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Is going gluten-free necessary for a good health of digestive system?

3/2/2017

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That’s the question I asked myself before opening the pages of Prof D Sanders book "Gluten Attack. Is gluten waging war on our health?".
Prof Sanders is Professor of Gastroenterology at Royal Hallamshire Hospital and University of Sheffield. His specialist interest is Coeliac disease and gluten, inevitably.

Reading this book perhaps is a must if you want concrete and reliable evidence based information written in a way that is easily understood.  It gives a great overview of gluten and food intolerance, food sensitivities, Irritable Bowel Syndrome, Irritable Bowel and Coeliac disease. So, there is something for everyone – those who are diagnosed clinically and those who think they need to go gluten-free for the benefits of general and digestive health.

Question-Answer format is probably the best way to review the information in the book. So this is how the rest of the post is going to go.

Q: I have symptoms (stomach pain, bloating, diarrhoea, indigestion, constipation...) of gluten sensitivity. What should I do?
A: Go and see you doctor.
The only way to confirm if the symptoms you are experiencing are a sign of Coeliac disease is to have medical tests done. It is pointed out that you must not restrict gluten before the tests because the results of the tests wouldn’t be accurate in this case.

For anyone to develop Coeliac disease, there must be a certain expression of genes. In other words, your genetic make up makes you prone to developing gluten sensitivity. However, having the “right” genes tells only half of the story. Even if you have specific genes, you might not develop the condition and medical community is not sure why that happens.

Coeliac disease is an autoimmune disorder meaning the cells in the small intestine attack themselves, provided there is a trigger which is in this case is gluten. In any autoimmune condition, our body produces antibodies, particles which are released in the blood stream to fight unfamiliar foreign bodies such like bacteria in immune conditions or gluten in Coeliac disease. Therefore, a doctor would ask you for a blood test and if that is positive you’d be referred for a biopsy of your small intestine.

If both tests confirm you have Coeliac Disease, then you are saved - gluten-free diet is your cure.

Given IBS is diagnosed by excluding other gut conditions, you might have to endure this first to make sure your gut symptoms are not a product of Coeliac disease of Inflammatory Bowel Disease.

Q: What is the difference between food allergy and intolerance?

A: In short, clues of food allergy lies in antibody tests. However, even if the test is positive, it doesn’t mean you have an allergic reaction to that food. Intolerance, on the other hand, is a freely used term and there are no diagnostic tests to confirm food intolerance.

Food allergy is an immunological response to a particular substance and can be diagnosed by the presence of particular antibody. Allergy testing is commonly done by skin prick tests. However, you can be sensitive to a food allergen and don’t have the allergy. Therefore, only an expert can diagnose food allergy based on your medical history and your test results.

Food intolerance doesn’t appear as an immunological response to food and there is no diagnostic test for it. Symptoms for food intolerance overlap with food allergy. Intolerance is usually diagnosed by exclusion and previous medical history. There is not "good science" in conventional Western medicine to explain food intolerance which only leads to potentially charlatan claims and tests endorsed by the media.

However, as Prof Sanders points out, “the absence of evidence should not be used as proof of no effect”. Any gluten sensitivity related symptoms you are experiencing are valid, it is just our current medical paradigm is not able to provide in depth understanding of food intolerance.

Q: What about the link with IBS and gluten? Or is it the wheat?

A: It exists but it’s not cause and effect. At least, there is little evidence to claim causality.
In short, people with IBS who eat gluten products, experience an immunological reaction when gluten crosses the lining of the small intestine which results in gastrointestinal symptoms.

In one German study, people with IBS who produce gliadin (component of gluten molecule) antibodies and have the genes found in Coeliac disease responded well to gluten-free diet (1). this effect, however, was observed and little conclusion can be made about causality between gluten free diet and improved IBS symptoms.

What is needed to confirm these observations is a randomised controlled trial. Monash University in Australia, the leading research centre in FODMAP foods and IBS symptoms, conducted a double blind trial were people with IBS were given gluten free or 16g of gluten-rich (5 slices of bread would approximately contain 16g) bread or muffins (2). Double blind control trial means that neither participants nor researchers knew gluten-free or gluten based flour products were consumed by participants. It only took a week of the trial to see that participants eating gluten-rich bread/muffins reported worse gut symptoms than participants in the gluten-free arm of the trial. The researchers concluded that people who were on gluten-free bread and muffin consumption had 28% improvement in their IBS symptoms compared to participants in the gluten arm. So, people who did eat gluten-free bread and muffins were feeling better but gluten was not the cure to symptom-free IBS. It just highlights the fact that there are so many different factors affecting gut symptoms.

Q: Should I go gluten-free or low FODMAP?

A: Gluten free diet is easier to follow than low FODMAP and does improve symptoms. However, it’s your choice.

It depends on a few things such as your motivation to feel better, your current awareness of the foods you are eating that may be causing symptoms, the support of the medical and nutrition professionals as well as your family and friends. Experimenting with a way of eating to improve symptoms can be a lonely journey and you have to have people on board with you. Professional advice is great to keep you on the track without causing more damage to your health and moral support from family to help you adhere to the diet. So, it's not only "eat this not that and feel better" but, also, having the right mindset to stick to the diet which is important.

After all, is going gluten-free necessary for a good health of digestive system?
It is not necessary. It is not required. It is not a be-all-end-all answer. However, it is likely to improve IBS symptoms. "It is the dosage that makes the poison," as it was once famously said by Paracelsus. We all have different threshold levels: your gut may react to a slice of bread or only show a signal of discontent after 3 slices. Self-monitoring and awareness over diving head down to all gluten-free trap is key.

References


1. Wahnschaffe, U., Schulzke, J.D., Zeitz, M., Ullrich, R. (2007) Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea-predominant irritable bowel syndrome. Clinical Gastroenterology and Hepatology. 5(7), pp. 844-50.

2. Biesiekierski,J.R., Newnham, E.D., Irving, P.M., Barrett, J.S., Haines, M., Doecke, J.D., Shepherd, S.J., Muir, J.G., Gibson, P.R. (2011) Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. American Journal of Gastroenterology. 106(3), pp.508-14.


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Types of IBS trigger foods you might unnecessarily avoid: Part 2

3/2/2017

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In Part 2, let’s see what the evidence (1) says about dairy, wheat, high fibre food and FODMAPs.

Should I restrict milk and dairy? Would that help with my IBS?

There was a high risk of bias reported for the studies included in the review. They were not randomised controlled trials, so the effects could have only been observed without definite conclusions about lactose malabsorption in adults with IBS.

There is no high-quality evidence to confirm that milk and dairy-free diet can alleviate IBS symptoms.
What this highlights though is that lactose intolerance, lacking enzyme to break down milk sugar, can be mixed up with IBS. Lactose intolerance needs to be ruled out first. If inability to absorb lactose is due to IBS, eliminating milk and dairy can only result in small benefit, as the review highlights. The evidence we have is far form definite and convincing.

This leads back to self-awareness and tolerance levels. Having a small cup of natural yoghurt with strawberries (note: low FODMAP fruit), in theory, should not do any harm and would ensure you are getting about 200mg of calcium out of 700mg of minimum recommended average intake for healthy adults. Calcium dose for individuals with Inflammatory Bowel Disease or Coeliac Disease is even higher. However, we are all different, so check with yourself first.

Is gluten-free the solution for IBS?

Gluten is a protein found in wheat, rye and barley. It is not clear if gluten causes IBS-type symptoms directly. The review suggests that reduced intake of gluten might improve symptoms such as abdominal pain, tiredness and stool consistency, but going gluten-free might not be be-all-end-all solution.

Gluten free diet is a quite expensive pleasure if you were to consume all your regularly eaten products to gluten-free variety. That is where whole foods may be a way to go, instead of changing your bread to gluten free bread, you could try potatoes or chickpeas as a side dish. Also, if reducing the obvious choices of gluten, remember that gluten can be hidden in processed foods, such as gravy or salad dressing. More information on that can be found here.

What's the fuss about high fibre food?

 If you are constipated, you should increase your fibre intake. If you are having diarrhoea, fibre intake should go down. Simple, right?

First, what is fibre anyway? Fibre is an umbrella term for complex carbohydrate structures which are known to pass through your digestive tract without being absorbed. It can be classified to soluble and insoluble types based on the ability to be soluble and fermentable in water. Sources of both types of fibre include cereal grains such as wheat, oats, barley; fruit and vegetables; legumes, pulses and seeds (2).

Now, the premise for treating constipation with having more fibre lies on the fact that bacteria in the gut feeds on the fibre and that has positive effects on gut flora. Happy gut = regular bowel movements.
Too much fibre can be not so good for your gut – bacterial overgrowth is another issue. You probably heard about SIBO (Small Intestine Bacterial Overgrowth) already.

‘How much is too much?’ you might ask. Well, new SACN guidelines advise 30g of fibre/day for healthy population even though we are not even meeting previous recommendations. This recommendation applies to IBS sufferers as well. Women need 25g of fibre/day.

Linseeds are often quoted to be great in improving IBS. Some advocate ground and others say whole linseeds are good. Well, if you are grounding your linseeds believing that it is better – stop because the evidence is conflicting. One study found that supplementing with ground or whole linseeds v placebo supplementation showed no benefit (3). Another study, showed that 6-24g of ground linseeds helped with reducing constipation and abdominal bloating when taken for over 3 months (4).

Note of caution for linseed supplementation if you believe it helps with your symptoms - the dose has to be introduced gradually: start with 4g (1 tsp) and slowly increase up to 24g/day being aware of what the dose is doing for you IBS. Another thing to remember is for fibre to do its job you have to be well hydrated. So, sprinkling linseeds on oat porridge, yoghurt, cereal, soup, salad might be a good idea, since these contain water.

Psyllium husk, as another alternative remedy, cannot be definitely claimed to improve IBS and IBS-C symptoms. There is simply insufficient evidence to give such claims (5).

OK, what about FODMAPs?

 It has become a dietary trend these days to talk about low FODMAP foods. There is growing evidence to say that low FODMAP diet is beneficial in managing IBS. FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols. In other words, a form of sugar/carbohydrates which are fermented in your small intestine.

It’s a topic in itself to talk about. The review suggests that low FODMAP diet is beneficial when supervised by a dietitian. Like with any other diet, the more consistent and strict you are with sticking to it – the greater the benefits. If you can’t stick to it, it was, in fact, suggested that following traditional health eating advice (6) or using a probiotic with L. rhamnosus GG strain, can be just as good (7).

Few things to be aware of, are lower fibre intake compared to habitual dietary intake on low FODMAP diet and lower calcium intake over short-term (8).

So, now what?

The evidence we have is not great. So, if you wanted concrete answers, it is not available yet and better quality research needs to be done to confirm current observations. This leaves us with practice of self-awareness. Identifying foods you react to is key, reducing the intake and then slowly reintroducing the amounts again to see if they are really causing your symptoms is key. You don't want to experiment with elimination of food products for a prolonged period of time as there is a risk of developing micronutrient deficiency and even creating energy deficit by eliminating a food group altogether and not balancing out the diet.

The takeaway message from is: be cautious about elimination of foods (you don't want to end up following a fad diet) and take care of yourself as you are here for the long run. Understanding your IBS and working with it is the way to go.

1. IBS Dietetic Guideline Review Group on behalf of Gastroenterology Specialist Group of the British Dietetic Association (2016) British Dietetic Association systematic review of systematic reviews and evidence-based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Journal of Nutrition and Dietetics. 29(5), pp. 549- 575.  
2. Dhingra, D., Michael, M., Rajput, H. and Patil, R.T. (2012) Dietary fibre in foods: a review. Journal of Food Science and Technology. 49(3), pp. 255–266.
3. Cockerell KM, Watkins AS, Reeves LB et al. (2012) Effects of linseeds on the symptoms of irritable bowel syndrome: a pilot randomised controlled trial. Journal of Human Nutrition and Dietetics. 25, 435–443.
4. Tarpila, S., Tarpila, A., Grohn, P., Silvennoinen, T., Lindberg, L. (2004) Efficacy of ground flaxseed on constipation in patients with irritable bowel syndrome. Current Topics in Nutraceutical Research. 2, pp. 119–125.
5. Bijkerk, C.J., de Wit, N.J., Muris, J.W.,Whorwell, P.J., Knottnerus, J.A., Hoes, A.W. (2009) Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. BMJ. 339.
6. Bohn, L., Storsrud, S., Liljebo, T., Collin, L., Lindfors, P., Tornblom, H., Simren, M. (2015) Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 149, pp. 1399–1407.
7. Pedersen, N., Andersen, N.N., Vegh, Z., Jensen, L., Ankersen, D.V., Felding, M., Simonsen, M.H., Burisch, J. and Munkholm, P. (2014) Ehealth:low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome. World Journal of Gastroenterology. 20, pp. 16215–16226.
 8.  Staudacher, H.M., Lomer, M.C.E., Anderson, J., Barrett, J.S., Muir, J.G., Irving, P.M. and Whelan, K. (2012) Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome. The Journal of Nutrition. 142(8), pp. 1510-1518.


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Types Of IBS Trigger Foods You Might Unnecessarily Avoid: Part 1

3/2/2017

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During my time with IBS I've been fortunate to meet many other people who have a passion for understanding the complexities of IBS. I'm very glad to have got to know Vesta Simkute, who is currently studying nutrition. She has written a series of blog posts regarding IBS trigger foods which can be found below. Her knowledge of diet and IBS is comprehensive and I'm sure you'll enjoy reading and digesting these.

You can see more of Vesta's work here
https://uk.linkedin.com/in/vestasimkute
Hopefully, by now you know that you are not alone in this, even if people around you may not understand how it feels to live with IBS, yet alone how to help manage it.

You have probably discovered what foods are triggering your IBS symptoms. In fact, nine out of 10 individuals report that certain foods generate symptoms and two thirds of them start restricting those foods to improve symptoms (1,2,3). It could all go wrong from here if there is no one to supervise your attempts to help yourself. Dietetic support is helpful because working alongside a professional provides you with the support and education you need. Otherwise, reliance on the web with the excess of information when you start googling, cannot only confuse you but give the wrong advice.

Professionals rely on scientific reviews, analyses and studies from authoritative bodies which is sometimes available for the general public, like you and me.

A recent review by British Dietetic Association (4) provides some interesting insights into the types of foods that could be triggering IBS symptoms and how to deal with it practically. It is available to the public but what often happens is that the length of the paper and the academic jargon can put you off reading journal articles. Fear not, we are in this together, so let’s dive into it!

Let’s start with the basics: intake of alcohol, caffeine, spicy foods and fatty food.

Why does alcohol trigger IBS symptoms?

Alcohol affects gastrointestinal motility, absorption and intestinal permeability(5).
Plain English: Alcohol can loosen the stools (resulting in diarrhoea in extreme cases). And so the nutritious food you have eaten previously could pass through without any benefit. Intestinal permeability is just a term to describe the passage of “foreign bodies” through the lining of the gut into the bloodstream. In other words, alcohol is thought to be an irritant to the gut and provoke your symptoms.

However, there is a ‘but’…

The evidence is very biased, based on people’s perceived affect. So, any recommendation in terms of alcohol intake should follow common sense for now. The review did not have any evidence from randomised controlled trials, the gold standard research studies in clinical research.
Things to keep in mind:
·      Be drink aware – a small glass of wine (standard 13% wine is about 2 units) shouldn’t be detrimental to the way you feel.
·      Be self-aware – it takes time to pin point what’s causing distress in you gut. Our diets are really complex and non-food factors also play a role in the way your gut feels.

What about caffeine?

"Caffeine increases gastric acid secretion and colonic motor activity in healthy subjects and coffee has also been found to rapidly increase rectosigmoid motor activity" (6).

Plain English: You probably used a cup of coffee/tea to power through that pile of work. Caffeine is a stimulant – we know that. So your stomach is affected in the same way and it produces more gastric acid, fluid in your stomach which helps with breaking down and digesting food. That’s good, right? Not necessarily. Having a sensitive stomach and gut you are more likely to have acid reflux which also happens to people who don’t even have issues with the gut – it’s normal. Caffeine is, also, a diuretic – you simply make more trips to the toilet after having that cuppa or an energy drink or raw cacao drink, for that matter – food and drink rich in caffeine.

Again, caffeine can upset your stomach but the evidence is rather biased. So, nothing is set in stone. It is down to you to see where your limit is.

Caffeine intakes up to 400mg/day appear to be safe to consume. That amount of caffeine is equal to 0.5l or 1 pint of black brewed coffee. You are safe with having a few cups of coffee/ day.
One thing to remember, coffee is also an appetite suppressant, and you might want to skip a meal because you’re not hungry. That’s perhaps not a wise idea, just try to have something light to eat anyway.

Any evidence to say that symptoms are triggered by spicy foods?

"Capsaicin the active ingredient in spicy food accelerates gastrointestinal transit via the transient receptor potential vanilloid-1 (TRPV) causing abdominal pain and burning sensations in healthy individuals(7)".
Plain English: Capsaicin, a chemical compound that makes food spicy, can upset the stomach of healthy, IBS symptom free people. Therefore, you should be extra cautious but that doesn’t mean that you should exclude spicy food if you enjoy it. The effects really depend on the dosage.  The review could not conclude any cause and effect relationship and put it down to nutrition content of the meal – high FODMAP ingredients such as onions or garlic, for example.

What effect does fat have on symptoms?

"Fat stimulates the gastrocolic reflex and, when delivered directly into the duodenum, the response is prolonged and exaggerated in individuals with IBS. Moreover, fat affects small intestinal motility (8)".
Plain English: Gastrocolic reflex is the response to the food you have eaten and which is being digested in your stomach and small intestine.

Now, the recommendation to reduce fat intake is rather vague.

‘What does it mean for me personally?’, you might ask. First, fat should be minimum 20% of total food intake in females  and 25% in males to maintain healthy body weight and ensuring optimal nutrient intakes (5). To say what that means for you personally is hard, since this is a relative value. Let me illustrate: if you are eating a 2000kcal diet – 400kcal (44g total) should come from fat. However, if you are trying to loose weight and your caloric intake is at 1, 700kcal than 340kcal (38g total) of fat would be your 20%. This ensures satisfying the needs of your body so your brain, your reproductive, hormonal and nervous systems are functioning well.
 This post has turned out to be quite lengthy and I have only gone through half of the review which means two things: the end of this post and Part 2 will follow.

1. Hayes, P.A., Fraher, M.H. & Quigley, E.M. (2014) Irritable bowel syndrome: the role of food in pathogenesis and management. Journal of Gastroenterology and Hepatology. 10, pp. 164–174.
2. Lacy, B.E., Weiser, K. & De Lee, R. (2009) The treatment of irritable bowel syndrome. Therapeutic Advances in Gastroenterology. 2, pp.221– 238.
3. Monsbakken K, Vandvik P & Farup P (2006) Perceived food intolerance in subjects with irritable bowel syndrome– etiology, prevalence and consequences. European Journal of Clinical Nutrition. 60, pp.667–672.
4.   IBS Dietetic Guideline Review Group on behalf of Gastroenterology Specialist Group of the British Dietetic Association (2016) British Dietetic Association systematic review of systematic reviews and evidence-based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Journal of Nutrition and Dietetics. 29(5), pp. 549- 575.
5. Bagyanszki, M., Krecsmarik, M., De Winter, B.Y. , De Man, J.G., Fekete, E., Pelckmans, P.A., Adriaensen, D., Kroese, A., Nassauw, L., Timmermans, J.P. (2010) Chronic alcohol consumption affects gastrointestinal motility and reduces the proportion of neuronal NOS- immunoreactive myenteric neurons in the murine jejunum. Anatomical Record. 293, pp. 1536–1542.
6. Rao, S.S.C., Welcher, K., Zimmerman, B., Stumbo, P. (1998) Is coffee a colonic stimulant? European Journal of Gastroenterology and Hepatology. 10, pp. 113–118.
7. Akbar A, Yiangou Y, Facer, P., Walters, J.R.F., Anand, P., Ghosh, S. (2008) Increased capsaicin receptor TRPV1-expressing sensory fibres in irritable bowel syndrome and their correlation with abdominal pain. Gut. 57, pp. 923–929.
8. Caldarella, M.P., Milano, A., Laterza, F.,  Sacco F, Balatsinou, C., Lapenna, D., Pierdomenico, S.D., Cuccurullo, F., Neri, M. (2005) Visceral sensitivity and symptoms in patients with constipation-or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion. American Journal of Gastroenterology. 100, pp. 383–389.
9. FAO (2010) Fats and fatty acids in human nutrition: Report of an expert consultation [online]. Available from: http://www.fao.org/3/a-i1953e.pdf [Accessed on 10 January 2017]




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Radio 5 Live interview and Alflorex

10/5/2016

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Yesterday Radio 5 Live with Adrian Chiles featured a discussion of IBS. Two sufferers were interviewed alongside Alison Reid, the CEO of the IBS Network and Simon Smale, a Consultant Physician and Gastroenterologist in York.

The full interview can be found here (from the 1 hour 36 minute mark).

http://www.bbc.co.uk/programmes/b07xf30v

One of the sufferers interviewed, Zoe Salmon, a TV presenter, explained that she’d had the condition for over 20 years and had only recently found a solution with the use of Alflorex, a probiotic. She said it had alleviated all of her symptoms which is quite something.  

A link to Alflorex can be found on the Useful Links page


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Christmas cards and calendars

12/6/2015

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The IBS Network have recently made for sale calendars and Christmas cards> help support the IBS Network by clicking on the following link. All proceeds go directly to the IBS Network helping people like us
http://www.theibsnetwork.org/merchandise/
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IBS Network Change Campaign

4/23/2015

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The IBS Network, the UK's charity for sufferers of IBS are trying to increase the awareness of IBS and help the wider public understand that it a serious condition.

The aim is to collect signatures online and hopefully attract the attention of political parties to take this matter seriously.

I'd like to ask you all to take 5 minutes of your time to sign the petition if you would please. Your support does matter a great deal.

Thanks,

Matt
www.letscureibs.com


https://www.change.org/p/all-political-parties-and-the-national-medical-director-recognise-it-s-not-just-irritable-bowel-syndrome-ibs?recruiter=27127791&utm_source=share
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Living Well With IBS film

1/5/2015

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Free From Allergy Show in Liverpool 25-26th October

7/22/2014

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Just a quick note about The Allergy and Free From show in Liverpool in October.

Tickets are free and having been myself in the past I can definately recommend it for an interesting day out and gives you the chance to look at some alternative products on offer that might help with your IBS.

Tickets are free and can be secured through the link below

***click on the drop down box which says "which show would you like... to select the Liverpool option***


http://www.allergyshow.co.uk/london/e-ticket-registration/?referrer=ibs
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York talk - Acupuncture and Nutrition

4/25/2014

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I’ve just heard about a talk taking place in York on 17th June.

It’s being led by an acupuncturist, nutritionist and a registered nurse who all specialise in the treatment of IBS.

I’ll be going as I think this could be really useful and a great opportunity to speak to medical professionals.

More information can be found on the poster which can be downloaded here.

Tickets are £7 and can be purchased through the link below.

http://www.eventbrite.co.uk/e/effective-ibs-care-tickets-11192056743?aff=es2&rank=1&sid=e611ce26cc5211e39c4f12313b00d4e1

Hope to see you there

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Can you help improve information for people with IBS?

4/13/2014

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I've recently been in touch with a company called Luto and they're looking for volunteers to help them with their work on IBS.
Please click on the link below to find out more and I've attached one of their leaflets if you want to pass this round. I think this is a great, easy way to help with IBS.


Luto are experts in writing clear health information. We are looking for volunteers to help us make information about IBS easy to understand. If you have IBS and live near the Leeds area, please contact us for more information. Volunteers who take part are paid for their time.

Call us on 0113 384 5893 or visit our website www.luto.co.uk/about/volunteering

To download a leaflet click here
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