August 5, 2024 • 44 mins
Not one of us are completely immune to an occasional episode of diarrhea. Whether you can trace it back to something you ate or an uptick in stress, liquid poop is not ideal. Kate and Megan are joined by a giant in the field of gastroenterology, Dr. Jessica Allegretti from Brigham & Women's Hospital in Boston, Massachusetts to do a deep dive discussion into diarrhea.
Together, they discuss the various causes of diarrhea, from common infections and food intolerances to more chronic conditions like irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Dr. Allegretti offers valuable insights into the concerns surrounding Clostridium difficile (C. diff) infections and the complexities involved in diagnosing and treating recurrent cases. We also explore cutting-edge research of live biotherapeutic products (LBPs) and their promising role in the innovative area of fecal microbiota transplantation (FMT) with the guidance of this world-renowned expert.
And, we couldn't discuss diarrhea without acknowledging the potential role of food, stress and the intricate relationship between our gut microbiome and our behaviors. Kate and Megan provide practical tips and tricks to the nutritional and behavioral management of this often times anxiety provoking symptom that leave all listeners feeling empowered with strategies when it comes to the runs.
Whether you've had C.Diff, are managing IBS-D or just curious about this common symptom this episode is a must listen! Tune in for practical insights and valuable strategies to improve your well-being and gut health.
Read more:
Diagnosis and Management of Clostridioides difficile Infection in Patients with Inflammatory Bowel Disease
Yale Medicine: C. Diff Infection overview
Approach to the Patient with Diarrhea and Malabsorption
Low FODMAP tools
Diaphragmatic breathing (video by Dr. Megan Riehl)
This podcast was sponsored by Salix Pharmaceuticals
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate Scarlata (00:17):
This podcast has been sponsored by Salix
Pharmaceuticals, or a healthcareprovider, you are in the right
place.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome tothe Gut Health Podcast, where we
(00:42):
talk all things related to yourgut and well-being.
We are your hosts.
I'm Kate Scarlata, GI dietitian
Dr. Megan Riehl (00:52):
and I'm Dr Megan Riehl.
We have a very exciting podcastfor you today.
We are talking about perhaps aless rated symptom, but one that
can truly be embarrassing,unpredictable and sometimes
tricky to treat.
We're going to talk aboutdiarrhea friends.
We'll tackle different causesof diarrhea and treatments from
C, diff to IBSD, with ourincredible guest today, Dr
(01:14):
Jessica Allegretti.
Kate Scarlata (01:16):
Yes, so let's get some background.
Dr Allegretti is aworld-renowned
gastroenterologist andresearcher.
She serves as the medicaldirector of the Crohn's and
Colitis Center at the Brighamand Women's Hospital.
Fun fact, I got my dieteticstraining there, so she developed
and leads the hospital's fecalmicrobiota transplantation
program yes, we are going totalk about poop transplants and
(01:41):
she is an international experton this topic.
Her research focuses on theintestinal microbiome and the
consequences of its derangement,with the goal of understanding
the role of microbial dysbiosisand how it impacts disease.
Welcome, Dr Allegretti.
Dr. Jessica Allegretti (01:59):
Thank you so much for having me.
I'm really excited to be hereto talk about my absolute
favorite topic.
Dr. Megan Riehl (02:04):
Excellent, excellent, all right.
So in this world of gut health,we like to bust myths and
address misinformation, becausethere is a lot of stuff out
there that is not based inscience or coming from a
reputable source like yourself.
So, Dr.
Allegretti, what is a commonmyth in your world of GI that
you would like to bust today?
Dr. Jessica Allegretti (02:26):
Yeah, thank you for asking this and so
, as you mentioned, you know, alot of my practice is managing C
diff and complicated C diffinfections, and this is a
disease that really does affectelderly patients, can affect
anybody and I'm sure we'll getinto that.
But what I often see is thatpatients who are diagnosed with
C diff really get isolated.
(02:46):
Their families don't want to bearound them.
They really get isolated fromyou know, not invited to social
events, and really I'm here totell you that these patients are
not contagious.
They can be out in the worldand, in fact, once you're on
antibiotics and not havingdiarrhea anymore, it's totally
fine to be around your familymembers, to interact with them,
to have them in your homes andyou really don't need to isolate
(03:08):
from them.
In fact, we are probably biggerrisks to them than they are to
us, you know, as people not onantibiotics with intact
microbiomes and immune systems.
So please and let yourgrandparents and parents come
over for Thanksgiving.
Don't isolate from them.
Dr. Megan Riehl (03:23):
All right.
So people are probably alreadysighing a big feeling of relief
and we're already bringing thecommunity back together.
So thank you.
Kate Scarlata (03:31):
I love it.
All right, so I'm going to diveinto just a basic question.
Can you define diarrhea and howcommon is it?
Dr. Jessica Allegretti (03:40):
Yeah.
So it's incredible to me how Iwould say misunderstood diarrhea
is.
I think many people patients Itake care of really don't know
what I mean when I say that, andso I would say, just out the
gate, what I often will askpatients is if I was to put your
poop in a cup, does it take theshape of a cup or does it have
its own shape?
(04:00):
Right, you're really looking atunformed loose stool, and you
know I will often examine thesample myself because you'll be
surprised.
So people don't really knowwhat the definition is, and so I
would say the traditionaldefinition is loose stools,
liquid or watery bowel movements.
Right, it can be discussing theconsistency and really the
(04:20):
increase in frequency as well,and, as I'm sure we'll get into,
there's lots of reasons why youcan have diarrhea, but this is
an extremely common condition.
If we think about worldwideacute diarrheal illnesses that
are really mostly infectious innature, there's about 1.7
billion cases of diarrhea everyyear worldwide, so this is a
(04:42):
common problem.
Kate Scarlata (04:43):
Amazing.
That is amazing that it impactsso many people.
Is it more in underdevelopedcountries?
Is that a bigger problem withdifferent parasites and things?
Dr. Jessica Allegretti (04:53):
Yeah, it's interesting.
So I mean certainly, dependingif you're discussing the
developing world versus theother areas around the world,
you're looking at differentprevalences of different types
of diarrhea.
Certainly, world you're lookingat different prevalences of
different types of diarrhea.
Certainly, it's still a bigproblem in the development world
as well, but probably withregards to infectious disease
complications, certain viruses,norovirus, adenovirus, for
(05:14):
example we see a lot of that indeveloping nations.
Kate Scarlata (05:18):
Interesting.
So what are some of the commonsort of sources or underlying
causes of diarrhea in yourpractice?
Dr. Jessica Allegretti (05:27):
Yeah, so I think there's always several
buckets that you can putpatients in when they're
presenting with diarrhea.
That I think through when I'mthinking through.
What's the differential, forthis Infection certainly is
always high on the list that youneed to rule out and that can
be viral bacterial parasitic,and there's a number of tests
that we can run to rule that out.
Food intolerances certainly.
(05:47):
Could this be dietary-mediatedmedications.
So certain medications can havemany GI side effects and we
know certainly antibiotics canlead to diarrhea.
That's always the firstquestion I ask.
But then certainly underlyingGI disorders like irritable
bowel syndrome, likeinflammatory bowel disease,
celiac disease, bile salt,diarrhea, there's a number of
(06:07):
conditions that we can assessfor.
And so when I'm seeing somebodyout the gate, these are a lot
of the things that I'm thinkingthrough when I'm running through
the history.
But my practice by far and awayis inflammatory bowel disease
and C diff infection, which iswhat I tend to focus on.
Dr. Megan Riehl (06:22):
Okay, thank you .
So now I get to let you reallydive into the weeds here and
let's talk what is C.
diff diarrhea and start to tellus about how you treat it?
Dr. Jessica Allegretti (06:34):
Yeah, so C diff.
I think there's so manymisconceptions about C diff.
I think it's really complicated, you know, for being a bacteria
that's been around for a while.
You know it's identified in thefifties.
I think there's still a lot ofchallenges in both diagnosing
and treating this patientpopulation.
And so C diff is a bacteria,it's a gram-positive organism
that is everywhere.
(06:55):
It's in our environment.
If I was to take all the meatout of the grocery store and
culture it, a lot of it wouldhave C diff spores in it.
So C diff is around.
When you're eating, a lot of itwould have C diff spores in it.
So C diff is around.
When you're eating, you'reswallowing spores.
It comes in two forms a sporeform and then a vegetative form.
So the natural life cycle isyou're swallowing these spores,
you're pooping them out, you'regoing about your day and you can
(07:15):
be colonized with this organismwith really out any consequence
.
And throughout your life youwill be colonized and
decolonized again and you maynever know.
Throughout your life you willbe colonized and decolonized
again and you may never know.
And what happens under theright circumstances in the gut,
usually if you take anantibiotic and get rid of some
of the protective bacteria thatwe have, that is, keeping C diff
(07:36):
in its niche and its ecosystem.
It will then take theopportunity to vegetate and
release a toxin, and it'sactually the toxin that makes
you sick, not the bacteriaitself.
So when we're testing for this,we're really actually looking
for the presence of toxin, andthat's why testing actually can
be quite nuanced, because notall tests that are available
(07:56):
actually look for the presenceof toxin, and so it can be
really challenging todistinguish colonization from
actual infection, and I thinkthat's where somebody like
myself can really help come inand try to differentiate.
What happens is, if somebody iscolonized and there's really
another source of diarrhea, theantibiotics are probably not
going to work to treat thatcause of diarrhea, and the
(08:19):
patients don't know why they'regetting better.
And I've often had patientscome to me saying well, I have
refractory C diff, nothing works.
I'm here to tell you there isno such thing as refractory C
diff.
C diff responds to antibiotictherapy, if not entirely, at
least partially, and so if youare not having any response to
the therapy that's beingprescribed to you, that should
be a red flag to both you andyour provider that there's
(08:41):
something else going on.
That was missed.
But, that being said, themainstay of therapy in fact the
only thing we have to treat Cdiff right now is antibiotics.
There are several guidelines,both from the Infectious Disease
Societies and the GI Societies,that recommend either
vancomycin or fadaxomycin asfirst line.
So those are both two greatantibiotic choices.
(09:03):
The issue with this organism isthat both those antibiotics do a
great job at treating thedisease.
However, because of that sporeform that this organism can take
, there is a high likelihood ofrecurrence, meaning you take the
antibiotic, you feel better andthen somewhere days to weeks
later, the diarrhea just comesback unprompted.
(09:23):
You know it's not like you tookanother antibiotic or something
else happened, it just comesright back.
Most commonly that happensbetween week one and week four
of completing your antibioticcourse.
So that's the time you reallywant to be vigilant and keeping
an eye on your symptoms.
And we know about 20% of peoplewill ultimately recur after a
first course of antibiotics.
(09:43):
I'm here to tell you we don'tknow why people recur.
We don't know.
There's nothing I can tell youto look out for.
There's no specific riskfactors that lead to recurrence,
and that's a lot of the work Iactually do is trying to figure
out how can we predict betterand more quickly who's going to
recur and who's not.
But ultimately, once you dorecur, we know that having a
second, third and fourthrecurrence becomes exponentially
(10:05):
more likely.
And so, once you're down thatpathway, you need a treatment
strategy, which again is alwaysan antibiotic.
But then you need apreventative strategy as well,
and there are several thingsthat we can do to actually
prevent recurrences.
Dr. Megan Riehl (10:20):
So this is the hot topic, right, FMT, and let's
just dive right into that.
Dr. Jessica Allegretti (10:26):
Yeah, thank you, Megan, for bringing
this up.
A lot of ways to prevent C diff.
Well, I shouldn't say a lot.
There are several ways toprevent C diff and FMT is by far
and away, I think, the mostcommon.
You know, in the last decade atleast.
So, if you're not familiar, FMT, or fecal microbiota
transplantation, is literallythe installation of microbial
(10:48):
communities from the gut of ahealthy donor into a patient's
GI tract and so, just like ifyou were to get blood from a
blood bank for a blood donation,we get stool from a stool bank
and it's aggressively screenedfor everything, including
SARS-CoV-2, including monkeypoxand some of the emerging
pathogens.
It can be administered eitherin pill form or in a liquid
(11:09):
preparation that is typicallyadministered via a colonoscopy
or as an enema, and the way thatwe do this is you complete your
course of antibiotics.
We want to see that yoursymptoms have calmed down.
We do a washout because youdon't want any antibiotics on
board when you're putting thatgood bacteria in, and then we
will perform the FMT.
The window of recurrence for Cdiff is eight weeks, meaning
(11:33):
we're going to watch you reallyclosely for eight weeks.
If you get to that eight weekmark and you're still feeling
good, you are done.
This is not a chronic condition.
This is not something that'sgoing to hang over your head
forever.
Your risk goes back to baseline, but we're going to watch you
really closely.
In that eight weeks FMT ishighly successful, but it is not
a hundred percent, as nothingis.
So this yields about, dependingon which studies you read,
(11:56):
between a 75% and 80% successrate at preventing a subsequent
recurrence, which is very good.
However, if you do recur withinthat eight-week period, often
we'll repeat this, and that canbe done again with pills or
colonoscopy, depending on thepatient's preference be done
again with pills or colonoscopy,depending on the patient's
preference.
(12:19):
Now, what's exciting about theselast couple of years is that we
now have FDA-approved productsas well.
So I've been performing FMTwhich is not FDA-approved and
never will be, unfortunately,for the last almost 12 years now
under a policy calledenforcement discretion from the
FDA.
So what this means is that theFDA has stated that this is
investigational but because ofthe need, they allow us to
(12:41):
perform this for clinical careunder this policy, as long as we
state that it's investigationaland discuss the real and
theoretical risks with ourpatients before performing it,
and it can only be done in thesetting of recurrent C diff
infections or C diff notresponding to standard
antibiotics.
So you can't offer FMT foranything, unfortunately, I know
(13:02):
I would say that's another myth.
Busting opportunity here isthat a lot of patients reach out
to me because they want FMT forlots of indications and
unfortunately we cannot offer itfor really anything other than
C diff not responding tostandard antibiotics under this
policy of enforcement discretion.
But what's been exciting inthese last couple of years is
there have been two FDA-approvedproducts for the prevention of
(13:27):
recurrent C diff.
One is VOWST or FMT excuse me,fecal microbiota, spores, live-
brpk they have very long namesfor Vowst, and then also Fecal
Microbiota Live, jslm or REBYOTA, and so these are both
donor-based products, meaningdonors were screened, the
(13:47):
product was created from donormaterial.
One is a pill product and theother is an enema-based product,
and so what's great now is thatwe've got options.
We've got options for patients,and what's nice about how those
two products are labeled isthey don't have a mandate on how
many recurrences the patienthas to have.
It's just really for theprevention of recurrency diff.
(14:08):
So I can start to offer some ofthese things a bit earlier in
the disease paradigm and nothave to wait until somebody has
suffered three or fourrecurrences.
Dr. Megan Riehl (14:16):
So this is great in terms of, you've said,
the number of people that havediarrhea, and then we've got a
huge prevalence of people thatare living with IBS with
diarrhea.
But what you're also helpingour listeners to understand is
that not everybody with IBS,with diarrhea or just diarrhea
is going to be a candidate forthis, and I think you know
that's something.
(14:37):
Unfortunately, when people geton the internet and you know
you're feeling desperate forresources.
You see FMT and it looks soappealing.
The statistics and data, asyou're pointing out, are really
promising, but this is very muchfor those patients with C diff
that are getting these resultsin this treatment.
Dr. Jessica Allegretti (14:57):
Correct, and I have these discussions
almost daily, you know, andagain, I treat patients with
both IBS as well as inflammatorybowel disease, and I think that
there is clinical trial data inboth spaces, and so it's not
surprising that patients areexcited about this option.
And I think a lot of patientswill say to me well, I really do
feel better when I takeantibiotics or probiotics, and
(15:17):
so there must be a microbialpathogenesis to my disease, and
they may be right.
But I think right now that theFMT and these microbiome-based
therapeutics, or LBPs, which isgenerally what this class of
therapies is being called nowlive biotherapeutic products, is
really again only indicated forC diff.
But there is clinical trialinterest, there is definitely
(15:39):
investigations ongoing intoother GI diseases, and so I
think in the future we certainlymay have options that expand
beyond C diff.
We just don't have them rightnow.
Dr. Megan Riehl (15:49):
Okay, and so antibiotics may be the treatment
for C diff initially.
I know people are going to becurious about this.
I hear this in my clinic Arethere any antibiotics that make
you more at risk for developingC diff?
Dr. Jessica Allegretti (16:03):
Yeah, this is a question I get again
every day.
You know, like what's a safeantibiotic?
Which one is the betterantibiotic?
What I would say to that, andwhat I tell all my patients, is
there is no such thing as a safeor good antibiotic with regards
to C differex, although thereare certainly some that are
worse.
And so the first thing that Itell my patients is if you
really have an infection, wedon't want to not treat it.
(16:24):
Right, you need to treat aninfection if you have it, but
what we want to do is avoidunnecessary antibiotic use.
You know, especially in coldand flu season, z-pak
prescriptions run rampant.
Right, but if you have a viralinfection, you don't need
antibiotics.
So it's important to advocatefor yourself and always ask the
question do I need this?
Is there really a bacterialinfection that we're treating?
(16:46):
Because sometimes there isn'tand you don't.
So we want to avoid unnecessaryantibiotic use, because all
antibiotics essentially confersome risk, although there
certainly are some that areworse.
Clindamycin is by far and awaythe worst antibiotic you can
take with regards to C diff risk.
It's essentially likepathognomonic.
(17:06):
With C diff, you tookclindamycin, the risk is high,
and so, certainly if you haveany underlying GI pathology, if
you're immunosuppressed, ifyou've had C diff before, this
is an antibiotic you're going todefinitely want to avoid.
And I will say the most likelyplace you're going to get
clindamycin is at your dentist'soffice, and so if you have a
tooth abscess or you'reundergoing a dental procedure
(17:28):
and clindamycin is mentioned, Iwould say this is something that
you may want to bring up andask if there's an alternative.
Kate Scarlata (17:34):
Perfect, yeah, that's good information.
So I'm just wondering with ourlisteners when they're at the
doctors, when do they reallybring up diarrhea?
Like what are the red flagsthat?
Ooh, this really needs to getclinically worked up.
This isn't just like anoccasional episode of diarrhea
when they overate.
What's prompting a clinicalworkup in your eyes?
Dr. Jessica Allegretti (17:56):
Yeah, absolutely.
I mean, as somebody who assessesdiarrhea every day, you know.
I think that's honestly one ofthe main reasons why I went into
GI, because I saw so many youngpeople, and especially young
women, who were embarrassed totalk about this, who you know
would be suffering unnecessarilybecause they just didn't feel
comfortable bringing it up.
So one of my goals was tocreate a safe space where it
(18:19):
would be comfortable to discussthese things, and I always say
all of my patients universal,both men and women always
apologize to me before theystart to tell me about their
symptoms.
I'm like please stopapologizing.
This is my whole job is to hearabout this.
So you do not need to apologizeto your physicians for
discussing your bowel habits.
This is what we want to knowabout.
(18:39):
But I would say there aredefinitely some red flags blood
in the stool, weight loss,diarrhea that wakes you up from
sleep, that sensation wakes youup and you have to run to the
bathroom.
Those are things that reallyshould prompt an early workup,
and so if you're experiencingany of those, that is a definite
call to your doctor and need tobe evaluated.
Kate Scarlata (19:02):
So you've talked a little bit about infectious
diarrhea and, I think, aboutpatients that have diarrhea and
grab the Imodium, grab theKaopectate.
Is that a good thing if maybean infectious source is present?
What do you do with thatrecommendation?
Dr. Jessica Allegretti (19:18):
Yeah, it is tough and I do think that
this space is evolving as well.
I think, generally speaking, ifsomebody has an infectious
diarrhea we do say to avoidantidiarrheals because you want
to sort of get those toxins outof you, you want to kind of let
it run its course, and so othertypes of symptomatic therapies,
obviously staying very hydratedeven something like a
(19:40):
Pepto-Bismol is probably alittle bit gentler on your
system than, say, an Imodium.
But I would say after about 48or 72 hours, if you're not
getting any better, even withjust a brat diet and hydration,
again that would prompt a workup.
Because if you do have aninfection it would be helpful to
know so we could tailor thetherapy and help keep you
comfortable.
(20:00):
In the setting of C diff, forexample, we definitely don't
recommend Imodium upfront.
However, once we get somebodyon antibiotic therapy for about
48 or 72 hours and things startto calm down, then we actually
can safely use some Imodium tojust help again improve the
patient's quality of life, keepthem comfortable.
So there is a way to do itsafely.
(20:21):
But I would say, especially ifthe diarrhea sort of comes out
of nowhere, you're worried thatmaybe you either ate something
you know you have a foodpoisoning event or people around
you are sick and it does seeminfectious, I would hold off and
really focus on diet hydration.
Wait about 48 to 72 hours andagain, if it's not getting
better, get an assessment.
Kate Scarlata (20:41):
Yeah, that's important.
I think you know we have accessto so many things over the
counter and just once again,talk to your doctor before you
start mucking around withdiarrhea.
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(21:17):
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(21:37):
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Kate Scarlata (21:41):
Okay, so I know this is sort of my area of
expertise, but I'm just curiousas, as far as dietary measures,
you mentioned the BRAT diet,which is bananas, rice,
applesauce and toast.
It's kind of an old therapeuticregimen for diarrhea.
But are there other commondietary culprits that you see in
your practice?
Dr. Jessica Allegretti (22:00):
Yes, I would say both dietary culprits.
And then obviously we use dietas a therapy as well, right To
help with symptoms.
So I think it's on both endsand I think I'm very fortunate
that I get to partner withamazing dietitians as well.
So I think if you're fortunateenough to have that in your
practice, that's amazing.
But I think, especially if youhave a chronic diarrheal
disorder, I think working with anutritionist who has expertise
(22:23):
is obviously best case scenario.
But certainly there are thingsI'm asking about when somebody
is newly presenting.
And so I would say some of theculprits certainly are, I think,
like the classics are dairy andlactose intolerance, gluten
sensitivities, a lot of thosefake sugars, the sorbitols, the
xylatols.
(22:44):
I think a lot of people don'trealize even that they're
consuming them.
Maybe you chew a lot ofols.
I think a lot of people don'trealize even that they're
consuming them.
Maybe you chew a lot of gum oryou suck a lot of those hard
candies mindlessly and you don'teven realize it.
Certainly people who drink alot of carbonated beverages
sometimes that can really causesome real intolerances.
And so these are some of thethings I go through in my
checklist.
We use a lot of the low FODMAPdiet in our practice too, again,
(23:05):
as and.
So I always think about all thethings that are high in FODMAPs
and I start to go through themwith patients and we think about
how much of this are youactually eating?
Do you cook with garlic andonions every single day?
Especially if they're alsocomplaining a lot of bloating
and gas in addition to theirdiarrhea.
So these are some of thechecklists I start to go down
just to try to get a sense ofwhat's going on with the patient
at home, to try to see if theremay be a dietary culprit.
(23:28):
But I would love to hear, Kata,from you if you do anything
different in that regard.
I'm sure you do.
Kate Scarlata (23:33):
No, I mean, you really hit some top dogs.
I think the sugar-free gum andmints is really.
It's funny because patientswill be coming in.
They'll be chewing gum orpopping the mints constantly, so
that is definitely one that canbe a real problem.
I'll do a little recap at theend of our little session on
some of the things, but I thinkyou hit on definitely some of
the top things and the lowFODMAP diet certainly can.
(23:56):
You did good, I did it.
Dr. Megan Riehl (23:58):
Nice job, Dr.
Allegretti.
Kate Scarlata (24:01):
Yeah, so we'll talk a little more about that,
but we'll get into some of thedeets.
But yeah, I'm obviously aproponent of a low FODMAP diet
for diaries, particularly in IBS.
Dr. Megan Riehl (24:11):
I also that coffee, the caffeine, oh yes.
Dr. Jessica Allegretti (24:14):
Thank you.
The coffee yeah yeah, coffeemakes everyone go to the
bathroom, right?
I mean like that's one of itsgreatest functions, and so I
think too, people often don'trealize that, especially if
you're having your cup in themorning and then multiple iced
coffees throughout the afternoon, then maybe you're putting milk
in it and you're putting likebig sugar in it.
There's a lot of things thatcould be going on there.
Dr. Megan Riehl (24:34):
That's right.
That's right, all right.
So with IBSD, we know it'scommon.
We've had several DGBI disorderof gut brain experts on the
podcast already, so we know it'scommon.
And we also have talked alittle bit about overlapping
diagnoses such as IBD,inflammatory bowel disease and
celiac disease.
(24:54):
So what are some of the commonstrategies in your patient group
and in your clinic that you useto help treat these overlapping
conditions with IBSD?
Dr. Jessica Allegretti (25:04):
Yeah, it's interesting.
I see a lot of IBSD in mypractice.
One because there is so muchoverlap in inflammatory bowel
disease and I always tellpatients one of my jobs when
they're presenting with newsymptoms is to sort of
distinguish if they'reinflammatory symptoms or
functional, and so that's sortof the first part of the workup.
But also in a C diff population, even post-FMT, about 40% of
(25:26):
patients will havepost-infection irritable bowel
syndrome, and so this isextremely common.
And so even if they really didnot have any GI issues before
the C diff, many of them willhave what looks to be very
classic IBSD after, even oncethe C diff is completely gone.
And it can be, I would say,jarring to the patient because
(25:47):
they think the C diff is back orthey're worried that it hasn't
cleared.
But really this is sort of thesequela of that underlying
infection, and so I do manage alot of this in sort of various
different buckets and so workingit up and ensuring that that's
in fact what you're treating, Ithink is really important.
I also do a lot of reassurance.
Reassurance and I'm sure youguys have chatted about this
with other guests, but I find,especially in my population,
(26:11):
because I treat so many youngwomen, a lot of women have been
dismissed as well.
It's just IBS, right, and sothey feel like that's almost a
bad word.
When you say that it's like,well, you're, then I'm not going
to get any help or I'm notgoing to get any treatment.
And so I do a lot ofreassurance that these symptoms
are real, that even though Ican't see it, there's no
positive test, right, it'sreally more of a diagnosis of
(26:32):
exclusion, because the testingall comes back negative.
That that I think you know, toreally empower the patients that
this is real, that we're goingto treat this, and then there
are a lot of therapies that wecan use.
I think that in itself goes along way, but we certainly use
diet, as we just talked about.
We use a lot of low FADMAP dietin our practice and again, I
work really closely with anawesome nutritionist who helps
(26:53):
us manage these patients and wetalk about, you know, avoiding
those food triggers, as we justwent through.
I think the mainstay of what weuse is a lot of fiber, you know
, soluble fiber, especiallypost-FMT.
I think this is probably thefirst thing I get patients back
on One.
It's great for your microbiome.
We know that this is reallydietary fiber is the food that
(27:15):
your microbiome wants.
You know it's like a reallyeffective prebiotic, and so, and
also two, it's probably one ofthe only therapies that manages
both diarrhea and constipation.
And so really getting patientson a good bowel health regimen
that includes fiber.
And I would say too a lot ofpatients will tell me I eat a
lot of fiber.
I always think no one can eatenough fiber.
(27:36):
I always think Paleolithic manwas eating tree bark.
We can't be doing that.
So most people needsupplementation of some kind,
especially if you're battling anunderlying GI disorder.
And so we work on that.
And I always think, too a lot ofpatients don't appreciate that
if you are using fiber, you haveto be drinking water.
(27:56):
Water and fiber go hand in hand, and if you're not drinking the
water you're not getting thebenefit of the fiber.
So I really prescribe water ina real way and I want patients
to tell me truly how many ouncesthey're drinking.
And so that's usually, I alwayssay, like phase one, step one,
and then we step up to othertypes of therapies like
(28:17):
antidiarrheals, even imodium, aswe just discussed.
I use a lot of bile acidsequestrants in my patient
population, so cholestyramineQuestran.
It comes in a pill and a powderform, so we use a lot of that.
That can work tremendously well, and then I think that's sort
of like step two, and then youknow as we go down the pipeline
there's certainly otherprescription-based therapies
(28:39):
that I use a lot and are safe touse in IBD as well.
So I think there's a lot oflayers to IBSD management and
you can kind of step up to seewhat the patient's needs
actually are.
Dr. Megan Riehl (28:51):
Great.
And then we've also got ourgut-brain therapies.
Dr. Jessica Allegretti (28:54):
Of course.
How could we not mention that.
Critical?
Dr. Megan Riehl (28:57):
Critical right, so we'll talk a little bit more
about that.
I think in a little bit some ofthe strategies that I might
recommend for some patients.
Now the gut-brain microbiomeaccess this is certainly a topic
of your research and there'ssome very interesting scientific
adventures out there that arehappening in this area of
(29:18):
research.
Can you describe what we'relearning about this
interrelationship between ourgut microbes and the brain and
the gut microbiome?
Dr. Jessica Allegretti (29:26):
Yeah, absolutely, it really is
fascinating.
I think science has come a longway, but we still have so much
to learn, and I think I'vealways been a believer that the
brain and the gut are connected.
I think you know, a nervousstomach, like all of those
things, those phrases exist fora reason, and when your brain is
stressed, your gut is stressed,and so I think we see that in
(29:48):
practice and I think that's whythe work you do, megan, is so
critical, because, again,understanding that connection
and understanding your owntriggers and then how to deal
with them really can actuallyhelp tremendously the GI
symptoms, and so I thinkpartnering actually in that
regard is one of the best thingsthat we can do really to get
our patients all the way there.
I think the medications aloneare never enough, right.
(30:10):
I think it's diet and thebehavioral health.
I think all of that, you know,really is a holistic approach to
managing these patients.
But I think from the microbiomestandpoint, it's really
fascinating.
You know we're learning so much,even from animal models, about
how behavior and certainbehaviors can actually be
mediated by the gut microbiome.
(30:31):
You know, I would say there'salways this amazing animal study
that has not been replicated inhumans yet, but that really
it's the brave mouse experiment,where they have a sort of a
timid mouse who won't climb outonto a platform and a very brave
mouse who will.
They actually do fecaltransplants from each other on
these animals and you actuallycan see the behavior phenotypes
(30:51):
switch, and so to me that'sincredible.
And so there is clearlymicrobiome pathogenesis here.
I think how we're actuallygoing to implement that into
human disease I think is stillevolving.
We are seeing FMT and othermicrobiome therapeutics already
being assessed for otherneurologic conditions,
psychiatric conditions.
(31:11):
So I think not just you knowwell beyond GI, I think again
modulating the microbiome inother disorders, especially
those that are sort of brain-gutconnected, we're really
starting to see some problems.
So I think this is a reallyinteresting and exciting area of
exploration, but again, westill have so much to learn.
Dr. Megan Riehl (31:29):
Yeah, it's fascinating, our brave mice.
Look at them go, I know sobeing brave, being resilient.
Stress let's talk about it realquick.
Stress and diarrhea how do youtalk to your patients about how
these emotional factors canincrease diarrhea?
Dr. Jessica Allegretti (31:47):
Yeah.
So I mean I bring it up topatients.
I think one recognizing andhaving the patients recognize
that it is linked to theirsymptoms.
I think for some people it canbe eye-opening.
No one's ever said that to them.
Think about when your symptomsare the worst.
Is it when you're stressed,when something bad has happened
in your life, when work iskicking up?
Think about that.
(32:08):
And then are you avoidingleaving your house?
Are you, you know?
Are you now having a moreavoided behavior because of it?
And I think patients often willsay to me this is the first time
you know I'm having thisrealization.
So I think, just having thetime set aside to actually have
those conversations upfront, andthen really recognizing that I
can't just manage the diarrhea,we have to manage your stress as
(32:30):
well.
We have to manage your behavior, we have to help that aspect,
otherwise we're never going toget all the way there.
And so I think, again, reallyemphasizing that as a really
important part of their therapyplan is really important and
also de-stigmatizing it right,because I do think too, a lot of
patients may say, well, likeI'll take whatever medication
(32:51):
you prescribe, but like I'm notgoing to go talk to a therapist.
You know I've certainly heardpatients say that to me, and so
I'll explain that again a lot oftheir GI symptoms are being,
you know, modulated by theirmental health, by their stress,
and that I can't do my job if wedon't also address that.
And I think when it's phrased inthat way, I think patients are
(33:13):
a lot more open, although I willsay, I think today, luckily, I
think many patients are veryinterested in mental health
support and I think it really isan important part of GI care.
Thank you for acknowledgingthat.
Absolutely the hugely importantpart.
And I think, just a little plugfor our center we really feel,
(33:33):
again, that all new patientscoming through should meet not
only with their healthcareprovider but also with a
nutritionist and with apsychologist, which we're in the
process of hiring now, yay, sothat's really a whole package.
I think you really need thatwhole holistic approach and
everyone's going to havedifferent needs, right?
I mean, you may not need tomeet with a psychologist every
(33:55):
time you come in and you may notneed a dietitian every time,
but you know, I think everyoneis going to be different and
some people may need those muchmore than others and I think,
again, it's really hard for usto do our jobs if these other
aspects aren't being addressedin a meaningful way.
Kate Scarlata (34:09):
Yeah, we call that the dream team and mind
your gut, you know getting thatdream team in place and it does
make a difference and I think itlets you do your job.
We can do our job, thepsychologist can do their job.
Maybe a pelvic floor physicaltherapist is brought in too.
Yes, that's really nice whenyou can bring collaborative care
(34:29):
, absolutely.
So I just wanted to quicklyregroup with the nutritional
lens for diarrhea, and DrAllegretti did a great job
reviewing some of the key thingsand factors that I would also
address, but I'm going to justgo through these a little bit.
So lactose is the sugar in milk.
It's commonly malabsorbed andwhen we think about restricting
(34:50):
lactose, you don't necessarilyhave to restrict all dairy.
It's really this milk sugarthat's problematic.
So things like aged cheeses,butter, very little lactose,
milk, drinking a cup of milk,having some pudding or ice cream
it's going to have a lot more.
So milk and the things that arewatery have more lactose, so
(35:10):
keep that in mind.
Fructose can be a problem too,especially when it's an excess
of glucose in a food.
So some of the things to keepin mind fructose is a small
carbohydrate.
Like lactose drags water intothe gut, so things like agave
syrup that are added to a lot ofmore like health food type
products honey, high fructosecorn syrup that you may find in
(35:32):
a lot of convenience foods, buteven apples, watermelon, pears
those all have excess fructose,so those can be problematic as
well.
Caffeine we talked about that.
That can stimulate that gutmotility and when you have
diarrhea you want things to be alittle bit slower.
Give the colon some chance toabsorb some of the extra fluid
in the colon.
(35:53):
If you're speeding things up,that's a problem.
Alcohol can be a big problem.
So if you're a big weekendwarrior drinker and you notice a
big uptick in diarrhea on theweekends, hello, people pay
attention to your alcoholconsumption because that also is
a GI irritant but also canreally trigger diarrhea,
(36:14):
particularly when we'reoverdoing it.
And then Dr Allegretti did agreat job talking about sugar
alcohol.
So these are your sorbitol,your xylitol, maltolol in your
sugar-free gum and mints, alsonaturally found in some foods.
So prunes, for instance, greatremedy if you're constipated.
It also has natural sugaralcohols.
(36:34):
Drags a lot of water in the gut,causes diarrhea.
So stone fruits are in thatfamily as well.
Cauliflower, celery, even alittle sweet potato, might have
too much sugar alcohol for you.
A dietitian can help youidentify these foods and food
triggers for you.
But that's just a little quickrecap.
And then one last one that Ithink I actually had an issue
(36:56):
with this, and that is wheatbran, whole wheat breads, whole
grain crackers.
I ate a whole box of wheatthins in a car ride and yeah,
don't do that.
That might trigger a little bitof diarrhea, so that could be a
problem as well.
That's sort of a little regroupon diarrhea and diet and I'll
move on to Dr Riehl for maybesome behavioral therapies for
(37:19):
diarrhea.
Dr. Megan Riehl (37:20):
Yeah.
So thanks for bringing that up,being mindful of those car
snacks before you take a familyvacation.
I have to appreciate DrAllegretti mentioning creating a
safe space to talk about someof these things.
So, again, we don't tend toshare our diarrhea woes when
we're at a cocktail party or atour kid's soccer game, but being
(37:42):
able to talk with your doctorabout this and how stress
affects our body, and when weare stressed and stress can come
from all over the place stresshormones like cortisol and
adrenaline can stimulate ourintestines and speed up bowel
movements, which leads todiarrhea stimulate our
intestines and speed up bowelmovements, which leads to
diarrhea.
And so the relationship betweenstress and diarrhea also is
(38:03):
individual and complex.
There's a lot of differentfactors that we've talked about
today antibiotic use, nutrition,and then we've got stress.
And so, while just as I'mtalking and our listeners are
listening, think about this foryourself.
Listeners, how are you doingwith the management of your
stress?
Because it can really changeour eating habits.
(38:23):
So, for example, when we'rereally stressed, we might be
more prone to reach for thatcarton of Ben and Jerry's and
before you know it, it's gone.
You're eating more processed,high-fat foods, foods of
convenience, if you're feelingexhausted from your stress, it's
easier to pull throughMcDonald's and grab a
cheeseburger as opposed togetting home and preparing
something.
So that stress can really driveour behaviors.
(38:45):
And what I'll also say is thatthe three of us here going
through this podcast today, aswell as every single listener,
is not immune to stress, and sothis is our opportunity to
really recognize that havingyour toolbox ready to go and
practicing stress managementtechniques regularly is so
(39:06):
helpful for really just ahealthy lifestyle that makes you
less prone to GI distress.
Before I give you some tips andtricks of ways that I like to
practice relaxation, somethingthat I go through with a lot of
my patients when we're meetingand I'm actually prescribing
relaxation as an interventionfor their IBS, or even for IBD
(39:28):
and other digestive issues isthe idea that it's not wasted
time to sit and be present andbuild out space for your
relaxation practices.
A lot of times, people are likeI'm just sitting here doing
nothing.
I've got things to do, I amrunning from place to place to
place, and so here are somesuggestions that you might start
(39:50):
to incorporate or maybe you'rejust going to pat yourself on
the back because you're alreadydoing these things, but a couple
of things that we can all dofor relaxation.
So one of my favorite things todo is especially if I'm at my
desk and I'm working quietlyturning on a music app and
listening to piano covers ofcurrent music.
So that's just kind of apeaceful type of music.
There's no words.
(40:11):
I still am able to focus on mytasks, but I feel like I'm
relaxing Diaphragmatic breathing.
Nobody listening is going to besurprised that I mentioned this
, because we can do it in avariety of settings, with our
eyes closed or kind of foldedinto your day.
Also, thinking about things thatyou can do throughout the day
is body scanning.
(40:32):
So everybody, do this with me.
Think about what your shouldersare doing right now.
Chances are you can drop themdown away from your shoulders,
pull your chest back, open yourhands and your mind.
Think about just letting go,letting go of stress, letting go
of tension.
And then a final suggestion isgetting outside for fresh air,
(40:53):
taking a walk.
Leave the earbuds behind, don'tbe trying to multitask while
you're out there, just kind oftaking in the sounds of nature
being present, even if it's afive-minute walk.
This is going to help with youroverall digestion and wellness.
So the takeaways here?
Managing stress throughrelaxation, body movement,
(41:13):
exercise, healthy lifestylehabits.
They're helpful from a stressmanagement perspective, for our
general life and functioning,but also so profoundly helpful
for our GI health.
So hopefully, this hasempowered you with a few
strategies.
And now, Dr Allegretti, we'velearned a lot from your
expertise today and, as we wrapup this episode, we like to ask
(41:38):
all of our guests the followingquestion Dr Allegretti, what is
something that you prioritizewhen it comes to your overall
health and wellness?
Dr. Jessica Allegretti (41:48):
First of all, I feel like I just learned
so much from both of you, sothank you both.
And for me you know I am anewish mom, I have a
three-year-old and I think tojust like learning how to find
myself and make space for myselfwith a young child at home,
which I'm sure a lot of peoplelistening I'm sure struggle with
.
For me it was always aboutphysical movement and exercise
(42:10):
and just figuring out when to dothat and how to get it done.
And you know I used to do a loton the weekends, but once you
have a young child, yourweekends are no longer yours.
So scheduling exercise into myworkday, putting it on my
calendar like it's anappointment, has really helped
me, and also recognizing like itdoesn't have to be the craziest
workout you've ever done.
You know, even if it's justdoing something is better than
(42:32):
doing nothing, and so that'sreally what has helped me, I
think just maintain sanity andoverall health through the
pandemic and also through earlymotherhood.
Kate Scarlata (42:42):
Yeah, I can relate to that.
You know my kids are grown now,but we would put exercise on
our calendar like a doctor'sappointment.
You have to you know the thingsthat matter to you, the
important things.
Sometimes I would just say dosomething fun, you know, and
plan something fun because youneed fun date nights, whatever
it is, but just to really likewrap up and enjoy life and all
(43:07):
of that stress reducing rightwhen you're taking care of
yourself.
So huge thanks.
This was amazing.
Talk about learning a lot.
I learned a lot from you today,dr Allegretti, and really
appreciate the work that you'redoing, moving the bar and really
understanding the gutmicrobiomes role here in GI
conditions, and your name isworld-renowned for this work, so
(43:31):
it is quite amazing.
So thank you.
Next up we have the sportsdietitian for the Kansas City
Chiefs, eslie Bonsey, and she'sgoing to join us to discuss the
role of exercise in GI distress.
So this will be a reallyinteresting.
Maybe we'll get a little youknow, taylor Trav info.
(43:52):
You never know.
We'll try to dig a little deep,but this will be a really
excellent and informativepodcast coming up at you next.
So thank you, try to dig alittle deep, but this will be a
really excellent and informativepodcast coming up at you next.
So thank you and thanks again,dr Allegretti, for an amazing
podcast.
Dr. Jessica Allegretti (44:05):
Thanks for having me.
Dr. Megan Riehl (44:07):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at the Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
This podcast has been sponsored by Salix
Pharmaceuticals, or a healthcareprovider, you are in the right
place.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome tothe Gut Health Podcast, where we
(00:42):
talk all things related to yourgut and well-being.
We are your hosts.
I'm Kate Scarlata, GI dietitian
Dr. Megan Riehl (00:52):
and I'm Dr Megan Riehl.
We have a very exciting podcastfor you today.
We are talking about perhaps aless rated symptom, but one that
can truly be embarrassing,unpredictable and sometimes
tricky to treat.
We're going to talk aboutdiarrhea friends.
We'll tackle different causesof diarrhea and treatments from
C, diff to IBSD, with ourincredible guest today, Dr
(01:14):
Jessica Allegretti.
Kate Scarlata (01:16):
Yes, so let's get some background.
Dr Allegretti is aworld-renowned
gastroenterologist andresearcher.
She serves as the medicaldirector of the Crohn's and
Colitis Center at the Brighamand Women's Hospital.
Fun fact, I got my dieteticstraining there, so she developed
and leads the hospital's fecalmicrobiota transplantation
program yes, we are going totalk about poop transplants and
(01:41):
she is an international experton this topic.
Her research focuses on theintestinal microbiome and the
consequences of its derangement,with the goal of understanding
the role of microbial dysbiosisand how it impacts disease.
Welcome, Dr Allegretti.
Dr. Jessica Allegretti (01:59):
Thank you so much for having me.
I'm really excited to be hereto talk about my absolute
favorite topic.
Dr. Megan Riehl (02:04):
Excellent, excellent, all right.
So in this world of gut health,we like to bust myths and
address misinformation, becausethere is a lot of stuff out
there that is not based inscience or coming from a
reputable source like yourself.
So, Dr.
Allegretti, what is a commonmyth in your world of GI that
you would like to bust today?
Dr. Jessica Allegretti (02:26):
Yeah, thank you for asking this and so
, as you mentioned, you know, alot of my practice is managing C
diff and complicated C diffinfections, and this is a
disease that really does affectelderly patients, can affect
anybody and I'm sure we'll getinto that.
But what I often see is thatpatients who are diagnosed with
C diff really get isolated.
(02:46):
Their families don't want to bearound them.
They really get isolated fromyou know, not invited to social
events, and really I'm here totell you that these patients are
not contagious.
They can be out in the worldand, in fact, once you're on
antibiotics and not havingdiarrhea anymore, it's totally
fine to be around your familymembers, to interact with them,
to have them in your homes andyou really don't need to isolate
(03:08):
from them.
In fact, we are probably biggerrisks to them than they are to
us, you know, as people not onantibiotics with intact
microbiomes and immune systems.
So please and let yourgrandparents and parents come
over for Thanksgiving.
Don't isolate from them.
Dr. Megan Riehl (03:23):
All right.
So people are probably alreadysighing a big feeling of relief
and we're already bringing thecommunity back together.
So thank you.
Kate Scarlata (03:31):
I love it.
All right, so I'm going to diveinto just a basic question.
Can you define diarrhea and howcommon is it?
Dr. Jessica Allegretti (03:40):
Yeah.
So it's incredible to me how Iwould say misunderstood diarrhea
is.
I think many people patients Itake care of really don't know
what I mean when I say that, andso I would say, just out the
gate, what I often will askpatients is if I was to put your
poop in a cup, does it take theshape of a cup or does it have
its own shape?
(04:00):
Right, you're really looking atunformed loose stool, and you
know I will often examine thesample myself because you'll be
surprised.
So people don't really knowwhat the definition is, and so I
would say the traditionaldefinition is loose stools,
liquid or watery bowel movements.
Right, it can be discussing theconsistency and really the
(04:20):
increase in frequency as well,and, as I'm sure we'll get into,
there's lots of reasons why youcan have diarrhea, but this is
an extremely common condition.
If we think about worldwideacute diarrheal illnesses that
are really mostly infectious innature, there's about 1.7
billion cases of diarrhea everyyear worldwide, so this is a
(04:42):
common problem.
Kate Scarlata (04:43):
Amazing.
That is amazing that it impactsso many people.
Is it more in underdevelopedcountries?
Is that a bigger problem withdifferent parasites and things?
Dr. Jessica Allegretti (04:53):
Yeah, it's interesting.
So I mean certainly, dependingif you're discussing the
developing world versus theother areas around the world,
you're looking at differentprevalences of different types
of diarrhea.
Certainly, world you're lookingat different prevalences of
different types of diarrhea.
Certainly, it's still a bigproblem in the development world
as well, but probably withregards to infectious disease
complications, certain viruses,norovirus, adenovirus, for
(05:14):
example we see a lot of that indeveloping nations.
Kate Scarlata (05:18):
Interesting.
So what are some of the commonsort of sources or underlying
causes of diarrhea in yourpractice?
Dr. Jessica Allegretti (05:27):
Yeah, so I think there's always several
buckets that you can putpatients in when they're
presenting with diarrhea.
That I think through when I'mthinking through.
What's the differential, forthis Infection certainly is
always high on the list that youneed to rule out and that can
be viral bacterial parasitic,and there's a number of tests
that we can run to rule that out.
Food intolerances certainly.
(05:47):
Could this be dietary-mediatedmedications.
So certain medications can havemany GI side effects and we
know certainly antibiotics canlead to diarrhea.
That's always the firstquestion I ask.
But then certainly underlyingGI disorders like irritable
bowel syndrome, likeinflammatory bowel disease,
celiac disease, bile salt,diarrhea, there's a number of
(06:07):
conditions that we can assessfor.
And so when I'm seeing somebodyout the gate, these are a lot
of the things that I'm thinkingthrough when I'm running through
the history.
But my practice by far and awayis inflammatory bowel disease
and C diff infection, which iswhat I tend to focus on.
Dr. Megan Riehl (06:22):
Okay, thank you .
So now I get to let you reallydive into the weeds here and
let's talk what is C.
diff diarrhea and start to tellus about how you treat it?
Dr. Jessica Allegretti (06:34):
Yeah, so C diff.
I think there's so manymisconceptions about C diff.
I think it's really complicated, you know, for being a bacteria
that's been around for a while.
You know it's identified in thefifties.
I think there's still a lot ofchallenges in both diagnosing
and treating this patientpopulation.
And so C diff is a bacteria,it's a gram-positive organism
that is everywhere.
(06:55):
It's in our environment.
If I was to take all the meatout of the grocery store and
culture it, a lot of it wouldhave C diff spores in it.
So C diff is around.
When you're eating, a lot of itwould have C diff spores in it.
So C diff is around.
When you're eating, you'reswallowing spores.
It comes in two forms a sporeform and then a vegetative form.
So the natural life cycle isyou're swallowing these spores,
you're pooping them out, you'regoing about your day and you can
(07:15):
be colonized with this organismwith really out any consequence
.
And throughout your life youwill be colonized and
decolonized again and you maynever know.
Throughout your life you willbe colonized and decolonized
again and you may never know.
And what happens under theright circumstances in the gut,
usually if you take anantibiotic and get rid of some
of the protective bacteria thatwe have, that is, keeping C diff
(07:36):
in its niche and its ecosystem.
It will then take theopportunity to vegetate and
release a toxin, and it'sactually the toxin that makes
you sick, not the bacteriaitself.
So when we're testing for this,we're really actually looking
for the presence of toxin, andthat's why testing actually can
be quite nuanced, because notall tests that are available
(07:56):
actually look for the presenceof toxin, and so it can be
really challenging todistinguish colonization from
actual infection, and I thinkthat's where somebody like
myself can really help come inand try to differentiate.
What happens is, if somebody iscolonized and there's really
another source of diarrhea, theantibiotics are probably not
going to work to treat thatcause of diarrhea, and the
(08:19):
patients don't know why they'regetting better.
And I've often had patientscome to me saying well, I have
refractory C diff, nothing works.
I'm here to tell you there isno such thing as refractory C
diff.
C diff responds to antibiotictherapy, if not entirely, at
least partially, and so if youare not having any response to
the therapy that's beingprescribed to you, that should
be a red flag to both you andyour provider that there's
(08:41):
something else going on.
That was missed.
But, that being said, themainstay of therapy in fact the
only thing we have to treat Cdiff right now is antibiotics.
There are several guidelines,both from the Infectious Disease
Societies and the GI Societies,that recommend either
vancomycin or fadaxomycin asfirst line.
So those are both two greatantibiotic choices.
(09:03):
The issue with this organism isthat both those antibiotics do a
great job at treating thedisease.
However, because of that sporeform that this organism can take
, there is a high likelihood ofrecurrence, meaning you take the
antibiotic, you feel better andthen somewhere days to weeks
later, the diarrhea just comesback unprompted.
(09:23):
You know it's not like you tookanother antibiotic or something
else happened, it just comesright back.
Most commonly that happensbetween week one and week four
of completing your antibioticcourse.
So that's the time you reallywant to be vigilant and keeping
an eye on your symptoms.
And we know about 20% of peoplewill ultimately recur after a
first course of antibiotics.
(09:43):
I'm here to tell you we don'tknow why people recur.
We don't know.
There's nothing I can tell youto look out for.
There's no specific riskfactors that lead to recurrence,
and that's a lot of the work Iactually do is trying to figure
out how can we predict betterand more quickly who's going to
recur and who's not.
But ultimately, once you dorecur, we know that having a
second, third and fourthrecurrence becomes exponentially
(10:05):
more likely.
And so, once you're down thatpathway, you need a treatment
strategy, which again is alwaysan antibiotic.
But then you need apreventative strategy as well,
and there are several thingsthat we can do to actually
prevent recurrences.
Dr. Megan Riehl (10:20):
So this is the hot topic, right, FMT, and let's
just dive right into that.
Dr. Jessica Allegretti (10:26):
Yeah, thank you, Megan, for bringing
this up.
A lot of ways to prevent C diff.
Well, I shouldn't say a lot.
There are several ways toprevent C diff and FMT is by far
and away, I think, the mostcommon.
You know, in the last decade atleast.
So, if you're not familiar, FMT, or fecal microbiota
transplantation, is literallythe installation of microbial
(10:48):
communities from the gut of ahealthy donor into a patient's
GI tract and so, just like ifyou were to get blood from a
blood bank for a blood donation,we get stool from a stool bank
and it's aggressively screenedfor everything, including
SARS-CoV-2, including monkeypoxand some of the emerging
pathogens.
It can be administered eitherin pill form or in a liquid
(11:09):
preparation that is typicallyadministered via a colonoscopy
or as an enema, and the way thatwe do this is you complete your
course of antibiotics.
We want to see that yoursymptoms have calmed down.
We do a washout because youdon't want any antibiotics on
board when you're putting thatgood bacteria in, and then we
will perform the FMT.
The window of recurrence for Cdiff is eight weeks, meaning
(11:33):
we're going to watch you reallyclosely for eight weeks.
If you get to that eight weekmark and you're still feeling
good, you are done.
This is not a chronic condition.
This is not something that'sgoing to hang over your head
forever.
Your risk goes back to baseline, but we're going to watch you
really closely.
In that eight weeks FMT ishighly successful, but it is not
a hundred percent, as nothingis.
So this yields about, dependingon which studies you read,
(11:56):
between a 75% and 80% successrate at preventing a subsequent
recurrence, which is very good.
However, if you do recur withinthat eight-week period, often
we'll repeat this, and that canbe done again with pills or
colonoscopy, depending on thepatient's preference be done
again with pills or colonoscopy,depending on the patient's
preference.
(12:19):
Now, what's exciting about theselast couple of years is that we
now have FDA-approved productsas well.
So I've been performing FMTwhich is not FDA-approved and
never will be, unfortunately,for the last almost 12 years now
under a policy calledenforcement discretion from the
FDA.
So what this means is that theFDA has stated that this is
investigational but because ofthe need, they allow us to
(12:41):
perform this for clinical careunder this policy, as long as we
state that it's investigationaland discuss the real and
theoretical risks with ourpatients before performing it,
and it can only be done in thesetting of recurrent C diff
infections or C diff notresponding to standard
antibiotics.
So you can't offer FMT foranything, unfortunately, I know
(13:02):
I would say that's another myth.
Busting opportunity here isthat a lot of patients reach out
to me because they want FMT forlots of indications and
unfortunately we cannot offer itfor really anything other than
C diff not responding tostandard antibiotics under this
policy of enforcement discretion.
But what's been exciting inthese last couple of years is
there have been two FDA-approvedproducts for the prevention of
(13:27):
recurrent C diff.
One is VOWST or FMT excuse me,fecal microbiota, spores, live-
brpk they have very long namesfor Vowst, and then also Fecal
Microbiota Live, jslm or REBYOTA, and so these are both
donor-based products, meaningdonors were screened, the
(13:47):
product was created from donormaterial.
One is a pill product and theother is an enema-based product,
and so what's great now is thatwe've got options.
We've got options for patients,and what's nice about how those
two products are labeled isthey don't have a mandate on how
many recurrences the patienthas to have.
It's just really for theprevention of recurrency diff.
(14:08):
So I can start to offer some ofthese things a bit earlier in
the disease paradigm and nothave to wait until somebody has
suffered three or fourrecurrences.
Dr. Megan Riehl (14:16):
So this is great in terms of, you've said,
the number of people that havediarrhea, and then we've got a
huge prevalence of people thatare living with IBS with
diarrhea.
But what you're also helpingour listeners to understand is
that not everybody with IBS,with diarrhea or just diarrhea
is going to be a candidate forthis, and I think you know
that's something.
(14:37):
Unfortunately, when people geton the internet and you know
you're feeling desperate forresources.
You see FMT and it looks soappealing.
The statistics and data, asyou're pointing out, are really
promising, but this is very muchfor those patients with C diff
that are getting these resultsin this treatment.
Dr. Jessica Allegretti (14:57):
Correct, and I have these discussions
almost daily, you know, andagain, I treat patients with
both IBS as well as inflammatorybowel disease, and I think that
there is clinical trial data inboth spaces, and so it's not
surprising that patients areexcited about this option.
And I think a lot of patientswill say to me well, I really do
feel better when I takeantibiotics or probiotics, and
(15:17):
so there must be a microbialpathogenesis to my disease, and
they may be right.
But I think right now that theFMT and these microbiome-based
therapeutics, or LBPs, which isgenerally what this class of
therapies is being called nowlive biotherapeutic products, is
really again only indicated forC diff.
But there is clinical trialinterest, there is definitely
(15:39):
investigations ongoing intoother GI diseases, and so I
think in the future we certainlymay have options that expand
beyond C diff.
We just don't have them rightnow.
Dr. Megan Riehl (15:49):
Okay, and so antibiotics may be the treatment
for C diff initially.
I know people are going to becurious about this.
I hear this in my clinic Arethere any antibiotics that make
you more at risk for developingC diff?
Dr. Jessica Allegretti (16:03):
Yeah, this is a question I get again
every day.
You know, like what's a safeantibiotic?
Which one is the betterantibiotic?
What I would say to that, andwhat I tell all my patients, is
there is no such thing as a safeor good antibiotic with regards
to C differex, although thereare certainly some that are
worse.
And so the first thing that Itell my patients is if you
really have an infection, wedon't want to not treat it.
(16:24):
Right, you need to treat aninfection if you have it, but
what we want to do is avoidunnecessary antibiotic use.
You know, especially in coldand flu season, z-pak
prescriptions run rampant.
Right, but if you have a viralinfection, you don't need
antibiotics.
So it's important to advocatefor yourself and always ask the
question do I need this?
Is there really a bacterialinfection that we're treating?
(16:46):
Because sometimes there isn'tand you don't.
So we want to avoid unnecessaryantibiotic use, because all
antibiotics essentially confersome risk, although there
certainly are some that areworse.
Clindamycin is by far and awaythe worst antibiotic you can
take with regards to C diff risk.
It's essentially likepathognomonic.
(17:06):
With C diff, you tookclindamycin, the risk is high,
and so, certainly if you haveany underlying GI pathology, if
you're immunosuppressed, ifyou've had C diff before, this
is an antibiotic you're going todefinitely want to avoid.
And I will say the most likelyplace you're going to get
clindamycin is at your dentist'soffice, and so if you have a
tooth abscess or you'reundergoing a dental procedure
(17:28):
and clindamycin is mentioned, Iwould say this is something that
you may want to bring up andask if there's an alternative.
Kate Scarlata (17:34):
Perfect, yeah, that's good information.
So I'm just wondering with ourlisteners when they're at the
doctors, when do they reallybring up diarrhea?
Like what are the red flagsthat?
Ooh, this really needs to getclinically worked up.
This isn't just like anoccasional episode of diarrhea
when they overate.
What's prompting a clinicalworkup in your eyes?
Dr. Jessica Allegretti (17:56):
Yeah, absolutely.
I mean, as somebody who assessesdiarrhea every day, you know.
I think that's honestly one ofthe main reasons why I went into
GI, because I saw so many youngpeople, and especially young
women, who were embarrassed totalk about this, who you know
would be suffering unnecessarilybecause they just didn't feel
comfortable bringing it up.
So one of my goals was tocreate a safe space where it
(18:19):
would be comfortable to discussthese things, and I always say
all of my patients universal,both men and women always
apologize to me before theystart to tell me about their
symptoms.
I'm like please stopapologizing.
This is my whole job is to hearabout this.
So you do not need to apologizeto your physicians for
discussing your bowel habits.
This is what we want to knowabout.
(18:39):
But I would say there aredefinitely some red flags blood
in the stool, weight loss,diarrhea that wakes you up from
sleep, that sensation wakes youup and you have to run to the
bathroom.
Those are things that reallyshould prompt an early workup,
and so if you're experiencingany of those, that is a definite
call to your doctor and need tobe evaluated.
Kate Scarlata (19:02):
So you've talked a little bit about infectious
diarrhea and, I think, aboutpatients that have diarrhea and
grab the Imodium, grab theKaopectate.
Is that a good thing if maybean infectious source is present?
What do you do with thatrecommendation?
Dr. Jessica Allegretti (19:18):
Yeah, it is tough and I do think that
this space is evolving as well.
I think, generally speaking, ifsomebody has an infectious
diarrhea we do say to avoidantidiarrheals because you want
to sort of get those toxins outof you, you want to kind of let
it run its course, and so othertypes of symptomatic therapies,
obviously staying very hydratedeven something like a
(19:40):
Pepto-Bismol is probably alittle bit gentler on your
system than, say, an Imodium.
But I would say after about 48or 72 hours, if you're not
getting any better, even withjust a brat diet and hydration,
again that would prompt a workup.
Because if you do have aninfection it would be helpful to
know so we could tailor thetherapy and help keep you
comfortable.
(20:00):
In the setting of C diff, forexample, we definitely don't
recommend Imodium upfront.
However, once we get somebodyon antibiotic therapy for about
48 or 72 hours and things startto calm down, then we actually
can safely use some Imodium tojust help again improve the
patient's quality of life, keepthem comfortable.
So there is a way to do itsafely.
(20:21):
But I would say, especially ifthe diarrhea sort of comes out
of nowhere, you're worried thatmaybe you either ate something
you know you have a foodpoisoning event or people around
you are sick and it does seeminfectious, I would hold off and
really focus on diet hydration.
Wait about 48 to 72 hours andagain, if it's not getting
better, get an assessment.
Kate Scarlata (20:41):
Yeah, that's important.
I think you know we have accessto so many things over the
counter and just once again,talk to your doctor before you
start mucking around withdiarrhea.
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(21:37):
Xifaxin.
Kate Scarlata (21:41):
Okay, so I know this is sort of my area of
expertise, but I'm just curiousas, as far as dietary measures,
you mentioned the BRAT diet,which is bananas, rice,
applesauce and toast.
It's kind of an old therapeuticregimen for diarrhea.
But are there other commondietary culprits that you see in
your practice?
Dr. Jessica Allegretti (22:00):
Yes, I would say both dietary culprits.
And then obviously we use dietas a therapy as well, right To
help with symptoms.
So I think it's on both endsand I think I'm very fortunate
that I get to partner withamazing dietitians as well.
So I think if you're fortunateenough to have that in your
practice, that's amazing.
But I think, especially if youhave a chronic diarrheal
disorder, I think working with anutritionist who has expertise
(22:23):
is obviously best case scenario.
But certainly there are thingsI'm asking about when somebody
is newly presenting.
And so I would say some of theculprits certainly are, I think,
like the classics are dairy andlactose intolerance, gluten
sensitivities, a lot of thosefake sugars, the sorbitols, the
xylatols.
(22:44):
I think a lot of people don'trealize even that they're
consuming them.
Maybe you chew a lot ofols.
I think a lot of people don'trealize even that they're
consuming them.
Maybe you chew a lot of gum oryou suck a lot of those hard
candies mindlessly and you don'teven realize it.
Certainly people who drink alot of carbonated beverages
sometimes that can really causesome real intolerances.
And so these are some of thethings I go through in my
checklist.
We use a lot of the low FODMAPdiet in our practice too, again,
(23:05):
as and.
So I always think about all thethings that are high in FODMAPs
and I start to go through themwith patients and we think about
how much of this are youactually eating?
Do you cook with garlic andonions every single day?
Especially if they're alsocomplaining a lot of bloating
and gas in addition to theirdiarrhea.
So these are some of thechecklists I start to go down
just to try to get a sense ofwhat's going on with the patient
at home, to try to see if theremay be a dietary culprit.
(23:28):
But I would love to hear, Kata,from you if you do anything
different in that regard.
I'm sure you do.
Kate Scarlata (23:33):
No, I mean, you really hit some top dogs.
I think the sugar-free gum andmints is really.
It's funny because patientswill be coming in.
They'll be chewing gum orpopping the mints constantly, so
that is definitely one that canbe a real problem.
I'll do a little recap at theend of our little session on
some of the things, but I thinkyou hit on definitely some of
the top things and the lowFODMAP diet certainly can.
(23:56):
You did good, I did it.
Dr. Megan Riehl (23:58):
Nice job, Dr.
Allegretti.
Kate Scarlata (24:01):
Yeah, so we'll talk a little more about that,
but we'll get into some of thedeets.
But yeah, I'm obviously aproponent of a low FODMAP diet
for diaries, particularly in IBS.
Dr. Megan Riehl (24:11):
I also that coffee, the caffeine, oh yes.
Dr. Jessica Allegretti (24:14):
Thank you.
The coffee yeah yeah, coffeemakes everyone go to the
bathroom, right?
I mean like that's one of itsgreatest functions, and so I
think too, people often don'trealize that, especially if
you're having your cup in themorning and then multiple iced
coffees throughout the afternoon, then maybe you're putting milk
in it and you're putting likebig sugar in it.
There's a lot of things thatcould be going on there.
Dr. Megan Riehl (24:34):
That's right.
That's right, all right.
So with IBSD, we know it'scommon.
We've had several DGBI disorderof gut brain experts on the
podcast already, so we know it'scommon.
And we also have talked alittle bit about overlapping
diagnoses such as IBD,inflammatory bowel disease and
celiac disease.
(24:54):
So what are some of the commonstrategies in your patient group
and in your clinic that you useto help treat these overlapping
conditions with IBSD?
Dr. Jessica Allegretti (25:04):
Yeah, it's interesting.
I see a lot of IBSD in mypractice.
One because there is so muchoverlap in inflammatory bowel
disease and I always tellpatients one of my jobs when
they're presenting with newsymptoms is to sort of
distinguish if they'reinflammatory symptoms or
functional, and so that's sortof the first part of the workup.
But also in a C diff population, even post-FMT, about 40% of
(25:26):
patients will havepost-infection irritable bowel
syndrome, and so this isextremely common.
And so even if they really didnot have any GI issues before
the C diff, many of them willhave what looks to be very
classic IBSD after, even oncethe C diff is completely gone.
And it can be, I would say,jarring to the patient because
(25:47):
they think the C diff is back orthey're worried that it hasn't
cleared.
But really this is sort of thesequela of that underlying
infection, and so I do manage alot of this in sort of various
different buckets and so workingit up and ensuring that that's
in fact what you're treating, Ithink is really important.
I also do a lot of reassurance.
Reassurance and I'm sure youguys have chatted about this
with other guests, but I find,especially in my population,
(26:11):
because I treat so many youngwomen, a lot of women have been
dismissed as well.
It's just IBS, right, and sothey feel like that's almost a
bad word.
When you say that it's like,well, you're, then I'm not going
to get any help or I'm notgoing to get any treatment.
And so I do a lot ofreassurance that these symptoms
are real, that even though Ican't see it, there's no
positive test, right, it'sreally more of a diagnosis of
(26:32):
exclusion, because the testingall comes back negative.
That that I think you know, toreally empower the patients that
this is real, that we're goingto treat this, and then there
are a lot of therapies that wecan use.
I think that in itself goes along way, but we certainly use
diet, as we just talked about.
We use a lot of low FADMAP dietin our practice and again, I
work really closely with anawesome nutritionist who helps
(26:53):
us manage these patients and wetalk about, you know, avoiding
those food triggers, as we justwent through.
I think the mainstay of what weuse is a lot of fiber, you know
, soluble fiber, especiallypost-FMT.
I think this is probably thefirst thing I get patients back
on One.
It's great for your microbiome.
We know that this is reallydietary fiber is the food that
(27:15):
your microbiome wants.
You know it's like a reallyeffective prebiotic, and so, and
also two, it's probably one ofthe only therapies that manages
both diarrhea and constipation.
And so really getting patientson a good bowel health regimen
that includes fiber.
And I would say too a lot ofpatients will tell me I eat a
lot of fiber.
I always think no one can eatenough fiber.
(27:36):
I always think Paleolithic manwas eating tree bark.
We can't be doing that.
So most people needsupplementation of some kind,
especially if you're battling anunderlying GI disorder.
And so we work on that.
And I always think, too a lot ofpatients don't appreciate that
if you are using fiber, you haveto be drinking water.
(27:56):
Water and fiber go hand in hand, and if you're not drinking the
water you're not getting thebenefit of the fiber.
So I really prescribe water ina real way and I want patients
to tell me truly how many ouncesthey're drinking.
And so that's usually, I alwayssay, like phase one, step one,
and then we step up to othertypes of therapies like
(28:17):
antidiarrheals, even imodium, aswe just discussed.
I use a lot of bile acidsequestrants in my patient
population, so cholestyramineQuestran.
It comes in a pill and a powderform, so we use a lot of that.
That can work tremendously well, and then I think that's sort
of like step two, and then youknow as we go down the pipeline
there's certainly otherprescription-based therapies
(28:39):
that I use a lot and are safe touse in IBD as well.
So I think there's a lot oflayers to IBSD management and
you can kind of step up to seewhat the patient's needs
actually are.
Dr. Megan Riehl (28:51):
Great.
And then we've also got ourgut-brain therapies.
Dr. Jessica Allegretti (28:54):
Of course.
How could we not mention that.
Critical?
Dr. Megan Riehl (28:57):
Critical right, so we'll talk a little bit more
about that.
I think in a little bit some ofthe strategies that I might
recommend for some patients.
Now the gut-brain microbiomeaccess this is certainly a topic
of your research and there'ssome very interesting scientific
adventures out there that arehappening in this area of
(29:18):
research.
Can you describe what we'relearning about this
interrelationship between ourgut microbes and the brain and
the gut microbiome?
Dr. Jessica Allegretti (29:26):
Yeah, absolutely, it really is
fascinating.
I think science has come a longway, but we still have so much
to learn, and I think I'vealways been a believer that the
brain and the gut are connected.
I think you know, a nervousstomach, like all of those
things, those phrases exist fora reason, and when your brain is
stressed, your gut is stressed,and so I think we see that in
(29:48):
practice and I think that's whythe work you do, megan, is so
critical, because, again,understanding that connection
and understanding your owntriggers and then how to deal
with them really can actuallyhelp tremendously the GI
symptoms, and so I thinkpartnering actually in that
regard is one of the best thingsthat we can do really to get
our patients all the way there.
I think the medications aloneare never enough, right.
(30:10):
I think it's diet and thebehavioral health.
I think all of that, you know,really is a holistic approach to
managing these patients.
But I think from the microbiomestandpoint, it's really
fascinating.
You know we're learning so much,even from animal models, about
how behavior and certainbehaviors can actually be
mediated by the gut microbiome.
(30:31):
You know, I would say there'salways this amazing animal study
that has not been replicated inhumans yet, but that really
it's the brave mouse experiment,where they have a sort of a
timid mouse who won't climb outonto a platform and a very brave
mouse who will.
They actually do fecaltransplants from each other on
these animals and you actuallycan see the behavior phenotypes
(30:51):
switch, and so to me that'sincredible.
And so there is clearlymicrobiome pathogenesis here.
I think how we're actuallygoing to implement that into
human disease I think is stillevolving.
We are seeing FMT and othermicrobiome therapeutics already
being assessed for otherneurologic conditions,
psychiatric conditions.
(31:11):
So I think not just you knowwell beyond GI, I think again
modulating the microbiome inother disorders, especially
those that are sort of brain-gutconnected, we're really
starting to see some problems.
So I think this is a reallyinteresting and exciting area of
exploration, but again, westill have so much to learn.
Dr. Megan Riehl (31:29):
Yeah, it's fascinating, our brave mice.
Look at them go, I know sobeing brave, being resilient.
Stress let's talk about it realquick.
Stress and diarrhea how do youtalk to your patients about how
these emotional factors canincrease diarrhea?
Dr. Jessica Allegretti (31:47):
Yeah.
So I mean I bring it up topatients.
I think one recognizing andhaving the patients recognize
that it is linked to theirsymptoms.
I think for some people it canbe eye-opening.
No one's ever said that to them.
Think about when your symptomsare the worst.
Is it when you're stressed,when something bad has happened
in your life, when work iskicking up?
Think about that.
(32:08):
And then are you avoidingleaving your house?
Are you, you know?
Are you now having a moreavoided behavior because of it?
And I think patients often willsay to me this is the first time
you know I'm having thisrealization.
So I think, just having thetime set aside to actually have
those conversations upfront, andthen really recognizing that I
can't just manage the diarrhea,we have to manage your stress as
(32:30):
well.
We have to manage your behavior, we have to help that aspect,
otherwise we're never going toget all the way there.
And so I think, again, reallyemphasizing that as a really
important part of their therapyplan is really important and
also de-stigmatizing it right,because I do think too, a lot of
patients may say, well, likeI'll take whatever medication
(32:51):
you prescribe, but like I'm notgoing to go talk to a therapist.
You know I've certainly heardpatients say that to me, and so
I'll explain that again a lot oftheir GI symptoms are being,
you know, modulated by theirmental health, by their stress,
and that I can't do my job if wedon't also address that.
And I think when it's phrased inthat way, I think patients are
(33:13):
a lot more open, although I willsay, I think today, luckily, I
think many patients are veryinterested in mental health
support and I think it really isan important part of GI care.
Thank you for acknowledgingthat.
Absolutely the hugely importantpart.
And I think, just a little plugfor our center we really feel,
(33:33):
again, that all new patientscoming through should meet not
only with their healthcareprovider but also with a
nutritionist and with apsychologist, which we're in the
process of hiring now, yay, sothat's really a whole package.
I think you really need thatwhole holistic approach and
everyone's going to havedifferent needs, right?
I mean, you may not need tomeet with a psychologist every
(33:55):
time you come in and you may notneed a dietitian every time,
but you know, I think everyoneis going to be different and
some people may need those muchmore than others and I think,
again, it's really hard for usto do our jobs if these other
aspects aren't being addressedin a meaningful way.
Kate Scarlata (34:09):
Yeah, we call that the dream team and mind
your gut, you know getting thatdream team in place and it does
make a difference and I think itlets you do your job.
We can do our job, thepsychologist can do their job.
Maybe a pelvic floor physicaltherapist is brought in too.
Yes, that's really nice whenyou can bring collaborative care
(34:29):
, absolutely.
So I just wanted to quicklyregroup with the nutritional
lens for diarrhea, and DrAllegretti did a great job
reviewing some of the key thingsand factors that I would also
address, but I'm going to justgo through these a little bit.
So lactose is the sugar in milk.
It's commonly malabsorbed andwhen we think about restricting
(34:50):
lactose, you don't necessarilyhave to restrict all dairy.
It's really this milk sugarthat's problematic.
So things like aged cheeses,butter, very little lactose,
milk, drinking a cup of milk,having some pudding or ice cream
it's going to have a lot more.
So milk and the things that arewatery have more lactose, so
(35:10):
keep that in mind.
Fructose can be a problem too,especially when it's an excess
of glucose in a food.
So some of the things to keepin mind fructose is a small
carbohydrate.
Like lactose drags water intothe gut, so things like agave
syrup that are added to a lot ofmore like health food type
products honey, high fructosecorn syrup that you may find in
(35:32):
a lot of convenience foods, buteven apples, watermelon, pears
those all have excess fructose,so those can be problematic as
well.
Caffeine we talked about that.
That can stimulate that gutmotility and when you have
diarrhea you want things to be alittle bit slower.
Give the colon some chance toabsorb some of the extra fluid
in the colon.
(35:53):
If you're speeding things up,that's a problem.
Alcohol can be a big problem.
So if you're a big weekendwarrior drinker and you notice a
big uptick in diarrhea on theweekends, hello, people pay
attention to your alcoholconsumption because that also is
a GI irritant but also canreally trigger diarrhea,
(36:14):
particularly when we'reoverdoing it.
And then Dr Allegretti did agreat job talking about sugar
alcohol.
So these are your sorbitol,your xylitol, maltolol in your
sugar-free gum and mints, alsonaturally found in some foods.
So prunes, for instance, greatremedy if you're constipated.
It also has natural sugaralcohols.
(36:34):
Drags a lot of water in the gut,causes diarrhea.
So stone fruits are in thatfamily as well.
Cauliflower, celery, even alittle sweet potato, might have
too much sugar alcohol for you.
A dietitian can help youidentify these foods and food
triggers for you.
But that's just a little quickrecap.
And then one last one that Ithink I actually had an issue
(36:56):
with this, and that is wheatbran, whole wheat breads, whole
grain crackers.
I ate a whole box of wheatthins in a car ride and yeah,
don't do that.
That might trigger a little bitof diarrhea, so that could be a
problem as well.
That's sort of a little regroupon diarrhea and diet and I'll
move on to Dr Riehl for maybesome behavioral therapies for
(37:19):
diarrhea.
Dr. Megan Riehl (37:20):
Yeah.
So thanks for bringing that up,being mindful of those car
snacks before you take a familyvacation.
I have to appreciate DrAllegretti mentioning creating a
safe space to talk about someof these things.
So, again, we don't tend toshare our diarrhea woes when
we're at a cocktail party or atour kid's soccer game, but being
(37:42):
able to talk with your doctorabout this and how stress
affects our body, and when weare stressed and stress can come
from all over the place stresshormones like cortisol and
adrenaline can stimulate ourintestines and speed up bowel
movements, which leads todiarrhea stimulate our
intestines and speed up bowelmovements, which leads to
diarrhea.
And so the relationship betweenstress and diarrhea also is
(38:03):
individual and complex.
There's a lot of differentfactors that we've talked about
today antibiotic use, nutrition,and then we've got stress.
And so, while just as I'mtalking and our listeners are
listening, think about this foryourself.
Listeners, how are you doingwith the management of your
stress?
Because it can really changeour eating habits.
(38:23):
So, for example, when we'rereally stressed, we might be
more prone to reach for thatcarton of Ben and Jerry's and
before you know it, it's gone.
You're eating more processed,high-fat foods, foods of
convenience, if you're feelingexhausted from your stress, it's
easier to pull throughMcDonald's and grab a
cheeseburger as opposed togetting home and preparing
something.
So that stress can really driveour behaviors.
(38:45):
And what I'll also say is thatthe three of us here going
through this podcast today, aswell as every single listener,
is not immune to stress, and sothis is our opportunity to
really recognize that havingyour toolbox ready to go and
practicing stress managementtechniques regularly is so
(39:06):
helpful for really just ahealthy lifestyle that makes you
less prone to GI distress.
Before I give you some tips andtricks of ways that I like to
practice relaxation, somethingthat I go through with a lot of
my patients when we're meetingand I'm actually prescribing
relaxation as an interventionfor their IBS, or even for IBD
(39:28):
and other digestive issues isthe idea that it's not wasted
time to sit and be present andbuild out space for your
relaxation practices.
A lot of times, people are likeI'm just sitting here doing
nothing.
I've got things to do, I amrunning from place to place to
place, and so here are somesuggestions that you might start
(39:50):
to incorporate or maybe you'rejust going to pat yourself on
the back because you're alreadydoing these things, but a couple
of things that we can all dofor relaxation.
So one of my favorite things todo is especially if I'm at my
desk and I'm working quietlyturning on a music app and
listening to piano covers ofcurrent music.
So that's just kind of apeaceful type of music.
There's no words.
(40:11):
I still am able to focus on mytasks, but I feel like I'm
relaxing Diaphragmatic breathing.
Nobody listening is going to besurprised that I mentioned this
, because we can do it in avariety of settings, with our
eyes closed or kind of foldedinto your day.
Also, thinking about things thatyou can do throughout the day
is body scanning.
(40:32):
So everybody, do this with me.
Think about what your shouldersare doing right now.
Chances are you can drop themdown away from your shoulders,
pull your chest back, open yourhands and your mind.
Think about just letting go,letting go of stress, letting go
of tension.
And then a final suggestion isgetting outside for fresh air,
(40:53):
taking a walk.
Leave the earbuds behind, don'tbe trying to multitask while
you're out there, just kind oftaking in the sounds of nature
being present, even if it's afive-minute walk.
This is going to help with youroverall digestion and wellness.
So the takeaways here?
Managing stress throughrelaxation, body movement,
(41:13):
exercise, healthy lifestylehabits.
They're helpful from a stressmanagement perspective, for our
general life and functioning,but also so profoundly helpful
for our GI health.
So hopefully, this hasempowered you with a few
strategies.
And now, Dr Allegretti, we'velearned a lot from your
expertise today and, as we wrapup this episode, we like to ask
(41:38):
all of our guests the followingquestion Dr Allegretti, what is
something that you prioritizewhen it comes to your overall
health and wellness?
Dr. Jessica Allegretti (41:48):
First of all, I feel like I just learned
so much from both of you, sothank you both.
And for me you know I am anewish mom, I have a
three-year-old and I think tojust like learning how to find
myself and make space for myselfwith a young child at home,
which I'm sure a lot of peoplelistening I'm sure struggle with
.
For me it was always aboutphysical movement and exercise
(42:10):
and just figuring out when to dothat and how to get it done.
And you know I used to do a loton the weekends, but once you
have a young child, yourweekends are no longer yours.
So scheduling exercise into myworkday, putting it on my
calendar like it's anappointment, has really helped
me, and also recognizing like itdoesn't have to be the craziest
workout you've ever done.
You know, even if it's justdoing something is better than
(42:32):
doing nothing, and so that'sreally what has helped me, I
think just maintain sanity andoverall health through the
pandemic and also through earlymotherhood.
Kate Scarlata (42:42):
Yeah, I can relate to that.
You know my kids are grown now,but we would put exercise on
our calendar like a doctor'sappointment.
You have to you know the thingsthat matter to you, the
important things.
Sometimes I would just say dosomething fun, you know, and
plan something fun because youneed fun date nights, whatever
it is, but just to really likewrap up and enjoy life and all
(43:07):
of that stress reducing rightwhen you're taking care of
yourself.
So huge thanks.
This was amazing.
Talk about learning a lot.
I learned a lot from you today,dr Allegretti, and really
appreciate the work that you'redoing, moving the bar and really
understanding the gutmicrobiomes role here in GI
conditions, and your name isworld-renowned for this work, so
(43:31):
it is quite amazing.
So thank you.
Next up we have the sportsdietitian for the Kansas City
Chiefs, eslie Bonsey, and she'sgoing to join us to discuss the
role of exercise in GI distress.
So this will be a reallyinteresting.
Maybe we'll get a little youknow, taylor Trav info.
(43:52):
You never know.
We'll try to dig a little deep,but this will be a really
excellent and informativepodcast coming up at you next.
So thank you, try to dig alittle deep, but this will be a
really excellent and informativepodcast coming up at you next.
So thank you and thanks again,dr Allegretti, for an amazing
podcast.
Dr. Jessica Allegretti (44:05):
Thanks for having me.
Dr. Megan Riehl (44:07):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at the Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
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