July 1, 2025 • 51 mins
Dr. Iris Wang of the Mayo Clinic shares cutting-edge insights on gut health across the lifespan, including advancements in pharmacogenomics for personalized medication selection and innovative breathing techniques to relieve abdominal distension. She busts common myths about bloating, revealing how diaphragmatic dysfunction rather than excess gas may be the culprit. Dr. Wang also emphasizes the importance of starting gut health education early, helping kids and parents alike understand that pooping shouldn't be painful or forced.
• How pharmacogenomics helps identify why some patients metabolize medications differently, leading to better medication choices with exploration on the hope and/or hype of precision medicine in the GI world (Wang et al 2019)
• Explanation of abdomino-phrenic dyssynergia (APD) – when the diaphragm moves downward instead of upward, causing visible abdominal distention
• Specialized breathing technique developed in Barcelona that retrain the diaphragm for bloating relief (Barba E et al 2024) - see video link below
• The importance of normalizing healthy pooping habits from childhood through education & tools like toileting stools (e.g. Squatty Potty)
• Warning signs for parents about childhood constipation – including stool leakage, straining, & urinary problems (Tran DL et al 2023)
• How yoga can support gut health through mindful movement, core engagement, & stress reduction
Yoga videos:
Yoga For Digestion Flow| Yoga With Adriene (26 mins)
Yoga for Bloating, Digestion, Ulcerative Colitis, IBD & IBS (12 mins)
Check out Dr. Wang's children's book Boo Can't Poo, which helps normalize healthy pooping habits for kids while educating parents too.
References:
Specialized breathing technique for abdominal distention: Video Demonstration
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, MPH, RD (00:19):
Thank you.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Dr. Megan Riehl (00:34):
Hello friends, and welcome to The Gut Health
Podcast, where we talk about allthings related to your gut and
well-being.
We are your hosts.
I'm Dr Megan Riehl, a GIpsychologist.
Kate Scarlata, MPH, RD (00:46):
Hi everyone, I'm Kate Scarlata, a
GI dietitian.
We have a great episode today.
We're going to be talking abouttherapeutic interventions that
use our genetic makeup to guidebest medication selections for
your body, and interestingbreathwork used to treat
abdominal distension, and somuch more.
We have a great expert guest.
Dr. Megan Riehl (01:08):
That's right, Kate.
Let me introduce our phenomenalguest.
Dr Iris Wang is an assistantprofessor in the Division of
Gastroenterology and Hepatologyat the Mayo Clinic in Rochester,
Minnesota, where she is part ofthe comprehensive general GI
group.
She also serves as theAssociate Program Director of GI
Fellowship Programming there,where she is highly regarded by
(01:31):
the trainees for her clinicalexpertise and mentorship.
Dr Wang's clinical practicefocuses on one of our favorite
things disorders of gut-braininteraction, which include IBS,
functional dyspepsia and chronicabdominal pain.
Her research centers onunderstanding the
pathophysiology of DGBIs andevaluating both pharmaceutical
(01:53):
as well as non-pharmaceuticaltherapies.
That include gut-directedhypnosis, digital interventions
and extended realitytherapeutics Very cool
hospitality therapeutics.
Kate Scarlata, MPH, RD (02:03):
Very cool, but that's not all.
She's also the author of BooCan't Poo, which I love.
This book it's adorable, butalso very comprehensive and
really dives into all differenttypes of therapeutics, from diet
to squatty potties to breathingtechniques to help the little
ones get poop in.
So love that.
(02:24):
And also big congrats are inorder for your recent teaching
award, best Research Mentor atMayo Clinic.
So we are very thrilled for you.
That's amazing.
Dr. Iris Wang (02:35):
Thank you so much .
Thank you both so much forhaving me.
I think I'm a big fan of bothof yours, and so to be on this
podcast is really veryvalidating and a lot of joy for
me.
To be able to be on thispodcast is really very
validating and a lot of joy forme to be able to be on this
platform.
Thank you both for having me.
Kate Scarlata, MPH, RD (02:49):
Well, we're thrilled to have you.
Yes, so thrilled.
So we always start the episodewith a myth buster.
What myth pertaining to guthealth and or constipation would
you like to bust for ourlisteners?
I?
Dr. Iris Wang (03:02):
think one of the things that it took me until GI
fellowship to learn was that youare not supposed to strain when
you poop, and this is somethingthat you know spurred the
writing of Boo Can't Poo.
But I was shadowing with one ofour pelvic floor physical
therapists and was listening toher educate the patients and
guide them, and I was like wait,are you serious?
(03:24):
What do you mean?
It's supposed to happen,naturally, right, and maybe I'm
giving away too much aboutmyself here, but that's, I think
, something that we never talkabout and is a myth that we are
supposed to push or it'ssupposed to be a little
difficult sometimes, yeah,sometimes, once in a while we
can have a difficult to passbowel movement, but bowel
movements are supposed to happenwithout straining.
I love that.
Dr. Megan Riehl (03:45):
It's a good start and we're going to talk
more about that in a littlewhile, but before we do, there's
so much interest inpersonalizing our care and we
love this idea of precisionmedicine and being able to
tailor treatments to eachindividual so that they get the
best possible results with thefewest side effects, and it
(04:08):
feels really you know when we'rethinking about innovation and
how do we help patients that areliving with DGBIs.
One size fits all doesn't work,and patients know this.
Us, as providers, know this,and you've written a little bit
about this, and so can you giveus a sense of where we are right
now in the world of precisionmedicine and the DGBI space, and
(04:32):
even beyond that, and whatmight be on the horizon from
your perspective?
Dr. Iris Wang (04:37):
Absolutely.
I think in the DGBI spacethere's always this question of
diagnosis.
A lot of our DGBIs aresymptom-based diagnoses and can
be very challenging for bothproviders and for patients,
because so many different thingscan cause the same symptoms.
And that can lead to a lot ofdiagnostic uncertainty, where
doctors aren't sure what youhave, and just treating on a
(05:01):
symptom can limit the medicationoptions.
And for us on a research side,if we're just using a symptom as
something to test a drug, forexample, without really
understanding what causes thatsymptom, it makes it so that the
drugs are more likely to not behelpful because we're not
really getting to the root causeof the problem.
And so in DGBI space, one of thebiggest things is understanding
(05:23):
what is the root cause of oursymptoms.
Sometimes that's disruption ofthe gut microbiome and the
bacteria that live in our gut,because we had some sort of GI
infection or a viral infection,microbiome, and not necessarily
(05:46):
a physical illness.
Sometimes it's a surgery thattakes out a gall bladder, for
example, and that can mess upwith how our bodies recycle
these detergents that we hadcalled bile acids, and a lot of
the work that I have writtenabout and aim to keep doing is
to understand.
What are these contributorsthat have very narrow mechanisms
and narrow reasons for patientsto have symptoms, and can we
(06:08):
treat those reasons in adirected fashion so that we are
more precise right in ourdiagnosis and in our treatment?
On the other side of that isusing these big machine learning
models and artificialintelligence to really
understand who's at risk fordeveloping which disorder and
what predicts treatment response.
(06:29):
I think I'm answering the lastpart of your question there a
little bit early, but that'ssort of what's on the horizon,
right.
How do we use patientinformation, your background,
your history, other aspects thatwe might not even think about
but with a large machinelearning algorithm maybe can be
picked up from computer science.
(06:49):
Let's say things like if youlive within this many miles of
this location, maybe you're athigher risk because of some
environmental factors, right,and these are things that we
don't have the capacity to thinkabout as clinicians because
there's just not enough timecapacity to think about as
clinicians, because there's justnot enough time.
But if we could put it into amachine algorithm and have a
supercomputer try to tell us,hey, there's a higher risk of
(07:10):
this disease here, then that canreally help a patient, right?
So that's maybe what's on thehorizon.
But in between that space andwhat else there is is really
treatment and medication.
Treatments and using what weknow about genetics to both
understand risk for disease butalso understand treatment
response.
And so what?
Those are reallypharmacogenomics, and okay, if I
(07:31):
get into that, yes, definitely.
What this is is telling us kindof, what are the genes that your
body has to break down certainmedications?
And we know that these genescome in a variety of forms,
right?
Not everybody is made the same.
Some people chew throughmedications really fast, so that
the active ingredient iscompletely gone and all you're
(07:51):
left with is the side effects.
Some people don't break downthose pro-drugs or non-active
forms of these medications fastenough, so then it takes a
higher dose or a longer periodof time before they're actually
getting any of the activemedication doses, and if we
don't understand that, we mightgive them too much, and then
(08:12):
they're at risk for higher sideeffects again, and so
understanding whether someone isa normal metabolizer, an
ultra-fast metabolizer, reallymatters, but it also matters
what medication you're talkingabout.
So we have these amazingpharmacists who help us out with
that, who really understandwhat these mean for each of the
drugs that are important for usin GI, but also out of GI.
Dr. Megan Riehl (08:34):
Are there some patient characteristics to help
us know whether we're highmetabolizers or low?
How do we learn more about thatin like real world?
Dr. Iris Wang (08:46):
Absolutely, because you're absolutely right.
Right, in real world practiceit's not really feasible to send
genetic testing on everybodyand it's not necessary.
And so I think there's twoareas in GI specifically where I
think about thispharmacogenomic testing a lot.
One is in my DGBI patients,where I need to write some sort
of psychiatric medication orpsychiatric associated
(09:08):
medication for neuromodulation.
Right, we're not trying totreat anxiety, depression, but
those medications are reallyreally helpful for modulating
how much we feel pain in the gut.
And so in that patientpopulation, the ones that I
think about sending this testing, is the patient who tells me I
have had so many medicationintolerances.
I almost have every side effect.
(09:30):
Every time they try to give mesomething new, I don't react
well to it, and often you knowit's really hard to say that the
patient is allergic toeverything.
It's an intolerance and that'sprobably being driven by how
their liver breaks down thesemedications.
So when I hear that from apatient, that's my sign to say,
hey, let's see why you'regetting all these medication
responses, let's see why you'renot tolerating and let's see how
(09:53):
we can adjust the medication sothat we're really optimizing
the active ingredient andminimizing all the bad stuff.
The other area that we use thisa lot is in our reflux patients
and in our patients with thispepsia or this burning pain in
the pit of the stomach that wethink is related to acid, and so
one of the primary things weuse to treat either one of those
(10:14):
diseases acid blockerspredominantly are proton pump
inhibitors or PPIs.
Now, there's a lot of PPIs, butmost of the PPIs that are
currently on the market are runthrough this specific enzyme
that our liver produces.
It's the CYP2C19 enzyme.
Kate Scarlata, MPH, RD (10:33):
You'll be quizzed on this later.
Dr. Iris Wang (10:35):
Shows up on board exams, so important for our
medical audience members.
There you go, but a lot of thesemedications need to be
inactivated and run through thisenzyme.
But if you have too much or toofast of this enzyme, you can
break through those PPIs andbasically chew through all the
active ingredients and itdoesn't matter how much we give
you, it's not going to work.
(10:56):
In patients where we're runningthrough multiple lines of these
PPIs and they're still havingsymptoms and on our objective
testing we still see acidbreakthrough, we can say, hey,
let's check how fast youmetabolize these medications and
think about alternative drugs.
And there's two options on themarket.
One is a cousin drug.
(11:17):
I describe it as a cousin drugof our PPI drugs, which are all
like sister drugs, never brotherdrugs always sister drugs.
Not sure why these cousin drugs.
Or rabeprazole is also a protonpump inhibitor but is
inactivated by both CYP2C19 andalso a different CYP enzyme
called oh, I'm not going to giveyou that one because it's like
(11:38):
3A something there's anotherpath, there is another pathway.
Kate Scarlata, MPH, RD (11:43):
There is another pathway, another enzyme
.
Dr. Iris Wang (11:44):
There is another enzyme, and so, because it also
metabolizes through the secondenzymatic pathway, it's not
going to be as chewed up asquickly and can be more
effective in these patients.
We have new meds on the marketas well.
These potassium channel orPCABs binders can also be a good
option for patients who arechewing through PPIs too quickly
(12:06):
.
Kate Scarlata, MPH, RD (12:07):
So we're checking DNA and we're looking
at specific enzymes that someonehas or doesn't have, and then
we're able to decide you'regoing to chew through this too
quickly or it's not going to bebroken down by you, so therefore
you should try this othermedication.
So really important for peoplethat know they are not getting
(12:32):
at a therapeutic symptommanagement level or just the
drugs has side effects for them.
Dr. Iris Wang (12:39):
Exactly, exactly, and I had to look it up because
otherwise it was going tobother me but it goes through
the CYP 3A4.
I think I have most of thoseletters and numbers, but that's
what ribivirazole goes throughand absolutely you're correct.
Those are the times where wewould think about just let's
find out a little bit more aboutwhich genes and which
(13:00):
phenotypes of those genes apatient has.
Perfect.
Dr. Megan Riehl (13:04):
So, interesting , it's fascinating and you've
given us two really goodexamples, right.
So people that maybe have ahistory of using medication to
try and manage their psychiatriccondition and have struggled
with that, and there are a lotof people where the side effects
were not tolerable and thenthey present to their
gastroenterologist whorecommends an anti-anxiety,
(13:27):
antidepressant, neuromodulator,and that can be very scary, and
so there is an opportunity forgene testing to help inform that
decision.
And then knowing a billionpeople globally are affected by
GERD, and again we're getting toa more precise way of informing
.
But these are just two examples.
So this is not a globalsolution yet for the field of
(13:51):
gastroenterology.
So I think there's hope andthere's hype.
It's an and, but certainly nota solution yet for all of our GI
conditions, but very excitingand I think, for the patients.
Dr. Iris Wang (14:05):
It's really important to understand that
this is genetics, right.
This isn't you, this isn't inyour head.
It's not your fault that you'vehad all of these side effects,
right?
Sometimes patients are soapologetic and I'm like you have
nothing to apologize for.
It's not your fault.
You've had medication sideeffects.
It's your genes, it's yourgenetics, and the more we
(14:26):
understand that, the morepatients can.
Just this is the way I'm builtand we can maybe use these new
tools so that they can have aneasier time going forward with
future doctors the gutmicrobiome.
Kate Scarlata, MPH, RD (14:41):
So there's genetics you know that
we might use to guide treatmenttherapies.
And I wonder you know, are weseeing the gut microbiome or
metabolome different markers,being used to sort of guide
therapeutic interventions?
Are you seeing that at all?
Dr. Iris Wang (14:58):
I think not quite yet, but it is definitely an
area of high, high interest.
There was actually an amazingtalk at Digestive Disease Week
recently looking at how themicrobiome impacts hormone
metabolism, something that I hadcompletely not thought about.
Right, and that the microbiomeis actually key in making
testosterone accessible for oursystems, and without the right
(15:23):
microbiome to break downtestosterone, we actually can
change the levels in our bodies.
And that goes the same for alot of these medications, a lot
of foods, right, and so I thinkpart of the problem with the
microbiome is that it is so vast, right, and so it takes a lot
of computational power to beable to find those associations
(15:43):
and learn which because there'sno one good book, there's no one
bad book, it's a combination.
I always like to think about itas a garden, right.
It's not only which plants arein the garden, it's the variety
of plants, the interplay ofplants and how many weeds there
are, and so it's going to take alot of machine learning and a
lot of AI to really understandthat better.
(16:05):
But I definitely see that aspart of the horizon of precision
, medicine is understanding notonly bacteria, but also viruses,
fungi, these things that livewithin us that make up this
whole microbiome and how itinteracts with the human body.
Kate Scarlata, MPH, RD (16:21):
Yeah, Exciting.
So much to learn though right,absolutely.
Yeah.
Dr. Megan Riehl (16:30):
So we're going to move on a little bit and you
know we're going to also begiving you some insights here on
some new therapies that arecoming to the world.
So first let's start withbloating and abdominal
distension.
They're different.
So before we talk about atreatment that can probably help
these, can you briefly describethe difference for our
listeners From a purely medicalstandpoint, we think about
(16:51):
bloating as a sensation or asymptom, so something we feel
gas in the stomach, fullness,right.
Dr. Iris Wang (16:58):
Bloating is a feeling, is a sensation,
distension is what we call anobjective sign, and so it is
something that we can see on aphysical exam when we're talking
from the doctor's stand ofthings.
But from a patient's stand ofthings, it is that visible
outward push of the belly, andso you can have one without the
other.
Right, your belly can distendor push outwards and you don't
(17:20):
have to necessarily feel bloated.
You don't have to feel thatsensation of fullness, but you
can also have bloating where youfeel really uncomfortable
without your belly actuallycoming all the way out.
So, sensation versus or symptomversus a sign or an objective
finding.
Kate Scarlata, MPH, RD (17:37):
Yeah, so with that, I was totally
stalking you on Instagram andsaw that you were in Barcelona
and I had read about thisbreathing technique that they're
doing there specific forabdominal distension and it
seems like that paper.
They put out a couple papersbut it's getting a little
traction here in the US.
(17:58):
So I'd love to hear a littlebit about what you learned there
.
You mentioned you learned a newtool, so can you share with
your listeners some of what youlearned?
Dr. Iris Wang (18:09):
Absolutely.
And I have to say, this groupin Barcelona I've just admired
(18:36):
I've followed their researchfrom the moment I learned about
on GI fellowship.
It's just so elegant the typeof work they've done.
And so maybe, if you're OK withDr Fernando Azpiroz and his team
, Jordi Serra and ElizabethBarba they've been working on
understanding what happens whenpatients experience bloating and
when they see visibledistension, right.
So it's really very focused ondistension, and the very first
thing they did was they said,well, it must be the gas, right,
and that's what our patientsthink too.
It must be the gas.
We must be eating something togenerate all this gas.
And so they came up with thisradiology technique where they
(18:58):
could actually, on a CT scan,measure how much gas was in
somebody's belly.
And so they had all theirpatients come in when they felt
really good, flat bellies, nodistension measured the gas, and
then have them come back thesecond they feel like they're at
maximum distension.
Measured the gas and then havethem come back the second they
feel like they're at maximumdistension.
This is the biggest I get, andthey went right into the scanner
.
First of all Amazing that theycould do that Amazing.
(19:20):
And then they were sodisappointed because they
thought their experiment failed.
There was no increase in gas inthe majority of these patients.
At most it was maybe 50 mLs or50 cc's, and you know, that's
not very much at all.
It's one of our big syringes,right, and that amount of gas is
not going to extend out ofbelly in most people.
(19:41):
And so, through thatdisappointment they were looking
at their CT scans it's anamazing story and they found
that it was not the gas, it washow the diaphragm was moving.
And what they described was inindividuals who have gas in the
belly or kind of normalphysiology, what should happen
in response to that gas pushingon the intestinal walls is the
(20:02):
diaphragm should rise up intothe chest and then the belly
abdominal wall should contractinwards so that we're really
kind of elevating ourselves upfor vertical real estate.
That diaphragm kind of movementgets abnormal in individuals
with bloating and in response,the gas in the belly.
(20:24):
What they see is that thediaphragm actually contracts
downwards and the anteriorabdominal wall pushes out and so
you're kind of decreasing theamount of real estate in the
belly and then the anterior wall, for whatever reason, can't
keep the gas in, so it protrudesoutwards.
So even though there's no gasincrease, necessarily the belly
wall moves so that the bellysticks out.
And so then, once they figuredthat out, they validated a lot
(20:48):
of that stuff and they said,well, how do we fix it?
And so what they've done in alot of their prior studies and
they said, well, how do we fixit?
And so what they've done in alot of their prior studies, is
they actually were able toretrain a patient how to move
their diaphragm using a veryinvasive muscle monitoring.
So they dropped a probe intothe patient's esophagus so that
they could really monitordiaphragmatic contraction or
(21:09):
muscle tone.
I mean, it's just not reallyfeasible outside of a lab,
Dr. Megan Riehl (21:14):
hard to do that regularly
Dr. Iris Wang (21:15):
hard to convince a patient that that's what you
need, right.
But doing that, they found thatthey could fix this, that by
teaching a patient how tobreathe and how to move that
diaphragm they could reversethis process, which is very
hopeful for all of our patients.
So then they said, okay, can wedo better?
So then they developed atechnique using a biofeedback
tool which looks like an elasticband that was placed around the
(21:37):
chest and around the belly sothat as a patient moves their
belly they could get feedback tosay, okay, we've distended the
belly this much and now we'regoing down again.
And at the same time they wereable to look at the movement of
the diaphragm by using anultrasound to look at how much
the liver was moving.
Also great in a lab setting.
(22:01):
Also difficult to implement andspread without really having
the equipment and the technologyand then knowing how to like
deliver this kind of feedback.
So then they did one stepbetter, and that was the paper
that recently came out.
They said can we do this byjust teaching someone how to
breathe using our hands?
And so this new technique thatI learned is really this like
final evolution of theirtreatment of this abdominal
phrenic dyssinergia problem bigmouthful or shortened to APD,
(22:46):
not to be confused with APT.
What we've been doing and what'skind of described in a lot of
our journals is using atechnique called diaphragmatic
breathing where we're askingpatients to really push out
their bellies as they breathe inso that all the air goes into
the belly goes into the belly inquotes and then kind of push
(23:07):
all the air back out so that thebelly deflates, right.
And we've been teaching thistechnique but we've never
actually validated that it helpsbloating.
No tests have been run outsideof this group's lab to see that
that actually works.
And so this technique takesthat diaphragmatic breathing and
really builds on it and it usesa hands-on approach to guide
(23:29):
patients to isolate their chestwhen they breathe so that they
involve their intercostalmuscles, learn what it means to
contract them and in that thenlearn what it means to relax
them so that they fully deflatethe chest.
And then it goes into adiaphragmatic breathing teaching
, also hand-guided, so that wecan really get good relaxation
(23:51):
of that anterior abdominal walland strengthening of the
obliques and the internalexternal obliques which really
need to contract so that ourbellies go in and up, and so
it's not really a rectuscontraction that we want
patients to really achieve,right?
So sit-ups are not the right wayto go.
It's contracting the sidemuscles of the core so that we
(24:12):
can shift them upwards, andteaching them to do that via
hands-on breathing training.
They do a three-week breathingtraining program.
Patients are coming back once aweek in order to get various
components of that teaching andthen a complete review.
They've, you know, had thisfirst hands-on course, and so I
(24:33):
was oh my gosh, I was the onlyone in the US who was there and
I was, like, so excited andreally excited to be bringing
this back.
But they are running more ofthese hands-on approaches and so
hopefully more and more peoplewill learn.
They're also running amulti-center clinical trial that
involves several sites in theStates to figure out what's the
best way to teach this approach,and so I'm hopeful we'll see a
(24:55):
lot more coming out from this.
Dr. Megan Riehl (24:58):
Yeah, and the patients were practicing this in
between their sessions, for afew minutes before all of their
meals.
And in the literature that I'vebeen reading on this, it was
really exciting to see theevolution of the research that,
yes, we can't be dropping thingsdown the esophagus for
(25:19):
everybody that has theseproblems to, yes, what is
tangible takeaways thatpractitioners can teach their
patients and then it really canbe life-changing, incredibly
life-changing.
And again, all coming back toour breath, and I'm guessing
that our friend Dr BrennanSpiegel, who just is such an
(25:40):
advocate for gravity and beingupright and how we breathe, yeah
, I'm sure that he's going toreally validate a lot of this
too with his work in the gravityspace and how it impacts us.
Dr. Iris Wang (25:51):
Absolutely.
And if I could just take like asuper brief sidebar too, it's
gravity and it's also musclesright, that's right.
As internal medicine doctors,we are really not very good
about the external muscles.
Like it's not what we focus on.
We focus on organs, we focus oninternal, and then, especially
as GI doctors, we think aboutthe lumen, we think about the
(26:12):
inside of the lumen, and oftenthat comes at a cost of
forgetting that there's so manylayers of fascia, of muscles, of
fat, of connective tissue thatare between, kind of our
anterior muscle wall and theinside of our abdomens.
And so when we think about painright, which is something that
I'm very passionate about- Ialways want to take kind of an
(26:32):
outside-in approach, right, oris something that I'm very
passionate about.
I always want to take kind ofan outside-in approach right, or
even an inside-out approach,but making sure that I think
about yeah, there's no ulcer onthe inside, EGD is negative.
What else could it be?
Is it something within theperitoneum, but is it something
in the muscle layer?
Is it a trapped nerve?
Is it muscle movement that isabnormal?
And I think thinking aboutthose things can help our
(26:53):
patients more holistically,because those need different
treatments than a pill.
They need our colleagues inPM&R, in PT, they need muscle
strengthening, but the rightmuscles right, and so being able
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Dr. Megan Riehl (27:08):
That's right.
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Dr. Megan Riehl (28:31):
You mentioned abdominophrenic dyssnergia, or
APD.
Give us an idea of how commonit is, so that we can also have
an idea of how many people mayeffectively benefit from talking
to their doctors about this.
Dr. Iris Wang (28:45):
Absolutely.
I think it's really hard to say.
Actually, if you look at justbloating as a symptom, right, it
can be ranging anywhere fromlike 10% to 30% of the
population, and studies ofpatients with irritable bowel
syndrome or IBS, show up to like75% to 90% of them experience
bloating at some point.
Now, that's a little bitdifferent than distension.
(29:06):
The distension that really kindof you want to think about APD
in, is more intermittent.
So these are the patients whowake up with flat bellies in the
morning and then it kind ofgrows throughout the day as
they're eating and as they'restanding right.
It's not just the food, it'sthe gravity as well.
And so within that populationand their study population about
(29:27):
85%, depending on which cohortand which study from this
Barcelona group you're lookingat really had APD as a reason
for their distension.
And then even the patients whodid have an increase in gas,
they saw that they still hadthis abnormal muscle movement
and the muscle movement was moretightly linked with how bad
(29:50):
they felt as opposed to theactual volume of gas.
Kate Scarlata, MPH, RD (29:55):
So interesting.
So I was talking to agastroenterologist in Boston, Dr
.
Kyle Staller, and he's reallyinterested in this as well and
looking into it in a researchsetting and he said another sort
of indicator that he thinks ofAPD in is individuals that drink
(30:15):
water and can actually getsymptomatic.
So again, water's not going tocause gas, but the handling and
the way the diaphragm is pushingdown it could contribute to
those symptoms absolutely.
So standing a long time andyour symptoms get worse,
afternoon symptoms, evendrinking water causing symptoms,
(30:37):
those are some things where youmight want to talk to your
doctor about this condition andthis specialized breathing
technique, which is exciting tosee.
Dr. Iris Wang (30:48):
Yeah that is definitely something big on the
horizon.
Kate Scarlata, MPH, (30:52):
Absolutely so.
When we think about this is onebig area.
But then you know we definitelysee bloating and distention in
our patients and think of otherthings.
What are some of the things youdo in your practice when a
patient presents with bloatingand distension, outside of these
wonderful breathing techniques?
Dr. Iris Wang (31:10):
Absolutely so.
I think often we have to lookat the diet right, we have to
look at food, and I think youare much more qualified to speak
on this than I am.
In certain patients where it'sso food triggered right, I do
fine, unless I eat or if I fastall day, I don't bloat.
But every time I eat food right.
Not water, to your point,absolutely agree with that but
(31:32):
something that could potentiallygenerate gas, right.
Then we think about okay, isthere something in the diet that
we have to change?
And then I would refer them toa GI dietitian specifically to
be able to kind of review andreally think about this with the
patient so that we can maybehopefully identify something
that is triggering.
One of the biggest offenders isgoing to be lactose, right, and
(31:53):
so can we cut out lactose oruse some sort of supplement or
aid to help decrease thatsymptom.
So that's one thing, and moreof a workup than a treatment,
but if we can diagnose it right,then it's easier to treat.
One of the other options thatI'm personally very invested in
is hypnosis, and so we actuallydeveloped a hypnosis protocol
(32:13):
specifically targeting thisbloating feeling, with the idea
of you know and Megan, you arebetter equipped than I am to
talk about the hypnotherapyaspect, but the goal of that
protocol has really been to canwe decrease the amount of
distress the bloating symptomcauses.
So this isn't really about thedistension portion, but can we
(32:35):
figure out how to get patientsto tolerate this pressure being
put on their intestines withouthaving an abnormal pain reaction
to it, because they don't needthe pain reaction.
And so we did do a pilot testof that hypnosis protocol that
one does build in diaphragmaticbreathing.
We use that as part of ourinduction and part of our
(32:56):
deepening in certain dependingon the week.
This was something that wedeveloped with in conjunction
with Dr Oli Palsson, whodeveloped the UNC protocol for
IBS hypnotherapy.
Dr. Megan Riehl (33:06):
One of the GOATs.
Kate Scarlata, MPH, RD (33:08):
He is a GOAT.
Love him.
Dr. Iris Wang (33:11):
Just an amazing man?
Dr. Megan Riehl (33:12):
Yes, he is.
Dr. Iris Wang (33:14):
I was so fortunate that I got to work
with him before he retired onthis project, but it worked.
When we looked at our data aftertreating 25 patients with
bloating small sample size, butpatients bloating got a lot
better and we saw symptomimprovement across actually all
IBS symptoms in the severitycriteria in about 75% of our
(33:37):
patients, which we were reallyexcited about.
Now these are hand-selectedpatients who were really
committed in the setting of atrial, but at least that was
good and so we're gonna try tovalidate that protocol and do
some more tests and enroll somemore patients to see if it truly
works.
Dr. Megan Riehl (33:53):
Well, ship it over to me in Ann Arbor.
We're happy to pilot.
Kate Scarlata, MPH, RD (33:57):
I love that.
So if you see that, if it'svalidated, do you have next
steps?
Like how would you roll it outso patients have availability to
this?
I know that's down the line,but have you thought about that?
Dr. Iris Wang (34:09):
Oh, I had a plan and then the plan kind of went
sideways, but it is digitallydelivered and so it's a
completely recorded therapy andwe were hoping to be able to
deliver it, like some of thedigital therapeutic companies
that were on the market, becausea couple of them are no longer
available.
I'm trying to talk to othercompanies that are still
available to see if there'sinterest in rolling this
(34:30):
protocol into their offerings.
Excellent, so hopefullyavailable for clinical use with
or without a prescription downthe line.
Kate Scarlata, MPH, R (34:38):
Excellent , great work.
Dr. Megan Riehl (34:40):
Amazing.
Well, and to you know,highlight some of your other
work.
You're a life changer here, DrWang.
I mean in your day-to-daypractice you're working with
adults, you're an adult provider, but you wrote a kid's book and
it makes me wonder that if wecan just teach healthy pooping
(35:00):
habits very early on, we may beable to prevent some of the
bloating and distention, becauseit is so common among people
that have constipation andyou're hard-pressed to find a
constipated person without somebloating.
Yeah, so what inspired you towrite Boo Can't Poo.
Dr. Iris Wang (35:19):
Poo was really trying to decrease my clinical
burden down the road reallyreally early.
But going back to what westarted out the conversation
talking about, right, nobodyteaches anybody how to poop.
And as I had theseconversations about pelvic floor
dysfunction another musclegravity problem, right, that is
(35:39):
so impactful to the GI field Iwas describing these issues to
patients and the looks I got oflike why has nobody ever taught
me this my entire life?
It was just so.
It just kind of sparkedsomething, right, that this is a
problem.
And then, as my own child waspotty training, I was like okay,
is there really nothing thatteaches this?
(36:00):
And I was going through thepotty training literature and it
was like everybody poops andI'm like that's nice, but like
how does anybody poop?
Dr. Megan Riehl (36:08):
That's right, and if you talk to an adult, not
everybody poops.
Kate Scarlata, MPH, RD (36:12):
Exactly.
Adults don't know, so how arethey supposed to teach their
kids?
Dr. Iris Wang (36:15):
Yeah, absolutely.
And so then I was like, well,maybe I should just hit the
source, start really early.
And then I was realizing thatas I was reading the books to my
son, I was learning all thisstuff on the side and I was like
, okay, I'm going to secretlyalso hit their parents, and so
it's for the children, but it'salso for the parents reading to
their children to reallyunderstand some easy things that
(36:38):
we can do to preventconstipation, because I couldn't
just talk about pelvic floordysfunction, which is kind of
what I wanted to do.
But it's been well-received andI think I've been really,
really, really fortunate.
I really felt like I won thelottery when this was picked up.
Kate Scarlata, MPH, RD (36:54):
We love it.
Dr. Megan Riehl (36:55):
Yeah, we love it.
And you know when you'rethinking about giving a baby
gift and the assignment is togive a book instead of a card.
This is the gift that justkeeps on giving.
So think about this the nexttime you're invited to a baby
shower, because I think itreally is a beautiful gift to
normalize our pooping habits.
Dr. Iris Wang (37:17):
And that's such a great point to me the
normalization of pooping as athing we all do, right Like I'm
sure you both see this a lot inyour practices that people don't
feel comfortable talking aboutpoop.
And one of the most interestingthings that I've had that I've
come across since this book waspublished was people get upset
(37:37):
that I've had some negativereviews that why is it about
pooping?
Like you know, it's not good totalk about, and even when I
brought it to my son's school,the teacher was like, oh, I had
a lot of trouble with thisbecause we're not supposed to
say poo in school, it's a pottyword, and so I was like what do
they say?
yes, it is, yeah, literally butwhat do they say when they need
(37:59):
to go and now and she's like Idon't know, but they're not
supposed to say I need to poo.
And that has so manyimplications down the line,
because then when things gowrong, kids can't talk about it,
they don't feel like they can.
It's not polite conversation.
And then they have bloody bowelmovements and undiagnosed IBD,
right, and so part of the thingthat I really realized that I
(38:20):
champion is what I call breakingthe poo taboo right.
We're just going to talk aboutit as a thing that we all do so
that, when things go wrong, kidsfeel comfortable sharing that
with their patients, with theirproviders.
Brennan published a studysaying that up to like 30
something percent of adults haveconstipation and don't feel
like they're comfortable talkingto their primary cares about it
(38:40):
.
Kate Scarlata, MPH, RD (38:40):
Yeah, and it's common in kids.
It's like 14% of children haveconstipation and you know that
can delay getting off to school,impact play dates because
they're uncomfortable.
You know a lot of kids hold itin at school because they're not
comfortable.
They have a little bit of a shyintestine.
I think I have a little shyintestine.
(39:01):
I like to go potty at home, butyou know, again, just making it
.
This is a normal thing.
Everyone poops and if you knowhow to poop correctly, that is a
good thing.
But you know, can you talk alittle bit about we shouldn't be
holding our poop and we shouldlisten to our body.
And why is it a problem to waitall day or drive three hours in
(39:24):
a car and hold your poop andthen get home?
It's not really ideal forconstipation, right?
Absolutely.
Dr. Iris Wang (39:31):
And it's both a muscle issue and also a
neurohormonal issue.
So when poop comes down intoour system I'm going to get a
little bit into thepathophysiology here we have all
these sphincters in our pelvicfloor, at the end of the rectum,
that signal to us okay,something has hit and I need to
tighten up because there'ssomething here that doesn't need
(39:52):
to come out right.
And so all of our analsphincters are able to tighten.
And then our puborectalismuscle, which is like the
sling-like muscle that keeps ourrectum in a narrow angle to
again prevent things from justfalling out, also tightens.
But in order to poopeffectively, those muscles need
to open.
When we need them to open andthat's why we don't need to
(40:14):
strain is we can open thispassage.
When we hold in the stool, wekind of signal to our bodies one
, we can ignore those signalsthat the pelvic floor is sending
us.
And two, we kind of signal toour bodies one, we can ignore
those signals that the pelvicfloor is sending us.
And two, we increase thatpelvic floor tone so that then
it becomes harder to actuallyrelease the muscles when it
comes time to release.
Over time those two things canbecome more and more progressive
(40:37):
, and the more we hold, thebigger the rectum can get.
And when the rectum gets bigger, you can imagine how, if we
need stool to touch the rectalwall in order to send those
signals, if the rectum is superlarge, then we need a super big
amount of stool in order toactually send those correct
signals, and so then thesignaling becomes weaker and
(41:00):
weaker over time.
Signaling becomes weaker andweaker over time.
Then, if we're reallydescending out the rectum like
that it's hard to get to thatpoint without some sort of
genetic condition, but there isa point where our colons can
dilate so much that theyactually can't squeeze anymore.
So then the stool builds up andour body doesn't have a
mechanism for pushing it forwardas well.
(41:21):
It's actually a very similarmechanism to heart failure for
the doctors listening but it's adecrease in muscle tone,
because our muscle fibers aren'table to reach each other to
contract, and so that's a very,very severe case of constipation
.
But smaller versions of thatcan happen with this chronic
holding behavior.
(41:41):
So it's really important for usto allow our bodies to empty
when they need to empty.
Kate Scarlata, MPH, RD (41:48):
Yeah, absolutely, and I think at the
colon too is absorbing fluid asthe stool is sitting in there,
probably getting drier and weknow that.
You know, soft stools are alittle easier to pass and
absolutely.
So just an extra burden thereon the on the pooper.
Absolutely.
Dr. Iris Wang (42:05):
And with the dryness of that stool right,
these large bulky bowelmovements, especially for a
little kid it can hurt.
And then when you're not reallyaware of that and it hurts the
poop, you can really get intothe cycle of like this activity
hurts me and so I really don'twant to do it.
And then it just perpetuallygets worse and worse as there's
more holding, as the stool sitsfor longer.
Kate Scarlata, MPH, RD (42:26):
Yeah, one of the things you showed in
the book that we always talkabout and recommend we had a
pelvic floor physical therapistthat also recommends this is the
squatty potty.
You know, wondering, you know,I certainly we didn't have
squatty potties when I raised mychildren, but you know, is that
something do you think kids areeducated about?
Dr. Iris Wang (42:48):
Oh, absolutely not.
Kate Scarlata, MPH, RD (42:48):
A squatty potty?
Dr. Iris Wang (42:49):
Yeah, yeah.
Kate Scarlata, MPH, RD (42:50):
It's just yeah, I mean, that's what
I'm talking about.
It's so simple.
Dr. Megan Riehl (42:53):
We should be having stools in elementary
school bathrooms to normalize it.
And I think also, so manyparents don't know what normal
is either.
Especially with ourpreschoolers, and especially if
you're a first-time parent orcaregiver, we don't know what
the heck is normal and what'snot.
And when our little one arethey complaining of a
(43:18):
stomachache because they misshome and they just want to go
home from school?
Or do they actually have someconstipation and they have to
poop, but they're afraid or ithurts, yeah.
So yes, we've got to do abetter job at normalizing this,
and certainly your child, mychild.
They're hearing about healthypoops and farting and like we're
cheering it on and likenormalizing it.
So, whether they like it or not,their classmates are probably
(43:42):
getting some of what they'rehearing at home too.
Dr. Iris Wang (43:44):
A little sphere of influence for helping bowel
movements.
Dr. Megan Riehl (43:47):
That's right, that's right.
Dr. Iris Wang (43:48):
Their teachers are not happy with you.
Dr. Megan Riehl (43:51):
Well, they should.
They should be thanking you.
Kate Scarlata, MPH, RD (43:54):
I know I'm thinking poop school.
Why don't we have a curriculumcalled poop school and we
develop it for schools?
Dr. Iris Wang (44:02):
You know they do that in China.
Not necessarily poop school,but like how to wipe your bottom
and it's like like with twoballoons and like teaching how
to wipe.
There's some Instagram reelsabout this, oh my goodness.
Kate Scarlata, MPH, RD (44:11):
Yeah, we got to upgrade the education, I
think, although it sounds likeyou got a little pushback from
the school.
So I think we have somecultural changes we need to work
on first.
Dr. Iris Wang (44:21):
It's funny because there are some kids who
just figure it out right.
They figure out that if theyraise their knees they poop
better.
Yeah Right.
And actually a lot of parentsare doing this at home when they
get those low potties for theirkids?
Yeah, I mean, they get thembecause they don't want the
child, they can't reach the bigtoilet and they don't want to
fall in.
But when they're sitting on thelow potties then they actually
(44:41):
can be in a good coping position, and that's why that's part of
the reason it works so well.
So that's something to thinkabout, even if you don't get a
toileting stool.
And then some kids know thatthey need to bend their knees
and so they're using whateverthey can, and I have patients
who have figured it out.
Kate Scarlata, MPH, RD (44:56):
And they'll tell me.
Dr. Iris Wang (44:58):
Oh, whenever I'm traveling in a hotel, I'll
actually swing my legs to theside and use the bathtub and I'm
like, yes, that's why it works.
Congratulations, you listen toyour body.
So we do figure it out if welisten.
Kate Scarlata, MPH, RD (45:10):
That's right.
Knowledge is power.
Dr. Megan Riehl (45:13):
Yeah, as both a physician and a mom, to help
other parents out there.
When should a parent maybe beconcerned enough to reach out
for some help if they're worriedabout their child and their
toileting?
Dr. Iris Wang (45:27):
Yeah, it's hard for me to speak on that because,
again, like I only have onechild right, I don't really know
what normal is.
But I think that if there isblood in the stool, absolutely
please reach out, especially ifit's not just bright red blood.
If it is bright red blood andyou're seeing it a lot and the
child is kind of having trouble,right, you're hearing a lot of
straining, a lot of effort topass that bowel movement.
(45:48):
It might be good to speak tojust a primary care doctor to
say what are some gentlelaxative medications that can be
really helpful.
I actually think one of thebiggest signs that I've seen
parents around me present for isleaking, and that's actually a
constipation problem, becausethe stool starts leaking out
when there's a big blockage andkids are holding on for so long
(46:09):
that their muscles fatigue, theytire out, and then they all of
a sudden let go and they haveaccidents of whatever was in the
rectum, and so that's actuallya really good.
Well, not good, but that'sactually a time to think about.
Is there actually constipationdriving that problem?
We see it a lot too if there'strouble with urination, because
those two organs are so closelylinked that sometimes pooping
(46:32):
problems present as peeingproblems and inability to
control urine.
So a lot of straining, a lot ofeffort.
If they're not having at leastthree bowel movements a week, it
might be good to just kind ofget on top of it.
Any sort of leaking problem ortrouble controlling the stool,
especially if it's a change fromprevious and then urine
(46:53):
problems as well.
Kate Scarlata, MPH, RD (46:57):
Excess stool in the colon.
You know it sounds blockage.
You're like, oh, what is theblockage?
But it's excess stool, thestool that's collected and then
this liquid is oozing around itand that can contribute to
accidents in kids.
Exactly, thanks for clarifying.
Dr. Megan Riehl (47:12):
So not that you have to be obsessive about it,
but just like we ask our kids,you know how was your day?
You can also ask, hey, did youpoop today?
And you know it's a simple likeis your day?
You can also ask, hey, did youpoop today?
And you know it's a simple likeyeah, mom, I did or nope, and
you just take note of that as amom.
And then the next day, hey, didyou poop today?
And again, it's justnormalizing that.
Hey, we can talk about lots ofdifferent things and you know
(47:34):
your pooping habits is includedin that.
Dr. Iris Wang (47:37):
Absolutely.
Keep a copy of Boo Can't Pooaround and be like well, are you
like Boo today?
Kate Scarlata, MPH, RD (47:41):
Yes, exactly, I'm already reading
this to my granddaughter,Eleanor.
She's only six months.
She likes chewing on the pagesmostly, but she likes the
pictures and she's been a goodlistener.
There's a lot of fiber on thosepages, so perfect.
She's going to be the bestpooper ever.
Oh, I, know, I'm already likewe're getting plant diversity.
She's going to have the bestmicrobiome,
Dr. Megan Riehl (48:04):
That's right, that's right.
Kate Scarlata, MPH, RD (48:05):
She's not eating yet, but you know
she's just about six months, so.
Dr. Megan Riehl (48:09):
So, as we wrap up today's episode, we like to
ask all of our guests what theypersonally do for their gut,
health and wellbeing.
So can you share with us whatyou're doing?
Dr. Iris Wang (48:21):
This is terrible because this was the hardest
question to answer on the wholelist.
I am a big proponent ofexercise as a form of gut health
and movement.
My chosen form of exercise isyoga, and I find that not only
is it good from a professionalstandpoint because I do a lot of
(48:42):
scoping, I stand in oneposition for a pretty long time
sometimes, and so moving my bodyin different ways and
stretching out the muscles hasbeen really helpful, but yoga
has really good data for guthealth as well.
Yes, a lot of those positions,the twisting, the inversions,
can help move things along ourGI tract mechanically, which is
also why sometimes I don't doyoga outside the comfort of my
(49:04):
own home, just to be okay withanything that happens as a
result.
Dr. Megan Riehl (49:09):
Normalizing that I always normalize for my
patients at yoga class.
You know you might hearsomebody toot and that is just,
it's a good sign of things aremoving along, that's right.
Dr. Iris Wang (49:21):
Yep, yep, and actually assign yoga videos to
some of my patients to augmenttheir GI therapies if they're
bloated.
Kate Scarlata, MPH, RD (49:29):
I love that it's so relaxing too.
In another way.
I love the end where you justkind of chill out, and at least
I like those types of yogaclasses yes there you go I need
to do it more, so I know thename of it.
Dr. Iris Wang (49:45):
There are great apps for that.
Kate Scarlata, MPH, RD (49:46):
Yes.
So thank you so much forjoining us today, Dr.
Wang.
This has been amazing and soinformative and cutting edge.
I love talking about precisionmedicine and I know you wrote an
article.
We will link that.
You know link things that wetalked about today.
But we really appreciate yourexpertise and your time and for
writing the great book Boo Can'tPoo and for all the work that
(50:09):
you do for patients and all ofus in the gut health world.
Dr. Iris Wang (50:14):
Thank you so much for having me.
It's been my pleasure and myhonor.
Dr. Megan Riehl (50:18):
So don't forget to like, follow and subscribe
to The Gut Health Podcast.
We appreciate your support.
It means the world, our friends.
Thank you for joining us as wegrow 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@The Podcast,
(50:41):
where we'd love for you to shareyour thoughts, questions and
experiences.
Thanks for tuning in, friends.
Thank you.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Dr. Megan Riehl (00:34):
Hello friends, and welcome to The Gut Health
Podcast, where we talk about allthings related to your gut and
well-being.
We are your hosts.
I'm Dr Megan Riehl, a GIpsychologist.
Kate Scarlata, MPH, RD (00:46):
Hi everyone, I'm Kate Scarlata, a
GI dietitian.
We have a great episode today.
We're going to be talking abouttherapeutic interventions that
use our genetic makeup to guidebest medication selections for
your body, and interestingbreathwork used to treat
abdominal distension, and somuch more.
We have a great expert guest.
Dr. Megan Riehl (01:08):
That's right, Kate.
Let me introduce our phenomenalguest.
Dr Iris Wang is an assistantprofessor in the Division of
Gastroenterology and Hepatologyat the Mayo Clinic in Rochester,
Minnesota, where she is part ofthe comprehensive general GI
group.
She also serves as theAssociate Program Director of GI
Fellowship Programming there,where she is highly regarded by
(01:31):
the trainees for her clinicalexpertise and mentorship.
Dr Wang's clinical practicefocuses on one of our favorite
things disorders of gut-braininteraction, which include IBS,
functional dyspepsia and chronicabdominal pain.
Her research centers onunderstanding the
pathophysiology of DGBIs andevaluating both pharmaceutical
(01:53):
as well as non-pharmaceuticaltherapies.
That include gut-directedhypnosis, digital interventions
and extended realitytherapeutics Very cool
hospitality therapeutics.
Kate Scarlata, MPH, RD (02:03):
Very cool, but that's not all.
She's also the author of BooCan't Poo, which I love.
This book it's adorable, butalso very comprehensive and
really dives into all differenttypes of therapeutics, from diet
to squatty potties to breathingtechniques to help the little
ones get poop in.
So love that.
(02:24):
And also big congrats are inorder for your recent teaching
award, best Research Mentor atMayo Clinic.
So we are very thrilled for you.
That's amazing.
Dr. Iris Wang (02:35):
Thank you so much .
Thank you both so much forhaving me.
I think I'm a big fan of bothof yours, and so to be on this
podcast is really veryvalidating and a lot of joy for
me.
To be able to be on thispodcast is really very
validating and a lot of joy forme to be able to be on this
platform.
Thank you both for having me.
Kate Scarlata, MPH, RD (02:49):
Well, we're thrilled to have you.
Yes, so thrilled.
So we always start the episodewith a myth buster.
What myth pertaining to guthealth and or constipation would
you like to bust for ourlisteners?
I?
Dr. Iris Wang (03:02):
think one of the things that it took me until GI
fellowship to learn was that youare not supposed to strain when
you poop, and this is somethingthat you know spurred the
writing of Boo Can't Poo.
But I was shadowing with one ofour pelvic floor physical
therapists and was listening toher educate the patients and
guide them, and I was like wait,are you serious?
(03:24):
What do you mean?
It's supposed to happen,naturally, right, and maybe I'm
giving away too much aboutmyself here, but that's, I think
, something that we never talkabout and is a myth that we are
supposed to push or it'ssupposed to be a little
difficult sometimes, yeah,sometimes, once in a while we
can have a difficult to passbowel movement, but bowel
movements are supposed to happenwithout straining.
I love that.
Dr. Megan Riehl (03:45):
It's a good start and we're going to talk
more about that in a littlewhile, but before we do, there's
so much interest inpersonalizing our care and we
love this idea of precisionmedicine and being able to
tailor treatments to eachindividual so that they get the
best possible results with thefewest side effects, and it
(04:08):
feels really you know when we'rethinking about innovation and
how do we help patients that areliving with DGBIs.
One size fits all doesn't work,and patients know this.
Us, as providers, know this,and you've written a little bit
about this, and so can you giveus a sense of where we are right
now in the world of precisionmedicine and the DGBI space, and
(04:32):
even beyond that, and whatmight be on the horizon from
your perspective?
Dr. Iris Wang (04:37):
Absolutely.
I think in the DGBI spacethere's always this question of
diagnosis.
A lot of our DGBIs aresymptom-based diagnoses and can
be very challenging for bothproviders and for patients,
because so many different thingscan cause the same symptoms.
And that can lead to a lot ofdiagnostic uncertainty, where
doctors aren't sure what youhave, and just treating on a
(05:01):
symptom can limit the medicationoptions.
And for us on a research side,if we're just using a symptom as
something to test a drug, forexample, without really
understanding what causes thatsymptom, it makes it so that the
drugs are more likely to not behelpful because we're not
really getting to the root causeof the problem.
And so in DGBI space, one of thebiggest things is understanding
(05:23):
what is the root cause of oursymptoms.
Sometimes that's disruption ofthe gut microbiome and the
bacteria that live in our gut,because we had some sort of GI
infection or a viral infection,microbiome, and not necessarily
(05:46):
a physical illness.
Sometimes it's a surgery thattakes out a gall bladder, for
example, and that can mess upwith how our bodies recycle
these detergents that we hadcalled bile acids, and a lot of
the work that I have writtenabout and aim to keep doing is
to understand.
What are these contributorsthat have very narrow mechanisms
and narrow reasons for patientsto have symptoms, and can we
(06:08):
treat those reasons in adirected fashion so that we are
more precise right in ourdiagnosis and in our treatment?
On the other side of that isusing these big machine learning
models and artificialintelligence to really
understand who's at risk fordeveloping which disorder and
what predicts treatment response.
(06:29):
I think I'm answering the lastpart of your question there a
little bit early, but that'ssort of what's on the horizon,
right.
How do we use patientinformation, your background,
your history, other aspects thatwe might not even think about
but with a large machinelearning algorithm maybe can be
picked up from computer science.
(06:49):
Let's say things like if youlive within this many miles of
this location, maybe you're athigher risk because of some
environmental factors, right,and these are things that we
don't have the capacity to thinkabout as clinicians because
there's just not enough timecapacity to think about as
clinicians, because there's justnot enough time.
But if we could put it into amachine algorithm and have a
supercomputer try to tell us,hey, there's a higher risk of
(07:10):
this disease here, then that canreally help a patient, right?
So that's maybe what's on thehorizon.
But in between that space andwhat else there is is really
treatment and medication.
Treatments and using what weknow about genetics to both
understand risk for disease butalso understand treatment
response.
And so what?
Those are reallypharmacogenomics, and okay, if I
(07:31):
get into that, yes, definitely.
What this is is telling us kindof, what are the genes that your
body has to break down certainmedications?
And we know that these genescome in a variety of forms,
right?
Not everybody is made the same.
Some people chew throughmedications really fast, so that
the active ingredient iscompletely gone and all you're
(07:51):
left with is the side effects.
Some people don't break downthose pro-drugs or non-active
forms of these medications fastenough, so then it takes a
higher dose or a longer periodof time before they're actually
getting any of the activemedication doses, and if we
don't understand that, we mightgive them too much, and then
(08:12):
they're at risk for higher sideeffects again, and so
understanding whether someone isa normal metabolizer, an
ultra-fast metabolizer, reallymatters, but it also matters
what medication you're talkingabout.
So we have these amazingpharmacists who help us out with
that, who really understandwhat these mean for each of the
drugs that are important for usin GI, but also out of GI.
Dr. Megan Riehl (08:34):
Are there some patient characteristics to help
us know whether we're highmetabolizers or low?
How do we learn more about thatin like real world?
Dr. Iris Wang (08:46):
Absolutely, because you're absolutely right.
Right, in real world practiceit's not really feasible to send
genetic testing on everybodyand it's not necessary.
And so I think there's twoareas in GI specifically where I
think about thispharmacogenomic testing a lot.
One is in my DGBI patients,where I need to write some sort
of psychiatric medication orpsychiatric associated
(09:08):
medication for neuromodulation.
Right, we're not trying totreat anxiety, depression, but
those medications are reallyreally helpful for modulating
how much we feel pain in the gut.
And so in that patientpopulation, the ones that I
think about sending this testing, is the patient who tells me I
have had so many medicationintolerances.
I almost have every side effect.
(09:30):
Every time they try to give mesomething new, I don't react
well to it, and often you knowit's really hard to say that the
patient is allergic toeverything.
It's an intolerance and that'sprobably being driven by how
their liver breaks down thesemedications.
So when I hear that from apatient, that's my sign to say,
hey, let's see why you'regetting all these medication
responses, let's see why you'renot tolerating and let's see how
(09:53):
we can adjust the medication sothat we're really optimizing
the active ingredient andminimizing all the bad stuff.
The other area that we use thisa lot is in our reflux patients
and in our patients with thispepsia or this burning pain in
the pit of the stomach that wethink is related to acid, and so
one of the primary things weuse to treat either one of those
(10:14):
diseases acid blockerspredominantly are proton pump
inhibitors or PPIs.
Now, there's a lot of PPIs, butmost of the PPIs that are
currently on the market are runthrough this specific enzyme
that our liver produces.
It's the CYP2C19 enzyme.
Kate Scarlata, MPH, RD (10:33):
You'll be quizzed on this later.
Dr. Iris Wang (10:35):
Shows up on board exams, so important for our
medical audience members.
There you go, but a lot of thesemedications need to be
inactivated and run through thisenzyme.
But if you have too much or toofast of this enzyme, you can
break through those PPIs andbasically chew through all the
active ingredients and itdoesn't matter how much we give
you, it's not going to work.
(10:56):
In patients where we're runningthrough multiple lines of these
PPIs and they're still havingsymptoms and on our objective
testing we still see acidbreakthrough, we can say, hey,
let's check how fast youmetabolize these medications and
think about alternative drugs.
And there's two options on themarket.
One is a cousin drug.
(11:17):
I describe it as a cousin drugof our PPI drugs, which are all
like sister drugs, never brotherdrugs always sister drugs.
Not sure why these cousin drugs.
Or rabeprazole is also a protonpump inhibitor but is
inactivated by both CYP2C19 andalso a different CYP enzyme
called oh, I'm not going to giveyou that one because it's like
(11:38):
3A something there's anotherpath, there is another pathway.
Kate Scarlata, MPH, RD (11:43):
There is another pathway, another enzyme
.
Dr. Iris Wang (11:44):
There is another enzyme, and so, because it also
metabolizes through the secondenzymatic pathway, it's not
going to be as chewed up asquickly and can be more
effective in these patients.
We have new meds on the marketas well.
These potassium channel orPCABs binders can also be a good
option for patients who arechewing through PPIs too quickly
(12:06):
.
Kate Scarlata, MPH, RD (12:07):
So we're checking DNA and we're looking
at specific enzymes that someonehas or doesn't have, and then
we're able to decide you'regoing to chew through this too
quickly or it's not going to bebroken down by you, so therefore
you should try this othermedication.
So really important for peoplethat know they are not getting
(12:32):
at a therapeutic symptommanagement level or just the
drugs has side effects for them.
Dr. Iris Wang (12:39):
Exactly, exactly, and I had to look it up because
otherwise it was going tobother me but it goes through
the CYP 3A4.
I think I have most of thoseletters and numbers, but that's
what ribivirazole goes throughand absolutely you're correct.
Those are the times where wewould think about just let's
find out a little bit more aboutwhich genes and which
(13:00):
phenotypes of those genes apatient has.
Perfect.
Dr. Megan Riehl (13:04):
So, interesting , it's fascinating and you've
given us two really goodexamples, right.
So people that maybe have ahistory of using medication to
try and manage their psychiatriccondition and have struggled
with that, and there are a lotof people where the side effects
were not tolerable and thenthey present to their
gastroenterologist whorecommends an anti-anxiety,
(13:27):
antidepressant, neuromodulator,and that can be very scary, and
so there is an opportunity forgene testing to help inform that
decision.
And then knowing a billionpeople globally are affected by
GERD, and again we're getting toa more precise way of informing
.
But these are just two examples.
So this is not a globalsolution yet for the field of
(13:51):
gastroenterology.
So I think there's hope andthere's hype.
It's an and, but certainly nota solution yet for all of our GI
conditions, but very excitingand I think, for the patients.
Dr. Iris Wang (14:05):
It's really important to understand that
this is genetics, right.
This isn't you, this isn't inyour head.
It's not your fault that you'vehad all of these side effects,
right?
Sometimes patients are soapologetic and I'm like you have
nothing to apologize for.
It's not your fault.
You've had medication sideeffects.
It's your genes, it's yourgenetics, and the more we
(14:26):
understand that, the morepatients can.
Just this is the way I'm builtand we can maybe use these new
tools so that they can have aneasier time going forward with
future doctors the gutmicrobiome.
Kate Scarlata, MPH, RD (14:41):
So there's genetics you know that
we might use to guide treatmenttherapies.
And I wonder you know, are weseeing the gut microbiome or
metabolome different markers,being used to sort of guide
therapeutic interventions?
Are you seeing that at all?
Dr. Iris Wang (14:58):
I think not quite yet, but it is definitely an
area of high, high interest.
There was actually an amazingtalk at Digestive Disease Week
recently looking at how themicrobiome impacts hormone
metabolism, something that I hadcompletely not thought about.
Right, and that the microbiomeis actually key in making
testosterone accessible for oursystems, and without the right
(15:23):
microbiome to break downtestosterone, we actually can
change the levels in our bodies.
And that goes the same for alot of these medications, a lot
of foods, right, and so I thinkpart of the problem with the
microbiome is that it is so vast, right, and so it takes a lot
of computational power to beable to find those associations
(15:43):
and learn which because there'sno one good book, there's no one
bad book, it's a combination.
I always like to think about itas a garden, right.
It's not only which plants arein the garden, it's the variety
of plants, the interplay ofplants and how many weeds there
are, and so it's going to take alot of machine learning and a
lot of AI to really understandthat better.
(16:05):
But I definitely see that aspart of the horizon of precision
, medicine is understanding notonly bacteria, but also viruses,
fungi, these things that livewithin us that make up this
whole microbiome and how itinteracts with the human body.
Kate Scarlata, MPH, RD (16:21):
Yeah, Exciting.
So much to learn though right,absolutely.
Yeah.
Dr. Megan Riehl (16:30):
So we're going to move on a little bit and you
know we're going to also begiving you some insights here on
some new therapies that arecoming to the world.
So first let's start withbloating and abdominal
distension.
They're different.
So before we talk about atreatment that can probably help
these, can you briefly describethe difference for our
listeners From a purely medicalstandpoint, we think about
(16:51):
bloating as a sensation or asymptom, so something we feel
gas in the stomach, fullness,right.
Dr. Iris Wang (16:58):
Bloating is a feeling, is a sensation,
distension is what we call anobjective sign, and so it is
something that we can see on aphysical exam when we're talking
from the doctor's stand ofthings.
But from a patient's stand ofthings, it is that visible
outward push of the belly, andso you can have one without the
other.
Right, your belly can distendor push outwards and you don't
(17:20):
have to necessarily feel bloated.
You don't have to feel thatsensation of fullness, but you
can also have bloating where youfeel really uncomfortable
without your belly actuallycoming all the way out.
So, sensation versus or symptomversus a sign or an objective
finding.
Kate Scarlata, MPH, RD (17:37):
Yeah, so with that, I was totally
stalking you on Instagram andsaw that you were in Barcelona
and I had read about thisbreathing technique that they're
doing there specific forabdominal distension and it
seems like that paper.
They put out a couple papersbut it's getting a little
traction here in the US.
(17:58):
So I'd love to hear a littlebit about what you learned there
.
You mentioned you learned a newtool, so can you share with
your listeners some of what youlearned?
Dr. Iris Wang (18:09):
Absolutely.
And I have to say, this groupin Barcelona I've just admired
(18:36):
I've followed their researchfrom the moment I learned about
on GI fellowship.
It's just so elegant the typeof work they've done.
And so maybe, if you're OK withDr Fernando Azpiroz and his team
, Jordi Serra and ElizabethBarba they've been working on
understanding what happens whenpatients experience bloating and
when they see visibledistension, right.
So it's really very focused ondistension, and the very first
thing they did was they said,well, it must be the gas, right,
and that's what our patientsthink too.
It must be the gas.
We must be eating something togenerate all this gas.
And so they came up with thisradiology technique where they
(18:58):
could actually, on a CT scan,measure how much gas was in
somebody's belly.
And so they had all theirpatients come in when they felt
really good, flat bellies, nodistension measured the gas, and
then have them come back thesecond they feel like they're at
maximum distension.
Measured the gas and then havethem come back the second they
feel like they're at maximumdistension.
This is the biggest I get, andthey went right into the scanner
.
First of all Amazing that theycould do that Amazing.
(19:20):
And then they were sodisappointed because they
thought their experiment failed.
There was no increase in gas inthe majority of these patients.
At most it was maybe 50 mLs or50 cc's, and you know, that's
not very much at all.
It's one of our big syringes,right, and that amount of gas is
not going to extend out ofbelly in most people.
(19:41):
And so, through thatdisappointment they were looking
at their CT scans it's anamazing story and they found
that it was not the gas, it washow the diaphragm was moving.
And what they described was inindividuals who have gas in the
belly or kind of normalphysiology, what should happen
in response to that gas pushingon the intestinal walls is the
(20:02):
diaphragm should rise up intothe chest and then the belly
abdominal wall should contractinwards so that we're really
kind of elevating ourselves upfor vertical real estate.
That diaphragm kind of movementgets abnormal in individuals
with bloating and in response,the gas in the belly.
(20:24):
What they see is that thediaphragm actually contracts
downwards and the anteriorabdominal wall pushes out and so
you're kind of decreasing theamount of real estate in the
belly and then the anterior wall, for whatever reason, can't
keep the gas in, so it protrudesoutwards.
So even though there's no gasincrease, necessarily the belly
wall moves so that the bellysticks out.
And so then, once they figuredthat out, they validated a lot
(20:48):
of that stuff and they said,well, how do we fix it?
And so what they've done in alot of their prior studies and
they said, well, how do we fixit?
And so what they've done in alot of their prior studies, is
they actually were able toretrain a patient how to move
their diaphragm using a veryinvasive muscle monitoring.
So they dropped a probe intothe patient's esophagus so that
they could really monitordiaphragmatic contraction or
(21:09):
muscle tone.
I mean, it's just not reallyfeasible outside of a lab,
Dr. Megan Riehl (21:14):
hard to do that regularly
Dr. Iris Wang (21:15):
hard to convince a patient that that's what you
need, right.
But doing that, they found thatthey could fix this, that by
teaching a patient how tobreathe and how to move that
diaphragm they could reversethis process, which is very
hopeful for all of our patients.
So then they said, okay, can wedo better?
So then they developed atechnique using a biofeedback
tool which looks like an elasticband that was placed around the
(21:37):
chest and around the belly sothat as a patient moves their
belly they could get feedback tosay, okay, we've distended the
belly this much and now we'regoing down again.
And at the same time they wereable to look at the movement of
the diaphragm by using anultrasound to look at how much
the liver was moving.
Also great in a lab setting.
(22:01):
Also difficult to implement andspread without really having
the equipment and the technologyand then knowing how to like
deliver this kind of feedback.
So then they did one stepbetter, and that was the paper
that recently came out.
They said can we do this byjust teaching someone how to
breathe using our hands?
And so this new technique thatI learned is really this like
final evolution of theirtreatment of this abdominal
phrenic dyssinergia problem bigmouthful or shortened to APD,
(22:46):
not to be confused with APT.
What we've been doing and what'skind of described in a lot of
our journals is using atechnique called diaphragmatic
breathing where we're askingpatients to really push out
their bellies as they breathe inso that all the air goes into
the belly goes into the belly inquotes and then kind of push
(23:07):
all the air back out so that thebelly deflates, right.
And we've been teaching thistechnique but we've never
actually validated that it helpsbloating.
No tests have been run outsideof this group's lab to see that
that actually works.
And so this technique takesthat diaphragmatic breathing and
really builds on it and it usesa hands-on approach to guide
(23:29):
patients to isolate their chestwhen they breathe so that they
involve their intercostalmuscles, learn what it means to
contract them and in that thenlearn what it means to relax
them so that they fully deflatethe chest.
And then it goes into adiaphragmatic breathing teaching
, also hand-guided, so that wecan really get good relaxation
(23:51):
of that anterior abdominal walland strengthening of the
obliques and the internalexternal obliques which really
need to contract so that ourbellies go in and up, and so
it's not really a rectuscontraction that we want
patients to really achieve,right?
So sit-ups are not the right wayto go.
It's contracting the sidemuscles of the core so that we
(24:12):
can shift them upwards, andteaching them to do that via
hands-on breathing training.
They do a three-week breathingtraining program.
Patients are coming back once aweek in order to get various
components of that teaching andthen a complete review.
They've, you know, had thisfirst hands-on course, and so I
(24:33):
was oh my gosh, I was the onlyone in the US who was there and
I was, like, so excited andreally excited to be bringing
this back.
But they are running more ofthese hands-on approaches and so
hopefully more and more peoplewill learn.
They're also running amulti-center clinical trial that
involves several sites in theStates to figure out what's the
best way to teach this approach,and so I'm hopeful we'll see a
(24:55):
lot more coming out from this.
Dr. Megan Riehl (24:58):
Yeah, and the patients were practicing this in
between their sessions, for afew minutes before all of their
meals.
And in the literature that I'vebeen reading on this, it was
really exciting to see theevolution of the research that,
yes, we can't be dropping thingsdown the esophagus for
(25:19):
everybody that has theseproblems to, yes, what is
tangible takeaways thatpractitioners can teach their
patients and then it really canbe life-changing, incredibly
life-changing.
And again, all coming back toour breath, and I'm guessing
that our friend Dr BrennanSpiegel, who just is such an
(25:40):
advocate for gravity and beingupright and how we breathe, yeah
, I'm sure that he's going toreally validate a lot of this
too with his work in the gravityspace and how it impacts us.
Dr. Iris Wang (25:51):
Absolutely.
And if I could just take like asuper brief sidebar too, it's
gravity and it's also musclesright, that's right.
As internal medicine doctors,we are really not very good
about the external muscles.
Like it's not what we focus on.
We focus on organs, we focus oninternal, and then, especially
as GI doctors, we think aboutthe lumen, we think about the
(26:12):
inside of the lumen, and oftenthat comes at a cost of
forgetting that there's so manylayers of fascia, of muscles, of
fat, of connective tissue thatare between, kind of our
anterior muscle wall and theinside of our abdomens.
And so when we think about painright, which is something that
I'm very passionate about- Ialways want to take kind of an
(26:32):
outside-in approach, right, oris something that I'm very
passionate about.
I always want to take kind ofan outside-in approach right, or
even an inside-out approach,but making sure that I think
about yeah, there's no ulcer onthe inside, EGD is negative.
What else could it be?
Is it something within theperitoneum, but is it something
in the muscle layer?
Is it a trapped nerve?
Is it muscle movement that isabnormal?
And I think thinking aboutthose things can help our
(26:53):
patients more holistically,because those need different
treatments than a pill.
They need our colleagues inPM&R, in PT, they need muscle
strengthening, but the rightmuscles right, and so being able
to understand that and givethat to a patient is really,
really important.
Dr. Megan Riehl (27:08):
That's right.
So in our show notes we willlink a video demonstrating this
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Dr. Megan Riehl (28:31):
You mentioned abdominophrenic dyssnergia, or
APD.
Give us an idea of how commonit is, so that we can also have
an idea of how many people mayeffectively benefit from talking
to their doctors about this.
Dr. Iris Wang (28:45):
Absolutely.
I think it's really hard to say.
Actually, if you look at justbloating as a symptom, right, it
can be ranging anywhere fromlike 10% to 30% of the
population, and studies ofpatients with irritable bowel
syndrome or IBS, show up to like75% to 90% of them experience
bloating at some point.
Now, that's a little bitdifferent than distension.
(29:06):
The distension that really kindof you want to think about APD
in, is more intermittent.
So these are the patients whowake up with flat bellies in the
morning and then it kind ofgrows throughout the day as
they're eating and as they'restanding right.
It's not just the food, it'sthe gravity as well.
And so within that populationand their study population about
(29:27):
85%, depending on which cohortand which study from this
Barcelona group you're lookingat really had APD as a reason
for their distension.
And then even the patients whodid have an increase in gas,
they saw that they still hadthis abnormal muscle movement
and the muscle movement was moretightly linked with how bad
(29:50):
they felt as opposed to theactual volume of gas.
Kate Scarlata, MPH, RD (29:55):
So interesting.
So I was talking to agastroenterologist in Boston, Dr
.
Kyle Staller, and he's reallyinterested in this as well and
looking into it in a researchsetting and he said another sort
of indicator that he thinks ofAPD in is individuals that drink
(30:15):
water and can actually getsymptomatic.
So again, water's not going tocause gas, but the handling and
the way the diaphragm is pushingdown it could contribute to
those symptoms absolutely.
So standing a long time andyour symptoms get worse,
afternoon symptoms, evendrinking water causing symptoms,
(30:37):
those are some things where youmight want to talk to your
doctor about this condition andthis specialized breathing
technique, which is exciting tosee.
Dr. Iris Wang (30:48):
Yeah that is definitely something big on the
horizon.
Kate Scarlata, MPH, (30:52):
Absolutely so.
When we think about this is onebig area.
But then you know we definitelysee bloating and distention in
our patients and think of otherthings.
What are some of the things youdo in your practice when a
patient presents with bloatingand distension, outside of these
wonderful breathing techniques?
Dr. Iris Wang (31:10):
Absolutely so.
I think often we have to lookat the diet right, we have to
look at food, and I think youare much more qualified to speak
on this than I am.
In certain patients where it'sso food triggered right, I do
fine, unless I eat or if I fastall day, I don't bloat.
But every time I eat food right.
Not water, to your point,absolutely agree with that but
(31:32):
something that could potentiallygenerate gas, right.
Then we think about okay, isthere something in the diet that
we have to change?
And then I would refer them toa GI dietitian specifically to
be able to kind of review andreally think about this with the
patient so that we can maybehopefully identify something
that is triggering.
One of the biggest offenders isgoing to be lactose, right, and
(31:53):
so can we cut out lactose oruse some sort of supplement or
aid to help decrease thatsymptom.
So that's one thing, and moreof a workup than a treatment,
but if we can diagnose it right,then it's easier to treat.
One of the other options thatI'm personally very invested in
is hypnosis, and so we actuallydeveloped a hypnosis protocol
(32:13):
specifically targeting thisbloating feeling, with the idea
of you know and Megan, you arebetter equipped than I am to
talk about the hypnotherapyaspect, but the goal of that
protocol has really been to canwe decrease the amount of
distress the bloating symptomcauses.
So this isn't really about thedistension portion, but can we
(32:35):
figure out how to get patientsto tolerate this pressure being
put on their intestines withouthaving an abnormal pain reaction
to it, because they don't needthe pain reaction.
And so we did do a pilot testof that hypnosis protocol that
one does build in diaphragmaticbreathing.
We use that as part of ourinduction and part of our
(32:56):
deepening in certain dependingon the week.
This was something that wedeveloped with in conjunction
with Dr Oli Palsson, whodeveloped the UNC protocol for
IBS hypnotherapy.
Dr. Megan Riehl (33:06):
One of the GOATs.
Kate Scarlata, MPH, RD (33:08):
He is a GOAT.
Love him.
Dr. Iris Wang (33:11):
Just an amazing man?
Dr. Megan Riehl (33:12):
Yes, he is.
Dr. Iris Wang (33:14):
I was so fortunate that I got to work
with him before he retired onthis project, but it worked.
When we looked at our data aftertreating 25 patients with
bloating small sample size, butpatients bloating got a lot
better and we saw symptomimprovement across actually all
IBS symptoms in the severitycriteria in about 75% of our
(33:37):
patients, which we were reallyexcited about.
Now these are hand-selectedpatients who were really
committed in the setting of atrial, but at least that was
good and so we're gonna try tovalidate that protocol and do
some more tests and enroll somemore patients to see if it truly
works.
Dr. Megan Riehl (33:53):
Well, ship it over to me in Ann Arbor.
We're happy to pilot.
Kate Scarlata, MPH, RD (33:57):
I love that.
So if you see that, if it'svalidated, do you have next
steps?
Like how would you roll it outso patients have availability to
this?
I know that's down the line,but have you thought about that?
Dr. Iris Wang (34:09):
Oh, I had a plan and then the plan kind of went
sideways, but it is digitallydelivered and so it's a
completely recorded therapy andwe were hoping to be able to
deliver it, like some of thedigital therapeutic companies
that were on the market, becausea couple of them are no longer
available.
I'm trying to talk to othercompanies that are still
available to see if there'sinterest in rolling this
(34:30):
protocol into their offerings.
Excellent, so hopefullyavailable for clinical use with
or without a prescription downthe line.
Kate Scarlata, MPH, R (34:38):
Excellent , great work.
Dr. Megan Riehl (34:40):
Amazing.
Well, and to you know,highlight some of your other
work.
You're a life changer here, DrWang.
I mean in your day-to-daypractice you're working with
adults, you're an adult provider, but you wrote a kid's book and
it makes me wonder that if wecan just teach healthy pooping
(35:00):
habits very early on, we may beable to prevent some of the
bloating and distention, becauseit is so common among people
that have constipation andyou're hard-pressed to find a
constipated person without somebloating.
Yeah, so what inspired you towrite Boo Can't Poo.
Dr. Iris Wang (35:19):
Poo was really trying to decrease my clinical
burden down the road reallyreally early.
But going back to what westarted out the conversation
talking about, right, nobodyteaches anybody how to poop.
And as I had theseconversations about pelvic floor
dysfunction another musclegravity problem, right, that is
(35:39):
so impactful to the GI field Iwas describing these issues to
patients and the looks I got oflike why has nobody ever taught
me this my entire life?
It was just so.
It just kind of sparkedsomething, right, that this is a
problem.
And then, as my own child waspotty training, I was like okay,
is there really nothing thatteaches this?
(36:00):
And I was going through thepotty training literature and it
was like everybody poops andI'm like that's nice, but like
how does anybody poop?
Dr. Megan Riehl (36:08):
That's right, and if you talk to an adult, not
everybody poops.
Kate Scarlata, MPH, RD (36:12):
Exactly.
Adults don't know, so how arethey supposed to teach their
kids?
Dr. Iris Wang (36:15):
Yeah, absolutely.
And so then I was like, well,maybe I should just hit the
source, start really early.
And then I was realizing thatas I was reading the books to my
son, I was learning all thisstuff on the side and I was like
, okay, I'm going to secretlyalso hit their parents, and so
it's for the children, but it'salso for the parents reading to
their children to reallyunderstand some easy things that
(36:38):
we can do to preventconstipation, because I couldn't
just talk about pelvic floordysfunction, which is kind of
what I wanted to do.
But it's been well-received andI think I've been really,
really, really fortunate.
I really felt like I won thelottery when this was picked up.
Kate Scarlata, MPH, RD (36:54):
We love it.
Dr. Megan Riehl (36:55):
Yeah, we love it.
And you know when you'rethinking about giving a baby
gift and the assignment is togive a book instead of a card.
This is the gift that justkeeps on giving.
So think about this the nexttime you're invited to a baby
shower, because I think itreally is a beautiful gift to
normalize our pooping habits.
Dr. Iris Wang (37:17):
And that's such a great point to me the
normalization of pooping as athing we all do, right Like I'm
sure you both see this a lot inyour practices that people don't
feel comfortable talking aboutpoop.
And one of the most interestingthings that I've had that I've
come across since this book waspublished was people get upset
(37:37):
that I've had some negativereviews that why is it about
pooping?
Like you know, it's not good totalk about, and even when I
brought it to my son's school,the teacher was like, oh, I had
a lot of trouble with thisbecause we're not supposed to
say poo in school, it's a pottyword, and so I was like what do
they say?
yes, it is, yeah, literally butwhat do they say when they need
(37:59):
to go and now and she's like Idon't know, but they're not
supposed to say I need to poo.
And that has so manyimplications down the line,
because then when things gowrong, kids can't talk about it,
they don't feel like they can.
It's not polite conversation.
And then they have bloody bowelmovements and undiagnosed IBD,
right, and so part of the thingthat I really realized that I
(38:20):
champion is what I call breakingthe poo taboo right.
We're just going to talk aboutit as a thing that we all do so
that, when things go wrong, kidsfeel comfortable sharing that
with their patients, with theirproviders.
Brennan published a studysaying that up to like 30
something percent of adults haveconstipation and don't feel
like they're comfortable talkingto their primary cares about it
(38:40):
.
Kate Scarlata, MPH, RD (38:40):
Yeah, and it's common in kids.
It's like 14% of children haveconstipation and you know that
can delay getting off to school,impact play dates because
they're uncomfortable.
You know a lot of kids hold itin at school because they're not
comfortable.
They have a little bit of a shyintestine.
I think I have a little shyintestine.
(39:01):
I like to go potty at home, butyou know, again, just making it
.
This is a normal thing.
Everyone poops and if you knowhow to poop correctly, that is a
good thing.
But you know, can you talk alittle bit about we shouldn't be
holding our poop and we shouldlisten to our body.
And why is it a problem to waitall day or drive three hours in
(39:24):
a car and hold your poop andthen get home?
It's not really ideal forconstipation, right?
Absolutely.
Dr. Iris Wang (39:31):
And it's both a muscle issue and also a
neurohormonal issue.
So when poop comes down intoour system I'm going to get a
little bit into thepathophysiology here we have all
these sphincters in our pelvicfloor, at the end of the rectum,
that signal to us okay,something has hit and I need to
tighten up because there'ssomething here that doesn't need
(39:52):
to come out right.
And so all of our analsphincters are able to tighten.
And then our puborectalismuscle, which is like the
sling-like muscle that keeps ourrectum in a narrow angle to
again prevent things from justfalling out, also tightens.
But in order to poopeffectively, those muscles need
to open.
When we need them to open andthat's why we don't need to
(40:14):
strain is we can open thispassage.
When we hold in the stool, wekind of signal to our bodies one
, we can ignore those signalsthat the pelvic floor is sending
us.
And two, we kind of signal toour bodies one, we can ignore
those signals that the pelvicfloor is sending us.
And two, we increase thatpelvic floor tone so that then
it becomes harder to actuallyrelease the muscles when it
comes time to release.
Over time those two things canbecome more and more progressive
(40:37):
, and the more we hold, thebigger the rectum can get.
And when the rectum gets bigger, you can imagine how, if we
need stool to touch the rectalwall in order to send those
signals, if the rectum is superlarge, then we need a super big
amount of stool in order toactually send those correct
signals, and so then thesignaling becomes weaker and
(41:00):
weaker over time.
Signaling becomes weaker andweaker over time.
Then, if we're reallydescending out the rectum like
that it's hard to get to thatpoint without some sort of
genetic condition, but there isa point where our colons can
dilate so much that theyactually can't squeeze anymore.
So then the stool builds up andour body doesn't have a
mechanism for pushing it forwardas well.
(41:21):
It's actually a very similarmechanism to heart failure for
the doctors listening but it's adecrease in muscle tone,
because our muscle fibers aren'table to reach each other to
contract, and so that's a very,very severe case of constipation
.
But smaller versions of thatcan happen with this chronic
holding behavior.
(41:41):
So it's really important for usto allow our bodies to empty
when they need to empty.
Kate Scarlata, MPH, RD (41:48):
Yeah, absolutely, and I think at the
colon too is absorbing fluid asthe stool is sitting in there,
probably getting drier and weknow that.
You know, soft stools are alittle easier to pass and
absolutely.
So just an extra burden thereon the on the pooper.
Absolutely.
Dr. Iris Wang (42:05):
And with the dryness of that stool right,
these large bulky bowelmovements, especially for a
little kid it can hurt.
And then when you're not reallyaware of that and it hurts the
poop, you can really get intothe cycle of like this activity
hurts me and so I really don'twant to do it.
And then it just perpetuallygets worse and worse as there's
more holding, as the stool sitsfor longer.
Kate Scarlata, MPH, RD (42:26):
Yeah, one of the things you showed in
the book that we always talkabout and recommend we had a
pelvic floor physical therapistthat also recommends this is the
squatty potty.
You know, wondering, you know,I certainly we didn't have
squatty potties when I raised mychildren, but you know, is that
something do you think kids areeducated about?
Dr. Iris Wang (42:48):
Oh, absolutely not.
Kate Scarlata, MPH, RD (42:48):
A squatty potty?
Dr. Iris Wang (42:49):
Yeah, yeah.
Kate Scarlata, MPH, RD (42:50):
It's just yeah, I mean, that's what
I'm talking about.
It's so simple.
Dr. Megan Riehl (42:53):
We should be having stools in elementary
school bathrooms to normalize it.
And I think also, so manyparents don't know what normal
is either.
Especially with ourpreschoolers, and especially if
you're a first-time parent orcaregiver, we don't know what
the heck is normal and what'snot.
And when our little one arethey complaining of a
(43:18):
stomachache because they misshome and they just want to go
home from school?
Or do they actually have someconstipation and they have to
poop, but they're afraid or ithurts, yeah.
So yes, we've got to do abetter job at normalizing this,
and certainly your child, mychild.
They're hearing about healthypoops and farting and like we're
cheering it on and likenormalizing it.
So, whether they like it or not,their classmates are probably
(43:42):
getting some of what they'rehearing at home too.
Dr. Iris Wang (43:44):
A little sphere of influence for helping bowel
movements.
Dr. Megan Riehl (43:47):
That's right, that's right.
Dr. Iris Wang (43:48):
Their teachers are not happy with you.
Dr. Megan Riehl (43:51):
Well, they should.
They should be thanking you.
Kate Scarlata, MPH, RD (43:54):
I know I'm thinking poop school.
Why don't we have a curriculumcalled poop school and we
develop it for schools?
Dr. Iris Wang (44:02):
You know they do that in China.
Not necessarily poop school,but like how to wipe your bottom
and it's like like with twoballoons and like teaching how
to wipe.
There's some Instagram reelsabout this, oh my goodness.
Kate Scarlata, MPH, RD (44:11):
Yeah, we got to upgrade the education, I
think, although it sounds likeyou got a little pushback from
the school.
So I think we have somecultural changes we need to work
on first.
Dr. Iris Wang (44:21):
It's funny because there are some kids who
just figure it out right.
They figure out that if theyraise their knees they poop
better.
Yeah Right.
And actually a lot of parentsare doing this at home when they
get those low potties for theirkids?
Yeah, I mean, they get thembecause they don't want the
child, they can't reach the bigtoilet and they don't want to
fall in.
But when they're sitting on thelow potties then they actually
(44:41):
can be in a good coping position, and that's why that's part of
the reason it works so well.
So that's something to thinkabout, even if you don't get a
toileting stool.
And then some kids know thatthey need to bend their knees
and so they're using whateverthey can, and I have patients
who have figured it out.
Kate Scarlata, MPH, RD (44:56):
And they'll tell me.
Dr. Iris Wang (44:58):
Oh, whenever I'm traveling in a hotel, I'll
actually swing my legs to theside and use the bathtub and I'm
like, yes, that's why it works.
Congratulations, you listen toyour body.
So we do figure it out if welisten.
Kate Scarlata, MPH, RD (45:10):
That's right.
Knowledge is power.
Dr. Megan Riehl (45:13):
Yeah, as both a physician and a mom, to help
other parents out there.
When should a parent maybe beconcerned enough to reach out
for some help if they're worriedabout their child and their
toileting?
Dr. Iris Wang (45:27):
Yeah, it's hard for me to speak on that because,
again, like I only have onechild right, I don't really know
what normal is.
But I think that if there isblood in the stool, absolutely
please reach out, especially ifit's not just bright red blood.
If it is bright red blood andyou're seeing it a lot and the
child is kind of having trouble,right, you're hearing a lot of
straining, a lot of effort topass that bowel movement.
(45:48):
It might be good to speak tojust a primary care doctor to
say what are some gentlelaxative medications that can be
really helpful.
I actually think one of thebiggest signs that I've seen
parents around me present for isleaking, and that's actually a
constipation problem, becausethe stool starts leaking out
when there's a big blockage andkids are holding on for so long
(46:09):
that their muscles fatigue, theytire out, and then they all of
a sudden let go and they haveaccidents of whatever was in the
rectum, and so that's actuallya really good.
Well, not good, but that'sactually a time to think about.
Is there actually constipationdriving that problem?
We see it a lot too if there'strouble with urination, because
those two organs are so closelylinked that sometimes pooping
(46:32):
problems present as peeingproblems and inability to
control urine.
So a lot of straining, a lot ofeffort.
If they're not having at leastthree bowel movements a week, it
might be good to just kind ofget on top of it.
Any sort of leaking problem ortrouble controlling the stool,
especially if it's a change fromprevious and then urine
(46:53):
problems as well.
Kate Scarlata, MPH, RD (46:57):
Excess stool in the colon.
You know it sounds blockage.
You're like, oh, what is theblockage?
But it's excess stool, thestool that's collected and then
this liquid is oozing around itand that can contribute to
accidents in kids.
Exactly, thanks for clarifying.
Dr. Megan Riehl (47:12):
So not that you have to be obsessive about it,
but just like we ask our kids,you know how was your day?
You can also ask, hey, did youpoop today?
And you know it's a simple likeis your day?
You can also ask, hey, did youpoop today?
And you know it's a simple likeyeah, mom, I did or nope, and
you just take note of that as amom.
And then the next day, hey, didyou poop today?
And again, it's justnormalizing that.
Hey, we can talk about lots ofdifferent things and you know
(47:34):
your pooping habits is includedin that.
Dr. Iris Wang (47:37):
Absolutely.
Keep a copy of Boo Can't Pooaround and be like well, are you
like Boo today?
Kate Scarlata, MPH, RD (47:41):
Yes, exactly, I'm already reading
this to my granddaughter,Eleanor.
She's only six months.
She likes chewing on the pagesmostly, but she likes the
pictures and she's been a goodlistener.
There's a lot of fiber on thosepages, so perfect.
She's going to be the bestpooper ever.
Oh, I, know, I'm already likewe're getting plant diversity.
She's going to have the bestmicrobiome,
Dr. Megan Riehl (48:04):
That's right, that's right.
Kate Scarlata, MPH, RD (48:05):
She's not eating yet, but you know
she's just about six months, so.
Dr. Megan Riehl (48:09):
So, as we wrap up today's episode, we like to
ask all of our guests what theypersonally do for their gut,
health and wellbeing.
So can you share with us whatyou're doing?
Dr. Iris Wang (48:21):
This is terrible because this was the hardest
question to answer on the wholelist.
I am a big proponent ofexercise as a form of gut health
and movement.
My chosen form of exercise isyoga, and I find that not only
is it good from a professionalstandpoint because I do a lot of
(48:42):
scoping, I stand in oneposition for a pretty long time
sometimes, and so moving my bodyin different ways and
stretching out the muscles hasbeen really helpful, but yoga
has really good data for guthealth as well.
Yes, a lot of those positions,the twisting, the inversions,
can help move things along ourGI tract mechanically, which is
also why sometimes I don't doyoga outside the comfort of my
(49:04):
own home, just to be okay withanything that happens as a
result.
Dr. Megan Riehl (49:09):
Normalizing that I always normalize for my
patients at yoga class.
You know you might hearsomebody toot and that is just,
it's a good sign of things aremoving along, that's right.
Dr. Iris Wang (49:21):
Yep, yep, and actually assign yoga videos to
some of my patients to augmenttheir GI therapies if they're
bloated.
Kate Scarlata, MPH, RD (49:29):
I love that it's so relaxing too.
In another way.
I love the end where you justkind of chill out, and at least
I like those types of yogaclasses yes there you go I need
to do it more, so I know thename of it.
Dr. Iris Wang (49:45):
There are great apps for that.
Kate Scarlata, MPH, RD (49:46):
Yes.
So thank you so much forjoining us today, Dr.
Wang.
This has been amazing and soinformative and cutting edge.
I love talking about precisionmedicine and I know you wrote an
article.
We will link that.
You know link things that wetalked about today.
But we really appreciate yourexpertise and your time and for
writing the great book Boo Can'tPoo and for all the work that
(50:09):
you do for patients and all ofus in the gut health world.
Dr. Iris Wang (50:14):
Thank you so much for having me.
It's been my pleasure and myhonor.
Dr. Megan Riehl (50:18):
So don't forget to like, follow and subscribe
to The Gut Health Podcast.
We appreciate your support.
It means the world, our friends.
Thank you for joining us as wegrow 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@The Podcast,
(50:41):
where we'd love for you to shareyour thoughts, questions and
experiences.
Thanks for tuning in, friends.
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