The "Dream Team" for Managing IBS-C Needs GI Psychologist and Dietician

GI psychologist Megan Riehl and registered dietician and nutritionist Kate Scarlata discuss how their specialty care can help patients with constipation-predominant irritable bowel syndrome and which patients are the best candidates for clinicians to refer to them. 

Megan Riehl, PsyD, is a GI psychologist and an associate professor of medicine and the clinical director of the GI Behavioral Health Program at the University of Michigan in Ann Arbor, Michigan. Kate Scarlata, MPH, RDN, is a GI dietician in private practice in Boston, Massachusetts.

CLINICAL PRACTICE SUMMARY:

Integrating GI Psychology and GI Dietetics

• Irritable bowel syndrome with constipation (IBS-C) requires a definitive diagnosis and thorough medical workup before expanding care to a multidisciplinary team that may include a gastroenterologist, advanced practice provider (APP), GI dietitian, GI psychologist, and pelvic floor physical therapist. IBS is a disorder of gut-brain interaction with organic components, and no single provider can address all aspects of care within routine visit constraints.

• Nutrition therapy for IBS-C extends beyond elimination diets. The low FODMAP diet has the greatest evidence base (primarily IBS-D, with some benefit in IBS-C), and emerging data support Mediterranean diet approaches and NICE guideline–based dietary strategies (regular meals, moderate fiber, limiting high-FODMAP fruits and certain whole grains). A University of Michigan pilot study suggests a simplified oligosaccharide-restricted approach (beans, onion, garlic, wheat) may benefit select patients while preserving dietary variety. Notably, 77% of surveyed gastroenterologists/APPs reported spending <10 minutes on nutrition education, underscoring the need for dietitians.

• Brain-gut behavioral therapies, including GI-specific cognitive behavioral therapy and gut-directed hypnotherapy, are evidence-based treatments targeting brain-gut dysregulation, particularly in motivated patients without unresolved moderate-to-severe psychiatric comorbidities. These therapies can be delivered individually, in groups (including virtual formats), or via evidence-informed apps to improve access.

TRANSCRIPT:

Hello, I'm Dr. Megan Riehl and I'm a GI psychologist at the University of Michigan, and I'm so pleased to be joined by the Kate Scarlata. Tell us a little bit about yourself, Kate.

Kate Scarlata:

Oh, geez. What an introduction. Yes, I am Kate Scarlata. I'm a GI dietician and I'm based in a private practice outside of Boston, Massachusetts.

Riehl :

So we have the pleasure of really just chatting about what we like to call a dream team. And it's really kind of setting the stage for multidisciplinary care for patients that are living with irritable bowel syndrome with constipation. And so I cover the GI psychology side of things. You certainly cover the GI dietician side of things. We're really going to talk about why that's so valuable in the context of medical care.

So I believe that patients with IBS and especially those with constipation, they need a good thorough medical workup. They need to have a definitive diagnosis of IBS-C, and the team can kind of grow from there. Our advanced practice clinicians certainly play a role. And before we dive into maybe some of the other people that can help, why don't you tell us a little bit about how a patient might find themselves landing at your front door for care?

Scarlata:

Absolutely. I mean, I first want to just myth-bust a little bit. I think sometimes people think in the GI space that just refer to the dietician for specialty diets, and really we do a lot more. In fact, we often are really adding back foods to the diet versus taking away and doing elimination diets. So just keep that in mind. Some patients may come to see us and may need a low FODMAP elimination diet and many people will come to us with that background knowledge and really not be eating enough. And we are really adding to that diet to their plate and making sure that they're eating balanced meals and enjoying food more. So patients will come to me and I'm looking for a number of things. I'm looking, is there any accelerated food fear? How are they eating? What are they eating? Are they eating stressed and on the run? Because it's not just what you're eating, it's how you're eating. And we want to really engage that parasympathetic nervous system and really have them rest and digest when they're eating.

So there's so many things that we do. And we know that advanced practice providers and gastroenterologists simply don't have enough time to do this full assessment in nutrition education. In fact, I did a study with Dr. Chey at U Michigan where we surveyed gastroenterologists and advanced practice providers to get a general sense, how much time were they spending on nutrition education? And 77% were spending less than 10 minutes. And I applaud you for putting that time in because that's amazing. But on the other hand, patients really need a lot more handholding to really get an idea to add all these nutrition trips up, edit all these nutrition tricks onto their daily plate. How about you, Megan?

Riehl :

It's a great point. Yeah, I was just going to say that similarly to the things that I do, we can't expect that one provider is going to handle all aspects of care for a person living with IBS, that we know now it is a incredibly complex disease or disorder. And we were actually just talking how it's actually organic. We tend to say IBS is not an organic disease, but it actually is. It's organic. It's moving through our body and there are a bunch of different factors that can impact one living with IBS, therefore why so many different potential treatment options need to be available for a patient. So we can't expect that a gastroenterologist or a primary care doctor or an APP is going to be able to cover nutrition therapy in their visit, nor would we expect them to be providing brain-gut behavioral therapy, which is really what my bread and butter is.

So what is most beneficial is that a medical provider is teeing up a referral to a GI psychologist. Similar to your myth, my myth bust is that a GI psychologist is not like a last ditch effort. We don't know what to do with you. Your IBS is in your head. That's not at all where we're at or where the science is at now. IBS is a disorder of gut-brain interaction and that very strong pull between the brain and the gut impacts how a person experiences their IBS and how we treat it. And so when a gastroenterologist or APP can help a patient feel validated with their definitive diagnosis and that a GI psychologist is just another member of the team, like the dietician, like the pelvic floor physical therapist, like the acupuncturist, that we are all working together. That really helps with patient buy-in and understanding as to then what treatment modalities I may suggest to that patient.

And so then just a little bit of differentiation between what a GI psychologist does and a general mental health provider does. If a patient is really suffering with more moderate to severe anxiety, depression, trauma, eating disorder, before sending them to somebody like me, we want to really connect that patient with the appropriate mental health provider who can deliver that psychological intervention to help stabilize that patient's symptoms. Research shows us that our brain-gut behavioral therapies are not as effective if a patient has these kind of unresolved psychiatric symptoms or diagnoses in place.

And it also can be very frustrating for a patient to make that suggestion to go see a GI psychologist, and then we have to be the ones that say, "Actually, I'm so very sorry, but I now want to connect you to a trauma-informed therapist or to an eating disorder specialist." So for the appropriate patients, these are going to be the ones that they're very interested in working at that brain-gut dysregulation. They have insights into how stress may affect their symptoms. Maybe they've been through a life change and they've noticed that that's impacted their symptoms and the life change is maybe stabilizing a bit, but the GI symptoms are still prevalent. And so that patient who's motivated, they're insightful, they're really looking for another treatment option for themselves. They can be a really good candidate. The patients that really identify stress impacts my symptoms, I have this pain that happens.

Sometimes patients that are really avoiding food, but don't yet meet the threshold for an eating disorder diagnosis, that can be a great patient where we may tag-team with the dietician as well as myself and the gastroenterologist to help address the food-related anxiety, maybe some of the food-avoidant behaviors, while a dietician can be providing some insights and suggestions into some gentle foods that we can really work to optimize or maybe working on reintroducing regular eating patterns into a patient's life. So there really are opportunities for, again, that teamwork and collaboration for patients, but it's really, I find such a rewarding job because our treatments tend to be pretty short term and they really are targeting the roots of IBS, which are brain-gut access dysregulation. So I think we could probably talk forever about this, but Kate, what do you think patients really benefit the most from when they're coming to see a GI dietician?

Scarlata:

Absolutely. I think really understanding, getting a good history, understanding potential food triggers; dieticians use a lot of art and science. So we have really so much information to look at something and go, "Oh, I don't think it's the gluten. It might be the fructans," and really tease out some of these different food triggers that someone that's not doing this day-to-day might not really connect. Patients want to see a dietician. They're very interested in nutrition, so don't be afraid to refer. Most patients with IBS do have food-related symptoms. They have post-prandial symptoms and want to see a dietician. The patients that might not benefit from a GI dietician are those that have an overt eating disorder, and you're very concerned about their nutritional and mental health status relating to this eating disorder. In that case, you really want to refer them to an eating disorder expert, a therapist and a dietician that has that layer of expertise that not all GI dieticians have.

But when they're coming to see me, we're talking about adding two green kiwi fruit to their smoothie, how they might not like kiwi, but A, they don't see it or taste it really in a smoothie. I'm going to give them tip and tricks again to really incorporate foods that they enjoy, but that will work towards their constipation management. I'm also going to be very in tune if they're eating more, a lot of fiber and the fiber's not really working for them, or the doctors prescribe laxatives and they're not really working for them. Is this a conversation with the provider to say, "Hey, could there be pelvic floor disorders going on? Do we need to bring in another team member to assess for this because I'm seeing certain things that are clinically showing there may be some issues?" So that collaboration with the team is so wonderful.

It's one extra person to really help identify and lead the patient in the right path.

Riehl:

And you hit, I think, an important point that a lot of times if a patient with constipation is dealing with pelvic floor dysfunction, our therapies probably aren't going to be as effective either. And so us really being keyed in to the patient experience, applying some of our therapies and taking note of how things are happening, that's another team member that really can play such an important role.

You've discussed these nutritional therapies that really have a lot of really great evidence and research to support them. And some of the behavioral therapies that I'm using with a patient also are very well supported in the literature. The two most commonly used brain-gut behavioral therapies are GI-specific cognitive behavioral therapy, where we're working on that GI-specific anxiety and avoided behaviors and catastrophization, as well as gut-directed hypnotherapy. And I could launch in for much longer than we have today on the benefits of gut-directed hypnosis, but it is an evidence-based strategy that's been around for a very long time with very high rates of improving symptoms in patients that are refractory.

And our research has also shown that these therapies can be delivered one-to-one, personalized. And I think reserving that for your patients that may have a vast number of comorbidities that they're dealing with, and we really do need to personalize that care. These therapies though can also be delivered in group settings virtually, and there are some app products out there that are using evidence-based informed protocols. The key is improve access to care because as you said, patients want to work with a dietician, they want to work with a GI psychologist, and it's really been a true passion for you and I together to increase the knowledge and the benefits of this Dream Team approach.

Scarlata:

Absolutely. And I appreciate that you're talking about evidence-based approaches here. And when it comes to nutrition, the low FODMAP diet has the greatest evidence. Most of the studies have incorporated IBS-D patients, but there have been some studies that have shown that it's beneficial for constipation-predominant patients as well. We also have emerging research suggesting that in some patients, the Mediterranean diet can offer symptom benefits and quality of life benefits, but it does not work across the board. So there are patients that can feel better and then others that really feel worse. And then the NICE guidelines, IBS guidelines from the UK, have some level of evidence. And really these guidelines emphasize eating discreet meals, not skipping meals, not overdoing fiber, limiting fruit, which is rich in some FODMAP carbohydrates, not having a lot of whole grains. So just general, what we call, and we use in the ‘Mind Your Gut’ book is a diet cleanup. And that's sometimes just enough for some patients.

And more recent research has shown, it was just a pilot study out of U Michigan, but that a more gentle approach or simple approach to restricting FODMAPs also can be beneficial in a subtype of patients. And what I really like about this diet is it only restricted one FODMAP subtype, which is the oligosaccharides, your beans, your onion, your garlic, and wheat. And so far less restrictive than the full elimination diet, which really allows for greater food variety, which I'm all about. That's always my goal is for people to eat as much food as possible with good symptom control. So there's evidence and there's growing evidence for both behavioral therapies and nutritional therapies and your dieticians and GI psychologists, we're out here and we want to help you help your patient feel their very best.

Riehl:

That's right. You mentioned our book, ‘Mind Your Gut: The Science-Based Whole Body Guide to Living Well With IBS.’ We also talk a lot about IBS on our podcast, the Gut Health Podcast. And that's the key is making sure that you're connecting your patients with science-based information because a lot of patients living with IBS, they're digging. They want to feel better. They want to feel hope that they can feel better. And sometimes that can lead down a really tricky road of snake oil and fad diets and restriction. And really that's the key for patients that are living with IBS is to open up as much of the world back that maybe they've been avoiding and with the right tools and strategies and the team, that can certainly happen. So happy to talk about this topic and take care of patients.

Scarlata:

Absolutely. We're in it together.

Riehl:

That's right.