B (2:57)

Oh, my gosh. Dr. Gift. That means so much. This is a huge full circle moment for me, so thank you for having me on.

A (3:04)

No, it's really our pleasure. We've all been looking forward to this. You sent me the book, and I think I was texting you at the time. I was flying to the west coast from the east coast, and I read the book in one sitting on my flight there, and I was totally taken with it. I think I texted you right afterwards saying I learned so much. And it was funny. The book is called you'd've been Pooping all Wrong. And part of me felt like I needed to cover the title a little bit because I didn't want anyone asking

B (3:33)

me, have you been.

A (3:38)

How did you come up with the title?

B (3:40)

Yeah, the title is really a conversation starter or a conversation stopper, depending on the situation. But it actually came from something that I heard myself saying in my mind all the time when I was meeting patients. And then eventually I started saying it out loud. But I think that people who came to my clinic when I was starting up fellowship. So this was about five years ago, when I finished GI fellowship and was practicing on my own. I began to realize that what I thought was completely normal and normalized conversations about our bowel habits and pooping and how our gut works, how the enteric nervous system works. These were not conversations other people had grown up having. And I only had them because my dad was a guest, is and still is a gastroenterologist and loves what he does and was always getting into the weeds of these conversations. So I thought it was very normal. I came to find out later the hard way that some people find these conversations very embarrassing. And they're not having these conversations all the time. And patients would come in to me, you know, often they'd have one specific reason. They'd come like, maybe they have abdominal pain, maybe they need a colonoscopy. But what they really wanted to ask sometimes was, well, is this normal? Are my bowel movements normal? Like, they wouldn't even kind of know some of the basics. And then you'd kind of like, open up the door. You'd crack the door open to be like, well, what do we know about this? What do you, you know, like, what do you think is normal? And just the floodgates would open about how little people understood about their bodies. And sometimes I would find myself saying, wow, you've been doing this wrong your whole life. Let's start over. Let's just like, you know, eliminate everything you thought you knew about how you're supposed to do this and how your body works, and let's just start from scratch. And from there. I decided I was gonna write about it, partially because I think it helps spread the word more easily. It's hard, we know it's hard to get a GI doctor's appointment, but also for the fact that I think this topic has been stigmatized for so long with that title, I really wanted to just say it, say it up front, say it loudly, and hope to try to destigmatize something that we're all worried about. 40% of Americans struggle with their bowel habits every day. That's a huge number. And this is not people. These are not people who have a diagnosis per se. They don't necessarily have a labeled condition, but their bowel habits just interfere with their daily lives. I think we should change that because it doesn't have to be that way.

A (6:04)

Right. I remember years ago, Oprah did a thing with Dr. Oz, and it was like one of the first things Dr. Oz ever did, I think, for the show. And we were talking about it. I happened to be on set that day, and it was about bowel habits. And it was really interesting to me because they got really didactic. They showed what normal poop should look like. And what I can tell you is that while no one in the that audience probably would have asked about it, everyone was fascinated by it and because it affects all of us. But there's this taboo around it, this stigma around it. You didn't have it because you grew up in a family of gastroenterologists. But that's not the case for most people. Why do you think it is so taboo or stigmatized to talk about? And is that a us thing or is that a worldwide thing? Do different cultures approach this differently?

B (6:55)

You know, I have a lot of theories about why this is the case. One is that I think from our early days, like, probably the last time a lot of people had this conversation about pooping is when they were toddlers and when they were being potty trained. And even around that time, and I'm actually, like really deep in potty training my two year old right now. So I understand this. So it's close to my heart. But I think even around that time, a lot of parents treat going to the bathroom as Yucky, and they call poop yucky. And they kind of start to make you feel like this is something that you need to have control over. It's embarrassing when you don't. And you need to kind of distance yourself from it as soon as it's over. Like, it can. And I think it spreads from the idea that, yes, you can spread diseases through poop and through not, you know, washing your hands. That was an old fear that I think has lingered. But it's taken on this, like, idea that it's disgusting. And by no means do I think it's, you know, like, overly delightful by any means, but I certainly don't ever want my kids to feel like that they should be embarrassed by what's going on and that we shouldn't have this conversation. Once you bring it up, once you just open the door to it, everybody wants to talk about it. In fact, everyone's relieved that someone's able to have this conversation and that they can get knowledge about it, because it's the thing that I have found. I mean, I know this from my patients and from everyday experience, that it's something that can make or break your day. You know, like being able to eat what you like and then being able to comfortably get rid of. That's something that people would give up a lot in their own life to be able to get back.

A (8:29)

Yeah, I think there's no question. And I think this is one of the few topics. I mean, joking aside, one of the few topics in medicine that is so significant and so poorly discussed or inadequately discussed at the same time. Perhaps things like addiction would sort of fall into that category. But this is something that is so basic to human biology and yet so rarely discussed. So the book, I think, really does open. Open the door to this. And, you know, I think, like I said to you right away, I think this is going to be a really, really important, popular book because of that reason. You provide really sound medical guidance here, which, frankly, is very reassuring, I think, for a lot of people. And I think that that's going to be. But 40% is a big number, Tricia. You know, 40% of people have their daily lives disrupted because of their bowels. 15% have irritable bowel syndrome.

B (9:25)

Yes.

A (9:26)

Have those numbers gone up and what do you think is going on here?

B (9:29)

Certainly those numbers changed a lot with the pandemic. And every time there's a big infectious outbreak, about 1 in 3, 1 to 4 people do go on to develop irritable bowel syndrome. And so we certainly Saw just a population wide surge of irritable bowel syndrome after Covid. But it's one of those things that you'll see if there's a case of norovirus or if there's an outbreak of like everyone in your family gets food poisoning. It's actually a good percentage of people who get irritable bowel syndrome. And it may not be forever, but it may be something that lasts for months to years. And people are living with. So over time they track. The number of cases of irritable bowel syndrome went up the number of the 40%. Has that changed over time? I think that my guess that that particular number has probably stayed similar over time. I mean, it's a big number. And I sometimes see this with my patients. A lot of people might think, oh, I'm not in that group. Like, I think I'm doing just fine. But sort of my litmus test for that is ask your partner, do your bowel habits disrupt your daily life? And sometimes people are surprised because they're like, no, I'm not constipated, I have no trouble. And their partners will be like, are you kidding me? You spend 45 minutes in the bathroom every morning. We're like late to go out all the time. And sometimes you don't really realize how disruptive your habits are until you move in with somebody or until you go to college and you see what other people are doing, or until your partner finally breaks and says, we have to talk about this. But you might have normalized what you're doing for so long simply because you don't know that it's actually not the average experience.

A (11:04)

You know, I read a stat that for younger people, 80%. For some of these younger people, 80% of their diet is basically processed foods. Yeah. Are processed foods part of the culprit here?

B (11:16)

Yeah, I've read similar stats and that's changed certainly over time. And I think that's part of why ibs. I think that section of the population has been growing and changing. It's not just the infections. And they've done a few studies on this in large epidemiological studies where they have linked ultra processed foods with worsening symptoms. In irritable bowel syndrome, a lot of what we understand about ultra processed foods and the gut in irritable bowel syndrome and pain comes from translational or basic studies. And in those studies, we have certainly found that ultra processed foods decreases that mucus lining in our colon that is so important because our colons are lined with this layer of mucus that really protects us from the outside world. When these ultra processed foods, some of the additives and chemicals in them deplete that layer, not only does it change the bacteria that are living there happily in that layer now, they can't do that, but it makes you more susceptible to the outside world and the environment and what you're putting in there. And so we think that some of those things do have to do with it. And of course, then there's this other very concerning finding that I know you've reported on about ultra processed foods and this link to colorectal cancer. And we're certainly seeing a lot of early onset cases of colorectal cancer. Those have been rising for now several decades. And that link is starting to become much more clear with ultra processed foods.

A (12:38)

We've been using two terms, irritable bowel syndrome and constipation. I think most people understand what constipation is, although there may be a medical definition of it as well. But first of all, with irritable bowel syndrome, what is it exactly?

B (12:51)

Yeah, that is a huge, huge question. Irritable bowel syndrome is one of those syndromes that I think when people hear that word, they think it's what we would call a diagnosis of exclusion. It's what you give. It's the diagnosis you give somebody when you don't know what's going on, when all the tests are normal. And in fact, we've over the last two to three decades really clarified what it is that's happening. So on the surface of it, irritable bowel syndrome is this incredibly common disorder where people have pain or discomfort associated with having a bowel movement. And there's some people who have constipation, there's some people who have diarrhea. But in all cases of irritable bowel syndrome, there's a lot of discomfort that goes into that. And that's something that they live with for at least three months, often for several years. And the tricky thing about this is that most of the tests that we do in a standard clinical environment are negative. Meaning you could get a colonoscopy, you'll get biopsies, they won't show any abnormality, you'll get blood work, those probably won't show any abnormality. And sooner or later, your doctor will eventually say, well, okay, it's not something that's causing inflammation. It's certainly, you know, nothing worrisome. We're going to call this ibs. And what's actually happened is a change in the enteric nervous system. The enteric nervous system is this network of nerves throughout the gut that is in close communication with your central nervous system and your brain. And there are lots of different abnormalities in ibs. It's actually kind of like a lot of diseases where there's not one singular abnormality. It's multiple different things that happen. But one of the common themes is that the nerves in your gut become hypersensitive, meaning it takes a lot less for them to react and trigger and send pain signals up to the brain. The reason that we don't have a good test for that is that much of the enteric nervous system lives in the deep muscle layers of the gut. You can't reach that with a surface level biopsy on a colonoscopy. That would you would cause a hole in your colon. And we certainly don't want to do that. But in research studies, we know it's there. So sometimes even knowing yes, there is, people are aware that there is a true abnormality here can be really validating and reassuring to people.

A (15:03)

What can our bowel habits tell us about our health?

B (15:08)

Yeah, I think they can tell you a lot. And I sometimes think about this statistic that came from the uk, but it really bothers me, which is that one in three people will avoid talking to their doctor about their bowel habits because they're so embarrassed. And I always sort of anchor with that statistic in mind because if you don't get in the habit of routinely looking, looking is the first step. Knowing what your normal is, knowing what your kind of fluctuations in your pattern could be considered normal. You're not going to know when something is a little abnormal for you. There's a lot that you can learn first just by looking and understanding what your pattern looks like. One, the consistency tells you a lot. There's actually been very good data that shows that the consistency of the stool, so meaning how soft and fluffy it is versus how hard or pebbly it is, that can give you a good sense of how quickly that stool has moved through your body, how long it's been sitting in your colon. Because one of the colon's jobs is to suck water constantly out from what's inside back into your bloodstream. So if it takes longer, more and more water is getting sucked, you know, and the stool becomes drier, it can tell you about that. The color can give you a lot of information. And certainly there's a very important point to be made, that if somebody sees red, sees something that looks like blood, they haven't had beets. Beets are a classic masquerader. But anything that looks like blood, you shouldn't assume is hemorrhoids or shouldn't assume is no big deal until you have a doctor just confirm and make sure about that. So anything that looks like red is concerning. And then how you feel around the time. Are you feeling discomfort? Are you straining? Straining is a big sign. People often talk about frequency as being the most important thing, and to me, that can actually be the least important thing. How you feel, whether it was comfortable and effortless is the number one criteria for me about whether something is normal. If you go once a day, but you strain for 20 minutes and you strain your eyeballs out, I don't think that that's normal. But if someone's going, you know, every other day, but it's completely effortless, I think that's totally normal. So it really depends. But I think you have to ask yourself, how much time am I spending in the bathroom to do this? And am I disrupting my own life? Am I disrupting other people's lives because of this?

A (17:29)

More of my Frank discussion with Dr. Trisha Pasricha right after the break. Tab. I got news for your ears. The podcast. I am your host, Michael Ian Black. She would get us into a third world war. Yeah, see, and he's right. If it had been Kamala, we'd have millions and millions of people whose lives are at risk, as opposed to the billions of people whose lives are at risk right now.

B (17:55)

So it's actually a inflationary issue. If you put that clip right next to a clip of discussing his Easter, what would you call it? Greeting.

A (18:04)

It's an Easter greeting.

B (18:05)

Right. What do you call it when you.

A (18:06)

When you threaten genocide in front of the Easter bunny?

B (18:08)

Yeah, Easter bunny. What do you call that? Meltdown. Easter meltdown.

A (18:11)

Have I got news for your ears. Check us out on Apple, Amazon Music, wherever you get your podcast. Even better, you can watch the Vodcast on Spotify. Welcome back to Chasing Life and my conversation with Dr. Tricia Pasricha about a universal but taboo topic. Is there an ideal way that or amount even people should be. Should be having bowel movements?

B (18:41)

I think a lot of people think the answer to that is you should go once a day and you should go in the morning. And I think that your body actually is physiologically primed to go in the morning. So it can be nice if you can lean into that natural physiology. And the reason for that is that your colon is kind of like the rest of you, it operates on this circadian rhythm more strongly than a lot of your other organs. And so it can goes into this really quiet still state at night when you sleep, right. Like your heart is still beating. It might be a little slower. Your colon's really not moving too much at night. When you wake up, though, it buzzes with activity for the first one or two hours upon waking. And your colon on its own is gonna contract more strongly than it's going to do so for most of the rest of the day. So if you can lean in and try to have a bowel movement during those first hours when your colon's doing the work for you, it means you have to do less work. Cause you don't have to. And then often in the morning, people are having a cup of coffee, which can, for one in three people, coffee triggers a bowel movement. It causes those contractions. You might go for a walk in the morning. That's very common. I walk my dog. Exercise, and just even moving around gets things going. So you do a lot of things in the morning that come together. But again, it's very common for people to experience another wave of just those natural contractions in your colon anytime they eat. So just eating, that mechanical distension of your stomach sends this signal up to the brain in a reflex, and then it causes the colon to start to contract. It's why people sometimes within minutes of eating, sometimes feel like they have to go to the bathroom. And it's not because that food suddenly made it all the way down to the colon. That's not the case. But it's this reflex, and it's totally normal.

A (20:24)

And again, I just want to emphasize this point. You have to sort of compare yourself to you, right. I think that's. Again, one of the things I took away from the book is that things might be very normal for you, might be very different for someone else. But what you're really compari concerned about, Doctor, is when that individual has a change in bowel habits. Like if they start, if they're going every couple of days and now they're going three times a day, or vice versa, that would be a concern. And why is that a concern? What do you think? What are you worried about at that point if someone has a change in bowel habits?

B (21:02)

Well, I worry about two things. One is I certainly worry if it comes to your attention, because that change is now causing you spread problems. Like you now say, I have this urgency to go, and I'm struggling socially. I can't make it to the bathroom. This is like bothering me or suddenly I'm straining. This is like very uncomfortable. When you have symptoms, I'm always concerned and I will always try to figure that out. But sometimes it doesn't quite reach that level. Even of you saying this is overly bothersome, you might just say, I noticed that my stools are suddenly really, really thin. That doesn't inherently bother me, but it's new, it's different, it's weird. That bothers me because that's a change that's worth investigating. Why now? Every time you have a change in your bowel habits, it may not be something worrisome. What I'm worried about with the change in the caliber and something becoming thin is that could there be a mass or something squishing it that's causing it to be thin like that? But people are gonna have daily fluctuations.

A (22:04)

We've talked about processed and ultra processed foods being problem to sort of flip the script on that. Is there an ideal diet for colon health?

B (22:16)

Yeah, they've done so many of these studies. Actually a lot of them were done here by my colleagues at the School of Public Health looking at the Nurses Health study, which a lot of people have heard of, trying to figure out what are the kinds of ways that we eat in America that are linked to better health outcomes with our guts. And I think that at the end of the day, what we learned from a lot of these studies is that it doesn't have to be so prescriptive in terms of cutting out a lot of different foods. But it seems that diets that most closely mirror something like the Mediterranean diet seem to be beneficial not just for your brain and for your heart, but really for your gut. What the basic principles are that have been shown in the Mediterranean diet and in other kind of anti inflammatory diets that benefit the gut are eating more fiber. Like you said, if I could do just one, two and three things, I would eat more fiber. Eat more fiber and eat more fiber. And for women it's for under 50, it's 25 grams per day. For men, it's 38 grams per day. If you were to just stop and count like one day, a typical day in your life, how many grams of fiber are you actually getting? 95% of us are not going to be getting enough. And that's the first place to start. And then it's thinking about, okay, well what are the ways to incorporate more whole grains? Yeah, I'm eating more vegetables, but can I eat a diversity of vegetables and fruits and legumes? Legumes are really underappreciated. And the fewer kind of inflammatory foods, which are the processed foods, the processed meats, the better. It's not all or nothing. It's never going to be all or nothing. But if you can start making small swaps, even if it's as little as a fiber supplement, that's better for your gut health. And the reason that it's great for your gut is we talk so much about, in popular culture about probiotics and the microbiome. And the point that I want people to remember about the microbiome and why these foods matter is that your microbes feed off of the things we cannot digest. And usually that is fiber. It can be resistant starches and other things, but it's the fiber that makes their way down to the colon. And how much fiber you're getting, the kinds of fiber you're getting, it will change the species of the bacteria living there. And once they metabolize and they ferment these different kinds of foods that you are choosing to give them, they produce new compounds called postbiotics. The postbiotics is like the underappreciated part of the microbiome conversation that I think is the most important part. Postbiotics are the compounds that the microbes produce. They're new compounds. You're not making them, they're not technically your body, they're coming from the bacteria. But you absorb them, they enter the bloodstream. And a lot of these postbiotics people have heard of short chain fan fatty acids. Butyrate is like a very commonly known one because certain bacteria tend to produce it. They're anti inflammatory. They're the reason that we think your microbiome plays such a big role in dementia, in cardiovascular disease and different kinds of cancers. It's these postbiotics that your bacteria are producing. And so ultimately you can trace the pathway of those postbiotics back to what you're eating and what you're feeding yourself.

A (25:24)

You do talk about poopforia, which I think is another great term. What is poopforia and how do we get there?

B (25:33)

Yeah, poopphoria is a state of mind. It's a way of living that is somebody who actually never thinks about their bowel movements. Pooforia is really where pooping is the least of your daily concerns. And, you know, as simple as that sounds, it's like, it's quite profound for a lot of people. It means you can eat the foods you enjoy, you get rid of them, and you're not tied physically or Mentally, to where the bathroom is. Nobody is bothered by what you're doing. You're not bothered by what you're doing. And it's also not the thing that keeps you from going out to brunch with your friends, from a nice long hike with your dog, from traveling. All of these things get disrupted when you're not living with Pooforia. And frankly, that's so many of us, a lot of people. I was just talking about this earlier today. People can't poop at work. And these are small. It feels like small things, but they really can impact somebody's quality of life. And I, you know, as a gastroenterologist, I treat people who have a whole range of things going on. Some people are gonna need medications and more specialized treatment. A huge majority of people just need a little bit more education about how their bodies work and making small changes in their own lifestyle that can improve things so much more than they even realized.

A (26:58)

It's a great book. Everyone, I hope, gets a chance to read this book. I am curious, being a dad of girls who are not that much younger than you now. What'd your dad say when you read the book?

B (27:10)

Oh, he's the proudest dad in the world. He was so happy. He actually. I mean, he was moved. He was moved to tears. It was, like, really meaningful. But he really did just have such a big impact on who I became or the kind of doctor that I hope I still am today, or I'm trying to be.

A (27:27)

It would be no surprise to me if he was very proud of you. We all are. And I really do hope everyone gets a chance to read the book. Thank you so much for being on the podcast and thank you for sharing the book with the world.

B (27:39)

Thank you so much for having me.

A (27:44)

That was gastroenterologist Dr. Tricia Pasricha. I should point out she gave one more tip at the end of the podcast, which is, stop taking your phone into the bathroom. You end up spending way too much time there. Her new book is called you've Been pooping all wrong. It's out now. Thanks for joining us on Chasing Life, and we'll see you next week.