The Gut Health Podcast
The Gut Health Podcast explores the scientific connection between the gut, food, mood, microbes and well-being. Kate Scarlata is a world-renowned GI dietitian and Dr. Megan Riehl is a prominent GI psychologist at the University of Michigan and both are the co-authors of Mind Your Gut: The Science-based, Whole-body Guide to Living Well with IBS. Their unique lens with which they approach holistic conversations with leading experts in the field of gastroenterology will appeal to the millions of individuals impacted by gut health.
As leaders in their field, Kate and Megan dynamically plow through the common myths surrounding gut health and share evidence-backed information on navigating medical management, nutrition, behavioral interventions and more for those living with or without a GI condition.
The Gut Health Podcast is where science, expertise, and two enthusiastic advocates for wellness come together to help you live your best life.
Learn more about Kate and Megan at www.katescarlata.com and www.drriehl.com
Instagram: @Theguthealthpodcast
The Gut Health Podcast
The Promise of Vagus Nerve Stimulation and Virtual Reality Therapies for Gut Health and More with Dr. Brennan Spiegel
Can technology transform the way we approach health and healing? In this episode, we explore the intersection of neuroscience, innovation, and the mind-body connection with Dr. Brennan Spiegel from Cedars-Sinai. Dr. Spiegel challenges the long-standing myth that the mind and body function separately, revealing how our thoughts, emotions, and physiological responses are deeply intertwined.
We take a deep dive into alternative therapies that go beyond conventional treatments, including vagus nerve stimulation (VNS) and its impact on relaxation, well-being, and potential applications in treating health conditions. From implanted devices to non-invasive, direct-to-consumer options, we break down how VNS works and its role in the parasympathetic nervous system (think: rest and digest). We also discuss percutaneous electrical nerve field stimulation (PENFS), a distinct yet related therapy offering new opportunities for managing gastrointestinal disorders.
But the innovation doesn’t stop there. We explore the growing role of virtual reality (VR) in healthcare, examining its influence on physiology, pain management, and patient outcomes. Backed by research from leading institutions like Cedars-Sinai and the Mayo Clinic, we uncover how VR is shaping modern medicine. Also, Dr. Spiegel shares fascinating insights on how gravity affects the body and how cutting-edge technology provides immersive healing experiences for patients in need.
Join us as we navigate this exciting frontier where technology and health converge, offering fresh perspectives on how VNS, VR, and the power of the mind-body connection may revolutionize medicine.
Tune in now and discover how these advancements could change the future of healthcare and well-being.
This podcast episode is sponsored by Ardelyx.
References:
Resources mentioned by Dr. Brennan Spiegel
SynerGI - IBS VR Program available through research studies
Xaia - VR support program available through Apple Vision Pro
Tripp VR - Immersive meditation program on mobile and VR devices
Vagustim - Vagus nerve stimulation product mentioned by Dr. Spiegel (contains marketing affiliate link). Get an extra 20% off by using coupon code: GutHealth20
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.
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. 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 Kate Scarlata, a GI dietitian.
Dr. Megan Riehl:And I'm Dr Megan Riehl, a GI health psychologist, and we have a really fascinating episode for you today as we dive into the incredible power of the vagus nerve and some interesting treatments.
Dr. Megan Riehl:As one of the 12 cranial nerves, the vagus nerve connects the brain and the body and it stretches from the brainstem all the way to the gut.
Dr. Megan Riehl:That's why we think about the vagus nerve when we're thinking about some of our gut health issues.
Dr. Megan Riehl:It plays a very crucial role in parasympathetic nervous system activation. So we're thinking relaxation, response, and what we think is very exciting is that we're learning more and more about the ways that we can get at that vagus nerve. We see FDA-approved devices that can stimulate the nerve for conditions like epilepsy and major depressive disorder, as well as migraines. But research is emerging and how we're getting to the vagus nerve might include handheld devices that you can purchase on the internet, or even potentially enhancing brain function through deep breathing, meditation, massage or even moments of wonder and awe, which can all activate our vagus nerve to promote calmness and well-being. So we're thrilled to have an expert with us today to step outside the box and explore some of the science of this neurostimulation, and you'll hear us using some terms like vagus nerve stimulation, percutaneous electrical nerve field stimulation, also known as PENFS, and the transformative potential of virtual reality for our gut, health and beyond. So we are very excited to introduce you to our guest expert today.
Kate Scarlata:Yes, we are so excited. Dr. Brennan Spiegel is Director of Health Service Research for Cedars-Sinai in Los Angeles and directs the Cedars-Sinai Center for Outcomes Research and Education, a multidisciplinary team that investigates how digital health technology, including wearable biosensors, smartphone applications, virtual reality and social media, can strengthen the patient-doctor bond, improve outcomes and save money. His team developed one of the largest and most widely documented medical virtual reality programs at Cedars-Sinai, and his work has helped to support a new field of medicine called Medical Extended Reality or MXR, in which doctors use immersive technologies like virtual reality to help treat conditions ranging from pain to anxiety and depression and even irritable bowel syndrome. Dr Spiegel has published numerous best-selling medical textbooks, editorials and has more than 270 articles in peer-reviewed journals. His digital health research has been featured by major media outlets, including the New York Times, bloomberg, cbs News and more. Dr Spiegel published the book Bloomberg, cbs News and more. Dr Spiegel published the book VRX How Immersive Therapeutics Will Revolutionize Medicine, which was named by Wired Magazine as one of its top eight science books of 2020. We welcome you.
Dr. Megan Riehl:Dr Spiegel.
Brennan Spiegel, MD:Good to be here. Thanks for having me.
Dr. Megan Riehl:So, before we dive in, we like to start every episode by asking our guest about a myth they'd like to bust. So what myth would you like to bust pertaining to your area of expertise or gut health?
Brennan Spiegel, MD:Well, I think there's a myth that goes all the way back to around the 1600s probably well before that, but at least the 1600s when the philosopher, the famous philosopher, Rene Descartes anyone who studied philosophy has come across his work the French philosopher, and he came up with this idea. He called dualism. And the idea behind dualism is that the mind and the body are separate and distinct, that the mind is this immaterial experience with a spiritual component and the body is the physical machinery that moves that mind around in the world. And they're separate, they're distinct, they're dual. And that's how we've thought about modern medicine for years.
Brennan Spiegel, MD:You think about psychiatrists you know, manage the mind, and GI doctors manage you know the pumps and tubes in the body. There's plumbers that manage. You know the heart and the blood vessels and all that. And then there's people that think about the emotions that we experience. But that's a myth. In reality, we know that it's all one system. This says nothing about what you think about religion or spirituality. I'm just talking about the physical systems that connect the mind and body and in fact, that sets up the vagus nerve in part. Sure does.
Brennan Spiegel, MD:Because that is a clear and what we'll talk about today sign that the mind and body are not separate and distinct. They very tightly are coupled and interact with one another. So that's a big myth.
Dr. Megan Riehl:It's a great myth to bust.
Kate Scarlata:I like that, yes, and I think we're seeing just this integration of multidisciplinary teams, especially in gut disorders, being so much more beneficial. So we're really just this integration of multidisciplinary teams, especially in gut disorders, being so much more beneficial. So we're really, you know, looking at the whole body instead of separating things. So we're going to talk about vagus nerve stimulation. We're going to talk a little bit about virtual reality, but let's start with vagus nerve stimulation. I find the science really interesting and feel like we're not quite there yet, maybe with some of these devices that are out there, but they could have a lot of health benefits, or there's the signals that they might have some health benefits to a lot of different conditions. So how does one stimulate their vagus nerve? What are some of the techniques to do such?
Brennan Spiegel, MD:Yeah, well, there's different ways to stimulate the vagus and, as you said, the vagus nerve is one of the cranial nerves. Vagus shares the root for vagabond, which basically is a wanderer. And the vagus nerve is a wanderer. It is the longest nerve and it wanders all throughout the body. It takes twists and turns, it has branches and side branches. It goes all throughout the GI system, the heart, it gets all around.
Brennan Spiegel, MD:So you can imagine there's different ways to stimulate it because it goes in all sorts of different locations.
Brennan Spiegel, MD:We can stimulate it in the ear, can stimulate it in the neck. That's, the most common place is on the neck, because the vagus nerve runs right up the neck along the carotid arteries, the main big arteries where you can feel your pulse in the front of your neck on either side. And in the past it was stimulated by implanting an electrode underneath the skin through a procedure which is rather invasive. But now we have different ways to stimulate it through the skin. So, for example, I do have a vagus nerve stimulator that I have used and it stimulates it through the ear, and so it's almost like wearing an earbud. It releases a very light electrical pulse through the ear and it stimulates a branch of the vagus nerve that goes all the way up to the ear, and then you know it's a rather non-invasive, pretty simple way to stimulate the vagus nerve without having to do a procedure or an operation or something like that. But yeah, there's different ways of doing it like that.
Dr. Megan Riehl:But yeah, there's different ways of doing it. I think in my clinical practice, you know I've had patients that have been told by somebody you know they have vagus nerve dysregulation or dysfunction and you know they're here to fix that. How do I fix my vagus nerve? And you know, I think if you Google the vagus nerve you're going to see all of these different, more invasive vagus nerve stimulation which, to be very honest, when somebody would come to me, I used to be like I don't do that, like I'm not going to implant something in your system, but I would talk about lifestyle, that connecting the mind and the body, and that the things that we can do to activate our parasympathetic system are going to be good for your vagus nerve.
Dr. Megan Riehl:But there's so much in between that that people can find it is kind of cool to see that there are these devices that you can purchase and experiment with that, see what your experience is with. You know there are some contraindications that you will certainly want to talk to your medical providers about when you're thinking about exploring this on your own. And I think you know it's interesting to just kind of when you were looking at why you purchased, without getting too personal, but I'm curious like what were you looking for when you made that purchase?
Brennan Spiegel, MD:Well, mainly I wanted to understand what it felt like and whether it made an impact on my own body and mind. You know it's useful to have a first person experience. This is the reason why, by the way, when I had my first colonoscopy, I did it without sedation, so I'm not recommending that for everybody, but that's what I did so, you know, got to understand what you're talking about if you've been through it. So vagus nerve stimulation appealed to me because it's so non-invasive, generally quite safe and there's evidence behind it.
Brennan Spiegel, MD:It's evolving, like you guys said at the beginning, this is an area that we don't yet have a lot of information on, but it's growing and in some cases we have FDA-cleared indications, like for epilepsy. It's gotten so far that it's FDA-cleared. In other areas like, let's say, inflammatory bowel disease or irritable bowel syndrome or other GI conditions, are still learning. So I wanted to see what it was like and I looked at a bunch of different technologies. I also talked to some experts in the field see what they use, and the intraauricular or the earbud version was recommended as a good starting point. So I've really enjoyed using it. You know, talk more about our experiences, yeah.
Kate Scarlata:Love it. So what is like the biological mechanism behind stimulating the vagus nerve and some of these downstream effects like motility, maybe even inflammation, or you know how would it help epilepsy? What's going on? What do we know? How?
Brennan Spiegel, MD:Would it help epilepsy? What's going on? What do we know? Well?
Kate Scarlata:We don't know what we don't know.
Brennan Spiegel, MD:Okay, so that's a good place to start, that's always the case and we should always try and stay humble with science. And I will say that in science, particularly in academics, where we are in this sort of fortress of orthodoxy, we sometimes will just poo-poo ideas that seem like pseudoscience or we'll brand them as voodoo or pseudoscience. But they're not pseudoscience. Pseudoscience means you cannot under any circumstance even study this idea. It doesn't even make sense according to the laws of physics or science or whatever. That's not the case for something like vagus nerve stimulation. Although some people might think it's kind of silly, it's like any other new innovation we have to study it. So the vagus nerve does lots of things and if we stimulate it, you can imagine it's going to have different effects on the body. Certainly in the gut it's involved in promoting rhythmic contractions. Certainly in the gut it's involved in promoting rhythmic contractions. So we call this the rest and digest phase as opposed to the fight or flight phase. So these are the ways we think about it in physiology is you know, if you see a lion coming at you? God forbid that happens to you.
Brennan Spiegel, MD:But 10,000 years ago our ancestors were getting chased down by all sorts of threats. You got to either fight that thing or run like crazy and get away. You don't have time to digest your food right. That's not a time to be putting any blood flow into your gut. The blood's got to go into your muscles, your lungs, your brain, and you got to run like crazy and fight. Your pupils have to dilate right. You need to be ready to go.
Brennan Spiegel, MD:That's how too many people live their lives, as if they're being chased down by lions, and that leads to stress and anxiety and, at some point, just downright depression, because you can't handle it anymore.
Brennan Spiegel, MD:You just collapsed, and so the vagus nerve is a switch that helps turn on that rest and digest program. That's the exact opposite. This is where you're relaxing, you're digesting your food. Your heart rate is slowing down, you know, and you have what we call improved or more variable heart rate variability and this is an important concept of the beat to beat variation in the heart, not just the heart rate, but how is the heart beating and the vagus nerves involved in that too. And that's just the beginning. You know you've touched on some of these already in terms of inflammation and the microbiome and serotonin. We would definitely have to talk about serotonin today, and I don't want to get too far out there because I've just thrown out so much already. But all of these are potential ways that if we buzz this nerve, good things could happen, you know, if we're careful about it, and some of those I've just touched on there.
Dr. Megan Riehl:And there's different ways to buzz it.
Dr. Megan Riehl:That's the key, and I think, when we think about some of the GI literature out there, there are vagus nerve stimulation techniques that again are things that any of us could do, like diaphragmatic breathing or even gurgling to get at certain sound wave sensations that can move your body.
Dr. Megan Riehl:And then there's a separate but distinct type of therapy that I mentioned earlier the percutaneous electrical nerve field stimulation, and this is the type of intervention that we're seeing in some of the literature where, if you are Googling, especially for the peds population things like functional abdominal pain related to IBS we're seeing some products out there that are available that have really great data with reductions in pain and disability, improving well-being, some of those emotional outcomes that we're looking for in the treatment of these symptoms. So there are really cool things in the pipeline that are happening that are going to shift the way we look at what a treatment might look like for people, and so I'm wondering you know I mentioned a study that we'll link and it was a 2023 study on these devices but what is some of the latest research and studies in these neurostimulation therapy kind of worlds related to the brain-gut axis that are getting you excited?
Brennan Spiegel, MD:Yeah, I mean, you've hit it on the head. There's so many different approaches and so many different mechanisms and so many different conditions, so you almost think of it like a Venn diagram. There's the actual modality, the actual electrical system. There's what condition are we managing? And then what mechanisms do we think we're leveraging? Leveraging, and it's still a little bit murky. But this idea of percutaneous electrical nerve stimulation is really fascinating to me, because what we do know is that there are virtual gates that allow pain to pass through and up the spinal cord or not, and so you can imagine even just something like TENS therapy you know, transcutaneous electrical nerve stimulation for chronic lower back pain.
Brennan Spiegel, MD:Just take away abdominal pain for a second. The idea here is, when you were a kid or even as an adult, you hit your elbow and it hurts. The first thing you start doing is you rub it. You know, you like just rub your elbow because you got a boo-boo right and it hurts. And somehow you know a parent rubbing their child's boo-boo makes them feel better. Well, what's that all about? Is that just placebo? Well, no, actually what we think is happening is you're overriding the pain sensations with these additional stimulations, these additional signals, stimulations, these additional signals, and what that can do is overwhelm the pain processing sites and even close down these so-called virtual gates. And these gates are aligned up and down the spine and they are involved in kind of like a gate in a fence. If it's open, then the horse will go right out of the barn, but if it's closed, the horse stays in there. And by literally rubbing the skin, you are modulating or changing whether the gates are opened or closed. So with electrical stimulation, what's happening is it's a more precise and modifiable way of doing that, and we think that closing virtual gates is one of the ways that this works.
Brennan Spiegel, MD:We also know that people with irritable bowel syndrome in particular, and people in general who have chronic pain, often have difficulty closing those gates, and it has to do with the brain. Now, now we're back up on the brain side, because what the brain does is it sends signals down the spinal cord. The brain can fight back. The brain doesn't just sit there and take whatever it gets. It can fight back. And the way it fights back is by sending what are called inhibitory signals.
Brennan Spiegel, MD:The technical term is descending inhibitory pathways where these signals go down the spine and actively shut those gates so that you can just relax. So just imagine if you didn't have that. Every twist and turn your bowel takes, every stretch of the intestine, every movement of the food would be constantly bombarding your brain with signals and you would feel your food going through your body. I mean, just imagine how maddening that would be if we didn't have an ability to shut down those sensations. And that's how we do it. But if you can't shut those down, then that's very tough. So electrical stimulation one way we think it works is by shutting those gates down.
Dr. Megan Riehl:Yeah, and you know, I think that's where, to your point, we have to be open to exploring this. Because you know, just like, if you would have told me I would be doing gut-directed hypnotherapy every day in my clinical practice a decade ago, I would have told you we're kind of nuts. But yet here I am and it's so powerful and we have a fully integrated acupuncturist in our GI practice. And same thing they're looking at certain acupressure points, acupoints in the body, that if we hit on those in the right way, we can produce profound changes for patients. So it's exciting.
Brennan Spiegel, MD:And I will add one thing here, because we have, you know, a dietician with us.
Kate Scarlata:That's right.
Brennan Spiegel, MD:But the idea there is. It's all interrelated. So the intestinal system. If we think about this for a second, it's a little bit like a donut. So what do I mean by that? If you take a donut and you stick your finger straight through the hole, you're never actually inside of the donut, you're not in the substance of the donut at all. You've just put your finger right through the hole and you're touching nothing but air, right? Well, that's basically how our GI system works. It's like a hole, but it's a long one, right, and it's a long tube, but it's an inverted passageway and if you pass all the way through into the other end, you're actually never really inside the body. You know, it's like those water wiggler toys. If you've ever played with those. They inside the body. You know it's like those water wiggler toys. If you've ever played with those, they'll like invert on themselves and you can't keep them in your hands and they slide right out.
Kate Scarlata:Yes.
Brennan Spiegel, MD:So what's happening in the gut is it is the outside of our body, sampling the world around us and allowing some of it to pass in and some of it not. And so we know for sure that the microbiome which lines the colon and in some cases works its way up into the small intestine is really vital for modulating that interface with the world itself. And of course, the food that we put in will modify the microbiome and in some parts of the gut it may change how so-called leaky the gut is, how permeable the membranes are. And this is where the vagus nerve comes back. Again.
Brennan Spiegel, MD:It may be, it's thought, that stimulating the vagus nerve can help us modulate how tight the gut membrane is, even by changing the local immune system through these pathways, electrical pathways. And now it starts to all come together in a way that if we change the diet and we change the microbiome and we modify the local immune system and we can do some of that through the neck or the ear, that's like wild to think about that. But now we have tools diet, electrical stimulation. Of course psychotherapy, psychological therapies are vital, whether it's hypnotherapy, cognitive behavioral therapy. All of this gets back to my original myth that the mind and the body are not separate and distinct. They're tightly coupled with each other and they talk to each other. And these are some of the ways that they talk to each other.
Dr. Megan Riehl:It's fascinating, you know. I think it goes back to we don't have to do it all at once, you know.
Dr. Megan Riehl:I think it goes back to we don't have to do it all at once Right and subtle changes in our lifestyle can be a good stepping stone moving forward to making changes in your overall health and your gut health. And we don't want to overwhelm everybody with, like you got to do it all at once but over time, living this kind of mindful approach to our health, knowing that how we eat, how we move, how we engage with our environment, the air that we breathe, all of these things impact this incredible microbiome that we have. That's unique.
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Dr. Megan Riehl:So what do you say? We kind of dive into your other areas of expertise. We've got a couple of questions about virtual reality that our listeners will definitely be interested in, and I may even share a little bit about my experience with virtual reality.
Kate Scarlata:Yes, I think I maybe had a little experience with virtual reality as well. There you go. I know it's nice. We know people in high places like Dr. Spiegel, right? So let's talk a little bit about different VR products. How do they work? I know you've done a lot of work in virtual reality and IBS and pain, so can you talk a little bit about how they work for those issues?
Brennan Spiegel, MD:Yeah, absolutely, and this may seem like a big pivot from our last discussion, but not really. It's another mechanism where we try to modulate that relationship between we'll call it mind and body, or brain and gut, and VR, we have found is a very powerful way of positively affecting the mind in a way that can change the body. So most people when they think of VR, they think of a platform for gaming and entertainment. They might think about Mark Zuckerberg and meta or whatever. And yeah, it's been used for gaming and entertainment. But long before it was used for that, it was being tested in psychology labs all around the world, all the way back by the Department of Defense, even the 1950s, as a way to simulate complex environments. And it just got to the point where the technology got so good and so inexpensive, relatively speaking, that we could start testing it out in clinics. So, for example, we just published a paper recently with Mount Sinai, which was so fascinating, demonstrating how VR can change physiology directly. So what we did in this study is we took people and we put them in a really relaxing beach in virtual reality. You can hear the reality, you can hear the music, you can sort of hang out on a beach or on a lake or on a mountaintop and it really feels very, very real. The music's beautiful and we can do guided breathing, which starts to affect the heart rate and heart rate variability. So it's actually affecting the vagus nerve directly and when we actually measure heart rate variability we can see that it changes. But we also can see that we change cortisol levels in the body. We can see that we can change body temperature. We can cool the body down.
Brennan Spiegel, MD:We're doing a study now at the Mayo Clinic using VR for vasomotor symptoms of menopause. For example, can we literally cool the body down through beautiful snowy environments where you feel like you're sitting in the snow? We can even change white blood cell count through virtual reality. We've now been able to show, and so we've been using this for a bunch of conditions, especially pain, and not just for the immediate experience, but over the course of eight weeks. We can deliver different forms of cognitive behavioral therapy to supplement clinicians like Megan right who do the hard work of really tailoring therapy. But then you go home and you may not see your therapist for another week or two or more, and so having something like VR might help bridge that gap, and so we've created VR programs for irritable bowel syndrome. We're using it now in IBD and IBS. We're using it for chronic lower back pain, for cancer pain a whole variety of different conditions.
Dr. Megan Riehl:How do people receive this? You know, when you walk in and you say, in addition to your inflammatory bowel disease treatment, we're going to recommend this headset and this experience for you.
Brennan Spiegel, MD:I'll tell you, most people really are intrigued. Yeah, because we're not saying this is a substitute for your traditional medical care, it's to help augment it. And when we talk about the brain-gut axis or the mind-body axis and all the stuff we've been talking about today, people I think are very open to trying these things and all the stuff we've been talking about today, people, I think, are very open to trying these things. I can think of an example just from the hospital a few weeks ago, when I was on service and we had a patient who had had really significant abdominal pain after abdominal surgery and it really never got better. The pain just didn't get better.
Brennan Spiegel, MD:We see that sometimes after abdominal surgery better, the pain just didn't get better.
Brennan Spiegel, MD:We see that sometimes after abdominal surgery and it got to the point where this patient really couldn't eat and ended up being on TPN total parenteral nutrition, where all the calories are put through the veins. She couldn't eat anymore and we couldn't really figure out what was inhibiting her ability to eat. And so, you know, I spoke to this patient and really came to realize like there was a lot of anxiety, to the point where if they even sipped some water it would just cause immediate pain in the belly, and so that's the point where I say God, that doesn't even make physiological sense. That is a form of anticipation, anxiety at that point where the brain is primed, sensitized, to feel pain, and I don't think doing another surgery is going to fix that Right. So we tried virtual reality and we try to form a virtual reality that also uses artificial intelligence to help talk to people, and we've gotten better and better at this over the last couple of years, developing and you guys use an early version of this- Good old Maya.
Brennan Spiegel, MD:Yeah, maya, and so she used it and I mean this doesn't always happen, but it happens. Within five days she was eating I mean almost a full diet. She had bacon and eggs five days later and she hadn't eaten anything in months and months. And she was eating I mean almost a full diet. She had bacon and eggs five days later and she hadn't eaten anything in months and months and she was walking around the ward, really just conversational. Now we didn't secure anything and maybe it'll come back, but just to see that response, I realized like we are only working. We're like we're working with one hand tied behind our back if we don't use these kinds of techniques.
Dr. Megan Riehl:So you're mentioning something that's very, again, very similar with our brain-gut behavioral therapies, where openness to trying is really a key characteristic. Are there other characteristics that are going to contribute potentially to a patient's success and outcomes?
Brennan Spiegel, MD:Yeah, yeah for sure, openness is a big part of it, but there's also something called immersive tendencies, and this is kind of a technical term. It's easy to understand. Some of us get more easily immersed into fantasy worlds than others, and not even just fantasy, I mean just watching a football game. Some people love sports. They are so into that game that you can't talk to them, but that game is happening on a digital screen somewhere far, far away. In a way, it's like a fantasy experience. It's not literally happening in your, but you feel that it's happening. And or you're reading a book like my son loves reading, and I'll call his name out and he can't hear me because he's in the book or you're in a movie.
Brennan Spiegel, MD:Whatever the example is, it turns out that there is a natural variation among humans. Some people are very easily swept up into these narratives and some not so much, and it seems like that affects how well something like VR works. You know, you might just think, oh, this is really interesting and cool looking, but I'm not feeling anything, whereas other people they realize like I'm so immersed in this world that I've forgotten that I have pain, I don't feel it. My nervous system has released itself, and that's the moment where we say listen, like you've now learned that you have the superpower. Supernatural and I use the term supernatural Literally. I say super means above, like Superman flies overhead. Super means you have found a level of consciousness higher than where you normally operate. And natural, you did it yourself. We didn't give you a medication or inject something, so you've just learned something about it. It's the people who have immersive tendencies that are most likely to have that kind of supernatural reaction.
Kate Scarlata:That's me, you know it's funny. When I did yeah, I was like I'm just going to do this virtual reality thing with Brennan for like five minutes. And then it was like how long have I been doing this? But I am so immersive. My husband talks to me all the time. I'm like what you know, totally fishy, and my father was the same way too, like just locked into whatever you're doing. Yeah, so that's interesting.
Dr. Megan Riehl:And I don't tend to miss a thing. So when I had the headset on number one, I wanted to see if Maya was any good. You know, like she is me right, she's the AI version of a therapist and so it was interesting to put the headset on and you're seeing the visualization. And again, if you're a listener and you are an immersive person and you have IBS, you know, I would encourage you to check out Dr Spiegel's products and kind of work in this area, because you do get evidence-based treatment in this virtual way and she's using many of the skills and cognitive reframing and psychoeducation that really could reinforce, especially if somebody is working one-on-one with a therapist or doing group work. No-transcript. to the point of the beginning of our episode. We're thinking outside the box.
Brennan Spiegel, MD:Believe it or not, that was almost two years ago, I know, and that was a pretty early prototype. It was still pretty impressive, I'd say. Now we're at, I know, write a note out that's quite impressive and put it in the chart. We think of it kind of like a paratherapist that's a term I just made up, you know, a paramedic is. Para means beside, and in this case medic means doctor. So the paramedic is beside the doctor and as a liaison between the doctors in the emergency room and the patients out in the field and helps run back and forth between them.
Brennan Spiegel, MD:And the way I think of a paratherapist again, I just made this up, see what you think of it is, you know, like when you go to see a hairdresser, they cut your hair and then by the time you get home it's like all messed up, like how did they do that? How do I fix this hair? It's like, as soon as you spend all this time and energy with a client and they go home and then life starts to happen, they're like oh my God, how do I remember what we talked about and those skills that I learned? How do I reinforce those? And that's where, like, the real learning is happening, and so the idea of the paratherapist is have somebody who's got your back, who knows your patient and has almost like a prescription of exercises to follow and can inform you about what's been going on between visits, writing notes and also contacting you if something's not going well, and doing all of that to get it back to the VR within virtual reality, because the whole point of the VR, rather than just talking to a chatbot is we use AI to change the world around you. In virtual reality, we call this GR generated reality, so we're generating a reality around you based upon what you're talking about, and it will pull up the right music or the right visualizations or art based upon what you're saying.
Brennan Spiegel, MD:Like, if you're talking about stress, maybe it's going to put you in a Japanese you know, zen rock garden. If you're talking about your gender identity, maybe it's going to surround you with rainbow colored butterflies and with images of acceptance. Right, it's pretty wild with the VR pulls off, but it's really not a substitute for a human. It's. I think of it like a paratherapist.
Kate Scarlata:Yeah.
Dr. Megan Riehl:We could all benefit from that Right.
Kate Scarlata:I mean I loved it when I left. After doing that, I came home and I'm like everyone should have one of these headsets. You're just kind of lost in translation. I was very in my own little space and you know, sometimes you, we could all benefit from that, you know. Just see you later, everyone, that's right.
Brennan Spiegel, MD:People always ask like well, are people going to get addicted to it? Or what about real reality? And we're very concerned about that too. We don't want people to disappear into screens. We've seen enough of that.
Kate Scarlata:Right.
Brennan Spiegel, MD:We want people to learn something about their mind and their body and their reality and their emotions and whatever we can teach them that they then bring back to real reality. I call that RR real reality yes. And so we try to keep the experiences short 10 to 20 minutes, even though you were in there for quite a while.
Kate Scarlata:I know, all right, just beat me up, beat me up.
Brennan Spiegel, MD:And we also have an app that goes along with our programs. We have a new NIH study that, by the way, is about to start, so if you have any listeners who have been diagnosed with irritable bowel syndrome, they may be eligible for this study. It's a remote study, so you don't need to be in Los Angeles, where I live. It can be anywhere in the country and we can ship out the equipment to you. So that study is about to start, using our eight-week VR treatment program that I've been describing here as an aside.
Kate Scarlata:So can you give us a link to the study or something in the show notes? Perfect.
Brennan Spiegel, MD:Yeah, absolutely so. We'll post that information so that people can find out more about it.
Kate Scarlata:Excellent. How many people are you going to recruit for this?
Brennan Spiegel, MD:So it's a pretty small study. This is an NIH small R01. So it's a preliminary study. Dr Chris Almario is the principal investigator, the PI here at Cedars-Sinai, and the exact number is not that high. It's less than 100. I forget the exact number off the top of my head. I could be wrong about that, but it's not a big study, but the key is that we can recruit people from anywhere who are interested.
Dr. Megan Riehl:It's important for generalizability and learning more across the country. Well, you have a truly thought-provoking perspective on the human experience and health and from your paper on gravity's impact on the gut in IBS. This is a very noteworthy paper, and you know there's that. And then, spearheading an entirely new field of medicine. Your insights do challenge conventional thinking, and so you know what excites you the most about the future of AI and medicine.
Brennan Spiegel, MD:Oh, wow, so much. I'm really excited to announce that I've got a book coming out this year on the gravity hypothesis.
Dr. Megan Riehl:All right, awesome, give us your elevator pitch.
Brennan Spiegel, MD:Here's the title and the cover, but it's a little. You can't really see that on the screen. So the book is called Pull P-U-L-L. It's how gravity shapes your body, steadies the mind and guides our health. And this is maybe another podcast for another day, but a little brief intro. The vagus nerve is a big part of it. The vagus nerve, I believe, is a gravity management mechanism actually, and you'll have to read the book to learn more. Come back for a future podcast.
Kate Scarlata:Yes.
Brennan Spiegel, MD:And just standing up and staying up is our goal in life, literally from the moment we're conceived to the moment we die. Gravity is acting upon every cell in our body, in our gut, in our brain, in our gut, in our brain, in our nerves, in our muscles, in our lungs, everything. And our goal is to stand up and stay up as long as we can and as well as we can, until finally we're pulled back down and in some cases we end up. I hate to put it this way, but we end up literally in a grave, which is a word derived from the word gravity, that's, a gravity box. And so if we think of gravity in that way, we think that fighting it through not only strength training, which is, by the way, one of the most important interventions for all of medicine, and through diet, which can alter serotonin levels, which is, I argue, a gravity management substance that's what serotonin does is it helps us fight gravity both physically and mentally. We can get to that some other day, some other time yeah.
Brennan Spiegel, MD:You know, we can modulate our experience of the world and live better, stronger lives, find balance and stand stronger and really live longer, and so that's what this whole book is about and I'm really excited about that. That's just a preview of a whole other discussion about what I call biogravitational medicine, and it actually brings the vagus nerve back in, it brings virtual reality back in, it brings diet back in, psychology back in, and that's what I'm most excited about this book It'll be a wide release book from St Martin's Press, coming out actually October 7th of 2025. I just learned today.
Kate Scarlata:Excellent. Oh, I'm very excited about that. I love the way your brain thinks and you're definitely coming back on. So let's look at our schedule for October because, that would be awesome. Where do people go if they're interested in learning about VR? Are there sites? Can you talk a little bit about the IBS VR program? That is available. You know people are interested. What do they do?
Brennan Spiegel, MD:Yeah, so we have a website. It's virtualmedicine. org, so it's pretty easy to remember virtualmedicine one word, org and on that site we have a lot of information about our VR programs here at Cedars-Sinai, where I work, and some of the grants that we have in the ongoing studies that you can learn about. We haven't posted the IBS link yet, but that will come up soon and I'll be sure that you can distribute that to your listeners.
Brennan Spiegel, MD:Definitely we also have a conference that we put on every year and actually we have a number of people that join who are not doctors or not clinicians. It's called the Virtual Medicine Conference. This year it's March 27th and 28th in Los Angeles, so there's information on the website. It's a lot of fun. You can meet all these different people from around the world creatively using technology like VR to treat all sorts of different conditions. So we will have some GI topics. This year. We're going to talk about everything from menopause one of the world's leaders in menopause at the Mayo Clinic using VR to GI applications, chronic pain. So that's going to be again coming up in March.
Brennan Spiegel, MD:And then we have some software available. So our software is called SynerGI, spelled Syner-G-I instead of G-Y. It's kind of a play words. It is available through the MetaQuest, but right now we're keeping it within research, so you'll need to be enrolled in one of our trials. We also have a software program called XAIA X-A-I-A. That's available through the Apple Vision Pro, which not many people have at this point. It's a very expensive virtual reality headset that Apple made, but it is available. It's that AI therapy, mental health support bot, and so, yeah, there's different ways to learn about this stuff and you can even just go on to the App Store for Meta. I really like this program called TrippVR T-R-I-P-P. I'm not associated with it. TrippVR is an amazing software program for incredible beautiful worlds and guided imagery meditations. It's a very, very good program. I really love that program. So yeah, those are just a few thoughts.
Kate Scarlata:I love that. And just for going back to the vagus nerve stimulation, who would you see to talk about that? I just don't think that it's very mainstream. So if you're just curious and you wanted to talk to someone, or is there a good resource? Or can you share the product that you tried if you feel comfortable or you feel like it was beneficial?
Brennan Spiegel, MD:Yeah, so I don't have any relationship, and I will also say, just as an aside, that I have fully divested my financial interests in the products that I've talked about today, including SynerGI and Zaia, although I was involved in their development and testing and even an initial startup company. I've fully divested so I can feel comfortable about talking about these things. I just want to make so I can feel comfortable about talking about these things. I just want to make sure your audience is aware.
Dr. Megan Riehl:That's really important.
Brennan Spiegel, MD:Yeah, same thing with the vagus nerve stimulator. So the one that I use is called Vagustim, v-a-g-u-s-t-i-m, I believe, and I had learned about it from a colleague who recommended it because it's easy to put into the ear and relatively inexpensive. I think I got a discount like a few hundred bucks but you'll have to look up and see what they're charging these days and easy to use there's an app, so I've found it very helpful. I like the way it works and you can change a bunch of different parameters so it doesn't buzz too hard or just enough for your liking. Yeah, so who to see for vagus nerve stimulation is really interesting question, because it's one of these technologies that kind of falls in the cracks, kind of like VR. There isn't a VR provider yet. I would love to have a VR clinic and there are certain people that just do VR, particularly in psychology, but you won't find like a VR specialist all that easily or a vagus nerve stimulation specialist.
Brennan Spiegel, MD:Now, obviously, neurologists would be a reasonable place to start, because it is a neurological intervention and that's what they study, and there are certain neurologists who have particular expertise in vagus nerve stimulation. But I've also met rheumatologists that use VNS vagal nerve stimulation because they deal with so much chronic pain arthritis for example and there's some suggestion that even autoimmune conditions might benefit through these mechanisms of VNS. So you can see a rheumatologist and there's some gastroenterologists. I will recommend it from time to time as an augmentive, like an accessory tool. Sometimes I'll use it with virtual reality, recommend people use them together, although I don't have any data that they're synergistic. These are all wide open areas so it's not like there's one person to go to. I think you need to find somebody in your community that knows about it and has a clinical experience working with it, who you know can really guide you through the safe and appropriate use. Now, obviously, epilepsy is different. That's a neurological condition and neurologists would recommend VNS for that.
Kate Scarlata:Because that's surgical right, Don't they have to implant?
Brennan Spiegel, MD:They can implant it, yeah.
Dr. Megan Riehl:That's right, and I think safety is really something we have to be mindful of when we're having these kinds of conversations. So to the point that, having an implanted device, you're going to talk about your medical history, you're going to talk about your comorbidities, the risks, there tends to be a preference for the left side placement of these devices, as opposed to the right, based on location of the nerves and your cardiac nerves.
Dr. Megan Riehl:So it's important, before purchasing one of these, I think, to really read the fine print on the websites, or to, when you're talking about some of the transcutaneous types of devices that are available too, meaning you place them on your ear, on your neck, just being mindful there are some contraindications, and so being aware of what yours may potentially be is a conversation to have with your start, with your primary care, and if they don't know, they'll refer you onward to a subspecialist.
Kate Scarlata:Yeah, don't self-dianose. Talk to your doctor. I say that even with diet changes or supplements, just have a health professional involved in some of this.
Brennan Spiegel, MD:Absolutely I don't know if you ever watched that show Yellowstone. I've really gotten into this Netflix show Yellowstone. Kevin Costner's character is like never goes to the doctor for anything and ends up spending too much of his time worried about things he shouldn't be, or not being worried about things that he should. So that just happens to be. Anyone who's watched Yellowstone knows what I'm talking about. But yeah, the left versus right thing is a big deal because the right side has more direct connections to the heart and particularly the sinoatrial node, which is the part of the heart that is the pacemaker, and so one of the side effects would be slow heart rate, and I see that even on the left side. I definitely see my heart slow down when I use it, and so you know these are things you need to really check with a doctor. If you have low heart rate, you may want to be kind of careful about it, or arrhythmias or whatever. You need to work with somebody who knows what they're talking about.
Kate Scarlata:Unbelievable. Well, this was incredible. No surprise, because you are always just such an interesting wealth of knowledge and some very interesting topics that aren't really spoken in traditional medical settings or with other guests that we've had. We have learned so much from you, so thank you. We'd like to end our episode with a wrap up question to our guests, and that is what do you do in your daily life for your own wellness and health?
Brennan Spiegel, MD:Well, as I'm talking to you right now, I am wearing something that looks a bit unusual. This is actually a weighted vest. It's a 20-pound weighted vest. It's got metal inside of it. It's not a bulletproof vest, it's just a weighted vest and around both of my ankles I have 20-pound weights around my ankles. So I'm right now wearing 60 pounds of weight just sitting here talking to you, and all day long I'm at a standing desk. I have a balance board that I stand on and I passively wear about 60 pounds on my body. It goes back to that gravity story.
Dr. Megan Riehl:I was going to say working on some gravity.
Brennan Spiegel, MD:Yeah, when you release yourself from this weight, all of a sudden you feel so much stronger and there's even evidence you can lose weight just by weighting your body down and passively exerting yourself against this pull. So this is stuff that I do just on a regular basis to maintain balance on the balance board I have a desk stepper. I'll sometimes just walk in place. I don't have a walking treadmill. I want to get one of those, but those are a little expensive. But those are good too. Just simple things you can do. Drink a lot of water. I have a big thing of water here right now.
Brennan Spiegel, MD:This is about gravity too. If you stand up too quickly, get lightheaded, that's gravity intolerance. That's called orthostasis. You need to keep fluid in your body and I think we really under hydrate ourselves. So these are really simple things to do that can actually contribute to longevity. You know, we know that the sodium levels in your body I'm getting way off topic now, but you asked me will in some part determine your longevity, and sodium is determined in large part by how much fluid you drink. You know, don't overdo it. Too much fluid is bad too, Okay. So I want to be careful about that. If you drink water all day. That can literally kill you. So I'm just talking about keeping yourself well, hydrated, strong, standing up. These are things that I try to do every day, just to kind of keep myself in some modicum of shape.
Kate Scarlata:I think we need to get that vest.
Dr. Megan Riehl:You get the vest, Kate, I'm going to do some strength training and fill up my water.
Dr. Megan Riehl:There, you go, Dr. Spiegel. Thank you so much, and to all of our friends listening, we hope that you subscribe like, follow The Gut Health Podcast. Your support means the world to us. See you later, friends.
Dr. Megan Riehl: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 at The Gut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.
