You can also check out this episode on Spotify!
Did you know things like sugar-free gum, Advil, or simply eating too fast can cause gas and bloating? Everything we put into our ecosystem affects our gut health.
Our gut often reflects our emotional health, too.
In today’s solo podcast, Dr. McBride explains the practical framework she created to help patients conceptualize their health, integrating medical evidence, the patient’s story, and real life.
She calls it the FOUR “I”s:
Information & data = the elements of our health that we can measure and see.
Inputs = everything that we put into our health ecosystem.
Infrastructure = the vehicle (i.e., the skeleton) that drives us through life.
Insight = the process of laddering up from self-awareness to acceptance to agency over our health and well-being.
It turns out that this framework can help explain and trouble-shoot common gastrointestinal woes.
Health is about more than the absence of disease. Health is about having awareness of data and the stories we tell ourselves, acceptance over the things we can't control, and agency over our life.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
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The full transcript of the show is here!
Intro: Hello and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.
[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things: a framework to evaluate their risks; access to the truth and data; and tools and actionable information to be healthy mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.
[00:00:56] Today is a deep dive into gastrointestinal health. There is no possible way I could cover every crevice of the vast amount of knowledge we have on the gut, but I will focus on common things I see and common causes for gastrointestinal distress that often are missed. You may remember from a couple of months ago that I explained in detail the visual representation of how I think about patients.
[00:01:26] I call it the four I’s. It's a two by two grid. Imagine a box with four squares in it. And today what I want to do is talk about the gut and how the different I’s inform gastrointestinal health using some patient examples, things that I see commonly in my office. You can listen to that 15 minute podcast about the four I's for more of a dance remix version of the concept. But briefly, the four i's, are this: the top left square is information. Information and data. Things we can measure, things we can see like lab tests and colonoscopy reports. The top right corner is inputs; things we put in our body from kale and quinoa to alcohol and recreational drugs.
[00:02:15] The bottom left box is infrastructure. Our skeleton, literally the skeleton, literally the vehicle we drive through life, the container of all of our parts. And then finally, the bottom right box is insight. Awareness of the stories that we tell ourselves. Awareness of how our stories manifest in our bodies, and our understanding of our mental health, our anxiety, our moods, our relationships with food, alcohol, each other, and so on.
[00:02:45] So let's talk about a common complaint I see. I don’t think a day goes by in my clinic where I don't see someone who has gastrointestinal complaints like bloating, irregular stools, gas or abdominal discomfort. Now the list of possible diagnoses for these complaints is vast, from diverticulitis to colon cancer to I ate a hot chili pepper.
[00:03:11] But common things are common. That's a very favorite expression that doctors use all the time. And so I wanted to go through how I might conceptualize thinking about the diagnosis or how to help a patient troubleshoot these symptoms when it's sort of bread and butter. Take a middle-aged guy who comes in complaining of bloating, gas, and irregular bowel movements.
[00:03:32] When I think about the top left square, that information, I want to know, what do his lab tests look like? If he's over the age of 45, has he had a colonoscopy? Because 45 is the age where we start screening colonoscopies. By the way, if you have a family history, you should start earlier. So I want to know what's going on internally.
[00:03:52] What's his information? For example, if his lab tests show that he has hyperthyroidism or liver enzyme abnormalities, or a pancreas problem or celiac disease, that may directly inform how I'm going to recommend treatment. In other words, the data and the things we can measure are very important. So let's say he had a normal colonoscopy.
[00:04:14] Let's say his liver tests are normal, his pancreas is normal, his gallbladder is normal, and his blood counts show no evidence of infection or inflammation, and he's negative for celiac disease. So those are just some broad brush stroke tests I might order. I also might not order tests because sometimes it's a simple solution, but let's say that his information is normal.
[00:04:35] Then we'd move over to the inputs. That's the one I'm most interested in. When people have these kinds of complaints, I want to know, how much alcohol do they drink? What is the cadence of their eating? Are they eating a lot of processed, greasy food? Are they consuming a lot of sugar? What's the level of acidity in their diet and how fast do they eat? People who eat fast often swallow a lot of air and can get gas in the colon. Do they drink a lot of soda? Do they chew gym? Sugar-free gum is notorious for causing gas and bloating. So I would do a thorough history of what the patient's inputs are. What are they putting in their ecosystem?
[00:05:15] Sometimes people can get gas and bloating from taking too much fiber. I think most people know that fiber is healthy and fiber can help with digestion. But if people escalate the dose of their fiber intake too quickly, that can backfire and they can get bloating and gas. This is a common phenomena. The other thing I would ask in the input department is, are they taking any supplements or vitamins? Because even though supplements and vitamins are considered natural, sometimes they contain fillers or the supplement itself can accidentally cause bloating and gas. Magnesium, for example, which people often take to help them sleep, can cause diarrhea.
[00:05:50] It’s important to think about all the different things you put in your ecosystem and how they might affect your digestive health. One of the most helpful interventions I find for patients with this kind of complaint is to keep a food journal. It sounds really boring and it sounds kind of onerous, but writing down every single thing you eat is kind of an interesting exercise.
[00:06:12] People often connect the dots between their digestive health, their mood, their energy, and their bloating and gas when they look at the things they're eating. It's really interesting how mindlessly we consume foods, supplements, vitamins, and how little attention we pay to the things we pop into our mouth all day long. So I would suggest writing things down if you haven't done it already and you have this complaint.
[00:06:35] The next quadrant I would look at is infrastructure, our skeleton. So it's not uncommon for people who have a bum hip, a bum knee, an aching back to pop an Advil, to take Tylenol, to take supplements that are over the counter that they think will help with their achy joints and skeletal health. One of the more common triggers of gastrointestinal stress is NSAID's, non-steroidal anti-inflammatory medications. Advil is one of them. Aleve. Naproxen. So we want to think about are we taking any medicines to treat our skeletal woes? And then we can also think about pain and how pain itself can cause distress. Distress can show up in the gut.
[00:07:17] The other thing we need our skeleton for is just basic, everyday mobility. If we have some sort of limitation in our mobility, or we're just living a sedentary lifestyle, like we sit behind a desk most days, then that can affect our gut function, too. Often, one of the solutions for a chronic constipation is just regular walking, regular exercise, hydration, and movement to get our motor running. Our infrastructure really does matter. Sometimes just moving our bodies, hydrating and avoiding Advil is the way to keep our gut healthy.
[00:07:49] Moving over to the insight quadrant, it never ceases to amaze me how patients will report to me these terrible gastrointestinal woes. We will think it may be an appendicitis, a diverticulitis. They will have a colonoscopy, they'll have extensive lab work and maybe even a CAT scan. And some of the times we find a diagnosis, someone has diverticulitis and I put them on ciprofloxacin and Metron dissolve for 10 days and they get better. Other people have a diagnosis that we can name through blood work like celiac disease or inflammatory bowel disease like Crohn's or ulcerative colitis.
[00:08:24] When a patient has gastrointestinal distress and we have no obvious cause, tis is when I get my mojo on because I love talking about how our gut is often the home for our emotional health. It sounds kooky to many people, but I see it every day. Stress and anxiety in particular can manifest itself in our gastrointestinal tract. So when I have a patient who has a normal set of labs, normal imaging, a normal colonoscopy, and they're still suffering, we default to calling this irritable bowel syndrome. Now, patients often don't like having that diagnosis because they consider it a throwaway diagnosis. And I totally understand that because being diagnosed with IBS or Irritable Bowel Syndrome feels like the medical establishment is dismissing the patient.
[00:09:13] It’s like, we can't figure it out. We're gonna slap a diagnosis of IBS on it, and say, “see you next time, good luck.” But irritable bowel syndrome is a real phenomenon. It is literally the spasm and irritability of our colon, and it's from something. Just because it's IBS doesn't mean it's not real. IBS, however, is not a life-threatening diagnosis. It is not a result of inflammation. It is simply a functional issue that is often driven by emotional distress. One of my favorite exercises with patients is to take inventory of where they are on the continuum of anxiety. Where are they on the continuum of mood? Where are they on the continuum of their relationship with work, parenting, caregiving and just being alive in the modern world.?
[00:10:03] In other words, we all have fears. We all have moods, we all have relationships to food, alcohol, our work, and to each other. When those things are on the fritz, when our anxiety is out of proportion to the actual threat; when our moods are not stable, despite our best effort to get sleep and to get exercise; and when our mental health is not in balance; those are often the triggers for gastrointestinal distress. So sometimes, dare I say, often the solution for gastrointestinal woes, if we can't find an obvious cause again, to identify thoughts, feelings, and behaviors that are causing us to feel distressed. In the short term, I will recommend to a patient that they try this, I don't wanna call it a diet because diet to me implies weight loss, but there's a diet, or actually call it a framework called the low FODMAP Diet.
[00:10:55] You may have heard of the FODMAP Diet from a friend or on the internet or on Instagram. And when people say the FODMAP diet, they often mean a diet that is low in FODMAPs, F-O-D-M-A-P-S. And the diet is really designed to help people with irritable bowel syndrome, and one of the problems I think people run into is I give them the list of foods and they accidentally hear me say, cut all these foods out of your diet and good luck.
[00:11:20] That's not my plan. All I want people to do is use that list of foods that are potentially irritating to the gut, that potentially accelerate that gastrointestinal spasticity and see if they can connect the dots between what they're eating by that journal we talked about and how they feel in their gut. FODMAP stands for Fermentable, oligosaccharides, disaccharides, monosaccharides, and Polyols.
[00:11:45] What that basically means is that these are some foods that the small intestine absorbs very poorly, and people can experience cramping, diarrhea, constipation, bloating, and gas. So one of the occupational hazards of recommending the low FODMAP diet to patients is that people often go and restrict and then feel worse.
[00:12:03] Maybe their diarrhea and cramping is better, but they're hungry. So the other potential occupational hazard of recommending the low FODMAP diet is people using the diet as a panacea and not then addressing the other triggers of their irritable bowel in the first place. From work stress to the Advil they took for the headache to the alcohol they overdid and kind of forgot they did because they didn't count it because it was the weekend.
[00:12:29] In other words, there's really no one size fits all prescription for IBS/irritable bowel syndrome. But in my experience, it's usually a little bit of a lot of things and it's usually one little piece of something from the information quadrant. Maybe you have a predisposition to constipation or diarrhea given your family history.
[00:12:51] It's one little piece from the inputs, like maybe you had too much alcohol and you didn't really register it, or maybe you're eating too much tomato or Brussels sprouts. Maybe it's in the infrastructure space where your body isn't moving enough. You need to give your body and your colon a little more time and space for activity.
[00:13:09] And then sometimes it's in the insight. We need to recognize that our stories live in our bodies, and that self-awareness is often the key to health and wellbeing. So that is my little spiel about gastrointestinal health. It's pretty basic, but I find often that when we have these symptoms, we tend to overdo and over-test and over-worry when actually some of the solutions that I find the most helpful are really, really simple.
[00:13:35] It's paying attention to thoughts, feeling. Taking stock of what we're putting in our body and our everyday habits, and then thinking from the ground up about how to be more self-aware and how to problem solve using a very basic set of tools we already have inside us. I hope that's helpful. If you enjoyed this podcast, I would be so happy if you liked it, if you subscribed, and if you recommended it to a friend. Thank you so much for joining me, and I'll see you next time.
Trust Your Gut