The Eating Disorder-GI Connection | GI Dr. Jordan Shapiro, RD Brittany Rogers & psychologist Dr. Kelli Rugless

In this episode of Gut-Brain Therapy, the Nerva podcast, three GI experts tackle one of the most challenging presentations in clinic: the patient who arrives with both GI symptoms and disordered eating patterns, where it's rarely clear which discipline should lead or where to begin.

Gastroenterologists and APPs may reach for medication first and refer dietary care on. Dietitians and nutritionists may question whether behavioural strategies fall within their scope. And psychologists or physiotherapists may struggle to treat symptoms rooted in the gut. The result is a patient who can fall through the gaps between specialties.

Together, the panel walks through how each discipline assesses and treats the ED–GI patient, why coordinated cross-disciplinary care improves outcomes, and the actionable takeaways you can bring into your own practice right away.

Expert panel:

Jordan Shapiro, MD, MS – Gastroenterologist

Brittany Rogers, MS, RD/LDN, CPT – Registered Dietitian

Kelli Rugless, PsyD, CEDS – Psychologist / Eating Disorder Specialist

Disclaimer: Nerva is a self-guided program that may help people self-manage and live well with their diagnosed disorder of the gut-brain interaction. Nerva has not been evaluated by the FDA, TGA, MHRA or equivalent regulatory bodies. Users are directed not to make any changes to their prescribed medication or other type of medical treatment without seeking professional medical advice.

Find out more about Nerva here:
http://www.nervahealth.com?utm_source=ig&utm_medium=other&utm_campaign=pc

Gut-Brain Therapy podcasts are adapted from Nerva webinars, sign up for our next one here:
 www.crowdcast.io/@mindset-health

Transcript

SPEAKER_00 0:00

Braincut behavioral therapies like hypnosis and cognitive behavioral therapy have great efficacy in a controlled study, which is what you'd read on PubMed. So, should braincut behavioral therapies perhaps be offered earlier than listening to a NERVA podcast.

SPEAKER_01 0:14

Clinical conversations about the science of gut brain disorders and the real people we care for every day. These podcasts are created from our free webinars, which you can sign up for at the link in our bio. This week we have some news. NERVA's gut brain therapy program is now available at no out-of-pocket cost for eligible U.S. patients with original Medicare through the new CMS Access model.

SPEAKER_03 0:42

Hi, I'm Emily. I will be the host tonight. So starting off, we have Dr. Kelly Rugglis, who is a licensed health psychologist and certified eating disorder specialist. She is the owner of a bi-coastal private practice, Flourish Psychology, where she specializes in women's mental health. She's a native of Southern California, but currently lives in Maryland with her husband and three sons. Next, we have Brittany Rogers, who is a registered dietitian and the founder of Roman Well, an insurance-based telehealth private practice specializing in IBD and other gastrointestinal conditions. And then lastly, we have Dr. Jordan Shapiro, who is an internist and gastroenterologist and founder of Gentle GI PLLC, a trauma-informed gastroenterology practice in Houston, Texas. Dr. Shapiro's clinical areas of expertise include trauma-informed GI, disorders of the gut-brain interaction, pelvic floor disorders, GI complications of eating disorders, and transition from pediatric to adult GI care. And all three of these speakers are co-authors of the textbook Comprehensive Nutrition Therapy for Co-Occurring Gastrointestinal and Eating Disorders, which I have here. So they will talk a little bit more about that at the end. But without further ado, I'm going to hand it over to our speakers.

SPEAKER_00 1:57

Fantastic. Thank you, Emily, and thanks to the folks for ANURVA and everyone attending for the opportunity to speak to you. So here's our agenda for today. We're going to talk real briefly, like one slide briefly, about the uh intersection of eating disorders and GI symptoms. We'll do an overview of the case study that we'll follow throughout the course of the talk. We'll start with our interdisciplinary input on how we would assess the patient, give a little background on eating disorders, but that may be new to a lot of the people listening to this, give our interdisciplinary input for interventions for the patient in the case study, and then wrap up with our patients' outcomes and clinical pros. With patients with eating disorders, 98% of them have GI symptoms. And a lot of those are disorders of gut brain interaction or DGBI like irritable bowel syndrome, which many of you are familiar with. The link between the two is bi-directional. So some patients start with GI conditions, Crohn's disease, celiac disease, and the symptoms from the GI conditions lead to changes in their eating behaviors, and that can be a slippery slope and lead to disordered eating or eating disorders. Similarly, patients with eating disorders have complications from changes in their gut motility and sensation, where they can get a lot of pain, constipation, and a variety of other symptoms. So it's a two-way street. There's a greater risk of eating disorders in patients with diet-related chronic health conditions, self-led dietary exclusions, and GI-focused dietary therapy. So anything where we're using diet to treat GI conditions, we need to be cautious, and we'll talk more about that. And then eating disorders and disorders of gut brain interaction have a lot of shared risk factors like early adverse childhood events and trauma and a variety of other things as well. So this is our case study. It's a 38-year-old cisgender mow with non-stricturing iliocolonic, which just means the end of the small bowel and beginning of the colon or large intestine Crohn's disease, which is an inflammatory bowel disease. They're in endoscopic remission on this medication in fliximab every eight weeks, which is standard dosing. It's a biologic medicine that treats the inflammation and Crohn's disease. Their symptoms right now that they come in with are four bowel movements per day that are Bristol, stool form scale five and six. So I think four is the middle and kind of normal. One is rock hard little pellets, and seven is watery. So they're a little on the looser end than normal. Abdominal pain, gas bloating, GERD or heartburn symptoms. They have a history from a diet standpoint of intermittent fasting using a low FODMAP diet and the autoimmune protocol. They're complaining of binge eating and worried about symptoms during work. Their exercise history, they work out seven days a week. And their goals with the visit are to reduce their GI symptoms and binge eating and to lose weight. So we're going to go through each of our perspectives on how we kind of assess this patient and we'll go from there. And I will start. So initial thoughts for me in a patient with inflammatory bowel disease is to identify is the symptom or are the symptoms that the patient is presenting with related to unchecked, uncontrolled inflammation, or an alternative diagnosis to treat and alleviate the symptoms regardless of what they're coming from. And I think the initial observations that struck me with this patient are that this is a patient who has new symptoms but was previously really well controlled and concerned a bit about some of the at-risk eating behaviors, the multiple different diets they've tried, the goal of weight loss, and the exercise behaviors. Some key questions: how long have the symptoms been present? Any clear triggers that might have set off these symptoms? Some patients on medicines like inflictomab have a wearing off where every eight weeks isn't enough and they have to change to doing every four weeks. So did when did the symptoms start in relationship to the last dose of medication? Are the symptoms similar to how they presented when they were first diagnosed? Many patients flare in the same way that they initially presented. Any blood in the stools, if there is, that goes against this being something like IBS and is more concerning for inflammatory disease or infection. When was the last evaluation for inflammation? We'll talk more about that at any time. The symptoms seem to get better. So inflammation doesn't rest at night when we're sleeping and doesn't tend to rest on weekends either. Some testing, I won't go through all these, but most of the blood work was normal. Um, things checking for anemia with the complete blood count, some nutritional deficiencies, celiac disease, the C-reactive protein, which is a blood marker of inflammation that's elevated in most patients, but not like 15 to 20% of patients with Crohn's disease, won't mount a response, even if they're inflamed. It was normal. They didn't have any abnormal drug levels, they were in a good place and no antibodies that can bind to and render the drug ineffective. And then the stool fecal calc protectin, which is a great inflammatory marker, if it's completely normal to rule out the likelihood of inflammation in the gut, was normal and there were no infections. There's some other tests that we could do that I listed here at the bottom, but um since they had a recent colonoscopy that was normal and non-invasive testing with blood and stool was normal, we opted to um presume that this was probably superimposed IBS, which is very common in Crohn's disease, with possible drivers of symptoms being disordered eating, from restriction, edging, and purging, and some symptom-related anxiety and hypervigilance. I'll hand it over to Brittany.

SPEAKER_02 7:34

So here are all the components of a nutrition assessment, but since I only have five minutes, I'm going to focus more on the disordered eating side of the assessment, including screening and food and nutrition-related history. I like using an eating disorder screening tool like the short eating disorder examination questionnaire because it asks about disordered eating and really connects it to body image. Two examples of questions on it are do you have a definite fear that you might gain weight? And have you gone for long periods of time without eating anything in order to influence your weight or shape? No, it's not validated in GI simp and GI populations, but um that's okay because it's not diagnostic. It just really starts the conversation. And then you can ask additional follow-up questions. Um, disordered eating can come from body image concerns, fear of GI symptoms, or both. And while fear-driven restriction is common, we don't want to normalize that. Um, instead, we want to give patients tools and support to address it. Screening should be ongoing because, in my experience, many patients with IBD are focused on regaining weight when they've lost weight and have active IBD, but when they go into remission and start regaining weight, body image-driven disordered eating can show up. To start a conversation about disordered eating, you can say something like, Thanks for completing that questionnaire. Would it be okay if we talked a little about some of your answers? Most patients will say yes, but if they say no, that's fine. You can just focus on some safe GI interventions for now and then revisit the conversation once you've built some rapport because their symptoms have improved. Um, if they say yes, you can ask disordered eating is common in people with IVD and can come from fear of symptoms, body image concerns, or both. Do you think either might be affecting your eating? If one of the patient's goals is weight loss, like this patient, I like to clarify their motivation. Can you tell me what you're hoping weight loss will change or improve Rio? If their goal is body satisfaction, research actually shows that focusing on a specific weight or body shape off actually often increases body dissatisfaction. So some evidence-based strategies to improve body appreciation can include things like engaging in self-care behaviors, challenging negative body thoughts, focusing on a body appreciation, and accepting the here and now body. Food logging can really help VI dietitians understand diet patterns and consumption of um trigger foods. But is it actually appropriate for patients with co-occurring disordered eating? In short, yes, as long as it doesn't increase disordered eating thoughts or behaviors. You can check first by asking, have you ever tracked your diet before? And if so, how did it go? And have you ever noticed tracking your diet affects your mood, stress, or relationship with food? Um, some alternatives to traditional tracking could include things like discussing the intake verbally during the session, tracking meal satisfaction or hunger and fullness, um, or also logging meals to simply encourage regular eating. In terms of restriction, for this patient, I asked about his motivation for starting intermittent fasting. But to ask about restriction in general, you could ask something like: are there times you intentionally delay or skip meals because of concerns about weight or symptoms? Or do you ever intentionally skip taking your medication, which sometimes happens in my IBD patients? I also asked this patient about binging. Um, I think it's really important to clarify what patients mean when they use specific terms. And so for binging, um, sometimes patients will use that term and it'll be a true objective binge, but other times it may really be more of, you know, overeating related to ravenous hunger. Questions you could ask about um binging could be do you ever feel out of control with regard to food? And how often do you consume a large amount of food in a short period of time? Subjective binge eating is common in people with with Crohn's because they often delay meals due to symptom fear, which leads to rapid, ravenous eating, um, which can worsen symptoms. For asking about compensatory behaviors, you could ask something like has there been times you've changed eating, exercise, or other habits because you felt um, because of how you felt about what or how much you ate onto a psychological perspective.

SPEAKER_04 12:37

Just waiting for my video. Okay. Um, so a psychologist on a multidisciplinary team, um, our primary goal is going to be to both identify the source of the disordered eating andor exercise, um, as well as what is maintaining it. Um, and for this uh individual, my initial um observations are number one, that this person has some complex physiological abnormalities that are creating discomfort with eating. So this person already has some pre-existing um uh diagnoses that are have been shown to impact the way a person relates to food. And that's really important as I'm thinking about why might this person have disordered eating if they do have that. Um, I'm also thinking about their current engagement in dieting and their history of dieting. And I'm wondering, is this a function of um these diseases that they have, or what, or did this dieting predate the diseases? I'm also being aware of the fact that they have they engage in daily exercise. And my question in my mind is is this what they're doing to manage stress and for fitness sake, or could this possibly be a compensatory behavior or a more compulsive relationship with exercise? Um, and then lastly, there's a reported um level of anxiety and a desire to lose weight, right? These are things that can come up quite frequently with folks that have eating disorders, but are also fairly normal for the average person to experience as well. So those would be some of my initial thoughts about this individual. But before we kind of dive into this case, I want to make sure that we all have a basic understanding of what eating disorders are and how to think about them. So eating disorders are mental health conditions that have to do with a disruption in the relationship between a person and their relationship with food, their body, and exercise. Um and the best way to think about this umbrella of disorders is you can kind of separate them into three categories of behaviors and three categories of symptoms. And what you're really looking for is which symptom or behavior is primary. So uh you can think of eating disorders as restrictive eating disorders, disorders that involve some uh form of binge eating, and then disorders that involve some form of compensatory behaviors. So restriction just means that you're not eating enough to maintain your body's weight or your body's health. Binge eating typically refers to eating a large amount in a short period of time. Sometimes it is larger than what you would imagine, but other times binge eating could just be more than what this person is comfortable with. And it's usually accompanied by a sense of feeling out of control. And then compensatory behaviors are these behaviors that a person might engage in if they feel like they've eaten too much or eaten the wrong thing, how do they get rid of it? And so compensatory behaviors can be things like um purging or vomiting, like that's the most common one that we think of. But it can also include laxative misuse, diuretic misuse, and even exercise. So you might ask yourself, well, how can exercise be considered purging? Well, it sounds like this. When a person says, Oh my goodness, I ate a donut today, I'm gonna have to uh work out twice as hard at the gym, or I'm gonna have to add a couple more miles to my run to make up for that donut. When you hear someone try to do a one-to-one of, I ate this thing, therefore I must run it off, that's an example of exercise as a form of purging. Um so we're really looking at each of these symptoms and trying to identify are these symptoms present? And if so, are they primary? So some diagnoses that involve restriction include anorexia nervosa, restrictive type, um, avoidant restrictive food intake disorder, which is more related to sensory sensitivities with eating, or a traumatic experience with eating, or just an overall lack of interest in food. But regardless of the why, it results in not eating enough of what your body needs, and usually if there's some sort of malnutrition as a result. And then other specified feeding or eating disorder. This is an eating disorder that you might not have heard of, but this is actually the most commonly diagnosed eating disorder because it accounts for folks who have a variety of different symptoms but don't quite fit the boxes of some of the more commonly thought of eating disorders. One really important eating disorder under this category is atypical anorexia nervosa. And that diagnosis is for folks who experience the symptoms of an eating disorder, particularly a restrictive eating disorder like anorexia, but they are not extremely low weight. They are normal weight or even above normal weight, but are experiencing all the same health consequences that someone who is deeply underweight would experience. And that is actually a more common presentation of anorexia than anorexia nervosa-restrictive type. So those are all the common um restrictive eating disorders. Those eating disorders that involve binge eating are binge eating disorder, which sort of speaks for itself. Um, but this is when a person eats uh more than what you would expect in a given sitting. It happens quite frequently, but they do not do anything about it, meaning there is no purging, there is no exercising, there is no effort to get rid of whatever calories they've taken in. Um, bulimia nervosa, which does involve um binge episodes and purge episodes, anorexia nervosa as well. There is a subtype of anorexia nervosa that involves binge eating and or purging. So they could also have that diagnosis. And again, um other specified feeding or eating disorder. And then lastly, those eating disorders that include compensatory behaviors are bulimia nervosa, anorexia nervosa, and other specified feeding or eating disorder as well. The other thing you want to think about with eating disorders is why? Why is this person experiencing this disruption in their relationship with food? Is it because of a negative body image? They don't like how they look or they're uncomfortable with their appearance? Do they have a fear of gaining weight? Do they have a lack of interest in eating food in general? Um, do they have avoidance-based um concerns? Are they avoiding certain textures? Are they avoiding the appearance of certain foods? Or, as is common with a lot of folks with GI conditions, do they have concern about aversive consequences after eating? Meaning, do they experience nausea or constipation or diarrhea that make eating scary and make them want to avoid eating to avoid those negative consequences? So those are some things to think about when you're considering eating disorders in general and what to look for. Um, in general, when I'm assessing for an eating disorder, I probably use clinical interviews as well as self-report questionnaires. But I do want to be sure to note that regardless of what type of assessment you use, it's really important to create a non-judgmental and safe space by posing really gentle uh questions that generate authentic answers because there is a lot of stigma around mental health diagnoses and eating disorders in particular, in particular. So you want to be mindful of that. And then the little asterisk at the bottom is also letting you know that when using self-report questionnaires, it's important to know that these questionnaires are face valid, which means that when you read the question, you can pretty much tell exactly what they're getting at. So if you're not interested in your provider, knowing that you have this issue, it is very easy to answer the question in such a way that minimizes your symptoms. And so self-report questionnaires are very important, but they don't always pick up things if a person's not ready to talk about them. Um, so for this person, these are some examples. I won't go over all of them, but some examples of these non-judgmental, safe ways of talking about um eating disorders to kind of get authentic answers from your clients or patients is, you know, are there any foods or food groups that you try to avoid when eating? Right? You're not asking them, are you dieting? You're not asking them, are you not eating enough? You're just saying, hey, are there ever any food groups that you usually try to avoid? And if they say yes, then you ask why? What is it about that food group that makes you want to avoid it? Um, if they say, you know, I don't like how it makes me feel, or I don't like the taste of this, it's also it's always important to follow up and ask if they have any diagnosed food allergies because that can help you identify the difference between I just don't like this food versus I am actually allergic and experience um negative consequences when I'm eating these foods. Another non-judgmental question that you could ask when you're assessing for binge eating is uh when you're eating, are there times when you want to stop, but you just can't? Right? This isn't asking anything specific that might make a person feel judged. It's just asking the obvious are there times when you'd like to stop and you know that you're uncomfortable, but you're not able to? Because this is going to get at that lack of control feeling. Um, but do it in a way that makes a person feel like this is conversational rather than diagnostic. And then a non judgmental question for assessing compensatory behaviors is if you eat more than you should have, or let's say you eat something that isn't quote unquote healthy, how does that make you feel? Uh, and how do you handle that feeling? Do you Do anything about that feeling? Again, another conversational way that will help you better understand if they are experiencing symptoms of an eating disorder and/or disordered eating. And then again, a non-judgmental way to assess the why. When do you remember your relationship with food changing? Let's say you're having an amazing day and you notice a reflection in the mirror and you hate how you look. Does it ruin your day or overshadow all the great things that have already happened? Again, conversational ways of really trying to understand why this person might have this disruption in their relationship with food. For this particular client, based on the case presentation and the assessment, the diagnosis that I came to was other specified feeding or eating disorder. And that's because this individual did uh endorse binge eating, but he didn't endorse any compensatory behaviors. Um, but it is important to acknowledge that this binge eating is happening in the context of dietary restriction. Um, this person also endorsed rigid food rules and they endorsed body weight um concern. So, given that information, the diagnosis that fit the best was other specified feeding or eating disorder. Um and now we'll talk about the interventions, starting with the GI perspective and go through each one of our approaches to this client.

SPEAKER_00 23:27

All right. So getting into some of the interventions for IBS. I think the first thing just to highlight um and why this case was chosen and we we wanted to talk about it is the hierarchy of outcomes in IBD on the right. We talk about treat the target. Obviously, patient-reported symptoms matter. If they didn't matter to us, we would be bad providers. Um, diagnostic testing with labs and imaging tries to get objective data to say is there inflammation or not. And ultimately, the endoscopic um assessment where we look with a camera inside of patients and biopsies for histology and look under the microscope, those are the things that tell us, you know, how how deep is the remission or how active is inflammation in this patient. So, in a patient with Crohn's disease, just to highlight, a lot of those symptoms can seem very similar to their Crohn's disease. And the danger in diseases like Crohn's disease and other um non-disorders of gut brain interaction is everything becomes the fault of Crohn's disease and we miss other things. So if there's active inflammation, we always have to ask the question why is there not enough drug? The dose is too low, they need to be dosed more frequently, they have antibodies that are binding the drug and rendering it not effective anymore. Is there not, or is there enough drug? The drug levels are fine, but it's just not working where the mechanism failed and we have to switch classes. And then in this case, if there's no active inflammation, then we consider other conditions like IBS and treatments for those. This is a busy slide, and this is just to show that there are American Gastroentomological Association or AGA guidelines for irritable bowel syndrome of constipation and diarrhea, predominant subtypes. Um, they're tiered treatments by stool type and the severity of symptoms. And the treatments that are at the top in that yellow box are things that all patients should get. So the doctor-patient relationship and communication in a subset of patients, which at baseline is very frequently dismissed and gaslit. Um you add to that disordered eating on top of irritable bowel syndrome, and that gets exacerbated even more, magnified even more. So that's very important. Um, lifestyle changes, education, and diet. And we'll talk a little bit more about the nuances of diet and why we need to be more careful than just handing patients a pamphlet and saying, go do this diet, which is not how that's intended to work. Um on the IBS with diarrhea subtype side, you can see, you know, uh lopyramide and medicine should just slow down the stool, bile acid sequesterants like cholesteroline or cholesterol, um, antispasmodics, which can be prescription or peppermint oil capsules. And then there's some additional medications further down. Um, I think the thing to point out here is the gray box at the bottom, which sort of looks like that's like if all else fails, consider brain gut behavioral therapies or um some of the psychiatric medicines like tricyclic antidepressants, TCAs, or um SNRIs, which are medicines like duloxetine that also impact the gut nervous system. This can be very effective, but brain gut behavioral therapies like hypnosis and cognitive behavioral therapy are at the bottom of this, but we'll talk later why maybe they shouldn't be. And so they have great efficacy, meaning in a controlled study, uh, which is what you'd read on PubMed, they have amazing efficacy. They work really well when used in placebo-controlled trials or against an active control. The effectiveness, which is more real-world outside of such a controlled setting, or looking long-term, like the six-week study, already doing it one, two, seven years. And we have data for hypnosis that out to seven years, the durability of that uh treatment is is efficacious or and effective. And then uh safety, they're they're very safe. And so um, I think I had some further slides to kind of go through that more. This is just the AGA guidance on diet for IBS. And I just want you to focus on the red box around this complex algorithm, which is just that before we consider any diet, especially any diet that eliminates food groups in patients with any GI symptoms, we really should ask some question about disordered eating, because the last thing you want to do is push somebody off a cliff into further disordered eating or a full eating disorder by doing something that you think is helping them. And that's actually now in the guidelines. This is just a slide that I was a co-author on, but it's just to show there's a lot of non-drug treatments for IBS that have varying degrees of evidence. The ones on the right side, which are the brain cup behavioral therapies, by far, they have by far the most um extensive and uh high quality evidence for them. And those are the things that we're gonna focus a little bit on with this patient going forward. So, should brain cup behavioral therapies perhaps be offered earlier? This is a great study by Eric Shaw and the group at University of Michigan, and that top light gray row, um the first one there, shows if you do global IBS treatments before all the on-label drugs that are in the original algorithm I showed you. So, global treatments include the low FODMAP diet, global treatments includes the neuromodulators or the psychiatric medicines used for GI symptoms, and global treatments includes brain gap behavioral therapies, you end up saving substantial amount of money for both diarrhea and constipation-predominant IBS. The row right below that is what happens if you if you cycle through all of the on-label drugs first, and then, like the algorithm suggests, use those brain gap behavioral therapies and global therapies second, you can see there's like thousands of dollars of additional expense. Um, and that's also time that patients are suffering before they get better. So the durability and um effectiveness of the global therapies, including brain gut behavioral therapies, is actually much more cost-effective. And this is just to show IBS with the team sport. I love this study. There's actually a follow-up study, which is what the images or the figure is from, but it was a study looking at standard, just GI only versus a multidisciplinary team with GI, psychiatry, uh, gut-directed hypnotherapy, pelvic floor, physical therapists, and dietitians. And you can see that the outcomes were substantially better in the yellow bar group, the multidisciplinary group, and the standard GI group. It's a little bit more expensive up front, but when you look long term, uh it improved quality of life and cost effectiveness. And then lastly, bringing it back to our patients. So this patient wanted non-pharmacologic options, wanted to use diet therapy. As we mentioned, had gone through a number of different diets, like the autoimmune uh protocol and low FODMAP and intermittent fasting. But I mentioned, you know, this hasn't helped before, and elimination diets can be risky with some of the disordered eating that's happening. And so we talked about other options, specifically the brain gut behavioral therapies. They're safe in this patient population, or they haven't been specifically studied in them. Um in at least some of them haven't been, uh, there are components of them that have. Hypnosis and low FODMAP were shown in a study um back in 2016 to be similarly effective, but hypnosis actually perform better from a psychological standpoint. So if you're looking at them, not you know, it's somewhat equal in this patient population where elimination diets are high risk, um, gut-directed hypnosis wins hands down. And then some of the digital therapeutics has opened and expanded access to these therapies because there are a limited number of uh psychologists and counselors out there who are trained to do CBT and gut-directed hypnosis for GI problems. And then some of the new things that um, you know, Mindset Health and NERVA have rolled out are some of the AI support and things to help with compliance to push patients through this. So we did some sure decision making, which led to the initial treatment plan. Wanted something for acute symptoms. So we chose peppermint oil capsules, which have a lot of evidence, and to start uh NERVA, which is now includes gut-directed hypnosis and cognitive behavioral therapy and diaphragmatic breathing. So the full full gamut, and then talked about some future considerations just so they realized, hey, if this doesn't get us all the way there, we've got other things we can do. Turn it back over to Kelly.

SPEAKER_04 32:04

Um, Crohn's disease. Sorry, I think I was muted. Um, where we wanted to start with this individual was psychoeducation. So really making sure that he had a lot of education on the interaction between Crohn's disease, stress, and his eating behaviors, um, normalizing um post-inflammatory GI sensitivity even in remission, and discussing the risks of restrictive diets and excessive fasting on binge eating patterns and GI function, right? So as it relates to eating disorders, um, oftentimes binge episodes are preceded by a period of restriction. And most folks only focus on the binge and think that's the problem I need to focus on, when in fact it's the excessive fasting or the restriction that is pushing the binge episodes and their frequency. Um along with the psychoeducation, we also did um some cognitive behavioral therapy specifically for eating disorders. And I know, you know, one thing we talked about was really understanding the differences of why this eating disorder got started. And for this individual, it really does sound like it was related to the aversive consequences he was experiencing after eating as a function of the Crohn's disease and his GI sensitivity. But in the eating disorder world, regardless of the why, the treatment of most eating disorders is exactly the same. You might remove a module that focuses on body image if that's not your concern. But overall, um, a behavioral approach that is uh specifically for eating disorders will work regardless of the origin of the eating disorder. So uh CBTE really focuses on um stage one, self-monitoring of food, binge episodes, and GI symptoms. So just tracking how often these happen, helping him to identify any cognitive distortions he might have around eating, such as if I eat carbs, I'll flare, or I can't eat at work, or I'll embarrass myself, and undoing those um distortions and replacing them with things that are more accurate and realistic. Introducing regular eating is really important for binge episodes. So, really encouraging folks to eat in more of a timely and structured manner, three meals and two snacks, and incorporating safe foods. Um, and then addressing whatever over evaluation of weight and shape that might be there. So rather than having him really focus on the way his body looks, um, but start to focus on the way that his body functions and other uh health-based met health-based metrics, other um metabolic metrics to measure his health so that he's not primarily relying on weight to determine if he's healthy or not, because that can uh really kick up folks' um desire to diet and fast. Um, we would also do some GI-specific CBT and some acceptance and commitment therapy as well to address uh whatever um gut-directed symptom-related anxiety he might be having, may be having. So exposure to fear foods, mindless mindfulness of gut sensations, trying to reconnect those two things so that we could teach him that you know his body can be uncomfortable without being in danger. Um, and then incorporating diaphragmatic breathing and mindful movement as well to help regulate the gut brain communication. And some behavioral interventions would be establishing a balanced uh movement plan that involves sure, four to five runs a week, but also two rest days. If you remember this guy was running seven days a week, um, and it it might mean that his body might need a little bit more rest than what he was giving it. So establishing a more balanced relationship with movement, again, focusing on that structured meal timing, um, and then using that gut-directed hypnotherapy to retrain the brain to communicate properly with the gut. And then if the team agrees and believes it's safe, gradually reintroducing some of the previously avoided foods through exposure hierarchy, especially FODMAP reintroduction, if the dietitian and GI physician believe it's appropriate. And then the last part of my work, but also the most important, is developing a flare management plan to help him prevent relapse into restrictive eating and to build a workday symptom management toolkit so that he has a variety of things he can do if he feels the anxiety kicking up, if he feels any stress um rising in in relationship to how he's feeling in his body. And again, frequent collaboration with the gastroenterologist and dietitian to make sure that the work that we're doing is um in concert and not in opposition to one another. So I will pass this to Brittany.

SPEAKER_02 36:47

So I'm going to discuss a few eating disorder interventions as well as GI interventions that are safe for people with co-occurring IBS and disordered EDA. A key eating disorder intervention was um addressing the restrict binge cycle for this patient. Um eating regularly helps reduce feelings of loss of control and encourages more mindful eating, which can also help reduce symptoms. In this patient, practicing regular eating meant stop stopping intermittent fasting. And like Kelly mentioned, we ideally want them to consume three meals and two snacks a day. Ums motivational interviewing, I asked, on days you eat every few hours, how does your eating feel later in the day? Questions like this helped him see how skipping meals often triggered overeating. For instance, I think he mentioned or he realized that skipping breakfast led him to snack on large amounts of food in between lunch and dinner. We also introduced intuitive eating concepts and had him track his hunger and fullness, meal satisfaction, and an exercise enjoyment. For patients concerned about weight or overall health, um, like this patient, I recommend referring to their primary care physician to check objective metrics of health like um hemoglobin A1C, blood pressure, and a lipid tannel. Intuitive eating, like some of you may know, is a non-diet evidence-based approach to healthy eating. While it isn't formally um studied in GI populations, the principles can be adapted to improve the relationship with food. For this patient, focusing on the honor your hunger principle really helped him to prevent him from overeating later in the day. But it's important to explain the caveat here. This patient was in remission, but active Crohn's can suppress hunger. So it was really important to educate this patient on eating for self-care purposes when he does have active disease. Another principle is respect your body because IBD can cause significant weight changes due to inflammation, disease location, disordered eating, or medications. So learning to appreciate their here and now body is especially helpful for people with IBD. Another principle that was helpful for patients, uh for this patient was feeling the difference with movement. Um exercising seven days a week felt um like it was punishment for him. So working on adding in rest days and adjusting his exercise intensity made a big difference on his enjoyment of movement. The main GI interventions for this patient were establishing regular meals as part of the nice IBS guidelines and adding in a soluble fiber supplement. Honestly, this significantly reduced his symptoms. And I like to implement strategies like this first to help keep patients with co-occurring eating disorders and disorder and GI conditions diets as expensive, expansive as possible. If residual symptoms remain, some other strategies could be fiber texture modifications, ensuring adequate hydration, um, swapping out IBS triggers like uh sugar alcohols for real sugar, adding in oats or linseeds for residual bloating. We could have done some uh low FODMOP cherry picking if needed, um, if his previous low FODMOP diet was um not uh done with a dietitian and maybe he made some mistakes with it. Um, another culprit for this patient could have been sports gels or bars he was consuming for running. So that could have been something else that we looked into if we needed. Um he didn't want to add too many supplements, but if he was open to adding in more, we could have added in glutamine for global IBS symptom reduction and improving stool consistency or ginger extract or brown seaweed uh sodium alginate for GERD, um, for lifestyle modifications, uh, raising the head of the bed to sleep or sleeping on the left side could be helpful for any residual GERD symptoms and mindfulness-based stress management reduction, uh, stress reduction could help with global um IBS symptoms, especially since he mentioned he has some anxiety. So the key um interventions for this case um uh that the GI implemented were really adding in uh the peppermint oil supplement and initiating NERVA. Uh for the psych, the main interventions were um uh, you know, ACT and behavioral and relapse interventions. And from the dietitian, the main interventions were really establishing regular meals, um, intuitive eating concepts, and adding in that soluble fiber supplement. So this patient ended up having two Bristol four bowel movements a day. Um, he had improved abdominal pain, gas, and bloating. He switched from intermittent fasting to more of an intuitive eating focus. He did add in one rest day and he made one workout an easier workout for the week. He didn't have any binge eating anymore. He had decreased anxiety, he no longer prioritized weight loss as a goal. He even said um something like, I got my a lot of my life back um that was tied up in those behaviors.

SPEAKER_01 42:40

So I think Jordan is gonna be talking.

SPEAKER_00 42:47

All right. So in wrapping up with some clinical pearls, and and I think that this is somewhat similar to Nerva in the sense that you know there's this amazing product, and a lot of the challenge is just getting people to understand that it exists and getting providers comfortable with how do you have conversations about using this. Uh, I think eating disorders share that similarity and that they're very, very common. And eating disorder, disordered eating patterns are extremely common in GI patients and can either cause or exacerbate GI symptoms. The eating disorder GI relationship is bi-directional. It can be very dynamic and change over time, and it's on the spectrum. And I think disordered eating can originate from diet culture, fear of GI symptoms, or both, and both of these need to be addressed. And then lastly, asking direct questions about eating disorder symptoms may not always result in open answers, but the flip side is that not asking and not thinking about it misses an opportunity to address a common serious root cause of some patients' GI symptoms. And quick last slide before we go to some questions. The edgi training.com has a lot of information from the textbook that we all were co-authors on. Our book club right now is full and it's been going very, very well. And it's been a great community to get through the book and share learning about this topic. And so we're going to be starting another group early 2026. So feel free to check that out if you want to get some more information on that.

SPEAKER_03 44:29

So we're going to jump into the QA section. Like I said before, please drop those questions in the QA box. Also, during this time, I'm going to share a survey. Let me do that now. Which you guys should see at the bottom says provide feedback. Please take the time to fill that out. It's really helpful for us to hear more your thoughts about the webinars and what we can do to improve them or what you liked about them. But for now, I'm going to jump into the questions. I will ask them and you guys can share what your answers would be. So this one, this first one's for Kelly. Do you feel like patients might report allergies that they don't have or say that they are lactose or gluten intolerant or et cetera when asking non-judgmental questions? Yes.

SPEAKER_04 45:15

It it happens quite a bit that someone will say, Oh yeah, I'm lactose intolerant. And I do not argue with folks. I just say, oh my goodness, thank you so much for sharing that with me. Is it possible to sign a release of information so that I can chat with your allergist or so that they can send me those results so that I have it on file? Right. And that's just sort of a way of saying, great, I just need that paperwork. And normally at that point, a person will say, Oh, well, I've never formally been tested. It's just what I've experienced, or, well, it's on my to-do list to get tested, but I haven't been tested yet. So it's sort of a non-confrontational way of still sort of pushing for like tangible proof that they have the allergy. Um, uh, but at the same time honoring that like they feel uncomfortable, right? So my goal is never to make someone feel like they can't uh be honest or that they need to hide, but I do want to make sure that um I have the proper information so that as I'm making my assessment, it's based on um actual food allergies versus I'm afraid of this food or I think I have a food allergy.

SPEAKER_03 46:24

Great, thank you. Um this next question looks like it might be more for Jordan since I think you're the one who brought up peppermint oil. Um someone asked, what dosing do you recommend for peppermint oil capsules, or are these just available in the pharmacy?

SPEAKER_00 46:38

So they're I think all of them are non-prescription required. So they're over-the-counter. Um there are a couple that exist out there. They tend to range around 90 to 100 milligrams per capsule. And I would say the most standard studied dose is around 180 to 200 milligrams a dose, which is usually two of the capsules, um, like up to three times a day, often taken before meals if meals trigger some cramping and rapid movement of things through the GI tract. Um, the one thing to note is that whatever uh formulation you get, I mean, IBGuard is one that's available in the US that's common, but I've used a number of other ones. You just want to make sure that they're enteric coated. There's a theoretical risk that somebody who takes you know high doses of peppermint oil that's not formulated to open further into the small intestine can cause increases in reflux symptoms just because it's a muscle relaxant, it's a calcium channel blocker. And so while it helps relax the bowel from being really crampy and spastic, it can also relax the lower esophageal sphincter and cause reflux. And so that's the only thing. I think any formulation that's enteric coded would be okay to trial.

SPEAKER_03 47:57

Amazing. Thank you. We have a couple questions for our dietitian Brittany. One of them is which soluble fiber supplements do you usually recommend?

SPEAKER_02 48:07

My favorite is the uh is basically psilium husk fiber. It has the most research for um reducing global IBS symptoms and is often uh does not increase other symptoms. But I think it's really important with anything uh to make sure that you're adding it in slowly, and then that will help to reduce any bloating or uh other GI symptoms that might result from that if they're not used to fiber in general, um and also making sure that they're having adequate hydration as well.

SPEAKER_03 48:41

Great. And another one too, um, are you able to elaborate on the nice guidelines?

SPEAKER_02 48:47

Yes. So um some of the nice guidelines, uh guidelines for IBS would include things like eating regularly and slowly, um, avoiding uh meal skipping, drinking plenty of you know adequate fluids, um, not having too much um coffee or tea. I think it's like uh less than or equal to three a day, reducing um alcohol and fizzy drinks, reducing resistant starches, limiting fruits to three servings a day, avoiding sugar alcohols, um, yeah, among a few others, but yeah, I don't want to get into all of them. But you can you can check them out. Um you can just yeah, look for nice IBS guidelines.

SPEAKER_03 49:33

Great, awesome. That was really helpful. I know they're pretty um in, you know, there's a lot of them. Um awesome. We have another question for Kelly. Um, once you have identified an eating disorder, how would you share this information with the rest of the care team to ensure that everyone's taking appropriate precautions and keeping the you know the eating disorder in mind throughout the intervention?

SPEAKER_04 49:59

So when I work on multidisciplinary teams, I usually have like scheduled check-ins with the providers on the team, whether we're on uh, you know, a Zoom call or something like that. But there's usually a regular check-in. And I usually initiate that by just letting them know that, hey, this is the the serious condition that they have, in addition to their GI issues, um, and maybe whatever nutritional challenges they have. Hey, this is another important aspect. And these are the ways that you can uh, these are the ways that it should impact the way you're treating them, right? So um there are a ton of, I'm trying to think of the acronym, but there is a, I think it's called NSEAD, uh, where this is a um organization that focuses on training for physicians particular in particular for how to treat eating disorders. And they give you a bunch of guides that you can give to physicians that help them, that walk them through uh the things they need to know, um, how to assess. And so I for my uh physicians that I work with that don't specialize in eating disorders or don't understand, I will also include some sort of guide that they can keep with them to sort of uh jog their memory or remind them of things to look out for as they're treating this individual and uh with dietitians as well. So I will call, I will express what's going on, but then I also try to send something that they can uh quickly look over that's easy to digest so that the information stays with them because I recognize that eating disorders aren't, although they are very common, as Jordan stated, um, not a lot of healthcare providers have training in how to treat them. Um and I also make myself available to folks on the team if they have any questions in the future, because again, I understand um and I don't expect everyone to become an eating disorder expert, but I do want them to make, I do want them to reach out to me if they need that help and to know how important it is.

SPEAKER_03 51:56

Absolutely. Thank you. Um the next question is for Jordan. Can you explain or expand on how you might introduce the introduce gut brain therapy such as gut-directed hypnotherapy to patients? Do you talk about the gut brain axis or the role of the vagus nerve in this process?

SPEAKER_00 52:15

Yeah, I I will. I think the first thing I I will do is just try to invite them into what and ask what they know about it. Um, I think one of the things that's really delicate, but it's also a great opportunity to earn their trust, is to understand that a lot of these patients, when psychological-based therapies may have been brought to their attention before, was often in a way to that is very dismissive, where it is blaming. And I will often literally tell patients if you ever have a provider say, well, you know, your scopes are normal, your blood tests are normal, your imaging is normal, like this is all in your head, or this is all because of this, or um, run the other way. Um, and so I will let them know, you know, I think to varying degrees, um, many patients have a very significant part of their symptoms that can be related to um more than just I think stress. I think sometimes we oversell the acute stress-causing symptoms, which can certainly happen. But a lot of these patients who just have like significant amounts of trauma, we talk about, you know, the body keeps the score and how the gut and brain, there's this constant two-way street. And so I'll usually give an example of how, you know, if you have GI symptoms long term, which is some of the data Nick Taley in Australia initially published 20 years ago, um, you're much more likely, even if you started out without anxiety and depression and PTSD, you're much more likely if you have GI symptoms to develop psychological symptoms five years later. And the flip side is true too. If you start out with psychological symptoms or a history of trauma and you have no gut issues five years later compared to people who don't have those at baseline, you're much more likely to develop GI symptoms. And so I think it just normalizes it for them. And then we talk about how there's a whole menu of treatment options, but I think the opportunity to present treatments like brain gut behavioral therapies that are not medications, a lot of these patients with eating disorders are on other psychiatric medications for other coexisting disorders. And so just throwing in another medication is actually sometimes a lot riskier than maybe the general population, or they've got, you know, electrolyte abnormalities from malnutrition. And so I think the ability to offer them a therapy that, you know, the and I and I will sell them on if it if it doesn't work, it's not going to hurt you. But if it works, the potential that it lasts, even when you're done for years, is really unlike anything that we can offer with medications. Um and then the the last thing I would say, just to make a point kind of related to that, is you know, eating disorders, the traditional teaching was because GI symptoms are so common, fix the eating disorder and all the gut stuff will get better. Um, and that's often the case that it'll get better. But there are also patients who are well into recovery or their recovery is hindered because of the GI symptoms. So it really has to be a team effort because sometimes they get to a point where they really are making all the efforts to get better from the eating disorder, and they just need somebody to aggressively help manage the symptoms to get them there.

SPEAKER_03 55:27

So absolutely, that's a great answer. Thank you for that. Um, we have time for a few more questions, so please drop those in the QA box. I just want to remind everyone to fill out the survey if you haven't already. It's still there at the bottom. Um, this next question I imagine is probably for Kelly, but how would you go about a situation where you suspect a disordered eating, but the patient is in denial and not willing to address that aspect in their care?

SPEAKER_04 55:52

Yeah, that's extremely common, right? I again, uh, one of the criteria, particularly for anorexia nervosa, is a lack of insight into the seriousness of their condition. So this is an extremely common experience for someone to have all the red flags and to say, but I actually don't, and actually it's fine and it's no big deal. And what I tend to do in that case is really take a motivational interviewing approach, which essentially focuses on meeting the individual where they're at and saying things like, okay, it's if you don't think you have one, that's fine. Do you mind exploring what it would look like or what it would mean if you did? Like, I'm not telling you you do, but what if? Like, what if these symptoms are part of a larger story? Could that be possible? Is there any world where like you might have experienced any of these risk factors? And then I might talk about some of the different risk factors that people experience um who have an eating disorder. And oftentimes they'll say, Oh yeah, that happened to me, or yeah, I used to be bullied. I've been on a ton of diets. Oh yeah, I can't stand the way I look in the mirror, or you know, and so we'll talk about some of the risk factors, which are usually less um entrenched and easier to talk about and that have been normalized. And so it at least keeps the conversation open and it allows us to get to a place where maybe one day they might be open to addressing it or treating it, or they will think about it beyond the time that we've worked together. But that's extremely common. Um and I would again suggest a continued non-judgment, um, being really open to meeting them where they're at and asking questions that help you get to the point, but don't necessarily attack it uh directly. But still talking about it, I you know, I want to make sure that everybody understands that even if someone's uncomfortable, um, you should still push a little. You should still um say, I don't know. I I this it really sounds like that to me. I understand that you don't see it. Let's talk a little bit more, let's keep the conversation open. But it's an extremely common um experience.

SPEAKER_03 58:02

Amazing. Thank you guys so much for all of your insight. It's incredible. Last question is if your book is available for purchase. And if so, where can people get their hands on it?

SPEAKER_04 58:11

It is. Um, it is available for purchase. I don't know if I'm answering that. But yes, it is available for for purchase and on pretty much every site where you can buy books, you can buy it. I think Barnes and Noble is the main one that we try to send folks to. Um, Amazon sells it. Is there any other specific our website, um, the Edgy Training project? Um, you can buy the book on our website as well. But pretty much anywhere you can buy a book, um, the book is available.

SPEAKER_03 58:36

Amazing. Well, we are right at the hour marker. So thank you guys so much for your time. Thank you for everyone who joined live. Thanks for joining us and have a good rest of your day.

SPEAKER_01 58:48

Thanks for listening to this NERVA podcast, where we explore the science behind gut brain disorders and share real clinical insights from the people we support every day. If you found this helpful, you can join our free webinars for more evidence based discussions and practical guidance. You'll find the registration link in our bio. We'll see you in the next episode.