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Kate Scarlata, MPH, RDNMaintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health-conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food, and the gut. Come join us. We welcome you.
Dr. Megan RiehlHello,
friends, and welcome to the Gut Health Podcast. We are your hosts. I'm Dr. Megan Real, a GI psychologist.
Kate Scarlata, MPH, RDNAnd I'm Kate Scarlata, a GI dietitian. So did you know that up to 90% of people with IBS report that eating triggers their GI symptoms? Or more than half of patients with IBD believe their symptoms are induced or exacerbated by specific foods. It's really understandable, right? That you would begin eliminating foods in an effort to reduce pain and bloating and those changes in bowel habits. And it often will feel logical to do so. And it's sort of an adaptive response when eating causes pain, but progressively restricting your diet can really be a slippery slope. We see this all the time in practice. Patients eliminate more and more foods. And this really leads to poor food quality of life and inadequate calorie and nutrient intake, can really worsen fatigue and fear and anxiety around eating. And really their quality of life in general is really affected. We also know that poor nutrition can affect the gut microbiome. It may even affect the lining of the gut, which requires adequate fiber and makes symptoms sometimes even more difficult to manage. You know, your gut is a muscle, your intestine is a muscular organ and it needs protein and calories so that can function and move properly. So rather than continually removing foods, the goal really is to identify true triggers, which sometimes might not be the food. Which might not be the food. That's right. Thank you for saying that. And the goal, and I say this like shouting from rooftops, is really eating the most varied and nourishing diet possible. And ideally, that can be a lot easier to do with a health professional or a GI-registered dietitian.
Dr. Megan RiehlYeah,
it definitely requires, in many cases, a team approach. Yes. Where we see patients that may also have a history of an eating disorder and they are experiencing GI symptoms. And many of the symptoms that we see are abdominal pain, bloating, constipation, fluctuations in their bowel habits. And these symptoms can really mimic many of the disorders of gut brain interaction that you and I see in our clinic all the time. And so at the same time, these repeated experiences of painful, unpredictable GI symptoms can teach the brain to see eating itself as a threat. And it becomes really confusing and difficult for both the patient and the medical providers to figure out where do we go? Because I see lots of patients where the gastroenterologist is referring them to my clinic for GI symptom management. Yet maybe an eating disorder is still the more pervasive issue, which can impact the pelvic floor and the motility and really complicate the picture. And so then I have to work with the patient to educate them on why really getting to the root of the eating disorder is necessary to kind of help improve their GI symptoms longer term. It can be really complex.
Kate Scarlata, MPH, RDNIt really can be. You know, I think of just the aftermath of experiencing an eating disorder, whether that's a binge and vomiting episode or overusing laxatives or just not nourishing your body, how there would be this sort of effect to the gut and the gut's motility and so many factors that would lead these individuals into a GI practice.
Dr. Megan RiehlYeah. So we're not saying today that, you know, food restriction in our patient population, that everyone has an eating disorder. So we'll be very clear about that. But that overlap can happen. We will dive into some of these nuances and understandable restrictions. But what do we do with that? And really, we have some incredible experts and colleagues today that we're going to talk about diet therapy, how it fits into the clinical picture here, how to recognize when food fear is becoming more problematic and normalize some of that. And then why this collaboration across disciplines is essential to helping people regain confidence in eating.
Kate Scarlata, MPH, RDNAbsolutely.
And let's just mention social media because there's so many experts and influencers out there telling everyone they've got to do this, this, this protocol, diet, fear mongering around food. So it can really exacerbate your own personal questions about food and eating and GI symptoms. So try to stay away from wellness influencers because many of them don't really know nutrition in this area very well.
Dr. Megan RiehlWell, and I know that with the recent uh explosive diarrhea parasitic outbreak lately, certainly I am somebody that is cautious about my food practices, washing my vegetables and cooking them. Yes, cooking them. But man, this world uh well, nationwide health concern really got people worried about, you know, having a salad in the summer here in Michigan is a wonderful thing to do. And I was avoiding that. And so for somebody with maybe more pervasive food fears, something like that can really kind of get the anxiety ramped up.
Kate Scarlata, MPH, RDNWell, they've experienced the aftermath of that. So that makes a lot of sense. We have a whole nother group of people afraid of uh explosive diarrhea. Yeah. No, yeah, no, we don't want to understandably. So I'm really excited to introduce our expert guests.
I've long admired their thoughtful and really nuanced approach to caring for individuals with disordered eating and GI conditions. And let me start with my colleague. So Janelle Smith is a registered dietitian, nutritionist. She's a certified specialist in digestive health and a certified eating disorder specialist as well. She is a senior dietitian and nutrition research lead at UCLA, Walter and Shirley Wing Integrative Digestive Health Program. Janelle is also co-founder of the EDGI Training Project, a collective dedicated to educating providers on how to treat co-occurring GI disorders along with eating disorders.
Dr. Megan RiehlWe are excited to have her, and I am also excited to introduce Dr. Madison Simons. She is a GI psychologist at the Digestive Disease Institute at the Cleveland Clinic, where she specializes in treating patients with motility disorders and disorders of gut brain interaction. She received her doctorate in clinical psychology from Regent University and completed her postdoctoral fellowship in GI Psychology at Northwestern University. So we are family there. And her current work focuses on the precipitance and consequences of dietary modification in patients with digestive diseases and the overlap between gynecologic conditions and digestive symptoms. We are thrilled to have you both here today. Let's start with a myth busting question. Dr. Simons, tell us a myth that you'd like to bust pertaining to the overlap of GI conditions and disordered eating.
Dr. Madison SimonsI think the biggest myth in this discourse is that avoiding foods for GI symptoms is inherently pathological. I think our conversation needs to be a lot more nuanced than this, which we're going to get into a lot today. So I hope by the end of our conversation we'll have busted that myth.
Kate Scarlata, MPH, RDNOh, I love that one. Good one. And Janelle, how about you? What myth would you like to bust pertaining to the overlap of GI conditions and disordered eating?
Janelle Smith, RDNI think that disordered eating is a negative judgment. I wish that we could have these conversations with empathy and understanding and support rather than people feeling pathologized or blamed or dismissed in any way.
Dr. Megan RiehlWe are all giving big head nods. Yes. All of us.
Kate Scarlata, MPH, RDNChills, chills. Because we know in clinical practice that we've been on the other side of that, where the patient comes back and said, you have an eating disorder or you have RFID. Certainly that's not the way we want to approach these very sensitive topics that are very nuanced, right? So, Dr. Simons, how do you differentiate between dietary changes that are medically necessary for managing GI conditions or those that may be driven by fear, anxiety, or an emerging eating disorder?
Dr. Madison SimonsIn some ways,
I think we benefit from taking a step back and acknowledging that food avoidance in response to severe GI symptoms is actually like what we would expect the brain to do as a way of protecting survival. And the animal literature shows us this as well. Rats who are given an emetic agent after new flavors are observed to perpetually avoid that new flavor, basically forever going forward, compared to rats who are given the emetic agent after a familiar flavor. And so it seems like the rats can differentiate that there's something situationally different about this time that I had the flavor compared to last time, which can't happen in the case of a new flavor. And even if we think about like chemotherapy-induced nausea vomiting, it takes just one single experience of nausea and vomiting after chemo for that person to develop significant fear of nausea and vomiting with chemo, even if they've had other experiences that are not as bad. Our amygdala is hardwired to function based off of experience and not rational, logical thought processes. So it does not require multiple negative experiences before the brain starts to anticipate what's going to happen to us when we eat. That's biological and it's evolutionary. You asked a simpler question than this, which is like how we differentiate medical necessity versus not. I become more concerned when there's avoidance despite lack of symptomatic response to food, or if there's avoidance when symptoms haven't improved despite avoiding, or if we're avoiding broad food groups, we're having a really hard time introducing foods out of fear, not necessarily because of symptoms.
Kate Scarlata, MPH, RDNYeah, that's a great way to differentiate. And I just I'm glad you brought up the chemotherapy example because I feel like with IBS, 90% of people say they experience pain with eating. That's a big number. I mean, we're there are people that are really feeling this, but somehow it seems to me if it's IBS, it's like different rules of engagement. If someone had chemotherapy, it's like, oh, that makes sense. But it's like a different rule of engagement, right?
Dr. Madison SimonsIt's even like if we had a stomach bug as a kid, like the last thing that you threw up and you said, I'm never gonna touch that again, like no one would question you. You could forever avoid that food. But we ask our GI patients to like vomit and have pain and nausea when they eat and then go back and revisit that food again day after day. And I think it comes back to Janelle's myth about like, is disordered eating always a negative connotation?
Dr. Megan RiehlMaybe not. I love this conversation.
unknownYeah.
Dr. Megan RiehlAnd we see this in our screening measures, right? A very common screening tool. Janelle is gonna talk a little bit more. We're gonna ask you a question about that in a little bit, but we are trying to parse out, we're screening for disordered eating in our GI patient clinics, and the numbers are quite high. We're seeing high prevalence rates of avoidant restrictive food intake disorder. But it, you know, those of us in clinical practice are like, is it disorder light? Is it kind of, is it maybe? And again, it's just this reality that we have to eat, but food is so tied to our GI symptoms and therefore the complexity of that and the nuances of that. And how do we best support people that are trying to live their life with food? Right. That we all need. So, Madison, getting into some of the psychological and behavioral factors that contribute to the development and the persistence of the food fears that we see in patients living with IBS, what are those? And
how do you help patients begin to understand the role of the brain in interpreting food and eating that fear threat model that I think is going to be so helpful for our listeners today?
Dr. Madison SimonsI think the patients who have really significant postprandial or post-eating symptoms, whether that's pain or nausea or vomiting or bowel symptoms, these are our patients who are at greatest risk of developing food fear. And food fear, I really think about as being more symptom-driven fear. I'm not so afraid of the food itself. I'm afraid of what's going to happen to me after I eat. And so we'll get into it a little bit more later, but it's really so important that we help patients navigate the fear around symptoms before we even begin to bridge the road to fear of food. I think the amygdala is so important to understand in this process in its experience-driven way of existing, that the amygdala is fully formed when we're born to be able to detect threats in our environment. And it's only later that our prefrontal cortex is developed and we can try to create a rational logical thought process. But when we accumulate these experiences, either a number of them or they're really severe, it could only take one really severe post-eating set of symptoms that triggers the amygdala to remember what has happened to me. And so I give a lot of reassurance to patients of like, it really makes sense to me that you are this way today. Like, I would really expect you to be this way. And also maybe we don't have to stay in this place here, but it's gonna take a long time for us to unfold that. So I think just giving those words back to patients of like, it makes sense, I expect this, it helps them to not feel as stigmatized or pathologized for what's happening right now.
Kate Scarlata, MPH, RDNYeah, I love that they do feel blamed, you know, when so much is you know a little bit hardwired, so to speak, or maybe not hardwired, saying to the psychologists here.
Dr. Madison SimonsI think hardwired is the right word, and we have to like rewire that in a difficult way.
Dr. Megan RiehlRight. And that it's possible that we hear you, you've arrived at the place where we can instill some change and some education and some support. And Madison, what you said about it's gonna take some time. A lot of times our patients have been suffering already for a really long time. And so I'm working on that right now with many of my patients to kind of course correct realistic expectations for what treatment is gonna look like, how long it might take. And that I wish I had a magic button where I could say, okay, we're starting today, and in 65 days it's gonna be different. But we don't, and every brain is different, but we have good information about what brains are doing that we can work off from our treatment plan perspective.
Dr. Madison SimonsYeah, like I think the roadmap, you're working on kind of a similar progression of skills for most people. But I can think of people where two years later and like we're finally getting our fingers under it.
Kate Scarlata, MPH, RDNYeah. I feel like patience is something, even with untangling the diet piece. I always tell my patients, you're gonna be working with me for a little bit, because this is not like a quick fix. We have to really, and certain patients are clearly gonna need more than others, you know, and you can see that. And I think at least managing their expectations provides a little bit more reality to what they are gonna expect in your care, you know, it's important. So,
Janelle, what are some clinical signs or screening tools that you use in your practice to really identify a patient with a GI condition that may be at risk for disordered eating or an eating disorder?
Janelle Smith, RDNI think my favorite tools to use are just open-ended questions and connection because a standardized screening tool, which we don't have one with perfect validity and GI disorders, still just doesn't capture everyone. They're always imperfect. So I like to open up the conversation and help their answers inform the rest of my assessment and intervention. So, questions like how is your relationship with food? How much time do you spend worrying about food or thinking about what you're going to eat? How do you feel about your body image? Are other people concerned about your eating? And then whatever those other people think, what do you think about that? Because I want to know basically all the context to their eating situation. I don't want to come to a conclusion either that's wrong or that just doesn't reach the patient because they need to also be on the process. They're the most important part of the conversation, is that I'm helping them with what they think is problematic or what they would like to be better with their relationship with food. A patient-shared model, right? They should be a big part of that. Exactly. And I think it helps for them to not feel pathologized when finally when I talk about an assessment, I'm using their own words or their own assessment of themselves rather than me saying, Well, this is what I think about you. Right. Yeah, that's a really good point. So at UCLA digestive health program, we actually do use the screen for disordered eating, which is a quick five-item yes or no answer. And we've been using it for over two years and should have more data to publish on it that was released at DDW, but seems pretty consistent with other body image-based screening tools. And people are saying yes to questions that you wouldn't know if you didn't ask. Right. People who, especially someone who's preoccupied with thinness that's even irrelevant from their GI disorder. And then the nine item ARFID screen, I do like, which is a nine question screening tool for ARFID. The scoring needs to be discussed more of what's a significant score. But no matter what, their answers give me information. Again, people who have significant texture versions that maybe I would not have asked in the course of an IBS centered conversation. So a lot of really good information from both of those tools, in addition to the conversation.
Dr. Megan RiehlThat's great to hear that's what you're using. We're also using, I agree, we have the luxury of time to be able to ask those open-ended questions. But in order to accumulate for research purposes more broadly, we have to be using what's available and then diligently assessing whether it fits for our patient population. The NIAS is something that the University of Michigan, we actually have a publication coming out in the Clinical Gastro enterology and Hepatology Journal very soon. It was just accepted, talking about the diagnostic performance of the NIAS in our DGBI patient population. So more to come on that, but it looks very promising and we're excited to share that.
That's awesome. So, Janelle, one more question for you. So there are patients that you might suspect that diet is really the trigger. How do you go about applying nutrition in a patient population that you know is at risk? We know GI patients tend to be at higher risk for disordered eating and ARFID, or at least there's lots of signals that show that. So, how do you approach that without inducing more food fear and restrictive eating patterns? Like how do you manage that in your clinic?
Janelle Smith, RDNOne thing that I think is really important is that we ask patients if they want a diet intervention. Or how they think it will impact their quality of life. I mean, as a dietitian, I'm constantly getting referrals for presumably a diet intervention. But when I tell people there are other options and I kind of lay out the different treatment options, there's a lot of times that they choose, I don't want to do a specific elimination diet or diet pattern, you know, that it's not right for their relationship with food. And it's really helpful when people acknowledge for themselves that it would actually cause more harm or stress or that it could bring back previous patterns that like measuring or paying attention to portion sizes. That tends to be a really triggering part of certain elimination diets, like the low FODMAP diet, of maybe disordered eating behaviors that are well in the past. So what does the patient want first and foremost? And also how are they eating already? Like I'm not gonna stack on multiple elimination diets if someone's already eliminating too many foods is just not best for their overall quality of life. And it may actually worsen gut symptoms just by having too little intake. Yep. I encourage more now than in the past small gentle changes first rather than big sweeping changes all at once. I think emerging data on like FODMAP gentle approaches, thankfully, is supporting this, is that maybe we don't have to do everything all at once. Like, how can we do the least restrictive option while still getting at good symptom management and preserving quality of life? So more and more I'll suggest certain swaps rather than elimination. Yeah, I love that. And using dietary supplements can be just so helpful in someone who maybe already has disordered eating so that I can take some emphasis away from manipulating the food or controlling the food and put it back on let's treat symptoms more globally.
Kate Scarlata, MPH, RDNLet's not continue to correlate food symptom, food symptom. So what kind of dietary supplements would you like what are some common ones that you'll My favorite is soluble fiber, which is funny because when I was younger I was like, oh fiber.
Janelle Smith, RDNDo you like a particular type of soluble fiber or just I think the best one is the one that someone will take and that there's some trial and error in terms of how people react. So you know, psyllium husk is so well studied, but in my experience, it's not always the best for people, whether they can't swallow it because they don't like the texture, or it actually worsens gas or bloating or constipation. So I may use psyllium, I may use hydrolyzed guar gum, acacia fiber, those are probably the most common. Enteric coated peppermint, I really love. Me too. I think it just feels like a nice cool hug for the abdomen. And then certain digestive enzymes, not just any off-the-shelf enzyme, but one that's really evidence-based, especially for fructan and galacto oligosaccharides, I think can be very helpful.
Kate Scarlata, MPH, RDNYeah, love all of those. I couldn't agree more, definitely. It's nice to have a few things out there that are not just restricting the diet further, but you know, adding some other symptom management tools. That's awesome. And you think 90% of people don't get enough fiber. So tackling some of that fiber in a way that is manageable for them works well. That's awesome.
Janelle Smith, RDNAnd telling people that not all fiber is created equal, because a lot of IBS patients associate worse symptoms with fiber. So it definitely requires education sometimes to get the buy-in and the understanding to try the soluble fiber.
Dr. Megan RiehlSo
Janelle has certainly started to talk about her role, the dietician role, which is, you know, so important and critical in this topic. And so, Madison, talk to us a little bit more about. We may talk from more of a dream team ideal approach here. We recognize not everyone is going to have access to all of this. And so we recognize that. But hopefully podcasts like this help people at least know where to look in the right direction. But interdisciplinary collaboration here: dietitian, gastroenterologist, primary care doctor, GI psychologist, how does this improve outcomes and what are they looking for? What are the roles here?
Dr. Madison SimonsI think I want to talk about this in the sense of like, if from an IBS patient specifically, what are the different roles that each person is playing? So a gastroenterologist is going to help us make the initial diagnosis. And hopefully at that point, they're going to have a conversation about one of the things that's inherent in IBS is this heightened visceral sensation, that we're getting more communication from the intestines up to the brain than we otherwise would expect there to be. The GI psychologist and the dietitian play different roles that feed the same goal, which is to adapt to this degree of visceral sensation. When people eat foods that have these fermentable carbohydrates, like what we've been talking about, they create that dilation in the intestines. The dilation isn't in itself necessarily the issue, but in an IBS patient, it's an issue because it's putting pressure on those highly sensitive nerves. The low FODMAP diet works because we're trying to reduce the amount of dilation that happens in the intestines. And so we don't put pressure up against those highly sensitive nerves. Whereas a GI psychologist, maybe we're going to use something like gut-directed hypnotherapy or talk with our gastroenterologist colleague about the use of neuromodulation that helps those nerves become a little bit less sensitive. So maybe we can eat foods that have the fermentable carbohydrates without producing as much symptoms. And so this is where that interdisciplinary collaboration comes in, so that the patient can make a choice as to what path do I want to choose, which interventions are most feasible for me, whether that's taking a medication, it's engaging in gut-directed hypnotherapy, it's engaging in an elimination diet, but we're all feeding the same goal and hopefully using the same language with the patient of why does it hurt so much when I eat? Well, this is why it hurts, this is what you're feeling. Can we come to expect and predict that in a little bit that doesn't enhance fear, but makes us feel comfortable to say, I'm like feeling the act of digestion. This doesn't feel good to me, but I know it's the process of food moving through my gut.
Dr. Megan RiehlThat insight and awareness and growing to learn your body and to again validate, we know you might not be comfortable, but these are normal processes that your body is going through. Your body is just extra aware of what's happening here.
Kate Scarlata, MPH, RDNYeah. And I think if you expect like the little bit of loading, the little bit of gas that might be a little bit uncomfortable but tolerable, because sometimes I think patients are like, I don't want to have any gas. I don't want to feel anything, you know, and it's like, well, we all do, and I know you're feeling it a little bit more highly, but kind of leaning into having maybe a little expectation that your body, you're gonna feel sensations, even though I know that they're a little bit more heightened and uncomfortable. But I think it gets to the point sometimes, and I see this in clinical practice, like I had so much gas. I'm like, was it painful? You know, and it's like, no, but I could feel it. And it's like, that's okay, you know. So there's that whole like expectation too on what's normal. Sometimes that's part of this whole thing too. And certainly they're more sensitive to the dilation and the fermenting carbohydrates, etc. But I think it's also managing the expectation a little bit too for them, or helping them with that. Certainly, pain isn't acceptable, but sensations are okay.
Dr. Madison SimonsEven the sense of like our diarrhea patients who they say, like, I eat, and it just like ran right through me. I went running to the bathroom and it all just came right out. And just giving them some information of like that's your gastrocolic reflex, and it's triggered by the act of eating. And we expect there to be this big push that makes you feel like you need to run to the bathroom. And so then it takes that edge off of like, oh, like how quick can I run to the bathroom? Is it gonna happen five minutes after I eat, or it's gonna happen 20 minutes later, so that they can play with their own physiology to feel confident in what's going on.
Kate Scarlata, MPH, RDNI love that. Play with your own physiology. All right, a little bit of exposure.
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This next question, I really I'm excited to like get both of your brilliant brains at work here. So you have patients, many of them we all see it, develop some level of food fear, which, you know, in many ways makes sense if food hurts. How do you approach reintroducing foods back into the diet? And why don't we start with you, Janelle? You know, in your practice where people are really like, gosh, I finally feel better, or, you know, I don't really want to try that food again, or et cetera, et cetera. What do you do? How do you approach it?
Janelle Smith, RDNFor the general patient, I feel comfortable taking, you know, stepwise steps, basically giving them reassurance and coaching and support of, you know, let's start with a smaller portion of this food, and therefore any symptoms would be less severe than if you ate them in the past. Or here's a different version of that food that I think is going to be even better tolerated, even though it has the ingredient that you're also afraid of. I think for some patients, some of that is enabling their vigilance. And so I might work with the psychologist to actually do more exposure and response prevention rather than giving a lot of reassurance over and over. But I think a lot of people do well with just like dipping their toe in the water. And then once they get more confident, they tend to go with it themselves. Definitely for the more cautious patients. You know, sometimes they haven't even tried half the things that I've suggested via our follow-up. But some people, you know, come back and they're like, I introduced everything and I did have symptoms, but it was okay. And I'm like, great, that's exactly the best case scenario.
Kate Scarlata, MPH, RDNWhat about? Can I just interject a little bit? Because I think of the patient that may have multiple things that have restricted. And is there some kind of mental algorithm that you would do for an IBS patient on they don't have wheat, they don't do onion, they don't do beans, they don't do fructose containing foods. Like, do you have a certain like this might be a little bit more gentle on them? Because I've seen different approaches where providers go straight on wheat. You're gonna do wheat first. And for me, the way I've always approached, right or wrong, I try to really select something that I think is gonna build confidence and we'll do it slowly, that we both agree upon the portion. And based on, say, whether it's fiber or FODMAP content or something that is a potential trigger for them, I'm gonna go with something that I think is they're gonna be able to do. Do you use that kind of algorithm or do you think just go for it or sometimes just challenge a little harder? You know, I'm just curious.
Janelle Smith, RDNI think it depends on the patient, honestly. I don't think that there's a one size fits all approach. I mention sometimes not going gradually because I have seen it, unfortunately, in certain patients who have more like obsessive compulsive tendencies or avoidance behaviors. I've seen it not be effective in the long run. That any stepwise approach we take, they're too afraid to do it or they think it causes symptoms and it is just not a productive process. Yeah, right. They don't move forward. Yeah. Yeah. But I do, especially to build rapport, I often go slower, especially because I'm wanting I'm like kind of pitching to the patient like that this is gonna work. I want it to be successful initially so that I can build that relationship that encourages them to be resilient when they don't tolerate it, because it's gonna be okay when they don't tolerate it. I usually use my dietitian brain to really see the pattern and be like, I think they're gonna be fine introducing this thing first, whereas I'm gonna save the harder things for later. I think that's what we're kind of well equipped to do is to see those patterns.
Kate Scarlata, MPH, RDNYeah.
Janelle Smith, RDNBut sometimes I'm going based on what's most important to the patient or what would make their life easiest. For example, if they are undernourished and they really just need calories, I might choose something that's more likely to deliver that than polyols. Like it's okay if we don't eat mushroom or cauliflower for a little while.
Kate Scarlata, MPH, RDNFor a little while. I got you. Yeah, it is a little nuanced. It's that art and science of nutrition, right? And these nuanced conditions for sure.
Janelle Smith, RDNAnything else to add or I think I try to help people kind of play out the tape. And this is, I think sometimes that usually the GI psychologist will do more, but just talking with patients of what is the worst thing that could happen and what are all the other possibilities rather than just the worst case scenario. And then what could we do if that does happen? How can we cope with a symptom if it occurs? So a lot of times patients will say, Oh, well, I guess it will last about 12 hours, and then I'll feel better. And I'll say, Okay, so could you tolerate that just for the sake of science or experimentation? And I think when a lot of people realize the worst case scenario, again, if they have the right neurotype, they are kind of relieved of like, oh, well, I could tolerate that. That's not the end of the world.
Dr. Megan RiehlYeah, I love that. All right, Madison.
So what does dive deeper into the psyche? What is our role there?
Dr. Madison SimonsI think I prepare patients on the front end. Like I expect your brain to feel afraid until we do this and until we accumulate enough experiences. And so it wouldn't be reasonable for us to expect you not to feel afraid and to feel like super ready to do food exposures. So if we go into it expecting that there's going to be anxiety, and so we do have a conversation around like how was your anxiety during the food preparation phase while you were eating afterwards, how were you monitoring your body? So that we can use those as some metrics too as they go along. Of like, is my anxiety about making an introduction, is that getting less as time goes on? Am I able to separate out, like maybe my symptoms were food related, but maybe they were not. In some cases, like if we think about eating pizza, patients say pizza bothers me. Well, actually, they've been eating pizza like at the bowling alley with their friends, and like it's a loud environment and it's busy, and and they were kind of worked up while they were eating pizza. So there's other pieces of this that are not just the actual foods that I'm putting in my body, but a big social component too. And sometimes we're creating that separation. When I'm creating food exposures with patients, I talk with them, like I almost don't really want your brain to recognize what it is that we've done. We're gonna take one bite and then we're gonna step away from it, or we're going to chain foods, something that you're already eating. We're gonna add something to it that's almost negligible. We're gonna drop one single spinach leaf into your smoothie, one spoonful of frozen riced cauliflower, like just something that doesn't even fundamentally change what it is that they're doing. To me, I don't even really care what it is that they're expanding at first. It's just this idea of taking some risk and doing it consistently. And once they've done that with a handful of foods, they feel more comfortable to expand beyond that. So I always start with what is already tolerated in the diet. Can I increase the frequency of that food? Can I increase the volume of it? And then expand diversity out from there in such a way, again, that the brain can't recognize what we're doing.
Kate Scarlata, MPH, RDNThat sounds tricky.
Dr. Madison SimonsI talk with them, I tell them that we are tricking your brain. That is exactly what we're doing. Because if we can get on board that like my brain is a little bit of this like tricky third party that's like not really part of me, then they don't feel so much like they've made this big failure. It's like, how can I work with this organ who kind of has a mind of its own?
Dr. Megan RiehlThat is awesome. The controller.
Janelle Smith, RDNYeah. Are we doing parts work now? Right, right. Yeah.
Kate Scarlata, MPH, RDNOh, that's so funny.
Janelle Smith, RDNSo now I'll talk about micro-dosing food. So I like how you sneak it in or microdose it. Yeah. Just to inoculate your system and your brain, really. It's yeah, you know.
It's interesting. I love it. And that does help build some confidence. So again, I'm curious from both of you how the act of anticipating symptoms can certainly sometimes drive amplifying or even contributing to the symptom experience in our patients with IBS. And so, what strategies do each of you use to help patients rebuild their confidence with food while reducing that anticipatory anxiety and really breaking that cycle of like food, fear, symptoms? I'll start with you this time, Madison.
Dr. Madison SimonsI think again, talking with them, like the only way you'll feel less anxious is if we do this a lot of times. And I use an exposure ladder as the model for this with low stakes exposures at the bottom and high stakes exposures at the top. But patients often think about this big jump from like, I'm eating all of my food that I've prepared at home all the way up to like, I'm gonna order a burger at a restaurant with 20 of my best friends, like that that's what food exposure looks like. So we talk about like we're only gonna change one level of risk at a time. And those risks could include like how far away from home I drove or how much of the food I ate, what consistency it was, did I eat ahead of time? Like all of these different things. And so we talk about like if my goal is to eventually eat a burger with friends, then at first I want to be able to prepare a burger at home and eat just one bite of the burger until I work my way up to eating a whole burger at home at the time of day when I'm least likely to have symptoms. Then I take my next step and I'm gonna order takeout, like a takeout burger from the restaurant, but I'm still only gonna eat one bite of it and then I'm gonna put it away. And I work myself up to eating the whole takeout burger at home. Then I'm gonna go sit at the restaurant. Now I'm gonna eat one bite of the burger again, and I'm gonna work my way up to eating a whole burger. This process really could take us on an infinite level of steps until I can sit and eat a whole burger with a community of friends around me. But this has taken like 20 iterations of eating the burger in such a way that, again, my brain has hardly recognized what it's like to take each incremental step. So if I have someone that's super resistant in Janella, you're describing like maybe it feeds into some of those OCD like tendencies, and we need to take a bigger step at a time. But for many people, they can say, like, that feels like really doable to me to eat one bite at a time.
Janelle Smith, RDNI may ask patients to actually do some grounding and noticing what's happening in their body. Do they have any signs of stress like heart rate or dissociation, floating, or anything that could help them be aware of their anxiety and trying to? Calm the anxiety prior to eating, actually. So for some people, that's some diaphragmatic breathing. For others, it's actually distraction, like putting on a TV show, right? Whatever really helps their nervous system to regulate can be helpful for that anticipatory anxiety. And then I think part of my previous answer of playing out the tape of what's the worst that could happen and how am I going to cope with it, maybe even identifying moments of resilience already in their life that can prove to them that they can feel anxious, they could have a symptom, and they will get through it and it won't be the end of the world. I think those are a lot of the tools that I'll use with clients.
Kate Scarlata, MPH, RDNI love that. It makes me think of Dr. Real says all the time, I can do hard things and like reminding our patients, you know, it might feel really hard, but they can do it in whatever manner seems to work with their partner.
Dr. Megan RiehlAnd also that when food has been a fear of yours, your nervous system, that brain that we've been talking about, it is lighting up your nervous system. It is saying, this is a thing to be fearful of, a threat to the body. And so diaphragmatic breathing, grounding, cognitive restructuring with some of that. I can do this hard thing. I might not be comfortable, but I can tolerate this. This food isn't as dangerous as my body thinks it is right now, can help to activate the body's relaxation response, which is just gonna set you up for calming the system down to be more receptive to some of this hard work that you're doing with eating. Absolutely.
So I want to talk a little bit about Janelle, this is for you. Dietary therapy. We know that in IBS, for instance, reducing FODMAPS is really strong evidence. It's not appropriate for everyone, as we all know. So how do you make that decision? Is there, and I'm thinking like almost an elevator pitch, are there like key things that you're like, this person is a candidate for diet therapy? And I know it's nuanced. So maybe there isn't an elevator pitch or a checklist, but like, are there some things that you think about, yeah, this makes sense in this person, maybe less so for this person?
Janelle Smith, RDNAbsolutely. I'm gonna try. I'm gonna rise to the challenge of the elevator pitch. I think for patients who do have food-related symptoms, because there are patients who have morning symptoms before they've eaten anything, or more stress or menstrual cycle-based symptoms. So for patients who having food intake-based symptoms, I'm thinking of how I can modify diet to help them. In patients who have the feasibility to do a dietary change in LA out here, we have a lot of patients who have food prepared for them on set and they don't eat anything other than what is provided for them. So if a patient is not actually able to do a diet change, I'm not going to suggest it right off the bat, or I'm going to discuss it in a lot more depth. And then also if a patient is kind of in an overall not coping well with activities of daily living, it's not something I will go to first and foremost. So if they're struggling to work, if they're struggling to take a shower, leave the house, it may not be within their means to do a really complex diet change. And I might want to do a more gentle approach or like a diet supplement approach. Absolutely.
Kate Scarlata, MPH, RDNAnd I think that speaks to also if there's significant mental health issues going on, severe depression and diet change. You know, that's not the top, right? So referral out and getting the right help for the bigger issue, right? First.
Janelle Smith, RDNAnd or focus on eating enough. Can you eat something that doesn't require cooking because you can't imagine washing the pot after you cook it? That's more important than right how many FODMAPs is in that food.
Kate Scarlata, MPH, RDNAbsolutely.
Janelle Smith, RDNAbsolutely.
Dr. Megan RiehlAnd I've even had patients where they excellent answer. Yes, I agree. But again, because they've gotten information online and maybe sometimes not from the most reputable sources, they think they're supposed to be incorporating way more foods than they actually need to. And so then that added pressure of I'm not getting my 30 different fruits and vegetables in a day, and I must not be doing this the right way because I'm still symptomatic. And then that just pressure and that anxiety and just kind of downright feeling of defeat. And so helping them sometimes to recognize that, like, hey, you're actually doing okay. And if and even building the confidence and building them up a little bit, that I've found to be a nice corrective experience for people that are working really hard to eat.
Janelle Smith, RDNKind of like how they say good enough parenting. Well, there's good enough eating. Yeah. We don't have to be perfect to be doing it well.
Kate Scarlata, MPH, RDNYes. I'm just thinking of the influencers and fiber maxing and protein maxing and all these things. And it it's a bit overkill. Yeah.
Dr. Megan RiehlMm-hmm. Mm-hmm.
Madison, you wrote a paper on food anxiety and IBD that I really enjoyed. And it's through this fear and threat lens and this idea that the brain can start treating food as dangerous, as we've mentioned, after these repeated painful or stressful eating experiences. So you've touched on this, but maybe you can dive a little deeper into why it's so important to create a sense of safety before recommending any of these dietary changes. And what does this look like in your clinical practice?
Dr. Madison SimonsI think it's so important to create that safety first because our brain is really vulnerable to making food symptom associations, just like we've referenced today. And so if I talk through with patients, like it's important to me to try to treat your visceral sensitivity first. And it's important to me that we address your symptom anxiety, your food-related anxiety, that's going to be one of the last things that we do together. If weight is a problem or malnutrition is an immediate problem, then we need to solve some things sooner. But I really don't want the brain latching on to more opportunities to create food symptom associations before it's ready to do that. And so even if in the beginning we are spending time looking at pictures of food or we're going to a grocery store and we have a timer that we're standing there for 30 minutes and we're looking at food and we're smelling food without actually ingesting it. I have people practice like, can you become a master of baking chocolate chip cookies without you ever eating it? Like, can you really perfect your dough? Things that just increase the sense of like I can be around food without it being dangerous to me if I'm not ready to start ingesting it yet. By the time that people like grocery shop for food, prepare the food, and then get to eating it, like we're probably all fooded out and we we may not even be able to actually eat at that point. So maybe we're preparing the food and putting it in the fridge and we're going to eat it later so that we don't have too much contact with food all in one sitting, or using convenience foods that are easily microwaveable so that we don't overextend what we feel capable of at the time. And so I think all of that is super important for the brain to feel successful about making dietary changes and just finding incremental ways to meet the patient where they're at.
Dr. Megan RiehlThat's so helpful. I think, gosh, when I think about our listeners, I find we get a lot of physicians that are tuning into this. And I think them hearing your perspective on this graded exposure almost, and and that it takes time, that this all we've stressed this, this all takes time. And I want patients to hear that, you know, if you've given this a try and you found it just didn't work, it likely just it wasn't enough time. And maybe we didn't chunk or break things down far enough. I'm feeling a lot of hope from what you're saying, both you and Janelle, because I know there are so many people out there listening that have not had their food fear explained in these ways. And people are gonna feel really validated by this. I hope so.
Kate Scarlata, MPH, RDNYeah, there's a lot of people out there, and it's we're all trying to figure this all out in real time, right? So, and in what works for different people, and we just really need to work together as a community because we're, you know, see so much of this in the GI space, and patients are trying to navigate it and aren't always in the right hands, and really it's like throwing someone down a staircase, you know, they just not really getting the help they need. On
the other hand, I wanted to talk to you, Janelle, a little bit, because I certainly see this in practice too, and I know probably all of us do. When patients attribute every single thing that they eat or every little challenge, they feel like it's a trigger. And how do you help them distinguish sometimes? Some of that is just a fear-oriented thing, or some of it may be very true, but it's a nuanced conversation. And I just wonder how you handle it when it's like, no, I can't do that, I can't do that, I can't do that. And it doesn't really make sense scientifically. So you're trying to help them understand I'm not sure it's all true triggers.
Janelle Smith, RDNSome patients I think resonate with the idea that the symptoms are related to eating in general, not what the food that we ate is. So movement, distension, fullness, activation, those are normal physiologic processes, right? That move things through our gut. And that does not mean that we're allergic to what was in that food or we're intolerant or that it's causing harm, right? So when you said the word earlier, sensation, I loved that because it has such less negative connotation than symptom or you know, a variety of other words, is can I notice the sensation without assigning a judgment to it of this is wrong or I'm doing something wrong that made this happen. And I'll try to encourage them to look at longer trends rather than very short-term trends. You know, there are certainly times where I can see a really short cause and effect, but that tends to be how our lizard brain thinks of everything. But it's not all cause and effect, right? Like even food poisoning is rarely the thing that you just ate. It's the thing you ate 24 hours prior. So let me kind of be the one as the trained expert to identify the patterns and try to let go of predicting every single thing that caused the symptom.
Kate Scarlata, MPH, RDNYeah.
Janelle Smith, RDNI think it's also really important to distinguish between discomfort or sensation and harm so that people can observe less judgmentally what's happening in their body and try not to assign it to something they're predicting. And I'll explain that their brain wants to assign it to a reason so that they can control it and fix it and solve it. But that hasn't worked so far.
Dr. Madison SimonsYeah.
Janelle Smith, RDNSo what if we do it differently? I think what came to mind as you were talking about this too is like by nature of there being a disorder of gut-brain interaction, it means that the signals coming from my gut aren't entirely accurate. And so my brain doesn't know how to respond to those. So hunger may come as pain or it may come as nausea. And when my brain receives pain or nausea, my instinct is not going to be to eat, even though my body might be screaming at me to eat. I'm gonna probably avoid eating at that time. The body screams louder, but the brain doesn't understand the signal it's being given. And so a lot of the work in food is like disentangling these mixed-up signals about hunger and fullness and like time to poop or not. And that's part of the job, too.
Kate Scarlata, MPH, RDNYeah. We need you guys. I love this conversation. I was thinking what I was gonna interject here was just I think patients really appreciate that, like, let me be the nutrition expert here in your care. So many patients have been trying to be their doctor, their nurse, their everything. And when you can say, I got you, and you establish that rapport, it's like taking this huge elephant off their back that they've been carrying. And so there's so much about that rapport and trust in that therapeutic relationship in the work that you really require that, especially I think in this disordered food fear area. You know, patients really deserve that. And I think it's such a relief when a provider says, I'm gonna handle that part for you now, you know, when they've been trying to drive the bus and do all the other things too.
Dr. Megan RiehlThere's something really validating and knowing that, oh, you know what's going on with me. My brain is not the only brain that does this because a lot of times they feel like they're alone in this. And or they've found something on the internet that tells them they're the same as somebody else, and and the thing that that person tried worked for them and it didn't work for that person that's observing that. So going back to how Madison started, you know, the patient is right and needs to be heard and believed, and we believe them. Yeah, and we do that brain is just tricky. The brain is a big, beautiful, tricky trickster. Yes, those brains, those silly brain.
All right, we're gonna pick your brains a little bit more. We really thank you for this conversation, but we like to end with a speed round to get to know you just a smidge better. We know you're both brilliant, but let's find out a little bit more about you. So I'm gonna start with you, Madison. What's one thing you've changed your mind about over the course of your clinical career?
Dr. Madison SimonsProcessed foods. Ah. I can explain more. I used to be against them, but I do not feel that way anymore, especially in my gastroparesis patients. It's our entry point, and we build from there.
Dr. Megan RiehlYeah, I like that. What's a piece of advice you used to give that you'd phrase differently today?
Dr. Madison SimonsI used to think every meal and every snack needed to be properly proportioned in macronutrients, and I do not abide by that as strongly now.
Kate Scarlata, MPH, RDNWe're happy about that.
Dr. Megan RiehlYes, yes. Are you an early bird or a night owl? I am an early bird. All right. What's one small daily habit that makes a big difference in your own well-being?
Dr. Madison SimonsI practice doing things imperfectly or inefficiently as often as I can as a very type A individual at baseline. The more I practice doing things poorly, the more flexible I become.
Dr. Megan RiehlI love that. Coming from a psychologist, you're doing some good work. Exactly. What is one food that is always in your fridge?
Dr. Madison SimonsCookie dough. The cookie dough I spent many years perfecting without actually eating it, which is why it's part of the challenge for patients. But I do eat the cookie dough now.
Kate Scarlata, MPH, RDNOh, yay! I love cookie dough. All right. So let's move over to you, Janelle. So, what's one thing you've changed your mind about over the course of your clinical career?
Janelle Smith, RDNThat diet therapy shouldn't be used in anyone with an eating disorder history. I think it is so much more nuanced than that. And I have just seen such beautiful things happen to the most resilient people who are ready for that at that point in their life.
Kate Scarlata, MPH, RDNThank you for saying that. What's a piece of advice you used to give that you'd phrase differently today?
Janelle Smith, RDNI used to talk more about malnutrition because it makes so much sense to me, but I've learned that people have many projections and conceptions of their own about that word and tend to feel blamed or ashamed or something when I use the word malnourished. So I tend to talk more about needing to eat more consistently or fuel our body more frequently, or, you know, we're already getting so many good foods, but I think we're just still shy of the energy needs that we have. So we're still running a little bit on fumes, honestly, a lot more euphemisms just to help people get out of whatever shame or blame they feel around the word not eating enough, basically. Yeah. I like that. So you're an early bird or a night owl? I am neither. I love my sleep. I get like nine hours every night. So 10 p.m. to 8 a.m.
Kate Scarlata, MPH, RDNLove it. Love that. I'm kind of the same. I definitely need my sleep. What's one small daily habit that makes a big difference in your own well-being?
Janelle Smith, RDNBeing in the sunshine. I really need to feel it on my face and my chest. And it just is an ultimate, like immediate mood boost.
Kate Scarlata, MPH, RDNWell, it's a good thing you live in LA. You're getting that. Good move there. And lastly, what's one food that you have in your fridge at most times?
Janelle Smith, RDNAlways have lactose free milk. It is just the most consistently tolerated thing and satisfying. I remember a doctor once tried to get me to give up my lattes and I just couldn't imagine doing it. So, you know what? I learned how to make a latte at home.
Kate Scarlata, MPH, RDNPerfect. This has been fantastic. Really can't thank you both enough. I think it's really going to be an important episode that will really be uh supportive for a lot of people out there because we know there's a lot of people that that are experiencing a lot of food fear and you know, not really sure how to get the help they need. So this has been really helpful.
Dr. Megan RiehlThank you for all of your research, your patient experience, and sharing a bit of your journey. Thank you guys for having us.
Janelle Smith, RDNThank you for having this discussion.
Yeah, no, it's awesome. To our listeners, subscribe, like, share The Gut Health Podcast.
Dr. Megan RiehlThank 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.