I didn’t have a particular expectation about the book. When reading the back, which claims it will offer a ‘holistic and positive guide’, I did wonder whether I would find it at all agreeable, but I began with an open mind.
Contributions from Kay Greveson – IBD nurse and founder of IBD Passport and Sally Baker – therapist and author make for a good all-rounder. Travel, mental health and food (covered by the author, Jenna) are three of the common issues we face as IBD patients.
I decided not to go to Greece last year after discovering the ‘no flushing tissue’ issue. I am of course plagued by the question ‘to eat, or not to eat’, as well as being a little bit mental, so this book appears to have been written for me!
The introduction clearly states that this is not a medical facts resource, nor will you be finding statistics and insights in to IBD. Instead, it 'aims to provide a practical and balanced approach to help you live with Crohn’s Disease and Ulcerative Colitis’’
I have taken the executive decision to include the link to purchase the book HERE, as this blog is long and I am aware you may not reach the conclusion at the end…
I have a lot to say, and have made a conscious effort to showcase the type of knowledge you will gain from the book, without actually quoting the book too much and giving away valuable content that Jenna would like you to put your hand in your pocket and pay for.
Adjusting to life with IBD
Being diagnosed | Dealing with your diagnosis | Finding support | Mental health
We do actually begin with some facts and figures. I’m not complaining, I love a good statistic, but don’t let the intro fool you in to thinking that you’re not going to learn anything and this is purely some kind of spiritual journey!
Here you will learn about the causes of IBD and myths will dispelled. Trivial topics such as junk food and the MAP vaccine also get a little coverage.
Extra intestinal manifestations such as fatigue, joint pain, skin conditions ulcers and so on are highlighted, which I think is highly useful for those newly diagnosed or only just exploring the world of IBD as these could be symptoms that they’ve experienced but not linked to Inflammatory Bowel Disease. This could be a complete revelation!
I am guilty of both linking things to IBD when I have been unwell which have turned out to be completely unrelated and I should have sought help for sooner, but on the other end of the spectrum, I have not linked things to IBD and been completely off the mark there too. Regardless, it’s always worth seeking advice from a GP if a new health issue occurs as even if these are IBD related, they can be treated with different medications.
Jenna mentions 'self-care methods', now she is not saying ‘you’re not looking after yourself’. This section may reveal a few things that you could be doing to aid your health in general, that may not have been mentioned by your healthcare team so you may not have considered.
Self-care IS important regardless of whether you suffer a health condition or not. The practice of mindfulness and considering what you put in to your body is something that all people should consider, not just sick people.
Input from IBD nurse Kath details some of procedures you may encounter as part of your IBD journey, especially in the early stages when disease activity is being determined. It also includes a labelled diagram of the lower part of your digestive system – which I enjoy. I love biology, and let’s be honest, it’s useful to know what is where when reading what the medical professionals will be sticking where during the described procedures; from MRI’s and endoscopies to bloods and faecal calprotectin. A brief introduction to the medications frequently offered is also included.
Jenna shares her (pretty common) story which highlights the unpredictability of IBD, in which one day she was well and rejoicing, only to be in hospital undergoing surgery 3 days later.
“I felt helpless, because I had believed everything I has been doing was enough. It also taught me a valuable lesson – sometimes we can just be unlucky and things are out of control”
A little info is included about the common surgeries used to treat IBD, including: Strictureplasty, Jpouch, resection, ostomies and Fistulotomy.
I’d just like to include a quick link here which includes other methods of treating a fistula: Seton, Advancement flap, Bioprosthetic plug, LIFT, Firbrin glue.
Understanding potential triggers includes the opinions of other sufferers, but Jenna does point out that some of these, such as the weather are not backed scientifically.
Seeing my own Facebook ‘on this day’ posts from previous years does often show that I too seem to have been struggling at the same time of year for some time. This may be purely coincidental of course, but I wouldn’t like to say I am certain either way.
Whilst they may seem like ‘old hat’ to those diagnosed some time ago, the inclusion of tips on attending appointments and questions that could be useful, serves as a welcome reminder. Sometimes it’s the basic things that we know are important, we just sometimes forget. We can blame the brain fog if you like?
Jenna talks about being strangely excited to finally receive a diagnosis after feeling like she wasn’t being taken seriously for such a long time. This is a common story amongst IBDers, after years of pain and misdiagnosis.
This is something I remember reading in my first ever Crohn’s and Colitis information booklet during my hospital stay when I was initially diagnosed. It said that one of the common reactions to diagnosis is relief, because now there is a diagnosis, there can be an efficient treatment plan. Personally I found this book misleading (in my case specifically), as it hinted that people with IBD generally go back to living a normal life with the right medication. I was happy to have been diagnosed and happy that everything was going to be OK. To be honest I wish I hadn’t read that booklet as I had then believed that I was going to be OK and that I was going to be better. It was only a few days later when the IV hydrocortisone hadn’t worked that I was taken for emergency surgery to remove my colon and have a colostomy bag. I had never seen, nor heard of one, so this conjured up some pretty traumatic images in my mind about what it would be and look like. Had the booklet been a little blunter, I may have felt better prepared. Obviously I understand that jumping straight in with a ‘worst case scenario’ is not ideally what you want to face straight after diagnosis but some preparation for what could happen, pretty early on is important.
Jenna does say that she naively assumed that she would get better quickly and that all the dietary restrictions she had tried in the past would no longer be needed. Ultimately it took about 5 months to get on medication, and it didn’t really hit her until then.
“I remember crying on the way home as it finally hit me how serious the condition was. Over the years I have tried to get the balance right between knowledgeable and not researching for hours on end. I am honest enough to admit, it’s not always a balance I get right.”
I don’t think you can have too much knowledge. I obviously a run a support group and have a passion for raising awareness so feel I need to have facts, and figures if I am to educate anyone. I feel I need to know as much as possible so that I can answer people’s questions adequately. There are still times that I come across something I know very little about, which leads me to search the group for any other mentions so that I can refer them on but it also makes me hungry to know more about it. I follow the post to learn from personal experiences and I head off to search reputable sources and learn myself.
I know from seeing others posts that not everyone is mentally equipped to deal with ‘What’s the worst case scenario here?”. Anxiety is something that can completely take over someone’s thought process, and it’s common with IBD, meaning that sometimes these worst case scenarios build from being what should be thought of as exactly that, becomes something much more definitive. It may be something that isn’t anywhere near being on the agenda right now, but anxiety is a condition that may as well just be defined as ‘over thinking disease’ and all of those “What ifs”, become much more than that.
Jenna shares tips on starting the conversation about IBD, from explaining initially that you may not be too comfortable actually going in to it as it’s a little embarrassing and goes on to include the different aspects of your life that it may affect, such as socialising.
Don’t forget that you do not have to step out of your comfort zone to please other people, it’s completely personal, but those closest to you will need to be told things if you expect them to be patient and understanding.
I raise awareness. I post personal health matters publicly on Facebook and urge people to share them far and wide, but I do not like face to face conversations about them. During one on one conversations, I’m more likely to joke about it than share anything of any real importance. I don’t want to sit on a bus next to a stranger and start talking about it, yet I claim I want to raise awareness? To be clear, I very much DO want to raise awareness and educate the masses, but even I, am only going to do that in a way that I feel comfortable with, which is not face to face.
Jenna also suggests writing it down, build a journal which you can later share with family and friends if you feel comfortable doing so, but she also urges you to be patient. Large, life impacting changes can affect relationships, sometimes simply because you cannot do what you used to be able do. Be it picnics, or sometimes during a bad flare, being any distance from home.
My partner knows that he has a limited options when it comes to booking seats at the cinema. I need to be near an aisle so I can escape if needed without feeling stupid moving a row of people, and he needs to be in an area of greater leg room as he’s a very long huam. If those seats aren’t available, we just won’t go that day.
And… Wow, a London journey before Christmas – a few re-routes meant no toilet stops for me! For well over 90 minutes, and whilst I was pretty sure I could hold it long enough not to shit my pants, the pain when holding it was bad. So there I am – an angry passenger. He’s mad with me because I am suddenly mad about everything. I am mad about life, this disease, that sometimes, all of sudden there can be so much out of your control that you’re shouting at you’re other half, that you love very much and don’t actually want to upset, purely because he spoke to you and you don’t want to have a fucking conversation right now.
Seconds after the toilet stop, and the instant relief, suddenly happy again, and now a rather sheepish and apologetic passenger.
Jenna points out that whilst it’s easy to be resentful when loved ones appear to be unsupportive, it can be a huge change for them too, especially when they have to sit back and watch you suffer and can’t help.
I find this very prominent as my partner is not a very emotional character, in fact he has a distinct lack of emotion, and to be honest that’s one of the things that I initially liked about him. I’d spent a fair amount of time just enjoying my own company, not looking to be in any form of relationship because I feel a massive amount of guilt, and in my opinion have far too often had to look in to the sad eyes of people like my mum that care about me, sat at my bedside, upset that they can only stand back and watch whilst I struggle to operate and recover, and there is nothing that they can say, and I am just…. angry. A few months ago, when I was frustrated with something (common occurrence for me), I asked him, “Do you ever actually feel frustrated about anything?”, and his reply was “Yes, when you’re sick and I can’t help” – hurts a bit that. And whilst that is probably one of the most emotional and honest things he is ever going to say me, that makes me feel guilty, and my initial thought was purely “Shit”.
“Be realistic, like any major life change, there will always be people who are supportive and people that will not. IBD often makes it clear to us who are really confidantes are.”
I have written the very same, just a much longer version in a previous blog. Consider it like ‘separating the wheat from the chaff’.
During the Support networks outside friends and family, I am TUTTING very loudly…
Outside support networks can be extremely invaluable in helping you through your life with IBD. Sometimes it’s just enough to know that we’re not alone in what we’re going through”
Jenna mentions UK charities and Facebook groups, including her own; Healthy Living with IBD (find and connect with other people interesting in living a healthy lifestyle with IBD.)
This is my cue to interrupt Jenna’s info with the addition of
UK charity, Cure Crohn’s and Colitis, purely focused on funding research to find a cure for Crohn’s Disease and Ulcerative Colitis. 100% of donations are invested in to medical research. No money is taken from donations to pay staff as everyone is voluntary and works for Cure Crohn’s and Colitis because they believe in the cause and want to find a cure.
And of course, #IBDSuperHeroes Facebook group, which fundraises for Cure Crohn’s and Colitis and has Social media accounts on Facebook, Twitter, Instagram, Google+, Pinterest and Tumblr to raise awareness and promote fundraising activities.
“Understanding your medical team. It is important to get the most out of your treatment and services.”
Jenna covers all of the medical professionals that you should come in to contact with during your IBD journey, from your GP to your consultant, and even touches upon addition optional therapies.
I think it probably does depend on your area and your specific team, for example my GP is actually useless. 7 appointments in a row and I didn’t see the same person once, meaning that you are forever explaining your issues and symptoms again each time, plus what each GP / Practitioner before them has said and given you. My first port of call is always my IBD nurse, but they are so thin on the ground that that I usually wait 24 – 72 hours for a call back or email response, but in non-emergencies, she is a very useful woman to have.
IBD and Mental health is a section I am very pleased to see included as there’s often very little discussion about the emotional side, especially from the medical team.
Jenna includes some interesting key stats such as
Vitamin B12 deficiency is common in IBD patients and is linked to anxiety.
Anxiety is actually a symptom of B12 deficiency, which is pretty common in IBD due to the intestine not being able to absorb it properly thorough the ileum (the part of the intestine which connects the small intestine to the large).
Jenna has experienced anxiety herself which she talks a little about, and mentions that the side effects of medications are a big trigger for her.
Some side effects from certain medications such as Prednisone, can actually make us ugly, which is depressing. I know from very recent experience that feeling ugly can have a massive impact on wellbeing - see recent blog BEING FUCK UGLY IS A PERFECTLY ACCEPTABLE REASON TO BEIRRATIONAL AND SAD.
Prednisone, a very commonly used steroid for IBD symptoms causes: Greasy skin, acne, greasy hair (I could wash mine at night and wake up looking like someone had attacked me with a chip pan during my slumber), excess hair growth on your face – which is BIG AND ROUND (see moonface), and hair loss. Yes, there’s less hair on top of your big round head but more all over your body, which is not a look many can pull off!
Weight gain, insomnia, hunger and mood swings, all equate to one pretty ugly and extra tired looking thing - that vaguely resembles a human being.
Steroids are a big cause of depression for me. I believe they make me clinically depressed, rather than just sad about the other side effects. I had planned to top myself at one point, which at the time I didn’t find at all scary, but instead a massive relief, and I was much happier with the killing myself plan than the ‘plodding on’ plan.. I thought it was due to the situation at the time but looking back, every time I have had steroids, I have felt depressed, and I don’t believe this has been due to me being ill, as I have been ill for much longer periods of time whilst taking other medications such as Azathioprine and never once considered offing myself, which seemed to be a common thought process when taking Prednisone. If you want to read more about it, then you can do so here.
I have suffered major anxiety through living with IBD, from being scared to make plans, get in to a relationship, sometimes even scared to just be settled and be happy for fear that something is going to come along and cause spontaneous combustion of all that I have so carefully created – the best laid plans of mice and men.
“Indeed the erratic nature of the immune disease itself means that the logical and rational amongst us, like me, search desperately for patterns, threads, links, anything to find a reason for this often baffling disease.”
I know this is also me, my assumption is that it will be most IBDers at some point at some point or another in times of desperation.
Jenna also touches upon feeling guilt that it may in some way be something that you are doing wrong. I made this very point in my recent food blog here when I attempted to fight fatigue with food.
I would just like to quickly plug a free online CBT tool which has helped me in times of need. I actually find this through the Mind website. You can get an App, but I would recommend using a PC / laptop, as the app skips some of the bits I feel really helped the first time I did it. It helps with all aspect of anxiety such as ‘warpy thoughts’ and helps you understand where and how you can change these thought processes in to something less negative. Check out MoodGYM.
Anxiety is relatively new to me and is something that I have only suffered with during the last few years, partly due to IBD and partly due to a previous unhealthy relationship, so I always find mental health info interesting.
“It’s clearly an area where more medical service need to be directed. As I discussed in chapter 1, initial consolations after being diagnosed can lead to the patient being overwhelmed with information and having a variety of leaflets thrust in to their hands, but where’s the leaflet that tells us to how to cope with the associated emotions? The leaflet that gives us ways of not breaking down and staying strong. The leaflet that offers support groups and websites.”
Input from Sally Baker (Sally is a therapist who works specifically with the mind body connection).
Since many patients feel stress is a trigger for their IBD symptoms, it’s important to try and get a handle on emotions. Only 12% of IBD clinics offer mental health support.
I find Sally’s tips and insights really useful. You’ll have to read the book to see them, but here are a few links to Sally’s site. Please note, you’ll need to register to access the upcoming information links. It just requires your name, email and a username
Emotional Freedom Technique – you may have heard of this being referred to as ‘tapping’
These treatments are becoming more readily available by referral via the NHS so you may like to ask if this is a possibility. Mindfulness being explored as an anxiety treatment rather than medication, which is of course good news as we put enough in our bodies for the physical symptom treatment!
NICE also recognises the roles stress pays in IBD and has cited hypnotherapy as a possible treatment.
Mindfulness I think is something that should be practiced by everybody – being self-aware and being able to judge a situation for what it actually is rather than a heightened, and more stressful version of it can only be a positive!
Jenna also makes a few suggestions for Apps to improve Mindfulness - Calms & Headspace.
To be honest I found this bit a little weird, purely because Jenna writes about Sally rather than Sally writing this part, unless Sally wrote it in third person… but I am unsure. Hey, I am only here to review it!
Food and supplements
Nutritional supplements | The role of food | Beneficial foods to add to your diet | Staying hydrated
Thanks to Jenna's knowledge of nutrition, this section introduces insights that many IBD patient may not already know or have even considered, mainly due to dieticians not being part of the standard IBD management team through the NHS. Many hospitals don’t have a dietician, and the ones that do often don't have the capacity to introduce one ‘as standard’, therefore unless a dietician is strictly necessary due to symptoms then you will probably never meet one.
Jenna talks about Probiotics and prebiotics, and Probiotic rich foods, of course ensuring she makes it clear that it’s not always possible to get the nutrients we need from food due to malabsorption which is often the case when flaring.
18 months ago when attending an IBD conference, it was confirmed that probiotics have not been scientifically proven to have any effect on inflammatory Bowel Disease, other than in Pouchitis. That’s not to say that probiotics won’t help you feel more healthy and ‘spritely’ in other ways.
Info on the different supplements available and what these are useful for is explained eloquently, including deficiencies in B12, Anaemia, Magnesium (and its ability to help you deal with stress and anxiety, get a good night’s rest and relax muscles), Turmeric, Fish oil, Vitamin D, Iron and Calcium (needed with steroid use to prevent osteoporosis). Jenna again share her experiences of supplements and gives you space to trial and error some of your own.
There’s been many articles lately about a lack of Vitamin D linked to relapse in Ulcerative Colitis patients.
Iron for me is a particular trouble causer. I am prescribed liquid iron as the tablet form, as for many IBDers can cause constipation or the squits. I know a lot of IBD sufferers actually have the B12 injections as it’s much better tolerated.
I spent two years with a stricture which meant that any form of insoluable fibre was out of the question. Eventually my stricture was so narrow that I could not drink water without being in agony so nutritional supplementation was a must.
The role of food in IBD is an often discussed (and disagreed upon) topic, but Jenna handles it well and introduces multiple diets that could possibly ease symptoms (under the supervision of a professional of course). These include:
Specific Carbohydrate Diet
Weight loss diets (Weight Watchers / Slimming World etc)
I’m sure at some time or another you have been, and if you haven’t yet you will be, advised to keep a food diary. There are so many Apps available that you can do this with that I would recommend downloading a few and trying them out for yourself. Wearables are very popular at the moment, and whilst these allow you to log the food you’re putting in, I have yet to find one that enables you to log what is coming out and when, which is important if you’re looking to identify some form of correlation between food and bowel movements.
Jenna chooses not to share her recipes from her blog in the book, other than a few simple recipes for drinks “since this book is about personal IBD journeys and there are no ‘quick fixes’ for this disease.”
Understanding food is a section full of information that IS useful and impartial, and I imagine useful in at least gaining a little understanding of how certain foods such as dairy and gluten effect the body, specifically the gut.
Fibre is a topic I think there’s a fair bit of misconception about. Strictures, scarring and active disease can cause a lot of pain, so gaining more understanding of what is likely to aggravate symptoms will again be useful to IBDers.
A couple of queries I had about juicing were also answered for me in this section, so thanks, and I may well be investing in a cold press juicer!
Staying hydrated with IBD is also covered and I cannot stress how important I think this is!
“Hydration needs to be done properly, so here are some good sources of hydration (and some you may wish to avoid.”
A recipe I swear by is below, but PLEASE NOTE that this one is specifically for people with a short bowel, so those that have undergone a resection. I always have this made up and waiting in the fridge if I am going out and wil be consuming alcohol and on hot days during the summer.
Electrolyte replacement solutions are available from supermarkets over the counter and are suitable for people with a whole digestive system and functioning bowel. Dioralyte is probably the brand you have heard of but there are much more cost effective versions in supermarkets too.
I actually watched a programme a few months ago (I can’t remember what it was), but this claimed that it was scientific fact that milk is actually slightly more efficient in rectifying dehydration than water, obviously this would only be suitable if you’re fine with dairy!
This food and supplement section contains so many lists – and this pleases me because I loooove a list! I’m so excited by them that I feel I must share these lists with you! Guess what form I will share them in!? That’s right, a list!
Beneficial vitamins / supplement list
Dietary approaches to IBD
Naturally gluten-free foods
Possible problematic foods
Insoluble fibre / soluble fibre
Good sources of hydration
Drinks that may affect symptoms
You would expect this to be a particularly educational and informative part of the book thanks to Jenna’s background in nutrition, and I don’t think you will let down.
Living life to the full with IBD
Travelling | Working | Exercising | Hospital visits | Socialising
Tips for travelling with IBD, from taking your own food to questions you may want to ask the hotel in advance.
Admittedly I am not much of a traveller so found the suggestions extremely useful, and can honestly say I would have considered barely any of them, especially things like may be being eligible for express check in!
Apparently there was a recent campaign, #FlyWithIBD which I somehow completely missed, which aims to raise awareness and get airlines to offer more support to IBD sufferers.
Last year when travelling to Ibiza, the airline was more than happy to allocate seats near the toilet for me.
If you’re anything like me (anally organised), you will have a travel file that you call upon when you’re looking to go away, because there’s nothing worse than being unprepared! The checklist for travelling with IBD will be a great addition to my file!
Jenna on working with IBD: “Sometimes it seems that living with IBD is a full-time job (albeit one with zero pay or benefits!).”
There are a couple of good tips included as well as Jenna’s own experience of working with IBD. More info on dealing with employers and the legalities of living with IBD, plus studying and school, can be found here.
Exercise and IBD is briefly covered and offers tips and a little info on how exercise affects the gut, plus a few guidelines for socialising with IBD, covering mainly eating and drinking.
“I often think ruined social life should be added to the official symptom list of inflammatory bowel disease.”
I was actually accused of being bulimic once as I kept getting up to visit the toilet during a meal, and another time was told that my health (the ileostomy that I had at the time) was not appropriate conversation over a meal. I’m sure if it had been something non-bowel related such a broken leg (or fingernail), it would have been fine! I told her that it wasn’t appropriate for me having to get up and take a shit half way through the meal either but it is what it is.
I thoroughly enjoy Jenna’s account of healthcare in China. Some much needed humour is injected in to the book, and the talk of the minimal boundaries and ‘bedside manner’ from the health professionals there makes me want to visit China myself, just to have a hospital visit and a chat. Input from the IBD community is included and other IBD patients share their tips on how they manage hospital stays and what they take with them.
Other possible approaches
Alternative therapies | Dealing with a flare-up, a 24 hour self-care plan
Alternative therapies covered are: Acupuncture, Reiki and Reflexology. Evidence to support these as alternative therapies in IBD, plus Jenna adds her own experience.
A 24 hour self-care plan. I like this, I am unsure whether that’s because I always like to have a plan, but whatever the reason, I LIKE IT, and I WILL use it. The care plan includes your whole day mapped out and includes:
What to eat and drink
Relaxation time (including a breathing exercise)
Do eat / Don’t eat
Bristol stool chart (if you don’t know what it is, look it up. Poo of all shapes and sizes – riveting!)
I am so keen on having a plan that I fully intend to make myself an emergency kit, (like the one I have for the zombie apocalypse but with less ammo).
You can also use the following measures to determine the severity of your symptoms. After calculating your score you can then take appropriate action as the suggestions in the ’24 hour self-care plan’ are for mild disease activity only.
I think everyone should familiarise themselves with Harvey Bradshaw scale for Crohn’s Disease and the Simple clinical colitis activity index.
Firstly I should state that I pride myself on being a ‘know it all’ so whilst I can’t claim to have learnt a lot from this book, I actually did really enjoyed reading it - more than I expected too if I’m being honest. Everything is simply put and easy to understand. It is not filled with medical jargon that you’re going to have to take to Google to understand!
I think the book will serve as a comfort to those newly diagnosed or those just coming to terms with their condition and willing to look in to what they’re dealing with more. I know I mentioned earlier that sometimes, even people that have suffered with IBD for years forget the basics, but they’re all here to remind you.
For years I stuck my head in the sand and had no intention of admitting to myself, nevermind anybody else that this was something that was actually going to affect my life dramatically and that I actually needed to deal with, regardless of the fact I’d already had surgery and was living a colon free, and not particularly ‘normal’ life.
Case studies from other sufferers as well as Jenna herself will go some way to reassuring IBD sufferers that they are far from alone on the journey.
It does exactly what it says on the tin (back page). It will give you some tips and insights in to ‘Managing IBD’.
One issue I did encounter is that because Jenna is not wanting this book to be full of facts and figures, there are often external sites that will which she links to pretty frequently. It’s a well known fact that we live in a digital world – had this been a blog it would have been one simple click away, but here there are times when you’d end up cross eyed attempting to type in the links to access the information. This is obviously necessary as the book would be considerably longer had she included the information, but I think it would definitely be worth Jenna publishing a page on her blog, allowing for a simple ‘click through’ to the sources linked to in the book.
I feel quite childlike with this book. I have things to fill in! A bit like scrapbooking, or wreck this journal (but less fun), but notably more useful!
During your journey with Jenna through ‘life with IBD’, you will have multiple pages which you can fill in and refer back to:
Being diagnosed | Make a note of your own triggers
Dealing with your diagnosis | 10 questions to ask your doctor + additional
IBD and mental health | Coping with anxiety
IBD and mental health | Record some things you are proud of (Grab some paper)
Nutritional supplement and IBD | Supplement introduction and tracking
Staying hydrated with IBD | Record your food choices and responses
Dealing with a flare-up | Symptoms log for during a flare