← Rena Malik, MD Podcast
Rena Malik, MD Podcast
The 5-Minute Poop Rule (And Why It Matters) ft. Dr. Trisha Parischa
01:36:48
In this episode, Dr. Rena Malik, MD talks with Dr. Trisha Pasricha about gut health, covering topics like healthy bowel habits, the impact of smartphone use in the bathroom, rising colorectal cancer rates, and the gut-brain connection. Listeners gain practical tips for improving digestive wellness and recognizing important warning signs.
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- [00:00]
Dr. Tricia Pasricha
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- [00:18]
Dr. Rena Malik
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- [00:20]
Dr. Tricia Pasricha
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- [00:23]
Dr. Rena Malik
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- [00:45]
Dr. Tricia Pasricha
Bringing your smartphone into the bathroom was associated with a 46% increased risk of having hemorrhoids that we saw during the colonoscopy. If you're spending more than five minutes in there, straining, struggling to have a bowel movement, that's abnormal to me. And really, in an ideal world, this wouldn't be something that takes you more than a couple seconds to achieve. For me, the colonoscopy is not really for cancer screening. That's how we bill for it and that's why we do it. But it's really to detect polyps which are precancerous and to prevent cancer.
- [01:14]
Dr. Rena Malik
I saw somewhere that I think it was in your book. Up to 40% of Americans have bowel issues. That's four out of 10. Meaning that if you know 10 people, four of them have bowel issues.
- [01:24]
Dr. Tricia Pasricha
Yeah, exactly. And that's 40% who say not just that they have bowel issues, but that their bowel habits disrupt their daily lives.
- [01:33]
Dr. Rena Malik
You might think you know how to poop, but what if you're doing it wrong? And what if the smartphone that you bring into the bathroom with you every day is actually giving you hemorrhoids? I'm Dr. Rena Malik, urologist and pelvic surgeon. Welcome back to The Rena Malik, M.D. podcast, your trusted guide for leveling up your health, relationships and sex life with evidence based tools. Today I'm talking with Dr. Tricia Pasricha, Harvard gastroenterologist, director of gut brain research at Beth Israel Deaconess and NIH funded scientist, Washington Post medical columnist and author of the forthcoming book, you've been pooping all wrong. We're talking about the things that nobody tells you. What healthy bowel movements actually look like. How stress changes your gut contractions. Why ultra processed foods are linked to rising colorectal cancer rates in young people. The truth about leaky gut and probiotics and how trauma can actually rewire the neurons in your digestive system. Dr. Pasricha even tells us how the rate of your gut contractions can tell us if you're lying or not. This conversation will change how you Think about your gut health and maybe your bathroom habits, too. Guys, if you love learning about your health, you will also love my free ebook called Better Sex, Better Life. It is my top 10 ways to improve your sex life based on my years of clinical experience and research in sexual health. Check it out. It is completely free at www.renamelicmd.com. more pleasure. Thank you so much for joining us today.
- [03:02]
Dr. Tricia Pasricha
Thank you for having me. I'm so glad to be here.
- [03:05]
Dr. Rena Malik
So I want to start with just the very basics of poop.
- [03:11]
Dr. Tricia Pasricha
Yeah.
- [03:11]
Dr. Rena Malik
So what is a normal, healthy poop supposed to look like and feel like?
- [03:16]
Dr. Tricia Pasricha
You know, people think there's one answer to that question. And for me, the main criteria you would need to fill is one, your poop should be effortless, should be easy, shouldn't cause you discomfort, and it should occur at a socially appropriate time. Outside of that, you can do a lot of things with your poop, and I would still call them normal. There's some boundaries, but, like, a lot of people are like, okay, it has to be this beautiful, firm, but not too firm sausage once a day, or I'm weird, or there's something wrong with me. And that's not true. It can be a lot of different things. The times where I would say we need to reel you in a little bit would be if you're having bowel movements that interrupt with your social life. And people, you know, they've done these studies that show that you can have a bowel movement every third day or three times in one day still within the range of normal. So you could. There's a big variation there, but if you're really on one end of the spectrum and it's bothersome to you, we might want to reel you in.
- [04:14]
Dr. Rena Malik
And then effortless. So should you be straining? Because, you know, people will tell me, like, you know, as a urologist, we talk about bowel movements a lot because it's all intermingled.
- [04:24]
Dr. Tricia Pasricha
Amazing. Yes.
- [04:25]
Dr. Rena Malik
So people will tell me, like, you know, my bowels are okay, and then when I dig a little deeper, they're like, yes, I have to strain. Yes. It's not always easy. And. But again, how do you define easy? I think people don't really understand.
- [04:38]
Dr. Tricia Pasricha
Yeah. Isn't that the classic scenario? That to me too. And I'm like, do you feel like you're constipated? And they're like, no. I go once a day and I'm like, oh, okay. Well, how long do you spend in the bathroom? How long do you spend in a bathroom? Is the telling question. And they'll say, and sometimes it's funny, when someone comes in with their partner, you get two different answers. They'll be like, oh, maybe 10 minutes. And then the partner will be like, what are you talking about? It's like 30 minutes. If you're spending more than five minutes in there, straining, struggling to have a bowel movement that's abnormal to me, you shouldn't be spending more than five minutes. And really, in an ideal world, this, this wouldn't be something that takes you more than a couple seconds to achieve. And so you should be in. It should be, you go in, you're responding to the call at the right time, meaning your own body's doing that, you feel that urgency, that's your own colon contraction. So you go in, you do the job, and you come on out. To me, even five minutes feels like a long time. But that's kind of the parameter we, the data sort of puts on it. But if you're in there for more than 10 minutes, you really need to talk to someone. Even if you're like, wait, put the stool, it looks like it's nicely formed. I, you know, it's not bothering me. But the straining in and of itself is problematic and can lead to problems long term. So have a conversation with someone. If you're spending too much time and if you're not sure if you think you're okay, ask your partner, do they think you're okay? Sometimes you get a really different answer.
- [05:53]
Dr. Rena Malik
Yeah, that's so interesting. So I think five minutes or just minutes. I mean, sometimes people have like voluminous poops.
- [06:00]
Dr. Tricia Pasricha
Right.
- [06:00]
Dr. Rena Malik
Like they just have a lot of fecal matter that needs to be evacuated. And so in those cases, if someone, you know, had a lot of fiber laden food.
- [06:08]
Dr. Tricia Pasricha
Yeah.
- [06:09]
Dr. Rena Malik
And they have then a voluminous poop, would that take longer?
- [06:12]
Dr. Tricia Pasricha
It shouldn't have to. In fact, when you have more fiber, it should pass more easily, more quickly. It's more. Actually the kind of correlation is when it's harder, more firm, difficult to get through the sphincters, which often means it's stiffer. That's when it takes a little bit longer and you have a little bit of an issue. Now it can actually be that the consistency of the stool is not the issue. It actually can be that your pelvic floor is the problem. And that's a whole separate conversation that. So even if you've done everything you can, you've eaten all the fiber you can in the world to optimize your poop you may still have a lot of straining and difficulty having a bowel movement. Just because you're on pelvic floor isn't working with you. But in an ideal world, you know, it's five. It's time. Time starts to lose its meaning. I think when you're in the bathroom, sometimes, like, you pull out your phone, you don't really know what's going on. Like I tell people, just, you know, rather than count going by some number of minutes, like, just set yourself like a two TikTok limit or something. Like, really tangible two TikTok limit.
- [07:02]
Dr. Rena Malik
Well, TikToks are longer now, but yeah, yeah, that's true. This also brings up a really good point. Now, your dad is also a GI physician.
- [07:11]
Dr. Tricia Pasricha
Yeah, that's right.
- [07:11]
Dr. Rena Malik
So when you talk to your dad. Because I think you and I train in a time where phones have always been around. I mean, they were different when we were younger, but they've always been around. And to some degree, you could, I guess, play on your phone. When we were younger or in training, perhaps, so you could still idle in the toilet. But maybe during your dad's time, that wasn't the case. You know, like, people were just. There was nothing to do. Maybe they might take the paper in the bathroom, but, like, there wasn't really anything to do. So did he notice or did you guys talk about this? Was there a big difference when people started using smartphones in the bathroom?
- [07:43]
Dr. Tricia Pasricha
Totally. I mean, I remember the days back when we used to have. Everyone used to have that little discreet bookshelf by the side of the commode that had yesterday's newspaper, last week's newspaper, some old magazines from two years ago. That kind of reading material didn't hijack your brain the way smartphones do. And it was actually. So I write this column for the Washington Post where readers writing questions, and someone wrote in about hemorrhoids, and they were like, tell me about these. Like, how do I treat them? What are they? And I was like, great. I love hemorrhoids. I'm a gastroenterologist. We're gonna talk about it.
- [08:17]
Dr. Rena Malik
And that's probably the first time anyone here has ever heard someone say, I love hemorrhoids.
- [08:22]
Dr. Tricia Pasricha
But, yes, well, yeah, except a few. The proud. So I was, like, excited to write about this, like, very juicy topic. And I knew, like, one of the first things I knew about this when I started fellowship training was that we tell our patients, try not to spend more than five minutes about them. Just like I'm telling you now because of this risk of hemorrhoids. So when I went back to the literature to try to figure out where does the five minute rule really come from? Like, why did we draw a line in the sand there? It turns out it came from this study from 1989. It was published in the Lancet, and it was this small group in the UK that were colorectal surgeons, and they looked at people who read the newspaper in the bathroom or who didn't. And it turns out the people who read the newspaper in the bathroom spent longer, more than five minutes, and they were more likely to have hemorrhoids on their exam in the clinic. Hmm, that was kind of it. And this was 2024 when I was like, getting this question. And so I thought, okay, this is really funny because I haven't seen anyone read a newspaper in the toilet. Like, I haven't seen newspapers in. I haven't seen a physical newspaper in a long time. And I write for the Washington Post. Nobody's bringing those bathrooms. So I decided to do this study where certainly I knew anecdotally we're all bringing our smartphones into the bathroom, but I imagined it was going to change those dynamics a lot more than a newspaper could. And so we did kind of a similar study, but we modeled it a little differently, where we had people coming in for screening colonoscopies. So these were a little bit older people, 45 and older. We asked them all about their bathroom habits, if they brought their smartphone in, what they did on the smartphone, and then other things that we know can contribute to hemorrhoids, like fiber, exercise, how long they sit down, all these things during the day. And as it turns out, bringing your smartphone into the bathroom one was associated with a 46% increased risk of having hemorrhoids that we saw during the colonoscopy. So there's that. Um, but also importantly, people who brought their smartphones in, about half of them said, yes, I identify that bringing my smartphone in leads me to spend longer in the bathroom than I intend to. About half. And if I'm being honest, I think that true number is longer than that. Like, these were just the people who, like, were consciously aware of it, but that's a big number. And then the ones who are bringing those smartphones in were spending. They were five times as likely to spend more than five minutes in the bathroom. So I think the five minute rule is still a good anchor. But I do think that the issue is not like that the smartphone. There's something mechanical about the smartphone that's giving us hemorrhoids. I think it really is a time issue, and I think just the smartphone is what manipulates our time and forces us to spend longer in there. And really what's happening is you're sitting in the bathroom on this open toilet bowl. This is not like a chair. We have good pelvic floor support. In some ways, you're just on this open toilet bowl, and hemorrhoids are just cushions of veins, and so they, you know, they become engorged. The connective tissue weakens if you're sitting on this open bowl day after day, week after week after time, and then the straining can weaken that tissue as well. So the longer you're doing that, it builds up over time. We sort of think that's why these people are at increased risk of hemorrhoids. And I say these people as if I never bring my smartphone in. But of course, I do, too, from time to time. But I try to set a limit.
- [11:24]
Dr. Rena Malik
Yeah. Do you think it's because people sitting on the toilet for long periods of time? You've already said that sitting itself is a problem in that specific sort of ergonomic way. But is it also that maybe because you're sort of mindless, that you might be like, oh, I'll strain a little more to get a little more out or something? Like, is that something that people do?
- [11:43]
Dr. Tricia Pasricha
Yeah, I think what happens is one, you sit there and just that sort of passive pressure, even without straining, is the problem. And I actually. And we don't know yet, like, the dynamics of it is something that we're trying to study in the lab, which we're very excited about, but we don't know. Is it because you're straining a little bit harder, because you're like, oh, my gosh, I have to play catch up? Once you remember why you went in there in the first place, your, like, your TikTok ends or whatever it is. I actually think it's more just because you're sitting there passively and the time is moving by. Like, when I published this study, I published it last year. I'm a parent. I have two kids. They're toddlers. And I got a lot of pushback from parents who are like, come on, like, going into the bathroom is my only me time, you know? And, like, I like. And I know it's this, like, if me and my husband were like, oh, we got to go to the bathroom. You got the kids, I see us, we grab our smartphone. Then I'm like, I know exactly what you're going to do. But it's usually like, you're only protected time. But you know, I would say that like, you, you should be allowed to have that protected safe space in your bathroom. No one wants to take that away from anyone. But, you know, you don't have to sit on that open bowl if you're just gonna go into Doomsboro. Yeah, just like shut the door and like stand up and doom scroll. But you don't need to sit down.
- [12:48]
Dr. Rena Malik
Yeah, no, I like that. I mean, you and I've talked about this a lot on my channel. Like how sitting for. Even if you're sitting in a chair, but sitting all day is. Leads very often to pelvic floor dysfunction, which you and I see a lot in our practices, causing problems with defecation, obviously, constipation, difficulties with emptying, but also with urination, with pain, with sex, with back pain, hip pain, all sorts of things. And so I think just generally you shouldn't be sitting for long periods of time. You should be moving your body throughout the day. And so just use that as a guide. Like, the toilet bowl is no different.
- [13:22]
Dr. Tricia Pasricha
Yeah. Oh, I totally agree with you. And I think, you know, like, another rule of thumb. If you're like, sort of again, I think you like, lose track of time if your legs have fallen asleep. Your legs ever fall asleep sitting there, you got to get up and go. Like, that's your sign.
- [13:35]
Dr. Rena Malik
But I like the five minute thing, honestly, like, if you're going to take your phone and put a timer on, just see how long you actually sit there.
- [13:40]
Dr. Tricia Pasricha
Yeah.
- [13:41]
Dr. Rena Malik
Because I think we don't realize it. Right. And like, you know, my son has gotten in the habit of it and he's 12. And so I'll be like, okay, we, we are making a pact. We're never taking our phone in the bathroom. So we're doing it together.
- [13:52]
Dr. Tricia Pasricha
Oh, my God, I'm so proud of
- [13:53]
Dr. Rena Malik
you guys because I was like, okay, we're not going to do this. I'm like, yeah, we slip up. But then we both remind each other. Like a bit ago, we promised each other we're not going to do this.
- [14:00]
Dr. Tricia Pasricha
Gosh, the comfortability. I love it. Well, you know, it's true. Like, we say we don't want to. We do this in my family, where we're like, we don't want to bring our smartphones to the table, like the dinner table, or why try to do this really hard with myself. I don't want to bring it to my nightstand when I'm going to sleep at Night. We should treat the bathroom the same way. I love what you're doing. Yeah. Yeah.
- [14:17]
Dr. Rena Malik
Well, hopefully it works.
- [14:18]
Dr. Tricia Pasricha
Teaching your kid good habits at a young age.
- [14:20]
Dr. Rena Malik
Yeah, we're trying. We're trying. So I saw somewhere that. I think it was in your book. Up to 40% of Americans have bowel issues. That's a large number. That's four out of 10. Meaning that if you know 10 people, four of them have bowel issues.
- [14:34]
Dr. Tricia Pasricha
Yeah, exactly. And that's 40% who say not just that they have bowel issues, but that their bowel habits disrupt their daily lives. So that means their day doesn't function smoothly because of their bowel movements. And I think what struck Swan, that number is huge. Like, that struck me. But I also think there's this idea that that 40%, a good chunk of them, don't have, like, a known disease, a known diagnosis that goes with it, and it's just something that bothers them. And maybe it hasn't elevated in their minds to. Because they've lived with this pattern for so many years, that this is just what they've normalized how it is for them. Yeah. How it. And maybe because we don't talk about it, maybe what they're experiencing is how it is for everybody. You don't know until you start asking around. And I think that's how we landed in this situation where 40% of us can't go about our day the way we want to because something disrupt us related to our bowels.
- [15:24]
Dr. Rena Malik
Absolutely. It's crazy to me because I see it all the time, and, like, you know, I ask every single patient about their bowel headaches. Every single one. And a lot of times they'll say it's fine, but some of them will be like, I've been constipated my whole life, or, I've always been this way. And. And some people will be like, yeah, I have really bad GI issues. But they've never seen a gastroenterologist.
- [15:43]
Dr. Tricia Pasricha
Right.
- [15:43]
Dr. Rena Malik
Or they've never even talked to their primary care doctor. But they've just been, like. I was gonna say raw dogging it, but literally been just, like, figuring it out by themselves, you know, like, how to. How to, like, manage this with, you know, just over the counter, like, trial and error. When should they take that step? And I think a lot of it is like, okay, I'm embarrassed. I don't want to show my butthole to somebody. I don't want to have a rectal examination. I understand that. But, like, I think, let's talk about when, what they can expect when they see you and when should they see you.
- [16:11]
Dr. Tricia Pasricha
Yeah, all great questions and I think you've hit on it, that at least part of the problem is embarrassment. Like there was this big study in the UK that I think about where about a third of people will put off talking to their doctor about their bowel symptoms because so embarrassed. And then that's part of it. And then I think the other part is just not knowing that there's something to be done. Right. People who have been constipated their whole lives, or even people who have irritable bowel syndrome or who've either self diagnosed or maybe their primary care doctor said it, a lot of times what they hear is there's nothing to be done. This is just what you can do. And it turns out there's so much that can be done if you talk to the right people. So one, I would say, and this is something that is just uncanny to me, like you've experienced when I talk to my patients and I'm like, do your bowel habits, like disrupt your daily life? You might not self identify. You might, that question might not like make you say, oh, yeah, that's me. But if I were to say, like, you know, phrasing it a different way, if I were to say, do you ever miss out on parts of social activities because you've had to deal with like a bathroom situation? Or is everyone waiting on you because you're waiting because you're in the bathroom and you're dealing with a problem? If you phrase it like that, there's actually a lot of people who maybe a lot of their life, no one was waiting on them. It wasn't bothering like anyone. But then they go to college and they're suddenly their groups of friends are like, where are you? Why is this guy taking so long? Or their wife is like, we need to go. And they're like, oh, just 10 more minutes. When you think about how it's impacting you and then maybe the people around you, you can flip the question a little bit. So that's one thing. So if it's disrupting your social life, yeah, you got to talk to somebody because that can really impact your quality of your life. But I would say any symptom that bothers you, you should have a really low threshold to talk to your doctor about. And I'll walk you through, like what I would sort of ask about and evaluate and what a physical exam would look like. The big, I would say red flags that you should absolutely Talk to your doctor about are any rectal bleeding? And what's really disturbing is that, like, on first glance, like, yeah, if you see blood down there, everyone would be like, wait, this is weird. I should talk to them. But you'd be surprised. So many people say, it's my hemorrhoid. I know what this is. You know, And. And maybe it's because you've had a hemorrhoid before or because that sort of seems like has to be run it by someone, me or gastroenterologist or primary care doctor who can just actually confirm that one. You still do have that hemorrhoid that you had six years ago, and that's the problem. And if not, maybe we need to look a little deeper. Everyone's heard about these headlines of rising cases of colorectal cancer, right? And it's worrying a lot of us. And in younger people in particular, the kinds of cancers that they're getting are a little bit biologically, a little bit different. They're occurring in different parts of the colon. But also we're catching them late. That's. That's kind of the most disturbing thing. And part of why we catch them late is on us, the doctors, because we're not sort of thinking about this as alarming as cancer being a possibility. But part of it, too, is people aren't bringing it to their provider's attention too. So both of us need to kind of do that work. So one rectal bleeding, to come back to it. Always talk to your doctor. Even if you think you know what it is, just have someone take a look. And all I would do if someone came to my clinic is that I would take a look in clinic. I could one take a quick look outside if there's any external hemorrhoids. And then we have these small. We call them anoscopes, but they're just. Just like a small thing that we put in. And it just. It allows us to just take a look on the inside. It almost acts like a reflective surface that lets us see, like, all just on for the internal hemorrhoids that you can't see from the outside. Not painful. Very weird if you've never had anything like that before. And so I just warn people about that. But it should be comfortable. It'll take all of 10 seconds. And then we know, then we can both feel really reassured that we saw the problem. We know what it is. But if you have any change in your pattern, so bleeding, I think we can all say, okay, yeah, that's a literal red Flag any change in your pattern, whether that's new constipation, new diarrhea. You can't explain it. Like, you might, you know, like, if everyone goes on a cruise, everyone gets diarrhea. I think we have an explanation. But if it's something that's changed and you're like, what? I can't put my finger on this, you should talk to your doctor and you shouldn't wait too long to try to be a sleuth and figure it out. Just run it by them and see. And then pain, pain is a big one. Like, and it's not always like 10 out of 10, go to the emergency room kind of pain, just low level pain that you're living with that you didn't have a month ago. Don't wait on that. There was a study that came out of the National Cancer Institute that found that people who had three out of these four symptoms, rectal bleeding, abdominal pain, a change in their habits, like diarrhea, and the new iron deficiency anemia, which is not something you can know that you have on your own. You have to get a blood test to confirm that you've lost microscopic amounts of blood. But if you had three or four of those symptoms, you are at a six fold higher likelihood of having early onset colorectal cancer compared to people who didn't have those symptoms. And so I think about those all the time. If someone comes into my clinic and says those things, even one of them, I'm paying attention. But certainly when you start to stack them on top of each other, I pay real close attention and try to do more digging.
- [21:03]
Dr. Rena Malik
I will just say that I can totally understand the concerns that people have because we see it in urology a lot. People will have blood in the urine. People will have. See this. I mean, this is a rare cancer. But when people have lesions on their penis and they were worried about penile cancer, they will delay because they're embarrassed, they're worried. And I understand that. But I also think that guys, we care so much about our health. We spend so much time. People spend so much time learning about it, trying to be healthy. And this is just part of that.
- [21:31]
Dr. Tricia Pasricha
Yeah, yeah, I like that. So much we spend. It's. I mean, there's actually so much out there that is like we spend so much time, energy and money on. And sometimes the simple things we just wear, we brush to the side because it's hard. It's really hard.
- [21:44]
Dr. Rena Malik
And why are young people getting more cancer?
- [21:47]
Dr. Tricia Pasricha
That's the million dollar question. Billion dollar question. We Have a lot of ideas about why. And some of them are a little bit more proven than others. But I'll tell you this. In the past, like when I was in med school and you were in med school, we used to think about cancer, big word cancer, as like something that happened to older people and related to genetics or smoking. Right. And our genetics haven't changed in several generations. Although our epigenetics can, like how those cells and molecules and proteins on top of our genes might change. That changes as a result of our environment. And certainly we've also been smoking less and less. Again, pointing us back towards, well, what else could it be? It has to be something in our environment. And a few risk factors that people have identified that are specific to the birth cohorts. These 12 generations seem to be affected by early onset colorectal cancer are a couple of things. The biggest one is our diets. Our diets have fundamentally changed. And a lot of what's driving that change are ultra processed foods. That connection is becoming stronger every single year. There's more data about both in the lab, looking at mice, looking at translational tissue from humans and experimenting. What are the things that we put in ultra processed foods doing to those cells? We have a lot of that data. And then we're getting this growing body of literature of the epidemiological data where we're looking at just this. Within the last year, we had known already that ultra processed foods were linked to colorectal cancer. Now we see that they're linked to polyps, precancerous polyps. And so we're seeing more and more of the pieces of the mechanistic puzzle come together. And what happens with ultra processed foods is that one, they have a lot that goes into them that are added in that are different from the original ingredients. And maybe those chemicals and additives are part of the problem. We think they are, because we think that some of those additives and emulsifiers weaken this, this layer of mucus that is throughout our colon. It forms this nice barrier between ourselves and our cells in the outside world that becomes weakened and inflamed and it changes the microbiome with ultra processed foods. And we think that contributes to cancer. But it's also the issue with ultra processed foods is also what they don't have. So if you eat more ultra processed foods, what are you eating less of? And a big part of that answer is fiber. The ultra processed foods tend to lack fiber. They tend to have a lot of added sugar. And we know that fiber is protective against colorectal cancer for many reasons, but in part because when that fiber makes it to our gut, the gut microbes feed on it, they ferment it, they produce these really nice anti inflammatory short chain fatty acids that protect us. So not getting that in our diet is also harming us with the ultra processed foods. But it's not just that. And there are other aspects that I think we weren't considering as hard as we should have been a couple decades ago. Like alcohol for example. Alcohol has really emerged over the last several decades, but I think loudly being spoken about in the last couple years as a cancer risk factor. The problem as you remember is like we used to think about it as being heart healthy and like good for us. And we were actually pretty encouraging of like a glass or two of wine a day. We started to really backtrack on that because yeah, there, there is some mixed data about how it may or may not benefit the heart. But then actually the mortality data is pretty bad. I mean it doesn't actually help you live longer. And if anything, people are dying more from cancer. So alcohol is a big one. And then there's other aspects of our diet that seem to be linked more specifically in our childhood diets. When we're talking about these early onset cases, like for example, kids, and I'm talking about kids like adolescents, teenagers, early adults who drink more sugar sweetened beverages, they seem to be at a higher risk of colorectal cancer. Processed meat and even red meats, those seem to be linked. And then the other big factor that you know, I think everyone can agree on has changed over the last several decades is are kind of sedentary lifestyles. We're sitting at our desks more often, we're not getting up and exercising as much. All of those things are very closely electro colorectal cancer risk. Why it's happening in younger people, we don't know. But we do think it's because a lot of these cases, a lot of these risk factors are starting earlier and earlier. Like kids are being more and more exposed to ultra processed foods at a younger age in a way. I, you know, when I, when I talk about this topic, like it can feel really overwhelming because it can feel like, you know, now maybe you're in your 20s, 30s, 40s, and you're like, am I doomed? Because you know, like, like goodness knows I drank so much Capri sun and like, who knows what I did when I was a kid. Like all of the breakfast cereals were all more of my favorite thing. But. And you don't have control over a lot of what happened in your childhood. And I don't think there's any help. It's not helpful at all to think about blaming yourself or others for that. But I think what is useful is to say, like, well, now we have identified these very likely risk factors. And so whatever age you are now, it's never too late to start to change and start to reduce the, the risk that you have. Right. Like, we can never make our risk of cancer 0 at whatever age we are, but we can at least reduce the things that we have some control over.
- [26:35]
Dr. Rena Malik
It is, it is really sad though. I mean, we've lost so many, you know, notable people, but also obviously young people in general. And it's, it's scary and it's sad. The one thing that sort of concerns me is that the carnivore diet has become very popular. Oh, let's talk about that. With that diet, there is like no fiber intake.
- [26:53]
Dr. Tricia Pasricha
Yeah.
- [26:53]
Dr. Rena Malik
And so are you seeing more people who've been on that diet with polyps or issues or things of that nature? I mean, a lot of people will say their GI symptoms are better on the carnivore diet.
- [27:03]
Dr. Tricia Pasricha
Yeah, it's, it's really, it's tough. People's GI symptoms actually often do feel better when they eat highly refined carbs or simple kind of meats and not tough fibrous foods. Those are harder to break down. And, you know, if you, if you meet anyone who you, you know, and I, this happens in my clinic often where I, I'm always encouraging fiber. And someone will go home and they'll be like, okay, I'm going to, like next week I'm going to eat this salad every single day and I'm going to add these beans and broccoli and they go from 0 to 100. They're going to feel horrible because they're going to get a lot of bloating, they're going to get a lot of gassing, and their GI symptoms will get worse. With a high fiber diet, that sensation of those types of symptoms doesn't actually correlate with your health, you know, and I think there's this like, sort of kind of disconnect about like, well, why do some foods that make me feel bad? Actually, they're the ones that are good for me. And what I tell people is that you're going to feel great eating fiber. It actually just takes time, though. It takes time if you're not used to eating it. You know, most of the studies have shown that Our gut microbes, it takes eight to 10 weeks for them to change in response to your diet. So if you start low and you go slow, a lot of the things that bothered you might not bother you so much anymore if you give your body some time to respond. The issue I have with the carnivore diet is like everything. It's like with ultra processed foods, it's like what are you missing out on because you're not incorporating other foods into your diet. A lot of the other plant based foods are really important, but there is this independent risk of red meat in general. Not just processed meat, but red meat, although to a lesser sort of relative risk of colorectal cancer. And we don't know, I mean the conversation is very nuanced. We know that there's different processing that occurs with processed meats like hot dogs or bacon that we think contributes to why those seem to be, to put people at a higher risk of colorectal cancer. But even the unprocessed meats, like people will often tell me, well, what about grass fed beef for example? Like isn't that going to be good for me? And I can tell you that compared to non grass fed beef there is some data that says yeah, it might be a little better for your heart. It's, it's, we don't have any data to tell you it's going to be better for your colon. What we do know is that a lot of, when you look on aggregate of the epidemiological studies, there seems to be an increased association with red meat. Not processed meat, but just red meat when you start to eat more than three servings per week.
- [29:24]
Dr. Rena Malik
So the argument there then is did they separate out the processed meats in those studies?
- [29:28]
Dr. Tricia Pasricha
Yeah, and that's always the counterargument. They're like no, no, you can't do it. And, and there have been a handful of studies that did, that did try to do it. None of the studies are perfect. I actually think that, you know, like I hear and I recognize eating red meat is such a big part of our American culture. And a lot of people are like, but this is how my family gets together. We barbecue. Like we every Sunday we have our roast and this is like what we do. And I, and it's hard to be like, you know, this is bad for you. It's not like that. I think you can enjoy, you can have a hot dog and like still lead like a healthy life in, in some form of moderation. But I think with red meat, what we don't have full clarity on. There are a lot of mechanistic studies in mice that show us possibilities and it's harder to prove them in humans. But there's one, potentially something inherent about the red meat, regardless of the kind of processing. But two, and I think that this is the bigger issue. I think the issue with red meat is how we cook it and what we introduce when we cook it that's putting us at an increased risk. So I can't say this with full confidence today, but I do think like, so saying that like if you cook your meat at a lower temperature more slowly, that's definitely like, then there's no risk. But I do feel that there's enough evidence to say there are ways you can cook it that reduce that risk. And so I think it's like the charring that we do like when it's on the grill. I think that's the kind of ways that when then you take a big step back and do do an epidemiological study and you say, yeah, look at this correlation with red meat. We don't have a way of getting down into that nitty gritty and saying, well were the people who do that, were they typically the people who are grilling or who was using the slicker? Those studies don't exist. But I think that's actually a big part of how we should be thinking about if we don't want to fully cut out red meat because this is important to you, you enjoy it, what can we do to make it a little bit healthier and safer? And you know, the more that I think you can say, well let me think about what I'm going to add in rather than I'm going to take away your steak dinner, which you love. What if I just tell you I want you to add in a side of broccoli filling, your favorite vegetable. I think I've still done you more benefit than harm by, you know, eat the red meat. But now add in something else. Add in something that we know has a lot of fiber and can kind of help counteract that.
- [31:37]
Dr. Rena Malik
And I think that's really important. Right when we look at like anti inflammatory diets and pro inflammatory factors and anti inflammatory factors like these big cross sectional studies where I look at diet food frequency questionnaires.
- [31:49]
Dr. Tricia Pasricha
Yeah.
- [31:49]
Dr. Rena Malik
And they say, okay, these are pro inflammatory, these are anti inflammatory. They give them a score. What they're doing is they're looking at their entirety of their diet. They're not looking at just what they ate that one time. I think that's the way people should look at it, I think you bring up a great point about how you cook it. Right. So if you don't cook it on the grill and maybe cook it sous vide or cook it in a different way, that may be healthier. But, yeah, I think that's really interesting.
- [32:12]
Dr. Tricia Pasricha
Yeah. I mean, I think one of the things I found that people really like to hear and there is good data for is marinating your meat form first. Right. It's like one of the things that it kind of helps prevent the Maillard reaction from occurring with the meat itself and the heat, because you've coated this in this nice, like, you know, whatever glaze you want to buy. And of course, yeah, whatever you marinate in, you may introduce a lot of added sugar, like, who knows? But I think generally marinating your meat is probably. And then exposing that to a higher temperature is a safer thing to do than exposing the meat directly to temperature. So there are lots of ways that people can kind of make things a little healthier without anyone telling them they have to change. Oh, you know, overhaul your diet. Changing your diet and that. As a gastroenterologist, this is like half our battle is what we eat, and the second half is how we poop it out. But changing our diet is really, really hard. It's like one of the. I mean, it's so fundamental to who we are and to our cultures and to our families that these conversations are never met with anything but, like, really passionate reactions.
- [33:11]
Dr. Rena Malik
Yeah, absolutely. I mean, it's a big part of our lives.
- [33:14]
Dr. Tricia Pasricha
Yeah.
- [33:14]
Dr. Rena Malik
You know, the interesting thing about the Maillard reaction is in urology, they looked at tomatoes because lycopene has some studies that have shown it to be protective. And they actually found that when you cook the tomatoes, it's actually more protective. So the Maillard reaction is actually positive, which I thought was interesting when you said it was sort of a negative for meat.
- [33:32]
Dr. Tricia Pasricha
Yeah. I think there's something about the proteins within the meat that seem to create these compounds that we think are contributing to the cancer. But I hadn't heard this about tomatoes. Now I'm fascinated.
- [33:42]
Dr. Rena Malik
It's interesting, right? Yeah. What about these apps where you take a picture of your food and tells you how good it is for your gut?
- [33:48]
Dr. Tricia Pasricha
Oh, gosh. Well, there are a dime a dozen of these types of programs. I mean, I. I don't tend to want people to over police themselves when it comes to their diets. And sometimes, like, for example, I tell people, okay, women should try to aim. Women under 50 should try to aim for 25 grams of fiber. Men should try to eat for 30 grams of 38 grams of fiber. It can make people spend their whole day, like, trying to quantify their meal and trying to say, oh, good, I did. I meet this. How many grams do I think is in this cup? And then, you know, I, I aim more for a ballpark. Like, I, I think, like, for example, if you're taking a picture of your meal to judge if it's good or not, like, I think you can just use bigger principles that we kind of already know, right? Like how much of that meal is ultra processed. How much of that came from whole foods is half your plate. The fiber, like, the fibrous component of it. I think we can make it a lot simpler for ourselves. And, and sometimes the simpler way just feels lamer. Like anytime someone's like, hey, what's the best test I can do for my gut? Is it this fancy blood test I found, or is it this stool kit that'll cost me a couple hundred bucks? And I'll be like, nope, it's just your screening colonoscopy. That's the best test for your gut. It's the most boring and lame answer, but it's also kind of the most obvious one. And sometimes those are just the easiest and best things.
- [35:04]
Dr. Rena Malik
And the screening colonoscopy brings up a lot of anxiety for people.
- [35:08]
Dr. Tricia Pasricha
Yes.
- [35:09]
Dr. Rena Malik
Obviously the prep is not enjoyable. I have not yet 45, so I have not yet participated in it, but will when I turn 45, which is the age.
- [35:18]
Dr. Tricia Pasricha
Amazing. Yes, thank you.
- [35:20]
Dr. Rena Malik
But what about these other options like cologuard and, and virtual colonoscopy? Do these work? Can you use them if you're really anxious about this whole process?
- [35:31]
Dr. Tricia Pasricha
Yeah. Well, first let me start off by saying that I hear the anxiety. A lot of what people have heard about their colonoscopies, they hear from their dads, their grandfathers, or their grandparents. And the way we prep today is not how our grandparents prepped, you know? So, like, what we picture sometimes is like this, like, horrible, like, weird, chalky tasting 4 liter prep that you're gonna be trapped in your bathroom all night. You might still be trapped in your bathroom, but there's so many different prep options out there. Some of them are just pills, like, just a handful of pills that you take. You still have to drink water with it, but not talking about four liters. And there's like, lots of great tips and tricks to make the prep a little bit better. Like, you could mix it with, like, your favorite Ramen seasoning packet. That's like my go to, like, trick. You can mix it into jello and you can actually eat the jello. Even though jello is a solid, it's really not a solid. Like, it instantly stops being a solid once it gets inside of you. As long as you don't use, like, red, we don't want you to use, like, red color jello. But there's lots of ways that you can actually make the prep better. Like, I've had, I love when my patients are like, oh, I drink my prep out of a wine glass just to feel fancy. Sip it chilled with a straw, and you, like, kind of bypass your taste bud. So there's ways to make the prep better. But if it's more than just the prep, that's worrisome to you if you're like, you know, because you don't have to have anesthesia actually during a colonoscopy, but most Americans do. In other countries, they don't use anesthesia. But if you get anesthesia done, it means you have to take a day off from work, basically because you get the scope. And then afterwards, we don't want you to drive your car. You probably shouldn't go back to work
- [36:59]
Dr. Rena Malik
and make real serious decisions.
- [37:01]
Dr. Tricia Pasricha
Don't operate heavy machinery after anesthesia. So that's like, that's a big barrier for a lot of people. Then, you know, there's. Colonoscopies are incredibly safe. We do them all the time. There are some small risks that we talk about to people. Like, it's about a 1 in 10,000 risk of perforation, which is a small tear in the colon. It's really rare, but it happens, and a couple of other risks. So if you decide for whatever reason that you don't want to get the colonoscopy, there are some good options out there for cancer screening. And the reason I'm saying that is because for me, the colonoscopy is not really for cancer screening. That's how we bill for it, and that's why we do it. But it's really to detect polyps which are precancerous and to prevent cancer. There's no other test. Not the stool kit where you poop in a box, not the blood test, which is new on the market. There's no other test that will prevent cancer like a colonoscopy. And so sometimes when I frame it like that, and I remind people that that's really the goal here of the colonoscopy is to catch these little growths called Polyps that are going to grow in almost all of us, and if we do nothing about them, 5 to 10% of those growths will become cancer. So when we do those colonoscopies, it's a polypunt. We're just looking for those polyps, and we take them out so they never become a problem. When you do one of these other options, like the stool kits, where you poop in a box and they take a look and they look at, is there markers of cancer in there? They do a really good job of saying yes or no, there's a cancer present or not. They do a way less good job of saying, is there a polyp? Is there a worrisome polyp there? If there is, if any of these markers come back positive, you'll go to the colonoscopy and we'll say, okay, yeah, we need to go do this. We need to take it out, Whatever it is, this is picking up. But that's the reason why we do the. For example, the stool kit more frequently than we do a colonoscopy. If you have a clean colonoscopy, we say, come back in seven to 10 years. If you're at average risk, we'll see then with this stool kit, we don't know if, like, even if you had a negative test, you might have had two or three polyps in there that were just small. Like, we just didn't see them. And so then we say, come back in three years, because we don't want those to progress and we just didn't know it. So if somebody is saying, what I really want to do is prevent cancer, I bring them back to the colonoscopy. That's what I would do for myself. That's what I tell my family members to do. But if you have a lot of other reasons where you're like, this will, this is just not going to happen for me. But I do want to get screened for cancer. I want to make. I want to know today, do I have it? Do I not? This toolkit's wonderful. Get this toolkit. The company will mail you a box. It discreetly arrives. There's no label on it on the outside. The mail guy is not going to know what's in there. You pick it up, you put your specimen in, and they'll have all these instructions. But basically, you put a little collection kit inside the toilet bowl. You put it in, you collect it, and then you put a small amount of that in the tube, you mail it back, and then in a couple of days, to weeks. You get the result, and then the doctor tells you what it is. There's these other tests, too. More recently, the blood test, which is very exciting. It's similar. It performs maybe slightly less well than the stool kit, but it can still detect cancers. That one's easy. You can go to your doctor's office, you can get the test, go home, come back soon. You'll get the answer pretty soon. And then there's this last option, which is the virtual colonoscopy or the CT colography. And basically that is for people who. The only scenario where I think, well, there's a couple scenarios, but one scenario where I think that makes sense for people is when they can't tolerate the anesthesia for any reason. Like, maybe they have a lot of serious medical conditions. Anesthesia feels risky. You still have to do the prep for the CT calligraphy. Like, a lot of people are like, can't I just get a regular ct? Like, why doesn't an abdominal CT pick up these polyps? These polyps are so small and so subtle. You still have to do the prep. The point of the prep is not to torture you. The point of the prep is to clear out things so well, so that the inside of your bowel is so squeaky clean that we can see even the tiniest little polyp and we can identify it and take it out. Because that's the worst thing for me and for you is you come in, the prep's not clean, and it happens. Someone will have tried, but they'll fail, or they'll only do half of the prep, and then we go in there and it's just this sea of brown. You don't want me to say, I did an okay job, see you in 10 years. But actually, I hadn't seen everything that. Well, you want to give this prep your, like, A plus behavior. So anyway, the CT colography, you still have to do the prep, but then you do the special contrast, and we're able to see those polyps well. And then if you see one, we're going to have to do a procedure to remove it.
- [41:30]
Dr. Rena Malik
Well, that's very helpful because I think. I didn't know that, to be honest with you. And I. I think knowing that a colonoscopy is actually treating these precancerous polyps. Yeah, I mean, I knew that, but, like, I didn't really think of it that way, that treating this colonoscopy is treating these precancerous polyps so that they won't transform. It's reason enough because if you find a polyp in any other way, you're going to have to go to the colonoscopy anyways.
- [41:51]
Dr. Tricia Pasricha
Yeah. I mean, we don't have that many other tests, procedures that prevent cancer the way we have that for colonoscopy only, because in a way, we've understood for so many decades how colon cancer develops, that natural progression of these polyps and all of these things we're putting in our diet every day, that put us at just a slightly higher risk. I mean, that's causing mild amounts of inflammation and injury. We're going to get polyps. Almost all of us do get them. But the key is just to. And not every polyp will become cancer.
- [42:21]
Dr. Rena Malik
But.
- [42:22]
Dr. Tricia Pasricha
But we know predictably that some will. And we really just don't want to take a risk with that.
- [42:26]
Dr. Rena Malik
When we talk about diet. Right. I think there's a lot of people who will. There's these tests that you can get done that will say your sensitivity to certain types of foods.
- [42:34]
Dr. Tricia Pasricha
Oh, my gosh.
- [42:35]
Dr. Rena Malik
Right.
- [42:35]
Dr. Tricia Pasricha
Yes.
- [42:35]
Dr. Rena Malik
And because they may be having GI distress and they're still, like, trying to DIY it, and they're like, well, let me figure out what this is. And I just want. One test is going to tell me what I should stop eating.
- [42:44]
Dr. Tricia Pasricha
Yeah, yeah.
- [42:45]
Dr. Rena Malik
And are these worthwhile?
- [42:48]
Dr. Tricia Pasricha
No. I will say I have had the experience because, you know, a lot of times, food intolerances, it feels like a big black box. Like, it feels like you are someone who. You're eating foods and they upset you. But you'll go to your doctor and your doctor will say, oh, like, all your tests look normal. Like, you know, maybe they'll even do an upper endoscopy. Your endoscopy will look normal. And yet, you know, you feel this, like you're living your daily life, that certain foods upset you. And it can be really hard to figure out what those are. And then these companies come along and they'll tell you some list. Maybe it's based on your stool, maybe it's based on your blood, what you have a true intolerance to. And very often I see people come in and they'll be like, look, I got these results back. They'll show me 10 foods that are now on their list that they shouldn't be eating. And we'll look at those foods together. And I'll be like, hey, did mushrooms actually ever bother you before? Do you talk to them? And they'll be, think so, I don't know. You know, and like, to me, a food intolerance should be something that is pretty clear, like a yes or a no, like and sometimes what makes it to those lists are actually like, you don't need a third party to tell you what you do or do not tolerate. You need to figure that out. And there. And those tests aren't based on real validated science. What is based on validated science is this kind of experiment called the low fodmap diet. And if someone's experiencing food sensitivities, we often put them on a low fodmap diet. And the word diet can feel a little troublesome because it implies it's a long term way of living. Like the Mediterranean diet. This is not, this should only be two weeks and it should just be a couple weeks where you eliminate all of the foods that we know traditionally cause triggers of GI symptom. Each F O D M A P stands for a different food group. And then you eliminate all of that. And then you say wait, two weeks have gone by. I haven't eaten anything here. Do I feel better? And usually that's, that's very restrictive. Like you're just eating like very, very few types of like, usually like refined carbohydrates. And if you feel no better than you did before, like even just like plain pasta still hurts you, then the problem is not really a food intolerance. The problem is something else inherent to your mucosa or the cells in your gut or your entire nervous system. We need to figure that out better. If you feel a lot better, then the problem is food. And then you systematically can add those foods back in one by one. Give yourself two weeks on that new group. And then you keep a food diary. You work with a registered dietitian and you ask yourself, do I feel a little better? Do I not? Which food is it? And over time that's how you identify what your food triggers are. It's a long process. This is going to take weeks of adding foods back in. And I never like people to do this alone without a dietitian who's working with them. But the low fodmap diet was just, was first written about by Monash University. They developed it, we've been studying it for decades. So it's a really nice system, a lot of research backing it up that can help people. The food sensitivity industry that markets these tests, that's not based on that kind of valid data. We know that there are molecular reactions that people are having to different kinds of foods and there's been a lot of studies on that. But that's not what they're tapping into when they're doing these food sensitivity tests. So I think that those can be a big waste of time. And I've rarely met somebody who said that. I got one of these tests and it helped me. Usually they get the test and they're like, help me. I don't understand what to do with this now. And like, what are they testing in those tests? They'll test like lots of different types of. Well, oh, what, what are they looking for? Yeah, I don't know. It depends. Every company's looking for different things and they'll tell you, oh, we're looking for different antigens, different antibodies and things. It'll all sound very plausible. It'll sound like, yeah, this is what I want. Yeah, it makes total sense. And, and then, you know, there'll be another type of test that will say, okay, we're going to look at the composition of your microbiome. We're going to look at bacteria that we know grow in response to.
- [46:33]
Dr. Rena Malik
But that changes every day, right?
- [46:34]
Dr. Tricia Pasricha
Or every. Yeah, it's these. There's like a whole industry out there that responds to people who are desperate for answers with GI symptoms. And that's because as much as our gastrointestinal tracts and our physiology has been well understood, there's also so much. I mean, I think it's like one of the most exciting areas of research. There's also a lot that still either needs to be understood about the microbiome and there's a lot that needs to be translated from what we know to the public. And I think that that gap is where, you know, everyone can jump in and make a quick buck. And they do.
- [47:04]
Dr. Rena Malik
It's really sad. Another place I think people are making a big quick buck is by talking about leaky gut.
- [47:12]
Dr. Tricia Pasricha
Oh my gosh. Yes.
- [47:13]
Dr. Rena Malik
So what is leaky gut?
- [47:16]
Dr. Tricia Pasricha
Leaky gut is this word that got hijacked from this concept in GI called increased intestinal permeability. This is something that we study and I'm a neurogastroenterologist, so I studied the gut brain connection and, and this is a really old and well described phenomena that throughout our day, you know, we have these cells that line our intestines and they're really close together oftentimes. But then there's these different things, even just throughout a normal day that will cause them to open up just a little bit. Those junctions between the cells open up a little. Food will do it. Just eating stress will do it. People who exercise vigorously, like runners, they get a little Bit of so called leaky gut when they go exercising. The problem is that people on social media have taken this term to mean a lot of things that it doesn't really mean. Like, you know, I've seen these videos that are like, do you have bloating? Do you have constipation? Do you have a little brain fog? Sounds like leaky gut. And all three of those things are very common. A lot of people are going to have one of those things. A lot of people are even gonna say, yeah, wait, all of those things are me.
- [48:18]
Dr. Rena Malik
Right?
- [48:19]
Dr. Tricia Pasricha
But then you, there's no, like, you cannot connect the dot necessarily to leaky gut just from those two things. But, but those are also three things. Bloating. Bloating is one of the hardest symptoms in GI to treat, period. It's also one of the most poorly understood. And people know that they feel that bloating like they'll get dismissed by providers before brain fog, incredibly difficult thing to parse out. So when you put all of these vague nebulous entities together that nobody's given you a good answer for before and someone confidently tells you this is sounds a textbook, like leaky gut, like you want to believe that that could be true and should be true and there, you know, there's this whole scientific sort of sounding explanation for what that is. It's certainly true that having increased intestinal permeability over the long term is linked to bad health outcomes. We probably know that most strongly from the data between alcohol, which increases intestinal permeability and liver damage. That is a classic example of leaky gut, that it can eventually cause liver fibrosis and liver cirrhosis. That's never what people think. I'm going to tell them when I talk about leaky gut, like nobody's thinking about liver cirrhosis from alcohol use. They want to hear a little bit more about the brain fog and the bloating. And that's a connection that's harder to make because for the most part with an intact functioning liver, as I said, all during the day we have increased intestinal permeability from lots of different exercise
- [49:43]
Dr. Rena Malik
you said, right, Exercise, that's a good thing. I mean, exercise is a good thing, so it can't be damaging your gut, right?
- [49:50]
Dr. Tricia Pasricha
Well, that's a kind of a separate conversation. Like too vigorous exercise might damage your gut, but for the most part, yeah, yeah, it's healthy. In fact, your gut thrives on exercise. Your microbes change. It can help with reduce your risk of colon cancer, for example, usually even when you have these moments where those junctions are not so tight anymore. Your liver filters everything that's coming through. And I think people forget that, that. That what you eat doesn't go directly into your bloodstream. Right. Like, first, it often doesn't make it past that very thick mucus layer that you have to protect you. And then even if it does, because it's supposed to or just it has a way of doing that, it's going to get filtered by your liver. So if you have a healthy liver, you don't need to worry so, so much about leaky gut, necessarily outside of certain medical conditions. But I also will say that the flip side of this coin is that when patients come to me worried about leaky gut, but they're not actually really worried about the leaky gut part of it. They're really just worried about the underlying symptoms that they're looking for treatment for, they're looking for help for. And so I think what's important is to find someone who takes those symptoms seriously. Because the goal is not to be like, leaky gut's not real. Goodbye. It's to be like, wait a minute, what could be causing your bloating that we're missing? Is it celiac disease? Why did IBS have leaky gut?
- [51:06]
Dr. Rena Malik
What is prompting you to feel that way? Your doctor should be asking, why? Because sometimes patients will come to you about something and it may not make sense to you. It's happened to me all the time. But then I ask, why? And then that's when you figure out, okay, they're worried about leaky gut because they have this miserable bloating, or they're worried about this because they can't have sex or whatever the situation is.
- [51:29]
Dr. Tricia Pasricha
Right.
- [51:29]
Dr. Rena Malik
And so I think that it's really important, like, if your doctor just dismisses you and says, no, you don't. It doesn't. One, not all doctors are really great with people, so maybe that person is not your person. Right. Maybe you find a different doctor. But two, like, they just. They're like, yeah, it's not a thing. They're not wrong. It's not truly a thing. It's not truly a condition. But, like, it. They're. They don't know what to say. Right. Because they're like, well, I can't fix something that doesn't exist.
- [51:53]
Dr. Tricia Pasricha
Yes.
- [51:54]
Dr. Rena Malik
But the real thing is, like, why do you think. And I think as a patient, you can go in thinking, like, what's making me think I have this condition? And lead with that. Yeah.
- [52:02]
Dr. Tricia Pasricha
I think so often it's So I do this. It's so easy to be like, here are my symptoms. Let me just see what chat GPT thinks it is. Or let me see what, like, what's trending on tick tock about these symptoms. And. And there are a lot of times even something as simple as a patient coming to me saying, I have really bad heartburn, but I've tried everything and it's not responding. And we might accidentally kind of go down this route of like, okay, they have refractory heartburn, they have really bad reflux. But if you were to take a step back and you just say, wait a minute, you came in telling me you have a diagnosis.
- [52:36]
Dr. Rena Malik
What are your symptoms?
- [52:37]
Dr. Tricia Pasricha
What are the symptoms? Let's step back. And then it turns out, you know, you just think it's something. Because that's how everyone has always talked about heartburn. You've had pain in your chest, and so you assume it's heartburn and you're gonna use that word. And then your doctor latches onto that word and everyone. That's the word that gets used. But in reality, maybe that's not what this was the whole time. Maybe you had an ulcer in your stomach all the time.
- [52:58]
Dr. Rena Malik
Guys, in medicine, for people who are listening, when someone writes a note, if you're like in a big system, right, Someone writes a note and says you have a condition, if they're incorrect, that may be copied forward in everyone else's note, even if they're in a different specialty, because they just assume that that physician or that provider, whoever saw you
- [53:15]
Dr. Tricia Pasricha
knew what they thought, they thought it through. You guys had a conversation, or you
- [53:18]
Dr. Rena Malik
said, this is what I have, and they wrote it down as a past medical history. And so it is really easy for things to get very muddled. And I think always lead with your symptoms. Lead with what? Is the specific thing that's bothering you rather than what you think the diagnosis is, just because you might miss a real diagnosis that you need.
- [53:36]
Dr. Tricia Pasricha
Totally. Yeah. It's not to try play dumb for the doctor at all. I think it's just to make sure that we're not missing anything else that could lead us astray.
- [53:44]
Dr. Rena Malik
Yeah, absolutely. I want to talk about your expertise as a gut brain specialist.
- [53:49]
Dr. Tricia Pasricha
Ah.
- [53:50]
Dr. Rena Malik
And I read this about you that when you were in 10th grade, you had a science project.
- [53:56]
Dr. Tricia Pasricha
Oh, yeah.
- [53:57]
Dr. Rena Malik
Where you were able to determine if people were lying based on gut contractions. So you made like a special lie detector test, essentially monitoring gut contractions. In 10th grade.
- [54:11]
Dr. Tricia Pasricha
Yeah. Can you tell? I was the most popular Girl in my high school, I was like, how cool I must have been.
- [54:15]
Dr. Rena Malik
First of all, we got to hear how you made this test. And, like, how did you not even look at this?
- [54:21]
Dr. Tricia Pasricha
Yeah. Okay. Well, there's two parts to the story. One was that I'm a theater kid. I was, like, a big theater dork in high school. And I know I can even think about this, and I'm going to feel it. When you blow your lines on stage, you get this feeling in your gut that is like. So it feels like this pit that's like this big knot. And I felt it in other scenarios, too. Like, if I was lying to my mom and she knew I would feel it there. And my mom. This is the second part of this backstory here. Is that so she used to work for the FBI. She was not a woman you wanted to lie to. And she used to tell me about what I did.
- [54:56]
Dr. Rena Malik
It was a tough house to grow up in.
- [54:58]
Dr. Tricia Pasricha
Gastroenterologist, dad, mom. But she was an engineer. She wasn't an agent. But she did talk about lie detector tests a lot. And the thing about the traditional lie detector test is, one staple of it is an ekg, an electrocardiogram. And so they hook your chest up to electrodes, and it measures how fast your heart rate's going. And the idea is that when you're nervous, when you're lying, your heart rate should go faster because you're nervous, even if you look calm on the outside. But people had come up with all kinds of ways to evade the lie detector test. Like, one, you can stay calm when you're, like. If you believe you're lying, you can stay calm, and your heart rate might not. Not spike.
- [55:31]
Dr. Rena Malik
Or.
- [55:31]
Dr. Tricia Pasricha
There's actually a classic trick where spies used to, like, step on tacks in their shoes so they would cause them a little bit of pain every time you asked a question, so their heart rate would spike. And because my dad was a gastroenterologist, he was working on this condition called gastroparesis, which is where the stomach doesn't empty correctly. And they used a very similar device to an electrocardiogram called an electrogastrogram, where it measures. You put electrodes on your stomach, and it measures the contractions of your stomach. Your stomach contracts about three times every minute in a pretty regular fashion, just like your heart does. It occurred to me, and this was my, like, wild, genius hypothesis, was that, like, you might be able to control your heart rate or mask it with some of these, like, painful but brilliant techniques with the tack in Your shoe. But how. And how in the world could you mask that feeling you get in your stomach? And so I had this idea that we could take this electrogastrogram and then try to experimentally get people to lie and see if we could recreate that same feeling. And it turns out that when people are telling the truth, and this is what I measured, it was a small study. It was like more than a dozen people when they're telling the truth. Your stomach does contract at 3 cycles per minute at its sort of baseline. But when you start to tell a lie within a minute, that cycle goes into total chaos. It's this rhythm called arrhythmia, which means we don't have a normal rhythm anymore. And you can see that playing out in real time. And it was really cool. And so that was the project that sent me to the science fair. And then I still wasn't allowed to sit at the cool kids table, but I did feel really cool in high school. And what it turns out is happening, and this is based on the work of a lot of other people, actually at UCLA and other places, is that your brain, when we're nervous, releases this hormone called corticotrophin releasing hormone. And that does a number of different things through your body. Eventually, your heart rate will go up, and maybe you can stabilize it or not. But one thing it does is that this is the thing that tells your stomach you need to stop doing what you're doing. It grinds it to a halt. And that's why the electrical rhythm, we think, goes into that, that arrhythmia pattern. At the same time, it also sends a signal to the very last part of your colon, saying, we need to speed up, get everything out. Which is why some people, when they're nervous, like right before they have to go on and they're backstage, they suddenly have to poop. And a lot of people feel that. And it's because you're having these two almost opposing things happen because of this one hormone, which is that your stomach is stopping, but your bowels are trying to empty. And it actually. The evolutionary hypothesis about why this happens actually ties back to leaky gut, which is that when we're stressed, we also know through a somewhat different pathway, that we have increased intestinal permeability. And if that's sustained, the hypothesis is that we'd want to empty our bodies of any toxins from our stool that could be hanging out in there, just to minimize the risk of them coming through. And so that's why we try to empty and then also not prevent things from coming in. What it means for you is that you might experience a sensation of, like, butterflies in your stomach. You might think that that's what that is and that has some, like, magical feeling to it, but actually it's just the same thing. It's actually a very similar feeling to what you might feel when you're stressed for other reasons. But it's interesting because it. It gives us a good sense of how powerfully our brains influence our guts. And that's half the field of neurogastroenterology, is the ways in which just thinking. There's almost no other organ. You can tell me if you. If you disagree, but there's almost no other organ where just your thoughts can induce such strong changes in what that other organ is going to do. Right. Like the first phase of digestion is the cephalic phase in your head. Like, just thinking about food, thinking about this. For me, it would be this, like, nice, cheesy fettuccine Alfredo. I could picture that. I could picture the cheese and I would start salivating. And not only would I start salivating, but unbeknownst to me, my pancreas would start to produce more insulin. Just because I'm thinking about food. There's almost no other organ that. That is so deeply controlled by the brain and that you can change what it's doing. The interesting thing about my field, and I think, which is why I wanted to go into it, is that all of this that I've described about stress and how the brain influences the gut is really cool. And it's how we thought about it for several decades, but in the last 20, 30 years or so, people are thinking more and more about how the gut influences the brain. And that's, I think, the exciting part of the field is all of the different ways that the gut is communicating over the brain. Because 90% of the signaling through the vagus nerve, which is this big highway through which the gut and the brain talk. Most of that 90% is coming from the gut upwards, not the brain downwards. And so my lab, we study Parkinson's disease. A lot of people when I say that, are like, why is a gastroenterologist studying Parkinson's disease, of all things? But it's because we have this very nicely supported hypothesis that something like Parkinson's disease, a disease that we think of as being in the brain, actually could start in the gut. And we're trying to figure out how.
- [60:21]
Dr. Rena Malik
I saw that, that you actually published recently a paper in jama.
- [60:24]
Dr. Tricia Pasricha
Yeah, thank You.
- [60:26]
Dr. Rena Malik
Parkinson's disease and how upper GI mucosal damage were correlated. And this blew my mind because I take care of Parkinson's patients all the time.
- [60:34]
Dr. Tricia Pasricha
Yes, I'm sure you do, neurourologist.
- [60:36]
Dr. Rena Malik
So I take care of those patients all the time. And it is shocking to me to think that something that we so firmly believe begins in the brain actually might have. It may be a correlation, but it may be a causation. We don't know. Right from the GI tract. That's crazy.
- [60:56]
Dr. Tricia Pasricha
Yeah. I think we had thought about Parkinson's as a brain first disease, just as we do so many other neurological disorders. But, you know, I think the other part of this that people don't remember sometimes, or maybe you've never heard, is that, yeah, you have this very sophisticated brain in your head, your central nervous system, but you have a huge network of neurons in your gut, your enteric nervous system. That is its own brain. Like, it operates. It can operate completely independent, like. But if you. You've seen people in the hospital. I have. Who are brain dead, but they're alive and they're, you know, they're functioning because their enteric nervous system is intact and. And they can be supported with breathing tubes even though the brain in their heads is not working. And so the gut is a lot more sophisticated than I think we give it credit for. It's not just this plumbing or a bunch of tubes that move things from point A to point B. If you think about it as a brain, then you can think about all of these neurological disorders, which we know. Yeah, they are in the brain, in the head, but that brain in your head is in close contact with this other network down here. And certainly they have to impact one another. And we see that in Parkinson's. The hallmark of Parkinson's is this misfolded protein called alpha synuclein. And we know if we looked at the brains of patients with Parkinson's disease, we'd see that misfolded protein build up in this part of the brain called the substantia nigra, where the dopamine neurons seem to be destroyed and die off because of this misfolded protein. Well, if you also do autopsies of patients with Parkinson's disease, it turns out that their guts are riddled with that misfolded alpha synuclein protein. And what we think happens is that some trigger occurs, and we're trying to figure out what that is. And it's probably different things for different people. Maybe it's damage, like I found in my paper to the Surface like an ulcer, like an erosion, something that causes a little bit of microscopic bleeding. Maybe it's that, maybe it's an infection, maybe it's some chemical. We've talked about pesticides a lot with Parkinson's disease. Maybe it's something like that in our environment. But it enters the gut first and it starts this cascade where then that protein starts to misfold and it travels up the vagus nerve and eventually it reaches the brain. But that inciting event will have happened years, if not decades, before it hits the brain. And what's exciting about that, in a way, is that it means there's this window of opportunity where maybe we could stop it in its tracks or we could halt it, or we could maybe even just catch it early. And if we were to do that, could we start to treat it early, too?
- [63:16]
Dr. Rena Malik
Yeah. Well, some of this makes some sense to me because, one, we look at every sort of metabolic outcome, every sort of bad thing that can happen in your body, and it's all correlated with diet, which essentially has to go through your GI system. Right. Has to be absorbed and managed and all those things. And that's the first place it goes before the bloodstream, before everything else. Right. The first place it sees. So it would make sense that your upper GI tract would be the first place you're going to see issues before you see it anywhere else.
- [63:46]
Dr. Tricia Pasricha
Yeah, I mean, I'm with you. And I think that thinking about, you know, my laboratory having started to look at Parkinson's in the last few years, and then also all this data about early onset colorectal cancer, it really makes you appreciate how what you do to your body a lot earlier than you're giving yourself credit for. Like, Parkinson's is not a disease of older people. We're learning that all of these things happen when you're younger, and they build up over time. And a lot of it has to do with what we eat. And even colorectal cancer. It's like you don't just wake up one day with cancer. Right. It's like, based on these patterns, a lot of it is related to how we eat that start when we're so much younger. And it's made me change a lot about. I mean, I think I'm relatively young, in my 30s, but even then I think a lot. And I've changed how I behave because I'm thinking about the fact that Parkinson's, cancer, these are not just things that will affect me later on. A lot of it is determined by what I'm doing today. And I think a lot of people in their 20s, I see a lot of college students in my practice, but a lot of younger people, I think feel like that's a time in their lives when they're immortal and they'll start to do the work when they get a little older and when they need to. But the work really starts when you're much younger than I think you appreciate.
- [65:00]
Dr. Rena Malik
Yeah, I think there's probably, I mean this is a theory, but I think that probably you are protected when you're younger, younger and your body's pretty resilient. But as you start aging, I think it starts 30s and 40s. I think you really don't have a choice but to make your your like, make your choice. And obviously the younger you start, the better you are. But I suspect that there's probably some protection in younger age. But I don't know, that's just a theory. Let's just talk a little bit about psychological health because I think that's another issue. And you've mentioned there's this beautiful connection between the brain and the gut. How is our, is our psychological health affecting our gut and vice versa?
- [65:36]
Dr. Tricia Pasricha
Yeah, they're closely, closely connected. And sometimes people will come in for just one or the other issue because the other one is the thing that embarrasses the most. Right. Like GI symptoms are hard enough to talk about, but mental health is actually also incredibly hard to talk about. And they're a vicious cycle. Like for example, people who have irritable bowel syndrome, which is one of the most common conditions in gi. It's like one of the most common neurogastroenterological conditions. They have very high rates of anxiety and depression. And because clinically the way we define irritable bowel syndrome is a diagnosis of exclusion, meaning we've done all these tests, all the tests are negative. So it has to be irritable bowel syndrome. It really can feel like the problem is non existent, that it's all in your head because yeah, you are stressed. And we know there are these studies, I've done one of them. But there are lots of studies that show that stress causes GI symptoms, causes changes in your gut. That I think a lot of providers, sometimes when somebody comes in with chronic diarrhea or chronic constipation, different GI symptoms, they'll say the answer for you is an anti anxiety medicine, or maybe it's mental health treatment. And that's often part of the answer. People often need that and they will find their symptoms get better. But there's this other half of this equation, which is that many mental health problems and more than we're appreciating can start in the gut. And we actually have several studies that have identified some of those cellular and molecular abnormalities. Like, for example, we know that when somebody experiences trauma early in life, the neurons in your gut will rewire. It's not just the neurons in your brain. We certainly know childhood trauma is linked to depression and anxiety later in life, but it actually is, it turns out out, it's linked to the neurons in your gut reacting at a much lower threshold than for people who haven't been traumatized. So it'll take a lot less to trigger those neurons to send pain signals up to your brain. So sometimes people, for example, will come in with this long list of food intolerance. So they'll say, what is it about what I'm eating? And it's actually not something inherent to the food that is triggering your symptoms. It's something inherent to the neurons. The neurons are just reacting at a lower level. And that can certainly, if you're living your whole life with this system that's constantly firing that nobody else can see, certainly that's going to fuel your anxiety as it would for anyone else. And so it sometimes hard to separate, well, what came first, the chicken or the egg. But I think what I hope people appreciate is that sometimes the treatment involves medications or therapies that are directed at the brain in our head. But we actually have a lot of therapies that are just directed at the gut. And sometimes those actually sound like antidepressants. Like we in gi, we use SNRI medications, we use tricyclic antidepressants. Not because we think we're trying to treat your depression per se, or we're not actually trying to get to. It's like, great if we do and you need that. But those medications that sound like antidepressants were developed to help do the same things we want to do to the enteric nervous system, and they can help rewire those over the long term. So. So we need to have louder conversations about both of these two issues. But I also think if you've been told that there's nothing wrong with your gut and you have gut symptoms and we don't have any way of treating this directly, it might be worth getting a second opinion, too, because there's this whole other half of that conversation.
- [69:13]
Dr. Rena Malik
Yeah, it's a very common issue, and I see it. So when I learned about something called interstitial cystitis, which is A inflammatory diet. It's sort of a diagnosis of occlusion as well. Very similar pain symptoms of the bladder that persists for long periods of time. What I was taught is sort of. It's part of the central sensitization syndrome. Right. Where they. You might have like five or six diagnoses. You've got fibromyalgia, interstitials, ibs, migraines, restless leg syndrome, whatever it is. And they all are actually just one thing. Right. They're all sort of a issue with the way your body perceives stimuli that are normally non toxic. Right. Like it could be someone just rubbed your arm and that's painful, or someone you had a bowel movement or you ate and that's painful, or you drank something and now your bladder hurts. Right. Whereas normally that wouldn't be painful. But because your nerves have changed, it's actually sort of causing these multiple diagnoses.
- [70:14]
Dr. Tricia Pasricha
Yeah. I love that you bring all of that together and you can't. None of those are, are easy to diagnose on simple tests. Like, you know, to be clear, when we do colonoscopies, we're not. We shouldn't usually ever get to the level of the myenteric plexus, which is this deep network of nerves in the gut because it's in the muscle layer. We're just like when we get a biopsy on a colonoscopy, we're getting like a little bit off the top surface layer. That's not the way to make these diagnoses. And so I think a lot like fibromyalgia, you'll get a couple of these different diagnoses and it'll just feel like there's nothing wrong because there's no formal lab abnormality. But you know, it's there. It's just hard to actually get deep enough to look.
- [70:55]
Dr. Rena Malik
Yeah. You can't really look at the nerves under a microscope.
- [70:58]
Dr. Tricia Pasricha
Yeah. Not unless we were to poke a real hole. Right. Yeah.
- [71:01]
Dr. Rena Malik
Like through and through.
- [71:02]
Dr. Tricia Pasricha
Yeah.
- [71:02]
Dr. Rena Malik
Let's talk about something a little less stressful. Right. So there's this phenomenon called the Mariko Aoki phenomenon.
- [71:12]
Dr. Tricia Pasricha
Oh my God.
- [71:13]
Dr. Rena Malik
Where people walk into a bookstore.
- [71:16]
Dr. Tricia Pasricha
Yeah.
- [71:17]
Dr. Rena Malik
And immediately have the urge to poop.
- [71:18]
Dr. Tricia Pasricha
Yeah.
- [71:19]
Dr. Rena Malik
Why does that happen?
- [71:20]
Dr. Tricia Pasricha
This is so common. This is like one of those things that I feel like a lot of you, you, if you have it, you know immediately what we're talking about.
- [71:26]
Dr. Rena Malik
Yeah.
- [71:27]
Dr. Tricia Pasricha
And. And it. I think the bookstore thing is really common. I hear a lot of people be like, it's Target for me. Like I walk Into a. I walk down the aisles of the Target and I gotta go. It's like a shopping mall. The, the interesting thing about all of this is that your gut is this organ that is a creature of habit and actually can be conditioned. And this is a good thing, right? Like, you know, if you think about even just classical conditioning with Ivan Pavlov's experiments where he was able to get his dogs to start salivating and their bowels to start moving just because they were thinking about this bell that they associated with a meal, you can, if you're struggling with your regularity and your bowel habits, you can train your colon to eventually start to respond to a pattern of things. And outside the bookstore, I often tell people, for that reason, try to set up a routine every day. And you stick to that routine. Like in the morning, you're going to wake up, walk the dog, grab your coffee, try to have a bowel movement. And even if the magic doesn't happen initially, you repeat that, you expose your body to this kind of same pattern, the same sensory stimuli. Maybe now it's even the smell of coffee starts to do it for you. You, that eventually your colon can become trained to respond. But for some people, this seems to happen in these, like, public settings. And I think it's actually the bookstore. This has been explored. It's written about by this journalist in Japan initially. And then like, apparently a flood of comments came in being like, that's me. This happens to me too. And I think what happens is that reading, harkening back to our earlier conversation, reading is actually very relaxing. They know that reading stimulates the vagus nerve. And I. You actually have to be calm and have a little bit of vagal nerve stimulation in order to have a bowel movement. Like when you bear down, when you, when you try to activate that val salva, that's what you're doing is you're stimulating the vagus nerve. And there are some people who similarly will tell me, like, when I tell them, don't bring your smartphone in, they're like, but I just, I have to look at some text. Like, I have to just be reading something, or I just can't seem to get my bowels to move. And I think everybody needs a little bit of distraction and relaxation in order to do that. And I think the people who have this response in a bookstore have just really leaned into that connection. And for some people, when you make that connection once, when you make that connection a couple times, the bookstore becomes your safe space. Then the next time you Go in there. All of those ingrained processes will start to become activated.
- [73:54]
Dr. Rena Malik
Target makes so much sense now. I think for a lot of women, Target is like a safety, safe space. Like you go and get away from everybody and go to Target.
- [74:00]
Dr. Tricia Pasricha
I love Target on like a good, like imagine like if I just went there on like a weekday.
- [74:06]
Dr. Rena Malik
By yourself?
- [74:07]
Dr. Tricia Pasricha
Yeah. Oh, yeah. In no way does this fantasy involve anyone else, but it's true. Like you need it. And actually this is why it's something like one in three people can't poop in a public bathroom because you, you have to. I mean, that's like deeply entrenched. You have to feel safe in order to have that bowel movement and open up those sphincters that. The last part of the bowel movement is you have to relax your anal sphincters. That's very hard to do if you. It's like very paradoxical in a way because you're bearing down, you're like clenching. But you need to feel relaxed and safe to do that.
- [74:36]
Dr. Rena Malik
You know, this is a real problem in schools. And I did a study about looking at lower urinary tract symptoms and school bathroom like environments.
- [74:44]
Dr. Tricia Pasricha
Oh man.
- [74:45]
Dr. Rena Malik
And it was so interesting because basically what we found was that these, these we know that people have issues with, with, with people who have trouble in school will. With lower urinary tract symptoms will also develop in adulthood. Right. There's actually studies, so why look at the environment? And we found that like these bathrooms either are non hygienic, some of them don't have stalls on them because they want to avoid kids sort of doing unsavory things or whatever.
- [75:08]
Dr. Tricia Pasricha
Oh my gosh.
- [75:10]
Dr. Rena Malik
Sometimes they have to leave the door open a little bit because the teacher has to be able to monitor like sort of for safety purposes. Like there's a whole bunch of things that happen.
- [75:17]
Dr. Tricia Pasricha
I couldn't, I couldn't go if my door was open.
- [75:19]
Dr. Rena Malik
Right. I mean, it's, it's crazy. And so there's all these. And there's kids like doing things that are like, you know, taunting other kids, whatever. But it's. Yeah, it's, it's a real problem that's horrible. Where the environment that the bathroom creates is not one that's conducive to being relaxed and having a bowel movement. Right?
- [75:38]
Dr. Tricia Pasricha
Yeah.
- [75:39]
Dr. Rena Malik
And so, I mean, it's also for urinary. Sometimes people get anxious, they pee more often or they hold it all day and then they develop issues because they've tried to hold their pee all day and the same thing, I'm sure happens with bowel movements. If you hold your poop for years and years and years, yes, you're going to develop pelvic floor dysfunction or other issues that are going to make it difficult for you to have bowel movements. So. And it's tough because the schools, their focus is on education, right? They don't have the, they don't have the funds to really put a lot of effort into, you know, like every little detail. But I think that like, it's a huge issue because these kids are, are struggling, some of them, with their urinary and bowel habits and it follows them into adult.
- [76:16]
Dr. Tricia Pasricha
I told. First of all, that's a fascinating perspective. I totally agree with you. And I also think like, schools, I mean, schools are a place where like so much of our lifelong habits do get set up that are outside the classroom. Like, would it kill anyone to just teach kids how to poop, how to pee, like how to do this properly a little bit at school? Like, I remember when I was in school, we had, it wasn't the best education. We had some education about our menstrual cycles. Right. Like, and obviously nobody looks back at that fondly, but, but we had it. We don't get any of that about proper bowel habits. And like, you're right. That school environment. Who wants to poop at school today? No. Adult like says, oh yeah, I love pooping at work. Nobody wants to do that. And I think that that's why a lot of people one have daily struggles. Cause they're holding it in. But even like something as simple as, like why people can't poop on vacation, it's because there's often like not a safe bathroom on vacation. You're sharing a hotel room with someone and suddenly everyone knows everyone's business. Or there's like 20 cousins running around. It's like really hard when you' not in your little Zen private spa at home.
- [77:19]
Dr. Rena Malik
Absolutely. I would like try to wake up early when I was on a girls trip so I could poop before everyone woke up.
- [77:24]
Dr. Tricia Pasricha
I've had friends. I'm not even kidding you. First of all, there's this myth when you start dating someone. I feel a lot of men feel women don't poop early on dating. I'm like, this is such a silly myth. How does this happen? I know why it happens because I have had friends who, when they start dating a guy, they'll wake up really early. They'll go down to the lobby of the like, whatever, whatever the Condo building is. And they'll poop there. And then look, they'll, like, come back up and. And they'll just like, oh, like, you know, like, I just don't poop, I guess. I don't put, like, come on. That's how these myths take place.
- [77:53]
Dr. Rena Malik
What happens when they get married?
- [77:54]
Dr. Tricia Pasricha
Yeah. Like, he'll discover that she has a human body. Yeah.
- [77:58]
Dr. Rena Malik
Talking about how to poop.
- [77:59]
Dr. Tricia Pasricha
Yeah.
- [77:59]
Dr. Rena Malik
Is there a way, a right or wrong way to wipe your butt?
- [78:02]
Dr. Tricia Pasricha
Oh, yeah, there's a wrong way. And. And I'm going to be honest, I don't think we should even wipe at all. I'm on Team Bidet.
- [78:11]
Dr. Rena Malik
I love bidets.
- [78:13]
Dr. Tricia Pasricha
Thank you, bidets. Bidets are a hard conversation for a lot of people who are just not used to trying new things back there. But bidets are more hygienic, they're more gentle, and they're actually better for the environment. I have counter arguments to everyone who would say, oh, but we waste all this water. Well, when you're confronted with this, like, one ply wad of toilet paper, you're going to use more toilet paper, waste more trees than you would with just the water you use with a bidet. But I like bidets. Not just for. I mean, I like them for everyone, but there are a lot of people who are either older and they kind of struggle with their stability to reach back there and wipe. Perfect for a bidet. Postpartum pregnant women love a bidet. When you're on your period and there's a lot of blood and there's a lot going on. Bidet, you're a little hairier back there and you don't feel like wiping. Gets the job done. Bidet, if you have to wipe. And that's sometimes the case because we don't. Not everyone has a bidet.
- [79:11]
Dr. Rena Malik
Well, and you're in public and you might have to wipe in public. Right. In a public bathroom, there's.
- [79:16]
Dr. Tricia Pasricha
I tend to, if you can, try to not vigorously wipe, like, if you can just, like, kind of do the gentlest of dabs and. And move on with your life. That's what I'd prefer. That skin back there is so sensitive and, and more fragile than I think it is because we think of our poop as, like, dirty. Therefore it, like, must be. We must be pretty thick skin back there. I mean, I'm sure you see this in. In your work too. That area is very fragile. Like, it doesn't take a whole ton for it to become inflamed. And if you get Something like a hemorrhoid. And you're wiping it. Every time you wipe it, it's going to become upset and angry. And so just a gentle dab. If you're a woman, we do say, try to avoid wiping back to front. Try to go front to back to kind of, Kind of. The, the data on this is actually more mixed than you'd think. But yeah, but we still say, well, why not? It won't, won't hurt to try. But yeah, I agree with you.
- [80:07]
Dr. Rena Malik
I think unless you're wiping your, like, fecal matter into your, like, vaginal area, like, you would have to go, yeah, like, you're most. It's usually not a big deal for most people. So I, I don't like to shame people about their hygiene because I think that's not why people get UTIs. You know, that's, that's like, I agree with you.
- [80:23]
Dr. Tricia Pasricha
When someone comes in with a uti, I'm never like, well, tell me about your wife.
- [80:27]
Dr. Rena Malik
So many people are shamed, like, so. Because I see all those women with recurrent UTIs and like, oh, my doctor told me I was dirty, or like, I. I need to work on my hygiene. They all get told to work on their hygiene.
- [80:39]
Dr. Tricia Pasricha
Oh my God.
- [80:39]
Dr. Rena Malik
And it is not a hygiene issue.
- [80:41]
Dr. Tricia Pasricha
Yeah, yeah, that's the, that's probably the main, those are the main spiels about, about wiping. But I will say, like, what about
- [80:49]
Dr. Rena Malik
using a wet wipe wipe, like a baby wipe or a. I love flushable wipe.
- [80:55]
Dr. Tricia Pasricha
I love them for what they do for you. Like, I like. For example, if you're getting a colonoscopy, wet wipes are your friend. If you don't have a bidet, if you have a bidet, then you don't need to even have this conversation. But wet wipes are great. The only problem is that you should never flush a flushable wipe. They're actually not degradable the way you think they would be. Based on the name and how it should work, you have to throw them in your little. A little trash by your commode. And then you do that often enough. Enough people get turned off to when the wipes, after a while, after that, like, little trash pile builds up. But they are gentler on the skin and they can be especially nice if you, if you do have a little bit of irritation or abrasion or a hemorrhoid or a little tear or anything like that going on.
- [81:34]
Dr. Rena Malik
So in urology we say, don't use the wet wipes. Get like the dry wipes and Just put water on them because of the irritants from the wipes.
- [81:42]
Dr. Tricia Pasricha
Oh, yeah.
- [81:43]
Dr. Rena Malik
That can cause some contact dermatitis sometimes for some people.
- [81:46]
Dr. Tricia Pasricha
Oh, my gosh. I believe that. I believe that. I haven't seen that yet, but I'm sure it exists, too. For the rear end, probably. Yeah, yeah, yeah.
- [81:52]
Dr. Rena Malik
I think the thing that we don't talk about enough is poop accidents. Fecal incontinence. Because I see it. Because I do a procedure called sacral neuromodulation, which is done for urinary incontinence but also helps with fetal.
- [82:04]
Dr. Tricia Pasricha
But also helps with fecal incontinence.
- [82:06]
Dr. Rena Malik
Yes. And so I talk about it with my patients, and it happens so often.
- [82:10]
Dr. Tricia Pasricha
Yes.
- [82:10]
Dr. Rena Malik
So let's talk about it. What is the prevalence of fecal incontinence and what can people do about it?
- [82:15]
Dr. Tricia Pasricha
Yes, it is. 7%. 7% of Americans are regularly. Not just like, oh, this happened to me once. 7% regularly pooping their pants.
- [82:27]
Dr. Rena Malik
It's a lot of people.
- [82:28]
Dr. Tricia Pasricha
It's a lot of people. And we're not talking about it, but yeah, like, go to a busy restaurant, have a look around. It's a lot of people that are living with this. And they are. And this is a. You know, I see this every week. They're so ashamed of it. And it's a big deal. Not because it changes your sense of self, like it really does, but it also has these impacts on how others perceive you. And for example, fecal incontinence is one of the most important predictors for whether you're going to be referred to a nursing home.
- [82:58]
Dr. Rena Malik
Right.
- [82:58]
Dr. Tricia Pasricha
Because it becomes this thing that caregivers are not really sure how to help with. And for something that is that big a deal and can really change your life, you know, it. It's something we should talk more about because we can treat it, because we often have ways to help treat it. And it's one of those things that I. If someone comes to me and what they're coming. What they are coming to me primarily is diarrhea or even constipation. And then sometimes you can get this thing called overflow diarrhea. I ask every single time, because if I don't ask, people don't say it. And then when they do, it, like, opens up this whole other conversation to thinking about it a different way and offering them treatments. There have been some. Some limited research that shows that how we ask about it changes. Like, people. If you say, like, do you have fecal incontinence? A lot of people Will kind of like, maybe not want to say yes, because even just. Even though they're there, even just admitting that out loud is really hard and embarrassing. But if you say, do you have any accidental bowel leakage? That's the phrase that some researchers have found people will be more likely to say, oh, yeah, that. That does happen sometimes. If somebody says that, I pounce. I say, my gosh, I'm so, so sorry that you're going through that. But thank you for sharing that with me, because now we can try to figure out how to help. Right? And in my world, one of the most common causes of fecal incontinence, bowel leakage, whatever you want to call it, poop in your pants, is actually just something causing diarrhea upstream that we can often fix. It's often this case that somebody's having diarrhea, they're going to the bathroom six or seven times, and then one of those times, they just can't quite make it to the bathroom in time. And if we were to just stop whatever was causing the diarrhea, we would stop most of the problem. There's another group of people where the problem. And often it's people have more than one thing going on. It's the sphincters themselves or something related to the pelvic floor. And in that group of people, there's good news as well, which is that we have pelvic floor physical therapy specifically for fecal incontinence. And I'm sure you see this too. A lot of times when we talk about pelvic floor physical therapy. A lot of times, a lot of men especially will be like, this is not for me. You're talking about, like, you know, my wife had to do that after childbirth. This is a very different thing, and it applies to us all. But this is something that you there. Yeah, there is actually. There is some data suggesting that there's a link with childbirth and fecal incontinence, especially, like right afterwards if you had a traumatic delivery. But later on in life, men and women develop fecal incontinence, and that's not really the issue. And this type of physical therapy that we can offer is really looking to strengthen and change and retrain those muscles there of the sphincter. People do really well with it.
- [85:36]
Dr. Rena Malik
Yeah. And we send patients for male. Male patients for physical therapy all the time, especially for post prostatectomy, but for all of these issues. And I would just tell guys, when you're looking for a physical therapist, ask if they've treated Men before. That's really the big thing. I mean, yes, there are a lot of pelvic floor physical therapists who unfortunately have only treated women. So maybe they haven't treated a lot of men. But ask if they feel comfortable treating men, because I think that's the key. Right. Sometimes you go to an office. So even when I used to work in Maryland, my office was in the women's health clinic. So my male patients would walk in and it would be like this pretty pink office, you know, and I'd be like, don't worry. Like, yes, the urologist works here, but it's, it's uncomfortable.
- [86:14]
Dr. Tricia Pasricha
Right.
- [86:15]
Dr. Rena Malik
And so I think just knowing that, like, yes, yes, our office is designed to appeal to women, but we still take care of men, or just knowing that they have that experience can be helpful.
- [86:25]
Dr. Tricia Pasricha
Yeah. I actually do think that unfortunately, that's one of the biggest barriers that my, my patients sometimes have is like, finding a provider who feels comfortable with men, but they, they're there. But I think you're right that you, you don't necessarily want to just settle with, like, with the first person you find. You want to make, I mean, physical therapy for this area. It's a, it's a committed relationship. It's a couple months. You want to feel really comfortable with that person.
- [86:45]
Dr. Rena Malik
Yeah. Are probiotics helpful?
- [86:47]
Dr. Tricia Pasricha
There is not strong data to suggest they're helpful for most conditions.
- [86:53]
Dr. Rena Malik
Okay, antibiotics. Are they going to destroy our gut microbiome?
- [86:58]
Dr. Tricia Pasricha
Not if you're an adult. If you're an adult, your microbiome is so resilient, it bounces back within two to three weeks. People. This is like a, this blows people's mind. People think they do. You're actually more resilient than you think.
- [87:09]
Dr. Rena Malik
What about in kids? So kids obviously sometimes need for recurrent ear infections, things like that. They need antibiotics. Should parents be avoiding them?
- [87:18]
Dr. Tricia Pasricha
They should absolutely take their antibiotics if their pediatrician tells them to take it. What we know is true is that, that the gut microbiome is more malleable when you're a child. Like from age zero, when you're born until about five years old, you are more susceptible to these kinds of things that can influence your microbiome. So what we shouldn't do, and I have a 2 and 4 year old, what we shouldn't do is push our doctors to give them antibiotics because, you know, they have some flu, like, symptoms and we're like, we want to just get them better. Suit. Like, who cares what the. Just get them better because we got to get back to where we got to put the magnetic. We should really just give them at the appropriate time and not overdo them. But that doesn't mean we should hold back when it's appropriate and the child needs it for another reason.
- [87:58]
Dr. Rena Malik
Got it. If there's one thing that you want someone to take away from our conversation that they should change about their daily activities or diet, what would it be?
- [88:08]
Dr. Tricia Pasricha
Don't bring your phone into the bathroom. Okay.
- [88:10]
Dr. Rena Malik
That's really good. And what's something that you've been. Even though you've only been a GI doctor for so many years, you've actually been exposed to the GI field for your whole life. What's something that you've changed your mind about that you really held fast as a true belief when you were younger?
- [88:26]
Dr. Tricia Pasricha
I mean, this is the biggest one is that I have fully let go of the idea that cancer is a disease of older people. Like when I was a medical student, if a young person came in with blood or abdominal pain, I'd be thinking hemorrhoid or maybe inflammatory bowel disease. It wouldn't ever cross my mind as a med student that we're talking about colorectal cancer. Now today, someone comes in with those things. That's the number one thing I'm thinking about. Not because it's the most common thing, not because it's the most likely thing. The most likely thing is still hemorrhoids and IBD and other things. But it's on my mind because it's the number one thing I don't want to miss.
- [89:01]
Dr. Rena Malik
So where can people find out more about you, your book, read your columns?
- [89:06]
Dr. Tricia Pasricha
They can. Well, I write a column every week in the Washington Post. I'm on Instagram, Trisha Pastricha MD and I've got a new book coming out April 7th. So they can check it out at anywhere they get their books.
- [89:15]
Dr. Rena Malik
Amazing. So I want to ask you four questions that we ask everybody. They can be about your life. They can be about gi. They can be whatever you want. Love it. So what is something you know now that you wish you knew earlier in life?
- [89:27]
Dr. Tricia Pasricha
Ooh. Oh, my gosh. I wish I knew that pre med courses and test scores didn't matter.
- [89:36]
Dr. Rena Malik
I mean, they kind of matter to
- [89:38]
Dr. Tricia Pasricha
get into medical school, but just enough, you know, like. But I don't think. I think I. Like, all through high school, college, college, med school, I think I worried too much about that stuff. Like, what matters is just you're going to be a good doctor. I've never met a single Patient who was like, how much did you get in your mcat? Yeah. What was your mcat? Where? No one even cares where I went to med school. Like, all that stuff that seemed to matter a lot. Like 10 years ago, 20 years ago. It doesn't matter to anybody now. Not even to me.
- [90:00]
Dr. Rena Malik
Yeah, absolutely. What's a non negotiable? Something you have to do every day.
- [90:05]
Dr. Tricia Pasricha
Oh, I'm a big coffee drinker.
- [90:07]
Dr. Rena Malik
Me too.
- [90:07]
Dr. Tricia Pasricha
If I don't have. I go into it. This is like too much. I go into withdrawal if I don't have coffee. Coffee.
- [90:11]
Dr. Rena Malik
Yeah. I love my coffee. It's funny because I tell my patients, like, you should limit your caffeine if you're having overactive bladder. But I tell them, look, you can you will not find me giving up my coffee. You will buy it from my cold, dead hands.
- [90:23]
Dr. Tricia Pasricha
Yes.
- [90:23]
Dr. Rena Malik
So I'm not gonna tell you to stop completely. I'm just gonna say maybe do a half caf or a decaf. Right?
- [90:30]
Dr. Tricia Pasricha
Yeah.
- [90:30]
Dr. Rena Malik
Like, you can still have your coffee.
- [90:32]
Dr. Tricia Pasricha
Yeah, yeah, yeah. I'm with you. 100.
- [90:37]
Dr. Rena Malik
What's a life hack or health hack you'd share with people?
- [90:40]
Dr. Tricia Pasricha
The main thing that I, I practice, what I preach is I take psyllium husk. It's like a fiber supplement. I'm not endorsing any brand, whatever brand you want, no name brand. And I mix it in my coffee. It like combines my two things. So I have fiber, I have coffee. You have to chug it. It turns into water. But this is the thing that, like, I try to get my fiber goal every day. I have two kids, I work in a hospital. I sometimes do not do that. So when I don't, I like have this fiber supplement.
- [91:05]
Dr. Rena Malik
I know I'm gonna have fiber in my co. I use the wheat maldextrin. Like the benefiber. Optifiber.
- [91:12]
Dr. Tricia Pasricha
Oh, yeah. So then you don't have to chug it as fast as I have to usually chug small.
- [91:17]
Dr. Rena Malik
It doesn't also give me that gritty texture.
- [91:19]
Dr. Tricia Pasricha
Yeah. If you don't, you have to. I'm like, so intense. I constantly stir so that it doesn't totally become gel. And I'm like, poking my eye out with the spoon. You don't have to do all this. Okay. But you should. But try a fiber supplement. It'll get you over the line if you need to.
- [91:33]
Dr. Rena Malik
If you can. Couldn't be a physician, an author, a writer. What would you be?
- [91:39]
Dr. Tricia Pasricha
Maybe I would be a lab manager.
- [91:41]
Dr. Rena Malik
I thought you'd be an actress.
- [91:43]
Dr. Tricia Pasricha
Yeah. Oh, no, no. The fear, the pain in my belly when I blew my lungs. I don't want to live through that again.
- [91:50]
Dr. Rena Malik
All right, well, thank you so much.
- [91:52]
Dr. Tricia Pasricha
Thank you so much. This was so fun.
- [91:54]
Dr. Rena Malik
Thank you guys so much for joining me. You guys made it to the end of this podcast. That means you actually like this podcast. So if you like it, make sure you are subscribed or following the podcast. Guys, it takes one second to follow the podcast and it tells all the podcast platforms that hey, this podcast is worth listening to and allows other people to see it. Zero cost way to support all the work we do here at the Rita Malik MD Podcast. And as always, we're gonna take care of yourself because you're worth it.
- [92:21]
Dr. Tricia Pasricha
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