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
Tailored to the Core: Breathing, Bloating and Precision Medicine
Dr. Iris Wang of the Mayo Clinic shares cutting-edge insights on gut health across the lifespan, including advancements in pharmacogenomics for personalized medication selection and innovative breathing techniques to relieve abdominal distension. She busts common myths about bloating, revealing how diaphragmatic dysfunction rather than excess gas may be the culprit. Dr. Wang also emphasizes the importance of starting gut health education early, helping kids and parents alike understand that pooping shouldn't be painful or forced.
• How pharmacogenomics helps identify why some patients metabolize medications differently, leading to better medication choices with exploration on the hope and/or hype of precision medicine in the GI world (Wang et al 2019)
• Explanation of abdomino-phrenic dyssynergia (APD) – when the diaphragm moves downward instead of upward, causing visible abdominal distention
• Specialized breathing technique developed in Barcelona that retrain the diaphragm for bloating relief (Barba E et al 2024) - see video link below
• The importance of normalizing healthy pooping habits from childhood through education & tools like toileting stools (e.g. Squatty Potty)
• Warning signs for parents about childhood constipation – including stool leakage, straining, & urinary problems (Tran DL et al 2023)
• How yoga can support gut health through mindful movement, core engagement, & stress reduction
Yoga videos:
Yoga For Digestion Flow| Yoga With Adriene (26 mins)
Yoga for Bloating, Digestion, Ulcerative Colitis, IBD & IBS (12 mins)
Check out Dr. Wang's children's book Boo Can't Poo, which helps normalize healthy pooping habits for kids while educating parents too.
References:
Specialized breathing technique for abdominal distention: Video Demonstration
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.
Thank you. 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, MPH, RD:Hi everyone, I'm Kate Scarlata, a GI dietitian. We have a great episode today. We're going to be talking about therapeutic interventions that use our genetic makeup to guide best medication selections for your body, and interesting breathwork used to treat abdominal distension, and so much more. We have a great expert guest.
Dr. Megan Riehl:That's right, Kate. Let me introduce our phenomenal guest. Dr Iris Wang is an assistant professor in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota, where she is part of the comprehensive general GI group. She also serves as the Associate Program Director of GI Fellowship Programming there, where she is highly regarded by the trainees for her clinical expertise and mentorship. Dr Wang's clinical practice focuses on one of our favorite things disorders of gut-brain interaction, which include IBS, functional dyspepsia and chronic abdominal pain. Her research centers on understanding the pathophysiology of DGBIs and evaluating both pharmaceutical as well as non-pharmaceutical therapies. That include gut-directed hypnosis, digital interventions and extended reality therapeutics Very cool hospitality therapeutics.
Kate Scarlata, MPH, RD:Very cool, but that's not all. She's also the author of Boo Can't Poo, which I love. This book it's adorable, but also very comprehensive and really dives into all different types of therapeutics, from diet to squatty potties to breathing techniques to help the little ones get poop in. So love that. And also big congrats are in order for your recent teaching award, best Research Mentor at Mayo Clinic. So we are very thrilled for you. That's amazing.
Dr. Iris Wang:Thank you so much. Thank you both so much for having me. I think I'm a big fan of both of yours, and so to be on this podcast is really very validating and a lot of joy for me. To be able to be on this podcast is really very validating and a lot of joy for me to be able to be on this platform. Thank you both for having me.
Kate Scarlata, MPH, RD:Well, we're thrilled to have you. Yes, so thrilled. So we always start the episode with a myth buster. What myth pertaining to gut health and or constipation would you like to bust for our listeners? I?
Dr. Iris Wang:think one of the things that it took me until GI fellowship to learn was that you are not supposed to strain when you poop, and this is something that you know spurred the writing of Boo Can't Poo. But I was shadowing with one of our pelvic floor physical therapists and was listening to her educate the patients and guide them, and I was like wait, are you serious? What do you mean? It's supposed to happen, naturally, right, and maybe I'm giving away too much about myself here, but that's, I think, something that we never talk about and is a myth that we are supposed to push or it's supposed to be a little difficult sometimes, yeah, sometimes, once in a while we can have a difficult to pass bowel movement, but bowel movements are supposed to happen without straining. I love that.
Dr. Megan Riehl:It's a good start and we're going to talk more about that in a little while, but before we do, there's so much interest in personalizing our care and we love this idea of precision medicine and being able to tailor treatments to each individual so that they get the best possible results with the fewest side effects, and it feels really you know when we're thinking about innovation and how do we help patients that are living with DGBIs. One size fits all doesn't work, and patients know this. Us, as providers, know this, and you've written a little bit about this, and so can you give us a sense of where we are right now in the world of precision medicine and the DGBI space, and even beyond that, and what might be on the horizon from your perspective?
Dr. Iris Wang:Absolutely. I think in the DGBI space there's always this question of diagnosis. A lot of our DGBIs are symptom-based diagnoses and can be very challenging for both providers and for patients, because so many different things can cause the same symptoms. And that can lead to a lot of diagnostic uncertainty, where doctors aren't sure what you have, and just treating on a symptom can limit the medication options. And for us on a research side, if we're just using a symptom as something to test a drug, for example, without really understanding what causes that symptom, it makes it so that the drugs are more likely to not be helpful because we're not really getting to the root cause of the problem.
Dr. Iris Wang:And so in DGBI space, one of the biggest things is understanding what is the root cause of our symptoms.
Dr. Iris Wang:Sometimes that's disruption of the gut microbiome and the bacteria that live in our gut, because we had some sort of GI infection or a viral infection, microbiome, and not necessarily a physical illness.
Dr. Iris Wang:Sometimes it's a surgery that takes out a gall bladder, for example, and that can mess up with how our bodies recycle these detergents that we had called bile acids, and a lot of the work that I have written about and aim to keep doing is to understand. What are these contributors that have very narrow mechanisms and narrow reasons for patients to have symptoms, and can we treat those reasons in a directed fashion so that we are more precise right in our diagnosis and in our treatment? On the other side of that is using these big machine learning models and artificial intelligence to really understand who's at risk for developing which disorder and what predicts treatment response. I think I'm answering the last part of your question there a little bit early, but that's sort of what's on the horizon, right. How do we use patient information, your background, your history, other aspects that we might not even think about but with a large machine learning algorithm maybe can be picked up from computer science.
Dr. Iris Wang:Let's say things like if you live within this many miles of this location, maybe you're at higher risk because of some environmental factors, right, and these are things that we don't have the capacity to think about as clinicians because there's just not enough time capacity to think about as clinicians, because there's just not enough time. But if we could put it into a machine algorithm and have a supercomputer try to tell us, hey, there's a higher risk of this disease here, then that can really help a patient, right? So that's maybe what's on the horizon. But in between that space and what else there is is really treatment and medication. Treatments and using what we know about genetics to both understand risk for disease but also understand treatment response. And so what? Those are really pharmacogenomics, and okay, if I get into that, yes, definitely.
Dr. Iris Wang:What this is is telling us kind of, what are the genes that your body has to break down certain medications? And we know that these genes come in a variety of forms, right? Not everybody is made the same. Some people chew through medications really fast, so that the active ingredient is completely gone and all you're left with is the side effects. Some people don't break down those pro-drugs or non-active forms of these medications fast enough, so then it takes a higher dose or a longer period of time before they're actually getting any of the active medication doses, and if we don't understand that, we might give them too much, and then they're at risk for higher side effects again, and so understanding whether someone is a normal metabolizer, an ultra-fast metabolizer, really matters, but it also matters what medication you're talking about. So we have these amazing pharmacists who help us out with that, who really understand what these mean for each of the drugs that are important for us in GI, but also out of GI.
Dr. Megan Riehl:Are there some patient characteristics to help us know whether we're high metabolizers or low? How do we learn more about that in like real world?
Dr. Iris Wang:Absolutely, because you're absolutely right. Right, in real world practice it's not really feasible to send genetic testing on everybody and it's not necessary. And so I think there's two areas in GI specifically where I think about this pharmacogenomic testing a lot. One is in my DGBI patients, where I need to write some sort of psychiatric medication or psychiatric associated medication for neuromodulation. Right, we're not trying to treat anxiety, depression, but those medications are really really helpful for modulating how much we feel pain in the gut.
Dr. Iris Wang:And so in that patient population, the ones that I think about sending this testing, is the patient who tells me I have had so many medication intolerances.
Dr. Iris Wang:I almost have every side effect. Every time they try to give me something new, I don't react well to it, and often you know it's really hard to say that the patient is allergic to everything. It's an intolerance and that's probably being driven by how their liver breaks down these medications. So when I hear that from a patient, that's my sign to say, hey, let's see why you're getting all these medication responses, let's see why you're not tolerating and let's see how we can adjust the medication so that we're really optimizing the active ingredient and minimizing all the bad stuff. The other area that we use this a lot is in our reflux patients and in our patients with this pepsia or this burning pain in the pit of the stomach that we think is related to acid, and so one of the primary things we use to treat either one of those diseases acid blockers predominantly are proton pump inhibitors or PPIs. Now, there's a lot of PPIs, but most of the PPIs that are currently on the market are run through this specific enzyme that our liver produces. It's the CYP2C19 enzyme.
Kate Scarlata, MPH, RD:You'll be quizzed on this later.
Dr. Iris Wang:Shows up on board exams, so important for our medical audience members.
Dr. Iris Wang:There you go, but a lot of these medications need to be inactivated and run through this enzyme. But if you have too much or too fast of this enzyme, you can break through those PPIs and basically chew through all the active ingredients and it doesn't matter how much we give you, it's not going to work. In patients where we're running through multiple lines of these PPIs and they're still having symptoms and on our objective testing we still see acid breakthrough, we can say, hey, let's check how fast you metabolize these medications and think about alternative drugs. And there's two options on the market. One is a cousin drug. I describe it as a cousin drug of our PPI drugs, which are all like sister drugs, never brother drugs always sister drugs.
Dr. Iris Wang:Not sure why these cousin drugs. Or rabeprazole is also a proton pump inhibitor but is inactivated by both CYP2C19 and also a different CYP enzyme called oh, I'm not going to give you that one because it's like 3A something there's another path, there is another pathway.
Kate Scarlata, MPH, RD:There is another pathway, another enzyme.
Dr. Iris Wang:There is another enzyme, and so, because it also metabolizes through the second enzymatic pathway, it's not going to be as chewed up as quickly and can be more effective in these patients. We have new meds on the market as well. These potassium channel or PCABs binders can also be a good option for patients who are chewing through PPIs too quickly.
Kate Scarlata, MPH, RD:So we're checking DNA and we're looking at specific enzymes that someone has or doesn't have, and then we're able to decide you're going to chew through this too quickly or it's not going to be broken down by you, so therefore you should try this other medication. So really important for people that know they are not getting at a therapeutic symptom management level or just the drugs has side effects for them.
Dr. Iris Wang:Exactly, exactly, and I had to look it up because otherwise it was going to bother me but it goes through the CYP 3A4. I think I have most of those letters and numbers, but that's what ribivirazole goes through and absolutely you're correct. Those are the times where we would think about just let's find out a little bit more about which genes and which phenotypes of those genes a patient has. Perfect.
Dr. Megan Riehl:So, interesting, it's fascinating and you've given us two really good examples, right. So people that maybe have a history of using medication to try and manage their psychiatric condition and have struggled with that, and there are a lot of people where the side effects were not tolerable and then they present to their gastroenterologist who recommends an anti-anxiety, antidepressant, neuromodulator, and that can be very scary, and so there is an opportunity for gene testing to help inform that decision. And then knowing a billion people globally are affected by GERD, and again we're getting to a more precise way of informing. But these are just two examples. So this is not a global solution yet for the field of gastroenterology. So I think there's hope and there's hype. It's an and, but certainly not a solution yet for all of our GI conditions, but very exciting and I think, for the patients.
Dr. Iris Wang:It's really important to understand that this is genetics, right. This isn't you, this isn't in your head. It's not your fault that you've had all of these side effects, right? Sometimes patients are so apologetic and I'm like you have nothing to apologize for. It's not your fault. You've had medication side effects. It's your genes, it's your genetics, and the more we understand that, the more patients can. Just this is the way I'm built and we can maybe use these new tools so that they can have an easier time going forward with future doctors the gut microbiome.
Kate Scarlata, MPH, RD:So there's genetics you know that we might use to guide treatment therapies. And I wonder you know, are we seeing the gut microbiome or metabolome different markers, being used to sort of guide therapeutic interventions? Are you seeing that at all?
Dr. Iris Wang:I think not quite yet, but it is definitely an area of high, high interest.
Dr. Iris Wang:There was actually an amazing talk at Digestive Disease Week recently looking at how the microbiome impacts hormone metabolism, something that I had completely not thought about.
Dr. Iris Wang:Right, and that the microbiome is actually key in making testosterone accessible for our systems, and without the right microbiome to break down testosterone, we actually can change the levels in our bodies. And that goes the same for a lot of these medications, a lot of foods, right, and so I think part of the problem with the microbiome is that it is so vast, right, and so it takes a lot of computational power to be able to find those associations and learn which because there's no one good book, there's no one bad book, it's a combination. I always like to think about it as a garden, right. It's not only which plants are in the garden, it's the variety of plants, the interplay of plants and how many weeds there are, and so it's going to take a lot of machine learning and a lot of AI to really understand that better. But I definitely see that as part of the horizon of precision, medicine is understanding not only bacteria, but also viruses, fungi, these things that live within us that make up this whole microbiome and how it interacts with the human body.
Kate Scarlata, MPH, RD:Yeah, Exciting. So much to learn though right, absolutely. Yeah.
Dr. Megan Riehl:So we're going to move on a little bit and you know we're going to also be giving you some insights here on some new therapies that are coming to the world. So first let's start with bloating and abdominal distension. They're different. So before we talk about a treatment that can probably help these, can you briefly describe the difference for our listeners From a purely medical standpoint, we think about bloating as a sensation or a symptom, so something we feel gas in the stomach, fullness, right.
Dr. Iris Wang:Bloating is a feeling, is a sensation, distension is what we call an objective sign, and so it is something that we can see on a physical exam when we're talking from the doctor's stand of things. But from a patient's stand of things, it is that visible outward push of the belly, and so you can have one without the other. Right, your belly can distend or push outwards and you don't have to necessarily feel bloated. You don't have to feel that sensation of fullness, but you can also have bloating where you feel really uncomfortable without your belly actually coming all the way out. So, sensation versus or symptom versus a sign or an objective finding.
Kate Scarlata, MPH, RD:Yeah, so with that, I was totally stalking you on Instagram and saw that you were in Barcelona and I had read about this breathing technique that they're doing there specific for abdominal distension and it seems like that paper. They put out a couple papers but it's getting a little traction here in the US. So I'd love to hear a little bit about what you learned there. You mentioned you learned a new tool, so can you share with your listeners some of what you learned?
Dr. Iris Wang:Absolutely. And I have to say, this group in Barcelona I've just admired I've followed their research from the moment I learned about on GI fellowship. It's just so elegant the type of work they've done.
Dr. Iris Wang:And so maybe, if you're OK with Dr Fernando Azpiroz and his team, Jordi Serra and Elizabeth Barba they've been working on understanding what happens when patients experience bloating and when they see visible distension, right. So it's really very focused on distension, and the very first thing they did was they said, well, it must be the gas, right, and that's what our patients think too. It must be the gas. We must be eating something to generate all this gas. And so they came up with this radiology technique where they could actually, on a CT scan, measure how much gas was in somebody's belly. And so they had all their patients come in when they felt really good, flat bellies, no distension measured the gas, and then have them come back the second they feel like they're at maximum distension. Measured the gas and then have them come back the second they feel like they're at maximum distension. This is the biggest I get, and they went right into the scanner.
Dr. Iris Wang:First of all Amazing that they could do that Amazing. And then they were so disappointed because they thought their experiment failed. There was no increase in gas in the majority of these patients. At most it was maybe 50 mLs or 50 cc's, and you know, that's not very much at all. It's one of our big syringes, right, and that amount of gas is not going to extend out of belly in most people.
Dr. Iris Wang:And so, through that disappointment they were looking at their CT scans it's an amazing story and they found that it was not the gas, it was how the diaphragm was moving.
Dr. Iris Wang:And what they described was in individuals who have gas in the belly or kind of normal physiology, what should happen in response to that gas pushing on the intestinal walls is the diaphragm should rise up into the chest and then the belly abdominal wall should contract inwards so that we're really kind of elevating ourselves up for vertical real estate.
Dr. Iris Wang:That diaphragm kind of movement gets abnormal in individuals with bloating and in response, the gas in the belly. What they see is that the diaphragm actually contracts downwards and the anterior abdominal wall pushes out and so you're kind of decreasing the amount of real estate in the belly and then the anterior wall, for whatever reason, can't keep the gas in, so it protrudes outwards. So even though there's no gas increase, necessarily the belly wall moves so that the belly sticks out. And so then, once they figured that out, they validated a lot of that stuff and they said, well, how do we fix it? And so what they've done in a lot of their prior studies and they said, well, how do we fix it? And so what they've done in a lot of their prior studies, is they actually were able to retrain a patient how to move their diaphragm using a very invasive muscle monitoring. So they dropped a probe into the patient's esophagus so that they could really monitor diaphragmatic contraction or muscle tone.
Dr. Iris Wang:I mean, it's just not really feasible outside of a lab,
Dr. Megan Riehl:hard to do that regularly
Dr. Iris Wang:hard to convince a patient that that's what you need, right.
Dr. Iris Wang:But doing that, they found that they could fix this, that by teaching a patient how to breathe and how to move that diaphragm they could reverse this process, which is very hopeful for all of our patients. So then they said, okay, can we do better? So then they developed a technique using a biofeedback tool which looks like an elastic band that was placed around the chest and around the belly so that as a patient moves their belly they could get feedback to say, okay, we've distended the belly this much and now we're going down again. And at the same time they were able to look at the movement of the diaphragm by using an ultrasound to look at how much the liver was moving. Also great in a lab setting. Also difficult to implement and spread without really having the equipment and the technology and then knowing how to like deliver this kind of feedback. So then they did one step better, and that was the paper that recently came out. They said can we do this by just teaching someone how to breathe using our hands? And so this new technique that I learned is really this like final evolution of their treatment of this abdominal phrenic dyssinergia problem big mouthful or shortened to APD, not to be confused with APT.
Dr. Iris Wang:What we've been doing and what's kind of described in a lot of our journals is using a technique called diaphragmatic breathing where we're asking patients to really push out their bellies as they breathe in so that all the air goes into the belly goes into the belly in quotes and then kind of push all the air back out so that the belly deflates, right. And we've been teaching this technique but we've never actually validated that it helps bloating. No tests have been run outside of this group's lab to see that that actually works. And so this technique takes that diaphragmatic breathing and really builds on it and it uses a hands-on approach to guide patients to isolate their chest when they breathe so that they involve their intercostal muscles, learn what it means to contract them and in that then learn what it means to relax them so that they fully deflate the chest. And then it goes into a diaphragmatic breathing teaching, also hand-guided, so that we can really get good relaxation of that anterior abdominal wall and strengthening of the obliques and the internal external obliques which really need to contract so that our bellies go in and up, and so it's not really a rectus contraction that we want patients to really achieve, right?
Dr. Iris Wang:So sit-ups are not the right way to go. It's contracting the side muscles of the core so that we can shift them upwards, and teaching them to do that via hands-on breathing training. They do a three-week breathing training program. Patients are coming back once a week in order to get various components of that teaching and then a complete review. They've, you know, had this first hands-on course, and so I was oh my gosh, I was the only one in the US who was there and I was, like, so excited and really excited to be bringing this back. But they are running more of these hands-on approaches and so hopefully more and more people will learn. They're also running a multi-center clinical trial that involves several sites in the States to figure out what's the best way to teach this approach, and so I'm hopeful we'll see a lot more coming out from this.
Dr. Megan Riehl:Yeah, and the patients were practicing this in between their sessions, for a few minutes before all of their meals. And in the literature that I've been reading on this, it was really exciting to see the evolution of the research that, yes, we can't be dropping things down the esophagus for everybody that has these problems to, yes, what is tangible takeaways that practitioners can teach their patients and then it really can be life-changing, incredibly life-changing. And again, all coming back to our breath, and I'm guessing that our friend Dr Brennan Spiegel, who just is such an advocate for gravity and being upright and how we breathe, yeah, I'm sure that he's going to really validate a lot of this too with his work in the gravity space and how it impacts us.
Dr. Iris Wang:Absolutely. And if I could just take like a super brief sidebar too, it's gravity and it's also muscles right, that's right. As internal medicine doctors, we are really not very good about the external muscles.
Dr. Iris Wang:Like it's not what we focus on. We focus on organs, we focus on internal, and then, especially as GI doctors, we think about the lumen, we think about the inside of the lumen, and often that comes at a cost of forgetting that there's so many layers of fascia, of muscles, of fat, of connective tissue that are between, kind of our anterior muscle wall and the inside of our abdomens.
Dr. Iris Wang:And so when we think about pain right, which is something that I'm very passionate about- I always want to take kind of an outside-in approach, right, or is something that I'm very passionate about. I always want to take kind of an outside-in approach right, or even an inside-out approach, but making sure that I think about yeah, there's no ulcer on the inside, EGD is negative. What else could it be? Is it something within the peritoneum, but is it something in the muscle layer? Is it a trapped nerve? Is it muscle movement that is abnormal? And I think thinking about those things can help our patients more holistically, because those need different treatments than a pill. They need our colleagues in PM&R, in PT, they need muscle strengthening, but the right muscles right, and so being able to understand that and give that to a patient is really, really important.
Dr. Megan Riehl:That's right. So in our show notes we will link a video demonstrating this type of breathing from this literature. What if the secret to feeling happier and healthier lies in your gut? It's true, your gut produces about 90% of your body's serotonin, the feel-good hormone. That means what you eat and how you manage stress directly impact not just your digestive health but your mood too. For the 11% of people globally living with irritable bowel syndrome, this connection is life-changing.
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Dr. Megan Riehl:You mentioned abdominophrenic dyssnergia, or APD. Give us an idea of how common it is, so that we can also have an idea of how many people may effectively benefit from talking to their doctors about this.
Dr. Iris Wang:Absolutely. I think it's really hard to say. Actually, if you look at just bloating as a symptom, right, it can be ranging anywhere from like 10% to 30% of the population, and studies of patients with irritable bowel syndrome or IBS, show up to like 75% to 90% of them experience bloating at some point. Now, that's a little bit different than distension. The distension that really kind of you want to think about APD in, is more intermittent. So these are the patients who wake up with flat bellies in the morning and then it kind of grows throughout the day as they're eating and as they're standing right. It's not just the food, it's the gravity as well. And so within that population and their study population about 85%, depending on which cohort and which study from this Barcelona group you're looking at really had APD as a reason for their distension. And then even the patients who did have an increase in gas, they saw that they still had this abnormal muscle movement and the muscle movement was more tightly linked with how bad they felt as opposed to the actual volume of gas.
Kate Scarlata, MPH, RD:So interesting. So I was talking to a gastroenterologist in Boston, Dr. Kyle Staller, and he's really interested in this as well and looking into it in a research setting and he said another sort of indicator that he thinks of APD in is individuals that drink water and can actually get symptomatic. So again, water's not going to cause gas, but the handling and the way the diaphragm is pushing down it could contribute to those symptoms absolutely. So standing a long time and your symptoms get worse, afternoon symptoms, even drinking water causing symptoms, those are some things where you might want to talk to your doctor about this condition and this specialized breathing technique, which is exciting to see.
Dr. Iris Wang:Yeah that is definitely something big on the horizon.
Kate Scarlata, MPH, RD:Absolutely so. When we think about this is one big area. But then you know we definitely see bloating and distention in our patients and think of other things. What are some of the things you do in your practice when a patient presents with bloating and distension, outside of these wonderful breathing techniques?
Dr. Iris Wang:Absolutely so. I think often we have to look at the diet right, we have to look at food, and I think you are much more qualified to speak on this than I am. In certain patients where it's so food triggered right, I do fine, unless I eat or if I fast all day, I don't bloat.
Dr. Iris Wang:But every time I eat food right. Not water, to your point, absolutely agree with that but something that could potentially generate gas, right. Then we think about okay, is there something in the diet that we have to change? And then I would refer them to a GI dietitian specifically to be able to kind of review and really think about this with the patient so that we can maybe hopefully identify something that is triggering. One of the biggest offenders is going to be lactose, right, and so can we cut out lactose or use some sort of supplement or aid to help decrease that symptom. So that's one thing, and more of a workup than a treatment, but if we can diagnose it right, then it's easier to treat.
Dr. Iris Wang:One of the other options that I'm personally very invested in is hypnosis, and so we actually developed a hypnosis protocol specifically targeting this bloating feeling, with the idea of you know and Megan, you are better equipped than I am to talk about the hypnotherapy aspect, but the goal of that protocol has really been to can we decrease the amount of distress the bloating symptom causes. So this isn't really about the distension portion, but can we figure out how to get patients to tolerate this pressure being put on their intestines without having an abnormal pain reaction to it, because they don't need the pain reaction. And so we did do a pilot test of that hypnosis protocol that one does build in diaphragmatic breathing. We use that as part of our induction and part of our deepening in certain depending on the week. This was something that we developed with in conjunction with Dr Oli Palsson, who developed the UNC protocol for IBS hypnotherapy.
Dr. Megan Riehl:One of the GOATs.
Kate Scarlata, MPH, RD:He is a GOAT.
Kate Scarlata, MPH, RD:Love him.
Dr. Iris Wang:Just an amazing man?
Dr. Megan Riehl:Yes, he is.
Dr. Iris Wang:I was so fortunate that I got to work with him before he retired on this project, but it worked.
Dr. Iris Wang:When we looked at our data after treating 25 patients with bloating small sample size, but patients bloating got a lot better and we saw symptom improvement across actually all IBS symptoms in the severity criteria in about 75% of our patients, which we were really excited about. Now these are hand-selected patients who were really committed in the setting of a trial, but at least that was good and so we're gonna try to validate that protocol and do some more tests and enroll some more patients to see if it truly works.
Dr. Megan Riehl:Well, ship it over to me in Ann Arbor. We're happy to pilot.
Kate Scarlata, MPH, RD:I love that. So if you see that, if it's validated, do you have next steps? Like how would you roll it out so patients have availability to this? I know that's down the line, but have you thought about that?
Dr. Iris Wang:Oh, I had a plan and then the plan kind of went sideways, but it is digitally delivered and so it's a completely recorded therapy and we were hoping to be able to deliver it, like some of the digital therapeutic companies that were on the market, because a couple of them are no longer available. I'm trying to talk to other companies that are still available to see if there's interest in rolling this protocol into their offerings. Excellent, so hopefully available for clinical use with or without a prescription down the line.
Kate Scarlata, MPH, RD:Excellent, great work.
Dr. Megan Riehl:Amazing. Well, and to you know, highlight some of your other work. You're a life changer here, Dr Wang. I mean in your day-to-day practice you're working with adults, you're an adult provider, but you wrote a kid's book and it makes me wonder that if we can just teach healthy pooping habits very early on, we may be able to prevent some of the bloating and distention, because it is so common among people that have constipation and you're hard-pressed to find a constipated person without some bloating. Yeah, so what inspired you to write Boo Can't Poo.
Dr. Iris Wang:Poo was really trying to decrease my clinical burden down the road really really early. But going back to what we started out the conversation talking about, right, nobody teaches anybody how to poop. And as I had these conversations about pelvic floor dysfunction another muscle gravity problem, right, that is so impactful to the GI field I was describing these issues to patients and the looks I got of like why has nobody ever taught me this my entire life? It was just so. It just kind of sparked something, right, that this is a problem. And then, as my own child was potty training, I was like okay, is there really nothing that teaches this? And I was going through the potty training literature and it was like everybody poops and I'm like that's nice, but like how does anybody poop?
Dr. Megan Riehl:That's right, and if you talk to an adult, not everybody poops.
Kate Scarlata, MPH, RD:Exactly. Adults don't know, so how are they supposed to teach their kids?
Dr. Iris Wang:Yeah, absolutely. And so then I was like, well, maybe I should just hit the source, start really early. And then I was realizing that as I was reading the books to my son, I was learning all this stuff on the side and I was like, okay, I'm going to secretly also hit their parents, and so it's for the children, but it's also for the parents reading to their children to really understand some easy things that we can do to prevent constipation, because I couldn't just talk about pelvic floor dysfunction, which is kind of what I wanted to do. But it's been well-received and I think I've been really, really, really fortunate. I really felt like I won the lottery when this was picked up.
Kate Scarlata, MPH, RD:We love it.
Dr. Megan Riehl:Yeah, we love it. And you know when you're thinking about giving a baby gift and the assignment is to give a book instead of a card. This is the gift that just keeps on giving. So think about this the next time you're invited to a baby shower, because I think it really is a beautiful gift to normalize our pooping habits.
Dr. Iris Wang:And that's such a great point to me the normalization of pooping as a thing we all do, right Like I'm sure you both see this a lot in your practices that people don't feel comfortable talking about poop. And one of the most interesting things that I've had that I've come across since this book was published was people get upset that I've had some negative reviews that why is it about pooping? Like you know, it's not good to talk about, and even when I brought it to my son's school, the teacher was like, oh, I had a lot of trouble with this because we're not supposed to say poo in school, it's a potty word, and so I was like what do they say?
Dr. Iris Wang:yes, it is, yeah, literally but what do they say when they need to go and now and she's like I don't know, but they're not supposed to say I need to poo. And that has so many implications down the line, because then when things go wrong, kids can't talk about it, they don't feel like they can.
Dr. Iris Wang:It's not polite conversation. And then they have bloody bowel movements and undiagnosed IBD, right, and so part of the thing that I really realized that I champion is what I call breaking the poo taboo right. We're just going to talk about it as a thing that we all do so that, when things go wrong, kids feel comfortable sharing that with their patients, with their providers. Brennan published a study saying that up to like 30 something percent of adults have constipation and don't feel like they're comfortable talking to their primary cares about it.
Kate Scarlata, MPH, RD:Yeah, and it's common in kids. It's like 14% of children have constipation and you know that can delay getting off to school, impact play dates because they're uncomfortable. You know a lot of kids hold it in at school because they're not comfortable. They have a little bit of a shy intestine. I think I have a little shy intestine. I like to go potty at home, but you know, again, just making it. This is a normal thing. Everyone poops and if you know how to poop correctly, that is a good thing. But you know, can you talk a little bit about we shouldn't be holding our poop and we should listen to our body. And why is it a problem to wait all day or drive three hours in a car and hold your poop and then get home? It's not really ideal for constipation, right? Absolutely.
Dr. Iris Wang:And it's both a muscle issue and also a neurohormonal issue. So when poop comes down into our system I'm going to get a little bit into the pathophysiology here we have all these sphincters in our pelvic floor, at the end of the rectum, that signal to us okay, something has hit and I need to tighten up because there's something here that doesn't need to come out right. And so all of our anal sphincters are able to tighten. And then our puborectalis muscle, which is like the sling-like muscle that keeps our rectum in a narrow angle to again prevent things from just falling out, also tightens. But in order to poop effectively, those muscles need to open. When we need them to open and that's why we don't need to strain is we can open this passage.
Dr. Iris Wang:When we hold in the stool, we kind of signal to our bodies one, we can ignore those signals that the pelvic floor is sending us. And two, we kind of signal to our bodies one, we can ignore those signals that the pelvic floor is sending us. And two, we increase that pelvic floor tone so that then it becomes harder to actually release the muscles when it comes time to release. Over time those two things can become more and more progressive, and the more we hold, the bigger the rectum can get. And when the rectum gets bigger, you can imagine how, if we need stool to touch the rectal wall in order to send those signals, if the rectum is super large, then we need a super big amount of stool in order to actually send those correct signals, and so then the signaling becomes weaker and weaker over time.
Dr. Iris Wang:Signaling becomes weaker and weaker over time. Then, if we're really descending out the rectum like that it's hard to get to that point without some sort of genetic condition, but there is a point where our colons can dilate so much that they actually can't squeeze anymore. So then the stool builds up and our body doesn't have a mechanism for pushing it forward as well. It's actually a very similar mechanism to heart failure for the doctors listening but it's a decrease in muscle tone, because our muscle fibers aren't able to reach each other to contract, and so that's a very, very severe case of constipation. But smaller versions of that can happen with this chronic holding behavior. So it's really important for us to allow our bodies to empty when they need to empty.
Kate Scarlata, MPH, RD:Yeah, absolutely, and I think at the colon too is absorbing fluid as the stool is sitting in there, probably getting drier and we know that. You know, soft stools are a little easier to pass and absolutely. So just an extra burden there on the on the pooper. Absolutely.
Dr. Iris Wang:And with the dryness of that stool right, these large bulky bowel movements, especially for a little kid it can hurt. And then when you're not really aware of that and it hurts the poop, you can really get into the cycle of like this activity hurts me and so I really don't want to do it. And then it just perpetually gets worse and worse as there's more holding, as the stool sits for longer.
Kate Scarlata, MPH, RD:Yeah, one of the things you showed in the book that we always talk about and recommend we had a pelvic floor physical therapist that also recommends this is the squatty potty. You know, wondering, you know, I certainly we didn't have squatty potties when I raised my children, but you know, is that something do you think kids are educated about?
Dr. Iris Wang:Oh, absolutely not.
Kate Scarlata, MPH, RD:A squatty potty?
Dr. Iris Wang:Yeah, yeah.
Kate Scarlata, MPH, RD:It's just yeah, I mean, that's what I'm talking about. It's so simple.
Dr. Megan Riehl:We should be having stools in elementary school bathrooms to normalize it. And I think also, so many parents don't know what normal is either. Especially with our preschoolers, and especially if you're a first-time parent or caregiver, we don't know what the heck is normal and what's not. And when our little one are they complaining of a stomachache because they miss home and they just want to go home from school? Or do they actually have some constipation and they have to poop, but they're afraid or it hurts, yeah. So yes, we've got to do a better job at normalizing this, and certainly your child, my child. They're hearing about healthy poops and farting and like we're cheering it on and like normalizing it.
Dr. Megan Riehl:So, whether they like it or not, their classmates are probably getting some of what they're hearing at home too.
Dr. Iris Wang:A little sphere of influence for helping bowel movements.
Dr. Megan Riehl:That's right, that's right.
Dr. Iris Wang:Their teachers are not happy with you.
Dr. Megan Riehl:Well, they should. They should be thanking you.
Kate Scarlata, MPH, RD:I know I'm thinking poop school. Why don't we have a curriculum called poop school and we develop it for schools?
Dr. Iris Wang:You know they do that in China. Not necessarily poop school, but like how to wipe your bottom and it's like like with two balloons and like teaching how to wipe. There's some Instagram reels about this, oh my goodness.
Kate Scarlata, MPH, RD:Yeah, we got to upgrade the education, I think, although it sounds like you got a little pushback from the school. So I think we have some cultural changes we need to work on first.
Dr. Iris Wang:It's funny because there are some kids who just figure it out right. They figure out that if they raise their knees they poop better. Yeah Right. And actually a lot of parents are doing this at home when they get those low potties for their kids?
Dr. Iris Wang:Yeah, I mean, they get them because they don't want the child, they can't reach the big toilet and they don't want to fall in. But when they're sitting on the low potties then they actually can be in a good coping position, and that's why that's part of the reason it works so well. So that's something to think about, even if you don't get a toileting stool. And then some kids know that they need to bend their knees and so they're using whatever they can, and I have patients who have figured it out.
Kate Scarlata, MPH, RD:And they'll tell me.
Dr. Iris Wang:Oh, whenever I'm traveling in a hotel, I'll actually swing my legs to the side and use the bathtub and I'm like, yes, that's why it works. Congratulations, you listen to your body. So we do figure it out if we listen.
Kate Scarlata, MPH, RD:That's right. Knowledge is power.
Dr. Megan Riehl:Yeah, as both a physician and a mom, to help other parents out there. When should a parent maybe be concerned enough to reach out for some help if they're worried about their child and their toileting?
Dr. Iris Wang:Yeah, it's hard for me to speak on that because, again, like I only have one child right, I don't really know what normal is. But I think that if there is blood in the stool, absolutely please reach out, especially if it's not just bright red blood. If it is bright red blood and you're seeing it a lot and the child is kind of having trouble, right, you're hearing a lot of straining, a lot of effort to pass that bowel movement. It might be good to speak to just a primary care doctor to say what are some gentle laxative medications that can be really helpful.
Dr. Iris Wang:I actually think one of the biggest signs that I've seen parents around me present for is leaking, and that's actually a constipation problem, because the stool starts leaking out when there's a big blockage and kids are holding on for so long that their muscles fatigue, they tire out, and then they all of a sudden let go and they have accidents of whatever was in the rectum, and so that's actually a really good. Well, not good, but that's actually a time to think about. Is there actually constipation driving that problem? We see it a lot too if there's trouble with urination, because those two organs are so closely linked that sometimes pooping problems present as peeing problems and inability to control urine. So a lot of straining, a lot of effort. If they're not having at least three bowel movements a week, it might be good to just kind of get on top of it. Any sort of leaking problem or trouble controlling the stool, especially if it's a change from previous and then urine problems as well.
Kate Scarlata, MPH, RD:Excess stool in the colon. You know it sounds blockage. You're like, oh, what is the blockage? But it's excess stool, the stool that's collected and then this liquid is oozing around it and that can contribute to accidents in kids. Exactly, thanks for clarifying.
Dr. Megan Riehl:So not that you have to be obsessive about it, but just like we ask our kids, you know how was your day? You can also ask, hey, did you poop today? And you know it's a simple like is your day? You can also ask, hey, did you poop today? And you know it's a simple like yeah, mom, I did or nope, and you just take note of that as a mom. And then the next day, hey, did you poop today? And again, it's just normalizing that. Hey, we can talk about lots of different things and you know your pooping habits is included in that.
Dr. Iris Wang:Absolutely. Keep a copy of Boo Can't Poo around and be like well, are you like Boo today?
Kate Scarlata, MPH, RD:Yes, exactly, I'm already reading this to my granddaughter, Eleanor. She's only six months. She likes chewing on the pages mostly, but she likes the pictures and she's been a good listener. There's a lot of fiber on those pages, so perfect. She's going to be the best pooper ever. Oh, I, know, I'm already like we're getting plant diversity.
Kate Scarlata, MPH, RD:She's going to have the best microbiome,
Dr. Megan Riehl:That's right, that's right.
Kate Scarlata, MPH, RD:She's not eating yet, but you know she's just about six months, so.
Dr. Megan Riehl:So, as we wrap up today's episode, we like to ask all of our guests what they personally do for their gut, health and wellbeing. So can you share with us what you're doing?
Dr. Iris Wang:This is terrible because this was the hardest question to answer on the whole list. I am a big proponent of exercise as a form of gut health and movement. My chosen form of exercise is yoga, and I find that not only is it good from a professional standpoint because I do a lot of scoping, I stand in one position for a pretty long time sometimes, and so moving my body in different ways and stretching out the muscles has been really helpful, but yoga has really good data for gut health as well. Yes, a lot of those positions, the twisting, the inversions, can help move things along our GI tract mechanically, which is also why sometimes I don't do yoga outside the comfort of my own home, just to be okay with anything that happens as a result.
Dr. Megan Riehl:Normalizing that I always normalize for my patients at yoga class. You know you might hear somebody toot and that is just, it's a good sign of things are moving along, that's right.
Dr. Iris Wang:Yep, yep, and actually assign yoga videos to some of my patients to augment their GI therapies if they're bloated.
Kate Scarlata, MPH, RD:I love that it's so relaxing too.
Kate Scarlata, MPH, RD:In another way. I love the end where you just kind of chill out, and at least I like those types of yoga classes yes there you go I need to do it more, so I know the name of it.
Dr. Iris Wang:There are great apps for that.
Kate Scarlata, MPH, RD:Yes. So thank you so much for joining us today, Dr. Wang. This has been amazing and so informative and cutting edge. I love talking about precision medicine and I know you wrote an article. We will link that. You know link things that we talked about today. But we really appreciate your expertise and your time and for writing the great book Boo Can't Poo and for all the work that you do for patients and all of us in the gut health world.
Dr. Iris Wang:Thank you so much for having me. It's been my pleasure and my honor.
Dr. Megan Riehl:So don't forget to like, follow and subscribe to The Gut Health Podcast. We appreciate your support. It means the world, our 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@The Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.
