If food heals, why are we taking it away?

Download the presentation slides

‍

Full video transcript available below

If food heals, why are we taking it away? How evidence, bias, and misinformation is shaping the future of DGBI care

So I want to just jump into this right away, and really start to think about what is going on within the patients that we're seeing in front of us. So when I'm looking at this, I've given us two sample patients, and two different ways of looking at how we can approach things. So when I'm thinking about the first patient that I want to be looking at, patient A has an IBS diagnosis. And I should say, when we're talking about this presentation, I'm probably going to talk about irritable bowel syndrome fairly frequently. A lot of the time, I'm going to be using it interchangeably with disorders of gut-brain interaction or DGBIs.

Dis some things are going to be that there's a miscommunication or a miswiring between the gut and the brain. We also can see a lot of other changes going on with low level immune activation or mucosal changes, microbiota changes that are going on. But that inherent change within the gut-brain axis is something that we want to keep in mind.

So much of the research historically in this area has been done on irritable bowel syndrome, especially before they changed how we diagnose it, where pain wasn't a requisite and just having discomfort was. So sometimes the research may seem like it's about IBS and maybe the way that we would define things now isn't the same, but right now I'm going to be using the word irritable bowel syndrome. And I'm going to say that both patient A and patient B are very similar individuals. They have that classic presentation of pain in the abdomen. They both have bloating, distension, socially inappropriate gas that's going on. And we're going to make this really easy for us. And we're going to say that they both have IBS-D. It's a diarrhea type. Now in our first patient, we're giving them an early gut-brain intervention and looking at gut-directed hypnotherapy and going through that within the first visit. And then we're looking at diet strategically later. Now in this individual, what we see, and sorry, I've got to move something on my screen here. Let me see if I can get that down.

Why is this not moving away? There we go. Sorry about that. So when we're looking at the outcomes, what we see in this individual, we're going to talk about the research later so we understand what this looks like, but the symptoms improved. And that's using validated measures. So often what we would see here is the IBS-SSS or the symptom severity score. So we saw that the symptoms meaningfully improved. We saw that confidence increase with managing their symptom flares. And we saw that food variety was still preserved in this situation.

We also saw that they had less hypervigilance to the what they were feeling. So a lot of the time when we're thinking of these conditions, we see that they're feeling the feels of digestion all the time, which they're not supposed to. That's part of the condition. And so if we're not focused on that all the time, it can make life a little bit easier.

I really should have changed this line. I looked at it and I kept meaning to go back. I've said that they're still eating socially without fear. They weren't eating socially without fear previously or restriction. It is something that almost everyone who has concerns about conditions like IBS knows that food can trigger things. And so they are scanning menus, looking for the things that they can eat. They're scoping out where the bathrooms are. They are not comfortable in these situations. So now we're seeing that she is more comfortable with eating socially, able to travel more comfortably and not worry about awkward situations on planes. And overall, we're seeing that the quality of life was improved.

Now when we're looking at patient B, as I said, we're talking about the same sort of picture in this scenario. They have abdominal bloating, pain, distension, socially inappropriate gas. I feel like in Australia we say wind. That feels very foreign to me. And those altered bowel patterns, it's a diarrhea type that we're looking at. And a low FODMAP diet was done. Now I want to be super clear. I was a very early adopter of the low FODMAP diet and I still use it in patients. I'll be honest, I can't think of a time in recent years where it's not significantly modified and it doesn't come as easily to use with patients. But it is something that I think is important and it really has been a game changer within patients. Again, with sort of my training, what I learned about within diet was pretty awful. And the restrictive diets that I learned about, like things that were crazy like the brown rice diet and having lamb and peaches and these weird things, when the low FODMAP diet came out, it was something that it was studied and we could have more consistency in what was going on and there was a plan. And it's something that I don't want to be suggesting that it's not important that we have these things, but there can be issues with it. So one of the things that can become difficult is actually getting people to move into the next phases of things. But what did happen in this situation with patient B, the same symptoms really did improve. The diet absolutely worked in that sense and that can give a lot of freedom for individuals, at least for a short period of time. But a lot of the time, and this is one of the areas that has become really concerning for me, especially now that we've been doing this for years and really over a decade at this point, is what I've seen for a lot of people is that we started to get a lot of food fear around things. I will get people who come in who have been on a low FODMAP diet for years that somebody put them on or they read about themselves and they haven't, sometimes they don't know that they're supposed to come off of it. Sometimes they haven't come off of it because it doesn't work for them, but they have a huge amount of anxiety around trigger foods. And when we're looking at foods that can be things like dairy and not gluten per se, but gluten-based foods is the way that most people interpret it, and onions and garlic and apples and cauliflower and mushrooms and all of these things that are common healthy foods for us, that can become very difficult to work around. And a lot of the time what I see for individuals is this idea of narrow diet. So a lot of people will start with, "Okay, I took out dairy. It made me feel better for a while." And then I read about gluten and I took that out, but I was still having symptoms and I did a low FODMAP diet and that really helped me a lot. Legitimately helps people a lot, but it didn't fix everything. And then I started reading about histamines and what about a nickel allergy and what about lectins? And it seems that for a lot of people, because food was a thing that kind of worked, that they just keep taking things away. And that's a huge concern for me when we're not feeding our microbiota, but also how we live as social people within communities who have different cultures and it's very difficult. We see a lot of travel anxiety for people, social restrictions. These are things that when we're thinking about health, we really have to care about. Because for me, I'm not positive that just symptom improvement is the goal if people are living in a smaller box.

So if we're looking at this, both patients improved. This is the really important thing when we're looking at things in research, the symptoms reduced. Both count as treatment successes in many clinical trials if we saw these outcomes. But if we're only looking at symptom scores or even quality of life scores, if we're only looking at quality of life in a short period of time, we can miss some of the outcomes that matter most to patients.

So when I'm looking at this talk, I want to be clear about what this is and isn't. This isn’t anti-diet. I do think dietary interventions, including the low FODMAP diet, have a valuable role in IBS care. I think that nutrition is essential. I think it's essential for our own human body. I think it's essential for our microbiota. We have to be clear about when and how we're using it, but I think it's really important. And I adore guidelines. I am so excited for people who are newer to this. I'm going to say 2026 is a very exciting year. Rome 5, the Rome Foundation is the group that does the overarching information about disorders of gut-brain interaction. Every 10 years, we get new information coming out, and this is the year. So I am super excited that this is going to be happening now. But I think it is more than just having guidelines. It's thoughtfully applying the evidence. And that's going to be something we want to think about. What I do want people to be thinking about is how do we introduce things within therapy or treatment? When do we introduce things? Why do we do it at certain times? I want to think about examining our reflexive clinical patterns that maybe were the best things that we had available and maybe now are part of our clinical armory and not the main thing that we have. And again, I want us to be looking at long-term outcomes in our patients, which include being able to live life more freely, not more restricted.

So the core question that I want to think about, or I want people to think about when they're looking at this, is going to be that if we are seeing that gut-brain therapies, and I'm talking most about hypnotherapy today, and we'll look at some of the research as we go forward, but if it works as well as restrictive diets without taking food away, why do we still lead with restriction? Because the question isn't whether diet works. That is something that is, we know that. We know it makes a difference for symptoms, but does it serve people best if we go to it first? Because the gap between evidence and practice has real consequences for patients, and it isn't just symptom scores when we're thinking about things. But I think even though we've had this advances, our clinical defaults don't necessarily align with that. And I think we reflexively reach for the things that we've done previously because that's what we know. And so I really want us to think about why we do the things that we do with patients and why we might consider changing that.

So when I think about health, when I think about gut health, when I think about teaching, looking at evidence, the way that I tend to work is strong views loosely held.

I strongly believe that gut health matters. I believe that our understanding changes though. I think the microbiota is a huge deal in human health. I think we sometimes overstate it. It is something that there's a whole lot that we don't know. And there's a lot of things that I thought I knew in the past that have been shown to be different than what I believed. And I think that's okay. And my understanding of food within looking at gut health is really different than what I understood. So here I've said the problem isn't food. And I want to be clear that food matters a lot. Now for a lot of people who are listening, who are probably a lot younger than me, you may not remember what it was like to be in practice in 2014 and looking at gut health. That was a big year because in the guidelines, they started to look at dietary therapies within conditions like IBS. And one of the lead authors, and I cannot remember for the life of me, whether it was the American College of Gastroenterology or the AGA, but they were talking about food. And they had this line that said, "Most recently and belatedly, the important role of the ubiquitous interloper into the gastrointestinal environment food has become to be recognized and serious research efforts devoted to understanding its role in IBS and to the development of dietary approaches to the management of IBS."

Basically they were saying, "You know what? Patients have been saying that food makes a difference to their symptoms. And we have been telling them that that is wrong. It turns out we were wrong. We're finally starting to talk about diet within this. And it felt like such a big deal to start having those conversations. And what we understand is that certain foods can trigger symptoms in certain individuals who have certain conditions. But when I think about food as a problem, that it is the underlying issue. I'm often thinking about a peanut reaction where people have an anaphylactic reaction or celiac disease. I don't have another scenario other than taking gluten out of the diet. There is no situation where I'm going to suggest that someone does gut directed hypnotherapy for their peanut allergy. And hold on, I'll just hold your EpiPen over here. And at the end of six weeks, you eat peanuts. Those are problems. When we're looking at IBS, it is part of what the way that people can feel their symptoms. It can be a trigger. And understanding what's happening can be so powerful for patients. And we know that it can provide meaningful symptom relief.

But what happens when we lead with restriction before addressing the gut brain access? We know that we can gain symptom relief in a large number of patients. But what do we risk with this? And I want to think about what is a disorder of gut brain interaction?

If we're saying that it's something that we have a miscommunication and a miswiring between the gut and the brain, that anxiety and stress can play a part of it. But even more, we have that visceral hypersensitivity that's going on. We have that sensitization where the nerves are turned up and people are feeling normal digestion as discomfort or pain.

If that is the problem, food is part of it. But it's not the main issue, the way that it is with certain other conditions. So we want to think about what are we actually treating? What are we trying to fix in these situations? Now when we're looking at what's happening, patients did not get here by choice. Most people aren't saying, you know what, I want to take out all the foods that I can possibly take out and not have to think about anything else.

Often what's happening is it's taking years for people to get a diagnosis. We've seen in the research that's often it's up to seven years for someone to get an IBS diagnosis. Now I think sometimes it's not actually being understood what IBS is as a diagnosis, but still it's taking people a really long time to get diagnosed. And then they're basically being told, you know what, do a low FODMAP diet. You can Google that, get less stressed, we've done testing, everything looks fine. You come back, you can't get the foods back. And people are kind of left to manage. And this is not something that I think is due to a lack of empathy or compassion from providers. I think the way that we look at GI health has changed significantly, especially over the last decade. And we also have, and I'm going to speak for Canada, but we see absolutely in other countries as well, that our healthcare systems are under significant strain. They're struggling to provide basic care for a lot of individuals, no less the comprehensive integrated care for these complex conditions like DGBIs, where a lot of people aren't trained well to begin with. So what happens when this occurs? Because historically, if we were talking about this happening in 2005 and someone was kind of stuck in this situation, maybe they go to a health food store to ask someone at the store for a little bit of advice. Maybe it's something that they go to the library and they get this book that's like the A to Z of all the health conditions. And it gives a list of things that they can try, but most people aren't going to do that.

The world is different now. When care gaps exist, we have a lot of information to fill that void. So when patients search for answers, the internet becomes the de facto care pathway. And we see that volume replaces clarity.

It's hard because what they're finding online, and we've seen studies that in gut health, much of what is out there in social media, YouTube, things along those lines, we know that it's misinformation or wrong.

But it is so confident. It is simplified to such a fault that it can be harming patients. It's often inaccurate and it's urgency driven. It's fear-based and it's heightening anxiety. And that is something that is repeated over and over and over again. And teaching patients to change their outcome is not something that's an easy thing to do. So they're hearing this much more than they're hearing our voices.

So I speak a lot. Part of what I teach at the university is health misinformation, but it's going beyond that into the information overload is just changing behavior and belief.

So it's something that people want to work with, what they feel like they understand based on their own experiences and what they can control. And the hard thing about that is food is something that they can immediately control, not because it's always the right thing, but because it's there and accessible and it gives them something that really hasn't, they can't access some of the other things that maybe they would want to access.

And this is really hard because when we're talking about disorders of that brain interaction and again, going back to IBS, depending on the study that we're looking at, we absolutely see that the rates of anxiety are high in this population, 40 to 60% in some studies.

Now the thing about that is it means that 40 to 60% of people don't have generalized anxiety disorder. But when we're looking at disorders of gut brain interaction, we see that there is a hypervigilance, there's a catastrophizing, there's avoidance behaviors that come. And one of the things that we see is gut symptoms specific anxiety. So this is the anxiety that is very symptom focused and often rooted in past experiences or fears that they have within severe or embarrassing situations that they've experienced.

So we know when we're looking at the fact that disorders of gut brain interaction, we have this dysregulation in the gut brain access, we see that patients can be trapped in a cycle where because they're trying to avoid the symptoms, they drive more down into anxiety. So for me, I use a lot of validated questionnaires and I encourage people, especially if you're just getting started out and haven't looked at this too much, there is a lot of different sort of things that we can use to look at what is happening with our patients. But populations that are coming to see me, I know there's a higher risk for disordered eating patterns or frank eating disorders. So it's something that I am looking out for symptoms around orthorexia or ARFID, avoidant restrictive food intake disorder. And it's something that while I'm not necessarily going through the entire questionnaire, I commonly look at the visceral sensitivity index.

The questions that we're going to see in these sort of things are going to look at what are the fears that people have. And sometimes patients are going to say the words out loud to you that you don't even have to ask the questions, but it's going to be things like when I go to a restaurant, I get anxious about the experience. If I have discomfort in my gut, it frightens me. I'm constantly thinking about what's happening in my gut. And you'll hear people are saying, you know, I ate this and then I got bloated and it didn't happen the next time, but I was waiting for it to happen and it's always there. And so we know when symptoms happen unpredictably, people are worried about losing control in public or social situations. And we see it's the not going to your child's soccer game because they don't have a bathroom on the field. It's not going hiking any longer. It is changing the way that you travel. It's not wanting to give your mother-in-law a new food list and being embarrassed about what you can and can't eat. And this is the thing.

Symptoms may improve with dietary restriction, but dietary restriction doesn't necessarily stop the fear. And in fact, we see that restriction may be able to reinforce the belief that food is dangerous and that avoidance is the only path to safety, even when we're doing our best to explain to patients that that's not the reality of this.

So when we're looking at this, restriction can temporarily reduce symptoms. But if it's driving that fear that's there in the first place and individuals who have a gut brain miswiring, higher anxiety, higher stress, that's something that can make this psychologically harder, not easier. And so I always want to think about what can we actually do with this? And that's where when I started to look at some of the information around gut brain therapy, and you're going to hear me talk about how long it took me to do that because I was very averse to looking at this, to be honest. But when I started to see that we had real world data that showed that it could actually improve things around that visceral sensitivity and anxiety. So they're not as afraid of things. They're not as stressed about this stuff. And they're not as hypervigilant. That was pretty amazing. When I get people after the holidays who are telling me that they ate with their family and they weren't worried about things all the time and they weren't catastrophizing everything, that was amazing. And seeing that people can believe in their ability to cope and manage their symptoms, that feels really important to me. And so it is something that we want to start with the evidence. And what I've done is I've only highlighted a couple of studies and I actually saw in the chat that there was someone who was saying, I think it was Lauren was saying that she's newer to this. And there's a lot of presentations and studies and things that we can look at, but I just wanted to focus on two because I think they're important for actually getting patients to consider this more.

So prior to 2016, I know there were some studies that were out on using gut directed hypnotherapy and looking at its efficacy. And I will say, I refuse to look at those studies. I will tell you a little bit more about why, but I was very averse to hypnotherapy. And then in 2016, this study came out that looked at three different groups of individuals diagnosed with IBS. So a third of them went into gut directed hypnotherapy. They got six sessions over 12 weeks. A third of people went into the low FODMAP diet education, which was done with dietitian. So done very well over 12 weeks. And then the other group of people got both interventions that were delivered together. So this was like a head to head, let's see what happens here. And so at the end of this, what we saw was both groups responded well. So what they said was gut directed hypnotherapy is non inferior to a low FODMAP diet. So this was looking at that IBS symptom severity score.

And we saw that they were equal. And we saw that within the quality of life improvement as well, there was no significant difference between groups. So all of that was looking fantastic.

And my brain was still saying, I don't want to look at this. So again, putting my age out there a little bit more, I remember growing up through the 1980s, and my parents had these work Christmas parties, and they were very big for their employers. And they would have a whole hall and they would have a Santa who would come in and he would give presents to the kids. And then they would have entertainment for the adults. And it would usually be a comedian or a magician. But one year they had a hypnotist come on and you have someone who acts like a chicken on the stage.

And that was my picture of this. And being a naturopath, it is something that I really don't want to be associated with crazy. I don't want to be associated with the woo side of this. And so for me, I was like, how do I get up here and talk about this to patients, to clinicians, to anyone? It is something that I felt very backed into a corner about, that it just could not be okay. And so when I heard that it was non-inferior, in my mind I was like, fine, it's not worse, but that's not reasonable enough for me to use this. I have this low FODMAP diet that I am using consistently and it's working fantastically well and that's the end of that.

So then, and I have started using it since that point, but I just wanted to look at another trial that I really love and looking at the fact that we are seeing that we can actually use it within app-based care because I think that's one of the things that was one of my one of the things that I used in my list of reasons why I could not use gut directed hypnotherapy while I got started was that we just don't have great people who are doing it. I live in the largest province in Canada and we have three people who are certified to be doing gut directed hypnotherapy. So this was an interesting study that just came out last year that was looking at app-based gut directed hypnotherapy versus digital education.

So they had either the 42 sessions on the app or they looked at having this digital education where they were, it was a cognitive behavioral therapy informed program. So they did no hypnotherapy, but they did a lot of education around the gut brain axis. They looked at stress reduction, relaxation techniques, including deep breathing. So they did a lot of sort of good helpful things. And what did we actually see?

So when they look at having improvement in symptom severity, we want over a 50 point improvement. And we saw that in just over 80% of the hypnotherapy group and 63% in the control group, which is pretty fantastic. And as we'll talk about the end, there are other methods that look at this gut brain therapy beyond hypnotherapy. But it is something that both groups did well, hypnotherapy in the app did better. And when we looked at pain reduction, so greater than 30% pain reduction, we saw that was over 70% in the hypnotherapy group versus 35% in the control. And so we saw that the results demonstrate that app-based care could deliver meaningful results without dietary restriction, as we've seen, but at scale in a way that in-person therapy can't match necessarily.

So it is something that evidence isn't the barrier. And that was the problem for me. It wasn't the evidence. I could see the evidence. It was me. And this is something that changing practice requires us examining why we do what we do and whether those reasons still serve our patients. And so as I said, I was furious about this. And I've still changed my mind about using it. And so when I look at this, and especially because I mentor and teach a lot of practitioners and students, it is a question that comes up a lot of the time about using hypnotherapy. And for some people, and not everyone will have the same journey that I have, but feeling uncomfortable about it at first. So diet often does feel like the right first step. I'm going to jump to the last one first. It's what I was trained in. I had no training around gut-directed hypnotherapy or stress relief beyond go to yoga, do some deep breathing. Like it wasn't part of what I was trained in. And even when I look at conferences that I go to, still diet is the mainstay of the conversations that were happening in these scenarios. It's very tangible and it's structured. To be very honest, it makes me feel more doctor-y to have someone that I'm giving them this plan and they're going to walk through these steps and I'm going to be the one who's guiding them through it. It makes me feel like I'm doing more of my job in some ways. Now I have changed my mind on that, but I will say I came from that point. Those clear phases, having the handout that talks about how to handle no onions and garlic and how we want to work on the microbiota when this is like, it felt like that was my big role in what I was doing. And if I couldn't do that thing, where was my value any longer? It's also something that patients expect it. They are hearing so much more about food. It was harder historically to get people to take food away. And now they're just like, well, what am I supposed to take away? Like tell me the next thing. How can we test it? And we're like, no, please don't do that. But it's very much this big, they want to know what are the right foods for them. And it feels very active for patients. It feels like they're doing something concrete. So these are all understandable reasons and they reflect our real pressures in practice. But one of the things that I get a lot from practitioners is how do I get patients to do it? Because I'm going to say I get a lot of practitioners who struggle with that when they're starting to work with gut directed hypnotherapy.

And one of the questions that I want to ask for many of the practitioners who are struggling with this is that whether they have put as much effort into understanding gut directed hypnotherapy and how to introduce it to patients as they had spent on diet. Because for many people, the answer is going to be no. And I think that if this, if we're not doing the training on this and we're not looking at how to talk to patients, if it's an afterthought in your education, it's going to be an afterthought to patients as well. And I don't think that's good enough anymore when I'm thinking about this. So we need to think about how do we change our minds? And hopefully we're starting to see some reasons to change our own minds. But how do we change our patients' minds? Because when I started out with talking about this, it was something that was a little bit of a hard sell for some individuals. Some people are like, yeah, I love this sort of stuff. I am very susceptible to hypnosis. And I'm like, okay, anyways. But they're like, I'm all in with this. And there are a lot of patients who came up with a lot of reasons why this was the wrong thing. And I'm going to say what I use most commonly with patients. And first off, there are some patients who I will decide that they are not going to do this. And this is not a right start for people. It might be something that we're going to do it later within their care.

But I also think there's a lot of patients that if we can get them open and curious and listening, that it is something that we can get people to look at this as a really good option for them. So I don't know if people are familiar with Chris Boss. He wrote, I think he's an FBI negotiator or something. He wrote a book on negotiation techniques. And this is something that I use with my patients.

So I will go through our entire appointment and diagnose the patient and go through what we're going to be talking about. And probably because I love psyllium, we're going to have them doing some psyllium and some little things that we're going to get started with. And then I usually talking about gut-directed hypnotherapy last because it's going to be a bigger conversation to be quite honest.

Now I don't mention it right away with many of my patients. So I do not say the words gut-directed hypnotherapy until we're midway through the conversation. So often what I'll say is trying to name the objections before patients do. So I want to talk about something and we've just gone through this entire appointment. We've been talking for a really long time and I'm hoping that you think that I am a not crazy evidence-focused individual. And now I think I'm going to be talking about something that may seem weird or implausible or even annoying to you at this point. So I am trying to let them know that I get what they're going to be thinking right up front. And I let them know that this is what I thought when I heard about it. And then I go through my Christmas story and talking about the fact that when I started to hear research on this topic, I just, I couldn't even look at it because it seemed so impossible that this was something that could work. And then I started seeing more research on it. And then I saw that it was compared to a low FODMAP diet and it was equally effective in decreasing symptoms like pain and bloating and bowel irregularities, but it can also help with anxiety and stress. And then we start to talk about what it is and what's involved and why it's so important that we're actually trying to work at the level of the gut-brain connection because patients are often bought into this part already and go from there. We're trying to normalize the skepticism. I'm trying to clinically lower the threat or shame that they might feel and keep their nervous system open because I don't want patients to be defending themselves. I want them to be listening and come through the journey that many of us go through when we don't understand something properly. And if we think about the gut-brain axis being threat sensitive, how we introduce an intervention matters as much as the intervention itself. It's also something that I like to use cognitive load reduction with patients when we're introducing things. I want to remove the internal yabut loop before it starts. Yeah, but I'm not going to be hypnotized. I know that I'm not that type of person. So it's something that we want to bring these yabuts up as quickly as we can before a patient can say anything. So this is going to sound strange because most people think of that entertainment hypnosis, that they're going to be out of it and maybe you would or you're someone who would never have that happen. What's reassuring is that the study shows that it works just as well, whether you feel fully aware the whole time or you actually feel like you were deeply absorbed. It's okay either way. If your shopping list pops into your ped part way through, you're just going to bring yourself back and that's perfectly okay with this and it's not going to terribly affect your results.

We also want to think about our patients who are already deeply into restriction diets. It's something that I see this all the time, like I need to take out another food or I want to bring back other foods, but when we go into food chaining and trying to do it in really small, safe ways, some patients just can't do it. And this is a great place to be looking at the gut brain connection again. So we want the language to help make them feel safe and comfortable. We don't want there to be shame around this. You know what? Taking the foods out, they really helped in the short term, but we need a different tool to start working on that gut brain connection. We want to build longer term resilience. You know what? Your symptoms are calmer, but you know what? Your nervous system isn't yet. What if we start to work on that? What would it be like if it was easier to tolerate foods, if you didn't feel all the feels of your digestive tract all the time and we didn't have to try to bring back foods completely while you're terrified?

There's ways that we can approach this that make our patients feel empowered. As I said, it's not just hypnotherapy. We absolutely see that there are other things that we can be looking at. So cognitive behavioral therapy, we've got a lot of great research around this. Biofeedback, nervous system regulation approaches, breath work, pelvic floor physiotherapist. I know that's not actually gut brain connection, but there's so many things that we can be looking at that can help with reducing threat perception and building resilience without restricting food.

Because if we're really doing this, if we can help people with a therapy and we can drop their fear, the stuff around diet can work so much better. It can lower their anxiety. So patients can work with dietary changes, whether we're restricting or adding, with curiosity and not fear. They don't have to have that rigid adherence and that catastrophic thinking. We want them more flexible and greater tolerance. We know that so many of our patients with just, for example, bloating or patients who have reflux hypersensitivity, they're feeling the fields of digestion way too much. They're not necessarily producing more gas than the average person is or refluxing more than the average person is. They're just feeling it happen. So what if we could reduce that and find that foods are better tolerated in those scenarios? Then diet can become a tool rather than a threat. And this is something where if patients can experiment with modifications and adding things from a place of safety, everything becomes so much easier within this. And this really is about long-term outcomes for our patients. I no longer measure success solely by symptom scores at 12 weeks. And the same thing, even for quality of life scores at the end of 12 weeks, of course, people feel like their life is better if they don't have six diarrhea episodes per day. But what happens at one year or three years if they have less and less foods and their life is smaller?

These are the things that I care about. I want to know that my patients aren't living in a small box. I want to know that they can eat flexibly and not be trapped by really rigid rules. I want them to be able to go out and travel and hang out with friends and go to restaurants and not be afraid of sex.

All of these sorts of things really matter. And if you're afraid of socially inappropriate gas or having diarrhea or pain, it makes it really hard. And then just that psychological flexibility and safety of being able to move through the world and enjoy food and not feel everything all the time. It's so important within this.

Because if we say that food matters, freedom with food matters as well. So I really do encourage people to revisit their defaults and when appropriately lead with gut brain care and really aim to protect your patient's quality of life.

Okay. So I feel like I've been talking for quite a while right now. So I'm just going to bring the screen back up here. Excellent.

Oh, thank you so much, Kim. That was so great here. Do you need a minute to have a drink of water or anything? Oh, I can always take a sip.

Before we start asking questions. But I will just remind everyone that if anyone does have questions for Kim, if they're processing, please feel free to put them in the chat or in the Q\&A box wherever you'd like them to go.

But we will start with one question because there is one in the Q\&A. And that question is, oh, it's a good one. How do you approach or treat IBS plus IBD folks as it's quite common?

So I know that we've got someone on here who is a pretty huge expert in IBD. So it always makes me a little bit nervous when I hear about that. But it is something for IBD. And as a naturopath, and I work with a lot of gastroenterologists, so they are doing all the med side and scoping and scanning and all of that sort of stuff.

It's funny because I heavily look at the gut microbiota. So the work out of the University of Massachusetts, I really like their program that focuses on building up the gut microbiota.

And it's interesting because I don't think the low FODMAP diet does that. I think it's actually the opposite. And that's one of the things that makes it really challenging when we're looking at two different dietary kind of therapies because we're looking at one as a true inflammatory condition and the other one's a disorder of gut-brain interaction. So I actually lean more on gut-brain therapies for those patients or push them probably more than I would with other patients because I think restrictive diets are actually more risky for those patients.

So I am heavily trying to convince people to work in the direction of calming things down and looking at gut-directed hypnotherapy, diaphragmatic breathing, cognitive behavioral therapies, working with sometimes certain medications that are going to help with calming down the nervous system from that side. And that allows me to do more building of foods that are going to support not only the nutrition that those patients are going to need because there's often more nutritional deficiencies especially if we're looking at our Crohn's patients but also what the microbiota needs that we're often taking away within these restrictive diets. So I really fall back heavily in these scenarios on using gut-brain therapies quite a lot actually.

Thank you so much for that, Kim. It's a really challenging space. I've been trying to manage to underbite. I think for so long I had people coming in and saying, "My doctor told me I couldn't have IBD and IBS at the same time." So that's wrong. That's just not an accurate statement that we're talking about.

And we are having the push and pull of, because I always look at it, where do patients fall on the continuum of altered physiology and altered perception?

And they're hitting two different points on there. And so we are really looking at two different things that are both really important around quality of life. And some of the studies are so interesting when we look at health-related quality of life between IBD and IBS.

I would have logically thought that it meant that it had to be IBD because it's such a obviously severe and risky condition. Yet often we're seeing that patients with IBS have more of that symptom anxiety because they don't have options or feel like they have options a lot of the time and their quality of life is so micromanaged.

Yeah, it's a hard scenario for those patients. Yeah, that's super interesting.

We do have a couple more questions. Everyone here about what is the long-term follow-up for gut pitnotherapy? For example, NERVA, once a patient does a six-week program, are you recommending that they do it once a year or the follow-up maintenance program or is it just okay to stop because they're feeling better? Curious to know what you recommend here. Yeah, so I am super clear with my patients that it's going to be the six weeks that they're doing the initial program. It's generally going to be four to six weeks before they're starting to feel very much. But I will note, especially for some patients where you're like, "That's the patient who's going to have a placebo effect right off the bat." I will say immediately, you might start feeling this earlier, but we haven't actually rewired anything in that time period.

It's not necessarily going to be holding on long-term. This is going to be such a big piece of this.

I need you to do the six weeks to the best of your ability to get it done, and then we're going to move you into a maintenance program. With most patients, they've got a lot of stuff that's going on. I do move them into, and it depends on the individual, often two or three times a week. It is something that, depending on the individuals, we do send them emails that are just like, "Hey, we hope you're doing this. Here's the reminder on why you're doing this, why it's an important piece of this," so that we can really help with that. I have not had a chance to go through the new education program that you've done for clinicians, but I did the original one, and I found that some of the wording and ideas on how do we engage patients with this has been really helpful in the courses.

I absolutely do that. Once the year is up, I have had some patients who have done it again, not terribly often after the year is up, but I have been really clear. You have a year-long membership, and there are reasons that it went from six weeks or three months, I think it was, to the full year, because stressors and changes will come up, and there's sometimes that we're going to bring you back into the full program if we need to, because we really want this to be the normal way that your nervous system is going. For the longest time, it has been telling you that everything is scary and hard, and even if it gets boring, and actually I want it to be boring for you, I want this to be your absolute normal.

Yeah, that's cool. I like that statement about it. We want it to be boring. I want it to be exactly what you default to, that you automatically think if I'm trying this food, you can go back to the things that you've learned.

Thank you so much. We do have a question about in-person gut-directed hypnotherapy. Curious about what a one-on-one session with a gut-directed hypnotherapist looks like, and how this differs from that based hypnotherapy.

We know there's not that many practitioners that do it, so it's a bit hard to fully understand what that's like without experiencing it in action. I'm going to say that's the same for me. I'm not 100% positive. I haven't experienced it. It's actually interesting though, because I do have a friend who's done this, so I feel like if I find out, I will try and update around that a little bit more. Maybe someone else knows the answer a little bit better. I know the Rome Foundation, they do have a page that lists who has gone through their programming with this, and that's how I know who is available in Ontario. Because I speak about this, I will get practitioners who will come in, and they're like, "Oh, I have a hypnotist in my office. You can refer patients. We have availability." I'm like, "No, we're not doing that." I want someone who's actually medically trained and has gone through this specific programming that we're looking for. One of the differences, and I have a psychologist that I work with who does the mindfulness-based cognitive behavioral therapy for stress and anxiety. This is one of the things that I hear quite a lot, is that the one-on-one, because there aren't a lot of practitioners, is really great for people who need more care. They've got a lot of extra things that are going on that we would really want that to be there and more of a safety net and everything.

Even within those programs, I think about that mindfulness-based cognitive behavioral therapy. It's an eight-week program. People have once-a-week sessions. They're often a group program that they're doing, and they're there for a period of time. Then they have homework every night at home, because once a week isn't good enough.

That's one of the things that I actually like about an app, is that you just have it there all the time. I'll get some people who will also ask me, "I have calm. I have head space. I think that's amazing."

Here it's directed for this one thing specifically. The other thing I love is you don't have to make a decision on what you're listening to. You just show up and you listen to the thing. We have enough decision-making things. Anyways, the answer is I don't actually know what it's like.

Hopefully someone has a better answer than that. No, thanks, Kibba. That's really helpful. I think it's good to get the understanding that you do get that in-person support, but there is also an element of recordings that are going to be part of your care with the in-person therapy as well.

Cool. This is a bit of a different question. What are your thoughts on adding in homemade kefir to help rebuild the gut alongside brain gut therapy?

I'm someone who's very pro-probiotic and prebiotic food. People make sourdough at home. We see people making their own sauerkraut. I'm not sure that homemade is good or bad compared to store-bought necessarily, but I'm very pro-probiotic foods. I know someone in the chat has asked as well about how I add diet pieces to help with establishing a healthy microbiome with fiber foods.

I do work especially with patients who are really hypervigilant, catastrophizing, avoidant. We start with tiny amounts, so we'll use food chaining as a way to do things. I know this isn't the right example, but if I was looking at egg, we would do an egg baked into something and then they'd have a teaspoon of that food.

We'd eventually move to egg yolk. If we're looking at fiber, if someone who has no gut issues easily one to three tablespoons of something, we might be starting out if they're really afraid with an eighth of a teaspoon or just a sprinkle of something, a level that feels safe to people.

I had someone recently with cheese that they knew they weren't allergic to dairy. They knew cheese is low lactose, but they were still really afraid of it. We looked at the idea that half a cup of grated cheese is a serving, and so we walked it back. I was like, "So could you eat a strand of that grated cheese?" They were like, "Yes, I think I could do that." "Could you do five?" They're like, "No, I don't think I can do that." We settled on three.

We are trying with small amounts, with food chaining, all of that, that building up the microbiota, lots of plant food where we can. I think it's all really important.