Norine Miller

A prospective population-based study of triggers of symptomatic flares in IBD.

OBJECTIVES:We aimed to determine whether any of the nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, infections, and stress trigger symptomatic flares of inflammatory bowel diseases (IBDs).METHODS:Participants drawn from a population-based IBD research registry were surveyed every 3 months for 1 year. They simultaneously tracked the use of NSAIDs, antibiotics, infections, major life events, mood, and perceived stress. Social networks, childhood socioeconomic status, and smoking were assessed at baseline. Disease flare was identified using the Manitoba Inflammatory Bowel Disease Index, a validated disease activity index. Across any two consecutive survey periods, participants were categorized as having a flare (inactive/active), having no flare (inactive/inactive), or remaining active (active/active). Potential triggers were evaluated for the first 3-month period to determine predictive rather than concurrent relationships. Data from only one pair of 3-month periods from an individual were analyzed.RESULTS:A total of 704 participants completed the baseline survey; 552 (78.3%) returned all 5 surveys. In all, 174 participants who had a flare were compared with 209 who had no flare. Perceived stress, negative affect (mood), and major life events were the only trigger variables significantly associated with flares. There were no differences between those who flared and those who did not, in the use of NSAIDs, antibiotics, or in the presence of infections. Multivariate logistic regression analyses indicated that only high-perceived stress (adjusted odds ratio=2.40 (1.35, 4.26)) was associated with an increased risk of flare.CONCLUSIONS:This study adds to the growing evidence that psychological factors contribute to IBD symptom flares. There was no support for differential rates of use of NSAIDS, antibiotics, or for the occurrence of (non-enteric) infections related to IBD flares.

The Manitoba IBD Cohort Study: A Population-Based Study of the Prevalence of Lifetime and 12-Month Anxiety and Mood Disorders

BACKGROUNDG AND AIMS: ven the impact of anxiety and mood disorders on health, it is important to consider these disorders in persons with inflammatory bowel disease (IBD). We assessed the prevalence of anxiety and mood disorders in a population-based IBD cohort.METHODS:A structured diagnostic interview was administered to participants in the cohort (N = 351), and rates were compared to age-, gender-, and region-matched controls drawn from a national survey (N = 779).RESULTS: A comparison of lifetime prevalence suggests higher rates of panic, generalized anxiety, and obsessive-compulsive disorders and major depression and lower rates of social anxiety and bipolar disorders in the IBD sample than in national samples in the United States and New Zealand. Direct comparisons with matched controls (with data available for three anxiety disorders) found lifetime prevalence (IBD vs controls) as follows: social anxiety disorder lower in IBD (6% vs 11%, OR 0.52, 95% CI 0.32–0.85), panic disorder not significantly different (8.0% vs 4.7%, OR 1.59, 95% CI 0.96–2.63), agoraphobia without panic not significantly different (1.1% vs 0.6%, OR 1.44, 95% CI 0.37–5.55), and major depression higher (27.2% vs 12.3%, OR 2.20, 95% CI 1.64–2.95). Comparing IBD respondents with and without lifetime anxiety or mood disorder, those with a disorder reported lower quality of life and earlier onset of IBD symptoms and there was a trend toward earlier IBD diagnosis.CONCLUSIONS:Clinicians should be aware of the increased prevalence of depression and possibly other anxiety disorders in persons with IBD as these disorders may influence response to treatment and quality of life.

Predictors of medication adherence in inflammatory bowel disease.

BACKGROUND AND AIMS:This study reports cross-sectional medication adherence data from year 1 of the Manitoba Inflammatory Bowel Disease (IBD) Cohort Study, a longitudinal, population-based study of multiple determinants of health outcomes in IBD in those diagnosed within 7 yr.METHODS:A total of 326 participants completed a validated multi-item self-report measure of adherence, which assesses a range of adherence behaviors. Demographic, clinical, and psycho-social characteristics were also assessed by survey. Adherence was initially considered as a continuous variable and then categorized as high or low adherence for logistic regression analysis to determine predictors of adherence behavior.RESULTS:Using the cutoff score of 20/25 on the Medication Adherence Report Scale, high adherence was reported by 73% of men and 63% of women. For men, predictors of low adherence included diagnosis (UC: OR 4.42, 95% CI 1.66–11.75) and employment status (employed: OR 11.27, 95% CI 2.05–62.08). For women, predictors of low adherence included younger age (under 30 versus over 50 OR 3.64, 95% CI 1.41–9.43; under 30 vs. 40–49 yr: OR 2.62, 95% CI 1.07–6.42). High scores on the Obstacles to Medication Use Scale strongly related to low adherence for both men (OR 4.05, 95% CI 1.40–11.70) and women (OR 3.89, 95% CI 1.90–7.99). 5-ASA use (oral or rectal) was not related to adherence. For women, immunosuppressant use versus no use was associated with high adherence (OR 4.49, 95% CI 1.58–12.76). Low trait agreeableness was associated with low adherence (OR 2.03, 95% CI 1.12–3.66).CONCLUSIONS:Approximately one-third of IBD patients were low adherers. Predictors of adherence differed markedly between genders, although obstacles such as medication cost were relevant for both men and women.

Longitudinal study of quality of life and psychological functioning for active, fluctuating, and inactive disease patterns in inflammatory bowel disease.

Background: The aim was to assess quality of life (QOL) and psychological functioning in inflammatory bowel disease (IBD) as related to patterns of disease activity over time. Methods: Study participants were 388 recently diagnosed individuals from the population‐based Manitoba IBD Cohort Study. They completed mail‐out surveys at 6‐month intervals and clinical interviews annually. Based on their 2‐year pattern of self‐reported disease activity, participants were assigned to 1 of 3 groups: consistently active, fluctuating, or consistently inactive disease. Disease type (Crohns disease [CD] or ulcerative colitis [UC]) was confirmed through chart review. Change over time was modeled for measures of QOL and positive and negative psychological functioning using mixed‐effects regression analyses. Results: Half of the participants had fluctuating disease activity, while almost one‐third of participants reported consistent active disease. Participants with the fluctuating activity pattern showed significant improvement in disease‐specific QOL compared to participants with consistent activity. Perceived stress, health anxiety, and pain anxiety decreased while pain catastrophizing and mastery increased over time, although the amount of change was not significantly different among disease activity patterns. However, when the data were averaged over time there were significant differences among disease activity patterns on most outcomes. Significant effects of CD versus UC were observed only for the pain measures. Conclusions: Change in IBD QOL is influenced by ones longitudinal profile of disease activity, but change in psychological functioning is not. Effects of disease activity on psychological functioning were modest, suggesting that disease has an impact even when patients are not experiencing active symptoms.

A population-based study of fatigue and sleep difficulties in inflammatory bowel disease

Background: There has been little investigation of fatigue, a common symptom in inflammatory bowel disease (IBD). The aim of this study was to evaluate fatigue more comprehensively, considering relationships with psychological and biological factors simultaneously in a population‐based IBD community sample. Methods: Manitoba IBD Cohort Study participants (n = 318; 51% Crohns disease [CD]) were assessed by survey, interview, and blood sample. Fatigue, sleep quality, daytime drowsiness, stress, psychological distress, and quality of life were measured with validated scales. Hemoglobin (Hg) and C‐reactive protein (CRP) levels were also obtained. Differences were tested across disease activity and disease subtype. Results: Elevated CRP was found for 23% of the sample and 12% were anemic; 46% had active disease. Overall, 72% of those with active and 30% with inactive disease reached clinical thresholds for fatigue (Multidimensional Fatigue Inventory; P < 0.001); 77% and 49% of those with active or inactive disease, respectively, experienced poor sleep (P < 0.001). There were few differences between those with CD and ulcerative colitis (UC) on the factors assessed, except for higher CRP levels in CD (mean 8.8 versus 5.3, P < 0.02). Multiple logistic regression analyses found that elevated fatigue was associated with active disease (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.2–7.8), poor sleep quality (OR 4.0, 95% CI 1.9–8.6), and perceived stress (OR 4.2, 95% CI 2.2–8.1), but not with hours of sleep, Hg, or CRP. Conclusions: Fatigue and poor sleep are not only highly prevalent in active disease, but both are still significant concerns for many with inactive disease. Psychological factors are associated with fatigue in IBD in addition to disease and sleep considerations. (Inflamm Bowel Dis 2011;)

Vitamin D Status and Bone Density in Recently Diagnosed Inflammatory Bowel Disease: The Manitoba IBD Cohort Study

OBJECTIVES:Bone mineral density (BMD) is usually normal at the time of inflammatory bowel disease (IBD) diagnosis. The purpose of this study was to evaluate the role of vitamin D metabolism in recently diagnosed IBD.METHODS:Adult subjects with recently diagnosed IBD (median 4 yr) were recruited from the University of Manitoba IBD Research Registry into the Manitoba IBD Cohort Study. Baseline BMD and serum 25-hydroxy vitamin D (25OHD) were measured in a nested subgroup of 101 subjects of whom 94 had repeat BMD measurements 2.3 ± 0.3 yr later.RESULTS:Only a minority (22 [21.8%]) of recently diagnosed IBD participants had optimal serum 25OHD levels (75 nmol/L or greater). Serum 25OHD was positively correlated with baseline BMD for the lumbar spine, total hip, and total body (all P < 0.05). MANOVA confirmed significant between-group differences in baseline T-scores when vitamin D status was categorized according to serum 25OHD quartile (P < 0.05). Gain in total body BMD between the baseline and follow-up DXA scans was positively correlated with 25OHD (r = 0.20, P < 0.05).CONCLUSIONS:Poorer vitamin D status correlates with lower baseline BMD at all measurement sites and better vitamin D status is correlated with a gain in total body BMD. Early optimization of vitamin D may play an important role in preventing IBD-related bone disease.

Stress Coping, Distress, and Health Perceptions in Inflammatory Bowel Disease and Community Controls

OBJECTIVES:This study compares a community inflammatory bowel disease (IBD) sample of individuals with a matched non-IBD community sample of individuals on psychological functioning and health perceptions.METHODS:Participants in the population-based Manitoba IBD Cohort Study (n=388) were directly compared with sex-, age-, and region-matched controls from a national random-sample health survey on the aspects of psychological health, coping, and perceived general health.RESULTS:Overall, the IBD sample had lower psychological well-being and mastery, as well as higher distress than did the non-IBD controls (P≤0.02). Those with IBD used avoidant coping significantly more often, and active coping modestly more often than did the non-IBD sample; both had similar levels of “self-soothing” behaviors. Patients with Crohns disease and ulcerative colitis had similarly poor levels of functioning along these dimensions compared with the non-IBD sample, as did those with active disease (P<0.01). However, those with inactive disease were similar to the non-IBD sample, and had modestly higher mastery levels. Whereas nearly half of the non-IBD group reported chronic health conditions, those with IBD were threefold more likely to report poorer health (odds ratio 3.07, 95% confidence interval: 2.10–4.47). Psychological factors explained a greater amount of variance in perceived health for the IBD than for the non-IBD sample.CONCLUSIONS:Those with IBD have significantly poorer psychological health than do those without IBD and view their general health status more negatively, although adaptive stress-coping strategies were similar. However, when disease is quiescent there is little detriment to functioning. Active disease should be a flag to consider psychological needs in the care of an IBD patient.

The Manitoba Inflammatory Bowel Disease Cohort Study: a prospective longitudinal evaluation of the use of complementary and alternative medicine services and products

Objective To determine the prevalence of complementary and alternative medicine (CAM) use over time in a population-based cohort of patients with inflammatory bowel disease (IBD). Methods The Manitoba IBD Cohort Study is a longitudinal, population-based study of multiple determinants of health outcomes in an IBD cohort. Participants completed semi-annual surveys, and annual in-person interviews. Enquiries about the use of 12 types of CAM service providers and 13 CAM products, based on items from a national survey, were included at months 0, 12, 30 and 54. Results Overall, 74% of respondents used a CAM service or product in the 4.5-year period, with approximately 40% using some type of CAM at each time point, and 14% using CAM consistently at every time point. There was a trend for women to use CAM more than men; there was no difference in CAM use between patients with Crohns disease and those with ulcerative colitis. The most often used CAM services (on average) were massage therapy (30%) and chiropractic (14%), physiotherapy (4%), acupuncture (3.5%) and naturopathy/homeopathy (3.5%). A wide range of CAM products were used, with Lactobacillus acidophilus (8%), fish and other oils (5.5%), glucosamine (4%) and chamomile (3.5%) as the most common. On average, only 18% of consumers used CAM for their IBD, so the majority chose it for other problems. There were no differences in psychological variables between CAM users and non-users. Conclusions Those with IBD commonly try CAM, although very few use these approaches regularly over the years. CAM is not usually used by patients with IBD for disease management, but clinicians should be aware that many will test the services and products.

Common Symptoms and Stressors Among Individuals With Inflammatory Bowel Diseases

BACKGROUND & AIMS We evaluated symptoms and stressful life events over a 1-year period in a population-based sample of persons with inflammatory bowel disease (IBD). METHODS Participants from the University of Manitoba IBD Research Registry (n = 704) completed 5 surveys, given every 3 months for 1 year (552 completed all the surveys). Respondents were asked to indicate the specific gastrointestinal and other symptoms, if any, they had experienced in the previous 3-month period and to document any significant stressors experienced. The Manitoba IBD Index was used to categorize active versus inactive disease. RESULTS In any 3-month period, participants with Crohns disease, compared with those with ulcerative colitis (UC), reported more diarrhea (63% vs 38%), fatigue (54% vs 33%), abdominal pain (47% vs 32%), aching joints (42% vs 29%), painful joints (24% vs 16%), fever or night sweats (24% vs 15%), nausea/vomiting (18% vs 7%), and reductions in appetite (19% vs 11%) (P < .001 for each symptom). Individuals with ulcerative colitis complained more of stool mucous or blood than those with Crohns disease (27% vs 17%; P < .001). In periods of inactive disease, participants still experienced symptoms such as aching joints (17%), fatigue (15%), diarrhea (13%), or abdominal pain (9%). In any 3-month period, approximately 50% experienced some type of stress; family stress was the most commonly reported form, followed by work or school and financial stress. CONCLUSIONS Diarrhea and fatigue are the 2 most common symptoms of individuals with IBD. Those with inactive disease still report symptoms. Almost 50% of participants reported significant stress in any 3-month period, but the primary types were everyday life stressors more so than health-related stress.

The Manitoba IBD Index: evidence for a new and simple indicator of IBD activity.

OBJECTIVES:A single-item indicator of disease activity over an extended period of time, the Manitoba Inflammatory Bowel Disease Index (MIBDI), is introduced and compared against several standard measures for assessing activity in patients with Crohns disease (CD) and ulcerative colitis (UC).METHODS:Participants enrolled in the Manitoba IBD Cohort Study, a population-based longitudinal cohort study (N=353), were assessed semiannually by survey, clinical interview, and blood sample during a 2-year period. The MIBDI is based on patient self-reports of symptom persistence for the previous 6 months, using a 6-level response format.RESULTS:The MIBDI had good sensitivity compared with the Harvey–Bradshaw Index (HB; 0.88), Powell–Tuck Index (PT; 0.84), and Inflammatory Bowel Disease Questionnaire (IBDQ; 0.89), which was maintained at two subsequent annual measurements. Test–retest reliability was also strong (Spearmans r=0.81). Discriminant function analyses identified common discriminating variables of active disease for CD and UC that included HB, PT, and IBDQ subscales of bowel and systemic symptoms, prolonged symptom severity (e.g., abdominal and joint pain, tiredness, diarrhea), and recent persistent pain related to IBD. Unique discriminators included weight problems (CD) and blood in stool (UC).CONCLUSIONS:A single-item, patient-defined disease activity measure, the MIBDI, showed a high degree of sensitivity for classifying individuals with regard to disease status over time compared with the existing disease activity measures, and strong convergent validity with expected proxy measures of disease. These relationships remained consistent over time. Thus, the MIBDI shows promise as a valid, brief tool for measuring disease activity over an extended period.