Heart failure represents a major public health challenge in Saudi Arabia

Heart failure represents a major public health challenge in Saudi Arabia. Heart failure is characterized by an increase in prevalence, high costs, and a significant impact on quality of life and mortality (AlAyoubi, 2023). Having the right techniques to acquire data is essential to determine heart failure self-care behaviours, clinical results, and potential factors among the Saudi community. Self-reported scales such as the European Heart Failure Self-Care Behavior Scale (EHFScB) will be used to assess self-care maintenance, management, and confidence of heart failure patients. Such self-report scales directly assess the patients’ experiences with their daily management activities, symptom recognition, and self-efficacy beliefs (Jaarsma et al., 2021).  The medical record reviews will objectively supply clinical data on the disease characteristics, co-morbidities, treatments received, and healthcare utilization indicators, such as hospitalization rates. Therefore, this study will follow a quasi-experiment design showing how self-care practices affect HF outcomes.

Demographic Variables

The conceptualization of demographic variables is critical for this research. It provides a common understanding and a consistent approach to interpreting the variables across various contexts and populations relevant to the issue being studied. Conceptual definitions give a theoretical grounding for the variables, which ensures that they are valid representations of the intended constructs being studied (Gray et al., 2016). This strategy, on the other hand, improves the reliability and validity of the research outcomes. In the context of this research, the relevant demographic variables and their conceptual definitions are as follows:

1. Gender: This variable is categorical and defined as the socially constructed identity, roles, behaviours as consistent with other similar studies (Alshammri et al., 2023). The gender in this study is indicated via self-reporting and coded as male or female. From the aspect of self-care behaviours, treatment adherence, and seeking healthcare, gender differences will be observed among heart failure patients in Saudi Arabia.
2. Age: This is a continuous variable that refers to the number of elapsed years since birth. It will depend on the final duration of the elapsed years, as other scholars have already suggested (Chaudhary et al., 2024; Tromp et al., 2021). In this measure, age will be measured by self-reports and then divided into groups based on heart failure and self-care management of the sample distribution. The age groups will be divided into young adults (18-39 years), middle-aged (40-64 years), and older adults (65 years and above). This is the factor that is relevant in the research, and it determines health literacy, self-care ability, and readmission risks of heart failure patients (Wondmieneh et al., 2023).
3. Marital Status: This variable is a categorical one that denotes the current legally or socially accepted partnership of the participants. In this study, marital status will be measured by asking questions about it and grouped into married, single, divorced, and widowed. Marital status can make a difference in social support that also affects self-care management and outcomes of heart failure patients (Soofi et al., 2020). In this case, married couples might have a better chance of practising self-care routines. This, in turn, would make it less likely for them to be readmitted to the hospital.
4. Educational Level: This is an ordinal variable that reflects the highest formal education degree an individual has obtained. The study measures the level of education using self-report and classifies it as no formal education, primary education, secondary education, or tertiary education (undergraduate or postgraduate) (Soofi et al., 2020). People with poor health literacy may be low educated, which, in effect, can limit the capacity of patients with heart failure to take care of themselves. It may also affect their compliance with prescribed treatment protocols, and so, consequently, may lead to readmission.
5. Employment Status: This variable is nominal, specifying the current job activity of an individual. Work status will be ascertained through self-reporting and classified into employed, unemployed, and retired. Employment status can determine whether the patient will have enough healthcare resources and financial stability and whether the patient will participate in self-care activities (Aljohani, 2023). This will, thus, increase the rate of readmission of heart failure patients in Saudi Arabia.
6. Income Level/Socioeconomic Status: This is a multi-dimensional variable that incorporates one class in a society, which is defined by income, education, and occupation. This study will use the reported income levels and the validated socioeconomic status index of Saudi Arabia to determine the socioeconomic status. Socioeconomic status will be divided into categories according to how the sample will be segmented (for example, low, medium, and high). Monitoring this variable is essential for this research, as lack of health resources, financial strain, and barriers to self-care linked to low socioeconomic status can contribute to the heightened risk of readmission among heart failure patients.

Major Study Variables

It should be noted that for more reliable measurement and interpretation of results, it is important to define variables precisely. This section will define concepts, outline measurement tools, and present data related to the reliability and validity of the variables linked to heart failure readmissions and self-education programs.

30-Day Readmission Rate:

The 30-day readmission rate, which is a common outcome measure in heart failure studies, refers to the proportion of patients who are rehospitalized for heart failure within 30 days of discharge (Macchio et al., 2020). This is the principal outcome that this study plans to evaluate. It represents the number or percentage of hospital readmissions of heart failure patients after being discharged. This measure is regarded as a key indicator in the quality of care and is commonly used to assess the success of the programs targeting heart failure management improvement (Macchio et al., 2020; Madanat et al., n.d.; Rizzuto et al., 2022). One study detailed and operationalized this variable by tracking admissions and readmission rates of the patients within the 30-day window after heart failure hospitalization. They demonstrated that this variable is a valid and reliable outcome in heart failure research (Macchio et al., 2020). Readmissions can be linked to multiple other important clinical outcomes, such as death rates, and are often responsive to changes in the care processes. However, there will also be some limitations because even readmission rates are affected by factors outside the quality of care. These factors could be the demographics and co-morbidities of the patients, which may, consequently, cause negative health outcomes. The 30-day readmission rate is a binary variable (readmitted within 30 days or not). Therefore, traditional measures of internal consistency reliability, like Cronbach’s alpha, are not valid for this variable. Nonetheless, the replicability of this measure has been shown through its constant associations with other key outcomes, namely mortality and healthcare costs, across varied studies (Albinali et al., 2023; Aljabri, 2021; Alshammri et al., 2023; Macchio et al., 2020). This is a valid measure that shows the quality of care and healthcare system performance. It has been demonstrated that the measure is able to detect trends in healthcare delivery and stratagems directed towards better management of heart failures (Macchio et al., 2020). Furthermore, the 30-day readmission rate exhibits convergent validity because of its correlation with other indicators of poor performance, such as longer hospital stays and higher healthcare use. In this case, a higher score (that is, a higher percentage of patients readmitted within 30 days) is typically interpreted as an undesirable outcome, which may indicate some problems with the quality of care or patient transfers (Albinali et al., 2023; Aljohani, 2023).

Self-Care Education Programs:

Self-care programs for heart failure patients normally include lessons on medication management, symptom monitoring, and lifestyle modifications. This is the independent variable in this study. It is an educational initiative intended to educate patients about self-care, which involves details such as medication adherence, self-monitoring of the symptoms, and lifestyle changes (Aljohani, 2023). These programs try to change patients’ self-care attitudes. They primarily argue for patients to be actively involved in the management of their disease (Skouri et al., 2024). The key parts of such programs usually involve personalized learning, therapy, and care received from healthcare professionals. Scientific studies have outlined that educational programs aimed at self-care can increase self-care and reduce hospitalizations among heart failure patients (Aljohani, 2023; Alshammri et al., 2023; Mulugeta et al., 2022). Participants in these programs show better adherence to self-care instructions and have lower rates of readmission than those who receive no such intervention. These programs are subject to evaluation according to their effect on self-care behaviors and clinical outcomes, such as readmission rates. Demographic factors, as well as health-related elements like co-morbidities, are important variables that play a role in self-care behaviors and the likelihood of readmission in heart failure patients (Soofi et al., 2020; Tromp et al., 2021). These covariates should be accounted for when looking at the association between self-care, readmissions, and other outcomes. Researchers extract this information using standard demographic and medical history questionnaires (Aljohani, 2023). By transparently defining and operationalizing the key constructs, this research can guarantee that the measurements are reliable and valid. This is a precondition for drawing dependable conclusions from the studies and advising on clinical practice and policymaking on the management of cardiac failure.

Data Collection

The European Heart Failure Self-Care Behavior Scale (EHFScB-9)

EHFScB-9 is an accurate tool for evaluating patients with heart failure adherence to self-care behaviors. It deals with such behaviors as medication compliance, symptom monitoring, and lifestyle changes. The scale consists of 9 items, all on a 5-point Likert scale, and higher scores show better self-care conduct. Regarding the scores, 9-20 is low self-care, 21-32 is moderate, and 33-45 is high self-care. This affirms the relationship between higher scores on quality and better clinical results, such as reduced readmissions and lower scores on quality, which are connected with the need for intervention in patient self-management. The EHFScB-9 showed very good reliability, as Cronbach’s alpha of 0.61 was in a similar study (Mulugeta et al., 2022). Concerning validity, the EHFScB-9 showed evidence of construct validity, with positive correlations between self-care behaviors and health-related quality of life and medication adherence. In addition to that, the self-care behaviors as measured by the EHFScB-9 play a role in the prediction of important clinical outcomes, for instance, readmissions to hospital, which further demonstrates the predictive validity of the questionnaire (Mulugeta et al., 2022). There are numerous researches suggesting a positive correlation between improved self-care practices and lower hospital readmission rates among HF patients (Aljohani, 2023; Mulugeta et al., 2022; Skouri et al., 2024). Patients who partake in the prompted self-care methods have favorable outcomes and rarely need to be readmitted to the hospital.

Medical Record Review

The electronic medical record review (EMR) has been applied in Saudi heart failure studies to gather multiple items of clinical data (Aljabri, 2021; Mulugeta et al., 2022). This data consists of documented co-morbidities, laboratory results, medications prescribed, treatments received, and healthcare utilization episodes like hospitalizations and emergency visits.
One of the biggest advantages of EMR data is the ability to access objectively recorded clinical parameters, tests, and events, which reinforce and supplement subjective self-reported data provided by patients. Nevertheless, the uniformity and amount of EMR documentation may vary among institutions and providers, possibly limiting the availability of some data elements. Implementing common EMR data extraction rules with clear variable definitions, missing information handling procedures, and quality assessments ensures the credibility of EMR data collection.

Conclusion

This research study applies a comprehensive quasi-experimental design in order to investigate heart failure self-care behaviors, clinical results, including 30-day readmission rate, and related contributing factors among Saudi patients. Medical record reviews will be used as an essential tool to assess such parameters as clinical profiles and healthcare utilization patterns. Well-established procedures to guarantee reliable and valid measures of the essential variables using standardized tools and precise criteria will enhance the generalizability of the study results. In conclusion, the outcomes can guide the development of tailored self-care educational programs and those based on evidence-based care to improve the self-management of heart failure and the significant burden of hospital readmission among cardiac patients in Saudi Arabia.

References

AlAyoubi, F. Z. (2023). Cost of heart failure in-patient in saudi arabia: Role of heart failure multidisciplinary program. Cardiology Research and Reports, 5(1), 01–09. https://doi.org/10.31579/2692-9759/083

Albinali, H. A. H., Singh, R., Al Arabi, A. R., Al Qahtani, A., Asaad, N., & Al Suwaidi, J. (2023). Predictors of 30-Day Readmission in Cardiac Patients at Heart Hospital, Qatar. Heart Views : The Official Journal of the Gulf Heart Association, 24(3), 125–135. https://doi.org/10.4103/heartviews.heartviews_91_22

Aljabri, A. (2021). An inpatient multidisciplinary educational approach to reduce 30-day heart failure readmissions. Saudi Pharmaceutical Journal : SPJ, 29(4), 337–342. https://doi.org/10.1016/j.jsps.2021.03.008

Aljohani, K. A. (2023). Self-care practices among heart failure patients: A cross-sectional study in Saudi population. Saudi Medical Journal, 44(3), 277–283. https://doi.org/10.15537/smj.2023.44.3.20220799

Alshammri, M. R., Alhudayris, F. S., Alshuaibi, L. K., Alhusaini, B. A., Alfozan, O. A., Alsaleh, A. A., & Alzmamy, S. A. (2023). Heart Failure Awareness Among the General Saudi Population: A Cross-Sectional Study. Cureus, 15(7), e42077. https://doi.org/10.7759/cureus.42077

Chaudhary, A. G., Arshad, S. J., Dahdouleh, F. W., Heaphy, E. L., & Koulouridis, I. E. (2024). The Characteristics and Outcomes of Nonhospitalized Patients With Heart Failure in Saudi Arabia: A Contemporary Single-Center Study. Cureus, 16(1), e51756. https://doi.org/10.7759/cureus.51756

Gray, J. R., Grove, S. K., & Sutherland, S. (2016). Burns and Grove’s The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence (8th edition). Saunders.

Jaarsma, T., Hill, L., Bayes‐Genis, A., La Rocca, H. B., Castiello, T., Čelutkienė, J., Marques‐Sule, E., Plymen, C. M., Piper, S. E., Riegel, B., Rutten, F. H., Ben Gal, T., Bauersachs, J., Coats, A. J. S., Chioncel, O., Lopatin, Y., Lund, L. H., Lainscak, M., Moura, B., … Strömberg, A. (2021). Self‐care of heart failure patients: Practical management recommendations from the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 23(1), 157–174. https://doi.org/10.1002/ejhf.2008

Macchio, P., Farrell, L., Kumar, V., Illyas, W., Barnes, M., Patel, H., Silverman, A. L., Hong Le, T., Siddique, H., Raminfard, A., Tofano, M., Sokol, J., Haggerty, G., Kaell, A., Rabbani, S., & Faro, J. (2020). 30-day readmission prevention program in heart failure patients (RAP-HF) in a community hospital: Creating a task force to improve performance in achieving CMS target goals. Journal of Community Hospital Internal Medicine Perspectives, 10(5), 413–418. https://doi.org/10.1080/20009666.2020.1800910

Madanat, L., Saleh, M., Maraskine, M., Halalau, A., & Bukovec, F. (n.d.). Congestive Heart Failure 30-Day Readmission: Descriptive Study of Demographics, Co-morbidities, Heart Failure Knowledge, and Self-Care. Cureus, 13(10), e18661. https://doi.org/10.7759/cureus.18661

Mulugeta, T., Duguna, D., Bekele, A., & Umeta, B. (2022). Adherence to Self-Care Behaviors and Associated Factors among Adult Heart Failure Patients Attending Chronic Follow-Up Care at Jimma University Medical Center, Southwest Ethiopia. The Open Nursing Journal, 16(1). https://doi.org/10.2174/18744346-v16-e2205110

Rizzuto, N., Charles, G., & Knobf, M. T. (2022). Decreasing 30-Day Readmission Rates in Patients With Heart Failure. Critical Care Nurse, 42(4), 13–19. https://doi.org/10.4037/ccn2022417

Skouri, H. N., Çavuşoğlu, Y., Bennis, A., Klug, E., Ogola, E. N., Bader, F., Saffar, H. B. A., Ragy, H., Alhumood, K. A., Abdelhamid, M., Yılmaz, M. B., & Tabbalat, R. (2024). Expert Recommendations to Bridge Gaps in Heart Failure Patient Support in the Middle East and Africa Region. Anatolian Journal of Cardiology, 28(1), 2. https://doi.org/10.14744/AnatolJCardiol.2023.3517

Soofi, M. A., Jafery, Z., & AlSamadi, F. (2020). Impact of a Social Support Program Supervised by a Multidisciplinary Team on Psychosocial Distress and Knowledge About Heart Failure Among Heart Failure Patients. Journal of the Saudi Heart Association, 32(3), 456–463. https://doi.org/10.37616/2212-5043.1046

Tromp, J., Paniagua, S. M. A., Lau, E. S., Allen, N. B., Blaha, M. J., Gansevoort, R. T., Hillege, H. L., Lee, D. E., Levy, D., Vasan, R. S., van der Harst, P., van Gilst, W. H., Larson, M. G., Shah, S. J., de Boer, R. A., Lam, C. S. P., & Ho, J. E. (2021). Age dependent associations of risk factors with heart failure: Pooled population based cohort study. The BMJ, 372, n461. https://doi.org/10.1136/bmj.n461

Wondmieneh, A., Getie, A., & Bimerew, M. (2023). Self-care behaviour and associated factors among heart failure patients in Ethiopia: A systematic review and meta-analysis. BMJ Open, 13(12), e071960. https://doi.org/10.1136/bmjopen-2023-071960

Part 1: Overview and Pathophysiology

Irritable bowel syndrome (IBS) is a disorder of the gastrointestinal system characterized by changes in bowel habits and abdominal pain or discomfort with no detectable biochemical and structural abnormalities. Patients fall into three subtypes as per the predominant bowel pattern. The subtypes are IBS with constipation, diarrhea, and mixed-stool-pattern IBS (Holtmann, Ford & Talley, 2016). The condition’s pathophysiology is not fully understood. Additionally, there are no specific diagnostic tests or effective treatments for IBS (El-Salhy, 2015). As a result, patients with IBS visit physicians more frequently, undergo more diagnostic tests, consume more medication, and get hospitalized more frequently than those without the condition.

IBS Prevalence estimates significantly vary worldwide, within, and between countries. Findings from the surveys indicate that within communities, the prevalence of IBS is between 10% and 15% (Canavan, West & Card, 2014). At the international level, estimates place the prevalence rate at 11.2%, with a variation by geographic region. The prevalence is estimated to be highest in South America at 21.0% and lowest in South Asia at 7% (Canavan, West & Card, 2014). IBS occurs across all age groups, but women, compared to men, tend to report the symptoms more frequently.

Many patients who have developed IBS report dietary triggers. Most patients link their symptoms to the intake of specific food items such as milk and dairy products, wheat products, hot spices, onions, cabbage, and smoked foodstuffs (El-Salhy, Patcharatrakul & Gonlachanvit, 2021). Reports indicate that “fermentable oligosaccharides, monosaccharides, and disaccharides and polyols (FODMAPs)” may exacerbate symptoms of IBS in a section of patients (Holtmann, Ford & Talley 2016, p.134). FODMAPs include lactose, fructose, sugar sources, galactans, and fructans.

FODMAPS occur in various foods, including legumes, wheat, vegetables, rye, and fruits. They contain poorly absorbed and indigestible short-chain carbohydrates (Aziz, Tornblom & Simrén, 2019). After ingestion of FODMAPs, the unabsorbed carbohydrates go into the distal small intestine and the colon. They increase osmotic pressure within the luminal cavity and provide a substrate for bacterial fermentation (El-Salhy, 2015). The bacterial fermentation results in gas production, and its accumulation brings about abdominal distension and pain (El-Salhy, 2015). Diets rich in FODMAPs are reported to trigger gastrointestinal symptoms in IBS (Cozma-Petruţ et al., 2017). However, a diet low in FODMAPs reduces symptoms and improves patients’ quality of life.

Part 2: Food Plan and Therapeutics Foods

Given the critical role that diet plays in the pathophysiology of IBS, dietary interventions may help manage and treat the conditions. One such intervention is the Low FODMAP diet, which is currently viewed as second-line dietary therapy for the disorder (Aziz, Tornblom & Simrén, 2019). The plan entails a three-step elimination diet that starts with the elimination phase. In the first step, all high FODMAP-containing foods are restricted for between 4 and 8 weeks (Aziz, Tornblom & Simrén, 2019). The second phase involves the gradual reintroduction of FODMAPs to identify the foods the patient can tolerate and those they cannot tolerate. The final step is the personalization phase, in which the intolerable foods are eliminated or limited, and the patient is taken into long-term follow-up (Aziz, Tornblom & Simrén, 2019). The diet must be implemented under the guidance of a qualified dietician.

Several studies have supported the efficacy of the Low FODMAP diet in managing IBS. In one study, de Roest et al. (2013) reported a significant improvement in most symptoms, such as diarrhea, bloating, and abdominal pain, among IBS patients, placed on the diet over 15.7 months. In another study conducted in Australia, Peters et al. (2016) report that a low FODMAP diet reduced overall gastrointestinal symptoms over six months. These findings support the potential usefulness of the diet for patients with IBS.

A Low FODMAP diet includes dairy products such as rice milk, almond milk, and lactose-free milk. It also includes fruits such as bananas, and oranges and vegetables such as potatoes, lettuce, and carrots (Liu et al., 2020). Proteins in the diet include beef, pork, fish, and chicken, while grains include gluten-free pasta, rice bran, and oat bran (Liu et al., 2020). Whole grain and bran cereals such as rice and oat bran are excellent sources of insoluble fiber. Consuming them daily will help promote regular laxation (Cozma-Petruţ et al., 2017). Their consumption also ensures that patients have enough energy throughout the day.

There are several negative aspects of the low FODMAP diet. The elimination of galactans and fructans could result in the alteration in the composition of gut microbiota and the reduction of beneficial bacteria (Zanetti et al., 2018). The dietary restriction could also result in weight loss among patients. The concerns can be overcome by educating patients about the importance of involving a qualified dietician in planning and implementing the diet. A qualified dietician will ensure that the diet is adequately balanced and with enough proteins to prevent possible weight loss. Involving a qualified dietician will also ensure that patients incorporate the right probiotics needed to maintain the suitable composition of gut microbiota.

Part 3: Dietary Supplements

Several dietary supplements are effective in the management of IBS. They include guar gum and glutamine. Guar gum is a water-soluble fiber extracted from the guar plant’s seeds (Niv et al., 2016). This plant is native to India and Pakistan. Guar gum’s primary component is a galactomannan. Niv et al. (2016) conducted a study to establish its efficacy in IBS. They report that administering 6 grams per day of partially hydrolyzed guar gum (PHGG) helps with bloating and gas in IBS patients. Contraindications for Guar gum include hypoglycemia, hypotension, and gastrointestinal obstruction (Rxlist, 2022). The dietary supplement should be avoided at least two weeks before surgery.

Figure 1: Guar gum seeds ( Retrieved from https://www.therealgoodnutrition.com/therealgoodblog/2018/10/18/the-good-gut-part-i-guar-gum)

The second dietary supplement, glutamine, is an essential amino acid. It is a preferred energy source for cells with a fast turnover, such as enterocytes and lymphocytes. It promotes the proliferation of enterocytes, controls tight junction proteins, and inhibits pro-inflammatory signaling pathways (Rastgoo et al., 2021). Zhou et al. (2019) conducted a two-month clinical study to evaluate the efficacy of taking a glutamine supplement in IBS with diarrhea. Their findings show that a 5-gram dose of glutamine supplement taken three times daily helps reduce symptoms’ severity and daily stool frequency. In addition, the supplement improved stool consistency and intestinal permeability compared to a placebo (Zhou et al., 2019). Contraindications for glutamine include liver disease and kidney disease (Drugs, 2022). The supplement is available in powder and tablet forms.

Part 4: Educating Clients in Self-Management

Self-management can be quite effective in relieving the significant symptoms of IBS. As part of self-management, patients should change the types of food they eat. They should be on the lookout for foods that worsen the symptoms and avoid them. Patients should be educated about foods rich in FODMAP and how they contribute to the exacerbation of IBS symptoms. They should be taught about the low FODMAP diets and some foods that can be incorporated into the diet. Clients should also be informed about the importance of regular exercise, relaxation, and avoiding stress in managing IBS.

Part 5: Collaboration with Healthcare Professionals

Among the many factors that contribute to IBS is stress. Stress can be managed through many approaches, yoga being one of them. D’Silva et al. (2020) report that yoga is safe and effective and may target several mechanisms involved in IBS treatments. Findings from their study indicate that yoga is equally as effective as dietary interventions in managing the disorder. This implies that a dietician can collaborate with a psychotherapist to ensure effective treatment of IBS.

Part 6: Conclusion

IBS is a manageable condition. Numerous factors trigger the condition, but diet is a significant factor. Available evidence supports the efficacy of a low FODMAP diet in managing the condition. However, this should be implemented with other interventions for optimum patient outcomes. Exercising regularly, yoga, and other practices that help promote mental well-being are some additional approaches patients should consider. One can download a simple guide to low FODMAP here.

References

Canavan, C., West, J., & Card, T. (2014). The epidemiology of irritable bowel syndrome. Clinical epidemiology, 6, 71–80. https://doi.org/10.2147/CLEP.S40245

Cozma-Petruţ, A., Loghin, F., Miere, D., & Dumitraşcu, D. L. (2017). Diet in irritable bowel syndrome: What to recommend, not what to forbid to patients! World journal of gastroenterology, 23(21), 3771–3783. https://doi.org/10.3748/wjg.v23.i21.3771

de Roest RH, Dobbs BR, Chapman BA, Batman B, O’Brien LA, Leeper JA, Hebblethwaite CR, Gearry RB. The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. Int J Clin Pract. 2013 Sep;67(9):895-903. DOI: 10.1111/ijcp.12128. Epub 2013 May 23. PMID: 23701141.

Drugs. (2022). Glutamine. Retrieved from https://www.drugs.com/mtm/glutamine.html

D’Silva, A., MacQueen, G., Nasser, Y., Taylor, L. M., Vallance, J. K., & Raman, M. (2020). Yoga as a Therapy for Irritable Bowel Syndrome. Digestive diseases and sciences, 65(9), 2503–2514. https://doi.org/10.1007/s10620-019-05989-6

El-Salhy M. (2015). Recent developments in the pathophysiology of irritable bowel syndrome. World journal of gastroenterology, 21(25), 7621–7636. https://doi.org/10.3748/wjg.v21.i25.7621

El-Salhy, M., Patcharatrakul, T., & Gonlachanvit, S. (2021). The role of diet in the pathophysiology and management of irritable bowel syndrome. Indian Journal of Gastroenterology, 40(2), 111-119. https://link.springer.com/article/10.1007/s12664-020-01144-6

Holtmann, G. J., Ford, A. C., & Talley, N. J. (2016). Pathophysiology of irritable bowel syndrome. The Lancet Gastroenterology & hepatology, 1(2), 133-146. https://doi.org/10.1016/S2468-1253(16)30023-1

Liu J, Chey WD, Haller E, Eswaran S. Low-FODMAP Diet for Irritable Bowel Syndrome: What We Know and What We Have Yet to Learn. Annu Rev Med. 2020 Jan 27;71:303-314. doi: 10.1146/annurev-med-050218-013625. PMID: 31986083.

Niv, E., Halak, A., Tiommny, E., Yanai, H., Strul, H., Naftali, T., & Vaisman, N. (2016). Randomized clinical study: Partially hydrolyzed guar gum (PHGG) versus placebo in the treatment of patients with irritable bowel syndrome. Nutrition & metabolism, 13(1), 1–7. https://doi.org/10.1186/s12986-016-0070-5

Peters, S. L., Yao, C. K., Philpott, H., Yelland, G. W., Muir, J. G., & Gibson, P. R. (2016). Randomised clinical trial: the efficacy of gut-directed hypnotherapy is similar to that of the low FODMAP diet for the treatment of irritable bowel syndrome. Alimentary pharmacology & therapeutics, 44(5), 447–459. https://doi.org/10.1111/apt.13706

Rastgoo, S., Ebrahimi-Daryani, N., Agah, S., Karimi, S., Taher, M., Rashidkhani, B., Hejazi, E., Mohseni, F., Ahmadzadeh, M., Sadeghi, A., & Hekmatdoost, A. (2021). Glutamine Supplementation Enhances the Effects of a Low FODMAP Diet in Irritable Bowel Syndrome Management. Frontiers in nutrition, 8, 746703. https://doi.org/10.3389/fnut.2021.746703

Rej, A., Aziz, I., Tornblom, H., Sanders, D. S., & Simrén, M. (2019). The role of diet in irritable bowel syndrome: implications for dietary advice. Journal of internal medicine, 286(5), 490-502. https://doi.org/10.1111/joim.12966

Rxlist. (2022). Guar Gum. Retrieved from https://www.rxlist.com/guar_gum/supplements.htm

Zanetti, A. J. A., Rogero, M. M., & Von Atzingen, M. C. B. C. (2018). Low-FODMAP diet in the management of irritable bowel syndrome. Nutrire, 43(1), 1-5. https://doi.org/10.1186/s41110-018-0076-z

Zhou, Q., Verne, M. L., Fields, J. Z., Lefante, J. J., Basra, S., Salameh, H., & Verne, G. N. (2019). Randomised placebo-controlled trial of dietary glutamine supplements for postinfectious irritable bowel syndrome. Gut, 68(6), 996–1002. https://doi.org/10.1136/gutjnl-2017-315136

Antibiotics should be given with caution. Using
the headings below describe how the administration of antibiotics could have contributed to the development
of thrush in Nevaeh. Destruction of normal flora. Proliferation of bacteria/fungus