Season 3, Episode 16: The IBS & IBD Overlap
Welcome back to The Gut Show! I'm your host, Erin Judge, and today's episode is all about IBS versus IBD. So we'll talk about the similarities, how they might overlap, the differences, and the diet therapies and treatments that are available for each. For today's show, our special guest is Neha Shah. She is a registered dietitian, a certified nutrition support clinician, and a certified health education specialist that has been specializing in gastrointestinal and liver health for the past 15 years.
Neha is an expert in the field, and she breaks down some things to think about with these conditions from a medical side, but also from a practical nutrition application side. So if you relate to this at all, or maybe you're just now figuring out what might be going on in your gut, you're gonna find value in this episode!
As always, join us at The Gut Community on Facebook if you have any thoughts or questions that you want to share after today's episode, enjoy.
Today’s episode is sponsored by Seed. Their signature product, the DS-01™ Daily Synbiotic, is a combination of science-backed probiotic strains and prebiotics that work in synergy to promote healthy digestion, ease of bloating, glowing skin, and more. You can learn more about Seed and the Daily Synbiotic at www.seed.com. Use my code erinjudge15 for 15% off your first month's supply.
Erin Judge: Neha, thank you so much for joining me and for being with us! Let's go ahead and jump in with your story. So how did you become a dietitian and then how did you also become a dietitian specializing in gastroenterology and digestive disease?
Neha D. Shah: Absolutely! So first of all, thank you so much for having me here today, I am definitely looking forward to our conversation today. And sure, I guess we'll start off with that I have always been fascinated with how nutrients from the diet are digested, absorbed, move the motility through the gastrointestinal GI tract. Even more, how I can manipulate the GI tract to help my patients have less symptoms while expanding the diet, that has been even more fascinating.
When I had the opportunity to take on the GI surgery floor when I was at Stanford Healthcare many many years ago as a newbie, entry level dietitian, I jumped at the chance. And there I counseled patients recovering from GI surgery. Maybe they had gastric, also known as stomach cancer, they had their stomach removed, or they were they had gotten a new ostomy because of IBD or colorectal cancer or maybe they got part of their pancreas removed because of pancreatic cancer or pancreatitis. So overall, it was just a really enjoyable experience, I looked forward to going to work every day. A gastroenterologist there once told me that the GI tract belongs to the gastroenterologist and dietitians. And I was thinking about it and I think I agree, what a supportive comment to make!
From there, I moved into the Digestive Health Center to start and build nutrition services for the GI and liver clinics. It was a role that I really dived into! I developed protocols, made handouts, taught fellows, and got into counseling patients. It was really counseling on a variety of other diagnoses beyond the surgery floor such as celiac disease, gastroparesis, IBS, IBD, SIBO, and pancreatitis. As a part of that role, I was also responsible to codevelop the outpatient nutrition support and intestine rehabilitation programs.
The outpatient nutrition support program is where I provided care and coordinated all home care for patients getting nourished through a feeding tube or on parenteral nutrition, which is IV nutrition. The intestinal rehabilitation program is where I provided care to those who have short bowel syndrome, including those with IBD that had also short bowel syndrome, I loved it. This is where I really saw the benefit of specialized and complex nutrition care, and helping those with that had a significant amount of intestines removed to eat more while reducing symptoms and getting off parenteral nutrition, just getting back to life. And overall, I just wore so many different hats in the GI and liver nutrition space that just really led to an extensive specialty in GI. I am grateful for all the experiences there as they really shaped me into the GI dietitian that I am today!
Erin Judge: That's incredible. And you're definitely one of the leaders in our field!
Neha D. Shah: Oh, that's always good to hear!
Erin Judge: Yeah, absolutely! And what you're bringing up in your story I think is so interesting. And those listening, especially those who aren't dietitians or healthcare providers, like it's easy to think that digestive health nutrition is all about what we see on Instagram of eat more fiber and drink water and move your body, like the fun stuff that we do and even the stuff that I talked about, but what you're breaking down is how complex the role of the dietitian can be, especially for conditions like short bowel or surgeries and cancer and IBD, which is inflammatory bowel disease. And so I love that you brought that up because it's easy to think, oh, like a dietitian just tells me what to eat. It's like no, so much more complex than that. Do you want to share anything kind of about that?
Neha D. Shah: There's definitely a science behind this, I can't stress enough that I use the knowledge of how nutrients are digested, absorbed, how they move through the GI tract, the role of the different enzymes and hormones that play a role in all of that, how each organ has its own function and what it does in the digestive tract, all that knowledge, I factor that in when I'm counseling my patients and I explain that to my patients as well. It's always important to understand that process before I go into a plan of why I'm recommending certain foods or certain portions of foods to help them feel better.
I would have to say, I always tell my patients that the gastrointestinal tract is one long tube and they all somehow communicate with one another. So it's really important, again, to understand that process and the science behind it, and a GI dietitian is not just counseling on one medical condition associated with the GI tract. I have worked with patients that are diagnosed with multiple GI disorders, like gastroparesis, celiac disease, fatty liver, all in one person or someone with IBD, with short bowel that has an ostomy. So again, I feel very comfortable in counseling my patients when they come to me with complex multiple diagnoses, because I feel like I possess a really good understanding of the GI tract.
Erin Judge: Yeah, definitely helps you personalize right, because each of those have to meet a personal plan and while it might look on the outside similar, the specifics are what's different and how you address it because of those complexities, right?
Neha D. Shah: Absolutely, yes.
Erin Judge: Which is the value of having a dietitian! I had someone ask why do GI doctors not provide all of this information and GI dietitians are fit for that role, because you have the ability to develop all of that knowledge, but also put it into practice and turn it into a nutrition recommendation, not just the knowledge, but also the actual recommendation and the practical application of the recommendation. I’m biased, I think dietitians are the best for that reason!
Well, I know some people listening might connect to that of like, oh, I'll have short bowel or I have fatty liver, I've got all these conditions, our focus today is going to be really about IBS and IBD, we're going to hone in on that, but if you are listening and your brain is going off, because you connected to something that Neha said, show notes, connect with Neha, ask questions. There's a lot of ways to connect and learn more about those different things and how the dietitian can connect with you and play a good role.
As we go into IBD, so one of the big things that we see with IBS and what I see online is this misunderstanding of what IBS is compared to IBD, how they're connected or how they're not connected, and then how they’re treated right, because they're two acronyms that go together and it's just one letter different. So I would love for you to break down what IBD actually is, how it's diagnosed and how it's different from IBS as well as maybe how there could be some misdiagnoses or how they might fit together.
Neha D. Shah: Absolutely. So first things first, inflammatory bowel disease, IBD, is an inflammatory disorder. It consists of inflammation in the GI tract of which the most common types are Crohn's disease and ulcerative colitis. Other forms may also exist, including collagenous and lymphocytic colitis.
Crohn's disease involves inflammation anywhere along the GI tract from the mouth to the anus. Inflammation in Crohn's disease may look like lesions or ulcers, could incur in some areas as patches, and may go deep in the lining of the GI tract. Complications from Crohn's disease may include fistulas and strictures. Fistulas are, the best way I can describe it is it's a connection between two different areas of the body that's not supposed to be there, like the gut to the skin and strictures refers to a narrowing of the GI tract of some aspect.
The inflammation found in ulcerative colitis is located in the colon, rectum and anus only. Inflammation may appear on the surface of the lining in the colon. It's really more continuous inflammation without patches. Symptoms may include abdominal pain, diarrhea, constipation, gas, bloating, and cramping.
IBD is diagnosed through an endoscopy or a colonoscopy with biopsies and imaging studies that can really confirm like a visible presence of inflammation and its location in the GI tract as appropriate. There can be an increase in inflammatory markers such as C reactive protein, also known as CRP or stool Fecal Calprotectin to really assess for any inflammatory markers there. It is important to diagnose the type of IBD to really help determine appropriate medical and nutrition treatments.
Now with IBS, irritable bowel syndrome, on the other hand, is really considered to be more of a functional disorder. There are no visible signs of inflammation seen in IBS, but there is a change in the function of how the GI tract may work and it may not be visible through endoscopy or colonoscopies or imaging studies. There are currently no laboratory or procedural type tests available to diagnose IBS. IBS is diagnosed with meeting symptom criteria using the Rome IV criteria for abdominal pain related to the passage of stools, either with a change in frequency or consistency of stool that has really have been occurring at least one day in the week for the past three months with onset of symptoms for at least six months ago.
There are several types of IBS. IBS-C for constipation-predominant, IBS-D for diarrhea-predominant, IBS-M for mixed bowel movements, and IBS-U for unspecified. The Bristol stool chart is used to determine the stool appearance and to help really classify constipation as types one and two, normal as types three and four, and diarrhea as types five, and seven.
IBS and IBD definitely can be present together, as well, the symptoms of IBS and IBD may overlap, there is just so much potential for misdiagnosed because of the symptoms that may overlap. And for those with IBD in remission, I know just from my conversations with my patients, they may get concerned that their active disease is back again, and it really concerns them. So again, it's really important to, as the symptoms come up and about, work with the medical team to really evaluate these symptoms. Any red flags, such as weight loss that did not happen on purpose, bleeding from the rectum, or the presence of anemia, should all be evaluated before the diagnosis of IBS is made.
Erin Judge: That's a good point. And that's always something to bring up with your doctor, like those specific details that have happened in your history, like really highlighting those, because the provider should ask, but they may not, they may miss that and it's really important.
One thing that you mentioned there is that in remission, those with IBD may actually have more IBS like symptoms on dealing with. We know that there's no cure for IBS, and there's no considered cure for IBD, correct?
Neha D. Shah: Correct.
Erin Judge: You have remission, which we don't really have for IBS, even though we may have like a state of symptom management. I’d love for you to talk about what remission for IBD actually means?
Neha D. Shah: Absolutely. So remission in IBD means that overall, there's no visible signs of inflammation in the GI tract. There are three levels of remission in IBD. There's the clinical remission, where there is like more of what we call symptom resolution. The symptoms are not present there, but there still could be active inflammation in the GI tract.
Then we're looking for endoscopic remission where we're starting to see some findings of healed areas of the GI tract, but there is still presence of inflammation, but we're progressing towards healing and that's really looking at the surface level of the lining of the GI tract.
Then we have what we call a histological remission. It's really taking a biopsy of that tissue in the GI tract and assessing for inflammation through that. So we're aiming to achieve remission through all of that and this is really why we really need the help of the medical team to help us learn whether remission is in progress or if it's not, then we need to fine tune any medical treatments, or nutritional treatments or look into to see what we can do to help with that.
Erin Judge: Yeah, that's a good, helpful understanding of how that works. It's like an inactive disease. It's not gone, it's not cured fully, but it is inactive or less active and then maybe the symptoms that come after that may not be due to the disease but maybe due to the IBS like piece that can have an overlap.
When we're looking at nutrition and the role of nutrition, we already talked about how personalized it is, so I know there's going to be some nuance there, but what are some of the similarities and the differences seen in nutrition concerns between IBD and IBS?
Neha D. Shah: Absolutely, and that's a really important question. The similarities in nutrition concerns between IBD and IBS is that intolerance of diet is there between the both. There are multiple GI symptoms present in both as mentioned before abdominal pain, diarrhea, constipation, sometimes both at the same time, gas, bloating, and cramping.
The difference is that in IBD, additional concerns might be present, such as blood in stools, and ulcerative colitis, perhaps vitamin and mineral deficiencies seen in both Crohn's disease and ulcerative colitis, such as iron, folic acid, vitamin B12, vitamin D, and zinc. Malnutrition can be present in both IBD and IBS, however, the cause could differ. Malnutrition involves ongoing issues with decreased intake from diet, weight loss that did not happen on purpose, and certainly presence of symptoms. As I mentioned before, that can lead to an intolerance to diet, the loss of muscle and fat stores, changes in the level of physical activity, and certainly in IBD, inflammation is a significant cause of malnutrition, and inflammation may damage the lining of the intestines and therefore impairing digestion, absorption, and motility of nutrients. The impact of malnutrition is based on the segment of the bowel that is involved, how severe the active disease is, and how long the IBD has been present. Malnutrition occurs more often in Crohn's disease, which is about 65 to 75% in Crohn's, which is a high number, however, it can also be present in ulcerative colitis, which is about 18 to 62%.
Where IBD may share with IBS is that malnutrition can also arise due to beliefs and fears that avoiding certain foods may worsen symptoms. The self-imposed food restrictions due to fear can be significant enough, where multiple food groups have been removed from the diet, leading to eating much less, there's a lack of variety with foods and nutrients to stay fully nourished.
So overall, it's really important to tell the medical team, to work with a dietitian if there are fears with food. It's so valid when we're dealing with symptoms like this. Healing the relationship with food is just as important as reducing symptoms physically, and certainly having a dietitian as part of the team maybe along with a psychologist to help address some of these fears will be beneficial.
Erin Judge: That's great, and when we're thinking about food intolerances, I think something to pull together, just clarify, you mentioned because of the inflammation in IBD and the damage that's done to the GI tract, that's the cause of the malnutrition, that's the cause of potentially the food intolerance. Food is not the cause of IBD, right?
Neha D. Shah: Yes, that is correct.
Erin Judge: So food is not going to reduce inflammation. It's not gonna like be the cure, because it's not the cause. But food might, especially in the short term, while we're going towards remission, be a problem, but as we deal with the cause, hopefully, we are able to see more variety in the food and more tolerance of the food, correct?
Neha D. Shah: Absolutely. And one thing I can also add is that there's a lot of interest to use diet to reduce inflammation, it's really something that what we call the presentation of IBD is so different from one person to another, that, you know, even though there are some studies showing that diet can help reduce inflammation or reduce the inflammatory markers or reduce symptoms, but again, it's not, it's not repeated from one person to another. So, again, the use of diet, you know, to help address these nutrition concerns is very important, but it's not the only therapy on the table for IBD. Where, you know, with IBS we're not seeing any visible signs of inflammation, where the goal of IBD is we need to really bring down this information to help address the many of the nutritional consequences that are occurring from that.
Erin Judge: Yeah, I have a theory on this and I wonder if you feel the same? Instead of the food decreasing inflammation, and we know it doesn't really do that, so this anti-inflammatory way of eating that we know is healthy, but instead of it decreasing inflammation, my belief is that it properly nourishes and supports the body to then work to decrease the inflammation, right, would you say this?
Neha D. Shah: Yes, correct.
Erin Judge: So it's like proper nourishment, which dietitians, it's what we focus on is like, nourish the body, nourish the body, nourish the body, and what you're mentioning with IBD, based on where the disease is present, and based on the state of inflammation and state of damage, that nourishment might be more personalized. And then those with IBS, you know, we talked about inflammation may be contributing to poor intake or poor absorption of nutrients, with IBS, that functional piece might be contributing to the food intolerance,
Neha D. Shah: Absolutely.
Erin Judge: So in the similar way you deal with the cause of the inflammation, the disease or the functional problem, and then you can improve the tolerance of the food and nourish the body.
Neha D. Shah: 100% yes!
Erin Judge: Which is, I think, you know, when we go down to well, what's the one thing you should do, or the one thing that you should eat? It's not that simple, there's some patterns and steps that we have to take to get there. And I know you see that on another level with the specifics that you work with.
Neha D. Shah: Absolutely. And then one thing I can add is that, you know, IBD it really also, factor in all the complications that are there or not so someone who's newly diagnosed, they may have a different level of tolerance to foods where another individual with, like, say, Crohn's disease, who has strictures, maybe how we work with diet and nutrition might be different, or another individual with a Crohn's disease or ulcerative colitis who had significant surgery to remove that disease, bowel, how do we eat with an ostomy? Or how do we eat with short bowel syndrome? How do we eat when there is a significant amount of intestines removed? Like, so much goes into determining that plan for nutrition, so it's really important to understand how this IBD is, like, I guess presenting itself in this in this individual's standing before you.
Erin Judge: Yeah, absolutely. If someone's living with IBD, that's the value of having a dietician working closely with you, as part of the team, not even someone fully disconnected, but someone who really is part of the full team, knowing exactly what's happening, who's doing what, like how that's gonna impact you, so that you can get that care and you're not feeling lost in space, trying to figure out
Neha D. Shah: Nutrition care is chronic care in IBD and IBS, actually, you know, we need to be able to what are the outcomes we are looking for? Are we looking for a one-time visit?
Erin Judge: And then you factor in the relationship with food, variety and diversity, and you know, travel, it's like all of the things that come after. It's never that simple. We've already kind of started talking about this a little bit, but as a dietitian in this space, what are some of the diet misconceptions you see with IBD and with IBS that you really dispel with some of your patients?
Neha D. Shah: Oh, definitely front and center that there's no need to limit fiber. Traditionally, a low fiber diet has been often recommended during the course of a flare or active disease. There are very limited studies to support a low fiber diet. Studies have shown that a high fiber intake, especially through fruits and vegetables, may reduce the risk of developing IBD as well as reduce the risk of reoccurrence. So, fiber is going to be you know, front and center as I mentioned. Foods with fiber are often seen as one in the same whereas not all foods with fiber are equal to one another. The properties of fiber include solubility, fermentability, viscosity, and these properties determine how the fiber may function with the GI tract. So using the same knowledge, the properties of fiber are considered when modifying the diet to include the type of fiber to help reduce some of these symptoms like the diarrhea or the constipation or gas or bloating.
Erin Judge: That's a big one. And that's so interesting, because we do even hear that even from some dieticians, right, like that is something that I think is still recommended and I'm sure also by some GI providers that may not have a dietitian very closely tied to their team may actually still recommend low fiber, when that isn't gonna have the best outcomes according to research. Are there any others? I know we talked about, obviously, food isn't necessarily the cure, but anything else that you see, especially in the IBD world that may not actually be accurate?
Neha D. Shah: On the top of my head, no, I think it's because I have a conversation on fiber every single day with my patients with IBD that that is what really was front and center for me. I would have to say that other misconceptions, you know, that have come my way that you know many of my patients with IBD have gone dairy free. There is some discussion out there that dairy may cause inflammation. We haven't really come across any significant data for that. If there is an intolerance to dairy, then I tend to look deeper into the lactose. Some of the research studies have shown that the enzyme lactase is produced in sufficient quantities, it's not fully clear why those who reported intolerance to dairy have an issue with dairy. But then I find that most people can tolerate dairy in very small amounts and if that's the case, I tend to start with dairy that's lower amounts of lactose, like hard cheeses, or a lactose free milk, treat it like a sprinkle or a slice, not the main entrée, and that can be potentially helpful.
Other diet aspects have come my way, many have been going gluten free with the belief that gluten can also contribute to inflammation, we haven't come across a significant conclusion that is the case as well. Some of the studies have shown that, you know, patients with IBD do feel better when they eat less gluten and if they do feel better with eating less gluten, I think that's okay to continue, however, it's important to have, you know, a mix of different foods in the diet, a mix of the different food groups in the diet to really get all the nutrients that we need to stay nourished. So, you know, a common recommendation I'll make there is that can we have a mix, you know, to really bring in a variety of grains such, similar to the notion that we may recommend a variety of fruits and vegetables or variety of grains to help reduce any symptoms that could be potentially associated with gluten as well.
Erin Judge: Yeah, I love the recommendation of diversity to bring down loads of certain nutrients versus it being full exclusion, I think it's more valuable for the people who are living through it but also as a provider, you're providing actual resources of how to get the nutrients in versus just exclusion of nutrients, which I think has been the past, right? Exclude FODMAPs, we exclude this versus how we want to approach it now, which is diversify, add this, incorporate this instead, or, you know, build in more variety.
Before we get into some more kind of nutrition approaches, one thing that just came across my mind, I'd love to hear your thoughts in regards to IBD. There is some new upcoming data, right? It's emerging, it's not conclusive yet. It's interesting and I think we're gonna learn more in the coming years, but looking at even the slight immune reactions that we might be seeing in IBS, I don’t know if you’ve seen this recently, that there might be like a slight immune reaction happening, which might also highlight the need to kind of consider allergens and like, look at that in certain patients with IBS. Do you see any kind of immune responses to allergens with IBD, depending on where the disease has been present, or even the response to the disease and fighting off the disease? Is that something that you've seen in practice?
Neha D. Shah: That's a really good question. I haven't come across any significant data for that, but it's definitely something I'm going to look up. I think that would be helpful to learn a little bit more. With that said, I haven't come across any significant data from my understanding,
Erin Judge: Yeah, we need so much more, we need more research!
Neha D. Shah: We definitely do. I definitely think that diet plays a role, we don't have a full understanding of what that role is, but we're learning more and more whether it's alterations in our gut microbiome and, you know, changes in diet from a higher fiber intake into a lower fiber intake, which again, can possibly lead to alterations like gut microbiome, that may promote the growth of certain types of bacteria that may promote some aspects of inflammation injury upon the GI tract, environmental genetics, I mean, there's just so many different factors that come into play when we're looking at the causes of the IBD and IBS. So it's definitely not just one single contributor.
Erin Judge: Absolutely, just personalization, individualization, and hopefully more technology, the money towards nutrition, science, and not just pharmacological research, which is also great, but we need some research to support or dispel certain things that we do. In terms of what is evidence based, going off of what is evidence based, or even just in your practice, because you've been doing this for a while, you've worked with different patients, you've had to get creative. What are some of the nutrition approaches, especially the newer ones, or maybe unique nutrition approaches that you use for treatment and management of IBD and IBS?
Neha D. Shah: Absolutely. So one aspect is the nutrition treatment for IBD depends on the type of IBD present and whether there's evidence to support the treatment in IBD. The same thing with IBS, you know, the nutrition treatment for IBS is depending on the symptoms present, and then how we can use, you know, what medical nutrition, psychosocial aspects that we can look at.
Looking at diet and IBD, there are so many diets out there that are proposed to treat IBD, such as a specific carbohydrate diet, a low FODMAP diet, the Crohn's disease exclusion diet that just came out maybe two years ago, three years ago, the Mediterranean diet that all have different food lists and claims of how this diet may assist. However, as I mentioned before, IBD presents itself so differently in each individual that the nutrition alone is not recommended to be the sole therapy for IBD, but to be used in conjunction with medical treatment, as fiber is recommended to be included in the diet. And that's the similarity I see with a lot of diets, they focus on bringing in the fruits and vegetables, some diets focus bringing on more legumes, maybe less grains. I tend to look at the similarities between all the diets and they'll be like, okay, this is how I can coordinate with my, you know, the person sitting in front of me how I can help them with their diet is this fiber. So, diets that include the food groups with fiber at each meal, especially fruits and vegetables is really what I like to encourage.
And then certainly when it comes to asking about nutrition treatment with the team, you know, the questions I can encourage is, it's not just to focus on oh, I heard this diet can help me from XY and Z, you know. What did the studies say about this particular diet? What is the proposed mechanism of how this diet may help or not help. What foods I can eat more of on this diet? And I say, eat more, because we have this common practice, what I've seen over the years, and what do we need to take away from the diet? And it's really also focused on what do we need to add more of to help, you know, address the symptoms in the treatment of IBD or IBS? Or how long do I need to follow the diet? Is there risk for any deficiencies? What are some nutrition perimeters that will be monitored while I'm on the diet? Weight changes, symptoms, vitamin and mineral labs? And then finally, who can help me learn more about my options, my approaches and how to implement it? That is the key. Information is easily available on the internet, but is there a registered dietitian available to help me understand how I can develop a system or systems around this diet to be successful with it?
Erin Judge: Absolutely. And getting that extra bit of guidance over like the personalization that we mentioned is because every diet that's recommended is not one size fits all, even think about like the low FODMAP diet for IBS. Like yes, it has research behind it, that doesn't mean that that alone is one size fits all for every single person who's living with IBS.
Neha D. Shah: Correct. Absolutely.
Erin Judge: It’s more that every person who does low FODMAP diet will do it in a way that's best, because there's nuance to it right? There's just so many pieces to diet and even lifestyle and how we think about food and fears around food that can make such a big difference and that's really going to be found the most with that one to one care versus just what you read online because there's not a lot of resources that can take into account all those different pieces.
If someone's listening right now, so I think that I know what you're going to say because there's been a common thread, but if someone's listening and they have IBD or IBS, what could they do to modify their diet and other lifestyle aspects now to better control their symptoms?
Neha D. Shah: So with the focus on fiber, I'm always going to bring the focus back to fiber just because again, I just seen so many eliminate entire food groups of fruits and vegetables and grains and legumes in order to eat less fiber, this is really not needed. What is needed is to really determine what type of fiber, what texture of fiber, such as blended or mashed or minced, what portions of fiber that can be eaten in the diet to help reduce symptoms. For example, if there is diarrhea, you know, along with gas and bloating, additions of soluble fiber, which can help possibly thicken that stool, they’re are also low fermentable, which can be you know, less gas producing such as unripe bananas or kiwi or potatoes or chia pudding or oatmeal that can be brought more often in the diet and not contribute to the symptoms. While insoluble fiber or raw vegetables and nuts, none of those foods need to be out of the diet, but it can certainly be eaten in smaller portions. Maybe not every day really depends on the diet and the symptoms to help reduce the diarrhea as insoluble fiber may speed up the passage of stool, so it's highly individualized, so it's really important. It's really not a question of low fiber, high fiber, I don't get caught up with the numbers. I focus on the type of fiber and the portions of fiber to really help bring the symptoms down.
Erin Judge: That's exactly what I thought you would say. That's been the common thread, right? Fiber, inclusion of fiber, personalize how you're intaking fiber and also have a process and a plan, like you mentioned with a dietitian.
Well, I know that we have a few resources for those with IBS and IBD in our show notes, we also have your website and how you can connect with her on social media, but is there anything else that you want to share or anything else you're excited about with new research or just anything else for our listeners?
Neha D. Shah: I think one thing I can add that, you know, the symptoms are…my approach here is, it's gonna be more of a holistic approach where it's not just a diet that can influence the symptoms. What are some of the other influences on the gut that can also worsen symptoms, you know, like a non diet way to help control symptoms is enhancing stress management. Stress is inevitable, like, it's part of our day to day lives. It's not saying to avoid all stress, that's not realistic, but as there is a connection between the brain and the gut, finding ways to cope with stress, with mindfulness, incorporating self care, finding ways to do enjoyable activities can help calm down the gut. As an example meditation, in some studies for IBS and IBD, has been shown to reduce anxiety and symptoms and improve quality of life, again, in both IBS and IBD. So how do we bring in a non diet approach with that and non medication approach to help with that to help reduce the symptoms. So, again, overall, when it comes to producing these symptoms, diet is just one piece of this, but looking at ways that we can work with stress, or how we breathe or even, you know, enhancing our sleep quality is all going to be very important.
Erin Judge: Absolutely, I agree with you 1,000%, as many percent’s as possible, I definitely agree. If there's only one option, like that's just not how it works, right, because the body is complex, and there's a lot of different needs that we have, there's also a lot of creativity that we have with managing conditions and even treatment, so making sure to ask for those options and find people who are going to help you develop those options. If someone is listening, and they're really interested in your approach, and maybe have IBD or short bowel or some of these complex issues going on, how could they work with you?
Neha D. Shah: Absolutely. So for one, I do have a website. On the contact page, there is a link to schedule a preliminary complimentary call with me. I always like to offer this call because it is important for me to learn what the concerns are. I want to see how I can help, I want to understand the pain points and frustration, I'm here to answer any questions about my services before we move forward with a formal appointment. I certainly don't want to use the first appointment with me as the first time I'm learning about all of this, you know, so I feel like that's important. And then from there, we can see if we're a good fit and if you feel like hey, this is something that I really want to move forward with, then we'll move forward with setting up sessions.
Erin Judge: Awesome. And I have that link in the show notes if you're like, oh, I definitely want to jump on that, the link is there as well as Neha’s social media. Thank you so much Neha, this has been really helpful just to get a better understanding of the nuance of IBD and IBS nutrition considerations and just thoughts to have as well as approaches that we can all take. I appreciate you sharing your wealth of knowledge with us!
Neha D. Shah: Thank you for having me here today!