An Overlooked Cause of Distention & Bloating

The power of deep breathing & biofeedback with professor & researcher Erik Peper.

Lack of deep breathing can contribute to distention, bloating, gut pain, and other GI symptoms. In this podcast, SFSU Professor and researcher Erik Peper explains the profound power of deep breathing and biofeedback, how shallow breathing increases the stress response, and how to improve your gut health through good breathing technique.

In This Episode

The Absolute-ness of Specialty Diets 00:02:41
Meet Dr. Peper … 00:04:54
Breathing Basics … 00:08:50
Breathing and the GI Tract … 00:11:10
Breathing Experiment … 00:16:12
Optimizing your System … 00:22:50
Extending the Abdomen … 00:26:44
Breathing Therapy … 00:29:36
Posture’s Impact on Health … 00:34:13
How Successful is Therapy … 00:40:08

An Overlooked Cause of Distention & Bloating -

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Hello everyone. Today I spoke with Dr. Eric Peper, who is both a clinician and a researcher. We went into detail regarding a nuanced form of biofeedback therapy. To make a long story short, for some of us who have chronic bloating and distension, there may actually be a diaphragmatic and breathing etiology or cause to this. This is something that’s been documented actually in a number of published studies. So if you are someone who suffers with this kind of chronic look of being bloated and/or feeling bloated and distended, there may be some aberrancies in your breathing affecting your diaphragm which then affects the movement of contents, including blood and lymphatic in your abdomen which then leads to distension, pain, discomfort, and potentially pre-menstrual pain. This was a quite insightful conversation.

For those of you, especially those who tend to be a bit more type A, this has a very high probability of landing for you. Especially if you’ve gone through some of the other more preliminary therapies that can help with bloating and distension, like personalizing your diets using probiotics, perhaps a touch of elemental dieting as a bit of a reset and gut de-load. I would definitely encourage you to give this podcast a listen because it does tie together a few very important concepts. One of which is the impact of stress and the impact of being locked in this sympathetic state and how this can alter breathing that can thwart proper circulation through the abdomen. As I mentioned a moment ago, not only physically/mechanically, but also lymphatically and venously.


Sponsored Resources

Let’s talk about one of my favorite tests for digestive health, the GI-MAP from Diagnostic Solutions, who has helped to make this podcast possible. Now if you’ve been reading any of the case studies that I’ve published in the Future of Functional Medicine Review clinical newsletter, you’ve likely seen that this test, the GI-MAP, is a test I frequently use in my practice.

An Overlooked Cause of Distention & Bloating - diagnostic solutions

Why? Well, one of my favorite things about this test is it has excellent insurance coverage. So this is a few hundred dollars that I save patients. This lab is also CLIA certified, which is essentially the quality assurance bureau for labs. So it’s important that these labs are being monitored, not cutting any corners. That’s where you get your CLIA certification.

Now, this test uses quantitative PCR technology. So it’s a DNA test. And you’ll get a good read on dysbiosis with this test because they will assess and report out various types of bacteria, yeast, and parasites including protozoa, worms, and amoeba. They also have some valuable and helpful clinical markers like calprotectin which can help rule in or out inflammatory bowel disease, and zonulin, a marker of leaky gut. So head over to DiagnosticSolutionsLab.com to learn more and to order your test.

This actually does tie into something I just want to showcase and point to from Healthy Gut, Healthy You, which is how we frame the narrative about diet. Of course, I’ve repeatedly criticized how portraying gluten-free or low FODMAP or the autoimmune paleo diet as diets that have to be followed at 100% is inherently foolish because that ends up causing quite a bit of stress. In fact, I was just on Facebook the other day, looking at some comments on the SIBO SOS forum. It’s so disheartening seeing some of the comments in there where people are saying, “Oh my goodness, I’m trying to do low FODMAP and I had a few deviations the diet, have I undone all the good” and it causes a great deal of worry. That’s because, again, I think the messaging is couched in an absolutist framework regarding to approach the diet. So that is something in Healthy Gut, healthy You that I think is of utmost importance, which is none of the recommendations or theories are couched or framed in absolutist or fear-based terms.

We also discussed the importance of simple interventions, like time in nature. This is something else that really seems to help people get more into parasympathetic tone or parasympathetic state, which impacts breathing. As we learned today from Dr. Peper this has a carry over impact on bloating and distention, and essentially the overall health of your abdomen and associated musculature. So again, great points by Dr. Peper and those dovetail into many of the concepts laid out in Healthy Gut, Healthy You. So if you haven’t yet grabbed a copy of Healthy Gut, Healthy You and gone through that, I felt even more confident about the importance of the book after the conversation today with Dr. Peper. Our discussion revolved about how there may be this overlooked cause of distension and bloating that has do with breathing sympathetic tone, diaphragmatic breathing, and the like. So now we will go to the conversation with Dr. Eric Peper.

➕ Resources & Links
➕ Full Podcast Transcript

Intro:

Welcome to Dr. Ruscio Radio discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit drruscio.com and sign up to receive weekly updates. That’s DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hello everyone. Today I spoke with Dr. Eric Peper, who is both a clinician and a researcher. We went into detail regarding a nuanced form of biofeedback therapy. To make a long story short, for some of us who have chronic bloating and distension, there may actually be a diaphragmatic and breathing etiology or cause to this. This is something that’s been documented actually in a number of published studies. So if you are someone who suffers with this kind of chronic look of being bloated and/or feeling bloated and distended, there may be some aberrancies in your breathing affecting your diaphragm which then affects the movement of contents, including blood and lymphatic in your abdomen which then leads to distension, pain, discomfort, and potentially pre-menstrual pain. This was a quite insightful conversation. For those of you, especially those who tend to be a bit more type A, this has a very high probability of landing for you. Especially if you’ve gone through some of the other more preliminary therapies that can help with bloating and distension, like personalizing your diets using probiotics, perhaps a touch of elemental dieting as a bit of a reset and gut de-load. I would definitely encourage you to give this podcast a listen because it does tie together a few very important concepts. One of which is the impact of stress and the impact of being locked in this sympathetic state and how this can alter breathing that can thwart proper circulation through the abdomen. As I mentioned a moment ago, not only physically/mechanically, but also lymphatically and venously.

The Absolute-ness of Specialty Diets

DrMR:

This actually does tie into something I just want to showcase and point to from Healthy Gut, Healthy You, which is how we frame the narrative about diet. Of course, I’ve repeatedly criticized how portraying gluten-free or low FODMAP or the autoimmune paleo diet as diets that have to be followed at 100% is inherently foolish because that ends up causing quite a bit of stress. In fact, I was just on Facebook the other day, looking at some comments on the SIBO SOS forum. It’s so disheartening seeing some of the comments in there where people are saying, “Oh my goodness, I’m trying to do low FODMAP and I had a few deviations the diet, have I undone all the good” and it causes a great deal of worry. That’s because, again, I think the messaging is couched in an absolutist framework regarding to approach the diet. So that is something in Healthy Gut, healthy You that I think is of utmost importance, which is none of the recommendations or theories are couched or framed in absolutist or fear-based terms. We also discussed the importance of simple interventions, like time in nature. This is something else that really seems to help people get more into parasympathetic tone or parasympathetic state, which impacts breathing. As we learned today from Dr. Peper this has a carry over impact on bloating and distention, and essentially the overall health of your abdomen and associated musculature. So again, great points by Dr. Peper and those dovetail into many of the concepts laid out in Healthy Gut, Healthy You. So if you haven’t yet grabbed a copy of Healthy Gut, Healthy You and gone through that, I felt even more confident about the importance of the book after the conversation today with Dr. Peper. Our discussion revolved about how there may be this overlooked cause of distension and bloating that has do with breathing sympathetic tone, diaphragmatic breathing, and the like. So now we will go to the conversation with Dr. Eric Peper.

Meet Dr. Peper

DrMR:

Hi everyone. Welcome back to another episode of Dr. Ruscio. This is Dr. Ruscio today. I’m here with Dr. Eric Peper and the backstory on this is pretty interesting. I read a lot as you guys probably know. On a good week I spend at least three to four nights reading Pub Med abstracts for at least 45 minutes to an hour. That’s how I keep abreast of new developments in gut health predominantly, but also with thyroid health, general nutrition, and an assortment of other topics I follow. I came across this paper regarding biofeedback therapy, which we’ve talked about before with Satish Rao. In that context, it was biofeedback therapy for constipation. This was biofeedback therapy for bloating and distension. And I said, is this the same biofeedback? Or could this be something different? So we handed this over to one of our research assistants and they dug into it and found that no, this is actually a different type of biofeedback therapy that is specifically for bloating and distention. So I was very eager to have Dr. Peper on the podcast to elaborate. So Eric really excited to have you here and explore more of what you’re offering with your biofeedback therapy.

DrErikPeper:

Well, thank you, Michael, for the opportunity. I’m so happy to be here. I think the key is it’s an integrated approach. Usually it’s not just one. So I gladly will explain if you like, or if you would rather approach with questions, whatever works for the audience.

DrMR:

Right. Perfect.I think integrative multifaceted approaches tend to perform better than just a mono kind of therapeutic intervention. So already I think we’re on the same page there. Before we go into some of the nuances or just the details of the approach, can you tell people a little bit about your background and kind of how you

DrEP:

Well, I’m a professor at San Francisco State. I run a practice in biofeedback as well, and my expertise is biofeedback. I started many years ago asking what can you do to mobilize your own health? What is so interesting is that we are often totally unaware what happens in our body. Yet we may have feelings or body experiences much later. Biofeedback allows us to monitor, then show that back to the person. It makes the invisible, visible, the unmeasured, measurable. It’s a great way to really show to a person who may not know that emotions or body postures affect them and even have a physiological effect. So we’ve worked both with clients on the one hand who come, and the other group would be our students and professionals at San Francisco State and many other places. What happened with the GI challenges is that this accidentally came out of my work with students. It’s not that I purposely set out to do this. We have students that they need to do a self healing project every semester. It’s a great project in the class. Then they do self management. One of the things we have observed is when people do slower, lower breathing, often their GI discomfort, whether it’s acid reflux or irritable bowel often will dissolve or disappear. Now the question is why can that be? It works out that you have to start looking at the body differently. Most of us, or at least as a biologist, you think of the GI tract or you think of the heart, you think of these independent systems and it really isn’t that way. So the first thing to think about is really how does the whole chest and abdomen work together, especially during breathing.

Breathing Basics

DrEP:

The easiest way to see how “normal” breathing should work is to look at a baby. You will see when a baby inhales, his or her stomach gets bigger, then the stomach gets smaller again when they exhale. It’s like a pump that goes back and forth. In medicine as a general rule, and I’m being totally unfair, obviously, but we think of breathing mainly in terms of gas exchange. That’s one. We look at how much air or pulmonary volume we can inhale or what the airway restrictions are. We almost never asked the question, “do you breathe through your nose or mouth”, “do you breathe through your right or left nostril”, “does your stomach move?”. What is so interesting is that many different illnesses really go back to the way a person is breathing or allowing their abdomen to expand in breathing. You know, if you think back to the 19th and 20th century. Think of the women who wore corsets, really tight corsets. There was an epidemic at that time for a disorder called neurasthenia. This was a disease with symptoms such as anxiety, panic attacks, GI distress. They had something called “wandering uteruses”. They were often medicalized. In reality, it was just because they wore a tight corset. If you have wear a tight corset, you get something called designer jean syndrome. That’s the term we made up. Basically, when your belt is tight, then by definition, the abdomen cannot expand and it gets even worse when you sit. We don’t think about that. When I stand, my waist is okay but when then I sit the whole diameter increases and now my belt becomes a corset. That means I breathe slightly higher in my chest, slightly more rapid. That means I move towards slightly hyperventilation. I reduce the variability of my heart rate. I tend to move to sympathetic activity, which really affects my GI tract.

Breathing and the GI Tract

DrEP:

So let me summarize very quickly in a way, how breathing is much more. I want to underline it much more than just the gas exchange. One of the hidden functions of breathing is that it acts as a pump in our abdomen for the movement of lymph and venous return. Now, what do I mean by that? I’m going to explain with an anaology to walking. Many people have observed that when you go walking, after a while, you may get something called fat finger syndrome. That means your fingers get a little bit swollen. Why does occur? It occurs because you’re not tightening the muscles in your hands and arms while walking. So to the lymph and venous return does not pump back up the arm. This is identical to what happens in our abdomen? So when we are just sitting and our belt is held tight, the abdomen does not move. There is no movement there to pump the venous or lymph return easily back. Especially if you’re breathing mainly in your chest. On the other hand, if you could let the abdomen expand upon inhalation, meaning giving it more space. Oh my gosh, what will people say that my stomach gets bigger? But when my abdomen gets larger when I inhale and then constrict slightly when I exhale, then I have an alternation of a pump that occurs. So when I inhale the intraabdominal pressure is reduced that allows the veins and the lymph vessels to fill. When you exhale, there’s a slight increase in pressure that squeezes it upward and back to the heart.

DrEP:

Which increases appropriate circulation around your GI tract. In our limited experience with students, who are the largest population and with clients, almost everyone who has abdominal discomfort tends to breathe in their chest. They tend to hold their abdomen protectively. When you hold your abdomen protectively, you interfere with digestion. Think of it in the early way, how we were wired for survival. When I go outside, I see something dangerous, for human beings, it doesn’t have to be a real danger. It can be an imaginary danger. It can be what occurs on the screen. I react with an alarm reaction, fight/flight response. At that moment, our body shifts, it moves towards sympathetic arousal. That means it’s going to essentially enhance all those functions that allow us to survive so we can run better. Blood flow goes to the deep muscles, et cetera. Our blood pressure may go up. More importantly, our digestive system slows down and stops in a way. More simplistically stated: If a danger occurs, why should my body restore itself? Why digest foods to build itself up when it’s going to be someone else’s lunch. There’s no need for that. It’s simplistic, but once we accept that concept, we see that it underlies a large component of people who have these issues.

DrMR:

Fantastically well said. There’s a lot there to unpack, of course. You did a phenomenal job of, of kind of giving us a synopsis to how important breathing is. We’ve discussed breath work on the podcast in the past. We’ve discussed looking at the mouth and oral health as an indicator that someone might be mouth breathing and that that’s a problem. We’ve also had some dentists on the podcast who have sounded the alarm about folks with a litany of oral health issues and the possibility that they may be mouth breathers. We’ve also discussed how there’s this movement within exercise science of showing that performance may actually increase when people train and do cardiovascular training with nose-only breathing. There’s also obviously this difference between parasympathetic and sympathetic based upon how you breathe, the importance of diaphragmatic breathing. I love the piece about the lymphatic and venous return. So a lot there that I think just really showcases for people how important breathing is. I’ve said this before. I think it’s really easy for people to kind of ignore breathing because we take it for granted.

Breathing Experiment

DrEP:

For the listener, let me do a little experiment. How breathing may quickly change something in you. Just as you said, we don’t often think about it. It’s just in the background. We have no idea unless we have asthma or emphysema or something like that. It’s much more potent than that. Let me give an example. While you’re listening, what I’d like you to do in a moment is to just keep breathing normally. Inhale normally, then exhale only half the air you have inhaled. Inhale again, exhale only half the air you inhaled. Each time only exhale about half the volume. Let’s start, start now. Remember, breath normal. Inhale, exhale half. Inhale again, exhale half. Keep doing that pattern, keep doing it and keep doing it. But I’ll keep talking to remind you to keep exhaling only half the air that you have inhaled. Keep doing that. If you looked at people doing this, you wouldn’t notice much difference in the body posture. I think that’s enough. What did you experience?

DrMR:

Well, I noticed a bit of a kind of sympathetic drive there where I feel a little bit amped up. Also probably a bit more breathing into my chest and not into my diaphragm. those are the two things that I noticed.

DrEP:

That’s one. Two, half the people who report an increase in anxiety, some will get fuzzy in their head. They feel their thinking is affected. We’ve published this as a study. Many people get palpitations increasing, a few will get more pain. It is a slight change in the breathing rhythm and the pattern, but it results in radical changes for a number of people.Now imagine if you do this many times during day. In some ways, you could say it’s a normal pattern. When I’m fearful, for example I see a tiger. What I do is I tend to gasp. At that moment I freeze. It’s useful to freeze and not move in that moment because the tiger can’t see me as well. Then when the danger goes away, I can continue to breathe. But what I do when I freeze, I very shallow breathe on top. So many of us work in this are in this during the whole day. The most important part in our findings was the result when we reverse that. When our students really shift and breathe lower the whole time, slower. When stresses occur, they can identify it and they interrupt and shift their breathing. Their GI distress, for a number of them, totally disappears.

DrMR:

Let me ask a few clarifying questions there. I know for our audience that there are probably some specific quandaries and also for the clinicians. I look at this maybe in two different patient subtypes who are both exhibiting a gastrointestinal complaint or complaints. One would be, said loosely, those with IBS and also bloating and distension as the one group. The other group, those who have minimal to no other digestive symptoms other than distension and or bloating. How are you delineating these at all, if you are. The way I typically proceed is almost the way we would look at a constipative IBS patient, where you first focus on the IBS and then reevaluate if treatment of the IBS resolves constipation. And if not, you can then use constipative directed therapies. Is that how you’re parsing this? Or how do clinicians start to look at some of this in the context of the therapeutic algorithm, they’re building out for each patient.

DrEP:

Okay. For us at least, remember the largest large group of people we have are students who we don’t technically do diagnostics with one. We want to be very careful here. They just happen to have these histories, and then we do it. So we are asking the question almost in a different way and saying, let’s look at how you are physiologically reacting. So we monitor the person’s breathing pattern. We monitor their heart rate variability. We monitor whether even at the end of the exhalation, the transverse or the abdominal muscles may slightly activate to pull the abdomen in. Especially in constipation and other issues. When they inhale it really relaxes, so the area can expand. Then we start teaching them how to shift their breathing pattern without effort. Basically if you think of your body, the movement is more like a pear shaped body movement. Where the belly button is the center of the pear. The bottom of the pear gets bigger when the air comes in, and smaller when the air goes out. If you look at this by analogy, I used the baby already. So instead, think of a dog lying on it’s side. You see the movement is almost entirely in the abdomen. There’s almost no movement in the upper chest. So if you saw me or the patient, and when they’re talking the the upper ribs and be lifting almost when they inhale, they would allow the air to flow in easily. Then how quickly do they breathe during stressors and where? So what you observe is, and we show this in the graphs as well, the person may be breathing 14, 16 times a minute or 12 times a minute when they come in. Sometimes even more, and mainly in their chest. If you give a stressor they either hold their breath or the breathing rate really increases, and the abdomen shows no more movement at all. Then you have recovery. Then we say, that is a pattern that affects our sympathetic parasympathetic balance because they have less heart rate variability, which is when you inhale heart rate goes up and you exhale, heart rate goes down.

Optimizing your System

DrEP:

So now we say, let’s optimize your system for you to do this. So how can you breathe lower and slower? How can you do it when faced with stressors, which is most interesting. How can your heart rate variability improve? In some cases, the symptom clusters disappear. So I don’t do that diagnostic myself because that’s not my expertise. I want to be very clear. We’re asking what can anybody do preventatively? When people do this, we observe not only, which is the most interesting part, the classical GI distress. When we work with students who have PMS premenstrual syndrome, or have especially menstruation cramps, when they really start doing it and they let their abdomen be expanded versus contracted they do much better. Again, look at posture. When we have pain, what do we do? We curl up. It’s a normal, protective response. You want to hide away. But think about that. When I move myself in that body position, I really aggravate it. Let’s look at an analogy. When you have a cramp your calf in sports, what do you do? You keep the cramp or you stretch it out. You tend to stretch it out. Now, if you think about the abdomen the same way, we are compressing it. Curling up. We do that because it feels safe. You’re protecting this area. If on the other hand, I could now extend myself, like totally open it up, be tall, lie flat then I will put a nice warm pack on my stomach and breathe lower, especially slower around six breaths a minute. It’s remarkable how many people benefit. Isn’t just the mechanics. It’s also your thoughts and emotions you have to change. Now, interestingly, we did a book just being published now called Tech Stress: How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics. In the book, we really list many of these strategies. It is our posture. When you sit at the computer and every so often collapse, we feel worse by the end of the day. So they’re not separate.

SponsoredResources:

Let’s talk about one of my favorite tests for digestive health, the GI-MAP from Diagnostic Solutions, who has helped to make this podcast possible. Now if you’ve been reading any of the case studies that I’ve published in the Future of Functional Medicine Review clinical newsletter, you’ve likely seen that this test, the GI-MAP, is a test I frequently use in my practice. Why? Well, one of my favorite things about this test is it has excellent insurance coverage. So this is a few hundred dollars that I save patients. This lab is also CLIA certified, which is essentially the quality assurance bureau for labs. So it’s important that these labs are being monitored, not cutting any corners. That’s where you get your CLIA certification. Now, this test uses quantitative PCR technology. So it’s a DNA test. And you’ll get a good read on dysbiosis with this test because they will assess and report out various types of bacteria, yeast, and parasites including protozoa, worms, and amoeba. They also have some valuable and helpful clinical markers like calprotectin which can help rule in or out inflammatory bowel disease, and zonulin, a marker of leaky gut. So head over to DiagnosticSolutionsLab.com to learn more and to order your test.

Extending the Abdomen

DrMR:

So a couple of things. I definitely want to come back to your book and tie in how things like sitting may actually exacerbate this problem. The first question I want to ask, and I think the answer is already kind of been tacitly given in the explanation, but I want to ask it directly for the person who maybe didn’t connect the dots here. That is if someone’s saying, well, I don’t want to relax my abdomen because it’s already distended. I already feel like I look pregnant. Isn’t this antithetical to my goal of flattening my tummy. Again, I think you already answered this, but what would your concise answer to them be and how to reframe this?

DrEP:

I would say whether the abdomen is extended or held in, the lack of movement is the problem. So by allowing the breathing to start moving, at least you start working on a pump. There may be many other factors, human biome, etc. This is only a big a strategy to do. I would definitely recommend, to each person asking the question, do an experiment. What you do is lie on your back, put a three or four pound weight on your lower abdomen, over your belly button, which is very challenging sometimes. Then as you inhale you can let the abdomen push that weight away from you more so the stomach gets bigger, then as you exhale, let it push the abdomen down. That pushes the diaphragm upwards and lets the air flow out. So in a way, lying down, you do work by pushing your abdomen away from you, upwards, expanding it, let that that weight go up. Let the air go out on exhalation. I often recommend that people for a moment during the exhalation phase may make a sound, like an sssss sound, although, ideally, you want to breathe in and out from your nose. In the beginning, we have an easier time modulating the rapid flow. So you want to work at elongating the exhalation. As you do that, your heart rate will slow. You’ll support your parasympathetic system. When you inhale the abdomen, widens gets bigger. You’re pushing this weight away.

DrMR:

I love that exercise. That is a good transition into my next question, which is what does the therapy here look like? I know you mentioned before we started the recording is kind of a multimodal where it’s not just maybe necessarily the biofeedback therapy itself, but I’m assuming there’s minding your posture, daily reminders of breathing, but give us kind of the overview of what this therapy looks like.

DrEP:

Well, if on this purely in a kind of biofeedback model, initially the first session would be basically a kind of an assessment.

Breathing Therapy

DrEP:

We would always monitor the person’s physiology, their breathing, their heartrate, their sensors. Out of that, distinctly start giving a home practice because the key is that the person needs to practice the skills and integrate into their lives. Then by the next time you see what happens. What people may observe, and it’s most interesting, is that there are many situations where they are unaware that they held their breath. You know, when you show this kind of physiology on the screen, it’s like people get an aha. They have no idea that they are doing this. Let me do it in a totally different analogy. So when people, because so many of us are now online all the time, and we’re working at the computer and by the end of the day, we get neck and shoulder pain. That’s the obvious one. Our eyes are fatigued, but we don’t really notice the process occurring. What really happens when you monitor people at the computer, you use similar sensors, you look at the muscle activity of their shoulders, their trapezius or their deltoid, which may abduct the arm or extended it forward. Then when a person is working, unbeknownst to them, these muscles may be activated and tense. Especially when they work under stress. Then the trapezious tends to tighten. Now they don’t know these muscles are tight all the time because it’s not much. Muscles, however, are not made to be tight continually. They are made to relax, tense, relax. The analogy for the listener would be, as you’re sitting right now. Well first, don’t do this if you’re driving. But if you are not driving, just sit, lift your right knee slightly up, so the foot is an inch away from the ground just lifted.

DrEP:

As you’re lifting this way, starting right away you will begin to feel an achiness already in the hip, in the muscles. Not much. It depends how much you’ve practiced. Depending on how strong you are the achiness will occur quicker or later. That’s enough. Let it go. Notice just the momentary tightening for literally less than a minute. You start to feel some sensations of discomfort, but what is so interesting? Most of us, unless you have hip pain, hip problems or knee problems or feet problems, we can walk for miles. It’s activating the same muscle, but why doesn’t it hurt when we walk? It doesn’t hurt because the muscle tightens in the face of the walking and relaxes and with each step, they tighten and relax. It’s the alternation of tightening and letting go that’s health promoting. The muscles act as a pump for the lymph and venous return. The same thing you need in a way your abdominal area. So many people either hold our pelvic floor really tight or totally relaxed. Health is always the alternation between tightening and letting go.

DrMR:

For people who are interested in this therapy. Is there a distance application that you’re able to do with maybe a zoom video assessment. Is anything like this available? Yes. Ideally the biofeedback component is great because that is the most believable part because you don’t know. But yes, it’s fairly easy with zoom to look at somebody. If they’re willing to sit slightly sideways and you can see how when they are breathing, you can see how their chest is going up, how their abdomen is held, if there is no movement. They can even take a belt around their waist and notice when to inhale whether they feel much more pressure against that waist or not? So there are many techniques you can use. Then the training can be done by coaching easily.

DrMR:

Great. We have an audience all over. Are you located in San Francisco only? Are there multiple centers?

DrEP:

I have two roles. I am mainly a professor at San Francisco State. So that’s where any student can take classes and learn some of these techniques in holistic health. Then I have a practice in Berkeley called Biofeedback Health.

DrMR:

Gotcha.

Posture’s Impact on Health

DrEP:

But you know, but I want to go back to that piece for a moment about posture, if that’s okay. We did some interesting studies which really apply to your gut as well, but we don’t realize that. Many people who have gut discomfort often become anxious and may even get depressed because it’s difficult to resolve. We forget that our bodies communicate to our emotions and our brain. It’s a very powerful influence. They’re not separate. We used to think everything originated in thoughts and emotions going downward. No, it’s a two way street. So let me go back to that posture perspective, which we wrote up really well in our book, because everybody sits at the computer now. So when you sit, we tend to slouch. When we slouch we put our body in a defensive, submissive position. Imagine we have two dogs. They meet. One dog is happy, it’s the dominant dog. His tail is way up, it is frisky. Then it meets another dog who becomes submissive. His tail goes under, he forms a defensive reaction. That is how we react just as much to signals outside of ourselves. We, in many cases, are the more submissive or the more dominant. We don’t realize that we do that. When we are depressed, our bodies tend to collapse. Not always, but for many people we slouch a bit. After a while, and I think it’s a truly a biological reflex, when we put our bodies in this collapsed position, slouching position, it tells the brain “I am submissive” and my energy drops. You know, you can have this experience right now, just as you’re sitting. Get up for a moment, just get up. As you’re getting up, stand up, really arch. Now, skip in place. As you skip, bring your right arm to the ceiling, like you’re picking flowers or whatever, but really reach up into the sky with your hands as you’re skipping in place. Skip, and skip, and skip, and move. Just keep doing that for a moment.

DrEP:

What happens when you skip, even for a moment, where you’re looking up, you’re extending. You’re really doing an extension and energy, for almost everyone, increases significantly. Subjectively. What is also interesting in published studies we have done, we have compared slouch walking and skipping. So you alternate between slouch walking and skipping. When people do slouch walking, those who have a history of feeling more low energy and depression over the last two years, their energy drops the most. For people who never had a history like that, it doesn’t have much of an effect. For everybody [when skipping], their energy goes way up. That’s sort of interesting. So you feel more optimistic. Then we did a most interesting study asking people to do something very similar. When I have abdominal pain, I tend to protect myself. I curl, I slouch. I mean, I really protect myself in the letter C often. You know, we see this all the time. With our women students who may have dysmenorrhea (menstrual cramps), they want to curl up. But when you’re in that protective position, it also means you have much easier access and preferred access to hopeless, helpless, negative thoughts. As the listener, you can test this. All you do is slouch. May put your body in letter C. At that moment, while sitting in this letter C start evoking, hopeless, helpless, powerless, defeated memories, one after the other. You can do that for 30 seconds. Then after 30 seconds you would shift, keep same position, evoke only positive, optimistic, empowering memories. Do that for 30 seconds.

DrEP:

Then after you’ve done that, sit up. Arch up, look up and repeat the same exercise where you, while looking up, think of hopeless, helpless, powerless memories followed by empowering, positive memories. It can be balanced in all ways. So it’s scientifically correct. What do you find? There are always exceptions, but almost uniformly, it’s such a powerful phenomenon. Over 95% of the people will report when they are slouched, it is much easier to access hopeless, helpless, powerless memories than when they are looking up and erect.

DrMR:

That’s a great point. I think this is kind of hearkens back to the importance of the breath work podcast we’ve done previously. And potentially for those who may feel like they’re somewhat inundated with fear or worry regarding their diet or their environment. This is where being very devout with the birth of work and or meditation may be a great idea and, or even going so as far to do limbic retraining therapy, because of this whole kind of sympathetic abdominal pump, tie-in that you’re describing, I do want to shift gears just for a moment for some of our practitioner audience and just discuss in brief what you’ve published.

How Successful is this Therapy

DrMR:

I’m curious, is there any kind of prevalence data for how often people are afflicted by this? Do you have an average response rate to your therapy? Has this been vetted against placebo? You know, all of the kind of standard practitioner questions. What have you kind of found through your publications? Can you tell us a little bit more about those?

DrEP:

Well, probably the best studies have been done by Dr.Richard Gervirtz and his graduate students at Alliant International University. They have found, for example, that for young people who have RAP- recurrent abdominal pain- which is often common in junior high or high school students. They have an 80% success rate in about eight sessions compared to the control groups. It is mind boggling and it makes perfect sense. It can be a diagnostic as well. Namely, when you have a person who has RAP (recurrent abdominal pain), if they are anxious, perfectionistic, those kinds of qualities, then the outcome is supurb. If, on the other hand, the person doesn’t have any of those characteristics, they are mellow and relaxed and don’t care about their performance, you send it back to the gastroenterologists because there’s something wrong. It’s probably the best work I know of. There are a number of biofeedback studies. There are very few specifically for the work we have done, like in acid reflux. There are many more students studies and case reports. What we find, and this is probably the best observation I can give, is that if you truly practice this breathing every day and almost becomes a differential diagnostic. We don’t do diagnostics that way, but if you really practice and do the stress management and the heart rate variability, then if it doesn’t go away, there’s really something else going on. Whether you need to really check the human biome, whether you need to check for many other factors and all of this assumes a matrix of a healthy diet. I would argue more organic foods, moreunindustrialized, unwesternized, non-processed foods, which I think personally are quite harmful and increase inflammatory disease.

DrMR:

Sure. Agreement there. I also appreciate how you don’t assume that a high intake of fiber is automatically the best, which unfortunately there seems to be a lot of dogma around that which pervades much of the narrative regarding the gut microbiota. Just because fiber prebiotics feed the gut microbiota doesn’t mean that everyone needs to be increasing those in their diet, especially if someone’s coming from an already fairly healthy diet. I’m kind of side stepping onto my soapbox here, but what’s unfortunate is that it’s almost like the archaic recommendations that all fat is bad for you. Those just permeated every research. Same thing seems to happen a lot in GI where we know that fiber and prebiotics feed gut bacteria but that doesn’t mean it’s always going to be the right maneuver for an individual. If you have a patient who has gone from a diet devoid of fiber and prebiotics because they were eating mostly processed adulterated, Western food, it doesn’t automatically mean that they then have to go to a high fiber, high vegetable diet if we’re in the realm of food quality. This is evidenced by low FODMAP diets being very helpful. Obviously that helps with gas, production and bloating in some cases, not in all and a vegetarian diet seems to work well for some. I really appreciate the fact that you’re not just holding diet out as this “just feed your biome and your biome will be great” situation. So I just want to acknowledge that.

DrEP:

Yeah. The way I would say it is the foods we eat are critical. I mean, I look at my skin, I look at my hand, I realized that’s the summary of all the food I ate. I look at it like we are building a house. You need good construction material, then you’re house will survive better. That’s the same thing as the foods we eat. What they eat specifically will really depend upon many factors. You know, if you study indigenous culture, you realize, wait a minute, the Inuits in the Arctic had almost no cancers, basically no diabetes and they mainly ate fats.

DrMR:

Yup. Well said, great example.

DrEP:

You know, while if you go through the !Kung Bushmen they ate lots of seeds and they also had no heart disease and very low cancer rates. In the US we have such mixtures. We are remarkable that we have flexibility. The key is the one piece I would always say is, do not eat nutrients, eat foods.

Speaker 2:

Yeah. We’re definitely on the same page regarding diet.

SponsoredResources:

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Episode Wrap-Up

DrMR:

Well, this has been a great conversation. I hope that for people who are struggling with distension, if you haven’t taken up some of the recommendations about relaxation, breath, work, breathing quality that you will now consider that. Your book Tech Stress, I’m assuming lays out a set of guidelines for people. Do you want to tell us a little bit about that book and where they can pick it up? Any website information to point people to?

DrEP:

Sure. The book is Tech Stress: How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics. I think it’s a book for anyone who has GI distress. Once you look in that, there’s a whole section about breathing, how body posture collapses the abdomen and it almost becomes predictable by people get sick. At the same time, we’re now all linked in or captured by the computer for communication: work, education, socializing. We don’t move. The book really gives an evolutionary model, why we react the way we do and offers both the cognitive solutions, how we can think differently. Also breathing strategies as well as ergonomics. I think it’s the mixture of all of those together that allows us to do health. So when you have GI distress, but in the broadest terms, you know, ergonomics in some sense is critical because if we compress our abdomen, it’s harder to heal. It can be also be the clothing we wear. The foods we eat are how we react. We forget that our gut is highly reactive to any stimulation, any fight flight response. Anytime the signal hits our brain, our eyes especially, we need to identify is that safe or dangerous? We don’t know we do that, but the moment we react, we almost stop our gut. We freeze that area to protect it. Once we understand that then we realize what we see on screens affects us. So I think the book is a must for anyone who has GI distress and also, especially those who work on computers or even parents with concerns. I have many parents who say, gosh, when my kid sits there, collapsed and playing computer games they’re captured. I tell them it’s time for dinner and they say, yes, I’ll be up in five minutes and then ahalf an hour later, I still have to remind them. All the time they were sitting like that they’re breathing in their chest and they may impact their digestion.

DrMR:

Well said. If someone wanted to reach out to your clinic for either an in person, or if they’re out of the area, out of state at a distance referral, what’s the best spot to go to for that?

DrEP:

There are two ways. First, a lot of the material I’ve talked about, obviously recommend the book first, but we have done a number of blogs. I have a blog called peperperspective.com. Just put IBS or reflux or whatever you are looking for in the search box. You’ll see both the science with all the links, as well as sometimes interviews with the client or students. Second, I have a practice website where people can contact me and that is biofeedbackhealth.org.

DrMR:

Awesome. Well, Eric really appreciate what you’re doing, especially the fact that you’re, bringing a holistic awareness that that does tie to the gut and maybe this pain-point that people are focusing on, bloating and distention, but making sure not to just kind of pigeonhole people into therapeutics only for that. There is a compelling case to be made, obviously that there’s a breathing epidemic and a tech stress induced epidemic in this country that some may be very, very amenable to. No matter how good the diet is and the probiotic protocol and everything else like we’ve talked about on the podcast ad nauseum, if those other facets of health are not in place, then there’s a pretty dismal outcome potentially.

DrMR:

So I really appreciate you publishing the work that you’ve been doing and documenting this and really helping people get this last bit dialed in. I shouldn’t say last bit, I say last bit because I think for our audience, they’ve got all the other things. So for us, this may be the last bit that we’ve really vectored in the conversation, but clearly this is a foundational piece that will hopefully help people who perhaps have not yet fully addressed this. So just really appreciate what you’re doing the nuanced and holistic perspective that you’re bringing to it.

DrEP:

Well, thank you so much because to me the key is you want to empower people to listen to themselves, to become aware and implement ways by which they have some control to mobilize their health.

Outro:

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