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BackTable Urology
Ep. 230 Gut Instincts: GI Fundamentals for Urology Providers Who Want to Elevate Care with Dr. Michelle Pearlman
00:45:28
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- [00:00]
A
Foreign this week on the Back Table podcast. So let's say they don't have pelvic floor dysfunction. Let's say there's no alarm symptoms. A couple things we need to make sure. Okay. Are they eating enough dietary fiber? Most people are not. We should be aiming for 25 to 35 grams of dietary fiber a day, but not all at once. Okay. So we don't digest a lot of that fiber. If you were to have one of these, like keto breads with 25 grams of fiber for a slice of bread, too much fiber all at once can definitely cause GI issues and worsens constipation. So we want to spread it out. For instance, a cup of broccoli has about 4 grams of fiber. So basically, to put it in, you know, very simple terms, every time we're eating or having a snack, it should have protein and it should have fiber in order to reach those daily requirements.
- [00:53]
B
Hey folks, welcome to back table Urology. I'm your host, Dr. Amy Perlman, and and I have my business partner, colleague, and twin sister, shall we say, Wu Mate, here with me today, Dr. Michelle Pearlman.
- [01:06]
A
Dr. Amy, thank you so much for having me.
- [01:08]
B
Awesome. So, Dr. Michelle, why don't you give the audience a little overview? Who are you? What do you do on a daily basis?
- [01:17]
A
Yeah, so that's a great question. I am a gastroenterologist. But it's interesting because most of how I spend my days now is actually not being what most people would think a gastroenterologist does every day. So what does a normal GI do? Well, they're probably doing procedures about 50% of their time doing upper endoscopies and colonoscopies and looking at imaging studies and talking about gas bloating, heartburn, diarrhea and constipation. What I focus my time now in my practice at Prime Institute is focusing on the foundation, which is nutrition. But my primary focus is actually weight management, sports, its nutrition and hormonal care for women during perimenopause and menopause.
- [01:59]
B
I love that. So why don't you describe a typical patient that walks into your clinic to give us some context on this discussion.
- [02:07]
A
So the typical patient that comes to see me is usually middle aged, really male or female, who probably in their 40s or 50s is either, you know, a CEO or an attorney. So they're very busy on the day to day. They're struggling. You know, they go to their primary care doctor. They're very plugged into the healthc care system. They are health conscious. But now all of a sudden they're having more fatigue and some brain fog and they go out to eat a lot because they don't have a lot of time to cook and they have busy work schedules. And now they're told, oh, you know, you have high cholesterol and it looks like, you know, this time you're also pre diabetic. And so those are definitely alarming things that come up with these people because for decades they were kind of just getting away with their daily activities and didn't really have many problems on that diagnosis list. So they're struggling, though. They're successful, but they're struggling with their health and they're really looking for help and they're looking for non invasive techniques on how to optimize their overall cardiometabolic health and get to a healthier weight.
- [03:15]
B
And a lot of these patients, I'm also assuming, although I should never make any assumptions, are coming in and they have GI symptoms, whether it's constipation, bloating, maybe hemorrhoids, maybe some heartburn. They also certainly have urinary problems and they're struggling with their weight. So the reason why I'm glad that we started off this conversation talking about this person is for the urologist listening. These are our patients too. We're all seeing the same mutual patient. So the goal of today's podcast is to really talk about who this patient is that shows up to a clinic like my sister's and in our clinics and to figure out what that shared message is. And I'm going to ask some pointed questions to Dr. Michelle today. Some pointed questions that ask her. Give me some exit strategies. We know that our patients are going to come in, they're going to have some questions about GLP1s before or after surgery. They're going to have some questions on anti inflammatory nutrition, about gut health, bloating and constipation. What's like a 20 or 30 second script that I can tell my patient as a urologist, from the perspective with all the knowledge and expertise you have as a gastroenterologist. So those are our goals today, is to give people like me, my urology colleagues, some exit strategies. Now, let's begin with why this conversation matters, other than the fact that we're all seeing the same person just in different clinics, and, and why urologists should care about our patients who also have gut health issues. Well, we have this gut urogenital connection and it doesn't take a rocket scientist to understand the anatomy. And the rectum is right near the bladder and all the pelvic organs that we deal with. So intuitively, we already know we're seeing a lot of these patients with GI issues. And certainly the patients we see with pelvic floor dysfunction are coming in with constipation, bloating, and all these other GI problems. So we know that's why this matters. Now, Michelle, I'm gonna put you on the spot here a little bit, and I wanna start this conversation talking about a hot hot topic right now, the GLP1 agonist medications. So I want you to help us understand what urologists should know related to these medications. And I think a good place to begin is giving us an overview. How have these medications revolutionized your practice as a weight management specialist, and what are some of the common medications people are on?
- [05:37]
A
All right, Dr. Amy that's a lot. So let me try to start with the first thing, which is how long have these medications actually been out? Right. And even if you, as the urologist is not prescribing them, the reality is your patients are on them. And they're either on the commercially available options from Lilly or Novo or other companies, or they're getting them compounded, which you're not quite sure what they're getting or what dose they're on. So. So the more prevalent these medications become, the more accessible they become, your patients are going to be on them. And so you have to understand, not as the prescriber, but how are they going to affect your management and potentially some symptomatology that people are presenting with. Now, these medications in this class have been out since the early 2000s. So we often think of like the Ozempic commercials with that really kind of cute jingle. But those really have been out, you know, for the past, let's say four, five to seven years with Ozempic. But we had Liraglutide, which is Victoza, that's been out for diabetics since the early 2000s. That's a GLP one. It's a daily injection. We started seeing that people were actually losing weight, so we did additional studies. And the first weight loss injectable G.L.P. one medication was Saxenda. That again came out in, in the early 2000s. So these medications have been around in one form or another. Ozempic came out around like 2017 or so, and that is Semaglutide. The non diabetic weight loss version of Ozempic is Wegovy, and that came out around 2021. And then the newer medications are Tirzepatide. So that's either Zepbound for non diabetics who need to lose weight or Manjoro for diabetics. Okay. They are all injectable medications. The liraglutide was a once daily injection. The, the semaglutide and tirzepatide formulations are once weekly injections. Okay? They all act in very similar mechanisms. So let's look at how that may affect not only the GI tract, but also the genital urinary anatomy. Everything starts in the brain. Now, we should not tell people that it's all in the head because then patients think we're telling them they're crazy. But the reality is everything starts up here. And these GLP1 receptors are also located in the brain along with other areas of the body. So, so when we eat, we have to chew our food, okay. That allows for the mechanical breakdown of the food to allow for proper digestion and absorption. The food bolus then goes down the esophagus into the stomach. It takes a normal stomach about four hours to empty a standard meal. Now, a standard meal would be like an egg sandwich. Unfortunately, in America, the standard meal is often a 16 ounce tomahawk steak and a baked potato that's loaded. So imagine all of that food and fat may actually be staying in the stomach a lot longer than that egg sandwich. So then it's broken down and the food then travels into the small intestine. And our body makes this GLP1 hormone, glucagon, like peptide hormone. It's released from the small intestine, sends signals back to the brain, says, brain, I'm full. And delays the rate at which the stomach empties the food. So in essence, these medications help help us get fuller sooner and keep us fuller longer. Now how may that affect the GI system? So because it works on the brain as well as the gut, the most common side effects are gastrointestinal related, not surprisingly. So that would be nausea, heartburn, bloating, diarrhea, constipation. The problem is, is these symptoms can be highly variable. It can cause constipation one time and diarrhea another. It can. If people are going to have symptoms, it will tend to be when you start the medication within the first 24 to 48 hours after each injection. And if we go up on the dose.
- [09:28]
B
Wow. And what percentage of patients are going to experience GI side effects?
- [09:34]
A
So with semaglutide, it tends to have more gastrointestinal symptoms. About 7% of patients end up actually coming off the medication because of Side effects. But over 50% of patients will end up having GI symptoms. With tirzepatide, it tends to be less.
- [09:50]
B
And how have these medications revolutionized your practice? Because they weren't around your entire career. What were you using before?
- [09:57]
A
Yeah, it's so interesting in that most of my training. Well, I'll preface this with this, around 14, 15 years worth of medical training. It wasn't until my 14th year of medical training that I actually sought mentorship outside of my own fellow fellowship training by an endocrinologist at UT Southwestern who actually taught me most of what I do today. Now, Ozempic was out at that time, but Wegovy was not. So most of what I do today I actually learned while I was already in practice, which is a beautiful thing, I think. So often in medicine we think we're going to be practicing what we learn during training, but training for most people is three, three, you know, to six, maybe neurosurgery is 10 years. But the reality is our careers last decades. Most of what we practice is going to be what we learn while we're practicing.
- [10:48]
B
Awesome. So these medications really revolutionize your practice, and I certainly see it with the patients that we share together. So now let's talk about these medications in the context of muscle loss. Why is this conversation important when it comes to muscle loss and this term sarcopenia, which is now all the rage online?
- [11:06]
A
You know, it's fascinating because I don't know about in your training, but I'll tell you, in my training and in most healthcare scenarios, we are so focused on the number on the scale. What is the first thing we do when you show up to a healthcare provider's office? Well, one, you're rushing. And if you live in Miami, you're probably running late. So we rush you in, we check your blood pressure. Notoriously, it's going to be high because you're anxious and you were rushing in. And then we get you on the scale and, and then we, you know, bring you back into clinic and then have, you know, probably not the most nuanced discussion on nutrition and muscle, but we're looking at that number on the scale. And then we're doing a very, you know, barbaric calculation to determine your BMI or body mass index, which tells me absolutely nothing about your muscle mass or your cardiometabolic health. So what I do in my clinic at Prime Institute is I have a SAA bioimpedance scale, which is a medical grade scale. And, and I am measuring this critical tissue right here. This is your muscle mass. And I'm able to differentiate it from fat, but in particular visceral fat, which is the fat around our abdominal organs and contributes to a larger waist circumference. Why is muscle key? Not only is it, you know, for many, aesthetically pleasing, right? You get the, the biceps here. It's also incredibly metabolically active. So a lot of our patients are pre diabetic or diabetic or just have some sort of degree of insulin resistance or know that the more muscle you have, muscle is a glucose sink. So that's really important. And what I see and what you and I see in our practice is we have the movers and shakers of South Florida in our clinic, and they are working hard. And when they retire, they want to travel the world. And what happens? Many of them have subspecialist after subspecialist because over decades worth of sitting at a desk and not doing resistance training, they lose an incredible amount of muscle. And if you're throwing in menopause and you're throwing in andropause, they have no idea what degree of muscle loss that looks like. And one little trip, one little misstep on a curb and they fall. One out of two, you know, postmenopausal women have osteoporosis. One little bone fracture at the age of 70, the mortality within one year is absolutely incredible. We have to preserve muscle over time. The problem is, if we're not measuring it, we can't track it. And most people have no clue what their underlying muscle mass looks like. So they don't know what they need to do to modify it.
- [13:37]
B
That's such a good point there. And, you know, when we think about, I was at a recent conference and there was a talk on frailty in the urologic patient. And the talk was really focused. It was an incredible talk. And the talk was focused on as people get older and they become frail, what are some considerations when it comes to treatments that you may or may not consider in a frail patient? But I think our perspective is how do we prevent that person from becoming frail in the first place? And that discussion really has to happen decades before that person becomes frail. So what are some of the things from a maybe urologist perspective? What are some easy topics that urologists can bring up with their patients that that might reduce their frailty long term?
- [14:26]
A
So there's three critical components here. One which urologists often deal with is going to be hormones, right? So we want to make sure, in our male patients, we're checking testosterone and in our female patients that we're also addressing the perimenopause and menopause, because as women get older, their testosterone will also drop and estrogen is going to go to almost zero. And estrogen is incredibly important for bone health. And now a lot of urologists are not doing, let's say women's health or perimenopause, or maybe most of them are doing prostate health and not doing men's health and hormone optimization. But we still need to have even just a basic conversation, but at least at the bare minimum, direct them to the appropriate person. Every single woman deserves a conversation on her hormones because every single woman living on this earth is, is going to enter menopause. And after menopause, a couple years before and a couple years after you have a rapid loss of bone, that if we have a strategy that we implement early on, we can prevent, I think, a lot of osteoporosis that we're missing. And then in men, doing a simple testosterone screen to kind of see what their baseline is, and if they're on the lower end, then setting them to the appropriate specialist. It's not about training to be a bodybuilder. It is about preserving bone and muscle, which is absolutely critical for every aspect of our life.
- [15:55]
B
Yeah, I'm so glad that you brought up that point because a lot of urologists listening, you know, do treat hormones and a lot of urologists listening don't. And so the conversation, I think that, or the point that you're making is it's really important whether we do it or someone else. Every single one of our patients needs that discussion. And really it's these middle aged people and, you know, it's the guys coming in or the women coming in in their late 30s and early 40s. That's really the time to introduce some of these conversations. So why don't you tell the audience how you actually track muscle mass in real time?
- [16:26]
A
Well, and I'll say the two other things that I forgot to mention that a urologist can bring up. One would be obviously optimizing nutrition. Now, I can spend 90 minutes with a patient and have a very nuanced discussion on nutrition. So I would not expect a urologist to have those nuanced conversations. But protein is critical and quality protein. So we want to make sure that we're having protein with every meal and snack to make sure we provide the amino acids to actually help preserve and build muscle over time. And then the last one is moving our body. Now I used to just tell patients, move your Body, I don't care what you do, just move it. But the reality is, is that we need to do strength training. Okay. Or resistance training. Obviously. The cardio, the walking, incredibly important for every aspect of our health. Not good for weight loss and not good for building strength and preserving muscle. So it's hitting the weights. If you're just starting out in a program, you probably need a trainer or some sort of supervision because you don't want to hurt yourself. But as we get older, the data is actually showing we should be lifting heavier, not lighter. We need to stop telling people as we get older to just go lighter on the weight, pick up those pink dumbbells, go, you know, lighter on the weight and higher on the reps. We need to be telling people the opposite. We need to actually, in order to stimulate muscle protein synthesis, we actually need to strain the muscle and bone more when we're in our 50s, 60s, 70s and 80s than we would have had to in our 20s, 30s and 40s.
- [17:54]
B
Let's touch a little bit on the cardio because I know you see some of the cardio bunnies and you see people who are trying to eat all the right things and they're on the elliptical, they're on their treadmill for hours and they're not losing weight and they're losing muscle in the process. So what are some good cardiovascular exercises that will actually help with bone health?
- [18:13]
A
Exactly. So great question, because all cardio, you know, is great. And a lot of times it's going to have to do with if you have any sort of musculoskeletal limitations. But when it comes to protecting bone, it needs to be weight bearing exercise. What are non weight bearing cardio activities that are not going to help with your bone? That would be biking and that would be, let's say swimming and that would be the elliptical. Your feet need to come off the ground and then hit the ground to put force down into the ground and then up, back through your spine. So walking, you know, running is fine, but really we should be doing like jump training. So that would be like jumping jacks or let's say you step up onto a box and then you jump down or you walk down or kind of jog downstairs. You, you need that impact. Okay. Now a lot of our kind of plane of motion is forward and backwards. So a lot of people would say, oh well, running must be really good impact for the bone, probably more so than walking. Right. But the reality is it's still walking or running a forward and backward motion. We need more up, down. We need to apply forces from all over the place onto our bone to help strengthen it. So we want to incorporate all different types of movement. So not CrossFit but cross training where we're doing, let's say walking or jogging if you're able to, plus the, the jumping exercises. But again, your feet need to lift off the floor and then plant back down with the impact.
- [19:38]
B
So how do you go about asking a patient about their exercise routine in maybe a clear and concise way that a urologist might be able to ask their patients to get a sense of what they're doing?
- [19:48]
A
Yeah, so I ask them, what do you do for planned activity, you know, or a lot of people have wearable devices. So do you have, let's say a Fitbit or an Apple watch or a Whoop or an Oura ring? And how many steps on average are you doing a day? And sometimes they'll guess and I'm just like, we'll pull up the data. Right? We want to get accurate data here. And if you're tracking it and wearing the device that we can actually pull that up. So looking at wearable devices and using technology to give us the information as opposed to just people pulling it out of nowhere is very helpful. And then just understanding like, you know, do they have any sort of equipment at home? Do they have, let's say a rower, a treadmill, you know, are they using, you know, Bowflex machine? Do they have, you know, a gym membership or access to a gym? Do they have bands? A lot of our patients also travel all the time. So they could have a really good gym membership and a trainer. But if 60% of the month they're traveling, I need to understand what's going on during that 60%. So. So when they travel, do they tend to walk a lot? Are they hitting up the hotel gyms, all of those things? It's a very dynamic thing. So I need to get a better understanding on what their, you know, day to day life looks like from a planned activity standpoint. I don't like calling it exercise because I have some people that are like on the job, they're general contractors, they're constantly moving and lifting things and they tend to have a lot of really good muscle mass. I'm not going to make that person go to the gym. And if they're doing a lot of planned exercise and lifting now I wanna.
- [21:12]
B
Take a little bit of a step back. Cause you mentioned the importance of nutrition and protein. So if a urologist were to ask you or a patient Were to ask you, and we'll pretend like you're a urologist here for a second, what are good high quality protein options? Where would someone begin?
- [21:27]
A
So I think we wanna get a mixture of both. And again, it depends on if someone has certain dietary preferences, allergies, food sensitivities. And again, as a gastroenterologist, I'm getting into the weeds when it comes to that. And what sort of foods they have at home, what do they like, what do they not like. But we want, you know, a mixture. If let's say someone has no restrictions. We want a mixture of both animal protein sources, lean animal protein sources, and plant based protein sources. So your animal based protein sources that are easy on the go options would be, let's say like a plain cottage cheese. This right here has 19 grams of protein, which is an amazing source for gut health. We need dietary fiber for most people, 25 to 35 grams of dietary fiber a day. This isn't getting you any, but it's super easy to, let's say add a packet of like chia or flax seeds, which would get you an additional 2 grams of protein and 4 grams of fiber. So you add this to here, maybe you add some fresh or frozen berries and that could be either like a breakfast, let's say, or an easy snack. So super easy to put together. Or one of my favorites, and I think yours too is just like the plain Greek yogurt. You get calcium, you get probiotics which are important for gut health as well as this One here has 15 grams of protein. But you always want to choose like the plain options. Anything that's flavored tends to either have artificial sweeteners or added sugars. Eggs are also another great option. I know they are hard to come by nowadays, but you can either make your own eggs or, you know, these are some good options, just hard boiled pre made eggs and Each egg has 6 grams of protein. So these are some great options. Now some plant based protein options would be things like chickpeas or edamame or nuts. Have some, some protein or tofu. All of those are good options. I like to have a mixture because we need fiber also in our diet for optimizing our gut health and helping with diarrhea or constipation. So getting a mixture can be very beneficial. There is nothing smart about this smart food. Popcorn, okay? If you cannot easily make it in the kitchen at home, we should not be eating it. So don't be fooled by a lot of these processed diet products that are often quite Harmful for our gut microbiome, including a lot of the pre made protein shakes out on the market.
- [23:38]
B
Okay, so if a urologist listening or a patient says, well, how do I determine if a product is healthy for me by looking at the nutrition label. What are the key things someone should be looking at? What's the most important?
- [23:51]
A
The most important is that ingredients list. So unfortunately many of us probably have to put on our glasses or bifocals to actually read that two point font on the ingredients list. But, but we really want to minimize ultra processed food. Again, from a gastroenterology perspective, we know that ultra processed food, things like deli meat or processed meats like hot dogs and other sorts of ingredients can actually increase risk of colorectal cancer. A lot of ingredients like these gums that are in a lot of diet food products as well can disrupt the barrier lining the mucin layer in our gut and cause either GI symptoms or again, colorectal cancer. So many minimizing ingredients. We should really be opting for options that have less than five to seven ingredients. We should be able to pronounce all the ingredients. We should be able to identify what we're eating. Salami, I have no clue what that came from. We probably shouldn't be eating it.
- [24:41]
B
That's a really good segue into our next discussion point, which is the connection between inflammation, gut health and cancer risk. And you mentioned that inflammatory foods and some of these processed meats, meats can increase risk for things like colorectal cancer. And we know that foods that promote inflammation can also increase risk for things like prostate cancer and can change outcomes after prostate cancer treatment and impact recurrence risk. So let's talk about basic anti inflammatory foods. What's a rundown of what that category looks like? And maybe you can provide some good options that urologists can provide to their patients.
- [25:22]
A
Yeah, I actually want to start out with just a quick personal story on one of the reasons why I became so fascinated with nutrition and avoiding the cakes and the cookies. So a lot of people will tell me, oh, just why don't you have some pizza or eat a cookie? It's not a big deal. It's not going to kill you. My personal story is, I'm sure a lot of people on this podcast can relate. When we're stressed or anxious or bored or sad or happy or, you know, celebrating some events, do we often. Do we eat really delectable food? And it's often high in fat and high in sugar because that's how we celebrate. When I was in medical school, obviously I had stress levels up to here. And after or before board exams, I would eat candy. I remember like going to the grocery store after every board exam and I would go through like the bulk aisle and get a big bag of candy to help kind of celebrate, right, the ending of the board exam. And I started to wake up and my neck hurt, my neck hurt. And I said I would ask myself, did I sleep funny? Like do I have fibromyalgia? And I came to the conclusion that it was just the candy. It was the high fructose corn syrup that has an immediate effect on our gut. And our gut, remember, is our largest immune organ. So what we eat multiple times a day, you better believe has an immediate effect on our underlying inflammation and how we feel. So that was my personal story. When I ate crap, I felt like crap. I was tired of feeling like crap, so I, so I stopped eating the junk. And so now I ask myself if I have the cookie, it may give me immediate pleasure, but am I okay waking up tomorrow and just being sore and not feeling my best? The answer is no. So what are some pro inflammatory foods? Unfortunately it's basically the American diet. So it's ultra processed foods again, things that have a ton of ingredients, it's your added sugars and it's saturated fat. What are anti inflammatory foods? Produce. So veggies and fruits and whole grains and nuts and seeds and lentils and beans, things that we can identify, things that are lean protein sources and also have good amounts of dietary fiber.
- [27:29]
B
This conversation is not only relevant to patients who have a prostate, but also when it comes to erectile function because that we know that anti inflammatory foods are also good for promoting the entire nitric oxide know access. So whenever I'm in the office and I'm trying to counsel patients, a 20 year old on the importance of changing his nutrition, I always try to bring it back to his presenting concern and that might be erectile dysfunction. So I talked to him about how an erection happens, the importance of nitric oxide, and how some of these more processed foods will just kill off the nitric oxide. And that's sometimes all someone really needs to hear.
- [28:05]
A
And also what is equally as important as what we eat is how we eat, how much we eat, how late we eat, how fast we eat, all, all of these dietary habits that we learn from when we're infants carry into adulthood and are often really misaligned with health. So we want to be mindful and we hear that term all the time, but really properly chewing our Food, we have to do it, otherwise we're swallowing tons of air and we're going to get maladigestion, malabsorption and we're not going to feel well. So oftentimes we blame the food. Sometimes it may be the mere fact that we just inhaled, you know, that steak at 10 o' clock at night and went straight to bed or kind of doused it down with a bunch of, you know, coffee or beer. And now we're also waking up with urinary symptoms.
- [28:49]
B
So we oftentimes talk about limiting fluid intake before bed to reduce nocturia or nighttime urination. What would be some of your guidance for food intake before bed?
- [28:59]
A
Yes. So remember, it takes a normal stomach four hours to empty a standard meal like an egg sandwich. So, so we really shouldn't be eating within like three hours of going to bed. And oftentimes, unfortunately, our dinner is our largest meal and tends to have more fat. We actually need to reverse that. So we should be actually starting our day with more protein. So, you know, specifically like women, Perry and postmenopausal women, especially after exercise, we shouldn't be doing intermittent fasting. In women, that actually tends to drive up our cortisol and promote fat gain and muscle loss. So women really need to be starting their day with 40 to 50 grams of protein, especially within 30 minutes after working out. For men, they can get away with maybe like an hour, an hour and a half after working out. But men, when it comes to like the intermittent fasting, there's probably some data to support that. Not so in women. But we need to be front loading our calories, specifically starting our day off with a really good source of protein and then, you know, having a sensible lunch and dinner again should be our smallest meal.
- [29:59]
B
Eat.
- [30:00]
A
If we know that dinner is going to be late and it's going to be like at 10 o' clock at night, then we really should be eating something, let's say around six, so that if we go out to eat, we're kind of just picking so we don't feel awkward around other people. But we really should not be eating a super heavy meal at 10 o' clock at night. We also can't have everything, at least not all at once. So if we know we're going heavy on the meal, then we shouldn't be going heavier on the alcohol. Okay, we got to kind of pick and choose what that poison is going to be.
- [30:26]
B
Pick your poison. So for patients who are on the GLP1 medications, how might your guidance change or not change Depending on when people should be eating.
- [30:36]
A
Yeah, that's the beautiful thing is that the recommendations are really the same for anyone, anyone just trying to improve their cardiometabolic health, improving their gut health, trying to maintain or trying to lose weight. It's all about promoting anti inflammatory foods, reducing the pro inflammatory ultr, processed foods, you know, eating a little bit earlier in the day, eating lighter at night and just not eating right before bed. I mean, the beautiful thing is the recommendations are all pretty much the same, but there are going to be nuances in folks who already have underlying GI conditions. Then oftentimes, at least with the medication, we're going to titrate slower. That also plays a factor. We may have to give them antacids or other medications to kind of treat through some of the symptoms, at least in the beginning. And then if someone, let's say the first one to two days after their injection is just really not hungry, then we may go for more liquid or protein shakes that are easy, easy to digest, but still get enough protein. And then maybe days like three through six, they're eating more substantial meals because their, their hunger goes up a little bit. Every person is different. So both from a GI perspective and a urologic perspective, every patient that walks into my office is different. We cannot just give someone a packet and say here are the guidelines and stick with that. These really have to be nuanced discussions.
- [31:53]
B
So let's talk about the dreaded patient who sees both of us in our clinics, which is the patient with constipation. What should urologists know? Or what can urologists tell their patients? Or sort of good and simple ways of maybe preventing constipation and managing it once they have it.
- [32:09]
A
Yeah, so a couple things here. I think you and I actually have obviously a lot of mutual patients. One kind of common denominator here is pelvic floor dysfunction. I think you probably send more patients to a pelvic floor physical therapist than I do. I could put someone on tons of fiber and put them on a bunch of laxatives. If we're not treating the underlying pelvic floor dysfunction, oftentimes those things are not going to be all that beneficial. So we definitely want to make sure we're doing the appropriate evaluation. If someone has alarm symptoms like change in bowel habits, unintentional weight loss, rectal bleeding, even if it sounds hemorrhoidal, they need to be seen by a gastroenterologist and make sure that they get a colonoscopy like we mentioned, with cancer with colorectal cancer. We are actually seeing more metastatic colorectal cancer in 20 year olds without a genetic predisposition. So anyone with those alarm symptoms needs to seek an evaluation. So let's say they don't have pelvic floor dysfunction. Let's say there's no alarm symptoms. A couple things we need to make sure. Okay. Are they eating enough dietary fiber? Most people are not. We should be aiming for 25 to 35 grams of dietary fiber a day, but not all at once. Okay. So we don't digest a lot of that fiber. If you were to have one of these, like keto breads with 25 grams of fiber for a bag or, you know, for a slice of bread, too much fiber all at once can definitely cause GI issues and worsens constipation. So we want to spread it out. For instance, a cup of broccoli has about 4 grams of fiber. So basically, to put it in, you know, very simple terms, every time we're eating or having a snack, it should have protein and it should have fiber in order to reach those daily requirements. And then movement is really key. You know, if we're on death by zoom and constantly sitting down one, we probably have pelvic floor dysfunction. It's probably going to irritate hemorrhoids and it's not going to help stimulate the bowels. So for me, you know what I do every morning? I put on my weighted vest, I put on some tennis shoes, I hop on my walking pad and I brush my teeth for 10 minutes. And then. And that gets me moving. And it definitely helps with regulating bowel movements. And then the last one is going to be adequate hydration. You are probably more guilty than me of walking around just chronically dehydrated. I think as proceduralists or surgeons, we're so used to, honestly, not drinking water for 10 hours because we're stuck in the OR or doing 15 colonoscopies in a day. And we never had honestly, time or access to adequately hydrate. So adequate hydration is key. If we're thirsty, we're already dehydrated.
- [34:32]
B
Let's talk about the patient. You mentioned being in the operating room as a surgeon, but let's talk about a patient who's in the operating room and now is post op, you know, after a major surgery. And I remember in residency I used to have patients after a cystectomy or prostatectomy, and they would ask Dr. Perlman, what should I be eating after surgery? And I gave them the following advice. I would say, you Just had a major operation. Eat whatever tastes good. Just pick at the plate. Now, looking back, I cannot believe how terrible that advice was. What is some good advice that we as urologists can tell our patients about as they're preparing for surgery and as they're healing from surgery? To minimize the constipation, the diarrhea, and their inflammation.
- [35:20]
A
So we have to anticipate that post surgery because they may be on, let's say, antibiotics, which can cause diarrhea, or, you know, they may be on narcotics or other pain medications, which are going to cause constipation. We need to be proactive. Once, you know, someone, let's say, gets their surgery, they're obviously inactive. They're probably not eating a ton of fiber. They may or may not be dehydrated, and they're taking pain meds. If we wait a week for them to then tell us that they're constipated, it it's going to be so much harder to actually treat that constipation. And, you know, sometimes we'll get fecal impactions and they're extremely painful. And that also prolongs hospital length of stay. And because people are in pain, they end up taking more pain medications. And it's a vicious cycle. We have to be proactive. So, one we have to understand. Does the patient have any underlying bowel issues like diarrhea or constipation? If they do, then we should continue their bowel regimen in the hospital. Oftentimes we stop a lot of these, like, unnecessary meds and forget the patient's been on them for a long time and probably requires them, you know, chronically. So it's understanding what is their baseline bowel habits and then being proactive post op. So if you're trying to heal in the perineal area or pelvic region, the last thing you need is obviously too much diarrhea, which can obviously cause infection with the wound or too much constipation. It's going to wreck a lot of havoc. So. So we just need to keep an eye on it. Patients need to give us feedback. Have you had a bowel movement today? Was it diarrhea? Was it constipated? Are you having pain with bowel movements, things like that, and then being proactive, understanding that there are a lot of laxatives on the market. If someone's having abdominal pain, we probably should not be giving them stimulant laxatives like Sena components. Maybe Amir Lax with a bunch of water and some colace would be more Beneficial. So we also need to make sure that we understand not all laxatives are created equal.
- [37:14]
B
So let's think about the hospital menu. And I know it makes us both cringe a little bit to think about a hospital menu, but what might be some healthier options on a hospital menu that can help people get through their recovery period post surgery?
- [37:27]
A
If you have family or friends in the area, honestly, your best bet is to have them bring food to the hospital. It really depends on where you're staying. Most of the time we will like do the protocol where it's advanced as tolerated. So oftentimes you want your bowels to kind of wake up after surgery and start with liquids. The problem is a lot of times in the hospital it's going to be juices which have high fructose corn syrup or a lot of these soup broths which are just, you know, full of sodium but have no protein. So something you could easily do would be you have, let's say the soup broth they're giving you, but maybe bring, if you're anticipating being in the hospital for surgery, bringing like packets of like collagen, know, protein or unflavored protein powder, just mixing that in with the soup to make sure that you don't lose a lot of muscle while you're in the hospital. We know that post op that drives up our cortisol and our overall systemic inflammation. And cortisol is a catabolic hormone. It breaks down muscle. So even if we're in the hospital just for two to three days, even if we're walking around the hospital, the mere fact that we're healing from a surgery and our cortisol. Cortisol levels are high will break down a profound amount of muscle. Many times people then need to go, you know, to a physical therapist just to recover from that muscle loss. So making sure that we're getting adequate protein post op is very key. The problem is at most hospitals is they're giving you, you know, the insurer or the boost or the glucerna, which have pro inflammatory sugar in there with high fructose corn syrup or artificial sweeteners. So honestly, if you want to really make sure you're getting adequate nutrition, it's to bring these things from home, try them out before surgery. Obviously you want to get clearance from your provider to make sure they're allowed, but that would be your best bet is to bring things from home. If this is a planned, you know.
- [39:09]
B
Hospital stay after surgery, that's a really interesting concept because we usually tell people to bring comfy clothes to the hospital. Don't bring any valuables. I don't think I've ever told someone to pack some good healthy snacks for when they're in the hospital, but that sounds like a phenomenal idea.
- [39:24]
A
It would be the same thing. Like our patients that travel, right. People are surprised there's no healthy options at the airport. Let's be real. We know there are no healthy options at the airport. We know there are no healthy options in the vending machines at the hotel. We that that day will probably never happen, unfortunately. So we need to bring these snacks with us. You know, bring the roasted chickpeas or the edamame or the nuts, those non perishables we should be bringing with us to really set ourselves up for success.
- [39:53]
B
I love that. So you mentioned a lot of different snacks and for those of you watching, like on YouTube, you can see some examples of these snacks. But for people who want to dive in and maybe try some of these healthy options, where can people find these options online to know that they're getting a good protein source, fiber source, recommended by yours truly, Dr. Michelle.
- [40:14]
A
Yeah, so just like with medical information and Dr. Google, there's a ton of information online that can be very overwhelming for people. So I, you know, have a website actually called Bite MD B Y T E M D app where I've actually created a whole shop page for my patients and the community. So you can actually go on that website and there's a shop page and it will actually all the items that my partner and I recommend. He's also a gastroenterologist here in South Florida. It will actually populate into your Amazon cart. So. So I'm not really. My goal is not to tell people what they should be eating per se, but people need to know what sort of resources can they go to to find the better, less processed items that are accessible and then figure out what they like and what they don't like and then to try different options. So a lot of the items that we have on that website are the little snack packs. So you can try them. If you like them, you order more. If you don't, you move on to the next option.
- [41:11]
B
Yeah, what I like about your snack options too, other than the fact that they're literally really right across from my office and so I snack on them all day long. But I know every time I open up that package, I'm getting something out of it. It's not just empty calories. I'm at least getting some fiber and, or some protein, which I really like where else can people find out some more information on what you do? And maybe, you know, because a lot of us as urologists, we're not going to have the time to go into the depth that obviously you went into today. So is there a place where people can find some of these videos that maybe they could say in the office, this is out of my Arab expertise or I don't have time to discuss this today, but why don't you check out this link to learn more?
- [41:47]
A
Yeah. So on my Instagram I have a lot of information on both the exercise component, how to maintain and build muscle over time, and That's Michelle Perlman, MD. On my Instagram we have a YouTube channel which is Prime Institute US where we also have a lot of educational videos on there as well as it pertains to GLP1 medications, how to minimize muscle loss when you're on them. And really the foundation with or without these medications when it comes to nutrition and exercise and hormone optimization.
- [42:17]
B
Awesome. And we'll have in the show notes, we'll have information on where you can find all this great information from Dr. Michelle. So in closing thoughts, I was hoping you could tell the group, why do you do what you do?
- [42:29]
A
We have incredible control over how we want to live the last 10 years of our life. I feel great and I want other people to wake up every day and feel confident in the skin that they're in, feel healthy, feel ready to take on the day, enjoy going to work, enjoy their time with friends and family, enjoy the time we have on this earth. And as much as we feel like things are out of our control and many things are, it's just about making that next right decision. Right? It's am I going to take the plain Greek yogurt or, or the yoplait, Am I going to have the Coca cola or am I going to have water and infuse it with lemon or lime? It's those next decisions. That's all we have to decide. And that, my friends, will have a profound impact on how we live the next five, 10, 30 and 40 years. It's those micro decisions and we have incredible control.
- [43:28]
B
I absolutely Love that message, Dr. Michelle. And with that we are going to wrap up today, today's back table urology episode. Stay tuned for more knowledge.
- [43:50]
A
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars and share with a friend. If you have any questions or comments, DM us @Backtable on Instagram, LinkedIn or Twitter back Table is hosted by Aditya Baghrodia and Jose Silva.
- [44:08]
B
Our audio team is led by Kieran.
- [44:10]
A
Gannon with Support from Josh McWhirter, Aaron Bowles, Josh Spencer Design and digital marketing led by Brian Schmitz Social media and PR by Chi Ding.
- [44:21]
B
Administrative support provided by Jamila Kinnab.
- [44:25]
A
Thanks again for listening and see you next week.