MCAS: A Whole-Body Condition Through the GI Lens (with guest Dr. Zac Spiritos)

MCAS is one of those diagnoses that can make it feel like your body is telling a dozen stories at once—and no one is listening. If you're experiencing GI symptoms alongside flushing, hives, brain fog, fatigue, palpitations, medication sensitivities, or a persistent "fight-or-flight" feeling, this episode is designed to help connect the dots without oversimplifying your experience.

In this episode, we sit down with gastroenterologist Dr. Zachary Spiritos to unpack mast cell activation syndrome (MCAS) and explore the connections between immune activation, the gut-brain axis, and symptoms that can affect nearly every system in the body. We discuss why patients are often dismissed, how stress and hormonal changes can amplify symptoms, and what a realistic, stepwise treatment approach looks like when the evidence base is still evolving.

In this episode, we discuss:

• What mast cells do and why MCAS can affect multiple organ systems 
• Why MCAS is often missed in siloed medical care and mislabeled as anxiety 
• Barrier dysfunction, environmental triggers, and intestinal permeability as a useful framework 
• Histamine as one mediator among many and why antihistamines are not a perfect treatment for all
• Links between MCAS, IBS, visceral hypersensitivity, dysautonomia, and POTS 
• Hypermobility, pelvic floor dysfunction, and neck tension as common clinical clues 
• Treatment principles including start low and go slow, informed consent, and layered individualized plans 
• Dietary approaches patients commonly explore, including low-histamine, low-FODMAP, and gluten-free patterns 
• Hormonal influences across the menstrual cycle and during perimenopause
• The role of sleep, nervous system regulation, and stress reduction in decreasing symptom reactivity 

If you've ever felt like your symptoms don't fit neatly into a single diagnosis, this episode will help you make sense of the bigger picture and explore what healing can look like when the gut, immune system, and nervous system are all part of the conversation. 

References:

Ford AC, Staudacher HM, Talley NJ. Postprandial symptoms in disorders of gut-brain interaction and their potential as a treatment target. Gut. 2024;73(7):1199-1211. Published 2024 Jun 6. doi:10.1136/gutjnl-2023-331833

Walker MM, Warwick A, Ung C, Talley NJ. The role of eosinophils and mast cells in intestinal functional disease. Curr Gastroenterol Rep. 2011;13(4):323-330. doi:10.1007/s11894-011-0197-5

Pasricha PJ, Talley NJ. Functional Dyspepsia. N Engl J Med. 2026;394(2):166-176. doi:10.1056/NEJMcp2501860

Find Dr. Spiritos on IG @drzacspiritos

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Transcript

Welcome To MCAS And The Guest

Kate Scarlata, MPH, RDN 0:03

Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health-conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food, and the gut. Come join us. We welcome you. Hello, friends, and welcome to The Gut Health Podcast. We are your hosts. I'm Kate Scarlata, GI dietitian.

Kate Scarlata, MPH, RDN 0:40

And I'm Dr.

Dr. Megan Riehl 0:41

Megan Riehl, a GI Health Psychologist. In today's episode, we are diving into the science and growing awareness surrounding mast cell activation syndrome. This is also known as MCAS. This complex immune condition happens when mast cells release excessive inflammatory chemicals like histamine, tryptase, and more, triggering symptoms that can affect nearly every system in the body. It is complicated.

Kate Scarlata, MPH, RDN 1:11

It is complicated. So from chronic hives and digestive issues to brain fog, anxiety, fatigue, and even rapid heart rate, MCAS or mass activation is often misunderstood because its symptoms can mimic allergies and other chronic illnesses. Researchers are also exploring links between MCAS, long COVID, dysautonomia, and connective tissue disorders, making it an increasingly important topic in modern medicine. In this episode, we'll break down what mast cells actually do, why inflammation can spiral out of control, and how patients are navigating a diagnosis and treatment in a condition that still leaves many unanswered questions.

Dr. Megan Riehl 1:56

So whether you're personally affected, caring for someone with MCAS, scouring the internet for information, or simply curious about the emerging science in this health topic, this conversation will offer insight into one of the most talked-about immune disorders today. We've also got a fantastic expert guest, gastroenterologist Dr. Zac Spiritos, who treats a wide range of gastrointestinal and liver disorders with specialty interests in irritable bowel syndrome, functional abdominal pain, motility disorders, and dysautonomia. His practice also sees many patients with postural orthostatic tachycardia syndrome, or POTS, and mast cell activation syndrome. He is also well-versed in gastrointestinal complications associated with hypermobility syndromes like Ehlers-Danlos syndrome or EDS. Dr. Spiritos is passionate about patient education and a holistic approach to GI health. He integrates nutrition, lifestyle modifications, and gut brain therapies into his practice, and we will certainly dive into this in our episode. Outside of medicine, he and his wife stay very busy with our two young children and they enjoy being outside, playing basketball, and exercising whenever he gets a chance. Welcome, Dr. Spiritos.

Kate Scarlata, MPH, RDN 3:21

We are so glad you're here. And we always start our podcast with a little myth busting. So can you share a myth you'd like to bust about mast cell activation syndrome or MCAS?

Dr. Zac Spiritos 3:34

It's really common. It's not a rare thing.

Kate Scarlata, MPH, RDN 3:37

Yeah. I know. Mainstream is starting to catch up, right?

Dr. Zac Spiritos 3:42

Yeah. I mean, I think there's a lot of idiopathic conditions out there that we were taught just happen, primarily to women, that we just say, you know what? You're gonna have to see a pain doctor for this and a therapist to deal with the pain, and maybe take a neuromodulator. But beyond that, we're not really gonna figure out much more than this. You know, fibromyalgia, interstitial cystitis, complex regional pain syndrome, vestibular migraines, IBS, right? And so there's these conditions that when you look at the data, like there's inflammation here, albeit it's not overt, like these aren't whopping ulcers on endoscopy. It may be just, you know, more white blood cells on a urinalysis, but there's no bacteria, right? So people have signs and symptoms of UTI. So just because we may not be elegant enough yet to detect these things, it doesn't mean it's not real. And there's, if you go back decades, like there's suggestions that inflammation really exists around some of these quote unquote

Why MCAS Gets Dismissed

Dr. Zac Spiritos 4:50

idiopathic conditions. And when you take that next step, you realize that, man, there's a lot of mast cells in a lot of these conditions. I think that's where we need to just we need better conversation and more data around why this happens and how to go about fixing it.

Kate Scarlata, MPH, RDN 5:04

Yeah, and helping a lot of people that are suffering and jumping doctor to doctor. It's tough out there. So, how would you describe mast cell activation syndrome to a patient? And you kind of talked about why it's controversial a little bit. So we don't need to dive so much into that, but why don't other doctors really know about it? So this is kind of a two-part. How do you explain it? And why don't you think some doctors really are just not nailing it?

Dr. Zac Spiritos 5:33

Yeah, I mean, I'll go into the why we don't recognize it. It's because we weren't taught about it, right? Like we go into IBS, like as in a GI fellowship, we learn about peptic ulcer disease and Crohn's disease and cancer. There's nothing on IBS, but it's the most complex condition out there, right? Right. I defined it as a neuroimmunologic condition. And, you know, there's that's a bigger conversation. And why don't we know a lot about it? It's because it's probably controversial, but it mainly affects women, right? I think this is a white guy disease. We'd have figured this out decades ago. And maybe that's a controversial take, but ever since, you know, going back a hundred years, right? Women's issues were blamed on hysteria, the wandering uterus, right? Like there's roots in history that are very disturbing, that albeit we are more aware and woke today, but I mean, there's so many, you know, women who go to the ED get less pain medications than men, right? Like we see this time and time again. And oftentimes in mass cell activation syndrome, and we can get into the why. You know, people have symptoms beyond their GI tract or beyond one symptom, right? And so we're siloed in medicine. So when you go to GI clinic and you have IBS, they're not trying to hear about the brain fog and the fatigue and the vestibular migraines and the palpitations that don't make sense, right? It's under the guise of, oh, you must be anxious, right? Because this is what anxious people get, right? And I had a panic disorder for like 10 years through medical training. I didn't have a single GI symptom, none of this, right? So it's not anxiety. It is a real set of symptoms that has inflammation behind it. Anxiety certainly makes it worse, but I think it's easy when someone comes in with symptoms across multiple organ groups to say, oh, they must be anxious. And they also are intolerant of a lot of medications. And I was taught, or the culture was, oh boy, this patient's coming in with 11 allergies to medication. They're a little bit, they're probably not easy to do. It's like, no, they want to tolerate medications and they just can't, right? And so it's this construct of what this person is, and it must be superindutorial, must be all upstairs, right? But it's not, it's not, it's inflammatory. And I have hundreds and hundreds of patients that back this. And so I think that's why it's dismissed. And we're not taught to think across multiple organ systems. Like GI doctors look at the lumen, right? Right. They're lumen doctors. But it turns out that most people that walk in a GI clinic with symptoms, you're not finding the reason within the lumen, right? So what is it? What else is there? Well, it's the nervous system and the immunologic system, right? And so I spend most of my day trying to understand what happens in the lining of the GI tract with all the immune cells here and how they communicate with the nervous system, because these are all neuroimmune conditions.

Dr. Megan Riehl 8:20

So many of our patients are getting siloed, you know? And I think it's not necessarily by the choice of the physician. I think that's how our system is set up these days, where you are the gastroenterologist, you are the cardiologist, you are the endocrine specialist, you are the psychologist. And MCAS really is one of those diagnoses or conditions where having time really makes a big difference because it is so complex. And that is a luxury that a lot of physicians just don't have these days. Right. Which then the patients suffer.

Dr. Zac Spiritos 8:59

Yeah. I was taught that the patient gets two things they can talk about, right? Because there's just not enough time in 30 minutes to get through this. But you know, truth be told, they do have a whole log of symptoms because they do. And it's not okay to say you have two because it's minimizing them to two symptoms within the specialty that you're treating them. But to your point, that's how we were taught. So I put no blame on any particular physician if they're, you know, having a difficult time managing these folks. And it can come off as dismissive when you're just like, I just don't have enough time for this. But you know, I think providers are set up to fail and patients are set up to not be adequately taken care of in the current system that that exists, which is really tough.

Dr. Megan Riehl 9:38

So when somebody gets to you, how do you deliver that diagnosis of MCAS? Like, what's your pitch to them? I know, like, I have one and we think about gastronaut, like the pitch for how to understand IBS, the pitch for starting to understand the complexities of a chronic disease. What is your pitch for helping a patient begin to understand MCAS?

Mast Cells Barrier Dysfunction And Triggers

Dr. Zac Spiritos 10:00

Yeah. So I do think it's an very much environmentally triggered condition. I've never seen people feel so poorly in one environment and feel so great in another one. I tell people that the mast cells are, they're just doing their job. They get all the blame, but they're just doing their freaking job. Mast cells are sentinels in the body. They are positioned at every environmental barrier within our body. So sinuses, respiratory tract, GI tract, bladder, and what they're evolutionarily, they were meant to look out for threats. So viruses, bacteria, parasites, and also wound healing. But in mast cell activation syndrome, they're reacting too much because they're getting too many signals. And I do think that it's an issue with barrier dysfunction. That we have these epithelial barriers in our body and the nasal passages and the lungs and the GI tract. And when those get compromised, the immune system just sees more. And I don't think it's any surprise that since the Industrial Revolution in the 1960s, there's been an explosion of atopic conditions and autoimmune conditions. The immune system is freaking out, right? The growing body of data that, and I'm no environmental scientist, but you know, processed foods, polysorbate from ice cream, exhaust, pesticides, like they can mess with some of these epithelial barriers. And for some people, it's irreparable, right? And some people, when they move to different countries, they feel so much better than they do here with MCAS. And so I don't think it's a mast cell problem. I think it's a barrier function problem. And that's kind of how I phrase it, and that's how I talk about it. And a lot of folks also have hypermobility, so they have a lot of loose joints, but they also have very overcompensating musculature. So hypermobile Ehlers-danlos is virtually overlapping with MCAS, almost 100%, in my personal experience, albeit we're kind of still understanding all of this. And so they wonder why they have really tight cervical muscles. So they have pelvic floor dysfunction when they've never, when they're 25, female or male, because not only do they have loose joints, but they have muscles that are trying to overcompensate for the laxity of connective tissue ulcers. They have the muscles are really tense up here because it's trying to hold the head up and the pelvic floor is really to so people often describe they can't get everything out. So I try to at first describe, you know, what MCAS is, in my opinion. But I'm I may not be right. I'm I think we're all figuring this out. So I use the data that I have at my disposal, but recognizing that in six months, I may be telling a whole different narrative. So I take what I say with a ginormous grain of salt, yeah, and then I try to explain like why they feel this way in their bodies and how it's all connected and why they get small fiber neuropathy in pots and how this all plays together. And then I dive into like the therapy plan, which is environment and diet and sometimes medications as well. Because once you create the construct that this is the mast cell just doing its job in the world that we live in, it sets the stage for the therapies that we talk about.

Kate Scarlata, MPH, RDN 12:50

And stress too.

Dr. Zac Spiritos 12:51

Stress, right. And so that I'm so you know, corticotropin releasing hormone, there's a very receptor for mast cells for CRH. So, you know, when we talk about like GI psychology, I've always wondered like, why does it work in IBS? Same for low FODMAP, right? And so why got low FODMAP by way of mast cell active mast cells create increased intestinal permeability, right? Like, why does GI psychology, why is it so important in IBS? And I really think it's CRH on mast cells. Like I really think that connection is real and dialing us down from sympathetic to parasympathetic tone. And I've like treated people's MCAS just by using therapy and guanfacine, and the reactivity calms down a lot. And so it's all connected and it's just trying to figure out what kind of angle to take. But yeah, so stress is so important.

Kate Scarlata, MPH, RDN 13:38

And that diagnosis that like takes forever to get and you're bouncing around, like that's not stress-provoking.

Dr. Megan Riehl 13:46

Yeah, no, it lights up that I just think about like the poor nervous system is just lit up like the New York skylight. It's just lit up. And so anything we can do to kind of dampen some of that activation. And that's that is why some for some patients they may benefit from our brain gut behavioral therapies, but oftentimes not just that. So, as you said, like there's so much that we're learning, and that's why we appreciated you coming on because you are somebody that is, you know, overturning some of these puzzle pieces and individualizing care based on the science that we currently have, which is so ever evolving. So let's talk about another masked cell mediator, histamine. I think if you Google MCAS and histamine is gonna come up here, it's been hiding in plain sight as a driver of complex multi-system

Histamine Limits And Treatment Clues

Dr. Megan Riehl 14:40

illness. And so if you believe this, why has mainstream medicine been so slow to catch up with all of this?

Dr. Zac Spiritos 14:49

There's data. There's data, right? If you look back, there's data on cyproheptadine in IBS, right? There's data on what's another antihistamine that's been studied? You know, ketotifen is a mast cell state alert, but as an antihistamine, like there's been kind of groundwork here. So to put histamine in context of mast cells, like mast cells secrete over 1300 chemical mediators, and histamine is a pain, like an absolute pain. And there's receptors all over the place, like the brain, the cardiovascular system, the obviously the GI tract, the nerves. Like I've seen people's like nerve pain get better with frickin' pepcid. So antihistamine is always a nice place to start, but there's also like 1,300 chemical mediators that mast cells secrete, like prostaglandins and leukotrienes and interleukins, right? Like tons of inflammatory signaling. So antihistamines can be helpful, but it's, you know, some people are like, you know, I didn't respond well to antihistamines. Could I still have MCAS? I was like, 100% you could, right? If you could treat this with medications, you could pick up in aisle 2 from CVS, like this would be a piece of cake, but it's not. But the question is, why are we late to this? I don't know. I don't know. I mean, I think it goes back to like there's symptoms all over the body, right? Which doesn't really fit a paradigm that we have outside of maybe like lupus, right? Or TB, where it's like I can do everything. We don't have great diagnostic data points. Like I used to order like $2,000 with a lab work on everybody, and it's be like, this isn't good. And I still think we have one test. And they'd be like, well, then why do you make me go through all those jumping hoops and like urine tests and blood tests? Like, that's just what we do. We order tests. And I was like, it's not, we don't have yet a construct to work up these patients. So I don't even do it anymore. So we don't have good data points. It affects people that have historically been overlooked and dismissed, and it affects various parts of the body and can easily be dismissed as being anxiety related. So it's like the perfect storm of, you know, gaslighting is like implies intent, but certainly like it's being overlooked and not yet fully recognized by everybody.

Kate Scarlata, MPH, RDN 16:47

I think of it like SIBO and MCAS. You know, it's like, I mean, you see it now. There are people that just are adamant that bacterial overgrowth of the small intestine does not exist. And then you see people get treated and feel 100% better, and clearly there's something there, right? And I feel like MCAS is in that same camp. You know, we just got back from Digestive Disease Week, and it's still quite controversial, you know, and some people are fully on board or partially on board. We're starting to see signals like out of Bill Chey's lab with Prashant Singh and FODMAP and mast cell activation and intestinal permeability. So things are popping, but there's definitely camps. It seems like almost like it's controversial, which is unfortunate, I think, for patients because some patients are getting, you know, some level of gatekeeping. Like I don't believe in that diagnosis. And it's like diagnosis.

Dr. Zac Spiritos 17:42

And I was like, tell me this then. What else is going on? And you can't use the word anxiety.

Kate Scarlata, MPH, RDN 17:47

Right.

Dr. Zac Spiritos 17:48

An alternative diagnosis, anything, just go for it. What is episodic multi-system condition that in someone who has hypermobility, just give me one thing that does this? And the answer is there's nothing, right? Jay Pasricha up at Mayo.

Kate Scarlata, MPH, RDN 18:03

Yeah, love it.

Dr. Zac Spiritos 18:03

I've never met him. I'd love to meet him one day. He published a paper at, I think it was a New Journal of Medicine about functional dyspepsia. He's like, look, there are eosinophils and there are mast cells here. And like the eosinophil mast cell connection is just fascinating. So a lot of people with MCAS also have eosinophilic esophagitis, eosinophilic gastritis, like mast cells, when they start freaking out, they're like their best buddies, the eosinophiles. Like, get on over here. And then you realize that this all makes sense. Like you just immunology is an immunologist's job. GI is a GI doctor's job.

Kate Scarlata, MPH, RDN 18:36

Yeah.

Dr. Zac Spiritos 18:37

This is both. And so until we can get merging of the minds, it's going to be continue to be left siloed.

Kate Scarlata, MPH, RDN 18:43

Nick Talley's another one too. He's written a lot about it and he talks a lot about the role of mast cells and eosinophils in a variety of, you know, quote unquote functional and bowel disorders. So he's definitely getting the word out. I think people are starting to sink their teeth into it a little bit, but then connecting it to mast cell activation is like another extra leg. There was a really good paper, and we'll we'll share it too, that looked at certain IBS medications that also had antihistamine effects like tricyclic antidepressants and ebastine and other drugs that are working in IBS, but they actually have antihistamine effects. So that's another connection. And that was a really good paper done by, I think, Alex Ford and Heidi Staudacher and colleagues. So that's an awesome paper, and I'll post that one too.

Dr. Zac Spiritos 19:33

I studied under the great Doug Drossman, and he was a lot of neuromodulators. And I was always wondering, why did these work?

Kate Scarlata, MPH, RDN 19:41

Right.

Dr. Zac Spiritos 19:41

And it's tough to have the dialogue with a patient because they're like, you're using an antidepressant. I may be stressed about me symptoms, but I am not depressed. And then that was one of my first inroads to mast cells. Like, what do these medications do? I was like, they have pretty significant antihistaminergic properties. And it's like, well, maybe I don't think it's all it does, but yeah, that's a lot of these medications, you know, mirtazepine, you know, similar thing, seroquil. Yeah.

Kate Scarlata, MPH, RDN 20:03

Yeah. There's been some really interesting viral trends going on in TikTok and Instagram looking at, you know, combining antihistamines, H1, H2 blockers, and getting some attention and various disorders. So, like so many therapies in IBS, I see many of these are grassroot efforts, patient sharing with patients. Not always the best way to get educated in some ways, right? We want to see some research, and there really seems to be a failure here in formal research in this area. Would you agree with that?

Dr. Zac Spiritos 20:41

Oh, 100%.

Kate Scarlata, MPH, RDN 20:42

Yeah.

Dr. Zac Spiritos 20:42

I think it starts with we don't have diagnostic data points. I think there's a couple different cants of how you even diagnose MCAS. So, how do you run a study with something that has it's controversial that it even exists, let alone we don't have diagnostic data points. So, how do you even pick your consortium? How do you pick your cohort? And it's so hard to do. And anytime you try to publish it, you're going to run into issues of how do you even know they even have MCAS? Right. Like it's just, it becomes really, really fraught with issues when you lay out the logistics of trying to run a research study.

Kate Scarlata, MPH, RDN 21:14

True, but we don't have a biomarker for IBS. And somehow they seem to get around that as well. And, you know, so are they all IBS patients? Who knows? And, you know, you got to start somewhere. So we can't just be waiting for a biomarker, right?

Dr. Zac Spiritos 21:31

100%. I'm fully on board with running, you know, I'm collecting my own data right now on various therapies because the goal is to phenotype these patients.

Kate Scarlata, MPH, RDN 21:39

Yeah.

Dr. Zac Spiritos 21:39

Which is really hard. And I've started to kind of get a sense of like where people live. And there's I've identified like five different phenotypes, but it's all based on gestalt and gut feel, which is I'm just a guy in a room thinking about this all day, which is like inherently fallible. It'd be nice to be able to kind of be like, all right, well, if someone presents with X type of Their symptom cluster is this, then they will respond more to XYZ.

Dr. Megan Riehl 22:05

But that is the way some of this research works, right? Is that you're collecting enough people coming to a place where you're starting to obviously use the science, but humans are end of ones no matter what. And especially we're learning that with this. And so kudos to you for collecting the data and coming up with some standardization of how you're doing that to help start to get this path a little bit more run down as opposed to like path over here, path over there, path over here. It's important. I did that with our GI Behavioral Health program many, many years ago, was just, I'm like, I am seeing a lot of these patients. Let me collect data. Some of the work that we're doing is, you know, again, just kind of personalization and observation too, because we get so many different comorbidities of patients. I'm not just seeing a patient for IBS very often. I'm seeing patients with a lot of different things happening for them and trying to find the treatment plan that works best. So it's, I think,

Hypermobility POTS And Overlapping Syndromes

Dr. Megan Riehl 23:10

going to be very exciting to see what you and other people that become really interested in this and help people. We have to move the field honestly forward, and that's going to happen. And this is the baby. MCAS is kind of the in its infancy in terms of where we're at with this diagnosis and treatment.

Speaker 23:30

What complicates things even more is that these folks are disproportionately affected by GI conditions that I was taught I'd never see in my entire career. So by definition, if people have hypermobility, they're at higher risk for median arcuate ligament syndrome, superior mesenteric artery syndrome, May-Thurner disease, which is only thought to happen in postpartum women, but you see it in 18-year-old guys. And there's no data or even a pattern recognition that we're taught of like how these conditions look, and they overlap tremendously. So like I'm realizing that everything that I was taught was rare, it just happened to people with hypermobility. And so it's like my first thing to look at is are you hypermobile or not? Because it completely changes the menu of things that you're you're looking at. Like when someone has nausea, you got to think something different. If someone has pain, like it's not probably not H. pylori. We can't look for H. pylori, but it's probably something different. And so that's, I think, what I'm trying to actually put out there as well is that we should really be better at identifying hypermobility because it just changes the entire narrative and it colors all their symptoms differently.

Kate Scarlata, MPH, RDN 24:38

Yeah, we're definitely seeing some awareness on that. We had Brennan Spiegel on and he was talking about just shaking a patient's hand and like click, click, click, and asking about hypermobility. And I'm definitely doing that more. It's like, were you our gymnast or dancer? Like you super flexible, like, yeah, why? I'm like, let's get you worked up and you know, see what's going on. Pull the thumb back. Pull the thumb back. Exactly. Exactly.

Dr. Zac Spiritos 25:05

Most sensitive question is tight cervical musculature and tight pelvic floor.

Dr. Megan Riehl 25:11

Mm-hmm.

Kate Scarlata, MPH, RDN 25:11

Well, that's like every woman with IBS. But I'm like, is it stress? Because you're so tight. But yeah.

Dr. Zac Spiritos 25:18

I don't know. Does stress, I mean, again, I bring it back to like I was stressed for so long and I never had any of these symptoms. Does stress cause that? I don't know if stress causes like, unless you're just like, maybe you're walking around like this all day, but like they really feel like they're just, it's so tight here. Their head is too heavy for their head. Ask those questions. Like, that's the most sensitive screening that I've I've found yet, as opposed to the Beighton score. And the EDS Society, Laura Bloom are doing amazing things. Chip Norris down in Charleston are doing amazing things to rewrite the definition of like how we approach HEDS. But that's, you know, from I don't think I've seen anybody without hypermobility in like a year in my clinic. And so those are questions that I might be the most sensitive.

Kate Scarlata, MPH, RDN 25:56

It's a big overlap.

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Dr. Megan Riehl 27:11

Well, another overlap we've mentioned this earlier is IBS. And as we said, it's certainly a diagnosis without an organic biomarker. How much do you think could be rooted in immune dysfunction or mast cell activity when we think about IBS?

Dr. Zac Spiritos 27:26

That's a good question. You know, I have my issues with the term IBS. I really do.

Kate Scarlata, MPH, RDN 27:31

Me too.

Dr. Zac Spiritos 27:32

Yeah, it's just such a bad name, guys.

Kate Scarlata, MPH, RDN 27:35

Yeah.

Dr. Zac Spiritos 27:35

Mainly because, you know, people usually fall into the IBS bucket when their endoscopies are normal, right? And so without a proper look for SIBO or exocrine pancreas insufficiency or fat malabsorption or small bowel Crohn's or alpha gal, whatever, right? But if someone has done their due diligence and ruled out those things, and I would also argue a lot of people with MCAS have SIBO but don't respond to SIBO therapy, and that's a different conversation. That a lot, a lot, like if you step back in clinic and you say, Hey, do you have symptoms outside of your GI tract? Like how much time you got, right? There are people that exclusively have GI symptoms, but like, you know, the post-infectious IBS crew, like why do we think that happens, right? It's mast cell-driven intestinal permeability. Like it's it's what happens with a lot of these folks where they're living their lives, maybe they have some background symptoms, and then boom, something happens. Right. COVID, vaccine, pregnancy, something that is very immunologic, and then nothing's ever the same, right? And so I think a lot. Assuming the diagnosis is true, I mean, there's so many papers on mast cells and IBS folks. Like there's not only in quantity, but where they're located close to nerves, how much they degrading. Like the studies have been done. I mean, there's like six of them, but they're out there, right? Yeah. But I I think all of them? I don't know. Yeah. I don't know. You guys think?

Kate Scarlata, MPH, RDN 28:57

Yeah, I mean, it's funny, you don't know until you know, right? So once you kind of get it and you're connecting the dots, I can remember it was like, uh, I don't even know how many years ago, a while ago, about 10 years ago, I started noticing like certain patients had a lot of facial swelling or hives, showing me things. And I'm like, there's something here. This is a different kind of patient than you know, someone just coming in. And I I hate to use the word just because bloating and pain, abdominal pain can be terrible to live with, but not really having these other additional symptoms or patients that maybe didn't benefit from some dietary intervention, need a little bit more, still looking. And just once you see it, you see it. And it does make you like, hmm. And fortunately, we have we do have a mast cell clinic in Boston, but it's very, very difficult to get in, and even more difficult now because the word is starting to get out and they just can't handle the number of patients. And that's a whole other conversation. It's hard to find someone. You know, I send them often to allergists, immunologists, and it's like, oh, we don't believe in mast cell activation. Okay. Thanks.

Dr. Zac Spiritos 30:12

Another thing that's really hard is that a lot of patients complain of brain fog and fatigue, and doctors have no construct for what that means.

Kate Scarlata, MPH, RDN 30:20

Right. Right.

Dr. Zac Spiritos 30:21

And so when you do this for a while, I know exactly what to do with brain fog. I know exactly what to do with fatigue. But it's like, well, are they iron deficient? And outside of that, not sure what it says, right? It must be stress. You know, how's your sleep? And and so, and you know, obviously sleep's really important, but they complain of certain things that we just don't even know what to deal with. You know, they they bloat tremendously. The bloating in MCAS is like out of this world. I'm gonna say something else controversial. Anybody in the DGBI world, I'd love to have this conversation. Abdominophrenic dysynergia gets better with mast cell therapies. I have dozens of patients who I put on a therapy that I'm not even gonna say because it's even gonna cause more controversy. Pre- and post pictures, it gets better with mast cell therapy. And I'm sure there's an APD subtype that gets better that is truly like a coordination issue. But uh you look more broadly, all these patients have MCAS. And this is the first time I'm saying it out loud because I realize I feel like I'm gonna step on some toes here. But hey, it's my experience, and I will uh die on that hill. I mean, I've like I've you know, well, it's patient attestations because I'm gonna write it up because I have patients with like their pre-pictures where they show me pictures of their abdomen that as soon as they eat, it's not bloating. I'm so I mean what APD is, but it's a swelling, right? You look more broadly, they have tons of other symptoms. But they eat and they just like whoosh. And it's I've never seen anything like it. And I used to think APD, and you know, I send it to diaphragmatic

IBS Mast Cells And Severe Bloating

Dr. Zac Spiritos 31:50

breathing, and I wonder if diaphragmatic breathing because it kind of, you know, mast cells can get worse.

Kate Scarlata, MPH, RDN 31:56

Benefit, yeah.

Dr. Zac Spiritos 31:56

Yeah, so you it, you know, helps people kind of engage that parasympathetic tone, and that's the way you get at it. But goodness, I've I've seen people turn around with mast cell therapies. But yeah, it's again, I'm not dying on any.

Kate Scarlata, MPH, RDN 32:08

I mean, I don't You're not gonna die on a hill.

Dr. Zac Spiritos 32:10

I think there's something inflammatory and immunologic here that we have yet to really put our finger on.

Dr. Megan Riehl 32:15

Yeah. And that's the thing, right? It is exciting and it gives people another potential option besides the breathing, that they have to find a provider that has trained in Barcelona, who knows the new protocol, or is a GI psychologist that has, you know, like it's not a straight pathway for so many people. So if you can write that up and you can show your data, I think the world will welcome that because we just need more treatment options. Exactly.

Dr. Zac Spiritos 32:45

There's a lot of that are evidence-based. Make them a little bit nuts, right? Because they're like, you did what to this person? And I like, I get it because everything is off label. And you know, the therapies that we're sometimes using are crazy. But it's all about matching pathophysiology with how medications work, right? And so protose GLP is a perfect example, right? At face value, it's like, what are you doing? But like if you understand or if you think about how we believe mast cell activation happens and how GLPs work, it's like it kind of makes a lot of sense. GLPs are one of the things our intestines do to patch up tight junctions, right? And there's data for that. And there's a reason why they're looking into it to treat Crohn's disease and UC and why people with IBD tend to do better on a GLP than not on a GLP, right? It gets wacky, but in a world where we don't have good solutions because there's been no studies on this, right? Then you have to reach into a bag of tricks that is very unconventional.

Dr. Megan Riehl 33:41

And is it fair to say, I think it's important for our listeners to know that you're not in a traditional medical setting anymore either. I say this because you are spending a lot of time with your patients. I always say, as a psychologist, I get an hour with patients and I look at that as a luxury because I get to dive a lot deeper into the biopsychosocial of an individual and gather information to inform things. And in a multidisciplinary team, I can share that with my colleagues, where when they just talk to somebody for 10 to 15 minutes, it's hard to get that full clinical picture. So, you know, I think as somebody who has a nice medical pedigree yourself, and then to come from academics and move into the way in which you're practicing medicine, this is quite unique. And I just want to highlight that to be able to inform the medical decision making that you're doing.

Dr. Zac Spiritos 34:40

100%. We have a lot of informed consent, right? And I love academics. I love academics. You know, I was a duke trained GI doctor. Like I love this stuff. I need more time with my patients. All I do is clinic. I used to scope. I don't scope. All I do is hang out with patients and try to figure this frickin' thing out, right?

Kate Scarlata, MPH, RDN 34:59

Yeah.

Dr. Zac Spiritos 35:00

And I am committed to understanding this freaking thing. So all I do is read about the compliment system and bradykinin and intestinal permeability. Like, all I do is try to figure this out and try to find tools. But like when we talk about like MCAS clinics, like the hard thing about it is that these patients also have hypermobility and chronic pain and POTS and dysautonomia. Are you telling me that they need to see an allergist, a POTS cardiologist, a PM and R doctor? Like, so what we try to do is we do, we treat POTS, we treat dysautonomia. Like I put people in IVIG for autoimmune gastropresis where their stomach doesn't move. Because it's all a package deal, right? And some people are lucky enough to have ME/CFS as well, where they have chronic fatigue and they crash after they do some things. And that's endothelial dysfunction. Like there's layers to this, but like it's so hard because it's kind of they have it's one thing, but if you're in the traditional system, they're now seeing three doctors, each of whom hard to get in with, right?

Dr. Megan Riehl 35:54

Hard to get into. Yeah. Yeah, exactly.

Dr. Zac Spiritos 35:56

I started treating POTS in as a GI doctor. Alexis Cutchins has been like my mentor, who is like my cardiology attending in residency. And the local POTS doctor, I started seeing a ton of these patients, the local POTS one at UNC cardiologist started as like training me as well because like he was booked out for years, right? And my patients were like, Yeah, we got him pooping again and maybe less inflammatory, but they can't stand up with their heart going to 120 beats per minute. So it's like, well, how can we really satisfy the need here? It's like, well, let's try to do all the above.

Kate Scarlata, MPH, RDN 36:25

Yeah.

Dr. Zac Spiritos 36:26

And so that's also why we spend a lot of time with patients. And I branched out because truthfully, I get 80 messages, inbox messages a day, right? Like there's no way to do this in traditional practice unless it's built a very specific way with a different whole billing system. It just needs time.

Dr. Megan Riehl 36:42

Yeah. So we'll see what happens. I think there's room for both. I mean, we need both models. That's the reality. We need both models. And we have a long way to go in the current medical systems. But thanks for sharing that. I just think it's it's an important kind of point to make and and highlight.

Dr. Zac Spiritos 36:59

This needs to be done in academics because I charge cash, right? Yeah. Right. And that's the only way, if you're not doing procedures, the only way you can pay the bills is if you and you spend this much time. And so academics, it needs to happen to serve a lot of these folks.

Kate Scarlata, MPH, RDN 37:15

Yeah. You need a mix. I know in Boston the the Mast cell docs were covering everything had to be at least run through them. Like they were the top dog provider for the patient, which I thought was really important. Like they got the understanding that this is a systemic disorder. And so everything had to be like whatever medication, whatever they were thinking, the different providers had, they were the top dog, which was kind of interesting to see. So I want to talk a little bit about hormones, estrogen, and their potential immune modulation. Do you think clinicians are connecting those dots dramatically as far as mast cell disorders and fluctuations?

Dr. Zac Spiritos 38:00

Because what about testosterone? What are we even doing?

Kate Scarlata, MPH, RDN 38:03

Oh, I'm just, you know, we just wrapped up a woman's health month. So we're just talking estrogen. No, yeah, talk about hormones. I just mentioned estrogen, but I'm curious. Well, too. True, true.

Dr. Zac Spiritos 38:16

You know, there's IBS symptoms, whether

Off Label Tools And Care Models

Dr. Zac Spiritos 38:20

you attribute it to motility or pain sensitivity, really fluctuate with the cycle. And perimenopause is a uniquely challenging time for people with mast cell activity.

Dr. Megan Riehl 38:28

Amen.

Dr. Zac Spiritos 38:29

I guess I know, I know. So, yeah, I mean, so if we're all bringing it back to mast cells, and not everything is mast cell activation syndrome, but you know, so actually let's talk about motility first. So estrin seems to kind of be the go button, progesterone seems to be kind of rather the stop button. So constipation can get worse during the luteal phase when progesterone picks up, and then after the period, you know, bowel habits can can pick up again. But you know, from a visceral hypersensitivity, which I think is just mast cell-driven nerve sensitivity via like TRPB1 and various other pathways. So estrogen seems to be rather inflammatory for mast cells and rather destabilizing, where progesterone is rather stabilizing. Testosterone is stabilizing as well. There have been people, uh, young folks, or I think those are the case studies of folks who have transitioned from female to male and their mast cell or their IBS gets a lot better. Once they transition around kind of superphysiologic for their birth gender, for testosterone, their symptoms get a lot better. Yeah, I mean, so we see this a lot, and it offers an opportunity to potentially use hormone therapy to help with symptoms. It's not that, you know, it'd be great if you just put everybody on hormone therapy and everybody gets better, but it's not that easy. It's still very much, it's a big decision to put someone in hormone therapy. It has to be the right thing for them. And, you know, I usually bring it up in conversation if someone has a lot of catamenial kind of patterns for their symptoms, like, man, like everything's good until the luteal phase, and I'm just everything is really, really challenging. We also think PMDD may be also a mast cell phenomenon as well.

Kate Scarlata, MPH, RDN 39:59

Yeah. Well, that's why they're pushing the H1, H2 blockers on TikTok for PMDD.

Dr. Zac Spiritos 40:05

Oh, okay.

Kate Scarlata, MPH, RDN 40:06

Yeah, oh, that butt went really, really, really viral. Yes.

Dr. Megan Riehl 40:11

We thought we found the answer.

Dr. Zac Spiritos 40:14

For some, it may be really, really awesome for some, H1 and H2. But yeah, there's again, it's not, it doesn't work for everybody. But yeah, so you know, sometimes just stabilizing hormones through the month is beneficial because the mast cells don't particularly like changes in those hormones when they're primed. And so sometimes just like the huge fluctuations during the month can be particularly challenging. And sometimes putting people on like a bioidentical progesterone can be a nice option, especially if they're dealing with a lot of insomnia and anxiety. But some people react poorly to it. So everything that's mast cell ward is just truthfully so unpredictable. You just kind of try things, but you know, testosterone, you know, postmenopausal, women who have a lot of fatigue, decreased sexual drive, and a lot of pain, checking testosterone DHEA levels is something that we should probably start doing because as long as one knows how to do it responsibly, but it's another angle to take because we also as providers don't really get trained in hormone therapy as it pertains to like quality of life for women in paired menopause. So just another another angle there. But yeah, so hormones have to play a big role.

Kate Scarlata, MPH, RDN 41:11

And so you're seeing, I believe you kind of said this earlier, but do you feel mast cell activation is more common in women than men? Definitely.

Dr. Zac Spiritos 41:22

Estrogen.

Kate Scarlata, MPH, RDN 41:23

Yeah, estrogen.

Dr. Zac Spiritos 41:25

I think my son has MCAS. But I think when he's 13, I think he's gonna, he has all these kind of, you know, kind of behavioral symptoms where they're like, oh, it's just he's gonna grow out of it and he's really itchy all the time and he's a little dermatographism. And but I think when he hits puberty, I think if things are gonna get a lot better. You know, these mast cells, I think they just get primed by the environment, right? And some people like, why does barometric pressure really set people off? There's nothing inherent about barometric pressure. Mast cells can detect barometric pressure, but I think when they're particularly primed by the environment, that's when it flips it off. I think estrogen is rather priming, but I think it's also much more nuanced than that. I think I am, I think it's a gross oversimplification.

Dr. Megan Riehl 42:03

Yeah. All right. So as we wrap up this really interesting, thought-provoking, we've been a little provocative. We've had these, you know, we appreciate you getting on the hill and at least sharing your experience. Give us kind of a clinical idea to, if you'd like, one or two patients that you have seen. What's the scenario with MCAS and what does it look like in your clinic to work with them?

Dr. Zac Spiritos 42:32

Yeah, so I'm trying to phenotype folks because the data is reliably unreliable in terms of trying to figure out what people will respond to. So I think there's a kind of a, for lack of, I haven't like really thought about how I title this, but there's a intestinal permeability flavor of this where people have a lot of GI symptoms. They usually are more on the diarrhea side, but it's a little bit of both diarrhea and complication. They bloat a lot. If you ask her if they bloated, they're like, oh yeah. Everybody's had SIBO tests, everybody tests positive, they treat the SIBO, it doesn't get any better. And I we can talk about why I think that happens, but it's speculative. These are the chronic SIBO patients. They also have a lot of brain fog and a lot of fatigue. Food sensitivities, maybe some joint pains here and there, but it's mainly like brain, gut, some joint stuff, can't sleep very well. And that's one phenotype painting with a humongously broad brush here. And I always have the same dialogue about the environment and diet, which Kate, I need to talk to you about diet. Yeah, we will see how diets work for what people, because some, you know, non-Celiac gluten sensitivity, I think, is a mast cell phenomenon. Some people really do better on a gluten free

Hormones And Symptom Swings

Dr. Zac Spiritos 43:40

diet, some people do better on a low histamine diet, some people do better on a low FODMAP diet. And I've yet to figure out which of the three works for who. I think the more autoimmune phenotype works or gluten free works for the more autoimmune phenotype, but that's kind of a different conversation. But in any event, so yeah, we'll talk about diet and we'd have a big conversation about stress and sleep and what do we do. For people dealing with chronic debilitating symptoms are invariably, I have a lot of stress. Yeah. If you're not doing this already, we should probably make a plan for it. Like, is it CBT? Is it GI psychology and working with someone like Megan? Is it, you know, there's brain retraining things like DNRS and primal trust that people have really benefited from? I haven't done that myself, but I've heard of these. There's various different things. Is it taking a walk outside? Is it meditating? It's always getting good sleep. So these are things that we talk about. And then we talk about, you know, different pharmacotherapies as well. And that's kind of a bigger conversation. And I hesitate to be like, just use this because it's certainly not a one-size-fit-all approach.

Dr. Megan Riehl 44:35

When you described that first phenotype, I like to normalize for people that wouldn't be shocked if you were depressed. I wouldn't be shocked if you've been navigating all of this on your own, or you've seen God only knows how many specialists about this. It would be shocking if you weren't depressed or and and maybe, you know, of varying degrees, right? It might be mild depression when you're doing pretty well. It might be no depression if you're doing okay, more severe depression when all of this is storming. So, yes, like stress, but I couldn't envision somebody not benefiting from a consult with a psychologist to just normalize that this is a lot and it's not gonna get better overnight either. No, but it can get better. It can get better.

Dr. Zac Spiritos 45:27

That's a great point. Everybody should have that in their corner. I will also say that there's something about chronic inflammation that really tips people towards fight or flight. I always ask people, what happens if I can't even dropped a pan behind you? Everybody's gonna jump through the roof. Everybody is not everybody, a lot of people are on edge. This physiological, and it's like this some people have kind of intrusive thoughts and worry, but a lot of people are just this physical anxiety that's so incredibly unique. So I try to support people from the immune side, the nervous system side, whether that's like pots or calming down that nervous. There's like very, you know, guanfacine is a really nice option. But again, I don't want to paint with a broad brush, but also like addressing their pain and their nausea. And so it's like, because you don't want to do a million things simultaneously because it gets overwhelming. And a lot of people with MCAS don't respond well to medications. You're like, they're the people that doctors like, no one's ever responded this way to a medication. Like this couldn't have happened. That's part and parcel of having MCAS, unfortunately. So it's starting low, going slow, understanding the process, and a lot of communication. Like we I talk to patients a lot because that's the only way to kind of make sure that we're on the right path. And if they you know, I misread the situation, I get things wrong, right? And then we say, I'm so, so sorry. And then we like, let's refocus and then kind of maybe take a different angle here.

Dr. Megan Riehl 46:40

It totally humanizes the experience of having a chronic illness or of just medicine that we have to find providers that we trust. We have to use the science that's available, we have to instill hope for people, and also the realistic expectations of the journey here. It's gonna be a journey. And I think it goes a really long way for patients when they have a provider that can be really true and honest about all of that, and also that hey, I'm gonna be here. We may make mistakes, we might not be where we want to be yet, but we're working through this. That's I think maybe the special sauce of this.

Kate Scarlata, MPH, RDN 47:24

Well, I think too, like the whole notion of having, and I do this in my practice, like this is plan A, but I have plan B, C, D, and E, maybe F G. You know, and it's like, so they know that okay, if I don't get better after A, like, no worries, we've got more in the toolkit. That's leaves them with that hope. And one other point I wanted to make, and you know, this patient population, stress is always on the top because they've gone through so much, and it is stressful, you know, to both of your points. You know, I see a lot of people with IBS, but in MCAS, it's like the top of the list is really trying to figure out ways to mitigate their stressors because living in fight and flight all the time. It might be just saying no, all of the things. But even though I'm a dietitian, it's on the top of my list with these patients because it does help them. I see it repeatedly.

Dr. Zac Spiritos 48:24

You have to address it because it's hard to make a lot of progress if that isn't shored up first.

Kate Scarlata, MPH, RDN 48:28

Yeah.

Dr. Zac Spiritos 48:29

Talking about, and you know, none of these patients sleep well. None of them do. They always wake up at two in the morning in a panic. That's also like a secret mast cell question. Do you wake up at two in the morning in a panic? And there's something weird about you know, cortisol's anti-inflammatory, right? And cortisol's lowest at like two in the morning. And I wonder if like that nadir of cortisol is when people like their mast cells are the angriest, but I'm making that.

Kate Scarlata, MPH, RDN 48:51

Interesting.

Dr. Zac Spiritos 48:51

Fascinating.

Kate Scarlata, MPH, RDN 48:52

You know, you're gonna be one of these, you're gonna go down as one of those gurus that like I remember when H. pylori was like, it's a bacteria, it's not stress that you're getting ulcers or all these other things they thought ulcers were caused by, you know? And now it's gonna be this mast cell activation thing that you're living through probably a little bit. Like, what is he saying? He's using what for what, you know? But it changes medicine because we have to go outside of the box when the answers aren't there sometimes.

Dr. Zac Spiritos 49:23

I think I see the patients who have seen 11 doctors, right? And so it's like, well, what other answers do you have, right? This isn't first line, right? I'm not, you know, you have to do your due diligence and make sure that nothing else is going on. But I think that's also the counterargument. It's like, well, what else do you got?

Dr. Megan Riehl 49:38

Right. Right.

Dr. Zac Spiritos 49:39

You know, more neuromodulation and more, like it's just, you know, sometimes the DBGI, it's just like, it's just like, well, let's just do more neuromodulation. It's like at some point in time, you can't do more neuromodulation. There has to be another hand to play here. And it of course worked for so many people. I don't want to minimize that. But there's also that's like me, the defensive side of me being like, well, that's why we try X, Y, Z, but doesn't always work. But yeah, so the other phenotype of patients is the more classic allergic type folks who have more non-allergic rhinitis, a lot of hives, a lot of vasomotor symptoms of tons of flushing, tons of seasonal allergies. But they also have like, they're not the classic allergy patient because they also get the brain fog, they get the fatigue, they have some joint pains, they're they're hypermobile as well. So that's the more like allergic type phenomenon. I think most people in GI clinic will see the former patient. But this patient fits more of the kind of the allergy type. And that's probably the like the second biggest subtype that I see. And that's more obviously you have to all the things we spoke about are very important, like diet, lifestyle, stress, sleep. But then there's just like a different toolbox that you theoretically use there.

Dr. Megan Riehl 50:43

Well, we'll look forward to the paper. Those phenotypes, the write-ups. You know, you gotta get the stuff out there to provoke the conversations. I'm sure there are some medical situations you walk into and you're like, all right, I'm ready. Let's go, let's talk. Like, you're okay.

Dr. Zac Spiritos 51:00

I will have patients whose family are all physicians.

Kate Scarlata, MPH, RDN 51:03

Yeah.

Dr. Zac Spiritos 51:04

Like, okay.

Kate Scarlata, MPH, RDN 51:06

Here we go.

Dr. Zac Spiritos 51:07

Let's talk about what I think is going on here. And like, but I'm also not defensive. I don't get angry about this stuff. Like, I'm not gonna, if you think I'm doing a bad job, I want to hear about it. I want to know about it so we can talk about it. I think you could critique me for like over-pathologizing when things just maybe anxiety. Like, I get all that critique if you want to, but I am just open for dialogue and thinking that maybe there's some stuff out there that we don't quite get yet. And that's where I'm trying to live without overstepping and being too aggressive, too, like an irresponsible. So it's always informed and consent, always start low and go slow. I don't want anybody to think that I'm just like going rogue and doing crazy, crazy stuff without, in my hope, the patient understanding exactly what the intent is here. And we're watching things so incredibly closely to make sure that we're we're moving in the right direction.

Dr. Megan Riehl 51:56

I think that's a great wrap to this, I think, just beginning of questions that we might ask you. And we may have to bring

Phenotypes Stress Sleep And Next Steps

Dr. Megan Riehl 52:05

you back again next year to see where we've moved the needle. But before we wrap up, we like to do a speed round. So we get to do that with you. And I'm gonna ask the first question here. What's one word your friends would use to describe you?

Dr. Zac Spiritos 52:22

I think goofy. I mean goofy. I have to be very serious about a lot of things. Like I'm obviously serious about my job and this stuff, but I try to keep things pretty light, even when they're pretty tough.

Kate Scarlata, MPH, RDN 52:33

I'd say that's pretty evident from your Instagram accounts. We'll actually make sure we link that as well. So coming from the dietitian, I'd like to know what one food is always in your fridge.

Dr. Zac Spiritos 52:45

I don't know if this counts, but iced coffee.

Kate Scarlata, MPH, RDN 52:48

Iced coffee.

Dr. Zac Spiritos 52:49

I abuse iced coffee.

Kate Scarlata, MPH, RDN 52:52

We won't hold it against you.

Dr. Zac Spiritos 52:54

Yeah, don't look at my bell had my stool, my Bristol stool table.

Kate Scarlata, MPH, RDN 52:57

I was gonna say, uh oh.

Dr. Zac Spiritos 52:59

This is I go on podcasts and they're like, Zac, what do you what do you eat on a day-to-day basis? I was like, don't ask me. This isn't why you invited me on here.

Kate Scarlata, MPH, RDN 53:05

All right, nutrition consult is next.

Dr. Megan Riehl 53:08

That's right. That's right. Okay, so this may tell us even more about you guilty pleasure TV show or movie.

Dr. Zac Spiritos 53:14

Oh man. So I have young kids, and so I kind of end up watching what they watch a lot. There's a show, Is it cake?

Kate Scarlata, MPH, RDN 53:21

Oh, yeah.

Dr. Zac Spiritos 53:23

These are the most talented people I've ever seen.

Kate Scarlata, MPH, RDN 53:26

I'm not familiar with this. Is this a kids' program? It's not, but kids love it.

Dr. Zac Spiritos 53:32

So Kate, they will take a whole room, a living room, a set, and they say, pick what's real and what's cake. And random objects, the couch will be cake, and you don't even know. And then they cut into it. And it's like, oh yeah.

Kate Scarlata, MPH, RDN 53:46

What?

Dr. Zac Spiritos 53:47

Saying it out loud, it sounds pretty silly, but holy cow, it's the best.

Kate Scarlata, MPH, RDN 53:52

Yeah. Okay. I'm I'm checking that out soon. All right. So, what is an instant mood booster for you? Iced coffee.

Dr. Zac Spiritos 54:02

I think playing basketball is my I love playing basketball.

Dr. Megan Riehl 54:05

Yeah, I like playing basketball too. All right, your UNC roots there.

Dr. Zac Spiritos 54:10

That that probably Yeah, I went to Duke and UNC, so I'm a little bit, but I'm a UNC.

Dr. Megan Riehl 54:15

You're pulled. You're pulled. Okay. And then cook at home or eat out.

Dr. Zac Spiritos 54:20

Man, I like to eat out. I get really excited about eating out. My kids don't eat any of my cooking. So I think when I eat at home, I'm associating with just complaining about the meals that my wife and I put on the table. So eating out at least takes shifts the pressure away from us.

Dr. Megan Riehl 54:35

Are you like my family? We're the first ones for dinner, you know, 4 p.m., 5 p.m. eating out, or and then it's obviously different on date night, but you know, we are like early bird specials as family going out. Yeah.

Dr. Zac Spiritos 54:48

Yeah. My dinner is, I start getting hungry on 4: 45 now. So yeah. Great. It's just like it's just the whole restaurant's for you.

Dr. Megan Riehl 54:55

That's right. It is a private dining experience. Yes. Perfect. Yes.

Dr. Zac Spiritos 55:00

Yeah. Plus, no one wants to be around my kids when we're eating. It's just too crazy.

Kate Scarlata, MPH, RDN 55:05

They're a little goofy like you.

Dr. Zac Spiritos 55:07

Very goofy.

Dr. Megan Riehl 55:10

Well, this is amazing. We appreciate your time. We know that you

Speed Round And Closing Requests

Dr. Megan Riehl 55:15

have very graciously talked about our podcast before. And so to have you on, we had a lot of fun today. And we're really appreciative of the work that you're doing. So thanks for joining us. Of course.

Dr. Zac Spiritos 55:27

Such a big fan of you guys. So thanks for all you do.

Kate Scarlata, MPH, RDN 55:29

Oh, thank you. So please like and subscribe and share The Gut Health Podcast.

Dr. Megan Riehl 55:37

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 GutHealth Podcast, where we'd love for you to share your thoughts, questions, and experiences. Thanks for tuning in, friends.