The Liz Moody Podcast - How To Eliminate Bloat & Constipation (+ SIBO, IBS, Parasites, Period Poops & More) With Tamara Duker Freuman, MS, RD, CDN

Episode Date: July 5, 2023

Registered dietitian tips for identifying your stomach problems, addressing the root cause, and managing ongoing illnesses like IBS, celiac disease, Crohn’s, & more.  the one thing you SHOULDN’T do if you’re experiencing bloating or constipation why you might have food intolerances + what to do about it  the most common cause of bloating  exactly what to do in the moment to alleviate bloating why some people have no gut issues + other people have a lot of them how to prevent travel constipation how to know if you have SIBO + what to do if you do how to know if you have IBS + what to do if you do how to know if you REALLY have a parasite + what to do if you do tips for managing GI symptoms throughout the menstrual cycle  how to know if your poop is healthy the link between stress and stomach issues  and so much more!  For more from Tamara, head to her website thebloatedbellywhisperer.com, find her on Instagram at @tamarafreuman, and grab her latest book Regular: The Ultimate Guide to Taming Unruly Bowels and Achieving Inner Peace.   To join the Healthier Together Podcast Club Facebook group, go to https://www.facebook.com/groups/healthiertogetherpodcast. This episode is sponsored by: Seed: go to seed.com/lizmoody and use code LIZMOODY for 25% off your first month. RocketMoney: sign up for Rocket Money today by going to RocketMoney.com/lizmoody. Reliefband: go to reliefband.com and use code HEALTHIER for 20% off plus free shipping.  LMNT: go to DrinkLMNT.com/Liz a to get a free LMNT sample pack with any order.  Healthier Together cover art by Zack. Healthier Together music by Alex Ruimy. Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello, friends, and welcome back to the Healthyer Together podcast. I'm your host, Liz Moody, and I'm a best-selling author and long-time journalist. This podcast is all about helping you live your healthiest, happiest life, whether we're learning the most effective hacks for managing anxiety, getting all of the latest research on changing our DNA expression to change our health outcomes, or uncovering exactly how to be more confident in every aspect of our lives. And yes, those are all real episodes, so if any of those topics sound good to you, scroll on back in the archives. Today, I am so excited to welcome Tamara Duker Freeman to the podcast.

Tamara is a registered dietitian whose expertise is in helping find the causes of gas, bloating diarrhea, and constipation in her patients, and achieve symptom control to improve their lives. Tamara is the author of two books, The Bloated Belly Whisper, See Results Within a Week and Tamed Digestive Distress Once and For All, and Regular, the ultimate guide to taming and ruling inner peace, which addresses. the causes and treatments that she employs in her practice. Her work has been featured on CNN, Good Morning America, The Washington Post, Insider, and more. On this episode, we get into the one thing that you shouldn't do if you're experiencing bloating or constipation, why you might have food

intolerances and what to do about it, the most common cause of bloating, exactly what to do in the moment to alleviate bloating, why some people have no gut issues and other people have a lot of them, how to prevent travel constipation, how to know if you have you have, you have Sebo in what to do if you do. How to know if you have IBS and what to do if you do. How to know if you really have a parasite in what to do if you do. Tips for managing GI symptoms throughout your menstrual cycle. How to know if your poop is healthy, the link between stress and stomach issues and so much more. We would both love to hear your thoughts and your biggest takeaways as you're listening to the episode. So definitely screenshot and tag me. I'm at Liz Moody and

Tamara. She's at Tamara Freeman on Instagram. I get so many questions. from all of you on Instagram about bloating and constipation and other GI issues. And I'm so excited to finally have an episode all about addressing these symptoms and getting to the root cause of them. If this episode helps you or you feel like it could help someone you know dealing with GI issues, please share it with anyone in your life whom you think could benefit. Thank you for always spreading the word about these episodes. It's truly the best way to support the podcast and it is so, so appreciated.

Okay. Now let's get right into it with Tamara Duker Freyman. Tamara, I am so happy to have you here today. I'm so excited to dive into all things, poop and bloating and farting and constipation and just all the things that I feel like people really struggle with, but sometimes we're told we shouldn't be addressing on a societal level. Yes, I never got that memo. So I talk about this stuff incessantly at dinner, at parties.

And sometimes I get the looks that remind me that I'm the only person that clearly didn't that memo. I think it's so silly. I was listening to somebody on a podcast this morning and she was like, how are we expected as women to fight the patriarchy when we're still like running from our new boyfriend's house down to the Starbucks down the street to take a poop in the morning? And I'm like, that is so true. It's such a good point. How did you get into this line of work? So dietetics is my second career. I had a corporate marketing job going on before this. And around the time I turned 30, I really just got much more interested in my personal health and health and nutrition in general, so I switched careers, went back to school. And pretty early on in my re-education, I was introduced

to a graphic of the human intestines and this roadmap of all the spots along the way throughout the GI tract and what happens there. So different things are absorbed at different places and different amounts of microbes in different neighborhoods. And it really captured my attention and my interest and this idea that if you can really understand your guts physiology and what could go wrong at different points along the way, there's just such a direct impact on how that would affect you nutritionally in terms of absorption of different nutrients or tolerance of certain foods. And so I just got really interested in GI-focused nutrition, even before I became a dietitian and immediately started specializing in it as soon as I got my

license. If you were going to tell us one thing that we should know about our GIs physiology and one way that should impact what or how we eat, what would that be? Your gut microbiome, which is the ecosystem of microbes that lives in your GI tract, most of which are living in the colon, they thrive on fiber and not just fiber in terms of the amount, but also diversity of fiber. Diversity of fiber promotes diversity of microbiome species. Makes sense. A lot of the approaches you hear out there in the internet world or influencer world around gut health really focuses on elimination diets. All the things that you're supposed to cut out as being allegedly toxic or inflammatory or negative in some way. And what often

happens is when you take this elimination diet approach, the diet and the different types of fiber often gets very, very narrow. Once you cut out greens and nightshades and soy and corn and fill in the blank, you know, fruits because they have too much sugar or whatever you want to have it, by the time you kind of get to the bottom of that elimination diet list, you have really kind of cut down the diversity of fiber in your diet in a way that we know adversely affects the gut microbiome and theoretically also gut health. So when you start to starve the gut microbiome of that diversity, you may actually be having an adverse or negative impact on gut health. And so, And that's just something really important for people who care about gut health and who care about wellness and want to do the right thing.

We're getting a lot of really inaccurate messaging online, and it's important to understand that about your microbiome. Diverse microbiomes are resilient, healthy microbiomes. And when you starve them, they become less diverse and less resilient. I think a lot of people do elimination diets because they're having bloating, constipation, cramping, they're having these symptoms, and they don't know where to start in terms of getting rid of them. So instead of an elimination diet, what would you do in that scenario? You know, elimination diets, when you have no idea why you have a symptom, is like throwing spaghetti against the wall to see what sticks. If your problem is fundamentally that you're completely

backed up full of stool, then eliminating legumes or dairy or whatever is not going to help you. Or if you're bloating is caused because your stomach is just really slow to empty, it's not that you have a food intolerance to something that a test is going to show you. So if you're just kind of like assuming that an elimination diet is the intervention, you're making an assumption that a specific food is the cause of your symptoms. And so I really try to encourage people not to go that route until we have a reasonable hypothesis that yes, it does really actually look like an adverse food reaction or food intolerance is underlying the symptoms. And then to really be as pinpointing and kind of scalpel as possible rather than sledgehammer.

So rather than completely eliminate everything other than like chicken and rice and build your foods back up one by one, can we develop a reasonable hypothesis, an educated guess? What's the most likely culprit is? Do we think that it might just be lactose? Or is it maybe just onions and garlic? If you need to undertake some sort of elimination diet because you're pretty sure it's something specific that you're eating, can you, with the help of a registered dietitian, narrow it down a little bit so that it's not like a sweeping elimination diet. It's a very targeted elimination diet. And really a good elimination diet, if you get it right, you only need a week or two to know if it's helping. Things are in and out of your gut within 24 to 72 hours. You don't need more than two weeks on an elimination diet to know if it's helping. And if it's not helping, please reintroduce the food. In your opinion, if we find a food-based culprit, are we likely going to be eliminating that thing forever, or are we going to be healing our microbiome in a way that allows us to eventually reintroduce it? Great question. Totally depends on why you have that intolerance. So some people have what we would call a primary

intolerance to something, meaning that you organically, Liz, your body does not like that food, you do not digest that food, even when your microbiome is doing great and you are well. And that's just how your body is. A good example of that is lactose intolerance. Some people just are programmed genetically to become lactose intolerant in their teens or 20s, and that's how you roll. Some people similarly could have other genetically programmed intolerances like fructose intolerance or even sucrose intolerance, which we don't hear about, but it's a real thing. Some people have celiac disease, right?

These are things that are like native to you that cannot be fixed, no matter how much healing you try to do in your gut. For many of these food intolerances, there are enzymes available either over the counter or prescription that can help with food tolerance. So in those cases, you still may be able to reintroduce a food with the use of enzymes if they exist. But then there are these other cases where you may have a secondary food intolerance. In other words, you have developed a sensitivity to a food because of something else going on in your body that is treatable. And if we can identify what that is and treat it, your tolerance of those foods may very well be restored. A really good example of that

would be something called SIBO, small intestinal bacterial overgrowth. Sometimes there are circumstances in your gut where excess bacteria can really thrive in the small intestine where they don't belong. You're not really supposed to have a lot of bacteria in your small intestine. Some people have various physiological reasons, predispositions, that their small bowel gets really hospitable to excess bacteria. And if you start to get too much bacteria in your small intestine, There's a whole host of foods that maybe once upon a time you tolerated, that now these bacteria are like, oh, I love artichokes. I love beans.

I love the sugar alcohols and peaches and nectarines. And every time you eat all these categories of foods, you get a ton of gas and bloating. That's a temporary food intolerance. If we can identify, diagnose, treat the CBO, hopefully correct the underlying cause why you developed it. Your tolerance of those foods should be restored. and it's not a given that you should have to avoid those foods forever. We kind of have to distinguish between, is this an organic food intolerance that is not really remediable? Or is it a secondary food intolerance that is?

I got so many questions about SIBO. In your mind, what are some good signs that their symptoms are pointing to SIBO? And what's the first step they should take if they suspect that they have it? So with SIBO, one of the first things you're seeing is foods that you used to tolerate, fine, are all of a sudden giving you a lot of pretty immediate grief. Immediate, I'd say, within the hour. Maybe 90 minutes. But SIBO symptoms onset pretty quickly after eating. And again, these are foods that you used to do fine with. It's not like, oh, ever since I was a little kid, garlic gave me trouble. You probably haven't had SIBO since you were a little kid. But if you could eat a certain Chinese restaurant meal all the time and feel fine, all of a sudden you're blowing up like a balloon with horrible

gas, bloating, maybe diarrhea, that's one sign, new onset food intolerances to a variety. of different foods, not just like one random thing. With Siba, we often, not always, but usually see a change in your stool consistency or your bowel patterns. Your poops look weird. There are weird textures. Sometimes people describe them as like sticky or tarry or hard to wipe, kind of a mess. Or some people will kind of start to just have more diarrhea or more frequent bowel movements. Some other people will be like, I used to be totally regular and now I'm super constipated and I've literally changed nothing about my diet. So some sort of change in bowel. So some sort of change in bowel patterns or stool consistency is pretty common with SIBO. With SIBO usually morning is your best

time of day. In other words, when you're fasted, you haven't eaten since overnight and everything is clear and the bacteria haven't been active or fermenting anything for like hours, you feel fine. And then the symptoms typically start to get worse with subsequent meals throughout the day. That's often a sign of SIBO. Sometimes we'll see people have a vitamin B12 deficiency, even though they eat their usual diet and they're not vegans. Like, why would I be B12 deficient? Sometimes we see that with SIBO. Sometimes we can see weight changes, mostly weight loss. Every so often people claim that they get so bloated and swollen that they gain, but it's usually a loss. These are a variety of the things that I'm looking for when I start to get suspicious for SIBO. And if you

suspect it, you should see a gastroenterologist and ask for a breath test to confirm the diagnosis. Other than SIBO, what are some common causes of bloating that you see in your practice? The most common cause of bloating I see in my practice is people who are completely full of stool. And I don't mean just like, oh, I'm a little bit constipated. These are people when we do an x-ray, all five to six feet of the bell, is completely full of stool. And there are cases where people are shocked to be told this because you don't have to be constipated to be full of stool. A lot of your listeners and my patients and our community who are wellness-minded have gotten the memo about fiber. Everyone knows like high fiber, like go for it, like fiber is so important and so healthy and it's true. It is very important. It's very good for you. But what we sometimes don't really truly understand is that all the fiber that goes in by definition must come out. So if you're someone who gets one great poop a day and you've just doubled your fiber intake because you're trying to be super healthy and you're still only getting that same exact volume of stool out per day, then all that additional fiber that you're eating that you're not keeping up within the bathroom is starting probably.

to pile up. And your colon is five to six feet long. If that is 75 to 100 percent full, you're going to be bloated from the time you wake up in the morning mildly. It'll improve a little bit when you poop. But as you start consuming your healthy high fiber diet with each subsequent meal and you're not keeping up with a commensurate amount of stool output, you're going to be incredibly bloated. And you're going to do an elimination diet and it's not going to make an ounce of difference. You'll be like, I eliminated all the things. Maybe I was 5% better. But I'm still so bloated. Like I don't even know what else to do. I don't know what else to eliminate because it's not a food intolerance. It's an imbalance of fiber in and fiber out. That's the number

one thing I see in terms of causes for bloating. But I wrote a whole book about it. There's about 10 others that I also see really commonly. And so it's not always stool burden, but that's one of the most common culprits. What do you do in that situation? I've interviewed so many gastroenterologists and they seem universally against colonics because it disrupts your gut, microbiologists. them so much, which you're welcome to disagree with if you do. But I think the reason people get them is because they feel like they're full of poop and they would like to have that very clean, internal feeling. So what do we do if we're backed up with so much poop? Great question. Again, totally depends on why you are so backed up full of poop. There are many people who when they eat

more fiber fiber, they just poop more and they just keep up with it, right? Like if you had a super extra high fiber day, maybe you'd have an extra poop the next morning. If you're not one of those people, you have a couple of options. The first is to take a little bit of magnesium, what we call an osmotic laxative, it just works by drawing water into the colon, and that just might help you have an increased amount of stool output so that you can keep up with your preferred fiber intake. So many people will just start with that because they love their diet, they don't want to change their diet, they just need to keep up with it better. So they might start like with some sort of therapeutic dose of magnesium, which usually starts at 400 milligrams. I go about as high as 1,200 milligrams. That's a pretty safe range,

as long as your kidneys are working fine, that's a very safe range. I go up a little at a time because too much magnesium could give you diarrhea, but that's really the only possible side effect if your kidneys are functioning well. And see if we can just help you keep up with your pooping with some magnesium. So that's the easy out. And sometimes that works really well and we're done. In other cases, we might need you to scale back a little bit on the fiber intake and not necessarily have a low fiber diet. That's not at all what I'm suggesting. But there are people whose fiber has fiber. And what I mean by that is they'll have, you know, the steel cut oatmeal and then they'll add flax and chia and coconut flakes and this and that. And it's like they're adding 20 grams of fiber to the fiber

meal. And like sometimes we can just have like a regular beautiful bowl of steel cut oats with blueberries, which has a lovely amount of fiber and not like overkill. Or instead of a giant kale salad every day, maybe we have our salads as a side salad and get more of our veggies from soups and you know period sort of where the fiber is still there it's still healthy but the particle size is so much smaller it takes up so much less physical space in the body especially in the colon which is super crowded already clearly pulling back on the raw stuff the roughage taking skins off of things getting a little bit more of what I would call a gentle textured fiber and just less sheer massive quantities of it so you have like a normal high fiber diet not an extra super

duper extra crowded high fiber diet and often some combination of fiber. And often some combination of hyper modification and magnesium will get the job done. But if you're super duper aggressive with magnesium or even other laxatives and you've pulled back on the fiber and you're still really struggling to get poop out of you, then often I'll refer you to have your pelvic floor function evaluated because some people really struggle with complete defecation because their pelvic floor muscles just aren't working properly. And maybe they need a little bit of physical therapy or some biofeedback to help with the mechanics of efficient complete pooping so that laxatives like a magnesium will work better so that fiber modification will work better for them. Okay, I have so many

questions. First of all, for the record, can we get your thoughts on colonics? I mean, look, colonics are not a long-term solution, right? It's not like if somebody was in the desperate, they haven't pooped in two weeks and they're like miserable, dying, agonizing pain, that I would say, no, don't get a colonic. You can have a colonic. You can have a Yes, it absolutely disturbs your microbiome, but your microbiome is resilient. It will bounce back. If you're doing this like once randomly just because like you're at your wits end, I don't think it's something that I would recommend as an ongoing long-term sustainable solution. Because, I mean, it's a high-powered enema. It will kind of disrupt the microbiome. And you're not really getting to

the underlying problem, which is either your pelvic floor issues, your motility is really crappy. You really want to try to address the underlying problem rather than become dependent on. colonics. And it's just like really not a sustainable solution. Second, the magnesium trick, how often is too often to do that? You can do it every day. Okay. So it's not like if you need the magnesium every day, you should be thinking to yourself, oh, I'm not keeping up. I'm not resetting to some sort of baseline where I don't need this. I should be consulting an expert, a pelvic floor specialist, et cetera, et cetera.

If magnesium works, you probably don't have a pelvic floor problem. It's when magnesium doesn't work or other. laxatives, even prescription things don't work that you have to start wondering. I like to compare magnesium use of eyeglasses, which is like when your eyesight starts to get wonky as mine has, you never like tell yourself like, oh, I don't want to become dependent on my glasses. Maybe if I just stop wearing them or just use them a little bit, my eyes will retrain themselves and learn how to see clearly. You might have slower motility. You cannot train your bowel to be faster. If your motility is slow, your motility is slow. So the question is, will you use a really safe,

effective tool like magnesium every night to offset that and be comfortable and get great poops and be able to tolerate your preferred healthy diet? Or will you get stubborn and say, like, no, I should be able to poop without magnesium. I'm going to try to retrain my bowel or, you know, do all these like really high intensity things just to go to the bathroom because like, darn it, I don't want to be dependent on magnesium. I'm dependent on my glasses to see. Some people with slow motility are dependent on a perfectly safe, healthy, normal dose of magnesium to go. And if that's all it takes to get you to feel comfortable, oh my gosh, you're so lucky. That's incredible because it's cheap and it's accessible and it's safe and it's easy.

That was my next question. Is there a reason that some people have poor eyesight, quote unquote, and some people have better eyesight? Like, is there a reason some people, when they eat a lot of fiber, they get really backed up? And other people who eat a lot of fiber just poop two or three times a day? Genetics. We have different genes. We have different microbiomes. Your microbiome is as unique to you as your fingerprints, and that certainly plays a role. And genetics often play a role. You hear all the time, like, I'm so constipated. My mom has the same exact problems. I have the same stomach as my mom. We're all different special unicorn snowflakes. We all have different bodies. And we have to really just

understand the bodies that we have and learn how to work with the bodies that we have and optimize how they function and how we feel. I love hearing you say that because I think sometimes people can be very self-flagellating. Like, why am I dealing with this when other people aren't dealing with this? Stuff like that. And I think it's like we all are doing the best we can with what we've been given at any given moment. A hundred percent, Liz. And that applies to everything, not just GI function, right?

Like people who are always upset like, oh, like why can she eat everything she wants and her weight is that? And I eat a fraction of what she eats and my weight is this. we spend so much time comparing ourselves and just being so hard on ourselves about what we think our bodies should do rather than kind of acknowledging and accepting and frankly being grateful for the bodies that we do have and learning the rulebook. Our bodies don't come with a rulebook. We have to kind of pay attention to them and learn what they need from us to operate at their best and to feel good. Yeah, I love that. This is a little bit of a weird question, but I feel like

there's kind of an epidemic on social media of being like, oh, I'm so bloated. look at my stomach and I keep thinking like, that looks like a normal stomach to me. Are we just calling normal stomachs loaded right now? Do we all believe we should have this perfectly flat stomach so that it's not quote unquote bloated? Is there a way in your opinion that we can tell if we are indeed bloated or if that is simply what our stomach looks like? It's such a great observation and it's a thousand percent true. Social media, especially the more visual social media, not like Twitter, but Instagram and things like that, have really fueled. a lot of public displays of body dysmorphia or people who have a very skewed and distorted perception

of what their body looks like and sort of what's normal. And there is absolutely this phenomenon of very thin, very fit people posting these before and after selfies of a flat belly and a bloated belly that I often can't even tell the difference between which is which. So yes, your abdomen is supposed to stretch when there is more matter in it, right? Like, that is by design. Can you imagine if you were nine months pregnant and your abdominal wall was like hard as a rock and when something was growing inside you,

your abdominal wall is like, nope, we're not budging. Like, we're going to stay flat. Your abdominal wall needs to have give. Otherwise, the human species could not procreate. And if you're on vacation for a couple days and you don't poop for a couple days because you're traveling, whatever, you would be so uncomfortable if your abdominal wall was like rigid and hard as a rock and you couldn't

kind of stretch a little bit to accommodate a little bit of extra stuff in there. And so it is normal and expected and frankly a very good thing that the abdominal wall can stretch when it needs to to accommodate volume. And that volume could be liquid, right? You could chug egg drop soup or something from the Chinese restaurant or like a giant amount of water that takes up space. There is volume associated even with water that the abdominal cavity has to accommodate. And there's already lots of organs in there already that the abdominal cavity is accommodating. You eat a meal, you know, the stomach starts stretching. Your abdominal cavity needs to be able to accommodate the stretch of a stomach that is filling with a meal. So it is normal after you eat for the belly

to look slightly more distended than before you eat. And several hours after you eat, it may come down a little bit, and then you'll eat again. It might come out a little bit. It's normal for your waist size at the end of the day to be somewhat different than it was first thing in the morning after you peed and pooped and before you ate anything. The question is, what is that difference, right? Like if you are literally a completely different clothing size, in other words, like you're wearing something in the morning that fits you perfectly, it's comfortable, you're fine, and at the end of the day, you like, you have to unbutton your pants or you have two different size pants for the morning and the evening because literally you cannot wear the same size clothes

without it digging into and feeling horrific, that's probably a problem. That's probably an exaggerated amount of bloating. If there's like a very significant distension of people, like you kind of have a flatter stomach in the morning and then later in the day, people are giving you their seat on the subway because they think you're a pregnant person. Like that's probably bloating, right? And even if you're not visibly distended in a way that's very apparent, if you feel subjectively so uncomfortable and over full, even when you eat like a pretty modest amount or even when you drink a little bit of water, if it feels like so overfull in a way that is not commensurate with what you just ate, that's also not normal. And that also would be considered kind of a bloating situation that you

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The birch mattress is incredible. It is made with organic coffee. natural latex and ethically sourced wool. So it has literally no off gassing. You can not smell anything right when you unbox it. It has no microplastics, no synthetic foams or flame retardants. And the wool makes it so breathable, which if you've listened to this podcast for more than five minutes, you know that I run very, very hot. Like I am a furnace. Zach has basically accepted that sleepy next to me is like sleeping next to like a little fire. And the birch mattress has been a game changer for that. It's made me sleep so much better like I can see my sleep score going up because I'm not hot all night long. It's also hypoallergenic, which is really worth paying attention to if you find

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mitopure gummies from Timeline. Visit Timeline.com slash Liz and save up to 39% on your mitochondrure gummies. That is timeline.com slash Liz. I just want to touch on a fiber thing that you mentioned because I've heard somebody else say that when you blend fiber, you eliminate it essentially. And you said that when you're blending or cooking fiber, you're changing its form. So I would love to know, is the fiber and smoothies still fiber? Is the fiber and soups still fiber, how do you view the form changing of fiber? It is still fiber. It just has a different physical footprint in the body. Its particle size is smaller, right? Like what makes fiber fiber is that its chemical bonds are not breakable by human digestive enzymes. When you put greens into a smoothie

and take the physical particle size of the leaves down, you're not breaking chemical bonds at the molecular level. That's what enzymes do. But what you are doing is you're taking the physical particle size of half of a leaf that you like would barely have chewed if you were eating a salad really quickly. And you're taking the particle size of the fiber in that leaf down to really taincy, wimsy places or pieces so that it's less likely to bottleneck or like overcrowed because it just takes up less physical space in the body. And so it can be more comfortable. But it still is very nourishing and it's still very health promoting, which is why when people want to like juice or do liquid meals for whatever reason, I always would say, maybe let's do a smoothie.

instead because then you still get the benefits of the fiber for the microbiome, whereas when you kind of remove all the fiber from juice, like with a juicing rather than smoothing, you are kind of denying the microbiome what it wants and needs. That makes intuitive sense to me because I feel like when I'm regularly having my smoothies, which is just one of my favorite things to add to my diet, I am pooping significantly better. Like I feel like it is helping my microbiome. It is helping my gut. So I just wanted to get clarity on that. Let's talk about the hormonal thing for a second. Let's start with periods.

We have different hormonal levels at different phases in our cycle, and a lot of people experience symptoms associated with different phases of their cycle. Notably, I think bloating right before your period is pretty common. And then I think loose stools when you are on your period is common. So I would love to get your take on sort of what's happening from a bloating and pooping and all of that perspective in our cycle and maybe some tips you would have to assuage those symptoms. Certainly at different phases of your period, you may just be more likely to retain fluid just overall. Sometimes people will have abdominal bloating, but also they'll say they feel puffy all over, not just their belly.

And so sometimes there is changes in fluid retention and fluid balance throughout the body that is hormonally driven. That's one piece of it. And as we talked about earlier, when the lining is fuller and thicker, there is more fluid. and stuff in the abdominal cavity because the uterine lining has expanded. There's a part of that regardless. As far as the actual menstruation, when you said like, oh, people sometimes get looser stools, I mean, think about what's happening hormonally when the uterus, which is a smooth muscle, starts to contract. That's what causes you to start bleeding and having your period. The hormones that are responsible for that are acting on smooth muscle in general. It's not

uterus-specific hormones. They are hormones that act on smooth muscle. Well, guess what? What else is smooth muscle? Your colon. And so as your uterus is kind of contracting and the smooth muscle is contracting, the smooth muscle in your colon will also often be contracting. And that's why people might be pooping more frequently or things might be moving through a little bit faster, therefore it's looser. And so that's often what you're seeing happen with the looser period pooping. That's so interesting. Is there anything that we can do about any of that? Or is that just like part of the deal? I mean, menopause. Cause.

Cool, cool, cool. Awesome. I mean, different forms of birth control that affect menstruation, whether you menstruate, will probably impact that in some different ways. I think that if it's really bothersome, the loose stool being really bothersome. I mean, there are some, like, cheap and cheerful over-the-counter supplements, like a fiber supplement, like citra cell or benefibre, or even like cillium, metamusel. Those aren't soluble fibers that suck up extra liquid and kind of create more form to those

loosey, goosey, piecey kind of stools. and can help just make the stools a little bit more cohesive, a little bit more completes that you're getting fewer incomplete, loosey-goosey stools and more of a consolidated form-bound movement, if it bothers you that much. You can take those at night for a couple days during your cycle, and that might be helpful. You can try taking some peppermint oil. I-B-G-A-R-D is a really common brand, I-B-G-A-R-D, or Heather's Tummy Tamers is another peppermint oil brand. And those are natural antispasmodics, and they can reduce that bowel spasmy action that can kind of create that frequency, especially if it's like a crampy pooping situation.

So some combination of soluble fiber and peppermint oil supplements, which are all over the counter, could be helpful if you take them at night during that really symptomatic part of your period. And many people are just like, you know, it's annoying. It doesn't really bother me. It's just like a thing and they let it go. So it just depends on the person. I'm fine with it. I just like to know why.

You know what I mean? I want to know what's going on there. Is there anything that happens when we're pregnant or right after birth that might be impacting our digestive system? Oh, yeah. Pregnancy really impacts your digestive system. So once you start growing an embryo, it starts to displace different sections of your colon. I saw when I was pregnant. I had twins.

So, like, I don't even know where all my organs were. I'm five feet tall. I have no torso. My colon was probably, like, in my neck. I saw a diagram of, like, a cross section of a pregnant person's torso. and the colon was like really high. Like it was like really displaced. So I mean, there's like a lot of things are displaced a little bit, like a lot of rerouting going on.

And which is why a lot of pregnant people will start to experience constipation at some point as the pregnancy progresses because the stool is taking detours because the colon becomes displaced in certain areas because the embryo is kind of pushing it out of the way. That's a super common thing that we'll see is constipation. We see a lot of acid reflux again because the stomach is kind of being. like hiked up and pushed up a little bit because there's just so much pressure on it from the growing baby. And so often there's a lot of acid reflux in pregnancy. Again, as the pregnancy advances, usually less so in the early phases, but by the third trimester, acid reflux and constipation are probably the most common GI symptoms that people experience. And both of those should be immediately relieved upon delivery. Is there anything that you recommend during pregnancy to

help with those symptoms? Most gynecologists are having their patients do like something like a Miralax, which is an osmotic laxative. Historically, they were like, maybe we shouldn't do magnesium, but there's really no data on that. And the GI doctors that I work with will also use magnesium during pregnancy as well. They'll use like sort of like a safe, gentle, what we call osmotic laxative, which draws water into the bowel and just kind of help scoge things along. And that's kind of the preferred. Or we'll try the natural remedies like prunes and prune juice, which also have a natural osmotic effect because the sorbitol that they contain will also kind of draw water into the bowel. Problem is if you've got like gestational diabetes, you really don't want to be

drinking a lot of juice and eating dried fruit. And so that recommendation may or may not be relevant to all of your listeners. But the prune juice thing is like real, my mom whenever she travels has like a little baggy of dried prunes she brings with her and that's scientifically sound. That's legit. Yeah. So prunes and uncertain other dried fruits. Well, so prunes obviously have fiber in them. more specifically they have a certain type of sugar called sorbitol. It's called a sugar alcohol. It is not well digested by humans and it does draw water into the bowel and have that osmotic effect. So prunes and prune juice have it. Other fruits that would have sorbitol or their juices would be things like dried cherries and cherry juice, pear nectar or apricot nectar. These are all juices

that are high in sorbitol, which might have that osmotic effect. Can you be very very, very clear for me about the effect of fiber. I feel like what I'm getting is that a good amount of fiber will help your whole digestive system and is in fact incredibly important for it, but too much fiber can be the cause of bloating, constipation, et cetera. Is that right? It can be. It's not always. There are some magic people out there who can eat unlimited amounts of fiber and feel great. I don't see them in my practice because why would they ever come to see me? I see the people who don't do well with it. So I can't tell you what percentage of people for whom too much is too much. But extremely high amounts of fiber can either promote a lot of diarrhea and loose stools because

it can be very stimulating and bulky on the bow walls and really stimulate them to keep moving. And so some people who eat a ton of fiber can become very diarrhea prone. And paradoxically, other people with their different magical unicorn snowflake bodies will eat the same exact amount of fiber and find that it actually makes them more constipated and bloated. I call it a window of pooperunity. Some people will just poop like before 10 a.m. or between 9 and 10, and that's when their body can poop. And if you're eating like tons and tons of fiber all day long, it might feel good to have a poop after lunch or maybe even one after dinner. And like some people's bodies just hormonally will not give it up. What they get out in the morning is what they get out. For people like that or for people who have a pelvic floor issue where when they're sitting down to poop, their body is just not really able to relax and produce like the full stool that really needs to come out to. much is too much. And like eating more than they can comfortably eliminate will start to create this backlog where the stool burden builds and builds and builds and builds. And then it's just like, they are just bloated all the time. Because we're all so unique, you should not assume that there is

a perfect number of fiber that all human beings are going to be equally tolerate and feel good. And just because this person on Instagram or this influencer is eating this amount of fiber and feeling awesome, there's nothing wrong with you if you do the same exact thing and you don't feel awesome. Like, you have a different body, but too much fiber can predispose to diarrhea or constipation or be perfectly fine. Totally depends. Okay, so our goal should be figuring out what the right sized amount of fiber for our body is. Yes, my goal for all of my patients is, can we identify the healthiest fiber-rich diet that you can comfortably tolerate? And in terms of number of grams, that may be anywhere from 10 or 12 a day to 40 to 50 a day. Or it might be different types of fiber

in different forms. For some people, it might be intact salads and nuts and roughagy fiber. For some people, it's only cooked and purees and nothing raw. Even within the number ranges that we kind of get to, there also might be differences in tolerance in terms of the types and the physical properties of the fiber. That's the magic of what I do is I work with people to kind of figure out what works best for their body and what is the healthiest diet that they can comfortably tolerate. I love that. Okay, let's say you are in the moment bloated. You don't really want to get to the root cause. You just want to feel better right now. What is the first thing that you would do? That's a hard question to answer, Liz, because I don't even know if you're bloating is because of

your stomach or your bowels. Some causes of bloating are not related to your intestines or your colon or your bowels, it's your stomach. Maybe you've swallowed a ton of air and you're just like literally full of air and it needs to kind of be burped out or you use some gas x or some ethyacone to break down these big air bubbles. Maybe that's why you're bloated. Maybe it is an acid reflux situation and that's why you're bloated and maybe some baking soda and water or a tombs would do wonders for you. Or maybe the reason you're bloated is intestinal. You're full of stool and you need to poop and like you're desperate to poop but nothing's coming out and you feel this pressure in the pelvis or your rectum, like you know that there's a poop there and you're not getting the urge to go.

And maybe you can pop in a glycerin suppository and just see whatever stool is there in the rectum should come out in the next five to 20 minutes if there's some poop there. So there's not like one answer to that. I know that you want one answer, but like it's so dependent on the cause. It matters whether it's an upper GI issue or a lower GI issue. And if it is gas from like a food that you've eaten, like if you're lactose intolerant, and you ate a bunch of dairy six hours ago and all of a sudden you're full of gas and bloating from the dairy you ate six hours ago, there's absolutely nothing you can do in the moment to speed that

through because the time to take your lactate enzyme was six hours ago. And anything you put in your mouth now is six to eight hours away from where the gas is. Like it's just too little too late. So there are some causes of bloating that you just have to wait out. And there's some things that you can in the moment, like, hit yourself with a remedy and quell. You really do need to have an idea why you're bloated if you're going to know how to fix it. Is there anything that you can do to make yourself fart if you have that, like, crampy where you're like, oh, I'd feel so much better if I just farted. Absolutely. Yeah, there's different yoga poses that you can do to kind of help yourself fart. You could look online, but like the happy baby, the knees into the chest or have kind of like

bending and contorting around the waistline. Like a lot of those yoga poses can help you kind of move. gas along and help induce farting. So a lot of positional stuff. Sometimes you can even do gut massage where you're massaging down the flow of where your colon is. And so I know your listeners can't see me right now, but your colon kind of goes up the side across the top of your abdomen and down the other flank of the colon. There are ways to kind of do these like directional massages that will just kind of push along the trajectory of the colon around the top, down the side to kind of help just expel, eliminate gas. Again, there's a lot of really good videos online that show how to do the colon massage should just help dislodge gas if it feels like it's trapped or pooling. But really the name

of the game with bloating is an ounce of prevention. It's really worth a pound of cure. You can really understand why you get bloated. If it is, you know, some sort of carbohydrate intolerance to lactose or fructose or sucrose, can you take an enzyme when you eat those foods? If you're someone who swallows a ton of air when you eat, can you take a gas X with every meal so that you can just break down those pooled gas bubbles. It really is around prevention is such a better strategy rather than waiting until you get bloated and then having to like, you know, figure out your rescue remedy. That's fair. I'm very much guilty of knowing that I'm somewhat, I think, at least lactose intolerant. I get stomach aches every time I eat ice cream, not cheese as much. Is that because it's

fermented. Because cheese is pretty low lactose and usually pretty lactose-free. Okay. That's nice to hear because I do love cheese. But if I eat ice cream and I will do it because the flavors always sound so interesting and delightful and so I'll like eat a cup of it and then I'll be like crying and pain later. My husband's like, you do this every single time, you know? And I'm like, yeah, yeah, I do. Okay, let's dive into poop for a second. What is the ideal amount we should be pooping? What should our poop look like? How do we know if we have a healthy poop situation. So if you never give your pooping a second thought, you have a healthy pooping situation. If you don't even ever think about whether you've pooped or how often you poop because

your bowels literally don't bother you, then your pooping is fine. I'm just going to push back on that for a second because I think we're a lot of overachievers here at the Healthier Together podcast. So we're always like, is our poop as good as it could be? what I mean? Fair. I would discourage you from using sort of like objective metrics and really focus more on subjective metrics. And what I mean by that is I could tell you that the quote unquote normal range of pooping is anywhere from three poops a week on the low end to four poops a day on the high end. That is sort of what is considered a normal range. It's a very big range. But that tells you nothing

about whether you're pooping is okay. Because you could be squarely in the middle of that range. You could poop twice a day, which is pretty good on paper, and be miserable because every time you poop, you're cramping and you're full and like it never feels complete and you're straining and it hurts. And so I don't care that you poop a normal amount. You don't feel good. It's not subjectively good. Or you could be someone on the very other end or maybe you poop only twice a week, which would be considered abnormal. But in between those pooping sessions, your belly feels fine. It doesn't look distended. You have no gas, no bloating, no discomfort. And the two times a week you go, you just get an urge, you go to the bathroom, you unleash a massively large amount of stool easily in like just moments,

it glides right out of you. You feel like a million bucks and you don't think about your bowels again until you have to go again. Do I need to micromanage that situation just so that on paper you're going three times a week? Probably not. So you should really be thinking about these subjective metrics. In other words, when you go, is it relatively easy to go without straining or pain or discomfort? Do you get an adequate sense of relief after you've gone? Do your bowel patterns impact your quality of life? In other words, are you contorting your day around the pooping? Are you waking up hours early to get it done? because you skipping meals on a day that you have to have a presentation at work because you're worried that your pooping is going to interfere? Or are you canceling vacations or theater tickets or

dates because your lack of pooping or your fear of pooping is interfering with your ability to just enjoy and live your life? Subjective measurements, I think, are really what we should be focusing on in terms of what's normal and healthy because the objective numbers I gave you really only tell a very small part of the story. Is that what you mean when you're talking about your unique bowel regimen in your book? So your bowel habits are very unique to you. A bowel regimen is really what you do to stay regular. So if you do have pooping problems, if you're not eliminating adequately, if they feel incomplete or if things are too crampy, then your bowel regimen are the behaviors or the tricks or the tools that you implement to smooth out those rough edges and to make things regular and predictable and sustainable for you. So that's what I would refer to as your bowel regimen. So for some people, your bowel regimen is taking

magnesium every night. For some people, it's waking up between seven and eight, having a cup of coffee and eating breakfast, and that's your bowel regimen. For some people, it might be very elaborate. It's taking supplemental fiber and magnesium and eating a certain amount of fiber per day or taking something prescription even. So your bowel regimen can be a lot of different things. What are your thoughts on the Squatty Potty? Love it. So the Squatty Potty is really great, especially for people who have pelvic floor muscle dysfunction because what it does is by getting your feet off the ground, you're getting your knees bent, it creates a more physiologic angle. So the rectum, when we sit up right on a toilet, is a little bit kinked. And I actually have a diagram of this in my book.

When you're sitting and pushing out a poop, the rectum is a little bit kink. So it's almost like the stool comes down and kind of has to go uphill a little bit before coming down. When you use a squatty potty, it really straightens out that rectum. So there is just a nice, clear shoot like right out of the body. And so less straining, less pushing is required to empty a stool. So it's really great in general, but especially for people who have any kind of pelvic floor muscle dysfunction. And then I've heard people say that if you have to wipe a lot, that's a sign that your poops aren't as healthy as they should be. Is there any truth to that? Very messy, wipey stools can indicate a problem. For example, when I said sometimes with SIBO, you'll get those really messy wipey stools. Sometimes if you've

malabsorbed, like a lactose intolerant stool where there's like some malabsorption of lactose or something else. Those can be a harder to wipe stool. Not all of those situations where the stool is messy and hard to wipe are necessarily problems or signify like poor gut health, although certainly there are conditions like problems in the gut, like a bile acid diarrhea or SIBO or Crohn's disease where the stool consistency will often be a sign that something is wrong. But it's not always. Sometimes it's just, like a function of the different types of fiber in your diet, the fiber balance in your diet, or if you had like a lot of fruit, a lot of sorbitol, because it's summer and you're like going to town on the watermelon and the peaches, whatever, you might have a messy or wiper stool that's

I think wrong with it. It's like you just had a lot of sorbitol and the poop got a little weird. And so it can be a sign that something's a miss, but it's not necessarily a sign that something's a mess. So we should be looking for other symptoms to indicate it might be worth looking into. A hundred percent. Like if you just like the morning, after like a watermelon vendor have a weird stool, but you otherwise feel fine, it's probably just like, okay, well, that's how eating a lot of watermelon affects my stool. Do with that information what you will. What about travel constipation? What's happening there? Oh gosh, you know, there's a lot that's happening there. There's a very strong brain gut connection, obviously, and bowels often really do

prefer their home toilet. There's just no question about that. And you know that because the second you're pulling into your driveway, like after vacation, you're like, oh my God, I call dibbs on the bathroom. So like, we know that our bells generally prefer the home toilet overall. But also with travel, there's a lot of disruptions in your diet routine, in your sleep routine, your waking times, your sleeping times. Airplane travel can cause like expansion of gases in the intestine that can kind of impact pooping. And so there's a lot of stuff like that is part of travel that can also affect regularity. Many people who are eating high fiber breakfast and salads every day, they're not eating that way on vacation. And so your fiber intake might be really different. If you are someone who

typically has that window of poop opportunity in the morning, if you're waking up like really early to go on this tour to get in line for this thing, like you might miss your window because you're running out the door and then your body's like, oh, sorry, I don't poop when I'm waiting online for ancient ruins. There's like a lot of just schedule, diet disruptions that can kind of impact the rhythm. your bowels love routine, your bowels love rhythm. And our rhythms are really off when we're traveling. I did another podcast with the doctor and he said one of the best things you could do for constipation was literally to just go sit on the toilet at the same time every day. Like you're a kid that you're potty training and just to train your bowels to get into that rhythm, which I thought was really, really interesting. I mean, that could work when you're traveling. What's really tricky, though, is when there's a time change, right? Like, what is that time? And hormonally, you're not like the day that you get somewhere, you're not fully caught up to that local time zone. And so what is that window of poop opportunity for you on your trip? And how does that correspond? It's tricky. For sure. He wasn't referencing travel. I just thought that getting into a pattern element is so interesting. Are there tools that you recommend to your clients or that you utilize yourself when traveling to be as comfortable with your

situation as possible, given the circumstances? I happen to be blessed with a body that will poop pretty much anywhere. I know. Don't be jelly. If I skip a day also, like I'm not super uncomfortable. So, like, I'm pretty lucky in that regard. But for my patients who are prone to these disruptions, plan ahead. If you get constipated when you travel, even if you don't need to use it when you're at home, pack magnesium. Bring magnesium with you and don't wait until you've skipped three days to start taking it. Take it the first night you get there so that you're not skipping days. Because when you start to skip days in the buildup and build up, it's almost like it makes it even harder to treat. Take a backup regimen with you. So whether that's magnesium, for some people, it's like a supplemental

fiber, like a cillium or a fiber con. But practice that bowel regimen before you go, make sure that it's something that works for you that you tolerate well and pack it and bring it. Well, a lot of my patients, they're consultants and they travel a lot to stay at like these random places and motels that have those like crappy continental breakfast with really nothing fibrous. And so often, like what I'll say is, can you also pack in your suitcase individual packets of like instant oatmeal, like a little individually thing of chia seeds? Can you pack something that will guarantee a good, consistent high fiber breakfast every day come what may and then have some coffee and take your bowel regimen at night and create these little mini routines on the road just to give your body some degree of

consistency and predictability with morning routines with fiber intake? that can also be helpful. This is so validating because I never travel without my oatmeal and my chia. So I'm like, all right. And my magnesium, actually. So I'm really hitting all the boxes. You are. A plus. Thank you so much. Thank you. I'd love to dive into IBS for a second. How do we know if the issues that we're dealing with might in fact be IBS? The hallmark characteristic of IBS is pain. being constipated or irregular does not mean that you have IBS. But having pain associated with your irregularity, especially if that pain is alleviated by having a bowel movement, that should make you pretty suspicious for IBS. A lot of people are kind of lumped in the IBS category just because

they have a looser stool or because they're constipated. But that doesn't necessarily mean that you have IBS if you're missing the pain component. Like there's something called chronic idiopathic constipation, which is basically IBS, constipation, without the pain, right? So it's not IBS. Like you said, you're lactose intolerant. You might have a lot of diarrhea because you drink a latte every single morning that's not lactose-free milk and then 3 p.m. rolls around and you're having diarrhea. That's not IBS. That's lactose intolerance. You can't diagnose IBS just based on irregular bowel movements. It's the pain component associated with that irregularity. There's a chronic nature to IBS. It's not something that just like you have like a bad week and then like you're fine for like seven months.

Like it's pretty chronic in terms of the irregularity and the discomfort. And the pain is typically alleviated when you poop. And by pain, you don't mean that like mild crampiness that signifies that you need to poop. No, it's pain. It's cramping. It's like a real kind of like achiness. It's something that's not just like, ooh, I got a sensation of my bell that means I have to go and then I go and I'm fine. That's just a sensation.

The other aspect to IBS and knowing that you have IBS is that a doctor has ruled out two main other causes for those symptoms, which would be inflammatory bowel disease like Crohn's disease or celiac disease. And that's really the diagnostic criteria for IBS is you're having these chronic irregular symptoms and pain. The doctor has tested you for inflammatory bowel disease. You don't have it. The doctor tested you for celiac disease. You don't have it. Then they can make a positive diagnosis based on symptom criteria.

And if you have IBS, is that something that you would? have for lifers, that's something you can recover from? For the most part, it is a chronic condition. It is something that is treatable, but not curable. In other words, there are a lot of remedies that have been shown to be effective for managing IBS symptoms, prescription medications, dietary interventions, over-the-counter supplement, even behavioral therapies like gut-directed hypnotherapy and cognitive behavioral therapy. So there are a lot of tools that clinicians have in our toolkit to manage IBS symptoms. And most people with IBS respond substantially to one or more of those. And so they'll still have underlying IBS, but like really great tools to manage it.

If your physician or dietitian have thrown every single medication, antispasmodics and laxatives or antidiereals and all the different diets, a soluble fiber therapy or the FODMAPs or they've thrown everything at you and literally nothing has changed at all, you probably don't have IBS. You probably have been misdiagnosed because almost all IBS responds to one of the many, many interventions that have been tested and demonstrated to be effective for symptom management. Is there anything that you think that people get wrong in trying to treat or manage IBS? I think fiber is something that people often get wrong because the internet treats fiber as a monolith. But there's different types of fiber, like kind of main categories of fiber that have really

different properties in the body. So like there's soluble fiber, which we talked about earlier that absorbs that extra liquid and sucks things up like a sponge, kind of glues a poop together. And for someone who has a diarrhea predominant IBS, that is definitely their more tolerable form of fiber. So they could eat mostly that or more of that and even supplement that and do really well. But if they're just getting a message, eat more fiber and they're already diarrhea prone, and they interpret that to be like, oh, just eat more of all fiber, they could end up eating a lot of salads and nuts and seeds and popcorn, which also have fiber.

But they have another type of fiber called insoluble fiber, which is very bulky and stimulating, and it doesn't hold on to liquid in the bowel and can really make them more diarrhea-prone. A lack of understanding on the nuances of the different types of fiber and how they behave in the body is something that a lot of people with IBS don't fully understand, at least initially. if you spend enough time poking around in the IBS support groups, like you'll learn about this stuff.

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The worst stomach issues that I have ever personally had in my life were caused by stress. I legit thought that I had IBS. I did this whole elimination diet, and then I moved out of New York City, and I calmed down, and my stomach felt completely fine. I would love for you to share the relationship between stress and stomach issues. I feel like when we talk about this, people are like, well, stress less, and then your stomach will feel better. But that's very hard to do. So other than stressing less, what can we do about that?

There is something called the brain gut axis, right? And it is a two-directional communication channel between the GI tract and your brain. And I say two-directional because your gut also communicates with your brain. It's not just top-down. It's also bottom-off two-way. And one of the ways that this communication happens is through neurotransmitters and hormones. Right. So like cortisol is like cortisol is a stress hormone. But like we all make it. Like you have cortisol like even when you're not stressed out. But certainly when you're more stressed, there's more cortisol. Cortisol is, you know, one of the hormones that kind of wakes up the bowel in the morning. Your cortisol levels start to rise like 4 a.m. They peak at 10. They start to come down. And that's why most people poop in the morning. like your cortisol levels kind of prime the gut. But cortisol could also be that shot in the stomach or the bowel when you realize like, oh crap, I forgot this or oh my God, I screwed that thing up at work. And that feeling that immediate sensation in your intestine, that's cortisol. It acts on the gut

as well as elsewhere in the body. That is kind of like that immediate panic that you feel in your intestines. That's your cortisol. The more common mediator of brain gut communication and stress's impact on the gut is serotonin. Serotonin is a neurotransmitter. 90% of it lives in the GI tract and there are receptors for serotonin in the GI tract, but also there's receptors for serotonin in your brain. And the amount of serotonin that's hanging out in the gut will have an impact on both your motility, so how quickly things move, as well as your sensation, how sensitive you are to pain or like the normal stimuli that would travel through the GI tract, normal amounts of gas, a normal amount of stool, a spicy food, any kind of thing that kind of creates a sensation,

your sensitivity and the receptiveness to the sensory nerves are also going to be impacted by your serotonin levels. And your serotonin levels obviously are directly connected to anxiety and depression and where you are right now mentally, which is why a lot of IBS is treated off-label using different types of antidepressants. Serotonin re-uptake inhibitors or tricyclic antidepressants. It's not because your doctor thinks you're making it all up or it's all in your head. It's because by manipulating the amount of serotonin in the intestines, you can manipulate motility and sensation. We use a lot of these antidepressants off-label to treat IBS symptoms. And they're used at levels that are too low to really impact your mood. They're not at high enough doses to actually act as anti-anxiety medication

or antidepressant, but they certainly impact the serotonin receptors in your gut in both directions. So there's certain ones that we can use to promote more bowel movements if you're really constipated. And there's other ones that can kind of block the action, like the receptiveness of serotonin if you're diarrhea prone. And so these are used in clinical practice to manage IBS symptoms. It's really annoying because when you're anxious to get stomach issues on top of that that make you more anxious and then that creates this like vicious cycle. It's incredibly annoying. And so you're saying that one of the best ways to disrupt that is potentially with these prescription medications. Is there any other ways to disrupt that cycle? If it's a chronic issue, then the medications,

many people find are helpful. But there are behavioral therapies and there's also breathing exercises people can do like in your situation when it's very situational. One thing that everybody can learn to do at home is diaphragmatic breathing. So this is a very specific type. of belly breathing that actually helps kind of reset that fight or flight response to a neutral place. Diaphromatic breathing, you can look online. There's a great video by Megan Reel. She's a GI psychologist out of University of Michigan and she put together a diaphragmatic breathing demo on YouTube for GI patients or people with IBS or GI issues that teaches you how to do diaphragmatic breathing. And it's something that people can practice, you know, for a few minutes, you know,

three or four times a day or just as needed when they're in a stressful situation and you want to bring your gut back down to neutral. If it's a chronic issue, if you're stuck in New York and you can't just move away and become a global nomad, you could try working with a cognitive behavioral therapist or a gut-directed hypnotherapist. These are sort of modalities that have been demonstrated to help people with IBS. The data suggests that it helps about 50% of the people improve their symptoms by about 50% and with gut direct and hypnotherapy for people who are good candidates for that, we see that the results last for years and years after the initial short course. There are these new apps even that you can use that are evidence-based apps that deliver

home-based gut-directed hypnotherapy. There's one called NERVA, which is an app that you would subscribe to, and it's this beautiful Australian woman's accent and like your headphones. And like it kind of guides you through a six-week gut-directed hypnotherapy. protocol and that's something that people can also try on their own. So because that brain gut connection is well established, you can harness your subconscious and your brain to bring the gut under better control. And a lot of these interventions and these behavioral health modalities have now, I think we're like a 30 years worth of data on them that they can be really effective and in many

cases as effective as diet. Okay, one more for me and then I have a few listener questions. A lot of people are talking about parasites, parasite cleanses, parasites as the root of their stomach issues. How often in your practice do you see that as the root of somebody's stomach issues? And what should somebody do if they suspect a parasite? It's very rare. It's exceedingly rare. The most common paris that I see is something called Giardia, which is... I had that within like the first few months of dating my now husband. And it makes you shit your brains out for like lack of a better way of saying it. And And I was still at the point where I wasn't staking my claim against the patriarchy and embracing my pooping. And so I was trying to hide the fact that I was shitting my brains out because I was trying to impress him.

It was not a good time. Yeah. So Giordia is legit. That's a real thing. I got it from drinking downstream in a river from a pack mule station because my dad got us lost when we were hiking and we ran out of water. That is very specific. That is a very specific cause of Giordia. Yeah.

It didn't just happen randomly. Exactly. You get it from swimming in lakes or in your case, you know, pack mule contaminated water. You could get it from your pets, right? Like dogs and cats get Giority. And you can absolutely get it if you're like cleaning a litter box. My cat had Giorita right when we adopted her. And like, I knew it because she was farting up a storm and like having diarrhea. And I was like that's not normal. And so like in theory, if I hadn't done really good handwashing with scooping, I could have gotten Giority from my cat. I will also say though, like you know if you have Giorgia. That's not like you looking at an internet ad for a parasite cleanse and being like, oh man, I wonder if I have parasites.

Like, you know if you have. Yeah, something's wrong. Yes. You're very symptomatic. And it feels kind of more acute. And that would be diagnosed by gastroenterologist through a stool panel of like common GI pathogens. A lot of the stuff around like the parasite stuff is there's something called blastocystis, which is technically a parasite. And it's really controversial whether or not it is something that causes symptoms and whether or not it's something that needs to be eradicated. In other words, it may be one of those just like benign old friend freeloaders that, you know, like if we just tested 100 or 200 people who felt perfectly fine, like we might find blastocystis in a significant percentage of that, right? And I think that a lot of kind of more of the alternative medicine,

functional medicine world is kind of looking for that and seizing upon that. In my experience, even when people have been told that they have that and they get treated with whatever they get treated for. Generally, they're still symptomatic, and so hard to imagine that the blastocystice was really the cause of it. That's kind of what I'm seeing a lot of in terms of the parasite realm. And then there's sort of like the other layer, which is somebody doesn't even test you for blastocysticist or any other parasites and just tell you have a parasite and starve you and make you drink goat milk or take wormwood or all sorts of supplements. And that's kind of scummy. When people do the parasite cleanses and they're pooping out stuff that looks like a worm, what's going on there?

You do have to be aware that there are certain things in your stool that can be thread-like in their appearance, right? Like, depending on what your parasite cleanse is, like if you're eating a lot of stringy fiber, like lettuce, kale, like celery, like that type of stuff will be very stringy in the stool. If it's causing you to have more like diarrhea and you're pooping a lot, you might actually be shedding some of the intestinal lining, some of the actual like cells and tissues of the intestinal lining when you're having diarrhea. And that can look kind of like seaweed appearance of like kind of like flaky, floaty, wavy kind of, you know, I think it really depends like what they're taking supplement wise, what they're eating on their cleansed diet wise. And whether it's inducing any type of diarrhea that could actually be causing a little bit of like mild. tissue damage that could also look like wormish in the stool. So I would reserve judgment based on what's actually being done in that particular situation. I don't want to speculate. My biggest thing is if you genuinely suspect you have a parasite, like go see a gastroenterologist, go see a RD who specializes in these things, go see some sort of expert rather than just ordering a kit online, you know? Absolutely. Look, I'm an RD. I can't treat parasites. Like,

That is a medical condition that requires prescription medications if there actually is a true parasite. And I can't prescribe. I'm not a prescriber. And I'm not aware of any supplements that would actually treat the type of parasites that affect humans. So you should absolutely see a gastroenterologist. Don't see me. I can't do anything about your parasite. Okay.

A few listener questions. Why do I always get so bloated post-workout? You might be swallowing a lot of air. Oh. So when you're working out, we're like air hungry and we're gasping. a lot of the time we're chugging water, like when you're breathing heavily in you're chugging water. I once had a patient who was super, super bloated, and we figured out that it was happening more on the days that he was swimming laps.

And there was something about his breathing when he was coming up and then like swallowing these big gulps of air. And so you might want to kind of check your breathing. And if it does feel like it's related, you want to think about when you're working out, focusing on inhale through the nose, exhale through the mouth, especially if you're a runner, to try to get in, nose, out mouth and really kind of not be a mouth breather when you're exercising. And if you are hydrating a lot while you're exercising to try to get off your machine or stop for a moment, take a moment, like let your heart rate come down a little bit, catch your breath and then not be chugging, gulping air, like while you're drinking because you'll swallow a lot of air.

And so that might be something related to exercise that I do see. Oh, that's so interesting. This is a little bit tangentially related, but I feel like I get way fartier when I bet higher altitudes. Is that like an air thing happening in my body? Yeah. So great story. I wrote an article about why air travel bloats you back in, I want to say 2019 when I was appearing on live with Kelly and Ryan. And it was the morning after the Golden Globes. And Ryan Seacrest casually mentioned, like, as I'm going to the green room, like, I just flew overnight on the red eye and I'm like so bloated. Like, why does airplane travel make me so bloated? And I was like, oh my God, what if Ryan Seacrest

asked me that on air? I have no idea. So I'm like texting my gastroenterologist colleagues at 7 clock in the morning. Like, Ryan Seacrest is super bloated after airline travel. Tell me why. And I learned, and then I subsequently wrote an article about it on US News, which you can Google and like, why does plane travel make me bloated? When you are flying, the low air pressure causes gases to expand by about 30%. So all of the normal air and gas that is in your GI tract when you are in the air is now taking up 30% more space. And so you are going to feel more bloated. And then when you come down, the gas pressure and the bowel is probably going to induce some farting because your bowel is like, ooh, like I'm really distended with air and it's going to induce some farting.

Wait, so is that true? Like I'm in a mountain town right now where I'm at 7,000 feet. Would that be true there as well? Yes, in theory, but you do acclimate to it, right? And so it's like- No, I'm farty like right at the beginning. Whenever I come to these mountain towns on Nomad Life, I'll be like, I'm weirdly farty right now, and I just want to know if it's in my head or not.

No, it's not in your head. Okay. gases expand about 30% when the air pressure is lower. Okay, interesting. And then you mentioned the gulping water and you were referencing it in terms of air intake. But what role does dehydration play at all the things that we're talking about? And how should we be thinking about water in relation to constipation, bloating, etc.? I don't know that dehydration has like a huge relationship with bloating per se.

And with constipation, I mean, look, you're not going to drink your way out of constipation. Like if you are truly clinically dehydrated, sure, it can absolutely be constipating. If you're taking a fiber supplement and you're just washing it down with like one sip of water and not a full glass of water along with the fiber supplement, forget it. You're going to make a brick. You're not going to make a poop. But if you're just eating like a normal diet and drinking enough liquids that your pee is basically light colored or clear, drinking like a full gallon of water is probably not going to make a difference for your constipation. and frankly could blow you even more because water also takes up space. And people who are drinking 100, 200 ounces of water per day are often very bloated.

I've heard people say that you shouldn't drink water when you're eating food because it dilutes your digestive juices or something like that. Is there any truth to that? Nope. The pH of your stomach is so incredibly low that drinking like mouthfuls of water is not substantively going to dilute the pH of the stomach more so than actually. eating food does. So it doesn't inactivate your digestive enzymes. I mean, can you imagine if the human body was so frail and persnickety, like, overthrew evolution that it couldn't digest food if we drank water while we were eating? Like, human species would not have survived. Your body can multitask. Humans have made it this far because they can multitask and, like, they're not so delicate.

Okay. I love that. Last listener question. I get so. tired after I ate any meal, even healthy ones. What's happening there and how can I prevent it? That's not something I can diagnose without really knowing what's going on with this person. Like, I don't know what their thyroid levels are. I don't know how much they sleep. I don't know if it's like a blood sugar issue. There could be a lot of things going on. This is the kind of question that doesn't lend itself to like a quick answer. It's something I would really need to sit and talk to someone about and understand big picture life stuff. If somebody's experiencing something like that? Is that something you'd recommend they see in RD or a gastroenterologist

about? Absolutely, yeah. Sometimes it's something I can help with. Sometimes it's a glycemic effect of the meal and we can work on glycemic load. Sometimes it's a blood pressure. We're seeing a lot of like post-COVID patients who get like really crashy and fatigued after eating because they have something called pots, which is sort of like a difficulty managing their heart rate and their blood pressure. And then eating just like draws all the blood away from their head and their extremities to the digestive tract. And they just like get really kind of crashy and fatigy, and so I'd want to see if that's going on. I'd want to see if there's other signs that might make me think that this person is a hypothyroid issue. So I would really need to see meal patterns and specific foods and get a full health history to be able to answer

a question like that. Can you leave us with just one homework assignment for somebody who's experiencing bloating regularly and just want something that they could try out or do today? And similarly, somebody who's experiencing constipation or trouble eliminating, and they just want one thing they can try out today. The one thing that your listeners can do to try to figure out what's going on so they know how to fix it is go to my website and take the quizzes. I have free quizzes on my website, one from the bloated belly whisperer, which is for people who experience bloating, and one from my new book regular, which is for people who experience irregularity. And these are symptoms-based quizzes that you can get on my website, the bloatedbellywhisper.com, for free. Take the quiz, and it will give you

at the end, a narrow down educated guess of like the top two reasons that you may be conspated or that you may be bloated. And that will help you figure out what is the right path in terms of how am I going to address this because the answer for someone who's bloated because they're swallowing air while they're exercising is completely unrelated to the answer for someone who's bloated because they're constipated. And so there is no one size fits all solution, but I do have really helpful screening tools that Anybody can access for free online to help get their own individualized answers. Can you tell us a little bit more about the resources you have online, your books, where people can find you? You can find me on the bloated belly whisperer.com, which is my website. It's also my name, tamara duker.com.

And there's information about my clinical practice. So if you're in New York or one of the states where I practice, then I can work with you by telehealth. And you can find all that information on my website. You can find links to my books. I wrote the bloated belly whisper, which, is for my bloated friends and regular for constipated diarrhea friends or both. I have both of my quizzes, the diagnostic quizzes from both of my books, available for free online, just a variety of resources about things that I've written. Anytime you have a GI issue, if you Google the GI issue and the word Tamara, which is my first name, chances are I've written an article about it on US News. So literally like anything you can think of to Google digestively and my name, you will probably find an article I wrote with really practical tips about management and diagnosis. And so,

you know, Google Tamara plus your problem and chances are you'll find something I've written. Love it. Thank you so much, Tamara. This was very educational. It was my pleasure, Liz. It was really awesome to talk to you. I think you kind of get an A plus and digestive health management. You're killing it. Oh, thank you so much. I'm looking for A pluses wherever I can get them. So I appreciate that. I honestly love talking about this stuff. I could have gone on forever. It's like we can all be hot girls without stomach issues, you know. We just need the right information. Please send a link for this episode to someone you love. Let's normalize talking about this stuff and addressing it so we can all get on with living our best lives. Text them,

slack them, mention it the next time that you see them. It is the best way to help your friends and to support the podcast. If you're new here, welcome. I'd say I'm sorry that you join the fam on a poop episode, but honestly I'm not. We are very devoted to covering every single thing that makes your life healthier and happier here. And your colon is very much not off limits. Before you go, make sure that you're following the podcast on whatever platform you like to listen on. Just go to the main podcast page. It's the one that lists all of the healthier together episodes. And you'll see the word follow under the logo on Spotify. And then there's a little follow with a plus sign button on the top right of that same page on Apple Podcasts. That way, all of the new episodes will show

right in your feed so you will never miss out on one. And you are definitely going to want to be following along because we have some amazing episodes coming up, including one all about taking back your power and asking for what you need, and an episode designed to help you keep your fur babies alive and feeling good for as long as possible. So make sure that your following so you do not miss out. Okay, I love you and I will see you next week on the next episode of the Healthy Together podcast. The number one rule of habits is to make the things that you want easier and the things that you don't want harder. Yet so many of us want to eat healthier, but so few of us actually take the steps to make eating healthier easier. That's where Marley Spoon comes in. What I love about

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