This episode of the What the Health podcast delves into the often stigmatized and under-discussed topic of Irritable Bowel Syndrome (IBS), affecting millions globally, including about 45 million Americans. IBS is characterized by recurrent abdominal pain associated with changes in bowel movements, including constipation, diarrhea or a mix of both. With guest expert Dr. Megan Riehl, clinical director of the GI Behavioral Health Program at the University of Michigan and co-author of 'Mind Your Gut: Living Well with IBS,' the conversation illuminates the causes, symptoms, treatment option, and research surrounding IBS. 

The discussion emphasizes the importance of seeking professional help and the multifactorial nature of IBS causes, including stress, genetic and environmental factors. It also explores the integral role of a multidisciplinary treatment approach involving dieticians, psychologists and potentially physical therapists. It also tackles common misconceptions and highlights the need for greater research and awareness to improve the quality of life for those suffering from IBS.

00:30 The Unspoken Reality of IBS

01:09 Introducing Dr. Megan Riehl: An IBS Expert

01:55 Understanding IBS: Symptoms, Causes and Prevalence

05:24 The Impact of Stress and The Pandemic on IBS

07:19 Treatment Approaches and the Importance of Professional Help

13:09 Exploring the Symptoms and Seeking Diagnosis

24:13 Addressing IBS: Behavioral and Dietary Strategies

26:27 Mind Your Gut: A Comprehensive Guide to Living Well with IBS

29:06 The Future of IBS Research and Combating Misconceptions

32:36 Final Thoughts and Health Hacks for IBS

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Yet it might be something we all need to spend a little more time focusing on, especially if these symptoms are severe and constant. In fact, those dealing with these types of problems may be facing a condition known as irritable bowel syndrome, or IBS, a disorder that affects millions of people worldwide, including tens of millions in the U.

S. alone. IBS symptoms, after all, can be devastating on a professional and social level if left untreated, which too many do because they're embarrassed to discuss their problems. Thankfully, we've lined up a leading authority on all things IBS to help us shed some light on its causes, symptoms, and treatments in hopes of helping people reduce the stress related to IBS and get their lives back on track.

So keep listening. It's worth it.

Welcome to What the Health podcast. And again, this is the part everybody looks forward to when we get to delve into a subject with an expert, and we certainly have an expert on hand for this interview, and that is Dr. Megan Riehl.

Dr. Riehl is clinical director of the GI Behavioral Health Program at the University of Michigan, and she is also the coauthor of Mind Your Gut, Living Well with IBS, which gives you a clue of exactly what we're going to be talking about today. So Dr. Riehl, welcome to our podcast.

[00:02:13] John Salak: Okay. We're not going to get into what happened to Michigan's basketball team. team this year. But I know you're probably still sort of glowing from the football wind. So we'll just move right on to IBS. So IBS, exactly what is IBS? Because we hear about it or everyone hears about it all the time.

And we look at this over about a three month period, and that's when we start to kind of meet the criteria. And, unfortunately with this diagnosis, a lot of people live with it for a long time before they actually then go see a doctor. But it's a complex disorder where we're learning more and more about it, but we have come so far from where we used to be to be. A lot of times people were told to just kind of live with it. It's not cancer. It's not inflammatory bowel disease. When you have a colonoscopy, there's no benign or an unremarkable colonoscopy with an IBS diagnosis. And so, that can be very challenging for people that are living with these really, uncomfortable and at, many times unpredictable symptoms.

[00:03:38] Megan Riehl: It's a

[00:03:42] Megan Riehl: it, yeah, it's a syndrome. And really we think that it's probably a combination of a lot of different things. And that's where it is important , to meet with a doctor to get that diagnosis. Because, there's a lot of what we call IBS mimickers out there, like small intestinal bacterial overgrowth or SIBO.

Sometimes these symptoms that are similar to something like an inflammatory bowel disease, which can be Crohn's disease or ulcerative colitis. The treatment plan is going to be very different based on what the diagnosis is. And therefore, it really is important to talk with your doctor about all of the symptoms that you're experiencing.

[00:04:27] Megan Riehl: Yeah, our number is around 45 million Americans that have IBS and, there's been lots of research to identify that number. You can find the global prevalence of between 6 and 10 percent of the global population. So it's prevalent and it's kind of fun to be in a room with a hundred people and kind of say like, Hey, at least I have IBS.

that showed that one in five people with IBS do not want to discuss their symptoms with their providers. And, a quarter of people are managing their symptoms with just over the counter medications or non medical treatments. and even a further a quarter mentioned that their symptoms were not bothersome enough to seek medical care.

So I think that this shows that there are lots of people out there that just haven't gone to, the doctors and a lot of people have just been kind of conditioned to believe they have to live this way.

people

[00:05:47] John Salak: Do you suspect the number's growing? And I guess that may tie into if it is growing, or regardless, there's certainly a lot of people who are suffering from it or dealing with it.

What's causing it?

But even people that had COVID sometimes saw a worsening of GI symptoms or that the COVID. Diagnosis led to some gastrointestinal conditions. So for a variety of reasons the prevalence could be on the rise. And I think, the story is unfolding here over the last four years of how our world has been impacted by the stress of the pandemic.

And the cause of IBS is also multifactorial. So there can be, environmental factors that can lead to this diagnosis, genetic factors, stress factors, psychological factors. So I always say the road to an IBS diagnosis is typically very individualized. But as we, do a clinical interview with patients it's not uncommon for them to say, growing up, my mom always had a sensitive stomach, or my dad, His family has a history of GI problems, but nobody ever sought treatment or nobody ever went to the doctor for it.

So, I think that there could be some kind of genetic tie there that eventually draws somebody into the clinic to talk about their symptoms. But a lot of times the factors are, multi factor, like I said. And it's, there's a complex interactions of even food, our microbiota and what it leads to is this impaired barrier function in your immune activation which basically means the way the brain and the gut are communicating is dysregulated.

And our goal with treatment is to try and restore it. But how we do that can include a variety of multidisciplinary strategies.

[00:08:05] Megan Riehl: so, actually, I have a podcast called the Gut Health Podcast, and we just had on one of the leading experts in terms of IBS and small intestinal bacterial overgrowth, Dr. Mark Pimentel. And he highlighted that, people can go on vacation or they can go on to a wedding. And, you find out that a bunch of people got food poisoning or you had a couple hours of diarrhea while you were on vacation and you kind of move on and you don't really think about it.

And then three months later, you've started to have IBS symptoms. And so it can be as, unfortunate as that, where just a few hours of an exposure to something in your food can then change the functioning of your microbiota and lead to an IBS diagnosis that then they're dealing with for, essentially the rest of their life.

So, so there's that kind of exposure experience that can lead to this diagnosis. And then, I can use psychological stress as another example where we know that people that have IBS diagnoses have a higher prevalence of a history of trauma. And so, people will sometimes show up in my clinic and say, yes, I had a history of trauma, but I processed that.

I dealt with that. Like I didn't have GI issues as a kid when I was, dealing with all of that. And so, what's the deal? Why now? And so it really just highlights the intricate nature of the trauma. the way our body is and how our brain and our gut are so bi directionally tied and that can lead us to, unfortunately this diagnosis.

[00:09:56] Megan Riehl: The thing about it is that, when you can't predict it. Yeah. necessarily when you're either going to go to the bathroom too frequently, or if you're struggling to go and the fate let's look at, so IBS D IBS with diarrhea, predominant symptoms, these patients experience that abdominal pain and then frequent diarrhea that again, a lot of times they tie to the food that they're eating or stress can, Send them to the bathroom and then it's really hard to get out and that then makes it difficult to get to school, to get to work, to think about dating or, being intimate.

and like you mentioned earlier, these aren't symptoms that we tend to talk about at a cocktail party. You're not like, my IBS. I was, although I think we are normalizing it a bit more. I have little kids and we talk all the time about, everybody poops and I want to know if you're not pooping.

I want to know if you're pooping too much because I've had so many patients that get to my office and they're in their thirties, forties, fifties, and they're like, We never talked about going to the bathroom in our household. In fact, it was taboo. Nobody wanted to know about it. And so they didn't learn as children that going 5, 6, 7 days without going to the bathroom wasn't normal.

And so, I think we do have to kind of normalize. I've kind of been talking jokingly with friends, but I'm like every kindergartner should, really have a conversation about how are they pooping, proper pooping position, how frequently they should be going. That it's not normal to have a tummy ache every day because that's what then leads to the perpetuation of some of these symptoms later in life.

And IBS with constipation more women than men will have IBS with constipation and that's general. So women are 2. 5 times more likely than men to have IBS, so it is more prevalent in women. But when we look at the prevalence types, women are more likely to have constipation.

And with that comes not only the abdominal pain, but bloating, distension, which is very uncomfortable on top of not being able to pass stool. And that then impacts appetite. It impacts the pelvic floor. And We also see that those symptoms can be worsened during the menstrual cycle. So to not address any of this and to just kind of feel like you have to live with it is just like my nightmare.

I want people to know that we do have ways to address it. We do have treatment. It's just a matter of you may have to think outside of the box if you haven't made progress by working with, medical doctor.

[00:12:34] Megan Riehl: Yeah. And, I was once at a dinner table with a bunch of gastro neurologists and so, this is the most common diagnosis that most gastro neurologists will treat and about two of them were like, yeah, I have IBS, but, I've never seen a doctor for it. I just deal with it, you know, and I'm like, Come on, like, this is what you do.

But it's a matter of, are we too busy? Are we, I don't know. I don't know the stigma. There's certainly still a lot of stigma around this diagnosis. And I think part of my motivation and passion as an educator in this space is to talk more about it, to let people know that, if you've tried medications on and off for the last 20 years and it just hasn't worked, the good news is that working with a registered dietitian can be very beneficial working with a dietitian.

A GI psychologist like myself can be very beneficial. So there are other ways that we can address this diagnosis that haven't historically been, available and around for all that long.

[00:13:46] Megan Riehl: So one thing you can do is you can Google the Bristol stool chart, and this is a chart of poop. There are two charts. Types one to seven and on, up at the number one is going to be stool that's almost pebble like so hard to pass pebbly stool. This is going to be obviously constipation and from there it kind of progresses to a number seven, which would be watery diarrhea.

Like the worst watery, loose diarrhea. And then, in between there a number four would be kind of like a smooth snake like stool that comes out easily. That's ideal. We want to have kind of that ideal. three, four stool , that is a normal inconsistency. And so if you start at pebbles and then you're kind of lumpy and then you're progressing to loose, watery diarrhea, that's kind of stool consistency that you want to be mindful of.

Color can be also one thing. So most of us, we eat different things. And so your stool won't always be Brown. Like if you've had beets and you look in the toilet, you're probably going to get a little bit of a shock because your stool is going to be like a beet color. Or if you've had too much processed.

food coloring, then that also can change things. But generally speaking, being mindful of the color of your stool can be something to report to your doctor. And your doctor will know what you talk about if you tell them, I'm a type one on the Bristol stool chart, or I'm a type seven, or I'm a type five.

And so your diarrhea, your constipation fluctuating between the both, those are symptoms to watch for. That abdominal pain cramping, bloating. These are also symptoms that go along with this type of diagnosis. And there's also a lot of overlap in terms of pelvic floor dysfunction in this patient population.

So, this may be something that your listeners can will take away because they've never considered working with a pelvic floor physical therapist, because sometimes patients with IBS will have what's called dysenergic defecation, which basically means that the functioning of the muscles needed to pass stool is not where we need it to be.

And so working with a pelvic floor PT they help strategically strengthen those and learn more about the mechanics of how you're pooping which can then help with some of those other abdominal pain, bloating type of symptoms in addition to helping pass stool easier.

[00:16:29] Megan Riehl: So nausea, from a symptom perspective that you might not necessarily be thinking of anxiety or depression. These are also symptoms and they're more prevalent too in patients that have IBS. So people that have IBS are at a threefold higher risk for anxiety and depression.

And so especially if the fact that you're having those other symptoms is worsening anxiety or depression then we really want to be mindful of that risk. correlation and that connection and address that with your medical providers.

[00:17:12] Megan Riehl: So it is bi directional that, the chemicals in our brain that can be produced related to anxiety or depression can impact our GI tract but also the chemicals in our GI tract can impact our brain and worsen symptoms of anxiety and depression. also there can be. Very GI specific anxieties.

So, for example, people that are avoiding social situations because they're afraid of having access to a bathroom or maybe having a fecal accident which is actually, also something I point out to my patients that, fecal incontinence with I. B. S. is typically not common symptom unless you have pelvic floor dysfunction and those muscles aren't coordinating to be able to hold the stool until it's the right time to evacuate.

So if you're having a lot of bouts of fecal incontinence, and you think have IBS you definitely want to be talking to your medical provider about that. But that's a side note.

So anxiety that's related to the GI symptoms, things that we work on in behavioral therapy are addressing avoidant behaviors, helping to manage some of the catastrophic thoughts that we might have of like, Oh, if I pass gas or if my stomach gurgles in a classroom or in a boardroom, I'm just going to be too mortified and people are going to think I'm gross.

People are going to think that like there's something wrong with me. So I'm just going to avoid those situations. We really want to address those GI specific worries, anxieties, and stressors. from a behavioral perspective and we can do that. And then there's also something called GI specific visceral anxiety, where you feel a sensation in your stomach or your rectum, or some somewhere along the GI tract.

And the brain, really hyper focuses on that sensation, which then ramps up anxiety. And then the anxiety wakes the physical symptom worse. And it becomes this kind of dreadful cycle that people get stuck in. But the pain is real and it's driven by nerve sensitivity. And then it's driven by.

It's also driven by how closely the brain is focusing on those symptoms and we know that people that are living with IBS, their brain has a more difficult time down regulating those pain signals coming from the digestive tract. And so a lot of our behavioral therapies will focus on that as well.

[00:19:44] Megan Riehl: The reality is that for, I think, probably hormonal reasons or maybe some women being more likely to go to their doctor for care. I know that, sometimes my husband will be complaining of symptoms and I'm like, go to the doctor. And he's like, no, no, no, go to the doc. And then a year later, Same symptoms.

Go to the doctor. Oh, yeah. Maybe I'll go. So, I think there's definitely the hormonal component is a piece that I think makes this more prevalent in women, but that being said, it's still heavily impacting men as well. So, I think that we really need to continue to learn more about this.

And unfortunately though, in the research, it shows that women then have a lower quality of life compared to men when they both have IBS. Women have more fatigue. Women are more likely to have depressed mood and higher levels of anxiety. So, I think we have to do a better job in the research to nail down more reasons why women are more heavily affected.

and we need research dollars for that.

Or people just saying, I can live with this, yeah, I can live with the social issues too.

So I, I do think there's psychological risk for people that don't have the right treatment plan in place. I have patients that have severe. IBS that profoundly impacts their ability to work, ability to socialize their mood.

And then I have some patients that, are more on the mild end of the spectrum and they're grateful to receive treatment and get things very well controlled. But again, I think that it just depends on the severity level of IBS and also this diagnosis is comorbid with a lot of other diagnoses.

So, it's not uncommon to see endometriosis, fibromyalgia, autoimmune issues. And so if this is one of many medical issues or psychological issues that you're managing it really is not the icing on the cake that you want to have.

[00:22:32] Megan Riehl: This is an evolving field where a primary care doctor can typically manage IBS pretty well and they're likely to be able to do that. kind of use treatment plans based on the symptoms that the patient is having. So, if they have diarrhea, they're probably going to, recommend an anti diarrheal.

If they have constipation, they're going to, work on a laxative treatment. And the medications have become more sophisticated over the years. However, it's typically unless you're one of the lucky patients, medication doesn't manage at all. And so there is a growing recognition that the gold standard care for IBS at this point is an integrative multidisciplinary perspective that includes not just a primary care doctor or a gastro neurologist, but a dietician, a psychologist, a, potentially pelvic floor physical therapist We talk about this as, creating your dream team in our book and access to that though is still quite limited.

So you know, at the University of Michigan, we have all of that and we can get patients access to, really a wide range of subspecialists. But for those that, don't have a fully integrated GI psychologist. I think the good news is digital therapeutics are emerging and that can be something that a local gastroenterologist or a primary care doctor can refer to such as, a gut directed hypnotherapy app or a, there are digital therapeutics out there that are doing GI specific cognitive behavioral therapy and then the field of GI nutrition is also really growing.

So it's. probably easier to find a GI dietician who specializes in the variety of dietary and nutrition therapies that are recommended for IBS. And so depending on what you have access to, that's going to be what you recommend to your patients. I think as stigma reduces with IBS and more of these kind of multidisciplinary approaches become available, then people are going to be more likely to talk about them in their clinics.

[00:24:43] Megan Riehl: that's a great question because, if you Google IBS you will find a lot of snake oil out there. And what I mean by that is, any product or program that says that they're going to cure, Your IBS they either are unintentionally using the wrong word or they're making a blanket statement that science has not allowed us to say as possible.

So the goal with treatment is that we're able to reduce the severity of your symptoms, reduce how frequently you have symptoms, reduce, how you are experiencing. So severity, frequency and duration. That's my other one. And, which means maybe you have a couple hours of abdominal pain, you've had, a bout of diarrhea or you feel like you have to go and you can't go.

However, instead of getting super anxious about that and, and further maybe eating more foods that might exacerbate your symptoms Our goal with treatment is to empower you with a whole toolbox of strategies that you'll turn to. So that way, the symptoms are far more impactful on your quality of life and you feel like you've got this, when you start to feel your symptoms, this is what I'm going to do.

I'm going to do some diaphragmatic care. breathing. I'm gonna, choose foods that are really gentle for the next couple of hours and see how I do. I'm gonna keep eating. So a lot of times people will avoid food for way too long in an attempt to manage their symptoms. But the body needs to keep some food in.

So, whether it be as gentle as, some chicken broth or, something that's very easy that works for your stomach it's important to keep kind of hydrated and getting your food into your system. But also gut directed relaxation interventions. So, these are some of the behavioral strategies that I specialize in being able to turn to those knowing that they help to calm and soothe and restore the way the brain and the gut are communicating.

It's really empowering for patients and it takes people that felt like they have nothing that works to a whole bunch of different things that they can turn to.

[00:27:08] Megan Riehl: So there you go. Mind Your Gut, the science based whole body guide to living well with IBS. And I co wrote it with a world renowned GI dietician, Kate Scarlotta. And it's kind of the first of its kind book that we help you understand the IBS diagnosis. We review the science, we review the pathophysiology.

So, the mechanics of IBS. And as I was talking about that, really unique roadmap that each individual with IBS might fall into to, land at an IBS diagnosis. And then from there we have several chapters dedicated to reviewing nutrition where Kate highlights the evidence.

The science not just for the low FODMAP diet, which is an evidence based nutrition therapy for IBS, but you know, we, we highlight that not everybody needs to follow a restrictive diet to manage their IBS. Maybe they could benefit from, following some of our suggestions for a gentle diet cleanup.

Which again kind of falls into, what are the foods that are easy on your stomach? We list out foods that we give you lots of different options. We give you recipes to help you have a healthy gut a diverse microbiome that's so important for all of us.

My chapters cover behavioral strategies that, you can implement from home. So, different relaxation strategies I give an overview of stress management interventions that can be really helpful, not only for your IBS, but just for, all of us have stress and we can all benefit from some good strategies there.

And then I dive into some of the science related to the benefits of stress. of using gut directed relaxation which stem from the world of gut directed hypnotherapy. And then we also have several chapters that talk about very symptom specific strategies. We cover the science on medications, probiotics, prebiotics.

We give you, our thoughts and opinions as well as what the literature says. And then the very end of the book is filled with. Lots of different resources, so, some of those digital therapeutics that are available on the market that can be helpful from a behavioral strategy, different food companies that are really great from a gut friendly perspective, and as I mentioned, we have a whole section for different really amazing recipes that are also wonderful for your gut.

[00:29:47] Megan Riehl: I think that you're absolutely right There's never enough. And I think the more that we can destigmatize this diagnosis and recognize how complex it is the cool thing is that the more we learn about the microbiome, and we're just skimming the surface on what we're going to learn about the microbiome this type of research is really something that we're looking for research funding and research dollars around because, we've found that even using some of our psychological therapies, like cognitive behavioral therapy in very preliminary research has shown that it impacts the brain gut microbiome access, which is going to impact our GI symptoms.

So, I can't personally speak to exactly the dollars and cents of how this stacks up across medical diagnoses, but by far, it doesn't receive as much funding as cancer or some of our other major diagnoses out there.

[00:30:51] Megan Riehl: I think one is that you just have to live with it and that if you've tried a couple different medications and you haven't had relief that, there's nothing out there that's going to work for you. Because I think a lot of times people turn to probiotics and prebiotics and again, those are things that potentially could work, but the science just doesn't support it at this particular time.

In fact, the major guidelines for gastroenterology don't recommend use of probiotics because everybody's microbiome is so different. And so I think that there are great natural ways. That you can also, address your microbiome and natural prebiotics and probiotics from food. And so, that's one area that you can look at.

And then also taking a look at your overall mental health. If you feel like, your symptoms of diarrhea, constipation, abdominal pain are really precluding you from engaging in the life that you want to have, then working with a mental health provider who is expert in this area of health can really give you concrete tools and strategies to help you address those feelings and those symptoms. The timeline of treatment really can range from about five to ten sessions and people can have a really profound impact on their overall quality of life and onward they go. So, I think if you're somebody that has just been living with this, then check out our book where we have a lot of different options.

Listen to our podcast that's focused tremendously on overall gut health and don't stop looking for a provider. Who will really listen to you and help, create the treatment plan that's going to get you feeling better.

So, Dr. Real, thank you very much. And hopefully we can talk about this or some other element going

[00:32:55] John Salak: for visiting with

[00:33:02] John Salak: Before we move on, we wanted to again encourage listeners to take advantage of the hundreds of exclusive discounts WellWell offers on a range of health and wellness products and services. These cover everything from fitness and athletic equipment to dietary supplements, personal care products, organic foods and beverages, and more.

Signing up is easy and free. Just visit us at WellWellUSA. com, go to Milton's Discounts in the top menu bar, and the sign up form will appear. Signing up will take seconds, but the benefits can last for years. Okay, when it comes to IBS, I think we all realize now that the consequences can be pretty nasty.

But the issue can be dealt with. But there's some don'ts and some do's first the don'ts don't be embarrassed. You're not alone IBS is a common mind gut disorder Don't wait seek professional help right away. IBS is not going to get better on its own Don't be fooled by false ads boasting IBS cures. They are not going to help.

You need professional help. Don't get discouraged. These symptoms can be brought under control. But with these don'ts, there are a couple of do's. Do get professional help. Your doctor, your primary care physician, whomever. Do remember that all treatments are not effective for every person. Solutions vary by person.

But help is available that will get these conditions, these symptoms, under control. That's it for this episode of What the Health. We'd like to thank Dr. Megan Reel, Director of the GI Behavioral Health Program at the University of Michigan. Her insights were great. Dr. Real is also the co author of Mind Your Gut, the science based, whole body guide to living well with IBS.

We'd recommend everyone who is dealing with IBS or who may think they have some IBS issues to get a copy and learn more about living well with IBS. Again, that's it for this episode of What the Health. Thanks for listening in, and we hope you'll join us again.