And is it the same as like when we talk about gut or do you think those are different

terms? So the microbiome has been one of the hottest areas of research in the last several decades.

And I think the best comparison I can make for what the microbiome is, is that it is like this garden that is inside our gut.

Most of the...

The microbiome are all of the microbes, the trillions of microbes that live in our guts.

Trillions, trillions.

Oh yeah, you heard it.

That wasn't accurate.

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So what have we been doing wrong?

Well, the first thing we've been doing wrong, which you hinted at, is that we haven't been talking about it and, and not talking about it has consequences.

But then also, you know, there's just the dynamics about what we're doing, the ergodynamics.

We are not designed the way our modern life and our modern toilet seats, that's not designed for a healthy, safe bowel movement.

And I'll give you a couple examples.

You know, one is that the way we eat now is obviously very different from how our grandparents and, and even ancestors used to eat.

60% of our diet is coming from ultra-processed foods, and it impacts our gut microbiota, which then impacts our gut health, certainly impacts how we're having a bowel movement.

[laughs]

So, you know, what is I'll say, what is the connection or what are you finding in your research that does start to make that connection between the two? Yeah.

Yeah, the connection between GI symptoms and issues actually dates back to James Parkinson himself back in 1817.

So when I went back and looked at, so he wrote these original sort of series of cases of patients that later would become called Parkinson's disease, patients with Parkinson's, named after James Parkinson.

And he described a lot of those symptoms that we think of as Parkinson's, like tremors or difficulty with walking and movement.

But in several of those cases, he also noted really, really severe constipation.

And at that time, you know, it was just noted to be incredibly profound, not responding to kind of their usual set of treatments at that time.

But it wasn't until several decades later, like actually almost two centuries later, that it was first really proposed in the literature.

Hopefully it makes

So going back to the more serious situation, like the high amount of cancer in young people, why are more young people getting this kind of cancer nowadays?

Yeah, that's, that's the question.

One of the most common etiologies that a lot of the data's pointing towards is our diet, and it is specifically ultra-processed foods.

And it's probably a lot of different factors beyond that as well, but ultra-processed foods do two things.

One, they introduce these chemicals and additives and high sugar and, and high salt that our microbiome doesn't love at all and can cause microscopic inflammation, and then the second thing is that ultra-processed foods notoriously are low in fiber.

Fiber is protective against colorectal cancer.

And then I think what's really disturbing about that is that in these early onset cancer cases particularly, a lot of the studies point towards our diets when we're young, like in our adolescence and our teenage years when we're eating ultra-processed foods as young kids, when we're drinking these sugar-sweetened beverages.

What advice do you have for me, for our listeners, um, to poop better?

Mm-hmm.

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 is, 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've 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.

Yeah.

Wow.

Isn't that astounding? And that's one piece of the epidemiological clue that led people to say, "Okay, and it's not zero, so some people are still getting Parkinson's disease," but what was happening to that almost 50% of people who didn't? And we've come to realize that the hallmark of Parkinson's disease is this misfolded protein called alpha-synuclein, and you can see that in a certain part of the brain, that, uh, it causes the destruction of dopamine-producing neurons, and that's what's responsible for the tremors and, and some of the symptoms that we classically associate with Parkinson's disease.

However, when I started seeing patients out of my GI fellowship with Parkinson's disease, and this was sort of by chance and serendipity that more and more patients came to see me, almost all of them would say that they were suffering from debilitating GI symptoms, from constipation, from nausea.

And if you started to probe, that, those GI symptoms started years if not decades before their tremors.

And now we've done these big studies where we find that what we think could be happening is alpha-synuclein, that protein, actually may start to misfold first in our gut, and then there's this period, we call it a prodromal period, that can be years, could be decades, where that protein is misfolding and maybe it's traveling along the gut, slowly up the vagus nerve, but it hasn't hit the brain yet.

So you don't have tremors, but you're starting to get these GI symptoms and what we call autonomic dysfunction, which is where your blood pressure might change, um, and you have issues with, with hypotension.

Right.

Um, but you know, sometimes, I, I don't want people to say, like, "This is gonna completely block my ability to eat vegetables," 'cause all vegetables are often wrapped in plastic.

Trisha says it comes down to several things.

If we take a step back and remember the physiology of our colons, our colons are a creature of habit.

So they actually operate on a circadian rhythm.

They go pretty quiet at night with very little movement, and then the first one or two hours upon waking, they're really bustling with activity.

And that's why a lot of people do regularly go in the morning because that's a time when your colon is naturally starting to contract and push things forward.

And then other things happen in the morning, like we often drink a cup of coffee.

That helps stimulate contractions.

Mm-hmm

now so curious, like what else do people do on the toilet? They like, do you decide the difference between like reading on a phone versus reading a book versus like doing a crossword puzzle versus Sudoku? Like, what does that mean, Trisha? We should recruit you to the

lab.

Like those are the exactly correct questions.

So we know in the past there was this like very nice study in the 70s that showed that people who read the newspapers, it was a British study, read the newspaper tended to spend longer on the toilet than people who didn't bring the newspaper in.

That's not terribly surprising.

I think reading on the toilet is not inherently a bad thing.

I think it can help you relax.

And is that related to anything that we do?

When we talk about the gut and the brain talking to each other, how are they talking? What is the mode of communication? Trisha?

Yeah.

There's, there's two main ways.

You know, um, w- well most of how we've thought about the gut-brain connection, I think, has been in terms of how the brain communicates with the gut.

We live that experience every day, right? You know, when you're going on a date, you get butterflies in your stomach, like Flora mentioned, or if you're nervous, like suddenly you have to use the bathroom and it's your turn at karaoke, and there's no bathroom in sight.

Why? And then when you sing your song, suddenly you don't have to go anymore.

And some of the ways those types of communications happen, some of it is hormone signaling, some of that can happen through the bloodstream from the brain down to the gut.

What's the connection to the gut?

Mm-hmm.

Your gut contains 500 million nerve cells, so it's producing dopamine, it's producing serotonin, it's interacting with those trillions of microbes living in our body.

So that's why it's responsible for supporting our immune system, for regulating our metabolism, and even our mood, right? And so like when we're stressed and nervous, we feel it first in our stomachs, right?

Like supplements or food?

Ideally food.

But supplements are great if it's just not gonna happen with diet.

Take a supplement.

Take something like psyllium husk.

And we need electrolytes, especially sodium, for basic bodily function.

The reason your muscles can contract, the reason your heart muscle is contracting, the reason your stomach muscle is contracting, is because of this exchange of sodium.

It's like a battery, just, like, recharging your cells to fire off, like, signals to each other.

Without the sodium, our hearts wouldn't beat, right? And our, like, our...

We wouldn't be able to move our muscles.

I couldn't grab my cell phone up right now and take a call because my arm wouldn't work.

And so sodium is critical to everything that we do second to second, and so it's actually, like, amazing how quickly, if our sodium gets too low or too high, you can start to see these very dangerous abnormal electrical rhythms in your heart develop that can be fatal.

And I'm just wondering if you could talk about those a little bit.

Yes.

Leaky gut is one of my favorite topics because I don't think a week goes by that someone hasn't not only asked me about leaky gut, but has, like, spent hundreds of dollars on these kits, and I try so hard to get people to stop spending their money on these kits.

So let's take a step back, 'cause I think you actually, you, you said it quite well.

Leaky gut, if we think about it in terms of what is a real physiological phenomena called increased intestinal permeability, happens to us all the time.

Uh, healthy or, or whether we have some disease or disorder, at multiple points in our day when we're feeling more stress than usual, if we go for a jog, if we're eating, those junctions between the cells, the lining of our gut, will open up just a little bit and then they'll close, and some of that helps modulate what kinds of cells, often immune cells or inflammation, uh, related cells can move in and out of the gut.

And the problem is this, is that this is real.

Yeah, it just wasn't, you know, yeah.

So what are the other criteria that you care more about?

It is the comfort.

Um, 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...

W- what's your view?

So they would take proton pump inhibitors like Prilosec and would reach for that medication right before bed.

Well, right before you go to bed is, is not a very helpful time to take it.

It would have been much more efficacious if you'd taken it 30 minutes before your meal.

Sometimes that, that in- this entire instruction just gets lost in translation, and they think that, "Well, the proton pump inhibitor isn't working.

This medication isn't working for me.

I have something else going on," or, or, "My," you know, "my heartburn is refractory to medication." Actually, that's not the case at all.

It's just that we weren't taking the medication optimally and sometimes having a conversation with your healthcare provider, say, "This is what I've been trying," could help clear that right up.

But she says sometimes it makes more sense to take a small dose when you start to feel the pain.

So they would take proton pump inhibitors like Prilosec and would reach for that medication right before bed.

Well, right before you go to bed is, is not a very helpful time to take it.

It would've been much more efficacious if you'd taken it 30 minutes before your meal.

Sometimes that, that in- this entire instruction just gets lost in translation and they think that, "Well, the proton pump inhibitor isn't working.

This medication isn't working for me.

I have something else going on," or, or, "My, you know, my heartburn is refractory to medication." Actually, that's not the case at all.

It's just that we weren't taking the medication optimally, and sometimes having a conversation with your healthcare provider, say, "This is what I've been trying," could help clear that right up.

But she says sometimes it makes more sense to take a small dose when you start to feel the pain.

Mm-hmm.

They'll show me 10 foods that are now on their, like sort of list that they shouldn't be eating, and we'll look at those foods together, and I'll be like, "Hey, did, did mushrooms actually ever bother you before? Like did, do you tolerate them?" They'll be like, "I 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 a- 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 they're ...

Mm-hmm

Okay, and then what about psyllium husk?

Yes.

So s- psyllium husk is great.

So what's interesting about psyllium husk is that not all fiber and fiber supplements are created equal.

So psyllium husk, it's f- comes from this thing called the Plantago ovata plant, and it is a soluble fiber.

Soluble fiber is notable because it dissolves in water and it forms a gel, and that gel is the key to why psyllium husk is so special.

When you are constipated, it softens up that hard stool through the gel, and it makes it softer and easier to pass.

How would you define ultra-processed foods?

Okay, and then what about psyllium husk?

Yes.

So psyllium husk is great.

So what's interesting about psyllium husk is that not all fiber and fiber supplements are created equal.

So psyllium husk, it's f- comes from this thing called the Plantago ovata plant, and it is a soluble fiber.

Soluble fiber is notable because it dissolves in water, and it forms a gel, and that gel is the key to why psyllium husk is so special.

When you are constipated, it softens up that hard stool through the gel, and it makes it softer and easier to pass.

How would you define ultra-processed foods?

Tell me a little bit about, you know, what you studied in school before you went to medical school and what you specialized in through your medical training.

Yeah.

So there was probably never a time in my life when I didn't want to be a gastroenterologist, which I know sounds really wacky.

But most people, that sounds really bizarre.

But it won't sound bizarre if you know that my dad was also a gastroenterologist and he was a researcher.

So when I, even before I went to med school, he was studying the gut-brain connection at a time when that field was really starting to crystallize for the first time.

This was in the 1990s and early 2000s.

So that's my spiel.

Mm.

And then of course, if anyone's traveling, that will change your habits.

Like, a lot of people get blocked up when they travel, and that's a big problem.

Um, and then as we age, especially f- women, hormones can play a big role.

When you're on your period, that plays a big role because there's different changes in compounds, the prostaglandins, the hormones.

So there are a lot of things that we don't think about immediately as being part of the issue, even if you haven't changed anything.

And sometimes we can figure it out, sometimes we just have to figure out how we're gonna move forward.

Hmm.

Yes.

P-S. It's psychology, you know, so it's not psyllenium or something like that.

But yeah, psyllium husk is great because it's a soluble fiber, and, um, soluble means that it's gonna dissolve in water and it's gonna turn into a gel, and that's where this concern about, okay, does this gel somehow maybe absorb other medicines that you've been taking or interfere with that? And, and the data on whether it does that is actually pretty weak.

So you can always run it by your doctor, but I wouldn't worry about, is this gonna somehow interfere with the absorption of other foods? All it's gonna do is slow things down to some extent.

That's actually a good thing.

It gives you more time to digest, and, uh, you get some benefit from the soluble fiber, both in terms of whether you have constipation, because it kinda loosens things up, but soluble fiber also helps if things are too loose because it can kind of bind those looser pieces together in that gel.

So it's a, it's a shape shifter and it's a really wonderful, gentle, easy to take fiber.

Doctor, go ahead.

So let's first talk about what does this mean, gut permeability? How is it measured and why it matters? And then I guess we should leave alone why the mainstream doesn't really pay attention to it.

Well, I can answer all of the above.

Like, I think that the reason, you know, you'll meet two kinds of gastroenterologists.

One, which are the neuro gastroenterologists will be like, of course, increased intestinal permeability is real.

And we've been studying this and there's these studies that I'll tell you about.

But you'll also meet a lot of gastroenterologists who are so wary.

of the misinformation around the term leaky gut on social media, that they're like, leaky gut's not real.

And if you can, maybe reveal how one could assess gut permeability in a clinical setting.

Right

... more often than not, you need more fiber.

Propulsion is the other problem.

Propulsion refers to how your muscles are generating these contractions in your own gut to push that poop forward.

So that's the second P.

And then the third mistake that, that can come into play is in our pelvic floor.

And I think this is the most underappreciated part of it.

Hmm

Or you have other ways to get in a position that powers your pelvis, unlike the way we are doing it today.

Yeah.

So the third P is the pelvic floor.

And I'll say off the bat, when I tell patients about the pelvic floor, what I'm talking about is like, imagine trying to squeeze a toothpaste tube and never taking the cap off.

You can take all the stimulant laxatives you want.

You can have the softest, plushiest stool in the world.

And if you don't take that cap off, that toothpaste isn't going anywhere.

Maybe you could amplify that.