The Dr Louise Newson Podcast - 152 - Irritable bowel, bloating and digestive health with The Gut Experts

Episode Date: May 17, 2022

Consultant Gastroenterologist Professor Barbara Ryan and Clinical Dietitian Elaine McGowan are The Gut Experts, passionate about digestive health and helping women with debilitating bloating and irritable bowel symptoms. In this episode, the experts discuss why more women are troubled by gut related symptoms compared to men, how gut and bowel problems have a very real impact on women’s lives, and why eating the right type, amount and variety of foods is so important for your gut health and overall wellbeing. The Gut Experts also talk about their new book written for women of all reproductive ages experiencing gut and bowel related symptoms. Barbara’s tips for improving your future digestive health: If you’re having digestive symptoms seek a correct diagnosis rather than self-diagnosing Don’t look at your gut and digestive health in isolation, take a whole-body approach. Remember TEAMS: Total gut and body health, Exercise, Alcohol (reduce/cut out), Mental health, S Elaine’s tips for improving your diet: Fibre is a superfood for your gut microbiome – find the right amount of fibre intake for your own gut as everyone is different Variety and diversity of foods is crucial, eat the rainbow, following a Mediterranean style diet. Visit the Gut Experts website at https://thegutexperts.com/ The Gut Experts book, ‘What every woman needs to know about her gut’, contains solutions for bloating, IBS, and digestive symptoms and is out now, published by Sheldon Press. Follow Barbara and Elaine on instagram @thegutexperts

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So this morning I'm very delighted to have two people on the podcast today who I've recently met and really enjoyed following so far and there's going to be a lot more. We'll hear about them going forwards. So

there's Professor Barbara Ryan and Elaine McGowan who are both friends and co-authors actually of a book that we will talk about. So welcome both to the podcast today. Thanks very much Louise. Thank you, Louise. So let's start with you, Barbara. I think you reached out to me a few months ago, and it's been absolutely stimulating, having conversation with you, not just about gut health, but about medicine and all sorts of things as well. So talk through, if you don't mind, a bit about your background and what you do. Yeah, so I'm a gastroenterologist and I'm a professor gastroenterology at Trinity College, Dublin. So I did most of my training in Ireland. And then I worked in the Netherlands for a couple of years. I worked in Germany. And I worked in Manchester. in the UK as well, furthering my training. I was a consultant in the UK for a while, and then I returned to Ireland. So I guess over the years of my gastroenterology work, while I do a lot of interventional endoscopy, I've actually found over the years that more and more of my work involves sort of listening to people and what I have technical skills, that you can actually gillane such a huge amount from just listening to patients. And we see a lot of women in particular with

problems like irritable bowel syndrome, which we might talk about that, but that's much more more women. And while men and women have lots of digestive problems in common, the vast majority of people, 70% of people with irritable bowel syndrome are female. So I suppose that really stimulated my interest in what's different about women. And eventually that culminated in myself and Elaine, you know, talking about this and deciding that there was a need for a book specifically directed at women, because there are very particular problems and child. that a woman faces in her life that men don't face, predominantly hormonal, pregnancy, etc. And our bodies go through a lot. And that was really what sort of spurred me on to write this

book with Elaine. So Elaine, tell us a bit about you. So I'm a registered dietitian, Louise, and I am working over 35 years as a dietitian, giving my age away here. And I started off working in hospital clinical practice first for many, many years. And then I went on to do a master's in actual sports nutrition. And while I was doing that, I set up my first dietetic clinic in 1992. And at that time, there was a surgeon and a gastroenterologist that had a huge interest in nutrition, and particularly the role that it played in gut health. So I've been working in the area of gut nutrition and digestive complaints that women often suffer with for over 30 years. So I had gone on to set up other practices as well. And in the time, I actually also had worked a lot in sports

nutrition for about 12 years. So I had an interest in the area of exercise and its role that plays on gut health as well. And I love helping women find solutions to difficult and problematic gut symptoms that can often affect their daily quality of life. Yeah. And it's so important, isn't it? Because we think about the gastrointestinal system as in isolation almost. And, you know, I remember listening and very learned professors and lectures when I was a medical student. And it's very much about, you know, it starts in the mouth, ends in the anus, and it's very much the sort of isolated and you've got the liver and the pancreas just attached a bit. And food is just for fuel, really. And so, and this was in the 80s and 90s. And things have changed, but there's

still a lot we don't know. And actually, it's not in isolation, is it the gut? No, absolutely. And I think it's been a really interesting time to be working as a gastroenterologist, because you're absolutely right. When I started out, it was sort of seen as this, you know, a tube and things could go wrong within the tube. And now we realize, that the 50 plus trillion bacteria in our gut are talking to all the other parts of our body. So, you know, they produce serotonin. You know, 70% of serotonin in our body is produced within the gut. And serotonin is such a profound effect on our mood.

We produce dopamine. The gut bacteria produce so many important factors that are important for our overall body health. We know now about the gut brain axis. So, you know, this sort of information superhighway that's going between your brain and your gut. and the vagus nerve and the sympathetic nerves and all the connections so that what's going on in your brain obviously, you know, like if you go and do a big presentation, you get a bit nervous, it affects your gut. But we also know that what's going on in our gut, that mix of bacteria, our diet, etc., that also has a profound effect on our mood as well and every other part of our body. And now there's,

you know, there's evidence that the gut bacteria can affect your risk of rheumatoid arthritis, of lots of autoimmune conditions, of MS, there are changes. If you look at pretty much any medical condition and you look at the gut bacteria of the people with that condition, you will find that it is different. So it has been a really fascinating area to be involved in because, you know, now we can say, well, you know, no, we always, it's what we thought these gastroenterologists were really looking after the most important organ in the body. But yeah, it's really, and I think we don't know everything yet either, which is really, No, there's so much we don't know.

And we don't know how individuals, we're all different, aren't we? So our gut microphones are all very different and react very differently as well. And the way we eat can affect different people in different ways. And so, which makes medicine interesting because I think so much it is a science, but it's an art as well. And everyone's different. And certainly in my clinical practice, I really like to try and individualise because even if symptoms are the same, they affect people in different ways. And I know when I was in Manchester actually, they have a very big irritable bowel syndrome unit there in South Manchester.

And, you know, I wish I could go back in time because I remember sitting in clinics there and they just started to give antidepressants to people with irritable bowel syndrome in the 80s and 90s. And if I could go back in time and look at these women, I'm saying women because they were all women in the clinic, I bet they were all perimenopausal and menopausal women. And so they were giving the antidepressants for their gut symptoms. So this is not, as a lot of women sadly are offered or given antidepressants for their mood symptoms related to the menopause, which we know don't help. And antidepressants might help some of the gut symptoms, but you're not really treating the underlying cause. And certainly in the 80s or 90s, I didn't know we had any bugs in our bowel. We just started talking about helico-paxibylori. And that was the only bug I think I knew was in.

Yeah. And we were trying to get rid of it. So things have really changed, haven't they? Absolutely. I mean in Manchester, Professor Warwell in Manchester, he was really at the forefront of this and really, you know, quite groundbreaking research that he was doing at the time. And he was one of the really earliest people to look at hypnotherapy in the treatment of IBS as well. And I think if what it really goes to show you is that it is all connected. I mean, we do obviously irritable bowel

syndrome, for example, tends to start in younger women in their late teens and 20s at a time when there are, you know, very marked monthly fluctuations in hormone levels and any person with irritable bowel. In fact, most women will tell you during their fertile years that their bowel function is sensitive to their hormones. And I think when you have a monthly cycle, that's quite predictable because you get the same changes every month. I think when you go into menopause transition, it's a bit of a wilderness because the changes are much less predictable and there are fluctuations. It differs so much from woman to woman. So I think that's a lot. It's a bit of that's really great about, you know, the work you're doing is recognizing that menopause transition

is a very, very particular phase of a woman's life and it affects every other system. And I think we're really only beginning to look at and find out how it affects all these other symptoms. And I mean, you take a very holistic approach. Sometimes in specialty areas, we look at things in isolation. But I think we have to look at the whole person. We really do. But it is fascinating, the research that has been done in the last 30 years. Yes, yes. So Elaine, when you started as a nutritionist. When we talk about gut health, it's very broad. But if we think about the microbiome, was that something that was on your radar many years ago or how has it developed as an interest for you? Yes. So certainly when I started 30 years ago, Louise, the gut microbiome wasn't on the radar at that time.

And it's really only in the last decade that we've seen so much about the gut microbiome. What I would have seen 30 years ago was people presenting with gut symptoms when they ate, particularly brassica vegetables. One of the ones that common at the time was certainly cabbage and certainly people, if they put an awful lot of onion in their stew, they could get symptoms of bloating and wind. We weren't seeing as much of these functional gut symptoms where people's tests were all coming up normal,

but they were still suffering with bloating and wind and discomfort. And we know now that diet has a huge role to play in the gut microbiome. And as you said, everybody has their own set of gut microbiome. So the amount of fibre that you give, one person could affect them differently to another. So some people are able to eat 50 grams of fibre and not suffer with any gut symptoms or uncomfortable symptoms. And then other people can only tolerate about 20 grams of fiber.

So it's very individual as to how your gut microbiome actually digest certain foods. But I chime in there for a second as well. I mean, I think, I mean, there've been, you know, 40,000 publications on the gut microbiome in different conditions in the last few years. I mean, it's absolutely exploded. But I came across a term a few years ago that I absolutely love, and it's the mysterium to describe the gut bacteria.

Because while we, you know, we're now great at identifying all the different families of bacteria, firstly, there's no one signature in any one person that indicates this is the optimal. We know that having plenty of gut bacteria and having a huge amount of diversity is really beneficial. And most people will have somewhere between two to 400 different types of bacteria predominating. And in general, the more the merrier. but we still don't know the function of all those. We don't understand the cross-talk between all the bacteria. And I find it sometimes a little bit disconcerting

because obviously there are commercial gut microbiota tests done now. And while they're very interesting, I think our understanding of the science lags behind our ability to test these things. Because if somebody comes to me and shows me a printout of this, and it looks so impressive if it's 10 pages of printout, and this bacteria is a little bit, it's red because it's a little bit low, and this one's green. We don't really know what to do with that information at this point.

I suppose if you've got very little diversity, okay, eat more fiber and plant-based foods and try and increase your diversity. But I think it's a little bit cynical for people to be offering these tests when we don't absolutely understand the therapeutic implication of it at this point. Yeah. And I think that's very, very interesting because I do see a lot of women as well, like you, with printouts. And it worries me because actually they're very expensive. And I really worry about people spending money unnecessarily.

And it can be interesting, but actually because we don't know what we're aiming for, it's not like if we do a blood test for iron level, you know, is quite useful then sometimes. And we know, you know, if they improve with the iron replacement, we can see that in a blood test. But this, we don't know what we're aiming for. And so it is about individualisation, but it's also about taking a step back and thinking what else is going on and thinking beyond the gut, isn't it? because I didn't actually realize until probably five years ago. I've been running my penipause clinic for more than that. But over the first few months,

I started to ask people more about their other symptoms. And bowel symptoms came up a lot. And a lot of heartburn, a lot of indigestion, a lot of bloating, a lot of irritable bowel type syndrome. And it was only because I've treated so many women. And when I see them when their hormones are balanced, the lot of them said, oh, my heartburn's improved.

my bloating's improved. And some of it is because they feel better at their diets improved. I understand that. But a lot of it is because of their hormones. And we're starting to do a little bit of work about estrogen in the gut. But as you know, testosterone is another hormone that we produce four or five times or three or four times, depending on what you read more. But anyway, we produce it more than estrogen before the menopause.

And there are receptors for all our hormones, aren't there, in our gut. So I'm very interested in thinking, well, how does. estrogen have a direct effect on the gut by stimulating various cells, but also how does it have an effect on the gut microbes, but also testosterone as well, you know, men aren't getting these symptoms as much as women. And we've always, or I've always been taught because women are more stressed and women are a bit more chaotic with their food. And actually, I'm not sure that we are. I think we can be stressed well. And actually, most of us, I'm not saying, oh, but a lot of us control what the whole household eat, you know, it's.

additionally. And I don't think it's because we all go to a sweet cupboard and eat rubbish food. We actually are quite sensible, but people don't believe us. And I've sort of known other healthcare professionals, and I've done it a bit myself with women, women sit there and say, oh, I haven't changed my diet, I haven't changed my exercise, but I've changed my body shape, and I've got this bloating, and I've got these symptoms. And you can sit there in a 10-minute consultation and think, really, you're really telling me the truth because this isn't very help. You know what to mean? And then, And then I've rebalanced their hormones because they've had other symptoms and their menopausal. And they come back and go, oh, Dr. Newsom, and it's best I felt in 10 years.

And I were thinking, oh, my goodness, why didn't I think about this before? And so it's really interesting, the work that you're doing and the connections because people don't think about hormonal health and gut health as being something that is together really. And I think it is more than we think. Absolutely. It is all connected. I think particularly what you say about reflux symptoms is really interesting. I mean, there is some research showing that reflux symptoms are about three times more common in women, particularly in that sort of early menopause transition phase. And they do seem to improve afterwards.

Now, I think the research doesn't tell us, is that because those women go on HRT? Is it because even if you've got stably low levels of hormones, that's kind of an easier situation to deal with? I think you're right there. And I think we all talk about the menopause. And I sort of really battled for my book to have perimenopause on the title because, perimenopause, I didn't know, even existed, you know, 10, 20 years ago because no one talked about it, but it's a great state of flux in the body. And people have very high hormone levels and then very low. And I think it's the, we know the change in hormone levels often trigger the vasimotor symptoms and the psychological symptoms. The brain's very unstable with this flux.

So it's got to affect the gut and the gut microbiome as well, hasn't it? Yeah, it does. And the rate of hormones. So as you said, we've got estrogen and progesterone receptor and cortisol receptors, all these really important hormones that play such an important role during perimenopause. We've got all those receptors on our gut. And actually, it's been shown that people with irritable bowel syndrome actually have an increased density of estrogen receptors on their gut. So it may leave them more sensitive to these changes. But it's not just the actual hormone levels. It's the rate of change that also affecting. If a hormone level changes very slowly, as you know, you kind of the receptors increase to kind of to counter them.

But if it change very quickly, the receptors don't change. So that's an important thing. We know that estrogen increases mast cell activity within the gut as well. And we now, there's a big interest in mass cells in its role in sort of in many, many different symptoms, allergic type symptoms, but increase pain sensitivity. So it's thought that changing estrogen levels also in changes pain receptors. Esterine also affects our pain receptors in our brain. so that all the pain pathways maybe are, you know, affected by it as well. So, and there's certainly, you know, research showing that sort of widespread body pain increases

in people again, particularly, I think, in early menopause transition and maybe improves later during the perimenopause. So it's an incredibly interesting area. Progesterone also increases or has a big effect on gut. Many women would identify with, you know, when they're pregnant and progesterone levels are really high, tend to get a bit of constipation. They may get more reflux because progesterone kind of slows everything down. And these changes and the fluctuations, they really do vary from person to person.

So I think we've got to, whether we're in a digester, you know, in a gastroenterology clinic and just speaking somebody only about their gastro problems or if they're in your menopause clinic, we need to talk to the individual person and find out what are your individual predominant symptoms and try to address those because, as you said, it isn't a one-size-fits-all and it isn't a simple story. Yeah, absolutely. And so that brings me on to your brilliant book that I've just heard is the number one bestseller in Ireland. And you humbly said Ireland's very small, but there are a lot of books in Ireland. So I'm still going to give you credit for that.

And I know I know on personal experience, it's a huge amount of work, especially when you're working full time and have a big, busy clinical practice, to find time to dedicate a book. And I know you're like me in that you want more people to learn from you and to share your knowledge, which is just amazing. So tell me about the book, Elaine, why you decided to do it. Well, I think Barbara actually approached me about two years ago, and I've always had an interest in sharing some of our knowledge to impact more women. And I jumped at the opportunity. So it took us about two years. A lot of work, as you said, but COVID allowed us time during the evenings and at the weekends

to concentrate on it. And for the first three months of COVID, my practice was closed. So I was able to give it a lot of attention. But the main reason why we wrote it is we wanted to share really our combining. experience of medicine and certainly nutrition, which is over 50 years' experience of working with people and women with gut problems, not only women, but men as well. And we wanted to impact more lives and help women who are suffering with uncomfortable gut symptoms like bloating, pain and discomfort. So that's what we actually wanted to attain. And I think we've achieved that

in our book because it's definitely a book that includes medicine, diet and lifestyle. And it's got a whole body approach to managing uncomfortable gut symptoms. Bobba, what's the feeling? feedback been like so far? It's been really great. So our book, Louise, it's called what every woman needs to know about her gut. And we're hoping that it does exactly as it says on the tin. The feedback has been great. We've had some lovely feedback on Instagram. I've had, you know, patients bringing the book in to be signed. I had a lovely letter from an older woman because we want the book to speak to women of all ages. You know, it's not just for people during their fertile years. It's also for women to understand what's happening their body after menopause and the sort of

pelvic floor problems people can get, et cetera, and also to try and reduce the stigma of talking about these things, but I had a lovely, lovely letter from, Lady I don't know, and she didn't put her name on it, but she'd read an article in the paper and she'd got the book, and she sent me two miraculous medals, just to thank us for talking about these issues. So we've had really lovely feedback, and we're hoping that, you know, more people will hear about the book, because we're both really passionate about, like yourself, I mean, sharing our knowledge and our information, and one of the things is we feel that if you have knowledge, you have power. So we're trying to empower people to take control of their problems

and understand what's going on. Because I think it would be very trite of us to say, oh, look, there's an easy solution for every problem. There isn't. And there isn't an easy solution for the women you see. It can be very complex. Hormone replacement therapy is part of that. But it's all the other things you said as well as diet, lifestyle, sleep,

looking after mental health. And we're really passionate about trying to give women the power to try and gain some control on things. And, you know, the whole area of irritable bowel syndrome, it's really like the whole area of menopause transition because for years, women were told it's in your head because they have all these really uncomfortable symptoms. They're bloating.

They've, you know, having to dash to the toilet because they're getting terrible cramps and diarrhea. It's held people back professionally because they don't want to go for an interview because they're afraid in the middle of the meeting. They'll have to dash or their tummy let them down. And so women have been told, look, all the investigations are normal, everything is fine, you're absolutely fine, nothing's serious,

go on and get on about things. And very similar to what's happening women during menopause. So we wanted to say this is not in your head. These are real physical conditions. Oh yes, standard tests are normal, but this is not normal to be experiencing these symptoms. And one in six women has IBS and one in two women will have bloating, a little bit of constipation, maybe not enough. So these are really common symptoms. One in two is huge, isn't it? And we know that, for example, one of the symptoms of ovarian cancer, which is not nearly as common, obviously, reassuringly, is bloating. So when I was working as a GP, a lot of women would come and say, I've got bloating and they'd be worried about ovarian cancer.

And if they had their tests, everyone was so reassured they didn't have ovarian cancer, that was like, well, you're fine. And of course they're not fine. They've got symptoms. And I think it's very difficult and it's happening more I think as people not just women but people in general are more aware of their bodies they're more aware of symptoms that they might have dismissed before and I mean as you know Barbara I had pancreatitis a few years ago and when I had symptoms for about six months after I kept going to a very eminent gastroenterologist and saying I've got pain I've got discomfort I just don't feel myself I can't bend down I feel very nauseated and he at the last consultation, I went to him and he examined me and said, look, your scan's fine, your examination

is fine, I think you need antidepressants. And then I burst into tears and said, but I'm not depressed, which made me look like I was even more depressed. And he said, no, I know you're not depressed, but antidepressants can work really well for irritable bowel syndrome. I said, but I don't have irritable bowel syndrome. It's all in my upper, you know, gastrointestinal tract. And I came away really sad and I thought I cannot live like this because it's really important. I really enjoy yoga. I couldn't bend down. So how could I do a headstand, of course? And I just thought, this is terrible, actually. And then I saw as someone else had my gallbladder taken out and the rest is history, if you like. But if I hadn't had been persistent and had the medical knowledge, I would

have been labelled as something. And as women, we're often being labeled because, you know, there's all sorts of misogyny that goes on out there that's going to continue. And we're always being suppressed as women. So I think to have something that empowers us, it's quite unusual actually, isn't it, to have a book that's aimed at women as well. Are there any other books like that on the market? Well, apart from yours. And we also wanted to, sorry to interrupt, we also wanted to reduce the stigma around talking about these symptoms.

So very much like the menopause, we feel like we have some women. Barbara was looking after one woman who couldn't go in a long haul flight to see her children in Australia because she was suffering with loose biles associated with urgency. And she had been suffering with that for about 20 years. wasn't it, Barbara? Yeah, more than that. And she hadn't really spoken about it. So very much, I think, like the menopausal symptoms over the years,

a lot of people are embarrassed to talk about the gut symptoms because, you know, particularly the loose bowels that can be associated with urgency, the excessive wind. And they tend to put up with the symptoms. So we really wanted to reduce the stigma associated with talking around these symptoms. And one of the things that I really hate to hear somebody say, I just have something. I just have IBM or something.

It's just because, okay, it's not life-threatening, but it can be, something like that can be life-altering. As can you would have a lot of people with pelvic floor problems, you know, particularly older women, so they have their children at a young age, their muscles are good and strong. They have a big baby. They kind of bounce back. But then when they go through menopause into post-menopause, those muscles that were damaged 30 years ago are suddenly becoming much weaker and suddenly they have problems with control. of, I mean, I think it's just cuts to the core of somebody having a problem controlling wind or bowel motions or urine. It's just like as an adult human being, there are things we expect to be able to do. And, you know, I hate when anything is used in terms of it's just that or are you. These are absolutely really important things that affect people's daily lives. And that's, we want to talk to people.

We want people to be able to go to their. I mean, I'm sure, I'd say you've always been a very approachable person, but I've certainly seen patients who've gone to their GP. a number of times wanting to speak about something, but then they can't bring them to them to say, well, actually, I'm having trouble controlling my bowel motions, and they talk about something else, and they come away, and it takes a few visits sometimes to actually, you know, get the courage to talk about what's really on their mind. Absolutely, because it's embarrassing, isn't it? And I think also a lot of people are scared that they are just going to be sent for tests and or have invasive tests, and it might not be the right thing to do in the first line. And I think

a lot of what I'm trying to do is empower people so that they can make the right choices, not just for their treatment, but maybe their investigations as well. And the more information we can give, the more we can help people direct. And I think this is great. And even just looking at your Instagram account, you know, you're giving out some very, very simple messages that for a lot of people, it will be the first time they've heard it. And actually to have it from a voice of authority is really reassuring

because there's so much noise. I mean, there's now, thankfully, more noise about menopause than they used to be. But with diet and nutrition and weight loss and gut health, it's massive, isn't it? But then it means that the good evidence, or not always evidence, but the good clinical practice is drowned out by other sort of things that are just confusing women. So they don't know where to go. And I think also anything that we do that changes our gut doesn't happen overnight, does it? I've listened to people because I have a very diverse diet

and a lot of people say I couldn't eat that I'd get so much bloating and I would be having so much wind well yes they would for the first week or so but you've got to persist and I think that's having the knowledge that it's quite safe to have some symptoms that will short term but they will improve and knowing that you can do various things is really reassuring as well isn't it for people

yeah Elaine you've a particular interest in fibre yeah I think having worked over 30 years in the gut I can't actually believe that there's never been so much information available to people. And yet in our clinics, we have so many people that still have so many symptoms. And they're really confused. And they're making very large decisions like taking whole food groups out of their diet, like eliminating wheat and eliminating dairy. And there's also the very simple practical tips that you can look at,

like the way that you're eating, whether you're eating, you know, on the run to all your behavior around eating. So to eat more slowly, eat smaller meals. take your time while eating and also eating more fresh food, less processed food, cooking, foods that are in season, maybe batch cooking if you're very busy. So there's lots of practical tips that people can do that are really easy wins. But people are going from A to Z very quickly and eliminating whole food groups out of their diet. And we see really two sets in our population today. We have a whole load of people that are eating very processed, convenience, takeaway foods. and then we have people that are eating healthy,

which would be sometimes maybe too much fiber for their gut. So it's very much about finding what suits you and more of a middle ground. We are very committed to more moderation in certain food groups as well. And exactly as you said, Louise, if you are going to make some dietary changes, you know, try and do them slowly because fiber is food for a gut bacteria,

so our gut bacteria fermented produce gas. So if you're going to increase your fiber, you know, we would say that you kind of start low and go slow, maybe look at increasing it by five grams a week. Don't go and eat, you know, 15 tablespoons of lentils if you haven't been eating them at all, because that will cause bloating because your gut bacteria are practically having a feast on the fiber within those foods. So it's normal to get a little to produce some wind. It's normal to feel a little bit bloated.

But if you do things gradually by making changes to your diet, as Elaine said, you know, you will have fewer symptoms and our gut bacteria will adjust as we change our diet as well. But we are very concerned about the number of patients we see at our clinics who are following overly restrictive diets. And that's one of the messages in our book. And it's very strongly our ethos that we want people to follow as much as possible to follow an inclusive diet and possibly look at how much of certain foods you eat. Because lots of foods will call some wind and bloating in people.

And people with IBS are much more sensitive to that. So that's where our dietary approach has really evolved from. and we feel that some of the approaches are putting people down, sending people down a line of over-restriction. And as Elaine said, like, we see so many people who have cut out dairy completely and it's such a wonderful source of calcium. Then that, you know, cut out gluten. And gluten has really been demonised.

I mean, there's a study from Cessield a few years ago showing that in 2012, 12% of people in that area were following a gluten-free diet. In 2015, 33% of people. And now 1% of people in our part, parts of the world and the UK and Ireland has celiac. So why are 33% of people saying they're buying gluten-free products? And so gluten and wheat is being demonised unnecessarily because it's a wonderful source of fibre and diversity. And it may be that it's how much of it you eat that

might cause a little bit of discomfort as opposed to an all or nothing. So we don't want people cutting out things. And that's where we came up with our flat gut diet as well that was as a result of trying to include certain amounts of most things. Yes. So it's so important. So there's so much to talk about and I think I'm going to have to get you to come back for follow if that's okay and hopefully we can start to do some research because I think that's so so important so we'll put links to the book and to your Instagram and everything else with the notes because it is really important that people just take time to look for themselves is really important so this is a book for anyone who's listening to just have a bit of time to reflect

and think about what they're doing for their diet, not just for today, but for their long-term health as well. So I'm very grateful for you coming, but before I end, I need three take-home tips. So there's going to have to be one and a half from each, or maybe I'll allow four and you can do two each. So really I'd like to know maybe from you, Barbara, two tips how people can just start to think about what they eat for their future health.

And then two tips for you, Elaine, about what people can eat to improve their gut microbes, if that's okay. Okay. So my two tips would be, firstly, I think if anybody is having digestive symptoms, I think you should try and get a correct diagnosis to start with. And I think you shouldn't self-diagnose. Now, I'm all about empowering people, but I think people should talk to their GP and get some basic test done. And the GP will help them decide whether or not they need to be referred for further investigation. I think this is particularly important around menopause transition around perimenopause because while hormonal changes may be causing our gut symptoms,

you can't assume that. So it's really important to get the diagnosis right to start with. Secondly, my top tip would be, Elaine is going to talk to you about diet, but I think that you cannot look at your digestive and gut health in isolation, and you do need to look at your total body health and have a holistic approach. And we've come up with a little acronym for total gut health, and we call it Teams. T is for total, gut and body health. E is for exercise. That has to be part of what we do. A is for alcohol because people can sometimes be doing all the right things with diet and then maybe overdoing it a little bit on alcohol as well. So it's really important to stay within safe drinking guidelines. M is for your mental health and S is for your sleep. So we think of

looking after your gut health as being a team's approach and they would be my top tip. I love it. That's really great. Thank you ever so much. So Elaine, how can we? improve what's going on? My top two tips is first of all, fiber. Fiber really is a superfood for your gut microbiome. And it's very important for those that are gut sufferers or that they're transitioning through hormonal changes, that they find the right amount of fiber for their gut. So certainly not too little and not too much. And in our book, we certainly help people navigate finding their fiber tolerance. And my second one would be variety and diversity of foods, eating the rainbow, lots of color, from basically a Mediterranean-style diet, which is lots of vegetables, fruits, salads, herbs, spices,

nuts and seeds, and also some animal-based proteins, such as some poultry, dairy products, and also lots of good fats, healthy fats from fish oils, olive oils, and also the nuts and seeds. Amazing. So much to take in. There's a lot going on in this podcast, but it's so, so important. we've all got guts and we've all got guts that can improve. And it's up to us to make that difference. So thank you so much. I'm really grateful for your time. And I'm looking forward to seeing the book a number one bestseller over here as well.

That would be fantastic. Thanks ever so much. Thank you so much. Lovely to talk to you. Thank you. For more information about the perimenopause and menopause, please visit my website, balance, balance,com, or you can download the free balance app, which is available to download from the App Store or from Google Play.