The Gut Health Podcast

Get a Grip on Bloating with Mayo Clinic Gastroenterologist, Brian Lacy, MD, PhD

• Kate Scarlata and Megan Riehl • Episode 5

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Bloating can range from mildly annoying to downright painful, can happen for a multitude of reasons and you've likely experienced it! Expert and world-renowned gastroenterologist, Dr. Brian Lacy from Mayo Clinic Jacksonville joins Kate and Dr. Riehl to explore the science behind bloating and abdominal distention.  Dr. Lacy breaks down the details of when extraintestinal gas may not be your bloating culprit and how stress and diet can mess with your gut.

Join us as we explore the brain-gut connection and uncover how our mental state can influence digestive symptoms. Discover how stress can turn a sensitive gut into a full-blown uproar of discomfort.  By highlighting that these symptoms are not "all in your head," Dr. Lacy helps us navigate the intersection of emotional well-being and physical health. He also emphasizes the importance of diet to manage bloating and why sometimes, eating the healthiest foods can bloat the belly.

Finally, we focus on the often-neglected discussion connecting constipation and bloating. It's time to get acquainted with our pelvic floor muscles and learn why sometimes the best remedy is not another pill but a new understanding of our body's inner workings. Dr. Lacy sheds light on the relief pelvic floor physical therapy can offer and shares actionable tips — from diaphragmatic breathing to abdominal massages — that might just offer the release you've been seeking. So, if you're ready to banish bloating and calm your gut for good, this is an episode not to be missed.

This episode is sponsored by Ardelyx

References to check out:





Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Kate Scarlata:

This podcast has been sponsored by Ardelyx. Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health-conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food and the gut. Come join us. We welcome you.

Dr. Megan Riehl:

Hello friends, and welcome to the Gut Health Podcast, where we talk about all things related to your gut and well-being. We are your hosts. I'm Dr Megan Riehl, a GI psychologist.

Kate Scarlata:

And hello, I'm Kate Scarlata. We have an exciting podcast for you. Today. We're talking all about bloating. We'll get into the complexities of this troublesome symptom that every one of us deals with from time to time. We'll learn about what causes bloating and how to treat it. Today's guest is world-renowned gastroenterologist, Dr Brian Lacy from Mayo Clinic Jacksonville, Florida. Dr Lacy focuses his research in clinical interests in disorders of gastrointestinal motility. His scientific articles on bloating are my personal go-tos, especially for clinical tips with my patients. He is the author of nearly 200 peer-reviewed articles on GI motility disorders. As well, he is the past co-editor-in-chief of the American Journal of Gastroenterology. Welcome, Dr Lacy.

Dr. Brian Lacy:

Well, thank you so much for being here. I'm just as excited as you guys. This is great.

Dr. Megan Riehl:

Yes. So as we kick off today's podcast, we want to start with some myth-busting. So what is a common misconception about gut health that you would like to dispel with our audience?

Dr. Brian Lacy:

I think that's a great question. I think there are a lot of myths and misconceptions about gas and bloating, but one of the ones I hear most commonly from my patients is that they firmly believe that they produce much more intestinal gas than anybody else and that's the root cause of all their symptoms of gas and bloating. But that's really a misconception.

Dr. Megan Riehl:

All right, so we're going to get into the details here. So let's dive in. What is bloating and how does it differ from abdominal distension? Tell us a little bit more about this.

Dr. Brian Lacy:

Yeah, and I think that's a really important point for all of your listeners because it makes us think about the symptoms differently and it makes us think about the underlying pathophysiology differently and therefore likely thinking about the treatment differently. So bloating, which is incredibly common, as you've already mentioned, is a sense of being gassy. It's that sense of gas on the inside, bloating, and it's very prevalent and we talk about, you know, 14% of adult Americans having symptoms of bloating within the last week. Distention is the physical manifestation and patients may come in saying I look three months pregnant, I look six or nine months pregnant. When they're not, I look like I've got a basketball in my belly. Frequently they overlap and people may have symptoms of gas and bloating, but they may also then describe periods of significant distension. Pathophysiologically they may exist on a bit of a spectrum, but to some degree pathophysiologically they may also be a little bit different. So it's good to kind of tease that out with your patients.

Dr. Megan Riehl:

So you're saying you know this is a pretty common symptom in the general population and how common in IBS or in SIBO small intestinal bacterial overgrowth- yeah, great question.

Dr. Brian Lacy:

So there's a recent nice study from Cedars-Sinai published about a year ago. There's a recent nice study from Cedars-Sinai, published about a year ago, surveying nearly 90,000 patients across the United States. Thought to kind of capture the general US population and in that sample size one of the questions they asked about was gas and bloating and one in seven 14% said within the last week they had symptoms of gas and bloating. And, as you mentioned, this is very prevalent in people with IBS symptoms, whether IBS and constipation or IBS and diarrhea or those who go back and forth, and some studies have shown that 60 to 70% of patients with IBS have overlapping symptoms of gas and bloating. It's not part of the formal definition but it's so common. I always ask about it and I think most healthcare providers and psychologists and dieticians ask about it as well.

Dr. Brian Lacy:

SIBO (small intestinal bacterial overgrowth) is interesting. The definition is that you have too many bacteria in your small intestine where they don't really belong. We have a lot of bacteria in the colon. As everybody knows right, we have four pounds of bacteria in your colon. We don't have a lot in the small intestine, but the definition of SIBO is really just more bacteria than usual. They don't talk about symptoms at all as part of the definition, probably a mistake. That said, most patients with SIBO small intestinal bacterial liver come in because they have symptoms of gas and bloating. The vast majority the occasional SIBO patient comes in just with chronic diarrhea, but most have symptoms of gas and bloating. You're right.

Kate Scarlata:

So everyone gets bloated once in a while and I think people think I'm bloated. It's terrible. You eat a large meal, overdo beans, whatever you can feel a little bloating, but as a gastroenterologist, when do you escalate a workup based on an individual's symptoms of bloating? What are some red flags?

Dr. Brian Lacy:

Yeah, that's a great question because you're so well aware of healthcare efforts, especially for something like ovarian cancer, and they mentioned that bloating could be a sign of ovarian cancer, and they're really trying to help the public and make young and middle-aged women aware of this potentially disastrous fatal disease. The problem is bloating is so prevalent. It extends across all different disease states, whether constipation or diarrhea, gastroparesis, functional dyspepsia, ibs, as we talked about. It is so prevalent it overlaps almost everything, and so you have to be very careful about a non-specific symptom such as bloating, feeling gassy You're right, people have it all the time, obviously. Symptoms such as bloating, feeling gassy. You're right, people have it all the time, obviously, and then thinking, wow, that symptom must represent something bad or dangerous, because rarely does it represent something dangerous.

Dr. Brian Lacy:

So your question really is how do you tease out that nonspecific symptom and make sense for all of our listeners who are worried it could represent something bad? So then, what I want to focus on is what are some other warning signs, maybe paired up with it, that would make me want to investigate further, such as are you losing weight unintentionally, more than 10% of your ideal body weight? Is there a family history of a GI malignancy or ovarian or uterine cancer? Are you anemic? Is your blood count too low? Do you have significant other warning signs, such as maybe sweats at night, or you have significant abdominal pain that doesn't be relieved by having a bowel movement or urination? Then I might want to investigate, and certainly a simple investigation might be an abdominal ultrasound or pelvic ultrasound to get the ball rolling.

Kate Scarlata:

Perfect In your practice. What are some of the common sort of related disorders that you see that are associated with bloating just every day? As a gastroenterologist, Right.

Dr. Brian Lacy:

So if we were to make up a list of common causes of gas and bloating, we could probably quickly list 25 or 30 between the three of us in the next minute. But to help our patients and to help other healthcare providers, I try to really focus on five big areas and I think that encompasses about 90 to 95%. So I start thinking about diet and dietary causes of gas and bloating. Fortunately we have an expert right here on the call, Kate Scarlata, who can educate us about diet and dietary causes of gas and bloating. Fortunately we have an expert right here on the call, Kate Scarlata, who can educate us about diet and dietary causes of gas and bloating. I think about constipation and bowel habits. Again, some patients with diarrhea have bloating, but it's much more common with constipation and, as I explain to patients, if you're having difficulty evacuating stool, don't be surprised. You have difficulty evacuating gas as well. They're handled similarly in many ways. As you've already mentioned, I think about small intestinal bacterial overgrowth and, depending on which study you read, the prevalence may be one in 25 people or one in five people. So it may be much more common than we think. We have a wonderful psychologist on the phone call, Dr Megan Riehl. And then I start talking about visceral hypersensitivity.

Dr. Brian Lacy:

As I mentioned, most patients don't make more gas than other patients. One to two liters per day on average, by the way, is what the average American produces in terms of intestinal gas. But some patients sense normal amounts differently. They sense that little bit of gas differently and they sense it as pain, bloating, discomfort. Lastly, there's a smaller group of people who have kind of this funny reflex and I actually tell them they have a wiring problem. We call it abdominophrenic dyssinergia, phrenic, referring to both the phrenic nerve and the diaphragm. And to briefly explain that normally if you get some gas in your GI tract, whether the colon or the small intestine, you sense that gas. Normally what happens is your diaphragm ascends. That makes your belly cavity bigger. Your diaphragm goes up higher into your chest, makes your belly cavity bigger, as you both know, and subconsciously your external obliques and abdominal wall muscles contract. And now they've got this immediately protuberant abdomen, they're very distended expert, I'm going to pick your brain a little bit.

Dr. Megan Riehl:

Sometimes I'll teach patients diaphragmatic breathing to help with their bloating, what you're just describing. Can diaphragmatic breathing reset some of that, do you think, or maybe make it worse?

Dr. Brian Lacy:

I think it can definitely help reset it, however. So for all you listeners out there, this is the problem talking to somebody who knows the field so well. If you were to challenge me, what I'm talking about is actually Dr Megan Reel, not me. If you challenge me and say where's the data, we don't have the data. This is routinely practiced by a lot of healthcare providers and generally the clinical experience is good. That diaphragmatic breathing, which can be tricky to teach, as you know, Dr Riehl, but when taught appropriately and when performed at home we recommend before meals, so at least three times a day can be very effective at treating gas and bloating. But we don't have great clinical data. However, if you ask me the same question in one year, we just started a pilot study here, prospective, randomized. We're going to give you the data in one year's time.

Dr. Megan Riehl:

Perfect, awesome, thank you.

Dr. Brian Lacy:

How's that for a shameless plug? Oh no, that's not shameless.

Kate Scarlata:

We like to let our listeners know what's coming down the pipeline, that's awesome.

Dr. Megan Riehl:

Yeah, I think this is. We know that there are lots of evidence-based strategies for IBS and we also know that bloating is a very common symptom of IBS. But when people are looking to expand with their dream team, we call it. You know, working with a dietician, working with a psychologist, I do tell my patients, you know that I've got a lot of evidence to suggest that gut-directed hypnosis or diaphragmatic breathing is very helpful for bowel symptoms, including your diarrhea, constipation, reducing that visceral hypersensitivity. But I find and I think some of my colleagues feel this way, when somebody is presenting specifically with their bloating, we all kind of are like okay, like buckle in, we can help you, we definitely have strategies for you. It's just the evidence isn't as strong. So we're really going to personalize things. So that's what I think you're just highlighting that bloating can be tricky, but there are different strategies out there that can be helpful. And then you're going to produce the evidence-based literature that we really need to back up what we're doing in clinical practice.

Dr. Brian Lacy:

You know I like, Megan, so much of what you said, because I think all of us, at heart, we're scientists. We want to understand how things work, why symptoms develop. I think, at heart, we're all educators, because what do we really want to do every day? We want to educate our patients right, we want to reassure them, we want to make them feel better and we try to use the best data from the literature. And at least in this space we don't have as much data as we would like. When you think about it, it's such a common problem, but it's actually understudied and so you know, hopefully in the next year or so we'll get a lot of really good data and you can say now, based on this study, we can tell you with very strong feelings that this is what's going to work for you very strong feelings that this is what's going to work for you.

Dr. Megan Riehl:

Yeah, so can you tell me a little bit about how you describe how stress may impact bloating ?

Dr. Brian Lacy:

Yeah, that's complicated, isn't it?

Dr. Megan Riehl:

Right.

Dr. Brian Lacy:

So let's, can we set the stage for 30 seconds and talk about the brain-gut axis?

Dr. Megan Riehl:

Yes, please.

Dr. Brian Lacy:

I'm sure you've had other speakers on this wonderful show talking about the brain-gut axis, but for maybe listeners who weren't there before or aren't quite as up to date, think about this brain-gut axis, and what I mean by axis is this bidirectional pathway between the brain and the gut, and what I tell my patients is that this brain-gut axis, this bidirectional pathway, signals from the brain to the gut and the gut to the brain. You have more nerves in your GI tract than the spinal cord. In fact, you have five times as many nerves in the GI tract than in your spinal cord. The GI tract is a sensory organ and 90% of the nerves in the GI tract are sensory in nature. So you could imagine that if you're having gut symptoms, it sends signals to the brain.

Dr. Brian Lacy:

Brain is affected. Similarly, if you have brain signals and stress or emotion, it can affect your brain, which can affect your gut. So you could imagine we've already discussed the fact that with these disorders of gut-brain interaction, such as IBS, your gut is sensitive. Your gut is wired differently and patients feel things differently than other patients, and so you could imagine, with this brain-gut interaction, if you are getting some stress on the outside emotion, there's a fight with a boyfriend, there's financial issues, there are problems with your spouse or children. It affects your brain and it's going to affect your gut, and if you already have a sensitive gut, it's going to make it even more sensitive.

Dr. Megan Riehl:

Yeah, so we love talking about how impactful the brain is on the gut, but that it's bi-directional, because certainly, you know, unfortunately, people have heard that some of these symptoms are, oh, they're in your head, you know, and that's like the last thing that we want people to experience, and so that's another thing that we dispel often that your head is heavily involved in these symptoms, but in a really impactful way through the brain-gut axis, and so you do a beautiful job describing that and, again, I think, helping people to understand that these symptoms are very, very real. They're just complex and impacted by things that you never would have thought would cause bloating or cause bowel problems, but they can and they do.

Dr. Brian Lacy:

Absolutely, absolutely well said. You know, I think too just as an aside, you know, sometimes patients will say, oh, I've just told it's stress. Everybody blames it on stress, and I think I always try to take a step back and say, yeah, it's easy to say stress, but when you think about it, this is why stress can do it, and if you go that extra step, as you do, as Kate does, it just makes sense to patients.

Dr. Megan Riehl:

Right when you label what stress hormones are and that stress certainly can be emotional, but that stress has very profound physiological impacts on the body too. That, I think, also is what you're talking about in terms of connecting and again validating that patient's experience.

Dr. Brian Lacy:

Agreed.

Kate Scarlata:

Yeah, and I just I love the way you described the gut as such a sensory organ in such clear description, because I don't think people realize how the gut and brain are connected, but also just so much sensory ability it can really take in. You know, is very affected by whether it's food or gas, depending on how heightened that brain-gut access is, especially like in something like IBS, how stress can really exacerbate those symptoms.

Dr. Brian Lacy:

Absolutely, absolutely. I mean, as I tell the medical students what's the smartest organ in the body? Well, it's the stomach, right, you know? It's not your brain, it's not your heart, it's the stomach, because it's telling you, really on a second-by-second basis, what its functional status is. Am I a little queasy? Am I full? Am I overly stuffed? Am I too hungry? Do I have butterflies in my stomach? A brain-gut problem, right, because everybody's had some butterflies before. So, on a second-by-second basis, it's telling you its sensory status.

Dr. Megan Riehl:

I love that (Kate). Those of us that can lean into that gut instinct. It's real. That's another thing that you're teeing me up to talk about, that that there is a gut instinct and your thoughts are connected to that, and so sometimes giving pause when your stomach is giving you some signals and then sifting through some of the cognitions and the emotions that go along with that, leaning into that and learning how to lean into that, can really help guide you in terms of all the things that we navigate in the world, absolutely.

Kate Scarlata:

So let's segue a little bit into nutrition, and this is obviously working with IBS patients that experience a lot of bloating. I'm making diet modifications on a regular basis, but I'd love you to just talk a little bit about your practice and what are some of the dietary culprits that you find frequently in your patients, and I'd love you to talk a little bit about just the notion that fiber and plant-based diets are really hot right now, and I can see why eating plant-based diets are good for us from a gut microbiome, gut health standpoint, but I think for some people they might be overdoing it and whether it's too fast to ramp up or just too much fiber all at one time, what are your been asked a diet question from an internationally recognized expert in diet and nutrition, so she's just setting me up to fail.

Dr. Brian Lacy:

But let me tell you how I do it in my I'm teasing. Let me tell you how I do it in my practice. I take time with every patient and I try to be very efficient, but this is the way I approach it, knowing that this is not the way a dietitian would approach it during a 45-minute visit. So when I think about common dietary offenders, I ask about dairy. So don't forget that lactose intolerance is present in 35% of adult Americans and up to 95% in African-Americans and Asians, and it happens slowly over time. I ask about fructose. Remember we don't have an enzyme that breaks down fructose. It's absorbed very slowly through co-transporters. There's a lot of fructose out there. The average American takes in 40 pounds a year of high fructose corn syrup. Yeah, I see Megan closing her eyes, thinking this is terrible, and it is terrible because it causes gas, bloating and, of course, obesity. I think about healthy foods that can backfire. So cruciferous vegetables are healthy, but too much broccoli, cauliflower, brussel sprouts can backfire gas and bloating. And I think about legumes, which can be very healthy. You know we're talking about galactans now. It can be very healthy, reduce cholesterol, good source of protein, but they can cause gas and bloating because many Caucasians don't have the enzyme to break it down. I ask about sugar-free candies, gums and mints, because anything that ends in O L, sorbitol, lactitol, erythritol, mannitol can cause horrible gas and bloating. And I ask about artificial sweeteners as well. Your point is a great one.

Dr. Brian Lacy:

I think many of your listeners are trying to become healthier, trying to shift more to a plant-based diet, which is great, and incorporating more fiber-rich foods. The problem there is sometimes eating healthfully great for your overall health backfires for your gut, because if you do add things in too fast you can cause gas and bloating. But also fiber, if it goes through the GI tract and gets to the colon, ferments and a scary fact or maybe not so scary, but maybe a surprising fact is a teaspoon of fiber can produce 200 cc's of gas A teaspoon of fiber. So your teaching point, kate, was perfect. If you start that plant-based diet, start that higher fiber diet, do it slowly, let those gut bacteria get used to it. Don't overwhelm them all at once, because if you add a huge fiber load you're going to look like the Pillsbury Doughboy the next day.

Kate Scarlata:

I love that and you know it is so true. I think people like it's all or nothing and I'm going to be on a high fiber diet tomorrow and eat 50 grams at breakfast. I was just looking I think it's the cereal poop like a champion. I don't know if you're familiar with that cereal, but it's like 23 grams of fiber and a half a cup and I thought, oh boy, this is like a sprinkle on top of your lactose-free yogurt, but not a half a cup at one shot.

Kate Scarlata:

I think yes, I'm so grateful that you agree with me. Go slow, let that colonic environment adjust the little microbes residing there so that you'll tolerate things better. I am so grateful you talk about sugar-free gum and mints and ask that question because I have had so many patients come into my office chewing gum, popping the mints and thinking to myself okay, I got my first recommendation here.

Dr. Megan Riehl:

Drinking the carbonated soda.

Kate Scarlata:

Right, exactly, or even the bubbly waters.

Dr. Megan Riehl:

Right. We think that that's a healthier choice, which in a lot of ways it can be. But all that carbonation sometimes can be really a killer on the gut.

Dr. Brian Lacy:

Yes, absolutely.

Dr. Megan Riehl:

I was smiling as you're describing the sugar, because you know, in the real household we try to take a liberalization, moderation approach.

Dr. Megan Riehl:

So you know, just like we may eat an entire head of broccoli all together at the dinner table, you know, then we go get our ice cream in the summer. And so the approach of moderation, but also then knowing that I live a pretty healthy lifestyle and I'm not immune to bloating just like the next person. But I think that knowing that, like when you can step back and take a little bit of a self-assessment of, huh, I've been more bloated recently, is it that summer's around the corner here in Michigan, where it's not warm down in Florida all the time, so we're more likely to have ice cream and we're eating more of those fresh fibrous vegetables as we get them a little easier, and so you might see this kind of uptick in bloating. And there may be some gentle ways that you can approach that through some changes. And I think that not catastrophizing around the why right away can be really helpful, especially when it comes from a stress management perspective.

Dr. Brian Lacy:

I agree with all that yeah.

Kate Scarlata:

IBS-C, or irritable bowel syndrome with constipation, is a common condition in which people experience constipation along with other belly symptoms like pain, bloating and discomfort. Sound familiar like pain, bloating and discomfort Sound familiar. Many people with IBS-C are willing to give up key parts of their lives in exchange for symptom relief. And because the causes of IBS-C may differ for each person, there is no one-size-fits-all treatment approach. If you're suffering from IBS-C, you may have to try a number of different medications before you find the right one for you. So don't be okay with just feeling okay. If you have IBS symptoms that continue to bother you, talk to your healthcare provider to find out if your current medication is right for you or if it's time to try something different. The more you know about IBS-C, the better prepared you will be to speak with your doctor about the right treatment option for you.

Dr. Megan Riehl:

As a psychologist in this area, I feel pretty comfortable giving patients some guidance around the breathing techniques, so we'll link our diaphragmatic breathing video that's available on YouTube in the show notes. Today I also will talk with patients about exercise and gentle movement of their body. But what about some of those holistic over-the-counter remedies that I'm sure people are asking you about? The simethicone activated charcoal is one I hear about probiotics. Do these work and also what are the risks to using some of them?

Dr. Brian Lacy:

At heart I'm kind of a scientist, so let's preface this whole conversation saying that for most of what I'm going to say, we don't have great data, so we'll have to rely. I've done this job for about 30 years, so I've seen a lot of patients with gas and bloating and I try to keep up with the literature. What do we really know? So activated charcoal can bind different chemicals and can bind medications and may help prevent a poisoning overdose, but the data supporting its use for gas and bloating is essentially zero. And then you take activated charcoal, your stool is really dark and you get everybody all excited because they think you're bleeding on the inside.

Kate Scarlata:

So don't use activated charcoal.

Dr. Brian Lacy:

Exactly. Just stay away from that. What about simethicone? So we know that we give that to babies for colic, biliary colic, which is really gas bubbles stretching the colon and small intestine cramps and spasms. What does simethicone really do? What it really does is take a big gas bubble and breaks it into little gas bubbles. It doesn't get rid of your gas, but it may help a little bit. So could you add a little bit of simethicone Can't hurt, but we don't have great data at all.

Dr. Brian Lacy:

Some people use probiotics and a concept again we kind of started almost a conversation with that is that probiotics may change your gut microbiome, may change that gut flora, that delicate balance of good and bad bacteria. But the data supporting bloating is very weak at best. Matter of fact, if we looked at IBS and looked at 53 published studies in IBS, probiotics are barely better than placebo and don't do much for pain or bloating. So I don't usually recommend them and sometimes it makes bloating worse. I think watching your diet, I think exercising, I think taking control of your constipation Again, if it's hard to evacuate stool, it's hard to evacuate gas and thinking about some of those other common offenders we've already discussed.

Dr. Megan Riehl:

And what about the pharmaceutical treatments? So there's more rigorous research around this. Antibiotics, the prokinetic agents, tricyclic antidepressants, antispasmodics are probably the things that if people were Googling, they would find and bring to their doctor. What do you use and what might you suggest for patients?

Dr. Brian Lacy:

Now we actually have some data. So let's talk about data. So let's think about antispasmodics first, with smooth muscle antispasmodics. The theory there is that they can relax the gut and there is some data showing that smooth muscle antispasmodics I'll use a generic name, hyosiamine or dicyclamine as an example might improve some symptoms of gas and bloating. And there's one product sold in Central America that's a smooth muscle antispasmodic with simethicone, as you know, showing that was better than placebo. So there's a little bit of data. Some people translate that to using warm peppermint tea. Peppermint oil helps spasms and cramps, but remember it's not changing the gas content. It's really changing how you respond to the gas.

Dr. Brian Lacy:

Could you use antibiotics? So we use antibiotics for people with documented small intestinal bacterial overgrowth. I don't recommend it just for bloating in general because antibiotics have risk and I would feel terrible giving somebody horrible diarrhea like C difficile clostridium difficile diarrhea, somebody horrible diarrhea like C difficile clostridium difficile diarrhea. But antibiotics can definitely change gut flora and treat small intestinal bacterial overgrowth and therefore improve symptoms of gas and bloating. But I want to have that documented. The best data for medications might come in the IBS with constipation field. We have five FDA approved drugs for this disorder I'm sure your listeners are very familiar with them such as linaclotide or plecanatide or lubiprostone. Those are the generic drugs and the data shows that in all the studies performed to date, as we improve IBS and constipation symptoms, those agents prokinetic agents, as you mentioned, Megan also improve symptoms of gas and bloating. Is one necessarily much better?

Dr. Megan Riehl:

Yeah, and we're going to shift in I'm going to let Kate bring this up but I think the constipation so often. Sometimes patients get stuck on their bloating. But then I'll ask them when's the last time you've had a bowel movement and they're bloating? But then I'll ask them when's the last time you've had a bowel movement and they're like yeah, I go, I don't know, every five or six days. They oftentimes don't even recognize. That's not normal, and so I'll let Kate take it away from here.

Kate Scarlata:

Yeah, I mean I would say, and I'm a 30-year veteran too, Dr Lacy.

Kate Scarlata:

And most of my patients are constipated and it's just. I don't know if this is an increasing problem in America, but I see constipation so frequently and I wanted to mention the condition as well, which I'd love you to just quickly define. But I am really seeing this as a big driver of bloating the constipation and maybe even which I think we're seeing in a lot of constipated patients. So I'd love you to describe and just the relationship. How significant is constipation in this bloating picture from your clinical experience?

Dr. Brian Lacy:

Okay, great question. So a couple of points here. One is, as you've highlighted, constipation is common we talk about 15% of US adults at minimum and if you imagine trouble evacuating stool gas is handled to some degree the same way. So it may be difficult to evacuate gas. The anal rectal area is very smart and if the muscles aren't working properly you may have trouble evacuating gas.

Dr. Brian Lacy:

Your point about dyssynergic defecation comes to that pelvic floor. So what I tell my patients is going to the bathroom should be really easy, right? What's the big deal? People go to the bathroom every day. It's incredibly complicated, right. So what I tell my patients is one it has to be an appropriate time. So if you're outside of New York and you're on 95, that's probably not the best time, so it has to be appropriate setting.

Dr. Brian Lacy:

Number two, stool has to move through the colon normally, and in most people it does. Number three you have to be able to sense it normally. So maybe think about a longstanding diabetic who has now lost some sensory function and actually can't sense that pressure in the rectum. It's time to go to the bathroom. They've lost that sensation. Number four, and this is the key point in split-second sequences, certain muscles have to relax and certain muscles have to contract. And if they are a split-second off sync, patients think they're pushing to evacuate, but instead the muscles are clamping down, they're holding back and that's what's dyssynergic defecation, it's out of sync, it's synergy, so it's out of sync, dyssynergic. And a key teaching point here is that those patients, as you well know, don't get better with medications. Usually it's physical therapy. But when their physical therapy goes well and their constipation gets better, their bloating always gets better as well, hand in hand.

Dr. Megan Riehl:

Another team member, the pelvic floor physical therapist. They get another shout out and you know I just had a patient today actually, that I was describing how, you know, pelvic floor dysfunction could be a part of the puzzle. This is a patient that has constipation and she hadn't yet met a doctor that had done a rectal exam. She's coming up on a first colonoscopy and we really gave a playbook today around concepts to talk with her doctor about, because she hadn't even thought about pelvic floor dysfunction. Nobody had ever mentioned that before and it really can be a big part of the picture, especially for women that have had babies or a variety of factors that can impact the pelvic floor.

Dr. Brian Lacy:

Absolutely so. I think it is overlooked. I think some people don't want to open Pandora's box and start talking about this, because it's a little bit of a longer discussion. So you just did your patient a great service today. That's wonderful, right. Very lucky. They met you Well there we go.

Kate Scarlata:

I love that. Just to go back to abdominophrenic dysnergia, did I say that right?

Dr. Brian Lacy:

Absolutely.

Kate Scarlata:

Okay, outside of maybe trying diaphragmatic breathing, are there any other evidence-based therapies for this? I should have asked you earlier, but before I wrap up anything, the simple answer is no.

Dr. Brian Lacy:

So we do think about this as being this wiring problem where subconsciously something has happened, and that gas that stretches the small intestine or colon again. Normally your diaphragm goes higher in your chest, your belly cavity gets bigger and your abdominal wall muscles contract to keep your belly flat. It's the exact opposite. Why that occurs, we don't really know. Some prior infection, some insult, some learned behavior? We really don't know why it occurs. The best data we have but we don't have much data, as we already discussed is probably diaphragmatic breathing. It seems to make sense and at least in clinical practice by a lot of smart providers it works. Some people have tried electrical stimulation to the abdominal wall. That doesn't seem to work very well. Some people have tried medications to fix that, but the medications really don't work. So I think we really need to focus on behavioral strategies for this.

Kate Scarlata:

There you go, Megan. Let's go, let's go. You're the valued team member in this case. So real quickly for our listeners.

Kate Scarlata:

Dr Lacy brought up some really key factors from the diet that may be a player for bloating, lactose malabsorption. We drink a lot of milk. We love our ice cream. There's lots of lactose-free options, but if you're experiencing bloating, that might be the first thing you might want to look at.

Kate Scarlata:

There are some fibers that are small fibers that are fast food for our gut microbes. Dr Lacy brought these up galactans or galactoaligosaccharide. These are common in legumes. We also have another type of fiber called fructans, and they're common in garlic, onion and wheat in the American diet. Those are also fast food for our gut bacteria, so those two types of fibers can be problematic for bloating.

Kate Scarlata:

The other consideration is ramping up fiber and your goal to have the best gut, healthiest microbiome in the whole entire universe. Go slow, make sure you're adding water and then be careful of those sugar-free mints and additives that you might find in various granola bars and supplements, because those are poorly absorbed too, and those types of sugars that are poorly absorbed can be food for your gut microbes, and what they do is they make gas, and gas makes you feel bloated. And there you go. A couple other lifestyle tips that I bring up with my patients is walking, you know. Go for a nice evening walk after dinner. That can stimulate colonic motility and may move through some of that gas. And another tip that I often encourage and we did include it in the Mind Your Gut book is a gentle abdominal massage which sometimes can help move the gas further down into the rectum for easier passage. So, Megan, what about you?

Dr. Megan Riehl:

Ye s and I love that Dr behavioral himself a simple gastroenterologist.

Kate Scarlata:

It's about the furthest thing from that, hello.

Dr. Megan Riehl:

And another equally simple gastroenterologist, Dr Baha Moshiree, she and I. She's another motility specialist. You know, back in April the New York Times just ran this article on gas and bloating while traveling and she was featured. She's a fabulous Atrium Health gastroenterologist who explained more of the physiology around it. So the high altitude of being on an airplane might slow down the muscle contractions that are needed to kind of push the digestive process through. So I had the privilege of being a part of this New York Times article as well, because of the behavioral sides of gas and bloating while traveling, and I got to normalize that.

Dr. Megan Riehl:

You know, if you're somebody that feels these symptoms while traveling or you've wondered wow, when I travel I get constipated, I'm more gassy, I'm bloaty, and I got to be quoted saying trust me, you're not the only one farting on an airplane. Never in my life did I think that would be the quote that came out. But the reality is, if you've ever seen a chip bag on an airplane and it expands, that's what can happen to all of us, and especially those that are probably more prone to IBS or other digestive symptoms. And I really think that the normalization that even if you're not traveling but you're in class. Now you don't want to be the person that's just letting your fart fly in class. But standing up, leaving the room, excusing yourself to go to the bathroom, sucking in, holding your stomach, excusing yourself to go to the bathroom, sucking in, holding your stomach, holding your gas when you're out and about, it's not good. And you're not alone. Other people are experiencing this.

Dr. Megan Riehl:

Dr Lacy highlighted the statistics of people that are experiencing these symptoms and if you're doing that, you're more likely to just worsen bloating, worsen your constipation. So in the real household we have normalized that everyone poops, everyone toots. My two-year-old says it to me all the time Mama, I tooted and I'll say that's great. And I want everybody to kind of feel destigmatized in their normal bowel habits and their patterns and this can go a long way. So you know, if you're seated around the dinner table talking about things, normalize our bodily processes, make sure that we're having conversations about, especially with your kids. Are they pooping at school? Are they going to the bathroom? Do they feel uncomfortable at school, so that we can get them the help that they deserve at a young age instead of what I'm sure the three of us experience where we're seated with. You know 50, 60-year-olds that are just starting their pathway of addressing these symptoms.

Dr. Megan Riehl:

So, as we've kind of mentioned, gentle yoga, going for walks, thinking about the foods that you're eating, but if your belly is bothering, you don't ignore it. Get help it might not be with a gastroenterologist, it might be with a dietitian or a behavioral health specialist and just know that it's okay to let it go when you need to, and you know that we all support that. As we wrap up this incredibly informative podcast today with Dr Lacy, we like to wrap up by asking each of our guests the following questions. So, Dr Lacy, what is something that you prioritize when it comes to your overall health and your wellness?

Dr. Brian Lacy:

So first of all, thank you. This has been a wonderful discussion. Your listeners are very lucky to have you both. I learned a lot. So what do I do? I guess can I say three or four little things.

Dr. Megan Riehl:

Please.

Dr. Brian Lacy:

So some seem. I'm sure your listeners have heard all this before. So one I do prioritize sleep, and the reason being is that poor sleep changes sensory thresholds in your gut and if you don't sleep well your gut feels worse. So try to prioritize sleep. I try to exercise, so I do something six or seven days out of the week and it could just be that wonderful half-hour walk with your family after supper. It doesn't mean three hours at the gym. Exercise comes in different forms. It could be playing ping pong with your family, it could be any number of things, but do something physically active.

Dr. Brian Lacy:

Number three I turn devices off. People laugh at me. I think I have four apps on my cell phone. Sorry, guys, but turn your device off on vacation and at night at home. Don't stay connected. You need to focus on your friends and your family and yourself. And number four I guess what I would say, other than try to eat healthily you'd be prod, Kate is I try to express gratitude. You know, all of us are so lucky in so many different ways and even if you're having a bad day, if you do one nice thing to somebody every day, express gratitude to that checkout clerk, to the person who helped you at the pharmacy. That one minute interaction, that 30 second interaction of expressing gratitude to somebody else completely changes that person's day and my day as well. Right, we have so many wonderful things around us. So, at 30 seconds, that one minute of gratitude each day can be just a life changer.

Dr. Megan Riehl:

And this is why he's such a gem.

Kate Scarlata:

I know it's amazing.

Kate Scarlata:

I'm like geez Louise the nicest guest, the nicest person and everyone that knows you says that about you, just so you know like the nicest, kindest individual on the planet. So I love what you do for well-being. I'm going to take those, every single one of your tips, and incorporate them into my life. I do get my sleep, but I'm bad with the device, but that was excellent, thank you. Thank you so much for being our guest today. You shared so much around this topic that is confusing for people and worrisome for people. Just leading us down a scientific path, which is really the goal of this podcast, is to provide the real truth, the real science as we know it today. So thank you again for spending time with us on our podcast.

Dr. Brian Lacy:

Absolute pleasure and thank you for having me. Delighted to do it, and best wishes to all your listeners.

Dr. Megan Riehl:

So next up we are talking with Dr Darren Brenner, gastroenterologist and professor of medicine at Northwestern University in Chicago, Illinois, and it really features you know it's going to swing right in from bloating to constipation, so we're going to talk about everything you need to know about constipation. Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode and don't forget to subscribe, rate and leave us a comment. You can also follow us on social media @TheGut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.

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Kate Scarlata

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Megan Riehl

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