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Survey Examining Herbal Supplement Use for Treatment of Gastrointestinal Disorders

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Title:
Survey Examining Herbal Supplement Use for Treatment of Gastrointestinal Disorders
Creator:
Mason, Sydney
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Language:
English

Subjects

Subjects / Keywords:
Complementary therapies ( jstor )
Diarrhea ( jstor )
Gastrointestinal disorders ( jstor )
Institutional review boards ( jstor )
Irritable bowel syndrome ( jstor )
Peppermint oil ( jstor )
Social media ( jstor )
Student surveys ( jstor )
Symptomatology ( jstor )
Websites ( jstor )
Gastrointestinal system--Diseases
Herbs--Therapeutic use
Genre:
Undergraduate Honors Thesis

Notes

Abstract:
PURPOSE: Specific aims are to 1) examine demographic characteristics of online users who have Gastrointestinal (GI) symptoms and link them to herbal supplement use, and 2) investigate perceived effects of the herbal supplements on GI symptoms. BACKGROUND: GI disorders affect millions of Americans annually. Sufferers left unsatisfied with traditional medicine are more inclined to seek complementary alternative medicine (CAM) therapies for symptom management. METHODS: An anonymous, multi-question format online survey was created through Qualtrics. The link is made available on the Medical Futures Iberogast Website, the International Foundation of Functional Gastrointestinal Disorders website, and specific GI-related Facebook groups. Data collection ends mid-April. FINDINGS: A preliminary data analysis using SPSS software consisted of 26 respondents. 17 (65.4%) were female, 20 reported experiencing GI symptoms in the past four weeks, and 15 (88.2%) of 17 people reported past or current use of herbal supplements to treat a specific health problem. IBS was the most reported GI disorder and ginger the most common supplement used. DISCUSSION: A recent IRB amendment allowing the survey to reach a wider population will improve study feasibility by providing increased information to GI disorder sufferers on current perceived effectiveness of herbal supplements in managing GI disorders among respondents. ( en )
General Note:
Awarded Bachelor of Science in Nursing; Graduated May 7, 2013 summa cum laude. Major: Nursing
General Note:
Advisor(s): Dr. Saunjoo Yoon
General Note:
College/School: College of Nursing

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University of Florida
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University of Florida
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Copyright Sydney Mason. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Running head: HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS Survey Examining Herbal Supplement Use for Treatment of G a strointestinal Disorders Sydney Mason University of Florida College of Nursing

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 2 Abstract The purpose is t o examine self reported herbal supplement use for the management of Gastrointestinal (GI) disorders among internet users. The specific aims are to 1) examine demographic characteristics of online users and compare them to herbal supplement s and Complementary and Alternative Medicine ( CAM ) use and 2) evaluate the perceived eff ects of specific supplements in managing GI symptoms. GI disorders have a significant physical, social and financi al impact on sufferers and are reported to affect 6 0 70 mi llion Americans annually. An estimated 50% of patients suffering from Ir ritab le Bowel Syndrome (IBS), a common functional GI disorder are more inclined to seek out CAM and herbal supplements as a way to self treat GI symptoms A n anonymous online survey was created through the University of Florid a Qua ltri cs server platform consisting of Likert scale questions, choi ce questions and brief text answer s. The survey link is made available on the Medical Fu tures Inc. Iberogast website and the International Foundation of Functional Gastrointestin al Disorders (IFFGD) website. The link is also made available on Facebook groups related to GI disorders. The study is ongoing with data collection ending in mid April 2013 A preliminary data analysis based on 26 responses revea ls 65.4% were female, 92.3% were non Hispanic white and the most common age range was 36 45 years old Ginger was the supplement most often used by participants. IBS was the most commonly reported hea lth problem initially, however a review of the most recent influx of responses indicates this as well as othe r trends in the data may be changing. A recent IRB amendment allowing the surve y to reach a wider population will help improve study feasibility It will accomplish this by providing increased information to sufferers of GI disorders on current perceived effectiveness of herbal supplements in managing GI disorders among respondents.

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 3 Introduction Gastrointestinal (GI) disorders have an overwhelming preval ence both in the United States and worldwide. They affect not only the physical and emotional health of sufferers but also place a considerable financial bu rden on those afflicted A multitude of current pharmacologic treatment modalities exist for th ese disorders, however many people are left unsatisfied with these alone and thus more inclined to seek o ut Complementary and Alternative Medicine (CAM) therapies as a way to self treat for their symptoms. Surveys have been utilized in the past to collect information on general herbal supplement use in the population in a variety of formats, for example the community setting (Yoon, 2006). However, an I nternet based survey format could result in a larger response rate, and reach a grea ter population from different regions of both the U.S. and worldwide. Literature Review GI disorders affect a larg e percentag e of the population with as much as 60 70 million as one of common GI disorders lack a definitive organic cause, and are often diagnosed through exclusio n criteria when compared to more organic dis orders (Talley, 2008 ). One county in Minnesota was reported that up to 42% of the population in the county had one or more functional GI disorder over a 12 year period (Talley, 2008). Irritable Bowel Syndrome (IBS) and Fu nctional Dyspepsia (FD) are two categories of impact on the population, and range in severity from mild to debilitating (Talley, 20 08). Another study in Sweden estimated the prevale nce of IBS and FD combined to affect approx imately 50% of the population ( Stake Nilss on, Hultcrantz, Unge, & Wengstr m, 2012) When examining I BS alone i t i s projected to have a prevalence rate of 10 15% in industrialized countries ( Maxion

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 4 Bergemann, Thielecke, Abel, & Bergemann, 2006). Despite these alarming figures, i t is still estimated that as much as 75% of people suffering fro m IBS go undiagnosed due to inconsistencies in the diagnostic criteria (Yoon, Grundmann, Koepp, & Farrell, 2011) Other GI disorders are those with a more concrete pathological epidemiology, such as inflammatory bowel diseases (IBD) cancers affecting the GI tract, Gastroesophageal Reflux Disease (GERD) and diverticular d isease These dis orders are more organic in nature, with pathological and biochemic a l mediators, and therefore easier to diagnose than such as IBS (Yoo n, Grundmann, Koepp, & Farrell 2011). Information collected from the 2009 National Ambulatory Medical Care Survey (NAMCS) lists some of the most common of these disorders to be Gast roesophageal Reflux Disease ( GERD ) IBD d i verticular disease, hemorrhoids and colorectal neoplasms (Peery et al., 2012). GERD, for example, accounted for 8,863,568 outpatient clinic visits in the U.S. in 2009 (Peery et al., 2012). These organic disorders are also more commonly linked with increased mortality rates. Approximately 10% of the 2,437,163 deaths in the U.S. were attributable to GI disease, most notably colorectal and pancreatic cancers (Peery et al., 2012). In contrast, deaths due to functional GI disorders such as IBS are considered rare, as are hospitaliza tions for the same disorders (Everhart, 2009). Financial and Social Burden of GI di sorders GI dis orders place a considerable economic burden on those aff licted, and extensive financial costs on the U.S. as a nation (Sander et al., 2002). The direct and indirect costs of IBS alone in the U.S. are estimated to be 15 30 billion doll ars annually (El Salhy, 2012). G astrointe stinal disorders combined have an ap proximate cost of 142 billion dollars annually in the U.S. in both direct and indirect costs (Peery et al., 2012). Direct costs include hospital services, prescription drugs, over the counter drugs and physician services (Everhart & Ruhl,

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 5 2009). Indirect costs for GI disorders are calculated based on such things as wages lost from missed work and costs associated with premature death (Everhart & Ruhl, 2009). Some of the more expensive GI disorders, costing more than $1 billion, inc lude abdominal wall hernias, gallstones, liver diseas e, GERD and colorectal c ancer (Everhart & Ruhl, 2009). Prescription medications used to treat GI dis orders are extremely costly for the consumer. One of the more costly of these groups of medications are proton pump inhibitors used to treat GE RD. I n 2004 Lansoprazole (a PPI) had a total retail cost of $3, 104,963,208 in the U.S. (Everhart, 2009). GI disorders also imp act the overall quality of life of sufferers. According to the 2010 United States National Health and Wellness Survey (NHWS), colorectal cancer is the GI disease connected with the worst quality of life (Peery et al., 2012). IBS has also been connected with lower reports overall on qu ality of life (Yoon, Grundmann, Koepp, & Farrell, 2011) Symptoms associated with IBS, such as bloating and diarrhea, are said to cause people suffering from the confidence (Yoon, Grun dmann, Koepp, & Farrell, 2011). Avoidance of social settings and reported feelings of lack of control over their lives may be due to such things as being forced to stay near a toilet which is primarily associated with diarrhea predominant IBS (Yoon, Grund mann, Koepp, and Farrell, 2011). CAM and Herbal T herapies Although pharmacologic treatments exist for both functional and organic GI disorders, many people are l eft unsatisfied with them alone For example, t he difficulty in diagnosing and treating IBS, as well as the chronic nature of the disease, make people more inclined to seek out alternative therapies for symptom control (Yoon, Grundmann, Koepp, & Farrell, 2011) This can likely be attributed to severa l factors, including lack of perceived effica cy from prescribed

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 6 medications, side effects of the medication regimen or financial burden accrued from purchasing such medications. The National Center for Comple mentary and Alternative Medicine (NCCAM) defines CAM as a broad array of therapies used for healthcare treatment that are not considered par t of traditional medicine (NCCAM 2012). One study estimates that approximately 50% of patients with IBS seek out C AM therapies as a way of self treating symptoms unrelieved with conventional medicine (Shen & Nahas, 2009). CAM can be divided into several areas including mind body medicine, body based practices, and natural products (NCCAM, 2012). Herbal supplements f it in to the latter category of CAM, and will be the focus of this study. A multitude of herbal supplemen ts are covered in the survey, h owever only six of these are included in the supplemental GI loop (discussed in methods) These are as follows: fiber, Iberogast Padma Lax peppermint oil, probiotics and Tongxie Yaofang. Fiber is found in many foods ( e.g. fruit s, vegetables, and whole grains ) and dietary supplements containing fiber are commonly used in t he treatment of GI disorders for relief of such symptoms as constipation (Leung, Riutta, Kotecha & Rosser, 2011). Low fiber intake has commonly been thought to be a contributing factor to chronic constipat i on (Leung, Riutta, Kotecha, & Rosser, 2011). However, the efficacy of it as an appropriate supplement in the dietary management of GI symptoms is still under debate. One systematic review of clinical trials found that 155 of 300 (52%) pa tient s assigned to fiber in the trials studied still had persistent s ymptom s after taking it compared to 168 of 291 (57%) participants in control groups (Ford et al., 2008). However, another report suggest s it may be useful in symptom management of specific GI disorders, such as constipation predominant IBS (Grundmann & Yoon, 2 010). Iberogast (STW5) is a combination of nine essential herbal extracts, includin g bitter candytuft, angelica root, celandine herb, caraway fruit, liquorice root, cham omile, milk thistle,

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 7 lemon balm and peppermint (Krueger et al., 2009). Studies suggest that this combination supplement has prosecretory effects on the intestines, making it suitable for treating such disorders as functional dyspepsia and IBS (Krueger et al., 2009). Another study found that Iberogast was also effective in re ducing abdominal pain associated with IBS (Madisch, Holtmann, Plein, & Hotz, 2003). Padma Lax is a Tibetan herbal formula that acts as a laxative. This combination supplement contains many herbs, including such things as Aloe extracts, Frangula tree ba rk, Natrii Sulfas and ginger. It has often been used in the treatment o like constipation predominant IBS (Gschossman n Krayer, Flogerzi, & Balsiger, 2010). A study examining the effect of the supplement on GI motility of rats suggests that this combination supplement reduced s pontaneous contractile activity of the smooth muscle in certain regions of the intestines (Gschossmann, Krayer, Flogerzi, & Balsiger, 2010). Most of the literature surrounding the use of peppermint oil examines it in the context of the treatment of motility disorders like IBS A meta ana lysis performed by Ford et al. in 2008 demonstrated that peppermint oil was more effective than placebo in the management of IBS symptoms Symptoms targeted by pep permint oil may include those related to constipation, such as bloating, abdominal distension and feelings of incompl ete or difficult evacuation (Cappello, Spezzaferro, Grossi, Manzoli, & Marzio, 2007). It is also tho ught that peppermint oil has a relaxing and antispasmodic ef fect in the intestinal smooth muscle and thus is also useful in relieving diarrhea associated with di arrhea predominant IBS (Cappello, Spezzaferro, Grossi, Manzoli, & Marzio, 2007). Probiotics are used for a number of health conditions, and products co ntaini ng them are increasingly seen in television and other advertisements. Some of these health conditions

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 8 include allergies, bacterial vaginosis and urinary tract infections (Verna & Lucak, 2010). Probiotics are also considered a safe treatment for th ose suffering from GI disorders. Benefits of probiotics as a treatment have been shown in the following GI disorders: Antibiotic associated diarrhea, Clostridium Difficile colitis, infectious diarrhea, IBD and IBS (Verna & Lucak, 2010). Tongxie Yaofang is a traditional Chinese herbal supplement used in the treatment of diarrhea. Although limited trials could be found on the use of the supplement in specific health problems, o ne study was performed to investigate the clinical effect of Tongxie Yaofang i n treating diarrhea predominant IBS and researchers found that property of stool, abdominal pain and distension as well as mental condition were all improved in subjects receiving the herbal supplement (Pan, Zhang, Zhang, Xu, & Chen, 2009). However, ther e was no clinically significant difference in efficacy between the experimental and control groups (Pan, Zhang, Zhang, Xu, & Chen, 2009). Summary of the Literature The literature suggests that people suffering from such as IBS are especially inclin ed to seek out CAM including herbal supplements for managing GI symptoms. Studies examining the use of such herbal supplements as described above (e.g. Tongxie Yaofang, peppermint oil, probiotics) in treating GI symptoms are often exam ined in the context of IBS ( Cappello, Spezzaferro, Grossi, Manzoli, & Marzio, 2007; Pan, Zhang, Zhang, Xu, & Chen, 2009; Verna & Lucak, 2010). However, the perceived efficacy of many of these supplements in managing GI symptoms is still under debate (Ford et al., 2008) and warrants more evidences Purpose The purpose of this study is to investigate the effectiveness of herbal supplements in treating gastrointestinal disorders. The specific aims are 1) examine demographic characteristics

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 9 of online users and compare th em to general supplement and CAM use and 2) evaluate the perceived effects of specific supplements in managing GI symptoms. Demographic characteristics collected include gender, age, ethnicity, employment status, and insurance information, to name a few. Methods The s tudy was approved by IRB 02, and utilizes the HIPAA compliant Qualtrics server platform made available to UF students and faculty for online questionnaires The anonymity of the survey stems from the untraceable IP addresses of the survey t akers, a feature of Qualtrics The link to the survey was made available to two separate websites. The first one is an Iberogast website ( http://www.iberogast.ca/ ), owned and operated by the distributors of Iberogast in North America Medical Futures In c. ( http://medfutures.com/ ). The second website is the International Foundation for Functional Gastrointestinal Disorders website ( http://iffgd.org/ ). A recent protocol revision has allowed the links to be posted to Facebook group pages related to GI disorders upon consent of the group administra tor, and thus far the link is posted on the Facebook page Gastroparesis Patient Association for Cures and Treatments, Inc. (G PACT) at h ttps://www.facebook.com/GPACT and GI Stromal Tumor (GIST) Support International at https://www.facebook.com/pages/GIST Support International Inclusion criteria for the study requires that participants be 18 years of age or older and consent to taking the survey Aside from the age requirement, no sp ecific exclusion criteria exist The survey is estimated to take approxi mately 25 minutes to complete. The links were made active on January 1 6 th 2013 and data collection will end on April 15 th 2013 The study was unfunded, and no compensation was provided to the we bsites for posting the link, or to the survey participants for completing the anonymous survey

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 10 The survey consists of Likert sc ale questions, choice questions and brief text answers Another feature is the supplemental GI loop, meaning that future questions presented to t he survey taker are dictated by their previous answers to questions regarding supplement use. For example, if a parti supplement Iberogast, the next question s would then ask them how they originally heard about that particular herbal supplement if they have taken it before, for what health problems do they take it, etc If they were to have answer then they are taken to the end of that particular block, and the next question they will receive will be regarding a different supplement. Intermittent and final data analysis will utilize SPSS version 21, Microsoft Excel, and GraphPad Prism version 5.0. Results The first analysis of the data was performed on February 18 th 2013 and SPSS software version 21 was used for the analysis. The data set included 26 responses. In regards to demographic information, 17 (65.4%) of the respondents were female, 24 (92.3%) were non Hispanic white, and the most common age range was 36 45 years old. Of the 26 responses, 18 (69.2%) are married and the most frequently recorded employment status (46.2%) was currently employed (full time). The most common type of insurance among tho se 26 responses was private insurance through an employer (46.2%). A majority (53.8%) of the respondents recorded their highest level of e ducation being college graduate. When looking at health status, 23 (95.8%) of 24 people said they do not currently s moke, and 18 (75%) of 24 people said they have not consumed alcoholic beverages during the past week On a scale of one to seven, one being the worst and seven being the best, six among 20 respondents (30%) rated three (3), which was the most common current health rating for that question. N o one rated his or her health as being a seven out of seven overall or the best possible health rating.

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 11 The survey then continued on to address questions surrounding gastrointestinal symptoms and herbal supple ment and CA M use. When asked the question, Do you currently (during the last 4 weeks) experience any gastrointestinal symptoms such as bloating, abdominal pain, stomach pain, heartburn, or flatulence? for that particular quest ion 17 (85.0%) responded supplements for their own health or treatment. 16 (88.9%) of 18 people said they used dietary or herbal supplements within the past 12 months for the same re ason. When answering the question on whether or not the dietary or herbal supplement was used for a specific health problem, 15 (8 8.2%) of 17 people responded The most commonly reported health problem by survey respondents was IBS with a freque ncy of 8. The two most common self reported herbal therapies or dietary supplements used by participants in rank order were ginger and then peppermint. With the presence of the supplemental GI survey loop, subjective information in the form of short resp onse answers from survey takers was also obtained. When they were then asked if they believed it to be helpful in symptom management for their GI disorder. Their response was, It has never really helped, but I continue taking it because I read so much about how helpful it is and I keep hoping one of these times it will work The revised IRB approval letter allowing us to post to GI related Facebook groups was received on March 7 th That same e vening, the first Facebook group we have been in contact with posted the link to our survey along with the approved statement describing it. Another group consented two days later, bringing us to two Facebook groups participating as of March 10 th That being said, we have already seen a drastic increase in the respon se rate over the past few days where the number of completed survey responses has almost doubled Although we

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 12 have yet to do a nother data analysis of the newest results using SPSS software, looking through the individual surveys completed since the first analysis reveals a great deal of information. O f the respondents taking one or more of the supplements included in the supplemental GI loop (e.g. Iberogast fiber, and peppermint oil ) 35.48% rep orted having originally learned about the supplement ( s ) th r ough information found on websites. Also, the most common health problem reported since the first data analysis is Heartburn/GERD, where 26 survey respondents reported having the healt h issue. This differs from the majority health problem reported in the initial analysis, which was IBS. Several more people have provided written feedback since the first data analysis on specific supplements included in the GI supplemental loop. O ne pe rson who reported taking Iberogast I have not been on the treatment (Iberogast ) long as indicated above, however my symptoms have improved almost immediately using Iberogast on with DGL (deglycyrrhicinated) licorice and ginger. Yoga and massage are much more effective. mixed feelings regarding the effectiveness of different herbal supplements. Discussion When examining the feasibility of the study, it is important to look at whether sampling methods allow to recruit enough subjects as planned and the questionnaires are filled out without unexpected issues via online methods. The IRB amendment allowing us to include Facebook groups ha s let us reach a wider population, and in turn generate valuable data from increased response rate. Subjective responses from preliminary results indicate that there are mixed feelings over perceived efficacy of certain herbal products. Another consideration is t he sources in which respondents report ed learning about herbal supplements they used that were included in the supplemental GI loop the most common source reported being websites (35.48%). This is

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 13 important considering much of the information available f or free on the i nternet lacks support from scientific evidence. Following completion of the study and final analysis of the results, the information gathered on demographics, health status and the effectiveness of herbal supplements in managing GI symptoms can be disseminated to others suffering from similar disorders, so they will have research based findings to make an informed decision of CAM selection in symptom management. Honors Exp erience Personal Functions in the Study I had several functions throughout the study, and much of the time I was collaborating with another nursing student during the process. The survey was des igned primarily by the principal investigator and one of t he things we did during the design process was go through the different parts of the survey, look for potential problems or corr ections that needed to be made and make suggestions as necessary. Once our initial draft of the survey was complete, we did te st runs of it while also distributing a practice version of it to 10 of our family members or peers so tha t they could themselves take it and provide feedback. Feedback included ease of which the survey could be read and interpreted technical problems ex perienced on their computers and length of time it took them to complete the questionnaire as well as other suggestions This feedback allowed us to make the appropriate corrections to the survey prior to the initial IRB submission of the protocol. Another function in the study was assisting in the IRB submission process o f the protocol as well as brainstorming revisions to the original protocol with the aim of increasing total response rate. With this specific revision, we contacted certain GI rela ted groups on the social media site Facebook to gauge interest in participating in the posting of the survey link to their

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 14 group walls. A revision to the protocol was then generated based on the interest they expressed, and the letter of approval for the revision was received on March 7 th The approval was then message d to the Facebook gr oup administrators, and upon their agreement via e mail correspondents the message describing the study was posted by the research team or the social media site and the survey was linked directly to the Facebook page. M onitor ing daily response rate on Qualtrics has been the responsibility of this Honors student A decline or stop in the data collection could be indicative of problems in the links or the websites to wh ich the surveys are posted This also allows me to examine whether surveys are completed and to review demographic characteristics, supplement use and health status of respondents. Monitoring process also allows me to examine the subjective content of the survey responses and review their narrative answer describing experience or any feedback regarding supplement use. Problems Encountered Several problems have been encountered during this research process O ne such problem has been meeting the projected number of respondents which is expected to b e between 150 500 responses based on the feedback of two internet sites posting the survey during the study period However we have yet to reach the minimum projected numb er after nearly two months of posting the study D ifficulty obtaining responses may be due to the length of time required to take the survey, an approximated 25 minutes. When reviewing the results on Qualtrics many people started the survey but did not complete it. The reasons may be due to the length of survey and lack of incentives for completion of a lengthy survey. Another problem was the need for IRB revisi ons. As mentioned earlier, we just received app roval for one revision that al lows us the ability to post the links to the survey on Facebook group pages also However, we had to

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 15 undergo a couple of revisi ons prior to this that cause d delays in the research process Our first revision as requested by the IRB asked us to chang e min o r wording in the protocol which did not actually push back the start date of the proposed study. The second revision was related to website announcements that would be posted on the two websites explaining the survey links that were posted along wi th it the IRB approval number and a short description of the survey. Thi s revision was necessary after one of the websites had thei r legal team review the survey resulting in their request that an announcement be posted along with the link to b etter explain i t. Unlike the first revision, this one caused a considerable delay while we waited for IRB approval of the revision, and delayed the start date from January 7 th to January 16 th As with any survey, literacy levels of the participants is something that can pose a significant problem when it comes to them being able to read and interpret it. This may have been a potential problem for any stud y ; however, it might not have been an issue for this study because the questions were written at the 8 th grade reading level and based on the preliminary analysis of demographics of education level of the respondents. Also, frequent users of the websites may be a group of people who have knowledge related to GI disorders and the rapies as the websites themse lves (the Iberogast, IFFGD, and now the Facebook pages ) provide helpful information related to the treatment of GI disorders and cater to suffer ers of such disorders Another problem this honors student discovered when monitor ing data was that Qualtrics kept counts of incomplete responses. This is problematic when reviewing the data through the server, since it takes some extra time to manually exclude the incomplete the responses It would be helpful if surveys that were not finished were just exclude d from being recorded at all. Learning Experiences

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 16 This study provided for multiple learning experiences. Prior to beginning the study, this student had the mentality that the study would not run into many problems and receive a very high response rate as compared to other survey formats because the survey was internet based However, as mentioned above, this was not the case. Like other studies, multiple revisions were nee ded to the original protocol to meet the Based on current knowledge, it seems to be the social media link postings seem to be very effective to recruit subjects. Another learning experience was that overall l ength of the survey really does influence whether people w ould finish it or not. Shorter length of survey could increase the number of respondents. The cost of scaling back the survey would be the loss of potentially valuable information that could be use ful in the analysis of the results. The benefit, however, could be an overall increase in response rate, which also could itself provide valuable information in overall data analysis. Working with websites and social medi a groups for online research ha s provided huge lea rning experience. Our principal investigator did an excellent job of communicating effectively with the administrators of the two websites (Iberogast and IFFGD) on which the survey links were posted and then sending us copies of the co rrespondence so we could see the process. There are many different issues and concerns that need to be addressed when studies are done via the I nternet. One such issue is that of endorsement. There needs to be clarification that when a website agrees to post a link to a survey from an outside group, it does not mean that that website is in any way endorsing the s urvey or the products mentioned in the survey. This is to en sure all precautions are taken to avoid a potential misperception among survey respondents When working with GI related Facebook groups, one gr oup expressed their concern over

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 17 endorsemen t with this honors student and it was her duty to address all of their concerns prior to them agreeing to participate. One consideration that might have helped to address this proble m and alleviate some fear amo ng groups would have been to include a statement specifically about endo rsement in the message posted alongside t he link Summary For the honors research, the researcher worked with UF faculty members, Dr. Saunjoo Sunny Yoon and Dr. Oliver Grundmann o n an online study analyzing self reported herbal supplement use among Internet users for t he management of GI disorders. The goal for the thesis was to not only demonstrate the overall physical, social and financial impact of GI disorders Additional emphasis was on the functional GI disorder IBS since the literature indicates that it makes up a large percentage of people who seek out CAM therapi es Once data collection is complete in April, the perceived effectiveness among users of herbal supplement s in the treatment of GI disorders such as IBS will be analyzed I nformation on perceived efficacy may play an integral role in future healthcare provider recommenda tions of herbal supplements for those sufferin g from GI disorders. This honors student greatly appreciate s being a part of the team and find it a pleasure to have the opportunity to work w ith s uch an esteemed UF faculty. This research experience has provided valuable in sight into the research process, including the nume rous intricacies and considerations involved in protocol and survey development, as well as potential problems that may arise when research is done via the internet. Overall, it has been an excellent learning experience. Becoming involved with it was one of the best choices this student has made during her nursing school experience.

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HERBAL SUPPLEMENTS AND GASTROINTESTINAL DISORDERS 18 References Cappello, G., Spezzaferro, M., Grossi, L., Manzoli, L., & Marzio, L. (2007). Peppermint oil (Mintoil) in the treatment of irritable bowel syndrome: a prospective double blind placebo controlled randomized trial. Digestive and Liver Disease, 39 (6), 530 536. El Salhy, M. (2012) Irritable bowel syndrome: d iagnosis and pathogenesis. World Journal o f Gastroenterology, 18(37), 5151 63. doi: 10.3748/wjg.v18.i37.5151. Everhart, J.E., & Ruhl, C.E. (2009). Burden of digestive diseases in the United States part I: o verall and upper gastrointestinal diseases. Gastroenterology 136 (2), 376 86. doi: 10.1053/j.gastro.2008. Ford, A.C., Talley, N.J., Spiegel, B.M.R., Foxx Orenstein, A.E., Schiller, L., Quigley, E.M.M., & Moayyedi, P. (2008). Effects of fiber antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome : s ystematic re view and meta analysis. British Medical Journal. doi: 10.1136/bmj.a2313. Grundmann, O., & Yoon, S. L. (20 10). Irritable bowel syndrome: e pidemio logy, diagnosis and treatment: A n update for health care practitioners. J ournal of Gastroenterol ogy and Hepatol ogy 25 (4), 691 699. Gschossmann, J.M., Krayer, M., Flogerzi, B., & Balsiger, B.M. (2010). Effects of the Tibetan herbal formula Padma Lax on visceral nociception and contractility of longitudinal smooth muscle in a rat model. Neurogastroenterology & Mo tility, 22 1036 e270. doi: 10.1111/j.1365 2982.2010.01512.x Krueger, D., Gruber, L., Buhner, S., Zeller, F., Langer, R., Seidl, K., Schemann, M. (2009). The multi herbal drug STW 5 (Iberogast ) has prosecretory action in the human intestine.

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