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The mindbodygreen Podcast
652: A guide to healthy pooping | Trisha Pasricha, MD, MPH
00:44:04
A graduate of Harvard College, Pasricha earned her medical degree from Vanderbilt University School of Medicine and a Master of Public Health from the Harvard T.H. Chan School of Public Health. Her training includes an internal medicine residency at The Johns Hopkins Hospital and gastroenterology and motility fellowships at Massachusetts General Hospital. Currently, Pasricha is an assistant professor of medicine at Harvard Medical School and director of the Institute for Gut-Brain Research at Beth Israel Deaconess Medical Center, an NIH-funded research laboratory at the forefront of gut-brain science. Her book, You've Been Pooping All Wrong, is out now.
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- [00:00]
Jason Wakab
Welcome to the MyBodyGreen podcast. I'm Jason Wakab, founder and co CEO of MyBodyGreen and your host. Study and play come together on a Windows 11 PC. And for a limited time, college students get the best of both worlds. Get the unreal college deal everything you need to study and play with select Windows 11 PCs. Eligible students get a year of Microsoft 365 Premium and a year of Xbox game Pass ultimate with a custom color Xbox wireless controller. Learn more@windows.com student while supplies last ends June 30 terms at aka mscollegepc.
- [00:37]
Dr. Tricia Pasricha
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- [01:08]
Jason Wakab
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Dr. Tricia Pasricha
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Jason Wakab
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- [01:25]
Dr. Tricia Pasricha
They're hunting us. It's time we started hunting them. I can work with them. This should be tons of fun.
- [01:33]
Jason Wakab
Marvel Television's Daredevil Born streaming only on Disney plus. What if the quote unquote normal things you're doing in the bathroom are actually working against you? Dr. Tricia Pasrica is a gastroenterologist at Beth Israel, a Washington Post health columnist, and the author of the new book, you've been pooping all wrong. In today's show, Tricia explains her lab's findings that bringing your phone to the bathroom raises your risk of hemorrhoids by 46%. We dig into why pooping anywhere from three times a day to once every three days is normal. And the $30 bidet she recommends to almost every patient. And we even get into traveling and what happens there when it comes to bowel movements. Let's dive in. Let's start with frequency. Frequency might not be the right metric. So can we talk about that?
- [02:30]
Dr. Tricia Pasricha
Yeah. I think whenever somebody is like, are my bowel movements normal? They think I'm gonna tell them, well, if you go once a day, then yeah, of course you're normal. That's almost never what I tell anyone. And I don't think frequency is the number one thing, for lack of a better word, that we should be so worried about. For me, what makes a healthy, comfortable bowel movement is, one, it should be comfortable. That comfort is the most important metric to me. I want it to be effortless. I don't want you to be str. Straining your eyeballs out. And then, two, I want it to be something that doesn't interfere with your social calendar. You know, like, you can go once a day, but. And this is something I hear in my clinic all the time. It'll be like somebody has come in having been dragged in by their partner, and they'll be like, you know, yeah, he goes once a day, I suppose, or she goes once a day, but I'm waiting 45 minutes to get out the door, you know, because they're in the bathroom. They're hogging the bathroom. And if it's like that, I don't think that's healthy. Right? Like, you shouldn't be spending more than five minutes in there at a time. But it's often that you don't really know how many times you go per day, you know, is considered normal until you, like, pair up with somebody later in your life or you go to college. So I think we spend most of our young adult, adolescent life not really knowing what other people are doing. Like, we barely discuss our habits with our parents or our siblings, like, much less like other people in the world. So we've become really fixated on going one. Today. They did this study at Beth Israel, which is where I work in Boston, and my colleagues found, if they look at this national survey of Americans, people who consider themselves to have normal bowel movements going everywhere from once every three days to up to three times per day is normal. So that's a huge range. And in a way, I think that should feel comforting. I mean, it's. You can live a complete and full life pooping every other day, taking a day off from pooping, and you're still gonna be okay as long as you meet these other criteria that I care more about.
- [04:28]
Jason Wakab
So what are the other criteria that you care more about?
- [04:31]
Dr. Tricia Pasricha
It is the comfort. It is whether or not pooping and thinking about the bathroom hijacks your day. There are a couple of caveats I'll say, though, that, like, no matter, you know, like, whether it's comfortable or not, I. I would. I would hit the pause button. That would be, if you ever see blood in your stool, I would say, wait a minute. This is Never normal. I like, even if it's like, not even if it's painless, blood in your stool is never normal. And, and I will say, I have a lot of people, especially younger people in my clinic who will be like, well, I, I do see blood from time to time. I'm pretty sure it's my hemorrhoid. And the most likely scenario is that, yeah, it's pretty. It's probably your hemorrhoid. Make sure you've had a doctor just take a look at that hemorrhoid once before you start to dismiss blood the rest of your life as hemorrhoids. Right. Cause we don't want to miss anything more serious, especially in this age where we're seeing this rise in early onset colorectal cancer. So blood never normal until someone takes a look at it. If you have pain. A lot of people do experience this. They experience pain, cramping associated with going. Sometimes it's relieved when they go, sometimes it's not. Or sometimes it's relieved just quickly and then it comes right back. If you're going every day and yeah, you're able to go in the morning, it doesn't interrupt any of your social activities, but you're bloated and uncomfortable all the time, and it seems to be tied to your bowel movements. That's not normal to me. So there's a couple of these other factors that I think matter more. But just going once a day is wonderful. Our bodies are naturally primed to go in the mornings. Like that sort of thing that is lurking in the back of our, like our, that we, you know, our dads and moms tell us try to go once a day in the morning. That's true. That has some, some basis physiologically. And that's because when we first wake up, you know, our colons have been sleeping through the night, just like we have a lot of other organs in our bodies. They kind of don't fundamentally change what they do overnight. Like, your heart rate will slow down, but it's still beating pretty regularly. Your colonial stops working, it goes to sleep. It's just like the rest of us. But in the morning, it wakes up with your circadian rhythm, and you get some of the strongest contractions naturally of your colon that you're going to ever get the rest of that day during the first one or two hours of waking. So anytime you can lean into your body's own physiology, and that is to say, like, when your colon is doing the work for you, it means you have to do less Work, you have to generate less of a Valsalva maneuver to get that bowel movement out. And so first thing in the morning is a great time to go. It's also when people are drinking their first cup of coffee, which will trigger contractions in about a third of people who drink coffee. It's often when people might go for a quick walk, take the dog out quickly walking, a little bit of exercise will trigger contractions. So all of these things tend to happen in cluster in the mornings. So it's a good time to go. There'll be easy for you if you can build into your pattern.
- [07:20]
Jason Wakab
So much to unpack there. I feel like you answered like half my questions and I've got like a dozen more. So in terms of what counts, does the Bristol stool chart still count? In terms of what is that because you touched on a lot. We touched on frequency, we touched on effort, we touched on time of day, we touched on significant changes in terms of pain or seeing blood in the stool. We touched on hemorrhoids, which I want to come back to. But does the Bristol stool chart still matter? What's your take?
- [07:56]
Dr. Tricia Pasricha
Yeah, the Bristol stool chart is interesting. You might have seen this if you ever go to your doctor's office. We in GI usually have one in every clinic room. And basically for people who don't know it is this pictogram of, on a kind of a seven point scale of what stool can look like from like these tiny little rabbit pebbles, which I don't think anybody finds comfortable or pleasant to, all the way down to pure liquid. And then somewhere in the middle is this like nice beautiful snake like, or smooth sausage like poop. And, and most people tend to think that that middle ground, It's a Bristol 4 is what people want. And that's the best way to poop. And what when the. The researcher who developed the Bristol stool scale, what he did was he surveyed inhabitants of Bristol, England and he found that where they fell on this scale, how their poop looked actually pretty nicely correlated to how long it took for that poop to move through their colon. So if you had a fast moving colon, meaning your colon doesn't have enough time to absorb water before you get it out, then you have a much more softer, watery stool. And then if it's spending a lot of time moving really slowly through your colon, it gets drier and drier and drier and you get these pebbles. So it does tell you something about how long it's been sitting there in your colonial. I think what I find people Tend to, like, especially in the UK, in America, where we're probably most of us, 95% of us are not meeting our fiber goals. People tend to think that the fluffier, softer, looser stool is diarrhea. They'll come to me and they'll be like, I have three fluffy stools a day. I think I have diarrhea. You know what, actually surprise. If you meet your fiber goals, you're gonna have fluffier, more frequent stools, and that's normal. And I think we should all embrace that new you if you're somebody who's new to fiber. So to me, I don't fully anchor on. Do you have that, like, perfect middle ground just once a day? Some people call that sort of a wipeless wonder. I think it's lovely if that happens for you.
- [09:56]
Jason Wakab
Yeah, so you mentioned the wipeless. You're just filled with some. There's some. The book's amazing wipeless wonder. I feel like you should trademark that.
- [10:07]
Dr. Tricia Pasricha
I heard it from a college student. One of my. One of my patients said it to me, and I was like, I was definitely going to use that again.
- [10:14]
Jason Wakab
Yeah, take that one. Understood that all these things change. Let's talk about wiping. Like, in a perfect world, should. Should everyone have the wipeless wonder? What's your. What's your take?
- [10:30]
Dr. Tricia Pasricha
I have, like, oddly strong feelings about wiping again. I feel like as a gastroenterologist, I spend more time thinking about this thing that nobody else is really spending too much. But here's something that I think people don't appreciate. You know, that skin around our derrieres is actually incredibly delicate. And I think we think of it as, like, being really rough and tough, and it just, like, you know, because it's dealing with stool all day, it's actually pretty delicate. And it. You can create these micro abrasions and small micro tears if you're somebody who has looser stools and you're just constantly wiping. Right. And honestly, I have become a bidet believer, like, a long time ago, like years and years ago. And I recommend bidets in my practice to literally almost everyone. It's not a concept that I think a lot of Americans are used to, although, as you might remember, during the great toilet paper shortage of 2020, a lot of people did discover bidets as a result of not being able to find toilet paper in the stores. And honestly, it's completely eliminates this problem of, like, wiping and creating irritation and redness, which I see all the time in my patients who have irritable bowel. Syndrome, people who are prepping for their colonoscopy, women who are postpartum. Bidet is a lovely gift because everything's sensitive, everything's sore. Women who are on their periods love a bidet. Anybody who has hair back there who just doesn't feel wiping is getting the job done. Bidets are lovely. So in short, bidets are wonderful for everyone to just feel cleaner. But also, and this is like, maybe the more convincing reason to some people, they're actually just literally cleaner in terms of the microbes that will be lingering on your hand afterwards. They have someone actually in Japan, where of course, they have, like, really modernized the bidet. They did this study where they found that if you wipe just with toilet paper, as one does, you end up with significantly more microbes on your hand than if you cleaned up afterwards with a bidet. So if that's, like, not enough, I mean, I think between the comfort, the heated seats, the joy of it, bidets are the way to go. But if not, if you're. If you're not ready for that conversation, I get it. Not everyone's fully ready.
- [12:41]
Jason Wakab
No, it's interesting. And not everyone has a bidet. And, like, a quick antidote. I didn't even. I remember the first time I discovered a bidet. I was visiting someone. I think I was like 26 or 27, and their family was staying at a very expensive, fancy hotel in New York City. I think it was the Palace Hotel. And I went to the bathroom, I was visiting and I saw it and I was so confused. It was like, what is this? Is this, like, handicapped? And it was. They were like, no, this is a bidet. I was like, what is this? What is this? We're going back. This is a long time ago. I think this was 2002. And I was just like, wow, this is fascinating. But to your point, not everyone has access, but if you do, it is incredible. And something I've discovered is I used to be a very hard wiper. Just because that's what I did. I'm just a hard wiper. And the unintended consequences is I probably have, like, I have super sensitive skin and I'm like, worn it off like around there. And I probably have all these, like, micro tears. And, like, I get itchy because of it. Like, I've got, like. I'm like, trying to deal with it now, but no idea. And. And I've become a believer. If you have it, if you have access to it, it makes a lot of sense. Not to mention. And I don't want to, like, be a fear monger, but there's. There's so many, so much on social media now around, like, so much toilet paper is, like, kind of toxic.
- [14:12]
Dr. Tricia Pasricha
You're not the only person who experiences. We just don't talk about it. But a lot of people get that kind of irritation just from toilet paper.
- [14:19]
Jason Wakab
And so you mentioned hemorrhoids, too. Where do hemorrhoids sit in this conversation?
- [14:25]
Dr. Tricia Pasricha
Where do they physically sit? Well, you know, and actually, I'm glad you mentioned hemorrhoids, because people who have hemorrhoids, they often get them over and over again. This is a great group of people who will. Who would benefit from a bidet and, you know, the bidet idea. There are these, like, wonderful fancy Japanese 3, 4, $600 bidets. They're also like $30 nozzles you could get at Home Depot that are. That are pretty cheap. And so, you know, even my patients with. I see a lot of patients with Parkinson's disease who have a lot of difficulty moving. Those little nozzles actually make their lives so much easier. So there are options for everybody. But to come back to the hemorrhoid question, hemorrhoids, I think, are deeply misunderstood as well. So everybody has hemorrhoids. We all do. Hemorrhoids are just internal cushions of veins, and they usually sit just inside our anal sphincters. But over time, and we can talk about the reasons why, the connective tissue around those veins can weaken, they can engorge, and when they engorge, they can become a problem. We get two kinds of hemorrhoids, the internal kind, which never pop out and you actually don't really feel them, the internal ones, for the most part, until they bleed. And then you notice that they're there because when they bleed, you often see this, like suddenly a bright red bowl in your toilet of blood, and you're like, my God, what is happening? And it's often hemorrhoids, the external ones that are just outside the sphincter, those are the ones that are itchy, uncomfortable. They also bleed. It feels like a lump in there. And then sometimes you get actually this third kind where the internal ones pop out to the external side and give to kind of they prolapse. And you put that away. So they're. No, they're not one of those things that will necessarily kill you. I mean, they can. Sometimes you can have a catastrophic bleed, but it's pretty rare. But they can really destroy your quality of life, and they can really make you Feel embarrassed and ashamed to not know what to do about them. And so they're a big problem.
- [16:19]
Jason Wakab
And what's the relation between. In my experience, when I've had a hemorrhoid or hemorrhoids, it's been tied to too much effort, too much pushing, and, like, the stress of, like, I gotta go. And then I would, oh, okay, I just caused this. But walk me through the science. What's going on?
- [16:36]
Dr. Tricia Pasricha
Yeah. Decades ago, I think we thought of this in a much more simplistic way, which was that if you're constipated, that's the thing that puts you at risk of hemorrhoids. And they had done these studies that looked at, yeah, if you eat more fiber, you tend to have less hemorrhoids. And they look at these in populations. But over time, we've evolved that to realize it's. It's a little bit more nuanced. It's the straining that seems to be a bigger risk factor. And so when you're sitting there straining, you're generating this pressure that seems to be the thing that one weakens that connective tissue and then fills that tissue, fills the hemorrhoids with blood. My lab looked at smartphone use in the toilet because we were interested in this idea. I write this column for the Washington Post where I answer health questions, and a reader wrote in and was like, I've heard that reading a newspaper is bad for hemorrhoids. Tell me, is that true? What should I do? And, like, my goodness, this was like, 2024. And, like, how many of us are reading physical newspapers on the toilet anymore?
- [17:39]
Jason Wakab
That's like an old Norman Rockwell photo from, like, the 1950s.
- [17:43]
Dr. Tricia Pasricha
Yeah, yeah. He just, like, the pants at the ankle. Yeah. And I, like, I remember in my childhood, everyone's house had that, like, little discreet bookshelf of, like, old newspapers and, like, who knows what other kind of reading. Like, the Far side comic was always somehow in there. But nobody has that anymore because Everybody's bringing their SmartPH. And so we did this study where we tried to understand what happens. First of all, how many of us are bringing our smartphones into the bathroom. And what we found, we looked at people who were coming in to get their screening colonoscopies. So older adults, 45 and older, two thirds of them bring their smartphones in. But the really interesting thing is that the ones who brought their smartphones in were at a 46% higher likelihood of having hemorrhoids, which we were able to see endoscopically when we were doing their colonoscopy, even though they reported similar amounts of straining compared to the people who didn't bring their smartphones in. And we controlled for lots of other factors like fiber intake and exercise. But what really stood out and what we think the driving issue here is is not necessarily something inherent about the smartphone, but the fact that the smartphone users spent more time in the bathroom every time they went. So they were more than five times as likely to spend more than five minutes at a time, not necessarily because they were straining harder. That was equal between the group, simply because the smartphones distract us and hijack our brains the way they do in any other sphere. And the hypothesis that we have is that the longer you're sitting in this open bowl that doesn't have any pelvic floor support, and you're just kind of passively sitting there, like, doing that a couple times is certainly not going to be a problem. But when that's what you do every day, maybe multiple times a day now, every week now, you compound it by years and years and years. Yeah, I think that is what contributes to that. That tissue weakening ultimately the hemorrhoids, prolapsing and bulging and then ultimately giving you problems down the line. So my take home from that is we should all be sticking to less than five minutes. We should ideally not be bringing our smartphones in, but if we do, because it's obviously really, really hard to. Not if you do at least set a 2 TikTok limit. Don't watch a full episode of the Pit. Yeah, just. Just go in and out and ask yourself after five minutes, am I even focused on the task that I kind of came in here to do in the first place.
- [20:03]
Jason Wakab
Interesting. So you mentioned fiber more than a few times, and I think everyone's gotten the memo. Fiber is very important. Where do you see, where do you like to see fiber intake?
- [20:13]
Dr. Tricia Pasricha
Well, several ways. One, I think people tend to cluster their fiber later in the day. I like when people eat their fiber earlier in the day and obviously spread throughout the day. But I think early morning breakfasts that are high in fiber, high in protein, that's the thing that's going to set you up for success later on in your day with your energy and your hunger levels. But there's certain kinds of fiber that I think can be. Have been especially proven in some of these studies. Like, for example, soluble psyllium husk is a fiber supplement that even though, again, as a gastroenterologist, I am way more obsessed with fiber intake than a lot of people. Like I meet my fiber goals most days, but even on the days that I don't, I still take psyllium husk just because psyllium has been so nicely studied to lower cholesterol, which lower runs in my family. It also is associated with these changes in the microbiome which are not really related to how they would impact your poop. It's gonna do that, but more that they shift the microbes more towards the kind that produce these beneficial short chain fatty acids. So I tend to just supplement with this and I there's no particular brand I endorse, but just, just to take it in general because it's been so well studied and nicely shown so early in the day and then throughout the day continuing to take small bits of fiber, whether that's through a supplement or through your snacks. Like I, I eat nuts a lot. I keep cashews at my desk so that I have no other option and I actually happen to love them so I eat a lot of those. And we eat a lot of lentils as well. I think lentils are underappreciated for protein and for fiber, so we eat a lot of that at dinner.
- [21:48]
Jason Wakab
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- [22:34]
Dr. Tricia Pasricha
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- [22:36]
Jason Wakab
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- [22:42]
Dr. Tricia Pasricha
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- [22:55]
Jason Wakab
love it and I'm going to send you our debloat supplement which has fibrosol which I love after this podcast. Ooh, it's amazing. So you've touched on Colon cancer. And there's certainly an uptick. It is complex. What is your take? And I know we're still getting information on this, but what is your take on the uptick? Is it too many ultra processed foods? Is it not enough fiber? Is it metabolic health issues? Is it all the above? Is it? What's your view?
- [23:29]
Dr. Tricia Pasricha
I spend so much time thinking about this, both as a researcher and then also, I mean, I've been seeing this among my patients more than I ever was. Like in medical school, earlier in my training, if a young person came in with bleeding, I wouldn't have been thinking about cancer. And now I see these cases like I have to think about it because we were just diagnosing it more often. And I think we've felt a little more in the dark five or ten years ago than we do today. I think today we can say with relative confidence diet. Ultra processed foods are a big part of the story. And I think what's the part that we still need to understand is why cancer seems to happen in younger people who eat ultra processed foods in certain groups but not in others. And there was some really interesting data that came out within the last year or two that you might have heard of about this toxin called colobactin that was produced by certain bacteria. And they were able to isolate this from the tumors of some people who had early onset colorectal cancer. And they said, wait a minute, this toxin called colorectal colobactin is responsible for some of the changes in the DNA that are toxic and seem to be linked to the cancer. And when you trace it back, it seems that early in life, if you have more E. Coli that are producing this colobactin, that seems to be what increases your risk of colorectal cancer at a young age, like in your 20s and 30s. And what's so disturbing to me about this is that although it makes sense, is that we're talking about exposures that happen like in the first decade or two of life, you know, and then that's when you get the cancer in your 20s and 30s, when people get diagnosed in their 25, it's not something they did in the last year, it's not something they did two years ago. It's something that happened in childhood. And it's not one thing like, it's not like, oh, well, we know the bacteria. Well, why, why don't we just eradicate that bacteria? Well, that bacteria is thriving because in certain people there are other things in the environment that allow it to. Maybe it is the Diet the ultra processed foods. Right. Like there's all these studies that link ultra processed foods to the development of polyps, sugary beverages to the development of polyps and cancer and then other things in the environment that we haven't quite nailed down. But I do think for me, as the mother of, I have two kids who are pretty young, like they're in that three to four age range. The thing I obsess about when I think about this is fiber intake. It's exactly as you said, because fiber seems to be protective across any life stage. And I also think in kids, we know that their microbiomes are Most malleable when they're 0 to 5, 5 years of age and it starts to become more and more fixed. So like I, this might sound really nuts, but like I fiber max. My kids, you know, like I will mix in flax seeds into their pancake mix and like they like, they'll snack on veggies during the day and ultimately they may make different choices as they will because who can resist a good chicken nugget? But at least is while I have some control, that's the thing that I do think about a lot more, I think than the average person is like, like fiber maxing them while I have this window where their microbiomes are going to be so heavily shaped.
- [26:42]
Jason Wakab
Right. I'm curious too on that note. It feels like with regards to the microbiome and I'll use, use stool testing. You know, there's so many tests out there and what I hear consistently is they're interesting, it's something. But we're not, not quite there. It's a snapshot and take it with a grain of salt.
- [27:06]
Dr. Tricia Pasricha
Yeah, I fully agree with that. I have a lot of excitement about where we'll be in the next maybe 10 to 20 years.
- [27:14]
Jason Wakab
Let's go there. Yes.
- [27:16]
Dr. Tricia Pasricha
Yeah, I think one day we will. And not in like in my lifetime. So like not, you know, 100 years from now, I think we will be able to say, here's exactly what's happening in your individual microbiome. Here's a like really sophisticated way of testing for it. And here's the things we can do that might influence the bacteria present there that we know will then have these specific health outcomes we want. Where we are right now is exactly like you described. We can get a snapshot in a way that may or may not be a perfect way. And I think it's a little too soon for us to take that snapshot and say, okay, this bacteria is elevated. This Bacteria is low. What we need to do is give you more of the bacteria that's low because we think that's a good bacteria. And I think sometimes we might make a mistake where we say, okay, the bacteria is low in diabetes or the bacteria is high in diabetes. That means that bacteria is bad. And what if that bacteria we're seeing is not bad? What if that's the result of the diabetes rather than the cause? And now we're chasing the bacteria and trying to fix it here, where maybe we need to take a step back and figure out what is driving the actual disease process. And I think that's where we are right now, is we see a lot of associations that are intriguing and are going to be the foundation of what we'll do later. But we're not quite there yet.
- [28:41]
Jason Wakab
It's interesting. I think the more I learn about this, the more I just kind of throw my hands up to some degree and say, we really don't know. I think there are some things we know for sure, but there's just so much that I'm curious. I think we've, we've established some things. I think it's safe to say we know for sure. You know, ultra processed foods, not, not good. You know, sugary drinks, not good. What are, what are things, in your view, that, you know, we really don't know right now? And like, beyond the stool testing, beyond, like, what are the mysteries in the gut as it relates to pooping, where you're like, huh, that's interesting. If I could, you know, wave, wave my magic wand and get a, a huge grant and do a double blind placebo, this is where I'd go. This is what I want to know.
- [29:27]
Dr. Tricia Pasricha
Oh, my gosh, Huge questions. Well, I'll tell you a couple things. I think intermittent fasting is one where I think there's a lot of intrigue and not enough data quite yet. There's a lot of really interesting data in mice and in translational studies and there's some clinical data, but not enough yet. I know, don't I? I do think that. And, and in terms of how it impacts your gut, how it impacts your microbes, and then also indirectly, then also the other aspects of your health right now, I think what we can all agree on with intermittent fasting, probably almost everyone can agree on, is avoiding late evening, late night eating is, is a good idea. And if you can kind of shorten the window that you're eating every day is good. But, but certainly nobody will tell you. We all agree skipping breakfast is A good idea. We all agree fasting for a couple days in a row is a good idea. Some people do. A lot of people say no, we don't agree that. And I don't think we have enough data to strongly show in humans what the right move is there. But we will certainly, I think, get there soon. I also think the. I mean, the second thing that is related to these kind of stool kits that you can get to test your microbiome is fecal transplant. Fecal transplant. We are. That is not ready for prime time. So let me just, like, preface that before everyone gets excited about what I'm about to say, but I think it will be again in a couple of years, because fecal transplant, as opposed to a probiotic pill, you're really going directly at the source. And we've seen that it can do really profound things in really specific scenarios, like, for example, an infection with C. Difficile, which is a really scary and harmful bacteria. It can. It can completely change your health. We have not yet seen it pan out for things like irritable bowel syndrome, Parkinson's disease. That doesn't mean, to me that it'll never work. It absolutely can't work. I think it just means that we haven't figured out who we need to target and how we target them 100%.
- [31:26]
Jason Wakab
So I'm going to bring it back
- [31:28]
Dr. Tricia Pasricha
to bowel movements as we do.
- [31:30]
Jason Wakab
Yes, we're bringing it back. Why do so many of us struggle going in a public, unfamiliar setting or traveling, Traveling, traveling, traveling. We're not. The bowels are. The bowels are not traveling while we're traveling.
- [31:50]
Dr. Tricia Pasricha
Yeah, yeah. You're carrying a lot of extra baggage with you in your colon when you travel. And it's. It's horrible. I mean, I think that this is, like, not a narrative we discuss enough out loud. But so many people struggle to go on vacation, and it can really ruin your experience. And there is a couple of things that go into traveling, one of which is this, like, issue of, like. Like, I can't poop in public. And when you're traveling, like, maybe you're sharing a hotel room with your cousins, and that's really awkward because the walls are paper thin. Or I've had a lot of people who come to my clinic, and they're like, I had to run down to the lobby every morning to go to. Just get away from, like, everyone in all these rooms. And like, that's not a setup for success. But when you travel, like, again, remember, your colon does operate on a Circadian rhythm. And so. So one of the biggest things that will sort of like, remind your colon, wait a minute. We're in a new time zone. We need to start behaving differently is the time of day that you're eating. So if you're traveling, the moment you get on the plane, start behaving as if you're already at your location. If you're going to Europe, you're going to Asia, Start eating as if you're in that time zone, because that's going to immediately, even before you get there, start to retrain your colon to when it should be awake, when it should be asleep. And that'll help. Help. But it's more than that. Once you. We get to our vacation destination, we often, by design, are lounging on the beach, like, for the whole time. Like, we're not exercising. We're often eating richer foods that are lower in fiber than what we usually eat at home. And then sometimes, like, I actually have found this to be my biggest struggle on vacation. I, for whatever reason, I struggle to get, like, a good cup of coffee in the morning. At the time I want coffee. Like, it's just, like, a big problem for me that'll throw off my routine. So everything about your routine often gets thrown off. And then as much as we're on vacation trying to enjoy, we're often stressed because we're with our family. And that, too, stress can certainly do a number on your bowel. So I usually tell people, one, try to incorporate a little short walk in the morning. Go walk on the beach and find whatever else you can in your routine and try to reincorporate that. And maybe the most important thing is to aggressively seek out fiber on vacation. If I could just tell you to do one, two, and three things. Pack a fiber supplement, if that's like, the absolute minimum. And I do that. But otherwise, like, indulge, have everything that you want to eat, because this is your vacation. But just rather than take anything away, just add a side of broccoli. Like, order those Brussels sprouts at dinner, even though that's not something you normally do. Just incorporate a lot of extra vegetables, more than you think you need, and you will thank yourself later for that.
- [34:28]
Jason Wakab
So segueing from incorporating lots of vegetables, can we talk about gas issues?
- [34:34]
Dr. Tricia Pasricha
Yeah. Speaking of, like, getting on a plane, which is where people are extra gassy.
- [34:39]
Jason Wakab
So good, bad, like, talk to us about gas. What's. What's acceptable, what isn't?
- [34:44]
Dr. Tricia Pasricha
Yes. Okay. That's a great question. You might be surprised to Learn that most normal people pass flatus 10 to 15 times a day. Even up to 20 could be considered normal. So sometimes people are like, my God, this is so embarrassing. I'm like farting all the time. But then when I ask them to count it, it's like just very average. It's like disappointingly average. It's just that sometimes you don't know what, how many other times people in your life are going. But 10 to 20 could be within the range of normal. It's totally fine. It is a normal part of life. The gas comes from the food that you're eating, how it's being digested and the gases that we're producing as a result. And the part that people are probably most embarrassed about is the smell. And that comes from the sulfur containing gas. And that's only 1% of the gas. 99% of the gas in our bodies is odorless. But that 1% is like really strong and kind of overwhelms everyone else. And usually I would tell most people, like, I don't think this is a big deal. Like everybody's doing this. Like, you know, we can just normalize this and live with this. But if you are extra nervous about offending somebody because you are going on a date or you're meeting your in laws for the first time and you're like, I really just, I cannot take this risk. I know we're going to be eating a lot of like garlic and onions and pinto beans. Whatever it is. You could take bismuth subsalicylate. That is like the oldest trick in the book. That's just Pepto Bismol. And it, it binds and it neutralizes the sulfur. And if you take it like the day or two before whatever this event is that you're worried about, you'll actually like completely neutral, almost completely. Nine, almost 90% neutralize that gas. And you can kind of like rest assured and, and just you have to worry about offending people with your personality
- [36:31]
Jason Wakab
instead of am I jumping the gun here? It's sulfur. Sulfur is the core issue. Is it too many sulfur rich foods?
- [36:37]
Dr. Tricia Pasricha
Yeah. And you could certainly there's certain foods like that, you could that tend to be classic offenders for people. And it is the sulfur rich stuff. And so you could try to like change that out. But you know, for me I usually actually, I want people, if you love those kinds of foods, I want you to be able to eat them and be happy. And I'd rather we normalize the result of it rather than like make you kind of not live your best life.
- [37:01]
Jason Wakab
So something else I just such a great chapter title in the book, Runners with the Runs.
- [37:10]
Dr. Tricia Pasricha
Yes. Oh, my gosh. And it was just the Boston Marathon here this week. So this was on my mind.
- [37:15]
Jason Wakab
So let's talk about that. Runners with the Runs.
- [37:18]
Dr. Tricia Pasricha
Yeah. And this is something that immediately, anyone who runs knows exactly what we're talking about. But. But when people are training for marathons, when people are engaging in vigorous exercise, it is so common that they have to use the bathroom. I mean, these marathons are lined with porta Potties for a very good reason. And running in particular has been pretty well studied. And, you know, we know that just a little bit of movement, even just walking, can start to stimulate contractions throughout your gut. That's why actually, we tell people, like, for example, if you've just gotten surgery and you're feeling constipated, get up and walk, get up and move, start ambulating early, because we know that's going to help you get less constipated. And we also know that running, like the more kind of moderate to intense activity that you engage in that's beneficial for your gut in terms of reducing your risk of colorectal cancer. It certainly stimulates those contractions in the moment, and long term, it'll help keep you regular. But when you are running something like a marathon, you can cross this threshold in which you start to shunt maybe too much of your blood in your systemic circulation towards your muscles, because you have to, to sustain them in order to keep up this activity that you're doing. And in doing so, the amount of blood that makes it to your intestines can drop to 20% of its baseline. That's when things start to turn a little bit for people. Like, suddenly they'll be like, at mile 18 and they'll get these. This horrible cramping, or suddenly they'll just. You know, we've seen this. Like there were some famous cases in the Olympics. Like, people will just start to poop. Poop, and they're like mid run and they're looking for the bathroom, or maybe there's already a disaster. And that's because your colon, in that scenario, is not getting enough blood. When it doesn't get enough blood and it doesn't get enough oxygen, you start to see microscopic damage which they've measured. Later, actually, you can start to lose blood microscopically and get anemia as a result of being a frequent runner. If you run at a threshold where your heart rate is just a little bit too high, and so exercise is really good for you. Certainly, marathon running can be incredibly good for you and healthy. And if that's something you enjoy. But what's not healthy is if you're reaching this threshold where your stomach, your colon is sending these distress signals, and we kind of push past and overlook. You kind of want to retrain your training goals to be such that your heart rate never hits that rate. And I usually tell people, keep your smart watch on. Like, see how high does your heart rate go when you start to get this call of nature? That's a threshold you don't want to go above in future.
- [39:55]
Jason Wakab
It's fascinating. The book is, you've been pooping all wrong, which I love, and I encourage everyone to go get. I thought I knew so much about the subject, but then I realized I really knew nothing. So it is a great book. Other than picking up the book. If someone wanted to, say, dramatically change and improve their gut health and say, like, the next 30 days, what are the. What are the top few things they should do? That's my closing question.
- [40:28]
Dr. Tricia Pasricha
Yeah, that's a great question. I'm going to give you a couple of different ones that everyone would benefit from. One, if you're not already doing this, and actually the majority of people are not in America, start raising your knees above your waist when you poop. And that's not how our modern toilets are designed. They're designed so that you sit the exact same way you and I are sitting right now. But when we do that, we actually close off. We put a small kink in our colon at the end that shuts it off because of this muscle that acts as a sling around it. And when we raise our knees up, such as if we put a stool underneath there, the higher the stool, the better that colon can straighten out again, because that sling, like, muscle relaxes and the tube straightens. So that's something that they've actually studied this in healthy people. Like, so people who didn't think they were constipated, and when they did that, they were like, oh, my God, I had no idea how much better it could be. And I think that, like, sort of summarizes, like, a lot about pooping is that there are a lot of people out there who just kind of think they're doing it fine and think it's okay, and they've kind of normalized their kind of average experience as being as good as it gets. But actually, something like this very simple maneuver, it will make it so much easier on you and on your body to Go. So that's one thing that will take you like 30 seconds, not 30 days to fix, but the other things that will fix your gut over a 30 day period, which is actually what I tell people to do, if you're not doing this already, is just try for 30 days to see as much as you can. Minimize the amount of these things. Ultra processed foods, alcohol and NSAIDs. NSAIDs are ibuprofen, Aleve, Excedrin, like all of these types of medicines, which if your doctors told you you need it for a really specific reason, by all means, take it. But I think a lot of us often just kind of take it for aches and pains throughout the day. And what people don't appreciate is that those medicines do actually cause damage to the lining of the gut. Like any gastroenterologist has seen too many people come in with ulcers from NSAIDs. And it's something that's kind of ubiquitous, like we're taking them all the time. But if you do these things to kind of maximize the integrity of that lining of your gut, which is fewer ultra processed foods, a little bit less alcohol, fewer NSAIDs, while increasing fiber, and to the extent possible, decreasing stress, those five things are like my mantra of when someone comes to me and we can't figure out what's going on, I say, let's try these five things and then we'll see what your real baseline is of symptoms.
- [42:56]
Jason Wakab
Very approachable. I think everyone can do that. Tricia, thank you so much.
- [43:01]
Dr. Tricia Pasricha
Thank you for having me.