST could help healthy young people prevent heart disease and the rise in blood pressure that tends to occur with aging.

 

There may also be benefits for elite cyclists, runners and other endurance athletes, he says, citing data that six weeks of IMST increased aerobic exercise tolerance by 12% in middle-aged and older adults.

 

“So we suspect that IMST consisting of only 30 breaths per day would be very helpful in endurance exercise events,” Craighead says. It’s a technique that athletes could add to their training regimens. Craighead, whose personal marathon best is 2 hours, 21 minutes, says he has incorporated IMST as part of his own training.

 

The technique is not intended to replace exercise, he cautions, or to replace medication for people whose blood pressure is so elevated that they’re at high risk of having a heart attack or stroke. Instead, Craighead says, “it would be a good additive intervention for people who are doing other healthy lifestyle approaches already.”

 

Theresa D. Hernandez, 61, sees the breathing exercises. She lives in Boulder, has a family history of high blood pressure and participated in the Colorado research. When the study began, she had blood pressure readings near the threshold at which doctors recommend medications.

 

“It was a surprise that something as simple could be so profound in terms of its impact,” says Hernandez of the six weeks of breathing exercises. “It took my blood pressure to under the threshold so that I would not need to take medication,” she says.

 

Her blood pressure dropped significantly, and she says she plans to stick with it — five minutes every day.