Romance and bathroom habits may not seem like they go together, but somehow bestselling author Susan Mallery managed it in her novel ONE BIG HAPPY FAMILY. We talk to Susan and Mayo Clinic gastroenterologist Dr. Tisha Lunsford to explore irritable bowel syndrome (IBS) and the accompanying physical, logistical and emotional challenges of managing a chronic gastrointestinal condition. Susan shares her personal connection to her character’s symptoms, while Dr. Lunsford provides clinical insights into IBS diagnosis, treatment options, and the importance of patient-centered care.
Romance and bathroom habits may not seem like they go together, but somehow bestselling author Susan Mallery managed it in her novel ONE BIG HAPPY FAMILY. We talk to Susan and Mayo Clinic gastroenterologist Dr. Tisha Lunsford to explore irritable bowel syndrome (IBS) and the accompanying physical, logistical and emotional challenges of managing a chronic gastrointestinal condition. Susan shares her personal connection to her character’s symptoms, while Dr. Lunsford provides clinical insights into IBS diagnosis, treatment options, and the importance of patient-centered care.
The episode was made possible through the generous support of Ken Stevens.
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Dr. Denise Millstine:
Welcome to the Read. Talk. Grow. podcast, where we explore health topics through books. Our topic today is a very popular and important one, irritable bowel syndrome, and our book is ONE BIG HAPPY FAMILY by Susan Mallery. I'm your host, Doctor Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine, and integrative medicine.
I am so excited about my guests today. Susan Mallery is the number one New York Times bestselling author of novels about the relationships that shape women's lives, family, friendships, romance. 40 million copies of her books have sold worldwide. Her warm, humorous stories make the world a happier place to live. Susan grew up in California and now lives in Seattle with her husband. Susan, welcome to the show.
Susan Mallery:
Wow. Well, thanks for having me. This is going to be fun.
Dr. Denise Millstine:
Dr. Tricia Lunsford is a gastroenterologist with specialty interests and expertise in disorders of gut-brain interaction and gastrointestinal motility disturbance. Doctor Lunsford clinical practice focuses on the treatment of patients with functional bowel disorders, such as irritable bowel syndrome, fecal incontinence, bloating, functional dyspepsia, visceral pain, nausea and vomiting. Tisha, welcome to the show.
Dr. Tisha Lunsford:
Thanks so much for having me.
Dr. Denise Millstine:
This is going to be fun. ONE BIG HAPPY FAMILY is a fun loving, if messy at times, family story of a holiday gathering at the large family cabin of the main character, Julie. One character, Blair, who's Julie's daughter in law, has irritable bowel syndrome, and that's going to be the focus of this episode. Okay, you both now how Read. Talk. Grow. works. We discuss books that portray health topics in an effort to better understand health, experience through story. In this case, we'll discuss functional bowel conditions, especially irritable bowel syndrome, which is often called IBS.
Susan, I'm so thrilled to talk to you about this book. My good friend Kiki from church came up to me one day. She's a big fan of the podcast, and she said, I just read this book and one of the characters has IBS. Please see if Susan will come on the show. We're so excited you're here! Tell us your inspiration for the novel, particularly the character of Blair.
Susan Mallery:
Well, thanks for having me and I will admit I've been writing it since college, so a very, very long time. And this is the first time we're going to I'm going to be discussing irritable bowel on a microphone. So the idea for ONE BIG HAPPY FAMILY came about because I told my agent I was done writing Christmas books. I was burned out. I didn't want to do it anymore. And she's like, it's fine. You don't have to write another Christmas book. And I was very whiny that day and I said, no, no, I'm really not going to do it, I swear. And if I ever did, I would only write a book about someone who didn't want her family to come home for Christmas.
So that was the inspiration. And then I said, I have to go. I have to make some notes. I'll call you in an hour. So it came about just serendipitously. So for me, I start with one character, which is Julie, and then I build. And so I knew I wanted Blair and I was thinking, so who is she?
And what is different? And I personally have irritable bowel. I was having a really bad day and I came back from the bathroom and I thought, you know what, I'm gonna put this in a book. I happen to know every good bathroom from Seattle to Snoqualmie, which is where their Christmas cabin is. And I could talk about that.
I personally have stopped at Indian John Hill to use the restroom. It's very clean and worth going to. The one eastbound is better than the one westbound, I will say, but they all work. So that's where Blair came from and it was really. I'm sorry for everyone who suffers. I don't mean this disrespectfully, but I giggled all the way through every time we were dealing with Blair and symptoms, it's like, yeah, I know exactly how that feels. I know how to write about this. So Blair got stuck with my issues. Hers are way worse than mine. They say every author puts you put yourself in the book. And this time I really did. So Blair and I are not alike character wise, but we have similar gastrointestinal tracts.
Dr. Denise Millstine:
Well, it's so interesting where people are inspired and how they do their research. And you can tell an author who's either deeply researched the topic or has an authentic understanding of what it is to have this experience because of the way they portray it. So I for one, I'm really glad that you included it in this novel, and I know Tisha is as well.
Tisha, tell us what it's like to be a gastroenterologist who focuses on disorders like IBS. And also your reaction to the book.
Dr. Tisha Lunsford:
Yes, I thought it was a meaningful book that it chose to feature a character with the chronic GI disorder of IBS because it's very common. It affects around 10% of the U.S. population, especially women and young adults. But yet they're very rarely represented in fiction or in any type of media, because it's not exactly a glamorous topic. You know, bowel habits don't tend to make it into rom coms, but that's why this particularly stood out, and it's important to see these experiences reflected in storytelling.
Like Susan referenced, it is a more of a marathon than a sprint with a disorder like IBS. So in terms of being a gastroenterologist who deals with these conditions, unlike the often, not always, but often clear cut path of a surgeon, who may identify a physical problem like inflammation or obstruction and provide a swift, often curative solution. My work as a gastroenterologist revolves around symptom management.
This is really directed at patient-centered care, building trust and supporting patients over extended periods of times. So these conditions, they used to be broadly labeled under the term functional GI disorders. But we're really moving away from that. They're more accurately now called disorders of gut-brain interaction. And it's because it's felt that the term functional often carries an unintentional bias, sometimes stigmatizing patients. And even the word even, the term, irritable bowel syndrome has come under fire because no one wants to be called irritable, and no one really wants to be told that they have a syndrome which carries the assumption that this is dismissive and not a true disease. That's really where I start.
So a lot of my work is spent in counseling and talking to patients. I spend a significant amount of time reviewing symptom patterns and explaining the selective role of diagnostic testing and discussing a wide spectrum of treatment options. And my care is often collaborative. So instead of going into an O.R. and having it be one time, I often involve nurse educators, physical therapists, dieticians, and GI health psychologists that each play a vital role in helping the patient achieve meaningful quality of life.
And that means different things to different people. So Susan touched on something very salient in that her symptoms aren't as bad as Blair's. So these patients can experience the spectrum of this disorder on a wide range of impairment and quality of life. And so we have to really get to what the patient's goals are.
Dr. Denise Millstine:
That is a lot of information. And I introduced the topic as functional bowel disorders. So thank you for correcting me. And even I learn something as we make and present these shows. So thank you so much. Susan, we meet Blair when she's at work because she's introducing some healthy recipes to a group of fairly surly seniors who aren't so excited about what she is offering. And her husband, Nick, stops by and asks Blair how she's feeling, and then is so relieved when Blair's response is that she's having a good day. She's doing well. I guess I wanted to start by thinking about how conditions like IBS don't just affect the person who is living them, but then the people in their lives and the people who care about them. Would you comment on that?
Susan Mallery:
Oh, absolutely. Well, one of the ways to define a character is to put them in a situation and see how they react. And he is so supportive and so loving, and he is the one who will, if you have these issues in my house, we refer to it as “issues,” “I'm having issues” because you're right, people don't want to talk about it.
I had a girlfriend who had a nosy neighbor who just wouldn't leave her alone monitoring her life, and she said, I just one time want to make her go away and not come back and bother me in 10 minutes. And I said, just look her in the eye and say, I have to go have diarrhea. I promise you she will not bother you for probably 2 or 3 days because nobody wants to talk about it.
And so his happiness at her good day is because he loves her, but it also means they can probably have sex. Because if you're having a bad day, you really don't want to be doing that. So it does, it affects everything. It affects your mood. It affects the quality of life. It affects whether or not you want to cook dinner or if you're just feeling crappy, last thing you want to do is be frying and onions. But Nick was very supportive. I have enough, I don't want to say trouble happening in the book, but there were enough complications that he got to just pretty much be a good guy. He quarreled a little with his sister, but very supportive of Blair. And when you find out about their first date, you think this is the best people in the world because this is a back story issue, but on their first, they meet by accident. Her blind date goes badly. The blind date calls a guy and says, I think you'd like her better than I do, and she gets nervous and that triggers. And she's in the bathroom for an hour. When she gets out, Nick is still waiting and it's like he's a keeper. So it was important for me that she had the support because it's a tough thing to deal with.
And it's not graphic in the way you don't follow her into the bathroom. But I really tried to go through, what is it really like? There's a scene where they're driving up the mountains and she's very upset and is just trying to get the car ride over, and she's got the windows down, because if you're having issues and the cold is so much better, if you're in a hot room, it's over. And so she's got the windows down, it's 30 degrees outside and her mother's in the back complaining that she's cold. And so there's a nice contrast between the warm, loving husband and the the dark, evil mother.
Dr. Denise Millstine:
Wow Tisha, Susan just went for it right there. Talking about all these aspects, I think we often think about irritable bowel syndrome and the diarrhea, the bloating, the pain that comes with it. But she wants to talk about sex. Let's talk about sex, because I think she's absolutely right that this is probably a component of IBS, that even people who talk about IBS maybe don't talk about how it can impact some other really important parts of your life.
Dr. Tisha Lunsford:
Yes. So there are no known studies looking specifically at sexual dysfunction in women specifically with IBS. There are subgroups that are looked at, patients who have symptoms, functional bowel disease or inflammatory bowel disease, and also are either premenopausal or going through the menopausal transition or postmenopausal. But just in terms of IBS, there is not a lot of knowns. We kind of take it by assumption that impaired quality of life and functioning, of which those daily interactions and relationships, of course, are impacted adversely. And we certainly consider that with quality of life issues.
Dr. Denise Millstine:
And I would say, I hear my patients talk about the unpredictability of it and just not kind of knowing what's coming and, you know, wanting to make sure that they feel clean and they don't feel like they've had any soiling or something that was going to make them feel uncomfortable being intimate. But now we've talked about this group of conditions and IBS in terms of many of their symptoms. But Tisha, there actually are diagnostic criteria for IBS. Would you share how you make a diagnosis of IBS with our listeners?
Dr. Tisha Lunsford:
Absolutely. So it's there's clinicians use something that's called the Rome criteria. So this is a validated set of symptom based guidelines. They do need to be fulfilled. They have some latitude in that it can be a change in bowel habits, either developing constipation, developing diarrhea or going back and forth between them. And there are some associated conditions, like bloating, that can make their way in. But many people in the field almost feel that should be a separate diagnostic category, because it is so difficult to manage on its own. These criteria have to be present for at least six months, and they have to be associated with abdominal discomfort. So if someone is just experiencing diarrhea or constipation without pain, which of course is very subjective, so if someone could have been describing terrible pain, that really is just somebody else's discomfort or vice versa, some kind of a bowel discomfort has to occur at least once per week, and the symptoms had to have occurred within the last three months. So at least six months within the last three months, a change of symptoms to constipation or to diarrhea, some kind of shift in the bowel habit and then associated with pain that either gets better or worse with the bowel habit change.
And this is a practical, it's a widely accepted approach that helps avoid unnecessary procedures and helps us to guide therapies to assess how therapies work based on the response to their initiation in patients who need these validated criteria.
Dr. Denise Millstine:
I heard you say two things. When you're first talking, you talked about selective use of procedures, and now you've just said avoid unnecessary procedures. So will you comment further or are you talking about colonoscopy, are you're talking about surgery? What are you talking about?
Dr. Tisha Lunsford:
Yes. So irritable bowel syndrome by definition to what we know, how sensitive our testing is, doesn't allow for us to visualize any visible damage that can lead to all of these symptoms of pain, bloating, change in bowel habits. So it's kind of like having a computer where the computer or the hardware looks really good on the outside, but there's a software glitch on the inside.
And so we don't have an evidence-based way to look at that yet that may be in the future. So when we approach a patient who does not have what we call alarm criteria, which we can review our alarm symptoms, red flags, when we see a patient who meets the Rome criteria. So chronicity and they have a classical they meet the the Rome the validated Rome criteria. And they do not have any weight loss, bleeding out their gut, a family history of cancer that might be concerning or other systemic symptoms based on the clinician's assessment, like fever or abnormal imaging that may have been done in the past. It is within guidelines not to perform unnecessary or invasive procedures, like colonoscopy or a stool-based testing or upper endoscopy, in some cases looking for celiac disease, although we do look for some of those conditions non-invasively using blood tests sometimes and other stool studies that can look, there's a there's a test called a fecal protectin. There's a very simple test that is very good about looking to see if there is active inflammation in the gut or not, that can push us in one way or the other if we're on the fence about whether or not a patient meets criteria for IBS. So it's very important to come into a patient with who is suffering with IBS from a positive diagnostic standpoint. The worst thing that we can do as physicians is to go in and take down all their symptoms and then go in and do a big diagnostic workup and then come back and say, “Well, everything's negative. So you don't have anything really. You have IBS.” And that is very dismissive often. And while the patient may be relieved they don't have cancer or inflammatory bowel disease, it really doesn't doesn't do much, I think for their confidence. And it can fracture the patient-physician therapeutic relationship. And so I try to go in with a positive diagnosis when I know patients meet those criteria, I'm always open to looking for red flags, to looking for things that are atypical or don't quite fit with the clinical picture, listening to the patient and evolving as things come about as well. So I'm never decisive or prescriptive in a way that's dismissive, but I do want to instill confidence in the patient so that -- because often there's a lot of unnecessary testing that is done on patients, it actually does very little, the evidence does support, it does very little to alleviate their fears or concerns.
Susan Mallery:
I really appreciate that because it's difficult being a woman and having these vague symptoms. And I have had countless doctors as I tried to treat this over the years, basically tell me I was crazy and that just just wrap your fingers around their little throat is always really calm. Which one does not do except in one's mind.
Susan Mallery:
So yes.
Dr. Denise Millstine:
Or novels? You could do it in your novel?
Susan Mallery:
Yeah. I don't write murder mysteries, but I could certainly look at doing a little change. It is. As a patient, it's very frustrating to be told. I had a doc, I was having horrible and it was bile-based diarrhea, and I don't that's the worst. And nothing should be that color. So yeah, my doctor basically said, I think you should do yoga. And I'm like, really? Because it's like multiple times a day, every day. And that was her prescription was yoga. And I'm just like, okay, I'm going to need a new GI doctor. So I appreciate that so much what you said.
Dr. Tisha Lunsford:
And again, it's the delivery. So it's not exactly wrong that she offered up the mindfulness practice because there it is, the catastrophic thinking. So when Blair's going up the mountain, it's the fear of the what if, it's the unpredictability, it's the I'm going to, it's the signal is being amplified. So it's like the, the signal between the gut brain axis is like a static on a radio. And then when you're in times of severe stress or heightened awareness, you go into further fight or flight and then the volume goes up. And so we do teach and acupuncture, yoga, other mindfulness practices, cognitive behavioral therapy, GI gut-directed hypnosis. We do teach techniques to modify maladaptive thought patterns. You're right. It doesn't fix always the actually the triggers for the diarrhea or it doesn't take away the circumstances, but it can reteach, it can disrupt the maladaptive signal that the brain is sending down that's leading to severe gut dysfunction. Leading to more pain, bloating or changes in bowel habits. So managing stress is a key part of treating IBS, but it's alongside other dietary, lifestyle changes, and of course medications. And so the way it was delivered, it probably could have been delivered as a less prescriptive and more like patient-centered and had more of a discussion about why that might be helpful as a part of your treatment plan.
Susan Mallery:
Exactly. I had another doctor. We spent 15 minutes talking about different breathing exercises that would help, and that was great. I mean, yes, it does. It's nice to feel that you've been listened to and poor Blair gets all my things. The cold air does help because it's also, as you say, disruptive. And you can focus on how cold you feel rather than, oh my God, oh my God, and the rest stop is 15 miles away. And even at 60 miles an hour, that's really far.
Dr. Tisha Lunsford:
Yep.
Dr. Denise Millstine:
Susan, you also have Blair manipulate her diet quite a bit. Will you comment on that and whether or not that's effective for her?
Susan Mallery:
It is mostly effective for her. I wanted to do that specifically to show that she and her mother-in-law were very close, and she and her mother were not very close. So that was specifically done for that. I know that everyone's different, and I think that's one of the challenges of any sort of GI issue. No two people are the same, and there are general solutions that will work for a large part of the population. But everybody has their own quirk, I know, and to this day, I don't eat on travel days. If I'm flying, I will be doing the fasting because if I don't eat food, I've now reduced my chance of symptoms significantly. Eventually one has to eat. But you once you’re on the plane you can usually get to bathroom. But I did do some research beyond my own personal stuff, so I was looking .like I've never quite understood FODMAP. I've tried, but avocados are both on the eat and don't eat listj, and as soon as I found that I was like, okay FODMAP, you have failed me.
Dr. Tisha Lunsford:
Avocados is more about the portion size, right? Because we can handle our gut can probably handle a certain portion of it, but sometimes it can get overwhelmed. The FODMAP diet is a way of eating that, as Susan really well illustrated. It does work for some people. It is the only evidence-based dietary approach that has been proven to be helpful. There's a lot of fads out there, but it doesn't work for everyone. And I certainly tell patients that right away. What I find is the most frustrating with patients is they often get handed a handout, which is not particularly helpful because it is very overwhelming. It covers a broad range of foods. So FODMAPs are just short-chain carbohydrates that are poorly absorbed in the gut. That's it. So they're fermentable. So they cause gas, bloating, pain and changes in bowel habits. And the name is an acronym that's a very long collection of five different types of categories. And no one needs to remember all of that. It's just important that these are found in everyday foods like onions, garlic, wheat, apples, milk, and beans. But what's important about the diet is that it works in three phases.
It's the elimination where you temporarily cut out the high FODMAP foods. This is anywhere from 2 to 6 weeks. We happen to be blessed. We have dietitians. We have very wonderful dietitians here that offer. But now there are more mainstream availabilities. Two out there books like Mind Your Gut and other books that are very helpful and are very practical in their application and evidence-based and don't go too far off the rails and actually give patients really good advice.
So the elimination is 2 to 6 weeks. Most patients land somewhere around four because it is difficult. And then there's a reintroduction. So every 72 hours you're slowly adding back foods one at a time to see if you can identify a trigger. So it doesn't mean you never have avocado. It just means that during the reintroduction phase, if you notice the avocado causes symptoms, then at that point in time you would identify that as either as one that you need to accept the consequences, or one that you would try to avoid or limit the portion size. And then there's the meeting with, we have patients to a group class where they're introduced to all of those concepts. And then we have the personalization phase which is the third phase. And that's about six weeks later. And they settle into a long-term eating plan that avoids only the patient's personal triggers.
It's never meant to be forever. And we really want to make sure we don't do over restriction, because that gets into a completely different area of disordered eating. And that can even lead to serious health consequences like avoidant restrictive food intake disorder or ARFID. It's I try to explain to patients, it's like if you have arthritis and you go for a walk and you have pain one day, but you don't have it the next, it doesn't mean you're never going to walk again. You understand it's just a bad day for your arthritis. So it's the same with trying to figure out foods sometimes. We don't want to eliminate every food because your gut is misbehaving. We want to try to get your gut better behaved. And this is one of those ways to hopefully identify triggers.
Dr. Denise Millstine:
Wow, that was really helpful.
Susan Mallery:
It's exhausting. Yeah, it is.
Dr. Denise Millstine:
Hey listeners, we hope you're enjoying this episode of Read. Talk. Grow. If you find our discussions helpful and insightful, please take a moment to subscribe to and rate Read. Talk. Grow. on your preferred podcast platform, and don't forget to tell your friends to listen. Your support will help us reach more readers and those eager to learn about health through books. As always, feel free to drop us a line at readtalkgrow@mayo.edu with suggestions for books, topics or any comments. Thanks for listening.
Dr. Denise Millstine:
I know when I counsel people on the low FODMAP diet, I often say it's not intuitive. You know, one of the reasons you need training and lists is that unless you're a chemist, you won't really understand which foods are on the okay to eat and which ones are the eat with caution. I like what you said though, Tisha, about the reintroduction and when or even if that food provokes symptoms in a condition like IBS, you don't have to absolutely then never eat that food again. It's just more of an awareness that should you eat that food or should you eat that food at a certain dose, you might provoke some of your symptoms, which is much different than, say, celiac disease, where you don't eat gluten, you don't eat gluten to symptom tolerance. Can you just re-emphasize that for our listeners?
Dr. Tisha Lunsford:
Yes, absolutely. So there is an actual, there's with celiac disease, there's an actual allergic condition. There's an immune reaction that is happening that results in damage, mucosal damage and inflammation and malabsorption and even long-term cancer risk. That's not the case in IBS. If you eat a food, you may regret it or have symptoms, but there's no long term consequence to that in terms of inflammation that we can actively identify currently with the current testing that we have.
And there there there is not known to be any long term impairment in mortality or reduction in length, but certainly in just quality. So it's really a quality of life issue more than it is quantity or having other implications, like in celiac disease where it is a true gluten allergy. Well, patients with IBS might be gluten sensitive. That is a completely different category than a gluten avoidance that is necessary in celiac disease to avoid long term malabsorption consequences like bone disease and even lymphoma.
Dr. Denise Millstine:
Yeah. Thank you. I liked Susan, how you didn't necessarily call it a low FODMAP diet, but at one point Julie is making some food to share with the family. And she says, I made a batch without onions because that's one of Blair's iffy foods. And I don't know if you would agree that a lot of times people have figured out their triggers without having to label it as a specific type of diet, do you agree?
Susan Mallery:
I do, I think if you have lived with this for a long time, you start to learn how much is food sensitivity, how much is stress. So we're all I think we're all on basically on a spectrum of where I am. I am much less food sensitive. Personally, I am much more emotional sensitivity. My husband has joked for years that I will never have an affair, because there is not enough Imodium in the world to keep me functional from the stress. And it's true. If we have a fight, I'm going to have a bad day the next day and I know it. So I am much more mind body. So I personally focus on mind body things. Not yoga but other things. But I have friends who are just so triggered by food and it's sort of, okay, I'm home all day tomorrow, so I'm going to eat this food I love and I'm going to have a bad day because I'm willing to pay that price.
So I think people do start to learn that. I don't know if it's a good news or bad news, but I think for most people with any kind of IBS, it's not subtle and it's not slow. It's within 12 hours, you were going to have your answer. So it's not like you have to wait and get results from a blood test. Your body is going to explain to you incredibly quickly and with great clarity: That was a bad move. You should not have done this. And now we're all going to pay.
Dr. Denise Millstine:
I really like how you draw that connection, because we had an interesting conversation about migraine and migraine triggers, which is a very complicated topic. And I love how you're simplifying that in this case, for many people, the trigger, whether it's stress or a food that you've and there is a pretty direct line to the results depending on what your symptoms are. Tisha do agree?
Dr. Tisha Lunsford:
Yes, definitely.
Dr. Denise Millstine:
Susan, what about the trauma aspect of it? You know, Blair is in a loving marriage with a supportive family of her husband's and is navigating her relationship with her mother, but she has a history of childhood trauma. Do you see that as being related to her IBS, or was that a literary device?
Susan Mallery:
Well, it was a literary device, but I was trying to, for reasons of the story, I needed to get her away from her family and into another situation. What I chose is she has uncontrolled diarrhea in middle school. That is an unrecoverable event. She can never go back to school there. It will be talked about for generations. I don't know that it is the most humiliating thing that could happen, but I think it would certainly hit the top three of the list and it is a fear having any kind of GI issues. I always used to, just especially when I was in my 20s. It's like, why can't I vomit? Vomiting is easier. It's there isn't the stigma, but the whole diarrhea thing is just, it's so culturally it there's just no good there. So I that's I pick that for, and then yeah she was traumatized. And I can think of events where I've had to leave or times I couldn't go somewhere or I couldn't enjoy the, the whatever it was because I was so terrified that something was going to happen.
It's difficult to live with that on a day-to-day basis. And it and for me, it is cyclical. I'm currently in a pretty good place and that's great. It's been a couple of months of better, but in six months it could be worse. And like when we travel, I'm on alert. It's like, oh my god, bus ride. How long is the bus ride. Is it going to be okay? And nobody wants to go to the bathroom on a bus so it can be consuming. It's in the background. It's not always a front of mind issue, but I think for most people who have this with any significance, it is constant. It is something you never, you can never completely forget.
Dr. Denise Millstine:
Yeah, I would, I would agree. I mean, I think in women's health we talk a lot about how people talk about periods and that's shifting. But I don't see a lot of shifting in people being open to talk about bowel movements and diarrhea, Tisha maybe because this is your world, you would disagree with that statement. But you made the point at the very beginning that this is a really prevalent condition and that many of the people who live with it are young women. Will you just comment on that component of the trauma early in life and the embarrassment and bullying and, and that that I'm sure you see many of your patients navigate.
Dr. Tisha Lunsford:
There’s a growing evidence that early life stressors like childhood abuse or trauma, and even some evidence this is not childhood stress or trauma, but overuse of antibiotics even can predispose patients to have IBS later in life.
But for the emotional aspect in childhood, there is a connection rooted in how the brain and gut communicate. And when someone experiences trauma, especially during critical developmental periods, it can alter how their nervous system responds to stress. And so that heightened sensitivity carries over into adulthood and can affect how the gut functions. In people with IBS, the gut often overreacts to stress, and that can be joyful, too.
Never forget that we have other conditions, like cyclic vomiting and other conditions where people have nausea and vomiting, even when they're joyful, like on their wedding day. It's spectrums of emotion, both spectrums joy and sorrow, leading to symptoms like pain, bloating, and urgency. And so when the brain is on high alert because of past trauma, so it's always in that that ready to fight or flight mode, the gut can be too. So it's not just psychological, it is real. It's a physical response of that fight or flight.
The biggest fear they have too is of not having a rescue plan. So I like to give them a rescue plan like this is what we're going to do. If you're needing to get on the plane, you know, this is what we can do potentially with antispasmodics or potentially even using more long-term medications that are called neuromodulators. And we call them that. Again, that's also they’re, many of them are psycho pharmacotherapy drugs or for depression, but I really make it clear to my patients that I do not use them for those reasons. Kind of like how an aspirin, it has dualistic nature. It can be for a heart attack or for a headache. Neuromodulators are primarily in GI used to reset that abnormal signal that is in the gut, that disorder of the gut-brain axis. And I'll tell them that we use very low doses often to sort of prophylactically prevent the brain from going into overdrive in the gut from going into overdrive.
And I have to be really clear about that on visit one, I have to offer it doesn't mean that I'm going to prescribe it on visit one, but I have to bring it up along with the role of of mitigating stress with GI health psychology and other stress management strategies. Because I don't want them to hear that on the third visit when they're still struggling and our tests are negative, and then they hear me bring up the word antidepressant or psychology or psychiatry, because then, exactly as Susan said, they feel that it's just been sort of a diagnosis of exclusion rather than coming from a positive diagnostic strategy. So and all those things are very important.
I have to say, patients do a very good job of trusting me with their stories, and I can hold space with their story. Because of the time that I'm given here at Mayo, I have more time to talk to patients than many clinicians, so I'm very grateful for that. And that's one of the things that sets us apart. They're often forthcoming, and I have to say, I will ask them, do you think this is impacting your current condition? If they do say “no, I have worked through it, I've been through therapy or I have a strategy to mitigate it.” I will let that go, meaning I don't perseverate it and keep telling the patient you have to deal with that. You know, if they tell me they have, they have. It doesn't change their physiologic response. We have to work on that. But it may not have as high of a role that's happening in the now. So we have to be careful on both sides. We don't want to overemphasize it, but we certainly don't want to dismiss it.
Dr. Denise Millstine:
There's a lot in that. And I think what we've heard as general themes that for IBS you have mind-body, psychologically based, body movement based approaches. You have dietary manipulations that could include Susan not eating before you get on a plane, if that's what you find, quiets your symptoms sort of reliably. And then we do have pharmaceutical approaches for IBS. And we see Blair talk about that a bit in the novel, particularly as she's thinking about being a newlywed and maybe starting a family and being very careful around what she's choosing to put in her body should she want to become pregnant. There's a moment, Susan, where Blair has some extra symptoms and she is trying to just pass it off as her IBS as a bad day, but her husband and people around her are realizing, but it's not the same. It's now nausea. And it's not that you're able to eat this (unclear). You're actually avoiding this specific food that you usually are able to tolerate. Without spoiling, the novel will you tell our listeners how you were making a distinction that not all digestive symptoms are IBS when you have IBS?
Susan Mallery:
It's true. Not it is exactly what you said there are. You can have IBS and you can still get heartburn and they are often very unrelated. It's just like, no, do not be eating that much spicy Thai food so close to bed. The normal everyday occurrences that happen to everybody else also happen. If you have IBS, or if you have cancer, or if you have any other disease, you're still going to get the other things going on. And so there is the I mean, I will occasionally argue with my body. It's like, really did this not seem like enough? Did we have to go in another direction too? I will say, one of the few bright spots of having irritable bowel is when you have to do your first colonoscopy, the prep mix it's like, no, I, I do this professionally. This is nothing. It's nasty. It still tastes bad. But the whole going to the bathroom over and over again, it's like, yep, I know how to do this one. This one is easy for me. And plus, most of us who have IBS are incredibly compliant. The, the body's like, oh, we know this. And yes, my doctor always teases me that I am one of his cleanest patients ever. It's like your body knows how to get rid of that stuff. And there it goes. So. But for Blair, I did want to show different symptoms. And I have a girlfriend who has pretty serious issues. She's not quite at Crohn's, but she's getting there. And so I know some of the medications she's on, and that's what I was trying to avoid for Blair. I didn't want her to do that because that really does, that is a serious impact on your life just because of the restrictions. And those are not kidding drugs. Those are pretty serious things. So I didn't want to go that far. So I wanted her that she'll be fine. For those of you who are concerned, she'll be fine.
Dr. Tisha Lunsford:
I think what you're sort of touching on is the red flag symptoms. So like other symptoms, the presentation doesn't quite fit. So we think of unexplained weight loss, blood in the stool, anemia, fever or symptoms that start after age 50, we certainly worry that something else could be going on. It's not impossible that it could still be IBS. But we also have to worry about what you were alluding to was the development of inflammatory bowel disease, celiac disease, you know, or even colon cancer. So it's important to attend to all of those as well, making sure that we don't need to dig deeper. But I would say that the drugs that the medications that we use, a lot of people do consider those serious, meaning I don't want to minimize the seriousness of some of the neuromodulators. For some patients, they may not be biologics that people are prescribed with Crohn's or ulcerative colitis. But I do also want to make sure that that we take them just as seriously when we give out, you know, pharmacotherapy, making sure that the patient understands, you know, the rationale and the mechanism of action and potential side effects that could come from the medication, like with family planning or with with other things, it is different. You can also have both. It's extraordinarily common to have, disorders of gut-brain interaction or so-called functional bowel diseases with all diseases like inflammatory bowel disease and GERD and celiac. There's an extraordinary overlap.
Dr. Denise Millstine:
And one thing I was thinking is, yes, the red flags. But also if you've lived with your irritable bowel syndrome for decades and suddenly the pattern has changed, even if it's not that you're losing weight and having fevers, but you were used to your rhythm and now it's something different, I think it's at least worth a conversation with a health care professional, just to make sure that this is part of the same condition that you've been navigating.
I'm hoping, as we wrap up, that you both will share something that you hope our listeners who perhaps are living with irritable bowel syndrome or care about somebody who lives with your bowel syndrome, something that you might want them to know, particularly if they're navigating their symptoms in silence on their own?
Susan Mallery:
Well, I would say don't navigate in silence. You have people who love you and put them on your team. When I the conference writing conferences are less so now, since Covid. But pre-COVID I would do a lot of writing conferences and I had a circle of writer friends and it was not uncommon we would just be talking and someone would come up and say, the bathroom at the back of the ballroom is bigger, quieter and nicer than the one in the front of the ballroom.
And so you can have all these resources who can help. I have another friend who we were having lunch and she just looked at me and she said, okay, go, go. It's I apparently got the look and she's like, I know you know, I'll be here. It's fine. And people will judge you less than you think they will because everybody has something. To reiterate what you said, yes, if there is a change, people who have a chronic disease are the best, they have the best knowledge of their own symptoms. And if there is a change, go get it looked at because it shouldn't be different and you want to know if it's something bad. So don't be stoic about it. If you're not sure, ask.
But I would definitely, the people in your life who love you let them be warriors for you. They want to help and this is not a disease where they can help you very much, except possibly pass you more toilet paper under the door. So let them participate and it will make them feel good about doing something for someone they love.
Dr. Denise Millstine:
Or know where the good bathrooms are. Absolutely.
Susan Mallery:
Yes. Good bathroom. You always want to know the good bathroom.
Dr. Tisha Lunsford:
Yeah. And I would say my best advice would be if you find a physician that you care about, or even if you do a one time consultation like an academic center, you know, like Mayo, I think it's being open to the fact, to IBS. And what I mean by that is there are a lot of providers, because the disease is not curable, there are a lot of providers who with good intent but want to provide quick fixes with unproven cures and testing. So whether it's for food allergies or for stool-based testing for a variety of the microbiome that we do not know how to interpret in context at this time, giving you other diagnoses like SIBO, which is small intestinal bacterial overgrowth without any known risk factors.
So somebody who offers something as a quick fix or cure or says, you have this bad bacteria or this good or you're allergic to these foods without any evidence of true allergy, as defined by, the, by an allergist or immunologist. I think it's just to be really careful to be open to the fact that this could be IBS and to be cautious and be open to quality of life, like getting more good days than bad, recognizing there's no cure and someone who promises a cure right now, it's probably going to be an expensive road. And if you get benefit, that's wonderful. But just being careful to remember the evidence that thoughtful, evidence-based care is the best approach. And if you have a trusted provider that is providing that to you. I'm not saying you can't do your own research or explore other avenues, but just do it with caution.
And many of us who are experts in, disorders of gut-brain interaction are very familiar with the integrative and functional side of things. And we'll tell you what we know. And if we don't know, I'm very honest about what I don't know. But we use peppermint oil very often. And we do know some, some conditions that can predispose you to pancreatic insufficiency or SIBO, so we'll go looking for those things. We're not opposed to it, but we do want to partner with you to keep you from expensive, invasive, invasive and, and treatments that are not evidence-based.
Dr. Denise Millstine:
There is so much wisdom in those statements. I want to thank you both for coming on Read. Talk. Grow. to talk to me about irritable bowel syndrome and disorders of gut-brain interaction. It's been my pleasure to talk to Dr. Tisha Lunsford and Susan Mallery about the book, ONE BIG HAPPY FAMILY. Thank you both.
Susan Mallery:
Thank you, thank you.
Dr. Tisha Lunsford:
Thanks so much.
Dr. Denise Millstine:
Today's read, Talk Grow is a product of the Women's Health Center at Mayo Clinic. This episode was made possible by the generous support of Ken Stevens. Our producer is Lisa Speckhard-Pasque, and our recording engineer is Rick Andreasen. Visit our show notes to see the books discussed today and for links to other health education materials. Follow us on social media like Instagram and Facebook, or reach out directly to our email, readtalkgrow@mayo.edu, with suggestions for books or topic ideas. We'd love to hear from you.
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