Why Your Gut Feels Everything: The Science of the Gut-Brain Connection in IBS (And 3 Tools That Actually Help)

1. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology. 2016;150(6):1262-1279.
2. Rome Foundation. Rome IV Criteria for Disorders of Gut-Brain Interaction. Available at: theromefoundation.org.
3. Lacy BE, Pimentel M, Brenner DM, et al. ACG Clinical Guideline: Management of Irritable Bowel Syndrome. American Journal of Gastroenterology. 2021;116(1):17-44.
4. Mayer EA, Labus JS, Tillisch K, Cole SW, Baldi P. Towards a systems view of IBS. Nature Reviews Gastroenterology & Hepatology. 2015;12(10):592-605.
5. Ford AC, Lacy BE, Harris LA, Quigley EMM, Moayyedi P. Effect of Antidepressants and Psychological Therapies in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-Analysis. American Journal of Gastroenterology. 2019;114(1):21-39.
6. Peters SL, Muir JG, Gibson PR. Review article: gut-directed hypnotherapy in the management of irritable bowel syndrome and inflammatory bowel disease. Alimentary Pharmacology & Therapeutics. 2015;41(11):1104-1115.
7. Ma X, Yue ZQ, Gong ZQ, et al. The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults. Frontiers in Psychology. 2017;8:874.
8. Johannesson E, Simrén M, Strid H, Bajor A, Sadik R. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. American Journal of Gastroenterology. 2011;106(5):915-922.

Jessie (00:00):
Welcome to the IBS Nutrition Podcast, your go – to source for navigating the complex diagnosis of irritable bowel syndrome. Here we dive deep into IBS and discover the power of diet and lifestyle to find freedom from your IBS symptoms. Whether you’re newly diagnosed or have been managing IBS for years, you are in the right place for relief. I’m your host, Jesse Wong, FODMAP dietician and a gut expert. For years, I suffered from debilitating gut symptoms that kept me out of work, feeling constant discomfort in my body and anxious around food. Today, I’m in control of my IBS, able to eat the food I love again, travel whenever I want and spend quality time with loved ones. It is my mission to help you do the same and transform the way you live with IBS. Let’s get started. Hi everybody. Welcome to another episode of the IBS Nutrition Podcast.

(00:54)Today we are taking a highly clinical yet very incredible validating look at what’s actually causing your IBS. For decades, patients have been told by doctors that their scopes look totally normal, leaving them to feel like their pain is just all in their head, but modern science have completely shifted the narrative. IBS is now officially classified as a disorder of the gut brain interaction, DGBI. So to help us understand the science behind, we have Dr. Megan Riehl to the show. Welcome, Dr. Megan Riehl. Thank you so much for being here.

Dr. Riehl (01:34):
Jesse, it’s a pleasure to join you again. Thank you so much for having me.

Jessie (01:38):
Dr. Riehl is an internationally recognized GI psychologist, associate professor of medicine and the director of the GI Behavioral Health Program at the University of Michigan. She specializes in gut brain behavioral therapies and is fiercely dedicated to delivering compassionate practical care for DGBI. She is also the co-author of the fantastic book, Mind Your Gut, and the co-host of the Gut Health Podcast. I have to say the book, Mind Your Gut is something everybody needs, especially for those with IBS. Read it on better understand the condition and it’s also packed with tools to help you better manage your condition. Dr. Riehl, again, so thrilled to have you and for our listeners today, we have three major topics on the agenda. Topic number one, we are diving into the science of DGBIs and the gut-brain axis. Number two, we’re going to unpack the vasovagal reaction, the terrifying dizzy or sweating feeling on the toilet and what it means for IBS patients.

(02:46)And number three, Dr. Rio is going to give us three highly actionable, evidence-based tools to help you calm your nervous system and find relief. Now, let’s dive right into our first topic, the first one. What is DGBIs?

Dr. Riehl (03:05):
Yeah. So we think about DGBI as more of this modern medical term and it moved from functional gastrointestinal disorders into this era of DGBI. And really this wasn’t too long ago in terms of time. Really, five to 10 years ago is when we started to make this shift. And things like irritable bowel syndrome and some of our other functional conditions didn’t really feel functional for patients. And so literally the nomenclature of how we were describing these very complex, difficult to manage, frustrating conditions, patients really literally were like, “I do not feel very functional,” and there was really a big disconnect here. And so when we start to bring in the brain, I think there can also be a little bit of worry there because many patients that have been living with functional gastrointestinal disorders, now known as disorders of gut brain interaction, have had that experience of having a complete workup of their medical symptoms, being told, “Hey, everything looks great. You’re doing fine. Just keep taking your medication, come back and see me if something gets worse and good luck to you. “That almost is not even on the bad side of the spectrum. The really horrible experiences come when a patient is told, “This is just in your head, go ahead and go live with this. ” So when we bring in the brain into how we describe these conditions, I think that what we really are doing is highlighting the true reality of how these conditions are driven in the body and that’s through our brain gut connection, which is a very real phenomenon and a situation where our brain is constantly assessing what’s going on in the gut and the gut is sending signals up to the brain and so we call it a bidirectional communication pathway. So this is how we kind of came to rename these same conditions.

(05:20)So IBS is the most well known in the disorders of gut-brain interaction, but really just this shift from better identifying and helping patients and the field to recognize that this is a condition where the digestive system and the nervous system are not communicating and regulating the way we want them to. And even though things may look normal, and I’m putting that in quotes, we really have to get into how the brain and gut interact in order to help you manage those conditions.

Jessie (05:56):
Yeah, absolutely. Now some of the symptoms patients feel, right? Let’s move on to point number two. What are some of the symptoms that patients view that stems from the gut brain interaction?

Dr. Riehl (06:09):
Yeah. These are common ones that even people without a disorder of gut brain interaction can experience subdominal pain, cramping, bloating, diarrhea, constipation, urgency, belching. Sometimes you can get a chest or even a throat discomfort, feeling fu more easily or quickly after meals. Those are some of our very common symptoms. And then how those present really in terms of severity, frequency, duration helps us then classify some of the diagnoses within that group of disorders of gut-brain interaction.

Jessie (06:48):
Right, absolutely. Now, what is vasovagal reaction?

Dr. Riehl (06:54):
So this is also something that a lot of people have probably experienced. And I think sometimes when we think about IBS, as you mentioned at the top of the podcast here, you can get that sweaty, clammy feeling, but really some of the symptoms that people are prone to with this response is heightened nervous system sensitivity. Say that 15 times fast or five times fast, heightened nervous system sensitivity. And this is really where our body’s autonomic nervous system is responding in a way where we feel our heart rate increase. Our blood pressure becomes a bit dysregulated and that can trigger some of our pain symptoms like that cramping. You might get sweaty, you might feel a little faint, you might feel really nauseous or dizzy and patients that are living with IBS can experience this in kind of the midst of a flare up of their GI symptoms.

(07:58)I have some patients that will feel this kind of vasovagal response just before having more urgency or a bout of diarrhea. Some patients where they’ve had those bouts of diarrhea, those more severe symptoms, and then after the fact they feel some of these symptoms. So it’s really your nervous system, specifically your autonomic nervous system revving up and really making the whole situation a bit worse.

Jessie (08:32):
Can we explain a little bit more about what is our autonomic nervous system? What do they do? How are they regulated so our audience can better understand this?

Dr. Riehl (08:42):
Yeah. This is a really important concept, especially for those that might be living with a DGBI because this is really where the heart of our brain gut behavioral therapies can target. So our autonomic nervous system is made up of your parasympathetic system and your sympathetic system. And the sympathetic system is thought to kind of, you can think about it as your fight, flight or freeze response. It’s going to kind of go on guard to keep your body safe. And our parasympathetic system is also known as our body’s relaxation response or the rest and digest state. So our goal is to kind of keep us moving toward that parasympathetic state, specifically when we’re at baseline and we’re just going about our day. And so this is what the autonomic nervous system regulates. Its job is to kind of tell the body where to be focused. And in a lot of patients that are living with IBS or DGBIs, our sympathetic system begins to dysregulate in situations where it really doesn’t need to.

(09:54)So in a way, it’s interpreting situations with threat that it perceives as a threat and then responding, which then kicks up the symptoms that happen when our sympathetic system is ramping. And that can be your heart rate is racing, your breathing gets short shallow, your muscles clench, tense and tighten. And those are all kind of bodily responses that are not very conducive to GI symptoms because it also is going to make cortisol surge through your system and it can really impact the stress hormones that are going through your body. And so that can further perpetuate some of these GI symptoms of feeling faint or feeling more severe nausea, having that cramping and spasming kick up so that your urgency worsens. And when you can understand some of the mechanisms of which your body is and your brain, because this is really being driven by your brain gut connection.

(11:02)And so when we can understand this and help you identify that, yes, these are real symptoms that are happening, that your brain is a part of this picture, but also the interpretations that the brain is making about the sensations that are happening in your body we can shift into when we have some of these symptoms, how might we respond a bit differently to help activate our parasympathetic system, which is our relaxation response, as I said, and different things like diaphragmatic breathing or muscle relaxation. I’ll get into those tips in a little bit. Those are beautiful ways that you can more quickly activate your relaxation response to help calm some of these uncomfortable physical sensations.

Jessie (11:49):
I love that. Now for patients who are listening, when is a good time for them to maybe start thinking about this or start thinking about working with a psychologist or a therapist who specializes in GI disorder?

Dr. Riehl (12:02):
Yeah, it’s a great question because it is important to highlight that the majority of GI psychologists, our job is to kind of jump right in there. We’re going to be working on skills and strategies to help you better understand your condition, how to implement our brain gut behavioral therapies to address your physical symptoms and some of the GI specific anxiety that can go along with that using what are called brain gut behavioral therapies. And so our work is a bit different from a general mental health provider who for Lord knows none of us are short on stress these days and our mental health is so very important. And so you would want to prioritize if you’re experiencing anxiety, depression, trauma that is not so related to your GI condition, we want to prioritize your mental healthcare with somebody who really can kind of work with you to stabilize those mood and anxiety and trauma symptoms.

(13:02)But if you’re somebody who, as I’m talking today, you’re kind of going, “Yeah, before a trip, I always get increased bloating and urgency and diarrhea. While I’m traveling, I get more constipated. I have bloating and gas. I’m always afraid of what I’m going to eat or how that trip is going to go or man, my work stress every time that kicks up my GI symptoms worsen.” Man, I really am a stress responder and when I feel my stress, I feel it in my gut and my GI symptoms are worse. Those are really patients that we can do some remarkable work with in a pretty short amount of time with our evidence-based therapies and we can really help you. I always say our goal is that I’ll never completely cure IBS.That’s not a possibility and anybody that promises that out there is selling you snake oil.

(13:55)But what we can do is improve your confidence to manage IBS and we can also reduce the severity, the frequency and the intensity of your flareups and hopefully go longer and longer periods of time without a bout of these symptoms. But the key is that if you do have a flareup of symptoms, you’ve got a really good toolbox of strategies and you know what to do, you know what’s happening and you know how to calm it down and that makes living with some of these conditions much more bearable. And in fact, you can live a very full, wonderful life where you travel, you manage your stress and you can have all the relationships and beauty of the world.

Jessie (14:40):
Yeah, I love that. So for anybody listening, this is a really key option or key team member to help you manage your IBS. And we often say when it comes to managing IBS, you need a team of providers behind you, PCP, GI provider, GI psychologist, GI dietician, and oftentimes a pelvic floor therapist if needed.

Dr. Riehl (15:01):
Yes. We need a team. The dream team.

Jessie (15:06):
Yes, a dream team. All right. Well, now let’s move on to the next topic, which is three actionable tools to help patients find relief. I’m sure everybody is eager to learn what tools they can use today to find some relief with their gut symptoms.

Dr. Riehl (15:21):
Yes. Well, I wouldn’t be able to talk about this topic and tips without mentioning diaphragmatic breathing. It is a strategy that I teach pretty much every patient that comes before me and I mentioned it in talks and to my colleagues. So me and diaphragmatic breathing go way back. And this is a simple strategy of learning how to slow your breath and deepen it down into the belly. The way I teach it is about a four second inhale through the nose and your goal is to learn how to help that belly rise and then a six second exhale through the mouth so that the belly falls naturally and gently. And this is going to activate and move your diaphragm. And the beauty about this is a lot of people have learned it maybe with a mental health provider as a stress or anxiety management strategy. But when you’re actively doing this type of breathing, it can calm and soothe and even massage the intestinal organs in a way that we don’t get with our normal breathing.

(16:24)So this is one of those strategies that’s going to activate that relaxation response for you, activating your parasympathetic system. And that is a really important thing to have in your back pocket. If you have some cramping or urgency and you have that, oh crap moment, where is the bathroom? When you can learn to shift into, oh crap, okay, let me start breathing, as opposed to, oh crap, like, oh my God, my god, oh my God, I got to get to the bathroom. I’m going to make it. I’m going to have an accident. It’s going to be the worst thing in my life. That’s just ramping that sympathetic system up. Our breathing is going to activate our parasympathetic system. So I have a YouTube brief about four minute clip that if you just Google my name with diaphragmatic breathing, you’ll find it and people have found it really helpful in terms of just learning the strategy. So that would be tip number one.

Jessie (17:15):
Okay. I love that you have a YouTube video and it does take practice for somebody who have never really done it before, it does take practice.

Dr. Riehl (17:22):
It does. And so give yourself some grace and space to practice this. I actually prescribe it to my patients to kind of get them comfortable building the habit. So the prescription is usually practicing for just two minutes, three times a day and anchoring it to things that you’re already doing. So eat breakfast and then do a little diaphragmatic breathing. Have lunch, do a little diaphragmatic breathing, get into bed at night, do a little diaphragmatic breathing. And before you know it, it feels a lot more comfortable because you’re learning a new skill.

Jessie (17:56):
Yeah, absolutely. I love that. Okay. What is our second tool here to help calm that gut bring access?

Dr. Riehl (18:02):
So another one is, again, just a simple strategy of body scanning. A lot of times, especially these days, we still are doing a lot of Zoom meetings, we’re doing a lot of sitting, we’re doing a lot of computer work. And so even in this sitting position in front of a screen, our body kind of just the tension builds and before we know it, we’re sitting here for hours on end and holding tension in our body. And so I will have people put a little sticky note right on their computer screen with some kind of a reminder. For me, for years, my sticky note was just an up arrow and that my eye would catch it and I would just sit up straighter. I would pull my shoulders back and down. I would release any stress and tension in my jaw, wiggle my fingers around a little bit, but that really like sitting up straight, pulling your chest back, pulling the shoulders down a little bit, you really just very quickly notice, oh my gosh, I wasn’t even thinking I was tense.

(19:04)I wasn’t thinking I was stressed, but now my breath, I can get a deeper breath. I can kind of also feel a little bit of energy come into my system as I kind of work to release some of the stress and tension. So again, a body scan does not have to be you sit down for a 20 minute meditation. I like to kind of encourage you to pick three places in your body where you know you hold tension and for a lot of people it’s that those shoulders, neck, upper back, jaw, hands. And so it could be a simple like open up your hands, move the fingers, come up to the shoulders, open the shoulders and the chest and then kind of think about your hips sinking back into your chair wiggling around so that you loosen the lower back as well and that’s it.

(19:55)And if you can get into the habit of kind of doing a body scan a few times a day, again, you’re activating your relaxation response. You’re telling your body that when you’re sitting at your desk, there’s no need to sit here uncomfortably tense because that’s another thing that a lot of people will kind of have an aha moment with is we get just comfortable being uncomfortable. I say that sometimes with my patients and their pants that how often are you sitting in tight pants for hours and hours and hours and the why? Why? If you’re sitting at your desk at work, now granted, don’t sit there pants free, but we have bodies that can kind of expand and contract based on what we’ve eaten and what’s going on in our day. And so making us comfortable is really all a part of the second tip.

Jessie (20:48):
Yeah. I love that. And I just did a little bit of… I followed what you were saying and doing it. I thought, oh my goodness, I was tense. And I think a lot of the times we hear from our patients too with IBS especially is that they’re very tense in the abdomen area.

Dr. Riehl (21:03):
Of course.

Jessie (21:04):
And that is one area we usually recommend doing a belly massage. If they notice that tense, maybe doing the body scan and then doing the shoulders and maybe massaging your belly if that’s where you hold a lot of tension at. I love that. What a great tip. I’m going to put an arrow on my computer as well to remind myself.

Dr. Riehl (21:22):
Yeah. And I think I would have patients back in the day when I used to have patients come into my office where they would see my up arrow and they’re like, “Doctor, what is that? ” And I would then explain, “Hey, you’re going to get this tip as well, and I do my best to practice what I preach.”

Jessie (21:42):
That’s the hard part when we have a very busy day is hard, but having that visual sign, right? Visual reminder really helps us to do it and it doesn’t take long. That’s the amazing thing about the tips you are giving. It takes maybe two minutes to do deep breathing and maybe take a minute or 30 seconds to scan your body and then shake things up a little bit. Well, and now let’s move on to our third tip. What is the last thing you would recommend for patients to do right away?

Dr. Riehl (22:08):
Yeah, movement and being really, really gentle with yourself and trying your best to let go of an all or nothing mentality with this. So I have three little kids and my relationship with exercise has been different for the last decade. When I was kid free, I guarantee I was getting that 150 minutes plus of moderate to significant exercise. I wouldn’t miss my exercise. It was a big mood booster for me and also just really important. Well, as I’ve aged and I’ve had kids, sometimes it’s I get on my Peloton still in my work clothes with really the intention, I’m going to sit here for 10 minutes and just pedal my legs and that’s going to be good enough. And so I really think that people are, you can get in your head about what your routine has to… I have to exercise every other day or I’m going to do it every day.

(23:09)And as the hours tick by in the day and you’re like, “I don’t know when I’m going to fit this in. ” Even if it’s a 10 minute walk at the end of the day, it’s still moving your body or there are times where I might get a good decent lunch hour and I’ll just run out to our parking lot and walk just for fresh air and feel the sun and get my body moving even if it’s 10, 15 minutes. So that can be really good for our gut, but also tremendously beneficial for our brain health and boosting our mood. I think it’s something that you can do as a family or with loved ones too. So it’s just one of those things where if my daughter wants to go for a bike ride, it’s not going to be like a strenuous exercise activity for me.

(23:58)I know that because the bike veers off and the training wheels fall off and somebody is looking at a bug, but it’s moving our body together as a family and that I think also helps to set some healthy values around just our whole body health that we’re aiming for and it’s not going to be perfect, but it’s got to be practical.

Jessie (24:22):
I love that. Right. It’s not I have to do 30 minutes of exercise, but maybe how can I add in five to 10 minutes here and there through the day? That makes me feel better and I can let go of being perfect about what I’m doing. Oh my goodness. These are amazing tips. Thank you so much. Now let’s move on to our five rapid firing questions. First one.You ready?

Dr. Riehl (24:49):
I’m Ready.

Jessie (24:50):
What is your go – to chaotic weeknight dinner when you have no energy to cook?

Dr. Riehl (24:56):
Okay. Let’s see. I would say so Costco has these, I think it’s Tyson chicken nuggets, frozen chicken nuggets and I’m not a processed meat kind of gal, but they’re actually pretty good. So we do them in the air fryer and again, I keep it so simple. I always have frozen veggies in the freezer and rice packets are another microwaveable rice packets. And so sometimes we’ll get a little creative and like mix it all up, maybe do a fried rice situation. But if I’m really truly honest, it’s like they’re getting chicken nuggets on the plate, but with some veggies and a starch and I’m letting any mom guilt go with that.

Jessie (25:43):
Well, your kids are fed and they are happy.

Dr. Riehl (25:46):
That’s right. That’s right. That’s what matters.

Jessie (25:47):
Yes. I would add maybe a fruit to that, then it’s perfect.

Dr. Riehl (25:52):
Yes. And thank you for the dietician always pointing that out. My kids are nine, seven, and four. And also that’s another life stage where I could prepare the most wonderful, nutritious meal in the world and somebody’s going to love it, somebody’s not going to eat it, somebody’s going to want it later, somebody’s going to eat it for… And so we put dinner on the table and I try to put it on as early as possible, like as close to after school as possible, but depending on schedules, just who knows? But once they want to eat again, which may be five minutes later or an hour, fruits and vegetables are the choice. So that’s usually where they’re getting extra fruits and vegetables and that’s their before bedtime kind of routine.

Jessie (26:42):
I love that. I get it. You’re such a super mom with three kids, busy

Dr. Riehl (26:48):
Work. Well, I’m not going to lie. There’s probably fruit by the foots in there and there’s other stuff, but we do. We always have lots of fruits and vegetables around and they’re all of the age where they can kind of cut it up. And my daughter knows she’s not allowed to use a very sharp knife. So watching her cut an apple with a butter knife as she figures it out. But yeah, they’re gravitating toward the good stuff too. And I just did the thing I try not to do, which is good versus bad and using more of that language of like, this is really healthy for our bodies as opposed to like, you can never have fruit by the foot. We do, but it’s available, but quite honestly, they’ll choose the other stuff as well.

Jessie (27:38):
Well, it’s okay to choose, right? It’s about the balance and eating more rainbow. Yeah, I love that. Okay. Well, second question. Are you a coffee or tea person to start a busy clinic day?

Dr. Riehl (27:50):
Coffee. Coffee all the way. I love coffee.

Jessie (27:54):
I know I just had a friend on the podcast and she said, “I’m a mean person without my coffee and I agree a hundred percent. All right. Next one, sweet or savory when you want something comforting.

Dr. Riehl (28:07):
Sweet.

Jessie (28:09):
Okay. All right. Will, what is one wellness trend or diet trend that you wish would dissapear from social media forever?

Dr. Riehl (28:18):
I just wish those that didn’t have the degree or the education would just disappear and stop muddying the waters for people that are just trying to feel better. So I think that really relying on people that have science-based appropriate qualifications, that’s who we really want to focus our attention on for some help and support.

Jessie (28:44):
I think that is so important for our listeners to hear. When you are hearing a message on social media, go take a look at the person’s profile. Can you figure out if this person has any actual real certifications or licensure, not just something made up. And if somebody says that they’re a doctor but there’s no way to figure out what type of doctor they are, chances are they’re not a real doctor. Yeah. So be careful. There is so much misinformation on the internet. Okay. Last but not least, what is your personal favorite 60-second trick to come your own nervous system?

Dr. Riehl (29:22):
In 60 seconds, self-talk and deep breathing. I am okay. I’m going to be able to make it through this. I can get through hard stuff and just starting to kind of feel my body do that body scan deepen my breath. It’s a superpower to be able to recognize that your body is responding to whatever stressor is in front of you and know that if you intentionally release the stress and tension from the limbs and the body and you use your cognitions to help you move Through that period of time, it will pass quicker.

Jessie (30:04):
I love that. Well, Dr. Riehl, thank you so much for joining us and especially thank you for sharing all of these tips that can really help IBS patients and anybody who is struggling with GI symptoms.

Dr. Riehl (30:17):
Yes. Thanks for having me. Always happy to talk about it.

Jessie (30:21):
Yes. And for those of you listening again, you can find Dr. Megan Rio on social media. I’ll link off the links in the show notes and she has an amazing book. Can you tell us what the name of the book is?

Dr. Riehl (30:32):
Yes. It’s Mind Your Gut, the Science-Based Whole Body Guide to Living Well with IBS. I co-wrote it with Kate Scarlata and we’re really proud of it. It’s now available in Spanish. We also just heard it was available in Turkish, so it’s getting around the world and we’re really excited for people to continue to read it.

Jessie (30:54):
I love that. I’m going to have to get it for my family members when it comes out in Chinese or maybe I have to translate it first for

Dr. Riehl (31:00):
Them. We need to do that. Yes. So we’ll have to mention that to the publishers.

Jessie (31:07):
Please do. Again, thank you so much, Dr. Riehl.

Dr. Riehl (31:11):
Thank you.

Jessie (31:12):
Thank you for tuning into the IBS Nutrition Podcast. We hope today’s episode has brought you closer to understanding and managing IBS. Remember, you are not alone on this journey and finding freedom is possible. For more on IBS, make sure to follow us on your favorite podcast platforms and please leave us a five-star review. We would really appreciate that. You can access links mentioned in this episode in the show notes to learn more about your type of IBS and how to identify your own food or lifestyle triggers. Register for our free IBS Masterclass, Three Steps to IBS Relief for our proven, holistic three-steps approach to managing IBS once and for all. Head to IBSdietician.com/masterclasstoregister. Until next time, take good care of your gut and hears to your health and happiness.