The Checkup with Doctor Mike - The Biggest Mistake People Make On The Toilet | Dr. Trisha Pasricha

Episode Date: March 15, 2026

Today’s episode is brought to you by Microsoft Dragon Copilot. Dragon Copilot is an AI clinical assistant that streamlines documentation, surfaces critical information, and automates routine tasks ��� empowering healthcare teams to focus more on patients and less on administrative work. Learn more at http://www.aka.ms/clinicdayI'll teach you how to become the media's go-to expert in your field. Enroll in The Professional's Media Academy now: https://www.professionalsmediaacademy.com/Pick up Dr. Trisha Pasricha's new book "You've Been Pooping All Wrong" here: https://www.trishapasricha.com/youvebeenpoopingallwrongFollow her on Instagram here: https://www.instagram.com/trishapasrichamd/00:00 Intro00:56 Her Background05:35 Leaning To Poop10:45 Is Your Gut Inside Or Outside?15:10 Don't Say That Word16:30 Smartphones On Toilet23:40 Fiber29:29 IBS44:00 Probiotics56:50 Constipation1:00:05 Colorectal Cancer / Red Meat1:21:10 Symptoms To Be Aware Of1:33:52 The Science Of Farts1:42:10 MisconceptionsHelp us continue the fight against medical misinformation and change the world through charity by becoming a Doctor Mike Resident on Patreon where every month I donate 100% of the proceeds to the charity, organization, or cause of your choice! Residents get access to bonus content, and many other perks for just $10 a month. Become a Resident today:https://www.patreon.com/doctormikeLet’s connect:IG: https://go.doctormikemedia.com/instagram/DMinstagramTwitter: https://go.doctormikemedia.com/twitter/DMTwitterFB: https://go.doctormikemedia.com/facebook/DMFacebookTikTok: https://go.doctormikemedia.com/tiktok/DMTikTokReddit: https://go.doctormikemedia.com/reddit/DMRedditContact Email: [e-mail] Producer: Doctor MikeProduction Director and Editor: Dan OwensManaging Editor and Producer: Sam BowersEditor and Designer: Caroline WeigumEditor: Juan Carlos Zuniga* Select photos/videos provided by Getty Images *** The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional **

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988 suicide crisis helpline is funded by the government in Canada. It sounds kind of strange. That is a fully grown adult, you could have been pooping wrong this whole time. I can't believe there are people in this world who don't look every time they go to the bathroom. So you should have a bit of looking. Yeah. Always look. 100%.

Thank you. Yeah. Dr. Pesricha's new book, you've been pooping all wrong, provides an honest, accurate, and unintimitating look into the science of your stool. What is the number of poops per day that we should strive for? Everybody right now listening is going to think that answer is one. How many times a day would you think is normal to fart?

A lot of people. people can't poop on vacation. What does the color of your stool or your poop tell you about yourself? We talked about what warning signs to look out for. When you need to go see a doctor and the genuine risk that comes with bringing your phone to the porcelain throne. Huge thanks to Microsoft Dragon co-pilot for sponsoring this video. The topic that I'm excited to talk to you about today is one where I feel nuance has been probably missing from the most. Is that a fair statement? I think so. I mean, if we're talking about health information, especially health information online.

Yeah. Nuance is hard. Nuance is hard. And in my field, I'm a medical journalist. That's a little bit of a different category than the traditional sort of medical influencers. It's a different category than a lot of doctors. And all of these different groups

have an important role to play in the ecosystem. But all of them, I think, take that idea of nuance a little bit differently and they interpret it differently, and they kind of have to because the mediums can be a little different. Yeah, that's very true. How did you find yourself where you are today? You're a neuro-gastroenterologist? That's right.

Yeah, tell us what that means. Yeah, neuro-gastentorologist. It's a fancy word that means somebody who studies the gut-brain connection. So it's someone who goes through internal medicine training, GI, fellowship, and then a special fellowship for neuro-GI. It's kind of a new field, like in the scheme of things. It's been around- during that fellowship, are you doing mostly research?

Are you seeing patients that have a gut-brain potential diagnosis? Yeah, it's both. So, and I think every fellowship program's a little bit different. It's like probably a mix of research and patient care. We study probably the most common disorders in GI, like irritable bowel syndrome. It's one of the most common disorders in GI. And so even though you might think neuro GI is a little niche, it's actually like one of the broadest categories of patients that we see. So irritable bowel syndrome, but it's a lot more than that.

It's like chronic, unexplained abdominal pain. Right. That's something that we see all the time. We often don't put a label on it. one word could be functional dyspepsia. That's all us. That's what we see. So we study pain signaling from the gut to the brain and vice versa.

And then in my world, my NIH grant is studying Parkinson's disease of all things. And a lot of people are like, why is a gastronologist studying Parkinson's disease? And it's because I study how Parkinson's disease and other neurodegenerative disorders might start in the gut. So it's a lot of different things. It's a cool subspecialty, but it's kind of a relatively new one within GI. Right. And how did you transfer out of that to doing medical journalism?

That's a good question. I had always been interested in journalists. I actually thought I was going to be a medical journalist way before I knew I was going to be a neuro gastroenterologist. Who wakes up with that as a dream? I'm curious. What led you to that? Any Indian American who grew up watching Sanjay Gupta? Okay. You know, I think who's... And you're following in his footsteps. He was here two weeks ago, three weeks ago? Yeah. He's been one of my mentors, like for the last couple of decades. He's a wonderful person. And he, at that time, so I grew up in the 1990s and 2000s, what he, he's, he's did and what a lot of, you know, there weren't that many medical journalists, as you know, he's certainly one of the more prominent ones. What they did, I thought, was so cool and unique. Like, they took what I thought was the best of medicine and the best of storytelling. And they put it in with this journalistic rigor and ethos, and they put their information out in the world. And that's what I wanted to be. And so I, when I was in college, I interned at CNN with him, which was the best experience. It was lovely. And it really, you know, it did make me say, yes, I want to be a journalist. But actually the incredible thing was that I've told him this before too. It actually

really made me say, I need to be a doctor too, right? Because one thing that is true about him, and I think true of probably any good science communicator, doctor, influencer, medical journalist, is that they put patients first. Right. And I think that's like the number one thing that I think a lot of other journalists don't have to grapple with. Right? But he, you know, the lesson that he taught me that summer, it was one summer, was that whatever the story was unfolding on the ground, like he'd be on camera, he'd be in these different countries. There was a great story to be had. Often it was like in the middle of a disaster. There was like a big earthquake he was covering. And if there was a patient didn't need, he would say, you need to stop the camera because I'm

going to assess this patient. And when I saw that play out, I was like, wow, this is like, this is the real deal right here. And this guy is the real deal. You know, and like, that's really what I wanted to be. So I said, okay, let me go and come down. I said, so I, you know, as you know, I spent the next, like, 15 plus years in training as one must. And only in the last, like, maybe four or five years, I was able to get back into journalism. The pandemic was a big sort of instigator for me to come back into that world. Well, let's talk about gut health because we've been pooping all wrong this whole time. What does that mean? Because I thought I was doing great. I got stickers when I was in kindergarten. Like when you were two years old kindergarten.

I mean, maybe I was in Russia at the time, so I don't remember. I probably got the belt more than I got the stickers because it was USSR times. God Lord. But tell me why we've been pooping, well, you're right that I think most people don't remember most about what they learn about pooping, except for what they were potty, being potty trained, which was at an age when we probably don't remember much of that conversation. Our parents remember it. I am deep in this conversation with my two-year-old son right now.

I guarantee you he's not going to remember what we teach. talked about later. But that's kind of the extent of the conversation that you get about how you're supposed to it. What are the mechanics of pooping? What is that bestselling book? Everybody Poops, right? Yeah, we read that every night. We do. Right. Because I'm telling you, we are in the trenches right now. We have like five different books about pooping that we read. But it's whatever you got told by your parents when you're like two or three years old, maybe four or five, six. That's probably a very similar conversation to the conversation that they got from their parents when they were younger. And that, like, it gets passed down from generation to generation, I think without people ever really learning about their bodies in the way that I think they should. So, for example, brushing your teeth. We learn how to brush our teeth initially from our parents. But then we get this check-in with our dentist at least every six months, maybe every year, like, depending, but usually every six months for the rest of our lives where a dentist checks in is like, here's your technique. Are you doing it right? By the way, you've been flossing wrong. Or are you getting your gums? Are you, like, doing all four, like, all this stuff?

we don't get any of that for pooping, you know. And I think when I became a gastroenterologist, I grew up with a gastroenterologist as a father. So we talked about pooping all the time. Really? We had a really fun household. What was the poop conversation? It was like every morning, you know, like some dads would be like, hey, like, how was school today? Like, did you do your homework? Your dad would ask you, how was your poop today? Yeah, he like, did you poop? First of all, did you? Yeah. So was there shame if you didn't? No shame. There was never shame. I mean, that's, the key. There was no shame, but there was, I don't know, maybe judgment. There was just like a hey, concern. Yeah, concern. Yeah, there was like a healthy amount of like, why not? Like what do,

you know, like what do we need to? And he was like very excited. This is like his favorite topic in the world. It quickly became my favorite topic in the world. But I think I grew up knowing a lot more about pooping and the mechanics of it. And he was also a researcher. And so I think that was like partly what got him really excited and telling me about all the stuff he was doing in his lab. But when I started seeing patients on my own, first of all, a statistic that blew my mind. as a gastroenterologist, I do this for a living, is that a third of people will avoid seeing their doctor about their bowel symptoms because they're so embarrassed.

That's a huge number. Wow. Yeah. And another statistic that I started to learn, but then it like made sense with what I was seeing is that in America, 40% of Americans say that their bowel habits disrupt their daily lives. And so clearly, I mean, that's a big number for people who,

like, we don't have it together, the way we kind of assume we do, considering we don't really talk about this with our friends, as much as we should. We don't talk about it within our families. In fact, we kind of like treat poop jokes as like really immature and like what happens behind the closed door is like your business and nobody else's. And as a gastroenterologist, like this is our, you know, like what we do every day. Like we're asking everyone about poop. And I sort of found that people were one really embarrassed. Even people who'd come to my clinic who like have a need made the appointment, waited weeks to see me, like they would sit and they'd squirm in their chair, like, unable to find the right words

to kind of get it out. And it's hard to see because, again, like, this is what I do for it. There's, like, nothing that you could say that would embarrass me. But I wrote this book because I realized there's just this huge gap between when we were potty trained and when we become these fully grown adults who are, like, sitting in my clinic, sort of like not sure what a normal poop looks like. And even people, maybe you're in this category, maybe you're not, but people who think they have it under control think there's no problem there. There's actually a lot you could learn. I think about how to maybe optimize a little better,

how to improve all of your gut health as it relates to pooping. But you just don't know because we're not really having that conversation at a lot. Are people doing something wrong when it comes to their bowel habits in general? Yes. Like, is there a pattern that you're seeing? Yes. I mean, definitely the TikTokification in the bathroom leading to hemorrhoids, perhaps.

But anything... That was my study. Did you know that? No, okay. Tell me about this study. Because that's just something I see with all. my patience that I'm like, well, how long are you spending? Well, you know, you watch one TikTok and then you're down the rabbit hole. Right. Right? You don't watch one TikTok. Okay. I know you don't watch one.

Who watches one TikTok? Yeah, you go in there and you know like full details of the latest celebrity divorce. Like 45 minutes later, you come out of there. You're like ready to have that conversation. Well, so this is actually a fun example. So like when I write my column, usually what I write my column about is what readers send in questions. Like we have this forum. They can send me questions, people could DM me. And they're usually like fantastic questions. Do you get weird ones? Yeah, of course I get weird ones. Okay, what's the weirdest one you've ever got? Okay, can I tell you the weird one? Yeah. Well, I will say like the most common question I get is like people asking me really specific medical questions, which I can't answer. And that's like really tough and like sad to, you know,

like not be able to respond to. But I got this great one. Um, that was like, okay. Do you consider the gut inside or outside of your body. Yeah, yes, because you can think about the gut as like a donut. Yeah, or like, yeah, right, so it's the donut hole inside the donut. Yeah, I always say everything's outside. Get out. I think the gut's inside. I'll tell you my argument why.

Oh, okay. I think it's inside. Okay. Okay, my argument for that. Okay. Yeah, because I don't really have an argument as to why, but I'm just like, if you swallow something and it comes out, it never was in. Okay.

I see that argument. Non-digestible. Yeah. object. Yeah, like so the, yeah, the fiber component. Or the non-edible things that some people accidentally swallow. That's true that we go fish out at 12 a.m. Exactly.

Well, I think about it. And I think this is, yeah, this is a deeply philosophic, like we could argue this. But, you know, at the beginning and end of the GI track, you have two sphincters that usually stay pretty tightly closed. The lower esophageal sphincture, you can consider that one end you might. mouth, but I think I would start with the lower soft gel sphincter. And then you've got the internal and external anal sphincters. I think when you have those sphincters that are closed, and then along the way, you've got like the Iliocel valve, which is pretty much a one-way valve. Like I think these,

there's not really that much flow. Once it's in, it's not going back up. Once it's getting towards the end, like, it's got to go out. You know what I mean? And so like I think once you have like these closed doors, what's inside is an inside space. Like you can let air out. So you're saying it's like revolving doors. Don't make a space outdoors. Yeah. That was a good line.

That was really good. Yeah, it's like it's not an atrium, right? It's not like this open passage of like free flowing. It is like a revolving door type situation. If we're arguing about airflow and there's obviously airflow throughout the GI track, but there's also airflow when you have a revolving door, it doesn't mean that the lobby is outdoors. The lobby's inside.

Yeah. I think we could all agree. So anyway. You may have changed my mind. I hope so. I'm, obviously I haven't published this question yet because it's been like bothering me so much.

It keeps me up in the night. How did we get? But that's like, that was the weirdest question you've got to ask people. Like in the last week. In the last week. No, no, come on weird.

Give me something weird. Well, okay, I get a really common questions, which I don't think are weird. You can tell me if you think they're weird. But these are the questions that I get, like,

people will be like, hey, I had this like bright orange poop. What do you think about that? Okay. And these are like the kinds of questions I get in clinic all the time. Or they'll be like, hey, my poop was like purple this morning. And first of all, I usually tell people like picks or it didn't happen. You have to show me what this looks like so I can like evaluate it in real life. Like I can't just take your word for it.

See, when you said the percentages of people being embarrassed about their bodies, about their bowel symptoms, I have a lot of patients. Can I show you? Can I show you? And I'm like, right now I don't need to see. So do you have motivated patients that want to show you? Yeah. Well, there's like there's like another extreme too, right? It's like a little bit, but I actually am like very encouraging of this behavior because I love a picture.

Okay. It's so much harder to describe your poop. And then people want to dance around it and be deli-in. In fact, that's like why I use the word poop in the first place. Like you'd be surprised. Well, you might not be surprised. This word offends a lot of my Washington Post readers. Really?

Like I get a lot of speaking of like funny questions. They want excrement? Like what's the- Well, yeah, they're like, first of all, they're like, this is like, why is a doctor using that word? Like, shoot, you should say bowel movement or BMs or like maybe you should. talk about this topic at all. And I'm like, hmm, you see the problem we're running into care. Yeah, exactly. So I, so like when I started writing about poop, it actually came from, so when I was a student, I had this one like wonderful GI mentor who, um, I had shout at a lot

of gastroenterologists because I thought that's what I wanted to do. Um, and he was the first guy who a patient came into his room and he was like, so tell me about your poop. And when he said that and I was like, this is so weird, like a, like a doctor's using that word. But that patient, was like so, you could just see it. At ease. Like, oh. The relief. And so then when I became a doctor, I was like, you know what, I'm meeting people like of all ages, like all backgrounds. And I tried to, I tried to say bowel movement. And I later had some of my, like, college students who would come to see me as patients being like, I didn't even know what a bowel movement was. Like that was the first time I heard that word and you just, it, you made it weirder.

Like you made it feel like I couldn't really tell you what was really going on. At Desjardin, our business is helping yours. We are here to support your business through every stage of growth, from your first pitch to your first acquisition. Whether it's improving cash flow or exploring investment banking solutions, with Desjardin business, it's all under one roof. So join the more than 400,000 Canadian entrepreneurs who already count on us, and contact Desjardin today.

We'd love to talk. Business. When I say poop in my clinic, and like I let people leave. Like I don't really care. I don't care what word we use. But like when I say a word like that, like everyone's relieved. Like you just like this wall breaks down. And then they know they can say whatever word they want to use afterwards.

You know, so it's like it's the word I use that's like safe. But I get a lot of comments and questions and letters to the editor that's like, can she never write that word again? You need a, did. Did you finish editing the book in terms of chapters and everything? I did. Yeah, yeah, yeah. Because I was going to say you should have a chapter called why censorship is poop.

Because that's that's very apt for our conversation. Yeah, exactly. I do have a whole, like a little bit of a chapter about like why we don't talk about it, like what the response has been. But then it's like, I do think that that's like the 1%. You know, like I think 99% of people are like, thank God. Right. Yeah. Like we can just talk about this like comfortably freely with a judgment free space.

And that's the goal. Like if you have somebody, I have, listen, it's happened a couple of times that I've been like, well, tell me about your poop. And I can see that I've made it work. Like that person's like, I thank your pardon. And then I'm like, you know what? BM, BN. BN.

Yeah, yeah, yeah. Then I back. Like, I want it to be whatever word. Do you want it to be? Right. But usually. It's like when people come in, it's how would you like to be addressed? How would you like the excrement to be addressed?

Just the excrement in the room. Yeah, exactly. Yeah, exactly. So that should be in my intake form. Okay. So we know that people are spending too much time. The smartphone thing. So, okay.

Tell me about the smartphone thing. I lost track. But so, so usually I get quite. that inform what I'm going to write about. In this case, I had gotten this question about hemorrhoids, and we wanted to write about hemorrhoids for the column. And so, look, I'm a gastroenterologist. I know, just like you know, we tell patients all the time, don't spend more than five minutes on the toilet, right? And so for my column, what I like about the column is it gave me a chance to do some nuance, some deep digging into the research. I was like,

I'm going to tell people where that five minutes come from. I'm telling them why we say that. And I did all this digging. And there's actually like, there's one. It wasn't a good day. The best data, and this was like, I love this. There was a 1989 study from the Lancet. Like, this is what it took. Me too. 89 babies.

Great year. Yeah, I know. What a time to be alive. At that time. And like, as a scientist, like, if someone publishes in the Lancet, I'm like, wow. Like, that's like, you've achieved something great. And this is what it took to get published in the Lancet in 1989. They did a study of about a hundred people.

It was a cross-sectional study. Okay. People came in. The, like, colorectal surgeons in. England in this one clinic asked them, do you read the newspaper when you poop? Yes or no? And then maybe how much time they spent reading the newspaper. And then they peaked. They looked and saw if they had some hemorrhoids or not. 100 patients, cross-sectional study, made it to the Lancet. And they found that reading the newspaper was associated is not a

logistic regression model. It was like just a like a kind of correlation. Yeah, yeah, I know, like was associated with hemorrhoids. And I and that's. And how strongly? Strongly. But that was the best study I could find in like decades of like why is the case. And of course, we know like this was in my childhood. Yeah, like people were reading old magazines in the bathroom. You had those like old fashioned bathroom bookshelves. Nobody's doing that anymore. Everyone's bringing their smartphones.

So there was no data. So this was like a cool example of where I was like, I'm taking this reader question. And I'm going to do the study. Like I'm going to answer this question in my own lab. So we asked people coming in for their screening colonoscopies at Beth Israel. Do you take your smartphone in? Yes or no? How long do you spend on the toilet?

Like, what are you, do you exercise? How much fiber are you eating all these things? And then we looked during the colonoscopy, if that hemorrhoids or not. And it was true that we too found that taking your smartphone into the bathroom was associated with this 46% increased risk of us finding hemorrhoids. So that part we kind of had a good feeling was going to be the case. But what we also found is that most people who brought their smartphone in also said that they spend more time in the bathroom by accident,

like that they don't intend to spend that much time in the bathroom, but the smartphone sort of makes them. And they were five times as likely to be spending more than five minutes at a time. So it's not like a, it's not a randomized control trial of, will you get hemorrhoids by using your smartphone? I would love to have 20 years to do that trial. But it's as good as we get, I think, in the smartphone era. If Kevin Hall was not removed from his post,

studying metabolic medicine in the NIH, he has those metabolic labs where for two weeks, sometimes four weeks, he would have people that he would really control their diets. Yeah. It would be cool to have seen those people have some sort of marker that when they went to the bathroom, it flagged the time that they spent in the bathroom with their cell phone. Yes. And then, because it's already a research institute, get that answer of, oh, on average,

people spent this long. And once they hit this marker, the chance of, you know, the chance of that. them having hemorrhoids was this much higher. That would be cool. Yeah. We also, I think that is a good study. I also want to do a study. We have this test called an anorectal monometry. Have you heard of this test? No. It's a lovely study. So it's just basically if, so one out of three people with constipation who've been trying laxatives, the issue is not really that their colon's not moving and squeezing or even how soft the stool is. This is the pelvic floor. And so that's one out of three people. And so we do this test in neuroGI called

Interrectomyotometry where we basically is going to sound weirder than it is. But we put a small balloon in your bum and you push it out. And that balloon has sensors all over it. And then it measures like, you know, like what the pelvic floor muscles are doing. Are they contracting at the right times or predacclosureation? What I believe is the case we're trying to do the study is that I think when you're sitting with your smartphone and you're like kind of like enmeshed in like whatever doom scroll you're in, I think your pelvic floor muscles are not coordinating as well as they should. And I think that they're, you know, the whole idea about why sitting. on an open bowl for like too long, this five minute rule sort of came about is because we think

what happens is that, you know, on a toilet, there's no pelvic floor support. Like on a chair, like we're sitting against something that's giving us some counterpressure. You're not getting that with the open bowl. And I think that passive pressure, all hemorrhoids are our veins, right? They're just veins that become engorged when there's more pressure. And so I think the longer you spend over time, you spend more than five minutes every time, but you do that every day for weeks to years. I think that's what leads to the development of hemorrhaping. And so I think that's what leads to the development of hemorrhoids. But I think also that pressure causes those muscles to start to contract, shouldn't be contracting and the ones that should be sort of maybe increasing with their

pressure to like augment it. You're distracted so they're not doing that. And I think it leads to long-term pelvic fluorid dysfunction. This is what we're working on. If you want to know like the exciting frontier in my lab, that's what we're working on. Hot air balloons up the bum. Yeah, thank you. Exactly. Because I'm family medicine, I would need a good screening question. So for example, before I give someone a PHQ9 screening questionnaire, I do the pH2, which I ask them two screening questions that if they flag, then we go deeper. So maybe in this case, we asked them a screening question like,

have your legs ever fallen asleep while you're on the toilet? If they say yes, we're screening for hemorrhoids. Yeah, we're just going to take a quick look in there. Wouldn't that be a great question? Yeah, rather than, because I think it's a useless question to be like, do you bring your smartphone in? Yeah, because everyone's going to say yes. Yeah, or they'll say no.

But if your legs are falling asleep, that's a sign. That's deeply concerned. Yeah. And again, that's not medically validated, but it just feels like it would be medically validated. Oh, I think, yeah, yeah. Well, actually, you know, this is like a fun fact about pooping in hemorrhoids. Verico's veins. The same risk factors that lead to hemorrhoids, constipation, straining, low fiber diet,

are what leads to varico's veins because they're all connected. And so, I mean, I think there's totally a valid reason. I had a lot of, when this study came out, like, it got a lot of attention, right? Because it's like, I mean, who cannot relate, right? even if you think you don't relate, you relate. I got a lot of push back from, like, so I have two toddlers. I got a lot of parents who are like, okay, but like going to the bathroom and having my phone, that's like my only me time, you know?

And I was like, I get that. Like, I can't even go to the bathroom without like my dog coming in. Like it's like a blessing. But, you know, I think that people, like you don't have to reach the point that your legs are falling asleep. Like you should still feel like you have your me time. Doom scroll away. But I just think like put that.

Don't do it in the back. Put the seat lid down and keep your pants on. Like, you don't have to do this in this, like, compromise position. Yeah, yeah, good point. Okay, so that's a big factor in our lives. Totally. Treatments that were overusing or underusing for hemorrhoids. Well, I do.

The most underutilized treatment is, of course, fiber. Like all of us, like 95% of Americans, we're not reaching our fiber goals. Fiber is one of those things that it's like the most boring answer you can give anyone for what they need to do to improve their gut health. And yet it's like the hardest one to achieve, right? Like I think the most overutilized, and it's not for hemorrhids, but like what I mean any kind of supplement is easier than getting more fiber in your diet, except maybe a fiber supplement, which I'm okay with. But even in that regard, isn't it not as clear that it's just the fiber that's getting the patient, all the benefits? Or is it the combination of the fiber plus the phytonutrients and all these other. It's always better to get it in your diet, right?

Because I think we can do really sophisticated epidemiological studies, and they have, to the best that we can. And yet, I think we're never going to be able to fully, in epidemiological studies, say this was purely the contribution of the fiber versus like, yeah, exactly like all of the other nutrients. However, in terms of fiber supplements, Cillium husk has been sort of independently studied as like a supplement for hemorrhoids. It's been studied for fecal incontinence, which affects about 7% of Americans. So I do think if you're going to do nothing else, changing your diet's really, really hard. So I think if you're going to do nothing else, like Cillium Husk is probably the oldest and best studied supplement. But it's never going to be as good as changing your diet in a way that incorporates whole grains with all of the other nutrients that come with that, like colorful fruits and

vegetables, all of those things are hard to distill into a capsule. What do you say to people, because I know some folks in my personal life that I've given that recommendation to, that say their body doesn't tolerate fiber well? Yes. That is the most common sort of push-out. They'll be like, but I try, and then I immediately blow it, and it's so uncomfortable. Well, one, I think we should investigate whether or not that person has something like irritable bowel syndrome or maybe there's some other pathology going on.

But in somebody who maybe there's not a disorder or a disease process that we should think about, it's common that I usually when I tell people we need to increase our fiber, which is applicable to almost everybody, I never say we need to go from zero to 100 overnight because it will cause a lot of bloating and changes. The nice thing about the microbiome is that, you know, as you know, when we're born, those first few years of life or at the time when our microbiome is most malleable, afterwards we kind of get set in our ways for the next several decades of our lives. And really the biggest way we can change our microbiome afterwards is diet. And most of the studies have shown that it takes two to three months for our diet to change our microbiome. And meaning that if we start to increase

our fiber intake, it very well could be uncomfortable for the first couple of days, even weeks. But if we increase it slowly over time and give our bodies a chance to respond to it to change for that microbiome, maybe those species to shift a little bit, I usually find people are able to tolerated if they go low and slow, but they eventually, you know, they get there. So I think when people say, like, but I've tried it and it was awful, I usually say let's start over and let's just start low and get there because it's better. I mean, ultimately, eating a high fiber diet in the long term is so much more important than like the short term when by avoiding the high fiber in the first place. Yeah, yeah. Yeah, it's interesting because I've also seen patients who I've recommended

fiber supplement too, that actually they were, let's say, not perfect, but we wanted to optimize them a little bit better. And they said, oh, this actually created constipation in them and had sort of a paradoxical impact on their GI health. And I'm like, whoa, did not expect for this to happen. So I guess you're saying it's because of the microbiome changes that that? Well, partly, it depends on the fiber too. Like, what I like about Cillium Husk, which is a salt. Like there's, people will like beat to death,

like the difference between insoluble and insoluble fiber. And if I'm being honest, I usually don't tell patients to like worry so much about it because in your diet, it's a mix of insoluble and soluble. And like, and I'd rather just. You can have the people taking these gummies that are not.

Yeah. The correct form of fiber or sodas that have fiber. That's not really fiber. They're basically hijacking the term fiber. Yeah. Because of poor. definition set forth by the FDA? I think if fiber shows up in an ultra-processed form, like, we need to, like, take a step back

and say, like, what were we trying to fix in the first place? But, yeah, I think so soluble fiber, which is the kind of fiber that you put it in a cup of, like, you're supposed to take it with water if you take it in the capsule form, and it's present in a lot of foods. It's the kind that turns to gel. And I actually, like, I sometimes take cillium fiber myself because I, like, don't always meet my fiber goals, but I, like, like, like, like, to overdo it. If I don't drink, like I put it in my coffee, if I don't drink that coffee quick enough,

it will turn into jelly. And that is like not fun. So this turns off a lot of people, but that gel is what gives it the ability to add bulk to the stool. And so it can, for some people, it like may cause a little bit of constipation, but it can also kind of loosen it up. It sort of is supposed to be a bit of a shape shifter. And there have been studies that show it helps with constipation and paradoxically like it also helps with diarrhea. So I think usually if somebody swings in one direction, constipation or diarrhea the other, I usually tell people to just give it a little bit of time to kind of let their bodies normalize and kind of acclimate to the fiber. Where are my gloves? Come on, heat. Winter is hard, but your groceries don't have to be.

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All eight episodes now streaming, only on Disney Plus. So it seems like that would be a good choice, perhaps, for someone with an IBS mix type. Yeah, yeah. They're kind of fluctuating between the two. Yeah, like, you know, it's funny in IBS. There was a study that came out in the Red Journal, which is like our, it's like the American Journal of Guestradit. It's like our big journal in the field. And so the study was like, what are the number one recommendations that?

that people are making on TikTok for IBS. And fiber's like not on that list, I find. Like people tend to recommend abdominal massages and probiotics for IBS. And I think sometimes the basics like get, like fiber is like very well studied for IBS. Either ideally in your diet or and or through a supplement. Some people with IBS go on this diet

called a low fodmap diet you've probably heard of. And that's something that can help some people. We try it sometimes with our patients. Yeah, and it helps. Like, sometimes people pick out triggers. It can be limiting sometimes, especially when people have specific cultural diets. Totally. And I, like, and this could be because I see a lot of people who, like, you know, I'm like,

we're a tertiary center in Boston. But, like, I often end up seeing people who have been living on that really restricted low phodmap diet for months. And, you know, like, one thing I always try to remind people of is that low, Fodemap diet is not a long-term diet. It was never meant to be a long-term diet. So if you're living that way and you're like, but I can't eat anything outside of it, you definitely need to talk to either your doctor or get another opinion because you're not, you can't meet your nutritional needs on that diet. Yeah. Yeah, it's really tricky. And I'm curious, what bit of misinformation are you

seeing in the IBS community? Because this is a diagnosis I've seen patients get as a result of, of perhaps not making a diagnosis. Yes. And it becomes like not a diagnosis of exclusion, but almost like a catch-all diagnosis or a punted diagnosis where someone doesn't know what to say. They put IBS as the reason. And being family medicine,

I have a little bit more of a holistic view of things because I'm treating so many different elements in their body as well as their mental health. the amount of time that I see a comorbidity related to anxiety, depression, NIVS is super interesting to me and I'm curious in your line of research. Have you seen perhaps the nervous system that's in our GI track? Yeah. That is influenced perhaps in our neurotransmitter function in the brain play a role also similarly

in the gut and how that's connected. This is my favorite topic in the whole world. So I'm so glad you got into this. Well, one, I think you're right that when somebody gets diagnosed with IBS, it feels like such a disappointment for the patient, because the patient hears, I think often we don't know what's going on when you say it's irritable bowel syndrome. First of all, like, that name irritable bowel syndrome, like, is so fraught for so many reasons. But also, I think even the doctors, the way we diagnosed IBS is this like set of clinical criteria, which, you know, I'm not, you

By definition means your tests are all normal. Like you have to have normal tests or it can't be IBS according to our criteria. And eventually because there's a lot of comorbid anxiety and depression, I find a lot of patients end up hearing it's all in your head. This is all in your head because there's nothing wrong in your gut. We've done all these tests. They're normal. We know you have anxiety and depression.

We know there are studies that show things like cognitive behavioral therapy or antidepressants can help with your gut symptoms. And when all that comes together, the patient just feels like nobody believes me or this is all in my head and they keep getting told you need to de-stress to get these psych treatments. And if I'm being honest,

that's what I think a lot of medical students in residents learn too. Like, I did, it wasn't until I was a resident that I finally, like, really dove into the literature and learned that there are dozens and dozens of abnormalities

at the level of the, enteric nervous system, which is the nervous system in the gut, that are different in IBS compared to people who don't have IBS. For example, this is like just one of many. There are microbiome changes too. But like the barrow receptors and how they perceive pressure. Yes, exactly. Like we, the nerve cells, because the gut has millions of nerve cells, just like our spinal cord and brain, those nerve cells react at a lower threshold than people who don't have IV. So we will perceive normal changes in pressure from digestion, from food, from stool moving along that other people either don't perceive or just perceive as normal. They will perceive this as very uncomfortable,

and that can be measured. And that's, you know, we're just, we just don't do those. One, we don't do those stains on the kind of regular biopsies we get in colonoscopies. And two, a lot of the pathology, the enteric nervous system is in the deep muscle layers of the gut. When we do a colonoscopy, we're getting this like superficial biopsy, just like on the mucosa, the top layer. it's not necessarily going to reach where a lot of that pathology is. But once I realize, like, there are abnormalities, you would totally change your perception of the patient sitting in front of you. Just in the way that, like, in my field in GI,

if we have a patient with inflammatory bowel disease who comes into the ED, and they're saying, I have 10 out of 10 pain, and now, and then we have a patient who comes in who says, I have 10 out of 10 abdominal pain, they have IBS. When we scope both of them, we do colonoscopy, or an upper endoscopy. And we see the patient with IBD has bleeding everywhere.

And there's inflammation. And it just, it looks so, so horrible and uncomfortable. We immediately feel sympathy to that patient. And we say, my gosh, there's like,

there's something so wrong here. And we have all these treatments that can help you and we're going to get you better. We go in and scope this other person who has saying they have the same amount of pain, but everything looks normal. We take the biases. We're like waiting. They all come back normal. Those people don't get that sympathy.

They don't get that like, It's like an invisible illness, right? Yeah, yeah. And on top of it, we don't have 20 different, like we don't have 20 pharmaceutical companies who have come up with these brilliant treatments for them. There's not even like a race for the cure, right? For some of these like disorders of gut brain interactions is what I treat. And so it can just be really isolating difficult.

So I think like one of the big myths about IBS that I try to combat every day is that it is not all in your head. Usually the conversation I have with people, and there's different degrees of IBS. There's like kinds of IBS that you can manage. kind of with some simple dietary changes. And then there's really more intense cases. And that's probably with the kinds that I end up seeing. But usually the conversations I have start with me saying, one, I know it's not all in your head. Two, even if your tests are normal, I believe you, that your symptoms are real. And I know there are abnormalities, whether or not the tests that we have

are reflecting them or not. Because of all the tests that we've done in research where we've done these full thickness biopsies of the gut and researchers have tried to understand that. I try to also tell people, there are hundreds of companies out there who will sort of like prey on your vulnerability and wanting testing abnormalities. Like, you want to something. And for the fact that the healthcare system has written you off and made you feel like it's all in your head. And then you get this company that will say like, exactly, like you, you know, we have this

set of testing. Maybe it's food allergy testing. Maybe it's microbiome abnormality, like something. And for however many hundreds of dollars, we'll do that test and we're going to show you what's wrong. And then the test come back and often there is something that the test is flagged as not being normal. I usually, I try to tell people that those tests that are these third parties, they don't necessarily change what we do. They can point out abnormalities that may or may not be clinically valid, that may not correlate to the pathology that is actually underlying the issue. But I also, the good news is that we have a lot of treatments.

I think we just haven't done a good job of like advertising what they are, of like making people aware. Some of those treatments are very natural. Their diet approaches, their physical therapy approaches. Well, walk me through the sort of hierarchy of if you're starting from a mild case and you're making dietary recommendations to whatever your big guns are, your vancomyze. My gosh, no.

No, but I mean in terms of antibiotic treatment. Yeah, yeah. Diet is often the first thing. So people with ibates, and again, you are right to say that IBS is this word that catches dozens of different kinds of pathology, which is kind of the challenge of it. But it means that some people are going to respond to changes in diet. Some people are going to have different dietary triggers than someone else who is equally labeled IBS, but they're just dealing with very different.

things. So sometimes it's changing their diet. Sometimes it's a low FODMap diet. But you said they shouldn't be on that long term. What would be a solution long term for that individual? What we want. Reintroducing individual. Yes. So with the low FodMap diet, what you're supposed to do. And this is why I actually, I don't like when people go on these without a registered dietitian, like watching very closely, because I too often see people just restricting for the long term. But what should happen is maybe for about two weeks, you cut out everything that are in this group of FODMaps, the FOD, MAP, each stand for a different food group. And each of those six food groups are kind of known and studied to have been triggers

in people who have IBS. If after the end of those two weeks you feel a lot better, it tells me that there is something in one of those foods that is triggering your symptoms. If you at the end of those two weeks actually don't feel much better, we can stop the experiment right there. Like we don't have to, you know, do it. It tells us foods maybe not the problem. Or food could be the problem,

but we need to approach it a different way. If you feel a lot better, then we systematically add back in those food groups, one at a time, and then we say, okay, we've added back in the F category, and now we keep a food drive, and we say, how do you feel over the next week? And if objectively you still feel pretty good, great, means that food group is not the problem. Then we add in the next group, and then suddenly you feel worse. Then we say, okay, this is helpful. There's something in that, oh, category that we need to, like, pick out.

And so ideally, it would just be like one or two things that we find. And that's often the case. Like maybe it's onions. Onions and garlic are like the secret ones, right? When you find what those one or two things are, you can liberalize your diet again. You can eat things that you previously might have restricted yourself from eating because now you've picked those two things. So it shouldn't be this long-term thing.

It should just be a tool to find maybe just a couple things that are the triggers. For some people, and what's interesting is, you know, food intolerances, they're very, different from food, traditional food allergies, right? And there are third party tests that will tell you if you have these kind of like non-traditional food allergies like I'm talking about. And so like people will come in because the low phobab diet's hard to manage and they'll get these companies, they'll be like, we'll do this blood test and we'll tell you what the problem is, you know? And they'll be like, look, I got this result and it's like horse radish and it's cabbage and it's like these things. And I'll be like, maybe it is. Like you tell me, did you stop eating

horse radish and you felt better? And they'll be like, oh no, I used to. tolerated in the past. And it's like, well, wait a minute. Then that then that's not necessarily telling us anything. But there is a study that I like, I think about a lot. And I don't know how to know if it applies to the person sitting in front of me every time. But someone might come in with IBS and they have like totally, like they'll get the kind of go to an allergist. They'll have totally normal food allergy testing. But they did this study. I think it was 2021. It was by these neurogestan anthropologists in Belgium, who are our colleagues, and they do really good work, and it was published in nature, and they basically found that in a small cohort of people with IBS, who would just

have met criteria for IBS, if they were to expose them to the antigens in different classic food groups, like maybe it's dairy, maybe it's gluten, maybe it's shellfish, things like this, that they didn't actually have a formal allergy to, but during the endoscopy in this research study, they like sprayed this like slurry of shellfish on their, because normally we don't do, right? This is a test we don't do in real life because we always tell you to fast before your endoscopy. But they did this in the research study. They were able to see, they took videos that for people, some people with IBS, and was the case in this study, they would have these like kind of wheel and flares like we see, like an allergic reaction to certain types of food triggers that you would never have caught.

On a blood test. Yeah, you would never see it on a blood test. You would go in, you know, like during a standard endoscopy after they'd been fasted. You'd never see that because you just weren't looking at the right time. But they were having a reaction that we think could be mediated by just local mass cells. So not causing this big inflammation in your bloodstream, but by mass cells that are just in the gut. And sometimes those people actually respond well to mass cell inhibitors, which, you know, if you had just done a blood test, you would never think to try those on. So sometimes you don't have to cut out the food groups, but you need to kind of think about medicines that might address what those foods are doing.

to you. Again, sometimes we don't have the perfect test in a clinical setting and it can be a little bit of trial and error. But anyway, food is the first thing that we think about. We try to see if there are certain food triggers without telling someone to eat so restricted a diet that their life is miserable. Yeah. There are also like simple. Before you move on, I'm just curious, for those clinicians who do sell some kind of kit to get these answers. Do you feel like what they're doing is unethical? Yeah, I mean, I think anybody who is profiting off of a vulnerable patient who's looking for answers, would they knowingly know the data isn't there?

I think that's completely unethical. I think that there's a difference probably in, I mean, this is a very different thing, like in doctors who are trying to think outside the box and trying to think of ways to help patients, where they're not profiting from it. Like so, you know, okay, probiotics are another like sort of top thing that patients think about. Sometimes doctors recommend probiotics themselves. They're not making money off of that. They're just like, we try it, right?

I don't think that's unethical to try because I think the doctors want to try to give an idea to a patient. And I think probiotics are really tricky because, first of all, patients tend to think that gastroenterologist in general love probiotics, right? Like it comes as a huge shock when we say actually, formally, the American Gastroenterological Association, we don't recommend probiotics. That's a big surprise sometimes because the marketing...

Well, outside of specific uses. Yes, for most indications. Yeah, like pouchitis and IBD, we do. And there have been a handful of randomized controlled trials, a handful that show it may be beneficial in IBS, but then when you look at the data on aggregate, when you do these meta-analysis, it's actually not great.

So we don't recommend it formally. That doesn't mean that when a patient comes to me in my clinic and they say, I try this probiotic, and it's the only thing that worked, like my bloating went away or my pain went away. That doesn't mean I think they're lying. I don't think that at all. I think one of two things.

One, I think they got really lucky, which is wonderful. they found they were the right phenotype. They found the right formulation, the right strain that happened to be what they needed. Maybe it's the placebo effect. Could be the other possibility. Usually, regardless, I'm happy for them and I move on with my life. They move on with their life and they live their best life. So I like putting myself in the shoes of the listener.

Yeah. Or viewer. And in this case, it's someone who's experiencing unusual abdominal symptoms, hasn't really gotten a diagnosis is considering spending their limited health care budget on a probiotic. Yeah. And historically, I've said on the channel similar to this statement that we shouldn't be using them except in very specific instances. I don't like doctors who sell them.

I've called them out publicly on the podcast. Yeah. But then when we say something like maybe by chance you got lucky and it worked, isn't that person just thinking, what if I'm the lucky one that hasn't tried it yet and I should try I think that... Back to the interview in just a second, but first I want to tell you about Microsoft Dragon Co-Pilot, an AI clinical assistant built to simplify and transform the way care teams work. I've needed something like this since I started practicing medicine.

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is to make the day-to-day work lighter, so we can stay focused on care. All right, let's get back to the interview. Yeah, I think we you're hurting and you're suffering, like you want to believe you're going to be that lucky person. And we also know the placebo effect is real. Like we know that some people are going to experience a benefit. But that is not maybe sustainable. And that's not necessarily due to like physiological changes in the gut. They may be due to changes in the brain. That's not, however, the vast

majority of people who come to my clinic are not people who say, I tried this probiotic and I got better. It's the vast majority, they're on a probiotic, or some are on probiotics, and I say, hey, you know, but is this helping? And they'll be like, well, I don't know. Yeah, or now that we're thinking about it, like, no. And if that's the case, then I think that's a good opportunity for us to look at the data and just say, like, you know, the truth is, the data is not as hot as it seems like it is when you're walking down the supplement aisle. And I think if it was, like we'd all be on a probiotic. There's also a lot of people who take probiotics who don't even really have symptoms. They just take it because they think it's good for gut health, right? It's just been marketed

as like, can't hurt might only help. And like they somehow think they're optimising. Well, they treat it like the gym. Like they're not using it as physical therapy. They're like, I'm just going to get better with this. Yeah, there's only upside to this. And I would argue that like truly, I think the downside of the probiotic supplement industry is that we neglect probiotics through our diet. Like if we could all optimize, like there's no GI doctor who would disagree that we need more probiotics in our diet.

We all want that. And we want that for our patients. Like, and, but we're not probably all getting that, right? Like when we talk about probiotics in our diet, we're talking about like maybe obvious choices, like, Greek yogurt, for example, it's like a good one. First of all, Greek yogurt, I love Greek yogurt. Yogurt's sometimes like, you know,

you have to be very careful when you pick a yogurt too, right? Because a lot of them are ultra-processed. They have a lot of added sugar. You have to kind of, you know, it's not as straightforward as it could be. But besides that, it's like fermented foods, right? Like, we love fermented foods in GI. Well, a lot of people, like, take time to come on board with the idea of eating more fermented foods.

It's so much easier to just take a capsule or a pill if you think they're doing the same thing for you when they're not. And what about the fact that some of the yogurts are, let's say, pasteurized? Yeah. And then they add the cultures in after the fact. How different is that? than taking the supplement? I don't, well, there haven't been, to my knowledge,

any head-to-head trials of like Greek yogurt in that form with the supplements. Usually the trials are done like supplements versus nothing, like placebo, like empty, empty capsules. But what they do often find is that if there are, if it says what it should be, I should say, if there are live cultures in the yogurt, that's supposed to be the beneficial part.

So what the problem is that a lot of when it's in capsule form, the live cultures are dead. They're not actually like living by the time they enter your body. They're not reconstituting anything in your gut. I mean, the big problem about microbiome directed therapies that you can just buy in your grocery store is that despite what I think some companies are currently saying, we don't actually even really know if the microbes that we associate with certain disease states are the cause or the effect of that disease. We know that there's a lot of associations with some bacterial strains seem to be upregulated or higher in certain diseases that we don't want.

Those same bacteria seem to be lower in disease that we do. So it doesn't always add up. And sometimes I tell people like your gut microbiome, it's like this garden, right? And what you see sometimes are the flowers or the weeds that are growing there, and you think to yourself, gosh, there's all these weeds. Like, what I really want are these flowers because they seem to be associated with happier people, healthier people.

But you can maybe pull those weeds out and you can sprinkle some probiotics, like some nice, lovely seeds for beautiful flowers. But if the whole problem here is that the soils pH is wrong, that you're like not getting enough sunlight to that garden. in, it doesn't matter what you're messing around with, with the supplements and the probiotics. You need to change kind of the underlying issue here, which is the prebiotic part of it, potentially that could be it. Like, maybe you're just not getting enough nutrients in your diet to support the growth

of the right type of flowers or microbes. So I think we've oversimplified, we've monetized the probiotic industry in a way that has just gotten eons ahead of the science. As a gastroenterologist and as a scientist, I think the microbiome, is one of the coolest frontiers in our field. And I hope, and I think in the next, if I'm being optimistic decade, probably longer, we will have microbiome-directed, targeted therapies for each person,

where we say we have an effective way of understanding what your microbiome looks like, and we know exactly how to change it for you. We have the right way to do that. We don't have that today. We do not have that today. Like even fecal microbiota transfer transplant, FMT, which is probably, you know, the most intense, in-depth way to change someone's microbiome doesn't work in so many indications. Like the numerous meta-analys have shown it doesn't work for irritable bowel syndrome. It doesn't work for Parkinson's disease, which is what I study.

There was a big meta-analysis in JAMA about this. As you've seen, it works really well for C-DIF, C-DIF facility. Yeah, for sure. Right? But that's so, so narrow. And it's a very specific situation happening in C. diffacil. And so, like, what hope do we have by ingesting this capsule of dead microbes and, like, hoping it makes its way all the way down into our colon?

It's very little. So, ultimately, when patients come in, you discourage probiotic use? I don't encourage. I don't rip it from somebody's hands if they believe that it has made a big difference to them. But I'll tell you, like, that's also just not usually the case. for someone who's come to see me. I don't see that. I also, if somebody's spending a lot of money on it,

and they're like sort of on the fence, I try to think about, well, what are the other things that have been slightly better studied or even greatly, like, far better studied than probiotics that we can think about? And sometimes, I think, what the appeal of probiotics

is in a way that it feels natural, right? Like in gut health, there is a lot of people, and this is actually not just true of gut health, to evolve medicine, people want a natural solution to their problems that don't involve a medication per se or something that we call a medication. And that's why changing the diet when possible feels very alluring. And I think that's also why probiotics feel very alluring because it feels like something natural you're taking. Oftentimes the answer, though, is a medication. And we have a lot of, what I think people don't appreciate is that you might think from what

here online, or even from what your own doctor tells you, because this is like a subspecialized field. NeuroGI is like not even just gastronologist. It's like this special thing. There are a lot of medications that target the interic nervous system that we have that you just might not have thought to use, might not have heard of. Or, you know, you've heard of them, but in the wrong context. I'll give you an example. Like we often in neuroGI use medications that at one point in time were developed as antidepressants. Like we use things like tricyclic antidepressants, which are not very good antidepressants anymore. But when they were developed, they were thought to help with depression. They're kind of weakly, they have some of those properties. But what we discovered in GI is that

maybe they're not so fantastic at affecting our central nervous system, but they're very good at increasing the threshold at which the nerves in our gut respond and react. And so it can take somebody who responds so easily to triggers within their body to send off these messages that tell their brain they're in pain, it just raises the threshold, these medications. And so those nerves are not responding to every small gurgle, every change in pressure and distension. You have to be very careful, I think,

when you talk about these medicines, that you don't present them as like a, well, the real issue here is your stress and your anxiety, and this is a medication that's going to treat your, you know, it's what we're really trying to do is treat your depression, Sometimes you have to, as you should, you have to go through the whole kind of physiology of how these things work to help people understand that you're really targeting the gut more than you're targeting the brain. But it's a longer discussion and there's like a lot of nuance to it. You often just don't get that in a rushed visit.

Yeah, that's tough to get into a 15-minute visit. I know, and you're just trying to check someone's blood pressure. So we started with the diet. What's the escalation of care after that? Perhaps cyclic antidepressants and amtripylene anything else? Yeah, well, it depends. Yeah, there's, it depends on if you have like more diarrhea, more constipation. There are a lot of medications for constipation, like over the counter laxatives that people

usually will have tried by the time they come to see me. Yeah, Sena or Miralax. Colase is kind of a placebo. It's been shown like in a lot of our randomized control trials to not really do too much. What about in combination with Senna? Because that was the cocktail that we would use inpatient quite often. Yeah, I usually, if somebody has like 20 medicines on their list, I just take colase off. Interesting.

Because it's just, it's not giving you much bang for your buck. SENA is pretty effective. And SENA is like a stimulant laxative. It's effective. But there are people who, you know, very commonly in IBS, they won't have responded to most of the stuff you get over the counter, right? And then they're struggling. And then they say, but I have IBS, so there's no treatment.

And actually, there's lots of different prescription medication. that treat not just the constipation, but most importantly, the pain and the bloating that go with IBS. That's like kind of what makes people extra miserable. And you might have seen some of these like linnaclitide or Pucalipride is another one. But there are all these medicines that like the average person

isn't talking about because... Is that Linzess? Linzest, yeah, yeah, yeah. And they're there and they show that, yeah, they work very quickly to relieve constipation in the first couple of days. They're very, very good laxidus. But then the clinical trials,

are shown over eight to 12 weeks, they can help kind of rewire the system to help with bloating and help with the pain. And so I like those medicines for people who not just have constipation, but have a lot of the discomfort that goes with it. And they're great. And like they're easy to titrate. You just kind of needs a doctor to help you get there. And you don't get some of those neuromodulatory effects, neuromodulating meaning changing a little bit of the threshold at which those nerves react through diet alone, or it can be really hard. I think that a lot of, you know, you mentioned the interic nervous system. The interic nervous system is creating neurotransmitters very similarly to how our brain does. A lot of those can be influenced by what we eat,

and then they can be influenced by how our microbiome processes what we eat. And there have been some limited studies that show epidemiological studies, mostly that show that even, eating a certain kind of diet, whether it's the Mediterranean diet or like a more anti-inflammatory kind of diet can help with chronic pain and IBS and these types of symptoms. But I often find that you need both. You need the diet part of it. Some people just will benefit from the medicine as well. And I don't think there's ever really any shame in that in needing to get the help that you need. It just people want the natural way with the probiotics. And it just, I get why that feels more natural, but when you then sort of realize, wait a minute, it's like dead bugs,

suddenly that feels a little bit less natural. Yeah. Yeah, that's tricky. Have you heard the information coming out recently that younger and younger people are getting colorectal cancer? Yeah. What are your thoughts on that? Yeah, this is, well, this is probably one of the biggest medical mysteries of, I think, our time in GI. It's something that we're thinking about all the time. I've probably made a handful of colorectal cancer diagnoses myself during colonoscopy in the last year on younger people. More often, fortunately, what I see are the polyps. You know, what we know is that there is this trend in younger people that is a really, that's a real trend where younger people, meaning under the age of 45 or 50, depending on how the study was done, they're getting diagnosed at higher and higher rates with colorectal cancer. cancer. Meanwhile, older adults, those rates have been falling, which we think is probably due to

screening uptake. We used to, I think, like when I was in medical school, I used to think of the big risk factors for cancer as being smoking, and then like your genes. And obviously, we've been smoking a lot less as a society with every generation. And our genes themselves haven't been changing, although I think our epigenetics can certainly be changing. And most of the, this is something I've written a lot about for the Washington Post, but most of the, of the oncologists and experts that I talk to sort of all agree that it has to be something in our environment that's changing. And I think what I've come to appreciate is that there's no like one smoking gun here about what it is, but I do think it's a confluence of a lot of different

factors. I do think diet is a big part of it. I think the other thing that I've come to appreciate, which is pretty sobering, is that a lot of our risk for early onset color bacterial cancer, the groundwork for that starts to get laid when we're really young. You know, like it's early childhood factors that often we don't have that much control over. You know, like there's this classic scenario that's tragic that we see patients all the time who will say, like, I did everything right. And they did kind of do what we might say is everything right. You know, like they're fit. They eat healthy, like all these things. And I try to sometimes, I'm explaining these cases to my patients or to the public, you know, with cancer, what we see

is the end result. We see when someone gets cancer, it doesn't get cancer. And I think about cancer risk, like sometimes I try, the analogy I use is like you're building a tower with a stack of blocks. And when somebody gets 10 blocks, they get cancer or they don't if they never hit that threshold. But some people are born, maybe it's their genes or maybe it's their early. childhood, they have like nine blocks by the time they hit adulthood, stacked against them,

right? Like, we know there are these risk factors from epidemiological studies, like drinking sugar sweeten beverages has been associated with early onset chloropal cancer, sedentary lifestyle, ultra-processed food, some of these things. Maybe some of those things were part of their lifestyle before they even really remember, like what? Like right now, today, if I were to ask you, like, Mike, when you were seven, how many hours of sunlight did you get? Got a lot of sunlight, but I also got a lot of sunlight. But I also got it. a lot of two liters of soda. Yeah, right.

Like, I mean, and sometimes it's hard to quantify. Like, you might be like, yeah, I drink two liters, I think,

like, on average every week, or was it every two week? Every day. It was every two weeks. That was my hydration. I used to drink a lot of capri sun, if that helps.

Yeah, yeah, yeah. And so you might actually, like, have more blocks stacked against you than it seems to the outside world than you even know. And then you say,

like, well, you know, like then it takes very little for you to hit that threshold. And then somebody else, you know, like seems like they've done all the wrong things. And I don't even like that label. But they'll live at seven blocks their whole life. They'll never get cancer.

But you'll look at them from the outside and you'll judge. So I think, one, it's important to not judge anybody for, and certainly never to blame somebody when they have cancer. Because that's the first thing that a patient does. When I tell them you have cancer, they say, like, why me? Like, what did I do? And it's never so black and white as what did you do? This is like a really hard topic.

Of course. But I also think it's important to remember that we do think 40 to 50% of our risk factors for cancer can be modifiable. So it is a helpful conversation not to blame anyone or ourselves, but to say, okay, these are the risk factors that we think are associated. Maybe I'll make some changes going forward that will help me lower that risk. We won't eliminate that risk. We can't do that for anyone, you know, for any disease almost. but it might help us lower that risk. And so, I mean, one of the biggest ones is, is probably ultra-processed foods and how much

ultra-processed foods we're eating. It is, I think ultra-processed foods are, there are certainly inherent chemicals and additives and problems with the foods themselves. But I think for me, the bigger thing is like what we don't get when we fill our diets with ultra-processed foods, and that's fiber. Fiber has just been known to be so protective against cholesterol cancer. But it's also, like you said, eating a whole food diet, one that is filled with lots of different nutrients from different plant-based sources, those are the kinds of diets that the studies have

shown are probably most protective, more than just like a fiber supplement per se. So I think changing how we eat is like an important big part of the conversation. It's also the, I see whether we're talking about cancer or something else, changing how we eat is one of the hardest things any of us can do because it's so linked to our culture. it's linked to our pleasure. It's like part of who we feel we are. So it can be really hard to tell somebody like I want you to cut down your alcohol or I want you to cut down how much red meat you're eating in a week. So sometimes I say an easier place to start is rather than saying like here's all the five things you should cut down.

You could do that and should. But maybe think about what are you going to add. Like maybe at dinner just think about I'm going to add one more serving of vegetables or I'm going to eat like one more serving of beans this week. And even like a small thing that you're going to add that's good for you, rather than starting by taking things away, can be like that gateway into eating a little bit. Or unique swaps. Like I found a great way to get some fiber in as I switched over to fiber pasta. And I've experimented with different ones, the classic chickpea, edamame pasta? Yeah, mong bean.

Oh, I love a good mong bean. Mung bean pasta is not for the week because it's like a 40 gram dose of fiber in a single serve. I think legumes are like, oh, I'm sorry, so underappreciated. I actually don't know where you get mung bean pasta. I eat mong bean pasta. I'm just like on the own. I'm sure it's sold in supermarkets, but I'm a big Amazon shopper. So yeah, mung bean pasta was a great hack.

There's even just classic spaghetti that is fiber rich. I think it's called like fiber spaghetti. Yeah. And I feel like that's a great way. And I know some people like to do the protein fiber pasta. I don't like getting my protein from pasta because I'm already consuming a protein as a meat eater. Yeah. That I'm like doubling up on protein and getting 100 grams in a meal is not very valuable.

The protein, like protein is like the new like I don't even know like everything's got a little added protein. Yeah, protein water now in Costco. Isn't that why? Protein water? Yeah. How do you do that? That's what I ask. I don't know what is.

To me it's like that's just a shake. Amino as like I don't know. Isn't that a shake? No. it's thin, it's water. Fascinating. Yeah. Sam, we got to get it, by the way, because we reacted to it, but we never purchased it.

We should. Oh, yeah. You should taste it. We should taste it and see what it looks like. What if you love it, though? You might accidentally sell it. Who knows? It doesn't hurt.

So, yeah, that's an interesting way to get people to make healthier swaps. I know people were encouraging that for meat substitutes, but fiber substitutes, I think, is a little bit easier. Yeah. I mean, the meat substitutes. Even I, I mean, I, I, I, I, I, I, I, I, meat in my family too. We tried for a while, like this is like a couple years ago. We were like, let's eat more of the meat substitutes like for taco.

Like we do, Taco Tuesday. Yeah. Big hit in my family. Um, eventually we kind of like got turned off of it a little bit too because I think even some of the like highly ultra processed meat substitutes. I was like, they're also. Yeah. Like they weren't actually like probably like they were.

Like they were making like a win in one category. Yeah. Maybe. And then like maybe I was taking a hit in another category. I think even the types of meat. you're consuming, you can have a much healthier meat. I found an amazing thing because I was looking to lower my saturated fat intake. My cholesterol was quite high.

Yeah. And I found a type of bison cut that was in a serving six or seven ounces, I forgot what the number was, one gram. Oh, it's really low. Super low. And I'm like, this, I couldn't even believe it was real, but it's so valuable to get a lean piece of meat because you're still getting all of the iron, the B12, like the things that you'd be concerned about. And you're not raising your cholesterol as much as you would be otherwise. Yeah.

Because otherwise people think, oh, let me get a fatty rib eye. You know, that's not necessary. Yeah, that's like the only way. It's in the world of colorectal cancer, actually, I'm glad you brought this up because it's, I mean, there's two degrees of meat eating that I, that tend to polarize people. Like there's, I think almost everybody agrees that processed meat. are probably have the strongest data to being linked to colortical cancer.

And those are things like the hot dogs or cured meats and stuff. I often get a lot of pushback when I talk about red meats in general being linked it to chloroctal cancer. And, you know, I think this is like worth exploring because red meat, I think we don't have all the data yet

about what it is specifically about red meat that's contributing to the cancer risk. Right. You know, like so I think, for me, I'm convinced enough by the data on red meat that I think most of the epidemiological studies seem to indicate that more than three servings a week is linked to a higher risk. And there are a lot of people who are eating so much more than that that I think even like a little bit of cutting down helps. What I think we don't know yet is, is it something inherent

about the red meat itself that's the problem? Or the type of red meat we're consuming. Yes. Or is it the type of or how we're consuming it without marines. Is it the Mayard reaction with or without mariner? grenades. Is it, but I, and so I often, like, because I write about this on the post, I've done reels about this, like, I get that red meat is like a big part of our American culture. So it is like, it's hard to tell people, like, it's the cookouts, you know, it's the stuff that you love to eat when you're gathered with your family and everyone's having a great time, that that stuff could be harmful. So I often get a lot of pushback that's like, you know, it's not, it's not red meat. it's the fact that you're not eating organic grass-fed beef.

When you eat organic grass-fed beef, there's no cancer. There's no data that will make that true. At this point, but I do believe that, like, there's probably healthier ways to eat the red meat to lower your risk. But as we're eating it today, the way we can do these epidemiological studies, we haven't gotten to the point where we can, like, really slice down the, you know, like a year ago,

what temperature was your grill? like how did you merit, how many? Open flame or not open flame? Yeah, we don't know that. So I think the safest thing I can recommend to somebody is to try to eat no more than three servings a week in whatever way it is that you're making it right now. And I like there are studies that show like you mentioned marinating, like marinating your meat can in theory prevent some of those carcinogens locally from forming directly with the proteins from the meat. So that could be protective. We're probably not at this stage where I can tell you, if you marinate your meat every day, you'll never get cancer. Your cancer will be, you know, half by like a, you know, whatever percent. But there are ways to

make it better and there are ways to keep eating meat in your diet. And we also have to remember when we say, you know, by consuming three times or X number of times per week, your number goes up by having colorectal cancer by 19% or 20%. Absolute versus relative risk. What that actually means big picture in comparison to all the other things going on in your life. Like how well is your cholesterol managed is probably going to be a way bigger factor for that red meat consumption? Yeah. And is this the hill that you personally want to die on?

You know, that's like a very personal choice. So because in family medicine, I'm pulled by specialists in so many different ways because of the organ they're looking to protect and serve. And I'm like, hold on a second. There's a person in front of me. And while, yes, I want to reduce their red meat intake. but it's not because the red meat raises colorectal cancer by 19%. It's because their cholesterol is also really high.

Their family history of cardiac disease is high. They have a high risk for Alzheimer's because they did genetic tests. So I think about it broadly. Do you, as a family medicine doctor, do you find that you're seeing more people uptake the screening in that 45 to 50 range for colorectal cancer screen? Well, whether they choose to uptake it or not, we kind of like force them into.

You were recommending it. In the sense, yeah, I recommend it. We have such a good relationship that I guess everyone goes for it. Yeah, exactly. That's great. And we also have really great screening protocols in our hospital because we're academic institution. We have residents.

We have free options for people who are charity care. It makes it a lot easier to get this stuff approved and done. So even from like a scheduling perspective, we have like open access scheduling where they can direct schedule. Oh, it's the best. Yeah, I do a lot of open access. Yeah, exactly. So that makes it easier. I will say with some of the non-colonoscopy screening options, people do get excited about

those for those who have fear of sedation. But to me, I always try to avoid that because there's limited things you can do in terms of prevention by getting the polyps out and being more preventive in that way. Yeah. I mean, I think like a lot of the conversation about early onset chloroctal cancer is about changes you can make in your lifestyle and diet and changes. but I also know that I forget the exact statistic, but a good portion of patients who were diagnosed with early on sick, colorectal cancer, so like before the age of 50, we could have caught that

case earlier if they had gotten screened according to just age appropriate guidelines based on a family history, you know, like 10 years prior. Yeah, like first of all, I think we're like not enough people in that 45 to 50 year old category are getting the screening. Like we're all so worried about the rising. kind of number of cases. But then I think when it's our turn to go get the colonoscopy, like we're a little shy sometimes. But the number of people who I sometimes come to my clinic and we're deciding, like, when are we going to get the colonoscopy? Like, what are their risk factors?

And I tell them, like, well, tell me, you know, who in your family has GI issues. It's actually, like, pretty common. I mean, and I think I know this from my own family, too. They'll say, like, I think my uncle had some kind of cancer. You know, but they don't know exactly what the cancer was. And then maybe the most important question is how old were they even got the cancer? Nobody knows that stuff. You know, and like, you know, she was like, do I know that for like a lot of Mike Sand family? But it makes such a big difference. Do you think if we were to parse out that data, obviously you'd be hypothesizing here, but would it bring the numbers to a less scary increase than what we're seeing now? If we were to have caught the people who would do.

Meaning if we were, yeah, if we were screening the people that were needed to be screened. I think they have parsed these numbers, and most cases are not genetic that are attributing, that are contributing to that rise. So what we would be catching are the genetic cases, but those are actually not the majority of cases. But there are still cases that are preventable. And like any portion of that puzzle that's preventable, we have to try to hone in on. I function in a weird space because I work at a community health center, but I also spend

time in their private clinic in the hospital system. and being that I'm in the media space, I have a lot of people that come to me asking questions. So I have this world where people need care and they can't afford it or they have difficulty getting access and they need their colonoscopies. But then I also have some of my friends

that are in their 30s. They're like, I heard this on the news. I want a colonoscopy right now. And I'm like, bro, you do not need a colonoscopy. Trust me. Delightful as it is. Yeah. There is no need for this.

So what do you do when a patient comes in really excited about getting a colonoscopy? but clearly doesn't need one. Yeah. I love what people are excited to get a colonoscopy. But it's true. And I actually will say, like, I think the discussion about the rise in cases has made a lot of people want to just get a colonoscopy, even if they don't necessarily have any of the

symptoms. I get that tension because I get that the signs are often really subtle. Like, we think of the signs traditionally as like rectal bleeding, right? And that would flag almost any doctor to say, yeah, we've got to look. We've got we take that really seriously. And so like if anyone's listening or was rectal bleeding, like do not brush that off at all. But sometimes the signs are more simple. They're like just a.

Stool caliber pain. Yeah. Like it gets like thin caliber stool or maybe looser stool. Like it can be diarrhea. It just be some bowel habit change. That's so vague. And I, and I think often, of course, people with irritable bowel syndrome are like, it's me. This is what happens to me all the time.

I have these changes. And, and how can I. be sure it's not cancer. And I do think that's where having a good close relationship with your doctor that you trust, who trusts you, is important. I obviously don't give out klonoscopies to everyone who wants them. People, you know, they don't meet the criteria for them. But I've also become a lot more thoughtful than I was 20 years ago. Like 20 years ago, if someone was young, came in, and they didn't have rectal bleeding, like, cancer wouldn't have been on my mind, right? Like, in my early days of med school, because this rise, it was starting

then, but it, like, wasn't on the forefront of people's minds. And it is really scary how some of these early cases can be missed. And people, you know, we can say they got dismissed by their health care providers for some period of time, a couple weeks. But it's also, I think, just because the healthcare providers aren't thinking cancer is just not even on their minds for a young person. It's now on my mind for somebody who's coming in in their 20s, 30s, 40s, certainly. But in those scenarios, it's a diagnostic holoscopy. You're seeing some symptom that's warranting them getting it. Totally. Totally. I'm talking about the examples of people coming and asking for a screening one. But otherwise feel fine. Oh, oh, got it. Like the worried well population,

which it's almost like the biohacking population. Who want their full. body's MRI'd every year, like that kind of. And I feel like we fueled a lot of health anxiety with some of our Instagram videos and health headlines because it almost seems like there's an affront to all of our systemic organs. So they're like, well, I have the means. I'm just going to pay for it. Yeah.

Yeah. What's the worst thing that can happen? And there's a lot of things that can happen. Yeah. And like, listen, colonoscreens are very safe. We do them all the time, but they're not zero risk either. And when we're screening, yeah, we think the benefits usually. outweigh the risk, and that's an individual conversation. But if somebody's just more worried,

I certainly like to figure out what they're worried about and have that conversation. Like, it's not uncommon that I, I mean, I'm sure you've experienced this too. Like sometimes a patient will come to you and this happens to me all the time. They want a colonoscopy. They're worried about cancer. They've seen these headlines. And the more you sort of like say what I want to address what's bothering you and what's concerning you, you know, maybe it turns out that their sister diet of cancer or that they have front. Like you find out like sort of what's really concerning them. And then you can kind of talk through like maybe what the differences and what happened to that person are for them and what is they're going on. And I try to, I try to understand what the

like underlying issue is. But I mean, of course at the end of the day, we can't do colonel squeeze on everyone who wants them even though like, you know, it's, it wouldn't, it feels like why not that would, it's a money issue. It's really not. It's like it's a we would cause more harm. Yeah, exactly. You want to maximize the benefit of these. Yeah, and that's tough. Like, because when you're one person, you're like, well, I don't care about how this would harm society. I just want to know what's going to help me. And what if you're in that percentage of people who get the complication? Like we always, and then it would have been totally necessary. So this is a good question to ask. Given the rates of colorectal cancer being on the rise in young people,

yeah. What should people be on the lookout for symptom-wise? Yes. Certainly rectal bleeding. certainly changes in bowel habits. This is the vagus one, so I'm going to walk through what that means. So new persistent diarrhea, new persistent constipation, changes in the consistency or the caliber of the stool. That means how thin or thick it is. Classically, we think about like new kind of pencil thin stools. Everyone's allowed to have a weird poop from time to time.

So if you have like diarrhea, you know you ate something weird, you know, maybe you can you can say that's clearly due to this one other thing. But if it's stuck around for a couple days, a couple weeks, run it by your doctor. Like, it doesn't have to be a big, big. Yeah, worst case scenario, get reassurance. Yeah. And a plan of follow up if it is to persist. Yeah, totally.

I think I have a low threshold. I mean, in my patients, you know, like we use this online messaging system, you could just send me a message and just say, like, I've had this diarrhea for two weeks. Like, I don't know how to explain it. If it's been going on, like, I often will say, like, let's talk about it. Like, come on in. But if they're like, you know what, it's, you know, like I also, everyone in my family got sick, we ate something.

Like maybe I'll say, okay, you know what? Like, let's just see what happens over the next week or two. But have a low threshold to like, to just ask somebody about it. Weight loss that you can't explain. You're not trying to lose weight. And then this one's, I think, really important for women, iron deficiency anemia. This is different from, like, a lot of people think they need iron supplements for fatigue in general, but this is like, this is not quite just that.

this is a specific medical diagnosis. Somebody's looked at your labs. You have an iron deficiency. In women, it's often like, well, it's probably your period, you know, and we lose a lot of iron during our periods. That's true. But if you're somebody who's like, wait a minute, but I don't really have heavy periods or like, this doesn't seem quite right. We'd want to make sure that it's not that you're microscopically losing blood through your colon. So those four or five things are the things that you should always just double check.

Just like make sure your doctor knows everything that you know about your body. And what about color? Bleeding. So signs of bleeding in terms of color are bright red stool, maroon colored stool, black, black sticky stool. And it's not, I don't get excited for dark brown. It's like kind of be like the color of this microphone black. And you can imagine like GI doctors think like we get a lot of false. alarms for like, we think it's black, but actually it's brown. You should always, like I said,

take a picture because sometimes I think you can't tell the difference, sometimes even we can't tell the difference unless we're seeing it live, but take a picture. If it's sticky, so the reason blood turns black is because when it mixes with the acid in the stomach, it can kind of make it that like shiny, sticky black. That would make me really worried to go see a doctor. And sometimes that sticks a little bit more to the bowl. Yeah. And it's a little bit more to the bowl. Yeah. And it In general, what does the color of your stool or your poop tell you about yourself? Should it be changing all the time? If it changes once, should be worried.

What's the general rule? Yeah. Well, I think my general rule is, like, except for bleeding and a few accessions I'll tell you about, like, it's okay to have a weird poop from time to time. First of all, I think you should look. Like, I can't believe there are people in this world who don't look every time they go to the bathroom. So you should get in a habit of looking. Crossing the street, you're pooping. Always look. 100%. Thank you. Yeah, exactly. Look twice and then look one more. But like, get in the habit of

knowing what you look like, what's normal for you. Because then it'll be a little bit harder to know, well, what's abnormal. The one time you do peek back there. Right. But get in the habit of looking. What your color tells you, well, first of all, brown. Most of people, most people poop some shade of brown. Brown is not like the natural color of stool. Like brown comes from. Brown comes from, the Billy Rubin. That's something that your body is producing is digestive juice. If you didn't have that bile, the stool would actually be like clay colored. Like it could be like, you know, like the color of that book almost. That's a weird color. That's an emergent, or maybe the color of your shoe. I've seen it kind of like that. That's an emergency color because that means there's

some blockage the bile is not making it in. And not once. Even once, I actually, for that color, I'd be like, you should run it by me. I'd love to get a picture of that. And like we could talk about it. But certainly if it persists, we should intervene quickly. Bleeding is also one of those things that even if it's once, I kind of want to know about it. You know, like you could be convinced that you have a haemroid. Let's just make sure it's a hemorrhoid, you know, because sometimes bleeding from other sources, it happens once it goes away and you might brush it off as normal. Let's just make sure. You know, let's just like make sure we have an explanation for it. even if it's most commonly bleeding is not going to be from cancer.

Thank goodness. There are these other common causes. Like hemorrhoids, like fissures tags. Sure. That particular can bleed other things. Purple greens and yellows are probably what gets into my DMs the most. Like people are asking about. Purple poops.

Purple poops. Yes. So anthocyanins are these like pigments and berries. Beats will give you a nice maroon stool. If you've had beats like the night before, the day, two days before, I'll give you a pass for that maroon stool, unless you're feeling dizzy, lightheaded. Like, unless there's something else going on,

you're in a lot of pain. But purple can happen sometimes even with, like, red wine. People will drink wine and they'll have a little purple poop later. Or, like, fun questions that I get in my DMs are like, well, what does it mean when like half my poop was one color, the other half was like another color? Like, why do I have a multi-cutte, like a segmented? I have a very diverse poop.

Yeah. Yeah, first of all, congrats. We want a diverse flora. doing something right. Yeah. Well, it can also mean that like, you know, poop, your gut is constantly in motion. Things are moving through your small bowel, through your colon at all times. But it eventually hits this like red light, which is your pelvic floor. And then you, we decide as human beings, when is a socially appropriate time to go to the bowel, go to the bathroom. But your stomach, your gut is still moving at the same rate. So the poop from like the meal you had at dinner,

that's arrived. It's sitting in there, but maybe you've told it like, wait, I'm on a date. I don't want to go right now. So it says, okay, we'll hang out. It sits there. Meanwhile, now your breakfast has started to make its way along. And then it kind of mashes up with what you have. So it's not impossible. As you said, 7% of the population can't control it. They miss. And that's okay too. I mean, we actually have treatments for that. So don't feel embarrassed about bringing that up. But it's okay to have a multi-segmented poop because it just means that different parts of your meals have been making away. It's long. But they all, kind of arrive at the same spot waiting for you to kind of release it out into the free world. And what is the number of poops per day that we should strive for or that we consider normal? Everybody right now listening is going to think that answer is one, right? Like once a day is like the godly answer. Well, it's eight glasses of water a day answer. Yeah, exactly. Right. It's like the number that like somehow. Ten thousand steps a day. It's like the number in green. can't question that number, right? And if you don't hit that number, is there something on with you? Well, it turns out that's like another one of those things that if you do a lot

of digging about where did that number come from, the closest, there's two things that I think explain that number. One is there is a time of day when we're physiologically most primed to poop. And so morning time, just like dad told you. So the reason is that your colon, it's a little bit different than your other organs. Your colon actually operates very strongly on a circadian. and rhythm. So it enters this quiescent state at night, and they've done these physiological studies that find that there are certain moments during the day and with certain kinds of activities that wake that colon up. Because, you know, in order to have a bowel movement, in order to generate that propulsion, we can do a val salve maneuver. Like, we can bear down and kind of generate push pressure

downwards that can help move things outwards. But it's really lovely when your colon contracts into some of that work for you. Like, we feel that we feel that urge to go. That's your colon on its own saying we need to propel this outward. That happens a few times during the day. When you wake up, that circadian sort of reset accounts for probably the most strong contractions you're going to get throughout the day. And it can be augmented by exercise. So if you go for a walk in the morning, if you walk the dog in the morning, you drink coffee. Coffee is like a very strong trigger of that reflex. And then meals in general, like people often have to poop after their like lunch or dinner, are big meals done to do it. So I think because a lot of those factors convene early in the

morning, I think that's how this myth of like once a day blossomed. And like when I was writing this book, I went to the Harvard medical school archives into these old like civil war medical manuals. And they say like in the 1850s, they were like once a day. Yeah. And what we should all be striving for. And they like even swung so, this is like a little bit of like lunacy, but they went so far as to say, if you feel the urge to go twice in a day, hold it in so that you can have that like one perfect form still in life. Yeah. Wow. Okay. Wild. If you look at it like so they, so actually this, this was a study that came from my colleagues at Beth Israel. They looked at the Enhanes data set. And they looked at that subset of Americans who consider themselves to have normal bowel movements.

And they said, well, how frequently do you go? And it turns out Americans who think they have normal bowel movements go as often as three times a day to once every third day. That's a huge range of frequency that could be considered normal. And once a day is great if that's who you are. But for me, I think the criteria is more like you should be going as often as is comfortable for you and in a way that doesn't interfere with your social life. You know, like, that you have control over it. Yeah. If you're going once a day, And I have this all the time. Like I have patients who, you know,

say like, do you feel constipated? They'll be like, no, I'm not constipated. I go once a day. And then you're like, but you spend 20 minutes straining to have that once a day bowel movement. That's constipation. You know, like that's not normal.

That's not like a healthy frequency to me. We can still optimize that. And if you look at different parts of the world, like there was a study that was done a kind of similar type of study that N-Haines one in America where they looked at a population in East India, and they said, well, how often do you think is normal?

And for them, it was like a median of 14 poops a week was normal. And that's just because they eat a lot of fiber. By the way, if you start meeting your fiber goals, you're going to poop more often. Like that's just, it's a, like, you should embrace that new you because that's healthy. And that's just sort of the softer that stool is, the more easily it's going to come out with very,

with a lot less effort on your part. Your Val Salva doesn't have to like pop an eyeball. once you're meeting your fiber goal. So it really just depends on a lot of different things. I don't get so hung up on the once a day, unless that's something that makes you really happy. Or if it's been once a day for 10 years and then suddenly it's every three days

or four times a day, and you're like, what change? I change nothing about my dietary habits. Something's going on. Yeah, I think when you have a change that you can't account for, that's a good time to just say, let me just run this by my doctor.

But oftentimes I end up telling people you might not think you've done anything, But there's so much that goes into our bowel movements. It's stress. It's like subtle. Travel with the circadian rhythms. Yes. Yeah.

In fact, a lot of people get constipate. Like we don't talk about that enough, but a lot of people can't poop on vacation. Yeah. And that's really hard. And it could be your travel and also you're like people are often stressed while they're traveling. And together in a small room. Yeah, with like family members.

Yeah, exactly. Or it could be that like people, a lot of people can't poop at work, you know. Or they're like in an environment where they just don't feel safe and comfortable. like college students. I think college students have like the worst of several social factors. Like they had these shared dormitory bathrooms. You know, like everyone's watching, staring, smelling, judging. They're stressed. They're not eating well. Like they often are the ones who have like a lot of times. But sometimes you might not say like, oh yeah, I can pinpoint. Like I changed my coffee creamer or something. Like you might not be able to make that pinpoint. But when we take a big step

back and say like what else has been going on in life recently, there's often something that could account for the change. What don't we know about the science of, parts. You know what? We know so much about farts that I this is one of my favorite topics. We did. I've never seen anyone's face light up as much as I did yours. I love this subject so much. Okay. Farting was like one of these physiological topics that we studied like as a scientist, I feel like a lot of the studies we do now today that are funded by the NIH are like studying interventions and treatments and answering these big questions. But like back in the 1970s, 80s, 90s even, people were just asking these very basic questions about how our

bodies worked. And I feel like that was the golden age of farting. So there was this one doctor, Dr. Levitt, who's like a hero in gastroenterology, but he really studied farting. A fart king. Yes. You know him. Oh, no. Is that a thing? That's his name. That's his moniker. But it was like a moniker, he embraced. Like, this is wonderful. Okay. Yeah. So I think there's, I mean, there's probably, there's always more to be learned about farting.

But there actually is a lot more that we know. What do we know? Tell me some fun facts about farts. Okay. How many times a day would you think is normal to fart? I get this question from patients a lot. Ten to 20. You know, I have patients who come in and they're like, I probably fart more than anyone else I know.

And then I'm like, okay, why don't we like, you know, for the next week, let's count how many times you're going. And then we both discover it's like, disappointingly low. Yes. They keep the journal and you're like, wait a minute, you are right in the median. That's like I have that situation occur not with farts, but with hair loss. Patients don't realize they can lose up to 100 strands a day. And they're like, look, I pulled out five strands. What is going on? I'm losing it. I'm like, so average. So average. Like you're below average. Yeah. You could lose more. Fart more. Yeah. Okay, so that's how much we fart with us.

Here's a good one. Who do you think farts? Whose farts are more offensive, men or women? Offensive in volume, in follow-through in scent? You're asking the right follow-up questions. There was a study that he did, that he led. The fart king. The fart king, where he was trying to say whose farts are more offensive to the

the average human nose. Oh, it knows. Okay. Yeah. Yeah. Yeah. Not like your sense of propriety. Oh, I feel like men get blamed for farting more, so maybe men's are worse?

Yeah. I think that that's true. I also think that probably, I mean, here's what the data says. So they did this. You're like personal anecdotes of a side. You know what? I have an opinion, but I'll just tell you the science. They did the study where they looked at, first of all, the experimental design is like the

best part of this, like, story, more than the results. basically they hooked up a group of men into a small cohort but enough of men and women. They had them eat like what they called a flatulogenic diet of like beans the night before. Okay. They hooked them up to a rectal tube. Because they're good for your heart and they. And they help you. Part.

Thank you. They hooked them up to a rectal tube that would collect all the gas and into this chromatograph and they would measure it. Okay. That's step one of the experimental. I know. But this is why you can see why as a little girl I wanted to do GI science. right? Yeah, totally. Yeah.

You were dying to put rectal tubes and collect farts for chromatography. Yes. So they looked at men, they looked at women. And what they found was that, so first of all, 99% of our gas is actually odorless. It's the like 1% that contains sulfur that is responsible for the bad smell and it like ruins it for everyone else. They found that women's female farts were more concentrated with sulfur.

So stronger smelling than the men's. However, men had a greater amount of volume per two such that. Is that a mass scenario? Yeah, in how they measured it. Not meaning is that because men on average are larger mass? No, well, actually, I'm probably the men were slightly like had were slightly larger than the women. But I don't know if the volume has more to do with your sex than it does with your size of rectum. I have to think about that. Well, because on average, like even if we think about

muscle mass or mass in general, if they're large, was it controlled? Because if you controlled for the size and you said, well, this 118 pound versus 180 pound individual. You've got you, you're asking a good question. They didn't. It's like journal club for farts. I know. This is, they, they did not control for like kilogram or BMI, which is an imperfect measure, but I wonder if it would have been a good measure for this particular question. Sounds like we have some research to do. I think there's room to do the follow-up study. Who makes...

He was funded by the NIH. He was? He was? Yeah, yeah, yeah. Well, I mean, who's going to get mad if a bean company hires us? No one's going to claim that we're doing some kind of corrupted work. They were funded by Big Bean?

Yeah, big bean. Yeah. I mean, I think if we're helping people answer some of life's most important questions here. I don't even know who makes me Goya? Who is a bean manufacturer now? Yeah, Goya sounds right. Goya, right? They're listening.

Well, because I'm watching Mad Men, you know, the show. Oh, yeah. And Hines was making beans back in the day. Oh, yeah. So I don't know if Hines still makes beans. Sam, do you know? Those are the beans my British wife and I have with beans on toast. Oh, look at that.

Ooh, yeah, that's a classic breakfast. That's a nice high fiber breakfast, actually. I know why Sam is suffering now because there's beans and there's the heavier sulfur load. Yeah, the result of. It seems that, so if we take apart the possible confounding factor of the mass, I don't know the answer to that. It seemed that the volume in general that the men produced was larger. So that the second part of the experiment was they've collected the gas.

They had a group of volunteers smell the gas and rate the gas in terms of how offensive it was. That group of independent noses thought that it ended up equaling out, that there was no real winner between men and women because there's only losers because the women might have been more concentrated technically, however smaller volume, the larger volumes was more offensive. Wow. Yeah. I'm learning so much about farts.

Okay. So we have the more you know. Limited difference between the gender. Yeah. The amount that we're going 10 to 20 times a day is normal. Yep. And can you prevent the smell? That's like the number one question I get from people in my clinic.

Are people looking to prevent the smell of a bad fart? I mean, suppose, yeah, suppose you have like this hot, first of all, of course, they're looking to prevent the smell. Are they? Suppose you have. Is that a concern people have? Yeah, I mean, I think they're. I mean, 12 years of seeing patients, I've never had that as a question, let alone a concern. You don't run a GI clinic.

Clearly. But tell me, like what, what? Maybe you're not creating a safe enough space for people. I need to be more safe around fart. So wait, they're coming in and they're saying, hey, my farts are clearing out a room. What do I eat? Yes. Okay, I will say I don't think I've had someone coming with their primary question. Like they haven't made a whole visit for this, but it'll be like, by the way, like I have this like date coming up.

I'm, this is like always been a problem. Is there a fart supplement that you're about to pitch right now? Not quite. No, okay. So how do we make farts smell better? There is a substance though that's already on the market, which is bismet subcellate. Oh, pepto. Yeah. It neutralizes sulfur. Wow.

Yeah. So I don't make any money off of telling people. people to do that. And you obviously shouldn't take it long term. But then we're going to get all black stools that everyone's going to freak out. I know. And then they'll come right back. Exactly. But it can't. If you take it the day of high risk event, you're like, get your family Thanksgiving with your in-laws maybe. Interesting. Pop a little pepto. You know, all of this conversation about black stools, iron deficiency, anemia, haemorrhoids got me thinking. Tell me. I'm putting this out there. This is a new theory that I've developed in the midst of of this conversation.

Theory is a bad word for it, a very wild guess. Would you find it interesting, given the rates of increases in colon cancer in young people, and that a lot of times we blame rectal bleeding on the hemorrhoid, which sometimes could be because of the hemorrhoid,

even though we examine and we see the hemorrhoid. Yeah. That there is a link with iron deficiency anemia in young people. Yeah. That if someone is iron deficient and not very clearly losing a lot of blood due to their mencies. Yeah, not clearly. Or they have a hemorrhoid, and still, we recommend them getting not a colonoscopy,

but like a cologard. Okay. In younger people. Because we're like, yeah, your rectal bleeding is probably from your hemorrhoid, but because some might be slipping through and not be from your hemorrhoid, we would never know the difference. So maybe we should screen this population. The problem, unless I've misunderstood.

is the problem with the coligard is that you're going to get a lot of false positives triggered by the hemorrhoid, right? Like, so like... But the coligard doesn't just check for presence of blood, like those FIT tests, right? Yeah. It tests for the DNA, too. You'll still get the false positives. Oh, really? Okay. So, it's best for people where there's not another possible source of blood being introduced

that you're aware of, at least. Got it. But I wish it was... Because it would be good to screen those people because our usual symptoms that we would use to do a diagnostic colonoscopy are kind of not great because it's being hidden by, oh, I get frequent hemorrhoids. That's why there's blood. It could be in the future. And I think we don't know the answers yet because that kind of study hasn't been done. But like the blood test, for example, that could be a place where we say like you're a someone who we might put down. is like lower risk overall. Let's like just do the blood test, right? Because then you're not introducing like this like kind of confounding factor.

Exactly. Maybe that's the way. I have to, I mean, I think the blood test is, we haven't used it probably as much in clinical practice yet as we should. But I think it's a great, there's some people who are just never going to be able to make it for the colonoscopy easily. But when you have a positive like stool kit, that's enough to say like, okay, let's definitely, let's do it.

And I think the, if you can just catch them while they're there. And how good is the blood test? I'm not familiar with it since. It came out within, the data is like within the last two years. It came from Mass General. It's pretty good. The issue with both of those. It's a high false positive.

High false positives, but also more like you will miss polyps. You know? Well, of course. Yeah. Like you do. Can't intervene. There's no intervention. You can't intervene.

And you don't know. Like the stool kit detects some polyps, but it's just not as good. And I think you can like live with this false sense of security. When you say stool kit, what are you? referencing. I'm talking about the, yeah, I'm talking about the combined, like the Kola Guard. Got it. Yeah. Interesting food for thought. If you will. Quite literally in some regard. Um, final two questions. Please. One, biggest piece of misinformation you're seeing surrounding people's poop.

Oh, where does it end? Um, where does it begin? I would say the anal sphincter is probably where it ends. The internal and external. Yeah. Um, um, I think that this is maybe bigger and broader than you meant to go, because I know we've talked about a lot of the big misconceptions, but I think a lot of what has actually changed my own opinion about myself. And what I do is that I think a lot of times people think about certain gut health diseases or even neurodegenerative diseases, diseases that affect older people. Constipation comes for you when you're older.

Parkinson's comes for you when you're older. and cancer is a disease of older people. And I think a big misconception is that. Like Parkinson's, what I study is actually how that protein that misfolds alpha synuclein in the brain in Parkinson's disease. We study how it misfolds in the gut decades beforehand. And so I think it's important to take care of your gut when you're young and healthy, when you don't have symptoms long before that's the issue.

And I think that's also the time in your life when you're, you may be least likely to want to pay attention to those things. You know, like, and the flip side of that is that I also meet a lot of people who will say, like, they'll meet me in their 30s and 40s, and they'll say, like, gosh, when I was in my 20s in college, like, I was a wreck. I didn't treat my body well. Like, am I doomed? You're not doomed, right?

With almost any disease intervening at any point to make a change, we'll start to lower your risk by some amount. So it's never too late. It's also never too early. Yeah. And if you were to change one thing about the first. field of gastroenterology, what would you change? You have a magic wand. You can fix anything. Oh, gosh. I love our field so much. I think our people are so, so fun. This is what I would change. And I think we're trying to change it. I wish we had a way to safely get a cross-section of somebody's

enteric nervous system, get to the muscle layers in a routine scope. Because I think, if you think about liver disease, before we were doing like percutaneous liver biopsies at the bedside, we were diagnosing liver disease based on blood tests, based on jaunded. Like did your skin turn a little yellow? Is your eyes turning a little yellow? And history. We were like, well, what are your risk factors? It was not based on histology. It was not based on what the cells look like.

In a lot of ways, that's where we are right now with so many disorders like irritable bowel syndrome. We're saying you have irritable bowel syndrome because you have pain when you go to the bathroom and you poop X number of times per week. But what if we were making that diagnosis based on the specific pathology we were seeing in your internal nervous system? We're not doing that because right now we don't have the technique. We don't have a way of safely getting that deep into your muscle layer without creating a perforation without sending you to surgery to get it fixed.

Naive question? Please. Do you know what an EEG would look at? like for someone's, like to diagnose carpal tunnel or to look at their distal nerves. Yeah. You send one signal, you catch it on the other end, and it shows if there's compression of the nerve, etc. Yeah.

There is no world where there is like a intestinal EEG? You are referring to the electro gastrogram. Oh, that's a thing. Yeah, yeah. Do we do that for anything? Can this be the substitute for your enteric study? That's so funny. I've studied the EGG extensively.

And you're onto it in that our stomach, just like actually our entire intestines, it has an electrical activity, a regular rhythm, your stomach contracts at three cycles per minute. You can capture that on an EGG. It does correlate in some ways to changes that we might see in something like gastroporesis

or delayed gastric emptying, but it's not quite... It's too macro, not micro. Thank you. It doesn't quite... get us there. It doesn't quite good at that. We, but I do think, I mean, they're, this is like an emerging frontier. A lot of the advanced endoscopist, like the intervental endoscopist, they're coming up with their innovating ways to safely do these types of full thickness biopsies.

There are a lot of cool research papers about this. So I think in the next 10 years we're going to get there. I think when we get there, the field is going to explode. We're going to completely change how we diagnose, how we classify these diseases. And I think then how we treat them, like the innovation around therapies is going to totally change. And I think it's going to benefit the patients. I think it's also going to destroy, thankfully, some of this predatory supplement world surrounding GI disorders. Yes.

Much in the same way. I don't know if you felt this, especially because we grew up in the same time frame, when I was 15, 20, I'm sure you were watching infomercials at some point. There would be all these weight loss ads. Yes. And now there's none because we actually have a medical treatment that works for weight loss. It's true. Jenny Craig was such a thing, right?

Right? I mean, like how many grapefruit cleanses were playing on all the stuff? But now there's zero commercial. We don't need it anymore. Because we don't need it. Yeah, that market is gone. And they'll just keep moving on to the next thing that they want to try. People still come to me talking about cleanses.

I guess it hasn't totally gone. Well, cleanses for detoxing now. Yeah, yeah, yeah. But now weight loss. Yeah, right, right. People think they go hand in hand sometimes, so. Well, we solved it today. Yeah, we did.

Thank you so much for teaching me about poop and farts. Where can people follow along your job? journey. They can follow me on Instagram, TikTok, or they can check out you've been moving all wrong. Share your full handle so they know where to look. Oh yeah. Tricia Pesricha M.D. Okay. There you go. Thank you so much. Hopefully you had fun. Great time. Awesome. Thanks. Huge thanks to Dr. Pesricha, who came down from Boston for this interview. If you enjoyed this episode, you'll probably also enjoy my conversation with Dr. Elizabeth Potter, where we discuss how health insurance companies are very angry at her. Scroll back on to find that one and make sure

give us a five-star review and leave a comment as it's the best way to help us find new listeners. And as always, stay happy and healthy.