Irritable Bowel Syndrome
Irritable bowel syndrome, a commonly encountered problem in family medicine, affects five to 15 per cent of the global population . In Canada, patients with IBS take three times the number of sick days as their colleagues without IBS .
IBS is currently diagnosed clinically using a set of criteria, such as the Rome III or Manning Criteria. Given the variability in patient-reported symptoms and the imprecision of patient memory, smartphone apps may help provide a convenient way for patients to document and assist the physician with the diagnosis of IBS. Moreover, once IBS is diagnosed, apps may be used longitudinally to assess symptom response to treatments.
Currently, there exists a wide spectrum of treatments used to address IBS, including dietary, psychological, pharmacological and complementary treatments. Unfortunately, no single treatment exists that has been identified as being universally beneficial to all IBS patients. Despite the lack of strong evidence, certain dietary and lifestyle changes are often recommended as part of IBS management . One such example is a diet low in FODMAPs (fermentable oligo-di-mono- saccharides and polyols). FODMAPs are short-chain carbohydrates with poor intestinal absorption that are subject to fermentation by colonic bacteria. In theory, by reducing the amount of FODMAPs in one’s diet, there should be less bloating, abdominal pain and flatulence . We selected four apps designed to help patients with documentation and management of their IBS symptoms. All of the apps incorporated a symptom diary, which may help patients more objectively assess their response to various treatments.
IBS Diet Tracker
This iOS and Android app is an IBS symptom logger that also provides some information about low FODMAP foods. It is difficult to recommend this app because it does not allow for any robust logging of medications and diet other than in a separate notes section. Further, there are many errors encountered in the day-to-day use of this app, which render it unreliable. Given that this app has not been updated since 2015, it is uncertain whether the encountered bugs will be fixed any time soon.
The main use of this app is to help users log their daily IBS symptoms. Each recording begins with the user identifying what diet they are following, e.g. standard, gluten free, low FODMAP, along with their symptoms such as stool changes, abdominal pain, bloating, flatus, energy level and mood. Unfortunately, there is no ability to log foods consumed and medications taken at the time of the entry. There is a separate notes section that allows users to record “problem foods” and medications, but these are not time-stamped. Logged information can be graphed and exported via email and Facebook. There are also direct links to PDFs containing suggestions for low FODMAP foods and recipes, which claim to have been tested. There are no other educational or engagement tools, although the app is linked with an online paid nutritional service that costs about C$31.
The app would have been more effective if it allowed for the logging of pharmacological treatments along with specific foods eaten on a particular day, rather than an overall dietary category, e.g. gluten-free. Moreover, there is no explicitly mentioned involvement of any health care professionals in the development of this app. However, the app is linked with a paid nutritional service that is associated with a dietician and physician. The app itself has not been peer-reviewed for its effectiveness.
The app is simple and straightforward to use and includes a written instructional guide for first-time users. The design is simple and symptoms are easy to enter.
Privacy & Security+-
Once the app is downloaded, no further registration is needed. No password protection is offered, allowing anyone with access to your phone to review diary entries. No privacy statement could be found for the app.
A number of bugs were encountered during the use of this app. One was the logging of symptoms; users can only enter “none” or “v. mild” under bloating, flatus and pain. Also, the data export button to email or post information on Facebook did not work. Further, on several occasions the app needed to be restarted due to the screen suddenly blanking. This app was last updated in 2015, so it is unclear whether these bugs will be fixed in a future revision. Further, there is no technical support offered.
The app is available for both iOS and Android devices. While it is currently free for Android users, it costs $2.79 for Apple users. There are no in-app purchases in the app. The app is only available in English. The language used is easy to understand.
Gi BodyGuard helps users track their bowel habits, symptoms, medications, exercise, weight and diet. It was developed by the Canadian Digestive Health Foundation (CDHF). The overall interface is clunky and cumbersome but there is room to add custom entries. While the app itself is available on both Android and iOS and is free, it is clearly supported by Rexall Pharmacy with extensive branding inside the app. As another concern, there is no privacy statement and the future of the app is uncertain given that the last update was in 2014.
This app is designed to help individuals keep a log of their bowel routine, symptoms, medication, exercise, weight and diet. The app allows for customized food, symptom and medication entries in addition to a pre-populated list. Users can set reminders to log information, drink water or take medication. Each user entry is time and date stamped. The logged data can be exported as a file via email. Certain graphed information is exported as JPEG files. Regarding educational material, when launched, the app features a “Fact of the Day” although it is not always IBS-related and quickly disappears once data is entered. The app also contains a link to the CDHF website, which has educational materials.
This app is designed mainly as a data logging tool for patients to track their symptoms. There is easy access to a Bristol Stool Chart when logging bowel movements and customized entries allow for more expanded data logging for some categories. Some of the pre-populated symptom choices are questionable, e.g. anemia, which is not a symptom, while others are vague, e.g. well-being: poor.
The involvement of experts at the CDHF provides credibility to the app, though no names are provided on the website. Moreover, there is no peer-reviewed evidence on the app’s effectiveness.
The app does not provide a tutorial although there are videos on the CDHF website that provide an overview.
The interface is dated and logging information is cumbersome and clunky. Entering data requires users to tap through multiple screens, which makes logging needlessly time consuming. Historical information cannot be edited. The overall layout is otherwise straightforward and intuitive. The home screen provides easy access to previously logged information. Interestingly, Rexall, a sponsor for this app, has a prominently placed button – visible on almost every screen – that shows you the closest Rexall location.
Privacy & Security+-
The free app does not provide a privacy statement and there is no information pertaining to data collection. Users will only require an Apple ID / Android ID account to download the software. Once installed, no further registration is required. Under the profile tab, users can optionally enter personal details, such as gender, ethnic origin and health card number for export along with logged information.
This app is the first and only app released by the CDHF. It was last updated in 2014. The app worked reliably without any crashes during its use. There is an email address listed in the app for comments, but no specific details regarding technical support.
The app is free and available in iOS and Android. There are no in-app purchases needed to use all of the features. The app is available in English only and uses language that is easy to understand.
This iOS exclusive app is designed to help individuals keep track of their bowel movements along with their mood, diet, water intake and stress levels. Users can include up to a maximum of five custom categories, which some will find restrictive. Logged information can be exported. The app is not peer-reviewed and there is no mention of physician involvement in its creation. As of this writing there is no privacy statement.
This app is designed to help individuals keep track of their bowel movements along with their mood, diet, water intake, stress levels and up to five custom categories that are user-created. Photographs can be taken of food entries. This app provides daily reminders to input information. Users can also quickly glance at their daily summaries and average symptoms. Data can be exported as files that may be helpful for physicians to review. Unfortunately, the app does not offer anything beyond this basic journaling function and includes no patient engagement or education tools.
The ability to add custom categories partially compensates for the lack of relevant categories such as abdominal symptoms and treatments, both pharmacologic and non-pharmacologic. However, the limitation of adding only five custom categories is restricting. Further, there is no documentation that any health care professionals were involved in the app’s creation, nor is there any peer-reviewed evidence on the app’s effectiveness.
There is a limited tutorial that explains how to use the app, which has a simple interface and is easy to use. Large icons and colours guide quick data entry. Historical data can also be edited. However, the use of custom categories is less straightforward as they are lumped together and data can only be input on a numeric scale or using text.
Privacy & Security+-
The app does not provide a privacy statement and does not mention what, if anything, is done with the information collected. Users will require an Apple ID to download the software; no subsequent registration is needed once the app is used and there is no option to password protect information.
Bowelle is the first and only app released by its creator, Cane Media Ltd. It works reliably. It loads and operates quickly and smoothly; there were no crashes during its use. Only one error was encountered during the use of the app, while exporting photographs. The app is also updated regularly. While there is no specific technical support, the creator offers an email address for feedback and suggestions.
The app is free and available for iOS only. No in-app purchases are needed to use all of the features. The app is available in several languages, including French, and uses simple language and large, clear icons.
The Monash University Low FODMAP Diet
This app is designed to help users learn about and follow a low FODMAP diet in order to manage their IBS symptoms. It includes recipes, a symptom diary, shopping lists and a food guide. It is not a comprehensive IBS app and, therefore, may not appeal to all individuals. The fact that the app was developed at Monash University adds credibility to the content. However, the app is expensive and lacks Canada-specific information.
The focus of this app is to help users follow a low FODMAP diet in the management of their IBS. The app features educational written material about FODMAPs, low-FODMAP recipes, a symptom diary, a built-in shopping list and a pre-populated food guide. With its built-in food and symptom diary, users are encouraged to record their meals and their abdominal symptoms. There is also a built-in reminder tool.
This app will appeal to users who wish to focus on dietary changes to manage their IBS symptoms. It is not, however, a comprehensive IBS app.
The app was created by a research team in the Department of Gastroenterology at Monash University of Melbourne, Australia. The foods and recipes listed within the app were tested for their FODMAP content, utilizing methods developed by research teams. These techniques have been published in peer-reviewed journals and references have been listed within the app. The app itself has not been peer-reviewed for its effectiveness. Further, users should be aware that dietary recommendations are not based on Canadian guidelines.
The app is easy to use, with an intuitive design. There are colour photos of foods and meals. There is no in-app tutorial, but there is an instruction guide on the app’s website. This is not mentioned in the app itself. Navigating the app was simple and pleasant.
Because the app was developed in Australia, most of the foods tested for FODMAPs are Australian. There is a limited “international” selection of tested foods; Canada was not included. The number of recipes available in the app is small, although it is easy to add additional recipes. This may be cumbersome for those with a lot of recipes to add.
Privacy & Security+-
The food and symptom diary component of the app is not password protected. As a result, anyone with the phone could access logged information. We were also unable to find any privacy statements for this app. Once downloaded, no subsequent registration is needed.
The app worked reliably throughout its entire use. There were no crashes and pages loaded without incident. The app has also been updated numerous times this year. There is no obvious technical support but a contact email is available on the app’s website. There were no errors encountered during its use.
The app is available for both iOS and Android devices. The app itself is relatively costly and may be a barrier for some users: at the time of writing this article, the app costs C$10.99 on iOS devices and C$9.38 on Android devices. No in-app purchases are needed to use all of the features. The app is available only in English and German.
What Experts Say
Watch our interview with leading specialist Dr. Zenlea regarding IBS.
What do IBS patients want? According to a 2011 paper published in Current Gastroenterology Reports, IBS patients want validation.
“Providers often assume patients want more testing or expect a “magic pill” and complete cure, while the literature suggests otherwise,” according to Irritable Bowel Syndrome: What Do Patients Really Want? by Albena Halpert, Boston School of Medicine.
“What IBS patients are looking for the most is validation. In addition to empathy, support and hope, many patients would like to hear that they have a real gastrointestinal condition that is not simply in their heads.” The report cites a study that surveyed more than 1,200 patients in 2010. It found that IBS patients value the relational aspects of medical care as highly as technical skills and knowledge. They desire support and hope from their health care providers.
The study found the most desired quality of a health care provider is the provision of comprehensive information (96%). Patients had the most educational interest in topics foods to avoid (63.3%), causes of IBS (62%), coping strategies (59.4%), medications (55.2%), whether they would have to live with IBS for life (51.6%)and research studies (48.6%).
The report concludes that “What patients with IBS want is not only a competent, but also a caring, health care provider. They value the relationship qualities of care as highly as they value knowledge and technical skills. It is becoming more apparent that not eliciting or addressing what patients want carries a high cost to human experience and health care spending. If the saying, ‘people don’t care how much you know until they know how much you care,’ is true, then health care professionals have an obligation to respond to patients’ expectations for medical care, because care is what our patients both want and need.”
- Ford, A.C., et al., American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation. Am J Gastroenterol, 2014. 109(S1): p. S2-S26.
- Fedorak, R.N., et al., Canadian Digestive Health Foundation Public Impact Series 3: irritable bowel syndrome in Canada. Incidence, prevalence, and direct and indirect economic impact. Can J Gastroenterol, 2012. 26(5): p. 252-6.
- Paterson, W.G., et al., Recommendations for the management of irritable bowel syndrome in family practice. Canadian Medical Association Journal, 1999. 161(2): p. 154-160.
- Wilson, K. and R. Hill, The role of food intolerance in functional gastrointestinal disorders in children. Australian Family Physician, 2014. 43: p. 686-689.