Body of Wonder Podcast

Episode #17 The Low-FODMAPs Diet with Dr. Peter Gibson

Irritable Bowel Syndrome (IBS) is one of the most common gastrointestinal disorders, affecting more than 10% of the population. Symptoms include chronic constipation, diarrhea, or acute abdominal pain a short time after eating. The unpredictable and disruptive nature of these symptoms along with their emotional toll can lead to heightened levels of stress, which in turn, may worsen symptoms.

Our guest on this episode is Dr. Peter Gibson, Professor and Director of Gastroenterology at The Alfred and Monash University in Australia. Prof. Gibson’s clinical research has revealed a surprising link between certain carbohydrates and gut dysfunction. On the episode, he explains how FODMAPs (which stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols) slowly digest in the gut releasing gas and drawing in excess water thereby interfering with normal GI function. Together with his research team at Monash University, Dr. Gibson has developed the Low-FODMAP Diet which temporarily eliminates certain foods thus preventing fermentation and providing relief to sensitive colons.

Drs. Weil, Maizes, and Gibson discuss the ins and outs and complexities of following a low FODMAP diet and the value of this useful tool for relieving the symptoms of IBS as well as other GI disorders.

Please note, the show will not advise, diagnose, or treat medical conditions. Always seek the advice of your physician or healthcare provider for questions regarding your health.


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Guest Bio

Peter Gibson
Peter Gibson is Professor and Director of Gastroenterology at The Alfred and Monash University, having previously been Professor of Medicine at Eastern Health and Head of the Eastern Health Clinical School. He is a Past-President of the Gastroenterological Society of Australia. From a background of research in epithelial cell biology, he now directs a large program of translational research, and has active clinical interests in inflammatory bowel disease, coeliac disease and irritable bowel syndrome. Major foci of his work include the use of diet to control gut symptoms and influence outcomes in chronic intestinal conditions, and the optimization of clinical management in inflammatory bowel disease. He has published widely on these topics. He was awarded the Distinguished Research Prize by the Gastroenterological Society of Australia in 2010.
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Dr. Victoria Maizes: Hi, Andy. So today on our podcast, we will be interviewing Dr. Peter Gibson

Dr. Andrew Weil: And the subject is the FODMAPs diet, which some people may not have heard of…

Dr. Victoria Maizes: Yes, it's a really unusual and I say strict, elimination diet, but it can be very useful for people who have irritable bowel syndrome, especially, but also some people with inflammatory bowel and celiac.

Dr. Andrew Weil: Good. Well, let's, let's hear what he has to say.

Dr. Victoria Maizes: Fantastic.

Intro Music

Dr. Victoria Maizes: It's my pleasure to welcome Dr. Peter Gibson, who is professor and director of gastroenterology at the Alfred and Monash university. He's also past president of the GI Society of Australia. His present research interests include inflammatory bowel, celiac disease and irritable bowel syndrome. And a major focus of his work is on the use of diet to control gut symptoms and to influence outcomes.

Today, we will be speaking specifically about the FODMAP diet. Welcome Dr. Gibson.

Peter Gibson: Thank you for that introduction.

Dr. Victoria Maizes: You're welcome. So I want to start by asking what does FODMAP stand for and what are they.

Peter Gibson: Well, the, the story behind the origin of that term is quite interesting because they are a group of short chain carbohydrates.

Peter Gibson: FODMAPS stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols.

So in other words, sugars are little chains of sugars that are in our diet. That are not either not digested or very poorly or slowly absorbed into the circulation from the gut, from the small bowel. And, and the, they comprise things like, fructose, lactose, if you can't adjust lactose, things called polyols, like sorbitol, mannitol, which you use, which are in food and also uses artificial sweeteners, and oligosaccharides, which are just short trains of, of sugars, that I've read the most common ones, probably fructo-oligosaccharides.

But the key thing about it was that no one had they put these together before. And, and when we started talking about that, you can see how it was quite difficult talking about them when there was no term to, to a collective term for them. So that's where we have competition in the department. We said we have to have a collective term and FODMAPs won. And FODMAPS stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols.

By using this term, we were able to focus people's attention on the group rather than the individual. Cause it'd be prior to that, everyone was focused on mother lactose or fructose and putting them together was very important.

Dr. Andrew Weil: And how did you come up with the idea that these, compounds as a group are implicated in, in various disorders of the bowel?

Peter Gibson: We knew in the past that there'd been lots of information to say that if you have lots of lactose and you can't digest the lactose that you get symptoms like IBS symptoms afterwards, you'll get bloating, you get a change in your bowel habits. You might get pain. The same had been documented fructose.

If you have a lot of fructose in excess of glucose, then then that, that's slowly absorbed. So that used to cause the same problem. And there was plenty of information about collect oligosaccharides, which are, which are very rich in things like baked beans, so that people knew they got wind. They got, got disturbed, they got pain, wind, meaning gas and, and it's actually British. So I blame the English for that term. So, and that, that all of these things did the same. They all upset the bowls. Now, one of the problems we had was that they were that a lot of times, which had been the diets out there where do you, you just don't have the legumes, which you've got the oligosaccharides. You don't have the, you go a low lactose. you go low fructose, but unfortunately those do not really have much of an impact in in, in people who say had irritable bowel syndrome, because they only work when you had lots of, lots of them.

So it would only work if you had a big glass of milk for the lactose, for instance. Whereas if you have little bits of lactose it really didn't have any difference. And so the, the idea was that since I all do the same things and we knew they all produced more water in the bowl, we knew that they produce more gas in the bowel because they were all doing similar things we, we may, we assumed that they would have an additive effect, so that you don't have to have a lot of one of them to cause symptoms. A little bit of one, if it's with a bit of another one and another one and another one, which is what happens when we eat our diet, what happened an additive effect. And so the idea is that you can more bang for your buck if you like, if you then restrict all of these, rather than just one of them.

And in fact, that's, that's the way it could. So that's how the ideas all came up again, came forward and, they also came forward through, through just experiment. Dieticians experimenting in there, you know, using this and their patients, saying we'll reduce this, reduce that and, let's see what happens.

And happened to notice that they were doing better with this and it all fit it in without with these hypothetical considerations. So that's how it all started. And then we went from there.

Dr. Victoria Maizes: Can you help our audience understand by giving some examples of a high and also low-FODMAP foods.

Peter Gibson: Well, the, the, probably the, enemy number one is, is, onion. Onions, and garlic, and leeks, and the onion family.

They have fructo-oligosaccharides in them and they, a very, they're a real, a real problem. Many wheat products have a lot of fructans in them. Beans, legumes, have a lot of the lacto-oligosaccharides which are these collectors containing all guess a short chain, molecules. Fructose is, things like, there are certain fruits that have a lot more fructose and glucose, because if you have fructose and glucose together, they get absorbed very well.

We've got mechanisms of dealing with that. Whereas if you have lots of fructose itself, it causes problems. And, and these are apples, pears and then there are the polyols, like, mannitol in mushrooms for instance. And there's sorbitol which not only is it added to things like sugar was chewing gum and, and candies, but they're also its present in, in apples and pears.

And you could see that if you have, you have apples or pears, they've got fructose, and polyols and sorbitol, so they have a double whammy and a lot of people did describe apples, being a problem or pears. So, so these are the sort of examples of things, but, but what we do know is that a lot of foods that have more than one of these in them.

Dr. Victoria Maizes: It's striking to me that a lot of these foods are things we generally consider healthy… apples and beans and onions, the onion family, I mean, we usually think of these as rather healthy foods. Is it a good idea to eliminate these? How long do you have to eliminate them for?

Peter Gibson: Well, the whole thing is that healthy food is not a one size fits all thing.

If you don't have irritable bowel syndrome, these are healthy foods. They're not a problem. They're healthy foods if have irritable bowel syndrome, if you, if you want to put up with the symptoms. So, so the idea is that if you reduce them, you don't have to eliminate them, but to reduce them.

For instance, if you want to have a schnitzel, you can have that with a bit of breadcrumbs on it. That's very small dose, whereas, or you don't have a big bowl of pasta, which would be a big dose of the fructans. So the whole idea is that if you restrict all of these things, not eliminate, but just restrict them that people seem to improve at least we, if we feed people, diets where we've restricted them, so we know what they're actually getting they improve for them within a few days.

Dr. Andrew Weil: Do you find that if people restrict these and there is significant improvement, is it possible at a later date to re-introduce them at a low level and find some level at which people are tolerant to them.

Peter Gibson:  Absolutely. The first phase of this, the diet, that we designed to try to address this was where we it was really when we restricted everything. And, and it was really a method, a way of telling whether people are sensitive to these things. So that was the first thing. That of course, that is not what we consider that as a good diet, you know, we we'd like people to have some of these things.

And, and also we don't like restricting people's diets any, any more than is needed. So the second phase of the diet, which has developed after we initially showed that the first phase is very, very, almost draconian restriction phase worked, was then to re-introduce things because what we also observed was some people were very sensitive to fructose, but not so sensitive to fructans, or they were very sensitive to fructans or oligosaccharides but not to fructose. So, so the idea was that some people could tolerate apples quite well, but couldn't go near onion or, or a bit of bread. What has developed is the dive in the second phase of it is then to reintroduce small amounts of each thing.

For instance, you would go through a phase where if you were really good on the, the big restriction over the first few weeks, you would then say, let's try, let's try fructans, we'll go pull one of these components and you try and onion rings. And then the second day you'd have two onion rings.

And if you get a lot of symptoms on that, well then fructans are really one of the major things for you. And what we've found is that, as about 75% of people can actually markedly, de-restrict their diet because they don't need what they have to do is find the threshold at which they can tolerate the various, FODMAPs by groups. Now, the, the other origin of all this was that when we, we, put people on this diet in the early days and we'd see them six months, 12 months later saying, “Hey, how are you going with that diet?” They said, “Oh no doctor, I don't use that diet anymore. I'm not going to that doctor anymore.”

They've been, how are you? I'm really good. And I'd say, well, that's good that you're not on the door. So you have onions now. They said, “Oh no, I don't touch onions”. And then, it's well you can have, you know, having less fruit salad with apples and pears. “No, no, I wouldn't have apples, pears.” And so what was happening was people were actually going, do doing this themselves, and that they, what the diet had done was to taught them what the major issues were with them.

Then they would just avoid those things and they weren't then on a diet where they were counting. What they're eating you'll know are looking up, everything that was on, on the plate on the, on the food app and things like this, they were, and so, so basically they were on this sort of personalized, modified, diet, but they didn't consider it being on the diet.

And so, and in fact, that is what happens. And then where was a recent study that I, I heard of where people were, that we're looking at people who've been on the diet or were taught the diet and what happened in the future. And we we've also done this sort of work. And what we find is that there are, you know, a whole group, they put the, say nine, 10 on the diet, others who are, who are on the restrict, you know, the, the personalized thing where they went through all the phases and still believe that we're on the diet and what we found when we measured, how much, how much FODMAPs they were actually eating in their diet. We found that, in fact, they're both reduced through compared with what you would expect in a healthy population. So, so then the thing about it is that it's not a, like a, you go on this diet and it's a life sentence that you've got a bit on a bit like unfortunately, celiac disease where you know, you really have to, there's only one way you have to be completely devoid of gluten for your health. Whereas here, what people are, they're going on a diet, which is actually teaching them how to choose foods more wisely, and then they can live quite happily in longer-term.

There are some people though who have to, who really find their symptoms to require fairly strict restriction all the time. And we don't like that situation. And that's where we would certainly be utilizing other ways of helping them in their sensitivity and their psychological therapies and this sort of thing would be really good.

Cause we don't like people being strictly restricting these things in the long-term. So, you know, it's a different concept of a diet. In fact, you know, it's been a very interesting revelation of how people respond to it and the concepts of whether they're on a diet or not.

Dr. Victoria Maizes: In integrative medicine we also use elimination diets as a tool, and it's similar. They may be rather restrictive at the beginning and then you test to see what foods are tolerable and what are not. And this is not necessarily FODMAP foods, but a wider perhaps variety of, of things that aren't true allergies, but may irritate, the gut.

Peter Gibson: Absolutely. The people who have been doing that a lot, I know from colleagues who do it a lot, find that it's, it's challenging because there's less form to it. And, and, and it's very hard for them. For all the gastroenterologists who got very poor training in dietary things and you'd know all about

That we find the, the exclusion diet part, quite challenging to us, whereas this is a way in which it's called a lot more form. And, and we know why things are doing certain things.

Dr. Andrew Weil: Dr. Gibson, do you, do you note any interactions between the gut microbiome and these kinds of sensitivities? And do you think that by adjusting the gut microbiome, you can change some of the situation.

Peter Gibson: Well, let's see, we'd love to say yes. There are some studies that have looked at the microbiome and the structure of it and whether you can pick someone who is going to be more sensitive to FODMAPs, by what bugs they have in their bowl and there is some overlap. There are people who respond to the diet. You might see, 80% who have got this pattern respond whereas only 50% with this population would respond. But unfortunately it's not a way of predicting who should be on the diet or not, unfortunately. However, it was then when you would say, well, we've, we can adjust the microbiome by, by throwing in probiotics or, or doing something else, even using antibiotics, which are, you know, like Rifaximin, which has become all the rage in gastroenterology, that you might be able to change the microbiome to tolerate these things better. Unfortunately, I don't think we have any information that actually is the way to do it. We don't know what, what we would like would be the microbiome of course, induces many of the symptoms by producing the gas.

And, and it's certainly, theoretically, if we can change the microbiome to, to not produce this gas or to not like these things, then, then that would, be better, will reduce the symptoms. The trouble with that approach is that then when you do that, then you throw in the FODMAPs and what happens is you feed the bacteria that likes to make the gas they grow and you're back to square one. So, so I I'm, I'm a little skeptical about the fact that we can change the microbiome and change the ability to tolerate FODMAPs. I think the way to do it is just throw much FODMAP at the microbiome and then it all settles down and you live in harmony.

Dr. Victoria Maizes: We do like harmony. Yeah. I think then when you've been speaking most recently, you probably been referring to, SIBO, small intestinal bowel overgrowth, and that's an incredibly challenging problem to manage in my experience of it because people do get better with the antibiotics and then they get worse and then they get better and so, it sounds like you feel that modifying the amount of FODMAP is a useful piece of the overall strategy, but not necessarily the end.

Peter Gibson: Well, SIBO is a very perplexing thing everyone wants it to be a real thing. and we think it is real. The trouble is our test finding it are really very poor.

The breath tests and things are, have got very poor performance. And even though there are a lot of people pushing them as being very useful we, we've stopped doing them because we find them, its cheaper to toss a coin than to do tests which are fairly inaccurate. However, you then look at the theory where there are methods being developed to actually diagnose it with more certainty and then we'll understand a lot more.

But the theory is that bacteria in the small bowel their major food that helps them grow are FODMAPs, fructans, particularly these oligosaccharides, so strictly speaking, what should happen is that if you reduce the FODMAPs, you should reduce the small bowel bacterial populations.

Now that hasn't been shown because we haven't been able to get to the right places to show that we're reducing these populations, so I would say the low FODMAP diet is a diet for SIBO in any case, the problem with the problem with antibiotics I think says is that, of course they, they don't have any maintenance you know, they, they reduce it, symptoms improve, and we don't know where the antibodies are doing it by changing the large bowel or the small bowel bacteria. That's the other problem. So, you know, I think, I'm sure that you're in agreement with me that antibiotics are you know, there might be a temporary solution for some people in difficult problems, but they're not a long-term option.

And, we, we have a grave reservations about using antibiotics in any, any situation, any routine situation, much rather keep them for people who are really struggling with their symptoms to try to get control.

Dr. Andrew Weil: How about for inflammatory bowel disease.

Peter Gibson: Well, this has been now very well studied.

There are now I think three randomized controlled trials showing that, that it can improve symptoms in people who don't have marked inflammation. So then people have quit quiescent disease. In other words, are there, the inflammation is well controlled who have persisting symptoms. So the functional gut symptoms, rather than symptoms due to nasty inflammation, ulceration, and, and so on that that, at least 50% of them will improve considerably with a lifelong.

The, the issue here is that, that it doesn't do anything for the inflammation itself. So it's not a treatment for inflammation. It's a treatment for the symptoms of might be an aftermath of the inflammation, or of course people have inflammatory bowel disease can also have irritable bowel. I mean, it's, if it's 10% of the population, 10% of people that are IBS, IBD might have IBS you know, this is the, the whole concept. So, so we, we utilize it in, in many of our patients who have ongoing symptoms after we've got the inflammation better. Now, the problem we have, and the thing that we really worry about is the people with inflammatory bowel disease already have their, their diet and their nutrition a bit compromised.

And we really don't like overly restricting people's diets when in that situation, so we would never be suggesting people go low-FODMAP professional, dietary dietician advice. regarding this because, because, you know, restricting your diet no matter which way you do it, whether it's gluten free, low-FODMAP or whatever, if you're going to restrict the diet in someone who was already, their nutrition is impaired, you you've got an increased risk situation.

And so, so that's, that's always the, the sort of the caveat of, using it in people with inflammatory bowel disease.

Dr. Victoria Maizes: So we've talked about, irritable bowel syndrome, inflammatory bowel disease, SIBO. Is there anything else that you think is especially amenable to treatment with FODMAP?

Peter Gibson: There was a lot of experience in people with celiac disease who have been compliant with a gluten free diet have done well from the from, their small bowel, healing point of view, but have persisting symptoms. And there's one randomized controlled trial that showed that a low FODMAP diet was better than just staying in gluten free. Gluten free diet of course does reduce the FODMAPs to some extent, because you're not having the wheat

Derive FODMAPs, but it doesn't reduce it enough, in many people to help their symptoms. another really fascinating area, which, which was something which we didn't believe at first, but a lot of people, a lot of mothers, with children who had colic, babies with colic said that when they went on the low FODMAP diet, that their babies were better.

And we thought this is a little stretch. This is just a step too far. So what we did, we did a, an open trial with mothers who've got children with colic, fed them a low-FODMAP diet and found that night and they seem to improve the children seem to improve much more than what, what you would normally expect.

So we did a randomized control trial where we gave mothers a normal FODMAP diet and a low FODMAP diet, crossed them over a random way. And we found that the colic was based around the children when there are low-FODMAP. Now, now this, we still don't know the mechanism and we haven't worked out the mechanism.

And it's something which, which only randomized control trial would make us even believe this. The thing is that the low-FODMAP diet in this situation is a very temporary thing because colic gets better and you know that, but if you've had a colicky child, fortunately my children were colicky, but it really is a very, very difficult thing.

And so anything that can help in that situation is, is useful. What we, of course don't want people to do is to go low-FODMAP the mothers, and then stay that way forever more. When you know, it was really just trying to resolve a problem in the child.

Dr. Victoria Maizes: I just want to connect the dots, these were breastfeeding mothers.

Peter Gibson: Yes. Breastfeeding, we haven't done it. We haven't done it with the, with, formula fed children, but there's these with a hundred percent breastfeeding we've looked at different mechanisms. And, how the mother eats, effecting what the child has and the breast milk doesn't seem to be different, although we haven't measured all the, all the HMO's, the human milk oligosaccharide and maybe changes in that, it was a very big diversion for us, from what, what we usually do. There the other area, which is of great interest, which we're just embarking upon big studies in the people that women with endometriosis.

One of the observations that has always been made between is that obstetrician, sorry gynecologists would, would, have people who've got lower gut symptoms, but then then they blame the endometriosis. If that person went to the gastroenterologist, they were blame the irritable bowel. And we know that people who have endometriosis do have increased sensitivity in their bowel.

The mechanism, there are lots of theoretical mechanisms. We don't know why, but one observation was in a, in a study done by, by one of our, nurse researchers who was running a clinic in New Zealand. For, for irritable bowel syndrome, that, that, when she looked back at the large number of people who, women, who had endometriosis and those who didn't, the ones with endometriosis did better with low-FODMAP not the ones who did it.

And, and this, this is a fascinating thing. And then when, when you look at all this, you know, that people with endometriosis do tend to have more sensitive bowels. They too tend to have more irritable bowel syndrome. So this link is, is being made. It's not that my FODMAP diet fixes endometriosis that's far from it, but it may be a strategy in which symptoms which are attributed to endometriosis can be, can be improved. And we're trying to look at what this relationship is, because it's, because in the endometriosis era, there's that, you know, it's a difficult area and strategy that might improve people's suffering is going to be every well worthwhile.

And the other thing is that gynecologist and gastroenterologist very seldom talk, and we don't do research across the layers as it hasn't been integrated at all.

Dr. Victoria Maizes: Yeah. Is there some group of people or individuals who should absolutely avoid a FODMAP diet?

Peter Gibson: Absolutely. One of the things that we were always concerned about was that in dealing with a population of people with irritable bowel syndrome, you know, there's 10, 15, 20% of people that depends on what your referral population is already have a disordered eating. Not talking about eating disorders, I'm talking about anorexia nervosa or anything like that. We talking about they already restricted, their diet and are frightened to eat this frightened away, because, because they find that food causes their problems and I've been searching for issues.

And what would we have papers well, who have referred to us who have been, Who were, like where stopped lactose, then they, they stopped gluten. Then they went on a vegetarian, or then they went on a, this diet and that diet.. And they, they, when, what, what was happening is people tend to accumulate these dietary restrictions.

And when they get to see us they’re on chicken and rice diet and a nutritionally very poorly off, and often don't eat much because to avoid their symptoms and already underweight. And, we are really a very disordered eating pattern. And so the last thing you want to do, then they send that person to a dietician to further restrict quote, I have, I suppose chicken and white rice is okay, but then it's hardly a diet.

Dr. Andrew Weil: So have you heard the term orthorexia nervosa?

Peter Gibson: Orthorexia I love that they're published in the journal of, of the yoga first. Yes. When I can tell you, when I, when we, we're aware of this term, and this is a very nice concept.

I had a meeting in our department now at a seminar and, with about 20 or 30 gastroenterologists there and we presented this term orthorexia and everyone was nodding the head thinking of all their patients. Who had this really picky eating and, and, and it it's, it's actually gaining more traction as a legitimate term.

I think that, I think that this is one of the issues that we have that our dieticians and I think all dieticians should be incredibly aware of that they have to look for these people. Who've got these orthorexia or are at risk of these things. Yeah. And then we don't, when you're using your restrictive diet, you, you have to know what their diet is prior to it.

And most doctors are not well versed at understanding or, or picking these things. They don't to think about this enough. and I think the education is going on now certainly there's a lot of work being done in the U.S. in this area, trying to, increase awareness of the, the disordered eating pattern. And what we would do in that situation is try to help the disordered eating before even thinking about restricting FODMAPs and then a psychologist, much more important role. So that's one area that we would definitely be not be putting people on on the diet. Other areas would be where people don't want to be on a diet.

It's not good sending someone to a dietician who doesn't want to, to put in the effort in that area. And there are other situations, era, dieticians, won't put their personal life on a diet. If they already don't eat very much in the way of FODMAPs. And, that's another thing that the dieticians got the skill of, of actually finding this with more accuracy than, than, for poorly trained gastroenterologists, who haven't been trained in, in working at dietary intake of people you know, that's, it's a, it's a big deficiency in our training.

Dr. Victoria Maizes: Earlier you mentioned, thinking about people's psychology. And I noticed when I was preparing for our conversation, that you've actually studied, gut hypnotherapy as an approach. I'm really interested in what you found.

Peter Gibson: Well, we know that diet, diet is not the treatment.

It is one modality we have. And as you know, in all this integrated integrative sort of approach that this is what, you know, it's, there's not one treatment for anything. And we used a, we, we got involved with using loads of very interested in gut directed hypnotherapy. We had a couple of hypnotherapists who were very good and we had some fantastic responses.

And so we needed to see whether this was, this was all sort of a little bit of good luck, just placebo, whether it was, how, how did it compare with low FODMAP? Because we had good evidence that blood probably would not have worked, from randomized controlled trials. So we did a trial with our hypnotherapist, we randomize people to, to a hypnotherapy or to the diet or to both at the same time. And what we found was that they all three work equally as well in about 75% of people were really good at six weeks. At the end of the course of, of two dietician meetings or their, their six weeks of weekly hypnotherapy. And then at six months, the majority of the vast majority of them were still doing really well. So, so, but what we found was that if you did them both through, through both of them, but so that people at the same time, they didn't do any better, which was a really interesting thing because you wonder why, whether it's they only have to the diet or half to the therapy or, or whether they're both attacking the same sort of, physiology and that you can't do better.

So, what the study did tell us was that got directly to the therapy was not something for rescuing people who have filed everything else that it was, these were people who hadn't had much in the way of therapy in the past. And, and the sidecar directed therapy is a very good first line therapy, just like diet is just like.

Just like cognitive behavior therapy and many other psychological approaches. So we're very, very enthusiastic about integrating, psychological physiotherapy, dietary, and drugs. Are they useful to help a few symptoms if, if necessary? And, I must say in our own clinic, we have, we have an integrated clinic with, with dieticians and we did have a physiotherapist and psychologist when we could afford them very hard to fund them in this time.

I think everywhere, you know, in a public hospital sort of, setting in Australia, but, but we have a hypnotherapist, and we’re gradually, clinical experience with what is the best approach for the, for the individual in many people it's, multi-pronged. And it's a matter of the timing of when you do one push the other.

And it's been, it's sort of explained a bit of a revolution really in how we manage IBS. And there, there have been recently a recent study done in Melbourne at the hospital where they looked at a standard gastroenterologist one-to-one care versus an integrated, not integrating the care that they had, they, they saw not necessarily in the clinic, but they saw a psychologist, psychologist, dieticians, psychiatrist, whatever was, was beneficial for them.

And the results were it's like chalk and cheese, the people who saw the gastroenterologist with a one-to-one fantastic. Didn't get any better than, than, than doing nothing. you know, really didn't improve the quality of life. The people who got the integrated care, improve the quality of life very, very much.

And it was what, you know, this wasn't randomized, but it was a pragmatic sort of study, which just highlights why exactly what we feel that, that the integral and I'm sure, I'm sure I'm talking to the converted here, that this integrated care for many chronic illnesses, inflammatory bowel disease, irritable bowel syndrome, chronic liver disease, all these things that is really important because it helps people cope with their illness, reduces unnecessary things that, that improves their mental wellbeing and, I guess improves the symptoms. And as we now see if I was abandoned, one of the most powerful tools we have, and if we can enhance it to say that, somebody, Boston initially coined this term that I love is “harnessing the placebo” is really, really important. and it's, it's not just that it's sort of fooling people it's, it's also, it gets to the mechanisms, you know, inflammatory back pain, all that. So, you know, this, this is a really important part, very hard to, to, you know, if you're trained in using a drug for everything, it's really hard to change your whole way that you manage these things in that way. And so we're aware we're working on our young trainees in gastroenterology go through our multidisciplinary clinics and I seen the different way of doing things and it's starting to change, the medical attitude to, to chronic illness.

Dr. Andrew Weil: Well, I would say we are very philosophically aligned. I'm delighted to hear your integrative treatment. And it's just wonderful to hear that I know that this is happening.

Peter Gibson: Yes. The biggest problem we have as you know, is getting the really solid evidence behind it. And, and it's much easier to study a drug than a diet because studies have been criticized, quite rightly on technical grounds that you just can't blind as well.

You can't, it's really hard to get the precision in the, in the, in the scientific design. Psychological therapies is even harder. That's why we looked at low FODMAP diet, versus gut hypnotherapy, rather than having some sort of a placebo.

so, so, you know, this is the real problem in any effecting change in conservative medicine is about what the evidence and, and the fact is the evidence is accumulating. Both in, in trials as best we can do them. And then in the real world, responses. So, so it, it's, it's a hard slog as you were quite aware of how, how to change, people's views about these things. Particularly the fenders.

Dr. Victoria Maizes: Well, thank you, Dr. Gibson for being one of the folks tackling this really challenging area of research. And, as you said, researching, diet, dietary patterns, mind, body, it is not straightforward because it is hard to blind those, those therapies.

So we really appreciate your work.

Peter Gibson: And we also have to get away from this idea of its all in your head type attitudes that that would generate last century. And that's why you often hear that in men conservative medicine, when we don't know what the cause of something is, it's either psychosomatic or it's autoimmune.

Dr. Andrew Weil: I've said I've suggested using the term somatopsychic to avoid the connotation all in the head.

Peter Gibson: But of course, all illnesses have a physical, organic and psychological component. And I'm sure we can do a lot better in inflammatory bowel disease by tackling, tackling a whole holistically.

Dr. Andrew Weil: Thank you for your time. It's been a fascinating conversation.

Dr. Victoria Maizes: Thank you so much for joining us today. Really appreciate it.

Peter Gibson: Thanks very much for the opportunity as you can stay on quite enthusiastic about all of this.

Dr. Victoria Maizes: Thank you bye.